Article

"Health regains but livelihoods lag": Findings from a study with people on ART in Zambia and Kenya

Overseas Development Institute, ODI, London, UK.
AIDS Care (Impact Factor: 1.6). 06/2011; 23(6):748-54. DOI: 10.1080/09540121.2010.532535
Source: PubMed
ABSTRACT
Although ART is increasingly accessible and eases some stresses, it creates other challenges including the importance of food security to enhance ART-effectiveness. This paper explores the role livelihood strategies play in achieving food security and maintaining nutritional status among ART patients in Kenya and Zambia. Ongoing quantitative studies exploring adherence to ART in Mombasa, Kenya (n=118) and in Lusaka, Zambia (n=375) were used to identify the relationship between BMI and adherence; an additional set of in-depth interviews with people on ART (n=32) and members of their livelihood networks (n=64) were undertaken. Existing frameworks and scales for measuring food security and a positive deviance approach was used to analyse data. Findings show the majority of people on ART in Zambia are food insecure; similarly most respondents in both countries report missing meals. Snacking is important for dietary intake, especially in Kenya. Most food is purchased in both countries. Having assets is key for achieving livelihood security in both Kenya and Zambia. Food supplementation is critical to survival and for developing social capital since most is shared amongst family members and others. Whilst family and friends are key to an individual's livelihood network, often more significant for daily survival is proximity to people and the ability to act immediately, characteristics most often found amongst neighbours and tenants. In both countries findings show that with ART health has rebounded but livelihoods lag. Similarly, in both countries respondents with high adherence and high BMI are more self-reliant, have multiple income sources and assets; those with low adherence and low BMI have more tenuous livelihoods and were less likely to have farms/gardens. Food supplementation is, therefore, not a long-term solution. Building on existing livelihood strategies represents an alternative for programme managers and policy-makers as do other strategies including supporting skills and asset accumulation.

