Addressing the HIV/AIDS—food insecurity syndemic in sub-Saharan Africa

Low body mass index as a predictor of sputum culture conversion and treatment outcomes among patients receiving treatment for multidrug-resistant tuberculosis in Lesotho

BACKGROUND

A low body mass index (BMI) at the start of treatment for rifampicin- or multidrug-resistant tuberculosis (MDR/RR-TB) is associated with poor treatment outcomes and may contribute to delayed sputum culture conversion, thereby prolonging the period of potential transmission to others. Whether the relative importance of low BMI in predicting treatment outcomes differs by HIV status is unclear.

OBJECTIVES

We evaluated the association between low BMI and two dependent variables, sputum culture conversion and end-of-treatment outcome, among patients receiving treatment for MDR/RR-TB in Lesotho, a setting with a high prevalence of HIV infection.

METHODS

Secondary data from a prospective cohort of patients initiating a longer (18-20 months) treatment containing bedaquiline and/or delamanid under routine programmatic conditions in Lesotho were analysed. Risk ratios and differences were adjusted for potential confounders using multivariable logistic regression, and estimates were stratified by HIV status.

RESULTS

Of 264 patients, 105 and 250 were eligible for culture conversion and end-of-treatment analyses, respectively. Seventy-one per cent of patients (74/105) experienced culture conversion within six months, while 74% (184/250) experienced a favourable end-of-treatment outcome. Low BMI was associated with a lower frequency of culture conversion at six months among those who were not living with HIV (relative risk [RR]: 0.50 [95% CI: 0.21, 0.79]); this association was attenuated among those living with HIV (RR: 0.88 [95% CI: 0.68, 1.23]). A low BMI was moderately associated with a lower frequency of treatment success (RR = 0.89 [95% CI: 0.77, 1.03]), regardless of HIV status.

CONCLUSIONS

Low BMI was common and associated with the frequency of six-month culture conversion and end-of-treatment outcomes. The association with culture conversion was more pronounced among those not living with HIV. Addressing the myriad factors that drive low BMI in this setting could hasten culture conversion and improve end-of-treatment outcomes. This will require a multipronged approach focused on alleviating food insecurity and enabling prompt diagnosis and treatment of HIV and TB.

The salience of structural barriers and behavioral health problems to ART adherence in people receiving HIV primary care in South Africa

Multilevel factors (individual and structural) influence adherence to antiretroviral therapy, particularly in high HIV prevalence areas such as South Africa. The present study examined the relative importance of structural barriers to HIV care and behavioral health factors, depression and alcohol use, in Khayelitsha, Cape Town, South Africa. People receiving HIV care in six primary care clinics in Khayelitsha (N = 194) completed the Center for Epidemiologic Studies Depression Scale, the Alcohol Use Disorders Identification Test, the Structural Barriers to Medication Taking questionnaire, and a qualitative rating of past-two-week adherence. Correlations were employed to examine associations among these variables, and hierarchical regression analysis was used to examine the unique effects of structural barriers over and above depression and alcohol use as predictors of adherence. Participants were primarily Black South African (99%) women (83%), and 41 years old on average. All four variables were significantly correlated. The hierarchical regression analysis showed that among behavioral health predictors, alcohol use alone significantly predicted ART adherence (b = -.032, p = .002). When structural barriers was added to the model, it was the only significant unique predictor of ART adherence (b = -1.58, p < .001). Findings highlight the need to consider structural vulnerabilities in HIV care in South Africa when developing behavioral health interventions.

Associated factors of diet quality among people living with HIV/AIDS in Ghana

INTRODUCTION

Nutrition is a very important element of a comprehensive care for people living with HIV/AIDS (PLHIV), especially in resource-constrained settings where malnutrition and food insecurity are common. Dietary diversity is a useful indication of nutritional adequacy (diet quality) in people of all ages. An optimally diverse diet strengthens the body's immune system.

OBJECTIVE

This study aimed to assess diet quality and its associated factors among PLHIV.

METHODS

A facility-based cross-sectional study design was employed to select 440 PLHIV from two hospitals in the Eastern Region of Ghana. Dietary intakes were determined using 24-hour recall. A stadiometer and bioimpedance analysis machine were used to obtain anthropometric and body composition data. Diet quality was assessed using FAO's individual dietary diversity score (IDDS) as a proxy. SPSS version 20 was used for analysis. Odds ratios and ordinal logistic regression were used to identify factors associated with diet quality among the PLHIV. P-value was set at 0.05.

RESULTS

Most of the PLHIV (73%) consumed from 'Starchy staple" food group. Less than 20% of the study sample consumed 'Fruits' and 'Vegetables' (17% and 14% respectively) a day before the survey. The mean IDDS was 4.11 (SD = 1.29). Overall, most of the PLHIV (56%) had medium IDDS which is equivalent to "diet needing improvement', 14% had higher IDDS (good diet), whiles about 31% of the participants actually had poor diet (lower IDDS). Associated factors of diet quality were age (AOR = 0.966: 95%CI: 0.936-0.997: p = 0.031), married (AOR = 4.634: 95%CI: 1.329-16.157: p = 0.0016), separated (AOR = 0.0203: 95%CI: .036-0.994: p = 0.049), and daily meal frequency (AOR = 0.441: 95%CI: .478-1.948: p = 0.020). Overall, the model accounts for about 20% of the variation in diet quality of the participants (pseudo-R square = 0.196).

CONCLUSION

This study demonstrates that most of the PLHIV did not consume good diet which may have an implication on their immune system, which is already under attack by HIV, and probably emerging infections. Age, marital status, and meal frequency were the variables that predicted diet quality among the study participants.

