hiv and nutrition -...

HIV and Nutrition

Beyond Child Survival: Nutrition and Child development

KPA Conference

Dave Muthama - Regional EGPAF Projects Director

Justine Odionyi - Senior HIV Technical Advisor- Pediatric/Adolescent

Judith Kose – Regional Senior Technical Adviser, Pediatric HIV

April 28th 2017

Presentation Outline

1.HIV Back ground

2.HIV and Nutrition interrelationship

• How HIV affects Nutrition

• How Nutrition affects HIV

3.EGPAF supported interventions

4.Concluding remarks

Background: UNAIDS 90-90-90 Strategy • Number of children living with HIV:

98,170 (6.5%)

• Number of new infections

• 0-14: 6,613 (8,5%)

• Treatment coverage – 71,547(77%)

• AIDS related deaths- 5,004 (14%)

• Viral load suppression

• Children - 2 to 10 years – 61.4%

• Adolescents

• 10 to 14 years – 60.4%

• 15 to 19 years – 61.4%

• Adults

• Young – 20 to 24 years – 78.5%

• Above 25 years – 83.4%

Kenya AIDS progress report 2016

51% New HIV

Infections

were among

15 to 24 year

olds

Fast-track plan

targeted to reduce

new infections in

adolescents by

40% from 26,400

Adolescents: An increasingly vulnerable decade in life

Kenya AIDS progress report 2016

404

806

1075

0

200

400

600

800

1000

1200

Adolescents

(17.7%)

Young Girls

(35.3%)

Above 25 years

(47.0%)

New ANC Women Sep to Nov 2016

Kakamega

Kenya relies on under 25 year olds for sustenance

Source: UNAIDS 2013 estimates

Rationale Low Knowledge of HIV

status among adolescents

Increasing new adolescent

HIV infections associated

with early sexual debut and

high risk traits

High mortality of untreated

pediatric / Adolescent

patients,

Low ART coverage of

treatment in Pediatrics and

Adolescent

Adolescents and HIV

Increasing mortality among adolescents

Adapted from: Nutrition in Care

and Treatment of PLHIV 7

Five key aspects of nutrition

Availability

Intake

Digestion /

Absorption Metabolism

/ Utilization

Excretion

Nutrition in Care and Treatment of PLHIV 8

How HIV affects nutrition

• Destroys the body’s immune response and ability to resist disease, leaving it vulnerable to infections.

• HIV and frequent infections increase energy and nutrient needs.

• HIV and infections may interfere with food intake and nutrient absorption.

• A PLHIV with unmet energy and nutrient needs may lose weight and become malnourished.

• A malnourished person’s immune system is further weakened and is more vulnerable to infection and faster progression to AIDS.


Why is good nutrition important for PLHIV?

• Helps PLHIV resist infections and reduces their frequency and duration

• May delay progression to AIDS • Helps PLHIV look well and maintain

healthy weight • Helps PLHIV gain strength and maintain

muscles, hence continue physical activity and be productive

• Helps medicines work effectively and may reduce side effects

• May affect MTCT and pregnancy outcomes

PY1; June – O t 6: HTS y SDP’s

Service Delivery Points

VCT/OPD IPD TB CWC Nutrition MCH (ANC+PNC+FP)

Routine

Outreach Others

No. Tested 132,873 20,072 540 16,761 1,727 12,074 18,987 8,377

Positive 1,027 167 55 89 32 165 71 58

% Postivity 0.77% 0.83% 10.19% 0.53% 1.85% 1.37% 0.37% 0.67%

Second

highest in

positivity

Data from 139 facilities in 7 Counties


Energy requirements of PLHIV

• Healthy HIV-uninfected adult: 1,990-2,580 kcal/day

• HIV-infected adult with no AIDS-related symptoms (WHO stage I): 10% more energy (about 210 additional kcal/day, equivalent to 1 cup of porridge)

• HIV-infected adult with AIDS-related symptoms (WHO stages II, III and IV): 20-30% more energy (420-630 kcal/day, depending on severity of symptoms)

• HIV-infected child with no AIDS-related symptoms: 10% more energy than HIV-negative children

• Child with AIDS-related symptoms but no weight loss: 20-30% more energy than HIV-negative children

• HIV-infected child experiencing weight loss: 50-100% more energy

Malnutrition rates among CLHIV : program data

from supported sites

[VALUE]

39, 13%

95, 33%

0 50 100 150 200 250 300 350

No.Peditarics Assessed

No. Severe Acute Malnutrition,

SAM

No. Moderate Acute

Malnutrition, MAM

Malnutrition Rates among CLHIV, at Supported

Sites, Turkana County

Total Malnutrition Rates, 46%

EGPAF Interventions for Nutritional Outcome

Improvement, Turkana County

• Collaboration with the different national suppliers KEMSA, NHPplus, WFP, NASCOP to ensure therapeutic feeds at supported sites ; F75, F100, RUTF and RUSF

• HRH Support : hire of nutrition officers at high volume CCC sites

• Capacity building of staff through trainings and mentorship to ensure optimum service delivery to malnourished CLHIV

• Support for re-distribution of nutrition supplements from the central sites to the satellite sites

• Purchase and distribution of anthropometric equipment to the facilities to optimize nutrition assessment

• Facility level assessments and support to optimize NACS for CLHIV


Monitoring Changes in weight over

time

Unintentional decrease in weight

Issue and action in CCC

>5% in 2–3 months Associated with increased risk of hospitalization

Dietary (and food security) assessment to ensure adequate intake; address infections

