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USAID P.L. 480 Title II Food Aid Programs and The President's Emergency Plan for Aids Relief: HIV and Food Security Conceptual Framework

USAID Bureau for Democracy, Conflict & Humanitarian Assistance, Office of Food for Peace and the U.S. President�s Emergency Plan for AIDS Relief

September 2007

Introduction

This paper describes the rationale for and proposed approach to developing and implementing an HIV and Food Security Conceptual Framework for coordination of activities between the President�s Emergency Plan for AIDS Relief (PEPFAR) and the USAID Office of Food for Peace (FFP). The Conceptual Framework will establish and facilitate a programmatic continuum to address the nutrition, dietary supplementation and food security needs of HIV-infected and -affected populations. This Conceptual Framework will address the mutual objectives of FFP and PEPFAR.

In many countries, there is a complex interface between chronic food insecurity and HIV. The infection itself affects metabolism and causes wasting, especially in more advanced stages and in the absence of anti-retroviral therapy (ART). For the past four years, nongovernmental organizations (NGOs) and the World Food Program (WFP) that have been implementing P.L. 480 Title II (otherwise known as Food for Peace) emergency and non-emergency programs have not necessarily worked closely with PEPFAR, nor have resources been programmed systematically in conjunction with PEPFAR to address the food needs of PEPFAR beneficiaries and their communities. Recognition of this situation has highlighted a significant potential for broadening synergies to strengthen the U.S. Government�s (USG) response to HIV-related nutrition, food and food security needs in countries where FFP emergency and non-emergency food aid programs and PEPFAR both operate.

In 2005, the U.S. Congress called on the Office of the Global AIDS Coordinator (OGAC) at the U.S. Department of State to take the lead in developing and implementing a USG interagency strategy to address the food and nutrition needs of people living with HIV (PLHIV). Submitted to Congress in May 2006, the Report on Food and Nutrition for People Living with HIV builds on the respective comparative advantages of the USG agencies working in HIV, nutrition, food assistance, agriculture and livelihood assistance in order to benefit individuals, families and communities affected by HIV. The Report has led to greater clarity on how PEPFAR and FFP, as well as other USG agencies, international partners and host countries can better collaborate to strengthen nutrition and food interventions for individuals and communities affected by HIV and reduce any remaining programming gaps. By formalizing and expanding the basis for collaboration, a P.L. 480 Title II/ PEPFAR HIV and Food Security Conceptual Framework will ensure that more effective and comprehensive programs are implemented. By continuing to draw upon the technical expertise and resources of both FFP and PEPFAR, the goals of meeting the nutrition, food and food security needs of individuals, households and communities affected by HIV, while strengthening HIV prevention, care, support and treatment, will be better achieved.

Impacts of the HIV Pandemic

HIV imposes a series of dynamic shocks on livelihoods and food security, and these cannot be addressed in the same way as droughts and other natural disasters. As was noted in a collaborative World Food Program (WFP) and International Food Policy Research Institute (IFPRI) paper for the 2001 UN Standing Committee on Nutrition Meeting: HIV/AIDS Food and Nutrition Security: Impacts and Actions held in Nairobi, Kenya, the impact of HIV is felt through individual, household, community, national and regional levels because of the loss of human, financial, physical, social and political capital. These impacts include:

• Human capital: HIV decreases the productivity of household labor due to sickness and HIV-related opportunistic infections. Additionally, infected individuals die prematurely, resulting in lost productivity. The labor pool is further diminished as healthy individuals have to care for those infected and attend the funerals for those who have died. Children in particular suffer from the emotional and psychological pain of the loss of parents. They are often displaced and forced to leave school early, resulting in lower levels of education. Because of the premature deaths of adult workers, there is a loss of indigenous knowledge transfer between generations. According to the Food and Agriculture Organization�s 2005 Focus Report on HIV, more than seven million farmers have died and an additional 16 million are likely to die over the next two decades in 25 Sub-Saharan countries.
   
• Financial capital: Medical costs and funerals are a major financial burden. HIV-affected households are often forced to sell assets or increase their burden of debt to pay HIV-related costs. Thus, affected households risk facing difficulties in getting loans from banks. The poor usually rely on informal money-lenders, often at very high interest rates. Infected and affected adults may lose employment as a consequence of illness or because of pressures of caring for the sick, leading to depletion of financial capital and, sometimes, to destitution.
   
