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Food & Nutrition Support within PEPFAR Clinical Programs. The United States President’s Emergency Plan for AIDS Relief. Track 1 ART Program Meeting Atlanta September 25, 2007 Tim Quick, USAID. Overview: HIV/AIDS & Nutrition.

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food nutrition support within pepfar clinical programs

Food & Nutrition Support within PEPFAR Clinical Programs

The United States President’s Emergency Plan for AIDS Relief

Track 1 ART Program Meeting

Atlanta

September 25, 2007

Tim Quick, USAID

overview hiv aids nutrition
Overview: HIV/AIDS & Nutrition
  • Food often stated as the most urgent need of PLHIV and their families – food insecurity highly pervasive in PEPFAR countries.
  • AIDS is a wasting disease (“Slim Disease”) --PLHIV typically present late & first tested after chronic illness & significant weight loss.
  • Strong correlation between wasting & mortality before & during Tx – very high mortality rate in patients w/ low BMI in 1st months of ART.
  • ART & Tx of OIs improves appetite & nutritional status of most malnourished patients.
slide3

Clinical Picture for PLHIV

  • Nausea, oral thrush, altered taste & depressed appetite.
  • Accelerated nutrient losses due to malabsorption, diarrhea & hypermetabolism.
  • Multiple micronutrient deficiencies pre-existing & precipitated by infection (& Tx).
slide4

Dietary Implications of HIV

  • Need to increase total energy intake:
    • Asymptomatic: 10% increase (kcal/day)
    • Symptomatic: 20-30% increase (kcal/day)
    • Children w/ weight loss: 50-100% increase (kcal/day)
  • Maintain protein @ 12-15% of energy intake to maintain and recover lean body mass.
  • Essential micronutrients (vitamins/minerals) @ 1 RDA
  • Require high-energy, nutrient-dense foods, NOT JUST MORE OF THE SAME FOOD
guiding principles for food nutrition support under pepfar
Guiding Principles for Food & Nutrition Support under PEPFAR
  • Support for F&N must contribute directly to the 2/7/10 goals.
  • PEPFAR is NOT a food security program.
  • Emphasis on integration of nutritional assessment, counseling & support within clinical care & Tx.
  • Emphasis on leveraging food security & livelihood assistance support from other sources (“wrap-arounds”).
  • Limited PEPFAR procurement & provision of food to specific target groups under defined eligibility criteria.
target groups for pepfar nutrition support
Target Groups for PEPFAR Nutrition Support
  • OVC, especially infants & young children.
  • HIV+ pregnant & lactating women in PMTCT programs.
  • PLHIV in care & Tx programs.
nutritional support begins with nutritional assessment
Nutritional Support Begins with Nutritional Assessment
  • Anthropometry (wt, BMI, MUAC)
  • Symptom mgmt (appetite, nausea, taste, oral thrush, diarrhea, drug X food interactions
  • Dietary adequacy (micronutrients)
  • Household food security
  • Family-centered approach – referral (HBC) and assessment of others in family, esp young children
nutritional care of adult plhiv
Nutritional Care of Adult PLHIV
  • Nutrition/dietary counseling
  • Therapeutic/supplementary/supplemental feeding
  • Multi-micronutrient supplementation
  • Safe water/hygiene/sanitation
  • Management of drug/food/nutrient interactions
  • Management of chronic HIV infection
    • Lipodystrophy/heart disease
    • Insulin resistance/diabetes
    • Osteoporosis
nutritional care of infants children
Nutritional Care of Infants & Children
  • Infant feeding counseling & support, incl weaning/supplemental foods, to minimize MTCT & maximize survival (AFASS framework).
  • Routine growth monitoring & clinical assessment.
  • Therapeutic & supplementary feeding support for malnourished infants & young children.
  • Multi-micronutrient & routine vitamin A supplementation.
  • ORT/Zn supplementation for acute diarrhea.
  • Safe water/hygiene/sanitation
slide10

