Poverty, landlessness exacerbating impact of HIV

More than 60 percent of Rwanda's eight million people get by on less than a dollar a day, but grinding poverty is an even greater threat to HIV-positive people.

Rwanda, one of the world's poorest countries and the most populous in central Africa, has an estimated 340 people per square kilometre. The land is also very unequally divided, with the majority having tiny plots or none at all to cultivate.

"Families that have to look after AIDS orphans have nowhere to grow food and nowhere to find money for their medical treatment. I am looking after my daughter's children but have no money for school fees and, sometimes, even for food," said Annette Nyiraneza, an elderly widow in the capital, Kigali.

According to the United Nations Children's Fund (Unicef), more than 800,000 Rwandan children have been orphaned by AIDS and the 1994 genocide that killed nearly a million people. Most of these children are being raised by relatives who are actually too poor to look after their immediate families. The result is thousands of households headed by children, who are often forced to perform sexual favours to feed their families, making them even more vulnerable to HIV.

Nyiraneza said her daughter used to help cultivate the family's tiny plot but fell ill, and she is too old and weak to work, so she and her grandchildren depend on handouts from nongovernmental agencies.

"When giving antiretroviral [ARV] drugs to HIV-positive people, especially in the rural areas, we try to give nutritional support as part of the package," said Shakilla Umutoni, executive secretary of Reseau Rwandais des Personnes Vivant avec le VIH/SIDA, an umbrella body for 800-plus organisations for people living with the virus. "One cannot expect people who cannot afford to buy food to adhere to their drugs [regimens]."

Umutoni, whose organisation is supported by the Global Fund for AIDS, Tuberculosis and Malaria, the US Agency for International Development and the British government's Department for International Development, said providing nutritional support was difficult.

"We have to ensure the whole family is well fed, because if they are not, they may all have to share the small portion of the HIV-positive person, or they could become malnourished and fail to look after their sick relative," she explained.

Persuading people to spend their money on medication rather than food was a constant challenge. "It is necessary to improve the quality of life of these people, so that they have the basic needs such as food, after which they can be taught the importance of taking their medicines in the correct dosage," she said.

The Rwandan government provides free antiretroviral drugs, but the health centres are often too far away - Unicef estimates that 88 percent of women have to walk for more than an hour to reach a health facility, an impossible journey for people with immune systems compromised by illness or malnutrition.

"Providing HIV services to people in Rwanda goes beyond giving people ARVs," Umutoni said. "They need food, they need education and sensitisation, and also need home care and follow-up."