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However, by the time of WHO's 2008 universal access report, the heads of UNAIDS, UNICEF
and WHO conceded that most countries would not meet the 2010 targets of 80 percent of those
in need receiving treatment. In 2011, the international community recommitted to the goal of
universal access. This time, countries committed to achieving universal access by 2015.
The goal of universal access is also part of Millennium Development Goal (MDG) 6 which
includes the goal of halting and beginning to reverse the spread of HIV/AIDS by
2015(UNAIDS 2011). According to the global HIV/AIDS response progress report 2011,
access to antiretroviral therapy in lowand middle income countries increased from 400. 000
in2003 to 6.65 million in 2010(47% )coverage of people eligible to treatment, resulting in
substantial declines in the number of people dying from AIDS related causes during the past
decade.
The 2010 WHO recommendations on Antiretroviral therapy which reflect the clinical
evidence that early initiation of ARV therapy(recommended at CD4 cells counts less than 350
mm
3
) significantly reduced morbidity and mortality and also has important preventive benefits.
Coverage of pregnant women receiving the most effective antiretroviral regimens to prevent
mother-to-child transmission of HIV (excluding single-dose nevirapine) is estimated at 48% in
2011. Access to ART among children has also risen significantly, although they have less
access than adults. The number of children receiving antiretroviral therapy increased from 71,
500 at the end of 2005 to 456, 000 in 2010. Introducing ARVs therapy have averted 2.5 million
death in low- and middle- income countries globally since 1995.Sub sharan Africa accounts
for the vast majority of the averted death: about 1.8 million death (UNAIDS/WHO, 2011).
Despite these successes, more than 60% of those in need of ART still have not received it.
Adherence, side effects, viral drug resistance, stigma and cost are challenges to the
implementation of safe and effective ART program (UNAIDS 2010).
The 2011 UN high level meeting, at its Political Declaration on HIV/AIDS, set ten targets and
commitments which among others includes halving sexual transmission of HIV, ensuring that
no children are born with HIV infection, increasing access to antiretroviral therapy to 15
5
million people and halving tuberculosis deaths in people living with HIV, by
2015(FDRE/MOH,2012)
Ethiopia is one of the hardest hit sub-Saharan African countries by the HIV pandemic. The first
case of HIV in Ethiopia was reported in 1984. Since then, HIV/AIDS has become a major
public health concern in the country, leading the Government of Ethiopia to declare a public
health emergency in 2002. In 2007, the estimated adult HIV/AIDS prevalence was 2.1 percent
(ibid).
Ethiopia is among the few sub-Saharan countries showing a decline of more than 25% in new
HIV infections. Although the epidemic is currently stable; HIV/AIDS remains a major
development challenge for Ethiopia. Poverty, food shortages, and other socio-economic factors
amplify the impact of the epidemic (UNAIDS, 2010).
According to ANC surveillance results, HIV prevalence among pregnant women aged 15-24
declined from 5.6%in 2005, to 3.5% in 2007, and then to 2.6% in 2009; showing a declining
HIV prevalence trend. DHS 2011 data had shown overall prevalence of 1.5 %( female 1.9%
and male 1.0%) among the general population. The estimates show 789,900 people currently
living with HIV/AIDS (607,700 adults and 182,200 children aged 0-14 years); and 952,700
AIDS orphans. Adult HIV prevalence in 2010 was estimated to be 2.4 %( urban 7.7% and rural
0.9%)
.
Variations were also observed among administrative regions. According to the
Ethiopian Demographic and Health Surveys HIV prevalence ranges from 1% in SNNP and
1.3% in Oromiya region to 6% in Addis Ababa and 7.9% in Gambella region (FDRE/MOH,
2012).
Key intervention have been in place as part of the national HIV prevention response includes
HIV counseling and testing (HCT),prevention of mother to child transmission
(PMTCT),infection prevention, post- exposure prophylaxis(PEP),sexually transmitted
infections prevention and control, condom promotion and distribution and provision of anti-
retroviral treatment. As was elsewhere, Ethiopia's initial response to the epidemic had primary
focus on prevention, with little attention to treatment (MOH, 2006)
6
With the introduction of highly active antiretroviral therapy (HAART) in resource-limited
settings in early 2000's, Ethiopia was among the first few African countries to introduce ART
in 2003 in selected health facilities. A National Guideline on the use of ARV drugs was
developed and the Antiretroviral Treatment (ART) programme was launched in 2003.