Intersecting Relationships of Psychosocial and Structural Syndemic Problems Among People with HIV in South Africa: Using Network Analysis to Identify Influential Problems

In South Africa, little is known about interrelationships between syndemic problems among people with HIV (PWH). A better understanding of syndemic problems may yield important information regarding factors amenable to mitigation. We surveyed 194 PWH in Khayelitsha, outside of Cape Town, South Africa. We used network analysis to examine the frequency of 10 syndemic problems and their interrelationships. Syndemic problems among PWH in South Africa were common; 159 (82.8%) participants reported at least 2 co-occurring syndemic problems and 90 (46.9%) endorsed 4 or more. Network analysis revealed seven statistically significant associations. The most central problems were depression, substance use, and food insecurity. Three clusters of syndemics were identified: mood and violence; structural factors; and behavioral factors. Depression, substance use, and food insecurity commonly co-occur among PWH in sub-Saharan Africa and interfere with HIV outcomes. Network analysis can identify intervention targets to potentially improve HIV treatment outcomes.

COVID-19, Mental Health, and Chronic Illnesses: A Syndemic Perspective

BACKGROUND

The COVID-19 pandemic is an epidemiological and psychological crisis; what it does to the body is quite well known by now, and more research is underway, but the syndemic impact of COVID-19 and mental health on underlying chronic illnesses among the general population is not completely understood.

METHODS

We carried out a literature review to identify the potential impact of COVID-19 and related mental health issues on underlying comorbidities that could affect the overall health of the population.

RESULTS

Many available studies have highlighted the impact of COVID-19 on mental health only, but how complex their interaction is in patients with comorbidities and COVID-19, the absolute risks, and how they connect with the interrelated risks in the general population, remain unknown. The COVID-19 pandemic can be recognized as a syndemic due to; synergistic interactions among different diseases and other health conditions, increasing overall illness burden, emergence, spread, and interactions between infectious zoonotic diseases leading to new infectious zoonotic diseases; this is together with social and health interactions leading to increased risks in vulnerable populations and exacerbating clustering of multiple diseases.

CONCLUSION

There is a need to develop evidence to support appropriate and effective interventions for the overall improvement of health and psychosocial wellbeing of at-risk populations during this pandemic. The syndemic framework is an important framework that can be used to investigate and examine the potential benefits and impact of codesigning COVID-19/non-communicable diseases (NCDs)/mental health programming services which can tackle these epidemics concurrently.

Breastfeeding Outcomes and Associated Risks in HIV-Infected and HIV-Exposed Infants: A Systematic Review

Purpose: To critically appraise recent literature regarding breastfeeding outcomes and associated risks in HIV-infected (HI) and HIV-exposed (HE) infants, using the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) statement guidelines. Materials and Methods: Five electronic databases were systematically searched to obtain English publications from the last 10 years (2010-2020), pertaining to breastfeeding outcomes and associated risks of HI and HE infants and children. Gray literature sources were also included. Data were extracted according to various data items and were synthesized using thematic synthesis. Results: Of the initial 7,151 sources identified, 42 articles were eligible for final inclusion. The final selection included 19 cohort studies and 2 expert committee reports, classified as gray literature. The remaining 21 studies comprised case-control, cross-sectional, and randomized controlled trial studies. The following themes were identified: breastfeeding outcomes in HI and HE infants, risks for suboptimal breastfeeding, HI and HE infant growth and developmental outcomes, and barriers and facilitators to feeding decisions. Most studies highlighted HE infants' growth and developmental outcomes and did not directly interrogate breastfeeding outcomes. The most prevalent risks for suboptimal breastfeeding were maternal factors affecting decision making for breastfeeding. Conclusions: This systematic review adds to the evidence of breastfeeding in HIV-affected mother-infant dyads. Findings reiterated that exclusive breastfeeding has a positive outcome on growth and development of all infants irrespective of HIV status. The review highlighted a dearth of research on breastfeeding outcomes of HI and HE infants. Large-scale prospective comparative studies should profile breastfeeding and developmental outcomes of infants with HIV infection or exposure and antiretroviral treatment exposure to enable early identification and intervention for this vulnerable population in low-income settings.

Characteristics and impacts ofSystematic review nutritional programmes to address undernutrition of adults living with HIV in sub-Saharan Africa: a systematic review of evidence

OBJECTIVES

Although some studies have identified various challenges affecting nutritional programmes to effectively tackle undernutrition among people living with HIV, evidence about the characteristics and impacts of these programmes on weight-related nutritional outcomes varies based on country contexts, specific programme goals and the implementation processes. This systematic review sought to synthesise evidence on the characteristics and impact of nutritional programmes on weight-related nutritional outcomes of people living with HIV in sub-Saharan Africa.

DESIGN

Systematic review.

DATA SOURCES

We searched for primary studies published in the following databases: Web of Science, Medline, Scopus, ScienceDirect, ProQuest and Google Scholar, supplemented by checking reference lists of included papers.

ELIGIBILITY CRITERIA

Studies published from 2005 to 10 July 2020 and reporting on the weight-related nutritional outcomes of undernourished people enrolled in nutritional programmes in HIV care in sub-Saharan Africa were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using a data extraction proforma. Weight-related nutritional outcomes of people living with HIV before and after enrolment in a nutritional programme were compared and narratively synthesised.

RESULTS

Sixteen studies assessing the impact of nutritional programmes in HIV care on weight-related nutritional outcomes were included. Of these, 13 examined nutritional programmes implemented in health facilities and the remaining three were delivered outside of health facilities. Nutritional recovery (defined differently in the studies) ranged from 13.1% to 67.9%. Overall programme failure rate, which included default after enrolment in a nutritional programme or non-response, ranged from 37.6% to 48.0%. More specifically, non-response to a nutritional programme ranged from 21.0% to 67.4% and default from the programme ranged from 19.0% to 70.6%. Key sociodemographic, clinical and nutritional characteristics that affect nutritional recovery, non-response and default were also identified.

