ANTHROPOLOGICAL RESEARCHES AND STUDIES
No: 15, 2025

NUTRITION-RELATED BEHAVIORS AND THE QUALITY OF LIFE AMONG INDIVIDUALS DIAGNOSED WITH HIV/AIDS: A CROSS-SECTIONAL STUDY EXAMINING THE INFLUENCE OF SOCIO-ECONOMIC STATUS AND NUTRITIONAL HABITS IN ALBANIA

Rozarta NEZAJ (1), Redona DUDUSHI (2)
Keywords: Nutritional behavior, PLHIV, Socioeconomic Status, Adherence to Antiretroviral Therapy, Quality of Life

DOI: https://doi.org/10.26758/15.1.7

(1) Department of Food Research Centre of Biotechnology and Food Faculty, Agricultural University of Tirana, Albania.

(2) Institute of Public Health, Department of Epidemiology and Control of Infection Diseases. National HIV/AIDS Program, Albania; e-mail:  redona.dudushi@alumni.emory.edu

Authors correspondence to: Rozarta NEZAJ, Department of Food Research Centre of Biotechnology and Food Faculty, Agricultural University of Tirana, Albania.

Phone: ++ 355 68 454 8421. E-mail: roziredi@finmail.com 

Abstract

Objective. The present study aims to assess the influence of socioeconomic status on the dietary patterns and nutritional practices of individuals affected by AIDS in Albania.

Methods and materials. Through a descriptive cross-sectional research design with non-random sampling, the study’s objective is to explore the specified group’s social, economic, and health-related encounters and relationships. A total of 264 individuals living with HIV were assessed regarding their dietary behaviors and quality of life during the preceding six months.

Results. Results show that notwithstanding the comparatively low socioeconomic status of individuals living with HIV (PLHIV) in Albania, they exhibit well-developed coping mechanisms, resilience and adaptability in face of stressors. Dietary supplements and vitamins appear to be significantly influenced by the insufficient focus on nutritional programs and financial limitations. Findings from the Mann-Whitney U-test illustrate a definitive correlation between educational attainment and dietary practices. Those possessing higher levels of education demonstrate a pronounced propensity towards healthier nutritional habits, while individuals with only elementary education show a diminished inclination. The correlational analysis revealed a positive association between overall nutritional behavior and education, a positive correlation with income, and a negative relationship with adherence to antiretroviral therapy (ART). A noteworthy finding was the establishment of a negative correlation between nutritional behaviors and fixed sexual partnership status.

Conclusion. Promoting healthy nutritional practices through a proactive approach and substantial financial and educational backing from all segments of society is imperative. Additional empirical research is essential to address the existing gaps in literature and scientific knowledge related to the Albanian context.

Keywords: Nutritional behavior, PLHIV, Socioeconomic Status, Adherence to Antiretroviral Therapy, Quality of Life

Suggested citation (APA)

Nezaj, R., & Dudushi, R. (2025). Nutrition-related behaviors and the quality of life among individuals diagnosed with HIV/AIDS: A cross-sectional study examining the influence of socio-economic status and nutritional habits in Albania. Anthropological Researches and Studies, 15, 113-130. https://doi.org/10.26758/15.1.7

Introduction

Studying nutrition behaviors, bio-psycho-social patterns, and their distinct impact on the quality of life for individuals living with AIDS has garnered increasing attention among scholars over the past three decades. Nutrition transcends mere sustenance and security concerns; it also encompasses a framework for emotional and mental well-being, serving as a bio-psycho-social asset for security and personal growth. Behavioral patterns refer to the actions that exhibit a consistent approach towards an object or specific situation, especially in the context of nutrition. Various studies have explored the role of micro and macro-nutrients,, but also supplements and vitamins have been widely studied among HIV-AIDS populations (Sound, 2023; Rezazadeh, Ostadrahinimi, Tutunchi, Kermanshahi, & Pourmoradian, 2023; Soo, Pai, Bartlett, Esmail, Dheda, & Bhatnagar, 2023; Omwanda, Moriasi, Mburu, Okello, Kiarie & Komora, 2020; Khatri, Amatya & Shrestha, 2020;  Hudayani & Sartika, 2016; Thapa, Amatya, Pahari  & Newman, 2015; Weiser et al., 2011; Venter, Gericke & Bekker, 2009; Houtzager, 200, Wintergerst, Beveridge & Hornig, 2008; Thapa et al., 2005). Nevertheless, limited research has been conducted on investigating the correlation between income, socioeconomic status, and dietary habits. However, research on the correlation between their income, socioeconomic status, and dietary habits remains limited. Establishing a connection between the nutritional behaviors and the financial resources as a factor determining the well-being of individuals living with HIV-AIDS (PLHIV) is the central focus of the current study. Specifically focusing on Albania, a country with a unique HIV-AIDS demographic profile in terms of economic resources, epidemiology, modes of transmission, and economic and social progress. This argument is based on two main points: firstly, obtaining a comprehensive dataset for the Western Balkans region proves to be challenging; secondly, Albania serves as a bridge connecting the Western Balkans to the European Union. This study holds significance as it is, to the best of our knowledge, the first of its kind to analyze such factors in the country. Starting with a review of existing literature and a macroeconomic examination of the epidemiological information from the Western Balkans and Albania, the paper then delves into a thorough statistical evaluation of the research. It concludes by presenting various findings and implications concerning the impact of the socioeconomic status on shaping dietary habits and impacting the overall well-being of individuals living with AIDS.

