(September 2010) The relationship between HIV/AIDS and the natural environment is complex and operates at many levels in countless ways. HIV/AIDS morbidity and mortality may affect people's use of natural resources and the institutions that govern resources, while environmental change may affect people living with HIV/AIDS and increase susceptibility to illness and even HIV infection among certain groups, especially women and girls. Recognizing the associations between HIV/AIDS and the natural environment can contribute to the well-being of both humans and the environment, and the achievement of the Millennium Development Goals.

How does HIV/AIDS exacerbate vulnerability to food security and thus result in exploitation of natural resources? What is the impact of HIV/AIDS on conservation efforts and how does the epidemic affect land and resource ownership? How do scarce resources and conservation initiatives influence migration and vulnerability to HIV/AIDS? A growing number of research studies and health and conservation programs are examining these relationships, and their results may surprise you.

During a PRB Discuss Online, Lori Hunter, associate professor of sociology and environmental studies at the University of Colorado, Boulder; Ben Piper, director of research and programs for the University of Washington at KEMRI in Kenya; and Jason Bremner, program director of Population, Health, and Environment at Population Reference Bureau, answered participants' questions about what is being done to address HIV/AIDS and the environment. This Discuss Online session was sponsored by the BRIDGE project, a cooperative agreement between USAID's Global Health Bureau and PRB.

Sept. 20, 2010 1:00 PM EST 

Transcript of Questions and Answers

Jeanne Humble: What role do male and female circumcision practices play in the transmission of HIV/AIDS? Why has the rate of HIV/AIDS increased significantly in southern Africa when previously it was higher in Sub-Sahara Africa?
Lori Hunter: On the role of circumcision, this is outside of my expertise but certainly there is a tremendous amount of good scholarship on the topic. Although not yet in the peer-reviewed scientific literature, a colleague of mine that also works in the Agincourt field site in rural South Africa has been working on microsimulations with regard to this topic: http://www.csss.washington.edu/Papers/wp85.pdf. On the issue of significant increases in AIDS in southern Africa, again this is beyond the scope of my own focus on the environment but I believe it's critically important to examine the socio-political factors that have shaped the pandemic broadly. Specifically, it would be useful to consider the timing and type of governmental response to the pandemic across nations as related to the pandemic's trajectory.

Dr. Anima Sharma: Dear All, It is true that even after so many attempts done by several agencies and so much information floating about HIV/AIDS, many aspects about it are still shrouded under mystery. For instance, the contribution of natural environment is limited to keeping the people healthy. A healthy person is lesser likely to be affected and even if affected it would not be very severe. I am looking forward to read more about it.
Lori Hunter: I agree that there's not sufficient attention paid to this important connection—and hopefully this online discussion will help spread the word!

Dr. Theresa C. Smith: Are immunodeficiency viruses global among mammals? Does HIV have analogs in many other species besides HIV and SIV, e.g. why is feline IV now an extremely common cat illness? Is the appearance of IV viruses part of the evolution of microorganisms in their own ecological niche, a result of climate change, increased solar radiation, or is their origin unknown? Will there be other devastating, species-jumping rapid mutators, and if so, what is a reasonable protective strategy for the human population?
Lori Hunter: Thank you for this interesting question but a reliable answer requires someone with a background in the medical aspects of IVs—I study the social dimensions.

Dr.sanjeev Badiger: As we know the impact of HIV/AIDS on environment is not immediate, but it may take several decades. Please give an example of such an impact in the past. Thank you
Lori Hunter: In the study site where I work, the Agincourt Health and Population Unit operated by the School of Public Health, University of Witwatersrand, my colleagues and I have documented reliance on fuel wood and local wild foods among mortality-impacted households. Such intensified resource use yields immediate impacts. Even so, we are only now beginning to collect ecological data to measure shifts in longer-term environmental processes. If you are interested in reading some of our results from the Agincourt field site, please see:
* Lori M. Hunter, Wayne Twine, and Laura Patterson. 2007. "Locusts Are Now Our Beef": Adult Mortality and Household Dietary Use of Local Environmental Resources.” Scandinavian Journal of Public Health. Vol. 25 (Suppl. 69)165-174.
* working papers under review and forthcoming: http://www.colorado.edu/ibs/pubs/pop/pop2009-0016.pdf  

