PREVALENCE OF OPPURTUNISTIC INTESTINAL PARASITIC

INFECTION AMONG HIV/AIDS INFECTED PATIENTS WHO

ARE TAKING ANTIRETROVIRAL TREATMENT IN

SHASHAMANE HEALTH CENTER --------- ETHIOPIA

BY: DEGEFA ------------------------

ARESEARCH PROPOSAL TO BE SUBMITTED TO DEPARTMENT

OF MEDICAL LABORATORY SCIENCES SHASHAMANE HEALTH

CENTER IN PARTIAL FULFILLMENT OF THE REQUIREMENT

FOR A BACHELOR DEGREE OF SCINCE IN MEDICAL

LABORATORY SCIENCES

May, 2014

SHASHAMANE, ETHIOPIA

1

HARAMAYA UNIVERSITY

COLLEGE OF PUBLIC HEALTH

AND MEDICAL SCIENCES, DEPARTMENT OF

MEDICAL LABORATORY SCIENCES.

PREVALENCE OF INTESTINAL PARASITIC INFECTION

AMONG HIV/AIDS INFECTED PATIENTS WHO ARE TAKING

ANTIRETROVIRAL TREATMENT AT SHASHAMANE HEALTH

CENTER

BY: DEGEFA------------

2

ADVISOR:-

TESFAYE DIGAFE(MSc.)

May, 2014SHASHAMANE

3

AbstractBackground-one of the major health problems amongHIV/AIDS sero- positive

Patients is superimposed infection due to the deficient

immunity. Furthermorethe

parasitic infections of the intestinal tract is a major

source of disease in patients with HIV particularly in

the tropics, where diarrhea is a common compliant with

variable severity and specific pathogens are being

identified in more than 90% of HIV/AIDS patients with

persistent diarrhea. Generally diarrhea is a major

gastro intestinal symptom in HIV infected patients and

itsbecomesmore frequent as immuno-deficiency progresses.

Objective- the primary objective of this study will beto determine the magnitude of Intestinal Parasite

particularly inHuman Immuno deficiency Virusor Acquired

Immunodeficiency Syndrome patients who are taking Anti-

Retroviral Treatment in Shashamane Health Center.

Method: –Acrossection study will be conducted.Date

will be conducted with the convenience sampling will be

used for patients who come to the hospital for therapyI

of HIV/AIDS within the specified duration. Parasite

infection will be diagnosed by examination of single

stool specimen which will be examined as fresh wet

mountsand Acid fast bacillus (AFB) stain.

Result- Data will be sorted manually and analyzedwith

scientific calculator, summarized and presented with

frequencies tables and percentage. Date will be

discussed and compere with similar studies.The total

budget is 1642.30 birr. Finally based on the result

conclusion and recommendation will be forwarded to the

concerned body.

AcknowledgementI would like to express my heartfelt gratitude to my

advisor ----- (BSC. MSC) for his constructive advice

and continuous follow up.

I would also like to thank to computerserves providers

and the library circulation staff members and theII

library documentation staff for their helpfulness in

searching literatures, journals and other relevant

material.

I would like convey my heartfelt gratitude to Shashamane

Health center Staff for allowing me to conduct research

on the prevalence of intestinal parasites among the

patient who are taking ART.

I would like to thank to my friends ----------- for

helping inwriting.

III

TABLE OF CONTENTESpage

Contents

Abstract..........................................I

Acknowledgement..................................II

Table of contents...............................IIIList of tables....................................VOperational Definitions..........................VIAbbreviations...................................VIIChapter One.......................................1Introduction......................................1Background Information............................11.2. Statement of the problem.....................31.3. Significance of the study....................5Chapter Two.......................................6Literature Review.................................6Chapter Three.....................................8Objective.........................................83.1. General objective............................83.2. Specific objective...........................8Chapter Four......................................9Methodology.......................................94.1. Study area...................................94.2. Study design.................................94.3. Study period.................................94.4. Population...................................94.4.1. Source of Population.......................9

