December 6, 2016
SAMHSA Reports Clearance Officer
5600 Fishers Lane, Room 15E57-B
Rockville, Maryland 20857
Re: Minority AIDS Initiative — Survey of Grantee Project Directors
Dear Ms. King:
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Substance Abuse and Mental Health Services Administration (SAMHSA) in response to the information collection published in the October 7, 2016 Federal Register. The Academy is the world’s largest organization of food and nutrition professionals, with more than 100,000 members comprised of registered dietitian nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree nutritionists. We are committed to improving the nation’s health through food and nutrition and providing medical nutrition therapy (MNT)2 and other nutrition counseling services to meet the health needs of all citizens, including those with HIV infection. RDNs are integral components of the coordinated health care team at SAMHSA-funded centers across the nation at which low-income, uninsured, and under-insured individuals with HIV infection can get proper medical care. In addition, RDNs can and do play integral roles in improving the lives and health of people with serious mental illness (SMI) through chronic care management and preventive services.
The Academy recognizes the important nexus between nutrition and improved health for people living with HIV/AIDS (PLWHA) and the importance of reducing new HIV infections among high-risk populations, and we thus support the proposed collection of information as necessary for the proper performance of the functions of the agency, particularly given the practical utility resulting from the Minority AIDS Initiative—Survey of Grantee Project Directors.
A. Utility and Necessity of the Proposed Information Collection
The Project Directors to be surveyed run grantee programs with the goal "to integrate behavioral health treatment, prevention, and HIV medical care services for racial/ethnic minority populations at high risk for behavioral health disorders and at high risk for or living with HIV." We support the Project Director Surveys to assess the impact of SAMHSA funded programs and improve outcomes through judicious use of various program types and models appropriate for various individuals based upon their particular circumstances and demographics.
The Academy encourages SAMHSA to ensure the survey includes input not only from the Program Director, but also from the providers and clinical staff on the grants. These individuals in the trenches often have answers to questions not available to administrative staff who have little client or patient contact. The Academy anticipates that SAMHSA will set measurable goals and success rates as to how many surveys will need returned out of the 152 program directors surveyed as part of effective data collection and will provide Program Directors with its estimate of how long the survey is expected to take and the impact it will have.
Lastly, the Academy encourages SAMHSA to more clearly outline how the following health indicators will be measured and whether these be quantified or whether experiential and/or subjective data also be collected:
- Reducing behavioral health disorders and HIV infections;
- Increasing access to substance use disorder (SUD) and mental disorder treatment and care; and
- Improving behavioral and mental health outcomes; and reducing HIV-related disparities in four specific grant programs.
B. Importance of Nutrition Services for People with HIV/AIDS
The Academy encourages SAMHSA to continue recognizing the importance of nutrition services for PLWHA, particularly among low-income and other high-risk populations. Individuals who are food insecure routinely forego critical medical care – including making and keeping appointments for primary care and filling medication prescriptions - in order to pay for food.3 Food insecure PLWHA rely extensively on cheap, highly processed, low-nutrient foods.4
For PLWHA, proper nutrition is central to increasing absorption of medications, reducing side effects, and maintaining a healthy body weight. Research has identified the virus as an independent risk factor for cardiovascular, liver and kidney disease, cancer, osteoporosis and stroke. HIV medications can cause nausea and vomiting and may affect lab results testing lipids and kidney and liver function. These compounding health effects, caused by the virus, its medications, and co-morbidities reinforce the important role a nutrient-rich diet plays in a patient's overall care. In addition, providing food and nutrition services facilitates access and engagement with medical care, especially among vulnerable populations.
C. Food and Nutrition Services are Essential to Meeting the Goals of the National HIV/AIDS Strategy
As SAMHSA, the Ryan White program, and the Health Resources & Services Administration (HRSA) continue to support the implementation of the National HIV/AIDS Strategy (NHAS), it is important to note that food and nutrition services are critical to the success of the strategy. In brief, the provision of Food and Nutrition Services (FNS) support the following goals of the NHAS:
- NHAS Goal: Reducing new HIV infections
- PLWHA who are food insecure are less likely to have undetectable viral loads in a statistically significant way. Undetectable viral loads prevent transmission 96% of the time,5 thus, FNS is key to prevention.6
- NHAS Goal: Increasing access to care and improving health outcomes for people living with HIV
- PLWHA 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 medicines.7
- NHAS Goal: Reducing HIV-related disparities and health inequities
- By providing FNS to PLWHA who are in need largely because of poverty, we improve health outcomes, thereby reducing health disparities.8
The Academy appreciates the opportunity to offer comments regarding the Minority AIDS Initiative—Survey of Grantee Project Directors. We are pleased to offer our assistance and expertise, including information from our Evidence Analysis Library related to HIV/AIDS care. Please contact either Jeanne Blankenship at 202/775-8277, ext. 6004 or by email at email@example.com or Pepin Tuma at 202/775-8277, ext. 6001 or by email at firstname.lastname@example.org with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Vice President, Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Pepin Andrew Tuma, Esq.
Director, Regulatory Affairs
Academy of Nutrition and Dietetics
1 The Academy recently 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 Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process focused on prevention, delay or management of diseases and conditions, and involves an in-depth assessment, periodic re-assessment and intervention. [Academy of Nutrition and Dietetics' Definition of Terms list, accessed 31 June 2012.] The term MNT is sometimes used interchangeably with, but is sometimes considered different from, nutrition counseling in health insurance plans.
3 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.
4 Adaila A, Caban M, Castro C, Cespedes H, Sharma N, Yomogida M. Who Needs Food & Nutrition Services and Where Do They Go for Help?
5 Palar K, Laraia B, Tsai A, Weiser SD (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.
6 Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. Food insecurity is associated with incomplete HIV RNA suppression among homeless and marginally housed HIV-infected individuals in San Francisco. J Gen Internal Med 2009; 24(1):14-20.
7 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.
8 Weiser SD, Frongillo EA, Ragland K, Hogg RS, Riley ED, Bangsberg DR. 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. doi: 10.1007/s11606-008-0824-5. Epub 2008 Oct 25.