Nutrition Assessment,Counseling, and Support: Scale-up of PEPFAR Nutrition Programs

Presented by:Clinton Sears, MPHUSAID Office of HIV/AIDS

Friday, October 8, 2010

Contents

Four topics, with a programmatic focus:

• PEPFAR and Nutrition

• Technical Evidence (2009 Mini-U)

• The NACS Model

• Scale-up Challenges and Opportunities

Feel free to ask questions at any time!

PEPFAR and Nutrition

“Adequate nutrition cannot cure HIV infection, but is essential to maintain the immune system and sustain

physical activity, and to achieve optimal quality of life.”

- A participant at the 2005 WHO Consultation in Durban

“Adequate nutrition cannot cure HIV infection, but is essential to maintain the immune system and sustain physical activity, and to achieve optimal

quality of life.”- A participant at the 2005 WHO Consultation in

Durban

Do HIV and nutrition link?

PEPFAR and Nutrition

Malnutrition:• Weakened immune system• Increased susceptibility to OI • Slower healing• Poorer response to treatment

HIV:• Reduced food intake• Increased nutrient needs• Altered nutrient absorption• Altered nutrient metabolism

Nutrition Requirements for PLWHA:

Energy• 10% increase for asymptomatic• 20-30% increase for symptomatic• 50-100% increase for children with growth

faltering

Protein• About 12-15% of energy intake to maintain

and/or recover lean body mass

Micronutrients• Essential micronutrients @ 1 RDA

PEPFAR and Nutrition

Timeline:

2003 – PEPFAR authorized

2005 – WHO Durban Meeting

Food & Nutrition TWG

2006 – Food by Prescription begins in Kenya

2007 – Cochrane Review on Food

Supplementation for PLWHA

2008 – PEPFAR re-authorized

2009 – New WHO Guidelines

2010 – Regional Meeting in Jinja, Uganda

PEPFAR and Nutrition

PEPFAR programs:• Must contribute to PEPFAR goals for prevention / care /

and treatment: 3/12/12• PEPFAR is a health program, NOT a food security

program • Emphasis on integrating nutritional assessment,

counseling, and support within clinical care and treatment

Non-PEPFAR Programs:• Food assistance (Title II) programs• Primary objective is usually food security

• PLHIV feeding• School feeding• Food for assets• WFP

PEPFAR and Nutrition

Technical Evidence

Programming without evidence can be irresponsible; waiting for complete evidence to program can be a

travesty.- Dr. Tony Castleman, AED

www.anafricanphotoblog.com

Evidence

Program Practices

“True genius resides in the capacity for evaluation of

uncertain, hazardous, and conflicting information”

- Winston Churchill

• Among PLHIV not on ART, lower BMI at time of diagnosis is associated with higher mortality

• Each unit decrease in BMI associated with a 13% increase risk of death after controlling for baseline immune status (CD4 count)

(van der Sande et al. 2004)

Technical Evidence

• Among PLHIV receiving ART, moderate to severe malnutrition at the start of ART more than doubled the risk of death

• Differences in CD4 counts were not statistically significant between those with lower and higher baseline BMI

Technical Evidence

FBP vs. No Food for HIV+ Adults

Does provision of supplementary food to malnourished HIV-infected adult ART and pre-ART clients improve nutritional status?

Technical Evidence

FBP vs. No Food for HIV+ Adults

Does provision of supplementary food to malnourished HIV-infected adult ART and pre-ART clients improve nutritional status?

A randomized effectiveness trial (six month intervention, plus six month follow-up) addressed this in Kenya.

Technical Evidence

Key Results:

• Food supplementation benefits malnourished adult PLHIV, with greater benefits for pre-ART than ART clients and for women than men.

• Most benefits occur during the period of food supplementation and may not persist beyond then (sample size issues).

