Literature review
Only a few studies have been carried out to determine the associated factors with the outcome of malnutrition and recovery time in adult HIV patients. As the researcher searched, there is no published literature on the time to nutritional recovery from malnutrition in adult HIV patients in Ethiopia.
2.1.1 Median recovery time
Few researchers struggled to determine the median time recovery from malnutrition in HIV patients in their recent study.
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A study on Descriptive characteristics and health outcomes of supplementation in HIV patients was done to determine time to recovery from malnutrition and associated factors in Kenya. According to this study, patients gained greater than 20 BMI with a mean time of 100 days(26).
A retrospective cohort study in Kenya and Uganda also shows that Cured patients were discharged from the Nutritional supplementation Program after a median of 3.7 months (IQR 2.2-6.1)(21).
Similarly, a retrospective cohort study done in Ethiopia in a finite Selam hospital also determined the median time to recover from malnutrition. According to this study, participants had a median recovery time of 12 weeks (IQR 9-17 weeks) for moderate acute malnutrition and 25 weeks (IQR 22-31 weeks) for severe acute malnutrition(27).
Another study in Ethiopia concluded that patients who participated in the study recovered after a median time of 68 days (for moderate malnutrition) and 128 days for severe malnutrition(28).
2.1.2 Outcome of malnutrition in adult Hiv Patients
Reducing or eliminating malnutrition has the potential to significantly slow the progression of the disease, decrease its severity, and improve longevity. Early identification and treatment of undernutrition were found to be cost-effective. Additionally, patients who recovered through the addition of supplementary food experienced long-lasting positive effects on their health and nutrition status(28). In order to know the outcome of malnutrition in HIV patients after baseline diagnosis some scholar tried their best.
A study done in sub-Saharan Africa raveled that out of the 1106 patients admitted into the NP and discharged, 524 (47.4%) were considered cured according to the predefined NP exit Criterion (program success). From participants 149 (13.5%) discharged uncured, 250 (22.6%) defaulted from NP care, 132 (11.9%) died, 26 (2.4%) transferred to another programme, and 25 (2.3%) stopped RUTF due to treatment intolerance. The overall program failure rate was 48.0% (531 of 1106); if patients who transferred to another program or who stopped NP were also considered, the program failure rate was 52.6% (582 of 1106(21).
Similarly, a study done in Kenya suggested that 13.1% of clients attained a BMI of greater than 20 according to the criteria for discharge in Kenya. But 22.2% of participants gained a BMI of greater than 18.5 Participants gained an average weight of 2 kg(26).
A randomized control trial study was performed in Senegal in HIV patients in 2016. In this study, one group (case) was supplemented with 100 gm RUTF, and the control group with no supplementation. A study shows that a group with supplementation with 100 gm of RUTF for 3 months was significantly increased body weight; fat-free mass and fat mass(29).
A study done in Ethiopia in partnership with Tift`s University and save children suggested that 84.3% of participants were increased BMI among the intervention group, compared to 54.2% in the comparison group(28).
In Ethiopia in finite Selam hospital a retrospective cohort, the study was done in 2020 and revealed that 61.2% of malnourished patients recovered. An overall total of 146 of 376 (38.8%) patients did not recover from undernutrition, 58 (15.4%) of whom died(27).
In addition, another retrospective cohort study done in north Tigray in 2014 reported that 62.2% of patients enrolled in to ready to use therapeutic food recovered. According to the predefined RUTF exit criterion, 31 (5.9%) defaulted from the food therapy and 10 (1.9%) died(25).
A cross-sectional study done in Gonder in 2015 also shows the outcome of malnutrition in patients. According to this study, 24% of participants in the study were recovered from malnutrition from all participating patients in the study(30).
Another cross-sectional study on the retention and outcome of nutrition programs in HIV patients was done in Gonder Ethiopia in 2016. This study concluded that 44.2% of the patient`s recovered from malnutrition. The overall default cases were found to be 24.8 %(31).
A case-control study in Amara regional state in Ethiopia shows that around 40.6% of participant's body mass index was improved( greater than 18.5)(32).
2.1.3 Associated factors of nutritional recovery
Different scholars in different countries including Ethiopia tried to examine predictors of recovery from malnutrition in adult HIV patients. Even though, they have found different associations; socio-demographic variables, the type of malnutrition, comorbid diseases, ART adherence level, WHO clinical stage, and type of facility were considered as associated factors in nutritional recovery(21,26,27,30,33).
2.1.3.1 Socio-demographic factors
Some studies have been done to determine the association between nutritional recovery and socio-demographic factors.
A retrospective cohort study done in sub-Saharan countries suggested that age and gender were the only significantly associated variables. Being female increased nutritional recovery by 57% when we compared to males. Also, the study concluded that as age increases nutritional recovery decreases(21).
Another retrospective cohort study done in Kenya in 2014 concluded that those younger ages had a greater chance of achieving of BMI greater than 20. Sex is also one of the associated factors for gaining a normal BMI after treatment and men`s had a higher chance of gaining a normal BMI compared to females(26).
A study done in north Ethiopia in Tigray revealed that sex and education was significantly associated with the outcome of undernutrition in HIV patients. Females were 2 times higher to recover than males following ready-to-use therapeutic food. Patients who were educated were 1.8 times higher to respond to therapeutic food than that illiterate one (25).
