THE IMPACT OF ANTIRETROVIRAL THERAPY ON NUTRITIONAL STATUS AMONG ADOLESCENTS IN THE PEDIATRIC DAY CARE UNIT OF THE BAMENDA REGIONAL HOSPITAL, NWR, CAMEROON

ABSTRACT

For more than 30 years now, HIV/AIDS has been a major public health threat globally, including Cameroon. Antiretroviral therapy (ART) remains one of the most remarkable ways in the fight against HIV/AIDS. However, cases of higher mortality following ART initiation have been reported in resource limited settings. On the other hand, some studies have pointed out a high prevalence of malnutrition among HIV/AIDS patients on ART and few studies fom India suggests that ART may be a contributing factor to this high prevalence. Because of paucity of this information in Cameroon, the aim of the study was to investigate the impact of ART on the nutritional status of adolescents in the pediatric daycare unit of the Bamenda Regional Hospital (BRH). To achieve this, a hospital based cross-sectional study was carried out on subjects at BRH in which questionnaires were administered to collect socio-demographic information, feeding habits, ART information, and anthropometric measurements. Blood samples were collected and plasma prepared from which calcium, albumin, total cholesterol, HDL cholesterol, and triglycerides were quantified; and LDL cholesterol was calculated. Of the 133 participants, 52.63% (70/133) were males and 47.37% (63/133) were females. Most (91.73%) of the subjects were of the grassfield ethnicity. Side effects were reported in 32.33% of the participants with nausea as the most common. Overall 34.59% of participants had meals twice or less on daily basis and the prevalence of food insecurity stood at 63.16%. Overweight and obesity were found to be significantly higher in females, P=0.004. Hypoalbunemia was 6.01% (8/133) while hypocalcaemia was 7.52% (10/133), hypocalcaemia was 13.53% (18). The prevalence hypercholesterolemia was 12.78% (17/133), hypocholesterolemia was 21.05% (28/133), low HDL cholesterol was 18.79% (25/133), elevated LDL cholesterol was 33.08% (44/133), and elevated triglyceride was 12.78% (17/133). We found an association between nutritional status and ART line of treatment at p values of 0.011 for total cholesterol in females and 0.022 and 0.019 for LDL cholesterol in females and males respectively. Also, between nutritional status and duration ART at p values of 0.046 and 0.011 in males and females respectively. In conclusion, ART was found to have a significant negative influence on the nutritional status (biochemical parameters) of HIV/AIDS adolescents.

Key Words: Antiretroviral therapy, nutritional status, HIV/AIDS, adolescents

CHAPTER ONE

INTRODUCTION

1.1.  Background of the study

The Human Immunodeficiency Virus (HIV) has been a major public health concern globally, including Cameroon (Bradley et al., 2014).  HIV is a virus that attacks the body’s immune system, specifically the white blood cells called CD4⁺ T-cells. HIV destroys these CD4⁺ T-cells, weakening a person’s immunity against infections such as tuberculosis, and some cancers. If the person’s CD4⁺ cell count falls below 200 cell/ ul, the immunity is severely compromised, leaving them more susceptible to infections (WHO, 2020). Infection with HIV, if untreated, leads to acquired immunodeficiency syndrome (AIDS) and premature death. However, a continuum of services including HIV testing, HIV medical care, and antiretroviral therapy (ART) can lead to viral suppression, increase in CD4⁺ T-cell count and survival of persons infected with HIV (PIHIV), and prevention of HIV transmission (Bradley et al., 2014). With advances in antiretroviral therapy, most deaths in people with HIV are now attributable to non-communicable illnesses, especially cardiovascular diseases (Shah et al., 2018).

The high rates of early mortality (death within 3 months) after ART initiation in resource-limited settings has been well documented (Filteau et al., 2015). As a matter of fact, up to 17% of adults die in the first year after ART initiation (Bisson et al., 2017; Agbor et al., 2021). In a review study by Ahmed and Lemma (2019). the overall proportion of deaths among pediatric patients on ART across all cohorts ranged between 2.0% in Ethiopia to 21.0% in South Africa. In another systematic review conducted in low and medium-income countries (LMICs) reported a higher proportion of mortality, ranging from 0.0% in Botswana to 26.0% in Mozambique (Ahmed and Lemma, 2019) According to available literature, the last decade has seen great advances in expanding access to antiretroviral therapy (ART) for HIV-infected Africans (Filteau et al., 2015). Thanks to these efforts many more HIV-infected people in low and middle-income countries are now receiving ART. One of such example is Cameroon where the number of HIV-infected subjects receiving ART increased from 28,000 in 1998 to about 200,000 in 2013 (Fonsah et al., 2017). Cameroon has endorsed the UNAIDS strategic 90–90-90 targets: 90% of HIV-infected children and adolescents know their status, 90% of HIV-infected children who know their status are receiving ART and 90% of ART-experienced children have viral suppression (Penda et al., 2018) with a national prevalence standing at 3.7% (Agbor  et al., 2021). Mortality rates in the HIV-infected patient populations have decreased with the advent of highly active antiretroviral therapy (HAART) for the treatment of AIDS (Leonard et al., 2003; Oumer et al., 2019). However, nutrition-related complications remain a challenging issue for HIV-infected patients and for those involved in their care. Involuntary weight loss is associated with disease progression and death, even where access to HAART is not limited (Mangili et al., 2006). 

