Food is Medicine for HIV: Improved health and hospitalizations in the Changing Health through Food Support (CHEFS-HIV) pragmatic randomized trial.

BACKGROUND: Policy support for "Food is Medicine"-medically tailored meals or groceries to improve health-is rapidly growing. No randomized trials have heretofore investigated the benefits of medically tailored food programs for people living with HIV (PLHIV). METHODS: The CHEFS-HIV pragmatic randomized trial included PLHIV who were clients of Project Open Hand (POH), a San Francisco-based nonprofit food organization. The intervention arm (n = 93) received comprehensive medically tailored meals, groceries, and nutritional education. Control participants (n = 98) received less intensive (POH "standard of care") food services. Health, nutrition, and behavioral outcomes were assessed at baseline and 6 months later. Primary outcomes measured were viral non-suppression and health related quality of life. Mixed models estimated treatment effects as differences-in-differences between arms. RESULTS: The intervention arm had lower odds of hospitalization (odds ratio [OR] = 0.11), food insecurity (OR = 0.23), depressive symptoms (OR = 0.32), antiretroviral therapy adherence <90% (OR = 0.18), and unprotected sex (OR = 0.18), and less fatty food consumption (ß= -0.170 servings/day) over 6 months, compared to the control arm. There was no difference between study arms in viral non-suppression and health-related quality of life over 6 months. CONCLUSIONS: A "Food-is-Medicine" intervention reduced hospitalizations and improved mental and physical health among PLHIV, despite no impact on viral suppression. CLINICAL TRIALS REGISTRATION: NCT03191253.

Preliminary Effects of an Urban Gardens and Peer Nutritional Counseling Intervention on HIV Treatment Adherence and Detectable Viral Load Among People with HIV and Food Insecurity: Evidence from a Pilot Cluster Randomized Controlled Trial in the Dominican Republic.

A pilot cluster randomized controlled trial involving two HIV clinics in the Dominican Republic assessed preliminary efficacy of an urban garden and peer nutritional counseling intervention. A total of 115 participants (52 intervention, 63 control) with moderate or severe food insecurity and sub-optimal antiretroviral therapy (ART) adherence and/or detectable viral load were assessed at baseline, 6- and 12-months. Longitudinal multivariate regression analysis controlling for socio-demographics and accounting for serial cluster correlation found that the intervention: reduced the prevalence of detectable viral load by 20 percentage points at 12 months; reduced any missed clinic appointments by 34 and 16 percentage points at 6 and 12 months; increased the probability of "perfect" ART adherence by 24 and 20 percentage points at 6 and 12 months; and decreased food insecurity at 6 and 12 months. Results are promising and warrant a larger controlled trial to establish intervention efficacy for improving HIV clinical outcomes.Trial registry Clinical Trials Identifier: NCT03568682.

RESUMEN: Un estudio piloto de un ensayo controlado aleatorio por conglomerados que involucró a dos clínicas del VIH en la República Dominicana evaluó de forma preliminar la eficacia de una intervención de huertos urbanos y consejería nutricional entre pares. Un total de 115 participantes (52 de intervención, 63 de control) con inseguridad alimentaria moderada o grave y con adherencia subóptima a la terapia antirretroviral (TARV) y/o carga viral detectable fueron evaluados al inicio del estudio, y a los 6 y 12 meses. El análisis de regresión longitudinal multivariada controlando por variables sociodemográficas y tomando en cuenta la correlación serial de clúster encontró que la intervención: redujo la prevalencia de carga viral detectable en 20 puntos porcentuales a los 12 meses; redujo las citas clínicas perdidas en 34 y 16 puntos porcentuales a los 6 y 12 meses; aumentó la probabilidad de adherencia "perfecta" al TARV en 24 y 20 puntos porcentuales a los 6 y 12 meses; y disminuyó la inseguridad alimentaria a los 6 y 12 meses. Los resultados son prometedores y justifican un ensayo controlado más grande para establecer la eficacia de la intervención en mejorar los resultados clínicos del VIH.

Longitudinal Relationship Between Food Insecurity, Engagement in Care, and ART Adherence Among US Women Living with HIV.

