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

Food Insecurity Prevalence and Risk Factors among Persons with HIV in a Southeastern US Clinical Care Setting

Food insecurity (FI) is associated with adverse health outcomes for persons with HIV (PWH). Little is known about FI among PWH in southern or non-urban settings. We examined FI prevalence, risk factors, and access to services in a southeastern HIV clinic. Among PWH in the UNC CFAR HIV Clinical Cohort who were screened for FI as part of HIV care between 2021 and 2022, we estimated unadjusted prevalence ratios (PRs) comparing the probability of reporting FI by demographic and clinical characteristics. The 479 PWH screened for FI were 65% cisgender men, 62% non-Hispanic Black PWH, a median of 54 years old (IQR 41-62), and 93% with an HIV viral load (VL) < 200 copies/mL. FI prevalence was 36.3% (95% CI 32.3%-40.9%). Cisgender women and transgender adults were more likely to report FI than cisgender men (PRs 1.24 [95% CI 0.97-1.59] and 2.03 [1.32-3.12], respectively). Compared with White PWH, the PR was 1.71 (1.20-2.42) for Black and 2.44 (1.56-3.82) for Hispanic PWH. The PR was 1.42 (0.98-2.05) for PWH with VL ≥ 200 versus < 200 copies/mL. Having no or public versus private health insurance was also associated with FI. PWH with FI had a high prevalence of comorbidities including hypercholesterolemia (49%) and hypertension (48%), though these were not associated with FI. Almost half of PWH with FI were not accessing a food pantry or nutrition assistance program. Identifying FI in PWH is critical as FI is common and may contribute to viral non-suppression, poor comorbidity control, and gender and racial/ethnic health disparities in PWH.

Addressing food insecurity in HIV care: perspectives from healthcare and social service providers in New York state

Ending the HIV epidemic in the United States will require addressing social determinants contributing to poor care engagement among people living with HIV (PLH), such as food insecurity. Food insecurity is associated with poor care engagement among PLH. Yet, few studies have examined the perspectives of healthcare and social services providers on addressing food insecurity in HIV care. Guided by the Social Ecological Model, we conducted semi-structured interviews with 18 providers in New York State to understand barriers and facilitators to addressing food insecurity in HIV care. Thematic analysis illustrated eight themes across various levels of the Social Ecological Model. At the patient-level, providers perceived patients' feelings of embarrassment, shame, and judgement, and low health literacy as barriers. At the provider-level, challenges included limited time. Facilitators included fostering strong, patient-provider relationships. Barriers at the clinic-level included limited funding, while clinic resources served as facilitators. At the community-level, challenges included intersecting stigmas arising from community norms towards PLH and people who receive food assistance and limited access to healthy food. Findings suggest the need to incorporate their insights into the development of interventions that address food insecurity in HIV care.

Associations between social determinants of health and comorbidity and multimorbidity in people of black ethnicities with HIV

OBJECTIVE

Social determinants of health (SDH) are important determinants of long-term conditions and multimorbidity in the general population. The intersecting relationship between SDH and multimorbidity in people with HIV remains poorly studied.

DESIGN

A cross-sectional study investigating the relationships between eight socio-economic parameters and prevalent comorbidities of clinical significance and multimorbidity in adults of African ancestry with HIV aged 18-65 years in South London, UK.

METHODS

Multivariable logistic regression analysis was used to evaluate associations between SDH and comorbidities and multimorbidity.

RESULTS

Between September 2020 and January 2022, 398 participants (median age 52 years, 55% women) were enrolled; 85% reported at least one SDH and 72% had at least one comorbidity. There were no associations between SDH and diabetes mellitus or kidney disease, few associations between SDH (job and food insecurity) and cardiovascular or lung disease, and multiple associations between SDH (financial, food, housing and job insecurity, low educational level, social isolation, and discrimination) and poor mental health or chronic pain. Associations between SDH and multimorbidity mirrored those for constituent comorbidities.

