EFFECTS OF ANTIRETROVIRAL DRUGS ON NUTRITIONAL STATUS OF ADULT WHO HAVE BEEN ON DRUGS FOR 6-10 WEEKS AGED 18-50 YEARS

CASE STUDY: BWEYOGERERE HEALTH III

LIST OF ACRONYMS AND ABBREVIATION

AIDS                          Acquired Immunodeficiency Syndrome

ART                            Antiretroviral Therapy

ARV                           Antiretroviral

ATZ                            Zidovudine

BCM                           Body Cell Mass

BF                               Body Fat

CD4                            Cluster Designation four

CDC                           Centre for Disease Control and Prevention

DEXA                        Dual energy x-ray absorbometry

D4T                             Stavudine

EFV                            Efaviranz

FANTA                      Food and Nutrition Technical Assistance

FAO                            Food and Agricultural Organization

FM                              Fat Mass

HAART                      Highly Active Antiretroviral Therapy

HIV                             Human Immunodeficiency Virus

LBM                           Lean Body Mass

MOH                          Ministry of Health

MUAC                        Mid-upper Arm Circumference

NGO                           Non-governmental organization

NNRTIs                      Non Nucleolus Reverse Transcriptase Inhibitors

NRTIs                         Nucleolus Reverse Transcriptase Inhibitors

NVP                            Nevarapine

PEPFAR                    President’s Emergency Plan For AIDS Relief

PLHIV                       People living with HIV

PI                                Protease Inhibitors

SPSS                           Statistical Package for Social Sciences

TASO                         The AIDS Support Organization

UBOS                         Uganda Bureau of Statistics

UDHS                         Uganda Demographic and Health Survey

UHSBS                       Uganda HIV/AIDS Sero-Behavioural Survey

UNAIDS                    The Joint United Nations Programme on HIV/AIDS

UNWFP                     United Nations World Food Program

USAID                        United States Agency for International Development

UNSSCN                    United Nations system standing committee on Nutrition

WHO                          World Health Organization

3TC                             Lamivudine

ABSTRACT

The topic of the study is the effects of antiretroviral drugs on nutritional status of adult who have been on drugs for 6-10 weeks aged 18-50 years

This study was conducted at Bweyogerere health Centre iii and the purpose is toassess the effects of nutritional status of adults who have been on drugs for 6-10 weeks aged 18-50 years at Bweyogerere health Centre iii

The research objectives are to; effects of specific ARVs drugs on nutritional status of client for the period of 6-10 weeks, the relationship between dietary partners and ARVs on the nutritional status of the clients and the variation in anthropometric indices during the duration of 6-10 weeks on ARVS.

The study used both qualitative and quantitative techniques of data analysis, The researcher will use the above methods because many aspects will be covered in the study, Qualitative research method will be used because it collects information within a short time while quantitative will be through interview to cross check what has been given.

The study recommends that there is a need to introduce programs like physical exercise, nutrition education and counseling aiming at improving lean body mass and reduction of unnecessary body fat gain as well as abdominal obesity for the subjects who gain more body fat but less or not lean body mass.

All HIV patients who are starting HAART at Bweyogere health III should be advised on dietary management of nutrition related side effects in order to reduce problems that are common in the first few weeks of ARV treatment.

CHAPTER ONE

1.0 INTRODUCTION

This chapter presents the Background, problem statement, purpose, general objectives, specific objectives, research questions, Significance of the study, and scope of the study.

1.1 Back ground

The last two decades, HIV/AIDS has continued to spread across all continents causing the death of millions of adults in their prime age, disrupting and impoverishing families and turning millions of children into orphans, (UNAIDS, 2009).

HIV/AIDS affects the most productive segments of the populations, and the epidemic has thus tremendously reduced workforces and reversed many years of economic and social progress and has in some cases posed threat to political stability.

According to the Joint United Nations Programme on HIV/AIDS (UNAIDS, 2009), there were about 39.5 million people living with HIV by the end of 2006. Out of these, 37.2 million were adults and 2.3 million were children below the age of 15 years. There were 4.3 million new infections in 2006. In Sub-Saharan Africa about 2.8 million people were infected with HIV and 24.7 million people were living with HIV. Despite recent improved access to antiretroviral treatment (ART) and care in many of the world’s regions, the epidemic claimed 2.9 million lives in 2006.

Although efforts have beenput in place to fight HIV/AIDS in Uganda, about 1million people are leaving withHIV/AIDS (MOH and ORC Macro, 2006). According to Uganda HIV/AIDS serobehaviouralsurvey (2004-2005), the prevalence of HIV among adults (18-59 years ofage) was 6.7 % and the prevalence is higher in Kampala district about 8.5 % thanother districts. The high prevalence of HIV/AIDS in this most productive age hasgreat impact on health, economic and social aspects.

The advent of potent Anti-Retroviral Treatment (ART) in 1996 led to a revolution in thecare of patients with AIDS in the developed world.

Although this treatment is notcurative and also presents new challenges with respect to side effects and drug resistance,it has dramatically reduced rates of morbidity and mortality, have improved the qualityof life of people with HIV/AIDS and have revitalized communities (3) Moreover,HIV/AIDS is now perceived as a manageable chronic illness rather than as a plague.Unfortunately, most of the 39.5 million people currently living with HIV/AIDS reside indeveloping countries and do not share this improvement in prognosis, (UNAIDS, 2009).

Studies conducted before the widespread use of ART showed that wasting wasassociated with diminished survival rate (Kotleret al., 1989).

Analysis of a morecontemporary cohort of patients, many of whom were taking highly activeantiretroviral therapy (HAART) showed that wasting still occurs and remains animportant predictor of death (Wankeet al., 2002).

Most of body composition studies have been done in developed countries and it wasfound out there were changes in body composition among HIV positive individuals onHAART or and those not on HAART (Ottet al., 1993; Yelmokaset al., 2001;Shikumaet al., 2004).

Although there are data available from developed countriesindicating that HAART may result in changes in body composition, these changesalong with dietary pattern of HIV positive individuals initiating HAART are lackingin resource limited settings (Schwenk, 1999; Wanke, 2002).

Good nutrition along with continued monitoring of body composition changes andantiretroviral treatment are therefore vital for the well being of PLHIV. Basing on this background this study therefore intends to investigate into the effect of antiretroviral drugs on nutritional status of adult aged 18-50 years, with specific reference to Bweyogerere health III.

1.2 Problem Statement

The high increase in the availability of antiretroviral drugs among adults aged 18-50 years has a great impact on the nutritional status of people living with HIV/AIDS (PLHIV), (MOH and ORC Macro, 2006).

