Nutrition, HIV/AIDS, TB and parasites - Psychology and health

Psychology: an introduction (Oxford Southern Africa) - Leslie Swartz 2011

Nutrition, HIV/AIDS, TB and parasites
Psychology and health

Linda Richter & Shane Norris; Inge Petersen, Arvin Bhana, Jane Kvalsvig, Sheldon Allen & Leslie Swartz


After studying this chapter you should be able to:

•demonstrate that both under- and over-nutrition are problems in many parts of the world owing to food shortages and aspirations to thinness on the one hand, and dietary transitions and fast food consumption, on the other

•argue that nutritional effects on growth patterns are determined early in life, primarily in the prenatal period and infancy

•discuss how important changes in growth and nutrition occur during the pubertal growth spurt

•demonstrate that the nutrition of older people is an important part of continuing health and longevity

•demonstrate a basic understanding of the spread of HIV/AIDS, tuberculosis (TB) and parasites, and associated risk factors

•understand how HIV/AIDS, which affects millions of people, directly impacts on the immune system, and how nutritional interventions can help to maintain the health and prolong the life of infected individuals

•understand how HIV/AIDS, tuberculosis (TB) and parasites are spread

•appreciate the social and psychological factors that contribute to high levels of these diseases

•understand the role psychologists can play in curbing these diseases

•understand how these diseases impact on mental health and human development.


Nosipho was aware of how many young women worried about their weight. Dieting was often a major topic of conversation during their lecture breaks. Magazines and newspapers were full of pictures of thin models and it was hard not to compare themselves with them. There had been a number of girls in her class at school who had developed eating disorders, some becoming frighteningly thin and others vomiting their food up in the toilet after lunch. Nosipho also sometimes worried about gaining weight, although she didn’t believe in dieting. Rather, she tried to just eat healthily and exercise when she could.

Nosipho found it strange that some people worried about staying thin, while there were so many people in southern Africa who were not getting enough to eat. It was very hard to imagine what it must be like to be hungry all the time or to worry about feeding your children. In her own neighbourhood, young children sometimes came to the door to ask for food and Nosipho’s mother would always try to give them something, knowing that it might be the only meal they would have that day. Nosipho wondered what it was like for a child to try to learn, play, or even sleep with an empty stomach.

Nosipho was also aware, like most young South Africans, that she was living through a pandemic. At school and on campus, she had been given information on HIV/AIDS and how it was spread. She wondered if HIV/AIDS could be as serious as something like malaria, which she knew affected many people living near the Mozambique border, where her aunt lived. But Nosipho now realised the impact of HIV/AIDS and TB on people’s lives. She saw and heard about people in her local community who were ill or dying and she had been to many funerals. In many cases, no-one would say outright what was wrong, but Nosipho and everyone else knew that it was AIDS and/or TB that was killing them. Nosipho had heard that people who had HIV were more likely to get TB and to die from it. It seemed that mainly young adults were dying and quite often it was their parents or neighbours who had to take in the children left behind.

Nosipho felt it was really important that everyone understood, right from an early age, how the virus was transmitted and what they could do to protect themselves and other people from getting it. She understood the importance of using condoms. But she also knew how hard it could be to persuade your partner to use a condom. Some of her friends said they were sometimes just too embarrassed to raise the subject, but then they worried afterwards that they could have been infected. A few of her friends had already been tested for HIV/AIDS, and fortunately their test results had come back negative. At university, very few people admitted openly that they had HIV, but Nosipho assumed that there must be quite a few who were infected. Because it was possible to have no signs of illness and still be infected, there were also probably many more people in her immediate environment who had the virus and didn’t even know that they had it. These days in South Africa, HIV/AIDS was an inevitable part of life and even though she didn’t want to think about it, she knew that it was important that she did.


Food and water are basic constituents of life. People of all ages and in all conditions need a sufficient quantity and quality of food and water. The nature and amount of food consumed by people has an important effect on their physical and mental health. Too little or too much food, or food too low or too high in specific constituents (e.g. iron or zinc), can cause dramatic changes in immune function, energy levels, attention, cognitive acuity, mood and emotional reactivity (Mason, Lotfi, Dalmiya, Sethuraman & Deitchler, 2001; Sorsdahl et al., 2011).

The nutritional sciences have developed norms for required food intake under normal conditions, expressed as recommended dietary intakes (RDIs). Special feeding regimens are also required during illness and recuperation, including recovery from periods of extreme under-nutrition.

However, the influence of food on mental health is not unidirectional. Existing or developing states of physical and mental health (e.g. infection with HIV/AIDS, malaria or parasites) also affect what and how much food people select to eat. Children and adults who have had little to eat for a long time lose their appetite, and may even refuse food when it becomes available. Similarly, abnormal eating patterns, such as anorexia, bulimia and bingeing, are associated with disturbed mood states and psychopathology (Jordaan, 2014).

Under- and over-nutrition

Both extreme under-nutrition and over-nutrition are serious global problems. According to the United Nations Development Programme (2014), 12 per cent of the world’s population suffers from chronic hunger. Number 1 among the United Nations development goals was to eradicate extreme poverty and hunger by 2015 (United Nations, n.d.). While extreme poverty rates had improved by 2013, with 700 million fewer people living in extreme poverty in 2010 compared to 1990, 1.2 billion people still lived in extreme poverty (United Nations, n.d.). Extreme income poverty is associated with hunger, starvation and dramatically increased mortality in comparison to people living in developed countries. The United Nations (n.d.) reports that one in eight people worldwide are going hungry, a figure that is ’disturbingly high’.

In South Africa, 21 per cent of children under the age of five years are underweight (World Bank, n.d.). It is of concern that vulnerability to malnutrition is associated with political conflicts — the United Nations Development Programme (2014) reports that 20 per cent of the world’s population lives in countries affected by conflict. However, in terms of malnutrition, some improvements have been achieved with respect to micronutrients.

In a national study of nearly 3 000 children, a South African research team found that one in 10 children were underweight for their age, and one in five were stunted (with diminished height for their age). Children between one and three years of age were affected the worst, as were children living in rural areas and, ironically, children living on commercial farms. By contrast, one in 13 children in formal urban areas were overweight, and this number was higher (one in eight children) among the children of women with comparatively higher levels of education (Labadarios, 2000).

In developed countries, particularly the US, as well as in some developing countries, public health concern has grown around the increasing population-wide trend in obesity (over-nutrition) among children and adolescents (Lobstein, Baur & Uauy, 2004). The prevalence of obesity in the US among female children and adolescents rose from 13.8 per cent in 1999—2000 to 16 per cent in 2003— 2004 (Ogden et al., 2006). Among male children and adolescents, the prevalence of obesity rose from 14 per cent to 18.2 per cent (Ogden et al., 2006). In children and adolescents, obesity carries the risk of non-insulin-dependent diabetes and cardiovascular disease (traditionally rare conditions in this age group) (Lobstein et al., 2004).

In South Africa, a similar trend in obesity is emerging, with seven per cent of preschool children being overweight, (De Onis & Blossner, 2000). In 2012, the overweight prevalence in children under five was six per cent (World Bank, n.d.). The World Bank (n.d.) reports that for 2012, 68 per cent of women and 41 per cent of men were overweight or obese. The obesity epidemic in South Africa, particularly noticeable among adult females, is due to rural—urban migration and the transition to a more Western lifestyle, with reduced physical activity and increasing availability of energy-dense foods, as in many types of fast food (Puoane et al., 2002).

Although balanced nutrition is important throughout the life span, its effects on psychological health are most apparent during periods of rapid growth. Adequate intake of nutrients is critical for growth and the expansion of physiological capacity and function. Very rapid growth occurs during the prenatal period, during infancy and in early adolescence during the pubertal growth spurt. In addition to these three periods, it should be noted that nutrition also has very important effects on emotions, cognitive capacity and mental health during early adulthood (between 16 and 24 years), when there is another growth spurt and bone mineralisation, menopause in women (which occurs between 45 and 55 years of age), and old age.


•All people need adequate food and water.

•Too much or too little food, or imbalances in specific constituents, causes various health problems.

•Physical and/or mental health can also impact on appetite and eating behaviour.

•Both extreme under-nutrition and over-nutrition are serious global problems.

•The effects of malnutrition are most severe at certain developmental stages (when rapid growth occurs, menopause and old age).

Nutrition across developmental stages

Nutrition during prenatal development

As explained in Chapter 3, incredible growth occurs during the prenatal period. In the 270-day duration of a normal pregnancy, the fertilised egg, barely visible to the naked eye, grows to a baby with an average weight of 3.3 kg and an average length of 105 cm. At around four months (gestational age), the foetus grows at roughly 1.5 cm per day. With such rapid growth, adequate nutrition is critical. Nutrition has two main effects on the foetus. Together with other influences on the baby, nutrition affects birth weight and certain nutritional components, for example alcohol, can act as teratogens (environmental influences that can disrupt prenatal development).

A woman needs a balanced diet during her pregnancy, as well as sufficient food to gain the requisite weight to support a foetus. The foetal brain grows especially rapidly during this period, and diminished nutritional intake can severely affect cognitive and emotional development. Under-nutrition later in pregnancy tends to be associated with foetal growth retardation and low birth weight (Antonov, 1947).