Food insecurity disproportionately affects people with HIV and women in the United States (US). More evidence is needed to understand the interplay between levels of food insecurity and levels of antiretroviral therapy (ART) adherence over time, as well as how food insecurity relates to engagement in HIV care. We used random effects models with longitudinal data from the US Women's Interagency HIV Study to estimate the (1) adjusted associations of current and 6-month lagged food security with ART adherence categories (n = 1646), and (2) adjusted associations of food security with engagement-in-care (n = 1733). Very low food security was associated with a higher relative risk of ART non-adherence at prior and current visits compared with food security, and this association increased across non-adherence categories. Very low food security was associated with lower odds of receiving HIV care and higher odds of a missed visit. Food insecurity among US women with HIV is associated with poorer engagement in care and degree of ART non-adherence over time.

Exploring feasibility and acceptability of an integrated urban gardens and peer nutritional counselling intervention for people with HIV in the Dominican Republic.

OBJECTIVE: Food security interventions with people living with HIV (PLHIV) are needed to improve HIV outcomes. This process evaluation of a pilot intervention involving urban gardening and peer nutritional counselling with PLHIV assesses feasibility, acceptability and implementation challenges to inform scale-up. DESIGN: Mixed methods were used, including quantitative data on intervention participation and feasibility and acceptability among participants (n 45) and qualitative data from a purposive sample of participants (n 21). Audio-recorded interviews were transcribed and coded using a codebook developed iteratively. SETTING: An HIV clinic in the northwest-central part of the Dominican Republic. RESULTS: The intervention was feasible for most participants: 84 % attended a garden workshop and 71 % established an urban garden; 91 % received all three core nutritional counselling sessions; and 73 % attended the cooking workshop. The intervention was also highly acceptable: nearly, all participants (93-96 %) rated the gardening as 'helpful' or 'very helpful' for taking HIV medications, their mental/emotional well-being and staying healthy; similarly, high percentages (89-97 %) rated the nutrition counselling 'helpful' or 'very helpful' for following a healthy diet, reducing unhealthy foods and increasing fruit/vegetable intake. Garden barriers included lack of space and animals/pests. Transportation barriers impeded nutritional counselling. Harvested veggies were consumed by participants' households, shared with neighbours and family, and sold in the community. Many emphasised that comradery with other PLHIV helped them cope with HIV-related marginalisation. CONCLUSION: An urban gardens and peer nutritional counselling intervention with PLHIV was feasible and acceptable; however, addressing issues of transportation, pests and space is necessary for equitable participation and benefit.

Assessing the Health Outcomes of the Food Access Pilot Project: An Evaluation of a Medically Supportive Food Support Program for People Living with HIV in Rural California Counties.

Food insecurity disproportionately affects rural communities and people living with HIV (PLHIV). The Food Access Pilot Project (FAPP) was a California state-funded program that provided home-delivered, medically supportive meals via online meal vendors to food-insecure PLHIV in three rural counties. We performed longitudinal, retrospective analyses of FAPP participant data (n = 158; 504 and 460 person-time observations for viral load and CD4 count, respectively) over 36 months from a Ryan White client management database. Pre-post analyses demonstrated increased prevalence of food security and CD4 ≥ 500 between baseline and 12 months. Population-averaged trends using generalized estimating equations adjusted for participant demographics demonstrated increased odds of viral suppression and CD4 ≥ 500, and increased CD4 count (cells/mm3) for every six months of program enrollment. Home-delivered, medically supportive meals may improve food security status, HIV viral suppression, and immune health for low-income PLHIV in rural settings.

Exploring antiretroviral therapy adherence, competing needs, and viral suppression among people living with HIV and food insecurity in the Dominican Republic.

