Synopsis
The effects of the HIV/AIDS pandemic on public health
are well-known: more than 40 million are currently infected
with HIV, and approximately 29 million have already died
of AIDS since the pandemic began. Every day, more than 8,200
die from this disease. As bad as these numbers are, HIV/AIDS
is having an increasingly devastating impact on other development
sectors as well. In countries where the pandemic is most
advanced, HIV/AIDS is eroding human capital, degrading organizational
capacity, fragmenting social and economic networks, and
disrupting the transfer of knowledge and skills that are
vital to socioeconomic performance and development. These
changes produce a self-reinforcing downward spiral that
becomes increasingly more difficult to arrest the longer
it continues.
This session will start with a 20-minute presentation on
“Mitigating the Impacts of HIV/AIDS on Development”
by Richard Cornelius (Senior Policy Advisor for Health,
PPC/P) on new policy guidance from PPC on programming to
mitigate the development impacts of HIV/AIDS. The presentation
will focus on the following issues:
- What is the rationale for supporting efforts to mitigate
the development impacts of HIV/AIDS?
- What are the costs and benefits of cross-sectoral collaboration
on mitigation programs?
- What are examples of best practices from the field?
- What are some of the practical funding and organizational
considerations to consider?
The second part of the session will be a 20-minute presentation
on the scope and nature of “HIV/AIDS and Complex Emergencies”
by Peter Salama (HIV/AIDS Senior Advisor, Africa Bureau).
The presentation will focus on the following issues:
- What is the scope and nature of the HIV/AIDS problem
in complex emergencies?
- What are inter-agency recommendations to address the
problem in complex emergencies?
- How is this problem being addressed?
- What can be done to improve our efforts, and what is
the way forward?
Notes
Richard Cornelius, USAID/PPC
Cornelius set the stage for this Summer Seminar on HIV/AIDS
by pointing out that 29 million have died of AIDS-related
causes and 40 million people are currently infected. The
world has mobilized political and financial energy to fight
HIV/AIDS, coordinating multilateral and bilateral partners,
especially in the health sector. The United States has pledged
$15 billion dollars over a five-year period under the President’s
Emergency Plan for AIDS Relief (PEPFAR).
The Plan aims to treat up to two million people with antiretroviral
(ARV) drugs, to prevent seven million new infections focusing
on 15 key countries where the disease is most prevalent,
and to provide care and support for 10 million individuals
that are infected or affected by HIV/AIDS.
Cornelius heavily stressed that HIV/AIDS affects every
sector of development. HIV/AIDS threatens to reverse development
gains and destroy the fabric of societies in which it is
prevalent. Diminished social and economic infrastructure
in turn creates an environment where HIV/AIDS pandemic can
flourish. On the economic front, HIV/AIDS generates a depletion
of manpower, particularly in the most productive age groups.
Administrator Natsios has called for an Agency- and development-wide
effort to combat the negative consequences of the epidemic.
USAID’s Bureau for Policy and Program Coordination
is drafting policy guidance that supports all sectors of
missions in mitigating the impacts of HIV/AIDS in high-prevalence
countries, including facilitation of impact assessments
in each sector as well as support for new information to
aid in government decision-making.
The cumulative impact of HIV/AIDS aggravates old development
problems in new ways with respect to educational and economical
infrastructure due to teacher mortality and loss of labor.
Agricultural production has decreased as a result of reductions
in the amount of land being cultivated, often because women
lose their land if their husband dies. HIV/AIDS also affects
military capacity; and Cornelius noted that the military
is also a critical “vector for infection” of
civilian populations. The rapid spread of HIV/AIDS creates
intense pressure on government investment in training and
equipping of personnel. Human resource losses mean difficulties
in everything from resource planning to providing social
services.