Jordan Rosenblat: What can we do to engage more and more people being aware of AIDS and also how to tell people of all ages how to prevent and stop being HIV positive?
Ben Piper: For many countries education and awareness campaigns are a key component to lowering HIV transmission rates. Thailand was able to reduce their rates of infection from 44% in some populations down to an overall rate of 1.4% in 2007. A large part of this success was due to good political backing and advocacy under the leadership of Mechai. However the declining HIV rates of the 1990s have brought about a younger generation in the 2000s that are not as aware of the risks. Decreased funding rates have also made the HIV education campaigns a lower priority. As with environmental movements, the key in the HIV field is to have champions to lead the efforts and make people aware. Mechai was a huge part of the success that led to the decline in HIV rates in Thailand. http://www.avert.org/thailand-aids-hiv.htm  

Jordan Rosenblat: What gender has an significantly greater chance of becoming HIV positive and how do we reach out to that gender to explain to them how to prevent them from getting AIDS?
Ben Piper: Women are often more at risk. http://www.unaids.org/en/PolicyAndPractice/KeyPopulations/WomenGirls/default.asp. There are some recent advances in allowing women to better protect themselves. At the July 2010 International AIDS conference in Vienna, an announcement was made of the improved effectiveness of a vaginal microbicide gel, however much more research and work needs to be done. Like many interventions, it will not be a 'silver bullet' solution. Education and research are paramount for lowering HIV transmission rates.

Chandra Mani Acharya: How can HIV/AIDS spread in the natural environment? In my opinion there is no relationship between HIV/AIDS and Natural Environment but Social environment can help for spreading the HIV/AIDS.
Ben Piper: Droughts, floods, crop failures, desertification, forced eviction from conservation areas are among the many factors that contribute to environmental migration. Migration often results in the break down of social controls. This can lead to behaviors that facilitate the spread of HIV. Thanks goes to Susan Bolton for helping to answer many of these questions!
Lori Hunter: Hello Chandra. The concern here is not the spread of HIV/AIDS *to* the natural environment, but the relationship between HIV/AIDS and the ways in which households make use of local environmental resources. Still, I believe there's a connection between the natural and social environments in that, resource scarcity (change in the natural environment) can alter the ways in which people relate (change in the social environment) through, for example, willingness to engage in risky transactional sexual behavior.

Lynne Gaffikin: Please discuss in more detail what specific aspects of environmental change you feel may affect people living with HIV/AIDS, i.e., how does land degradation and/or ecosystem change directly versus indirectly affect people's health, especially those living with HIV/AIDS. Please also discuss how environmental conservation could contribute to improved well-being/health among people, including those living with HIV/AIDs. Thank you
Ben Piper: Direct effects are malnutrition and undernutrion. There is evidence that Antiretroviral treatments are less effective if the patient is under or mal nourished. Climate changes or variations that lead to drought or floods can destroy crops and even land productivity. The history of desertifaction has forced many people to migrate away from their native lands and culture. This social disruption often predisposes individuals to behaviors that facilitate the spread of HIV. All humans depend on ecosystem services (clean air, clean water, productive soil, flood control, etc.,) for their health and well-being. Poor people live even closer to this relationship as they are more directly dependendt on the natural environment for food, fuel, and shelter. Poor people with HIV may be especially vulnerable as they may be too weak to undertake regular heavy labor required for farming. The health community often views the use of nutrient rich 'bush' foods as a great source of protein and vitamins for people with HIV, but conservationists recognize the potential for destruction of biodiversity and healthy ecosystem services if the environment is unsustainably used. The data are lacking for a solid understanding of how much of thes types of HIV/Environment links are due to the disease and how much to poverty itself. Thanks again to Susan Bolton for answering this question.
Lori Hunter: Thanks for the great question Lynne. Shifts in precipitation and temperature regimes will alter the local environments on which many rural households depend. Particularly in areas where households rely heavily on local wild foods, clearly we can anticipate dietary impacts. This can impact HIV+ individuals through nutritional declines. Scarcity of local natural resources might also increase the likelihood of individuals engaging in risky transactional sex in order to meet daily needs—thereby increasing the potential for HIV transmission. Environmental conservation could improve the health and well-being of local residents in a variety of ways--in a broad sense, through enhanced assurance of the availability of local natural resources on which households depend. In a way, securing access to natural resources is insurance that rural livelihoods can remain diverse and, therefore, resilient.

