Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland

Focusing attention on the important association between food insecurity and psychological distress: a systematic review and meta-analysis

BACKGROUND

Food insecurity has involved more than 750 million individuals worldwide. The association of food insecurity with socio-economic factors is also undeniable demand more consideration. Food insecurity will become a global priority by 2030. This systematic review and meta-analysis examined current literature concerning the association between food insecurity and psychological distress.

METHODS

Relevant researches were identified by searching databases including PubMed, EMBASE, Scopus, and Web of Science, ProQuest, and Cochrane Library up to June 2024 without language limitation. Then a snowball search was conducted in the eligible studies. The quality assessment was made through Newcastle-Ottawa Scale.

RESULTS

Data were available from 44 cross-sectional articles for systematic review and 17 eligible articles for meta-analysis with 2,267,012 and 1,953,636 participants, respectively. Findings support the growing segment of literature on the association between food insecurity and psychological distress. The highly represented groups were households with low income. Psychological and diabetic distress was directly associated with food insecurity as it increased the odds of distress to 329% (OR: 3.29; 95% CI: 2.46-4.40). Sleep problems, anxiety, depression, lower life satisfaction, obesity, and a higher rate of smoking were among the secondary outcomes.

CONCLUSION

Food insecurity was a common stressor that can have a negative impact on psychological well-being and even physical health. The findings should be considered in the public health and making policy-making process.

Exploring Correlates of Resource Insecurity Among Older Black or African Americans with HIV in Ohio

OBJECTIVES

Resource insecurity is a social determinant of health that can impact people with HIV (PWH), in particular older African Americans (AA) or blacks with HIV. The purpose of this study was to identify resource insecurities among older Blacks or AA PWH specifically related to food and housing. Secondary focus was to find associations between resource insecurity and substance use history, stigma, and various forms of discrimination.

METHODS

Eligible participants (N = 52) of this cross-sectional study were 50 years old or older, identified as Black or AA, diagnosed with HIV, and living in Ohio. Food insecurity was assessed using the Household Food Insecurity Access Scale and housing insecurity was defined as not having stable housing. Resource insecurity was categorized into food and housing secure, food or housing insecure, and food and housing insecure.

RESULTS

Almost half (48.1%) of participants reported housing insecurity, with approximately 58.0% experiencing food insecurity, and 38.5% facing both. Current substance use, particularly opiates, showed significant association with resource insecurity (OR = 5.54; 95% CI = 1.91-17.30). Moreover, experiences of everyday (OR = 1.19; 95% CI = 1.10-1.30) or major forms (OR = 1.75; 95% CI = 1.33-2.39) of discrimination, as well as HIV stigma (OR = 1.24; 95% CI = 1.01-1.55), were also linked to increased odds of resource insecurity among participants.

CONCLUSIONS

Findings highlight how social factors contribute to resource insecurity among older AA PWH. Understanding the factors offers insight for targeted intervention in the fight against HIV transmission.

Examining Pathways from Food Insecurity to Safer Sex Efficacy Among Northern and Indigenous Adolescents in the Northwest Territories, Canada

BACKGROUND

Food insecurity is a social determinant of health linked with elevated HIV exposure. Safer sex efficacy (SSE), the ability to navigate sexual decision-making and condom use, is an important marker of sexual wellbeing. Pathways from food insecurity to SSE are understudied, particularly among adolescents in Arctic regions who are at the nexus of food insecurity and sexual health disparities. We examined pathways from food insecurity to SSE among adolescents in the Northwest Territories (NWT), Canada.

METHODS

We implemented cross-sectional surveys with adolescents aged 13-18 recruited through venue-based sampling in 17 NWT communities. We conducted multivariable logistic regression to assess socio-demographic factors associated with food insecurity. We then conducted structural equation modeling (SEM) using maximum likelihood estimation to assess direct effects of food insecurity on SSE and indirect effects via resilience, depression, and relationship power inequity. We assessed both condom use SSE (e.g., confidence in using condoms) and situational SSE (e.g., SSE under partner pressure).

RESULTS

Most participants (n = 410) identified as Indigenous (79%) and 45% reported experiencing food insecurity. In SEM, we did not find a significant direct effect from food insecurity to SSE; however, we found indirect effects from food insecurity to condom use SSE through resilience and depression and from food insecurity to situational SSE through resilience.

CONCLUSIONS

Findings call for structural interventions to address food insecurity, alongside resilience-focused strategies that address the intersection of sexual and mental health. Sexual health strategies focused on individual behavior change are insufficient to address larger contexts of poverty among Northern youth.

Pathways to transactional sex among peri-urban South African women: the role of relationship control, food insecurity and alcohol misuse

Transactional sex increases sub-Saharan African women's risk of HIV acquisition. We quantitatively explored the pathways contributing towards women's future engagement in transactional sex with casual partners and khwapheni (secret concurrent sex partners). We conducted secondary data analysis from a cluster randomised controlled trial in urban informal settlements in eThekwini Municipality., South Africa. Data were collected at enrolment (t0) and 24 months' later (t2) using self-completed questionnaires. Structural equation modelling (SEM) assessed pathways leading to transactional sex over two years. 677 women 18-35 years were enrolled and 80.5% (n = 545) were followed up. At t2, 44.6% of respondents reported transactional sex with a casual partner or khwapheni. The SEM demonstrated a small effect (d = 0.23) between transactional sex at t0 and at t2. Controlling for past transactional sex, main partner relationship control had a large effect size on future transactional sex (d = 0.60). Hazardous drinking had a medium effect size (d = 0.45) and food insecurity a small effect (d = 0.24), (RMSEA 0.03, 90%CI 0.02-0.04; CFI 0.97; TLI 0.96). HIV prevention programming should highlight current transactional sex but also address structural issues predicting future transactional sex, including food insecurity and alcohol misuse. Gender transformative interventions to reduce controlling behaviours in main relationships are worth investigating.

How men influence young women taking PrEP: perspectives from young women, male partners, and male peers in Siaya county, Western Kenya

BACKGROUND

Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention option for those who are most vulnerable to HIV infection, especially young women (YW). Objection by or lack of support from male sexual partners has been shown to impact YW's ability to take PrEP consistently. We explored the views of YW, and male partners and male peers of YW in Siaya County, Western Kenya, to illustrate how men influence, and can support, YW in using PrEP.

METHODS

We used Photovoice to capture the views of YW ages 18-24 who were currently or previously enrolled in the DREAMS program and with current or previous experience taking PrEP. We also captured the views of YW's sexual partners and male peers. The YW completed eight photo assignments that focused on identifying factors influencing their PrEP use, and male participants completed four photo assignments focused on identifying ways men support or hinder YW's PrEP use. Photographs were presented and discussed in same- and mixed-gender groups using the SHOWeD method. YW also participated in in-depth interviews. The analysis focused on identifying themes that described men's influence on YW's PrEP adherence and persistence.

RESULTS

Among YW, a restricting male influence on PrEP use emerged in the majority of photo assignments such that YW's photographs and discussions revealed that men were more often viewed as barriers than supporters. YW perceived that they had little autonomy over their sexual lives and choice to use PrEP. YW's PrEP use was perceived to be hindered by stigmatizing community narratives that influenced men's support of PrEP use among women. Male participants suggested that men would support YW's PrEP use if PrEP was better promoted in the community and if men were more knowledgeable about its benefits.

CONCLUSIONS

A lack of support from male partners and peers and stigmatizing community narratives influence YW's PrEP use. Community-based programs should include education about PrEP specifically for male partners and peers of YW to positively influence PrEP use among YW.

