HIV/AIDS and Food Security in Malawi

By Kathryn Lockwood, Martin Davidson Mtika and Richard Mmanga, CRS

Kathryn Lockwood is a nutritionist and is the Health and Nutrition Programme Manager for CRS/Malawi.

Martin Davidson Mtika is a public health specialist and is CRS/Malawi's Deputy Head of Programming responsible for Health, HIV/AIDS & Advocacy.

Richard Mmanga is CRS/Malawi's Senior HIV/AIDS Project Officer.

A field of crops as part of a food security project

Malawi, a land-locked country in southern Africa that is prone to food shortages, is bearing the full brunt of the African HIV/AIDS pandemic, while also struggling to strengthen its democratic institutions after 30 years under an extremely repressive dictatorial regime. In Malawi, where nearly 80 percent of households rely on agriculture as their major livelihood strategy, HIV/AIDS is having devastating consequences. However, by building on the existing capacity of local communities, Catholic Relief Services (CRS) programmes are creating positive changes in the lives of vulnerable Malawians.

CRS in Malawi

In 1997, the Episcopal Conference of Malawi (ECM) extended a formal invitation to CRS to work in Malawi. With this invitation, CRS first responded to the needs of Malawians through small-scale initiatives addressing food insecurity. Since then, over 60 national and international staff members, located in the main office in Lilongwe and sub-office in Blantyre, have contributed to the expansion of programming. Developments include long-term sustainable interventions in agriculture, health and nutrition, HIV/AIDS, justice and peace. CRS' primary implementing partners in Malawi include the Catholic Development Commission of Malawi (CADECOM) and the Catholic Commission for Justice and Peace (CCJP).

Context of programme approach

HIV/AIDS and related diseases are now the leading cause of adult mortality in Malawi. The National AIDS Commission (NAC) estimates that approximately 15 percent of Malawians among the most productive age group (15-49 years) are infected and, in urban areas, the level of infection in adults reaches 20 percent. Every year, as many as 100,000 new infections occur, and at least half of those are among people aged 15-24 years. The three greatest impacts of the HIV/AIDS pandemic in Malawi noted by NAC were:

• 800,000 of Malawian children under the age of 15 years have lost at least one parent to the disease
• the death rate has tripled since 1999
• the number of tuberculosis cases is three times higher than it would be without AIDS.

Households affected by HIV/AIDS - whether caring for and supporting orphans or a chronically ill relative or neighbour - represent a staggering 64 percent of the population in central Malawi. Loss of productive labour is the most direct and significant impact of HIV/AIDS on these rural households who rely on agriculture. Extremely poor and vulnerable households possess no excess capacity to survive additional burdens. HIV/AIDS is also diminishing the human capital of upcoming generations as children, particularly young girls, are taken out of school to care for sick family members or sent out to work in order to subsidise family income. This severely limits their ability to gain education and life skills. Intergenerational knowledge is also deteriorating as parents die before passing on wisdom and learning to their children.

Within this context, CRS/Malawi strives to support individuals affected by and infected with HIV/AIDS. The agency will continue to support initiatives that complement the goal of helping the people they serve to better cope with their situation through the following approaches:

• Improved quality and increased scope of community-based home care
• Increased support to orphaned and vulnerable children
• Empowerment for affected communities through integration of HIV/AIDS with other programmes
• Increased advocacy at all levels of society on addressing stigma and discrimination.

Dedza Integrated HIV/AIDS Project

A significant component of the CRS operation in Malawi is the Dedza Integrated HIV/AIDS Project. This has recently completed a three-year programme and intends to continue in the future with increased activities. The project is implemented in nine townships in Dedza, Ntcheu, and Salima Districts and strives to minimise the impact of HIV/AIDS within the Dedza Diocese. Through home-based care volunteers, infected and affected persons receive care and support and communities receive messages regarding HIV transmission. Additional components of the project include income-generating activities (IGA), distribution of food commodities to people living with HIV/AIDS, promotion of community-based HIV/AIDS education, and provision of vocational training for older orphans. The project has indirectly touched 200,000 of the 900,000 people living in the Dedza Diocese and has 6,000 direct beneficiaries, including orphans, chronically ill persons, widows, and HIV/AIDS infected families.

Home based care

Home-based care (HBC) is the main component of the Dedza Project. It is a community-based approach to providing health care and support to chronically ill persons and people living with HIV/AIDS (PLWHA). The programme operates in three deaneries, with each deanery comprising one HBC provider, one medically trained project officer, and 90 volunteers. The community identifies volunteers for the programme. The volunteers are both women and men and usually work in teams of two. Each volunteer supports three to five clients and makes at least one visit per week to a client. During client visits, the volunteer educates clients and other members in a household on primary health care, good nutrition, and HIV/AIDS prevention and transmission. The volunteer also assesses the condition of the client and provides basic medicines and other items to provide comfort. These items include pain relievers, malaria treatment, oral rehydration salts, antiseptic ointment, bandages, plastic sheets, gloves, and disinfectant. The volunteers will also do household tasks if necessary (e.g. sweep, clean, cook, fetch water and or firewood) depending on the condition of the patient.

