Guyana: Poor nutrition, poverty may be affecting HIV patients - govt welfare subsidy in the works

Stabroek News, By Iana Seales, May 30th 2006

Guyana--In the last decade nothing has grabbed more attention as far as health issues go in Guyana than HIV/AIDS and given its far-reaching implications and devastating impact, international funding continues to come in as the fight against this epidemic endures. But there is a side of HIV/AIDS we hardly hear about.

Perhaps it pales in relevance to the successes we have had locally in making adequate treatment and drugs available free of cost, in manufacturing our own antiretroviral drugs, in commencing viral load testing and in getting more infected persons to join the treatment programme at the Genito-Urinary Medical (GUM) Clinic at the Georgetown Public Hospital.

But the story we are still to know is just how many infected persons are getting the proper nutrition they need and how many are wasting away because of inadequate meals. It is of concern because poverty is part of the lives of many infected persons, particularly those living on the streets and in run-down sections of the city, who eat perhaps one meal a day or none at all.

This is troubling since in order for the antiretroviral (ARV) therapy to be of effect, those using it must have regular meals. In fact, infected persons who are homeless and without family support and who have no access to regular meals are not offered ARV treatment.

Deficiencies of important nutrients, vitamins and minerals severely affect the body's immune function and studies have shown that this coupled with the destructive effects of HIV on the immune system, increases the risk of infected persons contracting opportunistic infections and dying.

Not on ARV treatment
There are a number of reasons why some infected persons do not qualify for ARV treatment.

Firstly, their CD4 count is above 350 in which case they are considered to be doing okay but they could be placed on treatment if they have an opportunistic infection. Then there are tuberculosis patients who are at a high risk of dying faster.

Some infected persons who default on the treatment programme, by missing doses and not taking their drugs on time also do not qualify for ARV treatment.

Dr Jadunauth Raghunauth who now heads the GUM Clinic at the Georgetown Public Hospital recently explained that it is absolutely necessary that certain requirements are met before infected persons are placed on ARV treatment because some persons run the risk of developing resistance to the treatment.

"We have to be assured that persons on treatment are taking the drugs and doing so on time when they are required to. This is important and though 95 percent adherence is somewhat acceptable, we expect patients to have 100 percent," he related.

In the years that he has worked with HIV infected persons, Dr Raghunauth said he has not known any specific case whereby persons could not be placed on ARV treatment mainly because of their nutritional status. But he admits that there may be many infected people out there who are poor and are not getting help in terms of regular meals.

Dr Emanuel Cummings, Assistant Dean within the Medical Faculty of the University of Guyana was part of a team that recently studied the nutritional status of infected persons who attend the GUM clinic.

Of the 150 patients studied, the majority, 55.17% were unemployed and 44.83% were employed. Some 59.31% said they do not earn a salary (some did not wish to disclose their income). While 10.34% earned between $10,000 and $20,000 (US$50-US$100); 8.97% earned more than $80,000 (>$US400) and 2.07% earned less than $10,000 (

On average, more than half of the participants ate beef, ham, luncheon meat, salmon, pork, shellfish, soy protein, hot dogs and sausages, pepperoni and bacon less than once per month. Of the protein group, the most common foods eaten on a fairly regular basis were fried chicken 32.39%, 1-2 times per week; eggs - 30.99%, 3-4 times per week; legumes - 37.32%, 1-2 times per week; white fish - and chicken - 32.39% - more than 5 times per week.

The study also found that 66.52% of patients thought that their nutritional intake was satisfactory; 33.10% thought that it was unsatisfactory and 69% did not know whether it was satisfactory or not and 65.52% were unable to respond to the question.

It said that 15.17% attribute their lack of proper nutrition to the lack of money; 6.90% attributed this to a lack of appetite; 4.83% attributed this to their lack of knowledge; and 3.45% attributed it to a lack of access to food.

Government subsidy programme
A street dweller who walked into Stabroek News a few months back begging for something to eat aroused much curiosity because of his deteriorating physical condition. Sickly is a mild way of describing how he looked and though he did not initially say that he was HIV positive, people who saw him concluded that almost immediately.

"I ain't gat nobody to give me food and de condition I in right now people ain't even wan give me a dollar when I beg. Is na me family alone turn from me is everybody I know in me life," the street dweller said.

He looked about ten years older than his stated age of 27 years and his physical condition was bad. When he spoke with Stabroek News he was covered in ulcers from head to toe and frothing at the mouth.

The man said he was not on ARVs because of his economic situation and though he had been treated for opportunistic infections many times he always slipped back into a deteriorating state.

Several years ago he recalled living a reckless life in Cayenne, French Guiana. He summed up his life then in three words: drinking, money and sex. In his late teens he came back to Guyana with nothing and had no place to go but on the street. He later learned that he was infected with HIV.

He said dying was not something he feared. For him, it would be "a way out of the endless days of hunger". But he said while he was waiting to "close his eyes and go wherever," it would be nice to get a plate of food each day.

