Coffee, Popcorn, Soup, and HIV
Chronic food insecurity and achieving strict adherence to antiretroviral therapy (ART) are global challenges that, together, have a deleterious effect on children and pregnant women living with HIV. In Ethiopia, where the child malnutrition rate is one of the highest in the world, side effects of treatment threaten to reduce adherence to drug regimens and contribute to the development of drug-resistant strains of HIV. This case study examines how the Breedlove Project integrates HIV programming (treatment and PMTCT) with nutrition programming to address short-term and long-term needs of families and households in Ethiopia.
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- Coffee Ceremony
- Soup Distribution
- Urban Gardening
- What Worked & Challenges
- Replication and Conclusion
Coffee, Popcorn, Soup, and HIV
By Kara Greenblott
Promoting Food and Nutrition Security for Children and Pregnant Women Living with HIV in Ethiopia
It is 11:00 a.m. at the antiretroviral therapy (ART) unit of Gandhi Hospital in Addis Ababa, Ethiopia. Women have been arriving slowly over the last two hours for their monthly coffee ceremony discussion. The reception area is transformed—condoms and pamphlets swept off the table to make way for a colorful tablecloth and a bowl of flowers. Popcorn is popping, coffee brewing, and the aromas of coffee, popcorn, and incense mingle in the air. Smiles appear on the women's faces as they enter the room and rekindle their monthly friendships.
The coffee ceremony, part of everyday life in Ethiopia, is a key component of the "Food Secure and HIV-Positive in Ethiopia" project managed by Project Concern International (PCI), a San Diego-based nongovernmental organization. The project—an example of integrated HIV and food and nutrition security (FNS) programming—combines distribution of highly nutritious soups, promotion of urban agriculture, and delivery of educational messages (via coffee ceremonies) on issues related to HIV and FNS. All of the women participating are either living with HIV and pregnant or lactating;(1) or, they are caring for children living with HIV who receive life-saving antiretroviral (ARV) drugs at the hospital.
As the coffee ceremony participants begin to seat themselves in a large circle, laughter erupts on the far side of the room. Two women share their story with the others.
One woman ran into her neighbor at the hospital this morning and the neighbor asked, "Oh, why are you here?" The first woman did not hesitate to reply that she was visiting a friend who was sick. When she asked her neighbor why she was at the hospital, the neighbor quickly gave the same response. Thirty minutes later, both women found themselves seated at the coffee ceremony. They laughed as they spotted each other from across the circle; one comments that now they will be real friends and not just neighbors! Their story became an ideal introduction to the group's discussion on stigma and the lies people tell, without hesitation, to their own neighbors and family members to avoid the shame and discrimination of living with HIV in Ethiopian society.
Over the next few hours, they drink coffee, listen, and discuss their experiences as a counselor leads them through the agenda. The program does not use a specific facilitator's curriculum, but the counselors from PCI and the hospitals have been trained and develop the topics themselves, setting topics in advance. The topics, as always, cover ART adherence, nutrition, and opportunities for producing food at home. Other topics are added based on current events and issues noticed along the way, as well as a variety of issues raised by the women themselves. Many women linger afterwards, building friendships and sharing stories about how they cope with the challenges of living with HIV.
The Breedlove Project: Integrating HIV and Food and Nutrition Security Programming
Food Secure and HIV-Positive in Ethiopia began in 2006 as a supplementary feeding intervention supported by a small, one-year grant to PCI from the U.S. Agency for International Development's (USAID) International Food Relief Partnership (IFRP). The women and hospital staff call the project "Breedlove," in reference to the lentil and potato blended soups (manufactured by Breedlove Foods Inc.) that are distributed to project participants. The grant has been re-awarded annually since 2006: IFRP provides the food and a cash budget to support administrative costs for distributing the soup, but very little for complementary programming.
Working closely with hospital staff, PCI designed the project to complement the PMTCT, ART, nutrition assessment, education, and counseling services that women and children living with HIV receive during hospital and health facility visits. As the project gathered momentum, PCI deliberately linked the soup distributions to its coffee ceremony and agriculture activities to ensure that nutrition supplementation does not stand alone. Thus, this linkage intentionally integrates HIV programming (ART and PMTCT) with FNS programming in a manner that addresses both short-term and long-term needs of these households.