IV

4.4.2. Study Population..........................104.5. Sampling technique and sample size..........104.5.1. Sampling technique........................104.5.2. Sample size...............................104.6. Study variables.............................104.6.1. Dependent Variables.......................104.6.2. Independent Variables.....................104.7. Materials and Reagent.......................104.7.1. Materials.................................104.7.2. Reagent...................................114.8. Ethical consideration.......................114.9. Data collection process.....................114.10 Data processing and analysis................12Chapter five.....................................13Work plan........................................14Chapter six......................................156. Budget plan...................................156.1. Budget proposal.............................166.2. Budget justification........................17Chapter Seven....................................18Dummy Tables.....................................18Appendix -1......................................19Procedures.......................................19Specimen collection..............................20Appendix- 2......................................20Appendix-3.......................................22Reference..........................................

Questionnaire....................................24Instruction......................................24

V

List of tables page

Table. 1. Age and sex distribution of HIV infected

patients those stool will be examined for opportunistic

infection who are taking ART from—to----,

-------------------------------------------------------

------------------------18

Table.2. Appearance of stool among HIV infected ART

from --- E.C to --- E.C.

-------------------------------------------------------

VI

---------------------19

Table.3. Types of parasitic infection HIV patients who

are taking ART from ---

to-----------------------------------------------------

----------19

Table.4 Duration of treatment for ART on sample

population at Shashamane, ART clinic from ----to_---.

-------------------------------------------------------

--20

Operational Definitions

VII

Co-infection:- An infection by two or more diseases.

Diarrhea: - is loosely defined as passage of abnormally

liquid or unformed stools at an increased frequency and

chronic if ---- weeks in duration.

Illiterate: -Person who were not able to read and write

Literate: -Person who were able to read and write

Immunocopromization: -A state of the body in which some

elements of the immune system either fail to respond or

respond in less optimal manner.

Opportunistic infection: -Is an infection with an

organism such as Bacteria, fungi, and parasites that

does not cause disease in a healthy person, but

threatening illness in the personae of

immunodeficiency.

Cyst: -A stage in the life cycle of certain parasites

during which they are enclosed with in a protective

sac.

Host: -isan organism which harbors the parasite and

gives nutrition and or physical protection for the

parasite.

Specimen:-sample selected for diagnosis, study or

testing

VIII

Abbreviations

AIDS ---- -Acquired immune Defiance Syndrome

ART - Anti Retroviral Treatment

CD4 - Cluster for Differentiation

CNS - Central Nervous System

HTLV - Human Thymus Lymphocyte Virus

IP –Intestinal parasites

SHC-Shashamane Health Center

MOH - Ministry of Health

RPM- Revolution Per Minute

SRP- Student Research Project

STI - Sexually Transmitted Infection

UN - United Nation

IX

UNAIDS- United Nation Program on HIV/AIDS

X

Chapter One

Introduction

Background

HIV/AIDS has become major public health concern in

Africacontinent it

Account for 67%of infection worldwide

(1).Gastrointestinal problem resulting from

opportunistic parasitic infection in HIV and AIDS

infected subjectsoffend present as diarrhea and

significant disease has been recorded in 50-96% of

cases worldwide with 90%prevalance rate reported in

Africa (2).Acquired immunodeficiency syndrome was first

recognized in 1981, in united states of America, in

young homosexual men who had Kaposi Sarcoma and series

infection, predominately pneumocystis carnii pneumonia,

that were unusual in men of this age group with

underlying disease(3).AIDS is caused by retroviral

HIV attacks of CD4 T. lymphocyte’s impact on immunity

and subsequent development of clinical diseases is

directly related a member of circulated CD4

cell .infection in AIDS patients are often severe,

1

persistent and relapsing soon after appropriate

treatment is terminated. Opportunistic infection in

AIDS generally results from reactivation rather than

from primary infection (3). The etiologic agent (HIV)

for AIDS replicates in T. Lymphocytes carrying the CD4

molecules also is the receptor for the virus

glycoprotein in attachment. All CD4 cell, types,

including peripheral blood macro phages, skin

lagerphones cells and brain microvillus cells are

susceptible to HIV infection (4).Full blown AIDS

manifest itself by infection with opportunistic

organisms such as parasites, fungi and bacteria (4) The

definition of AIDS is currently based on the presence

of antibody to HIV, a reduction of CD4 T. cell level to

less than 500/µL3 (5).

