At baseline, the mean PHS was 43.1 (SD = 11.9) and this increased subsequent to ART initiation (Table 3). After statistical adjustment for baseline sociodemographic and clinical variables, the mean PHS was greater at every time point, beginning with the first quarter (b = 5.2; 95% CI: 3.1 to 7.4) and ending with the last quarter (b = 11.9; 95% CI: 3.1 to 20.6). F tests for the joint statistical significance of the time indicator variables and for a linear trend in them were statistically significant (P < 0.001).
Improvements in physical health status partially explained the decreases in food insecurity over time. When PHS was added to the regression models examining trends in food insecurity over time, the time indicator variables were no longer statistically significant as a group (P = 0.37) and the magnitude of the regression coefficients decreased by approximately 40% (Table 2, column 3). Conversely, when social support was added to the regression models examining trends in food security over time, the time indicator variables were still statistically significant as a group, and the regression coefficients were not attenuated, suggesting no mediation (Table 2, column 4). For BMI or MUAC, when either PHS or food insecurity were added to the models, the time indicator variables were still statistically significant as a group, and the regression coefficients were only minimally attenuated suggesting minimal mediation (Table 4, columns 2 and 4).
In this analysis of data from people living with HIV/AIDS initiating ART in rural Uganda, we found that food insecurity decreased and nutritional status increased after initiation of ART. Physical health status also improved, and changes in physical health status partially explained the observed trends in food insecurity but not in nutritional status. These findings have several important implications for food-insecurity programming and for policies on early initiation of ART in resource poor settings.
The striking declines in food insecurity that we observed subsequent to ART initiation are of substantive importance given the high prevalence of food insecurity among HIV-infected individuals, as well as the known negative impacts of food insecurity on HIV/AIDS morbidity and mortality.1,2,11,14 HIV/AIDS devastates affected households economically, by debilitating prime-working age household members and by increasing out-of-pocket medical expenses and caregiver burden.4,15,16,20 Our results suggest that ART may be able to reverse some of these negative trends in food insecurity and are consistent with recent work in India showing substantial improvements in employment and income within the first 2 years after ART initiation47 with a study in Kenya showing a 20% increase in the likelihood of being employed, and a 35% increase in hours worked within 6 months after ART initiation.48 The attenuation of food insecurity on ART seen in this study also highlights that a substantial proportion of food insecurity among HIV-infected individuals in the region is likely HIV related.
Our findings related to changes in physical health status for individuals on ART are consistent with studies from resource-rich settings that found substantial improvements in physical health status after initiation of ART, although these results have not been entirely consistent, and prior studies on this topic have been limited by shorter length of follow-up.23–25,49,50 Our findings add to the literature by suggesting that these trends also apply to resource poor settings26,51 and over longer follow-up durations.24 Similarly, although our findings that nutritional status improves on ART are supported by previous studies, results have been inconsistent in different populations and settings, with weight loss and wasting persisting on ART among certain groups.27–30
The mechanisms underlying the changes in food insecurity remain unclear, but we hypothesized that improved physical health status contributes to improved food security by earlier return to work and engagement in food-generating activities. In our analysis, the time trend in food insecurity was no longer statistically significant after the addition of PHS to the model, consistent with this hypothesis. This finding fits with those of a qualitative study in Uganda suggesting that adherence to ART may be accompanied by decreased food insecurity as a result of improved physical health and ability to work.10 Future studies should further evaluate this hypothesis by including changes in work status as a possible mediator of trends in food security. A second channel through which ART may decrease food insecurity is through social reintegration resulting in enhanced ability to draw on social networks for assistance during times of shortage.19,41,52 We investigated whether changes in social support on ART partially explained the decreases in food insecurity on ART and saw no evidence of mediation by social support. In our analysis, improvements in measures of nutritional status did not seem to be mediated by improved physical health status or food insecurity as measured by the food security scale, suggesting other mechanisms such as the amelioration of HIV-associated wasting with suppressed viral loads on ART or dietary improvements, which are required for regaining lost tissues and are not well reflected in the food security scale. Future studies should examine these mechanisms more fully to help elucidate the pathways through which nutritional status improves on ART.
