Communication Knowledge

April 2001

Strategic approaches to HIV prevention and AIDS mitigation in rural communities and households in Sub-Saharan Africa

Prepared by Sabine Isabel Michiels
in collaboration with
The Extension, Education and Communication Service (SDRE)
Research, Extension and Training Division

Draft for Discussion
Part 1 of 4

1 2 3 4

"Poverty fuels AIDS and AIDS brings poverty. If we are to fight AIDS we must develop our communities."
Sheikh Saidi Bifamengo, Acting District Khadi
Kamuli Uganda (cited in UNAIDS 1998a)

"FAO has come a long way since it first addressed the issue of AIDS and agriculture at a time when the epidemic was still considered essentially an urban problem. One of the lessons we have learned over the past years is that institutional collaboration is imperative for effective action to take place." Statement by Mr. Henri Carsalade, Assistant Director-General
Sustainable Development Department, FAO (1999)

Foreword

AIDS has emerged as one of the most serious diseases facing the developing world. As the twentieth century comes to a close, over 34 million people with HIV/AIDS face a future darkened by the fatal disease. Of these 34 million people, 70% live in Africa and one third of them are young people between the ages of 10 and 24 (UNAIDS 1999). Alarmingly, this percentage is set to grow even further as infection rates continue to climb where a combination of endemic poverty, fragile health infrastructures and limited investments in prevention programs fuel the spread of the deadly virus.

Nowhere has the impact been more disquieting, more devastating than in Sub-Saharan Africa. More than 11 million Africans have already died and the World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) estimate that another 24.5 million are now living with HIV/AIDS. In countries like Botswana and Zimbabwe, more than one in four adults is infected. Before the end of the year 2000, a cumulative total of 13 million children will have lost their mother or both parents to AIDS and 10.4 million of these children will still be under 15. At the dawn of the new millennium a child born in Zambia or Zimbabwe is more likely than not to die of AIDS.

The most frightful long-term characteristic of the HIV/AIDS epidemic is its impact on life expectancy. Instead of reaching an average of 64 years, by 2010-2015, life expectancy in several Sub-Saharan countries will regress to an average of just 41 years: a reversal of most development gains over the past 30 years. People have died partly because of the alarmingly high concentration of HIV in Africa, but also because the continent's leaders and the international community have been outrageously slow to respond to the epidemic.

Today, it is widely acknowledged that HIV and AIDS have substantial economic and social impacts on individuals, on families and households, on communities and thus on society as a whole. The disease is killing people in their most productive years, decimating the workforce, impoverishing households, shredding traditional safety nets and tearing the social fabric of the communities, for many the only reliable support systems. Furthermore, in many Sub-Saharan African nations AIDS has destabilised the health systems, education, industry, the formal and informal agricultural sector, transport, political stability and civil society.

Orphan-headed households, grandmothers struggling to care for their numerous grandchildren, farm-households completely asset-less, income-less and food-less, people living with HIV/AIDS marginalised with nowhere to turn to for support, community-based organisations and self-help groups with limited coping capacity and scarce resources, companies and firms with a drastically reduced skilled workforce, highly trained extension staff dying off, schools without teachers...without students… such is the reality of an Africa destroyed by AIDS.

Box 1: Some figures for Sub-Saharan Africa

Out of 18 countries in Sub-Saharan Africa that experienced a declining or stagnationg life expectancy during 1990-1995, all but one (Togo) were described as having a general HIV/AIDS epidemic, that is an HIV prevalence of more than 5% in the adult population.

World Bank, 1999

Table of contents

Foreword
Acknowledgements
Acronyms
Definition of terms
Overall development goal
Purposes of the paper
Desired outcomes


Executive summary
   Background
   What are the problems?
   What are the needs?
   Recommendations

        Advocacy
        Policy
        Programs and activities: General
        Agricultural research: towards a new agenda?
        Involving the private sector
        Developing strong partnerships
        Characteristics of the proposed approach

1. Introduction
   1.1. The silent epidemic
   1.2. AIDS: A threat to development?
        Impact on various segments of society:
   1.3. HIV/AIDS, Agriculture and food security
   1.4. The impact on rural institutions
        Extension
   1.5. The implications of HIV/AIDS for FAO programmes and projects

2. Preventing and mitigating HIV/AIDS
   2.1. Communication
        Communication in low prevalence areas
        Communication in high prevalence areas
        Communication needs and applications
   2.2. Education and training
        Non-formal education
        Tertiary institutions
        HIV/AIDS-related education needs
   2.3. Mitigation and support
   Low prevalence areas
        Community mobilisation
        Community mobilisation needs
        Extension
   High prevalence areas
   2.4. Agricultural research agenda

