PEPFAR

The Evolution of the Nutrition Assessment, Counseling & Support

(NACS) ApproachTim Quick

USAID Office of HIV/AIDSCo-Chair, PEPFAR Food & Nutrition Technical Working Group

AIDS 2012 - Turning the Tide Together

Slim disease: a new disease in Uganda and its association with HTLV-III infection

Lancet 1985 Oct 19;2 (8460):849-52

D Serwadda, Nk Sewankambo, JW Carswell, AC Bayley, RS Tedder, RA Weiss, RD Mugerwa, A Lwegaba, GB Kirya, RG

Downing, SA Clayden, & AG Dagleish

Malnutrition:•Weakened immune system• Increased susceptibility to

opportunistic infections•Wasting & increased mortality • Poorer adherence & response

to treatment

HIV/AIDS:• Loss of appetite• Increased nutrient

requirements• Impaired nutrient absorption• Altered nutrient metabolism

Nutrient requirements for people living with HIV/AIDS

Report of a Technical Consultation World Health OrganizationGeneva, 13–15 May 2003

2005: WHO Consultation on Nutrition and HIV/AIDS in Africa calls for “the integration of nutrition into the essential package of care, treatment and support for people living with HIV/AIDS and efforts to prevent infection.”

2006: The World Health Assembly passes a resolution calling on Member States “to develop evidence-based policies and programs on HIV/AIDS and nutrition.”

Policy Guidance on the Use of Emergency Plan Funds to Address Food and Nutrition Needs

September 2006The Emergency Plan has a clear responsibility to support

prevention, treatment and care for people living with HIV/AIDS (PLWHA), but comprehensively addressing issues of food

insecurity is beyond the scope of the Emergency Plan.

Key precepts of the Emergency Plan include remaining focused on HIV/AIDS, maximizing leverage with other partners that

provide food resources and providing support for limited food assistance in defined circumstances.

Kenya Foodby

Prescription Program

Entry Points

Assessment

Counseling

Clinical Mgmt PMTCT/ART

Support

Community Surveillance,

Referral, Counseling &

Support

Clinic Community

NACS -- Linking Clinics & Communities

• Links vulnerable to clinical services -- reciprocal impact between health & nutrition

• Corrective chronic nutrition mgmt -- continuum of care

• Link patients to support groups & community services• Referrals for economic strengthening, livelihood &

food security (ES/L/FS) support• Health system strengthening -- NACS is a HSS

approach to integrate nutrition within health services for all, not just PLHIV

• Clinics “anchor” nutrition support within communities

Why NACS?

Fortification

CMAM

Zinc supplementation

Growth

monitoring

&

promotion

Universal

salt

iodization

PD Hearth

Vitamin A

supplementation

Infant &Young child feeding

Iron/FA

supplementation

Maternal nutrition

NACS

NACS

NACS

NACS

NACS

Nutrition Assessment, Counseling & Support

Establishing a Nutrition Standard of Care

Standard of Nutrition Care

Continuum of Nutrition Care

Assessment Counseling Support

Infants & Young Children

Women in Pregnancy & Postpartum

Adults & Adolescents

Entry Points

Assessment

Counseling

Clinical Mgmt

Support

Clinic

NACSHousehold Economic

Strengthening & Livelihood Support

Promotionvocational training, IGAs,

microcredit

Protectionhousehold food

production, savings

Provisionsocial grants, food

assistance

CBO

Household Assessment &

Service Referral

Service Mapping

Service Strengthening

NACS: A Life Cycle Approach

Adul

thoo

d

Birth

Pregnancy

Infancy

ChildhoodAdolescence

NACS

BirthPregnancy Infancy Childhood Adolescence Adulthood

Linearizing the Life Cycle as a Continuum of Care

BirthPregnancy Infancy Childhood Adolescence Adulthood

C & TART & ARV Prophylaxis

Tx of Malnutrition

Maternal Nutrition &

IYCF Counseling

Photo: Wendy Hammond

Photos: Wendy Hammond

BirthPregnancy Infancy Childhood Adolescence Adulthood

ART & ARV Prophylaxis

Peri-/Postnatal Care

Maternal Nutrition &

IYCF Counseling Photo: Wendy Hammond

BirthPregnancy Infancy Childhood Adolescence Adulthood

Photos: Save the Children Federation

Postnatal CareDeworming

MicronutrientsIYCF/GMP

CMAMTracking/Follow-Up of

Mother-Infant Pairs

BirthPregnancy Infancy Childhood Adolescence Adulthood

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

Pediatric CareNutrition

Surveillance/GMP & Referral

MicronutrientsCMAM

BirthPregnancy Infancy Childhood Adolescence Adulthood

Photo: LINKAGES Project

Nutrition Surveillance,

Referral, Assessment & CounselingDeworming

MicronutrientsCMAM

Nutrition Surveillance,

Referral, Assessment & Counseling

MicronutrientsTx of malnutrition

Early ImplementationNigeria, DR Congo, Lesotho, Vietnam

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

Implementation at National ScaleMalawi and Kenya

Phased Implementation of NACS

Partnership for HIV-free survival

Six-country PMTCT initiative supported by a partnership under umbrella of IATT (Inter-Agency Task Team on Children and HIV/AIDS):• Ministries of Health• PEPFAR• WHO• UNICEF• IHI• MEASURE Evaluation• FANTA-3• HCI

KenyaUganda TanzaniaMozambiqueSouth Africa Lesotho

Enabling Environment

Policies, Strategies & Guidelines Training

Research/M&E/HIS

Supply Chain Management

Quality Improvement

Human Resources

Funding/Financing

Patient Referral & Tracking

Mapping/Strengthening

Referral Services

NACS

Community Demand