Speakers:
Paluku Bahwere, Community Therapeutic Care (CTC) Adviser, Valid International

Claire de Menezes, Health & Nutrition Adviser, Action Against Hunger UK

Dr Fiona Samuels, Research Fellow, ODI

Chair:

Paul Harvey, Research Fellow, ODI

1. Paluku Bahwere began the meeting by describing a small pilot project run by Valid International in Selima, Malawi providing Ready-to-Use Therapeutic Food (RUTF) to adults with AIDS living in their homes.

2. He noted that in Africa, HIV/AIDS developed faster and led to higher mortality than in Europe. Health systems could not cope and many sufferers were cared for at home. (He works to support networks.) ART coverage is still very low, and many people only come for treatment late on and when malnourished already, leading to relatively high mortality rates.

3. In Malawi, Valid International had been administering RUTF to children. The pilot programme experimented with giving 3 months of RUTF to adults via the network of Home-Based Care (HBC) volunteers that they supported. The food was a chickpea/sesame supplement produced locally. Key research questions included:
- whether it would be unpalatably sweet
- whether there would be side effects and
- whether HBC volunteers would prove an effective delivery network

4. He said that 60 malnourished people were accepted onto the programme: most of these were severely malnourished and at an advanced stage of HIV/AIDS. After 3 months, the outcomes for the 60 people were:
- 5 left the programme unable to eat RUTF (or advised against it by traditional healers):
- 2 moved to another district after improving
- 11 died
- 42 completed the 3 months

5. Of those that completed, he said that the great majority showed significant improvement in capabilities, with 72% back to "normal activities". At the start, 34 people were unable to walk as far as the health clinic - 22 of these could do this at completion. He gave two individual case studies illustrating the dramatic effects of the programme, including one of a woman who gained too much weight and had to be taken off the programme.

6. He concluded that lessons learnt from the pilot included that:
- The majority of adults will eat RUTF
- Nutrition stabilisation prior to commencing ART is possible for some patients and may help improve response to ART
- Nutritional support provides relief for guardians and relatives
- Improved physical activity gives hope and increases willingness to undergo testing and ART

7. He finished by outlining the next phase of research, in Mangochi district, which will include:
- looking for better evidence on optimum duration and composition of RUTF for adults
- describing body composition change during weight gain

8. Claire de Menezes of Action Against Hunger (ACF International /ACFIN) then described how the impact of HIV had been visible in the 2002/3 food crisis in Southern Africa. ACFIN undertook a number of studies to look at the prevalence of HIV in malnourished children and their response to therapeutic feeding.

9. Overall HIV prevalence was 21.9%, however there was showed significant variation:
- Along regional divides: highest rates in the South, lowest in the centre
- Urban prevalence was almost three times higher prevalence than rural
- Dry season results showed significantly higher prevalence - there is more malnutrition in general during the rainy season

10. Preliminary results from clinical research revealed that around two-thirds of the HIV positive children receiving food would qualify for ART in Malawi on the CD4 count criteria (a measure of immune suppression). In practice only a handful are getting it. However, over one third would not, showing that severe malnutrition is not necessarily a sensitive marker for immune supression.

11. HIV positive children showed slower recovery from malnutrition. (The analysis of mortality data is not yet finalised.)

12. She outlined other ACF HIV related interventions, including:
- Several in Malawi, including setting up a cross-referral network between nutrition units, HIV services and TB services under the umbrella of the National Aids Council and
- Others across Southern Africa, including sociological, medical and public health approaches, highlighting the need for ACF to partner with local community organisations more specialised in HIV

13. She said ACFIN had also identified many outstanding issues, including infant weaning, risks of rapid weight gain under treatment, and nutrition for uninfected children with HIV positive mothers.

14. In conclusion she said that their work showed that:
- HIV positive children do respond to therapeutic feeding
- CD4 counts are not necessarily depleted in HIV positive children with severe malnutrition
- Nutrition rehabilitation centres are a good entry point for VCT and HIV services
- Stigma needs to be addressed through family centred and local community approach

15. Fiona Samuels then concluded the presentations with an account of a longitudinal study of the impact of HIV/AIDS on livelihoods in Zambia. This study had two waves (1993 and 2005), and used an analysis based on clusters of households to look at vulnerability, adaptability and resilience to HIV/AIDS.

