|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.)|
Phetsile K Dlamini
Minister for Health and Social Welfare Swaziland
Swaziland is a small country with a population of about one million where children under 15 years of age represent about 45% of the population. It is a very young population with a high dependency ratio. When AIDS kills the active young adults, many children are left unsupported. There are many elderly people who are called elderly orphans. These are our mothers and grandmothers, who were hoping to have a better life after educating their children. They are now left behind to look after their grandchildren and great-grandchildren and they are unable to cope.
The first known case of HIV/AIDS in Swaziland was in 1986. In a survey two years later, HIV/AIDS affected three percent of the population. For some reason we were lulled into believing that someone must have imported this problem and that it would pass. However, prevalence rates have increased progressively in antenatal women; in 1998, the rate was 31%. You can imagine what this means for the women of Africa, especially those in rural areas where hard physical work is such a burden. These women provide for their family and farm the land when the men go to seek work in the urban areas. A recent study11 showed a rise to 34% of pregnant women infected. This is a devastating situation. The four most affected countries for HIV/AIDS are the countries of southern Africa. Hence, this is a real problem for the region and we need practical and affordable solutions, not fancy statements.
...It is like building a house. If you have a roof but there are no walls and no foundation, the house is not very useful. It is similar with HIV/AIDS care. We need to build that house with walls and foundation made of nutritious food
Other countries such as Senegal and Uganda have very good stories to tell, but we see teenagers dying in Swaziland. These teenagers were not infected at birth; they were infected further down the line. Life expectancy is being reduced to the late 30s and early 40s in the region. With a general population prevalence rate of 20-25%, a good section of society is not well enough to be productive and not well enough to do their daily work such as farming. Academics, skilled and semi-skilled workers are being lost. Thus, land utilization and food production will actually go down. Malnutrition and HIV/AIDS are intertwined. Both are worsened by poverty, while both deepen existing poverty. We are losing all the health gains, economic gains and societal advancements of the previous decades in a very short space of time.
When we talk about care we need to look at what we really understand about care. Many people talk about care and instinctively they are thinking about anti-retrovirals. This is a gross mistake because we know anti-retrovirals are mainly beyond our reach. We would like them to be affordable, but in the wave of excitement about anti-retrovirals, we have forgotten some of the solutions that are affordable and available locally. Good nutrition is one of these solutions. We have seen, together with other countries, policies and plans on how we care for people affected by HIV/AIDS but there is very little coverage on issues of nutrition. It is like building a house. If you have a roof but there are no walls and no foundation, the house is not very useful. It is similar with HIV/AIDS care. If you include drug therapy but you do not have adequate nutritious food, you will not be able to fight the infection. We need to build that house with walls and foundation made of nutritious food. In trying to fight the HIV virus we sometimes forget to use the ammunition that is available to us. We look for sky high solutions and forget the ones that are very close to us which are affordable and could impact tremendously on our societies.
In a survey2 of the nutritional status of the Swazi people carried out in 1983-84, we found that 30% of our children under five years were stunted. We were hoping to have reduced that stunting to below 20% by the year 2000, but by 1995, we had only managed to reduce it to 27%. Another study2 in 1997 showed that one percent of children are wasted. Wasting is a form of acute malnutrition. Furthermore, 8.2% of babies delivered in hospital were below 2.5 kg. This is a reflection of maternal malnutrition because mothers who are not well fed or have other diseases have a greater risk of delivering low birthweight babies.
...the focus should be on sustainable community solutions such as small gardens near the home and advice on what foods to grow. We need to encourage our communities to grow indigenous foods
A study2 completed in 1993 showed that there was iodine deficiency in some regions of our country varying from six to 38%. We also found vitamin A and iron deficiencies. Some of the interventions3 focus on solving these problems, such as adding vitamin A capsules to national immunization programmes. There is legislation requiring that all salt be iodized. Also, we are negotiating with the sugar industry, one of the biggest income earners in the country, to fortify sugar with vitamin A. This experience shows that it is possible to identify nutrition problems, and have solutions ready in a short time.
Why do we believe that nutrition is the most important solution for Africa, whereas other regions have found other solutions that work for them? When HIV invades, it enters the immune cells that protect against disease. The virus goes right into the cell, sits there comfortably and quietly for three months or even for many years and then it multiplies. As the virus multiplies, it destroys this host cell. As it destroys the cells, harmful chemicals are released, such as cytokines and free radicals, which can further damage the body. It becomes a vicious cycle as the cell environment promotes replication. This is a complex process put very simply. The critical question is What can we influence in that cycle?
