nutrition assessment, counseling, and support: scale-up of pepfar nutrition programs presented by:...
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Nutrition Assessment,Counseling, and Support: Scale-up of PEPFAR Nutrition Programs
Presented by:Clinton Sears, MPHUSAID Office of HIV/AIDS
Friday, October 8, 2010
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Contents
Four topics, with a programmatic focus:
• PEPFAR and Nutrition
• Technical Evidence (2009 Mini-U)
• The NACS Model
• Scale-up Challenges and Opportunities
Feel free to ask questions at any time!
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PEPFAR and Nutrition
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“Adequate nutrition cannot cure HIV infection, but is essential to maintain the immune system and sustain
physical activity, and to achieve optimal quality of life.”
- A participant at the 2005 WHO Consultation in Durban
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“Adequate nutrition cannot cure HIV infection, but is essential to maintain the immune system and sustain physical activity, and to achieve optimal
quality of life.”- A participant at the 2005 WHO Consultation in
Durban
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Do HIV and nutrition link?
PEPFAR and Nutrition
Malnutrition:• Weakened immune system• Increased susceptibility to OI • Slower healing• Poorer response to treatment
HIV:• Reduced food intake• Increased nutrient needs• Altered nutrient absorption• Altered nutrient metabolism
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Nutrition Requirements for PLWHA:
Energy• 10% increase for asymptomatic• 20-30% increase for symptomatic• 50-100% increase for children with growth
faltering
Protein• About 12-15% of energy intake to maintain
and/or recover lean body mass
Micronutrients• Essential micronutrients @ 1 RDA
PEPFAR and Nutrition
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Timeline:
2003 – PEPFAR authorized
2005 – WHO Durban Meeting
Food & Nutrition TWG
2006 – Food by Prescription begins in Kenya
2007 – Cochrane Review on Food
Supplementation for PLWHA
2008 – PEPFAR re-authorized
2009 – New WHO Guidelines
2010 – Regional Meeting in Jinja, Uganda
PEPFAR and Nutrition
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PEPFAR programs:• Must contribute to PEPFAR goals for prevention / care /
and treatment: 3/12/12• PEPFAR is a health program, NOT a food security
program • Emphasis on integrating nutritional assessment,
counseling, and support within clinical care and treatment
Non-PEPFAR Programs:• Food assistance (Title II) programs• Primary objective is usually food security
• PLHIV feeding• School feeding• Food for assets• WFP
PEPFAR and Nutrition
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Technical Evidence
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Programming without evidence can be irresponsible; waiting for complete evidence to program can be a
travesty.- Dr. Tony Castleman, AED
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www.anafricanphotoblog.com
Evidence
Program Practices
“True genius resides in the capacity for evaluation of
uncertain, hazardous, and conflicting information”
- Winston Churchill
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• Among PLHIV not on ART, lower BMI at time of diagnosis is associated with higher mortality
• Each unit decrease in BMI associated with a 13% increase risk of death after controlling for baseline immune status (CD4 count)
(van der Sande et al. 2004)
Technical Evidence
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• Among PLHIV receiving ART, moderate to severe malnutrition at the start of ART more than doubled the risk of death
• Differences in CD4 counts were not statistically significant between those with lower and higher baseline BMI
Technical Evidence
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FBP vs. No Food for HIV+ Adults
Does provision of supplementary food to malnourished HIV-infected adult ART and pre-ART clients improve nutritional status?
Technical Evidence
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FBP vs. No Food for HIV+ Adults
Does provision of supplementary food to malnourished HIV-infected adult ART and pre-ART clients improve nutritional status?
A randomized effectiveness trial (six month intervention, plus six month follow-up) addressed this in Kenya.
Technical Evidence
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Key Results:
• Food supplementation benefits malnourished adult PLHIV, with greater benefits for pre-ART than ART clients and for women than men.
• Most benefits occur during the period of food supplementation and may not persist beyond then (sample size issues).
