Journal of Behavioral Medicine

, Volume 38, Issue 3, pp 397–406 | Cite as

Synergistic effects of food insecurity and drug use on medication adherence among people living with HIV infection

  • Yiyun ChenEmail author
  • Seth C. Kalichman


Food insecurity and drug use are closely connected in the context of poverty, and both have been suggested to interfere with HIV medication adherence among people living with HIV/AIDS (PLWH). Yet the potential interaction between the two factors on adherence has not been examined. For this study we collected longitudinal data on HIV medication adherence among PLWH in Atlanta, GA, to assess a possible synergistic effect between the two factors on HIV medication adherence. People informed about the study came to the research site and completed an audio computer-assisted self-interview and instructions for pill counting. Over the next 5 weeks participants received three unscheduled follow-up phone assessments conducted 2 weeks apart to collect pill counts of their HIV medication. The prevalence of food insecurity was 60 % (488) and that of drug use was 33 % (274) in the sample of 809 participants. Among 770 participants who completed follow-up phone assessments, both food insecurity and drug use were associated with HIV medication adherence after adjusting for socio-demographic characteristics. The negative association between drug use and adherence persisted after further adjusting for health-related characteristics. Moreover, drug use appeared to moderate the effect of food insufficiency on adherence, with drug users who were food insufficient being the least likely to achieve 85 % adherence. Results from the current study demonstrate a synergism between food insecurity and drug use that may impede adherence among PLWH. The findings imply that the disruptive effects of food insecurity and drug use on adherence are likely to be intensified with the presence of each other, and encourage interventions to address the problem of HIV medication adherence from a multi-faceted perspective that takes into account detrimental combination of problem factors.


Food insecurity Drug use HIV ART Adherence 



This project was supported by National Institute of Drug Abuse Grant R01-DA017399.

Conflict of interest

Yiyun Chen and Seth C. Kalichman declare that they have no conflict of interest.

Human and animal rights and Informed Consent

All procedures followed were in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.