More specifically, the project is comprised of three components: 1) Distribution of highly nutritious foods to address short-term nutritional needs; 2) Holding coffee ceremony discussions to provide emotional support and education around HIV and FNS; 3) Promoting urban agriculture, including vegetable gardening and poultry raising, to address longer-term nutritional needs. The project's overall aim is to reduce vulnerability to malnutrition and food insecurity among households affected by HIV.
Activities target two groups in Addis Ababa: 1) Pregnant or lactating women living with HIV who are heads of households and attending a PMTCT program in one of the 16 participating health facilities in Addis; 2) Parents and/or caregivers of children who are living with HIV, under the age of 12, and attending a pediatric ART program in one of the five participating hospitals in Addis.
Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
The Coffee Ceremony: Making Friends, Learning Survival Skills
The coffee ceremony is a central part of Ethiopian life and a sign, to those invited, of friendship and respect. In traditional village life, the coffee ceremony is the main social event in the village, a time to discuss current events, politics, and gossip about who did what with whom. It is impolite to retire until you have consumed at least three cups, as the third round is said to bestow a blessing. The Breedlove project's coffee ceremonies build on this tradition of friendship and information-sharing to deliver and reassert a variety of messages related to HIV and FNS.(2)
The idea for the coffee ceremony emerged at the beginning of the project, when staff were delivering the lentil and potato soups to participating health facilities. It became clear that women needed a place to discuss concerns about their HIV status and the status of their children. PCI had used the coffee ceremony successfully in other programs to discuss difficult social issues and saw the ceremony as a platform for advancing nutrition education goals of the Breedlove project.
Twenty to thirty women normally attend the monthly coffee ceremonies (while men are also invited—being caretakers of orphans and vulnerable children—few attend). Every ceremony routinely includes discussions on health, FNS, and their relationship to HIV and AIDS. As with other PCI programs, the familiar setting and ritual of coffee-drinking encourages participants to relax and talk openly about HIV, sex, illness, domestic abuse, rape, birth control, and other taboo topics that are normally difficult to discuss in this extremely traditional society. Given the traditional three-cup minimum, the ceremony provides enough time to delve into a wide array of issues; some ceremonies last up to two or three hours.
Session topics are planned in advance. There are usually four or five, and some are selected by the participants themselves to ensure relevance and a sense of ownership. The facilitators, trained by PCI, keep discussions focused. Often, facilitators launch a topic with the delivery of several key messages. They keep messages clear and succinct, and deliver them slowly and repeatedly, giving women of different education levels time to absorb the concepts. Sometimes, the ceremony will include a guest speaker; alternatively, the facilitator will invite some of the women from within the group to speak about their own experiences.
Breedlove Soup Distribution: Supplementing Daily Food Intake
PCI addresses the short-term nutritional needs of HIV-affected households by distributing two fortified, dehydrated soups: the Lentil Blend and the Harvest Pro Vegetable Blend, both containing vegetables, fortified vegetable protein, and spices. The soup is not meant to provide a complete diet, but to supplement a person's existing intake and, importantly, to facilitate improved retention of women receiving PMTCT services and improved adherence for children enrolled in ART. Pregnant women living with HIV receive two kilograms per month and the children receive one kilogram.
PCI implements the Breedlove project in partnership with the Ethiopian Federal HIV/AIDS Prevention & Control Office (F-HAPCO) and Addis Ababa HIV/AIDS Prevention & Control Office (AA-HAPCO). The hospitals and locations that receive the commodity were selected jointly by AA-HAPCO and PCI on the basis of the number of beneficiaries and the facility's ability to keep records and produce reports.
The method of soup distribution depends on the type of recipient. For children living with HIV receiving pediatric ART services, PCI delivers the commodity directly to the hospital staff at the five city hospitals. Mothers or caregivers receive the soup when they bring the child for monthly checkups. During the same visit, either the counselor or home-based care volunteer briefs the caregiver on PCI's urban agriculture program and if they are interested, puts them in contact with the urban agricultural promotion officer. This initiates the transition from short-term assistance (the soup) to more sustainable FNS programming.
