Food Access of People Living with HIV (PLHIV)

Export Indicator

The number and proportion of PLHIV receiving care and treatment services whose households have poor access to food based on the Household Hunger Scale. PLHIV are individuals who have tested positive for HIV. For the purpose of this indicator, the definit
What it measures

The purpose of the indicator is to measure the status of access to food
among PLHIV in care and treatment services. HIV can cause or worsen poor food access by
reducing income, depleting assets or savings, reducing availability of household labor, diverting
human and financial resources to health care, severing intergenerational transfer of skills and
knowledge, and constraining community coping mechanisms. Poor food access may also
worsen the impact that HIV has on individuals and households, for example when food needs
limit the resources available to spend on health care, reduce the availability of household
members to care for sick individuals, or negatively affect adherence to treatment (Yoder et al.
2009, Cantrell et al. 2008). Programs implement a range of interventions designed to improve
access to food among HIV-affected households. This indicator tracks the level of food access
among PLHIV in care and treatment programs, and can track the impact of interventions aimed
to improve food access by measuring changes over time in the percentage of PLHIV whose
households have poor access to food. In addition to use at the national level, in some cases
individual programs may choose to use this indicator.

Interpretation. This indicator uses a validated measure of household food deprivation and can
be interpreted to directly measure the extent to which HIV-infected clients in care and
treatment programs face food insecurity. The indicator focuses on the food quantity dimension
of food access and does not measure food availability or food utilization, which are other
components of food security. Because the Household Hunger Scale is designed to measure
the more severe levels of food insecurity, even households that score in the more moderate
range (2-3) may be experiencing significantly poor access to food.

Only PLHIV who receive care and treatment services are included in this indicator. There may
be differences in the food security status of clients in such programs and those who are not, so
results should not be interpreted to reflect the status of PLHIV who have not yet been tested
for HIV or who are not yet in care and treatment programs.

Changes in food access measured by the indicator may not be entirely attributable to
interventions implemented by programs. External conditions such as weather, changes in the
economic environment, conflict, or government policies may influence access to food. When
this indicator is used to evaluate the impact of a program, these factors should be considered
during the evaluation design.

When the indicator is measured as a proportion, the indicator result will be affected by how
many and which clients are assessed for household food insecurity. Changes in the population
receiving such assessments (e.g. introduction of food security assessments in new geographic
areas or clinics) may affect the indicator measure. Interpretation of results should take into
account that program impacts, environmental impacts, and the influx (or exit) of populations to
(or from) the indicator’s measurement universe can all cause changes to the indicator value.
This consideration applies to many other indicators as well. This interpretation issue is one reason the indicator reports both the number and the proportion of PLHIV who are food
insecure; measuring both the proportion and the absolute number of PLHIV meeting the
indicator definition and tracking trends in that number over time allows fuller interpretation of
progress than the proportion alone does.

The unit of measurement is the individual, but the information relates to the individual’s
household so some households may be included in the indicator results multiple times, e.g. if
two HIV-infected members of the same family are included in the same reporting period. This
is not a problem since the indicator is designed to measure how many clients in care and
treatment programs face poor food access, not how many households. But this issue is helpful
to keep in mind when interpreting results.

Because the indicator uses a standardized scale and has been shown to generate results that
are directly comparable across contexts, results across programs, geographic regions, or
countries can be compared, subject to the caveat above about different levels of assessment
coverage.

Rationale

Uses. Information provided by this indicator can be used for a variety of purposes. Information
collected at facilities using the Household Hunger Scale can be used by service providers to
inform nutrition counseling and refer clients to food security support services where available.
It can be used to understand and track the extent of poor food access among PLHIV and the
need for interventions to improve access to food, and in some cases can be used to inform
identification of high priority geographic areas for support. The indicator can serve this
function at the global level, as well as at country and regional levels. At the global level,
tracking changes in the indicator can assist donors and international organizations to monitor
and evaluate the extent to which efforts to improve food access among PLHIV are effective.
Similarly, government officials and program managers can use the indicator to monitor the
results of food security support efforts within countries. Programs can use the information to
assess the impact of their interventions, inform resource allocation and program management,
and report to donors. Notwithstanding the caveats mentioned above, the indicator can be
used in some cases to compare impacts achieved with different interventions or in different
locations, though the population included and other factors affecting the indicator need to be
considered in interpreting such comparisons.

Numerator

The number of PLHIV in care and treatment services who have been assessed using the Household Hunger Scale and who had a score of 2-6 (moderate to severe hunger) at some time during the reporting period. If an individual has been assessed more than one time in the reporting period, s/he is counted in the numerator if s/he scored 2-6 at least one time in the period.