Birth weight indicates the quality of the intrauterine environment, and is a strong predictor of both physical and psychological development during the preschool years (Cole & Cole, 2001). Low birth weight (LBW) refers to weight at birth below 2.5 kg, while very low birth weight (VLBW) refers to weight at birth below 1.5 kg. LBW infants are more likely to have neurologically based developmental handicaps and lower intellectual abilities than normal-weight babies. They also have more respiratory problems, seizures and other neurological problems, and later show a higher prevalence of hyperactivity. About 15 per cent of South African babies are born with low birth weight (World Health Organization, 2006a).

Nutrition during infancy and early childhood

Apart from prenatal development, growth during the first two years occurs at a more rapid pace than at any other time of life. In a child’s early life, the emergence of complex neural networks enables the acquisition of motor, cognitive and social skills that are the essential building blocks of psychosocial development. Birth weight, infant feeding, illness and postnatal growth strongly affect neuropsychological development (Barbarin & Richter, 2001).

The five most common causes of child deaths in the world are malaria, measles, pneumonia, diarrhoea and under-nutrition. Because under-nutrition increases the likelihood that a child will succumb to the effects of disease, under-nutrition is believed to account for about 70 per cent of all under-five mortalities in developing countries.

Malnutrition has a variety of negative effects on young children. Micronutrient deficiencies permanently damage the brain and severely affect children’s performance in school (Chopra & Darnton-Hill, 2006). These deficiencies reduce energy, activity and attention levels, and distort exploration and social interaction. Malnourished children tend to cling to their caregivers and thus lose opportunities to manipulate objects. Over time this is likely to negatively affect cognitive development and social adjustment (Grantham-McGregor et al., 2007).

It should also be noted that feeding should occur in the context of an affectionate and stable relationship, and children need to be fed or be encouraged to feed by someone who is responsive to their state, mood and tempo. Excluding the effects of poverty, malnutrition occurs more frequently in households that are disorganised, in which there has been a change of caregivers, and in which caregivers fail to express affection towards the child (Nti & Larty, 2005).


Figure 23.1 Exercise is an important part of weight management

The strong link between psychosocial care and nutrition is illustrated in a disorder called non-organic failure to thrive (NOFTT), or growth retardation with no clear organic cause. The syndrome was first described in institutionalised infants who experienced little contact with caregivers, and it occurs in a very large number of poor children in developing countries, regardless of the children’s nutritional status (Richter, 2004). Apart from growth deficits, NOFTT may include diminished physical activity, depressed cognitive performance, decreased immunologic resistance and long-term behavioural problems and developmental delays (O’Connor et al., 2000). NOFTT infants and young children appear listless, with diminished vocalisations, little smiling or cuddliness, and they are unusually watchful (Steward, 2001). Most cases of NOFTT are due to inadequate nutrition that results from biological and environmental factors that intersect in such a way as to preclude adequate nourishment of the child (Gahagan, 2006).

Interventions consisting of compensatory nutrition and psychosocial stimulation for young children show very positive benefits (Steward, 2001; World Health Organization, 1999). Interventions at later ages, for example through schools, are also important. In September 1994, the Primary School Nutrition Programme (PSNP) (now the National School Nutrition Programme or NSNP) was launched in South Africa as part of the Reconstruction and Development Programme. The NSNP aims to contribute to the improvement of education quality by alleviating hunger and, in so doing, enhancing primary school children’s attendance, punctuality and learning capacity, while also contributing to general health and development.

There is sound empirical evidence linking school performance and nutrition. Pollitt (1994), for example, argued that poor nutrition and concurrent illnesses interfere with children’s schooling in low-income countries, and that educational interventions have to include children’s health issues, including chronic protein-energy malnutrition, iron-deficiency anaemia, iodine deficiency and intestinal infections. Although the NSNP has been fraught with maladministration and fraud in some South African provinces, there is some evidence to suggest that the programme has increased school attendance and school performance due to increased alertness (Saloojee & Pettifor, 2005).

Nutrition during the pubertal growth spurt and adolescence

As discussed in Chapter 4, during puberty the primary sexual organs mature and very rapid increases in height occur. Among girls, this growth spurt takes place between nine and 15 years of age; on average it happens a bit later amongst boys (between 10 and 16 years of age). These changes are triggered by hormones but are also affected by environmental factors, particularly nutrition (Euling, Selevan, Pescovitz & Skakkebaek, 2008). The tallest and heaviest girls start to menstruate the earliest. The age of menarche, or the start of menstruation, is becoming progressively earlier all over the world, a change associated with improved nutrition. In the early 1800s in the US and Europe, menarche occurred at around 17 years, whereas the mean age of starting to menstruate is now 12.4 years (McDowell, Brody, Jeffery & Hughes, 2007), although this varies a little from country to country. In addition, Euling et al. (2008) found that this trend towards earlier puberty applied to girls but that there was insufficient evidence to say that it applies to boys.

Adolescence is considered to be a nutritionally vulnerable phase for several reasons:

•There is an increased demand for macronutrients (carbohydrates, fats and proteins) and micronutrients (e.g. iron, calcium and vitamin A) to meet the dramatic increase in physical growth and cognitive development.

•Changes in lifestyle, body esteem and food habits affect adolescents’ nutrient intake. These shifts may result in pathological eating behaviour, while environmental influences (family, peers and the media) may impact on dietary practices.

•There are special nutrient needs associated with participation in sports, adolescent pregnancy, development of an eating disorder, excessive dieting, and the use of alcohol and drugs (Spear, 1996; Stanner, 2004).


Recent evidence has supported a hypothesis that intrauterine nutritional experiences can contribute to the adult risk of diseases such as obesity, hypertension, ischaemic heart disease and glucose intolerance. It is suggested that the lower the birth weight of a child, the greater the risk of adult obesity, hypertension and diabetes (Briana & Malumitsi-Puchner, 2009). The hypothesised cause is a priming of the absorption patterns of the physiological system in response to deprivation.

Studies have demonstrated that instead of a straightforward linear relationship between birth weight and adult obesity, the relationship is curvilinear (J- or U-shaped). This means that a higher prevalence of obesity is seen among people who had the lowest and highest birth weights (Fall et al., 1995). For example, Brisbois, Farmer and McCargar (2012) found that childhood obesity is a probable predictor of adult obesity.

Data from the 1958 British birth cohort study found that maternal body mass index (BMI) during pregnancy largely explains the association between an individual’s birth weight and later BMI. Heavier mothers have heavier babies who tend to become heavier adults. From this evidence, maternal weight may be a more important risk variable for obesity in the child than low birth weight (Parsons, Power, Logan & Summerhill, 1999).

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Figure 23.2 Childhood obesity is a probable predictor of adult obesity

Several facets of eating behaviour may change during adolescence, namely: missing meals (especially breakfast), snacking, eating fast foods, high consumption of soft drinks and the start of alcohol intake. The danger is that habits started during adolescence are often continued into adulthood and may ultimately contribute to a number of debilitating diseases (Spear, 1996; Stanner, 2004). The needs and concerns of young people change during the course of adolescence. By late adolescence, the teenager is likely to have achieved a more established body image, be oriented towards the future, and be developing intimacy and permanent relationships. However, adolescents in this stage may have already developed unhealthy eating practices and activity patterns (Massey-Strokes, 2002).

Both over-nutrition (obesity) and under-nutrition (dieting and anorexia) are seen among adolescents, and both are associated with mental health problems, most notably anxiety and depression, as well as difficulties in social relations (Hudson, Hiripi, Pope & Kessler, 2007). The South African Department of Health has adopted the South African Food-based Dietary Guidelines (see Box 23.4) to encourage responsible eating habits, ensuring that all macro- and micronutrient requirements are met. Obesity is a complex medical disorder that is affected by genetics and the environment. Environmental factors that contribute to adolescent obesity include high caloric intake (diets high in saturated fat and sugar) and sedentary behaviour. Youth learn these unhealthy behaviours from parents and other influential role models (Daee et al., 2002). There are serious negative consequences to obesity, and consequently, controlled health-promoting behaviour such as increased fruit and vegetable intake, lowered fat intake and more exercise should be encouraged for overweight and obese adolescents.

Over one-third of American adolescent females engage in at least one episode of a harmful weight-loss practice (such as chronic dieting, excessive exercise, self-induced vomiting and abuse of laxatives, diet medications and diuretics) (Massey-Strokes, 2002). Adolescent weight-loss behaviour is associated with anaemia (iron deficiency), poor calcium intake (which may lead to a risk of osteoporosis in later life), stunting, poor body image, decreased immune function, menstrual cycle disruptions and even death (Daee et al., 2002).


One of the World Health Organization initiatives is Move for Health. Physical activity among children and adolescents is being encouraged, not only for its benefit in weight management, but also as a crucial element of a healthy lifestyle that reduces the risk of developing diabetes and cardiovascular disease.


Figure 23.3 Dehydration is a danger that is often underestimated

While exercise should be encouraged, adolescent athletes are particularly vulnerable to nutritional misinformation. Pressures to achieve optimal performance and muscle mass encourage athletes, particularly adolescent males, to experiment with supplements, muscle fuels and steroids in order to achieve a competitive edge. These may negatively affect health and growth. Adequate fluid intake and prevention of dehydration are critical for younger athletes. Heat illness ranks second to head injury as a cause of reported non-cardiac causes of death in adolescent athletes (Petrie, Stover & Horswill, 2004; Steen, 1996).