HIV patientsymptoms (weight loss and diarrhea for more

than one month) and occurrence of Kaposi sarcoma or

specific opportunistic disease, especially pneumocytic

carnii pneumonia. Indication of an HIV can be obtained

from analysis of T Lymphocytes (normally CD4: CD8 cell

ratio >1.5), which are abnormally low in HIV infected

individuals. The stages of AIDS disease is defined by2

the concentration of CD4 Lymphocytes (5).HIV virus

appeared to have been introduced to Ethiopian in 1984

G.C or the year before at time when AIDS had already

assumed epidemic proportions in other sub- Saharan

African countries the first two HIV Sero – Positive

individuals were detected in 1984 while testing a

collection of sera from 167 hospital patients in A.A.

(6).

Intestinal parasites infection play an important role

in the progression of HIV infection, by further

disturbing the immune system while it is already

engaged in the fight against HIV(7) The

gastrointestinal pathology associated with HIV

infection comprises significant enteropathy with

increasing level of inflammation and decreased level of

mucosa repair and regeneration (7) Intestinal

helminthes induce immunological alteration that favors

the progression form HIV Sero – conversion to AIDS. HIV

viral load was significantly higher in individual with

various helminthes infection than in individual without

helminthes and correlated positively with parasitic

load. Furthermore there is viral load decrease after

elimination of the parasite by antipatriotic treatment3

(8).

The prevalence of intestinal pathogens among HIV

infected individuals has dramatically decreased in

countries where antiretroviral agents are widely

available. However, in most African countries, where

patients have access to ART, intestinal pathogens still

represent a frequent cause of diarrhea, wasting and

weight loss. (9)Prevalence rate of intestinal pathogen

including opportunistic protozoa in Africa vary form

study to study depending on the diagnostic technique

used and the study population (10).

Among those opportunistic pathogens, I belle, C.

parvum, C. cayetanenis and microsporodia species being

increasingly reported as causes of enteritis and as

opportunistic pathogen in immune compromised

individuals.(11)This study will be tried to determine

the magnitude of opportunistic IP among HIV /AIDS

patient who are taking ART drug. The study will help to

increase the awareness of health professionals about

the association of opportunistic parasitic infection in

HIV/AIDS patients who are taking ART.

4

1.2. Statement of the problemWorldwide HIV/AIDS has created enormous challenges on

survival of mankind, sincerecognitions of virus;it has

infected closes to 65million individuals and killed

over25 million people worldwide(12). The Sub Saharan5

Africa is the most part of the world where more than

two third of all people are living with HIV AIDS

(13).According to MOH report approximately 3.2. Million

Ethiopians are living with HIV/AIDS through the UNAIDS

estimated a totals of 2.1. Millions of the ends of

adulate6.4 present. (3).Tghediscovered of aid high

prevalence of gastro intestinal alteration has been

reported especially diarrhea associated with

parasite .these became more evident when the appearance

of syndrome Slimdiseas charter zed by intestinal weight

lose by chronic diarrhea prolonged fever and diffuse

musical weakens observed in Africa especially

Uganda .among case of diarrhea in developed country

parasitic organ are prominent in patients with aid is

infected by c.parvim label and microspores species

constitute major cause of disease offer responsible

for worsening the general health condition

manifestation of diarrhea which are difficult to

control resulting in death of patient (14).

