Integrating food and nutrition security interventions into AIDS care and treatment: Fostering evidence based programming
Integrating food and nutrition security interventions into AIDS care and treatment: Fostering evidence based programmingTASO-RENEWAL-WFP- Concern Worldwide and other food and livelihood program partners
2 Years Ago: RENEWAL 3 Workshop 2007HIV and Nutrition Security Theme Working group
Malnutrition and HIV disease progression• Degree of malnutrition clearly linked with mortality risk in adults and children• Compromises efficacy & increases toxicity of ARVs – Undesirable ARV side effects – Threats of decline in ARV adherence – Higher mortality in the first three months of ART initiation• High levels of vitamin B, C, E, folate, Se slow the progression from HIV to AIDS (↑ CD 4 counts & ↓ viral load) – Role of Vitamin A and Zn not consistent across studiesSource: WHO 2005; Fawzi 204; Moore et al 2006; Zachariah et al 2007; Au et al 2008; and other sources
Impact of AIDS on Household Welfare• Deterioration of food security due to chronic morbidity & mortality through – reduced income, increased expenditures – loss of labor productivity – time for care-giving• Reduced human capital investments – Childrens education – Child survival and growthSource: Gillespie and Kadiyala 2005; Gillespie 2006; Chapoto and Jayne 2007; Yamauchi et al 2007; Kadiyala et al 2009 & other sources
Integrating nutrition security interventions• A significant response of food assistance programming to people affected by HIV & AIDS (mostly by WFP, USAID programs incl. PEPFAR)• Many organizations attempting to integrate livelihood programs to improve food security. – TASO partners with many such organizations• Evidence base on these programs still weak: – If the programs are effective? – If not, why not? E.g. Quality of implementation?
Food and nutrition along the HIV timelineRisk HIV AIDS Impacts Prevention Care & treatment Mitigation At each point, what are the key roles of food and nutrition research and programming?Source: IFPRI/RENEWAL
RENEWAL 3 2007 Agenda• What is the evidence of effectiveness and cost- effectiveness of relatively short-term interventions?• How to integrate long-term sustainable interventions?• How do we make use of the date we have to build the evidence base?
The AIDS Support Organization (TASO)• TASO (www.tasouganda.org) was founded in 1987 to contribute to prevention of HIV, restoring hope and improving the quality of life of persons, families and communities affected by AIDS.• It provides counseling, medical care, and social (including nutritional) support to PLWHA and their families; HIV education to the public , training and capacity building of other NGOs/CBOs.• It has 11 branches and serves 80,000 clients annually following Government of Uganda service guidelines.• It is a key play in the National (Uganda) response and works in partnership with various agencies. 8
Collection, Analysis, and Use of Programming Data in TASO• TASO maintains databases on its clients and the services they receive.• The data is routinely analyzed for purposes of improving service delivery and management.• The data is also used in collaborative studies aimed at answering key strategic questions; the hence current partnership with IFPRI/ RENEWAL, & others.• The interest in the studies is contribute to service improvement, the knowledge base, and to national and international policy development.
