It takes a village to defeat HIV
Every morning, Baba Conteh leaves his home in the village of Waterloo, Sierra Leone, and walks straight to the local community centre where he runs an HIV support group. As one of the 37.9 million people living globally with HIV and AIDS , Baba Conteh is very clear: psychological support is one of the three things that have turned his life around. The other two are antiretroviral treatment (ART) and, perhaps less obviously, the nutritious food and support he receives from the World Food Programme (WFP).
Over the past ten years, successful treatment has brought AIDS-related mortality down by 33 percent. "As life expectancy increases, we are now looking at the first generation of people who will grow old with HIV," says Sara Bernardini, a WFP nutritionist with extensive field experience in HIV settings. "This means we have to shape our interventions so that they reflect each phase of the person's life cycle and provide the right form support at the right time."
It starts at birth. HIV-positive mothers on ART are now able to give birth and breastfeed with minimal risk of transmitting the virus — approximately 5 percent, down from rates ranging from 15 to 45 percent in the absence of treatment. Ensuring they receive adequate nutrition does not only improve their treatment outcomes, but also guarantees their babies have the best start in life.
"Nutrition support has been our traditional entry point into HIV work," Bernardini explains. "Adults with HIV have increased energy needs, ranging from 10 percent more calories, in the absence of symptoms, to up to 20–30 percent more when symptoms are present, and children can have a 50 to 100 percent increase over normal requirements." Beginning HIV treatment while malnourished can mean up to a 5 percent higher mortality rate than for someone with adequate nutrition.
But it is not just about calorie intake. "People also need to eat the right kind of food. Antiretroviral treatment can have side effects, which vary greatly depending on how each person reacts to it," Bernardini adds. "This is why we place great emphasis on personalized nutrition assessment, counselling and support, and we are advocating for it to be an integral part of the package of services provided to people living with HIV.
"More people are receiving treatment than ever before, but too many have not yet been diagnosed and/or are still accessing the services when they are already sick and frequently their nutrition condition is deteriorated. The provision of nutrition support can play a key role in improving retention and adherence to treatment."
Ensuring people living with HIV have enough of the right type of food throughout childhood — including with school meals, where rations can be adapted to meet the needs of HIV-positive children — adolescence and adulthood remains vital. But there's more to it. Mental health and psychological well-being must be taken into consideration.
"People will be on ART for the rest of their lives, they need to take treatment on a daily basis and they still face stigma and discrimination in many settings," Bernardini explains. Peer support groups, like the one Baba Conteh convenes in his community, have a great role to play, allowing participants to share experiences as well as learn and cook together.
"People should not be put in a position where they have to choose between a day's wage and going to the clinic to get their drugs."
Support, however, must go beyond individuals. "Families, communities and society at large must be involved and sensitized. This is about changing behaviours: the goal is to create an environment where people living with HIV can access and fully benefit from their treatment and lead fulfilling lives," says Bernardini.
For example, in certain contexts, if the patient is a woman, the men in her family might need to be brought on board for her to access treatment. Also, in many countries, adolescents require parental approval to do an HIV test. In other cases, social protection schemes can ease the pressure: "People should not be put in a position where they have to choose between a day's wage and going to the clinic to get their drugs," Bernardini says.
"This [support] has changed my life, so I will not end up being like a parasite, living off other people."
Creating opportunities for people living with HIV to generate an income is also crucial to ensure their long-term food security, preventing them from falling into malnutrition or resorting to activities that might damage their physical and mental well-being. Baba Conteh has used part of the cash transfers he receives from WFP to help set up a small business selling charcoal. "This has changed my life, so I will not end up being like a parasite, living off other people," he says.
Across the Atlantic, in the Dominican Republic, WFP works with the Ministry of Agriculture to train people living with HIV — with a special focus on women and adolescents — in food production through urban and community gardens. This allows them to have access to fresh food and to improve their nutrition and food security, as well as generate income by selling surplus.
In emergency contexts, the disruption of health facilities and the reduced availability of nutritious food put people living with HIV at greater risk. Recent experience from Mozambique highlights how HIV considerations can be woven into humanitarian response plans.
"In the aftermath of cyclone Idai in March this year, we included HIV as a focus of our response in Sofala province, where 16 percent of the population is HIV-positive," Bernardini explains. Community radio journalists were trained to inform listeners on how to access services, encourage them to adhere to treatment, spread awareness on behaviours that could lead to new infections, and promote the reduction of HIV-related stigma.
"Whatever the context, involving the community is really the key to success in creating an environment where people living with HIV can not just survive but thrive," Bernardini concludes.