Food Insecurity and HIV Health: Nutrition Program Utilization among People Living with HIV in Alameda County, CA

Key steps to ending the HIV epidemic include ensuring that all people living with HIV (PLWH) are in care and improving their adherence to antiretroviral therapy (ART) to attain undetectable, non-transmittable viral status. Prior research demonstrates that food insecurity among PLWH leads to poorer HIV-related health outcomes [1], while nutritious food provision can improve outcomes, including better mental health, enhanced ART adherence, and reduced likelihood of being hospitalized [2, 3]. Ensuring that PLWH have access to healthy food resources thus has the potential to interrupt the cycle of food insecurity and poor health, contributing to efforts to end the epidemic.

Food insecurity affected 13.4% of people in Alameda County in 2016, representing a higher rate than state (11.7%) and national (12.9%) averages [4]. PLWH face increased strain around accessing adequate healthy food as the cost of living in the Bay Area skyrocketed and disability benefits remained stagnant [5]. Food resource utilization among PLWH in Alameda County is not well understood. Project Open Hand (POH), a long-established food resource for PLWH in the Bay Area, serves medically tailored meals to about 350 of the 6,000 PLWH in Alameda County. This brief report discusses the barriers and facilitators to POH utilization at their Oakland-based grocery center, and provides recommendations to improve access to healthy food resources among PLWH in the region.

“With me, the three meals a day is out of the question…And then with me having high blood pressure, I’ve got to watch the sodium intake on a lot of things. Sometimes I’ve just got to be like, ‘You know what, I can’t turn the back of this box over today. I just can’t. I can’t afford it…I can’t worry about it being high in sodium. It’s food.’”

– PLWH who is not a client at POH

To investigate factors related to POH utilization, we used semi-structured guides to interview 14 PLWH who are clients at the agency and 13 PLWH who are not clients. We recruited by posting fliers in the lobby at POH’s Oakland grocery center and at other local agencies that serve PLWH, as well as by word of mouth. We also recruited three staff members from agencies serving Alameda County that provide food support to PLWH, including POH and other agencies, in order to triangulate our findings from the PLWH sample and to provide insights into POH’s programming and infrastructure. We discussed experiences of food acquisition, community resource utilization, such as food and transportation, and practices related to acquiring, preparing and consuming food with our PLWH sample. With agency staff, we discussed perceived facilitators and barriers to PLWH accessing POH food and nutrition support, and interagency relationships between POH and agencies and clinics that refer PLWH to POH. Interviews lasted between 40 and 110 minutes, were audio recorded and transcribed. A team of analysts developed a codebook, guided by thematic analysis, and coded the transcripts in Dedoose, an online qualitative data analysis software tool.

We present our findings based on factors that facilitated access, or served as barriers, to food security programs. Each finding is illustrated with quotations from our participants (see Table 1). Prominent in our findings are narratives describing the grocery center environment as safe and welcoming, and positive experiences with POH staff and volunteers, facilitating POH utilization. Common narratives of barriers to utilizing POH services include getting to and from the grocery center in downtown Oakland, and the onerous paperwork required for client recertification every six months. Narratives from marginally housed individuals were of particular interest, and we highlight one such participant describing how hot meals at POH improve access to healthy food.

Facilitators to accessing Project Open Hand Services

• Consistent POH outreach efforts among local healthcare providers increases new client referrals. POH improved their outreach with positive results, increasing weekly meals served from about 200 to 300 between 2015 and 2018. (Q1)
• Hot meals served during weekly food pick up at the POH grocery center improves healthy food access for marginally housed and food insecure clients. (Q2)
• Nearly all POH clients interviewed describe positive and supportive experiences with staff, especially with the registered dietician during one-on-one meetings and in group educational settings. (Q3)

Barriers from accessing Project Open Hand Services

• Burdensome client (re)certification procedures, required at the federal, state, local, and agency levels: to initiate POH services, and every six months thereafter, clients must (1) verify HIV/AIDS diagnosis by having their medical provider complete a POH application, (2) verify identity with picture ID, (3) provide proof of income, (4) provide proof of residence, and (5) complete a POH dietician assessment.
  • • Many participants expressed frustration in the frequency paperwork is required, particularly because there were no changes to report. Some participants report gaps in food services while gathering necessary verification paperwork and fulfilling their dietician assessment. (Q4)
• Interviews with both POH clients and non-client PLWH revealed a lack of knowledge about general POH client eligibility, and the POH requirements for services such as food delivery, or nominating a proxy to collect food for a client. (Q5)
• A common barrier to accessing food at POH is affordable and reliable transportation to and from POH. Clients reported spending hours on public transit trying to arrive between the grocery center hours of 10am and 2pm Monday to Friday. (Q6)

Feedback about accessing food and nutrition support in Alameda County

• Although POH offers services that cover either one or two thirds of client daily caloric requirements, some participants rely completely on POH for food. Vulnerable POH clients experience acute food insecurity when POH implements changes in how much food clients qualify to pick up weekly. (Q7)

Policy implications to address food insecurity in Alameda County

Our findings support POH continuing to invest in outreach efforts among healthcare providers in Alameda County, highlighting details about POH eligibility and services to improve provider identification of PLWH who would benefit from POH services. To address difficulties PLWH face getting to and from POH, we recommend funding be made available to POH to provide transportation vouchers to PLWH. Additionally, our findings support POH changing their Oakland grocery center hours, currently Monday to Friday 10am and 2pm, to ease difficulties clients face in arranging transportation to POH within their limited hours of operation, and to improve overall availability of POH’s food services. We recommend increasing the number of hours open and considering a Tuesday to Saturday schedule, similar to that of the San Francisco POH grocery center. We recommend policymakers to consider food security an essential component of wrap-around services for PLWH, and identify appropriate funding streams to augment programs that pay for medically tailored meals, such as the Ryan White HIV/AIDS Program. (Q9) Agencies such as POH, and policymakers committed to addressing the needs of PLWH, may want to consider partnering with app-based technologies and other technological modalities to improve food and nutrition resource distribution. (Q8)

POH recertification every six months poses an excessive burden to clients and potential clients and interferes with POH accessibility. The Ryan White HIV/AIDS Program (RWHP), which partially funds food services for PLWH at POH, defines what information clients are required to verify and the frequency clients must show verification to (re)certify for services [6]. Additionally, the RWHP requirements are modified by state (California Office of AIDS) and local (Alameda County Ryan White Steering Committee) level administrators of RWHP funds. POH requirements for (re)certification go beyond those defined by the RWHP. Clarification is needed around what administration level (federal, state or local) defines the current POH requirements in order to investigate the feasibility of reducing re-certification requirements with the appropriate agencies.

Table 1. Themes and Representative Quotes