The effect of an economic empowerment and relationship strengthening intervention on food insecurity among couples living with HIV in Malawi

Background: People living with HIV (PLHIV) are highly impacted by food insecurity through pathways including poor adherence to antiretroviral therapy and inadequate nutrition. Limited evidence exists on whether economic empowerment interventions can improve food insecurity among PLHIV in sub-Saharan Africa. We evaluated the effectiveness of Mlambe, an economic empowerment and relationship-strengthening intervention, on food insecurity among couples living with HIV who drink alcohol in Malawi. Methods: We analyzed data from 78 couples who participated in the Mlambe study, implemented in Zomba, Malawi. The study enrolled married couples living with HIV and unhealthy alcohol use (based on the AUDIT-C) from HIV care settings: an urban hospital, a rural private community, and a peri-urban health center. Couples were randomized into two groups: the Mlambe intervention or enhanced usual care (EUC). Mlambe intervention included incentivized savings accounts and sessions on financial literacy training and relationship skills over ten months. Study assessments occurred at baseline, 10- and 15-months. Food insecurity was assessed using the Household Food Insecurity Access Scale (HFIAS), which was categorized into four levels (food secure, mild, moderate, and severe food insecurity). We fit two-level, logistic mixed effects models testing the effect of Mlambe on severe food insecurity, given that most couples reported being food insecure. Results: The mean age of participants at baseline was 43.4 years, with 78.2% reporting primary education. On average, couples had been married for 13.8 years. Over half (53.3%) reported unhealthy alcohol use, 91.6% were HIV-positive, and 57.1% experienced severe food insecurity. Couples in Mlambe intervention showed a significant reduction in severe food insecurity as compared to the EUC arm at the 15-month follow-up (OR = 0.81, 95% CI: 0.66, 0.99). No significant reductions were observed at 10 months, which immediately followed the intervention period. Conclusion: Mlambe intervention demonstrated a significant reduction in severe food insecurity among HIV-positive couples with unhealthy alcohol use at 15-months. This pilot study provides evidence that integrated interventions targeting economic and relationship factors at household level have the potential to effectively reduce food insecurity in settings like Malawi. A full-scale efficacy study is needed to confirm findings with a larger sample and longer follow-up. Study clinical trial registration: Mlambe was registered on ClinicalTrials.gov (NCT #04906616, 08/15/2019).