Sunil Acharya: In rural areas of many developing countries where livelihood largely depends on subsistence agriculture, it is frequently debated that HIV/AIDS may threaten food security,livelihood and development that also impacts natural environment in several ways. For example:
- Increased economic burden due to time lost on care and support of the infected by other household members,
- Increased burden to women household members
- AIDS related deaths leading to loss of skilled human resources,
- Decrease in productivity leading to weak food security, food stability, and increase in the prevalence of malnutrition and disease
The situations discussed above are believed to have negative impact on natural environment as well. Do we have evidence from countries that may shed some light on these issues?
Lori Hunter: Sunil, you've nicely outlined so many of the different pathways through which impacts emerge. Yes, we have evidence of some of these, even within my own work in rural South Africa. An advanced graduate student of mine here at CU-Boulder, John Reid-Hresko, just returned from both South Africa and Tanzania where he is studying AIDS impacts on the conservation sector. He has important findings on the various pathways of impacts (as you note, lost human capital, for example) —stay tuned for results! Available now, Nancy Gelman (Africa Biodiversity Collaborative Group) and Judy Oglethorpe (WWF) have written on these topics—this overview will take you to some links for more information: http://www.bushmeat.org/node/51. On food security, this is the core of some of my own research in rural South Africa. Yes, we have found increased experience of hunger, as well as greater reliance on wild foods, among mortality-impacted households. Still, we've not extended the analyses to examine the physiological impacts of these dietary shifts. A study is in the field now collecting anthropometric data that will allow for examination of these important connections. More information here, can send PDF:
Lori M. Hunter, Wayne Twine, and Laura Patterson. 2007. "Locusts Are Now Our Beef": Adult Mortality and Household Dietary Use of Local Environmental Resources.” Scandinavian Journal of Public Health. Vol. 25 (Suppl. 69)165-174.

roger-Mark De Souza: This is an interesting relationship. Could you tell us what the policy and program implications are of the relationship between HIV/AIDS and the natural environment—particularly at different scales (i.e., local, regional, national, etc.)—and which measures provide opportunities to address these relationships in the short term? Thank you!
Ben Piper: Geographical scale is a critical issue to consider when making policy and program decisions. It also depends on what aspect of HIV/AIDS and/or environment your policy of program intends to impact. HIV prevention? AIDS care? HAART adherence? Urban sanitation environment? Natural resource management? Maintaining biodiversity? In your neighborhood, county, country, hotspot, watershed, community forest? The measures to be used in monitoring and evaluation depend on what the intended impact is. HIV transmission rates are a good basis for comparison both in terms of progress made, but also to be used against other regions or country levels. Different geographical areas might have differing HIV rates depending on a number of factors including income levels, education levels, migration patterns, amount of vulnerable populations such as refugees. Short term measures are even more difficult to measure. One area that has been identified as critical in the HIV field is HIV testing. Most communities depend on people to voluntarily go to a clinic to get tested, but often the people most in need of testing (at risk men) do not go for testing. There is a growing movement to promote community or home based testing and counseling (HTC). Testing rates are a good way to measure the amount of progress that has been made in a community, county, or country.

Geoff Dabelko: Given what we know about the HIV and environment relationship, what would you flag as the key research findings policymakers need to pay more attention to? Does this new research warrant changes in policy? Likewise, are there lessons for the practitioner in the field who should adjust ground levels programs to take account of new research findings?
Lori Hunter: Thanks for the practical question Geoff! In my opinion, a very simple finding is key—that is, simply the fact that there are important associations between HIV/AIDS and the environmental aspects of rural livelihoods. There's a lot of nuance that can be added to that simple finding (more on context, pathways, etc), but for the purposes of policies and programs, this big picture suggests something important: that integration is key. Educating on the importance of HIV prevention is certainly important—just as environmental conservation initiatives are certainly important—but when individuals are faced with difficult choices in the very short term (harvest the last tree for fuelwood? engage in risky sex to put food on the table?), lessons from single sector initiatives will be lost. Key is merging conservation, health, and livelihood initiatives such that the all aspects of livelihoods are covered and that decisions don't risk the health of either rural residents or their local environments.
Ben Piper: The University of Washington, IUCN and IPPF recently released the following report: Bolton S. and Talman A. (2010): Interactions between HIV/AIDS and the Environment: A Review of the Evidence and Recommendations for Next Steps; IUCN, The International Union for Conservation of Nature, Eastern and Southern Africa Regional Office. http://cmsdata.iucn.org/downloads/hiv_aids_and_environment.pdf. As part of the report, Bolton and Talman reviewed 177 relevant papers, reports, studies, and other materials. They met with key stakeholders and conducted a workshop during which they came up with recommendations for both policy makers and practitioners on the ground:
• Incorporate better and more extensive monitoring and evaluation of all projects.
• Determine the interrelationships between HIV/AIDS and the upstream determinants of social conflict, poverty and gender inequality in terms of their effects on ecosystems, ecosystem services and natural resource use. Insofar as possible, address upstream factors with every intervention.
• Identify and measure appropriate ecological indicators to identify status and trends of critical resources affected by HIV/AIDS.
• Create inventories of known medicinal plants to track changes in numbers of plants and identify areas needing protection to avoid extirpation.
• Pursue additional pharmaceutical and clinical research regarding the effects of medicinal plants and their interactions with ART.
• Investigate the relationship between food insecurity and HIV/AIDS outcomes (for example, clarify the relationship between food insecurity and the effectiveness of ART, susceptibility to infection, and mother-to-child transmission).
• Improve understanding of land use/land tenure issues. Collect additional data on site-, gender-, age-, culture-specific uses of land and inheritance patterns.
• Quantify and predict food insecurity and human health effects of climate change.
• Build internal, national capacity for conducting research in developing countries.
• Advocate for integration at the policy-level. Convince policy-makers that integration is an important principle.
• Mainstream HIV/AIDS at the institutional level and implement internal workforce-based interventions.
While I am not an expert on policy issues, I would encourage policy makers and funding agencies to allow for more integrated multidisciplinary approaches to field projects with collaborations with research institutions. There are many wonderful projects around the world that are attempting to address HIV/AIDS and the environment. However, there are few that have good monitoring result primarily because of the lack the time, funding and expertise. At the end of the day, it is difficult to determine if they have made a beneficial impact.

