HIV

1
HIV Nutrition A Framework for Addressing
Patient Family Needs
The United States Presidents Emergency Plan for
AIDS Relief
Global Health Mini-University George Washington
University October 5, 2007 Tim Quick, USAID
Office of HIV/AIDS
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The U.S. Presidents Emergency Plan for AIDS
Relief (PEPFAR)

• PEPFAR initiated in 2003
• 5-year, 15 billion comprehensive program to
  fight HIV/AIDS worldwide
• 10 billion for 15 focus countries (50 global
  HIV/AIDS burden)
• 4 billion for other PEPFAR countries for
  additional activities including HIV/AIDS research
• 1 billion for the Global Fund to Fight AIDS,
  Tuberculosis, and Malaria (GFATM)
• Current reauthorization of PEPFAR II under
  consideration by Congress 5-year, 30 billion

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PEPFAR Goals

• Treatment of 2 million HIV-infected people
• Prevention of 7 million new HIV infections
• Care for 10 million people infected with
  affected by HIV/AIDS, including orphans
  vulnerable children

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PEPFAR 15 Focus Countries
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Overview HIV/AIDS Nutrition

• Food often stated as the most urgent need of
  PLHIV and their families food insecurity highly
  pervasive in PEPFAR countries.
• AIDS is a wasting disease (Slim Disease)
  --PLHIV typically present late first tested
  after chronic illness significant weight loss.
  
• Strong correlation between wasting mortality
  before during Tx very high mortality rate in
  patients w/ low BMI in 1st months of ART.
• ART Tx of OIs improves appetite nutritional
  status of most malnourished patients.

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Clinical Picture for PLHIV

• Nausea, oral thrush, altered taste depressed
  appetite.
• Accelerated nutrient losses due to malabsorption,
  diarrhea hypermetabolism.
• Multiple micronutrient deficiencies pre-existing
  precipitated by infection ( Tx).

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Dietary Implications of HIV

• Need to increase total energy intake
• Asymptomatic 10 increase (kcal/day)
• Symptomatic 20-30 increase (kcal/day)
• Children w/ weight loss 50-100 increase
  (kcal/day)
• Maintain protein _at_ 12-15 of energy intake to
  maintain and recover lean body mass.
• Essential micronutrients (vitamins/minerals) _at_ 1
  RDA
• Require high-energy, nutrient-dense foods, NOT
  JUST MORE OF THE SAME FOOD

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PEPFAR Engagement to Provide Food Nutrition
Support

• April 2005 PEPFAR Food Nutrition TWG
  established.
• Nov 2005 House Appropriations Bill mandates OGAC
• to develop and implement a strategy, in
  coordination with groups responsible for issues
  of nutrition, such as USAID, the Department of
  Agriculture, the World Food Program, and the Food
  and Agriculture Organization, to address the
  nutritional requirements of those on
  antiretroviral therapy.
• May 2006 OGAC submits Report on Food and
  Nutrition for People Living with HIV/AIDS to
  Congress outlining FN strategy.
• Sept 2006 PEPFAR Policy Guidance on the Use of
  Emergency Plan Funds to Address Food and
  Nutrition Needs approved by OGAC
  (www.PEPFAR.gov/guidance) and disseminated to
  country programs.

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Guiding Principles for FN

• Support for FN must contribute directly to
  PEPFAR 2/7/10 goals.
• PEPFAR is NOT a food security program.
• Emphasis on integration of nutritional
  assessment, counseling support within clinical
  care Tx, as well as nutritional support for
  PMTCT OVC programs.
• Emphasis on leveraging food assistance food
  security support from other sources, e.g. GFATM,
  Title II WFP.
• Limited PEPFAR food procurement provision to
  specific target groups under defined eligibility
  criteria.