Sex was associated with recovery in HIV patients in a study done in Ethiopia. According to the study, females were 1.5 times more likely than males to recover(28).
Another retrospective study in finite Selam suggested that residence and educational status were independent factors for nutritional recovery for this study. Based on the finding it was found that participants with rural residences had a 47% lower probability of recovery when compared with urban. Also having an educational background increases recovery from malnutrition by 76%(27).
A study in northwest Ethiopia shows that males have a better chance of BMI improvement than females. The odds of BMI improvement of males is nearly 2 times as compared with the chance of BMI improvement of females(32).
A case-control study in Gonder hospital revealed that from participants in the study males were 1.58 times more likely not to recover than females. Another cross-sectional study in this area suggested that age was significantly associated with the outcome of malnutrition in HIV patients. According to the study as age increases, it`s difficult to recover from malnutrition so recovery decreases(30).
2.1.3.2 Type of malnutrition and nutritional recovery
Studies show, as there is a significant association between the type of malnutrition and recovery from malnutrition. Moderate malnutrition and severe malnutrition have different median times besides of proportion of the patient recovery.
For instance, a longitudinal study in a sub-Saharan country revealed that the type of malnutrition was significantly associated with recovery from malnutrition in HIV patients. According to this study, those patients who were severely malnourished patients had 2.2 times less likely to recover when compared to moderately malnourished HIV patients(21).
A retrospective cohort study in North West Ethiopia in 2014 suggested that patients with moderate malnutrition have a better chance of 7 times more to recover from malnutrition than that of severely malnourished patients(32).
In a study was done in Gonder northern Ethiopia, types of, malnutrition at baseline was associated with the outcome of treatment in HIV patients. This study revealed that those participants who are moderately malnourished at baseline were 4 times higher for recovery as compared with those severely malnourished(30).
Types of malnutrition are also predictors in case-control studies in Ethiopia in 2019. According to the study, those who were diagnosed to have SAM at baseline were 4.5 times more likely not to respond to therapeutic food than patients who had a diagnosis of mild malnutrition(34).
A cross-sectional study in Gonder shows that types of malnutrition was significantly associated with the outcome of malnutrition in HIV patients. This study concluded that those patients with SAM has 0.2 less likely to recover from malnutrition compared to those patients with MAM(30).
However, a retrospective cohort study on nutritional recovery and associated factors in adult malnourished HIV patients concluded that types of malnutrition was not associated with recovery from malnutrition(27).
2.1.3.3 Who staging and recovery
Advanced disease in HIV has an association with the outcome of malnutrition in HIV patients. Some studies show this in their findings.WHO staging is significantly associated in some research, which can affect the time to recovery and proportion of recovery from malnutrition in patients living with HIV.
Some study shows evidence of an association between who staging and recovery. For instance, a study done in Ethiopia in finite selam suggested that the probability of nutritional recovery was 62% lower for participants who were WHO clinical stage III or IV at baseline as compared with those who were stage I or II(27).
Also, a case-control study in Gonder suggested that WHO staging were significantly associated with nutritional recovery. So this study revealed that those patients who were in who clinical stage 3 were 3.63 times less likely to not recover from malnutrition when compared to another clinical staging(34).
However, a cross-sectional study on the outcome of treatment in Gonder hospital did not show any association between who staging and nutritional recovery(30).
A retrospective cohort study in Mekelle found that an association between WHO clinical staging and recovery. Participants who were in WHO clinical stage 1 and 2 had four times more likely to recover than patients in WHO stage 3 and 4(25).
2.1.3.4 OTHER clinical-related factors and nutritional recovery
Some clinical-related factors are significantly associated with nutritional recovery in some studies. Even though different factors were associated with recovery in different studies but adherence, CD4 count, and co-morbid conditions like pneumonia, diarrhea, and mouth ulcer were significantly associated with the outcome.
A case-control study in Ethiopia concluded that those patients who adhered to supplementation were 11 times more likely to achieve normal BMI. Also, this study suggested that patients with good adherence to ART had 2 times more chance to regain normal BMI when compared to poor adherence(34).
Another retrospective cohort study in Ethiopia concluded that the probability of nutritional recovery was 86% lower for participants who had poor ART adherence compared with those who had a good adherence level (27).
A case-control study in Gonder suggested that those who had a CD4 count below 100 were 2.3 times less likely to recover than that had a CD4 count above 350(34).
Similarly, another cross-sectional study was done in Gonder concluded that participants who had opportunistic infections like diarrhea, mouth ulceroral thrush, pneumonia, meningitis and CNS toxoplasmosis were less likely to recover as compared with those who are severely malnourished at entry(30).
A study done in Ethiopia suggested that ART status at baseline was significantly associated with recovery from malnutrition. This study concluded that participants who were on ART for less than six months at baseline were 2 times more likely to recover than those who were not on ART at baseline. While there was no significant difference in the likelihood of recovery between those who were on ART for more than six months and those who were not on ART. This study also revealed that a CD4 count between 200 and 350 at baseline was associated with an increased likelihood of recovery 1.7 times compared to a CD4 count of less than 200. There was no significant difference in the recovery of CD4 between those with CD4 counts above 350 versus those with CD4 counts less than 200(28)
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