CONCLUSION

We demonstrate strong associations between SDH and poor mental health, chronic pain and multimorbidity in people of black ethnicities living with HIV in the UK. These findings highlight the likely impact of enduring socioeconomic hardship in these communities and underlines the importance of holistic health and social care for people with HIV to address these adverse psychosocial conditions.

Obesity Modifies the Relationship Between Raltegravir and Dolutegravir Hair Concentrations and Body Weight Gain in Women Living with HIV

Integrase strand-transfer inhibitors (INSTIs) are associated with weight gain in women living with HIV (WLH). Relationships between drug exposure, baseline obesity, and INSTI-associated weight gain remain unclear. Data from 2006 to 2016 were analyzed from virally suppressed WLH enrolled in the Women's Interagency HIV Study, who switched/added an INSTI to antiretroviral therapy: [raltegravir (RAL), dolutegravir (DTG), or elvitegravir (EVG)]. Percent body weight change was calculated from weights obtained a median 6 months pre-INSTI and 14 months post-INSTI initiation. Hair concentrations were measured with validated liquid chromatography-mass spectrometry (MS)/MS assays. Baseline (preswitch) weight status evaluated obese (body mass index, BMI, ≥30 kg/m2) versus nonobese (BMI <30 kg/m2). Mixed models examined the drug hair concentration*baseline obesity status interaction for each INSTI. There were 169 WLH included: 53 (31%) switched to RAL, 72 (43%) to DTG, and 44 (26%) to EVG. Women were median age 47-52 years, predominantly Non-Hispanic Black, median CD4 counts >500 cells/mm3, >75% with undetectable HIV-1 RNA. Over ∼1 year, women experienced median increases in body weight: 1.71% (-1.78, 5.00) with RAL; 2.40% (-2.82, 6.50) with EVG; and 2.48% (-3.60, 7.88) with DTG. Baseline obesity status modified the relationship between hair concentrations and percent weight change for DTG and RAL (p's < 0.05): higher DTG, yet lower RAL concentrations were associated with greater weight gain among nonobese women. Additional pharmacologic assessments are needed to understand the role of drug exposure in INSTI-associated weight gain.

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.

Food Insecurity Is Associated With Low Tenofovir Diphosphate in Dried Blood Spots in South African Persons With HIV

Background

Food insecurity has been linked to suboptimal antiretroviral therapy (ART) adherence in persons with HIV (PWH). This association has not been evaluated using tenofovir diphosphate (TFV-DP) in dried blood spots (DBSs), a biomarker of cumulative ART adherence and exposure.

Methods

Within a prospective South African cohort of treatment-naive PWH initiating ART, a subset of participants with measured TFV-DP in DBS values was assessed for food insecurity status. Bivariate and multivariate median-based regression analysis compared the association between food insecurity and TFV-DP concentrations in DBSs adjusting for age, sex, ethnicity, medication possession ratio (MPR), and estimated glomerular filtration rate.

Results

Drug concentrations were available for 285 study participants. Overall, 62 (22%) PWH reported worrying about food insecurity and 44 (15%) reported not having enough food to eat in the last month. The crude median concentrations of TFV-DP in DBSs differed significantly between those who expressed food insecurity worry versus those who did not (599 [interquartile range {IQR}, 417-783] fmol/punch vs 716 [IQR, 453-957] fmol/punch; P = .032). In adjusted median-based regression, those with food insecurity worry had concentrations of TFV-DP that were 155 (95% confidence interval, -275 to -35; P = .012) fmol/punch lower than those who did not report food insecurity worry. Age and MPR remained significantly associated with TFV-DP.

Conclusions

In this study, food insecurity worry is associated with lower TFV-DP concentrations in South African PWH. This highlights the role of food insecurity as a social determinant of HIV outcomes including ART failure and resistance.

Food insecurity and mental health during the COVID-19 pandemic in cystic fibrosis households

BACKGROUND

The COVID-19 pandemic impacted many households due to shelter-in-place orders and economic hardship. People with cystic fibrosis (CF) experienced increased food insecurity compared to the general population before the pandemic, even though adequate food access is needed to maintain nutrition goals associated with improved health-related outcomes. Little is known about the impact the pandemic had on the food insecurity of people with CF and their families.

