From Durban to Lusaka Ensuring Food and Nutrition Security in the Time of AIDS Stuart Gillespie

1. 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

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

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

6. 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?

7. 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)

8. 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

9. 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

10. 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”?

11. Impacts of HIV and AIDS on agriculture

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

13. 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

14. 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

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

16. Dynamics of the epidemic

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

18. Development Relief Rehabilitation Development - Relief - Rehabilitation

19. 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

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

21. 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.

22. Bifocal lens

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

24. 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)

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

26. From data to wisdom(Selvester and McLean)

27. 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.

28. Action research Capacity Communications Core pillars/processes of RENEWAL

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

30. First Phase RENEWAL Studies (2004-2006)

31. Second Phase RENEWAL Studies (2006-2008)

32. 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