Food insufficiency and medication adherence among people living with HIV/AIDS in urban and peri-urban settings

Global prevalence of suicide in patients living with HIV/AIDS: A systematic review and meta-analysis

BACKGROUND

In fact, people living with HIV are at a greater risk of mental health disorders. Based on lack of necessary information in this area the present systematic review and meta-analysis study was conducted to determine the magnitude of committed suicides among HIV/AIDS people as well as their associated factors in a global setting.

METHOD

Firstly we registered the protocol of study in PROSPRO. Then the publications were searched in the 4 main databases from January 2000 to April 2022. After removing duplication and inappropriate studies we applied inclusion and exclusion criteria. Finally 60 studies were included for analysis. Comprehensive meta-analysis software were used for analyzing.

RESULTS

After reviewing 60 articles published from January 2000 to April 2021 in 24 countries, the total prevalence rate of suicide among 61,904 patients was estimated at 0.249 (95 % CI, 0.2-0.306). Findings indicated that the highest suicide prevalence was related to single patients estimated at 0.257 (95 % CI, 0.184-0.347). A gender-based meta-analysis depicted that the prevalence of suicide/ suicidal ideation was higher among females estimated at 0.22 (95 % CI, 0.15-0.29) compared with men at 0.17 (95 % CI, 0.11-0.23).

CONCLUSION

Health planners and policymakers should develop suicide-prevention strategies aimed at female patients in younger age groups who live alone and are deprived of social support to effectively promote their self-efficacy in successful management of the disease. Integrating mental health services into anti-retroviral therapy for HIV/AIDS patients is also suggested in order to effectively design integrated programs for the management of individuals living with HIV/AIDS.

Employment as HIV Prevention: An Employment Support Intervention for Adolescent Men Who Have Sex With Men and Adolescent Transgender Women of Color

BACKGROUND

The purpose of this study was to adapt and pilot-test an employment support, primary HIV intervention tailored to the needs of adolescent men who have sex with men and adolescent transgender women of color.

SETTING

The intervention was implemented in 2 settings: controlled environment (Phase 1) and real-world community-based (Phase 2) setting in Chicago, IL.

METHODS

Eighty-seven adolescent men who have sex with men and adolescent transgender women of color ages 16-24 participated in Work2Prevent , a 4-session employment and HIV prevention intervention, designed to increase job-readiness and reduce HIV risk. Intervention sessions consisted of group activities: educational games, roleplaying/modeling behavior, and self-regulation exercises. Participants were assessed at baseline, postintervention, and 8-month (Phase 1) or 3-month follow-up (Phase 2).

RESULTS

Participants evaluated Work2Prevent as feasible and acceptable, rating intervention quality, usefulness, and satisfaction highly. Overall, 59.6% (Phase 1) and 85.0% (Phase 2) participants attended 2 or more sessions. At 8 months, Phase 1 participants reported a mean increase of 11.4 hours worked per week. Phase 2 participants reported a mean increase of 5.2 hours worked per week and an increase in job-seeking self-efficacy. Phase 2 participants also reported a decrease in transactional sex work.

CONCLUSION

Work2Prevent is one of the first structural primary HIV interventions to specifically focus on adolescent employment readiness. Findings suggest Work2Prevent is feasible and acceptable, improved adolescent employment outcomes, and reduced HIV risk associated with transactional sex work. Our study underscores the need for alternative pathways, such as addressing socioeconomic determinants, to prevent adolescent HIV infection.

Factors associated with non-adherence to antiretroviral therapy among female sex workers living with HIV in Hyderabad, India

We determined factors associated with non-adherence (consuming <90% of monthly antiretroviral therapy) among female sex workers (FSWs). An interviewer-administered questionnaire was used in a sample of 100 South Indian FSWs living with HIV. We examined demographics, food insecurity, side effects, stigma, alcohol/substance use and self-efficacy. Non-adherence was assessed by self-report, pill-count and combined measures. Prevalence ratios and 95% confidence intervals (CIs) were calculated at p-value <0.1. Thirty-seven percent (33/90) of FSWs were non-adherent by pill-count, 29% (28/95) by self-report and 52% (51/99) by the combined measure. Seventy-six percent (76/100) of FSWs reported experience of at least one form of food insecurity in the past six months. In the regression analysis, arrest in the past year was independently associated with the combined measure of non-adherence (crude prevalence ratios 1.7, 95% CI 1.0-2.8). A successful combination adherence intervention should consider several of the socio-behavioral factors identified in this study including arrest and food insecurity.

The Relation of Age on HIV-Positive Women's Cluster of Differentiation 4, Antiretroviral Therapy, Papanicolaou Test, Human Papillomavirus test and Visual Inspection with Acetic Acid

Despite increased life expectancy, mortality rates among women infected with HIV are 3-15 times higher than those in the overall population, HIV-infected women are also excessively affected by HPV and have increased risks of HPV-associated developments. This study's objective is to examine the relation between the ART treatment, CD4 levels, Pap, HPV and VIA tests with p16 detection among HIV-infected women. The data used in this study was collected by survey questionnaire instruments in 2009 in Kenya. Descriptive and explanatory statistics using frequency and chi-square/fisher's exact tests were performed for analysis using SAS-software. The data was stratified by age groups (30-39, 40-49, and 50 years and older). 75.28% of single HIV-positive women between the ages 30-39 participated significantly in the study, with a p-value of <0.0001. 52.24% of HIV-positive women 30-39 years old were most likely to receive ART treatment for less than two years by a margin of 11.2% compared to those who received the treatment for more than two years and those who were off treatment by a margin of 2.24% (p-value of 0.03). The HIV-positive women 30-39 years old had lower CD4 counts of less than 350 cells/μl (44%) and higher CD4 counts of 500 cells/μl or higher (46.64%). 45.3% of the HIV-positive women 30-39 years old were more likely to have positive VIA tests with a p-value of 0.05. 65.87% of HIV-positive women 30-39 years old were most likely to have positive VIA tests with a p-value of <0.05. HIV-positive women 30-39 years old were most likely to have high-risk HPV compared to their older counterparts. This study shows that incorporating screening strategies (Pap tests, VIA tests and HPV genotyping) in conjunction with ART treatment were more effective in preventing cervical cancer in HIV-positive young women 30-39 years old.

