RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
PERFORMA FOR REGISTERATION OF SUBJECTS FOR DISSERTATION.
1 / NAME OF THE CANDIDATE AND ADDRESS / Mrs JANE D’SOUZA1 YEAR M.Sc. NURSING,
KEMPEGOWDA COLLEGE OF NURSING,
K.R. ROAD, V.V. PURAM,
BANGALORE- 560004.
2 / NAME OF THE INSTITUTION / KEMPEGOWDA COLLEGE OF NURSING,
BANGALORE-560004.
3 / COURSE OF THE STUDY AND SUBJECT / 1 YEAR M.Sc. NURSING,
PEDIATRIC NURSING.
4 / DATE OF ADMISSION TO COURSE / 12/05/2012
5 / TITLE OF THE TOPIC / “EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON
KNOWLEDGE OF STAFF NURSES REGARDING NUTRITION FOR CHILDREN WITH HIV/AIDS AT SELECTED HOSPITALS, BANGALORE”.
6. BRIEF RESUME OF THE INTENDED WORK:
6.1. NEED FOR STUDY:
"We need to band together as a unit every day, especially to conquer the strength of the AIDS virus."
-Dustin Hoffman.
Children represent the future, and ensuring their healthy growth and development ought to be a prime concern of all societies. Newborns are particularly vulnerable and children are vulnerable to malnutrition and infectious diseases, many of which can be effectively prevented or treated1. Every parent's worst nightmare is having a sick child. While some childhood illnesses are mild with minor symptoms and side effects, others may be life changing or deadly2. HIV/AIDS is the deadliest epidemic of our time. The epidemic affects every aspect of human life, with devastating consequences3.
Acquired Immune Deficiency Syndrome, or AIDS, is a disease caused by a retrovirus known as the Human Immunodeficiency Virus (HIV), which attacks and impairs the body’s natural defense system against disease and infection. During this period other viruses, bacteria and parasites take advantage of this opportunity to further weaken the body and cause illnesses, such as pneumonia, tuberculosis and oral thrush. This is why the infections and cancers seen in HIV-infected individuals are called opportunistic. When a person starts having opportunistic infections, he/she has AIDS4.
An estimated 34.0 million people were living with HIV as of 2011; 3.3 million of them were children under 15 years. Every day, nearly 7,000 persons became infected with HIV and nearly 5,000 persons died from AIDS, mostly because of inadequate access to HIV prevention care and treatment services5. More than 95 percent of all HIV-infected people now live in developing countries, which have also suffered 95 percent of all deaths from AIDS6. More than 90 percent of HIV infections in infants and children are passed on by mothers during pregnancy, labor, delivery or breastfeeding. Without any intervention, between 15 percent and 45 per cent of infants born to mothers living with HIV will become infected (5–10 percent during pregnancy, 10–20 percent during labor and delivery and 5–20 percent through breastfeeding). Approximately 50 percent of infants infected with HIV from their mothers die before their second birthday7. There are 5.7 million people living with HIV/AIDS in India. It has an estimated 220,000 children infected by HIV/AIDS. It is estimated that 55,000 to 60,000 children are born every year to mothers who are HIV positive8.Nearly 11,000 children in Karnataka currently live with HIV/AIDS. It is estimated that nearly 300 children died of the disease in the state during 2007-20109.
Children with AIDS tend to get common childhood infections like conjunctivitis, otitis media, and tonsillitis, but they experience symptoms much worse than the infection usually causes10. HIV infection has increased the prevalence of severe acute malnutrition and vice versa11. Nutrition and HIV are closely interlinked creating a vicious cycle12. According to a UNICEF report, India has the highest number of undernourished children in the world at 57 million. Nearly 2.1 million children die of malnutrition every year13. HIV infection has a substantial impact the nutritional status of infected people due to poor food intake as a result of poor appetite and difficulty eating, intestinal malabsorption because of chronic diarrhea and HIV caused intestinal cell damages, metabolic changes and increased nutrient requirements related to opportunistic infections. In turn malnutrition can further weak the immune system and worse the effects of the HIV-disease12. As many as 50 percent of children with HIV fail to thrive. Along with stunting, symptomatic HIV-infected children commonly show HIV-related wasting, mainly marasmus14.
Children infected with HIV also show preferential decreases of fat-free mass compared to uninfected children. This may be associated with: High viral load, also associated with decreased proportion of free fat mass; Host immune response to the replication of the virus, which may increase the basal metabolic demands (and thus increased energy expenditures) in HIV- infected children14.More recently it has been found that people taking antiretroviral treatment, losing as little as 3-5% of body weight significantly increases the risk of death; losing more than 10% is associated with a four- to six-fold greater risk15. As the HIV/AIDS epidemic is occurring in populations where malnutrition is already endemic, there is an urgent and increasing need to implement nutrition as fundamental part of all HIV/AIDS control and treatment programs12.