Judd Walson: In response to the question regarding water availability. Changes in the availability of water clearly have significant impact on individuals, families and communities. Access to water is exchanged through both formal and informal markets. Forced migration from areas with little access to water to areas with improved access (urban slums) is happening in many areas. These changes in migration clearly result in higher rates of high risk activity, as individuals leave behind family farms and resources and enter a more "monetary" economy. In addition, the need to participate in these economies forces many to engage in higher risk activities in exchange for precious resources. These pressures also force individuals away from home and family, again, increasing the risk of higher risk activities. Changing water availability also had direct impacts on malaria and diarrhea disease, both of which may lead to higher HIV viral load and increased risk of transmission. For example, in women, exposure to the water borne parasite schistosomiasis has also been linked with genital lesions that significantly increase susceptibility to HIV.
Jason Bremner: Judd, Thanks for your great answer to the question. I just want to add that people living with HIV/AIDS have a great need for clean water and then globally progress is being made in meeting the MDG7 indicator related to access to improved water sources. Also important is access to improved sanitation and unfortunately little progress has been made on this front. See PRB's most recent World Population Datasheet and the associated Population Bulletin from July of this year at www.prb.org There are still more than a billion people who defecate out in the open.
Lori Hunter: Judd, you've raised so many important issues here! In my own research in rural South Africa, we've examined differences in water collection strategies between AIDS-mortality-impacted households and those without such shocks. Indeed, we found that the loss of household members responsible for natural resource collection directly affects the time allocation of others, particularly if there is insufficient household income to consider purchasing the required resources (in this case, water as delivered by some enterprising local residents with a pickup truck!). The survey data suggest that male household heads pick up collection duties, for both wood and water, in the crisis period after an adult household member dies. Interview data further reveal important impacts on time allocation. CITE: Lori M. Hunter, Wayne Twine, and Aaron Johnson (forthcoming). “Adult Mortality and Natural Resource Use in Rural South Africa: Evidence from the Agincourt Health and Demographic Surveillance Site.” Society and Natural Resources.You can find the working paper version of the manuscript here:

Cynthia Buckley: Access to potable water is a growing concern for millions. We know water shortages negatively influence a variety of health outcomes. Water is an increasing challenge in Central Asia—where HIV infections continue to rise. Might the panelists address the links between water access (specifically) and HIV/AIDS?
Lori Hunter: Cynthia, an important connection in areas challenged by access to potable water is the shift in time allocated for collection by other household members. Children may be pulled from educational pursuits, while adults may be pulled from livelihood activities which may have diversified income streams and/or otherwise contributed to household well-being. See the response to Judd Watson for additional insight and a citation. Thanks for the question!