CONCLUSIONS AND RECOMMENDATIONS

Nutritional programmes in HIV care have led to some improvements in weight-related nutritional outcomes among people living with HIV. However, the programmes were characterised by a high magnitude of default and non-response. To improve desired weight-related nutritional outcomes of people living with HIV, a holistic approach that addresses longer-term determinants of undernutrition is needed.

PROSPERO REGISTRATION NUMBER

CRD42020196827.

Syndemics: A Cross-Disciplinary Approach to Complex Epidemic Events Like COVID-19

In this review, we trace the origins and dissemination of syndemics, a concept developed within critical medical anthropology that rapidly diffused to other fields. The goal is to provide a review of the literature, with a focus on key debates. After a brief discussion of the nature and significance of syndemic theory and its applications, we trace the history and development of the syndemic framework within anthropology and the contributions of anthropologists who use it. We also look beyond anthropology to the adoption and use of syndemics in other health-related disciplines, including biomedicine, nursing, public health, and psychology, and discuss controversies in syndemics, particularly the perception that existing syndemics research focuses on methodologies at the individual level rather than at the population level and fails to provide evidence of synergistic interactions. Finally, we discuss emerging syndemics research on COVID-19 and provide an overview of the application of syndemics research.

Syndemic contexts: findings from a review of research on non-communicable diseases and interviews with experts

Background

Syndemics are characterized by the clustering of two or more health conditions, their adverse interaction, and contextual factors that create the conditions for clustering and/or interaction that worsens health outcomes. Studying syndemics entails drawing on diverse disciplines, including epidemiology and anthropology. This often means collaboration between researchers with different scholarly backgrounds, who share and – ideally – integrate their findings.

Objective

This article examines how context within syndemics has been defined and studied.

Methods

A literature review of empirical studies focusing on syndemics involving non-communicable diseases (NCDs) and mental health conditions was conducted and the full text of 13 articles was analyzed. The review was followed-up with semi-structured interviews with 11 expert researchers working in the field.

Results

The review and interviews highlighted a relatively consistent definition of syndemics. The reviewed studies of NCD-related syndemics tended to focus on micro-level context, suggesting a need to analyze further underlying structural factors. In their syndemics research, respondents described working with other disciplines and, although there were some challenges, welcomed greater disciplinary diversity. Methodological gaps, including a lack of mixed methods and longitudinal studies, were identified, for which further interdisciplinary collaborations would be beneficial.

Conclusions

NCD-related syndemics research would benefit from further analysis of structural factors and the interconnections between syndemic components across multiple levels, together with more ambitious research designs integrating quantitative and qualitative methods. Research on the COVID-19 pandemic can benefit from a syndemics approach, particularly to understand vulnerability and the unequal impacts of this public health crisis.

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.

The association between HIV/AIDS and food insecurity at the US-Mexico border: Experiences of low-income patients in the Rio Grande Valley

US-Mexico border communities are uniquely vulnerable to human immunodeficiency virus (HIV) transmission given the economic and social challenges these communities face. We surveyed low-income, predominantly Latinx residents receiving sexually transmitted infection testing and/or HIV/acquired immune deficiency syndrome (AIDS) care in the lower Rio Grande Valley of southernmost Texas about their experiences of food insecurity. Participants aged 18 years and over took a self-administered survey available in English or Spanish in a clinic waiting room (N = 251). Ordinary least squares regression results suggested that those with a prior HIV/AIDS diagnosis reported a response for food insecurity that was approximately 0.67 points higher than peers without a prior HIV/AIDS diagnosis (coefficient = 0.67; p < 0.05), even when adjusting for sociodemographic characteristics, social support, perceived discrimination, and neighborhood environment. Interaction results between age and HIV status indicated that younger individuals living with HIV/AIDS experienced uniquely higher food insecurity; those who reported a prior HIV/AIDS diagnosis experienced an additional reduction in food insecurity by approximately 0.06 points for each additional year of age (age × HIV/AIDS interaction coefficient = -0.06; p < 0.05). Community programs serving low-income populations should consider screening for and intervening on food insecurity, especially among young adults living with HIV/AIDS.

Food insecurity and neurocognitive function among women living with or at risk for HIV in the United States

BACKGROUND

Neurocognitive impairment (NCI) persists among women living with HIV. Food insecurity is also common among women and may be an important modifiable contributor of NCI.

OBJECTIVE

The goal of this study was to determine the association of food insecurity with neurocognitive function among women living with or without HIV.

METHODS

From 2013 to 2015, we analyzed data from a cross-sectional sample from the Women's Interagency HIV Study (WIHS). Measures included food insecurity and a comprehensive neuropsychological test battery assessing executive function, processing speed, attention/working memory, learning, memory, fluency, and motor function. We conducted multivariable linear regressions to examine associations between food insecurity and domain-specific neurocognitive performance, adjusting for relevant sociodemographic, behavioral, and clinical factors.

RESULTS

Participants (n = 1,324) were predominantly HIV seropositive (68%), Black/African-American (68%) or Hispanic (16%), and low income (48% reported <$12,000/y), with a median age of 49.6 y (IQR = 43.1, 55.5). Approximately one-third (36%, n = 479) were food insecure. Food insecurity was associated with poorer executive function (b = -1.45, SE = 0.58, P ≤ 0.01) and processing speed (b = -1.30, SE = 0.59, P ≤ 0.05). HIV serostatus modified the association between food insecurity and learning, memory, and motor function (P values <0.05). Food insecurity was positively associated with learning among women living with HIV (b = 1.58, SE = 0.77, P ≤ 0.05) and negatively associated with motor function among HIV-negative women (b = -3.57, SE = 1.08, P ≤ 0.001).

