HIV/AIDS and Food Insecurity, with Jacob Bleasdale

Jacob Bleasdale, MS is a fourth-year Doctoral Candidate in the Department of Community Health and Health Behavior at the School of Public Health and Health Professions, University at Buffalo. His program of research seeks to understand the multi-level determinants of HIV prevention and treatment among communities most impacted by the HIV epidemic. Specifically, his dissertation work explores the complex relationships between food insecurity and engagement in the HIV care continuum.

Read Jake's most recent publication discussed in the podcast here:
Socio-Structural Factors and HIV Care Engagement among People Living with HIV during the COVID-19 Pandemic: A Qualitative Study in the United States 

Credits: 
Host/Writer: Sarahmona Przybyla, PhD, MPH
Guest: Jacob Bleasdale, PhD(c), MS
Production Assistant: Sarah Robinson
Video/Audio Editor: Omar Brown
Theme Music: Sungmin Shin, DMA
Faculty Consultant: Nicole Klem, MS, RD

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Transcript

Intro  0:00 
Welcome to Buffalo HealthCast, the official podcast of the University at Buffalo's School of Public Health and Health Professions. We are your cohosts, Schuyler Lawson and Tia Palermo. In this podcast we'll cover topics related to health equity in Buffalo, around the US, and globally. This season we'll be talking about nutrition from a health equity perspective. You'll hear from community members, practitioners, researchers, students, and faculty on topics related to nutrition, including food security, food access, social protection to improve nutrition outcomes, food apartheid, culturally tailored nutrition interventions, and more in this season of Buffalo HealthCast.

Sarahmona Przybyla  0:47 
Hi there, my name is Sarahmona Przybyla. I'm in the Department of Community Health and Health Behavior, and today we're going to be interviewing Jacob Bleasdale, who is a fourth year PhD student in the Department of Community Health and Health Behavior at the UB School of Public Health and Health Professions. So Jake, I'm just going to jump right in with some questions if that's okay. I think it's important for us to hear a little bit about how you became interested in HIV prevention and treatment research.

Jacob Bleasdale  1:13 
Yeah, absolutely. So historically, and within present day, we know that the HIV epidemic has affected marginalized communities, particularly the queer community. And as a member of the queer community, it was important to me when deciding on a career path that my work that I was doing was based in equity and justice and work towards providing better health for a particular group. So working to end the HIV epidemic through research is what I decided to do. And that's how I came about with HIV prevention research. It also kind of just bridges my two interests. So my undergrads are in Biomedical Sciences in Pharmacology and Toxicology. My PhD is obviously in Community Health and Health Behavior. And HIV research combines both that Biomedical and Behavioral Sciences and allows me to give a nice lens to the work that I'm doing, but also understand the full complexities of the epidemic itself.

Sarahmona Przybyla  2:03 
Great. Tell me a little bit more, though, about the difference between HIV prevention versus HIV treatment, because I understand those to be related, but not the same thing. So talk a little bit more about that.

Jacob Bleasdale  2:13 
Yeah, absolutely. So when we think about HIV prevention, we're primarily thinking about people who are not living with HIV, or HIV uninfected people and preventing them from getting HIV. So most of my work and the work that we do in our work and our research really focuses on increasing HIV pre-exposure prophylaxis, or HIV PrEP uptake within communities that are most at risk for HIV acquisition. So that includes communities of color, men who have sex with man, gay and bisexual men. So really focusing on increasing PrEP uptake for those communities. Then on the other hand, you have HIV treatment, which includes really amplifying engagement across the HIV care continuum. So that includes making sure that people who are living with HIV receive a timely diagnosis, are engaged in care and then take their medication enough so that they're virally suppressed, or the HIV in their body is so low, it cannot be detected on a viral load test. So that's HIV treatment research - it really focuses on bolstering and amplifying engagement across the care continuum and making sure that people who are living with HIV achieve and maintain viral suppression.

Sarahmona Przybyla  3:20 
That's great. Okay, so now I want to ask you a little bit more about nutrition, right? So this is a different path. But how did you become interested in nutrition and food insecurity research?

