CCIH 2012 Conference, Breakout 4, Emily Chambers Sharpe, Addressing and Understanding Nutrition as a Component of Global Health

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Emily Chambers Sharpe of the Office of the Global AIDS Coordinator discusses the importance of nutrition and the relationship between ARVs and breastfeeding in preventing mother to child transmission …

Emily Chambers Sharpe of the Office of the Global AIDS Coordinator discusses the importance of nutrition and the relationship between ARVs and breastfeeding in preventing mother to child transmission of HIV.

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  • Just a moment to give some attention to the 1000 days initiative. Are any folks familiar with this?
  • This is an overall approach to nutrition, and in some countries you have likely heard about efforts to develop national policies for the prevention and treatment of undernutrition. For example, in Sudan, the Ministry of Health adopted the community-based management of acute malnutrition model, a model originally used in emergency settings, as the foundation for national nutrition programs. In other countries where ‘hunger gaps’ are common, or there is periodic drought/famine, US government, UNICEF, WFP, and other governments are developing similar guidelines.
  • The goal of all these nutrition programs is to really focus on the issues of malnutrition on the under-nutrition end of the spectrum
  • Linked to these efforts, through the funding of the President’s Emergency Plan for AIDS Relief, or PEPFAR, nutrition is being addressed in the context of the scale up of HIV treatment interventions. HIV and malnutrition have been linked, from the early days when many people referred to this disease as “Slim”. There are proven links in this particular co-morbidity of malnutrition and HIV.
  • The approach used in PEPFAR started in Kenya with a program known as Food by Prescription, which has now been taken to scale. This program is based on nutrition assessment, counseling, and support of PLHIV and others affected by HIV, such as orphans and vulnerable children. From the perspective of a patient, a woman might enter into ANC and have to opt out of HIV testing for preventing mother to child transmission (PMTCT). If this woman is also assessed for her BMI (body-mass index) or even more simply, her MUAC (mid-upper arm circumference) and found to be malnourished (BMI <18.5), then she should be able to access services that provide her with nutritional supplements by prescription, at the clinic site, rather than in a separate nutrition program standing alone in the village. Through the clinic, she should also receive counseling for herself about how to eat well as she gains weight, and about how to appropriately feed her child. We are now looking to link individuals like this woman to community based services, using a case-work type model, to community services that can help improve her household food security to keep her and others from becoming malnourished again in the future. We are using links to programs that are supported by WFP and the US government, including Feed the Future programs.
  • Is anyone familiar with the former recommendations? AFASS
  • Botswana


  • 2. U.S. Government Approach to Nutrition  Target the first 1,000 days:  Critical period from pregnancy to two years of age is when infants and children are most vulnerable and that nutrition interventions during this period have immediate and long-term consequences.  Improve maternal nutrition  Promote exclusive breastfeeding  Encourage diet quality and diversification for mothers and infants.Source: USAID‟s Global Health Strategic Framework: Better Health for Development, FY 2012-FY 2016
  • 3. U.S. Government Approach to Nutrition  Balance prevention and treatment of undernutrition:  Prevention of undernutrition in the 1,000 day window of opportunity is at the core of USAID‟s strategy.  Treatment of moderate and severe undernutrition is necessary.  Nutritionally dense, ready-to-use foods enhances the capability to treat undernutrition,  Latest developments in nutrition science into food assistance programs seeks to advance the opportunities to prevent undernutrition  Scale-up of community-based management of acute undernutrition.  Bring nutrition programs to scale: Building on earlier successful pilot programs, USG is working with country governments to bring nutrition programs to national scale.Source: USAID‟s Global Health Strategic Framework: Better Health for Development, FY 2012-FY 2016
