Improving Health-Related Quality of Life among People Living with HIV: Results from an Impact Evaluation of a Food Assistance Program in Uganda

August Improving Health-Related Quality of Life among People Living with HIV: Results from an Impact Evaluation of a Food Assistance Program in Uganda John A. Maluccio 0 1 Tia Palermo 0 1 Suneetha Kadiyala 0 1 Rahul Rawat 0 1 0 1 Department of Economics, Middlebury College, Middlebury, Vermont, United States of America, 2 Program in Public Health, Stony Brook University (SUNY), Stony Brook, New York, United States of America, 3 Department of Population Health, London School of Hygiene and Tropical Medicine , London , United Kingdom , 4 Poverty, Health , and Nutrition Division, International Food Policy Research Institute , Dakar , Senegal 1 Editor: Eduard J Beck , UNAIDS, TRINIDAD AND TOBAGO - Widespread food insecurity in Africa continues to compromise an effective response to the AIDS epidemic. Health-related quality of life (HRQoL) is a comprehensive indicator of physical, mental, and social well-being that is associated with food insecurity and increasingly used to assess the well-being of people living with HIV/AIDS (PLHIV). We examined the impact of a food assistance intervention, previously shown to have reduced household food insecurity and improved nutritional status, on HRQoL of PLHIV. We capitalized on an existing intervention targeting antiretroviral therapy (ART)- naïve PLHIV in Uganda, and conducted a prospective impact evaluation including a treatment and a comparison group. Data analyzed included 640 participants from two districts (318 in the intervention district) interviewed in both clinic and household settings at baseline and again approximately one year later. The main outcomes considered were physical and mental health dimensions of HRQoL, and other outcomes included self- and healthcare provider-reported symptoms. We utilized difference-in-difference propensity score matching methodologies to infer causality and examine program impacts. Over 12 months, food assistance significantly increased physical health scores (PHS) by 2.85 (P < .01) or approximately 0.35 SD, and reduced substantially the number of self- and healthcare provider-reported HIV-related symptoms by 3.83 and 2.68, respectively (P < .01). There was no significant impact, however, on mental health scores (MHS). Abbreviations: (ART), Antiretroviral therapy; (ATT), average treatment on the treated; (BMI), body-mass index; (g), grams; (HRQoL), Health-related quality of life; (HFIAS), Household Food Insecurity Access Scale; (MHS), mental health summary score; (MOSHIV), Medical Outcomes Study HIV Health Survey; (PLHIV), People living with HIV/AIDS; (PHS), physical health summary score; (SD), standard deviation; (TASO), The AIDS Support Organization; (WFP), World Food Programme; (WHO), World Health Organization. This study demonstrates the potential importance for HRQoL of including food assistance programming as part of the standard of care for PLHIV in areas of widespread food insecurity. HIV/AIDS exacerbates food insecurity through its effects on the productivity of prime workingage adults and, in a mutually reinforcing cycle, food insecurity diminishes the health and welfare of people living with HIV (PLHIV). Prevalent in Uganda and other regions of sub-Saharan Africa, especially among PLHIV [1,2], food insecurity is associated with nutrient inadequacy [3], poor self-reported health [4,5], high-risk behaviors [6], cardiovascular risk factors and diabetes [7], and mortality [8]. Moreover, it has been shown to compromise retention in care and treatment programs, as well as adherence to anti-retroviral therapy (ART) [9,10]. Consequently, improving food security is recognized as fundamental across the four pillars—prevention, care, treatment, and mitigation—of a holistic response to the AIDS epidemic [11–13]. With this recognition has come increased emphasis on food security interventions and growing evidence on their effectiveness. Research has demonstrated that interventions such as food assistance often are able to improve the food security and nutritional status of PLHIV, for example, but generally do not affect immunological outcomes such as CD4 count or disease progression [14–17]. There is minimal evidence, however, on whether food security interventions can improve other important welfare indicators such as health-related quality of life (HRQoL), which captures physical, mental, and social well-being. This is an important evidence gap as consideration of HRQoL and its role has grown in recent years [9,18–23] and it has been argued that programs incorporating economic strengthening have high potential for improving quality of life [24]. Pozniak [19] argues that recent findings from high-income settings demonstrate PLHIV (including those on ART) typically have lower levels of HRQoL than the general population [18], but that additional research is needed. Furthermore, studies from Africa demonstrate that among PLHIV, worsening HIV disease progression, as measured by lower CD4 count or higher viral loads, is asso (...truncated)