Wolaita Sodo University

Graduate Studies Directorate

Dietary quality and associated factors among adult HIV positive patients on ART
in Wolaita Sodo University Comprehensive Specialized Hospital, South Ethiopia,
2022.

By: Nebiyu Daniel (BSc in Biology)

A thesis proposal to be submitted to Wolaita Sodo University College of Health

Science and Medicine, School of Public Health in partial fulfillment of the
requirement for the master’s degree in Human Nutrition in regular program.

September, 2022

Wolaita Sodo, Ethiopia

1
 Wolaita Sodo University

Graduate Studies Directorate

Dietary quality and associated factors among adult HIV positive patients on ART
in Wolaita Sodo University Comprehensive Specialized Hospital, South Ethiopia,
2022.

By: Nebiyu Daniel (BSc in Biology)

A thesis proposal to be submitted to Wolaita Sodo University College of Health

Science and Medicine, School of Public Health in partial fulfillment of the
requirement for the master’s degree in Human Nutrition in regular program

Advisors: Wondimagegn P. (MPH, Ass. professor, PhD candidate)

Fekadu E. (MPH)

September, 2022

Wolaita Sodo, Ethiopia

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Acknowledgement
My deepest thanks goes to Wolaita Sodo University College of Health science Science and
Medicine School of Public health and all my instructors for their great role directly or indirectly
in the success of this thesis proposal development.

My special deepest gratitude, heartily and grateful thanks also goes to my advisors
Wondimagegn Poulos and Fekadu Elias for their frank and constructive comments,
unreserved guidance, kind support, stimulating ideas and also for giving me the full benefit of
their expertise throughout this proposal development.

Last but not the list I would like also to extend my sincere appreciation to my beloved mates for
sharing their genuine ideas and knowledge while preparing this thesis proposal. It will not be an
exaggeration to say this proposal would not have this shape if this support was not there.

Table of Contents
3
Acknowledgement.......................................................................................................................................3
List of tables................................................................................................................................................6
Abbreviations and Acronyms.......................................................................................................................7
Summary.....................................................................................................................................................8
1. INTRODUCTION.......................................................................................................................................9
1.1 Background........................................................................................................................................9
1.2 Statement of the problem...............................................................................................................10
1.3 Significance of the study..................................................................................................................11
2. LITERATURE REVIEW..............................................................................................................................12
2.1 Introduction..................................................................................................................................12
2.2 Nutrition and HIV/AIDS....................................................................................................................12
2.3. Malnutrition and HIV/AIDS.............................................................................................................13
2.4. Nutritional requirements of HIV patients.......................................................................................14
2.5. Factors associated dietary quality of HIV/AIDS Patients.................................................................15
3. Objectives..............................................................................................................................................19
3.1. General objective............................................................................................................................19
4. Method and Materials...........................................................................................................................20
4.1. Study area and period....................................................................................................................20
4.2 Study design....................................................................................................................................20
4.3 Population.......................................................................................................................................20
4.3.1 Source population.....................................................................................................................20
4.3.2 Study Population.......................................................................................................................20
4.4 Inclusion and exclusion criteria........................................................................................................20
4.4.1 Inclusion criteria.......................................................................................................................20
4.4.2 Exclusion Criteria......................................................................................................................21
4.5 Sample size determination..............................................................................................................21
4.6 Sampling technique and procedures...............................................................................................21
4.7 Data collection tool and procedures................................................................................................21
4.8. Data quality assurance....................................................................................................................21
4.9. Variables of the study.................................................................................................................21
4.9.1. Independent variables.............................................................................................................21
4.9.2 Dependent variable..................................................................................................................22

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 4.10. Operational definitions.................................................................................................................22
4.11. Data Processing and analysis........................................................................................................22
4.12. Ethical considerations...................................................................................................................23
4.8 Dissemination of results..................................................................................................................23
5. WORK PLAN & BUDGET BREAKDOWN...................................................................................................24
5.1. Work plan.......................................................................................................................................24
Table 1:..................................................................................................................................................24
5.2. Budget breakdown.........................................................................................................................24
7. References.............................................................................................................................................26

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List of tables

6
7
Summary
Background: HIV/AIDS is a disease that affects nutrient uptake and metabolism. As a result,
energy needs rise and food intake declines, HIV transmission, leads to inadequate viral load
suppression, and raises the likelihood that HIV-infected people will develop an AIDS-defining
illness.

Objective: The aim of this study will beis study will aim to assess the dietary quality and
associated factors among adult HIV HIV-positive patients on ART in Wolaita Sodo University
Comprehensive Specialized Hospital, south Ethiopia, 2022.

Methods: Facility based cross -based cross-sectional study will be conducted among a total of
424 adult HIV HIV-positive clients on ART. Simple A simple random sampling technique will
be used to select the participants while an interviewer interviewer-based structured questionnaire
will be used to for data collection. Data will be entered by Epidata version 4.60 software and it
will be exported to SPSS version 26.0 software for statistical analysis. Bi-variable and
Multivariable Logistic regression model will be applied to identify factors associated with
dietary quality. Both Crude and adjusted odds ratios with a 95% confidence interval will be
determined and variables with p-value < 0.05 will be considered as statistically significant
factors.

