Search tips
Search criteria 


Logo of jgimedspringer.comThis journalToc AlertsSubmit OnlineOpen Choice
J Gen Intern Med. 2013 January; 28(1): 91–98.
Published online 2012 August 18. doi:  10.1007/s11606-012-2176-4
PMCID: PMC3539018

Food Insecurity Is Associated with Greater Acute Care Utilization among HIV-Infected Homeless and Marginally Housed Individuals in San Francisco



Food insecurity, or the uncertain availability of nutritionally adequate, safe foods, has been associated with poor HIV outcomes. There are few data on the extent to which food insecurity impacts patterns of health-care utilization among HIV-infected individuals.


We examined whether food insecurity was associated with hospitalizations, Emergency Department (ED) visits, and non-ED outpatient visits.


HIV-infected, homeless and marginally housed individuals participating in the San Francisco Research on Access to Care in the Homeless (REACH) cohort underwent quarterly structured interviews and blood draws. We measured food insecurity with the validated Household Food Insecurity Access Scale, and categorized participants as food secure, mild/moderately food insecure, and severely food insecure. Primary outcomes were: (1) any hospitalizations, (2) any ED visits, and (3) any non-ED outpatient visits. Generalized estimating equations were used to estimate model parameters, adjusting for socio-demographic (age, sex, ethnicity, education, income, housing status, health insurance) and clinical variables (CD4 nadir, time on antiretroviral therapy, depression, and illicit drug use).


Beginning in November 2007, 347 persons were followed for a median of 2 years. Fifty-six percent of participants were food insecure at enrollment. Compared with food-secure persons, those with severe food insecurity had increased odds of hospitalizations [adjusted odds ratio (AOR) = 2.16, 95 % confidence interval (CI) = 1.50–3.09] and ED visits (AOR = 1.71, 95 % CI = 1.06–2.30). While the odds of an outpatient visit were 41 % higher for severely food insecure individuals, the effect was not statistically significant (AOR = 1.41, 95 % CI = 0.99–2.01). Mild/moderate food insecurity was also associated with increased hospitalizations (AOR = 1.56, 95 % CI = 1.06–2.30), ED visits (AOR = 1.57, 95 % CI = 1.22–2.03), and outpatient visits (AOR = 1.68, 95 % CI = 1.20–2.17).


Food insecurity is associated with increased health services utilization among homeless and marginally housed HIV-infected individuals in San Francisco. Increased ED visits and hospitalizations are not related to fewer ambulatory care visits among food-insecure individuals. Addressing food insecurity should be a critical component of HIV treatment programs and may reduce reliance on acute care utilization.


The introduction of antiretroviral therapy (ART) has led to substantial decreases in morbidity and mortality among HIV-infected individuals1,2 with a concomitant decline in the use of acute health-care services. Longitudinal studies have shown downward trends in both hospitalizations and emergency department (ED) visits after initiation of ART.35 Gains in health, longevity, and reductions in acute care usage, however, have not been uniform across all population groups in the US. Among HIV-infected individuals, women,69 injection drug users,7,8,10 and racial/ethnic minorities8,11,12 account disproportionately for morbidity and suboptimal health-care utilization patterns. Socioeconomic marginalization, in the form of unmet subsistence needs, may drive the acute care usage seen in these sub-populations.13,14

Food insecurity, the limited availability of nutritionally adequate or safe food, or the inability to procure food in socially acceptable ways,15 is an important form of socioeconomic marginalization. In the general population, food insecurity has been associated with many adverse health impacts, including poor nutritional status,1621 depression,2226 suicidal ideation,26 obesity,27 and increased cardiovascular risk.28,29 Cross-sectional studies among non-HIV infected individuals in the US found that food insecurity is associated with postponing needed medications and care, increased emergency department use, and increased hospitalizations.30,31 In cross-sectional studies among HIV-infected individuals in the US and Canada, food insecurity has been associated with decreased immunologic and virologic responses,3235 and worse mental health, even when controlling for other markers of socioeconomic status such as income, education, and employment.3537 Qualitative and cross-sectional quantitative studies in resource-rich and resource-poor countries have found food insecurity is an important cause of ART non-adherence and treatment interruptions.32,34,38 A few longitudinal studies have reported negative health impacts of food insecurity among HIV-infected individuals, including worse physical health status and increased opportunistic infections in Uganda, lower CD4 counts in a study in the Boston area, and higher risk of mortality in British Columbia.3941

There is little understanding of how food insecurity impacts patterns of health-care utilization among HIV-infected individuals, particularly in resource-rich countries without universal health care such as the US. Such understanding is critical because use of health services reflects both population-level morbidity and overall costs to the health-care system. We undertook a longitudinal study in an urban area in the US to examine the association of food insecurity and health-care utilization patterns among homeless and marginally housed, HIV-infected individuals. We hypothesized that food insecurity would be associated with hospitalizations and ED visits. Given that use of outpatient services is both a product of need for services (which food insecurity could theoretically increase) and the ability to get services when needed (which food insecurity could theoretically decrease), we also set out to understand whether and how food insecurity was associated with utilization of non-ED outpatient care services.


Participants were from the Research on Access to Care in the Homeless (REACH) study, a cohort of HIV-infected homeless and marginally housed adults in San Francisco recruited using probability sampling from homeless shelters, free meal programs, and single room occupancy hotels charging less than $600/month, as previously described.42,43 REACH participants received quarterly blood draws and structured interviews. All participants signed a written consent form at the onset of the study and were reimbursed $15 per interview. Between August 2007 and March 2010, we administered the Household Food Insecurity Access Scale (HFIAS) as part of the REACH study. The UCSF Human Subjects Committee approved all study procedures.


