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  • Since 1995, over 46 million people have been successfully treated and an estimated 7 million lives saved through use of DOTS and the Stop TB Strategy recommended by WHO and described in the slide.
  • IN C&T (Care and Treatment)HIV beneficiariesinclude ART and PMTCT both clients and clients’ householdsTB beneficiaries include both clients and clients’ households
  • It should be noted that ODP and ODB make a significant contribution to capacity development, which cannot be captured in beneficiary figures.
  • Data on HIV prevalence from: UNAIDS Report on the Global AIDS Epidemic 2010
  • The 31 UNAIDS Priority Countries are listed in the 2012-2015 UBRAF. These countries meet three of the following five criteria according to independent data sources: (1) >1% of the people newly infected with HIV globally; (2) >1% of the global gap in antiretroviral therapy for adults (CD4 count >350/ml); (3) >1% of the global burden of HIV-associated TB; (4) estimated to have more than 100 000 people who inject drugs and an estimated HIV prevalence among them exceeding 10%; and (5) the presence of laws that impede universal access for marginalized groups, including sex workers; men who have sex with men; transgender people; and people who inject drugs.Calculation done as follows: # of ART and PMTCT clients benefiting from both C&T and M&SN in 2011 (SPR 2011) 384,452. % of 6,650,000 people receiving ART benefiting from the WFP assistance = 384,452 *100/6,650,000
  • Data from WHO 2011. TB incidence is per 100,000.
  • Source: WHO 2011, Global Tuberculosis ControlAfghanistan 189/100,000 Bangladesh 225/100,000Brazil 43/100,000Cambodia 437/100,000
  • This figure describes the clinical process of a comprehensive treatment package for the ART or TB client. Nutrition support is required to ensure nutritional recovery of the malnourished ART or TB client.
  • Corporate IndicatorsEMOP:C&T- ART, TB & PMTCT default ratePRRO: C&T- ART, TB Nutritional recovery rateM&SN- HHS FCSCP/DEVC&T-Art Adherence rate, TB treatment success rate, ART &TB Nutritional Recovery rateM&SN-HHS FCS
  • The context can be: emergency, transitional phase or development- HIV and TB epidemiology (HIV and TB prevalence and/ or incidence; HIV/TB co- infection if relevant for the intervention).Generaliseepidemic: HIV has spread into the general population of a given area. In practice, generalized epidemics have usually been declared when the prevalence exceeds 1% in the general population; Concentrate epidemiologic : HIV has spread rapidly in one or more subpopulations (like injecting drug users or men having sex with men) but has not become well established in the general populationTheses factors are measured by: Default, adherence, nutritional recovery and survival rates 3. Food insecurity can have an pivotal impact in HIV/TB context- increased food insecurity leads to negative coping strategies: increased risky behaviour, depleting of assets, migration, children dropping out of school etc.
  • All HIV and TB activities fall under the following two categories as defined by the new WFP HIV and AIDS Policy:Care and Treatment: ensuring nutritional recovery and treatment success through nutrition and/or food supportMitigation and Safety Nets: mitigating the effects of AIDS on individuals and households through sustainable safety nets
  • A client may be given either individual or household ration (normally calculated multiplying the number of clients by five).The term household will be used rather than the term family.
  • PEPFAR is a bilateral donor with strong in country-presence and set of prioritiesUS$ 6.6 billion PEPFAR funds (enacted 2012) US$ 5.3 billion for Bilateral HIV and AIDS Programs
  • Module one presentation

    2. 2. Outline of the Module I • Basic information on HIV/AIDS, TB, Malnutrition and Food securityII • Global Perspective: role and responsibilities within UNAIDS DoLIII • HIV response in Humanitarian settingsIV • WFP HIV and AIDS Policy and Programme StrategyV • How to design an HIV and TB ProgrammeVI • Overview of funding opportunity within Global FundVII • Module Test 2
    4. 4. What is HIV/AIDS • Stands for Human Immunodeficiency Virus • It is a special type of virus called “retrovirus” HIV • The virus kills white blood cells called CD4 lymphocytes that are responsible for the immune response • Acquired because is a condition one must acquire or get infected with • Immune because it affects the immune system AIDS • Deficiency because it makes the immune system deficient • Syndrome because the person may experience a wide range of diseases and opportunist infections • A person HIV positive can stay from 2 to 10-15 years before having CD4 below the HIV vs threshold and thus developing symptoms AIDS • AIDS when a) CD4 count drop below 350 cell/mm3; b) The infected person shows symptoms mainly due to opportunist infections, such as TB • Only specific fluids (blood, semen, vaginal secretions, and breast milk) from an HIV-TRANSMISSION infected person can transmit HIV • These specific fluids must come in contact with a mucous membrane or damaged tissue or be directly injected into the blood-stream for transmission to possibly occur • No curative treatment and no vaccine • Antiretroviral (ARV) drugs: When these drugs are given to patients, their viral load TREATMENT decreases and their CD4 cell counts increase • ARV drugs are never given one at a time, but always in combination, thus “therapy” • ART stands for Antiretroviral Therapy. All patients with CD4 <350cells/mm3 should be treated 4
    5. 5. What is TB & linkages with HIV • Tuberculosis (TB) is caused by a bacterium called Mycobacterium Tuberculosis. TB • The bacteria usually attack the lungs • Not everyone infected with TB bacteria becomes sick. As a result, two TB-related conditions exist: latent TB infection and TB disease DISEASE • Latent infection: TB bacteria can live in the body without making you sick • Disease: TB bacteria become active because the immune system cant stop them from multiply • TB is spread through the air from one person to another trough sneezes, speaks, or sings.TRANSMISSION People nearby may breathe in these bacteria and become infected TB and HIV • For people whose immune systems are weak, especially those with HIV infection, the risk of developing TB disease is much higher than for people with normal immune systems • TB disease can be treated by taking several drugs, usually for 6 to 9 months • Directly Observed treatment Short Course (DOTS) is an internationally recommended comprehensive approach to TB control, used since 1995. It is five-point package to; I) TREATMENT Secure political commitment with adequate and sustained financing II) Ensure early case detection, and diagnosis through quality-assured bacteriology III) Provide standardized treatment with supervision, and patient support IV) Ensure effective drug supply and management and, V) Monitor and evaluate performance and impact 5