  • 4. Key Nutrition Outcomes for USGovernmentReduce Stunting/Wasted/Underweight …….. % Change in prevalence of stunted children under five years of age  % Change in prevalence of wasted children under five years of age  % Change in prevalence of underweight women
  • 5. HIV & Nutrition:“Slim” HIV: • Loss of appetite • Impaired nutrient absorption • Altered nutrient metabolism • Increased nutrient requirements Malnutrition: • Weakened immune system • Increased susceptibility to OIs & comorbidities • Wasting & increased mortality • Poorer adherence & response to treatment
  • 6. The NACS Approach -- Nutrition Assessment, Counseling & Support Clinical Mgmt & PMTCT Services: ART Opportunistic Assessme Infections Support: nt: Chronic Food by Prescription: Anthropometri disease therapeutic & Community c Counselin management Services: supplementary Biochemical g: feeding Nutrition surveillance Clinical Adherence & clinic referrals MN Dietary Diet Nutrition counseling & supplements Food Security WASH support within home- Livelihood & Infant/child food security based care feeding referrals Economic Referral to strengthening, Community livelihood & food Services security supportEntry Points: ClinicANC/PMTCTClinical referral CommunityCommunity Referral
  • 7. WHO 2010 Revisions
  • 8. PMTCT, Postnatal Care, and Infant Feeding IMPACTIncrease HIV-Free Survival (HFS) among HIV-exposed infants up to 24 months of age A PARTNERSHIP FOR HIV-FEE SURVIVAL TO IMPLEMENT THE WHO 2010 PMTCT, ART, & INFANT FEEDING GUIDELINES PEPFAR, WHO, IHI, HCI, FANTA-2, UNICEF, EGPAF, M2M & Country Implementing Partners
  • 9. Revised WHO Recommendations on the use ofantiretroviral drugs for treating pregnantwomen and preventing HIV infection in infants(2010) Eligibility criteria for ART  CD4 count <350, irrespective of clinical stage  Clinical stage 3 or 4, irrespective of CD4 count The 2010 recommendations … provide two alternative options for women who are not on ART and breastfeed:  A) daily NVP for infants from birth until the end of the breastfeeding period. or  B) continued regimen of triple ARV therapy to the mother until the end of the breastfeeding period. ARV prophylaxis …. should continue until one week after all exposure to breast milk has ended.
  • 10. Maternal health and child outcomes 100%  Strong relationship between maternal health and both HIV 90% In the absence of any transmission risk and also child interventions about survival 80% 36% infants will 60% become infected.  ~40% HIV-infected mothers have 70% CD4 counts <350 26 of the infants will be but account for 80% transmissions 60% born to mothers with (26/36) and 80% HIV-associated 50% CD4 counts <350 maternal mortality 40% 30% • Maternal ART improves child 10 survival independent of the 20% 40% effect on transmission 10% 26 Mothers with CD4>350 0% Mothers with CD4<350 HIV-infected Infected infants mothers
  • 11. Mother and child survivalin the context of HIV are inextricably linkedPathophysiology Clinical interventions 80% HIV-related maternal deaths  ART significantly improves CD4 counts, are in women with CD4 counts reduces maternal mortality and <350/ml improves AIDS free survival  Effective ARV prophylaxis and ART 80% infants who become HIV- reduces peripartum transmission to infected are born to mothers with less than 2% CD4 counts <350/ml  ARV interventions also significantly Infants who are HIV infected are reduce postnatal transmission 17-30 times more likely to die  HIV-infected mothers can breastfeed When a mother with HIV dies, her infants with minimal risk of children are at least 4 times more transmission and thereby improve HIV- likely to die free survival
  • 12. National (or sub-national) health authorities shoulddecide whether health services will principallycounsel and support mothers known to be HIV-infected to:breastfeed and receive ARV interventions, or,avoid all breastfeeding,as the strategy that will most likely give infants the greatestchance of HIV-free survival This decision should be based on international recommendations and consideration of the socio-economic and cultural contexts of the populations served by Maternal and Child Health services, the availability and quality of health services, the local epidemiology including HIV prevalence among pregnant women and main causes of infant and child mortality and maternal and child under-nutrition.
