I

Joint MPH program

Hawassa University and Addis Continental Institute of Public

Health

Prevalence of Malnutrition and Its Associated Factors in

Adult People Living With HIV/AIDS, In Hawassa Health

Institutes, SNNPR, Ethiopia

By:

Sisay Tadesse ( Bsc Nurse)

A thesis Submitted to:

Hawassa University College of Medicines and Health Science School

of Public Health and Environmental Health in Partial Fulfillment of

the requirement for degree in Master of Public Health.

September , 2014

Hawassa, Ethiopia

II

Joint Mph Program

Hawassa University and Addis Continental Institute of Public

Health

Prevalence of Malnutrition and Its Associated Factors in

Adult People Living With HIV/AIDS, In Hawassa Health

Institutes, SNNPR, Ethiopia

By:

Sisay Tadesse (Bsc Nurse)

Advisor: Achamyelesh G/Tsadik (Mph, PhD fellow)

September , 2014

Hawassa, Ethiopia

III

COLLEGE OF MEDICINE AND HEALTH SCIENCE SCHOOL OF PUBLIC HEALTH AND

ENVIRONMENTAL HEALTH GRADUATE PROGRAM

Approval of the Thesis by the advisor (s)

This is to certify that the thesis entitled “Prevalence of malnutrition and its associated factors in

adult people living with HIV/AIDS, in Hawassa health institutes, SNNPR, Ethiopia” submitted

in partial fulfillment for the requirement of master degree in public health, to the school of public

and environmental health, college of medicines and health science, is a record of original research

carried out by Sisay Tadesse Bekele, ID.No PGH/131/04 under my supervision and no part of the

thesis has been submitted for any degree or diploma.

The assistance and help received during the course of this investigation have been duly

acknowledged. Therefore, I recommended that the thesis be accepted as fulfilling the requirement.

Approved by:

_______________________ __________ ______________

Name of primary Advisor Signature Date

________________________ __________ ______________

Name of Co-advisor Signature Date

IV

HAWASSA UNIVERSITY COLLEGE OF MEDICINE AND HEALTH SCIENCE

SCHOOL OF GRADUATE STUDIES FINAL THESIS APPROVAL FORM

As a member of the board of examiners of the final MPH open defense, we certify that we have

read and evaluated the thesis prepared by Sisay Tadesse, under the title of “Prevalence of

malnutrition and its associated factors in adult people living with HIV/AIDS, in Hawassa health

institutes, SNNPR, Ethiopia”, and examiner the candidate. This is therefore, to certify that the

thesis has been accepted in partial fulfillment of the requirement for the degree of Master of public

health.

___________________ _____________ _______________

Name of the chairperson Signature Date

Achamyelesh G/Tsadik ______________ ______________

Name of Primary advisor Signature Date

__________________ ________________ _______________

Name of Internal examiner Signature Date

___________________________ ________________ _______________

Name of External Examiner Signature Date

V

Acknowledgements

First of all I am indebted to thank my very grateful Advisor Achamyelesh G/Tsadik (MPH, PhD

Fellow). The advice, encouragement and guidance she gave me was so helpful and valuable.

Starting from writing this thesis proposal throughout the whole thesis work, her knowledge and

many years of experience has been the light of my way. To study public health was my all night

dream and I am also grateful to thanks Hawassa University and Addis continental institute of public

health for making my dream real.

My appreciation also extends to Hawassa City Health office for providing me the necessary

information and facilitating conditions, while I was carrying out this study. I also thank Mr.

Sintayehu Assefa for his help during the fieldwork and the rest of my friends who devoted their

precious time helping me in every aspects of my work. I would also like to thank all the

interviewers (data collectors) for their unreserved commitment and careful field work. Data clerks

and nurses at Hawassa referral hospital, Adare hospital and Bushilo Health center ART unit deserve

my great acknowledgment. My gratitude goes to all of the study participants for their willingness

and participation in the interview. Special thanks also go to my wife Sr. Meaza Samuel for sharing

me her valuable ideas and support.

VI

TABLE OF CONTENTS

Contents

Acknowledgements ........................................................................................................................ V

TABLE OF CONTENTS ..................................................................................................................... VI

LIST OF TABLES ............................................................................................................................ VIII

LIST OF FIGURES ....................................................................................................................... IX

LIST OF APPENDEX .................................................................................................................... X

Acronyms ...................................................................................................................................... XI

Abstract .......................................................................................................................................... 1

1. Introduction ............................................................................................................................ 2

1.1. Statement of the problem ..................................................................................................... 2

1.2. Rationale of the study............................................................................................................... 3

2. Literature review ..................................................................................................................... 5

2.1. Food and nutrition security ................................................................................................. 5

2.2. HIV/AIDS and malnutrition .................................................................................................. 5

2.3. Nutrition and HIV/AIDS ....................................................................................................... 8

2.4. Nutrition and ART ................................................................................................................ 8

3. Objective .............................................................................................................................. 11

3.1. General Objective.............................................................................................................. 11

3.2. Specific Objective ............................................................................................................. 11

4. Methodology ......................................................................................................................... 12

4.1. Study setting ..................................................................................................................... 12

4.2. Study design ...................................................................................................................... 12

4.3. Study period: ..................................................................................................................... 12

4.4. Source population.............................................................................................................. 12

4.5. Study Population ............................................................................................................... 12

4.6. Inclusion and exclusion criteria ......................................................................................... 12

4.7. Sample size ....................................................................................................................... 13

VII

4.8. Sampling procedure ........................................................................................................... 15

4.9. Data collection procedure .................................................................................................. 17

4.10. Variable ........................................................................................................................ 18

4.9. Operation definition .......................................................................................................... 19

4.10. Data management .......................................................................................................... 19

4.11. Data analysis procedure ................................................................................................. 20

4.12. Ethical consideration ..................................................................................................... 21

5. Result.................................................................................................................................... 22

5.1. Socio-demographic characteristics Respondents ..................................................................... 22

5.3. Nutritional and food security status of patients’ On-ART and Pre-ART .................................. 27

5.4. Association between risk factors and Under Nutrition and over nutrition among adult PLWHA.29

5.4.1. Association factors between risk factors and under nutrition among adult PLWHA.............. 29

5.4.2. Association factors between risk factors and over nutrition among adult PLWHA ............... 32

6. Discussion............................................................................................................................. 35

7. Strength and weakness of the study ....................................................................................... 38

7.1. Strength of the study .............................................................................................................. 38

7.2. Limitation of the study ........................................................................................................... 38

8. Conclusion ............................................................................................................................ 39

9. Recommendation .................................................................................................................. 40

10. Reference .......................................................................................................................... 41

ANNEXES: .................................................................................................................................. 46

VIII

LIST OF TABLES

Page

Table 1. Socio-Demographic Characteristics of PLWHAs in Hawassa health facilities, Hawassa,

SNNPRS, Ethiopia, 2014………………………………………………………………………….23

Table 2. Health and clinical characteristics of HIV/AIDS clients in pre-ART and on ART care in

Hawassa Health facilities, Hawassa, SNNPR, 2014……………………………………………..26

Table 3. Nutrition and food security status of HIV/AIDS clients in pre-ART and on ART care in

Hawassa Health facilities, Hawassa, SNNPR, 2014………………………………………………28

Table- 4.Associated risk factors for under nutrition in HIV/AIDS clients in pre-ART and on ART

care in Hawassa Health facilities, Hawassa, SNNPR, 2014……………………………………….30

Table 5. Associated risk factors for over nutrition in HIV/AIDS clients in pre-ART and on ART

care in Hawassa health facilities, Hawassa, Ethiopia……………………………………………....33

IX

LIST OF FIGURES

Page

Figur 1. Vicious cycle of HIV and malnutrition (Source: FMOH, National Guidelines for

HIV/AIDS and Nutrition)……………………………………………………………………….6

Figure 2. conceptual framework of malnutrition among Pre-ART and On-ART patients……...10

Figure 3. Thematic presentation of participant selection or sampling procedure ………………16

X

LIST OF APPENDEX

Page

Annes I. English version questionnaire ………………………………………………………..47

Annex II: Guideline for anthropometric measurement…………………………………………53

Annex III. Amharic questionnaire ………………………………………………………………55

Annex IV. Hawassa City Maps ………………………………………………………………...62

XI

Acronyms

AIDS: Acquired Immune Deficiency Syndrome

AOR: Adjusted Odds Ration

ART: Anti Retro Viral Therapy

BMI: Body Mass Index

BWL: Body weight loss

CD4 cell: T-lymphocyte bearing CD4 receptor

CI: Confidence Interval

COR: Crude Odds ratio

EDHS: Ethiopia Demographic Health and Survey

FAO: Food for Agriculture Organization

HAART: Highly Active Anti Retro Viral Therapy

HIV: Human Immune deficiency Virus

Kg: Kilo gram

MAM: Moderate Acute Malnutrition

MDG: millennium Development Goals

MOH: Ministry of Health

M2: Meter square

OIs: Opportunistic infections

PLWHA: People Living With HIV/AIDS

SAM: Severe Acute Malnutrition

SNNP: Southern Nation Nationality people

TB: Tuberculosis

WHO: World Health Organization

1

Abstract

Background: HumanImmunodeficiencyVirus/AcquiredImmuno Deficiency Syndrome(HIV/AIDS)

and malnutrition effects are interrelated and exacerbate one another in a vicious cycle. Nutrition

insecurity is a serious problem of People Living with Human Immunodeficiency Virus (PLWHA)

and it is a silent factor that delays treatment outcomes. Currently due to the advent of antiretroviral

drug therapy and subsequent improved life expectancy, HIV has become a chronic disease. Long-

term complications related to diet, overweight, and obesity has gained a new importance. This

study will find new and additional facts on HIV/AIDS and Malnutrition through assess prevalence

of malnutrition and its associated factors among adult PLWHA in Hawassa health facilities.

Objectives: To assess the prevalence of malnutrition (over & under nutrition) & its associated

factor among adult PLWHA in Hawassa city health facilities, Hawassa, Southern Ethiopia

Methods: Facility based cross sectional study design was used to all ART clinics in Hawassa city,

from February 2014 to April 15, 2014. Systematic sampling method was used to get the study

subjects and the sample size was 719. A structured pre-tested questionnaire was used to collect

data. Descriptive statistics, Bivariate and multivariate logistic regression were used for data

analysis.

Result: A total of 715 study participants were interviewed; of them 16.6% were chronic energy

deficiency (BMI <18.5Kg/m2);15.1% from ART and 18.7% from Pre-ART care and 14.1% were

overweight and obese. The proportion of mild, Moderate and sever malnourished of the study

participants were 68.9%, 16% and 15.9% respectively. Nutritional support (AOR=2.353, 95%CI

(1.305, 4.242)) and greater than 10% Body Weight Loss (BWL) (AOR=3.967 , 95% CI (1.682,

9.358)) were significantly associated with under nutrition for ART and Pre-ART Clients. CD4

count less than 200 (AOR= 0.264, 95% CI (0.082,0.85); nutritional support ( AOR=0.164 , 95%CI

(0.039,0.694), Daily eating pattern of the last six month [AOR=0.183, 95% CI (0.042, 0.796)],

Eating difficulties [AOR= 0.488, 95% CI (0.26, 0.914)] and age between 30-39 [AOR= 5.273,

95% CI (2.291, 12.138)] and 40-49 [AOR=2.938 , 95% CI (1.437, 6.006) were significantly

associated with Over nutrition for both ART and Pre-ART clients.

Conclusion: In this study the prevalence of Malnutriton is lower than most of the study conducted

before. Nutritional support and body weight loss percentage of >10% were predictor of under

nutrition. CD4 count less than 200cell/mm3, getting nutritional support, Daily eating pattern of the

last six month, eating difficulties and age were predictor of over nutrition. The Nutritional

counseling should be strengthen and focus on the prevention of both types of malnutrition .

2

1. Introduction

1.1. Statement of the problem

Nutrition is a critical determinant of immune responses and malnutrition is the most common cause

of immune-deficiency worldwide(1). Human Immunodeficiency Virus/Acquire Immune Deficiency

Syndrome (HIV/AIDS) is associated with biological and social factors that affect the individual’s

ability to consume and utilize food and to acquire food. These biological and social factors lead to

poor nutritional status and weight loss, which is an important cause of morbidity in an individual’s

infected with HIV, resulting in a poor quality of life; weight loss is an important predictor of death

from AIDS (2). In the social context malnutrition aggravates the negative effects of HIV/AIDS on

food and nutrition security (3).

Malnutrition is one of the major complications of HIV infection and adding a fuel to the fire by

accelerating the progress of HIV infection to AIDS (4, 5, 6, and 7). The effect of malnutrition along

with HIV/AIDS patients are weakens the immune system and ability to fight the infection,

decreases CD4 count leads to appearance of Opportunities Infections (OIs), the appearance of OIs

leads to increase viral replication and further damage to the immune system, delays/weakens

reaction to infections and it also associated a patients with poor treatment outcome (7, 8, 9, 10, 11).

Even in the current era of highly active antiretroviral therapy (HAART), weight loss and muscle

wasting remain significant clinical problems (12). HIV/AIDS Patient with SAM are 4 to 5 times

more likely to die and with MAM are 2 to 3 times more likely to die within the first 90 days after

starting ART (11).

Barely two decades ago, had HIV disease deemed a terminal illness accompanied by severe

wasting. Today, HIV disease has become a chronic illness, largely due to the success of highly

active antiretroviral therapy (ART). In the U.S., this increased longevity has naturally led to HIV-

infected persons becoming increasingly overweight and obese, with rates of weight excess similar

to that of the general population. Weight excess in the general and HIV-infected populations is

associated with adverse medical conditions, such as hypertension, dyslipidemia and diabetes

mellitus (13).