The parasitic infections are mainly due to unsanitary

conditions. Several species of protozoa have been

associated with acute and chronic diarrhea in HIV6

Patients. This includes C. parvum, I. belli

Microsporadia species, G. Lamblia, E. histolytic/E.

diaper cyclosporine species, Blastocytosis homins,

Dientameba speciesetc. (11). Ethiopia is one of the

most seriously affected countries in the world. As

would be expected HIV/AIDS is more wide spread in urban

rather than rural areas. Urban HIV prevalence rates

continue to be high 13.1% with HIV prevalence rates for

rural areas remains relatively low as 3.7 %

( 15).distribution of this ratio leads to increase

susceptibility to infection with pathogen such as

mycobacterium tuberculosis and opportunistic parasitic

infection mainly caused by isopoda belli, crypto

sporadium parvum and strogyloides strecoralis.(16)

Study conduct west Ethiopia 2002 to determined

prevalence of intestinalparasite infection in HIV/AIDS

in JUSH at 78 patient 45(52.8) are infected one or more

type of intestinal parasite .the parasite detected

among HIV/AIDS Patient including A.lmbercoid

30%,T.trichres10%, E.histoletic(6.4%)S.steroclorid

(5.4%)and Tina(1.3%) among HIV patient (17).In

addition to opportunistic infection parasite infections

are still an important problem in HIV infected patients7

at any immunity level with or without symptom of

diarrhea. (18)With the present wide distribution of

HAART, the prevalence of opportunistic intestinal

protozoan infection However is expected to decrease

adequate treatment, proper health education and good

personal hygiene will help introducing intestinal

parasitic infection. However, a proper monitor in and

evaluation of the case from time to time is required to

assess all the preventive and rehabilitative schemes

and delivering the expected activity and thinking to

achieve the desired goal and hence such an up to date

follow up study is required (19).

Even if most studies on HIV/AIDS positive and negative

individuals carried out to determine prevalence of

parasitic infection, this study will be tried to

address the magnitude of parasitic infection on

patients taking ART at Shashamane health center.

8

1.3. Significance of the study

As it is indicated in the statement of the problem, the

severity and magnitude of intestinal parasites in HIV/

AIDS patients require attention and study, especially

in the countries like Ethiopia and other developing

countries where there is high HIV/AIDS and parasite

prevalence.

Chronic immune activation by parasitic infection could

be one of the several causes of T. cell depletion in

HIV infection and could considerably contribute to the

progression of HIV disease. Therefore studies in such

problems are highly significant. So this study will

tried to provide a base line data on the prevalence of

opportunistic intestinal parasites in HIV/AIDS

infected patients who are taking ART. It also provides

a clue or other researchers to more on the effect of

ART on opportunistic intestinal parasites infection of

the patent.

9

Chapter Two

Literature ReviewGastrointestinal involvement in HIV/AIDS is almost

Universal and disease occurs in 50- 96% of patients.

Diarrhea can be of presenting manifestation or a life

threatening complication of infection with HIV

sometimes during course of the disease. Infections

causes of diarrhea have been found in 30-80% of

patients depending on the extent of the study and

patients characteristic. (20)Intestinal parasite

infections are one of the major health problems among

HIV infected patients. The intestinal helminthes

infestation in HIV infected patient is common.

Intestinal protozoa infections are also important

10

problems for HIV infected patients. Some infections are

ordinary, while the other is opportunistic infection.

The most important opportunistic intestinal parasites

include c.paoryum. I.belli, cyclosporine and

microsporadial .especially in low immune case diarrhea

and diagnosed based on stool examination with special

stain. The treatment of the opportunistic infection can

wholly get control of present illness, but not prevent

the reinfection. Luckily, with the present of wide

distribution of HAART the prevalence of the

opportunistic parasitic infection is significantly

decreased (21). In a study carried in Thailand the

prevalence of IP among the HIV infected patients is

about 50%, H. worm, A. lumbricoid appeared to have the

highest prevalence (13.33%) and I. belli (5%), S.

stercoralis (3.33%, C. parvum (3.33%) and

Microsporidium (1.67%). The prevalence of Intestinal

Parasites was significantly higher in patients with

diarrhea. (18)

