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areviewofinternationalexperience

MichaelLoevinsohn

AppliedEcologyAssociates,Wageningen,Netherlands

March2008,revisedJune2008

Background

Thisdocumentaimstoreviewinternationalexperienceontheroleofagricultureandnaturalresourcemanagement（NRM）inpreventingandalleviatingHIV/AIDS.Inparticularitdrawsattentiontotheimportanceoflocalinnovationintheseeffortsandtotheexperiencegainedinidentifyingandboostinglocalinnovationprocesses.Examplesoflocalinnovationsofbothasocialandtechnicalnaturearedescribed,asfaraspossibletogetherwithanassessmentoftheconditionsthathavefavouredorhinderedinnovation.Thepurposeistoprovideguidancetothecountryteamsintheirsearchforrelevantlocalinnovationsandinplanningfortheworkshopsthattheywillbeorganisingwithpartnersinboththeagriculture/NRMandAIDS/healthcommunities.

WefirstoutlinesomeofthekeyfeaturesofHIV/AIDSepidemicsandoftheirrelationshipwithrurallivelihoodsdependentonagricultureandNRM.WethendiscussinturnhowthespreadofHIVinfectioncanbehastenedwhenrurallivelihoodsareunderminedandhowtheillnessanddeathsthatfollowinfectioncancontributetounderminingrurallivelihoods.ThissetsthestagefordiscussionoftheroleslocalinnovationplayinthestrugglewithHIV/AIDSandforconsideringsomeofthelocalinnovationsthathavecometolight.Wealsoaskwhylocalinnovationisnotbetterrecognisedandappreciated,describesomeoftheconstraintsitfacesandprovidesomeideasonwaysthisinitiativecanimprovethesituation.

HIV/AIDSispredominantlyasexually-transmitteddiseasethatisalsopassedfrommothertochildduringpregnancy,deliveryorbreastfeeding.Inmostcountries,thefirstcasesofAIDSwereobservedincitiesintheearlytomid1980’sandtheproportionofpeopleinfectedwithHIVremainshigherinurbanthaninruralareas.However,infectionintheruralareashastendedtoincreasefasterandinsomeplaces,includingpartsofGhana,MozambiqueandMalawi,nowexceedsthatintownsandcities.Similarly,intheearlyyearsinfectionrateswerehigherinmenthaninwomen.Ineveryregionoftheworld,thedifferencehasreducedovertimeandinsub-SaharanAfricacurrently,wherethegreatestnumberofinfectionsisfound,morethan60%areamongwomen.Youngwomenunder20yearsoldbearanevenmoreunequalshareofinfection,oftenseveraltimesthatofmentheirage.

Box1:

Keytermsusedinthisreview

Susceptibility

Vulnerability

Resistance

Resilience

Thelikelihoodofapersonbecominginfectedbythehumanimmunodeficiencyvirus（HIV）

ThelikelihoodofapersonsufferingsignificantimpactasaconsequenceofHIVinfectionandAIDS-linkedillnessordeath

TheabilityofapersontoescapeoravoidHIVinfection

TheabilityofapersontoavoidtheworstimpactsofHIVandAIDSortorecovertoalevelacceptedasnormal

ThesearegeneralfeaturesofHIV/AIDSepidemicsbutwhatisstrikingisthevariabilityoftheseepidemics.Ratesofinfectionvarygreatlybetweencountriesandbetweenregionsofthesamecountryandthesedifferencesappeartobestable.Forexample,some3%ofpregnantwomanarefoundtobeHIV+inGhanacomparedto30%inSouthAfrica.WithinSouthAfrica,16%ofpregnantwomenareHIV+intheWesternCapecomparedtosome39%inKwaZuluNatal（WHO2006,DepartmentofHealth2006）.Itisincreasinglyclearthatawiderangeofcultural,social,natural,economicandpoliticalfactorsinfluencepeople’sriskofbeingexposedandthenofbecominginfectedwiththeHIVvirus.Therisksonefacesofprogressingfrominfectiontofull-blownAIDSandthenofdying,andtheconsequencesofillnessanddeathforthehousehold,community,regionandcountryareaffectedbythesesamefactorsandinturnaffectthem.Thisbi-directionalrelationshipbetweenHIV/AIDSandtheconditionsoflifeisimportanttobearinmindwhenconsideringtherolethatinnovationrelatingtoagricultureorNRMcanplayinthestrugglewiththedisease.Thesefactorsoperateatdifferentlevels,i.e.someaffectanindividual’srisksinafairlydirectfashionwhileothersexerttheirinfluenceindirectlyandonmanypeopleatthesametime.

Aconceptualmap（Figure1,Loevinsohn&

Gillespie2003）maybeofhelpinvisualisingtheserelationshipsandsituatingtheroleoflocalinnovation.AtthecentreliesinfectionbyHIV.Thetopleftsectionillustratesthecausesofinfection,beginning,intheinnermostcircles,withthemostdirectandimmediate（e.g.nutrition）andprogressingleftwardstothemostindirect（e.g.climateandpolicies）.Thetopright-handsectionillustratestheconsequencesofinfectionbeginningagainwiththosethataremostimmediate,experiencedbyinfectedpersonsthemselves,andprogressingthroughtheeffectsexperiencedbyhouseholds,communitiesandcountries.Thebottompanelofthemapportrayssomeoftheprincipalopportunitiesforinterventionandthelevelatwhichtheycanbeimplemented:

thoseadvancingpreventionontheleft,thoseaddressingcare,treatmentandimpactmitigationontheright.Thefollowingsectionsdescribetheselinkagesandopportunitiesinmoredetailandsomeofthewaysinwhichtheyvaryindifferentsituations.

