Food Aid and the President's Emergency Plan for AIDS Relief: An Expanding Partnership

These are clear, quantifiable goals; we are holding ourselves, and the organizations we are funding, accountable for achieving them. We expect to measure the results from that investment, to increase the funding for the programs that produce results, and to stop the funding for the programs that do not produce results.

I’m pleased to report that we have been able to make very encouraging early progress. For example, the Emergency Plan has made a commitment to support lifesaving antiretroviral drug therapy on a scale never before attempted. To better understand this progress, consider that at the time the President announced the Emergency Plan in January 2003, about 4 million of the 18 million HIV positive people in sub-Saharan Africa should have been receiving the benefits of antiretroviral drug therapy. But only about 50,000 people in all of sub-Saharan Africa were receiving these drugs at that time.

At the end of our 2004 fiscal year, in just the first eight months of our program, the United States was already providing support for the treatment of over 155,000 people in the 15 focus nations, more people than any other donor in the world had been able to support until then. In the seven months since the end of the fiscal year, we’ve continued to scale up our programs at an aggressive pace, so the number is now proportionally higher.

I think it’s fair to say that many of us had concerns about whether treatment could successfully be scaled up and delivered in resource-poor settings on such a large scale, because the challenges are so daunting. But it is already clear that if we work with our host nations and invest in system-wide infrastructure and capacity building, indeed we can do it. And this early success is no doubt the best foundation for hope for the future.

We have also made impressive progress in providing care for those infected and affected by HIV/AIDS. In the first year of implementation, the U.S. supported care for more than 1.7 million people infected and affected by HIV/AIDS, including over 630,000 orphans and vulnerable children and over a million HIV-positive people in need of palliative care. There is much more to do, but all of this represents a very a promising start.

In confronting HIV/AIDS, one learns very quickly what a complex issue it is -- and also how intimately it is entwined with a welter of other very complex issues. The relationships among this pandemic, poverty, food security, and so many other issues are incredibly subtle.

Focusing on the relationship between HIV/AIDS and food security, it is noteworthy that people in the developing world who are living with HIV/AIDS often cite food as their greatest need. The need for nutrition is closely related to all three of the core elements of the Emergency Plan -- prevention, treatment, and care. Let me describe some of the linkages.

In terms of prevention, people who are hungry are more likely to engage in sexual behavior that puts them at high risk of HIV infection. When finding food is a daily struggle, women may turn to transactional sex in order to keep themselves -- and their families -- from starvation.

Nutrition is also critical to prevention in another sense. Breastfeeding by a HIV-positive mother poses a risk of transmission to the child, but in the absence of other food for the child, the mother may choose to take that risk.

Food is thus significant for effective prevention. At the same time, adequate nutrition is also an element of successful antiretroviral drug treatment, as it greatly improves a patient’s response to medication.

As is so often the case with HIV/AIDS, the benefit of treatment to one patient is just the beginning of benefit to the wider community in which they live. Patients who are successfully treated and adequately fed can regain their health and rejoin the work force, again becoming productive members of their community and thus improving food security.

Food also supports drug treatment in a second way. Antiretroviral therapy regimes are not easy to maintain -- they require several pills per day, and the medication must be taken for life. People without food are understandably less likely to adhere to their drug regimens.

In this case, the harm from adherence failure is not only to the health of the individual in question -- it also facilitates the development of drug-resistant strains of the virus, potentially making the HIV/AIDS tragedy even worse.

The third focus of the Emergency Plan, care for those infected and affected by HIV/AIDS, is also closely linked with nutrition. For one thing, if people whose HIV infection has not yet progressed to AIDS are adequately fed, the onset of AIDS can delayed. Even apart from its cost, antiretroviral therapy comes with significant side effects for the patient, so keeping people healthy longer is of tremendous importance.

A second element of our care programs is care for orphans and vulnerable children. When a child loses a parent, of course, that child often loses his or her access to food. In many communities, the sheer number of orphaned children has overwhelmed the capacity of family and community networks to provide food for these children.

Care must also mean support for caregivers -- those, predominantly women, who assume the responsibility to care for dying husbands, or for their own children, or for their neighbors’ children. These caregivers are among the most important human resources we have in responding to HIV/AIDS, and we must ensure that they have sustenance. Clearly, if the Emergency Plan is to meet its ambitious prevention, treatment and care goals, the food challenges I have described must be addressed.

On the other hand, it is essential that the Emergency Plan maintain its focus on HIV/AIDS prevention, care, and treatment. If the Emergency Plan were to purchase food for all the people that need it, the $15 billion would be quickly dissipated and we would not meet the requirements that President Bush has tasked to us.