In a study done in south India, the prevalence of IP11

was C. parvum (28.7%), E. histolytic/despair (17.5%),

B. coli (20-%), A. lumbericoid (7.5%), H. nana (1.2%),

G. Lembilia (2.7%) and I belli (1.2%) in HIV/AIDS

patients with diarrhea. Protozoa accounted for the

majority of diarrhea case Endameba species (17.5%) and

C. parvum (28.7%). (22)Similar study conducted in HIV

infected adults in Cameroon, IP were found 33% of the

patient studied. Helminthes were identified in 12.3% of

patients, of whom 26.3% had S. stercoralis Larvae. Non-

opportunistic protozoa mainly non- pathogenic amoeba

were identified in 18% of patients. 4.5% of patients

had E. histolytic /despair and 29% patients had

diarrhea. Opportunistic protozoa were found in 3.9% of

patient, half of them had diarrhea and 1. 9% patients

had I. belli. (10)

A study carried out to determine the parasitic profile

on Ethiopia HIV positive patients shows that the

incidence of intestinal parasitic infection like A.

lumbericoid, E. histolytic/despair, G. Lambilia, T.

Stagnate, was higher in HIV positive. (23)

Study on intestinal parasites in Hawassa referral

hospital, the prevalence of any intestinal parasitic

infection was significantly higher among HIV positive12

participants.sepecifical rate of infection with

Cryptosporidium, I.belli ,and S.stercorasis less than

200cell,Diarrhea was more frequently seen at lower

CD4Tcell counts (24) .In similar study conducted in

Jimma hospital among HIV/AIDS infected patients, the

parasites detected were A. lemricoid (30.8%),

blastocyst is species (14.1%), E histolytic/despair

(10.3%). T. Trichina (6.4%), S. stercoralis (5.1%), G.

lembilia (3.8%) and multiple infections were common

among HIV /AIDS infected patients. (24)

Chapter Three

Objective

3.1. General objective To determine the prevalence ofopportunistic intestinal

parasite in HIV /AIDS infected patients who are taking

ART at Shashamane Health Center

3.2. Specific objective 1 To determine prevalence intestinal parasites in

HIV infected patients on ART

2 To examine the association between opportunistic of

and HIV/AIDS in patients taking ART.13

3 To discuss the result and to forward possible

recommendation to the concerned body.

Chapter Four

Methodology

4.1. Study area The study will be conducted in Shashamane Health Center is ------ km away from AddisAbaba in ------ of Ethiopia .The town has an altitude of about -----m above sea

level with temperature ranges from ----to---its annual

rainfall is ---to----mL. According to the data obtained

from Shashamane town , the total population is 14

estimated of 120,000 according the date reported in

2007E.C.

4.2. Study design A cross- sectional study will be conducted on HIV/ AIDS

patients who are taking ART at SHC

4.3. Study period The study will be conducted from 29/03/2014—19/04/2014

4.4. Population

4.4.1. Source of Population All HIV/AIDS positive patient who will be diagnosed

at Shashamane Health Center.

4.4.2. Study Population

15

HIV/AIDS infected patient who are taking ART at Shashamane Health Center

4.5. Sampling technique and sample size

4.5.1. Sampling technique A convenience sampling technique will be employed on

HIV/AIDS patients who come for ART during study

period.

4.5.2. Sample size Sample size mainly depends on the number of HIV

infected patients who comes for ART with in the study

period. Sample size population was selected according to

standard formula for sample size determination

calculated as follow

N=(z/2)2p(1-p)1(1.96) 2 0.488 (1-0.488) =380

d2 (0.05)2

z=standard normal value

p=estimated the prevalence’s rate for population16

d=margins of sample error tolerated

Hence Z=1.96 andPere valance in study area(p) =44.8%

The total population sample size is

---------------------380

4.6. Study variables

4.6.1. Dependent Variables 1 opportunistic Intestinal Parasitic infection

taking ART drug

2 Presence or absence of diarrhea

4.6.2 Independent Variables

- Age - Educational status

-Latrine usage Habit of hand washing

before meal

- Sex - Water source

17

4.7. Materials and Reagent

4.7.1. Materials - Pen - Applicator stick- Pencil - Tissue paper - Disposable glove - Microscope - Specimen container - Diamond pencils - Test tube /conical - Gauze- Centrifuge /electrical - Drying rack

- Pasture pipette - Staining rack - Microscopic slide - Washing reagent/bottle - Cover slide - forceps - Filter paper - soaps

4.7.2. Reagent - 0.85% Normal saline

- Methanol

- Carboulfuschin 18

- 1% Acid Alcohol

4.8. Ethical consideration Ethical issues will be considered in all stages of

research process and the most crucial issues are as

follows:-

Letter of permission will be obtained from the

university to the concerned bodies to inform

the objectives.

