Background
Human immunodeficiency virus (HIV) without a doubt is a grave public health and development problem in sub-Saharan Africa. The Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2012 estimated that more than two-thirds of the over 35 million people living with HIV worldwide live in sub-Saharan Africa [
1]. This region hosts only 12% of the world population [
2]. The fight against HIV/AIDS is being pursued through interventions to stop the spread of the virus, and prolong the lives of those infected through the use of antiretroviral therapy (ART). Significant successes have been made in this drive. The most recent estimates suggest that the total number of new HIV infections in sub-Saharan Africa has dropped significantly [
1,
2]. The HIV epidemic has been stable in Ghana over the past half-decade. Indeed, linear trend analysis of prevalence data from 2000 to 2013 shows that HIV situation in Ghana has declined [
3]. The most recent prevalence data shows an estimated national adult HIV prevalence of 1.3% [
4].
There has been an increased access to ART globally [
1] and locally [
5]. Access to treatment commodities have been shown to lead to a reduction in the number of AIDS-related deaths [
2,
6,
7]. In spite of these efforts, one major challenge many HIV-affected individuals and households in sub-Saharan Africa grapple with is food insecurity. Studies have shown that HIV exacerbates the vulnerability of affected families to food insecurity, leading to hunger and malnutrition [
8,
9]. For instance, a longitudinal study in Uganda among HIV-infected individuals had shown that severe food insecurity was associated with worsened quality of life [
10]. Indeed, scholars have previously provided elucidation on the relationship between HIV and food insecurity. The relationship is complex and intertwined in a vicious cycle, with each worsening vulnerability and thus exacerbating the severity of the other [
10,
11]. Food insecurity heightens susceptibility to HIV exposure and infection; HIV on the other hand increases vulnerability to food insecurity. This relationship is often compounded by low income, resulting in profound consequences on health and nutritional status. Households that suffer from food insecurity due to poverty are malnourished prior to infection [
11]. As a disease, HIV’s impact on malnutrition as a result of its effect on the infected individual’s metabolism, ingestion and digestion of food has long been clarified [
12-
15].
HIV also disrupts livelihoods as infected persons often lose the ability to work and generate income [
16]. In addition, the propensity for uninfected family members to contribute economically to the household income basket is seriously affected due to the burden of care for the infected person(s). For instance, it is reported that caring for an individual with AIDS in sub-Saharan Africa can deplete as much as one-third of a family’s monthly income [
17]. This situation feeds into the vicious cycle of HIV and food insecurity described above.
Sometimes described as a syndemic
a, the relationship between HIV and food insecurity often causes individuals and households to adopt coping strategies to maintain the status quo. Studies have demonstrated that such strategies are often negative, undesired, unsustainable and often irreversible [
18,
19]. Strategies that have often been adopted include sale of assets, taking children out of school, migrating and engaging in transactional sex [
11,
16,
20]. Some authorities posit that these coping strategies may bring short-term relief, but increases the risk of exposure to HIV. Destitution and despair brought on by negative coping behavior may increase the risk that a person will resort to trading unprotected sex for food [
21,
22].
This background shows that there is a growing body of literature on HIV, food insecurity and negative coping mechanisms in sub-Saharan Africa, with majority of the studies originating from Southern African countries [
10,
16,
20,
23-
25]. Little is known about other sub-Saharan African countries, including Ghana. Most HIV-related studies in Ghana have largely focused on epidemiology, behavioral, social and psychological aspects of the disease. There is paucity of data on how HIV-infected individuals and affected households address their economic needs amid living with the disease. This paper presents data on the various coping strategies of a nationally representative sample of 1,745 Ghanaian HIV-affected households.
Discussion
The study assessed among others the negative coping skills that Ghanaian HIV-affected households adopt in ensuring their livelihoods. Our respondents were randomly selected from both rural and urban ART centers in the nation. We have presented the socio-demographic and health attributes household asset wealth, and coping strategies of 1,745 HIV-affected households in Ghana. Our analyses are descriptive in nature; and therefore encourage that caution be exercised when generalizations beyond this descriptive perspectives are done.
A greater proportion of them were educated. The higher attainment in formal education in HIV-positive households is likely to impact income earning opportunities and influence household food security and coping options [
28]. Higher education in rural communities enhances peoples’ ability to participate in off-farm income activities, which is likely to increase household income and subsequently enhance access to food [
29]. Polygynous unions are common in many parts of Africa [
21]. The larger households (>5 members) reported in the study may actually be clusters of smaller nuclear families who then share the same lower risk factors as the households with less than five members.