CONCLUSIONS

Food insecurity was associated with domain-specific neurocognitive function in women, and HIV serostatus modified associations. Food security may be an important point of intervention for ethnically diverse women with low socioeconomic status. Longitudinal studies are warranted to determine potential pathways by which food insecurity is associated with neurocognitive function among women living with or at risk for HIV.

Using syndemic theory to understand food insecurity and diet-related chronic diseases

Syndemic Theory (ST) provides a framework to examine mutually enhancing diseases/health issues under conditions of social inequality and inequity. ST has been used in multiple disciplines to address interacting infectious diseases, noncommunicable diseases, and mental health conditions. The theory has been critiqued for its inability to measure disease interactions and their individual and combined health outcomes. This article reviews literature that strongly suggests a syndemic between food insecurity (FI) and diet-related chronic diseases (DRCDs), and proposes a model to measure the extent of such interaction. The article seeks to: (1) examine the potential syndemic between FI and DRCDs; (2) illustrate how the incorporation of Life History Theory (LHT), into a syndemic framework can help to highlight critical lifeperiods when FI-DRCD interactions result in adverse health outcomes; (3) discuss the use of mixed methods to identify and measure syndemics to enhance the precision and predictive power of ST; and (4) propose an analytical model for the examination of the FI-DRCD syndemic through the life course. The proposed model is more relevant now given the significant increase in FI globally as a result of the ongoing COVID-19 pandemic. The differential impact that the pandemic appears to have among various age groups and by other demographic factors (e.g., race, gender, income) offers an opportunity to examine the potential FI-DRCD syndemic under the lens of LHT.

Syndemic Classes, Stigma, and Sexual Risk Among Transgender Women in India

Syndemic theory could explain the elevated HIV risk among transgender women (TGW) in India. Using cross-sectional data of 300 TGW in India, we aimed to: identify latent classes of four syndemic conditions (Depression-D, Alcohol use-A, Violence victimization-V, HIV-positive status), test whether syndemic classes mediate the association between stigma and sexual risk, and test whether social support and resilient coping moderate the association between syndemic classes and sexual risk. Four distinct classes emerged: (1) DAV Syndemic, (2) AV Syndemic, (3) DV Syndemic, and (4) No Syndemic. TGW in the DAV Syndemic (OR 9.80, 95% CI 3.45, 27.85, p < 0.001) and AV Syndemic classes (OR 2.74, 95% CI 1.19, 6.32, p < 0.01) had higher odds of inconsistent condom use in the past month than the No Syndemic class. Social support significantly moderated the effect of DAV Syndemic class on inconsistent condom use. DAV Syndemic was found to be a significant mediator of the effect of transgender identity stigma on sexual risk. HIV prevention programs among TGW need to: (a) incorporate multi-level multi-component interventions to address syndemic conditions, tailored to the nature of syndemic classes; (b) reduce societal stigma against TGW; and (c) improve social support to buffer the impact of syndemics on sexual risk.

Risk and resiliency: the syndemic nature of HIV/AIDS in the indigenous highland communities of Ecuador

OBJECTIVES

This community-based study explores the syndemic nature of HIV/AIDS risk and resilience among Indigenous Kichwa communities in the province of Imbabura, Ecuador. This study elucidates individual and community-level factors that serve to exacerbate HIV/AIDS risk, as they relate to underlying macrolevel, structural forces. Critically, this study also elicited opportunities for community-based opportunities for resiliency from HIV/AIDS.

STUDY DESIGN

Exploratory qualitative study.

METHODS

Guided by syndemic theory, a qualitative study was conducted to explore HIV risk and resilience among Indigenous Kichwa communities in the Northern Andean highlands of Ecuador. Eight focus groups (n = 59) with men and women from two communities were conducted. The data were analyzed using applied thematic analysis techniques.

RESULTS

Identified risk factors for HIV/AIDS centered around the following themes: (1) parents leaving the community for work, (2) alcohol and drug consumption, (3) unprotected sex, and (4) barriers to health care. Identified HIV/AIDS resiliency factors included the preservation of Indigenous culture and family-focused interventions.

CONCLUSIONS

The identified risk factors for HIV/AIDS are interrelated within a complex syndemic relationship. The mutually reinforcing individual-level risk factors of substance abuse and risky sexual behavior coalesce with violence to exacerbate the risk for HIV/AIDS acquisition among Ecuadorian Highland Indigenous communities. Moreover, HIV/AIDS risk prevails in the macrolevel context of disproportionate unemployment among Indigenous peoples and a systematically fragmented healthcare system. It is critical that public health professionals work to revolutionize the systematic discrimination that underpins indigenous health disparities at-large.

The Investigation of the Use of Prealbumin as a Tool for Nutritional Assessment in Adults Coinfected with HIV and Intestinal Helminth Parasites in KwaZulu-Natal, South Africa

Serum prealbumin is considered to be as important as albumin in the nutritional status assessment. However, there is relatively little evidence of its advantage over the commonly used albumin. This study investigated the use of prealbumin compared to albumin as a marker of nutritional status in adults singly and dually infected with human immunodeficiency virus (HIV) and intestinal helminths, with or without inflammatory conditions, in different body mass index (BMI) categories. This cross-sectional study was conducted in a periurban setting in KwaZulu-Natal, South Africa. Multivariate multinomial logistic regression models were fitted to investigate the effect of prealbumin and albumin in nutritional assessment among HIV and helminth individuals with or without inflammation, indicated by elevated and normal C-reactive protein (CRP) levels. In normal CRP, albumin was significantly lower in unadjusted BMI [RRR = 0.8, p = 0.001] and in normal weight [RRR = 0.7, p = 0.003] and overweight [RRR = 0.5, p = 0.001] participants. In elevated CRP, albumin was significantly lower [RRR = 0.8, p = 0.050] and prealbumin was significantly higher in unadjusted BMI [RRR = 1.2, p = 0.034] and overweight [RRR = 1.4, p = 0.052] individuals. The current study found that prealbumin can differentiate between inflammation-induced reduction of albumin and true malnutrition in adults singly or coinfected with HIV and intestinal helminths in the presence or absence of inflammation in various BMI categories.