Nutrition at older ages

The risk of nutrition-related health problems increases in later life, either as a result of impaired food intake or reduced nutrient utilisation. At this stage of life, the stomach mucosa (lining) deteriorates, which results in less acid and pepsin secretion and, ultimately, a reduction in the bioavailability of calcium, iron, folate and vitamin B12 (Minuti et al., 2014). Post-menopausal women need increased calcium to protect against osteoporosis as their oestrogen levels drop, resulting in greater bone loss. Overall, older adults need similar intakes to younger adults of most vitamins and minerals, but they usually need less energy-dense food as their activity levels decline. Therefore, a nutrient-dense diet is a high priority for older people. Nutrient deficiencies in older adults can exacerbate both physiological and cognitive deterioration.


Birth to Twenty (Bt20) is the largest and longest-running birth cohort study of child health and development in South Africa, and has been tracking more than 3 000 children born in Johannesburg-Soweto during a seven-week period in 1990.

Mean birth weights of the Bt20 children were less than American norms (National Center for Health Statistics, 2001) and girls weighed significantly more than boys. The percentage of LBW children of normal gestation age (about seven per cent) was similar to that of developed countries. Thereafter, growth in weight exceeded that of the National Center for Health Statistics reference standards during the first six months of life, a trend that is attributed to almost universal breastfeeding among African mothers.

However, after six months, weight began to fall below the norms. Poor weaning foods, infections and low levels of stimulation are believed to account for the characteristic drop-off in weight seen among preschool children in developing countries. By two years of age, 22 per cent of Bt20 children were stunted (having a lower than expected height for their age) and seven per cent were wasted (having very much less than their expected weight).

Catch-up growth occurred between four and five years, resulting in a reduction in the prevalence of stunting and wasting to five per cent and one per cent, respectively, at five years of age (Cameron, De Wet, Ellison & Bogin, 1998).

See Richter, Norris, Pettifor, Yach and Cameron (2007) for a summary and evaluation of the Bt20.


Source: Vorster, Badham & Venter (2013)

To eat responsibly you should follow these guidelines:

•Enjoy a variety of foods.

•Be active.

•Make starchy foods the basis of most meals.

•Eat plenty of vegetables and fruit every day.

•Eat dry beans, peas, lentils and soya regularly.

•Have milk, maas or yoghurt every day.

•Chicken, fish, lean meat or eggs can be eaten daily.

•Use fats sparingly. Choose vegetable oils rather than hard fats.

•Drink lots of clean, safe water.

•Use sugar and foods and drinks high in sugar sparingly.

•Use salt and food high in salt sparingly.


•The rapid growth of the foetus during gestation requires adequate nutrition, in terms of quality and quantity.

•Under-nutrition later in pregnancy tends to be associated with foetal growth retardation and low birth weight.

•Birth weight is an indicator of the quality of the intrauterine environment, and it strongly predicts both physical and psychological development during the preschool years.

•Low- and very-low-birth-weight babies are more likely to have neurological and respiratory problems.

•Growth is again very rapid during infancy and early childhood.

•Under-nutrition is one of the five most common causes of child deaths.

•Malnutrition has a variety of negative effects on young children.

•Feeding is also an opportunity to nurture the infant emotionally.

•Non-organic failure to thrive (NOFTT) involves a failure to grow, with no clear organic cause. It is more common in institutionalised infants and may lead to both physical and cognitive deficits.

•Interventions include compensatory nutrition and psychosocial stimulation.

•Nutritional status may influence the age of menarche.

•The growth spurt in puberty means that adolescents need more macronutrients and micronutrients.

•Changes in lifestyle, body esteem and food habits also affect adolescents’ nutrient intake.

•There may be special nutrient needs associated with participation in sports, adolescent pregnancy, development of an eating disorder, excessive dieting, and the use of alcohol and drugs.

•Poor nutritional habits started during adolescence may continue into adulthood and may lead to disease.

•Both over-nutrition (obesity) and under-nutrition (dieting and anorexia) are seen among adolescents, and both are associated with mental health problems.

•The risk of nutrition-related health problems increases in later life, either as a result of impaired food intake or reduced nutrient utilisation.

HIV/AIDS, tuberculosis (TB) and parasites

HIV/AIDS, tuberculosis (TB) and malaria (a parasitic infection) collectively accounted for 3.5 million deaths in 2013 (World Health Organization, 2014b; 2014c; 2014d), with the majority of these occurring in the developing world. One and half million died of HIV/AIDS, and sub-Saharan Africa is home to 70 per cent of the 35 million people worldwide infected with HIV (World Health Organization, 2014b). One and a half million died of TB, with 95 per cent of these from low- to middle-income countries (World Health Organization, 2014d). Just over half a million people died from malaria, the majority of these being African children (World Health Organization, 2014c).

These statistics illustrate why the United Nations included the goal to fight HIV/AIDS, malaria and other diseases amongst its millennium development goals (United Nations, n.d.). By 2013, the number of new infections with HIV had dropped considerably although 2.3 million people were still being newly infected with HIV. In terms of TB, the mortality rate decreased 41 per cent between 1991 and 2011; however, multi-drug resistant TB remained a major problem. Malaria deaths fell 26 per cent between 2000 and 2010 (United Nations, n.d.).

Infections and parasites, therefore, can have a devastating impact on families, communities and economies, particularly in developing regions of the world (and Africa in particular). These diseases and parasites act immediately on the body, compromising its integrity. They also have a profound psychological effect on those unfortunate enough to be infected with them. Many of these conditions are curable or preventable. Although there is no cure for HIV/AIDS, we know how it is spread and how people can avoid becoming infected. In the case of TB, there are well-established biomedical cures. Similarly, we know how to prevent and cure malaria and bilharzia. However, these conditions continue to spread due to social, political, economic and personal factors. If HIV/ AIDS, TB and parasites are to be effectively controlled, or even eradicated altogether, a holistic approach is imperative. Biomedicine needs to work closely with psychology and social science, taking into account the bio-psychosocial influences that promote and maintain these infections.


It has been suggested that one of the strongest sociocultural factors influencing girls and women today is the Western beauty ideal, in which fatness is stigmatised and thinness praised. Worldwide media focusing on mainstream cultural values are a powerful force in shaping public perceptions regarding the value of thinness, and therefore contribute to the rise in eating disorders in non-Western populations.

Among the cultural changes taking place in South Africa is a change in what is considered to be acceptable body size and shape. Recent findings show that predisposition to an eating disorder was significantly higher in black adolescents compared to their white counterparts, although the prevalence of obesity was higher in the white girls (Gitau, Micklesfield, Pettifor & Norris, 2014). More white girls desired to be thinner although they had a better body image score. These results indicate that Western ideals of thinness are having an effect on eating attitudes and behaviour.


•HIV/AIDS, tuberculosis (TB) and malaria collectively accounted for 3.5 million deaths in 2013.

•The majority of these occured in the developing world.

•These infections and parasites can have a devastating impact on families, communities and economies.

•Social, political, economic and personal factors all contribute to the spread of these diseases.

The HIV/AIDS pandemic

The extent of the problem

HIV/AIDS is a devastating pandemic. According to the World Health Organization (2014b), since it was first identified in 1980, 39 million people worldwide have died of acquired immunodeficiency syndrome (AIDS), with 35 million people living with the human immunodeficiency virus (HIV) in 2013. Across the globe, there were 2.1 million new infections during 2013 (World Health Organization, 2014b). As suggested above, the vast majority of new infections occur in developing countries (Lamptey, Wigley, Carr & Collymore, 2002).

Sub-Saharan Africa has both the highest prevalence of HIV (5.5 per cent) and the most infected people (25 million), as depicted in Figure 23.4. The area with the next-highest prevalence is the Caribbean (1.2 per cent) and the area with the next-highest number of infected people is South and South-East Asia (3.9 million). More people die of AIDS-related illnesses in sub-Saharan Africa than of any other cause.

By 2012, 6.4.million South Africans were infected with HIV, which is the highest absolute number of infections of any country in the world (Shisana et al., 2014). It is estimated that infection rates in the South African population average at 12.2 per cent (9.9 per cent males; 14.4 per cent females). However, in the 25—49 age group, around one in four are living with HIV (Shisana et al., 2014). Of pregnant women who were tested in 2011, 29.5 per cent were HIV positive (Department of Health, 2012). The leading causes of under-five mortality are HIV/AIDS, neonatal causes and childhood infections (diarrhoea and lower respiratory tract infections) (South Africa Every Death Counts Writing Group, 2008).

Notwithstanding the grim statistics presented above, there has been significant progress in South Africa in fighting the pandemic. By 2012, two million South Africans were taking antiretroviral treatment (ART), which means the prevalence of HIV/AIDS is increasing because these people are living longer (Maartens & Goemare, 2014). Adult life expectancy has increased significantly and the great success of prevention of mother-to-child transmission has seen a 67 per cent drop in new infections in children from 2009 to 2012 (Maartens & Goemare, 2014).

