Running head: INTEGRATED REVIEW

Integrated Review: Food Insecurity and Antiretroviral Therapy
Rachel G. English
Nursing Research
December 4, 2015

I have neither given nor received aid, other than acknowledged,
on this assignment, nor have I seen anyone else do so.
-Rachel G. English

1

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Abstract

The aim of this integrated review is to explore research on the influence food insecurity plays on
the use of antiretroviral therapy on Human Immunodeficiency (HIV) positive patients in subSaharan Africa. Food insecurity is the most common reason patients are not compliant with
their antiretroviral therapy treatment. It is estimated that 22.5 million persons in sub-Saharan
Africa with HIV or Acquired Immunodeficiency Syndrome (AIDS) are suffering from food
insecurity. The research design is an integrated review. The articles were found through the Bon
Secours Memorial College of Nursing library database using Elton B. Stevens Company
(EBSCO) Host and Pub Med. The inclusion criteria focused around the purpose being related to
food insecurity and its influence on antiretroviral therapy, which yielded five articles, two
qualitative and three quantitative articles. The findings and results of the five articles reviewed
show that there is a harmful relationship between food insecurity and the effectiveness of
antiretroviral therapy. The results of the five articles reviewed studied the relationship food
security plays on an HIV infected person and their adherence to antiretroviral therapy. The
nursing student’s lack of experience in writing integrated reviews, limits on the number of
articles used for the review, and the complexity of the reviewed studies contribute to the
limitations of this paper. In order to create sufficient interventions to correct this issue, more
research is recommended. Each of the articles’ results implied the need for food assistance
interventions for HIV men and women undergoing antiretroviral therapy.

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An Integrated Review: Food Insecurity and Antiretroviral Therapy
The purpose of this integrated review is to explore research on the influence food
insecurity plays on the use of antiretroviral therapy on HIV positive patients in sub-Saharan
Africa. HIV/AIDS, food insecurity, and under nutrition are interconnected and pose a greater risk
of mortality for the ones affected (Rawat, Faust, Maluccio, & Kadiyala, 2014). Food insecurity is
the most common reason patients are not compliant with their antiretroviral therapy treatment.
Food insecurity is, “the limited or uncertain availability of nutritionally adequate, safe foods or
the inability to acquire personally acceptable foods in socially acceptable ways” (Weiser et al.,
2010, p. 2). It is estimated that 22.5 million persons in sub-Saharan Africa with HIV/AIDS are
suffering from food insecurity; it is a major problem in HIV- affected households (Nagata et al.,
2012). Food insecurity is known as a major factor in antiretroviral non-adherence (Tsai et al.,
2011). The importance of food security for patients with HIV receiving antiretroviral therapy
was important to the researcher because of an experience she had while working in Botswana,
Africa. She helped care for many children with HIV who had access to medication but did not
have the resources for adequate nutrition. The PICO question for this study is as follows: In
people living with HIV from sub-Saharan Africa, how does food insecurity influence
antiretroviral therapy?
Design/Search Methods
The research design is an integrated review. The articles were found through the Bon
Secours Memorial College of Nursing library database using EBSCO Host and Pub Med. The
search words used included, ‘HIV’,’ AIDS’, ‘food’, ‘hunger’, ‘food assistance’, ‘food
insecurity’, ‘nutrition’, ‘sub-Saharan Africa’, ‘antiretroviral therapy’, ‘medication’ and,
‘treatment.’ The original search revealed a total of 61 articles from Pub Med and 49 from

