Socio-demographic characteristics
A total of 408 HIV positive adults were approached for consent, among which 392 participants consented to participate in this study, with a response rate of 96.1% and this is more than 100% of the power calculated sample size (n = 371). Those 16 patients who did not consent or agree to participate in the study reasoned lack of interest and time constrain.
The mean age of the participants was 40.5 (± 8.5) years and the majority of them 259 (66.1%) were females. Only 7.9 % of them reported to be from rural, majority of the participants were underweight (52.8%), above one-fourth did not have formal education. About 47% reported to be jobless and 43% answered to have low income (< 1500 Ethiopian birr). The majority of the participants 77.3 % reported lack of family support. Most of the subjects (94.1% and 86.9%) self-reported no previous or current smoking and alcohol habits respectively Table 1.
Table 1 Socio-demographic characteristics of people living with HIV/AIDS attending ART clinic, in the University of Gondar Hospital, University of Gondar, Northwest Ethiopia, 2019 (n=392).
Variables
|
Sample total
n (%)
|
Fatigue n (%)
|
χ2
|
P
|
Yes
|
No
|
Sex
|
|
|
|
|
|
Female
|
259 (66.1)
|
173 (66.8)
|
86 (33.2)
|
55.7
|
0.000
|
Male
|
133 (33.9)
|
36 (27.1)
|
97 (72.9)
|
|
|
Age group (years)
|
|
|
|
|
|
< 25
|
16 (41)
|
04 (25)
|
12 (75)
|
5.7
|
0.06
|
25-44
|
255 (65.1)
|
141 (55.3)
|
114 (44.7)
|
|
|
≥ 45
|
121 (30.9)
|
64 (52.9)
|
57 (47.1)
|
|
|
Religion
|
|
|
|
|
|
Orthodox
|
310 (79.1)
|
164 (52.9)
|
146 (47.1)
|
0.19
|
0.91
|
Muslim
|
48 (12.2)
|
18 (52.8)
|
16 (47.2)
|
|
|
Protestant
|
34 (8.7)
|
27 (56.2)
|
21 (43.8)
|
|
|
Marital status
|
|
|
|
|
|
Single
|
91 (23.2)
|
44 (48.4)
|
47 (51.6)
|
18.3
|
0.04
|
Married
|
203 (51.8)
|
112 (55.2)
|
91 (44.8)
|
|
|
Divorced
|
75 (19.1)
|
35 (46.7)
|
40 (53.3)
|
|
|
Widowed
|
23 (5.9)
|
18 (78.3)
|
05 (21.7)
|
|
|
Level of education
|
|
|
|
|
|
No formal schooling
|
114 (29.1)
|
68 (59.6)
|
46 (40.4)
|
7.1
|
0.044
|
Grade 1-6
|
82 (20.9)
|
38 (46.3)
|
44 (53.7)
|
|
|
Grade 7-8
|
53 (13.5)
|
30 (56.6)
|
23 (43.4)
|
|
|
Grade 9-10
|
53 (13.5)
|
32 (60.4)
|
21 (39.6)
|
|
|
Grade 11-12
|
44 (11.2)
|
19 (43.2)
|
25 (56.8)
|
|
|
Diploma and above
|
46 (11.7)
|
22 (47.8)
|
24 (52.2)
|
|
|
Residence
|
|
|
|
|
|
Urban
|
361 (92.1)
|
197 (54.6)
|
164 (45.4)
|
2.88
|