HIV infection increases energy requirements and affects nutrition through increasing energy expenditure, reductions in food intake, nutrient malabsorption and loss andcomplex metabolic alterations (Macallan, 1995; Babamento and Kotler, 1997).

The inadequate dietary intake among PLHIV to meet the increased demand for both energy and protein associated with HIV infection result in weight loss (Piwoz and Preble, 2000).

Hogg et al. (1998) and Castlemanet al. (2004) noted the role of antiretroviral therapy in the management of HIV and contribution to improved nutritional status; however, they mentioned that ART could create additional needs and dietary constraints which can contribute to weight change.

Despite of the fact that there has been a considerable rise in the number of people having access to Antiretroviral drugs among adults aged 18-50 years, most of PLHIV have been found to posses poor nutritional habits coupled with poor appetite, basing on this the study therefore intends to investigate in to the effects of antiretroviral drugs on nutritional status of adult aged 18-50 years at Bweyogerere Health III.

1.3 Objective of the Study

1.3.1 General objective

The study intended to assess the effects of nutritional status of adult who have been on drugs for 6-10 weeks aged 18-50 years at Bweyogerere Health III.

1.3.2 Specific Objectives

1. To establish the effect of specific ARVs drugs on nutritional status of client for the period of 6-10 weeks.
2. To establish the relationship between dietary partners and ARVs on the nutritional status of the clients.

• To determine the variation in anthropometric indices during the duration of 6-10 weeks on ARVS.

1.4 Research Questions

1. What are the effects of specific ARVs drugs on nutritional status of client for the period of 6-10 weeks?
2. What is the relationship between dietary partners and ARVs on the nutritional status of the clients?

• What are the variations in anthropometric indices during the duration of 6-10 weeks on ARVS?
  • Hypothesis

ARV drugs have an effect on nutritional status of client with in a period of 6-10 weeks.

There is no observable relationship between ARV drugs and nutritional status of the clients with a period of 6-10 weeks.

• Conceptual Frame Work

Antiretroviral drugs                         Nutritional status

The conceptual frame work demonstrated that the antiretroviral drugs and nutritional status have an effect on the CD4 count of the HIV positive people.

1.5 Scope of the study

The study scope covered the following aspects;

1.6.1 Study scope

The study scope covered, the effects of specific ARVs drugs on nutritional status of

client for the period of 6-10 weeks, the relationship between dietary partners and ARVs on the nutritional status of the clients and  the variations in anthropometric indices during the duration of 6-10 weeks on ARVS.

1.6.2 Geographical scope

The study was carried out at Bweyogerere health III.

1.6.3 Time scope

The period of data to be considered in the organization was from 2012-2015 and period of body of knowledge in reviewing literature was from 2000-2015.

1.7. Significance of the study

The will assist future researchers with information regarding the dietary patterns and nutrition related life styles of HIV positive adults aged 18-50 years during the first 6 and 10 weeks of ARV treatment.

The study will also enable future researchers with information regarding the nutritional related side effects arising from taking of antiretroviral Drugs.

The study will also enable the academicians with knowledge regarding nutrition status of adults aged 18-50 years.

Nutritional related side effects arising from taking of antiretroviral

1.8 justifications of the study

Due to the fact there is a global rise in the number of HIV/AIDS positive patients on antiretroviral drugs there is a need to carry out research on nutritional status of adult aged 18-50 years.

CHAPTER TWO

LITERATURE REVIEW

• Introduction

This chapter reviews literature related to effects of antiretroviral drugs on nutritional status of adult who have been on drugs for 6-10 weeks aged 18-50 years.

2.1 Effects of specific ARV drugs on nutrition status

ARVs interact with food and nutrition and result in positive and negative outcomes(Castlemanet al, 2004). Some positive effects of ARVs on dietary intake are intensehunger and craving for certain foods. This is because the body is starting to rebuilditself and needs the energy that comes from food (Alliance, 2007). On the other hand,the side the negative effects that arise from taking of ARVs include nausea, tastechanges, mouth ulceration, loss of appetite, abdominal pain, constipation, flatulence,headache, diarrhoea and vomiting which are common especially in the early stage oftreatment (FANTA, 2004; Hoffmann et al., 2006).

These problems lead to reducedfood intake or reduced nutrient absorption that exacerbates weight loss and nutritionalproblems experienced by PLHIV (Table 2.2). Moreover a study in the USA showedthat 30% of drug interruption in the first 90 days is attributed to nausea, vomiting, andother gastrointestinal effects of ARVs (Chen et al., 2003). This drug interruption canlead to health deterioration and risks of malnutrition in patients.

Source: National Antiretroviral Treatment and Care Guidelines for Adults and

Children (MOH, 2003).

Antiretrovirals (ARVs) are medicines used to treat HIV infection. They reduce theamount of HIV (the viral load) in the body, which protects the immune system andallows it to recover. ARV treatment is a lifelong treatment (Alliance, 2007).

According to a report by United States president’s emergency plan for AIDS relief,about 145,000 individuals were receiving ARVs by September 2008 (PEPFAR,2009).

HIV positive patients, who are eligible to start ART, start with the first lineregimens. A first line ART is an antiretroviral drug regimen that is recommended forpatients who have never been exposed to ARVs or those who were on treatment butstopped all drugs at once for more than three months (MOH, 2003). In initiating ofART a three drug combination should be used. This combination may contain two Nucleo Reverse Transcriptase Inhibitors (NRTIs) plus one Non Nucleo Reverse Transcriptase Inhibitors (NNRTI) or a Protease Inhibitors (PI) (MOH, 2003).

2.2 Relationships between Dietary Patterns and ARVS on nutritional status

Having proper nutrition in HIV/AIDS includes; consuming diversified or variety offoods that will provide the body with the necessary energy, protein, fats, vitamins andminerals (MOH, 2006). According to the Kenyan national guidelines on nutrition andHIV/AIDS (2006), dietary intake along with regular exercise, controlling weight,avoiding alcohol intake, smoking and other narcotic drugs are makeup nutritionrelated healthy life styles.

Dietary diversity, the consumption of an adequate variety of food groups, is an aspectof dietary quality and can be considered an indicator of general nutritional adequacy (Nontobekoet al., 2008). Low dietary diversity is associated with specific nutrient deficiencies. The main reason for promoting food diversification is that, no single food except breast milk contains all the nutrients the body needs in the right quantities and combinations (MOH, 2006). Another study by Bukusubaet al. (2007) noted that there is very low dietary diversity in developing countries, the majority of studied households reported consuming fewer than six food groups (low quality diet)moreover their daily diet was dominated by one main staple food group mainly cereals. According to FANTA (2004), maintaining adequate nutritional status means consuming a variety and adequate quantity of foods to meet energy, protein, and micronutrients needs. PLHIV should eat balanced and diverse diets consisting of starchy staples with cooked legumes, nuts and animal foods, fat and oil, fruits, and vegetables.

