food assistance in the context of hiv: ration design guide · i < food assistance in the context...
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FoodAssistanceintheContextofHIV:RationDesignGuide>i
FoodAssistanceintheContextofHIV:
RationDesignGuide
July2008
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FoodAssistanceintheContextofHIV:
RationDesignGuide
i <FoodAssistanceintheContextofHIV:RationDesignGuide
TableofContents
Table of Contents ii
Acknowledgements iii
Acronyms iv
At a Glance 1
Introduction 2
Section 1: Food, Nutrition and HIV 5NutritionalrequirementsofpeoplelivingwithHIV....................................5
Sub-populationsaffectedbyHIVandAIDSthatcouldbetargetedthroughWFP’sprogrammes......................................8
Section 2: Ration Design–the Five Steps 15Step 1:Reviewthenutritionandfoodsecuritysituationofthetargetedpopulation......................................................15
Step 2:Reviewtheobjectivesoftheprogrammeandtheroleoftheration.....................................................................17
Step 3:Determinehowmuchfoodneedstobeprovidedandforhowlong...................................................................20
Step 4:Selectthemostappropriatefoodcommoditiesandtypeofrations..........................................................23
Step 5:Consideractivitiestoputinplacetoenhancetheproperuseofthefoodration............................................28
Section 3: Monitoring the Ration and Operational Considerations 31Monitoring.........................................................................................31
Operationalconsiderations..................................................................32
FoodAssistanceintheContextofHIV:RationDesignGuide>ii
Section 4: Food Aid Commodities 37Cereals..............................................................................................37
Pulses...............................................................................................37
Oil.....................................................................................................38
Fortifiedblendedfoods.......................................................................39
Sugar/salt..........................................................................................39
Animalproducts.................................................................................40
Driedskimmedmilk............................................................................41
Ready-to-UseTherapeuticFood...........................................................41
Micronutrientpowders........................................................................42
Breastmilksubstitute..........................................................................42
Otherspecializedproducts..................................................................43
Section 5: Examples of Ration Design Process 45HypotheticalCase:FoodAssistanceinResponsetoDroughtandConflictin‘Gotongo’.....................................45
Exercise1:RationdesignforPLHIVinIDPcamps.................................47
Exercise2:RationdesignforOVCinSouthernProvince........................49
References 52
iii <FoodAssistanceintheContextofHIV:RationDesignGuide
Acknowledgements
This guide was developed through extensive consultations with many WFPcolleaguesbasedinthefieldandinHeadquarters,whomwewishtothankfortheirvaluablecontributions.WewouldliketosingleoutthespecialcontributionsofFrancescaErdelmann(currentlywithWFPMozambique),whodevelopedtheearly draft of this guide, which was later restructured and retooled into thepresentguidethankstopainstakingworkbyWillyMpoyiwaMpoyi(HIVandAIDSService)andAndrewThorne-Lyman (NutritionService),whoalsocoordinatedandmanagedtheguidedevelopmentprocess.
Special thanks go to the following colleagues who provided specific input:JohnSsemakalu(WFPUganda),NeilBrandenandSimonSadler(WFPBangkokRegional Bureau), Thobias Bergmann, Laurence Bequet and Mary Njoroge(PDPH),SibiLawsonandKebbyMutale(WFPZambia),andOlivierNkakudulu(WFPDakarRegionalBureau).
Wewould like to thankDelphinDiasoluaNgudi (UniversityofGent,Belgium),who reviewed the draft and incorporated the substantive comments fromvariouscolleagues.
We would also like to thank Robin Landis for her sound advice and BrettShapiro,oureditorialconsultant,forhisefficientworkineditingandformattingthisguide.
Finally,wearethankfultoRobinJacksonandMartinBloem,respectivelyformerChief, and current Chief of the HIV andAIDS Service, for their support andleadership.
FoodAssistanceintheContextofHIV:RationDesignGuide>iv
Acronyms
ART Anti-retroviraltherapyARVs Anti-retroviraldrugsCDC USCentersforDiseaseControlandPreventionCSB corn-soyablendDOTS DirectlyObservedTreatment,short-courseDSM driedskimmilkEDP extendeddistributionpointFBF fortifiedblendedfoodFDP finaldistributionpointFFW foodforworkGFD GeneralFoodDistributionHBC home-basedcareIDP internally-displacedpersonLIFD low-incomefood-deficitMNP micronutrientpowdersODOC OtherDirectOperationalCostOVC orphansandothervulnerablechildrenPDPH HIVandAIDSServiceinWFPHeadquartersPLHIV peoplelivingwithHIVPMTCT preventionofmother-to-childtransmissionPRRO protractedreliefandrecoveryoperationRDA RecommendedDailyAllowanceRTUF ready-to-usefoodRUTF ready-to-usetherapeuticfoodTB tuberculosisTFD targetedfooddistributionWHO WorldHealthOrganizationWSB wheat-soyablend
1 <FoodAssistanceintheContextofHIV:RationDesignGuide
At a Glance
1. Mostofthecoreprinciplesofnutritionandrationplanningforpeopleliving
withHIVarethesameastheyareforpeoplewhoareuninfectedbythevirus.
2. Abalanced,healthydietthatprovidesforadequateintakeofenergy,protein,
fatandmicronutrientsisessentialforthehealthandsurvivalofallpeople,
regardlessofHIVstatus.
3. Auniversallyapplicable“HIVration”doesnotexist.
4. HIVbyitselfdoesnotmeanthatpeoplearefoodinsecure.Thefoodsecurity
assessmentdataofpotentialbeneficiariesmustbereviewedaspartofthe
rationdesignprocess.
5.The World Health Organization (WHO) recommends increasing energy
requirementsby10percenttomaintainbodyweightandphysicalactivity
inasymptomaticHIV-infectedadultsandgrowthinasymptomaticHIV-infected
children.ForsymptomaticHIV,energyrequirementsincreaseby20-30percent
foradultsandby50-100percentforchildrenexperiencingweightloss.
6. Unlesspotentialbeneficiariesaretotallydependentonfoodassistancefor
survival,thefoodprovidedshouldserveasanutritionalsupplementand/or
foodsecuritysupportthatcomplementsthebeneficiary’sdiet.
7. WhereWFPprovidesstaplefoodstopopulationswithhighHIVprevalence,
thesestaplefoodsshouldbemilledandfortifiedwherepossibletoprevent
micronutrientdeficiencies.
8. The food provided by WFP should be complemented with fresh foods
whereverpossible.
9. NutritioneducationshouldbeanessentialcomponentofHIV-relatedactivities,
as itcanhelpbeneficiariesdealwithsymptomsof thevirus,manageside
effectsofmedication,andpreventadversenutrient-medicineinteractions.
FoodAssistanceintheContextofHIV:RationDesignGuide>2
Introduction
“We’restartinganewactivityrelatedtoHIV… WhatrationshouldIgive?”
ThisquestionisoneofthemostfrequentlyaskedquestionsposedtotheNutritionandHIV/AIDSServicesinWFPheadquarters.PlanningafoodrationforapopulationthatisaffectedorinfectedbyHIVcanoftenbedaunting.StudiesofnutritionandHIVarerelativelynew,asarefood-basedprogrammesthataimtorespondtotheHIVpandemic.ThereislittleguidancetohelpplanrationsfortargetedfoodandnutritionactivitiesaimedatsupportingthecareandtreatmentofpeoplelivingwithHIV,orforpopulationsmadevulnerablebythepandemic.
This guide was developed to help ensure that the rations provided throughWFP’sprogrammesaredesignedthroughaprocess thatconsiders theneedsofthe beneficiaries as well as the practical concerns that dictate the feasibility ofimplementingprogrammes.Itisimportanttorememberthatplanningrationsisonlypartofalargerprocessofprogrammedesign.
This guide has been prepared primarily for WFP programme officers in thefield who are responsible for designing rations for HIV programmes. The guidewill also be helpful to other agencies, including WFP co-operating partners,to help them understand the rationale behind different WFP rations and tostrengthenpartnership.
Theguideisdividedintofivesections.Section1discussestheneedsofpopulationsaffectedbyHIVandtheirrelevancetoWFPprogramming.Section2presentsthestepstodesigningfoodrationsthat take intoaccount theHIVcontext.UsersareadvisedtofamiliarizethemselveswiththefivestepsdescribedinthissectionandapplythemtodesignrationsfortheirHIV-assistedprogrammes.Section3discussesoperationalconsiderationsofplanningandprovidingfoodrationsinanHIVcontext.Section4discussesfoodaidcommoditiesandsection5providesexamplesoftherationdesignprocess.Referencesandhyperlinksaregiventoprovideuserswithfurtherreadingmaterialsonthesubject.
3 <FoodAssistanceintheContextofHIV:RationDesignGuide
FoodAssistanceintheContextofHIV:RationDesignGuide>4
Section1:Food,NutritionandHIV
Section 1: Food, Nutrition and HIV
5 <FoodAssistanceintheContextofHIV:RationDesignGuide
Section1:Food,NutritionandHIV
Nutritional requirements of people living with HIV
“Adequatenutrition,whichisbestachievedthroughconsumptionofabalanced
healthydiet,isvitalforhealthandsurvivalofallindividualsregardlessofHIVstatus.”
–WHONutrientRequirementsforPeopleLivingwithHIV(PLHIV)
ScientificknowledgeaboutthespecificnutritionalrequirementsofPLHIVremainslimited,despiteamarked increase in thenumberofscientificstudiesconductedin recent years.2; 3; 4The table below presents the main conclusions of aWHOtechnical assistance group meeting convened in 2003 to examine the scientific
evidencebaseofnutritionalrequirementsforPLHIV.
Box 1: Macronutrient requirements of PLHIV
Nutrient Population Group Recommendation*
Energy AsymptomaticHIV+adults Increaseof~10%
AdultswithsymptomaticHIVinfectionorAIDS(includingpregnant/lactatingwomen)
Increaseof~20-30%
AsymptomaticHIV+children Increaseof~10%
Childrenexperiencingweightloss(regardlessofHIVstatus)
Increaseof~50-100%
Childrenwithsevereacutemalnutrition NochangefromWHOguidelines
Protein Allpopulationgroups Nochangeindicatedtodate(10-12%oftotalenergyintake)
Fat IndividualswhoareHIV-orHIV+butnottakingantiretroviraldrugs
Nochangeindicatedtodate(atleast17%oftotalenergyintake)
*ComparedwithnormaldietaryrequirementsfromWHO.Sources:WorldHealthOrganization(WHO).“NutrientrequirementsforPLHIV.”Geneva:WHO,2003;
WHO.“Executivesummaryofascientificreview.ConsultationonnutritionandHIV/AIDSinAfrica:evidence,lessonsandrecommendationsforaction”.Durban,SouthAfrica10–13April2005.WHO,Geneva,2005
FoodAssistanceintheContextofHIV:RationDesignGuide>6
Asnotedinthetable,thereisa10percentincreaseintheamountofenergyneededbypeoplelivingwithHIVwhohavenotyetbegunexperiencingsymptoms.Energyneedsincreaseby20-30percentforadultsdevelopingsymptomsandby50-100percentforchildrenexperiencingweightloss.Fromanutritionalperspective,havingadequateenergy intake (alongwithadequate intakeof cleanwater) is themostessentialthingthatPLHIVcandotomaintaintheirhealthandweight,andtoengagein normal activities.Although a lack of appetite and the symptomsof infections(suchasmouthsores)maymakeitdifficulttoeat,itisimportanttoincreaseenergyintakeoncenormalappetitehas returnedduring the recoveryphase fromacuteinfection.Currentevidence is insufficient to recommend increasedproteinor fatrequirementsduetoHIVinfection,althoughincreasingfoodconsumptiontomeetenergyneedsimpliesaproportionalincreaseinproteinandfatintake.
