Food insecurity is associated with poor virologic response among HIV-infected patients receiving antiretroviral medications

Food Insecurity at HIV Diagnosis Associated with Subsequent Viremia Amongst Adults Living with HIV in an Urban Township of South Africa

We assessed the temporal impact of food insecurity on 12-month antiretroviral (ART) adherence, retention in care, hospitalization, and HIV viremia (> 1000 copies/mL) in ART naïve adults presenting for HIV testing in Umlazi, South Africa. At the time of HIV testing and prior to ART initiation, we determined each participants' food security status using the validated Household Food Insecurity Access Scale (HFIAS). Following HIV testing and ART initiation, we then assessed the above outcomes of each study participant at 3-month intervals for a total of 12 months. Among 2,383 participants with HIV in this study, 253 (10.6%) experienced food insecurity. We found that food insecurity is associated with 20% higher adjusted prevalence odd ratios (aPOR) of having HIV viremia (> 1000 copies/mL) at 12 months following initial diagnosis (aPOR 1.2, 95% CI 1.1-1.4). We found no significant differences in ART adherence, retention in care, and hospitalization occurrences between the food secure and food insecure cohorts.

The impact of food insecurity on receipt of care, retention in care, and viral suppression among people living with HIV/AIDS in the United States: a causal mediation analysis

Introduction

Attaining The Joint United Nations Programme on HIV/AIDS 95-95-95 targets to end the HIV epidemic by 2030 will require a greater understanding of the underlying mechanisms influencing care engagement among people living with HIV/AIDS (PLWHA). One such mechanism is food insecurity, defined as limited or uncertain access to food. Food insecurity has been shown to significantly impact HIV outcomes. Yet, few studies have examined the mechanisms through which food insecurity may influence these outcomes. We aimed to examine the effects of nutritional, behavioral, and mental health mechanisms through which food insecurity may impact HIV care continuum outcomes: receipt of care, retention in care, and viral suppression.

Methods

We conducted a cross-sectional study of 200 PLWHA in New York State, United States from May-August 2022. Participants were recruited using convenience sampling methods. Multivariable logistic regression models were conducted to examine the associations between food insecurity and care continuum outcomes (receipt of care, retention in care, viral suppression), adjusting for age, race, ethnicity, education, income, and marital status. Individual causal mediation analyses were conducted to assess whether behavioral, mental health, and nutritional mechanisms mediated the hypothesized associations.

Results

The median age of participants was 30 years (IQR: 27-37 years). The majority self-identified as Black (54.0%), male (55.5%) and straight/heterosexual (63.0%). Increasing severity of food insecurity was associated with greater odds of non-retention in care (aOR: 1.35, 95% CI: 1.07, 1.70) and viral non-suppression (aOR: 1.29, 95% CI: 1.08, 1.54). For the impact of food insecurity on non-retention in care, there was an indirect relationship (natural indirect effect; NIE) mediated through Body Mass Index (BMI) (ORNIE: 1.08, 95% CI: 1.00, 1.18). For viral non-suppression, there was an indirect relationship mediated through BMI (ORNIE: 1.07, 95% CI: 1.00,1.16) and an indirect relationship mediated through depression (ORNIE: 1.27, 95% CI: 1.07, 1.47).

Discussion

Food insecurity was associated with greater odds of non-retention in care and viral non-suppression among PLWHA. Nutritional and mental health pathways are important mediators of these relationships. Results highlight the need for interventions to target these pathways to address food insecurity as an underlying mechanism influencing engagement in HIV care.

Impact of Food Insecurity and Undernutrition on Frailty and Physical Functioning in Aging People With HIV in the United States

ABSTRACT

We conducted an observational cross-sectional study to explore whether food insecurity or undernutrition was associated with frailty or low physical functioning in aging persons with HIV (PWH). Forty-eight PWH aged 50 years and older were enrolled. Independent samples t -tests and chi-square tests were used to examine the relationship of food insecurity or undernutrition to frailty or physical function. Participants were 58.6 (±6.3) years old, 83% male, 77% White, 21% Hispanic. In total, 44% experienced food insecurity and 71% experienced undernutrition, whereas 23% were frail and 69% were prefrail. Food insecurity was associated with impaired total short physical performance battery score ( p = .02), impaired balance ( p = .02), slower chair rise time ( p = .03), and weight loss within 12 months ( p = .05). Undernutrition was related to female gender ( p = .01), worse frailty ( p = .04), and weaker grip strength ( p = .03). In this sample of undernourished and frail PWH, strong relationships between undernutrition and frailty were observed.

Prevalence and predictors of food insecurity among people living with and without HIV in the African Cohort Study

OBJECTIVE

We determined the prevalence and identified predictors of food insecurity in four African countries.

DESIGN

Cross-sectional analyses at study enrolment.

SETTING

From January 2013 to March 2020, people living with HIV (PLWH) and without HIV were enrolled at twelve clinics in Kenya, Uganda, Tanzania and Nigeria.

PARTICIPANTS

Participants reporting not having enough food to eat over the past 12 months or receiving <3 meals/d were defined as food insecure. Robust Poisson regression models were used to estimate unadjusted and adjusted prevalence ratios (aPR) and 95 % CI for predictors of food insecurity among all participants and separately among PLWH.

RESULTS

1694/3496 participants (48·5 %) reported food insecurity at enrolment, with no difference by HIV status. Food insecurity was more common among older participants (50+ v. 18-24 years aPR 1·35, 95 % CI 1·15, 1·59). Having 2-5 (aPR 1·14, 95 % CI 1·01, 1·30) or >5 dependents (aPR 1·17, 95 % CI 1·02, 1·35), and residing in Kisumu West, Kenya (aPR 1·63, 95 % CI 1·42, 1·87) or Nigeria (aPR 1·20, 95 % CI 1·01, 1·41) was associated with food insecurity. Residing in Tanzania (aPR 0·65, 95 % CI 0·53, 0·80) and increasing education (secondary/above education v. none/some primary education aPR 0·73, 95 % CI 0·66, 0·81) was protective against food insecurity. Antiretroviral therapy (ART)-experienced PLWH were more likely to be food secure irrespective of viral load.

CONCLUSION

Food insecurity was highly prevalent in our cohort though not significantly associated with HIV. Policies aimed at promoting education, elderly care, ART access in PLWH and financial independence could potentially improve food security in Africa.

HIV Infections and Food Insecurity Among Pregnant Women from Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

There are few studies on the occurrence of food insecurity (FI) in pregnant women living with HIV/AIDS (PrWLWHA). Our objective was to estimate the prevalence of food insecurity among PrWLWHA and to analyse the association between HIV and FI. For this we searched eight databases. We used the prevalence and prevalence ratio (PR) with a 95% confidence interval (CI) as the summary measurements for the meta-analysis. We identified 300 studies, 13 of which were eligible. The prevalence of FI was 64%, ranging between 26% (mild), 33% (moderate) and 27% (severe). People living with HIV/AIDS (PLWHA) had a 23% greater chance of facing FI (PR = 1.23, 95% CI 1.16-1.38) compared to those not living with HIV. The results revealed a high prevalence and positive association with FI among PLWHA, which suggests the need for food security assessments in HIV/AIDS clinical care.

Food Insecurity in US Military Veterans

BACKGROUND

Food insecurity (FI) is an important public health issue for US veterans. For many veterans, civilian life is fraught with service-incurred health issues and socioeconomic challenges, each risk factors for FI. The FI literature on veterans is limited due to insufficient coverage of the topic's complexity and the methods used to study it in this population. No published analysis has evaluated how FI has been examined in US veterans.

OBJECTIVES

We assessed how FI has been examined in US military veterans by identifying (1) the major content areas, or domains, studied in association with FI and (2) the existing research gaps.

METHODS

A scoping literature review was conducted to map the main research domains of the FI literature and identify knowledge gaps. Electronic database and hand searches identified potentially relevant studies (n = 61). Data extraction, utilizing a standardized set of design parameters, was completed. Duplicate removal and application of inclusion/exclusion criteria resulted in the studies (n = 21) selected for critical review.

RESULTS

Eight research domains were determined: FI prevalence, health status, dietary practices, health care utilization, economic instability, homelessness/housing instability, food program participation, and community/emergency preparedness-the most dominant was health status and the least dominant were social determinants (ie, homelessness/housing instability, food program participation). Research on validity and usability of FI assessment methods in veterans was virtually absent. Military service factors, longitudinal effects, FI among women, intervention effectiveness, and other areas lacked sufficient inquiry.

