Testimony Prepared by the Academy of Nutrition and Dietetics for the United State Senate Subcommittee on Labor, Health and Human Services, and Education, and Related Agencies addressed to the Department of Health and Human Services
April 3, 2015
We are pleased to submit this testimony to the Members of this Subcommittee on the urgency of continuing to support the Ryan White Program through the Appropriations process and increasing funding for the domestic HIV/AIDS portfolio in Fiscal Year 2016 (FY16). This support and funding will be decisive for achieving the goals of the National HIV/AIDS Strategy (NHAS), the AIDS Free Generation and halting the devastating effects of the HIV Treatment Cascade.
The Academy of Nutrition and Dietetics (the Academy) is part of a nationwide coalition, the Food is Medicine Coalition, of over 80 food and nutrition services providers, affiliates and their supporters across the country that provide food and nutrition services to people living with HIV/AIDS (PLWHA) and other chronic illnesses. The Academy represents 75,000 members, comprised of registered dietitian nutritionists (RDNs), dietetic technicians, registered, and other dietetics professionals holding undergraduate and advanced degrees in nutrition and dietetics. Collectively, the Food is Medicine Coalition is committed to increasing awareness of the essential role that food and nutrition services (FNS) play in successfully treating HIV/AIDS and to expanding access to this indispensable intervention for people living with other severe illnesses.
1. Why Food and Nutrition Services (FNS) Matter for PLWHA
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 that test lipids and 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 Program includes medical nutritional therapy (MNT) and food and nutrition services (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 a licensed RDN outside of a primary care visit. The range of FNS provided through the Ryan White program complements the needs of PLWHA 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, 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 Ryan White Program. These services play a critical role in ensuring that PLWHA enter and continue in primary medical care, adhere to their medications, and ultimately achieve viral suppression.
2. FNS as a Care Completion Service Unique to Ryan White
Social and economic interventions, most often in the form of care completion service like food and nutrition services, are fundamental to making health care work for PLWHA. Support services for PLWHA 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 needs are met, and life’s emergencies are held at bay, PLWHA are poised to remain connected to care and treatment.
3. Access to FNS and Triple Aim
Access to appropriate food and nutrition services (FNS) are increasingly recognized as key to accomplishing the triple aim of national healthcare reform for PLWHA.
Better Health Outcomes
When clients get effective FNS and become food secure, they then 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 medicines1. Studies show both the health benefits of access to MNT and/or nutrition counseling for people with HIV infections2 and the resulting decreases in their healthcare costs. Compare these outcomes to PLWHA who are food insecure, who have:
- Lower CD4 counts & lower likelihoods of having undetectable viral loads3
- More ER visits4 & increased morbidity and mortality5
- More missed primary care appointments & reduced use of antiretroviral therapy6.
Lower Healthcare Costs
Millions of dollars in healthcare expenditures are saved through the provision of FNS to PLWHA. A recent study comparing participants in a medically-tailored FNS program vs. a control group within a local managed care organization found that average monthly healthcare costs for PLWHA fell 80% (more than $30,000) for first three months after receiving FNS7. If hospitalized, FNS clients' costs were 30% lower, their hospital length of stay was cut by 37% and they were 20% more likely to be able to be discharged to their homes rather than a more expensive institution8. Furthermore, FNS are a very inexpensive intervention. For each day in a hospital saved, you can feed a person a medically-tailored diet for half a year.
Improved Patient Satisfaction
Studies show nutrition counseling improves quality of life9. Members overwhelmingly report that our services help them live more independently, eat more nutritiously and manage their medical treatment more effectively.
4. FNS and the National HIV/AIDS Strategy (NHAS)
Access to FNS for PLWHA is fundamental to fulfilling the 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 time10, thus, FNS is key to prevention11.
- 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 medicines12.
- 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 disparities13.
We are deeply aware of the difficult decisions that face the members of the Subcommittee in the current fiscal environment. Yet, research shows that investment in FNS, with the great return in prevention and retention in HIV care, are vital to lowering the number of new infections in the domestic HIV epidemic and ultimately 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, if not impossible. Early and reliable access to medically-appropriate FNS helps PLWHA 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 Ryan White, making support for Ryan White 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 the Ryan White and the ACA.
Along with our colleagues, we appreciate the opportunity to offer testimony regarding the FY 2016 Appropriations process. We are also pleased to offer our assistance and expertise, including information from our Research Library.
Mary Pat Raimondi, MS, RD
Vice President, Strategic Policy and Partnerships
Academy of Nutrition and Dietetics
1120 Connecticut Ave NW, Sute 460
Washington DC 20036
1 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..
2 Academy of Nutrition and Dietetics (formerly American Dietetic Association). HIV/AIDS Nutrition Evidence Analysis Project. Accessed 29 July 2012.
3 Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team (2011).
5 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
6 Aidala A., Yomogida M., and the HIV Food & Nutrition Study Team (2011).
7 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. [Epub ahead of print].
8 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. [Epub ahead of print].
9 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. 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
10 M. S. Cohen et al., "Prevention of HIV-1 Infection with Early Antiretroviral Therapy," N. Engl. J. Med. 365, 493-505 (2011). HPTN 052
11 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.
12 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.
13 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.