Nutritional Status of HIV-Positive Pregnant Women in Luanda, Angola

During pregnancy, maternal intake of nutrients and their nutritional status affects both mother and baby. Good nutritional status plays an important role for a healthy pregnancy, for this it is necessary that the pregnant woman have a healthy diet to assist in weight gain. Objective: To evaluate the pregestational and gestational nutritional status of HIV-positive women. Methods: This is a cross-sectional and descriptive study, conducted from August to November 2018 in which 171 HIV-positive pregnant women were selected at random, in order of arrival and submitted to nutritional assessment through the Global Subjective Evaluation, whose data collected, were analyzed using EpiInfo software version 7.2. Results: From the main results found it was observed the presence of maternal nutritional eutrophic, considering the pre-gestational Body Mass Index (BMI) of 107 (62.56%), and the gestational BMI of 94 (54.97%). It was found 31(18.12%) of pre-gestational overweight and 54 (28.07%) of overweight during pregnancy, and it was also observed that 12 (7%) of pregnant women were obese before pregnancy and 15 (15.28%) became obese during pregnancy. A signicant association was found between pregestational BMI, height (p(cid:0)0.0001), gestational BMI, current weight (p(cid:0)0.0003), brachial perimeter (p(cid:0)0.002), and uterine height (p(cid:0)0.005). Conclusion: The results of this study indicate the need to develop nutritional care programs for HIV-positive women, in order to ensure an adequacy of their nutritional status.


Introduction
Pregnancy is a period that imposes increased nutritional needs, and adequate nutrition is paramount for the health of the mother and the unborn child, when women must consume speci c foods, variety, and quantity, taking into account cultural dietary guides and practices to meet energy and nutritional needs, and weight gain recommendations [1]. Despite the need for increased energy intake during pregnancy, women living in underdeveloped countries are often exposed to food insecurity and, to long-term malnutrition; food insecurity combined with malnutrition can affect the growth and development of the fetus [2]. Food insecurity is present in the lives of pregnant women in Africa because a large proportion of these women are responsible for family income and, during the period of pregnancy, their potential for income gain decreases, leading to a period of vulnerability and, in many cases, food insecurity leads to depression, a factor that impairs the well-being of both mother and baby [3].
The World Health Organization (2016) has published recommendations on prenatal care for a positive pregnancy experience, where it recommends that in undernourished populations, women receive nutritional education during pregnancy, guiding them to increase their daily energy and protein intake to reduce the risk of low birth weight newborns. The same document also recommends a daily oral supplementation of iron and folic acid with 30 to 60 mg of elemental iron and 400μg (0.4 mg) of folic acid in order to avoid anaemia of mothers, puerperal infection, low birth weight and premature birth [4].
The presence of Human Immunode ciency Virus (HIV) in the pregnancy does not reduce positive feelings about motherhood, but imposes many fears and strict care to prevent vertical transmission, particularly during birth [5]. When a HIV-positive woman becomes pregnant, some additional aspects must be considered in relation to her nutritional status, because the energetic demands of this woman are determined by the high energetic expenditure of rest, in the occurrence of infection and by the physiological adjustments proper to the gestational process, so that the increase in nutritional needs should re ect both the demands of pregnancy and infection [6]. Nutritional alterations, such as weight loss and protein reduction are common in HIV infection, alterations that lead to malnutrition, which results in a weakened immune system, requiring multivitamin supplementation during pregnancy and in the postpartum period, which signi cantly improve the hematological status of HIV-infected women as well as their children [7]. Experiences of guilt and fear of transmitting HIV to the child add to the health policies and actions that contribute to motherhood prophylaxis [5], the challenge posed by the HIV/AIDS epidemic in Africa, Angola, through the support of UNAIDS and the UN, support the initiative of the 37 First Ladies of African countries, whose program named "Born Free to Shine" has sought to offer treatment conditions to HIV-positive pregnant women in order to reduce the rate of mother-to-child transmission of HIV by offering them quality and humane care services [8].
It is estimated that between 223.350 and 290.000 adults over the age of 15 live with HIV in Angola, in addition to almost 30.000 children, in a prevalence of 2.34% among adults aged 15-49. It is estimated that women living with HIV, having a higher prevalence among young women (15-24 years = 0.9%), and about 15.575 pregnant women test positive for HIV each year, in a national average prevalence of 15-49 age group in 2.8%, being higher in the urban area (3%) than in the rural area (1.6%) [9].
Hence the need to carry out this study, with the objective of conducting nutritional assessment in the pregestational and gestational stages of HIV-positive women, in order to verify how much the results of these assessments may indicate risks of morbidity and mortality in these women, taking into account the various changes that guess the HIV infection and the maternal nutritional status, and the fact that there is no nutritional monitoring directed to these pregnant women in Angola until the time of the study.