The role of nutrition, micronutrients, and bio-psychosocial factors in HIV-AIDS people.

The role of nutrition and nutritional behaviors in addressing HIV-AIDS populations is well known in the literature. The research is mostly focused on the relationship between the nutritional and the micronutrient deficiencies especially in African and sub-African countries (Khatri et al., 2020; Omwanda et al., 2020; Elmadfa & Mayer, 2019; Rodas-Moya, Kodish, Manary, Grede, & De Pee 2015; Gaikward, Garg, Giri, Gupta, Singh, & Suryawanshi, 2013; Dibari, Bahwere, Gall, Guerrero, Mwaniki,  & Seal, 2011; De Pee & Semba, 2010; Anabwani, & Navario, 2005). The malnutrition, the limited-resources countries, the low socio-economic status and all the deficitary processes which deal with the highest prevalence of infections are among the most significant factors researched by the scholars (Shallangwa, Dibal, Bhandari, Musa & Bello,2023; Soo et al., 2023; Khatri et al., 2020; Bärnighausen, Hosegood, Timaeus & Newell, 2007; Burke, Thieman, Gielen, O’Campo & Burke, 2005). A considerable proportion of individuals diagnosed with HIV in developing nations encounter a significant psychological distress, stemming from instances of neglect within their communities or households, leading to their isolation, the researches show (Odwee et al., 2020). Authors also suggest that patients with HIV experience a significant financial burden while grappling with the management of opportunistic infections linked to their illness. It can be deduced from this that a considerable group of these individuals belong to the lower socioeconomic strata, often facing challenges in employment, what resulting in a diminished economic standing that hinders their ability to purchase essential nutritional supplements. The complexity of this scenario is further exacerbated through the intermede of an extension system that lacks efficiency, displaying a tendency to overlook the nutritional needs of adults in favor of children during counseling services. This issue is particularly prevalent in rural areas, where HIV patients afflicted with opportunistic infections are at a heightened risk of malnutrition. This particular situation emphasizes the critical role of geographical location in influencing the outcomes of patients across Africa (Takarinda et al., 2017; Ahoua et al., 2011; Magadi, 2011). Malnutrition and HIV/AIDS are closely interlinked disorders; both disorders can cause and contribute to severe immune suppression. Various research identifies the role of nutritional patterns in chronic diseases in HIV-AIDS patients. Semba and Tang (1999) contend that the consumption of micronutrients could potentially be influenced by conditions such as anorexia, central nervous system disorders, dysphagia, and odynophagia (painful swallowing) in individuals affected by HIV. Symptoms such as decreased appetite, food aversion, and difficulty swallowing were frequently observed in adults living with HIV. The same authors, drawing upon an extensive literature review, demonstrated that vitamins and supplements are also significantly involved in the nutritional framework of individuals with HIV-AIDS. Similar findings were reached by further research. The pivotal role of Vitamin A is evident in the development and operation of T and B cells, immune responses through antibodies, and the upkeep of mucosal epithelia in areas such as the respiratory, gastrointestinal, and genitourinary systems (Kaio, Rondo, Oacute, Souza, Firmino, Luzia, & Segurado, 2013; Stanojevic et al.,2012). All categories of immune cells and their secretions (e.g., interleukins, interferons, and complements rely on metabolic pathways that utilize various nutrients as essential cofactors for their functions and behaviors, Thus, host defense mechanisms are altered in protein-calorie malnutrition and during deficiencies of trace elements and vitamins. Vitamin A, through its active metabolites, all-trans, and 9-cis retinoic acid, acts via nuclear receptors to regulate gene expression. Vitamin A has been shown to modulate immune function and HIV pathogenesis. As an adjunct to ART therapy, nutrition intervention supplements such as Dietary A vitamins can improve appetite and improve quality of life, and, potentially, adherence to ART. Dietary vitamin A may be obtained as retinyl palmitate from animal sources or in the form of pro-vitamin A (including the carotenoids β-carotene, α-carotene, and γ-carotene and the xanthophyll β-Cryptoxanthin) from plant sources, such as dark leafy greens and orange-colored vegetables (Huey & Mehta, 2018; Kaio et al., 2013; Jones et al., 2006; Baeten et al., 2002). An interaction between HIV-AIDS disease and the nuclear retinoic acid receptors, Vitamin D, and the thyroid hormone receptors was also noticed by specific researches (Sidell & Kane, 2022; Micali et al., 2022; Chun et al., 2015; Semba et al., 1999). Zn plays a key role in the growth, development, and function of neutrophils, macrophages, natural killer cells and the T and B lymphocytes (Dirajlal-Fargo, 2019). Vitamin E influences the function of the T cells, B cells, and phagocytic cells and may protect immune effector cells against oxidative stress thus affecting HIV-AIDS patients (Kaio, Rondó, Luzia, Souza, Firmino, & Santos, 2014).