Policies

Guidelines

Funding

Resources

Staffing

Commodities

Adult Care & Tx

OVC

PMTCT

Pediatric Care & Tx

  • Continuum of care for U5 PMTCT infants and older children:
    • Growth monitoring
    • VA, Zn, multi-Mn supplementation
    • Therapeutic/ supplementary/ supplemental feeding
  • Nutritional assessment
    • Anthropometry
    • Symptom mgmt
    • Dietary assessment
  • Nutrition Counseling
  • Multi-MN suppl (MN by Prescription)
  • Therapeutic/suppl feeding (Food by Prescription)
  • Infant Nutrition
    • Infant feeding counseling
    • Growth monitoring
    • Multi-MN supplementation
    • Therapeutic/ supplementary/ supplemental feeding
  • Maternal nutrition
    • Assessment &Counseling
    • Multi-MN suppl
    • Supplemental feeding
  • Nutritional assessment
    • Anthropometry
    • Symptom mgmt
    • Dietary assessment
  • Nutrition Counseling
  • VA, Zn, multi-MN suppl
  • Therapeutic/suppl feeding

Facility Level

  • Infant feeding counselling
  • Links to basic CS, e.g. cIMCI, CTC, CB-GMP
  • Safe water/hygiene/ sanitation
  • Counseling
  • Nutritional assessment & clinic referral
  • Household food security assessment
  • Links with food security support for food-insecure OVC & families
  • Links with livelihood assistance, micro-credit, microenterprise, (re) employment opportunities, vocational training
  • Household food security assessment for clinic patients
  • Links with food security support for food-insecure families of clinic patients
  • Links with livelihood assistance, micro-credit, micro-enterprise, (re)employment opportunities, vocational training
  • Home-based care
    • Safe water
    • MUAC clinic referral

Quality Assurance/Quality Improvement

  • IYCF/ENA counseling
  • Continued BF to 2 yrs for HIV+ infants
  • Clinic referral for growth faltering
  • Community Therapeutic Care (CTC) for severely malnourished HIV+ children

Training

Procurement, Logistics & Inventory Control

Monitoring & Evaluation

Targeted Evaluation

Household/Community Level

Maternal & Child Health/Family Planning

Food Assistance/Security

Wrap-Around Programs

Livelihood Assistance/Employment/Microcredit

Education/Vocational Training

kenya food by prescription program
Kenya “Food by Prescription” Program
  • Model of integration of nutritional support within clinical services – piloted at 60 CCCs
  • Senior Nutritionist at NASCOP
  • National Guidelines for HIV & Nutrition (incl PMTCT & infant feeding)
  • GFATM – nutritionists & lay counselors staffed at CCCs
  • Assessment: anthropometry, symptoms, & dietary
  • Counseling
  • Support
    • multi-MN supplements
    • supplemental (preg/lact women and OVC) and therapeutic/supplementary (malnourished adult and OVC) feeding support
food by prescription
Food by Prescription

Hospital/Clinic

  • Food Company
  • Food production
  • Direct delivery to hospital/clinic

VCT

  • Physician
  • Symptom diagnosis
  • Integrated symptom Tx/management
  • Nutritionist/Health Worker
  • Assessment
  • Counseling
  • MN supplement & food prescription
  • Referral clinical care & household food security

Referral

  • Pharmacy
  • Food dispensing
  • Inventory control
  • Record keeping
  • Lay Counselor
  • Nutrition education/ counseling
  • Peer support

Inpatient

Patient

Follow-up

  • Community Programs
  • Food security
  • Livelihood assistance
  • MCH
adult patient bmi at entry time to fbp graduation
Adult Patient BMI at Entry & Time to FBP “Graduation”
  • ~1 in 3 new ART patients clinically malnourished (BMI < 18.5), of which ~1 in 4 is severely malnourished (BMI <16).
  • Average time for ART patients to graduate from feeding support (BMI >20) is ~3 mo for patients w/ BMI 16-18.5 at entry and ~5 mo w/ BMI <
  • On-going TE will evaluate clinical outcomes associated w/ FBP & improved BMI, as well as “recidivism” to BMI <18.5 post-FBP.
slide15

Cost Breakdown for Nutrition Component

The costs above represent a ‘delivered’ cost of product.