HIV-sensitive social protection for unemployed and out-of-school young women in Botswana: An exploratory study of barriers and solutions

Promotive social protection programs aim to increase income and capabilities and could help address structural drivers of HIV-vulnerability like poverty, lack of education and gender inequality. Unemployed and out-of-school young women bear the brunt of HIV infection in Botswana, but rarely benefit from such economic empowerment programs. Using a qualitative exploratory study design and a participatory research approach, we explored factors affecting perceived program benefit and potential solutions to barriers. Direct stakeholders (n = 146) included 87 unemployed and out-of-school young women and 59 program and technical officers in five intervention districts. Perceived barriers were identified in 20 semi-structured interviews (one intervention district) and 11 fuzzy cognitive maps. Co-constructed improvement recommendations were generated in deliberative dialogues. Analysis relied on Framework and the socioecological model. Overall, participants viewed existing programs in Botswana as ineffective and inadequate to empower vulnerable young women socially or economically. Factors affecting perceived program benefit related to programs, program officers, the young women, and their social and structural environment. Participants perceived barriers at every socioecological level. Young women's lack of life and job skills, unhelpful attitudes, and irresponsible behaviors were personal-level barriers. At an interpersonal level, competing care responsibilities, lack of support from boyfriends and family, and negative peer influence impeded program benefit. Traditional venues for information dissemination, poverty, inequitable gender norms, and lack of coordination were community- and structural-level barriers. Improvement recommendations focused on improved outreach and peer approaches to implement potential solutions. Unemployed and out-of-school young women face multidimensional, interacting barriers that prevent benefit from available promotive social protection programs in Botswana. To become HIV-sensitive, these socioeconomic empowerment programs would need to accommodate or preferentially attract this key population. This requires more generous and comprehensive programs, a more client-centered program delivery, and improved coordination. Such structural changes require a holistic, intersectoral approach to HIV-sensitive social protection.

Food Insecurity and Engagement in Transactional Sex Among Female Secondary Students in Rwanda

The relationship between food insecurity and transactional sex is well recognized, but less is known about this relationship among adolescents. We analyzed cross-sectional baseline data from 3,130 female secondary students aged 12-19 enrolled in a three-arm, cluster randomized controlled trial to examine the association between food insecurity and transactional sex. The explanatory variable was food security and the outcome was ever engaging in transactional sex. Over one quarter (28.7%) reported any food insecurity and 1.9% of all participants (9.6% of sexually active participants) reported ever engaging in transactional sex. In adjusted models, ever experiencing any food insecurity was associated with a higher prevalence of ever transactional sex (PR: 1.60; 95% CI: 1.02, 2.49) compared to little to no food insecurity. These results provide insight into potential predictors of higher-risk sexual behavior in Rwanda; they also provide policy-makers with populations with whom to intervene on upstream determinants of transactional sex, notably poverty and food insecurity.

Food insecurity and depressive symptoms among young people living with HIV in Eastern Zambia

Background: Mental health problems are common among people living with HIV/AIDS and contribute to poor HIV-related outcomes, including AIDS-related mortality. We examined the association between severe food insecurity and depressive symptoms in young people living with HIV (YPLH) in Zambia. Methods: We sampled 120 youth living with HIV aged 18-21 years in the Eastern Province of Zambia. Household food insecurity was measured using the Household Food Insecurity Access Scale (HFIAS). Mental health was assessed using the Children's Depression Inventory-Short Form. We fitted linear regression models to assess whether food insecurity is associated with depressive symptoms. Results: The mean age was 19 years, and 63% were female. Overall, 43% were severely food insecure. After adjusting for sociodemographic variables and other confounders, severely food insecure participants were more likely to report depressive symptoms (β = 0.81, 95% Confidence Interval [CI] 0.07-1.55) and engagement in sex work (β = 1.78, 95% CI 0.32-3.25). Conclusion: Almost half of the sample reported severe food insecurity which was associated with depressive symptoms. Interventions aimed at improving food insecurity may have beneficial effects on mental health and HIV outcomes among young people living with HIV in resource-limited settings.

Predictors of Treatment Adherence and Virological Failure Among People Living with HIV Receiving Antiretroviral Therapy in a South African Rural Community: A Sub-study of the ITREMA Randomised Clinical Trial

A large proportion of people living with HIV (PLHIV) in sub-Saharan Africa reside in rural areas. Knowledge of enablers and barriers of adherence to antiretroviral treatment (ART) in these populations is limited. We conducted a cohort study of 501 adult PLHIV on ART at a rural South African treatment facility as a sub-study of a clinical trial (ClinicalTrials.gov NCT03357588). Socio-economic, psychosocial and behavioral characteristics were assessed as covariates of self-reported adherence difficulties, suboptimal pill count adherence and virological failure during 96 weeks of follow-up. Male gender was an independent risk factor for all outcomes. Food insecurity was associated with virological failure in males. Depressive symptoms were independently associated with virological failure in both males and females. Household income and task-oriented coping score were protective against suboptimal pill-count adherence. These results underscore the impact of low household income, food insecurity and depression on outcomes of ART in rural settings and confirm other previously described risk factors. Recognition of these factors and targeted adherence support strategies may improve patient health and treatment outcomes.

Examining Cash Expenditures and Associated HIV-Related Behaviors Using Financial Diaries in Women Employed by Sex Work in Rural Uganda: Findings from the Kyaterekera Study

BACKGROUND

Women employed by sex work (WESW) have a high risk of human immunodeficiency virus (HIV) infection and experience economic barriers in accessing care. However, few studies have described their financial lives and the relationship between expenditures and HIV-related behaviors.

METHODS

This exploratory study used financial diaries to collect expenditure and income data from WESW in Uganda over 6 months. Data were collected as part of a larger trial that tested the efficacy of an HIV prevention intervention method. Descriptive statistics were used to quantify women's income, relative expenditures, and negative cash balances. Bivariate and multivariate logistic regressions were used to examine the odds of sexual risk behavior or use of HIV medications for several cash scenarios.

RESULTS

A total of 163 WESW were enrolled; the participants mean age was 32 years old. Sex work was the sole source of employment for most WESW (99%); their average monthly income was $62.32. Food accounted for the highest proportion of spending (44%) followed by sex work (20%) and housing expenditures (11%). WESW spent the least on health care (5%). Expenditures accounted for a large but variable proportion of these women's income (56% to 101%). Most WESW (74%) experienced a negative cash balance. Some also reported high sex work (28%), health care (24%), and education (28%) costs. The prevalence of condomless sex (77%) and sex with drugs/alcohol (70%) was high compared to use of ART/PrEP (Antiretroviral therapy/Pre-exposure prophylaxis) medications (45%). Women's cash expenditures were not statistically significantly associated with HIV-related behaviors. However, the exploratory study observed a consistent null trend of lower odds of condomless sex (adjusted odds ratio (AOR) = 0.70, 95% confidence interval (CI): 0.28-1.70), sex with drugs/alcohol (AOR = 0.93, 95% CI: 0.42-2.05), and use of ART/PrEP (AOR = 0.80, 95% CI: 0.39-1.67) among women who experienced a negative cash balance versus those who did not. Similar trends were observed for other cash scenarios.

CONCLUSION

Financial diaries are a feasible tool to assess the economic lives of vulnerable women. Despite having paid work, most WESW encountered a myriad of financial challenges with limited spending on HIV prevention. Financial protections and additional income-generating activities may improve their status. More robust research is needed to understand the potentially complex relationship between income, expenditures, and HIV risk among vulnerable sex workers.

The impact of food insecurity on health outcomes: empirical evidence from sub-Saharan African countries

BACKGROUND

Food insecurity adversely affects human health, which means food security and nutrition are crucial to improving people's health outcomes. Both food insecurity and health outcomes are the policy and agenda of the 2030 Sustainable Development Goals (SDGs). However, there is a lack of macro-level empirical studies (Macro-level study means studies at the broadest level using variables that represent a given country or the whole population of a country or economy as a whole. For example, if the urban population (% of the total population) of XYZ country is 30%, it is used as a proxy variable to represent represent country's urbanization level. Empirical study implies studies that employ the econometrics method, which is the application of math and statistics.) concerning the relationship between food insecurity and health outcomes in sub-Saharan African (SSA) countries though the region is highly affected by food insecurity and its related health problems. Therefore, this study aims to examine the impact of food insecurity on life expectancy and infant mortality in SSA countries.

METHODS

The study was conducted for the whole population of 31 sampled SSA countries selected based on data availability. The study uses secondary data collected online from the databases of the United Nations Development Programme (UNDP), the Food and Agricultural Organization (FAO), and the World Bank (WB). The study uses yearly balanced data from 2001 to 2018. This study employs a multicountry panel data analysis and several estimation techniques; it employs Driscoll-Kraay standard errors (DKSE), a generalized method of momentum (GMM), fixed effects (FE), and the Granger causality test.

RESULTS

A 1% increment in people's prevalence for undernourishment reduces their life expectancy by 0.00348 percentage points (PPs). However, life expectancy rises by 0.00317 PPs with every 1% increase in average dietary energy supply. A 1% rise in the prevalence of undernourishment increases infant mortality by 0.0119 PPs. However, a 1% increment in average dietary energy supply reduces infant mortality by 0.0139 PPs.