"Before the Breedlove support there were beneficiaries who discontinued the ART and PMTCT follow-up but after they heard about the food support they returned. Because of the food support, others who joined after the Breedlove support are also following the PMTCT regularly without dropout. In addition to this I have also observed some dropout when it was discontinued for some time at the end of the first phase."
–Zewditu Ambaw, Nurse at PMTCT Section of Kality Health Center
For mothers living with HIV attending PMTCT services, the system is slightly different. PCI stores and distributes the soup through AA-HAPCO and the World Food Programme (WFP), making use of their significantly larger food distribution systems. To increase efficiency, PCI delivers the commodities to AA-HAPCO's main warehouse. From there, WFP staff delivers them, along with their own commodities, to 10 subcity stores. Women receiving PMTCT services are scheduled one day each month to pick up the food. While the women are gathered, the storekeepers explain the ingredients of the soup blends, describe various cooking methods—the blends can be prepared as a soup or a main dish—and conduct a cooking demonstration. They also solicit interest in PCI's urban agriculture program.
In the 2009 review of Breedlove distributions conducted at Alert Hospital in Addis, Breedlove participants overwhelmingly found the soup tasty and easy to prepare. While most serve it as soup, some separate out the lentils and prepare them as wot (a spicy stew), then mix the rest of the contents with rice. Others said it was delicious when used with meat. Some of the pregnant women commented that they cannot eat many things during their pregnancies, but the soup is a great meal for them as it tastes good and they can keep it down.
A total of 2,441 children (1,193 boys and 1,248 girls) on ART and 1,915 mothers enrolled in the PMTCT program directly benefited from Breedlove supplementary soup in 2009. The total amount of commodity distributed equaled 74,998 kilograms (PCI 2009).
"Some of the women call it Almi—the nutritious food. We provide both the WFP and Breedlove foods at this warehouse and what I hear from the women is that they prefer cash instead of food for some of the food items, but with the Breedlove and oil they want the food itself."
–Ato Zeru Desale, Storekeeper at Bole Subcity Warehouse
Urban Gardening and Poultry: Sustaining Good Nutrition
PCI staff and the Breedlove participants acknowledge that while food assistance is an important short-term remedy, it is not sustainable in the long-term. Hence the value of the Breedlove project's urban gardening and poultry component, which teaches women to meet their nutritional needs by producing their own food at home. Participants in the urban agriculture program describe the benefits they have reaped: improved access to fresh, nutritious vegetables, eggs, and meat for the entire family; a source of income for those who choose to produce more than they consume; and the therapeutic value of tending the garden and chickens and of watching them grow and produce over time.
The urban garden training is conducted in groups of between 10 and 30 people over the course of one or two days. Most participants already have a basic knowledge of gardening, so the course is meant to strengthen their skills. The training covers such topics as preparing plots, improving the soil, handling seedlings, spacing plants, and intercropping with legumes. Participants also learn about organic pest control—creating a spray from the dodinam plant to control aphids—and making compost from chicken waste, ash, and vegetable scraps. Importantly, the curriculum also includes a nutrition component that reviews the benefits (i.e., vitamins and minerals) of fresh vegetables and their importance in fighting disease. The training stresses cooking vegetables lightly to kill germs, but cautions participants against overcooking, which reduces the nutritional value.
Participants choose one of two options: direct soil gardening or container gardening (using plastic bags, pails, metal drums, and similar containers). They are offered a wide variety of seeds to get started, including kale, Swiss chard, lettuce, cabbage, tomato, green pepper, carrot, and beet. They also receive farming tools: a pick axe, a hoe, and a watering can; those without their own land also receive containers.
The poultry production training likewise takes one to two days. Instruction covers basic poultry care, feeding, and disease management. Each participant receives two roosters, six laying hens, 50 kilograms of feed, and a cage.
To date, more than 200 people have received training, seeds, and tools for home gardening, and about 60 received training and supplies for poultry production. Several participants have produced excess food and specialty crops, such as herbs, which brings in regular income (though this production has not been quantified yet). The vast majority of the participants in the urban agriculture program are mothers or caregivers of children on ART. However, PCI is trying to increase recruitment of women in the PMTCT program as well.
