RAFIU FISHBONE - HIV/AIDS and water supply, sanitation and hygiene

Men, women and children with HIV/AIDS infection are highly susceptible to other diseases. Most of these are related to poor water supply, sanitation and hygiene. Diarrhoeas and various types of skin diseases are common secondary (or 'opportunistic') infections. The risk of getting malaria is also greater, and is worsened by poor drainage creating extra mosquito breeding places in and around communities.

According to WHO estimates, HIV/AIDS killed over 3 million people in 2002, malaria over 1 million and TB 1.9 million. When infected people have better access to treatment and basic services and hygiene education, they can live longer and continue to help their family and nation. Unfortunately, 95% of those infected do not know about their being HIV positive and most do not want to get tested because of stigma and lack of access to treatment. People can stay healthy for a very long time if they ensure that they live a healthy life and treat illnesses immediately.

The period of latency on average lasts about 7-10 years, depending on the type of HIV, access to health and reproductive health services, poverty and other issues (if people do not know they are infected they can easily get reinfected and then their immune system breaks down faster). In Uganda, for example, the Medical Research Council reported a post-infection life expectancy of 10 years, against an average of 13 years in the countries of the North. Out of these ten years, patients suffered from various illnesses for nearly eight years (Kayizzi, 2001). 

 During their years of illness, AIDS patients are mainly cared for by relatives, friends and neighbours (home-based care). Easy access to a safe, reliable and sufficient water supply and basic sanitation in this stage is essential. For the caregivers, it greatly reduces the extra burdens which they already carry. For the patients, it means human dignity and basic access to personal hygiene. For example, over half of patients suffering from HIV/AIDS have chronic diarrhoea. Having a latrine nearby is then crucial. For mothers who are HIV positive, the risk of transmitting the virus through breast milk is 1:3. Irrespective of whether they can, or for various reasons cannot replace breastfeeding by bottle feeding, clean water is important for the babies' care. 

Within households, water is also needed for productive uses, to increase food security and maintain nutrition levels. This helps patients to stay healthy for a longer time and keeps the household's income from falling so rapidly and deeply. Access to a plot and water for staple crops, vegetables and fruit for home consumption and marketing are especially crucial for poor families.  

So far, the water and sanitation sector has paid little or no attention to the actual and future impacts of HIV/AIDS on the financial, social and economic feasibility and sustainability of water supply and sanitation systems. Due to the stigma associated with HIV/AIDS, few organisations have developed an internal HIV/AIDS policy and created an atmosphere of openness, prevention and coping. Such a policy would for example address mobility of staff, number of nights away in the field and postings away from families (Wegelin et al, 2003). Other measures would relate to information, health education, counselling, social security measures and support for treatment.

More robust water supplies, water treatment and sanitation systems requiring less (and less complex) maintenance and repairs, and more attention to home systems, including home treatment of drinking water, would make communities and households less dependent on outside support. Basic sanitation and enough water nearby for personal hygiene is crucial as 50% of patients suffer from chronic diarrhoea.

Where households have no safe water, or the supply is intermittent and breakdowns are long, SODIS, or solar disinfection of less safe water, is suitable for household use. A transparent container such as a plastic bottle is filled with water from a nearby source with a lower water quality and closed. The caretaker places the container in strong sunlight. This will kill most bacteria when the water is exposed for a period of 4-6 hours in full sunlight, or an entire day when the sky is overcast. The water is disinfected by UV rays, and in addition reaches a temperature of up to 50-60 degrees so it needs to cool down before use (http://www.sodis.ch/) (WHO, 2001) 

Although some material exists (FAO, 2002), health education is not yet addressing the chronic disease effects of HIV/AIDS infections. A case study in Limpopo province, South Africa, showed a lack of adjustment not only of water supply and sanitation services, but also of hygiene education. The participating focus groups of caregivers and people living with HIV/AIDS identified good food and exercise as important ways of staying healthy longer. There were, however, no concerted efforts from the departments of water, health, agriculture and the communities to address production around homes and/or waterpoints for better nutrition. Poor sanitation was another problem that was insufficiently addressed.

The households in the case study saw drinking river water as a potential risk for catching cholera, but there was little awareness of the importance of personal and domestic hygiene behaviour for the patients' health. The local health educators focused on the prevention of HIV/AIDS but did not address secondary diseases stemming from poor quality or inadequate water supply, hygiene and sanitation. (Kgalushi et al, 2003). 

Safe water, sanitation and hygiene are basic needs and human rights. They help those affected by HIV/AIDS to remain in good health for longer, facilitate care for ill patients and increase their dignity. Programmes and policy makers can give higher priority for water supply, sanitation and hygiene promotion to areas with a high incidence of the disease.

Hygiene education needs to be integrated in the training given to home care volunteers and their trainers in order to ensure safe water handling practices.

As most caregivers are women, their influence on planning and implementation of service provision is more necessary than ever. Because often very young and very old women take over much of the water and sanitation related tasks, both hygiene education and technology selection may have to be adapted to suit their requirements.

Community based approaches are known to enhance sustainability and use. They can at the same time function as an entrance to promote community–based prevention and mitigation activities. The principles are the same, the issue at hand more sensitive. It requires well-trained, motivated and non-stigmatising facilitators. Experience with participatory methods exists and can be built on. 

Water agencies are affected by the disease. This necessitates the development of policies and strategies within the agencies and for the sector. Agencies need an internal HIV/AIDS policy and strategy to mitigate impact on the agency and the development of a strategy to integrate HIV/AIDS in service provision.

In the sector, facilities are needed that require less frequent maintenance and repairs by outsiders and limited time and money from households to keep them going. Development of low-cost home treatment is an alternative.

A poverty alleviation framework can ensure that the socio-economic and equity aspects that play a role in water, sanitation and HIV/AIDS are addressed. As treatment becomes cheaper and more available, HIV becomes a chronic disease requiring a multi-pronged strategy for keeping those infected in good health and able to work. This includes more attention to personal hygiene and the means for hygiene preservation: access to adequate and safe water, good sanitation and hygiene education.