Food Insecurity Is Associated With Lower Levels of Antiretroviral Drug Concentrations in Hair Among a Cohort of Women Living With Human Immunodeficiency Virus in the United States

BACKGROUND

Food insecurity is a well-established determinant of suboptimal, self-reported antiretroviral therapy (ART) adherence, but few studies have investigated this association using objective adherence measures. We examined the association of food insecurity with levels of ART concentrations in hair among women living with human immunodeficiency virus (WLHIV) in the United States.

METHODS

We analyzed longitudinal data collected semiannually from 2013 through 2015 from the Women's Interagency HIV Study, a multisite, prospective, cohort study of WLHIV and controls not living with HIV. Our sample comprised 1944 person-visits from 677 WLHIV. Food insecurity was measured using the US Household Food Security Survey Module. ART concentrations in hair, an objective and validated measure of drug adherence and exposure, were measured using high-performance liquid chromatography with mass spectrometry detection for regimens that included darunavir, atazanavir, raltegravir, or dolutegravir. We conducted multiple 3-level linear regressions that accounted for repeated measures and the ART medication(s) taken at each visit, adjusting for sociodemographic and clinical characteristics.

RESULTS

At baseline, 67% of participants were virally suppressed and 35% reported food insecurity. In the base multivariable model, each 3-point increase in food insecurity was associated with 0.94-fold lower ART concentration in hair (95% confidence interval, 0.89 to 0.99). This effect remained unchanged after adjusting for self-reported adherence.

CONCLUSIONS

Food insecurity was associated with lower ART concentrations in hair, suggesting that food insecurity may be associated with suboptimal ART adherence and/or drug absorption. Interventions seeking to improve ART adherence among WLHIV should consider and address the role of food insecurity.

Digital HIV Care Navigation for Young People Living With HIV in San Francisco, California: Feasibility and Acceptability Study

BACKGROUND

HIV continues to be a public health challenge adversely affecting youth and young adults, as they are the fastest-growing group of new HIV infections in the United States and the group with the poorest health outcomes among those living with HIV. HIV prevention science has turned to mobile health as a novel approach to reach and engage young people living with HIV (YPLWH) experiencing barriers to HIV care.

OBJECTIVE

This study aimed to assess the feasibility and acceptability of a text message-based HIV care navigation intervention for YPLWH in San Francisco. Health eNavigation is a 6-month text message-based HIV care navigation where YPLWH are connected to their own HIV care navigator through text messaging to improve engagement in HIV primary care. Digital HIV care navigation included delivery of the following through SMS text messaging: (1) HIV care navigation, (2) health promotion and education, (3) motivational interviewing, and (4) social support.

METHODS

We evaluated the feasibility and acceptability of a text message-based HIV care navigation intervention among YPLWH. We assessed feasibility using quantitative data for the overall sample (N=120) to describe participant text messaging activity during the intervention. Acceptability was assessed through semistructured, in-depth interviews with a subsample of 16 participants 12 months after enrollment. Interviews were audio-recorded, transcribed, and analyzed using grounded theory.

RESULTS

Overall, the text message-based HIV care navigation intervention was feasible and acceptable. The majority of participants exhibited medium or high levels of engagement (50/120 [41.7%] and 26/120 [21.7%], respectively). Of the majority of participants who were newly diagnosed with HIV, 63% (24/38) had medium to high engagement. Similarly, among those who were not newly diagnosed, 63% (52/82) had medium to high engagement. The majority of participants found that the intervention added value to their lives and improved their engagement in HIV care, medication adherence, and viral suppression.

CONCLUSIONS

Text message-based HIV care navigation is a potentially powerful tool that may help bridge the gaps for linkage and retention and improve overall engagement in HIV care for many YPLWH. Our results indicate that participation in text message-based HIV care navigation is both feasible and acceptable across pervasive structural barriers that would otherwise hinder intervention engagement.

Neighborhood Alcohol Environment: Differential Effects on Hazardous Drinking and Mental Health by Sex in Persons Living with HIV (PLWH)

Despite greater mental health co-morbidities and heavier alcohol use among PLWH, few studies have examined the role of the neighborhood alcohol environment on either alcohol consumption or mental health. Utilizing cross-sectional data from a cohort study in a southern U.S. metropolitan area, we examine the association between neighborhood alcohol environments on hazardous drinking and mental health among 358 in-care PLWH (84% African American, 31% female). Multilevel models were utilized to quantify associations between neighborhood alcohol exposure on hazardous drinking and effect modification by sex. Neighborhood alcohol density was associated with hazardous drinking among men but not women. Women living in alcohol dense neighborhoods were nearly two-fold likely to report depression compared to those in less dense neighborhoods, with no association between neighborhood alcohol density and depression among men. Neighborhood alcohol environments may be an important contextual factor to consider in reducing heavy alcohol consumption and improving mental health among PLWH.

Food Insecurity and Unmet Needs Among Youth and Young Adults Living With HIV in the San Francisco Bay Area

PURPOSE

Little is known about food insecurity and unmet subsistence needs and their association with antiretroviral therapy adherence among youth and young adults living with HIV (YLWH).