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EBSCO Host and a review of the title and abstract excluded articles unrelated to the PICO
question. This left 25 articles that fit the required description. The chosen articles needed to be
peer-reviewed quantitative or qualitative research studies, published within the last ten years and
written in English. The articles selected were published between 2010-2015 and related to the
following PICO question: In people with HIV from Sub-Saharan Africa, how does food
insecurity influence ARV therapy. The reader reviewed each article and based the selection on
the inclusion criteria. The inclusion criteria focused around the purpose being related to food
insecurity and its influence on antiretroviral therapy. The articles that did not examine the
relationship described in the PICO question were omitted from the integrated review. This
process removed twenty articles leaving the reader with five articles, two qualitative and three
quantitative articles.
Findings/Results
The findings and results of the five articles reviewed show that there is a harmful
relationship between food insecurity and the effectiveness of antiretroviral therapy (Nagata et al.,
2012; Palar et al., 2012; Rawat et al., 2014; Tsai et al., 2011; Weiser et al., 2010). A summary of
each article can be found in Appendix A. The review of the five included articles can be
separated into the following two themes: outcomes of food insecurity and sample characteristics.
Outcomes of Food Insecurity
Each of the five articles studied in this integrated review obtained outcomes related to
food insecurity and the relationship between it and antiretroviral therapy (Nagata et al., 2012;
Palar et al., 2012; Rawat et al., 2014; Tsai et al., 2011; Weiser et al., 2010). These five articles all
aim to expose the detriment food insecurity places on an individual, however each take on a
unique approach to investigate and present their findings.

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The qualitative study using cross-sectional and parallel mixed methods by Nagata et al.,
(2015) explored the factors and outcomes of the lack of food in HIV positive persons living in
Kenya. In using systematic sampling, the researchers gathered 67 food insecure individuals
living with HIV. Data on the lived experiences, determinants and consequences of hunger was
collected using semi-structured questionnaires, surveys and interviews following the Household
Food Insecurity Access Scale (HFIAS). This data was then analyzed using both a simple and
multiple linear regression model as well as a backwards stepwise regression model. It was
concluded that greater age, greater number of children, not having a spouse, and living in a rural
area were among determinants that significantly contributed to food insecurity. Forty percent of
the reasons reported for not complying with the antiretroviral therapy were related to hunger and
food insecurity.
The quantitative, quasi-experimental study by Rawat et al., (2014) was intended to assess
the effect of providing monthly food baskets to 640 individuals living in Uganda with HIV. The
study design was a longitudinal and non-randomized control study. The authors studied the
individuals over 12 months and they were selected using a non-randomized sampling strategy.
The data was collected by biological measurements (body mass index, mid-upper arm
circumference, hemoglobin concentration and CD4 count), the HFIAS (food insecurity status),
Individual Dietary Diversity Score (diet quality). The overall variables studied included the
nutritional status, progression of HIV, health status, quality of life, diet quality, food insecurity,
and the antiretroviral adherence of the individuals over the 12-month period. To analyze the
collected data, the researchers used non-experimental matching techniques, difference-indifference estimators, the propensity score model and a heteroskedasticity robust variance
estimator. The results of this study showed that with the initiation of food baskets, there were

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significant findings to support a decrease in the HIV related symptoms experienced by the
individual. The food assistance helped to improve the patient’s body mass index, mid-upper arm
circumference and the household food insecurity.
The quantitative, ongoing prospective cohort study by Tsai et al., (2011) looked at the
relationship food insecurity had on individuals with HIV. The study focused on social support,
HIV- related stigma, and the disclosure of HIV serostatus. The study design and sampling
strategy were not identified. Four hundred and fifty six individuals were included from a local
hospital in Uganda. Data was collected using the HFIAS, Functional Social Support Scale,
Internalized AIDS-Related Stigma Scale, and an unnamed scale for enacted stigma developed by
the researchers. The study analyzes data by descriptive statistics and identifies inferential
statistics using the regression model. Results demonstrated that less social support and higher
levels of stigma related to HIV led to a greater amount of food insecurity. Each of the
investigated variables, social support, HIV-related stigma, and disclosure of HIV serostatus,
showed a statistically significant association with food insecurity
The qualitative study that used grounded theory by Weiser et al., (2010) directly relates
to the theme of food insecurity outcomes. The purpose was to determine the relationship between
food insecurity and antiretroviral therapy adherence in HIV patients. The study design was not
identified. The sample was collected using inductive and iterative sampling strategies and it
comprised of 47 men and women living with HIV/AIDS in Uganda. The researchers were
looking at the effect of food insecurity on the subjects and how the food insecurity could lead to
noncompliance in antiretroviral therapy. The data was collected by semi-structured and openended interview questions and analyzed by making conclusions and creating themes and subthemes according to data. The major findings concluded with five themes: increased appetite