16. She gave some detail on the cluster methodology, which moves away from households as the unit of analysis to look at clusters of individuals and households and seeks to thus reflect the complexity and fluidity of peoples' lives.

17. The study took place in two rural locations, one (Mpongwe) close to the copper belt, the other (Teta) relatively remote. She noted that the study found that HIV/AIDS prevalence was higher in Mpongwe, which had become a full "impact site" in which the disease was spread, while it was still relatively peripheral to remote Teta.

18. She noted a number of findings from analysis so far, including:
- The category of person(s) who had died in the cluster is important for determining the resilience of a cluster: the death of a "Primary Producer" was particularly serious
- Both vulnerability and resilience were high in Mpongwe, while Teta was protected by more diversified livelihoods, cropping systems & a less input intensive farming system
- The flexibility of the matrilineal system, particularly through weak marriage bonds and multiple residential options, has increased the possibilities for people and clusters to adapt to death and illness

19. She presented several conclusions and policy recommendations -

Clusters:
- vulnerability can only be understood in the context of multiple flows and relationships among households
anti-poverty programmes should target resource-poor clusters, rather than poor households
- a multi-faceted definition of vulnerability, not just AIDS-related, is needed.

Livelihoods and vulnerability:
- social networks can provide resilience, nevertheless even better-off farmers continue to be vulnerable to shocks and strains
- crop diversification remains important for household nutritional security, raising questions for national food policy
- livelihood diversification contributes to resilience.

Popular perceptions of HIV/AIDS in rural areas:
- AIDS is more openly discussed than in 1993 but the link to HIV is still poorly understood - health education is failing to address this
- traditional belief systems, e.g. relating to sexual cleansing and witchcraft, are strong and affecting health behaviour
- health education is failing to reach appropriate people: e.g. older women are channels for transmitting cultural norms about sex and sexuality, but are neglected in prevention programmes
- in the rural cultural context, the use of condoms is seen as promoting promiscuity.

Discussion

20. Areas covered in the discusion included:

- Gender analysis of the Zambian data: matrilineal systems seem to give women ability to farm independently - crucial in areas like Teta with diverse farming systems dependent on female labour. However, AIDS's social dynamics can increase women's vulnerability and intra-cluster tensions - divorce as well as death leaves more female-headed households that tend to accumulate orphans.

- Cost of and alternatives to the RUTF supplement: produced locally, a daily dose cost $2 (c half the price of imported RUTF) and was more cost-effective than the WFP's corn-soya blend. Storage and distribution was straightforward - refrigeration was not necessary, and HBC volunteers distributed it on bicycles. RUTF is not available on markets so cash was not an appropriate alternative. However, other nutrition was recommended alongside.

- The effect of aid interventions on resilience and clusters: a credit for maize production programme benefitted wealthier clusters in Mpongwe (while increasing inequality). Some households were deemed ineligible for external support on the basis of their health and resources, when a cluster analysis would have shown that their responsibilities for other poorer households were putting a severe strain on them, and that supporting them might be the best way to reach these poorer households. Primary households in a cluster might be able to share out goods that poorer ones might sell to meet short-term needs.

- Identifying AIDS-related deaths: while greater openness and willingness to be tested had improved the reliability of identification, stigma was still widespread and proxy indicators were still used in many cases.

- Relationships with traditional healers and use of medicinal plants: in Malawi there is a list of traditional plants that may have some impact. In the case presented today, traditional healers saw the intervention as competition, but in other districts cooperation had been achieved, to the point of joint surgeries and the programme receiving patients referred from traditional healers.

- VCT protocols for children: agreed that there was work to be done in this area.

- Nutrition in general: nutritional security the benefits of good diet rich in micro- and macro-nutrients etc are felt best before the onset of illness. In the Zambian study traditional crops and diverse diet seemed to improve nutritional balance - this might be a better route than multiple supplements and interventions.

- Speakers also highlighted the importance of HBC networks in the context of patient's reluctance to go to hospital, and the possibility for much more work that can be done on the Zambian data to increase understanding of clusters.

21. The Chair concluded the meeting by commenting on the innovation displayed in the work presented at the meeting, the importance of monitoring impact and constructing an evidence base, and the importance of understanding the complexity and fluidity of people's lives.