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1、a review of international experienceMichael LoevinsohnApplied Ecology Associates, Wageningen, Netherlands March 2008, revised June 2008Background This document aims to review international experience on the role of agriculture and natural resource management （NRM） in preventing and alleviating HIV/A

2、IDS. In particular it draws attention to the importance of local innovation in these efforts and to the experience gained in identifying and boosting local innovation processes. Examples of local innovations of both a social and technical nature are described, as far as possible together with an ass

3、essment of the conditions that have favoured or hindered innovation. The purpose is to provide guidance to the country teams in their search for relevant local innovations and in planning for the workshops that they will be organising with partners in both the agriculture/NRM and AIDS/health communi

4、ties. We first outline some of the key features of HIV/AIDS epidemics and of their relationship with rural livelihoods dependent on agriculture and NRM. We then discuss in turn how the spread of HIV infection can be hastened when rural livelihoods are undermined and how the illness and deaths that f

5、ollow infection can contribute to undermining rural livelihoods. This sets the stage for discussion of the roles local innovation play in the struggle with HIV/AIDS and for considering some of the local innovations that have come to light. We also ask why local innovation is not better recognised an

6、d appreciated, describe some of the constraints it faces and provide some ideas on ways this initiative can improve the situation. HIV/AIDS is predominantly a sexually-transmitted disease that is also passed from mother to child during pregnancy, delivery or breastfeeding. In most countries, the fir

7、st cases of AIDS were observed in cities in the early to mid 1980s and the proportion of people infected with HIV remains higher in urban than in rural areas. However, infection in the rural areas has tended to increase faster and in some places, including parts of Ghana, Mozambique and Malawi, now

8、exceeds that in towns and cities. Similarly, in the early years infection rates were higher in men than in women. In every region of the world, the difference has reduced over time and in sub-Saharan Africa currently, where the greatest number of infections is found, more than 60% are among women. Y

9、oung women under 20 years old bear an even more unequal share of infection, often several times that of men their age.Box 1: Key terms used in this reviewSusceptibilityVulnerabilityResistanceResilienceThe likelihood of a person becoming infected by the human immunodeficiency virus （HIV）The likelihoo

10、d of a person suffering significant impact as a consequence of HIV infection and AIDS-linked illness or deathThe ability of a person to escape or avoid HIV infectionThe ability of a person to avoid the worst impacts of HIV and AIDS or to recover to a level accepted as normalThese are general feature

11、s of HIV/AIDS epidemics but what is striking is the variability of these epidemics. Rates of infection vary greatly between countries and between regions of the same country and these differences appear to be stable. For example, some 3% of pregnant woman are found to be HIV+ in Ghana compared to 30

12、% in South Africa. Within South Africa, 16% of pregnant women are HIV+ in the Western Cape compared to some 39% in KwaZulu Natal （WHO 2006, Department of Health 2006）. It is increasingly clear that a wide range of cultural, social, natural, economic and political factors influence peoples risk of be

13、ing exposed and then of becoming infected with the HIV virus. The risks one faces of progressing from infection to full-blown AIDS and then of dying, and the consequences of illness and death for the household, community, region and country are affected by these same factors and in turn affect them.

14、 This bi-directional relationship between HIV/AIDS and the conditions of life is important to bear in mind when considering the role that innovation relating to agriculture or NRM can play in the struggle with the disease. These factors operate at different levels, i.e. some affect an individuals ri

15、sks in a fairly direct fashion while others exert their influence indirectly and on many people at the same time. A conceptual map （Figure 1, Loevinsohn & Gillespie 2003） may be of help in visualising these relationships and situating the role of local innovation. At the centre lies infection by HIV

16、. The top left section illustrates the causes of infection, beginning, in the innermost circles, with the most direct and immediate （e.g. nutrition） and progressing leftwards to the most indirect （e.g. climate and policies）. The top right-hand section illustrates the consequences of infection beginn

