Process evaluation on adherence to the national nutritional guideline for people living with HIV in care and treatment centers, Dar es salaam, Tanzania

Abstract

ABSTRACT. Background: The interplay between HIV and malnutrition presents a critical public health concern, particularly in sub-Saharan Africa where the burdens are significantly high. In Tanzania, the HIV prevalence stands at 4.9% among adults, coupled with a noticeable rate of malnutrition among those living with HIV. Despite the availability of nutritional guidelines for People Living with HIV (PLHIV), there is a notable gap in data and evidence on adherence to these guidelines in Care and Treatment Centers (CTCs). This study aims to evaluate the adherence to the National Guidelines for Nutrition Care and Support of PLHIV in CTC clinics in Dar es Salaam, Tanzania. Objective: To evaluate adherence to the National Guidelines for Nutrition Care and Support of People living with HIV attending in CTC clinics in Dar es Salaam and identifying factors influencing it. Methods: An explanatory sequential mixed method design was used, encompassing PLHIV, health facility administrators, and healthcare providers in CTC Clinics in Dar es Salaam. Data collection was an observational checklist, structured questionnaire interview and in-depth interview to assess the level of adherence to the guideline, evaluate the factors influencing adherence and identifying the facilitators and challenges respectively. Descriptive and inferential statistical analyses was done to summarize data and explore the associations between adherence levels and multiple determinants. Content analysis to identify codes and patterns was employed in qualitative analysis. Results: Out of 485 approached participants, 478 were included. The study included 25 CTCs, predominantly dispensaries 15(60%), with an average client volume of 2322. Staff allocation met minimum requirements in 19(76%) clinics, yet 16(64%) clinics lacked adequately trained staff. Supervision and feedback were deficient in 15(60%) facilities, despite widespread availability of 24(96%) weighing scales and 23(92%) stadiometers, while 17(68%) clinics lacked MUAC tapes. Only 93 out of 478 PLHIV (19.46%) adhered fully to nutritional vi guidelines. Anthropometric assessments were universal 478(100%), but only 5(1%) participants received micronutrient supplements. Other areas, such as clinical nutritional assessments 325(68%) and nutrition counseling 244(51%), showed varied adherence rates across facility types. Multivariate analysis identified higher education (AOR=5.08, p=0.019) and attendance at referral hospitals (AOR=8.23, p=0.032) as significantly associated with guideline adherence. Conversely, nurse attendance (AOR=0.34, p=0.038), adequate staffing (AOR=0.31, p=0.010), and urban residence (AOR=0.47, p=0.009) correlated negatively. Facilitators included consistent training, supportive leadership promoting guideline adherence, and patient education sessions enhancing nutritional understanding. Barriers comprised financial constraints affecting supplement distribution, high staff turnover disrupting continuity of care, and poor documentation practices impeding effective monitoring. Conclusion: The study reveals significant gaps in adherence to national nutritional guidelines among people living with HIV in Dar es Salaam. Despite robust follow-up care and anthropometric assessments, the provision of essential micronutrient supplements is severely lacking. Variations in adherence across healthcare facilities suggest that resource distribution, staff training, and facility capabilities are critical factors. Additionally, socio-demographic elements such as education levels and geographical location further influence adherence outcomes, highlighting complex challenges in managing patient health. Recommendation: Continuous training for healthcare providers ensures adherence to nutritional guidelines. Strengthened resource allocation across health facilities improves adherence levels. Patient education integrated into routine care emphasizes nutrition's role. Addressing systemic barriers ensures consistent resource availability. Improved data quality enhances patient management.