HIV/AIDS and Nutrition

1. HIV/AIDS and Nutrition Module 18

2. Learning objectives • Be able to identify the changing nutritional requirements of people living with HIV and how these could be managed in emergencies • Be aware of the complex issues surrounding targeting of people living with HIV in emergencies • Understand the issues linked to breastfeeding for HIV-positive mothers in emergencies • Have enough knowledge to understand the importance of key services for the treatment and care of people living with HIV in emergencies to maintain nutritional status • Understand the importance of good hygiene, water and sanitation for people living with HIV. 2

3. The Global AIDS epidemic • Since the beginning of the epidemic, almost 60 million people have been infected with HIV and 25 million people have died of HIV-related causes • In 2008, some 33.4 million people living with HIV, 2.7 million new infections and 2 million AIDS-related deaths • In 2008, around 430 000 children were born with HIV, bringing to 2.1 million the total number of children under 15 living with HIV • Young people account for around 40% of all new adult (15+) HIV infections worldwide • Sub-Saharan Africa is the region most affected and is home to 67% of all people living with HIV worldwide and 91% of all new infections among children • In sub-Saharan Africa the epidemic has orphaned more than 14 million children. 2

4. Humanitarian crises and HIV and AIDS • Factors that may accelerate the spread of HIV in emergencies include: • Rape and sexual violence • Mass displacement of people • Severe impoverishment leading to transactional sex for survival • Breakdown in normal health and social services leading to reduction in the availability of: • Voluntary counselling and testing for HIV • Reproductive health options • Treatment for Sexually Transmitted Infections (STIs) • Antenatal care • Antiretroviral treatments for breastfeeding HIV+ve women 2

5. HIV and AIDS programming • The challenges faced by humanitarian workers, governments and civil society fall within all the 3 pillars of HIV/AIDS programming, namely: • Prevention • Health care and treatment • Support and care • Prevention – condoms, counselling, infant and young child feeding counselling and support, etc • Health care and treatment - ARTs, opportunistic infections treatment, nutritional support including micronutrient supplements • Support and care – psychosocial support, family and community support, etc 2

6. 2010 Inter-Agency Standing Committee Guidelines • The 2010 IASC guidelines for addressing HIV in humanitarian settings action framework lists 9 sectors into which HIV should be integrated: • Awareness raising • Health • Protection • Food security • Education • Shelter • Camp coordination • Water, sanitation, and hygiene • The workplace • Earlier guidelines focused on avoiding stigmatisation • The 2010 guidelines emphasise the need for coordination of existing and fragmented HIV support groups to provide targeted nutritional support, food security, and livelihood support. 2

7. What is the link between HIV and AIDS and Nutrition? • One of the most common signs of HIV progression is weight loss • Unexplained weight loss (>10% of body weight) is one of the signs used to indicate that a patient is moving from the asymptomatic phase towards AIDS • There are 2 patterns of weight loss: • First pattern is a slow gradual decline in weight over time with HIV infection • Second pattern is a rapid and drastic weight loss often associated with a serious infection 2

8. Link between HIV and AIDS and Nutrition • Early detection of HIV provides an opportunity to build up good nutritional status and healthy eating habits • Good nutrition is a form of immune protection, especially important in the presence of HIV • People living with HIV may reduce the amount of food they consumedue to the following factors: • Sores in the mouth, throat, and digestive tract • Persistent nausea, vomiting, diarrhoea, or stomach pains • Depression which reduces appetite • Economic problems due to loss of income or lack of access to adequate food • Tiredness making food preparation slow or difficult • People living with HIV may also have poor absorption of nutrients from food consumed due to: • Diarrhoea • Intestinal tract infection • Medications side effects • (Anaemia)

9. Link between HIV and AIDS and Nutrition (2) • The metabolism of a person living with HIV is altered • In the asymptomatic phase an additional 10% of energy is required • As a person moves into the symptomatic phases, the energy requirement goes up 20-30% more • Children in symptomatic phases require 50-100% more energy than expected by age and weight •  If nutritional needs are not met, the body is more susceptible to infections and may take longer to recover from minor illnesses • This leads to a cycle of more weight loss, more vulnerability, and worsening illness

10. Nutrient requirements for HIV+ in relation to Normal Dietary Requirements *Adapted from WHO, 2003: Nutrient requirements for People Living with HIV/AIDS, Report of technical consultation. Geneva, WHO. Refer to this document for details and discussions on nutrient requirements

