Experience of Nutritional Counselling in a Nutritional Program in HIV Care in the Tigray Region of Ethiopia Using the Socio-ecological Model


 Background: In many resource-poor settings, nutritional counselling is one component of nutrition support programs aiming to improve nutritional and health outcomes amongst people living with HIV. Counselling methods, contents, and recommendations that are culturally appropriate, locally tailored, and economically affordable are essential to ensure desired health and nutritional outcomes are achieved. However, there is little evidence showing the effectiveness of counselling in nutritional programs in HIV care, and the extent to which counselling policies and guidelines are translated into practice and utilised by people with HIV suffering from undernutrition. This study aimed to explore these gaps in the Tigray region of Ethiopia. Methods and participants: A qualitative study was conducted in Tigray Region Ethiopia between May and August 2016. Forty-eight individual interviews were conducted with 20 undernourished adults living with HIV and 15 caregivers of children living with HIV enrolled in a nutritional program in three hospitals, as well as 11 health providers, and 2 program managers. Data analysis was undertaken using the Framework approach and guided by the socio-ecological model. Qualitative data analysis software (QSR NVivo 11) was used to assist data analysis. The study findings are presented using the consolidated criteria for the reporting of qualitative research (COREQ). Result: The study highlighted that nutritional counselling as a key element of the nutritional program in HIV care varied in scope, content, and length. While the findings clearly demonstrated the acceptability of the nutritional counselling for participants, a range of challenges hindered the application of counselling recommendations in participants’ everyday lives. Identified challenges included the lack of comprehensiveness of the counselling in terms of providing advice about the nutritional support and dietary practice, participants’ poor understanding of multiple issues related to nutrition counselling and the nutrition program, lack of consistency in the content, duration and mode of delivery of nutritional counselling, inadequate refresher training for providers, and the absence of socioeconomic considerations in nutritional program planning and implementation. Evidence from this study suggests that counselling in nutritional programs in HIV care was not adequately structured and lacked a holistic and comprehensive approach. Conclusion: Nutritional counselling provided to people living with HIV lacks comprehensiveness, consistency, and varies in scope, content, and duration. To achieve program goal of improved nutritional status, counselling guidelines and practices should be structured in a way that takes a holistic view of patient’s life and considers cultural and socioeconomic situations. Additionally, capacity development of nutritional counsellors and health providers is highly recommended to ensure counselling provides assistance to improve the nutritional wellbeing of people living with HIV.


Introduction
There is strong evidence on the interaction between undernutrition and HIV infection, with impacts at individual and community levels. HIV infection and AIDS increases people's predisposition to undernutrition [1]. Due to clinical, social, and economic factors, people living with HIV are more likely to suffer from undernutrition and its consequences [1][2][3]. Estimates of the prevalence of undernutrition among people living with HIV in sub-Saharan Africa varies -for example from 19.4% in Tanzania to [4] to 42.5% in Ethiopia [5]. International health agencies including the World Health Organization (WHO) recommend nutritional care as an important component of HIV care services, particularly in resource-poor settings [6,7].
Evidence suggests that a combination of antiretroviral therapy (ART) and nutritional care can improve adherence to ART and nutritional wellbeing. Ivers and colleagues found that adults living with HIV had better adherence to ART at 6 and 12 months of using nutritional supplementation respectively than those who were not provided with food assistance [8]. In addition, there is strong evidence on the bene ts of nutritional support in terms of improving the nutritional status of people living with HIV [9][10][11].
To address HIV-related undernutrition and to improve HIV care outcomes, nutritional programs have been incorporated into HIV care services in many countries, particularly in sub-Saharan Africa [11][12][13][14].
Nutritional programs mainly comprise three components:1) nutritional assessment; 2) nutritional support; and 3) nutritional counselling. A nutritional assessment can involve a range of parameters but most commonly includes nutritional screening which measures key anthropometric indicators to guide the provision of different therapeutic and supplementary foods [11,12,15]. Food-based supplements such as high-energy ready-to-use therapeutic foods (RUTF) and corn-soy-blended (CSB) are the most common nutritional supports used in HIV care settings to treat protein-energy undernutrition [16]. The third component of nutritional programs is nutritional counselling. The general aim of nutritional counselling is to assist patients to: a) maintain weight through increased energy intake; b) practice safe infant feeding; c) practice safe food or water handling; and d), manage HIV-related illness [15,17].
