Food & Nutrition Support within PEPFAR Clinical Programs

1. Food & Nutrition Support within PEPFAR Clinical Programs The United States President’s Emergency Plan for AIDS Relief Track 1 ART Program Meeting Atlanta September 25, 2007 Tim Quick, USAID

2. 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.

3. Clinical Picture for PLHIV • Nausea, oral thrush, altered taste & depressed appetite. • Accelerated nutrient losses due to malabsorption, diarrhea & hypermetabolism. • Multiple micronutrient deficiencies pre-existing & precipitated by infection (& Tx).

4. Dietary Implications of HIV • 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

5. 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.

6. Target Groups for PEPFAR Nutrition Support • OVC, especially infants & young children. • HIV+ pregnant & lactating women in PMTCT programs. • PLHIV in care & Tx programs.

7. Nutritional Support Begins with Nutritional Assessment • Anthropometry (wt, BMI, MUAC) • Symptom mgmt (appetite, nausea, taste, oral thrush, diarrhea, drug X food interactions • Dietary adequacy (micronutrients) • Household food security • Family-centered approach – referral (HBC) and assessment of others in family, esp young children

8. 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

9. 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

10. Policies Guidelines Funding Resources Staffing Commodities Adult Care & Tx OVC PMTCT Pediatric Care & Tx • Continuum of care for U5 PMTCT infants and older children: • Growth monitoring • VA, Zn, multi-Mn supplementation • Therapeutic/ supplementary/ supplemental feeding • Nutritional assessment • Anthropometry • Symptom mgmt • Dietary assessment • Nutrition Counseling • Multi-MN suppl (MN by Prescription) • Therapeutic/suppl feeding (Food by Prescription) • Infant Nutrition • Infant feeding counseling • Growth monitoring • Multi-MN supplementation • Therapeutic/ supplementary/ supplemental feeding • Maternal nutrition • Assessment &Counseling • Multi-MN suppl • Supplemental feeding • Nutritional assessment • Anthropometry • Symptom mgmt • Dietary assessment • Nutrition Counseling • VA, Zn, multi-MN suppl • Therapeutic/suppl feeding Facility Level • Infant feeding counselling • Links to basic CS, e.g. cIMCI, CTC, CB-GMP • Safe water/hygiene/ sanitation • 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 • 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 care • Safe water • MUAC clinic referral Quality Assurance/Quality Improvement • 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 Training Procurement, Logistics & Inventory Control Monitoring & Evaluation Targeted Evaluation Household/Community Level Maternal & Child Health/Family Planning Food Assistance/Security Wrap-Around Programs Livelihood Assistance/Employment/Microcredit Education/Vocational Training

11. Food Assistance for PLHIV & Families

12. 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

13. Food by Prescription Hospital/Clinic • Food Company • Food production • Direct delivery to hospital/clinic VCT • Physician • Symptom diagnosis • Integrated symptom Tx/management • Nutritionist/Health Worker • Assessment • Counseling • MN supplement & food prescription • Referral clinical care & household food security Referral • Pharmacy • Food dispensing • Inventory control • Record keeping • Lay Counselor • Nutrition education/ counseling • Peer support Inpatient Patient Follow-up • Community Programs • Food security • Livelihood assistance • MCH

14. 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.

15. Cost Breakdown for Nutrition Component The costs above represent a ‘delivered’ cost of product.