Stuart Gillespie

Is poverty or wealth driving HIV transmission

Evidence of associations between socioeconomic status and the spread of HIV in different settings and at various stages of the epidemic is still rudimentary. Few existing studies are able to track incidence and to control effectively for potentially confounding factors. This paper reviews the findings of recent studies, including several included in this volume, in an attempt to uncover the degree to which, and the pathways through which, wealth or poverty is driving transmission in sub-Saharan Africa. We investigate the question of whether the epidemic is transitioning from an early phase in which wealth was a primary driver, to one in which poverty is increasingly implicated. The paper concludes by demonstrating the complexity and context-specificity of associations and the critical influence of certain contextual factors such as location, gender and age asymmetries, the mobility of individuals, and the social ecology of HIV transmission. Whereas it is true that poor individuals and households are likely to be hit harder by the downstream impacts of AIDS, their chances of being exposed to HIV in the first place are not necessarily greater than wealthier individuals or households. What is clear is that approaches to HIV prevention need to cut across all socioeconomic strata of society and they need to be tailored to the specific drivers of transmission within different groups, with particular attention to the vulnerabilities faced by youth and women, and to the dynamic and contextual nature of the relationship between socioeconomic status and HIV.

Maternal and child nutrition: building momentum for impact

372 www.thelancet.com Vol 382 August 3, 2013 In the 5 years since the Maternal and Child Undernutrition Series was published in The Lancet there has been a substantial increase in commitment to reduction of malnutrition at global and national levels. Most development agencies have developed or revised their strategies to address undernutrition focused on the fi rst 1000 days of life—the period from pregnancy to a child’s second birthday—as called for in the 2008 Series. One of the main drivers of this new international momentum is the Scaling Up Nutrition movement. National commit ment in low-income and middle-income countries (LMICs) is growing, donor funding is rising, and civil society and the private sector are increasingly engaged. Despite this progress, improvements in nutrition still represent a massive unfi nished agenda. The 165 million children with stunted growth in 2011 have compromised cognitive development and physical capa bilities, making yet another generation less productive than they would otherwise be. Countries will not be able to break out of poverty or sustain economic advances when so much of their population is unable Maternal and child nutrition: building momentum for impact support for the interventions that can be quickly scaled up or linked to nutrition programmes—such as early child development initiatives. It is equally important to take note of the message of Marie Ruel and colleagues— that in certain sectors, such as agriculture, the evidence of the eff ect of targeted programmes on maternal and child nutrition is largely inconclusive and requires new approaches to fi eld evaluation. Since 2008, there have been only limited increases in donor aid for nutrition. It is true that nutrition is not so readily attractive to politicians as an international development priority. Undernutrition has a complex set of political, social, and economic causes, none of which are amenable to easy solutions that fi t within the timeframe of a single political cycle. For this reason, the outlook today for nutrition is not wholly good. The target endorsed only a year ago at the World Health Assembly—to reduce by 40% the number of children stunted by 2025—is already on course to be missed. As the endpoint of the Millennium Development Goals approaches, countries and the international community may agree that nutrition was one of the great missed opportunities of the past 15 years. But this neglect can be turned around quickly. As sustainable development becomes the dominant idea post-2015, nutrition emerges as the quintessential example of a sustainable development objective. If maternal and child nutrition is optimised, the benefi ts will accrue and extend over several generations. This remarkable opportunity is why Stuart Gillespie and colleagues take a very diff erent approach to implementation than in any previous Lancet Series. Instead of exhorting politicians and policy makers to do something—or worse, simply hoping that political commitment will appear like a rabbit out of a hat—they set out a practical guide about how to seize the agenda for nutrition, how to create political momentum, and how to turn that momentum into results. This is the prize we have to grasp in the next 18 months.

Integrating nutrition security with treatment of people living with HIV: lessons from Kenya.