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with antiretroviral therapy, worse side effects when medication is taken without food, the advice
to take medication with a balanced diet, competing demands of cost of food and health care
costs, and not being able to take medication on time due to working or searching for food. This
study found that food insecurity and hunger play a major role in an individuals compliance with
their antiretroviral medications; an individual is likely to delay initiation of therapy, skip a dose,
or even discontinue treatment as a result of food insecurity and the themes listed above.
And lastly, the quantitative, prospective cohort study by Palar et al., (2012) had a
different point of view on the relationship between food insecurity and antiretroviral therapy. The
purpose of this study was to examine food insecurity changes after patients experience their first
year receiving antiretroviral therapy. The study consecutively recruited 602 participants getting
ready to begin antiretroviral therapy in Uganda. Data was collected using the US Household
Food Security Survey Model, the Patient Health Questionnaire, the Medical Outcomes Study
HIV Health Survey, and the World Bank Living Standard Measurement Survey. This data
showed the status of food insecurity, mental and physical health and work status. Bivariate
statistics, a paired-test, McNemar’s test, and longitudinal multivariate logistic regression were
utilized when analyzing the data collected. The study found that initiating antiretroviral therapy
might decrease an individual’s food insecurity by way of decreasing depression symptoms and
improving employment status. This finding is different in that food security was claimed to be
found with the start of antiretroviral therapy where as the other four studies in this integrated
review showed food security should be provided in addition to antiretroviral therapy to ensure
adherence.

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Sample Characteristics
In completing the study of the five articles selected, all five utilized similar sample
characteristics including location and HIV status of the subjects (Nagata et al., 2012; Palar et al.,
2012; Rawat et al., 2014; Tsai et al., 2011; Weiser et al., 2010). There was also a similarity in the
minimum age of the subjects. Each study recruited individuals from a local HIV clinic in subSaharan Africa.
In Nyanza Province, Kenya, 67 persons with HIV were collected using systematic
sampling (Nagata et al., 2012). Each patient was either moderately or severely food insecure. 49
of the subjects were receiving antiretroviral treatment before the study began. It was required
that the persons chosen were older than 18 years old and were patients at the Family AIDS Care
and Education Services Sena Clinic; the health care providers at the clinic recruited the
participants.
For the 12-month quasi-experimental study (Rawat et al., 2014), 640 subjects were
recruited from The AIDS Support Organization (TASO) and the World Food Program (WFP).
The subjects were from the Gulu and Soroti Districts of Uganda, which commonly suffer from
food insecurity. The subjects were HIV positive and were required to be 18 years or older, not
pregnant, active patients at the TASO clinic, eligible for WFP assistance, had not received any
assistance in the last 12 months, had a CD4 count between 200-450, and had never received
antiretroviral therapy. The sampling strategy was non-randomized.
And for the 12-month prospective cohort study (Palar et al., 2012), 602 HIV positive
participants were gathered from the two clinics operated by the Joint Clinical Research Center in
Kampala and Kakira Uganda. The authors utilized consecutively sampling to recruit the subjects.

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The subjects were required to be over 18 years old with a CD4 count less than 400 and were
eligible for antiretroviral therapy but had never used the therapy.
In the study by Weiser et al., (2010), the sample comprised of 47 men and women
between 24 and 59 years old living with HIV/AIDS. Forty-one were patients from the Immune
Suppression Clinic and the remaining six were from the Adherence Monitoring Ugandan Cohort
Study (Weiser et al., 2010). Participants were from two areas: Mbarara and Kampala (Weiser et
al., 2010). 23 subjects are from rural areas, 13 from peri-urban and 11 subjects from urban areas;
this accounts for the different lifestyles and socioeconomic levels affected (Weiser et al., 2010).
To get a better representation, the researchers picked out 36 patients who had been on ARV
therapy and 11 who had not started the therapy yet (Weiser et al., 2010). This is important to get
the opinions of those experiencing it as well as those preparing to begin the therapy. The
requirement to be included in the study was to be 18 years or older, HIV-infected and receiving
HIV care at a clinic (Weiser et al., 2010). The researchers used inductive and iterative
approaches to gather samples. The staff at the HIV clinic was a large resource for the researchers
in picking out the subjects (Weiser et al., 2010).
A sample of 456 Ankole persons with HIV/AIDS living in the Mbarara District of
Uganda were collected for the ongoing- prospective cohort study by Tsai et al. (2011). The study
demonstrated that 71.4% of the total population was female and the median time to the clinic for
the sample was 40 minutes. The participants were recruited from the Mbarara Regional Referral
Hospital Immune Suppression Syndrome Clinic. The sample criteria for inclusion was clearly
explained and required that the patients were over 18 years old, were initiating antiretroviral
therapy and lived within 20 kilometers from the clinic. The sampling strategy was not stated nor

