The Mediating Role of Depressive Symptoms in the Association Between Food Insecurity and HIV Related Health Outcomes Among HIV–HCV Co-Infected People

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Food insecurity may lead to depressive symptoms, which are known to be associated with poor HIV related health outcomes. However, it is unclear to what extent food insecurity ‘directly’ affects these outcomes. We used data from the Food Security & HIV–HCV Sub-Study of the Canadian Co-Infection Cohort to assess the controlled direct effect. People experiencing severe food insecurity had 1.47 (95% CI 1.04–2.09) times the risk of having detectable HIV viral load and 0.94 (95% CI 0.87–1.02) fold change in CD4 count. After holding depressive symptoms constant, the association between severe food insecurity and HIV viral load was attenuated to a statistically non-significant level (RR 1.36, 95% CI: 0.95–1.96), whereas the association between severe food insecurity and CD4 count was unchanged. Depressive symptoms partially mediate the effect of severe food insecurity on HIV viral suppression; interventions focused on depressive symptoms alone may not be sufficient, however, to eliminate this effect.

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  1. 1.

    Anderson SA. Core indicators of nutritional state for difficult-to-sample populations. J Nutr. 1990;120(Suppl 11):1559–600.

  2. 2.

    Anema A, Weiser SD, Fernandes KA, et al. High prevalence of food insecurity among HIV-infected individuals receiving HAART in a resource-rich setting. AIDS care. 2011;23(2):221–30.

  3. 3.

    Cox J, Hamelin AM, McLinden T, et al. Food insecurity in HIV–Hepatitis C virus co-infected individuals in Canada: the importance of co-morbidities. AIDS Behav. 2017;21(3):792–802.

  4. 4.

    Palar K, Kushel M, Frongillo EA, et al. Food insecurity is longitudinally associated with depressive symptoms among homeless and marginally-housed individuals living with HIV. AIDS Behav. 2015;19(8):1527–34.

  5. 5.

    Weiser SD, Palar K, Frongillo EA, et al. Longitudinal assessment of associations between food insecurity, antiretroviral adherence and HIV treatment outcomes in rural Uganda. AIDS (London, England). 2014;28(1):115–20.

  6. 6.

    Kalichman SC, Washington C, Grebler T, et al. Treatment outcomes among people living with HIV who are food insecure and prescribed antiretrovirals taken with food. J Prim Care Community Health. 2015;6(1):35–40.

  7. 7.

    Weiser SD, Yuan C, Guzman D, et al. Food insecurity and HIV clinical outcomes in a longitudinal study of urban homeless and marginally housed HIV-infected individuals. AIDS (London, England). 2013;27(18):2953–8.

  8. 8.

    Aibibula W, Cox J, Hamelin AM, Mamiya H, Klein MB, Brassard P. Food insecurity and low CD4 count among HIV-infected people: a systematic review and meta-analysis. AIDS Care. 2016;28(12):1577–85.

  9. 9.

    Aibibula W, Cox J, Hamelin AM, McLinden T, Klein MB, Brassard P. Association between food insecurity and hiv viral suppression: a systematic review and meta-analysis. AIDS Behav. 2017;21(3):754–65.

  10. 10.

    Aibibula W, Cox J, Hamelin AM, et al. Food insecurity may lead to incomplete HIV viral suppression and less immune reconstitution among HIV/hepatitis C virus-coinfected people. HIV Med. 2018;19(2):123–31.

  11. 11.

    Chakraborty H, Sen PK, Helms RW, et al. Viral burden in genital secretions determines male-to-female sexual transmission of HIV-1: a probabilistic empiric model. AIDS (London, England). 2001;15(5):621–7.

  12. 12.

    Garcia PM, Kalish LA, Pitt J, et al. Maternal levels of plasma human immunodeficiency virus type 1 RNA and the risk of perinatal transmission. N Engl J Med. 1999;341(6):394–402.

  13. 13.

    Nagata JM, Palar K, Gooding HC, et al. Food Insecurity Is Associated With Poorer Mental Health and Sleep Outcomes in Young Adults. J Adolesc Health. 2019;65(6):805–11.

  14. 14.

    Arenas DJ, Thomas A, Wang J, DeLisser HM. A systematic review and meta-analysis of depression, anxiety, and sleep disorders in US adults with food insecurity. J Gen Intern Med. 2019;34(12):2874–82.

  15. 15.

    Whittle HJ, Sheira LA, Wolfe WR, et al. Food insecurity is associated with anxiety, stress, and symptoms of posttraumatic stress disorder in a cohort of women with or at risk of HIV in the United States. J Nutr. 2019;149(8):1393–403.

  16. 16.

