Food insecurity, sexual risk behavior, and adherence to antiretroviral therapy among women living with HIV: A systematic review

Figures & data

Figure 1. PRISMA flow diagram of the search and screening processes of a systematic review.

Table 1. Descriptions of included studies.

Author, year	Location/setting and population	Study objective	Study design and methods	Sample size and food security status	Outcomes
Fielding-Miller et al., 2014	Location: Four sites in Swaziland: a rural border town, a peri-urban community, and two side in the urban Manzini-Mbabane corridor Population: HIV-positive female sex workers	Self-identified female sex workers were recruited for participation in this study through purposive and snowball sampling in order to examine the relationship between food insecurity and risky sexual practices.	Study design: Qualitative Participant selection: Purposive Sampling Methods: Two semi-structured in-depth interviews were conducted with each participant.	Sample size: Total: 20 Food security status: Not specified	Relevant themes: Hunger and poverty: Hunger was often the reason participants first engage in sex work. Insufficient resources for themselves and their families, particularly in relation to adequate food remained a concern for participants. The use of food to manage HIV status: Participants emphasized the role and importance of food in managing HIV leading some to continually engage in sex work. Others cited the necessity of adequate food in order to take ART medications. Social stigma: Stigma associated with both sex work and HIV resulted in a continued dependence on sex work to address hunger.
Miller et al., 2011	Location: Mbarara, Uganda Population: HIV-positive adults both on and off ARV treatment	Interviews were conducted with people living with HIV attending an ARV distribution clinic in Mbarara, Uganda, in order to examine the relationship between food insecurity and risky sexual behaviors.	Study design: Qualitative Participant selection: Purposive Sampling Methods: Semi-structured in-depth interviews	Sample Size: Total: 41 Women: 25 Men: 16 Food security status: Not specified	Relevant themes: Food insecurity contributes to women's decision to engage in transactional sex The vulnerability of women whose husbands died of HIV: Widows are more likely to be food insecure and exchange sex for food, and men frequently approach these women for sex Food insecurity and control over sexual relationships: Dependence on male sexual partners for food and resources made condom negotiation extremely difficult for many women Staying in high-risk relationships for food: Lack of resources and dependence on male partners forced some women to remain in abusive relationships in order to access food.
Murray et al., 2009	Location: Urban Zambia Population: HIV-positive pregnant and breastfeeding women attending an HIV clinic	Conducted among women involved in the Zambia Exclusive Breastfeeding Study (ZEBS), this cohort study examined mother to child transmission of HIV through breast milk to uncover barriers to ART adherence.	Study design: Qualitative Participant selection: Purposive Sampling Methods: Free listing and key informant interviews	Sample size: Total: 80 Free listing: 47 Key informant interviews: 33 Food security status: Not specified	Relevant themes: Food insecurity acts as a barrier to starting ART Lack of consistent access to food was identified as a barrier to continued ART adherence
Musumari et al., 2014	Location: Kinshasa, Democratic Republic of Congo Population: HIV-positive adults on ART, those on ART after an interruption, and those who had been off ART for 3+ consecutive months.	Interviews were conducted with people living with HIV of different treatment profiles to identify barriers and facilitators of ART adherence in Kinshasa, DRC.	Study design: Qualitative Participant selection: Purposive Sampling Methods: Semi-structured in-depth interviews	Sample Size: Total: 38 Women: 24 Men: 14 Food security status: 42.1 % reported having irregular meals (≤1 meal/day)	Relevant themes: Food insecurity as a barrier to ART adherence: Food insecurity was the most common theme as a barrier to daily ART adherence and was driving force behind treatment interruption across the different treatment profiles. Participants described an increased incidence of negative side-effects of ART when taken without food. Adherence was also affected by the belief of some participants that the medication is not effective or can be harmful when taken on an empty stomach.
Peretti-Watel et al., 2006	Location: France Population: HIV-infected patients at hospital departments delivering HIV care	A national cross-sectional study was conducted among a random stratified sample of HIV patients to investigate the correlates of non-adherence to ART.	Study design: Cross-sectional Participant selection: Random stratified sampling	Sample size: Total: 1809 Women: 408 Men: 1401 Food security status: 17.2% of heterosexual women living with HIV (70/408) experienced food privation in the household in the prior 4 weeks	ART adherence: Among heterosexual women living with HIV who reported food privation in the household in the prior 4 weeks, 56% were non-adherent to ART and 44% were adherent (p = 0.04); among those who did not report food privation, 43% were non-adherent to ART and 57% were adherent. (OR = 1.30, 95%CI: 0.79–2.14)
Shannon et al., 2011	Location: Vancouver, Canada Population: HIV-positive people who inject drugs both on and not on HAART	HIV-positive people who inject drugs in inner city Vancouver were recruited through snowball sampling and street outreach to participate in a prospective observational cohort study, also known as the AIDS Care Cohort to evaluate Exposure to Survival Services, 2005–2008	Study design: Prospective Cohort Participant selection: Non-random Follow-up time: Observations taken every 6 months between Dec 2005 and May 2009	Sample size: Total: 470 Women: 183 Men: 287 Food security status: 39% of those severely food insecure were women and 38% of those not severely food insecure were women (No difference between men and women p=0.789)	Behavioral outcomes: Unprotected sex (vaginal and/or anal) and severe food insecurity Unadjusted OR: 2.98 (1.56–5.05) p < 0.10 Adjusted OR: 2.68 (1.49–4.82) p < 0.10 *Adjusted for age, sex/gender, married/cohabitating partner, binge drug use, homelessness, and HAART use Unprotected sex (vaginal and/or anal) among females Unadjusted OR: 1.54 (1.00–2.37) p < 0.10 Adjusted OR: 1.5 (1.02–2.22) p < .10 *Adjusted for age, sex/gender, married/cohabitating partner, binge drug use, homelessness, and HAART use
Whittle et al., 2015	Location: San Francisco and Alameda County, CA, United States Population: Low-income people living with HIV	Semi-structured in-depth interviews were conducted with participants recruited from a program providing 3 meals a day with the aim of documenting experiences with food insecurity and risky sexual practices.	Study design: Qualitative Participant selection: Purposive Sampling Methods: Semi-structured in-depth interviews	Sample Size: Total: 34 Women: 6 Men: 28 Food security status: Not specified but all participants were receiving daily food assistance	Relevant themes: Transactional sex as coping strategy when facing food insecurity: Absolute lack of food and hunger motivated engagement in transactional sex Food insecurity leading to unprotected sex: Obtaining food and resources were given precedence over using condoms when experiencing food insecurity

