HIV/AIDS, Under-nutrition and Food Insecurity

Malnutrition, particularly among children, is currently one of the largest and most devastating global health issues. Worldwide, approximately 795 million people are undernourished, with the largest share in sub-Saharan Africa and southern Asia (FAO, 2015). (See: https://www.worldhunger.org/2015-world-hunger-and-poverty-facts-and-statistics) For example, in sub-Saharan Africa almost one in every four people is undernourished (23.2% of the population). In particular, children suffer greatly from hunger and malnutrition. (See: https://www.worldhunger.org/world-child-hunger-facts) In the developing world, among children under the age of 5, approximately 13% are undernourished and 17% are underweight (FAO, 2015). Hunger and HIV/AIDS are inter-related. Malnutrition is both a contributor to and effect of HIV/AIDS.

The human immunodeficiency virus (HIV) epidemic is closely linked to the problem of hunger and malnutrition. Approximately 37 million people who are infected with HIV/AIDS (also termed “people living with HIV/AIDS”) are at an increased risk for food insecurity and malnutrition, which includes 2.1 million children under the age of 15 (UNAIDS, 2017). In fact, early in the HIV epidemic, it was known as “Slim Disease” in Africa because of the thin, wasted appearance of someone with advanced AIDS (Piwoz, 2000). The graphs below depict adult prevalence of people who live with HIV and the top countries worldwide with HIV/AIDS. The highest prevalence countries are in Africa.

HIV prevalence is highest in eastern and southern Africa due to a number of contributing factors, including: high rates of poverty, limited access to healthcare, governments who delayed their public health response to the disease, and differences in sexual behaviors (for example, a higher rate of multiple concurrent sexual partners).

Causes of HIV-associated Undernutrition and Food Insecurity

People living with HIV/AIDS generally have a reduced food intake due to loss of appetite, which can cause weight loss. The virus also reduces the absorption of nutrients in the intestines, so that HIV-infected people don’t absorb as many nutrients from the food they eat. Additionally, infection with HIV increases metabolism due to the chronic stimulation of the immune system, which is working hard to fight off the infection. HIV-infected individuals have suppressed immune systems, which mean they are particularly vulnerable to co-infections, such as tuberculosis. These combined factors result in AIDS-related wasting (low weight-for-height). It must be emphasized that the relationship between HIV infection and nutrition is highly complex and affected by numerous factors, including age, HIV disease stage, individual physiology and metabolism, diet and body composition (de Pee & Semba, 2010).

Co-infections with HIV are particularly problematic for those in more advanced stage of disease. As the immune system is weakened, individuals become more susceptible to other infections, including parasitic (e.g., malaria), viral (e.g., hepatitis), and bacterial diseases (e.g., tuberculosis). In fact, the most common and most life-threatening co-infection with HIV is tuberculosis (TB). Worldwide, it is estimated that 14 million people are co-infected with HIV and TB (Getahun, 2010). This co-infection is particularly problematic because TB infection increases HIV viral replication, and people living with HIV who become infected with TB are much more likely to advance to active TB disease (USAID, 2014). TB accounts for approximately 25% of AIDS deaths.

Meanwhile, HIV/AIDS-associated illness and mortality also affects food insecurity in a number of important ways. Households with an HIV-infected individual typically have a reduced work capacity due to the illness, which reduces household income and savings. Simultaneously, HIV-infection is associated with an increase in household expenses due to healthcare costs associated with HIV, such as purchasing HIV treatment medications and transportation to health clinics (Gillespie & Kadiyala, 2005; Piwoz & Preble, 2000). HIV transmission can also be accelerated by adoption of risky coping behaviors to improve household food security, such as engaging in sex work (Aberman et al., 2014).

Communities that are strongly affected by HIV/AIDS also have a high rate of orphans, which places an even greater burden on the community. In 2014, it was estimated that 13.3 million children (aged 0-17) have been orphaned by AIDS (UNICEF 2016). Households often take in children who were orphaned by HIV/AIDS, which forces them to stretch their limited resources even further to feed an additional person. This additional resource burden may increase food insecurity at the household level.

The map below shows where there are the most adults living with HIV in the world.

Source: Kaiser Family Foundation, based on UNAIDS, How AIDS Changed Everything, 2015

 

The complex relationship between HIV/AIDS and malnutrition has often been referred to as a vicious cycle because malnutrition contributes to susceptibility to HIV infection and HIV disease progression, but it is also a consequence of the disease. HIV infection increases an individual’s risk for nutritional deficiencies, which decreases the function of his or her immune system, which in turn allows the virus to replicate and can worsen an individual’s stage of disease, further contributing to malnutrition (See Figure 1).

This vicious cycle has serious consequences for people living with HIV/AIDS. Wasting and underweight among people living with HIV/AIDS is associated with greater susceptibility to other infections and increased mortality. People living with HIV/AIDS who experience food insecurity are less likely to adhere to their HIV treatment because many of the antiretroviral drugs (ARVs) prescribed for HIV must be taken with food. Poor treatment adherence is associated with worse disease outcomes and a greater likelihood of transmitting the infection to others.

Figure 1. Vicious Cycle of Nutrient Deficiencies and HIV Disease
Adapted from Piwoz & Preble, 2000.

