Academy Comments to HRSA re "Assessing Client Factors Associated With Detectable HIV Viral Loads and Models of Care and the Ryan White HIV/AIDS Program"

July 17, 2017

HRSA Information Collection Clearance Officer
Room 14N39
5600 Fishers Lane
Rockville, MD 20857

Re: Info Collection: Assessing Client Factors Associated with Detectable HIV Viral Loads and Models of Care and the Ryan White HIV/AIDS Program

Dear Sir or Madam,

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Health Resources and Services Administration (HRSA) at the United States Department of Health and Human Services (HHS) related to its May 18, 2017 information collection, "Assessing Client Factors Associated with Detectable HIV Viral Loads and Models of Care and the Ryan White HIV/AIDS Program." Representing more than 100,000 registered dietitian nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to supporting the provision of essential food and nutrition services (FNS) to people living with HIV (PLWH) and to expanding access to this indispensable intervention.

The Academy supports these surveys as vital to addressing the substantial health needs of PLWH. This population's challenges with food insecurity and comorbid chronic conditions create an even more critical state of disease, which limits prognosis, decreases quality of life, and increases costs. FNS can provide a substantial return on investment, whether return is measured in outcomes, quality of life or health care expenditures. We offer the following suggestions to improve program quality and reinforce the necessity of FNS in these communities.

Why Food and Nutrition Services (FNS) Matter for PLWH

While adequate food and nutrition are basic to maintaining health for all persons, good nutrition is crucial for the management of HIV infection. Proper nutrition is needed to increase absorption of medication, reduce side effects, and maintain healthy body weight. Research has identified the virus as an independent risk factor for cardiovascular, liver and kidney disease, cancer, osteoporosis and stroke. Several HIV medications can cause nausea and vomiting and some can affect lab results used to monitor lipids, kidney and liver function. These compounding health effects, caused by the virus and its medications, reinforce the important role a nutrient-rich diet plays in a patient's overall care plan. In addition, providing food and nutrition services can serve to facilitate access and engagement with medical care, especially among vulnerable populations.

The Food and Nutrition Services category within the Ryan White HIV/AIDS Program (RWHAP) includes medical nutritional therapy (MNT) and FNS. MNT covers nutritional diagnostic, therapy, and counseling services focused on prevention, delay or management of diseases and conditions, and involves an in-depth assessment, periodic reassessment and intervention provided by an RDN outside of a primary care visit. The range of FNS provided through the RWHAP complements the needs of PLWH at any stage of their illness. For those who are most mobile, there are congregate meals, walk-in food pantries, and voucher programs. For those whose disease has progressed and are immobile, home-delivered meals and home-delivered grocery bags complement their medical treatment.

Since 2006, HRSA has included MNT and FNS provided under the guidance of RDNs as a clinically effective core medical service in the RWHAP. These nutrition services play a critical role in ensuring that PLWH enter and continue in primary medical care, adhere to their medications, and ultimately achieve viral suppression.

FNS as a Care Completion Service Unique to Ryan White

Social and economic interventions, most often in the form of care completion services such as food and nutrition services, are fundamental to making health care work for PLWH. Support services for PLWH are not covered in any comprehensive way by Medicaid or other public insurance initiatives that have been expanded by the Affordable Care Act. As the HIV epidemic in the United States increasingly impacts low-income individuals, support services help stabilize individuals living with or at risk of HIV. When comprehensive needs are met and life’s emergencies are held at bay, PLWH are far better poised to remain connected to care and treatment.

Access to FNS and the Triple Aim

Access to appropriate FNS are increasingly recognized as key to accomplishing the Triple Aim of national healthcare reform for PLWH.

Better Health Outcomes

When clients get effective FNS and become food secure, they are more likely to keep scheduled primary care visits, score higher on health functioning, are at lower risk for inpatient hospital stays, and are more likely to take their medicines.2 Studies show both the health benefits of access to MNT or nutrition counseling for people with HIV infections3 and the resulting decreases in their healthcare costs. In contrast, PLWH who are food insecure have:

  • Lower CD4 counts & lower likelihoods of having undetectable viral loads;4
  • More ER visits5 & increased morbidity and mortality; and6
  • More missed primary care appointments and reduced use of antiretroviral therapy7.

One study in particular found that "half of people living with HIV/AIDS … lacked sufficient food, and food insufficiency was associated with multiple indicators of poor health, including higher HIV viral loads, lower CD4 cell counts, and poorer treatment adherence. Adjusted analyses showed that food insufficiency predicted HIV treatment non-adherence over and above" numerous other social factors.8

Lower Healthcare Costs

Millions of dollars in healthcare expenditures are saved through the provision of FNS to PLWH. A recent study comparing participants in a medically-tailored FNS program compared to a control group within a local managed care organization found that average monthly healthcare costs for PLWH fell eighty percent (more than $30,000) for the first three months after receiving FNS9. If hospitalized, FNS clients' costs were thirty percent lower, their hospital length of stay was cut by thirty-seven percent and they were twenty percent more likely to be able to be discharged to their homes rather than a more expensive institution10. Furthermore, FNS are a relatively inexpensive intervention. For each day in a hospital saved, you can feed a person a medically-tailored diet for half a year.11

Improved Patient Satisfaction

Studies show nutrition counseling improves quality of life.12,13 PLWH overwhelmingly report that FNS help them live more independently, eat more nutritiously and manage their medical treatment more effectively.

FNS, the National HIV/AIDS Strategy (NHAS), and Models of Care

Access to FNS for PLWH is fundamental to fulfilling the goals of the NHAS and should be incorporated as formalized core components of Models of Care in the RWHAP.

