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Food Insecurity Predicts Worse Outcomes for People with HIV

Lack of adequate nutrition was associated with reduced adherence to antiretroviral treatment, incomplete viral load suppression, and lower CD4 cell counts among HIV positive people in both Uganda and San Francisco, according to 2 recently published studies.

The advent of effective combination antiretroviral therapy (ART) has dramatically reduced illness and death among people with HIV in industrialized countries, and expanding availability of ART has begun to do the same in resource-limited settings worldwide. But food insecurity remains a barrier to successful HIV treatment in rich as well as poor countries.

Rural Uganda

As described in the August 9, 2013, advance online edition of AIDS, Sheri Weiser from San Francisco General Hospital and the University of California at San Francisco and colleagues conducted a longitudinal cohort study looking at associations between food insecurity and HIV treatment outcomes in rural Uganda.

The analysis included 438 participants in the Uganda AIDS Rural Treatment Outcomes study, who underwent blood draws and structured interviews every 3 months, for a median follow-up duration of 33 months.

The researchers assessed food insecurity using the validated Household Food Insecurity Access Scale. Primary outcomes were ART non-adherence, incomplete viral load suppression, and low CD4 cell count.

Results

• 79% of participants were found to be food insecure at baseline.
• After adjusting for other socio-demographic and clinical factors, food insecurity was significantly associated with:

o   Higher likelihood of ART non-adherence (<90%): adjusted odds ratio (OR) 1.56;

o   Incomplete viral load suppression (>400 copies/mL): adjusted OR 1.52;

o   Low CD4 T-cell count (<350 cells/mm³): adjusted OR 1.47.

• When adherence was included as a covariate in the other 2 models, this eliminated the association between food insecurity and viral suppression, but not between food insecurity and CD4 count.

"Food insecurity is longitudinally associated with poor HIV outcomes in rural Uganda," the study authors concluded. "Intervention research is needed to determine the extent to which improved food security is causally related to improved HIV outcomes and to identify the most effective policies and programs to improve food security and health."

San Francisco

In a separate study, described in the August 6, 2013, online edition of AIDS, Weiser's team also looked at food insecurity among homeless and marginally housed people with HIV in San Francisco, which pioneered the public health response to AIDS in the early 1980s.

This analysis included 284 HIV positive individuals in the San Francisco Research on Access to Care in the Homeless cohort. Again, participants underwent quarterly blood draws and structured interviews. The study ran from May 2007 to March 2010, with a median follow-up duration of 22 months.

Food security was assessed using the same Household Food Insecurity Access Scale, but this study used lower viral load and CD4 count thresholds.

Results

• 55% of participants were food insecure at baseline.
• Again, food insecurity was significantly associated with:

o   Increased odds of ART non-adherence: adjusted OR 1.48;

o   Incomplete viral load suppression (>50 copies/mL): adjusted OR 1.29;

o   Low CD4 count (<200 cells/mm³): adjusted OR 1.26.

• When adherence was included in multivariate models, the associations between food insecurity and incomplete viral suppression and low CD4 count remained, but the magnitude of the effect decreased slightly.

"Food insecurity was associated with poor HIV outcomes, including non-adherence, in a longitudinal study of US-based HIV-infected unstably housed individuals," the researchers wrote. "Efforts to address food insecurity should be included in HIV-treatment programs, and may help improve health outcomes."

9/4/13

References

SD Weiser, K Palar, EA Frongillo, DR Bangsberg, et al. Longitudinal assessment of associations between food insecurity, antiretroviral adherence and HIV treatment outcomes in rural Uganda. AIDS. August 9, 2013 (Epub ahead of print).

SD Weiser, C Yuan, D Guzman, MB Kushel, et al. Food insecurity and HIV clinical outcomes in a longitudinal study of homeless and marginally housed HIV-infected individuals in San Francisco. AIDS. August 6, 2013 (Epub ahead of print).