Undernutrition, Food Insecurity and Associated Factors among Adult HIV Positive people on HAART in Public Health Facility in Oromia Special Zone Surrounding Finnne, Oromia, Ethiopia.

Background: Malnutrition is resulted from inequalities in nutrients intake and body demands. People living with Human Immunodeciency virus (PLHIV) are more vulnerable to malnutrition, due to opportunistic infection, metabolic disorder, and increased need of energy during infection. Worldwide, over 800 million people are chronically undernourished. The dual burden in areas of severe food insecurity and Human Immunodeciency virus (HIV) epidemic are highly contributing to morbidity and mortality of people living with HIV, especially in developing countries particularly Sab- Saharan Africa is considered as home of malnutrition and food insecurity. The major problem of PLHIV in Ethiopia is under nutrition and its complication. Objective: This study aimed to assess magnitude of under nutrition, food insecurity and associated factors among adult clients on ART attending ART clinic, at public health facilities, Oromia regional states central Ethiopia Method: An institution based cross-sectional study was conducted among adult PLHIV and on highly active antiretroviral therapy(HAART) attending public health facility in Oromia Special Zone Surrounding Finnne (OSZSF) was conducted from August 2020 to May 2021. A systematic sampling was applied for sample selection. A pre tested semi structured questionnaire was used to collect data. Bivariate and multivariable analysis also employed to identify the presence, strength, direction of association and other confounding. After calculating for both rst objective (prevalence of under nutrition) and second objective or factors associated with under nutrition the maximum sample size 305 was selected for this study. Result: The prevalence of under nutrition was 22.4% and house hold food insecurity was also high in current study 54.3%. Factors associated with under nutrition among participants were absence of ration (AOR=0.42, 95%CI: 0.0-0.9), World health organization clinical stage II, III and VI (AOR= 6.8, 95%CI: 2.5-18.6) and household food in secure (AOR=0.51, 95%CI: 0.27-0.95) while literacy status primary and less (AOR=2.24, 95%CI: 1.1-4.6), household average monthly income

insecurity and Human Immunode ciency virus (HIV) epidemic are highly contributing to morbidity and mortality of people living with HIV, especially in developing countries particularly Sab-Saharan Africa is considered as home of malnutrition and food insecurity. The major problem of PLHIV in Ethiopia is under nutrition and its complication.
Objective: This study aimed to assess magnitude of under nutrition, food insecurity and associated factors among adult clients on ART attending ART clinic, at public health facilities, Oromia regional states central Ethiopia Method: An institution based cross-sectional study was conducted among adult PLHIV and on highly active antiretroviral therapy(HAART) attending public health facility in Oromia Special Zone Surrounding Fin nne (OSZSF) was conducted from August 2020 to May 2021. A systematic sampling was applied for sample selection. A pre tested semi structured questionnaire was used to collect data. Bivariate and multivariable analysis also employed to identify the presence, strength, direction of association and other confounding. After calculating for both rst objective (prevalence of under nutrition) and second objective or factors associated with under nutrition the maximum sample size 305 was selected for this study.
Conclusion and recommendation: This study nding reveals high prevalence of under nutrition and HH food insecurity results in disturbing the success of the program, thus Comprehensive care and support bio-medical and inter-sectorial collaboration is suggested for alleviating the problem.