Technical Evidence

Ultimately, we have target groups:

1. Children <2

2. Women in PMTCT programs

3. OVC (with growth faltering)

4. PLWHA in care and treatment programs

Technical Evidence

The NACS Model

“…If it were not for the services, I would have died”

- Food by Prescription client, Kenya

“…If it were not for the services, I would have died”

- Food by Prescription client, Kenya

“…If it were not for the services, I would have died”

- Food by Prescription client, Kenya

NACS is

NutritionAssessmentCounselingSupport

The NACS Model

The Nutrition Assessment, Counseling, and Support Model expands Food by Prescription

EntryPoint

Assessment

Food Productionand Supply

Chain

Counseling

Clinical Management

FoodBy

Prescription

Community ProgramsClinic

Entry Points:

• ANC/PMTCT• Clinical referral:

• HIV/AIDS care and Tx• General patient care and Tx

• Community nutrition surveillance and referral:• HBC• OVC• CHW

The NACS Model

Assessment:

• Anthropometric• Biochemical• Clinical• Dietary

• Household food security

The NACS Model

Integrated Clinical Management:

• ART (if eligible)• OI treatment and management• Drug-food interactions• Chronic nutrition management of:

• Dyslipidemias• Arteriosclerosis• Diabetes• Osteoporosis

The NACS Model

Counseling:

• Treatment adherence • Dietary quality• Weight recovery/stabilization• WASH/food safety• Referral to community services

The NACS Model

Food by Prescription:

Pharmacy and Voucher Distribution:• Therapeutic (severe)• Supplementary (mild to moderate)• Supplemental (vulnerable)• Micronutrient supplements

(corrective and preventive)

The NACS Model

Food Productionand Supply Chain:

• Food Processing sector:• Quality and safety standards• Product development• Packaging• Commercial viability

• Product procurement, distribution, and inventory control

The NACS Model

Community Links:

• Household activities:• Food production and access• IGAs• Microcredit/microsavings• (Re-)Employment• Vocational training

• Support groups:• Care and treatment• Mother-to-mother

• MCH • Family planning

The NACS Model

Scale-up

“A complete baseline nutrition assessment should be performed as part of the … care

plan.”- Position of the American Dietetic Association

“A complete baseline nutrition assessment should be performed as part of the … care

plan.”- Position of the American Dietetic Association

Scale-up Challenges

Challenge Response

HIV-Free Survival Postnatal continuum of care including infant feeding

Integration of nutrition into clinical care and support Quality Improvement

Clinic/community linkages and referrals

Nutrition surveillanceHBC/MCH supportES/L/FS supportGHI/ FTF linkages

Food Production Procurement and Distribution

PPPSupply chain management

Human Resources Institutionalization of Knowledge

Global Health Initiative$63B over 6 years (FY09-FY14)

Merged funding (FY11):• 73% from PEPFAR• 9% from PMI• 18% from Other Initiatives

Bottom line—Almost no new funds apart from a small amount for MCH

Scale-up Opportunities

Scale-up Opportunities

Scale-up Opportunities

Feed the Future Initiative$22B over 3 years (FY10-FY12)

Inter-agency programming to tackle:

• Availability (support agriculture sector growth)

• Access (increase access to markets and facilitate trade)

• Utilization (support positive gains in nutrition)

• Stability (reduce risk and vulnerability)

Scale-up Opportunities

Feed the Future Overlap

NACS Countries

Cote d’IvoireNamibiaVietnamSouth Africa

FEED the FUTURE Countries

HondurasNicaraguaTajikistan

No Nutrition focus

Large Nutrition Investment, Non-focus Countries

DRC PakistanIndia SudanNigeria Yemen

JOINT NACS/FtFCOUNTRIES

EthiopiaGhanaHaitiKenyaMalawiMozambiqueRwandaTanzaniaUgandaZambia

“Nutrition advice, counseling, care, and support for HIV-infected women are especially important because of the dual burdens of HIV and reproduction.”

- World Health Organization

• E. Ashley Blocker (AED)• Tony Castleman (AED)• Amie Heap (USAID)• Tonya Himelfarb (OGAC)• Robert Mwadime (AED)• Tim Quick (USAID)

Thank You!

1. Nutrition is essential

2. Balance programming and evidence

3. Nutrition assessment (and counseling) should be part of the care plan

Key Messages

Questions?