Poverty, Agriculture and Health:

Lessons from the HIV response

Stuart Gillespie

International Food Policy Research Institute

Regional Network on AIDS, Livelihoods and Food Security

London International Development Centre, 23 June 2010

The World of HIV

© Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).

The World of Income

© Copyright 2006 SASI Group (University of Sheffield) and Mark Newman (University of Michigan).

HIV prevalence in Africa

Livelihood/food insecurity

HIV & AIDS

Malnutrition

Three coexisting/interacting crises

Vulnerability of Livelihood Systems to AIDS

Vulnerable Groups - Orphans, Elderly and Youth Headed Households,

Effect on InstitutionsCommunity-based, Civil society, Market, State, Global

OutcomesNutrition, Food Security, Education, Community Cohesion, Income

Effect on AssetsHuman, Financial, Social, Natural, Physical, Political

ResponsesIndividual, Household, Community

Vulnerability to infection

HIV

Stigma and Discrimination

HIV AIDS

upstream downstream

Food insecurity

Malnutrition

mid-stream

Three stages of vulnerability

HIV AIDS

prevention mitigation

Food insecurity

Malnutrition

care & treatment

HIV strategies

HIV

Food insecurity

Malnutrition

Upstream vulnerability

HIV and Income Poverty

0%

5%

10%

15%

20%

25%

0 10 20 30 40 50 60 70

Botswana

Lesotho

Zimbabwe

Zambia

Malawi

Mozambique

TanzaniaCôte d'Ivoire

UgandaKenya

South Africa

Nigeria

Cameroon

Ghana

Central African Republic

Mali

Namibia

HIV and Income Inequality

0%

5%

10%

15%

20%

25%

30%

35%

25 35 45 55 65 75

Botswana

Lesotho

Namibia

Zimbabwe

Zambia

Malawi

Mozambique

Tanzania

Central African Republic

Ethiopia

Côte d'IvoireUganda

Kenya

Rwanda

South Africa

NigeriaCameroon

BurundiGhana

Senegal

Swaziland

HIV

Food insecurity

Malnutrition

Upstream vulnerability

Poverty? Wealth?Food insecurityMobilityGender inequalitiesSocial cohesionHope?

HIV AIDS

Mid-stream vulnerability

The Vicious Cycle of Malnutrition and HIV

Insufficient dietary intakeMalabsorption , diarrheaAltered metabolism and

nutrient storage

Increased HIV replication

Hastened disease progression

Increased morbidity

Increased oxidative stress

Immune suppression

Nutritional deficiencies

Source:Semba and Tang, 1999

HIV AIDS

Mid-stream vulnerability

ART access and adherenceSTIs (especially HSV-2)MalnutritionFood insecurity (time, resources for care)

AIDS

Food insecurity

Malnutrition

Downstream vulnerability

Impacts of HIV and AIDS on agriculture

Subsistence, commercial, and agricultural extension

Resource (e.g. cash, labor) shortages and reduced productivity

- affects land use (crops, diversity, yields, livestock)- move to low input/low output farming- natural resource mining- child labor

Loss of farm-specific knowledge

- less intra-household learning (inexperienced farmers)- greater risk aversion to new technology- less appropriate farming practices (environment)

(less schooling due to dropout & teacher mortality)

Institutional capacity and organizational change

- loss of formal and informal institutional capacity- weaker rural organizations- changes in cultural norms, property rights

AIDS

Food insecurity

Malnutrition

Downstream vulnerability

Depends on quantity, quality and mix of assets at household and community levels, institutional context and processes.

AIDS impoverishes (directly and indirectly)

Intra-household effects (women, children)

More volatile food prices

Source: Data from FAO 2009 and IMF 2009.

Prices fell as financial crisis and recession developed

Food prices and food crises

• RENEWAL/UNAIDS/ NAP+ eastern and southern Africa– Impacts on PLHIV– Impacts on HIV response– Rapid qualitative appraisals, key informant interview, focus

groups

• Negative interactions more common and more severe• Additional threshold effects e.g. children denied

schooling, ARV treatment stopped….

How to respond?

Livelihood/food insecurity

HIV & AIDS

Malnutrition

Agriculture

Social protection

HIV programs

Nutrition/health programs

HIV AIDS

prevention mitigation

Food insecurity

Malnutrition

care & treatment

HIV strategies

Securing Livelihoods• Local food production (home gardens, ag inputs, small livestock)

• Training (e.g. conservation farming, vocational; farmer field schools)

• Support existing livelihoods activities where possible• Address real asset constraints (cash, land, labor?)

• Maximize efficiencies, pooling labour where appropriate• Attention to laws, rights, norms: e.g. inheritance• Challenges: Programs tend to be small-scale; hard to

rigorously evaluate; uncertain sustainability• AIDS-sensitive pathways out of poverty (e.g. IMAGE)• Linkages and integration

– With food aid, ART programs, and/or HIV awareness (e.g. TASO in Uganda, AMPATH in Kenya)

– Linking small-scale agriculture with social protection, school feeding, HIV treatment and nutritional support.

Lower capacities-----------------------------------------Higher capacitiesFaster to scale----------------------------------------------Slower to scaleLower inputs-----------------------------------------------Higher inputs

Secure basic consumption

Reduce fluctuations in consumption and avert asset reduction

Enable people to save, invest, and accumulate throughreduction in risk and income variation

Build, diversify, and enhance use of assets• Reduce access constraints

• Directly provide orloan assets

• Build linkages with institutions

• Food Transfers

• Public works• Insurance (e.g. health, asset)

• Livelihoods support• Savings and credit

• Maternal and Child Health and Nutrition• Child and adult education/skills

• Early childhood development

Conditional food transfers

Transform institutions

and relationships

• Economic• Political• Social

Protective Preventative Promotional Transformational

Conditional cash transfers

•Unconditional cash transfers

SOCIAL PROTECTION: OBJECTIVES AND INTERVENTIONS

Skill buildingCapitalProductive AssetsProtection from asset/capital erosionEmployment

SurvivalProductive AssetsEmployment

PROTECTION AND PROMOTION

Agricultural inputs subsidy Public worksInsurance programmes (Social, Crop & Livestock)Village savings loansMicro-credit/finance

PROMOTION

Public works School FeedingCash and food for assets combined with skills building and cash for consumption/ Adult literacy training

PROVISION

Social cash transfers Food and nutrition

NEEDS INTERVENTIONS

Malawi’s Draft Social Support Programme (Government of Malawi and UNICEF 2009)

5%

10%

25%

SurvivalInvestment in human capital

Ultra Poor with

Labour Capacity

Ultra Poor & Incapacitated

Moderately Poor

40% MALAWI POVERTY LINE

15%

Ultra Poor

The Regional Network on AIDS, Livelihoods and Food Security

Facilitated by IFPRI, RENEWAL

brings together national networks of

• Researchers• Policy makers• Public and private organizations• NGOs

to focus on the interactions between HIV, AIDS, food and nutrition security

www.ifpri.org/renewal

Lessons and Challenges

• Beware AIDS exceptionalism– Use an HIV lens, not a filter

• Think livelihoods, not agriculture per se.• Rarely is it “either/or”• Face challenge of diversity, complexity, context-specificity• Use/adapt tools to move from understanding to responding• Evidence-based action (but don’t wait for last 5%!)• Learn by doing (action research)….• …and by monitoring, evaluating and communicating• Balance quality, speed, capacity• Scale up:

– Focus on the process beyond the project, think about capacity and incentives. Aim for transformation, not exit strategies.

• Link research with action, both ways