What then could be done for infected persons like the street dweller who is thankful if he gets one meal a day?

Perhaps soup kitchens in the city and a few other areas that are open to anyone who is in need of a meal would be the answer. That way, there would be no stigma attached and those really in need could benefit. But even this appears too demanding an effort in the long term, which is why the idea of government offering a subsidy to infected persons is a more welcome initiative.

Minister of Health, Dr Leslie Ramsammy when contacted on this said it is something that government is planning. He said they are trying to put together funds at the moment to introduce such a programme.

"We are trying to make the resources available and if I am to project when such a programme would come on stream I would say some time in 2007 providing everything is in place," the minister added.

But in the meantime a few non-governmental organisations (NGOs) have begun providing meals to persons in need regardless of their status. These include the Network of Guyanese Living With and Affected by HIV/AIDS (G+) and Comforting Hearts, which is based in New Amsterdam, Berbice.

Free Hot Meals
Early this month, Comforting Hearts started its UNICEF-sponsored Hot Meals Programme, which has become very popular. Free meals are offered to children and adults in the area who are in need and among them are HIV/AIDS infected and affected children and adults.

Beaming boys and girls flocked the Comforting Hearts building at Coopers Lane, New Amsterdam when Stabroek News visited around midday last week, awaiting lunch. And when wafts of delicious frying fish floated on the air, one boy happily announced, "Fish today".
Shawndelle Charles-Gouveia, Project Coordinator at the NGO related that the programme was initiated for orphans and vulnerable children in the area but they are also providing meals for their shut-in clients (those who are really ill) and other adults. When it started earlier this month, she said, they were catering for around 60 persons but as word spread that number quickly climbed to 100.

She said Comforting Hearts handed out hampers in the past to persons infected and affected by HIV but it was not long before they realised that the children were not benefiting.

"We embarked on this new project after we found that the children were still in need and that many of them were not going to school because of [a lack of] meals. A lot of them could not attend school because they had nothing to eat," Charles-Gouveia said.

According to her, the programme is going well and though UNICEF funding is only for one year she is optimistic it will continue to receive support because of the impact it has already had in the Berbice area.

Comforting Hearts has already received a request from the New Amsterdam Hospital to provide meals for a few shut-in patients. They also have plans to take meals home to persons who are in need and do not want to go to the NGO.

A nutritionist has joined forces with the NGO so balanced meals are being prepared, Charles-Gouveia related. She said they had sessions with their clients before the Hot Meals Programme started and persons were educated on how to prepare healthy low-cost dishes.

Comforting Hearts also offers home-based care, counselling and voluntary counselling and testing. There are 12 full-time persons on staff, 20 mentors who work with the children and other volunteers.

Charles-Gouveia who has been a volunteer since her early teenage years has been at Comforting Hearts since 2002, four years after the organisation started operating in the Berbice area. She said bringing a smile to a child's face does a lot in terms of job satisfaction and she also loves working in a field where she is able to help people on a daily basis.

She added that the people she works with have an unwavering dedication, which makes it easier to get things done. "Sometimes we are here until eight at nights and no one ever complains because this is what we do," she said.

Dusilley Cannings, President of G+ said their nutritional programme will commence some time next month since they recently got the okay that was required. She said that they have long recognised the need for such a programme and hence its provision in their recent proposal to the Ministry of Health.

According to her, this support effort will complement what the Ministry of Health will soon implement - a welfare subsidy programme for persons living with and affected by the disease.
Cannings said G+ hopes to distribute food hampers to persons in serious need on a regular basis.

She said orphans and vulnerable children will also benefit from hampers. Since their work is also about empowering those affected with the disease, Cannings said, they will continue to provide basic needs, school materials for orphans and vulnerable children, support and home-based care as well as counselling.

Extending lives
According to the study, the nutritional status of the HIV+ patient is of utmost importance to their quality of life and relates to the ability of that person to live an extended and productive life. This is of utmost importance in Guyana as most of the persons affected by HIV/AIDS fall into the 15-44 age bracket.

"Extending the lives and the economic productiveness of these persons is crucial. Guyana has recently suffered from massive emigration, which has depleted the number of skilled and educated persons. Extending the life span of those affected by HIV/AIDS is of utmost importance in helping to maintain a steady and productive workforce and economy," it said.

Further it stated that nutrition and AIDS operate in tandem, both at the individual and at the societal level. Nutritional deficits make people with HIV more susceptible to disease and infections of all sorts. Malnutrition is one of the major clinical manifestations of HIV infection.

At the household level, HIV/AIDS and food security are closely linked: an HIV-infected household increasingly risks food security and malnutrition via declines in work, income and time available for care of younger children, together with increased expenses for health care.

Food insecurity may, in turn, further increase both the risk of being exposed to HIV and a household's vulnerability to its increasing impact as the disease progresses.

Nutrition is also linked to treatment, the study added, and as access to antiretroviral drugs improves, clean water supplies and adequate food must be made available as part of an overall treatment, care and support package.

