1. Seasonal hunger, the 2001-03 famine and the dynamics of HIV in Malawi Michael Loevinsohn, PhD Seasonality Revisited International Conference IDS, July 8-10, 2009

2. Hunger pushed people further into existing situations of HIV risk From contemporary accounts:  Distress migration: People moved to other rural areas, towns & cities for food/work  Transactional (“survival”) sex: Young women sent out for a bowl of maize; sex for day work  Early marriage: Young women forced into unwanted relationships with older men

3. Methods Data sources: Antenatal clinic surveillance 1999 & 2003  Rural & non-rural sites, 1/district  HIV status, age, education, occupation Survey of food needs at the crisis’ peak  proportion of HHs needing assistance, by district Integrated HH Survey 2004-05  migration Analysis: Multilevel modeling (1-woman, 2-district/clinic)

4. HIV prevalence at Malawi antenatal sites 1994-2005

5. Change in HIV vs. rural hunger Rural antenatal sites

6. Change in HIV vs. rural hunger Non-rural antenatal sites ■ cities ▲ towns

7. Change in proportion of farmers vs. hunger: rural antenatal sites

8. Change in proportion of farmers vs. hunger: non-rural antenatal sites

9. Rural-to-non-rural migration 2004-05

10. Conclusions The famine has had a rapid and substantial effect on HIV prevalence & population distribution across Malawi  Beyond hunger & malnutrition Additional HIV burden among village women Additional HIV burden among migrant women The bill in illness, death, medical costs, etc. to be paid over the coming years Disrupted lives from involuntary migration

11. Conclusions  The situations of risk exist elsewhere in famine and hungry seasons  Extrapolation of the quantitative effect needs care: Threshold in the rural prevalence response to hunger (?) Effects may be understated due to relief effort in 2002-03 absent in hungry seasons

12. Conclusions  Actions that help people secure food and livelihood may help them avoid situations of risk and may be yielding an uncounted “prevention dividend”  Cassava cultivation appears to have yielded such a dividend in Malawi in 2001-03  Many more robust opportunities exist and can be built

14. Cassava and hunger Dec 2002 – Mar 2003

15. Cassava and maize price February 2002