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Severe food insecurity is associated with elevated unprotected sex among HIV-seropositive injection drug… Shannon, Kate; Kerr, Thomas; Milloy, M-J; Anema, Aranka; Zhang, Ruth; Montaner, Julio; Wood, Evan Mar 17, 2014

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Severe food insecurity is associated with elevated unprotectedsex among HIV-seropositive injection drug users independent ofHAART useKate Shannon1,2,3, Thomas Kerr1,2,3, M-J Milloy1,3, Aranka Anema1, Ruth Zhang1, Julio S.G. Montaner1,2, and Evan Wood1,2,31BC Centre for Excellence in HIV/AIDS, University of British Columbia, Vancouver, BritishColumbia, Canada2Division of AIDS, Department of Medicine, University of British Columbia, Vancouver, BritishColumbia, Canada3School of Population and Public Health, University of British Columbia, Vancouver, BritishColumbia, CanadaAbstractObjective—Despite emerging evidence of a significant adverse relationship between foodinsecurity and sexual risk-taking, data have been primarily derived from resource-constrainedsettings and HIV-negative populations. To our knowledge, this study is the first to longitudinallyevaluate the relationship between food insecurity and unprotected sex among HIV-seropositivepeople who inject drugs [injection drug users (IDUs)] both on and not on HAART.Design—Longitudinal analyses were restricted to HIV-positive IDUs who completed baselineand at least one follow-up visit in a prospective cohort (AIDS Care Cohort to evaluate Exposure toSurvival Services, 2005–2009).Methods—We constructed a multivariate logistic model using generalized estimating equations(GEEs) to assess an independent relationship between severe food insecurity (e.g., hunger due tolack of access or means to acquire food) and unprotected vaginal/anal sex.Results—Among 470 HIV-positive IDUs, the median age was 42 years (interquartile range 36–47) with 61% men and 39% women. The prevalence of severe food insecurity was 71%, with nodifferences by HAART use. Severe food insecure IDUs were marginally less likely to have asuppressed HIV-1 RNA viral load (31 vs. 39%, p=0.099). In multivariate GEE analyses, severefood insecurity [adjusted odds ratio=2.68, 95% confidence interval 1.49–4.82] remainedindependently correlated with unprotected sex among HIV-positive IDUs, controlling for age, sex/gender, married/cohabitating partner, binge drug use, homelessness, and HAART use.Conclusion—These findings highlight a crucial need for structural HIV interventions thatincorporate targeted food assistance strategies for IDUs. Given recent evidence of poor virologicalresponse among food insecure individuals on HAART, innovative HIV care models shouldintegrate targeted food security programs and early access to HAART.Send correspondence to: Kate Shannon, PhD, Assistant Professor, Div. of AIDS, Depart. of Medicine, University of British Columbia,BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608 – 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada,kshannon@cfenet.ubc.ca.E.W. had full access to all of the data in the study and takes full responsibility for the integrity of the data and the accuracy of the dataanalysis. K.S. and E.W. designed the study and wrote the protocol. R.Z. conducted the statistical analysis and all authors interpretedthe results. K.S. wrote the article. T.K., M.J.M., A.A., J.S.G.M., and E.W. critically revised the article and contributed importantintellectual content. All authors have read and approved the final version of the article.NIH Public AccessAuthor ManuscriptAIDS. Author manuscript; available in PMC 2014 March 17.Published in final edited form as:AIDS. 2011 October 23; 25(16): 2037–2042. doi:10.1097/QAD.0b013e32834b35c9.