Food insecurity and associated factors among people living with HIV/AIDS on follow up receiving anti-retroviral therapy at public hospitals of Wollega zones, Oromia, Ethiopia, 2019

Background : Food insecurity and HIV/AIDS are intertwined in a vicious cycle through nutritional, mental health, and behavioral pathways. Food insecurity is a potentially important barrier to the success of antiretroviral treatment, increased hospitalizations, and higher morbidity among HIV-infected individuals in resource-poor settings particularly in sub-Saharan Africa including Ethiopia. Therefore, the purpose of this study was to assess the prevalence of food insecurity and its associated factors among adult people living with HIV/AIDS on follow up receiving ART at public hospitals of wollega zone, west Ethiopia. Methods : An institutional-based cross-sectional study design was conducted on a sample of 428 among people living with HIV/AIDS on follow up receiving antiretroviral therapy at public hospitals of wollega zones. Data was collected using the Household Food Insecurity Access Scale and dietary diversity scale by interviewer-administered questionnaires. The data was checked, cleaned and entered into Epi data version 3.1 and then exported into Statistical Package for the Social Sciences (SPSS) window version 21 for analysis. Descriptive statistics - cross-tabulation frequency table, mean, standard deviation, percentage, were employed. Bivariate and multiple logistic regression analyses were used with AOR at CI 95% and p<0.05 were used. PLWHA receiving ART and severe Being were predictors of food insecurity. Conclusion : The prevalence of food insecurity was relatively high. Educational status, marital status, cigarette smoking, presence of anemia, opportunistic infection and inadequate dietary diversity were the major significant factors affecting food insecurity. We recommended Wollega Zonal Health Bureaus to effectively intervene in behavioral modification and health information dissemination (HID) which is the key strategies to improve food security.


Introduction
Food insecurity is at the heart of the universal movement to overcome hunger and poverty [1]. It refers to the unavailability of adequate and sustainable food supply, inability to access adequate balanced diet, and inability to utilize safe and quality food which is nutritionally adequate and socially acceptable ways for all household members [2].
HIV/AIDS and food insecurity has a bidirectional relationship. Food insecurity increases the risk of HIV infection, as well as HIV infection, leads to food insecurity by reducing agricultural production, reducing income, increasing medical expenses causing reduced capacity to respond to the crisis. Food insecurity affects health directly or indirectly through the impact of poor nutritional status, a social and behavioral mechanism that influences adverse health outcomes [3,4].
More than 1 billion people worldwide are affected by food insecurity that is inseparably linked to the HIV epidemic in both resource-rich and resource-poor settings. Approximately, 89% of food-insecure individuals live in Asia and Africa.
About 28.5 million HIV/AIDS infected people live in sub-Saharan Africa and about 70% where food insecurity and malnutrition endemic [5,6]. 4 Worldwide one-third of 40 million PLWHA are co-infected with opportunistic infections related to malnutrition that weakens the immune system, leading to greater susceptibility. About 41% of adults and 32% of children had access to antiretroviral treatment [7]. HIV/AIDS and food insecurity are two of the leading causes of morbidity and mortality that increase vulnerability and worsening the severity of one another. The prevalence of food insecurity was high in sub-Saharan Africa among PLWHA particularly in Ethiopia were 63%, Uganda 75%, Democratic Republic of Congo 57%, and Tanzania 52% [8,9,10,11].
Both HIV/AIDS and food insecurity are intertwined in a vicious cycle. HIV/AIDS affects food insecurity mainly through its corrosive effects on people's economic sustainability, through the loss of earnings as a result of disease progression. Food insecurity is recognized as a key determinant of reduced adherence to antiretroviral therapy, increased behavioral risk of HIV transmission, reduced access to HIV treatment, adverse antiretroviral pharmacokinetics, and worse clinical outcomes among HIV infected individuals [12].
The study showed that food insecurity can lead to macronutrient and micronutrient deficiencies, which can affect both vertical and horizontal transmission of HIV through contributing immunologic decline and increased morbidity and mortality.
Food insecurity can have mental health consequences, such as depression and increased drug abuse finally contribute to HIV transmission risk and incomplete viral load suppression, increased probability of AIDS-defining illness, and AIDS-related mortality among HIV-infected persons [13].
Study conducted in various countries among PLWHA receiving HAART showed a high prevalence of insecurity indicated that Canada 71%, Namibia92%, and Kenya revealed that 20-50% were food insecure [14,15,16].
In Ethiopia, about 1.5% of adult people aged 15-49 are infected with HIV that was intensely affected by food insecurity. It was estimated that almost 1 in 10 Ethiopians struggled to have access to safe, sufficient and nutritious food for themselves and their families [17].
Study showed that lower age, lower educational level, marital status, low health status, political and demographic factors such as gender, income, body mass index, smoking, household composition, nutritional status, physical and mental development, social vulnerability to infectious and chronic diseases are related to food insecurity [18].
In spite of Food insecurity compromise the effectiveness of HIV treatment, reduce ART adherence, and induce HIV related stigma, isolation and anxiety; understanding the predictors of food insecurity is crucial to create awareness for social support for infected patients and integrates comprehensive nutritional therapy for infected individuals. The status of food insecurity is not well known among PLWHA in Wollega zones. Therefore, this study was designed to fill this gap and determine the levels and predictors of food insecurity among adult patients taking highly active antiretroviral therapy at public hospitals of wollega zones, Oromia, West Ethiopia.

