ENN in the Field - Editorial by Mary Corbett

Editorial

Mary Corbett is a food security and nutrition consultant who visited southern Africa on behalf of ENN in early 2005.

When approached to be part of a team to collect material for a special edition of Field Exchange focusing on HIV/AIDS and nutrition/food security, I was extremely excited and felt it would be a great learning opportunity. At an ENN planning meeting, we decided to only attempt focusing on Africa and in particular, the Horn and Southern Africa. Again, we had to narrow this down to a small number of countries and try to pull out experiences from a manageable number of programmes, given a limited travel time of approximately six weeks. The initial planning started in late 2004 and involved contacting agencies and pencilling in meetings and potential projects to be visited.

The field trip started with regional meetings in Johannesburg in early January 2005. From here I moved onto Malawi for a very hectic two weeks, rounded off by a trip to the airport for a non-existent flight to Zambia. In some ways, an extra two days to tie down and write up findings from the Malawi trip was welcome, but it did mean the Zambian trip was shorter than initially planned. However, with good co-operation, I still managed to see quite a lot of people and some interesting programmes. On to Kenya and though a mere four day trip that included a week-end, was extremely fortunate to make it to western Kenya to see a very dynamic local organisation. This was largely due to the support of WFP. But, again, we had flight problems. As I rocked up for the Friday evening flight out of western Kenya, I found that it was over-booked by 29 people and I was rescheduled to the early morning flight on Saturday. I finished off my travels with two weeks in Uganda, again achieving a substantial amount due to all the support from implementing partners on the ground.

Working as an independent consultant meant that I missed the usual luxury of an agency picking me up from the airport, having accomodation organised for me, and my itinerary all planned. Basically, I had to organise my own itinerary within a very tight timeframe. Therefore I spent some time haggling with taxis, trying to book accommodation prior to arrival (some of the lodgings proving a bit dodgy), and actively locating people/agencies in order to set up meetings. However, thanks to a number of good friends in the region, my trip was made much more successful than it might have been. I really appreciate their support and hospitality in providing food and accommodation. Furthermore, WFP was extremely supportive in terms of planning, organising and taking time out to travel to the field with me. Many of the implementing agencies were also extremely helpful, very honest and openly discussed issues.

At times, people were a little surprised at my focus on HIV/AIDS and nutrition/food security. To many it seemed so logical that there should be integrated programming, and that this should be part of a programme approach, that there was really little need to discuss a rationale. However, in my fieldwork I found these assumptions not to be the case. In a region with very high levels of HIV prevalence - 10-20% in many countries - and underlying poverty affecting between 40-60% of the population, food security in many households is currently a major issue. This places an extra stress on the household, already marginalised by HIV. Furthermore, many households are made even more food insecure as a result of hosting orphans from HIV affected families.

Although all the countries visited during this trip have many similarities, there are also significant differences. Generalisations about programme approach are, therefore, not wise. For example, in Uganda where there has been a culture of awareness and openness around HIV for almost two decades, prevalence is now down to around 6.2% and targeting is much easier (stigma is reduced but still present). Furthermore, there are more facilities for testing for HIV. Indeed some of the programmes will only admit beneficiaries if they have documentation to show they have been tested. This contrasts with other countries visited where testing is not available countrywide (e.g. Malawi) and stigma is more prominent so that proxy indicators, such as chronic illness, are used for programming purposes.

It is really very difficult to target 'chronic illness' and it probably leads to both high levels of inclusion and exclusion error. In one programme, where chronic illness was the initial criteria, beneficiaries were offered VCT due to the potential introduction of ARVs. Around 20% of these chronically ill tested HIV negative. Some were upset to know their status, as it meant they would lose the resources they were receiving. This seems amazing, as they should be delighted to be HIV negative. This suggests many of these people are living in a state of chronic poverty and need to be supported, even if not under this particular type of programme.

When visiting programmes, in particular those with HIV positive and TB affected beneficiaries, there was huge gratification for the food component. Over and over people said to me that the food had "saved their lives". They often testified to their poor health status prior to receiving the food, stating that many of them were now back to living well, had regained weight and were in relatively good health. Although these testimonies are anecdotal, they are nonetheless important and need to be documented with other relevant data collection.