Subsequently, in 2004, a free ART programme was initiated in three government hospitals in
Addis Ababa. Since then the geographic distribution and number of centres providing ART
services have increased. These efforts have led to marked increase in the number of health
facilities and sites providing HIV treatment and care services. While there were 550 facilities
providing ART in 2009/10, this reached 743 public and private health facilities in
2010/11fiscal year (FHAPCO, 2010).
By December 2006, a total of 96,897 AIDS patients had ever been enrolled at 192 ART
facilities, 58,405 had ever started ART and 46,045 were currently receiving ART at 168
facilities, constituting a drop-out rate of 20.7% for patients who had ever started ART. The
actual treatment adherence rate (78.8%) was higher because deaths were included in the default
data (MOH, 2005).
According to a comparative cross sectional survey carried out at Yirgalem Hospital between
July 10 and August 30, 2006 prevalence of ART adherence was 74.2 %( Enderias et al, 2006).
Over the six year reporting period, 473,772 HIV positive client were enrolled for HIV chronic
care, and 268,934(56.8%) were initiated on ART treatment. From the number ever initiated on
ART, 207,733(72.2%) were currently on ART (FHAPCO, 2010). During the reporting period,
a total of 333,434 people had ever started ART. There were 249,174 adults (86%of eligible)
and 16,000 children currently on treatment (20% of eligible) by the end of 2011(FDRE/MOH,
2012). Similarly, the percentage of women who received antenatal care (ANC) from a trained
health professional at least once for their last birth has increased from 28% in 2005 to 34% in
2010(FMOH/EHNR,2011)
Most people living with HIV or at risk for HIV do not have access to prevention, care, and
treatment, and there is still no cure (WHO, 2010). The epidemic not only affects the health of
individuals, but also it impacts households, communities, and the development and economic
growth of nations. Many of the countries hardest hit by HIV also suffer from other infectious
diseases, food insecurity, and other serious problems. Despite these challenges, new global
7
efforts have been mounted to address the epidemic, particularly in the last decade, and there are
signs that the epidemic may be changing course.
On the other hand
over the past five years, the
world has been hit by a series of economic, financial and food crises that have slowed down,
and at times reversed, global efforts to reduce poverty and hunger.
Now a day, price volatility and weather shocks such as the recent devastating drought in the
horn of Africa continue to severely undermine such efforts. In this context, promoting
livelihood resilience and food and nutrition security has become central to the policy agendas
of governments. According the Food and Agriculture estimates there are 952 million hunger
people in the world .The situation becomes even worse among household affected by
HIV/AIDS (FAO, 2011).
Food insecurity, defined as "the limited or uncertain availability of nutritionally adequate, safe
foods or the inability to acquire personally acceptable foods in socially acceptable ways"
(Normen et al, 2005), has recently been identified as a key structural barrier to ARV adherence
and as a contributor to ARV treatment interruptions in resource-poor settings (Sanjobo et al,
2008)
The relationship between the HIV epidemic and household food and nutrition insecurity
situation is complex. HIV infection can negatively impact food security and nutrition, which in
turn affects the disease progression and treatment outcome. Moreover, HIV/AIDS interact with
nutrition and food security at a number of different levels such as biological and individual
(WHO, 2003)
At a biological level, HIV and AIDS and malnutrition interact in a vicious cycle: HIV-induced
immune impairment and heightened risk of infection can worsen nutritional status, lead to
nutritional deficiencies through decreased food intake, mal absorption, and increased
utilization and excretion of nutrients. These processes in turn hasten the progression of HIV
infection to AIDS at individual level, while HIV infection exacerbates malnutrition by
attacking the immune system and by negatively impacting nutrient intake, absorption and the
body's use of food (Semba and Tang, 1999). Like HIV /AIDS, malnutrition also compromises
the immune function and thus increases susceptibility to severe illnesses and reduces survival.