Background The increased caloric requirements of HIV-positive individuals, undesirable side effects of treatment that may be worsened by malnutrition (but alleviated by nutritional support), and associated declines in adherence and possible increased drug resistance are all justifications for developing better interventions to strengthen the nutrition security of individuals receiving antiretroviral treatment. Objective To highlight key benefits and challenges relating to interventions aimed at strengthening the nutrition security of people living with HIV who are receiving antiretroviral treatment. Methods Qualitative research was undertaken on a short-term nutrition intervention linked to the provision of free antiretroviral treatment for people living with HIV in western Kenya in late 2005 and early 2006. Results Patients enrolled in the food program while on treatment regimens self-reported greater adherence to their medication, fewer side effects, and a greater ability to satisfy increased appetite. Most clients self-reported weight gain, recovery of physical strength, and the resumption of labor activities while enrolled in dual (food supplementation and treatment) programs. Such improvements were seen to catalyze increased support from family and community. Conclusions These findings provide further empirical support to calls for a more holistic and comprehensive response to the coexistence of AIDS epidemics with chronic nutrition insecurity. Future work is needed to clarify ways of bridging the gap between short-term nutritional support to individuals and longer-term livelihood security programming for communities affected by AIDS. Such interdisciplinary research will need to be matched by intersectoral action on the part of the agriculture and health sectors in such environments.

Rethinking food aid to fight AIDS.

While the realization that AIDS is far more than a health problem has dawned only recently, many development organizations have yet to undertake thorough analyses of what this means for what they do, and how they do it. Even fewer have actually changed their policies and procedures to adjust to these new realities. We know that food and nutrition are fundamentally intertwined with HIV transmission and the impacts of AIDS. Food and nutrition security is fundamentally relevant to all four of the conventional pillars of HIV/AIDS response—prevention, care, treatment, and mitigation—and food aid can be an important weapon in the arsenal. This paper, based on a detailed review of the relevant literature and the findings of a mission to eastern and southern Africa, highlights the implications of the HIV/AIDS pandemic for food aid strategy and programming. By viewing food aid programs through an “HIV/AIDS lens” and in the context of a livelihoods approach, the authors argue that organizations can effectively design interventions that reduce both susceptibility to HIV and vulnerability to AIDS impacts. Though there is little empirical evidence regarding the effectiveness of food aid in responding to HIV/AIDS, the authors argue that this should not constrain action. Using past experience as a guide, organizations can learn by doing, documenting, and continually reassessing their programs using the evolving lens, so as to ensure maximal relevance and impact.

Agriculture and nutrition in India: mapping evidence to pathways.

In India, progress against undernutrition has been slow. Given its importance for income generation, improving diets, care practices, and maternal health, the agriculture sector is widely regarded as playing an important role in accelerating the reduction in undernutrition. This paper comprehensively maps existing evidence along agriculture–nutrition pathways in India and assesses both the quality and coverage of the existing literature. We present a conceptual framework delineating six key pathways between agriculture and nutrition. Three pathways pertain to the nutritional impacts of farm production, farm incomes, and food prices. The other three pertain to agriculture–gender linkages. After an extensive search, we found 78 research papers that provided evidence to populate these pathways. The literature suggests that Indian agriculture has a range of important influences on nutrition. Agriculture seems to influence diets even when controlling for income, and relative food prices could partly explain observed dietary changes in recent decades. The evidence on agriculture–gender linkages to nutrition is relatively weak. Sizeable knowledge gaps remain. The root causes of these gaps include an interdisciplinary disconnect between nutrition and economics/agriculture, a related problem of inadequate survey data, and limited policy‐driven experimentation. Closing these gaps is essential to strengthening the agriculture sectors contribution to reducing undernutrition.

Investigating the empirical evidence for understanding vulnerability and the associations between poverty, HIV infection and AIDS impact.

It is just over 25 years since the first cases of AIDS were reported. Over this quarter-century, AIDS has become one of most highly studied diseases in history. There have been significant medical advances in understanding the consequences of HIV infection and treating AIDS, as is well documented in many journals, including AIDS. The complex and place-specific social, economic, behavioural and psychological drivers of the spread of HIV remain less well delineated. The consequences of increased illness and death in poor countries and communities are still unfolding.

Scaling Up Impact on Nutrition: What Will It Take?