Understanding factors related to suboptimal adherence to antiretroviral therapy (ART) and detectable viral load (VL), especially among vulnerable populations, is needed to improve HIV outcomes. The Caribbean is highly impacted by HIV and socioeconomic inequalities, but few studies have been conducted there to explore food insecurity among people with HIV and factors associated with viral suppression in this vulnerable population. Using baseline data from a pilot intervention trial among people living with HIV and food insecurity in the Dominican Republic, we examined psychosocial and behavioral factors associated with viral suppression, ART adherence, and competing needs. Among participants (n = 115), 61% had a detectable VL; the strongest factor associated with detectable VL was having missed taking ART in the last six months due to not having food (OR = 2.68, p = 0.02). Greater odds of reporting missed ART doses due to not having food were associated with severe food insecurity (OR = 4.60, p = 0.006), clinical depression (OR = 2.76, p = 0.018), Haitian background (OR = 6.62 p = 0.017), and internalized HIV stigma (OR = 1.09, p = 0.041), while lower odds were associated with social support (OR = 0.89, p = 0.03) and having health insurance (OR = 0.27, p = 0.017). Ensuring that people with HIV and food insecurity have food to take with their ART is essential for viral suppression.

Longitudinal Associations Between Neighborhood Factors and HIV Care Outcomes in the WIHS.

Identifying structural determinants affecting HIV outcomes is important for informing interventions across heterogeneous geographies. Longitudinal hierarchical generalized mixed-effects models were used to quantify the associations between changes in certain structural-level factors on HIV care engagement, medication adherence, and viral suppression. Among women living with HIV in the WIHS, ten-unit increases in census-tract level proportions of unemployment, poverty, and lack of car ownership were inversely associated with viral suppression and medication adherence, while educational attainment and owner-occupied housing were positively associated with both outcomes. Notably, increased residential stability (aOR 5.68, 95% CI 2.93, 9.04) was positively associated with HIV care engagement, as were unemployment (aOR: 1.59, 95% CI 1.57, 1.60), lack of car ownership (aOR 1.14, 95% CI 1.13, 1.15), and female-headed households (aOR 1.23, 95% CI 1.22, 1.23). This underscores the importance of understanding neighborhood context, including factors that may not always be considered influential, in achieving optimal HIV-related outcomes.

Food Insecurity and Chronic Disease in US Young Adults: Findings from the National Longitudinal Study of Adolescent to Adult Health.

BACKGROUND: Food insecurity, or the limited or uncertain access to food resulting from inadequate financial resources, is associated with a higher prevalence of chronic disease in adulthood. Little is known about these relationships specifically in young adulthood, an important time for the development of chronic disease. OBJECTIVE: To determine the association between food insecurity and chronic disease including diabetes, hypertension, obesity, and obstructive airway disease in a nationally representative sample of US young adults. DESIGN: Cross-sectional nationally representative data collected from Wave IV (2008) of the National Longitudinal Study of Adolescent to Adult Health was analyzed using multiple logistic regression models. PARTICIPANTS: US young adults ages 24-32 years old MAIN MEASURES: Food insecurity and general health; self-reported diabetes, hypertension, hyperlipidemia, "very overweight," and obstructive airway disease; measured obesity derived from body mass index; and inadequate disease control (hemoglobin A1c ≥ 7.0%, blood pressure ≥ 140/90 mmHg) among those with reported diabetes and hypertension. KEY RESULTS: Of the 14,786 young adults in the sample, 11% were food insecure. Food-insecure young adults had greater odds of self-reported poor health (2.63, 95% confidence interval (CI) 1.63-4.24), diabetes (1.67, 95% CI 1.18-2.37), hypertension (1.40, 95% CI 1.14-1.72), being "very overweight" (1.30, 95% CI 1.08-1.57), and obstructive airway disease (1.48, 95% CI 1.22-1.80) in adjusted models compared with young adults who were food secure. Food insecurity was not associated with inadequate disease control among those with diabetes or hypertension. CONCLUSIONS: Food insecurity is associated with several self-reported chronic diseases and obesity in young adulthood. Health care providers should screen for food insecurity in young adults and provide referrals when appropriate. Future research should evaluate the impact of early interventions to combat food insecurity on the prevention of downstream health effects in later adulthood.

Persistent Food Insecurity Is Associated with Adverse Mental Health among Women Living with or at Risk of HIV in the United States.