Vitaminsandminerals(micronutrients)arevitalforallpeople,butareparticularlyessential for people with compromised immune systems. At the same time,micronutrientdeficienciesareverycommonamongPLHIV.RecentrecommendationsbyWHOconcerningintakeofmicronutrientsareprovidedinBox2.
Box 2: Micronutrient requirements of PLHIV
“HIV-infected adults and children should consume diets that ensure
micronutrient intakes at RDA levels. However, this may not be sufficient to
correctnutritionaldeficiencies inHIV-infected individuals…Safeupper limits
fordailymicronutrientintakesforPLHIVstillneedtobeestablished.”
Food insecurity and dietary diversity
LackofdietarydiversityisoneofthemainnutritionalchallengesfacedbypopulationsinthecountrieswhereWFPoperates.(Forexample,insub-SaharanAfrica,70-80percentofenergyconsumedcomesfromstaplesandtubers.)Thislackofdietarydiversityisamajorcauseoffoodinsecurityandmicronutrientdeficienciesingeneral,butmoresoforhouseholdsinwhichchronicillnesshasledtopovertyandchangesinagriculturalpractices.5BecauseHIVinfectionusuallyimpactsfoodconsumption
7 <FoodAssistanceintheContextofHIV:RationDesignGuide
andutilization,itfurtherincreasestheriskofmicronutrientdeficiencies.Therefore,itisextremelyimportanttostrivetoensurethatbasicmicronutrientneedsaremet–throughadiversediet,fortifiedfoodsormicronutrientsupplements.
HIV and AIDS symptoms, opportunistic infections, and their effect on food consumption, absorption and nutritional status
AdvancedformsofHIVinfectionandAIDS,aswellasmedicaltreatmentitself,areoftenaccompaniedbyvarioussymptomsthatinterferewithfoodconsumptionandutilization,bothofwhichoftenleadto“wasting”.Wasting–thethinnessassociatedwith lossofbodyweight– isoneof themajorsymptomsofAIDS.6;7AIDS-related“wastingsyndrome”isdefinedbytheUSCentersforDiseaseControlandPrevention(CDC)8asa10percentweightlossfrombaselineinasix-monthperiodaccompaniedbydiarrhoeaorfeverformorethan30dayswithoutaknowncause.
TypicalsymptomsexperiencedbyPLHIVareshownintheboxthatfollows.9
Box 3: Symptoms commonly experienced by PLHIVDiarrhoeaDiarrhoeaisaproblemformanyPLHIV;itleadstolossofwaterandminerals
fromthebody.Inseverecases,diarrhoeacausesdehydration,poorabsorption
of food, significant weight loss and malnutrition, resulting in weakness and
furtherillness.
Lack of appetitePoorappetiteisoneofthemostcommonproblemsamongPLHIV.Itcanhave
manycauses,includinginfections,pain(particularlyinthemouthorabdomen),
depression,anxiety,fatigueorpoornutritionalintake.
Nausea and vomitingNausea reduces appetite and can be caused by certain foods, hunger,
infections,stressandlackofwater.Itcanalsobeaside-effectofmedicines.
FoodAssistanceintheContextofHIV:RationDesignGuide>8
Ifvomitingoccurs, thebodywill losewaterandmineralsandwilldehydrate
evenmorequickly.
Sore mouth or painful eatingSorenessof themouthand tongue iscommonamongPLHIV.Asmentioned
above,asoremouthcanmakeitdifficulttoeat,thusreducingfoodintake.
Digestive problemsPLHIVmayhaveproblemsdigestingcertainfoodsormaysufferfromconsti-
pationandbloating.Theseproblemsarecausedbydamageto thenaturally
occurring bacteria in the intestine, which are needed to digest food.
Thebacteriamaybedestroyedbyantibioticsorothermedicines.
Changes in taste of foodAsaresultofdrugside-effectsandinfections,peoplemayfindthattasteor
textureoffoodshaschangedfortheworse,thusdiminishingtheirappetite.
It is typical for PLHIV to experience repeated opportunistic infections (such aspneumonia,tuberculosis(TB)andcanceroustumors)contributingtomalnutrition.EffectivetreatmentofHIVinfectionorAIDSinvolvescarefulmonitoringandnutritionalmanagementoftheseconditions.VariousrecommendationshavebeendevelopedtohelphealthcarepractitionersimpartknowledgethatcanhelpfamilymembersandPLHIVmanagesymptoms.10;11Theserecommendationsarerelatedtothetypeoffoodstoconsume,fluidintake,mealfrequencyandsize,rest,andotherpracticesthatcanhelptodealwiththesymptoms.
Sub-populations affected by HIV and AIDS that could be targeted through WFP’s programmes
WFPprovides foodassistance to an array of beneficiaries that include refugeesand displaced persons during emergencies, vulnerable populations (such asmalnourishedchildrenorpregnantandlactatingwomen)toimprovenutritionandhealth,andspecificpopulationgroupstohelpthemrebuildtheirassetsandpromote
9 <FoodAssistanceintheContextofHIV:RationDesignGuide
theirfoodsecurity.WFPfoodassistancealsotargetschildrenthroughschoolfeedingprogrammes.PopulationsinfectedoraffectedbyHIVshouldbeconsideredforWFPassistance if theyaremalnourishedor food insecure,provided thatall theotherlogisticalconsiderationsforfoodprocurementanddistributionaremet.
Persons on anti-retroviral treatment
“Adequatenutritionisrequiredtooptimizethebenefitsofantiretroviraldrugs
(ARVs),whichareessentialtoprolonglivesofHIV-infectedpeopleandprevent
HIVtransmissionfrommothertochild.”
–WHOParticipants’Statement,DurbanConsultation,2005
Anti-retroviral therapy (ART)consistsof theconsumptionofspecificmedicationsto reduce the replicationofHIV.Someanti-retroviraldrugs (ARVs)affectnutrientutilization throughchanges inmetabolism,distribution,excretion,andabsorptionof nutrients. Therefore, ART is a process of drug and nutrition management –monitoringweightchanges,CD4countandsideeffects,andadjustingtheregimetostabilizethepatient.Therearealsoknowninteractionsbetweencertainfoodsanddrugsthathavebeensummarizedinotherpublications.12
PeoplegoingontoARToftensufferfrommalnutrition–theresultofopportunisticinfections, metabolic changes, and often household food insecurity. Focusednutritioninterventionscan“transformthepreventionandmanagementofHIV/AIDSandhelpgetthehealthofchildrenandadults‘backontrack.’”13
Orphans and vulnerable children affected by HIV
TheimpactoftheHIVepidemiconchildreniswidelyacknowledged.Worldwide,14millionchildrenundertheageof15havelostoneorbothparentstoAIDS.By2010,this number is expected to exceed25million.There is thus a growing concernaboutcareandsupportoforphansandothervulnerablechildren(OVC).
It isgenerallypreferable toplaceorphansorunaccompaniedchildrenwith localfamiliesratherthanwithorphanages.Butcaringforanadditionalchildcanbecome
FoodAssistanceintheContextofHIV:RationDesignGuide>10
aburdenwhenthefosteringfamilyispoor,orisheadedbyanelderlyorillperson
who is food insecure.Asupplementary rationcanease theburdenofcaring for
thesechildrenandenablemorefamiliestotakethemin.
OVCexpertsbelievethattraditionalriskfactorsforchildmalnutritionamongnon-
HIVinfectedchildren,suchasinsufficientintakeofqualityfoodsanddiarrhea,are
alsomajorcontributorstopoorgrowthinHIV-infectedchildren.
Based on current evidence in malnourished HIV-infected children who are not
receivingART,energysupplementationaloneappearstoimproveweightgainbut
nottoreversedeficitsinheight.14
ThereisevidencefromMalawithatseverelymalnourishedchildrenwhoareHIV-
positiverespondwelltotherapeuticcarethatmakeuseofreadytoeatfoods.15
MuchisstilltobelearnedaboutthenutritionalimplicationsofARTonchildren.Like
adults, children with HIV/AIDS often experience wasting syndrome and frequent
infections. Unlike adults, the additional nutritional demands associated with
growthmeanthattheeffectsofHIV/AIDSareoftenmoredevastatingforchildren
thanadults.
Children born to HIV-infected mothers
In resource-poor settings, theoverall riskofmother-to-child transmissionofHIV
is 15-25 percent in non-breastfeeding populations and 20-45 percent in breast-
feedingpopulations.16;17
InthelatestguidelinesfromWHOonpreventionofmother-to-childtransmissionof
HIV,“HIV-infectedwomen,includingthoseonART,areadvisedtooptforexclusive
breastfeedingasopposedto‘mixedfeeding’withbottle-feeding,waterorformula
feeding.HIV-infectedwomenshouldavoidbreastfeedingonlyifreplacementfeeding
isacceptable,feasible,affordable,sustainableandsafe.”18Currentprotocolsalso
recommendearlycessationofbreastfeeding(atsixmonths)inordertoreducerisk
oftransmission.
11 <FoodAssistanceintheContextofHIV:RationDesignGuide
Earlycessationofbreastfeedingpresentsasignificantnutritionalchallengetoyoungchildren,asbreastmilknormallyprovidesabouthalfoftheenergyconsumedbychildrenaged6-11months.Thelossofanimportantsourceofadditionalprotein,fats,mineralsandvitaminscanhaveserioushealthandnutritionalconsequences.
Pregnant and lactating women
Nutritionalrequirementsincreaseduringpregnancyandlactation,independentofHIVstatus.AnecdotalevidenceshowsthatpregnantwomenwhoareHIV-positivetendtobeintheearlystagesofHIVinfection,andthereforetendnottosufferextensivelyfromopportunisticinfections.LowbirthweightiscommonamongchildrenborntoHIV-infectedmothersandinaddition,thesechildrenoftensufferfrompoorgrowth.IrrespectiveofHIVstatus,targetedfoodassistancehasthepotentialtosignificantlyimprovethenutritionandfoodsecuritysituationofpregnantandlactatingmothersandtheirhouseholdmembers,especiallyinfantsandyoungchildren.