Nutritional status modulates the immunological response to HIV infection, affecting the overall
clinical outcomes (WHO, 2003).
8
1.2 Statement of the problem
Food security is immediate need for individuals, households and communities affected by HIV
in developing countries. Lack of food security may enhance the progression to AIDS-related
illnesses, undermine adherence and response to antiretroviral therapy, and exacerbate
socioeconomic impacts of the virus. Shortage of food is reported to be one of the reasons for
non-adherence to ART as the drugs were said to increase appetite (Hardon et al., 2006). HIV
infection itself undermines food security by reducing work capacity and productivity, and
jeopardizing household livelihoods (Gillespie S, Kadiyala S, 2005).
ARV can interact with food in variety of ways, resulting in negative outcome. Thus, it is
critical to understand the specific interactions and implication of drugs taken. This
understanding enables effective management of these interactions to maintain food security
and improve drug efficacy and adherence. Food affects the efficacy of ARVs by affecting
absorption, metabolism and distribution kinetics of the drugs
.
The side effects of ARV
medications can also lead to reduced food intake and nutrient absorption that exacerbates the
weight loss and nutritional problems of PLHIV (WHO, 2003). If not properly managed, these
interactions result in reduced effectiveness of the therapy.
A person living with HIV/ AIDS therefore needs additional nutrients to help them fight off the
virus and related opportunistic infections. It is important to note that individuals infected with
HIV have special nutritional needs, such as increased energy requirements (FAO, 2002). Food
insecurity is considered as one of the barriers to antiretroviral (ARV) therapy access and
adherence in sub-Saharan Africa. But little is known about the mechanisms through which
food insecurity leads to ARV non-adherence and treatment interruptions .A combination of
energy giving, body building and protective foods are essential (PANOS, 2007).
Amount of food consumed is key to strong immune system. ARV adherence is a strong
predictor of biologic (virologic and immunologic) and clinical outcomes in HIV, including
quality of life, HIV progression, hospitalizations, and death. Consistent adherence to
antiretroviral therapy (ART) is the cornerstone of effective HIV treatment. When used
correctly, antiretroviral (ARV) medications decrease viral load and improve immune system
functioning (Bangsberg et al., 2000; Paterson et al., 2000).
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However, the potential for viral mutations and the chronic nature of HIV infection necessitates
near perfect adherence (95%) over sustained periods (Conway, 2007; Hogg et al., 2002).
Unfortunately, 2546% of HIV-positive persons on ART are nonadherent (<95% adherence;
Gwadz et al., 1999; Paterson et al. 2000). Adherence <95% permits HIV to resume rapid
replication producing drug-resistant strains that worsen patient health and complicate treatment
(Bangsberg et al., 2000; Bartlett, 2002).
Non-adherence to antiretroviral (ARV) therapy is one of the important predictors of
incomplete HIV RNA suppression, immunologic decline, progression to AIDS and death
(Paterson et al., 2000)
.
Non-adherence may lead to development of drug- resistant strains of
HIV (Hardon, 2006). Failure to suppress viral replication inevitably leads to the selection of
drug-resistant strains and limiting the effectiveness of therapy. Though, the World Food
Program have recommended integration of food assistance into HIV AIDS programming,
there has been little research on the mechanisms through which food insecurity may lead to
gaps in treatment and compromise ARV effectiveness.
Thus, understanding such mechanisms is important for designing ARV treatment programs that
incorporate food or nutritional supplementation and guiding policy decisions about
intervention strategies (WFP, 2003). It is estimated that adherence rates lower than 95% are
associated with the development of viral resistance to antiretroviral medications (Nachega et.
al., 2007). Failure to effectively manage ARV-food interactions can result in non-adherence
(Mills, 2006). In a study among PLHIV living in urban areas in Uganda, 95% of households
reported that they sometimes or often had to eat less preferred foods, 62% reported that
sometimes or often all household members had to skip meals, and 22% reported that
sometimes or often all household members did not eat for an entire day (Bukusuba J. et al,
2007). This study expected to explores the interrelationship between household food insecurity
and adherence to ARV treatment. Such studies could help inform policy maker in the study
area on ways of improving or maintaining adherence to ARV and scale up the treatment level.
