Expert says HIV drugs give only 5-10 year window to come up with new ways to beat AIDS in Africa

Aidsmap, Theo Smart, April 26, 2005

Noted researcher Dr. Tony Barnett of the London School of Economics believes the potential transmission of viral resistance could quickly limit the effectiveness of antiretroviral treatment (ART) in Africa."Five-to ten-year is the window of opportunity we have," to find other responses to mitigate the impact of an HIV/AIDS endemic in Africa - which, according to Dr. Barnett "will be with us for the foreseeable future." Dr. Barnett made these statements during his keynote address at the International Conference on HIV/AIDS and Food and Nutrition Security, held last week in Durban, South Africa.

"The problem is, we don't know what to do with that 5-10 years. There is an urgent need for innovative solutions," said Dr. Barnett. But he fears that action could lead in the wrong direction if it is based upon 'simple stories' - narratives of the epidemic and its impact that have become accepted by policy makers, donors, opinion leaders and the research community.

"We do not have long-term evidence with the kind of detailed analysis which is necessary if we are to understand the complexity and diversity of the impact of the epidemic on rural society in Africa," said Barnett.

The story of HIV/AIDS in a rural Ugandan village Dr. Barnett himself helped establish one of the best-known narratives on the effects of HIV/AIDS in Africa. Early in the epidemic, Dr. Barnett evaluated the impact of HIV/AIDS on rural households in Uganda over the course of 1980-89. He observed that Ugandan families were losing their older children to illness, followed by the head of the household and then the mother falling ill. Over this period, farm productivity would fall. In the end, orphans would be left behind to run a child-headed household.

"For quite awhile, it became a story that was accepted as 'the truth.' And that story has appeared in various forms over the last fifteen years or so," said Dr. Barnett.

These stories led to predictions that Africa would experience:

*Labour shortages as a result from the impact of the epidemic on the productive age group

*A progressive decline of agricultural production and food capability

*A reduction of cultivated land area

*A reduction of crop portfolio

*A decay of infrastructure

*Reduced production and productivity

*And possibly, some have claimed, "famine"

"But we don't have are any long-term studies tracing the effects of HIV/AIDS on rural livelihoods and food security over the last 15 to 20 years," said Dr. Barnett.

Last year, Dr. Barnett went back to the same Ugandan village where he had worked in 1989." What he found was unexpected.

"The farming system had not collapsed," he said, "because there had been a profoundly moving and very strong community response. This is not a devastated community; this is a community where the farming system has remained intact."

Hard to generalise
"But this is just what happened in one place - in a very resilient farming system," Barnett continued. "What we don't know is what has happened in other systems that are less robust. There is probably a diversity of responses."

Less resilient agricultural systems are probably less able to cope with the impact of epidemic. But little is known about the "stories" from those communities.

Barnett explained that, until recently, there were few studies of how the HIV/AIDS epidemic has been affecting the wide range of rural environment and livelihoods in Africa, including fishing communities or animal herding regions.

But recently, there has been a upsurge in such research and much of the available data on the impact of the epidemic on rural livelihoods was reviewed in a recent meta-analysis (Gillespie and Kadiyala) published by the International Food Policy Research Institute (see www.ifpri.org).
Dr. Barnett noted that, "while the analysis found an indication of increasing inequalities in some societies, my reading is that it is actually hard to generalise for all of "Africa" or even "southern Africa."

He pointed out that it is also hard to isolate the causal influence of HIV/AIDS from other underlying environmental and policy conditions: "The epidemic may be a tipping point factor, but in many circumstances, it may not be the sole reason for the effects that we are seeing. We're dealing with an extremely complex set of causal links here - which may be different or nuanced from place to place," said Barnett.

"The challenge," he added, "is to recognise the diversity and to create large-scale responses that can cope with it."

"Governments, multilateral agencies, bilateral agencies have great difficulty in dealing with diversity," said Barnett. "It's very hard to have large programmes that take into account the complexity of the situation. One size does not fit all."

Pay attention to the pathogen
Barnett believes a better understanding of HIV virology could help prepare those planning responses to the epidemic.

For example, the average time from infection to AIDS is eight or nine years. Partly, as a result of this slow rate of disease progression, "the epidemic has shown itself to be both too slow and too fast for us to respond," said Barnett. "It's so slow that it's put on the backburner for a long time, and then it moves so fast that by the time you realise what is happening it's too late to do what you should have done ten years before."

And viral resistance may limit the effectiveness of our best available
intervention: ART. Resistance should be uncommon if effective regimens are administered to motivated individuals who have continuous access to treatment. But a very high rate of adherence is necessary to keep from developing resistance to the drugs.

Dr. Barnett thinks adherence could be difficult in rural areas where access is a problem - especially because treatment centres may be effectively inaccessible to many patients. Furthermore, in remote small communities there can be very little privacy and stigma which could act as a disincentive to adherence.

"How long before we see new epidemics of resistant HIV?" said Dr.
Barnett, "and when resistance comes, the big pharmaceutical companies will not respond hurriedly to Africa's need for a new generation of antiretrovirals - not after their experience with the last generation and the lowering of prices."

An unprecedented long wave crisis
"HIV/AIDS is not like other emergencies in food and nutrition - it is a long wave event, said Dr. Barnett. "We have to recognise that the entire balance between relief, rehabilitation and development work may have changed - in some communities. Policy, operations and thinking must switch into a new paradigm."

The disease has altered regional demographics, as well as the local social and economic circumstances in which policies and programmes will be operating. "We have to recognise that institutions on the ground may have short institutional memories," said Barnett "because people who are resourcing those institutions are younger and dying young. And we need to take into account that the institutions in which we work are themselves affected by the epidemic."