When these conditions are concurrent, their effect on the immune system is synergistic and the interaction between HIV infection and malnutrition leads to a growth failure and the stunting in HIV-AIDS subjects. At their first contact with healthcare professionals, all persons who have HIV/ AIDS should be nutritionally assessed and screened for nutritional problems and concerns (Khatri et al., 2020).

Other factors that play a key role in the response of HIV-AIDS contaminated populations include the socioeconomic, social, and psychological factors. Gender is also revealed as a significant risk factor in HIV-AIDS-infected persons. Gender roles of women and the need to maintain connections in relationships at the cost of one’s health are key issues for all women living with chronic diseases, especially those who are seropositive (Klaas, Thupayagale-Tshweneagae & Makua, 2018; Muula, 2008; Ackerman & Klerk, 2002). Researches also revealed that the lifetime exposure to violence and substance use is further complicated by gender and sexual decision-making norms (Teplin et al., 2005; El-Bassel, Gilbert, Wu, Go & Hill, 2005). Furthermore, a link between the violence-related post-traumatic stress disorder and the comorbid depression on immunity to HIV acquisition and HIV disease progression warrants further investigation. A connection between sexual risk related to IPV was found between gender behavior, and physiological consequences of violence and these affect women across the lifespan (Campbell, Baty, Ghandour, Stockman, Francisco & Wagman, 2008; El-Bassel et al., 2007; Boarts, Sledjeski, Bogart & Dalahanty, 2006; Teplin et al., 2005; Burke et al., 2005; Delahanty, Bogart & Figler, 2004; Beadnell, Baker, Morrison & Knox, 2000; Cohen et al., 2000). Violence and the threat of violence hamper women, including young women and adolescents females in their ability to protect themselves from HIV infection and to make smart decisions regarding sexual health (Mondal & Shital, 2013). The study by Mondal & Shital (2013) also identified education as a significant important determinant of the HIV prevalence rate in the globe. Health education is important in promoting healthy behavior and preventing diseases as a powerful tools in reducing the HIV disease burden, especially in high-risk groups such as adolescent women, sex workers, and gay partners. The present work will try to notice the relationship between nutrition (including micronutrients and vitamins) in Albania in a descriptive cross-sectional approach. As a developing country with upper-middle income according to the World Bank (2024), Albania is continuously trying to advance its public health policies. Nevertheless, there is a lack of evidence in research from the Western Balkans and Albania. Therefore, this article will try to cover this gap by giving a comprehensive view of the situation.

The epidemiology of HIV-AIDS in the Western Balkans and Albania

The “Western Balkans” defines a multidimensional term within the context of the geopolitical, financial, academic, and public spheres in Europe. This definition now refers to the countries from the region that are not yet part of the EU but aspire for membership, specifically Albania, Bosnia and Herzegovina, Serbia, Kosovo, Montenegro, and North Macedonia, collectively referred to as the 6WB. The states of South-Eastern Europe, despite facing challenges such as political instability and financial vulnerabilities, were targeted for expansion by the main Western powers in the post-war era (Bartlett & Osbild, 2009). Situated as a natural bridge connecting Europe, the Middle East, and Africa, the Western Balkans region held, – along the time, – a significant commercial, strategic, and military importance for both eastern expansion and the reinforcement of positions held by major global powers in the Mediterranean basin. Concerning the HIV-AIDS epidemics, as argued by Stanojevic et al. (2012) the HIV-1 epidemic in the Balkan region exhibits variability in terms of duration and status. Several significant factors contribute to the emergence and the dissemination of the HIV/AIDS epidemic in various Balkan countries, as evidenced by the effects of social transition, armed conflicts, elevated levels of unemployment, substance abuse, risky sexual behavior, and other related variables. The data utilized in this study were sourced from the World Bank and secondary sources from the Institute of Public Health of various countries. However, there is a noticeable lack of data for Kosovo, North Macedonia, and Bosnia and Herzegovina about epidemiological contexts. The Western Balkans pose a challenge for researchers when it comes to HIV-AIDS reports and data due to the difficulty in accessing information and the sensitive nature of the issue. As a result, this research focused on Albania as a case study, which exhibited significant changes in prevalence and profile.