HIV/AIDS and malnutrition effects are interrelated and exacerbate one another in a vicious cycle

(9, 11, and 12). HIV infection may result under nutrition as a result of increasing energy

requirements, insufficient dietary intake, frequent diarrhea and vomiting, OIs, malabsorption, and

altered metabolism (4, 7, 9, 10, and 11). HIV-infected adults have greater energy needs than

uninfected adults (10). The energy needs depend on whether the PLWHA is symptomatic or

asymptomatic. When the patients is asymptomatic (WHO stage 1), HIV-positive adults need to

3

increase energy intake by 10 percent. In the presence of symptoms (WHO stage 2 and above), HIV-

positive adults need to increase energy intake by 20 to 30 percent (4, 7, 10, 11, 15, 21).

Obesity is a major long-term concern in human immunodeficiency virus (HIV)-positive (HIV+)

persons given their increased cardiovascular risk , and the pathogenic link of obesity to diabetes

mellitus, cardiovascular disease and all-cause mortality(16.).

Empirical evidences on malnutrition among People Living with HIV/AIDS had shown that socio

demographic factors such as gender, Age, educational status, occupation and monthly income were

closely related determinants of nutritional status. Additionally, gastrointestinal symptom,

Adherence to HAART in past 6 month, CD4 cell count, Eating difficulty, ART status, ART

duration, number of previous opportunistic infections and WHO clinical AIDS stage were reported

to be risk factors for malnutrition among PLWHA(36, 37).

The aim of the study was to discover the prevalence of under nutrition, over nutrition (obesity and

over weight) among adult PLWHA in all reference to ART clinics in Hawassa, SNNPR, Ethiopia.

The study was also designed to predict those factors that have the potential to contribute to the

development of under and over nutrton in PLWHA. This is the first study on Over nutrition

(overweight and Obesity) among PLWHA Hawassa, Ethiopia.

1.2. Rationale of the study

The rate of malnutrition under nutrition among PLWHA is high in different settings and remains to

be the key challenge of to achieve MDG 6 in many countries of the world and worsen the disease

impact and poses significant challenge to HIV care and treatment. In Ethiopia, although not well

documented, and some studies were conducted in different health institutions depict that the rate of

under nutrition among PLWHA on ART and pre-ART is high. Malnutrition is a frequent, marker

for poor prognosis among HIV-infected subjects and it is critical underestimated factors

susceptibility to infection. Different scientific evidence is needed to discover and maintain possible

factors with malnutrition among PLWHA.

There is miniature evidence on the factors associated with over and underweight among PLHWA in

Ethiopian in general and in the study area in particular regarding to the nutritional status of peoples’

living HIV/AIDS in ART and pre-ART follow up.

The study conducted before in the same study area in 2012, only assessed under nutrition among

PLWHA but this study tried to overcome the gaps seen on the previous study by assessing the

prevalence and factors associated with both under and overweight among PLWHA on all ART

clinics (Pre-ART and ART). Inaddtion the studies conducted previously only assessed chronic

4

energy deficiency using BMI but this study determined both acute and chronic malnutrition using

both BWL percentage and BMI.

The findings of this study will be used as additional input to enhance nutritional status of HIV

patients on ART and Pre-ART. It will also improve adherence to and efficacy of ART at local

and/or national levels. Moreover it will be used as reference for other researcher/investigator.

5

2. Literature review

2.1. Food and nutrition security

According to FAO estimates that 870 million people worldwide, the vast majority live in

developing countries, were undernourished in 2010-2012 (17). In Ethiopia, approximately 49% of

the population is without adequate nutrition (11). The EDHS 2011 revealed that the level of under

nutrition among women and men in Ethiopia is relatively high, with 27 %of women and 37% men

either thin or undernourished—that is, having a body mass index (BMI) of less than 18.5 kg/m2.

And on the other hand, 5% overweight and 1% Obese women, 2 % are overweight or obese (BMI

25 kg/m2 or above) in Ethiopia (43). In addition to this, according to two studies in Ethiopia (Dire

Dawa and Jimma) the prevalence of food insecurity among PLWHA on ART were 90% and 63%

respectively (44, 45), which indicates that adults on ART are suffering from malnutrition.

2.2. HIV/AIDS and malnutrition

HIV/AIDS and malnutrition are highly prevalent in many parts of the world, especially in sub-

Saharan Africa (15). The twin global epidemics of HIV infection and food scarcity

disproportionately affect sub-Saharan Africa, and a significant proportion of patients who require

ART are malnourished because of a combination of HIV-associated wasting and inadequate

nutrient intake. Protein-calorie malnutrition, the most common form of adult malnutrition in the

region, is associated with significant morbidity and compounds the immunosuppressive effects of

HIV. A low body mass index (BMI), a sign of advanced malnutrition in adult, is an independent

predictor of early mortality (6 month) after ART initiation in several analyses (23).

Under nutrition and HIV status have negative feedback loops, resulting in severe effects on the

resilience of individuals, households, and communities. Such interactions manifest at both the level

of the HIV-infected individual and the level of the affected household in terms of clinical,

nutritional, quality-of-life, and economic outcomes (18). Malnutrition and HIV have similar

deleterious effects on the immune system (24-26). In both malnutrition and HIV there is reduced

CD4 and CD8 T-lymphocyte numbers (27, 28), delayed cutaneous sensitivity, reduced bactericidal

properties (25, 29).

This synergistic effects of malnutrition and HIV on the immune system occur in a vicious cycle

(Fig. 1) in which decreased immunity associated with both conditions leads to increased

susceptibility to infections (including HIV infection), morbidity, and mortality through OIs, fever,

diarrhea, loss of appetite, nutrient malabsorption and weight loss, that in turn lead to increased

nutrient requirements, which if not adequately met lead to more malnutrition (11, 15, 22, 30, 31).

Malnutrition, specifically wasting, is an important predictor of HIV progression to AIDS (32).

6

Fig 1. Vicious cycle of HIV and malnutrition (Source: FMOH, National Guidelines for HIV/AIDS

and Nutrition)

One of the possible signs of the onset of clinical AIDS is a weight loss of about 6-7 kg for an

average adult. So as evidence indicates that even relatively small losses in weight (5%) are

associated with decreased survival rate (21). When a person is already underweight, a further

weight loss can have serious effects. A healthy and balanced diet, early treatment of infection and

proper nutritional recovery after infection can reduce this weight loss and reduce the impact of

future infection(20).

A cross sectional study conducted in Iranian shows that the prevalence of malnutrition among

HIV/AIDS was 77% (33In Brazil a cross sectional study conducted the overall prevalence

malnutrition among patients with AIDS showed that 43% and severe malnutrition (BMI ,16

kg/m2) was 15% and 35% presented a weight loss greater than 20% and 55% presented a weight

loss greater than 10%(34). Another cross sectional study conducted in China the prevalence of

Malnutrition in hospitalized people living with HIV/AIDS 37.2% (47).

A Meta analysis from 11 sub Sahara African countries indicated that the prevalence of HIV-

related malnutrition among women (HIV-positive women with low body weight) varied widely,

from 0.6% in Lesotho to 16.9% in Burkina Faso and in all 11 countries yielded an overall pooled

prevalence of 10.3% and in the same study in Ethiopia was 13.2 % and in the same study

prevalence malnutrition was higher among women residing in rural areas than among women

residing in urban areas; and lower among women that were professionally employed than

unemployed( 35). Another study conducted in Sub Sahara Africa in 12 country on HIV and

Nutrition among women showed that HIV-positive status becomes significantly positively

associated with being underweight and the prevalence of under nutrition, or BMI below 18.50, is

highest in Ethiopia, at over 25 percent, and is also widespread in Burkina Faso, Niger, and Senegal,

7

where approximately 20 percent of women are underweight (36). Cross sectional study was

conducted in Botswana the prevalence of malnutrition among HIV/AIDS was 28.5% (37).

Institutional based cross sectional research was conducted in Dilla showed that the overall

prevalence of malnutrition among PLWHA was 12.3 % and Unemployment, WHO clinical stage

Four, gastrointestinal symptoms, previous (one) opportunistic infection and two & above previous

opportunistic infections were significantly associated with malnutrition among PLWHA (38).

While 7 % of the male had malnutrition and the proportion among female was 16% (38) and the

same study conducted Bahirdar showed that 25.5% were chronic energy deficiency

(BMI<18.5kg/m2); 36.5% from pre-ART, 63.5% from on ART care (39) and eating difficulty, Pre

ART clients and on ARV drugs < 12months were the predictors associated to malnutrition, besides

Females were most affected (56.7%) (39). Similar study conducted in Gondar referral hospital

showed that the prevalence of malnutrition among PLWHA was 27.8% and Income, duration of

ART in months, presence of eating problems and nutritional support were significantly associated

with malnutrition(40) . A case control study conducted in Northern Ethiopia the prevalence of

malnutrition with BMI < 18.5 Kg/m2 in the ART adherent group were 8% and non-adherent group

was 42.5% which was associated with non-adherence to ART. Inability to get enough and quality

food was also associated with non-adherence to ART (41). Another study conducted in Tigray,

Humera hospital in HIV positive women shows that the prevalence of under nutrition (Body mass

index < 18.5 kg/m2) was 42.3%. Severe, moderate and mild under nutrition was detected on 12%,

10% and 20.3% respondents, respectively. The prevalence of wasting (percentage body weight loss

>5%) was 75% (95% CI: 70.4% - 79.2%). Severe wasting was accounted for 26.9% of respondents

and house hold food insecurity, dietary diversity, anemia and absence of nutritional support were

found to be independent predictors of under-nutrition.(46) similar study conducted in India

(Kolkata)in HIV positive women showed that the prevalence of malnutrition 27.3% (BMI

<18.5kg/m2) (48)

The prevalence of adult malnutrition in sub-Saharan Africa is not easy to estimate and varies with

natural and man-made disasters, but an analysis of multiple demographic and nutrition surveys

anticipated that 10–20% of African women age 20–49 are malnourished (BMI <18.5kg/m2; similar

data for men not available (49).

A cohort study conducted in Swiss showed that the prevalence overweight/obesity was 38% in

2012 among PLWHA and .CD 4 counts, and being black are predicator of overweight/obesity

(51). A cross-sectional study was conducted in the city of São Paulo was showed that the

prevalence of central obesity was 45.7% among HIV/AIDS patients and it was associated with

greater consumption of lipids (52). A retrospective cross-sectional study conducted in Philadelphia

8

revealed that 14 % Obesity and 31 % overweight(53). A cross sectional study conducted in

Porto Alegre, Brazil, showed that 8.3% were obesity and 34.2% were overweight.(54).

2.3. Nutrition and HIV/AIDS

The HIV/AIDS epidemic has had a devastating impact on health, nutrition, food security and

overall socioeconomic development in countries that have been greatly affected by the disease (7).

Evidence has show important links between improved HIV outcomes and nutrition and although

epidemiological studies show that a strong relationship between micro-nutrients and HIV and

progression, and the efficacy of ARV drug treatment is greatly increased by sound nutrition (19).

Good nutritional is very important from the time a person is infected with HIV and also helps to

maintain good health and quality of life of the person suffering from AIDS (19, 20). People living

with HIV who are well nourished are able to work and contribute to family income, and thus

remain active and able to care for themselves and help with the care of children and other

dependants, have reduced illnesses and recover more quickly from infections, therefore reducing

costs for health care, maintain a good appetite and stable weight, Children can go to school

regularly, resulting in better education and development (19, 20).

The hormonal connection between immunity and nutrition becomes equally evident in nutritional

dysregulatory eating disorders such as obesity, which is becoming alarmingly common in high-

income countries, notably in the United States and United Kingdom, and is also spreading to

transitional societies at an unexpectedly high speed. (47)

Poor nutrition weakens the immune system leading to frequent illnesses, poor growth and

development in children, and an inability to replace and repair body cells and tissues, resulting in

severe weight loss (5). Poor nutrition quickens the progression from HIV to AIDS while good

nutrition slows it down (19). Infection with HIV damages the immune system, which leads to other

infections such as fever, diarrhea and other. These infections can lower food intake because they

both reduce appetite and interfere with the body’s ability to absorb food. As a result , the person

becomes malnourished, loses weight and is weakened (20). In addition inadequate nutritional status

may increase the risk of vertical HIV transmission by influencing maternal and child factors for

transmission (3).

2.4. Nutrition and ART

Antiretroviral therapy (ART) based on combinations of antiretroviral drugs is prescribed to

PLHIVs with immune suppression, signs and symptoms of AIDS based on clinical staging criteria,

or both (13). ART is essential to save lives of PLWHA, and clearly nutritional support alone cannot

substitute ART. Nutrition is an essential component of antiretroviral therapy (ART) interventions,

9

particularly in resource limited settings (15, 42). Because good nutrition can reinforce the effect of

drug, supporting the recovery of the defense system and improving overall well-being and also

ensures optimal benefits from the use of ART, and prevent transmission of HIV from mother to

child (10, 15, 20, 42). To be ART effective must be regular food supply, a good nutrition plan and

continuous support to ensure healthy eating. Food and nutrition play an inextricable role in the

bioavailability (i.e. absorption, digestion, metabolism, and transport) of drugs (15, 42). On other

hand poor nutrition reduces the body’s ability to absorb medication and individuals may find it

difficult to cope with the side effects of ART (15, 42). Due to the advent of antiretroviral drug

therapy (ART) and subsequent improved life expectancy, HIV has become a chronic disease. Long-

term complications related to diet, overweight, and obesity have gained a new importance. Among

the Nutrition for Healthy Living (NFHL) cohort in 1998, 27% of women were overweight and 21%

were obese while 33% of men were overweight and 6% were obese(50).

