The relationship between HIV/AIDS and food security is incredibly complex. For this guest post, I invited two experts on this issue to share their knowledge, insight, and experience. I'm delighted to introduce the article's two authors. Suneetha Kadiyala is a Senior Lecturer in nutrition-sensitive development at the London School of Hygiene & Tropical Medicine (LSHTM), in London, United Kingdom and Rahul Rawat, is a Research Fellow at the International Food Policy Research Institute (IFPRI), in Dakar, Senegal.
Progress in the fight against HIV/AIDS in the last decade has dramatically transformed HIV from a disease that was at once an imminent death sentence to a chronic condition giving countless individuals a chance at a healthy and productive life. Several achievements are noteworthy. New infections continue to decline, with the greatest reduction seen in new infections passed on from a mother to her child. Worldwide, 61 percent of people eligible for treatment under the 2010 World Health Organization (WHO) guidelines had access to antiretroviral therapy (ART).¹ Lastly, AIDS-related mortality has dropped markedly from its peak of 2.3 million in 2005 to 1.6 million in 2012.
These achievements should not breed complacency. By any measure, the promise of an AIDS-free generation is a distant reality. Retention in care and treatment remains a challenge, with attrition rates five years after the initiation of treatment as high as 40-50 percent in several African countries. There remain stark inequities in who becomes newly infected, who among the 35 million people living with HIV has access, and just as crucially, who adheres to ART and has access to social safety nets to help mitigate the consequences of HIV.
One of the drivers of this inequity, particularly in sub-Saharan Africa, is widespread food insecurity, which continues to thwart an effective and comprehensive response to the AIDS epidemic. Food insecurity is a risk factor for the spread of HIV, especially when coping behaviors adopted to mitigate the negative impacts on food security (such as engaging in transactional sex) increase the risk of HIV transmission. At the same time, HIV/AIDS precipitates and exacerbates food security and undernutrition by increasing medical-related expenditures, reducing work capacity, and jeopardizing household livelihoods.
Food insecurity and undernutrition among people living with HIV, in turn, compromise adherence to treatment and hasten AIDS-related mortality, even among those receiving ART. Recent evidence from our research collaboration with The AIDS Service Organization (TASO) in Uganda shows that both food security and diet quality predict nutritional status and quality of life among people living with HIV. Consumption of nutrient-rich foods was associated with better immunological outcomes and was protective against HIV disease progression and mortality.
Over the last decade, the policy environment has increasingly recognized the importance of integrating food security and nutrition interventions for effective HIV prevention, care, and treatment. Among the international agencies leading this charge are the United States Government’s President’s Emergency Plan for AIDS Relief (PEPFAR), the joint United Nations program on HIV/AIDS (UNAIDS), and the World Food Programme (WFP). At the national level, countries most affected by the epidemic have increasingly adopted food and nutrition security policies within larger HIV and AIDS policies. For example, the 2009-2014 Ugandan Strategic Plan for nutrition, TB and HIV—Nutrition in the Context of HIV and Tuberculosis Infection—incorporated food and nutrition into the national AIDS response.
The key programmatic responses to improve food security and nutrition status in the context of HIV/AIDS that have consequently emerged can be broadly categorised as follows:
I. Individual nutritional treatment, care and support This includes nutrition supplementation to HIV positive individuals using specialized therapeutic products (typically for about 6 months) for nutritional rehabilitation of undernourished individuals, to prevent early mortality, particularly when initiating ART.
II. Food, cash, or voucher transfers to food insecure households This intervention has historically included food transfers targeted to food-insecure households affected by HIV in the form of a food basket (cereals, legumes, fortified corn-soy blend, vegetable oils and sugar) as a safety net to improve household food security and mitigate the impact of HIV within the household. The duration of the transfers vary, though 12 months is most common, with orphans and vulnerable children receiving longer-term transfers. More recently, alternatives to direct food transfers, such as cash and voucher transfers in the context of HIV/AIDS are being provided. These alternate intervention modalities are yet to be rigorously evaluated.
III. Livelihood activities This includes livelihood interventions to improve long-term food security and are targeted to households or communities heavily affected by the AIDS epidemic, sometimes linked to the above interventions, which are limited in duration.
After more than a decade of programming integrating food security and nutrition interventions into the HIV response, what do we know about what works? The collective evidence from food security interventions targeted to people living with HIV, including the findings of our research in Uganda, have demonstrated the potential of these interventions to achieve the following:
- Improve retention in care and promote treatment adherence
- Reduce early mortality of people on ART
- Minimize ART side-effects
- Support nutritional rehabilitation and improve nutritional status
- Improve household food security
- Improve health-related quality of life
Conversations with people living with HIV lend a human voice to the need for effective food security programs integrated into HIV care and treatment.
