Nutritional support has always been regarded as an important part of the long history of HIV prevention and control. However, the importance of a nutritious diet is often underestimated, especially for people living with HIV, where undernutrition and food insecurity are among the major challenges.
In recent years, with the in-depth research and practice of the concept of "food as medicine", a study led by Kartika Palar, Ph.D., of the University of California, San Francisco, has revealed how tailored food programs can significantly improve the health of people living with HIV, reduce hospitalizations, improve treatment adherence, and improve physical and mental health.
According to findings published in the Journal of Infectious Diseases, a program that provides healthy food and nutrition counseling to people living with HIV has reduced hospitalizations, increased treatment adherence, and improved physical and mental health.
"Medically tailored meals and groceries, coupled with nutrition education, reduce hospitalizations, improve mental health and medication adherence, and reduce unprotected sexual behavior among people living with HIV who are at high risk of food insecurity," the study's authors concluded. "These findings highlight the promise of [tailored food programs] in multiple areas of health for people living with HIV and to reduce health care costs by reducing health care utilization.
It's no secret that a nutritious diet is the key to good health, but many people have little knowledge about good nutrition and limited access to affordable healthy foods. Inconsistent access to healthy food has been identified as a key determinant of poor health for people living with HIV, and support for the "food as medicine" approach is increasing.
Kartika Palar, Ph.D., of the University of California, San Francisco, said that U.S. food support for people living with HIV includes a "patchwork" of government support, including the Supplemental Nutrition Assistance Program ("food stamps") and the Ryan White HIV/AIDS Program, nonprofit and community programs such as church food pantries and soup kitchens, and colleagues are documented as backgrounds.
"Traditional nutrition safety net approaches focus on preventing hunger and reducing economic hardship, but sometimes have unintended consequences that undermine health, such as providing foods high in salt or sugar," they wrote. In contrast, the "food as medicine" approach "has the potential to achieve the twin goals of improving food security and health".
Previous studies have linked food insecurity in rich countries to high rates of depression, anxiety and other mental health conditions, an increased risk of HIV and other sexually transmitted infections (STIs), poor adherence to antiretroviral therapy, increased viral load, lower CD4 cell counts, and increased mortality. But there have been no previous randomized trials of medically tailored food programs in HIV-positive people.
Palar's team conducted a study to evaluate the results of existing customers of Project Open Hand, a San Francisco-based nonprofit that provides food assistance to people with chronic conditions. The CHEFS-HIV trial (NCT03191253) conducted between 2016 and 2017 included nearly 200 low-income people living with HIV. The study compared 93 clients who were randomized to participate in a special food program and 98 clients who received standard food services.
Most of the participants were middle-aged men (median age 55 years), and their median age of HIV infection was 22 years. About one-third are white, a quarter are black, and about 10 percent are Latino. At baseline, 39 per cent were infected with uncontrolled HIV, higher than the citywide rate. Many have comorbidities, including diabetes, hypertension, and cardiovascular disease; Mental health diagnoses and substance use are common. The median income is about $1,000 per month, and more than 60% report food insecurity. Participants must have the ability to store and reheat perishable food, which may not include some homeless people.
People in the intervention group received medically appropriate meals and groceries (14 frozen prepared foods or 7 meals and groceries per week) and a bag of supplemental groceries tailored to support their health to meet their nutritional needs. They also attended three group nutrition education sessions and two individual nutrition counseling sessions led by a registered dietitian. People in the control group received standard meals and grocery distributions (enough for one to two meals a day) per week, with brief meetings with a dietitian every six months. If a customer can't pick up their food, it can be delivered. Health, nutrition, and behavioural outcomes were assessed at baseline and after six months.
At six months, nearly 90% of participants in both groups remained in the study. People in the intervention group reported lower levels of food insecurity and consumed less fatty foods, although there was no difference in reported fruit and vegetable consumption. Those who participated in the program were 89 percent less likely to be hospitalized, and the researchers estimated that the intervention could reduce hospital costs by $178,781.
People who received intensive food services were also less likely to report depression, unprotected sex, and treatment adherence below 90%. Viral suppression rates improved in both groups, with no significant difference between the two. Despite these favorable outcomes, there was no significant difference in reported health-related quality of life.
"The six-month CHEFS-HIV intervention, which combines an intensive community-based program (medically tailored meals and groceries) with registered dietitian-led nutrition education, does not affect HIV viral suppression or health-related quality of life," the study's authors concluded.
"However, it improved food security and adherence to [antiretroviral therapy] and reduced the severity of depressive symptoms, unprotected sexual contact and overnight hospitalization compared to the control group. The researchers speculate that the decrease in unprotected sex may be due to the fact that addressing food insecurity reduces the need to engage in transactional sex, or succumbing to the pressure to secure food resources through unprotected sex. "Therefore, medically tailored food programs may help reduce sexually transmitted infections by reducing unprotected sex among individuals whose food insecurity influences sexual decision-making," they wrote.
The researchers believe that the difference between the two groups may have been reduced because both groups received meals and groceries. The effect may be stronger if the intervention group is compared to those who did not receive food assistance. In terms of viral suppression, most participants in both groups controlled HIV at the outset, and the city's "zero discharge" initiative to increase citywide viral suppression began around the same time.
"While suppressing viral load is essential for the health of people living with HIV and reducing HIV transmission, the social factors associated with food insecurity ...... is often a significant contributor to emergency department use, hospitalizations, and deaths in San Francisco," the researchers wrote. "These factors could explain the reduced odds of hospitalization for the intervention, although there was no effect on viral suppression.