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1.3 Objectives of the Study
1.3.1 General Objective
The main objective of the study is
to assess the prevalence of ART adherence and associated
factors (with particular focus on household food insecurity) among urban PLHIV in Hawassa
City, SNNPR State, Ethiopia.
1.3.2 Specific Objectives
The specific objectives of the study are:
· To assess the level of prevalence of adherence of PLHIV to ART in the study area.
· To analysis factors that affect adherence of PLHIV to ART in the study area.
· To describe the association between household food insecurity and
ART adherence in the
study area.
1.4 Research Questions
The central research question this study aimed to answer is, whether there was a link between
household food insecurity and adherence of ARV therapy among urban PLHIV in Hawassa
City, SNNPR State, Ethiopia.
The study is expected to address the following research sub- questions:
· What is the level of adherence to ARV by PLHIV in the study area?
· What are factor that affects adherence of ARV in the study area?
· How does household food insecurity affect ARV adherence?
1.5 Significance of the Study
The introduction of antiretroviral drugs (ARVs) or Highly Active Antiretroviral Therapy
(HAART) in 1996 transformed the treatment of HIV/AIDS by improving the quality of and
also greatly prolonging the lives of the many infected people in places where the drugs are
available (UNAIDS 2007).
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Consistent adherence to antiretroviral therapy (ART) is the cornerstone of effective HIV
treatment. When used correctly, antiretroviral (ARV) medications decrease viral load and
improve immune system functioning (Bangsberg et al., 2000; Paterson et al., 2000)
Long-term adherence interventions are needed for durable effect, particularly in chronic
diseases such as HIV (Sharon et al., 2006). Antiretroviral therapy lowers viral load only when
treatment regimen is fully adhered to. Human immunodeficiency virus (HIV) poses a unique
challenge due to its rapid replication and mutation rates hence very high levels of adherence
(greater than 95%) are required to achieve long-term suppression of viral load (Paterson et al.,
2000). It is estimated that adherence rates lower than 95% are associated with the development
of viral resistance to antiretroviral medications (Nachega et. al., 2007).
Food insecurity and poverty may lead to high-risk sexual behaviors and migration, increasing
the risk of acquiring HIV. At the same time, HIV weakens a household's ability to provide for
basic needs. When a PLHIV cannot work, food production or earnings may decrease (Gillespie
and Kadiyala 2005; Piwoz, 2004)
Interactions between antiretroviral therapy (ART) and food and nutrition can affect medication
efficacy, nutritional status, and adherence to drug regimens. Drug-food interactions consist of
the effects of food on medication efficacy, the effects of medication on nutrient utilization, the
effects of medication side effects on food consumption, and unhealthy side effects caused by
medication and certain foods. Lack of food was cited as a major impediment to quality of care
for the clients on ART in an assessment carried out among ART clients in Homabay. ART
clients from poor backgrounds (slums and rural areas) always mentioned food access as a key
problem and often gave poor access to food as a reason for poor adherence to ARVs and TB
medication(WOFAK,2004).
The result of this study will highlight the dynamic link between household food insecurity and
access and adherence to ARV and will provide information and guidance about the food and
nutrition implications of ART to manage the effects of these implications in resource limited
settings. The finding of the study can be used in guiding program planners and groups
developing guideline on care and support, service providers, and networks of people living
with HIV/AIDS to understand and address ART interactions with food and nutrition.
12
Moreover, the information presented on this study can also help managers of programs that
include ART components to incorporate food and nutrition counseling and other interventions
as needed.