A study by Nontobekoet al (2008) showed that in South Africa, diets for PLHIV were significantly less diverse than those of HIV negative individuals. However a balanced diet will ensure that the individual consumes sufficient nutrients to maintain energy, normalize weight, and ensure the body’s proper functioning. The main types of food people need to live a healthy life include energy-providing foods (i.e.carbohydrates, fats), body-building foods (i.e., proteins, minerals), and protective foods (i.e., vitamins, minerals) (FANTA, 2004).

2.2 .1 Energy Giving Foods

This includes the carbohydrates, fats and oils that are in food groups like cereals, tubers, and plantain. Staples are good sources of energy. Staple foods should be the part of every meal and form the base and largest part of daily meals.

Cereals

Cereals are one of the staple foods in Africa and other parts of the world. Examples of cereals are maize, sorghum, millet, rice etc. Some cereals such as millet and sorghum contain some proteins and iron. However, they don’t contain adequate nutrients on their own. Nutrients from staple foods may not be available to the body unless eaten in combination with other foods (MOH, 2006b).

Tubers & Plantain

Tubers are known as good sources of energy. The most common tubers and roots that are consumed in Uganda are mattoke (plantain,) sweet potatoes, cassava, yams, are among others (MOH, 2006b).

Fats/Oils and Dairy products

Fats and oils are the richest sources of energy. One gram of fat provides twice the energy of one gram of carbohydrate. Therefore people only need small amount of fats because excessive consumption of fats may predispose individuals to obesity and heart disease. Vegetable oils are obtained from corn, simsim, sunflower, cotton seed, shear butter, palm oil and margarine. Animal source fats include butter, cheese, whole milk, fatty meat and fish (including fish oil) (MOH, 2006a). Fat also facilitate absorption and utilization of some essential vitamins such as A, E, D and K.

2.2.2 Body-Building Foods

Proteins are referred to as body-building foods. They are essential for cell growth, support the function and formation of the general structure of all tissues, including muscles, bones, teeth, skin and nails. The two main types of proteins are: plant source of proteins and animal source proteins. Plant source proteins include beans and peas of different varieties, green grams, groundnuts, soybeans and simsim. Whereas animal source proteins include meat, milk (including products like cheese, yoghurt and fermented milk), fish and eggs. Other sources of protein include nsenene(grasshoppers) and white ants. Williams et al. (2003) found that high protein diets areassociated with increased gain of Body cell mass among HIV positive persons.

Legumes

MOH (2006) recommends including legumes in everyday diet as frequently as possible. Legumes include beans, peas, lentils, groundnuts, and soybeans. Legumes provide nutrients that are needed to develop and repair the body as well as building strong muscles. As compared to animal products, legumes provide cheaper source of protein and energy. Legumes when eaten with staple foods such as maize, millet, sorghum and rice, improve quality the diet. Legumes are also rich in other essential nutrients including: the B vitamins, vitamin E, iron, and calcium.

Animal Products

Animal products supply good quality proteins, vitamins, minerals and extra energy.

Micronutrients in animal products include iron, vitamin A, selenium and zinc that strengthen muscles and immune system. Animal products include beef, chicken, fish, eggs, offal and milk (MOH, 2006b).

2.2.3 Protective Foods

Fruits and vegetables are known as protective foods because they provide vitamins and minerals that are important in strengthening the immune system. Vegetables and fruits are also major sources of fibre and roughage required for bowel movement and prevention of constipation (MOH, 2006a).

Vegetables

Vegetables add taste, flavour and colour to our meals. Common vegetables include:doodo, nnakati, malakwang, eboo, spinach, kale (sukumawiki), pumpkin leaves,cowpea leaves, carrots, cassava leaves, and green peppers. Cabbage is a vegetable thatis important mainly as roughage. Vegetables contain useful immune substances calledbeta-carotenes. In many cases, vegetables are seasonal in availability, quality andprices (MOH, 2006a). Kristy (2003) noted that HIV patients who consume of highfibre foods have shown lower fat deposition in their bodies.

Fruits

A variety of fruits grow in Uganda. The deep yellow or orange coloured fruits arericher in vitamins, particularly beta-carotenes and vitamin A. Such fruits includeavocadoes, mangoes, pawpaw, pumpkin, passion fruit, pineapple and jackfruit.

Oranges, lemons and other citrus fruits are rich sources of vitamin C. Like vegetables, most fruits in Uganda are seasonal (MOH, 2006a). Fruits are known as good sources of antioxidant substances (FANTA, 2004).

2.3 Variation in anthropometric indices during the duration of 6-10 weeks

It is important to understand what body compartments are in order to understand the changes in body composition. According to the fact sheet published by ROWETT Research Institute (2002), it was stated that; a healthy normal weight person has major component of water. Compared to water, the protein and fat components are small.

The remaining body compartments are the bones and minerals. The non-fat compartment of body composition is termed as fat free Mass (FFM) and exists primarily as the chief structural and functional component of the human body.

The FFM compartment consists (in proportions) of water (72%), protein (21%) and bone minerals (7%). Furthermore, FFM can be broken down to body cell mass (BCM) and extracellular tissue (ECT). Body cell mass is associated with survival and is primarily made up of muscles and organs, which process nutrients and medications.

While the ECT compartment is comprised of structure and transport (such as bone, collagen and fluids outside of the body cell mass). Phase angle is calculated and appears to reflect the ratio of body compartments (Zanetaet al., 2003). Components like proteins, body water and fat can be measured by a portable and user friendly machine called Bioelectric Impedance Analysis (BIA) machine while bone minerals can be measured by dual-energy x-ray absorpiometry (DEXA) (Wanke, 2002). Typically, an adult has around 2-4 kg of body weight only from bone.

The fat compartment of the body is termed fat mass (FM) and will vary considerably between individuals in terms of absolute amount. Fat mass consists of 20% water and80% adipose tissue however in obese persons; it could be the largest component of the body. Table 2.1 shows an obese man has almost twice the amount of adipose tissue on his body, compared to the lean man.

 Need for Assessment of body composition

In most HIV clinics in Kampala and Uganda at large, patients are weighed almost atevery visit however measuring weight alone can be a misleading indicator ofnutritional status because lean body mass is lost in preference to fat and in addition toit, there is no way to distinguish between body fat (BF), and lean body mass (LBM)when weight measurements alone are used (Wankeet al., 2002).

