This study was carried out in North Wollo Zone Hospitals, Amhara region, Ethiopia. According to the 2007 Census conducted by the Central Statistical Agency of Ethiopia (CSA), this Zone has a total population of 1,500,303, of whom 752,895 are men and 747,408 women. The largest ethnic group in North Wollo is the Amhara (99.38%), and all other ethnic groups made up 0.62% of the population. Amharic is spoken as a first language by 99.28% of the population and the remaining 0.72% spoke other primary languages. 82.74% of the populations are Ethiopian Orthodox Christianity followers, and 17.08% are Muslims. There are 5 public hospitals in this zone. These are Kobo Hospital (KH), Lalibela hospital (LH), Shediho Meket Hospital (MH), Wadla hospital (WH) and Woldia general hospital (WGH).
Study Design and Period
A health facility-based case-control study was conducted from February 1 to March 30, 2019.
All HIV Positive Children on Highly Active Antiretroviral Therapy (HAART) attending hospitals of North Wollo Zone, Amhara, Ethiopia.
All HIV Positive Children on Highly Active Antiretroviral Therapy (HAART) attending selected hospitals of North Wollo Zone, Amhara, Ethiopia.
Sample Size Determination
The sample size is determined using a double population proportion difference formula by using major determinant variables such as iron deficiency, inflammation, underweight, malaria Pf, albumin deficiency, and ART regimen. Since it gives the maximum sample size, iron deficiency was considered as an independent predictor (exposure) variable (Table 1). From that study, the proportion of children among cases with iron deficiency was 26.9% and the proportion of children among controls with iron deficiency was 8.3%. (30). Using Epi-Info version7, one to two ratio (1:2) of cases to controls and with a power of 90%, the total sample size becomes 350 with 117 cases and 234 controls.
Sampling Technique and procedure
Simple random sampling technique was employed to select the required number of cases and controls attending hospitals in North Wollo Zone. First, out of the total 5 hospitals in North Wollo Zone, 3 hospitals were selected through simple random sampling technique. Then, the required sample size was allocated proportionally to the selected hospitals based on the number of cases and controls. Study participants (cases and controls) in the selected hospitals were selected using consecutive sampling technique by considering client flow is random. Cases were selected consecutively among HIV positive children's on HAART in the selected hospitals. The next immediate two corresponding age and sex-matched controls were selected consecutively among HIV positive children on HAART in the selected hospitals.
- Socio-demographic variables
- Occupation of mother
- Family size
- Household wealth index status
- The educational level of a mother
- The educational level of father
- Cd4 count /percentage
- WHO stage
- Stool result (IP)
- Malaria history
- Opportunistic infection (OPs)
- Inflammation (ultrasensitive CRP > 1.0) mg/dl)
- Past medical history
- HAART duration
- HAART status (new….experienced…
- HAART regimen
- Previous and current drug history,
- Nutritional related variables
- Dietary Diversity Score
- Nutritional status
Inclusion criteria for cases
HIV Positive Children on Highly Active Antiretroviral Therapy (HAART) who were anemic and may not be diagnosed with other medical illness.
Inclusion criteria for controls
HIV Positive Children on Highly Active Antiretroviral Therapy (HAART) who were not anemic, age and sex-matched with cases
Exclusion criteria for cases
Children with an incomplete chart, children passed-away on arrival, children admitted without their caregiver.
Exclusion criteria for controls
Children with an incomplete chart, children passed-away on arrival, children admitted without their mothers.
Definitions of terms and operational definitions
Case (anemia) - HIV Positive Children on Highly Active Antiretroviral Therapy (HAART) whose Hg level is less 11 g/dl for children <5 years old, <11.5 g/dl for children 5–11.9 years old and <12 g/dl for children 12–14.9 years old or may not be diagnosed with other medical illness (31).
Control (non anemic)-HIV Positive Children on Highly Active Antiretroviral Therapy (HAART) whose Hg level is more than or equal to 11 g/dl for children <5 years old, 11.5 g/dl for children 5–11.9 years old and 12 g/dl for children 12–14.9 years old age and sex-matched.