CONCLUSION

Research is required on lesser examined content areas and methodology to optimize surveillance and policy for veteran FI.

Association between Food Insecurity, Mental Health, and Intentions to Leave the US Army in a Cross-Sectional Sample of US Soldiers

BACKGROUND

Previous research has demonstrated that certain groups in the United States are at a greater risk for food insecurity. However, food insecurity has not been sufficiently characterized in active duty military populations.

OBJECTIVES

The primary objective of this study was to determine the prevalence of marginal food insecurity at a large US Army installation. The secondary objective was to determine how marginal food insecurity may be associated with intentions to leave the US Army after the current service period ("intentions to leave").

METHODS

A cross-sectional, online survey was administered by the US Army Public Health Center at an Army installation in 2019 (n = 5677). The main predictor was the 2-item food insecurity screener (Hunger Vital Signs), and the main outcome was a 5-point Likert question, "How likely are you to leave the army after your current enlistment/service period?" that was dichotomized for this analysis. Multiple logistic regression was used to assess the association between marginal food insecurity and intentions to leave. Mental health covariates were analyzed as a potential mediator.

RESULTS

The sample was primarily male (83%), age <25 y (49%), and White (56%). One-third of respondents were classified as marginally food insecure using the Hunger Vital Signs, and 52% had intentions to leave. There was no significant association between marginal food insecurity and intentions to leave in the composite multivariable model, but mediation analyses revealed that food insecurity was significantly and independently associated with anxiety, depression, and suicidal ideation, which was in turn associated with intentions to leave.

CONCLUSIONS

The association between marginal food insecurity and mental health showed that addressing food insecurity could improve mental health and subsequently reduce intentions to leave. Solutions to reduce military food hardship include expanding Supplemental Nutrition Assistance Program eligibility requirements, improving food resources communication, and expanding healthy food choices on-post.

Social Determinants of Health and Care Outcomes Among People With HIV in the United States

Background

Fewer than 70% of people with HIV (PWH) in the United States have achieved durable viral suppression. To end the HIV epidemic in the United States, clinicians, researchers, and public health practitioners must devise ways to remove barriers to effective HIV treatment. To identify PWH who experience challenges to accessing health care, we created a simple assessment of social determinants of health (SDOH) among PWH and examined the impact of cumulative social and economic disadvantage on key HIV care outcomes.

Methods

We used data from the 2015-2019 Medical Monitoring Project, a yearly cross-sectional survey of PWH in the United States (n = 15 964). We created a 10-item index of SDOH and assessed differences in HIV care outcomes of missed medical appointments, medication adherence, and durable viral suppression by SDOH using this index using prevalence ratios with predicted marginal means.

Results

Eighty-three percent of PWH reported at least 1 SDOH indicator. Compared with PWH who experienced none of the SDOH indicators, people who experienced 1, 2, 3, and 4 or more SDOH indicators were 1.6, 2.1, 2.6, and 3.6 as likely to miss a medical appointment in the prior year; 11%, 17%, 20%, and 31% less likely to report excellent adherence in the prior 30 days; and 2%, 4%, 10%, and 20% less likely to achieve durable viral suppression in the prior year, respectively.

Conclusions

Among PWH, cumulative exposure to social and economic disadvantage impacts care outcomes in a dose-dependent fashion. A simple index may identify PWH experiencing barriers to HIV care, adherence, and durable viral suppression in need of critical supportive services.

Prevalence of Food Insecurity and Its Associated Factors among Adult People with Human Immunodeficiency Virus in Ethiopia: A Systematic Review and Meta-Analysis

BACKGROUND

Food insecurity is the shortage of both the quantity and quality of food and a negative impact on the overall nutritional and health status of people with human immunodeficiency virus (HIV). Ethiopia is intensely affected by food insecurity which is about 87.4% of adult people living with human immuno deficiency virus (HIV) are still facing shortage to have access to safe, sufficient, and nutritious food for themselves and their family. However, there is no concrete scientific evidence established at the national level in Ethiopia. Hence, this review gave special emphasis on adult people with human immunodeficiency virus (HIV) to estimate the pooled prevalence of food insecurity and its associated factor at the national level in Ethiopia.

METHODS

Studies were retrieved from selected electronic data bases, including PubMed/Medlin, Cochrane library, Sciences Direct, Google, and Google Scholar. Random-effects model meta-analysis was used to estimate the pooled prevalence of food insecurity and its associated factors at 95% confidence interval with odds ratio (OR) using statistical R-software version 3.6.1. Moreover, quality appraisal of the included studies, publication bias was checked using the funnel symmetry test, and heterogeneity was checked using forest plot and inverse variance square (I 2). The searches were restricted to articles published in the English language only, and Medical Subject Headings (MeSH terms) was used to help expand the search in advanced PubMed search.

RESULT

A total of 650 articles were identified through the initial search of which 20 studies were included in the final review yielding a total sample size of 7,797 adult people with human immunodeficiency virus (HIV). The pooled prevalence of food insecurity was 52% (95% CI, 40%, 63%). Cluster of differentiation 4 (CD4) count < 350 cell/mm3 [AOR = 1.29 (95% CI, 1.08, 1.54)], develop opportunistic infection [AOR = 4.09 (95% CI, 2.47, 6.78)], rural residence [AOR = 1.59 (95% CI, 1.09, 2.34)], and World Health Organization (WHO) clinical stages III and IV [AOR = 1.98 (95% CI, 1.23, 3.19)] was among the significantly associated factors.

CONCLUSION

In this review, there was a high prevalence of food insecurity among adult people with human immunodeficiency virus. Therefore, the responsible stockholders should strengthen the system and procedure for early diagnosis of opportunistic infection, under nutrition, screening of underlying problems.

Intersections of food insecurity, violence, poor mental health and substance use among US women living with and at risk for HIV: Evidence of a syndemic in need of attention

Background

Food insecurity and intimate partner violence (IPV) are associated with suboptimal HIV prevention and treatment outcomes, yet limited research has explored how food insecurity and IPV intersect to influence HIV-related behaviors. To fill this gap, we conducted a qualitative study with women living with or at risk for HIV in the United States.

Methods

We conducted 24 in-depth interviews with women enrolled in the San Francisco and Atlanta sites of the Women’s Interagency HIV study (WIHS). Participants were purposively sampled so half were living with HIV and all reported food insecurity and IPV in the past year. Semi-structured interviews explored experiences with food insecurity and IPV, how these experiences might be related and influence HIV risk and treatment behaviors. Analysis was guided by an inductive-deductive approach.

Results

A predominant theme centered on how food insecurity and IPV co-occur with poor mental health and substance use to influence HIV-related behaviors. Women described how intersecting experiences of food insecurity and IPV negatively affected their mental health, with many indicating using substances to “feel no pain”. Substance use, in turn, was described to perpetuate food insecurity, IPV, and poor mental health in a vicious cycle, ultimately facilitating HIV risk behaviors and preventing HIV treatment adherence.

Conclusions

Food insecurity, IPV, poor mental health and substance use intersect and negatively influence HIV prevention and treatment behaviors. Findings offer preliminary evidence of a syndemic that goes beyond the more widely studied “SAVA” (substance use, AIDS, and violence) syndemic, drawing attention to additional constructs of mental health and food insecurity. Quantitative research must further characterize the extent and size of this syndemic. Policies that address the social and structural drivers of this syndemic, including multi-level and trauma-informed approaches, should be implemented and evaluated to assess their impact on this syndemic and its negative health effects.

Factors associated with HIV care and treatment cascade in Rio Grande do Sul, Brazil, 2014-2017: A cross-sectional study

In 2018, Rio Grande do Sul (RS) had some of the highest HIV/AIDS rates in Brazil, and we did not find any studies about the HIV care and treatment cascade (HCTC) related to this state. We aimed to estimate the indicators of HCTC of RS, Brazil, and associated factors. A cross-sectional study with all people living with HIV (PLWH) in RS between 1 January 2014 and 31 December 2017 was conducted using a national database which registers all HIV notifications, CD4 and viral load laboratory data and antiretroviral therapy (ART) usage in the public health system. We considered sex, age, education, race, year of HIV diagnosis, and health region as predictor factors, and defined linkage to care, retention to care, being on ART, and having undetectable viral load as the HCTC indicators. Descriptive analysis and multivariable logistic regression were performed using Stata 15.2. A total of 116,121 PLWH were diagnosed, 79,959 were linked to care, 72,117 retained in care, 69,219 on ART, and 54,857 had undetectable viral load from 2014 to 2017. We observed greatest attrition for younger age, non-white, and lower education in all HCTC indicators. Women are more likely to have undetectable viral load (OR = 1.04, 95% CI: 1.01-1.07), even though they are less likely to be retained to care (OR = 0.92; 95% CI: 0.89-0.96) and on ART (OR = 0.82; 95% CI: 0.78-0.86). Although all HCTC indicators have increased over the period and the "test and treat" policy indicates improvements in ART and in undetectable viral load outcomes, evidence suggests specific attrition and disparities such as those related to HIV healthcare facilities should be addressed. These findings may be used by researchers, health professionals, and policymakers in order to investigate and implement interventions to better engage PLWH across the HCTC.

