Project Summary
HIV and food insecurity pose severe and interrelated problems in Latin America and the Caribbean, including
in the Dominican Republic (DR), where HIV ranks as one of the top 5 causes of death and our prior studies
have found that nearly 70% of people with HIV (PWH) have moderate or severe food insecurity. Despite the
established, detrimental role of food insecurity on poor HIV treatment outcomes, evidence on sustainable
interventions that address the cycle of food insecurity and poor HIV health is scarce. To address this gap, we
developed and piloted ProMeSA (through an R34 grant), an integrated urban gardens and peer nutritional
counseling intervention, and found it feasible, acceptable, and with preliminary efficacy at 6 and 12 months of
improving food security and HIV virologic suppression. The purpose of this five-year study is to conduct a fully-
powered cluster randomized controlled trial (RCT) of ProMeSA to assess intervention efficacy evaluated over a
longer period (18 months) as well as mediators and barriers and facilitators to intervention uptake,
implementation, and sustainability. The specific aims are: (1) Determine the efficacy of an integrated urban
gardens and peer nutritional counseling intervention on the primary outcome of HIV viral suppression
[undetectable HIV viral load (VL)] and secondary outcomes of ART adherence and HIV care retention care
among people with food insecurity across diverse regions in the DR; (2) Examine the intervention effects on
intermediate outcomes posited to mediate the impact of ProMeSA on ART adherence, care retention, and viral
suppression; (3) Evaluate process-related factors associated with intervention uptake and implementation
(facilitators, barriers, fidelity, and replication costs) to inform future scale-up. The trial will include 20 HIV clinics
randomized to intervention or usual care control (n=25 per clinic; 500 total study participants). VL and other
key outcomes will be assessed at baseline, and 6-, 12- and 18-months. Following our intervention causal
framework and pilot findings, we hypothesize that ProMeSA will improve food security and diet quality and
reduce stigma and competing needs, which in turn will improve HIV clinical outcomes. The predominant causal
paths identified will inform tailoring ProMeSA to enhance impact in future dissemination and implementation. In
addition, we will collect extensive quantitative and qualitative data on intervention implementation and
participant experiences with the intervention across diverse settings and participants to inform scale-up. The
study involves a partnership among researchers from the University of Massachusetts Amherst, University of
California, San Francisco, RAND, and the Universidad Autonóma de Santo Domingo as well as the Dominican
Ministries of Agriculture and Public Health, the Dominican National HIV/AIDS Council, and the United Nations
World Food Program. To our knowledge, this will be the first full-scale trial to integrate nutritional counseling
with food-generating activities among PWH with food insecurity, in support of national and international goals
to achieve viral suppression and reduce the disease- and economic burden of HIV.
