1. Improving feeding practices and nutrition status of HIV-positive children in Tanga, Tanzania: the role of health workers’ nutrition training 1 Bruno F. Sunguya MD, MSc, PhD Lecturer, School of Public Health and Social Sciences Muhimbili University of Health and Allied Sciences, Dar es salaam, Tanzania

2. …..we thought ART was a silver bullet.. 2

3. Background HIV has exacerbated childhood undernutrition in developing countries UNAIDS 2009 Even in regions with high food production, PLHIV suffer from a vicious cycle of food insecurity and poverty Weiser 2011 Case fatality rate is high; even when PLHIV are treated with ART Weiser 2009 Unless this cycle is broken, efforts to reduce child mortality and achieve SDGs may not be realized 3

4. Poor feeding practices: mid-point to undernutrition 4

5. Cost effective interventions for undernutrition: An opportunity for LICs like Tanzania Child undernutrition can be controlled if HCWs counsel caregivers frequently Pelto 2004 Knowing the local determinants for undernutrition may streamline nutrition counseling WHO 2009 Treatment and monitoring of undernutrition  However, such management would require qualified medical personnel Tanzania and other 56 HRH crisis countries do not have enough qualified personnel for such additional workload  It has 1:30,000 doctor to patients ratio  The shortage is severe in semi urban and rural areas  Over-reliance on mid-level providers to assume tasks with high burden of patients WHO 2006, 2010 5

6. Tanzania: HIV and undernutrition situation Tanzania is among SSA countries with high burden of HIV  About 2.4 Million people (5.1%) suffers from HIV NACP 2012  14,000 children are born with HIV every year UNAIDS 2013 Has unprecedented burden of undernutrition  42% of under-fives suffer from stunting TDHS 2010 HIV-positive children have higher risk of undernutrition  ART-treated children had a 4.6 and 9.6 times higher risk of underweight and wasting Sunguya 2011 Determinants of undernutrition can be controlled  Feeding practices, treatment and prevention of diarrhea  Targeting poor households and with food insecurity Sunguya 2011 6

7. Making use of the available resources 7

8. Effectiveness of nutrition training on HCWs In-service nutrition training improves quality of health workers through improving knowledge, skills and competence to manage child undernutrition Nutrition training of health workers can help to fill the gap created by inadequate nutrition training existing in medical and nursing trainings 8

9. Nutrition training on feeding practices Nutrition training of health workers can improve child’s  Energy intake  Feeding frequency and  Dietary diversity of children aged 6m-2yrs Nutrition training can offer an important entry point for a sustainable strategy towards improving nutrition status of young children 9

10. Feeding practices and undernutrition in Tanga A formative research  HIV-positive children attending CTCs in Tanga had poor nutrition status and feeding practices  Low feeding frequency was associated with stunting, underweight, and thinness  Factors associated with low feeding frequency included: low wealth index, low caregivers’ education, food insecurity, and ARI 10

11. Food production is high but not reflecting consumption 11

12. Efficacy of the intervention - A cluster randomized controlled trial Objective To examine the efficacy of the nutrition counseling of trained mid- level providers on  Their nutrition knowledge essential to manage undernutrition among HIV-positive children  Feeding practices (dietary diversity and feeding frequency)  Nutrition status of HIV-positive children attending CTCs 12

13. Protocol development Trial protocol was developed and registered at current controlled trials: ISRCTN65346364 Published in Trials 13

14. Participants selection: randomization 14

15. Cluster RCT process  Baseline: examined MLPs’ nutrition knowledge, counseling skills, and practice Children’s nutrition status, feeding practices, demographic characteristics  Intervention : intervention group Nutrition In-service training to MLPs (modified standard guideline)  Based on local determinants of undernutrition among HIV-positive children  Emphasis on food available locally, feeding behaviors, restrictive beliefs Trained MLPs gave:  Nutrition counseling to caregivers of HIV-positive children on each visit  Identified and managed undernutrition  Followed the progress and monitor adverse outcome  Follow up : Intervention and control groups Monthly for 6 months Evaluated child’s nutrition status and feeding practices 15

