Dietary diversity (DD) is the number of individual food items or food groups consumed over a given reference period(Reference Ruel1). It is eating different food types across and within food groups, such as vegetables, fruits, grains and animal source foods(Reference Tesfaw, Jara and Temesgen2). To guarantee the adequate intake of essential nutrients and promote good health, DD is thought to be very important, and no single food can contain all nutrients. The more different food types are included in the daily diet, the greater the probability of meeting nutrient requirements(Reference Labadarios, Steyn and Nel3).
Adequate nutrient intake that is necessary for good nutrition has often been associated with the food variety and diet quality of individuals. Micronutrient malnutrition is one form of malnutrition affecting the lives of millions of people worldwide(Reference Bandoh and Kenu4,Reference Chagomoka, Drescher and Glaser5) . Micronutrient malnutrition remains a major public health concern in developing countries due to the intake of monotonous, predominantly starchy-based diets that are lacking in diversity(6), and hence, over 2 billion people are affected worldwide(Reference Chagomoka, Drescher and Glaser5).
Although anti-retroviral therapy (ART) medication-related side effects such as poor appetite, fatigue, and nausea make human immune deficiency virus (HIV)-infected individuals hard to eat well, the nutritional needs of people with HIV are greater because the body has to work overtime to deal with a chronic viral infection and to fight against opportunistic infections(Reference Lyon and Nambiar7). For a healthy, strong, and productive life, good nutrition is of paramount importance. It has been indicated that a diversified diet is an indicator of quality food. The DD score at the individual level is a proxy indicator of adequate intake of energy and micronutrients(8), which implies that increasing the diversity of foods and food groups in the diet helps to ensure adequate intake of essential nutrients and promotes good health(Reference Becquey, Capon and Martin-Prével9).
HIV is one of the most serious global public health challenges. In 2019, 38 million people were living with HIV/acquired immune deficiency syndrome (AIDS) worldwide (36⋅2 million adults). Among these, 67 % (25⋅4 million) were accessing ART globally(10). Nutrition care and support is one of the components of comprehensive care for people living with HIV(Reference Weldegebreal, Digaffe and Mesfin11) since more than half of people living with HIV are in low- and middle-income countries: 19⋅6 million (53 %) in eastern and southern Africa, 6⋅1 million (16 %) in western and central Africa, 5⋅2 million (14 %) in Asia and the Pacific, and 2⋅2 million (6 %) in Western and Central Europe and North America(Reference McGovern12). In Ethiopia, the prevalence rate of HIV is 1⋅15 % (1⋅4 % urban and 0⋅6 % rural prevalence), and people living with HIV/AIDS (PLWA) is 737 186. And in Amhara, PLWA is 210 410(13).
DD is recommended for a healthy life and is an important component of diet quality(Reference Martin-Prevel, Arimond and Allemand14). Globally, in the last half a century, the food diversity consumed around the world deteriorated(Reference Khoury, Bjorkman and Dempewolf15), and repetitive/monotonous low-quality diets are common in resource-limited countries(Reference Mekuria, Wubneh and Tewabe16).
DD is very important to help people living with HIV/AIDS prevent weight loss or maintain weight, maintain muscle mass, boost immunity and prevent viral progression and opportunistic infection(17).
Studies have shown a wide variation in the magnitude/level of DD (29⋅5–71⋅3 %) among adults on ART follow-up in East Africa(Reference Weldegebreal, Digaffe and Mesfin11,Reference Woldemariam, Yusuf and Beyen18,Reference Beatrice and Francis19) .
In Ethiopia, several studies have been carried out focusing on women and children nutrition(Reference Temesgen, Yeneabat and Teshome20,Reference Weldehaweria, Misgina and Weldu21,Reference Yimer and Tadesse22,Reference Temesgen, Negesse and Woyraw23,Reference Eshete, Kumera and Bazezew24) , yet DD in vulnerable groups like people with HIV/AIDS is limited. Besides, to the best of the investigators’ knowledge, little is investigated about the DD of people living with HIV and associated factors in Ethiopia, particularly in the Amhara region and Bahir Dar City.
Therefore, this study was conducted to assess DD and associated factors among HIV-positive adults attending the ART clinic at Felege Hiwot Comprehensive Specialized Hospital (FHCSH), Bahir Dar in Northwest Ethiopia. Moreover, the finding of this study will give evidence on DD and selected factors among HIV-positive adults attending the ART clinic at FHCSH. This will also help to identify and define the intervention areas for the target groups and ART attendants, to ultimately enhance nutrient intake. Hence, it is a vital input for different stakeholders, such as healthcare professionals working in HIV/AIDS care, health facilities, regional health bureau and nutrition-related programme designers at a different level, including the ministry of health and researchers, who are working so as improve the quality of life and better survival in HIV-infected patients.