Food,livelihoodandHIVinfectionrisks

PeoplevaryintheirlikelihoodofbecominginfectedwithHIV,that’stosaytheirsusceptibility.Infectionwithanothersexuallytransmitteddiseasesuchassyphilis,herpesandgonorrhoeafacilitatestheentryofHIVandisamongthemostimportantoftheimmediatecausesofinfection.Malnutrition,particularlyvitaminAdeficiency,favoursanumberofsexuallytransmittedinfectionsandtogetherchronicmalnutritionandparasiteburdenweakenaperson’simmunefunction,makingHIVinfectionmorelikely（Auvertetal2001,Stillwaggon2002）.TransmissionoftheHIVinfectionfrommothertochildisalsoaffectedbyhernutritionandimmunestatus.Thereareoftenimportantseasonalpatternstomaternalnutritioninruralareas,linkedwiththehungryperiodbeforeharvestandtothetimesofheavyworkinthefield.Theseseasonaleffectsareoftenmostpronouncedamongthelandlessorthoseotherwisemarginalised（Kinabo1993,Bangetal2005）.Ruralpeopleareoftenwellawareofthecloselinksbetweenfood,nutritionandhealthevenifthedetailsoftheinteractionsarenotalwaysapparenttothem.

HIVbeingasexuallytransmittedinfection,sexualbehaviour–sexwithwhomandunderwhatconditions–iscentral.Therearemanyinfluencesonthesedecisions.Cultureisone,influencing,forexample,theageatwhichoneinitiatessexandwithwhom,theageatwhichoneexpectstomarryand–laterinlife–whetherandwithwhomwidowsremarry.KnowledgeofHIVandAIDSisalsocrucial:

howonebecomesinfected,thewaysinwhichonecanavoidinfection,howHIVrelatestoAIDSandtheconsequencesofthedisease.Thecombinationofintimateknowledgeofthedisease（manypeopleknowingsomeonewhohasitorhasdiedfromit）andfrankdiscussionamongfamilyandfriends–whathasbeencalledthe“socialvaccine”–appearstohavebeenanimportantfactorinlimitingHIV’sspread,particularlyinUganda（Low-Beer&

Stoneburner2004）.Wereturntothisfurtherbelow.

Figure1:

AIDSmap:

causes,consequencesandresponses（Loevinsohn&

Gillespie2003）

However,one’sabilitytoactonwhatoneknowsisoftenconstrained.Inparticular,poverty–notablyhungerandlackofopportunity–andinequalities–especiallythosebetweenmenandwomen,amongsocialgroupsandbetweenruralandurbanareas–canforcepeopleintosituationswheretheyareatheightenedriskofbecominginfectedwithHIV.Commonsituationsofriskinclude:

∙Transactional（“survival”）sex,whereespeciallywomenareobligedtosellsexforfoodormoneyinordertokeepthemselvesandtheirfamiliesalive.Therearetimeswhencasuallabourcontractshavebecomeabusiveandwomenhavebeenforcedtohavesexinordertohavework（Bryceson2006）.Intheseconditions,itisdifficultforthewomantoinsistonsafesex.Notethattherelationshipturnsoninequality:

awomanwhoisforcedtosellsex;

aman,betteroff,whoispreparedtobuy.ResearchinBotswanaandSwazilandhasfoundthatwomenwhohadrecentlybeenhungryweremorelikelytohavesoldsexandtohaveagreednottousecondomsthanthosewhohadhadenoughtoeat.Thelinkwasmuchlesspronouncedformen（Weiseretal2007）.

∙Migration,wherepeopleareobligedtomoveawayfromhomeinsearchofworkorfood,eithertotownsorcitiesortomorefavouredruralareas.Theremaybeparticularrisksforthosewhomoveindistress:

alone,oftenwithfewcontactsorskills,theyareatheightenedriskofbecominginvolvedinriskysexualbehaviour.Otherpeoplemaybeimpelledtomovemorebylackofopportunitywheretheylivethanbydistressperse,forexamplemanyseasonalworkersatplantations,ruralindustriesormines.Again,however,conditionstheremayputthematincreasedriskofinfection,e.g.separationfromtheirfamilies,stayinginsame-sexdormitoriesandpaymentthatissometimeslateandoftenreceivedallatonce（Ngwiraetal2002）.Ineverydevelopingregion,migrantsarealmostinvariablycasefoundtohavemoreextramaritalsexualrelationsandtobemoreoftenHIV+thennon-migrants（Decosasetal1995,Mehendaleetal1996）.

∙Earlymarriage,wheregirlsoryoungwomenarepushed,inmanycasesbytheirfamilies,intomarriagewitholdermen.Povertyoftenliesbehindthesepressures.Theman,beingolder,ismorelikelyto