    6. 6. GLOBAL SUMMARY AIDS EpidemicNumber Total 34.2 million [31.8 million-35.9 million]of PLHIV Adults 30.7 million [28.6 million-32.2 million] Adults and children estimated to be living with HIV |2011 Women 16.7 million [15.7 million-17.8 million] Children1 3.4 million [3.1 million-3.9 million]People Total 2.5 million [2.2 million-2.8 million]newlyinfectedwith HIV Adults 2.2 million [2.0 million-2.4 million]in 2011 Children1 330000 [208 000-380 000]AIDS Total 1.7 million [1.6 million-1.9 million]deaths in2011 Adults 1.5 million [1.3 million-1.7 million] Children1 230 000 [2000 000-270 000] UNAIDS epidemiology, 20121. Children < 15 years old 6
    7. 7. GLOBAL SUMMARY ART Coverage Eligibility for antiretroviral therapy versus coverage, low- middle-income countries, by region, 2011 7UNAIDS, together we will end AIDS, 2012
    8. 8. What is Malnutrition • A state in which the physical function of an individual is impaired to the point where he or she can no longer maintain adequate bodily performance processes such as growth, pregnancy, lactation, physical work, and resisting and recovering MALNUTRITION from disease • Malnutrition is a broad term commonly used as an alternative to undernutrition but technically it also refers to overnutrition (overweight and obesity) • It occurs as low body weight, short stature, micronutrient deficiencies, low birth- weight and suboptimal breastfeeding practicesUNDERNUTRITION • For HIV and other infections (such as TB) undernutrition is the commonest form of malnutrition observed. In particular: low body weight, weight loss, micronutrients deficiencies that affect immune system • They are used to assess low body weight • In Children are mostly used Weight for Height (W/H) & Mid-Upper Arm Circumference (MUAC)ANTHROPOMETRIC MEASUREMENT • For PLW it is used MUAC • For Adult Man & Non-pregnant Women it used Body Mass Index (BMI) that it is calculated by taking a persons weight and dividing by their height squared Formula: weight (kg)/ [height (m)]2 8
    9. 9. HIV & Malnutrition & WHY FOCUS ON NUTRITION Vicious cycle 2 3 To increase To faster weight immune system gain strength 1 To balance nutrients loss 4 To improve treatment outcomes & effectiveness 5 To improve treatment access and adherence 9
    10. 10. Tuberculosis & Malnutrition & WHY FOCUS ON NUTRITION Vicious Cycle • Reduced appetite, ability to take food and increase loss of weight • Reduce ability of body to absorb nutrients To faster weight gain • Reduced access to food due to morbidity/low productivity & balance nutrient • Increased nutritional needs through metabolic changes loss 2 Tuberculosis (TB) MalnutritionTo improve treatment effectiveness and To increase faster treatment immune system1 success strength 3 • Weakens the immune system, this increase likelihood of progression from latent infection to active disease • Increased risk of mortality for those with low BMI (on treatment) • Impair adherence to treatment and may compromise access to treatment 4 To improve treatment access and adherence 10
    11. 11. Benefits of good nutrition for PLHIV and their familiesExample of the crucial role of food and nutrition support in the success of the treatment 11
    12. 12. What is Food Insecurity FOOD INSECURITY • A situation in which household members lack stable, secure access to sufficient amounts of safe and nutritious food for normal growth and development and an active and healthy life • Food security comprises three elements: availability ,access and utilization • Amount of food that is physically present in a country or area through all forms AVAILABILITY of domestic production, commercial imports and food aid. • Households ability to regularly acquire adequate amounts of food through a ACCESS combination of their own stock and home production, purchases, barter, gifts, borrowing or food aid. • It refers to: (a) households’ use of the food to which they have access, and (b) UTILIZATION individuals ability to absorb nutrients – the conversion efficiency of food by the body 12
    13. 13. HIV, Tuberculosis & Food Insecurity & WHY FOCUS ON IT Vicious Cycle • Reduced utilization of food due to loss appetite, ability to take food and reduced metabolism Mitigate the affect • Reduced access to food due to morbidity/low productivity of HIV & TB on • Reduced productivity and out-put including non-food households 2 Food Insecurity Availability Tuberculosis (TB) Increase food access & 1 Accessibility HIV/AIDS Utilization • Weakens the immune system, this increase likelihood of progression from latent 3 Reduce coping infection to active disease mechanism • Increased livelihood of engage in irreversible, negative coping mechanism • Prevent people from seeking a diagnosis and/or initiating and adhering treatment 4 13 Increase treatment adherence and outcomes
    15. 15. UNAIDS Cosponsor Joint Outcome Framework Division of labour area Convener (s) Reduce sexual transmission of HIV World Bank cosponsors UNFPA Prevent mothers from dying and babies from becoming infected WHO HIV UNICEF Ensure that PLHIV receive treatment WHO Prevent PLHIV from dying of tuberculosis WHO Protect drug users from becoming infected with HIV and ensure UNDOC access to comprehensive HIV sensitive for people in prisons and other closed settings Empower men who have sex with man, sex workers and UNDP transgender people to protect themselves from HIV infection and UNFPA fully access antiretroviral therapy Remove punitive laws, policies, practices, stigma, and UNDP discrimination that block effective responses to AIDS Meet the HIV needs of women and girls and stop sexual and UNDP gender-based violence UNFPA Empower young people to protect themselves from HIV UNICEF UNFPA Enhance social protection for people affected by HIV UNICEF World Bank Address HIV in Humanitarian emergencies UNHCR WFP Integrate food and nutrition within HIV response` WFP Scale up HIV workplace policies and programmes and mobilize the ILO private sector Ensure high-quality education for a more effective HIV response UNESCO Support strategic, prioritized and costed multisectoral national World Bank AIDS plans 15