• Physical capital: Land is often sold to pay for medical and funeral expenses. Land inheritance patterns can make widows more vulnerable to becoming homeless and similarly disinherit their children. In agriculture, less labor-intensive, livelihood-sustaining ways of farming land are required, resulting in reduced crop value and dietary diversity. Affected households are forced to sell productive assets and livestock and the loss of productive traction animals further reduces agricultural output. Loss of employment may also lead to sale of assets.
   
• Social capital: With rising HIV prevalence rates, social networks within communities fragment, as an increasing number of households and individuals become affected by the disease and cannot provide support to other families in the community. At the national level, the capacity of government and social institutions to provide formal safety nets and support to HIV-affected people decreases with the progression of the epidemic, because of increasing costs and diminished revenues due to illness or death of populations in productive age groups.
   
• Political capital: Political participation of HIV-affected family members is constrained due to the burden of illness and the diversion of time to tasks related to survival. Additionally, HIV-affected families are often deliberately excluded from the political process due to stigma and discrimination.

II. Background

FFP Policies and Programs Addressing HIV

HIV-infected and -affected populations often cite food as one of their greatest needs. In response, FFP has addressed the food security needs of these groups since 1999. These efforts began with the Leadership and Investment in Fighting an Epidemic (LIFE) Initiative, which provided food assistance and other support to PLHIV and orphans and vulnerable children (OVC) in four countries: Kenya, Malawi, Rwanda and Uganda. Between FY 2002 and FY 2004, FFP invested approximately $14,000,000 in the LIFE Initiative and provided supplementary feeding for more than 118,000 children and family members affected by HIV.

By 2006, FFP NGO programs with HIV components had expanded to Benin, Burkina Faso, Central African Republic, Dominican Republic, Ethiopia, The Gambia, Ghana, Guinea, Haiti, Indonesia, Kenya, Lesotho, Malawi, Mozambique, Romania, Rwanda, Senegal, Sierra Leone, South Africa, Uganda, Zambia and Zimbabwe. The programs included more than $50,000,000 in FY 2006 for prevention, care and support, vulnerable group feeding, education and food security-enhancing activities for one-half million HIV-infected and -affected beneficiaries. Over 30,000 MT of food aid for vulnerable group feeding was distributed as take-home rations under Food-for-Work (FFW), Food-for-Assets and general relief activities. In fact, most USG food resources directed to support HIV-affected communities and individuals are currently allocated through P.L. 480 Title II FFP programs.

As a result of partners� experiences with mitigation of HIV impacts on food-insecure families, Food for Peace developed guidance in 2004 for both emergency and non-emergency programs on HIV and food insecurity. The guidance seeks to ensure that, where appropriate, partners take HIV into account when analyzing food insecurity and include HIV in their mapping of food insecurity. They are encouraged to develop tools and programming designs that ensure that targeted resources are provided only for food-insecure HIV-affected families. These resources should also facilitate collaboration between food security programs and HIV programs. According to the guidance, food may be programmed for related, coordinated food security activities that wrap around nutritional care and support, as an incentive to participating in program activities and as a safety net or income transfer. Ration size and composition are to correspond to the objectives of the program. Food utilization issues should receive adequate attention. In addition, partners are required to present clear, realistic and sustainable eligibility and graduation criteria, as well as appropriate and adequate monitoring and evaluation of the activities.

Most of this assistance has been targeted at HIV-affected food-insecure households through community-level mechanisms, such as home-based care (HBC) networks, PLHIV associations and the use of village health committees and/or village elders. Generally, this aid has not been targeted at HIV-infected individuals in clinical settings�with the exception of some of the more recent WFP programs ─ nor have the resources necessarily been programmed in conjunction with PEPFAR programs to maximize program synergies. One of the main reasons for this is that P.L. 480 Title II programs are mandated to focus on areas with the highest food insecurity prevalence, which tend to be rural, whereas the majority of HIV clinical treatment, care and support services tend to be clustered in urban areas, where HIV prevalence is higher. Thus, it has become clear, especially to HIV service providers, that urban and peri-urban food insecurity among HIV-affected individuals, households, and their communities has largely been neglected and requires alternative targeting strategies by Title II and other food security and livelihoods assistance programs.