Nancy Gelman: What can we do to engage with other sectors (e.g. health, labor, agriculture, development) to get them to better understand the linkages between HIV/AIDS and the natural environment, to take action, and to scale up efforts?
Jason Bremner: Thanks for your question Nancy and all of the work that you have done on to examine and promote these linkages. From my perspective visiting the field I see many new things being done. First and foremost is that sectors are recognizing the risks that their own staff face in the field and are addressing workplace safety for field staff. This involves HIV education and awareness raising and providing staff with means of prevention and testing. Second development sectors are understanding that their work may create conditions that increase the risk for certain populations. Departments of transportation and roadbuilding now understand that new road building projects will result in increased transmission of HIV among workers and local populations that provide services to the workers. Understanding this impact is a first step towards taking the means to prevent it. Third, I am increasingly seeing innovative mechanisms by which health funding is linked to other development projects. For example USAID has been linking PEPFAR funds to some of its existing agriculture and conservation efforts in Rwanda and Tanzania. The lessons learned from these so called health "wraparounds" are still being collected. Two examples are the SPREAD project in Rwanda and the Jane Goodall Institute's work in Tanzania. It's a great means however of getting new sectors engaged.
Lori Hunter: This is so important Nancy, thanks for your question. In my opinion, it's essential that facts are provided that clearly document the linkages as well as the costs incurred by other sectors due to lack of attention to these intersections. As an example, if conservation organizations better understand the negative impacts on their efforts due to HIV/AIDS (e.g., loss of personnel), integration may be more likely. Related, if health organizations better understand that their interventions may be more effective if linked with efforts to secure availability and access to necessary natural resource, perhaps integration may be more likely. As always, I believe evidence is essential, as is the dissemination of that evidence.
Ben Piper: We need to undertake rigorous monitoring and evaluation of interventions to scientifically determine which interventions work best in which situations. We also need long-term studies that look at the use of the environment by people with and without HIV to help tease apart the differences that the disease makes.

Sharon Gordon: What are your top 3 pieces of advice to environmental departments/organizations in developing countries that you believe could make a positive difference/reverse current trends that are taking place in understanding the HIV/AIDs, natural environment relationship? For example, I think I understand that to combat HIV/AIDs one needs a multifaceted approach that primarily focuses on education and providing anti-retrovirals. Where then should the environmental department invest its 1 dollar in to make the optimal and best difference in the next decades?
Lori Hunter: Sharon, my thoughts on this question take a path similar to my response to Geoff Debalko. I firmly believe that the simple finding that there IS an association between HIV and natural resources suggests that environmental departments MUST collaborate with organizations focused on social and health needs. The potential success of conservation initiatives is seriously undermined without consideration of broader local needs. In settings where households lack few options, lessons with regard to HIV prevention and/or environmental conservation may not be heeded in order to meet shorter-term household requirements. Environmental departments could better ensure the success of their own initiatives by collaborating with other organizations in the provision of alternative livelihood strategies as well as health services (including, but not limited to, those related to HIV/AIDS).

Natalie Bailey: The Africa Biodiversity Collaborative Group (www.abcg.org) has several years of experience in looking at the connections between HIV/AIDS and the environment (see: http://frameweb.org/CommunityBrowser.aspx?id=137&lang=en-US). Our forthcoming manual for conservation organizations on impacts and solutions to HIV/AIDS and environment linkages emphasizes the importance of conservation organizations developing a workplace HIV/AIDS policy. What other steps should conservation organizations take to appropriately address the impacts of HIV/AIDS not only on the natural environment, but also on their staff and surrounding communities?
Ben Piper: ABCG certainly has been on the forefront of making conservation organizations aware of HIV/AIDS related issues. By partnering together with research institutions we can provide conservation organizations with more concrete evidence based solutions. The University of Washington has developed a new initiative on Environment, Climate Change and Global Health. In fact, TODAY (Mon, Sept 20, 2010) at 1:45 PM-3:15PM EST (3:45 - 5:15 pm PST) there will be a live webcast of a plenary discussion at the Consortium of Universities for Global Health (www.cugh.org) 2nd Annual Meeting on the same topic: The Environment, Climate Change and Global Health. A lot of what needs to be done is to develop the metrics to identify the core issues to be addressed. Partnering with family planning / reproductive health organizations can help to mitigate the impact of HIV/AIDS on conservation staff and the communities they work in. However, strengthening monitoring and evaluation tools has been identified as a priority by many organizations for identifying and addressing HIV/AIDS and environment linkages. M&E data can also provide a good baseline for more advanced research.
Lori Hunter: Natalie, thank you to ABCG for all your efforts in bringing attention to the important connections between AIDS and the conservation sector. On other steps, I firmly believe conservation organizations should collaborate with others engaged in social and health interventions (see responses Gordon and Debalko below). Rural livelihoods are not single-sector, why should interventions be!?