CONCLUSIONS

Food insecurity harms the health status of SSA countries, but food security impacts in the reverse direction. This implies that to meet SDG 3.2, SSA should ensure food security.

The Impact of Land Tenure Security on a Livelihood Intervention for People Living with HIV in Western Kenya

Few studies have explored land access, a structural driver of health, and women's participation in livelihood interventions to improve food security and HIV outcomes. This qualitative study, embedded within Shamba Maisha (NCT02815579)-a randomized controlled trial (RCT) examining the impact of a multisectoral intervention among farmers living with HIV in western Kenya-sought to explore the influence of perceived access to and control of land on agricultural productivity, investments, and benefits. Thirty in-depth interviews (IDIs) were conducted with purposively sampled men and women, 3 to 6 months after receiving intervention inputs; data were deductively and inductively coded and analyzed. Farming practices and participation in Shamba Maisha were dependent on land tenure and participants' perceived strength of claim over their land, with participants who perceived themselves to be land insecure less likely to make long-term agricultural investments. Land tenure was influenced by a number of factors and posed unique challenges for women which negatively impacted uptake and success in the intervention. Data underscore the importance of secure land tenure for the success of similar interventions, especially for women; future interventions should integrate land security programming for improved outcomes for all.

Vulnerable young women and frontline service providers identify options to improve the HIV-sensitivity of social protection programmes in Botswana: A modified Policy Delphi approach

Poverty, lack of education and gender inequality make unemployed and out-of-school young women extremely vulnerable to HIV infection. Promotive social protection programmes aim to increase livelihood and capabilities and could empower this priority population to act on HIV prevention choices. In Botswana, they rarely benefit from such programmes.A modified Policy Delphi engaged a panel of 22 unemployed and out-of-school young women and eight frontline service providers to consider alternative policy and practice options, and tailor available programmes to their own needs and social situation. The panel assessed the desirability and feasibility of improvement proposals and, in a second round, ranked them for relative importance.Nearly all 40 improvement proposals were considered very desirable and definitely, or possibly, feasible, and panellists prioritised a wide range of proposals. Frontline service providers stressed foundational skills, like life skills and second chance education. Young women preferred options with more immediate benefits. Overall, panellists perceived positive role models for programme delivery, access to land and water, job skills training, and stipends as most important to empower HIV-vulnerable young women. Results suggest ample policy space to make existing social protection programmes in Botswana more inclusive of unemployed and out-of-school young women, hence more HIV-sensitive.

Food Insecurity and Risky Sexual Behaviors among University Students in KwaZulu-Natal, South Africa

Objective: Risky sexual behavior (RSB) is associated with increased rates of sexually transmitted infections (STIs), Human Immunodeficiency Virus (HIV) infection, and unwanted pregnancies among university students. In view of its global impact on public health, the potential association between food insecurity and RSBs among university students requires investigation. This study aimed to determine the association between food security status and the likelihood to engage in RSBs amongst university students in KwaZulu-Natal (KZN), South Africa (SA). Methods: This cross-sectional study was conducted at four public sector higher educational institutions (HEIs) in KZN. A convenience sampling strategy was used to recruit participants (N = 375). All data were analyzed using STATA version 15 software. Results: Our data shows that food insecurity increased the odds of students engaging in transactional sex for "money" or "to meet basic material needs." Participants who were food insecure were two times more likely to have multiple sexual partners. Conclusions: Our findings demonstrate a significant association between food insecurity and RSBs. It is recommended that interventions targeting the alleviation of food insecurity, should be developed and implemented by HEIs to reduce RSB participation.

Analysis of Heavy Rainfall in Sub-Saharan Africa and HIV Transmission Risk, HIV Prevalence, and Sexually Transmitted Infections, 2005-2017

IMPORTANCE

Extreme precipitation, including heavy rains and flooding, is associated with poor health outcomes mediated in part by decreases in income and food production. However, the association between heavy rains and HIV burden is unknown.

OBJECTIVE

To investigate the association between heavy rainfall, HIV prevalence, and HIV transmission risk over a 12-year span in sub-Saharan Africa.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional population-based study, using data collected from the 2005-2017 Demographic and Health Surveys, was conducted in 21 countries in sub-Saharan Africa and analyzed from July 29, 2021, to June 14, 2022.

EXPOSURES

Heavy rainfall was defined based on the extent to which annual rainfall deviated from the historical average (standardized precipitation index ≥1.5) at the enumeration area level.

MAIN OUTCOMES AND MEASURES

HIV, self-reported sexually transmitted infections (STIs), and number of sexual partners.

RESULTS

The study included 288 333 participants aged 15 to 59 years; 172 344 were women (59.8%), and 183 378 were married (63.6%). Mean (SD) age was 31.9 (10.0) years. Overall, 42.4% of participants were exposed to at least 1 year of heavy rainfall in the past 10 years. Each year of heavy rainfall was associated with 1.14 (95% CI, 1.11-1.18) times the odds of HIV infection and 1.11 (95% CI, 1.07-1.15) times the odds of an STI in the past 12 months. There was also an association between heavy rainfall and the reported number of sexual partners (incident rate ratio, 1.12; 95% CI, 1.10-1.15). The odds were greater for the association between heavy rainfall and HIV prevalence and STIs among participants aged older than 20 years and participants in rural areas.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that heavy rainfall was associated with a higher HIV burden in sub-Saharan Africa. The association between heavy rainfall and STIs and number of sexual partners suggests that an increase in the risk of sexual transmission is a plausible mechanism for the observed findings around HIV prevalence. Heavy rainfall could also worsen food insecurity, increasing the risk of transactional sex, or cause damage to public health infrastructure, reducing access to STI education, HIV testing, and treatment.

Associations Between Mobility, Food Insecurity, and Transactional Sex Among Women in Cohabitating Partnerships: An Analysis From 6 African Countries 2016-2017

BACKGROUND

Mobile women are at risk of HIV infection in sub-Saharan Africa, although we lack evidence for HIV risk among women in mobile partnerships, especially in the context of household food insecurity, a growing concern in the region.

SETTING

Women aged 15-59 years with a cohabitating male partner who participated in population-based HIV impact assessment surveys in Eswatini, Lesotho, Namibia, Tanzania, Uganda, and Zambia.

METHODS

We evaluated the association between women's and their partner's mobility (being away from home for more than 1 month or staying elsewhere) and transactional sex (selling sex or receiving money or goods in exchange for sex). We examined associations for effect measure modification by food insecurity level in the household in the past month. We used survey-weighted logistic regression, pooled and by country, adjusting for individual, partner, and household-level variables.

RESULTS

Among women with a cohabitating male partner, 8.0% reported transactional sex, ranging from 2.7% in Lesotho to 13.4% in Uganda. Women's mobility [aOR 1.35 (95% CI: 1.08 to 1.68)], but not their partner's mobility [aOR 0.91 (0.74-1.12)], was associated with transactional sex. Food insecurity was associated with transactional sex independent of mobility [aOR 1.29 (1.10-1.52)]. Among those who were food insecure, mobility was not associated with increased odds of transactional sex.

CONCLUSION

Food insecurity and women's mobility each increased the odds of transactional sex. Because transactional sex is associated with HIV risk, prevention programs can address the needs of mobile and food-insecure women, including those in cohabitating relationships.

Coping Strategies for Household Food Insecurity, and Perceived Health in an Urban Community in Southern Mozambique: A Qualitative Study

In low- and middle-income countries, food insecurity (FI) is a living reality for many households, particularly among the most vulnerable groups. The burden of household FI in Mozambique and how FI and coping strategies relate to perceived health are unknown. This study investigated the lived experiences and coping strategies of food-insecure households, along with their perceived health. Altogether, 16 in-depth interviews were performed, audio-recorded, and transcribed verbatim. A qualitative content analysis was carried out and five themes emerged: lived experiences of FI, coping strategies used in situations of FI, food choices, climate change and food security, and FI and perceived health. A wide range of lived experiences and coping strategies were reported, including cooking whatever is available, skipping meals, receiving money or food from friends and relatives, eating unsafe and low-quality foods, taking on additional work, cooking least-preferred foods, and having a monotonous and less-nutritious diet. Furthermore, the participants reported emotional distress, anxiety and depression, substance use, and other negative health outcomes. Some had diagnoses of hypertension, diabetes or HIV/AIDS. The findings suggest the need for employment creation and women’s empowerment, as well as the implementation of appropriate policies and programmes to alleviate household FI.

