HIV/AIDS and Food Security

Summary of meeting

Child-headed households benefiting from a home based care project

Action Against Hunger (AAH) and Oxfam GB hosted an inter-agency meeting in London on Food security and HIV/AIDS on December 1, World AIDS Day. The aim of the meeting was to build consistency and coherence in international non-governmental organisation's (INGOs) response to food insecurity in HIV/AIDS affected areas. The objectives were:

• to share practical experiences of food security programmes aimed at HIV/AIDs affected communities
• to share lessons learnt, innovative approaches, and planned programming or research
• to look at key theoretical documents and discuss how they are utilised by INGOs
• to discuss specific challenges faced in programming
• to decide on the need for a HIV/Food Security (FS) working group to be established to co-ordinate information/activities.

Agency presentations

Paul Harvey from the Overseas Development Institute (ODI) opened proceedings by presenting key findings of a recent review¹. Describing how HIV/AIDS has an impact across the whole spectrum of livelihoods, not just food security, he highlighted the need for greater clarity on the type of interaction between HIV and livelihoods. There are many examples of food security programmes geared towards HIV/AIDS affected populations, e.g. new types of food for work activities, but these are mostly based on assumptions that labour is a big constraint and that there is community cohesiveness. However, there is little monitoring and evaluation of these projects and there are numerous issues around these approaches, for example, an over-focus on agriculture and food aid, and AIDS 'exceptionalism', i.e. AIDS is assumed to be the only factor contributing to food insecurity.

Shelling maize

Cathy Mears outlined the thinking and activities of the International Federation of the Red Cross (IFRC) with regard to HIV/AIDS and food security. Within the IFRC, food security has an important role in the strategy to prevent HIV/AIDS and also, as an integrated part of care and treatment. The IFRC are implementing a programme in Zimbabwe (set up in 1992), which aims to prevent transmission, provide care and support for people living with HIV/AIDS (PLWHA), and undertake advocacy work². The IFRC are also piloting a food security project to support affected households in Swaziland involving skill development to generate new income generating activities.

Cathy outlined a number of issues and constraints to HIV community-based home care programmes which included the need for multi-sectoral programming and consideration of medium and longer term vulnerability, difficulties monitoring programme impact, how to increase the volunteer base, the need for more research on appropriate diets, and the challenges of targeting HIV/AIDS affected households where there is a stigma.

Celia Petty from Save the Children UK (SC UK) presented the agency's newly adapted approaches to the assessment of the economic impact of HIV/AIDS, which separate out the effects of other shocks (such as climate, market liberalisation) at a macro and household level. The SC UK approach is based on Household Economy Analysis, involving detailed information from a representative sample of households, and is being developed to understand the way households can reallocate labour in response to shock. The main challenge is understanding how HIV has changed vulnerability of households to other shocks. Work is ongoing to determine what interventions will reduce this altered vulnerability through targeted assistance, and directing resources to sustain or promote collective assistance and community support roles

Home worker talking to home based care group at communal garden

Oxfam's project in Malawi, presented by Laura Phelps, is an integrated approach to improving food security and protecting livelihoods in Mulanje and Thjolo district, an area with a high incidence of infected /affected households. Since 2001, the programme has concentrated on food aid (mainly to protect livelihoods), and provision of seeds and cuttings, fertiliser, vegetable seed, livestock, and technical support. Programmes are operated through Village Development/ Relief Committees and the Ministry of Agriculture. The modality of assistance has been both free and through loans, using a short and medium term approach. Extension support has included manure making, crop diversification, intercropping, bank fixing, soil and water conservation, kitchen gardens and livestock production.

Successes have included a reduction in the hunger gap reduced from 5 to 3 months, dietary diversification, links between humanitarian and development approaches, and flexibility of approach (e.g. did not demand repayment for seeds). However, there was no evidence of activities being translated into improved income. Furthermore, although there were higher crop yields, there was no evidence of a labour saving. Overall, the cost per person was higher due to targeting of vulnerable households and strategic partnership development. Major challenges were targeting vulnerable households that were fluid in nature and building the capacity of extension workers due to absences and deaths. The Oxfam team learnt that adolescents were often not interested in agricultural activities, but were more motivated by income generating opportunities.

Oxfam also presented information on their Global strategy (2002 - 2005), the Oxfam GB HIV/AIDS workplace policy, and development of a tool kit to assist in mainstreaming in Food Security/ Livelihoods (currently in draft).

Carer working in home based care project

Action Against Hunger's (AAH) HIV-related work in Malawi was presented by Rebecca Brown, who described three profiles of HIV affected households in Malawi.