HIV as social and ecological experience

The spread and varied impacts of the HIV/AIDS epidemic demonstrate the complex and reciprocal relationships between the socio-political and biophysical dimensions of human health. Yet even with increasing research and policy attention there remain critical gaps in the literature on how HIV-positive households manage health through their engagement with social and ecological systems. This is particularly urgent given improvements in the global response to the epidemic, whereby expanded access to antiretroviral therapy has extended the possibility for survival for years or decades. Because many HIV-positive families and communities in the Global South remain dependent upon a diverse set of resources to generate income and meet subsistence needs, the impacts of disease must be understood within a mix of social processes, including the maintenance of land and collection of natural resources. Similarly, biophysical systems disrupted by HIV/AIDS vary depending upon resource use and locally-specific dynamics that influence opportunities for agrarian production. This paper reports on the findings from a structured survey completed in three communities in northeast South Africa in 2013 that is integrated with focus group discussions and qualitative interviews conducted from 2012-2016. We concentrate upon the diverse ways that individuals and families experience HIV through livelihood systems that are reliant on economic and natural resources. Because the access and use of these resources are mediated by existing social, cultural, and institutional systems, as well as historical spatial economies, we analyze how this produces differential lived experiences for HIV-positive individuals and households in the age of expanded access to antiretroviral therapy.

High magnitude of under nutrition among HIV infected adults who have not started ART in Tanzania--a call to include nutrition care and treatment in the test and treat model

Background

Undernutrition among people living with HIV (PLWHIV) can be ameliorated if nutrition specific and sensitive interventions are integrated into their HIV care and treatment centers (CTC). Integrated care is lacking despite expansion of antiretroviral therapy (ART) coverage, representing a substantial missed opportunity. This research aims to examine nutritional status and associated risk factors among HIV-positive adults prior to ART initiation in Tanzania in order to characterize existing gaps and inform early integration of nutrition care into CTC.

Methods

We analyzed data from 3993 pre-ART adults living with HIV enrolled in CTCs within the Trial of Vitamin (TOV3) and progression of HIV/AIDS study in Dar es salaam, Tanzania. The primary outcome for this analysis was undernutrition, measured as body mass index (BMI) below 18.5 kg/m². We conducted descriptive analyses of baseline characteristics and utilized multiple logistic regression to determine independent factors associated with pre-ART undernutrition.

Results

Undernutrition was prevalent in about 27.7% of pre-ART adults, with a significantly higher magnitude among males compared to females (30% vs. 26.6%, p < 0.025). Severe undernutrition (BMI < 16.0 kg/m²) was prevalent in one in four persons, with a trend toward higher magnitudes among females (26.2% vs. 21.1% p = 0.123). Undernutrition was also more prevalent among younger adults (p < 0.001), those with lower wealth quintiles (p = 0.003), and those with advanced HIV clinical stage (p < 0.001). Pre-ART adults presented with poor feeding practices, hallmarked by low dietary diversity scores and infrequent consumption of proteins, vegetables, and fruits. After adjusting for confounders and important co-variates, pre-ART undernutrition was associated with younger age, low wealth indices, advanced clinical stage, and low dietary diversity.

Conclusions

One in every four pre-ART PLWHIV presented with undernutrition in Dar es salaam, Tanzania. Risk factors for undernourishment included younger age, lower household income, advanced HIV clinical stage, and lower dietary diversity score. Knowledge of the prevalence and prevailing risk factors for undernutrition among pre-ART PLWHIV should guide targeted, early integration of nutrition interventions into routine HIV care and treatment in high-prevalence, low-income settings such as Tanzania.

Factors contributing to food insecurity among women living with HIV in the Dominican Republic: A qualitative study

BACKGROUND

Food insecurity contributes to poor health outcomes among people living with HIV. In Latin America and the Caribbean, structural factors such as poverty, stigma, and inequality disproportionately affect women and may fuel both the HIV epidemic and food insecurity.

METHODS

We examined factors contributing to food insecurity among women living with HIV (WLHIV) in the Dominican Republic (DR). Data collection included in-depth, semi-structured interviews in 2013 with 30 WLHIV with indications of food insecurity who resided in urban or peri-urban areas and were recruited from local HIV clinics. In-person interviews were conducted in Spanish. Transcripts were coded using content analysis methods and an inductive approach to identify principal and emergent themes.

RESULTS

Respondents identified economic instability as the primary driver of food insecurity, precipitated by enacted stigma in the labor and social domains. Women described experiences of HIV-related labor discrimination in formal and informal sectors. Women commonly reported illegal HIV testing by employers, and subsequent dismissal if HIV-positive, especially in tourism and free trade zones. Enacted stigma in the social domain manifested as gossip and rejection by family, friends, and neighbors and physical, verbal, and sexual abuse by intimate partners, distancing women from sources of economic and food support. These experiences with discrimination and abuse contributed to internalized stigma among respondents who, as a result, were fearful and hesitant to disclose their HIV status; some participants reported leaving spouses and/or families, resulting in further isolation from economic resources, food and other support. A minority of participants described social support by friends, spouses, families and support groups, which helped to ameliorate food insecurity and emotional distress.