Food insecurity and the risk of HIV acquisition: findings from population-based surveys in six sub-Saharan African countries (2016-2017)

OBJECTIVE

To assess the potential bidirectional relationship between food insecurity and HIV infection in sub-Saharan Africa.

DESIGN

Nationally representative HIV impact assessment household-based surveys.

SETTING

Zambia, Eswatini, Lesotho, Uganda and Tanzania and Namibia.

PARTICIPANTS

112 955 survey participants aged 15-59 years with HIV and recency test results.

MEASURES

Recent HIV infection (within 6 months) classified using the HIV-1 limited antigen avidity assay, in participants with an unsuppressed viral load (>1000 copies/mL) and no detectable antiretrovirals; severe food insecurity (SFI) defined as having no food in the house ≥three times in the past month.

RESULTS

Overall, 10.3% of participants lived in households reporting SFI. SFI was most common in urban, woman-headed households, and in people with chronic HIV infection. Among women, SFI was associated with a twofold increase in risk of recent HIV infection (adjusted relative risk (aRR) 2.08, 95% CI 1.09 to 3.97). SFI was also associated with transactional sex (aRR 1.28, 95% CI 1.17 to 1.41), a history of forced sex (aRR 1.36, 95% CI 1.11 to 1.66) and condom-less sex with a partner of unknown or positive HIV status (aRR 1.08, 95% CI 1.02 to 1.14) in all women, and intergenerational sex (partner ≥10 years older) in women aged 15-24 years (aRR 1.23, 95% CI 1.03 to 1.46). Recent receipt of food support was protective against HIV acquisition (aRR 0.36, 95% CI 0.14 to 0.88).

CONCLUSION

SFI increased risk for HIV acquisition in women by twofold. Heightened food insecurity during climactic extremes could imperil HIV epidemic control, and food support to women with SFI during these events could reduce HIV transmission.

Women's Economic Contribution, Relationship Status and Risky Sexual Behaviours: A Cross-Sectional Analysis from a Microfinance-Plus Programme in Rural South Africa

In sub-Saharan Africa, women bear a disproportionate burden of HIV/AIDS while also facing economic and gender inequalities. To explore the association of women's economic contribution and relationship status with risky sexual behaviour, this study analysed cross-sectional data from 626 women aged 22 to 84 in rural South Africa. All women were enrolled in a microfinance plus gender training programme (Intervention with Microfinance for AIDS and Gender Equity (IMAGE)). We used univariable and multivariable logistic regression to explore the associations of relationship status and women's household income contribution with inconsistent condom use, multiple sexual partners and transactional sex, respectively. We found that married, older women had the highest odds of inconsistent condom use, while those contributing all the household income had higher odds of multiple sexual partnerships, but lower odds of transactional sex compared to those with no contribution. Income contribution and relationship status have a nuanced relationship with sexual risk behaviours. Thus, economic strengthening interventions should target relevant vulnerable women while also addressing the broader social and economic drivers of risky sexual behaviour.

Food Insecurity and Health Outcomes Other than Malnutrition in Southern Africa: A Descriptive Systematic Review

Food insecurity (FI) is one of the major causes of malnutrition and is associated with a range of negative health outcomes in low and middle-income countries. The burden of FI in southern Africa is unknown, although FI continues to be a major public health problem across sub-Saharan Africa as a whole. Therefore, this review sought to identify empirical studies that related FI to health outcomes among adults in southern Africa. Altogether, 14 publications using diverse measures of FI were reviewed. The majority of the studies measured FI using modified versions of the United States Department of Agriculture Household Food Security Survey Module. A wide range in prevalence and severity of FI was reported (18-91%), depending on the measurement tool and population under investigation. Furthermore, FI was mostly associated with hypertension, diabetes, anxiety, depression and increased risk of human immunodeficiency virus (HIV) acquisition. Based on the findings, future research is needed, especially in countries with as yet no empirical studies on the subject, to identify and standardize measures of FI suitable for the southern African context and to inform public health policies and appropriate interventions aiming to alleviate FI and potentially improve health outcomes in the region.

HIV serostatus disclosure to sexual partner: a survey among women in Tehran, Iran

BACKGROUND

Disclosure of HIV-positive status in women is associated with many factors. Consequently, status disclosure remains a challenge for Iranian women living with HIV. This study aimed to assess the prevalence, related factors, and reflections of HIV-positive status disclosure to a sexual partner(s) among Iranian women living with HIV.

METHODS

A cross-sectional study was conducted on 170 HIV-seropositive women. Participants were selected from patients registered in the largest HIV clinic and HIV-positive club of Iran. The "HIV disclosure" questionnaire had 38-items and all the interviews were administered by the researcher. Data were analyzed using SPSS version 21.0 software. We used a logistic regression method to calculate the crude odds ratio (COR) and the adjusted odds ratio (AOR) for self-disclosure as the independent predictor variable and the dependent variable, respectively.

RESULTS

One hundred and seventy HIV-positive women were enrolled. Most of them had disclosed their HIV status to at least one person (94.1%) and their sexual partners (86.5%). In the univariate analysis, being married (COR = 18.66, 95% CI 5.63-61.87), living with a sexual partner (COR = 4.72, 95% CI 1.92-11.62), being aware of sexual partners' HIV status (COR = 6.20, 95% CI 1.79-21.49), and gaining the support of sexual partner (COR = 9.08, 95% CI 3.48-23.64) were associated with higher odds of HIV status disclosure. In the multivariate analysis, being aware of sexual partners' HIV status, and gaining the support of sexual partners remained associated with HIV status disclosure. Most women reported a positive reflection from their sexual partners after disclosure, however, negative reflections from society were more common compared to sexual partners and family members.

CONCLUSION

This study shows high overall HIV disclosure proportions. It should be noted that a large number of women were infected by their sexual partners, especially by their spouses. The high rate of transmission in married people indicates an urgent need for more emphasis on appropriate prevention behaviors by infected partners.

Factors associated with HIV testing among youth in a generalised hyperendemic setting: findings from a national survey in Eswatini

Aim: Even though Eswatini was the first country in Africa to achieve the UNAIDS 95-95-95 targets among people living with HIV nationally, youth aged 15-24 years lag behind in HIV testing. This study determined the overall prevalence of HIV testing among the youth and the factors associated with HIV testing.Methods: Data were analysed for 1 834 young people from the 2016-2017 Swaziland HIV Incidence Measurement Survey (SHIMS2) using multivariable logistic regression.Results: Overall, 66% of the young people had tested for HIV in the past 12 months before SHIMS2. Lower odds of HIV testing were observed among males, among those aged 15-17 years, the never married/cohabited, those with primary and secondary education, and among those who had high perceived stigma towards people living with HIV and AIDS. Youth from households classified in the poor and middle quintiles had higher odds of testing for HIV compared to those from rich households.Conclusion: Efforts to increase HIV testing should consider the sociodemographic and behavioural factors identified as determinants of HIV non-testing in this age group.

HIV and Herpes Simplex Virus Type 2 Incidence Among Adolescent Mothers in South Africa: A Longitudinal Analysis of HIV Prevention Trials Network 068 Data

BACKGROUND

Adolescent motherhood is common in South Africa and occurs against a backdrop of high HIV risk. While childbearing during adolescence may result in social and economic strain that may negatively impact health, there has been limited study of whether adolescent motherhood increases the risk of HIV or herpes simplex virus type 2 (HSV-2) acquisition or engagement in high-risk sexual partnerships.

SETTING

Data are from HIV Prevention Trials Network 068, a longitudinal conditional cash transfer study of adolescent girls and young women (age, 13-23) in rural South Africa.

METHODS

We used survival analysis to estimate hazard ratios to determine if adolescent motherhood (live birth before 20 years) predicted incident HIV and incident HSV-2 and generalized estimating equations for behavioral risk ratios to determine if adolescent motherhood was associated with transactional sex and age-disparate partnerships.

RESULTS

Of 2452 adolescent girls and young women who were HIV negative at baseline, 5% were adolescent mothers; 16% were adolescent mothers by the end of the study period. After controlling for covariates, adolescent motherhood predicted incident HSV-2 acquisition [ adjusted hazard ratios, 1.30; 95% confidence interval (CI): 1.01 to 1.95] but not HIV acquisition ( adjusted hazard ratios, 1.19; 95% CI, 0.76 to 1.86). Adolescent motherhood was also associated with being in an age-disparate partnership (adjusted risk ratio, 1.30; 95% CI: 1.07 to 1.58) but not transactional sex.

