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).
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.
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.
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