Positive Health Online

Abstract

The human immunodeficiency virus (HIV) pandemic, also known as acquired immune deficiency syndrome (AIDS), is a global crisis with consequences that will be felt for decades to come. The ability of households and communities to ensure their food and nutrition security in the face of AIDS is being severely challenged. Livelihoods are being eroded through the effects of premature illness and death on household labour power and through the fracturing of intergenerational knowledge transfer. [Coffin et al., 2006] Social relations and capacity to care are being put under immense strain by HIV-related stigma and exclusion, increasing orphaning rates, and reducing incentives for collective action. Financial stress is increased as expenditures for health care and funerals increase, and as credit becomes harder to access.[Greener, 2002] Labour losses affect the ability to farm and to maintain common property resources, and assets are sold off to raise cash. Though sub-Saharan Africa is currently being hit hardest, the spread of HIV in other regions, especially South Asia, is accelerating, and the downstream impacts are beginning to be felt. Not only does HIV/AIDS precipitate and exacerbate food and nutrition insecurity, but the spread of the virus is accelerated when people, because of their worsening poverty, are forced to adopt ever more risky food provisioning strategies. [UNAIDS, 2006 b] Hence, food security is essential to the prevention of the spread of HIV/AIDS and to the care and support of affected individuals, communities, and nations.

Nutrition and HIV: The cycle of benefits from nutrition interventions. (Source: Federal Ministry of Health, 2008, Ethiopian Guide to Clinical Nutrition Care for Children and Adults with HIV)

http://labspace.open.ac.uk/mod/oucontent/view.php?id=452801&extra=thumbnail_id392363230846

Except for third party materials and otherwise stated, content on this site is made available
under a Creative Commons Attribution-NonCommercial-ShareAlike 2.0 Licence

Aim

The aim of this essay is to examine the evidence regarding the interactions between HIV/AIDS and household level food security, and then review the recent attempts by different stakeholders to respond to these interactions.

Introduction

AIDS is a collection of symptoms and infections resulting from the specific damage to the immune system caused by the human immunodeficiency virus (HIV). The late stage of the condition leaves individuals prone to opportunistic infections and tumours. [Coffin et al., 2006] Although treatments for AIDS and HIV exist to slow the virus's progression, there is no known cure. HIV is transmitted through direct contact of a mucous membrane or the bloodstream with a bodily fluid containing HIV. This transmission can come in the form of sex, blood transfusion, contaminated hypodermic needles, exchange between mother and baby during pregnancy, childbirth, or through other exposure to one of the above bodily fluids.[Greener, 2002]

Most researchers believe that HIV/AIDS originated in sub-Saharan Africa during the twentieth century.[Greener, 2002] HIV/AIDS is now a pandemic and the rampant spread of this disease has exceeded all expectations.[UNAIDS, 2006 a] In 1991 the World Health Organization (WHO) forecasted that by year 2000 the cumulative global total of HIV toll in men, women and children would be 40 million, in reality this prediction has proven to be a serious underestimate. Subsequent estimates raised it to 36 million people living with HIV, and 20 million persons to have died from a total of 56 million cumulative HIV infections in 2001.[Piot et al., 2001] Year 2001 added worldwide another 5 million new HIV infections and 3 million to the death toll.[UNAIDS, 2002] These statistics reveal an alarming trend: Women are becoming increasingly affected by HIV, accounting for approximately 50% of the most recent estimate of 38.6 million people living with HIV/AIDS worldwide, raised to 42 million according to the Center for Disease Control.[Edwards & Al-Hmoud, 2003]

Socio-economic determinants of HIV/AIDS pandemic in relation to household food security

At the 1996 World Food Summit, 185 countries and the European Community reaffirmed, in the Rome Declaration on World Food Security, the right to food security, defined as existing “when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life”.[Gerbasi, 2002] Food security refers to physical and economic access to food of sufficient quality and quantity. Food security is necessary for ensuring nutrition security. Nutrition security is achieved for a household when secure access to food is coupled with a sanitary environment, adequate health services, and adequate care to ensure a healthy life for all household members. It appears that there is a huge gap between the endorsement of the right to food and the practical implications of this right.