1.6 Limitations of the study
There are various limitations of this study. Fitst,the study was only limited to adults aged 18
years or older, as the determinants of sub-optimal adherence among children likely vary
significantly from that of those included in this study. Similarly, due financial constraints, the
study only considered the selected PLHIV associations in the city. Hence, it only generalizable
to the participating PLHIV associations' However, the findings of the study could be
applicable to other setting in large extent. Moreover, the research findings could be serve as
back ground information for others who seek to do further related researches and would help
serve in formulating and revising the system towards linking the food assistance for PLHIV to
improve the level of ARV adherence in the study area in particular and the region in general.
Finally, Self report adherence to ARV tools reflects only short term or average adherence and
may overestimate compared to more objective measures such as pill counts and electronic
medication monitor (Haynes et al, 1998).Nevertheless, another potential advantage of the tool
is that it can provide information about the reasons why a patient did or did not take the
medication properly and easy.
1.7 Organization of the study
While the first chapter, the introductory section, describes the overview of HIV/AIDS
prevalence and situation of food insecurity in the world, sub-Saharan Africa, in Ethiopia, the
SNNPR and statement of the problem, objectives and significance of the study. The second
chapter deals about literature reviews which both include theoretical and empirical framework.
It is then followed by the third chapter which deals about the research methodology used for
the study that includes description of the study area, study design and population, sampling
procedures, types of data used and data analysis methods and ethical considerations. Chapter
four presents results of quantitative, qualitative finding of the study and discussion of the
result. Finally, chapter five deals about conclusions of the finding and further
recommendations based on the findings.
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CHAPTER TWO
Literature Review
2.1 Theoretical framework on Food Security
2.1.1 Definition and concepts of food security
Many definitions of food security have been developed. However, there are some, which have
been widely used than others. According to World Bank definition, food security implies
"access by all people at all times to enough food for an active, healthy life" (World Bank,
1986). From the nutrition point of view, Salih defines the food security of a country, region or
household as its ability to meet up with its "target consumption levels on a yearly basis" (Salih,
1995)
However, food insecurity can either acute (transitory) or chronic. According to Salih, 1995,
"transitory food insecurity is a temporary decline or shortage" in the food needs of a country,
regions or households. The declines may be due to fluctuations in the production of food,
changes in incomes and food prices. On the other hand, chronic food insecurity occurs when
there is persistence in food declines. Thus, food insecurity can be defined as a situation in
which households and individuals are neither able to access nor afford food for an active and
healthy life.
Despite the diversity in these definitions, most of them evolve around some common themes,
which are very important in the measurement and analysis of food insecurity. These themes
include availability, accessibility and affordability, otherwise known as the forces of demand
and supply or the entitlements at the disposal of individuals and households to produce or
command food (Dreze and Sen, 1989).Therefore, food security can either be ensured through
production, purchase, and public food distribution from food aid. However, for individuals to
have access to this food, they must have the opportunities of either producing the food or
purchasing it in the case where they cannot produce. That is why; food insecurity does not
apply only to food insufficiency and availability but also to accessibility and affordability of
the food by the needy.
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2.1.2 Concept of food security
There is no one single universal concept of food security. More than thirty definitions were
found between 1975 and 1991 (Maxwell & Frankenberg, 1995), showing the many different
approaches that exist to the issue. However, the term first originated in the mid-1970s, when
the World Food Summit (1974) defined food security in terms of food supply- assuring the
availability and price stability of basic foodstuffs at the international and national level
"Availability at all times of adequate world food supplies of basic foodstuffs to sustain a steady
expansion of food consumption and to offset fluctuations in production and prices".
In 1983, FAO analysis focused on food access, leading to a definition based on the balance
between the demand and supply side of the food security equation "Ensuring that all people at
all times have both physical and economic access to the basic food that they need" (FAO,
1983).
2.1.3 Dimensions of Food Security
According to 1996 world food summit, Food security exists when all people, at all times, have
physical and economic access to sufficient safe and nutritious food that meets their dietary
needs and food preferences for an active and healthy life (FAO, 1996).
From the above definition, three main dimensions of food security identified:
· Physical availability of food:
Food availability addresses the "supply side" of food security and is determined by the level
of food production, stock levels and net trade.
· Economic and physical access to food:
An adequate supply of food at the national or international level does not in itself guarantee
household level food security. Concerns about insufficient food access have resulted in a greater
policy focus on incomes, expenditure, markets and prices in achieving food security objectives.
