Uganda: Food insecurity decreases after starting ART

Food insecurity significantly decreased over time, and nutritional status improved, in adults starting antiretroviral treatment (ART) in Uganda, researchers report in the advance online edition of the Journal of Acquired Immune Deficiency Syndromes.

In this prospective cohort of 228 HIV-positive adults newly starting ART, recruited from the Uganda AIDS Rural Treatment Outcomes (UARTO) study and followed for up to three years, improvements in physical health status partly explained observed trends in food insecurity but not in nutritional status.

These findings, the authors state, have important consequences for food-insecurity programmes as well as for policies on starting ART early in resource-poor settings.

In sub-Saharan Africa – where more than 50% of HIV-infected people are estimated to be food insecure – the epidemics of HIV and food insecurity are inextricably linked in a downward cycle: food insecurity increases the vulnerability to HIV, worsening the severity of that condition, and vice versa.

Food insecurity may lead to behaviours putting people at increased risk for HIV infection. Among HIV-infected individuals, food insecurity has been linked to increased risk of HIV-related death and disease, including reduced adherence to ART and poorer virologic and immunological responses.

HIV-related death and disease can devastate families economically, increasing caregiver burden and so worsening food insecurity. Stigma of HIV infection individuals may make finding work more difficult, inhibit a reliance on social networks when food is scarce, or make getting a loan to help out in times of poverty and food insecurity harder.

ART has significantly reduced HIV-related death and disease and so may affect the overlap of these two epidemics, the authors note. 

While there is evidence of considerable improvement in nutritional status on ART, results are inconsistent. The authors theorise that improved physical health status should lead to better functioning and economic productivity, so leading to improved food security and nutritional status. However, they note that the negative effect of HIV on social relationships may still adversely affect food security after starting ART.

Noting that scant data exist, in any setting, on how starting ART affects food insecurity and nutritional and physical health status, the authors chose to undertake a longitudinal study to address this gap.

Participants were recruited from the UARTO study, a prospective cohort of HIV-positive people starting ART free of charge at the Mbarara Regional Referral Hospital Immune Suppression Syndrome (ISS) Clinic in Mbarara, Uganda.

All individuals starting ART from August 2007, when measures of food insecurity were added to the UARTO survey instrument, were included in the analysis.  Participants were followed until November 2010.

Every three months, participants were assessed using structured interviews, anthropometric measurements (body mass index and mid-upper-arm circumference, or MUAC) for nutritional status, and bloods taken for viral load and CD4 cell count.

Time on ART was the primary explanatory variable and household food insecurity the primary outcome; nutritional and physical health status were two additional outcomes.

Analyses were adjusted for potential confounding by clinical and socio-demographic characteristics measured at baseline.

Methods included looking at whether food insecurity could be explained by changes in physical health status; whether changes in social support potentially explained changes in food insecurity; and examining whether changes in food insecurity and or physical health status explained changes in nutritional status.

Out of a total of 257 participants, six died and eight were lost to follow-up. Of the remaining participants, 228 were included in the analysis: eight died and 28 were lost to follow-up. After starting ART, participants were monitored from three months to three years with a median follow-up time of 1.8 years.

Over 70% were female. The mean CD4 count at baseline was 185.1 cells/mm³ and the median CD4 count at the start of ART was 161 cells/mm³. At baseline, 43% (97) were categorised as severely food insecure.

The significant and progressive declines in food insecurity over time – from six months (b=-1.7; 95% CI: -2.8-0.6) and ending with the final quarter or 36 months (b=6.5; 95% CI: -10.4-2.7) – are of critical importance in HIV-infected populations where food insecurity is highly prevalent. After one year on ART, only 36 participants remained severely food insecure.

These findings suggest ART may be able to reverse some of the negative trends in food insecurity, note the authors. They add that these results are consistent with recent work in India showing that, after two years of starting ART, employment rates and income improved considerably; a study in Kenya showed that, within six months of starting ART, the likelihood of being employed increased by 20%, with a 35% increase in hours worked.

As in other studies, nutritional status improved – but this is not true of all populations and settings; weight loss and wasting may persist after starting ART.

While the mechanisms underlying these changes in food insecurity are not clear, the authors note their findings are in line with those of a qualitative study in Uganda suggesting adherence to ART may result in decreased food insecurity because of improved physical health and the ability to work.

Given the substantial decreases in food insecurity and improvements in nutritional status after starting ART, “programmes aimed at decreasing food insecurity among HIV-infected individuals should consider earlier initiation of ART as part of their strategy”.

These findings also support a study from Malawi where children getting prompt ART after an outpatient therapeutic feeding programme had better nutritional recovery than those children who did not get prompt ART.

The authors caution that interpretation of these findings does not mean that ART alone can ensure adequate food and nutrition for HIV-positive people. In many settings, they add, “interventions to improve food security and nutritional support are urgently needed regardless of timing of ART initiation”.

These findings lend further support to policymakers and programme developers’ claims that food and nutritional support are most critical at the start of ART, when health status is fragile and getting back to and staying in work at its most challenging.

“The optimal strategy to simultaneously reduce HIV/AIDS morbidity and improve food security likely involves better integration of programmes aimed to reduce food insecurity with HIV/AIDS treatment programmes.”

Limitations of the study include the fact that there was no comparison group with individuals not on ART. While there were no differences between included and excluded individuals regarding key outcomes, loss of the sickest and most food-insecure may lend bias.

In addition to the limitations of the small sample size, food insecurity and physical health were measured by self-report. The potential for over-reporting may have biased the estimate of the extent of improved physical health and observed trends in food insecurity.

The authors conclude: “Since food insecurity is associated with worse HIV health outcomes and increased risk of HIV transmission, our data further bolster the rationale for early initiation of ART in resource-poor settings coupled with measures to improve food and nutrition security.”

Weiser SD et al. Changes in food insecurity, nutritional status, and physical health status after antiretroviral initiation in rural Uganda.  J Acquir Immune Defic Syndr, advance online edition, doi: 10.1097/QAI.0b013e318261f064, 2012.