In addition, when people think that they may have limited life expectancy, it affects the decisions they make. It affects their investments and the effort they put into learning new techniques and new technologies. "How we introduce innovations, responses to the epidemic at a time when people are not living long enough and not healthy enough to adopt innovations?" said Dr. Barnett.

When the Black Death struck medieval Europe, the loss of the work force made new labour saving technologies practical. "But old solutions may no longer be appropriate in the context of changes brought on by the epidemic. For example, prevention has failed miserably in Africa," said Dr. Barnett. "What happened is that we went for already installed responses, condoms and vaccine development. What we didn't go for were microbicides, which are a gender specific, woman controlled response.
And now, in the third decade of the epidemic, we are just beginning to think seriously about testing microbicides."

The challenges, according to Dr. Barnett, are to understand the situation (rather than listen to the stories) "because this situation is unprecedented and unknown. We need to engage critically with established narratives.

"We have to consider the appropriateness of known technologies and approaches and think of new and innovative responses to a novel and changing situation," he concluded.

Source: ProNut- HIV, pronut-hiv@healthnet.org

TAC/AIDS Law Project (ALP) Statement on World Health Organization (WHO) Consultation on Nutrition and HIV/AIDS in Africa

"Improved social grants and scientifically accurate public information on nutrition, particularly HIV and nutrition, are essential to reduce food insecurity."
************

On 10-13 April 2005 in Durban, a number of international, regional and local organisations and scientific bodies from Eastern and Southern Africa met under the auspices of the WHO to discuss the nutritional aspects of treating persons living with HIV/AIDS in Africa.

The meeting was co-hosted by the South African National Department of Health. On Friday 15 April the Durban meeting issued a Participants' Statement. It is available at http://www.sahims.net/ and on the Treatment Action Campaign (TAC) website (http://www.tac.org.za/).

The Participants' Statement puts to rest unfounded allegations that adequate nutrition alone can cure HIV infection. It cannot. It is uncontroversial that nutrition is an essential part of managing HIV. The statement makes clear that:

**Both antiretrovirals (ARVs) and proper nutrition are essential in providing comprehensive care, treatment and support of persons living with HIV/AIDS.
**Nutrition alone cannot cure HIV infection.
**The life-saving benefits of ARVs are clearly recognised.
**Adequate nutrition is required to optimise the benefits of ARVs, which are essential to prolong the lives of people living with HIV and prevent HIV transmission from mother-to-child.

President Mbeki and Minister of Health Tshabalala-Msimang frequently cite the importance of nutrition in alleviating AIDS. However, the Minister's comments are often scientifically inaccurate, with her overemphasizing the importance of particular foods such as garlic, olive oil and the African Potato.

Both leaders also create the impression that nutrition is an alternative to antiretroviral treatment; it is not. Furthermore, there is little evidence of Department of Health action to improve nutrition in people with HIV based on science, despite the Minister's rhetoric.

TAC and ALP are conducting an investigation to see what nutritionbal interventions are being made available as part of the Operational Plan and whether they are sufficient and sustainable.The Durban meeting reached the following evidence based conclusions:

Nutrition and ARV interaction

The life-saving benefits of ARVs are clearly recognised.
** To achieve the full benefits of ARVs, adequate dietary intake is essential.
** Dietary and nutritional assessment is an essential part of comprehensive HIV care both before and during ARV treatment.

The Participants' Statement also notes that the long-term use of ARVs can be associated with metabolic complications (cardiovascular disease, diabetes and bone related problems). However, it unambiguously states that the benefits of ARVs far outweighs the risks and that metabolic complications need to be adequately managed. It made the following important recommendations:

** Interactions between nutrition and ARVs in chronically malnourished populations, severely malnourished children, and pregnant and lactating women need to be investigated.
** The effects of traditional remedies and dietary supplements on the safety and efficacy of ARV drugs need to be evaluated.

TAC and ALP also agree with the Participants' Statement that “there is a proliferation in the marketplace of untested diets and dietary therapies, which exploit fears, raise false hopes and further impoverish those infected and affected by HIV and AIDS”. In this respect, we agree that we must “strengthen the capacity of government and civil society to develop and monitor regulatory systems to prevent commercial marketing of untested diets, remedies, and therapies for HIV-infected adults and children”.

Micronutrients
** Micronutrient supplements are not an alternative to comprehensive HIV treatment including ARV therapy.
** Micronutrient intakes at daily-recommended levels need to be through consumption of diversified diets, fortified foods, and micronutrient supplementation as needed.

Macronutrients
** Adults and children living with HIV have increased energy needs compared with uninfected adults and children.
** However, there is no evidence for an increased need for protein intake of people living with HIV/AIDS over and above that required in a balanced diet to satisfy energy needs (12 to 15% of total energy intake).

Growth
** The growth and survival of children living with HIV is improved by prophylactic cotrimoxazole, ARVs and the early prevention and treatment of opportunistic infections.
** Improved dietary intake is essential to enable children to regain lost weight after opportunistic infection.

Pregnancy and Lactation
** Optimal nutrition of HIV-infected mothers during pregnancy and lactation increases weight gain, improves pregnancy and birth outcomes.

Infant and Young Child Feeding
** WHO/UNICEF recommend that HIV-infected mothers avoid breastfeeding when replacement feeding is acceptable, feasible, affordable, sustainable and safe. However these conditions are not easily met for the majority of mothers in the region. Early breastfeeding cessation is recommended for HIV-infected mothers and their infants. There is an immediate need to evaluate suitable ways of meeting nutritional needs of infants and young children who are no longer breastfed.

