On the ground perceptions of WFP food assistance and PMTCT in Zambia

Summary of a qualitative study¹

By Pamela Fergusson

The risk of mother to child transmission is approx 40% in Zambia

Pamela Fergusson is a dietitian/nutritionist whose research and practice areas include international community health, nutrition, food security and HIV. Pamela is currently lecturing in nutrition and dietetics in the UK and working on consultancies and research in southern Africa.

The author would like to acknowledge the contributions of the WFP Zambia office and WFP headquarters to this work.

The deadly triangle of interaction among malnutrition, infection and poverty has long been recognised. Nowhere is this interaction more apparent than in southern Africa. According to the 2004 UNAIDS Global report on the AIDS epidemic, sub-Saharan Africa is home to only 10% of the world's population, but almost two-thirds of all people living with HIV. The report also states that 57% of adults infected in the region are women, and 75% of young people infected are women and girls. This growing trend in the 'feminisation' of HIV represents an epidemiological shift in infection rates and modes of transmission, which has prevention, treatment and policy implications. As the prevalence increases among women, the risk of transmission from mother to child has become an important public health issue and is growing in significance as a route of transmission.

Research suggests that without interventions to prevent mother to child transmission, the risk of mother to child transmission in Zambia is approximately 40%². Considering the high HIV prevalence in Zambia, without intervention, about 41,000 babies annually will acquire HIV, which translates into about 112 new infections per day. The government of Zambia is rolling out services to prevent mother-to-child HIV transmission (PMTCT) across the country, and they are currently providing services at 83 sites with the cooperation of implementing partners.

Rationale for providing food and nutritional support through PMTCT programmes

In addition to their primary objective of preventing HIV transmission, PMTCT programmes also offer an opportunity to revitalise the broader system of antenatal care into which they are being integrated. With HIV testing facilities in place, health care providers have a unique opportunity to provide services to pregnant HIV positive women in the early stages of infection, and to reach their families. One of the main opportunities this early intervention provides is to establish positive dietary practices. Another opportunity is to provide food to women at a particularly vulnerable period of their lives. Very little is known about the dynamics between pregnancy, nutritional requirements, and HIV infection. However, HIV infection is known to increase energy requirements³, and studies have shown beneficial effects on birth outcomes of HIV+ women associated with supplementation of certain micronutrients⁴. Although it is conceivable that under nourishment may also reduce the efficacy of anti-retroviral drugs, there have been no studies to date of the relative efficacy of Nevirapine or AZT in preventing mother to child transmission in undernourished populations. There is, however, some evidence that low birth weight is associated with increased risk of HIV transmission from mother to child.

As a pilot initiative, the World Food Programme (WFP) partnered with PMTCT programmes being implemented at seven sites by the Government of Zambia, to provide food assistance. There are three major goals associated with food support to this programme: (1) to enable women to participate in the programme, thus supporting the existing intervention to prevent transmission, (2) to support women's nutritional status at a particularly vulnerable period of their lives, and (3) to gather operational and experiential information on the feasibility and acceptability of such a programme when linked to ongoing PMTCT services.

WFP field study

At the beginning of 2005, as part of an internship at the WFP Zambia field office, the author conducted an analysis of the role and impact of food aid in PMTCT programmes.

The analysis included evidence gathering through interviews, questionnaires, direct observation, document review and analysis of collected data. This article focuses on one part of the report, relating to the perceptions of beneficiaries, clinic staff and stakeholders of the role of food aid in PMTCT programming in Zambia.

Perceptions of beneficiaries

During clinic visits, beneficiaries were interviewed about their impressions of the impact of WFP food. Only one of the six beneficiaries interviewed was aware of food availability in the programme before coming to be tested, suggesting that, in this instance, food was not perceived to be an incentive for testing. In some smaller communities in Zambia, however, awareness of food ration distribution through the programmes is reported to be higher.