Denominator
Calculation

Numerator / Denominator

Method of measurement

The indicator will be measured using the Household Hunger Scale, a
tool that has been developed to measure food deprivation at the household level. The
Household Hunger Scale has been tested in multiple contexts: Kenya, Malawi, Mozambique,
South Africa, West Bank and Gaza Strip, and Zimbabwe, including both rural and urban settings.
The questions comprising the Household Hunger Scale have been shown to be applicable across
cultures. The Scale has also been shown to provide directly comparable results upon use of the
indicator in diverse settings. Detailed information about the validation of the Scale is available
in the report referenced below under “Additional sources of information”.

The Household Hunger Scale consists of three sets of questions about how frequently specific
situations of food deprivation occurred in the household during the four weeks prior to data
collection. Responses are categorized into three codes – never, rarely or sometimes, and often
– and each response code is assigned a numerical value. These are given in the table below.

Household Hunger Scale Questions and Response Codes
Questions Response codes and score values
In the past four weeks was there ever no
food to eat of any kind in your house
because of lack of resources? If yes, how
often did this happen in the past 4 weeks?
Never = 0; Rarely or Sometimes = 1; Often = 2
In the past four weeks did you or any
household member go to sleep at night
hungry because there was not enough food?
If yes, how often did this happen in the past
4 weeks?
Never = 0; Rarely or Sometimes = 1; Often = 2
In the past four weeks did you or any
household member go a whole day and
night without eating anything at all because
there was not enough food? If yes, how
often did this happen in the past 4 weeks?
Never = 0; Rarely or Sometimes = 1; Often = 2

The raw score for an individual’s household is calculated by adding up the three score values
from the responses. The level of household hunger is classified into two categories, as given in
the table below.

Hunger Classification using the Household Hunger Scale
Household Hunger Scale score Household hunger classification
0-1 Little or no hunger in the household
2-6 Moderate or severe hunger in the household

When reporting the indicator as a proportion, the denominator is the number of PLHIV in care
and treatment services who have been assessed using the Household Hunger Scale at some time during the reporting period. If an individual has been assessed more than one time in the
reporting period, s/he is only counted once in the denominator.

The numerator is the number of PLHIV in care and treatment services who have been assessed
using the Household Hunger Scale and who had a score of 2-6 (moderate to severe hunger) at
some time during the reporting period. If an individual has been assessed more than one time
in the reporting period, s/he is counted in the numerator if s/he scored 2-6 at least one time in
the period.

When reporting the indicator as a number, the numerator is reported.

Data collection method. Data should be collected in clinical facilities as part of client
assessments. Data should be collected from all clients in care and treatment services.
Understanding the food access situation of clients is a valuable part of nutrition assessment as
well as socio-economic assessment. It also contributes to understanding the need for referral to
economic strengthening and livelihood support services. The questions in the Scale are very
short, and asking the questions and recording responses does not require much time.

Nurses, counselors, or other service providers ask clients (or guardians in the case of HIV-
infected children) the three questions and they record and tabulate responses on client or clinic
registers. When reporting indicator results, the total number of clients assessed using the Scale
is reported, as well as the number whose score was between 2-6 at least once during the
reporting period.

In some cases, data for this indicator can be collected at the community level. For the purpose
of this indicator, community-based data collection is recommended only when the community
workers are linked to a health facility (e.g., social workers or community health workers
attached to an HIV treatment facility). This will help ensure that the data can be compiled,
analyzed, and reported at the health facility level because the population measured by this
indicator is PLHIV receiving care and treatment services.

If data are not routinely collected during clinic visits or community workers attached to a clinic,
data can be collected through a special survey. The survey should be of a representative sample
of PLHIV in care and treatment programs. Because the Scale is a short set of questions, these
could also be incorporated into other surveys of PLHIV that receive care and treatment services,
for example health facility assessments or client satisfaction surveys conducted as exit
interviews. In this case, the indicator should be reported as a proportion.

Frequency of measurement and reporting. When the Household Hunger Scale is part of
routine assessment, measurement may occur regularly, though reporting is likely to only be
needed annually. If the Scale is not applied as part of routine assessment but as part of special
surveys for the purpose of reporting on the indicator, then it can be measured annually. In this
case, data should be collected during the same season of the year because food security status
can be affected by seasonal factors.

Disaggregation. Disaggregation for this indicator is recommended for the following categories:

ART vs. no ART
Sex
Pregnancy status
Postpartum status (i.e. with
infants Age
• • 24-59 months
• 5- • > 15 years

Programs may also decide to disaggregate the indicator based on categories that are relevant
to their target groups and services, e.g., by geographic region.