Jacob Bleasdale  3:32 
Yeah, absolutely. So my first exposure to nutrition and dietary and eating behavior work was in my undergrad. So I worked as a research assistant all throughout my undergrad in the Child Health and Behavior Lab in the Jacobs School of Medicine under the direction of Dr. Stephanie Anzman-Frasca,
 and in this lab, I really learned a lot about developmental psychology and early childhood health behavior in relation to obesity prevention. So we focused a lot on nudging techniques and techniques that would make the healthiest choice, the easiest choice for children to prevent obesity. And when I decided to pursue a PhD, and really focus my work on HIV prevention and treatment, I really wasn't ready to give up the nutrition aspect of that yet. So I decided to look at how dietary intake and food insecurity would start to influence HIV treatment outcomes for those living with HIV. And that's kind of how I have been marrying the two within my work a little bit.

Sarahmona Przybyla  4:23 
I think food insecurity is a term that a lot of people use, but not everybody may understand what it means. So what does food insecurity actually mean?

Jacob Bleasdale  4:32 
Yeah, absolutely. So broadly speaking, when we think about food insecurity, we are talking about it with people we think about lacking access to food or not having food within the household that meets sufficient needs. So whether that's access in terms of physically having the food or access about getting the food, it's really just not having the needs to get an ample and a sufficient amount of food for you or your household.

Sarahmona Przybyla  4:55 
Got it. Okay, great. I want to bounce back to HIV. So tell us a little bit more about what HIV looks like in the United States.

Jacob Bleasdale  5:03 
Yeah, absolutely. So we've definitely made strides since the beginning of the epidemic in the late 80s and early 90s. But even still in 2020, we had about 31,000 people in the United States who were diagnosed with HIV. And of those diagnosed with HIV, we're still seeing significant disparities. So among those, 70% were among gay, bisexual, and other men who have sex with men, 22% were among people who identified as heterosexual, and 7% were among those people who inject or use drugs. Currently in the United States, there are approximately 1.2 million people living with HIV. And while HIV diagnosis has decreased about 8% overall, there are still stark disparities with new HIV incidence. So we see a lot of new diagnosis primarily among Black and Hispanic men who have sex with men, and among other disparate groups of people within the United States.

Sarahmona Przybyla  5:53 
So that's great to hear what HIV looks like on a national level. How about closer to home? Can you talk a little bit about what HIV incidence or prevalence looks like, either here in Buffalo, or more broadly, maybe in Erie County?

Jacob Bleasdale  6:07 
Yeah, absolutely. So it's nice to contextualize what HIV or the work we're doing looks like in Buffalo and Erie County. So in 2020, Erie County had about 85 new HIV diagnoses, which is actually the highest number in the state outside of New York City, and those number of diagnoses in Erie County has decreased in 2018 and 2019, but actually in 2020, was the first time it's actually increased. So among these new infections, we saw that 63% were among non-Hispanic Black persons, 69% were actually among people ages 13 to 34, and 58% were among men who have sex with men. So we see that the number of new diagnoses and among the new diagnoses in Buffalo kind of represents and contextualizes on to the steps that we see at the national level as well.

Sarahmona Przybyla  6:53 
So that's actually really interesting to hear some of those 2020 numbers, because that's when we entered the early years, early months of the pandemic. So talk a little bit about how may that have happened, right? I guess we might assume that HIV cases would have gone down, and especially when you know, the first few months, or even first half of 2020, what might explain that pattern you see?

Jacob Bleasdale  7:15 
Yeah, so the intersections between HIV incidence and COVID-19 are complex and interrelated. And we're still working very hard to figure out what those complexities are. But a lot of people have hypothesized that the COVID-19 pandemic has led to decreases in HIV testing, which would increase not only the proportion of people who are diagnosed with HIV, but also decrease what as people's statuses. So one of the major things of HIV prevention is knowing your HIV status. We know that one in seven people who are diagnosed with HIV were unaware of their status. So a lot of researchers hypothesize that that is a major contributor to what we see, an increase in HIV incidence is that people weren't getting tested during the pandemic, but still engaging in risky sexual behaviors, despite social distancing guidelines and the risk of contracting COVID-19. But because of that, and because health centers are shifting gears towards treating and maintaining COVID-19 infrastructure, there was less testing that was potentially available, or people just were not willing to go get tested. So a major hypothesis is that less testing led to more unknown cases of HIV, which led to greater incidence within 2020.

Sarahmona Przybyla  8:31 
That makes sense, okay. So let's flip back to food insecurity. Can you give us a sense of what food insecurity looks like across the United States?

