Longitudinal assessment of associations between food insecurity, antiretroviral adherence and HIV treatment outcomes in rural Uganda.
BACKGROUND
Food insecurity is a potentially important barrier to the success of antiretroviral therapy (ART) programs in resource-limited settings. We undertook a longitudinal study in rural Uganda to estimate the associations between food insecurity and HIV treatment outcomes.


METHODS
Longitudinal cohort study.


METHODS
Participants were from the Uganda AIDS Rural Treatment Outcomes study and were followed quarterly for blood draws and structured interviews. We measured food insecurity with the validated Household Food Insecurity Access Scale. Our primary outcomes were: ART nonadherence (adherence <90%) measured by visual analog scale; incomplete viral load suppression (>400 copies/ml); and low CD4 T-cell count (<350 cells/μl). We used generalized estimating equations to estimate the associations, adjusting for socio-demographic and clinical variables.


RESULTS
We followed 438 participants for a median of 33 months; 78.5% were food insecure at baseline. In adjusted analyses, food insecurity was associated with higher odds of ART nonadherence [adjusted odds ratio (AOR) 1.56, 95% confidence interval (CI) 1.10-2.20, P < 0.05], incomplete viral suppression (AOR 1.52, 95% CI 1.18-1.96, P < 0.01), and CD4 T-cell count less than 350 (AOR 1.47, 95% CI 1.24-1.74, P < 0.01). Adding adherence as a covariate to the latter two models removed the association between food insecurity and viral suppression, but not between food insecurity and CD4 T-cell count.


CONCLUSIONS
Food insecurity is longitudinally associated with poor HIV outcomes in rural Uganda. Intervention research is needed to determine the extent to which improved food security is causally related to improved HIV outcomes and to identify the most effective policies and programs to improve food security and health.
aDivision of HIV/AIDS, San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco bDepartment of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California cDepartment of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina dMassachusetts General Hospital Center for Global Health, Boston, Massachusetts, USA eMbarara University of Science and Technology; Mbarara, Uganda fUnited Nations World Food Programme, Rome, Italy gDepartment of Epidemiology and Biostatistics, UCSF, San Francisco, California hRagon Institute of MGH, MIT and Harvard University iDepartment of Global Health and Social Equity, Harvard Medical School jDepartment of Global Health and Populations, Harvard School of Public Health, Boston, Massachusetts, USA.
Sheri D
SD
Weiser
Kartika
K
Palar
Edward A
EA
Frongillo
Alexander C
AC
Tsai
Elias
E
Kumbakumba
Saskia
S
Depee
Peter W
PW
Hunt
Kathleen
K
Ragland
Jeffrey
J
Martin
David R
DR
Bangsberg
D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D005523:Food Supply; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007407:Interviews as Topic; D008137:Longitudinal Studies; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D012424:Rural Population; D016896:Treatment Outcome; D014454:Uganda; D019562:Viral Load; D055815:Young Adult
D044966:Anti-Retroviral Agents