People who struggle to get food on the table are more likely to test positive for HIV in South Africa, according to a study of 2,742 adults testing for HIV at three primary healthcare clinics in KwaZulu Natal.
In the study, researchers at the Prevention Research Unit, South African Medical Research Council, Durban, Columbia University, New York, Ibis Reproductive Health, Cambridge, Massachusetts and the CUNY Institute for Implementation Science in Population Health, City University of New York, hypothesised that household food insecurity – where people report ever having gone hungry – would be associated with not testing for HIV, and a higher likelihood of being HIV-positive when testing.
While they found no association between food insecurity and a history of testing, the odds of testing HIV-positive were significantly higher for those reporting hunger, even after adjusting for socio-economic and demographic variables.
In their sample, most of the participants were women (53%), aged less than 24 years (37%), had not completed high school (62%), were not currently studying (87%), were married or in a relationship but not living together (63%), were unemployed (65%), and currently caring for a dependent child or adult (59%).
At 35%, the authors reveal an alarmingly high prevalence of food insecurity in this group. Food insecurity was highest in adults with incomplete high schooling (43%), among those who were unemployed (39%) and among those whose primary source of income was government grants (50%).
This data is important for several reasons. First, across sub-Saharan Africa, it is well documented the link between food insecurity and HIV as it relates to sexual risk-taking behaviour and antiretroviral treatment adherence challenges. In Swaziland and Botswana, food insecurity resulted in people being less likely to use a condom. While in South Africa, people accepting HIV treatment report that their biggest concern is having to take treatment on an empty stomach because they don’t always have food. In Tanzania, some worried about the additional costs of food needed to sustain lifelong antiretroviral therapy.
But there is much less research on the impact of food insecurity on health-seeking behaviour, such as HIV testing. This is the first evidence from South Africa – which has the largest HIV epidemic in the world – and demonstrates the negative impact food insecurity has on HIV testing. As testing is the first step in getting people living with HIV diagnosed, onto treatment and on the road to healthy lives, it is important to understand all the determinants of HIV in a setting.
The authors summarise that socio-economic and structural interventions can play a crucial role in mitigating vulnerability to HIV infection in South Africa, ones that turn food-insecure houses into food-secure houses. Means testing, much like existing child support or old age grants in South Africa, could be used to target the households most at risk.
They conclude: “If left unaddressed, household food insecurity is likely to adversely affect the global targets of ending AIDS by 2030 through the 90-90-90 and test-and-treat initiatives.”
HIV and food insecurity are two prominent causes of morbidity and mortality in sub-Saharan Africa. Food insecurity has been associated with risky sexual practices and poor access to healthcare services. We describe the association between household food insecurity and previous HIV testing and HIV status. We used logistic regression to analyse the association between food insecurity and prior HIV counselling and testing (HCT) and testing HIV positive. A total of 2742 adults who presented for HCT at three primary healthcare clinics in KwaZulu-Natal, South Africa, participated in the study. The prevalence of household food insecurity was 35%. The prevalence of food insecurity was highest in adults who had incomplete high schooling (43%), were unemployed (39%), and whose primary source of income was government grants (50%). Individuals who were food insecure had significantly higher odds of testing HIV positive (adjusted odds ratio 1.41, 95% CI 1.16–1.71), adjusted for demographic and socio-economic variables. There was no association between food insecurity and prior HCT. The findings of this study highlight the important role food insecurity may play in HIV risk. Interventions to turn food-insecure into food-secure households are needed to reduce their household members’ vulnerability to HIV acquisition. The absence of such interventions is likely to severely impact ambitious global targets of ending AIDS by 2030 through the 90-90-90 targets and test-and-treat-all initiatives.
Makandwe Nyirenda, Renee Street, Tarylee Reddy, Susie Hoffman, Suraya Dawad, Kelly Blanchard, Theresa M Exner, Elizabeth A Kelvin, Joanne E Mantell, Gita Ramjee