Primary Independent Variable

To measure recent food security, we used the Household Food Insecurity Access Scale (HFIAS), version 1, January 2006, previously adapted for use in homeless and marginally housed individuals.35 The HFIAS was initially developed by Food and Nutrition Technical Assistance (FANTA) project based on validation studies in eight countries including the US.44,45 Validation studies have demonstrated that the HFIAS distinguishes food-secure from -insecure individuals or households across different cultural contexts. The questions cover three domains of the experience of food insecurity: (1) anxiety and uncertainty about food supply, (2) insufficient quality and variety of food, and (3) insufficient food intake and its physical consequences.46 Possible responses for each question were never, rarely, sometimes, and often; these were coded as 0, 1, 2, and 3, respectively. Scores range from 0 to 27; higher scores reflect more severe food insecurity. The internal consistency of this measure was high in our sample, with a Cronbach’s alpha of 0.94.35

Primary Outcomes

Health-care utilization in the previous 3 months was measured by participant self-report and included the following outcomes: (1) any hospitalizations, (2) any ED visits, and (3) any outpatient or non-ED ambulatory visits (defined as any visit with a nurse, doctor, or other health-care provider for a physical health problem or preventative health care). We selected covariates for the study based on prior literature and theory,35,4750 and included age (continuous), sex (male/female), race/ethnicity (African American versus Latino versus other), income (≥ versus < sample median), education (≥ versus < high school diploma), health insurance status (insured/uninsured), recent homelessness (sleeping on the street or shelter in past 3 months), illicit drug use (including cocaine, heroin, and methamphetamine) over the past 3 months (yes versus no), nadir CD4 count (continuous -100 cells/μl), and months on ART at baseline of analysis (continuous). We defined risky drinking as greater than an average of 14 drinks/week for men and 7 drinks/week for women in accordance with definitions by the National Institute of Alcohol Abuse and Alcoholism.51 Depression was assessed using the Beck’s Depression Inventory (BDI) version II as a continuous variable, which has been shown to be a reliable and valid measurement of depression in different populations.5255


We categorized individuals as food secure, mildly/moderately food insecure, or severely food insecure, based on a standardized algorithm of the HFIAS scale within the FANTA guide that is dependent upon the specific questions that are answered affirmatively. We used generalized estimating equations to determine factors associated with hospitalizations, ED visits, and outpatient visits controlling for possible socio-demographic and clinical confounders. For each outcome, all factors associated with our outcomes of interest with a p  0.2 in bivariate analysis were included in multivariate models, which then were reduced using backward elimination with a p-value of 0.05 for retention of covariates. These models included both time-invariant covariates (e.g., age at baseline, ethnicity, high school education) and time-varying variables (e.g., food insecurity, substance use, depression). Because we were interested in the association between recent food insecurity in relation to recent patterns of health care utilization, we examined associations over time between food insecurity and health-care utilization patterns reported at the same study visit. Regression diagnostic procedures yielded no evidence of multi-collinearity or overly influential outliers in any model. We conducted two additional sensitivity analyses where we excluded those who (1) were currently homeless or (2) had ever been homeless from our models to better understand whether housing status modifies associations between food insecurity and hospitalization and ED visits.


A total of 347 participants were included in our analysis. The sample was predominately male (71.3 %), with a median age of 48 years (Table 1). More than half of participants were food insecure, and 31.4 % were severely food insecure. The median monthly income was $918, 70.0 % of participants had completed high school, and most (93.4 %) had some form of health insurance (only 1.4 % with private insurance and the remainder having Medicaid/Medicare or Veterans Administration insurance). Only a small proportion of the sample had experienced recent homelessness, with 9.2 % having slept on the street or having been in a homeless shelter in the prior 3 months. While 72.0 % of participants had received some form of food aid at baseline [food aid from a church, clinic, soup kitchen, food bank, Supplemental Nutrition Assistance Programs (SNAP), or other sources], only 17.6 % had received SNAP over the previous year, and only 9.8 % had received SNAP over the previous month.

Table 1
Descriptive Characteristics

Nearly one-quarter of participants (23.3 %) reported an ED visit in the 3 months prior to the baseline interview for this analysis, and 10.7 % reported a hospitalization. Only 5.2 % of participants reported risky drinking, and more than one third of the sample (34.0 %) reported recent illicit drug use. The median CD4 nadir was 180 [interquartile range (IQR) = 75–312], and a majority of participants had been on ART for over 3 years (median length of ART = 44 months; IQR = 17–89). The median BDI score was 11 (IQR = 4–19); depression, as measured by a standard BDI cutoff of >13, was prevalent (29.6 %).

Relationship Between Food Insecurity and Recent Hospitalizations

Both mild/moderate and severe food insecurity were significantly associated with hospitalizations in the prior 3 months in both unadjusted and adjusted analyses (Table 2). Compared to individuals who were food secure, the odds of recent hospitalization were one and a half times higher among individuals who were mildly or moderately food insecure [adjusted odds ratio (AOR) = 1.56, 95 % confidence interval (CI) = 1.06–2.30] and twice as high among individuals who were severely food insecure (AOR = 2.16, 95 % CI = 1.50–3.09) in adjusted analyses. In addition to food insecurity, individuals who had higher BDI scores or lower CD4 nadirs had significantly higher odds of hospitalizations in adjusted analysis.

