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RAND’s work in Honduras and Bolivia grappled with the challenge of improving adherence to antiretroviral therapy (ART) among individuals for whom food insecurity was a constant source of anxiety and poor nutrition.
In Honduras, RAND explored finding the right balance between educating participants about nutrition and providing them with food. In the end, education alone turned out to be effective with people of all nutritional statuses—teaching participants about how to have good nutrition on a low budget reduced their food insecurity while also increasing weight for those underweight and reducing weight for those overweight. RAND’s efforts also helped to develop human capital: The peer nutrition counselors that RAND trained were later hired by the Ministry of Health to support the government’s nutrition education efforts.
In Bolivia, RAND faced a different challenge—to explore, in partnership with the World Food Programme, how to transition recipients off of food support and into salaried jobs. To provide context, RAND documented the extraordinary measures that participants took to maintain adherence and livelihoods despite the barriers they confronted. Participants also noted characteristics of the health care system that made balancing more challenging—for example, clinic schedules and locations. RAND also supported the World Food Programme’s efforts to implement nutritional counseling at HIV clinics. This work prompted the National AIDS Program to focus on nutrition in its national plan.
This study was the first prospective clinical trial to test how a nutrition intervention would affect ART adherence among adults living with HIV in Latin America, and the first to our knowledge in a cohort with a high proportion of overweight or obese ART patients.
Participants received nutrition education from study-trained nutritionists using a highly interactive curriculum.
Among participants in this study, many fewer were underweight (11 %) than overweight or obese (31 %). As a result, it was possible to test whether food aid and nutrition education would improve ART adherence in a context of high food insecurity and among patients with varied nutritional statuses.
Many participants had compromised HIV status. They were at all stages of ART and adhered poorly to treatment. In all four study clinics, participants received nutrition education from study-trained nutritionists using a highly interactive curriculum that was developed after extensive research on locally available foods and dietary patterns among people living with HIV. In two of the study clinics, participants also received a monthly household food basket.
Effects on Adherence
Both strategies improved participants’ adherence to ART (making appointments, picking up medications on time, and taking their medications as prescribed). Adding the food basket increased the effect for picking up medications on time. However, the researchers concluded that the content of the food basket in environments such as this one may need reappraisal. The types of foods provided were high calorie because they were mostly intended for areas where undernutrition is the norm and residents need calories.
Food insecurity and malnutrition negatively affect adherence to antiretroviral therapy (ART) and are associated with poor HIV clinical outcomes.
Effects on Food Security and Body Weight
Researchers found that giving individuals food support plus nutrition education increased food security compared to education alone, but it also led to weight gain for overweight or obese participants. Those who received only nutrition education both lost weight and increased food security. It’s plausible that nutrition education could improve food insecurity and reduce weight by improving diet quality, making the most of existing food resources, and reducing anxiety about procuring healthy food.
Optimal strategies to improve food security and nutrition for people living with HIV (PLHIV) may differ in settings where overweight and obesity are prevalent and cardiovascular disease risk is a concern.
Training Peer Nutritional Counselors
As part of scale-up of the nutritional counseling intervention, the RAND team recruited and trained 17 peer counselors from 14 government-run HIV clinics in Honduras to deliver nutritional counseling to ART patients. The clinics covered 80% of patients attending government-supported HIV clinics in the country. The team found that culturally and locally appropriate nutritional counseling delivered by peer counselors appeared to reduce food insecurity and improve nutritional knowledge and diet quality among this population.
Peer nutritional education may be especially important in low-resource settings where many food insecure individuals are overweight or obese. Training peer leaders to deliver HIV-specific nutritional counseling may improve key nutritional outcomes using readily available human capital.
This study examines nutrition and food insecurity among antiretroviral therapy patients in Honduras.
After the study was completed, the nutritionists trained through RAND’s study were later hired by the Ministry of Health to support nutritional care at government HIV clinics. Many of the peer nutritional counselors that we trained through an extension project in Honduras were also hired by the HIV clinics. Thus, the project helped to develop human capital to support Honduras’ efforts to address the food and nutrition security of individuals living with HIV. The training manuals and intervention materials developed during the study became resources for the Ministry of Health to use in HIV care.
In Bolivia, the World Food Programme implemented nutritional education via trained nutritionists and a monthly household food basket and partnered with RAND to explore the feasibility of transitioning recipients off food support and into income generating projects. RAND and the World Food Programme conducted exploratory research to understand the income-generating experiences of food insecure ART patients in four Bolivian cities. This research revealed the complex economic lives of participants, as they struggled to manage their ART treatment and livelihoods simultaneously. Lack of HIV disclosure, stigma and discrimination were prevalent, making it difficult for participants to adhere to treatment.
Health and development organizations increasingly promote livelihood interventions to improve health and economic outcomes for people living with HIV (PLHIV) receiving treatment with antiretroviral therapy (ART).
This exploratory research influenced the National AIDS Program to include nutrition as a focus in its national plan. The Ministry of Health hired nutritionists trained through these efforts to support nutritional care at government HIV clinics. Municipalities that had participated in this research included a line item in future budgets for nutritionists at their HIV clinics.