CONCLUSION

Adolescent motherhood increased the risk of HSV-2 and engagement in age-disparate partnerships, both known risk factors for HIV infection. Sexually transmitted infection screening and/or tailored combination HIV prevention interventions that account for the context of adolescent motherhood are critical to maximize adolescent mothers' long-term health and to meet UNAIDS 95-95-95 targets by 2030.

Individual and Relationship-Level Correlates of Transactional Sex Among Adolescent Girls and Young Women in Malawi: A Multilevel Analysis

Transactional sex increases HIV risk among adolescent girls and young women (AGYW). Understanding the individual and dyadic nature of transactional sex may provide evidence for risk reduction interventions. Multilevel logistic regression was used to cross-sectionally examine correlates of transactional sex among AGYW in Lilongwe, Malawi. Participants (N = 920) reported 1227 relationships. Individual-level associations were found between being divorced/widowed (AOR 5.07, 95% CI 1.93, 13.25), married (AOR 0.26, 95% CI 0.09, 0.72), or unstably housed (AOR 7.11, 95% CI 2.74, 18.47) and transactional sex. At the relationship-level, transactional sex occurred in relationships with: non-primary primary partners (AOR 4.06, 95% CI 2.37, 6.94), perceived partner concurrency (AOR 1.85, 95% CI 1.11, 3.08), and feared violence with couples HIV testing (AOR 2.81, 95% CI 1.26, 6.29), and less likely to occur in relationships with children (AOR 0.15, 95% CI 0.06, 0.38). Multiple co-occurring social and structural vulnerabilities increase transactional sex engagement warranting the need for social protection and gender transformative approaches.

Effect of COVID-19 on food security, hunger, and food crisis

COVID-19 affected the world’s socioeconomic and food security more than other infectious diseases. In many countries, food industries’ workers were moderated because of the COVID-19 pandemic, which caused food factories to reduce or slow down their production. Airline closures, national and international restrictions, and lockdowns have severely disrupted the food supply chain. These, along with structural weaknesses in the world food system such as production, distribution, access, and stability in the food chain, have exposed more people to the food crisis and acute hunger in the world. Therefore it is necessary to use proper planning by governmental organizations and charities in the field of food supply in critical situations.

The role of food security in increasing adolescent girls' agency towards sexual risk taking: qualitative findings from an income generating agricultural intervention in southwestern Kenya

BACKGROUND

Food insecurity is an important underlying driver of HIV risk and vulnerability among adolescents in sub-Saharan Africa. In this region, adolescents account for 80% of all new HIV infections. The primary purpose of this analysis is to understand perceived mechanisms for how a multisectoral agricultural intervention influenced sexual risk taking among HIV-affected adolescents in southwestern Kenya.

METHODS

We conducted semi-structured, individual interviews with 34 adolescent-caregiver dyads who were participants in Adolescent Shamba Maisha (NCT03741634), a sub-study of adolescent girls and caregivers with a household member participating in the Shamba Maisha trial (NCT01548599), a multi-sectoral agricultural and microfinance intervention. Interviews were audiotaped, transcribed, translated, and analyzed using framework and interpretive description analysis methods.

RESULTS

Adolescents receiving the Shamba Maisha intervention described no longer needing to engage in transactional sex or have multiple concurrent sexual partners as a way to meet their basic needs, including food. Key mechanisms for these effects include greater sexual agency among adolescent girls, and increased confidence and self-efficacy in overcoming existing reciprocity norms and sexual relationship power inequity; as well as staying in school. The intervention also increased caregiver confidence in talking about adolescent sexual reproductive health issues. In contrast, driven primarily by the need for food and basic needs, girls in the control arms described engaging in transactional sex, having multiple sexual partners, being unable to focus in school, getting pregnant or becoming HIV infected.

CONCLUSION

These findings emphasize the need to address food insecurity as a part of structural interventions targeting adolescent HIV risk in low-resource countries. We recommend that future interventions build upon the Shamba Maisha model by combining sustainable agricultural production, with household level interventions that deliberately target gender norms that contribute to unequal power dynamics.

The Mental Health Outcomes of Food Insecurity and Insufficiency in West Africa: A Systematic Narrative Review

(1) Background: Food insufficiency is a global pandemic affecting many people, especially those residing in developing countries. African countries have been affected by food insufficiency, which is mostly caused by drought or wars. Famine or food insufficiency has been reported to have an impact on the psychological health and quality of life of people affected. This review assessed the mental health outcomes of famine and food insufficiency in West Africa. (2) Methods: A search of the published literature was conducted using PubMed, PsycExtra, Medline, and PsycINFO databases. The search was limited to papers published in English between the years 2010 and 2020. Two reviewers independently screened the titles and abstracts of the retrieved papers using pre-defined inclusion and exclusion criteria and a third reviewer resolved conflicts. Data were extracted and appraised using a data extraction form and an appraisal checklist. (3) Results: A total of 81 papers were identified through the journal databases search. Out of the seven papers that met the inclusion criteria, six papers used cross-sectional designs and one paper used an experimental design. The six papers used quantitative approach for data collection, while the one paper used a qualitative technique. The evidence synthesized from this review indicated that exposure to food insecurity or insufficiency is associated with increased psychological distress including anxiety, sleeplessness, intellectual disability, general mental, and emotional instability. (4) Conclusions: This review strongly highlights the need for further research across the sub-region. It further suggests that famine and food insufficiency are associated with significant mental health problems in adults and impacts the cognitive and intellectual development of children. Although there is paucity of literature about famine and its impact on mental health in West Africa, these findings are important for developing social policy initiatives for increasing food supply and mental health interventions for all ages.

Alcohol use during pregnancy in rural Lesotho: "There is nothing else except alcohol"

OBJECTIVE

Reducing alcohol use during pregnancy is a pressing public health priority in Sub-Saharan Africa, but insight into the factors that influence prenatal drinking practices is lacking. This study investigated perceptions of, and motivations for, alcohol consumption during pregnancy and associated practices in a rural district of Lesotho.

METHODS

A combination of purposive and snowball sampling methods were used to identify pregnant women and mothers with young children from the general community, as well as from alcohol-serving venues. Between September 2016 and March 2017, a trained data collector conducted in-depth interviews with 40 women on reasons why pregnant women drink, what they know about the risk of drinking alcohol during pregnancy, and perceptions of women who drink during pregnancy.

RESULTS

Sixty-five percent of women (n = 26) reported that they consumed alcohol during pregnancy. Findings were clustered into four themes: 1) alcohol use in daily and cultural life; 2) alcohol as relief from stress and hunger; 3) alcohol's effect on the baby; and 4) access to information about alcohol consumption. Our data suggest that alcohol use was a prominent feature of daily life and a key part of traditional events and ceremonies. Other than potentially harming the baby through falling on their stomachs while inebriated, women did not mention other risks associated with prenatal alcohol use. Rather, there were prominent beliefs that drinking alcohol - home-brewed alcohol in particular - had cleansing or protective benefits for the baby. Experiences of food insecurity were prominent, and women reported that alcohol helped curb their hunger and allowed them to save food to give to their children.

CONCLUSIONS

Within this context of chronic poverty and food insecurity, alcohol use during pregnancy will continue to represent a valid, though tragic choice if the structural conditions and current social arrangements that facilitate prenatal alcohol use remain unchanged.

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.

Relationship between food insecurity and smoking status among women living with and at risk for HIV in the USA: a cohort study

OBJECTIVES

People living with HIV (PLHIV) in the USA, particularly women, have a higher prevalence of food insecurity than the general population. Cigarette smoking among PLHIV is common (42%), and PLHIV are 6-13 times more likely to die from lung cancer than AIDS-related causes. This study sought to investigate the associations between food security status and smoking status and severity among a cohort of predominantly low-income women of colour living with and without HIV in the USA.

DESIGN

Women enrolled in an ongoing longitudinal cohort study from 2013 to 2015.

SETTING

Nine participating sites across the USA.

PARTICIPANTS

2553 participants enrolled in the Food Insecurity Sub-Study of the Women's Interagency HIV Study, a multisite cohort study of US women living with HIV and demographically similar HIV-seronegative women.