0.81
|
Rural
|
31 (7.9)
|
12 (38.7)
|
19 (61.3)
|
|
|
BMI (kg/m2)
|
|
|
|
|
|
Underweight (< 18.5)
|
207 (52.8)
|
26 (12.6)
|
181 (87.4)
|
292.1
|
0.000
|
Normal weight (18.5-24.9)
|
172 (43.9)
|
170 (98.8)
|
02 (1.2)
|
|
|
Overweight (25-29.9)
|
10 (2.6)
|
09 (90)
|
01 (10)
|
|
|
Obese (> 29.9)
|
03 (0.7)
|
02 (66.7)
|
01 (33.3)
|
|
|
Employment status
|
|
|
|
|
|
Unemployed
|
186 (47.4)
|
157 (84.4)
|
29 (15.6)
|
137.4
|
0.000
|
Employed
|
206 (52.6)
|
52 (25.2)
|
154 (74.8)
|
|
|
Income/wealth index
|
|
|
|
|
|
Low income
|
170 (43.4)
|
147 (86.5)
|
23 (13.5)
|
202.5
|
0.000
|
Medium income
|
91 (23.2)
|
56 (61.5)
|
35 (38.5)
|
|
|
High income
|
131 (33.4)
|
06 (4.6)
|
125 (95.4)
|
|
|
Having children
|
|
|
|
|
|
Yes
|
243 (62.0)
|
182 (74.9)
|
61 (25.1)
|
119.6
|
0.000
|
No
|
149 (38.0)
|
27 (18.1)
|
122 (81.9)
|
|
|
Family support
|
|
|
|
|
|
Yes
|
89 (22.7)
|
38 (42.7)
|
51 (57.3)
|
4.3
|
0.91
|
No
|
303 (77.3)
|
171 (56.4)
|
132 (43.6)
|
6.2
|
0.4
|
Smoking
|
|
|
|
|
|
Current smokers
|
16 (4.1)
|
11 (68.7)
|
5 (31.3)
|
7.8
|
0.2
|
Previous smoker
|
07 (1.8)
|
4 (57.1)
|
3 (42.9)
|
|
|
Never smoked
|
369 (94.1)
|
194 (52.6)
|
175 (47.4)
|
|
|
Alcohol
|
|
|
|
|
|
Never
|
341 (86.9)
|
175 (51.3)
|
166 (48.7)
|
5.4
|
0.34
|
Current
|
46 (11.8)
|
31 (67.4)
|
15 (32.6)
|
|
|
Past
|
05 (1.3)
|
03 (60)
|
02 (40)
|
|
|
Clinical characteristics
Among the total participants, 94.6% were on ART during the study period. About 40% of the participants had been diagnosed with HIV infection for > 60 months as of May 2019. The recent CD4 cell count of two hundred and fifty-one (n = 251, 64%) participants was below 350 cell/mm3, and about 3/4th of the participants were diagnosed to be in clinical stage I and II. Majority of participants (93%) were diagnosed with weight loss, nearly half of them (48.7%) had anemia, and only 4.6% and 9.4% had been diagnosed to have diabetes mellitus and hypertension respectively. According to the PHQ-9 score of depression, about 3/4th of the HIV-infected adult participants were suffering from depression, of those, almost half of them had severe depression. About one in four reported to suffer insomnia 23.2% and 29.8% were physically active Table 2.
Table 2 Clinical characteristics of people living with HIV/AIDS attending ART clinic at University of Gondar Hospital, University of Gondar, Northwest Ethiopia, 2019 (n=392).
