To our knowledge, this is the first study to determine whether food insecurity is associated with increased morbidity, missed clinic visits, and increased hospitalizations among HIV-positive adults accessing ART in a resource-limited setting. This is also the first study in any setting to examine these relationships longitudinally. We found that a majority of adults accessing ART in rural Uganda were food insecure, and that food insecurity was associated with increased markers of morbidity in longitudinal analyses. Food insecurity also negatively impacted patterns of healthcare utilization as a result of competing demands between food needs and healthcare needs.
Our findings on the associations between food insecurity and HIV-related morbidity are supported by previous cross-sectional research linking food insecurity with worse physical and mental health status [14
], lower CD4 cell counts [9
], lower ART adherence [9
], and reduced viral load suppression [9
]. They are also supported by findings from a longitudinal study in Vancouver that found that food insecurity was associated with mortality among ART-treated individuals after controlling for clinical and socioeconomic variables [17
In this study, the relationships observed among food insecurity, socioeconomic status, and patterns of healthcare utilization reflect the fact that accessing healthcare (either primary care or acute care services) is the product of both need and means; that is, an observed hospitalization results when one has the need for acute healthcare and has the means to pay for it. Consistent with this, we found in concurrent models that severe food insecurity was associated with number of hospitalizations, and that mild and moderate food insecurity were associated with missed clinic visits. Declining physical health status likely outweighed the financial constraints to accessing healthcare and need for hospitalizations for severely food-insecure individuals. This interpretation is supported by the lagged models in which individuals who were severely food insecure were significantly less likely to miss outpatient clinic visits. The increased risk of hospitalization seen among severely food-insecure individuals may also be a consequence of missed clinic visits and failure-to-receive necessary medical treatment among those with mid-to-moderate food insecurity. Greater asset wealth was also associated with an increased number of hospitalizations in concurrent models and with decreased odds of missed clinic visits in lagged models, possibly because individuals with greater resources were better able to access hospitalizations and outpatient care when needed. Addressing food insecurity will not only help reduce the need for hospitalization by increasing outpatient care utilization and decreasing morbidity, but may also help reduce overall costs of healthcare if individuals are accessing health services at earlier stages of illness.
Consistent with previous research [11
], participants in our study grappled with trade-offs between subsistence needs and healthcare needs, and as a result forewent hospitalizations, clinic visits and ART in order to procure food. Even more striking was the extent to which participants in this study gave up adequate food for themselves or their families in order to access healthcare. This suggests that the negative impact of food insecurity on patterns of healthcare utilization may become even more pronounced over the long term, when these tradeoffs are no longer sustainable, and when HIV comes to be appreciated as a chronic, manageable condition in Uganda. The strong links between food insecurity and HIV/AIDS morbidity and access to care have important policy implications. Poverty, deteriorating infrastructure, and inadequate capacity for service provision in many parts of sub-Saharan Africa are tied to the dual epidemics of HIV/AIDS and food security. Although governments have invested in ART provision, less funding has directly targeted the building blocks underlying ART success, including improved food insecurity. Moreover, policies surrounding food security in the region have been primarily focused on increasing food self-sufficiency at an aggregate national level rather than increasing food security at the household level. This policy stance leads to less resource allocation for the poor, and can hinder the political and institutional reforms necessary to achieve food security in the longer run [36
To improve food insecurity and hence health outcomes among PLWHA, WHO, UNAIDS, and the World Food Programme have recommended integrating sustainable food production strategies into HIV/AIDS programming [37
]. Yet, the most effective strategy for improving food security among PLWHA has yet to be elucidated. Several small studies in developing countries have demonstrated the potential for macronutrient supplementation to improve health outcomes among PLWHA [39
]. Macronutrient supplementation provides critical nutritional support, but does not address all of the downstream health consequences of food insecurity and also causes dependency on health programs [40
]. Moreover, relying on health programs for food may be socially unacceptable, or may contribute to ongoing anxiety and uncertainty about food supply. Other solutions for improving food security that have been discussed in the literature include income transfers for food, micro-credit interventions, and livelihood interventions [6
]. These may better address some of the root causes of food insecurity, and hence may have a better chance of improving health outcomes. One small study in rural Kenya showed that a microirrigation water pump combined with a microfinance loan led to increases in crop yields, household income, BMI, and CD4 cell counts [41
]. Further research is critical to provide empirical evidence to guide policies to integrate structural interventions into the expansion of HIV care, treatment, and prevention programs.
There are several limitations to our study. Many of our measures (including those related to our key outcomes and predictors) were self-reported, which can result in correlated measurement errors that introduce bias. There were few participants who fell into the ‘mildly food insecure’ category, which may limit our ability to draw conclusions about this group. Although we controlled for many relevant demographic, socioeconomic, and clinical variables, unobserved confounders may explain some of the associations detected. Our longitudinal design and analysis with both concurrent and lagged models provided some strength in understanding the causal direction and in mitigating the effects of unobserved variables. Nevertheless, randomized intervention studies are needed to fully understand the causal relationships among food insecurity, HIV-related morbidity, and patterns of healthcare utilization and the impacts that can be gained by addressing food insecurity.
In summary, we found that food insecurity is highly prevalent among PLWHA accessing ART in rural Uganda and that it is associated with HIV-related morbidity, increased hospitalizations and decreased utilization of outpatient care services as a result of competing demands for resources. Our findings support the need for food insecurity interventions as an integral component of HIV programs serving impoverished populations [38
]. Interventions should aim to address upstream causes of food insecurity, rather than the downstream consequences, in order to interrupt the vicious cycle of food insecurity and HIV/AIDS and contribute to improved health-related quality of life, access to healthcare, and decreased morbidity and mortality among PLWHA.