Source: Stabroek News

ART and Nutrition in HIV and AIDS

The Third Voice, by David Patient & Neil Orr May, 2006
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For the last few years we have been following the ART (antiretroviral) medication versus nutrition debate in South Africa.

This debate is not unique in the world. What makes it unique is the scale of it, and that the government is (correctly or incorrectly) placed within the ‘alternative’ camp, with civil society (e.g., TAC) as the apparent protagonist of mainstream science and medicine. This has led to a highly polarised situation, with common sense nowhere in sight, and the victims being those infected.

How is it possible that, in a civilised society, people are being asked to choose between appropriate medication and food to keep their body healthy? Do we ask the same of those with diabetes or heart disease? Since when has there been any question that maintaining body strength through exercise and nutrition is in conflict with proper medical treatment? It defies logic, yet that is what the public is being led to believe.

Initially, the ART lobby groups stated that their opposition to promoting nutritional measures was simply to ensure that ART access was placed on the forefront of government responsibilities to those infected. This is understandable and laudable. Indeed, their efforts were essential in making ART more widely available to those infected. Many lives have been saved as a direct result of their efforts. And yes, more work is required to make ART more widely available.

In response, some of the ‘nutrition-only’ protagonists escalated their efforts and claims, telling people that ART is deadly, and that AIDS can be cured with various plants, vitamins, and minerals.

In all this heated debate, a simple fact has been overlooked: Adequate and appropriate nutrition is – and always been – a critical factor in defending against illness, and sustaining optimum health. Common sense – the missing factor in this debate – is that medication and nutrition are both important to ensuring health and warding off disease: The one fights germs, and the other strengthens the body. Where’s the conflict?

The conflict lies in the fact that most people – not only those living with HIV – are largely ignorant of the basic facts about both ART and nutrition, and also when and where those options are appropriate. To make things worse, the media is not doing a very good job of explaining how things work in HIV.

You may ask what right we have in commenting upon these issues. Yes, one author (David Patient) is living with HIV, since 1983. However, infection with the virus does not automatically imbue you with insight, wisdom or information regarding the disease, medicine, or how your body works. Instead, it is useful to note that David has been involved in HIV and AIDS activism long before ART as we know it came onto the scene.

Like many others, whenever there was a claim of some ‘miracle’ treatment or cure (e.g., Compound Q from Chinese cucumber, and AL721 from egg yolk), he was one of the first to give it a go. When AZT - the first ART available – came onto the scene, he was part of the first human clinical trials, back in 1986 at Duke University.

The fact that none of the ‘miracle cures’ cured anything, nor the fact that the doses of AZT back in 1986 were so toxic that most subjects died, is not as important as recognising that – like most people living with HIV – he wanted to live, and wanted options to do this. When second-generation ART’s became available in the early 1990’s (3TC, and D4T), both authors helped get these medications to South African AIDS patients.

We have also been part of the nutrition and HIV debate since it’s early days and in some instances, we instigated it. We spent several years poring over research documents on nutrition and viral infections, distilling these into guidelines that have become the basis for many
nutritional interventions for those living with HIV. We even published a book on it called Positive Health that currently has a circulation of over 14 million copies.

When originally published in 1999, ART was simply not available to the general public, and it was felt that people living with HIV needed to know what else they could do to sustain their health until medication was available. As access to ART improved, information on this treatment was included in the book. The point is that we have never viewed either ART or nutrition as stand-alone options. Indeed, the one supports the other.

Rarely has there been a period of time when we have not been approached to promote some or other product, herbal or otherwise, which the developers claim to ‘cure’ HIV and or AIDS. We have investigated many of these, sometimes through personal trials. And no, we have not found the cure in any of these ‘miracle cures’.

Instead, we have gained a great deal of insight into how traditional medicine and western medicine view treatments and cures quite differently. For example, traditional medicine views a cure as the alleviation of symptoms, whereas western medicine views a cure as the removal of the causative agent, such as HIV. Hence, there is a perennial misunderstanding in this regard.

So, at the risk of being presumptuous, we believe we have the experience and knowledge to make certain statements regarding the nutrition-ART debate, based upon current facts and research:

1. There is no cure for HIV from the medical, traditional healing, or ‘alternative’ fraternities. Instead, there are proven methods for keeping HIV under control (e.g., ART), and for strengthening the immune system (e.g., sound nutrition and other practical measures).

2. ART is effective in extending life in those living with AIDS, on average extending productive health by 4 or more years. Yes, there are those who respond badly to the medications. It is also true that long-term use often leads to side effects such as liver problems. Mixed into the equation is that early ART did indeed have severe side effects due to high dose levels. These dose levels have now been reduced to less toxic levels. All these disadvantages are outweighed by the clearly demonstrated benefits of the medication. Like any chronic medication (e.g., blood pressure pills), it requires close monitoring to detect and control the side effects.

3. Nutrition likewise extends life in those living with HIV and AIDS, but through different mechanisms to ART medication. Where ART focuses upon destroying the virus or interfering with its’ ability to reproduce, nutrition focuses upon providing the body with what it needs to create new immune cells, and thus do its’ part in fighting infections. These two methods are complementary, not conflicting.

