ASSESSMENT OF THE EFFECT OF NUTRITIONAL STATUS ON

TREATMENT RESPONSE AMONG HUMAN IMMUNODEFICIENCY

VIRUS POSITIVE ADULTS ON HIGHLY ACTIVE ANTIRETROVIRAL
TREATEMENT IN JIMMA UNIVERSITY SPECIALIZED HOSPITAL

By Selam Bogale
(Medical Intern)

A RESEARCH PAPER TO BE SUBMITTED TO COLLAGE OF PUBLIC

HEALTH AND MEDICAL SCIENCES, JIMMA UNIVERSITY IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR DEGREE OF
MEDICINE (M.D.)

Jimma, Ethiopia
August, 2011
 ASSESSMENT OF THE EFFECT OF NUTRITIONAL STATUS ON
TREATMENT RESPONSE AMONG HUMAN IMMUNODEFICIENCY
VIRUS POSITIVE ADULTS ON HIGHLY ACTIVE ANTIRETROVIRAL
TREATEMENT IN JIMMA UNIVERSITY SPECIALIZED HOSPITAL

By Selam Bogale
(Medical Intern)

ADVISORS
Alemshet Yami (MD )
Argaw Anbelu (MD,Phd)
Mirkuze Woldie (MD,MPH)
August, 2011
JIMMA, ETHIOPIA

2
 ABSTRACT

Introduction:- HIV infection; a global pandemic, since its first recognition has
caused serious socio-economic problems especially in Sub-Saharan Africa where
up to 38.8% adult prevalence was reported. HIV/AIDS added on food shortage has
brought some countries to a crisis. Through nutritional status is predictive of
survival and functional outcome in HIV patients it is not well dealt especially in
those on HAART.

Objective:- To assess prevalence of mal-nutrition and its effects on treatment

response in HIV positive adults in JUSH .
Method;-A retrospective cross sectional study design will be used and a data of
313 patients on HAART at JUSH ART-clinic will be analyzed SPSS window 13
version software.
Result

A total of 313 patients of HAART of JUSH ART clinic were included in the study and
46% of them have evidence of malnutrition. And malnutrition is common in
advanced stages a 77.78% in stage IV patients while 23.07% of stage I patients are
malnourished. 1.2% of the patients have immunologic failure with all of them
having a CD4+ count less than 100 at initiation of HAART.

Conclusion and Recommendation

Malnutrition is prevalent in HIV–AIDS patients and should be managed

accordingly especially in those with advanced disease

I
 ACKNOWLEDGMENT

I would like to express my deepest gratitude to my advisors Dr Alemeshet Dr

Mirkuzie and Dr Argaw for their invaluable supervision since the development of
the topic.
My heartfelt thanks goes to my family and W/o Tiruwork A. for their support in
the development of this proposal.

List on Content

II
ABSTRACT.....................................................................................................................................................I

ACKNOWLEDGMENT...................................................................................................................................II

List on Content...........................................................................................................................................III

List of Abbreviations....................................................................................................................................V

List of dummy Tables.................................................................................................................................VI

CHAPTER ONE..............................................................................................................................................1

Introduction.................................................................................................................................................1

1.1 Background Information....................................................................................................................1

1.2 Statement of the problem.................................................................................................................2

CHAPTER TWO.............................................................................................................................................4

Literature review.....................................................................................................................................4

CHAPTER THREE..........................................................................................................................................6

3.1 Significance of the study....................................................................................................................6

CHAPTER FOUR............................................................................................................................................7

Objectives....................................................................................................................................................7

4.1 General............................................................................................................................................7

4.2 Specific............................................................................................................................................7

CHAPTER FIVE..............................................................................................................................................8

Methodology...........................................................................................................................................8

5.1. Study area and period....................................................................................................................8

5.2. Study design..................................................................................................................................8

5.3 . Population....................................................................................................................................8

5.3.1. Source population...................................................................................................................8

5.3.2. Study population..................................................................................................................8

5.4 Sampling Size and sample technique.........................................................................................8

III
 5.5. Variables...........................................................................................................................................8

5.5.1 Independent............................................................................................................................8

5.5.2 Dependent..................................................................................................................................8