15
· Food utilization:
Utilization is commonly understood as the way the body makes the most of various nutrients
in the food. Sufficient energy and nutrient intake by individuals is the result of good care and
feeding practices, food preparation, and diversity of the diet and intra-household distribution
of food. Combined with good biological utilization of food consumed, this determines the
nutritional status of individuals
.
2.1.4 Measurement of Household Food Insecurity
Food security occurs when "all people at all times have physical and economic access to
sufficient food to meet their dietary needs for a productive and healthy life."(USAID1992).
This definition of food security is founded on three fundamental elements: adequate food
availability, adequate access to food by all people and appropriate food utilization/
consumption. Food availability is derived from domestic agricultural output and net food
imports at the national level. Food access is the ability of a household to acquire sufficient
quality and quantity of food to meet all household members' nutritional requirements for
productive lives. Food utilization/consumption is determined by how much a person eats and
how well a person converts food to nutrients, all of which affect proper biological use of food,
nutritional status and growth (Gary B et al, 2000)
In light of the complex, multi-dimensional nature of food security, it is generally agreed that
separate indicators and data collection methods are needed to assess each of the three elements
underlying food security attainment (FAO, 2002). Whereas food balance sheets and
anthropometric indicators provide well-established methods for attaining comparable measures
of the availability and utilization components of food security (FAO, 2006)
16
2.1.4.1 Dietary diversity as measure of household food security
· Definition and measurement of dietary diversity
Obtaining detailed data on household food access or individual consumption can be time
consuming, expensive, and requires a high level of technical skill both in data collection and
analysis.
According to Ruel (2003) dietary diversity is defined as the number of individual food items or
food groups consumed over a given period of time (Ruel, 2003). It can be measured at the
household or individual level through use of a questionnaire. The dietary diversity
questionnaire is a tool providing a more rapid, user-friendly and cost-effective approach to
measure changes in dietary quality at the household and individual level. Most often it is
measured by counting the number of food groups rather than food items consumed. The type
and number of food groups included in the questionnaire and subsequent analysis may vary,
depending on the intended purpose and level of measurement. At the household level, dietary
diversity is usually considered as a measure of access to food, (e.g. of households' capacity to
access costly food groups), while at individual level it reflects dietary quality, mainly
micronutrient adequacy of the diet. The reference period can vary, but is most often the
previous day or week (FAO, 2011; WFP, 2009).
· Scientific evidence for use of dietary diversity scores
Over the past decade there have been three large multi-country validation studies and many
smaller studies which have looked at the association between dietary diversity and food
security and/or micronutrient adequacy of the diet.
Hoddinott and Yohannes (2002) studied the association between household dietary diversity
scores and dietary energy availability in ten countries. Increasing household dietary diversity
significantly improved energy availability. The study results suggest that dietary diversity
scores have potential for monitoring changes in dietary energy availability, particularly when
resources are lacking for quantitative measurements (Hoddinott et al., 2002)
17
A second multi-country study of diets of children 6-23 months from ten sites was undertaken to
test the association between dietary diversity and mean micronutrient density adequacy of
complementary foods. Significant positive correlations were observed in all age groups and in
all countries except one (Working Group on Infant and Young Child Feeding Indicators, 2006).
Recently the association between dietary diversity and micronutrient adequacy of diets of
women of reproductive age was assessed in five countries. Dietary diversity was significantly
associated with micronutrient adequacy in all sites (Arimond et al., 2010).