A person may be receiving treatment for the opportunistic infections and also perhaps combination

therapy for HIV; these treatments and medicines may influence eating and nutrition (21).

Furthermore, there are metabolic complications associated with long-term ART use that have

nutritional implications. Currently, body mass index (BMI) may be the ―best predictor‖ of mortality

in PLWHA. Thus, BMI and nutritional issues also need to be monitored once a patient is on

treatment (15).

10

Figure 2- conceptual framework of malnutrition among Pre-ART and On-ART patients

Dietary and food security

Related factors:

Inadequate dietary intake Change in dietary diversity Change dialy meal frequency Food security Nutritional support Nutritional counseling

Clinical and Health related factors

- CD4, WHO HIV stage, Opportunistic infections (tuberculosis, diaharia and others) , HARRT adherence, and ART status

- Care and support of PLWHA ( alchol, Drug addiction, HAART Adherence , cotrimoxazole prophlaxis

- Body weight loss

- Malabsorption

Socio-demographic factor

Age , Sex, Education,

residence, marital status, Religion,

Ocupation,

NUTRITION status of PLWHA

- Mortality

- Malnutrition among PLWHA

- Faster progression of HIV to AIDS

- Increase severity, duration and frequency of

OIs( morbidity) among PLWHA

Socio-economic , behavioral factors and Hygien and sanitation

- Disclosure

- Drinikng water

- Sanitation facilities

- Income

- Soft drug (Khat, shisha)

- Smoking

- Alcohol drinking

- Hard drug

-

11

3. Objective

3.1. General Objective

- To assess prevalence of malnutrition and its factors associated in adult PLWHA in ART and

pre-ART clinics at Hawassa health facilities, Hawassa, SNNPR, Ethiopia.

3.2. Specific Objective

- To determine the prevalence of under nutrition among PLWHA in Hawassa health facilities

- To determine the prevalence of over nutrition among PLWHA in Hawassa health facilities

- To assess factors associated with Under nutrition among PLWHA in Hawassa health facilities,

Hawassa, SNNPR, Ethiopia

- To assess factors associated with over nutrition among PLWHA in Hawassa health facilities,

Hawassa, SNNPR, Ethiopia

12

4. Methodology

4.1. Study setting

The study was conduct in Hawassa health institutions on those receiving ART and pre-ART

services in Hawassa, SNNP, Ethiopia. Hawassa is the capital city of SNNP Regional State, situated

275 Km southern of Addis Ababa. The area is dominated by hot climatic condition. The city is

divided into 8 sub city (7 urban and 1 sub city which is partially rural) and 32 total kebeles (21

urban and 11 rural kebeles).

According to 2007 CSA projected total population of the city for 2013/2014 were 341,659(175,773

males and 165,886 females) with estimated household of 69,727. The health service coverage of

Hawassa city was 92% with one referral hospital, four hospital, 8health centers, 12 Pharmacy, 13

Diagnostics laboratories and 15 health post owned by the government. Currently in Hawassa city

there are five health facilities were providing ART and pre ART service for a total of 8,609 clients

living with HIV/AIDS among which 4,841 clients of PLWHA on ART service and from the five

health facility Hawassa referral hospital comprise the highest number of PLWHA.

4.2. Study design

Facility based cross sectional study design was e used.

4.3. Study period:

February 1-April, 2014

4.4. Source population

All adult people living with HIV/AIDS who were enrolled to ART care for ART and Pre-ART

follow up in all Health facilities of Hawassa administrative town .

4.5. Study Population

All adult people (people aged 18 years and older) living with HIV/AIDS who were enrolled to

ART care clinic for ART and Pre-ART follow up in all Health facilities of Hawassa administrative

town, which were included in the study.

4.6. Inclusion and exclusion criteria

Inclusion

Those who were actively following HIV/AIDS chronic care in Hawassa health Facilities aged

18years and older, followed to ART clinic for ART and Pre- ART service was included.

13

Exclusion

Patients who were seriously ill and/or with spinal deformity , those who are not willing to include

in the study and Clinical records that did not have complete information to relevant the study was

excluded.

4.7. Sample size

Sample size was computed using the formula for single population proportion. The assumption of

prevalence of undernutrition among PLWHA patients is 25.5% which was obtained from study

conducted in Gondar, Gondar Referral Hospital (38) and prevalence of over nutrition among

PLWHA was 38%, whoch was obtained from the study conducted in Swiss . A 95% confidence

level and 3% precision was taken. The following formula was used

n = sample size

Z 1- /2= 95% CI two tailed (1.96)

d= desired precisions = 4%

P= prevalence of undernutrition among PLWHA = 27.8 % and prevalence of over nutrition among

PLWHA=38%

Accordingly the total sample size for this study will be 482 for under nutrition and 622 for over

nutrition.

14

Sample size for the third and fourth objective

Table-1 Sample size calculation summary

*Dilla

** Bahirdar

Using Epi-info version-7, and using different factors such Gastro intestinal symptom, ART

duration, Eating difficulty, ART status, symptoms 2wks prior to survey and WHO clinical stage

four of AIDS were Used to determine the sample size. And non response rate of 10% was made

the total sample size in the table above and from the calculated sample size for the two objectives

(prevalence and the factors) the largest sample size is 719, therefore for this study the final sample

size required was 719.

Factors Confiden

ce level

Power Exposed–

to-non

exposed

ratio

Prevalence

of

Malnutrition

among non

exposed

Odds

ratio

response

rate

Required

sample

size

Gastrointestinal symptom* 95% 80 1 8.56 % 5.3 10% 110

ART duration ** 95% 80 1 19.7% 1.7 10% 719

Eating difficulty ** 95% 80 1 20.4% 1.8 10% 570

WHO clinical stage of

AIDS *

95% 80 1 7.5% 7.01 10% 84

ART status** 95% 80 1 34.5% 1.77 10% 473

Symptoms 2wks prior to

survey**

95% 80 1 21.9 1.93 10% 433

15

4.8. Sampling procedure

From the total 8,609 HIV/AIDS patients who were in pre-ART and on ART chronic care, 4,851

were on ART and 3,758 were on Pre-ART care. Therefore in order to select 719 participants from

on ART and Pre-ART cases proportionately, we used mathematical equation. That means n1 =

(N1*nf)/Nt. At the same time, n2= (N2*nf)/Nt, where n1 is the required sample size from ART

care cases, n2 is the required sample size from Pre-ART care cases, nf is be the total required

sample size, N1 is the total number of ART care cases, N2 is the total number of pre-ART care

cases, and Nt is the total number of both on ART and on Pre-ART care cases. I.e., n1=

(4,851*719)/8,609= 405, and n2= (3758*719)/8,609= 314 cases will select proportionately. Since

nf= n1+n2, then a total of 405 cases from on ART care, and a total of 314 cases from Pre-ART care

were recruited making the final sample size 719.

A systematic sampling was used to select the participant for interview, anthropometric

measurement and clinical records review from register of each hospital/health center as a sampling

frame. The selected study participants of this study were used for face to face interview,

anthropometric measurement and record review. Sample size for each hospital/ health centers were

obtained in proportion to the number of PLWHA patients registered in each hospitals/health

centers. Sampling interval (Kth

) was determined by dividing the total PLWHA patients in each

hospital/health centers by the allocated sample size. From the total cases in sample the first clinical

record was selected by simple random sampling and every (kth) record was selected for gathering

information until the required sample was obtained.

16

Fig. 3. Thematic presentation of participant selection or sampling procedure

As you see on the above sampling procedure in two health facilities (Millennium and Tula Health

Center) the sample sizes are very small. Therefore I was proportional allocated the number in to the

rest of three health facilities.

Hawassa City ART sites health facilities

Hawassa Referal Hospital

5428

PLWHA

ART

3340

Sampled ART

(279)

Pre-ART

2088

Sampled Pre-ART

(174)

Adare Hospital

1723

PLWHA

ART

847

Sampled ART

(71)

Pre-ART

876

Sampled pre-ART

(73)

Millenium Health center

189

PLWHA

ART

48

Sampled ART

(4)

Pre-ART

141

Sampled Pre-ART

(12)

Bushilo Health center

1677

PLWHA

ART

586

Sampled ART

(49)

Pre-ART

556

Sampled Pre-ART

(47)

Tula health center

127

PLWHA

ART

30

Sampled ART

(2)

Pre-ART

97

Sampled Pre-ART

(8)

Total Sample (719)

715

4 Missing

17

4.9. Data collection procedure

Eight clinical nurse working in each health facilities were data collectors and 2 ART, Nutrition and

HIV/AIDS trained nurses or health Officer supervisors were recruited and train for 3 days with the

objective of standardizing the data collection instrument among the data collectors and providing

them with basic skill of communicating with the study participants and taking height and weight

measurement of the study participants.

The data collection process was followed daily by the supervisors and principal investigator. Socio-

demographic details such as Age, sex, marital status, level of education, religion, ethnicity,

residence, monthly income, source of water and occupation collect using face to face interview.

Similar instrument was used for the collection of gastrointestinal symptoms, eating difficulty, the

existence of tuberculosis and side effect of ARVs in the past six months from each participant.

Weights of participants were taken using standard beam balance and the scale was check at zero

before and after each measurement. Participants’ weight was measured after removal of heavy

clothes and recorded to the nearest 0.1KG.

Height measurement of participants was taken using the standard measuring scale. Participants’

takeoff his/her shoes, stand erect (knees straight and feet together), and look straight in horizontal

plain. The shoulder blades, buttocks, heels, and back of the head against the measuring board/ wall

and height will record to the nearest 0.01cm.

Body mass index (BMI), was calculated as weight in kilograms divided by the square of height in

meters (kg/m2). For the initial analysis, BMI was stratifying into the WHO criteria: <17 (moderate

to severe malnutrition), 17 to < 18.5 (mild malnutrition), >18.5 to 25 (normal nutrition) and >25

kg/m2 (overweight and obese) (6). Again this study was used the weight measured as a part of

routine monthly ART follow up activity to classify weight loss percentage of the study participant.

Percentage of body Weight Loss was calculated as follows: (Usual body weight - current

weight)/usual body weight x100%. It was classified in to four, normal (<5%), mild (5-10%),

moderate (10.1- 20%) and severe (>20%). Blood samples was drawn from subjects as part of

routine monthly ART follow up investigation to measure CD4 cell count. This study was used the

CD4 cell count to classify the patients into four categories according to WHO criteria; <200

cells/mm3 severe, 200–349cells/mm

3 as moderate or advance, 350-499 cells/mm

3 as mild and >500

cells/mm3 as not significant. Patients’ medical chart was reviewed for extraction of AIDS’ clinical

stage, ART duration, and history of previous opportunistic infections (OIs) in the last 6 months. In

addition, adherence to HAART was extract from each medical chart of individual patients which

was registered during their monthly spell of follow up. Similar to the previous opportunistic

infection, adherence status was delimited to the last six months follow up time. However, self

18

report adherence measurement technique was used by asking the patients about the number of times

they have missed taking their pills each month and recorded. In this study, the mean adherence to

HAART for each eligible record was operationally defined as ―good adherent‖ if the average

adherence was equal to or greater than 95% or < 3 doses missed per month), Fair adherent (85-

94% or 4-8 doses missed per month), or Poor adherent (less than 85% or > 9 doses missed per

month).

4.10. Variable

Independent

Socio demographic characteristics (Age, sex, marital status, level of education, religion,

ethnicity, residence, monthly income, occupation)

Clinical characteristics (CD4 count, WHO clinical stage of AIDS (I, II, III, IV), Side effect

of HAART (treatment of HIV), Opportunistic infections, Adherence to HAART (poor, Fair

and good))

Weight loss, Source of water

Disclosure

ART status

Gastrointestinal symptom (diarrhea, nausea and vomiting),

Eating difficulty (loss of appetite, swallowing difficulty, oral thrush and esophageal thrush)

Tuberculosis

Daily Meal Frequency

Dietary diversity

Food security

Dependent

Malnutrition (Over and undernutrtition)

19

4.9. Operation definition

Malnutrition: - Is the condition that results from an imbalance between dietary intake &

requirements. It includes both under nutrition & over nutrition.

Under weight (under Nutrition):- means the person BMI less than 18.49Kg/M2

Overweight (over nutrition):- means the person BMI greater than 25Kg/M2- 29.99Kg/M

2

Obese (Over Nutrition):- means the person BMI greater than 30 Kg/M2

Adult people: - age greater or equal to 18 years old

Adult Malnutrition: Adult malnutrition (under nutrition) is defined by using; BMI or body mass

index is called underweight or overweight. Under weight means the person BMI less than

18.49Kg/m2.

Therefore to say mild underweight (BMI is between 17-18.49 Kg/m

2), moderate

underweight (BMI must between 16 -16.99 kg/m2) and severe underweight (BMI must be less than

16 kg/m2).These three groups are considered to be chronically energy deficient (CED).

Adherence: - fulfillment with a drug regimen, as in taking medications properly and on time.

Opportunistic infection: - Illnesses caused by various organisms, some of which usually do not

cause disease in persons with normal immune systems. Persons living with advanced HIV infection

suffer opportunistic infections of the lungs, brain, eyes, and other organs. Opportunistic infections

common in persons diagnosed with AIDS include Pneumocystis carinii pneumonia; Kaposi’s

sarcoma; cryptosporidiosis; histo plasmosis; other parasitic, viral, and fungal infections; and some

types of cancers.

CD4 (T4): - A type of T cell involved in protecting against viral, fungal, and protozoa infections.

