This study reports extremely low levels of food security among PWID in a rural Appalachian community grappling with disproportionately high rates of substance use and overdose. In Cabell County, where an estimated 2.4% of the population inject drugs,(27) we found that only 17% of PWID were food secure. This prevalence is much lower than food security in the general population (88%)(30) and considerably lower than estimates of food security among populations of PWID from North American studies in California (38%- 42%),(12) Ontario (45%),(15) and Vancouver,(35%).(17, 31, 32) However, meaningful comparisons are hampered by several factors, including that the majority of injection drug use-related literature reflects urban populations as well as varying definitions of food security. Nonetheless, these data highlight the extent of unmet need for food, a basic requirement for health and survival, among vulnerable individuals with multiple competing health needs.
Consistent with existing literature,(21, 31–34) there was an inverse relationship between food security and sharing injection equipment. While the direction of this association cannot be inferred from cross-sectional analyses, this finding highlights the co-occurrence of hunger and HIV risk behaviors which may act to reinforce one another and compound risks of HIV acquisition. Lack of food security is linked to both increased susceptibility to HIV infection, and poorer adherence to anti-retroviral therapy(31, 35) underscoring the importance of food security for initiatives promoting prevention among PWID who are HIV-negative, and viral suppression among PWID living with HIV. More broadly, basic subsistence needs such as access to food and housing serve as competing priorities(36) that drive lower uptake of prevention and treatment among people who are vulnerable to or living with HIV,(37, 38) thereby compounding their risks of negative health outcomes.(16) These factors are particularly relevant in the context of Cabell County, which is among a growing list of counties experiencing injection-associated HIV outbreaks in recent years.(39–42) Interventions to promote access to sufficient quantity and quality of food for PWID may be complementary to HIV prevention and substance use services in these settings. Various global health initiatives integrating food security and nutrition interventions with HIV/AIDS programs in lower and middle-income countries exist; however, a recent review (43) highlighted that a paucity of evidence and best practices to achieve this in the United States. Despite growing calls to pursue food provision as an important harm reduction strategy among PWID, the drug treatment or syringe service programs in North America that do offer food services are highly variable and there remain no rigorously evaluated examples to inform best practices or implementation at scale.(44) These data further highlight the need for formative research and pilot programs to inform interventions promoting food security among people at risk of and living with HIV in rural settings, including PWID.
Another important finding from this study was that women who inject drugs had significantly lower odds of being food secure than their male counterparts. This may be due to several factors related to gender roles and disparities. Women in our study more frequently engaged in transactional sex. Research demonstrates low food security among women who sell sex, and that decreased food security has been shown to reinforce their need to engage in sex work as well as reduce their negotiating power in terms of utilizing HIV prevention measures with clients, such as condom use.(19, 21, 29) However, this population often has a high prevalence of overlapping structural vulnerabilities, including homelessness, making specific effects difficult to decipher. Women are also more likely than men to be responsible for children, increasing their financial burdens. Decreased food security may therefore reflect the stretching of limited resources among women with their dependents,(19, 41, 45) and introduce even greater incentive for women to prioritize food acquisition over other health needs.(16) In West Virginia, 42–52% of households with children utilize SNAP benefits (46) and national data demonstrate that single mother households have the lowest rate of food security in the country.(29) There is a well-established body of evidence demonstrating the importance of food security and nutritional sufficiency for women’s reproductive health and the subsequent health of their children.(47) Bolstering food security may therefore represent a useful and high-impact entry point for averting downstream health risks among children in this setting. Food security among a vulnerable sub-population of women who use drugs represents an important avenue for future research to inform tailored interventions.
Recent arrest was associated with lower odds of food security among our sample, but the direction of this association cannot be inferred with the available data. Individuals with low food security may be arrested for crimes related to their hunger and fundamental survival (e.g., food theft); alternately, arrests may lead to financial costs (e.g. bail, legal fees) and interrupt stabilizing forces, which in turn can impact food security. For example, loss of employment due to arrest may indirectly lead to reduced food security, particularly if there are work requirements for food assistance as in West Virginia. Evidence also suggest that arresting people with substance use disorders can interrupt access to treatment and result in higher-risk substance use and overdose.(48, 49)Taken together, this suggests that PWID with recent arrests may be particularly vulnerable to hunger and drug-related harms; efforts should therefore be made to ensure that all PWID, regardless of interaction with the justice system, have consistent and low-threshold access to food.
We identified several factors associated with food security among PWID in rural Appalachia that illustrate a portrait of pervasive structural vulnerability. Rather than being specific to substances used, food security was related to factors such as education and housing. This is consistent with the broader literature, which highlights structural markers of poverty (e.g., lack of housing,(12, 17, 19, 29, 31, 32, 35) education (29) and employment (50, 51) as the most strongly and consistently associated with hunger. In the state of West Virginia, prevalence of these indicators in the general population is higher than the United States average; in 2019, for example, 18% of the WV population were living in poverty(52) compared with 12% nationally, and the unemployment rate was 5% relative to 3.5% nationally.(53) Data specifically among people who inject drugs throughout the state are not available, to our knowledge. In this study sample, however, we observed an unemployment rate of 66%, in stark contrast to state-wide levels among the general population. Further, since measures to reduce the spread of the novel SARS-COV-2 (COVID-19) virus began in March 2020, the overall unemployment rate in West Virginia immediately increased to 15% and Supplemental Nutrition Assistance Program (SNAP) applications have more than tripled. Other supportive services, such as school feeding programs, are struggling to meet demand,(54) and it is estimated that over 20% of children in the state are food insecure.(55) As such, the proportion of PWID, and specifically women with children, who are at risk of hunger in this setting is likely to be even higher than estimates provided here. Taken together, these data suggest that integrated programs designed to address multiple, overlapping vulnerabilities are needed to respond to the crisis of food insecurity in this population.
Results should be viewed in light of several limitations. Measures of food security vary across studies and have not been standardized in this population, and self-report data can be dependent on the individual’s perception.(12) Further, our outcome was captured using a single measure; studies assessing levels of food access and security in other populations employ multi-item scales to capture this construct more comprehensively, and there is a need for the use of more sophisticated metrics to better describe hunger among drug-using populations. Given the trauma associated with hunger, and the ways in which trauma is also a driver of substance use itself and related risk behaviors,(56) we adopted a strict cutoff classifying any recent experiences of going to bed hungry as counter to being food secure. This is further supported by prior literature suggesting that moderate definitions of experiencing hunger may be more sensitive than extreme or severe ones.(57, 58) We also posited that any recent experience of uncertainty about securing one’s next meal could comprise a tangible competing priority potentially influencing HIV risk. Nonetheless, comparison with other studies should be made keeping the lack of consistency between metrics of food security, particularly in this population, in mind. Results should therefore be viewed with full consideration of the differences between our metric and other published estimates. We lacked an adequate sample size to detect meaningful interactions, e.g., between sex work and gender. We also did not have data on pregnancy or motherhood, limiting our ability to more fully explore whether the relationship between food security and gender was related to these factors. Data on nutritional indicators (e.g. underweight, specific micronutrient deficiencies, overweight/obesity) and food assistance (e.g., proportion enrolled in SNAP) were also not collected. While we explored a range of drug use via any route of administration, results should not be extrapolated to the broader population of PWUD given the parent study’s focus on injection drug use and the restriction to PWID within this analysis. Finally, as a cross-sectional study, we are unable to make inferences regarding causality or the direction of associations.