Work plan and budget: The study will be conducted from—to--- 2022/2023 and the total
budget of this study will be ...ETB.

Key words: Dietary quality, HIV, ART

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1. INTRODUCTION
1.1 Background
HIV/AIDS is a disease that affects nutrient uptake and metabolism. As a result, energy needs rise
and food intake declines, Poor nutrition affects PLHIV patients' ability to survive, speeds up the
disease, and raises morbidity. Malnutrition is one of the major complications among PLWH
(people living with HIV/AIDS) infection and a significant factor in advancing the disease and
Leads Failure to meet dietary needs may cause weakened immunity and increased vulnerability
to opportunistic infections. (1-3).

Both HIV/AIDS and nutrition have a significant association with the biological ability of
individuals to consume, utilize, and acquire nutrients. They compete with each other. Both can
be used separately causes causing progressive damage to the immune system(4)

Nutritional care is considered a crucial component of comprehensive care for people living with
HIV/AIDS. Adults with HIV infection are urged to consume a healthily
diet, and people with HIV/AIDS need to consume more protein and micronutrients to maintain a 
compromised immune system(5, 6)

Nutritional issues are very critical to HIV-positive people.  Optimal immunological function
depends on an adequate diet.  Dietary support is consequently seen as a crucial adjuvant in the
clinical treatment of HIV-positive individuals .(7).

Diet quality is broadly defined as a dietary pattern or an indicator of variety across key food
groups relative to those recommended in dietary guidelines, Dietary qualities refer to healthy or
optimal measures of nutrients for overall well-being, including body maintenance, growth,
physiological status, and physical activity. (8)Indicators of diet quality have been developed in
recent years to measure adherence to dietary guidelines as well as the totality of individual
dietary components (diversity, recommendation, intake, and practice); an indication index is the
Healthy Eating Index (HEI)(9) ].

9
Various diet indices have been developed, and diet quality is typically evaluated based on how
well people adhere to dietary recommendations. As well as Diet quality measurement is a useful
tool to understand diet-disease relationships(10, 11).

1.2 Statement of the problem

One of the main and preventable causes of poor health Pproblems worldwide is poor nutrition
quality. In terms of nutrition and food security, the global HIV/AIDS epidemic has created a new
type of vulnerability, having poor eating habits and limited access to a macro and
micronutrient micronutrient-rich diet has a negative influence on health, especially in HIV
patients(5, 11)

Micronutrient and macronutrient deficits can be brought on by a lack of food insecurity. These
impairments affect how HIV spreads both vertically and horizontally, which lowers immunity
and raises morbidity and death. It can have negative effects on mental health, depression,
promote drug misuse, and hasten HIV transmission, lead to inadequate viral load suppression,
and raise the likelihood that HIV-infected people will develop an AIDS-defining illness. Many
PLWHA in third third-world countries do not have access to sufficient quantities and qualities of
nourishing foods, which creates additional obstacles for antiretroviral medication to be
effective(12, 13)
In SubSaharan Africa (SSA), food insecurity and HIV/AIDS are two of the primary causes of illn
ess and mortality. They are linked in a vicious cycle whereby each 

Increases vulnerability to and exacerbates the severity of the other. 240million people in the SSA

experience food insecurity. HIV risk is increased by food insecurity(14)
There were 63% of PLHIV in Ethiopia, 75% in Uganda, 57% in the Democratic Republic of the 
Congo, and 52% in Tanzania who experienced food insecurity in sub-Saharan Africa (SSA). Acc
ordingly, acute food insecurity among PLHIV in SSA was widespread, ranging from 38 to 66%(
15)

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1.3 Significance of the study    

While the healthfulness of food choice has- been examined in the all the groups   of the
Ethiopian HIV/AIDS patients there is still a tangible shortage of credible research that looks
dietary potential of Ethiopians to their diet quality, food security, food cost are one of the most
underlined critical factor and commonly accepted motivator that drives people especially house
heads to their food choices .additionally it is noted that dietary cost is an important determinant
of dietary quality.

This study will bring new credible facts on the association between food security, socio-
economic status, and BMI with regards to dietary quality in HIV/AIDS patients in Wolaita, Sodo
University comprehensive specialized hospital.

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2. LITERATURE REVIEW
2.1 Introduction
This chapter reviews the literal materials that have been written in the subject area of these with
a view to examiningto examine what has been researched before delineating what the current
study is going to accomplish. For the purpose of this study, literatures published in English
focusing on the dietary quality on of adult HIV/AIDS patients in countries of the world was
reviewed. Books, journals, and online materials are considered in the review process.

2.2 Nutrition and HIV/AIDS

Diet also plays an important part in HIV/AIDS patients' immune systems, enough the amounts of
macro- and micronutrients are essential for its normal functioning. Weight loss and protein
depletion are common nutritional abnormalities in HIV infection. A finding that is connected to a
reduction in body cells in untreated patients, using highly active antiretroviral medication has
reduced but it has also changed how body fat is distributed and altered certain metabolic
processes. Malnutrition can emerge for a variety of reasons, including changes in calorie intake,
Clinically, famine or other nutritional uptake causes the development of malnutrition .(16, 17).

