1. Nutritional Support for Children Born to Mothers living with HIV Kara, Togo, West Africa Jennifer Schechter, Andrea Hobby, Jen Taylor, Amy Baisden March 15, 2011 Photo credit: Jared Macary

2. Overview Background Problems and Plan Objectives and Training Supervision, Monitoring and Evaluation

3. Photo credit: Jared Macary Meet Irene

5. Demographics: 6.8 million people Political: Long history of political corruption; Major donor governments withdrew 1990’s; Non-violent coup 2005; Presently transition to democracy Socioeconomic: GDP per capita $900; 65% employed in agriculture; 60% have access to water (compared to 82% in neighboring Ghana) Foreign Assistance: Financial development assistance for Health $23, compared to $202 in Ghana in 2007 Photo credit: Wikipedia Background

6. Togo in Context

7. Northern Togo Population: 669,000 Association Espoir pour Demain (AED-Lidaw) Clinics in 4 of 7 sub- regions in cities of o Kara -- pop: 100,400 o Bafilo -- pop: 18,400 o Ketao -- pop: unknown o Kande -- pop: 9, 600 Kara Region

8. Photo credit: Jared Macary Association Espoir pour Demain

10. Community Structure Photo credit: Jared Macary

11. Needs Assessment Photo credit: Jared Macary

12. HIV Positive Mothers and their Infants HIV Positive Mothers and their Infants HIV can be transmitted through breast milk Studies have shown poor outcomes for non-breastfed newborns of HIV positive mothers Prenatal transmission of HIV is associated with decreased body weight, length and head circumference 48% of children are Exclusively breastfed (<6 months) 70% of children are breastfed with complementary food (6-9 months)

13. Breastfeeding and HIV: Conflicting Messages

14. 1. HIV positive women fear transmitting HIV through breastfeeding. 2. Togo MOH recommendations do not match the WHO guidelines and women receive conflicting counseling ARV's are provided by the government 3. If a woman is going to stop breastfeeding she needs to be able to provide for the nutritional needs of her child Formula and milk are expensive Pumping, heat treating and storing milk is difficult and often unsanitary 4. Risks to infants associated with early breastfeeding cessation: Neglect, Distress, Loss of appetite, Diarrhea, Malnutrition 5. In Togo, 20% of children under 5 are undernourished 21% are underweight 6% suffer from wasting 27% suffer from stunting Problems

15. Nutritional Needs of Infants

16. nutrition training enriched flour nutrition assessments children < 2 years Our Plan

17. Training Mothers/Families/Caregivers By the end of the project 75% of HIV positive pregnant women and mothers/caregivers with children under 24 months participating in the pMTCT HIV program will attend a half-day community training session each month at the clinic regarding nutrition and other revolving pertinent topics. Output indicator - # in attendance Objectives

18. Training Providers and Health Workers By the end of the project, 95% of the facility providers/health workers interacting with HIV positive pregnant women/mothers of children under the age of 2 years will attend a 3-day training regarding the importance of proper nutrition for children. Output indicator - # of providers/health workers in attendance By the end of the project, 95% of the facility providers/health workers interacting with HIV positive pregnant women/mothers of children under the age of 2 years will effectively counsel women on the on the importance of proper nutrition for children. Output indicator - # of women reporting having received counseling Objectives continued

19. Nutrition By the end of the project 90% of HIV positive mothers participating in the pMTCT HIV program with children 6-24 months will serve their children enriched flour porridge. # of women reporting serving porridge By the end of the project 90% of fewer children born to HIV positive mothers enrolled in the pMTCT program will show physical signs of undernourishment. # of children with signs of undernourishment Objectives continued

20. Inputs Outputs Activities Participation Outputs Activities Participation Outcomes – Impact Short Term Long Term Impact Outcomes – Impact Short Term Long Term Impact Staff Time Classroom and Demo Supplies Incentives for Participation Ingredients for Porridge Staff Time Classroom and Demo Supplies Incentives for Participation Ingredients for Porridge Training Supervision Assessment Mothers/Fa milies Health Workers Children < 2 # of women receiving nutrition counseling # of women/fam ilies and health workers recognizing the benefits of proper nutrition # of trained health workers # of trained mothers/ families # of children assessed in clinic # of women serving porridge to their children # of women/fam ilies and health workers recognizing signs of under- nourishment # of women/fam ilies and health workers recognizing signs of under- nourishment Empowered Women Reduced infant/und er 2 morbidity and mortality Reduced # of children with signs of under- nourishment Reduced # of children with signs of under- nourishment # of women correctly making porridge

21. Participants will meet monthly A nutritional topic will be discussed at each monthly meeting including:  fluid needs  nutrient rich local food sources  feeding frequency  breastfeeding duration  weaning techniques Demonstration - every six months including making nutrient rich porridge. Monthly meeting with doctor where women are given fortified flour for porridge and baby assessed. Training – Mothers and Other Caregivers

22. 3 day in-service to train medical staff regarding: Current breastfeeding recommendations Nutritional needs of breastfed and non-breastfed infants. Follow-up workshop every 6 months to address additional questions and issues that may arise. Training – Providers and Health Workers