Effects of Undernutrition on Treatment Outcomes Among Adults Living with HIV in Northwest Ethiopia: A Longitudinal Study

Abstract

Background:Undernutrition is one of the most common problems among people living with HIV (PLHIV), particularly in sub-Saharan Africa (SSA), where both undernutrition and HIV are highly prevalent. The relationship between HIV and undernutrition is multifactorial and multidimensional. HIV increases the risk of undernutrition, and at the same time, undernutrition accelerates the disease progression from mild to severe, leading to poorer treatment outcomes, including mortality. In addition, the success of antiretroviral therapy (ART), the drug used to treat HIV, depends on the nutritional status of patients. In Ethiopia, although these interrelated conditions highly affect PLHIV, longitudinal studies evaluating the effects of undernutrition on treatment outcomes of this population are lacking. This thesis was designed to fill this gap and inform evidence-based practice.

Aim:The aim of this study was to assess the effects of undernutrition on the overall treatment outcomes of adults living with HIV (ALHIV) on antiretroviral therapy (ART) in Ethiopia.

Objectives:This thesis has five objectives:

1) To examine the effects of undernutrition on mortality and morbidity among ALHIV in SSA since 2002;

2) To determine the effect of undernutrition on loss to follow-up among ALHIV on ART;

3) To determine the effects of undernutrition on opportunistic infections (OIs) among ALHIV on ART at Debre Markos Comprehensive Specialized Hospital, Ethiopia;

4) To assess weight change during the two years of ART among adults living HIV at Debre Markos Comprehensive Specialized Hospital, Ethiopia; and

5) To examine the association between body mass index variation and early mortality among adults living HIV at Debre Markos Comprehensive Specialized Hospital, Ethiopia.

Methods:Different quantitative research methods and analytical approaches were employed to address the objectives of this research. The first objective was addressed using a systematic review and meta-analysis. The systematic review included all observational studies reporting the effects of undernutrition on mortality and morbidity among ALHIV in SSA. The pooled effects of undernutrition on mortality and morbidity were estimated using a random-effects meta-analysis model. The remaining four objectives were addressed through a retrospective longitudinal study. Data for this study were obtained from the medical records of ALHIV, who received ART at Debre Markos Comprehensive Specialized Hospital, Ethiopia, between June 2014 and June 2020. Data from patients' medical records were extracted manually using a standardized data extraction format. Specifically, the second objective examined the impact of undernutrition on loss to follow-up (LTFU) among 844 ALHIV receiving ART using proportional hazards regression model. The third objective examined the effects of undernutrition on time to develop OIs in 841 participants using inverse-probability weighting. The fourth objective explored weight change during the first two years of ART among 848 ALHIV using a linear mixed-effects model. The last objective examined the association between body mass index (BMI) variation and early mortality in 834 participants using a joint modelling approach (longitudinal and time-to-event data).

Results:Manuscript I found that undernutrition significantly (AHR [adjusted hazard ratio]: 2.1, 95% CI: 1.8, 2.4) increased the risk of mortality in ALHIV, while severely undernourished ALHIV were at higher risk of death (AHR: 2.3, 95% CI: 1.9, 2.8) compared to mildly undernourished ALHIV. This review also showed that undernutrition significantly increased the risk of developing tuberculosis (AHR: 2.1, 95% CI: 1.6, 2.7) among ALHIV.