How food insecurity contributes to poor HIV health outcomes: Qualitative evidence from the San Francisco Bay Area
Introduction
Food insecurity is “the limited or uncertain availability of nutritionally adequate, safe foods, or the inability to acquire personally acceptable food in socially acceptable ways” (Anema et al., 2009). This definition incorporates overlapping challenges, including insufficient quantity, poor quality, limited diversity, or compromised safety of food; inadequate access to food, leading to hunger or anxiety; and the need for socially unacceptable procurement of food, including begging, relying on charity, exchanging sex for food, stealing food, and other illicit activities (Anema et al., 2009). Food insecurity affects hundreds of millions of people globally, and remains a major challenge in many high-income countries. The United States is a prominent example: 48 million Americans (15.4% of the population) were food-insecure in 2014 (Coleman-Jensen et al., 2015).
The link between food insecurity and HIV/AIDS is well characterized. In this bidirectional relationship, the two impact each other by heightening vulnerability to and worsening the severity of each condition (Weiser et al., 2011). On the one hand, people living with HIV/AIDS (PLHIV) and their families are put at risk of food insecurity from the loss of labor, wages, assets, and productivity associated with HIV-related morbidity, stigma, and treatment costs (Weiser et al., 2011). At the same time, food insecurity increases the risk of both horizontal and vertical transmission, and food-insecure PLHIV consistently exhibit worse clinical outcomes than their food-secure counterparts (Weiser et al., 2015a).
In resource-rich settings, food insecurity has been associated with higher viral loads (Feldman et al., 2015, Wang et al., 2011, Weiser et al., 2013), lower CD4 counts (Weiser et al., 2013), and HIV-related morbidity (Weiser et al., 2012) and mortality (Anema et al., 2013). Quantitative data suggest that food insecurity worsens patients' HIV-related health through three interrelated pathways—nutritional, behavioral, and mental health (Fig. 1) (Weiser et al., 2011, Weiser et al., 2015a). While the nutritional pathway operates exclusively at the physiological level, with micro- and macronutrient deficiencies leading to immunologic decline and faster disease progression (Weiser et al., 2015a), the behavioral and mental health pathways represent biopsychosocial processes through which food insecurity contributes to poor HIV health. Extensive evidence from resource-rich as well as resource-poor settings shows that food-insecure PLHIV have poorer adherence to ART and are more likely to miss scheduled clinic visits than their food-secure counterparts (Singer et al., 2014, Young et al., 2014). Food insecurity has also been associated with depression (Anema et al., 2011, Palar et al., 2015, Vogenthaler et al., 2011, Weiser et al., 2009) and increased alcohol and substance use (Anema et al., 2011, Weiser et al., 2009) among PLHIV in the United States and Canada, all of which are predictors of ART non-adherence (Chander et al., 2006, Uthman et al., 2014, Vagenas et al., 2015). Depression is additionally associated with poor immunologic outcomes independent of ART adherence (Evans et al., 2002, Ickovics et al., 2001).
These quantitative associations support the design of interventions and policies aimed at addressing food insecurity to improve HIV clinical outcomes. Doing so, however, requires a deeper understanding of how such associations arise in different populations, in order that interventions are optimally tailored to the underlying causal processes shaped by patients' complex needs and broader social contexts. While qualitative research is the best approach for obtaining such an understanding, few qualitative studies have investigated the relationship between food insecurity and HIV health. Importantly, no such studies have been conducted in high-income countries, where the mechanisms may be different compared with resource-poor settings. It has been theorized that HIV health behaviors are influenced by factors operating across individual, interpersonal/network, community, institutional/health system, and structural levels, which interact both within and between these levels to shape patterns of health behavior (Kaufman et al., 2014). This socio-ecological model includes diverse factors such as motivation, emotions, knowledge/information, and reactions to stress (individual level), social networks and social capital (interpersonal/network level), stigma and cultural norms (community level), culturally and structurally competent healthcare providers and appropriate services (institutional/health system level), and structural factors such as poverty and food insecurity. Here we aimed to understand how food insecurity exerts its influence on HIV-related health behaviors and outcomes across the different levels of the socio-ecological model by studying a population of low-income PLHIV in San Francisco and Alameda County, California.
Section snippets
Research setting
The San Francisco Bay Area has high rates of both food insecurity and HIV/AIDS. In 2013, 16.7% of the population of San Francisco (∼136,000 individuals) and 15.3% of the population of Alameda County (∼235,000 individuals) were estimated to be food-insecure (Gundersen et al., 2015). Around 200 food pantries and other non-profits were providing close to 100,000 citizens of San Francisco with direct food provision that year, serving at capacity and unable to meet demand (San Francisco Food
Results
The majority of the 34 participants were men, aged between 45 and 65 years, well educated, and never married or divorced (Table 1), broadly representative of POH's HIV-positive client base. During the interviews, almost all participants described personal episodes of food insecurity, and these experiences collectively encompassed every aspect of food insecurity. Individuals described living through times of insufficient quantity of food, reported long-term struggles with diet quality, regularly
Discussion
The PLHIV in this study described how food insecurity contributed to sub-optimal adherence to ART, missing scheduled clinic visits, and depressive symptoms, the last of which they perceived could both further erode ART adherence and worsen HIV clinical outcomes. The overlapping, interacting, and mutually reinforcing nature of the mechanisms involved demonstrates the complex manner in which food insecurity shapes the health behavior and outcomes of low-income PLHIV, exerting its effects via
Acknowledgements
This study would not have been possible without the incredible expertise and leadership of Simon Pitchford and Mark Ryle at POH, as well as the Client Services Team and all the other staff and volunteers there whose work facilitated the collaboration. Equally, we offer deep appreciation to the POH clients who so generously and patiently shared their experiences to inform this study as its participants. Finally, we thank Lee Lemus Hufstedler, Irene Ching, Manali Nekkanti, and Ian Whitmarsh at
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