An Empirical Analysis of Nutritional Regimes and Associated Aspects Among Prisoners Living with HIV/AIDS in Agip Prison, Asmara, Eritrea
Corresponding author:Dr. Osborne E. Nyandiva, Département of Pathology, St Francis University college of Health and Allied Science TZ. Tel: +255624523283 ; Email: firstname.lastname@example.org
A prison is luminously regarded as an institution that holds people who have been remanded or sentenced to a period of imprisonment by the federal courts for offences that are against the law. In some occasion, a prisoner who is also known as inmate or detainee, is an individual deprived of liberty against his or her will and therefore has no control over their surroundings as a result of their charges.
Proundingly, the inmates are not deprived freedom rights and thus they usually depend on prison diet. It’s for this reason that they don’t have any say on the quality and quantity of meals they are fed on consumed .
The reports of HIV/AIDS in prisons have been published more than 25 years ago thus issuing alarm on how the condition of the inmates in the prison are. The findings in these reports indicates that prison health issue has been the most highly researched worldwide because there have high cases of motilities reported no clear medical information is available. The researches on prison populations in many nations have consistently indicated that the rates of HIV infections in remands and prisons exceeds that of the general population in the countries. Most of the time it is sighted that access to medications in prison settings is usually low therefore it does not equate to the services that are in provisional by the wider societies. Most of the people living with HIV/AIDS are the victims of incarceration probably because the conditions of their health they are in especially those on ART medication. The majority of the inmates’ faces the health risks due to treatment adherence inabilities that proves challenging in lieu of food shortage and scarcity .
From various documentations, it is plural agreed that there is convincing relationship between the HIV epidemic and malnutrition especially amongst People Living with HIV since they are more likely to become malnourished following reduced food intakes, medication side effects, depression, and malabsorption of nutrients. For this reason, the inmates have been subjected to HIV-caused intestinal cell damage, elevated energy needs due to virus replication and the adverse of opportunistic infections. All these have physiologically changed the way the body uses the nutrients received or stored. The effects of Malnutrition have as well contributed to compromising of immune system leading to its impairment thus making the body vulnerable to frequent sickness. This has in return effected the acceleration of disease progression . Much more, it is felt that appropriate nutrition can increasingly contribute to the improvement on ART absorption and tolerance to the HIV/AIDS. In actual sense, the quality of life for People Living with HIV/AIDS improves once all the stated measures are put in place and strictly followed .
Materials and Methods
Study design and period
The study initiated an institutional based cross-sectional quantitative design for research in Agip prison, Asmara, Eritrea which helped in assessing the nutritional regimes and associated aspects among the inmates living with HIV/AIDS, from October to November, 2015.
The Agip government prison, is a state police-run prison centre away from others which are military guarded in Eritrea. This prison is located in Asmara, sub city of Adi Keith about 30 km from Asmara town. It is located on the East South edge of the city and serves as one of the main prison in the federated country. The prison is divided into male and female zones which in total they make up 4,000 prisoners. The male inmates are about 3,400 while 600 are females. Close to 550 prisoners were living with HIV/AIDS and 300 prisoners were on pre ART while 250 were on ART. The institution runs its own clinic which has various section including ART clinic, TB clinic, inpatient and outpatient departments, laboratory and pharmacy in one roofing. Some well-trained medical health personnel has been mandated to supervise the ART clinic and is supported by a data clerk.
The Source Population
All the inmates aged above 18 years and living with HIV/AIDS in Agip Prison were recruited during the study period.
The study population
The inmates who were above 18 years living with HIV/AIDS and were randomly selected in Agip Prison during the study period.
The inmates above 18 years old, living with HIV/AIDS, both pre ART and ART were engaged as participants as well as those who had stayed in the prison for at least six months were also included in the study.
The Inmates who were seriously sick were not allowed to participate. Also the inmates who had incomplete medical information were in registration records were excluded e.g CD4 cell count, WHO clinical stage, adherence status.
Sample size determination and sampling procedure
Sample size for the first objective:
The following calculation were done using the formula for the estimation of single population proportion:
n=sample size required in the study
Z=95% confidence level (1.96)
P= (malnutrition among prisoners living with HIV/AIDS or the whole prisoners 50%)
d2=margin of error (5%) =384
By considering a non-response rate of 10%, the sample size was 422
The researcher was able to ascertain HIV status of the inmates from their archived medical chart s and reports available at inmates’ card room. The total numbers of inmates living with HIV/AIDS in Agip Government prison was approximately 550 of which 300 were on ART and 250 were on Pre- ART. A stratified random sampling technique was employed in order to select 422 participants from on ART and Pre-ART proportionately and therefore mathematical equation was generated.