Methods
Study area and period
The study was conducted in the FHCSH ART clinic, which was found in Bahir Dar city from 6 October 2019 to 15 November 2019.
Bahir Dar city is the capital city of Amhara National Regional State, which is located 565 km in the Northwest of Addis Ababa, Ethiopia.
FHCSH is a tertiary referral hospital with approximately 400 beds and nine operating tables serving over 7 million people from the surrounding area. The hospital provides obstetrics, paediatrics, internal medicine, ophthalmology, general, gynaecology, ENT (ear, nose and throat) and orthopaedic surgery services. The FHCSH ART clinic started functioning since 2002. It has forty-two staff, five out-patient departments and 7500 HIV/AIDS patients registered for ART clinic service.
Study design and population
An institution-based cross-sectional study was conducted. The source population was all HIV-positive adults who are registered for care and support at the FHCSH ART clinic. The study population was all HIV-positive adults who were attending the ART clinic within the data collection period.
HIV positive adults (aged 18–65 years old) who were attending the ART clinic within the data collection period were included in the study, as also HIV-positive adults who were previously diagnosed with diabetes mellitus, hypertension and/or pregnancy. Those who participated in special festivals or special occasions away from home within the last 24 h before the data collection were included. However, adults who took ART less than 3 months before the beginning of the data collection were excluded from the study.
Sample size determination and sampling procedures
Sample size was determined by using a single population proportion formula with a 95 % confidence level and a 5 % desired level of precision and by considering the proportion of adult HIV-positive individuals attending public health facilities in Motta town who consume diversified diet (29⋅5 %)(Reference Tesfaw, Jara and Temesgen2). Considering a 10 % non-response rate, the final sample size was 352 adults.
Study participants were selected by the systematic random sampling technique at every kth (sixth) interval, where k is the sampling fraction, which is calculated as N/n 2000/352 ≈ 6. The numerator 2000 was estimated as an average number of HIV-positive clients attending the ART clinic per month (100 pts/d × 5 d/week × 4 weeks/month). The starting sample was selected by the lottery method among the first six clients' chart. Then, the procedure continued (the selection of every sixth client as a study subject) until the required sample size was obtained. In the case of exclusion, the next client was taken. Data were collected on every working day except Thursday (to avoid Wednesday fasting influence for Orthodox followers), and one study subject was recruited only once.
A dependent variable is DD (low and high DD).
Independent variables are as follows:
• Socio-demographic characteristics: sex, age, religion, current residence, educational status, marital status, employment status, family size, wealth index quantile.
• Behavioural factors: alcohol drinking, cigarette smoking, khat chewing, exposure to media sources. Health-related characteristics are co-trimoxazole prophylaxis use, duration of anti-retroviral treatment, CD4 cell count, ART regimen category, World Health Organization (WHO) clinical stage.
• Nutritional-related factors: household food insecurity, source of food, nutrition counselling, food preference.
Data collection and quality assurance
Data collection instrument
Data were collected using a structured interviewer-administered questionnaire with chart review. The standardised individual DD score (IDDS) tool with the 24-h food recall method was used to assess the DD of HIV-positive adults.
The questionnaire was adapted from Food and Nutrition Technical Assistance (FANTA)/Food and Agriculture Organization (FAO) and by reviewing the literature(6,Reference Woldemariam, Yusuf and Beyen18,Reference Coates, Swindale and Bilinsky25) . The questionnaire was first prepared in English by reviewing the literature, then translated into Amharic and then translated back to English to maintain consistency; nutrition experts were consulted for comments and pre-tests were done.
The questionnaire had seven parts: part I, questions on socio-demographic characteristics; part II, behavioural factors; part III, health-related characteristics; part IV, nutritional-related characteristics; part V, DD questions; part VI, household food insecurity; part VII, wealth index.
Data collection personnel
A total of six nurses were recruited: five for data collection and one for supervision. They were trained and oriented for 1 day on the questionnaire and data collection.
Data on health-related characteristics, such as the duration of ART, co-trimoxazole prophylaxis, last CD4 count, WHO clinical stage and opportunistic infections, were collected by reviewing patient clinical records and interviews.
