Catholic Relief Services Speeches and Testimony
CRS Testimony On HIV and Nutrition
October, 2007
Good afternoon Chairman Payne, Ranking Member Smith and Members of the Subcommittee. I commend you for calling this timely hearing and giving Catholic Relief Services the opportunity to share our experiences as an implementer of PEPFAR programs. We are especially concerned about the nutrition and food security needs of people living with HIV (PLHIV).
My name is Annemarie Reilly, Chief of Staff for Catholic Relief Services (CRS). For over 60 years and currently operating in more than 100 countries, CRS—the international relief and development agency of the United States Conference of Catholic Bishops—has been responding to the needs of people around the world in emergencies, humanitarian crises, and in development—especially for the poor, marginalized, and disenfranchised. Catholic Relief Services has been involved in HIV and AIDS interventions for more than 20 years—almost since the beginning of the pandemic. In 1986, our first HIV project supported a local congregation of Catholic sisters in Bangkok, to provide HIV and AIDS awareness, HIV prevention education, as well as compassionate care and support services among HIV positive sex workers and their children. By 2002, CRS had supported more than 300 HIV and AIDS projects.
Today CRS supports over 250 HIV projects in 52 countries. Local Catholic Church-based organizations are our principal and priority partners; however CRS also partners with other faith-based and community-based organizations, as well as with other local and international NGOs, Ministries of Health and national AIDS control entities. CRS' largest project—AIDSRelief—supports 140 local partners in 9 countries to provide antiretroviral therapy to more than 84,000 PLHIV and care and support services to another 140,000 PLHIV not yet eligible for antiretroviral therapy (ART). Our comprehensive and holistic HIV and AIDS projects provide mainstream interventions such as HIV and AIDS awareness education, abstinence and behavior change programming, support for orphans and other vulnerable children (OVC), support for PLHIV, home-based care, and the provision of antiretroviral therapy and related services. Many of our projects also include agriculture, microfinance, education, health, and water and sanitation activities. Monitoring and evaluation and operations research are important components of our programming. CRS projects give preference to women and girls, orphans, and other poor and marginalized populations in the countries in which CRS works. We and our partners are thankful to be able to partner with PEPFAR in 12 of the 15 focus countries.
First of all, I would like to thank Ambassador Dybul and colleagues at the Office of the Global AIDS Coordinator and the United States Agency for International Development for developing the conceptual framework on HIV and Food Security released in September. The background and analysis that inform the conceptual framework and the resulting recommendations reflect the reality that we as implementers face. Many of the following remarks serve to illustrate and support the findings and recommendations of the conceptual framework.
The number one issue that we hear from people living with HIV and AIDS and their families in the 52 countries where we have HIV specific programs, is lack of food and the money to purchase it . All aspects of food insecurity—availability, access and use of food—are exacerbated by high rates of HIV and AIDS. The chronic and debilitating progression from HIV infection to full-blown AIDS (if untreated or treated late) accompanied by the loss of work and income while seeking treatment leads to hunger, poor nutrition, and food insecurity.
The Food and Nutrition Technical Assistance Project of World Food Program has accurately summarized the pernicious results when HIV meets hunger.
HIV significantly undermines a household's ability to provide for basic needs because HIV-infected adults may be unable to work, reducing food production and/or earnings. Healthy family members, particularly women, are often forced to stop working to care for sick relatives, further reducing income for food and other basic needs. The households may have trouble paying costs associated with heath care and nutritional support. They also may be severely restricted in participating in community activities. Children may be withdrawn from school because families cannot afford school fees because of the need for the children to care for ill relatives. This affects the opportunities for future generations. 1
As a result of this HIV-to-poverty or poverty-to-HIV cycle, the quantity and quality of diet diminishes for both the PLHIV and other household members.
The interaction between nutrition and ART is well documented.2 3 Inadequate nutrition causes malabsorption of some ARVs. Some medications have to be taken on an empty stomach, while others with a fatty meal. Preliminary evidence from the 140 CRS AIDSRelief ART sites suggests that patients initiating ART with access to food respond to treatment better than those lacking adequate nutrition. Continued data collection is important for a more comprehensive picture.
