Persistent household food insecurity, HIV, and maternal stress in Peri-Urban Ghana

Household food insecurity (HFI) is defined as the limited or uncertain availability of foods that are nutritionally adequate, safe, and acquired through socially acceptable ways [1]. Globally there is an overlap between HFI and HIV/AIDS [2, 3]. Both HFI and HIV/AIDS have been identified not only as major independent biological but also as mental health stressors [4, 5]. There are reasons to expect for the joint effect of these two conditions to become synergistic when simultaneously present. HIV/AIDS and food insecurity in Sub Saharan Africa have been characterized as a syndemic not only because they coexist but also they are both rooted in social inequalities and, as in a vicious cycle, the presence of one condition is likely to exacerbate the second condition [6–8]. On one hand HIV can have a profound effect on the structure and functioning of households [8]. For example, a woman diagnosed with HIV may be abandoned by her husband and experience a significant reduction in social support [8]. HIV may also weaken her immune system and ability to work productively [8] and follow sustainable livelihood strategies conducive to good health outcomes [7]. As a result maternal HIV is likely to worsen the economic situation of a household and to negatively affect its access to food [6, 7]. On the other hand women living in food insecure households may engage in risky economic generation activities (e.g., unsafe sexual practices) that may increase their risk of acquiring HIV [6, 9]. In Sub-Saharan Africa poverty-related migration might represent a coping mechanism that has a negative effect on well-being of women and children [10]. For instance, male labor migration has been linked to maternal HIV and household food insecurity status in Sub-Saharan Africa, especially in places where there is a high level of gender inequality [7]. And among women who are already infected with HIV food insecurity may prevent them from taking adequate care of HIV and as result transition more rapidly into full blown AIDS. Food insecurity may foster the further infection of other individuals by HIV positive women who follow risky sexual behaviors as a result of their lack of access to food. In sum, both maternal HIV and food insecurity are major household stressors that can be expected to affect maternal mental health [7]. Because both conditions exacerbate each other we hypothesize that they may act synergistically on affecting maternal stress. Answering this innovative question is of considerable public health significance as poverty related maternal stress has been linked with other maternal mental health problems (e.g., depression) and poor child development [11].

The primary objective of this paper is to examine the independent and synergistic associations between HIV status, persistent household food insecurity (PHFI), and perceived stress in Ghanaian mothers of young children. We hypothesize that HIV and food insecurity might create a synergy on maternal stress that is greater than the additive influence of these risk factors. Even though Ghana is a “low” HIV prevalence country the district where the study took place had significant HIV rates at the time of the study. The prevalence of HIV in the Ghanaian district of Manya Krobo, where this study took place, was 8.9% in 2007 among pregnant women [12]. This prevalence was indeed much higher than the prevalence among pregnant women nationally, which was estimated to be 1.8% in 2008 [13].

To our knowledge, this is the first study to examine the independent and combined influence of both HIV and PHFI on maternal stress. Consistent with the syndemic and the ‘new variant famine’ frameworks (6–8), findings strongly suggest that PHFI and HIV amplify the influence of each other on maternal stress, after controlling for key socio-economic and demographic covariates. Results showed that both PHFI and HIV were independently associated with maternal stress. Yet, when both risk factors were present simultaneously there was a strong synergism on maternal stress. One possible explanation is that household food insecurity is likely to be a strong maternal stressor with important consequences for the mental health of pregnant women. This stress may be further exacerbated by HIV as HIV-positive women who may have the expectation of not being able to perform the tasks needed to secure food needed by the family. On the other hand food insecurity may amplify the stress of HIV by preventing women from taking proper care of their disease.

Previous studies have identified food insecurity as a mental health stressor. In rural Tanzania, Hadley and Patil [4] found that food insecurity increases the risk of mental health problems, such as anxiety and depression. Whitaker et al. [20] also found that there was a positive association between higher levels of food insecurity and higher levels of generalized maternal anxiety disorder. Food insecurity was found to increase distress in mothers after pregnancy [21]. Hromi-Fiedler et al. [22] found that low-income pregnant Latinas that were food insecure were more likely to be depressed.