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was the power analysis stated. The attrition rate for the study was a total of 20 participants
(4.4%); those twenty patients “were lost to follow-up“ (Tsai et al., 2011, p. 1720).
Discussion/Implications
The results of the five articles reviewed studied the relationship food security plays on an
HIV infected person and their adherence to antiretroviral therapy. Each articles supported the
PICO question. Tsai et al., (2011) states “food insecurity is recognized as a key determinant of
reduced adherence to HIV antiretroviral therapy” (p. 1718). Many HIV patients choose not to
take their medication due to food and hunger related problems (Nagata et al., 2015). Through
Weiser et al.’s study, five ways in which food insecurity impacts antretoviral compliance were
discovered (2010). Two of the articles provided support to the postivie effects food assistance
can place on a patient recvieing antiretroviral therapy (Palar et al., 2012; Rawat et al., 2014).
Overall the studies concluded with similar suggestions. Each of the articles’ results
implied the need for food assistance interventions for HIV men and women undergoing
antiretroviral therapy (Nagata et al., 2012; Palar et al., 2012; Rawat et al., 2014; Tsai et al., 2011;
Weiser et al., 2010). One article made an all-encompassing statement, “freedom from hunger is a
basic human right and warrants immediate attention in its own right” (Weiser et al., 2010, p. 7).
Rawat et al., (2014) resolved that it should become the standard of care to provide food
assistance to patients with HIV suffering from food insecurity.
The ultimate goal per the World Health Organization, The Joint United Nations
Programme on HIV/AIDS, and World Food Programme is to put into practice interventions for
food and nutrition assistance. Tsai et al., (2011) clarified that “more research is needed to guide
the targeting of such interventions” (p. 1722). It is through continued randomized studies that the
“cycle of food insecurity and HIV/AIDS” may be interrupted (Tsai et al., 2011, p. 1722). The

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lack of a control group was pointed out in two of the studies; this is an area that should be
included in later studies (Nagata et al., 2015; Palar et al., 2012). In another article, the authors
recommend to future studies looking at the same topic to explore “more diverse qualitative
techniques to help triangulate findings” (Weiser et al., 2010, p. 7).
Limitations
This integrated review contains several limitations. The review only included five articles
total and those articles were from the previous five years; this is not an exhaustive review. This
integrated review was written for a class assignment. The researcher has limited experience in
writing integrated reviews.
There are a number of limitations found in the study articles reviewed. For example, a
power analysis was not mentioned in the three quantitative studies (Palar et al., 2012; Rawat
2014; Tsai et al., 2011). With the exclusion of the power analysis, it is unknown what size of
sample would be required for a valid study and how the authors decided on the size of the sample
(Fain, 2013). Both the qualitative studies included smaller sample sizes; this is appropriate due
to the large volume of narrative data in qualitative research (Nagata et al., 2012; Ryan, Coughlan
& Cronin, 2007; Weiser et al., 2012). Of the five articles reviewed, the strongest study was the
randomized control trial by Rawat et al. (2014). A randomized control study is the gold standard
for determining the strength and quality of the evidence (Fain, 2013). The next strongest studies
were prospective cohort studies by Palar et al., (2012) and Tsai et al., (2011). The type of study
was not included in the article of three studies (Palar et al., 2012; Tsai et al., 2011; Weiser et al.,
2010). The theoretical framework or conceptual framework was not mentioned in three of the
articles (Nagata et al., 2012; Rawat et al., 2014; Weiser et al., 2010). A theoretical framework is
important to determine the role theories play in the study (Coughlan, Cronin, & Ryan, 2007).

