In recent years, access to antiretroviral therapy (ART) for HIV has increased dramatically in Latin America and the Caribbean (LAC) and in particular in the Dominican Republic (DR); however, food insecurity and poor nutrition have emerged as barriers to ART utilization and adherence among people living with HIV (PLHIV), especially in low-resource settings. Our pilot work in the DR found that 68% of PLHIV report moderate or severe food insecurity. Most programs aimed at addressing food insecurity among PLHIV in low-resource settings have involved providing food supplementation, with positive results; however, such efforts are typically not sustainable. Further, most interventions focus primarily on PLHIV who are underweight, while overweight and obesity are also a growing concern. Sustainable approaches that increase access to food and also promote balanced nutrition among PLHIV are needed. Urban gardening together with peer nutritional counseling represents a potential solution. The purpose of this three-year study is to develop, implement, and evaluate the feasibility, acceptability, and preliminary effectiveness of a culturally appropriate, multi-component intervention that targets food insecurity and nutritional health with the ultimate goal of improving ART adherence and virologic suppression for PLHIV in the DR. The specific aims are to: (1) Use formative research on dietary patterns and locally available foods, together with our preliminary research on nutritional counseling and urban gardening, to develop a multi-component nutrition intervention to address food insecurity among PLHIV that integrates culturally-appropriate, peer-led nutritional education with a sustainable urban garden component; (2) Evaluate the feasibility, acceptability and preliminary effectiveness of urban gardening plus peer nutritional counseling on improving our primary outcomes (HIV care retention, ART adherence, and virologic suppression) in both the short (month 6) and longer terms (month 12); and (3) Explore the preliminary intervention effects on potential mediators (food security, nutritional status, internalized HIV stigma, and social support), which are secondary outcomes. The proposed study involves a partnership among researchers from RAND, University of California San Francisco (UCSF) and the Universidad Autónoma de Santo Domingo and other local partners, including program staff from the United Nations World Food Program (WFP), the Dominican Ministry of Agriculture, and the Dominican National HIV/AIDS Council. It builds on our previous work elsewhere in LAC and established relationships between RAND, WFP, and local partners in the DR. As one of the first studies to develop a sustainable food production approach with peer nutrition counseling among PLHIV, key products will include: 1) an easy-to-use peer nutritional counseling curriculum and urban gardens training materials; 2) pilot data on the feasibility, acceptability, and effects of our intervention on primary outcomes and potential mediators; and 3) if results are promising, an R01 application to conduct a fully- powered cluster RCT that examines effects across a larger number of clinics in the DR.

NARRATIVE This study proposes to develop, implement, and evaluate the acceptability, feasibility, and preliminary effectiveness of a culturally appropriate, multi-component intervention combining peer-led nutrition education with sustainable urban gardening to support the goal of improving ART adherence and virologic suppression for PLHIV in the Dominican Republic (DR). If results are promising, we will follow with an R01 application to conduct a fully-powered cluster RCT examining effects across a larger number of clinics in the DR.