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

Food and Nutrition Technical Assistance III Project (FANTA)FHI 360 1825 Connecticut Ave., NW Washington, DC 20009Tel: 202-884-8000 Fax: 202-884-8432 Email: [email protected] Website: www.fantaproject.org

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INTEGRATION OF NUTRITION INTO HIV AND OTHER INFECTIOUS DISEASES :THE NACS APPROACHSerigne M. DIENE, PhD, Senior Nutrition and HIV AdvisorAIDS 2012 Communications-Hosted Satellite SessionJuly, 22, 2012

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Presentation Outline

• Evidence Supporting NACS• NACS’s overview• Elements of the NACS approach

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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.

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EVIDENCE SUPPORTING NACS

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Supplementary Feeding and Nutritional StatusOutcome Findings Other Comments

Kenya - Food Supplementation v Control (n=1058)1

ART Group1.9kg v 1.0kg at 1/124.6kg v 3.4kg at 3/12

Pre-ART GroupFood Supp significant in

change in BMI at 3/12 & 6/12

* 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

Malawi - Fortified Spread (FS) v Corn Soy Blend (CSB) (n=491) 2

Greater anthropometric ↑ FS group v CSB group at 14/52BMI 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 weight compared with nutrition counseling and standard care

* ↑ in weight, BMI, MUAC, FFM, and BCM in both groups

1. KEMRI, FANTA Project - Report June 20112. Ndekha MJ et al.. BMJ. 2009 May 22;338:b18673. Cantrell RA,. J Acquir Immune Defic Syndr. 20084. Swaminathan S,et al. Clin Infect Dis. 2010 Jul 1;

All results reported in findings are significant unless indicated

Selection of

Studies

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Outcome Findings Other Comments

Micronutrient Supplementation and Disease Progression

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

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

•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.

1. Fawzi WW, et al. A N Engl J Med. 2004 Jul 2. Kaiser, JD.. J Acquir Immune Defic Syndr. 2006 Aug 15

All results reported in findings are significant unless indicated

Selection of

Studies

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OVERVIEW OF NACS

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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.

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Fortification

CMAM

Zinc Supplementation

Growth

monitoring

&

Promotion

Universal

Salt

Iodization

PD Hearth

Vitamin A

Supplementation

Infant &Young Child Feeding

Iron/FA

Supplementation

Maternal Nutrition

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NACS

NACS

NACS

Nutrition Assessment, Counseling, & Support

Establishing a Nutrition Standard of Care

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NACS: A platform for integrating nutrition into the continuum of care

Economic strengthening,

livelihoods & food security

Nutrition care & support

HIV-Free Survival Health system strengthening

OBJECTIVES:• Improve nutritional status• Improve infant survival• Reduce food insecurity• Strengthen health systems

GOAL: Improved health and quality of life

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NACS: A Life Cycle Approach

Adul

thoo

d

Birth

Pregnancy

Infancy

ChildhoodAdolescence

NACS

IIIBirthPregnancy Infancy Childhood Adolescence Adulthood

C & TART & ARV Prophylaxis

Tx of Malnutrition

Maternal Nutrition &

IYCF Counseling

Photo: Wendy Hammond

Photos: Wendy Hammond


ART & ARV Prophylaxis

Peri-/Postnatal Care

Maternal Nutrition &

IYCF Counseling Photo: Wendy Hammond


Photos: Save the Children Federation

Postnatal CareDeworming

MicronutrientsIYCF/GMP

CMAMTracking/Follow-Up of

Mother-Infant Pairs


Photo of Plumpy’nut® from Valid International; all others: Save the Children Federation

Pediatric CareNutrition

Surveillance/GMP & Referral

MicronutrientsCMAM


Photo: LINKAGES Project

Nutrition Surveillance,

Referral, Assessment & CounselingDeworming

MicronutrientsCMAM

Nutrition Surveillance,

Referral, Assessment & Counseling

MicronutrientsTx of malnutrition

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• 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

Why NACS?

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NACS Hinges on Nutrition Assessment

1. Routine Comprehensive Assessment• Anthropometry• Biochemical• Clinical• Dietary• Household Food security

2. Analyze/interpret data using evidence-based standards

3. Identify nutrition problems

4. Determine causes/contributing risk factors

5. Cluster signs/symptoms and defining characteristics

6. Determine an appropriate Nutrition Care Plan

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Nutrition Counseling

1. Understanding of client preferences, constraints & options2. Nutrition Care Plans3. Optimal diet4. Dietary management of symptoms5. Dietary management of drug side-effects6. Adherence to medications & clinical visits7. Chronic disease management8. Exercise9. Water, sanitation, and hygiene (WASH)10. Referral to community services, including household

ES/L/FS support

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Nutrition Support

Treatment of Malnutrition

Prevention of Malnutrition

Economic Strengthening, Livelihood & Food Security Support

Water, Sanitation, & Hygiene (WASH)

• Corrective Medical Care & Treatment

• Food by Prescription

• Provision of MN Supplements

• Routine Medical Care & Tx

• Provision of MN Supplements

• Provision of Complementary Foods/Dietary Supplements

• Savings• Microcredit• Income-

generating activities

• Household food production

• Food assistance

• Distribution of POU water treatment products or vouchers

• Latrine construction

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NUTRITION ASSESSMENT

NUTRITION SUPPORT

NUTRITION COUNSELING

Biochemical

WASH

IYCF/GMP

Nutrition Care Plan

Adherence to medications

Dietary management of symptoms, drug

side-effects and drug-food interactions

Maternal Nutrition

Exercise

Prompt treatment of

infections

Household food

rations

Referrals

Referrals

CommunityFood by Prescription: Therapeutic,

Supplementary & Complementary

Foods

Micronutrient supplements

Point-of-use water treatment

Food

security

AnthropometryClinicalDietary

Referrals

Referrals

ClinicSupport Groups

Community Health Workers

Economic Strengthening, Livelihoods & Food Security

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Enabling Environment

SUN/1000 Days

Feed the

Future

Global Health

Initiative

Policies, Strategies & Guidelines Training

Research/M&E

Supply Chain Management

Quality ImprovementHuman Resources

Funding/Financing

Referral Links & Tracking

Mapping/Strengthening

Services

NACS

PEPFAR

Title II

Community Demand

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CLINIC

COMMUNITY

Referrals

Referrals Refe

rral

s

Referrals

Pre-

NAC

S….

Service Gaps

Limited linkages and referrals

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CLINIC

COMMUNITY

Referra

ls

Referrals Refe

rral

s

Referrals

The

NAC

S Ap

proa

ch…

.

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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

NACS

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Early Planning & ImplementationSouth Africa, Mozambique, Vietnam

Program ExpansionCôte d’Ivoire, Ghana, Ethiopia, Uganda, Tanzania, Namibia, Zambia, Haiti

Implemented at National ScaleMalawi and Kenya

Phased Implementation of NACS in HIV

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Elements of the NACS Approach

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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

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• 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

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• Service delivery– Nutrition assessment– Nutrition education and counseling– Specialized food products– Micronutrient supplementation– Water , sanitation, and hygiene (WASH)– Food security support

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THANK YOU

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

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