Integration of nutrition into hiv and other infectious diseases : the nacs approach

1. Integration of nutrition into hiv and other infectious diseases :the nacs approach Serigne M. DIENE, PhD, Senior Nutrition and HIV Advisor AIDS 2012 Communications-Hosted Satellite Session July, 22, 2012

2. Presentation Outline • Evidence Supporting NACS • NACS’s overview • Elements of the NACS approach

3. Emerging evidence • Evidence is emerging on the impact of various nutrition interventions on the health and wellbeing of PLHIV. • Opportunities for randomized controlled trials were limited in the past but are expanding with the increased adoption of NACS.

4. Evidence supporting NACS

5. Supplementary Feeding and Nutritional Status Selection of Studies Outcome Findings Other Comments Kenya - Food Supplementation v Control (n=1058)1 • * CD4 ↑ int. at 3/12 and CD4 ↓ control at 3/12. Not signif. at 6 or 12/12 • * Food predictor of attendance at 6/12 in both • Pre-ART Group Food Supp significant in change in BMI at 3/12 & 6/12 ART Group 1.9kg v 1.0kg at 1/12 4.6kg v 3.4kg at 3/12 Malawi - Fortified Spread (FS) v Corn Soy Blend (CSB) (n=491) 2 Greater anthropometric ↑ FS group v CSB group at 14/52 BMI change (2.2 v 1.7), weight change (5.6kg v 4.3kg), FFM (2.9kg v 2.2kg), and MUAC (2.2cm v 1.6cm) * BMI at enrollment 16.5. * Mortality rate 27% for FS and 26% for CSB * Spread 3x more expensive * No differences in CD4 count, VL, QoL, or adherence Zambia – CSB/Oil/Beans v Control (n=636)3 No differences were not found for weight gain *Food supplementation assoc. with better adherence * No difference in CD4 change India – Fortified Blended Food (Indiamix) v Control (n=636)4 Food supplementation did not result in increased weightcompared with nutrition counseling and standard care * ↑in weight, BMI, MUAC, FFM, and BCM in both groups All results reported in findings are significant unless indicated • KEMRI, FANTA Project - Report June 2011 • Ndekha MJ et al.. BMJ. 2009 May 22;338:b1867 • Cantrell RA,. J Acquir Immune DeficSyndr. 2008 • SwaminathanS,et al. Clin Infect Dis. 2010 Jul 1;

6. Micronutrient Supplementation and Disease Progression Selection of Studies Outcome Findings Other Comments • Tanzania – MMVM v MMVM/Vit A v Vit A v Placebo (n=1078)1 • 24.7% MMVM progressed to WHO stage 4 or died • 31.1% placebo progressed to WHO stage 4 or died • MMVM group had reduced risk of AIDS related death • MMVM and MMVM/Vit A group had fewer people progress HIV stage 3 or higher. • The MMVM and MMVM/Vit A had slight increases in CD4+ • MMVM group had slight reduction in viral loads. • Study period was over 6 years • >1000 pregnant women enrolled • Vit A group had similar results to placebo • MVM group also had reduced incidence of complications • No change in any other biochemical parameters e.g. blood lipids and glucose • 42% improvement in neuropathy symptoms in MMVM group, • 33% improvement in neuropathy symptoms in placebo group – result not statistically significant but clinically significant. • USA – MMVM v Placebo (n=40)2 • MMVM group – CD4 ↑ 65 cells/mL (↑ 24%) at 12/52 • Placebo group - CD4 ↓ 6 cells/mL (↓ 0%) at 12/52 All results reported in findings are significant unless indicated • Fawzi WW, et al. A N Engl J Med. 2004 Jul • Kaiser, JD.. J Acquir Immune DeficSyndr. 2006 Aug 15

7. Overview of nacs

8. What is NACS? • Nutrition assessment, counseling, and support (NACS) is an approach that aims to improve the nutritional status of individuals and populations by integrating prevention and treatment of malnutrition into policies, programs, and health service delivery infrastructure. • The NACS approach strengthen the capacity of facility- and community-based health care providers to deliver nutrition-specific services while linking clients to nutrition-sensitive interventions provided by the health, agriculture, food security, social protection, education, and rural development sectors.