Measurement frequency

Annual

Disaggregation

Age group: (greater than) 15 years

Gender: Male, Female

Pregnancy status: Pregnant, Not Pregnant

Explanation of the numerator
Explanation of the denominator
Strengths and weaknesses

Strengths. One strength of the indicator is that it measures the primary impact that most
household food security services aim to achieve – access to food among households. Another
strength is that substantial work has been undertaken to develop and validate the Household
Hunger Scale: the psychometric properties of the Scale have been evaluated using Rasch
measurement models and the Scale has been shown to provide directly comparable results
across contexts. The Scale has also demonstrated a substantive association with other proxy
measures of household food access (e.g. household wealth score, household dietary diversity
score, household income by consumption unit). A third strength is that the questions in the Household Hunger Scale have been field tested in
seven diverse sites in six countries, and the Household Hunger Scale has been used in practice
in more than six countries, including countries with high prevalences of HIV. A fourth strength
is that the questions needed for the indicator are simple and quick to administer. A fifth
strength is that the data can be valuable to inform counseling and referrals to food security
support services.

Weaknesses. A weakness of the indicator is that it only measures food access among PLHIV in
care and treatment programs so it may not be representative of a country’s population of
PLHIV and specifically may not capture PLHIV who do not have access to care and treatment
services or who do not yet require such services. The indicator is designed this way because
care and treatment programs are an important point for identifying PLHIV and referring them
to support services and because of the challenges associated with identifying HIV-affected
households in which no one participates in a care and treatment program. A second weakness
is that although the questions are relatively simple and quick to administer, the indicator does
require already busy service providers at clinical facilities to collect additional information from
clients, which can add to existing time burdens. On the other hand, the data do not necessarily
need to be collected by health providers, as lay staff or possibly community-based workers
could be trained to collect the information as well.

Resources required. The main resources required to use this indicator are the training and time
required for data collection and analysis. Although the questions are fairly simple to
administer, time is required from service providers to collect data and time is required from
individuals analyzing the data. Those collecting the data also require basic training in how to
ask questions and tabulate responses. Paper or electronic forms are also needed with the three
questions and to record and tabulate responses. If special surveys are conducted for this
indicator, that would require substantial additional resources, unless the question were added
to an existing survey.

Further information

Ballard, Terri, Jennifer Coates, Anne Swindale, and Megan Deitchler. Household Hunger Scale:
Indicator Definition and Measurement Guide. Washington, DC: FANTA-2 Bridge, FHI 360, 2011.
http://www.fantaproject.org/downloads/pdfs/HHS_Indicator_Guide_Aug2011.pdf

Cantrell, Ronald A., Moses Sinkala, Karen Megazinni, Sibi Lawson-Marriott, Sierra Washington,
Benjamin Chi, Bushimbwa Tambatamba-Chapula, Jens Levyt, Elizabeth Stringer, Lloyd Mulenga,
and Jeffrey S.A. Stringer. “A Pilot Study of Food Supplementation to Improve Adherence to
Antiretroviral Therapy among Food-Insecure Adults in Lusaka, Zambia.” Journal of Acquired
Immune Deficiency Syndrome, 2008, 49:190–195.

Megan Deitchler, Terri Ballard, Anne Swindale, and Jennifer Coates. Introducing a Simple
Measure of Household Hunger for Cross-Cultural Use. Washington, D.C.: Food and Nutrition
Technical Assistance II Project, AED, 2011. http://www.fantaproject.org/downloads/pdfs/TN12_HHS.pdf

Deitchler, Megan, Terri Ballard, Anne Swindale and Jennifer Coates. Validation of a Measure of
Household Hunger for Cross-Cultural Use. Washington, DC: Food and Nutrition Technical
Assistance II Project (FANTA-2), AED, 2010.
www.fantaproject.org/publications/hhs_validation_2010.shtml.

Journal of Nutrition Supplement (2006) 136. (A supplement with six articles on the Household
Food Insecurity Access Scale.) jn.nutrition.org/cgi/content/full/136/5

Swindale, Anne and Paula Bilinsky. “Development of a Universally Applicable Household Food
Insecurity Measurement Tool: Process, Current Status, and Outstanding Issues.” Journal of
Nutrition (2006) 136: 1449S-1452S.
jn.nutrition.org/cgi/content/full/136/5/1449S?ijkey=shP2TlEii15uA&keytype=ref&siteid=nutriti
on

Yoder, P. Stanley, Sibongile Mkhize, and Siyabonga Nzimande. 2009. Patient Experiences in
Antiretroviral Therapy Programmes in KwaZulu-Natal, South Africa. Durban, South Africa:
Health Systems Trust and Calverton, Maryland, USA: Macro International Inc.