PEPFAR�s Approach to Supporting Food and Nutrition Needs

PEPFAR is the largest public health initiative focused on a single disease in history. Initiated in January 2003, PEPFAR coordinates and funds HIV/AIDS activities aimed at providing comprehensive and integrated prevention, treatment, care and support services. PEPFAR supports programs worldwide, and focuses its efforts on 15 heavily impacted countries in Africa, Asia and the Caribbean: Botswana, C�te d'Ivoire, Ethiopia , Guyana, Haiti, Kenya , Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia. The goals for these countries, known at the �2/7/10 goals� are to support, in an accountable and sustainable way:

• Prevention of 7 million new HIV infections
• Treatment of 2 million HIV-infected people
• Care for 10 million people infected and affected by HIV/AIDS, including orphans and vulnerable children

Based on the May 2006 Report on Food and Nutrition for People Living with HIV/AIDS presented to Congress, PEPFAR released field guidance in September 2006 in order to further inform country-level programs. A central precept of the PEPFAR guidance is to leverage other partners for broad support for the provision of food and livelihood assistance to vulnerable families while targeting PEPFAR resources to specific priority target groups. PEPFAR priorities include meeting the nutritional needs of HIV-positive pregnant and lactating women (P & L ♀), orphans and vulnerable children born to HIV-positive parents, and HIV patients in care and treatment programs, especially those who are severely malnourished at entry. The following are illustrative examples of the types of food and nutrition interventions that contribute to achievement of the 2/7/10 goals, as stated in the 2006 Report:

• Development and/or adaptation of food and nutrition policies and guidelines;
• Nutritional assessment and counseling, including hygiene and sanitation education, maternal nutrition, and safe infant and young child feeding related to prevention of mother-to-child transmission (PMTCT);
• Therapeutic and supplementary feeding that is well-targeted to the priority groups noted above;
• Micronutrient supplementation, where adequate intake of micronutrients is not being addressed through a diverse diet, including fortified foods;
• Replacement (weaning) feeding and support, within the context of WHO and national PMTCT and infant feeding guidelines; and
• Linking Emergency Plan programs to food assistance, food security and livelihood programs.

While PEPFAR remains focused on supporting food and nutrition interventions in limited, priority circumstances, its strategy also strongly promotes and fosters linkages to food security and livelihood assistance activities. These include, for example, improved agricultural practices, and skills training and microcredit programs supported by other donors and USG entities, including FFP, to avoid dependency and address chronic individual and family food needs. Models of innovative sustainable approaches that link HIV/AIDS care and treatment can be found in many PEPFAR programs. One notable model is partnerships in Kenya through the AMPATH program that links clinical care and treatment with food production and distribution programs as well as small business development. FFP is also a partner in sustainable approaches in countries where programs overlap. Partnering with the private sector, the PVO and NGO community and relevant USG and other international partner agencies to strengthen these linkages is a key PEPFAR priority. One of the past challenges with establishing specific FFP linkages however, has been differences in the geographical targeting of the two programs, combined with FFP�s approach of identifying vulnerable households within food-insecure communities versus the PEPFAR focus on HIV-infected and -affected individuals. The Food Security Conceptual Framework outlined below seeks to address this challenge.

III. Toward a New Title II- PEPFAR HIV Food Security Conceptual Framework

While opportunities for closer collaboration between P.L. 480 Title II and PEPFAR programs have begun to emerge, some programming challenges have prevented a more seamless continuum of support. For example, as previously mentioned, the focus of P.L. 480 Title II programs on areas with the highest levels of food insecurity, which tend to be rural, often differ from those areas that have the highest HIV prevalence, which tend to be urban and peri-urban. Also, P.L. 480 Title II uses community-level mechanisms for targeting food-insecure households, rather than targeting through clinics or HIV service delivery sites. P.L. 480 Title II programs are also awarded through a Washington-based process while PEPFAR funding is determined at the country level. Table 1 illustrates the different focal points, targeting strategies and inputs of Title II and PEPFAR food support in the HIV context.