Meal frequency – is the number of reported daily eating occasions by household members in a

household experienced within a day. This does not include eating occasions by the household

members experienced outside home.

Dietary diversity – is the number of reported different foods and food groups consumed in a

household over a 24-hour period. This does not include food group consumed by the household

members outside home.

Household food security – the ability of household members to have the type of food they need at

the time they need it sufficiently to meet their dietary needs and food preferences for an active and

healthy life. It is assessed by asking whether the household has enough food or money to meet its

basic food needs and on the normal behavioral and subjective responses to that condition, as these

have been observed.

4.10. Data management

The questionnaire was adjusted and modified in to our context from previous literatures. It was

prepared first in English and then translated into the local language Amharic, and then retranslated

20

back to English by an expert who was fluent in both languages to maintain its consistency. To

achieve good quality data, training was provided to selected 8 data collectors and 2 supervisors for

two consecutive days on data collection tools and interview guide for questions on food security,

and diatery. Before the actual data collection pursue a pre-test of questionnaire was conducted on

both ART and PR-ART care clients in the nearby Yirgalem Hospital a week prior to the actual

survey and appropriate corrective measures was taken. .

Both principal investigator and supervisors check the collected data for completeness clarity,

consistency and accuracy on daily basis. Then questionnaires will be cleaned and coded for

computer data entry by principal investigator

4.11. Data analysis procedure

The collected data from the respondents were entered and cleaned in to Epi info version 3.5.1 and

imported to SPSS for windows version 16 for analysis.

To measure food security status of households number of affirmative answers given by study

participants to the 18 questions in the core module were added and depending on the presence of

children in the households (in the absence of children maximum possible affirmative answer would

be 10 because 8 questions were not applicable in households without children) the households were

classified as food secure (0-2 affirmative answers), food insecure without hunger (3-7 affirmative

answers in households with children and 3-5 in households without children), food insecure with

moderate hunger (8-12 affirmative answers in households with children and 6-8 in households

without children) and food insecure with severe hunger (13-18 affirmative answers in households

with children and 9-10 in households without children). The first and the last two categories were

combined throughout the analysis with the assumption that hunger is important in population where

food insecurity is a common phenomenon as in the participants of this study. Seven meal occasions

and 12 food groups were asked to assess the food frequency and dietary diversity situation of

households and those households with more than the median score of the meal frequency and

dietary diversity scores were classified as high meal frequency and high dietary diversity

households.

The data analysis was range from the basic description of outcomes to the identification of

statistically significant associations. First, the basic descriptive summaries of patients’

characteristics and outcome of interest was computed. Accordingly, simple frequencies, measure of

central tendencies and measure of dispersions were scrutinized. Second, bivariate analysis and

multiple logistic regression models were used to show the relation between malnutrition and

various associated factors. Finally, all explanatory variables that were statistically significantly

associated with the outcome variable in the bivariate analyses (P < 0.05) were entered in to logistic

21

regression model to identify independent variable of malnutrition. Confidence interval of 95% was

used to see the precision of the study and the level of significance was taken at α <0.05.

4.12. Ethical consideration

To conduct this research project ethical approval was secured from Hawassa University and Addis

continental Institute of public Health (ACIPH), Institutional review board [IRB] and permission

from Hawassa City Health Department and all Hawassa health facilities providing Pre-ART and

ART service was obtained.

During data collection process the data collectors were informed each study participant about the

purpose and anticipated benefits of the research project and the study participants were also be

informed on their full right to refuse, withdraw or completely reject part or all of their part in the

study and they were assured that their treatment and other benefits they gain from the hospital,

health center and/or other organizations were not be influenced by their participation in the study.

Finally, they were asked for their informed written consent to participate or not in the study and for

their willingness on use of their files and records for the study. Interviews and measurements were

conducted in a quiet, ventilated, lighted room to respect the study participants’ anonymity and

boost their confidence on the study.

During the interview and measurements study participants were provided with general information

by interviewers on the means of improving their household food and nutrition security status and on

the mechanisms to promote their health and maximize their well being and adherence to ART.

22

5. Result

5.1. Socio-demographic characteristics Respondents

A total of 719 PLWHA (405 on ART and 314 Pre-ART) were approached and 715(405 On-ART

and 310 Pre-ART) consented to participate in the present study giving a response rate of 99.4%, of

which females accounted 264 (36.9%) On ART and 192(26.9%) from Pre-ART. The mean age of

the study participants was 34.56 + 8.5 years with 188 (26.3%) on ART and 136 (19%) from Pre-

ART of them belonging to the age group 30 – 39 years.

Among 715 participants 239 (33.4%) On ART and 137 (19.2%) Pre-ART were orthodox and

140(19.6%) on ART and 136 (19%) Pre-ART were protestant. The majority of the study

participants were married, 209 (29.2%) On ART and 192 (26.9%) Pre-ART.

About 378 (52.8%) On ART and 255 (35.7%) Pre-ART) study participants claimed that they are

disclosed their HIV serum status to at least one person other than their counselor/doctor and from

the total study participants the majority were from urban dwellers 386 (54%) On ART and 270

(37.7%) from Pre-ART.

From the total study participants 394 (55.1%) On ART and 282 (39.4%) Pr-ART was received

drinking water from improved source but 250 (35%) On ART and 213 (29.8%) Pre-ART of the

respondent have unimproved sanitation facilities in their household. Regarding the main source of

food in the house hold 382 (53.4%) On ART and 264 (36.9%) Pre-ART of the respondents was got

their food from purchased from market.

23

Table 1. Socio-Demographic Characteristics of PLWHAs in Hawassa health facilities, Hawassa,

SNNPRS, Ethiopia, 2014.

Variable (n=715)

ART (405) Pre-ART (310) Total (715)

n (%) n (%) N (%)

Sex Male 141(19.7%) 118 (16.5%) 259(36.2%)

Female 264(36.9%) 192(26.9%) 456 (63.8%)

Age 18-29 107(15%) 100 (14%) 207(29.0%)

30-39 188 (26.3%) 136 (19.0%) 324(45.3%)

40-49 76(10.6%) 60(8.4%) 136(19.0%)

>=50 34(4.7%) 14(2.0%) 48(6.7%)

Religion Orthodox 239(33.4%) 137(19.2%) 376(52.6%)

Protestant 140(19.6%) 136 (19.0%) 276(38.6%)

Catholic 1(0.1%) 9 (1.3%) 10(1.4%)

Muslim 21(2.9%) 27 (3.8%) 48(6.7%)

Other* 4 (0.6%) 1(0.1%) 5(0.7%)

Current Educational

level

Not Able to read &write 48 (6.7%) 36 (5.0%) 84(11.7%)

Able to read and write 9 (1.3%) 13 (1.8%) 22(3.1%)

Grade 1-4 46 (6.4%) 56 (7.9%) 102(14.3)

Grade 5-8 129(18.0%) 100 (14.0%) 229(32.0%)

Secondary school 122 (17.1%) 71 (9.9%) 193(27.0%)

College/University 51 (7.1%) 34 (4.8%) 85(11.9%)

Ethnicity Sidama 42 (5.9%) 80 (11.2%) 122(17.1%)

Wolayta 86 (12.0%) 74 (10.4) 160(22.4%)

Gurage 42 (5.9%) 34 (4.7%) 76(10.6%)

Amahara 139 (19.5%) 63 (8.8%) 202(28.3%)

Gedoe 3 (0.4%) 2 (0.3%) 5(0.7)

Oromo 75 (10.5%) 48 6.7%) 123(17.2%)

Other** 16 (2.2%) 11 (1.6%) 27(3.8%)

24

Table 1. Socio-Demographic Characteristics of PLWHAs in Hawassa health facilities,

Hawassa, SNNPRS, Ethiopia, 2014 continued

Variable (n=715)

ART (405) Pre-ART (310) Total (715)

n (%) n (%) N (%)

Marital status Married 209 (29.2%) 192 (26.9%) 401(56.1%)

Unmarried 54 (7.6%) 40 (5.5%) 94(13.1%)

Divorced 76 (10.6%) 44 (6.2%) 120(16.8%)

Widowed 66 (9.2%) 34 (4.8%) 100(14.0%)

Disclosure No 27 (3.8%) 55 (7.7%) 82(11.5%)

Yes 378 (52.8%) 255 (35.7%) 633(88.5%)

Current Residence Urban 386 (54.0%) 270 (37.7%) 656(91.7%)

Rural 19 (2.7%) 40 (5.6%) 59(8.3%)

Main Occupation Student 3 (0.4%) 4 (0.6%) 7(1%)

Casual worker 96 (13.4%) 72(10.1%) 168 (23.5%)

Employed 106(14.8%) 66 (9.3%) 172 (24.1%)

Farmer 15 (2.1%) 26(3.6%) 41 (5.7%)

Business (Self employed) 111 (15.5%) 80 (11.2%) 191(26.7%)

Unemployed 74(10.3%) 62(8.7%) 136 (19%)

Main source of food

for the house hold

Purchase 382(53.4%) 264 (36.9%) 646 (90.3%)

Household farm/garden 21(2.9%) 42(5.9%) 63 (8.8%)

Others*** 2(0.28%) 4(0.56%) 6 (0.84%)

Main source of

drinking water

Improved 394(55.1%) 282(39.4%) 676 (94.5%)

Unimproved 11(1.5%) 28(3.9%) 39 (5.4%)

Monthly Income <=200 21 (2.9%) 17(2.4%) 38 (5.3%)

201-700 164(22.9%) 99 (13.9%) 263 (36.8%)

701-1500 130(18.2%) 111 (15.5%) 241 (33.7%)

>1500 90 (12.6%) 83 (11.6%) 173 (24.2%)

Sanitation facility unimproved 250(35%) 213 (29.8%) 463 (64.8%)

Improved 155(21.7%) 97(13.5%) 252 (35.2%)

Key: *: Johva, aethist, Adventist,

**: Hadiya, Kembata, Somalia, Tigrey, Gamo

*** Welfare/NGO support, Relatives and friends

25

5.2. Health and clinical characteristic of the study participants PLWHA

Regarding health related characteristics of PLWHA (405) 56.6% of the study participants were

received ART, of which 73.3% of the respondents were received ART greater than 12 months and

from the total ART user 93.6% of them were good adherence to HAART in the past six month.

From the total interviewed study participants 36.5%(261) and 31.7%(227) were on World Health

Organization (WHO) clinical stage of Acquired Immuno Deficiency syndrome ( ADIS) one and

two respectively, 253 (35.4%) had CD4 count between 350-499cells/mm3

and 36.5%(261) above

500cells/mm3.

More than 1/3rd

(252) ( 13.8%(99) from On-ART and 21.4% (153)from Pre-ART) of the study

participants were developed eating difficulties in the past six month and among them more than

76% (193) (28.6% (72) from On –ART and 48% (121) from Pre-ART) of them complained loss of

appetite. Of the total study participants 24.3% (174) of were complains gastrointestinal symptom

(9.1% (65) from On-ART and 15.2% (109) Pre-ART).

26

Table 2. Health and clinical characteristics of HIV/AIDS clients in pre-ART and on ART

care in Hawassa Health facilities, Hawassa, SNNPR, 2014.

Variable (715) ART (405) Pre-ART (310) Total (715)

n (%) n (%) N (%)

ART Status 405

(56.6%)) 310 (43.4%) 705(100%)

Gastrointestinal

Symptom

No 340 (47.6%) 201(28.1%) 541 (75.7%)

Yes 65 (9.1%) 109 (15.2%) 174 (24.3%)

Eating Difficulty No 306 (42.8%) 157 (22%) 463 (64.8%)

Yes 99 (13.8%) 153 (21.4%) 252 (35.2%)

Kind of Eating

Difficulty

Loss of appetite 72 (28.6%) 121 (48%) 193 (76.6%)

Nausea/ Vomit 27 (10.7%) 27 (10.7%) 54 (21.4%)

Others* 0(0%) 5 (2%) 5 (2%)

Pulmonary

Tuberculosis

No 399 (55.8%) 282 (39.4%) 681 (95.2%)

Yes 6 (0.8%) 28 (3.9%) 34 (4.8%)

Tuberculosis

Drug Side Effect

No 6 (17.6%) 25 (73.5%) 31 (91.2%)

Yes 0(0%) 3 (8.8%) 3 (8.8%)

Unwell in the

Past 2 weeks

No 346 (48.4%) 218 (30.5%) 564 (78.9%)

Yes 59 (8.3%) 92 (12.8%) 151 (21.1%)

Adherence to

HAART in past 6

month

Good adherence 379 (93.6%) 0 379 (93.6%)

Poor adherence 26 (6.4%) 0 26 (6.4%)

WHO ADIS

stage

Stage I 169 (23.6%) 92 (12.9%) 261 (36.5%)

Stage II 79 (11%) 148 (20.7%) 227 (31.7%)

Stage III 135 (18.9%) 67 (9.4%) 202 (28.3%)

Stage IV 22 (3.1%) 3 (0.4%) 25 (3.5%)

CD4 count

<200 cells/mm3 44 (6.2%) 17 (2.4%) 61 (8.5%)

200-349cells/mm3 101 (14.1%) 43(6%) 144 (20.1%)

350-499 cells/mm3 127 (17.8%) 124 (17.3%) 251 (35.1%)

>500 cells/mm3 133 (18.6%) 126 (17.6%) 259 (36.2%)

ART Duration < or = 12 month 108 (26.6%) 0 108 (26.6%)

> 12 months 297 (73.4%) 0 297 (73.4%)

Key: * Swallowing difficulty, oral or/ and esophageal thrush

27

5.3. Nutritional and food security status of patients’ On-ART and Pre-ART

The nutritional status of patients among On-ART and Pre-ART follow up care were determined

using BMI in Hawassa health facilities; the overall prevalence of under nutrition 16.6% (119), of

which 15.1% on _ART and 18.7% on Pre-ART were undernourished.