    Rani D, Singh JK, Acharya D, Paudel R, Lee K, Singh SP. Household food insecurity and mental health among teenage girls living in urban slums in Varanasi, India: a cross-sectional study. Int J Environ Res Public Health. 2018;15(8):1585.

  17. 17.

    Hadley C, Tegegn A, Tessema F, Cowan JA, Asefa M, Galea S. Food insecurity, stressful life events and symptoms of anxiety and depression in east Africa: evidence from the Gilgel Gibe growth and development study. J Epidemiol Community Health. 2008;62(11):980–6.

  18. 18.

    Palar K, Frongillo EA, Escobar J, et al. Food insecurity, internalized stigma, and depressive symptoms among women living with HIV in the United States. AIDS Behav. 2018;22(12):3869–78.

  19. 19.

    Aibibula W, Cox J, Hamelin AM, et al. Impact of food insecurity on depressive symptoms among HIV–HCV co-infected people. AIDS Behav. 2017;21(12):3464–72.

  20. 20.

    Vogenthaler NS, Hadley C, Rodriguez AE, Valverde EE, del Rio C, Metsch LR. Depressive symptoms and food insufficiency among HIV-infected crack users in Atlanta and Miami. AIDS Behav. 2011;15(7):1520–6.

  21. 21.

    Tuthill EL, Sheira LA, Palar K, et al. Persistent food insecurity is associated with adverse mental health among women living with or at risk of HIV in the United States. J Nutr. 2019;149(2):240–8.

  22. 22.

    Mayston R, Kinyanda E, Chishinga N, Prince M, Patel V. Mental disorder and the outcome of HIV/AIDS in low-income and middle-income countries: a systematic review. AIDS (London, England). 2012;26(Suppl 2):S117–135.

  23. 23.

    Mehrotra ML, Glidden DV, McMahan V, et al. The effect of depressive symptoms on adherence to daily oral PrEP in men who have sex with men and transgender women: a marginal structural model analysis of the iPrEx OLE study. AIDS Behav. 2016;20(7):1527–34.

  24. 24.

    Smith Fawzi MC, Ng L, Kanyanganzi F, et al. Mental health and antiretroviral adherence among youth living with HIV in Rwanda. Pediatrics. 2016;138(4):e20153235.

  25. 25.

    Wagner GJ, Goggin K, Remien RH, et al. A closer look at depression and its relationship to HIV antiretroviral adherence. Annals Behav Med: Publ Soc Behav Med. 2011;42(3):352–60.

  26. 26.

    Salas J, Scherrer JF, Tuerk P, et al. Large posttraumatic stress disorder improvement and antidepressant medication adherence. J Affect Disord. 2019;260:119–23.

  27. 27.

    Whittle HJ, Sheira LA, Frongillo EA, et al. Longitudinal associations between food insecurity and substance use in a cohort of women with or at risk for HIV in the United States. Addiction. 2019;114(1):127–36.

  28. 28.

    Sanchez-Rivero I, Madoz-Gurpide A, Parro-Torres C, Hernandez-Huerta D, Ochoa ME. Influence of substance use and cognitive impairment on adherence to antiretroviral therapy in HIV+ patients. Adicciones. 2018;1(1):1025.

  29. 29.

    Amin P, Douaihy A. Substance use disorders in people living with human immunodeficiency virus/AIDS. Nurs Clin North Am. 2018;53(1):57–655.

  30. 30.

    Kim MH, Mazenga AC, Yu X, et al. High self-reported non-adherence to antiretroviral therapy amongst adolescents living with HIV in Malawi: barriers and associated factors. J Int AIDS Soc. 2017;20(1):21437.

  31. 31.

    Jiang W, Luo Z, Martin L, et al. Drug use is associated with anti-CD4 IgG-mediated CD4+ T cell death and poor CD4+ T cell recovery in viral-suppressive HIV-infected individuals under antiretroviral therapy. Curr HIV Res. 2018;16(2):143–50.

  32. 32.

    Whittle HJ, Palar K, Seligman HK, Napoles T, Frongillo EA, Weiser SD. How food insecurity contributes to poor HIV health outcomes: qualitative evidence from the San Francisco Bay Area. Soc Sci Med. 2016;170:228–36.

  33. 33.

    Kirkpatrick SI, Tarasuk V. Food insecurity is associated with nutrient inadequacies among Canadian adults and adolescents. J Nutr. 2008;138(3):604–12.

  34. 34.

    Chandra RK. Numerical and functional deficiency in T helper cells in protein energy malnutrition. Clin Exp Immunol. 1983;51(1):126–32.

  35. 35.

    Aibibula W, Cox J, Hamelin AM, et al. Association between depressive symptoms, CD4 count and HIV viral suppression among HIV–HCV co-infected people. AIDS Care. 2018;30(5):1–7.