16. Sessions schedule & material source 16

17. Theoretical part in a class 17

18. Practical sessions: Nutrition assessment, counseling and management of undernutrition 18

19. Four aspects of knowledge improved post training 19 Aspect of knowledge Training status MeanSD95% C.IP-value Pediatric HIV/AIDS Before9.80.97.8-11.7<0.001 After14.50.214.2-14.8 Food preparation hygiene Before2.91.02.4-3.5<0.001 After4.61.04.0-5.1 Feeding practices for HIV-positives Before4.42.13.3-5.5<0.001 After9.30.98.9-9.8 Nutrition and feeding counseling Before6.41.65.6-7.3<0.001 After8.81.77.9-9.7

20. Results: cluster RCT- general characteristics Variable InterventionControl n% (mean) n Age (m)397(103.6)379(98.2) Sex (Male)19950.317345.7 Orphan22559.422964.5 Advanced HIV28372.826274.0 On ART34386.433688.9 Education (primary +)28471.528374.9 Food insecure27168.327575.6 20

21. Feeding practices and anthropometry at baseline and six months 21 Variable InterventionControl P nmeann Feeding frequency Baseline3972.83792.60.041 Month 63834.43623.1<0.001 Dietary diversity Baseline3972.83792.90.061 Month 63834.33623.4<0.001 Weight Baseline39721.737920.90.134 Month 638322.036219.2<0.001 Height Baseline397115.7379114.00.240 Month 6383113.5362113.80.794

22. Efficacy of intervention on anthropometry through changes of feeding frequency First stage: Changes in feeding frequency at six months post intervention VariableWeight-(kg) modelHeight (cm)-model B95% CIpB p Intervention*Follow-up1.171.07, 1.28<0.0011.171.07, 1.28<0.001 Intervention0.26-0.54, 1.060.5280.29-0.60, 1.180.519 Follow-up0.420.34, 0.50<0.0010.420.34, 0.50<0.001 Second stage: Random effect regression: changes in anthropometry indices VariableWeight-modelHeight-model B95% CIpB p Feeding frequency1.270.87, 1.66<0.001-0.10-1.04, 0.840.830 Intervention-0.31-4.80, 2.190.464-4.11-13.41, 5.180.386 Follow-up-1.25-1.17, -0.78<0.001-1.10-2.21, 0.020.053 Model adjusted for age, sex, caregiver’s education, wealth index, and food insecurity 22

23. Efficacy of intervention on anthropometry through changes of dietary diversity First stage: Changes in dietary diversity at six months post intervention VariableWeight (kg) modelHeight (cm) model B95% CIpB p Intervention*Follow-up1.120.96, 1.28<0.0011.100.98, 1.23<0.001 Intervention-0.08-0.25, 0.080.331-0.07-0.22, 0.070.326 Follow-up0.480.36, 0.60<0.0010.460.37, 0.55<0.001 Second stage: Random effect regression: changes in anthropometry indices VariableWeight-modelHeight- model B95% CIpB p Dietary diversity1.390.84, 1.93<0.0010.01-1.26, 1.290.984 Intervention0.21-0.39, 0.810.495-0.45-2.05, 1.150.581 Follow-up-1.18-1.83, -0.53<0.001-1.54-3.65, -0.060.042 Model adjusted for age, sex, caregiver’s education, wealth index, and food insecurity 23

24. Conclusions & Recommendations Nutrition training of MLPs in Tanga: improved  Their knowledge to manage undernutrition among HIV-positive children  Feeding practices of HIV-positive children  Weight gain but not linear growt h Recommendations 1.Nutrition training of the available workforce can help to address child undernutrition  Can improve the quality of the available workforce and mitigate the HRH crisis while solving deficits caused by inadequate professional training  Can benefit all cadres 2.Sub Saharan African countries need to adopt the WHO’s nutrition guidelines for integrated approach to manage HIV-positive children  Locally tailor-made approach is necessary for sustainability 24