  • 13. HIV free survival Children of HIV-infected mothers remaining HIV uninfected and staying alive Policy, interventions and programmes (including cost-effectiveness) should be judged on their ability to promote HIV free survival among all children and the health and survival of mothers … … and not just HIV transmissions averted
  • 14. J Acquir.Immune.Defic.Syndr. 2010;53(1):28-35 Decreased survival among infants who stopped BF early or who were never BF. AHR = 6.19; (95% CI 1.41–27.0, P = 0.015) 97% infants were tested at 6 wks – none infected. Difference was independent of maternal health or if receiving ART
  • 15. Replacement feeding in PMTCT sites Sample of milk collected from bottles (n=94) being offered to infants brought by mothers to PMTCT clinic follow-up visits  63% heavily contaminated with E.coli  28% diluted (based on protein concentration)In spite of  All mothers having completed • 15-20% mothers reported free 12 years of education FF being used for something  72% having fridges other than index child  All received good counselling on IFP – Sold – Exchanged • 50-75% reported running out – Mainly because of clinic supply Bergstrom. Acta Paeds 2007
  • 16. Knowledge of nurses and counsellors about risk of BFtransmission 160 Number of respondents Response to question: If 100 HIV-infected 140 women breastfeed until their children are 120 two years old how many children will be 100 infected at 2 years of age? (mother and child do not receive any antiretroviral medicines) 80 60 40 20 0 0 - 20 20 - 40 40 - 60 60 - 80 80 - 100 Dont KnowCorrect answer ~14 Number of infants infected Chopra and Rollins, Arch. Dis. Child. 2008
  • 17. Feeding at some PMTCT sites in SA 100 90 80 70 60 50 BF 40 FF 30 20 10 0 Rietvlei ZeerustShongwe COSH Durban Pmb Rural Rural Rural Rural Urban Urban The quality of infant feeding counselling translated into HIV free survival of infants Woldenbeset. IAS 2009
  • 18. Why does WHO recommend that nationalauthorities promote a single infant feedingstrategy for all HIV-infected mothers and theirinfants? High quality evidence that ARVs very significantly reduce the risk of HIV transmission through breastfeeding Documented evidence of increased mortality when replacements feeds are given inappropriately in the context of HIV Even with good protocols and training, difficult to assure high quality counseling and support for all infant feeding practices Cost effective interventions are available that improve survival of mothers and infants and reduce transmission
  • 19. What‟s happening in countries: Revising positions and policies around HIV and infant feeding  Evidence reviews  Assessments of the type of epidemic  Assess the contribution of infectious diseases and malnutrition to infant mortality  Assess quality and coverage of PMTCT/ART services  Consider financial and human resource costs of options  Formulate national infant feeding and HIV
  • 20. How does a mother decidewhether or not to attend forcare and how she feeds herchild? If she considers that health services serve her interests and those of her child If benefits of attendance are not prejudiced by the way she is received by health staff If the sentiments of families and communities are favourable towards the health services
  • 21. Mma bana study 2 randomised arms and one observational Mothers not eligible for ART received either: lopinavir/ritonavir and combivir } for 6m or abacavir/AZT/3TC } while BF Mothers eligible for ART – outcomes observed 10 9transmission % 8 Infant HIV 7 6 5 4 3 2 1 0 1248 pregnant women referred to study Mothers not eligible for Observational ART sites. After counselling about study interventions, 110 (8.8%) declined enrolment as preferred to give formula feeds.
  • 22. What wins? Effective interventions Risk factors Health system issues Gerry Boon
  • 23. What wins? Risk factors Effective interventions Health system issues Gerry Boon
  • 24. Guidelines, toolkits, and trainingabound… BUT there is little experience on scaling up the postnatal continuum of PMTCT care, particularly around infant and child feeding
  • 25. How to we go „to scale‟?How can training bring about real change?Affordability, equity, and sustainability?Integrating nutrition, IMCI, TB, HIV, and otherprograms?
