Food and Nutrition Food and Nutrition Activities in the Activities in the

President’s Emergency President’s Emergency Plan for AIDS Relief Plan for AIDS Relief

(PEPFAR)(PEPFAR)CAPT Pamela Ching, RD/LD, MS, SDCAPT Pamela Ching, RD/LD, MS, SD

Nutrition Medical OfficerNutrition Medical OfficerDivision of Global HIV/AIDSDivision of Global HIV/AIDS

Center for Global HealthCenter for Global HealthCenters for Disease Control and PreventionCenters for Disease Control and Prevention

GoalsGoals Background on food insecurity and Background on food insecurity and

undernutritionundernutrition

OverviewOverview Global Health Initiative (GHI)Global Health Initiative (GHI) President’s Emergency Plan for AIDS Relief President’s Emergency Plan for AIDS Relief

(PEPFAR) (PEPFAR)

Food and Nutrition (F&N) activities Food and Nutrition (F&N) activities Assessments of food insecurity and malnutritionAssessments of food insecurity and malnutrition Provision of therapeutic and supplemental foods to Provision of therapeutic and supplemental foods to

eliminate macro- and micro-nutrient deficiencieseliminate macro- and micro-nutrient deficiencies Training clinical and community-based personnelTraining clinical and community-based personnel

Food InsecurityFood Insecurity““The limited or uncertain availability of The limited or uncertain availability of

nutritionally adequate, safe foods or the nutritionally adequate, safe foods or the inability to acquire personally acceptable inability to acquire personally acceptable foods in socially acceptable ways.” foods in socially acceptable ways.”

(American Institute of Nutrition)

““The right to adequate food is realized The right to adequate food is realized when every man, woman and child, alone when every man, woman and child, alone or in community with others, has or in community with others, has physical and economic accessphysical and economic access at all times at all times to adequate food or means for its to adequate food or means for its procurement.”procurement.”((United Nations Committee on Economic, Social, and Cultural Rights,

1999)

~ 850 million people were food insecure last year

Global Food Insecurity

(World Food Programme)(World Food Programme)

Chronic Undernutrition, 1990-2008

Global Undernutrition

INTERVENTIONS

- Breastfeeding- Complementary feeding- Vitamin A- Zinc- Hygiene

INSTITUTIONS

POLITICAL & IDEOLOGICAL FRAMEWORK

ECONOMIC STRUCTURE

Food/nutrientintake

Health

Water/Sanitation

health services

Immediate

Underlying causes at

household/family level

Basic causes at societal

level

- Agriculture- Poverty Reduction- Income generation- Education- Women’s empowerment- Health Systems Strengthening

Maternal and

child-care

practices

Access to food

RESOURCESENVIRONMENT, TECHNOLOGY,

PEOPLE

CAUSESCAUSES

UndernutritionUndernutrition

(Adapted from: United Nations Standing Committee on Nutrition News, 2008)

PEPFARPEPFAR

GHI

US EffortsUS Efforts

UndernutritionUndernutrition

Department of State

Department of State

BreastfeedingComplementary feedingVitamin AZincHygiene

INSTITUTIONS

POLITICAL & IDEOLOGICAL FRAMEWORK

ECONOMIC STRUCTURE

Food/nutrientintake

Health

Water/Sanitation

health services

AgriculturePoverty ReductionEducationHealth Systems StrengtheningIncome generationWomen’s empowerment

Maternal and

child-care

practices

Access to food

RESOURCESENVIRONMENT, TECHNOLOGY,

PEOPLE

““We cannot simply confront individual We cannot simply confront individual preventable illnesses in isolation. The preventable illnesses in isolation. The world…demands an integrated world…demands an integrated approach to global health. We will not approach to global health. We will not be successful in our efforts …unless we be successful in our efforts …unless we do more to improve health systems do more to improve health systems around the world…and ensure that around the world…and ensure that best practices drive the funding for best practices drive the funding for these programs.”these programs.”