HIV and nutrition are closely associated and mutually beneficial. HIV impairs the immune
system, which in turn creates malnutrition, which causes even more immunological deficiencies,
and speeds up the progression of HIV infection into AIDS. Given that a starving person's body is
less equipped to fight infection than a well-nourished one, a malnourished person's HIV infection
is more likely to proceed quickly to AIDS. Infected with the human immunodeficiency virus,
poor nutritional status can result from numerous causes, including anorexia, catabolism, chronic
infection, fever, poor nutrient intake, nausea, vomiting, diarrhea, mal-absorption, and metabolic
disturbances. It has been demonstrated that consuming a healthy diet boosts energy, strengthens
the immune system and increases productivity. Loss of more than 10% of the average body
weight with no other known causes of wasting other than HIV infection itself is known as
wasting syndrome.(18-20),

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Malnutrition has negative medical effects. In clinical disease, malnutrition is typically regarded
to occur subsequent toafter the underlying disease, and improvement is seen to be only attainable
by treating the underlying disease.  Studies have shown, the effects of malnutrition in HIV/AIDS
to be independent of immune dysfunction(21, 22)
The relationship between HIV and diet is favorable to both. HIV weakens the immune system, w
hich leads to malnutrition, which further exacerbates immunological deficits and hastens the dev
elopment of HIV infection into AIDS
Given that a malnourished individual's body is less prepared to fight infection than a well-
nourished one, a person with HIV is more likely to get AIDS soon. 
The immune system and many other generalized components of host defense are strengthened
and protected by optimal nutrition, which includes protein, energy, minerals, and vital
micronutrients (23)33 )
According to recent studies, PLWHA exhibited poor food intakes, a decline in nutritional status,
and a reduced quality of life. Due to their gastrointestinal symptoms, which include changed
changing taste and smell, nausea, vomiting, weight loss due to diarrhea, changes in metabolism
and food absorption, and greater caloric demands, people with HIV/AIDS (PLWHA) usually eat
less(24, 25).

While HAART may be associated with lower or higher resting energy expenditure, opportunistic
infections are associated with higher resting energy expenditure. Practically, these symptoms
may prevent consuming enough nutrition, resulting in continued weight loss and loss of lean
tissue, vitamin deficiencies, and other health problems.
Anorexia, catabolism, chronic infection, fever, inadequate vitamin intake, nausea, vomiting, diarr
hea, malabsorption, and metabolic problems are just a few of the many causes of poor nutritional 
status in people with HIV.
It has been proven that eating a nutritious diet enhances energy, maintains the immune system, a
nd boosts productivity reduce reducing the
Loss of 10% or more of the normal body weight without any other recognized causes (21, 22).

2.3. Malnutrition and HIV/AIDS

Decreased CD4 T-cells, suppressed delayed hypersensitivity, and abnormal B-cell responses are
just a few of the immune system's well-documented consequences of malnutrition The causes of

13
malnutrition in HIV include: inadequate dietary intakes; nutrient loses; metabolic changes;
increased requirements, Rrecent research has shown that inadequate nutrition increased the
immune system's sensitivity to HIV replication and that malnourished PLWH were more
susceptible to opportunistic infections than those who were nourished properly(26, 27)

The consequences of starvation on the immune system have been well
studied and include decreased CD4 T-cells, suppressed delayed hypersensitivity, and aberrant B-
cell responses. Inadequate food intakes, nutritional losses, metabolic alterations, and higher need
s are some of the factors contributing to malnutrition in HIV patients.
Recent studies have demonstrated that malnourished PLWH had an immune system that was mor
e susceptible to HIV replication (26, 27)
HIV/AIDS infection frequently causes weight loss. Through decreased food intake, decreased
nutrient absorption and utilization, and increased metabolic demands, HIV gradually weakens
the immune system and degrades nutritional status (28)

Malnutrition weakens the immune system, making a person more prone to illness, and increases 
a person's need for nutrients and energy, which speeds up the onset of diseases. Malnutrition can 
also increase a person's risk of contracting HIV by forcing them to take part in high-risk activitie
s to survive on a daily basisdaily (29)
Deficits in micronutrients are a major factor in the progression of HIV-related AIDSLow levels o
f zinc and iron have also been associated with gastrointestinal problems including diarrhea in add
ition to heightened susceptibility to infections and immunological disorders. PLWH frequently la
cks essential nutrients such as selenium, zinc, and the vitamins A, B-
complex, C, and E. (those living with HIV)
(26, 30, 31).

2.4. Nutritional requirements of HIV patients

The impacts of HIV/AIDS and under nutrition are linked and intensify one another in a vicious
cycle. By increasing energy needs, lowering food intake, and negatively altering nutrient
absorption and metabolism, HIV affects nutritional status. Adults who are asymptomatic and
symptomatic require 10% and 30% more energy, respectively, to maintain their optimum body
weight and level of physical activity(3, 28)

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Optimal nutrition, involving protein, energy, minerals, and essential micronutrients, serves to
strengthen, and protect the immune system as well as the many generalized aspects of host
defense(29)

Recent research has shown that PLWHA had inadequate dietary intakes, decreased nutritional
status, and a lower quality of life. People with HIV/AIDS (PLWHA) frequently eat less because
of their gastrointestinal symptoms, which include altered taste and smell, nausea, and vomiting,
weight loss owing to diarrhea, changes in metabolism and nutrient absorption, and higher caloric
needs .(30, 31).

