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Comparing Food and Cash Assistance for HIV-Positive Men and Women on Antiretroviral Therapy

Development Challenge

The challenges of living with HIV infection are complex and multifold, ranging from daily adherence to treatment, to maintaining a healthy weight, eating a well-balanced diet, and staying healthy enough to participate in the labor force.  Although there is no cure for HIV, antiretroviral therapy (ART) has significant clinical benefits and reduces transmission of the virus to others. But for ART to be effective, recipients must adhere to treatment regimens. In many resource-constrained settings, the cyclical combination of poverty, poor nutrition, and food insecurity increase the risk of trade-offs and often forces people living with HIV (PLHIV) to make difficult choices between food, medicine, and other essential goods and services. It has been hypothesized that improving food security could potentially improve the health of PLHIV. However, while there have been some lower quality studies on the benefits of food assistance, there is insufficient rigorous evidence on how best to support PLHIV and improve health outcomes.


In sub-Saharan Africa, the “syndemic” of HIV/AIDS and hunger is increasingly regarded as a barrier to ART success.[1] [2] High rates of extreme poverty, and the pervasive threat of food insecurity, have devastating health effects for PLHIV, exacerbating HIV’s effects on malnutrition and weight loss.  As a result, PLHIV have less energy to work and are at greater risk of opportunistic infections, which further undermines their income generation and access to nutrient-dense food.  Furthermore, PLHIV who initiate ART with low BMI have two to six times higher mortality rates than nonmalnourished patients in the first years of treatment.[3],[4] This suggests that food availability is especially critical in the first months of treatment.[5]  The focus of this project is therefore to examine whether providing support to PLHIV when they first initiate treatment – either in food or cash transfers – will improve the health and nutrition of PLHIV and other HIV-related outcom

Evaluation Strategy

Researchers will select food insecure HIV-positive men and women in Tanzania who recently initiated ART for the research study.  Food security status is determined with the Household Hunger Scale developed by the Food and Nutrition Technical Assistance III Project (FANTA). Participants are randomized into three groups: 1) 6 months of nutrition assessment and counseling (NAC) alone (standard of care), 2) NAC plus 6 months of food assistance (a monthly food basket consisting of maize meal, beans, and pulses), and 3) NAC plus 6 months of cash transfers (equivalent to the market value of the food basket). Receipt of the food and cash transfers is conditional on attending regularly scheduled treatment and care visits at the clinic.

The researchers will evaluate the comparative effectiveness of food and cash assistance to determine their effects on HIV outcomes including adherence to ART, retention in care, food security, body mass index, CD4 cell count, and participation in the labor force. Additionally, a qualitative study will be conducted to understand participant attitudes, beliefs and preferences to reveal how they utilized the food and cash transfers. The results from this study will provide greater evidence about the independent role of cash versus food assistance in HIV-related outcomes, as well as whether cash and food transfers are equivalent interventions for food insecure HIV-positive populations.

Results and Policy Implications



2013 - Ongoing

[1] Reddi A, Powers MA, Thyssen A. HIV/AIDS and food insecurity: deadly syndemic or an opportunity for healthcare synergism in resource-limited settings of sub-Saharan Africa? Aids. 2012;26:115-117.

[2] Singer M. Introduction to syndemics: a critical systems approach to public and community health. San Francisco: Jossey-Bass.

[3] Paton NI, Sangeetha S, Earnest A, Bellamy R. The impact of malnutrition on survival and the CD4 count response in HIV-infected patients starting antiretroviral therapy. HIV Med. Jul 2006;7(5):323-330.

[4] Zachariah R, Fitzgerald M, Massaquoi M, et al. Risk factors for high early mortality in patients on antiretroviral treatment in a rural district of Malawi. Aids. Nov 28 2006;20(18):2355-2360.

[5] de Pee S, Semba RD. Role of nutrition in HIV infection: review of evidence for more effective programming in resource-limited settings. Food Nutr Bull. Dec 2010;31(4):S313-344.

Photo credit: César González Palomo via Flickr