Despite consensus on actions to improve nutrition globally, less is known about how to operationalize the right mix of actions—nutrition-specific and nutrition-sensitive—equitably, at scale, in different contexts. This review draws on a large scaling-up literature search and 4 case studies of large-scale nutrition programs with proven impact to synthesize critical elements for impact at scale. Nine elements emerged as central: 1) having a clear vision or goal for impact; 2) intervention characteristics; 3) an enabling organizational context for scaling up; 4) establishing drivers such as catalysts, champions, systemwide ownership, and incentives; 5) choosing contextually relevant strategies and pathways for scaling up, 6) building operational and strategic capacities; 7) ensuring adequacy, stability, and flexibility of financing; 8) ensuring adequate governance structures and systems; and 9) embedding mechanisms for monitoring, learning, and accountability. Translating current political commitment to large-scale impact on nutrition will require robust attention to these elements.

Impact of Orphanhood on Underweight Prevalence in Sub-Saharan Africa

Background In Africa, approximately 25 million people live with HIV/AIDS and 12 million children are orphaned. Although evidence indicates that orphans risk losing opportunities for adequate education, health care, and future employment, the immediate effects of orphanhood on child nutritional status remain poorly understood. Objective This paper assesses the nutritional impact of orphanhood, with particular emphasis on taking account of various factors potentially confounding or masking these impacts. Methods Child anthropometry and orphan status were examined in 23 Multiple Indicator Cluster Surveys and Demographic and Health Surveys throughout sub-Saharan Africa, which were subsequently merged into larger, region-specific datasets (East, West, and Southern Africa). To compare orphans and nonorphans, linear regression and probit models were developed, taking account of orphan status and type, presence of a surviving parent in the household, household structure, child age and sex, urban versus rural residence, and current wealth status. Results Few differences emerged between orphans and nonorphans in controlled and uncontrolled comparisons, regardless of orphan type, presence of surviving parent, or household structure. Age differentials did confound nutritional comparisons, although in the counterintuitive direction, with orphans (who were 8 months older on average) becoming less malnourished when age differences were taken into account. Wealth did appear to be associated with orphanhood status, although it did not significantly confound nutritional comparisons. Conclusions Orphans were not consistently more malnourished than nonorphans, even when potential confounding variables were examined. Since household wealth status is likely to change after becoming affected by HIV, ruling out wealth as a potential confounder would require more detailed, prospective studies.

Educating and Training a Workforce for Nutrition in a Post-2015 World

Nearly all countries in the world today are burdened with malnutrition, manifesting as undernutrition, micronutrient deficiencies, and/or overweight and obesity. Despite some progress, efforts to alleviate malnutrition are hampered by a shortage in number, skills, and geographic coverage, of a workforce for nutrition. Here, we report the findings of the Castel Gandolfo workshop, a convening of experts from diverse fields in March 2014 to consider how to develop the capacity of a global cadre of nutrition professionals for the post-2015 development era. Workshop participants identified several requirements for developing a workforce for nutrition, including an ability to work as part of a multisectoral team; communication, advocacy, and leadership skills to engage decision makers; and a set of technical skills to address future challenges for nutrition. Other opportunities were highlighted that could immediately contribute to capacity development, including the creation of a consortium to link global North and South universities, online training modules for middle managers, and practical, hands-on experiences for frontline nutrition workers. Institutional and organizational support is needed to enable workshop recommendations on education and training to be effectively implemented and sustained. The findings from the Castel Gandolfo workshop can contribute to the delivery of successful nutrition-relevant actions in the face of mounting external pressures and informing and attaining the forthcoming Sustainable Development Goals.

Agriculture, Food Systems, and Nutrition: Meeting the Challenge

Malnutrition is a global challenge with huge social and economic costs; nearly every country faces a public health challenge, whether from undernutrition, overweight/obesity, and/or micronutrient deficiencies. Malnutrition is a multisectoral, multi‐level problem that results from the complex interplay between household and individual decision‐making, agri‐food, health, and environmental systems that determine access to services and resources, and related policy processes. This paper reviews the theory and recent qualitative evidence (particularly from 2010 to 2016) in the public health and nutrition literature, on the role that agriculture plays in improving nutrition, how food systems are changing rapidly due to globalization, trade liberalization, and urbanization, and the implications this has for nutrition globally. The paper ends by summarizing recommendations that emerge from this research related to (i) knowledge, evidence, and communications, (ii) politics, governance, and policy, and (iii) capacity, leadership, and financing.