4. ART is only considered appropriate when a person living with HIV reaches a CD4 (Helper T-cell) count of 200, or when an AIDS illness emerges. Therefore, simply being infected with HIV does not qualify you to receive ART. In contrast, nutrition and other practical measures such as exercise provides tangible and effective measures for people living with HIV to get involved in their health, long before AIDS emerges, and thus before ART treatment is called for. The focus of nutrition is to improve immune function, and thus prolong the period of infection before AIDS develops. It does not prevent this from occurring – it simply delays it.

5. Without awareness of nutritional interventions (and structures such as support groups), there is little motivation to get tested early, a key to effective health management. Without the promotion of empowering options such as nutrition, promoting early testing is extremely difficult. When absent, people tend to wait until they become ill before they seek assistance.

6. Specific ART medications do indeed conflict with specific foods and herbs. Examples are garlic and Ritonavir or Saquinovir, and African Potato or Sutherlandia and most ART medications. These herbs interfere with enzymes in the stomachs that absorb the medications. This conflict is resolved by waiting for several hours after taking the medications, before consuming the herbs.

7. According to published clinical trials, African Potato does indeed improve immune function. However, it does not boost the immune system, as the immune system is not a simple unified entity. Instead, it strengthens only one part of the immune system (cellular immunity). It is this part of the immune system that deals with viruses. Heat (e.g., boiling) destroys the active ingredient of African Potato, making it useless. To obtain benefit from the plant, you need to know how it was prepared.

8. Garlic has no direct effect on viruses, including HIV. Instead, it is a sulphur-based natural antibiotic, about 1/10th the strength of penicillin. Regular garlic consumption reduces bacterial, yeast and parasitic infections. This in turn allows the immune system to put more resources into fighting viral infections. Deodorised garlic is useless if the sulphur-based ingredient is removed.

9. Beetroot is high in iron. Like garlic, beetroot does absolutely nothing to viruses. Instead, the iron improves blood oxygenation, energy levels, and supports various important body functions. Dark green vegetables and liver do the same thing. Malnourished people are often anaemic, which is a condition caused mainly by low iron levels. Pregnancy can also induce anaemia.

10. Malnourished people respond poorly to medication (including ART), and have a lower resistance to infections in general. Nutritional interventions (e.g., vitamin A supplements) have little beneficial effect when applied to groups of people (including those infected with HIV) who already have an adequate and varied diet. However, when applied to groups with a restricted diet – either in quantity or variety – specific nutritional supplements have a dramatic effect on health, including response to ART. Therefore, when evaluating nutritional studies, it is important to consider the economic background of the study group. Failure to do so leads to a perception of ‘sometimes it helps, and sometimes it doesn’t’.

11. Given the economic and other conditions that we live in, nutritional interventions should focus upon ensuring either an adequately varied diet, or supplementation of existing diets to ensure basic nutritional needs are fulfilled. It should be clearly understood that such nutritional interventions have nothing to do with ‘curing’ disease. It is simply about ensuring normal immune function. Furthermore, legislation concerning mandatory fortification of popular foods types such as maize meal needs to recognise that heat destroys vitamins (but not minerals) and that certain forms (typically the cheaper forms) of vitamins and minerals are not well absorbed.

12. The most clearly scientifically proven nutritional substance to make a statistically significant difference in how long and well a person lives with HIV is selenium. This effect occurs regardless of other dietary factors, and is seen even in those who have an otherwise good diet. This effect has been demonstrated in several controlled studies. Selenium cannot reliably be obtained from most foods, as levels of selenium in food such as vegetables depend entirely upon the soil they were grown in. Commercial agricultural methods reduce selenium levels in food because of alterations of the acid/alkaline levels of the soil. The exception is the aloe, which actively extracts selenium from the soil. Sea fish also contain reliably adequate levels of selenium. You cannot overdose on selenium from food sources. However, in pill form you should not exceed 500 micrograms per day (for adults).

13. The ‘remarkable’ effects of various nutritional products can largely be explained in terms of simply addressing underlying malnutrition. Many people have poor diets, regardless of income or volume of food consumed. This is because of processing and preserving methods that typically destroy vitamins in food. Fresh food is far better than mass-produced food for this reason. Techniques such as trench gardens make it possible for almost anyone to grow their own vegetables, even in dry and difficult situations.

14. Variety is as important as volume. There is not one (naturally-occurring) food that can give you all that you need, nutritionally. Mono-diets (e.g., maize meal with the occasional meat) can lead to malnutrition in terms of many vitamins and minerals.

15. Maintaining normal body temperature (37 degrees Celsius) through exercise and diet (e.g., energy foods, and ‘hot foods’) does indeed help the body fight viruses. The cooler the body, the more active germs become. The warmer the body, the more active the immune system becomes.