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Priority Activities

• Policy guideline development/adaptation
• Nutritional assessment counseling
• Therapeutic, supplementary and supplemental
  feeding of malnourished PLHIV OVC
• Micronutrient supplementation where dietary
  vitamin mineral intake inadequate
• Infant feeding support in line with WHO
  national PMTCT guidelines
• Linkages to MCH nutrition, food assistance, food
  security livelihood assistance programs

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Key Partners

• USAID (FFP/Title II EGAT), CDC, USDA
• WFP, WHO, UNICEF, FAO
• Governments
• GFATM
• PVOs/NGOs
• Private Sector
• Pharmaceutical industry
• Food Industry

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Target Groups for PEPFAR Nutrition Support

• OVC, especially under-5s
• HIV pregnant lactating women
• PLHIV patients in care treatment programs

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Nutritional Support Begins with Nutritional
Assessment

• Anthropometry (wt, BMI, MUAC)
• Symptom mgmt (appetite, nausea, taste, oral
  thrush, diarrhea, drug X food interactions
• Dietary adequacy (micronutrients)
• Household food security
• Family-centered approach referral (HBC) and
  assessment of others in family, esp young children

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Nutritional Care of Adult PLHIV

• Nutrition/dietary counseling
• Therapeutic/supplementary/supplemental feeding
• Multi-micronutrient supplementation
• Safe water/hygiene/sanitation
• Management of drug/food/nutrient interactions
• Management of chronic HIV infection
• Lipodystrophy/heart disease
• Insulin resistance/diabetes
• Osteoporosis

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Nutritional Care of Infants Children

• Infant feeding counseling support, incl
  weaning/supplemental foods, to minimize MTCT
  maximize survival (AFASS framework).
• Routine growth monitoring clinical assessment.
• Therapeutic supplementary feeding support for
  malnourished infants young children.
• Multi-micronutrient routine vitamin A
  supplementation.
• ORT/Zn supplementation for acute diarrhea.
• Safe water/hygiene/sanitation

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Policies

Guidelines
Funding
Resources
Staffing
Commodities
Adult Care Tx
PMTCT
OVC
Pediatric Care Tx

• Continuum of care for U5 PMTCT infants and older
  children
• Growth monitoring
• VA, Zn, multi-Mn supplementation
• Therapeutic/ supplementary/ supplemental feeding

• Nutritional assessment
• Anthropometry
• Symptom mgmt
• Dietary assessment
• Nutrition Counseling
• Multi-MN suppl (MN by Prescription)
• Therapeutic/suppl feeding (Food by Prescription)

• Infant Nutrition
• Infant feeding counseling
• Growth monitoring
• Multi-MN supplementation
• Therapeutic/ supplementary/ supplemental feeding
• Maternal nutrition
• Assessment Counseling
• Multi-MN suppl
• Supplemental feeding

• Nutritional assessment
• Anthropometry
• Symptom mgmt
• Dietary assessment
• Nutrition Counseling
• VA, Zn, multi-MN suppl
• Therapeutic/suppl feeding

Facility Level

• Household food security assessment for clinic
  patients
• Links with food security support for
  food-insecure families of clinic patients
• Links with livelihood assistance, micro-credit,
  micro-enterprise, (re)employment opportunities,
  vocational training
• Home-based care
• Safe water
• MUAC clinic referral

• Infant feeding counselling
• Links to basic CS, e.g. cIMCI, CTC, CB-GMP
• Safe water/hygiene/ sanitation

• Counseling
• Nutritional assessment clinic referral
• Household food security assessment
• Links with food security support for
  food-insecure OVC families
• Links with livelihood assistance, micro-credit,
  microenterprise, (re) employment opportunities,
  vocational training

Quality Assurance/Quality Improvement

• IYCF/ENA counseling
• Continued BF to 2 yrs for HIV infants
• Clinic referral for growth faltering
• Community Therapeutic Care (CTC) for severely
  malnourished HIV children