WFP has a policy that food should not be provided specifically as an incentive for HIV testing. Providing food to somebody who is food insecure as an incentive for testing can be seen as coercive- an approach that might force a person to disclose their status to the community and therefore place them at risk of stigma and abuse. The risk of abuse associated with HIV testing remains very real in many contexts; an abstract presented by Kusimba at the XV International AIDS Conference entitled 'Community Perception of PMTCT Services: the Kenyan Experience' found that the key barrier associated with non-use of PMTCT services was fear of testing positive, and the potential consequences of HIV positive status. The authors recommended that community sensitisation, service integration, and women's empowerment could help to minimise risks associated with PMTCT. These communication strategies are in place as part of this programme, however the issue of stigma must remain a consideration in programme planning.

Measures of food security include food adequacy and dietary diversity. Beneficiaries in the PMTCT programme said that WFP food was an important motivator in attending follow-up appointments. Women also reported that they were eating a greater variety of food, including more fruits, vegetables, soya beans, meats and eggs, and were eating more frequently. Although WFP was not distributing fruit, vegetables, meat or eggs, some beneficiaries said that the receipt of WFP food had enabled them to purchase some of these items themselves. This may have facilitated them to be able to take action on some of the nutritional education that they receive as part of services. One woman said, "We have been taught about a balanced diet. I make an effort to eat more green vegetables and beans." Another woman said, "We know that we have food in the house. We used to think, if this mealie meal finished, where are we going to get the food from?" Four of the six women said they felt they had gained weight as a result of the food rations, and all of the beneficiaries said they felt healthier because of the food. This last response could indicate a perceived increase in quality of life due to the food. Pursuing further assessment of the impact of WFP support on quality of life, using qualitative research methods with beneficiaries, would be a good direction for further research.

Perceptions of PMTCT clinic staff

A workshop-based training session of staff members was carried out, involving nurses and nutritionists working directly with women and families involved in the PMTCT programmes at Zambian Ministry of Health, and several MTCT clinics in Lusaka. A 'problem tree' was developed on perceived problems related to nutrition and food security faced by women in the PMTCT programme (see figure 1). The participants wrote these problems on cards, and then arranged the cards on the wall with the problem they felt was most central in the middle. The staff chose poverty as the central problem. Problems below poverty in the problem tree are seen as root problems, or causes, and problems above poverty were branch or effect problems on the problem tree. Problems clustered around the problem of poverty were seen as most closely related to the central problem.

Participating staff were also asked, as part of a second exercise, to put forward objectives for the WFP food support of PMTCT programme. The objectives they suggested were:

• To promote good nutrition to all pregnant women in the PMTCT programme
• To provide knowledge about preparing nutritious food, eg. balanced diet
• To provide knowledge and skills to health workers in PMTCT programme
• To provide food security to all pregnant women in PMTCT programmes
• To help have healthy babies.

A questionnaire on the effects of WFP food support was returned by fifty-five staff members from WFP supported PMTCT clinics, or clinics where training was provided in preparation for starting food support. Of these:

• 86.3% felt that the women's nutritional status improves because of the food
• 86.1% felt that the food encourages women to return to the clinic for follow-up
• 62.5% felt that the women are less likely to sell off assets because they have more food available at home
• 58.4% felt that the food encourages women to come to get tested
• 54.7% felt that women have healthier babies because of the food
• 51.1% felt that women are less vulnerable to engaging in high-risk behaviours because they have more food available at home.

Additionally, the respondents provided their own ideas of the impact of WFP food. Some of those comments included:

"It will help prevent early progression of HIV into AIDS"

"If the mother is healthy, the chances of transmitting the HIV virus in utero (while pregnant) to the baby will be minimised"

"Since we always teach them about the importance of diet, with food being supplied it will be very easy for the clients to understand the whole concept"

"Because the people in our programme are vulnerable. Right now we only give a mother PMTCT drugs and forget about her nutritional status in pregnancy and after delivery now with food we can help the mother a lot more."

"Yes - most people in our community can not afford three meals a day. At least if they can have soya porridge in the morning, then they may be able to have their regular meal in the evening."

"For those who might be single, divorced or widowed and have no source of income, it could help in sustaining them, and prevent them from infecting others whilst engaging in activities like sex to buy food."

Categorising clinic staff responses, 9% (4/44 points raised) were programme related, 14% (6/44) were HIV mitigation related, and 45% (20/44) were food and income security related.