Opportunistic infections are linked to higher resting energy expenditure, while HAART may be
linked to lower or higher resting energy expenditure. Practically, these symptoms may limit the
consumption of enough nutrients, leading to continuing weight loss and loss of lean tissue,
vitamin or mineral deficiency, and poor nutritional status(32, 33)

Depending on age, weight, height, and gender restrictions, there are specific dietary
requirements for people with HIV. By taking these things into account the complication of the
disease will be delayed, Inadequate dietary intake to meet the increased metabolic demands
brought on by HIV infection is likely to have an impact on PLHIVs' nutritional status, further
lowering their immunity and hastening the disease's progression, resulting to higher mortality
rates(3, 34).

The inability to utilize nutrients as a result of opportunistic infections, and malabsorption drug
toxicities all contribute to inadequate daily calories. The resting energy expenditure was roughly
10%-35% higher in patients with untreated HIV and subsequent weight loss compared to normal
individuals(35)

2.5. Factors associated with dietary quality of HIV/AIDS Patients

2.5.1 Socio-economic factors

Developing nations are characterized by low socioeconomic status   status

which is correlated with lower educational attainment, economic deprivation, and poor health,
Human immunodeficiency virus (HIV) is a disease with social and economic disparities both do

15
mestically and abroad because it primarily affects people with lower socioeconomic status this is
a clear indication to get quality of diet (36).

In the USA, lower levels of socioeconomic status, as evidenced by a lower level of education, un
employment, homelessness, or household poverty, are found in people was comparatively higher
than their counter-
part, ethnic profile of the HIVpositive individuals in the UK and Europe is also distinct, with a w
ide range of social conditions. Therefore, social inequality may lead to variations in HIV health o
utcomes(37, 38).

Low treatment adherence is largely determined by the
high direct and indirect cost of food, which leads to low and extended recovery
rates and a high risk of death among the poor and vulnerable groups (39).

The most cost-effective way to provide desired behavioral changes to stop or lessen the spread of
the illness is through widespread the dissemination of education concerning nutrition made a
positive impact on HIV/AIDS patients (40)

Food- insecurity
Food insecurity, which is characterized as a lack of access to enough, safe, nutritious food to mee
t dietary demands and maintain a healthy and active lifestyle, has significant ramifications for the 
successful integration of nutritional interventions into HIV programs. Considering that 70% of th
e 35 million individuals living with HIV live in sub-Saharan Africa, this is very crucial (41, 42).

According to observational research, food insecurity is associated with higher HIV transmission 
risk behaviors and lower access to HIV care and treatment. Food insecurity among those undergo
ing antiretroviral medication (ART) is linked to decreased ART adherence, lower initial CD4 cell 
count, insufficient viral load suppression, and lower survival rates(43, 44).

Anthropometry

Anthropometric indicators are considered of as straightforward, affordable, and non-invasive

approaches that can be utilized in clinical practice to categorize patients regarding the risk of
diseases related to fat excess/redistribution. Body Mass Index (BMI) is a marker of total
adiposity and has been extensively researched in all age groups. Waist circumference (WC) is a

16
core fat measurement, while waist to -to-hip ratio (WHR) assesses the distribution of body fat.
Both have been recommended as screening instruments to find people who are at risk of
developing diseases in the future(45, 46).
Anthropometric assessments are very responsive to a wide range of nutritional status, but bioche
mical and clinical indicators are only helpful at the most severe levels of undernutrition. The mid
-upper
arm circumference (MUAC) and body mass index (BMI) are the most significant and trustworth
y anthropometric measurements. In
general, BMI (Body Mass Index) is regarded as a good indicator and is used to evaluate people's 
chronic energy insufficiency, particularly in underdeveloped nations(47, 48).

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Conceptual frame work

HOUSE HOLD FOOD SECURITY

SOCIO ECONOMY

AGE

SEX

Dietary quality

DIETARY INTAKE BMI

CARBOHAYDRATE

PROTEIN

FAT

Figure 1: Conceptual framework adopted from different literatures works of literature for the

assessment of dietary quality among HIV HIV-positive adults on ART in WSUCSH, south

Ethiopia, 2022.

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3. Objectives
3.1. General objective

 To assess the prevalence and associated factors of dietary quality among adult HIV HIV-
positive patients on ART in Wolaita Sodo University Comprehensive Specialized Hospital
(WSUCSH), south Ethiopia, 2022.

3.2. Specific Objectives

  To determine the prevalence of dietary quality among adult HIV HIV-positive patients on
ART in Wolaita Sodo University Comprehensive Specialized Hospital (WSUCSH), south
Ethiopia, 2022.
 To identify factors associated with dietary quality among adult HIV HIV-positive patients on
ART in Wolaita Sodo University Comprehensive Specialized Hospital (WSUCSH), south
Ethiopia, 2022.