Prevalence of household food insecurity among people living with HIV/AIDS (Kerman- the southeast of Iran)

Background: Household food insecurity is one of the major public health issues that may affect an individual’s nutritional state, especially in patients with chronic diseases. The aim of this study was to evaluate the prevalence of household food insecurity and its association with sociodemographic and clinical factors among patients with HIV/AIDS in Kerman province, Iran.

Methods: A cross sectional study was performed among the 179 patients with HIV/AIDS in Kerman province. Participants completed a questionnaire focusing on personal information, health, and clinical status. Also, household food security status was evaluated by the USDA (US Department of Agriculture) questionnaire. Data were analyzed using SPSS (Version 22) by descriptive, univariate, and multivariate logistic regression. P<0.05 was considered statistically significant.

Results: Overall, 98 responding men and women were classified as household food secure (n=41; 40.8%) and household food insecure (n=58; 59.2%). Among the household food insecure patients, 14% (n=8) experienced lower household food insecurity, 38% (n=22) moderate household food insecurity, and 48% (n=28) severe household food insecurity. No significant differences were observed between household food secure and insecure groups in demographic variables. In clinical variables, only BMI index was significantly different between the two groups (p=0.040), but CD4 count was not significant between groups (p=0.220).

Conclusion: Prevalence of household food insecurity was high among people living with HIV/AIDS in Kerman. It seems clinical variables such as BMI index, which indicates the nutritional status of individuals, affect household food security status among people living with HIV/AIDS.

Mechanisms from Food Insecurity to Worse HIV Treatment Outcomes in US Women Living with HIV

Food insecurity (FI) contributes to HIV-related morbidity and mortality, but the mechanisms whereby FI negatively impacts HIV health are untested. We tested the hypothesis that FI leads to poor HIV clinical outcomes through nutritional, mental health, and behavioral paths. We analyzed data from Women's Interagency HIV Study (WIHS) among 1803 women living with HIV (WLWH) (8225 person-visits) collected from 2013 to 2015 biannually from nine sites across the United States participating in the WIHS. FI was measured with the US Household Food Security Survey Module. Outcomes included HIV viral nonsuppression, CD4 cell counts, and physical health status (PHS). We used longitudinal logistic and linear regression models with random effects to examine associations adjusting for covariates and path analysis to test nutritional, mental health, and behavioral paths. Increasing severity of FI was associated with unsuppressed viral load, lower CD4 counts, and worse PHS (all p < 0.05). Report of FI 6 months earlier was independently associated with most outcomes after adjusting for concurrent FI. For viral nonsuppression, the nutritional and behavioral paths accounted for 2.09% and 30.66% of the total effect, with the mental health path operating via serial mediation through the behavioral path. For CD4 count, the mental health and behavioral paths accounted for 15.21% and 17.0% of the total effect, respectively. For PHS, depressive symptoms accounted for 60.2% of the total effect. In conclusion, FI is associated with poor health among WLWH through different paths depending on the outcome. Interventions should target FI and its behavioral and mental health mechanisms to improve HIV outcomes.

Structural Barriers to Women's Sustained Engagement in HIV Care in Southern California

Since the introduction of antiretroviral therapy, the number of women living with HIV (WLHIV) continues to increase. Despite the decrease in HIV diagnosis among women in California, less than half of WLHIV are retained in HIV care. Structural barriers put women at increased risk for delayed HIV diagnosis, delayed entry into HIV care, and poorer treatment outcomes. The objective of this qualitative analysis is to identify how structural barriers negatively impact women's sustained engagement in HIV care in Southern California. WLHIV accessing local HIV support services participated in a qualitative study by completing a semi-structured interview and brief survey between January and April 2015 (n = 30). Poverty, unemployment, housing instability, and needs for transportation emerged as the dominant structural barriers for women when discussing their challenges with sustained engagement in HIV care. System-level interventions that decrease these noted barriers may help improve HIV care continuum for women living in Southern California.

Magnitude of non-adherence to antiretroviral therapy and associated factors among adult people living with HIV/AIDS in Benishangul-Gumuz Regional State, Ethiopia

Introduction

Following global efforts to increase antiretroviral therapy (ART) access and coverage, Ethiopia has made significant achievement with a 6.3% annual decline in the HIV/AIDS incidence rate between 1990 and 2016. Such success depends not only on access to ART but also on attaining optimum treatment adherence. Emerging studies in Ethiopia has shown the increasing prevalence of poor adherence and lack of the desired viral suppression, but the extent and factors associated with non-adherence to ART are not well known, especially in the current study setup. In this study, we examined the magnitude and factors associated with treatment and non-adherence to ART among people living with HIV in Benishangul-Gumuz Regional State, northwest Ethiopia.

Methods

An institutional facility based cross-sectional descriptive study was carried out among adult people living with HIV/AIDS from mid-December 2016 to February 2017 with only 98.9% response rate. Sociodemographic factors (age, gender, marital status and residential area), economic factors (educational status, income, asset possession, employment status, dietary diversity, nutritional status and food security), and clinical characteristics (CD4 count, duration on ART and history of opportunistic infections) were explanatory variables. ART non-adherence was measured using a visual analogue scale (VAS). We used binary logistic regression and subsequent multivariate logistic regression analysis to determine the factors associated with ART non-adherence.

Result

Overall, 39.7% of the participants were found non-adherent to ART. Strong association was found between non-adherence to ART and young age below 25 years (AOR: 4.30, 95% CI [1.39-3.35]; p = 0.011), urban residential area (AOR: 2.78, CI [1.23-7.09], p = 0.043), lack of employment (AOR: 1.75, 95% CI [1.05-2.91], p = 0.032), food insecurity (AOR: 2.67, 95% CI [7.59-8.97]; p < 0.0001), malnutrition (AOR: 1.55, 95% CI [1.94-2.56]; p = 0.027) and opportunistic infections (AOR: 1.81, 95% CI [1.11-2.97]; p = 0.018).

Conclusion

The prevalence of non-adherence to ART in this study was high. Sociodemographic and economic factors such as young age of below 25 years, urban residential area, lack of employment, food insecurity, malnutrition and opportunistic infections were among the factors associated with non-adherence to ART.

Longitudinal patterns of illicit drug use, antiretroviral therapy exposure and plasma HIV-1 RNA viral load among HIV-positive people who use illicit drugs

OBJECTIVES

HIV-positive people who use illicit drugs (PWUD) experience elevated rates of HIV-associated morbidity and mortality compared with members of other key affected populations. Although suboptimal levels of access and adherence to antiretroviral therapy (ART) are common among HIV-positive PWUD, there is a need for studies investigating the possible biological impacts of noninjection illicit drug use among people living with HIV in real-world settings.

METHODS

We accessed data from the ACCESS study, an ongoing prospective cohort of illicit drug users with systematic HIV viral load monitoring in a setting with universal care and ART dispensation records. We used multivariable generalized linear mixed models to estimate the longitudinal associations between noninjection use of crack cocaine, powder cocaine, opioids, methamphetamine, cannabis and alcohol on plasma HIV-1 RNA viral load, adjusted for ART exposure and relevant confounders.

RESULTS

Between 2005 and 2018, 843 individuals from the ACCESS cohort were included and contributed to 8698 interviews. At baseline, the mean age was 43 years, 566 (67%) reported male sex and 659 (78%) used crack cocaine in the previous 6 months. In multivariable models adjusted for ART exposure, only crack cocaine use in the last 6 months was found to be significantly associated with higher HIV viral load.

CONCLUSION

We observed significantly higher HIV viral load during periods of crack cocaine use independent of ART exposure. Our findings support further research to investigate the possible biological mechanisms of this effect.

Association between household food insecurity and mortality in Canada: a population-based retrospective cohort study

BACKGROUND

Food insecurity affects 1 in 8 households in Canada, with serious health consequences. We investigated the association between household food insecurity and all-cause and cause-specific mortality.

