Overnutrition and its associated factors among adult human immunodeficiency virus positive patients on antiretroviral therapy, Northwest, Ethiopia

Background Anti-retroviral therapy was introduced to treat human immunodeficiency virus patients; comorbidities affecting individuals with human immunodeficiency virus-positive have changed dramatically, with increasing the prevalence of overnutrition. Overnutrition has increased from time to time in people living with the human immunodeficiency virus. However, there is scarce adequate documented evidence regarding nutrition on human immunodeficiency virus Objective The study aimed to assess the magnitude of over nutrition and its associated factors among human immunodeficiency virus receiving antiretroviral therapy Methods We used a cross-sectional study design to collect data from 422 participants from Debre Markos hospital. We used a systematic sampling technique to select the total number of participants. The outcomes of Data were entered, and coded using Epi-data version 4.1 and analysed using STATA Version 14.1. We performed a multivariable logistic regression model to identify determinants of over-nutrition at a p-value of less than 0.05. Results The magnitude of overnutrition was 19.7% (95%CI: 14.6–25.4). Age group > 45 years (AOR: 3.18:95%CI: 1.09, 9.22), being farmer (AOR: 0.068, 95%CI (0.007, 0.611), family size greater than or equal to 4 (AOR: 3.18:95%CI (1.09–9.22), viral load less than 1000 copies/ml (AOR: 4.45 95%CI (1.69–11.76), and use of prophylaxis therapy (AOR: 2.67:95%CI (1.138–6.291) were significantly associated with over nutrition. Conclusions In this study one-fifth of Human Immunodeficiency Virus/Acquired Immunodeficiency Virus patients had over nutrition. In this study, the magnitude of overnutrition is high associated with a viral load of fewer than 1000 copies/cell, age greater than 45, and having taken prophylaxis therapy. Therefore, education about lifestyle change, regular monitoring of weight, regular nutritional assessment, and intervention of the existed problems like doing regular exercise is highly recommended.


Introduction
Overnutrition is a patient with a body mass index between 25 and 30 Kg/m 2 and greater than 30 Kg/m 2 1 . According to the World Health Organization (WHO), overnutrition remains "one of today's most blatantly visible-yet most neglected-public health problems" 2 . The prevalence of overnutrition across the world has increased by more than 200% since 1980 with nearly 2 billion adults estimated to be overnutrition in 2014 3 . The prevalence of overnutrition is an increasingly important public health concern in sub-Saharan Africa, especially in urban areas 4 . Anti-retroviral therapy was introduced to treat HIV infection, and comorbidities affecting individuals with HIV infection have changed dramatically, with increasing the prevalence of overnutrition 5 . Human immunodeficiency virus-infected individuals are seriously affected by nutrition 5,6 , and the prevalence of overnutrition is also rising 7,8 . Long-term ART is associated with a multitude of metabolic abnormalities of over nutrition similar to uninfected individuals, evidenced that a combination of treated HIV infection and excess adiposity may compound the risk for the development of comorbid conditions 9 . Overnutrition is a growing public health problem among HIV-positive people on ART worldwide. Increased weight and physical inactivity have been attributed to overnutrition among HIV-positive people on ART 10 . Overnutrition among people with ART has been characterized by a dorso-cer-vical fat pad and visceral fat accumulation that may increase the risk of cardiovascular diseases 11 . Overnutrition has increased from time to time in people living with the human immunodeficiency virus with ART 12,13 . The study which is conducted in the USA, Atlanta, Maryland, Brazil, California, Tanzania, Zimbabwe, France showed that the prevalence of overnutrition was (46%) 14 14 were factors associated with overnutrition in people living with HIV receiving antiretroviral therapy. In Ethiopia, the government designs different strategies to achieve sustainable development goal (SDG) #2. For example, national consolidated ART care and end hunger, achieve food security and improved nutrition and promote sustainable agriculture yielding marked success in reduction of HIV and over nutrition patient morbidity and mortality 24, 25 respectively. Despite the seriousness of the problem, a study conducted to evaluate factors responsible for overnutrition among HIV-positive persons during the ART period remains largely unknown. Therefore, this study aimed to identify factors associated with over-nutrition and its magnitude. The results obtained from this study will improve the quality of care of clients in the study area and similar settings in Ethiopia.

Methods and materials Study design, setting, and period
The study was conducted at Debre Markos Referral Hospital. The hospital is situated in Debre Markos Town and is located Northwest of Ethiopia 300 Km away from the capital city of Addis Ababa. It was built in 1957 to serve about 25,000 people and now it is serving more than 3.5 million people. A facility-based cross-sectional study design was employed from March 1 to May 1, 2020. We have recruited HIV/AIDS patients from one comprehensive specialized hospital rendering ART treatment services. An average of 3220 patients per month in the ART clinic have had fellow up.