Table 1: Food Support in the HIV Context

	Title II	PEPFAR
Beneficiaries	Households	PLHIV		HIV+ P & L ♀ OVC
Point of Entry	Community	Hospital, Clinic, Community		Community, Hospital, Clinic
Criteria for Entry	Food Insecurity	Clinical Malnutrition		Any nutritional status
		Severely malnourished adults	Mild and Moderately malnourished adults
Assessment Tool	Household Food Security	Nutritional Assessment and counseling	Nutritional Assessment and counseling	P & L ♀: HIV Status, OVC:HIV- affected/infected (i.e. any nutritional status)
Nutrition Support	Food aid commodities, Supplemental foods	Therapeutic or Supplemental foods Micronutrient supplements	Supplementary food if severely malnourished at entry; Micronutrient supplements	Basic Food Commodities, Therapeutic or Supplemental foods Micronutrient supplements
Types of food	Fortified and blended foods legumes, oil	F-100, F-75, and ready-to-use therapeutic foods (RUTF)	Fortified and blended foods and RUTF in pilot study areas	Fortified blended foods

Table 2 shows the allowable coverage for the direct distribution of food for various HIV-infected and �affected target groups under P.L. 480 Title II and PEPFAR. The table illustrates that while the allowable coverage under these two programs is extensive, in practice, even when all of the interventions described below are being implemented, there could be gaps in coverage.

Table 2: Allowable Coverage by Direct Food Distribution and Livelihood Support by Target Group and Funding Source

Target Group	HIV-Related Goal	PEPFAR	Title II
Severely malnourished ART & pre-ART clients	Treatment Care & Support	Therapeutic Feeding Supplemental Feeding Select support for livelihoods (improved sustainable agricultural practices, microfinance etc.)	Supplemental feeding for food insecure HH & improved sustainable livelihoods for food-insecure (FIN) families
Food insecure or moderately malnourished ART & pre-ART clients	Treatment Care & Support	N/A (some clinic-based supplemental feeding in pilot study areas only) Select support for livelihoods (improved sustainable agricultural practices, microfinance etc.)	Supplemental feeding Improved sustainable livelihoods for FIN families
HIV+ pregnant/lactating women	Care & Support	Supplemental Feeding Select support for livelihoods (improved sustainable agricultural practices, microfinance etc.)	Supplemental Feeding for FIN Improved sustainable livelihoods for FIN
OVC < 2	Care & Support	Replacement Feeding Supplemental Feeding Select support for caretakers� livelihoods (improved agricultural practices, microfinance etc.)	Supplemental Feeding Improved sustainable livelihoods for FIN
OVC 2-5 years	Care & Support	Supplemental Feeding Select support for caretakers� livelihoods (improved sustainable agricultural practices, microfinance etc.)	Supplemental Feeding Improved sustainable livelihoods for FIN caretakers
OVC primary school-age	Care & Support	Supplemental Feeding Select support for livelihoods (improved agricultural practices, microfinance etc.)	Supplemental Feeding Food for Education (including take-home rations) Improved sustainable livelihoods for FIN caretakers
OVC secondary school-age	Care & Support Prevention	Supplemental Feeding Select support for caretakers� livelihoods (improved sustainable agricultural practices, microfinance etc.)	Supplemental Feeding Food for Education (including take-home rations) Food for Training Improved sustainable livelihoods for FIN
Food-insecure HIV negative household members in HIV affected communities	Prevention Mitigation	N/A	Supplemental Feeding Food for Education Food for Training Food for Work Improved sustainable livelihoods
Food-insecure, high-risk groups: female headed HH, child-headed HH, HH with high dependency ratios	Prevention Mitigation	N/A	Food for Education Food for Training Food for Work Improved sustainable livelihoods

Beyond harmonized targeting and coordination of PEPFAR and FFP support to address the immediate needs of individuals and families for food assistance, a commitment is needed by the USG, international agencies, governments and the NGO community to strengthen the long-term capacity of HIV-affected families to provide for their own basic food and other needs. Thus, a number of program modifications are necessary to provide more complete coverage for HIV-infected and -affected target groups through P.L. 480 Title II and PEPFAR programming, including:

1. Reducing the geographic disparity between food aid and HIV program targeting, by expanding the focus of FFP resources to include food insecurity within urban and peri-urban areas.
2. Strengthening the use of clinics, PMTCT sites and other HIV service delivery sites for the targeting of PLHIV and their households for food aid to address household food insecurity.
3. Improving the ability of community-based P.L. 480 Title II programs to link with and refer beneficiaries for HIV services, such as VCT, ART, PMTCT and palliative care, including nutritional support.
4. Improving the ability of HIV clinical services to link with and refer food-insecure beneficiaries to community food security, food aid and livelihood assistance programs.
5. Increasing FFP support for institutions, community organizations and families providing services and support to food-insecure OVCs, including orphanages, training centers and programs for street children, which tend to be more urban and peri-urban based.
6. Strengthening prevention programs among food-insecure high risk populations such as female and child-headed households, families with high dependency ratios, etc.
7. Improving monitoring and evaluation, including the utilization of shared indicators and reporting systems.
8. Strengthening the capacity of all individuals and families receiving nutrition and food support to sustainably address their long-term food needs through improved food production, employment and other vocational and livelihood assistance.