The Director-General of the Rome-based UN Food and Agriculture Organization, Dr Jacques Diouf, said in a message delivered to the Special Session of the UN General Assembly on HIV/AIDS:[2006) b] "HIV/AIDS is a major development problem, it is jeopardizing the basic human right to food for millions of people in the developing world." "HIV/AIDS poses a serious threat to the food security of the millions who are infected and their families, both HIV/AIDS also affects food security by impoverishing affected families and hence reducing their ability to buy food.” Dr Diouf continued.[UNAIDS, 2006 b]

As a matter of fact, studies in Africa and South-East Asia have shown that the cost of caring for a patient and meeting the subsequent funeral expenses exceeded the average annual farm income. As a result, poor rural households sell their productive assets, including their livestock, to care for the sick or pay the funeral expenses. Businesses located in areas with high HIV/AIDS rates suffer from high absenteeism and staff turnover, loss of institutional memory, and reduced innovation.  HIV/AIDS causes spending to rise, particularly on medical care and funerals. These expenses are immediate and unpredictable and commonly necessitate borrowing of money or selling of assets. Furthermore, HIV/AIDS can reduce productive labour time and income by 67–83%.[CDC, 1996]

Moreover, children may be left without parents, increasing the orphanhood levels. In 2001, 13.2 million children lost at least one parent to AIDS. The AIDS mortality of parents eventually will result in family nutrition declination, economic status deterioration, and increasing number of children out of school (especially girls), which leads to the de-education of the future generation.[Breuer, 2000]

Migration is also an important determinant in terms of the HIV/AIDS pandemic: The main reason for migration is the search for better job opportunities.[Guillies et al., 1996] The inability of economic development to offer everyone the opportunity to make a decent way of life triggers the development of parallel sexual economies of prostitution sometimes associated to HIV.[Piot et al., 2001] Hence, migration is expected to have further impact on the HIV/AIDS rate and food security.

Dr. Diouf[UNAIDS, 2006 b] also said that HIV/AIDS is affecting food security at the national level, by reducing countries' ability to import food when needed. It has been estimated that HIV/AIDS is currently reducing annual GDP growth per capita by 0.8% in Africa. Many of the worst affected countries are low-income food-deficit countries (LIFDC), and many are also highly indebted poor countries (HIPC). Their difficulties to import food are thus being exacerbated," the FAO Director-General added.[2006 b] These facts indicate that wealth of nations, HIV/AIDS Regions, countries and groups that are already economically, politically, and socially disadvantaged, are often the most vulnerable to HIV/AIDS.[Guillies et al., 1996] This causes a vicious circle with the loss of young wealth-producing adults and the high cost of caring for those with AIDS.[Naik et al., 2003]

The HIV/AIDS global epidemic is comprised of a series of overlapping micro-epidemics. While a few relative affluent countries have been able to arrest the growth of the epidemic within their boundaries, in other parts of the world, the epidemic not only has not been controlled, but it has grown explosively.[Piot et al., 2001] Sub-Saharan Africa accounts for 10% of the world population, but 77% of the global AIDS death toll, 70% of the world’s HIV/AIDS infected 42 million persons, and 80% of the world’s infected women and children; [MGDs, 2006] its HIV infection increase of 13.5% in 2002 is second only to Eastern Europe/Central Asia region’s (26.3%).[Zimmerman, 2002]

The impact of the epidemic continues to be very serious on individuals, households and nations, reducing by more than half the GDP of severely infected countries and reducing by 480 million people the UN estimate of global population by year 2050.[Joint UN Program on HIV/AIDS and WHO, 2002] In Africa, HIV/AIDS has caused previously positive trends in life expectancy to be reversed, and the average reduced by 10 years. Expected life at birth will fall to 32 years in Uganda, from 59 years without AIDS.[CDC, 2001] In Botswana, where almost a third of adults are infected with HIV, life expectancy has dropped from 65 years in 1995 to 56 years in 2000 to 39.7 years in 2005.[UNAIDS, 2006 a] Other projections show that by the year 2010 the life expectancy of 10 Sub-Saharan countries (most affected by HIV/AIDS) will be reduced by more than 20 years.[Piot et al., 2001] Increasing mortality affects households and communities in a variety of ways. According to Piot et al.[2001] AIDS kills people as well as killing economic activity. Hence, the cyclical relationship is clear: AIDS generates poverty, and poverty makes people more vulnerable.  AIDS kills the most productive - and reproductively active - members of society, rendering both households and entire societies vulnerable. AIDS reduces the agricultural workforce in many developing countries, where the sector is critical for export earnings and is often the largest single source of employment. By 2020, the agriculture workforce in Botswana, Mozambique, Namibia, and Zimbabwe could be 20 percent smaller because of the epidemic.[UNAIDS, 2006 a] By 2010, the Gross Domestic product (GDP) of South Africa, which represents 40 percent of Sub-Saharan Africa’s economic output, will be 17 percent lower than it would have been without AIDS.

