Issue: December 2019
October 29, 2019
3 min read

Hair study strengthens link between food insecurity, ART nonadherence

Issue: December 2019
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Anna Leddy, PhD, MHS 
Anna M. Leddy
Sheri Weiser, MD, MPH, MA 
Sheri Weiser

Among women living with HIV, study findings showed that food insecurity was associated with lower ART concentrations in hair, suggesting that it impacts ART adherence and/or drug absorption, researchers said.

“HIV should be solved by now,” Monica Gandhi, MD, MPH, who was not involved in the study, told Infectious Disease News. “We should be done with HIV and the reason we are not done with HIV is because of the social determinants of health that keep leading to new HIV infections and people living with HIV not doing as well as they should. One of those social determinants is lack of access to food or nutritious food.”

New evidence

Food insecurity is “widespread” in the United States, affecting an estimated 40 million people, said University of California, San Francisco researchers Anna M. Leddy, PhD, and Sheri Weiser, MD, MPH, MA.

“Low-income populations and people living with HIV/AIDS are generally impacted the most,” they told Infectious Disease News.

In their study, Leddy, Weiser and colleagues aimed to investigate the association between food insecurity and ART adherence using objective adherence measures — namely, by testing ART concentrations in hair.

The Women’s Interagency HIV Study is a multisite prospective cohort study of women living with HIV (WLHIV) and HIV-negative controls. The researchers analyzed longitudinal data from the cohort collected semi-annually between 2013 and 2015, which included 1,944 person-visits from 677 WLHIV.

“We’ve known from other studies that food insecurity reduces self-reported adherence to drugs,” said Gandhi, a professor of medicine at the University of California, San Francisco, and medical director of the “Ward 86” HIV Clinic at Zuckerberg San Francisco General Hospital. “However, this is the largest study that has looked at adherence using objective metrics, which I think is the most unique aspect of the study.”

At baseline, viral suppression was recorded for 59% of participants and food insecurity was reported by 45%. Using the base multivariable model, Leddy, Weiser and colleagues observed that every three-point increase in food insecurity was associated with 0.94-fold lower ART concentrations in hair (95% CI, 0.89-0.99).

When adjusted for self-reported adherence, the association remained unchanged, according to the study.

“This study provides the first evidence to suggest that food insecurity is associated with lower concentrations of ART in hair, which is the most objective measure of adherence and drug absorption,” Leddy and Weiser said. “This finding strengthens the rationale for intervening on food insecurity to improve adherence and absorption among people living with HIV.”

Monica Gandhi

Leddy, Weiser and colleagues previously published study findings showing an association between food insecurity and inflammation among women with HIV. They demonstrated that independent of HIV control, food insecurity was associated with elevated levels of inflammation.

“A large body of research has demonstrated a bidirectional relationship between HIV and food insecurity,” Leddy and Weiser said. “Food insecurity is associated with worse outcomes along the cascade of care from disease acquisition to death.”

Gandhi noted that food insecurity often leads to obesity and not malnutrition, “because here, not having access to food means not having access to healthy food choices.” Weiser and Leddy said food insecurity among people with HIV can increase the risk for worse outcomes.

“Food insecurity is associated with prevalent HIV, missed clinic visits, HIV viral load suppression, lower CD4 cell counts, opportunistic infections, acute-care use and mortality,” they said. “Evidence suggests that food insecurity can increase risk for HIV acquisition and disease progression through nutritional, mental health, and behavioral pathways.”


According to Gandhi, “ID practitioners have been on the forefront of thinking about social determinants and how they affect health outcomes and starting interventions within their own unique HIV/AIDS centers.”

“This kind of wraparound care has been there since the beginning,” she said.

She highlighted strategies that could improve care, such as providing food vouchers or farmer’s market vouchers to patients, as well as a strategy already being employed in some cities of connecting patients to food programs.

“I definitely think it should be part of an HIV practice, just like HIV practices should think about housing situation and substance use and mental illness and everything else that can decrease adherence to HIV treatment,” Gandhi said.

Leddy and Weiser recommended similar interventions, underscoring the importance of “consistent access to nutritious and high-quality food.”

“ID clinicians should assess their patients’ food situation. If their patients are food insecure, they should link them to local food support services,” they said. – by Marley Ghizzone


Leddy AM, et al. Clin Infect Dis. 2019;doi:10.1093/cid/ciz1007.

Disclosures: Leddy reports receiving grants from the NIH during the study. Please see the study for all other authors’ relevant financial disclosures. Gandhi reports no relevant financial disclosures.