When Medicine Is Not Enough

Enlisting food and nutrition in the fight against HIV/AIDS

Photo of HIV-positive woman farmer working in garden in Rwanda

This farmer and her family, who are all HIV-positive, receive agricultural assistance to help ensure they have enough to eat. Rwanda. Source: Dieter Telemans/PANOS

When peasant households in Malawi need extra cash, members often leave their own fields temporarily to work for wealthier families, a system known as ganyu labor. Ganyu helps rural households meet urgent needs for food, but during the widespread famine that struck much of Africa in 2001 and 2002, it took an ominous twist. Women who visited trading centers in search of food came under increasing pressure to offer sex as part of the bargain, which put them at risk of becoming infected with HIV.

IFPRI recently concluded a 10-year research program focusing on interactions between HIV/AIDS and food and nutrition security, such as these instances of transactional sex in Malawi. The Regional Network on AIDS, Livelihoods, and Food Security (RENEWAL) was designed to deepen understanding of how food insecurity and economic inequality contribute to the spread of HIV and, in turn, are made worse by HIV-related illness and deaths.

“There was a lot of research and thinking about livelihoods and food systems and agriculture in Africa, but no one bothered to mention HIV/AIDS. That was strange considering how out of control the disease was, especially in southern Africa,” says Stuart Gillespie, IFPRI senior research fellow and director of RENEWAL. “It has a huge impact on people’s ability to work, especially in labor-intensive sectors like agriculture.”

In 2001 Gillespie and his colleagues launched RENEWAL as a “network of networks” that would link up organizations focused on agriculture, food, and nutrition with partners active in HIV/AIDS and public health. By bridging these fields, the program forged connections and broadened the scope of many HIV care programs in the region.

RENEWAL initially focused on analyzing interactions between HIV/AIDS and livelihoods, especially for communities that depend on agriculture. “Medical approaches were not yielding the kinds of results that people wanted to see. We thought that there had to be other factors placing people at risk,” said Suneetha Kadiyala, a research fellow in IFPRI’s Poverty, Health, and Nutrition Division.

To understand how agriculture may have been contributing to the spread of HIV and how it was affecting livelihoods, RENEWAL commissioned studies from local researchers in participating countries (Kenya, Malawi, South Africa, Uganda, and Zambia). One survey looked at poor households in rural Zambia and urban South Africa that were struggling with dual epidemics of AIDS and tuberculosis. It found that although these illnesses were costly in both settings, the economic burden was greater in Zambia because patients lived farther away from healthcare providers. Moreover, no local nongovernmental organizations working on TB or HIV in Zambia provided food aid, even though TB drugs increase patients’ appetites. Households coping with TB and HIV in Zambia were thus especially vulnerable to debt and food shortages.

During RENEWAL’s second phase researchers increasingly focused on ways to help households resist HIV and cope with AIDS stresses through food and nutrition programs. Then, in 2007 and 2008, high energy prices, population growth, and other factors converged to produce a global spike in food prices.

“There was a lot of concern about vulnerability, but not a lot of focus on HIV,” Kadiyala said. RENEWAL made the connections, showing that food insecurity often causes people to move in search of food or work and to engage in transactional sex—behaviors that increase risks of contracting HIV. Additionally, people who are HIV-positive need more daily calories for adequate nutrition, so food shortages can degrade their health and speed up the onset of AIDS. For people fortunate enough to be under treatment, an adequate diet minimizes the side effects of antiretroviral therapy and thus helps increase the chances that they will stick with the regimen.

“HIV attacks food security through many routes,” said Kadiyala. “It increases medical costs, it incurs stigma that makes it hard for people to access food through social networks, and it affects the next generation. Diet quality is a huge challenge in the context of HIV.” As the links between food security and HIV/AIDS became clearer, RENEWAL’s emphasis shifted toward reforming policies and programs to make them more effective.

The results of the program’s work are increasingly visible at national and international levels. Kenya and Uganda now include food and nutrition security in their national AIDS strategic plans. Mozambique and Tanzania are implementing HIV/AIDS strategies for their agriculture sectors. And the World Health Organization has called for nutrition to be integrated into a comprehensive HIV/AIDS response strategy.

Agriculture, like any sector, faces major challenges in responding to shocks and stresses that originate outside its core mandate, said Gillespie. But in the early 2000s, the primary livelihood for most people living with HIV in Sub-Saharan Africa was agriculture. People’s agricultural livelihoods generated risk and vulnerability to HIV, and they were not well equipped to adapt to the sickness and death that AIDS brought in its wake. “The more we engaged with this field, the more we realized it was not enough to bring an HIV awareness into agriculture and food systems,” said Gillespie. “We also needed to bring food and nutrition into HIV policy and programming—all buttons needed to be pressed.”

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