|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.)|
Stuart Gillespie, Lawrence Haddad, IFPRI and Robin Jackson, WFP
* This paper represents a collaboration between a research organization and an operational agency, both concerned with issues of food and nutrition security, and both concerned with how best to respond to the raging HIV/AIDS crisis in Sub-Saharan Africa. It builds on and complements previous work done by Haddad and Gillespie, which in turn benefited from a consultation on HIV/AIDS and rural livelihoods, held at IFPRI in January 2001, and supported by DFID. It also encompasses the main findings of five country studies of heavily impacted countries undertaken by WFP, aimed at improving understanding of the appropriate uses of food aid in prevention, care and mitigation.
The magnitude and depth of HIV/AIDS impacts in Sub-Saharan Africa are staggering. Livelihoods are being devastated and the food and nutrition security of millions of households seriously undermined. This paper is an attempt to shed light on the various impacts and pathways through which HIV/AIDS affects food and nutrition security, the types of responses made by households and communities in trying to reduce these effects, and their policy and programme implications, including any lessons from recent attempts at direct impact mitigation. The specific role of food aid is examined since inadequate access to food is one of the first signs of distress in an HIV/AIDS-impacted household.
Over 36 million individuals are currently living with HIV/AIDS, 95% of whom are from developing countries. More than 150 million people are affected by the disease, if we assume that each HIV/AIDS case directly influences the lives of four other individuals1. Sub-Saharan Africa is the region most affected, where HIV/AIDS is now the leading cause of adult morbidity and mortality. Most, if not all, of the 25 million people in Sub-Saharan Africa who are living with
HIV/AIDS will have died by the year 2020, in addition to the 13.7 million Africans already claimed by the epidemic. HIV/AIDS also is spreading dramatically in Asia. India is estimated to have three to five million HIV infections and, though national data are not reliable, some Chinese specialists estimate up to 10 million HIV infections in China. Asia will overtake Sub-Saharan Africa in absolute numbers before 2010 and by 2020 Asia will be the HIV/AIDS epicentre1.
Is HIV/AIDS a unique shocka?
a A shock is here defined as an unanticipated event that has a significant (usually negative) impact on a large number of people's ability to fulfill their capabilities.
The HIV/AIDS pandemic is transforming the landscape upon which development must take place in much of the developing world, but it is different from other diseases or shocks for the following reasons:
· It is incurable and fatal. It kills the most productive members of society. Thus, it increases household dependency ratios, reduces household productivity and caring capacity, and impairs the inter-generational transfer of local knowledge and skills. The effect on the household may be permanent;
· This bleak prognosis makes intervention efforts (prevention or mitigation) difficult. Most development interventions can offer some hope of some improvement in human welfare. Effective HIV prevention can only offer an absence of decline. Effective HIV mitigation can only offer a temporary improvement in human welfare from an already HIV/AIDS-lowered level;
· Life-prolonging treatment is too expensive for most HIV-infected people, although there is significant scope for major cuts in the prices of drugs;
· It is socially invisible. The private nature and divergent cultural attitudes towards sex lead to silence, denial, stigma, and discrimination at many levels. This makes effective prevention and mitigation difficult to implement;
· HIV has a very long incubation period between infection and full-blown symptoms during which individuals are infective. In the absence of routine HIV testing, infected individuals have less of an incentive to alter risky behaviour and a long period over which to undertake those activities. Both invisibility and long duration increase chances of HIV transmission. Individuals who are unaware of their HIV status and their families cannot begin to alter livelihood strategies in response to the coming shock;
· It has both rural and urban dimensions. As with poverty, the death of one or more income-earners in rural households often forces survivors to migrate to seek work in cities. A death of an urban worker may force survivors to send children back to rural extended families to be cared for;
· It affects both the rich and the poor, though it is the poor who are most severely exposed and most severely impacted;
· It affects both sexes but is not gender-neutral. To the extent that women are marginalized and powerless, they are more at risk of being exposed to HIV. Women are also more likely to succumb rapidly to HIV/AIDS, as they are more biologically vulnerable;
Finally, one of the most disturbing aspects of the pandemic is the fact that, as it intensifies with a parallel need for action, the actual capacity to act is decreasing. Organizations that are located in areas that are experiencing a high HIV/AIDS prevalence, are characterized by high absenteeism, high turnover, a loss of institutional memory, and reduced innovation. As individuals in government and nongovernmental organizations continue to die, the capacity gap - between what is needed and what can be delivered - is becoming an abyss.
The poverty dimension
HIV/AIDS and poverty (a large part of which relates to food insecurity) interact in a vicious cycle. Poverty increases the exposure to, as well as the impact of, HIV. It diminishes the perceived value of avoiding HIV (we will die soon anyway). It increases the relative costs of both avoiding and treating the illness, and it exacerbates the impact of weakened immunological integrity as a result of a more hostile bacterial and viral environment. Poverty also increases the radius of impact of HIV on family and friends. For the poor, informal coping mechanisms are more dependent on family and friends and less so on insurance companies and the state.
In the reverse direction, HIV/AIDS also impoverishes. It increases poverty in the short to medium run by stripping assets of many kinds-human, social, financial, physical, natural, informational and political. Asset rundown leaves individuals, families and communities more exposed to future shocks-children are pulled out of school to help with labour needs and young women may be forced to become commercial sex workers.
Nevertheless, as compared to other aggregate shocks, the nonpoor are thought less able to avoid HIV infection and its impacts. While this might generate wider political support to confront AIDS, it undermines the ability of middle income-staffed governments, private sector firms and other formal organizations to mobilize human resources to combat it. There is also a danger that public sector health budgets will become more skewed towards the wealthier and more vocal urban HIV/AIDS population to the detriment of the rural poor in general. Primary health care clinics may become increasingly poorly equipped. Waiting and travel times for the poor might also increase as a consequence, further stretching the demands on the remaining able-bodied labour.