Of which 2.5 % On-ART and 2.6% Pre-ART were severe malnourished, 2.2 % On-ART and 3.2%

Pre-ART were Moderate malnourished and 10.4% On-ART and 12.9% Pre-ART were mild

malnourished.

In addition to underweight or under nutrition, the present study was found the prevalence of over

nutrition (overweight and Obese) was 14.1% (101), of which 14.3% On-ART and 13.9% Pre-ART

were overweight and Obese. Among the total study participants had 11% of overweight and 3.1%

obese.

The study also sought food security situation of households of PLWHA and it was found that close

to 65%; 64.2 % from On-ART and 65.5% from Pre-ART of the households were food insecure

(with Mild, with moderate or severe hunger). Of the total study participant of PLWHA in Hawassa

health facilities 55.1 % (28.7% (205) On ART and 26.4% (189) Pre-ART) were ate less or three

times daily. Furthermore the present study was seen the nutritional status of PLWHA in Hawassa

health facilities using percentage of Body Weight Loss. Therefore accordingly 16.6% of PLWHA

were Undernourished; 8.9% from ART and 26.8% from Pre-ART care.

Out of the total PLWHA more than 85% (50.6% from On-ART and 34.7% from Pre-ART) the

study participants were counseled for nutrition and 88.1% (50.1% from On ART and 38 % from

Pre-ART) PLWHA were not got nutritional support. From the entire interviewed participants

57.5% (32.9% from On-ART and 24.6% from Pre-ART) of them were changed their feeding style

after knowing the HIV sero status.

28

Table 3. Nutrition and food security status of HIV/AIDS clients in pre-ART and on ART care

in Hawassa Health facilities, Hawassa, SNNPR, 2014

Variable ART(405) Pre-ART(310) Total (715)

n (%) n (%) N (%)

Daily Meal

Frequency

Less than two time 2 (0.3%) 2(0.3%) 4 (0.6)

Two or three times 203(28.4%) 187 (26.1%) 390 (54.5)

More than three times 200(28%) 121(16.9%) 321 (44.9)

Daily Eating

Pattern the Last

6 months

Three meals & above 341(47.7%) 236(33%) 577 (80.7)

Two meals & eating

between meals

23(3.2%) 23(3.2%) 46 (6.4)

Two meals or less 41(5.8%) 51(7.1%) 92 (12.9)

Body Weight Loss

percentage <5% 369(51.6%) 227(31.7%) 596 (83.4)

5-10% 28(3.9%) 61(8.5%) 89 (12.4)

>10 8(1.1%) 22(3.1%) 30 (4.2)

Food Security Food Secure 145(20.3%) 107(14.9%) 252 (35.3)

Food Insecure without Hunger 123(17.2%) 78(10.9%) 201 (28.1)

Food insecure with moderate

Hunger 50(7%) 56(7.8%) 106 (14.8)

Food Insecure with sever

Hunger 8(12.2%)7 69(9.6%) 156 (21.8)

Dietary Diversity Low dietary Diversity 12(1.7%) 14(1.9%) 26 (3.6)

Medium Dietary Diversity 119(16.6%) 91(12.7%) 210 (29.4)

High Dietary Diversity 274(38.3%) 205(28.7%) 479 (67)

Body Mass Index <15.99 10(1.4%) 8(1.1%) 18 (2.5)

16-16.99 9(1.3%) 10(1.4%) 19 (2.7)

17-18.49 42(5.9%) 40(5.6%) 82 (11.5)

18.5-24.99 286(40%) 209(29.2%) 495 (69.2)

>=25 58(8.1%) 43(6%) 101 (14.1)

Nutritional Support No 358(50.1%) 272(38%) 630 (88.1)

Yes 47(6.6%) 38(5.3%) 85 (11.9)

Changing feeding

style after Knowing

HIV status

No

170(23.8%) 134(18.7%) 304 (42.5)

Yes 235(32.9%) 176(24.6%) 411 (57.5)

Nutritional

counseled

No 43(6%) 62(8.7%) 105 (14.7)

Yes 362(50.6%) 248(34.7%) 610 (85.3)

29

5.4. Association between risk factors and Under Nutrition and over nutrition

among adult PLWHA.

5.4.1. Association factors between risk factors and under nutrition among adult

PLWHA.

Logistic regression analysis was used to identify the variables which influence malnutrition. The

study found that getting nutritional support and Body Weight Loss (BWL) greater than 10% has

significantly associated with Malnutrition for both Pre-ART and ART of PLWHA in Hawassa city

health facilities. In this study those who had Body Weight Loss percentage (>10%) was 3.9 times

more likely develop Malnutrition than that of normal body weight loss (<5%) (AOR=3.967, 95%

CI (1.682, 9.358) for ART and Pre-ART of PLWHA. From this study getting nutritional support

were 2.3 times higher risk of developing malnutrition than not getting nutritional support (

AOR=2.353,95%CI(1.305, 4.242).

30

(Table- 4.) Associated risk factors for under nutrition in HIV/AIDS clients in pre-ART and

on ART care in Hawassa Health facilities, Hawassa, SNNPR, 2014.

Variable prevalence of

Malnutrition

COR (95%) AOR (95%)

Yes No

WHO ADIS

Stage

stage IV 3 22 1.05(.296 , 3.720) 2.217 (0.568, 8.657)

Stage III 49 153 2.466(1.498, 4.058) 1.348( 0.336, 5.413)

Stage II 37 190 1.499(.893,2.518) 1.315 (.326,5.304)

Stage I 30 231 1 1

Nutritional

counseled

Yes 91 519 0.482(0.296, 0 .784) 0.731 (0.388, 1.377)

no 28 77 1 1

Nutritional

Support

Yes 29 56 3.107(1.883, 5.127) 2.353(1.305, 4.242)*

no 90 540 1 1

current Residence Rural 18 41 2.412(1.333, 4.367 1.145 (0.403, 3.253)

Urban 101 555 1 1

Main source of

drinking water

unimproved 16 23 3.87(1.977, 7.575) 0.697 (0.287, 1.69)

improved 103 573 1 1

Taking

Cotrimoxazole

yes 73 286 1.72(1.150, 2.572) 1.129 (0.705,1.809)

no 46 310 1 1

Gastrointestinal

Symptom

yes 46 128 2.304(1.518, 3.498) 1.092 (0.581, 2.054)

No 73 468 1 1

Eating

Difficulties

Yes 63 189 2.423(1.625,3.611) 1.209 (0.69, 2.121)

No 56 407 1 1

Pulmonary

Tuberculosis

Yes 13 21 3.358(1.631, 6.913) 1.272 (0.529, 3.059)

No 106 575 1 1

31

Table.4. Associated risk factors for under nutrition in HIV/AIDS clients in pre-ART and on

ART care in Hawassa Health facilities continued

Variable

prevalence of

Malnutrition

COR (95%) AOR (95%)

yes No

Daily Eating

Pattern the Last

6 months

Two meals or less 30 62 3.05(1.837, 5.011) 0.626(0.248, 1.581)

Two meals & eating

between meals

10 36 1.751 (0.836,3.669) 0.616 (0.334, 1.134)

Three meals & above 79 498 1 1

Number of OI

in the past 6

months

2+ 30 81 2.380(1.415, 4.001) 0.809 (0.415, 1.578)

1 times 42 213 1.267( 0.807,1.990) 0.93 (0.446, 1.939)

None 47 302 1 1

Food security Food Insecurity with

Severe Hunger

37 119 2.487(1.451, 4.262) 0.938 (0.482, 1.824)

Food insecurity with

moderate Hunger

22 84 2.095( 1.136, 3.864) 0.951 (0.517, 1.748)

Food insecurity

without Hunger

32 169 1.515(0.878, 2.613) 0.714 (0.377, 1.352)

Food secure 28 224 1 1

Unwell in the

last 2 weeks

Yes 38 113 2.005(1.296, 3.102) 1.272 (0.712, 2.274)

No 81 483 1 1

Body Weight

Loss

percentage

>10% 15 15 6.74(3.169,14.336) 3.967 (1.682, 9.358)*

5-10% 27 62 2.935(1.76, 4.895) 1.75(0.953, 3.212)

<5% 77 519 1 1

Main source of

food

others 2 4 2.796(0.505, 5.473) 1.271 (0.152, 10.63)

Household

farm/garden

19 44 2.415(1.353, 4.310) 0.809 (0.12, 5.451)

Purchase

(Market/grocery

store)

98 548 1

*P-value < 0.05

32

5.4.2. Association factors between risk factors and over nutrition among adult

PLWHA .

Logistic regression analysis was used to identify the variables which influence over nutrition. The

study found that CD4 count less than 200cell, getting nutritional support, ,age, eating difficulties

and Daily Eating Pattern the Last 6 months has significantly associated with Malnutrition (over

nutrition) for both Pre-ART and ART of PLWHA in Hawassa city health facilities. In this study

those who had CD4 count less than 200 is significantly associated with the over nutrition (AOR:

0.264, 95% CI (0.082, 0.85) for ART and Pre-ART of PLWHA. Who had CD4 count less than 200

reduced the risk of developing over nutrition by odds of 0.264.

Similarly, getting nutritional support is significantly associated with the development of over

nutrition of PLWHA (AOR= 0.164, 95%CI (0.039, 0.694), which means getting nutritional support

is reduce the risk of developing over nutrition by odds of 0.164. In this study being age 30-39

[AOR= 2.336, 95% CI (1.256, 4.342)] and 40-49 [AOR= 2.938, 95% CI (1.437, 6.006)] are 2.3 and

2.3 times higher risk of developing over nutrition than age 20-29 respectively. Additionally having

eating difficulties [AOR=0.488, 95%CI (0.26, 0.914)] is protective for over nutrition. Who had a

problem of eating difficulties were reduced the risk of developing over nutrition by odds of 0.488.

Similarly Two meal or less daily eating pattern the last six month [AOR=0.183, 95%CI (0.042,

0.796)] is protective for over nutrition. Those who had two meal or less daily eating pattern in the

last six month reduced the risk of developing over nutrition by odds of 0.183.

33

Table 5. Associated risk factors for over nutrition in HIV/AIDS clients in pre-ART and on

ART care in Hawassa health facilities, Hawassa, Ethiopia.

Variable Prevalence of

Over nutrition

COR (95%) AOR (95%)

Yes No

No of Opportunistic

Infection

2 or more 15 96 0.738(0.401, 1.358) 1.65(0.786, 3.462)

1 25 230 0.513(0.312,0.843) 0.611(0.358,1.042)

None 61 288 1 1

Nutritional counseled Yes 95 515 3.044(1.298, 7.140) 2.426(0.993, 5.928)

no 6 99 1 1

CD4 count <200 cells/mm3 4 57 0.325(0.112, 0.940) 0.264( 0.082,0.85)**

200-349

cells/mm3

23 121 0.880(0.509,1.523) 0.872(0.453, 1.68)

350-499

cells/mm3

28 223 0.581(0.351,0.964) 0.615(0.356,1.064)

>500 cells/mm3 46 213 1 1

Ever used Soft Drug Yes 4 86 0.253(0.091,0.706) 0.347(0.118,1.016)

No 97 528 1 1

Daily Eating Pattern

the Last 6 months

Two meals or

less

2 90 0.114(0.028,0.472) 0.183(0.042,

0.796)**

Two meals &

eating between

meals

5 41 0.627(0.241,1.627) 0.991(0.355,2.768)

Three meals &

above

94 483 1 1

Nutritional Support Yes 2 83 0.129(0.031,0.534) 0.164(0.039,0.694)**

No 99 531 1 1

Sanitation Facilities Improved 50 202 2(1.307, 3.056) 1.131(0.818, 2.097)

unimproved 51 412 1 1

34

Table 5. Associated risk factors for over nutrition in HIV/AIDS clients in pre-ART and on

ART care in Hawassa health facilities, Hawassa, Ethiopia. Continued

**P-value < 0.05

Variable Prevalence of

Over nutrition

COR (95%) AOR (95%)

Yes No

Age >=50 7 41 2.038(0.788, 5.270) 1.937(0.708, 5.299)

40-49 26 110 2.822(1.450, 5.489) 2.938(1.437,6.006)**

30-39 52 272 2.282(1.265, 4.117) 2.336(1.256,4.342)**

18-29 16 191 1 1

Educational

level

College/University 17 68 3.95(1.384, 11.271) 2.448(0.788, 7.604)

Secondary school 34 159 3.379(1.272, 8.973) 2.325(0.827, 6.537)

Grade 5-8 32 197 2.566(0.965, 6.825) 2.209(0.784, 6.227)

Grade 1-4 11 91 1.910(0.636, 5.733) 2.096(0.657, 6.687)

Able to read and write 2 20 1.580(0.285, 8.750) 2.403(0.397, 14.53)

Not Able to read &write 5 79 1 1

Taking

cotrimoxazole

Yes 41 318 0.305(0.094, 0.994) 0.804 (0.475, 1.359)

No 60 296 1 1

Eating

Difficulties

Yes 19 233 0.379 (0.224, 0.640) 0.488 (0.26, 0.914)

No 82 381 1 1

35

6. Discussion

The present study found that malnutrition were serious problems of PLWHA and in this study the

overall prevalence of under nutrition (under weight) in HIV/AIDS clients who attend chronic care

was 16.6% (BMI <18.5Kg/m2); 15.1% from On-ART and 18.7% from Pre-ART care and the

overall of prevalence of over nutrition (over weight and Obese) is 14.1% (14.3% from On-ART and

13.9% from Pre-ART)

The prevalence of malnutrition differed based on the client ART status (Pre-ART and On-ART). In

this study the prevalence of under nutrition (under weight) was higher in Pre-ART than ART clients

due to underlying condition. The proportions of under nutrition among on ART and Pre-ART

clients were much lower than the study conducted in Bahirdar (37); the difference may due to good

adherence to HAART, changing feeding style after knowing HIV status, and availability of

nutrition counseling and therapy in each health facilities .