Nutritional counselling plays a critical role in improving individuals' nutritional knowledge and understanding of the importance of nutrition in their lives [18]. Such engagement through individual or group counselling sessions can empower patients to make informed decisions regarding their eating practice based on their nancial circumstances and food availability and to take control over their nutritional circumstances [18,19]. Culturally appropriate nutritional counselling involves tailored content to the local cultural context, incorporating local knowledge, expertise and lifestyle choices, distributing locally and culturally appropriate food and adapting the nutritional counselling to the local people's educational level [19,20] The evidence base regarding the availability and practice of nutritional counselling in HIV care is mixed. While a study in sub-Saharan African countries found the inclusion of nutritional counselling in 95% of the study sites [21], another study from Ghana reported a lack of nutritional counselling in HIV care programs [22].
Evidence on the role of nutritional counselling in improving the nutritional status of people living with HIV is varied [23][24][25]. Some studies support the importance of nutrition counselling [24] but others are inconclusive about the bene ts of counselling for the management of nutrition in HIV care. For example, a study conducted in Nigeria found that people living with HIV who were offered regular nutritional assessment and counselling had better nutritional outcomes than those who were not [25]. In contrast, a study from Brazil had shown that the provision of nutritional counselling to undernourished people living with HIV who had tuberculosis showed no improvement in their nutritional status [23], though tuberculosis infection might have undermined the positive impact of nutritional counselling. In a study from Uganda, nutritional counselling was found to be effective in improving the overall quality of life of people living with HIV, when given as a package of nutritional and other interventions such as nutritional support to [26].
There is little evidence on the best techniques of counselling such as individual vs groups, frequency and duration of counselling, and the possible roles of counsellors such as peers, nurses, physicians, and other auxiliary health workers in HIV care settings [27].

Th nutritional program in HIV care in Ethiopia
The nutritional program in HIV care settings in Ethiopia commenced in 2010 and involves three main components to address the nutritional challenges of people living with HIV [12]. The program involves nutritional assessment for all people living with HIV on ART and pre-ART, classi cation of nutritional status, and enrolment of those undernourished into a nutritional program. The nutritional support program provides therapeutic food (Plumpynut) for six months for severely acute undernourished (SAM) and supplementary food (Plumpysup) for three months in moderately or mildly undernourished people living with HIV. Nutritional counselling is also one of the key components of the nutritional programs in HIV care in Ethiopia, similar to other areas in sub-Saharan Africa [11].
In Ethiopia according to the national guidelines, nutritional counselling involves the provision of general information to people living with HIV who are enrolled in the nutritional program as stated in the nutritional guideline [28]. The information includes how to: 1. conduct a periodic nutritional assessment at a health facility; 2. increase intake and dietary diversi cation; 3. maintain a good level of hygiene and sanitation; 4. increase clean and safe water intake; 5. maintain a healthy lifestyle; 6. early treatment and diagnosis of illness and symptoms; and 7. adherence to advice by a health provider on how to take medications and manage dietary needs. Despite the potential bene ts of nutritional counselling to people living with HIV, there is little evidence about the practice and experiences of nutritional counselling in HIV care settings from the perspectives of bene ciaries, service providers, and program managers. A study conducted in Ethiopia examined the availability of nutritional education in a nutritional program in HIV care but failed to examine the experience of various stakeholders of the nutritional counselling [29]. This paper presents the experiences of different stakeholders on nutritional counselling in HIV care settings in Ethiopia, with a view to help inform policy on how to effectively address the challenges of nutritional counselling for people living with HIV.

The Socioecological model
This study draws on the socioecological model (SEM) that can assist an understanding of a problem at multiple levels [30]. The SEM is a theory-based framework employed to comprehend the interaction of individual and environmental factors that impact health behaviours and outcomes [31,32]. By highlighting that are problems are not solely explained by individual behaviour, the SEM helps to understand the dynamics and interactions between individual, interindividual, institutional, community, and social policy level factors in in uencing health outcomes and behaviours [33]. The SEM has been applied in studies involving nutritional programs in HIV care, sexual and reproductive health among people living with HIV, adherence to ART, and acceptability of infant feeding to prevent HIV [34][35][36][37].