People supported through home-based care
According to WHO, home-based care (HBC) is the provision of comprehensiveservices(includinghealthandsocialservices)byformalandinformalcaregiversinthehome,inordertopromote,restoreandmaintainaperson’smaximumlevelofcomfort,functionandhealth.19Inmanyresource-limitedsettings,HBCistheonlywaytodelivercaretothepatient.Around50-60percentofPLHIVworldwidehavenoaccesstoprofessionalhealthcareworkerstoaddresstheirmedicalneeds,andthusrelyonHBCservices.
Due to increased nutritional requirements of PLHIV mentioned on page 5, foodassistanceneedstobeprovidedtomalnourishedorfoodinsecurepeople,usingtheHBCnetworkofvolunteers.TheimplementationofHBCactivitiesvariesconsiderably.However,HBCteamsoftenofferongoingcounselingandsupport,assistancewithprovidingandpreparing food, cooking, cleaning,woundcare,hygiene, symptomassessment,painandsymptommanagement,identificationofspecificopportunisticinfections,treatmentofsomeofthem,supervisionofdrugtaking,andmonitoringfordrugsideeffects.
FoodAssistanceintheContextofHIV:RationDesignGuide>12
Recommended reading
1. Recommendation for the Nutrient Requirements for People Living withHIV/AIDS(FANTA,2007)
2. Consultation onNutrition andHIV/AIDS inAfrica: Evidence, lessons andrecommendationsforaction,ICC,Durban,SouthAfrica,10-13April2005
http://www.who.int/nutrition/topics/consultation_nutrition_and_hivaids/en/index.html
3. FawziWWetal.StudiesofvitaminsandmineralsandHIVtransmissionanddiseaseprogression.JNutr135:938-944,2005.
4. FawziWWetal.ArandomizedtrialofmultivitaminsupplementsandHIVdiseaseprogressionandmortality.NewEnglJMed351:23-32,2004.
5. Conducting a situation analysis of orphans and vulnerable childrenaffectedbyHIV/AIDS,Williamson,Jetal.USAID,BureauforAfrica,OfficeofSustainableDevelopment,2004
6. AIDSandfoodsecurity.EssaysbyPeterPiotandPerPinstrup-Andersenand by Stuart Gillespie and Lawrence Haddad. Reprinted from IFPRI’s2001-2002annualreport.
http://www.ifpri.org/pubs/books/ar2001/ar2001e.pdf
7. Antiretroviral drugs for treating pregnant women and preventing HIVinfection in infants inresource-limitedsettings.Recommendationsforapublichealthapproach.WHO,2006
8. TheWorldHealthReport2005:Makeeverymotherandchildcount.WHO,2005 http://www.who.int/whr/2005/whr2005_en.pdf
9. HIV and Infant Feeding Technical Consultation on Prevention of HIVInfectionsinPregnantWomen,MothersandtheirInfants.WHO,2006
http://www.who.int/reproductive-health/stis/mtct/infantfeedingconsensusstatement.pdf
Continuedonnextpage
13 <FoodAssistanceintheContextofHIV:RationDesignGuide
10. KuhnLetal.“DoesSeverityofHIVDiseaseinHIVInfectedMothersAffectMortalityandMorbidityamongtheirUninfectedInfants?”ClinicalInfectiousDisease.41:1654-1661,December2005
http://www.journals.uchicago.edu/doi/pdf/10.1086/498029
11. IllifPJetal.EarlyExclusiveBreastfeedingReducesHIV-transmissionandIncreases HIV-free Survival. AIDS 2005, 19(7): 699-708and IncreasesHIV-freeSurvival.”AIDS2005,19:699-708
Continuedfrompreviouspage
Section2:RationDesign–theFiveSteps
Section 2: Ration Design —
the Five Steps
15 <FoodAssistanceintheContextofHIV:RationDesignGuide
Section2:RationDesign–theFiveSteps
Thedesignof rations for foodassistanceprogrammesdependsonanumberoffactors.Thissectiondescribesfivestepstohelpguidethedecision-makingprocessrelatedtorationdesignforHIV/AIDSactivities:
➤ Step 1: Review the nutrition and food security situation of the targeted population
➤ Step 2: Review the objectives of the programme and the role of the ration
➤ Step 3: Determine how much food is needed to be provided and for how long
➤ Step 4: Select the most appropriate food commodities and type of rations
➤ Step 5: Consider activities to put in place to enhance the proper use of the food ration
Itisimportanttorealizethatfoodrationdesignisaniterativeprocess,inwhichthefivestepsmaybe repeated.Theprocessalso requiresconsultationwith variousstakeholders, including operational and technical partners, national counterpartsandpreferablybeneficiaryrepresentatives.Althoughtheprocessmainlytakesplaceatthestageofprojectformulationandpreparation,therecommendedrationanditssubsequentusemustbecarefullymonitoredandmodifiedifrequired.
Step 1: Review the nutrition and food security situation of the targeted population
Thefirststepinthedesignofarationistoreviewvulnerabilityandfoodsecuritysituationdataofthetargetedpopulation.Datatobereviewedinclude:
• Proportionofthedailyfoodrequirementsthatcanbemetbyhouseholdsources
FoodAssistanceintheContextofHIV:RationDesignGuide>16
• Householdfoodstocksandstorage
• Seasonalpatternsoffoodinsecurityandmalnutrition
• Dietarydiversity–thetypesoffoodcommoditiesthatareconsumedbythehousehold
• Nutritionalwell-being–thetypesofnutritionalproblemsfoundandthepercentageofpeople(childrenandadults)whosufferfrommalnutrition(bothmacro-andmicronutrients)
• Foodpreparationpractices
• Dependencyratios
• Healthproblems,includingfactorsthatmayinfluencefoodconsumptionandutilization
• Householdlivingconditions–accesstofuel,safewater,sanitation,cleanenvironment,shelter,etc.
• Characteristicsofparticulargroupswhomaybemorevulnerableormoreatrisk
Theabove information isnormallyavailableat thecountryofficethroughreportsof foodsecurityassessmentsandnutritional surveysof vulnerablecommunities.This informationcanalsobecomplementedby rapid foodsecurity andnutritionassessmentsofthetargetedpopulation.
In the case of care and treatment programmes, other factors may need to beconsidered,suchas:
• Enrolmentinoruptakeofhealthandcareservices(doesfoodinsecuritypreventthetargetgroupfromseekingservices?)
• Attendanceatservicesandactivities(whatarethebarrierstoregularattendance?)
• Adherencetothemedicalprotocol
• Speedofrecovery(towhatextentdoprovidersbelievethatrecoveryfromsicknessisbeinginhibitedbypoornutritionalstatusorinadequatefoodintake?)
Manyofthesefactorsmaybedirectlyorindirectlyrelatedtofoodconsumptionandnutritionalvulnerability.
17 <FoodAssistanceintheContextofHIV:RationDesignGuide
Step 2: Review the objectives of the programme and the role of the ration
RationdesigninanHIVcontextwillbebasedontheprogrammeobjectivesandtheration’srole inachievingtheseobjectives. It isextremely important tobeable tojustifyandexplainthefoodbasketintermsofwhattheprogrammeaimstoachieve.Thefirststepinthisprocessistodefinetheroleofthefoodbasketinachievingtheobjective.Table1providessomeexamplesoftypicalobjectivesoffoodassistanceinHIVprogrammesandthepossiblecorrespondingroleofthefoodration.
Table 1: Examples of food assistance objectives in the HIV context
Food assistance objective Possible role of the ration in the HIV context
Maintainthenutritionalwell-beingofHIV+pregnantandlactatingwomen
Nutritionalsupplement,enablerforregularlyattendingPMTCTservices
ImproveadherencetoART Supportformanagingdrugside-effects,enablerforregularattendanceatARTsite
ProvideasafetynetforHIV-affectedhouseholds
Contributiontohouseholdfoodsupply,incometransfer,protectionofproductiveassets,reductioninadoptionofriskylivelihoods
EnhancelivelihoodsofolderOVCthroughlivelihoodtraining
Coverageofopportunitycostsfortimespentintraining,incentivetoattendandcompletetraining
Theobjective(s)offoodassistanceshouldbedirectlyrelatedtotheproblemsthathavebeenidentifiedandclearlydefined.InthecontextofHIVandAIDSactivities,theobjectivesmayberelatedtotheobjectivesoftheprogrammebeingsupported(forexample, increasingadherencetodrugtreatment)butalsomayrelatetothefoodandnutrition insecuritychallengesexperiencedbythetargetgroup.Severalexamplesfollow.
FoodAssistanceintheContextofHIV:RationDesignGuide>18
• When the role of a ration is to maintain or improve nutritional status,the ration should include commodities that are high in nutritional value andappealtothetargetedgroups.
• When the role of the ration is to increase or ensure participation in services or activities, commoditiesshouldbechosen for their incentiveormonetaryvalueaswellastheirnutritionalvalue.Insuchcases,theration’svaluemustbeequaltoorslightlygreaterthantheopportunitycostofparticipatingintheactivity.
• When the role of the ration is to act as a safety net,itmustbedesignedtoprovideprotectionfromtheriskstheprogrammehopestohelpbeneficiariesavoid, suchasofferingenough value toprevent saleofproductiveassetsorriskybehaviors.
Theobjectiveandtheplannedroleofthefoodrationinfluencethecompositionandsizeofthefoodbasketandmaydeterminewhethertherationswillbeanindividualration/supplementorahouseholdfoodbasket.
In general food assistance programmes (e.g. general food distribution (GFD),targeted fooddistribution (TFD), food forwork) (FFW)), theobjectivemaynotbedirectlyrelatedtoHIV.However,theenvironmentinwhichfoodassistanceisprovidedmaybehighlyimpactedbythepandemic.Insuchsituationsitmaybeappropriatetoadjust conventional rations toaccommodate thenutritionalanddietaryneedsassociatedwithHIV.
Box 4: HIV prevalence and its impact on general food assistance
TodetermineiftheHIVsituationinagivenpopulationwarrantsanadjustment
of the food basket in general food support activities (relief, recovery or
development),thesituationneedstobecarefullyinterpreted.
High prevalenceInhigh-prevalencecountries,suchas inEasternandSouthernAfrica,HIV is
sowidespreadthatitcanbesafelyassumedthatmanypeopleareaffectedin
somewayorotherandasaresultmayexperiencefoodsecuritychallenges.Continuedonnextpage
19 <FoodAssistanceintheContextofHIV:RationDesignGuide
Continuedfrompreviouspage
Ofcourse,theactualleveloffoodinsecurityneedstobedeterminedthrough
appropriateassessmentandanalysis.
Furthermore,alargeportionofthetargetpopulationislikelytohaveparticular
nutritional needs associated with HIV and/or drug treatment. It is important
to remember that thenutritionalwell-beingofmanypeoplemayalreadybe
compromised by limitations in appropriate food, health and care that are
unrelated to the particular implications of HIV and AIDS. However, these
nutritional weaknesses are likely to have implications on the effect of the
diseaseonPLHIVaswellastheimpactonaffectedhouseholds.
Insuchcircumstancesitisimportantthatappropriateadjustmentstothefood
basketbecarefullyexplored,intermsofcommoditiesandpossiblythesize.