3. The next steps
   3.1. Recommendations
        Advocacy
        Policy
        Programs and activities: General
        Programs and activities (1): Prevention
        Programs and activities (2): Mitigation
        Agricultural research
        Private sector
        Partnerships
   3.2. Planning for action
   3.3. The role of institutions
   3.4. Partnerships
        The Joint United Nations Programme on HIV/AIDS (UNAIDS)
        World Bank Rural AIDS Initiative (WB-RAI)
        Southern Africa Development Community Center of Communication for Development (SADC CCD)

4. Conclusions
   4.1. Suggested actions to be undertaken by FAO
   4.2. General conclusions

Annex 1: A Pyramid of involvement by PLWHA

Annex 2: Cooperation framework UNAIDS/FAO

Bibliography

Endnotes


Acknowledgements

The author would like to thank the following people:

First, all the professionals and researchers who continue to dedicate their energy to fighting the AIDS epidemic and taking care of people affected by HIV/AIDS. Thank you all for sharing your experiences with me. Without your unconditional dedication, there would not be room for change!

Philippe Vander Stichele, former Communication Officer, Extension, Education and Communication Service (SDRE), Ester Zulberti, Chief of SDRE, and Loy Van Crowder, Senior Officer Communication for Development SDRE, for giving me the opportunity to work on such an important issue, for their thoughtful and insightful comments, ideas and advice but also for their commitment to incorporating HIV/AIDS issues into the work of the Service. Jacques du Guerny, former Chief of FAO's Population Program Service, Women and Population Division (SDWP) and AIDS focal point, for providing the conceptual framework for this paper along with valuable insights on the systemic and multi-faceted impact of HIV/AIDS on agriculture, food security and rural development as a whole. Florence Egal, Nutrition Officer, Nutrition Porgrammes Service (ESNP), for gently "advising" me to write something useful and practical and for passionately continuing to lobby for the incorporation of HIV/AIDS considerations into FAO programs and activities. Peter Steele, Senior Agro-Industries Officer, Agro-Industries and Post-Harvest Management Service, for his invaluable insights on the role of agricultural technologies and industries and income-generating activities for AIDS impact mitigation. Rob Van Poelje, from the Royal Tropical Institute in the Netherlands, for his knowledgeable advice and information sharing. Werasit Sittirai, Bunmi Makinwa and Tina Boonto Krittayawan from The Joint United Nations Programmes on HIV/AIDS and Wendy Roseberry from the World Bank for reviewing the document internally. Finally, all those who have responded and contributed to the AF-AIDS postings and discussion.

Acronyms

AIDS

Acquired Immune Deficiency Syndrome

ASO

Aids Support Organisation

CBO

Community-based Organisation

FAO

Food and Agriculture Organisation of the UN

HIV

Human Immunodeficiency Virus

ICT

Information Communication Technology

IGA

Income Generating Activities

ILO

International Labour Office

NGO

Non-government Organisation

PLWHA

Person Living With HIV/AIDS

SADCCCD

Southern Africa Development Community Center for Communication for Development

SAfAIDS

Southern Africa AIDS Information and Dissemination Service

SSA

Sub-Saharan Africa

UNAIDS

Joint United Nations Programme on HIV/AIDS

UNESCO

United Nations Education, Scientific and Cultural Organisation

UNDP

United Nations Development Programme

UNICEF

United Nations Children's Fund

USAID

United States Agency for International Development

WB

World Bank

WHO

World Health Organisation

Definition of terms

AIDS: the last and most severe stage of the clinical spectrum of HIV-related diseases.

Community: a specific group of people usually living in a common geographical area who have a common culture, are arranged in a social structure and exhibit some awareness of their identity as a group. (Allman et. al 1997 cited in UNAIDS 1999a). This group will also tend to act together in their common interest if they have a clear understanding of what it is they have in common.

Food security: exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food which meets their dietary needs and food preferences for an active and healthy life. (Rome Declaration on World Food Security 1996)

Food insecurity: low level of food intake, which can be transitory (when it occurs in times of crisis), seasonal, or chronic (when it occurs on a continuing basis).

HIV: a retrovirus that damages the human immune system thus permitting opportunistic infections to cause eventually fatal diseases. HIV is the causal agent for AIDS.

HIV prevalence rate: total number of persons (usually adults aged 15-49) with HIV infection alive at any given moment in time. In this paper the author refers to High adult HIV prevalence as 7% or more and to Low adult HIV prevalence as less than 7% in accordance with the distinction made by the World Bank Strategy (1999).