Serial weight measurements have been used by the Centers for Disease Control and Prevention (CDC) as a way to identify the wasting syndrome and predict the development of AIDS (Tamsin and et al., 2003). However, Kotleret al. (1989)showed that measurement of body weight alone failed to identify dramatic losses in body cell mass and other body composition parts. Thus, further measures of body composition are also needed, to identify losses or gains of lean body mass, body fat or body cell mass associated with increased mortality or/and nutrition intervention in patients with HIV (Tamsin, 2003).

Optimally, clinicians should try to prevent weight loss as well as treat it. Weight loss is often the first sign of a new AIDS-defining illness (Reiter, 1996). Patients should beweighed at every visit and their weight trends recorded on a graph. Because lean body mass is lost in preference to fat, weight alone can be a misleading indicator of nutritional status and clinical course (Reiter, 1996).

Methods of assessing of body composition in HIV/AIDS

Anthropometric measurements like skin fold thickness is the most widely used technique for estimating body fat and regional muscle mass. Using in-expensivecalibrated-controlled tension callipers and semi flexible tape measures, the techniqueis inexpensive and particularly handy for use in many field environments (Wankeetal.,2002). The validity of skinfold measurement is dependent on two assumptions.

First, subcutaneous adipose tissue thickness represents a constant proportion of totalbody fat. Second, skinfold sites selected for measurements reflect averagesubcutaneous adipose thickness (Ludyet al., 2005). Use of BMI in body compositionis also important because it measures person’s fat content, BMI is widely used toscreen for obesity. However, BMI can not differentiate, between lean and fat.

As11such, it is not able to distinguish between a body builder and an obese individual, (Wankeet al., 2002). Wankeet al also reported on the importance of MUAC in estimating of muscle mass that the measures of mid-upper arm circumference are correlated to measures of muscle mass. In general anthropometry is based on a two component model of body composition, and provides estimates of fat and fat-free mass only.

Bioelectric Impedance Analysis (BIA) has great potential for the use in estimatingbody composition. BIA measures the opposition of body tissues to the flow of a smallalternating current (Kotler, 1996). BIA is recommended in measurement of bodycomposition (ultimately lean body mass) in individuals and those with chronicconditions such as HIV infection (NIH, 1994). It is preferred because it’s rapid andeasy to perform. Portability of BIA machine also allows it to be used in a variety ofsettings including medical offices and hospitals (Wankeet al., 2002). Other bodycomposition assessment methods like Dual energy x-ray absorptiometry (DEXA),Isotope dilution methods, imaging techniques (CT and MRI) and total body potassiumcounting (TBK) in assessment of body composition.

CHAPTER THREE

METHODOLOGY

3.0 Introduction

This section presents the methodology which consists of the research design, area of study, study population, sample population and selection, sampling technique, data collection method, data quality control, data collection procedures and limitations of the study.

3.1 Research design

Qualitative and quantitative purposive, random, research designs were used. The researcher used the above methods because many aspects was covered in the study, Qualitative research method was used because it collects information within a short time while quantitative was through interview to cross check what has been given.

3.2       Study Area and population

The study was carried out in Bweyogerere health center III and the study involved a total population of 120, this consisted mainly of nurses, patients and clinicians.

3.3Sample Size, determination and sampling procedure

Mugenda and Mugenda (2003), argue that it is impossible to study the whole targeted population and therefore the researcher took a sample of the population. A sample is a subset of the population that comprises members selected from the population. Using Krejcie and Morgan’s (1970) table for sample size determination approach, a sample size of 92 respondents was selected from the total population of 120.

According to (Amin, 2005) sampling involves selecting a sample of the population in such a way that samples of the same size have equal chances of being selected.

The respondents were selected using purposive sampling techniques. Berg (2006) purposive sampling is where the researcher chooses the sample based on what they think would be appropriate for the study, According to Amin, (2003) A Purposive sampling technique was used because it’s cheap.

3.4Data type and source

The type of data was both primary and secondary, Primary data was obtained from the questionnaires administered on the target respondents to gain opinions and practices on the topic of the study. Secondary data is data which has been collected by individuals or agencies for purposes other than those of a particular research study. It is data developed for some purpose other than for helping to solve the research problem at hand (bell, 1997). This comprised of literature related to effects of antiretroviral drugs on nutritional status of adult aged 18-50 years in relation to the case study. Secondary data was sourced because it yields more accurate information than obtained through primary data, and it is also cheaper.

3.5 Data Collection Instruments

The major instrument for data collection was questionnaires. Surveys were just one part of a complete data collection and evaluation strategy. The major method of data collection for the study was the survey, which was done using selected instruments like questionnaires. The questionnaire provided respondents with ample time to comprehend the questions raised and hence, they were able to answer factually.

3.5.1 Questionnaires

The questionnaire was used to collect quantitative data. The researcher administered the questionnaires to respondents in different respondents, which was designed basing on study objectives and questions. Respondents read and wrote the questionnaires themselves. The questionnaires were close ended and were considered convenient because they were administered to the literate and its anonymous nature fetched unhindered responses.

3.6 Measurement of Variables

A five point Likert ordinal scales ranging from; strongly agree was assigned 5, strongly Agree, 4 agree, Not Sure assigned 3, Disagree allocated 2 and strongly disagree allotted 1 to obtain responses on the variables. The Likert ordinal scale has been used by numerous scholars who have conducted similar studies such as Bowling, (2007).

The structured questions were measured using the following variables;

The study has antiretroviral drugs as its independent variable and nutritional status as its dependent variable.

3.7Data collection procedures

Upon receiving the University permission to carry out research, the area of study was visited for purposes of familiarization.  The researcher sought permission from staff and once allowed to proceed with research, questionnaires were issued and interviews were carried out with the selected respondents.

3.8Quality control of data instruments

The instrument was taken to the supervisor to check its correctness there after pilot study was carried out to find out if it measured what it is meant for.

3.9 Data processing, presentation and analysis

The raw data was coded, edited, and arranged ready for analyzing only completed raw data was be analyzed using statistical packages like excel and SPSS.

3.10     Ethical Considerations

The researcher presented a letter of introduction, to the management of Bweyogerere Health centre III, when allowed he proceeded to administer the research instruments.  Consent letter was obtained from the respondents before they are engaged in the study.  This was after the study has been thoroughly explained to them and confidentiality was ensured that the investigation is purely for research purposes.

3.12 Anticipated Limitations of the study

The researcher faced the following challenges in the course of the study;

• Lack of enough time to interview all the respondents, but this was solved by budgeting for it appropriately.
• Language as other respondents felt comfortable expressing themselves in local languages like luganda.
• Lack of enough money to the respondents, this didn’t affect the study as the respondents were persuaded that the research is meant for academic purposes.