The transmission and course of HIV/AIDS

The HI virus is transmitted in three ways:

1.Through unprotected vaginal, anal or oral sex with an infected person

2.From mother to child (during pregnancy and/or childbirth and/or breastfeeding)

3.Through direct contact with infected blood or blood products (needle-stick injuries, unsterilised needles or blades, or through sharing needles during intravenous drug use) (Barnett & Whiteside, 2006)

In sub-Saharan Africa, however, HIV/AIDS is most commonly transmitted through heterosexual intercourse (Barnett & Whiteside, 2006; Desmond & Gow, 2002).

On entering the body, the HI virus enters the white blood cells of the human host and attacks the body’s immune system, thus rendering the person vulnerable to opportunistic infections, such as pneumonia, meningitis, cancers and TB (Barnett & Whiteside, 2006). TB accounts for about one-quarter of AIDS deaths in sub-Saharan Africa (World Health Organization, 2014d).

Because the HI virus attacks the body’s immune system slowly over time, newly infected individuals will not know they are infected unless they have an HIV test. A person who is HIV positive will pass through a relatively asymptomatic or HIV-well stage, lasting from 3 to 7 years, to a symptomatic HIV-ill stage. This stage lasts from 12 to 18 months during which the person may suffer weight loss and bouts of illness from opportunistic infections. In the final stage, the person has full-blown AIDS (characterised by a variety of persistent infections and other health problems like diarrhoea, oral and/or vaginal candida (thrush), severe mental deterioration and respiratory infections).

The long HIV-well stage means that the disease may spread widely without anyone realising it. Because many people infected with HIV do not know they are infected, they continue to have unsafe sex and thereby infect others with the disease.

Bio-psychosocial influences that increase vulnerability to HIV/AIDS

We are all vulnerable to HIV infection. However, in sub-Saharan Africa, certain biological, cultural and socio-economic conditions render women of child-bearing age, and especially those who live in informal settlements (which are characterised by a mix of poverty and social dislocation), relatively more vulnerable to contracting HIV/AIDS (Lamptey et al., 2002; Shisana & Simbayi, 2002). During unprotected vaginal intercourse, a woman’s risk of becoming infected is up to four times higher than a man’s. In addition to this biological vulnerability, unequal gendered power relations at a sociocultural level limit a woman’s ability to negotiate or control sexual interaction, especially with older men (Lamptey et al., 2002; LeClerc-Madlala, 2001).


Figure 23.4 Adults and children estimated to be living with HIV/AIDS in 2012 (UNAIDS, 2013)

Furthermore, in South Africa, women’s and girls’ vulnerability to infection is also increased by a culture of physical and sexual violence, which is so common that it has come to be perceived as normative and largely accepted (Dunkle et al., 2006; Jewkes, Dunkle, Nduna & Shai, 2010). The added presence of poverty and social dislocation compounds women’s risk of infection.

At a structural level, women’s relative lack of education, combined with the burden of domestic work, child bearing and child care, has increased the number of women living in poverty (see Chapter 18). This also increases their dependence on men, reducing their ability to negotiate safe sex and increasing their vulnerability to being sexually exploited, with many young women having resorted to transactional sex — exchanging sex for money or other goods in order to survive (Campbell & MacPhail, 2002; LeClerc-Madlala, 2001). Lastly, the youth in these communities, who are already vulnerable to HIV infection because of an adolescent tendency to engage in high-risk behaviours, often lack conventional role models (such as employed parents), as well as prospects of gainful employment.


In developing countries, government funding, resources, facilities and medication are restricted. HIV medical nutrition therapy also requires specialised knowledge of nutrition, especially in relation to HIV disease, medications, complications, and sensitivity to the infected and affected populations served. The number of qualified medical nutrition therapy providers is completely inadequate in developing countries. In the face of this, an increased effort needs to be made to educate primary health care providers around nutrition and nutritional counselling.


•HIV/AIDS is a devastating pandemic, with 39 million deaths worldwide thus far.

•Sub-Saharan Africa has both the highest prevalence of HIV and the most infected people.

•South Africa has seen significant progress in fighting the pandemic, especially in terms of ARTs and prevention of mother-to-child transmission.

•The HI virus is transmitted through unprotected sex, from mother to child and through direct contact with infected blood or blood products.

•The HI virus attacks the body’s immune system, making the person vulnerable to opportunistic infections.

•In the early stages, the disease is asymptomatic, after which the person may suffer weight loss and bouts of illness from opportunistic infections.

•In the final stages, there may be severe mental deterioration and respiratory infections.

•In sub-Saharan Africa, vulnerability depends on gender, age, and cultural and socio-economic circumstances.

•At a structural level, women are also at risk due to relative lack of education, burden of domestic work, child-bearing and child care, poverty, and dependence on men.

•The youth in these communities are vulnerable because of high-risk behaviours, lack of role models and unemployment.

Strategies for the prevention and management of HIV

The initial response to the HIV pandemic focused on preventing sexual transmission of the disease through the well-known ABC (abstain, be faithful, condomise) approach. However, since the mid-2000s it has become apparent that interventions need to account in more complex ways for sociocultural, economic, political and other factors in a person’s environment (AVERT, 2015). Thus, a combination of strategies is now considered to be a more effective approach. These include programmes at different levels and some of these are described below.

Prevention of mother-to-child transmission (PMTCT)

A baby may become infected with HIV from its mother at any stage during pregnancy, labour or delivery. This is the most common way in which children become infected (AVERT, 2015). If no treatment is received, the chance of infection is 15 to 45 per cent, thus it is very important that pregnant women attend ante-natal services. These should include HIV testing, antiretroviral treatment (if necessary), and advice on safe childbirth and infant feeding practices.

Post-exposure prophylaxis (PEP)

Where HIV-negative people have been exposed to HIV (through rape or needle injuries, for example), post-exposure prophylaxis can help prevent the virus taking hold (AVERT, 2015). It usually involves a month-long course of anti-retroviral medications. PEP is not 100 per cent effective, especially if treatment is delayed more than 72 hours after exposure. As with all antiretroviral treatment, consistent adherence to the treatment regimen is also essential to increase effectiveness.

Pre-exposure prophylaxis (PrEP)

In pre-exposure prophylaxis, an HIV-negative person who is at high risk of HIV infection takes a daily medication. This includes drugs used to treat HIV. People who are engaged in sex work or who use intravenous drugs tend to be at highest risk of infection. PrEP is also useful where one partner in a couple is HIV positive and the other is not. In combination with condoms, PrEP can be highly effective in preventing infection, but the medication must be taken consistently every day.

Treatment as prevention (TasP)

Treatment as prevention is a matching strategy to PrEP in that it is applied to the HIV-positive person. In this approach, anti-retroviral treatment is used to reduce the viral load in the person’s bodily fluids (blood, semen, vaginal and rectal fluid) to very low levels, such that transmission of the virus is unlikely (AVERT, 2015). TasP principles underly the PMTCT and PEP strategies. Users should be aware that TasP methods are not 100 per cent effective; indeed, health care providers have concerns that people will engage in higher-risk behaviours believing that their risk is low (AVERT, 2015). In addition, treatment adherence is critical as poor adherence may lead to drug-resistant HIV strains.

Voluntary male medical circumcision (VMMC)

During the 2000s, research showed that circumcised males were 60 per cent less likely to transmit HIV to their female partners (AVERT, 2015). As a result, in 2009 the World Health Organization launched a major public health intervention promoting voluntary male circumcision. Globally, acceptance of this strategy has varied considerably. In South Africa, VMMC was rolled out by the public health system in April 2010 and has had a reasonable success rate. There are, however, a number of challenges including consent issues, limited resources, issues around quality and safety of the equipment used, and the role and impact of traditional circumcision (AVERT, 2015; Treatment Action Campaign, 2011). In addition, as with TasP, there are concerns that high-risk behaviour will resume once a man is circumcised.

Needle and syringe programmes (NSPs)

In this approach, intravenous drug users are supplied with new needles and syringes in an effort to reduce transmission of HIV and other viruses from shared needles (AVERT, 2015). Many of these programmes also provide other support, including advice on safer injecting, how to avoid an overdose, as well as advice on how to reduce or stop injecting.

The role of psychology in the prevention and control of HIV/AIDS

Given the multiple factors that render people vulnerable to HIV infection, it is important that prevention efforts adopt an ecologically systemic understanding of risk (as described in Chapter 21), ensuring interventions at all levels: individual, interpersonal, community and societal. Psychology plays an important role at all these levels.

Given that heterosexual intercourse is the most common means of transmission in sub-Saharan Africa, reducing high-risk sexual behaviour remains the principal strategy for curbing infection. Psychology can thus provide health-promoting behavioural change strategies at the individual and interpersonal levels. Efforts have largely concentrated on promoting the ABC model of prevention, which encourages abstinence (not engaging in sex), particularly among the youth, as well as promoting safe sexual practices. In addition, male circumcision has been promoted, as well as targeted interventions with at-risk populations such as intravenous drug users (World Health Organization, 2009).