The purpose of the study will be briefly

explained to the patient or relatives with

patients.

Method of specimen collection will not be

invasive.

Some body that will not be willing to respond

information about him/her will not be

obligated.

Information obtained in course investigation

will be kept confidentially:-

19

4.9. Data collection process First the patients will be informed about the

objectives of the study.

all the volunteers will be filled the

questionnaires

the patients will be provided with appropriate

specimen container and applicator sticks to

brings sufficient amount of stool specimen.

Then the stool will be examined macroscopically

before and microscopically after concentration,

staining with Modified Zehil- Neelsen staining

techniques or wet mount preparation for detection

of different stage of parasite.

4.10 Data processing and analysis The completeness of all information on the

questioners will be checked.

The data of each patients will be tallied on tally

sheet

The result will be summarized and inserted into

dummy tables

The result will be analyzed using scientific20

calculator and computer, and considering

association between dependent and independent

variables will be done by using chi-square test.

CHAPTER 5

WORK PLAN

21

Topic

perform

ed

Responsib

le

individua

l

Sep Oct No

v

De

c

Jan Feb Mar Apr May Jun

Topic

selectio

n

PI

Proposal

writhing

and

submissi

on

PI

Feedback

from

adviser

PI

Collecti

on

necessar

y

material

PI

Date

collecti

PI

22

onAnalysis

date

PI

Submissi

on to

report

PI

Feedback

from

adviser PI

Collecti

on and

final

submissi

on

PI

Final

defiance

PI- principle of investiga

23

Chapter SIX

6. Budget plan

6.1. Budget proposal

Sr.No

List of Items UNIT Sub total Total birr

Birr Cent Birr

Cent

1 Disposable gloves of 50 pair

4 box 35 00 140 00

2 Pasture pipette 2 Box 50 00 100 00

3 Microscopic slide of 50 pcs

4 Box 80 00 124 00

4 Cover slide of 100 pcs 2 Box 30 00 60 005 Normal saline (0.85%)

X 1000ml 1 Bott

le16 00 32 00

24

6 Gauze X 12 pcs 1 Roll 13 00 13 008 Methanol of 500 ml 1 Bott

le 29 00 29 00

Carboul- fuchsin of 500ml

1 Bottle

43 00 43

9 Acid alcohol (3%) of 500ml

1 Bottle

50 00 50 00

10 Methylene blue 1 Bottle

25 00 25 00

Subtotal 655 00II Disinfectant and

cleaner 2 Soaps 2 Each 5 00 10 003 Bleach (5%) of 500ml 1 Bott

le 20 00 20 00

Subtotal 43 00III Stationary materials 1 Pen 2 Each 2 00 4 002 Pencil 2 Each 0 50 1 003 Duplicating paper 1 Pack 78 00 100 00

Unit Unit

price

Tota

l

25

pric

e Bir

r

Cent Birr Cent

4 Secretaria

l work

1 Each ---

-

--- --- ----

5 Microscopi

c

1 Each -- --- ----

-

----

----Sub total - - 582 00Total - - 922 00

IV Contingenc

y (10%)

- - 139 30

Grand

total

- - 1641 30

6.2. Budget justification For this study a total of 1641.30 birr will be needed

with 10% contingency. The listed materials, reagents

disinfectants and stationary materials are basic to

conduct the study.

The time given to collect data is for two weekdays and

this helps to get the needed sample size.

