Ellen Gustafson, the co-founder of FEED Projects , launched the " 30 Project " on TEDxEast this past Friday. In light of reading the statistics on the new 30 Project website (namely, "The U.S. now spends 20 times more on food aid to Africa than it does helping Africans develop ways to feed themselves," I've decided to post a paper I wrote last semester for my International Nutrition class (where Ellen actually was a guest lecturer). Ellen is a fantastic speaker, but more on that later. For now here's my paper.
Food Security and HIV/AIDS in Kenya (by Kelly Moltzen)
In Kenya, as well as many other places around the world particularly in sub-Saharan Africa, human immunodeficiency virus (HIV) is still a huge epidemiological issue despite access to antiretroviral medications. One of the reasons for the high rates of HIV in Kenya is because people do not have access to adequate food, thereby compounding the effects of the disease on the immune system. Rates of food insecurity in Kenya are very high, particularly in rural areas.  There are many contributing factors to the problem of food insecurity, not excluding political corruption, which led the World Bank and the IMF to delay giving loans to the government in 2006.  In addition, Kenya suffers from severe droughts which reduce agricultural output, and low investment in the country’s economic growth.2 There is still no funding specifically dedicated to food security for the HIV population.1
In any country in which it occurs, the coexistence of HIV, poverty, and food insecurity has devastating impacts on people’s health.1 HIV worsens nutritional status, further leading to the decline in health of people living with HIV/AIDS (PLWHA).  When HIV-infected people do not receive sufficient food to nourish them and help them recover, this leads to the perpetuation of the disease and increased numbers of PLWHA.  This happens through several mechanisms, occurring through biological as well as social and economic pathways.4 HIV can be transmitted horizontally when food insecure women – who are responsible for the health of their families – engage in transactional sex to make money to buy food for their families. It can also be transmitted vertically, as pregnant malnourished women with HIV have a greater chance of transmitting the disease to an unborn infant than well-nourished pregnant women. In particular, factors associated with higher mother-to-child transmission are low iron and Vitamin A stores, low BMI, and maternal weight loss.4
Food insecurity also impacts access to treatment and care services.4 While the Kenyan Ministry of Health has worked with Doctors Without Borders to provide free access to ARV treatments in the Nairobi slums of Kibera, a considerable number of eligible individuals have not accepted the offer for medications.  Oftentimes, even when receiving free ARV medications, parents need to choose between paying for transportation to attend health care appointments, and using the money to adequately feed themselves and their children.4 This problem seems like it would be even larger in rural areas than urban areas, where traveling is less convenient. Also, in the study of Kibera, one of the main reasons for not accepting the offer for medications was because of a fear of taking the medication on an empty stomach.5
Lack of food has shown to negatively impact the efficacy of antiretroviral (ARV) medications. Food insecurity has been associated with a decrease in the effectiveness of protease-inhibitor based regimens, and specifically a 30% decrease in drug plasma concentrations.4 Very high viral loads have been found among those receiving highly active antiretroviral treatment (HAART).4 Taking ARV regimens with food has been shown to increase the bioavailability of medications by as much as 700%.4 The ability of the human body to suppress the virus has shown to be 70% lower in people reporting food insecurity, even after levels of adherence to the medication regimen were taken into account.4 Thus, it is of paramount importance that patients receive adequate nutrition, if there is any chance of halting the spread of HIV in sub-Saharan Africa and elsewhere.
HIV prevalence in Kenya is more concentrated in the west of the country6 and where there are higher poverty rates, small plots of land, and poor soil quality.1 There are over 1.5 million people in Kenya currently living with HIV, and there are approximately 100,000 deaths from AIDS per year in this country.  Up to 700 people reportedly die on a daily basis in Kenya from infections related to their HIV status.  One study found that PLWHA were more likely to be malnourished than people whose status was not established.7
The study found that the majority of foods eaten by PLWHA were low in nutrients that help build up the immune system and maintain adequate weight, and that there was not a lot of variety in the foods consumed.7 High protein foods such as meats and legumes were found to be consumed by less than a quarter of the sampled households.7 Interestingly, those surveyed showed a lack of nutrition knowledge in terms of which foods were appropriate for PLWHA to eat to support a healthy immune system.7 This is likely related to the literacy rates, as many people cannot understand educational brochures which are handed out if they are illiterate. The literacy rates in Kenya are approximately 80% for females and 90% for males, as estimated in 2003.2
Additionally, there are high numbers of widows, orphans, and falling school attendance rates in Kenya.1 Many children must care for their ailing parents who have HIV/AIDS, and this adversely affects their ability to participate fully in obtaining their education. Mishra et al found that “orphans, fostered children, and children of HIV–infected parents are significantly less likely to attend school than non–orphaned/non-fostered children of HIV–negative parents.” 