Women are biologically, socio-economically and socio-culturally more at risk of HIV infection than men
The gender dimension
Women are biologically, socio-economically and socio-culturally more at risk of HIV infection than men2,3. Biologically, the risk of becoming infected with HIV during unprotected vaginal intercourse is between two and four times higher for women than for men4. Women are also more susceptible to other sexually transmitted diseases (STDs) and less likely to seek treatment. If untreated, STDs may multiply the risk of HIV transmission by 300-400%. This biological susceptibility further threatens reproductive health status. Pregnancy and child bearing now involve considerably greater risks not only for women but also for their future offspring, while STDs can be potentially life threatening.
HIV/AIDS also exacerbates social, economic, and cultural inequalities that define women's status in society. Women are often more susceptible to HIV infection and more vulnerable to AIDS impacts than men for the following reasons. The predominant culture of silence and passivity regarding sex stigmatizes women who try to access STD treatment services. The norm of virginity restricts adolescent girls' access to information about sex and increases risk of sexual coercion. Economic vulnerability increases the chance of exchange of sex for food and money. Male power is often manifested in sexual violence. Susceptibility to HIV infection is increased through sexual practices, including genital cutting, dry sex and ritual cleansing. Finally, women are discriminated against with regard to inheritance rights.
Other important changes in gender asymmetries relate to less personal but nonetheless crucial assets. Premature adult male death may deprive the female of the necessary time to build up a set of extra-family levers (such as access to community land, to community groups, and to micro-finance groups) that can be used to exert power within the family. If property and user rights for a whole range of assets are not clearly and equitably defined or are not enforced, women are likely to become less able to shape their own destiny. This lessening of women's relative power will tend to be reinforced via the subsequent diminished ability to control decisions relating to their own needs and those of their children in terms of health care, food intake and work timeb.
b However, the greater economic independence of women under conditions of weak control of choice over sexual partners may actually place women at a greater risk of HIV infection if such independence is associated with greater livelihood mobility.
Economic vulnerability increases the chance of exchange of sex for food and money
Impacts of HIV/AIDS on nutrition, food security and livelihoods
In this section, we examine the type of impacts that HIV/AIDS may have on households and communities with regard to their food and nutrition security, in the context of their livelihoods, particularly with regard to rural populations dependent on agriculture. There are three points to be made at the outset. First, impacts are often revealed through the responses, or coping strategiesc, made by households and communities. In this paper we prefer to use the term responses rather than coping. Second, it is important to differentiate susceptibility to HIV infection (the likelihood of becoming infected with the virus) from vulnerability to the different types of impacts, once infection has taken place. Third, it is important to recognize that different stages of the HIV/AIDS epidemic will have different indicators, different impacts and different responses. There are also differences between countries or sub-national regions with regard to the gradient and the peak prevalence of the HIV/AIDS epidemic relating in part to the velocity of transmission, which itself is related to behaviors and the pathogenicity of the particular HIV strain. An illustrative scenario of the dynamics of the impact and response of HIV/AIDS in an agriculture-based household is provided in Box 3.
c The term coping may not always be accurate simply because many responses are those of distressed households which are not coping. Coping implies a reversible management strategy. It also somehow suggests that the adoption of such strategies is not too costly. The reality is that many households are forced to make distress sales or change livelihood strategies in ways that are irreversible. The price of such short term coping may be long-term deprivation or even destitution.
Impacts on Nutrition
HIV/AIDS has significant impacts on nutrition at the level of the individual, household and community. Malnutrition in turn increases both the susceptibility to HIV infection and the vulnerability to its various post-infection impacts.
At an individual level, HIV infection accelerates the vicious cycle of inadequate dietary intake and disease that leads to malnutrition (Figure 2) while malnutrition increases the risk of HIV transmission from mothers to babies and the progression of HIV infection6. HIV infected individuals have higher nutritional requirements than uninfected individuals, particularly with regard to protein and energy. They are also more likely to suffer a loss of appetite, even anorexia, thus reducing dietary intake at the very time when requirements are higher. Moreover, such interactions are thrown into starker contrast for the poor who are more likely to be malnourished prior to becoming infected.
Box 3 - Dynamics of HIV/AIDS impacts and household responses in an agriculture-based livelihood
The following is an illustration of possible impacts and responses of an agriculture-dependent household containing an adult who contracts HIV. Many of these impacts have been shown in studies; some are speculative albeit plausible. Context is obviously crucial with regard to type and sequencing of impacts and responses at different stages of the epidemic.
· Adult becomes sick
· Downward spiral accelerates....
Research shows that the onset of the disease and even death might be delayed in well-nourished HIV-positive individuals, and diets rich in protein, energy and micronutrients help to develop resistance to opportunistic infections in AIDS patients7.
Mother-to-child transmission (MTCT, or vertical transmission) of HIV, which may occur during pregnancy, at birth or via breastfeeding, is a major nutritional issue. Recent studies conducted in South Africa8,9,10 confirm that there was no significant difference in HIV transmission between babies who were exclusively breastfed for the first three months of life and babies who were never breastfed. However, babies who received both breastmilk and formula were at significantly increased risk of transmission. By 15 months, exclusive breastfeeders had the lowest transmission of all three groups. Exclusive breastfeeding facilitates enterocyte junction closure of the intestinal mucosal barrier decreasing exposure to dietary antigens and environmental pathogens, which occur with the premature introduction of other foods and liquids (and formula).
This causes intestinal irritation and inflammation to allow direct contact of the virus with the infant's bloodstream11. These are the predominant direct impacts on infected individuals. There are other important indirect impacts at the household and community levels. These may be brought about by, for example, a diminished capacity of caregivers to care for themselves, for their young children, or for AIDS-infected household members. In many poor households, even those unaffected by the pandemic, child care may be compromised in the short term to ensure food security in the long term. Any adverse impact on the quality or quantity of child care of such decisions are likely to be exacerbated by shocks such as HIV/AIDS that may drastically reduce household caring capacity.