    16. 16. WFP 2011 HIV/TB Operations OverviewOPERATIONS # of Countries 38 BENEFICARIES Total beneficiaries: 2,259,200OVERVIEW OVERVIEW with HIV/TB project HIV2: 1,196,570 C&T beneficiaries: 1 # of HIV/TB project 51 TB : 209,965 1, 406,535 # of HIV/TB Emergency 4 HIV: 228,269 M&SN project in Recovery 27 beneficiaries: context of: TB: 260,658 852,665 Development 20 OVC: 363,738 1 Under HIV are included both ART and PMTCT beneficiaries 2 Under C&T are included clients and their households 16
    17. 17. WFP 2011 HIV/TB Programmes by Region ODCRegion Beneficiaries No. of 1% Countries ODDODJ/N 6%South-East 1,504,561 16 ODPAfrica 12%ODB 309,899 6Asia ODBODP 14% 277,215 3 ODJ/NLAC 67%ODD 135,870 12West AfricaODCMiddle East 31,655 1 Beneficiaries by Region 17
    18. 18. WFP Global Contribution to HIV Countries with Highest HIV prevalence rate Countries with 25 Highest HIV Prevalence Rates Rank Country HIV Prevalence Rank Country HIV Prevalence 1 Swaziland 25.9 14 Gabon 5.2 2 Botswana 24.8 15 Equatorial Guinea 5.0 3 Lesotho 23.6 16 CAR 4.7 4 South Africa 17.8 17 Nigeria 3.6 In 2011, WFP worked in 64% (16) 5 Zimbabwe 14.3 18 Chad 3.4 of the 25 countries 6 Zambia 13.5 18 Rep. of Congo 3.4 with the highest 7 Namibia 13.1 18 Cote d’Ivoire 3.4 HIV prevalence rates 8 Mozambique 11.5 21 Burundi 3.3 9 Malawi 11.0 22 Togo 3.2 10 Uganda 6.5 23 Bahamas 3.1 11 Kenya 6.3 24 Rwanda 2.9 12 Tanzania 5.6 25 Guinea-Bissau 2.5 13 Cameroon 5.3 25 Djibouti 2.5Countries in blue, bold italic had WFP HIV activities in 2011 18
    19. 19. WFP’s Global Contribution to HIV WFP Global Contribution to UNAIDS Priority Countries UNAIDS Priorities countries 31 UNAIDS Priority Countries UNAIDS Priority Countries UNAIDS Priority Countries LesothoBotswana • In 2011, WFP supported HIV andBrazil Malawi TB interventions in 16 out of theCambodia Mozambique 31 UNAIDS Priority Countries Myanmar (52%)Cameroon NamibiaChina NigeriaCongo DR Russian Federation • However, in 2011, WFP supportedDjibouti 38 countries with 51 HIV and TB RwandaEthiopia projects South AfricaGuatemala SwazilandHaiti Thailand • WFP provided assistance toIndia Uganda approximately 5.8 % of theIndonesia 6,650,0001 people receiving ART UkraineIran Tanzania in low and middle incomeJamaica Zambia countries in 2011Kenya ZimbabweCountries in blue, bold italic have HIV activities.1 Global HIV/AIDS response-Progress report 2011 (WHO, UNAIDS, UNICEF) 19
    20. 20. WFP Global Contribution to TB WFP’s Countries with Highest TB incidence rate Global Contribution: TB Countries with 26 Highest TB Incidence Rates 1 Ran Country TB Rank Country TB Incidence k Incidence per 100,000 1 1,287 14 455 Swaziland Togo 2 981 15 436 South Africa Cambodia 3 682 16 384 Sierra Leone Myanmar 4 633 17 372 Zimbabwe Congo In 2011, WFP worked 5 633 18 370 Lesotho Kiribati in 56% (14) of 26 19 Democratic 345 countries with the 6 620 Djibouti Peoples Republic of Korea highest TB incidence 7 603 Namibia 20 337 rates 8 553 Mauritania Gabon 21 334 Guinea 9 544 Mozambique 22 327 Congo DR 10 503 Botswana 23 CAR 319 11 502 24 304 Marshall Islands Angola 12 498 25 Papua New 303 Timor-Leste Guinea 13 462 26 298 Zambia Kenya Countries in bold italic had WFP TB activities in 20111 and 20
    21. 21. WFP’s Global Contribution: TBWFP Global Contribution to TB WHO Stop TB Plan II Priority Countries (2)WHO Stop TB Plan II Priority Countries Country 1 Afghanistan 2 Bangladesh 3 Brazil 4 Cambodia 5 China 6 Congo DR 7 Ethiopia 8 India In 2011, WFP supported TB programming in 8 9 Indonesia 10 Kenya out of the 22 WHO TB Priority Countries (36%) 11 Mozambique 12 Myanmar 13 Nigeria 14 Pakistan 15 Philippines 16 Russian Federation 17 South Africa 18 Thailand 19 Uganda 20 Tanzania 21 Viet Nam 22 Zimbabwe 21
    23. 23. Partnerships WFP’s Role in HIV in EmergenciesWithin Joint Outcome Framework andDivision of Labour (2010): WFP is co-convenor with UNHCR to address HIV in Humanitarian emergencies 23
    24. 24. IACS guidelines HIV in Humanitarian Settings Issued In 2004 by the Inter-Agency Standing Committee (IACS) Assist humanitarian and AIDS organizations to plan the delivery of a minimum set of HIV prevention, Purpose treatment, care and support services to people affected by humanitarian crises Target Mid-level programme planners and implementers from Audience agencies involved in providing humanitarian assistance The tool is generic and can be applied to any Use humanitarian setting in different epidemic scenarios 1.HIV awareness;2.Health;3.Protection;4.FoodMultisectoral security, nutrition and livelihood;5. Education 6. Shelter; response 7.Camp coordination and Camp management; 8.Water sanitation and hygiene; 9. HIV in the workplace 24
    25. 25. IASC guidelines HIV in Humanitarian Settings Key sectors in humanitarian plan: 1 HIV awareness raising and community support 2 Health 3 Protection 4 Food Security, nutrition and livelihood support 5 Education 6 Shelter 7 Camp coordination and camp management 8 Water, sanitation and Hygiene 9 HIV in workplace For each of these sectors essential actions need to be taken in response to humanitarian crises in two different phases: I) Early stages of any emergencies (minimum initial response) II) expanded response 25
    26. 26. Example of action framework Food security, nutrition and livelihoodSector: Food security, nutrition and livelihood support Preparedness Action Initial Response Expanded Response sheet titlePreposition supplies in the country and at 1. Ensure food Target and distribute food assistance to Adapt agricultural methods andregional hubs security, HIV-affected communities and households build capacity nutrition and Integrate HIV into existing food assistance Provide appropriate relief inputsDetermine criteria for food assistance to livelihood and livelihood support programmes and and training to vulnerable andaffected individuals and communities support food security, nutrition and livelihoods in affected households to HIV projects and activities restore/rebuild livelihoodsDevelop agreement on procurement of stocks,transport and distribution of commodities Introduce specific measures to Adapt food distribution rations protect/adapt the livelihoods of HIV- for hyperendemic settingsTrain staff and partners on (a) integration of affected households and supportHIV interventions in food and nutrition homestead food productionprogrammes and (b) integration of foodsecurity, nutrition and livelihoods skills insupport of PLHIV and OVC 2. Provide Ensure adequate nutrition and care for Expand nutrition and care nutritional vulnerable PLHIV programmes for PLHIVIntegrate HIV proxy indicators (household support to Respond to the specific needs of Integrate nutritional supportheaded by children or elderly, presence of a PLHIV pregnant and lactating women living with with other serviceschronically ill person in a household) into food HIV and their children Strengthen the capacity of PLHIVsecurity and vulnerability analyses and those on ART to provide for their nutritional needs 26