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptKeywordsfood insecurity; HAART; HIV/AIDS; injection drug use; sexual riskINTRODUCTIONThere is now global recognition that epidemics of food insecurity and HIV are closelylinked [1–4], with over 900 million undernourished individuals worldwide [5]. Although thevast majority of research to date has been derived from developing countries [5], the limiteddata available from resource-rich settings suggest a high prevalence of food insecurityamong HIV-positive individuals [6,7]. In North America, 6–9% of households in the generalpopulation are estimated to be food insecure [8,9], while among HIV-positive individuals onHAART, 48–49% are estimated to be food insecure, with 21% meeting the definition ofseverely food insecure with the presence of acute hunger [6,7]. Although severalinternational bodies, including WHO and the World Food Program, have called for targetednutritional interventions that are systematically linked to HIV interventions [1–3], thereremains a concerning lack of data on food insecurity among HIV-positive individuals indeveloped country settings. Of particular importance, in many inner city communities inNorth America, the majority of HIV-positive people who inject drugs [injection drug users(IDUs)] rely on food banks and shelters to obtain food, and yet the epidemiology of foodinsecurity among IDUs and intersections with sexual and drugs risks remain largelyunknown.In studies of HIV-positive individuals on treatment, food insecurity has been associated withlower adherence, adverse antiretroviral pharmacokinetics, worsening clinical outcomes,including a poor immunological response, and elevated mortality [6,10–13]. In addition toadverse clinical outcomes, a study among HIV-negative individuals in southern Africa nowsuggests a significant adverse relationship between food insecurity and sexual risk-taking,including elevated likelihood of unprotected sex and exchanging of sex for food or otherresources [14]. Similarly, in a case–control study of African–American men and womenwith heterosexually acquired HIV infection in south Carolina, hunger due to lack of accessto food was independently associated with HIV infection [15]. Although these cross-sectional data offer important research to suggest potential sexual risk pathways betweenfood insecurity and risk of HIV acquisition, there is a dearth of research among HIV-positive individuals in resource-rich settings, particularly among drug-using populations.This study, therefore, aims to evaluate longitudinally the impact of severe food insecurity –hunger due to lack of access or means to acquire food – on sexual risk-taking among HIV-positive IDUs both on and not on HAART.METHODSStudy populationData were derived from the AIDS Care Cohort to evaluate Exposure to Survival Services(ACCESS), a prospective observational cohort of HIV-seropositive IDUs in Vancouver,Canada that has been described in detail previously [16,17]. Briefly IDUs were recruitedthrough snowball sampling and extensive street outreach methods in the city’s inner citycommunity (Downtown Eastside). Individuals were eligible if they were aged 18 years orolder, HIV seropositive, and injected drugs in the past 6 months. At baseline and bi-annualfollow-up, participants completed a standardized interviewer-administered questionnaire andprovided blood samples for disease monitoring. The current analyses include all participantswho were recruited and completed at least one follow-up visit (December 2005 to May2009).Shannon et al. Page 2AIDS. Author manuscript; available in PMC 2014 March 17.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptData linkages to the British Columbia drug treatment programAs previously described [16,17], the local setting is somewhat unique in that there is aprovince-wide centralized antiretroviral dispensation program and HIV/AIDS laboratory,enabling a complete prospective profile of all patient CD4 cell counts, plasma HIV-1 RNAlevels, and HAART use [18]. Providence Healthcare/University of British ColumbiaResearch Ethics Board has provided approval for the study. Plasma HIV-1 RNA is measuredusing the Roche Amplicor Monitor assay (Roche Molecular Systems, Mississauga, Canada).Variable