26

Chapter Seven

Dummy TablesTable. 1:- Sex and age distribution of study population

at SHC,---to---E.C

Age in year SexMale Female No (%) No (%) No (%)

1-5 6-1415 – 6465+

Total

Table. 2:- Appearance of stool among HIV infected

patients, who are taking, SHC from ---to----27

Consistency of

stool

Positive Negative Number

percent

Number

PercentFormed Loose Diarrhea Watery Total

Table. 3:- Types of parasitic infection HIV patients who are taking ART at SHCfrom ---to----S. No Types of Parasite Frequency Percent

1 Non-opportunistic 2 Opportunistic 3 BothTotal

28

Table. 4:- Duration of treatment for ART on sample

population at SHC from –to--

S.

No

Duration of ART Frequency Percent

1 1-6 month 2 7- 12 month 3 > - year Total

Reference1 NASCOP (national AIDS and STI control

program),Ministry of health, Kenya.2008;keny AIDS

indicator survey 2007:preliminary Report.Nairobi,Kenya.

2OguntibejuOO.prevalance of intestinal parasites in HIV

–positive /AIDS patients in south Africa. Malaysian J

of Med Sciences.2006;13(1):68-73.thise articles on

PubMed.

3.Nelson, M. Gantz.Manual of clinical problems ininfectious disease. /Nelson [etal] -3 rd ed. 1998; 435-

29

437 and 440-442

4.Assefa. D. etal. Medical microbiology and immunology

lecture not series. Jimma University 1st ed. 2006. - 136

-147 and 210 -121

5. Medical Microbiology. 4th ed. Lowa city: Elselvir

Mosby; 2002. 694 – 696.

6.Federal Democratic republic of Ethiopia. Central

statistical authority. A.A statistical abstract, A.A,

2004. Available at http; //www. Global health

reporting/tb. asp.

7.Douek D C andBrenchly J M.HIV infection and the gastrointestinal immune system.Mucosal immunol.2008 1(1):23-30.8. H/Mariyam, G. etal intestinal parasitic in HIV /AIDS

and sero- negative individuals. Jimma University

teaching hospital Ethiopia. JPN. J. Infect DIS. 57 (1).

9. Awol Adam, M. etal. Medical parasitological UP-

graded lecture note series. 2nd ed. Jimma University.

2006; . 25-30 and 190 -191

10.CLAUDINE Sarfati, C. etal. Prevalence of intestinal

Parasites including mirosporidia in HIV infected

adults, Cameroon. Amir Trop. Med. Hys. 2006; 74 (1):

30

.162- 164.Available at

http://www.ajtmh.org/cgi/reprint(74).P.162.Pdf

(Abstract).

11.Mohammed A., M. Soul. etal. Prevalence of intestinal

parasites in HIV infected adult patients in the west

Ethiopia . Ethiopia J. Health. Dec. 2003; . 71-74

12.WHO.ARV treatment working group scaling ART inresores limited staffing, guildlines for publichealthapproach 2002;who publication (15B924/545074).

13. Disease prevention and control program. AIDS in

Ethiopia. 5th ed. Report June 2004.

14. Abaza S. makhlout M.sheary E. kael M. intestinal

opportunistic parasite among different group of

immune compromised hosts .sue canal university,

Ismailia Egypt. 1995,25(3);713-227.

15.USAIDS reported on global AIDS epidemic July

2007,pp,16.

16.Markos E,Woku A,Davey G.adherances to ART in PLW HAat Yirgalem Hospital South Ethiopian 23(3),2008.

17.Halimariam ,Getal,prevalance of intestinal parasitesinfection in HIV/AIDS and HIV sero negative individualteaching hospital Ethiopia JPN,dise 57,41-43,2002.at

31

htt:www.nail90p/SSID /17/41

18.Viro. J.W. prevalence of intestinal parasites in HIV

infected patients with different immunity status in

Thailand. J. Med. Assec. Thai: 2001 June ; available

at http;//www.pub.

19Kava Mohandas rakesh sehgal. Prevalence of intestinal

parasite pathogens in HIV seropositive individual in

Northern India JPN.J infect Dis 55,83- 84.2002.

