Food insecurity is defined as “the limited or uncertain availability of nutritionally adequate and safe foods or uncertain ability to acquire acceptable foods in socially acceptable ways” [1]. Food insecurity is pervasive in the United States, with almost 1/6 of U.S. households suffering from food insecurity per the USDA. For HIV-infected individuals, food insecurity is an even more important concern, with approximately half suffering from food insecurity [2]. Women may also be especially vulnerable: more women-headed households compared to male-headed households are food insecure [2]. Women may have constrained choices for partners in the context of food insecurity, which may increase susceptibility to HIV [3].

Little is known about the impact of food insecurity on HIV-infected women. The only prior national study of food insecurity in HIV-infected adults, completed within the U.S. Department of Veteran's Affairs, was composed of 97% men [4]. Prior longitudinal studies completed throughout North American cities were composed predominantly of men [5-9]. As a Global Food Initiative (GFI) fellow, I studied the impact of food insecurity using data from the Women's interagency HIV Study, a national longitudinal study of U.S. HIV-infected Women. We started by completing a cross-sectional analysis on initial data. In our preliminary research, food insecurity is associated with higher HIV viral loads and lower CD4 counts. This is a concerning finding: viral load and CD4 count are markers that predict HIV progression for HIV-infected individuals. Our group plans to study the effect of food insecurity over time to better understand the mechanisms through which food insecurity causes poor health outcomes in HIV-infected women.

As HIV treatment has advanced, more and more attention has focused on what has been termed the “HIV care cascade,” depicted in the bar graph below [10].

Number and percentage of HIV-infected persons engaged in selected stages of the continuum of HIV care — United States

Despite availability of effective HIV treatments, our healthcare system is still fractured at the level of linkage and retention in care and delivery of HIV treatment. Food insecurity may be one of many factors that could negatively impact retention in HIV care and overall health. There are several ways that food insecurity may affect HIV-infected women's health. HIV-infected women may not be able to visit the doctor due to prioritizing obtaining food for their families over their healthcare [11]. Food insecurity may also be a factor contributing to substance use, mental health, and physical health, as well as interfering with the ability of HIV-infected patients to access and effectively utilize HIV care [11]. We hope that by studying the mechanisms through which food insecurity may influence the health of HIV-infected patients, we can help design interventions to address food insecurity and health in HIV-infected women.

References

1. Bickel G, Nord M, et al. Guide to Measuring Household Food Security, Revised 2000. Alexandria, VA, US Department of Agriculture, Food and Nutrition Service. 2000.
2. Weiser SD, Yuan C, Guzman D, Frongillo EA, Riley ED, Bangsberg DR, et al. Food insecurity and HIV clinical outcomes in a longitudinal study of urban homeless and marginally housed HIV-infected individuals. AIDS. 2013;27(18):2953-8.
3. Robinson J. Transactional Sex as a Response to Risk in Western Kenya. Am Econ J Appl Econ. 2011;3(1):35-64.
4. Wang EA, McGinnis KA, Fiellin DA, Goulet JL, Bryant K, Gibert CL, et al. Food insecurity is associated with poor virologic response among HIV-infected patients receiving antiretroviral medications. J Gen Intern Med. 2011;26(9):1012-8.
5. Feldman MB, Alexy ER, Thomas JA, Gambone GF, Irvine MK. The Association Between Food Insufficiency and HIV Treatment Outcomes in a Longitudinal Analysis of HIV-Infected Individuals in New York City. J Acquir Immune Defic Syndr. 2015;69(3):329-37.
6. Kalichman SC, Cherry C, Amaral C, White D, Kalichman MO, Pope H, et al. Health and treatment implications of food insufficiency among people living with HIV/AIDS, Atlanta, Georgia. J Urban Health. 2010;87(4):631-41.
7. Kapulsky L, Tang AM, Forrester JE. Food insecurity, depression, and social support in HIV-infected Hispanic individuals. J Immigr Minor Health. 2015;17(2):408-13.
8. Surratt HL, O'Grady CL, Levi-Minzi MA, Kurtz SP. Medication adherence challenges among HIV positive substance abusers: the role of food and housing insecurity. AIDS Care. 2015;27(3):307-14.
9. Weiser SD, Yuan C, Guzman D, Frongillo EA, Riley ED, Bangsberg DR, et al. Food insecurity and HIV clinical outcomes in a longitudinal study of urban homeless and marginally housed HIV-infected individuals. AIDS. 2013;27(18):2953-8.
10. MMWR. December 2, 2011 / 60(47);1618-1623
11. Weiser SD, Young SL, Cohen CR, Kushel MB, Tsai AC, Tien PC, et al. Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS. Am J Clin Nutr. 2011;94(6):1729S-39S.