|Nutrition and HIV/AIDS United Nations Administrative Committee on Coordination, Sub-Committee on Nutrition. Nutrition Policy Paper #20. Report of the 28th Session Symposium Held 3-4 April 2001, Nairobi, Kenya (UNAIDS - UNSSCN, 2001, 85 p.)|
Executive Director, UNAIDS
Some weeks ago I was in Malawi and met with a group of women living with HIV. As I always do when I meet with people living with AIDS and other community groups, I asked them what is their highest priority. Their answer was clear and unanimous: food. Not care, not drugs for treatment, not relief from stigma, but food.
It is easy to forget in the complicated world of global AIDS politics, that for many people around the world, AIDS is one additional burden on top of many others. AIDS does not occur in a vacuum. The basic concerns remain as they have always been: a secure, decent livelihood for themselves and their families. In Africa in particular, AIDS emerged against a backdrop of many other problems - poverty, conflict and inadequate infrastructure. By eating away social capital, its effect has been to make those problems and their consequences far worse. It has decimated the very generation of young adults poised to take Africa's future into their own hands.
At the social level, food insecurity is a major cause of vulnerability to HIV
Not only in Africa, but around the world, the HIV epidemic continues to grow. There were 5.3 million new cases of HIV infection worldwide during the year 2000, and three million people died as a result of AIDS - more annual deaths than ever before. Sub-Saharan Africa has been the worst-affected region, accounting for three-quarters of all the deaths caused by AIDS since the beginning of the epidemic. Today, there are over 25 million people living with HIV in this region; in some countries over one in three adults is living with HIV/AIDS. Together with armed conflict it is the number one problem of development and survival.
As well, we need to look at the Caribbean and Central America where a number of countries are over the 2% prevalence level and should be ringing alarm bells. The same applies to some states of India, but low prevalence in other states means that national consciousness of the problem still has some way to go, despite the recent efforts of the Indian prime minister and president.
China is only at the early stages of an epidemic, but there are warning signs: escalating sexually transmitted disease (STD) rates and growing HIV prevalence in injecting drug users - reaching as high as 82% in one city.
In south-east Asia, the major epidemics in Cambodia and Myanmar continue to grow. In Eastern Europe, the epidemic has been explosive, mainly fuelled by injecting drug use. The Russian Federation had more new HIV infections in the year 2000 than all previous years combined.
This list of the most affected countries must have a depressing familiarity to those of you who have worked on food security and nutrition over many years. Of course, it is no coincidence that the maps of HIV prevalence and of undernutrition should overlap. The HIV epidemic is increasingly driven by many of those factors that also drive undernutrition - in particular poverty, conflict and inequality.
AIDS is not a disease of poverty, and it is often the case that those first affected by this epidemic are the better educated and more mobile sections of a population. However, over time AIDS and poverty cement their relationship - AIDS prolongs and deepens poverty and makes it harder to escape from.
Nutrition and HIV also operate in tandem, both at the level of the individual and the society. For individuals, nutrition deficits probably make people with HIV more susceptible to disease and infections of all sorts. Malnutrition is one of the major clinical manifestations resulting from HIV infection both in children and in adults. At the social level, food insecurity is a major cause of vulnerability to HIV. The impact of HIV is felt in reduced agricultural production as well as in increased fragility of affected households.
The effect of AIDS on food production is both immediate and long-term and increasingly well documented. A study from Zimbabwe modelled the household impact of an adult death on the output of different foods, estimating reductions of 61% for maize, 49% for vegetables and 37% for groundnuts. Yet AIDS also hits long term agricultural capacity. Livestock is often sold to pay funeral expenses, and orphaned children often lack the skills to farm or look after livestock in their care.
Over the past few years, there has been a major revolution in the world's thinking about HIV. The epidemic has been understood not just as a health issue which will always remain, but as a major threat to development and to human security. However, we are not powerless in the face of AIDS. We know what works in turning the epidemic back. This is our most important lesson and conviction: otherwise there is no way we can make a difference. There is a small - but growing - number of societies in different parts of the world that have achieved sustained success against the epidemic. To the familiar examples of Uganda, Senegal and Thailand we can now add parts of Zambia and Mbeya in Tanzania. In Brazil there has been national success in curbing the epidemic.