We have decided that under certain limited circumstances, the Emergency Plan will directly support nutritional interventions for HIV-positive people, affected family members, and orphans and vulnerable children and their caregivers. A particularly important focus is malnourished people who are just beginning antiretroviral treatment, because nutrition is so important to the success of that treatment.

For the most part, however, what we are doing is building and strengthening partnerships between the Emergency Plan and U.S. Government food and agricultural assistance programs -- the programs to which many of you make invaluable contributions. As you know, the government now has over 50 years of experience delivering legislated food aid to developing countries. Much as we now provide HIV/AIDS assistance through a variety of means, we have long provided food aid through agencies such as USDA and USAID, as well as through the World Food Program and other United Nations agencies and a myriad of nongovernmental partners.

These organizations have tremendous capacity to provide food support that, from our perspective, complements our HIV/AIDS efforts -- that’s why we refer to these complementary programs as ‘wraparound’ programs. In many cases, these wraparound programs provide the food, while we provide the accompanying nutritional education and training tailored to the circumstances of the pandemic in that community.

Let me highlight some of the populations affected by HIV/AIDS for whom the contributions of USDA and USAID food aid are especially important.

Many orphans and vulnerable children benefit from the McGovern-Dole Program and other USDA and USAID food assistance programs to help promote education, child development, and food security. For infants and young children infected or affected by HIV/AIDS, essential food commodities include non-fat dry milk and other food products that can be used for replacement, therapeutic, or supplemental feeding, or as ingredients for local food production. Food security and nutritional support for people living with HIV/AIDS, as well as for other family members affected by HIV/AIDS, are also priority areas.

In order to bring the vision of a comprehensive array of wraparound programs to reality, I have established an interagency group to look for opportunities to join forces with other U.S. Government programs that have comparative advantages in this area. Membership includes USAID’s Food for Peace program, USDA, the Peace Corps, and the National Institutes of Health and the Centers for Disease Control, both from the Department of Health and Human Services. We are now reaching out to Agriculture Attachés at Embassies.

Let me say how deeply I appreciate the willingness of the agencies involved in this working group to come together in a spirit of partnership with us. At the same time, we are also exploring opportunities to partner with other donors, such as the World Food Program and UNICEF.

An example of a model program is found in Mozambique. There, the President’s Emergency Plan interagency team and USAID’s agriculture teams are working together with the World Food Program to link HIV interventions and food. The United States is funding an international NGO and a local NGO to support prevention of mother to child transmission, antiretroviral therapy, and care interventions, as well as infant feeding and nutrition counseling. The World Food Program is providing the food. Thanks to this collaboration, almost 1,800 people are receiving food and related services through this program. So that’s a model, but we need to replicate it many times over.

The interagency working group I mentioned is currently examining all areas of international food assistance in the 15 focus countries, in order to identify further opportunities. Based on this information, we intend to identify one or two countries where we could apply this comprehensive wraparound model, quickly bring programs to scale, and then move on from there.

Now, it is important to remember a tragic reality: the nations suffering most from HIV/AIDS are many, many years away from getting their pandemics under control. So we must also focus on creating a sustainable response, just as we seek to in our food aid programs.

Among the greatest challenges we will continue to face for the indefinite future is helping our host nations build the capacity to respond to their HIV/AIDS emergencies. The challenge of sustainability is entwined with that of capacity. In so many of the nations where we are working, the capacity to deliver health care --just like the capacity to provide food security -- is severely limited by a history of poverty and neglect, war, and political instability.

It is thus important that we not only think about food distribution but also more sustainable approaches such as home and community gardens. I personally witnessed a powerful example of this in Kenya, where the Indiana University School of Medicine is working with a district clinic and food program. This program also typifies the leveraging we would like to achieve.

The Emergency Plan supports integrated health care services within the clinic. Other donors provide support for the home and community gardens. Severely malnourished people living with HIV/AIDS receive a "food prescription" from the clinic and obtain food and commodities at no cost from the garden. In terms of sustainability, the approximately 10 acres of farmland was donated by a local high school, and people in the program are also taught farming skills that they then use to cultivate their own plots of land for optimum production when they return to their homes.

After their health improves, many of the beneficiaries of services donate labor so staff costs remain low. Food grown within the community garden is also sold in the public market to generate income for the farm. We hope to support many such models that encourage sustainability.

Local ownership of this fight is essential if the programs we build are to be sustainable in the long term, as they must be. As someone observed to me, we must provide both fish and fishing poles. Down the road, we want these countries to be able to do all the fishing for themselves.