Variables
|
Sample total
n (%)
|
Fatigue n (%)
|
χ2
|
P
|
Yes
|
No
|
Type of HAART regimen
|
|
|
|
|
|
AZT+3TC+NVP
|
155 (39.5)
|
74 (47.7)
|
81 (52.3)
|
1.3
|
0.7
|
AZT+3TC+EFV
|
16 (4.1)
|
7 (43.8)
|
9 (56.2)
|
|
|
TDF+3TC+EFV
|
118 (30.1)
|
76 (64.4)
|
62 (35.6)
|
|
|
TDF+3TC+NVP
|
63 (16.1)
|
27 (42.9)
|
36 (57.1)
|
|
|
ABC+DDI+LPV/R
|
19 (4.8)
|
14 (73.7)
|
05 (26.3)
|
|
|
Pre-HAART
|
21(5.4)
|
11 (52.4)
|
10 (47.6)
|
|
|
CD4 counts
|
|
|
|
|
|
< 200 cells/mm3
|
23 (5.8)
|
07 (30.4)
|
16 (69.6)
|
4.5
|
0.23
|
200-350 cells/mm3
|
228 (58.2)
|
128 (56.1)
|
100 (43.9)
|
|
|
> 350 cells/mm3
|
141 (36.0)
|
73 (51.8)
|
68 (48.2)
|
|
|
Duration of HIV infection
|
|
|
|
|
|
< 60 months
|
232 (59.2)
|
176 (75.9)
|
56 (24.1)
|
119.7
|
0.000
|
60-100 months
|
87 (22.2)
|
24 (27.6)
|
63 (72.4)
|
|
|
> 100 months
|
73 (18.6)
|
09 (12.3)
|
64 (87.7)
|
|
|
WHO HIV/AIDS clinical stage
|
|
|
|
|
|
Stage I
|
230 (58.7)
|
99 (43)
|
131 (57)
|
25.1
|
0.00
|
Stage II
|
80 (20.4)
|
51 (63.8)
|
29 (36.2)
|
|
|
Stage III
|
81 (20.7)
|
58 (71.6)
|
23 (28.4)
|
|
|
Stage IV
|
1 (0.3)
|
01 (100)
|
0 (0)
|
|
|
Weight loss
|
|
|
|
|
|
No weight loss
|
26 (6.6)
|
24 (92.3)
|
02 (7.7)
|
31.9
|
0.01
|
Mild weight loss
|
148 (37.8)
|
102 (68.9)
|
46 (31.1)
|
|
|
Moderate weight loss
|
122 (31.1)
|
63 (51.6)
|
59 (48.4)
|
|
|
Severe weight loss
|
96 (24.5)
|
20 (20.8)
|
76 (79.2)
|
|
|
Anemic
|
|
|
|
|
|
Yes
|
191 (48.7)
|
180 (94.2)
|
11 (5.8)
|
111.2
|
0.000
|
No
|
201 (51.3)
|
29 (14.4)
|
172 (85.6)
|
|
|
Diabetes mellitus
|
|
|
|
|
|
Yes
|
18 (4.6)
|
15 (83.3)
|
03 (16.7)
|
13.6
|
0.001
|
No
|
374 (95.4)
|
194 (51.9)
|
180 (48.1)
|
|
|
Hypertension
|
|
|
|
|
|
Yes
|
11 (9.4)
|
10 (90.8)
|
01 (9.1)
|
9.2
|
0.002
|
No
|
381 (89.6)
|
198 (52)
|
183 (48)
|
|
|
Other co-morbid conditions
|
|
|
|
|
|
Yes
|
37 (9.4)
|
23 (62.2)
|
14 (37.8)
|
15.3
|
0.000
|
No
|
355 (90.6)
|
186 (52.4)
|
169 (47.6)
|
|
|
Depression
|
|
|
|
|
|
Yes
|
283
|
204 (72.1)
|
79 (27.9)
|
144.8
|
0.000
|
No
|
109 (28.1)
|
21 (19.3)
|
88 (80.7)
|
|
|
Insomnia
|
|
|
|
|
|
Yes
|
91 (23.2)
|
43 (47.3)
|
48 (52.7)
|
1.66
|
0.68
|
No
|
30 (76.8)
|
166 (55.1)
|
135 (44.9)
|
|
|
Physical activity
|
|
|
|
|
|
Yes
|
117 (29.8)
|
41 (35.1)
|
76 (64.9)
|
5.49
|
0.014
|
No
|
275 (70.2)
|
178 (64.7)
|
97 (35.3)
|
|
|
Physical disability
|
|
|
|
|
|
Yes
|
12 (3.1)
|
10 (83.3)
|
02 (16.7)
|
2.48
|
0.59
|
No
|
380 (96.9)
|
199 (52.4)
|
181 (47.8)
|
|
|
Fatigue among adults HIV/AIDS and distribution
Among 392 participants, two hundred and nine (n = 209, 53.3%; 95% CI; 48.5, 58.5) were found to have the experience of fatigue. A statistically significant difference was observed in the prevalence of fatigue between genders (men 27.1 versus women 66.8%; χ2 (1, n = 392) = 55.7, p < 0.0001, phi = 0.37). The majority of widowed participants reported fatigue 78.3% followed by married 55% and single 48%. The experience of fatigue was higher among anemic participants 180 (94.2%), unemployed 157 (84.4%), and those who reported low income 147 (86.5%). Depression was significantly associated with experience of fatigue (depression 72.1% versus no depression 27.9%; χ2 (1, n = 392) = 144.8, p < 0.0001, phi = 0.61). The frequency distribution of fatigue symptoms for the 9-item fatigue severity scale (FSS) reported by the respondents was almost even and majority of them reported that “exercise brings on my fatigue” 57.4% (225/392), and “I am easily fatigued” 55.9% (219/392) Figure 1.