This paper sought to examine experiences of the nutritional counselling program in nutritional programs in HIV care settings in the Tigray region, from the perspectives of program users, staff and managers, to identify strengths and challenges of the nutritional counselling that is offered in HIV care.

Methodology
Study design, Sampling, and recruitment: This study is part of a larger study that examined the determinants of nutritional outcomes and challenges of a nutritional program in the Tigray region of Ethiopia [37,38]. This paper presents ndings from a qualitative study involving individual interviews with adults living with HIV, caregivers of children living with HIV, health providers, and health managers to explore their experiences and perspectives about nutritional counselling in the nutritional program in HIV care settings.
The study was conducted in three hospitals namely: Mekelle, Shul, and Lemlem Karl hospitals in the Tigray region, northern Ethiopia. Twenty percent of people living with HIV on ART and 22% of those enrolled in the nutritional program in the Tigray region accessed HIV and nutrition related services from these hospitals.
Study participants consisted 20 adults and 15 caregivers of children living with HIV enrolled in the nutritional program. In addition, 11 health providers and two program managers were interviewed. Details of the study setting are described elsewhere [38].
Data collection procedure: The rst author (FT) conducted face-to-face in-depth interviews with participants. There was no relationship between the interviewer ( rst author) and the study participants prior to the interview date and participant information sheet and consent form were the only source of information for participants to know about the research interviewer (FT). A semi-structured interview guide was developed (in English) and the interview guide was eld-tested in a similar setting and adjustment was made based on the pretest. The interview guides are attached as a supplementary le (supplementary le 1). To induce open discussion on the topics and maintain the privacy of the study participants, the interview was conducted in a private room inside the health facility. All interviews were conducted in the local Tigrigna language by directly translating the interview guide to the local language during the interview process by the rst author (FT). He is a native speaker of the local Tigrigna language and uent in English with a good understanding of the study context and culture. All in-depth interviews were audio-recorded using a high de nition audio recorder. The duration of the in-depth interview ranged from 30-66 minutes. In addition, observation and eld notes were taken during the eld stay.

Data analysis:
Interviews were translated and transcribed verbatim from the Tigrigna local language to English by the rst author (FT). A translation and transcription accuracy test was done to improve the quality of translation from the local language to English using a person who was uent in the Tigrigna local language and English, with accuracy rated as high.
Data were analysed using a thematic framework analysis approach [39]. Interview transcripts were read and re-read to gain a holistic understanding of the range of responses and scope of counselling experiences. A list of codes was developed based on four transcripts which served as a framework for analysis and 11 nutritional counselling related working codes were generated. English translated transcripts were imported to NVivo 11 software for analysis. In the second phase of coding, the number of codes that emerged from all transcripts was increased to 14. Finally, these codes were merged, categorised and re-categorised to develop four themes to answer the research question. Coding and data analysis were done inductively by one person, and three transcripts were double coded by co-authors and disagreements were discussed in a team meeting to reach consensus. The socioecological model was used to guide the overall data analysis, presentation, and interpretation of ndings.

Characteristics of study participants
Participants' mean ages with standard deviation was 37.2±9.7 for adults living with HIV (hereafter 'adults'), 36±7.3 for caregivers of children living with HIV (hereafter 'children'), and 35.3± 8 for program staff. All caregivers and 12(60%) of adult study participants interviewed were female.
The majority of adults (60%) and caregivers (73%) were urban residents. While four (20%) and ve (33%) of adults and caregivers respectively attended no school, 10(50%) and ve (33%) adults and caregivers respectively had attended primary school. The average income in adults and caregivers ranged from no reliable income (N=9,4 caregiver and 5 adults) to 6,000 (N=3) (equivalent to 458 Australian Dollars) per month which is much lower than the average annual per capita income in Ethiopia (857 Australian dollars) for the year 2018. At the time of the interview, six (30%) adults were single and six (30%) married, and nine (60%) of caregivers were married. An equivalent number of males and females were represented when it comes to health care providers and program managers, and they all had achieved education level at BSc and above (Table 1). Experience of nutritional counselling in the nutritional program.
