The converging impact of tuberculosis, HIV/AIDS, and food insecurity in Zambia and South Africa

Abstract

An anthropological study carried out in 2006/7 in rural Zambia and peri-urban South Africa documented the impact of co-infection with TB and HIV on poor households in the context of poverty and overstretched public health services. The anthropological research was conducted in 18 households affected by TB throughout the period of TB treatment and in 17 comparative non-affected households. Findings reveal that families experience disease alongside desperate social and economic inequities, with more absolute poverty and a deeper degree and prevalence of food insecurity in rural Zambia. Charting patient’s journeys from falling sick with TB to completing treatment revealed that most faced a protracted diagnostic period, pingponging between treatment options with trips to the government health services the most frequent. Most were extremely sick and emotionally fragile once diagnosed, many had relocated back to their parents’ home, and, all were no longer able to contribute to household livelihood. During the first months of TB treatment, patients and caregivers experienced contracted mobility and networks, reduced income and increased expenditure on ‘special foods’. Foods prescribed for TB patients were beyond the normal diet of households, especially in rural Zambia. As caregivers did their upmost to provide these foods (soft drinks, meat, eggs, fish, porridge), tensions and food insecurity in the households escalated, often resulting in family quarrels and caregivers themselves falling sick. In peri-urban South Africa, disability grants, food aid from the government health services and chequered food aid and material support from NGOs helped households through this period. But in Zambia, although emotional and technical support reached the households through government health services, a household counselling intervention and visits of church members, no affected household received any food aid or material support from state or NGOs and support from extended kin was very limited. More extreme coping strategies were subsequently adopted—for example selling clothes, begging, relocating—and affected households spun into deeper poverty and by the end of treatment were mostly severely short of food and in nutritional jeopardy. Across both countries, most TB patients were unable to resume previous livelihoods and most (n=13) were co-infected with HIV, throwing them onto another more long term disease trajectory. Accessing antiretroviral therapy (ART) was much more feasible in peri-urban South Africa and much harder in rural Zambia. Stigma related to TB and to HIV was more pronounced in rural Zambia but still persisted in both countries. Outcomes of TB treatment were mixed in both countries. Better outcomes included co-infected patients who started ART and experienced physical and social transformations and HIV-negative TB patients who successfully completed treatment. However, five TB patients died, one fell sick with relapse TB, two co-infected patients never started ART and one patient was not aware of his HIV status and was unwell. In the short term, only one Zambian household and five South African households recovered from the event of TB. Recommendations oscillate around reducing diagnostic delay in government health services and the provision of a comprehensive nutritional programme and social protection for TB patients and people living with HIV (PLWH).