selectionThe primary outcome of interest was unprotected sex (vaginal and/or anal) in the previous 6months. The primary explanatory variable was severe food insecurity, defined according tointernational United Nations and World Food Program guidelines, based on a ‘yes’ responseto either or both of questions eliciting ‘going hungry due to lack of access or means toacquire food’ [4]. Mild-to-moderate food insecurity, including insufficient diversity of food,was not considered unless participants met the criteria for severe food insecurity: thepresence of acute hunger. Individual and structural covariates of interest considered a priorias potential confounders [6,7] included homelessness, binge drug use, and HAART. Allvariables were based on semi-annual follow-up intervals with a recall period of 6 months.Based on the confidential linkage to the centralized antiretroviral dispensary, we includedHIV-1 RNA level (>=500 vs. < 500 copies/ml) and CD4 cell count (<200, 200–350 copies/μl, vs. >350 copies/μl). If more than one measure of viral load or CD4 cell count wereavailable in any 6-month period, we used the mean of all available measurements.Statistical analysesBivariate GEE analyses were conducted to examine the relationship between explanatoryvariables and our primary outcome of unprotected vaginal/anal sex. As repeated measureswere available for each participant, we conducted marginal longitudinal analyses usinggeneralized estimating equations (GEEs) to analyze correlated data [19,20]. Standard errorswere calculated using an exchangeable correlation structure, adjusted by multipleobservations for each individual, to allow us to examine periods of food insecurity andunprotected sex both within and across individuals. A multivariate GEE model was fittedbased on a priori protocols of potential confounders [6,7] and variables with a p value lessthan 0.10 in bivariate analyses. Variables were retained as significant in our finalmultivariate GEE model at p less than 0.05. All statistical procedures were performed usingSAS version 8.0 (SAS, Cary, North Carolina, USA) and all p values reported were two-sided.ResultsOf a total of 491 HIV-positive individuals who injected drugs in the ACCESS cohort, 470were included in the analyses, contributing to 1310 observations over baseline and fourfollow-up visits (21 were excluded due to missing data on food insecurity). Of the total, 39%were women, with a median age of 42 years [interquartile range (IQR) 36–47].Approximately half were on HAART (n = 217), with 71% of IDUs reporting severe foodinsecurity. As indicated in Table 1, individuals who were severely food insecure weresignificantly more likely to be living in the inner city community (73 vs. 56%, p < 0.001),frequent non-injection crack cocaine user (48 vs. 26%, p < 0.001), homeless (35 vs. 19%, p< 0.001), frequent heroin injector (24 vs. 11%, p < 0.001), and frequent cocaine injector (12vs. 6%, p = 0.043). Severely food insecure individuals were also marginally more likely tobe younger (41.6 vs. 42.4 years, p = 0.061) and less likely to have a suppressed HIV-1 RNAviral load (31 vs. 39%, p = 0.099). There were no statistically significant differences inindividuals reporting and not reporting severe food insecurity by sex/gender or HAART use.Shannon et al. Page 3AIDS. Author manuscript; available in PMC 2014 March 17.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptOver the observation period, there were 789 and 245 events, respectively, of severe foodinsecurity and unprotected sex, and proportions were not statistically significantly differentacross follow-ups.Table 2 shows the bivariate and multivariate GEE results. In our final multivariate GEEmodel, adjusting for age, sex/gender, married/cohabitating partner, homelessness, bingedrug use, and HAART use, severe food insecurity remained independently correlated withunprotected sex (adjusted odds ratio = 2.58, 95% confidence interval 1.49–4.82) amongHIV-positive IDUs. Given hypothesized role