The prevalence of Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) among populations increases with time despite active antiretrovirals introduction to boost immunity. Latest statistics show that approximately 40 million persons are living with the virus globally. In 2018 an estimated 37.9 million people lived with HIV (including 1.7 million children), with a global HIV prevalence of 0.8% among young people and adults (1).Approximately 240,000 people in the Caribbean were living with HIV in 2009, second only to the Sub-Saharan African continent. There are many reasons why the epidemic has hit the Caribbean so strongly. These reasons include poverty, sexual partners, gender, and prostitution. Most of the people affected by HIV are young people. However, the disease attacks can have detrimental effects, especially among the aged in society. According to the Caribbean Public Health Agency (CARPHA)The Caribbean region has made significant progress in reducing AIDS related deaths.  The number of people dying of AIDS-related deaths have decreased from 11 thousand in 2010 to 6,900 in 2019. The Region has also seen a reduction of new HIV cases down from an estimated 18.000 new cases to 13.000 per year.\ Despite the progress made, the management of HIV/AIDS remains a priority public health issue.Young women continue to the   worst affected group.  The relationship between poverty and HIV in Tobago is crucial to investigate. Social and economic factors, such as income, education, employment, community safety, and social supports can significantly affect how well and how long we live. These factors affect our ability to make healthy choices, afford medical care and housing, and manage stress.

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HIV has no definite cure. However, drugs such as Antiretrovirals (ARVs) have been developed to promote effective care for HIV patients. Antiretrovirals are now the primary drugs used to increase life expectancy among HIV/AIDS patients in Tobago (1). One of the critical issues that need to be put into place to maintain good health for persons living with HIV is adopting health and nutrition outcome targets, especially for adults. Maintaining proper health standards and appropriate nutritional standards is a fundamental method to improve longevity and resilience among HIV positive persons in Tobago (2) (3).  The Study, therefore, aims to identify the health and nutritional needs of adults living with HIV on the island. The Study will highlight some of the health challenges that people living with HIV are facing and how important health and nutritional target outcomes for adults living with HIV in Tobago are essential. Therefore, it is a study that will identify challenging issues faced by adults living with HIV on the island.

The study is very relevant in understanding the difficulty persons living with HIV in Tobago are facing. This research will seek to evaluate how persons living with HIV can improve their health standards by developing health and nutrition outcomes and access the socioeconomic factors that can meet their health goals, target outcomes and considerations.  The Study will seek to establish the challenges of poor health and nutrition of HIV positive patients in Tobago relating to inadequate socioeconomic support systems and the dietary patterns that can potentiate health improvement.











  1. What are the socioeconomic factors leading to lack of access to a balanced diet and association with the quality of life of people living with HIV in Tobago?
  2. What are the determinants of undernutrition among people living with HIV in Tobago?
  3. What is the effect of early dietary intervention and nutritional counselling on patients?



  1. What challenges persons living with HIV face accessing public assistance and other related social assistance in Tobago?
  2. What are the Non-governmental, community-based organizations available to help persons living with HIV on the island?
  3. What lifestyle and behavioural factors influence the quality of life of the person living with HIV in Tobago?












  1. To determine the socioeconomic factors that inhibits the person living with HIV quality of life.


  1. To explore the outcome of early dietary counseling and nutritional intervention on the immune function and the progression of the HIV disease.


  1. To establish a list of a non-governmental community-based organization that has an established framework to help persons living with HIV.


  1. To identify governmental institutions geared towards providing financial assistance to people living with HIV.















The literature used in developing this proposal includes online sources from science websites and databases such as PubMed, Medline, and Scopus, written in English, Key search terms used were ; HIV, nutrients, socioeconomic, antiretrovirals, interventions, sample, approaches, qualitative, pilot study. The sources’ validity is approved by using sources that are not older than ten years to develop the most updated data based on the Study and data that relate to the significant changes that have occurred in managing HIV/AIDS patients. References and relevant information published more that ten yens was not excluded.