Jacob Bleasdale  8:41 
Yeah absolutely. So in 2021, about 90% of households were food secure. So they had adequate means to get the food that they need to support themselves. So that leaves about 10% or 11% of households that were food insecure, at least sometime during the year. And this includes 3.8% or 5.1 million households that had very low food insecurity. So the lowest bracket that we can think of when we're measuring food insecurity is very low food insecurity, which is very severe - severe lacking access to food or not having the ability to maintain the nutrition that they needed to survive. And we also see that this is highly correlated to socioeconomic status. So 32 or 33% of households that were food insecure, were among those with incomes below the federal poverty line. And rates of food insecurity were substantially higher for single parent households, and for Black and Hispanic households as well.

Sarahmona Przybyla  9:38 
You mentioned socioeconomic factors. Can you talk a little bit about either maybe geopolitical or even other economic drivers of food insecurity? So what comes to mind is things like inflation, right, and how we see our grocery store bills going up. How do those changes, you know, kind of differentially impact those who are food insecure?

Jacob Bleasdale  9:58 
Yeah, absolutely. So when we think - I think when we think about affording food and affording groceries, the first thing we think about is income, and inflation, it's definitely impacted what we can afford at the grocery store. I know, even personally, when you go to the grocery store, eggs are significantly more expensive than what they used to be. But another factor that plays a significant role in food insecurity, or food security status is actually access and having transportation to get to these areas or get to areas that have adequate food for your family. We know that the historical ideas of redlining or intentionally segregating areas, has influenced where grocery stores go not only here in Buffalo, but also across the United States. So one of the biggest factors that influence food insecurity is actually being able to have access to these grocery stores and lacking transportation, or not even perhaps lacking transportation, but someone may not want to have to take five buses and spend $4 just to get to the grocery store and then have to take that back. So access and transportation concerns plays a large role in food security and food insecurity status in the United States.

Sarahmona Przybyla  10:01 
Got it, makes a lot of sense. Are there any other things that you want to share with us about food insecurity, just generally speaking?

Jacob Bleasdale  11:15 
I think it's also important to contextualize it within Buffalo as well. So in 2020, nearly 56,000 households or 12% of all households in the Buffalo Niagara community lacked equitable access to supermarkets because they lived outside the average walking distance from shopping. So that kind of goes back to this idea of lacking adequate transportation or access to grocery stores. And a lot of this is predominantly within black and brown neighborhoods that have been redlined by supermarkets and grocery stores, so that these areas are politically and economically not able to fund or have their own grocery stores in these areas which significantly impacts access for people who live in Buffalo communities that don't have a Tops or a Wegmans right next to them. So it's an issue on the national level, but it's also a significant issue that hits very close to home within our Buffalo community.

Sarahmona Przybyla  11:30 
Sure, yeah. And I think maybe something that many of us might take for granted.

Jacob Bleasdale  12:09 
Absolutely.

Sarahmona Przybyla  12:10 
For sure. Okay. So you've shared with us a lot about HIV prevention, HIV treatment, and then this kind of parallel research world for you with respect to nutrition and food insecurity. How about this intersection, though, right? So talk to us a little bit about how HIV, nutrition, and food insecurity intersect.

Jacob Bleasdale  12:10 
Yeah, I think when you first think about HIV and food, you're like, there's no relationship there, or it's hard to contextualize the relationship between the two. But there's actually a significant relationship between not only food and nutrition and HIV, in terms of the biomedical and pharmacokinetic level, but also at the health care engagement level, and at the more social ecological level as well. So first, we know that research has illustrated significantly higher prevalence of food insecurity among people living with HIV compared to the general population. So like I said earlier, it's estimated that about 10 to 11% of the population in the US experienced food insecurity in 2020. But we have cross sectional longitudinal data among people living with HIV that estimates food insecurity, rates and prevalence to be about 25% to 70%. So we see a significant disparity in food insecurity affecting people living with HIV compared to the general population. Then we also just see significant risk factors that increase the risk for food insecurity among people living with HIV. So we see behavioral mental health concerns, illicit substance use, and the socioeconomic factors like we discussed earlier, such as low income, unemployment, unstable housing, transportation that all kind of compound and intersect together to significantly increase the risk of experiencing food insecurity while living with HIV.

Sarahmona Przybyla  12:34 
Got it, okay. I now want to hear a little bit more about this influence on HIV treatment and HIV prevention. So talk to us a little bit maybe about your own research of how food insecurity influences HIV treatment.