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Each of the qualitative articles clearly operationalized the variables (Palar et al., 2012; Rawat
2014; Tsai et al., 2011). Two of the quantitative articles did not mention validity (Palar et al.,
2012; Rawat et al., 2014). Validity is important because it identifies the accuracy of the
instruments; in this study the accuracy is unknown (Fain, 2013). One article did not mention
reliability (Rawat et al., 2014). Reliability is important so that the researcher may rely on the
results to be consistent with results obtained if the instrument were to be retested (Fain, 2013).
Lastly, one of the qualitative articles did not mention rigor (Nagata et al., 2012). Rigor is
important to note as it ensures trustworthiness (Ryan et al., 2007).
Conclusion
According to the findings of the five articles in this integrated review, food security does
have an influence on the patient’s compliance with the antiretroviral therapy (Nagata et al., 2012;
Palar et al., 2012; Rawat et al., 2014; Tsai et al., 2011; Weiser et al., 2010). The results of the
study by Weiser et al., (2010) expose the need of food assistance and the relationship between
food insecurity and HIV treatment. Tsai et al., (2011) adds that the issue of food insecurity can
be solved by structural interventions. Palar et al., (2012) concludes that those interventions
along with comprehensive care methods can create a positive effect for the individuals. “Both
HIV/AIDS and food insecurity are intertwined in a vicious cycle, with each heightening the
vulnerability to, and worsening the severity of, the other” (Tsai et al., 2011, p. 1718). The PICO
question addressed the crucial need for food assistance to be provided to people living with HIV
in sub-Saharan Africa receiving antiretroviral therapy.

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References

Coughlan, M., Cronin, P., & Ryan, F. (2007). Step-by-step guide to critiquing research. Part 1:
Quantitative research. British Journal of Nursing, 16 (11), 658-663. Retrieved from
http://www.huttvalleydhb.org.nz/content/e2d00f37-f0ed-4c59-b2bb-05254f2dec9b.cmr
Fain, J. (2013). Reading, Understanding, and Applying Nursing Research (4th ed.). Philadelphia,
PA: F. A. Davis Company.
Nagata, J., Magerenge, R., Young, S., Oguta, J., Weiser, S., & Cohen, C. (2015). Social
determinants, lived experiences, and consequences of household food insecurity among
persons living with HIV/AIDS on the shore of Lake Victoria, Kenya. AIDS Care, 24(6),
728-736. doi:10.1080/09540121.2011.630358
Rawat, R., Faust, E., Maluccio, J., & Kadiyala, S. (2014). The Impact of a Food Assistance
Program on Nutritional Status, Disease Progression, and Food Security Among People
Living With HIV in Uganda. Journal of Acquired Immune Deficiency Syndromes, 66(1),
E15-E22. DOI: 10.1097/QAI.0000000000000079
Ryan, F., Coughlan, M., & Cronin, P. (2007). Step-by-step guide to critiquing research. Part 2:
qualitative research. British Journal of Nursing, 16, 738-44. Retrieved from
http://www.magonlinelibrary.com/toc/bjon/current
Palar, K., Wagner, G., Ghosh-Dastidar, B., & Mugyenyi, P. (2012). Role of antiretroviral therapy
in improving food security among patients initiating HIV treatment and care. Aids, 26,
2375-2381. doi:10.1097/QAD.0b013e328359b809
Tsai, A., Bangsberg, D., Emenyonu, N., Senkungu, J., Martin, J., & Weiser, S. (2011). The social
context of food insecurity among persons living with HIV/AIDS in rural Uganda. Social
Science & Medicine, 73, 1717-1724. doi:10.1016/j.socscimed.2011.09.026

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Weiser, S., Tuller, D., Frongillo, E., Senkungu, J., Mukiibi, N., & Bangsberg, D. (2010). Food
Insecurity as a Barrier to Sustained Antiretroviral Therapy Adherence in Uganda. PLoS
ONE, 5(4), 1-8. doi:10.1371/journal.pone.0010340

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Appendix A
Evaluation Tables

First
Auth
or
(Year
)
J.
Nagat
a
(2012)

