Food & Nutrition Support within PEPFAR Clinical Programs

The United States President’s Emergency Plan for AIDS Relief

Track 1 ART Program MeetingAtlanta

September 25, 2007Tim Quick, USAID

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.

Nausea, oral thrush, altered taste & depressed appetite.

Accelerated nutrient losses due to malabsorption, diarrhea & hypermetabolism.

Multiple micronutrient deficiencies pre-existing & precipitated by infection (& Tx).

Clinical Picture for PLHIV

• 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

Dietary Implications of HIV

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

•OVC, especially infants &

young children.

•HIV+ pregnant & lactating

women in PMTCT programs.

•PLHIV in care & Tx programs.

Nutritional Support Begins with Nutritional Assessment

1. Anthropometry (wt, BMI, MUAC)2. Symptom mgmt (appetite, nausea,

taste, oral thrush, diarrhea, drug X food interactions

3. Dietary adequacy (micronutrients)4. Household food security5. Family-centered approach – referral

(HBC) and assessment of others in family, esp young children

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

• 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

Policies

Guidelines

ResourcesFundingStaffing

Commodities

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Wrap-Around Programs

Maternal & Child Health/Family Planning

Food Assistance/SecurityLivelihood Assistance/Employment/Microcredit

Education/Vocational Training

PMTCT OVC Pediatric Care & Tx Adult Care & Tx

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• Nutritional assessment

Anthropometry

Symptom mgmt

Dietary assessment

Nutrition Counseling

Multi-MN suppl (MN by Prescription)

Therapeutic/suppl feeding (Food by Prescription)

• 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 careSafe waterMUAC clinic referral

• Nutritional assessment

Anthropometry

Symptom mgmt

Dietary assessment

Nutrition Counseling

VA, Zn, multi-MN suppl

Therapeutic/suppl feeding

• 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

• Infant Nutrition Infant feeding

counseling Growth monitoring Multi-MN

supplementation Therapeutic/

supplementary/ supplemental feeding

• Maternal nutrition Assessment

&Counseling Multi-MN suppl Supplemental feeding

• Infant feeding counselling

• Links to basic CS, e.g. cIMCI, CTC, CB-GMP

• Safe water/hygiene/ sanitation

• Continuum of care for U5 PMTCT infants and older children:

Growth monitoring VA, Zn, multi-Mn

supplementation Therapeutic/

supplementary/ supplemental feeding

• 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

PEPFAR Wrap-around

Individuals OVC/PMTCT Women Households

Hospital/Clinic Level Clinic/Community Community

Clinical Malnutrition Any nutritional status Food insecurity

Severely malnourished

adults

Moderately malnourished

adults

Any nutritional status Household food security assessment

Therapeutic foods

Supplementary foods

Supplemental, supplementary & therapeutic foods

Food aid commodities

F-100, F-75, and ready-to-

use therapeutic foods (RUTF)

Fortified blended foods and ready-to-

use supplementary foods (RUSF)

Fortified foods,RUTF, RUSF.

Fortified blended foods, grains, legumes, oil

Food Assistance for PLHIV & Families

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

Physician • Symptom diagnosis• Integrated symptom

Tx/management

Pharmacy • Food dispensing• Inventory control• Record keeping

Lay Counselor • Nutrition education/

counseling• Peer support

Nutritionist/Health Worker

• Assessment• Counseling• MN supplement &

food prescription• Referral clinical care

& household food security

PatientFollow-up

Referral

Hospital/ClinicHospital/Clinic

Inpatient

VCT

Community Programs• Food security• Livelihood assistance• MCH

Food Company• Food production• Direct delivery to

hospital/clinic

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.

Cost Breakdown for Nutrition Component

Age GroupAmount of

Food/DayPeriod on Food Amount of

Food/PeriodCost of Food

6m – 2yrs 100g 18 months 54kg $40.54

2yrs – 4yrs 200g 6 months 36kg $27.03

5yrs – 10yrs 200g 6 months 36kg $27.03

11yrs – 17yrs 300g 6 months 54kg $38.92

18yrs + 300g 6 months 54kg $38.92

Pregnant/Post Partum

300g 9 months 81kg $72.06

Note: The periods detailed above represent the maximum amount of time on food.

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