1. Food and Nutrition Activities in the President’s Emergency Plan for AIDS Relief (PEPFAR)
CAPT Pamela Ching, RD/LD, MS, SD
Nutrition Medical Officer
Division of Global HIV/AIDS
Center for Global Health
Centers for Disease Control and Prevention
Good afternoon. I am CAPT Pamela Ching, and I am the Nutritional Medical Officer in the Division of Global HIV/AIDS within the Center for Global Health at CDC. I appreciate having this opportunity to talk with you today about Food and Nutrition Activities in the President’s Emergency Plan for AIDS Relief, also known as PEPFAR.

2. Goals Background on food insecurity and undernutrition Overview
Global Health Initiative (GHI)
President’s Emergency Plan for AIDS Relief (PEPFAR)
Food and Nutrition (F&N) activities
Assessments of food insecurity and malnutrition
Provision of therapeutic and supplemental foods to eliminate macro- and micro-nutrient deficiencies
Training clinical and community-based personnel
During the next few minutes, I will briefly describe food insecurity and undernutrition, provide an overview of the Global Health Initiative and PEPFAR, and describe food and nutrition activities supported within them. These activities include assessments of food insecurity and malnutrition, provision of therapeutic and supplemental foods to eliminate macro- and micro-nutrient deficiencies, and training of clinical and community-based personnel in nutrition assessment, counseling, and support.

3. (American Institute of Nutrition)
Food Insecurity
“The limited or uncertain availability of nutritionally adequate, safe foods or the inability to acquire personally acceptable foods in socially acceptable ways.”
(American Institute of Nutrition)
“The right to adequate food is realized when every man, woman and child, alone or in community with others, has physical and economic access at all times to adequate food or means for its procurement.”
(United Nations Committee on Economic, Social, and Cultural Rights, 1999)
According to the American Institute of Nutrition, food insecurity is defined as, “the limited or uncertain availability of nutritionally adequate, safe foods, or the inability to acquire personally acceptable foods in socially acceptable ways.” Over ten years ago the United Nations Committee on Economic, Social, and Cultural Rights stated that, “the right to adequate food is realized when every man, woman and child, alone or in community with others, has physical and economic access at all times to adequate food or means for its procurement.”

4. Global Food Insecurity
~ 850 million people were food insecure last year
This map illustrates the magnitude of the Global Food Insecurity problem. According to the United Nations’ World Food Programme, approximately 850 million people were food insecure last year. As you can see, the majority of countries where 35% or more of the population was undernourished were in sub-Saharan Africa.
(World Food Programme)

5. Chronic Undernutrition, 1990-2008
Unfortunately, this graph illustrates that the problem of undernutrition has not improved over the past 20 years in many parts of the world, especially in countries on the African continent.

6. Global Undernutrition
Undernutrition is a significant and longstanding public health problem for many developing countries. In addition to being an independent contributor, undernutrition heightens morbidity and mortality from infectious diseases such as measles, and parasitic diseases such as malaria. It also complicates clinical disease symptoms such as pneumonia and diarrhea, and neonatal morbidity and mortality.

7. Undernutrition
INTERVENTIONS
- Breastfeeding
- Complementary feeding
- Vitamin A
- Zinc
- Hygiene
INSTITUTIONS
POLITICAL & IDEOLOGICAL FRAMEWORK
ECONOMIC STRUCTURE
Food/nutrient
intake
Health
Water/
Sanitation health services
Immediate
Underlying causes at household/
family level
Basic causes at societal level
- Agriculture
- Poverty Reduction
Income generation
Education
- Women’s empowerment
- Health Systems Strengthening
Maternal and child-care practices
Access to food
RESOURCES
ENVIRONMENT, TECHNOLOGY, PEOPLE
CAUSES
Although this model from the United Nations’ Standing Committee on Nutrition is focused on the determinants of child nutritional status, many of the parameters apply to all segments of the population. Starting at the bottom of the model, the basic causes of undernutrition lie at the societal level, involving institutions, political and economic structures, and environmental, technological, and human resources. These all influence the underlying causes of undernutrition at the household and family level . These include poor access to food, inappropriate maternal and child care practices, and poor water, sanitation, and health practices, otherwise appropriately known as WASH. In turn, these influence food and nutrient intake which influences and is influenced by, health status. Food intake and health status ultimately determine nutritional status.
At the household level, interventions to prevent and/or remedy undernutrition focus on improving agricultural practices, and instituting poverty reduction, income generating, educational, and women’s empowerment programs. Such efforts improve a family’s ability to become food secure. Strengthening of health systems through recruitment and training of healthcare providers helps improve a family’s chances of receiving appropriate and adequate care through clinic and community-based programs.
To resolve immediate problems of poor food intake and health, intervention programs focus on provision of therapeutic and supplemental foods, micronutrients supplements, and supplies to provide safe and potable water.
(Adapted from: United Nations Standing Committee on Nutrition News, 2008)

