Prevalence and Factors Associated with Under Nutrition Among Newly Enrolled HIV Infected Adults Attending Ampath Ambulatory Clinic in Eldoret, Kenya

Background: Nutrition is the main foundation for health and development of the human being. HIV infection increases nutrient requirements and at the same time impairs nutrient intake and absorption. Poor nutrition increases the risk of opportunistic infections, further increasing energy and nutrient needs, thus accelerating the progression of HIV to AIDS. Study Population: Newly enrolled HIVinfected adult patients. Objectives: To investigate the prevalence of under nutrition among newly enrolled HIV-infected adults attending the Academic Model for Providing Access to Healthcare clinic (AMPATH). Methodology: A cross-sectional survey was carried out on 288 consecutively enrolled subjects. The prevalence of under nutrition was determined based on the World Health Organization recommended BMI cutoff points. The contents of 24-hour recalls were entered into a nutrient calculator to determine the nutrient content and compared to the Recommended Dietary Allowance in order to determine adequacy of food. Results: Of the 288 respondents in the study, 153 (54.4%) were female. For males and females the mean± (SD) daily energy and protein intakes were 1856± (536.8) Kcal/day, 1680± (517.3) kcal/day, 62.4± (20.7) g/day and 53.1± (17) g/day respectively. Folate, zinc, iron and vitamin A were significantly below the Recommended Dietary Allowances (RDA). Adjusting for energy and protein intake, those with adequate Folate intake had 88.9% lower chances of being-nourished (OR=.111, 95%CI 0.013, 0.973). Conclusion: Prevalence of under nutrition in the study population shows that 31.6% of subjects had inadequate Folate and Zinc intakes. Folate intake was a significant predictor of under-nutrition. It was recommended that patient health education on the need to consume foods rich in Folate and Zinc should be intensified in all the ambulatory clinics.