Low prevalenceIn (relatively) low-prevalence regions (for example in West Africa or Asia),
adjustmentoftherationstoaccommodateaverysmallnumberofuntargeted
individuals, many of whom may not be able to identify themselves as HIV-
positive,doesnotnormally result inpracticalandeffectiveresults.However,
whentargetingparticularlyhigh-riskgroupsorthosewithsuspectedorknown
elevatedprevalence,therationadjustmentcouldbeconsideredinlinewiththe
“highprevalence”situationdescribedabove.
High impactThe impact of HIV andAIDS on certain countries may be severe, although
prevalencemaybe lowordiminishing. Incountrieswhere thepandemichit
veryearlyon,theimpacthasprogressedfromincreasedHIVcasestoincreased
deathsandnumbersoforphanedchildren.Thisdelayedbutprofoundimpact
mayrequirethat thefoodbasketbeconsidered intermsof foodavailability,
access,preparation,etc.bytheaffectedpopulationratherthantheparticular
nutritionalrequirementsassociatedwithHIVandAIDS.Thetypicaldemographics
ofseverelyaffectedhouseholdsmayalsojustifyanadjustmentofcommodity
choicesand/orrationsize.
FoodAssistanceintheContextofHIV:RationDesignGuide>20
Step 3: Determine how much food needs to be provided and for how longInfoodassistanceprogramming,rationsizeshouldbebasedonspecificnutritional
needsofanindividualorhousehold.BasicnutritionalprinciplesapplytoPLHIVas
muchastoallotherpeople.WHOrecommendstoinclude12-15percentofprotein,
atleast17percentoffatandmineral,andvitaminintakesatRecommendedDaily
Allowance(RDA)levels.
Forfoodassistanceinthecontextofgeneralfooddistributionsandotherhousehold-
orientedfoodsupportprogrammes,theenergyrequirementisbasedonaweighted
averageofallageandgendergroupswithinapopulation.Theaveragerequirement
calculatedonthisbasisuses2100kilocalories(kcal)asaninitialplanningfigure,
andisthenadjustedbasedonfactorssuchasdemographiccomposition,ambient
temperature,healthandnutritionalstatus,andphysicalactivitylevel.20Fortargeted
feedingprogrammes,theinitialplanningfiguremaybehigherorlowerthan2100
kcalsdependingonthepopulationsub-groupsbeingtargeted.Insomecases,the
rationwillcomplementthedailydietbyofferinganutritionalsupplement;inothers,
itwilltaketheformofanentiremeal.Eitherway,itisimportanttoknowtheageand
sexdistributionofthetargetgroup.Forexample,therearesignificantdifferencesin
thenutritionalneedsofachildunderfiveyearsofageandthoseofanadultman.21
Fourfactorswillinfluencethedecisiononthesizeoftheration.
Increased energy requirements of PLHIV
WHOrecommendationsiforthenutritionalrequirementsofPLHIVcallforincreases
in energy.Theamount of this increasedependsonwhether the individual is an
adultorchild,asymptomaticorsymptomatic,andexperiencingweightlossorno
weightloss.
ItmaynotberealistictoassumePLHIVwillconsumetherecommendedamount
ofenergyfromatake-homeration,asoneneedstotakeintoaccountthefactthat
mostofthetimerationsaresharedamongthehouseholdmembers.
21 <FoodAssistanceintheContextofHIV:RationDesignGuide
Box 5: Some basic calculationsTotal energy requirements for PLHIVAsindicatedinBox1,researchhasshownthatPLHIVhaveincreasedenergy
requirements depending on the stage of the progression from HIV toAIDS.
These increases are reflected as percentages of the basic requirement.
Inorder to judgehowmuchenergy this increase represents incontextofa
food aid ration, it is important to know the sex and age distribution of the
targetgroup.
Example:a20percentenergyincreaserequiredbyanHIV+womanintheage
category15-19yearsiscalculatedasfollows:20%x2120kcal=424kcal.The
amountformeninthesameagegroupis20%x2700kcal=540kcal.
Associated increases in protein and fat intakeForPLHIVtheproportionofproteinneeds(10-12percentoftotalenergy)do
notincrease.However,withtheincreasedenergyneeds,theabsoluteamount
ofproteinneededalsogoesup.Similarly,theproportionalcontributionoffat
to the totalenergyrequirementdoesnot increase forPLHIV.However,when
theenergyincreases,sodoestheamountoffatrequiredtomaintainthe17
percentbenchmark.
Example: a 20%energy increase required byHIV+men in the age group
20-59yearsaddsup to:20%x2460=492kcal.Of thisenergy,10-12%
shouldbeprovidedbyprotein=59kcal(at12%),andatleast17%shouldbe
providedbyfat=84kcal.Thistranslatesto15gramsofadditionalproteinand
9gramsofadditionalfattobeconsumed.
Total energy requirement: 2460 + 492 = 2952 kcalTotal protein requirement: 74 + 15 = 89 gramsTotal fat requirement: 46 + 9 = 55 grams
FoodAssistanceintheContextofHIV:RationDesignGuide>22
The nutritional value of the meal that the ration is assumed to replace or complement
In somecases, the ration isassumed tocomplement thebeneficiary’sdietwithkeynutrients. Inothercases, therationmaybeassumedtocovermostorallofthebeneficiary’snutritionalrequirements(forinstance,100percentifthetargetedpopulationreliesentirelyonfoodassistanceforsurvival,or40,50or80percent,accordingtothenutritionandfoodsecuritysituation).Steps1and2shouldprovidetherationplannerwithenoughinformationtohelphim/herdeterminethesizeoftherationaccordingtotheroleheorsheidentifiedforfoodassistance.
The value of an income transfer that serves as an incentive for participation in services/activities or as safety net
Inaccordancewiththefoodsecurityandvulnerabilitysituation(Step1)ofthetargetpopulation,therationplannershouldmakeacleardecisionontheincomevaluehe/shewantstotransferthroughfoodassistance.Theincomevalueoftherationistheactualmoneyvalueoftherationdistributedtoeachbeneficiary.Inthiscase,therationissupposedtofreeupincomethatwouldotherwisebeusedtobuyfood.TheoutcomeofSteps1and2willagaindeterminehowmuchincome(intermsoflocalcurrencyordollars)therationwouldtransfertothebeneficiaries.Thiswillplayasignificantroleindeterminingthesizeoftheration.
Duration of the ration
Thedurationforprovidingrationsshouldbebasedonconsiderationofobjectivesand,toacertainextent,trialanderror.HIV-inducedfoodsecurityshocksdifferfromotherfoodsecurityshocksandcannotbeaddressedinthesamewayasdroughtsandothernaturaldisasters.Forexample,theimpactofHIVandAIDSoncommunityandhouseholdresiliencymaybemoresevereandlongerlastingthantheimpactofothershocks,whichwillinfluencethedurationoftherations.
23 <FoodAssistanceintheContextofHIV:RationDesignGuide
Table 2: Examples of duration of ration by beneficiary type and programme
Beneficiary Objective Duration of ration
ARTclients ✓ Improvednutritionalstatus
✓ StabilizationtobeginART
✓ Improvedadherence
✓ Managementofdrugsideeffects
✓ Untilaclientreachesaspecificanthropometrictarget(e.g.BMI=18.5)or
✓ Limitedtimeframe:6months
TBclients Improvedtreatmentcompletionrate
Durationoftreatment
PMTCT Maintainorimprovenutritionalstatus
✓ From6thmonthofpregnancythrough9-12monthsafterbirth
✓ Untilindicatorsoffoodaccessimproveor
✓ Limitedtimeframe,suchas6months
Affectedhousehold
Safetynet ✓ Untilindicatorsoffoodaccessimproveor
✓ Limitedtimeframe,suchas6months
OVC ✓ Safetynet
✓ Incentiveforparticipationinservices(e.g.school,lifeskills,etc.)
✓ Untilachildisnolongervulnerable
✓ Durationofservice
Step 4: Select the most appropriate food commodities and type of rations
Food commodities
There are several key considerations that help determine if the rationwillmeetbeneficiaryneedsandprogrammeobjectivesinanHIVcontext.
FoodAssistanceintheContextofHIV:RationDesignGuide>24
Processing requirements.Programmesshouldexploreopportunitiestoprovidemilledcerealsaswellasalreadyprocessed,fortifiedblendedfoods.MilledcerealstakelesstimeandenergyforPLHIVortheircaregiverstopreparebecauseprocessingcerealsoftenrequireslongwalkstomillingfacilities–iftheyareavailableatall–aswellasthestrengthtopoundthegrainintoflour.MilledandprocessedfoodscomeatahighercosttoWFPandassuchrequireadequateattentionintheprojectbudget.Itisimportanttonotethatifnon-milledornon-processedfoodsareprovided,thecostofmillingandprocessingisbornebythebeneficiariesratherthantheprojectbudget.Theactualfinancialcostofmillingcanbequantifiedandrationscanbeadjustedtocompensateforthiscost.However,thecostintermsofphysicalburdenandopportunitycostisdifficulttoexpressinmonetarytermsbutcan,particularlyinextremelyvulnerablehouseholds,create immensechallenges.Consumptionofwholegraincerealsisnotnormallyanacceptableoptionforchronicallyillpersonswhoexperiencevariousconsumptionanddigestionchallenges.
Preparation requirements. Chronically ill persons require a large number ofsmallmealsthroughouttheday,beyondthetwoorthreemealsnormallypreparedforfamilyconsumption.Inordertopreventcontamination,itisimportanttoavoidpreparinglargequantitiesoffoodthatwillbestoredandreheatedwhenmealsarerequired.Thus,inordertominimizetheburdenplacedonthecaregiverinchargeofmealpreparation,itisimportanttoconsiderfoodcommoditiesthatcanbecookedeasilyandquicklywithminimumwater,fuelwoodandtimerequirement.Cookingtimethatreducessoakingshouldalsobeconsideredwhereappropriate.Partiallyprecookedcommoditiessuchasfortifiedblendedfoods(e.g.corn-soyablend(CSB)andwheat-soyablend(WSB)),orready-to-usefoods(RTUFs)arepreferredchoices.Considering the susceptibility of PLHIV and particularly chronically ill persons toinfections, it is extremely important that foods be adequately cooked to kill anygermsandbacteria.Often thenatural response to thishygiene requirementwillbetocookfooditemsforextendedperiodsoftime.However,thismayalsohavenegative consequences as many micronutrients may be destroyed by excessiveheatandprolongedcooking.Thus,extensivecookingdefeatstheeffortsandcostsmadeinfortificationoffoodaidcommoditiessuchasmaizemeal,CSBandoil.