Azmal Hossain: How natural resources would be linked with the prevention of HIV/AIDS? Is there any natural way that can address both the issues (natural resource and HIV/AIDS) simultenously?
Lori Hunter: Azmal, the reciprocal nature of this association is so important, thank you for bringing this to the fore. In areas where households are dependent on local natural resources to meet day-to-day needs, environmental degradation reduces livelihood options. In the face of a reduction of such options, research shows that some individuals may resort to risky sexual behavior (transactional sex) simply to meet needs. In this way, environmental decline may be linked to potential HIV transmission .... so, if we think about programs to secure availability and access to local natural resources (conservation initiatives, for example), these could, indeed reduce risky sexual behavior. Basically, a diversity of sustainable livelihoods option can be good for both people and local environments.
Jason Bremner: I think Lori and Ben are doing a great job of illustrating how HIV/AIDS and natural resources are linked. A healthy natural environment benefits both prevention of HIV/AIDS and benefits those that are already afflicted. Some of the publications already referenced in this discussion summarize the efforts of organizations to address these issues simultaneously. See the IUCN/IPPF report authored by University of Washington and the soon to be released manual by ABCG. In addition there are an increasing number of organizations that are sharing there experiences addressing these issues simultaneously in East and Southern Africa. IUCN and IPPF convened a meeting in Kenya a year ago in June and I was able to hear about a multitude of efforts...urban gardening projects to address the nutrition needs of people living with HIV/AIDS, conservation organizations working with both their staff and beneficiary communities to prevent HIV/AIDS and improve local environmental conditions, agriculatural projects using coffee extension experts to also talk about HIV/AIDS prevention and distribute condoms to men and women.

Chi Ibe: There is indeed a strong link between the natural, environment and HIV/AIDS risk. I work in Nigeria and the geographic distribution of natural resources and how they have been subsequently developed is largely to blame for the pattern of the HIV/AIDS epidemic in the country. For example, in the Niger Delta area - where there has been oil exploration for several decades HIV/AIDS rates are very high. The reason being that the concentration of oil and oil companies in that region has led to the fostering of many inqualities in the region. There is economic, social and access inqualities.People who work in the oil companies are very well paid while the locals who own the land have very little to live on. This has created an environment of need. Consequently many young people engage in transactional sex, commercial sex and other forms of risk behaviors to survive. This pattern is very similar to that observed in other parts of Africa e.g., South Africa.
Lori Hunter: Chi, such disturbing observations for certain—but a pattern seen elsewhere. Transactional sex has been documented in a variety of settings—here is a list of recent references I found useful in my own work on this topic:
Working paper: http://www.colorado.edu/ibs/pubs/pop/pop2010-0001.pdf  
Béné, C., & Merten, S. (2009). Women and fish‐for‐sex: Transactional sex, HIV/AIDS and gender in African fisheries. World Development, 36(5), 875-899.
Dunkle, K., Jewkes, R., Brown, H., Gray, G., McIntryre, J., & Harlow, S. (2004). Transactional sex among women in Soweto, South Africa: Prevalence, risk factors, and associations with
HIV infection. Social Science and Medicine, 59(8), 1581-1592.
Hunter, M. (2007). The changing political economy of sex in South Africa: The significance of unemployment and inequalities to the scale of the AIDS pandemic. Social Science and Medicine, 64(3), 689-700. (2002). The materiality of everyday sex: Thinking beyond “prostitution.” African Studies, 61(1), 99-120.
Merten, S., & Haller, T. (2007). Culture, changing livelihoods, and HIV/AIDS discourse: Reframing the institutionalization of fish for sex exchange in the Zambian Kafue Flats.Culture, Health, & Sexuality, 9(1), 69-83.
Mojola, S. (2010). "Fishing in Dangerous Waters: Ecology, Gender and Economy in HIV Risk." Institute of Behavioral Science, CU Population Center, Working Paper Series. POP2009. 12. http://www.colorado.edu/ibs/pop/pubs/wp.html. Accessed January 2010.

Salomon Zundel: Why does AIDS create a panic in different countries for 10 weeks and then everyone forgets about it. For example it used to be a much more serious and often used conversational or debatable topic in the United States. Now there are randomly an ample amount of cases in France and it is creating chaos over there. I heard on TV, that in Africa getting AIDS is like getting a cold except the curing and healing part. Does this have anything to do with the natural environment or is it more of an economic and social impact?
Jason Bremner: I’m not sure I agree with this statement. AIDS has been a priority issue for many years now, and donor assistance through PEPFAR and the Global Fund have kept funding for public education, prevention, and treatment higher than most other diseases for nearly a decade. You are right that due to successful treatment regimens AIDS is not considered the death sentence that it once was in the 1980’s and early 90’s. Nonetheless AIDS has a huge impact on individuals, families, communities, and health systems. Research on HIV/Environment linkages illustrates the impact on families’ livelihoods. In Africa there are still many people who are unable to access treatment. Furthermore, demographic projections indicate that current levels of financial support for buying ARVs will not be adequate or sustainable in the future.
Lori Hunter: Salomon, certainly AIDS, such as other social problems, is subject to the ups & downs of the public's "issue attention cycle." Media and public opinion experts have examined just these cycles with regard to a variety of topics—I'm most familiar with those related to environmentalism and the environmental social movement. As to why the variation in prevalence rates across the world, there are so many factors. Knowledge is only part of the puzzle—factors such as poverty, gender inequality, environmental degradation and all combined, lack of livelihood options, certainly fuel the pandemic in parts of the world.