BACKGROUND: Food insecurity and mental health negatively affect the lives of women in the United States. Participants in the Women's Interagency HIV Study (WIHS) provided the opportunity to understand the association of food insecurity with depression and mental well-being over time. OBJECTIVE: We investigated the association between current and persistent food insecurity and depression among women at risk of or living with HIV in the United States. METHODS: We used longitudinal data from the WIHS, a prospective cohort study in women at risk of or living with HIV from multiple sites in the United States. Participants completed 6 semiannual assessments from 2013 to 2016 on food security (FS; high, marginal, low, and very low) and mental health (i.e., depressive symptoms and mental well-being). We used multiple regression analysis to estimate the association between these variables. RESULTS: Among 2551 participants, 44% were food insecure and 35% reported depressive symptoms indicative of probable depression. Current marginal, low, and very low FS were associated with 2.1-, 3.5-, and 5.5-point (all P < 0.001) higher depression scores, respectively. In models adjusting for both current and previous FS, previous marginal, low, and very low FS were associated with 0.2-, 0.93-, and 1.52-point higher scores, respectively (all P < 0.001). Women with very low FS at both time points (persistent food insecurity) had a 6.86-point higher depression score (P < 0.001). In the mental health models, there was a dose-response relation between current FS and worse mental health even when controlling for previous FS (all P < 0.001). Previous low FS was associated with worse mental health. These associations did not differ by HIV status. CONCLUSIONS: Food insecurity placed women at risk of depression and poor mental well-being, but the risk was substantially higher for women experiencing persistent food insecurity. Future interventions to improve women's mental health call for multilevel components that include addressing food insecurity.

Food insecurity is associated with anxiety, stress, and symptoms of posttraumatic stress disorder in a cohort of women with or at risk of HIV in the United States.

BACKGROUND: Food insecurity, which disproportionately affects marginalized women in the United States, is associated with depressive symptoms. Few studies have examined relations of food insecurity with other mental health outcomes. OBJECTIVE: The aim of this study was to investigate the associations of food insecurity with symptoms of generalized anxiety disorder (GAD), stress, and posttraumatic stress disorder (PTSD) in the Women's Interagency HIV Study (WIHS), a prospective cohort study of women with or at risk of HIV in the United States. METHODS: Participants were 2553 women with or at risk of HIV, predominantly African American/black (71.6%). Structured questionnaires were conducted during April 2013-March 2016 every 6 mo. Food security (FS) was the primary predictor, measured using the Household Food Security Survey Module. We measured longitudinal outcomes for GAD (GAD-7 score and a binary GAD-7 screener for moderate-to-severe GAD). Only cross-sectional data were available for outcomes measuring perceived stress (PSS-10 score) and PTSD (PCL-C score and a binary PCL-C screener for PTSD). We examined associations of FS with the outcomes through use of multivariable linear and logistic regression, including lagged associations with GAD outcomes. RESULTS: After adjusting for sociodemographic and health-related factors including HIV serostatus, current marginal, low, and very low FS were associated with increasingly higher GAD-7 scores, and with 1.41 (95% CI: 1.10, 1.80; P < 0.01), 2.03 (95% CI: 1.59, 2.61; P < 0.001), and 3.23 (95% CI: 2.43, 4.29; P < 0.001) times higher odds of screening positive for moderate-to-severe GAD, respectively. Low and very low FS at the previous visit (6 mo earlier) were independently associated with GAD outcomes at current visit. Associations of FS with PSS-10 and PCL-C scores exhibited similar dose-response relations. Very low FS was associated with 1.93 (95% CI: 1.15, 3.24; P < 0.05) times higher odds of screening positive for PTSD. CONCLUSIONS: Food insecurity may be associated with a range of poor mental health outcomes among women in the United States with or at risk of HIV.

Food Insecurity, Internalized Stigma, and Depressive Symptoms Among Women Living with HIV in the United States.

Food insecurity, internalized HIV stigma, and depressive symptoms are independently associated with poor HIV outcomes. Food insecurity, stigma, and depression may be interrelated among women living with HIV (WLHIV). We hypothesized that food insecurity would be independently associated with internalized stigma and depressive symptoms among WLHIV in the United States (US), and would partially account for associations between stigma and depressive symptoms. We tested hypotheses using regression models and partial correlation analysis with cross-sectional data among 1317 WLHIV from the Women's Interagency HIV Study. In adjusted models, greater food insecurity was associated with internalized HIV stigma and depressive symptoms (all p < 0.05), exhibiting dose-response relationships. Food insecurity accounted for 23.2% of the total shared variance between depressive symptoms and internalized stigma. Food insecurity is associated with depressive symptoms and internalized HIV stigma among US WLHIV, and may play a role in the negative cycle of depression and internalized stigma.