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4. Method and Materials
4.1. Study area and period
The study will be conducted in at Wolaita Sodo University Comprehensive Specialized Hospital
from November to December 2022. It is found in South Nation Nationalities and People
Regional State (SNNPRS), which is found 380 Km South of Addis Ababa which is the capital
city of Ethiopia & 158 km from Hawassa city which is the administrative city of SNNPRS.
According to the Wolaita Sodo administrative town health office annual plan of for 2020 the
current population of the town is 186,839 from of which 92,859 are males and 93,980 are
females.

Wolaita Sodo University Comprehensive Specialized Hospital is the only public referral hospital
in the Wolaita zone which that gives service for to greater than three million people in different
outpatient and inpatient subdivisions from the depiction of different near districts and regions.
The hospital was accepted as a clinic in Sodo town, Ottona village in 1928 by missionaries and
lived as district to general and secured referral hospital status on September 2013. The Hospital
has twelve staff members who are currently giving service for to 1,563 HIV HIV-positive
patients on ART.

4.2 Study design

A facility facility-based cross cross-sectional study design will be applied among adult HIV HIV-
positive patients on ART in Wolaita Sodo University Comprehensive Specialized Hospital.

4.3 Population

4.3.1 Source population

All HIV HIV-positive individuals on ART in wWolaita sSodo uUniversity cComprehensive
specialized hospital will be the source population of this study.

4.3.2 Study Population

HIV HIV-positive individuals on ART whose ages are greater than 18 years in wolaita sodo
university comprehensive specialized hospital will be the study population of this study.

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4.4 Inclusion and exclusion criteria

4.4.1 Inclusion criteria

HIV/AIDS AIDS-positive individuals they who are >18 years of age and have no complicated
clinical cases will be included.

4.4.2 Exclusion Criteria

HIV/AIDS patients who are seriously ill or involuntary to give the required information during
the data collection period will be excluded from the study.

4.5 Sample size determination

Calculation of sample size was done by using a single proportion formula. Since there is no prior
similar study about the dietary quality among HIV patients in Ethiopia, I used (p) as 50% to get
the maximum sample size for the current study.

n = z2pq/d2
n = 1.962×0.5× (1−0.5)/ (0.05)2
⇒ n = 384.16≈384

Here,

n = Sample size, z = 1.96 (with 95% confidence level), p= prevalence estimate (50%), q = (1-p),
d = Sampling error (0.05).

By adding a 10% non-response rate, the sample size becomes 423.5 ≈ 424.
4.6 Sampling technique and procedures

The total sample size of 424 adults living with HIV/AIDS patients on the anti-retroviral drug
during the study period will be selected using systematic random .

4.7 Data collection tool and procedures

A pretested and structured interviewer-administered questionnaire will be used to collect data
from HIV HIV-positive individuals. It will be constructed by adopting and modifying from
related research done on a related topic. First, the English version of the questionnaire will be
prepared. Then it will be translated to the Amharic and back into English. The questionnaire
consists of five parts. The first part is about the socio-demographic characteristics of the
respondent the second is about dietary intake and the third food security and socio-culture
questions respectively. And the last section will be regarding the current nutritional status the
anthropometric (BMI) will be used to assess the current nutritional status.

21
Bachelor of nurses workers will be recruited as data collectors and other senior nurses will be
recruited as supervisors. Data collectors will be responsible to interview the patients, consistently
recording the result, and finally submitting the result to the investigator as scheduled. Weight and
height will be measured carefully. To generate anthropometric data.

4.8. Data quality assurance

All data collectors and supervisors will be oriented and trained on how to interview and record
the data and will be assigned. In order tTo assess the appropriateness of wording, clarity of the
questions, and respondent reaction to the questions and interviewer, it will be pre-tested on 5%,
the collected data will be checked by the supervisor and investigator for its completeness and
corrections will be made accordingly.

4.9. Variables of the study

4.9.1. Independent variables

Socio-economic

 Age
 Ethnicity
 Religion
 Marital Status
 Educational Status
 Occupation
 Employment
 Residence
 Wealthy status

Dietary intake

Carbohydrate

Protein

Fat

ANTROPOMETRY

22
BMI

Socio-culture and healthy service

4.9.2 Dependent variable

Dietary Quality among HIV/AIDS patients

4.10. Operational definitions

HIV patients a person who is infected with the human immunodeficiency virus (HIV)

Dietary: food and drink regularly provided or consumed

Anthropometry Noninvasive Quantitative Measurements of the Body

Malnutrition: lack of proper nutrition, caused by not having enough to eat, not eating enough of
the right things, or being unable to use the food that one does eat

4.11. Data Processing and analysis

The collected data will be checked manually for completeness and consistenciesconsistency, and
then it will be coded and entered in epi info version 3.5.3 and exported to SPSS version 26 for
analysis will be uses used to analyze the anthropometric characteristics of patients. descriptive
statistics will be used to summarize the socio-demographic characteristics of the study
participants and the prevalence of dietary quality , to identify factors associated with the dietary
quality of adult HIV/AIDS patients, binary logistic regression analysis carried out at two levels,
first bivariate logistic regression will be performed to each independent variable with the
outcome variable, and those variables with a p-value < 0.25 will be included in the final model
(multivariate analysis). Strength The strength of the association will be measured using an odds
ratio, and 95% confidence intervals. Statistical significance will be declared at p-value <0.05.

