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Abstract
Background
Food insecurity has been linked to suboptimal antiretroviral therapy (ART) adherence in persons with HIV (PWH). This association has not been evaluated using tenofovir diphosphate (TFV-DP) in dried blood spots (DBSs), a biomarker of cumulative ART adherence and exposure.
Methods
Within a prospective South African cohort of treatment-naive PWH initiating ART, a subset of participants with measured TFV-DP in DBS values was assessed for food insecurity status. Bivariate and multivariate median-based regression analysis compared the association between food insecurity and TFV-DP concentrations in DBSs adjusting for age, sex, ethnicity, medication possession ratio (MPR), and estimated glomerular filtration rate.
Results
Drug concentrations were available for 285 study participants. Overall, 62 (22%) PWH reported worrying about food insecurity and 44 (15%) reported not having enough food to eat in the last month. The crude median concentrations of TFV-DP in DBSs differed significantly between those who expressed food insecurity worry versus those who did not (599 [interquartile range {IQR}, 417–783] fmol/punch vs 716 [IQR, 453–957] fmol/punch; P = .032). In adjusted median-based regression, those with food insecurity worry had concentrations of TFV-DP that were 155 (95% confidence interval, −275 to −35; P = .012) fmol/punch lower than those who did not report food insecurity worry. Age and MPR remained significantly associated with TFV-DP.
Conclusions
In this study, food insecurity worry is associated with lower TFV-DP concentrations in South African PWH. This highlights the role of food insecurity as a social determinant of HIV outcomes including ART failure and resistance.
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Details

1 Augusta University/University of Georgia Medical Partnership, Medical College of Georgia , Athens, Georgia , USA
2 Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine , Atlanta, Georgia , USA
3 Department of Medicine, University of KwaZulu-Natal , Durban , South Africa
4 Department of Biostatistics and Computational Biology, University of Rochester , Rochester, New York , USA
5 Department of Medicine, National Health Laboratory Service , Durban , South Africa
6 Department of Epidemiology, Rollins School of Public Health, Emory University , Atlanta, Georgia , USA
7 Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School , Boston, Massachusetts , USA
8 Department of Biostatistics and Bioinformatics, Colorado School of Public Health , Aurora, Colorado , USA
9 Department of Pharmaceutical Sciences, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus , Aurora, Colorado , USA
10 Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus , Aurora, Colorado , USA