16. Treatment of chronic infections such as parasitic infections (e.g., worms), TB, malaria, and sexually transmitted diseases, does increase the body’s ability to fight HIV. This is simply because these infections place an additional burden upon the immune system.

The bottom-line is that nutritional interventions are extremely important in dealing effectively with HIV and AIDS: Before you need ART - during the longest period of living with HIV, the period from diagnosis to CD4 of 200 - take care of your body and give it what it needs to do its’ job in keeping HIV under control for as long as possible.

There are proven natural methods that do enhance your body’s ability to control and even delay the onset of many conditions. However, when your immune system becomes compromised and your CD4 count drops below 200 and your viral load increases, then ART is critical. However, even on ART, continue with good nutritional practices to maximise the benefits of ART and help your body cope with the medication.

David Patient used nutrition (that includes vitamins, minerals and good food) for most of his HIV infection. Now, 23 years into his infection, he needs ART because his immune system was starting to show some wear and tear. He takes his ART religiously each day, and he still eats well, takes his supplements, does exercise, and generally tries to take care of his body. Is this medical heresy? Is this an abandonment of nutrition?

Of course not: He didn’t abandon the methods that worked for 23 years – he simply added ART to his daily regimen because that was necessary. As a result, his immune system is great (CD4 is at 900, and undetectable viral load). In addition, he hasn’t had any negative side effects, and his liver enzyme tests are normal.

So what, we ask, is the debate really about? How much of it is about ego and sheer pig-headedness? Since when did medical science - or nutrition - demand faith – not a careful consideration of known facts – to determine care and treatment options? We have been around HIV and AIDS a long time, longer than most. We have never seen a verified case of someone ‘cured’ of HIV from any food, herb, or medication. We have, on the other hand, met many people who have lived long and healthy lives with HIV, using both medicine and sound lifestyle practices.

The objective of any treatment intervention is to promote life and health. If it does, use it. It is not a matter of faith or political conviction – it is a matter of what works, and what doesn’t. Ask anyone with diabetes and other chronic illness.

When you hear someone insisting that ‘this is it’, be cautious: Rarely will such a person tell you of the people who did not benefit from the miracle cure … you only hear about the successes. It’s your life, your body: Demand explanations and evidence. Ask questions – don’t be a helpless victim in your health.

David R. Patient (M.H.;M.H.T.)
Empowerment Concepts
Ph. +27-(0)83-226-9466
Fax to email +27-(0)86-683-4585
david@empow.co.za
www.empowermentconcepts.com

Source: AF-AIDS eForum

Rwanda: Aids Therapy Beyond Drugs

Africa Renewal, June 1, 2006, By Stephanie Urdang

Kigali--Many Rwandan women and girls infected with HIV/AIDS are now getting supplemental food with their medicines.

For Grace and her daughter Juliette, the anniversary of the April 1994 Rwanda genocide means one thing: they have lived with HIV for a dozen years, and their disease has progressed to AIDS. Grace was among the estimated 250,000 women who were raped at the time and is one of the untold numbers of women who were infected with HIV as a result. Juliette, now eight years old, is also infected.

Until recently Grace was living in abject poverty, trying to cope with the stigma associated with being HIV-positive and with the daily worry that there would be no one to look after Juliette after her early death.

At first, when Grace began to get sick, she found it inconceivable that she had AIDS. Those who carried out the genocide "murdered my husband and left me to die slowly from their AIDS," she said. She found it equally inconceivable that there were drugs that could fight the disease. "In my case, only God, who knows that it wasn't my fault that I caught this sickness, could perform a miracle and heal me."

Grace and her daughter, like Josiane, Didacienne, Triphonie and other women in her situation, have now found that they do not have to wait for miracles to occur. All have been able to benefit from the Rwandan government's commitment to providing anti-retroviral (ARV) therapy to those who need it -- and for those who cannot afford it, at no cost.

These women are among the estimated 6 million Africans living with HIV/AIDS who are in immediate need of anti-retroviral medicines, out of a total of nearly 26 million HIV-positive people in the region.

Recent data from Rwanda's 2005 Demographic Health Survey indicates an estimated overall adult infection rate of 3 per cent nationally. Earlier estimates by the Joint UN Programme on HIV/AIDS (UNAIDS) for 2003 placed the prevalence rate in the towns at 6.4 per cent and in the rural areas at 2.8 per cent. The programme's Global Report for 2004, also using 2003 figures, estimated that some 250,000 Rwandan children and adults up to the age of 49 are living with HIV (figures for adults over 49 were not available). Of those, 22,000 were estimated to be children under the age of 15. Of particular concern is the high prevalence rate among young women between the ages of 15 and 24, five times the rate among young men of the same age group.

Wide treatment coverage

The Rwandan government, with financial support from a variety of sources including the Global Fund for AIDS, Tuberculosis and Malaria, the World Health Organization, the World Bank, bilateral donor agencies and private funds such as the Clinton Foundation, is able to provide ARV treatment to about 40 per cent of the people in need. Doctors and nurses are being trained, and a growing number of health clinics are able to treat AIDS patients. The estimated 19,000 people living with AIDS under treatment by December 2005 represented one of the highest coverage rates in sub-Saharan Africa.