Meta-analysis from 11 sub-Saharan African countries indicated that the prevalence of under

nutrition in Ethiopia among HIV-infected women was 13.2% (33). It is a bit lower than the

prevalence proportion of women’s malnutrition in this study (14.9%). Another study conducted

from 12 Sub Sahara Africa countries indicated that the prevalence of under nutrition in Ethiopia in

HIV positive women was 25% (34) and another the study conducted in Tigray Humera Hospital in

HIV positive women was 42.3% (44). The proportion of malnourished women in this study is much

lower than the study conducted in Tigray Humera Hospital; this is being may due to different socio-

cultural, residence and dietary diversity. The overall prevalence of under nutrition in this study

was lower than the findings from Botswana (35), Iranian (31), Bahrdar (37), Gondar (38), Brazil

(32) and China (45). But it was higher than the study conducted in Dilla (36). The difference may

be due to socio economic status, year of the study, and the differences in residence of the study

participants.

Malnutrition could occur in different forms and degrees. In this study the proportion of degree of

malnutrition it differs from different setting and circumstance. In this study the total malnourished

individual 2.5%, 2.7% and 11.5% were in severe, moderate, and mild malnutrition respectively are

lower than the other study conducted in Bahirdar (37). The variation may be due to ART service

increased, socio economic status, Awareness of PLHWAs were changed and year of the study.

Furthermore in this study the proportion of degree of malnutrition in women HIV positive

individual also was 2%, 2.4% and 10.5% were detected severe, moderate and mild malnutrition

respectively lowered than the study conducted in Humera Hospitals(44) revealed that 12%, 10%

and 20.3% were detected sever, Moderate and Mild malnutrition respectively. This difference may

due socioeconomic status of concomitant, and area of the study. The above descriptive result

showed that there is the difference in the distribution of degree of malnutrition. What so ever, the

36

difference degree of malnutrition is; what clearly seen is HIV/AIDS related malnutrition is the

major problem to HIV/AIDS patients.

One of the possible signs of the onset of clinical AIDS is a weight loss of about 6-7Kg for an

average adult, so as evidence indicated that even relatively small loses in weight (5%) were

associated with decreased survival rate (19). In this study found that 83.4%, 12.4%, 4.1% and 0.1%

were normal, mild, moderate and sever body weight loss. When a person is already underweight, a

further weight loss can have serious effects (17).Among the body weight loss study participants

12.9% from normal, 30.3% from mild and 48.3% from moderate were developed under nutrition.

In this study the prevalence of body weight loss percentage greater than 5% was 16.6%. The

prevalence was much lower than the study conducted in Gondar hospital 60.9% (38) the difference

may due to the increased expansion of HAART, awareness of individual and availability

therapeutic food in each health facilities.

This study found that there was strong association between body weight loss percentage and under

nutrition. The body weight loss percentage greater than 10% was 3.9 times more likely to develop

under nutrition than those who had normal body weight loss (<5%) [(AOR=3.967, 95% CI (1.682,

9.358)]. This finding is similar with the findings of the study done in the University of Gondar

Referral Hospital (38). This may be due to loss of weight by itself could cause under nutrition in the

patients with HIV/AIDS and make faster the progression of AIDS.

From the total under nourished study participants, those who get nutritional support were 2.4

times more likely to develop under nutrition than those who didn’t get nutritional support [(

AOR=2.353,95%CI (1.305, 4.242)]. This is due to those who get Nutritional support (both

therapeutic and supplementary) showed that they were already under nourished, presence of

inadequate dietary intake and HIV itself could affect the dietary intake of the patients. This finding

is also similar with the findings of the study done in the University of Gondar Referral Hospital

(38).

In present study prevalence of over nutrition , it was observed lower than the study conducted

Philadelphia (49), Swiss (51) São Paulo city(52) and Porto Alegre (55) due to different study

area, different economic status, study period and different feeding style.

In the present study of over nutrition , nutritional support , age between 30 -39 and 40-49, and

CD4 countless than200 cells/mm3, Two meal or less daily eating pattern of the last six months,

eating difficulties, were highly significant for over nutrition.

37

Getting nutritional support was protective for developing over nutrition (over weight and Obese).

Which means that 84 % of those who get nutrition support were less likely to develop over nutrition

than those who were not getting nutritional support [AOR=0.164, 95% CI (0.039, 0.694))]. This is

because of may be those people, who get nutritional support were already they were developed

under nutrition, inadequate dietary intake, low income. Similarly, people living with HIV that had

eating difficulties, were protective for having over nutrition by odds of 0.488 than those who hadn’t

eating difficulties [AOR=0.488, 95% CI (0.26, 0.914)]. This is due to the disease of HIV causes

oral and/or esophageal candidacies and could brought loss of appetite. In addition, two meal or

less daily eating pattern was less likely by 82% to develop over nutrition than those who had three

or more eating pattern in the last six months [AOR= 0.183, 95% CI (0.042, 0.796)]. This may be

due to people eating two meals or less daily were only fulfilling their daily energy requirement,

income, food insecurity.

CD4 count less than 200cells/mm3 is also protective for developing over nutrition [AOR= 0.264,

95% CI (0.082, 0.85)]. Among PLWHA those who had CD4 count less than 200 cell/mm3

were

less likely to develop over nutrition by 74% than those whose CD4 count higher than 500

cells/mm3. This is due to the fact that patients with CD4 count less than 200 cell/mm

3 were more

susceptible for infection than patients those who had CD4 count higher than 500 cells/mm3 and the

AIDS progression worsen.

Furthermore in this study age between 30-39 and 40-49 was also associated with the prevalence of

over nutrition [AOR=2.336, 95% CI (1.256, 4.342))] and [AOR=2.938, 95% CI (1.437, 6.006)]

respectively. This may be due to people after they knowing their sero type, they were changing

their feeding style intentionally and decline in physical function and frailty. From this study

finding, it was proved that 66% of PLWHA who were age above 30 year changed their feeding

style after knowing their sero type. In addition those age groups had increased feeding frequency.

38

7. Strength and weakness of the study

7.1. Strength of the study

The study was assessed the degree of malnutrition using both BMI and Body weight loss

percentage

To avoid recall biases, medical charts and ART data base were triangulated with the

primary data collected structured interview administered questionnaire.

7.2. Limitation of the study

Due to the nature of cross sectional study couldn’t established cause and effect relationship

between dependent and independent variable.

The present study is not study dietary intake and food record

The present study was not assessed central obesity using waist circumference

The present study was not assessed the information on diet and certain psychiatric co-

medications potentially associated with weight gain and physical activity

39

8. Conclusion

In this study the prevalence of under and over Nutrition is lower than most of the study

conducted before.

Nutritional support and Body weight loss percentage was predictor of under nutrition

(under weight).

CD4 count less than 200 cell/mm3, getting nutritional support, ,age, eating difficulties and

Daily Eating Pattern the Last 6 months has significantly associated with over nutrition (over

weight).

Over weight and obesity is an emerging health problem among HIV+ men and women

40

9. Recommendation

It has been learnt that malnutrition (over nutrition and under nutrition) & its problems in HIV

patients are complex & interwoven; no single recipe exists as solution either. A chronic HIV/ADIS

care and treatment should accompany or strength by nutrition support through governmental &

non-governmental organizations.

For Federal the Government

- All health facilities giving chronic HIV/AIDS care should start and strength both body weight

loss percentage and BMI to identify the malnutrition as early as possible.

- Need to look and have a policy or guideline to tackle newly emerging public health threat of

over nutrition (over weight and obese).

For Hawassa city Health department and each health facilities

- Improve screening methodology using both (BWL percentage and BMI) method and

management of under nutrition with PLWHA in each health facilities.

- Providing nutrition therapy doesn’t alleviate the nutritional problem of PLWHA therefore the

present study recommend need to improve house hold income through creating employment

opportunities and engaging PLWHA in different income generating activities could possibly

alleviate these predicament.

- ART access alone is not alleviating the problem of nutrition, therefore improve nutritional

therapy, dietary counseling, and support should strengthen with the access of ART.

- Provision of IEC/BCC on ART, nutrition, and adherence to the public in general and to the

PLWHA community in particular. IEC/BCC materials should be produced and distributed in

the context of PLWHA and cultural attractive and the public could improve the attitude

towards ART, nutrition, care and prevention.

- Assuring the food and nutrition security individual having HIV/AIDS is not enough to tackle

malnutrition (over nutrition), as a result of this all health facility providing ART service should

giving diet counseling at each contact point and need to strengthen counseling focusing drug

and food interaction.

- PLWHA should counseled focusing on altering dietary and physical activity patterns to prevent

development of obesity and to produce moderate weight loss.

- Provide awareness session on dietary therapy approaches such as low-calorie diets and lower-

fat diets; altering physical activity patterns; behavior therapy techniques; pharmacotherapy;

surgery; and combinations of these techniques.

- Furthermore this study is recommended to conducted comparative study, between PLWHA and

people not living with HIV that could discover more risk factors for malnutrition.

41

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45. Seifu A.: Impact of Food and Nutrition Security on Adherence to Anti-Retroviral Therapy

(ART) and Treatment Outcomes among Adult PLWHA in Dire Dawa Provisional

Administration. Addis Ababa University [Internet]. 2007. Available from:

http://hdl.handle.net/123456789/861.

46. Hailu T. ,Worku W, Tetemke D and Berhe H; Under nutrition among HIV positive women in

Humera hospital, Tigray, Ethiopia, 2013: antiretroviral therapy alone is not enough, cross

sectional study, BMC Public Health 2013, 13:943 doi:10.1186/1471-2458-13-943

47. Wen Hu, Hua Jiang, Wei Chen, Sheng-Hua He, Bin Deng, Wen-Yuan Wang, Yan Wang

,Charles Damien Lu, Karen Klassen , and Jun Zeng ; Malnutrition in hospitalized people

living with HIV/AIDS: evidence from a cross-sectional study from Chengdu, China

48. Ananya Bhowmik, Padmini Ghugre,, Shobha Udipi and Subhasish Kamal Guha; Nutritional

Status and Quality of Life of Women with HIV/AIDS, Kolkata 700073, West Bengal, India,

2012, cross sectional, American Journal of Infectious Diseases 8 (1): 13-18, 2012, ISSN

1553-6203

49. John R. Koethe, Benjamin H. Chi, Karen M. Megazzini, Douglas C. Heimburger, and Jeffrey

S. A. Stringer, Macronutrient Supplementation for Malnourished HIV-infected Adults: A

Review of the Evidence in Resource-Adequate and Resource-Constrained Settings, Clin

Infect Dis. 2009 September 1; 49(5): 787–798. doi:10.1086/605285

50. Kristy M. Hendricks, ScD, RD, Karen Willis, MS, RD, Robert Houser, PhD, Clara Y. Jones,

MD, MPH: Obesity in HIV-Infection: Dietary Correlates; Journal of the American College of

Nutrition, Vol. 25, No. 4, 321–331 (2006)

51. Barbara Hasse, Martin Iff, Bruno Ledergerber, Alexandra Calmy: Obesity Trends and Body

Mass Index Changes After Starting Antiretroviral Treatment: The Swiss HIV Cohort Study;

OFID • Hasse et al

45

52. Patrícia Constante Jaime, Alex Antonio Florindo, Maria do Rosário Dias de, Oliveira Latorre,

Aluísio Augusto Cotrim; Segurado IV Central obesity and dietary intake in HIV/AIDS

patients; Rev Saúde Pública 2006;40(4):634-40

53. Valerianna Amorosa, MD, Marie Synnestvedt, MSEd, Robert Gross, MD, MSCE: The

Intersection Between Obesity and HIV Infection in Philadelphia, J Acquire Immune Defic

Syndr _ Volume 39, Number 5, August 15 2005

54. Anderea Francis Kroll; Eduardo Sprinz, Suzete Carbonell Leal Maria Da Graca Labrea, Sergio

Setubal: Prevalence of Obesity and cardiovascular risk in Patients with HIVAIDS in Porto

Alegre, Brazil; Arq Bras Endocrinol Metab, 2012, 56/2

46

ANNEXES:

ANNEX I . ENGLISH VERSION QUESTIONAIRE

TO ASSESS THE PREVALENCE OF MALNUTRITION AND ITS FACTOR

ASSOCIATED WITH ADULT PLWHA IN HAWASSA

ENGLISH CONSENT FORM AND INFORMATION SHEET

Good morning/good afternoon. My name is ________. We came from Hawassa University

College of medicine and health science. We are working for an investigator doing this thesis for the

partial fulfillment of master’s degree in public health. You are selected for the interview by chance.

We would like to ask you few questions about your socio demographic characteristics, HIV related

symptom, adherence of ART, antiretroviral treatments out come and related factors affecting of

nutritional status. This will help us to identify some of the factor affecting nutritional status of

PLWHA based on your answer to our questions.

We will also take some measurements including weight and height from you. If you are interested

we can tell you your weight and height measurements. You have full right to refuse, withdraw or

completely reject part or all of your participation in the study. But we encourage your full

participation as the answers you give on this form and your participation in taking your

measurements are very important to this study and to plan ways to help other people who must take

pills and on Pre-ART follow up on a difficult situation. We need also to take some information

from your files and records achieved in the ART Unit from your hospital or health center log book.

