Number 14 April 2004

structured and delivered. These programmatic findings Key findings of the research are summarised below: Research Briefing • HIV/AIDS clearly has profound humanitarian • Early-warning systems and assessments need to consequences, both in terms of directly causing illness and death and in terms of the wider impact it is having incorporate analysis of HIV/AIDS and its impact on on societies. These effects will inevitably deepen as the livelihoods. impact of the epidemic grows. Existing models of • The emergence of new types and areas of development and relief assistance are likely to prove vulnerability due to HIV/AIDS should be considered in inadequate to cope with the consequences of HIV/AIDS. assessment and targeting. Groups such as widows, The pandemic, therefore, raises profound challenges for the elderly and orphans may be particularly the system of international assistance, which are only beginning to be fully appreciated. vulnerable, and urban and peri-urban areas may need • Aid agencies should endeavour to analyse the complex to be assessed. ways in which HIV/AIDS is affecting people’s livelihoods • The targeting and delivery of aid must be sensitive to and the impacts of livelihood insecurity on HIV/AIDS. the possibility of AIDS-related stigma and • The response of development assistance actors may discrimination. HIV/AIDS and need to draw on expertise and experience available • The HIV/AIDS epidemic reinforces the existing need within the humanitarian system, and vice versa. • Greater resources need to be invested in prevention, for humanitarian programmes to be gender-sensitive. care, treatment and mitigation. Urgent thought needs to • Emergency interventions must aim to ensure that they humanitarian action be given to what this implies for public expenditure do not increase people’s susceptibility to infection management systems within African countries, and how with HIV/AIDS. Researched, written and published by the Humanitarian Policy Group at ODI expanding access to treatment for HIV/AIDS can be part • Food aid in the context of HIV/AIDS should review of expanding access to basic health care more broadly. ration sizes and types of food and assess delivery and • HIV/AIDS reinforces the risk of periodic crisis and may Paul Harvey HPG Research Fellow make crises more likely. This reinforces the existing distribution mechanisms in the light of HIV/AIDS- need for greater investment in disaster preparedness related vulnerabilities, such as illness, reduced labour What are the implications of HIV/AIDS for our understanding of crisis and and mitigation. and increased caring burdens. humanitarian aid? HIV/AIDS is both a long-term crisis in its own right, and • HIV/AIDS will also increasingly add to the burden of • Labour-intensive public works programmes should a contributory factor in acute emergencies. The epidemic presents key chronic poverty and destitution in Africa. This reinforces consider the needs of labour-constrained households, challenges for both humanitarian and development assistance, and for the the need for greater investments in social protection the elderly and the chronically ill. interface between them. and long-term welfare. Given the limited capacity and resources of many African governments, this implies a • HIV/AIDS reinforces the need for health issues to be considered as part of a humanitarian response. need for long-term commitment by donor governments. The crisis in southern Africa during • It undermines the ways in which • Support to agricultural production (including seed • Aid agencies should endeavour to link humanitarian aid 2002 and 2003 highlighted the people have traditionally coped programming where possible to the development of distributions) should recognise adaptations that complex connections between with famine. local capacity for long-term welfare provision. people are making in response to HIV/AIDS. HIV/AIDS, food security and • It may increase mortality in famine. This briefing paper famines, as people with AIDS will Conclusions examines the implications of be less able to cope with In countries like Malawi, where a significant percentage HIV/AIDS is a long-term crisis. Humanitarian aid has a HIV/AIDS for our understanding of reduced food intake and of the population does not have access to basic primary role to play in the response, but agencies should crisis and of the role of additional disease burdens. health care, this implies a need to focus on basic health recognise that it is only part of a wider response and be humanitarian aid therein. The • Issues associated with crisis may care delivery. These are not new challenges. There is a clear about what humanitarian aid can and cannot disease is clearly a massive crisis in add to the risks of transmission danger in considering the broader impacts of HIV/AIDS achieve. Humanitarian agencies need to mainstream its own right: to the extent that of HIV/AIDS and contribute to on livelihoods of ‘AIDS exceptionalism’. For instance, consideration of HIV/AIDS issues both internally, in humanitarian response is the epidemic’s spread. privileging AIDS over other diseases in health systems or organisational policies, and externally, throughout the concerned with increased levels of focusing unduly on the impact of AIDS in food security programme cycle and across the different sectors of About HPG mortality and morbidity, HIV/AIDS HIV/AIDS has profound programmes. response. The Humanitarian Policy Group at the can clearly be described as an humanitarian consequences, both Overseas Development Institute is emergency. However, it is a long- by directly causing illness and dedicated to improving humanitarian HIV/AIDS and humanitarian programming: term crisis, and its impacts will be death