4.12. Ethical considerations

Ethical Clearance Will Be Obtained From WSU, The Department Of The Reproductive Health
And Human Nutrition Research Committee. Each Study Participant Will Be Adequately
Informed About The Objective Of The Study And Anticipated Benefits And Risks Of The Study
By Their Data Collector. And Assent Will Be Obtained From The patients For To Protecting
Autonomy and Ensuring Confidentiality. Respondents Will Also Be Told The Right Not To
Respond To The Questions If They Didn't Want To Respond Or To Terminate The Interview At

23
 Any Time. Malnourished Infants during the Study Period Will Be Linked To the Nearby Health
Institutions/ Other Concerned Bodies.

4.8 Dissemination of results

The result of the study will be submitted and presented to the department of reproductive Health
health and human nutrition, school of public health, college of health sciences, Wolaita Sodo
University.The Study Result Will Also Be Submitted to the Wolaita sodo University
comprehensive specialized. Effort Will Be Made To Present The Result results In Locally Or
Internationally Held Seminars, Workshops, Conferences, And Meetings. Efforts Will Also Be
Made to Publish the Study

5. WORK PLAN & BUDGET BREAKDOWN

5.1. Work plan

Table 1: Work plan for the assessment of dietary quality and associated factors among adult
HIV positive patients on ART in WSUCSH, South Ethiopia, 2022

S.N Tasks To Be Performed Res.Body NOV DECE JAN FEB MAR APRI MA JUN JULL Rema
CH L Y Y rk

1 Proposal Development Pi
2 Proposal Draft (1st, 2nd ...) Pi
3 Thesis Proposal Defense Pi &Spg

4 Last Date For Revised Proposal Pi

Submission To Pg-Co(2 Hard
Copies And A Cd)
5 Proposal Submission For Pi &Spg
Ethical Review
Ethical Review & Clearance Rerc

6 Recruitment And Training Of Pi

Supervisors And Data
Collectors & Pre-Teste
7 Data Collection Pi, Dc

8 Data Coding, Entry And Pi

Cleaning
9 Data Analysis Pi

10 Report Writing Pi
11 Submission Of 1st, 2nd... Draft Pi
Thesis Report To Advisors
12 Submission Of Final Draft Pi
Report To Advisors
13 Mock Defense Pi,Sph&Adv

14 Last Date For Final Thesis Pi

Submission To The Pg-Co(2
Hard Copies And A Cd)
15 Open Thesis Defense Pi,Spg

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18 Submission Of Revised Thesis Pi
Report To The Pg-Co(2 Hard
Copies And A Cd)
Key: - Pi = Principal Investigator, Advs = Advisors, Spg = School Of Post Graduate,
Rerc=Research Ethical Review Committee, Dc= Data Collectors, Sph= School Of Public Health

5.2. Budget breakdown

Table 2: Budget proposal and breakdown for the assessment of dietary quality and associated
factors among adult HIV positive patients on ART in WSUCSH, South Ethiopia, 2022.

Budget Category Unit Multiplying Total Cost Remark

Cost(Birr) Factors
Personal Cost
Data Collectors 150.00 6*150.00*10 9,000.00
Supervisors 210.00 3*210.00*10 6300.00
Subtotal 15,300.00
Stationeries
A4 Size Paper 370.00 4*370.00 1480.00
Duplication 2.00 2.00*650*5 6500.00
Pen 10.00 9*10.00 90.00
Pencil 5.00 6*5.00 30.00
Eraser 15.00 6*15.00 90.00
Sharpener 10.00 6*10.00 60.00
Usb Flash (Memory Card) 300.00 2*300.00 600.00
Binding 50.00 3*50.00 150.00
Compact Disk 50.00 3*50.00 150.00
Subtotal 9,150.00

2500.00
Telephone 500.00
Subtotal 3000.00

Budget Summary

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Personal Cost 15,300.00
Stationeries 9150.00
Transportation Cost &Telephone 3000.00
Contingency 2745
Grand Total 30,195.00