OUTCOMES

Current cigarette smoking status and intensity were self-reported. We used cross-sectional and longitudinal logistic and Tobit regressions to assess associations of food security status and changes in food security status with smoking status and intensity.

RESULTS

The median age was 48. Most respondents were African-American/black (72%) and living with HIV (71%). Over half had annual incomes ≤US$12 000 (52%). Food insecurity (44%) and cigarette smoking (42%) were prevalent. In analyses adjusting for common sociodemographic characteristics, all categories of food insecurity were associated with greater odds of current smoking compared with food-secure women. Changes in food insecurity were also associated with increased odds of smoking. Any food insecurity was associated with higher smoking intensity.

CONCLUSIONS

Food insecurity over time was associated with smoking in this cohort of predominantly low-income women of colour living with or at risk of HIV. Integrating alleviation of food insecurity into smoking cessation programmes may be an effective method to reduce the smoking prevalence and disproportionate lung cancer mortality rate particularly among PLHIV.

HIV-sensitive social protection for vulnerable young women in East and Southern Africa: a systematic review

INTRODUCTION

Social protection programmes are considered HIV-sensitive when addressing risk, vulnerability or impact of HIV infection. Socio-economic interventions, like livelihood and employability programmes, address HIV vulnerabilities like poverty and gender inequality. We explored the HIV-sensitivity of socio-economic interventions for unemployed and out-of-school young women aged 15 to 30 years, in East and Southern Africa, a key population for HIV infection.

METHODS

We conducted a systematic review using a narrative synthesis method and the Mixed Methods Appraisal Tool for quality appraisal. Interventions of interest were work skills training, microfinance, and employment support. Outcomes of interest were socio-economic outcomes (income, assets, savings, skills, (self-) employment) and HIV-related outcomes (behavioural and biological). We searched published and grey literature (January 2005 to November 2019; English/French) in MEDLINE, Scopus, Web of Science and websites of relevant international organizations.

RESULTS

We screened 3870 titles and abstracts and 188 full-text papers to retain 18 papers, representing 12 projects. Projects offered different combinations of HIV-sensitive social protection programmes, complemented with mentors, safe space and training (HIV, reproductive health and gender training). All 12 projects offered work skills training to improve life and business skills. Six offered formal (n = 2) or informal (n = 5) livelihood training. Eleven projects offered microfinance, including microgrants (n = 7), microcredit (n = 6) and savings (n = 4). One project offered employment support in the form of apprenticeships. In general, microgrants, savings, business and life skills contributed improved socio-economic and HIV-related outcomes. Most livelihood training contributed positive socio-economic outcomes, but only two projects showed improved HIV-related outcomes. Microcredit contributed little to either outcome. Programmes were effective when (i) sensitive to beneficiaries' age, needs, interests and economic vulnerability; (ii) adapted to local implementation contexts; and (iii) included life skills. Programme delivery through mentorship and safe space increased social capital and may be critical to improve the HIV-sensitivity of socio-economic programmes.

CONCLUSIONS

A wide variety of livelihood and employability programmes were leveraged to achieve improved socio-economic and HIV-related outcomes among unemployed and out-of-school young women. To be HIV-sensitive, programmes should be designed around their interests, needs and vulnerability, adapted to local implementation contexts, and include life skills. Employment support received little attention in this literature.

Supplemental Nutrition Assistance Program Eligibility and HIV Incidence in the United States

Background

The connection between food insecurity and HIV outcomes is well established. The Supplemental Nutrition Assistance Program (SNAP), the primary food safety net program in the United States, may have collateral impacts on HIV incidence. “Broad-based categorical eligibility” for SNAP is a policy that provides a mechanism for states to increase the income or asset limits for SNAP eligibility.

Methods

We estimated the association between the number of new HIV diagnoses in 2010–2014 for each state and (1) state income limits and (2) state asset limits for SNAP eligibility. We fitted multivariable negative binomial regression models with number of HIV diagnoses specified as the outcome; SNAP policies as the primary explanatory variable of interest; state and year fixed effects; and time-varying covariates related to the costs of food, health care, housing, employment, other SNAP policies, and Temporary Assistance for Needy Families spending.

Results

HIV diagnoses within states had a statistically significant association with state income limits for SNAP eligibility (incidence rate ratio [IRR], 0.94 per increase in the income limit by 35% of federal poverty level; 95% CI, 0.91–0.98), but no association with state asset limits (increased asset limit vs no change: IRR, 1.02; 95% CI, 0.94–1.10; eliminated asset limit vs no change: IRR, 1.04; 95% CI, 0.99–1.10).

Conclusions

State income limits for SNAP eligibility were inversely associated with the number of new HIV diagnoses for states between 2010 and 2014. Proposals to eliminate the use of broad-based categorical eligibility to increase the income limit for SNAP may undercut efforts to end the HIV epidemic in the United States.

The Synergistic Relationship Between Climate Change and the HIV/AIDS Epidemic: A Conceptual Framework

Climate change and HIV/AIDS represent two of the greatest threats to human health in the 21st century. However, limitations in understanding the complex relationship between these syndemics continue to constrain advancements in the prevention and management of HIV/AIDS in the context of a rapidly changing climate. Here, we present a conceptual framework that identifies four pathways linking climate change with HIV/AIDS transmission and health outcomes: increased food insecurity, increased prevalence of other infectious diseases, increased human migration, and erosion of public health infrastructure. This framework is based on an in-depth literature review in PubMed and Google Scholar from June 6 to June 27, 2019. The pathways linking climate change with HIV transmission and health outcomes are complex with multiple interacting factors. Food insecurity emerged as a particularly important mediator by driving sexual risk-taking behaviours and migration, as well as by increasing susceptibility to infections that are common among people living with HIV (PLWHIV). Future interventions should focus on decreasing carbon dioxide emissions globally and increasing education and investment in adaptation strategies, particularly in those areas of sub-Saharan Africa and southeast Asia heavily impacted by both HIV and climate change. Environmentally sustainable interventions such as urban gardening and investing in sustainable agriculture technologies also have significant health co-benefits that may help PLWHIV adapt to the environmental consequences of climate change.

The financial lives of female sex workers in Addis Ababa, Ethiopia: Implications for economic strengthening interventions for HIV prevention

Understanding the financial context of the lives of female sex workers (FSWs) is essential to address structural drivers of HIV risk. We used a financial diary methodology to record daily financial transactions over six weeks from a stratified purposive sample (n = 34) of FSWs in Addis Ababa, Ethiopia. FSWs also provided information on their experience with gender-based violence and condom use. FSWs generated 90.1% of total cash from sex work, with a median weekly income of USD 60.53. They engaged mostly in protected vaginal sex, earning approximately USD 4.57 per act. Food, housing, and clothing represented the largest areas of expenditure. Around 17% of expenses were recorded as costs of sex work (e.g., alcohol). Median weekly expenditures accounted for 62% of median weekly income. Nearly all participants reported depositing money into savings at least once over six weeks, while 71% reported a loan transaction during the six-week period, most as borrowers. Findings suggest that financial literacy and formalized savings activities, with life skills and empowerment training, have potential to build FSW's economic resilience, mitigating a structural driver of sex work and HIV risk.

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.

The impact of food insecurity on mental health in Africa: A systematic review

In 2018, 676.1 million people in Africa (52.5% of the population) were moderately or severely food insecure. This exceptionally high prevalence continues to increase as Africa experiences conflict, climate change, and economic declines. When Sustainable Development Goal 2.1 set out to end hunger and ensure access to sufficient food, particularly for vulnerable populations, by 2030, food insecurity emerged as a global priority. Food insecurity has been hypothesized to negatively impact mental health, a stigmatized area of health in Africa for which care is often inaccessible. This systematic review examines existing literature on the relationship between food insecurity and mental health in Africa, where progress remains to be made on both fronts. A systematic search of seven databases (EMBASE, Web of Science, CINAHL, PsychINFO ProQuest, Medline Ovid, Scopus, and Nursing and Allied Health) was conducted. Results were limited to studies examining food insecurity and mental health, written in English and published between January 2000 and May 2020. After title, abstract, full-text review, and quality appraisal using tools from the National Heart, Lung, and Blood Institute, 64 studies remained. Findings were summarized using a narrative synthesis approach. Studies unanimously highlighted that food insecurity is associated with poor mental health. This relationship was dose-responsive and independent of the measured mental health outcome. Two highly represented groups in the literature were women around pregnancy and people affected by HIV/AIDS. Factors which mediated the relationship included age, sex, social interactions, physical health, seasonality, and rural residence. The findings suggest that the relationship is likely amplified in specific populations such as women and seniors, and interventions which target livelihood as opposed to income may be more effective. Further research is needed which compares food insecurity's effect on mental health between at-risk populations, in order to guide resource allocation and context-specific policy making.

