1. Session 7: Integrating Nutrition Assessment, Counselling, and Education into HIV and AIDS Care
Nutrition Management with HIV and AIDS: Practical Tools for Health Workers
Session 7 should take approximately 3 hours, 20 minutes
Step 1: Overview and Objectives (Slides 1-2) – 5 minutes
Step 2: Stages of HIV and Nutrition (Slides 3-6) – 15 minutes
Step 3: Nutrition Assessment (Slides 7-18) – 20 minutes
Step 4: BMI Calculation Practice (Slide 19) – 20 minutes
Step 5: Nutrition Assessment and Action Plan (Slide 20) – 5 minutes
Step 6: Integration (Slides 21-26) – 15 minutes
Step 7: Nutrition Counselling (Slides 27-29) – 10 minutes
Step 8: Counselling Role Play (Slide 30) – 60 minutes
Step 9: Integration Case Study (Slide 31) – 45 minutes
Step 10: Key Points (Slide 32) – 5 minutes
Introduce the final session for this training and explain that it incorporates all of the previous sessions into how to conduct nutrition assessment and integrating nutrition into HIV and AIDS care.

2. Objectives
Appropriately assess and counsel patients on nutrition and HIV
Identify ways to integrate nutrition into HIV and AIDS care
Review the session objectives and ask if there are any questions

3. Nutrition at Each Stage of HIV: Stage 1
Symptoms
No other infections
Generalised fatigue
Nutrition Considerations
Healthy eating and hydration (drink fluids)
Nutrition assessment and education
Step 2: Stages of HIV and Nutrition (Slides 3-6) – 15 minutes
We can look at integrating nutrition care with HIV care through each stage of HIV. At the first stage, the individual has not developed any other infections yet, but feels generally fatigued.
During this stage, the client is generally healthy with few complications thus we want to promote healthy, balanced eating with a variety of locally available foods and hydration with fluids.
All clients should be assessed and provided nutrition education to prevent malnutrition and wasting.

4. Nutrition at Each Stage of HIV: Stage 2
Symptoms:
Some other infections, but still in good overall health
Weight loss (less than 10 percent of normal weight)
Nutrition Considerations:
Continue efforts for Stage 1
Follow-up nutrition assessment
Address nutrition-related side effects
Prevent weight loss
Prescribe micronutrient supplements, if indicated
In stage 2, there may be some other infections, and some weight loss, but overall the individual is still in good health. However, the weight loss should be addressed.
Nutrition considerations during this stages would be to continue efforts from stage 1, follow-up with nutrition assessment, address nutrition side-effects, such as weight loss or diarrhoea, prevent further weight loss, and provide micronutrient supplement if indicated and available.
Other Stage 2 Symptoms:
Recurrent respiratory tract infections
Herpes zoster
Seborrhoeic dermatitis
Recurrent oral ulcerations

5. Nutrition at Each Stage of HIV: Stage 3
Symptoms:
More serious infections
Severe weight loss (greater than 10% loss of usual weight)
Chronic, unexplained diarrhoea for > 1 month
Unexplained anaemia
Nutrition Considerations:
Continue efforts for Stages 1 and 2
Nutrition management for: weight loss/malnutrition, ART, and infections
Coping strategies
In stage 3 we see more serious infections, wasting syndrome (severe weight loss of greater than 10% of usual weight, unexplained diarrhoea), and anaemia.
Considerations during this stages are to more aggressively provide nutrition care in terms of treatment for weight loss and malnutrition, ART management and treatment of infections.
Coping strategies are also essential at this stage to explore psychosocial support systems available.
Other symptoms of stage 3:
Unexplained, persistent fevers for > 1 month
Oral candidiasis (thrush)
Nutrition management for
Side effects: nausea, diarrhoea, dehydration, mouth sores, infections (wound healing), anaemia and prevention of malnutrition.
Increase protein intake if infections persist or if untreated

6. Nutrition at Each Stage of HIV: Stage 4
Symptoms:
AIDS
More serious infections with life-threatening complications
HIV Wasting Syndrome
Nutrition Considerations:
Continue nutrition management of side effects, as appropriate for client’s prognosis
Provide comfort and manage pain
Fluids for hydration
Stage 4 is often quite severe with the client at full-blown AIDS with more serious complications and wasting syndrome. However, with proper treatment and support, an individual can reach this stage and recover to where they can live longer.
Nutrition considerations include providing management for side effects, as appropriate for prognosis, comfort and pain management, and hydration with fluids.
Other Stage 4 symptoms:
Pneumocystis pneumonia
Recurrent OI’s compromising food intake
If the patient is co-infected with another STI, TB, malaria, hepatitis A, B, or C, or other illnesses not associated with HIV their need for nutritional care and support is increased.