I would also like to underscore the impact of food insecurity on children and orphans in AIDS-affected households. Older children in AIDS-affected households are often forced to quit school because of deteriorating family finances and/or because they need to care for their ailing parent. Younger children of school age often never even start school. Those lucky enough to attend school often do not have enough to eat. Recent evaluation of CRS' PEPFAR-supported OVC program was conducted in five countries. In Haiti where food supplements are provided, 96% OVC reported that they "always have enough to eat." However, in Zambia where no food supplements are provided by the program an average of only 5% OVC reported "always having enough to eat." Furthermore, with fewer adults to earn income or farm, these households have fewer resources for food and adequate nutrition CRS' PEPFAR central grant directly supports 56,000 orphans and vulnerable children (OVC) in five countries (Haiti, Tanzania, Kenya, Rwanda, and Zambia). In its implementation we have created linkages with the World Food Program (WFP) office in Tanzania and Title II Food for Peace (FFP) programs in Kenya and Haiti. Inflexible requirements for PEPFAR and Title II have greatly complicated addressing linkages between food insecurity and HIV.
For example, in Tanzania during the early years of PEPFAR, WFP allotted food to different regions of the country than those covered by CRS' OVC project. While this particular problem was eventually fixed, we encountered similar constraints in other countries.
CRS' AIDSRelief program in Kenya provides ARVs to nearly one in nine PEPFAR-supported patients in the country through 19 local treatment partner facilities. Patients meeting certain criteria receive food and nutrition supplements for a limited period of time through "Food by Prescription". This innovative approach allows CRS to purchase food using PEPFAR funds for food distribution to patients only—with no ration for their households.
From our almost 50 years of food aid experience with Title II, when food is given only to the patient, we have observed that individual food rations are usually shared with the rest of the household—diminishing the intended benefit to the individual. As a result, CRS strives to use other resources—from Title II, WFP, and our private funds—to distribute basket rations to families and households affected by HIV.
Almost all of CRS' 250 HIV and AIDS projects have an integrated food and nutrition element. We also integrate our nutrition-based HIV response with efforts to address the wider health and food security needs of vulnerable communities. To this end, CRS' OVC and PLHIV support programs frequently include training in better agricultural techniques, nutrition education, and cooking demonstrations.
For example, the Scaling Up Community Care to Enhance Social Safety-nets (SUCCESS) Project in Zambia, improved the palliative care and support to people living with HIV (PLHIV) through multiple interventions, including home based care, community-based counseling and testing, prevention of parent to child transmission, targeted nutritional interventions, referral to ART, and adherence support. SUCCESS home based care initially provided food rations to PLHIV who were not strong enough to work. The project, and its successor the Return to Life project, then added income generating activities and food production combined with life-saving ART. Where agriculture is the main livelihood activity, the household also receives an ag-pack containing crop seeds, information on soil improvement practices (agroforestry or green manures), fertilizer and/or agricultural tools. Where livestock plays a larger role in supporting livelihoods, the program gives households a male/female pair of cattle, goats or chickens under a revolving loan agreement where one female offspring is later returned for distribution to another family.
In Malawi, the rural poor suffer from chronic food insecurity as a result of poor access, inadequate availability and poor utilization of food. Moreover, AIDS and related diseases are the leading cause of adult morbidity and mortality in Malawi. Approximately 15 percent of adults are HIV-positive, and more than one-third of all children under the age of 15 have lost at least one parent to the disease. There are approximately 740,000 people living with HIV in Malawi. Most live in the southern and central regions, where food insecurity and vulnerability are most intense.
Through the PL 480 Title II-supported I-LIFE program (Improving Livelihoods Through Increasing Food Security), CRS and its partners provide food assistance to the chronically ill (most of whom are PLHIV) and their households. This helps entire families maintain a healthy nutritional status, provides for increased calorie and protein needs of those infected, eases the time and resource constraints of caregivers, and allows other members living in vulnerable households to pursue productive livelihoods. I-LIFE also provides community education programs that incorporate information about HIV prevention, health and nutrition, and challenge the stigma associated with the disease. Through these interventions CRS and its partners reduced food insecurity and eased the effects of the HIV and AIDS epidemic in the region. Unfortunately, many beneficial Title II-supported programs like I-LIFE have either ended or are in their last year because of Title II funding cuts.
Despite some initial achievements and many efforts to integrate nutrition and HIV programming, much work remains to be done:
1) Short-term food/nutrition supplements and household basket rations, while necessary, do not address underlying food insecurity. What happens after a client receives food rations for several months and they are still without a means of livelihood?