  36. 36.

    Cox J, Hamelin AM, (principle investigators). Prospective investigation of the relationship between food insecurity and health and behavioural outcomes in HIV–HCV co-infection: clues for prevention interventions (ctn 264): a food security & HIV–HCV sub-study of the Canadian co-infection cohort (ctn 222). Accessed 14 April 2017.

  37. 37.

    Klein MB, Saeed S, Yang H, et al. Cohort profile: the Canadian HIV–hepatitis C co-infection cohort study. Int J Epidemiol. 2010;39(5):1162–9.

  38. 38.

    Health Canada. Canadian community health survey, cycle 2.2, nutrition (2004): income-related household food security in canada. Accessed 14 April 2017.

  39. 39.

    Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). Am J Prevent Med. 1994;10(2):77–84.

  40. 40.

    Boey KW. Cross-validation of a short form of the CES-D in Chinese elderly. Int J Geriatr Psychiatr. 1999;14(8):608–17.

  41. 41.

    Irwin M, Artin KH, Oxman MN. Screening for depression in the older adult: criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D). Arch Intern Med. 1999;159(15):1701–4.

  42. 42.

    Zhang W, O'Brien N, Forrest JI, et al. Validating a shortened depression scale (10 item CES-D) among HIV-positive people in British Columbia, Canada. PLoS ONE. 2012;7(7):e40793.

  43. 43.

    Rubin DB, Schenker N. Multiple imputation in health-care databases: an overview and some applications. Stat Med. 1991;10(4):585–98.

  44. 44.

    Robins JM, Hernan MA, Brumback B. Marginal structural models and causal inference in epidemiology. Epidemiology (Cambridge, Mass). 2000;11(5):550–60.

  45. 45.

    Greenland S. Quantifying biases in causal models: classical confounding vs collider-stratification bias. Epidemiology (Cambridge, Mass). 2003;14(3):300–6.

  46. 46.

    VanderWeele TJ. Marginal structural models for the estimation of direct and indirect effects. Epidemiology (Cambridge, Mass). 2009;20(1):18–26.

  47. 47.

    Hernan MA, Robins JM. Estimating causal effects from epidemiological data. J Epidemiol Community Health. 2006;60(7):578–86.

  48. 48.

    Greenland S. Model-based estimation of relative risks and other epidemiologic measures in studies of common outcomes and in case-control studies. Am J Epidemiol. 2004;160(4):301–5.

  49. 49.

    Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159(7):702–6.

  50. 50.

    Wei X, Ghosh SK, Taylor ME, et al. Viral dynamics in human immunodeficiency virus type 1 infection. Nature. 1995;373(6510):117–22.

  51. 51.

    Chop E, Duggaraju A, Malley A, et al. Food insecurity, sexual risk behavior, and adherence to antiretroviral therapy among women living with HIV: a systematic review. Health Care Women Int. 2017;38(9):927–44.

  52. 52.

    Cornelius T, Jones M, Merly C, Welles B, Kalichman MO, Kalichman SC. Impact of food, housing, and transportation insecurity on ART adherence: a hierarchical resources approach. AIDS Care. 2017;29(4):449–57.

  53. 53.

    Koehn K, McLinden T, Collins AB, et al. Assessing the impact of food insecurity on HIV medication adherence in the context of an integrated care programme for people living with HIV in Vancouver, Canada. Public Health Nutr. 2019:1–8.

  54. 54.

    Ho DD, Neumann AU, Perelson AS, Chen W, Leonard JM, Markowitz M. Rapid turnover of plasma virions and CD4 lymphocytes in HIV-1 infection. Nature. 1995;373(6510):123–6.

  55. 55.

    Bonner K, Mezochow A, Roberts T, Ford N, Cohn J. Viral load monitoring as a tool to reinforce adherence: a systematic review. J Acquir Immun Defic Syndr.2013;64(1):74–8.

  56. 56.

    Schneeweiss S. Sensitivity analysis and external adjustment for unmeasured confounders in epidemiologic database studies of therapeutics. Pharmacoepidemiol Drug Saf. 2006;15(5):291–303.

  57. 57.

    Westreich D, Cole SR. Invited commentary: positivity in practice. Am J Epidemiol. 2010;171(6):674–7. discussion 678-681.

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Correspondence to Paul Brassard.

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Aibibula, W., Cox, J., Hamelin, A. et al. The Mediating Role of Depressive Symptoms in the Association Between Food Insecurity and HIV Related Health Outcomes Among HIV–HCV Co-Infected People. AIDS Behav (2020) doi:10.1007/s10461-020-02784-7

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  • HIV–HCV co-infection
  • Food insecurity
  • HIV viral load
  • CD4 count
  • Mediation analysis