Where n1: is the required sample size from ART clients,
N1: is total number of clients on ART,
nf is the sample size of this study,
Nf is total number of prisoners living with HIV/AIDS in Kality prison,
Where n2 is the required sample size from Pre- ART clients and
N2 is total number of Pre-ART clients,
The researcher used systematic random sampling technique. The first subject was selected after having a complete serial number list gotten from ART registration book (k=N/n=550/422=1.3). The first subject was selected by sampling. The other subject was selected serially until the total number required was achieved. The repeated visits were excluded using codes, recordings and checking their registered numbers of client during data collection time.
Variables of the study
- Dependent variable:The dependent variable was nutritional regimes of inmates living with HIV/AIDS measured by Body Mass Index.
- Independent variables:
- Socio-demographic characteristics:Sex, age, educational status, marital status, Availability of social amenities.
- Medical and other related factors:The presence of eating difficulty, classical eating difficulty, adherence to ART, CD4 cell-count, Clinical progression stage.
- HIV treatment related factors:The Pre ART, ART in use, ART usage duration, ART currently in use, change of course of ART, reasons for changing course of ART and medication side effects.
- Prison related factors:The duration of prison stays and sources of water.
- Meal frequency:The frequency of energy source, proteins, vitamins and minerals utility.
- Operational definition
- Nutritional status:The nutritional regime is the condition of an individual measured by Body Mass Index (BMI).
- BMI: Body Mass index is the ratio of weight for height squared (wt/ht2) measured by kilogram per meter squared (kg/m2).
Based on WHO BMI classification:
<16 kg/m2 = severe under-nutrition
16-16.99 kg/m2 = moderate under nutrition
17-18.49 kg/m2 = mild under-nutrition
18.5-24.99 kg/m2 = normal-nutrition regime
25-29.9 kg/m2 = over-weight
≥ 30 kg/m2 = obese
- WHO criteria for CD4 cell count classification
<200 cells/mm3 = Severe immune deficiency
200-499 cells/mm3 = Moderate immune deficiency
>500 cells/mm3 = Mild immune deficiency
vii. Criteria for adherence classification:
- Good adherence:If an average adherence is >95% (he/she missed ≤ 2 doses of 30 doses or ≤ 3 doses of 60 dose).
- Fair adherence:If an average adherence is 85%-94% (he/she missed 3-5 doses of 30 doses or 4-8 doses of 60 doses).
- Poor adherence:If an average adherence is <85% (he/she missed ≥ 6 doses of 30 doses or ≥ 9 doses of 60 doses).
- WHO Clinical stage of established HIV infection:
Stage I -Asymptomatic
Stage II -Mild symptom
Stage III -Advanced symptom
Stage IV -Severe symptom
- Eating difficulties:
When a subject has any of the following symptoms at the time of data is collected:
-Loss of appetite
-Others like heartburn, flatulence, abdominal cramp, bloating
- Data collection procedure and quality control
The researcher collected data using a structured interviewer’s administered questionnaire which had two sections i.e English and Tigrinya language. This was done to ensure language expert keep the consistency of the questions. The questionnaires were pretested on 5% of study population in another prison centre that was not included in the main study for consistency of understanding and completeness of data to be collected and measured. The Tigrinya version was used for collecting information that was crucial to the study and also making the inmates familiarise with study.
The heights and weights of the inmates were measured in light clothing’s and bare feet. The values arrived at were recorded to the nearest 0.1 cm and 0.1 kg, respectively. The heights were measured while the inmates were standing erect in a Frankfurt position and the weights measured on a standing scale. When it was not possible to measure heights as in the case of inmates unable to assume erect positions, heights could be estimated from arm span or demi span or knee height positions.
The participants’ medical chart was reviewed for CD4 cell count status which was done every six months as routine for prognosis purpose. Their last visit CD4 cell counts and clinical status were taken based on WHO clinical Staging-Stage I, Stage II, Stage III, Stage IV. This was used to review client’s clinical condition of their last month visit and their last month drug adherence status in order get clients’ medical charts.
The training was conducted for data collectors and the supervisor. The supervisor held postgraduate diploma clinical medicine and short course on HIV management. The training was intended to educate the trainees on how to fill questionnaires and taking anthropometric measurements.it was a one-day training. The principal investigator was mandated to supervise data collection process and review all the questionnaire for completeness.
- Data processing and analysis
The data was cleared for completeness and consistencies. The responses in each question were coded for simplicity of data entry by the clerks. The data were entered to Epi-info version 7.0 and exported to SPSS version 20.0 for analysis and presentations.