8. Undernutrition US Efforts PEPFAR GHI Department of State INSTITUTIONS
Breastfeeding
Complementary feeding
Vitamin A
Zinc
Hygiene
INSTITUTIONS
POLITICAL & IDEOLOGICAL FRAMEWORK
ECONOMIC STRUCTURE
Food/nutrient
intake
Health
Water/
Sanitation health services
Agriculture
Poverty Reduction
Education
Health Systems Strengthening
Income generation
Women’s empowerment
Maternal and child-care practices
Access to food
RESOURCES
ENVIRONMENT, TECHNOLOGY, PEOPLE
PEPFAR
GHI
International diplomacy is the means by which donor countries work with governmental bodies in developing countries to address the societal factors underlying undernutrition. For the US, this is done primarily through the Department of State and its current Secretary, Hillary Clinton. For the remainder of my presentation, I will talk about some of the efforts focused at the household and family level through the Global Health Initiative or GHI, and at the individual level to alleviate immediate undernutrition through PEPFAR, which is headed by Ambassador Eric Goosby.
Department of State

9. President Barack Obama
“We cannot simply confront individual preventable illnesses in isolation. The world…demands an integrated approach to global health. We will not be successful in our efforts …unless we do more to improve health systems around the world…and ensure that best practices drive the funding for these programs.”
President Barack Obama
May 5, 2009
In recognizing the important role improving public health plays in promoting global diplomacy, President Obama stated…

10. Global Health Initiative (GHI)
Six-year, $63 billion commitment by the US government to assist developing countries in reducing morbidity and mortality from HIV/AIDS, tuberculosis, malaria, and neglected tropical diseases
Objectives:
Achieve significant health improvements
Create an effective, efficient and sustainable platform for the delivery of essential health care and public health programs
In support of the President’s comments, GHI was initiated. GHI is a six-year, $63 billion commitment by the US government to assist developing countries in reducing morbidity and mortality from HIV/AIDS, tuberculosis, malaria, and neglected tropical diseases.
Its objectives are to achieve significant health improvements through the creation of effective, efficient, and sustainable platforms through which essential healthcare and public health programs can be delivered.

11. GHI Goals
Nutrition: Reduce child undernutrition by 30% across assisted food insecure countries in conjunction with the President’s “Feed the Future” initiative.
HIV/AIDS: PEPFAR will support:
Treatment of > 3 million people with anti-retrovirals (ARVs)
Prevention of > 12 million new HIV infections
Care of > 12 million people, including 5 million orphans and vulnerable children
Among the eight goals of GHI, two specifically address Nutrition and HIV/AIDS. Concerning nutrition, efforts conducted under the Global Health Initiative will focus on reducing child undernutrition in food insecure countries by 30%. This will be conducted primarily through the President’s “Feed the Future” initiative, an effort funded and executed by the US Agency for International Development, or USAID.
Concerning HIV/AIDS, PEPFAR, the major US-funded international HIV/AIDS initiative, will support the treatment of at least 3 million people with anti-retroviral drugs, or ARVs, the prevention of at least 12 million new infections, and care for at least 12 million people affected or infected by HIV/AIDS. These are known as the 3/12/12 goals.