· Rationale of using dietary diversity as a food security indicator
Dietary diversity, the number of different foods or food groups consumed over a given
reference period - is an attractive indicator for four reasons: First, a more varied diet is a valid
outcome in its own right. Second, a more varied diet is associated with a number of improved
outcomes in areas such as birth weight (Rao et. al., 2001), child anthropometric status (Allen
et.al., 1991); improved hemoglobin concentrations (Bhargava, Bouis and Scrimshaw, 2001),
reduced incidence of hypertension (Miller, Crabtreeand Evans, 1992), reduced risk of mortality
from cardiovascular disease and cancer (Kant,Schatzkin and Ziegler, 1995). Third, questions
on dietary diversity can be asked at the household or individual level, making it possible to
examine food security at the household and intra-household levels. Fourth, obtaining dietary
diversity data is relatively straightforward and not complicated, and that respondents find such
questions relatively straightforward to answer, not especially intrusive, and not especially
burdensome. Asking these questions typically takes less than 10 minutes per respondent (Ibid)
2.1.4.2 Meal Frequency as measure of Household Food Security
The number of daily eating occasions is a proxy indicator for gauging the adequacy of
household macronutrients (calories and protein) intake. An advantage in selecting this as an
indicator of household food security is that data are relatively easy and inexpensive to collect.
Data on size and composition of meals are not required to calculate the indicator values
(Anne.S et al, 2005)
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2.1.4.3 Household Food Insecurity Access Scale (HFIAS) for Measurement of Food
Access
The full range of food insecurity and hunger cannot be captured by any single indicator.
Instead, a household's level of food insecurity or hunger must be determined by obtaining
information on a variety of specific conditions, experiences, and behaviors that serve as
indicators of the varying degrees of severity of the condition (USAID, 1992). Because it is
acomplex, multidimensional concept, measuring food insecurity has been an ongoing challenge
to researchers and practitioners alike.
Until very recently, most household-level measures of food access, such as income and caloric
adequacy, have been technically difficult, data-intensive, and costly to collect.
The household food insecurity access scale (HFIAS) which is an adaptation of the approach
that used to estimate the prevalence of food security in the United States annually. The method
is based on the idea that the experience of food insecurity (access) causes predictable reactions
and responses that can be captured and quantified through a survey and summarized in a scale
(Radimer et al., 1990)
Based on this growing body of evidence, FANTA and its partners have identified a set of
questions ( Household Food Insecurity Access Scale Generic Questions) that have been used in
several countries and appear to distinguish the food secure from the insecure households across
different cultural contexts.
These questions represent apparently universal domains
of the
household food insecurity (access) experience and can be used to assign households and
populations along a continuum of severity, from food secure to severely food insecure (ibid)
The questionnaire consists of nine occurrence questions that represent a generally increasing
level of severity of food insecurity (access), and nine "frequency-of-occurrence" questions that
are asked as a follow-up to each occurrence question to determine how often the condition
occurred. The frequency-of-occurrence question is skipped if the respondent reports that the
condition described in the corresponding occurrence question was not experienced in the
previous four weeks (30 days).
19
Some of the nine occurrence questions inquire about the respondents' perceptions of food
vulnerability or stress (e.g., did you worry that your household would not have enough food?)
and others ask about the respondents' behavioral responses to insecurity (e.g., did you or any
household member have to eat fewer meals in a day because there was not enough food?). The
questions address the situation of all household members and do not distinguish adults from
children or adolescents.
All of the occurrence questions ask whether the respondent or other
household members either felt a certain way or performed a particular behavior over the
previous four weeks (FANTA, 2004 and Coates, 2004).
Some field validation studies of this approach to measuring food insecurity (access) more
directly, by constructing measures based on households' experience of the problem, have
demonstrated the feasibility and usefulness of the approach in very different, developing
country context(Coates et al., 2003)
Generally, the household food insecurity access prevalence (HFIAP) indicator categorizes
households into four levels of household food insecurity (access): food secure and mild,
moderately and severely food insecure. Households are categorized as increasingly food
insecure as they respond affirmatively to more severe conditions and/or experience those
conditions more frequently (FANTA, 2007)
A food secure household experiences none of the food insecurity (access) conditions, or just
experiences worry, but rarely. A mildly food insecure (access) household worries about not
having enough food sometimes or often, and/or is unable to eat preferred foods, and/or eats
amore monotonous diet than desired and/or some foods considered undesirable, but only
rarely.