Source: Semba RD and Tang AM (1999) Micronutrients and the pathogenesis of human immunodeficiency virus infection. British Journal of Nutrition 81: 181-89.
Impacts on agriculture and other livelihoods
A livelihood represents the interaction between assets and transforming processes and structures that generate a means of living, all conditioned by the context that individuals find themselves in12. Agriculture is the main livelihood of most rural populations in Sub-Saharan Africa. Regarding assets, HIV/AIDS strips individuals, households, networks, and communities of different forms of capital (human, financial, social, physical and natural) as described here.
Most obviously, HIV/AIDS attacks human capital. Infected individuals die prematurely, prior to which their productivity will have already declined following the onset of AIDS-related opportunistic infections such as tuberculosis. However, the full impact of HIV/AIDS on labour is greater than this, as the labour of healthy individuals is diverted into other crucial activities such as caring for those infected and attending the funerals of those who have died.
With regard to agriculture, obviously farming systems that are less dependent on labour will be better able to respond to these losses. Studies have investigated the characteristics associated with vulnerability and resilience of farming systems in the face of loss of labour13,14,d. Other impacts on land and land use include the cultivation of crops that are less labour intensive, but less nutritious (e.g. some tubers) and the fallowing of land. The impacts of HIV/AIDS on the commercial agricultural sector are less well understood15,16. If the commercial sector is dependent on migrant labour it is susceptible to HIV/AIDS, especially if the labourer is resident without his or her family. Social networks will also tend to be weaker for labourers in the commercial sector.
d At the semi-subsistence level, the impacts on farming practices have been summarized in a number of reviews3,14,16,17,18.
However, the commercial sector can be a force for good in the sense that it can provide information and training for prevention. It might provide opportunities for AIDS orphans to learn some essential agricultural skills. However, human capital is about much more than manual labour. It is also about knowledge. The severe illness and death of adults in their prime by HIV/AIDS abbreviates the ability of individuals to transfer knowledge both within their generation and from their generation to the next. Both verbal and role model mechanisms are interrupted by HIV/AIDS. New generations are less able to draw on the body of knowledge that dies along with their parents. They are deprived of learning by doing under the guidance of someone more experienced.
The ability to acquire and use information is also impaired by HIV/AIDS as younger generations are pulled out of school to bolster the family's ability to provide care to the ill and to maintain its current livelihood or to develop new ones. This is an example of an ultimately destructive coping strategy. Tomorrow's livelihoods are sacrificed to hang on to today's.
Financial capital is damaged by HIV/AIDS in a number of ways. Because drug, burial and related transport expenses become major items in budgets, families need to find ways to maintain current consumption levels. In terms of financial capital services (credit, savings and insurance) poor families have to sell stores of value (e.g., jewelry and livestock) and assets (e.g., equipment or tools); borrow funds in a sustainable manner or, most unlikely, secure access to some kind of insurance, health, or otherwise.
The poor invariably are reliant on informal credit at high interest rates or on group-based microfinance services, both of which are vulnerable to aggregate shocks. Even when the epidemic is in its early stages, the affected family is less able to avoid default and hence is less attractive to group-based liability schemes. Despite these limitations, private credit has been described as the key distress response to adult death from HIV/AIDS-at least in the well-studied area of Kagera in Tanzania19. No doubt the ability of microfinance institutions to respond to the changing needs of their clients will be crucial to HIV/AIDS mitigation efforts.
Social capital (or the strength of associational life, trust, and norms of reciprocity) may be undermined by HIV in several ways. First, social reproduction in terms of the role-modeling of norms of trust and good citizenship is impaired. Future generations not only do not witness farming practices, they do not experience the informal exchanges of knowledge, tools and animal draught labour that are often embodied in such livelihood activities. Second, the incentives for coordinated group action may be diminished due to the heavy discounting of the future benefits of such action. This has a particularly negative consequence for natural resource management practices that are dependent on collective action such as integrated pest management, social forestry and watershed development20. Third, the formal institutions, which also contribute to social capital formation such as church groups, sports clubs, and professional associations, are likely to be weakened as members die. Fourth, social networks tend to be spatially concentrated. The networks, which are more heterogeneous, should have a greater carrying capacity. However, those members who are highly mobile or live in urban areas will make a network more susceptible to HIV/AIDS. Fifth, social capital may be weakened through an increased exclusiveness of network membership. The stigma attached to HIV/AIDS is not conducive to the establishment of crosscutting ties involving the different strands of social capital21. HIV/AIDS might lead to the generation of a type of social capital formation, which is exclusive.
Physical and natural capital
The basic infrastructure and productive equipment, which are relied upon for the pursuit of livelihoods, also comes under threat due to HIV/AIDS. The possible sale of productive equipment or mortgaging of land in response to large health and funeral expenses has been noted, as well as the possible neglect of health infrastructure for the poor. As time becomes an ever-scarcer commodity in HIV/AIDS areas, access to water and energy sources must be improved. This is particularly important given the fact that these activities are socially determined to be the responsibility of women who most often care for their family members, irrespective of their HIV/AIDS status. HIV/AIDS might undermine the ability of communities and user groups to pool risk and act collectively to manage sustainably common property including rangeland, cropland and river basins.
Clear and equitable delineation of property and land rights become more important as individuals leave their dwellings to search for alternative livelihoods or to help out friends and families outside of their community. If dwelling or land rights are linked to physical presence, property rights might be impaired, especially when widows and orphans are the primary claimants.