of sex/gender in modifying this relationship,we subsequently tested for interaction of gender and food insecurity (non-significant) andconducted sex-stratified models to examine differences in the effect size for men and women(results not statistically significantly different).DISCUSSIONIn this study, close to two-thirds of HIV-positive IDUs reported severe food insecurity overthe 2-year follow-up, a prevalence significantly higher than previously documented amongcross-sectional samples of marginalized HIV-positive individuals in North America [19]. Ofconcern, HIV-positive IDUs who were severely food insecure were slightly less likely tohave a suppressed HIV-1 RNA viral load at baseline, and severe food insecurity remainedindependently correlated with a two and half-fold elevated proportional odds of engaging inunprotected vaginal or anal sex.Although this study does not delineate the mechanism between severe food insecurity andunprotected sex, there are several plausible risk pathways. First, cross-sectional data fromsub-Saharan Africa suggest that food insecurity is associated with transactional sex, theexchange of sex for basic resources (e.g., food, shelter, money) among women, known todrive unprotected sex [21–24]. Second, competing resource demands of food and drugsamong HIV-positive IDUs may shape prioritization of risks in the absence of alternativemeans to acquire basic necessities. Third, physiological evidence demonstrates thatimmediate hunger can reduce the coping mechanisms of individuals [25], which couldmediate sexual decision-making and negotiation of condom use among both men andwomen.To our knowledge, these results are the first to longitudinally document a direct correlationbetween severe food insecurity and unprotected sex among HIV-positive individuals. Givenrecent research suggesting a temporal shift toward a sexually driven HIV epidemic amongIDUs following wide-spread needle exchange access in many North American cities [26],this study identifies an important sexual risk pathway for sustained HIV transmission thatrequires immediate attention. Furthermore, food insecurity can lead to malnutrition, whichincreases the risk of HIV transmission through sex and drug risk routes by compromising anindividual’s immunostatus and gut and genital mucosal integrity [6]. Whereas earlierresearch suggests gendered patterns of food insecurity and sexual risk [27–29], our resultsdemonstrate an elevated odds of unprotected sex that persists among HIV-positive foodinsecure IDUs, regardless of gender. At the same time, HIV-positive women in this samplewere 50% more likely to report unprotected sex than HIV-positive men, confirming earlierwork documenting gendered patterns in negotiation of male condom use that requiretargeted and couple-focused interventions.Given that HAART use, in combination with condoms, is now recognized as a critical HIVprevention strategy at the population level [26], and recent cross-sectional data from SanFrancisco showing food insecurity to be associated with poor virological response amongindividuals on HAART, these findings call for innovative structural interventions thatShannon et al. Page 4AIDS. Author manuscript; available in PMC 2014 March 17.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptcombine early access to HAART with targeted food security for IDUs as critical to effectiveHIV prevention and treatment scale-up. Among nondrug-using populations in resource-poorsettings, ecological analysis of US President’s Emergency Plan for AIDS Relief programsacross seven sub-Saharan African countries has shown nutritional support to be strongestpredictor of non-attrition from HAART [30]. Our results highlight a critical need to pilot andrigorously evaluate structural HIV interventions that incorporate food assistance programsfor IDUs within harm reduction and treatment programming, including supporting housingmodels, mobile outreach, syringe distribution, and substitution therapy. Further,consideration