Jacob Bleasdale  14:13 
Yeah, absolutely. So we know that among people living with HIV, food insecurity is associated with lower odds of completing healthcare outcomes or just lower odds of greater health outcomes. So we know that that means lower CD4 cell counts or HIV in the body, incomplete viral suppression. So people are having detectable HIV viral loads in their body which has the potential to increase transmission. They have worse immunologic responses so they're more likely to get sick easier, and they have increased opportunistic infections that are associated with HIV and AIDS as well and poor medication adherence. So those, for people living with HIV and HIV treatment, all kind of interplay to kind of influence health outcomes for people living with HIV that kind of decrease one's ability to maintain and achieve viral suppression, which is that last stage of the HIV care continuum, which we are trying to do.

Sarahmona Przybyla  15:11 
So I know that you do qualitative studies, and you interview people living with HIV. Can you give us maybe some examples of how this actually plays out? So you're making these connections between food insecurity, and you're talking about connections to treatment engagement, but how does that actually work in someone's day to day life?

Jacob Bleasdale  15:31 
Yeah, absolutely. So I recently just had a paper published in Tropical Medicine and Infectious Disease that looked at the influence of COVID-19 on HIV care engagement among people living with HIV, and my sample was 25 people living with HIV across New York State, the majority were food insecure. A lot of them talked about how the pandemic and food insecurity influenced their social determinants of health, so particularly income, housing, and transportation, and how that led to decreased engagement in care. People talked about just how food insecurity in general was significantly impacted by COVID-19, and how that led to increased periods of time where they didn't have food, and that increased their depression or their anxiety, and they physically felt weak, and they weren't able to go to their doctor's appointments, or they weren't able to take their medication. And a lot of our participants just talked about how, when you don't have food, the last thing on your mind is taking care of your other health needs, my main priority is going to find or do something so that I can eat dinner for the day, but the last thing on my mind is going to talk to my doctor or to take my medications. And a lot of these medications, people don't like to take on an empty stomach. So if they don't have food, they're not going to take it.

Sarahmona Przybyla  16:45 
That's a really good point about how the medicine actually works in their body, and that you need to take it with food, but food isn't available to you. You can see how that affects the way people make choices about their taking their medicine.

Jacob Bleasdale  16:46 
Absolutely.

Sarahmona Przybyla  17:00 
Are there other ways that the COVID-19 pandemic has influenced food insecurity? And how people living with HIV kind of manage their illness?

Jacob Bleasdale  17:09 
Yeah, absolutely. So a unique finding in our study was this idea of social support or support from other people within a person's social network. And despite other studies that have found significant social isolation and decreased social support among people living with HIV during the COVID pandemic, we found, or our participants described how during the pandemic, they actually had increased social support from families and friends and loved ones and clinicians that kind of helped them with receiving these material needs. So in times where they had insecurities such as housing, food, these people kind of came up and served to help them get food or to provide them housing or to give them the resources so that they were able to get a meal for the day. So that was a unique finding that we found that kind of really drives home, this idea of how social support acts as intrinsic motivation for engagement across the care continuum, despite the pandemic going on.

Sarahmona Przybyla  18:03 
You mentioned the social support, and you've talked about family and friends. But then you also talked a little bit about health care providers or other maybe social service providers. Talk a little bit more about how non-family members, non-friends can really help with tackling the food insecurity challenges that people living with HIV might experience.

Jacob Bleasdale  18:20 
Yeah, absolutely. So in our study, we found that a lot of participants got emotional and informational support from their healthcare providers or case managers and counselors. And that emotional support of encouragement to continue with their care, despite these challenges, really became internalized among people and participants really felt that their providers cared for their well being outside of their HIV. So that kind of became internalized for people to stay motivated to engage in their care and take their medication. But on the opposite side, it also made them more comfortable to talk about other needs that they had. So a lot of our participants were in unstable housing, did not have incomes, or lost incomes due to the pandemic, or even didn't have food to eat. So a lot of case managers, counselors and even healthcare providers and clinicians provided resources that allowed our participants to go within the community and find maybe a hot meal for the day or help them find, or give them the information to a shelter that would allow them to stay there for the night. So the social support expands beyond one's loved ones to include the health care sector as well. And that's a really important thing to drive home when we're thinking about HIV care engagement as well.

Sarahmona Przybyla  18:21 
So you're a public health practitioner, you're a public health researcher, how can other public health researchers and practitioners work to really reduce food insecurity among people living with HIV?