CHAPTER FOUR

RESULTS AND DISCUSSION

4.1 Findings on the sex of the respondents

Figure 1 indicating the sex of the respondents

Findings from table 4.1 above indicates that most of the respondents in  the study are female with a total of 53.26% this therefore shows that the female gender dominates the response rate at the Bweyogerere clinic while the male gender is only at 46.74%.

4.2 Findings on the gender of the respondents

Table 1: showing the gender of the respondents

The results in table 4.1 above indicates that most of the respondents were in the age categories of 30-39 years with a total population of 39.1%, while the second largest percentage of the respondents are in the age brackets of 18-29 who were 35.1% years however other respondents were in the age brackets of 40-50 years 22.8% .

4.3 Findings on educational level of the respondents

Figure 2 Showing the educational level of the respondents

Source: primary data

The results in figure 4.2 above indicates that most of the respondents/patients in Bweyogerere Health centre hold certificates as their highest level of qualification and 27% of the respondents hold secondary level education, 26% hold primary level of education and only 4% of the respondents are diploma holders.

4.4 Findings on Marital status of the respondents

Table 2:  showing the Marital status of the respondents

Source: primary data

The results in table 4.2 indicates that most of the patients on ARVS are married and their percentage is 45.7%, while 23.9% of the patients are single the results further indicate that few respondents are widowed and their percentage is 10.9% while 19.6% of the respondents are divorced.

4.5 Findings on the occupation status of the respondents

Figure 3 showing the occupation status of the respondents

Source: primary data

The results in the Figure 4.3 shows 33.7% of the respondents are involved in informal business, 29.3% of the respondents are unemployed and 22.8% are salaried employees while only 14% of the respondents depend on  in formal employment, this results further indicate that most of the respondents are poor unemployed.

4.6 Findings on the religion of the respondents

Table 3 showing the religion of the respondents

Source: primary data

The results in table 4.5 shows that 40.2% of  the respondents are Catholics, 28.3%  protestants, 10.9% Muslims, while 18.5% of the respondents  are Pentecostal, This findings further show that Catholics are the majority of the respondents.

4.7 Number of people on the patients’ house hold

Table 4 showing Number of people in the patients’ household

Source: Primary Data

The results in the figure above all indicates that 19.5% of the respondents have 2 households, 42.9%  have 3-4, while 14.3% have 5-6, 14.3% also have 7-8, 2.4%  have 9-10, 11 and above, 3%.

4.8 Findings on the source of income of the house hold

Table 5 showing the source of income of the house hold.

Source: primary data

The results in the study indicate that most of the respondents 33.3%  are involved in informal business, while 26.2% are salaried employees, while 11.9% were unemployed, 11.9% are formal business owner while the remaining 11.9% are involved in other business.

4.8 Findings on the source of food consumed by patients

Table 6 showing the source of food consumed by patients

Source: primary data

The findings in the study asserts that 90.5% of the respondents  buy food, 2.4% get food from their farm and 7.1% own farm and also buy food.

4.9 Findings on the duration the respondents knew about their HIV status

Table 7 showing the duration the respondents knew about their HIV status

Source: primary data

The results in the study indicates that most of the respondents

Majority of the study Subjects (62.0%) knew about their HIV status within the last two years, according to table 4.9, however 17.4% of the respondents knew their HIV status more than 5 years while 10.9% of the respondents knew their HIV status between 4-5 years and only 9.8% of the respondents knew their HIV status 2-3 years.

4.10 Findings on the ARV combination taken by the patients

Table 8 showing the different ARV combination taken by the patients

Source: primary data

The results in the study indicate that most of the respondents 51.1% in the study take ARV  combination of Zidovudine+Lamivudine+Nevirapine (ZDV+3TC+NVP) (Duovir-N), This could be due to availability of these drugs in the health centre they visit often, while 32% of the respondents take Tenofovir+Lamivudine+Efavirenz (TDF+3TC+EFV) while the rest of the respondents took the different combinations of  Stavudine+Lamuvidine+Nevirapine (d4T+3TC+NVP) (Triomune), Stavudine+Lamivudine+Evafrenz (d4T+3TC+EFZ).

4.11 Findings on the whether patients take drugs as required

Table 9 showing whether patients take drugs as required

Source: Primary Data

Findings from the study indicate that most of the respondents assert that they take their drugs as required this is shown by a high percentage of 82% of the respondents.

4.12 Findings on the how many drugs a patient takes in reality

Table 10 showing the drugs number of times the respondents take the drugs

Source: primary data

The results in the study indicates that 91.3% of the respondents take exact number of drugs while 8.7% take part of the drugs this shows that most of the respondents take exact number of drugs.

4.13 Findings on the number of times of taking drugs by the respondents

Table 11 showing the number of times taking drugs by respondents

Source: Primary Data

The findings in the study indicates that most of the respondents assert that they take drugs daily while only 4.3% of the respondents assert that every other day.

4.14 Side effects faced by patients after taking drugs

Table 12 showing side effects faced by patients after taking drugs

Source: primary data

Findings in the study indicates that 10.8% of the respondents have headache take a combination of Zidovudine+Lamivudine+Nevirapine (ZDV+3TC+NVP) (Duovir-N), 2.6% suffer from diarrhea take a combination of Stavudine+Lamivudine+ Evafrenz (d4T+3TC+EFZ), 5.8% suffer from Anoxeria (loss appetite), the results further show that patients who take a combination of Tenofovir+Lamivudine+Efavirenz (TDF+3TC+EFV) , 11.4% suffered from ANOXERIA, 11.4% had Nausea and vomiting, 8.5% experienced tastes changes, 8.5% abdominal pain, 5.8% constipation and 8.5% heart burn.

The findings in the study further shows that a combination of Tenofovir+Lamivudine+Nevrapine (TDF+3TC+NVP) had side effects of 2.6% of the respondents experiencing Anorexia and 2.6% Vomiting .

The findings in the study indicates that patients who take a drug combination of Zidovudine+Lamivudine+Nevirapine (ZDV+3TC+NVP) (Duovir-N), 10.8%  experience headache, 5.8% Anoxeria, 5.8% Nausea and vomiting, 5.8% Tastes changes and 2.6% faced mouth ulceration.

4.15 Findings on the weight of the respondents

Table 13 showing the weight of the respondents

Source: primary data

The results in the study indicates that 13.0% of the respondents had 46-50 kgs, 13.0 kgs were in the age bracket of 51-55 kgs, 56-60 kgs, 28.3% while 61-65 kgs 20.7%, patients with 66-70kgs were 16.3% and above 71 years there were 8.7%  of the respondents.

