Advertisement

Journal of General Internal Medicine

, Volume 26, Issue 9, pp 1012–1018 | Cite as

Food Insecurity is Associated with Poor Virologic Response among HIV-Infected Patients Receiving Antiretroviral Medications

  • Emily A. Wang
  • Kathleen A. McGinnis
  • David A. Fiellin
  • Joseph L. Goulet
  • Kendall Bryant
  • Cynthia L. Gibert
  • David A. Leaf
  • Kristin Mattocks
  • Lynn E. Sullivan
  • Nicholas Vogenthaler
  • Amy C. Justice
  • for the VACS Project Team
Original Research

ABSTRACT

BACKGROUND AND OBJECTIVE

Food insecurity negatively impacts HIV disease outcomes in international settings. No large scale U.S. studies have investigated the association between food insecurity and severity of HIV disease or the mechanism of this possible association. The objective of this study was to examine the impact of food insecurity on HIV disease outcomes in a large cohort of HIV-infected patients receiving antiretroviral medications.

DESIGN

This is a cross-sectional study.

PARTICIPANTS AND SETTING

Participants were HIV-infected patients enrolled in the Veterans Aging Cohort Study between 2002–2008 who were receiving antiretroviral medications.

MAIN MEASUREMENTS

Participants reporting “concern about having enough food for you or your family in the past 30 days” were defined as food insecure. Using multivariable logistic regression, we explored the association between food insecurity and both low CD4 counts (<200 cells/μL) and unsuppressed HIV-1 RNA (>500 copies/mL). We then performed mediation analysis to examine whether antiretroviral adherence or body mass index mediates the observed associations.

KEY RESULTS

Among 2353 HIV-infected participants receiving antiretroviral medications, 24% reported food insecurity. In adjusted analyses, food insecure participants were more likely to have an unsuppressed HIV-1 RNA (AOR 1.37, 95% CI 1.09, 1.73) compared to food secure participants. Mediation analysis revealed that neither antiretroviral medication adherence nor body mass index contributes to the association between food insecurity and unsuppressed HIV-1 RNA. Food insecurity was not independently associated with low CD4 counts.

CONCLUSIONS

Among HIV-infected participants receiving antiretroviral medications, food insecurity is associated with unsuppressed viral load and may render treatment less effective. Longitudinal studies are needed to test the potential causal association between food insecurity, lack of virologic suppression, and additional HIV outcomes.

KEY WORDS

food insecurity HIV patients antiretrovirals 

Notes

Acknowledgements

This work was funded by National Institute on Alcohol and Alcohol Abuse (U01 AA 13566 and U10 AA 13566), National Institute of Aging (K23 AG00826), Robert Wood Johnson Generalist Faculty Scholar Award, an Inter-agency Agreement between NIA, National Institute of Mental Health, and VA HSR&D Research Enhancement Award Program (REAP) PRIME Project (REA 08-266). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

Conflicts of Interest

None disclosed.

