Session 7: Integrating Nutrition Assessment, Counselling, and Education into HIV and AIDS Care

1. Session 7:Integrating Nutrition Assessment, Counselling, and Education into HIV and AIDS Care Nutrition Management with HIV and AIDS: Practical Tools for Health Workers

2. Objectives • Appropriately assess and counsel patients on nutrition and HIV • Identify ways to integrate nutrition into HIV and AIDS care

3. Nutrition at Each Stage of HIV: Stage 1 • Symptoms • No other infections • Generalised fatigue • Nutrition Considerations • Healthy eating and hydration (drink fluids) • Nutrition assessment and education

4. Nutrition at Each Stage of HIV: Stage 2 • Symptoms: • Some other infections, but still in good overall health • Weight loss (less than 10 percent of normal weight) • Nutrition Considerations: • Continue efforts for Stage 1 • Follow-up nutrition assessment • Address nutrition-related side effects • Prevent weight loss • Prescribe micronutrient supplements, if indicated

5. Nutrition at Each Stage of HIV: Stage 3 • Symptoms: • More serious infections • Severe weight loss (greater than 10% loss of usual weight) • Chronic, unexplained diarrhoea for > 1 month • Unexplained anaemia • Nutrition Considerations: • Continue efforts for Stages 1 and 2 • Nutrition management for: weight loss/malnutrition, ART, and infections • Coping strategies

6. Nutrition at Each Stage of HIV: Stage 4 • Symptoms: • AIDS • More serious infections with life-threatening complications • HIV Wasting Syndrome • Nutrition Considerations: • Continue nutrition management of side effects, as appropriate for client’s prognosis • Provide comfort and manage pain • Fluids for hydration

7. Nutrition Assessment • Anthropometric • Biochemical • Clinical • Dietary • Environmental • Food Security

8. Anthropometrics • Height (cm) at first visit for adults, at each visit for children • Weight (kg) at each visit • Percent weight loss, if applicable • Mid Upper Arm Circumference (MUAC) at each visit • Body Mass Index (BMI) at each visit

9. Weight Loss Calculation • Percent weight loss • UBW = Usual Body Weight • CBW = Current Body Weight • Formula: % loss = UBW – CBW x 100 UBW

10. Mid Upper Arm Circumference • Use measuring tape; measure in cm • Estimates muscle loss • If less than 23 cm, possible muscle wasting  intervene with nutrition counselling

11. Body Mass Index (BMI) • BMI is used to assess an adult’s weight based on their height. • Not used for children or pregnant women • A quick and easy way to estimate weight status (e.g. underweight, normal weight, overweight). Refer to BMI reference chart and calculation sheet

12. BMI Reference Chart Adapted from: RCQHC/FANTA

13. Biochemical • Laboratory values as available • CD4 count and all other routine values with: • Blood cholesterol (fat) • Blood glucose (sugar) • Haemoglobin (blood iron) • Urine test, look for ketones • Parasites (e.g. worms)

14. Clinical • Assess and counsel on management of complications • Diarrhoea • Nausea/vomiting • Poor appetite • Mouth sores • Changes in taste • Medication Regimen • Discuss food effects, interactions, and herbal/traditional therapies

15. Dietary • How many times a day does the client eat? • What does the client eat in a typical day? • How does the client: • Keep foods cold (refrigerator, freezer, other methods)? • Cook food (stove, open fire)? • Keep dishes, utensils, and cooking areas clean (soap, water)?

16. Environmental • Assess hygiene and sanitation situation at home and community • Where does the family get water from? • Is there a latrine in the home or communal latrine? If so, how is it maintained? • Is garbage removed often and safely? • Are client and family aware of basic food and water safety practices

17. Food Security • Where does the food come from? Market, supermarket, home garden? • Are there community or village gardening projects that client can be referred to? • Know which local, nutritious foods are available in the community, and promote these instead of expensive foods from shops

18. Additional Information • Other illness or opportunistic infections • E.g. Tuberculosis, malaria, pneumonia, or skin problems • Lifestyle practices (smoking, alcohol use, and unsafe sex) • Family/community support system • Educational level • Living environment (housing, income, and number of members per household)

19. Anthropometric Measurement and BMI Calculation Practice

20. Nutrition Assessment Action Plan

21. Integration of Nutrition into HIV and AIDS Care • Begin at VCT services • Address food availability and access • Weight loss prevention can improve survival

22. First HIV Visit • Complete full nutrition assessment • Obtain baseline height and weight, calculate BMI, and measure MUAC • Ask about recent weight loss or inability to eat (due to illness) • Ask about food availability, food storage, and cooking facilities in home • Provide nutrition counselling on healthy eating

23. Follow-up Visits • Continue with nutrition assessment • Obtain height (if not already done), weight, calculate BMI, MUAC and % weight loss, if necessary • Ask if any problems eating • Ask if any change in food availability, storage or cooking facilities at home

24. For Patients in the Hospital • Take note of whether the patient is eating and how much • If the patient needs help and family members are not there, provide help with eating • Weigh patients • Counsel patient on adjusting food intake for management of side effects

25. Integration into ART Programme • Before ART, assess food availability and intake situation • Assess weight status • Use Food and Medication Time Table when discussing medication schedule • At each follow-up, obtain current weight and side effects • Counsel appropriately on side effect management and good nutrition

26. Integration into PMTCT and Ongoing Paediatric Care • Counsel mothers and partners on all infant feeding options for PMTCT • Support infant feeding choice • Educate on dangers of mixed feeding • Monitor growth and feeding of infant • For infants on replacement feeding, educate on and monitor formula/milk supply and preparation

27. Nutrition Counselling • Listen to client; assess individual situation • Ask open-ended questions (who, what, when, where, why, how?) • Be realistic and practical with counselling; set realistic goals with client • Encourage good eating habits • Be a role model for clients • Maintain confidentiality always

28. Making Suggestions, not Commands • Commands use the imperative form of verbs (give, do, bring) and words like always, never, must, should • Suggestions include: • Have you considered …? • Would it be possible …? • What about trying … to see if it works for you? • Would you be able to …?

29. Making Suggestions, not Commands • Suggestions include: • Have you thought about …? Instead of …? • You could choose between … and … and … • It may not suit you, but some mothers … a few women … • Perhaps … might work • Usually … Sometimes … Often … • Follow-up with open-ended questions using: who, what, when, where, how, why

30. Counselling Role Play

31. Integration Case Study

32. Key Points • All persons with HIV and AIDS need nutrition counselling and assessment • Obtain weight and calculate body mass index • Integrate nutrition and food security assessment into regular HIV care