5.6. Data collection and analysis..........................................................................................................9

5.7. Data Quality assurance....................................................................................................................9

5.8. Ethical Consideration........................................................................................................................9

5.9 Operational definition......................................................................................................................9

Discussion..................................................................................................................................................18

Conclusions and Recommendations..........................................................................................................21

Annexes I...................................................................................................................................................22

REFERENCES..........................................................................................................................................22

QUETIONNRES.......................................................................................................................................24

List of Abbreviations

AIDS- Acquired immunodeficiency syndrome

IV
BMI- Body mass index
BCM- Body cell mass
CDC- Center for disease control and prevention
DHS- Demographic & health surveys
ECOSOC- United Nations Economic & Social Council
FAO/UN- United Nations food and agricultural organization
FMOH- Federal Ministry of Health
JUSH- Jimma University specialized Hospital
HAART- Highly active antiretroviral treatment
HIV- Human immunodeficiency virus.
MUAC- Mid upper arm circumference
NAIDS- Nutritionally acquired immune deficiency syndrome
OI’s- Opportunistic infections
SRP- Student research program me
UNAIDS- Joint United Nations Program on HIV/AIDS
WHO- World Health Organization
ICAP- International cooperation for AIDS patients

List of dummy Tables

Table 1.Sociodemgraphic characteristics of patients on HAART at JUSH ART clinic 2003-2009GC

Table 2 Nutritional status of patients on HAART at JUSH ART clinic 2003-2009 GC

V
Table 3 Immunologic status (CD4+) of patients on HAART at JUSH from 2003 to 2009 GC at initiation of
and after 6 months of HAART

Table 4 Baseline BMI Vs CD4+ count after 6 months of HAART at JUSH ART clinic 2003-2009

Table 5 CD4+ count after 6 months of HAART versus socio-demographic characterstics in JUSH ART

clinic2003-2009 GC

VI
 CHAPTER ONE
Introduction
1.1 Background Information
An estimated 33.2 million people worldwide were living with HIV/AIDS in 2007; 2.5
million became newly infected and 2.1 million people lost their lives due to AIDS in the
same year. Though HIV/AIDS is a global problem Sub-Saharan Africa was and continues
to be the region most stricken by the disease. Nearly 68% of adults and 90% of children
who are HIV infected reside in this area 1. Ethiopia is among Sub-Saharan African
countries suffering from the pandemic. There were 1.7 million people living with
HIV/AIDS in 2005. Prevalence is 1.4% in those 15-49 year-olds, with a 1:2 male to female
ratio 2.
The rate of malnutrition is increasing in sub-Saharan Africa. HIV/AIDS added on food
shortage has brought some countries to a crisis. Malnutrition in HIV patients has several
causes including but not limited to the decrease in food intake, the effect of
opportunistic infections, metabolic derangement due to inflammatory process, diarrhea,
job drop out and neglect from family members and community 2. Nutritional status is
strongly predictive of survival and functional status during the course of HIV
infection3,4.
Curbing the incidence and prevalence of malnutrition is the major target of international
organizations like United Nations Economic and Social Council (ECOSOC) with the
strategy of The Millennium Development Goal-1(MDG-1). Though some researches
confirm the emergence of malnutrition in HIV patients there are no enough studies
done to let international and local organizations to have a guideline on the management
of the new variant famine (3).

1
1.2 Statement of the problem

Malnutrition & HIV negatively affect each other. HIV infection results in poor
nutrition. This vicious cycle results in weight loss reported in 95%-100% of all
patients in the advanced stages, loss of muscle tissue and body fat, micronutrient
deficiency, & reduced immune function. Both conditions affect the body in a more
or less similar fashion that is both predominantly affect the cell mediated
immunity. Before the era of HIV/AIDS, impairment of immune function caused by
malnutrition was called nutritionally acquired immune deficiency syndrome or
NAIDS. The synergetic effect of malnutrition and HIV/AIDS results in various
metabolic and immune system impairments ending in high rate of OI’s frequent
and prolonged hospital stay, increased adverse effects of drugs and decreased
survival 10.