Policy and programming principles
This section provides a list of key generic principles for maximizing the contribution of food and nutrition programming to mitigate the impact of HIV/AIDS. These principles have been derived from a review of the existing literature and from the main findings of a series of case studies carried out by the World Food Programme.
Do no harm
Any public sector attempts to respond to HIV/AIDS in terms of mitigation must first, do no harm. A number of private sector responses has deliberately reduced the abilities of households with infected members to mitigate the effects of HIV/AIDS. Examples from South Africa include the capping of medical benefits for HIV-infected employees, reductions in funeral leave, and reductions in company contributions to funeral expenses16. More difficult to detect, but perhaps less difficult to amend, are the interventions or policies that inadvertently increase the risk of HIV infection, e.g., actions that reinforce gender imbalances in power or those that displace individuals without adequate HIV monitoring and prevention efforts3.
The painfully slow recognition of HIV/AIDS as a major global developmental crisis, not just an isolated health problem, has finally dawned. Yet, strategies where they exist, tend not to go beyond prevention and remain in the domain of the health sector. Very little is happening in mitigation and very little in reviewing food and nutrition security policies and programmes through an HIV lens. Many government/public servants who work in agriculture or rural development do not understand the link between HIV and food security. Programming is ad hoc.
Effective advocacy is vital to mainstreaming
HIV/AIDS. Advocacy strategies, which consider the role of values, attitudes, and interests as well as information per se need to be developed. These strategies should be undertaken by skilled policy entrepreneurs, ideally backed up by nationally prominent individuals, need to be developed.
Ensure strategic balance
Conventionally, a distinction is made between prevention aimed at reducing HIV infection through behavioural change, and mitigation aimed at reducing the severity of HIV/AIDS impacts on households, communities and other institutions. Care interventions focus on those who are HIV positive, though they may also benefit other family members.
The focus on programming for HIV/AIDS has been largely on prevention, care secondary and mitigation relatively neglected until recently. This needs to change. It is increasingly obvious that not only are all these strategies vital in the long run, they should be integrated as far as possible. Interventions need to be designed and assessed not only in terms of their ability to mitigate the current impacts of HIV/AIDS, but also in terms of their ability to reduce susceptibility to future infection and vulnerability to various types of impact.
Use an HIV lens
A hard look should be taken at the role that existing interventions and policies play, or could play, in HIV/AIDS mitigation before completely new and capacity-straining interventions are developed. What is the extent of HIV/AIDS-specificity required for an intervention to be effective in lessening the impacts of HIV/AIDS? Specifically, when do governments, NGOs, communities, and development agencies need to: i) improve the performance of existing efforts, ii) view HIV-prevention and mitigation interventions through a poverty lens and modify appropriately, iii) view agriculture, anti-poverty, and nutrition interventions through an HIV lens and modify appropriately, or iv) design completely new interventions to address HIV/AIDS?e Development practitioners should not be blind to the threat of HIV/AIDS, but neither should they be blinded by it.
e The lens essentially refers to an approach to viewing potential solutions to a problem (e.g. poverty) that derives from evolving knowledge of the important linkages with another problem (e.g. HIV/AIDS).
Food security programming per se is very weak in many countries. Programming for food and nutrition security rather than just agricultural production is difficult due to the multi-sectoral nature of the issues. Linking it with HIV/AIDS complicates the matter even more. This is coupled with the fact that many countries do not include extensive food security policies and programmes in their overall poverty reduction strategy, which marginalizes the issue further.
Context in general, and the context of poverty in particular, is not taken into account in programming sufficiently. For those who are poor, HIV/AIDS is just one more event or shock, which affects their ability to get ahead and improve their lives. Programming for mitigation needs to look very closely at the other constraints, which impact food security for HIV/AIDS affected households. It is often these other constraints which affect the success of the intervention and determine how HIV/AIDS impacts different households and different members of the household. Because of the complexity of these interactions, it can be difficult to identify activities which are sustainable, to address food and nutrition insecurity and to contribute to the prevention of HIV infection.
There is a need to recognize the different stages of the disease in different parts of a country. In some areas, the biggest issue is prevention. In others, where there has already been a clear impact on households' ability to ensure their food security, mitigation becomes increasingly important. Different interventions will also be required for different groups. The impact of HIV/AIDS on food security of a pastoralist group is likely to be different from that on an agriculturalist community. Particularly susceptible and vulnerable are communities affected by complex emergencies, which are usually epicentres for the transmission of the disease.
There is no need to identify HIV-infected individuals or households even if it is feasible. To avoid the stigma attached to HIV, community-based targeting is usually the most appropriate option. If the programme is designed to identify the poorest for safety-net schemes or food aid development projects, for example, using known community structures appears to be the best way to target. Programmes targeting very poor food insecure households which have been impacted by factors other than HIV should not be considered an inclusion error.
Most HIV/AIDS programmes are very small scale in nature. They have been referred to as expensive boutiques available only to a small percentage of the affected population22. For example, in Kagera, Tanzania, a highly studied region, only two of five districts are covered by HIV/AIDS preventive services to which a mere five percent of the population have access. Multisectoral top-down coordination of integrated rural development programmes failed in the 1970s and 1980s23, mistakes which should not be repeated. Nonetheless there remains a need for some top-down support of bottom up processes in the areas of setting of policies and programme parameters, cofinancing programmes, facilitation and training, monitoring and evaluation22. The challenge is to find ways of scaling up locally relevant, community-driven approaches.
Scale relates also to sustainability. As the use of an HIV lens in policy and programming becomes progressively systematized, sustainability is likely to increase. It is also important to reemphasize that the short- and long-term nature both of impacts and of mitigation responses need to be thought through clearly.