METHODS

We conducted a cross-sectional survey to examine this association in 101 YLWH (aged 18-29 years). Poisson regression models with robust standard errors were used to estimate adjusted risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

Approximately 51.7% of participants experienced at least one unmet subsistence need (difficulty finding enough to eat [36.6%], clothing [22.8%], place to sleep [21.8%], place to wash [17.8%], and bathroom [15.8%]), and 64.2% reported being food insecure. For every additional unmet need, the risk of very good/excellent adherence was reduced by 15% (RR = .85; 95% CI = .72-.99; p value = .04). The risk of very good/excellent adherence was lowered by 39% (RR = .61; 95% CI = .43-.87; p value = .005) among food insecure youth, compared with those who were food secure.

CONCLUSIONS

These data highlight the need for more research and structural interventions targeting food assistance strategies among YLWH.

Social Inequity and Structural Barriers to Completion of Ecological Momentary Assessments for Young Men Who Have Sex With Men and Trans Women Living With HIV in San Francisco

Background

Ecological momentary assessments (EMAs) administered via text messaging facilitate real-time data collection. With widespread cell phone access, EMAs are becoming more available to even the most disenfranchised communities, such as those living with HIV. However, structural barriers disproportionately burden young men who have sex with men (MSM) and trans women (TW) living with HIV and threaten participation in HIV research.

Objective

We aim to identify structural barriers to completing EMA text surveys nested within a digital HIV care intervention for young MSM and TW living with HIV in San Francisco.

Methods

A total of 10,800 EMA text messages were delivered daily over 90 days to 120 participants enrolled in the Health eNav intervention (2017-2018) at the San Francisco Department of Public Health. EMA surveys inquired about participants’ daily affect, sexual behaviors, substance use, and treatment adherence. Survey completion was calculated after 30, 60, and 90 days of follow-up. We described characteristics of nonstarters (those who provided less than four complete responses to the first seven EMA surveys) and analyzed structural correlates of days to first weeklong or more EMA survey noncompletion using multivariable Cox proportional hazards regression. Qualitative interviews were used to evaluate the acceptability of EMA surveys.

Results

Participants completed 4384 of 10,800 (40.59%) EMA surveys. Completion of 70% or more of EMA surveys was attained by 56 of 120 participants (46.7%) at 30 days of follow-up, 40/120 (33.3%) at 60 days of follow-up, and 30/120 (25.0%) by the end of the 90-day study period. Twenty-eight participants (23.3%) were identified as nonstarters, and were more likely to be recently incarcerated (prevalence ratio [PR] 2.3, 95% CI 1.3-4.4), forego basic needs for HIV medications (PR 2.4, 95% CI 1.3-4.5), and be diagnosed with HIV in the last year (PR 2.2, 95% CI 1.1-4.1). Adjusting for nonstarters, young MSM and TW living in temporary/transitional housing (adjusted hazard ratio [aHR] 1.8, 95% CI 1.1-3.0), foregoing HIV medications to afford basic needs (aHR 1.7, 95% CI 1.1-2.7), and having less than a college education (aHR 3.5, 95% CI 1.4-9.0) had greater hazard of weeklong or more EMA survey noncompletion. Overall, there was high acceptability of the EMA surveys.

Conclusions

Although access to and use of technology is increasingly ubiquitous, this analysis demonstrates persisting gaps in EMA completion by socioeconomic factors such as incarceration, education level, housing, and competing needs for young MSM and TW living with HIV in San Francisco. Moreover, those recently diagnosed with HIV were more likely to experience an immediate drop-off in completing EMA surveys. EMAs are feasible for individuals not experiencing social inequity and structural barriers. HIV prevention technologies addressing these barriers and leveraging similar methodology may prove effective for young MSM and TW living with HIV.

Social determinants of health and self-rated health status: A comparison between women with HIV and women without HIV from the general population in Canada

BACKGROUND

Women living with HIV (WLWH) continue to experience poorer outcomes across the HIV care cascade and overall health, an appreciable proportion of which may not be disease-related but due to socio-structural barriers that impact health. We compared socio-structural determinants of health and self-rated health between WLWH and expected general population values.

METHODS

Prevalences of socio-structural determinants and self-rated health were estimated from 1,422 WLWH aged 16+ in the 2013-2015 Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Prevalences were also estimated from 46,831 general population women (assumed HIV-negative) in the 2013-2014 Canadian Community Health Survey (CCHS), standardized to the age/ethnoracial group distribution of WLWH. Standardized prevalence differences (SPDs) and 95% confidence intervals (CI) were reported.

RESULTS

Compared to general population women, a higher proportion of WLWH reported annual personal income <$20,000 (SPD 42.2%; 95% CI: 39.1, 45.2), indicating that 42.2% of WLWH experienced this low income, in excess of what would be expected of Canadian women of similar ages/ethnoracial backgrounds. A higher proportion of WLWH reported severe food insecurity (SPD 43.9%; 40.2, 47.5), poor perceived social support (SPD 27.4%; 22.2, 33.0), frequent racial (SPD 36.8%; 31.9, 41.8) and gender (SPD 46.0%; 42.6, 51.6) discrimination, and poor/fair self-rated health (SPD 12.2%; 9.4, 15.0).

CONCLUSIONS

Significant socio-structural inequalities and lower self-rated health were found among WLWH compared to general population women. Such inequities support the integration of a social-determinants approach, social service delivery, and programming into HIV care, with additional resource allocation tailored to the particular needs of WLWH.

HIV Positive Patients' Experience of Receiving Health Care Services: A Phenomenology Study in Iran

Introduction:

Most of the studies on HIV/AIDS health care status are usually conducted in big cities while small towns and rural areas are faced with specific challenges. This study aimed to identify the barriers and problems encountered by HIV-positive patients when receiving health services in the small cities and rural areas of Iran.