PPC’s policy guidance is suggesting a number of tactics
for missions to combat the impact of HIV/AIDS and requires
relatively little resources. First, missions and governments
need to change their how they think about HIV/AIDS. They
need to understand that it affects more than just the health
sector and to create a space for dialogue among all sectors
of development. Second, it is imperative that missions take
actions to expand their awareness of the scale and nature
of the HIV/AIDS problem and mount an effective response.
Cornelius also suggested some medium- and long-term activities
to ameliorate the epidemic, including collaborative efforts
at the community level and mobilization of existing services,
including agriculture extension services. LDC governments
should also revisit policies and procedures to take account
of the social and economic impacts of HIV/AIDS. Additional
resources naturally are leveraged during the process of
broadening sectoral development approaches to include HIV/AIDS.
For example, the Mobile Task Team project funded by the
Africa Bureau at USAID and implemented by the University
of Natal, South Africa—works to build low cost systems
to monitor the impact of HIV/AIDS on teacher workforce and
school attendance in several countries.
Cornelius concluded his presentation by outlining several
roles that health workers can play a role in facilitating
mitigation interventions in non-health sectors, like participating
in local donor coordination.
Peter Salama, HIV/AIDS and Complex Emergencies:
Challenges and Progress
Salama chose to discuss HIV/AIDS and complex emergencies
in Africa because the continent is home to the world’s
majority of people with HIV/AIDS, people who suffer from
food insecurity, and refugees. The rate of HIV prevalence
in Africa increased from about 0 to 5 percent in 1985 to
39 percent in most countries in 2001 and has yet to peak.
One of the most significant factors of the continued spread
of HIV/AIDS is the burgeoning numbers of orphans left behind.
There were one million AIDS orphans in sub-Saharan Africa
in 1990; currently, there are 12 million.
Salama highlighted some important global trends in HIV/AIDS.
First, up to 60 percent of those infected in Africa are
women. Second, researchers are using better methods of acquiring
data, like population-based surveys. Third, access to treatment
(the theme of the Bangkok 2004 conference) is the linchpin
of the President’s Emergency Plan and the World Health
Organization’s (WHO) Three by Five initiative. Finally,
there has been an increase in resources for HIV/AIDS: from
one to seven billion dollars from 2000 to 2005.
Salama then went on to discuss the role of HIV/AIDS in
complex emergencies. According to Toole (1997), a complex
emergency is “a situation that affects large civilian
populations and usually involves a combination of war or
civil strife, food shortages, and population displacement
resulting in significant excess mortality.” A conflict-affected
population has two options: (1) to move domestically becoming
internally displaced peoples (IDPs) or (2) to cross the
border and become refugees. Either option leaves them vulnerable
to military and sex workers.
Surveillance systems are readily in place for monitoring
the major causes of death in complex emergencies, for instance
malnutrition and diarrhea. However, these surveillance systems
do not exist for HIV/AIDS. According to Salama, HIV/AIDS
is not just underestimated but is under-programmed for.
Some of the many causes of increased HIV/AIDS risk in complex
emergencies are the disruption of societal structures and
mores and economic vulnerability of women and unaccompanied
children (UAC).
The risk factors for conflict and displaced persons vary
according to HIV prevalence of the area of origin and the
surrounding host population, as well as the length of time
of the conflict. Behavioral change, gender violence, transactional
sex, and reduction in resources and services all increase
HIV risk. However, it is also possible that complex emergencies
actually decrease the risk of infection due to the remoteness
of most refugee camps from the general population, which
leads to a reduction in mobility and accessibility. In 2003
in Africa, HIV prevalence was significantly less in countries
of origin than in countries of asylum (UN High Commission
for Refugees, 2004).
The major challenges of HIV/AIDS in complex emergencies:
donor coordination, inclusion of HIV/AIDS refugees into
proposals and interventions, HIV/AIDS protection, and operational
research. He spoke to the coordination challenge by outlining
the UNAIDS program, the “Three Ones.” The “Three
Ones” is UNAIDS’ web site attempt to have all
governments to agree to three major principles: (1) one
national strategic plan, (2) one national coordinating body,
and (3) one national monitoring and evaluation plan.
