India: The HIV-hunger cycle

By Sugata Mukhopadhyay, HDN Key Correspondent, India

Let me tell you a story; of a woman who got HIV from her husband. There are so many stories of poor women who are infected by their husbands that you might ask what is special about this one. In many ways my story is sadly an ordinary one. But to me it is not only shocking but can teach us a hard lesson: Hunger and HIV are inextricably linked.

Sandhya (not her real name) was in her early thirties, living with her husband and two children in one of the cities in South India. Her husband was working in the private sector and had a good income. They had a happy life.

But things did not last. Sandhya’s husband suddenly fell ill and his symptoms, in the course of time, became chronic. He experienced rapid loss of weight, swollen glands, fevers and diarrhoea. His doctor finally gave him an HIV test which came back positive.

Sadly, Sandhya’s husband died despite attempts by the doctors to prolong his life. Sandhya and her two children were forced to move to her in-laws house.

At some point Sandhya also took an HIV test and was found to be positive too. Things got worse. Her in-laws threw her and her two small children out of the house. They thought Sandhya was woman of immoral character and that she had passed the virus to her husband causing his premature death.

Sandhya literally ended up on the street. She did not find any support from her parents or other relatives, nor could she find a job. Nobody wants to give people with HIV a job.

When hunger became intolerable, with the two small children to support, Sandhya made the boldest decision of her life. She became a sex worker.

So the crux of the story is, if you are hungry and your children are hungry, you will do whatever you can to survive.

Sandhya did not do anything different from what many would do in her place. She tried to provide enough food for her children and dreamt of a better future for them. Please don’t look at Sandhya’s story through the lens of morality.

My issue is not related to morality or sex work. It is food insecurity that makes people vulnerable to HIV. Sandhya is one such vulnerable woman but throughout the world there are millions of people who do not have enough food for themselves or their children and AIDS is constantly knocking at their doors.

More than 800 million people on earth know what is like to go to bed hungry. Around 200 million children below 5 years are underweight because they don’t get enough food. One child dies every five seconds from hunger and related causes. In India, which produces enough food for all its people, there are still incidences of death from hunger, and food insecurity is common place.

Food insecurity, most of the time, is man made and inevitably leads to corruption of human integrity thus generating numerous marginalized, hungry and humiliated populations all over the world. Hunger is the natural trigger mechanism for de-humanizing events like human trafficking, prostitution, drug use, child labour and migration pushing millions of people into the vacuum of AIDS. On the other hand, those already infected by HIV are constantly restrained from producing and utilizing food, being hobbled by disability, denial and discrimination. The cycle goes on incessantly making the virus even more deadly.

This is the HIV-hunger cycle gradually taking the shape of the ultimate destroyer and silently preparing to make the final assault in the form of AIDS.

Sandhya’s story is a perfect example of the HIV-hunger cycle. Breaking this cycle is probably the toughest challenge in tackling HIV/AIDS. I strongly believe that it is not condoms, ARV drugs, microbicides nor vaccines but an uninterrupted supply of food to the hungry people of the world that can really make the difference in reversing the pandemic.

As a doctor I have no medicine for AIDS so I am prescribing ‘food’ as medicine. Fight HIV with food if you really want to hit back at AIDS.

HDN Key Correspondent Team
Email: correspondents@hdnet.org
Web: www.healthdev.org/kc
HDN 2006 - Reproduction welcomed

Adequate Food Needed for ARV Programme

NAMIBIA feels the provision of Anti-Retroviral Therapy alone is not enough as there is a need for the adequate provision of food to people living with HIV if the implementation of this treatment programme is to succeed.
Speaking during the main festivity to mark World Aids Day yesterday, Prime Minister Nahas Angula said Namibia has been singled out as among the few countries in Southern Africa that have made strides in providing free Anti-Retroviral Therapy (ART) though he feels the programme is being hampered by the lack of food among those receiving treatment.
He called for the intensification of available social economic programmes to ensure those on ART have adequate food.
The event to mark World AIDS Day was attended by several MPs, diplomats and UN representatives among others.
In the past, cases have been reported that some of the HIV/AIDS sufferers in the country are unable to take their medication due to lack of food. Like most drugs, it is recommended that ARVs be taken on a full stomach.
In Namibia 13 274 people presently receive ART, making it one of the leading countries in the region with regard to provision of ART.
Since the declaration of HIV/AIDS in the country in 1986, the epidemic has shown some signs of stabilisation.
The Prime Minister announced that based on the 2004 National HIV Sentinel Survey, the prevalence rate in the past two years has decreased from 22 percent to 19,7 percent.
Windhoek, the capital and one of the most densely populated towns in Namibia, has in the past two years shown a decrease in the prevalence rate from 27 percent to 22 percent. Similarly, Oshakati reported a decline of 30 percent to 25 percent.
However, the decline does not necessarily call for celebration. The report reveals some worrisome trends in some parts of the country.
Swakopmund's prevalence rate went up from 16 percent in 2002 to 28 percent in 2004, while at Nankudu the rate increased from 16 percent to 19 percent. Looking at the critical age group of 15 to 19, there has been a decrease in the prevalence rate from 11 to 10 percent recorded at antenatal clinics. Even so, the Premier says it is very disturbing when one thinks of what this age group is doing at these places while they are supposed to be in classrooms studying to make a meaningful contribution to the economic development of the country.
"It is time to take stock of our interventions and strategies to ensure that they are appropriately targeted. It is time to see stabilisation and decline of HIV prevalence in all sites where the study is conducted," indicated Angula. This year's World AIDS Day is commemorated under the theme, "Stop AIDS, Keep the Promise".
Considering that the country does not only face the HIV/AIDS challenge but also high levels of violence against women, on this day the Prime Minister also urged men to "make a promise to stop AIDS and violence against women and children!
"For those who have already made the promise, keep the promise to stop AIDS and violence against women and children!"
The Namibian government vows to keep the promise and so have the civil society, private sector, development partners, and leaders called to "Stop AIDS, Make/Keep the Promise!"