Nations’ Efficiencies in the Fight against HIV/AIDS

Antiretroviral drugs (ARDs) reduces both the mortality and the morbidity of HIV infection, but routine access to ARDs is not available in all countries[Palella, 1998] Faster progression from HIV to AIDS, and a rapid decline in health, is caused by the weakening of the immune system from malnutrition, which makes infected people more susceptible to opportunistic infections such as tuberculosis. Further, inadequate nutrition interferes with the use of ARDs, thereby reducing the benefits of advances in health care in contexts where ARDs are available. Food insecure individuals and families must decide between expenditures on food or on health care, and often both health care and nutrition are compromised.[Loevinsohn & Gillespie 2003a] Poor nutrition is also associated with adverse outcome in HIV/AIDS. For example, multi-vitamin supplementation in HIV-1-infected pregnant women substantially decreases adverse pregnancy outcomes such as low birth-weight, pre-term birth, and increases maternal T-cell counts. However, even with the help of global organizations such as UNAIDS,[2006] a nation with low economic growth can hardly pay the cost of highly active antiretroviral therapy (HAART) and prevention programs[Voelker, 2000] for HIV.

The United States and Britain are the world's biggest Aids donors. George W Bush has committed $15bn over five years, and Gordon Brown has just come up with £1.5bn over the next three years. According to the latest figures, the US has an Aids prevalence rate six times that of our own. In the debate over funding for prevention versus funding for treatment, both the Department for International Development[DfID, 2006] and the Bush administration substantially favoured the treatment option. Hilary Benn[DflD, 2006] goes so far as to say that the British will support "increased, and eventually universal, access to treatment and care for people with HIV and Aids". This is a staggering ambition as, according to DfID,[2006] the global provision of such care would cost about $46bn a year, roughly what the ‘whole rich world’ now gives in aid to the developing world!

The British do not specify how they will allocate funds between treatment and prevention. The Americans are clear. More than $10bn of Bush's $15bn will go on treatment and care. The public health priority in tackling Aids in the developing world continues to be prevention, just as it was in Britain and the US in the 1980s. The American view is that since most prevention efforts have failed over the past 20 years, including in the US, we must try something else. This means spending $1bn on campaigns in poor countries against sex before marriage.[DfID, 2006] This may not work, and could cost many thousands of lives. The British reject this approach, but are also in danger of ignoring the lesson that past prevention efforts failed mainly because politicians and officials did not pursue them vigorously enough.

Food and nutrition security are fundamentally important to the prevention, care and treatment of HIV/AIDS.[Loevinsohn & Gillespie 2003a] Hence, appropriate strategies must take account of the fact that what those affected need most is usually food, at a time when their ability to acquire food may be diminished. Indicators and monitoring systems need to be put in place to track the effectiveness of policies and programs aimed at responding to the interaction of HIV/AIDS with food and nutrition insecurity, to improve and maintain nutritional status, protect productive assets and support households and communities to strengthen their resilience to current and future food security risks, which may affect their well-being and livelihoods. Building bridges between social scientists, epidemiologists, public-health specialists, nutritionists, and agricultural economists can overcome these challenges. In this way the causes and consequences of HIV/AIDS may be mapped in ways that facilitate effective action. By mainstreaming HIV/AIDS into food and nutrition policy, evidence of what works under what conditions can be accumulated, enhance learning, and help people become better equipped to address the multiple threats of the pandemic.