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“Health regains but livelihoods lag”: findings from a study
with people on ART in Zambia and Kenya
Journal:
AIDS Care - Psychology, Health & Medicine - Vulnerable Children
and Youth Studies
Manuscript ID:
AC-2010-02-0115.R1
Journal Selection:
AIDS Care
Keywords:
Antiretroviral therapy, Food security, Livelihood strategies, Zambia,
Kenya
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“Health regains but livelihoods lag”: findings from a study with people on ART in
Zambia and Kenya
Abstract
Although ART is increasingly accessible and eases some stresses, it creates other
challenges including the importance of food security to enhance ART-effectiveness. This
paper explores the role livelihood strategies play in achieving food security and maintaining
nutritional status among ART patients in Kenya and Zambia. Ongoing quantitative studies
exploring adherence to ART in Mombasa, Kenya (n=118) and in Lusaka, Zambia (n= 375)
were used to identify the relationship between BMI and adherence; an additional set of in-
depth interviews with people on ART (n=32) and members of their livelihood networks
(n=64) were undertaken. Existing frameworks and scales for measuring food security and a
positive deviance approach was used to analyse data. Findings show the majority of people
on ART in Zambia are food insecure; similarly most respondents in both countries report
missing meals. Snacking is important for dietary intake, especially in Kenya. Most food is
purchased in both countries. Having assets is key for achieving livelihood security in both
Kenya and Zambia. Food supplementation is critical to survival and for developing social
capital since most is shared amongst family members and others. Whilst family and friends
are key to an individual’s livelihood network, often more significant for daily survival is
proximity to people and the ability to act immediately, characteristics most often found
amongst neighbours and tenants. In both countries findings show that with ART health has
rebounded but livelihoods lag. Similarly, in both countries respondents with high adherence
and high BMI are more self-reliant, have multiple income sources and assets; those with low
adherence and low BMI have more tenuous livelihoods and were less likely to have
farms/gardens. Food supplementation is, therefore, not a long-term solution. Building on
existing livelihood strategies represents an alternative for programme managers and policy
makers as do other strategies including supporting skills and asset accumulation.
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Background
As understanding of the multidimensional nature of HIV improves, it is increasingly
recognized that policy and programme interventions, whether focusing on prevention,
treatment, care or impact mitigation, must take into account how people’s livelihoods evolve
and adapt to deal with the multifaceted nature of HIV and AIDS. While more programmes
are being implemented linking HIV and AIDS to livelihoods, food and nutritional security,
additional evidence on the effectiveness of these interventions particularly linked with anti-
retroviral treatment (ART) is needed to inform policy and programming. Furthermore,
insights are needed to move beyond the concept of therapeutic supplementary feeding to
encapsulate broader notions of food security.
In eastern and southern Africa, evidence of the interaction between HIV and AIDS and food
insecurity is mounting. Households affected by adult morbidity, mortality, with a high
demographic dependency ratio are significantly more vulnerable to food security shocks than
other households. These households suffer from reductions in agricultural production and
income generation leading to declines in food security and distress coping strategies (Tango
International 2003). A large body of evidence exists on how households and individuals
respond, cope or just ‘struggle’ with the affects of HIV and AIDS (Barnett & Blaikie, 1992;
Baylies, 2002; Rugalema, 2000; Jayne et al., 2004; Mather et al., 2005; Arrehag, 2006;
Slater & Wiggins, 2005).
The link between nutrition and HIV and AIDS is also in evidence: malnutrition lowers the
body’s resistance to infection, weakens the immune system and leads to longer, more
severe and frequent bouts of illness. Infections can cause appetite loss, mal-absorption,
metabolic and behavioural changes that affect feeding practices thus depleting body nutrient
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stores (Gillespie & Haddad, 2003; Gillespie & Kadiyala 2005; Scrimshaw et al. 1997). While
there is still no strong evidence that malnutrition directly increases bodily susceptibility to HIV
infection, it is a plausible hypothesis (Edstrom & Samuels, 2007). It is also increasingly
accepted that HIV infection increases energy requirements: depending on whether a person
exhibits AIDS-related symptoms, an HIV-positive person has 10-30% higher energy
requirements than a healthy non-infected person of the same age, sex and physical activity
level (FANTA, 2004; Piwoz, 2004).
ART is now becoming increasingly available in Sub-Saharan Africa with some public health
services providing antiretroviral drugs free of charge, including Zambia. Studies are also
showing, against expectations, that levels of adherence to ART in Sub-Saharan Africa are
relatively high (e.g. Mills et al 2006). With increasing accessibility, it is expected that some
stresses placed on individuals, households and communities may be alleviated. However, it
throws up other challenges. There is growing agreement that adherence to ART and its
efficacy are significantly influenced by access to adequate food and nutrition (Piwoz, 2004;
Sadler, 2006; Byron et al, 2006, Friis 2006). Generally, adequate nutrition is important to
support recovery from opportunistic infections and for reversing weight loss, as well as for
malnourished people embarking on ART (Samuels and Simon, 2006).
The above picture leads to the following questions: How are people on ART maintaining food
security and/or achieving food consumption levels that are sufficient enough for them to stick
to their medications? What livelihood strategies are they developing to assist them in the
process? Where food supplementation is not given, how do people manage and what
challenges do they face? And is food supplementation the best option in all cases?
To answer such questions, ODI and the Population Council carried out a study in Mombasa,
Kenya, and Lusaka, Zambia between September 2006 and January 2007. Both countries
have generalized HIV epidemics - HIV prevalence is 7.8% in Kenya and 14.3% in Zambia
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Table 2 Dietary Diversity
In Kenya for breakfast tea, mandazi, mahamri with bread, fruit, cassava, sweet potato
cooked with coconut, porridge, boiled egg, sausage, chapatti and liver was mentioned; lunch
could consist of ugali (maize meal porridge) with beans, fish, sukuma, cabbage or green
grams, rice with beans, kunde, mchicha, chapatti, chips, fish, chicken, dried meat and fruits
like bananas; and evening meals could be made up of a bowl of mboga and ugali -
variations were bananas mixed with spinach or mchicha, boiled vegetables, beans,
meat/sausage and onions, white rice, sukuma wiki.
In Zambia, people reported having tea and bread, rice, porridge with soya or groundnuts
were for breakfast; for lunch and dinner respondents reported eating nshima (maize meal
porridge) with relish such as aubergine, impwa, kapenta, beans, bondwe, eggs, rape,
kalembula, chibwabwa, vinkubala, cabbage, fish or meat.
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Table 3 - Data analysis using worst and best case scenarios
Variables affecting livelihood
security
Kenya
Zambia
Marital status & household
size
Respondents in group A tended
to be single and live in smaller
households, while those in
group D were married and lived
in larger households.
No difference between As and
Ds.
Education
Respondents in group A were
more educated than those in
group D, with all having had
some form of education (two
group A respondents reached
secondary level, while only two
group D respondents even
reached primary level).
No difference between As and
Ds.
Employment:
Respondents in group A tended
to be more involved in
formal/permanent employment
and therefore had higher
earning capacities than those in
group D
Respondents in group A
tended to have more
permanent ways of earning an
income; they also had assets
with which they could earn
money, including rooms to rent
out and farms where produce
was used both for
consumption and sale. In
group D, piecework was key to
their earnings, though one
person did report having a
more permanent job as a
hairdresser
Coping:
Respondents in group A were
much more self-reliant than
those in group D, of whom all
except one were dependent on
others.
Respondents in group A were
able to be self-reliant, though
they often had one key person
who they relied on; in group D,
respondents had a variety of
coping strategies, including
borrowing from various people.
Savings and credit:
Two people in group A had
savings accounts; none had a
savings account in group D,
though one was a member of a
merry-go-round.
None had savings accounts or
were members of informal
savings schemes.
Food consumption:
Respondents in group A had
access to sufficient, diverse,
and often relatively expensive
food, eating at least three
meals a day and often snacking
in between. For respondents in
group D, skipping meals was
more common and the variety
of food was more limited, with
less expensive foods being
consumed when compared to
While respondents in group A
did buy food items, their farms
played an important role in
their food security strategies;
in group D none had farms and
they relied on purchasing food
or receiving it from others.
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group A.
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