    27. 27. Coordination of the HIV response In Humanitarian Settings UN Country Team, under UN Resident coordinator, activates in Coordination coordination with the Government the cluster approach to when cluster is coordinate the humanitarian response. UNAIDS Country activated Coordinator is part of the Humanitarian Country Team and has a role to ensure link between humanitarian response and existing pre-crisis HIV coordination mechanisms and programming capacity in the country UNAIDS Country Coordinator should seek guidance from the UN Coordination resident Coordinator/Humanitarian Coordinator on the when cluster is humanitarian coordinator mechanism in place and should not activated ensure appropriate linkages between the humanitarian coordination mechanism and UN Joint Team on AIDS and the National AIDS programme 27
    28. 28. Coordination of the HIV response In Humanitarian Settings HIV should be integrated into all the following actions A B Resource mobilization: C Needs assessment and Preparedness, contingency information management: planning and early recovery: a) Inclusion of HIV into flash and Emergency–specific needs all key humanitarian and HIV consolidates appeals like CERF; b) should be integrated and actors should integrate HIV in reprogramming regular HIV funds assessed into all sectoral initial all plans and activities from form bilateral donors and GF; c) rapid assessments to determine preparedness and contingency Allocating existing funds for HIV the scale and the type of planning to the humanitarian response; assistance needed d)mainstream HIV programming within other proposal for funding WFP focal point should work with the Country Team to ensure HIV as well Food & Nutrition support are captured within the needs assessments, contingency plan and resource mobilization 28
    29. 29. WFP HIV Strategy fitted in Humanitarian settings Cote d’Ivoire: WFPsupport malnourished Horn of Africa: WFPART clients in areas of Food and Nutrition strategy in support tocountry most affected malnourished ART and by displacement due HIV settings TB clients has been to political turmoil integrated into the TSFP HIV-SPECIFIC INTERVENTIONS 1 2 Care & Treatment Mitigation & Safety Nets • Malnourished ART, TB-DOTS and • Food insecure HH affected by PMTCT Clients HIV/TB (HH of ART, TB-DOTS pre- • Sometimes HH members ART, PMTCT clients and OVC) Ethiopia: Training to 3 decentralised government officials to ensure Food for Nutrition: familiarity to HIV and thus General Food asset/Food for Targeted guarantee appropriate HIV School feeding Distribution work/Food for Supplementary response in areas hosting trainings Feeding refugeesIn DRC and South Sudan,where it is uncertain HIV HIV-SENSITIVE INTERVENTIONS impact, WFP offered support to extremely 4 vulnerable population, Enabling environment: ensuring sensitivity to HIV/AIDS issue advocacy/advisor role to government and collaboration with stakeholders 29
    31. 31. OVERVIEW CORPORATE CHANGES between 2010-2011 HIV and AIDS POLICY 1 2 2010 PROGRAMME CATEGORY REVIEW In 2010, a new WFP In the 2010 programme HIV and AIDS policy category review session has been approved. of the Executive Board2 attention was called to Two main pillars have been the need for a clearer link0 outlined between programme category and Strategic Objectives (SO)10 HIV/TB PROGRAMMING REVIEW Previous the 2010 Programme category review all HIV and TB activities were classified under SO4. With the closer link established between programme category and SO, HIV and TB activities have been added to SO1 and SO3, as well 3 STRATEGY RESULT FRAMEWORK REVIEW HIV &TB M&E FRAMEWORK REVIEW2 In 2011, the 2008-2013 SRF has been revised to Based on the new SRF, a new HIV and TB M&E0 translate its mandate and strategy into tangible outcomes by linking the five SOs with specific framework has been designed and corporate and project specific outcomes introduced. HIV &TB1 corporate outcomes and outputs, measured by M&E guidelines finalised and shared indicators 311
    32. 32. WFP HIV and AIDS POLICY HIV and AIDS POLICY In 2010, a new WFP HIV and AIDS policy has been approved While continuing to affirm the importance of safety nets in mitigating the effects of HIV, the new policy places stronger emphasis on good nutrition as a critical part of any HIV and TB regimen The Policy outlines two main pillars: 1. Care and Treatment: Ensuring nutritional recovery and treatment of individual 2. Mitigation and Safety Nets: Mitigating the effects of AIDS on individuals and households 32
    33. 33. HIV &TB Programme Pillars The Policy outlines two programme pillars 1 2 Mitigation & Care & Treatment Safety nets Ensuring nutritional Mitigating the effects of recovery and treatment AIDS on individuals and households Intervention Target Duration • Nutritional assessment, education and counselling • NAEC for all infected • NAEC throughout the (NAEC), including infant feeding treatment (TB)/life (HIV)Treatment, Care and • Specialised food products for nutritional • For all malnourished on • Food nutritional recovery Support rehabilitation treatment usually 6 months (Curative) • Finite income transfer in the form of food , voucher • Households of • For duration of client support or cash (conditional to the above) malnourished client (Curative) • Finite income transfer in the form of food , voucher • Affected household • Until indicators of foodMitigation or cash security improved& Safety Net • Finite income transfer in the form of food, voucher • Affected household • Based on need, may be (Enabling/ or cash for household hosting orphans and hosting orphans and longer termPreventative) vulnerable children vulnerable children • HIV/TB-sensitive safety nets • All • Long-term 33