But it does not cut back on quantity nor experience any of three most severe conditions
(running out of food, going to bed hungry, or going a whole day and night without eating). A
moderately food insecure household sacrifices quality more frequently, by eating a
monotonous diet or undesirable foods sometimes or often, and/or has started to cut back on
quantity by reducing the size of meals or number of meals, rarely or sometimes. But it does not
experience any of the three most severe conditions.
20
A severely food insecure household has graduated to cutting back on meal size or number of
meals often, and/or experiences any of the three most severe conditions (running out of food,
going to bed hungry, or going a whole day and night without eating), even as infrequently as
rarely. In other words, any household that experiences one of these three conditions even once
in the last four weeks (30 days) is considered severely food insecure(ibid)
2.2 Conceptual Framework of Household food Insecurity, HIV/AIDS and ARV
Adherence
No one really knows how many people are malnourished. The statistic most frequently cited is
that of the United Nations Food and Agriculture Organization, which measures 'under
nutrition'. The most recent estimate, released in 2010 by FAO, says that 925 million people are
undernourished. Nearly all of the undernourished are in developing countries (FAO, 2010).
Ethiopia has one of the world's highest incidences of under nutrition. An estimated 5.2 million
people in Ethiopia will require emergency food assistance, out of which 106,457 children will
need treatment for severe acute malnutrition (HRD, 2010).
Approximately 49 percent of the population lacks adequate nutrition, according to the Food
and Agriculture Organization (FAO, 2000). The country has high levels of chronic food
insecurity and is further prone to acute food insecurity, primarily during times of drought,
environmental degradation, and insufficient access to and availability of food. According to the
preliminary report of the Ethiopia Demographic and Health Survey (DHS) 2005 and the DHS
2000, one in four women of reproductive age have chronic energy deficiency and 27 percent
are anemic. In part as a result of this, 47percent of children under five experience chronic
malnutrition. Many children (50%) did not receive vitamin supplements in the six months prior
to the study and only 21 percent of mothers received vitamin A within 45 days of delivery
(EDHS 2005). Given these high levels of malnutrition and vitamin A deficiency, it is likely
that deficiencies of other micronutrients, such as zinc, iron, folic acid, and vitamin C, also exist
within Ethiopia's population.
21
2.2.1 HIV/AIDS, Labour Productivity and Food Insecurity
HIV / AIDS affect the economy in reducing the labour power through increased mortality and
morbidity. Productivity is more likely to decline as a result of HIV-related opportunistic
illnesses.
The International Labour Organization's(ILO)2006 Economic security Reports states that there
are witnessing of a systematic erosion of the productive capacity of the whole communities
stemming from the HIV/AIDS pandemic. In 2002-2003 at least 14 million people were deemed
food insecure and in need of food assistance. HIV/AIDS is a major significant factor to
Africa's food crisis, by increasing morbidity and mortality of the prime-age productive adult
population, which may lead to fewer agricultural worker and a reduced amount of food
produced and made available (ILO, 2006).
HIV/AIDS and food insecurity are becoming increasingly entwined in a vicious cycle, with food
insecurity heightening susceptibility to HIV exposure and infection, and HIV/AIDS in turn
heightening vulnerability to food insecurity (Loevinsohn and Gillespie, 2003).
HIV and AIDS have negative impact on household food security because often PLHIV are too
weak to work. Also, many family members are drawn away from production and income
generating activities to care for sick relatives. In addition, valuable resources, savings and
income are diverted to treatment and funerals which result in low food accessibility (wolf, et al.
2000). A study conducted in three main urban areas of Malawi to analyze the linkages between
HIV/AIDS and food security among urban households showed that HIV/AIDS affects food
security through its negative effects on human capital, financial capital and social capital
(Palamuleni et al. 2003).
Moreover, nutrition and immunity in HIV-positive individuals can interact in two ways. First,
HIV-induced immune impairment and heightened subsequent risk of opportunistic infection can
worsen nutritional status. HIV infection often leads to nutritional deficiencies through decreased
food intake; malabsorption and increased utilization and excretion of nutrients, which in turn
can hasten death (Semba and Tang 1999). Second, nutritional status modulates the
immunological response to HIV infection, affecting the overall clinical outcome. Immune
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