According to 2008 Hendricks et al. the type of diet and nutritional intake that HIV positive person intake can help in determining the positive growth of CD4 cells or not.  CD4 cells are the protective mechanism in the body that helps fight and deal with the rapid multiplication of HIV virions. Adequate nutritional intake is also the main reason to promote the highest BMI in the body and increase life expectancy.  Therefore, the author identifies that useful nutritional elements are among the core development factors that can promote positive development in the bodily health of patients living with HIV.  It is also the basis of promoting active body growth. Good nutrition helps in building up a good defence system. It is one of the programs that can help build a strong body defence system and be instrumental in promoting general good health. The main challenge that is facing the persons who are living with HIV in Tobago is undernutrition.  Many people are not able to afford the food that is needed to sustain them.  It is important to note that persons living with HIV need a balanced diet that makes them live well. However, research has shown that many of the people in Tobago cannot afford this food. Lack of money and other resources that can help them manage their nutritional needs is still a key challenge for the people. Therefore, undernutrition is still a core challenge facing the people living with HIV in Tobago. Many people living with HIV in Tobago have socioeconomic challenges, and hence these are people who cannot afford or access proper nutrition.

On the other hand, 2001 Kim et al. (3) argue that dietary intake is a significant factor in promoting healthy living among HIV patients.  The authors note that many people who fail to take up severe dietary measures with essential nutritional elements tend to have weaker defence systems.  The study also develops that most of the poor dietary system people are majorly due to socio-geographical factors.    Therefore, many people are consuming less than what has been prescribed due to social-related issues and poverty instigated measures. In this case, these are people who tend to develop flawed health system and have a weaker defensive system.

Kim et al. (3) also note a direct correlation between reduced and inadequate nutrient intakes in a large, clinically, and socioeconomically diverse cohort of HIV-infected adults (3). The people in the late stages of HIV tend to have more extreme needs for good nutritional measures than the others in the early stages. The late-stage is associated with extreme cases of destruction of body defence systems. Hence, there is a need for a more substantial nutritional program that will help sustain the body’s defence system (3).


Adherence to Antiretroviral Therapy Among Adults


Proper nutrition increases the absorption of antiretrovirals and tolerance among HIV patients (3). Vitamins play a vital role in preventing opportunistic infections in the cases where antiretroviral are not administered. Patients diagnosed with vitamin deficiencies such as vitamin C and B are weakened by the virus the most. Calcium is a vital mineral for HIV-positive patients because of its effect in strengthening the bones and enhancing cellular communication (4). High carbohydrate intake improves supplement energy stores that are affected by HIV, resulting in general weakness. Low energy in the body is associated with loss of body mass and available tissue reduction, influencing BMI (2). Adults with lower mineral intake have reduced metabolic processes and decreased tissue regeneration. Studies show that combining high protein intake vitamins and minerals has proved successful in reducing the opportunistic infections associated with HIV. Therefore, undernutrition among the Tobago population living with the disease might negatively impact the effectiveness of ARVs, which are used significantly to reduce the disease’s comorbidities.

Income and Resources


Income is critical among persons living with HIV for access to quality healthcare and improved quality of life (5). The management of opportunistic infections requires resources for correct interventions, such as purchasing the required vitamins and attending to basic needs. Low-income earners are challenged in accessing quality social services such as health, education, and a balance diet. In Tobago, public health advocates for the provision of programs to educate the patients on management interventions, especially low-income earners who lack adequate funds to finance healthcare services at the individual level and family (1) (2) (6). Lack of vital skills and knowledge about health wellbeing is associated with undernutrition among the Caribbean HIV patients living in unsuitable economic environments. Despite the provision of free education up to tertiary level among the Tobagonians, low education levels characterize challenges in adopting the management interventions, such as lack of knowledge on the required dietary interventions, timely antiretroviral interventions, and prevention measures (1). A 2011 study by Scott et al, on Poverty, Employment and HIV/AIDS in Trinidad and Tobago concluded that HIV/AIDS and poverty reinforce each other, with poor, vulnerable women being a significant driver of the disease while also bearing the burden of its impact. They further recommended that Policies are needed to protect the women of Trinidad and Tobago, as well as the rights of all participants in the labour force.









This chapter explicates the research design as well as the research method used. Due to the nature of the topic, a mixed method approach will be carried out . The data will be collected at the Tobago Health Promotion Clinic using questionnaires, interviews both in depth and semi-structured. The research design and the methods of data collection in this study are based on the objectives of the research and focused on understanding the nutritional and other socioeconomic factors that affects Tobagonians living with HIV/AIDS.

Research Design

Research design according to Polit and Hungler (1999) is an overall plan that is used to obtain answers to the research questions and also a way of dealing with certain difficulties that are encountered in the process of research.

This research will analytical cross sectional study that comprises of both qualitative and quantitative research methodologies of collecting and analysing data that will be used to answer the research questions. The study focuses on exploring and understanding the role of nutrition and other socioeconomic factors and how they affect the lives of Tobagonians’ living with HIV/AIDS. The qualitative methods that will be used in the collection of data are interviews. This will help the researcher in gaining insightful information concerning the socioeconomic factors that generally affects the lives of people living with HIV in Tobago.

