Africa Forum 2009

The Global Food Crisis and HIV/AIDS

A Proposal for Support to the

Canadian International Development Agency

Submission Date: October 20, 2008

Table of Contents

Acronyms

1. Executive Summary

2. Problem Analysis

3. PCI’s Response: The ‘Links for Life’ Initiative

4. Links for Life Significance & Relevance

5. Goals, Objectives, Outputs and Activities

6. Anticipated Results

7. Request

8. Monitoring and Evaluation

9. Previous CIDA Support: Africa Forum 2009 compared to 2006 Event

10. PCI’s Organizational Capacity

Appendices

Appendix 1: Conference Budget Projections

Appendix 2: Right to Set-Off Declaration

Appendix 3: Anti-Corruption Declaration

Appendix 4: PCI's Certificate of Incorporation and By-Laws

Appendix 5: PCI's Audited Financial Statements

Appendix 6: CoP Participating Organizations

Appendix 7: Africa Forum 2009 Call for Participation

Appendix 8: PCI’s Capacity in HIV/AIDS and FNS

Appendix 9: Africa Forum 2009 Invitation

Acronyms

AF09Africa Forum 2009

AIDSAcquired Immune Deficiency Syndrome

ARTAntiretroviral Therapy

CADCanadian Dollars

CIDACanadian International Development Agency

CoPCommunity of Practice

FANSHAFood and Nutrition Security and HIV & AIDS Advocacy Group

FFEFood for Education

FFPrFood for Progress

FNSFood and Nutrition Security

HIVHuman Immunodeficiency Virus

IFRPInternational Food Relief Partnership

M&EMonitoring & Evaluation

NGONon-Governmental Organization

OGACOffice of Global AIDS Coordinator

OPCOffice of the President’s Cabinet

OVCOrphans and Vulnerable Children

PCIProject Concern International

PEPFARPresident’s Emergency Plan for AIDS Relief

PLHAPeople Living with HIV/AIDS

UNUnited Nations

UNAIDSThe Joint UN Programme on HIV/AIDS

USAIDUnited States Agency for International Development

USDUnited States Dollars

USDAUnited States Department of Agriculture

USGUnited States Government

WFPWorld Food Programme

WHOWorld Health Organization

1.

1. Executive Summary

The epidemics of HIV/AIDS, hunger and malnutrition are inextricably linked. Food and nutrition insecurity contribute to the spread of HIV, and hasten the progression from HIV to AIDS for those living with the virus. Conversely, HIV undermines food and nutrition security (FNS), as the body demands and uses more nutrients to fight off infection. Experience and anecdotal evidenceshow that activities aimed at immune system strengthening and the prevention of malnutrition in people living with HIV can extend the average asymptomatic period by four to six years.[1] This is supported by evidence that micronutrient supplements, providing the recommended daily allowance of vitamins and minerals, slow the progression of HIV.[2]Prolonging the latent period not only brings valuable years of health to people living with HIV/AIDS (PLHA) and their children, it can also delay the need for antiretroviral therapy (ART) among those infected; reduce the cost of treatment; and provide time for overburdened health systems to build the capacity needed to meet demand. In summary, unless responses are designed and implemented with consideration to the dual and bi-directional relationship of HIV/AIDS and food/nutrition insecurity, the downward and devastating trend that has emerged in sub-Saharan Africa will be difficult to reverse.

