A program for people living with HIV that provides healthy food and nutritional advice led to fewer hospital admissions, better treatment adherence and improvements in mental and physical health, according to study results published in the Journal of Infectious Diseases.
“Medically tailored meals and groceries, combined with nutrition education, reduced hospitalizations, improved mental health and medication adherence, and reduced unprotected sex among people with HIV who are at high risk for food insecurity,” the study authors concluded. “These findings underscore the promise of [tailored food programs] to improve multiple domains of health care for people living with HIV and reduce health care costs through lower health care utilization.”
That is known a nutritious diet is a key to good health, but many people have little knowledge about good nutrition and limited access to affordable healthy food. Inconsistent access to healthy food is recognized as a key factor in poor health among people living with HIV, and support for a ‘food is medicine’ approach is growing.
Food assistance for people with HIV in the United States consists of “an interlocking patchwork” of government assistance, including the Supplemental Nutrition Assistance Program (“food stamps”) and the Ryan White HIV/AIDS program, nonprofit organizations, and community-based programs such as food banks and church soup kitchens, Kartika Palar, PhD, of the University of California San Francisco, and colleagues cited as background information.
“Traditional safety net approaches to nutrition aim to prevent hunger and reduce economic hardship, but sometimes have unintended consequences that undermine health, such as providing foods high in salt or sugar,” they wrote. The ‘food is medicine’ approach, on the other hand, “has the potential to achieve two goals, namely improving food security and health.”
Previous studies have linked food insecurity in wealthy countries to high rates of depression, anxiety and other mental health problems, increased risk of HIV and other sexually transmitted infections (STDs), poorer adherence to antiretroviral treatments, higher viral loads, lower CD4 counts cells and increased mortality. But there were previously no randomized trials of medically tailored feeding programs for HIV-positive people.
The Palar team conducted a survey to evaluate results among existing customers Project Open Hand, a San Francisco-based nonprofit that provides food assistance to people with chronic diseases. The CHEFS-HIV study (NCT03191253), conducted from 2016 to 2017, included almost 200 low-income people living with HIV. The study compared 93 clients who were randomly assigned to participate in a special food program and 98 who received standard food services.
Most participants were middle-aged men (median age 55 years) and had lived with HIV for an average of 22 years. About a third were white, a quarter were black and about 10% were Latino. At baseline, 39% had uncontrolled HIV, higher than the citywide proportion. Many had comorbidities, including diabetes, hypertension and cardiovascular disease; mental health and substance use diagnoses were common. The average income was about $1,000 per month, and more than 60% reported food insecurity. Participants required the ability to store and reheat perishable food, which likely excluded some unsheltered homeless people.
People in the intervention group received medically appropriate meals and groceries tailored to support their health (fourteen ready-to-eat frozen meals or seven meals and groceries per week) plus an extra bag of groceries to meet their nutritional needs. They also participated in three group nutrition classes led by a registered dietitian and two individual nutrition counseling sessions. Those in the control group received the standard weekly allocation of meals and groceries (enough for one or two meals a day) and had a short consultation with a dietitian every six months. Food could be delivered if customers were unable to pick it up. Health, nutritional and behavioral outcomes were assessed at baseline and six months later.
After six months, almost 90% of participants in both groups remained in the study. People in the intervention group reported less food insecurity and consumed less fatty foods, although there was no difference in reported fruit and vegetable consumption. People who participated in the program were 89% less likely to be hospitalized, and the researchers estimated that the intervention could have reduced hospitalization costs by $178,781. People who received improved food services were also less likely to report depression, unprotected sex, and medication adherence below 90%. Virus suppression rates improved in both groups, with no significant difference between groups. Despite these favorable results, there was no significant difference in reported health-related quality of life.
“The six-month CHEFS-HIV intervention, combined with an intensive community-based program of [medically tailored meals and groceries] with registered dietitian-led nutrition education had no impact on HIV suppression or health-related quality of life,” the study authors concluded. “However, it improved food security and [antiretroviral therapy] adherence and reduced severity of depressive symptoms, unprotected sexual encounters, and overnight hospitalizations, compared with controls.”
The researchers speculated that the reduction in unprotected sex might have occurred because addressing food insecurity reduced the need to engage in transactional sex or succumb to the pressure to have unprotected sex to secure resources for food. “Medically tailored nutrition programs can thus contribute to public efforts to reduce STDs by reducing unprotected sex among individuals for whom food insecurity affects sexual decision-making,” they wrote.
The differences between the groups may have narrowed because both groups received meals and groceries, the researchers suggested. The effect would probably have been stronger if the intervention group was compared with people who did not receive food aid. Regarding viral suppression, a majority of participants in both groups had the HIV virus under control from the start, and that too in the city Getting to Zero initiative to improve viral suppression rates citywide began around the same time.
“While suppressed viral loads are critical to the health of people living with HIV and reducing HIV transmission, social factors associated with food insecurity are often major contributors to emergency room use, hospitalizations, and deaths in San Francisco,” the researchers wrote. “These factors may explain the reduced risk of hospitalization with the intervention, despite its lack of impact on virus suppression.”
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