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Food Security and Antiretroviral Therapy Adherence Among People Living with Hiv in Lundazi District, Zambia: a Pilot Study

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Food Security and Antiretroviral Therapy Adherence Among People Living with Hiv in Lundazi District, Zambia: a Pilot Study FOOD SECURITY AND ANTIRETROVIRAL THERAPY ADHERENCE AMONG PEOPLE LIVING WITH HIV IN LUNDAZI DISTRICT, ZAMBIA: A PILOT STUDY Rainier DeVera Masa A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the School of Social Work. Chapel Hill 2016 Approved by: Gina A.N. Chowa Kathleen A. Rounds Kavita Singh Ongechi Shenyang Guo Michael Sherraden © 2016 Rainier DeVera Masa ALL RIGHTS RESERVED ii ABSTRACT Rainier DeVera Masa: Food Security and Antiretroviral Therapy Adherence among People Living with HIV in Lundazi District, Zambia: A Pilot Study (Under the direction of Gina A.N. Chowa) Food security, or adequate access to food at all times, is critical to the health and well- being of people living with HIV (PLHIV). Research has shown that food insecurity is associated with suboptimal adherence to antiretroviral therapy (ART). Nonadherence, in turn, predicts adverse health outcomes, including higher risk of mortality. However, evidence remains limited on the prevalence, correlates and effects of food insecurity on treatment adherence, as well as appropriate strategies to improve food security in rural and resource-limited settings. This dissertation aims to: 1) expand the literature on food insecurity and ART adherence in resource- limited settings, particularly in rural communities; and 2) examine the effectiveness of an income-generating strategy to increase food security and treatment adherence among PLHIV in Lundazi District, Eastern Province, Zambia. The study sample included 101 PLHIV who were attending two health facilities in Lundazi District and participating in a pilot integrated HIV and livelihood program. Consistent with prior research, food insecurity was highly prevalent among the study sample. Ninety-three and 95 percent of the sample were food insecure at baseline and follow-up, respectively. In addition, at least 70% of the sample was severely food-insecure at both time points. In this rural sample of PLHIV, food insecurity was predicted by lack of economic security in the household. Lower income, fewer assets, and having debts were significantly associated with food insecurity. Results also indicated an inverse, albeit not statistically significant, association between food insecurity and treatment adherence. Food- insecure PLHIV were less likely to achieve optimal treatment adherence contrasted with food- secure PLHIV. Finally, participation in a livelihood program contributed to statistically iii significant increase in food security, as well as positive effect on treatment adherence. Findings suggest that food security can be improved using a promising intervention that targets underlying social and economic determinants of food insecurity among PLHIV. Implications of findings for social work policy, practice, and research, as well as key study limitations, are discussed. iv In loving memory of my father, Generoso Montecillo Masa. v ACKNOWLEDGEMENTS Foremost, I express my sincerest gratitude to my advisor and mentor, Dr. Gina Chowa for the generous and continuous support of my dissertation research. She represents the kind of scholar I hope to be. Her guidance, enthusiasm, encouragement, and immense knowledge assisted and motivated me in all stages of my dissertation and scholarly training. Her support was instrumental in making my dissertation topic a reality – from a concept developed in our offices in Chapel Hill to an actual project implemented in Lundazi District in Zambia. It was no easy task to complete a dissertation topic conducted in a project setting nearly 8,000 miles away from Chapel Hill. This dissertation would not have happened without her generosity and backing. I could not have imagined a better advisor and mentor for my doctoral studies. I also thank my dissertation committee: Dr. Kathleen Rounds, Dr. Kavita Singh Ongechi, Dr. Shenyang Guo, and Dr. Michael Sherraden, for their encouragement and support, insightful comments, and challenging inquiries. Also, this dissertation would not have been possible without financial support from UNC School of Social Work and the Armfield-Reeves Innovation Fund. My tremendous gratitude goes to Victor Nyirenda for overseeing research activities in Lundazi. I am truly grateful for all his support in making this dissertation a reality. I thank all the interviewers, treatment supporters, and clinicians at Lumezi Mission Hospital and Lundazi District Hospital for their vital contributions to this project. Most importantly, I express my gratitude to all individuals who consented and participated in this study. Every one of them continues to inspire me to search for meaningful solutions to ensure that people living with HIV in resource-limited settings are surviving and thriving. vi Last but not the least, I am grateful to my family and friends: my spouse, life partner and best friend, Matthew Wescom, for the enduring support and encouragement; my mother, Lucia Masa, an educator herself, for instilling in me from an early age the value of learning and for supporting and believing in me; my very good friend and de facto mentor, Dr. Richard Ferrigno, for opening my eyes to immense possibilities and guiding and encouraging me to pursue graduate studies; my parents-in-law, Gary and Faith Wescom for the support and encouragement; and all my family and friends in the Philippines, Chapel Hill, St. Louis, and Zambia for all their support along the way. vii TABLE OF CONTENTS LIST OF TABLES ............................................................................................................................ xi LIST OF FIGURES ....................................................................................................................... xiii LIST OF ABBREVIATIONS .......................................................................................................... xiv INTRODUCTION ............................................................................................................................. 1 CHAPTER 1: BACKGROUND AND SIGNIFICANCE..................................................................... 6 Food Insecurity and HIV/AIDS in sub-Saharan Africa ...................................................... 6 Interaction of food insecurity and HIV/AIDS in SSA: A reciprocal link ................. 7 Definition of food insecurity .................................................................................. 12 Importance of food and nutrition for PLHIV ........................................................ 15 Summary ................................................................................................................ 17 Food Insecurity and Antiretroviral Therapy Adherence in sub-Saharan Africa ............... 18 Definition of adherence. ........................................................................................ 19 ART adherence in SSA .......................................................................................... 20 Food insecurity as a barrier to ART adherence .................................................... 23 How food insecurity contributes to treatment nonadherence .............................. 27 Interaction of Food and ART Medications ........................................................... 32 Effects of Adherence to ART ................................................................................. 34 Summary ............................................................................................................... 36 Interventions for Food Security for PLHIV: Integrated with HIV Treatment .................. 37 Food assistance programs .................................................................................... 38 Integrated HIV and livelihood programs .............................................................. 41 Combination food assistance and livelihood programs ....................................... 44 viii Analysis of interventions for food security and ART adherence ...........................45 Summary and implications for research................................................................45 Background Information on Zambia ................................................................................. 47 CHAPTER 2: THEORIES AND CONCEPTUAL FRAMEWORK, PROGRAM MODEL AND, RESEARCH QUESTIONS ...................................................... 57 Theories and Conceptual Framework ................................................................................ 57 Health belief model .............................................................................................. 58 Social cognitive theory ......................................................................................... .61 Conservation of resources theory ........................................................................ 63 Memberships theory of poverty ........................................................................... 66 Information-motivation-strategy model ............................................................. 68 Integrated conceptual framework for food insecurity and ART adherence ..................................................................................................... 69 Summary ............................................................................................................... 71 Program Model: Integrated HIV and Livelihood Program ............................................... 71 Empirical support for the program model
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