Background
Malnutrition is the state of diminished physical functioning of individual and can no more maintaining the body's performance process of productive life (growth, pregnancy, physical activity, recovering from disease) [1]and resulted from inequality in intake and body require of food or nutrients for productive life of individuals for growth, maintenance, regulation and reproduction [2]. People living with human immunode ciency virus (PLHIV), due to opportunistic infection, food mal-absorption, anorexia and increased nutritional demand; are most vulnerable to malnutrition. The increased need of additional food during infection is other problem for PLHIV [3].
Worldwide over 800 million people were constantly undernourished; the areas of already suffering from food insecurity and HIV epidemic overlaps that contributing for morbidity and mortality in developing countries [4,5,6]. Severe food insecurity and undernourishment increased in Africa and South America while stable in most regions of Asia [4,5]. More than 56% of African-American women living with HIV on highly active antiretroviral therapy (HAART) in rural Alabama, USA were categorized as food insecure [7].
Sab-Saharan countries are considered as the home of malnutrition and food insecurity sharing majority of the world's undernutrition and food insecure population. Poor infrastructure, restricted or limited resource, con ict, HIV and low access to health service are worsening the condition [8]. Undernutrition and nutrition related complications are one of the major challenges in Ethiopia among HIV positive reproductive age groups in achieving ART intervention. Currently; around 20% and 17% reproductive age HIV positive women are chronically undernourished and anemic respectively [9]. And there is also high prevalence of food insecurity among adult PLHIV attending ART clinic; at Butajira Hospital (78.1%) [10], in Kenbata Tembaro zone health facilities providing ART service were (57.3%) [11] and at Fitche Hospital 341 (87.4%) were food insecure [12]. Ethiopia provides nutritional support integrating in comprehensive HIV treatment, care and supports addressing food in security and under nutrition through nancial, food and income generating activity (IGA) support. In spite of this, there is high gap between interventions on nutrition and the desired outcome of nutritional status.
HIV affects the nutritional status both directly and indirectly. Direct effects are increased energy requirement, reduced food intake and poor nutrient absorptions. Negative effect of HIV indirectly, weakens immune system, illness and health care cost; Leads in to malnutrition [13,14,15]. Malnutrition, food insecurity and HIV are complexly related and worsen the negative impacts of one another. Food insecurity has a negative impact on the overall nutritional and health status of those infected and affected by HIV/AIDS, and people living with HIV often express that food is the greatest need for themselves and their families [8]. And malnutrition can be a contributor and outcome of HIV progress.

Malnourished HIV infected individual's progresses to AIDS faster [16].
Food insecurity is both the problem of developed and developing countries even if high in developing countries. By 2017 USAIDs Economic research service reports 15.0 million households (11.8%) in America were under food insecure [17]. About 49 million Americans were food insecure and 67.6% of individuals are adult [6].
Common problems in HIV infected people regarding nutritional status are weight loss due to dietary intake (anorexia, mouth ulcer, and food insecurity), mal-absorption and altered metabolism. Improving from weight loss and predominantly muscle mass; needs ART, treatment of OI, consumption of balanced diet, appetite stimulants and growth hormone. This is di cult in resource limited region and problematic if the infection is highly advanced [18].
High prevalence of malnutrition exacerbates the outcome of HIV and poses signi cant challenges to HIV care and treatment program in Ethiopia [19]. In Ethiopia currently around 26% of adults PLWHIV on ART follow up were undernourished [20]. A study conducted among adult clients attending ART clinic at public health facilities indicate that current cigarette smokers, those at WHO stage four and three those who consume less than ve food groups are at risk of getting under nutrition [19,21]. Other risks of malnutrition in people living with HIV receiving ART at organization for social health development in Arba-Minchi and Jimma town are low monthly income, educational status and advancement of HIV that increases the prevalence of under nutrition [21,22]. The report indicates that 43% of them are malnourished during the early initiation of antiretroviral therapy [22]. Also HIV and food insecurity can be a signi cant catalyst result of one another [23].
Regardless of complex interaction between HIV, malnutrition and food insecurity many studies identify the burden of under nutrition and food insecurity separately on adult HIV positive people on ART. Then, this study identi ed the magnitude of under nutrition, household food insecurity and risk factors affecting the nutritional status and household food in security of PLHIV in detail and their collective negative outcomes.

Study area and Period
The study was conducted in public health institutions providing antiretroviral therapy service in Oromia Special Zone surrounding Fin nne. Oromia Special Zone is found in Addis Ababa and the health facilities in which the study was conducted are found 30KM to 72Kms away from the Addis Ababa in all direction.
The Zone is established in 2014 and has 6 Woredas, one town administrative and 68 Kebeles (the smallest administrative unit in Ethiopia) structures. There are 28 public health institutions (2 primary hospitals and 28 health centers). Out of these; 9 of them are providing ART service. No private health facility providing ART service within the Zone. There are 2,440 paediatric and adult PLHIV currently on ART in the Zone. The study was conducted from August 13, 2020 to May, 2021.

Study Design
An institution based cross-sectional study was conducted among adults PLHIV on HAART.

Source Population
All adult PLWHA (≥ 18 years old) and on HAART in health institutions providing ART service in OSZSF, Oromia, Ethiopia were taken as the source population.