President Barack ObamaPresident Barack ObamaMay 5, 2009May 5, 2009

Global Health Initiative Global Health Initiative (GHI)(GHI)

Six-year, $63 billion commitment by the US Six-year, $63 billion commitment by the US government to assist developing countries in government to assist developing countries in reducing morbidity and mortality from reducing morbidity and mortality from HIV/AIDS, tuberculosis, malaria, and neglected HIV/AIDS, tuberculosis, malaria, and neglected tropical diseasestropical diseases

Objectives:Objectives: Achieve Achieve significant health improvementssignificant health improvements Create an Create an effective, efficient and effective, efficient and

sustainable platformsustainable platform for the delivery of for the delivery of essential health care and public health essential health care and public health programsprograms

GHI GoalsGHI Goals Nutrition:Nutrition: Reduce child Reduce child

undernutrition by 30% across assisted undernutrition by 30% across assisted food insecure countries in food insecure countries in conjunction with the President’s conjunction with the President’s “Feed the Future” initiative. “Feed the Future” initiative.

HIV/AIDS:HIV/AIDS: PEPFAR will support:PEPFAR will support: Treatment of Treatment of >> 3 million people with anti- 3 million people with anti-

retrovirals (ARVs)retrovirals (ARVs) Prevention of Prevention of >> 12 million new HIV infections 12 million new HIV infections Care of Care of >> 12 million people, including 5 12 million people, including 5

million orphans and vulnerable children million orphans and vulnerable children

President’s Emergency President’s Emergency Plan for AIDS Relief Plan for AIDS Relief

(PEPFAR)(PEPFAR) 2003: Congress authorizes 5-year, $15 billion 2003: Congress authorizes 5-year, $15 billion

Program Program A crucial component of US foreign policyA crucial component of US foreign policy Program focused on provision of comprehensive HIV/AIDS Program focused on provision of comprehensive HIV/AIDS

prevention, care, and treatment using a multi-sectoral prevention, care, and treatment using a multi-sectoral

approach in developing countries most affected by the approach in developing countries most affected by the

epidemicepidemic 15 focus countries (12 in Sub-Sahara Africa; Haiti; Guyana; 15 focus countries (12 in Sub-Sahara Africa; Haiti; Guyana;

Vietnam) accounting for >50% global HIV/AIDS burdenVietnam) accounting for >50% global HIV/AIDS burden

2009: 5-year reauthorization within GHI: $48 2009: 5-year reauthorization within GHI: $48

billion for HIV/AIDS, tuberculosis, and malariabillion for HIV/AIDS, tuberculosis, and malaria

HIV/AIDS, Food, and HIV/AIDS, Food, and NutritionNutrition

““Slim Disease” - People living with HIV/AIDS Slim Disease” - People living with HIV/AIDS (PLWHA ) typically present with advanced AIDS (PLWHA ) typically present with advanced AIDS after chronic illness and >10% weight loss after chronic illness and >10% weight loss

Strong correlation between wasting and Strong correlation between wasting and mortality before and during treatmentmortality before and during treatment

Food is often the most urgent need for PLWHA Food is often the most urgent need for PLWHA and their familiesand their families

Anti-retroviral therapy (ART) and treatment for Anti-retroviral therapy (ART) and treatment for opportunistic infections improves appetite and opportunistic infections improves appetite and nutritional status of most malnourished nutritional status of most malnourished patientspatients

Guiding Principles for Guiding Principles for PEPFAR F&N ProgramsPEPFAR F&N Programs

Support PEPFAR “3/12/12” goalsSupport PEPFAR “3/12/12” goals Strive to integrate nutrition assessment, counseling, and Strive to integrate nutrition assessment, counseling, and

support (NACS) services within clinical care and treatmentsupport (NACS) services within clinical care and treatment Provide food and specialized nutritional supplements to Provide food and specialized nutritional supplements to

target groups using defined eligibility criteria (“Food as target groups using defined eligibility criteria (“Food as

Medicine”)Medicine”) Be linked with food assistance and security programs Be linked with food assistance and security programs

supported by other initiatives or “wrap-arounds” (e.g., UN supported by other initiatives or “wrap-arounds” (e.g., UN

