1. Food & Nutrition Support within PEPFAR Clinical Programs The United States President’s Emergency Plan for AIDS Relief Track 1 ART Program Meeting Atlanta September 25, 2007 Tim Quick, USAID

2. Overview: HIV/AIDS & Nutrition Food often stated as the most urgent need of PLHIV and their families – food insecurity highly pervasive in PEPFAR countries. AIDS is a wasting disease (“Slim Disease”) -- PLHIV typically present late & first tested after chronic illness & significant weight loss. Strong correlation between wasting & mortality before & during Tx – very high mortality rate in patients w/ low BMI in 1st months of ART. ART & Tx of OIs improves appetite & nutritional status of most malnourished patients.

3.  Nausea, oral thrush, altered taste & depressed appetite.  Accelerated nutrient losses due to malabsorption, diarrhea & hypermetabolism.  Multiple micronutrient deficiencies pre-existing & precipitated by infection (& Tx). Clinical Picture for PLHIV

4. Need to increase total energy intake: –Asymptomatic: 10% increase (kcal/day) –Symptomatic: 20-30% increase (kcal/day) –Children w/ weight loss: 50-100% increase (kcal/day) Maintain protein @ 12-15% of energy intake to maintain and recover lean body mass. Essential micronutrients (vitamins/minerals) @ 1 RDA  Require high-energy, nutrient-dense foods, NOT JUST MORE OF THE SAME FOOD Dietary Implications of HIV

5. Guiding Principles for Food & Nutrition Support under PEPFAR Support for F&N must contribute directly to the 2/7/10 goals. PEPFAR is NOT a food security program. Emphasis on integration of nutritional assessment, counseling & support within clinical care & Tx. Emphasis on leveraging food security & livelihood assistance support from other sources (“wrap-arounds”). Limited PEPFAR procurement & provision of food to specific target groups under defined eligibility criteria.

6. Target Groups for PEPFAR Nutrition Support OVC, especially infants & young children. HIV+ pregnant & lactating women in PMTCT programs. PLHIV in care & Tx programs.

7. Nutritional Support Begins with Nutritional Assessment 1.Anthropometry (wt, BMI, MUAC) 2.Symptom mgmt (appetite, nausea, taste, oral thrush, diarrhea, drug X food interactions 3.Dietary adequacy (micronutrients) 4.Household food security 5.Family-centered approach – referral (HBC) and assessment of others in family, esp young children

8. Nutritional Care of Adult PLHIV Nutrition/dietary counseling Therapeutic/supplementary/supplemental feeding Multi-micronutrient supplementation Safe water/hygiene/sanitation Management of drug/food/nutrient interactions Management of chronic HIV infection –Lipodystrophy/heart disease –Insulin resistance/diabetes –Osteoporosis

9. Nutritional Care of Infants & Children Infant feeding counseling & support, incl weaning/supplemental foods, to minimize MTCT & maximize survival (AFASS framework). Routine growth monitoring & clinical assessment. Therapeutic & supplementary feeding support for malnourished infants & young children. Multi-micronutrient & routine vitamin A supplementation. ORT/Zn supplementation for acute diarrhea. Safe water/hygiene/sanitation

10. Policies Guidelines Resources Funding Staffing Commodities Training Quality Assurance/Quality Improvement Monitoring & Evaluation Targeted Evaluation Procurement, Logistics & Inventory Control Wrap-Around Programs Maternal & Child Health/Family Planning Food Assistance/Security Livelihood Assistance/Employment/Microcredit Education/Vocational Training PMTCT OVC Pediatric Care & Tx Adult Care & Tx Facility Level Household/Community Level Nutritional assessment  Anthropometry  Symptom mgmt  Dietary assessment  Nutrition Counseling  Multi-MN suppl (MN by Prescription)  Therapeutic/suppl feeding (Food by Prescription) Household food security assessment for clinic patients Links with food security support for food-insecure families of clinic patients Links with livelihood assistance, micro-credit, micro-enterprise, (re)employment opportunities, vocational training Home-based care  Safe water  MUAC clinic referral Nutritional assessment  Anthropometry  Symptom mgmt  Dietary assessment  Nutrition Counseling  VA, Zn, multi-MN suppl  Therapeutic/suppl feeding IYCF/ENA counseling Continued BF to 2 yrs for HIV+ infants Clinic referral for growth faltering Community Therapeutic Care (CTC) for severely malnourished HIV+ children Infant Nutrition  Infant feeding counseling  Growth monitoring  Multi-MN supplementation  Therapeutic/ supplementary/ supplemental feeding Maternal nutrition  Assessment &Counseling  Multi-MN suppl  Supplemental feeding Infant feeding counselling Links to basic CS, e.g. cIMCI, CTC, CB- GMP Safe water/hygiene/ sanitation Continuum of care for U5 PMTCT infants and older children:  Growth monitoring  VA, Zn, multi-Mn supplementation  Therapeutic/ supplementary/ supplemental feeding Counseling Nutritional assessment & clinic referral Household food security assessment Links with food security support for food-insecure OVC & families Links with livelihood assistance, micro-credit, microenterprise, (re) employment opportunities, vocational training

11. PEPFARWrap-around IndividualsOVC/PMTCT WomenHouseholds Hospital/Clinic LevelClinic/CommunityCommunity Clinical MalnutritionAny nutritional statusFood insecurity Severely malnourished adults Moderately malnourished adults Any nutritional statusHousehold 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 Food Assistance for PLHIV & Families

12. Kenya “Food by Prescription” Program Model of integration of nutritional support within clinical services – piloted at 60 CCCs Senior Nutritionist at NASCOP National Guidelines for HIV & Nutrition (incl PMTCT & infant feeding) GFATM – nutritionists & lay counselors staffed at CCCs Assessment: anthropometry, symptoms, & dietary Counseling Support – multi-MN supplements –supplemental (preg/lact women and OVC) and therapeutic/supplementary (malnourished adult and OVC) feeding support

13. Food by Prescription Physician Symptom diagnosis Integrated symptom Tx/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 clinical care & household food security Patient Follow-up Referral Hospital/Clinic Inpatient VCT Community Programs Food security Livelihood assistance MCH Food Company Food production Direct delivery to hospital/clinic

14. Adult Patient BMI at Entry & Time to FBP “Graduation” ~1 in 3 new ART patients clinically malnourished (BMI < 18.5), of which ~1 in 4 is severely malnourished (BMI <16). Average time for ART patients to graduate from feeding support (BMI >20) is ~3 mo for patients w/ BMI 16-18.5 at entry and ~5 mo w/ BMI < On-going TE will evaluate clinical outcomes associated w/ FBP & improved BMI, as well as “recidivism” to BMI <18.5 post-FBP.

15. Cost Breakdown for Nutrition Component Age Group Amount of Food/Day Period on FoodAmount of Food/Period Cost of Food 6m – 2yrs100g18 months54kg$40.54 2yrs – 4yrs200g6 months36kg$27.03 5yrs – 10yrs200g6 months36kg$27.03 11yrs – 17yrs300g6 months54kg$38.92 18yrs +300g6 months54kg$38.92 Pregnant/Post Partum 300g9 months81kg$72.06 Note: The periods detailed above represent the maximum amount of time on food. The costs above represent a ‘delivered’ cost of product.