We would like to assure you that all of your responses to our questions will be kept confidential

throughout the study process. Any of your information you provide will be used only by the

research team and will, by no means, be revealed to a third party. We will ask you questions and

take measurements in a place where other people or conditions couldn’t interfere. We would like to

assure you that your participation on this research will not affect any of your treatment and other

benefit that you get from any organization. We would be thankful if you spend few minutes with us

answering questions related to the issues described above and cooperating in taking some

measurements from you. The questions and measurements will take 30-45 minutes. If you have

any questions about this study you may ask me or the principal investigator Sisay Tadesse Tele:

0932659999 or Email: simafiker@gmail.com. May I get your permission to continue my

interview?

1. Yes 2. No if No Stop

If yes, Study participant’s Unique ART ID No. _______Signature ______Date___________

Data collector’s Supervisor’s

Name _____________ Sign.______ Name _______________ Sign._______

47

PART I

Socio-demographic characteristics

General direction: please, ask each question exactly as it is and circle it as per response of the study participants.

No. QUESTIONS AND FILTERS CATEGORIES CODE SKIPs

101 Sex of study participant Female

Male

1

2

102 Please state your age in year? _____ years

103 Please state your Religion? Orthodox Christian

Protestant

Catholic

Muslim

Others (specify)______________

1

2

3

4

5

104 What is the highest level of education you

have attained?

Not able to read & write

Able to read and write

Grade 1 − 4

Grade 5 − 8

Secondary school

College/University

1

2

3

4

5

6

105 Please state your Ethnicity?

Sidama

wolayta

Gurage

Amahara

Gedoe

Oromo

Others (specify)_______

1

2

3

4

5

6

7

106 What is your current Marital status? Married

Unmarried

Divorced

Widowed

Others(specify)______

1

2

3

4

5

107 Please describe your current Residence? Urban

Rural

1

2

108 How many people are living in your

household?

_________ people

109 House hold condition

109a How many rooms in your household are

used for sleeping?

_____ room

109b Electricity Yes

No

Don’t know

48

Part II. Socio- economic information

201 What is your main occupation? Student

Casual worker/part-time

Employed

Farmer

Business (Self employed)

Unemployed

Other (Specify) ---------

1

2

3

4

5

6

7

202 Are you the head of your household? Yes

No

1

2

If yes, skip to #

204

203 If no, what is the occupation of the head

of the household?

Employed

Business (Self employed)

Casual worker/part-time

Farmer

Unemployed

Other (Specify) ------------------

1

2

3

4

5

6

204 What is the main source of food for your

household the last six month?

Purchase (Market/grocery store)

Household farm/garden

Relatives and friends

Welfare/NGO support

Other (Specify) ------------------

1

2

3

4

5

205 What is your monthly income in Eth Birr? ____________ birr

206 Daily eating pattern of last 6 months Three meals & above

Two meals & eating between meals

Two meals or less

1

2

3

207 Please describe source of drinking water? Piped water into dwelling

Piped water into yard/plot

Public tap/standpipe

Tube well/borehole

Protected dug well Unprotected dug well Protected spring Unprotected spring Rainwater collection Bottled water Cart with small tank/drum Tanker truck Surface water (river, dam, lake,

pond, stream, canal, irrigation channels) Other (specify)___________

1

2

3

4

5

6

7

8

9

10

11

12

13

14

208 Food consumption pattern of last 24 hours Three meals & above

Less than three meals

Don’t know

1

2

3

209 Does your household have the following

communication media?

Television

Radio

1

2

49

Telephone(Mobile)

non-mobile telephone

Internet

If other ( specify)______________

3

4

5

6

Part III. Anthropometric assessment

301 What is the current height of the study

participants (in meter)?

________meter

302 What is the current Weight of the study

participants (in Kg)?

________Kg

303 What is current BMI calculated (Kg/m2) ________Kg/m

2

304 What is the usual body weight of study

participant before six month of Pre-ART

follow up and ART?

______ Kg

305 What is the current weight of the study

participant?

______Kg

306 Percentage of weight loss (%) Sever(>20)

Moderate(10.1 -20)

Mild(5 - 10)

1

2

3

Part IV. Health related factors and others

401 Are you starting ART? Yes

No

Don’t know

1

2

3

If no go to

403

402 Have you had any side effect of HAART in the past six month?

Yes No

1 2

403 Are you taking septrin? Yes

No

Don’t know

1

2

3

If no go to #

405

404 If yes, have you had any side effects from

taking the septrin in the last 1 month?

Yes

No Don’t know

1

2 3

405 Are you getting nutritional support? Yes

No

Don’t know

1

2

3

406 Are you Changing your feeding style after knowing HIV status?

Quality of food Frequency

Feeding cooked food

If other (specify)______

1 2

3

4

407 Are you disclosed your HIV sero type status to your relative or any one?

Yes No

Don’t know

1 2

3

408 If yes who? Wife/husband

Own child (ren) Parents

Brothers/sisters

Relatives

Friends Others (Specify)_________

1

2 3

4

5

6 7

50

409 Have you ever had gastrointestinal symptom

in the past six month?

Yes

No

Don’t know

1

2

3

410 Have you ever had eating difficulty in the past six month?

Yes No

Don’t know

1 2

3

If no go to 410

411 If yes, what kind of eating difficulty? Loss of appetite

Nausea/ Vomit Swallowing difficulty

oral or/ and esophageal thrush

If others(specify)_______

1

2 3

4

5

412 Have you ever had get nutritional counseling at your health facility?

Yes No

Don’t know

1 2

3

413 Have you ever had pulmonary tuberculosis

in the past six month?

Yes

No

Don’t know

1

2

3

414 If yes, are you taking anti Tb drug? Yes

No

Don’t know

1

2

3

415 If yes, have you had any side effects? Yes

No Don’t know

1

2 3

416 If yes, please specify what side effect(s). ________________________________

________________________________

417 Have you been unwell in the last 2 weeks prior to the survey?

Yes No

Don’t know

1 2

3

If no stop here

418 If yes, have you been taking any drugs? Yes

No Don’t know

1

2 3

419 If yes, have you had any side effects? Yes

No

Don’t know

1

2

3

420 If yes, please specify what side effect(s). ________________________________________________________________

Part V. Behavioral related factor

501 Have you ever smoked cigarette? Yes

No Don’t know

1

2 3

If no go #

502 Do you smoke cigarettes currently? Yes

No

Don’t know

1

2

3

503 Have you ever drunk alcohol? Yes No

Don’t know

1 2

3

504 Do you drink alcohol now? Yes No

Don’t know

1 2

3

505 Have you ever used soft drugs (e.g.

Khat, Shisha)

Yes

No Don’t know

1

2 3

If yes go

#506

51

506 Do you use soft drug currently? Yes

No

1

2

507 Have ever use hard drugs(cocaine,

morphine and others)

Yes

No Don’t know

1

2 3

If yes go #

508

508 Do you use hard drug currently? Yes

No

1

2

PART VI. Clinical characteristics of study participants( secondary data)

601 WHO clinical AIDS staging of a patients Stage I

Stage II Stage III

Stage IV

1

2 3

4

602 Adherence to HAART in past 6 month Good adherence

Fair adherence Poor adherence

1

2 3

603 What is current CD4 cell count of the study

participants

______cells/mm3

604 ART duration ≤ 12 month

>12months

1

2

605 How many times does the patients have

Opportunistic Infections in the past six

month

None

1

2+

1

2

3

52

ANNEX II: GUIDELINE FOR ANTHROPOMETRIC MEASUREMENT

To Measure Weight

- Make sure the scale pointer is at zero before starting. Ask the patient to remove any heavy

clothes.

- Ask the patient to stand straight and unassisted in the middle of the scale. Record weight to the

nearest 0.1 kg.

Standardize scales

- Standardize scales after and before of each measurement or whenever they are moved: Set the

scale to zero.

- Weigh one object of known weight and record the measured weight. (A container filled with

stone or IV fluids etc. if the weight is accurately known.)

- Repeat the weighing of these objects and record the weights again. If there is a difference of

0.01 kg or more between duplicate weighing, or if a measured weight differs by 0.01 kg or

more from the known standard, check the scales and adjust or replace them if necessary

To Measure Height

Ask the patient to remove her/his shoes and stand erect (knees straight and feet together), with

heels, buttocks, shoulder blades, and back of head against the wall, eyes facing straight forward.

Record height to the nearest 0.1 cm.

53

Guide to categorize “improved” and “unimproved” water source (UNICEF and WHO, 2012)

JMP category Supply technology

“Improved” -Piped water into dwelling, yard or plot

-Publiuc tap or standpipe

-Tubewell or borehole

- Protected spring

-Protected dug well

- Rain water collection

“Unimproved” - Unprotected dug well

- unprotected spring

- Cart with small tank or drum

- Tanker truck

- Surface water( river, dam, lake, pond, stream, canal

, irrigation canal)

- Bottled water

54

ANNEX III. AMHARIC QUESTIONNAIRE /አማረኛ ኮንሰት ፎርም

በሀዋሳ ዩንቨርሲቲ እና አዱስ ኮንቲኔታሌ የህብረሰተሰብ ጤና እንስቲትዩት ጥምር የህብረተሰብ ጤና ማስተርስ

ፕሮግራም

የ2ኛ ዴግሪ የምርምርና ጥናት መጠየቂያ

ጤና ይስጥሌኝ ስሜ ይባሊሌ፡፡ የሀዋሳ ዩኒቨርስቲ ተማሪ ነኝ፡፡

እኛ በዚህ ሆስቲታሌ ወይም ጤና አጠባበቅ ጣቢያ ከኤች አይ ቪ ቨይረስ ጋር የሚኖሩ ህብረተሰብ ሊይ የስነ ምግብ

ችግርን ሉያመጡ የሚችለ ነገሮችን/ችግሮችን ጥናት ስሇምንሰራ እርሶ የሚሰጡት መረጃ ሇጥናቱ ወሳኝና አስፈሊጊ

ከመሆኑም በተጨማሪ ከኤች አይ ቪ ቫይረስ ጋር ሇሚኖሩ ህብረተሰብ በተመሇከተ ከጥናቱ ውጠት በመነሳት

ሇወዯፊት መሻሻሌ ያሇበትን ችግር የሚጠቁም መሆኑን ሌንገሇጽልት እንወዲሇው፡፡

ስሇሆነም ጥያቄዎቹ የሚያተኩሩት ከቨይረስ ጋር የሚኖሩ ህብረተሰብን የስነ-ምግብ ችግር ሉያመጡ የሚችለ

ጉዲዮችን ሊይ ነው በመሆኑም ጥናቱ የሚዯረግባችዉ ቦታዎች እንዯሚከተሇዉ ይሆናለ በሀዋሳ ሪፈራሌ

ሆስፒታሌ፣ አዲሬ ሆስፒታሌ፣ ቡሽል ጤና አጠባበቅ ጣቢያ፣ ሚሉኒየም ጤና አጠባበቅ ጣቢያ እና በቱሊ ጤና

አጠባበቅ ጣቢያ ዉስጥ የፀረ ኤች አይ ቪ መዴሀጋኒት የሚጠቀሙ እና ፀረ-ኤች አይቪ መዴሃኒት ሇማግኘት

ክትትሌ ሊይ ያለ ሰዎችን ነው፡፡ ማንኛውንም ከርስዎ የወሰዴነውን መረጃ ከንተ ወይም ካንች ፈቃዴ ዉጪ

ሇማንም አይሰጥም፡፡ መረጃውን ሇመስጠት ከእርስዎ ሙለ ፈቃዴኝነት ይስፈሌጋሌ፡፡ ማንኛውን ጥያቄዎች

የመመሌስና ያሇመመሇስ ሙለ መብት አሇህ/ሽ፡፡በማንኛዉም ጊዜ ጥያቄዉን የማቋረጥ መብት አሇህ/ሽ፡፡

ስሇዚህ በዚህ ሆስቲታሌ ወይም ጤና አጠባበቅ ጣቢያ እርስዎን ከሊይ ሇተጠቀሰዉ ጥናት የተመረቱ ስሇሆነ

ሇምንሰራዉ ጥናት ችግር አምጭ ናቸዉ ያሌናቸዉን ጥያቄዎችን ሌንጠይቅዎ ፍቃዯኛ ነዎት?

አዎ ---------- አይዯሇሁም-----------

የኤርቲ መሇያ ቁጥር _________

የመረጃ ሰብሳብው ስም ---------------------------- ፊርማ ----------------------

መረጃው የተሰበሰበበት ቀን ---------------- የተጀመረበት ሰዓት-----------የተጠናቀቀበት ሰዓት------

ያረጋገጠው ሱፐርቫይዘር ስም ----------------------------ፊርማ --------------ቀን ---------------------

55

ክፍሌ አንዴ ፡ ሶሽዮ ዱሞግራፊን በተመሇከተ የመጠየቁ መመሪያ እያንዲንደን ጥያቄ ግሌፅ በሆነ መሌኩ ይጠየቅ

ተ.ቁ መሌሱን አክብቡ ወይም

ባድ ቦታ ሊይ ሙሊ/ሙይ

ምርጫ ዎች ኮዴ ዝሇሌ/ይ

101 ጻታ ወንዴ ሴት

1 2

102 እዴሜ (በአመት) ስንት ነው? ___________ አመት

103 እባክዎ ሏይማኖትዎ ምንዴን ነዉ? ኦርቶድክስ ክርስቲያን ፐሮቴስታት

ካቶሉክ ሙስሉም

ላሊ ከሆነ ይግሇጹ________

1 2 3 4 5

104 አሁን ያሇዎት የትምህርት ዯረጃዎ ምንዴን ነው?