    34. 34. Pillar one: Care & treatment Intervention Target Duration • Nutritional assessment, education and counselling • NAEC for all infected • NAEC throughout the (NAEC), including infant feeding treatment (TB)/life (HIV) Treatment, A Care and • Specialised food products for nutritional • For all malnourished on • Food nutritional recovery Support rehabilitation treatment usually 6 months (Curative) • Finite income transfer in the form of food, voucher • Households of • For duration of client support or cash (conditional to the above) malnourished client (Curative) A NAEC is provided to all clients regardless the nutrition status. It is composed of: • Nutritional assessment- the client’s nutritional status (anthropometric measurements) and dietary practices are investigated and reviewed • Nutritional Education- It include peer education, provision of information, education and communication (IEC) materials • Nutritional Counselling-Advices/suggestions are provided to any single client based on the medical status on simple lifestyle changes on diet, exercises, health living in order to manage metabolic changes and treatment side effects 34
    35. 35. Pillar one: Care & treatment Intervention Target Duration • Nutritional assessment, education and counselling • NAEC for all infected • NAEC throughout the (NAEC), including infant feeding treatment (TB)/life (HIV) Treatment, Care and • Specialised food products for nutritional • For all malnourished on • Food nutritional recovery Support rehabilitation treatment usually 6 months (Curative) B • Sometimes, finite income transfer in the form of • Household of • For duration of client support food, voucher or cash (conditional to the above) C malnourished client (Curative) B • Specialised Food products is only for those clients found to be malnourished during the nutritional assessment • They receive a nutritional supplement, usually composed of fortified blended food ration integrated with salt and sugar • It is a short term intervention aimed to rehabilitated from malnutrition, thus it is provided until the client reaches specific anthropometric target with a maximum of 6-8 months C • Income transfer (food, vouchers or cash) sometime, it is provided to the client’s households: • It is conditional to the client’s support and will last until the client is discharged • Income transfer should be designed either as a incentive or to complete the household’s members diet 35
    36. 36. Pillar one: Care & treatment Clinical process 36
    37. 37. HIV &TB Programme Pillars The Policy outlines two programme pillars 1 2 Mitigation & Care & Treatment Safety nets Ensuring nutritional Mitigating the effects of recovery and treatment AIDS on individuals and households Intervention Target Duration • Nutritional assessment, education and counselling • NAEC for all infected • NAEC throughout the (NAEC), including infant feeding treatment (TB)/life (HIV)Treatment, Care and • Specialised food products for nutritional • For all malnourished on • Food nutritional recovery Support rehabilitation treatment usually 6 months (Curative) • Finite income transfer in the form of food , voucher • Households of • For duration of client support or cash (conditional to the above) malnourished client (Curative) • Finite income transfer in the form of food, voucher • Affected household • Until indicators of foodMitigation or cash security improved& Safety Net • Finite income transfer in the form of food, voucher • Affected household • Based on need, may be (Enabling/ or cash for household hosting orphans and hosting orphans and longer termPreventative) vulnerable children vulnerable children • HIV/TB-sensitive safety nets • All • Long-term 37
    38. 38. Pillar two: Mitigation & Safety Nets Intervention Target Duration C • Finite income transfer in the form of food , voucher • Affected household • Until indicators of food or cash security improvedMitigation & Safety Net • Finite income transfer in the form of food, voucher • Affected household • Based on need, may be (Enabling/ or cash for household hosting orphans and hosting orphans and longer termPreventative) vulnerable children vulnerable children • HIV/TB-sensitive safety nets • All • Long-term D C• This intervention support households affected by HIV or TB that also exhibit other vulnerabilities such as food insecurity and asset depletion, including households hosting OVC • It is a temporary relief intervention during the acute stage of disease for clients receiving care and treatment • It is should be designed according to food security needs, including food availability, access and utilization • Households are targeted based on food insecurity information D All the interventions should be linked to livelihood promotion activities such as Food for • Assets (FFA), Food for training, Food for Work, Income generating Activities (IGA) to ensure economic/productive recovery and long term adherence 38
    39. 39. 2010 Programme Category Review & Strategic Objectives Programme Category Strategic Objective EMOP SO1 PRRO SO3, sometime SO1 CP and DEV SO4 Cross-Cutting SO2 and SO5 Strategic Objective 1: Save lives and protect livelihoods in emergencies Strategic Objective 2: Prevent acute hunger and invest in disaster preparedness and mitigation measures Strategic Objective 3: Restore and rebuild lives and livelihoods in post-conflict, post-disaster, or transition situations Strategic Objective 4: Reduce chronic hunger and undernutrition Strategic Objective 5: Strengthen the capacities of countries to reduce hunger, including through hand-over strategies and local purchase 39
    40. 40. The 2010 Programme Category & the HIV/TB programming REVIEW Before After 2010 2010 Following the programme categories review, ODXP successfully advocated to include HIV and TB activities also to SO1 and SO3Previous to the PROGRAMME STRATEGIC HIV&TBprogramme CATEGORY OBJECTIVES PROGRAMMEcategory EMOP SO1 Care & Treatmentreviewsession: all HIVand TB SO3, sometime Care & Treatment PRROactivities were SO4 Mitigation &Safety Netclassifiedunder SO4 CP/DEV Care & Treatment SO4 Mitigation & Safety net 40
    41. 41. Workflow of outcomes From shock to development In an emergency context In a recovery/transition context In a development context (EMOP): (PRRO), HIV/TB activities should (CP/DEV) allows for a longer- be focused on: term focus, HIV/TB activities Food assistance has a role can concentrate on: in stabilizing and • Nutritional recovery of maintaining access to clinically malnourished ART • Nutritional recovery of treatments by preventing and TB clients for improved malnourished ART and TB default treatment adherence and a clients return to a productive life • Improve adherence to ART • To prevent the adoption of or TB treatment success negative coping strategies and the deterioration of • Support food insecure productive assets of households affected by HIV households affected by HIV or TB, including OVC or TB, including OVC 41