Both semi-structured and in-depth individual interviews will be carried out by the researcher to gather information on the nutrition choices as well as other socioeconomic factors.

Qualitative methodology involves several aspects such as inquiring while exploring concepts such as “what” and “how” the hypotheses developed are utilized to gain a deeper understanding of a phenomenon (8,9). As such, this method of inquiry will aim to explore “what” is the role of nutrition and other socioeconomic factors, and “how” they influence the views, meanings, and perceptions of a person living with HIV in Tobago (8) (9).

Additional justification in using qualitative research is to include questions about people’s experiences, the social contexts, and environmental influences depending on the factors being analysed in a phenomenon. The qualitative Study facilitates a study in a natural setting, “an interpretive, naturalist approach to its subject matter (7).” Its limitations are that it is time consuming, labour intensive and it is hard to verify its results however, this inquiry method will be an important approach to facilitate exploring the relationship and impacts of the selected factors in real-life context to achieve a narrative description of evaluating the role of nutrition and other socioeconomic factors affecting persons living with HIV in Tobago.

The study will also utilize the quantitative methods of data collection that include questionnaires and interviews where the researcher will issue out questionnaires to the Tobagonians living with HIV and hold interviews with them. All these methods will enable the researcher to gather enough data that will be used to answer the research question while recommending the necessary measures that should be taken to help in improving the living standards of the Tobagonians living with HIV.

Quantitative research method is important since it offers an allowance to the formulation of statistically sound data, it offers a macro view comprising of all the needed details as well as comparatively larger samples, these methods allows for the evaluation of multiple data sets to be conducted all at once and at an accurate and faster rate. The method helps in revealing what and to what extent however, it does not answer more on how and why.  Another weakness of the method is that it involves the supply of quants in limited numbers and it generally involves complex disciplines that are usually hard to master.


Other valuable research methodologies will not be considered in this research due to specific factors. One of these methods is the Case Study design (10). This method will not be used because it requires a larger sample size for a longer duration (11). This is because the technique involves identifying persons based on the history of exposure time, which, in most cases, requires extra time to come up with reliable data. Additionally, the method involves identifying the causal agent of a disease, which in this case, the knowledge about HIV/AIDS is  clear about the causal agent and the transmission mode (11). The second research method is the cohort study because of its requirements in terms of sample size and the sampling procedure. The task requires a larger sample size where the studies are conducted for a period not less than a year to develop quality data (11). Considering this research will be addressing the factors impacting a population by a known disease, the method will not fit in designing this research.


Research setting

The research will be set in Tobago; an Island located on the Eastern side of the Caribbean within the republic of Trinidad and Tobago .All of the Study will be conducted at the Tobago Health Promotion Clinic which is located in Scarborough Tobago. The Health Promotion Clinic is an Outpatient HIV Clinic that provides Patients in Tobago with clinical care, including laboratory investigations and medications the Health Promotion Clinic at this point serves appropriately 460 clients This institution was chosen because access to patients in a familiar and confidential setting can be achieved. The study will involve the use of semi-structured interviews and a multiple case study approach to HIV-positive patients from the Health Promotion Clinic..



The target population for this study will include, both male and female adults, who are within the ages of 18-65 years. A sample will be obtained from the HIV/AIDS database of Tobagonian persons who utilize health care services at Health Promotion Clinic Scarborough Tobago. The inclusion and exclusion criteria are as follows:


Inclusion Criteria:


  • This Study will involve identifying and selecting potential participants that will meet the context of the Study, which is patients tested positive for HIV/AIDS and are between the age of 18 to 65 years old Those who will be available and willing to participate in the Study who can communicate and articulate their experiences or viewpoints expressively and reflectively will be given the first priority to participate.
  • Tobagonian participants who will be recorded to have used both inpatient and outpatient services to manage their state of HIV/AIDS infection at Scarborough General Hospital and the Health Promotion Clinic over the past five (5) years.

Exclusion Criteria:

  • Persons below the age of 18 years will be excluded.
  • Persons identified as visitors at the Health Promotion Clinic will be excluded because the Study seeks to assess only Tobagonians to develop reliable data based on Tobago patients living with HIV/AIDS.
  • Pregnant Women and adults over the age of 65.