  1. Alcabes, P., Schoenbaum, E. E., & Klein, R. S. (1993). Correlates of the rate of decline of CD4+ lymphocytes among injection drug users infected with the human immunodeficiency virus. American Journal of Epidemiology, 137, 989–1000.PubMedGoogle Scholar
  2. Anema, A., Chan, K., Chen, Y., Weiser, S., Montaner, J. S., & Hogg, R. S. (2013). Relationship between food insecurity and mortality among HIV-positive injection drug users receiving antiretroviral therapy in British Columbia, Canada. PLoS ONE, 8, e61277. doi: 10.1371/journal.pone.0061277 CrossRefPubMedCentralPubMedGoogle Scholar
  3. Anema, A., Vogenthaler, N., Frongillo, E. A., Kadiyala, S., & Weiser, S. D. (2009). Food insecurity and HIV/AIDS: Current knowledge, gaps, and research priorities. Current HIV/AIDS Reports, 6, 224–231.CrossRefPubMedGoogle Scholar
  4. Anema, A., Wood, E., Weiser, S. D., Qi, J., Montaner, J. S., & Kerr, T. (2010). Hunger and associated harms among injection drug users in an urban Canadian setting. Substance Abuse Treatment, Prevention, and Policy, 5, 20. doi: 10.1186/1747-597X-5-20 CrossRefPubMedCentralPubMedGoogle Scholar
  5. Antoniou, T., & Tseng, A. L. (2002). Interactions between recreational drugs and antiretroviral agents. Annals of Pharmacotherapy, 36, 1598–1613.CrossRefPubMedGoogle Scholar
  6. Au, J. T., Kayitenkore, K., Shutes, E., Karita, E., Peters, P. J., Tichacek, A., & Allen, S. A. (2006). Access to adequate nutrition is a major potential obstacle to antiretroviral adherence among HIV-infected individuals in Rwanda. AIDS, 20, 2116–2118. doi: 10.1097/01.aids.0000247580.16073.1b CrossRefPubMedGoogle Scholar
  7. Bangsberg, D. R., Kroetz, D. L., & Deeks, S. G. (2007). Adherence–resistance relationships to combination HIV antiretroviral therapy. Current HIV/AIDS Reports, 4, 65–72.CrossRefPubMedGoogle Scholar
  8. Barclay, T. R., Hinkin, C. H., Castellon, S. A., Mason, K. I., Reinhard, M. J., Marion, S. D., … & Durvasula, R. S. (2007). Age-associated predictors of medication adherence in HIV-positive adults: Health beliefs, self-efficacy, and neurocognitive status. Health Psychology, 2, 40–49. doi: 10.1037/0278-6133.26.1.40
  9. Bartlett, J. A. (2002). Addressing the challenges of adherence. Journal of Acquired Immune Deficiency Syndromes, 29, S2–10.CrossRefPubMedGoogle Scholar
  10. Campa, A., Yang, Z., Lai, S., Xue, L., Phillips, J. C., Sales, S., … & Baum, M. K. (2005). HIV-related wasting in HIV-infected drug users in the era of highly active antiretroviral therapy. Clinical Infectious Diseases, 41, 1179–1185. doi: 10.1086/444499
  11. Carrieri, M. P., Villes, V., Raffi, F., Protopopescu, C., Preau, M., Salmon, D., … & Spire, B. (2007). Self-reported side-effects of anti-retroviral treatment among IDUs: a 7-year longitudinal study (APROCO-COPILOTE COHORT ANRS CO-8). International Journal of Drug Policy, 18, 288-295Google Scholar
  12. Coates, J., Swindale, A., & Bilinsky, P. (2007). Household Food Insecurity Access Scale (HFIAS) for measurement of food access: Indicator guide. Retrieved June 1, 2014.Google Scholar
  13. Cohen, M. S., Chen, Y. Q., McCauley, M., Gamble, T., Hosseinipour, M. C., Kumarasamy, N., … & Team, H. S. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. The New England Journal of Medicine, 365, 493–505. doi: 10.1056/NEJMoa1105243
  14. Ensoli, F., & Sirianni, M. C. (2002). HIV/HCV co-infection: Clinical and therapeutic challenges. AIDS, 16, 1419–1420.CrossRefPubMedGoogle Scholar
  15. Hadland, S. E., Milloy, M. J., Kerr, T., Zhang, R., Guillemi, S., Hogg, R. S., … & Wood, E. (2012). Young age predicts poor antiretroviral adherence and viral load suppression among injection drug users. AIDS Patient Care STDS, 26, 274–280. doi: 10.1089/apc.2011.0196
  16. Hendricks, K., & Gorbach, S. (2009). Nutrition issues in chronic drug users living with HIV infection. Addiction Science and Clinical Practice, 5, 16–23.CrossRefPubMedCentralPubMedGoogle Scholar
  17. Himmelgreen, D. A., Perez-Escamilla, R., Segura-Millan, S., Romero-Daza, N., Tanasescu, M., & Singer, M. (1998). A comparison of the nutritional status and food security of drug-using and non-drug-using Hispanic women in Hartford, Connecticut. American Journal of Physical Anthropology, 107, 351–361. doi: 10.1002/(SICI)1096-8644(199811)107:3<351:AID-AJPA10>3.0.CO;2-7 CrossRefPubMedGoogle Scholar
  18. Hinkin, C. H., Barclay, T. R., Castellon, S. A., Levine, A. J., Durvasula, R. S., Marion, S. D., … & Longshore, D. (2007). Drug use and medication adherence among HIV-1 infected individuals. AIDS Behavior, 11, 185–194. doi: 10.1007/s10461-006-9152-0
  19. Kalichman, S. C., Amaral, C. M., Cherry, C., Flanagan, J., Pope, H., Eaton, L., … & Schinazi, R. F. (2008). Monitoring medication adherence by unannounced pill counts conducted by telephone: Reliability and criterion-related validity. HIV Clinical Trials, 9, 298–308. doi: 10.1310/hct0905-298
  20. Kalichman, S. C., Pellowski, J., Kalichman, M. O., Cherry, C., Detorio, M., Caliendo, A. M., & Schinazi, R. F. (2011). Food insufficiency and medication adherence among people living with HIV/AIDS in urban and peri-urban settings. Prevention Science, 12, 324–332. doi: 10.1007/s11121-011-0222-9 CrossRefPubMedGoogle Scholar
  21. Leaver, C. A., Bargh, G., Dunn, J. R., & Hwang, S. W. (2007). The effects of housing status on health-related outcomes in people living with HIV: A systematic review of the literature. AIDS Behavior, 11, 85–100. doi: 10.1007/s10461-007-9246-3 CrossRefPubMedGoogle Scholar