Conc
ept
Fram
ework
Not
menti
oned

Design/
Method

Sample/
Setting

-Purpose:
Investigate
s the
variables
among
individuals
living with
HIV/AIDS in
Kenya.
- Type of
study:
Parallel
mixed
methods
- Crosssectional
Philosophi
cal
approach:
Grounded
theory

-Who: 67
PLWHA
severely or
moderately
FI
Requirem
ents: Older
than 18 &
Had to be a
pt at the
FACES
- From:
FACES
- Sampling
Strategy:
Systematic
sampling

Major
Variables
Studied
(and their
definition)
- Lived
experience
Determinan
ts of FI
Consequen
ces of FI
- Hunger

Measure
ment

Data
Analysis

Findings

Appraisal:
Worth to
practice

- Semistructured
questionn
aire
- HFIAS
scale
- Surveys
&
Interviews

- Tools:
Simple &
multiple
linear
regression
model
Backwards
stepwise
regression
- Stat Sig:
p<0.05,
power of
80%
-Rigor: not
mentioned
- Validity:
HFIAS was
validated
Reliability:
not
mentioned

- Significant
determinants of food
insecurity include
increased age, a
greater number of
children, and not
being married
- Rural areas may
have higher levels of
FI
- More children, single
or widowed or older
age may increase FI.
- Increased hunger
and appetite after
therapy initiation,
ARV side effects
(n/v/diarrhea), &
hunger affecting
adherence (40% of
reasons they skipped
dose d/t hunger, FI, or
food)

- HIV
intervention
s should
address
food
insecurity
and hungerto promote
ART
adherence
and better
health
outcomes.
- PICO:
Provide
evidence to
support FI
impacts
patients and
the ARV
therapy
compliance.

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First
Auth
or
(Year
)
R.
Rawa
t
(2014
)

Con
cept
Fra
mewor
k
Not
men
tion
ed

Design/

16

Sample/
Setting

Method

-Purpose: To
evaluate the
impact of the
monthly
household food
basket
- Hypothesis:
food assistance
alleviates FI and
improves
nutritional
status and
disease
severity,
through food
intake.
- Type of
Study: Quasiexperimental
study
- Design of
Study: Nonrandomized
control trial &
longitudinal
study

- Sampling
Strategy: Nonrandomized
-Who: 640
PLWHA
Requirements
:
Non-pregnant,
over 18 years
old, patient of
TASO Clinics,
eligible for
WFP’s poverty
assistance, not
receiving food
assistance from
any source with
in last 12
months, CD4
count between
200-450 & ART
naïve.
- From: TASO
Clinics

Major
Variables
Studied
(and their
definition
)
Nutritional
status
(BMI,
MUAC, Hb
concentrat
ion)
- Disease
progressio
n (CD4
count)
- Health
status and
quality of
life
- FI (HFIAS)
& Diet
quality
(IDDS)
- ART
adherence
and
retention
in care

Measure
ment

Data
Analysis

Findings

Appraisal:
Worth to
practice

- BMI,
MUAC, Hb
concentra
tion, CD4
count
- HIFAS,
IDDS
- Nonexperime
ntal
matching
technique
s
Difference
-indifference
estimator
s
- Heteroskedastici
ty robust
variance
estimator

- Tools: initial
questionnaire,
CD4 count
drawn, Hb
concentration
drawn,
household
questionnaire,
12 month
interview
-Validity:
IDDS and
HIDAS are
validated.
Validated by
programs
worked
alongside
-Reliability:
not
mentioned
- Stat Sig:
p<0.01,
p<0.05

- SS 4.1
reduction in
the number of
reported
symptoms
related to HIV
in the previous
30 days.
- Food
assistance,
provided to
households of
ART-naïve
PLWHA in N.
Uganda,
significantly
improved BMI,
MUAC, and
household
food security.
- No impact of
food
assistance on
CD4 counts or
IDDS.

- Charge
to world:
Food
assistance
should be
part of the
standard of
care for
PLWHA in
areas of FI
- PICO:
This study
investigate
s a food
assistance
program,
which is
the
ultimate
solution for
my PICO
question.

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Firs
t
Aut
hor
(Yea
r)
K.
Palar
(201
2)

17

Conce
pt
Frame
-work

Design/
Method

Sample/
Setting

Major
Variables
Studied
(and their
definition)

Measure
ment

Data
Analysis

Findings

Appraisal:
Worth to
practice

Conce
ptual
framework
spoken
about
but not
identifi
ed.