Measurement of IDDS
The standardised IDDS tool, with a 24-h food recall method (FAO), was used to assess the individual DD of study subjects(6,Reference Woldemariam, Yusuf and Beyen18) .
For the estimation of the IDDS, nine food groups consumed in the study area, i.e. starch staples, dark green leafy vegetables, other vitamin A-rich fruits and vegetables, other fruits and vegetables, meat and/or fish, organ meat, egg, legumes, nuts and seeds, and milk and milk products, were studied.
Study subjects were asked to list all foods he/she consumed at home and outside the home in the last 24 h before the data collection date from breakfast to dinner. Food consumed for breakfast 6:00–10:00, then lunch 12.00–16:00 and dinner 20:00–24:00, while snacks considered to be eaten before or after the major mealtime. Then, food eaten by the respondent was classified into nine food groups.
If the respondent consumed food at least once during the last 24 h within each subgroup, 1 point was scored, and 0 point if they never consumed the food. Food groups that an individual has consumed during the preceding 24 h were counted, and the IDDS was calculated as the sum of food groups consumed over 24 h.
Data quality control
The collected data were reviewed and checked for completeness by data collectors, a supervisor and a principal investigator. The data collectors were given training, and the questionnaire was translated and pre-tested. To assure anonymity, code numbers were written on the completed questionnaires before they were returned to the investigator.
Statistical analysis
The data were cleaned and entered into Epidata manager 4.6, exported and analysed with Statistical Package for the Social Science (SPSS) version 26 software. The characteristics of the study subjects were described by presenting on tables, m and sd. The categorical variables were presented in frequencies and proportions.
To determine the level of individual DD among HIV-positive adults on ART, first, the IDDS was calculated as the sum of food groups consumed over 24 h. Then, based on the mean of the IDDS, the level of individual DD was classified into low DD and high DD.
Wealth index
The wealth status of households was assessed by collecting data on variables related to the ownership of livestock assets, crop produced in the previous year, possession of farmland, valuable domestic assets, the living condition of the house, and sanitation facility. For urban and rural participants, the principal component analysis (PCA) was run separately, and finally, the wealth index score was merged to a common variable (the wealth index score). Then, the wealth index score was generated by using the PCA and the wealth index score was categorised into five distinct wealth quintiles.
Household food insecurity access scale
Nine occurrence and nine frequency of occurrence questions/items of FANTA 2007 was used to examine household food insecurity scale. The frequency of an occurrence item was re-coded to ‘0’ if the answer for an occurrence item was ‘No’, and if ‘Yes’, the response would take one of the options, i.e. 1 (rarely), 2 (sometimes) or 3 (often). Thus, households were grouped based on scores achieved in specific items. Based on the criteria, a food-secure household experienced none of the food insecurity (access) conditions, or just experiences worry, but rarely. Hence, a study participant who responded to the first household food insecurity access scale (HFIAS) item did not worry at all or rarely worried about the availability of enough food for the household in the past 4 weeks and no for the remain items considered as a food-secure household, else re-coded in to food insecure(Reference Coates, Swindale and Bilinsky25).
To identify predictors of DD status, the sum of the IDDS was re-coded as low DD (0) and high DD (1) by considering the mean IDDS as a cut-off point (3⋅86 ± 1⋅18). Then, a bi-variable binary logistic regression analysis was performed between the dependent variable (DD status) and each of the potential factors to select candidate variables for the multivariable analysis.
Predictor variables with a P-value less than 0⋅20 in bi-variable binary logistic regression were included in the multivariable binary logistic regression analysis. P-values less than 0⋅05 were considered statistically significant in the multivariable analysis. Predictor variables that had a significant association with the DD status were identified using an adjusted odds ratio (AOR) with 95 % confidence interval (CI) and a P-value less than 0⋅05. Hosmer and Lemeshow goodness-of-fit-test of model computed, P-value (0⋅21).
Ethical considerations
This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving human subjects/patients were approved by the Bahir Dar University, Institute of Technology, Faculty of Chemical & Food Engineering, and the Department of Applied Human Nutrition (Ref. #BiT/FCFE/816/2011), and the Amhara Public Health Institute gave ethical clearance (Ref. #03/527) to FHCSH for the conduct of the research. Permission was obtained from the administrative body of FHCSH. Finally, verbal consent was obtained from all study participants immediately before the interview, was formally recorded and participation was made voluntary.