Partners and collaboration
Effective interventions are rooted in a community response and depend heavily on the participation of local health authorities, community representatives and people living with HIV/AIDS. The greater involvement of people living with HIV/AIDS in all aspects of related programming can be a powerful and influential factor in effective prevention, mitigation and care interventions. Many of the best organizations to partner with are community-based. However, these groups tend not to be national in scope and can be difficult to locate. They are often unable to scale up interventions.
It is also important also to look outside the usual nutrition and food security networks in order to identify partners working on HIV/AIDS with whom mutually beneficial partnerships may be forged. Many of the organizations aiding and supporting people living with HIV/AIDS and their families have religious affiliations. Food security programmes need to maximize the inputs of such organizations while recognizing the possible remaining constraints and gaps that remain. For example, in many areas, religious groups are active in home-based care, but they do not promote the use of condoms for HIV prevention. In these situations, other partners will need to be drawn in. As HIV/AIDS partner organizations may be very small with limited capacity, capacity development will be an essential element of support.
It is difficult for policies and programmes to respond to HIV/AIDS if the epidemic cannot be monitored effectively. A monitoring system that is relatively simple, but able to track the changing HIV/AIDS situation and its impacts on food and nutrition security, with the required accuracy and reliability to guide timely ameliorative action remains elusive. This is likely to be due both to a weak demand for such information and a weak ability to supply it. How to generate such a demand is a difficult question to answer. The stigma, denial and silence attached to HIV/AIDS makes the task more difficult than, for example, developing early-warning drought indicators. Moreover, the capacity to generate such information is undermined by HIV/AIDS.
A number of generic indicators have been suggested in the literature. Examples are suggested from the types of household and community impacts and responses mentioned in the previous section. Data from health centres on STDs, TB, and adolescent pregnancies are all relevant if they can be accessed. Again, it is not necessary to reinvent food and nutrition security indicators, but to apply the HIV lens to existing ones. A balance has to be found between indicators that can be compared across communities and administrative units, and a community-driven process that can generate more context-specific indicators. Community knowledge will be invaluable not only in identifying indicators, but in clarifying their use and delineating what is feasible in terms of who will collect relevant data.
Programming in emergencies
Programming in emergencies should focus on controlling HIV/AIDS in the affected population and prevent further spread of the disease. This can be done through the provision of free condoms, provision of information, prevention of HIV transmission through blood transfusions and adherence to universal precautions for all health staff. Efforts should also be made to protect women from gender-based violence. In addition, the UN uniformed services are at high risk of both transmitting and contracting the disease and represent a good target group for education and prevention.
Options for Action
In this section we review some of the specific options for action to mitigate HIV/AIDS impacts on food and nutrition security, starting with nutrition-relevant policy and programmingf before considering the role of food aid and finally the options for mitigation via the agriculture sector. It is important to keep in mind the generic principles described above when considering such options.
f In the section on nutrition policies and programming it is understood that much of the discussion applies to nutrition and care programmes which use food aid.
Nutrition policies and programmes
There are several different approaches to designing and implementing appropriate nutrition-relevant actions aimed at preventing and/or mitigating HIV/AIDS impacts. A first distinction needs to be made with regard to the objective. For people living with HIV/AIDS, nutritional care and support is critically important in preventing or forestalling nutritional depletion. Relevant specific objectives might include to improve quantity and quality of the diet, to build or replenish body stores of micronutrients, to prevent or stabilize weight loss, to preserve (and gain) muscle mass, to prevent diarrhoea and other digestive discomforts associated with fat malabsorption, to speed recuperation from HIV-related infections, and to prepare for and manage AIDS-related symptoms that affect food consumption and dietary intake.
Nutritional support has the potential of significantly prolonging the life of individuals for their own benefit and those who are dependent on them for care, e.g., young children24. Such interventions are likely to have the greatest overall impact early in the course of disease by prolonging the period of relative health with asymptomatic infection6. Unfortunately, relatively few people know they are infected at this time. Nutrition interventions may also be targeted to communities with the objective of preventing and/or mitigating impacts through reducing the interactions of HIV/AIDS with malnutrition, either upstream or downstream of HIV infection.
Any nutrition intervention should take into account the three main preconditions of good nutrition, i.e., food security, health and environment services, and care. For people living with HIV/AIDS this means that appropriate treatment of opportunistic infections, stress management, physical exercise, and emotional, psychological, and spiritual counseling and support are all relevant25, along with conventional approaches such as home-delivered, ready-to-eat foods for homebound AIDS patients who are unable to prepare their own meals.
Beyond a clinical setting, there is a major issue as to how to do this in a way that does not stigmatise the beneficiary. As mentioned, targeting to affected communities (not households) using whatever proxy indicators are relevant is likely to be most appropriate. A second-stage targeting might be employed with regard to stages in the life cycle that are particularly susceptible and vulnerable (e.g. adolescent girls, pregnant women, and young children).
Looking through the HIV lens, breastfeeding promotion and complementary feeding programmes will need to further emphasize the dissemination of clear information to policy makers, health providers, and communities about mother-to-child transmission facts, including risks and benefits of breastfeeding (Box 4). They will also need to anticipate that households affected by HIV/AIDS will have even greater time and economic constraints to the provision, preparation, and feeding of appropriate complementary foods. Programmes to address women's nutrition may not require substantial content changes, but need much greater support all around, especially for breastfeeding women. Again, these challenges will be further accentuated by the progressive weakening of health care and other delivery systems.
Box 4 - How does mother-to-child-transmission change policy?
The finding that HIV is transmitted through breastmilk has complicated infant feeding recommendations26. Recognizing breastfeeding as a significant and preventable mode of HIV transmission, the Joint United Nations Programme on HIV/AIDS (UNAIDS), WHO, and UNICEF issued new guidelines on HIV and infant feeding27. These guidelines call for urgent action to educate, counsel, and support HIV-positive women in making decisions about how to feed their infants safely.
