Household food security and associated factors among Adult people living with HIV/AIDS attending ART clinic in Hospitals of Hawassa Town, Southern Ethiopia 2017

Abstract Introduction: Globally 78 million peoples have been infected with HIV/AIDS. Ethiopia has one of the largest populations of HIV infected people in the sub-Saharan region of Africa. The relationship between HIV epidemic and food security situation in Ethiopia is complex. Hence, it is likely that the epidemic will contribute to worsening widespread food insecurity. The aim of study was to assess the level of food security and associated factors among adult people living with HIV /AIDS attending ART Clinic in Hospitals of Hawassa city Administration. Methodology: Thisinstitutional based cross-sectional study was conducted from October to December 2017. Systematic sampling technique was used to select a total of 532 study participant. Data entry was done with EPI-info version 3.5.3 and transferred into SPSS Version 20. Crude with adjusted odds ratio with 95% confidence interval at p- value < 0.05were computed to examine statistical significance. Results:Based on food security assessment core module scale 360 (67.3%) People living with HIV/AIDSwere food insecure. People living with HIV/AIDSwho disclose HIV status were 3.9 (AOR=3.902, 95% CI (1.238, 12.301) times more likely to be food secured compared with their counterparts.Similarly, those who were with high and medium dietary diversity were about 5 times more likely to be house hold food insecure compared to those with low dietary diversity AOR= 4.990(2.488,10.05), AOR= 4.696(1.54,14.36), respectively. Conclusions:Food Security status among People living with HIV/AIDSon ART in Hawassa town was low. Dietary diversity, household size, and disclosing HIV status were found to be significant predictors of food security.

HIV related cause due to AIDS epidemic. In 2015, 36.7 million people were PLWHA; and among those 2.1 million became newly infected and 1. 8  Study done in West Shewa Zone, Central Ethiopia indicated that the prevalence of household food insecurity with PLWHA was 35.2% (4).
In SNNPR, it is estimated that 169,700 people live with the virus. Whoever enrolled in the program and of which a total of 20,340 PLWHA were started ART since the initiation of the program. The regional adult Population  age prevalence of PLWHA in 2010 was estimated to be 1.7% (3).
Food insecurity is no longer seen simply as a failure of agriculture to produce sufficient food at the national level, but instead as a failure of livelihoods to guarantee access to sufficient food at the household level and at individual level .Food security and adequate nutrition are fundamental to HIV treatment. There is emerging evidence that patients who begin ART without adequate nutrition have lower survival rates. Given the importance of adherence in delaying viral resistance to first line drugs, nutritional support becomes even more important in the longer run for sustaining ART (5&6).
Many families throughout the developing world spend more than 50% of their household income on food, and food production and wage earning are adversely affected when an adult has AIDS. Food insecurity and poverty may lead to high-risk sexual behaviors and migration, increasing the risk of acquiring HIV. At the same time, HIV weakens a household's ability to provide for basic needs (7&8).
In Hawassa city administration, little is known about the level of household food security and associated factors among adult people living with HIV /AIDS attending ART Clinic.
Therefore the objective of this study was to assess the level of food security and associated factors among adult people living with HIV/AIDS in case of Hawassa city administration hospitals 2017.

Study area and Period
The study was carried out in Hawassa town which is the administrative city of SNNPR. This town is located 275km south to Addis Ababa.

Study design
Institution based cross-sectional study design was conducted from Oct-Dec/2017

Source population
The source populations were all PLWHA on Antiretroviral Treatment registered andhave a follow up for their treatment in Hawassa city administration at the time of the study.

Study population
The study population were all PLWHA on HAART whose age is >18 years regardless of their treatment regimen, duration of follow up category during the study period, and available during data collection period.

Inclusion criteria
Systematically selected Adult PLWHA whose age >18 years regardless of their treatment

Exclusion criteria
Those adults who were ill and unable to respond to the questions.

Sample size
The required sample size were estimated by single proportion estimation method .The study done in DireDawa town showed that 72% of the respondent was food insecure .By using the 72% proportion , 5% Precision and 95% confidence level was taken (9). Sample size 'n' was determined by using single population proportion formula with the Adding 10% for non-response was given an overall sample size of 532.

Sampling procedure
There are a total of four health facilities which provide ART services in Hawassa city administration and all of them provide the services free of cost. Hawassa referral comprehensive specialized hospital and Adare hospitals were randomly selected using lottery method and the samples were proportionally allocated to each of the selected health facilities. The study participants were selected randomly using a computer generated simple random based on patient ART unique identification number.
Random selection of participants was done prior to patients presenting to clinic.

Data quality assurance
At the beginning, questionnaire was pretested on, 5% of the samples at Yirgalem Hospital and the question modifications was incorporated to the questionnaire and not included in the actual study. The interview was conducted in private room to create an atmosphere of empathy and confidence within a secure environment. Three days training was given for all supervisors (2 public health officers) and data collectors (6 nurses) before the process of data collection. The overall activities were controlled by the principal investigator of the study and proper designing of the data collection materials and continues supervision during data collection was perform. All complete questionnaires were examined for completeness and consistency during data management, storage and analysis.

Data collection instrument
A pre-tested structured questionnaire was prepared in English language first and then translated in to local language, and back translated to English in order to ensure consistency. Questionaries' were adopted from the Global United States Household food security scale and from different literatures (10, 11& 12) used to assess the household food security level of PLWHA on ART. It consisted of 18 questions in the core module to assess food security and questions to assess dietary diversity and meal frequency situation of households. The optional first question was used as part of the first-stage screener in the core module proper, and/or for its additional information content. The instrument also contains questions related to dietary diversity and meal frequency situation of the households, socio-demographic (age, sex, education, occupation, religion, job, Household size and marital status), socio-economic variables (family income) and behavioral factors (alcohol intake, smoking habit, substance addiction).

