The Evolution of the Nutrition Assessment , Counseling & Support (NACS) Approach Tim Quick

1. The Evolution of the Nutrition Assessment, Counseling & Support (NACS) Approach Tim Quick USAID Office of HIV/AIDS Co-Chair, PEPFAR Food & Nutrition Technical Working Group

2. Slim disease: a new disease in Uganda and its association with HTLV-III infection Lancet 1985 Oct 19;2 (8460):849-52 D Serwadda, NkSewankambo, JW Carswell, AC Bayley, RS Tedder, RA Weiss, RD Mugerwa, A Lwegaba, GB Kirya, RG Downing, SA Clayden, & AG Dagleish

3. HIV/AIDS: • Loss of appetite • Increased nutrient requirements • Impaired nutrient absorption • Altered nutrient metabolism • Malnutrition: • Weakened immune system • Increased susceptibility to opportunistic infections • Wasting & increased mortality • Poorer adherence & response to treatment

4. Nutrient requirements for people living with HIV/AIDS Report of a Technical Consultation World Health Organization Geneva, 13–15 May 2003

5. 2005: WHO Consultation on Nutrition and HIV/AIDS in Africa calls for “the integration of nutrition into the essential package of care, treatment and support for people living with HIV/AIDS and efforts to prevent infection.” 2006: The World Health Assembly passes a resolution calling on Member States “to develop evidence-based policies and programs on HIV/AIDS and nutrition.”

6. Policy Guidance on the Use of Emergency Plan Funds to Address Food and Nutrition Needs September 2006 The Emergency Plan has a clear responsibility to support prevention, treatment and care for people living with HIV/AIDS (PLWHA), but comprehensively addressing issues of food insecurity is beyond the scope of the Emergency Plan. Key precepts of the Emergency Plan include remaining focused on HIV/AIDS, maximizing leverage with other partners that provide food resources and providing support for limited food assistance in defined circumstances.

7. Kenya Food by Prescription Program

8. NACS -- Linking Clinics & Communities Clinical Mgmt PMTCT/ART Community Surveillance, Referral, Counseling & Support Assessment Support Counseling Entry Points Community Clinic

9. Why NACS? Links vulnerable to clinical services -- reciprocal impact between health & nutrition Corrective  chronic nutrition mgmt -- continuum of care Link patients to support groups & community services Referrals for economic strengthening, livelihood & food security (ES/L/FS) support Health system strengthening -- NACS is a HSS approach to integrate nutrition within health services for all, not just PLHIV Clinics “anchor” nutrition support within communities

10. Maternal nutrition Universal salt iodization Zinc supplementation Fortification PD Hearth Iron/FA supplementation Vitamin A supplementation Growth monitoring & promotion CMAM Infant & Young child feeding

11. NACS Nutrition Assessment, Counseling & Support NACS NACS NACS NACS Establishing a Nutrition Standard of Care

12. Standard of Nutrition Care Assessment Counseling Support Continuum of Nutrition Care Infants & Young Children Women in Pregnancy & Postpartum Adults & Adolescents

13. NACS Household Economic Strengthening & Livelihood Support CBO Clinical Mgmt Service Mapping Promotion vocational training, IGAs, microcredit Assessment Support Service Strengthening Protection household food production, savings Household Assessment & Service Referral Counseling Entry Points Clinic Provision social grants, food assistance

14. NACS: A Life Cycle Approach Pregnancy Birth Adulthood Infancy NACS Adolescence Childhood

15. Linearizing the Life Cycle as a Continuum of Care Pregnancy Infancy Childhood Adolescence Adulthood Birth

16. Photo: Wendy Hammond C & T ART & ARV Prophylaxis Tx of Malnutrition Maternal Nutrition & IYCF Counseling Photos: Wendy Hammond Pregnancy Infancy Childhood Adolescence Adulthood Birth

17. ART & ARV Prophylaxis Peri-/Postnatal Care Maternal Nutrition & IYCF Counseling Photo: Wendy Hammond Pregnancy Infancy Childhood Adolescence Adulthood Birth

18. 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

19. 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

20. 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

21. Phased Implementation of NACS Early Implementation Nigeria, DR Congo, Lesotho, Vietnam Program Expansion Côte d’Ivoire, Ghana, Ethiopia, Uganda, Tanzania, MozambiqueNamibia, Zambia, South Africa, Haiti Implementation at National Scale Malawi and Kenya

22. Partnership for HIV-free survival • Six-country PMTCT initiative supported by a partnership under umbrella of IATT (Inter-Agency Task Team on Children and HIV/AIDS): • Ministries of Health • PEPFAR • WHO • UNICEF • IHI • MEASURE Evaluation • FANTA-3 • HCI Kenya Uganda Tanzania Mozambique South Africa Lesotho

23. Enabling Environment Funding/Financing Community Demand Policies, Strategies & Guidelines Patient Referral & Tracking Training Research/M&E/HIS Supply Chain Management Mapping/Strengthening Referral Services NACS HumanResources QualityImprovement