The Academic Model Providing Access to Healthcare (AMPATH) identified over 67,000 individuals from 17 clinics in Kenya as food insecure in 2007, which amounts to 33.5% of the total number of people assessed.1 AMPATH began as a collaboration between a consortium of universities in Indiana and the Moi Teaching and Referral Hospital and Moi University School of Medicine. When the extent of the problem of HIV and food insecurity was realized, AMPATH established partnerships with the World Health Organization’s World Food Program (WFP) and the United States Agency for International Development (USAID), and began producing food on farms in Kenya to complement food donations.1
Essentially, these international aid organizations are working with clinical staff and community groups to provide resources and support to HIV patients and their families. Nutritionists assess all patients in the AMPATH clinics with the Household Food Insecurity Access Scale used by USAID.1 The nutritionists were given criteria to use to decide who would qualify for the program, which included meeting one or more of the following: “a) having insufficient access to food to support patient recovery; b) Body Mass Index (BMI) below 19; c) Household income less than 3,000 Ksh per month; d) CD4 count less than 200.”3 In general, however, the nutritionists subjectively decide eligibility status, giving food insecurity the most weight.3 Those who qualify for the program are provided 6 months of nutrition support, as this is the amount of time thought necessary to recover and be able to carry out activities of daily living; however, there is some flexibility in the length of time a patient could receive the food support.1,3
The amount of food allotted to patients is determined based on the number of people in the household.1,3 Monthly follow-ups are used so that patients renew their “food prescription” on a regular basis1; patients are also weighed and receive nutrition counseling during these monthly follow-ups.3 Patients are enrolled either through the WFP or through the “HAART and Harvest Initiative” (HHI), and fill their food prescriptions at distribution sites on a regular basis, depending on how far the site is from their residence.3 When patients are weaned off food support, they are enrolled in the “Family Preservation Initiative” which provides education on income generating activities or food production.1,3 They could also choose to attend patient-led support group meetings.3
To provide necessary food to the patients, a combination of production, purchase, and donation of food is used; as stated, food production is “a key component of the AMPATH nutrition program.” 1 Six farms were started, 4 of which are used for high production of food (3 rural, 1 urban), and two of which are used for educating patients on how to increase the yield of small plots they may own.1,3 A continuous source of water is provided, which allows the farms to produce a year-round supply of fresh vegetables.1 Over 20 tons of vegetables are produced per month, and an expected 4 tons of fruits are also expected to be produced as the farms become more productive.1
In addition to food production, the WFP provides food donations of legumes, corn, corn-soy blends, and cooking oil, for up to 30,000 recipients and 1500 orphans and vulnerable children; an additional 2,000 people receive corn-soy blends from USAID. AMPATH also coordinates the distribution of eggs and milk which are produced by patients within the program,1 as well as local and exotic herbs.3
Industrial engineers from Purdue University worked with AMPATH to design a computerized nutritional information system that could be used to coordinate the distribution of food to patients throughout western Kenya. The foods available, as well as patients needing that food, are entered into the system, which then helps coordinate who will pick up, transport, and deliver the food to the proper places. Altogether, food and fixed costs of the program cost $0.27 per patient per day. 1
The AMPATH model and collaboration with the WFP and USAID provides a remarkable opportunity to improve the nutritional status of Kenyans, especially those living with HIV/AIDS. It uses an academic partnership, teaches native Kenyans how to farm the land and uses the crops they produce as part of the food support package given to the HIV/AIDS patients and their families. It also provides the patients with nutrition education, and an opportunity to learn skills on income-generating activities through the Family Preservation Initiative.
However, as noted by Mamlin et al, the current system still relies heavily on food donations and is unsustainable in the long run.1 It is necessary to teach more Kenyans how to till the land and increase the number of farms and gardens producing crops. There should be more diversity of crops grown on these farms, as this would help not only decrease dependence on foreign food aid, but also to improve the nutritional status of Kenyans – both PLWHA and those currently without the disease. By improving the nutrition of all Kenyans, this will strengthen people’s immune systems and make them less susceptible to acquiring and transmitting HIV to others.