This is particularly impressive in a country where 66 per cent of the population live below the poverty line and where the majority of households are unable to produce enough to feed themselves, even though 91 per cent rely on agriculture for their livelihoods. Rwanda's food crisis remains chronic. It is even more severe in the context of HIV/AIDS, presenting a challenge to the ultimate success of the government's treatment and care programme.

That programme involves not only medical and resource questions, but also interlocking issues of poverty, stigma and gender inequality. Because of these issues, access to ARVs is often not a reality for those who are the most marginalized and in greatest need of the medicines.

Poverty means going hungry. Hunger leads to malnutrition and a more rapid breakdown of the immune system. Social stigma against those with the disease means that many do not get tested in the first place. And gender inequality puts burdens on women that they cannot shake off on their own. Those burdens include responsibility for caring for children and other family members, ensuring that limited food supplies go first to hungry children and the risk of abandonment by men when an HIV-positive status is disclosed. Pivotal to all these issues is the need for food, a need as urgent as the drugs themselves.

Food a daily challenge

Sister Speciosa, a nurse and nun, is confronted with the reality of food every day as she provides treatment, care and counselling to AIDS patients at Butare Hospital, two hours drive from Kigali. "It is not only that they need the food to take with the medicine and that they need to eat more than they did when they were sick to get healthy," she says. "It's that their appetite increases. Some of my patients say they don't want to take the medicine because it makes them so hungry."

Although eligible for free tests and medication because of their lack of income, many find that the daily circumstances of their lives make it impossible for them to use those services. The lack of food or money for transport, difficult housing conditions, pervasive stigma, the stress of believing they will die without providing for their children's care -- all serve to accelerate a downward spiral into despair and hinder their access to ARV drugs, even when those drugs are free. Because women are primarily responsible for feeding their children and their families, they are most deeply affected by this inability.

Dr. Anita Asiimwe, coordinator for care and treatment at the Treatment and Research AIDS Centre, a government agency, also cited the food question in an interview with Africa Renewal. "It is clinically established that patients need to take their drugs with food," she said. "It's a dilemma for us, as everyone needs food. Is it right to only provide food for those on the drugs? What about everyone else who doesn't have enough to eat?"

She illustrated her point with an anecdote about a child whose mother couldn't afford to send her to school. The child, knowing that children of people living with AIDS had their school expenses covered, asked her mother why she wasn't HIV-infected so that she could go to school too.

"Would women," Dr. Asiimwe wondered aloud, "be encouraged to become infected in order to feed their children?" At times, she says, she has to try not to be despondent about the difficulty of providing for all those in need. "I have to remind myself," she said, "of how far we have come, and not despair about how far we still have to go."

'We cannot eat pictures'

The Ministry of Health's Nutrition Unit is fully aware of the need for a healthy diet for people living with AIDS, whether they are being treated with ARVs or not. In a recent interview for an assessment financed by the UN Development Fund for Women (UNIFEM) and undertaken by African Rights, a non-governmental organization, the ministry's secretary-general, Dr. Ben Karenzi, stressed that the government is not oblivious to the importance of nutrition in the fight against HIV/AIDS. However, he also underscored the huge challenge of maintaining an ongoing food support programme, particularly in the absence of adequate funding.

A woman living with AIDS cited in the same assessment highlighted this difficult reality. "They show us pictures of all the food we would love to eat, but we cannot eat pictures... We have to have the means to purchase or produce the food. Visit us in our homes and see how we live. Then you will understand."

Rape survivors

The experiences of Grace, Triphonie, Josiane and Didacienne attest to a critical need, not only for the availability of anti-retrovirals, but for more general support to enable the women to access the drugs. They were among some 200 rape victims who survived the genocide, many of whom were infected with HIV as a result, whose testimonies were included in a UNIFEM-funded report published by African Rights in 2004, Broken Bodies, Torn Spirits.

Ms. Rakiya Omaar, director of African Rights, told Africa Renewal that the most compelling issue that emerged from the the testimonies was not only women's dire need for anti-retrovirals and medication to treat opportunistic infections, but the difficulty in accessing them consistently.

"What became very clear to us was that even if the drugs were available, most of the women we interviewed were too poor to afford the food needed to take the drugs," she said. "If they did get some food they gave it to their children, as they couldn't eat when their children were hungry even if it was a matter of their own life. They also had no money for transport to the clinics. They worried incessantly about their horrendous living conditions, the desire to send their children to school. They were plagued by high levels of stress, not only for these reasons, but because they worried about their children when they were no longer around, which they knew was inevitable without ARVs."

What was especially painful to her, she added, was that a number of women cited in the report have already died. Every month she hears of more deaths, even though ARVs are now more available.

Little grounds for hope

Triphonie's story was typical. She grew thinner and sicker and her children went hungry as she tried to cope with living in a crowded, open army warehouse, rushing back and forth between her market stall and her four children to check on their safety. Her stall was rapidly failing, exacerbating the hunger.