IV. The Legal and Statutory Frameworks

PEPFAR and P.L. 480 Title II programs operate under separate authorities for acquisition of both services and commodities. To realize the most efficient and effective food security and nutritional support programs using resources from both, PEPFAR and FFP can explore a variety of funding options. These may include coordinated country PEPFAR and FFP operation and budget plans and either �hybrid� agreements or a central mechanism that would allow PEPFAR funds to be added to individual FFP agreements with PVO cooperating sponsors to conduct appropriate HIV/AIDS activities.

V. Next Steps

The Conceptual Framework will be implemented in FY 2008. Both PEPFAR and FFP have already strengthened guidance language for proposal submissions: PEPFAR for Country Operations Plans and FFP for its Multi-Year Assistance Programs (MYAP). There are several additional actions that have been identified as next steps. The FFP HIV Policy Working Group, in collaboration with the PEPFAR Food and Nutrition Technical Working Group (F&N TWG), should continue to support the implementation of these steps, including:

1. Stakeholder discussions: FFP, in collaboration with PEPFAR, will take the lead to share ideas and seek to develop a consensus, through discussions within the USG and with outside stakeholders, on how P.L. 480 Title II and PEPFAR can improve programmatic collaboration. FFP, in collaboration with PEPFAR, will also reach out to USAID Missions, and host country food and nutrition working groups to include them in this process.

2. Formation of FFP procurement task force: Led by FFP�s Policy and Technical Division (PTD), this group will work closely with PEPFAR to identify technical and programmatic parameters to achieve the objectives of both groups and develop an appropriate award process to facilitate tandem programming of P.L. 480 Title II funding in support of PEPFAR programs, as well as an examination of options to use Title II mechanisms for PEPFAR funds. This process will further ensure close collaboration with in-country teams, an optimal geographic focus and that the communities identified represent priority beneficiary groups.

3. Development of the program module: At the end of the procurement exercise, the Procurement Task Force should be able to present options for model program formats explaining programmatic/technical approaches, and possible funding and procurement configurations to the FFP and PEPFAR Directors for their approval.

4. Inventory of policies and guidelines for funding of initiative proposals: The Task Force will work with P.L. 480 Title II managers, Missions, and host country food and nutrition working groups, to develop written guidance on key criteria for the funding of future proposals.

5. Mapping of Current Title II and PEPFAR programs: Gaining a clearer idea of where existing Title II and PEPFAR programs are being implemented in each country is an essential starting point. This exercise is underway. This information will allow the joint Washington and country working groups to identify priority areas, gaps, and develop a clearer vision of coverage needs. It will also increase synergies of existing P.L. 480 Title II and PEPFAR programs already underway when the information is shared.

6. Determination of standardized eligibility and exit criteria: As with existing P.L. 480 Title II programs, food aid support to PEPFAR beneficiaries and their families would be based on levels of food insecurity as well as nutritional status, with clear eligibility 9 and exit criteria. Discussions with other stakeholders are needed to determine optimal vulnerability, eligibility and exit criteria to inform the development of guidelines for the program participation of future beneficiaries.

7. Assessing urban and peri-urban food insecurity in PEPFAR countries: P.L. 480 Title II implementing partners have extensive experience with vulnerability assessments. It will be important to gather food insecurity data from urban and peri-urban areas in the countries selected to be able to further define eligibility and exit criteria, priority target groups, rations, program design and monitoring and evaluation plans. In addition, further thought is needed on the additional program linkages for PLHIV who have successfully �graduated� from food support, are healthier, but have no source of income. PEPFAR and FFP will begin discussions with Missions, other USAID offices and implementing partners to create program links where possible.

8. Strengthening monitoring and evaluation: There is a need for more accurate tracking and reporting on beneficiaries from both programs. This process would use standard indicators that both identify numbers of people served with funding from either program as well as better account for dollars leveraged. A common set of indicators need to be identified or developed and agreed upon.

9. Development of a timetable: The FFP HIV Policy Working Group together with the PEPFAR F& N TWG representatives will develop a timetable for the steps necessary for successful implementation of the Conceptual Framework during FY 2008.