Palatability and digestibility. Palatabilityanddigestibilityareextremelyimportant,particularlywhenprovidingrationsforchronicallyillpeopleandPLHIV,whomayhave
25 <FoodAssistanceintheContextofHIV:RationDesignGuide
reducedappetite,eatingdifficultiesorgastrointestinalproblems.Rationsshouldbedesignedtominimizediscomfortoraggravationofthesesymptoms.Milledcereals,adequatelysoaked/cookedpulsesandfortified-blendedfoodsthatcanbemadeintoporridgesoftenaremorepalatableandeasiertodigestforsickpersons,aswellassmallchildrenortheelderly.Childrenoftenneedtobeencouragedtoeatadequatelybyaddingtastetothemeal–sugarand/orsaltareusefulasflavorenhancers.
Micronutrient needs/fortification.Micronutrientsarecriticalforallpeopleandarevitalinfightinginfection.PLHIVinparticularcanbenefitfromcommoditiesfortifiedwithmicronutrients.Therefore,itisveryimportantforfoodaidrationstoprovideaconsiderablecontributiontothedailyintakeofvitaminsandmineralstomakesurethatminimumrequirementsaremet.Manyfoodaidcommoditiesprovidedinkindcome in fortified form,suchascornmeal,wheatflour,CSBandoil.WhereCSBandoilarepurchasedbyWFP,standardspecificationsareusedtodeterminethefortificationlevels.Thefortificationlevelsinlocally/regionallyproducedcerealflourscouldbedeterminedlocally.Itisimportantinsuchcasesthatthedecision-makingprocess includes consultation with expert organizations and considers the localfortificationlegislation.AlthoughthereisatrendinthefortificationofcommerciallyavailablefoodsforPLHIVtoaddextremelyhighlevelsofmultiplemicronutrients,itis importanttoensuresafeconsumption:somemicronutrientscanbeharmful inhighdoses. It is importanttoensurethattheaddedmicronutrientsdonotcauseanyrisktothebeneficiaryortothehouseholdmemberswithwhomtheymaysharetheration.
Acceptability.Asinallfoodassistanceprogrammes,somecommoditiesaremorereadilyacceptedandconsumedbybeneficiariesthanothers.Factorsthatcaninfluenceacceptability include traditional and religious diet patterns and taste preferences.Forexample,commoditieslikeCSBmayhavehighacceptabilityinsomeareasbutmaybeconsidered“children’sfood”andrejectedbyadultsinotherareas.
Storage.Processedfoodsmaybesusceptibletospoilage(rancidity,contaminationorinfestation),particularlyifstoredinlargequantitiesunderunhygienicconditions.Similarlyitisextremelyimportanttoconsiderthequalityofwholegraincerealsandotherproductssuchasgroundnuts,particularlyintermsofafflatoxincontamination,which may be present in locally-stored produce. Salmonella contamination also
FoodAssistanceintheContextofHIV:RationDesignGuide>26
often occurs in foods handled and/or stored in unhygienicways and is amajorcause of diarrhoea. It is important to consider storage capacity and conditions,shelf-lifeofcommoditiesandthehygieneawarenessofpoorhouseholdsaffectedbyHIVandAIDSwhenexploringtheuseofcertainproducts.
Value.Whentherationservesasanincometransferorincentive,thecommoditiesmusthaveanappropriatevalueinlocalmarkets.Thesefactorsdeterminearation’sincometransfervalue:Whatdoesitcostthetargetpopulationtoparticipateintheprogramme (e.g. transportation, daily lost wages, daily wage rate)?What is thevalueofotherincentivesthatareoffered(e.g.training,healthservices)?Whatisthevalueofthecommoditiestotheparticipants?Itisimportanttokeepinmindthatfoodswithhighvaluesmaybegoodforincometransfersbutaremorelikelytobesoldratherthaneatenbybeneficiaries.
Type of rations
Inlinewiththeobjectiveoftheprogrammeandtherolefoodrationsaresupposedtoplay,therearedifferenttypesofrations,whicharedescribedbelow.
Individual nutritional supplements.Theserationsareprovidedwhentheobjectiveoftheprogrammeistoimprovethenutritionalstatusofthetargetedindividual.ThisisthecaseforpatientsonARVorTBtreatment(forexample,thefirsttwomonthsofdirectlyobservedtreatment,shortcourse–DOTS).Whennutritionalsupplementsareprovidedtotakehome,thequantityisnormallydoubledtoaccommodatetheinevitablesharingoftherationwithotherhouseholdmembers.Itisexpectedthatsupplements for adults will be shared with other family members, particularlychildren,toalargerextentthanwhensupplementsareprovidedforvulnerableormalnourishedchildren. Inaddition toor insteadofdoubling the rationsize, it ispossibletoprovideacomplementaryfoodpackagefor thehousehold inorder toreducesharingofthenutritionalsupplement,calleda“protectionration.”Individualsupplementsarelikelytobemoreeffectivewhencommoditiesarechosenthataredifferentfromthoseinthehouseholdfoodbasketandcanbepromotedashavingparticularbenefitsforthetargetedindividual.AtypicalcommodityoftenchoseninindividualsupplementsisCSB,orasimilarfortifiedblendedfood.Normally,75-100gofCSBareconsideredtobeoneadditionalsupplementforadults.Forchildren,this
27 <FoodAssistanceintheContextofHIV:RationDesignGuide
quantitymaybereducedtoapproximately50gperadditionalmeal.Wherenutrientdensityisofimportance(particularlywhenprovidingsupporttomalnourishedand/orillindividuals),itmaybeappropriatetoincludeoilandsugarinthesupplement.Twotothreeadditionalmealscouldbeconsumedontopofthetwoorthreemealsnormallyincludedinthehouseholddiet.
Household rations.Householdrationsarenormallyprovidedinprogrammesthataimtoimprovenutritionalwell-being,copingcapacityandlivelihoodopportunitieswithin theentirehousehold.Thedecision toopt for this typeof rationshouldbebasedonthe foodsecuritysituationof thePLHIV’shousehold.Theserationsarebasedontheestimatedneedofthehousehold,includingfoodavailabilityandaccessconsiderationsaswellasfoodutilization,dietarydiversityandnutritionalbalance.The ration needs to make a realistic contribution to the household food basketwithoutaimingtoprovidethefullrequirement.Thefoodbasketnormallyincludesabalancedvarietyofcommodities.Ahouseholdrationprovidedtopersonsincareand treatment programmes may be accompanied by a nutritional supplement.Tofacilitatethedistributionofhouseholdrations,astandardhouseholdsizemaybedeterminedand thequantitiesof thecommodities in thehouseholdpackageadjustedtoeasilymanageableunits.
On-site meals.Inprogrammeswherepeopleareattendingservicesoractivitiesonaregularbasis,on-sitemealsmaybeprovided.Thepurposeandroleofthefoodassistancemayrelatetonutritionalbenefitsaswellasregularityofattendance.Thisisoftenthecase inprogrammesforOVCincommunitycentresandschools, forskillstrainingprogrammes,etc.Whenpeopleresideinboardingfacilities,suchasinboardingschools,orphanagesandclinicalfacilities,themealsshouldprovidetheentiredailyfoodneedandbecomplementedwithfreshfoods.
Take-home rations.Inmostsituationsitisrelevanttoprovideabasichouseholdcomplementasatake-homerationinordertosafeguardthenutritionalimprovementof the targeted individual. In thiscase, thehouseholdpackageserves toprotecttheindividualsupplementfromexcessivesharing.Take-homerationscanalsobeprovidedasanincentivetothehouseholdtoencourageandsupportthepatient/client.Thismay be the case inPMTCT,TB andARTprogrammes.A take-homerationmayconsistofonecommoditythatisconsideredattractivetothehousehold
FoodAssistanceintheContextofHIV:RationDesignGuide>28
membersintermsofcontributiontothedailyfoodintakeand/orincometransfer.Thisisoftenprovidedinsimplepackingunitssuchasabagofmaize(preferablymilled and fortified so as to make a contribution to micronutrient status of thehouseholdmembers)oracanofoil.
Step 5: Consider activities to put in place to enhance the proper use of the food ration
A number of activities should be considered to ensure that food rations areadequatelyusedtoachievetheobjectivessetout:
Nutrition counseling and education.Foodassistanceactivities in thecontextofHIVandAIDSshouldbeaccompaniedtotheextentpossiblebyeducationandcounselingactivitiesthathighlighttheimportanceofnutritioninoverallwell-beingand demonstrate the appropriate use of the food assistance package provided.Topics could include: household utilization and distribution of the food basket;sharingofindividualnutritionalsupplements;appropriatepreparationformaximumnutritionalvalue;andtheappropriateuseoflimitedhouseholdresourcestosupportabalancedanddiversifieddiet.
Improved storage and preservation. It should be kept in mind that peopleinfectedwithHIVareparticularlysusceptibletoinfectionscausedbyspoiledfood.AsmentionedinStep4,itisimportanttoconsiderstoragecapacityandconditions,shelf-lifeofcommoditiesandthehygieneawarenessofpoorhouseholdsaffectedbyHIVandAIDSwhenexploringtheuseofcertainproducts.
Fuel-saving strategies. Itshouldbeensuredthateveryfamilyisabletocookthereceivedfoodproperly.Foodcommoditiesshouldbeeasytopreparewithaminimumuseoffuel.Considerationsregardingfuel-savingstrategiesarenotdifferentforPLHIVthenforotherpeople.Themostusualfuel-savingstrategiesinclude:i)useoffuel-efficientstoves; ii) energy-savingcookingpractices suchaspre-soakingof beansandusingtightlyclosinglids;iii)collectivecookingarrangements;iv)usingalternativebiomassfuelratherthancharcoal;andv)usingnon-biomassfuelssuchaskeroseneorsolarstoves.
Gardening. As food rations are usually designed as a complement to locallyavailablefood,gardening isagoodopportunity to increaseaccesstofreshfood.Whereverpossible,gardeningshouldbeencouraged.