Study Population
All adult PLWHA (≥18 years of age) on HAART who were attending ART clinic at the study public health facility during data collection period were taken as the study population.
2.4. Eligibility criteria 2.4.1. Inclusion criteria All study participants whose age was ≥18 years of age on HAART for more than three months were included in the study.

Exclusion criteria
Severely or unable to respond and mentally ill PLWHA on screening and those who was not be volunteer to participate on the study was excluded.
Pregnant and lactating mother those who were on PMTCT were excluded because of pregnancy and lactation increases the vulnerability of malnutrition.
2.5. Sample size and Sampling technique 2.5.1. Sample size The sample size was calculated using a single population proportion formula, taking the similar characteristic population, prevalence of under nutrition 23.6% based on study done in West Shewa zone among adult PLWHA attending ART clinic [24]. D = Margin of error of 5%, Zα/2 = 1.96 or 95% Con dence level:-=277. Adding a 10% possible non response rate, the total calculated sample size required was 305. To determine the required sample size for the second objective, different signi cantly associated with under nutrition variables were considered with the assumption of con dence level 95%, power 80% and odds ratio for each factor and 10% non-response rate using EI info version 7.2.1 was used. After calculating the required sample size for those selected variables, the maximum sample was used by comparing both objectives. Accordingly, the maximum sample used for this study was the rst objective 305[ Table 1].

Sampling technique
In Oromia special zone surrounding Fin nne zone, there were one primary Hospital and eight health centers providing ART service. One hospital and eight health centers were participated after which their respective sample was assigned proportionally as per their total adult PLWHA on ART visiting their ART clinic. List of eligible PLWHA were identi ed using their unique ART number. The actual study participants were selected using systematic sampling technique, which is calculated as:-K = N/n, 1449 /305, = 4.75 5. Where; N: Total ART clients and n: calculated sample size. Accordingly, every 5 th participant was included in the study. The 1 st participant was selected by lottery method from the rst one to ve listed clients in each facility [ Table 2]. The data were collected using structured questionnaire which was adopted from different literature and guidelines for measuring household and individual dietary diversity by Food and Agricultural Organization of United Nations (FAO). The questionnaire has three parts. The rst part addresses sociodemographics and economic characteristics and dietary related items; the second part was about taking anthropometric measurements of the respondents while the third part was reviewing patient's card.

Data collection procedures
Five data collectors and one supervisor were recruited and trained for two days concerning the objective, standardizing the data collection instrument among the data collectors and providing them with basic skill of communicating with the study participants. The interview was taken place after taking the written consent from the respondents. A single interview took from 15-20 minutes.

Data processing and analysis procedures
Data cleaning and coding:-Data cleansing was undertaken after the data collected was entered. Questionnaires were checked for completeness and accuracy after each interview and before data entry. As all questionnaires lled completely, any falling data values outside of expected values were rechecked with original questionnaire and cleaned data were analyzed.
Data Analysis:-After the data were entered in to Epi-Data version 3.1, it was exported to SPSS version 24.
Descriptive statistics was done to measure the prevalence of under nutrition and food insecurity in the study population. Bivariate analysis; binary logistic regression was employed to measure the strength, direction, association and signi cance of independent variables over dependent (under-weight and food insecurity) and multivariable analysis; was also employed to eliminate covariate expressed by Adjusted odd ratio (AOR) and 95% CI was used to measure direction, strength and signi cance of association at P value 0.05.

Data Quality Management
To assure the data quality different procedures were applied. The questionnaire was translated to Afaan Oromo and back to English by translators who were blind to the original questionnaire. The data collection instrument was tested prior to use for current study, on the one of adjacent woredas health facility providing ART service. Before starting data collection, the questionnaire was amended depending on the result of pretest. Final version of the questionnaire was used for data collection. And the interview was conducted in a separate room for privacy and con dentiality. Accuracy of anthropometric measurement was measured by evaluating the maximum standard difference in repeated measurements (0.5kg for weight and 0.1 cm for height). Completeness and accuracy of the data were checked after interviewing each respondent by the data collectors and daily by the supervisors. Also completeness, accuracy and consistence were checked during data entry and analysis. Over all activity was monitored by the principal investigator for the data management issues.