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

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

Improving the measurement of food insecurity among people with HIV in South Africa: a psychometric examination

OBJECTIVE

Food insecurity is a structural barrier to HIV care in peri-urban areas in South Africa (SA), where approximately 80 % of households are moderately or severely food insecure. For people with HIV (PWH), food insecurity is associated with poor antiretroviral therapy adherence and survival rates. Yet, measurement of food insecurity among PWH remains a challenge.

DESIGN

The current study examines the factor structure of the nine-item Household Food Insecurity Access Scale (HFIAS, isiXhosa-translated) among PWH in SA using a restrictive bifactor model.

SETTING

Primary care clinics in Khayelitsha, a peri-urban settlement in Cape Town, SA.

PARTICIPANTS

Participants (n 440) were PWH who received HIV care in Khayelitsha screening for a clinical trial. Most were categorised as severely (n 250, 56·82 %) or moderately (n 107, 24·32 %) food insecure in the past 30 d.

RESULTS

Revised parallel analysis suggested a three-factor structure, which was inadmissible. A two-factor structure was examined but did not adequately fit the data. A two-factor restrictive bifactor model was examined, such that all items loaded on a general factor (food insecurity) and all but two items loaded on one of two specific additional factors, which adequately fit the data (comparative fit index = 0·995, standardised root mean square residual = 0·019). The two specific factors identified were: anxiety/insufficient quality and no food intake. Reliability was adequate (ω = 0·82).

CONCLUSIONS

Results supported the use of a total score, and identified two specific factors of the HFIAS, which may be utilised in future research and intervention development. These findings help identify aspects of food insecurity that may drive relationships between the construct and important HIV-related variables.

Food insecurity and depression: a cross-sectional study of a multi-site urban youth cohort in Durban and Soweto, South Africa

OBJECTIVE

To assess the prevalence of food insecurity and the independent association between depression and food insecurity among youth living in two urban settings in South Africa.

METHODS

Baseline cross-sectional survey data was analysed from a prospective cohort study conducted between 2014 and 2016 among youth (aged 16-24 years) in Soweto and Durban. Interviewer-administered questionnaires collecting socio-demographic, sexual and reproductive health and mental health data were conducted. Household food insecurity was measured using the 3-item Household Hunger Scale, with food insecure participants defined as having 'moderate' or 'severe hunger' compared to 'no hunger'. Depression was assessed using the 10-item Center for Epidemiological Studies Depression (CES-D 10) Scale (range 0-30, probable depression ≥ 10). Multivariable logistic regression models were used to estimate the association between depression and food insecurity.

RESULTS

There were 422 participants. Median age was 19 years (interquartile range [IQR] 18-21) and 60% were women. Overall, 18% were food insecure and 42% had probable depression. After adjustment for socio-demographic variables (age, gender, female-headed household, household size and school enrolment), participants with probable depression had higher odds of being food insecure than non-depressed participants (2.79, 95%CI 1.57-4.94).

CONCLUSION

Nearly one-fifth of youth in this study were food insecure. Those with probable depression had increased odds of food insecurity. Interventions are needed to address food insecurity among urban youth in South Africa, combining nutritional support and better access to quality food with mental health support.

Food insecurity predicts loss to follow-up among people living with HIV in Senegal, West Africa

The goals of this study were to assess retention on antiretroviral therapy (ART) and to identify predictors of loss to follow-up (LTFU) among people living with HIV (PLHIV) in Senegal. HIV-positive individuals presenting for initiation of ART in Dakar and Ziguinchor were enrolled and followed for 12 months. Data were collected using interviews, clinical evaluations, laboratory analyses, chart review, and active patient tracing. Of the 207 individuals enrolled, 70% were female, 32% had no formal education, and 28% were severely food insecure. At the end of the follow-up period, 58% were retained on ART, 15% were deceased, 4% had transferred care, 5% had migrated, and 16% were lost to follow-up. Enrollment in Ziguinchor (OR 2.71 [1.01–7.22]) and severe food insecurity (OR 2.55 [1.09–5.96]) were predictive of LTFU. Sex, age, CD4 count, BMI <18.5, country of birth, marital status, number of children, household size, education, consultation with traditional healers, transportation time, and transportation cost were not associated with LTFU. The strongest predictor of severe food insecurity was lack of formal education (OR 2.75 [1.30–5.80]). Addressing the upstream drivers of food insecurity and implementing strategies to enhance food security for PLHIV may be effective approaches to reduce LTFU and strengthen the HIV care cascade in the region.

The impact of food insecurity on HIV outcomes in Senegal, West Africa: a prospective longitudinal study

BACKGROUND

Understanding the impact of food insecurity on HIV outcomes is critical for the development and implementation of effective, evidence-based interventions to address food insecurity and improve the HIV care cascade. We conducted a prospective, longitudinal study to determine the impact of food insecurity on HIV outcomes in Senegal, West Africa.

METHODS

HIV-infected individuals presenting for care and initiation of ART through the Senegalese National AIDS program in Dakar and Ziguinchor were eligible for enrollment. Data were collected using interviews, clinical evaluations, laboratory analyses, and chart review at enrollment, month 6, and month 12. Logistic regression was used to determine the association between food insecurity and HIV outcomes.

RESULTS

Among the 207 participants in this study, 70% were female and the median age was 37 years. The majority (69%) were food insecure at enrollment, 29% were severely food insecure, and 38% were undernourished. Nearly a third (32%) had no formal education, 23% practiced agriculture, and 40% owned livestock. The median daily food expenditure per person was $0.58. The median round trip transportation time to clinic was 90 min (IQR 30-240). The median cost of transportation to clinic was $1.74. At month 12, 69% were food insecure, 23% were severely food insecure, and 14% were undernourished. At month 12, 43% had not disclosed their HIV status; food insecurity was associated with non-disclosure of HIV-status due to fear of stigmatization and feelings of shame. Severe food insecurity was a strong predictor of loss to follow-up (OR 3.13 [1.08-9.06]) and persistent severe food insecurity was associated with virologic failure (OR 5.14 [1.01-26.29]) and poor adherence to ART 8.00 [1.11-57.57]. Poor nutritional status was associated with poor immunologic recovery (OR 4.24 [1.56-11.47]), virologic failure (OR 3.39 [1.13-10.21]), and death (OR 3.35 [1.40-8.03]).

CONCLUSION

Severity and duration of food insecurity are important factors in understanding the relationship between food insecurity and HIV outcomes. Our findings highlight the importance of nutritional status, socioeconomic opportunity, and self-stigmatization in the complex pathway between food insecurity and HIV outcomes. Interdisciplinary, multisectoral efforts are needed to develop and implement effective interventions to address food insecurity among people living with HIV.

Gender Disparities in Food Security, Dietary Intake, and Nutritional Health in the United States

INTRODUCTION

Food insecurity is associated with negative nutritional outcomes and is experienced differently by women vs men. We evaluated the effects of gender on food insecurity and dietary intake in the United States.

METHODS

Data from the National Health and Nutrition Examination Survey (2007-2016) were analyzed. Survey-weighted linear and logistic regression models were used to evaluate predictors of food security and the effect of food security on dietary consumption and body anthropometrics. Gender was modeled as a covariable and as an effect modifier.

RESULTS

A total of 30,251 respondents were included. Approximately 15.1% (95% confidence interval [CI]: 14.1%-16.1%) of participants were food insecure. This increased over time from 11.7% in 2007-2008 to 18.2% in 2015-2016. A higher proportion of women experienced food insecurity compared with men (53.3% vs 46.7%, P = 0.02), although this was not significant after adjusting for poverty and other confounders (adjusted odds ratio 1.01; 95% CI: 0.93-1.09; P = 0.81). Among food insecure women, 32.4% (95% CI: 30.0%-34.9%) received emergency food assistance and 75.0% (95% CI: 71.5%-78.2%) received supplemental nutrition assistance benefits. Relative to men, food insecure women were less likely to meet the recommended dietary allowance of most macronutrients and micronutrients. They were also significantly more likely to be obese, have a wider waist circumference, and have higher total body fat percentage (P interaction all <0.001).