World Food Programme; USAID’s Title II, Food for Peace World Food Programme; USAID’s Title II, Food for Peace

Program) Program)

Target Groups for Target Groups for PEPFAR PEPFAR

F&N SupportF&N Support Orphans and vulnerable children (OVC), Orphans and vulnerable children (OVC),

especially those under 5 years of ageespecially those under 5 years of age HIVHIV++ pregnant and lactating women in pregnant and lactating women in

prevention of mother to child prevention of mother to child

transmission (PMTCT) programstransmission (PMTCT) programs People living with HIV/AIDS (PLWHA) People living with HIV/AIDS (PLWHA)

in care and treatment programsin care and treatment programs

Food by Prescription Food by Prescription (FBP)(FBP)

Nutrition assessment, counseling, and support = Nutrition assessment, counseling, and support = NACSNACS

FBP - program supporting NACSFBP - program supporting NACS

NNutrition utrition aassessment: entry and “graduation” ssessment: entry and “graduation” anthropometric and clinical criteria for anthropometric and clinical criteria for malnourished and nutritionally vulnerable PLWHA, malnourished and nutritionally vulnerable PLWHA, pregnant and lactating women and their infants pregnant and lactating women and their infants enrolled in PMTCT programs, and OVC enrolled in PMTCT programs, and OVC

Provision of nutrition education and Provision of nutrition education and ccounselingounseling

Food by Prescription Food by Prescription (FBP)(FBP)

Therapeutic and supplementary feeding Therapeutic and supplementary feeding ssupportupport

RUTF (Ready-to-use Therapeutic Food), e.g., Plumpy’nutRUTF (Ready-to-use Therapeutic Food), e.g., Plumpy’nut FBF (Fortified Blended Foods – grain and legume based FBF (Fortified Blended Foods – grain and legume based

flour/cereals flour/cereals Sometimes: multi-micronutrient supplementsSometimes: multi-micronutrient supplements

Instruction and supplies to support safe water Instruction and supplies to support safe water treatment treatment

Referral and support for household food security Referral and support for household food security and livelihood assistanceand livelihood assistance

Food by Prescription Food by Prescription (FBP)(FBP)

Physician/Nurse • Symptom diagnosis• Integrated symptom

treatment/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 to clinical

care & household food security

HBC/Community

Referral

Hospital / ClinicHospital / Clinic

Inpatient

VCT

Community Programs• Food security• Livelihood assistance• MCH

Food Company• Food production• Delivery to

hospital/clinic

PEPFAR-Supported PEPFAR-Supported F&N EffortsF&N Efforts

Basic FBP program implementation:Basic FBP program implementation: In operation: Malawi, Zambia, Haiti In operation: Malawi, Zambia, Haiti Starting: Namibia, GhanaStarting: Namibia, Ghana Planning: Cote d’Ivoire, Mozambique, VietnamPlanning: Cote d’Ivoire, Mozambique, Vietnam

FBP with quality assessment and FBP with quality assessment and improvement evaluation activities:improvement evaluation activities: Kenya, Tanzania, Ethiopia, UgandaKenya, Tanzania, Ethiopia, Uganda

PEPFAR-Supported PEPFAR-Supported F&N EffortsF&N Efforts

LIFT (LIFT (LILIvelihoods & velihoods & FFood Security ood Security TTechnical Assistance) Projectechnical Assistance) Project

Provide household economic strengthening Provide household economic strengthening and livelihood assistance to food-insecure and livelihood assistance to food-insecure HIV/AIDS-affected families, including OVCHIV/AIDS-affected families, including OVC

Technical assistance in Nigeria, Malawi, Technical assistance in Nigeria, Malawi, Kenya, Ethiopia, Rwanda, Mozambique, South Kenya, Ethiopia, Rwanda, Mozambique, South Africa and Namibia.Africa and Namibia.