4.15 Findings on the Nutritional Status of the respondents

Table 14 showing Findings on the Nutritional Status of the respondents

Values are means and ± standard deviation

Values between males and females at p<0.05.

Fat

According to Table 14 the amount of consumption by females was at 47.3 ± 17.7gm while the male fat consumption in the tenth week was at 52.3±28.8gm while in the sixth week the fat consumption was at 19.6 ± 7.8gm and for the males was at 48.1±18.4gm for the females.

Protein

Table 14 indicates that the female protein intake is at 66.4±22.1 at the sixth week while for Men was at  74.4±31.1 in the sixth week  while during the tenth week the female had mean and  standard deviation of  50.9 ± 16.0 the men had  74.4±31.1.

Carbohydrate

The results in the Table 14 show that female mean and standard deviation are 370.8 ± 89.9 the results in the study further indicates that men mean and standard deviation of 384.3±90.9 , while during the tenth week the female mean and standard deviation was at 378.9±92.0

Micronutrients

Table 14 reveals that both females and males met the WHO requirements vitamin A intake in all contacts. The females had vitamin A intake of 2307.3±2812.1 μg, 1500.2±3193.3 μg and 1616.8±1820.7 μg at baseline, six weeks and ten weeks of treatment respectively.

4.16 Findings on changes in body mass index

4.16 Changes in Body mass index

There was a significant increase in body mass index all subjects from the baseline (22.7±4 kg/m2) to ten weeks of treatment (23.0±4.0 kg/m2; p=0.003) (Table 4.14). Unlike the males, female subjects showed significant increase in BMI (23.5±4.0 kg/m2; p=0.003) at the end of the study.

Table 15 Changes in BMI (Kg/m2) of HIV positive individuals after 6 and 10

Values are means and ± standard deviation

Values with * are statistically significant/different from the baseline at p<0.05

4. 17 Changes in Mid-Upper Arm Circumference (MUAC)

The results in Table 4.15 show that there was a significant increase in overall Mid-Upper Arm Circumference after six weeks (27.6±3.6cm; p=0.003) and at ten weeks (27.6±3.3cm; p=0.017) of treatment. The female subjects also showed a significant increase (27.9±3.6cm; p=0.009) in MUAC after six weeks of treatment, While the males did not show any significant increase in MUAC after six and ten weeks of treatment.

Table 4.18 Changes Mid-Upper Arm Circumference (cm) of HIV positive individuals after six and ten weeks of ART

Table 15 showing Mid-Upper Arm Circumference (cm) of HIV positive

Values are means and ± standard deviation                                                                                  ,   ,,
Values with * are statistically significant/different from the baseline at p<0.05. ‘ S’

CHAPTER FIVE

DISCUSSION OF RESULTS

This chapter discusses the results presented in chapter four in relation to the literature reviewed in Chapter Two, including the researcher’s views and additional findings.

5.1 Demographic Information

5.1.1 Age of the respondents

The results  in figure 1 in the indicates that most of the respondents in the study are female the study further shows that the female gender dominates the number of patients on ARVS this findings is also in line with MOH and ORC Marco (2006) which indicate the prevalence of HIV being higher among females than males. Similarly, Bukusuba et al. (2007) reported a majority of TASO Jinja beneficiaries were females, this high number of female response rate on females could be due to the fact that females go for HIV testing during their antenatal care and therefore they have high chances of having a high response rate in the study.

5.1.2 Age category of the respondents

The high proportion of study respondents in the age group 30-39 years old could be due to the fact that this age group is sexually active and therefore they have high chances of engaging in un protected sexual intercourse. This finding is also in correspondents with the findings of Macro, (2006) which identified that most of the people in the age group of 35-39 years are sexually active and therefore stand at a high risk of catching the virus.

5.1.3 Educational level of the respondents

This finding further show that HIV prevalence rate is high on people with low educational level, mostly certificate, secondary and primary educational level perhaps this could be because they don’t have information regarding the different ways of preventing the chances of acquiring HIV.

The poor level of education level among the respondents could be a barrier to access of knowledge on HIV prevention methods and awareness. In this study informal business was described as street vending, art, craft, market vending, food vending were among others while the unemployed ones did not have a stable income. This could possibly be due to the effect of HIV/AIDS on health of the patients and leading to absenteeism from job (Bukusuba et al. 2007).

5.1.4 Marital Status

The results in the study indicates that most of the respondents in the study asserted that they were married, this results show that there is high prevalence rate of HIV/AIDS on married people, this findings is also in line with macro, 2006 which asserts that there is high level of HIV infection among the married couple due to the fact they tend to have more than one sexual parterner.

5.1.5 Religion

The findings in the study further shows that most of the Catholics have been encouraged to test for their HIV status and therefore they were able to know about their status and start on ARVS.

5.1.6 Source of food consumed by patients

However the HIV/AIDS pandemic has increased the inability of affected households to put enough food on the table (Bukusuba et al. 2007). The very few subjects who responded that they don’t share food in the household could be due to the reduced productivity and increased medical costs for the PLHIV (Bukusuba et al. 2007).

5.2 Side effects faced by patients after taking drugs

The results in the study indicates that 5% had side effects of Anorexia (loss of appetite), Nausea and vomiting and taste changes while only 2.6% asserted that experienced mouth sores thi findings is also in line with International HIV/AIDS alliance (2007), which asserted that ARVs like Zidovudine, Combivir, Didanosine, Indinavir, and Nelfinavir are responsible for causing Nausea and vomiting, this is also further supported by findings of Meyer, 2003 who asserted that  multiple regimens may have effects such as gastrointestinal upset, diarrhoea, nausea, vomiting, malabsorption and anorexia that negatively affect the patient’s ability to eat adequate.

The results in the study further indicates that 10 (11.4%) of the respondents experienced Nausea and vomiting after taking a combination of Tenofovir+Lamivudine+Efavirenz (TDF+3TC+EFV), while 7 (8.5%) experienced tastes changes, 5 (5.8%) experienced Mouth ulceration (mouth sores) or thrush, 7 (8.5%) experienced abdominal pain, 5 (5.8%) of the respondents faced constipation, 5 (5.8%)  had side effects of Anorexia (loss of appetite) , due to a large percentage of the respondents experiencing Nausal vomiting this results further coincides with Castleman, (2004) who asserts that patients experiencing  nausea and vomiting are also advised to eat small quantities of food and frequently, limit intake of fluids with meals, avoid having an empty stomach, avoid laying down immediately after eating, rest between meals, The results in the study further indicates that 2.6% experienced diarrhoes and the same percentage faced headache.