REFERENCES

  1. 1.
    Nord M, Andrews M, Carlson S. Household Food Security in the United States, 2008. ERR-83, U.S. Dept. of Agriculture, Econ. Res. Serv. November 2009.Google Scholar
  2. 2.
    Weiser SD, Fernandes KA, Brandson EK, et al. The association between food insecurity and mortality among HIV-infected individuals on HAART. J Acquir Immune Defic Syndr. 2009;52:342–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Heflin CM, Siefert K, Williams DR. Food insufficiency and women’s mental health: findings from a 3-year panel of welfare recipients. Soc Sci Med. 2005;61:1971–82.PubMedCrossRefGoogle Scholar
  4. 4.
    Siefert K, Heflin CM, Corcoran ME, Williams DR. Food insufficiency and physical and mental health in a longitudinal survey of welfare recipients. J Health Soc Behav. 2004;45:171–86.PubMedCrossRefGoogle Scholar
  5. 5.
    Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. 2006;21:71–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Ma CT, Gee L, Kushel MB. Associations between housing instability and food insecurity with health care access in low-income children. Ambul Pediatr. 2008;8:50–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Seligman HK, Bindman AB, Vittinghoff E, Kanaya AM, Kushel MB. Food insecurity is associated with diabetes mellitus: results from the National Health Examination and Nutrition Examination Survey (NHANES) 1999-2002. J Gen Intern Med. 2007;22:1018–23.PubMedCrossRefGoogle Scholar
  8. 8.
    Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr. 2010;140:304–10.PubMedCrossRefGoogle Scholar
  9. 9.
    Weiser SD, Bangsberg DR, Kegeles S, Ragland K, Kushel MB, Frongillo EA. Food insecurity among homeless and marginally housed individuals living with HIV/AIDS in San Francisco. AIDS Behav. 2009;13:841–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Normen L, Chan K, Braitstein P, et al. Food insecurity and hunger are prevalent among HIV-positive individuals in British Columbia, Canada. J Nutr. 2005;135:820–5.PubMedGoogle Scholar
  11. 11.
    Anema A, Vogenthaler N, Frongillo EA, Kadiyala S, Weiser SD. Food insecurity and HIV/AIDS: current knowledge, gaps, and research priorities. Curr HIV/AIDS Rep. 2009;6:224–31.PubMedCrossRefGoogle Scholar
  12. 12.
    Bukusuba J, Kikafunda JK, Whitehead RG. Food security status in households of people living with HIV/AIDS (PLWHA) in a Ugandan urban setting. Br J Nutr. 2007;98:211–7.PubMedCrossRefGoogle Scholar
  13. 13.
    Cantrell RA, Sinkala M, Megazinni K, et al. A pilot study of food supplementation to improve adherence to antiretroviral therapy among food-insecure adults in Lusaka, Zambia. J Acquir Immune Defic Syndr. 2008;49:190–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. Food insecurity is associated with incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San Francisco. J Gen Intern Med. 2009;24:14–20.PubMedCrossRefGoogle Scholar
  15. 15.
    Campa A, Yang Z, Lai S, et al. HIV-related wasting in HIV-infected drug users in the era of highly active antiretroviral therapy. Clin Infect Dis. 2005;41:1179–85.PubMedCrossRefGoogle Scholar
  16. 16.
    Peretti-Watel P, Spire B, Schiltz MA, et al. Vulnerability, unsafe sex and non-adherence to HAART: evidence from a large sample of French HIV/AIDS outpatients. Soc Sci Med. 2006;62:2420–33.PubMedCrossRefGoogle Scholar
  17. 17.
    Kalichman SC, Cherry C, Amaral C, et al. Health and treatment implications of food insufficiency among people living with HIV/AIDS, Atlanta, Georgia. J Urban Health. 2010;87:631–41.PubMedCrossRefGoogle Scholar
  18. 18.
    Tang AM, Forrester J, Spiegelman D, Knox TA, Tchetgen E, Gorbach SL. Weight loss and survival in HIV-positive patients in the era of highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2002;31:230–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Wheeler DA, Gibert CL, Launer CA, et al. Weight loss as a predictor of survival and disease progression in HIV infection. Terry Beirn Community Programs for Clinical Research on AIDS. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18:80–5.PubMedCrossRefGoogle Scholar
  20. 20.
    Justice AC, Dombrowski E, Conigliaro J, et al. Veterans Aging Cohort Study (VACS): overview and description. Med Care. 2006;44:S13–24.PubMedCrossRefGoogle Scholar
