The Effect of Food Insecurity on Clinical Progression of HIV/AIDS and CD4 Cout Change among HIV-Infected Adults Receiving Antiretroviral Therapy in North Shewa Health Facilities, Oromia Region, Ethiopia
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Date
2025-04
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Addis Ababa University
Abstract
Background: Food security are critical for individuals, households, and communities affected by HIV. HIV and food insecurity are complexly linked and exacerbate the harmful impacts of each other. Food insecurity harms on the overall nutritional and health status of people infected by HIV. However, little is known about the effect of food insecurity on the clinical progression of HIV/AIDS and CD4 count change among adults receiving antiretroviral therapy in the Ethiopian context. The few studies conducted are cross- sectional, which do not show the temporal relationship and fail to identify the effects of food insecurity on the clinical progression of HIV/AIDS and CD4 count change among HIV-infected adults, and fail to serve as concrete evidence.
Objective: To assess the magnitude of food insecurity, magnitude of fruit and vegetable dietary intake, and examine the effect of food insecurity on clinical progression of HIV/AIDS and CD4 count change among adults on antiretroviral therapy in North Shewa Health Facilities.
Methods: A systematic review and meta-analysis were undertaken to address the study's first objective. A cross-sectional study was conducted for the Papers II and III objectives, and a prospective cohort study was conducted for Papers IV and V objectives. The sample sizes of 865, 574, and 442 were considered for Paper II and III, Paper IV, and Paper V, respectively. Simple random sampling was used to select 865 HIV-infected adults for paper II and III.The exposed groups were those who were food-insecure individuals, whereas the non-exposed groups were those who were food-secure HIV-infected adults. Simple random sampling was used to select both the exposed and non-exposed groups for Paper IV and Paper V, using a computer-generated random selection method based on a cross-sectional baseline assessment for food security status. We conducted an electronic, web-based search, using PubMed, CINAHL PopLine, MedNar, Embase, Cochrane Library, the JBI Library, the Web of Science, and Google Scholar to identifiy studies that reported the association between food insecurity and gender (Paper I). Baseline and food security status data were collected using a structured interviewer-administered questionnaire, and repeated measurements of HIV-infected adults for the effect of food insecurity on clinical progression of HIV/AIDs and CD4 count change. Food insecurity was measured using the Household Food Insecurity Access Scale (HFIAS) and reported across all papers, while fruit and vegetable dietary intake was measured through the frequency of consumption, using the Behavioral Risk Factor Surveillance System (BRFSS) assessment tools. The clinical progression of HIV-infected adults was measured by assessing viral load, with a viral load of 1,000 copies/mL or higher considered indicative of poor clinical progression. The primary data collected using the KoboToolbox digital data collection platform were exported to STATA 17 for cleaning and analysis (Paper II-V). A random effects model was used to estimate the pooled effect with a 95% confidence interval(CI) (Paper I). A log-binomial regression model was fitted to identify the association between food insecurity and independent variables (Paper II). A Poisson regression model with robust variance was fitted to identify associated factors with fruits and vegetables dietary intake (Paper III). A Generalized linear mixed effects model with logit links was fitted to assess the effect of food insecurity and other predictors on the clinical progression of HIV/AIDs and CD4 change (Paper IV-V).
Results: A total of 776 studies were identified, of which seventeen were included in the meta-analysis, comprising 5,827 HIV-infected adults receiving antiretroviral therapy (ART). The analysis revealed that gender had statistically significant effects on food insecurity. The pooled odds of developing food insecurity among female HIV-infected adults were 53% higher than among male HIV-infected adults (OR: 1.53, 95% CI: 1.29, 1.83).
In this study, 290(33.7%, 95% CI: 30.60, 36.91)) of HIV-infected adults studied experienced food insecurity during their treatment and follow-up, in which 152(52.41%, 95% CI: 46.64, 58.13) and 110 (37.93%, CI: 32.50, 43.68) of them were found to have severe and moderate forms of food insecurity, respectively. We found that younger age (age less than 35 years) (APR=2.27, 95% CI: 1.12, 4.60), being female (APR=1.87, 95% CI: 1.03, 3.39), lacking formal education (APR=10.79, 95% CI: 14.74, 24.58), having lower educational status (APR=5.99, 95% CI: 2.65, 13.54), being daily laborer (APR=6.90, 95% CI: 2.28, 20.85), having low monthly income (APR=1.89, 95% CI: 1.11, 3.22), advanced WHO clinical stage (APR=2.34, 95% CI: 1.08, 5.10), and receiving ART for less than 4 years (APR=2.28, 95% CI: 1.09, 4.74) were significantly associated with high proportion of food insecurity among HIV-infected adults.
The study indicated that 655 (76.34%; 95% CI: 73.38, 79.07) of HIV-infected adults reported consuming fruits and vegetables less than once per day, with 838 (97.67%, 95% CI: 96.41, 98.49) and 676 (78.79%, 95% CI: 75.92, 81.40) of HIV-infected adults reporting consuming fruits and vegetables less than once per day, respectively. The median (IQR) total fruits and vegetables intake was 271.3 (IQR: 92.5, 439.5) g/day, with the median (IQR) intake of fruits and vegetables being 248.1 (IQR: 100.0, 400.0) g/day and 273.78 (IQR: 82.44, 348.33) g/day, respectively.We found that being divorced (APR=1.57, 95% CI: 1.16, 2.12), daily laborer (APR=2.08, 95% CI: 1.36, 3.20), employed (APR=1.77, 95% CI: 1.10, 2.84), and merchants (APR=1.59, 95% CI: 1.03, 2.47), as well as having children as caregivers (APR=1.61, 95% CI: 1.02, 2.55), an advanced WHO clinical stage (APR=1.32, 95% CI: 1.32(1.03, 1.69), and receiving ART for more than 8 years’ duration (APR=1.78, 95% CI: 1.18, 2.67) were found to be independent predictors of fruits and vegetables dietary intake among HIV-infected adults.