The relationship between malnutrition and HIV/AIDS is well recognized especially

in Sub Sahara Africa where the disease was initially known as “slim disease”
because of the classic wasting syndrome typically experienced by HIV/AIDS
patients. Thought wasting remains an important hallmark of HIV/AIDS it is often
overlooked especially in those on HAART .The CDC defined the wasting syndrome
an AIDS indicator condition as the involuntary loss of more than 10% of baseline
body weight; also the definition is useful for epidemiologic purpose it lacked
substantive evidence and from a clinical stand point is not an appropriate
definition 5.

There is no international agreement regarding assessment of malnutrition in HIV

positive adults. Various indices like Body Mass Index (BMI), weight, Mid-upper

2
Arm Circumference (MUAC), skin fold thickness, serum albumin & electrolyte
values and Body Cell Mass (BCM) are suggested for nutritional assessment of
adults. BCM depletion remains the most important disease marker; which even
decreased in asymptomatic HIV patients 1. Patients with HIV associated wasting
irrespective of the underlying cause have a decreased rate of survival
independent of other factors 11 .

CHAPTER TWO

Literature review
The importance of nutrition in the context of HIV/AIDS is gaining more
recognition in various sectors, including the policy level and many researches are
under way in different parts of the world.[11]

3
In a study done on 77 HIV infected adults in Srinagarind Hospital, khan kaen
University medical center, Thailand in 1999, 41.3% of the patients were found to
have evidence of malnutrition. The mean BMI of this population was 18.9 in men
and 19.8 in women. Adults with OI’s were seen to have a high prevalence of
malnutrition (BMI of 21.0 Kg/m2 versus 17.7 Kg/m2 ) than those without OI’s. The
mean MUAC was 24.2 cm in men and 24.1 cm in women 5. ]

A meta analysis of Demographic And Health Survey (DHS) on HIV positive females
of reproductive age from 11 Sub Saharan Africa countries including Ethiopia
Showed a combined pooled prevalence of malnutrition ( based on BMI less than
18.5 Kg/m2) in HIV positive females to be 10.3%. The same source put a 15.3%
prevalence rate in HIV infected women in Ethiopia. The Meta analysis showed
that the prevalence of HIV associated malnutrition is higher among those living in
rural areas compared with their urban counterparts (6.8% versus 16.3%).
Professionally employed women were less likely to be underweight than skilled or
unskilled manual workers (9.0% versus 17.5%) and women not employed
(9.0%versus 11.6%). Wealth and educational status was also shown to have an
inverse relation with prevalence and severity of HIV associated malnutrition 6.

Treatment of HIV – infected patients with antiretroviral therapy (ART) leads to

improvement in CD+4 count and decreased viral load. A study conducted
Singapore in 2006 HIV referral hospital on 394 HIV positive adults showed that the
prevalence of underweight (BMI< 18.5kg/m2) to be 12% for those who started
HAART before 1997 compared to a 30% prevalence in those who started in 1999.
The same study showed the prevalence of underweight to be 70% in those having

4
CD+4 count less than 50/l compared with an 8% prevalence in those having CD +4
count less than 200/l. The result indicates that the prevalence of malnutrition
which has a vicious cycle with HIV is strongly associated with CD +4 count which is
one indicator of risk of opportunistic infections (OIS) hence survival. (7)

It is clear from the studies that malnutrition is prevalent in HIV/AIDs patients and
the severity varies with different variables like sex, residence, employment
indicating the need to ensure that HIV related malnutrition prevention &
management messages get across all strata of society2,6,7. In order to direct
the focus of prevention and management there should be a Clear data about the
burden at local basis. Lack of researches locally and inability to reach on
consensus on which indices to use and their cutoff points internationally has lead
to absence of organized work6.

CHAPTER THREE

3.1 Significance of the study

Among factors which affect response of HIV patients to HAART and survival
malnutrition which continues to be a main problem in sub Saharan Africa is not
given appropriate attention in our setup. This research is intended to show the
prevalence and impact of HIV related malnutrition and equip stake holders

5
working on HIV to have informed plan & action. The study will also help as a base
for future extensive studies.

CHAPTER FOUR
Objectives

4.1 General
The main aim of this study is to describe the prevalence of malnutrition
and effect of malnutrition on treatment response in those on HAART in
JUSH.

