According to the latest report by UNAIDS, 33.2 million people worldwide live with HIV, and new infections number 2.5 mil-lion annually . Hundreds of millions more are affected through the loss of parents , children or colleagues. The HIV and AIDS pandemic is everywhere, though sub-Saharan Africa is most severely affected with 22.5 million HIV-positive adults and children.

In the same vein, sub-Saharan Africa has 565 million people without access to sanita-tion and although the water situation is slightly better, with 300 million people without access, the region is by far the most behind.

In Botswana, Lesotho, Malawi, Mozam-bique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe, the adult HIV prevalence varies from 11 to 26 per cent. These regions have high levels of poverty and low access to the water and sanitation services that are critically needed to prevent and treat diseases.

Integrating HIV and AIDS and WASH

Background

Water, Sanitation and Hygiene (WASH)Programme Guide: HIV and AIDS

Lillian Pedzisa from Midlands Province, central Zimbabwe, collects water for her family.Lillian was

diagnosed with HIV in 2003 and her family has since received livestock and seeds from the Oxfam livelihoods programme. “I was identified

by the community because of my sickness – I have HIV. It’s very helpful because I’m now able to buy school fees, food and cooking oil. It means I’m ill less often. I’ve got five children, aged from four to 19 years old. My husband’s also got AIDS, so it’s very important to make sure we’ve got resources for the future – we need to lay the foundation for the future of our family.

“I’m trying to be a living example of a person coping with HIV, so that my family can learn from me.” Photograph: Annie Bungeroth/Oxfam

We shall not finally defeat AIDS, tuberculosis, malaria, or any other infectious diseases that plague the developing world until we have won the battle for safe drinking water, sanitation and basic health care.

Kofi Annan, former UN Secretary General

HIV adult prevalence, 2007 Sanitation coverage, 2008 Water coverage, 2008

The lack of access to WASH facilities greatly impacts people infected and affected by HIV and AIDS, including home-based caregivers.n Inadequate access to water and sani-tation linked with inadequate hygiene practices will accelerate the progression from HIV infection to onset of AIDS. WASH-related diseases, such as diar-rhoea and skin infections, accelerate the weakening of the immune system and severely diminish nutritional status.n Individuals weakened by AIDS need water and sanitation facilities that are nearby and accessible as they may not be able to walk far or lift heavy water containers (for example, using open wells).n It has been suggested that caregivers are chronically fatigued because of lifting bed-ridden patients. Poor access to WASH facilities increases the burden (eg. having to travel long distances to get water).n Women and girls who have to walk long distances to access toilets or fetch water, often at dark, are at greater risk of HIV infection due to sexual violence.n Those employed in the WASH sector (for example, drilling, construction contrac-tors) are often required to spend consider-able time away from their families, which can lead to some giving in to temptation and engaging in high-risk behaviour. n After the generally recommended six months of breast feeding, HIV-positive mothers should give their babies alterna-tive food to prevent contamination. Clean drinking water and good hygiene are

IMPACTS OF WASH ON HIV AND AIDS

crucial for the safe preparation of milk formula, since diarrhoea is the main killer disease of children under the age of five.n Individuals who take antiretroviral treatment with safe water will improve the effectiveness of the drugs because diarrhoea can limit the absorption of the medication by the body. In addition, it is important that antiretroviral medication is taken at the same time each day, so the water supply and storage needs to be reliable. Otherwise, a great irony exists in giving advanced, costly life-saving antiretroviral treatment to patients with