METHODS

We assessed the food insecurity status of Canadian adults using the Canadian Community Health Survey 2005-2017 and identified premature deaths among the survey respondents using the Canadian Vital Statistics Database 2005-2017. Applying Cox survival analyses to the linked data sets, we compared adults' all-cause and cause-specific mortality hazard by their household food insecurity status.

RESULTS

Of the 510 010 adults sampled (3 390 500 person-years), 25 460 died prematurely by 2017. Death rates of food-secure adults and their counterparts experiencing marginal, moderate and severe food insecurity were 736, 752, 834 and 1124 per 100 000 person-years, respectively. The adjusted hazard ratios (HRs) of all-cause premature mortality for marginal, moderate and severe food insecurity were 1.10 (95% confidence interval [CI] 1.03-1.18), 1.11 (95% CI 1.05-1.18) and 1.37 (95% CI 1.27-1.47), respectively. Among adults who died prematurely, those experiencing severe food insecurity died on average 9 years earlier than their food-secure counterparts (age 59.5 v. 68.9 yr). Severe food insecurity was consistently associated with higher mortality across all causes of death except cancers; the association was particularly pronounced for infectious-parasitic diseases (adjusted HR 2.24, 95% CI 1.42-3.55), unintentional injuries (adjusted HR 2.69, 95% CI 2.04-3.56) and suicides (adjusted HR 2.21, 95% CI 1.50-3.24).

INTERPRETATION

Canadian adults from food-insecure households were more likely to die prematurely than their food-secure counterparts. Efforts to reduce premature mortality should consider food insecurity as a relevant social determinant.

Food insecurity and substance use in people with HIV infection and substance use disorder

BACKGROUND

Food insecurity and substance use are common among people living with HIV (PLWH). Substance use may help people cope with hunger and thus be associated with food insecurity, but the association is uncertain. This study assessed whether, in PLWH and substance dependence, if there was an association between food insecurity and substance use.

Methods: We studied adults with HIV and current substance dependence or ever injection drug use interviewed at 12 and 24 months after enrollment in a prospective cohort study. The presence of food insecurity (insufficient food quantity or quality, or anxiety about its availability) was assessed using the Household Food Insecurity Assessment Scale questionnaire (HFIAS). Unhealthy alcohol use was assessed with the Alcohol Use Disorder Identification Test - Consumption (AUDIT-C) and past 30-day other drug use with the Addiction Severity Index. Associations using repeat cross-sectional data from each of two time-points, 12 months apart, from the same participants were tested using generalized estimating equations logistic regressions.

Results: The 233 participants had a mean age of 50 years and 65% were male. At the first interview, 44% reported food insecurity, 40% unhealthy alcohol use, 25% past 30-day cocaine use, and 17% past 30-day illicit opioid use. In analyses adjusted for demographics, social factors, physical and mental health function, and substance use related variables, there was no significant association between food insecurity and unhealthy alcohol use (adjusted odds ratio (aOR) = 1.06 (95% CI: 0.59, 1.87)). Those with food insecurity had higher odds of illicit opioid use (aOR = 2.5 (95% CI: 1.12, 5.58)) and cocaine use (aOR = 1.95 (CI 95%: 1.00, 3.81)).

Conclusion: Food insecurity was not associated with unhealthy alcohol use but was associated with cocaine and illicit opioid use. Given the prevalence and impact substance use has on PLWH, food insecurity should be identified and addressed.

The role of mental health on the relationship between food insecurity and immunologic outcome among people living with HIV in Guangxi, China

Background

Previous studies showed that food insecurity could adversely affect clinical outcomes of people living with HIV (PLWH). The mental health pathways of such effects are suggested in existing literature, but empirical data are limited in resource-limited settings.

Methods

This cross-sectional study aims to explore the role of depressive symptoms and anxiety on the association between food insecurity and CD4 counts among a sample of 2,987 PLWH in Guangxi, China. Path analysis was used to examine a hypothetical model and delta z test was used to assess the indirect effects of food insecurity on CD4 counts through depressive symptoms and anxiety.

Results

The prevalence of food insecurity in this sample was 25.3%, and the median CD4 counts were 318 cells/mm³. In correlation analyses, food insecurity was not directly associated with LogCD4 but was associated with depressive symptoms and anxiety. Path analysis indicated a significant indirect effect from food insecurity to LogCD4 through depressive symptoms, but not anxiety.

Conclusion

Improving mental health among PLWH with food insecurity may be beneficial for treatment outcomes. Besides intervening food insecurity, an intervention targeting depressive symptoms could improve the immunologic outcomes of PLWH.

A Systematic Review and Meta-analysis of Depression, Anxiety, and Sleep Disorders in US Adults with Food Insecurity

INTRODUCTION

A large number of peer-reviewed studies, with various methodologies and populations, have addressed the effects of food insecurity (FIS) on mental health conditions such as depression, anxiety, and sleep disorders. There are currently, however, no published systematic assessments or meta-analyses of this literature.

METHODS

A systematic search of the literature was conducted in PubMed, PsycInfo, Embase, Scopus, and Web of Science. Cross-sectional studies assessing the association between food insecurity and depression, anxiety, or sleep disorders were identified. For each of the three health outcomes, we extracted (or calculated when possible) the following effect sizes: odds ratio (OR), Hedges' g, Pearson correlation coefficients r, or bivariate coefficients. Then, for each mental health-outcome/effect-size pair, the available studies were combined using the random effect model. Heterogeneity, publication bias, and subgroup dependence, for each meta-analysis, were also assessed.

RESULTS

Fifty-seven studies provided cross-sectional data on the relationship between FIS and depression (n = 169,433), 13 on anxiety and psychological distress (n = 91,957), and 8 studies provided data on sleep disorders (n = 85,788). Meta-analysis showed that FIS is associated with an increased risk of testing positive for depression OR = 2.74 [95% CI 2.52-2.97, n = 135,500, Q(df = 41) = 69, I² = 40%], anxiety OR = 2.41 [95% CI 1.81-3.22, n = 51,541, Q(df = 3) = 8, I² = 63%], and sleep disorders OR = 1.80 [95% CI 1.51-2.15, n = 84,800, Q(df = 5) = 13, I² = 62%]. The highest risks were found for depression and anxiety which had statistically similar values. The results were robust to covariates and population groups.

DISCUSSION

This systematic review and meta-analysis demonstrates a strong association between FIS and depression, anxiety, and sleep disorders, for which more longitudinal studies addressing effect sizes are warranted to further study causation.

Food Insecurity Is Associated With Inflammation Among Women Living With HIV

Background

Chronic inflammation is associated with AIDS-defining and non-AIDS-defining conditions. Limited research has considered how food insecurity influences chronic inflammation among people living with human immunodeficiency virus (HIV). We examined whether food insecurity was associated with higher levels of inflammation among women living with HIV (WWH) in the United States.

Methods

We analyzed cross-sectional data collected in 2015 from 421 participants on antiretroviral therapy from the Women's Interagency HIV Study. The exposure was any food insecurity. The outcome was inflammation, measured by proinflammatory cytokine interleukin-6 (IL-6) and tumor necroses factor receptor 1 (TNFR1) levels. We conducted multivariable linear regressions, adjusting for sociodemographic, clinical, and nutritional factors.

Results

Nearly one-third of participants (31%) were food insecure and 79% were virally suppressed (<20 copies/mL). In adjusted analyses, food insecurity was associated with 1.23 times the level of IL-6 (95% confidence interval [CI], 1.06-1.44) and 1.13 times the level of TNFR1 (95% CI, 1.05-1.21). Findings did not differ by HIV control (virally suppressed with CD4 counts ≥500 cells/mm3 or not) in adjusted stratified analyses.

Conclusion

Food insecurity was associated with elevated inflammation among WWH regardless of HIV control. Findings support the need for programs that address food insecurity among WWH.

Clinical and Sociobehavioral Prediction Model of 30-Day Hospital Readmissions Among People With HIV and Substance Use Disorder: Beyond Electronic Health Record Data

BACKGROUND

Under the Affordable Care Act, hospitals receive reduced reimbursements for excessive 30-day readmissions. However, the Centers for Medicare and Medicaid Services does not consider social and behavioral variables in expected readmission rate calculations, which may unfairly penalize systems caring for socially disadvantaged patients, including patients with HIV.

SETTING

Randomized controlled trial of patient navigation with or without financial incentives in HIV-positive substance users recruited from the inpatient setting at 11 US hospitals.