29 <FoodAssistanceintheContextofHIV:RationDesignGuide
Recommended Reading
1. TargetedfoodassistanceincontextofHIV/AIDS.BetterPracticesinC-SAFETargetedFoodProgramminginMalawi,ZambiaandZimbabwe,USAID2004
http://wwww.reliefweb.int/rw/RWFiles2004.nsf/FilesByRWDocUnidFilename/EVIU-64VFPK-csafe-souafr-16sep.pdf/$File/csafe-souafr-16sep.pdf
2. TUFTSNutrition,ProgramGraduationandExitStrategies:TitleIIProgramExperiencesandrelatedResearch,DiscussionPapern◦25,April2004
http://nutrition.tufts.edu/docs/pdf/fpan/wp25-program_grad.pdf
3. FANTAandWFP.FoodAssistanceProgrammingintheContextofHIV,WashingtonDC:FANTAProject,AcademyforEducationalDevelopment,2007
http://www.wfp.org/food_aid/doc/Food_Assistance_Context_of_HIV_Oct_edits.pdf
4. CanahuatiJBasicPrinciplesforFoodAssistedProgramsinthecontextofHIV/AIDS(Powerpoint)November2004
www.fantaproject.org/downloads/pdfs/hfa04_3f.pdf
5. HIV/AIDS:A Guide for Nutritional Care and Support. 2nd Edition. Foodand Nutrition Technical Assistance Project, Academy for EducationalDevelopment,WashingtonDC,2004.
http://www.fantaproject.org/downloads/pdfs/HIVAIDS_Guide02.pdf
6. BatterhamMJet al.Calculatingenergy requirements inmenwithHIV/AIDSintheeraofhighlyactiveantiretroviraltherapy.EuropeanJournalofClinicalNutrition,2003,57:209–17.
http://www.nature.com/ejcn/journal/v57/n2/pdf/1601536a.pdf
7. GerriorJLetal.NutritionassessmentinHIVinfection.NutritioninClinicalCare,2005,8(1):6-15
8. GuidelinesforHIV/AIDSinterventionsinemergencysettings.Inter-AgencyStandingCommittee2003.
http://www.who.int/3by5/publications/documents/en/iasc_guidelines.pdf
9. IntegrationofHIV/AIDSactivitieswithfoodandnutritionsupportinrefugeesettings:specificprogrammestrategies.UNHCR/WFP2004
http://data.unaids.org/pub/Manual/2004/integration_hiv_nutrition_strategies_manual.pdf
FoodAssistanceintheContextofHIV:RationDesignGuide>30
Section3:MonitoringtheRationandOperationalConsiderations
Section 3: M&E and
Operational Considerations
31 <FoodAssistanceintheContextofHIV:RationDesignGuide
Section3:MonitoringtheRationandOperationalConsiderations
Monitoring
Theaimofmonitoringistoassessonaregularbasiswhethertheobjectivesoffooddistributionarebeingachieved.Threetypesofmonitoringneedtotakeplacewithrespecttofoodrations.Theyaredescribedbelow.
Process monitoring
Theaimofprocessmonitoringistoensurethatfoodisdistributedtotheintendedbeneficiariesandthatlossesareminimizedandaccountedfor.Processmonitoringincludesmonitoringof:
• Foodsupplyanddelivery
• Foodstorageandhandling
• Quantityoffooddistributed,andthenumberofactualvs.plannedbeneficiaries
• Inequalitiesindistribution
Post-distribution monitoring
Thepurposeofpost-distributionmonitoringistoassesswhetherbeneficiariesweresatisfied with the quality of distributed food, if the correct amount of food wasreceived and if the distribution was timely. Information should also be collectedregarding the utilization of food, i.e. if the food was consumed by the targetedbeneficiaries.Itisnormallydoneonarandomsampleofthebeneficiaries.
Outcome monitoring
Theselectionofindicatorstobecollectedformonitoringtheoutcomewilldependontheobjectivesofthefoodassistance.ForTBprogrammes,outcomeindicators
FoodAssistanceintheContextofHIV:RationDesignGuide>32
havebeenwellestablished:i.e.percentageofTBpatientscuredaftercompletingtreatment,includingfoodassistance.ForactivitiesrelatedtoPMTCT,ARTandHBCprogrammes, indicatorsrelated tonutrition,qualityof lifeanduptakeofservicesneedtobelookedat.
Operational considerations
Because of the specific nature of HIV programmes, a number of operational considerations need to be taken into account when designing and preparing them. The most important considerations are highlighted below.
Shelf-life of food commodities
MostWFPcommoditiesneedtobetransportedandstoredoverextendedperiodsof time. It is therefore important toassurea reasonableshelf-lifesoas toavoidspoilageofthefood.
Whensuggestingtheuseofmilledcerealsit isimportanttoconsiderthatlocallymilledcerealsmayhaveashort-shelf-life (1-1.5months).Althoughtheseflours/mealsareofhighnutritionalvalue(duetohighextractionrate),itmaybedifficulttoincludetheminthefoodbasketduetotheirshortershelf-life.Theinclusionofsuchproductsrequiresfrequentdeliveryofcommoditiestotheextendeddistributionpoint(EDP)/finaldistributionpoint (FDP),high-qualitystorageandstockmanagement.ThishasenormousimplicationsforqualityassuranceandWFP’sabilitytomanagethefoodpipeline.Ifpossible,themillingofcerealsshouldtakeplaceasclosetotheenduseraspossible.
Commercially-produced flours, milled under superior hygienic conditions andresultinginalowextractionrateproduct,maybeuseduptothreeorfourmonthsaftermilling(maizemealofUSspecificationshasashelf-lifeofaboutoneyear).Locally-producedCSB-typeproductsnormallylastupto6-12months.
Although milling and processing of commodities may seem to complicate theoperationsassociatedwithHIVsupportactivities, theirbenefits to theclientsarevital. Staggered procurement contracts (releasing small quantities on a regular
33 <FoodAssistanceintheContextofHIV:RationDesignGuide
basis)andpartnershipswithlocalmillingandfortificationfacilitiesareamongthefeasiblesolutionstohelpassurethequalityofthefoodbasket.
Distribution facilitation and pre-packing
Inordertosimplifydistributionproceduresandfacilitatethecumbersomescoopingexercise(useofmeasuresthatcorrespondtothecalculatedindividualration),WFP’spartnersoftensuggestpre-packingcommoditiesbefore the ration isdistributed.However, caution should be taken not to pre-pack the commodities too far inadvance and keep them exposed to potentially unhygienic conditions.This mayspeedupspoilageandcontaminationandputthebeneficiariesatrisk.
Anotheroptionwouldbetopre-packcommoditiesat industrial level inunitsizesthatarecompatiblewiththedistributionquantities.Thismaymeanadjustingtherationsizesslightlytoendupwithtotalquantitiesthatfitstandardpackaging.Wherelocaland/orregionalpurchaseismade,adjustedpackagingspecificationscouldbepursued.Commoditiesthataredeliveredinpredeterminedpackagingunitsmayberepacked/reconstituteduponarrival.Thisdoescomeatacosttotheproject,whichcouldbecoveredunderOtherDirectOperationalCosts(ODOC).
Theuseofspecialbagsforpre-packingmayoffertheopportunitytomarkthebagswithhealthmessagesaboutthecommodity,overallhealthandnutritionissues,HIVpreventioneducation,andthelike.
Pre-packingdoesrequireacompromise inhouseholdrationsizeas typically the“onesizefitsall”approachisadopted.
Pipeline coordination
Pipeline coordination comprises the management of the entire food supplychain,fromdonorstobeneficiaries.Itincludesassessmentandplanningoffoodrequirements,reportingonfoodprocurementneedsandthecorrespondingtimingandmeasuresforavertingpotentialpipelinebreaks.
FoodAssistanceintheContextofHIV:RationDesignGuide>34
Accurate stock-keeping is the first step in pipeline management, along with acontinualinventoryofthebeneficiarycaseloadsandsubsequentfoodrequirementfigures,inlinewithagreeddistributionfrequencyandmodalities.Goodknowledgeofleadtimesforfoodpurchase,shipping,landtransport,andhandlinganddeliveryarealsoimportant.
Pipelinecoordinationinvolvestimelycollection,organizationandanalysisofalltheinformationrelatedtothefoodsupplychain,inordertoensurethatsufficientandadequatefoodismadeavailableattherightplaceattherighttime.Incaseofapipelinebreak,programmemanagersshouldmakeeveryefforttoensurethatfoodsupport toHIVprogrammescontinues,asanabruptstopcouldhave irreversibleconsequencesontheoutcomesofcertaincareandtreatmentprogrammes(TBandART,forexample).
Cost
Mostrationsarebasedonacombinationofcereals,pulsesandoil.Somefoodaidcommodities (e.g.cannedmeat,fishandbiscuits)are relativelymoreexpensive,and their routine inclusion in theration isnotadvised.However,whendesigningrations for a targeted beneficiary group such as HIV-positive people with a lowBodyMassIndex,theinclusionofthesecommoditiesinthefoodbasketcouldbeconsidered.Furthermore, theprovisionofvegetableoil fortifiedwithvitaminAoriodizedsalt incursonlymarginaladditionalcosts.WFPspecifications require thefortificationoftheseitems.Asscientificknowledgeoftheeffectivenessofexistingand new commodities grows, the relative cost-effectiveness of different optionsfor specific programmes (especially those with nutritional objectives) should beconsideredratherthancostalone.
35 <FoodAssistanceintheContextofHIV:RationDesignGuide
FoodAssistanceintheContextofHIV:RationDesignGuide>36
Section4:FoodAidCommodities
Section 4: Food Aid Com
modities
37 <FoodAssistanceintheContextofHIV:RationDesignGuide
Section4:FoodAidCommodities
Cereals
Cereals include maize, rice, wheat, bulgur wheat, sorghum, millets, etc.
Cerealstypicallyprovidethebulkofthedailyfoodbasketandcontributemainlytotheconsumptionofcarbohydrates.Inpoorhouseholds,thedietislargelydominatedby cereals asmany people cannot afford to complement them with vegetables,pulses and animal products. This makes the diet very monotonous and largelydrivenbytheneedforenergyandvolume(tosatisfythehungerfeeling)ratherthanbalancednutritionalintake.
Where roots and tubers, such as cassava, yams and potatoes, are the staplefoods,theyplayasimilarroleinthedietascerealsdo.AsWFPdoesn’tnormallyprovidetheseproductsaspartofitsfoodbasket,theyaretypicallyreplacedbyorcomplementedwithcereals.
AlthoughitisimportantthatadequatecerealsbeconsideredinfoodaidrationsinthecontextofHIV/AIDS,thisshouldbedoneinacarefulbalancewithcommoditiesthat provide protein and fat, which are typically lacking in the household foodbasket.Wherecerealsareprovidedthisshouldpreferablybedone inmilledandfortifiedform.
Pulses
Pulses include green peas, yellow split peas, beans, lentils, etc.
Pulsesprovideanimportantcontributiontotheproteinintakeofpoorhouseholds.Togetherwiththeproteinsincerealstheyprovideanadequatebalanceofaminoacids(proteins).Inbetter-offhouseholds,proteinisalsoprovidedthroughtheconsumptionofanimalproductssuchasmeat,eggsandmilk.Althoughanimalproteinismoreeasilyandeffectivelyutilizedbythehumanbody,vegetableproteinsourcesareofgreatimportanceinthedietsofPLHIVandtheirfamilies.Foodaidrationsshould
FoodAssistanceintheContextofHIV:RationDesignGuide>38
respondtotheadequacyofproteinrichfoodswithinthehouseholdfoodbasketandcomplementthesewithpulsesinthefoodaidrationasnecessary.
Pulses requirecarefulpreparation tomake thempalatableanddigestible.Sometypesofpulsescanbepre-cooked,makingthemquickertoprepare.Theymustbesoaked,andthusrequiresafewater.Cookingcantakealongtimeandrequiresalotofcookingfuel.Cookingtimecanbereducedbyaddingashesorsalttothewater.Thesespecialcookingrequirementsmustbetakenintoaccountwhenconsideringthetypeandamountofpulsestobeincludedinthefoodbasketandwhendesigningcomplementaryeducationactivities.
Oil
Oil provided in food aid programmes is refined and comes from vegetable sources. It is fortified with vitamin A and sometimes vitamin D.
