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Integration of nutrition into hiv and other infectious diseases : the nacs approach. Serigne M. DIENE, PhD, Senior Nutrition and HIV Advisor. AIDS 2012 Communications-Hosted Satellite Session. July, 22, 2012. Presentation Outline. Evidence Supporting NACS NACS’s overview

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integration of nutrition into hiv and other infectious diseases the nacs approach

Integration of nutrition into hiv and other infectious diseases :the nacs approach

Serigne M. DIENE, PhD, Senior Nutrition and HIV Advisor

AIDS 2012 Communications-Hosted Satellite Session

July, 22, 2012

presentation outline
Presentation Outline
  • Evidence Supporting NACS
  • NACS’s overview
  • Elements of the NACS approach
emerging evidence
Emerging evidence
  • Evidence is emerging on the impact of various nutrition interventions on the health and wellbeing of PLHIV.
  • Opportunities for randomized controlled trials were limited in the past but are expanding with the increased adoption of NACS.
supplementary feeding and nutritional status
Supplementary Feeding and Nutritional Status

Selection of

Studies

Outcome Findings

Other Comments

Kenya - Food Supplementation v Control (n=1058)1

    • * CD4 ↑ int. at 3/12 and CD4 ↓ control at 3/12. Not signif. at 6 or 12/12
  • * Food predictor of attendance at 6/12 in both
  • Pre-ART Group

Food Supp significant in

change in BMI at 3/12 & 6/12

ART Group

1.9kg v 1.0kg at 1/12

4.6kg v 3.4kg at 3/12

Malawi - Fortified Spread (FS) v Corn Soy Blend (CSB) (n=491) 2

Greater anthropometric ↑ FS group v CSB group at 14/52

BMI change (2.2 v 1.7), weight change (5.6kg v 4.3kg),

FFM (2.9kg v 2.2kg), and MUAC (2.2cm v 1.6cm)

* BMI at enrollment 16.5.

* Mortality rate 27% for FS and 26% for CSB

* Spread 3x more expensive

* No differences in CD4 count, VL, QoL, or adherence

Zambia – CSB/Oil/Beans v Control (n=636)3

No differences were not found for weight gain

*Food supplementation assoc. with better adherence

* No difference in CD4 change

India – Fortified Blended Food (Indiamix) v Control (n=636)4

Food supplementation did not result in increased weightcompared with nutrition counseling and standard care

* ↑in weight, BMI, MUAC, FFM, and BCM in both groups

All results reported in findings are significant unless indicated

  • KEMRI, FANTA Project - Report June 2011
  • Ndekha MJ et al.. BMJ. 2009 May 22;338:b1867
  • Cantrell RA,. J Acquir Immune DeficSyndr. 2008
  • SwaminathanS,et al. Clin Infect Dis. 2010 Jul 1;
micronutrient supplementation and disease progression
Micronutrient Supplementation and Disease Progression

Selection of

Studies

Outcome Findings

Other Comments

  • Tanzania – MMVM v MMVM/Vit A v Vit A v Placebo (n=1078)1
  • 24.7% MMVM progressed to WHO stage 4 or died
  • 31.1% placebo progressed to WHO stage 4 or died
  • MMVM group had reduced risk of AIDS related death
  • MMVM and MMVM/Vit A group had fewer people progress HIV stage 3 or higher.
  • The MMVM and MMVM/Vit A had slight increases in CD4+
  • MMVM group had slight reduction in viral loads.
  • Study period was over 6 years
  • >1000 pregnant women enrolled
  • Vit A group had similar results to placebo
  • MVM group also had reduced incidence of complications
  • No change in any other biochemical parameters e.g. blood lipids and glucose
  • 42% improvement in neuropathy symptoms in MMVM group,
  • 33% improvement in neuropathy symptoms in placebo group – result not statistically significant but clinically significant.
  • USA – MMVM v Placebo (n=40)2
  • MMVM group – CD4 ↑ 65 cells/mL (↑ 24%) at 12/52
  • Placebo group - CD4 ↓ 6 cells/mL (↓ 0%) at 12/52

All results reported in findings are significant unless indicated

  • Fawzi WW, et al. A N Engl J Med. 2004 Jul
  • Kaiser, JD.. J Acquir Immune DeficSyndr. 2006 Aug 15
what is nacs
What is NACS?
  • Nutrition assessment, counseling, and support (NACS) is an approach that aims to improve the nutritional status of individuals and populations by integrating prevention and treatment of malnutrition into policies, programs, and health service delivery infrastructure.
  • The NACS approach strengthen the capacity of facility- and community-based health care providers to deliver nutrition-specific services while linking clients to nutrition-sensitive interventions provided by the health, agriculture, food security, social protection, education, and rural development sectors.
slide9

Maternal Nutrition

Universal

Salt

Iodization

Zinc

Supplementation

Fortification

PD Hearth

Iron/FA Supplementation

Vitamin A Supplementation

Growth monitoring

&

Promotion

CMAM

Infant &

Young Child Feeding

slide10

NACS

Nutrition Assessment, Counseling, & Support

NACS

NACS

Establishing a Nutrition Standard of Care

slide11

GOAL: Improved health and quality of life

  • OBJECTIVES:
        • Improve nutritional status
        • Improve infant survival
        • Reduce food insecurity
        • Strengthen health systems