HIV and AIDS impact the actual and future social and economic feasibility and sustainability of water supply and sanitation systems.n Knowledge and skills acquired by a community or service providers may be lost due to HIV and AIDS. This erosion of management capaci ties increases training costs because of higher turnover of trained individuals.n Households affected by HIV and AIDS may lose sources of income, reducing their capacity to financially contribute to the operation and maintenance of WASH

a glass of water that could infect them with a life-threatening illness.n Access to water for productive use increases food security and nutrition levels, and contributes to keeping people healthy for longer. People who are weakened by AIDS can still grow vegetables when suf-ficient quantities of water are accessible.n When people with AIDS are sick with diarrhoeal diseases, adequate quanti-ties of water are essential for washing not only the body, but also soiled clothes and linen. Adequate facilities for disposal of waste laundry water are also needed. Similarly, toilet facilities must be easily accessible, with enough space to allow a caregiver to support the patient.n Households affected by AIDS may lose a breadwinner and face financial difficul-ties. Elders and/or children have to take on additional duties including fetching water. Inadequate access to water and sanitation increases “time poverty” of those affected households, resulting in lower school attendance by children.

agement, is hampered as it requires time and energy. Affected households may not have the time or be too weak to partici-pate in planning, decision-making and implementation, and their specific needs may not be taken into account.n Low morale of individuals and communities affected by HIV and AIDS leads to stress and time off work, resulting in decreased productivity in the WASH sector.n Individuals infected by HIV and AIDS have supplementary requirements from water and sanitation services as reviewed in “Impacts of WASH on HIV and AIDS”. Those essential supplementary require-ments add pressure on already limited services for most vulnerable communities.

systems. Overall livelihood insecurity and increased medical expenditure have to compete with WASH-related expenditure.n Participation, a cornerstone in decentralised water and sanitation man-

IMPACTS OF HIV AND AIDS ON WASH

Water, Sanitation and Hygiene (WASH)Programme Guide: HIV and AIDS

Zujeta (5) drinks fresh water from pumps built by Oxfam in Mutarara district, Zambezi river region. Photo: Andy Hall/Oxfam

Infection HIV AIDS

Women and girls have to walk long

distance for WASH needs.

WASH workers spend time away

from families.

HIV positive mothers cannot safely prepare formula milk.

Households affected by AIDS suffer from “time

poverty” and face additional income challenges.

Caregivers have an increased burden and suffer

from chronic fatigue.

Sick people with AIDS cannot practice safe

sanitation and hygiene.

Effectiveness of ART is

compromised.

People with AIDS cannot grow vegetables.

People with AIDS access to WASH is limited by

weaker status

People are infected by WASH related diseases

Impact of WASH on the different phases of the disease: from exposure to infection; progression towards AIDS; and to specific needs for infected and affected people

WASH

HIV and AIDS

Reduced financial capacity for operation

and maintenance

Knowledge and skills lost due to HIV

and AIDS

Reduced participation by affected households

Increased stress and time

off work

Increased demand on

services

Challenges on WASH within an HIV and AIDS environment

PROGRAMME REQUIREMENTSSafe water, sanitation and hygiene are essential needs and human rights. WASH programmes need to give higher priority to water supply, sanitation and hygiene promotion to areas with a high incidence of HIV and AIDS.

n In locations with high or increasing HIV and AIDS prevalence, it is necessary to incorporate the demographic effects of the epidemic into the planning and design of WASH systems, both in terms of quality and quantity.n The water needed for adequate care of HIV and AIDS patients exceeds normal consumption rates by two to five times.n WASH programmes need to identify and address the par-ticular needs and constraints of HIV and AIDS infected and affected families, ie. analysing their ability to contribute and use those services.n When WASH facilities are community managed, con-straints of affected families must be integrated within the management plan to ensure sustainability.n There is a need to develop and promote new water collection technologies and strategies, which bring water closer to the home.n Hygiene promotion methods and tools must incorporate HIV infected and affected people’s circumstances in order to reach them.n Community-based approaches known to enhance sustainability provides an entry point to promote communi-ty-based HIV and AIDS prevention and mitigation activities. Programmes, like WASH, that engage with communities should use such opportunities.

