In the qualitative analysis, food insecurity emerged as one of the key factors that directly and indirectly influenced undernutrition, nutrition program participation and utilisation, and program outcomes – through its impact on weight loss, motivation to enrol in the program, driver of selling and sharing the nutritional support, as a disincentive to graduate from the program and final impact on relapse.
Food insecurity, poor livelihood, poverty and undernutrition
Adults cited household food insecurity as being a key cause of weight loss. For example;
“Yes, I made an effort to maintain my weight, but your economic status determines your nutritional status. You didn’t have enough, then from where can you get? I try [to get] by what I have but my economic status is very low. I know if you eat properly, I will have the energy to work and perform like others but if you are poor, you can do nothing” (Adult female, age 48 #9).
Poverty and HIV are interwoven, both contributing to food insecurity and undernutrition among people living with HIV. This was particularly reported as an important challenge for people enrolled in the nutritional program. Many adults and caregivers of child participants reported the absence of adequate educational attainment, lack of regular and reliable employment as well as lack of sustainable and reliable income to support them and their family.
“If you are poor and don’t have good job, even if you try to create your own job, no one allows you to work for the reason of no education. I asked the kebele administration for job but they told me that you have no education. This makes you very angry. Otherwise, if you have a job, you will not lack adequate and balance food.” (Adult female, age 31 #1).
Food insecurity as a motivation to participate in the nutritional program
Lack of access to adequate food was one of the key motivations for adults and caregivers to enroll in the nutritional program. Those who lived in urban areas and did not have a reliable source of income or were unemployed reported a lack of access to enough food in their household and that lack of adequate food was a motivation to enroll in the nutritional program. These motivations were shared by both male and female adult participants, reporting circumstances of food shortage in the household.
If you have something to eat, it should be fine but if you don’t have anything to eat like me this food support is very important (Adult male, age 40 #18).
Yes… many people suffer from lack of access to adequate food. The nutritional support is very helpful to all HIV patients. I have benefited a lot from the nutritional support. So, I suggest this nutritional support to all people with HIV (Adult female, age45 #2).
Food insecurity as a driver of selling and sharing of the nutritional support
Household economic problems was one of the main reasons encouraging people to sell and share nutritional support. A health provider and program manager stated that people sell the nutritional support because of their economic conditions and to exchange for other household consumables such as oil or coffee beans:
Instead of eating it [nutritional support] for himself only, they want to sell and exchange it for other household needs such as sugar, salt or oil. Most of the time the reason is this but the base is the poor livelihood condition. So, they are not doing it intentionally, but it is because of their problems (Health provider #9).
Even though the patients were counseled well, one reason for selling could be the existing economic problems. Poverty by itself would encourage individuals to sell it and spend the money on something that matters to the family is there (Program manager #1).
Sharing practices were also reported by health providers as common in mothers in circumstances of food insecurity, and caregivers themselves indicated this as highlighted below:
Yes, there is sharing among household members. As far as there is an economic problem, it is not necessarily selling but also sharing. Because if it is given to him, it is likely that the mother will share it with his siblings. If given two sachets then the mother gives one to her other child and keeps one for the HIV positive child (Health provider #7).
Even though it is prescribed to the sick child if there is no adequate food to eat in the household the mother may share it to other children. So, the mother shares it to fulfill the dietary needs of the other children in the household because she has nothing to give to the other child (Caregiver, age 35 #9).
“Even now, I can’t get enough [food] and I am not taking adequate food. I give everything [including RTUF] I have to my children and my main effort is to feed and care for them. With all the problems I have, I can’t get enough food to support myself and my children” (Adult female, age 29 #15).
Food insecurity, dependence and disincentive to graduate from the program
Some health providers expressed concerns of dependence of adults and caregivers on the nutritional program due to poverty and food insecurity.
Some patients become very reliant on the supports (soaps, water treatment jerrycan and the nutritional support) given from the health facility because they believe they should get supported due to their HIV condition (Health provider #2)
There were also concerns voiced by health providers that there was reluctance to graduate among some participants enrolled in the nutritional program due to poor socioeconomic status. For this reason, participants preferred prolonged enrolment in the nutritional program to fulfill poor household socioeconomic status:
It is because of their poor economic status that most don’t want to graduate. If he graduates, you will not give him Plumpynut in the next time because they don’t have other sources of income. Most want their weight to stay as low as possible (Health provider, age 35 #7).
Food insecurity as a contributor to relapse
Despite the high magnitude of food insecurity among those enrolled in the nutritional program, health providers identified that there was no remedial strategy as part of the program to prevent relapses of undernutrition among those graduated.
The major issue that creates a problem in this regard is that when they (people living with HIV) graduate from the nutritional program. There is no local or international NGO which we can link people with after their graduation from the program. There is no more NGOs in our area and I don’t know the reason. So, there are no efforts made to prevent relapse of malnutrition after nutritional recovery. Because they should be linked into other income-generating activities (Health provider, age 27 #2).
Things that needs improvement in the nutrition program, now after you treat him for malnutrition and he graduates, there is nobody who helps you prevention of relapse. At least you have to link the patients in order the problem not to come again. So, we have big problem in this regard and we don’t have supportive organization to do this (Health provider, age 37 #6).
Some adults indicated the presence of support for participants of the program in rural areas such as provision and maintenance of land as well as initiatives prioritizing adults living with HIV in income-generating activities, but no such experience was reported in patients living in urban areas.
I heard there are some support for people living in rural area. So they should do similar way in urban areas. Living in the city with HIV is very difficult and creates problem of house rent and others (Adult female, age 48 #9).
However, the above claim may be a perception as no other participant reported such an experience.