  • 26. “Real Life” issues: PMTCT programme attend Attend HAART facilityAccess ANC clinicissues Attend facility Attend postnatal care based delivery Counseled and tested for HIV, Start onPMTCT CD4 HAARTProgram referred fordelivery HAART issues CD4 Manage result AZT/sdNVP mother- Started on in labour child pairs AZT Postnatal Start IF and counseling, in high HIV infant ARVs tracking burden and testing countries
  • 27. Gap between clinical trial and “real life” PMTCT implementation % HIV transmission 25 20 15 clinical trials 10 real life implementation 5 0 NVP AZT/HAARTRollins N,. AIDS 21: 1341–1347 2007Horwood 2010
  • 28. Dependence of postnatal HIV care on reliable MNCH delivery systemContinuum Multi-step MCH System Parts of the PMTCTof MCH care PMTCT care Performance programme affected attend ANC clinic HIV counseling, HIV,CD4 testing (M) Attend ANC more Access to HAART and than 4 times AZT (M) Attend skilled Access to intra-partum delivery NVP/AZT (M) 53% HIV and feeding Establish early counseling (M). breast feeding Access to post-partum NVP/AZT (M&I) 53% Predicted HIV and feeding Attend postnatal counseling (M) Transmission clinic for 3 x DPT HIV/CD4 testing (M&I). ??? 86% Access to post-partum NVP/AZT (M&I)
  • 29. PMTCT and NACS Continuum of Care ANC Visits Delivery/Birt Early Postnatal EPI 6 months 9 months 12 months 15, 18, 21 & h Postnatal Visits 6, 10 & 24 months 14 weeks • PITC • CD4 & • CD4 & • CD4 & • CD4 & • CD4 & • CD4 & • CD4 &Women: • CD4 & clinical clinical clinical mgmt clinical clinical mgmt clinical clinical clinical mgmt mgmt • ART Tx or mgmt • ART Tx or mgmt mgmt mgmt • ART Tx or • ART Tx or prophylaxis • ART Tx or prophylaxis • ART Tx or • ART Tx or • ART Tx or prophylaxis prophylaxis • Maternal prophylaxis • Maternal prophylaxis prophylaxis prophylaxis • Maternal • Maternal NACS • Maternal NACS • Maternal • Maternal • Maternal NACS NACS • Infant NACS • Infant NACS NACS NACS • Infant • Infant feeding • Infant feeding • Infant • Infant • Infant feeding feeding counseling -- feeding counseling -- feeding feeding feeding counseling -- counseling -- EBF/ERF counseling -- CF counseling - counseling - counseling EBF/ERF EBF/ERF • FP CF • FP - weaning - weaning • FP (AFASS) (AFASS) • FP • FP • Initiation of • EBF/ERF • EBF/ERF • CF • CF • CF/weaning • CF/weaninInfants: EBF/ERF • ART • ART • ART • ART • ART g • ART prophylaxis prophylaxis prophylaxis prophylaxis prophylaxis • ARTEBF = prophylaxis • Infant • Infant • Infant • Infant • Infant prophylaxisexclusive NACS/Growt NACS/Growt NACS/Growt NACS/Growt NACS/Grow • Infantbreast h h monitoring h monitoring h monitoring th NACS/Grofeeding monitoring • EID • EPI/measles monitoring wthERF = • CTX monitoringexclusive • DPT 1,2,3 • Post-replacementfeeding weaningCF = comple- HIV testingmentaryfeeding
  • 30. U.S. Government Centrally-Funded Nutrition Programs through USAID1. Child Survival Health Grants Program (CSHGP), Maternal and Child Health Integrated Program (MCHIP)-Nutrition (PATH) & CORE Group2. Food and Nutrition Technical Assistance Project 3 (FANTA)3. Food Aid Nutrition Education Program (FANEP)4. Iodine Deficiency Disorder (UNICEF)5. Nutrition Collaborative Research Support Program (Nutrition CRSP)6. Technical and Operational Performance Support Program (TOPS)7. Strengthening Partnerships, Results and Innovation for Nutrition Globally (SPRING)8. Global Alliance to Improve Nutrition (GAIN)9. Conducting Research on Moderate Acute Malnutrition in Humanitarian EmergenciesKey Wraparound Programs1. Livelihood & Food Security Technical Assistance Project (LIFT) ( Alive and Thrive (BCC)
  • 31. Nutrition Resources Online _Management_of_Severe_Acute_Malnutrition. pdf
  • 32. Nutrition Resources Online nutrition/women-of-faith-for-the-1000.html ?iso=ETH&rid=161&template=nutrition&goButton =Go