12. President’s Emergency Plan for AIDS Relief (PEPFAR)
2003: Congress authorizes 5-year, $15 billion Program
A crucial component of US foreign policy
Program focused on provision of comprehensive HIV/AIDS prevention, care, and treatment using a multi-sectoral approach in developing countries most affected by the epidemic
15 focus countries (12 in Sub-Sahara Africa; Haiti; Guyana; Vietnam) accounting for >50% global HIV/AIDS burden
2009: 5-year reauthorization within GHI: $48 billion for HIV/AIDS, tuberculosis, and malaria
PEPFAR was launched in 2003 by President Bush to combat global HIV/AIDS, and at the time, was the largest commitment by any nation in history to combat a single disease. Then, as now, it was considered a crucial component of US foreign policy. During PEPFAR’s initial phase covering fiscal years , the program focused on provision of comprehensive HIV/AIDS prevention, care, and treatment using a multi-sectoral approach in 15 developing countries most affected by the epidemic. These focus countries included 12 in Sub-Sahara Africa, Haiti, Guyana, and Vietnam, and accounted for >50% of the global HIV/AIDS burden.
In launching the Global Health Initiative in May 2009, President Obama announced that investments in PEPFAR and other global health priorities would be expanded. PEPFAR would move from its initial emergency focus to a heightened emphasis on sustainability, and serve as a platform from which responses to a broader range of global health needs would take place during fiscal years (Source: World AIDS Day 2009: Latest PEPFAR Results,

13. HIV/AIDS, Food, and Nutrition
“Slim Disease” - People living with HIV/AIDS (PLWHA ) typically present with advanced AIDS after chronic illness and >10% weight loss
Strong correlation between wasting and mortality before and during treatment
Food is often the most urgent need for PLWHA and their families
Anti-retroviral therapy (ART) and treatment for opportunistic infections improves appetite and nutritional status of most malnourished patients
As back ground to the relationship between HIV/AIDS, food, and nutrition, AIDS is sometimes referred to as “slim disease” by patients because many only seek medical attention in the advanced stages of disease when they are anthropometrically wasted, having lost > 10% of their bodyweight.
Because there is a strong correlation between wasting and mortality before and during HIV/AIDS treatment, provision of food is often the most urgent need for people living with the disease. Food helps them respond optimally to care and treatment. For their families, provision of food brings a return to food security, previously jeopordized when the income earning potential of their HIV/AIDS family member diminished as their untreated disease progressed.
In a reciprocal relationship, anti-retroviral therapy or ART, and treatment for opportunistic infections improves appetite and nutritional status in most malnourished patients, allowing them to recover lost productivity.

14. Guiding Principles for PEPFAR F&N Programs
Support PEPFAR “3/12/12” goals
Strive to integrate nutrition assessment, counseling, and support (NACS) services within clinical care and treatment
Provide food and specialized nutritional supplements to target groups using defined eligibility criteria (“Food as Medicine”)
Be linked with food assistance and security programs supported by other initiatives or “wrap-arounds” (e.g., UN World Food Programme; USAID’s Title II, Food for Peace Program)
With this in mind, the guiding principles for Food and Nutrition programming within PEPFAR include …
“2/7/10” and “3/12/12” = treat 3 million, prevent 12 million infections, provide care to 12 million infected and affected by HIV and AIDS. (source: New Partners Initiative (NPI) Round 3 Launch, PEPFAR Indicators and Reporting Guidelines, February 9th – 12th, 2009, Kampala, Uganda
Food for Peace Strategic Plan addresses the problem of food insecurity, in accordance with the Title II Program’s authorizing legislation. The 1990 Farm Bill made ‘enhancing food security in the developing world’ the over-riding objective for the P. L. 480 food assistance programs and the subsequent 2002 Farm Bill has reinforced that message. The Title II program now represents the largest resource within the USG available to focus on the problem of global food insecurity. (Source: UNITED STATES AGENCY FOR INTERNATIONAL DEVELOPMENT, BUREAU FOR Democracy, Conflict & Humanitarian Assistance, OFFICE OF FOOD FOR PEACE. UPDATE: Proposals for Fiscal Year 2008 Multi Year Assistance Proposals are due January 22nd, P.L. 480 TITLE II PROGRAM POLICIES AND PROPOSAL GUIDELINES, FISCAL YEAR October 15, – accessed May 18, 2010)

15. Target Groups for PEPFAR F&N Support
Orphans and vulnerable children (OVC), especially those under 5 years of age
HIV+ pregnant and lactating women in prevention of mother to child transmission (PMTCT) programs
People living with HIV/AIDS (PLWHA) in care and treatment programs

16. Summarized graphically, Food and Nutrition Support provided through PEPFAR is presented here. It involves identification of HIV/AIDS care, treatment, and support service entry points for the three aforementioned target groups, resources and supporting activities to provide them appropriate and adequate food and nutrition services in facility, community, and home-based settings, and wrap-around services to which referrals can be made to ensure improvements in health and nutritional status, and food security are sustained.