Severe food insecurity is associated with overweight and increased body fat among people living with HIV in the Dominican Republic.

Food insecurity is an important risk factor for overweight and obesity among low-income populations in high income countries, but has not been well-studied among people living with HIV (PLHIV), particularly in resource-poor settings. To explore the association between food insecurity and overweight and obesity among PLHIV in the Dominican Republic, we conducted a cross-sectional study of 160 HIV-infected adults between March-December 2012 in four geographically-dispersed health centers (Santo Domingo, Puerto Plata, San Juan, and Higuey). We collected information on household food insecurity, anthropometric measurements, and socio-demographic data and ran descriptive and multivariate analyses, controlling for fixed effects of clinics and using robust standard errors. Mean age ± SD of participants was 39.9 ± 10.5 years; 68% were women, and 78% were on antiretroviral therapy (ART). A total of 58% reported severe household food insecurity. After controlling for age, gender, income, having children at home, education, and ART status, severe food insecurity was associated with increased body mass index (BMI) (ß = 1.891, p = 0.023) and body fat (ß = 4.004, p = 0.007). Age and female gender were also associated with increased body fat (ß = 0.259, p < 0.001 and ß = 8.568, p < 0.001, respectively) and age and ART status were associated with increased waist circumference (ß = 0.279, p = 0.011 and ß = 5.768, p = 0.046, respectively). When overweight was examined as a dichotomous variable (BMI ≥ 25.0), severe food insecurity was associated with an increased odds of 3.060 (p = 0.013); no other covariates were independently associated with overweight. The association of severe food insecurity with increased BMI, body fat, and overweight among PLHIV has important implications for clinical care as well as food security and nutrition interventions in resource-poor settings. Integrated programs that combine nutrition education or counseling with sustainable approaches to addressing food insecurity among PLHIV are needed to improve long-term health outcomes of this vulnerable population.

Food Insecurity is Associated with Poor HIV Outcomes Among Women in the United States.

Women in the general population experience more food insecurity than men. Few studies have examined food insecurity's impact on HIV treatment outcomes among women. We examined the association between food insecurity and HIV outcomes in a multi-site sample of HIV-infected women in the United States (n = 1154). Two-fifths (40%) of participants reported food insecurity. In an adjusted multivariable Tobit regression model, food insecurity was associated with 2.08 times higher viral load (95% confidence interval (CI): 1.04, 4.15) and lower CD4+ counts (- 42.10, CI: - 81.16, - 3.03). Integration of food insecurity alleviation into HIV programs may improve HIV outcomes in women.

Comprehensive and Medically Appropriate Food Support Is Associated with Improved HIV and Diabetes Health.

Food insecurity is associated with negative chronic health outcomes, yet few studies have examined how providing medically appropriate food assistance to food-insecure individuals may improve health outcomes in resource-rich settings. We evaluated a community-based food support intervention in the San Francisco Bay Area for people living with HIV and/or type 2 diabetes mellitus (T2DM) to determine the feasibility, acceptability, and potential impact of the intervention on nutritional, mental health, disease management, healthcare utilization, and physical health outcomes. The 6-month intervention provided meals and snacks designed to comprise 100% of daily energy requirements and meet nutritional guidelines for a healthy diet. We assessed paired outcomes at baseline and 6 months using validated measures. Paired t tests and McNemar exact tests were used with continuous and dichotomous outcomes, respectively, to compare pre-post changes. Fifty-two participants (out of 72 initiators) had both baseline and follow-up assessments, including 23 with HIV, 24 with T2DM, and 7 with both HIV and T2DM. Median food pick-up adherence was 93%. Comparing baseline to follow-up, very low food security decreased from 59.6% to 11.5% (p < 0.0001). Frequency of consumption of fats (p = 0.003) decreased, while frequency increased for fruits and vegetables (p = 0.011). Among people with diabetes, frequency of sugar consumption decreased (p = 0.006). We also observed decreased depressive symptoms (p = 0.028) and binge drinking (p = 0.008). At follow-up, fewer participants sacrificed food for healthcare (p = 0.007) or prescriptions (p = 0.046), or sacrificed healthcare for food (p = 0.029). Among people with HIV, 95% adherence to antiretroviral therapy increased from 47 to 70% (p = 0.046). Among people with T2DM, diabetes distress (p < 0.001), and perceived diabetes self-management (p = 0.007) improved. Comprehensive, medically appropriate food support is feasible and may improve multiple health outcomes for food-insecure individuals living with chronic health conditions. Future studies should formally test the impact of medically appropriate food support interventions for food-insecure populations through rigorous, randomized controlled designs.

