Identifying the mechanisms of water insecurity on HIV treatment outcomes

Project Summary / Abstract Water insecurity (WI) is a major challenge in sub-Sharan Africa (SSA), where the number of people living with HIV (PLWH) is disproportionately higher, and where populations are most likely to bear the impact of climate change. The effects of water insecurity on health are well-documented in SSA: emotional distress is associated with lack of safe water, including fear of contamination, worry over safety, and anxiety, increased migration and thus HIV risk, as well as disruptions to health, care engagement, livelihoods, and relationships. Further, the prevalence of WI among PLWH is high, and household WI and food insecurity (FI) lead to poor mental and physical health. WI is also an important determinant of FI, suggesting multiple causal pathways to poor health outcomes. While SSA least contributes to global warming, especially as compared to more industrialized nations, it is expected to be amongst the hardest by climate change. Water is required for food production and preparation8, and WI may directly and indirectly influence health outcomes by impacting FI and health. Among PLWH, WI can lead to dehydration and undermine PLWH’s ability to manage unpleasant side effects associated with ART, including diarrhea, nausea, and vomiting. In Ghana, one of the most vulnerable countries to climate change in SSA, flooding affects around 45,000 Ghanaians annually while nearly half of Ghana’s coastline is vulnerable to erosion and flooding as a result of sea-level rise and atypical rainfall. Further, an estimated 70% of all disease burden in Ghana is attributed to WI. To effectively intervene, a deeper understanding of the drivers of and sequelae of WI is critical. Therefore, we propose the first longitudinal convergent mixed-methods study to quantify and elucidate the impact of WI on HIV, related to climate-related drivers, infrastructure challenges, water accessibility, and heightened risk of water-borne diseases, to inform interventions to address WI among PLWH. In Aim 1, we will utilize innovative remote sensing technologies to investigate the role of climate-sensitive patterns (droughts, precipitation anomalies, and floods, capitalizing on state-of-the-art satellite technologies) and seasonality on WI in Ghana. In Aim 2, we will determine the impact of WI on HIV treatment outcomes (ART adherence/viral suppression) and opportunistic infections and comorbidities, and the mechanisms through which WI may influence these outcomes (nutritional, mental health, water, hygiene and sanitation, and empowerment pathways). In aim 3, using intervention mapping framework, we will develop intervention options to mitigate WI and improve health for PLWH, synthesized from theory and literature. Findings from this R01 will a) provide initial data on the drivers of and sequelae of WI and it impact on HIV treatment outcome; b) guide the integration of HIV and water access programs; and c) help identify and prioritize intervention development to address WI among PLWH.