TAC and ALP Recommendations
We recognise that the nutritional needs of countries cannot be dealt with in isolation of prevailing food insecurity. We support the call of the conference to all governments, including our own, to implement urgent measures to “reverse the current trends in malnutrition, HIV infection and food insecurity in most countries in the region, in order to achieve the Millennium Development Goals”.

At least the following three critical interventions are needed to eliminate food insecurity in people with HIV in South Africa. The third of these is already implemented.

1. The social grant system is the most effective mechanism for ensuring people can afford to eat enough. The disability grant is insufficient, because it lapses if people commence antiretrovirals and recover, leaving them the insiduous choice between the grant or medicine. A nutrition grant for people with HIV would be problematic because it would create inequalities between people with and without HIV. A Basic Income Grant, or similar measure is therefore the only viable solution that has been offered.

2. Government must run a public information campaign providing accurate information on nutrition. The only accurate nutrition and HIV facts sheets for wide distribution that we are aware of are the two produced by Soul City and TAC. Government should use these fact sheets to produce radio, television and print media to convey useful nutritional information. Government should also resist the prevalent pseudo-scientific claims that exaggerate the usefulness of particular foods, such as garlic, or food-groups, such as vitamins, in alleviating HIV.

3. Government should continue to distribute multivitamins through public clinics to people with HIV. The balance of evidence suggests that multivitamins, in moderate doses, do have some benefit.

There are proposals and efforts to distribute food parcels and nutritional supplements, other than multivitamins, to people with HIV through clinics. This gives a greater degree of food security to people with HIV, TB and other serious illnesses. However, it should be seen as a medium-term measure because it leads to inequalities and tensions between recipients of these parcels and other poor people. The main challenge is to meet the food and income security needs of every poor household.

Source: TAC Electronic Newsletter - 26 April 2005

World Health Organization Consultation on Nutrition and HIV/AIDS in Africa: Participant's Statement

Durban, South Africa, 10–13 April 2005

Participants’ Statement
HIV/AIDS is affecting more people in eastern and southern Africa than our fragile health systems can treat, demoralizing more children than our educational systems can inspire, creating more orphans than communities can care for, wasting families and threatening our food systems. The HIV/AIDS epidemic is increasingly driven by and contributes to factors that also create malnutrition -in particular, poverty, emergencies and inequalities.
In urgent response to this situation, we call for the integration of nutrition into the essential package of care, treatment and support for people living with HIV/AIDS and efforts to prevent infection.

We recognize that,
1. Far reaching steps need to be taken to reverse the current trends in malnutrition, HIV-infection and food insecurity in most countries in the region, in order to achieve the Millennium Development Goals.
2. Adequate nutrition cannot cure HIV infection but it is essential to maintain the immune system and physical activity, and to achieve optimal quality of life.
3. Adequate nutrition is required to optimize the benefits of antiretroviral drugs (ARVs), which are essential to prolong the lives of HIV-infected people and prevent HIV transmission from mother-to-child.
4. There is a proliferation in the marketplace of untested diets and dietary therapies, which exploit fears, raise false hopes and further impoverish those infected and affected by HIV and AIDS.
5. Exceptional measures are needed to ensure the health and well-being of all children affected and made vulnerable by HIV/AIDS. Young girls are especially at risk.
6. Knowledge of HIV status is important to inform reproductive health and child feeding choices.


Conclusions
This consultation reviewed the scientific evidence and discussed the programmatic experience on nutrition and HIV/AIDS and has come to the following conclusions:

Macronutrients
* HIV-infected adults and children have increased energy needs compared with uninfected adults and children. Energy needs increase by 10 percent in asymptomatic HIV-infected adults and children. Energy needs for adults suffering from more advanced disease are increased by 20 to 30%. In HIV-infected children experiencing weight loss, energy needs are increased by 50 to 100%.
* There is no evidence for an increased need for protein intake of people infected by HIV/AIDS over and above that required in a balanced diet to satisfy energy needs (12 to 15% of total energy intake).
* Loss of appetite and poor dietary intake are important causes of weight loss associated with HIV infection. Effective ways of improving dietary intakes need development and documentation.


Micronutrients
* Micronutrient deficiencies are frequently present in HIV-infected adults and children.
* Micronutrient intakes at daily recommended levels need to be assured in HIV-infected adults and children through consumption of diversified diets, fortified foods, and micronutrient supplementation as needed.
* WHO recommendations on vitamin A, zinc, iron, folate and multiple micronutrient supplements remain the same.
* Studies have shown that some micronutrient supplements may prevent HIV disease progression and adverse pregnancy outcomes. Additional research is urgently required.

Pregnancy and Lactation
* Pregnancy and lactation do not hasten the progression of HIV infection to AIDS.
* Optimal nutrition of HIV-infected mothers during pregnancy and lactation increases weight gain, and improves pregnancy and birth outcomes.
* HIV-infected pregnant women gain less weight and experience more frequent micronutrient deficiencies.

Growth
* HIV infection impairs the growth of children early in life. Growth faltering is often observed even before the onset of symptomatic HIV infection. Poor growth is associated with increased risk of mortality.
* Viral load, chronic diarrhoea and other opportunistic infections impair growth in HIV-infected children. The growth and survival of HIV-infected children is improved by prophylactic cotrimoxazole, ARV therapy and the early prevention and treatment of opportunistic infections. * Improved dietary intake is essential to enable children to regain lost weight after opportunistic infection.