25. Thank you 25

26. Efficacy of intervention through feeding practices: feeding frequency First stage: Changes in feeding frequency at six months post intervention VariableWAZ-score modelHAZ-score model B95% CIpB p Intervention*Follow-up1.150.99, 1.31<0.0011.181.07, 1.28<0.001 Intervention0.11-0.06, 0.270.1940.31-0.63, 1.250.513 Follow-up0.390.28, 0.50<0.0010.420.34, 0.49<0.001 Second stage: Random effect regression: changes in anthropometric z-scores VariableWAZ-score modelHAZ-score model B95% CIpB p Feeding frequency0.600.39, 0.81<0.001-0.04-0.21, 0.120.615 Intervention0.07-0.19, 0.330.605-1.14-2.87, 0.580.193 Follow-up-0.48-0.72, -0.24<0.001-0.25-0.45, -0.060.012 Model adjusted for Age, sex, Caregiver’s education, wealth index, and food insecurity 26

27. Efficacy of intervention through feeding practices: Dietary diversity First stage: Changes in dietary diversity at six months post intervention VariableWAZ-score modelHAZ-score model B95% CIpB p Intervention*Follow-up1.130.96, 1.29<0.0011.110.99, 1.23<0.001 Intervention-0.09-0.26, 0.080.294-0.08-0.24, 0.080.325 Follow-up0.470.35, 0.58<0.0010.450.36, 0.54<0.001 Second stage: Random effect regression: changes in anthropometric z-scores VariableWAZ-score modelHAZ-score model B95% CIpB p Dietary diversity0.610.39, 0.83<0.0010.01-0.21, 0.210.999 Intervention0.19-0.06, 0.440.141-0.19-0.49, 0.110.210 Follow-up-0.54-0.80, -0.27<0.001-0.34-0.59, -0.090.007 Model adjusted for Age, sex, Caregiver’s education, wealth index, and food insecurity 27

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29. Efficacy of intervention through feeding practices: feeding frequency First stage: Changes in feeding frequency at six months post intervention VariableUnderweight modelStunting model B95% CIpB p Intervention*Follow-up1.150.98, 1.31<0.0011.171.07, 1.28<0.001 Intervention0.12-0.03, 0.260.1290.27-0.54, 1.050.529 Follow-up0.390.27, 0.51<0.0010.410.34, 0.49<0.001 Second stage: Random effect regression: changes in nutrition status VariableUnderweight modelStunting model B95% CIpB p Feeding frequency-0.15-0.24 -0.07<0.001-0.01-0.05, 0.040.874 Intervention-0.07-0.16, 0.020.1330.35-0.06, 0.750.097 Follow-up0.120.03, 0.210.0120.05-0.01, 0.110.052 Model adjusted for Age, sex, Caregiver’s education, wealth index, and food insecurity 29

30. Efficacy of intervention through feeding practices: Dietary diversity First stage: Changes in dietary diversity at six months post intervention VariableUnderweight modelStunting model B95% CIpB p Intervention*Follow-up1.110.94, 1.28<0.0011.100.97, 1.23<0.001 Intervention-0.08-0.22, 0.070.310-0.07-0.20, 0.060.279 Follow-up0.480.35, 0.60<0.0010.450.36, 0.55<0.001 Second stage: Random effect regression: changes in nutrition status VariableUnderweight modelStunting model B95% CIpB p Dietary diversity-0.16-0.25, -0.070.001-0.01-0.08, 0.050.632 Intervention-0.10-0.18, -0.010. 0220.05-0.01, 0.120.137 Follow-up0.130.03, 0.240.0150.080.01, 0.150.047 Model adjusted for Age, sex, Caregiver’s education, wealth index, and food insecurity 30