Inclusion and exclusion criteria
We included all HIV-positive adults who received ART and were available during the data collection period at the ART clinic. We excluded patients who were pregnant and developed over nutrition before initiating ART.
Source of population, sample size determination, and sampling procedure Of the total 3220 adult patients with HIV/AIDS at the ART clinic, 422 participants were used for data collection. We used a systematic random sampling technique to select the participants for an interview, anthropometric measurement, and clinical records review from the register. The sampling interval (kth) was determined by dividing the total HIV/AIDS positive patients of the hospital allocated sample size. k=N/n=k=3220/422≈8 The first sample was selected by simple random sampling from clinical records and every (kth) was selected for gathering information until the required sample was obtained from the study participant. Assuming 50%, prevalence of over nutrition, 5% precision, 95% confidence level, and 10% non-response rate. We calculated a sample size of 422 adult HIV/AIDS patients.
≈384, after adding a 10% non-response rate, the final sample size was 422. Next, we used a proportional systematic random sampling was performed to select the eligible participants, who fulfilled the set inclusion criteria, from the total patients from daily attended patients.

Study participants
All HIV-infected adults receiving ART have a follow-up in the ART clinic and are available during the data collection period.

Outcome variable
The outcome of interest was over nutrition as measured using the body mass index (BMI), defined as the weight in kilograms divided by the square of the height in meters (kg/m 2 ). The body weight was determined to the nearest 0.1 kg on a standing electronic digital scale and height was measured to the nearest 0.1 centimetres (cm). BMI was calculated for each participant and their nutritional status was categorized according to World Health Organization (WHO) standards. Accordingly, a participant was declared to have overnutrition if the BMI metric is between 25 and 30 Kg/m 2 and a patient with a body mass index of greater than 30 Kg/m 2 1 .

Explanatory variables
Data were socio-demographic characteristics, including the age of the participants, sex, residence, occupation educational status family size, nutritional support, and counselling. Clinical-related factor information included CD4 count, viral load, ART adherence, WHO stage, OI, ART duration, ART regimen, prophylactic therapy, comorbidity diseases, and physical inactivity.

Operational definitions
Overnutrition: a patient with a body mass index between 25 and 30 Kg/m 2 and a patient with a body mass index of greater than 30 Kg/m 2 1 . Adult: a person whose age is ≥18 years old. Adherence to ART: the recent adherence status of the adult to the ART is recorded as poor, fair, and good based on leftover pill count. Adherence is poor when an adult takes less than 85% of the dose, fair when he/she takes 85-94% of the dose, and good when he/she takes 95% and above of the dose 24 . Comorbid diseases: are chronic diseases with a confirmed diagnosis of a disease other than HIV infection 24 . Opportunistic infections/diseases: is the list of opportunistic diseases indicated in national comprehensive HIV prevention, care, and treatment 24 . Prophylaxis Therapy: A co-trimoxazole/isoniazid preventive therapy that is implemented as an integral component of a package of HIV-related services based on an indication of prophylaxis 24 .

Data collection instruments
For the proposed study three data collection instruments were used. Primary data were collected using a structured interviewer-administered questionnaire, body mass index has done using standardized and calibrated weight and height measuring scales, and secondary data were reviewed from medical records.

Data collections and management
We used an interviewer-administered and structured questionnaire to collect the data. The questionnaires were adapted and modified into local context from previous works of literature [26][27][28][29][30][31][32][33][34][35] . FAO standard verbal questionnaires and a national comprehensive consolidated ART guideline checklist were also used 36 . To assure data quality, the tool was first prepared in English and then translated to Amharic and back to English. Besides, a principal investigator performed daily supervision. The two-day training was given for data collectors concerning the data collection tool and data collection process. We have done a pre-test on 10% of the total sample size at Finot Selam General Hospital, and the questionnaire was double-checked for completeness both by supervisors and data collectors. Data were collected at the time of ART care follow-up by interviewing all participants who attended the ART clinic. Additionally, we obtained clinical data by reviewing the chart. Four nurses screen the participants and collected data based on the inclusion criteria. Furthermore, we checked the collected data for completeness and consistency during the data management, storage, and analysis.

Statistical Analysis
Data were entered into EPI DATA version 4.1, and analysis was performed using STATA version 14.1 statistical packages. Descriptive statistics, like frequency and percentage, were used depending on the nature of the variable. Binary logistic regression analysis was computed to assess the associations of the independent variables with over-nutrition. In the bivariable analysis, variables with a p-value of less than 0.25 were entered into the final model. In this analysis, a potential problem of multicollinearity was checked using the variance inflation factor (VIF) at the cut-off point of 10. Finally, in the multivariable binary logistic model, a p-value of <0.05 was considered to declare statistical significance with the corresponding 95% confidence interval. The goodness of fitness of the model was checked using the Hosmer-Lemeshow GOF test. The p-value of the Hosmer-Lemeshow GOF test of our model is 0.562 which confirms that the model is correctly specified.