Findings indicates that 2.6% experienced Nausea and vomiting and and same percentage faced taste changes after taking Tenofovir+Lamivudine+Nevrapine (TDF+3TC+NVP). Findings in table further indicates that majority of the patients in Bweyogere health centre III hospital take a combination of Tenofovir+Lamivudine+Efavirenz (TDF+3TC+EFV)

5.3 Findings on the weight of the respondents

The results from table above indicates that most of the respondents in the study are in the age brackets of 56-60 this represents that the patients are not underweight , this could be due to improved medical care , this results also further shows that ARVS  were working well ans therefore their health was improving despite of the effects of HIV /AIDS, this findings is also in line with Nabiryo et al. (2004)  who asserts that ARVS  improves on the quality of life of the patients apart from that  The lower number of underweight subjects found in this study was possibly due to improved medical care in terms of treatment and prevention of opportunistic infections at the centre and decreased HIV and AIDS stigma among PLHIV.

5.4 Findings on the weight of the respondents

The results from study indicates that most of the respondents in the study are in the age brackets of 56-60 this represents that the patients are not underweight , this could be due to improved medical care , this results also further shows that ARVS  were working well and therefore their health was improving despite of the effects of HIV /AIDS, this findings is also in line with Nabiryo et al. (2004)  who asserts that ARVS  improves on the quality of life of the patients apart from that  The lower number of underweight subjects found in this study was possibly due to improved medical care in terms of treatment and prevention of opportunistic infections at the centre and decreased HIV and AIDS stigma among PLHIV.

5.5 Findings on the Nutritional Status of the respondents

According to the study amount of consumption by females was at 47.3 ± 17.7gm while the male fat consumption in the tenth week was at 52.3±28.8gm while in the sixth week the fat consumption was at 19.6 ± 7.8gm and for the males was at 48.1±18.4gm for the females, WHO (2004) recommends for most adults, that oils and fat should supply at least 15% of their energy intake. Women of reproductive age should consume at least 20% their energy from fat. Therefore, based on the above recommendation it was calculated that the males require about 44.5 grams while the females require 53.3 grams of fat.

According to the WHO (2003) guidelines, there is no evidence that fat requirements are different during HIV infection. However, certain ARVs or certain infection symptoms such as diarrhoea may require changes in the timing or quantity of fat intake (FANTA, 2004). Although fats facilitate absorption and utilization of fat soluble vitamins such as A, E, K and D (MOH, 2006); their consumption should be limited due to the reason that excessive fat intake may predisposes individuals to obesity and obesity related complications.

Protein

According to the findings in the table above the results indicate that, female subjects had lower protein intake than the male subjects at all contacts however, both sexes met the daily recommended amount of protein intake. WHO (2003) suggest that proteins should contribute about 10-15% of the total caloric intake of individual, Adequate protein intake is important to maintain muscle mass and to regenerate liver cells in HIV positive people without cirrhosis. HIV positive people without cirrhosis may need up to two or three grams of protein per kilogram of body weight daily to regenerate liver cells (Fabris et al., 1988). Furthermore, adequate protein intake is also equally important for the gain of body cell mass (Williams, 2003).

Carbohydrate

Carbohydrate was the major energy source for the subjects throughout the study by contributing more than 55% of the total calorie that had been taken in 4.18. It is suggested that carbohydrates should contribute about 55-70% to the total caloric intake of an individual (WHO and FAO, 2003). Based on the above recommendation, the carbohydrate requirements of the subjects were calculated as 330 grams for females and 367 grams for males per day. Therefore the carbohydrate intake of both males and females was adequate. This is most likely due to the low dietary diversity among the participants which makes them to feed on some energy rich staple foods like tubers, plantains and cereals. Williams (2002) noted that carbohydrate intake was negatively associated with body cell mass. The reason for this is unclear although it is possible that patients whose diets include a greater proportion of carbohydrates consume a proportionally lower amount of protein (Bukusuba et al., 2007). Similarly, Williams et al. (2002) noted that greater protein intake is positively associated with BCM. Macallan et al. (1995) reported that poor dietary intake among HIV patients contributed to loss of lean mass or poor recovery among people with severe malnutrition.

Micronutrients

The study reveals that both females and males met the WHO requirements vitamin A intake in all contacts. The females had vitamin A intake of 2307.3±2812.1 μg, 1500.2±3193.3 μg and 1616.8±1820.7 μg at baseline, six weeks and ten weeks of treatment respectively. Meeting the requirements of Vitamin A is important for maintaining epithelial cells, mucous membranes and immune system function (Piwoz and Preble, 2000, Stepenson, 2001). On the other hand, long term consumption of vitamin A in excess of 10 times of RDA (25,000 IU/day) may cause side effects like nausea, headache, fatigue, loss of appetite, dizziness, dry skin, desquamation, cerebral edema and osteoporotic fracture (Penniston and Tanumihardjo, 2006). Although both males and females had almost the same intake of vitamin B1, the female subjects met their daily vitamin B1 requirements while the males only met 91.7%, 83.3% and 75.0% of the requirements at baseline, six weeks and ten weeks of treatment. The reason for not fulfilling the requirements is only that, males have higher vitamin B1 requirement than females (FAO/WHO, 1998). Both female and male subjects met their daily vitamin C requirements in all contacts. Meeting the requirements of Vitamin A especially in HIV patients helps the body to protect against opportunistic infections and also aids in recovery after infection (WHO and FAO, 2002).

4.16 Findings on changes in body mass index

4.16 Changes in Body mass index

There was a significant increase in body mass index all subjects from the baseline (22.7±4 kg/m2) to ten weeks of treatment (23.0±4.0 kg/m2; p=0.003) (Table 4.14). Unlike the males, female subjects showed significant increase in BMI (23.5±4.0 kg/m2; p=0.003) at the end of the study. The increase in BMI is most likely due to the effect of ART against immune suppression which leads to body recovery and weight gain among HIV positive individuals. The results are in agreement with the findings of Wanke et al. (1998) where majority of the HIV positive individuals treated with HAART showed an increase in BMI. Esposito et al. (2008) reported similar results in HIV patients, Body mass index tends to increase after initiation of HAART.

4.17 Findings on changes in body mass index

There was a significant increase in body mass index all subjects from the baseline (22.7±4 kg/m2) to ten weeks of treatment (23.0±4.0 kg/m2; p=0.003) (Table 4.14). Unlike the males, female subjects showed significant increase in BMI (23.5±4.0 kg/m2; p=0.003) at the end of the study.