n In order for HIV-infected people to remain healthy as long as possible and for people with AIDS to reduce their chances of getting diarrhoea and skin diseases, adequate water supply and sanitary facilities are of utmost importance. But there are more reasons why good access to safe water and sanitation is important for people living with HIV and for the provision of home-based care to AIDS patients:c Water is needed for bathing patients and washing soiled clothing and linen.c Safe drinking water is necessary for taking medicines.c Nearby latrines are necessary for weak patients.c Water is needed to keep the home environment and latrine clean to reduce the risk of opportunistic infections.c Water and sanitation provision increases the sense of dignity of both patients and caregivers.c One consequence of HIV and AIDS is “time poverty”, whereby water collection and other tasks become increasingly burdensome and reduce time available for other activities. Good access to safe water allows more time for other tasks.n Hygiene education and basic WASH information has to be integrated into the training given to home care volunteers and should be adapted to suit requirements.n HIV and AIDS programmes need to promote safe water storage as well as point of use water treatment.n It may be necessary to assist with the identification of water-saving technologies to optimise water available. n HIV and AIDS programmes need to promote the design and installation of facilities (eg. toilets, handwashing devices , water points) that consider the circumstances of infected peole and affected households.

For WASH programmes For HIV and AIDS programmes

The need for improved multiple use water services and sanitation is most urgent in urban and rural communities affected by HIV and AIDS. Current demand-responsive approaches and policies that promote full cost recovery and private sector involvement have an inherent risk of further marginalising these communities and jeopardising their access to improved water supply and sanitation. Continued monitoring of access, equity and affordability is required to inform management strategies that are equitable, gender-sensitive and pro-poor.

Ntombizodwa Marufu (left) is HIV positive and has been an Oxfam beneficiary for many years. A latrine was built on her land in Zimbabwe. “Because of Oxfam, I have a toilet at home ... which means that even with my gastric problems , disease isn’t spreading to my children and the community ... they gave us education on how to use it, gave us gloves, cleaning fluid and a bucket.” Photo: Annie Bungeroth/Oxfam

A Let us Grow volunteer (below) fills a cup with wa-ter for a child attending the after-school club in Orange Farm, South Africa. Photo: Kaya Ngwenya/Oxfam

[1] WELL (2004). The HIV/AIDS Millennium Development Goal: HIV/AIDS and water supply, sanitation and hygiene in Southern Africa. Poster 5.2 Southern Africa.[2] Water Supply & Sanitation Collaborative Council (2009). HIV/AIDS & WASH. WSSCC reference note.[3] Oxfam GB (2006). Education for public health and HIV awareness. Southern Africa Regional Centre.[4] UN HABITAT (2006). HIV/AIDS checklist for water and sanitation projects. United Nations Human Settlements Programme.[5] The Mvula Trust (2007). Water services and HIV/AIDS – A guide for local government councillors and officials responsible for water, sanitation and municipal health services. Report to the Water Research Commission, TT 317/07[6] Ngwenya B.N., Kgathi D.L. (2006). HIV/AIDS and access to water: A case study of home-based care in Ngamiland, Botswana. Physics and Chemistry of the Earth 31: 669-680[7] Kgalushi R., Smits S., Eales K. (2004). People living with HIV/AIDS in a context of rural poverty: the importance of water and sanitation services and hygiene education. The Mvula Trust and IRC research.[8] Obi C.L., Onabolu B., Momba M.N.B., Igumbor J.O., Ramalivahna J., Bessong P.O., van Rensburg E.J., Lukoto M., Green E. and Mulaudzi T.B. (2006). The interesting cross-paths of HIV/AIDS and water in Southern Africa with special reference to South Africa. Water SA Vol. 32 No. 3 July.[9] Kamminga E., Wegelin M. (2005). HIV/AIDS and water, sanitation and hygiene. Thematic Overview Paper 2, IRC International Water and Sanitation Centre.[10] Tulenko K., Bery R. and Rosenbaum J. (2007). Analysis of research on the effects of improved water, sanitation, and hygiene on the health of people living with HIV and AIDS and programmatic implications. Research and resources linking water, sanitation and hygiene with HIV/AIDS home based care. Prepared by USAID/Hygiene Improvement Project with the World Bank/Water and Sanitation Program.[11] National Action Committee for Rural Water Supply and Sanitation (2003). Zimbabwe Water and Sanitation Sector HIV/AIDS Response: Programme, Strategies and Guide-lines. Ministry of Local Government, Public Works and National Housing.[12] Organ J. (2007). Water and HIV: working for positive solutions. Impacts of the HIV epidemic on access to safe water, sanitation and hygiene in the Copperbelt of Zambia. With collaboration of Action Against Hunger (ACF) and Children in Distress (CINDI), Zambia.[13] Oxfam GB (2008). Rough Guide to Mainstreaming HIV/AIDS. Oxfam GB intranet, Programme Resource Centre.[14] Mullins D. (2002). Mainstreaming HIV/AIDS into Development: What it can look like. Oxfam GB, Southern Africa Region.