Household: a group of persons who live in the same dwelling and eat meals together. (UNAIDS 1999)

Overall development goal

Purposes of the paper

This paper is intended to serve the following purposes:

Desired outcomes

Executive summary

Background

In view of the devastating health, economic, social and more recently political impact of the epidemic, international agencies such as FAO have increasingly begun to regard the AIDS epidemic not only as a health problem but more importantly as a legitimate development issue.

FAO perceives the HIV/AIDS pandemic as a problem of critical importance for development in general, and agriculture and food security in particular. FAO was the first United Nations Agency to apply the development perspective by carrying out several studies on the impact of HIV/AIDS on agriculture, nutrition, food security and people's livelihoods1 (see FAO 1988, 1995, 1997). Henceforth, FAO' s activities in the field of HIV/AIDS have focused mainly on two aspects of the epidemic:

FAO's involvement in HIV/AIDS-related work has been recently legitimised by signing a Cooperation Framework with UNAIDS in Geneva in July 1999. The Framework demonstrates to other International Organisations that FAO now regards the HIV/AIDS epidemic as a legitimate agricultural and food security topic and therefore an integral part of its activities aiming to reduce its impact on rural populations, their livelihoods and farming systems.

It is within this conceptual framework that an interdisciplinary collaboration between FAO's Extension, Education and Communication Service (SDRE) and the Population Program Service (SDWP) was agreed upon to develop a paper on the Strategic Approaches to Mitigating and Preventing the Impact of HIV/AIDS in Rural Sub-Saharan Africa.

This paper aims to provide a suggested framework of action for FAO' s engagement in HIV/AIDS prevention and impact-mitigation in rural Sub Saharan Africa. It presents a detailed list of potential activities to undertake in both high and low HIV/AIDS prevalence areas in order to contribute more effectively and significantly to preventing HIV, reducing and/or alleviating the impact of AIDS on rural households and communities. The activities proposed are mainly aimed at (1) alleviating the impact of HIV/AIDS on agriculture, food security and people's livelihoods, and (2) reducing the hardships the affected communities and households are confronted with. Finally, this paper provides the preliminary guidelines for FAO to "intensify" its action in the field of HIV/AIDS prevention and mitigation in Africa.

The activities proposed throughout the paper are neither exclusive nor definite in that they are entirely open to discussion and modification. In fact, one of the expected outcomes of this paper is to increase awareness and trigger discussion (both inside and outside FAO).

What are the problems?

The consequences of the HIV/AIDS epidemic are closely related with wider challenges to development such as food and livelihood insecurity, poverty and gender inequality. In fact, HIV/AIDS tends to either exacerbate already existing development problems or create new challenges (orphan-headed households, breakdown of social safety nets).

Not only does the HIV/AIDS epidemic pose a serious threat to health but also to development as a whole by erasing the gains acquired with utmost difficulty over the past decade (Topouzis 1998). Today, it is widely acknowledged that, the spread of HIV/AIDS has a significant impact rural people's livelihoods in several ways:

Loss of labour. Family members and People Living With HIV/AIDS (PLWHA) are drawn away from production and other income-generating activities to care for sick relatives, orphans or themselves. A recent study conducted by the International Labour Office (ILO) warns of catastrophic consequences of HIV/AIDS for workers and employers worldwide. The study indicates that sub-Saharan Africa is the worst affected area

Loss of capital. Households are forced to divest their income, tangible assets and savings for medical care, funeral expenses, and other immediate expenses.

Food insecurity increases. Food security is affected both in terms of quantity and in terms of quality as a consequence of a drastic decline in productivity of the household unit.

Loss of opportunities. Children are withdrawn from school due to lack of resources but also because extra-labour is urgently needed.

At the level of the national economy
The combination of a decline in food production, the sale of food reserves and diminished sources of income cause food shortages and long-term nutritional deficiencies. Moreover, AIDS is an expensive disease and taking care of AIDS patients is a twenty-four hour job. This does not leave much time to invest in other activities, hence the reliance of affected families on community support groups as well as the extended family for food, support, labour and money augmentation.

AIDS causes a range of problems which given its systemic impact is capable of attacking all levels of society. However, the primary target groups of this paper are the household unit and the community as it is there that AIDS hits hardest and that assistance is needed the most, especially when the traditional and social safety nets undergo additional stress.

The immediate concern to FAO is food insecurity and a decrease in agricultural productivity both at the household level and in the commercial agricultural sector.

At the national policy level
The other problem HIV/AIDS is confronted with is the lack of strong political commitment in many African countries. Inaction has only resulted in millions of new infections and deaths that could have been prevented.2 Many countries did not implement appropriate interventions when there was still time to contain the spread of the epidemic.