and in terms of the wider This HPG Research Briefing is drawn from Paul Harvey, policy and practice. It conducts lessons from southern Africa felt for decades. impact it is having on societies. HIV/AIDS and Humanitarian Action, HPG Report 16 independent research, provides specialist The southern Africa crisis in 2002 and 2003 raised a (London: ODI, 2004). advice and promotes informed debate. These consequences will develop series of practical questions around the programming of HIV/AIDS is one of many factors over decades, meaning that humanitarian aid in the context of an HIV/AIDS epidemic. The full report, a resource guide on HIV/AIDS and Britain’s leading independent contributing to food insecurity. It is existing models of humanitarian aid These range from whether and how food aid rations emergencies and background papers are available think-tank on international development important to understand how the may not be appropriate. Equally, and humanitarian issues need to be adapted, to the question of whether AIDS- from the ODI website at www.odi.org.uk/hpg/hiv.html. impact of HIV/AIDS relates to other existing models of development related stigma affects participation in relief programmes. Overseas Development Institute factors, such as drought and assistance are likely to prove 111 Westminster Bridge Road This study found that HIV/AIDS issues need to be © Overseas Development Institute, 2004. London, SE1 7JD conflict, to create acute inadequate. The challenges raised ‘mainstreamed’ by aid agencies both internally, in terms United Kingdom humanitarian crises. HIV/AIDS acts by the pandemic are only beginning of training and organisational policies, and externally, in Download this paper at www.odi.org.uk/papers/hpgbrief14.pdf Tel: +44 (0) 20 7922 0300 at many different levels: to be fully appreciated. Fax: +44 (0) 20 7922 0399 terms of how humanitarian aid programmes are Email: [email protected] Websites: www.odi.org.uk/hpg and www.odihpn.org 4 This HPG Research Briefing and the report on which it is Whatever label is applied to the situation – and perhaps Figure 1: The contribution of HIV/AIDS to the based has two main aims: Box 1: Why is HIV/AIDS a humanitarian concern? the best term is long-term crisis – it is clear that trajectory of crisis There are a number of reasons why HIV/AIDS must concern HIV/AIDS requires both a humanitarian response to humanitarian actors: • To investigate the relationship between HIV/AIDS and suffering, and a long-term perspective. This has obvious Chronic food insecurity HIV/AIDS as a humanitarian crisis. • The mortality and suffering created by HIV/AIDS is implications for how both relief and development contributory factor • To examine the role of humanitarian aid in the context clearly a humanitarian concern in its own right. The assistance are structured, and for the relationship of the HIV/AIDS epidemic. impact of the epidemic is growing, and will be felt for between them. decades. • HIV/AIDS is increasing the food insecurity of significant Findings are based on fieldwork in southern Africa, HIV/AIDS and the challenge for relief and where HIV/AIDS prevalence rates are the highest in the numbers of households, adding another burden to communities already vulnerable to other shocks, such as development assistance world. As HIV/AIDS rates are still rising in other parts of drought or conflict. In considering the challenge HIV/AIDS poses for both Africa and the developing world, some of the lessons • HIV/AIDS has particular characteristics that may create Shocks such as drought Underlying vulnerability forms of aid, it is important to be clear that there are from southern Africa may be applicable elsewhere. new types of vulnerabilities, or exacerbate existing or conflict tip the is higher due to different aspects to the impact of HIV/AIDS on ones. HIV/AIDS kills predominantly prime-age adults, situation into acute HIV/AIDS, so crises may livelihoods. Hence, different responses will be HIV/AIDS and livelihoods: what are the clusters in households, has a gender-specific impact and crisis be triggered more easily interacts with malnutrition. These are all factors that appropriate. Three linked but to some extent distinct connections? must be understood and taken into account in providing challenges present themselves. The literature on HIV/AIDS shows that it has clear humanitarian relief in the context of an HIV/AIDS negative impacts on food security at a household level, epidemic. 1. The impact of HIV/AIDS as a health crisis in its own and that these are complex, wide-ranging and gender- • Emergency situations may increase people’s right, in terms of massive and increasing levels of specific. The amount of original research is, however, susceptibility to HIV/AIDS, further fuelling the epidemic. Acute crisis develops People sick with AIDS are mortality, morbidity and suffering over a period of limited; there has been a tendency to focus on with the risk of less able to cope with decades. This is perhaps best seen as a long-term agriculture and neglect other aspects of livelihoods; and heightened malnutrition, poor nutrition and illness, emergency. This will require a long-term response to there is little information about the scale of the impact food insecurity. What is important, therefore, is to mortality and morbidity leading to greater HIV/AIDS, encompassing the need for prevention, of HIV/AIDS on food security at national and regional understand the ways in which HIV/AIDS interacts with mortality care, treatment and mitigation. levels. these other factors, and how this might affect the 2. HIV/AIDS as increasing underlying vulnerability, possibility and trajectory of famines. This research adding to the impact of other shocks and meaning There is a two-way