Table 2
Factors Associated with Recent Acute Health-Care Utilization among HIV-infected, Marginally Housed Individuals, N = 347

Relationship Between Food Insecurity and ED Visits

Individuals with mild/moderate or severe food insecurity had higher odds of recent ED visits (Table 2) in both unadjusted and adjusted models. In adjusted models, individuals who were mildly moderately food insecure had more than 50 % higher odds of ED use (AOR = 1.57, 95 % CI = 1.22–2.03) and individuals who were severely food insecure had 71 % higher odds of ED use (AOR = 1.71, 95 % CI = 1.30–2.25). Additional factors associated with ED visits in adjusted analyses included recent homelessness, illicit drug use, higher BDI scores, and lower CD4 nadir cell counts.

The results of our sensitivity analyses, where we excluded homeless individuals, were similar for both ED use and hospitalizations. For both outcomes, excluding subjects who were ever homeless or those who were currently homelessness led to a slight reduction in the adjusted odds ratios for food insecurity. The odds ratios for food insecurity remained statistically significant for both outcomes, however, and were not qualitatively different from those in the original multivariate models.

Relationship Between Food Insecurity and Outpatient Visits

Individuals who were mildly or moderately food insecure had higher odds of having had a recent outpatient visit (AOR = 1.64, 95 % CI = 1.17–2.29). The increased odds of outpatient visits among individuals who were severely food insecure were similar, but smaller (AOR = 1.41, 95 % CI = 0.99–2.01) and not statistically significant (Table 3). Men and those who were uninsured had lower odds of outpatient visits, and people with more education and more years on ARVs had higher odds of outpatient visits.

Table 3
Factors Associated with Recent Outpatient Visits among HIV-Infected, Marginally Housed Individuals, N = 347


This was the first study to our knowledge using a longitudinal design to examine associations between food insecurity and patterns of health-care utilization in a resource-rich country, the first among HIV-infected individuals, and the first among homeless and marginally housed individuals. We found that food insecurity was associated with utilization of both acute and non-ED ambulatory health-care services. These results add to the growing body of literature documenting negative health impacts of food insecurity, particularly for groups that are already socioeconomically marginalized. These findings may be helpful to guide development of interventions to improve HIV-related health outcomes and reduce acute care utilization.

Food insecurity was experienced by more than half of individuals within this cohort of homeless and marginally housed HIV-infected persons, consistent with estimates from other North American studies with similar populations.15,34,56 Many of the same factors that predispose individuals to food insecurity—including poverty, mental illness, and substance use—also put them at risk for HIV infection50 and predict poor overall health among HIV-infected adults.57 The prevalence of food insecurity among HIV-infected homeless and marginally housed individuals is higher than that seen in a nationally representative sample of non-HIV-infected homeless persons, where the prevalence is estimated at 25 %–32 %,30 and higher than the prevalence of food insecurity in the general US population, which is estimated to be 15 %.58

The odds of recent hospitalization increased with increasing severity of food insecurity, even when accounting for potential confounders including measures of socioeconomic status. Both severe and mild/moderate food insecurity were also associated with higher odds of ED visits, but the effect was most pronounced with severe food insecurity. Our findings that link food insecurity to acute care use are supported by previous literature. In previous cross-sectional studies among the general US population, food insecurity was independently associated with increased medical and psychiatric hospitalizations and ED use.30,31 While the context and contributors to health-care utilization are quite different in resource-rich and resource-poor countries, in a recent study in rural Uganda, severe food insecurity (but not mild/moderate food insecurity) was associated with an increased number of hospitalizations among HIV-infected individuals on ART.40 This is consistent with studies showing that impacts of food insecurity on HIV-related health outcomes, including immunologic and virologic outcomes, physical health status, and other measures of morbidity, are quite similar in resource-rich and resource-poor countries.33,34,3941,59 Such consistency across different settings suggests that food insecurity is a robust and seemingly universal predictor of worse outcomes, which may contribute to the increased need for acute care services.

Other studies have shown that competing subsistence needs are associated with acute health-care utilization among HIV-infected individuals in the US,60 but did not focus specifically on food security. Previous studies consistently demonstrated a linear relationship between the degree of housing instability and increased acute care use.61,62 Our study further supports this literature by showing that individuals who lived on the street or in a homeless shelter had higher odds of recent ED visits. The high prevalence of ED visits among homeless and marginally housed HIV-infected persons seen in this study is also consistent with previous research.10,63 While most US cohorts have shown a steady decline in acute care usage as ART regimens improve and people initiate treatment with higher CD4 counts,5 the ongoing high rate of acute care utilization in our study highlights that marginalized HIV-infected populations have not realized the same gains in overall health as the general HIV-infected population in the US.8,64

While we found that mild/moderate food insecurity was associated with increased outpatient care, severe food insecurity had a non-significant relationship with the same outcome. This finding is consistent with previous studies indicating mixed results. One study among low-income adults across the US found that food insecurity was associated with postponing needed medical care and medications, but was not associated with prior year outpatient care utilization.31 In related literature, housing instability shows no consistent relationship with increased or reduced ambulatory visits.61,6567 These inconsistent findings may be explained by the fact that outpatient clinic visits are the product of the need for care (which is likely increased by food insecurity) and ability to obtain care when needed (which is likely decreased by food insecurity). While available data preclude a definitive conclusion, the predominant mechanism by which mild/moderate food insecurity impacted outpatient care in the current study may have been via worsening morbidity rather than a compromised ability to access to health care. Since our study defined outpatient care broadly (including scheduled and unscheduled primary care, non-ED urgent care, nurse visits, specialist visits), future studies should separate these out in order to help unpack these mechanisms and help us understand whether food insecurity differentially impacts access to scheduled and unscheduled visits.