Four main themes that emerged from the interview data in relation to experiences of nutritional counselling in the nutritional program are summarised in table 2 and discussed in detail below. Comments received about the frequency of nutritional counselling ranged from 'no counselling at all to more than one counselling. The majority of study participants noted that the nutritional counselling was provided as a one-off session, commonly at the beginning of the nutritional program.
…At the beginning when they give you [the nutritional support], they [the health providers] tell you that it is a medication: that is all, nothing else after… (Adult male, #7).
A small number of adults and caregivers reported receiving no nutritional counselling at all and said that they had been sent home only with the nutritional support: Maybe since I am coming from far away, I may not reach the teaching session. Otherwise, I have not yet come across any counselling or teaching session (Adult female, #6).
We did the counselling at each visit. For example, when we have many clients. We send them to the case manager [peer counsellors] for counselling about ART adherence, cleanliness, or personal hygiene and so on" (Health provider #4)

Contents of the nutritional counselling as experienced by participants
Even though the nutritional counselling is meant to cover the seven elements mentioned in the introduction [40], participants reported that the nutritional counselling focused on three elements : a) nutritional support (Plumpynut/Plumpysup); b) dietary practice; and c) sanitation and hygiene, with a particular emphasis on the nutritional support.
In general, the nutritional counselling mainly focused on the nutritional support (Plumpynut/Plumpysup); including why the nutritional support is given and its bene ts as stated by a caregiver below: They [health providers] told me that my child's weight has been decreased and told me to give him the Plumpynut properly. They said, "this [the plumpynut] will improve his weight as well as general health status and told me to follow him properly"(Caregiver #5).
An adult female also reiterated the focus of the nutritional counselling around the nutritional support, speci cally on the bene ts of the nutritional support in terms of improving weight and wellbeing.
They [health providers] counsel me that the Plumpynut contains important nutrients including Plumpynut and vitamins. They told me that it is very important and bene cial for your weight and overall health (Adult female #1).
Discouraging patients to share and sell the nutritional support were also stated as part of the nutritional counselling regarding the nutritional support.
The health providers also advised us to take it (the Plumpynut) properly and not to share it with others. Selling, sharing or giving it to other persons is not allowed (Adult male #6) The second content focus of the nutritional counselling identi ed in HIV care related to dietary practice and increasing the frequency and diversity of foods to improve nutritional wellbeing. Even though the lack of access to adequate food was a problem in many participants, counselling to diversify dietary practice with whatever food available at home was another element of the nutritional counselling.
They counsel us about everything. For instance, they tell us 'it is not only meat that we [herself and her child] should take, we can also take other foods like grains and vegetables which are equally important (Caregiver #4).
We counsel them how their dietary pattern looks like and they are counselled to take balanced foods (Health provider #2).
The third component covered in the counselling sessions was on mechanisms to maintain hygiene and food safety including handwashing, hygienic handling of the nutritional support and other foods as well as consuming cooked foods: They [health providers] tell us to maintain our personal hygiene and environmental sanitation, to wash our hands before use of the nutritional support and to use Woha Agar [1] to treat water (Caregiver #2).
Hygiene, to drink clean and safe water and to use Woha Agarto treat the water or boil it (water) before use, otherwise I didn't remember any speci c counselling session (Adult male #6).
The health providers advised us to eat balanced food, drink clean water, and seek care for any sickness (Adult female, #4).
In a small number of instances, during the nutritional counselling other topics such as minimizing stress to improve overall health, wellbeing, and quality of life and ART adherence were also covered.
About our dietary practice, they told us to take foods that go with the ART medication such as eggs, meat, and milk. As I told you about that, if you have enough you will eat, if not you will use whatever you have with the ART (Caregiver #16).
Acceptability of the nutritional counselling "Acceptability refers to determining how well an intervention will be received by the target population and the extent to which the new intervention might meet the needs of the target population and organizational setting" [41].