    42. 42. ‹#›
    43. 43. ‹#›
    45. 45. Step I Context analysis Fist of all, it is crucial to define the CONTEXT CATEGORY, thus if we are in • Emergency • Transition phase • Development context1. Know your epidemic • Describe HIV & TB epidemiology (HIV and TB prevalence, incidence; HIV/TB co- infection, etc.) • Distinguee between concentrated and generalised HIV epidemic • Describe the HIV underlying determinants2. Know your national ART and TB treatment coverage and outcomes • Describe the ART and TB coverage • Provide information on adherence, default rate, TB treatment success, etc. • Describe the factors that hinder or facilitate ART and TB treatment access and success3. Know the food security and malnutrition levels in your context • Provide information on food insecurity, poverty levels, malnutrition rates, etc. • Provide geographically distribution of food security4. Describe the linkages • Linkages between malnutrition and HIV and AIDS • Linkage between HIV and AIDS and food insecurity 45
    46. 46. Step 2 National Framework- Policy and Capacity1. Describe National Policy Context • Indicate the presence of HIV National Policy Context • Indicate the presence of Nutrition Policy including HIV information • Indicate the presence of Nutrition Guidelines and if integrated with HIV2. Describe the extent of implementation of national strategy and level of funding outcomes • Provide information on the programmes implemented national wide by the Government and other partners • Provide information on the financial situation3. Describe the presence of co-ordination mechanism & key stakeholders • Indicate the presence of any national and/or UN HIV and TB co-ordination body • Define key stakeholders and their roles within the HIV&TB framework4. Outline WFP participation within the HIV and TB framework • WFP roles within the national framework • WFP participation within the UN Joint Country Team on HIV 46
    47. 47. Step 3 Identification of strategy and target Care & treatment Mitigation & Safety netAlso Know Rehabilitation of moderate malnourished ART Household (HH) support for ART/TB/PMTCT/OVC and/or TB clientsPurpose Improve health and/or treatment outcomes in Support affected by HIV/TB that exhibit vulnerabilities clients who are malnourished (food insecurity, asset depletion, etc.)Clients served Individual targeting based on nutritional status HH targeting based on food insecurity dataTargeting ART, TB, PMTCT, pre-ART clients and sometimes HH of ART, TB, PMTCT, Pre-ART clients and OVC their households (HH)Entry Criteria Undernutrition/Anthropometric screening Food insecurityExit Criteria & Until client reaches specific anthropometric target Until food security indicators improves or limitedduration with a maximum duration of 6 months or 8 timeframe of 6 months or 12 months months for TB clientsClient ration Energy-dense food commodities (FBFs or RUFs) N/AHousehold HH support is conditional to client’ s support and HH support contributes to HH food access, incomesupport will last up to client’s discharge. This support seen transfer, asset protection, reduction in adoption of risky as income transfer and an enabler for treatment behaviours, and is an enabler to improve participation in services (school, training, PMTCT, etc.)Family ration If provided it should be designed either as an It should be designed according to food security needs incentive or to complement the HH’s members including food availability and access, food utilization, diet to meet daily requirements dietary diversity, nutritional balance, etc.Complementary Nutritional education & counselling- throughout Linkages with livelihood activities, such as FFA, FFT, IGAactivities the program for clients in order to ensure economical/productive recovery and Equipment, time and capacity building long term adherence 47
    48. 48. EXAMPLE: “AMBROSIA” Country Understand Country Context Understand country context Ambrosia: Development context 1 2 Context analysis National Framework HIV EPIDEMIOLOGY NATIONAL STRATEGIES • 1.8% HIV prevalence (14-49 year) • Nutrition identified as critical element for • Higher prevalence in Northern (3%) and HIV treatment in the National Strategic Eastern regions (4%) Plan (NSP) on HIV and AIDS • 35% ART Coverage • Ghana Health Service National developed • 40% default rate a nutrition protocol for PLHIV • 23% HIV/TB co-infection • Government provides free access to ART POVERTY & FOOD INSECURITY PARTNERSHIP • 135 out of 187 countries in the UNDP • UNICEF/WFP assisting MAM PLW and Human Development Index Children under MCHN (activity sensitive to • About 16.3% of HIV-affected households HIV) are food insecure and 32% classified as Vulnerable to food insecurity 3 Identifying needs and gaps 48This case study is not based on a real situation, the information is hypothetical and has been added to better illustrate explain how to design a programme
    49. 49. EXAMPLE: “AMBROSIA” Country GAP ANALYSIS & IDENTIFICATION OF STRATEGY Understand country context 1 2 Understand Context analysis national response 3 Identification of needs and gaps GEOGRAPHICAL DISTRIBUTION High HIV in Northern and Eastern regions CURRENT INTEVENTIONS & PARTNERSHIP (4%) Lack of interventions aimed to support adults HIV/TB & FOOD INSECURITY on ART and/or TB treatment • High default rate • HIV-affected HHs are food insecure Describe your strategy GEOGRAPHICAL COVERAGE PROPOSED INTERVENTIONS Northern and Eastern regions • DEV project • C&T for malnourished ART and TB clients TARGET (no PMTCT because covered under MCHN) • Malnourished ART and DOTS clients and their HH (HH size of 5 members) • Food insecure HH • M&SN for HH affected by HIV based on food insecurity level 49
    50. 50. Step 4 Definition of beneficiaries Definition of Beneficiaries An individual who is entitled to WFP food at distribution site, either on- Index Client site consumption or as a take-home ration A social unit composed of individuals, with family or other social relations among themselves, eating from the same pot and sharing a Household common resource base Household of ART, TB, pre-ART and PMTCT clients entitled to food Household of assistance either under C&T (conditional to client’s support) or M&SN clients (to compensate for lost income and as enabler to improve participation). The household size average is estimated of 5 members Household of Household hosting Orphans and Vulnerable Children likely due to OVC HIV/AIDS and/or TB. The household size average is estimated of 5 members 50