Introduction
The first case of Acquired Immune Deficiency Syndrome (AIDS) was reported in the United States of America in 1981 and in Kenya in 1984. AIDS is caused by the Human Immunodeficiency Virus (HIV), which is transmitted through sexual contact, infected blood, blood products or transplanted organs or tissues, and from an infected mother to a child. Almost three decades since the first AIDS case was discovered in Kenya, HIV and AIDS still remains a huge problem affecting social and economic development [1]. An estimated 1.4 million adults aged 15-64 years are infected with HIV and AIDS, with about one million rural and 400,000 urban residents infected [2]. The growing incidence of HIV and AIDS is also known to indirectly increase levels of under nutrition through its effects on food production. Under nutrition among People Living with HIV and AIDS (PLWHAs) manifests itself most commonly as weight loss in adults and children, and faltered linear growth (stunting) in children, as a result of deficiency in specific macro or micronutrients. Weight loss among PLWHA occurs due to reduced food intake (starvation), malabsorption, and sudden increase in energy expenditure, problems with energy utilization, or a combination of both [3]. The nutritional needs of PLWHA are influenced by several factors including age, physiological changes, level of physical activity, clinical state of health, metabolic rate and viral load count. To maintain good nutrition, an adequate intake of energy-giving foods, proteins, vitamins and minerals, fibre and water are vital. The fundamental concerns are to maintain a balance of foods from each food group and to consume a variety within each food group daily [3]. At the social level, food insecurity is a major cause of vulnerability to HIV, hence the need to invest in nutrition in order to break the vicious cycle between food insecurity and HIV vulnerability Therefore we investigate the prevalence and associated factors to under nutrition among newly enrolled HIV adults attending the AMPATH clinic.
PROBLEM STATEMENT: The number of people living with HIV in sub-Saharan Africa in 2008 was 2.4 million [4]; accounting for 67% of HIV infections worldwide; with 68% of new infections among adults. The region accounted for 72% of the world's AIDS-related deaths; in a year when Kenya had a prevalence of 7.8%. In 2007, an estimated 1.42 million people in Kenya are infected with HIV, the virus that causes AIDS [5]. In 2012, national HIV prevalence was estimated to be 5.6% among Kenyans aged 15-64 years, significantly lower than the HIV prevalence estimate in 2007. The significant decline in HIV prevalence was observed among both women and men. Still, women aged 15-64 years had higher HIV prevalence rates (6.9%) than men (4.4%) aged 15-64 years, and young women aged 20-24 years were at least three times more likely to be infected (4.6%) than young men of the same age group (1.3%). HIV prevalence in older adults aged 50-54 years remained high, at 8.4%, but was lower among those aged 55-59 years (4.4%) and aged 60-64 years (4.0%) [12].
Nutrition and HIV are linked. Undernourished people have compromised immune systems, making them more vulnerable to HIV infection. HIV infection, in turn, makes it harder for people to absorb nutrients from food because of frequent diarrhea and other gastrointestinal anomalies. It also disrupts the absorption of fats and fat-soluble vitamins, exacerbating nutrient deficiencies. The virus also raises the energy spent resting, meaning that infected people need more protein than usual. There are social as well as clinical implications. Hunger can force people into risky behavior, such as selling sex for food or money, heightening their chance of HIV infection.
Any immune impairment as a result of HIV and AIDS can contribute to under nutrition, which leads to immune impairment, worsening the effects of HIV and contributing to a more rapid progression of the disease. In a sense, under nutrition both contribute to and is a result of HIV disease progression [7]. When an under nourished person acquires HIV, he/she progresses faster to AIDS because the body is already weak and cannot fight co-infections. A well-nourished person has a stronger immune system for coping with HIV and fighting illness. HIV infection affects nutrition through increases in resting energy expenditure, reductions in food intake, nutrient malabsorption and loss, and complex metabolic alterations that culminate in weight loss and wasting common in AIDS. The effect of HIV on nutrition begins early in the course of the disease, even before an individual may be aware that he/she is infected with the virus. AIDS-wasting syndrome is defined as a 10% weight loss of baseline body weight plus either chronic diarrhea (two loose stools per day for more than 30 days) or chronic weakness and documented fever for 30 days or more, intermittent or constant, in the absence of a concurrent illness or a condition other than HIV infection: wasting is characterized by a loss of lean tissues, responsible for most of the body's metabolic functions including processing medications. The body starts to lose its major functions as damage to the immune system and weight loss progress [7]. Symptoms and illnesses commonly caused by HIV infection have nutritional consequences that can lead to malnutrition. These include Anorexia (which leads to general weight loss and is common when individuals are depressed or living in socially and emotionally unfavorable environments) Diarrhea (a person has several loose bowel movements in a day), Fever (people with acute or chronic fever may have chills, sweat excessively, have muscle and joint aches, or be fatigued -this causes increased energy requirements) and anemia (this is a low level of hemoglobin in the blood -HIVinfected persons who are anemic generally progress faster to AIDS than those who are not). As HIV infection progresses, it causes a catabolic state and increased susceptibility to infection which are compounded by lack of caloric and other nutrient intake, leading to progressive worsening of under nutrition. Under nutrition therefore both contributes to and is a result of HIV disease progression [13]. A well nourished person has a stronger immune system for coping with HIV and fighting illness. It is thus apparent that nutrition intervention at enrollment may have a positive impact on HIV outcomes. JUSTIFICATION: About 1.02 billion People are estimated to suffer from under nutrition globally [8] with 99% of these living in developing countries. Poor nutrition leads to an increase in opportunistic infections; increasing energy ad nutrient needs thus accelerating the progression of HIV to AIDS. It also leads to reduced food production; hence declining income and ultimately a negative impact on the economy. On the other hand, good nutrition leads to an improved immune system, boosts energy and helps recovery from opportunistic infections. Assessment of nutritional status and nutritional risks through the determination of the

Study Area and Population
The study was conducted at the AMPATH Centre, Moi Teaching and Referral Hospital (MTRH) Eldoret, Kenya. Eldoret is located 320km west of Nairobi; with an estimated population of 400,000 people. AMPATH is a working model of urban and rural HIV preventive and treatment services in the public sector; caring for more than 100,000 HIV-infected adults and children. MTRH is the second National referral hospital in Kenya, and hosts the Medical school of Moi University. The study population consisted of newly enrolled HIV-infected adult patients.

Study Design and Sampling
A descriptive cross-sectional study was carried out on 288 consecutively enrolled subjects.

Data Collection
Data was collected using interviewer administered questionnaires which contained both open and close ended questions. This was used to determine socio demographic factors of the respondents that affected their nutritional status. A 24 hour recall was also completed at that time and was used to determine adequacy of the micro and macro nutrients intake and diet diversity at individual level. Anthropometric measurements of weight, height and arm circumference were recorded. Measurements of fat located just underneath the skin (subcutaneous fat) were done at the triceps using the skin fold thickness callipers.
A complete list of all foods and beverages consumed over the previous 24-hour period was obtained and adequacy of nutrient intake calculated. The derivatives from anthropometric measurements included Body Mass Index, Mid Upper Arm Muscle Area and Body Fat percentage. BMI was computed following the standard formula: BMI= Weight (kg)/height (m²).
The following World Health Organization recommended BMI cut-off points were utilized to determine the nutritional status of the subjects: Nutritional status BMI (kg/m²) Under nutrition <18.5 Normal 18.5-24.9 Overweight ≥25.0

