Food insecurity is associated with greater acute care utilization among HIV-infected homeless and marginally housed individuals in San Francisco.
BACKGROUND
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.


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


METHODS
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).


RESULTS
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).


CONCLUSIONS
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.
Division of HIV/AIDS, San Francisco General Hospital, University of California, San Francisco (UCSF), POB 0874, UCSF, San Francisco, CA 94143, USA. Sheri.Weiser@ucsf.edu
Sheri D
SD
Weiser
Abigail
A
Hatcher
Edward A
EA
Frongillo
David
D
Guzman
Elise D
ED
Riley
David R
DR
Bangsberg
Margot B
MB
Kushel
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002140:California; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D005523:Food Supply / Q000706:statistics & numerical data*; D015658:HIV Infections / Q000628:therapy*; D006296:Health Services / Q000706:statistics & numerical data*; D006302:Health Services Research / Q000379:methods; D006703:Ill-Housed Persons / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006798:Housing / Q000706:statistics & numerical data*; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital / Q000706:statistics & numerical data