Mild anemia-(Hgb 10.0–10.9 g/dl),
Moderate anemia - (Hgb 7.0–9.9 g/dl),
Severe anemia- Hb <7.0 g/dl for children aged 6–59 months; and Hb <8.0 for those 5 years and older (32, 33)
Very severe anemia - Hgb less than 4.0 g/dl
Data Collection tool and Procedure
Data was collected by face to face interview, chart review and anthropometric measurement with pretested and structured questionnaire adapted from previous similar literature. A review of the medical records was performed for concurrent opportunistic infections and WHO clinical staging of HIV disease. Laboratory investigation was performed by laboratory professionals to determine the hemoglobin level of participants and identify possible malaria and other parasitic infections (30). The questionnaire had 5 parts: Part1- Socio-demographic/economic variables, Part 2: Assessment of degree and type of anemia, part 3: Disease-related determinants of anemia, part 4: Drug-related determinants of anemia, and part 5: Nutritional status-related determinants of anemia.
Nutritional assessment: Dietary Diversity Score (DDS) was calculated from a single 24-hour dietary recall data. Additionally, study participants were screened for nutritional status using anthropometric measurements.
Chart review was done to identify hemoglobin concentration (Hgb), blood history of malaria and Viral load.
Stool specimen collection and examination: A stool sample was collected from each study participants using clean, wide-mouthed and leak-proof stool cup by laboratory professionals. Then, stool wets mount was prepared using saline and/or iodine and examined microscopically for identification of intestinal helminths.
Data quality control
A pretest was conducted on 5% (17) of the sample size among children on HAART attending Dessie referral hospital which was not included in the study settings and was selected by lottery method among the hospitals not included in the study settings. The pretest study was conducted 2 weeks before the actual data collection period. The study participants who fulfill the inclusion criteria were selected by simple random sampling technique. The result of the pretest was discussed and all the necessary amendments were made on, the instructions, contents, order and grammatical issues based on the results of the pretest.
Three-day intensive training was given for data collectors and supervisors on the overall data collection procedure to minimize systematic errors. A clear explanation of the purpose and objective of the study was provided for the respondents at the beginning of the interview. On spot-checking and correction was made for incomplete questionnaires by supervisors. Laboratory test quality was assured by giving training for laboratory professionals by MSc laboratory professionals using the standard operating procedure (SOP) and regular monitoring of reagents for manufacturing, expiry date, and proper storage. The sample was processed immediately after collecting from the study participants to minimize errors and the overall data collection process was monitored by investigators.
Data analysis and presentation
The filled questionnaires were checked for completeness, coded and entered into Epi Data version 4.2 and then exported to SPSS version 24 for further analysis. Descriptive statistics were computed and the result was reported using frequencies and percentages. Bivariate logistic regression was performed and variables with p < 0.25 were transported to multivariable logistic regression. Finally, variables with P-value < 0.05 in the multivariable logistic regression model were taken as statistically significant and adjusted odds ratio with its 95% confidence interval was considered to see the strength of association between the exposure variables and the outcome of interest.
Ethical clearance was obtained from the Woldia University research project office. Permission and support letter was sought and obtained from the North Wollo Zone Health Office. Then, officials at different levels in the hospitals were communicated through letters. The responsible bodies at each hospital were told about the purpose of the study. Written informed consent was obtained from parents of every study participants after a detailed explanation on the purpose and benefit of the study right before data collection and assent was obtained from the study participants. The respondents were notified that they have the right to refuse or terminate at any point during data collection. All data collectors and supervisors were instructed on how to comply with strict confidentiality practices for all participants both during and after data collection. The identity of the participants was kept anonymous.
Dissemination of the result
The results of the study were disseminated to Woldia University, faculty of health science, research directorate office. Furthermore; the findings and recommendations of the study will also be shared in a written document to North Wollo Zone Health Office and Hospitals in North Wollo Zone. After public defense and incorporation of comments, the result will also be disseminated through presentations on research conferences, workshops, and symposiums. Finally, the attempt will be made to publish in a reputable peer-reviewed journal. The study participants will remain anonymous during and after publication. The owners of the research are the researchers and Woldia University