Food insecurity and HIV clinical outcomes in a longitudinal study of urban homeless and marginally housed HIV-infected individuals

Background: Food insecurity is common among HIV-infected individuals and has been associated with poor health. Little longitudinal research has examined the association of food insecurity with HIV clinical outcomes, or the extent to which adherence mediates these associations. Design: Observational cohort study Methods: HIV-infected homeless and marginally housed individuals in the San Francisco Research on Access to Care in the Homeless cohort completed quarterly structured interviews and blood draws. We measured food insecurity using the validated Household Food Insecurity Access Scale. Primary outcomes were: antiretroviral therapy (ART) nonadherence (<90% adherence), incomplete HIV viral load suppression more than 100 copies/ml, and CD4 cell counts less than 200 cells/ml. We estimated model parameters using generalized estimating equations, adjusting for sociodemographic and clinical variables. Results: From May 2007 to March 2010, we followed 284 participants for a median of 22 months. At baseline 54.6% of participants were food-insecure. Food insecurity was associated with increased odds of ART nonadherence [adjusted odds ratio (AOR)=1.48; 95% confidence interval (CI), 1.19-1.85], incomplete viral load suppression (AOR=1.29, 95% CI 1.04-1.61), and CD4 cell counts less than 200 cells/ml (AOR=1.26, 95% CI 1.01-1.56). When we included ART adherence in adjusted models for incomplete viral suppression and CD4 cell counts less than 200 cells/ml, the magnitude of the effect decreased slightly. Conclusion: Food insecurity was associated with poor HIV outcomes, including nonadherence, in a longitudinal study of US-based HIV-infected unstably housed individuals. Efforts to address food insecurity should be included in HIV-treatment programs, and may help improve health outcomes.