Household food insecurity is associated with poor adherence to antiretroviral therapy

Household food insecurity associated with antiretroviral therapy adherence among HIV-infected patients in Windhoek, Namibia.

Hong SY, Fanelli TJ, Jonas A, Gweshe J, Tjituka F, Sheehan HM, Wanke C, Terrin N, Jordan MR, Tang AM. J Acquir Immune Defic Syndr. 2014 Dec 1;67(4):e115-22. doi: 10.1097/QAI.0000000000000308.

Objective: Food insecurity is emerging as an important barrier to antiretroviral therapy (ART) adherence. The objective of this study was to determine if food insecurity is associated with poor ART adherence among HIV-positive adults in a resource-limited setting that uses the public health model of delivery.

Design: A cross-sectional study using a 1-time questionnaire and routinely collected pharmacy data.

Methods: Participants were HIV-infected adults on ART at the public ART clinics in Windhoek, Namibia: Katutura State Hospital, Katutura Health Centre, and Windhoek Central Hospital. Food insecurity was measured by the Household Food Insecurity Access Scale (HFIAS). Adherence was assessed by the pharmacy adherence measure medication possession ratio (MPR). Multivariate regression was used to assess whether food insecurity was associated with ART adherence.

Results: Among 390 participants, 7% were food secure, 25% were mildly or moderately food insecure and 67% were severely food insecure. In adjusted analyses, severe household food insecurity was associated with MPR <80% [odds ratio (OR), 3.84; 95% confidence interval (CI): 1.65 to 8.95]. Higher household health care spending (OR, 1.92; 95% CI, 1.02 to 3.57) and longer duration of ART (OR, 0.82; 95% CI: 0.70 to 0.97) were also associated with <80% MPR.

Conclusions: Severe household food insecurity is present in more than half of the HIV-positive adults attending a public ART clinic in Windhoek, Namibia and is associated with poor ART adherence as measured by MPR. Ensuring reliable access to food should be an important component of ART delivery in resource-limited settings using the public health model of care.

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Editor’s notes:  United Nations Subcommittee on Nutrition defines food insecurity as “the limited or uncertain availability of nutritionally adequate, safe foods, or the inability to acquire personally acceptable foods in socially acceptable ways.” Qualitative studies in resource-limited settings have identified food insecurity as a potential risk for antiretroviral (ART) non-adherence. This is one of the first quantitative studies to analyse this issue. The findings from this cross-sectional survey of people living with HIV on ART in Namibia, are striking.  Four of the ten top reasons given for missing a medication dose, were related to food insecurity, e.g. “Did not take ARVs because they make me hungry and I did not have enough food” or, “Did not take ARVs because I cannot afford good food while taking medicine”. After adjusting for potential confounders, severe household food insecurity was significantly and positively associated with poor ART adherence. Depression and travel to the clinic via walking, biking or hitchhiking were also significantly associated with poor adherence. Research into the potential causal pathway between food insecurity and ART adherence is required, including evaluation of programmes to assess the relative effectiveness of nutritional versus livelihood programmes. 

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