Agricultural and microfinance programmes might be part of the mix to achieve the virologic suppression goal

Shamba Maisha: randomized controlled trial of an agricultural and finance intervention to improve HIV health outcomes in Kenya.

Weiser SD, Bukusi EA, Steinfeld RL, Frongillo EA, Weke E, Dworkin SL, Pusateri K, Shiboski S, Scow K, Butler LM, Cohen CR. AIDS. 2015 Jul 23. [Epub ahead of print]

Objectives: Food insecurity and HIV/AIDS outcomes are inextricably linked in sub-Saharan Africa. We report on health and nutritional outcomes of a multisectoral agricultural intervention trial among HIV-infected adults in rural Kenya.

Design: This is a pilot cluster randomized controlled trial.

Methods: The intervention included a human-powered water pump, a microfinance loan to purchase farm commodities, and education in sustainable farming practices and financial management. Two health facilities in Nyanza Region, Kenya were randomly assigned as intervention or control. HIV-infected adults 18 to 49 years old who were on antiretroviral therapy and had access to surface water and land were enrolled beginning in April 2012 and followed quarterly for 1 year. Data were collected on nutritional parameters, CD4 T-lymphocyte counts, and HIV RNA. Differences in fixed-effects regression models were used to test whether patterns in health outcomes differed over time from baseline between the intervention and control arms.

Results: We enrolled 72 and 68 participants in the intervention and control groups, respectively. At 12 months follow-up, we found a statistically significant increase in CD4 cell counts (165 cells/µl, P < 0.001) and proportion virologically suppressed in the intervention arm compared with the control arm (comparative improvement in proportion of 0.33 suppressed, odds ratio 7.6, 95% confidence interval: 2.2-26.8). Intervention participants experienced significant improvements in food security (3.6 scale points higher, P < 0.001) and frequency of food consumption (9.4 times per week greater frequency, P = 0.013) compared to controls.

Conclusion: Livelihood interventions may be a promising approach to tackle the intersecting problems of food insecurity, poverty and HIV/AIDS morbidity.

Abstract access  [1]

Editor’s notes: There is compelling evidence of a vicious cycle between food insecurity and HIV transmission, morbidity and mortality. Studies have been finding alarmingly high rates of moderate and severe food insecurity among ART initiates in east Africa, at least 70%. At a time when the world is aiming to achieve the 90-90-90 targets, (90% of HIV positive individuals knowing their status, 90% of people being on ART and 90% of people on ART being virally suppressed) and thus increase viral suppression to 90%, among people on antiretroviral therapy, it is clear that the effectiveness and efficiency of treatment will depend on how food insecurity is addressed, within and/or alongside the HIV programme.

In this pilot study in Kenya, the authors report on an agricultural and microfinance programme provided to food-insecure adults living with HIV, who had access to farming land and surface water. Study participants were mainly established patients who had been on ART for an average of 2.8 years. The study finds a significant increase in CD4 cell counts (165 cells/mm3) and a comparative increase in the proportion of patients with virologic suppression, of 33%. In addition, significant improvements were found on the food security scale. These included the diversity and frequency of food consumption, as well as increases in BMI, despite no significant changes in food expenditures. However, it is important to note that the programme and control samples were unbalanced, with the programme group starting with higher food insecurity and a lower proportion of virologic suppression. Moreover, with only two sites, the study could not separate the programme effects from cluster-level variables, underscoring the need for a larger cluster RCT to confirm these findings.

Although this is a pilot RCT with a small sample size and other limitations, it provides promising evidence that a multi-sectoral agricultural and microfinance programme can have direct effects on ART outcomes, as well as impacting on food insecurity and nutrition outcome measures. While previous studies have reported on the effects of food assistance for people on ART, this study is an important addition to the evidence, as it is one of the first to report on a potentially sustainable agricultural-microfinance programme. Also, by measuring multiple outcomes across sectors, it allows for a more balanced appraisal of the programmes societal benefits, rather than only considering its HIV dividend. 

Africa [7]
Kenya [8]
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