Evidence of the protective effect of exclusive breastfeeding8,10 only emerged after these guidelines were published. Further confirmation of this finding and the benefits of safer breastfeeding practices, on the risk of mother-to-child transmission of HIV is a necessary first step in the development of a policy recommendation that would permit infants to benefit from the myriad benefits of exclusive breast-feeding while avoiding the risk of HIV transmission through partial breastfeeding. Much of the debate and controversy in this area has revealed a limited understanding of the multiple extra benefits of exclusive breastfeeding and the serious trade-offs and dangers of moving away from such a policy recommendation.
Yet despite these findings slowly gaining acceptance, there remains a strong resistance on the grounds that exclusive breastfeeding is both rare28 and difficult to promote. Much remains to be done. Breastfeeding promotional efforts need to be rapidly improved, including expanding the Baby Friendly Hospital Initiative (BFHI) to rural hospitals, and strengthening its links with communities (the 10th step in the Innocenti Declaration). As well, advocacy is needed for the breastfeeding rights of working women using, for example, the new ILO Maternity Protection Convention 183 and Recommendation 19 which advocates longer paid maternity leaves and other needed workplace support.
Affected communities may be targeted for the following types of interventions: nutrition counseling in health facilities, community settings or at home to change dietary habits, to increase consumption of key foods and nutrients or to manage anorexia and other conditions that affect eating patterns; water, hygiene, and food safety interventions to prevent diarrhea; and supplementary food baskets for home preparation.
As with all nutrition programming, it is important that it is not just community based, but community driven. Process is thus a major consideration. At the community level the key is to create space and develop capacity for an iterative process of assessment, analysis and action.
It is also important to build partnerships and foster convergence of relevant programmes. As a multi-faceted subject requiring action from several sectors, nutrition is, and has always been, vulnerable to bureaucratic inertia derived from compartmentalized organizational structures that offer few incentives for integration or convergence. Magic bullets have generally been the preferred way to go, as reflected in the prominence attached to vitamin A capsule distribution and salt iodization during the 90s. There is nothing intrinsically wrong with magic bullets unless they end up crowding out other important and necessary longer-term holistic approaches to nutrition. This has certainly happened, as borne out by the relative stagnation of child anthropometric outcomes when compared to micronutrient indicators29. While micronutrient supplementation (particularly vitamin A) will have a role in nutritional support to AIDS affected communities, this mistake should not be repeated in the case of HIV/AIDS communities, not least given the significantly raised energy and protein requirements of people living with HIV/AIDS that cannot be met by pills.
Programming food aid
The role of food aid in HIV/AIDS mitigation and care has just begun to be explored by field-based organisations. The biggest challenge for food assisted interventions is to provide food to meet needs but also to programme interventions so that family members and communities are left with a means to improve their food and nutrition security after the food assistance stops. Issues of sustainability are difficult and yet need to be fully resolved.
Recent work has shown that there is a role for food aid in both care and mitigation packages30,31. However, certain programming principles should be followed.
· If HIV/AIDS impacted families and communities are to be targeted for food assisted interventions, there must be a clear need for food among the recipients. Tested and reliable methods for determining the relative level of a household's food and nutrition security exist and are used in most targeted food aid interventions;
· Food should only be provided as part of a larger package of assistance which will depend on country and community specific conditions, but would include, as far as possible, information, education and awareness (i.e. prevention) components;
· Combining food with either relevant training or income generating activities (e.g. micro-credit) appears to be a way to both assist households in dealing with reduced access to food and to build self-sufficiency in affected households;
· Close consultation with affected communities on how to target and deliver food assistance needs to be an integral part of the project. Appropriateness includes not only issues of taste and nutrition but also preparation, including cooking. For example, decreased family labour can have an impact on the supply of household energy, such as firewood. Communities often have their own means of identifying the poorest households and selecting those who need food. In order to avoid stigma, households which are poor and food insecure but which have not been visibly impacted by HIV/AIDS should still be included in the beneficiary group, if selected by the community.
Food assisted projects present certain challenges. For many reasons they can be more complicated for implementing organisations than other types of development projects. Most of the community-based HIV/AIDS organisations, which would assist in the implementation of food aid projects, are very small and operate on minimal funds. They frequently lack the expertise and full capacity to undertake expanded activities and lack experience in transporting, storing, handling and distributing food. Organisations dealing in food assisted projects need to recognise this capacity gap and plan for capacity building and training in these areas. Furthermore, many of these organisations have never used food in their programming. Education concerning the role food should play in either a care or mitigation intervention is essential.
Where to concentrate HIV/AIDS food assisted programmes and projects may present a challenge. Food aid is generally targeted to the geographic areas of a country that are the most food insecure, and then within those areas to those communities/families which cannot meet their food needs. In many countries these are not the areas that have the highest prevalence of HIV/AIDS 32. Food insecure areas are often more remote, have low production potential and weak market structures. Areas with high infection rates are often located in or around urban or semi-urban areas, or areas where markets and transportation networks function relatively well and where commercial activities, including agricultural trade takes place. Towns near or on trucking routes, and zones with active commercial markets often have high prevalence rates.
In order to target food aid effectively in areas which are considered food secure, food assisted interventions need to be able to locate and identify those families and communities which have been impacted by AIDS and are having difficulty meeting household food needs. Local institutions, NGOs, or community-based organizations working with HIV/AIDS affected populations will be key.
Furthermore, food assisted programmes dealing with HIV/AIDS need to broaden their reach in terms of prevention activities. Many organisations that deal with food aid also transport it within countries, either through their own trucks or through contracting local transportation companies. Because long-haul drivers are known vectors for the spread of HIV, it is important to include this group in education and awareness campaigns and training, including condom distribution.
