Prevalence of intestinal parasites and associated risk factors among HIV/AIDS patients attending at anti-retroviral treatment (ART) clinic at Mizan-Tepi university teaching hospital, southwest Ethiopia

Intestinal parasitic still very especially in areas where immune-compromised patients like HIV/AIDS patients are prevalent. the aim of this study was to assess the prevalence of intestinal parasite and risk factor among HIV/ AIDS patients attending ART clinic A cross -sectional survey was conducted from July to September, 2021. A total of 191 study subjects were participated in this study. A structured questionnaire was used for collecting socio-demographic and risk factors data. Stool sample was collected and processed using direct wet mount, formol-ether concentration technique and modied Ziehl-Neelson staining techniques. Data was analyzed using statistical package for social sciences (SPSS) Version 25 software and logistic regressions were applied to assess any association between explanatory factors and outcome variables.


Introduction
Parasitic infections, particularly intestinal parasites are among the most widespread of human infections worldwide and are the main threat in developing countries, as it has been noticeably heightened with the coexistence of large burden of HIV/AIDS and malnutrition in the area. It is estimated that as much as 60% of the World's population is infected with intestinal parasites which may play a signi cant role in morbidity due to intestinal infections [1][2][3].
Gastrointestinal problem resulting from opportunistic parasitic infection in HIV and AIDS infected subject has dramatically decreased in countries where antiretroviral agents are widely available. However, in most African countries, where patients have access to ART, intestinal pathogens still represent a frequent cause of diarrhea, wasting and weight loss. Evidence shows that HIV-infected patients are the most vulnerable risk group for acquiring parasitic infection, and about 85% of AIDS patients die as a result of AIDS related infections, rather than due to the HIV infection itself. These opportunistic infections most commonly occur in the later stages of HIV infection when numbering of CD4 T cells has declined mostly < 200mm 3 [4][5][6][7].
Despite ART improving the quality of life and reducing the occurrence of opportunistic infection due to immuno suppression, malnutrition, poor waste management, ignorance (illiteracy), unhygienic sources of drinking water and depleted CD4 counts among HIV/AIDS patients are the most common determinants of parasitic infection [6,7].
Intestinal parasitic worm infections are transmitted to humans through soil contaminated by human faeces, mostly in areas where sanitation is poor. Infection leads to anaemia, vitamin A de ciency, stunted growth, malnutrition, intestinal obstruction and impaired development. The most commonly reported intestinal parasites are Ascaris lumbricoides, hookworms, Trichuris trichiuria, Giardia lamblia, Entamoeba histolytica and Schistosoma species are the most common intestinal parasites. Among those opportunistic pathogens, Isospora belle, Cryptosporidium parvum, Cyclospora cayetanenis and Microsporodia specie increasingly reported as causes of enteritis and as opportunistic pathogen in immune compromised individuals [8][9][10][11].
As Ethiopia is one of the developing countries in the world it is categorized under a high prevalence of parasitic infections. According to the studies, the average prevalence of parasitic infections was 39.6% [12][13][14][15]. The estimated pooled prevalence of intestinal parasitosis in HIV/ AIDS patients was 39.2% [16].The severity and magnitude of IP in HIV/ AIDS patients require attention and study, especially in the countries like Ethiopia where there was high HIV/AIDS and parasite prevalence. Therefore, this study was aimed to determine the magnitude of intestinal parasite among HIV /AIDS patient who are coming to ART clinic at Mizan-Tepi university teaching hospital, South Western Ethiopia. The nding will help to sensitize local and national responsible bodies as prerequisite for updating strategies in the prevention and control of intestinal parasitic infection among HIV/AIDS patients.

Study Area and period
This study was conducted in Mizan-Tepi university teaching hospital from July to September 30, 2021. Mizan-Tepi university teaching hospital is found at 591Km, South west of Addis Ababa, capital city of Ethiopia. It is the second more than 139 bedded teaching hospitals in the Southwestern part of the country, providing services approximately for 5 million people from four zones such as BENCH SHEKO, KEFA, SHEKA and MAJANG as referral center. About 350 clients visit the hospital daily for different services and there were more than 750 HIV positive patients taking ART services.

Study design and subjects
A cross-sectional study design was conducted to determine the prevalence of intestinal parasites among HIV positive patients who are attending ART clinic in MTUTH south Western Ethiopia. Consecutive HIV/AIDS patients who come for ART services during study period were included. Those who are not willing to participate and those couldn't provide stool samples were excluded.

Sample size and sampling technique
The required sample size was calculated using single population proportion formula by assuming that con dence interval of 95%, margin error of 5%, and the prevalence of intestinal parasites among people with HIV/AIDS (p) as 13.9% [17], which is reported in previous study in Ethiopia.
By assuming 4% non-respondent rate, the nal sample size for this study was 191.