Conclusions

The evidence that the HIV/AIDS HIV/AIDS pandemic affects national and household level food security in more than one way is clear. Programming and policy that open up opportunities for less risky, less susceptible livelihoods are an essential part of prevention, treatment and care and support. HIV is a disease driven by inequality and poverty, which needs to be addressed and funded with this in mind. It should be recognised that where Anti-Retroviral Therapy is necessary, food is a key element in strategies to promote adherence to it and its efficacy. Donors and governments need to make better use of available mechanisms to strengthen the links among sectoral policies. This means using poverty reduction strategies and all sectors should be expected to work to minimize risk of HIV transmission and strengthen resilience to AIDS. A harmonized approach is needed in strategic planning, in line with an agreed AIDS action framework. Appropriate nutrition and impact indicators should be included in clinical and community surveillance, and in national, regional and international progress reporting. Hence, food security is an essential element to the prevention of the spread of HIV/AIDS and to the care and support of affected individuals, communities and nations.

References

Breuer N (2000) AIDS threatens global business. Workforce. Available from: www.workforce.com . Accessed 21 February 2006. 2000.

Centers for Disease Control and Prevention (CDC) "U.S. HIV and AIDS cases reported through December 1996". HIV/AIDS Surveillance Report 8 (2), 1-40. Available from: www.cdc.gov/hiv . Accessed 21 February 2006 . 1996.

Coffin J, Haase A,  Levy JA,  Montagnier L, Oroszlan S, Teich N, Temin H, Toyoshima K, Varmus H, Vogt P and Weiss RA "What to call the AIDS virus?". Nature 321 (6065), 10. 1986.

Department for International Development (DFID) 2006 Global Health Partnerships: The UK contribution to health in developing countries. Available from: www.dfid.gov.uk/pubs/files/ghp.pdf. Accessed February 2007.

Edwards J and Al-Hmoud RB. AIDS mortality and economic growth: A cross-country analysis using income-stratified data. Available from:

http://people.duke.edu/~yl148/Wahoo/Socio-economic%20determinants%20of%20HIVADIS%20and%20nations%20efficiencies.pdf

Accessed: 21 February 2007. 2003.

Food and Nutrition Technical Assistance (FANTA). Available from: www.fantaproject.org/focus/foodsecurity.shtml . Accessed 24 February 2007. 2007.

Gerbasi F. The challenges of the World Food Summit: five years later. M. Borghi and L. Postiglione Blommestein (eds.). For an Effective Right to Adequate Food. Fribourg: University Press Fribourg. pp. 79-84. 2002.

Greener R. AIDS and macroeconomic impact. S, Forsyth (ed.): State of The Art: AIDS and Economics, IAEN, 49-55. 2002.

Guillies P, Tolley K and  Wolstenholme J. Is AIDS a disease of poverty. AIDS Care 8 (3), 351–363. 1996.

Loevinsohn, Michael and Stuart Gillespie HIV/AIDS, Food Security and Rural Livelihoods: Understanding and Responding. Washington, D.C.: IFPRI and ISNAR. 2003.

Naik G. HIV’s impact is seen by UN as even worse. Wall Street Journal. February 27 2003.

Palella FJ, Delaney KM, Moorman AC. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators. N. Engl. J. Med 338 (13), 853-860. 1998.

Piot P, Bartos M, Ghys P and Walker N. The global impact of HIV/AIDS. Nature 410, 968–973. 2001.

The Millennium Development Goals (MDGs) Report (2006) Available from: http://unstats.un.org/unsd/mdg/Resources/Static/Products/Progress2006/MDGReport2006.pdf  Accessed 21 February 2007. 2006.

UNAIDS 2006a. Annex 2: HIV/AIDS estimates and data, 2005. 2006 Report on global AIDS. Available from: www.who.int/hiv/pub/guidelines/WHO%20HIV%20Staging.pdf .

Accessed 21 February. 2006a.

UNAIDS 2006 b.   Special Session of the General Assembly on HIV/AIDS Round table 3 Socio-economic impact of the epidemic and the strengthening of national capacities to combat HIV/AIDS. Available from: www.unaids.org/en/AIDSreview2006/AIDSReview2006/default.asp . Accessed: 21 February 2007. 2006 b.

UNAIDS Reference Group on Modelling and Estimation. Improved methods and assumptions for estimation of the HIV epidemic and its impact: Recommendations of the UNAIDS Reference Group and Estimates, Modelling and Projections. AIDS 16, W1–16. 2002.

Voelker R Setting priorities and budgets to fight against global AIDS. J. Am. Med. Assoc. 284 (21), 2709–2710. 2000.

Zimmerman R. AIDS’s spread inflames other crises. Wall Street Journal. November 27 2002.