METHODS

External validation of an existing 30-day readmission prediction model, using variables available in the electronic health record (EHR-only model), in a new multicenter cohort of HIV-positive substance users was assessed by C-statistic and Hosmer-Lemeshow testing. A second model evaluated sociobehavioral factors in improving the prediction model (EHR-plus model) using multivariable regression and C-statistic with cross-validation.

RESULTS

The mean age of the cohort was 44.1 years, and participants were predominantly males (67.4%), non-white (88.0%), and poor (62.8%, <$20,000/year). Overall, 17.5% individuals had a hospital readmission within 30 days of initial hospital discharge. The EHR-only model resulted in a C-statistic of 0.65 (95% confidence interval: 0.60 to 0.70). Inclusion of additional sociobehavioral variables, food insecurity and readiness for substance use treatment, in the EHR-plus model resulted in a C-statistic of 0.74 (0.71 after cross-validation, 95% confidence interval: 0.64 to 0.77).

CONCLUSIONS

Incorporation of detailed social and behavioral variables substantially improved the performance of a 30-day readmission prediction model for hospitalized HIV-positive substance users. Our findings highlight the importance of social determinants in readmission risk and the need to ask about, adjust for, and address them.

What causes non-adherence among some individuals on long term antiretroviral therapy? Experiences of individuals with poor viral suppression in Uganda

Background

Antiretroviral therapy (ART) use by people living with HIV reduces HIV transmission, morbidity, mortality, and improves quality of life. Good ART adherence is required to achieve these benefits. We investigated how the environmental, social, economic and behavioural experiences of people living with HIV with poor viral suppression could explain their non-adherence to long term ART.

Methods

This qualitative cross-sectional study was conducted in Uganda between September 2015 and April 2016. Thirty individuals on ART for 5 years or more (10 on first line and 20 on second line), with poor viral suppression, were randomly selected from a cohort of people living with HIV on ART. In-depth interviews about ART; awareness, adherence counselling, obstacles to daily adherence and regimen switches were conducted. Emerging themes from the interviews transcripts and field notes were identified and thematic content analysis done. Participants’ consent, compensation, confidentiality and study ethical approvals were ensured.

Results

We found that poor adherence to long term ART was due to: travel for work or social activities, stigma, receiving little or no continuous ART adherence education, alcohol consumption and use of alternative ‘HIV cure’ medicines. Other reasons included; ART side effects, treatment fatigue, belief that long-term ART or God can ‘cure HIV’, and food security.

Conclusions

Achieving optimal ART benefits requires continuous provision of ART adherence education to individuals on long term ART. This helps them overcome the challenges related to living with HIV: worries of food insecurity, alcohol misuse, economic hardship, and beliefs in HIV cures and use of unproven alternative HIV treatments. People living with HIV who travel require adherence support and larger quantities of ART refills to cover their time away.

Place-based predictors of HIV viral suppression and durable suppression among heterosexuals in New York city

Scant research has explored place-based correlates of achieving and maintaining HIV viral load suppression among heterosexuals living with HIV. We conducted multilevel analyses to examine associations between United Hospital Fund (UHF)-level characteristics and individual-level viral suppression and durable viral suppression among individuals with newly diagnosed HIV in New York City (NYC) who have heterosexual HIV transmission risk. Individual-level independent and dependent variables came from NYC's HIV surveillance registry for individuals diagnosed with HIV in 2009-2013 (N = 3,159; 57% virally suppressed; 36% durably virally suppressed). UHF-level covariates included measures of food distress, demographic composition, neighborhood disadvantage and affluence, healthcare access, alcohol outlet density, residential vacancy, and police stop and frisk rates. We found that living in neighborhoods where a larger percent of residents were food distressed was associated with not maintaining viral suppression. If future research should confirm this is a causal association, community-level interventions targeting food distress may improve the health of people living with HIV and reduce the risk of forward transmission.

Food security in a sample of clients attending HIV clinics in New South Wales: A cross-sectional study

AIM

The aim of this study was to determine the prevalence, demographics and location of food insecurity (FI) among people living with HIV at six health sites in Sydney, Australia and to identify the factors relating to FI.

METHODS

This was a cross-sectional study recruiting people living with HIV receiving HIV care from six sites across the Sydney metropolitan area. The United States Department of Agriculture abbreviated six-item Subset Food Insecurity Tool was used to assess FI and a demographic questionnaire was completed. Bivariate analysis was conducted to investigate differences between variables. Descriptive and frequency statistics were used to collate the demographic questionnaire and determine the prevalence of FI. All tests performed were two sided with a P-value of less than 0.05, or 95% confidence interval not overlapping, indicating a statistically significant association.

RESULTS

Of the 162 participants 47% (n = 76) reported FI. The percentage of FI was found to be higher among the females (61%, n = 8 out of 13), unemployed (65%), receiving a government pension (63%), with a lower perceived health status (68%), a lower CD4 T cell count (60%), a detectable or unknown viral load (67%), and missed taking their antiretroviral therapy either in the last week or month (64%). All of the six participants who were Australian Aboriginal were food insecure.

CONCLUSIONS

The study finds evidence of associations between FI, employment, lower immune function and poorer health outcomes for people living with HIV in Sydney.

Caffeine Intake and Its Association with Body Composition Measures and Macronutrient Intakes in People Living with HIV in the Miami Adult Studies on HIV Cohort

Background: Caffeine acts as an anorexic agent, increases energy expenditures, and decreases total body fat mass, and could be detrimental to people living with HIV (PLWH). The objective of this study was to explore the relationship between caffeine consumption, body composition measures (fat mass, body mass index [BMI], and lean body mass [LBM]), nutrient intakes, CD4 counts, and HIV viral load in PLWH. Methods: A convenience sample of 130 PLWH was recruited and followed for 3 months. Caffeine intake, body composition measures, and nutrient intakes were collected using Modified Caffeine Consumption Questionnaire, bioimpedance analyses, and 24-hour dietary recalls. Linear regressions were used to analyze the baseline data for relationships between these variables. Linear mixed models (LMMs) were used to determine the overtime changes. Results: In baseline, linear regression analysis, higher caffeine consumption was associated with lower fat mass (β = -0.994, p = 0.042). However, BMI and LBM did not show any significant association with caffeine intake. LMM analysis showed that the association between caffeine intake and fat mass strengthened overtime (β = -1.987, p = 0.035). Baseline linear regression analysis showed that higher caffeine intake was significantly associated with lower caloric intakes from fat (β = -1.902, p = 0.044) and lower total caloric intake (β = -1.643, p = 0.042). However, LMM analysis showed that these associations diminished and lost significance overtime. There were no associations between body composition measures, nutrient intakes, CD4 counts, and HIV viral load. Conclusions: Caffeine intake adversely affected dietary intakes of macronutrients and total fat mass. Therefore, caffeine, a known anorectic, should be regulated in PLWH.

Severe food insecurity is associated with overweight and increased body fat among people living with HIV in the Dominican Republic

Food insecurity is an important risk factor for overweight and obesity among low-income populations in high income countries, but has not been well-studied among people living with HIV (PLHIV), particularly in resource-poor settings. To explore the association between food insecurity and overweight and obesity among PLHIV in the Dominican Republic, we conducted a cross-sectional study of 160 HIV-infected adults between March-December 2012 in four geographically-dispersed health centers (Santo Domingo, Puerto Plata, San Juan, and Higuey). We collected information on household food insecurity, anthropometric measurements, and socio-demographic data and ran descriptive and multivariate analyses, controlling for fixed effects of clinics and using robust standard errors. Mean age ± SD of participants was 39.9 ± 10.5 years; 68% were women, and 78% were on antiretroviral therapy (ART). A total of 58% reported severe household food insecurity. After controlling for age, gender, income, having children at home, education, and ART status, severe food insecurity was associated with increased body mass index (BMI) (β = 1.891, p = 0.023) and body fat (β = 4.004, p = 0.007). Age and female gender were also associated with increased body fat (β = 0.259, p < 0.001 and β = 8.568, p < 0.001, respectively) and age and ART status were associated with increased waist circumference (β = 0.279, p = 0.011 and β = 5.768, p = 0.046, respectively). When overweight was examined as a dichotomous variable (BMI ≥ 25.0), severe food insecurity was associated with an increased odds of 3.060 (p = 0.013); no other covariates were independently associated with overweight. The association of severe food insecurity with increased BMI, body fat, and overweight among PLHIV has important implications for clinical care as well as food security and nutrition interventions in resource-poor settings. Integrated programs that combine nutrition education or counseling with sustainable approaches to addressing food insecurity among PLHIV are needed to improve long-term health outcomes of this vulnerable population.