CONCLUSIONS

Addressing food insecurity among WLHIV requires policy and programmatic interventions to enforce existing laws designed to protect the rights of people living with HIV, reduce HIV-related stigma, and improve gender equality.

Food insecurity, sexual risk behavior, and adherence to antiretroviral therapy among women living with HIV: A systematic review

Gender inequalities shape the experience of food insecurity among women living with HIV (WLHIV). We systematically reviewed the impact of food insecurity on sexual risk behaviors and antiretroviral therapy (ART) adherence among WLHIV. We included qualitative or quantitative peer-reviewed articles, extracted data in duplicate, and assessed rigor. Seven studies, from sub-Saharan Africa, North America, and Europe, met inclusion criteria. Food insecurity was associated with increased sexual risk through transactional sex and inability to negotiate safer sex. Hunger and food insecurity were barriers to ART initiation/adherence. Multidimensional programming and policies should simultaneously address poverty, gender inequality, food insecurity, and HIV.

Syndemics and the biosocial conception of health

The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.

Water insecurity in a syndemic context: Understanding the psycho-emotional stress of water insecurity in Lesotho, Africa

Syndemics occur when populations experience synergistic and multiplicative effects of co-occurring epidemics. Proponents of syndemic theory highlight the importance of understanding the social context in which diseases spread and cogently argue that there are biocultural effects of external stresses such as food insecurity and water insecurity. Thus, a holistic understanding of disease or social vulnerability must incorporate an examination of the emotional and social effects of these phenomena. This paper is a response to the call for a renewed focus on measuring the psycho-emotional and psychosocial effects of food insecurity and water insecurity. Using a mixed-method approach of qualitative interviews and quantitative assessment, including a household demographic, illness, and water insecurity scale, the Household Food Insecurity Access Scale, and the Hopkins Symptoms Checklist-25, this research explored the psycho-emotional effects of water insecurity, food insecurity, and household illness on women and men residing in three low-land districts in Lesotho (n = 75). Conducted between February and November of 2011, this exploratory study first examined the complicated interaction of water insecurity, food insecurity and illness to understand and quantify the relationship between these co-occurring stresses in the context of HIV/AIDS. Second, it sought to separate the role of water insecurity in predicting psycho-emotional stress from other factors, such as food insecurity and household illness. When asked directly about water, qualitative research revealed water availability, access, usage amount, and perceived water cleanliness as important dimensions of water insecurity, creating stress in respondents' daily lives. Qualitative and quantitative data show that water insecurity, food insecurity and changing household demographics, likely resulting from the HIV/AIDS epidemic, are all associated with increased anxiety and depression, and support the conclusion that water insecurity is a critical syndemic dimension in Lesotho. Together, these data provide compelling evidence of the psycho-emotional burden of water insecurity.

Depression, alcohol use, and intimate partner violence among outpatients in rural Uganda: vulnerabilities for HIV, STIs and high risk sexual behavior

Background

Intimate partner violence (IPV), alcohol use, and depression are key vulnerabilities for HIV in Uganda, and taken together may have a synergistic effect on risk. Our objective was to investigate the associations between depression, IPV, and alcohol use and HIV-risk indicators among a sample of outpatients in rural Uganda, and the effect of co-occurrence of these factors on HIV-risk indicators.

Methods

In a structured interview we collected data on high-risk sexual behavior, depression symptoms, emotional and physical IPV, and alcohol use, as well as a blood sample for HIV and syphilis tests and a urine sample for chlamydia and gonorrhea tests from 325 male and female outpatients receiving provider-initiated HIV testing and counseling (PITC) at a public hospital outpatient clinic in rural Uganda. We used logistic regression and generalized linear modeling to test independent associations between depression, IPV, and alcohol use and HIV-risk indicators, as well as the effect of co-occurrence on HIV-risk indicators.

Results

Twelve percent of men and 15% of women had two or more of the following conditions: depression, IPV, and alcohol use; another 29% of men and 33% of women had 1 condition. Each condition was independently associated with HIV risk behavior for men and women, and for women, depression was associated with testing positive for HIV or a sexually transmitted infection (STI). Men with one condition (AOR 2.32, 95% CI 1.95–2.77) and two or more conditions (AOR 12.77, 95% CI 7.97–20.47) reported more high risk sex acts compared to those with no potential co-occurring conditions. For men, experiencing two or more conditions increased risky sex more than one alone (χ² 24.68, p < 0.001). Women experiencing one condition (AOR 3.33, 95% CI 137–8.08) and two co-occurring conditions (AOR 5.87, 95% CI 1.99–17.35) were more likely to test positive for HIV or an STI and women with two co-occurring conditions were also at increased risk for risky sex (AOR 2.18, 95% CI 1.64–2.91). We also found preliminary evidence suggesting synergistic effects between depression and emotional IPV and between alcohol use and depression.

Conclusions

This study demonstrates the co-occurrence of depression, IPV, and alcohol use in men and women in an outpatient setting in rural Uganda. The co-occurrence of these factors was associated with greater HIV risk, highlighting the need for a more holistic approach to HIV prevention and care research and programming.