Food Insecurity is Longitudinally Associated with Depressive Symptoms Among Homeless and Marginally-Housed Individuals Living with HIV.

Depression and food insecurity are prevalent among people with HIV (PLHIV) and contribute to poor HIV outcomes. Longitudinal data can help clarify the effect of food insecurity on depression among PLHIV in the United States. We assessed the longitudinal association of food insecurity with symptoms of depression using validated measures among participants living with HIV from the Research on Access to Care in the Homeless cohort in San Francisco. We followed 346 participants for a median of 28 months. Over half of participants (55.0 %) were food insecure and 35.8 % had symptoms of depression. In adjusted models, severe food insecurity in the previous period was associated with increased depressive symptom severity (b = 1.22; p < 0.001). The association remained statistically significant in models including participant fixed effects. Severe food insecurity was also longitudinally associated with a binary variable indicating probable depression. Efforts to increase access to and participation in food security safety net programs for PLHIV could improve depression.

Impact of food support on food security and body weight among HIV antiretroviral therapy recipients in Honduras: a pilot intervention trial.

Optimal strategies to improve food security and nutrition for people living with HIV (PLHIV) may differ in settings where overweight and obesity are prevalent and cardiovascular disease risk is a concern. However, no studies among PLHIV have investigated the impact of food support on nutritional outcomes in these settings. We therefore assessed the effect of food support on food insecurity and body weight in a population of PLHIV with high prevalence of overweight and obesity. We implemented a pilot intervention trial in four government-run HIV clinics in Honduras. The trial tested the effect of a monthly household food ration plus nutrition education (n = 203), compared to nutrition education alone (n = 197), over 12 months. Participants were clinic patients receiving antiretroviral therapy (ART). Assessments were obtained at baseline, 6 and 12 months. Primary outcomes for this analysis were food security, using the validated Latin American and Caribbean Food Security Scale and body weight (kg). Thirty-one percent of participants were overweight (22%) or obese (8%) at baseline. At 6 months, the probability of severe food insecurity decreased by 48.3% (p < 0.01) in the food support group, compared to 11.6% in the education-only group (p < 0.01). Among overweight or obese participants, food support led to average weight gain of 1.13 kg (p < 0.01), while nutrition education alone was associated with average weight loss of 0.72 kg (p < 0.10). Nutrition education alone was associated with weight gain among underweight and normal weight participants. Household food support may improve food security but not necessarily nutritional status of ART recipients above and beyond nutrition education. Improving nutritional tailoring of food support and testing the impact of nutrition education should be prioritized for PLHIV in Latin America and similar settings.

Tailored nutrition education and food assistance improve adherence to HIV antiretroviral therapy: evidence from Honduras.

Food insecurity and malnutrition negatively affect adherence to antiretroviral therapy (ART) and are associated with poor HIV clinical outcomes. We examined the effect of providing household food assistance and nutrition education on ART adherence. A 12-month prospective clinical trial compared the effect of a monthly household food basket (FB) plus nutrition education (NE) versus NE alone on ART adherence on 400 HIV patients at four clinics in Honduras. Participants had been receiving ART for an average of 3.7 years and were selected because they had suboptimal adherence. Primary outcome measures were missed clinic appointments, delayed prescription refills, and self-reported missed doses of ART. These three adherence measures improved for both groups over 12 months (p < 0.01), mostly within 6 months. On-time prescription refills improved for the FB plus NE group by 19.6 % more than the group receiving NE alone after 6 months (p < 0.01), with no further change at 12 months. Change in missed appointments and self-reported missed ART doses did not significantly differ by intervention group.

