alexa Under Nutrition Status and Its Determinants among Adult HIV and AIDS Clients Enrolled on Antiretroviral Therapy at Nigest Elleni Mohammed Memorial Hospital, Southern Ethiopia
ISSN 2155-6113
Journal of AIDS & Clinical Research
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Under Nutrition Status and Its Determinants among Adult HIV and AIDS Clients Enrolled on Antiretroviral Therapy at Nigest Elleni Mohammed Memorial Hospital, Southern Ethiopia

Wondmagegn G Shiferaw1#, Assefa A Jegora1#, Lire Lema2# and Beminet M Gebremariam2*

1Department of Nursing, College of Medicine and Health Sciences Wachemo University, Hossana, Ethiopia

2Department of Public Health, College of Medicine and Health Sciences, Wachemo University, Hossana, Ethiopia

#Authors contributed equally

Corresponding Author:
Beminet M Gebremariam
Department of Public Health
College of Medicine and Health Sciences
Wachemo University, Hossana, Ethiopia
Tel: +251912122934
E-mail: [email protected]

Received date: September 01, 2017; Accepted date: September 22, 2017; Published date: September 29, 2017

Citation: Shiferaw WG, Jegora AA, Lema L, Gebremariam BM (2017) Under Nutrition Status and Its Determinants among Adult HIV and AIDS Clients Enrolled on Antiretroviral Therapy at Nigest Elleni Mohammed Memorial Hospital, Southern Ethiopia. J AIDS Clin Res 8:733. doi:10.4172/2155-6113.1000733

Copyright: © 2017 Shiferaw WG, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: HIV/AIDS and malnutrition effects are interrelated and exacerbate one another in a vicious cycle. HIV specifically affects nutritional status by increasing energy requirements, reducing food intake and adversely affecting nutrient absorption and metabolism. In spite of the number of People Living with HIV ever enrolled on ART increases significantly in Ethiopia. Nutritional care and other supports which help for the success of treatment received insufficient attention. The aim of this study was to assess the prevalence of undernutrition status and its determinants among adult HIV/AIDS Clients enrolled on ART at Nigest Elleni Mohammed Memorial Hospital in Hosanna Town, Southern Ethiopia. Method: Institution based cross-sectional quantitative study was conducted using systematic random sampling technique with sample size of 234. From each sampled patient, interview and anthropometric data were collected. Bivariate and multivariate logistic regression analysis was used and the variables which had significant association were identified on the basis of p-value ≤ 0.05 and AOR, with 95% CI. Results: Among adult HIV/AIDS Clients in rolled in ART, 32.5% of them were under nourished (BMI<18.5 Kg/m2). ART patients had no nutritional supports (AOR=2.22), patients who feed less than 3times in a day (AOR=3.29) and had smoking habit (AOR=6.06) were more likely to be under nourished and those patients in WHO Clinical stage 3 (AOR=0.12) were less likely to be under nourished. Conclusion: This study revealed that under nutrition among adult HIV/AIDS Clients in rolled in ART was high prevalent problem in the study area. WHO clinical stage, daily food intake, nutritional support, smoking status was identified as the determinants of under nutrition. Current study identified that there is a need to design and implement nutritional interventions including nutritional support in items or financially together with healthy habit counselling as part of integrated ART service for effective patient treatment outcome.

Keywords

HIV/AIDS; ART; Under nutrition; BMI; Southern Ethiopia

Abbreviations

AIDS: Acquired Immune Deficiency Syndrome; AOR: Adjusted Odd Ratio; ART: Anti-Retroviral Therapy; BMI: Body Mass Index;CD4:Cluster of Differentiation 4;CEM: Chronic Energy Malnutrition; COR: Crude Odd Ratio; EDHS: Ethiopian Demographic and Health Survey; FMOH: Federal Ministry of Health; FANTA: Food and Nutrition technical Assistance; FAO: Food and Agriculture Organization; HIV: Human Immunodeficiency Virus; KG: Kilogram; HT: Height; NEMMH: Nigest Eleni Mohammed Memorial hospital; OI: Opportunistic Infection; PLWHA: People Living With HIV/AIDS; RUTF: Ready to Use Therapeutic Food; SNNPR: South Nation Nationality Peoples Region; WHO: World Health Organization

Introduction

The Human Immunodeficiency Virus pandemic remains to have a prominent global impact, particularly among the world's resource- limited settings. According to Global AIDS Progress Report of 2014, approximately 36.9 million people were living with HIV and AIDS. In sub-Saharan Africa, there were 24.7 million people living with HIV and 1.1 million people died of AIDS-related causes in 2013 [1,2]. The prevalence of HIV was 1.5 percent among adults age 15-49 in Ethiopia based on Demographic and Health Survey of 2011 [3].