Future PEPFAR-Future PEPFAR-Supported F&N Supported F&N

EffortsEfforts PMTCT programs: greater emphasis on infant feeding PMTCT programs: greater emphasis on infant feeding practices which promote infant HIV-free survival in practices which promote infant HIV-free survival in addition to prevention of peri-natal HIV transmission addition to prevention of peri-natal HIV transmission

Promote prolonged breastfeeding in conjunction with use of ARTPromote prolonged breastfeeding in conjunction with use of ART

Counseling on appropriate and timely weaning from breastfeeding and Counseling on appropriate and timely weaning from breastfeeding and introduction of complementary foodsintroduction of complementary foods

Establish local capacity to produce therapeutic and Establish local capacity to produce therapeutic and supplementary foods (e.g., RUTF; FBF; urban and rural supplementary foods (e.g., RUTF; FBF; urban and rural gardens)gardens)

Establish globally-accepted food security and Establish globally-accepted food security and nutritional status indicators which are harmonized with nutritional status indicators which are harmonized with HIV/AIDS status indicatorsHIV/AIDS status indicators

AcknowledgementsAcknowledgements

Nicholas Vogenthaler - Emory UniversityNicholas Vogenthaler - Emory University

Roshelle Payes and Eunyong Chung - USAID, Roshelle Payes and Eunyong Chung - USAID, WashingtonWashington

Tonya Himelfarb – Office of the Global AIDS Tonya Himelfarb – Office of the Global AIDS Coordinator, US Department of StateCoordinator, US Department of State

Tim Quick and Amie Heap – USAID, WashingtonTim Quick and Amie Heap – USAID, Washington

AVAILABILITY:sufficient quantities of food from household production, other domestic output, commercial imports or food assistance

ACCESS:adequate resources to obtain appropriate foods for a nutritious diet, which depends on income available to the household, on the distribution of income within the household and on the price of food

UTILIZATION/CONSUMPTION: proper biological use of food, requiring a diet providing sufficient energy and essential nutrients, potable water and adequate sanitation, as well as knowledge within the household of food storage and processing techniques, principles of nutrition and proper child care and illness management

Food SecurityFood security = all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life.

Global Undernutrition

Stunting remains a greater problem than underweight or wasting.

More than 1/3 of children in Africa & Asia are underweight.

Issues to Address Concerning

Undernutrition Stunting and iron deficiency anemia Stunting and iron deficiency anemia have not been adequately have not been adequately addressedaddressed

Poor growth in many countries related to Poor growth in many countries related to inadequate breastfeeding, inadequate breastfeeding, complementary feeding, and infectious diseasecomplementary feeding, and infectious disease

Refocus on Refocus on dietary quality, high levels of morbidity, and possibly dietary quality, high levels of morbidity, and possibly intergenerational factorsintergenerational factors affecting linear growth. affecting linear growth.

Targeting of pregnant women and children under 2Targeting of pregnant women and children under 2 – ‘window of – ‘window of opportunity’ – especially in communities with highest prevalence opportunity’ – especially in communities with highest prevalence of stuntingof stunting

Gross inequitiesGross inequities throughout region and within countries: Rural vs. throughout region and within countries: Rural vs. urban; indigenous vs. non-indigenousurban; indigenous vs. non-indigenous

Human resources and capacity constraints for health and nutritionHuman resources and capacity constraints for health and nutrition

PEPFAR Five-Year PEPFAR Five-Year StrategyStrategy

(FY 2009-2013)(FY 2009-2013) Transition from an emergency response to Transition from an emergency response to

promotion of sustainable country programs.promotion of sustainable country programs. Strengthen partner government capacity to lead the Strengthen partner government capacity to lead the

response to this epidemic and other health demands. response to this epidemic and other health demands. Expand prevention, care, and treatment in both Expand prevention, care, and treatment in both

concentrated and generalized epidemics. concentrated and generalized epidemics. Integrate and coordinate HIV/AIDS programs with Integrate and coordinate HIV/AIDS programs with

broader global health and development programs to broader global health and development programs to maximize impact on health systems. maximize impact on health systems.

Invest in innovation and operations research to Invest in innovation and operations research to evaluate impact, improve service delivery and evaluate impact, improve service delivery and maximize outcomes.maximize outcomes.