7. Nutrition Assessment Anthropometric Biochemical Clinical Dietary
Environmental
Food Security
Step 3: Nutrition Assessment (Slides 7-18) – 20 minutes
Refer participants to Handout 7.1 to follow along a sample assessment form.
Listed are the key areas of nutrition assessment.
Ask participants to try and define each. Use the following notes for discussion:
Anthropometric is the collection of physical measurements such as weight, height, head circumference
Biochemical refers to lab values
Clinical refers to medical history, side effects, and/or medications
Dietary refers to all considerations around eating habits, food availability and storage.

8. Anthropometrics
Height (cm) at first visit for adults, at each visit for children
Weight (kg) at each visit
Percent weight loss, if applicable
Mid Upper Arm Circumference (MUAC) at each visit
Body Mass Index (BMI) at each visit
Listed are the indicators commonly used for anthropometric measurements.
These will each be discussed in detail

9. Weight Loss Calculation
Percent weight loss
UBW = Usual Body Weight
CBW = Current Body Weight
Formula:
% loss = UBW – CBW x 100
UBW
Body weight can be correlated to nutrition status and medication tolerance, therefore is necessary to be measured at each visit.
When a person loses weight, it is important to know how much they lost. We assess this by looking at percent weight loss. This is because, for example, losing 5 kilograms would be more serious for someone who weighs only 50 kg verses someone who weighs 80 kg. Therefore we want to know the percent weight they lost relative to their usual weight.
We consider usual weight to be baseline, or the most consistent weight recorded for a client.
The formula is as listed on the Slide.
Provide an example for participants using the flip chart.
For example a person who usually weighed 65 kg now comes to the clinic and weighs 60 kg. Complete the calculation with the help of participants so that they see how it is calculated.
65 minus 60 divided by 65 multiplied by 100 = 7.7% weight loss.
Take a few minutes to do this so that everyone understands the calculation. Provide participants with calculators if available, or they can use calculators on their cell phones.

10. Mid Upper Arm Circumference
Use measuring tape; measure in cm
Estimates muscle loss
If less than 23 cm, possible muscle wasting  intervene with nutrition counselling
Mid upper arm circumference is sometimes used as a way to see if a client who is losing weight is losing too much muscle. It has many limitations, but can be useful when looked at in combination with other anthropometric measurements. To measure MUAC, find the center part of the upper arm – between the shoulder and elbow. Measure around the arm at that spot with a measuring tape. If this measurement is less than 23 cm for an adult, there could be possible muscle loss.
This measurement is best used when done repeatedly, even as a patient is trying to gain weight.

11. Body Mass Index (BMI)
BMI is used to assess an adult’s weight based on their height.
Not used for children or pregnant women
A quick and easy way to estimate weight status (e.g. underweight, normal weight, overweight).
Refer to BMI reference chart and calculation sheet
Refer participants to Handouts 7.2.
The body mass index is used to assess an individual’s weight based on their height. Although this measurement has limitations as it does not take into account age or sex, it is useful in determining if someone is underweight, which has been linked to shortened survival in HIV-positive individuals.
It is also quick and easy for clinicians to use in assessing height and weight.

12. BMI Reference Chart Adapted from: RCQHC/FANTA
Explain the BMI reference chart.
Let participants know that they will get to practice this later on in the session
BMI reference chart and calculation sheet:
Adapted from BMI resources from the Regional Centre for Quality of Health Care, Makerere University Medical School, Kampala, Uganda. Technical support by FANTA (Food and Nutrition Technical Assistance) and LINKAGES and Bray, GA, Gray, DS. Obesity, Part I, Pathogenesis, Western Journal of Medicine Oct;149(4):
Adapted from: RCQHC/FANTA

13. Biochemical Laboratory values as available
CD4 count and all other routine values with:
Blood cholesterol (fat)
Blood glucose (sugar)
Haemoglobin (blood iron)
Urine test, look for ketones
Parasites (e.g. worms)
Ask participants what lab values are routinely taken for patients. For urine test, high level of ketones can be one indication of undernutrition or protein deficiency
Routine labs should be assessed when doing a nutrition assessment, and addition of lipids and glucose could help detect metabolic changes.
If a client continues to lose weight or malabsorb food, then have parasites tested to detect for worms.

14. Clinical Assess and counsel on management of complications
Diarrhoea
Nausea/vomiting
Poor appetite
Mouth sores
Changes in taste
Medication Regimen
Discuss food effects, interactions, and herbal/traditional therapies
In terms of clinical assessment, we want to assess potential nutrition complications, as discussed in Session 3.
Refer participants back to Handouts 2.1 (Symptom Management Guide) and 3.2 (Food Effects of ART) for information on common side effects.
Medication regimen is considered here, as well as traditional therapies.