6
4.2 Specific
- To determine the nutrition status of the HIV positive adults in JUSH
- To assesses response of the patient to HAART
- To indentify factors affecting treatment response

CHAPTER FIVE
Methodology

5.1. Study area and period

The study was conducted in JUSH –ART clinic establish in 1995 E.C by the support
of International Cooperation for AIDS Patients (ICAP) and currently has 2 medical
doctors 3 pharmacists 8 Nurses , 5 counselors and 4 secretaries and the data was
collected for 2000-2002 E.C

7
5.2. Study design.
Retrospective cross-sectional study design will be used

5.3 . Population
5.3.1. Source population.

All HIV positive adults on HAART in JUSH-ART clinic

5.3.2. Study population

A data of 313 patient collected by simple random
sampling will be used
5.4 Sampling Size and sample technique
Simple random sampling was used and 313 patients were selected
5.5. Variables
5.5.1 Independent
o Sociodemographic Variable
5.5.2 Dependent
o Nutrition Status
o Treatment response

5.6. Data collection and analysis

A face-to face interview was made to socio demographic Variables. Weight
height and MUAC was measured by the data collectors and card was
reviewed for WHO stage, CD+4,. Data was analyzed using SPPS window 17

version software.

8
 5.7. Data Quality assurance
Data collectors was thoroughly be trained; the data was carefully collected
and checked for completeness before entry to computer

5.8. Ethical Consideration

Before stating the research a letter of supports was obtained from SRP and
given to JUSH medical director. Each patient was reassured that
confidentiality of information was maintained during data collection,
analysis and interpreted .Then consent was taken.

5.9 Operational definition

-Urban & rural -as used for administrative purpose
- Malnutrition – (Guidelines for infected approach to the national care for
HIV infected children Geneve WHO 2008)
Normal BMI >18.5 Kg/m2
Moderate – BMI 16-18.5 Kg/m2
Servers- BMI <16 Kg/m2
Malnutrition – Based on MUAC value– ((Guidelines for infected approach
to the national care for HIV infected children Geneve WHO 2008)
Sever <16 cm
Moderate 16-21 cm
Normal > 21 cm

o Occupation

9
 o Should be the owner for farmer & merchant or is employed in
private or government
- Malnutrition
o Based on either of the above cut off points
-Immunologic failure
 Persistent CD+4 count <100/N after 06 months of HAART
 A 50% reduction in CD+4 count from the on treatment peak

RESULTS

A total of 313 patients who are on HAART at JUSH were included in the study. 204
(65.18%) were females and 109 (34.8%) were males. The age range 25 to 29
includes the highest proportion that is 76 (24.28%) patients and most (90%) of the
patients are from 20 to 49 years. Most of the patients are Oromo by Ethnicity and
Orthodox in religion. 48(15.33%), 98 (31.31%), 52 (16.61%), 81(25.88%) and 34

10
(10.87%) of the patients are illiterate, grade 1-6, grade 7-8, grade 9-12 and > 12
respectively. Most of the patients are daily laborers followed by government
employees and unemployed. 70 (54.31%) of the patients are married and 56
(17.89%) are single.

Table 1.Sociodemgraphic characteristics of patients on HAART at JUSH ART clinic 2003-2009GC

Sex M 109 34.82%
F 204 65.18%
Total 313 100%
Age (yrs) 15-19 2 0.64%
20-24 28 8.95%
25-29 76 24.28%
30-34 74 23.64%
35-39 54 17.25%
40-44 33 10.54%

11
 45-49 19 6.07%
50-54 14 4.47%
>55 13 4.16%
Total 313 100%
Religion Orthodox 161 51.43%
Muslim 94 30.03%
Protestant 53 16.92%
Others 5 1.62%
Total 313 100%
Ethnicity Oromo 135 43.13%
Amhara 93 29.71%
Guraghe 18 5.75%
Keffa 35 11.8%
Others 32 10.23
Total 313 100%
Educational level Illiterate 48 15.33%
Grade 1-6 98 31.31%
Grade7-8 52 16.61%
Grade 9-12 81 25.88%
>12 34 10.87%
Total 313 100%
Occupation Unemployed 60 19.2%
Gov’t employee 73 23.3%
House wife 43 13.7%
Merchant 47 15%
Daily laborer 77 24.6%
Student 5 1.6%
Others 8 2.6%
Total 313 100%
Marital status Single 56 17.89%
Married 170 54.31%
Divorced 31 9.9%
Widowed 38 12.14%
Others 18 5.76%
Total 313 100%