17. Food by Prescription (FBP)
Nutrition assessment, counseling, and support = NACS
FBP - program supporting NACS
Nutrition assessment: entry and “graduation” anthropometric and clinical criteria for malnourished and nutritionally vulnerable PLWHA, pregnant and lactating women and their infants enrolled in PMTCT programs, and OVC
Provision of nutrition education and counseling
Nutrition assessment, counseling, and support, or NACS, is the cornerstone of food and nutrition programming within PEPFAR, and the Food by Prescription program is the specific mechanism through which NACS is implemented.
Nutrition assessments focus on assessing PLWHA for entry and graduation from the program. Once identified, program participants receive nutrition education and counseling.

18. Food by Prescription (FBP)
Therapeutic and supplementary feeding support
RUTF (Ready-to-use Therapeutic Food), e.g., Plumpy’nut
FBF (Fortified Blended Foods – grain and legume based flour/cereals
Sometimes: multi-micronutrient supplements
Instruction and supplies to support safe water treatment
Referral and support for household food security and livelihood assistance
Support within the Food by Prescription program is through provision of therapeutic and supplementary foods such as RUTF (Ready-to-use Therapeutic Foods), FBF (Fortified Blended Foods), and sometimes multi-micronutrient supplements.
The first available RUTF, Plumpy'nut, was originally developed for use in famine relief programs. It is high in protein and energy, contains peanut paste, vegetable oil, powdered milk and sugar, vitamins, and minerals, and tastes slightly sweeter than peanut butter. It often comes wrapped in foil and has a long shelf life, making it ideal for settings where refrigeration and cooking of food is difficult.
Fortified blended foods (FBF) are blended grain and legume-based, flour-like products designed to complement “food basket”, which are supplementary, locally-available foods provided to food insecure families. Examples of FBF include Corn Soy Blend, with or without sugar, Wheat Soy Blend, Rice Milk Blend, Rice Soy Blend, Pea Wheat Blend, and Wheat Corn Blend. FBF are advantageous in that they are :
Fortified with essential micronutrients, especially those which cannot be obtained from locally available foods, and provide 400 calories and 15 grams of protein per 100g, or 3 oz. portion
Easy for older infants and young children to swallow and digest
Pre-cooked and distributed as flour; therefore their preparation is easy, requiring little time and only limited amounts of fuel for cooking
Versatile; they can be prepared in different ways, in salty or sweet preparations
Instruction and supplies to support safe water treatment, and referral and support for household food security and livelihood assistance are additional services provided through the Food by Prescription program.
(Source for Plumpty’Nut: (Source: – accessed May 18, 2010)
(Source for FBP: – accessed May 18, 2010)

19. This graphic summarizes NACS as it is provided through the Food by Prescription program. The farthest left column includes the three HIV/AIDS population groups targeted for services. The next two columns include primary anthropometric criteria, such as weight for length or height in young children, BMI in older children and adults, and mid-upper arm circumferences, identified during the nutrition assessment process, which qualify individuals to receive services from the program. The next column details secondary criteria, primarily clinical indications of undernutrition such as presence of edema and/or wasting, used to enroll individuals in the program. The next column provides specific information on the type of counseling and therapeutic and/or supplemental food and water treatment products provided to Program participants. The last column details anthropometric criteria, collected through repeated nutritional assessments, used to graduate individuals from the program.
This graphic was developed in Kenya to assist administrators of the Food by Prescription Program in that country. Similar graphics are used by other countries with Food by Prescription Programs, and can be found posted in healthcare facilities responsible for administering the program.

