Food Access of People Living with HIV (PLHIV)

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 < 6 months of age)
Age
• < 24 months
• 24-59 months
• 5- < 14 years
• > 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.