Hunger cuts chances of sustained viral suppression

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Not having enough food is associated with poorer chances of achieving a sustained viral suppression among antiretroviral-treated breastfeeding women in Uganda, investigators report. “In this cohort of HIV-infected women in rural Uganda who initiated ART during pregnancy, food insufficiency (FI) (defined as inadequate quantities of food available) was highly prevalent,” comment the authors. “FI was associated with 62% lower odds of achieving and sustaining viral suppression during pregnancy and breastfeeding.”

This is the first study to show an association between food insecurity and poor viral suppression among pregnant and breastfeeding women, a period “when viral suppression has implications both for preserving maternal health and reducing the risk of perinatal transmission.” Previous research has shown a relationship between food insecurity (uncertain access to safe and nutritious food) and lower rates of viral suppression among ART-treated patients in the US and Uganda.

Pregnant and breastfeeding women may be especially vulnerable to food insecurity and insufficiency. Moreover, food insecurity during pregnancy and breastfeeding has been associated with reduced blood levels of antiretrovirals, pre-term delivery and low birth weight infants. Food insecurity may also be a barrier to exclusive breastfeeding.

ART is now recommended for all pregnant and breastfeeding HIV-positive women. Investigators therefore wanted to establish if food insufficiency was associated with lower chances of sustained viral suppression among ART-treated HIV-positive women in the year after giving birth.

Participants were recruited from the PROMOTE-Pregnant Women and Infants study, which was designed to test the hypothesis that therapy with lopinavir/ritonavir would reduce the prevalence of placental malaria. HIV-positive ART-naïve women were recruited between weeks 12 and 28 of gestation.

Women under observation between September 2011 and February 2012 were included in the food insecurity sub-study. Viral load was measured eight weeks after delivery and then at regular intervals through to week 48. Patients who maintained a viral load below 400 copies/ml were regarded as having sustained viral suppression.

Food insufficiency was assessed using the Household Hunger Scale. Participants were asked how often: there was no food to eat in their house; they went to bed at night hungry; and went the whole day and night without eating. Responses were ranked on a scale of 0 (never) to 6 (often).

A total of 171 women were included in the analysis. Three-quarters reported food insufficiency and for 9% this was severe. At 24 weeks postpartum, almost all the women were breastfeeding. Women with sufficient food were more likely than women with food insufficiency to report exclusive breastfeeding (81% vs. 68%). At 48 weeks, 92% of food insufficient women and 95% of food sufficient participants reported partial breastfeeding. Two infants acquired HIV; both had mothers who reported food insufficiency.

Similar proportions of food-sufficient and food-insufficient women achieved viral suppression at some point during follow-up (90% vs 92.5%). However, women with enough food were more likely than women reporting insufficiency to have sustained viral suppression (79% vs 60%, p = 0.03).

In an analysis that controlled for potential confounders, food insufficiency was associated with significantly lower chances of sustained viral suppression (aOR = 0.38; 95% CI, 0.16-0.91, p = 0.03). Other risk factors were higher pre-therapy viral load (p < 0.01) and treatment with lopinavir/ritonavir vs. efavirenz (p = 0.04).

“Food insecurity may be an important and modifiable determinant of adverse virologic outcomes among pregnant and lactating women,” conclude the authors. “Interventions to reduce food insufficiency may result in improved outcomes among HIV-infected women and their children, and merit further attention from the research and programmatic communities.”

Abstract
Food insecurity is associated with poor virologic outcomes, but this has not been studied during pregnancy and breastfeeding. We assessed sustained viral suppression from 8 weeks on ART to 48 weeks postpartum among 171 pregnant and breastfeeding Ugandan women; 74.9% experienced food insufficiency (FI). In multivariable analysis, FI (adjusted odds ratio [aOR] 0.38, 95% confidence interval [CI] 0.16-0.91), higher pretreatment HIV-1 RNA (aOR 0.55 per 10-fold increase, 95% CI 0.37-0.82), and lopinavir/ritonavir versus efavirenz (aOR 0.49, 95% CI 0.24-0.96) were associated with lower odds of sustained viral suppression. Interventions to address food security may improve virologic outcomes among HIV-infected women.

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Journal of Acquired Immune Deficiency Syndromes abstract


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