20. Food by Prescription (FBP)
Physician/Nurse
Symptom diagnosis
Integrated symptom treatment/management
Pharmacy
Food dispensing
Inventory control
Record keeping
Lay Counselor
Nutrition education/ counseling
Peer support
Nutritionist/Health Worker
Assessment
Counseling
MN supplement & food prescription
Referral to clinical care & household food security
HBC/Community
Referral
Hospital / Clinic
Inpatient
VCT
Community Programs
Food security
Livelihood assistance
MCH
Food Company
Food production
Delivery to hospital/clinic
This graphic illustrates the multi-disciplinary and integrative approach utilized in the Food by Prescription program. As you can see, successful administration of the program involves a mix of different types of:
healthcare providers
in- and out-patient services, including home-based care, and referral to voluntary HIV counseling and testing
and involvement of public programs and private industries.

21. PEPFAR-Supported F&N Efforts
Basic FBP program implementation:
In operation: Malawi, Zambia, Haiti
Starting: Namibia, Ghana
Planning: Cote d’Ivoire, Mozambique, Vietnam
FBP with quality assessment and improvement evaluation activities:
Kenya, Tanzania, Ethiopia, Uganda
At the present time, the basic Food by Prescription program is operational in three African countries, about to start in two countries, and in the planning stages in three additional countries. Quality assessment and improvement activities have been integrated into the longest running FBP program in Kenya to see how the program can be improved and additional services provided. Quality assessment and improvements activities will soon begin in the FBP programs in Tanzania, Ethiopia, and Uganda to understand how such activities can be used by young programs as they grow and develop.
- 6 Critical Areas for Quality Improvement: Training; Supervision; Clinical Management and Referrals; Reporting and data management;
Community linkages; Policy
- Quality assessment and improvement activities: 1) Development of guide; 2) Field testing; 3) Production/Dissemination/Adaptation -

22. PEPFAR-Supported F&N Efforts
LIFT (LIvelihoods & Food Security Technical Assistance) Project
Provide household economic strengthening and livelihood assistance to food-insecure HIV/AIDS-affected families, including OVC
Technical assistance in Nigeria, Malawi, Kenya, Ethiopia, Rwanda, Mozambique, South Africa and Namibia.
A relatively new initiative supported through PEPFAR is LIFT, the Livelihoods and Food Security Technical Assistance Project. LIFT seeks to provide household economic strengthening and livelihood assistance to food-insecure HIV/AIDS-affected families, including those with OVC. At present, technical assistance is being provided to eight African countries to help them develop the project into a program which can be linked to the Food by Prescription program as well as to non-PEPFAR supported programs focused on creating sustainable food security for families.
LIFT program info: (source: LIFT PPR 2010.pdf)

23. Future PEPFAR-Supported F&N Efforts
PMTCT programs: greater emphasis on infant feeding practices which promote infant HIV-free survival in addition to prevention of peri-natal HIV transmission
Promote prolonged breastfeeding in conjunction with use of ART
Counseling on appropriate and timely weaning from breastfeeding and introduction of complementary foods
Establish local capacity to produce therapeutic and supplementary foods (e.g., RUTF; FBF; urban and rural gardens)
Establish globally-accepted food security and nutritional status indicators which are harmonized with HIV/AIDS status indicators
Future Food and Nutrition efforts within PEPFAR include broadening the focus of PMTCT programs to include greater emphasis on infant feeding practices which promote infant HIV-free survival in addition to prevention of peri-natal transmission. This will be done through promotion of prolonged breastfeeding in conjunction with use of anti-retroviral therapy, and provision of counseling to mothers about appropriate weaning practices and introduction of complementary foods.
Other activities include helping local public and private entities to develop the capacity to produce all of the therapeutic and
supplementary food products such as RUTF and FBF which meet their countries needs, and patients and community groups to grow their own produce through development of urban and rural gardens.
To support program evaluation and improvement efforts, globally-accepted food security and nutritional status indicators which are harmonized with HIV/AIDS status are also being planned for development.
(From LIFT): Countries in which the FBP is present often undertake efforts to develop the product in-country. It can be produced relatively inexpensively from locally and culturally acceptable grains and legumes, thereby maximizing its coverage of among targeted populations in need of food and nutritional supplementation. Also, because it supports the local economy, long-term sustainability of supplementation programs are improved. (Sources: – accessed May 18, 2010; program info: LIFT PPR 2010.pdf)