References
1. Thapa R, Amatya A, Pahari DP, Bam K, Newman M. Nutritional status and its association with
quality of life among people living with HIV attending public anti-retroviral therapy sites of Kathmandu
Valley, Nepal. AIDS research and therapy. 2015;12(1):1-10.
2. Diouf A, Badiane A, Manga NM, Idohou-Dossou N, Sow PS, Wade S. Daily consumption of ready-
to-use peanut-based therapeutic food increased fat free mass, improved anemic status but has no
impact on the zinc status of people living with HIV/AIDS: a randomized controlled trial. BMC public
health. 2015;16(1):1-10.
3. Birhane M, Loha E, Alemayehu FR. Nutritional status and associated factors among adult
HIV/AIDS patients receiving ART in Dilla University referral hospital, Dilla, Southern Ethiopia. J Med
Physiol Biophys. 2021;70:8-15.
4. Mulu H, Hamza L, Alemseged F. Prevalence of malnutrition and associated factors among
hospitalized patients with acquired immunodeficiency syndrome in Jimma University Specialized
Hospital, Ethiopia. Ethiopian journal of health sciences. 2016;26(3):217-26.
5. Ngo-Matip M-E, Pieme CA, Azabji-Kenfack M, Moukette BM, Korosky E, Stefanini P, et al. Impact
of daily supplementation of Spirulina platensis on the immune system of naïve HIV-1 patients in
Cameroon: a 12-months single blind, randomized, multicenter trial. Nutrition Journal. 2015;14(1):1-7.
6. Weldegebreal F, Digaffe T, Mesfin F, Mitiku H. Dietary diversity and associated factors among
HIV positive adults attending antiretroviral therapy clinics at Hiwot Fana and Dilchora Hospitals, eastern
Ethiopia. HIV/AIDS (Auckland, NZ). 2018;10:63.
7. Grobler L, Siegfried N, Visser ME, Mahlungulu SS, Volmink J. Nutritional interventions for
reducing morbidity and mortality in people with HIV. Cochrane Database of Systematic Reviews.
2013(2).
8. PONDOR I. DIET QUALITY AND ITS CONTRIBUTING FACTORS AMONG ADULTS IN THREE
DISTRICTS OF SELANGOR, MALAYSIA. 2017.
9. Weiss JJ, Sanchez L, Hubbard J, Lo J, Grinspoon SK, Fitch KV. Diet quality is low and differs by sex
in people with HIV. The Journal of nutrition. 2019;149(1):78-87.
10. Ha K, Kim K, Sakaki JR, Chun OK. Relative validity of dietary total antioxidant capacity for
predicting all-cause mortality in comparison to diet quality indexes in US adults. Nutrients.
2020;12(5):1210.
11. Miller V, Webb P, Micha R, Mozaffarian D, Database GD. Defining diet quality: a synthesis of
dietary quality metrics and their validity for the double burden of malnutrition. The Lancet Planetary
Health. 2020;4(8):e352-e70.
12. Aibibula W, Cox J, Hamelin A-M, McLinden T, Klein MB, Brassard P. Association between food
insecurity and HIV viral suppression: a systematic review and meta-analysis. AIDS and Behavior.
2017;21(3):754-65.

26
13. Oluma A, Abadiga M, Mosisa G, Etafa W, Fekadu G. Food Insecurity among people living with
HIV/AIDS on ART follower at public hospitals of Western Ethiopia. International Journal of Food Science.
2020;2020.
14. Weiser SD, Bukusi EA, Steinfeld RL, Frongillo EA, Elly W, Dworkin SL, et al. Shamba maisha:
Randomized controlled trial of an agricultural and finance intervention to improve HIV health outcomes
in Kenya. AIDS (London, England). 2015;29(14):1889.
15. Tesfaye M, Kaestel P, Olsen MF, Girma T, Yilma D, Abdissa A, et al. Food insecurity, mental
health and quality of life among people living with HIV commencing antiretroviral treatment in Ethiopia:
a cross-sectional study. Health and quality of life outcomes. 2016;14(1):1-8.
16. Faintuch J, Soeters PB, Osmo HG. Nutritional and metabolic abnormalities in pre-AIDS HIV
infection. Nutrition. 2006;22(6):683-90.
17. Duran A, Almeida L, Segurado AAC, Jaime PC. Diet quality of persons living with HIV/AIDS on
highly active antiretroviral therapy. Journal of Human Nutrition and Dietetics. 2008;21(4):346-50.
18. Duggal S, Chugh TD, Duggal AK. HIV and malnutrition: effects on immune system. Clinical and
developmental immunology. 2012;2012.
19. Hailemariam S, Bune GT, Ayele HT. Malnutrition: Prevalence and its associated factors in People
living with HIV/AIDS, in Dilla University Referral Hospital. Archives of Public Health. 2013;71(1):1-11.
20. Young JS. HIV and medical nutrition therapy. Journal of the American Dietetic Association.
1997;97(10):S161-S6.
21. Babameto G, Kotler DP. Malnutrition in HIV infection. Gastroenterology Clinics of North
America. 1997;26(2):393-415.
22. Hsu JW, Pencharz PB, Macallan D, Tomkins A. Macronutrients and HIV/AIDS: a review of current
evidence. Durban, South Africa: World Health Organization. 2005.
23. Gebremichael DY, Hadush KT, Kebede EM, Zegeye RT. Food insecurity, nutritional status, and
factors associated with malnutrition among people living with HIV/AIDS attending antiretroviral therapy
at public health facilities in West Shewa Zone, Central Ethiopia. BioMed research international.
2018;2018.
24. Maganga E, Smart LR, Kalluvya S, Kataraihya JB, Saleh AM, Obeid L, et al. Glucose metabolism
disorders, HIV and antiretroviral therapy among Tanzanian adults. PloS one. 2015;10(8):e0134410.
25. Balfour L, Spaans JN, Fergusson D, Huff H, Mills EJ, la Porte CJ, et al. Micronutrient deficiency
and treatment adherence in a randomized controlled trial of micronutrient supplementation in ART-
naïve persons with HIV. PloS one. 2014;9(1):e85607.
26. Amlogu AM, Tewfik S, Wambebe C, Tewfik I. Innovative Nutritional Approach to Attenuate the
Progression of HIV to AIDS Among People Living with HIV (PLWH): A Study Based in Abuja, Nigeria.
Journal of Advance Research in Medical & Health Science. 2019;5(1):01-16.
27. Liu X, Cao J, Zhu Z, Zhao X, Zhou J, Deng Q, et al. Nutritional risk and nutritional status in
hospitalized older adults living with HIV in Shenzhen, China: a cross-sectional study. BMC Infectious
Diseases. 2021;21(1):1-9.
28. Summerbell CD. Appetite and energy intake in human immunodeficiency virus (HIV) infection
and AIDS. Nutrients and Foods in Aids: CRC Press; 2017. p. 119-25.
29. Anand D, Puri S. Anthropometric and nutritional profile of people living with HIV and AIDS in
India: An assessment. Indian Journal of Community Medicine: Official Publication of Indian Association
of Preventive & Social Medicine. 2014;39(3):161.
30. Folasire O, Folasire A, Sanusi R. Measures of nutritional status and quality of life in adult people
living with HIV/AIDS at a Tertiary Hospital in Nigeria. Food and Nutrition Sciences. 2015;6(04):412.
31. Thuppal SV, Jun S, Cowan A, Bailey RL. The nutritional status of HIV-infected US adults. Current
developments in nutrition. 2017;1(10):e001636.

