Policy Brief

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

October 3, 2019

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 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.


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.

  • Services at Project Open Hand
    • New client and 6-month re-certification requirements: POH application, completed by medical provider; picture identification; proof of income; proof of residence; and POH dietician assessment.
    • Two service levels: level one clients receive 7 frozen meals or fresh groceries equal to 7 meals weekly; level two clients receive both 7 frozen meals and fresh groceries equal to 7 meals weekly.
    • Clients can pick-up food weekly at the POH grocery center in downtown Oakland. Qualified individuals receive weekly food delivery, but are not able to choose the fresh groceries option.
    • Medically tailored meals: meal plans designed by registered dieticians to meet the nutritional needs of clients with chronic health conditions, served hot and available frozen.
    • Fresh groceries: includes a balanced variety or proteins, dairy, fruits, vegetables, and grains.
    • Nutrition education: on-site registered dietician provides counseling, regular check-ins, and works with clients to ensure POH meets client dietary needs.

Key Findings

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

ThemeSub-Themes and Representative Quotes
for Project
Open Hand
Project Open Hand outreach to healthcare providers increases client referrals

Q1: “So I think one of the struggles that we have at POH is keeping our services kind of front of mind. When a patient's in a doctor's office, and they have all these other things that they are talking about, at what point does - not even Project Open Hand - but at what point does food security come into that conversation?...I definitely saw the response [after doing outreach]. I saw more referrals. But you do kind of see this trickling off of those referrals. So it's like this cycle where I would do a presentation and then a few months later check back in and see if they wanted another presentation. Or just kind of tending to those relationships…I'd say we've seen about a six percent increase…I know we've started receiving referrals from places that we haven't been seeing them from before….[T]wo years ago, we were seeing maybe 200 people pick up in the grocery center a week, and now it's closer to 300.” –Staff at Project Open Hand
Hot meals served during weekly food pick-ups, especially helpful for marginally housed clients

Q2: “[W]hen you come in to pick up your groceries every week, they give you hot tray, and that helps out also. I like it, and I like that variety of it, how they switch it up…their variety selection is good…So, praise to their chefs and their team out there, figuring those pieces out…And, it's also balanced. There is a vegetable, there's a carbohydrate, and there is a protein most of the time. So, that balances out the meal all together on one plate.” –Project Open Hand client
On-site registered dietician services

Q3:“I like the nutritionist…I love her. She's wonderful. She's very caring and very thorough. She calls periodically and checks on me to make sure we're on the same page as far as my regimen, and things I'm supposed to be eating, and my breakfast menu, and things like that. She sounds like she's really concerned as opposed to, this is my job and I'm going to ask you these questions so I can hurry up. I don't feel like I'm rushed. I feel like she really cares.” -Project Open Hand client
Barriers the Project Open Hand Services Burdensome certification requirements for Project Open Hand services

Q4: “Couple times - a few times I wasn't [able to shop] - because most of the time because the paperwork wasn't in on time… Every six months you have to provide that you're eligible to be able to shop here. I mean, that you fit the criteria to be eligible maybe, something from your doctor, proof of income, meet with [the registered dietician]. Now that's a criteria - you have to meet with her, the nutritionist, before - at a certain time of year. If you don't, then you're not able to shop until you do those things…I think that's a little much…It used to be once a year, which was great, but now it's every six months, and I think that's a little bit too much, especially when you don't have transportation. So you have to go to all these places and get these things and so forth andso on. And then six months go by so fast, yeah. And especially if nothing changed you still have to get those things and get them in. -Client at Project Open Hand
Lack of knowledge about POH delivery and phone consultation options for people with difficulty leaving home

Q5: “So something like Project Open Hand, which I've never done yet…Probably they won't do it but if they had like an outreach where they come to you and they say, ‘Well, this is what we have. We can sign you up here. This is what we have available in our pantry. You just mark down what you want and we'll give it to you, like bring it to you,’ that would be great for me. But I know they probably wouldn't do that but I'm just saying if they did something like that it would be great.” –Person living with HIV, not a Project Open Hand client
Inadequate accessible transportation support

Q6: “It’s also financial too. I've got to come up with the bus fare. Years ago, I used to get a bus pass monthly but now any time I get on the bus I have to pay so that also comes up. I'm going to the doctor. If I'm going to whatever I have to do I'm paying out of pocket. For some people it may be just a little drop in the bucket but twenty bucks is a lot for me because I could be doing a lot with twenty bucks.” –Person living with HIV, not a Project Open Hand client
Feedback on food resources in Alameda CountyClients who rely heavily or completely on POH services experience acute food insecurity in response to decreases in service eligibility

