Food insecurity among people living with HIV in the United States: time for structural level policy changes?

Food insecurity, chronic illness, and gentrification in the San Francisco Bay Area: an example of structural violence in United States public policy.

Whittle HJ, Palar K, Hufstedler LL, Seligman HK, Frongillo EA, Weiser SD. Soc Sci Med. 2015 Aug 20;143:154-161. doi: 10.1016/j.socscimed.2015.08.027. [Epub ahead of print]

Food insecurity continues to be a major challenge in the United States, affecting 49 million individuals. Quantitative studies show that food insecurity has serious negative health impacts among individuals suffering from chronic illnesses, including people living with HIV/AIDS (PLHIV). Formulating effective interventions and policies to combat these health effects requires an in-depth understanding of the lived experience and structural drivers of food insecurity. Few studies, however, have elucidated these phenomena among people living with chronic illnesses in resource-rich settings, including in the United States. Here we sought to explore the experiences and structural determinants of food insecurity among a group of low-income PLHIV in the San Francisco Bay Area. Thirty-four semi-structured in-depth interviews were conducted with low-income PLHIV receiving food assistance from a local non-profit in San Francisco and Alameda County, California, between April and June 2014. Interview transcripts were coded and analysed according to content analysis methods following an inductive-deductive approach. The lived experience of food insecurity among participants included periods of insufficient quantity of food and resultant hunger, as well as long-term struggles with quality of food that led to concerns about the poor health effects of a cheap diet. Participants also reported procuring food using personally and socially unacceptable strategies, including long-term dependence on friends, family, and charity; stealing food; exchanging sex for food; and selling controlled substances. Food insecurity often arose from the need to pay high rents exacerbated by gentrification while receiving limited disability income-a situation resulting in large part from the convergence of long-standing urban policies amenable to gentrification and an outdated disability policy that constrains financial viability. The experiences of food insecurity described by participants in this study can be understood as a form of structural violence, motivating the need for structural interventions at the policy level that extend beyond food-specific solutions.

Abstract access  [1]

Editor’s notes: Studies in the United States of America have demonstrated a high prevalence of food insecurity among low-income people living with HIV. Despite this high prevalence, little is known about the precise structural mechanisms by which food insecurity is distributed across low and high income participants, particularly among people living with HIV. This paper begins to fill that knowledge gap.  Using in-depth interviews among a group of low-income people living with HIV residing in the San Francisco Bay area, this study sought to investigate questions around how food insecurity manifests among certain groups in the population. Three themes relevant to the lived experience of food insecurity emerged from the interviews. The first being periods of significant food shortage where hunger or the anticipation of hunger was a serious source of anxiety for participants. The second was around the perceived poor quality of food where participants were unable to afford a diet that they believed to be sufficiently healthy. They considered this to be detrimental to both their general and HIV-associated health. This led to a third theme: participants using a multitude of resourceful strategies in order to procure food. Some of the strategies they found personally uncomfortable or they perceived as socially unacceptable. A relevant theme around structural determinants of food security that also emerged was the disparity between rent payments and the disability income which participants received. In particular, rising rents due to an influx of people who benefited from the technology boom, alongside gentrification taking place in the San Francisco area made it particularly difficult for low income people living with HIV to afford to live in the city. In order to be able to purchase food which they considered as high priority they would have to ration their money and avoid buying items they considered as less of a necessity (for example, entertainment, travel or toiletries). This is particularly exacerbated by the issue of monthly disability payments being low relative to the cost of living. The findings presented in this paper suggest certain structural activities in order to prevent the adverse effects of food insecurity such as sexual risk, sub-optimal ART adherence and poor clinical outcomes for people living with HIV. There were two suggested measures. The first was protecting vulnerable populations from the market effects of urban regeneration through better state subsidies in housing. The second was helping state-dependent individuals afford an adequate and sufficiently healthy diet by reassessing the amount disbursed through the disability income.

In summary, the authors describe low-income people living with HIV participants who often found themselves pushed into situations of indignity, shame and poor health by large-scale economic forces beyond their control. Without funds to purchase food with adequate nutritional content, they often fell into absolute hunger or had poor diets that prompted concerns about their physical health. Despite the United States of America being a high income country with one of the highest GDP per capita, food insecurity continues to be a challenge. Only broad structural approaches with policy changes can help chronically ill and vulnerable individuals escape both indignities and negative health consequences of food insecurity in the 21st century. 

Northern America [6]
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