Previous studies have also shown adverse impacts of food insecurity on morbidity, mortality, and quality of life among HIV-infected individuals.14,3234,39,41 Interventions are needed to address food insecurity and its negative impacts on the health and health-care utilization patterns of HIV-infected individuals. Related interventions that address other subsistence needs have shown promise in improving health-care use and treatment outcomes. For example, providing interim or supportive housing has been shown to strengthen engagement in HIV care, lead to fewer hospitalizations, and improve HIV treatment outcomes.6873 For non-HIV infected populations, federally funded food assistance programs (e.g., the Supplemental Nutrition Assistance Program and Special Supplemental Nutrition Program for Women, Infants, and Children) have been shown to have a protective effect on pregnancy outcomes among women,74,75 birthweight outcomes for infants,76 and nutritional outcomes for young children.77,78 Limited research has examined health-care utilization among program participants.79 Several studies in the general population have found equivocal80,81 or detrimental82 health outcomes associated with program participation; these studies are difficult to interpret because selection bias was probably not at all or only partially controlled.

Despite the high prevalence of food insecurity found in this study, fewer than 10 % of participants were receiving SNAP benefits at baseline, which is consistent with UDSA findings that only a portion (72 %) of eligible persons83 or food-insecure households (41 %)84 access SNAP. This uptake gap among study participants may be partly due to income limits, since a single-person household is eligible for SNAP only if they earn less than $ 1,080 monthly, including social security. As the median monthly income in our cohort is $ 918 (IQR $ 859–980), it is likely that a number of our food-insecure participants were ineligible. This echoes findings that federal poverty levels are set too low as a measure of what it means to be poor in the US today,85 particularly in metropolitan areas where the cost of living is high. It is also possible that participants in this cohort were unable to access a computer to complete the online application, which became necessary when SNAP moved program enrollment online in lieu of caseworkers.86 Overall, our findings suggest that access to and use of SNAP benefits is inadequate among HIV-infected homeless and marginally housed individuals. It is crucial to better link vulnerable HIV-infected persons to SNAP and other food assistance programs. More work is also needed to understand the extent to which enrollment in available food aid programs alleviates food insecurity among HIV-infected populations.

Among HIV-infected individuals, small studies 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,59,87 but few studies to date have evaluated food-insecurity interventions among HIV-infected individuals in North America. Such studies using the best possible designs are critical to better understand the impacts that can be gained by addressing food insecurity, to determine which food insecurity interventions are most effective, and to inform the integration of food security and HIV care and treatment programs.

There were several limitations to our study. Several key variables, including food security and health-care utilization, were measured through self-report, which may introduce bias. While we controlled for demographic, socioeconomic, and clinical variables, it is possible that unobserved confounders may explain some of the associations reported. For example, factors related to food insecurity such as household size, household expenditures, and non-monetary resources may influence whether clients seek care in outpatient clinics vs. emergency departments. In addition, mental illnesses other than depression may confound associations between food insecurity and patterns of health-care utilization. Randomized intervention studies are needed to fully understand the causal relationships among food insecurity, HIV-related morbidity, and patterns of health-care utilization; such studies are difficult to carry out in practice because of ethical concerns about withholding food support for a group identified to be in need.

In summary, we found a longitudinal association between food insecurity and increased utilization of acute and ambulatory health services among impoverished HIV-infected individuals in the US. Addressing food insecurity may reduce morbidity among HIV-infected individuals and lead to a reduction in the high utilization of expensive health services over the long term.


This publication was made possible by grant no. UL1 RR024131 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the NCRR or the NIH. Information on NCRR is available at http:///


We thank the collaborating researchers including Kathleen McCartney, Richard Clark, Greg Barnell, John Day, Nelia Dela Cruz, Minoo Gorji, Scot Hammond, Jackie Haslam, Zizi Hawthorne, Jay Jankowski, Rhonda Johnson, Mac McMaster, Sandra Monk, Rebecca Packard, Joyce Powell, Kathleen Ragland, Mathew Reynolds, Paul Rueckhaus, Jacqueline So, John Weeks and Kelly Winslow.


NIMH 54907, 79713-01; CHRP ID08-SF-054; UCSF Academic Senate; Hurlbut-Johnson funds from AIDS Research Institute award, UCSF, no. 557858-8-148. The authors acknowledge the following additional sources of salary support: the Burke Family Foundation and the Hellman Family Foundation (to Dr. Weiser), and K24 MH-87227 (to Dr. Bangsberg).

Conflict of Interest

The authors declare that they do not have a conflict of interest.


Please address all requests for reprints to the corresponding author.


