Climate change, hunger and HIV are a triple threat to vulnerable African women

“I have no other way out,” said Inês, a mother of four in the Mutauanha Piloto neighborhood of Nampula, Mozambique, who was interviewed by a member of my team. “I have children to support, I have to take risks.”

Every year, Inês cultivates a small crop of tomatoes and onions to sell, and every year, it gets harder to produce enough. So she turned to sex work in exchange for food. In 2007, she learned she was HIV-positive.

I have been working in the field of HIV care and research for over 20 years as an infectious disease physician and epidemiologist, and I’ve heard many similar stories of women endangering their health to cope with food insecurity against the backdrop of climate change.

In Africa alone, an estimated 140 million people face acute food insecurity. Recent extreme droughts coupled with erratic flooding in such countries as Burundi and South Sudan are rapidly damaging crop yields and displacing people. Globally, recent armed conflict will continue to exacerbate hunger, starvation and death.

For women like Inês, the increased risk of HIV acquisition compounds the climate change/food insecurity threat.

In concert with ministries of health, my ICAP at Columbia University colleagues and I analyzed data from a multinational project in sub-Saharan Africa testing hundreds of thousands of people for HIV, in addition to assessing access to — and factors associated with — HIV prevention and treatment. Looking at data from six countries in southern and eastern Africa with high HIV burden, we found that food insecurity was associated with a two-fold increase in HIV acquisition in women, but not men, which might have been driven by an increase in women having sex for money, food or gifts.

Women with severe food insecurity also reported more forced and condomless sex with partners whose HIV status they did not know. Young food-insecure women had more significantly older partners than food-secure women and unmarried women were shown to be at higher risk of severe hunger. Our data support other studies from this region, which have shown that hunger drives risk behaviors.

The intersection between food insecurity and HIV acquisition isn’t just tied to increased risk-taking, but one’s ability to maintain treatment. In the Solutions 4 Sustainability study, a separate study I conducted with my ICAP at Columbia University colleagues and the Mozambique National Institute of Health after the devastating cyclones of 2019, a focus group of women living with HIV reported that the most significant post-cyclone hardship they faced was a lack of food.

As one woman from the study stated, “You won’t have the strength to take those pills [antiretrovirals], those pills require you to eat.” 

Another participant observed the exchange of food for sex in the temporary communities set up for those displaced after the cyclone: 

“There was no way to … minimize these issues of violence, sexual abuse because although people have moved from one place to another, sex always goes with them.”

The implications of climate change on HIV health outcomes have not historically been made obvious, but as an international development community, we are beginning to see the range of risk behaviors associated with climate change impacts, especially among women. We have a responsibility to establish programming that reflects what we know.

Our research across the six sub-Saharan African countries showed that women receiving food support had almost 70 percent fewer new HIV infections, possibly due to less high-risk sex. It is vital to provide food support directly to women in communities with high HIV burden, especially young or unmarried women. In tandem with food support, women should also be linked to HIV prevention services at a minimum during food shortages or climate catastrophes.

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International development funders must begin considering the climate change/food insecurity health nexus in their programming requests to ensure that the “last mile” of those at risk of and those living with HIV have access to long-term solutions to barriers they confront every day to achieve health.

September’s African Climate Summit highlighted the potential of Africa’s ability to lead on innovative solutions to the climate crisis, which, in turn, would require the world’s industrialized countries largely responsible for the pollution causing climate change to invest in these efforts. This, too, could be a mechanism through which industrialized nations provide support during times of economic and climate catastrophe as a catalyst for HIV prevention.

Over the past two decades, I have observed historic advances made in HIV prevention, care and treatment firsthand. Antiretroviral pills can now be taken just once a day and pre-exposure prophylaxis, or PrEP, is increasingly available worldwide. Studies have shown that countries hardest hit by HIV in southern Africa are seeing major declines in new infections and improved viral suppression.

But our study suggests these hard-won gains are at risk, especially for women. Young, unmarried women will be left behind in the fight against HIV if we do not develop solutions that look at the bigger picture of global public health. 

As we watch nations around the world face unprecedented food shortages, brought on not only by climate disaster but rising conflict, we will see rising levels of disease forcing women to take greater and greater risks just to survive – unless the world acts now.

Andrea Low, MD, PhD, is an adjunct assistant professor of epidemiology at the Columbia Mailman School of Public Health. She previously worked as the Clinical and Scientific Director of the Population-based HIV Impact Assessment (PHIA) program at ICAP at Columbia University. Sara Hendery, communications officer at ICAP at Columbia University, contributed to this article.