Methodology:

This is a qualitative study that was conducted using an interpretive phenomenology method in 2016. This study was conducted through a semi-structured interview for which a purposeful sampling method was used. In the present study, data saturation was observed after 15 interviews, but more than 17 interviews were conducted to ensure the reliability of the interview. Data were analyzed by Colaizzi's method using MAXQDA10 software.

Findings:

Barriers and problems encountered by patients when receiving health care services consisted of 10 categories, 32 main themes and 67 sub-themes. The categories were as follows: fear of revealing the disease, fear of confronting providers, seeking support, not visiting health care providers, inappropriate behavior of health care staff, concealing the disease, hardship endurance, financial concerns, psychological stress and pressure, and disclosure of patient information.

Conclusion:

Recognizing the problems of HIV-positive patients in using health care services and resolving them can help to reassure the patients about the health system. Introduction of supporting policies and regulations, appropriate public education, training health sector personnel, and provision of medical equipment and facilities would positively affect the process of solving the problems of HIV-Patients (treating HIV patients).

Considering high alcohol and violence neighborhood context using daily diaries and GPS: A pilot study among people living with HIV

Our understanding of how community-level context impacts care of persons living with HIV (PLWH), including antiretroviral therapy (ART) adherence and retention in care, is limited. The objective of this study was to characterize the activity spaces of PLWH from an urban area in Southeastern U.S., where the epidemic is among the nation's highest, and to examine how such activity spaces are associated with daily mood and health behaviors. In this small, pilot study, 11 participants were tracked with a global positioning system (GPS)-enabled application on their smartphones for 2 weeks. Activity spaces were created by connecting GPS points sequentially and adding buffers. Contextual exposure data (e.g., alcohol outlets) were connected to activity spaces. Participants also completed daily diary entry through texts 3 times per day regarding outcomes of substance use behaviors, mood, and medication adherence. This yielded a total of 18,007 GPS polyline records that we aggregated into 258 person-days that captured discrete occasions of exposure to contextual factors and subjects' behaviors and moods. On average, the participants spent 19% of their time awake during the 2-week periods in their residential census tract. Exposure to social and built environment factors such as alcohol outlets was greater when participants were outside versus inside their residential census tract. Exposures on daily routes were also significantly associated with ART adherence, alcohol consumption, and mood. Findings suggest substantial differences between activity spaces and residential contexts. Activity spaces are relevant for PLWH and may impact HIV care and behavioral outcomes such as ART adherence and substance use.

Use of Unannounced Telephone Pill Counts to Measure Medication Adherence Among Adolescents and Young Adults Living With Perinatal HIV Infection

Objective

To examine unannounced telephone pill counts as a measure of adherence to antiretroviral therapy among adolescents and young adults living with perinatal HIV infection.

Methods

Participants were recruited from an ongoing longitudinal study to complete four monthly, unannounced telephone pill counts. Detailed notes concerning participants' medication habits surrounding adherence were recorded.

Results

Two-thirds of 102 eligible participants aged 18-27 years participated; 57% were female, 69% were Black. Blacks and participants with viral loads >40 and >1,000 copies/ml were less likely to participate. Average adherence across calls was 77%. Those who completed all calls averaged significantly higher adherence scores than those who did not. Calls revealed adherence barriers at individual (e.g., medication disorganization), social (e.g., limited support), and system (e.g., pharmacy problems) levels.

Conclusions

Despite challenges, this procedure can be implemented with this population and can help identify adherence barriers important for interventions that address medication-taking behaviors.

Population Density and AIDS-Related Stigma in Large-Urban, Small-Urban, and Rural Communities of the Southeastern USA

AIDS stigmas delay HIV diagnosis, interfere with health care, and contribute to mental health problems among people living with HIV. While there are few studies of the geographical distribution of AIDS stigma, research suggests that AIDS stigmas are differentially experienced in rural and urban areas. We conducted computerized interviews with 696 men and women living with HIV in 113 different zip code areas that were classified as large-urban, small-urban, and rural areas in a southeast US state with high-HIV prevalence. Analyses conducted at the individual level (N = 696) accounting for clustering at the zip code level showed that internalized AIDS-related stigma (e.g., the sense of being inferior to others because of HIV) was experienced with greater magnitude in less densely populated communities. Multilevel models indicated that after adjusting for potential confounding factors, rural communities reported greater internalized AIDS-related stigma compared to large-urban areas and that small-urban areas indicated greater experiences of enacted stigma (e.g., discrimination) than large-urban areas. The associations between anticipated AIDS-related stigma (e.g., expecting discrimination) and population density at the community-level were not significant. Results suggest that people living in rural and small-urban settings experience greater AIDS-related internalized and enacted stigma than their counterparts living in large-urban centers. Research is needed to determine whether low-density population areas contribute to or are sought out by people who experienced greater AIDS-related stigma. Regardless of causal directions, interventions are needed to address AIDS-related stigma, especially among people in sparsely populated areas with limited resources.

Food Insecurity, HIV Disease Progression and Access to Care Among HIV-Infected Russians not on ART

Food insecurity (FI) has been associated with HIV disease progression among people on antiretroviral therapy (ART), presumably a consequence of poor medication adherence. We assessed whether there is a longitudinal association between FI and two primary outcomes reflecting on HIV disease progression (i.e., CD4 count and time to ART initiation) among people not on ART. Analyses used linear mixed effects and Cox models controlling for confounders. In this cohort (n = 310) FI was common (53%). Most (71.3%) reported past month heavy alcohol use and 37.1% reported past month injection drug use. Only 50 participants initiated ART during the study and mean time to ART was 128 days (SD 120). There were no significant differences in CD4 cell count between the groups with mild/moderate FI or severe FI versus those with no FI [adjusted mean difference, mild/moderate insecurity versus no FI -32.5 (95% CI -94.3, 29.3); severe versus no FI -45.5 (95% CI -124.1, 33.0); global p = 0.42]. We found no significant association between FI and longer time to ART initiation (p = 0.36). Food security is a desirable goal for overall health and shown beneficial for those on ART, however it does not appear to be associated with HIV disease progression among those with high prevalence of substance use and not yet on ART.