Effective responses to the HIV epidemic come from:
· unified national planning;
· access to essential prevention and care commodities; and
· a public environment where people with HIV and those most at risk are not excluded, but considered part of the community and part of the solution.
Most importantly, we need to apply proven strategies on a scale commensurate with the epidemic. The time for pilot or demonstration projects is over. Now is the time to mainstream every aspect of our work and to decentralise. Success comes from long-term sustained commitment. Piecemeal approaches don't work. They are close to doing nothing, a waste of money.
This is a message that I know you are familiar with, because it is fundamental to nutrition practice. Let me quote from a report on HIV and nutrition by Florence Egal and Arine Valstar from the Food and Agriculture Organization:
Since nutrition requires an integrated approach to household food security, health and care, it forms a logical entry point for assisting affected communities in coping with the epidemic.
The nutrition community knows the global and the local are connected, that individual care comprises many inter-related elements, and that health always goes beyond the individual to involve the household and community. These lessons all need reinforcement within the HIV world. Therefore let me declare here that the nutrition voice needs to be heard louder and stronger in the HIV field. Let me also call on all of you to be allies in taking this message forward.
Despite what we know about how to turn back the epidemic, we are still a long way from achieving success. Let me discuss seven key challenges ahead.
First, emergencies, including food emergencies, are a major point of vulnerability to HIV. When populations are on the move and the basic security of life is threatened, HIV risks rise. Women, in particular, may often find themselves in circumstances where they are subject to sexual violence, or forced to trade sex for food. Therefore the challenge is to make sure that emergencies are the focus for interventions to reduce HIV risks. This is not easy.
We need to find innovative ways to make this happen. I am delighted, for example, that the World Food Programme is looking to use their network and logistics capacity in responding to AIDS. They will help community groups and others expert in HIV interventions to have a presence in emergency situations. They are also dealing with another very specific HIV risk that comes along with emergencies by making sure that their contract truck drivers receive intensive HIV preventive education and condom supplies. Good practice begins at home.
The second related challenge is how to break the vicious cycle between food insecurity and HIV vulnerability. As well as dealing with the immediate impacts of AIDS, we must continue to pay attention to sustainability and overcoming long term vulnerability. Are less labour intensive crops available that are still good food sources? How do we keep children at school against the pressure for them to replace the labour of sick or dying parents? Here, we can bring together a number of initiatives that focus on schools. For example, one of the UNAIDS cosponsors, UNICEF, is working on extending the role of schools as community resource centres. This is an initiative which complements the World Food Programme's proposal that school feeding programmes should include 'take-home rations' so that whole households will have an incentive to keep children in school.
Third, we need to assess the impact of rural development on the spread of HIV. Just as environmental impact assessment has become an integral part of development programs and major projects, HIV impact assessments should also become the norm. It is disturbing to see that major investments are being planned as though HIV was occurring on another planet. Some early drafts of World Bank's Poverty Reduction Strategy Papers (the PRSPs) did not even mention HIV/AIDS. Fortunately this is changing. Will agricultural development plans break up family structures and add to HIV risk? What plans are there for addressing HIV risk if new transport routes are created? What is the HIV-related impact of cash cropping versus food security? These are important questions to be addressed during the PRSP process.
...the nutrition voice needs to be heard louder and stronger in the HIV field
Fourth, we still have a challenge to deliver essential HIV care, and nutrition is a core part of any essential care package. Any discussion of the very complex issue of care and treatment of people with HIV/AIDS has been narrowed to the price of anti-retrovirals. This is a shame, it is also counterproductive.
Of course, UNAIDS working with our co-sponsors has been very active in ensuring that there is progress in this area. Nevertheless I am still waiting for the day when the New York Times chooses to write a thundering editorial on the moral unacceptability of the fact that most people with HIV in Africa fail to get adequate nutrition. Of course, we can be clever in the ways we use progress in anti-retroviral affordability. Instead of saying:
it is no use making anti-retrovirals affordable because most people don't have the clean water to take them, or they can't take the drugs on a full stomach because their stomachs are never full
the demand should be:
now we must implement anti-retroviral access, therefore the drugs must be provided with water supplies and with food.