Source: ProNut- HIV eForum

Malnourishment at time HIV treatment is started equals much poorer survival

AIDSMap, Michael Carter, Thursday, June 29, 2006

Malnutrition at the time antiretroviral therapy is started is associated with significantly poorer survival, according to a study published in the July edition of HIV Medicine.

In a retrospective study conducted in Singapore, investigators found that patients who were malnourished when they initiated potent HIV therapy had a six-fold increase in the risk of death compared to patients with good nutritional status.

However, CD4 cell recovery was comparable between malnourished and well-nourished patients, and the investigators speculate that the increased mortality seen in patients with malnourishment could have been due to factors such as poorer drug absorption, inability to tolerate treatment, or lower physical functioning.

They recommend that nutritional support should be provided to malnourished patients when anti-HIV treatment is started to reducing the risk of death. An association between malnourishment and poorer prognosis in HIV-positive individuals was well described in the period before anti-HIV treatment became available.

Even in the era of potent antiretroviral therapy, the unintentional loss of just 3% of body weight is associated with poorer survival. It is possible that malnourishment at the time anti-HIV treatment is started could result in poorer recovery of immune function, meaning that patients are vulnerable to opportunistic infections for longer.

No studies have previously investigated this connection, so researchers in Singapore conducted a retrospective analysis of the medical records of 394 HIV-positive individuals who started any form of antiretroviral therapy from 1991 to 2000 with a CD4 cell count of 250 cells/mm3 or less.

Nutritional status was defined by calculating a patient’s body mass index (BMI). If an individual had a BMI below 17 kg/m2 they were defined as being malnourished. Patients were followed for a median of 2.4 years.

A total of 79 individuals died during follow-up and median duration of survival was a little over five years. Median BMI was 20kg/m2 and 16% of patients were moderately to severely malnourished when they started HIV treatment.

Three factors were identified by the investigators as being associated with poorer survival after the initiation of HIV therapy: an AIDS diagnosis (p = 0.14); taking monotherapy or dual antiretroviral therapy as opposed to potent three drug HIV treatment (p = 0.03); and, malnutrition (p = 0.004). In the period 1991 – 2000, malnourished patients had a hazard ratio of death of 2.19 compared to well nourished patients.

When the investigators restricted their analysis to the 136 individuals who took potent antiretroviral therapy, they found that patients with malnutrition had a six-fold increase of death (hazard ratio 6.14, p = 0.01) compared to patients with good nutrition.

Data on CD4 cell count six months after the initiation of HIV therapy were available for 330 patients. The median increase in CD4 cell count was 64 cells/mm3 and there was no significant difference in the increase seen in patients with or without malnutrition.

“We found that malnutrition was significantly associated with reduced survival in patients commencing antiretroviral therapy”, write the investigators, who stress, “for patients starting antiretroviral therapy with moderate to severe malnutrition, the hazard ratio of death was doubled overall.

For patients who commence HAART, the hazard ratio for those with moderate to severe malnutrition was six-fold higher than for those with normal nutritional status.”

As recovery of CD4 cell count was similar between patients with good nutritional status and malnourishment, the investigators suggest that factors such as poorer drug absorption, reduced ability to tolerate side-effects, and decreased physical function which can accompany malnourishment.

Mortality amongst individuals initiating HIV therapy could, the investigators suggest, be reduced by providing nutritional support to malnourished patients.

They call for randomised controlled trials to conducted to determine the optimum nutritional support for patients starting HIV therapy. Reference Paton NI et al.

The impact of malnutrition on survival and the CD4 cell response in HIV-infected patients starting antiretroviral therapy.

Source: AIDSMap

HIV Medicine 7: 323 – 330, 2006.