Food insecurity and viral suppression in a cross-sectional study of people living with HIV accessing Ryan White food and nutrition services in New York City

Abstract Background There have been few studies of food insecurity (defined as limited access to nutritionally adequate food) among people living with HIV in the USA, perhaps because this issue is commonly associated with resource-poor countries. However, evidence that people living with HIV in resource-rich countries risk food insecurity underscores the need to understand how food insecurity affects treatment outcomes in this population. We aimed to examine the relation between food insecurity and viral load (VL) suppression among New York City (NYC) Ryan White food and nutrition programme clients. Methods NYC Ryan White food and nutrition programme eligibility requires residence in the New York Eligible Metropolitan Area, income below 435% of the federal poverty level, and a documented need for nutritional services or inability to purchase or prepare nutritious food. Enrolled clients are assessed at intake and approximately every 6 months on topics including food insecurity (which is not assessed in other NYC Ryan White programmes). Clients categorised as food-insecure reported "fairly" or "very" often not having money for food, "sometimes" or "often" not having enough to eat, or going a whole day in the past 30 days without anything to eat. The analysis included adult Ryan White food and nutrition programme clients with an assessment in 2012 covering food insecurity. For clients with multiple eligible assessments, the earliest 2012 assessment was used. Data for unsuppressed VL (defined as VL >200 copies per mL) came from laboratory reporting in the NYC HIV Surveillance Registry; clients not found in surveillance data were excluded (n=190). Covariates considered included age, sex, race with or without ethnicity, education, employment status, housing status, drug use, antiretroviral status, body-mass index, and poverty level. Those significantly associated with unsuppressed VL in bivariate models were included in the multivariate model. This project was classified as a programme evaluation (not research) by legal counsel at the NYC Department of Health and Mental Hygiene. Findings Among 3251 eligible NYC Ryan White food and nutrition programme clients in 2012, 2493 (77%) reported food insecurity. The study population was mostly male (2284 [70%]), non-Hispanic black (1616 [50%]), aged 50 years and older (1759 [54%]; range 18–84 years), and on antiretroviral medication (3065 [94%]). In bivariate analyses, unsuppressed VL was more common among food-insecure clients (872 of 2493 [35%]) than among food-secure clients (157 of 758 [21%]). Food insecurity was independently associated with unsuppressed VL in multivariate analyses (adjusted odds ratio 1·50, 95% CI 1·18–1·90). Interpretation Our findings suggest that food security is important in maintaining the physical health of people living with HIV. Future studies should examine biological and psychosocial mediators of the relationship between food insecurity and HIV treatment outcomes, to inform intervention development. The analysis was limited by the availability of food insecurity data only for participants in food and nutrition programmes. A strength of this analysis was the use of NYC surveillance data to determine VL suppression. As food insecurity data from these programmes mature and can be analysed longitudinally, future analyses will offer a strengthened basis for causal inference. Funding This work was supported through a grant from the Health Resources and Services Administration (H89HA00015) to the NYC Department of Health and Mental Hygiene.