Sanjay Mishra: If we look at the recent trends of HIV/AIDS and its increased prevalence we find that in most of the sub-Saharan countries especially southern parts like Malawi and other adjoining countries or elsewhere in the region, especially areas where poverty is extremely high or natural resources either untapped or under tapped are stagnant, because new entrants are still coming in old/infected are dying. In time to come more researches are needed to interlink the pandemic with the natural environment. But there might be definite link with natural environment and the pandemic. Many people in the region are in some (most of the) cases having access to ART but no access to normal diets, except maize meal(simmer and casaba) and average wages rate or very low people earn in Kwacha and spend in dollar. In my opinion little are known about relationship between HIV/AIDS and the natural environment so, what theme or line of action can be suitable for the further action/reserach is a big enigma?
Lori Hunter: Sanjay, I agree with Ben Piper that the UW-IUCN overview provides a nice summary of the existing scholarship on the AIDS-environment connection. To add to his response, I'd encourage you to also explore some recent work by sociologists in Malawi that really shed light on the complex socio-economic dynamics shaping the epidemic. Much of this has come from the Social Networks Working Group at the University of Pennsylvania: http://www.malawi.pop.upenn.edu/   
As examples: Anglewicz, Philip, Simona Bignami-Van Assche Shelley Clark, James Mkandawire. "HIV Risks Among Currently Married Couples in Rural Malawi: What do Spouses Know About Each Other" AIDS and Behavior, published online Dec 5, 2008. Schatz, E. 2005. 'Take your Mat and Go!': Rural Malawian women's strategies in the HIV/AIDS era, Culture, Health and Sexuality 7(5), 479-492.
Ben Piper: What you are seeing in Malawi is unfortunately common in many parts of the world. Here in Kenya some of the most fertile areas experience some of the highest rates of malnutrition in the pediatric wards due to poverty. Coping ability is a linchpin for many communities to be able to deal with maintaining healthy natural resource and preventing and living with HIV/AIDS. We all know that education and income often lead to better outcomes in many regards. These are some of the coping ability to deal with issues related to HIV/AIDS and the environment. I referred to a recent paper by Bolton and Talman in the response to Geoff Dabelko’s question. This paper highlights many of core links between the HIV/AIDS and the environment. Download the paper and scroll down to some of the figures to get a sense of the relationship between these different sectors and which factors contribute to increased coping abilities. Every site has specific issues depending on a whole host of factors. Part of what we need to do is pin point what factors to focus on and what factors will help a community to increase their coping abilities. Every situation is different and there is no single answer that can fit every situation. But once the issues are identified and you have determined your targets, you need a good monitoring plan to be able to measure your progress in achieving your goals.

Rahat Bari Tooheen: Understanding the relationship between HIV/AIDS and the Natural Environment may help to formulate a solution to this problem from an aspect perhaps never accepted before. In your opinion, how might changes in the natural environment change the HIV/AIDS scenario as we are experiencing it in the world today? If a strong link is established between HIV/AIDS and the Natural Environment, how might this affect current programs?
Jason Bremner: Rahat, I think you are right. The increased recognition of these linkages is bringing new perspectives and new types of solutions to the work of prevention of HIV and care and support for those already living with HIV/AIDS. There are local examples of environmental change that can inform us about mos of the future HIV/AIDS and environmental change linkages. The local water availability and agricultural changes that will occur in the future are the most concerning because they will have an impact on rural livelihoods. Ben has already pointed out that failing local livelihoods results in many mobility and livelihood changes that can affect vulnerability to HIV. More prolonged absences or temporary migration for labor opportunities can split couples up and result in extramarital sex. Failed livelihoods may also result in more transactional sex (sex in exchange for food, money, or other things). That's just a start but something that programs need to think about as environments continue to change

Harry van der Linde: For sure linkages and multi-disciplinary integrated approaches are key, but where to draw a line as still to be effective? While this discussion focuses on the relationship between HIV/AIDS and the Natural Environment a number of other sectors have already been mentioned. Ben mentioned earlier "A lot of what needs to be done is to develop the metrics to identify the core issues to be addressed." But what kind of criteria to be used for that?
Lori Hunter: Harry—my first thought here is that we need to be SO careful not to reinvent the wheel. A substantial amount of work has been done by a PHE working group, much of it supported by USAID, to develop "toolkits" with regard to integrated Population-Health-Environment programs. The website has information on outreach, measurement, capacity building, and insightful experiences from the field! Check it out here: http://www.k4health.org/toolkits/phe. Related, UNC-Chapel Hill MEASURE/Evaluation has done some very important work on metrics: http://www.cpc.unc.edu/measure/. Hope these are useful!

