40 CHAPTER 3
lems were also identified, one of which was stigma, because the program potentially rendered visible this singled-out group, although stigma was reported to have reduced over time. Many beneficiaries were keeping the food collection a secret from family and friends because of fear of revealing their HIV-positive status and facing discrimination. One problem was the vis- ibility of the food distribution points and the gossip that occurred as a result. Another was the fact that some food packets were labeled with AIDS aware- ness messages, something that beneficiaries requested be changed (Byron, Gillespie, and Nangami 2006). These findings have two potentially contradictory implications for target- ing. On the one hand, they demonstrate the importance of these food transfers for ART patients. On the other hand, they illustrate the stigma problem and raise the equity question—how can this group alone receive food if their HIV- negative neighbors are also hungry? The answer is that the lives of symptomatic people may depend on these transfers. Given the importance of adequate nutrition for people on ART, it is difficult to argue against programs providing them with food assistance, equity and stigma considerations notwithstanding. Schubert et al. (2007), in arguing for poverty targeting rather than AIDS-specific targeting of cash transfers, suggest a possible exception for people on ART. Although cash assistance for those on ART should also be explored, it may be that food transfers play a better role here, particularly because the money must be spent on food for it to be effective, and food can be fortified with micronutrients, whereas food purchased in the market is less likely to be. This might be akin to an emergency assistance program, in which it is less likely that cash transfers would be used when people were at immediate risk of starva- tion.8 Still, in light of equity and stigma concerns, targeting cash and food transfers only to those on ARVs might be difficult to sustain in the long run (despite the fact that cash can be better hidden than food, and family and neighbors are likely to learn about their neighbors’ regular new cash infusions). Furthermore, a poverty-targeted program could improve the nutrition of HIV- positive people who are asymptomatic, possibly delaying their need for ARVs.9
being. Problems included stigma, costs of transportation to distribution points, seasonal vul- nerability to food insecurity, and transitions off the supplement (Byron, Gillespie, and Nangami
2006). 8At the other end of the spectrum, food transfers are sometimes used in conjunction with liveli- hoods activities implemented by NGOs and CBOs where AIDS-affected households may or may not be able to take advantage of them. As noted earlier, these tend to be smaller in scale and found in pockets. These should not be at odds with cash transfer programs, although until cash transfers are operating at a large scale, the interventions should probably be coordinated so
that some areas do not have multiple interventions while others have none. 9Current research is also looking into whether better nutritional status for asymptomatic HIV- positive individuals may delay the need to start ARVs (Byron, Gillespie, and Nangami 2006, 2).
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