Many prevention efforts have focused on empowering individuals, particularly women. These focus on increasing knowledge about HIV transmission, promoting health-enhancing attitudes, and improving skills to negotiate and practise safe sex. These efforts need to be accompanied by interventions at the interpersonal, community and sociocultural levels. Of importance at the interpersonal level is the need to promote peer or social norms that enable behavioural change with regard to safe sexual practices. This is particularly important for males in Africa, where the sociocultural norm associates masculinity with multiple partners (Campbell, 2003). The need for interventions at this level is highlighted by the evaluation of a risk-reduction curriculum for tertiary-level students at one tertiary institution in South Africa (see Box 23.7).

Given the sociocultural factors that increase vulnerability to infection, behaviour change strategies cannot be separated from structural interventions at a societal level, which are focused on poverty alleviation, development and gender equality.

In addition, voluntary counselling and testing (VCT), prevention of mother-to-child transmission (PMCT), and the management of sexually transmitted infections (STIs) are all regarded as prevention interventions, as their primary function is to reduce transmission of HIV (Geffen, Nattrass & Raubenheimer, 2003; World Health Organization, 2009). Antiretroviral treatment (ART) slows down the rate at which the HIV multiplies in the body and therefore allows HIV-infected people to stay healthy for longer. It also plays a role in prevention, lowering viral loads, and the increasing availability of such treatment should hopefully encourage people to go for VCT.

Voluntary counselling and testing

Voluntary counselling and testing (VCT) is central in HIV prevention interventions and the supporting of infected and affected people. VCT encourages behavioural change towards safer sexual practices (Mola et al., 2006; UNAIDS, 2001), with people who are negative being motivated to practise safe sex in order to stay negative. UNAIDS (2000, p. 3) defines VCT as ’the process by which an individual undergoes counselling, enabling him or her to make an informed choice about being tested for HIV’. Testing must be freely chosen and individuals should be assured of confidentiality.

VCT typically consists of three stages: pre-test counselling, post-test counselling and follow-up counselling. Pre-test counselling is provided to all people who have requested and agreed to an HIV test. During pre-counselling the counsellor should

•explain what an HIV test is

•discuss the client’s risk behaviour(s)

•correct any misunderstandings the client may have

•discuss with the client the implications of knowing his/her status

•explore ways to cope with either a negative or positive result (Ross & Deverell, 2004).


Source: Petersen, Bhagwanjee, Bhana and Mahintso (2004)


A group of tertiary students was divided into two groups: an experimental group to whom the risk-reduction curriculum intervention was provided, and a control group to whom a series of lectures on HIV/AIDS was given. In the experimental condition, the participatory group-based risk-reduction curriculum over a number of sessions revolved around three dominant themes: knowledge of HIV/AIDS, awareness and skills building. Knowledge sessions included understanding the epidemiology of HIV/AIDS, modes of HIV transmission (including myths and conceptions) and biological factors that underpin progression from HIV to AIDS. Awareness sessions focused not only on understanding risky sexual behaviour, but also on developing a critical consciousness about gender roles involved in risky sexual behaviour. The skills-building exercises attempted to enhance relationship building, sexual communication, negotiation and condom use. In the control condition, the lectures on HIV/AIDS largely focused on knowledge regarding HIV/AIDS. Evaluation used a pre- and post-test knowledge, attitude and practices (KAP) survey questionnaire, followed by qualitative interviews with participants.


The findings showed an improvement in both the experimental and control conditions on knowledge of HIV/AIDS, with the experimental condition producing a significant improvement on awareness of the role of social influences on sexual behaviour. No significant change in behaviour was found for either group. The qualitative interviews revealed that while students exposed to the experimental condition felt empowered by the programme, behaviour change was difficult given the peer norms that prevailed on campus, which involved high-risk sexual behaviour.


To be successful, interventions targeting behaviour change at the individual level need to be accompanied by interventions aimed at creating peer norms that are enabling and supportive of behaviour change.

Before proceeding for the HIV test, the client must provide informed consent.

During post-test counselling, the counsellor begins by revealing the results of the HIV test. People who have tested HIV negative are told about the window period, which is a three-to-four month period after infection during which HIV antibodies may be undetected by the HIV test they have just had. People who test HIV negative are therefore advised to return for retesting three to four months later, and provided with information on how to remain negative (Ross & Deverell, 2004). HIV-positive people are encouraged to talk about their diagnosis and explore ways in which they will cope. Safe-sex practices are described and people are encouraged to practise them at all times. Follow-up counselling and support should be available to people for any subsequent questions or concerns.


•Early responses for prevention and management of HIV were based on the ABC method; more recently, combination approaches have been employed, using a selection of the following, as well as ABC:

”Prevention of mother-to-child transmission (PMTCT)

”Post-exposure prophylaxis (PEP)

”Pre-exposure prophylaxis (PrEP)

”Treatment as prevention (TasP)

”Voluntary male medical circumcision (VMMC)

”Needle and syringe programmes (NSPs)

•Prevention efforts should take an ecologically systemic understanding of risk.

•Reducing high-risk sexual behaviour through the ABC model remains the principal strategy for curbing infection.

•Male circumcision, increasing knowledge, promoting health-enhancing attitudes, and improving interpersonal and empowerment skills are all important, as are peer and social norms.

•Psychologists also contribute to ART adherence and prevention of mother-to-child transmission.

•VCT is central in HIV prevention interventions and providing support to infected and affected people.

•VCT encourages behavioural change towards safer sexual practices.

•VCT typically consists of three stages: pre-test counselling, post-test counselling and follow-up counselling.

•Testing must be freely chosen and individuals should be assured of confidentiality; before proceeding for the HIV test, the client must provide informed consent.

The impact of HIV/AIDS on mental health

Studies show that people who are infected with HIV are at greater risk of developing a mental disorder (Brandt, 2009; Chandra, Desai & Ranjan, 2005). This occurs at two levels (Chandra et al., 2005):

•The stress of knowing one’s positive status, often regarded as a death sentence, together with the stigma that accompanies the illness, may trigger an acute stress reaction, depression and/or anxiety, with an accompanying risk of suicide.

•People in the final stages of infection may suffer from dementia, delirium and psychotic disorders as brain cells are destroyed by the virus as well as by opportunistic infections such as meningitis.

HIV infection can result in mental disorders through a variety of mechanisms. A great deal of evidence indicates that people with the HI virus are significantly more stressed and distressed than the general population (Collins, 2006; Israelski et al., 2007; Saunders, 2006). The most common stress-related diagnoses are depression, post-traumatic stress disorder (PTSD) and acute stress disorder (ASD).

Furthermore, having family members infected with HIV is likely to impact on the psychological well-being of the rest of the family due to stigma and premature death. Children orphaned by AIDS are most vulnerable to economic hardship, challenges to their social and emotional development, as well as other psychosocial consequences. Grief over the death of a parent, fear of the future, separation from siblings, and distress about worsening economic circumstances and HIV/AIDS-related discrimination and isolation often results in depression and anxiety as well as symptoms of PTSD.

Nutrition for people living with HIV/AIDS

HIV/AIDS affects nutrition directly and indirectly. The direct effects involve the inability of AIDS-sick individuals to eat because of the pain of oral thrush and/or lack of appetite owing to generalised illness. The indirect effects result from increasing levels of poverty and malnutrition. In already impoverished communities, AIDS depletes the reserves of breadwinners, and impacts negatively on subsistence activities.

Common complications of HIV infection and AIDS are malnutrition, lactose intolerance, fat malabsorption and AIDS-related anorexia (Anabwani & Navarro, 2005; Kotler, 1998). Children with HIV have young immune systems and small protein reserves, thus it is important to maintain good nutrition to maintain immune system functioning. This, along with tolerable antiretroviral treatment, ultimately helps to minimise disease progression and promote survival (Fontana, Zuin & Plebani, 1999; Nerad et al., 2003).

Nutrient deficiencies occur in HIV-infected patients, because nutrients are used faster by the body to fight the infection and repair the damage caused by the virus and other infections. Poor absorption of nutrients results from intestinal infections, diarrhoea and vomiting. These nutrient deficiencies further strain the immune system and other physiological systems as nutrients provide the building blocks for both the body’s physical structure (cells, tissues and organs) and its function. Studies have shown that in both HIV-infected children and adults, deficiencies in zinc, selenium, copper, and vitamins C, E, B6 and B12 (all of which contribute to an intact immune response) are common (Nerad et al., 2003). Nutritional counselling, careful food preparation hygiene, oral nutritional supplementation and regular resistance exercise programmes have been shown to be effective in improving health outcomes in HIV-infected patients (Anabwani & Navarro, 2005; Rabeneck et al., 1998; Roubenhoff, McDermott & Weiss, 1999).


•People infected with HIV are at greater risk of developing a mental disorder; these include acute stress reaction, depression and/or anxiety, and risk of suicide.

•In the final stage, there may be dementia, delirium, psychotic disorders and meningitis.

•People with HIV may also experience stigma and discrimination, and children may be orphaned.

•HIV/AIDS affects nutrition directly and indirectly. Direct effects involve the inability of AIDS-sick individuals to eat because of the pain of oral thrush and/or lack of appetite owing to generalised illness. Indirect effects result from increasing levels of poverty and malnutrition.

•There are a number of common complications of HIV infection and AIDS, which may be exacerbated by impoverished social circumstances.