Socio-demographic characteristics of study participants
The response rate was 97.6% with more than half 240 (58.3%) of participants being females and the majority of 339 (82.2%) being from urban areas. The mean (±SD) age of study participants was 41.1 (±11.3) years. More than half of 250 (60.68%) participants had an age group of greater or equal to 45 years. Greater than one-third of 196 (47.6%) of participants were 1-12 grade, and more than two-thirds of 288(69.9%) got nutritional counsel and support. More than one-third of 144 (38.1%) participants had greater or equal to 4 family sizes (Table 1)

Clinical related characteristics of participants
A majority (85.44%) of participants did not make regular physical activity, and less than one-fourth (22.6%) of participants were taking prophylaxis therapy. Approximately one-tenth of 40 (9.8%) of participants had greater than or equal to 1000 copies/ml of viral load, the majority of 291(70.9%) of participants had WHO stage III, and more than two-thirds of 286 (69.4%) of participants did not develop OI. One-fourth of 103 (25%) participants have taken a combination of protease inhibitors with nucleoside reverse transcriptase, more than one-fourth (29.6%) had less than 500 cell/µL CD4, and more than one-third (40%) of participants had received ART greater than or equal to 5 years (Table 2).

Discussion
In general, this study has demonstrated over nutrition affects one in every five of the sample population, and factors such as older age, being farmer, family size greater than or equal to 4, viral load less than 1000 copies/ ml, and use of prophylaxis therapy were significantly associated with over nutrition. Magnitude of overnutrition among HIV positive patients attending ART clinics of Debre Markos hospital was 19.7% (95%CI: 14. 6-25.4). This finding is in line with the previous studies conducted in Zimbabwe (26.4%) 20 , France (27%) 21 , and Ethiopia (21%) 22 . However, this study's findings were lower than the studies conducted in the United State of America (46%) 14 , Atlanta (42%) 15 , Maryland 49) 16 , Brazil,(39.8%) 17 , California (33%) 19 Tanzania (63%) 18 . The above disparity between studies could be explained by the study settings, ART duration, and regimens, culture of the feeding of the study participants. This study showed that older age, being a farmer, family size greater/equal to 4, use of prophylaxis therapy, and viral load less than 1000 were statically significant associated factors with over nutrition. This study showed that older age was statically associated with overnutrition. These findings were consistent with studies reported from Ethiopia 22 , France 21 , Atlanta 15 , Tanzania 18 , Califor-nia 19 , and Zimbabwe 20 . This might be due to the paradox curves of overnutrition reaching the maximum point in the mid-50s and then declining. This study found that family sizes greater and equal to 4 were statically significant associated factors with overnutrition. This study found that family sizes greater and equal to 4 were statically significant associated factors with overnutrition. This finding is not consistent with other study reports 5,15,16,22 . The main justification could be most of the patients had taken prophylaxis therapy, had a viral load of fewer than 1000 copies/cell, and were physically inactive. Besides this, good availability, accessibility, stability, and utilization of food and nutrition in the house. Participants who had a viral load of fewer than 1000 copies/ml were at high risk for developing over nutrition compared with those who had greater than and equal to 1000 copies/ml. this finding is to align with the study conducted in Boston, USA 37 . It is plausible that leptin may be involved in the pathway of overnutrition to immune functioning, and it is an adipocyte-derived hormone that influences body weight 38 . The possible explanation is that if the patient's viral load is less than 1000 copies/cell, the CD4 count rise, and immune recovery is good. Therefore, the patient was free from opportunistic infection and had a good intake, absorption, and appetite.
Participants who were farmers were less likely to develop overnutrition compared to drivers and housewives. This finding is not consistent and significant in association with other studies reported from different countries 16,20,22,37 . The possible reason might be the habit of feeding, availability, accessibility, and utilization of food, nature of their work, and physical activity. Finally, the participant who has been taking prophylaxis therapy statically significant associated factors with overnutrition This finding is not aligned and significant association with reports of studies conducted in different countries 5,15,16,22 . This might be because patients have been taking prophylaxis therapy, they will be free from an opportunistic infection, and the patient also had good food intake, absorption, and free mal-absorption syndrome.

Conclusions
In this study, one-fifth of Human Immunodeficiency Virus/Acquired Immunodeficiency Virus patients had over nutrition. In this study, the magnitude of overnutrition is high associated with a viral load of fewer than 1000 copies/cell, age greater than 45, and having taken prophylaxis therapy. Therefore, educating about the use of lifestyle change, regular monitoring of weight, regular nutritional assessment, and intervention of the existed problems like doing regular exercise is highly recommended.

Limitations of the study
Since the study design is cross-sectional cause and effect relationship cannot be established. Moreover, the physical activity status of patients was obtained from self-report, and recall bias may have influenced the results.

Ethics approval and consent to participate
We obtained ethical clearance from the ethical review committee of Health Science Debre Markos University with institutional research ethics review number of HSC/R/C/SE/PG/Co/603/17/12. We also obtained permission from the hospital administrator. All participants signed the informed consent forms for the anthropometric measurement and questionnaire survey.

Consent for publication
Not applicable.

Viability of data and material
Data will be available upon reasonable request of the corresponding author.

Competing interest
The author has declared that they have no competing interests.