Operational De nition
Under-nutrition:-PLHIV on ART whose BMI is less than 18.5 Kg/m 2 [25]. Opportunistic infection:-An infection which takes advantage of weakness in immune system; people living with HIV are vulnerable to such opportunistic infections as tuberculosis, bacterial pneumonia, candidacies, herpes simplex and Kaposi sarcoma [27].
Food Security:-Households and individuals need to have available food, access to food, and the ability to fully utilize it once it is consumed. A food secure household experiences none of the food insecurity (access) conditions, or just experiences worry, but rarely [28, 29,30].
Food insecurity:-A exists when people lack secure access to su cient amounts of safe and nutritious food for normal growth and development and an active and healthy life, when the HFIAS is greater than or equal to 2 [30,31].
Dietary diversity:-is the number of reported different foods and food groups consumed by PLWHA within the last 24 hours [32].
Non adherent:-When a PLWHA not able to take more than 95% (missing at least one dose of all prescribed doses of ART) of the prescribed drug or failed to follow the schedule/time of the medication [19].
Low Dietary diversity:-When PLWHA ate less than the mean dietary diversity score High dietary diversity:-When PLWHA ate greater than or equal to the mean dietary diversity score [32].

Ethical considerations
After the proposal was presented, ethical clearance was obtained from research and ethical committee institute of Health Sciences, Wollega University. The support letter was given to OSZSF zone health department, Woreda/town health o ce and the selected health facilities providing ART service within the zone for facilitation of data collection. The purpose of the study was introduced to all participants prior to interview and their willingness to participate or not to participate in the study without any preconditions was con rmed. They were also informed that code was used rather than name for con dentiality, informed written consent was obtained from all participants on the study.

Result
Out of the total 305 study participants, three hundred four (304) Figure 2]. More than three fourth (79.9%) of PLHIV on HAART attending public health facility in OSZSF zone ate three times per day and only 6.3% ate two times with 24hour while the rest ate four and above times per day[ Figure 3].  Nine point ve percent of the study PLHIV on HAART attending public health facility in OSZSF zone were from severely household food in secure, while 73(24%) and 67(22%) were from moderately and mildly food in secured house hold respectively[ Figure 5].   from a family member of 3 and above were associated with under nutrition (COR = 0.56, 95CI = 0.32-0.97) and forty ve (66.2%) of clients had not their own monthly income similarly 49(22%) were from average household monthly income less than 2250 EB. Regarding, access to aids 31(45.6%) able to get money and others aids from some organization however, only 12(17.6%) were access to food ration from some organization [ Table 6].

Factors association with under nutrition and food in secure among clients on ART
To identify the association between the independent or predictor variables and dependent (under nutrition BMI<18.5), both bivariate and multivariable logistic regression were used. After entering all variables in to binary logistic regression; family size, individual monthly income, average house hold monthly income, presence of ration food from some organization, frequency of feeding, diet diversity score, food security status, CD4 count, and WHO clinical stage were signi cantly associated with under nutrition at p-value = 0.25. Similarly, Occupational status, literacy status, individual income households income, accessibility to ration foods, accessibility to money and other aids and feeding frequency were signi cantly associated to food insecurity. After controlling the confounding factors, in a multivariable logistic analysis, access to ration foods from some Organization, food security status and WHO clinical stage were signi cantly associated with under nutrition at p-value less than 0.05. And literacy, employment and feeding frequency exist associated signi cantly with food in security.
Clients who were access to ration foods from some Organization were by 58% less likely to get under nutrition than those who didn't get ration. The odds of PLWHA on HAART attending public health facility in OSZSF zone being WHO clinical stage two, three and four were 6.4 times more likely to be undernourished when compared with those who were stage one in WHO clinical staging. Concerning the house hold food security status, being from a house hold food secured were 49% less likely to develop under nutrition than those who were from in secured background. The odds of being primary and less in educational level were two folds more likely to be from food in secured house hold when compared with those who were with secondary and above educational status. Being from a household average income >2250 ETB were (AOR=0.41, 95%CI: 0.21-0.8) less likely being from household food in secured. Client those who ate two and less than two within 24hr were 4.1 times (AOR=4.1, 95%CI: 1.3-13.46) to be a member of food in secure house hold than those who ate three and above meal per day [ Table 7, Table   8].  and Severe 17.4% food in secure) [11]. However, relatively it was very lower than other studies done in Senegal Dakar 84.6% [40], Democratic Republic of Congo 91.3% [41] and Fitche General Hospital 87.4% [12]. The deference may be due to socio-economic status of study participants, study period that affects accessibility and availability of foods that leads in to absence of preferred food groups and level of health facilities they attend. Clients attending hospital are those who had advanced HIV/AIDS disease than the primary care unit attendants that leads them less productive and phase problem in securing food.
This study reveals that house hold food insecurity is one among signi cantly associated factors with undernutrition. Clients from house hold food secure were 61% less likely to develop undernutrition than those who were from house hold food insecure background. This is in line with other study in Ethiopia [24]. There were also other factors signi cantly associated with undernutrition; PLHIV on ART attending health facilities in OSZSF zone those who were different from WHO clinical stage one were 6.8 more likely develop under nutrition than those who were WHO clinical stage one. Similar studies verify this in Nepal [34], in Tanzania [35], and in Ethiopia [36,24] and in presence of food ration support from some organization; those who gets food ration support were 58% less likely to develop under nutrition than the counterpart. Whereas, CD4 count (COR=2.1, 95%CI: 1.2-3.6), family size (COR=0.56, 95%CI: 0.32-0.97) and diet diversity score (COR=3.7, 95%CI: 1.1-11.9) were signi cantly associated with undernutrition independently.
The odds of literacy status primary and less participants being from household food unsecured were 2.24 times higher than the counterpart (secondary and above educational status individuals). This is comparable with the study done in Nepal [34], and in Ethiopia [12]. Regarding average household monthly income among PLHIV on ART attending health facilities in OSZSF zone, those who were from household monthly income greater than 2250 ETB were less likely being from household food in secure by 59% than those who were from household average monthly income less than 2250 ETB. Similar study in Jimma zone recognizes this nding [24]. This may be due to PLHIV were had additional cost for medical care, time for production and less production due to morbidity. All these shares costs of foods for consumption that reduces types and amount of foods consumed.