The majority of caregivers and adults felt that the nutritional counselling they received was acceptable and bene ted them in terms of providing information about the nutritional support.
Since I understand the bene ts of the Plumpynut, I believe that the counselling service has bene ted me to take the Plumpynut accordingly (Adult male #6).
… counselling is very important. It helps me to understand its [the nutritional support] bene ts to him [the child]) and use it properly, on time and get the necessary next ration (Caregiver #1).
Most adult and caregiver participants reported improved knowledge about food and nutrition as the bene t of the nutritional counselling, as described by an adult male below: If you are taking the ART medication or the Plumpynut accepting it will bene t you, you will get the intended bene ts. All the counselling is good for me for my weight and health. I fully practice the counselling provided because I understand that all the bene ts of counselling are to improve my weight.
When they counsel you, they [the health providers] are giving your life not to get sick and weaker (Adult male, #13).
Sharing the information received from nutritional counselling with other adults and caregivers was an indication of a high level of acceptability amongst people living with HIV. This was noted by an adult male: As a volunteer, I also transfer information to people who are taking Plumpynut not to share it instead to consume it to themselves (Adult male #5). I also teach a mother who have children who are taking the Plumpynut not to share it with others (Caregiver #3).
Challenges for the provision of nutritional counselling in HIV care setting A number of challenges were identi ed for the provision and implementation of nutritional counselling including a lack of understanding by recipients, training issues and inconsistent delivery, and a lack of consideration of the context of people's lives.
Despite the reported acceptability of the nutritional counselling by most adults and caregivers, some health providers said that nutritional counselling was not well implemented by some patients, particularly by older adults. It was believed that this may be partly due to a limited understanding of the nutritional counselling: This is because we may not provide them with adequate counselling as well most HIV patients are uneducated which may result in poor or slow understanding of the counselling service (Health providers #1).
We give them similar counselling service to all patients, but some people understand you quickly and others didn't understand you at all despite the intensity of counselling. Some of those who didn't accept and apply the counselling are those old and uneducated ones who may not pay it adequate attention(Health provider #2).
Health providers also noted a range of issues relating to the training of staff and training materials and inconsistent delivery of the nutritional counselling. The lack of training of health providers related broadly to the general nutritional program provided in the HIV care service, with implications also for nutritional counselling: Issue related to the health system, one is the professional. In order to give good service; their training should also be good. The health professional should know the contents of the two food supplements.
The knowledge of the health provider is low (Health provider #10) "There are problems related to the health provider especially if they didn't take training about food by prescription (Health provider #4).
Adults further reported that there was no detailed assessment of household socioeconomic status and family situation during the nutritional counselling but underlined that they have been told to eat whatever food available at home. An adult female described the lack of socioeconomic consideration of the nutritional counselling below: These overall challenges associated with nutritional counselling were seen by health providers to have a signi cant impact on program outcomes: Had it been that they apply all the counselling services given to them like the ART medication, they may get the necessary bene ts from the nutritional program: as well we may not have default or loss to follow up from the nutritional program (Health provider #6).
[1] Woha Agar is a water treatment chemical used in Ethiopia mainly distributed by health providers to people living with HIV

Discussion
Nutritional counselling in HIV care settings seeks to improve the effectiveness of nutritional programs in HIV care via improving knowledge and nutritional program utilisation. Research has indicated that locally and culturally sound nutritional counselling is vital to enhance and maintain the nutritional status of people living with HIV [42][43][44]. Engaging with participants and empowering them to take control of their nutrition and health is the fundamental principle of successful nutritional counselling in HIV care settings [14]. Evidence from other studies suggests that standard nutritional counselling should empower individuals with essential nutritional knowledge and assist them to understand the importance of nutrition to make informed decisions regarding their nutritional options [19,20].
The importance of nutritional counselling is stipulated in the Ethiopian national nutritional program [45].