  22. Maisto, S. A., Conigliaro, J., McNeil, M., Kraemer, K., & Kelley, M. E. (2000). An empirical investigation of the factor structure of the AUDIT. Psychological Assessment, 12, 346–353.CrossRefPubMedGoogle Scholar
  23. Miller, C. L., Bangsberg, D. R., Tuller, D. M., Senkungu, J., Kawuma, A., Frongillo, E. A., & Weiser, S. D. (2011). Food insecurity and sexual risk in an HIV endemic community in Uganda. AIDS Behavior, 15, 1512–1519. doi: 10.1007/s10461-010-9693-0 CrossRefPubMedCentralPubMedGoogle Scholar
  24. Musumari, P. M., Wouters, E., Kayembe, P. K., Kiumbu Nzita, M., Mbikayi, S. M., Suguimoto, S. P., … & Kihara, M. (2014). Food insecurity is associated with increased risk of non-adherence to antiretroviral therapy among HIV-infected adults in the Democratic Republic of Congo: A cross-sectional study. PLoS One, 9, e85327. doi: 10.1371/journal.pone.0085327
  25. Normen, L., Chan, K., Braitstein, P., Anema, A., Bondy, G., Montaner, J. S., & Hogg, R. S. (2005). Food insecurity and hunger are prevalent among HIV-positive individuals in British Columbia, Canada. Journal of Nutrition, 135, 820–825.PubMedGoogle Scholar
  26. Pan, W. (2001). Akaike’s information criterion in generalized estimating equations. Biometrics, 57, 120–125.CrossRefPubMedGoogle Scholar
  27. Peretti-Watel, P., Spire, B., Schiltz, M. A., Bouhnik, A. D., Heard, I., Lert, F., … & Group, V. (2006). Vulnerability, unsafe sex and non-adherence to HAART: Evidence from a large sample of French HIV/AIDS outpatients. Social Science and Medicine, 62, 2420–2433. doi: 10.1016/j.socscimed.2005.10.020
  28. Piot, P., Greener, R., & Russell, S. (2007). Squaring the circle: AIDS, poverty, and human development. PLoS Medicine, 4, 1571–1575. doi: 10.1371/journal.pmed.0040314 CrossRefPubMedGoogle Scholar
  29. Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401.CrossRefGoogle Scholar
  30. Romero-Daza, N., Himmelgreen, D. A., Pérez-Escamilla, R., Segura-Millán, S., & Singer, M. (1999). Food habits of drug-using Puerto Rican women in inner-city Hartford. Medical Anthropology: Cross-Cultural Studies in Health and Illness, 18, 281–298.CrossRefGoogle Scholar
  31. Rose, A. M., Sinka, K., Watson, J. M., Mortimer, J. Y., & Charlett, A. (2002). An estimate of the contribution of HIV infection to the recent rise in tuberculosis in England and Wales. Thorax, 57, 442–445.CrossRefPubMedCentralPubMedGoogle Scholar
  32. Sethi, A. K., Celentano, D. D., Gange, S. J., Moore, R. D., & Gallant, J. E. (2003). Association between adherence to antiretroviral therapy and human immunodeficiency virus drug resistance. Clinical Infectious Diseases, 37, 1112–1118. doi: 10.1086/378301 CrossRefPubMedGoogle Scholar
  33. Shannon, K., Kerr, T., Milloy, M. J., Anema, A., Zhang, R., Montaner, J. S., & Wood, E. (2011). Severe food insecurity is associated with elevated unprotected sex among HIV-seropositive injection drug users independent of HAART use. AIDS, 25, 2037–2042. doi: 10.1097/QAD.0b013e32834b35c9 CrossRefPubMedCentralPubMedGoogle Scholar
  34. Singer, M., & Clair, S. (2003). Syndemics and public health: Reconceptualizing disease in bio-social context. Medical Anthropology Quarterly, 17, 423–441.CrossRefPubMedGoogle Scholar
  35. StataCorp. (2011). Stata Statistical Software: Release 12. College Station, TX: StataCorp LP.Google Scholar
  36. Strike, C., Rudzinski, K., Patterson, J., & Millson, M. (2012). Frequent food insecurity among injection drug users: Correlates and concerns. BMC Public Health, 12, 1058. doi: 10.1186/1471-2458-12-1058 CrossRefPubMedCentralPubMedGoogle Scholar
  37. USDA. (2006). Food Insecurity and Hunger in the United States: An assessment of the measure. Washington: National Academies Press.Google Scholar
  38. Weiser, S. D., Bangsberg, D. R., Kegeles, S., Ragland, K., Kushel, M. B., & Frongillo, E. A. (2009a). Food insecurity among homeless and marginally housed individuals living with HIV/AIDS in San Francisco. AIDS Behavior, 13, 841–848. doi: 10.1007/s10461-009-9597-z CrossRefPubMedCentralPubMedGoogle Scholar
  39. Weiser, S. D., Fernandes, K. A., Brandson, E. K., Lima, V. D., Anema, A., Bangsberg, D. R., … & Hogg, R. S. (2009). The association between food insecurity and mortality among HIV-infected individuals on HAART. Journal of Acquired Immune Deficiency Syndromes, 52, 342–349. doi: 10.1097/QAI.0b013e3181b627c2
  40. Weiser, S. D., Frongillo, E. A., Ragland, K., Hogg, R. S., Riley, E. D., & Bangsberg, D. R. (2009c). Food insecurity is associated with incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San Francisco. Journal of General Internal Medicine, 24, 14–20. doi: 10.1007/s11606-008-0824-5 CrossRefPubMedCentralPubMedGoogle Scholar
  41. Weiser, S. D., Young, S. L., Cohen, C. R., Kushel, M. B., Tsai, A. C., Tien, P. C., … & Bangsberg, D. R. (2011). Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS. The American Journal of Clinical Nutrition, 94, 1729S–1739S. doi: 10.3945/ajcn.111.012070
  42. Wood, E., Hogg, R. S., Yip, B., Moore, D., Harrigan, P. R., & Montaner, J. S. (2006). Impact of baseline viral load and adherence on survival of HIV-infected adults with baseline CD4 cell counts > or = 200 cells/microl. AIDS, 20, 1117–1123. doi: 10.1097/01.aids.0000226951.49353.ed CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of PsychologyUniversity of ConnecticutStorrsUSA

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