  • NHAS Goal of Reducing new HIV infections: PLWH who are food insecure are less likely to have undetectable viral loads in a statistically significant way. Undetectable viral loads prevent transmission ninety-six percent of the time,14 demonstrating FNS is a key to prevention.15
  • NHAS Goal of Increasing access to care and improving health outcomes for people living with HIV: PLWH who receive effective FNS are more likely to keep scheduled primary care visits, score higher on health functioning, are at lower risk for inpatient hospital stays and are more likely to take their medicines16.
  • NHAS Goal of Reducing HIV-related disparities and health inequities: By providing FNS to PLWH in need largely because of poverty, we improve health outcomes, thereby reducing health disparities17.

Specific Survey Suggestions

  1. The Outcomes Site Survey should have a due date. HRSA also may want to consider creating incentives to respond.
  2. Much of the provider survey will be difficult for front line medical providers to answer. HRSA should ensure that the providers who are interviewed have some minimal level of tenure at the organization providing services and that case management and social workers are included in this group. The social work staff may well have better ideas about demographics and other social and psychosocial issues than the medical providers.
  3. We question whether the client survey and focus group asks too many demographic questions and suggest including a "mixed race" option.
  4. We encourage HRSA to add questions regarding food insecurity, such as:
    • Are you concerned about your access to healthy food?
    • Do you think healthy food might help you better manage your condition?
    • How much of an issue is transportation for you to access healthy food (1-5)?
    • How much is cost an issue for you to buy healthy food (1-5)?
  5. We encourage HRSA to consider incentives for clients to participate; client participation is not an organizational responsibility. Consider gift cards to large stores (Target, Walmart, etc.) or grocery stores, particularly those from which tobacco or alcohol cannot be purchased.

Conclusion

Research shows that investment in FNS, with the great return in prevention and retention in HIV care as well as improved quality of life, are vital to lowering the number of new infections in the domestic HIV epidemic and ultimately in reducing healthcare costs and preserving healthcare resources for the future. A client's diet can literally have life and death consequences. When people are severely ill, good nutrition is one of the first things to deteriorate, making recovery and stabilization that much harder. Early and reliable access to medically-appropriate FNS helps PLWH live healthy and productive lives, produces better overall health outcomes, and reduces health care costs.

Most importantly, there remains a tremendous variation by state in coverage of food and nutrition services both inside and outside of RWHAP, making broader support for RWHAP all the more needed. Ultimately, if we are going to achieve a more coordinated national response to the HIV epidemic and our quest to reduce healthcare spending nationwide, FNS must be included in all healthcare reform efforts, including RWHAP.

The Academy appreciates the opportunity to comment on the proposed information collection for the National Survey of Older Americans Act Participants---Extension with Modifications docket. Please contact either Jeanne Blankenship at 312-899-1730 or by email at jblankenship@eatright.org or Pepin Tuma at 202-775-8277 ext. 6001 or by email at ptuma@eatright.org with any questions or requests for additional information.

Sincerely,

Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Mark E. Rifkin, MS, RD, LDN
Manager
Consumer Protection and Regulation
Academy of Nutrition and Dietetics


1 The Academy approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation’s food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 Aidala A, Yomogida M, Vardy Y & the Food & Nutrition Study Team. Food and Nutrition Services, HIV Medical Care, and Health Outcomes. New York State Department of Health: Resources for Ending the Epidemic, 2014.

3 Academy of Nutrition and Dietetics. HIV/AIDS Nutrition Evidence Analysis Project. Accessed 29 July 2012.

4 Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team (2014).

5 Ibid.

6 Anema A, Chan K, Yip B, Weiser S, Montaner JSG, Hogg RS. Impact of food insecurity on survival among HIV-positive injection drug users receiving antiretroviral therapy in a Canadian cohort. 141st APHA Annual Meeting, Nov. 2-6, 2013. Boston, MA. Abstract #: 290277

7 Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team (2014).

8 Kalichman SC, et al. Health and treatment implications of food insufficiency among people living with HIV/AIDS, Atlanta, Georgia. J Urban Health. 2010 Jul;87(4):631-41.

9 Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty N. Examining Health Care Costs Among MANNA Clients and a Comparison Group. OMG Center for Collaborative Learning, Philadelphia, PA, USA. J Prim Care Community Health. 2013 Jun 3.

10 Ibid.

11 Sarah Downer, Robert Greenwald, Emily Broad Leib, Kellen Wittkop, Kristen Hayashi, Marissa Leonce & Morgan Menchaca. 2015. Food is Prevention The Case for Integrating Food and Nutrition Interventions into Healthcare. Center for Health Law & Policy Innovation, Harvard Law School.

12 Rabeneck L, Palmer A, Knowles JB, Seidehamel RJ, Harris CL, Merkel KL, Risser JMH, Akrabawi SS. A randomized controlled trial evaluating nutrition counseling with or without oral supplementation in malnourished HIV-infected patients. J Am Diet Assoc. 1998; 98: 434-438.

13 Schwenk A, Steuck H, Kremer G. Oral supplements as adjunctive treatment to nutritional counseling in malnourished HIV-infected patients: randomized controlled trial. Clinical Nutrition. 1999; 18(6): 371-374.

14 M. S. Cohen et al., "Prevention of HIV-1 Infection with Early Antiretroviral Therapy," N. Engl. J. Med. 365, 493-505 (2011). HPTN 052 Study Team.

15 Palar K, et al. (2013). Food insecurity is associated with sexually transmitted infections and HIV serostatus among low income adults in the National Health and Nutrition Examination Survey (NHANES) (1999-2010). Presented at the American Public Health Association 141st Annual Meeting, Boston, MA, November 5, 2013.

16 Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team (2014).

17 Weiser SD, et al. Food insecurity is associated with incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San Francisco. J Gen Intern Med. 2009 Jan;24(1):14-20.