Josiane lost four children to the interahamwe, the militia force that led the genocide. She has suffered debilitating memory loss. She was living in an unprotected shack without the means to pay for food or transport. Her 11-year-old daughter was a product of the rape and like her was living with AIDS. When her daughter got sick, Josiane would carry her to the hospital on her back. Although her CD-4 count called for them, doctors would not prescribe anti-retrovirals for Josiane because of her memory. "I was always confused," she told Africa Renewal. "I did not know the day of the week or the time of the day."

Grace, unable to support all four of her children, sent Juliette to boarding school. Juliette stopped taking her anti-retrovirals because she worried that her classmates would find out about her HIV status. Very ill, she was sent back to Butare. There she lay in hospital, unable to eat the hospital food, while Grace sobbed by her bedside, with no money to buy food Juliette could eat and frantically worrying about her three hungry children alone at home.

Didacienne would walk 10 kilometres to the nearest clinic when she was ill, a distance that, in her frail state, took her many, many hours. She could not afford the equivalent of US$0.60 for the bus that passed near her house on the outskirts of Cyangugu twice a week on market day. Not long before Africa Renewal interviewed her at her family homestead, she had spent weeks in the hospital. When she recovered and returned, she found that her small but well built house had been totally dismantled by her late husband's relatives. They explained that they thought she was going to die and therefore sold everything, including the bricks and roofing, to pay for the funeral. Didacienne and her children share a shed that housed the cooking hearth with one goat and a growing number of rabbits.

'Gift for Life'

These particular women have been fortunate. They have benefited from a small programme started by African Rights, called Gift for Life, that provides food and other basic necessities to women involved in the testimony project. The support is intended as a five-year bridge to self-sufficiency. Other organizations are also providing food to women in similar straits.

As a result, Triphonie has moved to secure living quarters minutes from the market and her stall is flourishing. Josiane's "permanent" memory loss is improving now that her stress levels are diminishing; she is taking anti-retrovirals and is planning a small business enterprise while her daughter, healthy on her anti-retrovirals, is attending a nearby school. Juliette was found a space in a local high school and Grace has found some work, and all live at home where there is enough food for all the family. Didacienne now has transport money to go on regular visits to the clinic to monitor her disease; she is getting stronger every day.

Anti-retrovirals generally make an enormous difference to physical health. But without food and other related support, they may not make a difference to mental and emotional health. Women who receive anti-retroviral therapy and food and who are able to cover the cost of transport to the clinics are finding they have the physical and emotional energy to turn their lives around. Most of the women in the African Rights programme, for instance, have opened bank accounts, a sign that they are planning for their future.

The UNIFEM assessment points out that when women living with AIDS are given food support to relieve their immediate hunger and to regain their energy, they then often request assistance for income-generating activities and skills to develop alternative livelihood strategies or to turn their failing enterprises around. "A combination of food availability and anti-retroviral therapy," says the report, can ensure that women living with AIDS "lead a productive life, become less burdensome on their families and communities and put less strain on the health system."

UNIFEM, in partnership with African Rights and with the encouragement of the Ministry of Health, has started an advocacy campaign to address the critical link between food and anti-retroviral therapy in Rwanda. The campaign regards treatment not only as a health issue, but as a critical path towards women's economic empowerment and self-confidence.

Triphonie, who was at risk of dying before African Rights came into her life, sat in the living room of her new home, her two youngest children eating with gusto out of a large bowl of nutritious rice and beans placed before them on the floor. She reflected on the changes in her life: "Only now am I able to no longer regret that I survived the genocide."

Pills, food and seeds

Many health centres in Rwanda were finding that although they were providing ARVs to women who needed them, they were not getting the results they hoped for. The women visiting the clinics complained of extreme hunger and were disheartened by their inability to obtain the food they needed. And so seven clinics, funded by the US Agency for International Development and the International Centre for Tropical Agriculture, have begun an innovative programme. One of these, in Gitarama Province, has been particularly successful.

According to African Rights, the first step was to provide fortified SOSOMA (a nutritious mixture of sorghum, soya and maize) to the women to help them regain energy. The next step was to involve them in growing their own food crops. The project is based on the introduction of indigenous vegetables and tuberous seeds, which are well adapted to Rwanda's climate and soils. With this comes training in soil fertility, crop diversification and the use of hardy seeds.

To get women living with AIDS interested in the programme, Mr. Hodali Jean Gatsimbanyi, the coordinator, cultivated a demonstration plot next to the health centre. He encouraged the women to harvest the produce for their family's consumption during their visits to the centre. Then he distributed seeds to the women for planting in their home gardens, passing on tips and monitoring their progress. In order to join the project, the women were encouraged to form associations, known as amashyirahamwe. The project in Gitarama began with 50 women and soon grew to 90 as the results started to become evident.