Good nutrition does not cure AIDS or prevent HIV infection, but it could break this vicious cycle and improve the health and the life-quality of people living with HIV/AIDS, by maintaining body weight and strength, replacing losses of vitamins and minerals, improving the function of the immune system and the body’s ability to fight infection, extending the period of infection to development of the AIDS-disease, improving response to treatment, reducing time and money spent on health care and then keeping HIV-infected people active and productive12.For a child infected with HIV to consume enough calories, proteins, and nutrients, intake needs to be optimized by increasing the frequency of feeding, providing higher energy- and nutrient-dense foods, modifying the diet to enable the child to increase consumption. Nutritional assessment and intervention is to improve nutrition status, prevent further complications, and enhance the child’s quality of life and survival16.
With an estimated 16,000 new infections per day, worldwide, and the rapid decreases in life expectancy in the most affected countries, the AIDS epidemic should be a primary focus of development assistance in affected countries. Knowledge of the local dynamics among HIV/AIDS, food insecurity and malnutrition will allow identifying and designing activities according to existing needs and constraints and help to mitigate the impact of the epidemic. Nutrition education should include appropriate dietary recommendations for individuals suffering from the disease17.
It is important that every effort be made, by health care providers to educate community members. Be an adult they can trust and come to with their problems18. As front-line care providers, nurses play a critical role in HIV care and often have regular opportunities to provide counseling and equipping nurses with nutrition and HIV knowledge and skills enables them to provide effective nutrition care and support, but nursing school curricula include limited information on this subject19.
HIV and nutrition are intimately linked. HIV/AIDS can lead to acute severe malnutrition and poor nutrition can further worsen the disease condition. Thus it is necessary to create awareness on the relationship between HIV and nutrition; dietary recommendations to preserve energy and prevent fat loss; provide nutritional assessment which can prevent mortality due to malnutrition among HIV/AIDS children. Hence staff nurses must be provided with adequate knowledge regarding nutrition for children with HIV/ AIDS.
6.2. REVIEW OF LITERATURE:
A study was conducted on reasons of hospitalization for HIV-positive patients in the Infectology Center of Latvia to identify problems, which are related to hospitalization of HIV-positive patients, by improving patient care standards and if necessary change it and 1205 patient cards of hospitalization were analyzed. Within 3 years 1205 patients were hospitalized. In lateAIDSstage, 714 patients were hospitalized. Most common cause of hospitalization wasopportunisticinfection: 47.8%; 51.4%; 41.9% and second was liver disease: 10.5%; 14%; 10.1% in 2009, 2010 and 2011 respectively. Other reasons of hospitalization were pneumonia, bronchitis, 5.9% was acute retroviralsyndrome. Average time of hospitalization was 12.8 days. Thus HIV-positive patient hospitalization count increases every year20
A prospective study was conducted on clinical profile of HIV infection in children in HIV clinic at a pediatric tertiary care center in an urban metropolis. Two eighty five HIV positive children were referred among whom 213 patients were below the age of five years. Vertical transmission as the route of infection was documented in 86.66%, 11.57% were infected through blood and in 1.75%, the mode of transmission could not be ascertained. The clinical features noted were protein energy malnutrition in 44.56%, pulmonary and extrapulmonary tuberculosis in 29.47%, chronic diarrhea in 15.08%, oral thrush in 14.73%, pyrexia of unknown origin in 12.63%, recurrent lower respiratory tract infection in 8.42%. Forty-eight were asymptomatic, 10.52% died of AIDS during the study period and 13.68% have been lost to follow up. Hence, Vertical transmission was the commonest mode of infection. Perinatally infected children become symptomatic by five years of age21.
A study conducted on the impact of safer breastfeeding practices on postnatal HIV-1 transmission in Zimbabwe to find the association between safer breastfeeding practices and postnatal HIV transmission among 437 HIV-positive mothers in Zimbabwe, 365 of who did not know their infection status. Intervention exposure was assessed by a questionnaire, Turnbull methods. Cumulative postnatal HIV transmission was 8.2%; each additional intervention contact was associated with a 38% reduction in postnatal HIV transmission. HIV-positive mothers who were exposed to both print and video materials were 79% less likely to infect their infants compared with mothers who had no exposure. Hence the promotion of exclusive breastfeeding has the potential to reduce postnatal HIV transmission among women who do not know their HIV status and child survival and HIV prevention programs should support this practice22.