We are not dealing with step-by-step solutions, but solutions where we need to advance on multiple fronts simultaneously.
The fifth challenge is to turn rhetoric into reality on breastfeeding. We know breastfeeding by HIV-infected mothers carries a significant risk of HIV transmission - up to 20% in the absence of drug therapy. We also know that, HIV-transmission aside, breastfeeding is tremendously beneficial. It is one of the cheapest and most cost-effective interventions in public health and in social development. Our advice is avoidance of all breastfeeding by HIV-infected mothers when replacement feeding is acceptable, feasible, affordable, sustainable and safe. There is a policy statement on this.
There has been so much agony over the risks and benefits of this recommendation that, perhaps, we have lost sight of where our energies should be going. The recommendation is frankly irrelevant to most HIV infected women, because we are a long way from providing universal access to safe replacement feeding. We are a long way from exclusive breastfeeding, and even further away from providing voluntary and confidential HIV counselling and testing in the context of ante-natal care. Fewer than one per cent of women in ante-natal care in urban areas in Sub-Saharan Africa have access to HIV testing, and in rural areas their numbers are even smaller. Unless they know their status, women are unable to determine their risks. My message is that we have got to work very hard towards making progress on the ground.
The sixth challenge is to attack stigma. One reason AIDS is different from any other disease is the unprecedented stigma associated with it. It is transmitted by sex and illicit drug use. Stigma and discrimination against people living with HIV, or those thought to be most at risk, constitute two of the major barriers to effective responses to the epidemic. Unlike many of the other barriers, the costs of attacking stigma are not monetary. They take the form of leadership, commitment and compassion. Stigma is also a nutrition issue. We know of instances where, because of HIV, someone is thrown out of their home or their village and left hungry. We also know that a woman may breastfeed in public to avoid stigma, but use formula in private to avoid transmission, unwittingly exposing her infant to the worst combination of feeding strategies.
Finally, we must face the gender challenges of AIDS. We know that women are the caregivers for the children who have lost their parents. Women do more than half the food gathering and production work. They also do more than half the care for those sick with AIDS. Now, they make up more than half of those living with HIV in Africa. Addressing relationships between men and women is at the core of successful behavioural change to prevent the spread of HIV. So, too, is addressing those gender inequalities that make the impact of HIV fall harder on women - such as, inheritance laws preventing women from holding land or livestock upon the death of their husbands.
AIDS is complex, but I don't need to tell you that. You are already accustomed to dealing with the complexities of nutrition and you know that 'magic bullets' in health are mainly an illusion and are also dangerous. They detract us and create an appearance of safety, but we must not let the complexity of AIDS defeat us.
The solutions lie in adhering to the facts in our response, and in building new partnerships, better co-ordination, and sustainable change. Many years ago (in 1985) in Kenya, there was a silent epidemic. The research community at the time was trying to document the spread of HIV without thinking about the ultimate societal implications. What will HIV mean for the country and who should be involved in programmes to prevent transmission? There has since been a sea change, in terms of partnerships and action against AIDS. This will pay off. With a cadre of community actors Kenya will have fewer infections. One partnership that is still in its very early stages, here and elsewhere in the region, is the partnership between those whose primary concern is nutrition and those focused on HIV. We can be confident that the partnership will grow, based on the knowledge that food and nutrition policy is integral to success against AIDS.
I am sure that I can count on you to be part of that partnership.