To determine the sampling framework, a list of HIV patients who receive treatment at the Tobago Health Promotion Clinic was obtained. The Tobago Health Promotion Clinic is the only Outpatient HIV treatment clinic in Tobago at this time. The most updated list suggests a client list of 460 patients.


To calculate the Initial Sample Size we can apply the formula:





= 384 participants.


Where: Z = 1.96 (at a 95% confidence interval), p = estimated prevalence, d = desired margin of error.


In the next step of sample size considerations we can apply a Finite Population Correction Factor as the calculated sample size is greater than 5% of total population to be sampled.

We can apply the formula:



= 210 participants.


It is estimated that 90% of the approached participants will be willing to respond. To adjust for expected Non-responders we can apply the formula:



= 233 participants.

Where n = calculated sample size, k = estimated non-response proportion.




















The Study will utilize semi-structured interviews that are commonly used in health-care-related qualitative studies, mainly when the Study is concerned with interpersonal aspects of care when the available evidence is limited (10).  Open-ended questions will be developed to assess how the participants are affected by the socioeconomic factors and how well they manage to regulate their dietary patterns. The interview questions will be kept simple to potentiate receiving the correct responses in the aspect of understanding (8). Validating the instruments, which will constitute open-ended questionnaires and interviews, will involve various steps. Face validity will be established for the interviews by the interviewer at the Health Promotion Clinic in Scarborough. An evaluation to whether the questions capture the significant concepts based on the hypotheses developed for this Study (11).



Data collected from the questionnaires will be entered into IBM SPSS version 25.0.  Descriptive statistics will be used to describe the characteristics of the socioeconomic factors and the role nutrition play in the life of the person living with HIV. Dietary patterns will be assessed using the dietary questionnaires, assessment calibration, and the automated 24-hour nutritional assessment tool (ASA24). The dietary questionnaires’ will be conducted at the Tobago Health Promotion Clinic in Scarborough. The questionnaires will be revised using 20 participants to improve the pilot study’s validity (15). Subdomains will be constructed using the content developed under the constituency’s three items: the interviews, questionnaires, and nutrition scales. This piloting will help develop the nutrition knowledge based on the practice and the attitudes of the participant







Approval will be sought from the Ethics Committee of the Tobago Regional Health Authority regarding course of ethical action. Consent will also be sought from the General Manager Primary Care regarding accessing the participants’ medical files. Authorization will be sought from the Ethics Committee of the University of the West Indies St. Augustine. Selected participants will be verbally invited to participate in the Study; upon acceptance, a written consent form will be provided before the interview process (16). This document will contain objectives of the Study stated clearly, including the mode of data collection, notification of the voluntary participation, notification of their right to withdraw from the Study at any time during the research process, and the right to decline to answer any questions during the interview. Protection of the participants through the assurance of confidentiality of information shared, and the use of pseudonyms will achieve anonymity of identity (16); the commitment to participants that the information they share would be used only for the Study, the assurance that provisions will be made to secure the transcripts, and that the digital audio recordings will only be used for the transcription of information they shared. Participants will be informed that transcripts would be made available to them to verify the information documented. To achieve beneficence’s ethical principles, the participants will be informed that they might be asked to discuss sensitive information, which they will be under no obligation to share if it would be a potential source of distress to them.









USAID. [Online].; 2019 [cited 2020 November 19th. Available from:


Simpson F HF. Nutrition and AIDS in the Caribbean: Looking beyond survival. Journal of Epidemiological Research. 2017; 3(1): 1-15.


Khatri S AASB. Nutritional status and the associated factors among people living with HIV/AIDS: an evidence from a cross-sectional survey in hospital-based antiretroviral therapy site in Kathmandu, Nepal. BMC Nutrition Journal. 2020; 6(22): 2-8.


Martin R SMSJEGREASea. Dietary patterns and nutritional status on HIV-infected children and adolescents in El Salvador. A cross-sectional study. PLoS One. 2018; 13(5): 196-380.


Ogunmola OJ OOOA. Relationship between socioeconomic status and HIV infection in a rural tertiary health center. HIV/AIDS (Auckl). 2014; 6(1): 61-78.


  1. F. Review of HIV in the Caribbean: significant progress and outstanding challenges. Current HIV/AIDS Research. 2014; 11(2): 158-167.


Denzin N LY. Handbook of qualitative research. 1st ed. New York: Thousand Oaks: Sage Publications ; 1994.


Hammerberg K KMLS. Qualitative research methods: when to use them and how to judge them. Human Reproduction and Research. 2016; 31(3): 498-501.