-Purpose: to
examine how
the FI of a
treatmentnaïve
population
changes over
the first year
of HIV care.
Hypothesis:
ART will
influence
food security
via improved
mental
health,
improved
physical
health and
improved
ability to
work.
- Type of
Study: not
stated

- Sampling
Strategy:
consecutive
ly recruited
-Who: 602
participants
Requirem
ents: over
18 years
old, eligible
for ARTs,
CD4 count
less than
400, not
previously
receiving
HIV care.
- From:
two clinics
in Uganda
(Kampala
and Kakira)

- FI (5-item
scale from
the US
Household
Food Security
Survey
Model)
- Mental
health (PHQ9)
- Physical
health (MOSHIV health
survey)
- Work status
(binary
variable
defined as
having
worked in the
last 7 days.
Measured by
World Bank
Living
Standard
Measuremen

- US
Househol
d Food
Security
Survey
Model
- PHQ-9
- MOS-HIV
health
survey
- World
Bank
Living
Standard
Measurem
ent
Survey

- Tools:
bivariate
statistics,
paired ttest,
McNemar’
s test,
longitudin
al
multivaria
te logistic
regression
- Stat
Sig:
p<0.01
-Validity:
not
mentione
d
Reliabilit
y:
Cronbach’
s alpha
met for
USHFSSM

- ART benefits
people with HIV
beyond
improving their
health, and
extends the
range of
socioeconomic
benefits of ART
to include
improved food
security
- That greater
ability to work
and reduced
symptoms of
depression may
be the primary
pathways
through which
ART improves
food insecurity.
- ART improves
employment
status and
productivity for

- Charge to
world: Well
integrated and
implemented
interventions in
the context of
comprehensive
care have the
potential to
produce an
‘upward spiral’ in
which food
security and ART
can mutually
reinforce each
other for the
benefit of all
those in
treatment.
- How it relates
PICO?
This study
includes how
ART influences
the patients FI.

INTEGRATED REVIEW

18

- Design of
Study:
prospective
cohort study

Firs
t
Aut
hor
(Yea
r)
A.
Tsai
(201
1)

t Survey)

people with HIV

Concep
tual
Framew
ork

Design/
Method

Sample/
Setting

Major
Variables
Studied
(and their
definition)

Measur
ement

Data
Analysis

Findings

Appraisal: Worth
to practice

Concept
ual
framewo
rk used
but not
identifie
d

-Purpose: to
understand
the correlates
of food
insecurity
among PLWHA
in rural
Uganda, with a
specific focus
on the
associations
with social
support, HIVrelated stigma,
and HIV
serostatus
disclosure
- Hypothesis:
HIV serostatus
disclosure,

Samplin
g
Strategy
: not
provided
-Who:
456
PLWHA
Require
ments:
over 18
years old,
were
initiating
antiretrovi
ral
therapy,
and lived

- Food
security
(uncertain
or limited
availability
of
nutritionally
adequate
food, or as
being
unable to
procure
food in
socially
acceptable
ways)
- Social
support
(emotional,
financial, or

- HFIAS
(food
insecurit
y)
Function
al Social
Support
Scale
(Social
support)
Researc
her
develop
ed scale
for
enacted
stigma
-

- Tools:
descripti
ve
statistics
&
inferentia
l
statistics
using the
regressio
n model.
Validity:
not
mentione
d
Reliabili
ty: Each
scale

- Serostatus
disclosure,
social support,
and HIV stigma
had statistically
significant
associations
with food
insecurity
- FI is highly
prevalent
among ARTtreated PLWHA
in our study
area in rural
Uganda,
especially
women, and
that it is
seasonal and

- Charge to world:
recommended
incorporating food
and nutrition
interventions into
HIV/AIDS
programming, but
more research is
needed to guide the
targeting of such
interventions.
Structural
interventions are
needed to address
unequal gender
relations, food
insecurity, social
capital, and/or HIVrelated stigma in
the context of