Henry Lutaaya: Hi and thanks for this topic. How valid is the assertion that taking Chlorophyll—generated by crushing green leaves can help boost immunity among Aids patients?
Lori Hunter: Henry, thank you for this question, but it's out of my realm of expertise. It's certainly worthy of a literature search to see what evidence has emerged with regard to this connection!
Jason Bremner: Thanks for your question Henry, I'm not aware of any specific clinical research that validates this assertion. Your question, however, illustrates on of the important HIV/Natural Environment linkages that has been documented: people tend to rely on a combination of proven drugs in combination with natural remedies. Research in some settings indicates that families with people living with HIV/AIDS are more likely to forage in the forest both for food (because they don't have the available labor to work the family farm) and for natural remedies. In some contexts this foraging can have significant impacts on forests and particular medicinal species.

Antonio Cafoncelli: Do you feel strongly that the socio-economical conditions, such as poverty, lack of education and lack of health care are the main conditions that foster the spread of HIV?
Lori Hunter: Antonio, you ask about the "main" conditions, but the drivers of the pandemic vary across settings so this type of generalization is difficult to make. That said, certainly in poor, rural, resource dependent regions, such as those predominantly being discussed in this forum, poverty and lack of viable livelihood options are important factors shaping the disease's spread. Also critically important is gender inequality.

Terri Lukas: The international health sector has made it a point over the last couple of decades (!) to establish consensus on a large number of community based health indicators. What is the status of efforts to compile "ecological" indicators, or better, indicators of a changing climate at an equivalent level of observation, the community. Without monitoring health and environment/ecological indicators, how will programs/projects be able to guide their performance? This is a question that goes beyond HIV/AIDS obviously, but includes HIV/AIDS.
Jason Bremner: Great point Terri, I think that the health sector has reached a consensus on indicators largely because we all have the same unit of observation in common...individual people. Environmental indicators are so varied largely because you are dealing with different ecosystems, species, landscapes, etc. I think that remote sensing is providing some help in terms of a common tool that can be used across common ecosystems to measure baseline and impact. Otherwise, however, this will remain a challenge. Surveys of people's behavior regarding the environment are one way in which you might get some common indicators, but ecologists aren't as comfortable with surveys as a methodology and it is only an intermediate outcome.
Lori Hunter: Terri—I fear we need an environmental scientist or ecologist to fully answer your question! I can say, though, that in my research in rural South Africa, we have established both transects (across the study site) and circular plots both for monitoring of long-term ecological impacts (I collaborate with an ecologist, Wayne Twine). Baseline data are being collected this year and we intend to revisit regularly. There is also a substantial body of work that measures environmental change through the use of remotely sensed imagery—again, you can browse through the following working paper for some ideas on that approach and hopefully some useful references:
Ben Piper: You have identified a major challenge: what indicators to use? As mentioned in the response to Natalie, UW is in the process of identifying what those indicators might be through their Environment, Climate Change, and Global Health initiative. In the mean time, conservation and health organizations can help communities to identify what the key variables are that they would like to monitor. Often times there are regional or national indicators that can be used as comparisons. The important part is to develop a method for measuring the progress.

Sheridan Jones-McCrae: What are your thoughts on the use of photography, multimedia etc to document the physical impact of current practices on environment or pop health (e.g., before/after evidence of either improvement or degradation), in terms of an educating medium? Have you any experiences where this has significantly influenced behaviors of local population or decisions of policy makers? Any advice for those wanting to utilize such communication mediums? Thanks :)
Ben Piper: I do not have any experience using photography or multimedia, but many conservation organizations are using community mapping exercises. Satellite images can also be used as relatively accurate measures of environmental degradation.
Jason Bremner: I don't have much experience with this, but I have worked with time series of remote sensing satellite images and they can be very powerful. My sense is that people only trust photographs if you are able to show them that it is the exact same location and that the photo is representative of the larger landscape. Satellite images do this because they "photograph" the same large area over an over again. Aerial photography works similarly.
Lori Hunter: Sheridan, what an innovative idea—I'm thinking a bit differently about this than Jason. I'm wondering if you mean photographs in a more documentary sense? In this case, I would return to the old adage that a "picture is worth a thousand words" in that I think visuals are powerful representations of life on the ground. That said, they're not enough as an "educating medium" as Jason suggests. Visuals must be combined with scientifically valid data in order to convince audiences that the visuals are representative of broader, important socio-economic-environmental processes and patterns. Click!