4. 18 Changes in Mid-Upper Arm Circumference (MUAC)

The results show that there was a significant increase in overall Mid-Upper Arm Circumference after six weeks (27.6±3.6cm; p=0.003) and at ten weeks (27.6±3.3cm; p=0.017) of treatment. The female subjects also showed a significant increase (27.9±3.6cm; p=0.009) in MUAC after six weeks of treatment, While the males did not show any significant increase in MUAC after six and ten weeks of treatment. The significant change in MUAC shown in the female subjects could be showing females have good response towards HAART. A study in South Africa showed that HIV positive women showed a significant increase in mean MUAC after being treated with HAART for 24 weeks (Esposito, 2008). Therefore the increase in MUAC showed in the subjects was due to recovery and weight gain.

CHAPTER SIX

CONCLUSION AND RECONMENDATIONS

6.1 CONCLUSIONS

Antiretroviral treatment leads to an increase in overall weight, lean body mass, body fat and body cell mass in the first ten weeks of treatment. However the gain in the above body compartments could be in different proportions.

Most of the HIV positive patients who were on ARVS experienced an increase on body weight showing the ARVS had a good impact on the body.

Nutrition related side effects like headache, nausea/ vomiting and intense hunger are the most common among HIV patients starting ART.

Although patients starting antiretroviral treatment at Bweyogere meet their daily protein requirements, they had low energy intake and their dietary pattern was not constant during the first months of treatment this is shown by the fact their body weight was increasing showing a sign of the presence of balanced diet in their daily food.

6.2 Recommendations

There is a need to introduce programs like physical exercise, nutrition education and counseling aiming at improving lean body mass and reduction of unnecessary body fat gain as well as abdominal obesity for the subjects who gain more body fat but less or not lean body mass.

All HIV patients who are starting HAART at Bweyogere health III should be advised on dietary management of nutrition related side effects in order to reduce problems that are common in the first few weeks of ARV treatment.

6.3 Area of further research

Further studies should be carried out on the long-term impacts of ARVS on the body weight.

Further studies also should be carried out on the relationship be between body weight and HIV

Studies of large enough sample size to assess body composition and dietary pattern changes according to HAART regimen, clinical staging of HIV infection and other morbidity factors should be conducted that may help the development of widely applicable guidelines.

Further studies focusing on food security and socioeconomic status of the PLHIV on first line antiretroviral should examine the determinants of the fluctuations in micronutrient intake, and dietary patterns in general.

APPENDIX I: BUDGET ESTIMATES

APPENDIX II: TIME PLAN

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APPENDIX III: QUESTIONNAIRE

TOPIC: EFFECTS OF ANTIRETROVIRAL DRUGS ON NUTRITIONAL STATUS OF ADULT WHO HAVE BEEN ON DRUGS FOR 6-10 WEEKS AGED 18-50 YEARS

Dear respondent

I am KIBIRIGE GORDON a student of Kyambogo University, am carrying out a study on the above stated topic. You are one of the respondents randomly selected to participate in the study. The information given shall be treated with at most confidentiality and shall only be used strictly for academic purpose.

SECTION A:             GENERAL DATA

1. Sex: a) Male                  b)  female
2. Age a) 18 -29 b) 30 – 39                   c)  40 -50 years
3. Educational level
4. a) Certificate b) Diploma                      c) Degree         d) Masters and above
5. Marital status
6. a) Married
7. b) Single
8. c) Divorced
9. d) Widowed
10. Occupation
11. Unemployed
12. salaried
13. formal employment
14. Informal business
15. Religion
16. catholic
17. Protestant
18. Muslim
19. Pentecostal
20. others

SECTION B

1. Household information
2. How many people, including you, live in your household, (Including yourself)?
3. A) 2
4. B) 3-4
5. C) 5-6
6. D) 7-8
7. E) 9-10
8. F) 11 and above
9. Sources of income for the house hold (circle that applies)
10. A) Farming
11. B) Salaried employee
12. C) Formal business owner
13. D) Unemployed
14. E) Informal Business

F)Other

3. What is the source of food consumed in your household? (Circle that applies)
4. A) Buying.
5. B) Own farm
6. C) Own farm and Buying
7. D) Food aid
8. C) Others (specify)
9. Does every household member share food available in the house?
10. Yes B. No

SECTION C:General HIV status Drug administration, health services and Life style.

1. How long ago you knew you are HIV positive?
2. A) <2yr B) 2yr to 3 yrs

1. C) 4yrs to 5yrs D) more than 5yrs

1. E) Don’t know

2. CD4 count at starting of the treatment? _________

SECTION D: Effect of specific ARVS drugs on nutritional status of client for the period of 6-10 weeks

1. What type of ARV combination do you receive?
2. A) Zidovudine+ Lamivudine + Nevirapine (ZDV+3TC + NVP) (Duovir-N)

1. B) Stavudine + Lamuvidine + Nevirapine( d4T+3TC + NVP) (Triomune )

1. C) Stavidine +Lamivudine + Evafrenz (d4T+3TC + EFZ)

1. D) Tenofovir+Lamivudine+Efavirenz (TDF+3TC+EFV)

1. E) Tenofovir+Lamivudine+Nevrapine (TDF+3TC+NVP)

1. F) Zidovudine+ Lamivudine + Efavirenz (ZDV+3TC + EFZ)

1. G) Other combination _____________________
2. Do you take the drugs exactly as you expected to take them?

1. A) Yes B) No

3. How many do you take in reality?

1. A) Exact number B) Part of them

1. C) Over dose D) other (specify)

4. How often are you expected to take them?

1. A) Daily B) Every other day

1. C) Every week D) other specify

5. What strange feeling do you experience after taking the drugs or other medications?

10. Other specify;………………………………………………………………………….

SECTION E: Nutritional Status

Food frequency

Which foods do you normally eat and how often do you eat them.

SECTION: F

A 24 Hour Dietary Recall

Please name all foods and drinks that youconsumed starting from morning to evening yesterday including at night.

What amount of foods and drinks did you consume stating method of preparation?

*Description of ingredients: 01=Fresh; 02=Dried; 03=Tinned; 04=Frozen; 05=Bottled; 06=Others(specify).

**Method of preparation: 01=Eaten raw; 02=Boiled; 03=Steamed; 04=Roasted; 05=Deep fried;

06=Shallow fried; 07=Baked; 08=Mingled; 09=Others (specify).

***Description of indicative local measure: 01=Handful; 02=Cupful; 03=Spoonful; 04=Plateful;

05=Counts (eggs, slices); 06=1/2Cup; 07=1/2Plate; 08=others (specify).

SECTION: G ANTHROPOMETRIC INDICES DURING THE DURATION OF 6-10 WEEKS ON ARVS

Anthropometric Data Body Composition Measurement

Thank You