Household food insecurity, maternal nutritional status, and infant feeding practices among HIV-infected Ugandan women receiving combination antiretroviral therapy

Household food insecurity (HHFI) may be a barrier to both optimal maternal nutritional status and infant feeding practices, but few studies have tested this relationship quantitatively, and never among HIV-infected individuals. We therefore described the prevalence of HHFI and explored if it was associated with poorer maternal nutritional status, shorter duration of exclusive breastfeeding (EBF) and fewer animal-source complementary foods. We assessed these outcomes using bivariate and multivariate analyses among 178 HIV-infected pregnant and breastfeeding (BF) women receiving combination antiretroviral therapy in the PROMOTE trial (NCT00993031), a prospective, longitudinal cohort study in Tororo, Uganda. HHFI was common; the prevalence of severe, moderate, and little to no household hunger was 7.3, 39.9, and 52.8 %, respectively. Poor maternal nutritional status was common and women in households experiencing moderate to severe household hunger (MSHH) had statistically significantly lower body mass index (BMIs) at enrollment (21.3 vs. 22.5, p < 0.01) and prior to delivery (22.6 vs. 23.8, p < 0.01). BMI across time during pregnancy, but not gestational weight gain, was significantly lower for MSHH [adjusted beta (95 % CI) -0.79 (-1.56, -0.02), p = 0.04; -2.06 (-4.31, 0.19), p = 0.07], respectively. The prevalence (95 % CI) of EBF at 6 months was 67.2 % (59.7-73.5 %), and the proportion of women BF at 12 months was 80.4 % (73.3-85.7 %). MSHH was not associated with prevalence of EBF at 6 months or BF at 12 months. However, among those women still EBF at 4 months (81.4 % of population), those experiencing MSHH were significantly more likely to cease EBF between 4 and 6 months (aHR 2.38, 95 % CI 1.02-5.58). The prevalence of HHFI, maternal malnutrition, and suboptimal infant feeding practices are high and the causal relationships among these phenomena must be further explored.

An evaluation of a community-based food supplementation for people living with HIV in Ghana: implications for community-based interventions in Ghana

BACKGROUND

Community-based care and support services are limited in sub-Saharan Africa and as a result a high number of people living with HIV (PLHIV) are not getting the required care and support services. The aim of this study was to assess the impact of food supplementation services for PLHIV in Ghana on weight gained and factors associated with weight gained.

METHODS

The study employed mixed methods study design involving quantitative and qualitative techniques. These were structured questionnaire administered to 200 PLHIV selected through simple random sampling and a qualitative component consisting of 14 semi-structured interviews with purposefully selected stakeholders and eight focus group discussions with the beneficiaries.

RESULTS

The analysis of the quantitative data showed on average, beneficiaries had gained weight [mean difference in weight was 2 kg with 95 % CI (1.1, 2.9), P value <0.001]. Multivariate analysis showed that the support group to which the beneficiary belonged was the most important determinant of gaining weight. Through the qualitative interviews, beneficiaries indicated that the anti-retroviral drugs were making them hungry and the food helped to alleviate that effect. Notwithstanding, they indicated that the food was nutritious, made them healthy and strong, contributed to their weight gain and was their main sources of hope at home when they had no money.

CONCLUSIONS

A broad strategy of food supplementation for PLHIV should be implemented in different ways for different support groups taking into account the differences between different support groups when planning such an intervention.

Most at-risk populations: contextualising HIV prevention programmes targeting marginalised groups in Zanzibar, Tanzania

According to a 2009 UNAIDS report the HIV/AIDS prevalence rate in Zanzibar, Tanzania, is low in the general population (0.6%), but high among vulnerable groups, specifically sex workers (10.8%), injecting drug users (15.1%), and men who have sex with men (12.3%). In response to this concentrated epidemic, the Government of Zanzibar, international and local non-profit organisations have focused their prevention activities on these marginal populations. Although these efforts are beneficial in terms of disseminating information about HIV/AIDS and referring clients to health clinics, they fail to address how the socio-economic status of these groups places them at a greater risk for contracting and dying from the virus. Furthermore, there is an absence of qualitative research on these populations which is needed to understand the challenges these groups face and to improve the effectiveness of interventions. Through interviews with employees of government agencies and non-profit organisations, medical professionals, vulnerable populations and HIV/AIDS patients, this paper used a political economy of health and syndemic framework to examine how local realities inform and challenge HIV/AIDS programmes in Zanzibar.

Beyond Comorbidity: A Critical Perspective of Syndemic Depression and Diabetes in Cross-cultural Contexts

This article examines the comorbidity concept in medical anthropology. I argue that the dearth of articles on comorbidity in medical anthropology may result from the rise of syndemic theory. Syndemics recognize how social realities shape individual illness experiences as well as distribution of diseases across populations. I discuss synergistic interactions foundational to the syndemics construct through my research of depression and diabetes comorbidity in vulnerable populations from urban United States, India, and South Africa. I argue that social and economic factors that cluster with depression and diabetes alone and together exemplify the biosocial processes that are at the heart of syndemics. In doing so, I illustrate how social, cultural, and economic factors shape individual-level experiences of co-occurring diseases despite similar population-level trends. Finally, I discuss the relevance of syndemics for the fields of medicine and public health while cautioning what must not be lost in translation across disciplines.

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

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

Development, coinfection, and the syndemics of pregnancy in Sub-Saharan Africa

Notable among gaps in the achievement of the global health Millennium Development Goals (MDG) are shortcomings in addressing maternal health, an issue addressed in the fifth MDG. This shortfall is particularly acute in Sub-Saharan Africa (SSA), where over half of all maternal deaths occur each year. While there is not as yet a comprehensive understanding of the biological and social causes of maternal death in SSA, it is evident that poverty, gendered economic marginalization, social disruptions, hindered access to care, unevenness in the quality of care, illegal and clandestine abortions, and infections are all critical factors. Beyond these factors, this paper presents a review of the existing literature on maternal health in SSA to argue that syndemics constitute a significant additional source of maternal morbidity and mortality in the region. Increasing focus on the nature, prevention, and treatment of syndemics, as a result, should be part and parcel of improving maternal health in SSA.

Persistent household food insecurity, HIV, and maternal stress in peri-urban Ghana

Background

The mental health of caregivers has been shown to be important for improving HIV prevention and treatment. Household food insecurity affects hundreds of millions of individuals in Sub-Saharan Africa, a region that experiences a disproportionate burden of the HIV pandemic. Both maternal HIV diagnosis and household food insecurity may be linked with maternal stress. This in turn may lead to unhealthy coping behaviors. We examined the independent associations of HIV, persistent household food insecurity and the synergistic effect of both on maternal stress.