In the case of patients with TB, many present with moderate or severe malnutrition. A study completed in Malawi of 1181 TB patients found that 80% were HIV positive and that 57% of the cases were malnourished¹. Mortality was closely associated with severity of malnutrition, with higher rates in the moderate to severe group (early mortality within 4 weeks). This highlights the need for targeted nutrition support for this group. In general, once patients enroll on TB treatment, they report that their appetites improve rapidly. If they have little food in the household, it is a major problem for them and can result in failure to comply with the treatment. In some programmes, compliance has been noted to improve with food aid support.

Implementing partners are grappling with project inclusion criteria throughout the region. Some programmes use externally imposed targeting criteria for individuals, while others, particularly in rural areas, are more dependant on community targeting. The rural and urban context can be extremely different. However, in nearly all programmes, although exit strategies are recognised as necessary, they are only being discussed (rather than implemented) at present. In general, there is a feeling that there needs to be some sort of time frame for inclusion in a food assistance programme but at the same time, there needs to be flexibility, especially given the difference in vulnerability between beneficiaries.

For most implementing partners, the programmes are intended to be comprehensive; addressing immediate needs in the form of food assistance (safety nets), and then more longterm food security assistance in the form of income generation, loans and agriculture inputs. Implementing partners also recognise that the health component is essential, some agencies link in with either the MOH or other health focused implementing partners. There is continual learning with many innovative types of programmes being piloted. At the same time, many of the more traditional skill training programmes, such as tailoring and carpentry, are also in place. Projects aimed at strengthening marketing are also being looked at by some agencies, particularly those working in rural areas.

The introduction of ARVs is going to dramatically change the dynamics around HIV/AIDS. ARVs are already allowing people to live longer with AIDS. However, the rollout needs to be carefully handled. In many of these resource poor countries where the health infrastructure is extremely limited, adding the ARVs programmes to health care will stretch an already limited health care capacity. Other components of the care and support to PLWHA need to be in place in order to support compliance with ARV regimes. These components include basic health care, good nutrition support and food security. It is recognised that PLWHA require at least 10% more energy daily, but when sick with opportunistic infections, this requirement is increased even further. The opportunistic infections often reduce appetite and therefore can lead to rapid weight and weakening of an already weak immune system. Therefore good nutrition is a major factor in good health, particularly with this vulnerable group.

FFW road rehabilitation, Nsanje

Recent studies in Zambia² and Cote d'Ivoire³ have shown substantial reduction in mortality and hospital admissions for PLWHA after the introduction of cotrimoxazole as a daily prophylaxis. The objective of introducing cotrimoxazole is to reduce risk to opportunistic infections. The overwhelming evidence has led WHO/UNAIDS to provisionally recommend that all PLWHA in Africa should receive prophylactic cotrimoxazole as part of the minimum package. However this minimum package, in general, is not being offered. Some PLWHA, who are well informed and can afford the drug, buy it themselves. However, even at a cost of about a dollar a month, this is not affordable for many very poor people. Arguments for investing in prevention appear unchallengeable if one weighs up the cost of a prophylaxis against the benefits, i.e. improved well being of clients, fewer illnesses and less weight loss so that PLWHA remain well, and therefore productive, for longer. Also, infected individuals may not require ARV's until much later in their illness, resulting in cost savings.

Where activities are being focussed on three by five initiatives (to have 3 million people on ARV's by end of 2005), it is extremely important that this does not become the priority to the detriment of all other support to PLWHA and their families. It is important to adopt a holistic approach, supporting nutrition, food security and health care in conjunction with ARV rollout. It is essential to keep people well for as long as possible so that they can support their families.

I had the privilege of meeting families where a member was HIV positive, who, with the many types of support being offered - food aid, spiritual/ psychosocial support and food security activities - were actually "planning for the future". One particular family we visited in Uganda, where both the mother and father were HIV positive, had enough cassava planted for at least a year and were proudly able to tell us that their eldest daughter was preparing to go to teacher training college. Their inspirational energy showed the power of a well targeted programme, offering a variety of support to keep a family unit intact and giving people hope for the future.

Mary Corbett

¹Zachariah R et al, 2002. Moderate to severe malnutrition in patients with TB is a risk factor associated with early death. Trans Royal Soc Trop Med and Hygiene (2002) 96, 291-94

² Chintu C et al, (2004). Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): a double-blind randomized placebo-controlled trial. Lancet, 364, 1865-1871.

³Anglaret X et al, 2003 Pattern of bacterial diseases in a cohort of HIV-1 infected adults receiving cotrimoxazole prophylaxis in Abidjan, Cote d'Ivoire, AIDS 2003,17:575-584