Project Concern International (PCI) is taking the lead in identifying, documenting, disseminating, and scaling up successful integrated HIV/AIDS and FNS programs in sub-Saharan Africathrough an initiative called Links for Life: Promoting Integrated HIV and Food/Nutrition Security Programming. Links for Life is a joint response of more than 15 international organizations to the dual epidemics of HIV and hunger. The initiativeaddresses the causes and consequences of HIV and food andnutrition insecurity in ways that are more effective and sustainable thantypical, single-stream efforts. It combines country-specific learning and practice; regional knowledge sharing; and linkages to policy-makers and donors with the ultimate goal of scaling up “what works” in integrated HIV/AIDS and FNS programming

From May 25th–29th, 2009, Links for Lifewill bring together more than 250 practitioners from across sub-Saharan Africa and the globe for the Africa Forum 2009 (AF09), inMalawi. AF09is a participant-driven conference that will focus on building the capacity of participants to implement cost-effective and locally viable practices to reduce food insecurity and the burden of HIV/AIDS; ultimately saving lives and protecting future generations.Over the course of five days, AF09 will also create country-based mechanisms to promote learning on integrated HIV/FNS programs and facilitate the scale up of those models. This will be done through capacity building on how to establish, monitor and maintain in-country knowledge groups, or ‘Communities of Practice(CoP),’ that are focused on integrated HIV/FNS programming. AF09 will feature program models that have been identified, studied, and are recommended for scale-up by already established Links for Life CoPs in Malawi and Ethiopia. It will also focus on the ‘how to’ of creating and sustaining country-level CoPs, building the capacity of participants to replicate the Links for LifeCoP model within their own countries. The presence of key policy makers and donors at the event will also position practitioners to garner the additional support they need for establishing these knowledge groups. Country based CoPs, along with efforts of the Links for Life Food and Nutrition and HIV/AIDS Advocacy Group (FANSHA), will help to push policy decisions forward to fund integrated programs; ultimately, to offer a path to sustainable development in sub-Saharan Africa within the context of HIV and FNS.

PCI is submitting this proposal to request CAD $121,432 in financial support from the Canadian International Development Agency (CIDA) for the AF09. Resources will be used to facilitate the participation of local practitioners at AF09, in accordance with CIDA’s rules and regulations. Criteria for selecting these participants includes: (i) African national; (ii) demonstrated financial need; and (iii) an application that meets the technical integrity of the Forum agenda.These delegates have no other means of acquiring funding to attend AF09, and yet their participation is essential to the success of the event and the overall initiative. The future of HIV and FNS programming throughoutAfrica is dependent upon the ability of PCI and its partners to sponsor participants with no other means of attending such events, participants who are on-the-ground practitioners and innovators and whose voices must be heard if real change is to occur. This request provides CIDA with an opportunity to participate in a completely unique event designed to significantly improve the way we approach HIV and FNS programming in Africa and around the world.

2. Problem Analysis

Throughout sub-Saharan Africa, millions of people living with HIV are becoming ill and dying prematurely, not only from the lack of advanced medicines, but because of health problems associated with poor nutrition, inadequate access to food and preventable illnesses. Of the estimated 33.2 million people worldwide who are infected with HIV, more than 22.5 million (68%) reside in sub-Saharan Africa. While the region is home to only 10 percent of the world’s population, it comprises 60% of the global population living with HIV. Simultaneously, the region is defined by chronic food insecurity and malnutrition, with an estimated 206 million people chronically hungry and malnourished.[3] The global food crisis of 2008 has pushed even more Africans into chronic hunger, making the goal of the United Nations (UN) to reduce, by half, the proportion of people worldwide suffering from hunger increasingly remote.[4]Throughout the region, HIV, AIDS, malnutrition and food insecurity are inextricably linked.

We now know that people living with HIV in sub-Saharan Africawill experience fewer years of good health and productivity before the onset of AIDS, than those with HIV in other parts of the world. This is due, in large part, to long term inadequacies in nutritional intake which continue to erode already weakened immune systems. Most people in sub-Saharan Africa subsist on a cereal-based diet and are challenged to meet daily nutritional requirements, even when they are healthy. It is widely accepted that symptomatic HIV adults require a 20-30% increase in energy intake simplyto maintain body weight; symptomatic children require an increase of up to 50-100%.[5] Sickness in a family creates even more household hardships and difficulty in meeting household nutritional needs. PLHA are often sick and unable to participate in subsistence agriculture or other types of livelihood activities to earn income for food. Sick family members are unable to transfer knowledge between parent and child, leaving future African generations increasinglyvulnerable through the absence of both cultural heritage and livelihood skills.

