By Hisham Khogali
Hisham Khogali is currently the Senior Food Security Officer of the International Federation of the Red Cross and Red Crescent. Prior to this, Hisham worked for Oxfam as a Food and Nutrition Advisor and has worked for MSF-Holland in various countries in Africa and Asia.
The support of the Zimbabwe Red Cross and British Red Cross to the programme, and the contribution of Jane McAskill to this review, is gratefully acknowledged.
In this article, Hisham describes a home based care programme for people living with HIV/AIDS in Zimbabwe, highlighting constraints as well as areas for further development.
Across Zimbabwe, the level of infection and illness associated with HIV/AIDS is contributing to a dramatic rise in poverty levels. A recent assessment1 of people and households living with HIV/AIDS suggests that there has been an increase in widows, widowers and orphans. The assessment, moreover, showed that greater time was spent on caring for the sick, and that households were facing increased medical costs, as well as reducing spending on household requirements. Migration is also on the increase, with movement of people from rural to urban areas in search of treatment, and from urban to rural areas in pursuit of a cheaper life-style. At the same time, households have a deteriorating dependency ratio, characterised by a low number of healthy adults relative to people living with HIV/AIDS (PLWHA), children and elderly.
This experience of the impact of HIV/AIDS on households in Zimbabwe is supported by estimates2 that, by the end of 2001, 2.3 million people were infected by HIV/AIDS in Zimbabwe. One-third (33.7%) of all adults aged 15-49 years were estimated to be infected, with 200,000 deaths due to HIV/AIDS. By the end of 2001, Zimbabwe had approximately 780,000 orphans (children under 15 years who have lost one or both parents to HIV/AIDS).
Integrated Aids Project
As early as 1988, the Zimbabwe Red Cross (ZRCS) recognised the increasing vulnerability of households, with the start of the Integrated AIDS Project (IAP) which focused on prevention. As it became evident that the numbers of HIV affected households was growing, Home Based Care (HBC) was developed in 1992. The IAP now focuses on three main areas including:
- Prevention of transmission of sexually transmitted diseases (STDs) and HIV/AIDS
- Care and support for PLWHA and their affected families
The goal of the IAP is to "reduce the incidence of HIV/AIDS and its consequences among vulnerable groups in Zimbabwe through information dissemination, access to care and support". The programme reaches some 10,000 chronically sick clients3 in their homes and has registered over 35,000 orphans and vulnerable children (OVC).
There are currently 22 HBC projects across the eight provinces of Zimbabwe. The Zimbabwe Red Cross trains volunteers recruited from the community, often themselves infected with HIV, to become care facilitators. These volunteers then support households with PLWHA in various ways including hygiene training for infection management, promoting key health and nutrition messages, as well as work to reduce the stigma associated with HIV/AIDS.
Often the clients of home based care lack basic needs such as food, shelter and clothing - a key weakness of the programme identified prior to the current crisis. In order to meet these needs, the ZRCS started to distribute food to the HBC clients. However, due to funding constraints, this was erratic and often not enough to meet the ever-growing needs.
As a result of the political and drought induced crisis in Zimbabwe, the ZRCS was able to appeal for food provision for HBC clients and their household members in order to reduce the impact of the drought and political crisis on these particularly vulnerable households. [The monthly ration currently provided is shown in Table 1, which reflects the extra nutrient needs of HBC clients.]
As well as food provision, some of the HBC projects have support groups. These groups can be active through small income generating activities, as well as agricultural projects such as poultry production and home gardening. These support groups also act as an important means of psychological support by enabling people to talk and share concerns and ideas, while on a practical basis allow the sharing of costs for funerals.
HIV, food security and vulnerability
Although it is recognised that HIV/AIDS crosses wealth groups, it is clear that the poorest households in communities are the most vulnerable or at risk. The very poor have less access to HIV/AIDS information, may resort to prostitution to access money or food and have a poorer health and nutrition status. These are all factors that increase their vulnerability. At the same time, those better off may be vulnerable in that they have the resources to pay for multiple sex partners1.
Poorer HIV/AIDS affected households have a higher dependency ratio, with a lower number of healthy adults. They have less access to relatives in urban areas and abroad, while the gifts they receive are smaller in size and less regular than better off households. Poorer households also tend to have less access to regular employment, pensions or property and medical services. They have less access to nutritious food than better off households - a key factor in prolonging the lives of infected individuals.
