"I WAS in Malawi and met with a group of women living with HIV. As I always do when I meet people with HIV/AIDS and other community groups, I asked them what their highest priority was. The answer was clear and unanimous: food. Not care, not drugs for treatment, nor relief from stigma, but food."
This is Peter Piot, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), quoted in a World Food Programme (WFP) publication titled The First Line of Defence - Why food and nutrition matter in the fight against HIV/AIDS. The statement assumes increasing significance in the context of food becoming an important priority in the lives of people living with HIV and AIDS. The links between nutrition and disease, in a sense, appeared to have been rediscovered.
The first national consultation on Nutritional Security and the Prevention, Treatment and Mitigation of Tuberculosis and HIV/AIDS was organised jointly by the United Nations World Food Programme, the M.S. Swaminathan Research Foundation, the National AIDS Control Organisation and the National Commission on Farmers on December 2 and 3. The WFP and the Indian government signed a cooperation agreement for the prevention of HIV and AIDS. WFP Executive Director James T. Morris said that his organisation would supply technical expertise in a three-year project that used food for the prevention of infection and the care and support of people living with HIV and AIDS (PLWHA) as well as for the treatment of opportunistic infections such as tuberculosis (TB).
Several academic and quasi-academic presentations threw up ideas on how the nutritional component could be built in and around the ongoing programmes. Recalling how in the early 1980s the eradication of leprosy and blindness were top priorities in the 20-Point Programme of the Congress government, eminent agricultural scientist M.S. Swaminathan said that it became very clear that without nutritional support, the programme would never be successful. "Food has to be a tool for human resource development and not only for emergency aid," he said. The National Tuberculosis Control Programme and NACO have developed excellent infrastructure to reach inwards to start an integrated drug-cum-nutrition programme. "A purely drug-based approach will only compound the problem," Swaminathan said.
It is being planned to start such an integrated programme in the 150 districts where food-for-work programmes have been launched. In addition, the six high-prevalence States of Andhra Pradesh, Tamil Nadu, Maharashtra, Nagaland, Manipur and Karnataka would also be targeted for such a programme. According to NACO Director-General S.Y. Quraishi, there are 14 States that could be categorised as highly vulnerable and 12 States as vulnerable.
Even in this situation, a strong case was made out against a sharply targeted system of nutrition and food security by some speakers, notably Amitabh Kundu from the Centre for the Study of Regional Development, Jawaharlal Nehru University, who felt it would lead to social exclusion, would be discriminatory within families and within societies, and would increase the risk of stigma for the HIV/AIDS and tuberculosis patients. "If the targeted population is reached through an income criterion, there is a lot of leakage. But if it is done through the general population, through children, through the Integrated Child Development Scheme, the Annapurna and Antyodaya schemes, it will work out more effective," said Amitabh Kundu, while analysing how food and nutrition programmes could be used for TB-affected and HIV-infected and -affected populations. People, he said, were getting more exposed to social and economic exploitation, which may be a factor making them more vulnerable to HIV and AIDS.
The latest estimates indicate that there are about 5.1 million people living with HIV in the country and up to 50 per cent of them will develop TB, which is stated to be the leading cause of death among the infected persons. The consultation was held on the premise that research reports had shown that the nutritional status of an individual played a crucial role in preventing the onset of TB. Good nutritional support not only had a role in the battle against HIV/AIDS but also enabled resistance to opportunistic infections such as TB. The WFP chief, who spent two years in South Africa as the Special Envoy of United Nations Secretary-General Kofi Annan for Humanitarian Needs, said that he had seen life expectancy plunge from 68 years to 33 years in South Africa. It was the period of famine and HIV/AIDS as well. Morris said that the first thing people asked was for food and not for the drug. "When people are fed and nourished, they have the ability to stay on treatment. Food is critical in the fight against HIV/AIDS and that is why it is top priority.".
Interestingly, Union Minister for Health and Family Welfare Anbumani Ramadoss observed that in the effort to find a cure for diseases such as HIV/AIDS, basic tenets of biology were forgotten - if the human body was healthy and had robust immunity, even a person with HIV could live without symptoms for years.
That there was a vicious cycle between poverty, malnutrition and disease was borne out by Stuart Gillespie, Senior Research Fellow at the International Food Policy Research Institute. Gillespie began with a quote from Louis Pasteur: "The microbe is nothing, the terrain everything." The common terrain between parts of Africa and India is that of poverty, hunger, malnutrition and disease. According to Gillespie, there was a strong link between chronic and acute food and nutrition insecurity - the latter caused perhaps by a food crisis like famine, which had the potential to lead to HIV/AIDS. Food insecurity leads to an exposure to the virus; increases mobility and migration; exacerbates gender inequality; increases resort to transactional sex and enhances risks of malnutrition which may itself step up the risk of infection. Malnutrition compromised immune function and increased the risk of genital ulcers and sexually transmitted diseases and also that of mother-to-child transmission.
The academic presentations apart, the PLWHA had a lot to say on the subject as well. For most of them, treatment appeared to be out of bounds given the expense involved (the government's efforts are concentrated on providing anti-retroviral treatment to one lakh people but the focus is more on prevention, for example information campaigns on HIV/AIDS and the provision of condoms).
Almost every PLWHA reiterated the importance of good nutrition as part of holistic treatment and pleaded with the government to take it up at the earliest. P. Kousalya from the Positive Women's Network said that women infected with HIV were aware of what they should be eating but access to services, even within the government structure, was restricted owing to societal norms. Employment, she said, was a major requirement and she suggested the setting up of self-help groups among HIV-positive women. Kousalya, who hails from rural Tamil Nadu, lamented that even 15 years after she was diagnosed with HIV, the health information and infrastructure in her village continued to be the same.
If HIV/AIDS is a public health problem, then it should be treated as such. Conceptually, a lot of horizontal integration is being talked about in the form of inter-ministerial cooperation, inter-departmental coordination or even synergies between non-governmental organisations and the government. The National AIDS Control Programme will enter its third phase of implementation very soon but it needs to be realised that preventive health care is not only about health education and providing condoms, but also about ensuring access to affordable health care and nutrition.