A recent book by Piwoz and Preble4 summarizes the importance of nutrition in influencing this cycle. The macronutrients (carbohydrates, fats and proteins) along with vitamins and minerals are necessary for building and repairing tissues. Put simply, foods contain nutrients that can help protect the immune cells which have been invaded by HIV. HIV and its host can live symbiotically for a very long time. This is where we, as health workers, nutritionists and politicians, may have lost sight of our purpose. All we concentrate on is the inevitability of death once a person gets the infection. There are many things that we can do in the intervening period between contracting the infection and death.
For people living with HIV/AIDS, malnutrition often first appears as weight loss and muscle wasting. Metabolism is altered and there is increased utilization and excretion of nutrients. Deficiencies of vitamins and minerals needed by the immune system to fight infection commonly occur; these include vitamins A, C and E, as well as selenium and zinc. These different forms of undernutrition often co-exist. People with the infection more easily become debilitated which results in a loss of independence and inability to carry out daily activities. Good nutrition, especially beginning at the early stages of HIV disease, helps prevent weight loss and strengthen the immune system. Good nutrition thus plays an important role in positive living with HIV, and may help delay the progression of HIV disease. Because of the high energy demands during infection, adequate energy and protein intake and adequate anti-oxidant intake are important.
We need to be reminded of the nutrition-related activities in which we in Africa can engage. Yes, we do need the therapeutic agents. We need the anti-retrovirals to be affordable and available to everybody. However, these will not work in a vacuum. You need to be well-nourished for some of these medicines to work. The secret is that if you can stay well through improved nutrition for as long as possible you may actually even defer the need for anti-retrovirals. Consequently more focused attention is needed on affordable solutions. Here is a series of propositions (summarized in Box 6).
Box 6 - Swazilands care package summary
Broad Issues include ...
· Poverty reduction
Good nutrition includes, specifically, measures to ...
· Increase energy intake
Medications also have a role ...
· Provide vitamin and mineral supplements
Counselling and Support
· Legal provision for orphans and families
Let us look at the broad issues such as the reduction of poverty so that at least each household can have food on the table in sufficient quantities and in a balanced way so that each member of the family is able to survive. Now, how do we do that and still retain economic empowerment? It is good to have handouts and it is good to have assistance, but the focus should be on sustainable community solutions such as small gardens near the home and advice on what foods to grow. We need to encourage our communities to grow indigenous foods. To support this we need to analyse our indigenous foods for their food value so that when we advise people to grow peanuts or mug beans, we will know what the nutrient composition is. What is the best source of vitamin A? What is the richest source of riboflavin? Growing ones own food leads to economic empowerment; let people do as much as possible.
There is life between the time of initial infection and the development of AIDS. We should make the quality of life as good as possible and enable people living with HIV to do something for themselves because it restores their dignity. Even if people are HIV-infected they do not want to be made to feel they are already patients. They want to feel they are contributing to society. These are the problems when we talk about economic empowerment. If women cannot farm, they can still be involved in other sustainable solutions. As the Chinese say: Teach them to fish and not provide the fish all the time.
Food security and agriculture is another important issue. Africa is besieged with fluctuations in seasons. Africa has droughts, floods, often severe winters and naturally occurring lean seasons. How can communities best breach those times of need? We have to look at how to store and process our foods during times of plenty and develop and impart these skills within the local communities so that we can really have simple solutions to our problems. The ability to store food would bring enormous benefits to communities, especially those most severely affected by the HIV/AIDs epidemic.
Source: Adapted from Kraak V, Hernandez Y, Kaplan C (1994) Living with HIV: A Nutrition Guide with Emphasis for People In Recovery. Gods Love We Deliver: New York.
The second big issue in nutrition is increased energy and protein consumption. Families need assistance in estimating their new needs, especially of the staple food. It is not useful to come to a village and say to a mother or grandmother, You have to have 500 grams of cheese. We do not know how to make cheese and we do not know how to store it. Cheese is expensive to buy, it probably needs to be refrigerated. So the challenge is to think of local solutions and to learn more about what is available locally. Nutrition supplement packages are possible and again we are excited about this. In its fight against HIV/AIDS our neighbour South Africa is producing packages of highly-fortified powder from local foods, such as sorghum. These can be taken as a drink to supplement the diet. Making supplements for everyone may help to destigmatize HIV disease as well as improve the nutritional status of the overall population. Having said that, special attention should be given to those who are infected. For school age children, especially orphans, we need to look at school feeding schemes as well. As part of our fight, all countries should have their nutrition brochures or flyers in local languages. They should be written simply and indicate what to do for common ailments such as diarrhoea. By identifying simple solutions, and describing them in easy-to-understand language, we can make nutrition part of the solution to keeping our communities healthy for as long as possible.
Vitamin and mineral supplements can be given to the population. However, to be honest, there is a chance that we will miss many people who are sick at home. Vitamin and mineral supplements are included in Swazilands food pyramid, so as not to forget the potential role they can play (Box 7). However, it is better to teach about what can be grown in home gardens. Treating opportunistic infections early and using anti-retrovirals where affordable are also important.
