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
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
more than 50% of HIV-infected people are estimated to be food insecure
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
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
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:
– 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
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
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
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.”