Relapse of undernutrition and food insecurity in a nutritional program in HIV care: mixed-methods study in Tigray region, Ethiopia.
Authors: Tesfay Fisaha Haile , Ziersch Anna , Javanparast Sara , Mwanri Lillian 
Published: January 2020

Abstract
Introduction Food insecurity is one of the major contributors to poor attainment of nutritional recovery among people living with HIV who are enrolled in nutritional programs. Food insecurity also significantly contributes to high rates of relapse after nutritional recovery among the beneficiaries nutritional programs. Nevertheless, nutritional programs in HIV care settings implemented in many countries are not designed to address food insecurity. This study examined a nutritional program delivered in HIV care settings in the Tigray region, Ethiopia. It explored the factors that contributed to relapse of undernutrition, and in particular how food insecurity had an impact on effectiveness of the nutritional program, specifically relapse of undernutrition after nutritional recovery. Methodology This study employed mixed-methods approach involving quantitative and qualitative methods. In the quantitative part, hospital records were collected of 1757 adults and 236 children people living with HIV who were enrolled in the nutritional program. Logistic and cox-regression analysis were used to examine the frequency and determinants of relapse of undernutrition. In the qualitative study, data was collected through in-depth interviews with 20 adults, 15 caregivers of children living with HIV, and 13 health providers and program managers. Thematic framework analysis was used to analyse the qualitative data. Results Among those who graduated from the nutritional program, 18% of adults and 7% of children relapsed to undernutrition. The mean time to relapse for adults was 68.5 months (95% CI, 67.0–69.9). It was not possible to calculate the average time to relapse in children because of the small sample size. Lower educational status (primary and secondary), no membership of a community HIV support group, ambulatory and bedridden functional status, longer periods on ART (more than 24 months), presence of an opportunistic infection and poor baseline nutritional status were associated with relapse of undernutrition. Furthermore, those from rural areas, who did not attend formal education, were employed, and had bedridden functional status, anemia and worst nutritional status were likely to have more frequent episodes of relapse than their counterparts. Findings of the qualitative study also highlighted that poverty, poor livelihood, and food insecurity were the fundamental challenges to the effectiveness of nutritional programs in HIV care. Household food insecurity contributed to the selling and sharing of the nutritional supports and negatively impacted the program effectiveness, delaying nutritional recovery and contributing to relapse of undernutrition. Conclusion and recommendation Unless nutritional programs take into consideration the underlying determinants of food insecurity in the design, implementation, and funding of nutritional programs in HIV care, the success of the nutritional programs like those implemented in Ethiopia will be undermined and the vicious cycle of undernutrition amongst people living with HIV will continue.