What Worked Well
Food as an entry point for integrated programming: Linking monthly health care visits to food distribution is an effective strategy for ensuring optimal uptake and retention of HIV and FNS services (i.e., ART, PMTCT, nutrition assessment and counseling, coffee ceremonies, and urban agriculture). A strong referral network between each of the activities described above, along with intentional discussions about the benefits of each of these services during food distributions, is key to ensuring that they are tangibly integrated, and not just connected on paper.
Partnerships for effective programming and cost savings: Partnering with F-HAPCO, AA-HAPCO, WFP, and the health facility staff has been programmatically effective as well as cost-effective. F-HAPCO ensures that the commodity is imported duty-free; AA-HAPCO and WFP manage the bulk of distributions; and health facility staff handle nutrition counseling and education, with technical support and training provided by PCI.
Women speaking to women: When the health staff and PCI team speak at coffee ceremonies, the women listen. But when one of the women participants stands up and tells her story, they really listen. They are engaged and extremely supportive of one another. They often comment on how much they learn from each other's experiences; they remember the stories and the messages that are integrated within them. For this reason, the facilitators frequently invite and encourage the participants to stand and share their experiences on given topics. Some participants have even become PCI peer educators.
Careful timing: PCI learned through trial and error that the timing of ceremonies is critical. Given the frequency of holidays and social events in this culture, and the two- to three-hour duration of a typical ceremony, the date and time need to be carefully selected for optimal turnout.
Skilled facilitation: Facilitation also needs to be effective to guarantee attendance. When certain members dominate the session, other participants are discouraged and may not return. A strong facilitator is therefore crucial to managing the discussion and ensuring that it remains fruitful, inclusive, and relevant to participants' lives.
Reaching families and neighbors: The coffee ceremony is an effective means of reaching the participants' families and neighbors. Participants often share with their family what happens in the coffee ceremony, so the entire family can benefit. Because of the links to the urban agriculture activities, family members often get involved in gardening and poultry production. Some participants have noted that their neighbors will sometimes inquire once they see their success with gardens and chickens. They then use the opportunity to share their new knowledge about nutrition and dietary diversity, sometimes even sharing the information at coffee ceremonies held within their communities.
Using urban agriculture to support durable changes to dietary decision making: As stated in the next section on challenges, dietary recommendations made during coffee ceremonies are often difficult for the participants to implement because of their limited financial means, especially once they graduate from supplementary food support. The gardening and poultry programs facilitate more sustainable dietary changes, though to be effective, the programs would need to be expanded to reach all interested participants. In the 2009 review, participants asked that the urban garden and poultry program be expanded and strengthened so that they could maintain a diverse and healthy diet when the Breedlove project ends. Finally, several participants have been able to produce excess food and specialty crops (such as herbs) that bring in regular income. This income can also enhance participants' ability to purchase items they need to provide healthy, balanced meals.
Widespread poverty: Women participating in the coffee ceremonies said that while they now understand the need for nutritional diversity, they often cannot afford the variety of foods recommended. Vegetables, fruits, milk, and other suggested foods are more expensive than the ingredients for injera (the traditional grain-based bread), so they frequently default to foods they know and can afford. This demonstrates that while behavior change can result from acquiring new knowledge, the change must also be economically accessible.
Long distances: For many clients, traveling to one of the five central hospitals to receive treatment can be inordinately time-consuming and expensive. Hospitals are currently trying to refer them to health centers that are closer to home, but because they fear stigma and discrimination, beneficiaries often prefer to travel long distances so that they will not see neighbors and friends. Participants often cite travel costs as a reason for missing appointments.
Lack of support for monitoring and evaluation (M&E): The limited budget attached to the soup distribution makes it difficult to establish a comprehensive M&E system. A quarterly review meeting takes place, and informal interviews with beneficiaries are held sporadically by M&E staff from other PCI programs (who are "borrowed" by the Breedlove project). Unfortunately, formal monitoring against indicators for the objectives of each project component is not done in a systemic or comprehensive manner. In particular, the project does not review the attendance records of women receiving PMTCT or children's adherence to ART, and so cannot empirically assess whether these adherence objectives have been met. Instead, there is heavy reliance on anecdotal evidence. The project recognizes the need to improve its M&E system and is working to do so.