Results
Socio-demographic and behavioural-related characteristics of study participants
A total of 352 HIV-positive adults (18–65 years old) attending ART participated, which amounted to a 100 % response rate. The majority of the participants were male, totalling 197 (56 %), those in the age group of 35–44 years totalled 149 (42⋅3 %), Orthodox religion followers were 279 in number (79⋅3 %), there were 300 urban dwellers (85⋅2 %), secondary and above highest educational level achieved was 202 (57⋅4 %), married persons were 229 (65⋅1 %) and 211 (60⋅6 %) lay in the middle and above quintiles of the wealth index. m ± sd age of participants was 36⋅9 (m) ± 8⋅2 (sd) years old and the mean family size was 3⋅6 (m) ± 1⋅6 (sd). Among the study participants, 41 (11⋅6 %) smoked cigarettes, and 255 (72⋅4 %) followed news in the media. (Table 1)
Table 1. Socio-demographic and behavioural-related characteristics of HIV-positive adults (18–65 years old) attending ART clinics at FHCSH, Northwest Ethiopia, 2019 (n 352)
a Apostolic.
b Pension.
Health-related characteristics
More than two-thirds 239 (67⋅9 %) had no opportunistic infection in the last 1 month before the date of interview, 162 (46⋅0 %) had treatment stage I, a large proportion of 289 (82⋅1 %) were taking first-line ART drugs and 177 (50⋅3 %) had CD4 count ≥350 cells/mm3 (Table 2).
Table 2. Health-related factors of HIV-positive adults (18–65 years old) attending ART clinics at FHCSH, 2019 (n 352)
T-1, Treatment Stage 1; T-2, Treatment Stage 2.
a Diarrhea, herpes zoster.
Nutritional-related characteristics
The majority of the study participants who had nutritional counselling at a health institution were 298 in number (84⋅7 %) and 292 (83⋅0 %) had no food preference for their meals (Table 3).
Table 3. Nutritional-related factor of HIV-positive adults (18–65 years old) attending ART clinics at FHCSH, Northwest Ethiopia, 2019 (n 352)
Measurements of 24 h individual DD and level of individual DD
More than half of the study subjects, 203 (57⋅7 %), ate three times a day in the past 24 h and near a third, 115 (32⋅7 %), ate four or more times in a day. The average meal frequency was 3⋅2 ± 0⋅8 with a minimum of one time and a maximum of six times a day.
Among nine food groups, starchy staple foods (333, 94⋅5 %), other fruits and vegetables (291, 82⋅7 %) and legumes, nuts and seeds (228, 64⋅8 %) were the most commonly eaten foods, while organ meats were the least (28, 8⋅0 %) food types eaten in 24 h meals. The mean IDDS was 3⋅86 ± 1⋅18, the median was 4 and a minimum of one and a maximum of eight types of food were eaten (Fig. 1).
Fig. 1. Bar graph showing food groups consumed in 24 h among HIV-positive adults (18–65 years old) attending ART clinics at FHCSH, Northwest Ethiopia, 2019 (n = 352).
The 24-h IDDS was classified into two, low and high DD, by considering the mean IDDS (3⋅86 ± 1⋅18) as a cut-off point. Two hundred and nine (59⋅4 %) study subjects comprised more than the mean food category (high DD).
Household food insecurity
Adults on ART response for household food insecurity items were computed; the overall magnitude of household food insecurity was 134 (38⋅1 %), and 218 (61⋅9 %) were food secure. One hundred and twenty-seven (36⋅1 %) were mildly food-insecure households, and seven (2⋅0 %) moderately food insecure. One hundred and thirty-six (38⋅6 %) participants were worried that their households would not have enough food. The frequency of each of the food insecurity items is presented in Table 4.
Table 4. Household food insecurity of HIV-positive adults (18–65 years old) attending ART clinics at FHCSH, Northwest Ethiopia, 2019 (n 352)
Factors associated with the level of DD
Candidate variables were fitted into a multivariable binary logistic regression model (forward stepwise method); eight variables were found to be predictors of DD of HIV-positive adults attending the ART clinic. These are mentioned as follows.
Employment status
Self-employed individuals were 4⋅60 times more likely to consume a highly diversified diet (AOR 4⋅60 (95 % CI: 1⋅72, 12⋅27)) than unemployed adults on ART.
Quintiles of wealth index
These were other predictors of individual DD; the second (AOR 4⋅33 (95 % CI: 1⋅72, 10⋅89)), middle (AOR 4⋅40 (95 % CI: 1⋅71, 11⋅31)), fourth (AOR 6⋅60 (95 % CI: 2⋅36, 18⋅48)) and in the highest quintile (AOR 9⋅45 (95 % CI: 3⋅34, 26⋅77)) were more likely to have a diversified diet than those individuals in the lowest quintile.