(Executive summary of PEPFAR’s strategy: http://www.pepfar.gov/strategy/document/133244.htm)

Nutrition Implications of HIV/AIDS

Daily caloric needs: Daily caloric needs:

Asymptomatic: 10% increaseAsymptomatic: 10% increase

Symptomatic: 20-30% increaseSymptomatic: 20-30% increase

Children with weight loss: 50-100% increaseChildren with weight loss: 50-100% increase

Daily protein needs:Daily protein needs:

Maintain at 12-15% of daily caloric intake (typically at least twice that of cereal- and tuber-Maintain at 12-15% of daily caloric intake (typically at least twice that of cereal- and tuber-

based diets common in developing countries)based diets common in developing countries)

Micronutrients (essential vitamins/minerals) Micronutrients (essential vitamins/minerals)

At least daily recommended level s for non-HIV-infected individuals (which many such At least daily recommended level s for non-HIV-infected individuals (which many such

individuals as well s HIV/AIDS patients do not yet achieve)individuals as well s HIV/AIDS patients do not yet achieve)

Require high-energy, nutrient-dense foodsRequire high-energy, nutrient-dense foods

Recommended Elements Recommended Elements for PEPFAR F&N for PEPFAR F&N

ProgramsPrograms Nutrition CareNutrition Care – – GoalGoal: : Improved/Adequate Nutrition StatusImproved/Adequate Nutrition Status

Nutrition Assessment, Counseling & Support (Nutrition Assessment, Counseling & Support (NACSNACS)) Assessment: Assessment:

Anthropometric; Clinical; Dietary; Environmental (i.e., household Anthropometric; Clinical; Dietary; Environmental (i.e., household food security)food security)

Counseling:Counseling: Clinical (adherence to ART )Clinical (adherence to ART ) Dietary (use of special therapeutic and supplemental foods; Dietary (use of special therapeutic and supplemental foods;

adherence to WASH and food safety practices)adherence to WASH and food safety practices) PsychosocialPsychosocial

Support:Support: Food by Prescription; commodity supportFood by Prescription; commodity support Safe Water TreatmentSafe Water Treatment Multi-micronutrient supplementsMulti-micronutrient supplements Referral to social services for livelihood and food security Referral to social services for livelihood and food security

  

Recommended Elements Recommended Elements for PEPFAR F&N for PEPFAR F&N

ProgramsPrograms PMTCTPMTCT – – GoalGoal: : HIV-Free SurvivalHIV-Free Survival

ART: HAART; Maternal/Infant ProphylaxisART: HAART; Maternal/Infant Prophylaxis Infant Feeding Counseling & SupportInfant Feeding Counseling & Support Postnatal Care: Postnatal Care:

Growth monitoring;Growth monitoring; Basic child survival package (immunizations; routine Basic child survival package (immunizations; routine

micronutrient supplementation; insecticide-treated micronutrient supplementation; insecticide-treated bednets;bednets;

Opportunistic infections: Cotrimoxizole; clinic referral)Opportunistic infections: Cotrimoxizole; clinic referral) Feeding SupportFeeding Support

MaternalMaternal InfantInfant

ComplementaryComplementary ReplacementReplacement

Community Management of Acute Malnutrition (CMAM)Community Management of Acute Malnutrition (CMAM)

Recommended Elements Recommended Elements for PEPFAR F&N for PEPFAR F&N

ProgramsPrograms Livelihoods and Food SecurityLivelihoods and Food Security – – Goal: Goal: Household Food Household Food

SecuritySecurity Food ProductionFood Production (Re-) Employment(Re-) Employment Involvement in income-generating activitiesInvolvement in income-generating activities Vocational TrainingVocational Training Food Commodity AffordabilityFood Commodity Affordability

Nutrition Assessment, Nutrition Assessment, Counseling, and Support Counseling, and Support

(NACS)(NACS) Clinical care and treatment services and F&N support Clinical care and treatment services and F&N support

are linked for PLWHA and OVCare linked for PLWHA and OVC

Reciprocal impact between health & nutrition Reciprocal impact between health & nutrition