Regression analysis
Prior to analysis, fourteen variables potentially related to the experience of fatigue were identified for regression analysis: gender, age, marital status, education level, employment status, income index, parity, duration of HIV, HIV/AIDS clinical-stage, weight loss, anemia, comorbid conditions, depression, and physical activity. Of those, age, duration of HIV, and physical activity were found not significantly associated in univariate analyses. The remaining eleven variables were entered into the multivariate model. In multivariate analyses when adjusted for other independent variables; gender, marital status, income level, employment status, parity, anemia, depression, and weight loss were found to be significant predictors.
HIV-infected adult women patients were 3 times more likely to experience fatigue than their counterparts [AOR 3.19, 955 CI: 1.05, 6.92], patients who were married and living with their spouse were 87% less likely to experience fatigue than those who were not with their spouse. Those who were unemployed and had low income were four times (AOR 3.9, 95% CI: 1.02, 14.74) and twelve times (AOR 12.3, 95% CI: 2.5, 60.15) more likely to suffer from fatigue. HIV-infected patient those who have children were 7.9 times more likely to have fatigue compared to those who did not have children (AOR 7.99, 95% CI: 1.66, 38.41). HIV/AIDS patients diagnosed with anemia and depression were 13 times (AOR 13.34, 95% CI: 2.74, 65.01) and 4 times (AOR 4.01. 95% CI: 1.10, 15.6) respectively. Those who had mild and moderate weight loss were about five times more likely to develop fatigue as compared to those with no weight loss ( AOR 4.9, 95% CI: 4.33, 19.51) and (AOR 5.5, 95% CI: 3.11, 21.37) respectively Table 3. The interaction effect of unemployment, low income, gender, having children, and depression was not significantly associated with fatigue.
Table 3 Univariate and multivariate analysis for the associated and predicting socio-demographic and clinical characteristics to HIV-related fatigue, 2019 (n=392), Ethiopia.