The fact is that there is an urgent need for stronger political commitment both at national and international levels.

On the other hand, when there are internationally planned interventions they sometimes lack multi-disciplinarity and are based on a strictly uni-sectoral and un-targeted approach. Not only has this created confusion at national and local levels but it has inextricably impeded the "trickling down" of care, resources and support to those most in need of assistance: rural households and communities.

Inadequate support systems and coping strategies at the community and household levels combine to provide the setting required for urgent assistance.

What are the needs?

With the failure or inadequacy of socio-traditional coping strategies and mechanisms at community and household levels there is a pending need for building the capacity and crisis management skills of those at the front line of intervention.

The first question when starting the needs-identification process should always be to ask: whose "needs"?3 This to ensure that the needs to be addressed are really perceived as such by the community. However, there is no such concept as homogenous "needs". Needs vary dramatically from region to region and among countries within regions. Different factors and contexts will always contribute to the diversification of needs. This means that approaches to HIV/AIDS prevention and mitigation will have to be tailored to each situation.

In this paper, the focus is mainly on activities and programs that can help to prevent HIV and/or mitigate the impact of AIDS at household and community level, the justification being that this is where the epidemic has the most devastating impact. Priority should go to those most in need of assistance. In this sense the paper exhibits a people-oriented and need-oriented bias.

The needs listed below are those that have been identified by the author through an extensive literature research as well as through personal contacts with organisations and people working with PLWHA in Africa. It only depicts the type of problems and needs encountered.4

The further selection is made to reflect the needs FAO could potentially respond to. The needs identified are:

The needs of people in HIV/AIDS affected households: home-based care, food, less-labour-intensive technologies, money, credit, saving schemes, assistance with production, help with cultivating the land, Income Generating Activities (IGAs), nutrition information/education, schools that cater to new needs of youths and children, targeted training and assistance (girls, orphans, women), guaranteed access to resources and assets for women (land, livestock).

The needs of people in not yet (HIV/AIDS) affected households: HIV/AIDS education and prevention, IGAs, nutrition education, agricultural education and training, training in crisis management skills and disaster-preparedness, training in saving schemes, informal and formal education for children and youths (life skills).

The needs of communities and support groups: participatory action research (to express specific needs), impact and needs assessments, impact mitigation: training in mobilisation skills, management skills, training in saving schemes (rotating), capacity building, training of trainers (extension, researchers and staff from Non-government Organisations - NGOs), AIDS prevention and education programmes, Information, Education and Communication materials production and distribution.

Recommendations

In order to put the proposed activities into action, FAO5 should:

Make HIV/AIDS a central element of its development agenda for Africa due to its devastating impact on food security, agricultural productivity and rural development.

  1. Promote awareness within the Organisation on the need for integrating HIV/AIDS prevention and mitigation in its programmes.


  2. Stimulate discussion and ideas on the effects and implications of HIV/AIDS on development in general.


  3. Strengthen the Organisation's capacity to respond to the impact of HIV/AIDS on agriculture, food security and people's livelihoods by building capacity among staff both at Headquarters and in the field and through regular impact assessments, policies and by including HIV/AIDS considerations into all programme activities (especially at the level where HIV/AIDS has its greatest impact: in rural households and communities).


  4. Identify, in each country, the most vulnerable areas by engaging in action-research together with the local support groups, households and communities to: (1) identify specific characteristics of AIDS impact in the sub-region; (2) point out the survival/coping strategies in place; (3) plan for culturally and socially appropriate context-specific interventions.


  5. Expand resources available (within FAO) for HIV prevention and AIDS impact mitigation (e.g. by redirecting ongoing programme/project funds)


  6. Continue to address the root causes of vulnerability through poverty alleviation programmes, empowerment of women, agricultural education and training, micro-projects, agro-industrial technologies.


  7. Monitor the impact of development projects and programmes to find out whether increase or decrease vulnerability to HIV/AIDS.


  8. Set up a Formal Working Group on HIV/AIDS. An inter-divisional Informal Working Group is already in place yet in order to obtain any kind of commitment it is necessary to have a more formal working group.

In all of the above-mentioned strategies it is advisable to involve the stakeholders6 (front-line community-based organisations and support groups mainly) in appraisal, planning, implementation, monitoring and evaluation if feasible even PLWHA and front-line community-based support groups.

All of the actions proposed below cannot be carried out effectively without the active participation of PLWHA, their families, and affected communities.7

Advocacy

Policy

Programs and activities: General

Agricultural research: towards a new agenda?

Involving the private sector

Developing strong partnerships

Characteristics of the proposed approach

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