11. Poor Nutrition resulting in weight loss, muscle wasting, weakness, nutrient deficiencies Impaired Immune System Poor ability to fight HIV and other infections, Increased oxidative stress Increased Nutritional needs Reduced food intake and increased loss of nutrients HIV Increased vulnerability to infectionse.g. Enteric infections, flu, TB hence Increased HIV replication, Hastened disease progression Increased morbidity Vicious Cycle of Malnutrition and HIV Source: Adapted from RCQHC and FANTA 2003

12. Nutrition during pregnancy and early infancy for those affected by HIV • Condoms and ART supplies particularly for pregnant women are an important part of integrated HIV and nutrition planning • PLW with HIV require the same increase in foods and added micronutrients as HIV-ve pregnant women, plus an additional 10% to maintain their health in the context of HIV infection 2

13. Nutrition during pregnancy and early infancy for those affected by HIV (WHO, 2010) • The best way to approach nutritional care and prevent mother-to-child transmission of HIV: • Appropriate health care during pregnancy (with ART) • Breastfeeding exclusively in the first 6 months and continue up to at least a year • Replacement feeding if acceptable, feasible, affordable, sustainable and safe (AFASS) • Asymptomatic HIV positive lactating women require the same increase in rations and micronutrients as HIV-velactating women, plus an additional 10% for maintaining health in the context of HIV 2

14. Nutrition during childhood for those affected by HIV • After the first year of life, HIV exposed but uninfected children should transition to family foods with animal protein, particularly milk • Beyond the first year of life, children known to have contracted HIV should continue to breastfeed up to 24 months of age and beyond • In this case, breast milk offers no additional risk, and provides the best source of nutrition • Complementary foods should be added to the diet at 6 months to provide energy, nutrients, and dietary diversity. 2

15. HIV/AIDS and Nutrition in emergencies • 8 critical HIV/AIDS and nutrition-related activities in emergencies • Integration of HIV into all aspects of emergency care – prevention, education, health, basic services, planning and management • Targeted food support • Maternal and infant health and feeding • Treatment and care of HIV • Treatment of severe acute malnutrition • Support networks, including livelihood support and HBC • Food hygiene, sanitation, water, shelter • Protection 2

16. HIV/AIDS and Nutrition in emergencies • Integration of HIV into all aspects of emergency care – • prevention, education, health, basic services, planning and management • Mainstreaming HIV programming intoemergency coordination and management can help to prevent the transmission of HIV and uphold the human rights of those living with HIV • The type of emergency and the stage of the emergency will influence the HIV/AIDS and nutrition interventions that need to be undertaken (analysis to be conducted) • The ideal is to integrate HIV into existing food assistance and livelihood support, and integrate food assistance, security, nutrition, and livelihood support into HIV-related projects and activities. • The 2 programming activities can strengthen one another. 2

17. HIV/AIDS and Nutrition in emergencies • Targeted food support • Household food insecurity should be the main (initial) targeting principle, regardless of whether HIV status is known • HIV prevention and sensitization activities should be linked to large-scale food distribution • Particular attention should be given to the identification of households that may be vulnerable because of the presence of HIV or AIDS: • child or elderly headed HH • orphans hosting HH • HH with sick members, etc. • Targeting people living with HIV/AIDS directly may be possible • if there is no stigma or discrimination; • if the targeting does not increase stigma; • if the targeting does not unjustly exclude non affected households. 2

18. HIV/AIDS and Nutrition in emergencies • Targeted food support • Food rations should be specially designed and distribution should consider issues such as distance to cover, capacity to cook, to eat, etc. • Quality- balanced diet particularly important (preparation, consumption and digestibility) • Quantity- increase of 10% in energy required to maintain body weight • in asymptomatic HIV infected adults, can rise to 20-30% • for symptomatic adults and 50-100% for children with acute weight loss and infection • Safe access to food- women and girls should have direct access to food distributions and rations - protection

19. HIV/AIDS and Nutrition in emergencies • Maternal and infant health and feeding • Continuation of breastfeeding recommended • ART reduce rate of transmission from mother-to-child during pregnancy from 40% to 10%, and also reduce the risk of transmission through breastfeeding • HIV testing should then be offered to all mothers: • to determine status • to obtain and dispense appropriate ART treatments to breastfeeding mothers as a complement to breastfeeding • (testing of infants only reliable after 18 months) • Guidelines available for feeding non breastfed infants. 2