Facilitators and barriers to HIV activities in religious congregations: perspectives of clergy and lay leaders from a diverse urban sample.

This paper examines facilitators and barriers to HIV activities within religious congregations, the relative internal or external sources of these influences, and suggestive differences across congregational types. Results are based on in-depth interviews with clergy and lay leaders (n = 57) from 14 congregations in Los Angeles County, California, purposively selected to reflect diversity in racial-ethnic composition, denomination, size, and HIV activity level. Many common facilitators and barriers were related to norms and attitudes, only a few of which appeared overtly associated with theological orientations. Clergy support was a facilitator particularly prevalent among congregations having higher HIV activity levels, indicating its importance in sustaining and expanding HIV programs. Resource issues were also prominent, with material resource barriers more frequently mentioned by smaller congregations and human resource barriers more among larger congregations. Organizational structure issues were mostly centered on external linkages with various social service, public health, and faith-based entities. Analysis of internal versus external sources highlights the roles of different stakeholders within and outside congregations in promoting HIV activities. Potential differences across congregational types represent fruitful areas for future research.

Perceived Impacts of Urban Gardens and Peer Nutritional Counseling for People Living With HIV in the Dominican Republic.

OBJECTIVE: Explore participants' perceptions of urban gardens and peer nutritional counseling intervention for people with HIV and food insecurity on antiretroviral therapy in the Dominican Republic. METHODS: Semistructured endline interviews (n = 21) with intervention participants about their perceptions of diet, health, and quality of life. A codebook was applied to verbatim transcripts, and coded data were analyzed using matrices to identify themes. RESULTS: Participants were mostly Dominican (86%; 14% Haitian); 57% were men; the mean age was 45 years. The most salient experiences described by intervention participants were improved dietary quality and diversity, improved food security, and saving money. Participants also emphasized improved social interactions, mental health, and emotional well-being. CONCLUSIONS AND IMPLICATIONS: Urban gardens and peer nutritional counseling may improve participants' diet and psychosocial well-being. Nutrition programs with marginalized populations may need to improve access to healthy foods and build camaraderie and linkages to programs addressing structural factors.

Changes in HIV Internalized and Experienced Stigmas and Social Support After an Urban Gardens and Peer Nutritional Counseling Intervention Among People With HIV and Food Insecurity in the Dominican Republic.

BACKGROUND: Food insecurity and HIV-related stigma negatively affect HIV outcomes. Few studies have examined how food security interventions affect HIV-related stigma and social support. SETTING: Two HIV clinics in the Dominican Republic. METHODS: A pilot cluster randomized controlled trial of an urban gardens and peer nutritional counseling intervention was conducted to examine outcomes of HIV-related stigmas and social support. Adult patients (≥18 years of age) with moderate or severe household food insecurity and evidence of suboptimal ART adherence and/or a detectable viral load were enrolled; standard measures of internalized and experienced stigmas and social support were collected at baseline and at 6 and 12 months. Intervention clinic participants received training and materials from agronomists for a home garden, 3-4 sessions of nutritional counseling from the clinic's peer counselor, and a garden produce cooking workshop facilitated by professional nutritionists. RESULTS: Of 109 study participants (46 intervention and 63 control), 103 (94%) completed 12-month follow-up. Difference-in-differences multivariate longitudinal linear regressions adjusting for sociodemographic factors found that intervention participants had reduced internalized stigma by 3.04 points (scale 0-32) at 12 months (P = 0.002); reduced probability of experiencing HIV-related stigma or discrimination in the past 6 months (20 percentage points at 6 months, P = 0.05 and 25 percentage points at 12 months, P = 0.02); and modestly improved social support at 12 months (1.85 points on 30-pt scale, P = 0.093). CONCLUSION: A fully powered, larger trial is needed to establish the efficacy of the intervention and assess pathways by which the intervention may improve HIV stigma and social support.