The TB epidemic

The extent of the problem

The statistics on tuberculosis (TB) are shocking. In 2013, nine million people contracted TB and about 1.5 million people died from the disease (World Health Organization, 2014d). However, the death rate from TB dropped by 45 per cent between 2000 and 2013, and the number of new infections each year is slowly declining. Although southeast Asia and the Western Pacific had the highest number of new cases in 2013 (about 56 per cent of new cases), the highest prevalence is in Africa with 280 per 100 000 people (World Health Organization, 2014d). TB is also a leading cause of death for HIV-positive people, being responsible for one-quarter of all HIV-related deaths. In South Africa, 60 per cent of all reported TB sufferers are HIV positive (World Health Organization, 2006c).

The transmission and course of TB

TB is a contagious disease, which spreads through the air. The most common form is pulmonary TB (TB of the lung). When a person infected with pulmonary TB sneezes, spits, talks or coughs, that person releases TB germs, known as bacilli, into the air. Only a small number of bacilli need to be inhaled for a new infection to occur. However, people infected with TB will not necessarily become ill. The immune system protects the body against TB, and the bacilli can lie dormant in the body for years. When a person has a weakened immune system, they are more likely to become ill (World Health Organization, 2014d).

Drugs to cure TB have been available for 50 years. Currently, the best known are isoniazid and rifampicin. In order for the drugs to work, however, they have to be taken regularly for a long period of time (six to eight months). If people take the drugs for a short time and then stop, or take the drugs irregularly, strains of TB develop that are resistant to those drugs.

There are now increasing rates of multi-drug resistant TB (MDR-TB), which is defined as TB that does not respond to isoniazid and rifampicin. These infections need to be treated with more expensive therapies which may not be freely available. Treatment takes two years and may have severe side effects. These drug-resistant strains of TB can also be spread to other people. This can have very serious consequences, as it risks MDR-TB becoming a potentially incurable epidemic (World Health Organization, 2014d). About 480 000 new MDR-TB cases developed in 2013 (World Health Organization, 2014d). In addition, about nine per cent of MDR-TB cases have developed extensively drug-resistant TB (XDR-TB). These strains are resistant even to second-line medicines.


In developing countries, government funding for HIV support services is restricted, while medical nutrition therapy for HIV/ AIDS patients requires specialised knowledge of HIV-related nutrition, medications, complications and sensitivity in these patients. However, given that the number of qualified medical nutrition therapy providers is completely inadequate in developing countries, much more effort needs to be made to educate primary health care providers around the nutrition needs of their patients.

Bio-psychosocial influences that increase vulnerability to TB

A number of factors contribute to the high incidence rates of TB (World Health Organization, 2014d). These include the following:

•the increased impact of HIV, which weakens the immune system thus accelerating the spread of both diseases

•poorly managed TB programmes, which have led to the development of MDR-TB

•greater migration and displacement of people due to global trade, war and poverty.

TB spreads rapidly in poor countries, for complex reasons. Although TB is a well-understood physical problem, the factors that contribute to its continuing spread are economic, social and psychological. These factors operate at a range of levels.

Poor people are exposed to unhealthy working and living conditions, and are often poorly nourished. This makes them vulnerable to becoming infected with TB (Yong Kim, Shakow, Castro, Vande & Farmer, n.d.). Poverty also limits access to, and utilisation of, medical treatment (Yong Kim et al., n.d.). In South Africa, both poverty and TB have been divided unequally along racial lines. As a result, disadvantaged groups, particularly black workers, have been hardest hit by the disease (Benatar, 2013). This was fuelled by migration, urbanisation and overcrowding (Metcalf, 1991).

These factors, along with civil unrest, war and natural disasters have increased migration and displacement (Gandy & Zumla, 2002), especially in developing countries (Saraiya & Binkin, 2000). People are more mobile than ever before. For example, they move between and within countries to escape unrest or seek political asylum, or to find employment or to study. There are about one billion migrants in the world today (World Health Organization, 2014e). Particularly for illegal migrants, accessing health care and adhering to long-term treatment plans are particularly difficult. These migrant populations tend to have higher rates of TB infection and they also spread TB as they move (World Health Organization, 2014e).

Contributions of psychology to the prevention and control of TB

For TB to be treated successfully, patients must adhere to a long and challenging treatment regimen, which involves six to eight months of large amounts of drugs, initially taken daily. The drugs can have a variety of unpleasant side effects, such as rashes, stomach pain, nausea, ringing in the ears and blurred vision. After two months of treatment, most patients begin to feel well again and may want to stop taking their treatment. As described above, this has serious negative consequences for TB control. Psychology can play a significant role in improving treatment adherence, thereby influencing the control of the disease, and decreasing the incidents of MDR-TB.

In order to improve worldwide TB control, in 2006 the World Health Organization (n.d.b) developed a six-element strategy to address the main challenges facing TB (http:www.//

•pursue high-quality DOT expansion and enhancement

•address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations

•contribute to health system strengthening based on primary health care

•engage all care providers

•empower people with TB, and communities through partnership

•enable and promote research.

One critical aspect of treatment adherence is the directly observed treatment (DOT) programme. This approach is recommended by the World Health Organization and it involves supervised treatment in the patient’s home. According to the World Health Organization (n.d.a), the application of DOT is still fundamental to the Stop TB Strategy. The DOT approach has five components (World Health Organization, n.d.a):

•political commitment with increased and sustained financing

•case detection through quality-assured bacteriology

•standardised treatment, with supervision and patient support

•an effective drug supply and management system

•monitoring and evaluation system, and impact measurement.

Psychological and behavioural factors are critical for the application of DOT. At the heart of this approach is the commitment to observing the patient as they take the medication, for at least some of the treatment period. The rationale for DOT is simple: watching a person take the medication for five days a week for six to eight months provides the most effective way of ensuring patients adhere to the treatment regimen.

However, there are some problems with DOT. First, there does not seem to be conclusive evidence that DOT works better than other methods (Volmink, Matchaba & Garner, 2000). Second, there are inconsistent definitions of DOT in different countries and contexts (Macq, Theobald, Dick & Dembele, 2003). Third, the process of directly observed treatment may lead to the health provider treating the patent with disrespect as an unmanageable case of infection rather than as an independent person (Van der Walt & Swartz, 2002). The patient, on the other hand, may come to resent the health provider and avoid coming for treatment.

Psychology can play an important role in the control of the TB epidemic through understanding and developing behavioural strategies to increase treatment adherence. It is important to emphasise, though, that this widespread problem (see Jaret, 2001; Vermeire, Hearnshaw, Van Royen & Denekens, 2001; World Health Organization, 2003) cannot be solved by addressing patient behaviour alone. On the contrary, adherence needs to be addressed at the health provider level as well. Psychological interventions aimed at assisting patients to adhere to treatment include motivating patients to complete treatment, helping patients develop self-monitoring skills and confidence so that they take charge of their treatment, providing group support for patients and family members and helping patients cope with stigma.

Interventions aimed at assisting health care providers to create an environment conducive to adherence include increasing empathy for patients, helping providers empower patients, improving providers’ understanding of health behaviour and human motivation, as well as their communication skills and providing support to providers and their managers.

The challenge of adherence to treatment needs to be considered within the broader social, cultural and economic issues that underlie the attitudes, experiences and beliefs that patients, their family, friends and community hold about the particular illness and its treatment (Vermeire et al., 2001). To date, almost 200 different variables have been used to try to account for poor adherence, with little or no success (Vermeire et al., 2001). Among others, the characteristics of the disease, the nature of the referral process, the type of clinical setting, the therapeutic regimen and patient demographics do not seem to play a decisive role (Vermeire et al., 2001). However, the presence of psychiatric disorders, the degree of disability, and the features of the treatment (e.g. duration, number of medications, their cost and the frequency of doses) do seem to be closely linked to adherence.

The impact of TB on mental health

Like any other debilitating condition, TB can affect people’s ability to concentrate and learn, and to accomplish their daily tasks. Rarely, TB may have neuropsychological consequences. However, the most common impacts of TB on mental health arise from social and economic factors.

Because it is a disease of poverty, TB has long carried a stigma, and many people have felt ashamed of having TB. With the advent of the AIDS pandemic, this stigma is further complicated because people often think that TB-infected individuals are HIV positive or have AIDS.

Also, the long duration of treatment, and the amount and cost of medication are problematic. Work may be disrupted (and patients may even lose their jobs) because of the need to attend treatment regularly. This can have devastating effects on the mental health of patients and their families. The long course of the illness itself can be emotionally draining. Patients might wonder whether they will ever be well and they may worry about how the cost of treatment leads to other sacrifices. Broadly, the ongoing TB epidemic can contribute to demoralisation in families and communities, and can impact on productivity and entrepreneurship.


•Although the statistics on TB show widespread infection, there has been some progress in reducing mortality.

•TB is a major risk factor for HIV-positive people, being responsible for one-quarter of all HIV-related deaths.

•TB is a contagious disease, which spreads through the air; the most common form is pulmonary TB.

•People can be infected with TB without becoming ill; when a person has a weakened immune system, they are more likely to become ill.

•Drugs to cure TB must be taken for six to eight months, but resistance to first-line drugs is increasing, leading to growing rates of multi-drug resistant TB (MDR-TB). However, some strains have developed resistance to second-line drugs, leading to extensively drug-resistant TB (XDR-TB).