HIV specifically affects nutritional status by increasing energy requirements, reducing food intake, and adversely affecting nutrient absorption and metabolism. Asymptomatic and symptomatic adults have energy requirements increases by 10% and 30% respectively to maintain body weight and physical activity [4,5].

The latest available estimates indicate that about 795 million people in the world were undernourished. In Sub Saharan Africa including Ethiopia about 23.2%individuals were undernourished [6]. In Ethiopia the number of People Living with HIV (PLHIV) ever enrolled on ART increases significantly, currently, 871,334 PLHIV enrolled on ART [7].

Malnutrition and HIV/AIDS compound one another. People Living with HIV and AIDS (PLWHA) are more likely to become malnourished due to reduced food intake resulting from appetite loss and difficulty eating, possibly as a result of infections, side effects of medication, or depression. Poor absorption of nutrients that may be the result recurrent/chronic diarrhea and HIV-caused intestinal cell damage. And then the will develop malnutrition again it contributes to immune impairment, making the body vulnerable to frequent illnesses [8-10].

Antiretroviral therapy is critical to suppression of viral replication, reduced destruction of CD4 cells, prevention of viral resistance, promotion of immune reconstitution, and slowed disease progressions [11-13]. Nutrient intake can improve antiretroviral absorption and tolerance. Poor nutritional status in PLHIV speeds the disease progression increases morbidity, and reduces survival time. Good nutrition for PLHIV has been proven to increase resistance to infection, help PLHIV maintain weight, improve drug compliance and drug efficacy [14-16].

Despite there are a growing number of ART users in Ethiopia, nutritional care and support get insufficient attention to the success of treatment and also there is little evidence against to the nutritional condition of peoples' living HIV and AIDS those who are enrolled in ART care in the study area. The results of this study will also serve as baseline data onto program managers and decision makers to design nutritional intervention. Therefore this study aimed to assess the undernutrition status and its determinants among adult HIV/AIDS Clients enrolled on ART at Nigest Elleni Mohammed Memorial Hospital in Hosanna Town, Southern Ethiopia.

Materials and Methods

Study area and period

The study was carried out in Nigest Elleni Mohammed Memorial Hospital in Hosanna town the capital city of Hadiya Zone SNNPR State situated 196 Km from Hawassa and 232 Km from Addis Ababa. The Hospital was built in 1984 GC and it is serving 3.5 million people from different zones with 110 beds. A total of 882 adult HIV/AIDS patients have been enrolled at Nigest Elleni Mohammed Memorial Hospital ART care. We have completed the study from November 01 to June 14, 2016.

Study design and population

Institutional based cross-sectional quantitative study was conducted to assess adult undernutrition status and its determinants of ART users at Nigest Elleni Mohammed Memorial Hospital. The source populations were all adult HIV and AIDS patients that are enrolled in ART care clinic in Nigest Elleni Mohammed Memorial Hospital. The study population was the sampled adult HIV/AIDS patients who are actively taking ARV drugs at Nigest-Elleni Mohammed Memorial Hospital. Patients who were actively following ART care clinic in Nigest Elleni Mohammed Memorial Hospital and aged 18years and older, not have physical deformity and nonpregnant women were included in the study. Patients who seriously ill at the time of data collection were excluded.

Sampling size determination

The sample size was determined using single population proportion formula taking 25.5% [17] the prevalence of malnourished people living HIV and AIDS at Felege-Hiwot Referral Hospital in Bahirdar with 5% marginal error and 95% confidence interval (CI) of certainty (alpha=0.05). Since the source populations (882) which were <10000, an adjustment formula was used. By taking 5% non-response rate, the total sample size was 234. Systematic random sampling was used and we have taken every three (kth interval=3) of the daily attended clients consecutively and to start the first case a lottery method was used.

Data collection procedure

Data was collected using structured questionnaire and anthropometric measurements. Three collection team members participated. The weight of participants was taken using standard beam balance and the scale will be checked at zero before and after each measurement. Participants' weight was measured after removing heavy clothes and recorded to the nearest 0.1 kg. Height measurement of participants was taken using the standard measuring scale and height was recorded to the nearest 0.1 cm. To determine undernutrition status, BMI was calculated. The standard cut-offs that we used: <18.5 kg/m2 was under nourished (Chronic Energy deficiency or CED), 18.5-24.9 kg/m2 was normal.