Antiretroviral Adherence Perspectives of Pregnant and Postpartum Women in Guyana

The Caribbean region has the second highest HIV prevalence after Sub-Saharan Africa. Guyana's adult HIV prevalence is 1.9% among pregnant women, with women accounting for an estimated 58% of all persons living with HIV. However, there are few studies on ART adherence in the Caribbean, none from Guyana, and none focusing on adherence in pregnancy and the postpartum period. The objective of this study was to explore the perspectives of HIV-infected pregnant and postpartum women and healthcare providers in Guyana about barriers and facilitators to ART adherence. Data was collected using semi-structured interviews with 24 HIV-infected pregnant and postpartum women and nine healthcare professionals at five clinics between February and April 2012. The Framework Method for analysing qualitative data identified facilitators and barriers related to five core themes: (i) Concern for wellbeing of children; (ii) ART-related factors; (iii) Disclosure; (iv) Socio-economic issues; and (v) Religious and cultural beliefs. Non-disclosure did not adversely affect adherence, contrary to other studies in the literature. Two broad categories emerged from the lived experiences of women in Guyana. The first is related to the act of actually taking their medication where their tenacity is displayed in efforts made to ensure ART is taken. The second relates to the significance of ART to them in terms of reduced risk of MTCT, and the possibility of better health for themselves to enable them to care for their children. However, issues related to poverty, food insecurity and side effects reduced adherence need to be adequately addressed.

Food insecurity and other poverty indicators among people living with HIV/AIDS: effects on treatment and health outcomes

Health disparities in access to antiretroviral therapy (ART) as well as the demands of long-term medication adherence have meant the full benefits of HIV treatment are often not realized. In particular, food insecurity has emerged as a robust predictor of ART non-adherence. However, research is limited in determining whether food insecurity uniquely impedes HIV treatment or if food insecurity is merely a marker for poverty that interferes more broadly with treatment. This study examined indicators of poverty at multiple levels in a sample of 364 men and 157 women living with HIV recruited through an offering of a free holiday food basket. Results showed that 61 % (N = 321) of participants had experienced at least one indicator of food insecurity in the previous month. Multivariate analyses showed that food insecurity was closely tied to lack of transportation. In addition, food insecurity was associated with lacking access to ART and poor ART adherence after adjusting for neighbourhood poverty, living in an area without a supermarket (food desert), education, stable housing, and reliable transportation. Results therefore affirm previous research that has suggested food insecurity is uniquely associated with poor ART adherence and calls for structural interventions that address basic survival needs among people living with HIV, especially food security.

Does Food Insecurity Undermine Adherence to Antiretroviral Therapy? A Systematic Review

A growing body of research has identified food insecurity as a barrier to antiretroviral therapy (ART) adherence. We systematically reviewed and summarized the quantitative literature on food insecurity or food assistance and ART adherence. We identified nineteen analyses from eighteen distinct studies examining food insecurity and ART adherence. Of the thirteen studies that presented an adjusted effect estimate for the relationship between food insecurity and ART adherence, nine found a statistically significant association between food insecurity and sub-optimal ART adherence. Four studies examined the association between food assistance and ART adherence, and three found that ART adherence was significantly better among food assistance recipients than non-recipients. Across diverse populations, food insecurity is an important barrier to ART adherence, and food assistance appears to be a promising intervention strategy to improve ART adherence among persons living with HIV. Additional research is needed to determine the effectiveness and cost-effectiveness of food assistance in improving ART adherence and other clinical outcomes among people living with HIV in the era of widespread and long-term treatment.

Synergistic effects of food insecurity and drug use on medication adherence among people living with HIV infection

Food insecurity and drug use are closely connected in the context of poverty, and both have been suggested to interfere with HIV medication adherence among people living with HIV/AIDS (PLWH). Yet the potential interaction between the two factors on adherence has not been examined. For this study we collected longitudinal data on HIV medication adherence among PLWH in Atlanta, GA, to assess a possible synergistic effect between the two factors on HIV medication adherence. People informed about the study came to the research site and completed an audio computer-assisted self-interview and instructions for pill counting. Over the next 5 weeks participants received three unscheduled follow-up phone assessments conducted 2 weeks apart to collect pill counts of their HIV medication. The prevalence of food insecurity was 60 % (488) and that of drug use was 33 % (274) in the sample of 809 participants. Among 770 participants who completed follow-up phone assessments, both food insecurity and drug use were associated with HIV medication adherence after adjusting for socio-demographic characteristics. The negative association between drug use and adherence persisted after further adjusting for health-related characteristics. Moreover, drug use appeared to moderate the effect of food insufficiency on adherence, with drug users who were food insufficient being the least likely to achieve 85 % adherence. Results from the current study demonstrate a synergism between food insecurity and drug use that may impede adherence among PLWH. The findings imply that the disruptive effects of food insecurity and drug use on adherence are likely to be intensified with the presence of each other, and encourage interventions to address the problem of HIV medication adherence from a multi-faceted perspective that takes into account detrimental combination of problem factors.