2) Food and nutrition and HIV activities are not well integrated across USG agencies and programs. Title II programs are targeted to regions with the greatest food insecurity, which does not always allow us to reach food insecure OVC and PLHIV living in other regions. In addition, interagency coordination and integration of services is not always consistent across countries.
3) The inability to purchase food with PEPFAR funds where Title II or other resources are not available prevents addressing nutritional needs. CRS AIDSRelief ART Project provides "Food by Prescription" to ART patients in a part of Kenya where FFP resources are not available. This creative approach is not currently possible everywhere.
4) Cutbacks in Title II funding have exacerbated the challenge. Successful projects like I-LIFE, RAPIDS, SUCCESS, and Return to Life in the southern Africa region have led to better integration of HIV and nutrition programs with sustainability by targeting the causes of food insecurity. All have NOT received continued or expanded funding because of Title II cutbacks. A recent SUCCESS (Scaling Up Community Care to Enhance Social Safety-nets) evaluation report shows the overwhelmingly positive impact of nutritional supplements on HIV-positive home based care clients not taking ARVs that also met household food insecurity criteria for targeted nutritional supplementation.
5) Even when approved, breaks in the Title II food supply pipeline have reduced the effectiveness of the response as temporary commodity shortages result in an incorrectly balanced nutrition and food ration.
6) Shortages of healthcare workers, including nutritionists, limit the time and ability of existing staff to provide food/nutrition counseling.
7) Cutbacks and elimination of Title II food programming have caused programs to revert to "length of time on ration" as exit criteria for people receiving food. FFP programs like C-SAFE and I-LIFE in southern Africa used other more successful measures of household food security to trigger transition and exit strategies. These programs helped families affected by HIV sustain their nutritional needs through agriculture or other income generating activities which will allow them to buy nutritionally valuable foods. In an environment of Title II resource cutbacks, programs do not have the ability to implement these strategies.
8) Infant and young child feeding has not been adequately addressed. USAID funded Child Survival programming is not well integrated with PEPFAR-supported Prevention of Mother To Child Transmission programs (PMTCT). Many partners follow pregnant women through antenatal clinics and then follow up with their children with Child Survival and other health promotion programming. Lack of integration across USG funded programs has resulted in PEPFAR not exploiting antenatal clinics for counseling and testing of pregnant women, provision of identified HIV positive pregnant women with PMTCT services, and follow-up of children with more preventive services (cotrimoxizole prophylaxis) and infant and child feeding counseling (for the HIV positive mother) with provision of appropriate food supplements for mother and child. There are several missed opportunities in this sequence. Future PEPFAR interventions must provide resources for nutritional counseling for parents as part of an integrated package of services that bridge Child Survival and PMTCT.
Recommendations
Chairman Payne and members of the committee, CRS believes that access to food is a fundamental human right. It also is critical to maximizing the sizable and successful investment our government is making in responding to the needs of persons living with HIV. Catholic Relief Services submits the following recommendations to improve integration of nutrition and food security into the PEPFAR-supported programs:
1) Provide a budget for food in PEPFAR and revise the criteria for which patients can receive "Food by Prescription" so that more recipients will be eligible.
2) Increase the Title II budget in order to direct more funds and food commodities specifically for the purpose of providing nutritional support to PLHIV.
3) Require greater collaboration, integration, and flexibility of USG programs and funding mechanisms to meet the livelihood needs of the participants in PEPFAR-funded programs so that there can be longer term prospects for sustainability of people's nutritional status.
4) Focus more broadly on assisting households to reduce food insecurity by increasing livelihood strategies and approaches to sustain household security, in addition to addressing more community level systemic factors that contribute to poverty and food insecurity.
5) Increase funding for OVC support—including food basket to the household—to keep children in school and prevent the need for especially girl children to engage in transgenerational sex to meet their own and their family's food needs.
In conclusion, I want to once again thank you Chairman Payne, Ranking Member Smith and all members of the subcommittee for holding this hearing to respond to the nutrition needs of persons living with or affected by HIV and AIDS. Our recommendations are a sincere effort to improve the effectiveness of a PEPFAR program that is indeed saving lives and providing hope for millions. Thank you, Chairman Payne. I would be pleased to respond to any questions that the Committee may have.
