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
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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)