Unannounced telephone-based pill counts: a valid and feasible method for monitoring adherence

Phone-based unannounced pill counts to measure medication adherence are much more practical and less expensive than home-based unannounced pill counts, but their validity has not been widely assessed. We examined the validity of phone versus home-based pill counts using a simplified protocol streamlined for studies embedded in clinical care settings. A total of 100 paired counts were used to compare concordance between unannounced phone and home-based pill counts using interclass correlations. Discrepancy analyses using χ(2) tests compared demographic and clinical characteristics across patients who were concordant between phone and home-based pill counts and patients who were not concordant. Concordance was high for phone-based and home-based unannounced total pill counts, as well as individual medication counts and calculated adherence. This study demonstrates that a simplified phone-based pill count protocol can be implemented among patients from a routine clinical care setting and is a feasible means of monitoring medication adherence.

Parenting experiences of couples living with human immunodeficiency virus: a qualitative study from rural Southern Malawi

The advent of antiretroviral therapy (ART) has allowed couples living with human immunodeficiency virus (HIV) to live longer and healthier lives. The reduction in the mother-to-child transmission of HIV has encouraged some people living with HIV (PLWH) to have children. However, little is known about the parenting experiences of couples living with HIV (CLWH). The aim of this qualitative study was to explore and describe parenting experiences of seroconcordant couples who have a child while living with HIV in Malawi. Data were collected using in-depth interviews with 14 couples purposively sampled in matrilineal Chiradzulu and patrilineal Chikhwawa communities from July to December 2010. The research findings shows that irrespective of kinship organization, economic hardships, food insecurity, gender-specific role expectations and conflicting information from health institutions and media about sources of support underpin their parenting roles. In addition, male spouses are directly involved in household activities, childcare and child feeding decisions, challenging the existing stereotyped gender norms. In the absence of widow inheritance, widows from patrilineal communities are not receiving the expected support from the deceased husband relatives. Finally, the study has shown that CLWH are able to find solutions for the challenges they encounter. Contrary to existing belief that such who have children depend solely on public aid. Such claims without proper knowledge of local social cultural contexts, may contribute to stigmatizing CLWH who continue to have children. The study is also relevant to PLWH who, although not parents themselves, are confronted with a situation where they have to accept responsibility for raising children from their kin. We suggest the longer-term vision for ART wide access in Malawi to be broadened beyond provision of ART to incorporate social and economic interventions that support the rebuilding of CLWH social and economic lives. The interventions must be designed using a holistic multi-sector approach.

Discontinuation of antiretroviral therapy among adults receiving HIV care in the United States

BACKGROUND

Continuous antiretroviral therapy (ART) is important for maintaining viral suppression. This analysis estimates prevalence of and reason for ART discontinuation.

METHODS

Three-stage sampling was used to obtain a nationally representative, cross-sectional sample of HIV-infected adults receiving HIV care. Face-to-face interviews and medical record abstractions were collected from June 2009 to May 2010. Data were weighted based on known probabilities of selection and adjusted for nonresponse. Patient characteristics of ART discontinuation, defined as not currently taking ART, stratified by provider-initiated versus non-provider-initiated discontinuation, were examined. Weighted logistic regression models predicted factors associated with ART discontinuation.

RESULTS

Of adults receiving HIV care in the United States who reported ever initiating ART, 5.6% discontinued treatment. Half of those who discontinued treatment reported provider-initiated discontinuation. Provider-initiated ART discontinuation patients were more likely to have a nadir CD4 ≥ 200 cells per cubic millimeter. Non-provider-initiated ART discontinuation patients were more likely to have unmet need for supportive services and to have not received HIV care in the past 3 months. Among all patients who discontinued, younger age, female gender, not having continuous health insurance, incarceration, injection drug use, nadir CD4 count ≥ 2 00 cells per cubic millimeter, unmet need for supportive services, no care in the past 3 months and HIV diagnosis ≥ 5 years before interview were independently associated with ART discontinuation.

CONCLUSIONS

These findings inform development of interventions to increase ART persistence by identifying groups at increased risk of ART discontinuation. Evidence-based interventions targeting vulnerable populations are needed and are increasingly important as recent HIV treatment guidelines have recommended universal ART.

Food Insecurity and Depressive Symptoms: Comparison of Drug Using and Nondrug-Using Women at Risk for HIV

Food insecurity has been linked to poor physical and mental health as well as HIV risk behaviors. While prior research has shown that drug users are prone to food insecurity it is unclear if drug use exacerbates the physical and psychosocial consequences. A sample of women who used drugs (DU) (specifically heroin and cocaine) and women who did not use drugs (NDU) were examined to determine if the relationship between food insecurity and depression varied by drug use status. Approximately 29% (n=128) of the total sample experienced food insecurity. DU women were more likely to be food insecure. There were no differences in receiving food stamps. After controlling for demographics and receiving food stamps, a significant association between food insecurity and depression existed for both DU and NDU women. The strength of this association was approximately double for NDU women. The study results suggest that it is critical to integrate mental health, food assistance, and other services.

Relationship between hunger, adherence to antiretroviral therapy and plasma HIV RNA suppression among HIV-positive illicit drug users in a Canadian setting

Food insecurity may be a barrier to achieving optimal HIV treatment-related outcomes among illicit drug users. This study therefore, aimed to assess the impact of severe food insecurity, or hunger, on plasma HIV RNA suppression among illicit drug users receiving antiretroviral therapy (ART). A cross-sectional Multivariate logistic regression model was used to assess the potential relationship between hunger and plasma HIV RNA suppression. A sample of n = 406 adults was derived from a community-recruited open prospective cohort of HIV-positive illicit drug users, in Vancouver, British Columbia (BC), Canada. A total of 235 (63.7%) reported "being hungry and unable to afford enough food," and 241 (59.4%) had plasma HIV RNA < 50 copies/ml. In unadjusted analyses, self-reported hunger was associated with lower odds of plasma HIV RNA suppression (Odds Ratio = 0.59, 95% confidence interval [CI]: 0.39-0.90, p = 0.015). In multivariate analyses, this association was no longer significant after controlling for socio-demographic, behavioral, and clinical characteristics, including 95% adherence (Adjusted Odds Ratio [AOR] = 0.65, 95% CI: 0.37-1.10, p = 0.105). Multivariate models stratified by 95% adherence found that the direction and magnitude of this association was not significantly altered by the adherence level. Hunger was common among illicit drug users in this setting. Although, there was an association between hunger and lower likelihood of plasma HIV RNA suppression, this did not persist in adjusted analyses. Further research is warranted to understand the social-structural, policy, and physical factors shaping the HIV outcomes of illicit drug users.