Finally, I think that emotional and counselling support goes a long way, whether it is religious or spiritual counselling, family support or providing legal advice for orphans and widows. The AIDS Support Organization in Uganda is working with memory books and living wheels. These help people cope, especially young children. In Swaziland, we have community volunteers who are trained in home care and treating ailments. If a child has diarrhoea or an injury, they will provide the care right in the community.
In conclusion, maybe this is not the time to have repeated meetings and workshops. It is time to work with communities and to work on local solutions that come from the ground up. It is also important not to leave the policy makers behind. It is important not to demonise governments with all the weaknesses they have. It has been said that some donors have decided not to fund programmes in Africa anymore if they cannot control the recipient government. This is very alarming. We have to bring everybody on board, governments and NGOs, so that we find solutions together. The starting point should be the governments commitment of some funds to community programmes, no matter how small. We need to stimulate interest to move towards long lasting nutrition strategies that receive visible support from everyone. Of course this process has to start in our countries. Just as we need more relevant research on African indigenous foods and medicinal plants, Africa needs more home-grown initiatives to fight the HIV/AIDS epidemic. Our people are dying.
1. Swaziland Government (2000) Seventh HIV Sentinel Surveillance Report. Ministry of Health: Mbabane.
2. Swaziland Government (1985, 1994 and 1998) Informal Ministry of Health Reports. Ministry of Health: Mbabane.
3. Swaziland Government (1996) Swaziland National Plan of Action for Nutrition. Ministry of Health: Mbabane.
4. Piwoz EG and Preble EA (2000) HIV/AIDS and Nutrition. A Review of the Literature and Recommendations for Nutritional Care and Support in Sub-Saharan Africa. Academy for Educational Development: Washington DC.
5. Kraak V, Hernandez Y, Kaplan C (1994) Living with HIV: A Nutrition Guide with Emphasis for People in Recovery. God's Love We Deliver: New York.
Question from the audience I am interested in your experience and practical views regarding refugees, especially refugees living in camps where the population is closed in and stigma from HIV/AIDS is very high. Most of the time refugees depend on food rations from the World Food Programme and have very little access to income to buy additional food. We need to be guided by practicality when incorporating nutrition in our HIV/AIDS strategy for refugee camps. It is okay to say do no harm, but the how part is very important.
Comment from the audience Dr. Dlaminis paper shows how Swaziland approaches the process of capacity building and strengthening to promote nutritional well-being of all citizens. Swaziland is one place where nutrition units or councils are surviving, unaffected by the trend in the rest of Africa where nutrition councils or units are virtually dying. In Swaziland, nutrition is seen as a most important element of health care for people living with HIV/AIDS. Swaziland has also taken very seriously the principle of avoiding harm. For example, they are proceeding very carefully in terms of advice on what the infant feeding options really are. Programmes are evidence based. The government requested a study on infant feeding so that the basis for policy can be solid; study results are being discussed at the highest level. Community-based approaches are also very important in Swaziland. Community motivators, who work as volunteers, continue to be strengthened and are involved in all public health approaches including care for HIV-positive people and for nutrition promotion.
Question from the audience The reference to traditional foods is much appreciated because this can be a sustainable intervention, affordable by the very poor who perhaps have to make a decision on whether to plant cowpeas or pumpkin on a very small piece of land. However, there is little information on the nutritional composition of these foods. Firstly, what is being done in Swaziland to disseminate existing information and to encourage further analysis of these traditional foods? Secondly, in some of our communities people are programmed to think that these foods are inferior to exotic foods. What interventions are there to promote these traditional foods and to raise their status?
Comment from the audience Clearly the type of community involvement in Uganda and Swaziland is very good, but it has not gone far enough yet. In the early 80s, Thailand mobilized a huge number of volunteers: one per ten households. This meant that in every community several persons were trained in health and nutrition. Initially training was in the area of nutrition and community development. The same mechanism was then used to bring all pregnant women for ante-natal care. With quality services low birthweight was reduced from 18% to about 7% and preschool underweight from 51% to about 10% within ten years with the rapid rate of reduction in the first five years. The same mechanism was then used for prevention and control of HIV/AIDS because volunteers were selected on the basis of socio-demographics. The volunteers were respected in their communities. People living with HIV/AIDS were not hesitant to seek services through the volunteers.