Technical Evidence
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Ultimately, we have target groups:
1. Children <2
2. Women in PMTCT programs
3. OVC (with growth faltering)
4. PLWHA in care and treatment programs
Technical Evidence
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The NACS Model
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“…If it were not for the services, I would have died”
- Food by Prescription client, Kenya
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“…If it were not for the services, I would have died”
- Food by Prescription client, Kenya
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“…If it were not for the services, I would have died”
- Food by Prescription client, Kenya
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NACS is
NutritionAssessmentCounselingSupport
The NACS Model
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The Nutrition Assessment, Counseling, and Support Model expands Food by Prescription
EntryPoint
Assessment
Food Productionand Supply
Chain
Counseling
Clinical Management
FoodBy
Prescription
Community ProgramsClinic
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Entry Points:
• ANC/PMTCT• Clinical referral:
• HIV/AIDS care and Tx• General patient care and Tx
• Community nutrition surveillance and referral:• HBC• OVC• CHW
The NACS Model
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Assessment:
• Anthropometric• Biochemical• Clinical• Dietary
• Household food security
The NACS Model
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Integrated Clinical Management:
• ART (if eligible)• OI treatment and management• Drug-food interactions• Chronic nutrition management of:
• Dyslipidemias• Arteriosclerosis• Diabetes• Osteoporosis
The NACS Model
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Counseling:
• Treatment adherence • Dietary quality• Weight recovery/stabilization• WASH/food safety• Referral to community services
The NACS Model
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Food by Prescription:
Pharmacy and Voucher Distribution:• Therapeutic (severe)• Supplementary (mild to moderate)• Supplemental (vulnerable)• Micronutrient supplements
(corrective and preventive)
The NACS Model
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Food Productionand Supply Chain:
• Food Processing sector:• Quality and safety standards• Product development• Packaging• Commercial viability
• Product procurement, distribution, and inventory control
The NACS Model
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Community Links:
• Household activities:• Food production and access• IGAs• Microcredit/microsavings• (Re-)Employment• Vocational training
• Support groups:• Care and treatment• Mother-to-mother
• MCH • Family planning
The NACS Model
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Scale-up
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“A complete baseline nutrition assessment should be performed as part of the … care
plan.”- Position of the American Dietetic Association
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“A complete baseline nutrition assessment should be performed as part of the … care
plan.”- Position of the American Dietetic Association
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Scale-up Challenges
Challenge Response
HIV-Free Survival Postnatal continuum of care including infant feeding
Integration of nutrition into clinical care and support Quality Improvement
Clinic/community linkages and referrals
Nutrition surveillanceHBC/MCH supportES/L/FS supportGHI/ FTF linkages
Food Production Procurement and Distribution
PPPSupply chain management
Human Resources Institutionalization of Knowledge
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Global Health Initiative$63B over 6 years (FY09-FY14)
Merged funding (FY11):• 73% from PEPFAR• 9% from PMI• 18% from Other Initiatives
Bottom line—Almost no new funds apart from a small amount for MCH
Scale-up Opportunities
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Scale-up Opportunities
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Scale-up Opportunities
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Feed the Future Initiative$22B over 3 years (FY10-FY12)
Inter-agency programming to tackle:
• Availability (support agriculture sector growth)
• Access (increase access to markets and facilitate trade)
• Utilization (support positive gains in nutrition)
• Stability (reduce risk and vulnerability)
Scale-up Opportunities
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Feed the Future Overlap
NACS Countries
Cote d’IvoireNamibiaVietnamSouth Africa
FEED the FUTURE Countries
HondurasNicaraguaTajikistan
No Nutrition focus
Large Nutrition Investment, Non-focus Countries
DRC PakistanIndia SudanNigeria Yemen
JOINT NACS/FtFCOUNTRIES
EthiopiaGhanaHaitiKenyaMalawiMozambiqueRwandaTanzaniaUgandaZambia
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“Nutrition advice, counseling, care, and support for HIV-infected women are especially important because of the dual burdens of HIV and reproduction.”
- World Health Organization
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• E. Ashley Blocker (AED)• Tony Castleman (AED)• Amie Heap (USAID)• Tonya Himelfarb (OGAC)• Robert Mwadime (AED)• Tim Quick (USAID)
Thank You!
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1. Nutrition is essential
2. Balance programming and evidence
3. Nutrition assessment (and counseling) should be part of the care plan
Key Messages
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Questions?