The University of Pittsburgh Medical Center, Center for Care of Infectious Diseases, Pittsburgh Area Center for Treatment (PACT) began implementing the Food Assistance Program (FAP) in August 2017 to serve as a supplemental resource for people with HIV receiving care at PACT who experience food insecurity. FAP helps bridge gaps in Supplemental Nutrition Assistance Program (SNAP) benefits and monthly food costs while promoting access to healthy foods and retention in HIV care.
In 2017, incomes for almost half of Ryan White HIV/AIDS Program (RWHAP) clients at PACT fell below 130% of the federal poverty level (FPL). PACT staff identified food insecurity as a contributing factor to poor health outcomes in its client population. Data suggest that people with food insecurity who receive food assistance may be more likely to engage in routine HIV medical care and reach viral suppression goals. The PACT FAP is the first program of its kind in the Pittsburgh area for people with HIV and helps to bridge gaps in access to healthy food and support retention in HIV care.
The FAP is implemented in an urban RWHAP-funded clinic that provides medical services, case management, behavioral health services, telemedicine, and other support services.
Care team members (physicians, advanced practice providers, social workers, pharmacists, nursing staff, peer advocates) informally screen for food insecurity and refer clients who would benefit from nutritional services (such as identified need for food, issues with diabetes, need for more high-calorie food due to wasting) to the dietitian for formal screening.
RWHAP clients who fall at or below 130% of the FPL and have signed up for SNAP benefits qualify.
Participants receive a monthly gift card to a discount retail grocery chain. Participants are required to purchase healthy and nutritious food and return receipts to receive the next gift card (minimum of 30 days between gift cards). Participants must have seen their HIV provider within the previous six months to receive the next gift card.
In 30-minute nutrition counseling appointments with the dietitian each month, participants discuss nutrition-related comorbidities, overall healthy eating, other medical or psychosocial needs, and upcoming medical visits.
The FAP also offers classes to participants focusing on shopping on a budget for healthy foods, and strategies to turn them into tasty, well-balanced meals.
Participants in FAP have significantly better retention in care rates than the overall population at PACT, are meeting viral suppression goals, and have slightly lower average A1C values (for patients with diabetes only) as compared to the population of PACT.
|Evaluation data||Staff collect annual data for FAP participants on retention in HIV care (n=73 clients in 2018; 58 in 2019), viral suppression (n=77 clients in 2018; 71 in 2019), and diabetes management (n=22 clients in 2018; 26 in 2019) in individuals participating in the FAP, and compare it to the general client population at PACT.|
|Measures||Gaps in care indicator, viral suppression, average A1C (in clients with diabetes).|
Gaps in care indicator (lower rate of gaps indicates better retention in care)
Viral suppression (clinic goal >=90%)
Average A1C (in clients with diabetes)
- PACT FAP staff identified the following steps for implementation:
- Identify a need (food insecurity)
- Secure funding source
- Appoint staff member to manage program
- Develop screening tool to identify eligible participants, agreement form and guidelines for enrolling in program, and follow-up procedures
- Establish mechanism for accountability for following program guidelines
- Implementing the complementary cooking classes requires program staff to:
- Identify a client group who would benefit
- Secure funding source, location and cooking equipment—recommend a cooking demonstration lab
- Appoint a staff member to lead program
- Develop an agreement form for participation in class, lesson plan with measurable objectives, and pre/post survey
- PACT program income (340B funds) supports the purchase of gift cards. Staff positions (dietitian-nutritionist, manager, data analyst) are funded through the RWHAP. Cooking classes are delivered in partnership with the University of Pittsburgh (use of demonstration cooking lab) and involve the dietitian-nutritionist, a dietitian intern, peer advocate, and the program manager.
- Clients provide feedback during individual consultations with the dietitian and via surveys at the end of cooking classes to inform future activities.
The PACT FAP and associated cooking classes are fully integrated into the PACT clinic. Potential participants can be referred to the dietitian by any member of the PACT team or individuals can self-identify as food insecure. Budgetary constraints cap the number of program participants, limiting the ability to serve all individuals potentially living with food insecurity based on income. Given limited funding, staff have identified the need for a more in-depth screening tool to prioritize the most significant cases of food security among their client population.
Other challenges include instances where participants fail to follow program guidelines (such as failure to purchase healthy food items or return receipts) or do not have transportation to the grocery store. Staff have found that by providing additional options to help meet program requirements (such as sending a photo of the receipt from their phone) and discussing challenges and solutions with clients (such as managing grocery delivery, which may actually cost less than transportation) most clients are able to meet requirements and benefit from the program.
- The rapport and relationship that participants develop through frequent contacts with the dietitian support retention in care, early identification of other client needs, and referrals to other services.
- PACT FAP staff recognize that a program can provide monetary support to clients to contribute toward food purchases, but if they do not understand what to buy, how to stretch their food dollars, and how to use the ingredients, or if they do not have appropriate cooking equipment, then the additional funds will not be successful in helping clients improve health outcomes. Individual counseling sessions and cooking classes have contributed to the success of program participants.
- Providing other resources (such as a hygiene closet) helps ensure that the gift cards are used for healthy food purchases.
- It is imperative that all staff who engage with clients are aware of the program, know how to screen for food insecurity, and know the process to refer clients to the dietitian for potential participation in the FAP.