9. Maternal Nutrition Universal Salt Iodization Zinc Supplementation Fortification PD Hearth Iron/FA Supplementation Vitamin A Supplementation Growth monitoring & Promotion CMAM Infant & Young Child Feeding

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

11. GOAL: Improved health and quality of life • OBJECTIVES: • Improve nutritional status • Improve infant survival • Reduce food insecurity • Strengthen health systems Economic strengthening, livelihoods & food security Health system strengthening Nutrition care & support HIV-Free Survival NACS: A platform for integrating nutrition into the continuum of care

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

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

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

15. 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

16. 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

17. 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

18. Why NACS? Evolved in HIV, specifically from model of Food By Prescription Links vulnerable to clinical services -- reciprocal impact between health & nutrition Continuum of Care from rehabilitation to chronic nutrition management Link patients to support groups & community services Referrals for economic strengthening, livelihood & food security (ES/L/FS) support Contributed to overall health system strengthening

19. NACS Hinges on Nutrition Assessment • Routine Comprehensive Assessment • Anthropometry • Biochemical • Clinical • Dietary • Household Food security • Analyze/interpret data using evidence-based standards • Identify nutrition problems • Determine causes/contributing risk factors • Cluster signs/symptoms and defining characteristics • Determine an appropriate Nutrition Care Plan

20. Nutrition Counseling • Understanding of client preferences, constraints & options • Nutrition Care Plans • Optimal diet • Dietary management of symptoms • Dietary management of drug side-effects • Adherence to medications & clinical visits • Chronic disease management • Exercise • Water, sanitation, and hygiene (WASH) • Referral to community services, including household ES/L/FS support

21. Nutrition Support

22. NUTRITION SUPPORT NUTRITION COUNSELING Exercise IYCF/GMP Maternal Nutrition Referrals Referrals NUTRITION ASSESSMENT Household food rations Nutrition Care Plan Support Groups Clinic Anthropometry Clinical Dietary Food by Prescription: Therapeutic, Supplementary & Complementary Foods Prompt treatment of infections Community Health Workers Food security Biochemical Adherence to medications Economic Strengthening, Livelihoods & Food Security Referrals Referrals Dietary management of symptoms, drug side-effects and drug-food interactions WASH Point-of-use water treatment Micronutrient supplements Community

23. Enabling Environment Policies, Strategies & Guidelines Supply Chain Management SUN/ 1000 Days Training PEPFAR Funding/Financing Research/M&E Community Demand Feed the Future Title II Mapping/ Strengthening Services Referral Links & Tracking NACS Global Health Initiative HumanResources QualityImprovement

24. COMMUNITY Service Gaps Referrals Referrals CLINIC Pre-NACS…. Limited linkages and referrals Referrals Referrals

25. COMMUNITY Referrals Referrals CLINIC The NACS Approach…. Referrals Referrals

26. NACS Along the continuum of care, in a way that is client centered that includes assessment, counseling, and support with referrals and effective coordination for optimal quality and impact

27. Phased Implementation of NACS in HIV Early Planning & Implementation South Africa, Mozambique, Vietnam Program Expansion Côte d’Ivoire, Ghana, Ethiopia, Uganda, Tanzania, Namibia, Zambia, Haiti Implemented at National Scale Malawi and Kenya

28. Elements of the NACS Approach

29. Integrating Nutritioninto National HIV Responses (1) • National Policy and Coordination • National nutrition and HIV guidelines • National nutrition and HIV strategy • Nutrition incorporated into HIV policies and vice versa • Technical coordinating group • Nutrition focal point in National AIDS Control Program

30. Integrating Nutritioninto National HIV Responses (2) • Capacity Strengthening • In-service and pre-service training of health care providers (linking the two ?) • Job aids • SBCC materials • Anthropometric equipment • Mentoring and supervision • QA/QI • M&E

31. Integrating Nutritioninto National HIV Responses (3) • Service delivery • Nutrition assessment • Nutrition education and counseling • Specialized food products • Micronutrient supplementation • Water , sanitation, and hygiene (WASH) • Food security support

32. THANK YOU