As expected, in our study HIV-positive women were more likely to be psychologically and socio-economically vulnerable. HIV-positive mothers were more likely to perceive stress, were more likely to live in households that were persistently food insecure, to not have a spouse, to not have electricity at home, and to have lower levels of education. Specific causes for greater stress among HIV positive mothers are the possibility of transmitting the virus to their children and the potential inability to take care of the children after birth [23]. A recent study found that HIV-positive mothers were more likely to be depressed [24]. In a study conducted in New York City, Mellins et al. [25] found that a diagnosis of HIV is among the most traumatic stressful life events, and that parental stress and a greater number of household members were significantly associated with low adherence to treatment in HIV-positive mothers.

Our study design did not allow us to examine whether food insecurity lead to an increased risk of maternal HIV as we did not assess food insecurity prior to HIV diagnosis. On the other hand, however, our findings do suggest that an HIV diagnosis may have led to a worsening of the food insecurity situation in affected households. Whereas the levels of severe household food insecurity among HIV-positive mothers increased over time, HIV-negative mothers actually experienced a decrease. The increased divergence in between-group severe household food insecurity across time indeed suggests that HIV diagnosis may have led to the worsening of food insecurity in the households where HIV-positive women lived. Because this divergence became evident around 6-months post-partum it is important that future studies help understand if and how household food insecurity changes when there is a need to introduce complementary foods into the infant’s diet. Gibbs [26] argues that gender inequality makes households more food insecure due to the HIV and AIDS epidemic.

There were several limitations in this study. Although there was a significant relationship in being both HIV-positive and PHFI with perceived maternal stress, the sample size was relatively small. One reason is that PHFI was reported by only 25 (10.8%) of the women. This level of food insecurity is consistent with a relatively adequate level of maternal education (8^th grade on average) and socioeconomic status (e.g. 80% lived in households with electricity) in the study’s sample. Another reason is that HIV-positive women experienced greater attrition from the study, which is understandable considering that their greater socioeconomic and biological vulnerability makes them inherently less likely to continue in the study. Another limitation is that we didn’t have the statistical power needed to test different levels of persistence of HFI (e.g. being HFI three out of the four time points vs. throughout the study). This may have precluded us from better understanding how seasonal fluctuations in HFI may affect maternal stress levels. An additional limitation is that we did not have enough statistical power to formally test the full 2 × 2 interaction between HIV and HFI as only 7 women were both PHFI and HIV-negative. However the 3-level categorical variable modeled strongly suggests a high level of synergism between HIV and PHFI on maternal stress. Lastly, our analyses can’t determine whether HIV diagnosis led to PHFI, if PHFI led to high-risk behaviors that caused the HIV infection, or both. Indirect evidence from studies in other settings suggests that this relationship is indeed bidirectional. Weiser et al. [9] found that food insecurity and insufficiency can increase the risk of HIV infection and transmission among women. Transactional sex, intergenerational sex, and difficulties in negotiating condom use can result from stressors such as being a single mother [27]. In the other hand, findings do suggest that the risk of severe household food insecurity is likely to increase as a result of HIV diagnosis.

The majority of studies on HIV-positive mothers have been related to vertical transmission; thus, there is a dearth of research on stigma and coping mechanisms associated with both maternal HIV diagnosis [28–30] and household food insecurity [31]. This gap needs attention as maternal-child mental health has been identified as priority in Sub-Saharan Africa and globally [32, 33]. The strong synergy between PHFI and being HIV-positive on maternal stress has important implications for women’s health and the development of their children. Studies have shown that exposure to maternal stress in early childhood has long lasting effects on the psychological health of the child [34–36]. Clearly, intervention studies are needed to better understand how to reduce stress among HIV-positive women living in households experiencing persistent food insecurity. If effective, these interventions are likely to translate into better maternal health and child development outcomes. In addition, addressing household food insecurity may also help buffer women against the negative influence of HIV on maternal stress.

Findings from this study have important public policy implications. Most programs targeting HIV affected individuals or communities have strictly focused on HIV prevention, counseling and treatment without taking into account social inequality as the root of the epidemic and linked syndemics. Addressing maternal stress as a result of the interaction between food insecurity and HIV requires comprehensive multi-dimensional interventions that go beyond HIV prevention, counseling and treatment and include sustainable poverty reduction and community development, and education in addition to HIV treatment [6–8]. Our findings suggest that mental health should be an integral part of addressing maternal care in communities affected by the HIV-food insecurity syndemic. This recommendation has immediate implications for Ghana where the second HIV/AIDS National Strategic Framework implemented for the period of 2006–2010, did not fully address the need for understanding how to handle the risk of mental health problems, including mental stress, associated with an HIV diagnosis [13], and does not recognize that this risk becomes highly amplified in the presence of household food insecurity.