relationship between HIV/AIDS and suggests that HIV/AIDS needs to be understood as one that acute crises may be triggered more easily and be food security. HIV has an impact on people’s livelihoods, of the underlying processes that predisposes poor other, equally or more important, factors risk being more difficult to recover from. HIV/AIDS will need to reducing food security through illness and death, and people to possible famine. neglected. It has also been argued that the focus on be taken into account as a cross-cutting issue in food insecurity and poverty fuel the HIV epidemic as HIV/AIDS as a causal factor could obscure political short-term humanitarian relief for acute suffering. people are driven to adopt risky strategies in order to However, HIV/AIDS is not just a contributory factor to factors behind the crisis. There has been scepticism on 3. HIV/AIDS as one of many contributory factors to long- survive. Ultimately, HIV/AIDS damages the livelihood vulnerability: it also influences the outcomes of the the part of some donors and NGOs about how HIV/AIDS term and chronic food insecurity, poverty and outcomes of households. Households affected by emergency. It increases the risk of heightened mortality is being used to justify a need for continued destitution. HIV/AIDS therefore adds to the existing HIV/AIDS usually have less income and reduced food in emergencies due to the ways in which it interacts with humanitarian aid in some countries, and about the need for safety nets and long-term welfare, as part of security. They are also likely to be more vulnerable to malnutrition, undermines coping strategies and leaves underlying empirical evidence of the links between the overall response to poverty. Welfare may need to other shocks, such as drought. If it is severe enough, the people less able to cope with other illness. This is the HIV/AIDS and food insecurity. be a particular focus, due to the likelihood that impact of HIV/AIDS could result in destitution and process that Alex De Waal and Alan Whiteside have HIV/AIDS will increase levels of destitution. households becoming dependent on some form of called ‘new variant famine’. This reinforces the need for HIV/AIDS as an emergency external assistance. adequate levels of humanitarian aid in times of crisis, as The state of the current data means that disentangling Humanitarian aid is only part of a much larger communities will be less able to rely on their own the relative importance of HIV/AIDS compared to bad international response to the impact of the HIV/AIDS HIV/AIDS, humanitarian action and emergencies resources, and individuals less able to cope with poor governance or bad weather is, and will remain, difficult. pandemic, and it is important to be clear about what the Until recently, the slim literature on HIV/AIDS and nutrition. This is shown diagrammatically in Figure 1. What is clear, though, is that huge numbers of people relief system can and cannot do. The overall response to emergencies largely focused on HIV/AIDS in conflict and are dying from and suffering with HIV/AIDS in sub- HIV/AIDS needs to take place over decades, and across refugee situations, and to a lesser extent quick-onset HIV/AIDS and the southern Africa crisis Saharan Africa. To the extent that the core of the entire countries and regions. Humanitarian aid, based natural disasters. The main theme was the increased risk The argument that HIV/AIDS was a central component in humanitarian agenda is to save lives and alleviate as it is on short-term time horizons and funding cycles, of infection among affected populations caused by the the southern Africa crisis came about gradually. Initially suffering, HIV/AIDS is clearly a humanitarian problem. is obviously ill-suited to meet this extensive, long-term violence, displacement and militarisation resulting from defined as a food crisis caused by a combination of bad challenge. emergencies. During 2002 and 2003, however, the issue weather, bad governance and underlying poverty, AIDS Labelling HIV/AIDS as an emergency may be useful in of HIV/AIDS and emergencies leapt to the top of the moved to the forefront of the agenda following the visit generating additional action. For national governments, HIV/AIDS also raises a series of humanitarian challenges humanitarian policy agenda, prompted by the southern of the UN Special Envoy to southern Africa, James Morris, declaring HIV/AIDS an emergency may serve particular for development. The impact of HIV/AIDS on livelihoods Africa crisis, the publication of Inter-Agency Standing in 2002. purposes, such as demonstrating political commitment reinforces the need for some form of social protection or Committee (IASC) guidelines on HIV/AIDS and or allowing the importing of generic drugs to treat welfare safety net for the poorest; by increasing emergencies and the revision of the Sphere Handbook, There has been a backlash against both the new variant HIV/AIDS. Calling something an emergency also has underlying vulnerability, HIV/AIDS may also mean that where HIV/AIDS was seen as a cross-cutting issue. famine hypothesis and the increased focus on HIV/AIDS. important practical implications for aid agencies and crises are triggered more easily, which implies a need for The extent to which HIV/AIDS has contributed to the donors in terms of what funding is available, from which greater investment in disaster preparedness and HIV/AIDS and famine current crisis has been questioned. It has been argued budget lines and with what sort of timelines and mitigation. Much of the current focus of HIV/AIDS HIV/AIDS is only one of a host of factors contributing to that its importance has been over-emphasised and that conditions attached. response is on the need to expand access to treatment.

2 3