The Impact of Food Assistance on Dietary Diversity and Food Consumption among People Living with HIV/AIDS

Little is known about the outcomes of food assistance targeted to food insecure people living with HIV/AIDS. Using primary data from Zambia, we estimated the impact of food assistance on the dietary diversity and consumption expenditures of households with HIV infected members receiving antiretroviral therapy. Propensity score matching estimates show that food assistance increased dietary diversity by 9.8 points (23%) mainly through the consumption of food items provided in the ration. Food assistance recipients were 20% points more likely to have acceptable food consumption and 15% points less likely to have poor food consumption than non-recipients. Food assistance also increased food consumption expenditures but had no significant impact on food purchases and total consumption expenditures. Overall, our findings demonstrate that food assistance can be an effective instrument for improving diets and enhancing the food security of people living with HIV/AIDS.

Food Insecurity is Associated with Poor HIV Outcomes Among Women in the United States

Women in the general population experience more food insecurity than men. Few studies have examined food insecurity's impact on HIV treatment outcomes among women. We examined the association between food insecurity and HIV outcomes in a multi-site sample of HIV-infected women in the United States (n = 1154). Two-fifths (40%) of participants reported food insecurity. In an adjusted multivariable Tobit regression model, food insecurity was associated with 2.08 times higher viral load (95% confidence interval (CI): 1.04, 4.15) and lower CD4+ counts (- 42.10, CI: - 81.16, - 3.03). Integration of food insecurity alleviation into HIV programs may improve HIV outcomes in women.

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.

Prevalence and predictors of food insecurity among people living with HIV affiliated with AIDS service organizations in Ontario, Canada

Up to half of people living with HIV in resource-rich settings experience moderate to severe food insecurity. Food insecurity, in turn, has been linked to adverse health outcomes including poor antiretroviral adherence, poor HIV viral suppression, frailty, and mortality. We estimated the prevalence of food insecurity among 649 adults living with HIV and recruited from community-based AIDS service organizations in Ontario, Canada. Food security was assessed using the Canadian Household Food Security module. We used logistic regression modeling to identify demographic, socioeconomic, and psychosocial factors independently associated with food insecurity. Almost three-fourths of participants (70.3%) were food insecure and a third (31%) reported experiencing hunger. The prevalence of food insecurity in this sample is approximately six times higher than that of the general population. Factors independently associated with food insecurity were: having dependent children at home, residing in large urban areas, low annual household income (<$40,000), difficulty meeting housing-related expenses, cigarette smoking, harmful drug use, and depression. Broad, multisector interventions that address income, housing affordability, substance use and mental health issues are needed and could offset future public health expenditures.

Viral Suppression and Retention in Care up to 5 Years After Initiation of Lifelong ART During Pregnancy (Option B+) in Rural Uganda

BACKGROUND

Lifelong antiretroviral therapy (ART) is recommended for all HIV-infected pregnant women, but early studies suggest that women often drop out of care postpartum and data are limited on virologic outcomes.

METHODS

We evaluated viral suppression (primary outcome) and retention in care up to 5 years after ART initiation among HIV-infected women who started lifelong ART during pregnancy, irrespective of CD4 count, in a study in rural Uganda (NCT00993031). Participants were followed in the study for up to 1 year postpartum, then referred to clinics in surrounding communities. A random sample (N = 200) was invited to participate in a cross-sectional follow-up study after completing the trial, involving one visit for a questionnaire and pregnancy and HIV-1 RNA testing. Retention in care was defined as having attended an HIV clinic in the last 90 days. Logistic regression models were used to examine factors associated with viral suppression (HIV-1 RNA <400 copies/ml) at follow-up.

RESULTS

One hundred fifty women (75%) were successfully contacted for follow-up at a median of 4.2 years after starting ART; 135 were retained in care [90%, 95% confidence interval (CI): 84.0% to 94.3%] and 121 demonstrated viral suppression (80.7%, 95% CI: 73.4% to 86.7%). Women who had disclosed their HIV status to their primary partner had greater odds of viral suppression (adjusted odds ratio: 4.51, 95% CI: 1.02 to 19.8).

CONCLUSIONS

High rates of viral suppression can be achieved up to 5 years after initiating ART during pregnancy among women retained in care. Interventions to facilitate disclosure may improve long-term outcomes among women who initiate ART during pregnancy under universal treatment.

The Relationship Between Caffeine Intake and Immunological and Virological Markers of HIV Disease Progression in Miami Adult Studies on HIV Cohort

Although there are many studies on adverse health effects of substance use and HIV disease progression, similar studies about caffeine consumption are few. In this study, we investigated the effects of caffeine on immunological and virological markers of HIV disease progression. A convenience sample of 130 clinically stable people living with HIV/AIDS on antiretroviral therapy (65 consuming ≤250 mg/day and 65 consuming >250 mg/day of caffeine) were recruited from the Miami Adult Studies on HIV (MASH) cohort. This study included a baseline and 3-month follow-up visit. Demographics, body composition measures, substance use, Modified Caffeine Consumption Questionnaire (MCCQ), and CD4 count and HIV viral load were obtained for all participants. Multivariable linear regression and Linear Mixed Models (LMMs) were used to understand the effect of caffeine consumption on CD4 count and HIV viral load. The mean age of the cohort was 47.9 ± 6.4 years, 60.8% were men and 75.4% were African Americans. All participants were on ART during both the visits. Mean caffeine intake at baseline was 337.6 ± 305.0 mg/day and did not change significantly at the 3-month follow-up visit. Multivariable linear regressions after adjustment for covariates showed significant association between caffeine consumption and higher CD4 count (β = 1.532, p = 0.049) and lower HIV viral load (β = -1.067, p = 0.048). LMM after adjustment for covariates showed that the relationship between caffeine and CD4 count (β = 1.720, p = 0.042) and HIV viral load (β = -1.389, p = 0.033) continued over time in a dose-response manner. Higher caffeine consumption was associated with higher CD4 cell counts and lower HIV viral loads indicating beneficial effects on HIV disease progression. Further studies examining biochemical effects of caffeine on CD4 cell counts and viral replication need to be done in the future.

Predictors of CD4 health and viral suppression outcomes for formerly homeless people living with HIV/AIDS in scattered site supportive housing

Stable housing is key to improving health outcomes for people living with HIV/AIDS. Though many formerly homeless HIV positive individuals reside in supportive housing, little research has examined biometric HIV health outcomes for residents of these programs. Through a community-based research partnership, this study analyzed secondary data from a Shelter Plus Care supportive housing program in Cincinnati, Ohio to examine the likelihood of participants achieving a healthy CD4 count (>500 cells/mm³) and viral suppression (viral load <200 copies/mL) while in supportive housing and to identify participant characteristics associated with these outcomes. The study sample was 86 participants who entered the program between 2008 and 2016, including 50 current residents and 36 exited participants. Participants' average length of stay in Shelter Plus Care was 35.2 months (range 3.2-108.1 months) during the study period. Bivariate analysis indicated statistically significant improvements on both outcome variables, with 45% of participants achieving a healthy CD4 count and 79% achieving viral suppression by program exit or most recent time point. Participants who had health insurance at intake and who had never been incarcerated were more likely to achieve viral suppression, and longer length of stay in the program was also positively associated with viral suppression. These results add to the literature on the relationship between housing conditions and HIV health outcomes by demonstrating that residence in supportive housing is associated with improvements in CD4 count and viral load for a sample of formerly homeless persons living with HIV/AIDS, two-thirds of whom had co-occurring physical health, mental health, or substance abuse problems. Further research collaborations should expand on these findings to examine the service packages that are associated with optimal HIV health outcomes for supportive housing residents.