Last CD4 count (cell/mm3)
Subjects with CD4 count 200–349 cells/mm3 were 8⋅08 times more likely to diversify their food (AOR 8⋅08 (95 % CI: 2⋅93, 22⋅23)) than those below 200 cells/mm3.
ART regimen category
Individuals taking first-line ART regimen drugs were 4⋅49 times more likely to diversify their food (AOR 4⋅49 (95 % CI: 2⋅19, 9⋅21)) than those taking second-line ART regimen drugs.
Co-trimoxazole prophylaxis
Subjects who were not taking co-trimoxazole prophylaxis were 6⋅36 times more likely to diversify their food (AOR 6⋅36 (95 % CI: 2⋅54, 15⋅88)) than those who were taking co-trimoxazole.
Subjects who had nutritional counselling
Subjects who had nutritional counselling at a health institution were 2⋅36 times more likely to diversify their food (AOR 2⋅36 (95 % CI: 1⋅08, 5⋅16)) than those who had no nutritional counselling.
Having no food preferences
Adults who had no food preferences were 2⋅42 times more likely to diversify their food (AOR 2⋅42 (95 % CI: 1⋅14, 5⋅13)) than individuals having food preferences.
Household food insecurity
Subjects who had food-secure households were 3⋅51 times more likely to diversify their food (AOR 3⋅51 (95 % CI: 1⋅85, 6⋅67)) than their food-insecure counterparts (Table 5).
Table 5. Bi-variate and multivariable binary logistic regression analyses of variables with individual DD status among HIV-positive adults (18–65 years old) attending ART clinics at FHCSH, Northwest Ethiopia, 2019 (n = 352)
The forward stepwise elimination binary logistic regression model was run adjusting for the variables significant at P < 0⋅20 in the unadjusted model (bi-variate) which included variables shown in the table.
a The reference category is low DD.
Discussion
Nearly six in ten (59⋅4 %) study subjects had high DD (mean IDDS: 3⋅86 ± 1⋅18). This was similar to a study done in Kenya (62⋅7 %)(Reference Beatrice and Francis19). However, this number was higher than that in a study done in Metema hospital (41⋅2 %) and Motta Town Public Health Facilities (29⋅5 % participants consumed a diversified diet with mean IDDS: 3⋅2 ± 1⋅88)(Reference Tesfaw, Jara and Temesgen2) and lower than that in a study done at Hiwot Fana and Dilchora Hospitals (71⋅3 %)(Reference Weldegebreal, Digaffe and Mesfin11). This discrepancy might be due to variation in the data collection periods, i.e. in Motta and Metema, the data collection period was April to May, which was post-harvest time, and possibly food access will begin to decrease. However, data collection period for the Hiwot Fana & Dilchora Hospitals was November to February, which was harvesting time when there will be better food access. Moreover, the geographical location and feeding habit variation between Eastern (Hiwot Fana and Dilchora Hospitals) and northern Ethiopia may be a potential reason for the discrepancy in this study.
The present study showed that employment status had a significantly associated factor with DD. Self-employed adults (having their own work) on ART were more likely to have high DD than those unemployed. This finding was supported by a study done by Amare and his colleagues in Metema hospital(Reference Woldemariam, Yusuf and Beyen18) and Mukabana B. & Masika F. in Uasin Gishu District Hospital in Kenya(Reference Beatrice and Francis19).
Regarding the quintiles of wealth index, a statistically significant association was found between quintiles of wealth index and DD. From second to the highest quintile, there was an increase in the high DD compared with the lowest quintile. This can be credited to the fact that household assets have been used as a proxy indicator of the socio-economic status of a household that links the purchasing capacity of a variety of foods and diversified food. This was in line with the finding of the Metema hospital study(Reference Woldemariam, Yusuf and Beyen18). Besides, wealth was also mentioned as a factor for increasing DD in a study done in Tanzania(Reference Powell, Bezner Kerr and Young26), and households in the richest wealth quintile had the highest DD in Ghana(Reference Codjoe, Okutu and Abu27).
Another factor that was found to be associated with DD was the CD4 cell count. Subjects who had a CD4 cell count of 200–349 cells/mm3 had a better DD than those who had CD4 cell counts less than 200 cells/mm3. This was due to poor nutritional status (particularly micronutrients can lead to immunosuppression), advanced HIV clinical stage, or disturbance of the metabolic system and loss of appetite(Reference Sunguya, Ulenga and Siril28). This was similar to the study done in Uganda, which reveals that consumption of diversified diet was positively associated with higher CD4 cell count(Reference Venter, Gericke and Bekker29).