A binary logistic regression analysis was employed to examine the relationship between the outcome variable and independent variable. Those variables found to be significant at P<0.2 in the binary logistic regression analysis were entered into multi-variable logistic regression model and statistical significance was considered at P<0.05. The results were presented in tables and graph.
- Socio demographic characteristics
A total of 412 inmates living with HIV/AIDS were enrolled in this study with a response rate of 97.6%. The majority of respondents were male 362 (87.9%). Generally, the mean age of the respondents was 35.9 years with the standard deviation of + 9.6 years. The largest number of clients were in the age ranges of 30-39 years (36.7%). It is noted that the participants, 83 (20.1%) had accessibility to social amenities and from these 62 (74.7%) were from visitors who paid courtesy call to the prisons and some government agency.
- Medical issues
The presences of eating difficulties were observed in 256 (62.1%) of respondents. Additionally, loss of appetite was highly notes amongst the inmates at 134 (52.3%) which was followed by such conditions such as nausea/vomiting 81 (31.6%). The respondents also sighted by HIV related symptoms and it was observed in 170 (41.3%) in which some inmate presented clinical manifestation of chronic diarrhoea 57 (33.5%). This was noted to be the leading cause and probably there were other opportunistic infections. The majority of inmates’ respondents were noted to be on WHO clinical stage I 181 (43.9%), with CD4 cell-count 200-499 (36.4%) (Table 2)
Anti HIV Treatment Related Status
The majority of participants engaged were on ARTs 230 (55.8%). The commonest ART regimen was 1e 137 (59.6%). From study it was noted that many inmates, 20 (4.9%) changed ART regimen following the contraindication of side effects on ART medication 16 (80.0%). The commonly observed side effect was vomiting 6 (37.5%) and in second position was rush 4 (25.0%). About 8 (9.2%) interrupted ART medication on reason on condition of side effects of medication 13 (34.2%) that was necessitude by lack of adequacy of food 12 (31.6%) (Table 3).
**** Other – Lack of transfer in paper, Loss of ART identification card, Lack of availability of guard to bring the client to the clinic at the time of appointment, Feeling of hopelessness.
Table 3: The anti-HIV treatment related status of inmates living with HIV/AIDS at Agip Prison , Asmara, Eritrea October 2-November 28, 2015,(n=412).
- Prison conditions
The majority of inmates living with HIV/AIDS had stayed in the prison for more than 5years duration (53.6%). The least number had been the prison for 1-5 years (25.5%) and the rest one year 86 (20.9%). From further investigation it was noted that all inmates have their drinking water from municipal public tap water.
- Meal frequency
- Consumption of source of energy:The results showed that, 396 (96.1%) of inmates living with HIV/AIDS haven’t consumed maize meal for the seven days. Only 12 (2.9%) of inmates had consumed maize meal once per week. The majority of respondents did not consume rice 354 (85.9%) while sweet potatoes 378 (91.7%) for the whole week. The large number of participants received their source of energy from wheat 379 (92.0%) daily (Table 4).Table 4: The frequency (times per week) consumption of sources of energy of inmates living with HIV/AIDS at Agip prison, Asmara, Eritrea October 2 -November, 2015, (n=412). b. Consumption of source of protein:The results showed that, many of respondents got their source of protein from bean 357 (86.7%), milk 3 (0.7%) daily. (Table 5)
Source of proteins (pulses, meat and animal product consumption)
Table 5: The frequency (times per week) consumption of sources of proteins of inmates living with HIV/AIDS at Agip prison, Asmara, Eritrea October 2-November 28, 2015, (n=412).
a. The Consumption of vitamins and minerals:The results have shown that large number of participants hadnt consume mango 402 (97.6%), orange 396 (96.1%), salad 379 (92.0%) and cabbage 370 (89.8%) daily. It was noted that only 4 (1.0%) of respondents consumed banana, papaya, salads and cabbages on equal measures 2 (0.5%) daily (Table 6).
Table 6: The frequency of (times per week) consumption of sources of vitamins and minerals of inmates living with HIV/AIDS at Agip Government Prison, Asmara, Eritrea October 2-November 28, 2015,(n=412).
b.Nutritional status: The large number of respondents had normal nutritional regime 57.0%. The prevalence of the malnutrition among respondents was 43%. It was concluded that 0.5%, 8.0% and 26.7% were under-weight, moderately underweight and mildly underweight respectively.
d.Aspects associated with nutritional regimes: The association between dependent variable and every independent variable were put on test with binary logistic regressions. The results showed that, sex, age, educational status, availability of social amenities, presence of eating difficulties, presence of HIV symptoms and CD4 cell-count status had correlation with nutritional regime of inmates living with HIV/AIDS in Agip Government Prison.