INTEGRATED REVIEW
social support,
and HIVrelated stigma
would affect
food insecurity.
- Type of
Study: not
stated, but is
nonexperimental
- Design of
Study: Ongoing
prospective
cohort

First
Auth
or
(Year
)
S.
Weise
r
(2010)

Conc
ept
Fram
ework
Not
provid
ed

19
within 20
kilometer
s from the
clinic
- From:
Mbarara
Regional
Referral
Hospital
Immune
Suppressi
on
Syndrome
Clinic

instrument
al
assistance
received
from
others)
- HIVrelated
stigma
(enacted or
internalized
)
- HIV
serostatus
disclosure

Internali
zed
AIDSRelated
Stigma
Scale

met
Chronbac
h’s alpha
- Stat
Sig:
P<0.05,
P<0.01,
and
P<0.001

closely linked
to HIV-related
stigma and
social support.
The
- Lower levels
of social
support and
greater levels
of HIV-related
stigma are
strong
predictors of FI

ongoing HIV
treatment.
- PICO: provides
information on the
effects of food
insecurity and HIV.
“Food insecurity is
recognized as a key
determinant of
reduced adherence
to HIV antiretroviral
therapy”

Design/
Method

Sample/
Setting

Major
Variable
s
Studied

Measure
ment

Data
Analysis

Findings

Appraisal:
Worth to
practice

- Purpose: To understand
to
conceptualize
the role of
food
insecurity in
the lives of
HIV-infected
patients & to
investigate
the pathways
and

Sampling
Strategy:
inductive
and
iterative
-Who: 47
men and
women
Requirem
ents:
18 years

- The role
of food
insecurit
y in the
lives of
HIVinfected
patients
- How
food
insecurit
y could
lead to

- Semistructured
and open
ended
interview
questions

- Rigor:
was
achieved
in the
utilizatio
n of peer
debriefin
g and
consisten
t returns
to the
data
- Tools:

- Nutrition
interventions may be
an important adjunct
to the substantial
investment in ARV
programs in
resource-limited
setting
- That food insecurity
and hunger not only
interfere with day-today adherence but
that fears about

- Charge to
world:
Freedom from
hunger is a
basic human
right and
warrants
immediate
attention in its
own right.
The link
between food
insecurity and

INTEGRATED REVIEW
mechanisms
through which
food
insecurity
could lead to
missed doses
and treatment
interruptions
- Type of
Study: not
provided
- Major
Concepts:
the role of
food
insecurity in
the lives of
HIV-infected
patients” as
well as how
“food
insecurity
could lead to
missed doses
and treatment
interruptions”
Philosophica
l approach:
grounded
theory

20
or older,
HIVinfected
and
receiving
HIV care at
a clinic
- From:
(Mbarara
and
Kampala)

missed
doses
and
treatmen
t
interrupti
ons
- FI (the
limited or
uncertain
availabilit
y of
nutrition
ally
adequate
, safe
foods or
the
inability
to
acquire
personall
y
acceptab
le foods
in
socially
acceptab
le ways)

FI- food insecure
PLWHA- people living with HIV/AIDS
HFIAS- household food insecurity access scale
FACES- Family AIDS Care and Education Services
ARV- antiretroviral
ART- antiretroviral therapy
IDDS- Individual Dietary Diversity Score
SS- statically significant

Research
ers took
the
participa
nts
response
s to
interview
question
s and
drew
conclusio
ns to
create
themes
and subthemes

hunger and food
insecurity may also
cause people to
delay initiating or to
discontinue ARV
therapy
- Five mechanisms
through which food
insecurity impacted
ARV adherence:
increased hunger
with ARVs, worse
ARV side effects in
the absence of food,
counseling on the
need to take ARVs
with food, competing
demands between
food costs and health
care expenses, and
forgetting or being
unable to take ARV
doses while working
for or searching for
food.

poor ARV
outcomes
further
heightens the
importance of
addressing food
insecurity as
part of
comprehensive
care among
HIV-infected
individuals
worldwide
- How it
relates PICO?
Speaks to the
impact food
insecurity
places on HIV
infected
patients and
their ability to
comply with
treatment.

INTEGRATED REVIEW
PHQ-9- Patient Health Questionnaire
MOS-HIV- Medical Outcomes Study HIV

21