Albania is still a nation with a low prevalence of HIV/AIDS, as indicated by the reported cases in the country’s Institute of Public Health (Dudushi, 2020). The country’s HIV/AIDS prevalence was 0.06% in 2023, with an incidence rate of 4.1 per 100,000 individuals (IPH, 2023). Most HIV cases in Albania come from the general population, without a notable concentration in specific subgroups. Over the past thirty years, starting from 1993 when the first cases were documented, there have been a total of 1716 People Living with HIV (PLHIV), with approximately 20% of them succumbing to the disease. The majority of reported HIV cases are men (72.4%), and the most affected age group comprises adults over 24 years old (87.4%). Throughout the years, the number of men diagnosed with HIV has been consistently three times higher than that of women. Age group distribution reveals that individuals aged 35-44 constitute the highest percentage (28.4%), followed by the 25-34 age group (26.9%). The 45-54 age group accounts for 18.1% of cases, while young adults aged 16-24 make up 9.5%. Furthermore, individuals aged 55-64 represent 10.9% of total cases, while children (0-15 years) make up 3.1%. Individuals over 65 years old comprise less than 3% of cases. In the initial decade, there was an average annual increase of +2 cases, which doubled in the subsequent decade. However, there was a 0.1 decrease in the third decade compared to the second decade. The primary mode of HIV transmission in the country is through sexual contact, accounting for 96% of cases (72.6% heterosexual and 23.4% homo-bisexual transmission). Other routes include 2.4% vertical transmission, 0.6% through blood, 0.6% through Injection Drug Use (IDU), and 0.3% undetermined. Nevertheless, there has been a noticeable increase in reported cases among women over time. HIV/AIDS predominantly affects urban areas in Albania, with approximately 48% of reported cases residing in the capital city of Tirana, which has the highest population density.

The recent report of the World Bank (2024) for the Western Balkans, underscores the pressing necessity to advance public health policies and strategies, particularly concerning dietary programs related to AIDS, across most countries. This encompasses the enhancement of coordination across different sectors, the allocation of resources towards the psychological counseling communities and facilities, the promotion of awareness and the engagement within the civil society, in addition to the implementation of proactive measures aimed at capacity development and the augmentation of fundraising endeavors.

Research Methodology

Research purpose and objectives.

This research aims to study the dynamic interaction of nutrition in HIV-AIDS known status people in Albania. The unknown status target group is beyond the scope of the present work due to a major lack of data and a reliable reporting system.

Several objectives were raised in order to examine the research area relevant to this study as it follows:

  • To explore the situation of nutritional behaviors of PLHIV individuals in Albania.
  • To explore the connection between the socioeconomic status and the nutritional behaviors of PLHIV individuals in Albania.
  • To explore the quality of life of PLHIV individuals in Albania.

Research Hypothesis

In line with the research of the objectives, the following hypotheses were raised:

H1= There is a negative trend of dietary programs in PLHIV individuals due to their poor socioeconomic status.

H2= The quality of life of PLHIV in individuals is strongly affected by their socioeconomic status.

Sample

The present study’s sample consisted of 264 HIV-AIDS patients with a known status who consented to participate in the research conducted at the public health facility in Tirana. Inclusion criteria encompassed individuals with HIV-AIDS who were aware of their status and had undergone ART therapy for a minimum of six months. Eligible participants were required to be at least 18 years old and to have been engaged in either fixed or casual sexual relationships within the past 6 months. Exclusion criteria pertained to individuals unaware of their status, to those who were not undergoing therapy, to the pregnant individuals and to the respondents below 18 years old. This selection was motivated by the absence of data of reporting and the challenges associated with tracking individuals with unknown HIV-AIDS status.

Demographic characteristics of the sample

198 (74%) of the individuals in the study were male at birth, while 67 (26%) were female. Data availability on the Western Balkans is limited, making a comprehensive comparison with the region unfeasible within the scope of this study. The age group most affected by HIV-AIDS was composed of individuals between 35-44 years old, comprising 52% of the participants, while those aged 65 years (8%) and older were the least represented. This trend may be attributed to cultural influences impacting the awareness of testing and reporting of infectious status from Albania. This finding is consistent with the research conducted by Vistupakorn, Pierce & Ritchwood (2023), which highlighted the cultural impact on HIV-AIDS treatment and research publications in the USA, particularly among Black/African American individuals. Most participants in the current research identified as Albanian (154 or 58.3%), while other ethnicities chose not to disclose their identity. Over 56% of respondents held a university degree. Regarding marital status, 51.1% of respondents were in a relationship, 18.9% were single, 15.7% were married, and 14.3% were in cohabitation. Marital status was used as a proxy for evaluating the quality of sexual relationships among PLHIV participants in this study. As for the socioeconomic status, 62.5% of participants belonged to the middle class. The monthly income of most of the participants included the availability of one or two financial resources (45.4%).