However, despite evidence highlighting the importance of comprehensive nutritional counselling, this study has shown that counselling as one of the key components of nutritional program had a narrow focus, largely limited to a simple one way provision of information. One previous study from Ethiopia has highlighted the bene ts of nutritional counselling in HIV care but did not provide detailed information on the level of engagement of people living with HIV in the counselling sessions [46]. Generally, there was no evidence of true engagement with patients, empowerment and patient's involvement in decisions made/counselling provided to people living with HIV.
While the technical guidelines for nutritional counselling recommends covering seven elements [40], the current study found that the nutritional counselling in the HIV care settings examined covered three elements-counselling about the nutritional support, dietary diversi cation, and food and personal hygiene. Among the three elements, the main focus was on the nutritional support, which led people living with HIV to consider and relate the nutritional program in HIV care only to the nutritional support. This is not in line with the objectives of the nutritional counselling which is more holistic and comprehensive [14]. This nding is consistent with other studies reporting a focus of the nutritional counselling on the nutritional support among HIV positive children enrolled in a nutritional program [47]. The study found there was more limited coverage of dietary diversi cation and, in those cases where there was, no or limited consideration of household socioeconomic status. There was even less coverage of personal and food hygiene.
Disproportional emphasis on the nutritional support was mainly related to the medicalised orientation of the nutritional program in general and the nutritional counselling in particular. Medical orientation refers to a focus of the nutritional program on treating medical malnutrition [48,49]. The medicalised orientation of the nutritional counselling may contribute to the lack of a holistic approachlimiting the nutritional counselling to clinical malnutrition. A similar study from Kenya demonstrated that education about foods that were suitable for health and nutritional wellbeing was not given enough emphasis during the counselling of people living with HIV [50]. This highlights the need for reorientation of the nutritional counselling in HIV care settings toward a holistic approach.
According to the ndings of this study, the nutritional counselling on the management of nutritional requirements was well received by patients, providing them with information on the nutritional supplements. Health providers did identify less educated and older people as having potential di culties understanding the counselling. A study by Tobi and Voge found a lack of understanding of the nutritional counselling service reported as a barrier. [51]. Other studies have found that nutritional counselling improved understanding of the nutritional program and their nutritional management of people living with HIV [14,24,25]. For instance, peer-delivered nutritional counselling among people living with HIV was found to improve dietary practice and food security [24]. Furthermore, a study from Nigeria also reported that nutritional counselling was effective in improving the nutritional management of people living with HIV [25]. Despite contextual differences, individualised nutritional counselling about dietary diversi cation and improved consumption was also deemed to improve the nutritional management of people living with HIV enrolled in a nutritional program as highlighted by a study from India [52] There is no evidence on the speci c duration of nutritional counselling to bring the required behavioural change among people living with HIV. However, inadequate nutritional counselling session duration was one of the key challenges demonstrated in this study -with most participants reporting only one counselling session and health providers indicating that session times in some contexts are too short.
Other studies have also reported a short duration of nutritional counselling sessions. For example, a study by Tafesea and his colleagues which was conducted in Ethiopia indicated that a health provider counselled about 38 clients in a day and the average time spent on counselling a client was 3.26 minutes, which is very short to cover the contents and deliver key nutrition information [29]. Another study conducted in Cambodia among caregivers of children living with HIV also highlighted that counselling about the nutritional support was too short in duration [47]. Other studies suggest that shorter sessions also means less focus on prevention [53,54].
Health providers who provide nutritional counselling need specialised training and knowledge in relation to culturally sensitive foods, disease progression, ART medication, and complications [51,55]. However, a lack of continuous standardised training of health providers on nutrition for people living with HIV was identi ed and this nding is consistent with the ndings of studies conducted in Ethiopia [29,56]. A similar study by Kolasa and Rickett indicated that health providers lacked the necessary knowledge and skill to deliver brief and evidence-based nutritional counselling for people living with HIV [57]. This was also re ected in a lack of consistency in providing the nutritional counselling between health providers.
While the national policy framework in Ethiopia indicates the need for nutritional counselling [45], [40], despite, the need for clear technical nutritional counselling guidelines with clear outcomes in the nutritional program there were no clear and speci c operational guidelines that guide the delivery strategy, session duration, and other technical issues related to the nutritional counselling except a simple pamphlet which suggests some seven key nutritional information for people living with HIV (see the introduction) [40]. In addition to the absence of technical guidelines, there was no training guideline for health providers. Despite the contextual differences, similar problems in relation to the training of health providers regarding the nutritional counselling were reported from the US [59].