Several options for programming food aid are listed in Box 5. By slightly changing existing food aid projects, the specific needs of food insecure HIV/AIDS impacted families can be taken into account. For example, school feeding in particular has potential as a means to encourage school attendance of orphans and to prevent school drop-out. By providing take home rations for families fostering orphans as part of a regular school feeding programme, families are encouraged to continue caring for children whose parents have died and orphans are encouraged to attend school.
Although food can and should be distributed to and through institutions, caution must be exercised to avoid undermining household and community care strategies. For example, by supporting orphanages with food and other inputs, communities might be encouraged to send orphans there rather than finding foster families where children can stay in a family environment.
Agricultural policies and programmes
The options for policy and programme response in agriculture can be grouped around the main clusters of impacts: labour losses, knowledge losses, and weaknesses in institutions. These tend to be most noticeable beyond the initial phases of the epidemic. All are compounded in a downward spiral whenever asset depletion is a short-term response.
Box 5 - Examples of prevention, mitigation and care-related intervention options that use food aid
· Using food distribution sites to enable partners to raise awareness on HIV and AIDS, provide prevention information and promote and distribute condoms
· Food for vocational training for street children and orphans
· Providing food for women living with HIV/AIDS and their children in order to prolong the life of the mother while ensuring the nutrition of her children
Source: World Food Programme (WFP) (2001c) Food Security, Food Aid and HIV/AIDS: Project Ideas to Address the HIV/AIDS Crisis. WFP: Rome.
Discussion of HIV/AIDS issues can, and should as far as possible, be included in agricultural services provision. Examples include Integrated Pest Management (IPM) programmes in Southern Africa that have incorporated information on HIV prevention, care and mitigation into IPM training. Also, in Southeast Asia, farmer field schools and IPM student field schools have addressed HIV prevention issues16. There may be a benefit to targeting scarce extension resources to higher risk groups such as seasonal agriculture workers, estate workers, and fishermen. Research on national agricultural systems should be encouraged into the substitutability of labour and capital in local farming systems in anticipation of severe labour shortages.
But perhaps the most profound challenge to the agriculture sector in countries threatened by HIV/AIDS is the need to develop agricultural and natural resource management systems that are more labour-extensive and use less purchased inputs but support sustainable livelihoods. In the absence of new technology and techniques, farmers are switching to feasible low input, low output farming that is preferable to infeasible labour-intensive, higher input farming34. Yet, in so doing, they run the risk of adopting an ultimately destructive coping strategy. If the loss in agricultural productivity from pre-epidemic levels is sufficiently large, farm and nonfarm incomes will slowly cycle downwards.
The move to low input low output farming buys some time but is unlikely to be a sustainable solution. The challenge for the agricultural community and specifically for the agricultural research community is to develop farming practices that adapt to the reality of HIV/AIDS affected environments and yet maintain productivity levels. For this to happen, surviving farmers should be ever more closely involved in planning and implementation of supporting research35. One simple example of a technological adaptation to an HIV/AIDS environment is the development of lighter ploughs for use by women and youth16.
Proposed methods for combating information and knowledge losses include farmer field schools where experienced farmers share their knowledge with less experienced farmers (youth and widows). For example an initiative in Zimbabwe involves participatory training for AIDS widows in the production of cotton, a crop normally grown by men16. Extension services, themselves severely depleted by the epidemic, must focus more on youth to fill the void. Information losses are also crucial in terms of the role traders play in bridging the gap between farm and market. Recent research has emphasized the important role played by trader-farmer networks of information and social relations that embody reciprocity based on trust36. This is one of the forms of social capital that HIV/AIDS is thought to undermine. Mobile traders are likely to be relatively susceptible to HIV/AIDS and given the already thin nature of agricultural markets in many parts of Sub-Saharan Africa the consequences are likely to be serious. Efforts to support these networks need to be developed.
Agriculture does not take place in a vacuum. Successful efforts to strengthen the institutions that support farming in the face of the HIV/AIDS onslaught are difficult to find. An important first step is to improve the access to HIV prevention information and technology for members of that institution. Second, it is necessary to clarify the ability of the institution to strengthen itself. We do not know enough about which types of capacity constraints are most binding and which have been most damaged by HIV/AIDS. This is another important step to take before increasing resources for staff development and recruitment.
Recent experiences from some of the most badly affected countries have demonstrated the ability of an important rural institution, micro-finance, to innovate and develop products that better meet the needs of the emerging clientele, especially as in Uganda where national leadership has openly confronted HIV/AIDS37. The roles of micro-finance institutions and the NGO community that helps animate them will be crucial in the prevention and mitigation of HIV/AIDS in the new HIV/AIDS battlegrounds of South and Southeast Asia, where so much micro-finance innovation has taken place in general. If such types of innovation are to occur at the intersection between community and institutions that are accountable to them, donors will need to be more creative in the programming of resources.
The research base upon which HIV/AIDS impacts are assessed and upon which interventions for mitigation are evaluated is very narrow. A small number of good studies do exist in refereed journals, and more exist in the unpublished literature. Yet, given the scale of the problem, the research base is remarkably small.
There is no consensus as to whether information gaps are more constraining than funding gaps, but clearly better analysis and information can lead to a better use of existing resources and provide a firmer basis for arguing for moreg. There is a sense that many experiences in mitigation in the food, agriculture and nutrition field are not getting out to as wide an audience as they need to. Innovative practitioners have little incentive to document their experiences given the complex environment within which they work and in any case, the demand for such information may be muted due to the silence surrounding HIV/AIDS. Mechanisms for information sharing, for giving those at the front line a voice, have to be found.
g For a detailed description of the type of information gaps concerning appropriate mitigation responses to HIV/AIDS impacts, the reader is referred to a recent paper by Haddad and Gillespie38.