Data Collection
Social-demographic data During implementation of data collections, the study subject was asked for their willingness in participation of the study. A structured questionnaire was utilized to collect socio-demographical (age, sex, residence, marital status, educational status) and other risk factors data such as hand washing practice, habit of consuming raw food, own domestic animals, availability and usage of latrine, shoe wearing habits, source and treatment of water for drinking. Patients were also asked for complaints of diarrhea. Data on WHO stage of HIV, viral load and level of CD4 + T cell count and antiretroviral treatment (ART) status was obtained from patients' medical records.
Laboratory sample collection and processing A single fresh stool was collected with a labeled stool cup following standard procedures by laboratory technologist who worked at the ART clinic. The patients were provided with appropriate specimen container and applicator sticks to bring su cient amount of stool specimen. Each sample were labeled with speci c code number, and transported to the laboratory within 30 minutes of collection for parasitological analysis.

Sample processing
Then stool sample was examined both macroscopically and microscopically. Macroscopically its appearance was observed while microscopically it was examined using direct saline and iodine wet mount smear preparation, formol-ether concentration and modi ed Ziehl-Neelson technique [18,19].
During microscopic examination of intestinal parasite their diagnostic stage was identify based on their shape, color and motility.

Data Analysis
Data were entered into SPSS Version 25 software for analysis. Frequency distributions and descriptive statistics such as the number and percent of intestinal parasites in relation to different variables were determined. Bivariate and multivariate analyses were performed to assess the association or crude and adjusted odd ratio of parasitic infections with the independent variables. A statistical test result was declared as signi cant when its value was less than 0.05 and crude and adjusted odds ratios with 95% con dence intervals (CI) were reported.

Result
Socio-demography of the study subject A total of 191 subjects were participated in this study. Of these, 113 (59.2%) were females and 89 (46.6%) were age group of 35-50 years. Majority, 103 (53.9%) and 133 (69.6%) of study participants were urban residence and married, respectively. About 65 (34.0%) of the study participants were complete their primary school and 44 (23.0%) were working as house wives (Table-1).

Intestinal parasites among HIV/AIDS patients with ART and ART naïve group
In this study, a total of 191 stool samples were tested for the detection of intestinal parasites (IPs). Of these samples, 143 (75.0%) of them were taken from HIV/AIDS patients who were on-ART and the rest 48 (25.0%) were taken from ART naïve group. Accordingly, the overall prevalence of IPs was 67 (35.1%). The prevalence of IPs among HIV/AIDS patients who were on-ART was 45 (31.5%) and 22 (45.8%) among ART naïve group. The distribution of intestinal parasites was not statistically signi cant differences between ART and ART naïve group (X 2 = 3.256; Pvalue > 0.05). Entamoeba histolytica/dispar (7.7%) and (12.5%) and Giardia lamblia (7.0%) and (10.4%) was the most predominant parasites detected in HIV/AIDS patients who were on-ART and ART naïve group, respectively. The prevalence of opportunistic intestinal parasites among ART and ART naïve group were 1.4% and 4.2%, respectively for Cryptosporidium spps and 2.1% of Isospora belli were detected only in ART naïve group (Table-2).

Prevalence of intestinal parasites in relation with Sociodemographic characteristics of study participants
In this study, analysis with binary logistic regression showed that, place of residence and marital status of the study participants were identi ed as the major socio-demographic determinants of intestinal parasite among HIV/AIDS patients. Being rural residence were 61% (COR = 0.39; 95% CI: 0.205-0.755; pvalue = 0.005) more likely to had intestinal parasite than those of urban residence and being single by marital status were almost 3.38 times (COR = 3.38; 95% CI: 1.202-9.488; p-value = 0.021) more likely to harbour intestinal parasite than married one. Other socio-demographic characteristics, such as sex, age and educational status were did not show association with intestinal parasitic infection (Table-1).

Prevalence of intestinal parasites in relation with environmental and hygienic practices of study participants
In this study, among those studied variables related with environmental and hygienic practices of study participants, drinking untreated water, consuming raw food and eating unwashed raw vegetables were signi cantly associated with intestinal parasitic infection among HIV/AIDS patients in the multivariate logistic analysis. Those HIV/AIDS patients who was drinking untreated water are 87% (AOR = 0.13; 95% CI: 0.016-1.012; p-value = 0.035) more likely to be infected with intestinal parasite than those whose drinking treated water. Those HIV/AIDS patients consuming raw food are 77% (AOR = 0.23; 95% CI: 0.025-2.108; p-value = 0.017) more likely to have parasite than those who have not consuming raw food. In addition, those patients eating unwashed vegetables are 2.26 times (AOR = 2.26; 95% CI: 1.052-4.843; pvalue = 0.021) more likely to have parasite than those consuming unwashed raw vegetables (Table-4).