Oil is the main source of fats in the diet. It does not contain any protein orcarbohydrates. Cereals and pulses also provide some fat, and so do fortifiedblendedfoodssuchasCSB.Inbetter-offhouseholds,fatintakeisalsosupportedbyconsumptionofmeats,fishanddairyproducts.Somehouseholdsmayalsouseanimal fat sources such as butter.A vegetable source rich in oil is groundnuts.Insomecountries inAfrica,oil isderivedfrompalmnutsand isnaturally rich invitaminA.This type of oil tends to solidify at lower temperatures andmay thuscausesomechallengesinfooddistributions.
Oil is very important in providing energy without increasing the volume of themeal–itincreasesthe‘energydensity’.Fatsarealsoimportantinfacilitatingtheabsorptionofcertainvitaminsandtheymakethemealmorepalatable.Theseareimportantconsiderationswhenprovidingfoodrationstopeoplewhohavedifficultyeatingastheyneedtoconsumeasmanynutrientsandasmuchenergyaspossibleinfewandsmallmeals.
InPLHIV,fatconsumptionissometimesassociatedwithdiarrheaandoilshouldthusnotbeprovidedinlargequantities.Oneshouldalsokeepinmindthatoilisnormallyusedforfoodpreparationandmixedwithotheringredients.Itcannotbeeatenonitsown.Thus,thedailyconsumptionquantityislimited.
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Fortified blended foods
Fortified blended foods (FBFs) used in food aid include CBS, corn-soya milk, wheat-soya blend, pea-wheat blend, etc. Local variations are available under various names: IndiaMix, Likuni Phala, UniMix, FaMix, etc.
Blendedfoodsarenormallyamixtureofcerealsandpulsesthathasbeenprecookedthroughroastingorindustrialcooking(extrusion).Insomecasesthemixisfurtherenrichedbyaddingmilkpowderand/orsugar.Animportantbenefitistheadditionofavitaminandmineralmixwhichboostthemicronutrientvalue.Blendedfoodsarenormallyusedtoprovideappropriatesupplementsfor infantandyoungchildfeedingandfortherehabilitationofmalnourishedchildren.Inreliefrationstheyarenormallyusedasameanstoprovidebasicmicronutrientstothetargetpopulationandparticularlytovulnerableindividualssuchaschildren,pregnantandlactatingwomenandthesick.InthecontextofHIVandAIDS,FBFsprovideavaluableadditiontothefoodbasketforthefollowingreasons:
• Shortcookingtimeandreducedburdenforcaregivers,enablingmorefrequentmeals
• Highpalatabilityduetosmoothtextureandsalt/sweettaste
• Easilydigestedduetoprecooking(particularlyrelatedtothepulses)
• High-energydensity(rightbalanceofingredientsandhighfatcontent)
• Balancedmixofmacro-andmicronutrientsduetopre-blendingandfortification
FBFscanbeusedasthemainfoodinnutritionalsupplementsbutarealsoavaluablecomponentofabalancedfoodbasket.
Sugar/salt
Sugar and salt are often included in food aid rations as they provide taste to the meals and thus increase the palatability of the food. This is very important when providing food support to people with eating difficulties, particularly those who need to gain weight.
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Sugar provides energy through carbohydrates. It does not provide any othermacronutrient. Innatural formitalsodoesnot includeanymicronutrients,but insomecountriessugar is industrially fortifiedwithvitaminsandminerals (typicallyvitaminA)duringtherefinementprocess.Justlikeoil,sugarprovidesenergywithoutincreasingthevolumeof themealmuch.This isan importantconsiderationthatmaybetakenintoaccountwhendesigningmealsforpeoplewitheatingproblems.Oilandsugarareoftenmixed inmeals formalnourishedpeople to increase theenergyintake.
SugarisarefinedproductandcancausevariouscomplicationsinPLHIVwhoarefaradvanced in theprogression toAIDS.Forexample,candida (oral thrush)canbeworsenedbytheconsumptionofrefinedsugar.ItisthusimportanttocarefullyconsultwithexpertcounterpartsbeforeincludingsugarinfoodaidrationsthatarefocusedonPLHIV.
Salt does not provide any energy. It is normally included in the food basket forpurposes of taste, electrolyte balance in warm climates (making up for loss ofmineralsduetosweating)and,veryimportantly,asacarrierforiodine.Asamatterofprocurementpolicy,WFPrequiresthatall thesalt itprocuresbe iodized. Saltprovidedforfoodaidpurposesshouldalwaysbefortifiedwithiodine.Althoughmanycountrieshaveagreedtouniversallyfortifysaltwithiodine,notallconsumedsaltisfortified,particularlywherenaturalsaltsourcesareusedinsteadofcommerciallyrefinedsalt.Adeficiencyof iodinecan lead tophysicalproblemssuchasgoiter(enlargedthyroid)andcretinism(impairedphysicalandmentaldevelopment).Theseproblemsmaybeprevalent incertainpopulationsandaredangerousforwomenandsmallchildren.Itisthusimportanttoconsidertheiodinedeficiencylevelsinthetargetpopulationwhenmakingajudgmentabouttheinclusionofsalt.
Animal products
In food aid animal products are normally provided as canned fish, beef and cheese, and dried fish.
Animal products play an important role in providing protein, fat and a varietyof micronutrients. Unfortunately such products are not often available in poor
41 <FoodAssistanceintheContextofHIV:RationDesignGuide
households.Wherepossible,householdsshouldbeencouraged toprovidesomeofthesefoodstopeoplewithparticularnutritionalvulnerabilities,includingPLHIV.Animalproductsshouldbecarefullypreparedtomakesuretheyaresafetoeat.
Canned meat, fish and cheese are expensive and rarely available in sufficientquantitiestobeusedinlarge-scalefoodaidprogrammes.Astheyareindustriallyprocessed,usingheattreatment,theyareconsideredsafe.Driedfishissometimesusedinfoodaidprogrammes.
Sourcesofvegetableproteinaremuchcheaperthansourcesofanimalprotein,andcandramaticallyreducethecostofprogrammes.
Dried skimmed milkDriedskimmedmilk(DSM)issometimesavailableforfoodaidactivitiesandcanbe a valuable ingredient for drinks and porridges used in nutrition rehabilitationprogrammes (often mixed with sugar, oil and/or combined with FBFs). Thereconstitutionofthemilkpowderrequiresmixingwithsafewater,preferablyboiled.Astheonlywaytoascertainthesafeuseofmilkpowderistosupervisethemixing,DSM is not used in household or individual take-home rations as a standalonecommodity. However, it can be premixed with cereal flour or FBFs and as suchenrichthefoodbasket.Premixingshouldbedoneinhygienicconditionssoasnottoexposetheproducttocontaminantsorspeedupthespoilage(rancidity)process.
It is strongly recommended thatDSMnot beusedas a stand-alone commodityunless required for specific nutritional purposes and prepared and consumedundersupervision.
Ready-to-Use Therapeutic FoodReady-to-UseTherapeuticFood(RUTF)isaspecializedfooddevelopedspecificallyforthenutritionalrehabilitationofmalnourishedindividuals.Althoughmainlyknownunderthecommercialname‘PlumpyNut’,variouslocalproductioninitiativesaredevelopingappropriaterecipesforlocalvarietiesbasedonthesameprinciple.RUTFistypicallymadeofpeanutpaste(variationsusingbeansalsoexist),oil,sugarandDSMandarefortifiedwithaspecialmicronutrientmix.
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RUTFissufficientlydifferentinappearance,texture,tasteandsmellfromregularhouseholdfoodcommoditiestobesuccessfullytargetedtovulnerableindividualsasaspecialnutritionalsupplement.Whereasitwasoriginallydevelopedtosupportcommunity-based therapeutic care for severely malnourished children, it iscurrentlybeingtriedinMalawiandothercountriesforthenutritionalrehabilitationofseverelymalnourishedadultAIDSpatientsonART.Preliminaryfindingssuggesthigh acceptability rates of RUTF, and impressive changes in both weight gainandincreasedmobilityofpatients,indicatingthatRUTFholdsgreatpromiseasatherapeuticcomponentofHIVtreatment.However,thepreliminaryfindingsneedtobereplicatedonalargerscale.
RUTF’sdohaveasignificantlyhighercostthanthecommoditiesthatWFPnormallyuses. For example, locally produced RUTF in Malawi is estimated to cost aboutUS$3000-4000perton(possiblyloweronceitismassproduced)ascomparedtoUS$410pertonforCSB.
Duetothelackofevidenceofthebenefitofspecializedproductsoverlower-costcommodityoptionscurrentlyusedinWFP’sprogrammes,themostprudentoptionisforWFPtocontinuetouseexistingcommodities(suchasstaples,pulses,oil,andFBFs) in itsprogrammes tomeet thenutritionalneedsofPLHIVand tocarefullymonitornewstudiesoftheeffectivenessofnewcommodities.
Micronutrient powders
Micronutrientpowders(MNP)forhome-basedfortificationareincreasinglyusedasawayofaddressingmicronutrientdeficiencies.Oftendistributedinsmallsachets,theyaresprinkledonthefoodormixedinaftercookingbutbeforeeating.WFPiscurrentlypilotingtheuseofMNP inschool feedingprogrammesandemergencyprogrammes, and in the future there may be opportunities to use them inHIVprogrammes.
Breast milk substitute
The decision thatHIV-positivemothersmustmake aboutwhether to breastfeedorformulafeedtheirchildrenisadifficultonethatinvolvesbalancingtwosetsofrisks:theriskoftransmittingthevirustotheirchildrenagainstthesignificanthealth
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risksassociatedwithformulafeedinginunsafecontexts.WFPandotheragenciesrecognizetherightofHIV-positivemotherstomakethisdecision.CurrentguidancefromWHO/UNICEFstatesthatreplacementfeedingmayberecommendedwhereitis“acceptable,feasible,affordable,sustainableandsafe.”
WhilesomePMTCTprogrammessupportedbyWFPmayprovideformulaaspartoftheservicesbeingoffered,WFPhasapolicynottoprovideinfantformula.Thispolicyisbasedon:(i)concernsthattheconditionsoutlinedaboveforsafereplacementfeedingdonotexistamongthepopulationssupportedbyWFP;and(ii)thehighcostofinfantformula.WFP’sMemorandaofUnderstandingwithUNICEFandUNHCRforemergencysettingsplacestheresponsibilityofprovidingformulawiththosepartneragencies.
Other specialized products
WFPisfrequentlyapproachedbycompaniesofferingspecializedfoodcommoditiesproduced and marketed for PLHIV. Most of these commodities have not beentestedforeffectivenessoradequatelyevaluatedforsafety.ToensurethatWFPfoodcommoditiesaresafeforbeneficiaries,allnewproductsproposedforusebyWFPmustfirstbeapprovedbytheTechnicalAssistanceGroup,whichisanindependentpanelcomposedofexpertsonfoodtechnology,nutritionandfoodsafety.Furtherdetailscanbeobtainedbywritingtotag@wfp.org.