Data quality management, processing and analysis

Questionnaire prepared in English was translated into the Amharic language to make data collection easier and back to English for checking language consistency. Pre-testing of the questionnaire was done on 15 ART care clients in the Hossana Health Center a week prior to the actual survey. The collected data was checked out for the completeness and clarity by the students. This quality checking is done daily after data collection and amendments were made before the next data collection measure. The data was collected by 3 B.Sc. Nurses for 15 days. After data collection, each questionnaire was checked for competence and code was given before data entry. Data entry and analysis was done by SPSS version 16.0. To identify the determinants of undernutrition status among Adult HIV and AIDS clients enrolled on ART in this study logistic regression analysis was done. A variable with P-value<0.25 was transferred to multivariate analysis which helps all associated variables in bivariate analysis to compete with dependent variable together in order to control confounding factors. Lastly, variables with a p-value<0.05 and AOR, with 95% CI were identified to measure the strength of the associations.

Ethical consideration

Ethical clearance was obtained from an ethical review committee of Wachemo University, College of Medicine and health science. Official permission letter was sent to Nigest Elleni Mohammed Memorial Hospital in which the actual data collection was performed. The purposes and importance of the study were explained and informed consent was secured from each participant. Confidentiality was maintained at all levels of the study.

Results

Socio-demography characteristics of the respondents

A total of 234 adult patients enrolled on ART were involved in the study with response rates of 100%. From them, 135 (57.7%) of the participants was females and 126 (53.8%) were between age group 30-45 years. The majority 147 (63.6) was protestants and 167 (71.4%) from Hadiya ethnic group. Most were urban dwellers 148 (63.2%), 144 (61.5%) respondents had an occupation and more than half of the respondents 137(57.7%) had monthly income below 1000 ETB (Table 1).

Variables Number Percent
Sex of respondents    
 Male 99 42.3
 Female 135 57.7
Age respondent    
18-29 50 21.4
30-45 126 53.8
≥ 45 58 24.8
Marital status    
Married 111 47.4
Divorced 19 8.1
Widowed 61 26.1
Unmarried 43 18.4
Family size    
< 3 79 33.8
3-6 112 47.9
≥ 7 43 18.4
Residency    
Urban 148 63.2
Rural 86 36.8
Ethnicity    
Hadiya 167 71.4
Kembata 29 12.4
Silte 16 6.8
Gurage 12 5.1
Others 10 4.3
Religion    
Protestant 147 63.6
Muslim 22 9.5
Orthodox 43 18.6
Catholic 13 5.6
Others 6 2.6
Occupation    
No occupation 90 38.5
Had occupation 144 61.5
Educational status    
Illiterate 29 12.6
Primary 20 8.7
Secondary 58 25.1
Higher secondary and above 46 19.9
Monthly income    
<1,000 ETB* 135 57.7
≥ 1,000 ETB 99 42.3

Table 1: Socio-demographic characteristics of respondents at Nigest Elleni Mohammed Memorial Hospital, Hosanna, Ethiopia, 2016 (n=234).

Clinical profiles and ART status of the study participants

The HIV status of patients showed that 95 (40.6) were at WHO clinical stage II. Diarrhea of 58(24.8%) respondents was the most common GI manifestation. 83 patients (35.5%) were with a CD4 count of 351-500 cells/μl. 91 (38.9) patients had a current or past history of opportunistic infections, 109 patients (46.6%) were on ART treatment regimen 1e (TDF+3TC+NVP), most of the patients have taken ART for more than three years (Table 2).

Variables Number Percent
Eating fat    
No 153         65.4
Yes 81           34.6
Gastrointestinal symptoms    
 No 136 58.1
 Yes 98           41.9
 Diarrhea 58 24.8
 Indigestion 21 9
 Constipation 19                           8.1
WHO clinical stage    
Stage 1 80 34.2
Stage 2 95 40.6
Stage 3 47 20.1
Stage 4 12 5.1
CD4+ T cell count    
<200 cells/μl 33 14.1
200–350 cells/μl 49 20.9
351–500 cell 83 35.5
≥ 500 69 29.5
Current/past OI in the past 6 months    
No 143 61.1
Yes 91 38.9
ART regimen    
1e 109 46.6
1c 51 21.8
1d 35 15
1a 9 3.8
1f 8 3.4
2b    
Duration of ART    
<6 months 45 19.2
6 months-3 years 80 34.2
≥ 3 years 109 46.6

Table 2: Clinical profiles and ART status of the study participants at Nigest Elleni Mohammed Memorial Hospital, Hosanna, Ethiopia, 2016

Food and lifestyle-related characteristics

The study showed that 170 (72.6%) adult patients were changed their feeding style after knowing their HIV status. About 60 (25.6%) patients were consumed High fat containing foods. Tap water was the most common type of water used by 191 (81.6%) respondents. From the total study participants, 124(53.0%) of them has received feeding counseling (Table 3).