24. Acknowledgements Nicholas Vogenthaler - Emory University
Roshelle Payes and Eunyong Chung - USAID, Washington
Tonya Himelfarb – Office of the Global AIDS Coordinator, US Department of State
Tim Quick and Amie Heap – USAID, Washington
This brings me to the end of my presentation. I would like to thank:
Nick Vogenthaler of the Division of Infectious Diseases in the Department of Medicine at the Emory University School of Medicine for sharing his thoughts about food insecurity
Roshelle Payes and Eunyong Chung of the USAID office in Washington, DC for sharing their expertise in food insecurity and undernutrition
Tonya Himelfarb of the Office of the Global AIDS Coordinator in the Department of State who co-chairs PEPFAR’s Food and Nutrition Technical Working Group with me.
And special thanks to Tim Quick and Amie Heap of USAID, Washington, who share responsibilities with me for Food and Nutrition activities within PEPFAR, and for Tim, also co-chairing the Food and Nutrition TWG with me, who have both always generously shared their time and talents with me.
Thank you for your time and attention. I would be happy to address any questions you have at this time.

26. Food Security
Food security = all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life.
AVAILABILITY:
sufficient quantities of food from household production, other domestic output, commercial imports or food assistance
ACCESS:
adequate resources to obtain appropriate foods for a nutritious diet, which depends on income available to the household, on the distribution of income within the household and on the price of food
UTILIZATION/CONSUMPTION:
proper biological use of food, requiring a diet providing sufficient energy and essential nutrients, potable water and adequate sanitation, as well as knowledge within the household of food storage and processing techniques, principles of nutrition and proper child care and illness management

27. Global Undernutrition
Stunting remains a greater problem than underweight or wasting.
More than 1/3 of children in Africa & Asia are underweight.
“Underweight” = low weight for age
“Stunting” = low height for age
“Wasted” = low weight for height or length

28. Issues to Address Concerning Undernutrition
Stunting and iron deficiency anemia have not been adequately addressed
Poor growth in many countries related to inadequate breastfeeding, complementary feeding, and infectious disease
Refocus on dietary quality, high levels of morbidity, and possibly intergenerational factors affecting linear growth.
Targeting of pregnant women and children under 2 – ‘window of opportunity’ – especially in communities with highest prevalence of stunting
Gross inequities throughout region and within countries: Rural vs. urban; indigenous vs. non-indigenous
Human resources and capacity constraints for health and nutrition

29. PEPFAR Five-Year Strategy (FY 2009-2013)
Transition from an emergency response to promotion of sustainable country programs.
Strengthen partner government capacity to lead the response to this epidemic and other health demands.
Expand prevention, care, and treatment in both concentrated and generalized epidemics.
Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems.
Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes.
(Executive summary of PEPFAR’s strategy:

30. Nutrition Implications of HIV/AIDS
Daily caloric needs:
Asymptomatic: 10% increase
Symptomatic: % increase
Children with weight loss: % increase
Daily protein needs:
Maintain at 12-15% of daily caloric intake (typically at least twice that of cereal- and tuber-based diets common in developing countries)
Micronutrients (essential vitamins/minerals)
At least daily recommended level s for non-HIV-infected individuals (which many such individuals as well s HIV/AIDS patients do not yet achieve)
Require high-energy, nutrient-dense foods

31. Recommended Elements for PEPFAR F&N Programs
Nutrition Care – Goal: Improved/Adequate Nutrition Status
Nutrition Assessment, Counseling & Support (NACS)
Assessment:
Anthropometric; Clinical; Dietary; Environmental (i.e., household food security)
Counseling:
Clinical (adherence to ART )
Dietary (use of special therapeutic and supplemental foods; adherence to WASH and food safety practices)
Psychosocial
Support:
Food by Prescription; commodity support
Safe Water Treatment
Multi-micronutrient supplements
Referral to social services for livelihood and food security

32. Recommended Elements for PEPFAR F&N Programs
PMTCT – Goal: HIV-Free Survival
ART: HAART; Maternal/Infant Prophylaxis
Infant Feeding Counseling & Support
Postnatal Care:
Growth monitoring;
Basic child survival package (immunizations; routine micronutrient supplementation; insecticide-treated bednets;
Opportunistic infections: Cotrimoxizole; clinic referral)
Feeding Support
Maternal
Infant
Complementary
Replacement
Community Management of Acute Malnutrition (CMAM)

