The impact of food insecurity on HIV outcomes in Senegal, West Africa: a prospective longitudinal study

Abstract

Background: Understanding the impact of food insecurity on HIV outcomes is critical for the development and implementation of effective, evidence-based interventions to address food insecurity and improve the HIV care cascade. We conducted a prospective, longitudinal study to determine the impact of food insecurity on HIV outcomes in Senegal, West Africa.

Methods: HIV-infected individuals presenting for care and initiation of ART through the Senegalese National AIDS program in Dakar and Ziguinchor were eligible for enrollment. Data were collected using interviews, clinical evaluations, laboratory analyses, and chart review at enrollment, month 6, and month 12. Logistic regression was used to determine the association between food insecurity and HIV outcomes.

Results: Among the 207 participants in this study, 70% were female and the median age was 37 years. The majority (69%) were food insecure at enrollment, 29% were severely food insecure, and 38% were undernourished. Nearly a third (32%) had no formal education, 23% practiced agriculture, and 40% owned livestock. The median daily food expenditure per person was $0.58. The median round trip transportation time to clinic was 90 min (IQR 30-240). The median cost of transportation to clinic was $1.74. At month 12, 69% were food insecure, 23% were severely food insecure, and 14% were undernourished. At month 12, 43% had not disclosed their HIV status; food insecurity was associated with non-disclosure of HIV-status due to fear of stigmatization and feelings of shame. Severe food insecurity was a strong predictor of loss to follow-up (OR 3.13 [1.08-9.06]) and persistent severe food insecurity was associated with virologic failure (OR 5.14 [1.01-26.29]) and poor adherence to ART 8.00 [1.11-57.57]. Poor nutritional status was associated with poor immunologic recovery (OR 4.24 [1.56-11.47]), virologic failure (OR 3.39 [1.13-10.21]), and death (OR 3.35 [1.40-8.03]).

Conclusion: Severity and duration of food insecurity are important factors in understanding the relationship between food insecurity and HIV outcomes. Our findings highlight the importance of nutritional status, socioeconomic opportunity, and self-stigmatization in the complex pathway between food insecurity and HIV outcomes. Interdisciplinary, multisectoral efforts are needed to develop and implement effective interventions to address food insecurity among people living with HIV.

Keywords: Adherence; Agriculture; Care cascade; Food insecurity; HIV/AIDS; Loss to follow-up; Nutrition; Senegal; Social determinants; Stigma; Virologic failure; West Africa.

Fig. 1

Food insecurity^a and nutritional status^b at enrollment, 6 months and 12 months among HIV-infected individuals in Senegal. ^aAmong 199 participants at M0, 127 at M6, and 113 at M12; ^bAmong 198 participants at M0, 123 at M6, and 104 at M12

Fig. 2

a Percent of HIV-infected individuals who were lost to follow-up (LTFU) within 12 months of starting ART, or reported poor adherence to ART, or experienced virologic failure (VF) at 12 months of ART according to food insecurity status. *OR for LTFU 3.13 [1.08–9.06] compared to not severely food insecure at enrollment. **OR for poor adherence 8.00 [1.11–57.57] compared to not severely food insecure at enrollment. ***OR for VF 5.14 [1.01–26.29] compared to not severely food insecure at enrollment. ^aN = 141 at baseline, 84 among those retained in care; ^bN = 58 at baseline,12 among those retained in care; ^cN = 5; ^dN = 8. b Percent of HIV-infected individuals who died within 12 months of initiating ART, or had CD4 cell counts < 200 following 12 months of ART, or experienced virologic failure (VF) at 12 months of ART according to nutritional status. *OR for DCD 3.35 [1.40–8.03] compared to not undernourished at enrollment. **OR for CD4 < 200 4.24 [1.56–11.47] compared to not undernourished at enrollment; ***OR for CD4 < 200: 5.84 [1.93–17.67] compared to not undernourished at M6. ^αOR for VF 3.39 [1.13–10.21] compared to not undernourished at enrollment; ^βOR for VF 7.41 [1.99–27.59] compared to not undernourished at M6; ^γOR for VF 4.14 [1.13–15.11] compared to not undernourished at M12. ^aN = 122 at baseline, 87 among those retained in care; ^bN = 76 at baseline, 44 among those retained in care; ^cN = 31; ^dN = 15

Fig. 3

Theoretical framework showing pathways by which food insecurity may impact HIV outcomes