The problem tree reflects that, for clinic staff, food and nutrition issues are complex, connected and far reaching. The questionnaire responses demonstrate that staff feel food assistance to PMTCT programmes can have a holistic impact, on clinical as well as social factors.

Perceptions of expert stakeholders

In order to access opinions from experts in the field of PMTCT both locally in Zambia and internationally, a questionnaire was sent to researchers, policy makers, clinical specialists, government officials and relevant UN employees. One of the four open-ended questions asked, 'what impact do you think WFP food assistance is having/could have on programmes to prevent mother to child transmission of HIV?' Of the eight responses to this question received, five were related to impacts on maternal and child health, specifically on nutritional status and breastfeeding, and three responses were related to programming and food security.

The sample of responses below illustrate the broad range of impact that expert stakeholders feel food assistance could have in PMTCT programmes.

"Lots of women are educated as to the importance of breastfeeding for the child's health but a low percentage of women are exclusively breastfeeding until 6 months in Zambia, partly due to mother's malnutrition. Food aid for lactating women coming from food insecure families can be an important factor contributing to promotion of breastfeeding."

"It is hard to convince people to take medicine and engage in health care if their basic needs are not being taken care of. When you are really sick with AIDS, your nutritional requirement goes up, if you give them medicine and not food it won't work. Before medicine has to come food, without food, medicine can only do so much."

"WFP food assistance supplements the woman's existing diet. A satisfactory diet contributes to good nutritional intake/absorption and satisfactory health throughout her pregnancy. To further elaborate on this statement, WFP food assistance contributes to steady weight gain throughout her pregnancy, enables proper foetal growth and development and, ensures that she receives vital micronutrients. In addition, food encourages a woman to take medications, i.e. short-course ARV [therapy]. Regular attendance to antenatal clinic ensures that she receives awareness and education on prevention, treatment and care of both herself and her infant (regardless of their HIV status)."

These responses show that stakeholders feel that the impact of food is broad, including improving rates of exclusive breastfeeding, improving health seeking behaviours amongst HIV infected people (such as intervention programme uptake and retention), as well as improving clinical outcomes for maternal and child health.

Conclusions

Through the perceptions gathered here from beneficiaries, staff, and expert stakeholders, we can see that food aid has a powerful potential for positive impact on prevention of mother to child transmission of HIV programming. The impact of food appears to be spread across the HIV response continuum of prevention, mitigation, treatment and care. There are potential risks, including food serving as an incentive for testing and the risk of developing dependence on food assistance. These risks can best be addressed through integration with other programmes and services, including comprehensive maternal and child health programmes, health education and capacity building projects, and income generating projects.

One of the stakeholders spoken to in Zambia had attended the 2004 International HIV conference in Bangkok. She said she had not realised, until discussing it at the conference, that only a few countries are operating PMTCT programmes with food assistance. She said, "WFP Zambia is at the forefront of food support and HIV. WFP is not there yet on a global level, and they need to be." Taking lessons learnt from food supported PMTCT programmes, and moving forward with increased coverage in high prevalence regions, could have a positive, pervasive, and broad impact on the future of prevention of mother to child transmission of HIV. We need to ensure, however, that we make the best use of our pilot programmes to systematically measure and document the impact of food on PMTCT. This will allow us to scale up with programme designs that are robust, sustainable, and do not have unintended negative effects, but rather, maximise the potential for food improving maternal and child health outcomes.

For further information on this study, contact Pamela Fergusson, email: p.fergusson@chester.ac.uk. For more information on WFP PMTCT related programmes, contact Andrew Thorne-Lyman, Public Health Nutrition Officer, WFP, email: andrew.thornelyman@wfp.org

¹Report: WFP food support of PMTCT programmes in Zambia: A situational analysis of the needs, response and impact.

²Zambian Ministry of Health Prevention of Mother to Child Transmission (PMTCT) protocol guidelines

³Nutrient requirements for people living with HIV/AIDS: Report of a Technical Consultation. WHO, 2003.

⁴ML Dreyfuss and WW Fawzi, 2002. Micronutrients and vertical transmission of HIV-1. American Journal of Clinical Nutrition, Vol. 75, No. 6, 959-970, June 2002