Training
Procurement, Logistics Inventory Control
Monitoring Evaluation
Targeted Evaluation
Household/Community Level
Maternal Child Health/Family Planning
Food Assistance/Security
Wrap-Around Programs
Livelihood Assistance/Employment/Microcredit
Education/Vocational Training
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Food Assistance for PLHIV Families
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Kenya Food by Prescription Program

• Model of integration of nutritional support
  within clinical services piloted at 60 CCCs
• Senior Nutritionist at NASCOP
• National Guidelines for HIV Nutrition (incl
  PMTCT infant feeding)
• GFATM nutritionists lay counselors staffed at
  CCCs
• Assessment anthropometry, symptoms, dietary
• Counseling
• Support
• multi-MN supplements
• supplemental (preg/lact women and OVC) and
  therapeutic/supplementary (malnourished adult and
  OVC) feeding support

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Food by Prescription
Hospital/Clinic

• Food Company
• Food production
• Direct delivery to hospital/clinic

VCT

• Physician
• Symptom diagnosis
• Integrated symptom Tx/management

• Nutritionist/Health Worker
• Assessment
• Counseling
• MN supplement food prescription
• Referral clinical care household food security

Referral

• Pharmacy
• Food dispensing
• Inventory control
• Record keeping

• Lay Counselor
• Nutrition education/ counseling
• Peer support

Inpatient
Patient Follow-up

• Community Programs
• Food security
• Livelihood assistance
• MCH

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Adult Patient BMI at Entry Time to FBP
Graduation

• 1 in 3 new ART patients clinically malnourished
  (BMI lt 18.5), of which 1 in 4 is severely
  malnourished (BMI lt16).
• Average time for ART patients to graduate from
  feeding support (BMI gt20) is 3 mo for patients
  w/ BMI 16-18.5 at entry and 5 mo w/ BMI lt16.
• On-going TE will evaluate clinical outcomes
  associated w/ FBP improved BMI, as well as
  recidivism to BMI lt18.5 post-FBP.

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Cost Breakdown for Nutrition Component
The costs above represent a delivered cost of
product.
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Haiti Adaptation of FBP Model

• Development of national HIV nutrition
  guidelines
• Integration of patient-focused nutritional
  assessment, counseling and support within
  clinical care Tx services
• Patients linked to assessments of household food
  security livelihood assistance needs
• Title II WFP assistance to food-insecure
  HIV-affected families, especially in
  urban/peri-urban areas
• Hybrid agreements w/ Title II PVOs to use
  PEPFAR funding for HIV/AIDS activities
• Other wrap-arounds, especially MCH (e.g. CTC
  for malnourished HIV and exposed infants young
  children) and livelihood assistance.

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Title II/WFP Issues

• FFP Task Force for HIV, Food Nutrition
• Mandate food security HIV/AIDS not an
  entitlement
• Targeting rural vs urban/peri-urban
• Development vs Emergency Title II support
• Monetization vs direct food distribution
• PEPFAR funding
• Hybrids linked to MYAPs
• Central mechanism
• Transition/graduation to address longer-term food
  and livelihood needs of HIV-affected families

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Public Health Evaluation

• Impact cost effectiveness of therapeutic
  supplementary feeding of pre-ART ART adult
  patients.
• Effective food security livelihood assistance
  support for care Tx patients to maintain
  adequate nutritional status.
• Defining/establishing/maintaining AFASS, for
  HIV-exposed infants X age.
• Replacement diets
• Basic child survival package
• Safer breast feeding by HIV mothers.

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Summary

• PEPFAR committed to integration of nutritional
  support within care Tx of PLHIV OVC
• Primary focus is on clinical HIV/AIDS patients,
  PMTCT women in pregnancy lactation, and OVC
• Malnutrition in PLHIV requires comprehensive
  clinical mgmt incl ART Tx of OIs, if warranted
• Interim therapeutic supplementary feeding may
  be critical to clinical outcomes for malnourished
  PLHIV, but patients families need to also be
  linked to longer-term food security livelihood
  assistance support.