This thesis aims to contribute to current debates on the impact of the AIDS epidemic on the livelihoods and food and nutrition security of rural households in sub-Saharan Africa. Over the last 20 years, numerous studies have been conducted on this subject. Although these studies have generated a relevant line of inquiry that has provided valuable insights into the social and economic impacts of the epidemic, they have tended to extract AIDS from its social, economic, and political context. This has resulted in underexposure of the long-term and diverse patterns and trajectories of the impacts of HIV and AIDS on rural households. This thesis argues that in order to understand the impacts of an epidemic on society, it is necessary to analyse the contextual factors in which an epidemic emerges, spreads, affects society, and either persists, or declines and disappears, as well as the society’s and households’ responses to the epidemic.
The objective of the study was to investigate the contexts (political, economic, cultural, historical and geographical) in which the AIDS epidemic emerged in Uganda in the early 1980s and became a livelihood crisis that caused food and nutrition insecurity. It also sought to understand the ways in which communities and households were affected by the crisis and how they responded to the impacts of the AIDS epidemic over time. The latter was investigated more specifically at the local level of Masaka district. The study utilised the dynamic ecosystem approach developed by Ford (1971) in his work on the ecology of African trypanosomiasis and the work of Stillwaggon (2006) on AIDS and the ecology of poverty. Based on their approaches, four conceptual pillars were formulated that guided the research and analysis: context, diversity, impact, resilience, and their interrelationships.
The study was structured according to the following research questions: (1) What was the ecological context that shaped the AIDS epidemic in Uganda in general and Masaka in particular? (2) What has been the impact of HIV/AIDS on household structure, composition and human capital? (3) What has been the impact of the AIDS epidemic on land ownership, land utilisation and farming practices? (4) What has been the impact of the AIDS epidemic on household food and nutrition security? (5) How have households attempted to cope with the impact of the AIDS epidemic over time? These questions were addressed during the period 2007-2009 in three separate but interrelated stages of data collection. Data was collected using a mixed methods approach. A literature review was done on relevant topics and secondary data were collected. Primary data was gathered through a combination of methods: participant observation, interviews with key informants, a household survey, focus group discussions, and in-depth case studies of selected households. Acknowledging the methodological complexities of determining impacts in a basically cross-sectional study, in the household the survey impact measurement was done by comparing households having members living with HIV and AIDS (AIDS-confirmed households) and households for which this was not the case (non-confirmed households). Additionally, retrospective questioning and documenting historical narratives at the household level were done to capture the historical perspective.
The results show that prior to 1986 Uganda faced a governance crisis and experienced civil and armed conflict. Exacerbated by institutional dysfunctions and environmental deterioration, this crisis caused a decline in the economy, social investments and agricultural production, and an increase of population mobility that led to the expansion of sexual networks. Moreover, it led to the loss of trust in health care institutions and loss of cohesion in the household. The results of this study suggest that the above were accompanied by an ecological crisis resulting in intensification of poverty and migration that increased people’s vulnerability and susceptibility to HIV and AIDS. The results further show that after the country gained relative political stability in the mid-1990s, the context changed; the government restored political stability, and health and other essential infrastructures were put in place. These made it possible to detect HIV/AIDS, provide counselling and treatment of opportunistic infections. Later on antiretroviral (ARV) drugs became available and comprehensive programs for prevention, treatment and care of AIDS could gradually be implemented.
The study yields a mixed picture regarding the demographic impacts of AIDS on the rural households in Masaka. Whereas it is indisputable that AIDS has taken its toll on the households in the study area, the results of this study point to a rather diverse picture. The results show that for all variables analysed in this study to determine the demographic impacts of HIV and AIDS, only household mortality, female headship, in-migration and fostering in of children differed significantly between AIDS-confirmed and non-confirmed households, indicating impacts of the epidemic. The other variables, including household economic status, household dependency ratio and household size, did not show a clear effect of the AIDS epidemic. These results show no evidence of a negative effect of the epidemic on household labour availability. Although it is undeniable that AIDS had caused many deaths before the infected people could start accessing and using antiretroviral treatment (ART), as indicated by significantly higher past household mortality in AIDS-confirmed households, at the time of the study no major demographic impacts of the epidemic were visible at the household level.
Whereas previous studies on HIV and AIDS impacts had predicted and documented that the epidemic would affect household labour, which would result in reduced utilisation of land and affect the farming practices., the results of this study do not show significant differences in agricultural production and the amount of land owned and utilised between AIDS-confirmed and non-confirmed households. The results show that agriculture in the study area has been undergoing several changes, irrespective of household HIV and AIDS status. As the study shows, these changes have been due to a wide range of factors, including pests and diseases, declining soil fertility, falling prices for commercial crops, changes in crop growing and consumption preferences, apart from HIV and AIDS. Another factor that people pointed to in interviews and discussions is climate change, which is affecting the onset and offset of rain periods and causes flooding and drought.
Regarding household food consumption and household food security, this study found no straightforward relationship with household HIV and AIDS status. Also variables such as household mortality, changes in the area under cultivation, changes in crops and livestock enterprises, and gender of household headship proved to be not significantly related with (self-reported) household food security status. At the same time, the results indicate that household economic status is significantly associated with household food security, which suggests that economically better-off households, apart from owning more land, will often use off-farm income to safeguard their household’s food security. The results from interviews and discussion further show the declining importance of livelihoods solely based on agriculture in rural areas like Masaka, due to the emergence of a vigorous rural off-farm informal economic sector and improved rural infrastructures. These developments enable rural income diversification, in which people living with HIV and AIDS but benefiting from ART can participate as well, and are changing the rural agriculture-based livelihoods. Thus, the results suggest that a wide range of factors other than AIDS influence people’s food and nutrition security. This implies that the impacts of HIV and AIDS on food and nutrition security cannot be addressed in isolation from other factors and drivers affecting the rural livelihoods and household food security.
The nuanced picture of the impacts of the AIDS epidemic on households in Masaka that this study presents is also evidence of the coping, mitigation and adaptive practices of the affected households, which allowed many of such households to recover from the onslaught of the epidemic. The results from the in-depth household case studies provide a longitudinal picture and highlight the importance of understanding the impacts of the epidemic in the light of the different stages of the household domestic life course, as well as the stage of the epidemic itself and other societal developments like restored political stability and availability of antiretroviral treatment. The results also reveal the importance of the households’ access to and use of different forms of social capital and traditional social support mechanisms for their resilience to AIDS impacts.
The main conclusions about the contextuality of the emergence and course of the AIDS epidemic, the impact of general and location-specific factors other than HIV and AIDS on people’s lives and livelihoods, and the changes in the context that have occurred during the last two decades, indicate the need to move beyond HIV/AIDS-specific policies to broad development approaches, including policies aiming at social protection and addressing social inequalities in society. The need for an integrative approach also applies to agricultural policy and the need to address the challenges that this sector is facing. In doing so, contextual diversity has to be taken into account and local narratives should inform policy and practice. The kind of integrative approach used in this study, which could be referred to as political ecology, has yielded results that underscore the wider implications of the interrelations between HIV and AIDS impacts, rural livelihood, food and nutrition security, societal change and the advance of antiretroviral therapy, in Uganda and elsewhere. It is observed here that to understand and respond effectively to the negative impacts of AIDS and the problem of food and nutrition insecurity, it is necessary to pay attention to the diverse and interconnected causalities and drivers responsible for social change.