With respect to government intervention, only 43 percent
of asylum countries in Africa had a national HIV strategic
plan. In addition, only 23 percent of GFATM-approved (Global
Fund to fight HIV/AIDS, Tuberculosis and Malaria) proposals
include proposals for state activities for refugees. Protecting
displaced people from HIV/AIDS involves addressing gender
violence, discrimination, and stigma. Host countries should
not require mandatory testing or deny asylum, resettlement,
or right of return according to HIV status. UNHCR was reluctant
at first to provide testing and counseling services for
fear of stigmatizing the refugees; however, this has changed
in the last four years.
There are many questions that can be answered by operational
research in the area of HIV/AIDS and complex emergencies,
especially with respect to the unique context which complex
emergencies can bring. Recent examples of operational research
success can be demonstrated by the development of standardized
assessment and measurement and evaluation tools as well
as the integration of displaced peoples and surrounding
communities in Uganda.
Samala described a 2004 situation analysis of HIV/AIDS
in post-conflict Liberia to bring to light program issues
and relate them to longer-term development programs supported
by the U.S. government. In Liberia, and in West Africa in
general, it is very rare to see HIV/AIDS prevalence rate
above five percent. This is likely due to high rates of
male circumcision in West Africa. However, recent studies
vary and may be unreliable due to the post-conflict human
situation.
Samala briefly pointed out the instability due to internal
civil warfare in Liberia for more than a decade. He emphasized
the unusually high prevalence of systematic rape—including
multiple rapes and child sex slaves—as part of the
war strategy.
In order to capture the situation in Liberia, Samala met
with the National AIDS Control Program (NACP), US mission,
UN agencies, IOs and NGOs. He also conducted field visits,
interviews and debriefings. Samala used HIV prevalence in
blood donors and extrapolated the data in order to estimate
HIV prevalence in the country. Using the blood donor population
offered Samala a more unbiased sample than would blood taken
from those voluntarily seeking an HIV test. The study showed
that HIV prevalence in blood donors has steadily increased
since 1994. According to the study, five percent of the
Liberian population is HIV positive, which amounts to 75,000
PLWHA, with young women, mobile men, and commercial sex
workers left the most vulnerable.
In terms of the behaviors that contribute to the spread
of HIV/AIDS, Samala lamented that gang rapes, multiple rapes
and sex slaves—one-third of women in refugee camps
underwent rape counseling. These attacks significantly increase
the spread of HIV/AIDS because they involve high numbers
of partners and high numbers of sexual acts over time. He
talked about AIDS awareness statistics; for example, 75
percent of Liberians believe PLWHA look sick and thin.
Though the responses to war in Liberia were not commensurate
with the goals of HIV/AIDS awareness and prevention, there
is hope that church networks and HIV pioneers will bring
the issue of HIV/AIDS to center stage. Salama presented
a conceptual framework wherein he charted biological, social,
economic, and political factors that lead to the vulnerability
in HIV women. He also called attention to the 42,000 ‘double
orphans’ (children who have lost both parents) in
Liberia and the consequences, such as country instability,
that a large population of uprooted children present.
Salama concluded his presentation on HIV/AIDS and complex
emergencies by recommending several actions, including determining
the level of HIV prevalence in an area, standardizing and
improving care and treatment practices, and expanding non-institutionalized
care for orphans.
Food, Nutrition and HIV/AIDS: Evidence and Priority
Actions for AIDS Prevention, Care and Treatment Programs—Peter
Salama
HIV/AIDS and nutrition are “inextricably inter-related.”
Malnutrition is widespread in children and in pregnant women
resulting in health complications, such as stunted growth
and micronutrient and iodine deficiency disorders. Orphaned
children are at a greater risk of undernourishment.
HIV/AIDS exacerbates the negative effects of malnutrition,
including increased susceptibility to secondary infections
due to a weaker immune system. HIV directly affects nutrition
by increasing energy requirements, reducing dietary intake
(due to oral sores or depression), and contributing to nutrient
malabsorption and loss (diarrhea) and metabolic changes
(impaired and increased nutrient utilization).