Infant and Young Child Feeding
* For HIV-uninfected mothers and mothers who do not know their HIV status, exclusive breastfeeding for six months is the ideal practice because of its benefits for improved growth, development and reduced childhood infections. Safe and appropriate complementary feeding and continued breastfeeding for 24 months and beyond is recommended.
* The risk of HIV transmission through breastmilk is constant throughout the period of breastfeeding and is greatest among women newly infected or with advanced disease.
Studies further support that exclusive breastfeeding is associated with less HIV transmission than mixed breastfeeding.
* WHO/UNICEF recommend that HIV-infected mothers avoid breastfeeding when replacement feeding is acceptable, feasible, affordable, sustainable and safe. However these conditions are not easily met for the majority of mothers in the region.
* Evidence shows that safer infant feeding can be achieved with adequate support, however health systems and communities are not providing this support to make infant feeding safer.
* Early breastfeeding cessation is recommended for HIV-infected mothers and their infants. *The age for breastfeeding cessation depends on the individual circumstances of mothers and their infants. The consequences of this on transmission, mortality, growth and development need to be urgently studied. There is an immediate need to evaluate suitable ways of meeting nutritional needs of infants and young children who are no longer breastfed.

Nutrition and ARV interaction
* The life-saving benefits of ARVs are clearly recognized. To achieve the full benefits of ARVs, adequate dietary intake is essential.
* Dietary and nutritional assessment is an essential part of comprehensive HIV care both before and during ARV treatment.
* Long term use of ARVs can be associated with metabolic complications (cardiovascular disease, diabetes and bone related problems). The value of ARV therapy far outweighs the risks and the metabolic complications need to be adequately managed. The challenge is how best to apply that extensive clinical experience in managing these types of metabolic disorders in HIV infected adults and children in Africa.
* Interactions between nutrition and ARVs in chronically malnourished populations, severely malnourished children, and pregnant and lactating women need to be investigated.
* The effects of traditional remedies and dietary supplements on the safety and efficacy of ARV drugs need to be evaluated.

Recommendations for Action
Based on these conclusions all concerned parties are urged to make nutrition an integral part of their response to the challenges of the HIV/AIDS pandemic and the following recommendations are made for immediate implementation at all levels:

1. Strengthen political commitment and improve the positioning of nutrition in national policies and programmes.

* Use existing and develop new advocacy tools to sensitize decision-makers about the urgency of the problem, the impact on development targets and the opportunity to improve care.
* Advocate for increased resource allocation and support for improved nutrition, in general, and for addressing the nutritional needs of HIV-affected and infected populations.
* Prioritize the needs of children affected and made vulnerable by HIV/AIDS.
Clarify and improve multisectoral collaboration and coordination between agriculture, health, social services, education and nutrition.

2. Develop practical nutrition assessment tools and guidelines for home, community, health facility-based and emergency programmes

* Validate simple tools to assess diet and supplement use including traditional and alternative therapies, nutritional status, and food security so that nutrition support provided within HIV programmes is appropriate to individual needs.
* Develop standard and specific guidelines for nutritional care of individuals, and implementation of programmes at health-facility and community levels.
* Review and update existing guidelines to include nutrition/HIV considerations (e.g., integrated management of adolescent and adult illness, ARV treatment, nutrition in emergencies).

3. Scale-up existing interventions for improving nutrition in the context of HIV

* Accelerate the implementation of the Global Strategy for Infant and Young Child Feeding.
* Renew support for the Baby-friendly Hospital Initiative.
* Accelerate the fortification of staple foods with essential micronutrients.
* Implement WHO protocols for vitamin A, iron, folate, zinc, multiple micronutrient supplementation and management of severe malnutrition.
* Accelerate training and use of guidelines and tools for infant feeding counselling and maternal nutrition in prevention of mother-to-child transmission programmes
* Expand access to HIV counselling and testing so that individuals can make informed decisions and receive appropriate advice and support on nutrition, including in emergency settings.

4. Conduct systematic operational and clinical research to support evidence-based programming

* Develop and implement operational and clinical research to identify effective interventions and strategies for improving nutrition of HIV-infected and affected adults and children.
* Document and publish results and ensure access to lessons learned at all levels.
* Encourage scientific journals to give greater opportunity for publication of operational research and records of good practice.

5. Strengthen, develop and protect human capacity and skills.

* Include funding for nutrition capacity development in HIV scale-up plans.
* Incorporate nutrition into training, including pre-service training, of health, community and home-based care workers. Specific skills such as nutritional assessment and counselling, and programme monitoring and evaluation should be included. Such training should be not favour particular commercial interests.
* Strengthen the capacity of government and civil society to develop and monitor regulatory systems to prevent commercial marketing of untested diets, remedies, and therapies for HIV-infected adults and children.
* Improve the conditions of service and coverage of health workers, especially dieticians and nutritionists, to deliver nutritional services.
* Identify and utilize local expertise to improve response to emergency conditions.

6. Incorporate nutrition indicators into HIV/AIDS monitoring and evaluation plans

* Include appropriate nutrition process and impact indicators for clinical and community surveillance, and for national, regional, and international progress reporting.

***
Source: www.sahims.net

The Best Defense against AIDS, In the Long Run, Will Be Economic

by Christina Scott , Inter Press Service, April 18, 2005

DURBAN, South Africa--If one wants to find out how AIDS is increasing hunger and malnutrition, one can expect to harvest an abundance of depressing information. But soon, this may change.