Food has always been a critical need for the survival of the human species, and in order to improve child survival, promote healthy growth and development, contribute to better cognitive and economic development, good nutrition is required. Nutrition forms the foundation for human health and development across all stages of the life course (Akseer et al., 2017). Although food is essential, it has often been lacking, from the qualitative and quantitative point of view resulting in the occurrence of malnutrition (Nolla et al., 2014). Malnutrition contributes to more than half of deaths in children worldwide, although it is rarely listed as the direct cause, Malnutrition literally means “bad nutrition” and technically includes both over- and under- nutrition (Bain et al., 2013). Nutritional imbalance is a major challenge for living organisms to achieve systemic homeostasis and maintain normal physiology (Alwarawrah et al., 2018). Nutritional status assessment provides the data necessary to study the effects of nutrition on health and disease, to identify critical nutrients in a specific population and the groups within this collective (Elmadfa et al., 2014). Micronutrients are vitamins and minerals needed by the body in very small amounts. However, their impact on a body’s health is critical, and deficiency in any of them can cause severe and even life-threatening conditions (WHO, 2020). Of the 38 million individuals living with HIV/AIDS worldwide, 70% of them live in sub-Saharan Africa (Jacobi et al., 2020), where malnutrition has a high prevalence (Popkin et al., 2020).

1.2. Problem statement

The youths are much more prone to HIV infection as well as other sexually transmitted infections as a result of a lack of correct health information, engagement in risky behaviors, economic exploitation, regional and national conflicts and a lack of access to adequate reproductive health services (Nubed et al., 2016). Worldwide, an estimated number of two million adolescents are living with HIV, with over 80% of them residing in sub-Saharan Africa (SSA)  (Laurenzi et al., 2020). Since the year 2000, over 25 million people have died from HIV/AIDS, mostly in SSA (Fonsah et al. 2017). Statistics from the Bamenda Regional Hospital indicate that the number of HIV-infected children and adolescents increased from 303 in 2018 through 400 in 2020 to 517 in 2021.

Nutritional status is one of the factors that significantly affects the effectiveness of ART, survival status and quality of life among people living with HIV (PLHIV). Recent studies done in Ethiopia revealed that malnutrition is highly prevalent among people living with HIV and who are on ART (Weldehaweria et al., 2017). Patients who are on treatment are supposed to be getting better, but rather high rates of early mortality (death within 3 months) after ART initiation in resource-limited settings have been well documented (Liu, et al., 2011; Mwiru et al., 2015). Thus, patients are at a higher risk of death after ART initiation, but the risk factors for death in these patients are unclear (Mwiru et al., 2015 and Bisson et al., 2017). Previous studies of HIV+ subjects on ART in Cameroon showed high rates of non-adherence, treatment interruption, and loss of follow-up (Fonsah et al. 2017). Also, specific antiretrovirals used in the management of HIV and chronic HIV-associated immune activation have been associated with alterations in vitamin D levels (Hileman et al., 2016). Studies carried out in the central zone of Tigray in Northern Ethiopia (Weldehaweria et al.,2017), have revealed that there is a high prevalence of malnutrition among persons living with HIV and are on ART, and few studies from India suggests that ART maybe a contributing factor to this high prevalence of malnutrition among HIV patients on ART and hence the high mortality rates. Information on such studies is lacking in Cameroon and the Northwest Region in particular. Because of this paucity of information, there is need for this study in order to have an improved understanding of the relationship between ART and nutritional status among adolescents in the Northwest Region which may help in the development of strategies to reduce/curb mortality after ART initiation.

1.3. Research questions

1. What is the nutritional status of adolescents receiving ART at the BRH?
2. Does the ART line of treatment have an impact on the nutritional status of adolescent at the BRH?
3. Does the duration of ART have an impact on the nutritional status of adolescent at the BRH?

1.4. Objectives

I.4.1. General Objective

To assess the impact of ART on the nutritional status of adolescent HIV/AIDS patients at the Bamenda Regional Hospital.

I.4.2. Specific objectives

• To assess the general nutritional status of adolescents receiving ART at the BRH
• To assess the relationship between nutritional status and the specific ART lines used for treatment of adolescents
• To evaluate the relationship between the duration on ART and the nutritional status of the adolescents