Therapeutic and corrective model Therapeutic and corrective model Preventive and chronic nutrition Preventive and chronic nutrition management modelmanagement model

PLWHA and women in PMTCT are linked to groups for PLWHA and women in PMTCT are linked to groups for treatment and F&N support, education, and counselingtreatment and F&N support, education, and counseling Referrals for livelihood (income-generating) and food security supportReferrals for livelihood (income-generating) and food security support

Health system strengthening -- strengthens capacity of Health system strengthening -- strengthens capacity of clinics and communities to provide NACS for all clinics and communities to provide NACS for all individuals, not just HIV/AIDS infected and affectedindividuals, not just HIV/AIDS infected and affected

Food Assistance for PLWHA & Families

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

Nutrition and HIV Indicators

Lessons LearnedLessons Learned Clinics where NACS is initiated are understaffed Clinics where NACS is initiated are understaffed

and overstretched. Quality Improvement (QI) and overstretched. Quality Improvement (QI) efforts will be critical to finding efficiencies that efforts will be critical to finding efficiencies that allow integration of NACS within clinical servicesallow integration of NACS within clinical services

Training of healthcare workers are necessary, Training of healthcare workers are necessary, but not sufficient –all training should be linked but not sufficient –all training should be linked to QI efforts and the realities of Human to QI efforts and the realities of Human Resources (HR) Resources (HR)

Training should be decentralized, and Training should be decentralized, and individualized to the needs of each of the individualized to the needs of each of the different types of healthcare workersdifferent types of healthcare workers

Lessons LearnedLessons Learned Prioritize provision of F&N program and services to the most vulnerable: Prioritize provision of F&N program and services to the most vulnerable:

#1 - Infants and young children#1 - Infants and young children

#2 - Pregnant and lactating women in PMTCT programs#2 - Pregnant and lactating women in PMTCT programs

#3 - Adult PLWHA#3 - Adult PLWHA

Roll-out of NACS should precede initiation of FBP programs -- build Roll-out of NACS should precede initiation of FBP programs -- build ability to carry out NACS and secure commoditiesability to carry out NACS and secure commodities

Counseling of “Food as Medicine” in FBP leads to limited sharing of food Counseling of “Food as Medicine” in FBP leads to limited sharing of food by patient within his/her household, resulting in good weight recoveryby patient within his/her household, resulting in good weight recovery

Assessment and counseling , even without provision of therapeutic foods Assessment and counseling , even without provision of therapeutic foods and supplemental food commodities improves nutritional status of and supplemental food commodities improves nutritional status of patientspatients

Linkage of F&N support to other community programs and public health Linkage of F&N support to other community programs and public health surveillance results in improved nutritional and health outcomes at lower surveillance results in improved nutritional and health outcomes at lower costscosts

Challenges in F&N Challenges in F&N ProgrammingProgramming

Integration and expansion of comprehensive Integration and expansion of comprehensive NACS into other public health initiativesNACS into other public health initiatives

Linking clinical services with referral and Linking clinical services with referral and support for food and livelihood assistance so support for food and livelihood assistance so as to produce sustainable food security among as to produce sustainable food security among HIV/AIDS patientsHIV/AIDS patients

Balancing programming emphasis and Balancing programming emphasis and resources for nutritional assessment and resources for nutritional assessment and counseling with those needed for provision of counseling with those needed for provision of food and feeding supportfood and feeding support

Challenges in F&N Challenges in F&N ProgrammingProgramming

Balancing efforts to support food Balancing efforts to support food production among patients with support production among patients with support for (re-)employment, income generating for (re-)employment, income generating activities, and other livelihood assistanceactivities, and other livelihood assistance

Balancing support and resources Balancing support and resources equitably among three vulnerable equitably among three vulnerable population groups: adult patients in care population groups: adult patients in care and treatment programs, women and and treatment programs, women and infants supported in PMTCT programs, infants supported in PMTCT programs, OVCOVC