A summary of the demographic can be found in the following table.

Table 1

Demographic characteristics of the sample variables (to see Table 1, please click here)

Variables of the study

As independent variables that could explain the attainment of nutritional behaviors of the PLHIV patients in Albania, we have considered the followings: the socioeconomic status, the income, the education, the adherence to ART, and the quality of the sexual relations.

As a dependent variable, we considered the nutritional behavior. The concept, as defined by Oltersdorf, Kunter, & Sämann (1984) and later by Leonhäuser, Meier-Gräwe, Möser, Zander, & Köhler (2009), encompasses a wide range of actions undertaken by individuals or social groups about food procurement, but also about its preparation, consumption, storage, and their disposal. Gender and age were not included as indicators in the present work because these data do not produce sufficient evidence due to the refusal of respondents to report. As independent variables, this study evaluated Socioeconomic Status (SES), the Income, the Education, the Adherence to Antiretroviral Therapy (ART), and the quality of sexual relationships. SES encapsulates the intricate relationships among the educational attainment, the professional standing, and the individual perceptions of societal position and class. It serves as a barometer for the quality of life and the array of opportunities accessible to individuals within a community, and it consistently serves as a predictor for a diverse array of psychological outcomes. The income, in the context of this study, whether derived from personal or familial sources, encompasses wages, financial aid, or any other financial resources that the individual reports receiving every month. According to data from the World Bank (2024), Albania is categorized as a nation with upper-middle-income status. Education involves the dual processes of transmitting knowledge to individuals and the acquisition of knowledge from others. Adherence to ART is pivotal for achieving virologic suppression and is thus deemed a critical aspect to monitor in current research. Finally, the dimension of sexual relationship quality, as explored in this study, relates to the standard of sexual and interpersonal connections that individuals living with HIV establish with their partners. All variables in this study were delineated by the research objectives and the associated hypotheses, as referencing the World Health Organization Promotion Glossary of Terms database.

Study setting

The present study was conducted at the Ambulatory Clinics of the Mother Teresa Hospital Center in Tirana, which is the only public health facility for HIV-AIDS in the country that provides ART. Data were collected during 6 months, from December 2023 to June 2024.

Study design

This research utilizes a transversal design and a cross-sectional research one in order to employing the non-random sampling nested within random sampling aiming to explore the social, economic, and health-related experiences and interactions of the targeted population (Bryman, Clark, Foster & Sloan,2021). The methodology is mixed, involving the collection of quantitative data from the questionnaire and the qualitative data obtained from the observations with a micro-analysis of the observed quantitative data. Data was processed through the SPSS version 29 software for descriptive analysis. Quantitative data analysis was conducted using the SPSS software, while correlative and interpretive analyses were performed with MAXQDA 2024.

Instruments

The following measures were taken in the current work.

The Diet and the Behavior Scale (DABS) is a questionnaire developed by Richards, Malthouse & Smith (2015). It consists of twenty-nine items designed to evaluate the intake of the common dietary variables, focusing on functional foods and drinks and the present dietary program of the respondents. The questions cover various areas of eating and drinking that have shown the potential effects on behavior such as the behavioral impacts of coffee, tea, caffeinated soft drinks, breakfast, chewing gum, fruits and vegetables, and the junk food. The first part of the DABS focuses on the frequency of consumption of common foods and drinks, with eighteen dietary variables measured on a five-point scale ranging from never to every day. The second section examines the typical amounts consumed for eleven common foods and drinks. Participants are required to indicate their typical weekly consumption of items such as energy drinks, cola, coffee, tea, crisps, chocolate, burgers/hot dogs, and chewing gum, while the consumption of fruits, vegetables, and water is reported daily. Three items were used to assess the frequency by which subjects participated in mildly energetic, moderately energetic, and vigorous physical exercise, with answers being given on a four-point scale (1 = never/hardly ever, 2 = about once to three times a month, 3 = once or twice a week, 4 = 3 times a week or more). This section was not employed in the current research as it stands beyond its scope. Finally, participants are asked to indicate how many hours per night they typically spend sleeping and to assess their general health (1 = particularly good, 2 = good, 3 = fair, 4 = poor, 5 = extremely poor).