‘'In the last five years alone, there have been about 500 different papers on food and nutrition security related to AIDS,'' said Stuart Gillespie of the Washington-based International Food Policy Research Institute (IFPRI), now marking its third decade of work.

AIDS intensifies poverty in many devastating ways. Ailing farmers do not plough their fields, or pass on their knowledge of seeds and seasons to the next generation. Desperate widows are more likely to sell their bodies for sex in order to feed their children. The sick need more high-quality food than before, but find it far more difficult to eat.

Rural families reliant on money sent home by a relative working in the city suddenly find themselves with no source of income. The few people who receive life-prolonging anti-retroviral drugs (ARVs) may find that the medication is severely handicapped without expensive vitamin supplements and other food aid.

And while the richer portion of the population may make the most noise about HIV/AIDS, the poorest suffer the most.

‘'Rural people in particular adopt hedging strategies against risk, but the multiple shocks and strains lead to their collapse,'' noted Joseph Tumushabe, consultant to the Ethiopia-based United Nations Economic Commission for Africa (ECA). ‘'Rural people don't get remittances any more. They get bodies. They get orphans. They get the sick.''

Yet there are success stories. In Tanzania, human rights lawyers brought court cases on behalf of dispossessed widows and orphans that the government changed the laws of inheritance so that land and possessions did not all flow in the direction of the brothers of the deceased.

In parts of India, people researching small-scale agricultural improvements - merely plugging gullies to prevent further erosion, for example - found to their surprise that this could have a discernible knock-on impact on disease trends.

Even though there are creative ways to fill the empty stomachs triggered by the AIDS epidemic, tracking down success stories requires a lot of detective work.

One of the problems facing isolated community organisations and lobby groups is that they are simply too busy helping people to document their efforts in ways that satisfy sceptical academics and funders, who like to point out that drought, famine, politics and globalisation can also cause devastating hunger and malnutrition. In the meantime, the virus is hunting for new homes.

In addition, most small, cash-strapped organisations are not in a position to tell others facing the same issues about their attempts to solve the problem. So the epidemic spreads but solutions stay at home.

‘'Where organisations have launched actions that address these interactions between HIV/AIDS and food insecurity, they have tended to be in isolation,'' confirmed Gillespie, a nutritionist by training. ‘'They are rarely monitored and evaluated.''

For this reason, he organised an international conference on HIV/AIDS and food and nutrition security in South Africa's port city of Durban, which wrapped up Apr. 18 with a news conference in the commercial hub of Johannesburg.

The subtitle of the conference made Gillespie's intentions clear: it was called ‘'from evidence to action.'' While some academics muttered to each other at tea breaks about the need for more information, many government representatives noted that delays simply allowed the disease to continue dragging down progress on a variety of fronts.

The economic impact is already present. ‘'It is estimated that by 2010, the gross domestic product of Tanzania will be 15 to 20 percent lower than it would have been without AIDS,'' Tumushabe said. ‘'And this is despite steady economic growth.''

Gladys Mutangadura, an economics affairs officer with the United Nations in Zambia, noted that if a cure for AIDS was found today, its devastating destruction would linger for decades, like an earthquake or a tsunami.

However, some researchers took a more optimistic view, noting that HIV/AIDS provides a window of opportunity for assisting the poorest of the poor - not for charitable reasons, but to defend the rich against the spread of the disease. The best defence against AIDS, in the long run, will be economic - but there are many paths to this mountaintop.

Sub-Saharan Africa will play an important role in charting the way forward, particularly for Asian countries which are equally dependent on subsistence agriculture but lag behind the continent in terms of the epidemic's lifespan.

‘'South Asia is fertile terrain, both for the spread of the virus and for its damaging interactions with food and nutrition security,'' Gillespie predicted. ‘'It is imperative that future work extends beyond Africa in order to be better prepared in other areas where such impacts may soon be experienced.''

Turf wars were evident at the conference. Gender activists expressed surprise that anyone else could possibly be surprised when Kenyan research showed men objecting to their women moving from food crops to attractive market crops such as sugar cane in order to cope with the economic devastation wreaked by HIV/AIDS. Drugs versus food was an issue for South Africans who knew that their rollout of anti- retroviral drugs has been delayed amidst bizarre advice from the Ministry of Health suggesting that patients should eat more olive oil, local potatoes and lemons. Both are important, Gillespie said.

Meanwhile, small-scale agriculture specialists closely involved with getting HIV/AIDS patients to grow more nutritious crops bristled when economists suggested that it was more effective for farmers to grow high-value crops and buy what they needed instead.

Environmentalists suspicious of genetically modified food aid tried to bring their debates into this arena, only to be corrected by the development consultant Tumushabe. ‘'The type of food eaten by HIV-positive people in Africa is not the issue,'' he tartly told a news conference. ‘'The question is whether they are accessing food at all.''

So in part, the conference mission was to persuade various participants to work together. Michael Loevinsohn, an ecologist with the RENEWAL regional network on AIDS and rural livelihoods in east and southern Africa, summed it up when he said, ‘'weaken one link, and you weaken them all.''

For him, the problem is that while AIDS cuts across health and agriculture, trade and industry, these are all separate government departments - and frequently separate non-governmental organisations as well - accustomed to independence and a narrow window of expertise. But each is doomed to failure if it does not work AIDS into its policy.

Gillespie wants everyone trying to tackle poverty, in what ever way, to use bifocals. They needed to use what he called ‘'an HIV lens'' to view their efforts. ‘'It doesn't mean your primary goal is to eradicate HIV/AIDS. You don't have to fight the epidemic. But you won't achieve your goals, whatever they are, if you don't take AIDS into account.''