Table 2 Nutritional status of patients on HAART at JUSH ART clinic 2003-2009 GC

Variable Number Percent

Baseline BM <16 55 17.6%

16-18.49 90 28.8%

>18.5 168 53.6%

12
 Total 313 100%

MUAC (in cm <16 4 1.28%

16-21 59 18.85%

>21 250 79.87%

Total 313 100%

At initiation of HAART MUAC was available for all patients and 250 (79.87%)
patients have MUAC >21 cm, 59 (18.85%) have MUAC 16-21 cm and 4(1.28) have
MUAC < 16 cm.From the 313 patients included in the study baseline BMI was
available for all and 46% (145) of them have evidence of malnutrition 17.6% (55)
and 28.8% (90) having severe and moderate malnutrition respectively. 38.6% (42)
and 50.5% (103) of males and females have malnutrition based on the above
cutoff points.

54.2%(26) of illiterates have malnutrition compared to 8(23.5%), 34(42%),

24(46.2%) and 53(54.1) of those greater than 12 grade, grade 9-12, grade 7-8 and
grade 1-6 with no statistically significant heterogeneity.

42.9% (58) of Oromos have evidence of malnutrition compared to51.7% (48),

38.9% (7) and 34.3% (12) in Amharas, Guraghes and others respectively with no
statistically significant correlation.

47.9% (45) Of Muslims have malnutrition compared to 47.8% (77) and 39.6% (21)
in Orthodox and Protestants with no statistically significant correlation.

25(44.7%) of singles have malnutrition compared to 68(40.0%), 18(58%) and

23(60.5%) in those who are married, divorced and widowed respectively having
no statistically significant correlation

77.78%(28) of the patients who started HAART being in the WHO clinical stage IV
have moderate to severe malnutrition compared to 50.35%(71), 3814%(37) and

13
23.07%(9) of those who started HAART being stage III , II and I respectively with a
very strong statistically significant correlation(p=0.000)

49%(47) of those who have a baseline CD4+ count less than 100 have moderate to
severe malnutrition compared to 50%(60) and 40%(36) of those who started
HAART with CD4+ count 100-200 and 201-330 respectively with no statistically
significant correlation.

37.14% (13) of the patients who have elapsed 6 months after initiation of HAART
have moderate to severe malnutrition compared to 47.48%(134) of those who
have taken HAART for more than 6 months.

Table 3 Immunologic status (CD4+) of patients on HAART at JUSH from 2003 to 2009 GC at initiation of
and after 6 months of HAART.

Variable No of patients Percentage

CD4+ count at initiation <100 96 31.137%

of HAART
100-200 120 39.22%

14
 201-350 90 29.41%

Total 306 100%

CD4+ count after 6 <100 4 2.05%

months of HAART
100-200 45 23.08%

201-350 146 74.87%

Total 195 100%

Most of the patients started HAART with CD4+ count between 100 and 200 and
96(31.13%) were having a count less than 100.195 patients have their CD4+ count
measured after 6 months of initiation of HAART 4 (2.05%) of them have
immunologic failure (persistence of CD4+ and count less than 100 after 6months)
and none has a 50% reduction in count.

Table 4 Baseline BMI Vs CD4+ count after 6 months of HAART at JUSH ART clinic 2003-2009

CD4+ count after 6 months of HAART

<100 100-200 >201

Number of Percent Number of Percent Number of Percent

patients patients patients

15
 BMI <16 0 0% 7 15.6% 25 17.1%
baseline
categorized 16-18.49 2 50% 14 31.1% 46 31.5%

>18.5 2 50% 24 53.3% 75 51.4%

Total 4 100% 45 100% 146 100%

Three of them are male and one female. Three of them started HAART being
stage III while 1 was stage IV. Half of them were having moderate degree of
malnutrition of initiation of HAART. Half of them are above grade 12 while the
rest between grade 9 and 12. Three of them are Oromo and the rest Amhara by
ethnicity. Half of the patients are Muslims and the rest are orthodox. None of the
above variables has a statistically significant correlation with immunologic failure.
All of the four patients who has immunologic failure were having an initial CD4+
count less than 100 with a very significant statistical correlation (p=0.000)