Data analysis
The collected data were entered and coded in to Epi-info 3.5.4 version statically package and imported in to SPSS version 20 software. Frequency distribution and percentages were computed and presented by tables to describe socio-demographic and other characteristics of respondents. Both bivariate and multivariate logistic regression analysis was done to determine the association of the variables. Variables significant analysis (p<0.25) entered in to multivariate logistic regression. Odds ratio with 95% CI and statically significant were declared p<0.05.

Food security and dietary diversity scales
To measure food security status of the households, number of affirmative answers were provided by study participants for the 18 questions which were applicable to household in the presence of children; however house hold without children were used only maximum 10 possible affirmative answers. Households responses had scored from a total of 18 questions (each score as 1 for affirmative response and 0 for negative response).The total scored range (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18) was categorized in to four food security statuses as indicate below.

Operational definitions
Household's food security status: a household was classified in to one of the food security status level categories on the basis of its score on the food security scale, while the households' scale score is determined by it's over all pattern of response to the set of indicator questions. Households responses were scored from a total of 18 questions (each scored as "1" for affirmative response and "0" for negative response) and total scores (range 0-18) and its categorization was mentioned in the data measurement section above.
Meal frequency: is the number of eating occasions by an individual experience within a day. In this study respondents were ask the number of meal occasions they have in the preceding 24hrs.This does not include eating occasions by the house hold members outside home. Finally, they were asked for their informed written consent to participate or not to participate in the study and for their willingness on use of their files and records for the study.

Clinical-condition
Majority of the study participants had been on ART for more than one year with Mean

Dietary diversity
Based on the assessment, cereal food group and beverages such as tea and coffee were among the most commonly consumed food groups by 98.1% and 95.5% of the respondents respectively. While eggs and fishes were among the least consumed food groups.74.4% of the respondents answered that their usual meal frequency was three times a day during the preceding 24 hours.

Discussion
According to the food security assessment module score, which is validate for use in developing countries (13). 32.7% to household with PLWHA on ART in Hawassa town were food secured. Sixty-seven percent of PLWHA on ART were food insecure ranging from mild food insecurity without hunger (30.5%) to sever food insecurity with hunger (13.7%). while the majority had insecure without hunger. The meal frequency and dietary diversity scores supported the findings of the core module which yielding significant proportion of PLWHA eating less than the mean frequency (67.7%) and dietary diversity (62.7). This might be explained by the fact that the disease reduces access to food for many affected households due to decreased labor availability and income, erosion of saving and productive assets, and increased health care and other related expenses (14). This level of food insecurity closely compared to the findings of similar study in Zambia where, the results showed that most of those on ART were food in secured. Only 6 % were food secure, 24% insecure without hunger, 34% somewhat food insecure and 36% had severe food insecure with hunger (15). However, the food insecurity figure in this study is markedly higher than the estimated level of food insecurity in general population at national level of our country (Ethiopia), 41% secure and 59% food insecure in 2010 (16) .
This disparity of food insecurity among the general population and PLWHA may be explained by the popular notions that HIV/AIDS affects food security and livelihoods of individual, households and communities and the abilities of individuals& households to feed and care for themselves, while eroding the capacity of communities and institutions to provide basic service and support for people in need House hold size associated with food security.
The study indicated that small household size was 3.7 times more likely to be food secured compared with large house hold size (AOR=3.769, 95%CI (1.313, 10.823).
Household size revealed a negative relationship with food security and statistically significant (p<0.05). Food security decreases by a factor of 3.8% as household size increases by one. The possible reason is that with existing high rate of unemployment and less employment opportunity coupled with low wage rate payment, an additional household member shares the limited resources that lead the household to become food insecure (17).
In 2007 Qualitative Cross sectional study conducted in Southern Ethiopia of wolaita and sidama zone showed that the risk of food insecurity increases with household size: i.e.
Households with4-6 members were 79 % less likely to become food secured compared to household size with 0-3 and households with 7+members were 69 % less likely to become food secured. Compared with this study the food security status was lower than that of wolaita and sidama zone study. Household with 4-6 members were 98 % less likely to be food secured compared with household size with reference category .similarly households with 7+members were 96% less likely to become food secured. This indicates that large family size negatively affects household food security (18). Household dietary diversity also affected the functional improvement of PLWHA on ART.
Increases in dietary diversity are associated with increase in consumption, caloric availability and calories from staple and non-staples (32, 33, and 34) PLWHA who disclose their status had a positive association with food security. This study revealed that PLWHA on ART who disclosed their status was 2.4 times more likely to be food secured than those who was not disclosed (AOR, 2.359, 95%CI (1.312, 4.241). Not to disclosing HIV status usually was due to fear of discrimination or stigma. Stigma was one of the barriers to adherence to ART. One review paper reported being embarrassed to take medications in front of family, friends, or coworkers was one of the reason not to be adhere in USA (19) .
People who do not disclose their HIV status due to fear of stigma and discrimination, will not follow their treatment as protocol so that leads to lack of maximum adherence level to have adequate viral suppression. This again resulted in impairment of immune function, development of opportunistic infections, poor functional status and, decreased productivity. People who fear to disclose their HIV status will also have lack of social support like food aid and other similar events; hence they are prone to be food insecure.

Availability of data and materials
The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Competing interest
The authors declare that they have no competing interest

Funding
The source of fund is south region health bureau. This funding organization has no role in designing, collection and analysis of data.
Author's contribution TS: Actively involved from proposal development to final data analysis.

RF:
Actively participated in data analysis.