15. Dietary How many times a day does the client eat?
What does the client eat in a typical day?
How does the client:
Keep foods cold (refrigerator, freezer, other methods)?
Cook food (stove, open fire)?
Keep dishes, utensils, and cooking areas clean (soap, water)?
The dietary assessment involves asking open-ended questions to obtain a record of a client’s usual eating habits, where they obtain food from, and the type of storage they may have.

16. Environmental
Assess hygiene and sanitation situation at home and community
Where does the family get water from?
Is there a latrine in the home or communal latrine? If so, how is it maintained?
Is garbage removed often and safely?
Are client and family aware of basic food and water safety practices

17. Food Security
Where does the food come from? Market, supermarket, home garden?
Are there community or village gardening projects that client can be referred to?
Know which local, nutritious foods are available in the community, and promote these instead of expensive foods from shops

18. Additional Information
Other illness or opportunistic infections
E.g. Tuberculosis, malaria, pneumonia, or skin problems
Lifestyle practices (smoking, alcohol use, and unsafe sex)
Family/community support system
Educational level
Living environment (housing, income, and number of members per household)
These factors may or may not already be included in HIV counselling – want to emphasise them, however.

19. Anthropometric Measurement and BMI Calculation Practice
Step 4: Anthropometric Measurement and BMI Calculation Practice (Slide 19) – 40 minutes
Use scales, measuring tape and/or stadiometers to do the anthropometric measurement activity.
This is best done in pairs or small groups so that each person has a chance to practice on at least one person. Each participant should measure weight and height correctly on at least one other person.
For the next activity, break participants into pairs.
Ask participants to refer to Handout 7.2 again and to Worksheet 7.1.
Explain that they will take the measurement of weight and height in pairs, using height and weight scales.
Calculate one example for participants before they start their work in pairs
Allow participants minutes to calculate in pairs. Bring group back together and ask if there is any confusion or outstanding questions surrounding this process. Emphasise how quickly this measurement can be obtained.

20. Nutrition Assessment Action Plan
Step 5: Nutrition Assessment and Action Plan (Slide 20) – 5 minutes
Refer participants to Handout 7.3
This scheme is a nutrition assessment action plan for treating nutrition at various stages. Once an assessment is done, the client is diagnosed as one of three broad categories based on the assessment: severe malnutrition, moderate malnutrition, or well nourished.
Then based on the diagnosis, we need to formulate an action plan for either treating malnutrition or praising good eating habits.
All action plans must involve follow-up care, where the cycle begins again with nutrition assessment, diagnosis, and action plan.

21. Integration of Nutrition into HIV and AIDS Care
Begin at VCT services
Address food availability and access
Weight loss prevention can improve survival
Step 6: Integration (Slides 21-26) – 15 minutes
When integrating nutrition into HIV and AIDS care, we must begin at voluntary counselling and testing services. Issues such as food availability and prevention of side effects like weight loss can be discussed here.

22. First HIV Visit Complete full nutrition assessment
Obtain baseline height and weight, calculate BMI, and measure MUAC
Ask about recent weight loss or inability to eat (due to illness)
Ask about food availability, food storage, and cooking facilities in home
Provide nutrition counselling on healthy eating
At the first HIV visit, health workers should complete a full nutrition assessment to obtain a baseline height and weight, calculate BMI and measure MUAC.
Consider their stage of HIV at diagnosis – many clients are only tested once they’ve progressed into later stages.
Ask about recent weight loss or inability to eat (due to illness)
Ask about food availability, food storage, and cooking facilities in home
Provide nutrition counselling on healthy eating

23. Follow-up Visits Continue with nutrition assessment
Obtain height (if not already done), weight, calculate BMI, MUAC and % weight loss, if necessary
Ask if any problems eating
Ask if any change in food availability, storage or cooking facilities at home
At each follow-up visit, nutrition assessment should be completed again, to assess any changes in the client’s condition. This includes obtaining weight, calculating BMI and MUAC again, and assessing weight loss if applicable.
Side effects and problems with eating should be addressed at this time, as well as food availability, storage, and cooking facilities.

