Food assistance improved ART adherence, retention in care, in Haiti

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Providing food assistance to people living with HIV in a comprehensive HIV programme in Haiti, where the quality and quantity of food is poor, improved adherence and weight gain as well as clinic attendance, Louise C Ivers and colleagues reported in a prospective observational cohort study published in the August 26 online edition of AIDS Research and Therapy.

The health and well-being of people living with HIV In resource-poor settings is closely linked to food insecurity and being under nourished. HIV has long been associated with wasting syndrome. Evidence shows that being underweight, even in people on antiretrovirals, is predictive of a poor prognosis.

Both food insecurity (understood “as lack of access to food of sufficient quality and quantity to perform usual daily acitivities”) and HIV infection can, note the authors, make going to school, the ability to work and provide for the family, and adherence particularly difficult.

Glossary

body mass index (BMI)

Body mass index, or BMI, is a measure of body size. It combines a person's weight with their height. The BMI gives an idea of whether a person has the correct weight for their height. Many BMI calculators can be found on the internet.

p-value

The result of a statistical test which tells us whether the results of a study are likely to be due to chance and would not be confirmed if the study was repeated. All p-values are between 0 and 1; the most reliable studies have p-values very close to 0. A p-value of 0.001 means that there is a 1 in 1000 probability that the results are due to chance and do not reflect a real difference. A p-value of 0.05 means there is a 1 in 20 probability that the results are due to chance. When a p-value is 0.05 or below, the result is considered to be ‘statistically significant’. Confidence intervals give similar information to p-values but are easier to interpret. 

observational study

A study design in which patients receive routine clinical care and researchers record the outcome. Observational studies can provide useful information but are considered less reliable than experimental studies such as randomised controlled trials. Some examples of observational studies are cohort studies and case-control studies.

prospective study

A type of longitudinal study in which people join the study and information is then collected on them for several weeks, months or years. 

anxiety

A feeling of unease, such as worry or fear, which can be mild or severe.

While international programmes support the integration of food assistance into HIV programmes, evidence-based guidelines on how and who to target are lacking.

The qualitative benefit of food to relieve hunger is not in question. The authors note that, to date, no study has shown the improved quantitative benefits - including improved clinical outcomes - from food assistance.

Haiti, because of poverty, recurring natural disasters and political instability, is especially vulnerable to food insecurity.

The authors chose to look at how targeted food assistance would affect the body mass index (BMI), quality of life and household food security of people living with HIV, in a comprehensive HIV programme at three clinic sites (rural, urban and semi-urban) in Haiti, run by Partners in Health (PIH).

PIH, working in collaboration with the Ministry of Health, is a non-profit organisation providing comprehensive primary healthcare services, including HIV care, in rural Haiti. 

In 2006, PIH in collaboration with the World Food Programme (WFP) provided food rations to people living with HIV. Criteria for eligibility for receipt of monthly food rations included: co-infection with tuberculosis; a body mass index under 18.5kg/m2 CD4 cell count under 350/mm3 in the previous three months; or severe socioeconomic conditions based on a social work assessment and clinical team consensus.

Between May and July 2006, the authors undertook a prospective observational cohort study of 600 people living with HIV and enrolled in HIV care in Partners in Health (PIH) programmes. Three hundred participants were eligible for food assistance, and 300 ineligible, based on the criteria outlined above.

The monthly standard predetermined WFP family ration provided by prescription contained 50 gm of cereal, 50 gm of dried legumes, 25 gm of vegetable oil, 100 gm of corn-soya blend and 5 gm of iodized salt for each of three family members (approximately 949 calories), per person per day.

At six and 12 months, 488 and 340 subjects respectively, were eligible for analysis. The researchers focussed their analysis on those who remained in the food programme from the start, compared to those who were never eligible for food assistance, to see clearly the effect of food rations.

At six months, food security improved significantly in those who received food assistance, compared to those who did not. On a scale ranging from 0 (best) to 20 (worst), in those receiving food and those not the scores were -3.55 compared to -0.16 (p<0.0001) respectively.

At six months BMI decreased in both groups, but less so in the group receiving food (-0.20 compared to -0.66, p=0.012). The decrease, the authors suggest, is explained because this took place during the “lean season” when food supply is generally scarce.

At 12 months, food assistance was linked to improved food security (-3.49 compared to -1.89, p=0.011). BMI increased in those getting food assistance, but decreased in those not (0.22 compared to -0.67, p=0.036).

The authors highlight that the WFP-distributed rations are considered family support and not specifically for people living with HIV. The rations provide approximately 45% of the daily calorific requirement for a family of three; the authors note in this study that the median number of people eating in each household was six.

Nonetheless, the authors stress food that assistance was “protective against weight loss in the short-term and associated with weight-gain in the long-term for individuals with HIV”.

The authors note tha,t in line with national statistics, 72% of study participants spent almost all their income on food, with a high mean baseline food insecurity (14.6 on a scale of 0 to 20). 

The study supported other findings where in addition to relief from anxiety of getting food those getting food assistance showed significant improvements in general health, nutrition and health services usage.

Studies in Canada have shown food insecurity is associated with an increased risk of mortality as well as incomplete viral suppression in people with HIV, note the authors. In San Francisco in non-HIV infected individuals food insecurity has been associated with anxiety, depression as well as postponing needed medical care, they add. And, recently in Haiti food insecurity has been associated with childhood malaria.  

Food assistance was linked to improved adherence to monthly clinic visits at both six and 12 months. At six months out of six visits the mean attendance was 5.49 compared to 2.82 , p<0.0001 for those getting assistance compared to those not, and at 12 months out of 12 visits was 9.73 compared to 8.34, p=0.007.

The authors note that while attendance at baseline was good food assistance played an important role in keeping those HIV-infected individuals with food security issues engaged in care.

Additionally, food assistance made it easier to take antiretrovirals. A full stomach eliminated nausea. Competing demands between getting food and other necessities were also eliminated. The authors stress the importance of this finding that supports high levels of adherence and the positive long-term implications for people living with HIV.

Limitations, according to the authors include the observational nature of the study meant that the subjects were not randomly selected and multivariate analysis will have controlled only for those measured differences between the groups.

The authors conclude that food assistance was associated with improved food security, increased body mass index and improved adherence to clinic visits at six and 12 months among people living with HIV in Haiti and should be the standard of care in regions where HIV and food insecurity overlap.

References

Ivers LC et al. Food assistance is associated with improved body mass index, food security and attendance at clinic in an HIV program in central Haiti: a prospective observational cohort study. AIDS Research and Therapy 7:33, 2010.