Variables
|
Fatigue
|
Univariate
|
Multivariate
|
|
Yes
|
No
|
COR (95%CI)
|
AOR (95%CI)
|
Sex
|
|
|
|
|
Women
|
173
|
86
|
5.42 (3.45,8.6) *
|
3.196 (1.05, 6.92)*
|
Men
|
36
|
97
|
1 (ref)
|
1 (ref)
|
Marital status
|
|
|
|
|
Single
|
44
|
47
|
1 (ref)
|
1 (ref)
|
Married
|
112
|
91
|
1.32 (0.80,2.16)*
|
0.13 (0.23, 0.7)*
|
Divorced
|
35
|
40
|
0.94 (0.51,1.72)*
|
0.17 (0.03,1.2)
|
Widowed
|
18
|
5
|
3.85 (1.32,11.24)*
|
0.53 (0.01, 2.3)
|
Income
|
|
|
|
|
Low income
|
147
|
23
|
133.15(52.56, 337.3) *
|
12.3(2.5, 60.15)*
|
Medium income
|
56
|
35
|
33.33(13.26, 83.78)
|
7.05(1.49, 33.49)
|
High income
|
6
|
125
|
1 (ref)
|
1 (ref)
|
Educational status
|
|
|
|
|
Illiterate
|
68
|
46
|
1.6(0.81,3.21) *
|
0.422 (0.07, 2.63)
|
Grade 1-6
|
38
|
44
|
0.94(0.46,1.94)
|
0.184( 0.026, 1.29)
|
Grade 7-8
|
30
|
23
|
1.42(0.64,3.15)
|
0.12(0.008, 1.63)
|
Grade 9-10
|
32
|
21
|
1.66(0.75,3.7 )
|
0.122(0.012, 1.25)
|
Grade 11-12
|
19
|
25
|
0.83(0.36,1.9)
|
0.55(0.06, 4.1)
|
Diploma and above
|
22
|
24
|
1 (ref)
|
1 (ref)
|
Occupation status
|
|
|
|
|
Employed
|
52
|
154
|
1 (ref)
|
1 (ref)
|
Unemployed
|
157
|
29
|
16.033( 9.67,26.59)*
|
3.9(1.02,14.74)*
|
Having children
|
|
|
|
|
Yes
|
182
|
61
|
13.48( 8.11,22.40)*
|
7.99(1.66, 38.41)*
|
No
|
27
|
122
|
1 (ref)
|
1 (ref)
|
Anemia
|
|
|
|
|
Yes
|
180
|
11
|
17.05(7.01, 28.3)*
|
13.34(2.74, 65.01)*
|
No
|
29
|
172
|
1 (ref)
|
1 (ref)
|
Depression
|
|
|
|
|
Yes
|
204
|
79
|
5.61 (2.03, 19.1)*
|
4.01 (1.10, 15.64)*
|
No
|
21
|
88
|
1 ref
|
1 ref
|
Weight loss
|
|
|
|
|
No weight loss
|
6
|
20
|
1 (ref)
|
1 (ref)
|
Mild weight loss
|
109
|
39
|
12.3 (3.24, 24.22)*
|
4.9 (4.33, 19.51)*
|
Moderate weight loss
|
99
|
23
|
13.9 (2.89, 27.5)*
|
5.5 (3.11, 21.37)*
|
Severe weight loss
|
45
|
51
|
7.8 (1.01, 15.2)*
|
2.91 (1.12, 9.74)
|
Duration of HIV
|
|
|
|
|
< 60
|
176
|
56
|
22.35( 10.65, 47.78)
|
0.762(0.153, 3.79)
|
60-100
|
24
|
63
|
2.71(1.17,6.28)
|
1.93(0.392, 9.45)
|
≥ 100
|
9
|
64
|
1 (ref)
|
1 (ref)
|
Co-morbid condition
|
|
|
|
|
Yes
|
37
|
9
|
4.16(1.95,8.88)*
|
4.31(0.93, 20.05)
|
No
|
172
|
174
|
1 (ref)
|
1 (ref)
|
Clinical stage of HIV
|
|
|
|
|
Stage 1
|
99
|
131
|
1 (ref)
|
1 (ref)
|
Stage 2
|
51
|
29
|
2.33(1.38, 3.94)
|
0.34(0.04, 2.79)
|
Stage 3 and 4
|
59
|
23
|
3.39(1.1,5.9)
|
4.99(0.67, 37.24)
|
CD4 counts
|
|
|
|
|
< 200 cells/mm3
|
6
|
17
|
0.254(0.12,0.54)
|
1.28(0.23, 7.14)
|
200-350 cells/mm3
|
126
|
102
|
1.14(0.74,1.76)
|
0.884(0.254, 3.08)
|
>350 cells/mm3
|
77
|
64
|
1 (ref)
|
|
*Denotes significant association of the characteristics with HIV-related fatigue in the multivariate model, AOR-Adjusted odd ratio, CI - Confidence Interval