The first HIV case in Thailand was documented in 1984. By 1994 there were 400,000 cases and by 2000 one million cases were reported. By now the number has fallen to 800,000, in large part due to community based programmes. The whole process could be seen as social immunization. At the national level, Thailand accepted HIV/AIDS as a key problem. This was debated at first because of fears that HIV/AIDS would affect the tourist trade. HIV/AIDS was also perceived as a shame. Once the problem was recognized, one key message was used in all prevention and control programmes: Only safe sex will prevent HIV/AIDS. Condoms were promoted widely in the country. The incidence of sexually transmitted diseases has gone down quickly with the use of condoms. People living with HIV/AIDS have been encouraged to become community workers. Schools are also involved in information dissemination, including information on community care of people living with HIV/AIDS. In Thailand, religious leaders are very important in community care. They encourage meditation, physical exercise, home gardening and community work (cleaning temples and schools). As for nutrition, community care stresses optimal use of existing resources. Fish and unpolished rice are advised as well as leafy, green and yellow vegetables, which are high in antioxidants. Treatment for symptoms is based on locally available plant products, such as cumin and aloe vera.
Question from the audience How do people translate the information they get from the counselling guidelines on good nutrition to actual practice? The treatment of opportunistic infections is considered an essential part of the care package and it has a close link to nutritional care. What is the thinking in the region in terms of accelerating access to essential drugs and some of the lifesaving tools, like gloves for health workers in maternity wards? Sick pregnant women are expected to provide these as part of cost sharing. How can health sector reforms be implemented so that the essential tools for prevention of transmission of infection do not become items of cost sharing?
Minister Dlaminis response Swaziland received refugees when Mozambique went through a difficult time. We did not know how long their problems would last, so we set up camps. These were really villages big enough so that people could have a patch of garden near their houses, so they could farm. The government decided that refugees would be eligible for employment if they could find it. Many were involved in self-generating employment; some found employment in the theatre and others helped to implement the HIV/AIDS prevention and control strategies. Working together it was possible to identify a range of opportunities for employment and community work. Refugees feel caged in if they are idly receiving rations. They want to earn a living. It is up to each country to find the most relevant way to handle the situation. Swaziland developed an HIV/AIDS prevention and control strategy for the camps. Implementation of these strategies must involve the youth leaders who, after all, are the ministers of tomorrow.
The national nutrition council in Swaziland has been strengthened. The council is shared between the Culture and Health Ministries and legislation was passed in March 2001 to expand the council and give it budgetary support. Regarding infant feeding, Swaziland has adopted an attitude of giving mothers all the information available. We owe it to women to let them know the full implications of each infant feeding method. We are sensitive to the new scientific evidence that indicates that exclusive breastfeeding for the first six months may be more protective than mixed feeding. We promote exclusive breastfeeding.
Indigenous or traditional foods have been downplayed in Africa and they need to be brought back into fashion. Here is an example. Swazilands Queen Mother celebrated her birthday recently and she offered all the foods that I used to see my grandmother cook. Those present preferred to eat the indigenous foods, while they left the rice. Civilization can be regressive and the more modern African diet can contribute to chronic disease. In the past in Swaziland one would eat a good meal in the morning, work in the fields all day, then have a small evening meal of one or, at most, two foods. The more modern African diet can include a large mixture of foods. In Africa we need to work towards bringing back into fashion the traditional eating patterns and the indigenous or forgotten foods. As Minister of Swaziland, if I eat Kenyan green spinach one would think, Our minister is poor but she is supposed to be rich. My reply would be, Oh, this is fashionable. How we portray nutrition is important. We have to sell it and market it. This is what I hope will become part of the nutrition strategies. Reliable nutrient composition data on African indigenous foods is lacking; our universities should be engaged in analysis of indigenous foods rather than the imported more modern foods.
As in Thailand, one of our biggest partners is people living with HIV/AIDS themselves. The president of our AIDS Care organization in Swaziland is a young man who promotes nutrition materials that we have co-developed with the assistance of UNICEF and other collaborators. He was diagnosed sero-positive in 1993; so he is eight years post diagnosis. He is well and he has not taken any anti-retrovirals. At first people did not believe him, but now they do. He has become a living symbol. We have to involve the communities.
In Swaziland we can supply gloves in the hospitals. This is a problem in other countries where women ready to deliver must furnish all the basic needs. Governments should bring in reforms and make a commitment that there is a basic package of care. In our country, there is a clause in our legislation providing for free treatment if you are unable to pay. Many people do not know about this clause. Occasionally I remind people that it is in our legislation. We need to face the challenges together and not make cost sharing a burden, so that cost sharing becomes poverty sharing. Some end up with no care at all because they are cost sharing. Governments have a commitment to look after their people.
The ministers from central, southern and western Africa are meeting to determine how we can obtain drugs for opportunistic infections (such as tuberculosis and pneumonia) by purchasing these drugs at reduced prices. This means negotiating reduced prices from the pharmaceutical companies, not an easy task. Bulk ordering as communities or groups of countries may also be helpful, but we need our finance ministers to assist us with this. We also need to look at the World Trade Organisation and the TRIPPS Rules. The economists are now telling us that we can legislate access to generic drugs and obtain licenses for companies to manufacture them in the region, as long as we do it before the year 2005.