33. Recommended Elements for PEPFAR F&N Programs
Livelihoods and Food Security – Goal: Household Food Security
Food Production
(Re-) Employment
Involvement in income-generating activities
Vocational Training
Food Commodity Affordability

34. Nutrition Assessment, Counseling, and Support (NACS)
Clinical care and treatment services and F&N support are linked for PLWHA and OVC
Reciprocal impact between health & nutrition
Therapeutic and corrective model  Preventive and chronic nutrition management model
PLWHA and women in PMTCT are linked to groups for treatment and F&N support, education, and counseling
Referrals for livelihood (income-generating) and food security support
Health system strengthening -- strengthens capacity of clinics and communities to provide NACS for all individuals, not just HIV/AIDS infected and affected
Present food and nutrition programming within PEPFAR Operationalization of this framework, nutrition assessment, counseling, and support, or NACS, are emphasized. In this process, …
Why Nutritional Assessment, Counseling and Support (NACS)?
NACS links PLWHA and OVC to clinical services, recognizing the reciprocal impact between health & nutrition. Patients in good nutritional status respond better to highly active antiretroviral therapy (HAART) and treatment of opportunistic infections.
NACS should support both corrective nutrition management, often for undernourished/wasted AIDS patients early in treatment, and chronic nutrition management as patients are stabilized on HAART. NACS should be considered Standard of Care for patients from diagnosis to end-of-life care.
NACS offers opportunities to establish and support PLWHA & PMTCT/mother-to-mother support groups, often at or in proximity to clinic sites. NACS includes patient referrals to community social services, including livelihood and food security support, and referrals from the community (nutrition surveillance) for nutrition and clinical care.
NACS is an element of health system strengthening, establishing the capacity of clinics to provide NACS for all adults and children, not just those who are HIV-infected or affected.

35. Food Assistance for PLWHA & Families
PEPFAR
Wrap-around
Individuals
OVC/PMTCT Women
Households
Hospital/Clinic Level
Clinic/Community
Community
Clinical Malnutrition
Any nutritional status
Food insecurity
Severely malnourished adults
Moderately malnourished adults
Household food security assessment
Therapeutic foods
Supplementary foods
Supplemental, supplementary & therapeutic foods
Food aid commodities
F-100, F-75, and ready-to-use therapeutic foods (RUTF)
Fortified blended foods and ready-to-use supplementary foods (RUSF)
Fortified foods,
RUTF, RUSF.
Fortified blended foods, grains, legumes, oil

36. Nutrition and HIV Indicators
Nutritional Status
Nutrition Knowledge, Behavior
Nutrition Services
HIV-Free Survival
Feeding Practices
Counseling
Food Access
Income, Food Production
Food Security Services
Nutrition Care
PMTCT/
Infant Feeding
Food Security

37. Lessons Learned
Clinics where NACS is initiated are understaffed and overstretched. Quality Improvement (QI) efforts will be critical to finding efficiencies that allow integration of NACS within clinical services
Training of healthcare workers are necessary, but not sufficient –all training should be linked to QI efforts and the realities of Human Resources (HR)
Training should be decentralized, and individualized to the needs of each of the different types of healthcare workers

38. Lessons Learned
Prioritize provision of F&N program and services to the most vulnerable:
#1 - Infants and young children
#2 - Pregnant and lactating women in PMTCT programs
#3 - Adult PLWHA
Roll-out of NACS should precede initiation of FBP programs -- build ability to carry out NACS and secure commodities
Counseling of “Food as Medicine” in FBP leads to limited sharing of food by patient within his/her household, resulting in good weight recovery
Assessment and counseling , even without provision of therapeutic foods and supplemental food commodities improves nutritional status of patients
Linkage of F&N support to other community programs and public health surveillance results in improved nutritional and health outcomes at lower costs

39. Challenges in F&N Programming
Integration and expansion of comprehensive NACS into other public health initiatives
Linking clinical services with referral and support for food and livelihood assistance so as to produce sustainable food security among HIV/AIDS patients
Balancing programming emphasis and resources for nutritional assessment and counseling with those needed for provision of food and feeding support 39

40. Challenges in F&N Programming
Balancing efforts to support food production among patients with support for (re-)employment, income generating activities, and other livelihood assistance
Balancing support and resources equitably among three vulnerable population groups: adult patients in care and treatment programs, women and infants supported in PMTCT programs, OVC