From Durban to Lusaka Ensuring Food and Nutrition Security in the Time of AIDS Stuart Gillespie International Food Policy Research Institute Africa Forum, Lusaka, 8 May 2006

HIV and AIDS Food and nutrition insecurity Food and nutrition insecurity - chronic - chronic - acute - acute

Vulnerability of Livelihood Systems Vulnerable Groups - Orphans, Elderly and Youth Headed Households, Effect on Institutions Community-based, Civil society, Market, State, Global Outcomes Nutrition, Food Security, Education, Community Cohesion, Income Effect on Assets Human, Financial, Social, Natural, Physical, Political Responses Individual, Household, Community Susceptibility HIV Stigma and Discrimination

HIV/AIDS and Food and Nutrition Security From Evidence to Action An international conference Durban, South Africa 14–16 April 2005

PART ONE: INTERACTIONS AND IMPACTS Upstream: does food and nutrition insecurity hasten the spread of HIV? Downstream: does HIV/AIDS exacerbate or precipitate food and nutrition insecurity?

What determines susceptibility to HIV infection? “The microbe is nothing, the terrain everything” (Louis Pasteur, 1850) “In fact it is hunger that is leading to the rise in HIV infections in this area” (Religious leader in Vizimba, from CARE Malawi/RENEWAL 2004 “Poverty leads to hunger that leads to unprotected sexual encounters that leads to HIV/AIDS that leads to an increased number of orphans that leads to hunger again. This is a vicious cycle we are enclosed in.” (Dzama VAC, FGD, from CARE Malawi/RENEWAL 2004)

Food and nutrition insecurity HIV May increase exposure to the virus Increases mobility/migration (“looking for food”) Exacerbates gender inequality HIV/AIDS as an occupational hazard –Shifting livelihoods in Malawi (ganyu and sex) Ag. development may create nodes of risk (e.g. evening markets, trading centers) HIV/AIDS as a domestic hazard –Intra-household clustering of infection –Parasitic infestation when collecting water Reduced access to, and ability to use, information Food insecurity increases risk of malnutrition which may increase risk of infection

Malnutrition  HIV infection  Malnutrition compromises immune function  increases risk of genital ulcers, STDs, mastitis  increases risk of mother-to-child transmission  Vitamins B, C and E and immune function  Intergenerational transmission of malnutrition (LBW, prematurity) reduces infant gastrointestinal integrity and increases MTCT risk

HIV/AIDS Food and nutrition insecurity Who is impacted? Why? Vulnerability to AIDS impacts determined by status, conditions and inability to adapt to change Multiple, entwined processes of change lead to dynamic vulnerability Mortality x Vulnerability = Impact Impacts are revealed in responses that people make Is this “coping”?

Impacts of HIV and AIDS on agriculture Subsistence, commercial, and agricultural extension Resource (e.g. cash, labor) shortages and reduced productivity - affects land use (crops, diversity, yields, livestock) - move to low input/low output farming - natural resource mining - child labor Loss of farm-specific knowledge - less intra-household learning (inexperienced farmers) - greater risk aversion to new technology - less appropriate farming practices in more hostile environment (less schooling due to dropout & teacher mortality) Institutional capacity and organizational change -loss of formal and informal institutional capacity - weaker rural organizations - changes in cultural norms, property rights

The Vicious Cycle of Malnutrition and HIV Insufficient dietary intake Malabsorption, diarrhea Altered metabolism and nutrient storage Increased HIV replication Hastened disease progression Increased morbidity Increased oxidative stress Immune suppression Nutritional deficiencies Source:Sembaand Tang, 1999

HIV/AIDS, poverty and inequality Mismatch between micro and macro impacts For food and nutrition security, should we be so concerned about macro-level aggregates or means? Focus on poverty and inequality AIDS and poverty are converging, though HIV still spreads in higher-income groups. AIDS is worsening inequality (socio-economic, gender) Even AIDS programs can worsen inequality –Free formula to AFASS mothers

Stigma, poverty and disclosure Stigma and poverty mutually reinforcing As social networks in poorest communities erode and collapse, stigma is becoming a distress response of the overwhelmed, a ‘survival strategy’ for some affected households Depending on social environment, disclosure of HIV status may be a gateway to positive coping, or to social exclusion

PART TWO: RESPONSES Simultaneously: 1.Strengthen household and community: - resistance to HIV and - resilience to AIDS 2.Preserve and enhance livelihood options and strategies - incentives for community mobilisation and development - address real constraints (labor-saving or cash-saving?) 3.Social protection -more than “safety nets” -children affected by HIV and AIDS

Dynamics of the epidemic

Prevalence Impacts Time Impacts Prevalence Focus: resistance Focus: …+ resilience prevention mitigation

Development - Relief - Rehabilitation Development Rehabilitation Relief

Community-driven approaches Communities are responding They have incentives, local information, transparency, accountability, latent capacity -- but they lack power and resources. HIV/AIDS is crosscutting, multisectoral, horizontal......…just like people’s lives. Experience to build on (nutrition, CDD) Community-government partnerships

Pillars of local and community–driven development Local government Communities and NGOS Sectors

Mainstreaming HIV/AIDS Why? –To increase the scale of the response to HIV/AIDS –To reverse AIDS-induced capacity decline –HIV epidemics are endogenous to livelihood systems, not exogenous –Many sectors both affect, and are affected by, AIDS –To exploit positive synergies between prevention, care, treatment and mitigation –Because original food and nutrition goals (and MDGs) will not be achieved unless implications are taken on board. How? –Embed core HIV indicators in M&E plans of development programs –Develop/refine tools for undertaking HIV-literate assessments, and developing HIV-responsive policies and programs.