Rearing rabbits as part of food security interventions

HBC volunteers regularly gather for refresher training on palliative and home-based care. At these meetings they have the opportunity to discuss any issues regarding their clients or workload. Traditionally, volunteers are permitted access to small-scale income generating activities in return for participating in the programme. In addition, the volunteers maintain an elevated social status and are respected within their communities. As such, the retention rate for the volunteers surpasses 90 percent, which is quite high for a HBC programme. Lack of adequate food security and not having sufficient medicines are the main problems that the majority of volunteers report on behalf of their clients.

Targeting beneficiaries

Communities select the HBC beneficiaries for the project. In general, the first layer of targeting for the project is relatively easy, as the communities identify households that have chronically ill household members. The volunteers then visit the household to determine if that household genuinely does have a chronically ill household member, and not just an individual suffering from a short-term disability. Communities readily accept this aspect of targeting in the project. However, it has become apparent that communities were unclear as to the targeting criteria surrounding the Orphan and Vulnerable Children (OVC) component of the project, which led to a low-level tension in the communities between beneficiary OVC households and non-beneficiary households. Given this, in the future the project will hold community education and sensitisation meetings with each of the targeted communities to clarify targeting criteria.

Obviously, some clients did not survive the full length of the project, and additional new clients needed assistance. Therefore, the same HBC clients did not remain in the project the entire time. However, community HBC volunteers largely remained the same, and the same communities were targeted throughout the life of the project.

Food aid component

Local food, mainly maize, pulses, and fortified grains, is regularly made available to extremely vulnerable households. HBC volunteers demonstrate meal preparation to households using these food items along with other locally produced foods. Soy milk and porridge preparation is a new activity for the project. Using approximately two kilograms of soy and nearly 2 litres of milk, enough porridge to feed a large household can be produced. Volunteers also prepare traditional meals with maize and show households how to increase nutrient values with locally grown items. Community gardens also contribute to the food supply for vulnerable households.

Income generating activities (IGAs)

The project also supports income-generating activities for older orphans and vulnerable children and households supporting chronically ill persons. Orphans and vulnerable children learn vocational skills such as sewing, tin smithing, and carpentry. Upon completion of coursework, they receive materials to get them started, such as basic tools and sewing machines. Household income-generating activities include rabbit breeding and agricultural production . The rabbits mainly serve as food and, as they reproduce, are distributed to other households, however they can be used as assets if needed. Agriculture extension workers introduce time- and cost-saving mechanisms to help increase crop production. Beneficiaries learn how to use manure or their own compost for fertilizing, crop rotation techniques, multi-cropping (growing different crops together in one field), and how to grow kitchen gardens. In some areas they also receive treadle pumps for irrigation. Based on the experiences beneficiaries have had selling vegetables in markets, they have decided to form cooperatives to increase their profits by reducing competition and working together to set prices. A new activity due to start this year is honey production, which can be sold in the market and consumed by chronically ill persons as an alternative to refined sugar.

Impact of programme

The end of project evaluation revealed that 43 percent of households in the target area reported benefiting from this project, an increase over the project's objective to provide care and support to at least 25 percent of people infected and affected by HIV/AIDS. The project also aimed to provide HIV/AIDS education in the targeted area. Household surveys during the project evaluation demonstrated that approximately 67 percent of the communities had benefited from education and prevention messages.

During the same evaluation, 95% of respondents reported that they required additional food security interventions. Specific needs articulated by PLWHA included increased agricultural inputs, additional income generating activities, augmented support for orphans, more access to medicines, and scaledup psychosocial support.

Women making soya milk

Interviews conducted by ENN with HBC staff in the field supported many of the CRS findings. For example, the main challenges identified by HBC volunteers included;

• Lack of food and food security for clients
• Lack of medicines (although volunteers have been taught about use of local herbs for treatment of illnesses associated with HIV/AIDS
• Lack of clothes
• Patient isolation
• Lack of transport

An interviewed HBC co-ordinator described elements of the programme considered to have worked well, in particular patient care, including medication, orphan care, skills training, educational support, community empowerment, and income generation.

Youth mobilisation remains a challenge, while forging linkages with health infrastructure although started late, has made some progress. Since a workshop with staff from all the health institutions in operational areas to sensitise them to the work being carried out by the HBC teams, some of the health centres now have an official referral letter so that patients can access health care. However it was felt that these linkages need to be strengthened further.

Future plans

CRS/Malawi plans to continue supporting this project in the future and is currently adjusting their activity plan in conjunction with CADECOM based on the evaluation. Namely, CRS and CADECOM are in the process of developing a more integrated food security and HIV/AIDS project. In addition, the organisations are slightly modifying and scaling-up other interventions based on the results of the endof- project evaluation.

One of the interventions the new project will scale-up is the OVC component of the project, which focuses on mitigating the impact of HIV/AIDS on OVC and their quality of life. CRS and CADECOM will integrate food security, protection, and psychosocial activities into the OVC components. In addition, CRS and CADECOM plan to work closely with the Malawian Ministry of Health to ensure collaboration with the Government's antiretroviral therapy (ART) rollout for current HBC clients.

For further information, contact: Kathryn Lockwood, CRS/Malawi, Private Bag B319, Lilongwe 3, Malawi. Tel: +265 1 755 534, email: klockwood@crsmalawi.org