This study is additionally important for its focus on food consumption coping strategies adopted by HIV-affected households. Households commonly use a combination of any of these 5 coping strategies to mitigate food insufficiency in their homes. More than half of these families reported limiting portion size, reducing number of meals eaten daily and relying on less expensive foods. Begging and harvesting immature crops were least employed coping strategies. As expected, asset rich households had the lowest CSI, and asset poor households reported the highest CSI. Asset poor households are more likely to engage in negative coping strategies than asset rich households because of less household income to support food expenditure and fewer physical assets of worth that can be sold in time of crisis (Figure
2).
Generally, the CSI scores were higher among female-headed households compared to their male counterparts. As in other countries in sub-Saharan Africa, women in Ghana mostly carry the responsibility of caring for the sick; they are thus unable to engage in economic activities outside of the home to earn a steady income. Ghanaian women tend to have lower educational attainment levels compared with men due to discriminatory access to formal education as children [
30]. The lower attainment in formal education in households is likely to impact income earning opportunities [
28] and push households to adopt negative strategies in an attempt to moderate food insufficiency problems. Higher education improves women’s ability to participate in higher income-generation activities which is likely to increase household income and subsequently enhance access to food [
29].
The reported relationship between CSI and education level of the household head was mixed. Generally higher education of the household head was linked with lower CSI. However, in 4 regions, household heads with basic education had higher CSI than their uneducated peers. Not assessed in the current study, but nevertheless, significant in this discussion is the role of culture on coping mechanisms [
8,
9,
31]. Ghana is politically partitioned into ten regions, and 216 districts. In each region, and in most districts are various cultural/socio-cultural practices. The influence of these culturally-determined practices on coping behaviors could be in dependent of one’s scholastic attainment. There is no argument that culture explains quite a lot of human behavioral tendencies and patterns. Sometimes referred to as individualism/collectivism, these cultural characteristics are related to different coping strategies [
31]. See and Essau for example found that cultural values predicted coping, partly mediated by valuation of tradition, and cultural norms. Further research preferably employing both quantitative and qualitative techniques could provide a rewarding clarification to these relationships.
Based on the national average, HIV-affected households with AIDS orphans or chronically ill persons reported higher CSI, demonstrating the use of more negative food consumption coping strategies to buttress food security in these families (Table
3). Poor households with prime adult chronic illness are prone to food insecurity [
32]. Households experiencing chronic illness and of prime-age adults suffer from loss of income and household labor shortages, which adversely affects food security due to declining agricultural productivity [
33] and diminished household purchasing power [
34]. Thus, asset rich households, regardless of a high-burden level of care may be resilient to food insecurity if the chronically ill persons are not the prime age adults, who are typically the main income earners in the household.
Survey limitations
As is the usual in assessment of food security and vulnerability, the collection of market data is very critical, especially in settings characterized by instability/high food and fuel prices. In recent past, Ghana like many other countries in the sub-region fit this characterization. This phenomenon can impact negatively on household food security. The inability of the current survey to capture market data and subsequently provide necessary adjustments during the analysis is a limitation. Seasonality of food insecurity is a major problem in most parts of the country. Commonly referred to as the “lean season” and “harvesting season”, these periods respectively denote deterioration and amelioration of household state of vulnerability to food insecurity. Given that the data collection exercise was carried out during the course of the harvesting season, the level of food security could have been underestimated. In other words, households who were identified in this survey to be food secure during this period of the year could easily slip into food insecure during the lean season. As a consequence, the results of this assessment should be cautiously interpreted. These notwithstanding, it is unlikely that these limitations will significantly alter the main conclusions and recommendations.
Conclusions
In summary, this paper suggests that HIV-affected households in Ghana do employ negative food consumption coping strategies to cushion food insufficiency and other pressures in their homes. While these strategies may provide short-term relief they are erosive, unsustainable, and undermine resilience in the long run. Reducing food intake, buying low quality cheap foods, gathering unusual kinds of wild foods, relying on casual labor, or going begging to battle food insufficiency, has dire implications for household members’ health, children’s school attendance and performance, and adults’ income-earning capacity in the long run.
There is an urgent need for policies that focus on building the capacity and stability of these households. Well-informed interventions that are appropriate for the local setting should aim to support HIV-affected households with long-term coping strategies that improve resilient to food insecurity.
Acknowledgements
We are grateful to all the households, the twenty four field research assistants, the data entry clerks, and the PLHIV who voluntarily participated in the survey. This paper benefits from an earlier work commissioned by the United Nations World Food Program, and the Ghana AIDS Commission. The said assignment was executed by the first author.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AL, AE, RA and KA designed and implemented the field research. AL performed the statistical analyses. AL, AM, ML, AAA, IQ, and DQ drafted and reviewed the manuscript. AM and ML contributed to the interpretation of data. All authors read and approved the final version of the manuscript.