A key issue also identi ed as a challenge for nutrition counselling programs was a lack of focus on the context of people's lives. This study found that food insecurity and poverty were a key issue among people living with HIV enrolled in the nutritional program [38] that affected their capacity to implement some elements of the counselling. Other studies in Kenya [50], South Africa, and Ghana [51,58] have likewise demonstrated the importance of considering the individual patient's nancial and socioeconomic circumstances when providing the nutritional counselling for better effectiveness. For nutritional counselling to be effective, it should be tailored around the needs of people living with HIV.
The ndings were interpreted using the socioecological model [30] and this indicated that effective nutritional counselling can be in uenced by multilevel factors that interact with each other. At an individual level [60,61], this can be in uenced by the knowledge, cognition, and acceptability of the nutritional counselling of the individual patient. For instance, experiences of the acceptability of the nutritional counselling operated as an individual level factor that impacts the effectiveness of the nutritional counselling in HIV care setting. Acceptability can be further explained by the interaction of individual-level issues such as lack of understanding and social policy levels factors such as food insecurity and poverty [35,62].
Inter-individual level factors such as lack of socioeconomic consideration of the nutritional counselling was a community-level factor which highly interacts with social policy level factors such as poverty and food insecurity [63]. The nutritional counselling was implemented in a broader socioeconomic environment where poverty and food insecurity was common [60,64].
Nutritional counselling can also be an institutional level factor [60], where institutional structure, culture, and operational issues were important determinants of the nutritional counselling and outcomes. For instance, the nutritional counselling in the HIV care setting lacked standardised training for health providers as re ected by inconsistencies in the delivery of the counselling among and within the health facilities included in the current study. This could be related to health providers' skills and knowledge about the nutritional counselling and the lack of goal-oriented and individual problem-based focus of the nutritional counselling. Institutional level factors such as offering counselling session on an one-off basis, short duration of each session, lack of nutritional counselling guidelines, and lack of ongoing training of health providers coupled with policy level factors such as the medicalised orientation of the nutritional counselling negatively impacted the effectiveness of the nutritional counselling.
There is also an interaction between the institutional level factors which include, absence of structured and goal-oriented counselling and policy gap due to the lack of counselling guideline which responds to the individual needs as stipulated in the socio-ecological model [30].
The study was able to canvass the views of the nutritional counselling of people living with HIV and carers of children with HIV, supplemented by interviews with service providers and nutritional program managers. However, there are a number of potential limitations to the study. There may be issues around maintaining the original meaning of the data during translation and transcription as narrated by the study participants, but the maximum effort was made to maintain accuracy. Although issues of con dentiality were emphasised prior to and during interviews, some participants were concerned about the use of an audio recording device. This may have had an impact on participant responses. The issue of a man interviewing a woman may also constrain some participants to detail some views. However, the interviewer was very mindful in the interviews of being sensitive to this.

Conclusion And Implications
Compared to national guidelines, we found that nutritional counselling in HIV care is characterised by limited scope and is oftentimes provided as one-off session usually at enrolment to the nutritional program. The other challenges of the nutritional counselling were lack of comprehensiveness, consistency, and regularity, di culties of some recipients in understanding the recommendations, and a failure to respond to the circumstances of people's lives.
Comprehensive nutritional counselling that is locally tailored and takes individual patients' needs and their socio-economic factors into consideration is crucial to improve nutritional health and wellbeing amongst people living with HIV. The development and improvement of national guidelines on nutritional counselling should include strategies and mechanisms that facilitate their translation into practice. Health providers' training, and reorientation of the nutritional counselling towards a holistic approach that engage and empower patients is also crucial to enhance the nutritional wellbeing of people living with HIV.

Declarations
Ethics approval and consent to participate: Availability of data and material: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests:
The authors declare that they have no competing interests.
Funding: Figure 1 Shows the interrelationships of various factors that impact the nutritional counselling in HIV care settings

Supplementary Files
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