Food insecurity is associated with increased risk of non-adherence to antiretroviral therapy among HIV-infected adults in the Democratic Republic of Congo: a cross-sectional study

Background

Food insecurity is increasingly reported as an important barrier of patient adherence to antiretroviral therapy (ART) in both resource-poor and rich settings. However, unlike in resource rich-settings, very few quantitative studies to date have investigated the association of food insecurity with patient adherence to ART in Sub-Saharan Africa. The current study examines the association between food insecurity and adherence to ART among HIV-infected adults in the Democratic Republic of Congo (DRC).

Methods and Findings

This is a cross-sectional quantitative study of patients receiving ART at three private and one public health facilities in Kinshasa, DRC. Participants were consecutively recruited into the study between April and November 2012. Adherence was measured using a combined method coupling pharmacy refill and self-reported adherence. Food insecurity was the primary predictor, and was assessed using the Household Food Insecurity Access Scale (HFIAS). Of the 898 participants recruited into the study, 512 (57%) were food insecure, and 188 (20.9%) were not adherent to ART. Food insecurity was significantly associated with non-adherence to ART (AOR, 2.06; CI, 1.38–3.09). We also found that perceived harmfulness of ART and psychological distress were associated respectively with increased (AOR, 1.95; CI, 1.15–3.32) and decreased (AOR, 0.31; CI, 0.11–0.83) odds of non-adherence to ART.

Conclusion

Food insecurity is prevalent and a significant risk factor for non-adherence to ART among HIV-infected individuals in the DRC. Our findings highlight the urgent need for strategies to improve food access among HIV-infected on ART in order to ensure patient adherence to ART and ultimately the long-term success of HIV treatment in Sub-Saharan Africa.

Nutritional Deficiencies and Food Insecurity Among HIV-infected Children in Tanzania

BACKGROUND

Poor nutrition has been associated with impaired immunity and accelerated disease progression in HIV-infected children. The aim of this study was to quantify the levels of nutrient intake in HIV-infected children and compare these to standard recommendations.

METHODS

We surveyed HIV-infected Tanzanian children enrolled in a pediatric care program that provided routine nutritional counseling and vitamin supplementation. We obtained anthropometric measurements and determined 24-hour macronutrient and micronutrient intakes and food insecurity. Values were compared to recommended nutrient intakes based on age and gender.

RESULTS

We interviewed 48 pairs of children and their caregiver(s). The age of the child ranged from 2-14 years; median age 6 and 60% female. The median weight-for-height z-score for children ≤ 5 years was 0.69 and BMI-for-age z-scores for children >5 was -0.84. Macronutrient evaluation showed that 29 (60%) children were deficient in dietary intake of energy; deficiency was more common in older children (p=0.004). Micronutrient evaluation shows that over half of study subjects were deficient in dietary intake of vitamin A, vitamin D, vitamin E, thiamine, riboflavin, niacin, folate, vitamin B12, and calcium. Food insecurity was reported by 20 (58%) caregivers.

CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS

The diets of many HIV-infected children at a specialized treatment center in Tanzania do not meet recommended levels of macro-and micro-nutrients. Food insecurity was a contributory factor. Enhanced dietary counseling and provision of macro- and micro-nutrient supplements will be necessary to achieve optimal nutrition for most HIV-infected children in resource-poor regions.

Nurse's Desk: food bank-based outreach and screening to decrease unmet referral needs

The Nurse's Desk health screening project used the Intervention Wheel model to conduct outreach, screening, education, and referral for food bank clients (n = 506). Blood glucose, blood pressure, health care utilization, and unmet referral needs were assessed. Screening results identified 318 clients (62.8%) with 1 or more unmet referral needs, including 6 clients (3.16%) with capillary blood glucose more than 199 mg/dL and 132 (31.9%) with hypertension. Clients had higher-than-average systolic and diastolic blood pressures and undiagnosed diabetes than in the general population. A client-approved method for tracking completed referrals is needed for this potentially high-risk population.

The next therapeutic challenge in HIV: polypharmacy

With the adoption of combination antiretroviral therapy (ART), most HIV-infected individuals in care are on five or more medications and at risk of harm from polypharmacy, a risk that likely increases with number of medications, age, and physiologic frailty. Established harms of polypharmacy include decreased medication adherence and increased serious adverse drug events, including organ system injury, hospitalization, geriatric syndromes (falls, fractures, and cognitive decline) and mortality. The literature on polypharmacy among those with HIV infection is limited, and the literature on polypharmacy among non-HIV patients requires adaptation to the special issues facing those on chronic ART. First, those aging with HIV infection often initiate ART in their 3rd or 4th decade of life and are expected to remain on ART for the rest of their lives. Second, those with HIV may be at higher risk for age-associated comorbid disease, further increasing their risk of polypharmacy. Third, those with HIV may have an enhanced susceptibility to harm from polypharmacy due to decreased organ system reserve, chronic inflammation, and ongoing immune dysfunction. Finally, because ART is life-extending, nonadherence to ART is particularly concerning. After reviewing the relevant literature, we propose an adapted framework with which to address polypharmacy among those on lifelong ART and suggest areas for future work.