Once the project was underway, the centre found that the health of the majority of the participants improved considerably. They gained weight, opportunistic infections have been reduced and in some cases the participants look healthier then people who are not HIV-positive. There is also a spin-off effect in the community. Community members in general have shown greater interest in acquiring the seeds and cultivating their own plots and the women in the programme have been encouraged to impart their new knowledge and skills to non-participants in their villages.

Source: Allafrica.com

Kenya: Using ARVs to Fill Empty Stomachs

by Joyce Mulama, IPS News Service, June 2, 2006

NAIROBI - "ARVs can change things, but they do not change my socio-economic status. Yes, I get the ARVs; but I cannot afford to put a simple meal on the table," says a man who insists on being identified only as wa Kimani.

"This is why I had to register at two treatment sites, so that I could get ARVs (anti-retroviral drugs) twice: utilise one set from one site, then sell the other batch from the second site, so that I can get something small to put in my stomach."

Wa Kimani spoke to IPS outside one of the centres where he obtains treatment, his face perspiring in the hot sun as he sat on a stone, awaiting the client who buys medication from him. The stigma that continues to surround AIDS in Kenya has apparently made the client wary of obtaining ARVs through official channels -- something he fears may lead to his HIV-positive status being made public.

Wa Kimani, who is unemployed, began selling the drugs last year. He charges his client just under seven dollars for a month's worth of medication.

"This is not much, but at least it helps me purchase some basic food so that I do not take the medicine on an empty stomach. It can be dangerous, you know," wa Kimani says.

"I remember once, before I thought of the trade, I would take the medicine without any food -- just porridge alone. I nearly died. I got so weak, I developed ulcers which have not healed well until now."

Until the beginning of this month, government facilities had been charging about 1.4 dollars for the same amount of ARVs; however, the fee was waived from Jun. 1. About two million people are living with HIV/AIDS in Kenya -- more than 200,000 of whom require ARVs.

Wa Kimani's case does not seem to be unique.

Patricia Asero, a member of the Kenya Treatment Access Movement, heard of six other people receiving ARVs from more than one centre last year.

"I got interested and investigated the matter further because these people belong to the same support group as me. I found out that they had registered in more than one treatment centre so that they could get extra drugs to sell and buy food to take with medication," she told IPS.

In some cases, patients who only have one source of drugs will also sell their ARVs to buy food, added Asero. However, they present a different tale to staff at their treatment centres.

"They will tell you that their medication got lost; others claim that their bags were snatched by thieves. But when you interrogate them keenly, you get to know the truth," she noted. Asero is also an HIV/AIDS counselor at a government hospital.

Other patients who live long distances from ARV sites and who are too weak to walk to there -- also too poor to afford transport -- simply skip treatment, using what money they have to buy food.

With official figures indicating that about 56 percent of the population lives below the poverty line, the temptation that certain HIV-positive Kenyans face to sell their medication is unlikely to diminish in the near future.

"The fight against HIV/AIDS must be coupled with the fight against poverty. If not, we are wasting our time," says Omu Anzala, a senior lecturer in the Department of Medical Microbiology at Nairobi University's School of Medicine. Nairobi is the Kenyan capital.

The government claims to have steadily increased the number of persons who are receiving ARV medication in recent years: 39,000 patients were treated in 2005, up from 24,000 in 2004. The aim was to have 95,000 people on the drugs by the start of 2006.

But, says Anzala, "The government should get away from giving us numbers. It should be concerned about the quality and sustainability of the service. These numbers mean nothing when the majority of the patients are skipping or selling drugs."

The alleged sale of ARVs by some patients, and the erratic way in which others are said to take the medicine, has raised fears of drug-resistant strains of HIV in Kenya.

At present, there are only about 24 ARVs on the market -- and at any one time, a patient must be on three. If present trends continue, says Anzala, "we may not have any ARVs to talk about, since people will be resistant on all of them."

"There is a need to monitor people and to see if they are taking their medication as required, as well as monitor resistant strains of the disease."

Others claim that these problems would be circumvented if more attention was given to the matter of nutrition.

"When we talk about comprehensive care in HIV/AIDS, nutrition is part of it. But the government has neglected it; it only provides nutritional counseling and that is it," notes Asero.

"Some treatment centres may only give a packet of ujimix (porridge flour) per month. This is nothing."

A report issued last month by the International Treatment Preparedness Coalition, a grouping of AIDS organisations from across the world, also cites lack of nutrition as a major obstacle in the war against HIV/AIDS in Kenya.

"Nutritional support is still minimal except for nutritional education," says the document, titled 'Missing the Target -- Off Target for 2010: How to Avoid Breaking the Promise of Universal Access'.

The report was released last week ahead of the United Nations General Assembly Special Session on HIV/AIDS, which opened May 31 in New York.

Health officials say they are trying to improve nutrition amongst AIDS patients.

"There are activities going on to provide this service. Most of the hospitals are implementing it," David Mwaniki, head of the Technical Support Department in the National AIDS Control Council, told IPS.

"But, we need to work further to strengthen it." (END/2006)