  21. 21.
    Coates J, Swindale A, Bilinsky P. Household Food Inseucirty Access Scale (HFIAS) for Measurement of Food Access: Indicator Guide. Washington, D.C.: Academy for Educational Development; 2007.Google Scholar
  22. 22.
    Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption-II. Addiction. 1993;88(6):791–804.PubMedCrossRefGoogle Scholar
  23. 23.
    Maisto SA, Conigliaro J, McNeil M, Kraemer K, Kelley ME. An empirical investigation of the factor structure of the AUDIT. Psychol Assess. 2000;12:346–53.PubMedCrossRefGoogle Scholar
  24. 24.
    Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol use disorders identification test. Arch Intern Med. 1998;158:1789–95.PubMedCrossRefGoogle Scholar
  25. 25.
    Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA. 1999;282:1737–44.PubMedCrossRefGoogle Scholar
  26. 26.
    Braithwaite RS, Kozal MJ, Chang CC, et al. Adherence, virological and immunological outcomes for HIV-infected veterans starting combination antiretroviral therapies. AIDS. 2007;21:1579–89.PubMedCrossRefGoogle Scholar
  27. 27.
    Steiner JF, Koepsell TD, Fihn SD, Inui TS. A general method of compliance assessment using centralized pharmacy records. Description and validation. Med Care. 1988;26:814–23.PubMedCrossRefGoogle Scholar
  28. 28.
    Steiner JF, Prochazka AV. The assessment of refill compliance using pharmacy records: methods, validity, and applications. J Clin Epidemiol. 1997;50:105–16.PubMedCrossRefGoogle Scholar
  29. 29.
    Baron RM, Kenny DA. The moderator-mediator variable distinction in social psychological research: conceptual, strategic and statistical considerations. J Pers Soc Psychol. 1986;51:1173–82.PubMedCrossRefGoogle Scholar
  30. 30.
    Vogenthaler NS, Hadley C, Lewis SJ, Rodriguez AE, Metsch LR, Del Rio C. Food insufficiency among HIV-infected crack-cocaine users in Atlanta and Miami. Public Health Nutr. 2010;13:1478–84.PubMedCrossRefGoogle Scholar
  31. 31.
    Byron E, Gillespie S, Nangami M. Integrating nutrition security with treatment of people living with HIV: lessons from Kenya. Food Nutr Bull. 2008;29:87–97.PubMedGoogle Scholar
  32. 32.
    Mamlin J, Kimaiyo S, Lewis S, et al. Integrating nutrition support for food-insecure patients and their dependents into an HIV care and treatment program in Western Kenya. Am J Public Health. 2009;99:215–21.PubMedCrossRefGoogle Scholar
  33. 33.
    Hardon AP, Akurut D, Comoro C, et al. Hunger, waiting time and transport costs: time to confront challenges to ART adherence in Africa. AIDS Care. 2007;19:658–65.PubMedCrossRefGoogle Scholar
  34. 34.
    Parienti JJ, Das-Douglas M, Massari V, et al. Not all missed doses are the same: sustained NNRTI treatment interruptions predict HIV rebound at low-to-moderate adherence levels. PLoS ONE. 2008;3:e2783.PubMedCrossRefGoogle Scholar
  35. 35.
    Martin KS, Ferris AM. Food insecurity and gender are risk factors for obesity. J Nutr Educ Behav. 2007;39:31–6.PubMedCrossRefGoogle Scholar
  36. 36.
    Kalichman SC, Grebler T. Stress and poverty predictors of treatment adherence among people with low-literacy living with HIV/AIDS. Psychosom Med. 2010;72:810–6.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Emily A. Wang
    • 1
  • Kathleen A. McGinnis
    • 2
  • David A. Fiellin
    • 1
  • Joseph L. Goulet
    • 1
    • 3
  • Kendall Bryant
    • 4
  • Cynthia L. Gibert
    • 5
  • David A. Leaf
    • 6
  • Kristin Mattocks
    • 1
  • Lynn E. Sullivan
    • 1
  • Nicholas Vogenthaler
    • 7
  • Amy C. Justice
    • 1
    • 3
  • for the VACS Project Team
  1. 1.Department of Internal MedicineYale University School of MedicineNew HavenUSA
  2. 2.Pittsburgh VA Healthcare SystemPittsburghUSA
  3. 3.VA Connecticut Healthcare SystemWest HavenUSA
  4. 4.National Institute on Alcohol Abuse and AlcoholismNational Institutes of HealthRockvilleUSA
  5. 5.VA Medical Center and George Washington University Medical CenterWashingtonUSA
  6. 6.VA Greater Los Angeles Healthcare SystemDavid Geffen School of Medicine at UCLALos AngelesUSA
  7. 7.Division of Infectious DiseasesEmory University School of MedicineAtlantaUSA

Personalised recommendations