Variables Number Percent
Change of feeding style after knowing HIV status    
No                           170 72.6
Yes                                                             64           27.4
Eat High fat containing foods    
No 174 74.4
Yes 60 25.6
Frequency of daily food intake    
<3 41 17.5
≥ 3 193 82.5
Daily water intake (L)    
<1 14 6
1-2 7 3
≥ 3 191 81.6
Type of water    
No selection 7 3
Tap 191 81.6
Boiled 1 0.4
Treated 4 1.7
Others 31 13.2
Food counseling    
No 110 47
Yes 124 53
Nutritional support    
Had no support 188 80.3
RUTF 46 19.7
Regular physical exercise    
No 199 85
Yes 45 15
Alcohol use    
No 193 82.5
Yes 41 17.5
Smoking    
No 218 93.2
Yes 16 6.8

Table 3: Food and life style related characteristics of the study participants at Nigest Elleni Mohammed Memorial Hospital, Hosanna, Ethiopia, 2016 (n=234).

Support and dietary characteristics

From patients who had no nutritional support, 54 (71%) became undernourished. In the study patients that fed their meals less than 3 times per day and became undernourished were 20 (26%) however, 137 (87%) of patients that enrolled on ART were Fed 3 and more times per day and their nutritional status became normal (Figure 1).

Figure 1: Daily feeding frequency, nutritional support and undernutrition status among adult HIV and AIDS patients enrolled in ART at Nigest Elleni Mohammed Memorial Hospital, Hosanna, Ethiopia, 2016.

Undernutrition status of adult HIV/AIDS clients

In the analysis, the prevalence of undernutrition (Chronic Energy deficiency) among adult HIV/AIDS Clients in rolled in ART was 32.5%. From the ART users, 158 (67.5%) was Normal (BMI 18.5-24.9 Kg/m2). The prevalence of undernutrition and normal nutritional status among females were 46 (19.7%) and 89 (38%), respectively (Figure 2).

Figure 2: Under nutrition status and sex distribution of adult HIV/AIDS Clients in enrolled in ART at Nigest Elleni Mohammed Memorial Hospital, Hosanna, Ethiopia, 2016.

Determinants of undernutrition status among adult HIV/ AIDS patients enrolled in ART

In the study educational status, occupational status, monthly income CD4 count, WHO clinical stage, duration on ART, eating fat-containing foods, daily food intake, daily water consumption, nutritional support, smoking status were significantly associated with undernutrition status in bivariate analysis. The study result of multivariate analysis indicated that WHO clinical stages, daily food intake, nutritional support, smoking status were identified as the determinants of under nutrition in the study area. In the study daily food intake of ART patient was found one of the determinants of undernutrition, patients who feed less than 3 times in a day were 3.29 times more likely to be undernourished than patients who eat 3 or more times. (AOR=3.29; 95%; CI (1.49, 7.28).

Illness of patient within WHO Clinical Stage was one of the significant risk factors undernutrition in the study area. Those patients with the illness at WHO Clinical stage 3 were 88% less likely to be undernourished than WHO Clinical stage 1 ART patients (AOR=0.12; 95% CI: 0.03, 0.55). Having nutritional supports became one of the risk factors which significantly associated with undernutrition, those ART patients who had no nutritional support were 2.21 more likely to become Undernourished (chronic energy deficient) than who had no support (AOR=2.28 95: CI: (1.27, 3.85). Comparing from ART patients who did had smoking habit those patients who had smoking habits were 6.06 times more likely to be undernourished (AOR=6.06; 95% CI: 1.12, 32.8) (Table 4).