Food Insecurity in HIV-Hepatitis C Virus Co-infected Individuals in Canada: The Importance of Co-morbidities

While research has begun addressing food insecurity (FI) in HIV-positive populations, knowledge regarding FI among individuals living with HIV-hepatitis C virus (HCV) co-infection is limited. This exploratory study examines sociodemographic, socioeconomic, behavioral, and clinical factors associated with FI in a cohort of HIV-HCV co-infected individuals in Canada. We analyzed longitudinal data from the Food Security and HIV-HCV Co-infection Study of the Canadian Co-infection Cohort collected between November 2012-June 2014 at 15 health centres. FI was measured using the Household Food Security Survey Module and classified using Health Canada criteria. Generalized estimating equations were used to assess factors associated with FI. Among 525 participants, 59 % experienced FI at their first study visit (baseline). Protective factors associated with FI (p < 0.05) included: enrolment at a Quebec study site (aOR: 0.42, 95 % CI: 0.27, 0.67), employment (aOR: 0.55, 95 % CI: 0.35, 0.87), and average personal monthly income (aOR per $100 CAD increase: 0.98, 95 % CI: 0.97, 0.99). Risk factors for FI included: recent injection drug use (aOR: 1.98, 95 % CI: 1.33, 2.96), trading away food (aOR: 5.23, 95 % CI: 2.53, 10.81), and recent experiences of depressive symptoms (aOR: 2.11, 95 % CI: 1.48, 3.01). FI is common in this co-infected population. Engagement of co-infected individuals in substance use treatments, harm reduction programs, and mental health services may mitigate FI in this vulnerable subset of the HIV-positive population.

Food Insecurity Is Associated with Cognitive Deficits Among HIV-Positive, But Not HIV-Negative, Individuals in a United States Sample

People living with HIV/AIDS (PLWHA) in the United States (US) have disproportionately high rates of food insecurity (FI). In the general population, FI has been associated with cognitive impairment among older adults and may exacerbate HIV-associated neurocognitive disorders. The current study assessed the effects of FI and HIV infection on the neuropsychological performance of 61 HIV-positive and 36 HIV-negative adults in the US. While the main effects were minimal, the interactive effects revealed that FI was related to deficits in speed of information processing, learning, memory, motor function, and overall cognitive impairment for the HIV-positive group, but not the HIV-negative group. The interactive effects remained after controlling for relevant sociodemographic characteristics. Although bidirectional associations cannot be ruled out in a cross-sectional study, the results suggest that FI may contribute to cognitive impairment among HIV-positive adults in the US. Given the high rates of socioeconomic disadvantage among PLWHA in the US, addressing FI as part of routine clinical care may be warranted.

Mixed-Method Quasi-Experimental Study of Outcomes of a Large-Scale Multilevel Economic and Food Security Intervention on HIV Vulnerability in Rural Malawi

The objective of the Savings, Agriculture, Governance, and Empowerment for Health (SAGE4Health) study was to evaluate the impact of a large-scale multi-level economic and food security intervention on health outcomes and HIV vulnerability in rural Malawi. The study employed a quasi-experimental non-equivalent control group design to compare intervention participants (n = 598) with people participating in unrelated programs in distinct but similar geographical areas (control, n = 301). We conducted participant interviews at baseline, 18–, and 36–months on HIV vulnerability and related health outcomes, food security, and economic vulnerability. Randomly selected households (n = 1002) were interviewed in the intervention and control areas at baseline and 36 months. Compared to the control group, the intervention led to increased HIV testing (OR 1.90; 95 % CI 1.29–2.78) and HIV case finding (OR = 2.13; 95 % CI 1.07–4.22); decreased food insecurity (OR = 0.74; 95 % CI 0.63–0.87), increased nutritional diversity, and improved economic resilience to shocks. Most effects were sustained over a 3-year period. Further, no significant differences in change were found over the 3-year study period on surveys of randomly selected households in the intervention and control areas. Although there were general trends toward improvement in the study area, only intervention participants’ outcomes were significantly better. Results indicate the intervention can improve economic and food security and HIV vulnerability through increased testing and case finding. Leveraging the resources of economic development NGOs to deliver locally-developed programs with scientific funding to conduct controlled evaluations has the potential to accelerate the scientific evidence base for the effects of economic development programs on health.

Association Between Food Insecurity and HIV Viral Suppression: A Systematic Review and Meta-Analysis

Although an increasing number of HIV infected people are accessing antiretroviral treatment, many do not achieve complete HIV viral suppression and remain at risk for AIDS and capable of HIV transmission. Food insecurity has been identified as a potential risk factor for poor virologic response, but the association between these factors has been inconsistently documented in the literature. We systematically searched five electronic databases and bibliographies of relevant studies through April 2015 and retrieved 11 studies that met our inclusion criteria, of which nine studies were conducted in North America and the remaining two studies were in Brazil and Uganda respectively. Meta-analyzed results indicated that experiencing food insecurity resulted in 29% lower odds of achieving complete HIV viral suppression (OR = 0.71, 95% CI 0.61-0.82) and this significant inverse association was consistently found regardless of study design, exposure measurement, and confounder adjustment methods. These findings suggest that food insecurity is a potential risk factor for incomplete HIV viral suppression in people living with HIV.

Alcohol Use and Food Insecurity Among People Living with HIV in Mbarara, Uganda and St. Petersburg, Russia

Food insecurity (FI) is a documented problem associated with adverse health outcomes among HIV-infected populations. Little is known about the relationship between alcohol use and FI. We assessed whether heavy alcohol use was associated with FI among HIV-infected, antiretroviral therapy (ART)-naïve cohorts in Uganda and Russia. Inverse probability of treatment weighted logistic regression models were used to evaluate the association using cross-sectional baseline data. FI was experienced by half of the Russia cohort (52 %) and by a large majority of the Uganda cohort (84 %). We did not detect an association between heavy alcohol use and FI in either cohort (Russia: AOR = 0.80, 95 % CI 0.46, 1.40; Uganda: AOR = 1.00, 95 % CI 0.57, 1.74) or based on the overall combined estimate (AOR = 0.89, 95 % CI 0.60, 1.33). Future studies should explore the determinants of FI in HIV-infected populations to inform strategies for its mitigation.

Food Security Status is Related to Mental Health Quality of Life Among Persons Living with HIV

This study evaluated the association between health related quality of life and food security among persons living with HIV (PLHIV). We studied 167 PLHIV who completed questionnaires assessing food security, disease symptomatology, and several domains of the SF-36 health related quality of life survey. HIV disease state was assessed from medical records. Associations between independent and outcome variables were determined through linear regression models. Compared to food security, very low food security was significantly associated with lower mental component summary scores, [average difference -4.98 (95 % CI -9.85, -0.10)]; mental health, [average difference -5.44 (95 % CI -10.08, -0.81)]; and general health, [average difference -5.13 (95 % CI -9.65, -0.65)] after adjusting for covariates. About a fourth of participants experienced severe food insecurity, which negatively influenced their mental health and general wellbeing. The inclusion of resources for food assistance in HIV treatment programs may help ameliorate mental health challenges faced by PLHIV.

Comprehensive and Medically Appropriate Food Support Is Associated with Improved HIV and Diabetes Health

Food insecurity is associated with negative chronic health outcomes, yet few studies have examined how providing medically appropriate food assistance to food-insecure individuals may improve health outcomes in resource-rich settings. We evaluated a community-based food support intervention in the San Francisco Bay Area for people living with HIV and/or type 2 diabetes mellitus (T2DM) to determine the feasibility, acceptability, and potential impact of the intervention on nutritional, mental health, disease management, healthcare utilization, and physical health outcomes. The 6-month intervention provided meals and snacks designed to comprise 100% of daily energy requirements and meet nutritional guidelines for a healthy diet. We assessed paired outcomes at baseline and 6 months using validated measures. Paired t tests and McNemar exact tests were used with continuous and dichotomous outcomes, respectively, to compare pre-post changes. Fifty-two participants (out of 72 initiators) had both baseline and follow-up assessments, including 23 with HIV, 24 with T2DM, and 7 with both HIV and T2DM. Median food pick-up adherence was 93%. Comparing baseline to follow-up, very low food security decreased from 59.6% to 11.5% (p < 0.0001). Frequency of consumption of fats (p = 0.003) decreased, while frequency increased for fruits and vegetables (p = 0.011). Among people with diabetes, frequency of sugar consumption decreased (p = 0.006). We also observed decreased depressive symptoms (p = 0.028) and binge drinking (p = 0.008). At follow-up, fewer participants sacrificed food for healthcare (p = 0.007) or prescriptions (p = 0.046), or sacrificed healthcare for food (p = 0.029). Among people with HIV, 95% adherence to antiretroviral therapy increased from 47 to 70% (p = 0.046). Among people with T2DM, diabetes distress (p < 0.001), and perceived diabetes self-management (p = 0.007) improved. Comprehensive, medically appropriate food support is feasible and may improve multiple health outcomes for food-insecure individuals living with chronic health conditions. Future studies should formally test the impact of medically appropriate food support interventions for food-insecure populations through rigorous, randomized controlled designs.

