Sandra McCoy, PhD, MPH

mccoyGHES US Fellow 2014-2015

Fellowship Site: Shinyanga Regional Hospital, Tanzania
U.S. Institution: UC Berkeley

Project Title: Comparing Food and Cash Assistance for HIV-Positive Men and Women on Antiretroviral Therapy in Tanzania

Although early initiation of antiretroviral therapy (ART) among PLHIV has significant clinical benefits and can virtually eliminate onward HIV transmission, these benefits hinge on retention in care and high levels of ART adherence. However, in sub-Saharan Africa, food insecurity, poor nutrition, and poverty are pervasive threats to ART’s potential effectiveness. Food insecurity in particular is increasingly recognized as a barrier to ART initiation, retention in care, and adherence, thus fostering interest in the potential for food and nutrition interventions to improve the health of PLHIV. Nevertheless, there is a paucity of rigorous evidence to guide initiatives in this area, including which assistance modalities are best to improve both food security and nutrition, as well as clinical and economic outcomes.

Although both food and cash transfers increase food expenditures and food consumption, there is an ongoing debate over whether cash transfers can achieve the same nutritional and clinical goals as food transfers. Indeed, food transfers result in more consumption of food than cash transfers, may be preferred by beneficiaries, and may be more appropriate when markets are functioning poorly. However, cash transfers give beneficiaries freedom of choice, may be cheaper to distribute and easier to monitor, and may be more “efficient” (according to microeconomic theory) than food transfers. However, there are limited data about whether such assistance programs are effective for improving the health of PLHIV, and if so, the comparative effectiveness of these two transfer modalities.

To address this research gap, we are randomizing women and men on ART in Shinyanga, Tanzania who are food insecure (determined with the Household Hunger Scale) into one of three groups: 1) NAC alone , 2) NAC plus food assistance, or 3) NAC plus cash transfers. Food assistance consists of a standard food ration consisting of locally procured maize meal, beans, and groundnuts. The cash transfer is equivalent to the food ration (approximately $13 USD/month). Participants receive the food or cash transfer monthly for six months. We will compare the effect of the combined NAC and food/cash assistance program versus NAC alone on retention in care and ART adherence at 6 and 12 months. Then, we will examine the comparative effectiveness of food and cash transfers to determine if their effects are the same.

Selected publications associated with this fellowship:

Rationale and design of a randomized study of short-term food and cash assistance to improve adherence to antiretroviral therapy among food insecure HIV-infected adults in Tanzania.

Cash vs. food assistance to improve adherence to antiretroviral therapy among HIV-infected adults in Tanzania: a randomized trial.