17、ing again with those that are most immediate, experienced by infected persons themselves, and progressing through the effects experienced by households, communities and countries. The bottom panel of the map portrays some of the principal opportunities for intervention and the level at which they ca

18、n be implemented: those advancing prevention on the left, those addressing care, treatment and impact mitigation on the right. The following sections describe these linkages and opportunities in more detail and some of the ways in which they vary in different situations.Food, livelihood and HIV infe

19、ction risksPeople vary in their likelihood of becoming infected with HIV, thats to say their susceptibility. Infection with another sexually transmitted disease such as syphilis, herpes and gonorrhoea facilitates the entry of HIV and is among the most important of the immediate causes of infection.

20、Malnutrition, particularly vitamin A deficiency, favours a number of sexually transmitted infections and together chronic malnutrition and parasite burden weaken a persons immune function, making HIV infection more likely （Auvert et al 2001, Stillwaggon 2002）. Transmission of the HIV infection from

21、mother to child is also affected by her nutrition and immune status. There are often important seasonal patterns to maternal nutrition in rural areas, linked with the hungry period before harvest and to the times of heavy work in the field. These seasonal effects are often most pronounced among the

22、landless or those otherwise marginalised （Kinabo 1993, Bang et al 2005）. Rural people are often well aware of the close links between food, nutrition and health even if the details of the interactions are not always apparent to them. HIV being a sexually transmitted infection, sexual behaviour sex w

23、ith whom and under what conditions is central. There are many influences on these decisions. Culture is one, influencing, for example, the age at which one initiates sex and with whom, the age at which one expects to marry and later in life whether and with whom widows remarry. Knowledge of HIV and

24、AIDS is also crucial: how one becomes infected, the ways in which one can avoid infection, how HIV relates to AIDS and the consequences of the disease. The combination of intimate knowledge of the disease （many people knowing someone who has it or has died from it） and frank discussion among family

25、and friends what has been called the “social vaccine” appears to have been an important factor in limiting HIVs spread, particularly in Uganda （Low-Beer & Stoneburner 2004）. We return to this further below. Figure 1: AIDS map: causes, consequences and responses （Loevinsohn & Gillespie 2003）However,

26、ones ability to act on what one knows is often constrained. In particular, poverty notably hunger and lack of opportunity and inequalities especially those between men and women, among social groups and between rural and urban areas can force people into situations where they are at heightened risk

27、of becoming infected with HIV. Common situations of risk include: Transactional （“survival”） sex, where especially women are obliged to sell sex for food or money in order to keep themselves and their families alive. There are times when casual labour contracts have become abusive and women have bee

28、n forced to have sex in order to have work （Bryceson 2006）. In these conditions, it is difficult for the woman to insist on safe sex. Note that the relationship turns on inequality: a woman who is forced to sell sex; a man, better off, who is prepared to buy. Research in Botswana and Swaziland has f

29、ound that women who had recently been hungry were more likely to have sold sex and to have agreed not to use condoms than those who had had enough to eat. The link was much less pronounced for men （Weiser et al 2007）. Migration, where people are obliged to move away from home in search of work or fo

30、od, either to towns or cities or to more favoured rural areas. There may be particular risks for those who move in distress: alone, often with few contacts or skills, they are at heightened risk of becoming involved in risky sexual behaviour. Other people may be impelled to move more by lack of oppo

31、rtunity where they live than by distress per se, for example many seasonal workers at plantations, rural industries or mines. Again, however, conditions there may put them at increased risk of infection, e.g. separation from their families, staying in same-sex dormitories and payment that is sometim

32、es late and often received all at once （Ngwira et al 2002）. In every developing region, migrants are almost invariably case found to have more extramarital sexual relations and to be more often HIV+ then non-migrants （Decosas et al 1995, Mehendale et al 1996）. Early marriage, where girls or young women are pushed, in many cases by their families, into marriage with older men. Poverty often lies behind these pressures. The man, being older, is more likely to