Second, tools for the assessment of capacity need to be developed and employed. Capacity as a constraint to effective interventions is often overlooked with disastrous consequences, and the fact that HIV/AIDS directly undermines this capacity makes it even more important to assess what remains. The evaluation of HIV/AIDS mitigation through food, agriculture, and nutrition interventions is an area in which immediate work must begin. The work must be action oriented for advocacy and ethical reasons but it must conform to high scientific standards-a difficult but not impossible challenge as action research outside of HIV/AIDS and indeed HIV/AIDS prevention work has shown.
Third, more basic research needs to be undertaken on the dynamics of shocks, including HIV/AIDS. Which communities, families and individuals are best able to minimize the damage due to HIV/AIDS and why? Pragmatism needs to prevail if the research is to have payoffs within 2-3 years, and all efforts must be made to build on earlier data collection.
Finally, the policymaking process needs to be better understood. Why does HIV/AIDS register more quickly as a threat to development in some countries but not in others? How do policy makers learn and what is the role of research, communication and advocacy?
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Chair Clearly, there are many connections between nutrition and HIV/AIDS. Nutrition has an impact on HIV/AIDS and HIV/AIDS impacts on nutritional status. Breastfeeding is an important element in the discussion, but there are many other angles as well. The problems are so big that we need to attack them on different levels. We need to consider small-scale rural programmes as well as policy development. Research is also needed so that programmes are well designed and based on sound scientific evidence.
Question from the audience When considering how to accelerate programmes, there must be some focus on the critical points and not a long list of priorities. Is it possible to look at the critical points first rather than a long list? What are these critical elements? Of course, we would not want to neglect other issues totally, but can we focus on a very few things first?
Question from the audience When we talk about the relationship between food security and the distribution of HIV/AIDS, there would probably be regional differences. The distribution map for HIV/AIDS and the food security map for India are totally different. Is it possible to generalize?
Comment from the audience Many in this audience recall that 20 years ago we discussed multisectoral nutrition planning. The HIV/AIDS problem has many similarities with the nutrition planning problem. We say that HIV/AIDS is a complex problem, that it needs multisectoral action which is all about behaviour change and changes in practice. The fascinating thing is that the response so far is exactly the same response we had to nutrition 20 years ago. Countries set up big national committees, nutrition councils, regional and international planning meetings and developed a language that only the nutrition experts could understand. Can we learn from the last 20 years in nutrition and then jump ahead 20 years? We have learned that unless people and communities are incorporated into the solution nothing will happen. This is where I see the whole work with HIV/AIDS today. It should be oriented towards building capacity in the community. That is why I think the nutrition community can play an incredibly important role in saying to the HIV/AIDS people: look here my friends! We made that mistake long ago. You dont need to repeat it!
Chair Let us hope the nutrition community really will say that. From community to community, malnutrition is present but where are the actions to combat malnutrition in those same communities? Mrs. Monico described what TASO is doing in Uganda by working at the community level. The point has been made that governments should take HIV/AIDS seriously. If governments are going to take HIV/AIDS seriously they have to set up some kind of government machinery to look after HIV/AIDS. Of course, we should work at the community level, but it is not an either/or situation. Maybe we should shift more emphasis towards the community level, but we must maintain a balance somehow. Nutrition cannot be tackled in a vacuum at the community level. Lets try to encourage those who are working at the community level and others to develop national legislation. Discrimination against widows that leads to loss of land rights should be eliminated. This cannot be only a community level effort. Children who are orphaned should go to school. That cannot be only a community level effort. There are so many issues which need to be taken on board by a central administration.
Response from the audience I agree that it is not an either/or situation but I am frustrated and I am in good company. You come to a village in Kenya, Tanzania or Zambia. You meet an old lady who takes care of 20-30 children. You ask her: is there anything we can do? She comes with a very modest request, perhaps a few hundred shillings. Next day, I sit in a meeting in Geneva or New York or Nairobi and listen to donors saying we are increasing to 100 million dollars... or we are increasing to one billion dollars.... I do not see anything happening at the community level from these enormous promises. Second, we have to remember those who cope. Even with a 25% infection rate there are 75% not infected. They have already found a solution. We can learn from them. I still remember the frustration we had in the nutrition community and I was one of the most committed nutrition planners in the early 70s. I gave up because I realized that planning has limitations and solutions are constantly being produced at the community level.
Stuart Gillespie I agree entirely. This last point helps to answer the first question with regard to what we actually do. It has to be both top down and bottom up. However, there needs to be a significant shift in emphasis towards the community and understanding community needs, supporting as far as possible capacity building and the ability to respond and cope. There are many similarities with nutrition. Yet, we must not reinvent the wheel in terms of believing that multisectoral HIV/AIDS committees are going to be the answer.
With regards to India and the mapping of food security with HIV/AIDS, India right now is in phase one of the epidemic. I dont know if the relationship between HIV prevalence and food insecurity would still apply in phase three. It may or may not, but certainly the situation in sub-Saharan Africa is mostly phase three and there is a significant overlap and a linkage between poverty and food insecurity and HIV/AIDS.
Comment from the audience I liked the broad coverage of this presentation and the variety of topics. However, Dr. Gillespie did not talk about safe infant feeding and maybe that was not intended. We are in danger of having a new increase in malnutrition and other micronutrient deficiencies. We dont know what is going to happen with those mothers who are living in poor families who are persuaded to use some alternative method than breastfeeding. We need to discuss this and know more about it and the situation needs to be monitored. Increasingly one goes to countries and sees mothers being persuaded, or deciding for themselves, not to risk breastfeeding their babies. If they come from poor families, we do not know what the extent of the increased malnutrition will be. Will these children be getting more illnesses? The cost of mothers themselves getting medical care was mentioned, but infants are going to need more medical care as well. One of the nutritional implications of HIV/AIDS is going to be that if mothers who are poor choose not to breastfeed their babies and use one of the alternatives, then malnutrition will get worse.