Economic strengthening, livelihoods & food security

Health system strengthening

Nutrition care & support

HIV-Free Survival

NACS: A platform for integrating nutrition into the continuum of care

slide12

NACS: A Life Cycle Approach

Pregnancy

Birth

Adulthood

Infancy

NACS

Adolescence

Childhood

slide13

Photo: Wendy Hammond

C & T

ART & ARV Prophylaxis

Tx of Malnutrition

Maternal Nutrition &

IYCF Counseling

Photos: Wendy Hammond

Pregnancy

Infancy

Childhood

Adolescence

Adulthood

Birth

slide14

ART & ARV Prophylaxis

Peri-/Postnatal Care

Maternal Nutrition &

IYCF Counseling

Photo: Wendy Hammond

Pregnancy

Infancy

Childhood

Adolescence

Adulthood

Birth

slide15

Postnatal Care

Deworming

Micronutrients

IYCF/GMP

CMAM

Tracking/Follow-Up of Mother-Infant Pairs

Photos: Save the Children Federation

Pregnancy

Infancy

Childhood

Adolescence

Adulthood

Birth

slide16

Pediatric Care

Nutrition Surveillance/GMP & Referral

Micronutrients

CMAM

Photo of Plumpy’nut® from Valid International; all others: Save the Children Federation

Pregnancy

Infancy

Childhood

Adolescence

Adulthood

Birth

slide17

Nutrition Surveillance, Referral, Assessment & Counseling

Deworming

Micronutrients

CMAM

Nutrition Surveillance, Referral, Assessment & Counseling

Micronutrients

Tx of malnutrition

Photo: LINKAGES Project

Pregnancy

Infancy

Childhood

Adolescence

Adulthood

Birth

slide18

Why NACS?

Evolved in HIV, specifically from model of Food By Prescription

Links vulnerable to clinical services -- reciprocal impact between health & nutrition

Continuum of Care from rehabilitation to chronic nutrition management

Link patients to support groups & community services

Referrals for economic strengthening, livelihood & food security (ES/L/FS) support

Contributed to overall health system strengthening

nacs hinges on nutrition assessment
NACS Hinges on Nutrition Assessment
  • Routine Comprehensive Assessment
    • Anthropometry
    • Biochemical
    • Clinical
    • Dietary
    • Household Food security
  • Analyze/interpret data using evidence-based standards
  • Identify nutrition problems
  • Determine causes/contributing risk factors
  • Cluster signs/symptoms and defining characteristics
  • Determine an appropriate Nutrition Care Plan
slide20

Nutrition Counseling

  • Understanding of client preferences, constraints & options
  • Nutrition Care Plans
  • Optimal diet
  • Dietary management of symptoms
  • Dietary management of drug side-effects
  • Adherence to medications & clinical visits
  • Chronic disease management
  • Exercise
  • Water, sanitation, and hygiene (WASH)
  • Referral to community services, including household ES/L/FS support
slide22

NUTRITION SUPPORT

NUTRITION COUNSELING

Exercise

IYCF/GMP

Maternal Nutrition

Referrals

Referrals

NUTRITION ASSESSMENT

Household food rations

Nutrition Care Plan

Support Groups

Clinic

Anthropometry

Clinical

Dietary

Food by Prescription: Therapeutic, Supplementary & Complementary Foods

Prompt treatment of infections

Community Health Workers

Food security

Biochemical

Adherence to medications

Economic Strengthening, Livelihoods & Food Security

Referrals

Referrals

Dietary management of symptoms, drug side-effects and drug-food interactions

WASH

Point-of-use water treatment

Micronutrient supplements

Community

enabling environment
Enabling Environment

Policies, Strategies & Guidelines

Supply Chain Management

SUN/

1000 Days

Training

PEPFAR

Funding/Financing

Research/M&E

Community Demand

Feed the Future

Title II

Mapping/

Strengthening Services

Referral Links & Tracking

NACS

Global Health Initiative

HumanResources

QualityImprovement

slide24

COMMUNITY

Service

Gaps

Referrals

Referrals

CLINIC

Pre-NACS….

Limited linkages and referrals

Referrals

Referrals

slide25

COMMUNITY

Referrals

Referrals

CLINIC

The NACS Approach….

Referrals

Referrals

slide26

NACS

Along the continuum of care, in a way that is client

centered that includes assessment, counseling, and

support with referrals and effective coordination

for optimal quality and impact

slide27

Phased Implementation of NACS in HIV

Early Planning & Implementation

South Africa, Mozambique, Vietnam

Program Expansion

Côte d’Ivoire, Ghana, Ethiopia, Uganda, Tanzania, Namibia, Zambia, Haiti

Implemented at National Scale

Malawi and Kenya

integrating nutrition into national hiv responses 1
Integrating Nutritioninto National HIV Responses (1)
  • National Policy and Coordination
    • National nutrition and HIV guidelines
    • National nutrition and HIV strategy
    • Nutrition incorporated into HIV policies and vice versa
    • Technical coordinating group
    • Nutrition focal point in National AIDS Control Program
integrating nutrition into national hiv responses 2
Integrating Nutritioninto National HIV Responses (2)
  • Capacity Strengthening
    • In-service and pre-service training of health care providers (linking the two ?)
    • Job aids
    • SBCC materials
    • Anthropometric equipment
    • Mentoring and supervision
    • QA/QI
    • M&E
integrating nutrition into national hiv responses 3
Integrating Nutritioninto National HIV Responses (3)
  • Service delivery
    • Nutrition assessment
    • Nutrition education and counseling
    • Specialized food products
    • Micronutrient supplementation
    • Water , sanitation, and hygiene (WASH)
    • Food security support