Food Insecurity: Widespread among people living with HIV/AIDS
UPDATE Food security — having access to enough diverse, nutritious food — is fundamental to good physical and mental health. The opposite is food insecurity. People who are food insecure may feel constant stress linked to worries about running out of food, may have access to only a limited variety of food items or food of poor nutritional quality, or may engage in stigmatized activities to feed themselves, such as panhandling, stealing and sex work. In resource-rich countries such as Canada, recent studies have shown that the prevalence of food insecurity among people living with HIV/AIDS (PLHA) ranges from 49% to 71%.iv According to a study conducted in 2013,1 prevalence among PLHA in Québec is estimated to be 58%. Food insecurity in rich countries is widespread among people living with HIV/AIDS, and in Canada it is increasingly recognized as a major determinant of health for people living with HIV/AIDS.v Several studies have demonstrated a correlation between food insecurity, and decreased adherence to antiretroviral therapy and low CD4 cell counts,vi as well as between food insecurity and mental health disorders and psychosocial needs.vii Food insecurity may have a negative impact on quality of life, the immune system and, eventually, on chances of survival.viii However, many PLHA who live in poverty are unable to escape food insecurity and all that it entails in terms of other mental health or physical health problems (linked with poor food quality).ix In Québec, some groups of people living with HIV are at greater risk of food insecurity: low-income families affected by HIV, people who struggle with housing costs, people who use injection drugs, and those who have been in prison. Specific, adapted nutritional support can greatly improve a PLHA’s general health and well-being. Beyond medical follow-up, emergency actions are also needed to counter this problem, which is widespread among people living with HIV/AIDS. In 2012, 4 million Canadians experienced food insecurity, including 800,000 who were severely food insecure.i Up to 8% of Québec households were in this situation.ii It is estimated that in 2014, 841,191 Canadians turned to food banks every month, which is 25% higher than in 2008.iii In Québec, people living with HIV/AIDS are seven times more likely to experience food insecurity than the general population.1
1 D ata from the Québec component of the “Impact of Food Security on Health Outcomes in People Living with HIV/AIDS Across Canada” project, funded by Canadian Institutes of Health Research (CIHR).
Food Insecurity: Widespread among people living with HIV/AIDS
THE VICIOUS CYCLE OF AGGRAVATING CONDITIONS Food insecurity and HIV/AIDS are closely linked, with each condition aggravating the other.x Food insecurity is also based on a set of factors that can be described as aggravating conditions. We need to consider what puts a serious strain on the budgets of PLHA, what hampers these individuals’ access to work, and what prevents them from obtaining quality food items necessary for good mental and physical health. Housing It is becoming increasingly clear that high cost and poor housing conditions are significant causes of food insecurity. Aside from high rents, circumstances around housing instability make it difficult to keep and prepare food under good conditions. This is why some PLHA who are in very vulnerable positions cannot benefit from food bank items and could see their health deteriorate more rapidly. Cost of medication Most of the time, people with chronic illnesses or disabilities have to pay part of the cost of their medication, even if they are registered in the public prescription drug insurance plan.2 For some people, and depending on the type of coverage, the amount they have to pay may be high. In addition, the list of medications that are not covered has gotten longer over the past few years. This puts a serious strain on already limited budgets, and some people may go without food to pay those costs. Access to employment and job retention Aside from possibly facing job discrimination, a major difficulty that PLHA encounter in employment is that HIV is a chronic episodic illness: intermittent symptomatic periods can alternate with asymptomatic ones, where the person is in perfect health. The episodic nature of the illness is rarely taken into account by support programs or in legislation. In the Act respecting the Québec Pension Plan, the notion of “disability” implies that the person is suffering from “severe and prolonged disability,” which excludes episodic disabilities. The outcome of such an inflexible concept of disability can be that some people will prefer to stay on social assistance — especially to benefit from the public prescription drug plan — rather than have a full-time job they could lose due to episodes of absenteeism that cannot be accommodated. Because of this, they lose the opportunity to increase their incomes, and thus find themselves in situations of food insecurity.3 Stigmatization In a world where personal autonomy is highly valued, having to turn to food banks is a stigmatizing experience that suggests a person is incapable of feeding him or herself. PLHA are doubly stigmatized: they can be rejected by society because of persisting prejudices and because of ignorance about modes of transmission. Consequently, it is difficult to disclose this condition, even to justify specific needs. Also, when community workers refer individuals to other services, ethics prevent them from revealing their clients’ serostatus so that they can benefit from appropriate support.
2 R égie de l’assurance maladie du Québec, http://www.ramq.gouv.qc.ca/fr/citoyens/assurance-medicaments/Pages/montant-apayer-medicaments.aspx, accessed on April 22, 2015. 3 Interview with Me Liz Lacharpagne, COCQ-SIDA.