Oxfam GB Southern Africa Regional Centre195 Allcock Street, ColbynPretoria, 0083 South Africa

Tel: +27 12 423 9900Fax: +27 12 342 3484

www.oxfam.org.ukhttp://www.oxfamblogs.org/southernafrica/

REFERENCES

c What are the main diseases and their prevalence? Which diseases are WASH-related?c Is WASH included in government HIV and AIDS strategy?c Who are the important institutional stakeholders dealing with WASH? (Consider mapping institutions dealing with water, sanitation and hygiene promotion).c How will access to water and sanitation influence the HIV epidemic? (For example, by increasing vulnerability.)c What is the WASH coverage and what are the implications of WASH gaps for affected households and communities?c What are the knowledge, attitudes and practices of HIV and AIDS infected people and affected households?c What can be done to provide higher levels of WASH services in areas with gaps?c Are the WASH services provided suitable in terms of quantity, reliability, accessibility, quality and affordability?c Does the home-based care training include information on safe water, sanitation and hygiene practices?

PROGRAMME IDENTIFICATION and DESIGN

PROGRAMME IMPLEMENTATION, MONITORING and EVALUATION

HIV and AIDS treatment & home-based care programmes

WASH programmes

c Are HIV and AIDS included into government WASH strategy?c Who are the important institutional stakeholders dealing with HIV and AIDS? (Consider mapping institutions dealing with prevention, treatment, care and mitigation.)c How will the HIV epidemic affect access to water and sani-tation? (Use the demographic profile.)c Are consultation and participation mechanisms for planning accessible to affected and infected individuals? n Liaising with local clinic; n Talking to households affected by HIV and AIDS; n Engaging with home-based caregivers to find out more about the water and sanitation needs of their patients.c What is the HIV and AIDS prevalence likely to be over the next 10 to 15 years?c What local knowledge of HIV and AIDS exists and who transmits this knowledge?c What targets need to be set to ensure that there is adequate water and sanitation services provision for people affected with HIV and AIDS?

c Are all stakeholders (for example, staff, partners, contrac-tors, consultants, et cetera) aware of WASH-related diseases risks, modes of transmission and prevention?c Does monitoring measure access to water and sanitation by HIV and AIDS infected and affected households?c Does monitoring measure the prevalence of diarrhoeal and other WASH-related diseases among people living with HIV (PLHIV)?c Is there any new learning on linkages between WASH and HIV and AIDS?

c Are all stakeholders (for example, staff, partners, contractors , consultants, et cetera) aware of HIV risks, modes of transmission and prevention?c Does monitoring measure the programme’s impact on the HIV and AIDS epidemic?c What is the overall opinion of the people infected and affected by HIV and AIDS about the project’s impact on their life?c Is there any new learning on linkages between HIV and AIDS and WASH?

PROGRAMME CHECK LIST

Water, Sanitation and Hygiene (WASH)Programme Guide: HIV and AIDS