‘'We are at a watershed,'' he warned. ‘'The crucial next step - using this growing knowledge to improve and scale up effective actions has yet to be taken.'' (END/2005)

Source: allAfrica.com

More Policies Needed to Help Farmers Affected By AIDS

InterPress Service, April 14, 2005

MAPUTO, Apr 14 (IPS) - Lying outside her hut on a tattered mat, 20-year-old Maria struggled with her breathing as she tried to explain why she and her five orphaned nieces and nephews in her charge had not eaten.

Maria, whose name is changed to protect the family's privacy, was dying from AIDS-related diseases, as well as from severe malnutrition. ‘'I had to sell my plot of land to survive,'' she said through her gasps for breaths. Tears rolled down her hollow cheeks. ‘'I haven't taken my tablets (for tuberculosis) for five days, because I'm too hungry. The pills make me feel sicker, if I take them without food.''

Maria explained she dropped out of school when she was 15 years old to look after her own parents, who were ill for a long time before they died. Her own husband deserted her when she fell sick, and the children living with her are offspring of her three sisters, all of whom died of AIDS. Her eldest niece at 14 years already has a baby of her own.

A month after the interview, Maria died. The children had to leave their home as someone claimed it was theirs. A neighbour, who used to visit Maria, who herself is also living with the virus, gave Maria's destitute orphaned nieces and nephews temporary shelter.

The family lives in Nicoadala, in the northern province of Zambezia, which was once known as the breadbasket of Mozambique, as it has the potential to feed the whole country. But a combination of factors, namely the effect of 16 years of civil war which ended in 1992, widespread poverty, and unpredictable weather patterns have kept most families at subsistence level, and little able to withstand the HIV/AIDS epidemic which is growing fast in the country, although its full impact is yet to be felt.

In 2003 Mozambique's HIV/AIDS prevalence rate was 13.6 percent and last year it shot up to 14.9 percent. The UN Food and Agriculture Organisation (FAO) predict that between 1985 and 2020 Mozambique will lose over 20 percent of its agricultural labour force to HIV/AIDS.

Most policy makers recognise that HIV/AIDS is not just a health issue, but developing adequate policies to mitigate the devastating impact it is having, especially on subsistence farmers - who make up 77 percent of the population in Mozambique - remains a huge challenge.

What is clear is the anecdotal stories are tragically dramatic. ‘'The story of that family (Maria and her family of orphans) and others gives us an idea of the situation,'' said Bertine Niesten, project officer for FAO and focal point for HIV/AIDS.

‘'We must remember the vice versa effect of HIV/AIDS whereby HIV/AIDS can increase the risk of food and nutrition insecurity, and in turn food insecurity can increase vulnerability to the impact of HIV/AIDS as children are forced to drop out of school and young people, especially girls, turn to risky behaviour in order to survive,'' she said.

‘'It is a challenge still to ensure local organisations integrate HIV/AIDS into projects in the agricultural sector,'' Niesten said. ‘'And it is also difficult to identify families because of the stigma attached to HIV/AIDS.''

Since 1999 government policies including in the agriculture sector, focused more on HIV/AIDS prevention. In 2002, polices started to address the mitigation of HIV/AIDS, especially in the rural areas.

And since the beginning of last year, funds became available for limited treatment with life-prolonging anti-retroviral drugs (ARVs) in the public health system and care for the sick.

Most of the research into the impact HIV/AIDS has on subsistence farming is qualitative and anecdotal. A case study carried out in Chokwe, in the southern province of Gaza on farmers' knowledge of seed, supported by FAO, published January 2004 concluded that the long-term impact of HIV/AIDS is not addressed sufficiently. The paper argues that HIV/AIDS, along with other factors, could erode into the knowledge on seed and seed management - critical to household food security.

However, a report to be presented at an international conference in South Africa on HIV/AIDS and Food and Nutrition Security this month is calling for a re-think of current views. It suggests that certain shifts in agriculture in the southern African region were not always due to HIV/AIDS but were more likely due to change in agriculture policy.

Policy makers in Mozambique agree that more focus needs to be paid to mitigating the epidemic's impact on food security. The government is now implementing different initiatives in all of the country's 11 provinces, but the numbers of subsistence farmers reached are limited compared to the scale of the epidemic. More than 1.5 million people are living with HIV/AIDS.

Albertina Alage, the head of department of rural extension and focal point for HIV/AIDS in the ministry of agriculture said, ‘'We have advanced a lot, but we have problems. Sometimes finances for our plans are not timely or do not come at all.''

Alage explained that since 1999 rural extension workers have been educating the communities both about new agricultural practices and HIV/AIDS prevention. ‘'We have a problem in that we have few women rural extension workers. So we instead appoint a woman in the community to also assist in the sessions. We also do not have enough communication material in local languages,'' she said.

In 2002 programmes focused on trying to reduce the impact. Alage gave example of demonstrating communities' agro-processing machinery, which will assist families affected by the epidemic giving them time to both farm effectively and look after the sick. ‘'They can then form associations and apply for loans but the machinery,'' she said.

FAO supports the provincial government in the central province of Sofala implement a project prolonging the lives of agricultural extension workers. The HIV prevalence rates in Sofala is over 30 percent, and extension workers have been especially at risk of HIV infection, being a highly mobile group. They are posted in areas without their families for long periods at a time.

FAO, at the request of the provincial government, supports extensions workers who are taking ARVs with transport money so that they can make the often long journey to the provincial capital to receive treatment and collect their drugs. ‘'The provincial agricultural directorate is very organised. It was their request as they were concerned at the numbers of extension workers they were losing to HIV/AIDS,'' Niesten explained.

