Nutrition Assessment, Counseling, and Support: Scale-up of PEPFAR Nutrition Programs Presented by:...
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Transcript of Nutrition Assessment, Counseling, and Support: Scale-up of PEPFAR Nutrition Programs Presented by:...
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?