DISCUSSION

Food insecurity represents a substantial public health challenge in the United States that differentially affects women compared with men. Alternative strategies may be required to meet the nutritional requirements for food insecure women.

Food Insecurity With Hunger and Sexual Behavior Among Adolescents From 53 Countries

Objectives: To examine the relationship of food insecurity with sexual intercourse, multiple sexual partners and non-condom use. Methods: Data on food insecurity (hunger) and sexual behaviors from 205,296 adolescents from 53 countries. Associations were analyzed using meta-analysis. Results: Overall, 16.0% of the adolescents ever had sexual intercourse and the prevalence of moderate and severe food insecurity was 44.9% and 6.2%, respectively. Moderate and severe food insecurity was associated with higher odds for sexual intercourse. Any food insecurity was significantly associated with condom nonuse at last sex. Conclusions: Food insecurity was associated with higher odds of ever having sexual intercourse dose-dependently.

Food Insecurity, Sexual Risk, and Substance Use in Young Adults

PURPOSE

The aim of the study was to determine the association between food insecurity, sexual risk behaviors, sexually transmitted infections (STIs), and substance use in a nationally representative sample of U.S. young adults.

METHODS

Cross-sectional nationally representative data of U.S. young adults aged 24-32 years from Wave IV (2008) of the National Longitudinal Study of Adolescent to Adult Health were analyzed. Multiple logistic and linear regression analyses were conducted with food insecurity as the independent variable and self-reported STIs, sexual risk behaviors, and substance use as the dependent variables, adjusting for covariates and stratifying by sex.

RESULTS

Of the 14,786 young adults in the sample, 14% of young women and 9% of young men were food insecure. Food-insecure young women had greater odds of any STI, HIV, chlamydia, exchanging sex for money, and multiple concurrent sex partners in the past 12 months compared to young women reporting food security, adjusting for covariates. Food insecurity was associated with higher odds of any STI, chlamydia, and exchanging sex for money among young men who identify as gay or bisexual, but not in the general population of young men. Food insecurity was associated with greater odds of marijuana use, methamphetamine use, and nonmedical use of prescription opioids, sedatives, and stimulants in both young men and women.

CONCLUSIONS

Food insecurity is associated with risk behaviors and self-reported STIs, including HIV, in young adulthood. Health care providers should screen for food insecurity in young adults and provide referrals when appropriate.

Socioeconomic Predictors of Transactional Sex in a Cohort of Adolescent Girls and Young Women in Malawi: A Longitudinal Analysis

Transactional sex is associated with incident HIV infection among adolescent girls and young women (AGYW) in sub-Saharan Africa. Evidence on the dimensions of socioeconomic status (SES) which predict transactional sex are mixed and primarily come from cross-sectional studies. This study examined the association between SES and transactional sex in a longitudinal cohort (n = 844) of AGYW ages 15-24 years enrolled in a quasi-experimental study in Lilongwe, Malawi. Prevalence of transactional sex was 22% at baseline, 15% at 6-months and 20% at 12-months. Being divorced or widowed, being food insecure, living in a home without electricity or running water, and having few assets were associated with transactional sex. Higher educational attainment and school enrollment were protective. Having 6-7 socioeconomic risk factors increased odds of transactional sex (AOR = 4.13, 95% CI 2.45, 6.98). Structural interventions which address multiple dimensions of SES may reduce transactional sex and ultimately prevent HIV transmission among AGYW.

Women Trading Sex in a U.S.-Mexico Border City: A Qualitative Study of the Barriers and Facilitators to Finding Community and Voice

Poverty and income inequality can increase a woman's decision to engage in risky transactional sex, and may lead to unimaginable harms, such as violence, substance use, and human trafficking. This study examines the facilitators and barriers to finding community and voice among women trading sex in Tijuana, Mexico, and what factors, such as socio-structural support, violence, and substance use, may impact their potential to engage with others, including human service providers. Sixty qualitative in-depth interviews were conducted with women trading sex in Tijuana, Mexico. Researchers met with participants for in-depth-face-to-face structured interviews. Data were coded using ATLAS.ti. Participants were aged 19-73 (mean: 37), 98% were of Mexican nationality, 90% reported trading sex independent of the control of others, with 58% identified as independent and street-based. Thirty percent of women trading sex reported substance use (excluding marijuana) and 20% reported injection drug use within 30 days. The majority reported no involvement in mobilization activities, but 85% expressed interest. However, barriers included stigma, cultural gender norms, partner violence, and privacy in regards to disclosure of sex trade involvement, moral conflict (revealing one's involvement in sex trade), involvement in substance use, human trafficking, and feeling powerless. Facilitators were having a safe space to meet, peer support, self-esteem, feeling heard, knowledge of rights, economic need to support families, and staying healthy. Findings imply the potential to go beyond mobilizing limited groups of women in the sex trade and instead involve whole community mobilization; that is, to reach and include the more vulnerable women (substance use, trafficked) in supportive services (social services, exit strategies, better healthcare opportunities, and/or education for healthcare providers to help break societal stigmas regarding women in the sex trade) and to change the status of women in society in general.

Drying Climates and Gendered Suffering: Links Between Drought, Food Insecurity, and Women's HIV in Less-Developed Countries

HIV/AIDS represents the leading cause of death among women of reproductive age globally, and gender inequalities in the burden of HIV/AIDS are most pronounced in poorer countries. Drawing on ideas from feminist political ecology, we explore linkages between suffering from drought, food insecurity, and women's vulnerability to HIV. Using data from 91 less-developed countries, we construct a structural equation model to analyze the direct and indirect influence of these factors, alongside other socio-economic indicators, on the percentage of the adult population living with HIV that are women. We find that droughts are significant in shaping gender inequalities in the HIV burden indirectly through increased food insecurity. We draw on prior research to argue that due to gendered inequalities, food insecurity increases women's vulnerability to HIV by intensifying biological susceptibilities to the disease, reducing access to social and health resources, and motivating women to engage in risky sexual behaviors, such as transactional sex. Overall, our findings demonstrate that droughts serve as an important underlying factor in promoting HIV transmission among vulnerable women in poor countries, and that food insecurity is a key mechanism in driving this relationship.

"I was raped by the broker on the first day of my arrival in the town." Exploring reasons for risky sexual behavior among sexually-active unmarried young female internal migrants in Ethiopia: A qualitative study

BACKGROUND

Studies revealed that internal migrants are one of the most vulnerable groups for poor sexual and reproductive health (SRH) information and services. Risky sexual behavior (RSB) is a threat to public health and might lead to serious health problems such as unintended pregnancy, abortion, and sexually transmitted infections (STIs) including HIV/AIDS. The reported prevalence of RSB among young female internal migrants in Ethiopia was as high as 70.3%. This requires in-depth understanding of the underlying cause. So, this study aimed at exploring reasons for RSB among sexually-active unmarried young female migrants in Ethiopia.

METHODS

A descriptive qualitative study was conducted using focus group discussions among sexually-active young female migrants working Burayu town. The focus group discussions were done in the local languages of participants (Afaan Oromo and Amharic). The recorded data were transcribed verbatim and translated into English for analysis and presentation in the study. The data were coded and Atlas.ti 7.5 software packages were used for data analyses. Then, the findings were thematically organized and analyzed using content analysis.

RESULTS

This study revealed that poor socio-economic status, social media indulgence, rape, substance use, poor knowledge of condom use, unfavorable attitude toward condom use, misconceptions about emergency pills, and the nature of the new environment and work place were responsible for RSB among internal migrants. The participants described that the migrants' economic conditions and workplace sexual violence are pushing them toward engaging in unprotected sex, being sexually abused, commercial sex, and transactional sex.

CONCLUSIONS

Internal migrants' sexual behavior is a complex process influenced by multiple interrelating systems. We have explored a set of factors namely poverty, pressure and sexual abuse from brokers, sexual exploitation and abuses against domestic workers by their bosses, indulgence in social media, sexting, inadequate knowledge, and unfavorable attitude toward condom use that led young female internal migrants to risky sexual practices. An intervention to promote safe sex targeted to this population is urgently needed with a focus on an intervention to eliminate misconceptions about condoms, increase proper condom use, and end sexual violence. Moreover, a relevant policy is needed to safeguard internal migrants from sexual exploitation and abuses at their work place.