We undertook a longitudinal study in rural Uganda to understand the association of food insecurity with morbidity and patterns of healthcare utilization among HIV-infected individuals enrolled in an antiretroviral therapy program.
Longitudinal cohort study.
Participants were enrolled from the Uganda AIDS Rural Treatment Outcomes cohort, and underwent quarterly structured interviews and blood draws. The primary predictor was food insecurity measured by the validated Household Food Insecurity Access Scale. Primary outcomes included health-related quality of life measured by the validated Medical Outcomes Study-HIV Physical Health Summary (PHS), incident self-reported opportunistic infections, number of hospitalizations, and missed clinic visits. To estimate model parameters, we used the method of generalized estimating equations, adjusting for sociodemographic and clinical variables. Explanatory variables were lagged by 3 months to strengthen causal interpretations.
Beginning in May 2007, 458 persons were followed for a median of 2.07 years, and 40% were severely food insecure at baseline. Severe food insecurity was associated with worse PHS, opportunistic infections, and increased hospitalizations (results were similar in concurrent and lagged models). Mild/moderate food insecurity was associated with missed clinic visits in concurrent models, whereas in lagged models, severe food insecurity was associated with reduced odds of missed clinic visits.
Based on the negative impact of food insecurity on morbidity and patterns of healthcare utilization among HIV-infected individuals, policies and programs that address food insecurity should be a critical component of HIV treatment programs worldwide.
"However, these findings and theories are based on crosssectional studies that require further validation (Anema et al., 2011; Kalichman, 2010; Normén et al., 2005; Weiser, Fernandes, et al., 2009; Weiser, Frongillo, et al., 2009; Weiser et al., 2011) because they are limited to clinical outcomes (e.g., viral loads and mortality rate) and, for the most part, do not examine how food insufficiency affects overall physical and mental health and well-being over time for people living with HIV (Paton et al., 2006; Weiser, Fernandes, et al., 2009; Weiser, Frongillo, et al., 2009). To our knowledge, only one study examined a linkage longitudinally; however, it was conducted in Uganda (Weiser et al., 2012) and may, therefore, not be directly applicable to the Canadian context due to systemic differences in the characteristics of HIV-positive patients, food policies and health care delivery systems. Our primary objective is to examine the association between food insufficiency and physical and mental health-related quality of life (HRQoL) among participants from the Positive Spaces, Healthy Places (PSHP) cohort (2006 and 2009). "
[Show abstract][Hide abstract] ABSTRACT: Studies of people living with HIV who are homeless or unstably housed show a high prevalence of food insufficiency (>50%) and associated poor health outcomes; however, most evidence is in the form of cross-sectional studies. To better understand this issue, we conducted a longitudinal study to examine the impact of food insufficiency and housing instability on overall physical and mental health-related quality of life (HRQoL) among people living with HIV in Ontario. Six hundred and two adults living with HIV were enrolled in the Positive Spaces, Healthy Places study and followed from 2006 to 2009. Interviewer-administered questionnaires were used, and generalized linear mixed-effects models constructed to examine longitudinal associations between food insufficiency, housing instability and physical and mental HRQoL. At baseline, 57% of participants were classified as food insufficient. After adjusting for potential confounders, longitudinal analyses revealed a significant, negative association between food insufficiency and physical and mental HRQoL outcomes, respectively [effect size (ES) with 95% confidence interval (CI): (ES = −2.1, CI = −3.9,−0.3); (ES = −3.5, CI = −6.1,−1.5)]. Furthermore, difficulties meeting housing costs were shown to have additional negative impacts on mental HRQoL. Food insufficiency is highly prevalent among people living with HIV in Ontario, particularly for those with unstable housing. This vulnerable group of individuals is in urgent need of changes to current housing programmes, services and policies, as well as careful consideration of their unmet nutritional needs.