The drought and political crisis in Zimbabwe exacerbated the impact of HIV/AIDS on clients of the HBC programme and their household members, by reducing access to food from production in rural areas, as well as in some urban areas, and through food price inflation. It has resulted in household members having to spend longer looking for sources of money or food and reduced the value of pensions, savings and the social welfare system as a result of inflation. Poor households with PLWHA have tried to cope by relying more on wild foods in rural areas and on casual labour and petty trade as income sources. Some have joined public works programmes, such as food for work, whilst others are trying to access social welfare programmes. Rural households may have more care and support available from relatives while urban households may be able to rely on support from relatives in urban centres or abroad. [Table 2 provides a comparison of urban versus rural HBC project areas in Marondera and Chivi, in 2002.]
While recognising the important and necessary role of food aid for PLWHA and household members, the HBC programme continues to struggle with a number of key issues including targeting, improving medium to long-term food security and capacity to meet food needs.
The HBC project aims to target the most vulnerable, i.e. the poorest households with PLWHA. Although difficult, this has been more effective in urban areas where HIV testing is more available and can be combined with needs assessments by Social Welfare. In rural areas, testing was not available so that selection was based on clinical symptoms in the absence of a clear clinical case definition. This has meant that some vulnerable households without PLWHA have been included in the programme.
A recent assessment1 proposed the following criteria for targeting in the absence of HIV/AIDS testing:
i) "Clear evidence (medical card) of a combination of recurring infections associated with HIV/AIDS", including
- constant diarrhoea
- persistent coughing /recurring TB
- swollen lymph nodes
- kaposi sarcoma
- "permed hair"
ii) People undergoing TB treatment. TB patients should, however, be weaned off the programme at the end of treatment unless clear evidence exists of HIV/AIDS infection.
Work continues with the ZRCS to try to improve targeting in order to use scarce resources more efficiently, while recognising the implications of stigma and discrimination associated with HIV/AIDS.
Improving medium to long term food security
The home care programme has recognised the need to identify strategies that target the medium to long term food security of other household members. For example, orphans and vulnerable children are often left without the knowledge and skills base to undertake agricultural production at a time when labour is in increasingly short supply.
Less time is available due to the time spent on care for the ill. There is therefore a need to develop methods of less labour intensive production, whilst maintaining the nutrient quality of the food produced.
Poor households also lack access to employment and are often depleting assets to access curative services for PLWHA. Increasing access to income could play a key role in improving food security.
The current programme has small income generating, poultry and home gardening activities, which contribute more in terms of social and psychological support than to the food security of households. A challenge for the Zimbabwe Red Cross lies in how to improve the food security of affected households while not overburdening the capacity of volunteers.
Resources for the current food distribution of the HBC programme are funded through an Emergency appeal by the International Federation of the Red Cross and Red Crescent. The expectations raised by the intervention will require forging partnerships between the ZRCS and multilateral and bilateral donors in ensure a continuous supply of food.
As food provision remains an important part of the HBC, the ZRCS are faced with a fundamental challenge, namely, the capacity of the existing volunteer base to meet food needs and provide for an increasingly diverse set of priorities within the HBC. This means that volunteers are stretched to their limits.
Home based care for people living with HIV/AIDS provides a unique opportunity for the ZRCS to access vulnerable households. These households are, however, vulnerable in both the short term as well as the long term. Although current efforts are focussed on addressing the acute food crisis as a result of the drought and political crisis in the country, it will be important to pilot and support the development of programmes that address longer term vulnerability.
A fundamental concern remains over the increasing workload of volunteers, coupled with the concomitant increase in needs of clients and their households. The HBC programme will therefore need to consider the possibility of increasing its volunteer base through a recruitment drive, or develop food security programming in an independent, though integrated, way to address the needs of PLWHA and their household members, including orphans and vulnerable children.
Lastly, it is clear that the crisis in Southern Africa, including Zimbabwe, is not "business as usual" for the humanitarian community. The Zimbabwe Red Cross, amongst other National Red Cross Societies in the region, recognises the need to develop an integrated multi-sectoral programme in support of households and communities affected by HIV/AIDS.
For further information, contact Hisham Khogali, email: Hisham.Khogali@ifrc.org
1 MacAskill J, Chinyangarara E, Dimbo K, Maxwell Phiri, M Tambudzayi T, 2002. Assessment of the impact of the drought and HIV/AIDS on HBC clients in the Chivi rural Project area and in Marondera urban project area.
2 Source: UNAIDS/UNICEF/WHO estimates
3 The term chronically sick clients is used in order to reduce the risk of stigma associated with HIV/AIDS.