Data Analysis
The prevalence of under nutrition was determined based on anthropometric measurements. Household food security was assessed using the Household Dietary Diversity Score (HDDS) and Household Food Insecurity Access Scale (HFIAS). Adequacy of nutrient intake was assessed using the 24hr recall. All the analysis was done using SPSS version 12.0 and nutrient calculator. Mean nutrient intake was compared with RDA. Frequency tables, means, chi-square test of association and analysis of variance (ANOVA) were employed. Significance was assumed for p≤ 0.05. Minority 32(11.1%) were in WHO stage 4 as in Figure 2.

Prevalence of Under Nutrition
In the study, 91(31.6%) were underweight while 34(11.8%) were overweight as indicated in Figure 3. The prevalence of under nutrition based on BMI is 31.6%

Relationship Between CD4 Cell Count and Body Mass Index
A correlation between Body Mass Index and the CD4 count of the respondents yielded a Pearson's value, r=0.111, and an associated probability, p=0.06. A bigger percentage of female respondents than male were undernourished. Among the 128 male patients studied, 2(1.6%) had unhealthy hipratio, while 120 (75%) of the women had unhealthy hip ratio (Cut-offs Male ≤1 and Female ≤0.8).

Factors Associated with Under Nutrition
The Mean daily intake of energy was 1856.5± 536 kcal/day and 1658±513Kcal/day for male and female respectively. Macronutrient intake was generally low compared to the RDA with a mean protein intake of 62.4 ± 20.1.g/day for males and 53.1± 17.6g/day for females.

Household Food Insecurity Scale (HFIAS)
In order to ascertain the number of households that were experiencing household food insecurity-related conditions, a set of questions proposed by FANTA [13] household food insecurity access scale for measurement of food access indicator guide version 3.0 was used.

Prevalence of Household Food Insecurity
To be able to determine the household food insecurity prevalence, households were categorized into four levels of household food insecurity. These included food secure, mild, moderately and severe food insecure (Figure 4).

Household Dietary Diversity Score (HDDS)
In order to ascertain the number of households that were experiencing household food diversity related conditions, a total of 12 food groups were tabulated ranging from A-L [10], with either 0 (No) or 1(Yes) and each household was asked about the different food groups consumed. An increase in the average number of different food groups consumed provided a quantifiable measure of improved household food access. In general, any increase in household dietary diversity reflects an improvement in the household's diet. Using the cut off point as 5 after summing up the responses on the different types of food consumed in the households, 56(20%) of the households did not consume diversified diets ( Figure 5).

Discussion
The findings on the prevalence of under nutrition from this study were high (31.6%) compared to two studies [4] and [5]. Findings are however lower than those of another study [7]. These differences may have resulted due to the fact that this study was carried out in a specific locality within Kenya with a smaller population as opposed to the 11 countries sampled in the other studies. There was no statistically significant trend of adults with chronic energy deficit living in food insecure households (as measured by HFIAS and HDDS). One possible reason for the lack of association between BMI and HDDS is that only the diet of the previous day is considered while an adult's body weight is reflective of a longer time period. Energy and Protein intake in the study population were below the Recommended Daily Allowances for adults and strongly associated with under nutrition. Macro and micronutrient intake were below the Expected Average Requirements. These findings are in agreement with other studies [8] and [9]. Low serum vitamin A levels are associated with increased mortality, more rapid disease progression and an increased maternalfetal transmission. Zinc is an important micronutrient in immune function, and therefore Zinc deficiency is of great importance in HIV infection. The study findings indicated that there was a decrease in proportion of people with low BMI with increasing level of education. This is consistent with a study [4]. There was no significant association between CD4 count and nutritional status and this was in line with a study [5]. Despite majority of the study population being food diverse, more than half were mildly food insecure. The household food security condition based on Household Food Insecurity Access yielded comparable results to those of a study [11]. In the same study Households had limited variety of foods based on the Household Dietary Diversity Score as opposed to the current study outcomes where 80% of the study population consumed diversified diets. These differences could be attributed to seasonality, geographical differences, study population size, study design and political stability.

Conclusion and Recommendation
Prevalence of under nutrition in the study population shows that 31.6% of subjects had inadequate Folate and Zinc intakes. Folate intake was a significant predictor of undernutrition. We recommend that patient health education on the need to consume foods rich in Folate and Zinc should be intensified in all the ambulatory clinics.