20. HIV/AIDS and Nutrition in emergencies • Treatment and care of HIV • The treatment based on ART and cotrimoxazole(for opportunistic infections) helps nutrition by: • improving appetite • utilisation of nutrients by the body • reduction of opportunistic infections • Medication often combined with Food by Prescription (FBP) programmes to increase adherence • Protection and prevention is to be ensured with safe procedures at health facility level, access to condoms, access to post exposure prophylaxis, etc. 2

21. HIV/AIDS and Nutrition in emergencies • Treatment of severe acute malnutrition • Treatment remains the same as for non HIV children, with addition of cotrimoxazole • SAM cases and their caregivers should be encouraged to take voluntary testing and counseling on HIV • 3 care plans for HIV positive children include: • for those growing well (review every 2-3 months) • for those with poor weight gain (regular visit and support) • for the severely malnourished ones (treatment) 2

22. HIV/AIDS and Nutrition in emergencies • Support networks, including livelihood support and Home based care (HBC) • A functioning HBC system provides a safe channel for resources to households with chronically sick members and provide: • Blended fortified foods or fortified cereals ± food basket • RUF or LNS to decrease the preparation time for people with limited appetite • Cash benefits for the purchase of additional foodstuffs • Or the provision of services: • Monitoring of weight and health status • Individual nutritional assessments • HBC limits the risk of opportunistic infections when people with weakened immune systems are not required to wait in health care centres 2

23. HIV/AIDS and Nutrition in emergencies • Support networks, including livelihood support and Home based care (HBC) • HBC can also be used for provision of livelihood support such as: • Dietary diversity support with availability and access to tools, fertilisers, and improved variety seeds • Labour-saving tools adapted to local conditions • Alternative income-generating activities compatible with new activity constraints • Skill building programmes such as junior farmer fields and life school programmes to combine livelihood support with skills education for children who are unaccompanied, orphaned, or made vulnerable by the illness of family members. 2

24. HIV/AIDS and Nutrition in emergencies • Food hygiene, sanitation, water, shelter • These are critical in emergency: • Food Hygiene: avoid contamination during cooking or storage • Sanitation and water availability: latrine construction, control of stagnant water, promotion of hand washing, quality and quantity of water supplies, distance to water • Shelter: safety and security of sites, integration of HIV prevention into shelter programmes 2

25. HIV/AIDS and Nutrition in emergencies • Protection • Gender inequalities are common in emergencies, increasing the vulnerability of women to HIV • Vulnerable households are also common in high HIV prevalence contexts: • Child-headed households • Households with no adult male members • Elderly headed households • Orphans without family • Households hosting orphans • HIV-positive people who are suffering from discrimination or alienation 2

26. HIV/AIDS and Nutrition in emergencies • Protection (2) • Important policy points that should be in place to ensure the rights of individuals and families living with HIV: • Monitor allegations of HIV-related rights violations (and change program if violence associated to its design) • Ensure HIV service provision respects human rights, including the right to privacy. Use of alternative vulnerability criteria for programmes is recommended • HIV testing should not be mandatory, and all HIV testing should be under confidential conditions, with informed consent and counseling according to international standards • Establish protection for women and girls. • Protect orphans and unaccompanied, separated, and other vulnerable children and youth. • Develop programmes addressing gender based violence. 2

27. Key messages • HIV should be integrated into all aspects of the emergency management planning and response. • People living with HIV have increased nutritional needs in terms of energy requirements. • People living with HIV should be monitored regularly for weight loss which may be a sign of decreased intake or disease progression. • Steps can be taken to reduce the rate of transmission of HIV from mother to child with counselling on infant feeding and ART (antiretroviral therapy). Food/nutrition support may be needed. • Services for HIV care should be established as a priority. These include provision of ART and cotrimoxazole and VCT (voluntary counselling and testing) facilities. • All severely malnourished children require therapeutic care. HIV positive children should be regularly assessed and assigned to appropriate nutritional care plans. • Home based care (HBC) programmes and livelihood support programmes are important for improving the long-term food security status of HIV affected families. • People living with HIV are prone to infections, so access to clean water, appropriate food hygiene and sanitation are a key part of the emergency response for these people/families. • Targeted policies and practices are required to protect the rights and ensure the safety of people living with HIV as well as those at risk of contracting HIV. 2