    51. 51. Step 4 Estimation of client caseload Use the information collected to estimate the new caseload, bearing in mind If the programme potential variations which might affect the programme such as geographically already in place re-orientation, food insecurity, roll out strategies, etc. If targeting is: Malnourished PLW with HIV or TB • Estimated population of pregnant and lactating women of children under 6 months of age * Estimated HIV or TB prevalence in this group (if not available use HIV If it is new or a prevalence in child-bearing age women) * Estimated of PLW on ART or DOTS treatment * Malnutrition prevalence for this group (if not available use a proxy from reviewed other country or international publication) programme Malnourished Man or Malnourished Women or Malnourished Children with HIV or TB • Estimated population of women or man or children * Estimated HIV or TB prevalence in this group * Estimated on ART or DOTS treatment * Estimated malnutrition prevalence for this group (if not available use a proxy from other country or international publication) Caseload = Population * HIV or TB Prevalence * Treatment coverage * Malnutrition prevalence 51
    52. 52. Step 4 Estimation of household caseload HH support is conditional to the malnourished client, thus : Household • the number of HH correspond to the number of malnourished clients support in C&T • the number of household’s members is calculated normally multiplying the number of clients by an average of five members per HH HH support is based on food insecurity data Estimated number of beneficiaries of HH affected by HIV/TB, hosting ART, DOTS and PMTCT clients • [Estimated population in target geographical zone* Estimated HIV or TB prevalence in this group * Estimated on ART or DOTS treatment * Food insecurity rate in this group (if not available food insecurity in general population)]* Average of HH size (usually 5 members) Household HIV/TB HH members caseload = (Population * HIV or TB prevalence * Treatment support in coverage * Food insecurity) * Size of HH M&SN- Estimated number of beneficiaries of HH affected by HIV/TB, hosting OVC • Estimated population in target geographical zone* Estimated OVC prevalence * Food insecurity rate in this group (if not available in general population)* Average of HH size OVC HH members caseload = (Population * OVC prevalence * Food insecurity) * Size of HH 52
    53. 53. Step 5 Ration design • SUPERCEREAL, oil & • SUPERCEREAL, oil & sugar • FOOD BASKET sugar (INDIVIDUAL) (INDIVIDUAL) • or CASH&VOUCHER • Adult ART, TB and PMTCT • + FOOD BASKET or • (HH members, including malnourished clients CASH&VOUCHER clients) (CLIENT HH MEMBERS) Care & treatment – INDIVIDUAL +HH SUPPORTCare and Treatment- INDIVIDUAL ONLY (client) • SUPERCERAL PLUS • Individual ration for client only Mitigation & Safety nets HH SUPPORT ONLY • All ration calculated for 5 HH (Children 6-59 months) • This HH basket is conditional to members, including client the client’s support- calculated • Designed based on Food for average of 5 HH members security data (client included) • Designed based on food security data Ration Nutrients Ration Nutrients Ration Nutrients - profile (Example) profile (Example) profile Supercereal 1 1000-1200 (INDIVIDUAL) 1000-1200 Kcal Maize 160 g 836 Kcal Supercereal 1 200-250 g Kcal 35-45 g protein Supercereal 20g 22 g protein Oil 20-25 g 35-45 g 200-250 g 30-40 g fat Pulses 24 g 14 g fat Sugar 15-20 g protein Oil 20-25 g Oil 10g 30-40 g fat Sugar 15-20 g + + Rice 320 g 1658 Kcal 1 (HH SUPPORT) 1100 Kcal Pulses 50g 44 g protein The ration of Supercereal should be preferably integrated with sugar and oil. Maize 200 g 31 g protein Oil 20g 24 g fat However each CO can decide based on Pulses 60 g 9 g fat Supercereal 40g national situation. Oil 20g 53
    54. 54. Step 6 Design your logframe Programme Corporate Corporate Project Category Strategic & Project Specific (EMOP, PRRO, Objectives Outcomes Specific DEV/CP) Outcomes Indicators Project activities and outcomes should be linked to the relevant WFP Strategic Objectives (SO) and follow the correct programme category per each SO Corporate outcome(s) and indicator(s) corresponding to the SO should be inserted in the logframe. Targets should be set according to the country’s context Additional and optional project specific outcomes and related indicators can be chosen to build up a body of data that provides a more accurate and in depth performance measurement providing a comprehensive picture of the project dynamics 54
    55. 55. Step 6 Design your logframe 55
    56. 56. Resource-constrained Settings How design a Programme In resource constrained settings these steps need further consideration in order to prioritise activities, fine-tune the interventions and thus elaborate a cost efficient technically-sound programme Keys aspects to be addressed • Vulnerability- Identify the most vulnerable subgroup amongst the vulnerable HIV/TB infected TARGET and/or affected population • Geographical coverage- Identify the most vulnerable area for high HIV prevalence, high Food insecurity rate or a combination of both Identified all the activities run in country by partners in order to PARTNESHIP • Avoid overlapping • Define possible linkages with programmes • Synchronize/harmonise the interventions • Encourage when possible short term interventions with clear exit strategy to avoid dependency • Build and ensure linkages to productive safety nets livelihood interventions in order to SUSTANAIBILTY contribute to economic development of local community • Assess the capacity of national entities that might be involved in the implementation in order to ensure feasibility of a correct and effective execution • Explore alternative source of funding and familiarize with different funding mechanism process FUNDING of the main donors in case, in future, WFP is not longer able to support the interventions • Assess the capacity of Government to sustain financially the programme in the future • Assist the Government in resource mobilization process, such as GFATM 56
    58. 58. WFP is the lead agency and responsible for integration of foodand nutrition into HIV responseHIV and/or TB increase nutritional needs of infected individual while decreasing ability oftaking food, absorbing essential nutrients and meeting energy needs required for a strongimmune systemIncreased morbidity and HIV and TB treatment-related costs often impact negativelyhousehold productivity, disposable income and food securityFood insecurity and poverty may create barriers to treatment adherence and retention incare, while malnutrition increases risk of morbidity and mortality among people living withHIV (PLHIV) or infected by TBFood and nutrition (F&N) interventions as critical element of comprehensive HIV response • Nutrition stabilization, improved access and adherence to treatment, reduced morbidity and mortality, effective safety netsAs UNAIDS Cosponsor, WFP is lead agency and responsible for integrating F&N support intoHIV response 58