•A number of factors contribute to the high incidence rates of TB: HIV, poorly managed TB programmes, as well as greater migration and displacement of people.

•TB spreads most rapidly in poor countries, for complex, interacting, economic, social and psychological reasons.

•Psychology can play a significant role in improving treatment adherence, thereby influencing the control of the disease, and decreasing the incidents of MDR-TB. One technique is the application of directly observed treatment (DOT) programmes, involving supervised treatment in the patient’s home. Psychological and behavioural factors are critical for the application of DOT; however, there have been some criticisms of the approach.

•The problem of adherence needs interventions at both patient and health provider level.

•TB can affect people’s ability to concentrate and learn, and to accomplish their daily tasks.

•The most common impacts of TB on mental health arise from social and economic factors — stigma, association with HIV, cost and duration of treatment, work disruption and potential loss of employment.


The extent of the problem

Millions of people, especially in sub-Saharan Africa, are prey to common species of parasites, and often harbour several different parasite species simultaneously. Parasites, including malaria, bilharzia and intestinal worms, live off others, deriving food and shelter from their hosts.

Malaria is ’caused by parasites transmitted to people through the bites of infected mosquitoes’ with 198 million cases in 2013 (World Health Organization, 2014c). The disease killed 584 000 people in 2013, the majority of them children in sub-Saharan Africa. However, mortality rates have reduced by 47 per cent worldwide and by 54 per cent in Africa. Despite this, there are signs of increasing drug resistance to earlier generation medicines. Malaria also has significant economic effects, cutting growth rates in affected countries (World Health Organization, 2014c).

Bilharzia is even more widespread than malaria, and has been successfully controlled in many parts of the world, notably China, Japan, Brazil, Egypt and Morocco, but not in sub-Saharan Africa (Engels, Chitsulo, Montresor & Savioli, 2002). In 2013, more than 35 million people were treated for bilharzia and 83 per cent of these were in sub-Saharan Africa (World Health Organization, n.d.c). This lack of control in sub-Saharan Africa may be due to poverty, loss of diagnostic potential and the diversion of resources to more extreme health problems like HIV/AIDS and TB. Bilharzia tends to occur intensively over focal areas, so the total number of cases in a country may not be high, but some areas may have pockets of high-intensity infections.

The transmission and course of parasitic infections


There are four species of malaria, but Plasmodium falciparum is the main killer. All malaria is transmitted by the Anopheles mosquito, as it moves from one human host to another. The sporozoites (malaria parasites) find their way to the liver within minutes of the mosquito biting a host. In the liver they divide rapidly over about a week, forming thousands of merozoites, which burst out of the liver into the bloodstream, where they invade red blood cells, contributing to anaemia. This situation develops rapidly, and if unchecked, the inability to deliver oxygen to the body’s vital organs can result in death.

Usually the disease is limited either by treatment or by the host’s immune system, but in some cases it causes serious damage or death, for example in cerebral malaria where the patient is likely to have convulsions and may go into a coma (Marsh, 2002). Repeated infections are a fact of life for people living in malaria-endemic areas, and over time they acquire some degree of immunity.


The case of Bahati Kazungu shows how devastating the effects of cerebral malaria can be, although less than five per cent of children who survive will have such a severe outcome.

Bahati was two years old when he fell ill with malaria. By the time he and his mother had completed the two-hour bus journey to the nearest hospital, he had suffered three episodes of seizures, and was in a deep coma, where he remained for four days. At admission, Bahati was found to have a high number of Plasmodium falciparum parasites in his blood. He had no more seizures, but he had severe respiratory problems, and his blood sugar fell. When Bahati came out of his coma the doctors thought he was on the slow road to recovery. Unfortunately, within days Bahati fell back into a coma, a relatively uncommon biphasic pattern of illness. Bahati came out of the second coma, but he was discharged with severe impairments, and later developed epilepsy.

Five years later, he was still on regular medication and had severe cognitive impairments. He was unable to speak, wash and dress. His family members shared the 24-hour care that he needed. His older siblings tried to train him to feed himself. Bahati is able to walk, pick up objects, and stay close to his family, but he will remain totally dependent upon them (personal communication, P. Holding, Kilifi, Kenya).


Schistosoma haematobium and Schistosoma mansoni are the two main species of bilharzias affecting humans in southern Africa. All bilharzias are transmitted by water. When an infected person urinates in water, the eggs of the bilharzia parasite hatch into swimming miracidia. These penetrate water snails and develop further. They then move out into the water, ready to penetrate the skin of people where they come into contact. The eggs may lodge and calcify anywhere in the body, causing physical damage; in addition, loss of blood in the urine or faeces may contribute to anaemia.

The World Health Organization (WHO) advises member countries to control bilharzia through their primary health care systems; WHO has also designed strategies and assessment tools for high-burden communities and high-risk individuals (Montresor, Crompton, Hall, Bundy & Savioli, 1998; Montresor, Gyorkos, Crompton, Bundy & Savioli, 1999; World Health Organization, n.d.c). On the positive side, Praziqantal, the drug of choice, is freely available, and control can be effected through the delivery of regular chemotherapy (probably only once a year) to primary children at school. There is, however, a risk that resistance to this drug will emerge, as it has for many other treatments.

Other common parasites

Other very common parasite species common among children in sub-Saharan Africa include three kinds of roundworm: Ascaris, Trichuris and hookworm. The intestinal roundworm (Ascaris lumbricoides), in particular, may cause intestinal obstructions. Trichuris (Trichuris thrichiura) is also a form of roundworm called a whip-worm, which primarily lives in the large intestine, while the hookworm lives in the small intestine. All of these parasites are likely to cause diarrhoea and nutritional deficits which will reduce the body’s available energy, thus affecting brain development.


Figure 23.5 Poor hygiene in informal settlements increases vulnerability to disease and parasitic infections

Bio-psychosocial influences that increase vulnerability to parasitic infections

Anyone who is exposed to parasites may contract parasitic infections. However, parasites thrive in the following conditions:

•where nutrition and hygiene are poor

•where water and sanitation services are inadequate

•where preventative services are weak

•where treatment is difficult to obtain

•where the physical environment is hot and/or humid

•where poverty and destitution are widespread.

As is already clear, anyone with a compromised immune system or chronic illness (HIV/AIDS and/or TB) and living in such conditions is particularly vulnerable to parasites.

In the case of malaria, children, pregnant women and non-immune travellers are at greater risk of severe disease and death. In the case of bilharzia, children (usually from eight to 14 years) who play in rivers are the most likely to acquire the infection. Children are also more likely than adults to suffer serious effects from parasitic infections, due to their special nutritional needs for growth and cognitive development.

The role of psychology in the prevention and control of parasitic infections

Like HIV/AIDS and TB, prevention of parasitic infections should be manageable. However, in practice, a range of factors compromise effective prevention of parasitic diseases. Psychology can play a role in the development of behaviour change strategies. With regard to prevention, the following is important:

Malaria: Encourage people to cover themselves at night as well as to use mosquito nets and insecticide sprays.

Bilharzia: Encourage people living in infected areas to stop urinating in the local dams, lakes or rivers; to avoid swimming in contaminated water, and to have regular medical check-ups at the local clinic.

As with HIV/AIDS and TB, these behaviour change strategies are likely to be mediated by socio-economic factors. In some instances, covering up may not be practical, sprays may be too expensive and not bathing in contaminated water may be impractical because of constraints on water supply.

Again like TB, psychology can play an important role in the control of parasitic infections through understanding treatment-seeking and adherence behaviours, and developing strategies to address these.

The impact of parasites on mental health

Even if not fatal, cerebral malaria may cause severe and sometimes permanent structural damage to the brain and nervous system (see Box 23.9). Furthermore, both malaria and bilharzia considerably weaken and fatigue the body, which affects an individual’s mental health. The effect on children and foetuses is particularly devastating.

Psychologically, there can be little doubt that parasites affect the cognitive development and the socialisation of children. Being rundown and/or bedridden leads to absence from school and being unable to take part in social interactions and events. Developmentally, parasite infection may negatively impact the acquisition of skills in various domains in the preschool years, and the later development that normally follows on from these foundations. (For example, motor development precedes and facilitates the development of language and social skills, which involve the exchange of ideas and viewpoints and enable the formation of concepts.) Thus, the damage to psychological functioning is likely to be linked to the time of acquisition of the infection, its intensity and duration.

Table 23.1 Some examples of how psychology can contribute to the control of infectious and parasitic diseases

Health-related activity

Example of how psychology can contribute

Prevention of infection

Design and evaluation of prevention programmes

Reducing stigma

Design and evaluation of community-based programmes

Treatment support

Devise approaches to treatment that fit easily into patients’ lives and which do not alienate patients

Community-based care

Support family members and other carers in dealing with disablement, losses, and care of people who are ill, and those affected by illness and deaths in their family and social groups

Support to health care personnel

Train front-line health care personnel on psychological issues; providing support for patient-centred care

Advocacy for resources

Document the cognitive and mental health impact of parasitic infections, and bring the social cost of these infections to the attention of authorities

Health care innovation

Explore and evaluate new ways in which health care can be delivered, taking into account different social, economic and cultural contexts

Make health a community-wide issue

Work with community-based structures (such as civic, women’s and men’s organisations) to put health issues on their agenda for social change and development

It is, however, difficult to find evidence clearly linking parasitic infections to cognitive deficits in contexts that are fraught with other risk factors for development (such as poverty and poor nutrition). The evidence is mounting, however, and a pilot study tracking school-based control of bilharzia (as well as other parasites) in endemic areas showed that there was an association between grade repetition and high parasite load (Kvalsvig et al., 2001). A more recent publication (Eppig, Fincher & Thornhill, 2010) looked at the energy cost of parasitic infections in young children and showed a negative correlation between infectious disease and IQ at a national level. Further research is needed to establish a causal relationship.