1. A large population of healthy, HIV-affected people
2. A large population affected by premature death in the household
3. A small number of households caring for those with full blown AIDS

Strategies that could be considered for these three groups include boosting income and livelihoods, moving the focus of activities away from agriculture so that households are more resilient when individuals become ill. Labour saving and sharing interventions, as well as free food aid, home based care, medical intervention, and food security support to families are included in their programming. Strategies improving nutritional status will hopefully delay the onset of full blown AIDS. The types of intervention AAH have been implementing include homestead local farming, root crops as alternatives to maize (also vegetable and pulses), alternative agricultural techniques to improve yields without fertilizers, and provision of small livestock to households with low labour capacity.

In terms of targeting affected households, AAH have considered ways of getting around stigmatisation. A pilot programme in Ntchishi district used a food/labour ratio as a proxy indicator, which effectively measures dependency ratio. In this method, the age/gender profile of all households is assessed, leading to a theoretical daily energy requirement for each household. The household labour capacity is also estimated (adult male = 1, female = 0.8, young child capacity rises from 12-20 years, whereas contribution of elderly falls from 56-68 years). This allows calculation of a food/labour ratio and assessment of household vulnerability. AAH found that high food/labour ratios occur frequently in elderly-headed households, female-headed households and in households with orphans. One weakness of this approach is that it does not take into account wealth groups and different livelihood groups, or receipt of remittances. There is a need to crosscheck this targeting methodology with other, more traditional approaches.

Some of the recurrent problems that AAH faces are stigmatisation and reluctance to discuss HIV at all levels, and an apparent lack of successful programmes from which to learn. AAH are currently developing research protocols with the Institute of Child Health, London to look at the suitability of current therapeutic feeding protocols for HIV positive children with severe malnutrition, are investigating alternative nutritional treatments for children with HIV, e.g. lactose free products, and are looking into the need for alternative antibiotics. They are also working with the Ministry of Health in Malawi to improve quality of care and follow-up for HIV-affected individuals/households.

Summary of key issues raised

The afternoon session was devoted to a plenary group discussion of the issues raised in the presentations. Frances Mason from Oxfam summarised the main points to emerge from the presentations and the afternoon discussion.

• Labour constraints, as a result of loss of 'productive' adults, is obviously a major factor that needs to be considered in programming, but its importance in terms of impact on household food insecurity is still unclear.
• All presentations referred to the difficulty of finding alternatives to agricultural activities.
• Targeting of households is a huge challenge for a variety of reasons: stigmatisation, constant change in the composition of households, 'broad-brushing' of the characteristics of HIV-affected households (e.g. female-headed, elderly / child-headed, hosting orphans, etc.).
• How sustainable are the current programme approaches? AIDS is obviously a long-term issue and therefore, the programmes to address this should be long-term - what local links are we making to ensure the necessary sustainability of our programming?
• Most of the literature and debate focuses on programming in sub-Saharan Africa - there is also a need to consider programming outside of Africa.
• Are we just re-packaging 'standard' food security programmes? There is a danger that HIV could be an easy 'sticker' to justify intervention and to attract donor interest.
• All agencies need to consider issues of HIV/AIDS in relation to their own staff, ministry/partner staff, in terms of treatment/ prevention of HIV infection. There are issues around implementation of programmes in high prevalence areas, where many staff are infected, i.e. knowledge retention, investment in training, etc.
• There is very little information available on successes and failures of programmes. There is an urgent need to determine the effectiveness of programmes designed to mitigate the impacts of HIV/AIDS on food security. How do we monitor this? And what do we monitor to measure the impact? What indicators should be used?

The plenary agreed that there is a need for a working group on HIV/AIDS and Food Security, which should become part of the UK HIV consortium. The consortium has since been approached and is very keen to host the working group (including hosting meetings and a space on their website). The working group's broad remit would be to consider how food security programmes need adapting in relation to HIV/AIDS, and to plan actions, research, and programming accordingly. The group should encourage field-based agencies/staff to contribute experiences via media like Field Exchange.

If you are interested in joining the working group, contact Laura Phelps, email: lphelps@oxfam.org.uk or Rebecca Brown, email: r.brown@aahuk.org

¹Harvey, P. HIV/AIDS: What are the implications for humanitarian action? A Literature Review (draft). July 2003, ODI HPN. See HIV/AIDS, food security and humanitarian action: a resource guide, http://www.odi.org.uk/hpg/aidsresources.html

²Field Exchange Issue 19, HIV/AIDS Home Based Care in Zimbabwe, p4-6