FAO also supports some 840 orphaned pupils aged 12-17 years in the central provinces of Manica and Sofala with life skills and practical farming tips which are given on demonstration plots. The pupils learn how to prevent diseases, use fertilisers and irrigation and at the same time they learn life skills. The idea, explained Valentina Prosperi, A UN fellow for FAO, ‘'is that the pupils then teach their parents and the community.''

Another area that is crucial in the long-term to food security is the right to inheritance. The UN Children's Fund (UNICEF) and FAO are supporting the government to give more legal protection to children orphaned by AIDS.

The UN World Food Programme (WFP) also supports a number of programmes directed at improving the food security of subsistence farmers living with HIV/AIDS. For example, WFP provides corn soya blend, fortified with micronutrients to over 4,000 people, including pregnant women, who are on anti-retrovirals. People living with HIV/AIDS need 10-30 percent higher energy requirements than a person who is HIV negative.

WFP also provides 20,000 people affected by the epidemic and 50,000 orphaned children with a monthly food ration.

The deputy country director of WFP, Karin Manente, explained that, ‘'sustainability is a concern. That is why our support is for a limited time frame. For example we give food to ARVs patients for the first six months, so as to help them through the most difficult period to get back on their feet. We want to assist people to prolong their lives, this also helps children stay in school.''

Like Mozambique, most of the 13-member Southern African Development Community (SADC) countries face similar problems. Southern Africa holds two percent of the world's population; but it has 70 percent of the world's people who are living with HIV and AIDS, according to ActionAid, an international charity, based in South Africa.

Online at: http://ipsnews.net/new_nota.asp?idnews=28288

Source: AF-AIDS, join-af-aids@healthdev.eforums.com

Food insecurity fueling spread of HIVAIDS while HIV/AIDS increasing food insecurity, experts say in Durban

Aidsmap, Theo Smart, April 22, 2005

"HIV/AIDS and food and nutrition insecurity are becoming increasingly entwined in a vicious cycle, with food insecurity increasing the risk of exposure to HIV, and HIV/AIDS in turn increasing vulnerability to food insecurity," said Stuart Gillespie, Ph.D., a senior research fellow with the International Food Policy Research Institute (IFPRI). Dr. Gillespie was speaking at IFPRI's International Conference on HIV/AIDS and Food and Nutrition Security, held last week in Durban, South Africa, immediately after the WHO Consultation on Nutrition and HIV/AIDS in Africa. 'Food security' means having sustained physical and economic access to food of an acceptable quality and quantity.

The IFPRI meeting bought together over two hundred development experts, policymakers, donors, and researchers from health, agriculture and other sectors to hear how HIV/AIDS is affecting food security (and visa versa). Hoping that participants would forge links across sectors, the ultimate goal of the conference was to catalyse effective, large-scale action addressing the interactions between HIV/AIDS and food and nutrition insecurity.

"This conference aims to shine a light on the interactions to figure out what they mean for programmes and policies related to agriculture, research and development and to collectively figure out ways to take this agenda forward," said Gillespie, who was also the chief organiser of the event.

Rationale for the meeting
Central to the meeting was the theme that HIV/AIDS is not merely a medical problem with a simple medical solution. It is a multisectoral and developmental issue, affecting already struggling societies on many levels.

"Within the development community, HIV/AIDS is often viewed as only a health issue, separate from agriculture and other sectors. As a result, there is limited collaboration across sectors, resulting in lost opportunities to fight this pandemic effectively," said Gladys Mutangadura, of the United Nations Economic Commission for Africa at the opening press conference.

"HIV cannot be removed from Africa's long-standing problems; it is the culmination of these problems. It cannot be divorced from all these inequalities," and Professor Joseph Tumushabe, a development consultant for the United Nations Economic Commission for Africa

HIV/AIDS spreads through developing countries in the context of hunger, malnutrition, poor health, and deepening poverty. Those who contract the disease can find it more difficult to work to feed themselves and their families. As they fall ill, their resources are depleted; and they often lose their homes and other assets. The time and resources of their families and communities also must be redirected to their care and support. When a person with AIDS dies, their families are left even deeper in poverty and at greater risk of HIV exposure and infection themselves.

As a result, whole families are being wiped out and communities devastated. With as many as one out of three adults infected, the stability of entire nations is being put at risk.

Agriculture
"This disease is having disastrous consequences for agriculture by affecting adults at the height of their productive years, reducing labour power and other resources, and making it difficult for poor people to provide food for their families," said Professor Tumushabe. But while rural agricultural communities are becoming poorer, they are often forced to care for a disproportionate number of the ill and dying.

"People go to the rural areas for care or to die, and many of the orphans are in the rural areas, but where is the funding?" said Professor Tumushabe. "It is not being equally distributed to the rural areas."

Much of the conference would focus on what is known about the interaction between agriculture (and other rural livelihood systems) with the spread of HIV and effects of HIV/AIDS.

No one magic bullet
"We have a lot of evidence to suggest that those kinds of processes are happening - but they are almost always different in different places for different reasons," said Gillespie. "We are finding that there is no one single clear-cut problem."

Many of the papers presented at the conference discussed the capacities and strategies of households and communities to respond effectively to the impacts of HIV/AIDS.

"What are the appropriate types of solutions for that place, at that time?" said Gillespie. "There is no blueprint, there is no standard magic bullet intervention."

