Publications

Food insecurity is associated with negative chronic health outcomes, yet few studies have examined how providing medically appropriate food assistance to food-insecure individuals may improve health outcomes in resource-rich settings. We evaluated a community-based food support intervention in the San Francisco Bay Area for people living with HIV and/or type 2 diabetes mellitus (T2DM) to determine the feasibility, acceptability, and potential impact of the intervention on nutritional, mental health, disease management, healthcare utilization, and physical health outcomes. The 6-month intervention provided meals and snacks designed to comprise 100% of daily energy requirements and meet nutritional guidelines for a healthy diet. We assessed paired outcomes at baseline and 6 months using validated measures. Paired t tests and McNemar exact tests were used with continuous and dichotomous outcomes, respectively, to compare pre-post changes. Fifty-two participants (out of 72 initiators) had both baseline and follow-up assessments, including 23 with HIV, 24 with T2DM, and 7 with both HIV and T2DM. Median food pick-up adherence was 93%. Comparing baseline to follow-up, very low food security decreased from 59.6% to 11.5% (p < 0.0001). Frequency of consumption of fats (p = 0.003) decreased, while frequency increased for fruits and vegetables (p = 0.011). Among people with diabetes, frequency of sugar consumption decreased (p = 0.006). We also observed decreased depressive symptoms (p = 0.028) and binge drinking (p = 0.008). At follow-up, fewer participants sacrificed food for healthcare (p = 0.007) or prescriptions (p = 0.046), or sacrificed healthcare for food (p = 0.029). Among people with HIV, 95% adherence to antiretroviral therapy increased from 47 to 70% (p = 0.046). Among people with T2DM, diabetes distress (p < 0.001), and perceived diabetes self-management (p = 0.007) improved. Comprehensive, medically appropriate food support is feasible and may improve multiple health outcomes for food-insecure individuals living with chronic health conditions. Future studies should formally test the impact of medically appropriate food support interventions for food-insecure populations through rigorous, randomized controlled designs.

This longitudinal qualitative study sought to understand how and why a livelihood intervention affected the health and health behaviors of HIV-infected Kenyan adults. The intervention included a microfinance loan, agricultural and financial training, and a human-powered water pump. In-depth interviews were conducted at two time points with intervention and control participants and program staff. We double coded interviews (n = 117) and used thematic content analysis of transcripts following an integrative inductive-deductive approach. Intervention participants described improvements in HIV health, including increased CD4 counts and energy, improved viral suppression, and fewer HIV-related symptoms. Better health was linked to improved clinic attendance and ART adherence through several mechanisms: (1) reductions in food insecurity and abject hunger; (2) improved financial stability; (3) improved productivity which enhanced social support; (4) better control over work situations; and, (5) renewed desire to prioritize their own health. Livelihood interventions may improve health by influencing upstream determinants of health behavior including food security and poverty.

A large pool of clinicians are needed to meet the growing demand for HIV preexposure prophylaxis. We surveyed a mixed group of HIV specialists and nonspecialists in the San Francisco Bay Area to determine their attitudes toward and training needs regarding prescribing preexposure prophylaxis to persons at increased risk of HIV infection. Willingness to prescribe was associated with experience in caring for HIV-infected patients (adjusted odds ratio 4.76, 95% confidence interval: 1.43 to 15.76, P = 0.01). Desire for further training was associated with concerns about drug resistance (P = 0.04) and side effects (P = 0.04) and was more common among noninfectious disease specialists. Clinicians favored online and in-person training methods.