The Patient Health Questionnaire – PHQ-9 (Kroenke, Spitzer & Williams, 2001) serves as a tool for screening, diagnosing, monitoring, and assessing the severity of depression, as outlined in Table 2. Positioned as an extension to the Patient’s Health Questionnaire – PHQ, this questionnaire delves into the context of depression. Diagnosis of major depression hinges on meeting five or more of the nine criteria for depressive symptoms, enduring their presence for at least “more than half of the day” in the preceding two weeks, with a prerequisite that one of these symptoms encompasses either a depressed mood or anhedonia. On the other hand, other forms of depression were identified if 2, 3, or 4 depressive symptoms manifest “more than half the day” in the last fortnight, alongside one of these symptoms being a depressed mood or anhedonia. Notably, the criterion involving “thoughts that you would be better off dead or hurting yourself in some way” is deemed significant irrespective of its duration. Demonstrating a commendable level of reliability, the PHQ-9 scale exhibits an excellent Cronbach’s alpha score of 0.84. Repeated administrations of the PHQ-9 facilitates the tracking of the depression’s trends throughout the therapy. Aligned with the diagnostic criteria of major depressive disorders outlined in the DSM-5, participants assess the frequency of experiencing each of the symptoms over the past two weeks using a 4-point Likert scale across nine items, ranging from 0 for “Never” to 3 for “Almost every day.” The cumulative score spans from 0 to 27, with varying ranges such as 5-9 indicating minimal symptoms, 10-14 signaling minor depression, dysthymia, or mild major depression, 15-19 suggesting moderately severe major depression, and a score of 20 or above representing severe major depression. The scale’s robust psychometric properties underscore its reliability, with this study revealing Cronbach’s alpha and McDonald’s Omega values of ⍺ = 0.771 and ⍵ = 0.779, respectively.

Individuals facing chronic conditions like HIV often confront somatic manifestations such as pain and physical unease, which can precipitate depressive conditions linked to the illness, with the depressive disorder in turn exacerbating the somatic symptoms. Research has indicated a higher prevalence of the depressive disorder among all other affective disturbances in individuals living with HIV (PLWH). This type of disturbance may not be fully recognized due to the presence of HIV-related somatic symptoms that resemble those of depression (Dudushi, 2020). Depression stands out as the most prevalent mental health condition among PLWH, with effective depression management holding the potential to influence the overall well-being of populations grappling with chronic illnesses characterized by physical, social, and psychological complexities. The stress induced by living with HIV is examined in this study as a trigger for undesired reactions and the development of adjustment disorder, leading to lifestyle modifications and instilling apprehension and uncertainty regarding adaptation to the new circumstances. These manifestations are typically accompanied by a cluster of somatic symptoms that impede the daily functioning and frequently co-occur with depressive symptoms, which are the key indicators of the adjustment disorder as per the International Classification of Diseases (ICD, 2021). The primary focus of this study is not on delineating the nature of the somatic symptoms, but rather on recognizing the presence of the mental health issues such as the depressive disorder in PLHIV as part of the affected quality of life. In the present work, this scale was used to assess the impact of being with HIV-AIDS known status on their quality of life and mental health (Objective 3) For a comprehensive understanding of the findings, refer to Table 2.

Table 2

Interpreting Scores of PHQ-9 scale. (to see Table 2, please click here) 

Results

The attention was directed toward two primary categories: individuals who indicated their inability to purchase supplements because of limited financial resources (poor income), and those who could acquire supplements due to their financial means (good income). A poor income is defined in this study as having neither a salary nor a second financial resource while a good income is defined as having at least two or more financial resources. Individuals who received a disability payment from the state were excluded from the present analysis due to the challenge of accessing the financial assistance solely based on their status as People Living with HIV (PLHIV) or other forms of disability.

The table below displays the findings of descriptive statistics about the dimensions of Nutritional status and PLHIV.

Table 3.

Descriptive Statistics, Means, and Standard Deviations of Nutritional Status and PLHIV* (to see Table 3, please click here)

Among the various classifications utilized to assess the quality of life in individuals living with HIV, one intriguing finding pertains to the availability of nutritional support resources, as described in Table 4. The category concerning stress management and mental well-being demonstrates the highest mean score (M=100.71; SD=13.48), whereas the professional and socio-economic status category exhibits the lowest mean score (M=77.89; SD=13.06). Despite the comparatively low social and economic standing of PLHIV patients in Albania, they exhibit some well-structured coping mechanisms, and also a certain accommodation and adaptability to stressors. This observation can be attributed to the effective functioning of the social welfare institutions in Albania, some of which operate through voluntary efforts, providing emotional support, psychological assistance and psychoeducational guidance to this specific demographic spectrum. The use of supplements and vitamins is significantly influenced by the limited focus on dietary programs and financial constraints, resulting in a low score (M=98.9; SD=18.41). A low score, connected to the nutritional behavior is noticed in adherence to therapy status (M=98.85; SD=15.5).