Bifocal lens

Lens checklist 1.How does this policy affect community, household or individual: Susceptibility to HIV exposure? Vulnerability to the impacts of AIDS? 2.How serious and widespread are these effects? 3.Is policy still relevant and appropriate? 4.Are there unexploited opportunities to enhance: Resistance to HIV? Resilience to the impacts of AIDS? 5.How can this be done?

Interventions ARVS are not the (single) answer –Impending ARV resistance –5-10 window of opportunity…for those who can access drugs –Malnutrition may be narrowing this window –Need to innovate faster than the virus mutates Agriculture Community-based natural resource management Bio-structural interventions Home/community gardening Water, sanitation and environmental health Food aid Nutrition (links to WHO consultation)

Scaling Up LARGE-SCALE IMPACT CAPACITY ELEMENTS INSTITUTIONAL ARRANGEMENTS QUANTITATIVE FUNCTIONAL POLITICAL ORGANIZATIONAL PROJECT ACTIVITIES Sparks CONTEXT; - local - wider CONTEXT; - local - wider

From data to wisdom (Selvester and McLean)

The Regional Network on HIV/AIDS, Rural Livelihoods, and Food Security (RENEWAL) Facilitated by IFPRI, RENEWAL brings together national networks of  researchers,  policymakers,  public & private organizations, and  NGOs to focus on the interactions between HIV/AIDS and food and nutrition security.

Core pillars/processes of RENEWAL Action research Communications Capacity

RENEWAL active in Kenya, Uganda, Malawi, South Africa, Zambia

The Effects of HIV/AIDS on Agricultural Production Systems in Zambia: A Restudy CARE International Zambia International HIV/AIDS Alliance, FAO HIV/AIDS and Community Resilience in Zambia: Understanding the Implications for Food and Nutrition Policies Farming Systems Association of Zambia Ministry of Agriculture Michigan State University IFPRI Washington DC HIV/AIDS, Food and Nutrition Security in South Africa: Understanding and Responding University of Western Cape, South Africa IFPRI, Washington DC Promoting agricultural innovation in AIDS affected rural households in KwaZulu-Natal, South Africa Farmer Support Group, KwaZulu-Natal Vrije Universiteit, Amsterdam HIV/AIDS, land reform and land-based livelihoods in 3 provinces in South Africa Human Sciences Research Council, South Africa Impact of HIV/AIDS on inter- and intra- generational information flows among smallholder farmers, Malawi Chancellor College, Malawi ICRISAT-Malawi HIV/AIDS, rural livelihoods and depeasantisation in Malawi: finding pathways to social recovery CARE International Malawi Center of Social Research, Malawi University of Leiden, Netherlands Farming Systems and Resilience to HIV/AIDS in Malawi Institute for Policy Research and Analysis for Dialogue, Blantyre, Chancellor College First Phase RENEWAL Studies ( )

Dealing with vulnerability: parents efforts to secure the future of their children (regional) University of Cape Town, University of KwaZulu Natal, IFPRI, Southern Africa Vulnerability Initiative (SAVI) Tuberculosis: An Additional Tipping Stress to Poor Households in South Africa and Zambia Stellenbosch University, S.Africa; University Teaching Hospital, Zambia HIV/AIDS, Food and Nutrition Security and Urban- Rural Linkages in Southern Africa IFPRI, RENEWAL, Southern African Migration Project Impact of a Nutrition Program for AIDS Patients and its role in their Coping Strategies in Western Kenya Moi University, AMPATH, IFPRI, Columbia University, USA, World Bank HIV/AIDS Mortality and the Role of Woodland Resources in the Maintenance of Household Food Security in Rural Limpopo Province, South Africa. SUNRAE Program; University of Witwatersrand, University of Colorado at Boulder, USA Gender Issues in HIV/AIDS and Food/Nutrition security among Internally Displaced People’s Camps in Uganda Makerere University Land Ownership and Food Security in Uganda: A Study of the Use and Control of Land Among Households of Women Affected by HIV/AIDS in Four Districts Makerere University and National Community of Women Living with HIV/AIDS The Effects on Rural Livelihoods of Increasing Rates of HIV/AIDS-related Illness and Death in Zomba South, Malawi Kennedy School of Government, Harvard University, Bunda College of Agriculture, Zomba Second Phase RENEWAL Studies ( )

Lessons and Challenges Beware AIDS exceptionalism –Use an HIV lens, not a filter Think livelihoods, not agriculture Beware “either/or” mentality –ARVs are not the (single) answer Face challenge of diversity, complexity, context-specificity Use/adapt tools to move from understanding to responding Evidence-based action (but don’t wait for last 5%!) Learn by doing (action research)…. …and by monitoring, evaluating and communicating Don’t use yesterday’s blanket solutions (“installed capacity”) Innovate, document and disseminate Balance quality, speed, capacity, but….…..think big! Scale up: –Focus on the process beyond the project, think about capacity and incentives. Aim for transformation, not exit strategies. Link research with action, both ways