Moreover, adults who were taking first-line ART were four times more likely to diversify their diet compared with those who were on second-line ART. The possible reason would be that first-line ART drugs have less side effects such as lower gastrointestinal upset which will contribute to better appetite, feeding and DD(30).
This study showed that adults who were not taking co-trimoxazole prophylaxis were more likely to have high DD. The possible reason would be linked to co-trimoxazole-induced nausea and vomiting(Reference Meyer31), which potentially reduce appetite and thereby affect DD. This finding was in line with the Metam hospital study, which indicated that adults on co-trimoxazole were more likely to have low DD than those who did not take the drug(Reference Woldemariam, Yusuf and Beyen18).
Besides, those adult patients who had nutritional counselling at a health institution were found to have a diversified diet than adults who did not get nutritional counselling. The possible reason would be health education/information on nutrition possibly helps them to diversify their diet. This was in line with Addisu Tesfaw and his colleague's study in Motta(Reference Tesfaw, Jara and Temesgen2).
Food preference, the new variable added into this study, was a statistically significant predictor of DD among adults on ART. Adults who had no food preference were two times more likely to diversify compared with those who had food preferences for their meal. This would be because people who prefer food will eat selectively specific foods that influence food intake and finally end up with limited food variety and low DD. This finding was also supported by Jamie Hale and Eertmans's reviews on food likes and dislikes on human eating behaviour, which clarify that food preference has a notable contribution to make to individual food intake and change in dietary patterns(Reference Hale32,Reference Eertmans33) .
Moreover, household food insecurity was found to be a statistically significant determinant of DD among adults on ART. Adults from food-secure households were nearly four times more likely to have a highly diversified diet than their food-insecure counterparts. Dietary diversity is an indicator of food security as the inability of households to obtain access to enough food eminently enforce to have monotonous feeding habit which compromises DD. This was in line with a study done in Jimma, Ethiopia(Reference Tiyou, Belachew and Alemseged34) and in Nepal, a study done among lactating mothers(Reference Singh, Ghimire and Upadhayay35) that showed people with low DD tend to have food insecurity.
Limitation of the study
Some limitations should be considered while using the results of this study. Even though the study site gives ART service for clients coming from multiple places, the research conducted at a single site may have a limitation that may be attributed to a particular factor related to the institution. Hence, future researchers shall consider multiple sites in their studies.
Strength of the study
Data were collected on non-fasting days to avoid the possible effect of fasting on the DD of study participants. Additionally, new variables were added to the study.
Conclusion
In summary, this study finding revealed that DD was below two-thirds among adults attending the anti-retroviral treatment clinic. Moreover, self-employment status, quintiles of wealth index, last CD4 count, first-line ART regimen category, adults not taking co-trimoxazole prophylaxis, those having nutritional counselling at a health institution, the absence of food preferences and household food insecurity were found to be statistically significant factors for individual DD of adults taking ART. Therefore, the stakeholders concerned shall work to sustain patients’ treatment on first-line ART regimen category through different mechanisms like strictly adhering to the ART guidelines, strong counselling and regular support of people on ART to avoid defaulting or dropout from treatment and drug resistance.
Hospitals and health professionals working at the ART clinic shall strengthen their efforts to sustain the nutritional counselling service at the clinic through regular updating of the staff working there, adhering to the appropriate counselling methods by considering the background and situation of adults on ART and using different modalities like experience sharing among people on ART, and preparing model sites or simulation areas and educating them through these.
Health professionals working at the ART clinic shall encourage the patients to avoid food preference for their meals unless it is a cultural/religious taboo.
Government organisations and/or NGOs shall ensure household food security for adults on ART by providing food item support or creating job opportunities to those who are jobless.
Acknowledgments
We thank FHCSH ART Clinic staff, data collectors, study participants and the supervisor for their support for the successful data collection. We are also thankful to Bahir Dar University, Institute of Technology, Faculty of Chemical & Food Engineering, and the Department of Applied Human Nutrition for facilitating the research work.
H.A.S., G.T. and T.D.T. have actively participated in the study protocol design, acquisition of data, and analysis and interpretation of data. All authors read and approved the final version of the manuscript.
The datasets used and/or analysed during the present study are available from the corresponding author on reasonable request.
The authors declare that they have no conflicts of interest.
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