24. For Patients in the Hospital
Take note of whether the patient is eating and how much
If the patient needs help and family members are not there, provide help with eating
Weigh patients
Counsel patient on adjusting food intake for management of side effects
When people are ill, they often do not feel like eating or cannot physically feed themselves. These are times when people need extra support from family or community members to ensure they eat enough.
Terminally ill clients should be cared for with extra comfort to manage pain. In terms of food, they should not be forced to eat, but encouraged to eat small amounts of food and drink plenty of fluids as tolerated as part of comfort care.
Patients in the hospital may need assistance with eating, as family members may not always be available to assist. This should be considered by health workers in wards where patients are often too ill to eat. Patients can recover much faster if they are able to eat well.
As with patients in the hospital, those who are at home may also need assistance with eating. Home based care and other support systems should be considered to provide assistance.
Ask participants who are working in-patient whether there are people in the wards to assist patients with eating.

25. Integration into ART Programme
Before ART, assess food availability and intake situation
Assess weight status
Use Food and Medication Time Table when discussing medication schedule
At each follow-up, obtain current weight and side effects
Counsel appropriately on side effect management and good nutrition
Integration into the ART services at a health facility include assessing food availability and intake before ART begins.
This also includes assessing weight status
Use Food and Medication Time Table when discussing medication schedule and provide suggestion on food or medication adjustment to best fit the client’s situation
At each follow-up, obtain current weight and side effects
Counsel appropriately on side effect management and good nutrition

26. Integration into PMTCT and Ongoing Paediatric Care
Counsel mothers and partners on all infant feeding options for PMTCT
Support infant feeding choice
Educate on dangers of mixed feeding
Monitor growth and feeding of infant
For infants on replacement feeding, educate on and monitor formula/milk supply and preparation
To integrate into PMTCT, mothers and partners need to be counselled on all feeding options and supported in their infant feeding choice.
Important information to share includes the dangers of mixed feeding for HIV transmission and growth monitoring and promotion.
Infants on replacement feeding need to be monitored for adequate growth and correct preparation, steady supply of milk.

27. Nutrition Counselling
Listen to client; assess individual situation
Ask open-ended questions (who, what, when, where, why, how?)
Be realistic and practical with counselling; set realistic goals with client
Encourage good eating habits
Be a role model for clients
Maintain confidentiality always
Step 7: Nutrition Counselling (Slides 27-29) – 10 minutes
When we provide any type of counselling we must always listen to the client and take their individual situation into account.
Ask open-ended questions (who, what, when, where, why, how?)
Provide some examples of closed-questions and ask participants to rephrase them to be open-ended.
For example: Instead of “Do you eat every day?”…try “What did you eat yesterday morning, afternoon, evening, in between…?”
Be realistic and practical with counselling; set realistic goals with client
Encourage good eating habits
Be a role model for clients
Maintain confidentiality always

28. Making Suggestions, not Commands
Commands use the imperative form of verbs (give, do, bring) and words like always, never, must, should
Suggestions include:
Have you considered …?
Would it be possible …?
What about trying … to see if it works for you?
Would you be able to …?
Commands use the imperative form of verbs (give, do, bring) and words like always, never, must, should.
Suggestions include:
Have you considered …?
Would it be possible …?
What about trying … to see if it works for you?
Would you be able to …?
Give examples of good phrasing and poor phrasing for counselling.

29. Making Suggestions, not Commands
Suggestions include:
Have you thought about …? Instead of …?
You could choose between … and … and …
It may not suit you, but some mothers … a few women …
Perhaps … might work
Usually … Sometimes … Often …
Follow-up with open-ended questions using: who, what, when, where, how, why
Suggestions include:
Have you thought about …? Instead of …?
You could choose between … and … and …
It may not suit you, but some mothers … a few women …
Perhaps … might work
Usually … Sometimes … Often …
Follow-up with open-ended questions using: who, what, when, where, how, why

30. Counselling Role Play
Step 8: Counselling Role Play (Slide 30) – 60 minutes
Refer participants to Worksheet 7.3.
Divide class into groups of 3 and ask groups to assign one role to each group member: client, health worker, observer.
Allow minutes for the role plays, then minutes for large group discussion.
Use the instructions in the facilitator guide and Worksheet as needed.

31. Integration Case Study
Step 9: Integration Case Study (Slide 31) – 45 minutes
This case study incorporates all that was discussed in this unit and allows participants to put it into practice.
Refer participants to Worksheet 7.4
Divide class into 2-3 groups to work through the case study.
Allow about 20 minutes for groups to work on the case and about 20 minutes for discussion
Use the instructions in the facilitator guide and Worksheet as needed.

32. Key Points
All persons with HIV and AIDS need nutrition counselling and assessment
Obtain weight and calculate body mass index
Integrate nutrition and food security assessment into regular HIV care
Step 10: Key Points (Slide 32) – 5 minutes
List the key points on the Slide and ask if there are any final questions