AIDS Care 05/2015; DOI:10.1080/09540121.2015.1036725 · 1.60 Impact Factor
"Similar opportunities were not available in the remote and severely resource-constrained Kenyan setting and the intense deprivation was significantly more problematic for ART clients in this setting. Food insecurity reported by camp-based participants resonated with previous studies that found associations between food insecurity and adherence, morbidity, patterns of healthcare utilization (Franke et al., 2011; Weiser et al., 2012), and virological outcomes (Weiser et al., 2009, 2010). These links between hunger, food insecurity, and adherence were suggestive of more frequent or longer duration treatment interruptions potentially experienced within the refugee camp. "
[Show abstract][Hide abstract] ABSTRACT: HIV-positive refugees confront a variety of challenges in accessing and adhering to antiretroviral therapy (ART) and attaining durable viral suppression; however, there is little understanding of what these challenges are, how they are navigated, or how they may differ across humanitarian settings. We sought to document and examine accounts of the threats, barriers and facilitators experienced in relation to HIV treatment and care and to conduct comparisons across settings. We conducted semi-structured interviews among a purposive sample of 14 refugees attending a public, urban HIV clinic in Kuala Lumpur, Malaysia (July-September 2010), and 12 refugees attending a camp-based HIV clinic in Kakuma, Kenya (February-March 2011). We used framework methods and between-case comparison to analyze and interpret the data, identifying social and environmental factors that influenced adherence. The multiple issues that threatened adherence to antiretroviral therapy or precipitated actual adherence lapses clustered into three themes: "migration", "insecurity", and "resilience". The migration theme included issues related to crossing borders and integrating into treatment systems upon arrival in a host country. Challenges related to crossing borders were reported in both settings, but threats pertaining to integration into, and navigation of, a new health system were exclusive to the Malaysian setting. The insecurity theme included food insecurity, which was most commonly reported in the Kenyan setting; health systems insecurity, reported in both settings; and emotional insecurity, which was most common in the Kenyan setting. Resilient processes were reported in both settings. We drew on the concept of "bounded agency" to argue that, despite evidence of personal and community resilience, these processes were sometimes insufficient for overcoming social and environmental barriers to adherence. In general, interventions might aim to bolster individuals' range of action with targeted support that bolsters resilient processes. Specific interventions are needed to address locally-based food and health system insecurities.
Social Science & Medicine 06/2014; 120. DOI:10.1016/j.socscimed.2014.06.010 · 2.89 Impact Factor
"Over one-quarter of those in our cohort reported having gone without healthcare because they needed money for basic necessities, and they were more likely to present with late-stage disease. In several sub-Saharan African studies, food insecurity has been associated with poor ART adherence, more opportunistic infections, missed clinic visits, and increased hospitalizations –. Food insecurity is more common among older, unmarried, HIV-infected adults , and thus food insecurity should be addressed as part of comprehensive HIV treatment programs in resource-limited settings . While our findings support the observed negative effects of food insecurity, our results suggest that housing insecurity is also a common problem and associated with late-stage HIV disease presentation. "
[Show abstract][Hide abstract] ABSTRACT: After observing persistently low CD4 counts at initial HIV diagnosis in South Africa, we sought to determine risk factors for late-stage HIV disease presentation among adults.
We surveyed adults prior to HIV testing at four outpatient clinics in Durban from August 2010 to November 2011. All HIV-infected adults were offered CD4 testing, and late-stage HIV disease was defined as a CD4 count <100 cells/mm(3). We used multivariate regression models to determine the effects of sex, emotional health, social support, distance from clinic, employment, perceived barriers to receiving healthcare, and foregoing healthcare to use money for food, clothing, or housing ("competing needs to healthcare") on presentation with late-stage HIV disease.
Among 3,669 adults screened, 830 were enrolled, newly-diagnosed with HIV and obtained a CD4 result. Among those, 279 (33.6%) presented with late-stage HIV disease. In multivariate analyses, participants who lived ≥5 kilometers from the test site [adjusted odds ratio (AOR) 2.8, 95% CI 1.7-4.7], reported competing needs to healthcare (AOR 1.7, 95% CI 1.2-2.4), were male (AOR 1.7, 95% CI 1.2-2.3), worked outside the home (AOR 1.5, 95% CI 1.1-2.1), perceived health service delivery barriers (AOR 1.5, 95% CI 1.1-2.1), and/or had poor emotional health (AOR 1.4, 95% CI 1.0-1.9) had higher odds of late-stage HIV disease presentation.
Independent risk factors for late-stage HIV disease presentation were from diverse domains, including geographic, economic, demographic, social, and psychosocial. These findings can inform various interventions, such as mobile testing or financial assistance, to reduce the risk of presentation with late-stage HIV disease.
PLoS ONE 01/2013; 8(1):e55305. DOI:10.1371/journal.pone.0055305 · 3.23 Impact Factor
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