 

Programs to Improve Food Security and Nutrition Among People Living with HIV

Early in the HIV epidemic, nutrition was often not directly addressed as a component of treatment for the disease. Nutritional deficiencies have historically been perceived as a low public health priority relative to controlling incidence of infectious illness such as HIV, malaria and tuberculosis (Bryce et al., 2008), even though micronutrient deficiencies have significant implications for immune function. In order to break the cycle of disease and malnutrition, primary prevention efforts must be prioritized to improve nutritional status in communities affected by HIV/AIDS, ideally before nutrition or food insecurity becomes a contributor to disease progression.

Over recent decades, the global community has recognized the importance of integrating nutritional support and food security interventions into HIV programs (Aberman, 2014). The World Food Programme (WFP) joined the United Nations Program on HIV/AIDS (UNAIDS), thus contributing their expertise in the area of food aid and nutritional support to UNAIDS programs, designed to reduce the HIV epidemic. The President’s Emergency Plan for AIDS Relief (PEPFAR) began providing funding directly for nutritional support for people living with HIV/AIDS, and created a program called Food by Prescription, which effectively viewed food as medicine in the context of fighting HIV infection and malnutrition (Aberman, 2014).

This momentum to incorporate food and nutrition interventions into HIV programs has resulted in a number of nutrition-sensitive HIV intervention models. One commonly used model provides nutritional supplementation to HIV-infected people who are undernourished. These programs may incorporate nutrition assessment, counseling and support as a component of the care provided to all people living with HIV, regardless of their current nutritional status. Other programs focus more on improving household food security by providing direct cash transfers or vouchers to HIV-affected households. Finally, a number of programs run by non-governmental agencies and international organizations aim to support the livelihoods of households affected by HIV, typically through providing investments in income generating activities, such as small-scale agriculture, livestock, or handicrafts.

Available evidence collected through evaluation of these programs demonstrates that nutrition supplementation, food assistance and livelihood interventions can be highly effective in improving quality of life, adherence to treatment, nutritional status and food security of people living with HIV (Ivers et al., 2009; Singer et al., 2015; Young et al., 2014). Further research is needed to identify the preferred types and forms of interventions required to optimize health outcomes among people living with HIV.

Primary Author: Jennifer Peregoy, MPH; PhD student in Nutritional Sciences,
Cornell University

Date published: October 29, 2017

References

Aberman NL, Rawat R, Drimie S, Claros JM, Kadiyala S (2014). Food security and nutrition interventions in response to the AIDS epidemic: assessing global action and evidence. AIDS & Behavior, 18: S554-565.

Bryce J, Coitinho D, Darnton-Hill I, Pelletier D, Pinstrup-Andersen P; Maternal and Child Undernutrition Study Group (2008). Maternal and child undernutrition: effective action at national level. Lancet, 371(9611), 510-26.

de Pee S & Semba RD (2010). Role of nutrition in HIV infection: review of evidence for more effective programming in resource-limited settings. Food and Nutrition Bulletin; 31(4): S313-344.

Food and Agriculture Organization of the United Nations (FAO) (1996). Report of the World Food Summit. Available at: http://www.fao.org/WFS/.

FAO, IFAD and WFP (2015). The State of Food Insecurity in the World 2015. Meeting the 2015 international hunger targets: taking stock of uneven progress. Rome, FAO. Available at: http://www.fao.org/3/a-i4646e.pdf.

Getahun H, Gunneberg C, Granich R, Nunn P (2010) HIV infection-associated tuberculosis: the epidemiology and the response. Clinical Infectious Diseases; 50: Suppl 3S201–S207.

Gillespie S & Kadiyala S (2005). HIV/AIDS and Food and Nutrition Security: From Evidence to Action. Washington: International Food Policy Research Institute.

Ivers LC, Cullen KA, Freedberg KA, Block S, Coates J, Webb P (2009). HIV/AIDS, Undernutrition, and Food Insecurity. Clinical Infectious Diseases; 49: 1096-1102.

Piwoz E & Preble E (2000). HIV/AIDS and nutrition: a review of the literature and recommendations for nutritional care and support in sub-Saharan Africa. SARA Project. Washington, D.C.: U.S. Agency for International Development. Available at: http://repository.forcedmigration.org/show_metadata.jsp?pid=fmo:3406.

Singer AW, Weiser SD, McCoy SI (2015). Does Food Insecurity Undermine Adherence to Antiretroviral Therapy? A Systematic Review. AIDS and Behavior; 19(8): 1510-1526. Available at: https://www-ncbi-nlm-nih-gov.proxy.library.cornell.edu/pubmed/25096896.

UNAIDS (2017). Fact Sheet – Latest global and regional statistics on the status of the AIDS epidemic. Geneva: UNAIDS. Available at: http://www.unaids.org/en/resources/documents/2017/UNAIDS_FactSheet.

United Nations Children’s Fund (UNICEF) (2016). The State of the World’s Children 2016: A fair chance for every child. New York: UNICEF. Available at: https://www.unicef.org/sowc2016/.

USAID (2014). Fact Sheet – The Twin Epidemics: HIV and TB Co-infection. Available at: https://www.usaid.gov/news-information/fact-sheets/twin-epidemics-hiv-and-tb-co-infection.

Young S, Wheeler AC, McCoy SI, Weiser SD (2014). A Review of the Role of Food Insecurity in Adherence to Care and Treatment Among Adult and Pediatric Populations Living with HIV and AIDS. AIDS and Behavior; 18(5): 505-515. Available at: https://www-ncbi-nlm-nih-gov.proxy.library.cornell.edu/pubmed/23842717.

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