Food insecurity is a structural issue that also contributes to the spread of HIV, where hungry people may turn to unsafe practices to feed themselves. High risk behaviors are particularly relevant among females, who bear a disproportionate burden of the HIV epidemic. When there isinsufficient food to meet daily household needs, women, girls, andyoung boys may resort to transactional sex to generate income. As unprotected sex is generallymore lucrative than sex with a condom, these family members put themselves at risk of HIV infection in exchange for food, money, and/or material goods. In addition, parents may be compelled to marry off their daughters at ayoung age, unwittingly allowing them to become trapped in a network of concurrent relationships where HIV can rapidly infect every member.

Malnutrition not only thwarts efforts at HIV prevention, but also threatens HIV treatment. Individuals who start ART when malnourished suffer more severe side effects (e.g. nausea, taste changes, diarrhea, vomiting, and loss of appetite)than those who are sufficiently nourished. These side effects can threaten the effectiveness of treatment, decrease adherence to drug regimens, and speed the development of drug-resistant strains of HIV as individuals start and stop treatment. Most compellingly, those who start ART when malnourished are six times more likely to die than their well nourished counterparts.[6]

The compounding issues of HIV/AIDS and food and nutrition insecurityaffect all levels of society, specifically:

  • At the household level, illness and the premature death of parents have created a generation of orphans who will grow up unsupervised and take on adult responsibilities, such as caring for younger siblings and ill family members, doing their best to provide sufficient food to survive. In the absence of parental guidance, the agricultural and life skills ordinarily passed down from parent to child are no longer transferred, undermining the ability of these children and youth to pursue risk-free and productive livelihoods, and to eventually become parents themselves.
  • At the community level, fewer adults are able to harvest crops, earn income and contribute to the well-being of the more vulnerable members of society, thus weakening the fabric of traditional community safety nets which were once a staple feature of African societies.
  • At the national level, the convergence and dual impact of HIV and food & nutrition insecurity has decimated the capacity of governments to retain skilled staff and volunteers and, ultimately, to provide basic health care to its citizens. A weakened health sector is similarly constrained in its ability to roll out the life saving antiretroviral drugs, especially when scarce human and financial resources are diverted to manage critical scale food shortages.

Twenty-two of the 30 high-risk countries recently identified by the World Food Programme (WFP) as extremely vulnerable due to rising international prices of basic food commodities are on the continent of Africa.This year, wheat prices are up 120%, while rice prices have risen 75%; overall prices are expected to remain high through 2015. This‘global food crisis’,driven by high fuel costs, lower agricultural production, weather shocks, high meat consumption in transitioning Asian countries, and shifts to bio-fuel crops, is forcing alreadypoor families to spend as much as 80% of their budget on food.

Overall, it seems apparent that responses to HIV and AIDS must be designed and implemented with consideration to its dual and bi-directional relationship with hunger and malnutrition; yet, they are not. Funding remains silo-ed, with policies and funding streams organized in such a way that HIV programs target one population in one area, while FNS programs target another population in a different area. However, even if funding for integrated programming were abundant, identifying and scaling up successful programs would be difficult due to the current lack of mechanisms in place for promoting field-based learning on best practices.Without a platform for sharing of experiences, skills and knowledge,we will continue in our collective failure to recognize and take advantage of opportunities for positive synergy. Practitioners need support to build their own capacity to respond effectively with integrated approaches that work. Finally, on-the-ground innovations and policy makers must be formally linked to ensure funding streams are adapted to adequately support integrated programming,as well as the efforts to scale themup.

