This document discusses integrating nutrition into national HIV policies and programs based on experience from Africa. It summarizes the scientific evidence showing that nutritional supplementation can improve energy and protein intake as well as body weight and composition in HIV-positive individuals. However, more research is still needed to determine the impact on clinical outcomes like CD4 count and mortality. It also describes challenges faced and lessons learned from programmatic experiences integrating nutrition services into HIV care in several African countries. Key research gaps are identified around determining the effectiveness and cost-effectiveness of different food products and better harmonizing food security and nutrition programs for HIV-positive populations.

1. Integrating nutrition into
national HIV policies and
programs:
Experience from Africa
Pamela Fergusson PhD
Nutrition and HIV Advisor FANTA-2
pfergusson@aed.org
Food and Nutrition Technical Assistance II Project (FANTA-2)
AED 1825 Connecticut Ave., NW Washington, DC 20009
Tel: 202-884-8000 Fax: 202-884-8432 E-mail: fanta2@aed.org Website: www.fanta-2.org

2. Outline
Scientific evidence
Critical reflection
Programmatic experience
Research gaps and priority actions

3. SCIENTIFIC EVIDENCE

4. 2007 Cochrane review Eight trials (486 participants)
Significantly No effect
improved
Energy intake Body weight
Protein intake Fat-free mass
CD4 count
Small number of participants, no reporting of morbidity or
mortality, mostly resource-adequate setting
Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004536. Nutritional interventions for
reducing morbidity and mortality in people with HIV. Mahlungulu S et al

5. Review: macronutrient supplementation for
HIV in resource constrained/adequate
settings
• BMI <16 = >2X RR of mortality (Malawi, Zambia, Tanzania)
• Resource constrained settings: 2 trials
Zambia: food insecurity entry, modest improvement in adherence, no
difference in weight gain, CD4 count or mortality
Malawi: FBF vs RUF
Increase in BMI and LBM after 3 months in RUF group
no significant differences in survival, viral load, CD4, or quality of life
At 3, 6, 9 months after food ended, no differences in any outcomes.
Clin Infect Dis. 2009 Sep 1;49(5):787-98. Macronutrient supplementation for malnourished HIV-infected
adults: a review of the evidence in resource-adequate and resource-constrained settings. Koethe
JR et al
J Acquir Immune Defic Syndr. 2008 Oct 1;49(2):190-5. A pilot study of food supplementation to improve
adherence to antiretroviral therapy among food-insecure adults in Lusaka, Zambia. Cantrell RA et
al
BMJ. 2009 Supplementary feeding with either ready-to-use fortified spread or corn-soy blend in
wasted adults starting antiretroviral therapy in Malawi: randomised, investigator blinded,
controlled trial. Ndekha MJ et al.

6. CSB vs. RUFS for Adult ART Clients

7. Kenya KEMRI: FBF vs. No Food for HIV+
Adults
∆BMI (pre-ART N = 431 )
:
• Differences significant
through the 6th month.
• Food significant
determinant of ∆BMI at
3 and 6 months in
multivariate regression.
• Greater difference for
women than men.
• After 6 months
differences not
significant (n quite low
by then).

8. Kenya KEMRI: FBF vs. No Food for HIV+
Adults
∆BMI (ART N = 624)
• Differences significant
through the 3rd month.
• Food significant
determinant of ∆BMI at
3 months in multivariate
regression but not 6.
• Greater difference for
women than men.
• Rapid weight gain: 1.9
& 1.0 kg in 1st month
and 4.6 & 3.4 kg. by 3rd
month on food & non-
food respectively.

9. Kenya KEMRI: FBF vs. No Food for HIV+
Adults
Loss to Follow-up (pre-ART)
• Loss to follow-up a
huge problem in
Kenya.
• Among pre-ART
clients, LTF lower in
food group during
supplementation.
Difference not
significant for ART.
• Food is significant
independent predictor
of clinic attendance at
6 months among both
ART and pre-ART.

10. Implications from Studies
• RUF leads to faster weight/lean body mass
gain than CSB among adults on ART
• Impacts of food appear greater for pre-ART
than ART clients
• Improved adherence
• Impact of supplementation on CD4 and
mortality yet unproven
• Most benefits occur during the period of food
supplementation and may not persist beyond

11. CRITICAL REFLECTION

12. Issues in quality of evidence
base
• Small sample size
• High loss to follow-up
• Ethics: comparing to a control group with no
supplementation
• Less evidence for interventions with PMTCT
and children/adolescents
• Few trials in African settings
• Little research evidence evaluating
programmatic approaches

13. Belief in the importance of
food Before and after ART
Although the evidence for
macronutrient
supplementation for PLHIV
remains weak, there is a
strong belief in the importance
of food and nutrition support
by PLHIV, staff at ART clinics.
“Clients were unanimous in
saying that “food rations
were a life saver.”
(GAIN working paper #2, FBP a Landscape Paper)
Why? Photo credit:
http://www.annielennoxsing.com/about-sing

14. INTEGRATING NUTRITION
INTO HIV: PROGRAMMATIC
EXPERIENCE

15. NACS
Nutrition To clients who meet
criteria at sites
where available
Support .
Nutrition Counseling Periodically to
clients at all sites
Nutrition Assessment Routinely to all
clients at all sites

16. Integration of Nutrition into National
HIV Responses
• National Policy and Coordination
• Capacity Strengthening
• Service Delivery
• Information systems and evidence base

17. Challenges: managing service
provider time constraints
• Ghana 2010
assessment: nurses
report 6 min/patient
consultation
• Emphasis on strong
tools/job aids SBCC
• Sharing and
harmonising across
the region
appropriately
• Task shifting

18. Challenges: establishing national-
level coordination
• Establishing a nutrition and HIV technical
advisory group
• Ghana: Importance of membership of
group – coordination between HIV/medical
and nutrition stakeholders
• Ethiopia: Updating guidelines and policy –
working with gov’t and NGO stakeholders

19. Challenges: the importance of
quality improvement
• Training and materials are not sufficient
• Importance of harmonising indicators collected
and respecting staff time
• Kenya: good practice: electronic records
• Uganda: challenges: paper records means that
patients can be double or triple counted
• Namibia: multiple stakeholders creating M&E
systems, needs harmonisation
• Staff taking ownership of QI

20. Challenges: Linkages between HIV
and other services
CMAM
Antenatal Food
and <5 HIV security
TB

21. Integrating with food security
programmes
Good practice
• Ghana: WFP exploring opportunities
working in harmony with FANTA-2 through
GHS: stakeholder consultation
• Namibia: MOHSS, FANTA-2 and LIFT
(AED) partnering to explore food security
& livelihoods opportunities in HIV
Issues
• Entry and exit criteria
• Overlap of target population

22. Challenges: facility-to-community
referral systems
• CMAM (child)
– Harmonising guidelines
– Multiple service delivery points
– Loss to follow-up (resources)
– HIV testing at community level
• Adult MUAC community based screening
– Opportunity to refer adults for testing and
follow-up

23. RESEARCH GAPS AND
PRIORITY ACTIONS

24. Research Gaps
• Effectiveness studies with large enough sample
size to report on mortality
• Relative effectiveness and cost-effectiveness of
various food products
• How to harmonize food security and nutrition
supplementation programs in HIV
• Further exploration of impact on quality of life:
qualitative research?
• More evaluation research into programmatic
approaches & sharing best practice

25. Questions?