Section5:ExamplesofRationDesignProcess
Section 5: Examples of
Ration Design Process
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Section5:ExamplesofRationDesignProcess
Hypothetical case: food assistance in response to drought and conflict in ‘Gotongo’
Context
‘Gotongo,’with an estimatedpopulation of 7.4million (2005), is classifiedas aleast developed, low-income food-deficit country (LIFDC) and ranked as one ofthemostfoodinsecurecountriesintheworld. It isalsoparticularlyvulnerabletorecurringnaturaldisasters (floods,droughtandanimaldiseaseepidemics),whileHIVprevalenceisat9.5percent,making‘Gotongo’oneofthehardesthitcountriesin the region. Moreover, the region has been subject to conflicts for 15 years(1991-2005),andthepresenceof largenumbersof internallydisplacedpersons(IDPs)andrefugeescontinuestoincreasethepressureonalreadyover-stretchednatural,socialandeconomicresources.Atpresent,thesituationhasbeenfurtheraggravatedbyexceptionallysevereandprolongeddroughtsandpoorrainsoverthepastfouryears.Inmanypartsofthecountry,pastoralistshavelost50percentormoreoftheirlivestockherds;destitution,especiallyinthesouth,isontheincrease.Among the coping mechanisms are over-fishing and cutting trees for charcoal,leadingtosevereenvironmentaldegradationthroughoutthecountry.
Effects of the conflict and drought on agriculture and food availability
Foodavailabilityvariesgreatlyamongthefourareasintowhich‘Gotongo’isdivided.
IntheNorthern Province,nomadiclivestockrearingandsomerain-fedsubsistenceagriculturearetheprincipaleconomicactivities.
In Pokolo, which covers the regions in eastern ‘Gotongo,’ livestock rearing andfishingarethemainfoodproductionactivities.Pokoloistheareaofthecountrythat
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hassufferedthemostfromthelongdroughtcycleof2001-2004,compoundedbytheeffectsoftheAIDSepidemic.
In the Central Region, good rains in 2004/2005 led to improved range-land,increasedwateravailabilityandlivestockrecovery.Consequently,livestockproductionandtheavailabilityoflivestockproducts,particularlymilk,havegenerallyimprovedthroughouttheregion.Therecoveryprocessalsocontinuestobeconstrainedbypocketsofdrought,localizedconflictsandinsecurity.
Southern Provincehassufferedthemostfromcivilconflict.Since1991,extensionservices, credit, pest control and agricultural inputs have not been available tofarmers.Asa result, overall productionof staple food (sorghumandmaize) hasfallenbyasmuchas50percentinmostoftheagriculturallyimportantregions.Theoutputofmajorexportcrops(bananas,grapefruit,andwatermelons)hasdroppeddramatically.
Nutrition and health
IntheNorthernProvinceandPokolo,whichalreadyhadhighacutemalnutritionastheresultoffailed2005rains,thecurrentrateofacutemalnutritionisestimatedtobeover20percent.Foodinsecurityandmalnutritionhavebeenexacerbatedbylackof health care, poor infant-feedingpracticesand inadequate sanitationandpublic hygiene. Recent data available from sentinel sites have estimated acutemalnutritionratestobehigherthan15percent inthesouthwesternareasofthecountry.Also,UNICEFisoftheopinionthatmicronutrientdeficiencies–includingiron-deficiencyanaemia,vitaminAdeficiencyandiodinedeficiency–areserioushealth issues facing“Gotonguese” population.Anaemia is suspected to be highamongwomenandadolescents,andiodinedeficiencyisapublichealthconcern,asaccesstoiodizedsaltisextremelylow.
Objectives of WFP assistance
Theoverallgoalofthisprotractedreliefandrecoveryoperation(PRRO)istosavelivesandprotectlivelihoodswhilecontributingtonationalstabilityandthehouseholdfoodsecurityofIDPs,returnees,affectedhostcommunitiesandothervulnerablegroups
47 <FoodAssistanceintheContextofHIV:RationDesignGuide
throughfoodaidinterventionsthatencouragethelong-termrecoveryofpeoplewhohavesufferedasaresultoftheconflictandrecurrentnaturaldisasters.
Objectives
The immediate objectives and corresponding WFP strategic objectives of thisPRROareto:
• savelivesofpeopleaffectedbyconflictanddisaster;
• protectandrecoverpeople’slivelihoods;
• improvethenutritionandhealthstatusofchildren,mothers,includingthoseinPMTCTprogrammes,PLHIVandothervulnerablepeople;and
• supportaccesstobasiceducation,particularlyforgirls.
Based on this scenario, two ration designs are presented on the pagesthatfollow.
Exercise 1: Ration design for PLHIV in IDP camps
Thereareanestimated2500PLHIVamongtheIDPs,concentratedmostlyinPokoloprovince.ARTservicesarenotorganizedinthecamp,butmostofthePLHIVreceivetreatmentfortheirchronicillnessesthroughhome-basedcareservicesadministeredbyvolunteers.Asisthecasewithallpeoplelivinginthecamps,PLHIVreceivethegeneralfooddistribution(GFD)rationcomprisedofmaizemeal,beans,vegetableoil,andiodizedsalt(2100kcalstotal).Supplementaryandtherapeuticfeedingareorganized for moderately malnourished and malnourished children. Moderatelymalnourishedchildrenandvulnerablepregnantandbreastfeedingwomenreceiveadryrationof1200kcalscomposedofCSB,sugarandoil.
Step 1: Review the nutrition and food security situation of the targeted population
Thisstepisaccomplishedbyreviewingallinformationfromassessments,surveysandvulnerabilitystudies.Basedonthereview,weknowthat:
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• LikeotherIDPs,PLHIVlivingincampsarefoodinsecureandreceivefoodrationsthroughGFD
• Acutemalnutritionrateisveryhigh
• Healthandsanitationconditionsareverypoor
• HBCservicesareavailableinthecamp
• IDPs,includingPLHIV,engageinnegativecopingmechanismssuchassellingtheirassets(property,cattle)withdrawingchildrenfromschools,andeatingonlyonemeal
• Pokole,theregionhostingmostofthe2500PLHIVwashitbydrought
In conclusion, PLHIV are vulnerable and would benefit from a supplementary ration that would complement the ration they receive through GFD and allow them to take up HBC services.
Step 2: Review the objectives of the programme and the role of the ration
Accordingtotheinformationprovidedabove,theobjectiveoftheprogrammehereistoimprove/maintainthenutritionalwellbeingofPLHIVandtoincreasetheuptakeofHBCservicesinthecamp.ThefoodaidwouldplaytheroleofnutritionalsupplementandenablerforHBCservicesinthecamp.
Step 3: Determine how much food needs to be provided and for how long
WeknowthattheencampedpopulationreceivesGFDrationsthatnormallyprovide2100kcalsperperson.TakingintoconsiderationtheincreasedenergyrequirementsofPLHIV(seeBox5),weshouldincreasetherationofPLHIVby500kcal(equivalentto a 20 percent increase), which can be doubled to take into consideration theintra-householdrationsharing.Ideally,therationshouldbegivenuntilindicatorsofqualityoflife(primarilyweightgain)improve,butshouldbelimitedtoanaverageofsixmonths.
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In conclusion, a supplementary ration of 1000 kcal should be given for a limited period of time, to be determined by periodic assessments.
Step 4: Select the most appropriate food commodities and type of rations
Among the many considerations that should help decide on the choice offood commodities and type of ration, the most important in this context areprobably palatability and digestibility, fortification and micronutrient content.ThecomplementaryfoodbasketshouldconsistofCSB,oilandsugarastheyarealreadyprovidedthroughthegeneraldistributiontotheencampedpopulation.
In line with guidance beginning on page 23, the obvious solution here would be to give complementary rations as take-home rations to PLHIV through HBC services.
Step 5: Consider activities to put in place to enhance the expected benefits of the food rations
Potentialcomplementaryactivitiescould includenutritioneducation,hygieneandsanitationsensitizationand,ifclimacticconditionsallowit,gardening.
Exercise 2: Ration design for OVC in Southern Province
TheSouthernProvinceishosttoanestimated35,000OVC,includingsome12,000attendingschoolssupportedbyWFP.MostoftheOVCliveinfosterfamilies,despitetheincreasingreluctanceofsomefamiliestotakeinOVCduetosocio-economicconstraints.With theongoingmulti-sectoralcrisis, it is feared thatmore familieswillbeforcedtowithdrawOVCfromschoolsandevenworse,abandonOVCwhoarealreadyhosted.
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Step 1: Review the nutrition and food security situation of the targeted population
Areviewofvulnerabilityandfoodsecuritydatarevealsthat:
• Theregion,hosttomostOVC,istheonethathassufferedthemostfromthecivilwar, leading toacollapseof theeconomy,weakened livelihoodsamongfamilies,andincreaseddestitution
• FamilieswhotakeinOVCareverypoorandfoodinsecure
• OVCaredroppingoutofschoolbecause foster familiescannotafford topayschoolfees
In conclusion, families hosting OVC need a livelihood support to encourage them to continue to take in OVC and keep them in school.
Step 2: Review the objectives of the programme and the role of the ration
TheobjectiveoftheprogrammewouldbetoprovideasafetynetforfosterfamiliesandincreasethenumberoffamilieswhotakeinOVC.Anotherobjectivecouldbetomaintainor improveOVCschoolattendance.The roleof foodaidcouldbe tocontributetohouseholdfoodsupplyorincometransfer.
Step 3: Determine how much food needs to be provided and for how long
Inlinewiththeobjectivesandtheroleoffoodaidoutlinedabove,andinlinewiththefindingsfromtheassessments,let’sassumethatitwasdecidedthattherationshould aim to transfer an equivalent of US$4 per day (4000 ‘Gotongo’ Francs(GF))toassistedhouseholds.ThecompositionofthisrationwillbedeterminedatStep4.Therationshouldbegiveninprincipleuntilfoodsecurityindicatorsimprove;butforpracticalreasons,itmaybedecidedthatfoodsupportwillbeprovidedfor
51 <FoodAssistanceintheContextofHIV:RationDesignGuide
12months,atwhichtimeanassessmentwilldeterminewhetherfoodsupportcanbecontinuedorthehouseholdcanbetransferredtoanotherprogramme,suchasafoodsecurityorsocialprotectionprogramme.
Step 4: Select the most appropriate food commodities and type of rations
Inthecontextof‘Gotongo,’theagreedtransferof4,000GFperbeneficiaryperday(seeabove)wouldbeequivalentto10kgofcereal,1.2kgofpulses,600gofoiland600gofoilpermonthperbeneficiary.Thiswouldtranslateinto50kgofcereals,6kgofpulsesand3kgofoilperassistedhouseholdoffivebeneficiariespermonth.
Step 5: Consider activities to put in place to enhance the expected benefits of the food rations
Nutrition counseling and education should be emphasized, along with improvedstorageandpreservation,andgardening(seeguidanceonpages28and29).
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WorldFoodProgramme
ViaCesareGiulioViola,68/70
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