“The problem of hunger has reduced in my family; in fact hunger was another disease which would have killed me for instance before enrolling on food [assistance]. At times I would go the whole day without tasting anything, not because I had no appetite but the problem was there was nothing to cook and consume. But these days I feel relieved because at any time I feel like eating I just prepare the porridge and take.” ---TASO client, Uganda
Livelihood programs in the context of HIV can potentially support a care and treatment strategy, mitigate negative household and community-level impacts. Research on how livelihood interventions need to be designed and implemented to achieve impact is only just beginning to emerge. Findings from a village savings and loan program, implemented by CARE International in Côte d'Ivoire, revealed that when appropriate medical treatment is available, people living with HIV participate and benefit from microfinance activities and enhance their economic self-sufficiency. The results of our large-scale operations research study conducted with TASO and 16 of its livelihood program partners in Uganda also shows promise. Participants of these programs noted an increased amount of food available to their households, and an improved ability to procure a range of non-food goods and services (such as medicines, schools fees, and rent), as a result of the interventions. Some program participants reported feeling physically better because they were less anxious about being able to afford food. They also spoke of their increased ability to invest in business and expressed a sense of emancipation.
"We thought we were going to die soon but because of the skills, we have been able to work and get money and good food which have improved our lives. They have now removed the element of death in us. We are working like any other people. Training me more especially in tailoring I just wake up in the morning measure my clothing, make them and get money which I use to buy milk and my children and I survive.” (Livelihood program participant, TASO client in Mbale, Uganda)
“What has changed is that before I started growing my vegetables and keeping goats and pigs, every money I could get could be spent on buying vegetables and food but now that is history. My money only goes in school fees, my sickness takes the smallest percentage of my money like eating lunch when I go to the centre for treatment and may be transport but this is not much.” (Livelihood program participant, TASO client in Jinja, Uganda)
However, investments (in financing, strengthening capacity, and operational research) that are required to effectively scale-up food security programs in the context of HIV, are at risk. Encouraged by the laudable achievements in rolling-out ART, coupled with a changing funding environment, the attention of the global community towards food security and nutrition as an important means of combating the AIDS epidemic appears to be waning. As an illustration, food security and nutrition were conspicuously absent from the agenda at the two most recent biennial International AIDS Conferences (in Vienna in 2010 and Washington DC in 2012). We must not abdicate the tough lessons learnt in the last two decades in improving the effectiveness of a wide range of prevention, treatment, and impact mitigation efforts to tackle the AIDS epidemic. Food security and nutrition interventions are critical enablers for “stepping up the pace” (the theme for the 2014 International AIDS Conference) and must remain on the HIV/AIDS response agenda.
1. Kadiyala, S. and Rawat, R. (2013). Access and diet quality independently predict nutritional status among people living with HIV in Uganda. (2013). Public Health Nutr. Volume 16(1):164-702.
2. Palermo T., Rawat, R., Weiser, SD., Kadiyala S. (2013). Food access and diet quality are associated with quality of life outcomes among HIV-infected individuals in Uganda. PLoS One: 8(4):e62353.
3. Rawat, R., McCoy, S., and Kadiyala, S. (2013). Poor diet quality is associated with low CD4 count, moderate anemia and mortality among HIV infected adults in Uganda. J Acquir Immune Defic Syndr. Volume 62(2):246-53
4. Food and Nutrition Technical Assistance II Project. Meeting on Nutrition Assessment, Counselling, and Support in HIV Services: Strategies, Tools, and Progress.Washington DC: Food and Nutrition Technical Assistance; 2011. (http://www.fantaproject.org/sites/default/files/resources/Getting-the-Knack-of-NACS-Apr2012.pdf)
5. Joint United Nations Programme on HIV/AIDS (UNAIDS). HIV, Food Security and Nutrition Policy Brief. 2008. Geneva, UNAIDS. 11-28-2012.
6.World Food Programme (WFP). WFP HIV and AIDS Policy. 10-5-2010. Rome, World Food Programme
7.Rawat, R., Faust, E., Maluccio, J. and Kadiyala, S. The impact of a food assistance program on nutritional status, disease progression, and food security among people living with HIV in Uganda. J Acquir Immune Defic Syndr. 2013 Dec 8. [Epub ahead of print]
8. de Pee S, Semba RD. Role of nutrition in HIV infection: Review of evidence for moreeffective programming in resource-limited settings. Food and Nutrition Bulletin2010;31(4):S313-S344.
9. Holmes K, Winskell K, Hennink M, Chidiac S. Microfinance and HIV mitigation among people living with HIV in the era of anti-retroviral therapy: emerging lessons from Cote d'Ivoire. Glob Public Health 2011;6(4):447-61.
¹Using the revised the 2013 WHO guidelines, 34% of people eligible for ARTs have access to them.