Thereafter the researcher recommended multi-variable logistic regression analysis to be applied to control confounders and identify the actual factors that are vitally in connection with nutritional regimes of inmates living with HIV/AIDS. The variables that were found to be important from binary logistic analysis at p-value<0.2 were entered into the multi-variable logistic regression model for analytical process. After analysis, sex, age, Availability of social amenities, presence of eating difficulties and presence of HIV symptom, were found to be paramountcy connected with nutritional regimes.
In the workings it was noted, female respondents were 92% times less likely to develop malnutrition conditions than male respondents. The respondent in age range of ≥ 50 were eight times more likely to be victims of malnutrition’s. Participants who had access to social amenities were times less likely to be malnourished. The inmates who did not have eating difficulty were 95% times less likely to develop malnutrition complications with [95%]. Respondents with HIV symptoms at risk to develop malnutrition problems.
In this study, the prevalence of malnutrition condition in inmates living with HIV/AIDS was 43%. The prevalence was higher than studies done in other countries such as Ghana, 38% , Nigeria (39%) , prisons among the general inmates and a study done in selected inmates of Tanzania among inmates living with HIV/AIDS 23% . The discrepancy of malnutrition regimes might be due to the existence of different socioeconomic aspects of the study areas, partly due to the country’s limited resources and inadequate physical activity and feeding habits of the inmates.
From the study it was noted that females were 92% times less likely to develop malnutritional complications than males. It was alluded that this might have been due to the coordinated effort to improve the situation by female inmates’ prison authorities that put female inmates often in a relatively better state of health and nutrition than male. These has generally benefited the female inmates by having better living conditions, access to water and food in prison.
The inmates that falls in age group ≥50 were eight times more likely to develop malnutritional conditions [95 %] than other age groups. The findings suggest that this could be due to older adults were prone to age-related diseases, functional impairment and physical inability that may interfere with the maintenance of a good nutritional regimes .
It was noted in this study that respondents who had access to social amenities were 97% times less likely to develop malnutritional complication [95 %] than who had no access to social support. This could suggest that people who are socially isolated and that cannot attain nutritious foods are the most victims in this case. Other aspects that were noted included low income and insufficient nutritional support. All the enlisted aspects points malnutritional complication therefore failure to handle it cause or lead to adverse situations on inmate’s life thus posing great health risks [8, 9].
The other participants who had not suffered eating difficulties were 95% times less likely to develop malnutritional problems [95%). This finding is in accordance with the results of former studies conducted in Butajira  and Bahir dar  amongst People Living with HIV/AIDS. The study concludes that this might be due to reduction in food consumption as a result of eating difficulties e.g loss of appetite, vomiting, nausea and oral thrush. Other attributes could be that food eaten is poorly absorbed and assimilated in the body thus the body draws on its reserve stores of energy from body fat and protein from muscle. This therefore results to the person losing weight and becomes emaciated .
Much attention has been focussed on HIV/AIDS related symptoms. It is alluded that inmates who developed symptoms in the past six months were two times more malnourished [95%] than those inmates who were free of symptoms. In circumstances where there are infatuate food supplies, majority of HIV/AIDS inmates may have already developed malnourishment. Their weakened body immune systems further increase their susceptility to opportunistic co-infections. The Symptoms that accompanies such infections e.g loss of appetite, diarrhoea and fever has led to further reduced food intakes, poor nutritional absorption, nutrient loss and metabolism alterations. All these summed together have contributed to malnutritional complications which have weakened the individual body immune systems .
In conclusion, the researcher makes an opinion that the prevalence of underweight was very high among inmates living with HIV/AIDS in this area. Other aspects such as Sex, age, availability of social amenities, presence of eating difficulties and presence of HIV symptoms were the main contributory factors of malnutritional complications among inmates living with HIV/AIDS in Agip Government Prison. The study has also indicated that male inmates and old age respondents were more likely to become facets of malnutrition.
The researcher wishes to recommend that prison administration alongside other government body has solely duty to Improve living conditions of inmates. Equally the male inmates should as well enjoy the same treatments like female inmates because some disparity has been noted where the female inmates condition were much better than than their counterparts.
Another recommendation is drawn on improving financial capacity of the inmates by providing vocational training and they be subjected in indoor routine duties or work. The prison administrative body should give emphasis on increasing diversified food to the inmates in order to curb the issues of malnutrition. It is important to note that effect of nutritional support on malnourished respondents were not included in the study therefore the researcher recommend that further studies be conducted.
The Ethical clearance letter granted by ministry of health and home affairs of Eritrea
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