Study area, design, and period
The study was conducted at Butajira Hospital which is found in Butajira town, Gurage Zone, Southern Nations Nationalities and People’s Region (SNNPR), located 135 km from the capital city, Addis Ababa, Ethiopia. The town lies on the average at 2,100 m above sea level. Butajira Hospital is a zonal hospital with 110 beds that gives health services for people living in Butajira and the surrounding rural kebeles. The study was an institution-based cross-sectional study conducted from October 2013 to June 2014.
Populations
The source populations were all adult PLWHA in Butajira town and the surrounding area that were enrolled for ART follow-up service at Butajira Hospital. The study populations were people with the age of 18 years and above who were currently receiving ART. Patients who were receiving ART and involved in ART follow-up clinic at Butajira Hospital and aged 18 years and above were included in the study. However, pregnant women, lactating mothers (6 months of postpartum), and seriously ill and/or patients with spinal deformity were excluded.
Operational definition
Drug adherence status: it was estimated by percent of missed dose enclosed in the last 6 month follow-up time from patient ART follow-up form combined with self-reported adherence measurement technique by asking the patients about the number of times they have missed taking their pills each month and recorded. The category was based on WHO classification.
Good adherence: there is good adherence if the average adherence is greater than 95% (he/she missed ≤2 doses of 30 doses or ≤3 doses of 60 doses).
Fair adherence: there is fair adherence if the average adherence is 85%–94% (he/she missed 3–5 doses of 30 doses or 3–9 doses of 60 doses).
Poor adherence: there is poor adherence if the average adherence is <85% (he/she missed ≥6 doses from 30 doses or >9 doses of 60 doses).
Sample size and sampling technique
The sample size was determined using single population proportion formula taking 22.1% [18] prevalence of malnutrition among adults with HIV/AIDS on ART with 5% marginal error and 95% confidence interval (CI) of certainty (alpha = 0.05). In this study, 15% of non-response rate was taken, and the final sample size was determined as 305. A systematic random sampling technique was used to select the study subjects. According to the hospital report, on average, 10–20 patients that were currently taking ART have been visiting the hospital daily. Considering 3 months of study period, 660 patients were expected to visit the hospital. Since the sample size was determined as 305, the sampling interval was determined as 2. Of the first two subjects, one patient was randomly selected by lottery method; and then every second patient was selected to participate in the study.
Socio-demographic data
The data was collected from March to May 2014 using structured questionnaire. Socio-demographic characteristics were focused on data such as age, sex, monthly income, and educational and marital status together with nutrition and clinical-related characteristics were collected. Four data collectors (one nurse, one health officer, and two laboratory technicians) were recruited, and 2 days of training were given. The data collection process was followed daily by the principal investigator.
Laboratory data
Data on opportunistic disease in the past 6 months, WHO clinical stages of disease, drug adherence, and chronic diseases were obtained from patient charts and ART follow-up forms. CD4+ T cell count was measured with BD FACS machine (US) and categorized according to its clinical significance. Hemoglobin was measured with Cell Dyne hematology analyzer (US). Hemoglobin level ranged between 13–17 and 12–16 g/dl was considered as normal for male and female patients, respectively. Patients were graded anemic when the hemoglobin concentration was <12 and <13 g/dl for male and female patients, respectively.
Anthropometric data
Anthropometric measurements (weight, height) were recorded by a trained nurse. Weight of the participants was measured in kilograms with 0.1 kg increments using standard beam balance, and the scale was checked at zero before and after each measurement. Each participant was asked to remove heavy clothes. Measurement of height was conducted using the standard measuring scale and recorded to the nearest 0.5 cm. The participants were asked to take off their shoes, stand erect, and look straight in vertical plain.
Stool sample collection and microscopy
About 2 g of stool samples were collected in a clean leak-proof cupped plastic container following standard operating procedures. Each sample was examined by two clinical laboratory technicians independently for intestinal parasites using direct microscopic and concentration methods at Butajira Hospital parasitology laboratory. In the case of direct microscopic examination, stool samples were mixed with physiological saline (0.85% NaCl) on a microscope slide, covered with a cover slip, and then examined microscopically using low power objective first and high dry power objective to examine cysts of intestinal parasites. In the case of formal-ether concentration method, about 2 g or 2 ml of stool sample was mixed with 10 ml of normal saline solution and thoroughly mixed. This was filtered through two layers of gauze into a centrifuge test tube and centrifuged for 1 min at a speed of approximately 25,000 rpm for 10 min. When the supernatant fluid was very cloudy, the deposit was washed again by mixing it with 10 ml of normal saline. After pouring or removing the supernatant fluid, 10 ml of formaldehyde solution (10% formalin solution) was added to the sediment. After mixing the suspension well and allowed to stand for 5 min, 3 ml of ether was added and was immediately stopped and vigorously shacked for 30 s. The preparation was centrifuged for 1 min at low speed, usually 1,500 rpm. There appeared four layers in the preparation; the first layer which is an ether, the second layer which is a debris, the third layer which is a formaldehyde solution, and the fourth layer which is the deposit containing stages of parasites (cysts, egg, and/or larvae). The supernatant was removed by tilting the tube and poured off all the fluid. The sediment was mixed with the remaining small fluid, and about two drops of the deposit was placed on a slide, to which a drop of iodine solution was added and covered with a cover slide. The entire preparation was examined using × 10 objective for protozoa eggs and × 40 objective for cysts.
Quality control
The questionnaire was adapted and modified into our context from previous literatures. It was prepared first in English, translated into the local language Amharic, and then retranslated back to English by an expert to maintain its consistency. Training was given for data collectors and supervisor. Pre-testing of the questionnaire was made on 20 patients receiving ART in the nearby health center 3 weeks prior to the actual survey. Data collection process was strictly followed day to day by the supervisor and principal investigator. Standard operating procedures were followed during sample collection, processing, transportation, and identification of intestinal parasites. Data was checked for completeness, coded, and first entered in to EPI-info version 7; then, it was rechecked and transferred to Statistical Package for Social Science (SPSS) version 20 for analysis. Chi-square was used to carry out descriptive analysis. Bivariate and multivariate logistic regression analyses were used to assess the effect of the various factors on the level of malnutrition and to control possible confounders. The absence of multi-co-linearity was checked by using VIF/tolerance. The model adequacy was checked by using Hosmer and Lemeshow goodness of fit test. P value ≤0.05 at 95% CI was considered statistically significant.
Ethical consideration
Ethical approval was obtained from the ethical review committee of the School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, prior to data collection. Permission was taken from Butajira Zonal Hospital administrators. Written informed consent was obtained from each individual after the purpose of the study was explained. Participants were told that they had full right to participate or not, and they were also informed that all the data obtained from them would be kept confidential using codes instead of any personal identifiers. Any study participants who were positive for intestinal parasite were referred to ART clinicians for treatment. Finally, those participants identified as undernutrition were given nutritional counseling and RUTF in collaboration with the clinicians working in ART clinic at Butajira Hospital.