"There is no one single solution, so we need to be capturing innovations, looking at how certain communities have effectively responded. And we have to learn from them where the gaps are and how government, civil society, the private sector and international agencies need to position themselves to provide the appropriate types of support" he concluded.

Source: Pronut-HIVeForum, pronut-hiv@healthnet.org
*********

Resources
Gillespie S and Kadiyala S. HIV/AIDS and Food and Nutrition Security
**From Evidence to Action. International Food Policy Research Institute,
2005. Copies of this book and other related materials may be downloaded from the IFPRI site: http://www.blogger.com/www.ifpri.org

AFRICA: New thinking needed to counter AIDS in rural communities

IRIN News, April 16, 2005
************
DURBAN, South Africa- The link between HIV/AIDS and hunger in rural communities has received a great deal of attention over the past few years- particularly in Southern Africa, where HIV/AIDS has added a new dimension to the recent food crisis.

But research emerging from this week's international conference on 'HIV/AIDS and Food and Nutrition Security' in Durban, South Africa, showed that very little is know about the actual impact of the pandemic on rural communities.

The three-day conference, organised by the Washington-based International Food Policy Research Institute (IFPRI), brings together policymakers, donors and researchers to develop strategies for improving and expanding the response to HIV/AIDS and food security.

In his keynote address on Thursday, Dr Tony Barnett from the London School of Economics warned against the danger of demanding action when there was only "spotty and patchy evidence" about what was happening in farming systems.

Barnett raised questions that "fly in the face of conventional wisdom" on "what we think we know" about HIV/AIDS and food and nutrition security.

According to Stuart Gillespie, conference director and senior research fellow at IFPRI, researchers attending the conference were taking "a critical look at existing evidence", and finding that "while some of the research supports conventional wisdom about the massive impact of HIV/AIDS on livelihoods, more research put on the table [this week] is forcing us to change the way we look at things."

"We're seeing that HIV/AIDS is intertwined with multiple vulnerabilities, and we have to avoid AIDS exceptionalism ... it's a complex issue that looks different in different places," he told PlusNews. As an example, Barnett mentioned three studies he conducted in a small village in the Rakai district of Uganda, examining the effects of HIV/AIDS on farming communities from 1989 to 2004.

Contrary to expectations, and despite an HIV prevalence of 8 percent in 1993, the farming system had not collapsed from the strain of AIDS-related illnesses, and all the study respondents from 1993 were still alive. The region's "fairly robust and very resilient farming systems", sustained by good soils and "high ... rainfall", had created a buffer against the impact of HIV/AIDS.

This was not a "devastated community", but the situation was not the same everywhere and there was a need for more research and a greater diversity of responses. Barnett called for large-scale donor and state-driven efforts that recognised the complex nuances in the impact of HIV/AIDS on rural households. He admitted that this would be difficult for governments, but stressed that "one size will not fit all".

Previous assumptions during the early stages of the pandemic - that HIV/AIDS impacted wealthy, more educated people - were no longer valid, as poorer households were now more affected. But policies and programmes were not changing as quickly as the virus was progressing, and rural households remained neglected.

Labour technologies used in rural communities would also need to keep pace with the epidemic, he warned, as some were no longer appropriate. "The problem is: how can we introduce innovations at a time when people are not living long enough to adopt to the innovations - is there enough time for communities to adapt to these changes; is there existing and appropriate technology which will work in these changed circumstances?" he asked.

While the benefit of antiretroviral (ARVs) medication was that it increased life spans by between 5 and 10 years, this was still not being fully exploited. "The problem is, we don't know what to do - this is a novel situation, and the response must be rapid ... [but we] don't know what works," Barnett said.

With the danger of drug resistant strains of the virus developing during this window, African countries had to ensure that ARVs were used regularly, and continued access to the treatment was available. He expressed concern that large pharmaceutical companies, already feeling the pinch from dramatic ARV price cuts, would not respond rapidly to the need for a new generation of cheaper medicines for developing countries.

"We are in perilous waters," he declared. Making matters worse, rural households still had a problem accessing treatment, while widespread stigma remained prevalent in small communities. Under these circumstances, "how long will it be before we see a new epidemic of resistant HIV in rural areas?" Barnett wondered. He cautioned that "bureaucratic inertia” and using "yesterday's solutions for today's problems" would do more harm than good.

Current prevention methods had not provided all the answers; more research into the use of microbicides as a female-controlled prevention method was needed. "The history of prevention shows us the mistakes we've made ... it cannot be business as usual," Barnett concluded.

Source: IRIN News, April 16, 2005

AFRICA: UN highlights nutrition woes of HIV-positive people

[This report does not necessarily reflect the views of the United Nations]

JOHANNESBURG, 11 April (PLUSNEWS) - World Health Organisation (WHO) chief Lee Jong-wook on Monday appealed for greater attention to the nutrition of people living with HIV/AIDS in sub-Saharan Africa.

Addressing health experts from 20 African countries at a WHO meeting in South Africa's port city of Durban, Jong-wook said that despite being one of the critical aspects of care and support for HIV-positive people, nutrition had been largely ignored.

"We know that sound nutrition helps maintain the immune system, increases body weight and boosts energy levels but, in Africa, [infected people] are frequently admitted to hospital already malnourished," Lee said in statement.

The UN health agency chief warned that massive international investment in care, support and anti-AIDS treatment could be jeopardised if people receiving treatment were not sufficiently nourished.

Delegates attending the three-day meeting are to produce recommendations for immediate action to improve the nutrition and health of HIV-positive people in southern and eastern Africa.

Source: IRIN PLUS News
http://www.plusnews.org/AIDSreport.asp?ReportID=4690