should be given to strategies that account for the potential competing resourcedemands of food and drugs.This study has several limitations. First, as with all observational data, variables are self-reported and may be subject to social desirability or recall bias. Second, our measure of foodinsecurity does not capture the full range of mild-to-moderate food insecurity, such as lackof diversity or nutrients of available food, and additional research using standardizedmeasures of food insecurity among IDUs is warranted.In summary, these findings highlight a crucial need for structural HIV interventions thatincorporate targeted food assistance strategies for HIV-positive IDUs. Given evidence ofpoor virological response among food insecure individuals on HAART, innovative HIV careand treatment models that integrate targeted food security programs and early access toHAART will be crucial to realizing the positive prevention and treatment benefits ofHAART.AcknowledgmentsThe authors thank the study participants for their contribution to the research as well as current and past researchersand staff. The authors would specifically like to thank Deborah Graham, Tricia Collingham, Caitlin Johnston, SteveKain, and Calvin Lai for their research and administrative assistance. The study was supported by the US NationalInstitutes of Health (R01DA021525) and the Canadian Institutes of Health Research (MOP-79297, RAA-79918).Both K.S. and T.K. are supported by Michael Smith Foundation for Health Research Scholar Awards and theCanadian Institutes of Health Research New Investigator Awards. K.S. is also partially supported by US NationalInstitutes of Health (R01DA028648).J.S.G.M. has received educational grants from and is serving as an ad hoc advisor to or speaking at various eventssponsored by Abbott Laboratories, Agouron Pharmaceuticals Inc., Boehringer Ingelheim Pharmaceuticals Inc.,Borean Pharma AS, Bristol-Myers Squibb, DuPont Pharma, Gilead Sciences, GlaxoSmithKline, Hoffmann-LaRoche, Immune Response Corporation, Incyte, Janssen-Ortho Inc., Kucera Pharmaceutical Company, Merck FrosstLaboratories, Pfizer Canada Inc., Sanofi Pasteur, Shire Biochem Inc., Tibotec Pharmaceuticals Ltd, and TrimerisInc. No other authors reported disclosures.References1. World Health Organization (WHO). [Accessed 1 May 2010] Nutrient requirements for people livingwith HIV/AIDS: report of a technical consultation. 2003. http://www.who.int/nutrition/publications/Content_nutrient_requirements.pdf2. [Accessed 1 June 2010] Save the children. Food security, livelihoods & HIV/AIDS: a guide to thelinkages, measurement & programming implications. Aug. 2004 http://reliefweb.int/sites/reliefweb.int/files/reliefweb_pdf/node-22012.pdf3. United Nations World Food Programme (WFP). Vulnerability Analysis and Mapping Branch andHIV/AIDS Service. Rome, Italy: 2008. HIV/AIDS analysis: integrating HIV/AIDS in food securityand vulnerability analysis. http://documents.wfp.org/stellent/groups/public/documents/manual_guide_proced/wfp193482.pdf [Accessed 1 June 2010]4. Anema A, Vogenthaler N, Frongillo EA, Kadiyala S, Weiser SD. Food insecurity and HIV/AIDS:current knowledge, gaps, and research priorities. Curr HIV/AIDS Rep. 2009; 6:224–231. [PubMed:19849966]Shannon et al. Page 5AIDS. Author manuscript; available in PMC 2014 March 17.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript5. United Nations Food and Agriculture Organization (FAO). [Accessed 1 June 2010] The State ofFood Insecurity in the World: high prices and food security – threats and opportunities. 2008. http://www.fao.org/docrep/011/i0291e/i0291e00.htm6. Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. Food insecurity isassociated with incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San Francisco. J Gen Intern Med. 2008; 24:14–20. [PubMed: 18953617]7. Normén L, Chan K, Braitstein P, Anema A, Bondy G, Montaner JS, Hogg RS. Food insecurity andhunger are prevalent among HIV-positive individuals in British Columbia, Canada. J Nutr. 2005;135:820–825. [PubMed: 15795441]8. Health Canada. Income-related household food security in Canada. Ottawa: Office of NutritionPolicy and Promotion. Report No. H164–42/2007E.2007. http://www.hc-sc.gc.ca/fnan/surveill/nutrition/commun/income_food_sec-sec_alimeng.php [Accessed 28 January 2009]9. Nord, M.; Andrews, M.; Carlson, S. Economic Research Report No. (ERR-66). Vol. 65. UnitedStates Department of Agriculture (USDA); 2008. Household food security in the United States,2007.10. Boffito M, Acosta E, Burger D, Fletcher CV, Flexner C, Garaffo R, et al. Current status and futureprospects of therapeutic drug monitoring and applied clinical pharmacology in antiretroviraltherapy. Antivir Ther. 2005; 10:375–392. [PubMed: 15918329]11. Sekar V, Kestens D, Spinosa-Guzman S, De Pauw M, De Paepe E, Vangeneugden T, et al. Theeffect of different meal types on the pharmacokinetics of darunavir (TMC114)/ritonavir inHIVnegative healthy volunteers. J Clin Pharmacol. 2007; 47:479–484. [PubMed: 17389557]12. Weiser SD, Fernandes K, Brandson EK, Lima VD, Anema A, Bangsberg DR, et al. Theassociation between food insecurity and mortality among HIV-infected individuals first initiatingHAART. J Acquir Immune Defic Syndr. 2009; 52:342–349. [PubMed: 19675463]13. Au JT, Kayitenkore K, Shutes E, Karita E, Peters PJ, Tichacek A, Allen SA. Access to adequatenutrition is a major potential obstacle to antiretroviral adherence among HIV-infected individualsin Rwanda. AIDS. 2006; 20:2116–2118. [PubMed: 17053359]14. Weiser S, Leiter K, Bangsberg D, Butler L, Oercy-de Korte F, Hlanze Z, et al. Food insufficiencyis associated with high-risk sexual behaviour among women in Botswana and Swaziland. PLoSMed. 2007; 4:1589–1598. [PubMed: 17958460]15. Adimora AA, Schoenbach VJ, Martinson FE, Coyne-Beasley T, Doherty I, Stancil TR, FulliloveRE. Heterosexually transmitted HIV infection among African Americans in North Carolina. JAcquir Immune Defic Syndr. 2006; 41:616–623. [PubMed: 16652036]16. Strathdee SA, Palepu A, Cornelisse PG, Yip B, O’Shaughnessy MV, Montaner JS, et al. Barriers touse of free antiretroviral therapy in injection drug users. JAMA. 1998; 280:547–549. [PubMed:9707146]17. Wood E, Hogg RS, Bonner S, Kerr T, Li K, Palepu A, et al. Staging for antiretroviral therapyamong HIV-infected drug users. JAMA. 2004; 292:1175–1177. [PubMed: 15353528]18. Wood E, Hogg RS, Lima VD, Kerr T, Yip B, Marshall BD, Montaner JS. Highly activeantiretroviral therapy and survival in HIV-infected injection drug users. JAMA. 2008; 6:550–554.[PubMed: 18677027]19. Weiser SD, Leiter K, Bangsberg DR, Butler LM, Percy-de Korte F, Hlanze Z, et al. Foodinsufficiency is associated with high-risk sexual behavior among women in Botswana andSwaziland. PLoS Med. 2007; 4:1589–1597. [PubMed: 17958460]20. Oyefara, JL. Poverty, food insecurity, and HIV/AIDS pandemic: evidence of relationship fromreproductive behaviour of commercial sex workers in Lagos metropolis, Nigeria. InternationalConference on HIV/AIDS, Food and Nutrition Security; Durban, South Africa. 2005.21. Alaimo K, Olson CM, Frongillo EA. Family food insufficiency, but not low family income, ispositively associated with dysthymia and suicide symptoms in adolescents. J Nutr. 2002; 132:719–725. [PubMed: 11925467]22. Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers tohealthcare among low-income Americans. J Gen Intern Med. 2006; 21:71–77. [PubMed:16423128]Shannon et al. Page 6AIDS. Author manuscript; available in PMC 2014 March 17.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript23. Siefert K, Heflin CM, Corcoran ME, Williams DR. Food insufficiency and physical and mentalhealth in a longitudinal survey of welfare recipients. J Health Soc Behav. 2004; 45:171–186.