Study setting and population
The study was conducted in four Public Hospitals of Wollega Zones (Nekemte referral Hospital (East wollega), Ghimbi hospital (West Wollega), Jimma Arjo Hospital (East wollega) and Nedjo hospital (West Wollega) from September 2019 -October 2019 which were randomly selected. An Institutional based cross-sectional study design was employed. All PLWHA on follow up receiving antiretroviral therapy at the 6 selected hospitals in Wollega zones were source population. A Selected adult PLWHA of above 18 years receiving ART for at least 12 months and present during data collection period were study population. All PLWHA above 18 years and receiving ART more than 12 months were included and those below 18 years and receiving ART less than 12 months and seriously ill and cognitive impaired adult PLWHA was excluded Sample size determination and sampling techniques The sample size of the study was calculated using the formula for estimation of a single population proportion with the assumptions of 95% Confidence Level (CL), marginal error (d) of 0.05. Taking proportion of 0.63 (63%) from the previous study conducted in Jimma university specialized hospital [8], and by adding a nonresponse rate of 10%, a total of 428 adult people living with HIV/AIDS on follow up receiving ART were enrolled in the study after using the correction formula.
Systematic random sampling method was used to select the study participants.

Data collection tool and procedures
Data was collected using an interviewer-administered questionnaire. Data collection tools consist of three-parts questionnaires: Demographic related consisting clinical profile, House Hold Food Access Scale (HFIAS) which was taken from tool developed by the Food and Nutrition Technical Assistance (FANTA) project with reliability of Cronbach alpha 0.934 [19]. It measures food insecurity in terms of occurrence and frequency questions with a total of 18 items within the previous four weeks.
Occurrence questions responded in terms of yes or no options with a score of yes = 1 or No = 0. The affirmative responses for occurrence were considered as food insecure scored as rarely (once or twice) = 1, sometimes (three to ten times) = 2 and often (more than ten times) = 3 in the past four weeks. Dietary Diversity Index 7 was taken from UN tool developed by the Food and Agriculture Organization and USAID (FAO) with the reliability of Cronbach alpha 0.637 [20].It measure household food insecurity in terms of 7 food items within the previous twenty-four hours by two possible values: 1 = yes and 0 = no. A Close-ended interviewer-administered structured questionnaire was distributed to participants by trained data collectors.
Data was collected by eight trained Bsc a nurse working in different hospitals.

