Food insecurity linked to self-stigma and HIV treatment failure in Senegal
A new study in Senegal finds that people living with HIV who face severe food shortages are more likely than others to be lost to follow up, experience treatment failure and have higher levels of self-stigma.
Researchers in Senegal who spent a year tracking people living with HIV have found that those who regularly face severe food shortages are more likely than others to feel ashamed of having HIV, leave HIV care, stop taking antiretroviral treatment (ART) and experience treatment failure.
Researchers followed 207 people beginning ART at public HIV clinics in Dakar and Ziguinch in 2017 and 2018. Participants were interviewed and underwent tests when they joined the study and at six and 12 months.
The majority (70%) were female, and their median age was 37. Nearly a third (32%) had no formal education. For food and/or income, around one in four (23%) farmed crops and 40% owned livestock.
Most participants (69%) were food insecure at enrolment, meaning they lacked access to nutritious food due to physical, social or economic reasons. Just under a third (29%) were severely food insecure, and 38% were undernourished. After 12 months, 69% still faced food insecurity; 23% were severely food insecure and 14% were undernourished. Although people moved between the different food insecurity categories, 7% were severely food insecure throughout.
After 12 months, 63% of participants remained in HIV care; 15% had died, 13% were alive but not visiting the clinic, and 9% were lost to follow up. One in four (26%) had CD4 cell counts less than 200, the level at which AIDS is diagnosed, and 15% had treatment failure.
People who faced constant severe food insecurity were more likely than others to experience treatment failure and poor ART adherence.
At 12 months, those who had been undernourished on enrolment were more likely to experience treatment failure than others (25% vs. 9%). They were also more likely to die (21% vs. 7%), and more likely to have a CD4 count less than 200 (44% vs. 16%). Those facing severe food insecurity on joining the study were more likely to be lost to follow up than those with good access to food (16% vs. 5%).
The frequency of poor outcomes increased the longer severe food insecurity went on for.
Researchers also found a link between food insecurity and self-stigma. Around 45% of participants had not told anybody they were living with HIV. Around a third of these participants said it was because they were afraid of stigma or felt ashamed. People who were food insecure were much more likely to give this as a reason compared to people with enough food (48% vs. 8%).
People spent a median of US$0.58 per person per day on food, but one in five spent less than US$0.25. People who spent less on food were more likely not to disclose their HIV status and more likely to be lost to follow up.
Travelling to and from clinics cost US$1.74, which is three times the amount spent on food. Facing the decision to either buy food or pay for transport, it is likely some people prioritised food. People may also have prioritised tending to their crops above going home to take medication or travelling to an HIV clinic.
HIV care interventions are needed that address the competing priorities that people who are food insecure have to feed themselves and their families while trying to maintain their health. Initiatives must also address the self-perceptions of people who regularly go hungry, and involve sectors like agriculture and transport to improve the conditions for many people living with HIV.