Intestinal helminth and protozoan infections remain common causes of morbidity in low-resource settings and can have amplified consequences in people living with HIV. HIV-associated immunosuppression, particularly when CD4 counts fall below 200 cells/µL, predisposes patients to more severe or opportunistic intestinal parasitic infections. Prior regional and global reviews indicate higher pooled prevalence of intestinal parasites among HIV-positive populations compared with the general population. In North Shoa Zone, Ethiopia, routine diagnostic capability in public hospitals has been limited, often relying only on direct wet mount microscopy, which may underestimate true prevalence. The present study was designed to determine the prevalence of intestinal parasites and identify associated factors among HIV-positive patients receiving ART at selected public hospitals in the North Shoa Zone.
A hospital-based cross-sectional study was performed from February to May 2024 in North Shoa Zone, Oromia Region, Ethiopia. The zone comprises multiple districts and public health facilities; four hospitals were randomly selected for the study: Salale University Comprehensive Specialized Hospital, Kuyu General Hospital, Chanco General Hospital, and Mukaturi Hospital.
The source population included all HIV patients receiving ART at public hospitals in the North Shoa Zone. Eligible participants were adults receiving ART at the selected hospitals during the study period, excluding those who had taken anti-parasitic medications within the previous two weeks or who were severely ill at data collection. The sample size was calculated based on a prior prevalence estimate, incorporating design effect and non-response allowance, yielding a final sample of 493 participants. A multistage sampling approach allocated proportionate samples to each hospital, and systematic random sampling selected individual participants.
Socio-demographic and clinical data—including age, sex, residence, drinking water source, hand-washing practices, toilet availability, WHO disease stage, and recent treatment history—were collected using a structured questionnaire after written informed consent. Stool specimens were provided by participants and processed in hospital laboratories.
Laboratory examination combined three microscopy-based methods: a direct wet mount with normal saline and Lugol’s iodine for initial detection; the formol–ether concentration technique to increase parasite recovery from preserved stool; and a modified Ziehl–Neelsen staining procedure for detection of coccidian parasites. Stool preservation in 10% formalin was performed when needed, and standard centrifugation and sediment examination procedures were described for the concentration method.
A total of 493 HIV-positive patients on ART were included. The mean age of participants was 43.26 years (SD ±12.38), and 61.1% resided in rural areas. Using the combined microscopy approaches, the overall prevalence of intestinal parasitic infection was 28% (95% CI: 24.1–31.8).
Bivariate and multivariable logistic regression analyses identified several variables associated with intestinal parasitic infection. In multivariable analysis, three factors were significantly associated with infection:
Other covariates examined in the study included age, sex, educational status, hand-washing habit, presence of a toilet, WHO stage, and history of eating uncooked vegetables; the manuscript reports the above three variables as independently associated in multivariable models.
The study documents a substantial burden of intestinal parasites among people living with HIV on ART in public hospitals of North Shoa Zone, with nearly one in four participants testing positive using microscopy-based methods. The association with rural residence and use of unprotected water sources highlights environmental and infrastructure determinants that likely increase exposure to parasitic transmission. The strong association with low CD4 counts aligns with known immunologic susceptibility to opportunistic and more severe parasitic infections in advanced HIV disease.
The authors note diagnostic limitations in many local facilities—where direct wet mount may be the sole routine test—that could lead to under-detection of parasites. By applying concentration and staining techniques in this study, detection sensitivity was improved compared with direct microscopy alone, but the cross-sectional design prevents assessment of temporality or causal inference.
Intestinal parasitic infections were common among HIV-positive patients receiving ART in the surveyed North Shoa public hospitals. Key independent risk factors included rural residence, CD4 count below 200 cells/µL, and reliance on unprotected drinking water. The authors recommend routine stool examination particularly for patients with low CD4 counts and interventions to improve access to safe drinking water in rural areas. They also call for longitudinal research with comprehensive assessment of additional risk factors. The study’s anonymized dataset has been made publicly available in a Zenodo repository.