Spatial access Many low-income families live in neighbourhoods that are poorly served by public transport and far from grocery stores that sell fresh food at affordable prices. These areas are called “food deserts.” PLHA also experience episodic periods of fatigue that can prevent them from travelling very far to a grocery store where food is affordable. COMMUNITY ACTION FOR FOOD SECURITY The price of fresh products, especially meat, went up significantly in 2014,4 sometimes more than 10%. As a result, it is increasingly difficult for organizations offering food aid to provide food of good nutritional quality. It is essential to integrate food security initiatives into support programs for people living with HIV to improve their health and quality of life. Therefore, it is very important to encourage strategies to counter food insecurity among PLHA, which presents a genuine public health problem by increasing demand for emergency and other medical services.5
“Nutrition is a major concern for people living with HIV/AIDS, and we have to be able to help them get fresh, nutritious food.” Claude Langlois, Fondation d’Aide Directe Sida Montréal (FADSM) “Everyone is being affected by budget cuts, and there are foods that we’re having a hard time buying, such as bread, milk, flour and eggs, for example” Serge Bigras, Bureau Régional d’Action Sida — Outaouais (BRAS)
Examples of initiatives to counter food insecurity: INITIATIVES
Thematic workshops on nutrition
Buyers’ club (items bought at a lower price for a group of members)
Food bank and emergency help
FADSM, ARCHE de l’Estrie, BRAS, MIELS-Québec, GAP-VIES
Christmas and Easter baskets
MIELS-Québec, GEIPSI, GAP-VIES, ACCM
4 A verage inflation rate for food was 2.2% according to Statistics Canada data published at the end of summer 2014, and 5% according to the SOS Cuisine Web site, http://www.soscuisine.com/fr/blogue/article/les-prix-viande-du-poisson-semballent, accessed on April 1, 2015. 5 I n 2013, food secure participants in the study “Impact of Food Security on Health Outcomes of People Living with HIV/AIDS Across Canada” visited emergency departments 1.7 times less often than food insecure participants.
To support local actions against food insecurity among people living with HIV/AIDS, contact:
Tarasuk V., A. Mitchell and N. Dachner, “Household Food Insecurity in Canada”, PROOF, Toronto: Research to identify policy options to reduce food insecurity, 2013, http:// nutritionalsciences.lamp.utoronto.ca/, accessed on 13 March 2015.
Fielden S, Otis J., Girard ME, Rusch M, Anema A, Roy J, Godin G, & the Maya Study Group. “Psychosocial needs associated with food insecurity in HIV-positive adults participating in a Canadian cohort study,” AIDS 2010 - XVIII International AIDS Conference: Abstract no. TUPE1045.
Institut national de santé publique du Québec “L’insécurité alimentaire dans les ménages québécois : mise à jour et évolution de 2005 à 2012,” 2014, http://www.inspq.qc.ca/ pdf/publications/1858_Insecurite_Alimentaire_Quebecois. pdf, accessed on 1 April 2015.
Weiser SD, Fernandes KA, Brandson EK, Lima VD, Anema A, Bangsberg DR, et al., “The association between food insecurity and mortality among HIV-infected individuals on HAART,” Journal of Acquired Immune Deficiency Syndromes, 52 (3), 2009, p. 42-349.
F ood Banks Canada. “HungerCount 2014,” http://www. foodbankscanada.ca/hungercount, accessed on 27 March 2015.
W eiser SD, Fernandes KA, Brandson EK, Lima VD, Anema A, Bangsberg DR, et al., “High prevalence of food insecurity among HIV-infected individuals receiving HAART in a resource-rich setting,” AIDS Care, 23 (2), 2011, p. 221-230. Normen L, Chan K, Braitstein P, Anema A, Bondy G, Montaner JS, et al., “Food insecurity and hunger are prevalent among HIV-positive individuals in British Columbia, Canada,” Journal of Nutrition, April 135 (4), 2005, p. 820-825.
Slater, Joyce, “HIV/AIDS and Food Security in Resource Rich Countries,” Purple Paper (CATIE) No. 35, January 2012, p. 1-7.
W eiser SD1, Yuan C, Guzman D, Frongillo EA, Riley ED, Bangsberg DR, Kushel MB. “Food insecurity and HIV clinical outcomes in a longitudinal study of urban homeless and marginally housed HIV-infected individuals,” AIDS, 2013 Nov 28; 27(18): 2953-8. doi: 10.1097/01. aids.0000432538.70088.a3.
W eiser SD, EA Frongillo, K. Ragland, et al., “Food insecurity is associated with incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San Francisco,” Journal of General Internal Medicine, 24, 2009, p. 14–20. ix
M uldoon KA, Duff PK, Fielden S, Anema A. “Food insufficiency is associated with psychiatric morbidity in a nationally representative study of mental illness among food insecure Canadians,” Soc Psychiatry Psychiatr Epidemiol, 2013; 48(5):795-803. doi: 10.1007/s00127-012-0597-3.
W eiser SD, Young SL, Cohen CR, Kushel MB, Tsai AC, Tien PC, Hatcher AM, Frongillo EA, Bangsberg DR. “Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS,” Am J Clin Nutr, 2011 Dec; 94(6): 1729S-1739S. doi: 10.3945/ ajcn.111.012070.