Conclusion
This study identi es the magnitude of undernutrition on adult PLWHA on HAART was 22.4%. Of this 11.8%, 5.6% and 4.9% were mildly, moderately and severely malnourished. Factors signi cantly associated with undernutrition were presence of ration food support from some organization, WHO clinical stage and household food insecurity. There was also high prevalence (54.3%) of household food insecure and severe food insecure (9.5%) identi ed. Participants' literacy status, feeding frequency per day and household average monthly income were factors associated with food insecurity signi cantly among adult PLWHA on HAART. This indicates that under nutrition and food insecurity has enormous implication on adult PLHIV and on ART.

Recommendation
As this study result states; there were complex interaction between food insecurity, undernutrition and HIV/AIDS. Thus, the following assumptions were proposed for intervention to alleviate the problems stated in this study.
Comprehensive and integrative bio-medical service should be provided at health facility level that recognizes care and support (like income generating activities, foods support, and educational support Oromia special zone surrounding Fin nne health department for their valuable contribution and unreserved cooperation in providing basic information about the health institution during the study. We also extend our thanks to data collectors, respondents, and supervisors for their cooperation during the study.
Ethics approval and consent to participate Ethical clearance was obtained from research and ethical committee institute of Health Sciences, Wollega University. The support letter was given to OSZSF zone health department, Woreda or town health o ce and the selected health facilities providing ART service within the zone for facilitation of data collection. The purpose of the study was introduced to all study participants prior to interview and their willingness to participate or not to participate in the study without any preconditions was con rmed.
They were also informed that code was used rather than name for con dentiality, informed written consent was obtained from all participants on the study.

Consent for publication 'Not applicable'
Availability of data and materials The nding of this study was generated from the data collected and analyzed based on stated methods and materials. The original data supporting this nding are available from the corresponding author on reasonable request.
Competing interests "The authors declare that they have no competing interests" Funding 'Not applicable' Authors' contributions DN participated in the design of the study, performed the data collection and the statistical analysis and served as the corresponding author of the manuscript. HB, TT, MD and ZK supervised the study, ensured quality of the data, assisted in the analysis and interpretation of the data. All authors read and approved the manuscript.  Percentage distribution of nutritional status of PLWHA on HAART attending public health facility in OSZSF zone, Ethiopia 2021. Food groups ate by PLHIV on HAART and attending public health facility in OSZSF zone, Ethiopia 2021.

Figure 5
Percentage distribution of house hold food in secure adult PLWHA on ART attending public health facility OSZSF zone, Ethiopia 2021.