Explanatory Variables Undernutrition Status  COR 95% CI AOR 95% CI P-Value
Under nourished Normal
WHO clinical stage          
Stage 1 31 49 1 1  
Stage 2 22 73 0.476 (0.247, 0.91) 0.283 (0.063, 1.26) 0.099
Stage 3 16 31 0.816 (0.384, 1.73) 0.123 (0.028, 0.54) 0.006*
Stage 4 7 5 2.213 (0.645, 7.59) 0.221 (0.047, 1.03) 0.055
Daily feeding frequency          
Less 3 times 20 21 2.330 (1.172, 4630 3.29 (1.49, 7.28) 0.003*
3 and more times 56 137 1 1  
Nutritional support          
Had no support 54 134 2.28 (1.18, 4.39) 2.22 (1.27, 3.85) 0.005*
RUTF 22 24 1 1  
Smoking Habit          
Yes 2 14 0.28 (0.06, 1.25) 6.06 (1.12, 32.8) 0.036*
No 74 144 1 1  

Table 4: Factors associated with under nutrition status among adult HIV and AIDS patients enrolled in ART at Nigest Elleni Mohammed Memorial Hospital, Hosanna, Ethiopia, 2016.

Discussion

The prevalence of undernutrition among adult HIV/AIDS Clients in rolled in ART was 32.5%. From ART users 158 (67.5%) were Normal (BMI 18.5-24.9 Kg/m2). The undernutrition in this study was higher than the study conducted in Kathmandu Valley Health center, Nepal 19.9%, Butajira Hospital, 25.2%, FelegeHiwot, Amhara Region of Ethiopia 25.5% and East Wollega Zone (26.47%) [16-19]. On the other hand, the prevalence of undernourished ART clients in the study was lower than studies conducted in Tigray, northern parts of Ethiopia 50.5% [20]. The difference of under nutrition may reflect due to population difference, sample characteristics, the existence of different socio-economic and other factors of the study.

Illness of patient within WHO Clinical Stage was one of the significant risk factors undernutrition in the study area. Those patients in WHO Clinical stage 3 were 88% times less likely to be under nourished than WHO Clinical stage 1 ART patients, this result were in contrary with the finding in Nepal [16] and also study HIV referral center in Singapore which indicated that Patients are often not diagnosed or do not commence ART until they have advanced disease [11]. The possible explanation for this finding could be patients with WHO clinical stage 3 starts ART treatment without CD4 count and get a chance to start drug early that make drug adaptation easier than stage one. Also, stage one patient mostly is asymptomatic so they might not start drug before their CD4 count decreases and immunity lowers.

Having nutritional supports became one of the risk factors which significantly associated with undernutrition, those ART patients who had no any nutritional support were 2.22 times more likely to become

Undernourished (chronic energy deficient) than who had nutritional support. The finding was supported by the studies in Central Haiti [21] and Uganda [22]. However, a study in Butajira hospital contradicts with a report which indicates there individuals who were not taking RUTF were 82% times less likely to be malnourished than those who were taking RUTF [19]. This might be due to patients who were not receiving nutritional support (RUTF) will lose the positive effects of therapeutic foods which help to enhance ART adherence. Moreover, RUTF support may improve the weight of patients.

Comparing from ART patients who did had smoking habit those patients who had smoking habits were 6.06 times more likely to be undernourished. The possible explanation for this finding could be, smoking can lead to body weight loss by increasing the metabolic rate, decreasing metabolic efficiency, decreasing caloric absorption (reduction in appetite) all of which are associated with tobacco use and results decreased immunity so they are susceptible to OIs and leads to economic problem to buy food instead they buy cigarette.

In the study daily food intake of ART patient was fund one of the determinants of undernutrition, patients who fed less than 3 times per day were 3.29 times more likely to be undernourished than patients who fed 3 or more times. The finding was in line with study in Northern Ethiopia in which, inability to get enough and/or quality food was about 2.1 times higher in the non-adherent group [20]. The possible justification for this may be patients who feed frequently gets the adequate energy that might make them productive and increases their immunity against opportunistic infection from food variety and amount they get.

Conclusion

In the study, the prevalence of undernutrition was high among adult HIV/AIDS Clients in rolled on ART in the study area. Nutritional support, daily food frequency, WHO clinical stage and smoking status were found to be the significant determinants of under nutrition at Nigest Elleni Mohammed Memorial Hospital in Hosanna Town, Southern Ethiopia. The Current study recommended that, there is a need to design and implement nutritional interventions including nutritional support in items or financially together with healthy habit counselling as part of integrated ART service to prevent undernutrition and for effective treatment outcome. Then, further studies needed to identify other key determine of under nutrition status among adult patients enrolled in ART using longitudinal methods.

Authors’ Contributions

WG, AA wrote the proposal of this research. BM, LL revised the proposal and Incorporate some comments. BM wrote the final manuscript. All authors read and approved the final manuscript.

Acknowledgement

This study received funds from Wachemo University research and community service and the authors want to extend his heartfelt gratitude to Nigest Elleni Mohammed Memorial Hospital and all participants of the research for their cooperation.

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