Table 5 CD4+ count after 6 months of HAART versus socio-demographic characterstics in JUSH ART
clinic2003-2009 GC

CD4+ count after 6 months of HAART

<100 100-200 >201 Total
Sex Male 3 18 46 67
Female 1 27 100 128
Total 4 45 146 195

16
 Educational Illiterate 0 8 23 31
level Grade1-6 0 15 44 59
Grade7-8 0 6 23 29
Grade9-12 2 9 43 54
>12 2 7 13 22
Total 4 45 146 195

Occupation Unemployed 0 7 25 32
Government 3 12 33 48
employee
Housewife 0 8 18 26
Merchant 0 6 23 29
Daily Laborer 1 11 39 51
Student 0 0 3 3
Others 0 1 5 6
Total 4 45 146 195
Marital status Single 1 10 25 36
Married 2 23 76 101
Divorced 0 5 20 25
Widowed 0 5 19 24
Others 1 2 6 9
Total 4 45 146 195

Discussion
Weight loss is very common in HIV and AIDS. And it has been correlated with
disease progression and mortality. Even moderate level of malnutrition has been
shown to have a detrimental impact on HIV outcome. This association has been
related to survival independent of CD4+ count. Almost half (46%) of the patients
included in the study have evidence of malnutrition, this result is almost similar to
the finding in Khon Kaen medical center in Thailand (41.3%). 50.5% (103) of

17
females have evidence of malnutrition this value is much higher than the 15.3%
prevalence of malnutrition in HIV positive females in Ethiopia. And 10.3% pool
prevalence in 11 Sub-Saharan African countries. 38.6% (42) of males have
malnutrition with no statistically significant variation in sex. Except for severe
malnutrition there is no statistically significant inverse relation between
malnutrition and educational level. 25% (12) of illiterates are severely
malnourished compared to 21.4% (21), 7.3% (9) and 16%(13) of those grade 1-
6,7-8, 9-12 respectively.

Socio-demographic variables used in the study didn’t show any statistically

significant relation with nutritional status and treatment response. In a study
done in eleven Sub-Saharan countries, nutritional status was strongly associated
with wealth index; the fact that no such relation is seen in this study might be due
to the use of income in this study and use of assets like ownership of radio, TV,
characteristics of dwelling like type of roof or floor, toilet facility and water source
which are widely used by international organization like The World Bank.

There is a very significant correlation between the nutritional status at initiation

of HAART and WHO clinical stage with a 77.8% (28) of the patients who started
HAART being in the WHO clinical stage IV have moderate to severe malnutrition
compared to 50.35%(71), 38.14%(37) and 23.07%(9) of those who started being
stage III, II and respectively.(p=0.00).

This clearly depict the fact that as the disease progresses (stage increases) the
various clinical and metabolic derangements are strong contributors of
malnutrition hence survival.

49% (47) of those who started HAART with cd4 count less than 100 have
moderate to severe malnutrition with no statistically significant correlation
between the two variables. And 34.9% of patients who started having CD4+ count
less than 200 have malnutrition compared to 8% prevalence in Singapore,
showing a higher rate of malnutrition in this study. 447.48% (134) and 37.14%
(13) of patients who took HAART for more than 6 months and less than 6 months
respectively have evidence of malnutrition, showing the fact that malnutrition is
still prevalent in those who are taking HAART.

18
 After 6 months of HAART immunologic failure was found in 4 (2.05%) patients
and all of them have an initial CD4+ count less than 100 (p<0.05) and there was
no statistically significant correlation with WHO stage, nutritional status and
socio-demographic variables.