Comment from the audience We are off to a very good start by putting this whole aspect of HIV/AIDS and nutrition in perspective. Dr Piot, you said that the time for pilot projects was probably over. I agree with you largely, but there are pilot projects going on now in which alternative methods of feeding are being tried. This is a first, I think, for poor people in Africa to be in pilot projects where large numbers of poor women are being shown and helped to formula feed their babies. I really dont think anybody knows what the outcome of these will be, whether in fact more harm will be done than good. You explained what needed to be in place for safe alternative feeding. For most families, because poverty is so rife in Africa still, it is not feasible to do this. I really would like to hear you state whether you think countries should move beyond these pilot projects without a very careful evaluation of the risks, and it is not just the risk of diarrhoea. It is all the other infections - pneumonia rates might be six times as high. If the formula is not given free there is a huge economic burden on the families. If it is given free, what happens after six months when breastmilk would still provide 80% of the nutrients and the mothers now have no breastmilk? What does it do to birth spacing if the mothers can become pregnant again in the first three months if she does not have access to family planning? I am concerned that these pilot projects are not going to be adequately evaluated so that we will not know the harm that might be done. We need to evaluate the risks before countries move to much larger implementation of those projects.
Comment from the audience There have been several references to breastfeeding but Dr. Piot you did not preface this with what seems to be emerging as the key component, exclusive breast-feeding. Although for years we have extolled the virtues of exclusive breastfeeding, we have not been quite sure if it is possible. We now know that if health workers have the confidence and can transmit this to mothers, then exclusive breastfeeding is indeed possible on a population level.
Comment from the audience My first comment is a note of caution and it is something we found in our research programmes on women and AIDS and stigma and discrimination. Women face particular problems relative to the epidemic. First, sentinel sites for HIV testing tend to be in maternal child health (MCH) clinics or hospitals. That means that women are the ones who are tested in large part because men do not come to maternal child health clinics. Women are then blamed for bringing the epidemic into the household. Second, women are also viewed as vehicles for HIV transmission because of breastfeeding. Third, when supplements are given out, at MCH or other clinics, women are hesitant to take them home because this is an overt statement that they are HIV positive. These are the realities for women living with AIDS. We really need to focus on how women can protect themselves, not focus just on what happens once they become HIV positive. My second comment is that we have an opportunity now to promote the adoption of technologies that have not been given a high status, such as particular food crops and food processing technologies that will make households less vulnerable to, or will mitigate the impact of, the epidemic on women. Womens crops such as roots and tubers are low status crops and post harvest food processing technologies do not traditionally generate large amounts of revenue. Little investment has been made in their development and dissemination. Yet, because women control the use and outputs related to these technologies, these are the very technologies that will help women-headed households, and others with labour constraints, maintain some level of productivity and food security in the long term.
Question from the audience Dr. Piot said that people living with HIV/AIDS in Malawi felt that access to food was their biggest problem. There is a project in Malawi, the Integrated Technology Information Education and Communication project, that focuses on community development and uses a triple entry point in the community: food security, HIV/AIDS and population. Are there any initiatives being developed by UNAIDS in the direction of a community-based approach to HIV/AIDS?
Peter Piot First, about pilots - there are a number of things that we know about and where one should not waste time with pilots, for example, in working with young people on sex education and condom promotion in schools. There is no need for pilots in this area, although there is still a need for good evaluations. The main challenge is going to scale and this is not just multiplying a small project by some factor X. It is as much an art as a science. On the other hand, we have a number of things where we still have to learn what is best. We shouldnt wait until everybody has clean water, access to aspirins, and a job, before we start talking about anti-retrovirals. There are instances where it is possible to use them now. The same thing is true when we are looking at anti-retrovirals for prevention of mother-to-child transmission. We cannot wait until the whole society is perfect. We have to wade in, and not wait for pilots, at least in the academic sense where the pilot is the final stage of the research. We need to have the courage to adapt our approach even in the middle of the project if the evidence indicates: (a) it is damaging, or (b) it is better. The key is careful evaluation and monitoring.
In terms of breastfeeding there is still a long way to go. The evidence, as I understand it from studies in Durban, is that the worst possible combination is mixed feeding, that is breast plus artificial feeding. One has to see in each environment what is attainable. We need recommendations that are practical and operational. This is an area where additional research is most needed. In terms of initiatives for a comprehensive approach, several UN agencies are working with the government in Mozambique and using micro-credit programmes with women as the major vehicle for HIV prevention. They focus on young people, on the needs of women, including nutritional needs and integrate both the prevention and the care components. There are many more programmes happening, and even more in the pipeline.