Food and Nutrition Technical Assistance III Project (FANTA) FHI Connecticut Ave., NW Washington, DC Tel: Fax: Website: III INTEGRATION OF NUTRITION INTO HIV AND OTHER INFECTIOUS DISEASES : THE NACS APPROACH Serigne M. DIENE, PhD, Senior Nutrition and HIV Advisor AIDS 2012 Communications-Hosted Satellite Session July, 22, 2012

III Presentation Outline Evidence Supporting NACS NACS’s overview Elements of the NACS approach

III 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.

III EVIDENCE SUPPORTING NACS

III Supplementary Feeding and Nutritional Status Outcome FindingsOther Comments Kenya - Food Supplementation v Control (n=1058) 1 ART Group 1.9kg v 1.0kg at 1/12 4.6kg v 3.4kg at 3/12 Pre-ART Group Food 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 14/52 BMI 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 * 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 Ndekha MJ et al.. BMJ May 22;338:b Cantrell RA,. J Acquir Immune Defic Syndr Swaminathan S,et al. Clin Infect Dis Jul 1; All results reported in findings are significant unless indicated Selection of Studies

III Outcome FindingsOther Comments Micronutrient Supplementation and Disease Progression Tanzania – MMVM v MMVM/Vit A v Vit A v Placebo (n=1078) % 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 Jul 2.Kaiser, JD.. J Acquir Immune Defic Syndr Aug 15 All results reported in findings are significant unless indicated Selection of Studies

III OVERVIEW OF NACS

III 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.

III Fortification CMAM Zinc Supplementation Growth monitoring & Promotion Universal Salt Iodization PD Hearth Vitamin A Supplementation Infant & Young Child Feeding Iron/FA Supplementation Maternal Nutrition

III NACSNACS NACSNACS NACS Nutrition Assessment, Counseling, & Support Establishing a Nutrition Standard of Care

III 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

III NACS: A Life Cycle Approach Adulthood Birth Pregnancy Infancy Childhood Adolescence NACS

III Birth PregnancyInfancyChildhoodAdolescenceAdulthood C & T ART & ARV Prophylaxis Tx of Malnutrition Maternal Nutrition & IYCF Counseling Photo: Wendy Hammond Photos: Wendy Hammond

III Birth PregnancyInfancyChildhoodAdolescenceAdulthood ART & ARV Prophylaxis Peri-/Postnatal Care Maternal Nutrition & IYCF Counseling Photo: Wendy Hammond

III Birth PregnancyInfancyChildhoodAdolescenceAdulthood Photos: Save the Children Federation Postnatal Care Deworming Micronutrients IYCF/GMP CMAM Tracking/Follow-Up of Mother-Infant Pairs

III Birth PregnancyInfancyChildhoodAdolescenceAdulthood Photo of Plumpy’nut ® from Valid International; all others: Save the Children Federation Pediatric Care Nutrition Surveillance/GMP & Referral Micronutrients CMAM

III Birth PregnancyInfancyChildhoodAdolescenceAdulthood Photo: LINKAGES Project Nutrition Surveillance, Referral, Assessment & Counseling Deworming Micronutrients CMAM Nutrition Surveillance, Referral, Assessment & Counseling Micronutrients Tx of malnutrition

III 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?

III 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

III Nutrition Counseling 1.Understanding of client preferences, constraints & options 2.Nutrition Care Plans 3.Optimal diet 4.Dietary management of symptoms 5.Dietary management of drug side-effects 6.Adherence to medications & clinical visits 7.Chronic disease management 8.Exercise 9.Water, sanitation, and hygiene (WASH) 10.Referral to community services, including household ES/L/FS support

III 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

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 Community Food by Prescription: Therapeutic, Supplementary & Complementary Foods Micronutrient supplements Point-of-use water treatment Food security Anthropometry Clinical Dietary Referrals Clinic 22 Support Groups Community Health Workers Economic Strengthening, Livelihoods & Food Security

III Enabling Environment SUN/ 1000 Days Feed the Future Global Health Initiative Policies, Strategies & Guidelines Training Research/M&E Supply Chain Management Quality Improvement Human Resources Funding/Financing Referral Links & Tracking Mapping/ Strengthening Services NACS PEPFAR Title II Community Demand

24 CLINIC COMMUNITY Referrals Pre-NACS…. Service Gaps Limited linkages and referrals

25 CLINIC COMMUNITY Referrals The NACS Approach….

III 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

III Early Planning & Implementation South Africa, Mozambique, Vietnam Program Expansion Côte d’Ivoire, Ghana, Ethiopia, Uganda, Tanzania, Namibia, Zambia, Haiti Implemented at National Scale Malawi and Kenya Phased Implementation of NACS in HIV

III Elements of the NACS Approach

III Integrating Nutrition into 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

III Integrating Nutrition into National HIV Responses (2) 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

III Integrating Nutrition into National HIV Responses (3) Service delivery –Nutrition assessment –Nutrition education and counseling –Specialized food products –Micronutrient supplementation –Water, sanitation, and hygiene (WASH) –Food security support

III THANK YOU