Data processing and analysis
Data were coded and entered checked, cleaned and entered into Epi Data version 3.1 and then exported to SPSS window version 21 for analysis. Descriptive statistics such as cross-tabulation, frequency, percentages, mean and standard deviation were employed. Binary logistic regression was employed to determine the association between food insecurity and independent variables by using Hosmer and Lemeshow test. Multiple logistic regression analysis was employed by backward stepwise (Wald) model to ascertain predictors of food insecurity among PLWHA receiving ART. Significant variables were determined by AORs, CI at 95% and Pvalue < 0.05. Finally, the result was summarized by percent, tables, pie charts, and bar graphs.

Data quality control
All questionnaires were translated into the local language Afan Oromo and then translated back into English languages by experts. Pretest was conducted on 5% of the questionnaire at Bedelle hospital. One-day training was also given for data collectors and supervisors. Data were cleaned, coded and checked for consistency and completeness. The principal investigator prepared the template and entered data using Epi Data version 3.1. Finally, after missing, value and incorrect entry checked the data was exported to SPSS version 21. 8

Socio-demographic characteristics of respondents
Four hundred sixteen participants were participated giving a response rate of 97.2%. The majority of the respondents 221(53.1%) were female and with regards to marital status, two thirds 260 (62.5%) were married respondents. The mean age of the respondents was 32.92 ± 7.304 years and 197 (47.4%) of the study participants were between 30 to 39 years' age group. Concerning educational status majority, 114 (27.4%) were can't read and write followed by who can read and write 106(25.5%). Concerning their occupation, the majority of the respondents 144(34.6%) were Daily Laborers followed by employee (both governmental and private) 141(33.9%). The study also showed that majority of respondents 238(57.2%) gain income less than 600 EBR. Moreover, the study also reveals most of 233(56%) the respondents' were urban indwellers (Table 1).

Prevalence of food insecurity among the respondents
The overall prevalence of food insecurity among PLWHA receiving ART at therapy at public hospitals of wollega zones was 68.8%. This prevalence was partitioned as mild (23.32%), moderate (29.09%) and severe (16.35%) food in secured. The remaining 31.25% of the respondents were food secured (Fig. 1).

Bivariate logistic regression analysis of factors associated with food insecurity
In this study, Bivariate logistic regression analysis revealed significantly associated variables with food insecurity at p < 0.05. Among significant variables were sex, marital status, educational status, occupation, and place of residence, family size, 12 and stage of HIV/AIDS, anemia, farmland, and presence of opportunistic infection, cigarette smoking and dietary diversity were significant variables with food insecurity (Table 3).   [21].
Limitation of the study Causality cannot be confirmed since the research design is cross-sectional.

Conclusion
The proportion of food insecurity among PLWHA on follow up receiving ART was found relatively high. This study found that educational status, marital status, cigarette smoking, presence of anemia, and inadequate dietary diversity were positively related to food insecurity. Enhancing educational status and behavioral modification is essential to improve food security. It is also better to provide health The study was reviewed and approved by the Institutional Review Boards of Wollega university Ethical review board. The purpose of the study was explained to the medical director and staff of the hospital and permission was obtained. All participants of the study were provided written consent, clearly stating the objectives of the study and their right to refuse. No minors were involved in the study and the consent was obtained from the participants themselves. Moreover, the confidentiality of the information was assured.

Consent for publication
Not applicable Availability of data and materials The data used during this study are available from the corresponding author on reasonable request.

Competing Interests
We declare that we have no competing interests.

Funding
This research work was funded by Wollega University. The funder didn't participate in designing and data collection, analysis, writing, and submission of the article for publication

Authors' Contributions
The study was conceptualized, result writing, analyses, and the manuscript was written by AO. Other authors MA, GM, WE and GF were involved in reviewing and approving the final manuscript. Figure 1 Pie chart Illustrating Prevalence of food insecurity among the respondents among people livi