The initial hypothesis (H1) argues that a downward trajectory exists in the nutritional and dietary programs for People Living with HIV (PLHIV) because of the challenges stemming from their social and economic precariousness. In this case, the Mann-Whitney U-test was employed to assess the advancement of various nutritional behaviors concerning our independent variables. Findings from the initial analysis, which are not presented here, suggest a clear correlation between the educational level and the dietary patterns. Individuals with higher levels of education exhibit a more pronounced inclination towards positive nutritional practices (Z=3.52; Sig. r=0.654; p<0,05), whereas those with elementary school qualifications demonstrate a lower tendency (Z=1.02; Sig. r=0.123; p<0.05). Conversely, the data indicates an inverse association between nutritional behaviors and the sexual partnership status of the respondents. Specifically, there is a weaker correlation between fixed sexual partnerships among HIV-AIDS patients and their dietary habits (Z=-2.45; Sig. r=-0.03; p<0.05). No significant statistical variances were observed in the dietary habits of People Living with HIV (PLHIV) based on their engagement with casual sexual partners. The study also found a reverse relationship between the adherence to therapy and the nutritional behaviors (Z= -5.02; Sig. r=-0.86; p<0.05). This indicates that while PLHIV patients may follow their therapy regimen diligently, there is not enough evidence to support the idea that they will also adhere to the different nutritional behaviors. Interestingly, the data showed that the more patients stick to their antiretroviral treatment, the less likely they are to make changes in their diet. This specific discovery warrants some further investigation in order to determine whether this phenomenon is influenced by the cultural background of the Albanian PLHIV patients or if other factors are at play. The first raised hypothesis, H1 is therefore confirmed and supported.

The following Table 4 introduces the Pearson correlations between the Nutritional behaviors and the quality of life variables. The table confirmed the previous U-test results in terms of correlational indices. As it can be deduced, a positive relationship between the Nutritional behavior total and Education (rw= .625), a positive relationship with Income (rw = .467), and an inverse relationship with the Adherence to ART (rw= – 0.86) were found. These results are in line with our Mann Whitey U and the descriptive data.

Table 4

Pearson Correlations of Nutritional behavior and PLHIV quality of life. (to see Table 4, please click here)

In order to assess the validity of the raised hypothesis 2 and to fully understand if there is an impact between the economic income and the nutritional behaviors, a linear regression model between the variables was computed. Regarding the correlation coefficients delineated in the augmented Model Summary, a value of 0.42 was regarded as being statistically significant. The model coefficients exhibit a significant level of Sig 0.001, which is less than the threshold of 0.05. Initiating the examination of the nutritional behavior patterns alongside the cumulative score on the PQH-9 scales, there were deduced the coefficients that emerge from the regression analysis of each variable within the specified methodology. The current R-value is .71 (standard error of .706), which indicates a substantial degree of variability, and the R-squared value of .710 suggests that there exists a considerable impact of income on the nutritional behaviors of individuals living with HIV.