Currently the country is still receiving a significant amount of corn-soy blend through the WFP and USAID. 1 Alternatively, people could learn to grow a variety of crops that are diverse, have a high nutrient density, and are native to the land in Africa, such as amaranth, millet and sorghum  . Research is beginning to show a tendency towards increased food security in Kenya when traditional crops are grown.  In rural areas, people should be provided with support needed to start new farms with a variety of crops. This can provide a source of nutrition as well as become an income-generating activity if a sufficient number of crops are grown. If these farms aim to produce large numbers of crops on a scale which could feed the nation of Kenya (either directly or through increased trade), it may be necessary to invest in resources to help farmers cope with the effects of climate change. Climate change has a greater negative impact on developing countries such as those in Africa, and has led to droughts and desertification across the continent. Work should be done to expand Navdana, the program Dr. Vandana Shiva has started in India which is a women-centered movement focused on biodiversity and food sovereignty in the face of climate change. 
On a smaller scale, in both rural and urban areas, gardens can be built alongside hospitals to provide patients with both nutritious food and the educational and physical exercise of harvesting the crops. In urban areas, support should be provided to allow people to start their own gardens at home.
There are already non-profit organizations helping to start these types of gardens to support PLWHA in Kenya, such as Development in Gardening (DIG)  . DIG has a partnership with USAID, so this relationship should be fostered further in order to provide more individuals with the opportunity to garden.
For the multitude of reasons outlined above, ensuring the food security of HIV/AIDS patients and their families is critical in improving the health of the patients and helping to limit the spread of HIV. This should be done by training Kenyans to increase the food productivity of their land in a sustainable manner.
 Mamlin J, Kimaiyo S, Lewis S, et al. Integrating Nutrition Support for Food-Insecure Patients and Their Dependents Into an HIV Care and Treatment Program in Western Kenya. American Journal of Public Health. 2009;99(2):215-221.
 The World Factbook. Kenya. Central Intelligence Agency. https://www.cia.gov/library/publications/the-world-factbook/geos/ke.html. Accessed December 14, 2009.
 Byron E, Gillespie S, Nangami M. Integrating nutrition security with treatment of people living with HIV: lessons from Kenya. Food Nutr Bull. 2008; 29:87–97. http://programs.ifpri.org/renewal/pdf/KenyaAMPATH.pdf. Accessed December 14, 2009.
 Anema A, Vogenthaler N, Frongillo EA, Kadiyala S, Weiser SD. Food Insecurity and HIV/AIDS: Current Knowledge, Gaps, and Research Priorities. Current HIV/AIDS Reports 2009;6:224–231.
 Unge C, Johansson A, Zachariah R, et al. Reasons for unsatisfactory acceptance of antiretroviral treatment in the urban Kibera slum, Kenya. AIDS Care 2008, 20:146–149.
 Kenya. Epidemiological Country Profile on HIV/AIDS. WHO. 2008. http://apps.who.int/globalatlas/predefinedReports/EFS2008/short/EFSCountryProfiles2008_KE.pdf. Accessed December 14, 2009.
 Kuria, EN. Food consumption and nutritional status of people living with HIV/AIDS (PLWHA): a case of Thika and Bungoma Districts, Kenya. Public Health Nutrition. 15 June 2009; 1-5. Published online: doi:10.1017/S1368980009990826.
 Mishra V, Arnold F, Otieno F, Cross A, Hong R. Education and Nutritional Status of Orphans and Children of HIV-Infected Parents in Kenya. AIDS Education and Prevention. 2007;19(5):383–395.
 Board on Science and Technology for International Development. The Lost Crops of Africa. Volume I: Grains. National Research Council. Washington, D.C.: National Academy Press; 1996.
 Figueroa Gomez de Salazar B, Tittonell P, Ohiokpehai O, Giller K. The Contribution of Traditional Vegetables to Household Food Security in Two Communities of Vihiga and Migori Districts, Kenya. Wageningen University. 2008. http://www.icuc-iwmi.org/Symposium2008/Theme%201/T1.3-Blanca%20Figuero.pdf. Accessed December 14, 2009.
 Navdana. Available at: http://navdanya.org/. Accessed December 14, 2009.
Food Security and HIV/AIDS in Kenya