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Longitudinal assessment of associations between food insecurity, antiretroviral adherence and HIV treatment outcomes in rural Uganda

Weiser, Sheri D.a; Palar, Kartikab; Frongillo, Edward A.c; Tsai, Alexander C.d; Kumbakumba, Eliase; dePee, Saskiaf; Hunt, Peter W.a; Ragland, Kathleena; Martin, Jeffreyg; Bangsberg, David R.d,e,h,i,j

doi: 10.1097/01.aids.0000433238.93986.35
Epidemiology and Social: Concise Communications

Introduction: Food insecurity is a potentially important barrier to the success of antiretroviral therapy (ART) programs in resource-limited settings. We undertook a longitudinal study in rural Uganda to estimate the associations between food insecurity and HIV treatment outcomes.

Design: Longitudinal cohort study.

Methods: Participants were from the Uganda AIDS Rural Treatment Outcomes study and were followed quarterly for blood draws and structured interviews. We measured food insecurity with the validated Household Food Insecurity Access Scale. Our primary outcomes were: ART nonadherence (adherence <90%) measured by visual analog scale; incomplete viral load suppression (>400 copies/ml); and low CD4+ T-cell count (<350 cells/μl). We used generalized estimating equations to estimate the associations, adjusting for socio-demographic and clinical variables.

Results: We followed 438 participants for a median of 33 months; 78.5% were food insecure at baseline. In adjusted analyses, food insecurity was associated with higher odds of ART nonadherence [adjusted odds ratio (AOR) 1.56, 95% confidence interval (CI) 1.10–2.20, P < 0.05], incomplete viral suppression (AOR 1.52, 95% CI 1.18–1.96, P < 0.01), and CD4+ T-cell count less than 350 (AOR 1.47, 95% CI 1.24–1.74, P < 0.01). Adding adherence as a covariate to the latter two models removed the association between food insecurity and viral suppression, but not between food insecurity and CD4+ T-cell count.

Conclusions: Food insecurity is longitudinally associated with poor HIV outcomes in rural Uganda. Intervention research is needed to determine the extent to which improved food security is causally related to improved HIV outcomes and to identify the most effective policies and programs to improve food security and health.

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aDivision of HIV/AIDS, San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco

bDepartment of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California

cDepartment of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina

dMassachusetts General Hospital Center for Global Health, Boston, Massachusetts, USA

eMbarara University of Science and Technology; Mbarara, Uganda

fUnited Nations World Food Programme, Rome, Italy

gDepartment of Epidemiology and Biostatistics, UCSF, San Francisco, California

hRagon Institute of MGH, MIT and Harvard University

iDepartment of Global Health and Social Equity, Harvard Medical School

jDepartment of Global Health and Populations, Harvard School of Public Health, Boston, Massachusetts, USA.

Correspondence to Sheri D. Weiser, MD, MPH, Division of HIV/AIDS, San Francisco General Hospital, POB 0874, University of California, San Francisco, California, 94143, USA. Tel: +1 415 314 0665; fax: +1 415 869 5395; e-mail:

Received 4 April, 2013

Revised 24 June, 2013

Accepted 4 July, 2013

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© 2014 Lippincott Williams & Wilkins, Inc.