How food insecurity contributes to poor HIV health outcomes: Qualitative evidence from the San Francisco Bay Area

RATIONALE

Food-insecure people living with HIV/AIDS (PLHIV) consistently exhibit worse clinical outcomes than their food-secure counterparts. This relationship is mediated in part through non-adherence to antiretroviral therapy (ART), sub-optimal engagement in HIV care, and poor mental health. An in-depth understanding of how these pathways operate in resource-rich settings, however, remains elusive.

OBJECTIVE

We aimed to understand the relationship between food insecurity and HIV health among low-income individuals in the San Francisco Bay Area using qualitative methods.

METHODS

Semi-structured in-depth interviews were conducted with 34 low-income PLHIV receiving food assistance from a non-profit organization. Interviews explored experiences with food insecurity and its perceived effects on HIV-related health, mental health, and health behaviors including taking ART and attending clinics. Thematic content analysis of transcripts followed an integrative inductive-deductive approach.

RESULTS

Food insecurity was reported to contribute to poor ART adherence and missing scheduled clinic visits through various mechanisms, including exacerbated ART side effects in the absence of food, physical feelings of hunger and fatigue, and HIV stigma at public free-meal sites. Food insecurity led to depressive symptoms among participants by producing physical feelings of hunger, aggravating pre-existing struggles with depression, and nurturing a chronic self-perception of social failure. Participants further explained how food insecurity, depression, and ART non-adherence could reinforce each other in complex interactions.

CONCLUSION

Our study demonstrates how food insecurity detrimentally shapes HIV health behavior and outcomes through complex and interacting mechanisms, acting via multiple socio-ecological levels of influence in this setting. The findings emphasize the need for broad, multisectoral approaches to tackling food insecurity among urban poor PLHIV in the United States.

Food insecurity and diabetes self-management among food pantry clients

OBJECTIVE

To examine the association between level of food security and diabetes self-management among food pantry clients, which is largely not possible using clinic-based sampling methods.

DESIGN

Cross-sectional descriptive study.

SETTING

Community-based food pantries in California, Ohio and Texas, USA, from March 2012 through March 2014.

SUBJECTS

Convenience sample of adults with diabetes queuing at pantries (n 1237; 83 % response). Sampled adults were stratified as food secure, low food secure or very low food secure. We used point-of-care glycated Hb (HbA1c) testing to determine glycaemic control and captured diabetes self-management using validated survey items.

RESULTS

The sample was 70 % female, 55 % Latino/Hispanic, 25 % white and 10 % black/African American, with a mean age of 56 years. Eighty-four per cent were food insecure, one-half of whom had very low food security. Mean HbA1c was 8·1 % and did not vary significantly by food security status. In adjusted models, very-low-food-secure participants, compared with both low-food-secure and food-secure participants, had poorer diabetes self-efficacy, greater diabetes distress, greater medication non-adherence, higher prevalence of severe hypoglycaemic episodes, higher prevalence of depressive symptoms, more medication affordability challenges, and more food and medicine or health supply trade-offs.

CONCLUSIONS

Few studies of the health impact of food security have been able to examine very low food security. In a food pantry sample with high rates of food insecurity, we found that diabetes self-management becomes increasingly difficult as food security worsens. The efficacy of interventions to improve diabetes self-management may increase if food security is simultaneously addressed.

Brief Report: Food Insufficiency Is Associated With Lack of Sustained Viral Suppression Among HIV-Infected Pregnant and Breastfeeding Ugandan Women

Supplemental Digital Content is Available in the Text.

Food insecurity is associated with poor virologic outcomes, but this has not been studied during pregnancy and breastfeeding. We assessed sustained viral suppression from 8 weeks on antiretroviral therapy to 48 weeks postpartum among 171 pregnant and breastfeeding Ugandan women; 74.9% experienced food insufficiency. In multivariable analysis, food insufficiency [adjusted odds ratio (aOR) 0.38, 95% confidence interval (CI): 0.16 to 0.91], higher pretreatment HIV-1 RNA (aOR 0.55 per 10-fold increase, 95% CI: 0.37 to 0.82), and lopinavir/ritonavir versus efavirenz (aOR 0.49, 95% CI: 0.24 to 0.96) were associated with lower odds of sustained viral suppression. Interventions to address food security may improve virologic outcomes among HIV-infected women.

Food insecurity and low CD4 count among HIV-infected people: a systematic review and meta-analysis

Food insecurity is defined as a limited or uncertain ability to acquire acceptable foods in socially acceptable ways, or limited or uncertain availability of nutritionally adequate and safe foods. While effective antiretroviral treatment can significantly increase CD4 counts in the majority of patients, there are certain populations who remain at relatively low CD4 count levels. Factors possibly associated with poor CD4 recovery have been extensively studied, but the association between food insecurity and low CD4 count is inconsistent in the literature. The objective is to systematically review published literature to determine the association between food insecurity and CD4 count among HIV-infected people. PubMed, Web of Science, ProQuest ABI/INFORM Complete, Ovid Medline and EMBASE Classic, plus bibliographies of relevant studies were systematically searched up to May 2015, where the earliest database coverage started from 1900. Studies that quantitatively assessed the association between food insecurity and CD4 count among HIV-infected people were eligible for inclusion. Study results were summarized using random effects model. A total of 2093 articles were identified through electronic database search and manual bibliographic search, of which 8 studies included in this meta-analysis. Food insecure people had 1.32 times greater odds of having lower CD4 counts compared to food secure people (OR = 1.32, 95% CI: 1.15-1.53) and food insecure people had on average 91 fewer CD4 cells/µl compared to their food secure counterparts (mean difference = -91.09, 95% CI: -156.16, -26.02). Food insecurity could be a potential barrier to immune recovery as measured by CD4 counts among HIV-infected people.

Emergency department use by people with HIV in Ontario: a population-based cohort study

BACKGROUND

Emergency department use may reflect poor access to primary care. Our objective was to compare rates and causes of emergency department use between adults living with and without HIV.

METHODS

We conducted a population-based study involving Ontario residents living with and without HIV between Apr. 1, 2011, and Mar. 31, 2012. We frequency matched adults with HIV to 4 HIV-negative people by age, sex and census division, and used random-effects negative binomial regression to compare rates of emergency department use. We classified visits as low urgency or high urgency, and also examined visits for ambulatory care sensitive conditions. Hospital admission following an emergency department visit was a secondary outcome.

RESULTS

We identified 14 534 people with HIV and 58 136 HIV-negative individuals. Rates of emergency department use were higher among people with HIV (67.3 v. 31.2 visits per 100 person-years; adjusted rate ratio 1.58, 95% confidence interval [CI] 1.51-1.65). Similar results were observed for low-urgency visits. With the exception of hypertension, visit rates for ambulatory care sensitive conditions were higher among people with HIV. People with HIV were also more likely than HIV-negative individuals to be admitted to hospital following an emergency department visit (adjusted odds ratio 1.55, 95% CI 1.43-1.69).

INTERPRETATION

Compared with HIV-negative individuals, people with HIV had high rates of emergency department use, including potentially avoidable visits. These findings strongly support the need for comprehensive care for people with HIV.

Understanding Cross-Sectional Racial, Ethnic, and Gender Disparities in Antiretroviral Use and Viral Suppression Among HIV Patients in the United States

To examine racial/ethnic and gender disparities in antiretroviral (ART) use and viral suppression among HIV-infected persons in care and identify factors that might account for observed disparities. The Medical Monitoring Project (MMP) is a complex sample survey of HIV-infected adults receiving medical care in the United States. We used weighted interview and medical record data collected 06/2009 to 05/2012 to estimate the prevalence of ART use and viral suppression among gender-stratified racial/ethnic groups. We used χ² tests to identify significant differences in outcomes between white men versus other groups, and logistic regression models to identify the most parsimonious set of factors that could account for each observed difference. We found no significant disparity in ART use between white and Hispanic men, and no disparities between white men and white and Hispanic women after adjustment for disease stage, age, and poverty. Disparities in ART use between white men and black persons persisted after adjusting for other factors, but the observed differences were relatively small. Differences in ART use and adherence, demographic characteristics, and social determinants of health such as poverty, education, and insurance accounted for the observed disparities in viral suppression between white men and all groups except black men. In our model, accounting for these factors reduced the prevalence difference in viral suppression between white and black men by almost half. We found that factors associated with disparities differed among men and women of the same race/ethnicity, lending support to the assertion that gender affects access to care and health status among HIV-infected patients. In addition to supporting efforts to increase ART use and adherence among persons living with HIV, our analysis provides evidence for the importance of social determinants of health in understanding racial/ethnic and gender differences in ART use and viral suppression.