Creswell J PC. Qualitative inquiry and research design. 3rd ed. New York: Sage Publications Inc.; 2012.


  1. T. Sampling methods in research methodology; How to choose a sampling technique for research. SSRN Electronic Journal. 2017; 5(2): 18-27.


Bhukari S. Slideshare. [Online].; 2019 [cited 2020 November 19th. Available from:



Skelly A DJBE. Assessing bias: the importance of considering confounding. Evidence-Based Spine Care Journal. 2012; 3(1): 9-12.


Ferreira J PC. Subgroup analysis and interaction tests: why they are important and how to avoid common mistakes. SCIELO. 2017; 43(3): 162.


  1. S. Methodology Series Module 3: Cross-sectional Studies. 2016; 61(3): 261-264.


BMJ Authors. BMJ Journals. [Online].; 2020 [cited 2020 November 19th. Available from:


Tarboush N AZAKDW. The understanding of research ethics at health sciences schools in Jordan: a cross-sectional study. BMC Medical Education. 2020; 121(1): 1


















Dear Patient,

I invite you to participate in this Research Study being conducted to evaluate how Nutrition and other Socioeconomic Factors affect the life of a person living with HIV in Tobago.  The study will be conducted by Dr. Ryan Kumar. The method used to meet this purpose is a semi-structured interview which will be audio recorded by digital recorder. It is estimated that the interview will take around 45 minutes, but please take your time when answering questions. Your participation in this study is voluntary, and you are free to withdraw at any time before or during the interview process. Should you choose to withdraw, all information collected (including tape recordings) will be destroyed and omitted from the final paper.  Our interview will be audio taped by digital recorder for the purpose of capturing your insights in your own words. The recording will only be heard by the researcher. Please feel free to voice any discomfort with this procedure, and the recorder will be turned off at any time.  Direct quotes from you may be used in the paper. However, your identity will be kept anonymous, as a pseudonym will be used. There will be non-disclosure of your personal information outside of the purpose of this paper. The interview questions may require you to speak about sensitive issues. It is always your choice to refrain from answering any question you are uncomfortable with.


By signing this consent form, I certify that I have read the above, and agree to the terms of this agreement:  __________________________________________










SECTION A: Demographics


Please indicate your gender


  • Male
  • Female


Please select the category that includes your age.


  • 8-24
  • 25-34
  • 35-44
  • 45-54
  • 55-65


What best describes your martial status


  • Single
  • Married
  • Living with a partner
  • Separated
  • Divorce
  • Widowed



Please specify ethnicity


  • Afro-Tobagonian
  • Indo-Tobagonian
  • Mixed Tobagonian
  • Caucasian
  • Other


What is the highest level of education you have attained?

  • Primary
  • Secondary
  • Tertiary



What is your current occupation?





What is your employment status?


  • Full-time
  • Part-time
  • Seasonal worker
  • Unemployed



Can you give me an estimate of your average monthly income?



  • under 2400
  • 2500-3500
  • 3600-4500
  • 4600-5500
  • above 5600



How many dependents do you have?


  • 0
  • 1
  • 2
  • 3 and above


Are you a member of any community or social associations?


  • Yes
  • No




Are you receiving any assistance from the government?


  • Public Assistance
  • Dietary Grant
  • Food Card
  • Pharmaceutical Grant
  • Rental Assistance









SECTION B: Medical and Social History



What is your current diagnosis?  _____________________________


Do you have any other co-morbidities or other medical issues?

  • Yes
  • No


How many medications do you currently take?




Have you had the need for surgical intervention in the past?

  • Yes
  • No



Do you use alcohol?


  • Yes
  • No


Do you smoke? (Probe: cigarette use, marijuana use)

  • Yes
  • No



Are your immunization/vaccinations up-to-date?

  • Yes
  • No




How do you feel about your current state your health?




How do you feel about your emotional health?





How do you feel about your quality of life?








PATIENT No:——————————–                                 DATE:————————


Medication/Vitamins/ Supplements:———————————————————————————————————————————————————————————————


Medical History/ Other Ailments:————————————————————————————



Meal and Time Actual Food




























WEIGHT :———–   HEIGHT:————–   OTHER:————————————————–


Food Allergies:————————– Mechanical Problems:——————————————-


Labs: ——————————————————————————————————————–

——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————–Exercise: —————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————-







Fats:                —————————————————————————————————

Seasonings:     —————————————————————————————————

Beverages:       —————————————————————————————————

Other:              ——————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————










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