ማንበብ እና መጸህፍ አሌችሌም ማንበብ እና መጸህፍ እችሊሇሁ

ከ1ኛ እስከ 4ኛ ክፍሌ ከ5ኛ እስከ 8ኛ ክፍሌ

ከ9ኛ እስከ 12 ኛ ክፍሌ ኮላጅ/ዩንቨርስቲ

1 2 3 4 5 6

105 ብሄርዎ ምንዴን ነዉ?

ሲዲማ ወሊይታ ጉራጌ አማራ ጌዴዮ ኦሮሞ

ላሊ(ይግሇጹ)_______________

1 2 3 4 5 6

106 እባክዎ የጋብቻ ሁኔታዎ ምንዴን ነዉ? ያገባ ያሊገባ/ች

አግብታ/ቶ የተፋታ/ች ባሎ/ሚስቱ የሞተበት/ባት

ላሊ ከሆነ ይግሇፁ_______________

1 2 3 4 5

107 መኖሪያ አዴራሻ የት ነዉ? ከተማ ገጠር

1 2

108 ስንት ሰዎች አብረዎት ይኖራለ? _______________ ሰዎች

109 የመኖሪያ ቤትን መሇከተ

ስንት መኝታ ክፍልች አሇዎት? _________________ ክፍሌ

ኤላክትሪክ ይጠቀማለ አዎ አሌጠቀምም አሊዉቅም

1 2 99

ክፍሌ ሁሇት ፡ ሶሾ ኢኮኖሚክ መጠይቅ

201 እባክዎ ዋና ስራዎ ምንዴን ነዉ? ተማሪ የቀን ሰራተኛ

ተቀጣሪ አርሶ አዯር

ነጋዳ

1 2 3 4 5

56

ስራ የሇኝም ላሊ ከሆነ ይግሇፁ____________

6 7

202 የቤቱ ሃሊፊ እርሶ ነዎት? አዎ አይዯሇሁም

1 2

አዎ ከሆነ ቁጥር 204 ሊይ ይሂደ

203 አይዯሇሁም ከሆነ የቤቱ ሃሊፊ ስራ ምንዴን ነዉ?

ተቀጣሪ ነጋዳ

የቀን ሰራተኛ አርሶ አዯር

ስራ የሊትም/የሇዉም ላሊ ከሆነ ይግሇጹ____________

1 2 3 4 5 6

204 ዋና የምግብ ምንጭዎ ከየት ነዉ? ከገበያ/ከግሮሰሪ ገዝቼ ከእርሻ

ከዘመዴ/ከጔዯኛ በእርዲታ

ከላሊ ከሆነ ይግሇፁ____________

1 2 3 4 5

205 እባክዎ የወር ገቢዎ በኢትዮጲያ ብር ስንት ነዉ?

__________ ብር

206 በቀን ስንት ጊዜ ይመገባለ ሶስት እና ከዚያ በሊይ ሁሇት ጊዜ እና በመሃሌ ሊይ እመገባሇሁ

ሁሇቴ ወይም ከዚያ በታች

1 2 3

207 የመጠጥ ዉሃ የሚያገኙበት ምንጭ ምንዴን ነዉ?

የታጠረ/የተከሇሇ የምንጭ ውሃ ያሌታጠረ/ያሌተከሇሇ ምንጭ ውሃ

የዝናብ ዉሃ የታሸገ ውሃ

ያሌታጠረ የጉዴጔዴ ውሃ የታጠረ የጉዴጔዴ ውሃ

የህዝብ ውሃ

የወንዝ፤የሀይቅ፤ የመስኖ፤የግዴብ፤

1 2 3 4 5 6 7

8

208 የአመጋገብ ሁኔታዎ ሊሇፉት 24 ሰዓት ምን ይመስሊሌ

ሶስት እና ከዚያ በሊይ ከሶስት በታች አሊውቅም

1 2 99

209 በቤትዎ ከሚከተለት ውስጥ የትኞቹ የመገናኛ ዘዳዎች አለ

ቴሇቨዥን ራዱዮ

ሞባይሌ ስሌክ መዯበኛ ስሌክ ኢንተረኔት

ላሊ ካሇይግሇጹ_____________

1 2 3 4 5 6

ክፍሌ ሦስት፡- የአንትሮፖሜትሪ የሌኬት ሁኔታ

301 ቁመት በሜትር

________ሜትር

302 ክብዯት በኪል ግራም ________በኪል ግራም

303 BMI በ ኪ.ግ/ሜትር2 ________ኪ.ግ/ሜትር2

57

304 ከስዴስት ወር በፊት የፀረ-ኤች አይቪ መዴሃኒት ከመጀመሩ ወይም የፀረ-ኤች አይቪ መዴሃኒት ቅዴመ ክትትሌ ከመጀመሩ በኃሊ ያሇዎት ክብዯት በኪ.ግ ስንት ነዉ

________በኪል ግራም

305 አሁን ያሇዎት ክብዯት ስንት ነዉ? ________በኪል ግራም

306 ክብዯት የቀነሱት በፐርሰንታይሌ ስንት ነዉ?

ከፍትኛ (ከ20% በሊይ) መካከሇኛ(ከ10.1 -20%)

ዝቅተኛ(ከ5-10%) ኖርማሌ(ከ5% በታች)

1 2 3 4

ክፍሌ አራት፡ጤና ነክ ጉዲዮችን እና ላልች

401 የፀረ-ኤች አይቪ መዴሃኒት(ART) ጀምረዋሌ

አዎ አሌጀመርኩም

1 2

ካሌጀምሩ ወዯ # 403 ይሂደ

402 ሊሇፉት ስዴስት ወር የፀረ-ኤች አይቪ

መዴሃኒት የጎኑየሽ ጉዲት (side

effect) አጋጥመዎታሌ?

አዎ

አሊጋጠመኝም

1

2

403 ኮትሪሞክሳዞሌ(Cotrimoxazole) መዴሃኒት ወስዯዋሌ?

አዎ

አሌወሰዴኩም

1 2

ካሌወሰደ ወዯ# 405 ይሂደ

404 አዎ፤ ከዎነ የጎንዮሽ ጉዲት (side effect) አጋጥመዉታሌ?

አዎ

አሌገጠመኝም

1 2

405 የስነ-ምግብ (nutritional) እርዲታ ያገኛለ?

አዎ

አሊገኝም

1

2

406 ኤች አይ ቪ ቫይረስ በዯሞዎ ዉስጥ መኖሩን ካዎቁ በኃሊ የአመጋገብ ሁኔታዎን ቀይረዋሌ

አዎ

አሌቀየርኩም

አሊዉቅም

1

2

99

407 አዎ ከሆነ መሌሱ ምን ሊይ ነዉ የቀየሩት

ጥራት ያሇዉ ምግብ

ዴግግሞሽ/ቁጥር ሊይ

የበሰሇ ምግብ መመገብ

ላሊ ከሆነ ይግሇፁ_____________

1

2

3

4

408 የኤች አይቪ ቫይረስ በዯመዎ መኖሩን ሇቤተሰበዎ ወይም ሇላሊ ሰው ነግረዋሌ?

አዎ

አሌነገርኩም

1 2

409 አዎ ከዎነ ሇማን ሇሚሰት/ሇባሌ ሇሌጆቼ

ሇወንዴም/ሇእህት ሇቤተሰብ አባሌ

ሇጔዯኛ

1 2 3 4 5

58

ላሊ ከሆነ ይግሇጹ________________ 6

410 የሆዴና አንጀት የህመም ነበርዎት ሇአሇፉት 6 ወራት?

አዎ አሌነበረኝም አሊዉቅም

1 2 99

411 ሊሇፉት 6 ወራት የምግብ መመገብ

ችግር ገጥመዎታሌ?

አዎ

አሌገጠመኝም

አሊዉቅም

1

2

99

ካሌገጠመዎት

ወዯ ቁጥር

413 ይሂደ

412 አዎ ከሆነ፣ ምን አይነት ችግር ነዉ? የምግብ ፍሊጎት አሇመኖር

ማቅሇሽሇሽ/ትዉከት

የመዋጥ ችግር

የአፍ ወይም የጉሮሮ ቁስሇት/ህመም

ላሊ ከሆነ ይግሇጹ________

1

2

3

4

5

413 የስነ-ምግብ የምክር አገሌግልት ህክምና

በሚወስደበት ጤና ዴርጅት

ተሰጥቶዎታሌ?

አዎ

አሌተሰጠኝም

አሊዉቅም

1

2

99

414 በሳንባ ነቀርሳ/Tuberculosis/ በሽታ

ሊሇፉት ስዴስት ወራት ታመዋሌ?

አዎ

አሌታመምኩም

አሊዉቅም

1

2

99

አሌታመምኩ

መ

ከሆነ ወዯ

#418 ይሂደ

415 አዎ ከሆነ መሌሱ የሳንባ ነቀርሳ

መዴሃኒት ጀምረዋሌ?

አዎ

አሌወስዴም

አሊዉቅም

1

2

99

416 አዎ ከሆነ የጎንዮሽ ጉዲት ነበርዎት አዎ

አሌነበረኝም

አሊዉቅም

1

2

99

417 አዎ ከዎነ ምን አይነት ነዉ ____________________________

____________________________

418 ከዚህ ጥናት 2 ሳምንት በፊት ህመም

ነበረዎት

አዎ

አሌነበረኛም

አሊዉቅም

1

2

99

አሌነበረኛም

ከሆነ ወዯ

ክፍሌ

አምስት

ይሂደ;

59

419 አዎ ከሆነ መዴሃኒት ወስዯዋሌ አዎ

አሌወሰዴኩም

አሊዉቅም

1

2

99

420 አዎ ከሆነ የጎንዮሽ ጉዲት ነበረዎ አዎ

አሌነበረኝም

አሊዉቅም

1

2

99

421 አዎ ከዎነ ይግሇጹ ____________________________

_______________________

ክፍሌ አምስት. የባህሪ ወይም ብሄቨራሌ ነክ ጥያቄዎች

501 ሲጋራ አጭሰዉ ያዉቃለ አዎ

አሊጨስኩም

አሊዉቅም

1

2

99

አሊጨስም

ከሆነ #

503 ይሂደ

502 አሁን የጨሳለ አዎ

አሊጨስም

አሊዉቅም

1

2

99

503 አሌኮሌ ያሇዉ መጠት ጠጥተዉ

ያውቃለ

አዎ

አሌጠጣሁም

አሊውቅም

1

2

99

504 አሁን የአሌኮሌ መጠጥ ይጠጣለ አዎ

አሌጠጣም

አሊዉቅም

1

2

99

505 ጫት፤ሺሻ ወይም ላሊ ተጠቅመው

ያዉቃለ

አዎ

አሌተጠቀምኩም

አሊዉቅም

1

2

99

506 አሁንም ጫት፤ሺሻ ወይም ላሊ

ይጠቀማለ

አዎ

አሌጠቀምም

አሊወቅም

1

2

99

507 ኮኬን፤ ሞረፊን ወይም ላልችን

ተጠቅምው ያውቃለ

አዎ

አሌተጠቀምኩም

አሊውቅም

1

2

99

60

508 ኡሁንም ኮኬን፤ሞርፊን ፤ላልችን

ይጠቀማለ

አዎ

አሌጠቀምም

አሊውቅም

1

2

99

ክፍሌ ስዴስት. ክሉኒካሌን ሁኔታን በተመሇከተ (clinical characteristics of study participants)

601 የአሇም ጤና ዴርጅት የኤዴስ ዯረጃ ዯረጃ አንዴ

ዯረጃ ሁሇት

ዯረጃ ሦስት

ዯረጃ አራት

1

2

3

4

602 ሊሇፉት ስዴስት ወራት ከጸረ-ኤች

አይ ቪ መዴሃኒት ጋር ያዎት

ቁርኝት(adherence) ምን ይመስሊሌ

ጥሩ ቁርኝት (Good adherence)

መካከሇኛ ቁርኝት (Fair adherence)

ዯካማ ቁርኝት (Poor adherence)

1

2

3

603 የCD4 ሴሌ ቁጥር መጥፎ/ከፍተኛ ቀንሷሌ (Sever)

በመካከሇኛ ቀንሷሌ(Moderate)

ትንሽ ቀንሷሌ (Mild)

ጥሩ (Not significant)

1

2

3

604 ስንት ወር ሆነዎት ፀረ ኤች አይ ቪ

መዴሃኒት ከጀመሩ

12 ወር እና ከዚያ በታች

ከ12 ወር በሊይ

1

2

605 ሊሇፉት ስዴስት ወር ሇኤች አይ

ቪ/ኤዴስ ተጔዲኝ በሽታዎች ሇስንት

ጊዜ ተጋሌጠዋሌ?

ምንም አሌተጋሇጥኩም

ሇአንዴ ጊዜ

ሇሁሇት ጊዜ እና ከዚያ በሊይ

1

2

3

61

Annex IV. Hawassa City Maps

62

DECLARATION

I declare that this thesis is my original work in partial fulfillment of the requirement for the degree

of Master of Public Health. I also declare that it has never been presented in this or any other

university and that all resources and materials used in the thesis have been duly acknowledged.

Student Name: Sisay Tadesse Signature: _________________

Place of submission: Hawassa University College of Medicine and Health Science, School of

Public and Environmental Health, Hawassa, Ethiopia

Date of submission: _____________________________________

This thesis has been submitted for examination with my approval as a university advisor.

Advisor Name: Achamyelesh G/Tsadik ( MPH, PhD fellow) Signature: ________________

Date of submission: _____________________________________