Food insecurity exists “whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain” (e.g., without resorting to emergency food supplies, scavenging, stealing, and other strategies). It is associated with poorer health outcomes (sub-optimal treatment success) for people living with HIV. Chronic hepatitis C (HCV) infection in combination with HIV may further contribute to food insecurity-related health and treatment complications. CTN 264 explored the risk factors of food insecurity and consequences of being food insecure in people living with both HIV and HCV.

Study population/design

CTN 264 was a substudy of the Canadian Co-infection Cohort (CTN 222), a national cohort that tracks over 1,500 Canadian participants who live with both HIV and HCV. The food security substudy recruited participants from CTN 222. Using a measurement tool created by Health Canada, participants were asked to complete a questionnaire to measure their food security status. Moderate food insecurity means that a person may have to compromise on the quality or amount of food that they consume. Severe food insecurity means that food intake is significantly reduced and eating patterns are disrupted.

Various social, economic, behavioural, and clinical variables were used to identify risk factors for food insecurity and explore outcomes associated with being food insecure over time.

Study Approach

Preliminary analyses of these data revealed that 59% of participants (312 of 525) were food insecure (moderate, 24%; severe, 35%) at their first study visit. Recent injection drug use (in the past 6 months) was significantly associated with food insecurity, and approximately one third of study participants had recently injected drugs. The recent occurrence of depressive symptoms was also significantly associated with food insecurity and roughly one half of participants experienced such symptoms.

One of most important factors related to HIV and food insecurity is its effect on viral suppression. In a meta-analysis of 11 previous studies, the CTN 264 team showed that people experiencing food insecurity were 29% less likely to achieve complete HIV viral suppression. This finding was confirmed in a 2018 analysis of the CTN 264 cohort, where the team also learned that people who experienced severe food insecurity had lower CD4 counts than people who were food secure. Later analyses showed that injection drug use, particularly weekly use, was associated with food insecurity, and methadone treatment was associated with a lower risk of severe food insecurity.

The relationship between food insecurity and depression was another main focus for the CTN 264 team. Over half of the CTN 264 cohort had depressive symptoms at the start of the study. More severe food insecurity was associated with increased risk of depressive symptoms; people with severe food insecurity were twice as likely to show depressive symptoms compared with people who were food secure. People experiencing depressive symptoms had a 32% increased risk of having a detectable HIV viral load. Furthermore, people with depressive symptoms were less likely to initiate treatment for their HCV using interferon-based therapies. However, now that direct-acting antivirals are available, it is unknown whether depressive symptoms would have an effect on treatment initiation in this population.


Food insecurity is a complex and important factor that affects how people are able to access care and manage their HIV and HCV infections. CTN 264 has helped identify potential targets for policies, programs, and future research areas to help reduce food insecurity in people living with both HIV and HCV. In particular, the study has highlighted the importance of understanding and addressing injection drug use and depressive symptoms, as they relate to treatment success in people who experience food insecurity.

Community Publications

HepCBC Bulletin (page 3)

Positive Living Magazine (page 23)

Principal Investigators

Here’s who is leading this study.

Can’t find what you’re looking for? Email ctninfo@hivnet.ubc.ca.