Methods

Ghanaian women recruited prenatally from hospitals offering voluntary counseling and testing (VCT) were followed for 12 months after childbirth (N = 232). A locally adapted 7-item version of the US Household Food Security Survey Module was applied at four time points postpartum. We dichotomized participant households as being persistently food insecure (i.e., food insecure at each time point) or not (i.e., food secure at any time point). We dichotomized participant women as not perceiving vs. perceiving stress at 12 months postpartum in reference to the median sample score on the 4-item Cohen’s stress scale. Binary multivariate logistic regression models were used to assess the independent and interactive effects of maternal HIV and persistent household food insecurity on maternal stress.

Results

The proportion of HIV-positive women that lived in severe food insecure households increased over time. By contrast, the HIV-negative group living in severely food insecure households experienced a steady decline across time. HIV-infection (AOR = 2.31, 95% CI 1.29-4.12) and persistent household food insecurity (AOR = 3.55, 95% CI 1.13-11.13) were independently associated with maternal stress in a multivariate model. Being both HIV-positive and persistently food insecure strongly and synergistically increased the risk for maternal perceived stress (AOR = 15.35, 95% CI 1.90-124.14).

Conclusion

In agreement with syndemic theory there is a powerful synergism between maternal HIV diagnosis and household food insecurity on maternal stress. Comprehensive multi-dimensional intervention studies are needed to better understand how to reduce stress among HIV-positive women living in persistently food insecure households and how to reduce the likelihood of food insecurity in HIV-affected households in Sub-Saharan Africa.

CYCLES OF POVERTY, FOOD INSECURITY, AND PSYCHOSOCIAL STRESS AMONG AIDS CARE VOLUNTEERS IN URBAN ETHIOPIA

With the rollout of AIDS therapies, volunteer AIDS care has been promoted across Africa under the assumption that volunteerism is economically imperative in settings of health professional and resource scarcity. As low-income volunteers have become a major part of HIV/AIDS prevention and treatment workforces, it is imperative to question how poverty impacts their well-being. This chapter presents epidemiologic data collected during the 2008 food crisis from a sample of 110 AIDS care volunteers in Addis Ababa, Ethiopia, as well as narratives offered by HIV-positive volunteers, highlighting a widely overlooked way in which food insecurity and mental distress impact efforts to treat AIDS in sub-Saharan Africa. Food insecurity and elevated common mental disorder (CMD) symptom loads were common and tightly linked among the volunteers in the sample. Volunteers who were HIV-positive (17 percent) fared slightly worse in terms of food insecurity and psychosocial well-being. However, positive HIV serostatus was not associated with CMD in multivariate analyses accounting for food insecurity. Narratives illustrate how being HIV-positive shaped experiences of psychosocial stress, which involved unemployment and lack of prospects for marital relationships or strife within them. Our focus demonstrates the potential for mixing ethnographic and epidemiological methods to inform policy questions regarding poverty-reduction through compensation for volunteers' valuable labor, as well as AIDS care program sustainability. [volunteerism, AIDS care, food insecurity, livelihoods, HIV, psychosocial health].

Exploring antiretroviral treatment adherence in an urban setting in South Africa

Antiretroviral treatment requires high levels of adherence to be effective. This qualitative study explores the reasons for poor adherence among 22 purposively selected poor urban participants in South Africa. Over a 4-month period in 2009, we prospectively investigated experiences of HIV diagnosis and treatment, adherence, and withdrawal from treatment. Patients with no stable food sources faced significant barriers in adhering to treatment regimens and staying sufficiently healthy to search for, obtain or retain a job. The narratives also identify the influence on adherence of self-esteem and social support, vulnerability generated by ill health, gendered conflict, social inequities amplified by HIV, and exhaustion due to the social burden of the epidemic. Multi-dimensional, inter-sectoral programs that tackle the social determinants of health, such as food insecurity, poverty, gendered inequities, and treatment adherence are more likely to be successful, than single interventions to support adherence.

Volunteer home-based HIV/AIDS care and food crisis in Addis Ababa, Ethiopia: sustainability in the face of chronic food insecurity

Low-income volunteers constitute a major part of AIDS care workforces in sub-Saharan Africa, yet little research has been conducted to determine how poverty and insecurity among volunteers impact their wellbeing and the sustainability of the AIDS treatment programmes they support. This paper presents longitudinal ethnographic and epidemiological research documenting how the 2008 food crisis in Addis Ababa affected AIDS care volunteers' care relationships and motivations. Ethnographic results highlight the distress and demotivation that rising food costs created for caregivers by contributing to their own and their care recipients' experiences of food insecurity and HIV-related stigmatization. Epidemiological results underscore a high prevalence of food insecurity (approximately 80%) even prior to the peak of food prices. Rising food prices over the 3 years prior to 2008, underemployment and household per capita incomes averaging less than US$1/day, likely contributed to the very high prevalence of food insecurity reported by caregivers in our sample. We also show that new volunteers recruited in early 2008 by one of the non-governmental organizations (NGOs) involved in this study were more likely to be dependants within their households, and that these participants reported lower rates of food insecurity and higher household income. While this shift in volunteer recruitment may help sustain volunteer care programmes in the face of widespread poverty and underemployment, food insecurity was still highly prevalent (58-71%) among this sub-group. Given the inability of the local NGOs that organize volunteers to address the challenge of food insecurity for programme sustainability, our results raise important policy questions regarding compensation for volunteers' valuable labour and poverty reduction through public health sector job creation.