Nutritional counselling as necessary

≥10% in 2–3 months Associated with 5-fold or more risk of death compared with no weight change

Rehabilitation depending on BMI status, address infections and eating problems


Supporting anthropometric assessments:

BMI for adults

BMI level Condition Action in the CCC

< 16 Severely malnourished

(Referral) Rehabilitation with therapeutic foods, counselling on intake issues and possible metabolic issues and infection, assessment for ART

16.0–18.5 Moderate/ mild Nutritional counselling (+ supplementary feeding if available), treatment and prevention of infections

18.5–25.0 Normal/ recommended

Nutritional counselling, resistance exercises to build muscles, prevention of infections

25–30 Overweight Nutritional counselling to reduce energy intake, aerobic physical activity to reduce weight

30+ Obese Counselling to change lifestyle and reduce energy intake, aerobic physical activity to reduce weight, pharmacological intervention if necessary


Key anthropometric cut-off points:

W/H for children W/H level Condition Action in the CCC

<80% or <-2Z Score

Moderate acute malnutrition

without medical complications

Supplementary feeding program providing dry take-home rations (e.g. CSB) every 2 weeks or monthly and routine basic treatment e.g. Vitamin A, deworming, iron folic supplementation.

<70% or <-3Z Score

Severe acute malnutrition

without medical complications

Outpatient therapeutic care using a recommended RUTF such as Plumpy’nut and routine basic treatment

<70% or <-3Z Score


with medical complications

Inpatient stabilization care to treat underlying illnesses, provision of F75 therapeutic food and adherence to treatment protocol


MUAC, adults MUAC level (adults) Nutrition condition

≥ 23 cm

Nutritionally normal

Education and counselling on CNP

18.5–23.0 cm

Mild acute malnutrition

Nutritional education/counselling on CNP

Treatment and prevention of infections

16.0–18.5cm


Admission for supplementary feeding, if available

If bilateral oedema, inability to stand or apparent dehydration, admission/referral for admission/ therapeutic feeding

<16.0cm


Irrespective of clinical signs, admission (referral) for therapeutic rehabilitation


MUAC, children MUAC level (children) Nutrition condition

≥ 13.5 cm

Nutritionally normal

Education and counselling of caregivers on CNP

12.5–13.5 cm

Mild acute malnutrition

Nutritional education/counselling on CNP

Treatment and prevention of infections

11.0–12.5 cm


Admission for supplementary feeding if available

If also with bilateral pitting oedema, apparent dehydration, severe infections (diarrhoea, ARI, loss of appetite, severe anaemia) admission/ referral for admission/therapeutic feeding

<11.0 cm


Irrespective of clinical signs, admission (referral) for stabilization/therapeutic rehabilitation

EGPAF Support : Improved Nutritional Service Delivery

2

5

8

0

5 6

23 23 23

20

0

5

10

15

20

25

Central Sites Facilities

Receiving CCC

food

supplements

Mentorship Testing at OTP Reporting

No

. o

f Fa

cili

tie

s

Services

Service Delivery

Feb-16 Feb-17


Biochemical assessment

• Haemoglobin (Hb)

• Haemogram

• Micronutrients (e.g., serum zinc, retinol)

• Blood sugar

• Triglycerides and cholesterol (especially if on certain ARVs)

• CD4 count / VL testing

90%

88%

90%

0%

66%

86%

99%

54%

62%

52%

76%

69%

70%

37%

71%

30%

0%

52%

0% 20% 40% 60% 80% 100%

Height / Weight / BMI / MUAC

Nutrition Intervention

TB Screening done

Diagnostic work up for suspected TB

IPT for Negative Screen

Correct ART Regimen

Adherence Assessment

Adolescent Checklist Available

PHDP

STI Screening

Disclosure Documented

CD4/Viral Load upto date

Virally Suppressed

Partner Tested or is a KP

Pregnancy Status Indicated

Contraceptive Methods Indicated

Children Tested or are KP

Family Testing

Nutritional indicators in CQI assessments:

21

Improving Household Security

• Improving household food security for PMTCT and women of child bearing age through linkage to sustainable livelihood programs supported by other partners : Case of

kitchen gardens for women

LHIV in Turkana North in

partnership with World

Relief

Multi-sectoral

approach for

nutrition :

Collaboration with

other Partners

Partner Areas of Support

UNICEF Supplementation of the under fives

World Food Program

Supplementation of the under-fives together with

the pregnant and lactating mothers

Save the Children

International Maternal Child Health Program

Food and Nutrition Security Enhancing Resilience

World Relief Turkana Family Nutrition Program

GIZ Food and Nutrition Security

Child Fund Food for Work

Seed for Peace Food Security for Peace

Real Medicine

Foundation

Food Security and Livelihood Program

Feed the Children Disaster response, WASH and ECDE feeding

To Optimize Early Infant HIV Diagnosis

through the Introduction of Point of Care

Testing

• Reduce TAT for EID

• Early diagnosis

• Early ART

Concluding remarks

• Malnutrition rate amongst CLHIV are still very – especially in Turkana County despite efforts address ;

• Malnutrition contributes to poor treatment outcomes

• Linkage to nutritional interventions for malnourished children still sub-optimal

• Need to lobby for incremental governmental and non-governmental support for programs to address household food security

Thank you

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