20. Countries, Trans. R. Soc. Trop. Med. Hyg; 1990,,1-

6

21Wiwanitivet V, intestinal parasite among HIV infected

patient’s cur HIV Res, 2006 Jan 4(1):87-96.

22.Remakishen, K.J.etal. Prevalence of intestinal

32

parasite infection in HIV/AIDS patients with

diarrhea. Muhaderi, south India; JPN. J.DIS: 2007; .

209-201, Available at http://www.nih

80.JP/5510/60/209.pdf(abstract)

23 H/Michael, T. etal. Increased incidence of

Intestinal parasitic infection in HIV positive when

compared with negative individual. Eth. Med.

1999;1999:. 124

24 H/Mariyam, G. etal intestinal parasitic in HIV /AIDS

and sero- negative individuals.Jimma University

teaching hospital Ethiopia.JPN. J. Infect DIS. Vol. 57

(1).

33

Appendix -1QUSTIONARY

Department of medical laboratory science and pathology.

Questioner for determination of intestinal parasites

among HIV/AIDS patients who are taking Ante Retroviral

Treatment

1.Patient identification Age ________________________

Sex ________________________ code

NO______

2. Back ground information

2.1Occupation, employed,

1 Government Privates Other

/specify______________

2.Student

3. Farmer

4.House wife

5. Merchant

6. Driver

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7. Sex worker

8Other /specify _____________

2.2 Educational status 1 Illiterate 2 Read and write only 1-4 grades

5-8 grades

9-12 grades

>12 grade

2.3. Marital status

Single Married Divorced Widowed 3. Predisposing factors for intestinal parasites

1 Habit of hand washing before meal Yes No

2 Shoe wearing habit Yes No 3 Habit of using latrine Yes No

4. Source of water supply for drink- Pipe water - Well - Spring - Stream - River - Public stand point

5.For how long does the patient take ART? (i). 1-6 month (ii). 7 -12 month

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(iii). >1 year 6.Weather the patient have diarrhea Yes No 7. If yes, how long? (i). < one month

(ii). > one month8. Did she/he take the treatment for diarrhea?Yes------- no---------

Procedures

Specimen collection

1.Leak proof wide mouth specimen container will begiven to patient with applicator stick. 2.Brief explanation will be given to patient about type

and amount of specimen. 3.Labeling specimen with patient code No.4.The specimen will be examined microscopically and

macroscopically after sample collection. A.Direct microscopy

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5. Match head size Stool of patient will be mixes withnormal saline or ilodine (lugol solution) on theslideandcover with cover slide.

6. Examine systematical for the entire preparation forlarvae, ciliates, helminthes, ova, cysts, trophozoites,oocysts and sometimes for adults worm macroscopically.

1 Use 10x objectives with the condenser irisdiagram are closed sufficiently.

2 Always exam several microscopic fields beforereport says No O/P seen”

B. Modified Zehil – Nelson staining technique. 1.Prepare smear from the above concentration technique.2. Air dry the smear and fix with Methanol for 2-3minutes. 3.Stain with unheated carboul – fuchsine for 15 minute

and wash with tape water.

4.Decolorize with 1% acid alcohol for 10-15 minute andwash with tape water.

5.Counter stain with 0.5% malachite green/ Methyleneblue / for 30 seconds and air dry on drying rack

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6.Examine microscopically for Oocyst- Using lower objective to detect the Oocyst- Using oil immersion objective to identify

them.

Appendix- 2

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Shashamane Health Center request format forstool examination

Age _______________ Sex ______________ code No.______________1.Macroscopic examination

1.1.Presence of adult worms ________________________1.2.Consistency of stool

a. Formed b. Loosen c. Diarrhea d. Dysentery e. Other specify__________________________

1.3. Color a. Brown b. Choky white c. Other specify________________

2.Microscopic examination 2.1.Wet-mount by Normal saline

Result ______________ 2.2. Modified Ziehil-Nelson (ZN) stainingtechnique. Result ________

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