Weight change at 1 mo of antiretroviral therapy and its association with subsequent mortality, morbidity, and CD4 T cell reconstitution in a Tanzanian HIV-infected adult cohort

BACKGROUND

The development of low-cost point-of-care technologies to improve HIV treatment is a major focus of current research in resource-limited settings.

OBJECTIVE

We assessed associations of body mass index (BMI; in kg/m(2)) at antiretroviral therapy (ART) initiation and weight change after 1 mo of treatment with mortality, morbidity, and CD4 T cell reconstitution.

DESIGN

A prospective cohort of 3389 Tanzanian adults initiating ART enrolled in a multivitamin trial was followed at monthly clinic visits (median: 19.7 mo). Proportional hazard models were used to analyze mortality and morbidity associations, whereas generalized estimating equations were used for CD4 T cell counts.

RESULTS

The median weight change at 1 mo of ART was +2.0% (IQR: -0.4% to +4.6%). The association of weight loss at 1 mo with subsequent mortality varied significantly by baseline BMI (P = 0.011). Participants with ≥2.5% weight loss had 6.43 times (95% CI: 3.78, 10.93 times) the hazard of mortality compared with that of participants with weight gains ≥2.5%, if their baseline BMI was <18.5 but only 2.73 times (95% CI: 1.49, 5.00 times) the hazard of mortality if their baseline BMI was ≥18.5 and <25.0. Weight loss at 1 mo was also associated with incident pneumonia (P = 0.002), oral thrush (P = 0.007), and pulmonary tuberculosis (P < 0.001) but not change in CD4 T cell counts (P > 0.05).

CONCLUSIONS

Weight loss as early as 1 mo after ART initiation can identify adults at high risk of adverse outcomes. Studies identifying reasons for and managing early weight loss are needed to improve HIV treatment, with particular urgency for malnourished adults initiating ART. The parent trial was registered at clinicaltrials.gov as NCT00383669.

The impact of DSM-IV mental disorders on adherence to combination antiretroviral therapy among adult persons living with HIV/AIDS: a systematic review

This is a systematic review of eighty-two published studies investigating the impact of DSM-IV mental disorders on combination antiretroviral therapy (cART) adherence and persistence among persons living with HIV/AIDS (PLWHA). Sixty-two articles examined depression, with 58 % (N = 32/62) finding lower cART adherence and persistence. Seventeen articles examined one or more anxiety disorders, with the majority finding no association with cART adherence or persistence. Eighty percent of the studies that evaluated the impact of psychotic (N = 3), bipolar (N = 5) and personality disorders (N = 2) on cART adherence and persistence also found no association. Seven out of the nine studies (78 %) evaluating the impact of antidepressant treatment (ADT) on cART adherence found improvement. Adherence and depression measurements varied significantly in studies; common research measurements would improve data harmonization. More research specifically addressing the impact of other mental disorders besides depression on cART adherence and RCTs evaluating ADT on cART adherence are also needed.

Food insecurity is associated with morbidity and patterns of healthcare utilization among HIV-infected individuals in a resource-poor setting

OBJECTIVE

We undertook a longitudinal study in rural Uganda to understand the association of food insecurity with morbidity and patterns of healthcare utilization among HIV-infected individuals enrolled in an antiretroviral therapy program.

DESIGN

Longitudinal cohort study.

METHODS

Participants were enrolled from the Uganda AIDS Rural Treatment Outcomes cohort, and underwent quarterly structured interviews and blood draws. The primary predictor was food insecurity measured by the validated Household Food Insecurity Access Scale. Primary outcomes included health-related quality of life measured by the validated Medical Outcomes Study-HIV Physical Health Summary (PHS), incident self-reported opportunistic infections, number of hospitalizations, and missed clinic visits. To estimate model parameters, we used the method of generalized estimating equations, adjusting for sociodemographic and clinical variables. Explanatory variables were lagged by 3 months to strengthen causal interpretations.

RESULTS

Beginning in May 2007, 458 persons were followed for a median of 2.07 years, and 40% were severely food insecure at baseline. Severe food insecurity was associated with worse PHS, opportunistic infections, and increased hospitalizations (results were similar in concurrent and lagged models). Mild/moderate food insecurity was associated with missed clinic visits in concurrent models, whereas in lagged models, severe food insecurity was associated with reduced odds of missed clinic visits.

CONCLUSION

Based on the negative impact of food insecurity on morbidity and patterns of healthcare utilization among HIV-infected individuals, policies and programs that address food insecurity should be a critical component of HIV treatment programs worldwide.

Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS

Food insecurity, which affects >1 billion people worldwide, is inextricably linked to the HIV epidemic. We present a conceptual framework of the multiple pathways through which food insecurity and HIV/AIDS may be linked at the community, household, and individual levels. Whereas the mechanisms through which HIV/AIDS can cause food insecurity have been fairly well elucidated, the ways in which food insecurity can lead to HIV are less well understood. We argue that there are nutritional, mental health, and behavioral pathways through which food insecurity leads to HIV acquisition and disease progression. Specifically, food insecurity can lead to macronutrient and micronutrient deficiencies, which can affect both vertical and horizontal transmission of HIV, and can also contribute to immunologic decline and increased morbidity and mortality among those already infected. Food insecurity can have mental health consequences, such as depression and increased drug abuse, which, in turn, contribute to HIV transmission risk and incomplete HIV viral load suppression, increased probability of AIDS-defining illness, and AIDS-related mortality among HIV-infected individuals. As a result of the inability to procure food in socially or personally acceptable ways, food insecurity also contributes to risky sexual practices and enhanced HIV transmission, as well as to antiretroviral therapy nonadherence, treatment interruptions, and missed clinic visits, which are strong determinants of worse HIV health outcomes. More research on the relative importance of each of these pathways is warranted because effective interventions to reduce food insecurity and HIV depend on a rigorous understanding of these multifaceted relationships.