27
32. Labban L. The Implications of HIV/AIDS on the Nutritional Status and the MNT for Its Patients. EC
Nutr. 2016;3(4):673-9.
33. Sashindran VK, Thakur R. Malnutrition in HIV/AIDS: aetiopathogenesis. Nutrition and HIV/AIDS-
Implication for Treatment, Prevention and Cure [series online]. 2020.
34. Petersen M, Yiannoutsos CT, Justice A, Egger M. Observational research on NCDs in HIV-positive
populations: conceptual and methodological considerations. Journal of acquired immune deficiency
syndromes (1999). 2014;67(0 1):S8.
35. Badowski ME, Perez SE. Clinical utility of dronabinol in the treatment of weight loss associated
with HIV and AIDS. HIV/AIDS (Auckland, NZ). 2016;8:37.
36. Ogunmola OJ, Oladosu YO, Olamoyegun MA. Relationship between socioeconomic status and
HIV infection in a rural tertiary health center. HIV/AIDS (Auckland, NZ). 2014;6:61.
37. Burch LS, Smith CJ, Anderson J, Sherr L, Rodger AJ, O'Connell R, et al. Socioeconomic status and
treatment outcomes for individuals with HIV on antiretroviral treatment in the UK: cross-sectional and
longitudinal analyses. The Lancet Public Health. 2016;1(1):e26-e36.
38. Burch LS, Smith CJ, Phillips AN, Johnson MA, Lampe FC. Socioeconomic status and response to
antiretroviral therapy in high-income countries: a literature review. Aids. 2016;30(8):1147-62.
39. Richter LM, Lönnroth K, Desmond C, Jackson R, Jaramillo E, Weil D. Economic support to
patients in HIV and TB grants in rounds 7 and 10 from the global fund to fight AIDS, tuberculosis and
malaria. PloS one. 2014;9(1):e86225.
40. Kahssay S, Amlaku S, Teka T, Workneh B. Effect of HIV/AIDS information distribution on the
status of behavioral change among students of higher education institutions in Ethiopia: experience of
Wollo University. HIV & AIDS Review International Journal of HIV-Related Problems.21(2):129-36.
41. Benzekri NA, Sambou J, Diaw B, Sall EHI, Sall F, Niang A, et al. High prevalence of severe food
insecurity and malnutrition among HIV-infected adults in Senegal, West Africa. PloS one.
2015;10(11):e0141819.
42. FANELLI TJ, JONAS A, GWESHE J, TJITUKA F, SHEEHAN HM, WANKE C, et al. Household food
insecurity associated with antiretroviral therapy adherence among HIV-infected patients in Windhoek,
Namibia. Journal of acquired immune deficiency syndromes (1999). 2014;67(4):e115.
43. Anema A, Vogenthaler N, Frongillo EA, Kadiyala S, Weiser SD. Food insecurity and HIV/AIDS:
current knowledge, gaps, and research priorities. Current Hiv/aids Reports. 2009;6(4):224-31.
44. Weiser SD, Young SL, Cohen CR, Kushel MB, Tsai AC, Tien PC, et al. Conceptual framework for
understanding the bidirectional links between food insecurity and HIV/AIDS. The American journal of
clinical nutrition. 2011;94(6):1729S-39S.
45. Beraldo RA, Meliscki GC, Silva BR, Navarro AM, Bollela VR, Schmidt A, et al. Comparing the
ability of anthropometric indicators in identifying metabolic syndrome in HIV patients. PLoS One.
2016;11(2):e0149905.
46. Adal M, Howe R, Kassa D, Aseffa A, Petros B. Malnutrition and lipid abnormalities in
antiretroviral naïve HIV-infected adults in Addis Ababa: A cross-sectional study. PloS one.
2018;13(4):e0195942.
47. Bhattacharya A, Pal B, Mukherjee S, Roy SK. Assessment of nutritional status using
anthropometric variables by multivariate analysis. BMC public health. 2019;19(1):1-9.
48. Ramlal RT, Tembo M, King CC, Ellington S, Soko A, Chigwenembe M, et al. Dietary patterns and
maternal anthropometry in HIV-infected, pregnant Malawian women. Nutrients. 2015;7(1):584-94.

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