Nutrition in turn affects AIDS. Because HIV infection increases
energy requirements, food intake must be enough to compensate
for the loss in calories. If not, weight loss occurs. Loss
of lean body mass was shown in a study by Wheeler et al.
(1998) to strongly predict the risk of illness and death
in HIV-positive adults. In addition, deficient levels of
micronutrients (MNs) are associated with more rapid disease
progression. To compound this finding, studies have suggested
that people living with HIV/AIDS (PLWHAs) have larger MN
deficiencies than the general population. Some MNs (Vitamin
A, iron, and zinc), if taken in too high amounts, have been
found to produce dangerous consequences. More studies are
underway to determine the nature of these relationships.
Samala outlined a few outcomes of nutrition intervention
and improvement on the progression, transmission, and survival
of HIV/AIDS. First, high energy/protein food supplements
support weight gain, but the gain is mostly fat, not lean
muscle mass. Samala emphasized that, contrary to the beliefs
and strategies of many organizations, increased protein
intake does not prevent or reverse muscle wasting. Second,
studies have shown micronutrient supplements to have widespread
positive consequences, such as increasing survival rates
in adults with advanced disease. Though nutrition interventions
can offer PLWHA many benefits, the impact depends on the
type of intervention, duration, and underlying nutritional
status.
There is a myth that nutrition, care, and counseling can
be discarded after starting antiretroviral (ARV) treatment,
but Salama showed research that this is not true. Two of
the most common reasons for not adhering to ARV treatment
in a 2003 study were nausea and vomiting, which could be
ameliorated through nutritional counseling. In addition,
about one-third of patients commencing ARV treatment developed
muscle wasting.
Samala concluded by recommending actions for nutrition
in HIV-care, including education and counseling, targeted
or prescribed supplementation, and other food interventions.
He also outlined a twelve-point ‘Proposed Framework
for Action’ that suggested guidelines from improving
HIV/AIDS advocacy and awareness to training and supervising
health workers.
Question and Answer Session
Early efforts to take a multi-sectoral approach
to the HIV/AIDS epidemic were stymied by the fact that development
assistance funds are appropriated for specific accounts.
Given the inherent multi-sectoral nature of many HIV/AIDS
programs, what restrictions remain on the use of PEPFAR
funding with respect to spending it on purposes that appear
not be directly related to AIDS, but that are? Are there
still significant problems with using PEPFAR funding in
[office business centers] OBCs and other multi-sectoral
programs?
Yes, there are still some issues. With respect to the child
survival and health account, Congress expects HIV/AIDS funds
to be used specifically for HIV/AIDS prevention, care, and
treatment. Earlier in my presentation, I emphasized some
low-cost ways of integrating HIV/AIDS into all sectors of
the development portfolio. These are things that should
be done. Over the last few years, the President has increased
the development assistance budget. In addition, there are
opportunities for collaborative efforts between the health
and other sectors for fighting HIV/AIDS. For example, agricultural
workers have been used to distribute condoms.
Is there anything that you all are working on that
deals with capacity issues in general? In particular, are
you addressing the global policy issues that are impinging
heavily upon capacity constraints in developing countries—especially
the flight of health care workers out of the developing
and into developed nations?
First, certainly PEPFAR is acutely aware that human capacity
is a barrier to achieving the established goals. Health
sector capacity is stretched thin already. More money is
going to improve capacity constraints. There is some concern
that human capacity will be removed from child survival
projects and redistributed to HIV/AIDS programs because
that is where the money is. They are aware of these problems
and have included them in the five year strategy. As I said
earlier in my presentation, loss of human capacity is one
of the foremost problems resulting from the AIDS crisis.
Regarding your case study on Liberia, can you talk
about what you’ve seen in terms of existing programs
to deal with HIV/AIDS in the DDR situation? What do the
peacekeepers have in place? Did you see NGOs or other interested
groups dealing with the guys with guns?