OBJECTIVE

To investigate how the COVID-19 pandemic impacted food insecurity, mental health, and self-care in people with CF.

METHODS

Adults with CF and parents/guardians of children with CF were recruited via social media to complete online questionnaires from May 2020 to February 2021. Questionnaires in English and Spanish included USDA 2-question food insecurity screening, Patient Health Questionnaire-4 for mental health screening, and directed questions on the impact of the pandemic.

RESULTS

Of 372 respondents, 21.8% of the households experienced food insecurity during the pandemic compared to 18.8% prepandemic (p < .001). More food insecure patients with CF reported weight loss (32.1% vs. 13.1%, p < .001), worse airway clearance adherence (13.6% vs. 5.8%, p < .01), and worse medication adherence (12.4% vs. 1.7%, p < .01) compared to food secure patients. Food insecure subjects were more likely to have an abnormal mental health screen compared to food secure subjects (53.1% vs. 16.2%, p < .001).

CONCLUSION

Food insecurity increased in the CF population during the COVID-19 pandemic. Food insecure subjects reported worse mental health and self-care during the pandemic compared to food secure subjects.

Mental Health Mediates the Association Between Gender-Based Violence and HIV Treatment Engagement in US Women

BACKGROUND

Gender-based violence (GBV) is associated with poorer engagement in HIV care and treatment. However, there is a dearth of research on the psychological (eg, mental health) and structural (eg, food insecurity) factors that mediate and moderate this association. GBV could lead to poor mental health, which in turn affects adherence, whereas food insecurity could worsen the effect of GBV on engagement in care. This study uses data from the Women's Interagency HIV Study to address these gaps.

METHODS

Women completed 6 assessments from 2013 to 2016 on GBV, mental health, food insecurity, adherence to antiretroviral therapy, and missed HIV care appointments in the past 6 months. Multilevel logistic regression models estimated associations between GBV and engagement in care and whether associations were mediated by depression, generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) and moderated by food insecurity.

RESULTS

GBV was associated with higher odds of suboptimal adherence (adjusted odds ratio: 1.88; 95% confidence interval: 1.24 to 2.87) and missed appointments (adjusted odds ratio: 1.76; 95% confidence interval: 1.16 to 2.67). The association between GBV and adherence was mediated by depressive symptoms, GAD, and PTSD, accounting for 29.7%, 15.0%, and 16.5%, respectively, of the total association. The association between GBV and missed appointments was mediated by depression and GAD, but not PTSD, with corresponding figures of 25.2% and 19.7%. Associations did not differ by food insecurity.

CONCLUSIONS

GBV is associated with suboptimal engagement in care, which may be explained by mental health. Interventions should address women's mental health needs, regardless of food insecurity, when improving engagement in HIV care.

Water Insecurity is Associated with Lack of Viral Suppression and Greater Odds of AIDS-Defining Illnesses Among Adults with HIV in Western Kenya

Reliable access to safe and acceptable water in sufficient quantities (i.e., water security) is important for medication adherence and limiting pathogen exposure, yet prior studies have only considered the role of food security as a social determinant of HIV-related health. Therefore, the objective of this analysis was to assess the relationships between household water insecurity and HIV-related outcomes among adults living with HIV in western Kenya (N = 716). We conducted a cross-sectional analysis of baseline data from Shamba Maisha (NCT02815579), a cluster randomized controlled trial of a multisectoral agricultural and asset loan intervention. Baseline data were collected from June 2016 to December 2017. We assessed associations between water insecurity and HIV-related outcomes, adjusting for clinical and behavioral confounders, including food insecurity. Each five-unit higher household water insecurity score (range: 0-51) was associated with 1.21 higher odds of having a viral load ≥ 1000 copies/mL (95% CI 1.07, 1.36) and 1.26 higher odds of AIDS-defining illness (95% CI 1.11, 1.42). Household water insecurity was not associated with CD4 cell count (B: 0.27; 95% CI -3.59, 13.05). HIV treatment and support programs should consider assessing and addressing water insecurity in addition to food insecurity to optimize HIV outcomes.