Strength and Limitations of the study

There were several limitations of the study and a number of things should be
considered in interpreting the results. During a period of acute illness there will
be loss or shift of extracellular fluid (ECF) which artificially changes nutritional
status and such data is not available in the study. The absence of population
specific BMI cut-points will obviously alter the result as Ethiopians are generally
slimmer and shorter than Westerns up on whom the cut points are set. The
absence of CD4+ count after 12 months for most patients made me use only the

19
one at 6 months indicating immunologic failure might have existed. And the
absence of data regarding clinical and virologic failure made the result to be less
predictive of treatment response as it is not only the immunologic response that
predicts survival but clinical and virologic response. Regarding wealth only income
is available but assets and expenditure should have been included.

Despite the above limitations there are strengths of the study among which
heterogeneity of the study population is significant.

Conclusions and Recommendations

 Malnutrition is prevalent in HIV-AIDS patients in JUSH ART clinic and
management modalities should be implemented in those especially who
have advanced disease.

 Every HIV patient should have nutritional assessment while enrolled to

chronic care and managed accordingly.

20
  Health care workers should be equipped with adequate knowledge in the
newly evolved nutritional crisis.

 JUSH should undergo extensive study on nutritional status of HIV patients

and various factors that affect it to direct the focus of attention

Annexes I
REFERENCES
1/ UNAIDS: and WHO
AIDS epidemic update.
Geneva Switherland, 2007
2/ DSH -2005
3/ Lish Arrehag, Alex de waal, Alan white side

21
 ‘ New Variant tamine revisited: chronic vulnerability in rular Africa
4/ FAO/UN
The state of food insecurity in the world 2005: Eradicating world hunger-Key
to achieving the MDGS, page 1-10
Rome Italy un/ FAO-2005.
5/ Guenter p; et al
Relationship among nutritional status, disease progression and survival in
HIV infection
AIDSLINE Med Journal. Volume 6 page 2-11 philadel phia USA 1993
6/ Olalekan A Uthman
Prevalence and pattern of HIV related minutes among women is sub-
Saharan Africa;
Boston medical center (BMC) public health Journal volume 6 page 1-6
Boston USA 2008
7/ NI pation, et al
The impact of malnutrition on survival and the CD+4, count response in HIV
infected patients starting ART.
British HIV association Journal volume 7 page 323-330 2006 London UK
8/Consultation on Nutrition & HIV/AIDS in Africa: Guidance, lessons and
recommendations fro action- ICC Durbon, south Africa 10-13 April 2005.
9/Laura Wyaness
Taking forward Reaseach on adult malnutrition
Medical Journal at university of Aberdeen Uk Volume 22 page 1-3
Aberdeen UK 2004
10/ Liana Steenkamp; et al

22
 Nutritional status of HIV positive preschool children in South Africa
University of port Elizabeth. Field exchange issue 22 page 1-3 port
Elizabeth. South Africa 2004
11/ Commonwealth Regional Health Community Secretariat and the SARA
Project. Nutrition and HIV in East, Central & Southern Africa. Tanzania &
Washington DC.2001.
12/ Tamsin A . Knox , et al
Assessment of nutritional status, body composition and HIV associated
morphologic changes, Oxford Journals Volume 36, Issue supplement 2
page 63-68.

Annexes II
QUETIONNRES

College of Medical Science and public health department of Medical

Part I
Card No -----------------------
Site of care --------- Inpatient Out patient
Identification
Age ----------

23
 Sex M F
Residency Urban Rural
Occupation----------------------
Educational Status-------------------------
 Never been to school
 1-6
 7-8
 >12
Ethicists Religion
1/ Oromo 1/ Muslim
2/ Amhara 2/ Orthok
3/ Gurage 3/ Protestant
4/ Kefa 4/ Other
5/ Others
Part II(Antropometry at initiation of HAART)
Weight ( in kg) ------------------
Height ( in m) -------------------
BMI ( KG/m2) ( Base line ) ----------------------
MUCA(Cm)---------------------

Part III
1/ WHO Stage at enrollment to care
1/ Stage I 2/ Stage II
3/Stage III 4/ Stage IV
2/ CD+4 at initiation ______________
3/ Duration since HAART.
1/ < 6 mo 2/ >6 mo
4/ CD +4 Count at o6 months of HAART

24
1/ < 2000/ l 2/ 200-350/ l 3/ > 300/

25