Overburdened health care staff: Distributing the Breedlove soup became an additional task for already stretched health workers at the distribution sites. The scarcity of qualified health professionals is a systemic problem throughout the country. Those handling the Breedlove commodity complain of being overworked and underpaid. The implications are insufficient communication about the commodity and the intention that it be consumed only by the targeted recipient (the pregnant/lactating mother or child living with HIV). Similarly, the urban agriculture program is not as thoroughly promoted during distributions as it could be.
Ration dilution via intrahousehold sharing: The most common complaint from participants is that the soup ration is not large enough, and that they often exhaust their monthly supply in two weeks or less. Two factors contribute to this problem. First, the soup is intended as a supplementary ration, and not as general ration—the soups are not intended to serve as the main source of nourishment. Second, the commodity and ration size were designed for individual use, but intrahousehold sharing is very common. In many cases, the purpose of the soup ration is not well understood. But even where the principles are understood, participants explain that it is difficult to prioritize one family member when the whole family is hungry. This dilemma is common where household food insecurity is endemic.
Stigma and discrimination: Stigma and discrimination remain significant problems in Ethiopia. In fact, many women who were photographed for this case study did not want their identities known for fear of discrimination within their communities. Stigma affects various aspects of the Breedlove project: women do not want PCI staff visiting them in their homes (to provide technical support or monitoring, for example) for fear that neighbors will suspect their status. Many women intentionally attend health clinics that are far from their homes where they will not see neighbors or be visited by health staff. Stigma exists not only at the societal level, but also within households. Women in coffee ceremonies frequently note that they do not tell their husbands that they are bringing the children for treatment or that they are attending coffee ceremonies at the hospital. Many say that their husbands left them once they discovered their HIV status.
Replicating and Implementing at Scale
The integrated Breedlove project could be replicated in other cultures or contexts, in both urban and rural settings. Implementing at scale would require a significant resource investment at the health facility level, as well as a revision of the urban agriculture strategy. Several enabling factors will help to make it successful:
- The existence of a tradition (like the coffee ceremony) that facilitates social interaction, bonding, and trust.
- A history of working closely with hospital and health facility staff, including familiarity with their systems and constraints.
- Referral networks between components to ensure integrated programming.
- Clarity among beneficiaries that the project is temporary, and that urban agriculture (or other livelihoods programming) can help replace the benefits currently provided through food assistance.
- Home-based care staff or counselors with strong facilitation skills or the ability to learn them.
- Strong willingness on the part of government to collaborate on each of the three components.
- Access to land (or space for containers) and water to plant vegetables and raise chickens.
In addition, there are some considerations for implementing at scale:
- To truly operate at scale, the project would have to focus on expanding and strengthening programming at the health facility level. Coffee ceremonies would need to be conducted both at the hospitals and health care facilities, and promotion of urban agriculture would need to be expanded to the health care facility level as well.
- The urban agriculture program is currently unable to keep up with demand, even though its promotion during the food distributions is limited. The program was originally established to serve participants from PCI's Better Education and Life Opportunities for Vulnerable Children through Networking and Organizational Growth (BELONG)(3) program, a USAID- and U.S. President's Emergency Fund for AIDS Relieffunded program for orphans and vulnerable children, and in 2007 began serving participants from Breedlove as well. To operate at scale, the project would need to consider using a larger infrastructure for training and support. Partnership with the Ministry of Agriculture and use of government extension workers may be one option for enhancing the project's ability to expand and better serve participants at the health facility level.
- With more support to hospital staff, coffee ceremonies could be absorbed into hospital and health facility portfolios of activities (i.e., become their responsibility). The ceremonies are not inordinately expensive; they are very cost-effective, and staff already recognize their value.
- In addition to urban agriculture skills, an option for small business training would make the project more attractive and feasible for a wider range of individuals. Not everyone is suited for (or interested in) gardening and poultry production.
