In many parts of the world, food insecurity and hunger overlap with the HIV epidemic. To learn more about the effects of food insecurity on HIV treatment and care, Sandra McCoy, an assistant professor of epidemiology at the UC Berkeley School of Public Health, initiated a large study in Tanzania. The goal of the study was to determine whether short-term cash transfers or food assistance could improve retention in HIV care and antiretroviral therapy (ART) adherence better than the standard of care services.
“This is probably the most rigorous and largest study of its kind to date,” says McCoy. “It’s also the first rigorous study of conditional cash transfers for antiretroviral therapy adherence in sub-Saharan Africa, where the HIV-epidemic is concentrated.”
The study showed that both food assistance and cash transfers increased adherence to treatment and retention in care, although cash transfers were more effective than food assistance after the assistance period was over. It also concluded that cash transfers cost less than food transfers, are easier to implement, and are often preferred by patients.
“The results suggest that cash transfers are feasible and acceptable in this setting and that they can be effective to improve health among people with HIV infection,” says McCoy.
The study randomized 805 adult patients at three HIV clinics in Shinyanga, Tanzania, to one of three groups and measured retention in care and ART adherence. The first group received the standard of care services including nutrition assessment and counseling (NAC). The second group was given NAC plus the opportunity to receive up to six monthly cash transfers for attending scheduled visits, allowing patients decide how to use the money. The last group received NAC plus the opportunity to receive up to six monthly food baskets for attending scheduled visits. Patients were followed for the 6-month intervention period and then for another 6 months post-intervention.
The researchers found that, after the 6-month intervention period, 85 percent of the group that received cash transfers adhered to their treatment, compared to 79 percent of the group that received food assistance and 63 percent of the group that received standard services. Furthermore, fewer patients who received cash or food disengaged from care at 6 months, with 11% of people lost to follow-up in the standard services group compared to 1% and 1.5% in the cash and food groups, respectively. At 12 months, 6 months after the incentives had ended, the positive effects on adherence and retention in care were sustained in the cash group. An analysis by quarter revealed that the interventions’ effects were strongest in the first 3 months of the program, shortly after treatment initiation.
“The first three months are a critical window for intervention, when people are starting treatment for the first time, establishing new adherence habits, and re-formulating their identities to include their HIV-infected status,” says McCoy.
Future research will focus on cost-effectiveness of the interventions and understanding the pathways through which the incentives work. The findings of this study were presented at the International AIDS conference in Durban, South Africa in July and at a Center for Global Public Health Symposium at UC Berkeley in October.
The UC Berkeley School of Public Health research team included Carolyn Fahey, PhD student in epidemiology; Dr. Nancy Czaicki, former PhD student in epidemiology; Nicholas Jewell, professor of biostatistics and statistics; William Dow, professor of health policy and management; and Nancy Padian, adjunct professor of epidemiology. Other research partners were Dr. Prosper Njau and Dr. Ntuli Kapologwe from the Ministry of Health, Community Development, Gender, Equity, and Children in Tanzania; and Associate Professor Suneetha Kadiyala from the London School of Hygiene and Tropical Medicine.
The project was funded by the National Institute of Health and PEPFAR.
By Jasmin Huynh