Methods
Data were collected from August to November 2018, in a cross-sectional and descriptive study designed to evaluate nutritional status of HIV-positive pregnant women in a current antenatal care at a secondary healthcare level in Luanda, Angola, based on an estimated prevalence of 5.94% (data collected from the Department of Statistics of the secondary healthcare facility), 95% con dence level and 5% sampling error. An increase of 20% was employed for possible cases of loss or refusal [10].
The project was approved under the Protocol n 0 1, by the Committee on Ethics in Research in Human Beings of the Catholic University of Angola, with the purpose of safeguarding the rights and dignity of research subjects, and all participants signed an Informed Consent Term as a sign of acceptance of participation in the research.
Sample was selected by a simple random, in order of arrival, considering the number of pregnant women needed to compose the sample. The classi cation proposed by Goldstein et al (2018) [11] was used to classify the anthropometric nutritional status. The criterion for calculating gestational age was based on the parameters of Kim ID, Han ID and Kim (2019) [12]. The results found were stored in a database, using the Microsoft O ce Excel spreadsheet, and were treated with the EpiI nfo software by CDC Atlanta version 7.2.
Results 171 HIV-positive pregnant women participated in the study and according to    Table 3 presents the analysis by correlation and simple linear regression between the variables related to the pre-gestational and gestational nutritional status of the study participants. There was a strong and positive correlation between the variable current weight and pre-gestational BMI (RR=0.9) and current weight and gestational BMI (RR=0.8) there was also a strong and positive correlation between the variable brachial perimeter and pre-gestational BMI (RR=0.8), and current weight and gestational BMI (RR=0.6) there was also a strong positive correlation between pre-gestational BMI and gestational BMI (RR= 0.8) the statistical association between pre-gestational and gestational BMI was (p 0.01). A statistically signi cant association was observed between pregestational BMI and height (p 0.0001) and current weight (p 0.007), and between gestational BMI height (p 0.02), current weight (p 0.0003), brachial perimeter (p 0.002) and uterine height (p 0.005).  Table 4 re ects the daily consumption of nutrients by pregnant women, which consisted mostly of carbohydrates (47%) and, in their minority, of vitamins (9%). One to two portions a day 9 Figure 2 describes that 131(76.61%) of the pregnant women who participated in the study were aware that they were HIV-positive before the onset of pregnancy and 40 (23.39%) of the pregnant women were aware that they were HIV-positive after the onset of pregnancy.

Discussion
This study presents a description of the anthropometric, sociodemographic and clinical characteristics of pregnant women with HIV-AIDS of the prenatal care system at secondary healthcare level in Luanda, Angola. Taking into account the socio-demographic data of pregnant women it was highlighted that most of the participants in the study (58.48%) practiced an informal activity, which is an important indicator in the labor pro le in which the majority of the country's population and women in the study (58.48%) are found, in informality. In Angola, there is a signi cant difference in wage levels across sectors and, in many cases, wages are not su cient to ensure a decent life for workers and their families. In turn, the informal economy is characterized by precarious working conditions, which include not only low wages, but also scarcity of labor rights and lack of social coverage or protection, where most women are unemployed (24.9%) [13].
Based on the anthropometric data of the study participants and taking into account the pre-gestational body mass index (BMI), it was observed that although most women in the pre-gestational (62.56%) and gestational (54.97%) stages were in a state of eutrophic, a good representation of pregnant women was found to be overweight (28.07%) and obese (15.28%), which indicates the need for supervision and nutritional counseling, since overweight in these women may not be associated with a balanced diet in terms of nutrients, as we see in Table 4, which re ects that the diet during pregnancy was rich in carbohydrates (47%) at the expense of low vitamin intake (9%). Although there are several factors that may in uence the food intake of pregnant women, we chose the two most predominant, rst the cultural factor, because in sub-Saharan Africa a diet based on cassava derivatives predominates, and second the income, taking into account that the socioeconomic level of women in underdeveloped countries means that at some point of the month there is not enough money to buy food, thus increasing food insecurity during pregnancy, which becomes a challenge to an appropriate diet in terms of quality and quantity [2].
Regarding the characteristics of maternal nutritional status, a strong and positive correlation was observed between the variable current weight and pre-gestational BMI (RR=0.9) and current weight and gestational BMI (RR=0.8), as well as signi cant statistical differences with respect to pre-gestational BMI and current weight (p 0.007), and between gestational BMI and current weight (p 0.0003), which corroborates with the pattern of food consumption of the women in the study, as well as in the data of the study carried out by Brandão et al. (2011) [6] in which observed signi cant associations in relation to the statistical difference found statistically signi cant results between pregestational BMI and pregestational weight (p<0.01), and in the evaluation during pregnancy was observed statistical difference in relation to gestational BMI and current weight (p<0.05).
Of the pregnant women who participated in the study, 131 (76.61%) were aware of their serological status before pregnancy, which can mean a positive advantage, so that most of them (99.42%) had regular antiretroviral treatment (ART) and nutritional supplementation (97.66%) (Unpublished data), and decrease the possibility of the baby being born HIV positive. It recommends the use of ART during breastfeeding for all HIV-positive women in the prevention of mother-to-child transmission, regardless of the CD4 + cell count. In addition, for this to happen, nurse women should be guided about the harms of HIV transmission through breast milk, while being aware of the bene ts of exclusive breastfeeding as a strategy in preventing mother-to-child transmission. The mechanism that leads mothers to choose exclusive breastfeeding is mainly the desire for child survival, and this process occurs in the best way when the woman receives the necessary support from her partner and health professionals, during the process and then, when the time comes for the introduction of other foods, assertive choices are made that do not harm the child's nutrition [14].

Conclusion
During the elaboration of the work we could see that the pregnant women who participated in the study have their anthropometric indexes measured by the prenatal program, but do not receive from health professionals of the health unit a feedback of such information and even nutritional guidance during pregnancy. Thus, we drew attention to the need to expand nutritional care to HIV-positive pregnant women in Angola, through the creation of a scheme of nutritional follow-up throughout the prenatal and also suggest that studies be conducted to verify the relationship between the nutritional status of pregnant women, associated with adherence to antiretroviral treatment and viral load dosage, as well as the impact of these factors as propitiators of breastfeeding by HIV-positive women.

AKNOWLEGMENT
We thank Quiosa Canguila for assistance in collecting data's and all the health technicians who helped us in handling the research instruments.