    59. 59. Food and nutrition (F&N) increasingly considered important element of HIV and TB programming Several organizations advocate F&N interventions increasingly included for F&N in HIV/TB programmes in Global Fund proposals 100% % of funded HIV proposals with F&N 90% component 80% 70% 60% 60% 55% Global Fund PEPFAR WFP 50% 44% 40% 30% 23% 20% 10% 0% UNAIDS WHO FANTA-2 Round 5 Round 6 Round 7 Round 8Sources: Global Fund,; PEPFAR,; WFP,; UNAIDS,; WHO,; FANTA-2, 59; WHO: Analysis of Global Fund Round 5-10. Unpublished
    60. 60. PEPFAR and GF two main funders of global HIV responseInternational assistance to HIV at US$ 8.7 billion in 2009 and US$ 7.6 billion in 2010 Global source of funds for HIV and AIDS Programmes (US$ billion) US$ billion 8 7 6 UNAIDS 5 Clinton Foundation 4 Global Fund (GF) - HIV only) 3 PEPFAR 2 1 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 60Sources: UNAIDS
    61. 61. US$ 9 billion potentially available from Global Fund for preventionand treatment of 3 diseases over next 2 years The Global Fund (GF) attracts and allocates resources to prevent and treat HIV/AIDS, TB, Malaria and support Health System Strengthening • Since 2002 US$ 22.9 billion committed in 151 countries for the three diseases − 55% portfolio for HIV/AIDS programs, 28% malaria and 17% TB The Global Fund • Round 10 (2010) approved grants for US$ 1.7 billion − 40% approved proposals focused on HIV/AIDS programs GF does not implement programmes directly but fund programmes with emphasis in scaling up proven concepts and filling gaps • Programmes¹ should be technically sound, country-specific, evidence-based and aligned with national strategy and capacity Estimated US$ 9 billion potentially available over next years (3 diseases and health system strenghtening) • US$ 8 billion for Phase 2 existing grant re-programming • US$ 1 billion for new funding mechanism - to be launched in Q4 2012 61(1) Typical grant duration of 5 years – Phase 1 lasts 2 years and Phase 2 lasts 3 years
    62. 62. F&N interventions can be included in new GF proposal or during grantre-programming (Phase 2 – Years 3,4,5) Global Fund provides two types of funding opportunities for F&N interventions 1. Call for proposals − Proposal written at country level in a multi-stakeholder process − New funding mechanism under finalization • National strategic plans and/or investments cases as starting point for any request • Countries grouped in bands - funds allocated by band 2. Re-programming of existing grants (Phase 2 – Years 3,4,5) − Grant re-programming can begin 18-24 months after starting implementation When included, F&N component tipically accounts for 5-10% of a new proposal budget − US$ 1-10 million for a 5 years period can potentially be allocated to fund F&N interventions 62
    63. 63. Overview of grant opportunities for ODD countries Status of Global Fund Grants in ODD countries GF grant in Ph. 1 (disease) Opportunity for Reprogramming and for new proposal submission 5 8 9M 17M 7 GF grant in Ph. 2 (round) 10 14M TB 0.7 8 HIV 41M Opportunity for new proposal 7 HSS 12M 1.0 ss 0.8 submission only ss HIV TB TB TB 8M 12M xx US$ million potentially 5/10 8 8M 34M M available in total for grant Reprogramming 63Source of information: The Global Fund
    64. 64. Country-led multi-stakeholder platform leads GF process 4 stages of proposal development and grant implementationNew funding Reprogramming Board approvalmechanism opportunity 1 2 3 4 Technical review (TRP) – Concept note development dialogue based on concept Grant negotiation Grant note implementation National strategy as starting point Technical review panel Final country-level PR and CCM • Independent group of funding amount request for grant GF Secretariat provides guidance on international experts determined renewal after level of funding reviews concept note 18-24 months of CCM (country coordination implementation • TRP determine/approve Concept note mechanism) enters dialogues with in- • Detailed adjusted allocation translated into country stakeholders information on disbursement-ready • Constituted by a multi-stakeholders grant grant renewal partnership process: http://www.the Board approves CCM Secretariat coordinates concept disbursement-ready note development en/activities/re grant newals/ Technical writing group develop concept note for CCM’s review 64
    65. 65. To tap future funding opportunities with Global Fund, critical toinvest time and engage in preparation phase… 1 PHASE 1 – CONCEPT NOTE DEVELOPMENT Lay the ground: prepare tools Active participation in TWG for engagement and national workshops Goal Open doors for F&N Include F&N into GF proposal • Active participation in workshops analysing national A Situational response, gaps and needs to assessment shape proposal priorities What does it mean in B Intervention • Integration and active practice? design participation in technical writing group (TWG) for Global C Stakeholder Fund proposal development collaboration 65
    66. 66. …and to make sure F&N does not drop out last minuteDuring grant implementation, critical to be alert for reprogramming opportunities Reprogramming opportunity 3 4 Grant implementation Grant negotiation Goal Avoid F&N drop out last Be alert on reprogramming minute potential • Maintain close relationship • Maintain relationship with with CCM, TWG and Nutrition CCM structures and coalition members Principal Recipient(s) and Sub-Recipients(s) What does it mean in • Ensure F&N stays in practice? negotiated proposal • Be informed on implementation progress and Re-programming opportunities 66
    67. 67. What tools are already available to WFP RBs, COs and Governmentsto integrate F&N into successful proposals? Available toolkits to develop F&N interventions for HIV response (short selection) WFP manual for stakeholders in the provision of F&N interventions Joint Global Fund info note on F&N for HIV response FANTA-2 and WFP toolkit for integrating F&N in GF grants ( ct2011.pdf) WFP M&E Guide for HIV and TB Programming (2011) oced/wfp235338.pdf WFP’s response to HIV and TB website and knowledge centre ( 67