Discussion
This study was a hospital based cross-sectional study which was conducted to assess the prevalence of intestinal parasites among HIV/AIDS patients at southwest district of Ethiopia. Accordingly, the overall prevalence of intestinal parasites was 35.1% which was higher than study ndings in different parts of Ethiopia in which the average prevalence of intestinal parasites among HIV/AIDS patients was 18.2% [20][21][22][23]. However, this nding is lower than a nding in Nekemte (73.3%) [24], Gondar (45.3%) [25], Ethiopia. As compared with other developing countries, this nding is higher than a study nding in Mozambique (26.4%) [26], India (27.6%) [27] and Colombia (29.2%) [28]; however, lowers than study ndings in Nigeria (68.2%) [29], Gabon (42.6%) [30], Cameroon (57.5%) [31] and Kenya (50.9%) [32]. The observed variations may be explained by the difference in geographic location, the difference in sample size, awareness and hygienic practices of the population in the preventions of intestinal parasite infections and moreover the variation in immune status of the study participants. In addition, the observed variations may be in uenced by study period in which nowadays there is a better awareness of the patients about intestinal parasite infection and their cause.
In this study, the prevalence of intestinal parasite among ART and ART naïve group was (31.5%) and (45.8%) which was in line with study nding in Northern Ethiopia, Dessie and Gondar, in which the higher proportion of intestinal parasite were observed in ART naïve group [21,25]. This higher prevalence in ART naïve group might be explained by the immune status of the study participants. In fact, ART improving the quality of life and reducing the occurrence of opportunistic infection due to immuno suppression. In addition, ART patients might be followed through laboratory screening for intestinal parasites and may get deworming and better awareness in adopting prevention and treatment measures against intestinal parasites.
Although there is no statistical signi cant difference in the overall detected parasitic species between ART and ART naïve group, Entamoeba histolytica/dispar and Giardia lamblia was the most predominant parasites detected both in ART and ART naïve groups in this study. However, the prevalence of Cryptosporidium spps in ART and ART naïve groups was 1.4% and 4.2%, respectively. This nding is in line with other study nding in Ethiopia [17,21,25] and Colombia [28], in which higher predominance of non-opportunistic intestinal parasites were reported. The higher proportion of non-opportunistic intestinal parasites indicates that, ART may also be contributed to the reduction of opportunistic intestinal parasites infections.
In this study, intestinal parasitic infections occurrence was signi cantly higher in patients with CD 4 count < 200 cell/mm 3 , which is in line with other study ndings [20][21][22][23][24][25]33]. Unlike others, in our study the occurrence of intestinal parasitic infections was also signi cantly higher in patients with CD 4 count 200-500 cell/mm 3 . However, other study in Ethiopia reported that CD 4 count < 500cell/µl was signi cantly associated with opportunistic intestinal parasitic infections [34]. In fact, immuno-de cient patients are more vulnerable in acquiring intestinal parasites and are unable to clear the infection once it is established [33,35].
In this study, being WHO stage II and III were also signi cantly associated with intestinal parasitic infection. The occurrence higher intestinal parasitic infection in patients with WHO stage III was in line with other study nding [21,36]. Similarly, in this study, viral load ≥ 150 copies/ml was also signi cantly associated with intestinal parasitic infection, which also is reported in other study [22]. The higher the viral load, may be related with low level of CD4 count and advanced WHO stage, which leads to the quicker a person's immune system will be damaged, increasing their chances of catching infections that the body would normally ght off very easily. Some studies reported that, baseline CD4 count of 500cells/µl or more was signi cantly associated with viral load reductions or suppression [37][38][39].
In this study, environmental and hygienic practices of study participants like drinking untreated water, consuming raw food and eating unwashed raw vegetables were found to be signi cantly associated with intestinal parasitic infections. Signi cant association of consuming raw unwashed raw vegetables and drinking untreated water with intestinal parasitosis is also reported in other studies in Ethiopia [17,23,40]. Therefore, a combination of public health and clinical strategies is required in the prevention and control of intestinal parasites. The efforts should be focused not only on the treatment of infected individuals but also on the other contributing risk factors.
In this study, only saline and iodine wet mount, formol-ether concentration and modi ed Ziehl-Neelsen staining method was used for the detection of intestinal parasites. Thus the added yield of intestinal parasites may be an underestimate as we have not used water-ether sedimentation method for Microsporidia and other methods like molecular techniques and immuno ouscent techniques which are sensitive for parasites. In addition, patients may be got deworming and/or diagnosed for parasites and treated as well before.

Conclusion
In this present study, high prevalence of intestinal parasites among HIV infected patient in was observed.
Higher rate of intestinal parasitosis were associated with hygienic practices like drinking untreated water, consuming raw food and eating unwashed raw vegetables and with some clinical ndings such as lower Ethical approval and consent to participate Ethical approval was obtained rst from Mizan-Tepi University Ethical committee. Legal permission was obtained from hospital administrative (COE). Informed consent was obtained from the parents for the study participation. All methods were performed in accordance with the relevant guidelines and regulations.
Consent for publications "Not applicable" Availability of data and materials "All the data supporting our ndings were incorporated within the manuscript".
Competing Interests "The authors declare that they have no competing interest".