1. Hogg RS, O'Shaughnessy MV, Gataric N, et al. Decline in deaths from AIDS due to new antiretrovirals. Lancet. 1997;349(9061):1294. doi: 10.1016/S0140-6736(05)62505-6. [PubMed] [Cross Ref]
2. Hogg RS, Heath KV, Yip B, et al. Improved survival among HIV-infected individuals following initiation of antiretroviral therapy. JAMA. 1998;279(6):450–4. doi: 10.1001/jama.279.6.450. [PubMed] [Cross Ref]
3. Buchacz K, Baker RK, Moorman AC, et al. Rates of hospitalizations and associated diagnoses in a large multisite cohort of HIV patients in the United States, 1994–2005. AIDS. 2008;22(11):1345–54. doi: 10.1097/QAD.0b013e328304b38b. [PubMed] [Cross Ref]
4. Hellinger FJ. The changing pattern of hospital care for persons living with HIV: 2000 through 2004. J Acquir Immune Defic Syndr. 2007;45(2):239–46. doi: 10.1097/QAI.0b013e3180517407. [PubMed] [Cross Ref]
5. Yehia BR, Fleishman JA, Hicks PL, Ridore M, Moore RD, Gebo KA. Inpatient health services utilization among HIV-infected adult patients in care 2002–2007. J Acquir Immune Defic Syndr. 2010;53(3):397–404. doi: 10.1097/QAI.0b013e3181bcdc16. [PMC free article] [PubMed] [Cross Ref]
6. Floris-Moore M, Lo Y, Klein RS, et al. Gender and hospitalization patterns among HIV-infected drug users before and after the availability of highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2003;34(3):331–7. doi: 10.1097/00126334-200311010-00012. [PubMed] [Cross Ref]
7. Fleishman JA, Gebo KA, Reilly ED, et al. Hospital and outpatient health services utilization among HIV-infected adults in care 2000–2002. Med Care. 2005;43(9 Suppl):III40–52. [PubMed]
8. Gebo KA, Fleishman JA, Conviser R, et al. Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001. J Acquir Immune Defic Syndr. 2005;38(1):96–103. doi: 10.1097/00126334-200501010-00017. [PubMed] [Cross Ref]
9. Sohler NL, Li X, Cunningham CO. Gender disparities in HIV health care utilization among the severely disadvantaged: can we determine the reasons? AIDS Patient Care STDS. 2009;23(9):775–83. doi: 10.1089/apc.2009.0041. [PMC free article] [PubMed] [Cross Ref]
10. Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in the care of HIV-infected adults in the United States: results from the HIV cost and services utilization study. Jama. 1999;281(24):2305–15. doi: 10.1001/jama.281.24.2305. [PubMed] [Cross Ref]
11. Losina E, Schackman BR, Sadownik SN, et al. Racial and sex disparities in life expectancy losses among HIV-infected persons in the united states: impact of risk behavior, late initiation, and early discontinuation of antiretroviral therapy. Clin Infect Dis. 2009;49(10):1570–8. doi: 10.1086/644772. [PMC free article] [PubMed] [Cross Ref]
12. Meditz AL, MaWhinney S, Allshouse A, et al. Sex, race, and geographic region influence clinical outcomes following primary HIV-1 infection. J Infect Dis. 2011;203(4):442–51. doi: 10.1093/infdis/jiq085. [PMC free article] [PubMed] [Cross Ref]
13. Nosyk B, Li X, Sun H, Anis AH. The effect of homelessness on hospitalisation among patients with HIV/AIDS. AIDS Care. 2007;19(4):546–53. doi: 10.1080/09540120701235669. [PubMed] [Cross Ref]
14. Riley ED, Neilands TB, Moore K, Cohen J, Bangsberg DR, Havlir D. Social, structural and behavioral determinants of overall health status in a cohort of homeless and unstably housed HIV-infected Men. PLoS One. 2012;7(4):e35207. doi: 10.1371/journal.pone.0035207. [PMC free article] [PubMed] [Cross Ref]
15. Normen L, Chan K, Braitstein P, et al. Food insecurity and hunger are prevalent among HIV-positive individuals in British Columbia, Canada. J Nutr. 2005;135(4):820–5. [PubMed]
16. Rose D, Oliveira V. Nutrient intakes of individuals from food-insufficient households in the United States. Am J Public Health. 1997;87(12):1956–61. doi: 10.2105/AJPH.87.12.1956. [PubMed] [Cross Ref]
17. Rose D. Economic determinants and dietary consequences of food insecurity in the United States. J Nutr. 1999;129(2 S Suppl):517S–20. [PubMed]
18. Lee JS, Frongillo EA., Jr Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. J Nutr. 2001;131(5):1503–9. [PubMed]
19. Dixon LB, Winkleby MA, Radimer KL. Dietary intakes and serum nutrients differ between adults from food-insufficient and food-sufficient families: third national health and nutrition examination survey, 1988–1994. J Nutr. 2001;131(4):1232–46. [PubMed]
20. Kirkpatrick SI, Tarasuk V. Food insecurity is associated with nutrient inadequacies among Canadian adults and adolescents. J Nutr. 2008;138(3):604–12. [PubMed]
21. Campa A, Yang Z, Lai S, et al. HIV-related wasting in HIV-infected drug users in the era of highly active antiretroviral therapy. Clin Infect Dis. 2005;41(8):1179–85. doi: 10.1086/444499. [PubMed] [Cross Ref]
22. Weaver LJ, Hadley C. Moving beyond hunger and nutrition: a systematic review of the evidence linking food insecurity and mental health in developing countries. Ecol Food Nutr. 2009;48(4):263–84. doi: 10.1080/03670240903001167. [PubMed] [Cross Ref]