The UNFPA and the International Rescue Committee are supporting
counseling services, HIV awareness, and condom distribution
as part of the demobilization process. One of the challenges
in the demobilization facilities is that people are only
there for a short time—one to two weeks. Voluntary
counseling and testing in camp situations makes it hard
to maintain confidentiality, which could lead to negative
consequences. Therefore, we’ve decided to push for
VCT more generally throughout the country.
It seems that in the hot spots when things are
exploding, U.S. government’s Office of Planning, Finance
and Budget isn’t keen on funding HIV/AIDS interventions
in Iraq. Is there any talk of including HIV/AIDS in hot
beds like Iraq?
We are funding several HIV/AIDS awareness projects in the
health sector and are looking to expand muti-sectorally.
We do have a memorandum agreement with Global Health to
provide condoms and test kits. If you wish to access those
two sources, I have a procedure and policy and that is free.
What are national governments of post-conflict
areas doing to reinforce local statutory rape laws? How
do you plan to address gender discrimination? I see a focus
on HIV/AIDS prevention and treatment, but not on the social,
emotional, or spiritual aspect. Who is funding the social-emotional
underpinnings of the AIDS epidemic?
With respect to gender discrimination, we need tangible
programs that address gender discrimination—i.e.,
counseling services and women’s health programs. Regarding
your question on the legal system, many times the legal
system is broken down; therefore, we cannot be totally reliant
on it. UNICEF and USAID are advertised as one of the core
programs addressing the issue of female exploitation. The
refugee environment, more specifically, is mandated by UNHCR
to ensure that women are protected both in terms of the
legal environment under refugee law and under practical
programs that can reduce women’s risk—such as,
placement of latrines.
Fighting gender discrimination and empowerment of women
have long been a critical priorities for USAID. Many of
the development activities endorsed by USAID are geared
toward women’s empowerment. For example, USAID supports
family planning and reproductive health programs for women.
Food, Nutrition, and HIV/AIDS
The issue isn’t about treating the victims;
it’s about changing the social institutions that create
a fertile environment for the spread of HIV/AIDS. I think
it’s absolutely essential to work with the Africa
government to tackle the fundamental problem of gender discrimination
that makes women so susceptible to HIV/AIDS infection.
I couldn’t agree more. Women shouldn’t have
to choose between short-term treatment programs and programs
that address the longer-term underlying social ills that
perpetuate the AIDS epidemic. It’s not an either/or
decision. It’s important to note that it was not the
donor governments that advocated for access to treatment.
It was the African people. For example, in South Africa,
people turned out by the thousands because they didn’t
want to die from AIDS.
You mentioned cross-sectoring in terms of how agencies
work together. You mentioned ‘scaling up’—where
does infrastructure or long-term development fall into this
equation? How do we provide equipment, when the USAID budget
allocates very little toward infrastructure. How can we
match out budget priorities with our policy priorities?
On the question of infrastructure, I can only talk about
the President’s Emergency Plan (available on the State
Department’s web site: www.state.gov). In the PEPFAR
there is actually a lot of money going into both the human
and physical, in terms of laboratories and health clinics.
There is a significant amount of money going for equipment
in PEPFAR. You are right about the importance of coordination
amongst agencies and donors. Historically, different donors
have a comparative advantage in providing different types
of assistance. Some donors are more willing or more prepared
to provide one type of equipment than another.
Zinc has been shown to the enhance immune system.
There has been a recent study by Johns Hopkins about Diarrhea.
Do you know of any studies in HIV/AIDS using zinc?
The data coming out on micronutrients needs to be inspected.
The current data suggests that vitamins B, C, and E have
positive effects in terms of decreasing HIV transmission
from mother to child. However, vitamin A, zinc, and iron
may have detrimental effects on morbidity and mortality
in certain dosages. We need much more data on what dosages
are most beneficial.
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