1. Utilizing the existing dataHow does the provision of food assistance affect BMI and change in WHO staging? – Preliminary Results: a) Food assistance had a positive impact on weight gain b) Food assistance helped slow transitions in WHO Stage c) Impacts varied by initial WHO stage at which food assistance is provided (earlier is better)(RENEWAL/IFPRI & Concern Worldwide, WFP, Univ. of Illinois and others )
2. Effectiveness of Food Supplementation Study (baseline recruitment ongoing)To estimate the effectiveness (including cost- effectiveness) of food support (in the form of a WFP HH food basket) provided to HIV-infected individuals who are not yet on anti-retroviral therapy (ART) • Individual welfare outcomes • Household welfare outcomes(TASO, WFP, RENEWAL/IFPRI , Concern Worldwide & Univ. of Illinois)
Study Design 800 HIV-infected, ART ineligible TASO clients w/ CD4 counts 200-450 & eligible for food assistance GULU SOROTI (Receiving food aid for 12 mo.) (Not receiving food aid) Eligibility: 400 PLHIV Eligibiliy:400 PLHIV CD4: 200-450 CD4: 200-450Not currently on food aid but eligible Not currently on food aid but eligible Baseline clinic and household survey (July 2008-June 2009) 12-month follow-up (September 2009- June 2010)
OutcomesIndividual Household• Disease progression (CD4 • HH food security & dietary count, WHO stage) diversity• Health –OIs and • Anthropometry (=<5yrs) symptoms • Health and quality of life• Nutritional status (BMI, • Economic activities and MUAC, Hb) employment• High risk behavior • Assets, indebtedness• Quality of Life • Expenditures (food & non food)• Disclosure • Agriculture production• Stigma • Intra-household labor• Access to health care allocations
3. Operations Research to Improve Livelihood Programming (data collection complete)OR, with livelihood program implementing partners (LP), to investigate – whether integrated livelihood and HIV/AIDS programs share a clearly elucidated causal pathway to impact – the service delivery and utilization plans of programs to realize the intended impact on food security – the household level determinants of program effectiveness and sustainability • E.g. relevance, quality of programs, local participation (TASO, RENEWAL/IFPRI, Concern Worldwide & 20 LPs )
RENEWAL-TASO Research TeamIFPRI/RENEWAL Research Assistance Team• Suneetha Kadiyala• Rahul Rawat (also CWW) • Mulowooza, Fiona• Terry Roopnaraine (consultant) • Ssegujja, Eric• Stuart Gillespie • Kyohangirwe, Rossette • Achola, ElizabethTASO • Werikhe, Susan• Robert Ochai • Christopher, Omoding• Frances Babirye • Murisho Shafi• Dr. Christine Nabiryo • Okello Robert Bob• Tina Achilla • Sentamu Ismail• TASO Jinja, Mbale, Gulu, Soroti • Alex Kagaha* With active participation from TASO clients
Traditional Evaluation of Impact Program ImplementationBaseline Endline Survey Survey Baseline and Endline Measures of Indicators of Interest: •Food Insecurity •Dietary Diversity •Nutritional Status (e.g. BMI, Hb) •HH level Indicators This design determines IF there is impact If there is NO IMPACT, this design does not answer WHY
How Programs Operate ProcessesInputs Outputs Outcomes Impacts Processes
Research Methods• in-depth key informant interviewing with program staff from TASO and 20 LP implementing partner organizations• in-depth, multiple-contact interviewing with TASO clients in 71 households• 4 TASO catchment areas (Jinja, Mbale, Soroti and Gulu)• Interviews were taped and transcribed into English• Coding & analysis using Nvivo 8
Framework for Conducting Operations Research of Livelihood Programs Integrated with HIV/AIDS Care and Treatment Services Program Theory Framework Impact Theory Process Theory •Specifies impact pathways •Shows steps by which intervention or program is •What are the steps by which implemented a program intervention is expected to impact •Includes steps related to outcomes? organizational plan •Specifies causal pathways to •Also includes steps related to achieving impact service utilization plan
Emerging Impact Theory Results• Program staff asked what their programs were trying to achieve – Senor staff usually able to offer responses consistent with objectives laid out in program documentation – Often not the case farther down the program chain• Inconsistencies in explanation of program design – Staff emphasize wide range of program inputs, but clients offer different opinion
Key Themes Addressed in Service Delivery and Utilization (Process Theory)• Necessary client actions to optimize program benefits• Necessary program actions to optimize program impact
Emerging Process Theory ResultsClient actions Program actions• Living positively: • Integration of LP services with other services: – Disclosure & overcoming stigma – medical, veterinary & extension – Non- fatalistic attitude • Client and community involvement:• Demonstrated commitment to the – In choice of input & program design program: – Intensive mobilization – Appropriate use of inputs – Monitoring & feedback – Peer training – Involve family members in program – Creating a sense of ownership• Joint monitoring & feedback with program staff: • Working within local community structures: – Provide honest information – Existing social capital• Effective group management: • Creating links : – Group cohesion – Ensuring that support is provided – Planning & management of along the entire chain including group resources processing and marketing – Fairness in resource allocation
Operations Research in Practice• Focus on process and delivery – Understanding the “how”• Feedback into program design• Adaptable, if planned well• Challenges – Requires human resource inputs – Requires monetary inputs – Requires careful planning at an early stage – Programs must be amenable to change– Creating Program-Research Synergy