23. Maes KC, Hadley C, Tesfaye F, Shifferaw S. Food insecurity and mental health: Surprising trends among community health volunteers in Addis Ababa, Ethiopia during the 2008 food crisis. Soc Sci Med. Feb 12 2010. [PMC free article] [PubMed]
24. Kim K, Frongillo EA. Participation in food assistance programs modifies the relation of food insecurity with weight and depression in elders. J Nutr. 2007;137(4):1005–10. [PubMed]
25. Heflin CM, Siefert K, Williams DR. Food insufficiency and women’s mental health: findings from a 3-year panel of welfare recipients. Soc Sci Med. 2005;61(9):1971–82. doi: 10.1016/j.socscimed.2005.04.014. [PubMed] [Cross Ref]
26. Alaimo K, Olson CM, Frongillo EA. Family food insufficiency, but not low family income, is positively associated with dysthymia and suicide symptoms in adolescents. J Nutr. 2002;132(4):719–25. [PubMed]
27. Dinour LM, Bergen D, Yeh MC. The food insecurity-obesity paradox: a review of the literature and the role food stamps may play. J Am Diet Assoc. 2007;107(11):1952–61. doi: 10.1016/j.jada.2007.08.006. [PubMed] [Cross Ref]
28. Seligman HK, Laraia BA, Kushel MB. Food insecurity is associated with chronic disease among low-income NHANES participants. J Nutr. 2010;140(2):304–10. doi: 10.3945/jn.109.112573. [PubMed] [Cross Ref]
29. Seligman HK, Bindman AB, Vittinghoff E, Kanaya AM, Kushel MB. Food insecurity is associated with diabetes mellitus: results from the national health examination and nutrition examination survey (NHANES) 1999–2002. J Gen Intern Med. 2007;22(7):1018–23. doi: 10.1007/s11606-007-0192-6. [PMC free article] [PubMed] [Cross Ref]
30. Baggett TP, Singer DE, Rao SR, O'Connell JJ, Bharel M, Rigotti NA. Food insufficiency and health services utilization in a national sample of homeless adults. J Gen Intern Med. 2011;26(6):627–34. doi: 10.1007/s11606-011-1638-4. [PMC free article] [PubMed] [Cross Ref]
31. Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. 2006;21(1):71–7. doi: 10.1111/j.1525-1497.2005.00278.x. [PMC free article] [PubMed] [Cross Ref]
32. Kalichman SC, Cherry C, Amaral C, 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. doi: 10.1007/s11524-010-9446-4. [PMC free article] [PubMed] [Cross Ref]
33. Wang EA, McGinnis KA, Fiellin DA, 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. doi: 10.1007/s11606-011-1723-8. [PMC free article] [PubMed] [Cross Ref]
34. Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. Food insecurity is associated with incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San Francisco. J Gen Intern Med. 2009;24(1):14–20. doi: 10.1007/s11606-008-0824-5. [PMC free article] [PubMed] [Cross Ref]
35. Weiser SD, Bangsberg DR, Kegeles S, Ragland K, Kushel MB, Frongillo EA. Food insecurity among homeless and marginally housed individuals living with HIV/AIDS in San Francisco. AIDS Behav. 2009;13(5):841–8. doi: 10.1007/s10461-009-9597-z. [PMC free article] [PubMed] [Cross Ref]
36. Anema A, Weiser SD, Fernandes KA, Brandson EK, Montaner JS, Hogg RS. High prevalence of food insecurity among HIV-infected individuals receiving HAART in a resource-rich setting. AIDS Care. 2010 (In Press). [PubMed]
37. Vogenthaler NS, Hadley C, Rodriguez AE, Valverde EE, Del Rio C, Metsch LR. Depressive symptoms and food insufficiency among HIV-Infected crack users in Atlanta and Miami. AIDS Behav. Jan 23 2010. [PMC free article] [PubMed]
38. Weiser SD, Tuller DM, Frongillo EA, Senkungu J, Mukiibi N, Bangsberg DR. Food insecurity as a barrier to sustained antiretroviral therapy adherence in Uganda. PLoS One. 2010;5(4):e10340. doi: 10.1371/journal.pone.0010340. [PMC free article] [PubMed] [Cross Ref]
39. Weiser SD, Fernandes KA, Brandson EK, et al. The association between food insecurity and mortality among HIV-infected individuals on HAART. J Acquir Immune Defic Syndr. 2009;52(3):342–9. doi: 10.1097/QAI.0b013e3181b627c2. [PMC free article] [PubMed] [Cross Ref]
40. Weiser SD, Tsai AC, Gupta R, et al. Food insecurity is associated with morbidity and patterns of healthcare utilization among HIV-infected individuals in a resource-poor setting. AIDS. 2012;26(1):67–75. doi: 10.1097/QAD.0b013e32834cad37. [PMC free article] [PubMed] [Cross Ref]
41. McMahon JH, Wanke CA, Elliott JH, Skinner S, Tang AM. Repeated assessments of food security predict CD4 change in the setting of antiretroviral therapy. J Acquir Immune Defic Syndr. 2011;58(1):60–3. doi: 10.1097/QAI.0b013e318227f8dd. [PMC free article] [PubMed] [Cross Ref]
42. Robertson MJ, Clark RA, Charlebois ED, et al. HIV seroprevalence among homeless and marginally housed adults in San Francisco. Am J Public Health. 2004;94(7):1207–17. doi: 10.2105/AJPH.94.7.1207. [PubMed] [Cross Ref]
43. Zolopa AR, Hahn JA, Gorter R, et al. HIV and tuberculosis infection in San Francisco’s homeless adults. Prevalence and risk factors in a representative sample. JAMA. 1994;272(6):455–61. doi: 10.1001/jama.1994.03520060055032. [PubMed] [Cross Ref]
