adults initiating ART in rural Tanzania Carolyn Fahey Prosper Njau Ntuli Kapologwe William Dow and Sandra McCoy July 25 2017 9th IAS Conference on HIV Science Food insecurity is a barrier to HIV care ID: 630609
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Slide1
The effects of short-term cash and food incentives on food insecurity and labor force participation among adults initiating ART in rural Tanzania
Carolyn Fahey, Prosper Njau, Ntuli Kapologwe, William Dow, and Sandra McCoyJuly 25, 20179th IAS Conference on HIV ScienceSlide2
Food insecurity is a barrier to HIV care
Food Insecurity
Adherence & Retention
Nutritional Status
Livelihood Activities
Weiser et al. 2011; Singer, Weiser & McCoy 2015
Inadequate access to food of sufficient quantity and quality, or the inability to acquire food in socially acceptable ways.
(UN, 2001)Slide3
Short-term cash/food assistance can improve ART adherence & retention
Improved ART adherence & retention in care after 6 months of randomized cash/food incentives in Tanzania (McCoy et al. 2017)MPR≥95%: 63% comparison vs. 85% cash
(P<0.01), 79% food (
P<0.01)Other evidence:
Zambia
(Cantrell et al. 2008,
Tirivayi
et al. 2012)
Haiti
(Ivers et al. 2010)Honduras (Martinez et al. 2014)Slide4
Limited understanding of pathways
Food Insecurity
Adherence & Retention
Nutritional Status
Livelihood Activities
Cash/Food Assistance
Weiser et al. 2011; Singer, Weiser & McCoy 2015Slide5
Mixed evidence for effects of cash/food on food insecurityFood assistance
Zambia ( adherence): weightHaiti (
visit attendance):
food security,
BMI
Honduras (
adherence):
food security,
BMIUganda: weight among ART naive,
weight among ART patientsCash or economic assistanceMalawi (
ability to obtain ARVs): food security Kenya (
viral suppression):
food security
Cantrell 2008,
Tirivayi
2012;
Ivers
2010; Martinez 2014 &
Palar
2015;
Rawat
2010; Miller &
Tsoka
2012; Weiser 2015
No effect Positive effect Negative effectSlide6
Study ObjectiveTo examine the effects of short-term cash and food incentives on food
security, nutrition, and livelihoods.Protocol: McCoy SI et al. BMC Infectious Diseases 2015;15:490.Trial Registration: Clinicaltrials.gov, NCT01957917
Ethical Approvals: National Institute for Medical Research & UC BerkeleySlide7
Study Population and SettingPLHIV at 3 HIV primary care clinics in Shinyanga, Tanzania
Inclusion criteria:≥18 years Initiated ART ≤90 days before enrollmentFood insecure (Household Hunger Scale, FANTA 2011)Exclusion criteria: Severe malnourishment (BMI<16 kg/m
2)Slide8
Study Design: Randomized Trial
Standard of care
Nutrition assessment & counseling
Cash
Monthly cash transfer
22,500 TZS (~$11)
Food
Monthly food basket
12kg maize flour + 3kg beans + 3kg groundnuts (~$11)
Up to 6 consecutive months of support.
Conditional on attending scheduled visits.
Comparison
InterventionSlide9
OutcomesFood securityHousehold Hunger Scale (HHS): severe hunger
Household Food Insecurity Access Scale (HFIAS): score 0-27Nutritional statusBody-mass index (BMI, kg/m²)Weight gain (kg)Participation in livelihood activitiesCurrently workingFunctional limitation (inability to work due to illness)
USAID, Food and Nutrition Technical Assistance Project (FANTA)
Poster Exhibitions
: Expenditures (TUPED1334), effect heterogeneity (TUPED1299) Slide10
Baseline Characteristics
Overall
(
n
=800)
Study group
P
a
Comparison
(
n
=112
)
Intervention
(n=688)
Demographics
Age
(years)
37 (10.3)
35 (9.3)
37 (10.5)
0.05
Female
509
(
64%)
73 (65%)
436 (64%)0.71Swahili is primary language489 (61%)80 (71%)409 (59%)0.02No formal education194 (24%)23 (21%)171 (25%)0.32Farmer (primary occupation)405 (51%)47 (42%)358 (52%)0.05Clinical characteristicsCD4 cell count (cells/μl) b210 (149)218 (160)
548 (160)0.58
WHO
clinical stage
3-4
453 (57%)
56 (51%)
397 (58%)
0.14
Data are mean (SD) or n (%). a. Chi-squared test for categorical variables and t-test for continuous variables. b.
n
=637.Slide11
Baseline Outcome Values
Overall
(
n
=800)
Study group
P
a
Comparison
(
n
=112
)
Intervention
(n=688)
Food security
HHS: Severe
328 (41%)
41 (37%)
287
(
42%)
0.31
HFIAS (0-27)
15.9 (5.2)
15.6 (5.2)
15.9 (5.2)0.59Nutritional statusBMI (kg/m2) b21.5 (3.5)21.7 (3.3)21.4 (3.5)0.40Weight (kg)56.5 (9.4)58.1 (10.2)56.2 (9.2)0.04Livelihood activitiesCurrently working462 (58%)72 (64%)390 (57%)0.13Functional limitation
439 (55%)64 (57%)
375 (55%)
0.60
Data are mean (SD) or n (%). HHS=Household Hunger Scale; HFIAS=Household Food Insecurity Access Scale;
BMI=Body-mass index. a. Chi-squared (
χ²
) test for categorical variables and t-test for continuous variables. b.
n
=772. Slide12
Participants assessed at 6 monthsSlide13
Outcomes at 6 months
Comparison
estimate (SE)
Intervention
estimate (SE)
P
Food security
HHS: Severe
13.4%
(0.06)
10.2%
(0.02)
0.57
HFIAS (0-27)
10.5
(1.3)
10.3
(0.3)
0.86
Nutritional status
BMI
(kg/m
2
)
22.2
(0.22)
22.5 (0.12)0.25Weight gain (kg)2.1 (0.42)2.4 (0.19)0.61Livelihood activitiesCurrently working72% (0.07)72% (0.02)0.97Functional limitation25% (0.07)11% (0.01)0.02Adjusted for baseline imbalances including age, language, occupation, and weight. Weighted using inverse probability of missing (IPW) 6-month assessment.Slide14
Changes in outcomesSlide15
Limitations
Attrition.Some self-reported outcomes.Small effects of cash/food may be obscured by strong benefits of starting ART.Slide16
DiscussionCash and food incentives increased ART adherence and retention.
Food security, nutrition and livelihoods improved within groups.Incentives did not augment these improvements.Except for significantly less functional limitation.
Suggests that cash and food transfers acted primarily via the price incentive to increase ART adherence, rather than
income effects. Future studies are needed
to understand long-term effects, and mechanisms that may increase and
sustain retention in HIV
services. Slide17
Acknowledgements
UC BerkeleyDr. Sandra McCoyDr. William DowDr. Nicholas JewellDr. Nancy PadianDr. Nancy CzaickiFinancial SupportNIH/NIMH: K01MH94246, R03MH105327
Shinyanga Regional Medical Office
Dr. Ntuli Kapologwe
Ms. Agatha
Mynippembe
Ministry
of Health, Gender, Community Development, Elderly and Children
Dr. Prosper
Njau