- The referral network between hospital and health facility staff and facilitators for urban agriculture and coffee ceremonies needs to be strengthened. Currently, not all beneficiaries of the Breedlove project are aware of, or have access to, all three services. In some cases, participants at food distributions express interest in the urban agriculture program, but when the promotion officer goes to enroll that person in the program, they cannot locate the person. A formal referral system would improve these problematic linkages.
- The establishment of a formal M&E system would be critical in the event of scale-up and even for moderate expansion. Developing and pilot testing indicators to monitor the progress and success of each component would improve the project's prospects for further funding and expansion, and ensure that it is indeed achieving some of its key objectives (e.g., improved adherence and retention).
Short-term nutritional support has a critical role to play in efforts to improve outcomes of women in PMTCT programs and children on ART. But while providing nutritious foods to PMTCT participants helps offset barriers to retention and helps pediatric ART participants adhere to their drug regimen, it does not address ongoing and long-term household food and nutrition insecurity, which is extremely common among HIV-affected families.
A larger strategy to address food, nutrition, and livelihood insecurity is frequently ignored, leaving these women, their infants, and their families without means to sustain their nutritional status once they graduate from food-supported PMTCT and ART programming.
PCI's Breedlove project is an example of integrated HIV and FNS programming that intentionally links food assistance with activities to address participants' long-term FNS needs. Breedlove soup, the coffee ceremonies, and urban gardening and poultry production combine to offer participants not only an improved quality of life today, but better opportunities for tomorrow. The hope is that the project detailed here, and the lessons that emerged through the development of this case study, will encourage agencies in other countries to experiment with applying the model and exploring the benefits of integrating HIV and FNS programming in their own contexts.
Addis Ababa HIV/AIDS Prevention & Control Office. 2010. AA-HAPCO Website. Available at http://aahapco.org/ (accessed August 2010)
Banteyerga, H. 2007. "System Wide Effects of the Global Fund with Respect to ART Scale-up: Evidence from Ethiopia." PowerPoint presentation given at Health Systems 2020 conference, November 22, Dublin, Ireland.
Central Statistical Agency (Ethiopia) and ORC Macro. 2006. Ethiopia Demographic and Health Survey 2005. Addis Ababa, Ethiopia, and Calverton, MD: Central Statistical Agency and ORC Macro. Available at http://www.measuredhs.com/pubs/pdf/FR179/FR179.pdf (accessed August 2010)
Ethiopian Health and Nutrition Research Institute. 2010. Nutrition Baseline Survey Report for the National Nutrition Program of Ethiopia. Addis Ababa: Ethiopian Health and Nutrition Research Institute.
Federal-HIV/AIDS Prevention & Control Office, Ethiopia. 2010. Report on Progress Towards Implementation of the UN Declaration of Commitment on HIV/AIDS. Available at http://www.unaids.org/en/dataanalysis/monitoringcountryprogress/2010progressreportssubmittedbycountries/ethiopia_2010_country_progress_report_en.pdf (accessed September 2010)
PCI. 2009. Single Year Assistance Plan. Final Results Report to USAID, Fiscal Year 2009.
UNICEF. 2007. UNICEF Website. Available at http://www.unicef.org/aids/index_preventionMTCT.html (accessed September 2010)
This case study was written by Kara Greenblott, with technical input and editing by Kate Greenaway (both of Nzinga International). Field research was conducted on site in Addis Ababa by Rachel Roseberry and Wasihun Eshetu. Specials thanks to Colette Bottini (Technical Advisor, OVC, Office of HIV/AIDS, USAID), Gretchen Bachman (Senior Technical Advisor, PEPFAR OVC Technical Working Group Co-chair, Office of HIV/AIDS, USAID), and the staff at USAID/Ethiopia for their support for the development of this case study.
The authors are grateful to Wasihun Eshetu, Walleligne Beriye, Goshu Seifu, Adisalem Tefaye, and Gwenelyn O'Donnell-Blake of PCI, who generously gave their time and reflections to the development of this case study. And finally, special thanks go to the women, men, and children who participate in PCI's project, and who graciously agreed to share their experiences so that lessons could be disseminated to a wider audience.
Greenblott, Kara. 2011. Coffee, Popcorn, Soup, and HIV: Promoting Food and Nutrition Security for Children and Pregnant Women Living with HIV in Ethiopia. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.