[PubMed: 15305758]24. Heflin CM, Siefert K, Williams DR. Food insufficiency and women’s mental health: findings froma 3-year panel of welfare recipients. Soc Sci Med. 2005; 61:1971–1982. [PubMed: 15927331]25. Gillespie, S.; Kadiyala, S. HIV/AIDS and food and nutrition security: from evidence to action.Washington: DC: International Food Policy Research Institute; 2005.26. Montaner JS, Hogg R, Wood E, Kerr T, Tyndall MW, Levy AR, Harrigan PR. The case forexpanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic.Lancet. 2006; 368:531–536. [PubMed: 16890841]27. Des Jarlais DC, Arasteh K, McKnight C, Hagan H, Perlman D, Friedman SR. Using hepatitis Cvirus and herpes simplex virus-2 to track HIV among injecting drug users in New York City. DrugAlcohol Depend. 2009; 101:88–92. [PubMed: 19108958]28. Kral AH, Bluthenthal RN, Lorvick J, Gee L, Bacchetti P, Edlin BR. Sexual transmission of HIV-1among injection drug users in San Francisco, USA: risk-factor analysis. Lancet. 2001; 357:1397–1401. [PubMed: 11356437]29. Strathdee SA, Sherman SG. The role of sexual transmission of HIV infection among injection andnoninjection drug users. J Urban Health. 2003; 80:iii7–iii14. [PubMed: 14713667]30. Nash, D.; Korves, C.; Saito, S.; Sherman, S.; Elul, B.; Hoos, D., et al. Characteristics of facilitiesand programs delivering HIV care and treatment services are associated with loss to follow-uprates in programs from 8 sub-Saharan African countries [abstract No: 838 2007]. Conference onRetroviruses and Opportunistic Infections (CROI); Boston, MA.Shannon et al. Page 7AIDS. Author manuscript; available in PMC 2014 March 17.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptShannon et al. Page 8Table 1Baseline individual and structural characteristics of 470 HIV-positive people who inject drugs in the AIDSCare Cohort to evaluate Exposure to Survival Services, stratified by severe food insecurity.Severe food insecurityYes (n=335) No (n=135) pMedian age (IQR) 41.6 years (35.6–47.5) 42.4 years (37.0–48.2) 0.061Female sex (vs. male) 131 (39%) 51 (38%) 0.789Aboriginal ethnicity (vs. non-Aboriginal) 136 (41%) 55 (41%) 0.977Married/cohabitating 90 (27%) 37 (27%) 0.905Homeless 118 (35%) 26 (19%) <0.001Inner city residency 245 (73%) 75 (56%) <0.001Frequent crack smoking 161 (48%) 35 (26%) <0.001Frequent heroin injection 82 (24%) 15 (11%) 0.001Frequent cocaine injection 41 (12%) 8 (6%) 0.043HAART use 50 (51%) 67 (55%) 0.412CD4 cell count <200 copies/μl 87 (27%) 38 (28%) 0.737 200–350 copies/μl 107 (33%) 42 (31%) 0.707 >350 copies/μl 132 (40%) 55 (41%) ReferenceHIV-1 RNA viral load (log10) <500 copies/ml 102 (31%) 53 (39%) 0.099IQR: Interquartile rangeAIDS. Author manuscript; available in PMC 2014 March 17.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptShannon et al. Page 9Table 2Bivariate and multivariate generalized estimating equation analyses of correlates of unprotected sex amongHIV-positive people who inject drugs both on and not on HAART in the AIDS Care Cohort to evaluateExposure to Survival Services, 2005–2008.Unadjusted ORs (95% CI) Adjusted ORs (95% CI)Age (continuous, years) 0.95 (0.92–0.98)* 0.97 (0.94–0.99)Female sex 1.54 (1.00–2.37)* 1.50 (1.02–2.22)Aboriginal ethnicity 1.03 (0.67–1.59) –Married/cohabitating 5.05 (3.40–7.85)* 4.56 (3.01–6.57)Severe food insecurity 2.98 (1.56–5.05)* 2.68 (1.49–4.82)Homeless 1.17 (0.80–1.72) –Inner city residency 0.87 (0.60–1.26) –HAART use 0.78 (0.44–1.23) –CD4 cell count <200 copies/μl 1.43 (0.86–2.49) – 200–350 copies/μl 1.35 (0.85–2.17) – >350 copies/μl ReferenceHIV-1 RNA viral load (log10) <500 copies/ml 0.92 (0.80–1.06) –Current STI 1.25 (0.82–1.92) –Frequent crack smoking 1.31 (0.93–1.83) –Frequent cocaine injection 1.54 (0.95–2.49) –Frequent heroin injection 1.53 (0.99–2.35) –Binge drug use (injection and/or non-injection) 1.63 (1.10–2.44)* 1.56 (1.08–2.55)CI: Confidence interval; OR: Odds ratio; STI: Sexually transmitted infection*Variables significant at p <0.10 in bivariate analyses and entered into the multivariate model. Final multivariate model adjusted for age, sex/gender, married/cohabitating partner, binge drug use, homelessness, and HAART useAIDS. Author manuscript; available in PMC 2014 March 17.

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