Q7: “Then, they changed the menu around, a year ago…[I]t cut down on some of my eating habits…Everybody asked why, and they said it was too many people. Now, that, I kind of believe. Still, why make us suffer?”
Interviewer: “Are you saying that, because you weren't getting frozen [prepared meals], you
were eating less?”
Participant: “Yes. After they had they cutbacks, I cut back…So, each week, had to decide which food I'm getting. I'm getting the [frozen prepared meals] already cooked, or I'm getting the [groceries] I can cook myself. That's really - I really have to cut back [eating]…I don't think it was right and I still don't.” –Project Open Hand client
Partnership with apps/tech-based modalities to improve access to healthy food

Q8: “How would they ideally provide a service to me?...I'm kind of homebound…If you could help, kind of like have a list of what, like I said, foods you have available in your pantry or even maybe on a website, whatever. And somebody can like, like they do at Safeway's now or Amazon. You just add it to a cart and give them an order and they bring it to you…So now if they had a service like that it would just be so much easier, and I think perhaps people that also are in my situation or even perhaps they have other issues that they can't get out there, that if they could do it that way and know that what you have you're going to bring to me and it's good.” -Person living with HIV, not a Project Open Hand client
Capital investment in POH Oakland to improve their capacity to provide medically-tailored meals to PLWH

Q9: “I would love to see a kitchen on this side so that we could be more self-sufficient and have
a lot more control of the food that's distributed in this area. And that would require more staffing, more capital expenses. I think we would need to have maybe also like a hub and spokes model where we have one main site, kind of like they have in San Francisco. There's one main site where the admin lives, the kitchen lives, and then we have satellite sites throughout
the county, or even throughout the city of Oakland. If we were able to have some presence in East Oakland, I think we would definitely meet a bigger need there…And so that would meet people where they are. The idea is that would meet people where they are, in their neighborhoods.” –Staff at Project Open Hand

  • References
    1. Weiser, Sheri D., Sera L. Young, Craig R. Cohen, Margot B. Kushel, Alexander C. Tsai, Phyllis C. Tien, Abigail M. Hatcher, Edward A. Frongillo, and David R. Bangsberg. “Conceptual Framework for Understanding the Bidirectional Links between Food Insecurity and HIV/AIDS.” The American Journal of Clinical Nutrition 94, no. 6 (December 1, 2011): 1729S–1739S. https://doi.org/10.3945/ajcn.111.012070.
    2. Palar, Kartika, Tessa Napoles, Lee L. Hufstedler, Hilary Seligman, Fredrick M. Hecht, Kimberly Madsen, Mark Ryle, Simon Pitchford, Edward A. Frongillo, and Sheri D. Weiser. “Comprehensive and Medically Appropriate Food Support Is Associated with Improved HIV and Diabetes Health.” Journal of Urban Health 94, no. 1 (February 1, 2017): 87–99. https://doi.org/10.1007/s11524-016-0129-7.
    3. Palar, K., Frongillo, E. A.; Riley, E; Ryle, M; Madsen, K; O’Donnell, A; Napoles, T; Sheira, LA; Phillips, B; Weiser, SD. (2018). Health Impacts of Medically-Appropriate Food Support in the San Francisco Bay Area: Results of the Changing Health through Food Support (CHEFS) randomized trial [Conference abstract]. 13th International Conference on HIV Treatment and Prevention. Miami, FL.
    4. “Food Insecurity in Alameda County, Feeding America Map the Meal Gap.” Accessed on April 16, 2019. http://map.feedingamerica.org/county/2016/overall/california/county/alameda
    5. Kordovski, Victoria M., Steven Paul Woods, Marizela Verduzco, Jessica Beltran. “The Effects of Aging and HIV Disease on Employment Status and Functioning.” Rehabilitation Psychology 62, no. 4 (November 2017): 591-599.
    6. “Clarifications on Ryan White Program Client Eligibility Determinations and Recertifications Requirements.” Accessed on July 10, 2019. https://hab.hrsa.gov/sites/default/files/hab/Global/pcn1302clienteligibility.pdf
  • Acknowledgments

    This report was developed using funds from the California HIV/AIDS Research Program, Office of the President, University of California, Grant Number RP15-SF-096 (Steward, PI).