Jacob Bleasdale  18:45 
Yeah, absolutely. So it's really, when I think about it, I think about approaching it from the social ecological model, thinking about the interpersonal, the community, and the policy levels of that, so really leveraging that social support to ensure timely and successful engagement. So we know that HIV stigma still runs very rampant within our society. And that is unfortunately the case within families as well. So ensuring that we can reduce HIV stigma within the community to ensure that people have social support when they are, or if they're diagnosed with HIV to ensure that healthcare providers have the information to help them stay engaged. Then also just leveraging health policies and public health infrastructure. So one thing to think about is increasing Supplemental Nutrition Assistance Program or SNAP benefits. So we have seen in the COVID-19 pandemic that some SNAP benefits just may not be enough when combating with HIV and on other crises such as COVID-19. So increasing those benefits so that people have more money and aren't stretching the dollar at the end of the month. But then also amplifying strategies that increase HIV care engagement, such as programs like Data to Care, which is an HIV surveillance program. So they use healthcare provider and health department models to identify people who are engaged in care but aren't virally suppressed. So what is that disconnect between being engaged in care, but you're still having detectable HIV in your body. And it's really taking that Data to Care program and stretching it beyond the healthcare or the siloed idea of medicine, and looking at what other material needs may be impeding someone's successful engagement. Perhaps it's housing, perhaps it's food, perhaps it's income that's inhibiting someone from taking their medication. So they're showing up for their appointments, but if you're not taking your medication, you're not going to be virally suppressed. But if that's because of income, if that's because of food, integrating those programs so that these programs not only have epi data and surveillance data, but also are able to look at these more sociostructural factors that impact care, and have solutions or abilities to engage and intervene on them.

Sarahmona Przybyla  22:06 
You mentioned stigma earlier about people living with HIV. I'm wondering if you have some thoughts on what you hope the general public would know about people living with HIV who experienced food insecurity, or maybe some misperceptions or misunderstandings? How can we do a better job of helping to kind of demystify HIV, or work with respect to food insecurity among people living with HIV?

Jacob Bleasdale  22:31 
Yeah, absolutely. And I think what you said, like demystifying HIV as an important thing that we still need to strive for, not only within our work, but also as a society as a whole. And I think what's really important is that people living with HIV are the same as everyone else, they're just living with a disease, and now with the antiretroviral therapies and engagement and care, we're looking and treating HIV as a chronic disease that's manageable and manageable with proper medication and care, similar to what we do with diabetes. So shifting the mindset from HIV being this infectious disease, which it still is, but to a more chronic manageable disease, is really important for the community to think about. Because back, there was a lot of myths that came out within the early times of the HIV epidemic. And I still think some of those are prevalent within the communities, but not because of ignorance, but because people just don't know. So really working with our communities, us as public health practitioners, researchers, health departments really getting out there to inform the community about HIV, make sure everyone knows their status, despite their risk factors. Because the more we do it, the more we'll normalize it, and the more we'll start to treat HIV as a chronic disease such as diabetes, instead of this death sentence that it was 20, 30 years ago.

Sarahmona Przybyla  23:52 
How about next steps for you, Jake, where do you see your future research about this intersection with food and nutrition, food insecurity within the realm of HIV?

Jacob Bleasdale  24:03 
Yeah, that's a really good question. So my goal is to really focus on starting to take this data that we have, and translating it into intervention work. So we have all this longitudinal and cross sectional data that shows that food insecurity, and nutrition-related and dietary-related stuff is much lower among people living with HIV, but what can we do about it within our community, so really looking at more like a social ecological approach to addressing some of these disparities within the communities, making and sustaining interventions within the communities is really what I strive to do. And I think that's how we're going to combat some of these issues. So yeah, those are kind of my next steps.

Sarahmona Przybyla  24:46 
Are there any other final concluding thoughts you'd like to share with us, Jake?

Jacob Bleasdale  24:49 
No, I think we covered them all.

Sarahmona Przybyla  24:51 
Great. This has been another episode of Buffalo HealthCast. Thank you again to our guest, Jacob Bleasdale, for taking the time to speak with us today. Nicole Klem is our faculty consultant. Sarah Robinson is our production assistant. Omar Brown is our sound editor. And our theme music was written and recorded by Sungmin Shin of the UB music department. My name is Sarahmona Przybyla, your host and writer for this week's episode. Thank you for listening and tune in next time to learn more about health equity in Buffalo, the United States, and around the globe.