Journal of General Internal Medicine

, Volume 28, Issue 1, pp 91–98 | Cite as

Food Insecurity Is Associated with Greater Acute Care Utilization among HIV-Infected Homeless and Marginally Housed Individuals in San Francisco

  • Sheri D. WeiserEmail author
  • Abigail Hatcher
  • Edward A. Frongillo
  • David Guzman
  • Elise D. Riley
  • David R. Bangsberg
  • Margot B. Kushel
Original Research



Food insecurity, or the uncertain availability of nutritionally adequate, safe foods, has been associated with poor HIV outcomes. There are few data on the extent to which food insecurity impacts patterns of health-care utilization among HIV-infected individuals.


We examined whether food insecurity was associated with hospitalizations, Emergency Department (ED) visits, and non-ED outpatient visits.


HIV-infected, homeless and marginally housed individuals participating in the San Francisco Research on Access to Care in the Homeless (REACH) cohort underwent quarterly structured interviews and blood draws. We measured food insecurity with the validated Household Food Insecurity Access Scale, and categorized participants as food secure, mild/moderately food insecure, and severely food insecure. Primary outcomes were: (1) any hospitalizations, (2) any ED visits, and (3) any non-ED outpatient visits. Generalized estimating equations were used to estimate model parameters, adjusting for socio-demographic (age, sex, ethnicity, education, income, housing status, health insurance) and clinical variables (CD4 nadir, time on antiretroviral therapy, depression, and illicit drug use).


Beginning in November 2007, 347 persons were followed for a median of 2 years. Fifty-six percent of participants were food insecure at enrollment. Compared with food-secure persons, those with severe food insecurity had increased odds of hospitalizations [adjusted odds ratio (AOR) = 2.16, 95 % confidence interval (CI) = 1.50–3.09] and ED visits (AOR = 1.71, 95 % CI = 1.06–2.30). While the odds of an outpatient visit were 41 % higher for severely food insecure individuals, the effect was not statistically significant (AOR = 1.41, 95 % CI = 0.99–2.01). Mild/moderate food insecurity was also associated with increased hospitalizations (AOR = 1.56, 95 % CI = 1.06–2.30), ED visits (AOR = 1.57, 95 % CI = 1.22–2.03), and outpatient visits (AOR = 1.68, 95 % CI = 1.20–2.17).


Food insecurity is associated with increased health services utilization among homeless and marginally housed HIV-infected individuals in San Francisco. Increased ED visits and hospitalizations are not related to fewer ambulatory care visits among food-insecure individuals. Addressing food insecurity should be a critical component of HIV treatment programs and may reduce reliance on acute care utilization.

Key words

food security HIV/AIDS acute care utilization 



This publication was made possible by grant no. UL1 RR024131 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the NCRR or the NIH. Information on NCRR is available at http:///


We thank the collaborating researchers including Kathleen McCartney, Richard Clark, Greg Barnell, John Day, Nelia Dela Cruz, Minoo Gorji, Scot Hammond, Jackie Haslam, Zizi Hawthorne, Jay Jankowski, Rhonda Johnson, Mac McMaster, Sandra Monk, Rebecca Packard, Joyce Powell, Kathleen Ragland, Mathew Reynolds, Paul Rueckhaus, Jacqueline So, John Weeks and Kelly Winslow.


NIMH 54907, 79713-01; CHRP ID08-SF-054; UCSF Academic Senate; Hurlbut-Johnson funds from AIDS Research Institute award, UCSF, no. 557858-8-148. The authors acknowledge the following additional sources of salary support: the Burke Family Foundation and the Hellman Family Foundation (to Dr. Weiser), and K24 MH-87227 (to Dr. Bangsberg).

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  • Sheri D. Weiser
    • 1
    • 2
    Email author
  • Abigail Hatcher
    • 1
  • Edward A. Frongillo
    • 3
  • David Guzman
    • 4
  • Elise D. Riley
    • 1
  • David R. Bangsberg
    • 5
  • Margot B. Kushel
    • 4
  1. 1.Division of HIV/AIDS, San Francisco General HospitalUniversity of California, San Francisco (UCSF)San FranciscoUSA
  2. 2.Center for AIDS Prevention StudiesUniversity of California, San Francisco (UCSF)San FranciscoUSA
  3. 3.Department of Health Promotion, Education, and Behavior, Arnold School of Public HealthUniversity of South CarolinaColumbiaUSA
  4. 4.Division of General Internal Medicine, San Francisco General HospitalUniversity of California, San Francisco (UCSF)San FranciscoUSA
  5. 5.Massachusetts General Hospital Center for Global Health, Ragon Institute of MGH, MIT and HarvardHarvard Medical SchoolBostonUSA

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