A study was conducted on oral manifestations in 101 Cambodians with HIV and AIDS to study oral manifestations with HIV disease. One hundred and one patients, Sixty-three men and 38 women with a median age of 32 years with HIV infection or AIDS were examined in Cambodia. The most frequent AIDS-defining diseases were wasting syndrome (54.5%), Pneumocystis carinii pneumonia (19.8%) and tuberculosis (18.8%). Puritic papular eruption (17.8%). Pseudomembranous candidiasis (52.5%) and bilateral hairy leukoplakia (35.6%). Only 10% of patients had no oral lesions. Necrotizing ulcerative gingivo-periodontal diseases (27.7%) which concluded that the generalhealthstatus of 101 Cambodian patients with HIV infection and AIDS was poor and they demonstrated a large number of oral manifestations23.
A retrospective cohort study was conducted on the impact of malnutrition in survival of HIV infected children after initiation of antiretroviral treatment (ART) at Addis Ababa, Ethiopia. A total of 475 HIV infected children starting ART were included in the study. Demographic, nutritional, clinical and immunological data were extracted from the existing ART logbook and patient follow up cards. Data were analyzed for univariate and multivariate analysis using Cox regression proportional hazard model. The average survival time for the entire cohort was 27.9 months. Independent baseline predictors of mortality were severe wasting (P < 0.00), absolute CD4 below the threshold for severe immunodeficiency (P = 0.04) and low hemoglobin value (P = 0.001). Thus despite the apparent benefit of ART use HIV related survival, severe wasting (WHZ < -3) appear to be strong independent predictor of survival in HIV infected children receiving ART24.
A study was conducted on hospitalization for severe malnutrition amongst HIV infected children starting antiretroviral therapy(ART) with a randomized trial of induction-maintenance and monitoring strategies which included three tertiary hospitals in Uganda; one in Zimbabwe; 1207 HIV-infected children, median age 6 years. Thirty nine of 1207 children were hospitalized for severe malnutrition (20 with edema), Hospitalized children had lower baseline and greater 24-week rise in weight-for-age Z-score (WAZ) than non-hospitalized children (P < 0.001). Of 220 children with advanced disease 7.3% developed kwashiorkor and 3.6% developed marasmus by week 12. CD4 cell percentage rise was similar among groups (P = 0.37). After twenty-four-week mortality was 32, 20 and 1.7% among children hospitalized with marasmus, kwashiorkor and not hospitalized, respectively, (P < 0.001). Hence, 1 in 9 children with advanced HIV required early hospitalization for severe malnutrition post-ART25.
A study was conducted on prevalence of underweight, stunting, and wasting among children infected with human immunodeficiency virus in South India to assess the utility of these parameters in predicting immune status. A cross-sectional study, anthropometric measurements and CD4 counts were performed on 231 HIV-infected children. Prevalence of underweight was 63%, stunting 58%, and wasting 16%, respectively. 33-45% of children were moderately or severely malnourished even at CD4 >25%; Hence undernutrition and stunting are common among HIV-infected children at all stages of the disease in India26.
A cross- sectional study supported by an observational study was conducted on maternal knowledge on mother-to-child transmission ofHIVand breast milk alternatives forHIV positivemothersin Homa Bay District Hospital, Kenya on 112 non-testedmothershavinginfantsaged 0-12 months in the community and a 10% ofHIV positivemothers. Those with high mother to child transmission (MTCT) knowledge tended to be more receptive and considered feeding alternativesotherthan cow milk like expressed breast milk (p=0.15), formula (p=0.036) andmilkfrommilkbank (p = 0.015) than their counterparts with low MTCT knowledge. Cow milk, formula and wet-nursing were the three feeding alternatives that were viable with varying socio-cultural, economic and/ornutritionalconstraints27.
A study was conducted on perceptions of professional nurses in rural hospitals of the Limpopo province. A qualitative study was conducted in one regional and two district hospitals in the rural areas with a purpose to explore and describe the perceptions of HIV/AIDS trained professional nurses regarding nursing care that is rendered in their own wards or units. Three rural hospitals of the Limpopo Province participated in the study. Knowledge of HIV and AIDS, respect for human dignity, trusting nurse-patient relationship, and confidence in the caring relationship were identified as the main contributory factors to giving good nursing care to HIV-positive patients. To improve the quality of care for all nurses working in the wards should have advanced knowledge and skills in the care of HIV and AIDS patients28.
A study conducted on nutritionalrehabilitation ofHIV-exposed infants in Malawi: results from the drug resources enhancement againstAIDSand malnutrition program. Thirty sixHIV-exposedchildren were evaluated at baseline upon presentation for malnutrition and at six months post- treatment. Parameters includedHIV-free survival,nutritional statusand change in diet. At 6 months post-intervention, a significant improvement in anthropometric parameters was noted. Dietary diversity scores increased from 5.3 ± 1.9 to 6.5 ± 1.3, p < 0.01 at 6 months. A significant increase (+25%, p < 0.02) in the number ofchildreneating fish meals was noted. Data describes positive outcomes from a rehabilitativenutritionalapproach based on use of local foods, peereducation, anthropometric and clinical monitoring in areas of high food insecurity29.