HIV-Aids is an ever-growing challenge in Africa’s rapidly growing cities, where prevalence rates are higher than in rural areas.
While the Aids epidemic is associated more with urban than rural areas in sub-Saharan Africa, the opposite is true of food security. There is a pervasive, and misleading, idea that food insecurity is largely a rural problem affecting rural households.
Considerable attention has been devoted to how the Aids epidemic impacts on smallholder agricultural production and productivity.
While this has resulted in an extensive body of knowledge on the negative impacts of the epidemic on agricultural production, it has also meant that our understanding of the link between HIV and urban food security is fragmentary, and has to be pieced together from case study evidence.
Research findings about the impact of the Aids epidemic on rural food security cannot be transferred unquestioningly to the urban setting, as the implications of the epidemic for food security differ in nature, scope and magnitude in rural and urban settings.
Despite the rapid rate of urbanisation in Africa, the reality is that the two spheres of “urban” and “rural” are entwined within a complex relationship, particularly in the context of the political economy of migration and mobility in southern Africa.
For example, urban populations that receive informal food transfers from the countryside will be affected by any Aids-induced fall in rural household production. And if HIV-Aids prompts migration out of rural areas, so the numbers of poor, food-insecure urban dwellers swells.
When urban HIV-infected people return to rural areas for family care, the food needs of the urban household decrease, while those of the rural household escalate.
If migrants living in urban areas are unable to work due to ill health and send money home, there is less income for both the rural and urban households to purchase food.
In other words, the epidemic in rural areas impacts on urban food security and the epidemic in urban areas impacts on rural food security. In this context, the separation of the “rural” and the “urban” into discrete spheres is highly artificial.
A survey by the African Food Security Urban Network (Afsun) in 2008-2009 of household food security in 11 SADC cities found that 28% of poor urban households had received food transfers from rural households in the previous year.
This varied considerably from city to city. In some, such as Windhoek, Lusaka and Harare, the proportion was more than 40%.
The amount and regularity of household income is critical to food security in the urban context, for it largely determines food accessibility. When a steady and sufficient income stream is absent, households quickly become food insecure, eating less, eating less well, sacrificing dietary diversity and relying more on foods high in sugar and carbohydrates.
The result in many of the poorer urban neighbourhoods of southern Africa is an epidemic of undernutrition. Rapid urbanisation in the last two decades has dramatically increased the number of people in this situation.
This means, in effect, that the number of people who were in a nutritional state that made them particularly vulnerable to the ravages of HIV was growing rapidly even as the virus itself began its inexorable spread.
The rapid spread and devastating impact of HIV has been exacerbated by mass urbanisation and undernutrition.
Urbanisation is unlikely to slow in the coming years. This leads to an obvious conclusion: food insecurity and HIV are locked in a vicious circle whose worst impacts can be mitigated by antiretroviral therapy and improved access to a rich, varied and adequate diet for all.
A consortium of international organisations led by the World Bank recently argued that adequate nutrition is necessary to maintain the immune system, manage opportunistic infections, optimise response to medical treatment, sustain healthy levels of physical activity, and support optimal quality of life for people infected with HIV.
Their lengthy list of “what we can do” elaborates a whole suite of nutrition-based interventions, which are sound and comprehensive and should be seriously considered as priority interventions for southern African cities.
But while the implementation of these proposals would bring great relief to people infected with HIV, the manual does not address the broader social and economic inequities that put so many people at risk. Nor does it say much about the needs of those whose nutrition and food security is negatively impacted by HIV-Aids, though they themselves may not be infected.
The presence of people living with HIV in the household changes the food and nutrition security of the whole household and may ripple out into the community. People who are no longer able to work means reduced household income and increased medical costs.
HIV not only has a negative impact on the nutritional status and requirements of the individual, but places additional demands on other household members and can make everyone more food insecure.
A broader approach is needed which encompasses all aspects of food security – availability, accessibility, appropriateness and reliability, as well as quality – and their relationship with HIV-Aids. Nutritional and biomedical research on the immediate impact of HIV and Aids on health needs to be reframed within an approach that identifies underlying causes of food insecurity and HIV vulnerability.
Structural problems such as rapid urbanisation, poverty and unemployment may seem more intractable, but they cannot be ignored in the search for sustainable solutions.