Professor Collins Iwuji

Professor Collins Iwuji is Professor of Global Health and HIV Medicine at the Brighton and Sussex Medical School and holds a faculty position in Population Science at the Africa Health Research Institute, South Africa. He tells us about his SSRP-funded research investigating the relationship between drought and HIV treatment and care in South Africa.

How would you describe your research background?

I’m an HIV physician, so my research initially focused on HIV treatment outcomes and adherence, HIV drug resistance, and how to improve treatment outcomes in people living with HIV.

How and why did your research move towards environmental and sustainability issues?

I was based in South Africa where I was undertaking HIV research, and the area I worked in, UMkhanyakude, was experiencing quite significant drought at the time. It was described as the worst since record-keeping began, resulting in the government declaring a state of disaster. People were queuing to get water. This is an area with high HIV prevalence – about 30 percent of the population are HIV positive.

Looking at these queues, I was thinking that about three out of 10 people in that queue would need to be in clinics for their repeat HIV medications. Because water was in short supply, though, some people would miss their appointments. I was too busy at the time with other work so didn’t do anything about it.

But you obviously returned to the issue later?

Yes. In 2017, I left South Africa to take up a position at the Brighton and Sussex Medical School. The first week I was there, I was told about the SSRP seed funding for projects with an environmental component. At that point I remembered my experience in South Africa, and I thought this would be a good opportunity to test my hypothesis: that the added shock from drought could lead to people living with HIV, prioritising their livelihoods over healthcare, resulting in HIV treatment interruption. That was my proposal.

How did you go about testing this hypothesis?

There were four different strands of work: a systematic review, qualitative interviews, quantitative analysis, and examination of institutional responses to the drought. We wanted to look at the impact of drought on HIV treatment adherence and retention in care. We decided to start with a systematic review, which required looking at the existing literature in segments. We looked at the impact of drought in Africa, treatment adherence in people living with HIV, and drought and health. We then triangulated these three sources of data to formulate a conceptual framework.

We thought, there was no direct relationship between drought and HIV, and there was no reason why there should be. But the relationship between the two was indirect. We were able to plot the different connections linking drought to poor HIV adherence and retention in care using systems thinking.

And what did the results of your other methods tell you?

We wanted to test the findings of the systematic review and conceptual framework empirically. So we did interviews with 30-35 people, a mixture of people who had dropped out of care and those who had remained in care during the drought period. The predominant theme of these interviews was that economic reasons like food insecurity provided an obstacle to HIV treatment. For instance, people did not want to take their medication on an empty stomach. During drought, people went without food and therefore didn’t take their medication. There were psychosocial issues like people’s state of mind and relationship with the healthcare system. People also migrated away from the drought area and fell out of contact with their clinics and didn’t establish contact with a healthcare provider in the new area they relocated to.

But we wanted to make sure our interview subjects weren’t just telling us what we wanted to hear, and that the data would support their responses. We looked at data from about 40,000 people living with HIV with over 1 million clinic visits . We used a technique called interrupted time series analysis to look at adherence to treatment just before the drought period, during the drought, and after the drought. What we found was that adherence dropped during the drought. There was some recovery post-drought, but not complete recovery. The same was true of retention in care.

Did the data reveal any other interesting results?

We looked at whether the effect was different by gender and age. We saw that women were more impacted than men in terms of reduced treatment adherence and  retention in care, which made sense, because they would be the ones looking for water and trying to hold the family together. In this context, women would do all the housework. Younger people were more impacted than older people. Young people already have a lot of reasons not to go to the clinic, and the drought was just another one.

What was the national context of this regional issue, in terms of policy and governance?

South Africa has a disaster preparedness and response plan outlining what should happen during natural disasters like drought. They have excellent documents describing what should happen, but implementation was weak and fragmented. There is a South African Weather Service which issues early warnings about events like drought. But again, the documents were good, implementation was poor.

Is there anything that has been, or can be, done about this problem – or was that outside the scope of your research?

It was outside the scope of that project, but we made recommendations based on our findings. One of these was improving information flow between the different sectors of government. It shouldn’t just be something the health sector deals with – it requires a multisectoral approach, involving the department of social welfare, disaster response and agricultural sectors, as well as the South African Weather Service amongst others

The problem with drought, though, is it’s not like a flood – you can track floods more accurately. With drought, it’s difficult to say exactly when it will start and end. It creeps up on people gradually. We also recommend that farmers grow drought-resistant crops, supported by government financial aid. Lots of people had failed crops during the drought resulting in financial hardship.

What are the recent developments in UMkhanyakude?

Three years ago there was catastrophic flooding in KwaZulu-Natal, with Durban more heavily impacted. The flooding killed nearly 500 people and displaced 40,000. All sectors were caught unprepared. Since then, structures and mechanisms have been put in place to better respond to future events. The intensity of these events is increasing with climate change. The Government has acted on our recommendations and is now taking the problem seriously.

What else have you been working on recently?

The data we garnered from the SSRP project gave me and my research partners some credibility in the climate and health space, so we have used that study to inform applications for more projects. We have started a project, funded by the National Institute for Health and Care Research, on health system resilience in the context of extreme weather events in South Africa, Zambia and Mozambique. We have another project, funded by Wellcome, looking at the mental health impacts of extreme weather events in South Africa, Burkina Faso, Kenya and Mozambique. These are countries that suffer recurrent extreme weather events. These events have huge psychological effects when people lose loved ones, their livelihoods, and homes.

How do you split your time between Sussex and South Africa?

I run the research activities I’ve just described here in South Africa. If the work is here, it doesn’t make sense for me to be in the UK full-time. What brings me to the UK is clinical work. I do three months of clinical work in Sussex over the course of a year, and the rest of the time I’m in South Africa.

Professor Iwuji’s research supports the fulfilment of the following Sustainable Development Goals:

SDG 3 – Good Health and Well-being
SDG 8 – Decent Work and Economic Growth
SDG 13 – Climate Action