1. Linking ARVs with Nutrition, Food Security and Livelihoods: RENEWAL in Africa Stuart Gillespie International Food Policy Research Institute International AIDS Conference, Toronto, 15 August 2006

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

3. Loevinsohn and Gillespie 2003

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

5. The Regional Network on HIV/AIDS, Rural Livelihoods, and Food Security (RENEWAL) Facilitated by IFPRI, RENEWAL brings together national networks of  researchers,  policymakers,  public & private organizations, and  NGOs to focus on the interactions between HIV/AIDS and food and nutrition security.

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

7. Why link nutrition with treatment? Because malnutrition and disease interact Many PLWHAs are often malnourished Because PLWHAs and families often demand food first Nutritional support leads to: Better drug bioavailability and efficacy of treatment Better tolerance/ fewer side effects leads to better adherence, which in turn leads to delays in development of drug resistance May prolong period before ARVs are required Better nutritional status at start of treatment increases survival (by a factor of six)

8. …but nutrition security is the goal Targeted nutrition interventions may provide useful short-term support for people living with HIV, so long as stigma and other barriers are dealt with…. ….but ultimate aim should be to promote sustainable livelihoods which will ensure household and community- level nutrition security

9. Community-driven approaches are key Communities are responding to HIV and AIDS They have incentives, local information, transparency, accountability, latent capacity -- but they lack power and resources. AIDS is crosscutting, multisectoral, horizontal......…just like people’s lives. Experience to build on (nutrition, CDD) Community-government partnerships

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

11. Can formal nutrition interventions complement local support networks? A case study of AMPATH’s Nutrition Supplementation Program for Individuals on ARV treatment, in western Kenya Elizabeth Byron, Stuart Gillespie and Mabel Nangami

12. Methodology Data Collection: 1. Qualitative Research (Dec. ’05 – Feb. ’06) Key Informant Interviews (18) Focus Group Discussions (9) In-depth Interviews (80) 2. Modular household survey (March-Sept. ’06) 3. Clinical data from AMPATH Medical Records System 4. Data from HAART & Harvest Initiative on food distribution

13. Sources of support to PLWHA Formal Support – narrow and focused –ARV treatment –HHI/WFP food supplements – short-term –FPI- loans, skills training, employment –Patient support groups Informal Support – irregular, reciprocal –Family and relatives – informal transfers –Borrow from neighbours/friends –Religious institutions –Community (Harambee, merry-go-rounds)

14. Factors determining support Stigma and attitude toward PLWHA Disclosure (awareness of needs vs. discrimination) Social relationships (family, in-laws) Competing needs and availability of resources Seasonality (demand/supply) Marital status Gender Children Health status, duration of sickness

15. Interactions between nutrition intervention and informal social support networks Positive impact –Improved health status  Catalyst for greater support –Balanced diet becomes accessible –Reallocation of household resources to other needs No change –No prior support (formal program fills gap) –Support remains constant Negative impact –Stigma, initially with food collection, declining –“Weaning” preparation not integrated –Dependency and expectation of support

16. Lessons 1.Stigma remains a barrier to accessing community support 2.Formal nutrition intervention acts as temporary relief and often replaces overstressed informal networks. 3.Observable health improvements in PLWHA can serve as a catalyst for additional sources of support from community/family. 4.Seasonal patterns of food availability imply a greater need for formal support at different times of year. 5.Large variation in individual access to support and ability to successfully transition off food support at 6 months 6.AMPATH Patient Support Groups fill unmet psychosocial needs that family/friends may be unwilling to provide. 7.Need for better local and external linkages and partnerships re: livelihood support