3. PCI’s Response: The ‘Links for Life’ Initiative

Project Concern International recognizes that targeted food and nutrition capacity building can reduce thehigh-risk, life-threatening behaviors people turn to in order to survive and support their families. PCI also recognizes that nutrition support aimed at immune system strengthening and the prevention of malnutrition can extend the asymptomatic period, delaying the need for ART among those infected. It also provides time for overburdened health systems to build capacity to meet the ART demand. Nutrition support and counseling can improve uptake and adherence to ART, prevention of mother-to-child transmissions, and tuberculosis programs––all crucial contributions to extending lives and rolling back the HIV pandemic. Furthermore, prolonging the asymptomatic period for those infected can mean the difference between life and death for vulnerable children, who have more time with their parents to learn critical life-saving skills. Finally, PCI is very much aware of the need for practice to influence policy decisions, and for building carefully cultivated relationships that willhave lasting impact.

With these principles in mind, PCI is taking the lead in identifying, documenting, disseminating, and scaling up successful integrated HIV/AIDS and FNS programs in sub-Saharan Africathrough an initiative called Links for Life: Promoting Integrated HIV and Food/Nutrition Security Programming. Links for Life is an initiative that promotesintegrated HIV and FNS programmingand in so doing, helps to address the causes and consequences of HIV and hunger in ways that are more effective and sustainablethantypical, single-stream efforts.

Responding to the urgent need, Links for Life addresses the dual epidemics of HIV/AIDS and food and nutrition insecuritythroughout sub-Saharan Africawith the following three, interlinked and complementary components:

1)Communities of Practice

Links for Life CoPswereestablished in Malawi and Ethiopia in 2008to promote field-based learning and information sharing around successful HIV/AIDS and FNS interventions. Each CoP is comprised of between 30-40 local practitioners representing non-governmental and government organizations, universities, operational research institutes, and UN agencies.Members of the CoPs have selected programmatic topics to explore in depth based on their own needs and experiences in integrated HIV/FNS programming. This learning will be documented in the form of “knowledge products” to be used as tools to help scale up programs. Monthly meetings are supplemented with field trips to local project sites, professional training sessions, and/or presentations by member organizations to enhance the learning experience. Links for Life CoP members in Ethiopia and Malawi have found the CoP methodology to be a hugely effective means to promote field-based learning and capacity building.

2)Africa Forum 2009

The Africa Forum 2009,the second component of the Links for Life initiative, is scheduled to take place from May 25–29, 2009, in Malawi. Up to 250 participants from across sub-Saharan Africa and the globe are expected to participate and contribute to the evidence base of successful HIV/FNS interventions and strategies.AF09 will be geared towards pragmatic, cost-effective ways to strengthen integrated programming at the community level, with particular emphasis on the special needs of women, children, elders, and PLHA. Hands-on learning and capacity building methodologies will be used to strengthen the capacity of participants to replicate and scale up successful models when they return home.

The ‘knowledge products’ generated by the Links for Life CoPs in Ethiopia and Malawi will be featured at AF09, and shared with participants as tools to help scale up the models identified in those two countries. AF09 will also focus on the practicalities of establishing a CoP, exploring the financial, management and staffing requirements, in addition to the overall methodology necessary to achieve success.

3)FANSHA(Food and Nutrition Security and HIV&AIDS Advocacy Group)

FANSHA, the third component of the Links for Life initiative, is the “Food and Nutrition Security and HIV & AIDS Advocacy Group.”Established in 2006 by PCI and sisterorganizations, the overarching purpose of FANSHA is to strengthen awareness around the interaction between HIV/AIDS, and food and nutrition insecurity.Theultimate aim of FANSHA is to influencedecision-making processes to encourage integrated HIV/FNS programming. The 45international members of FANSHA from across Africa, Europe, the United States, and Canadaconvenequarterly to identify global advocacy events for collective action. FANSHA will use knowledge products produced by the CoPs andAF09 to advocate for the need for integrated HIV/FNS programming.