HIV This Week

Weiser S, Leiter K, Bangsberg D, Butler L, Percy-de Korte F, Hlaze Z, Phaladze N, Lacopino V, Heisler M. Food Insufficiency is Associated with High-Risk Sexual Behaviour among Women in Botswana and Swaziland. PLoS Med. 2007;4(10):1589-97

Photo credit: Christian Aid/Photo Voice/Beatrice

Both food insufficiency and HIV infection are major public health problems in sub-Saharan Africa, yet the impact of food insufficiency on HIV risk behaviour has not been systematically investigated. We tested the hypothesis that food insufficiency is associated with HIV transmission behaviour. We studied the association between food insufficiency (not having enough food to eat over the previous 12 months) and inconsistent condom use, sex exchange, and other measures of risky sex in a cross-sectional population-based study of 1,255 adults in Botswana and 796 adults in Swaziland using a stratified two-stage probability design. Associations were examined using multivariable logistic regression analyses, clustered by country and stratified by gender. Food insufficiency was reported by 32% of women and 22% of men over the previous 12 months. Among 1,050 women in both countries, after controlling for respondent characteristics including income and education, HIV knowledge, and alcohol use, food insufficiency was associated with inconsistent condom use with a non-primary partner (adjusted odds ratio [AOR] 1.73, 95% confidence interval [CI] 1.27–2.36), sex exchange (AOR 1.84, 95% CI 1.74–1.93), intergenerational sexual relationships (AOR 1.46, 95% CI 1.03–2.08), and lack of control in sexual relationships (AOR 1.68, 95% CI 1.24–2.28). Associations between food insufficiency and risky sex were much attenuated among men. Food insufficiency is an important risk factor for increased sexual risk-taking among women in Botswana and Swaziland. Targeted food assistance and income generation programs in conjunction with efforts to enhance women’s legal and social rights may play an important role in decreasing HIV transmission risk for women.

Editors’ notes: Insufficient food to meet daily needs and infection with HIV are major causes of death in southern Africa. Good nutrition is essential for a strong immune system. Protecting and promoting access to food can act on the socio-behavioural plain to reduce HIV exposure and on the biological plain to both reduce the risk of becoming infected if exposed and to maintain good health for longer once infected. Supporting women’s subsistence farming and enhancing their control over their food supplies as well as their sexual lives are key steps to improving their resilience to HIV.

It is often asserted that AIDS is at the core of a “vicious circle” whereby the impacts of AIDS increase poverty and social deprivation, while poverty and social deprivation increase vulnerability to HIV infection. In examining this view, it is important to distinguish between the “downstream” effects of AIDS on poverty, and the “upstream” effects of poverty upon the risk of acquiring HIV. Understanding these interactions is vital to the development and implementation of effective strategies to prevent and treat HIV. Six elements are key to an effective, sustainable response. First, AIDS money has the most impact when strategies are based on the concept of “know and act on your epidemic”. UNAIDS’ Practical Guidelines for Intensifying HIV Prevention provide practical guidance to tailor national HIV prevention responses so that they respond to the epidemic dynamics and social context of the country and each populations who remain most vulnerable to HIV infection. Second, a growing number of small-scale activities indicate the value of combining HIV programmes with poverty reduction initiatives. The challenge now, however, is to make the shift from small-scale projects to large-scale programmes. Third, the provision of HIV treatment can help prevent poverty—and indirectly contribute to HIV prevention as well—by helping to break down stigma. Access for the poor to HIV treatment and prevention services requires action to increase investment in antiretroviral treatment—by both national and international funders; reduce the cost of antiretroviral drugs; improve HIV service delivery systems; and provide better services for the poor. Fourth, development plans (whether they concern the development of productive sectors or the provision of social safety nets) must “pass the AIDS test”, contributing to HIV prevention and treatment in the communities they work in. Fifth, both poverty reduction programmes and AIDS strategies must reduce vulnerability to HIV— particularly for women and young people. Doing so involves protecting human rights and tackling issues around social marginalization and stigma. Sixth, addressing AIDS in the world’s poorest countries and communities depends on increased and sustained international support, driven by high-level political will. Complex problems famously require complex solutions. In this case, it is crucial to place AIDS squarely at the centre of all socio-economic development, and provide long-term, high-level domestic and international investment in HIV prevention and treatment in the world’s poorest countries.

Editors’ notes: Economic and gender inequalities along with weakened social cohesion are key influences on sexual behaviour and risk of HIV transmission. The clear pattern of associations between the level of income inequality measured by the Gini coefficient and HIV prevalence in sub-Saharan Africa speak to the need to improve governance in general as well as strengthen the AIDS response.