Food insecurity, drug resistance and non-disclosure are associated with virologic non-suppression among HIV pregnant women on antiretroviral treatment

We determined social and behavioral factors associated with virologic non-suppression among pregnant women receiving Option B+ antiretroviral treatment (ART). Baseline data was used from women in Mobile WAChX trial from 6 public maternal child health (MCH) clinics in Kenya. Virologic non-suppression was defined as HIV viral load (VL) ≥1000 copies/ml. Antiretroviral resistance testing was performed using oligonucleotide ligation (OLA) assay. ART adherence information, motivation and behavioral skills were assessed using Lifewindows IMB tool, depression using PHQ-9, and food insecurity with the Household Food Insecurity Access Scale. Correlates of virologic non-suppression were assessed using Poisson regression. Among 470 pregnant women on ART ≥4 months, 57 (12.1%) had virologic non-suppression, of whom 65% had HIV drug resistance mutations. In univariate analyses, risk of virologic non-suppression was associated with moderate-to-severe food insecurity (RR 1.80 [95% CI 1.06–3.05]), and varied significantly by clinic site (range 2%-22%, p <0.001). In contrast, disclosure (RR 0.36 [95% CI 0.17–0.78]) and having higher adherence skills (RR 0.70 [95% CI 0.58–0.85]) were associated with lower risk of virologic non-suppression. In multivariate analysis adjusting for clinic site, disclosure, depression symptoms, adherence behavior skills and food insecurity, disclosure and food insecurity remained associated with virologic non-suppression. Age, side-effects, social support, physical or emotional abuse, and distance were not associated with virologic non-suppression. Prevalence of virologic non-suppression among pregnant women on ART was appreciable and associated with food insecurity, disclosure and frequent drug resistance. HIV VL and resistance monitoring, and tailored counseling addressing food security and disclosure, may improve virologic suppression in pregnancy.

Doctors have an ethical obligation to ask patients about food insecurity: what is stopping us?

Inadequate diet is the leading risk factor for morbidity and mortality worldwide. However, approaches to identifying inadequate diets in clinical practice remain inconsistent, and dietary interventions (on both individual and public health policy levels) frequently focus on facilitating 'healthy choices', with limited emphasis on structural constraints. We examine the ethical implications of introducing a routine question in the medical history about ability to access food. Not collecting data on food security means that clinicians are unable to identify people who may benefit from support on an individual level, unable to consider relevant dietary risk factors for disease and disease progression and unable to monitor population trends and inequalities in dietary access in order to design effective policy interventions. We argue that the current lack of routine screening for food insecurity is inconsistent with our approach to other health behaviours (eg, smoking and alcohol use), as well as with doctors' frequent informal role as gatekeepers to the food aid system, and recent calls for governmental action on food insecurity and health inequalities from individual clinicians and professional bodies. Potential ethical barriers to asking patients about food security are addressed, including concerns about stigma, limiting autonomy, fair resource allocation, unclear professional remits and clinicians' ability to offer effective interventions. We suggest that there is an ethical imperative for doctors to ask patients about their ability to access healthy food. Gathering this data provides a valuable first step in re-framing the social determinants of health as modifiable risks, rather than inevitable inequities.

Feasibility and Acceptability of a Program to Promote Positive Affect, Well-Being and Gender Empowerment in Black Women Living with HIV

While programs and interventions intended to increase positive affect among people living with HIV (PLWH) and other chronic diseases have been associated with improved health outcomes, including decreased depression, programs have not been tailored specifically for Black women. We tailored a program designed to increase positive affect and to decrease depressive symptoms in PLWH to a group format for Black WLWH. We also added skills to increase gender empowerment. We then tested the acceptability and feasibility of this program with 8 Black WLWH. The program was acceptable and relatively feasible, as assessed by women’s participation and feedback about program clarity and helpfulness, which women rated above 9 on a 10-point scale. A few women suggested that optimal delivery point for some skills taught would be shortly after HIV diagnosis. A proof-of-concept program intended to bolster positive emotions and gender empowerment and decrease depression can be tailored for Black WLWH and is relatively feasible and acceptable. A randomized controlled trial is needed to assess the preliminary efficacy of this program on positive affect, depression, and other health outcomes for WLWH.