The study found that 106 (18.56%; 95% CI: 15.58–21.97), 119 (21.14%; 95% CI: 17.95–24.71), and 134 (23.84%; 95% CI: 20.49–27.55) HIV-infected adults reported poor clinical progression at the first, second, and third visits, respectively, with double the incidence among food-insecure HIV-infected individuals: 71 (25.00%), 80 (28.78%), and 91 (32.85%) of those showing clinical outcomes were food insecure at the first, second, and third visits, respectively. The overall incidence of poor clinical progression during the follow-up period was 21.17% (95% CI: 19.27%, 23.18%), with 28.84% of food-insecure HIV-infected adults and 13.65% of food-secure HIV-infected adults experiencing poor clinical progression. The type of psychosocial care/support received (aRR = 4.72, 95% CI: 1.10, 20.52), being food insecure (aRR = 5.44, 95% CI: 1.36, 21.76), being undernourished over time (aRR = 3.34, 95% CI: 1.21, 9.26), advanced WHO treatment stage (aRR = 6.43, 95% CI: 1.21, 34.41), and receiving ART for at least 4 years (aRR = 4.22, 95% CI: 1.11. 12.07) were found to be significant independent predictors of poor clinical progression.
The median CD4 counts at the first, second, and third visits were 433 cells/μl (IQR: 255-607), 482 cells/μl (IQR: 326-698), and 523 cells/μl (IQR: 356-687), respectively. A total of 105 (23.76%; 95% CI: 20.01–27.96), 78 (18.35%; 95% CI: 14.96–22.34), and 73 (17.26%; 95% CI: 13.94–21.17) of HIV-infected adults had low CD4 counts (<200 cells/mm³) at the first, second, and third visits, respectively, showing an overall declining trend over the 9-months follow-up period. However, the incidence of low CD4 counts among food-insecure individuals remained higher than among food-secure HIV-infected: 59 (26.70%), 44 (20.37%), and 40 (19.14%) at the first, second, and third visits, respectively. The overall incidence of low CD4 counts during the follow-up period was 19.84% (95% CI: 17.76%, 22.11%), with 22.14% among food-insecure and 17.55% among food-secure HIV-infected adults. The gender of HIV-infected adults (aRR = 2.88, 95% CI: 1.14, 7.30), being food insecure (aRR = 2.56, 95% CI: 1.05, 6.26), being undernourished over time (aRR = 2.17, 95% CI: 1.03, 4.57), being anemic (aRR = 3.35, 95% CI: 1.37, 8.17), advanced WHO clinical stage (aRR = 4.11, 95% CI: 1.32, 12.84), and receiving ART for at least 4 years (aRR = 3.64, 95% CI: 1.25, 10.63) were found to be significant independent predictors of low CD4 count.
Conclusion: The systematic review and meta-analysis showed statistically significant effect of gender on food insecurity among HIV-infected adults receiving ART, in which odds of food insecurity was higher among female HIV-infected adults compared to male HIV-infected adults. This finding suggests the need to consider gender issues within food and nutrition interventions for HIV-infected adults, as well as culture- and context-specific gender-based policies to address gender-related vulnerability to food insecurity.
The magnitude of food insecurity among HIV-infected adults receiving ART was high with an extremely high magnitude of severe food insecurity. The finding suggests the need for culture- and context-specific nutritional interventions to address the gender dynamics of food insecurity, attention to the early stage of ART, and the integration of strategies to improve educational status and enhance income-generation activities of HIV-infected adults. This requires an emphasis on the link between food insecurity and HIV in Ethiopia's national food and nutrition policy.
The finding indicates a very low level of fruits and vegetables dietary intake among HIV-infected adults, falling below the minimum recommendation for the adult physically active population. Despite living in a surplus production area and producing these items, farmers are less likely to consume fruit and vegetable. The study emphasizes the importance of focusing on the early stage of ART treatment for patients and family therapy, including counseling and guidance on consuming healthy diets, such as fruits and vegetables, to enhance the role of children as caregivers for their families. Additionally, there is a need for comprehensive nutritional counseling to improve fruit and vegetable consumption, with a particular emphasis on educating individuals about portion size estimation for fruits and vegetables.
The study revealed that poor clinical progression was notably higher among food-insecure HIV-infected adults, with a persistent increase over time, underscoring the sustained, significant effect of food insecurity on HIV/AIDS progression. The types of care received, food security status, nutritional status over time, duration of ART, and advanced WHO treatment stage were identified as significant independent predictors of poor clinical progression. The study also found that the incidence of low CD4 count (<200 cells/mm³) remained high, particularly among food-insecure HIV-infected adults, significantly higher incidence of low CD4 counts among food-insecure HIV-infected adults throughout the follow-up period. Gender, food security status, nutritional status, presence of anemia, WHO clinical stage, and duration of ART were identified as significant independent predictors of low CD4 count.
The findings suggest the need for targeted food security interventions to mitigate the effects of food insecurity on HIV/AIDs clinical and immunological progression. There should also be culture- and context-specific food and nutrition interventions focusing on the gender dynamics of food insecurity and its health effects, including gender-related vulnerabilities.
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Keywords
Food insecurity, HIV/AIDS, Fruits and vegetables, clinical progression, CD4 count, antiretroviral therapy, HIV-infected adults