CNS: Food insecurity robs good outcome of quality HIV care

If people living with HIV (PLHIV) are food insecure, then we alarmingly lose the desired good outcomes of quality HIV treatment and care. This was powerfully articulated and backed by evidence in the session of Dr Christine Wanke, Director, Division of Nutrition and Infection, Tufts University School of Medicine in Boston, USA. She was speaking at the recently concluded Chennai ART Symposium (CART 2011).

CART 2011 was organized in Chennai, India (8-9 January 2011) by Y.R. Gaitonde Centre for AIDS Research and Education (YRG CARE), in collaboration with Centre for AIDS Research (CFAR), Brown University, National Institute of Health (NIH), University of California (San Diego), Karolinska Institute, and HIV Medicine Association of India (HIVMAI).

Food insecurity among PLHIV worsens viral suppression and lowers CD4 count, thereby, exacerbating HIV related morbidity and mortality, said Dr Wanke. She explained in details the cross-cutting issues and how it impacts HIV treatment and care outcomes if food security is undermined.

Food insecurity might present in different forms in different people which may include macronutrient and micronutrient deficiencies, ART interactions, obesity, lipodystrophy, range of mental health concerns, and more importantly, behavioural outcomes that can adversely impact ART adherence, missed clinic visits and treatment interruptions. If so, then no wonder with food insecurity, HIV treatment and care outcomes will be seriously compromised.

According to a study done by Hopers Foundation (Sahai Trust) in Chennai, India, much more severe food insecurity was found in PLHIV when compared to HIV negative population in the same communities. Up to two fold food insecurity was found in HIV positive injecting-drug-users (IDUs) when compared to food insecurity faced by HIV negative population in same vicinity.

Not just Chennai study outcomes but many other studies done in other countries also present similar data – where food insecurity is found to be high in HIV positive people. For instance, in a study done among HIV positive and HIV negative IDUs in Viet Nam, 5% of them who were HIV positive were food insecure, compared to 2% of HIV negative IDUs who were food insecure.

Another important fact Dr Wanke stated was that there is no correlation between body mass index (BMI) and food security. In a study done in Kenya, BMI was similar in four groups, but food security was different, said Dr Wanke.

In a study done on HIV positive women in Nairobi, Kenya, 25% women reported that they have not eaten for an entire day due to lack of food and 27% women reported that they have gone to bed hungry at night.

Most striking was the study outcome that one out of eight reasons given by women living with HIV for not willing to take the antiretroviral therapy (ART) was that they weren’t sure about getting enough food – so apprehending food insecurity, they denied getting on an available therapy that would have possibly given them a heightened quality of life and longevity.

Dr Wanke also outlined many direct benefits of food security on a population – not associated with HIV directly – but surely impacting HIV programme performance in a positive manner. For instance, providing food security to a population, decreases risk behaviours among at-risk population. Making communities food secure delays HIV progression. Making communities food secure is also directly linked to the willingness observed in communities to access care services and initiate ART. Another outcome of making PLHIV food secure is improved CD4 count as a result of ART.

Not surprisingly, low body mass index (BMI) is a strong independent predictor of early mortality (within first 12 months) in people on ART treatment.

Dr Wanke highlighted a best practice example of making communities food secure in Chennai, India. Y.R. Gaitonde Centre for AIDS Research and Education (YRG CARE) has initiated YRG Community Kitchen Project which has effectively engaged 32 women in nutritional education and livelihood generation having a profound positive impact on self esteem of these women as well as general well being for the women and their children if any. Each woman manages a cart called Eco-Kitchen Cart provided by YRG CARE and together they serve 1,800 meals a day.

“Female partners or members of injecting drug users (IDU) didn’t have enough food, their children didn’t have enough food, children were not getting education and male members were using alcohol to further exacerbate the problems. Such women who were earlier not even earning Rupee one are now earning Rs 200 – 300 a day from their Eco-Kitchen Cart” said Dr Suniti Solomon, founder-Director of YRG CARE and patron of CART 2011.

Due to YRG Community Kitchen Project, health of these women and their children has improved considerably and children are going to school – this indeed is a very positive outcome of this support programme.

Optimizing nutritional status in HIV has more benefits than meets the eye. Beyond the obvious nutritional benefits there are many non-nutritional benefits as discussed above. It is all the more vital to not ignore food security because HIV programmes are dealing with very vulnerable populations who may not have access to essential nutrients on a daily basis. Dietary intake should consist of macro- and micro- nutrients, and dietary quality and diversity is also key.

“What we need to remember is that nutritional status cannot be measured by weight alone” said Dr Wanke. Weight doesn’t necessarily mean that the individual is food secure as dietary intake doesn’t imply the individual is food secure. Being food secure also doesn’t necessarily mean that the individual has normal nutritional status.

For nutritional assessment among PLHIV, total dietary intake should be recalled in the past 24 hours – everything that went in the mouth. Otherwise the assessment will not reflect a true scenario.

Dr Wanke recommended a DataBase ‘DIGEST’ produced by the National Institute of Nutrition (NIN) in India to enquire calorific content of different food items.

Inadequate caloric intake by PLHIV may also manifest in malabsorption or diarrhoea.

Another important fact to remember is that the metabolism in PLHIV is altered as the person is likely to be dealing with HIV and associated conditions like opportunistic infections (OIs), malignancies, hormonal insufficiencies among others.

An ongoing debate is around the fact on what is the reason for the weight loss in PLHIV – is it the food insecurity or is it increased energy demand in PLHIV due to altered metabolism, probably both!

Food insecurity is measured at three levels: household, individual and community levels.

At the household level, lack of access for all members at all times to enough food in order to lead active, healthy life, is food insecurity.

At the individual level, inability to meet food needs at all times in socially acceptable ways is defined as food insecurity.

And at the community level, disruption of crop production, food delivery or food marketing in areas of high HIV prevalence are some indicators to define food insecurity.

According to a study done by S Weiser et al 2010, food insecurity impacts HIV acquisition via vertical or horizontal transmission.

For instance, as a direct outcome of food insecurity, people deal with compromised gut and mucosal integrity, micro- and macro- nutrient deficiencies, and at times may also be forced to opt for risky infant feeding and practices.

There are implications on mental health too of food insecurity like anxiety, depression, drug or alcohol use – which may heighten the risk of HIV acquisition for an individual.

Food insecurity adversely impacts the behaviour and incidence of unprotected sex, sex exchange incidents, labour migration or needle sharing among IDUs goes up. Also food insecurity has adverse impact on gender-based inequalities that put people at a greater risk.

Are we probably on the same square where we started from? Advancing from basic or primary healthcare to highly specialized and issue-focussed care over the past years have taught us what we lost over time - the synergy between different programmes.

Food for thought is: integration. What will an ideal collaborative health service look like? And how should we effectively implement it without any further delay? Synergy between programmes addressing HIV, TB, diabetes, food security, livelihood, housing, hygiene and sanitation, and a range of other health and development related issues is long over-due.