A conceptual model for understanding the rapid COVID-19-related increase in food insecurity and its impact on health and healthcare

Food insecurity, a well-established determinant of chronic disease morbidity and mortality, is rapidly increasing due to the coronavirus disease 2019 (COVID-19) pandemic. We present a conceptual model to understand the multiple mechanisms through which the economic and public health crises sparked by COVID-19 might increase food insecurity and contribute to poor health outcomes in the short- and long-term. We hypothesize that, in the short-term, increased food insecurity, household economic disruption, household stress, and interruptions in healthcare will contribute to acute chronic disease complications. However, the impact of the pandemic on food security will linger after social-distancing policies are lifted and the health system stabilizes, resulting in increased risk for chronic disease development, morbidity, and mortality among food-insecure households in the long-term. Research is needed to examine the impact of the pandemic-related increase in food insecurity on short- and long-term chronic health outcomes, and to delineate the underlying causal mechanisms. Such research is critical to inform the development of effective programs and policies to address food insecurity and its downstream health impacts during COVID-19 and future pandemics.

Social Support Mitigates Negative Impact of Food Insecurity on Antiretroviral Adherence Among Postpartum Women in Western Kenya

Food insecurity (FI), low social support, and low health-related quality of life (HRQoL) are associated with self-reported nonadherence to antiretroviral therapy (ART) among postpartum women, but these relationships have not been evaluated using objective adherence indicators. Hair samples were therefore analyzed among 83 postpartum Kenyan women living with HIV on efavirenz and nevirapine ART drug regimens in an observational cohort (NCT02974972). FI (0-27), social support (0-40), and HRQoL (8-40) in the prior month were also assessed. In multivariable models, each point increase in FI and decrease in HRQoL were associated with a 45.1% (95% CI: -64.3%, -15.6%) and 10.5% decrease (95% CI: 1.0%, 22.1%) in hair ART drug concentrations respectively, when social support was held constant. A significant interaction between social support and FI (β = 0.02, p = 0.017) indicated that greater social support was predicted to mitigate the negative impacts of FI on ART adherence. Addressing these modifiable barriers could improve ART adherence during this critical period.

Income Inequality Is Associated With Low Cumulative Antiretroviral Adherence in Persons With Human Immunodeficiency Virus

Background

The adherence biomarker tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is associated with viral suppression and predicts future viremia. However, its association with social determinants of health (SDoH) in people with human immunodeficiency virus (PWH) remains unknown.

Methods

Dried blood spots for TFV-DP were longitudinally collected from a clinical cohort of PWH receiving tenofovir disoproxil fumarate-based therapy (up to 3 visits over 48 weeks) residing in 5 Colorado counties. To assign SDoH, zip codes at enrollment were matched with SDoH data from AIDSVu (https://aidsvu.org/). The SDoH included household income, percentage living in poverty, education level, and income inequality (quantified using Gini coefficient, where 0 and 1 represent perfect income equality and inequality, respectively). Log-transformed TFV-DP concentrations were analyzed using a mixed-effects model to estimate percentage change (95% confidence interval) in TFV-DP for every significant change in the SDoH and adjusted for relevant covariates including age, gender, race, estimated glomerular filtration rate, body mass index, hematocrit, CD4⁺ T-cell count, antiretroviral drug class, and 3-month self-reported adherence.

Results

Data from 430 PWH totaling 950 person-visits were analyzed. In an adjusted analysis, income inequality was inversely associated with TFV-DP in DBS. For every 0.1 increase in the Gini coefficient, TFV-DP concentrations decreased by 9.2% (−0.5 to −17.1; P = .039). This remained significant after adjusting for human immunodeficiency virus viral suppression, where a 0.1 increase in Gini was associated with a decrease of 8.7% (−0.3 to −17.9; P = .042) in TFV-DP.

Conclusions

Higher income inequality was associated with lower cumulative antiretroviral adherence. These findings support the need for further research on how SDoH impact adherence and clinical care.