•Malaria is caused by parasites transmitted to people through the bites of infected mosquitoes. Children in sub-Saharan Africa are most affected.

•Bilharzia is even more widespread than malaria; again, sub-Saharan Africa is most affected.

•All malaria is transmitted by the Anopheles mosquito. The parasites divide rapidly in the liver and then cause anaemia by invading red blood cells, which deprives vital organs of oxygen. Cerebral malaria may cause convulsions and death.

•Some people become partially immune to malaria due to repeated exposure.

•All bilharzias (Schistosoma) are transmitted by water. The eggs hatch into miracidia which develop further in water snails. When they move back out into the water, they can penetrate the skin of people who come into contact.

•The eggs may calcify or cause loss of blood in the urine or faeces, contributing to anaemia.

•Other common parasites include three species of roundworms.

•Parasites thrive in conditions of poverty, poor nutrition and hygiene, high humidity and heat, and weak health services.

•Children and people with compromised immune systems or chronic illness are particularly vulnerable.

•Psychology can play a role in the development of behaviour change strategies and through understanding treatment-seeking and adherence behaviours, and developing strategies to address these.

•Cerebral malaria may cause permanent structural damage to the brain and nervous system.

•Both malaria and bilharzia weaken and fatigue the body, with devastating effects on children and foetuses.

•Parasites impact negatively both on the cognitive development and socialisation of children, although they often occur in contexts with many other risk factors for development.


The human condition is determined by mental and physical factors that are inextricably linked. Nutrition is a key aspect of mental and physical health, especially in cases of HIV/AIDS, TB and parasite infection. In the same way, poor nutrition may also result from mental and physical ill health.

Poverty, under-development and poor education are significant barriers to good nutrition in resource-poor environments. These factors also increase vulnerability to HIV/AIDS, TB and parasite infection. In addition to the obvious biophysical effects, disease perpetuates poverty and restricts economic growth at a societal level (there are medical costs of treatment and prevention, educational costs for interrupted and delayed schooling, financial costs due to job losses and the difficulty of finding employment if under prolonged treatment).

Furthermore, those who are ill need to be cared for, and they are frequently socially marginalised. They may have to bear the brunt of prejudice, they may feel anxious, depressed and guilty. Their growth and development may be stunted, thereby affecting their identity and sense of self. Family and carers may also suffer psychologically in the face of these illnesses.

However, most psychological and mental health problems associated with nutrition, HIV/AIDS, TB or parasites are preventable and/or can be remedied with appropriate intervention. Psychologists are already making important contributions (see Table 23.1), but much still needs to be done. An important strength of psychology is that, as a science, the discipline requires that we measure the outcomes of what we do, and that we apply the lessons we learn from both our successes and failures.


ImageABC model of prevention: a model of HIV/AIDS prevention (abstinence, be faithful, condomise)

Imageacquired immunodeficiency syndrome (AIDS): a collection of symptoms and infections resulting from damage by the human immunodeficiency virus to the human immune system

Imageantiretroviral treatment (ART): medication that slows down the rate at which the HI virus multiplies in the body and therefore allows HIV-infected people to stay healthy for longer

Imagebilharzia: a parasitic infection that is transmitted by water contaminated with parasites such as Schistosoma haematobium and Schistosoma mansoni

ImageBirth to Twenty (Bt20): the largest and longest-running birth cohort study of child health and development in South Africa, which has tracked children born in Johannesburg-Soweto during a seven-week period in 1990

Imagedirectly observed treatment (DOT): a strategy recommended by the World Health Organization for the detection and cure of tuberculosis

Imagediuretics: drugs which increase urination

Imageextensively drug-resistant TB (XDR-TB): tuberculosis that does not respond to even second-line drug treatment options

Imagehuman immunodeficiency virus (HI virus/HIV): the virus that leads to the acquired immunodeficiency syndrome (AIDS) in humans

Imagelow birth weight (LBW): weight at birth that is below 2.5 kg

Imagemacronutrients: nutrients such as carbohydrates, fats and proteins that are needed or used in relatively large quantities in order for an organism to function normally

Imagemalaria: a parasitic infection that is carried by the Anopheles mosquito

Imagemalnutrition: faulty or inadequate nutrition

Imagemenarche: the start of menstrual bleeding and reproductive functioning

Imagemerozoites: malaria parasites that divide in the liver and then enter the bloodstream, where they invade red blood cells

Imagemicronutrients: nutrients such as iron, calcium and vitamin A that are needed or used in relatively small quantities in order for an organism to function normally

Imagemiracidia: larvae of the bilharzia parasite

Imagemulti-drug resistant TB (MDR-TB): tuberculosis that does not respond to the commonly used treatment drugs, isoniazid and rifampicin

Imagenon-organic failure to thrive (NOFTT): growth retardation most likely due to inadequate nutrition that results from biological and environmental factors that intersect in such a way as to preclude adequate nourishment of the child

Imageobesity (over-nutrition): an increase in body weight beyond skeletal and physical requirements, resulting from an excessive accumulation of fat in the body

Imagepulmonary TB: tuberculosis of the lung, which is the most common form of tuberculosis

Imagerecommended dietary intakes (RDIs): norms developed by the nutritional sciences for required food intake under normal conditions

Imagesporozoites: cells that develop in a mosquito’s salivary glands, which enter the liver of a person who has been bitten by a mosquito

Imagetuberculosis (TB): a highly infectious disease that most commonly affects the lungs

Imagevery low birth weight (VLBW): weight at birth that is below 1.5 kg


Multiple choice questions

1.Which of these statements are true?

a)Environmental exposure, particularly nutrition, within the first year of life after birth is critical in determining an individual’s risk of developing mental illness.

b)Poor maternal health and nutrition during pregnancy can programme the foetus’s physiology in a way that can contribute to the risk of diseases such as obesity.

c)A baby born with low birth weight is at risk of respiratory problems, hyperactivity and neurological problems.

d)All of the above are true.

2.Two of the five most common causes of child deaths in the world are:

a)HIV/AIDS and measles

b)malaria and over-nutrition

c)pneumonia and malnutrition

d)measles and chicken pox.

3.Adolescence is considered to be a nutritionally vulnerable phase because of:

a)the increased demand for macronutrients (carbohydrates, fats and proteins) and micronutrients (e.g. iron, calcium and vitamin A) to meet the dramatic increase in physical growth and cognitive development

b)environmental influences and the shift in attitudes and perceptions around foods and body esteem, which may result in pathological eating behaviour

c)special nutrient needs associated with participation in sports, adolescent pregnancy, development of an eating disorder, excessive dieting, and the use of alcohol and drugs.

d)All of the above are correct.

4.The obesity epidemic in South Africa particularly affects:

a)young men in their teens

b)adult women

c)young women in their teens

d)adult men.

5.Which of the following is not a common nutritional complication of HIV infection and AIDS?

a)lactose intolerance

b)gluten intolerance

c)fat malabsorption

d)AIDS-related anorexia.

6.Psychology can contribute to the prevention and control of HIV/AIDS, TB and malaria through:

a)providing behaviour change strategies

b)researching the impact of these diseases on mental health and cognitive functioning

c)voluntary counselling and testing

d)all of the above are correct.

7.The most common method of transmission of HIV in Africa is through:

a)homosexual intercourse

b)mother-to-child transmission

c)sharing of needles during intravenous drug use

d)heterosexual intercourse.

8.Women and girls are more vulnerable to HIV infection because they are:

a)biologically more vulnerable

b)less able to negotiate sexual interaction because of economic and gendered power relations

c)vulnerable to sexual violence

d)all of the above are correct.

9.Increasing self-efficacy with regard to negotiating safe sex is an example of an intervention at:

a)the community level

b)the individual level

c)the interpersonal level

d)the societal level.

10.Tuberculosis can affect psychological functioning by:

a)leading to illness and people being off work and school

b)people being marginalised from their social groups because of stigma

c)in rare cases, affecting brain functioning

d)all of the above are correct.

Short-answer questions

1.Describe the disorder termed ’non-organic failure to thrive’.

2.Why is adolescence considered a nutritionally vulnerable phase?

3.What psychological and physiological dangers are associated with dieting?

4.In what ways does nutrition interact with the aging process?

5.’HIV/AIDS affects nutrition directly and indirectly.’ Discuss this statement.

6.What are the risk factors that make women of childbearing age particularly vulnerable to HIV infection?

7.Describe how HIV/AIDS impacts on mental health.

8.Critically discuss the directly observed treatment (DOT) approach to treating tuberculosis.

9.Describe the bio-psychosocial influences that increase people’s vulnerability to parasitic infections.


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