Our findings have several important policy implications. In countries with increasing availability of ART, maximizing quality of life and nutritional status are becoming increasing priorities as individuals live longer.51,53 In view of the marked decreases seen in food insecurity and improvements in nutritional status after ART initiation, programs aimed at decreasing food insecurity among HIV-infected individuals should consider earlier initiation of ART as part of their strategy. Although important barriers still exist for scaling up ART to reach all currently eligible individuals, recent studies have also shown that initiating ART at CD4 counts higher than current guidelines (≥350) show substantial benefits in terms of reducing morbidity and mortality among HIV-infected individuals and preventing secondary HIV transmission.54–56 Our study also supports recent findings from a study in Malawi showing that prompt ART after an outpatient therapeutic feeding program for children improved nutritional recovery compared with individuals who did not receive prompt ART.57 Future studies should also evaluate benefits of ART initiation on food insecurity, nutritional status, and physical health status among individuals with higher baseline CD4 cell counts.
Our findings should not be interpreted to mean that ART alone is sufficient to ensure adequate food and nutrition for HIV-infected patients. Even after 2 years on ART, a large proportion of the participants in our study were still food insecure. Other studies have shown that food insecurity and malnutrition are still highly prevalent among HIV-infected individuals stably on ART.10,58 A recent study from Zambia and Kenya similarly reported that livelihoods and economic security still lag among individuals on ART.59 Among individuals stably on ART, food insecurity is still associated with depression,60 worse immunologic, and virologic outcomes, ART nonadherence, higher incidence of serious illness, and mortality.1,9,12–14 These data support that ART treatment alone is insufficient for fully reversing the negative impacts of food insecurity on HIV/AIDS morbidity and mortality, and that in many settings interventions to improve food security and nutritional support are urgently needed regardless of timing of ART initiation.
Because food security, nutritional status, and physical health status were most compromised during the early phases of ART initiation among participants in our study, these findings lend support to claims by policymakers and program developers that provision of food and nutritional support may be most critical during the earlier phases of ART initiation, when health status is most compromised and engagement in livelihood programs may be more challenging.61 This hypothesis requires further testing in controlled trials. Small trials from Haiti and Uganda have shown significant improvements in food security, nutritional status, adherence, and engagement in care among individuals receiving food supplementation during the first 12 months after ART initiation.62,63 The optimal strategy to simultaneously reduce HIV/AIDS morbidity and improve food insecurity likely involves better integration of programs aimed to reduce food insecurity with HIV/AIDS treatment programs.
This study had several limitations. First, we did not have access to a comparison group that was not using ART. The observed trends in food security and nutritional or physical health status could theoretically be explained by secular trends over the 3-year period such as engagement in clinical care and associated programs. Yet, food prices have increased 50% in recent years in Uganda, suggesting higher, rather than lower, vulnerability to food insecurity.64 In addition, in our sample, less than 1% of participants were receiving governmental or nongovernmental food aid either at baseline or during follow-up, suggesting that increased access to food aid is unlikely to account for the observed trends. Second, while there were no differences between included and excluded individuals in terms of our key outcomes of interest, we can not rule out that attrition from the cohort by some of the sickest and most food-insecure participants may have biased our findings away from the null. Third, assessment of mediation with the analytic strategy used in our analysis is subject to the assumptions that: (1) there is no unmeasured confounding, including confounding of the relationship between the mediator and the outcome when conditioning on the mediator, (2) the direction of causality is from physical health status to food insecurity as discussed above, and (3) there is no correlation of measurement errors for food insecurity and physical status, both of which were measured by self-report. If people who over-report food insecurity also over-report difficulties with physical health, this could bias our estimate of the extent to which improved physical health mediates the observed trends in food insecurity away from the null.65–67 In addition, the small sample size may make it more difficult to fully assess mediation in this study.
In conclusion, we found that among HIV-infected individuals in rural Uganda, food insecurity declined and nutritional status improved continuously subsequent to initiation of ART. Changes in food insecurity, but not nutritional status, were largely explained by improvements in physical health status. Because food insecurity is associated with worse HIV health outcomes and increased risk of HIV transmission, our data further bolster the rationale for early initiation of ART in resource-poor settings coupled with measures to improve food and nutrition security.
The authors thank the Uganda AIDS Rural Treatment Outcomes study participants who made this study possible by sharing their experiences; Annet Kembabazi for providing study coordination and administrative support; and Doreen Akello, Marcy Mutumba, Christine Ngabirano, Ruth Ssentongo, and Florence Turyashemererwa for research assistance. They also thank Dr Nozmo Mukiibi, Dr Jude K. Senkungu, and Dr Jessica Haberer for providing invaluable input on all aspects of study design and implementation; and Abbey Hatcher, Maureen Forsythe, and Dr Saskia de Pee, for critical comments on the manuscript. Although these individuals are acknowledged for their assistance, no endorsement of manuscript contents or conclusions should be inferred.
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