44. Swindale A, Bilinsky P. Development of a universally applicable household food insecurity measurement tool: process, current status, and outstanding issues. J Nutr. 2006;136(5):1449S–52. [PubMed]
45. Frongillo EA, Nanama S. Development and validation of an experience-based measure of household food insecurity within and across seasons in Northern Burkina Faso. J Nutr. 2006;136(5):1409S–19. [PubMed]
46. Coates J, Swindale A, Bilinsky P. Household food insecurity access scale (HFIAS) for measurement of food access: indicator guide. Washington, DC: Food and Nutrition Technical Assistance. Academy for Educational Development; 2006.
47. Gelberg L, Andersen RM, Leake BD. The behavioral model for vulnerable populations: application to medical care use and outcomes for homeless people. Health Serv Res. 2000;34(6):1273–302. [PMC free article] [PubMed]
48. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1–10. doi: 10.2307/2137284. [PubMed] [Cross Ref]
49. Weiser SD, Young SL, Cohen CR, et al. Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS. Am J Clin Nutr. 2011;94(6):1729S–39. doi: 10.3945/ajcn.111.012070. [PubMed] [Cross Ref]
50. Anema A, Vogenthaler N, Frongillo EA, Kadiyala S, Weiser SD. Food insecurity and HIV/AIDS: current knowledge, gaps, and research priorities. Curr HIV/AIDS Rep. 2009;6(4):224–31. doi: 10.1007/s11904-009-0030-z. [PubMed] [Cross Ref]
51. National Institute on Alcohol Abuse and Alcoholism. The Physician’s Guide to Helping Patients with Alcohol Problems. 1995.
52. Beck A, Steer R, Garbin M. Psychometric properties of the beck depression inventory: twenty-five years of evaluation. Clin Psychol Rev. 1988;8:77–100. doi: 10.1016/0272-7358(88)90050-5. [Cross Ref]
53. Riley ED, Bangsberg DR, Perry S, Clark RA, Moss AR, Wu AW. Reliability and validity of the SF-36 in HIV-infected homeless and marginally housed individuals. Qual Life Res. 2003;12(8):1051–8. doi: 10.1023/A:1026166021386. [PubMed] [Cross Ref]
54. Storch EA, Roberti JW, Roth DA. Factor structure, concurrent validity, and internal consistency of the beck depression inventory-second edition in a sample of college students. Depress Anxiety. 2004;19(3):187–9. doi: 10.1002/da.20002. [PubMed] [Cross Ref]
55. Weiser SD, Riley ED, Ragland K, Hammer G, Clark R, Bangsberg DR. Brief report: factors associated with depression among homeless and marginally housed HIV-infected men in San Francisco. J Gen Intern Med. 2006;21(1):61–4. doi: 10.1111/j.1525-1497.2005.0282.x. [PMC free article] [PubMed] [Cross Ref]
56. Anema A, Weiser SD, Fernandes KA, et al. High prevalence of food insecurity among HIV-infected individuals receiving HAART in a resource-rich setting. AIDS Care. 2011;23(2):221–30. doi: 10.1080/09540121.2010.498908. [PubMed] [Cross Ref]
57. Riley ED, Moore K, Sorensen JL, Tulsky JP, Bangsberg DR, Neilands TB. Basic subsistence needs and overall health among human immunodeficiency virus-infected homeless and unstably housed women. Am J Epidemiol. 2011;174(5):515–22. doi: 10.1093/aje/kwr209. [PMC free article] [PubMed] [Cross Ref]
58. Nord M, Coleman-Jensen A, Andrews M, Carlson S.Household food security in the United States, 2009. Washington DC: United States Department of Agriculture (USDA);2010.
59. Ivers LC, Chang Y, Gregory Jerome J, Freedberg KA. 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 Res Ther. 2010;7:33. doi: 10.1186/1742-6405-7-33. [PMC free article] [PubMed] [Cross Ref]
60. Cunningham WE, Andersen RM, Katz MH, et al. The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States. Med Care. 1999;37(12):1270–81. doi: 10.1097/00005650-199912000-00010. [PubMed] [Cross Ref]
61. Kim TW, Kertesz SG, Horton NJ, Tibbetts N, Samet JH. Episodic homelessness and health care utilization in a prospective cohort of HIV-infected persons with alcohol problems. BMC Health Serv Res. 2006;6:19. doi: 10.1186/1472-6963-6-19. [PMC free article] [PubMed] [Cross Ref]
62. Reid KW, Vittinghoff E, Kushel MB. Association between the level of housing instability, economic standing and health care access: a meta-regression. J Health Care Poor Underserved. 2008;19(4):1212–28. doi: 10.1353/hpu.0.0068. [PubMed] [Cross Ref]
63. Knowlton AR, Latkin CA, Schroeder JR, Hoover DR, Ensminger M, Celentano DD. Longitudinal predictors of depressive symptoms among low income injection drug users. AIDS Care. 2001;13(5):549–59. doi: 10.1080/09540120120063197. [PubMed] [Cross Ref]
64. Betz ME, Gebo KA, Barber E, et al. Patterns of diagnoses in hospital admissions in a multistate cohort of HIV-positive adults in 2001. Med Care. Sep 2005;43(9 Suppl):III3–14. [PubMed]
65. Arno PS, Bonuck KA, Green J, et al. The impact of housing status on health care utilization among persons with HIV disease. J Health Care Poor Underserved. 1996;7(1):36–49. doi: 10.1353/hpu.2010.0013. [PubMed] [Cross Ref]
66. Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health. 1997;87(2):217–20. doi: 10.2105/AJPH.87.2.217. [PubMed] [Cross Ref]
67. Katz MH, Cunningham WE, Fleishman JA, et al. Effect of case management on unmet needs and utilization of medical care and medications among HIV-infected persons. Ann Intern Med. 2001;135(8 Pt 1):557–65. [PubMed]
68. Cunningham CO, Sohler NL, Wong MD, et al. Utilization of health care services in hard-to-reach marginalized HIV-infected individuals. AIDS Patient Care STDS. 2007;21(3):177–86. doi: 10.1089/apc.2006.103. [PubMed] [Cross Ref]
69. Aidala A, Cross JE, Stall R, Harre D, Sumartojo E. Housing status and HIV risk behaviors: implications for prevention and policy. AIDS Behav. 2005;9(3):251–65. doi: 10.1007/s10461-005-9000-7. [PubMed] [Cross Ref]
70. Leaver CA, Bargh G, Dunn JR, Hwang SW. The effects of housing status on health-related outcomes in people living with HIV: a systematic review of the literature. AIDS Behav. 2007;11(6 Suppl):85–100. doi: 10.1007/s10461-007-9246-3. [PubMed] [Cross Ref]
71. Kessell ER, Bhatia R, Bamberger JD, Kushel MB. Public health care utilization in a cohort of homeless adult applicants to a supportive housing program. J Urban Health. 2006;83(5):860–73. doi: 10.1007/s11524-006-9083-0. [PMC free article] [PubMed] [Cross Ref]
72. Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006;96(7):1278–81. doi: 10.2105/AJPH.2005.067850. [PubMed] [Cross Ref]
73. Kushel MB, Colfax G, Ragland K, Heineman A, Palacio H, Bangsberg DR. Case management is associated with improved antiretroviral adherence and CD4+ cell counts in homeless and marginally housed individuals with HIV infection. Clin Infect Dis. 2006;43(2):234–42. doi: 10.1086/505212. [PubMed] [Cross Ref]
74. El-Bastawissi AY, Peters R, Sasseen K, Bell T, Manolopoulos R. Effect of the Washington special supplemental nutrition program for women, infants and children (WIC) on pregnancy outcomes. Matern Child Health J. 2007;11(6):611–21. doi: 10.1007/s10995-007-0212-5. [PubMed] [Cross Ref]
75. Pehrsson PR, Moser-Veillon PB, Sims LS, Suitor CW, Russek-Cohen E. Postpartum iron status in nonlactating participants and nonparticipants in the special supplemental nutrition program for women, infants, and children. Am J Clin Nutr. 2001;73(1):86–92. [PubMed]
76. Kowaleski-Jones L, Duncan GJ. Effects of participation in the WIC program on birthweight: evidence from the national longitudinal survey of youth. Special supplemental nutrition program for women, infants, and children. Am J Public Health. 2002;92(5):799–804. doi: 10.2105/AJPH.92.5.799. [PubMed] [Cross Ref]
77. Black MM, Cutts DB, Frank DA, et al. Special supplemental nutrition program for women, infants, and children participation and infants’ growth and health: a multisite surveillance study. Pediatrics. 2004;114(1):169–76. doi: 10.1542/peds.114.1.169. [PubMed] [Cross Ref]
78. Rose D, Habicht JP, Devaney B. Household participation in the Food Stamp and WIC programs increases the nutrient intakes of preschool children. J Nutr. 1998;128(3):548–55. [PubMed]
79. Nicholas LH. Can food stamps help to reduce medicare spending on diabetes? Econ Hum Biol. 2011;9(1):1–13. doi: 10.1016/j.ehb.2010.10.003. [PMC free article] [PubMed] [Cross Ref]
80. Hamilton WL, Lin BH. Effects of food assistance and nutrition programs on nutrition and health: Volume 3, Literature Review. Food Assistance and Nutrition Research Reports. 2004.
81. Foster EM, Jiang M, Gibson-Davis CM. The effect of the WIC program on the health of newborns. Health Serv Res. 2010;45(4):1083–104. doi: 10.1111/j.1475-6773.2010.01115.x. [PMC free article] [PubMed] [Cross Ref]
82. Leung CW, Willett WC, Ding EL. Low-income supplemental nutrition assistance program participation is related to adiposity and metabolic risk factors. Am J Clin Nutr. 2012;95(1):17–24. doi: 10.3945/ajcn.111.012294. [PubMed] [Cross Ref]
83. USDA. Trends in Supplemental Nutrition Assistance Program participation rates: Fiscal Years 2002–2009 2011; Accessed 9 June, 2012.
84. Coleman-Jensen A, Nord M, Andrews M, Carlson S.Household food security in the United States, 2010. Washington DC: United States Department of Agriculture (USDA);2011.
85. Fremstad S.A Modern Framework for Measuring Poverty and Basic Economic Security. Washington, DC: Center for Economic and Policy Research;2010.
86. Heflin CM, Mueser P.Assessing the Impact of a Modernized ApplicationProcess on Florida’s Food Stamp Caseload. Lexington: University of Kentucky Center for PovertyResearch;2010.
87. Cantrell RA, Sinkala M, Megazinni K, et al. A pilot study of food supplementation to improve adherence to antiretroviral therapy among food-insecure adults in Lusaka, Zambia. J Acquir Immune Defic Syndr. 2008;49(2):190–5. doi: 10.1097/QAI.0b013e31818455d2. [PMC free article] [PubMed] [Cross Ref]

Articles from Journal of General Internal Medicine are provided here courtesy of Society of General Internal Medicine