Fielding-Miller, R., Mnisi, Z., Adams, D., Baral, S., & Kennedy, C. (2014). “There is hunger in my community”: A qualitative study of food security as a cyclical force in sex work in Swaziland. BMC Public Health, 14, 79.

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Miller, C. L., Bangsberg, D. R., Tuller, D. M., Senkungu, J., Kawuma, A., Frongillo, E. A., & Weiser, S. D. (2011). Food insecurity and sexual risk in an HIV endemic community in Uganda. AIDS and Behavior, 15(7), 1512–1519. doi:10.1007/s10461-010-9693-0

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Murray, L. K., Semrau, K., McCurley, E., Thea, D. M., Scott, N., Mwiya, M., Kankasa, C., Bass, J., & Bolton, P. (2009). Barriers to acceptance and adherence of antiretroviral therapy in urban Zambian women: A qualitative study. AIDS Care, 21(1), 78–86. doi:10.1080/09540120802032643

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Peretti-Watel, P., Spire, B., Schiltz, M. A., Bouhnik, A. D., Heard, I., Lert, F., & Obadia, Y. (2006). Vulnerability, unsafe sex and non-adherence to HAART: Evidence from a large sample of French HIV/AIDS outpatients. Social Science and Medicine, 62(10), 2420–2433. https://doi.org/10.1016/j.socscimed.2005.10.020

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Shannon, K., Kerr, T., Milloy, M. J., Anema, A., Zhang, R., Montaner, J. S., & Wood, E. (2011). Severe food insecurity is associated with elevated unprotected sex among HIV-seropositive injection drug users independent of HAART use. AIDS, 25(16), 2037–2042. doi:10.1097/QAD.0b013e32834b35c9

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Whittle, H. J., Palar, K., Napoles, T., Hufstedler, L. L., Ching, I., Hecht, F. M., Frongillo, E. A., & Weiser, S. D. (2015). Experiences with food insecurity and risky sex among low-income people living with HIV/AIDS in a resource-rich setting. Journal of the International AIDS Society, 18, 20293. doi:10.7448/IAS.18.1.20293

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