Discussion

Advancing research on HIV-AIDS in the 20th century holds a paramount importance due to the multifaceted dynamics and consequences that impact not only the affected population but also the society at large. The significance of nutrition and food-related concerns has become increasingly evident in shaping the social behaviors and some advancements. Various studies have highlighted the transformative influence of food and nutrients in shaping the dietary patterns of the individuals with HIV-AIDS, impacting of their habits, beliefs, health, and overall quality of life (Rezazadeh et al., 2023; Facina, Da Rocha Fonseca, Da Conceição-Machado, De Cássia Ribeiro-Silva, Santos, & De Santana  2023; Khatri et al., 2020; Elmadfa et al., 2019; Chun et al., 2015; Kaio et al., 2014; Dibari et al., 2011; De Pee & Semba, 2010; Maggini et al., 2008; Jones et al., 2006; Mangili, Murman, Zampini, Wanke & Mayer, 2006). This issue also bears relevance in the Western Balkans, an area characterized by emerging economies and social progress. Despite making strides in various aspects crucial for overall development, the area lacks comprehensive and progressive data accessible to researchers and scholars for in-depth analysis. Therefore, our focus is on a specific location in the Western Balkans, Albania, where data is readily available for examination. This research aims to evaluate the impact of socioeconomic status on the dietary patterns and nutritional behaviors of people living with HIV in the past six months (December 2023 – June 2024). Analysis of World Bank Data for the Western Balkans in 2024 reveals a concerning trend of inadequate policy support and strategic initiatives at both national and local levels concerning the operation and funding of facilities catering to HIV-AIDS patients. The absence of a coherent and consistent approach to monitoring and surveillance, antiretroviral therapy, dietary interventions, psychoeducation, and counseling not only hampers the well-being of affected individuals but also strains the societal framework. The data from the specific literature review has unveiled a strong association between nutrition, malnutrition, therapy adherence, gender, socioeconomic status, social factors, and psychological factors with the quality of life among individuals living with HIV (PLHIV) (Shallangwa et al., 2023; Soo et al., 2023; Sidell & Kane, 2022; Micali et al., 2022; Khatri et al, 2020; Dudushi, 2020; Odwee et al., 2020; Klaas et al., 2018; Kaio et al., 2013; Bärnighausen et al., 2007; Burke et al., 2005). Two hypotheses were formulated to address the research inquiries, with the first one focusing on the observation of dietary program trends among PLHIV individuals based on their socioeconomic status. The second hypothesis pertains to the connection between the socioeconomic status and the quality of life in PLHIV individuals. A total of 264 PLHIV were evaluated for their nutritional habits and quality of their life over the past six months, with 74% being men and 26% women. Among the affected individuals, 52% fell within the age range of 35-44 years. Furthermore, 56% possessed a university degree, and 51.1% were in a relationship. The majority of participants, accounting for 62.5%, belonged to the middle class and had one or two financial sources (45.4%). Upon examining the descriptive data of the variables, it was discovered that, despite the relatively low socioeconomic status of PLHIV patients in Albania, they demonstrate well-structured coping strategies, resilience, and adaptability to stressors. The utilization of supplements and vitamins seems to be notably impacted by the limited emphasis on dietary programs and financial restrictions, leading to a relatively modest score (M=98.9; SD=18.41). Moreover, a subpar score about nutritional behavior was identified concerning therapy adherence status (M=98.85; SD=15.5). Results derived from the Mann-Whitney U-test indicate a clear link between the educational attainment and the dietary behaviors. Individuals with higher educational levels display a stronger inclination towards positive nutritional habits (Z=3.52;Sig. r=0.654; p<0.05), whereas those with elementary school qualifications exhibit a weaker tendency (Z=1.02; Sig. r = 0.123; p<0.05). Correlational analysis unveiled a positive association between total Nutritional behavior and Education (rw=.625), a positive correlation with Income (rw = .467), and an inverse relationship with Adherence to Antiretroviral Therapy (ART) (rw= -0.86). The exploratory analysis conducted to investigate the second proposed hypothesis demonstrated a significant variability with an Rsquare =.710. It was established that a substantial relationship exists between income levels and the nutritional behaviors exhibited by PLHIV patients. A noteworthy discovery was the identification of a negative correlation between the nutritional behaviors and the fixed sexual partnership status of the participants (Z=-2.45; Sig. r  = – 0.03; p<0.05), as well as an inverse connection between adherence to therapy and nutritional habits (Z= -5.02; Sig. r= – 0.86; p<0.05). The primary finding of our research highlighted a direct impact of the socioeconomic status on the patterns of nutritional behaviors. Factors such as education, income, and interpersonal interactions play a crucial role in shaping the social and economic characteristics of PLHIV individuals and their dietary practices. This outcome aligns with existing literature which emphasizes the influence of bio-psycho-social factors as predominant in determining the  nutritional behaviors (Facina et al., 2023; Foroozanfar et al., 2022; Czarnocinska, Wadolowska, Lonnie, Kowalkowska, Jezewska-Zychowicz, & Babicz-Zielinska, 2020; Aslam et al., 2013). Nevertheless, the future investigations should focus on evaluating the effects of food insecurity, nutritional behaviors, and quality of life on a broader scale within the Western Balkans as both a commonwealth and a region for social development.

Conclusions

Drawing upon an extensive review of the specific literature and a solid theoretical framework, the aim was to highlight the impact of better financial policies, support, and income on promoting a healthy dietary regimen within the community of HIV-AIDS patients in Albania. The study underscored how the income and the economic standing influence the accessibility of a nutritious diet, subsequently enhancing the overall nutritional well-being of People Living with HIV (PLHIV). Additionally, this research indicated that variables such as gender, age, treatment adherence, and sexual relationships exert minimal to no influence on dietary habits. These results are noteworthy as they bridge the gaps in current data and challenge the prevailing assumption that gender and age wield significant sway over nutritional choices. Despite these advancements, the study is limited in a comprehensively understanding of the nutritional assessments of HIV-AIDS patients and in providing a broader perspective on the availability of dietary initiatives at both national and regional levels. Consequently, it is unable to offer a thorough comparative analysis of dietary patterns in Albania and neighboring nations. In a theoretical implication, this paper posits, based on its findings, the importance of expanding research endeavors and specific literature on nutritional practices, socioeconomic empowerment, and quality of life among PLHIV in Albania. Encouraging cross-border collaboration to enrich this dataset is strongly advocated. From a practical implication, it concurs that fostering regional collaboration among Public Health Institutes in the Western Balkans, the civil society and the non-governmental organizations dedicated to nutrition and HIV-AIDS care can significantly enhance health-related policies and strategies, ultimately benefiting both health outcomes and also the quality of life.

Competing interests

The authors declare no competing interests.

Consent to participate

Informed written consent was obtained from each participant at the time of recruitment. The subjects were informed that they could withdraw from the study at any stage, and they were assured of confidentiality.

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