Food and Nutrition Assistance Programs to  HIV Infected and Affected Individuals                            Rahul Rawat   ...
Rationale for Nutrition Programs    High geographic overlap between HIV prevalence, malnutrition, and     chronic food in...
Nutrition Program Responses HIV services integrating food and nutrition components   −   Food by Prescription        •   ...
Evidence of Impact: Specialized Foods Supplementary feeding to malnourished patients      −    Fortified spread compared ...
Evidence of Impact: Food Assistance   Zambia (Prospective Design)          Pilot study of WFP food supplementation to fo...
Evidence of Impact: Food Assistance     Uganda (Retrospective Evaluation of the TASO database)     TASO electronic monit...
Impact of Food Assistance on Weight Gain                                                Food assistance                Mat...
Impact of Food Assistance on Weight Gain                                                Food assistance                Mat...
Outcomes of Interest in Programs      Individual                                 Household• Disease progression (CD4 count...
Determinants of Nutritional Status among             Uganda HIV-infected Individuals Previous studies consistently show m...
Dietary Diversity, Food Security and                                  Nutritional Status Dietary diversity and HH Food Se...
Summary of Impact of Nutrition Support Improvements in weight, possibly ART adherence No impact on immunological status...
Livelihood Security Programs Livelihoods Programs   −   Objectives are to promote food and livelihood security   −   Prov...
Applying a Program Theory Framework to Examine           Integrated HIV and Livelihood Interventions Critically examined 2...
Operations Research to Examine Livelihoods Programs      Integrated with HIV Care and Treatment           Program theory i...
General Findings Monitoring and evaluation frameworks need strengthening   −   Key process and impact indicators not well...
PEPFAR Conceptual Framework for Food and Nutrition            Support in HIV Services
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Food and Nutrition Assistance Programs to HIV Infected and Affected Individuals

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Presented at RENEWAL’s Satellite Session "Nutrition Security, Social Protection and HIV: Operationalizing Evidence for Programs in Africa" at the XVIII International AIDS Conference. By Rahul Rawat

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Food and Nutrition Assistance Programs to HIV Infected and Affected Individuals

  1. 1. Food and Nutrition Assistance Programs to HIV Infected and Affected Individuals Rahul Rawat Research Fellow Poverty Health and Nutrition Division Regional Network on AIDS, Livelihoods, and Food security (RENEWAL)International Food Policy Research Institute (IFPRI) & Concern Worldwide
  2. 2. Rationale for Nutrition Programs  High geographic overlap between HIV prevalence, malnutrition, and chronic food insecurity; weight loss is a significant prognostic factor of mortality since the beginning of the AIDS epidemic  Despite improved access to ART, malnutrition complicates the provision of care in resource limited settings − low BMI at ART initiation is an independent predictor of early mortality (Zambia, Malawi, Tanzania)  The proposed benefits of early weight gain serve as the theoretical basis for food supplementation programs  Limited evidence of impacts of nutrition interventionsSource: Zachariah et al (AIDS 2006); Johannessen et al. (BMC Infectious Disease 2008); Koethe et al. (JAIDS 2010)
  3. 3. Nutrition Program Responses HIV services integrating food and nutrition components − Food by Prescription • Specialized Food Products (RUFs, FBFs) Food Assistance Programs − Delivery of food baskets (CSB, oil, maize meal, pulses etc.) − Title II, WFP Livelihood Security Programs − Provision of agricultural inputs and training to promote local food production
  4. 4. Evidence of Impact: Specialized Foods Supplementary feeding to malnourished patients − Fortified spread compared vs. CSB Outcome at 14 Fortified Corn Soy Difference weeks Spread Blend (95% CI) Gain in BMI 2.2 (1.9) 1.7 (1.7) 0.5 (0.2 - 0.8) Gain in fat free 2.9 (3.2) 2.2 (3.0) 0.7 (0.2 – 1.2) body mass (kg) Weight gain (kg) 5.6 (4.8) 4.3 (4.0) 1.3 (0.5 – 2.1) − No significant differences in mortality, immunological status, quality of life, or ART adherence − Impacts were not sustained at 12 monthsSource: Ndekha et al. (BMJ 2009); Ndekha et al. (TMIH 2009)
  5. 5. Evidence of Impact: Food Assistance  Zambia (Prospective Design)  Pilot study of WFP food supplementation to food insecure adults initiating ART in ART sites in Lusaka  Food supplementation for 6 months to food insecure patients/HHs had no impact on weight gain or CD4 count  Impact on adherence: 70% of patients in experimental group achieved 95% MPR vs. 48% in control groupSource: Cantrell et al .(JAIDS 2008)
  6. 6. Evidence of Impact: Food Assistance  Uganda (Retrospective Evaluation of the TASO database)  TASO electronic monitoring data system − patients intake registration form; medical visit summaries; counseling visit summaries; ART initiation and other drug use; social support services  Between 2002-2007 TASO had 195,676 registered patients − Database for analysis had 14,481 patients  Examined changes over 12 months for patients and how the receipt of FA influences weight gain and disease progression • Used PSM to match each FA recipient with similar non-FA recipients; uses the outcome of the non-FA recipients as a proxy for the outcome of the FA recipients if they had not received FASource: Rawat et al. (BMC Public Health 2010)
  7. 7. Impact of Food Assistance on Weight Gain Food assistance Matched ATT a Recipients Controls (absolute value of Change in Weight (kg) (n) (n) t-statistic) 0.36 Overall 3202 11069 (3.19)** Conditional estimates 0.48 Without ART 2783 9661 (2.14)* 0.17 With ART 546 1120 (1.5) -0.2 Baseline WHO stage 1 327 1479 (0.55) 0.26 Baseline WHO stage 2 2329 7318 (2.3)* 0.2 Baseline WHO stage 3 615 1807 (1.8)+ 1.9 Baseline WHO stage 4 58 129 (1.9)+ ** significant at 1% ; *significant at 5% ; + significant at 10% a Absolute value of t-statistics on ATT, in parentheses, are based on bootstrapped standard errorsSource: Rawat et al. (BMC Public Health 2010)
  8. 8. Impact of Food Assistance on Weight Gain Food assistance Matched ATT a Recipients Controls (absolute value of Change in Weight (kg) (n) (n) t-statistic) 0.36 Overall 3202 11069 (3.19)** Conditional estimates 0.48 Without ART 2783 9661 (2.14)* 0.17 With ART 546 1120 (1.5) -0.2 Baseline WHO stage 1 327 1479 (0.55) 0.26 Baseline WHO stage 2 2329 7318 (2.3)* 0.2 Baseline WHO stage 3 615 1807 (1.8)+ 1.9 Baseline WHO stage 4 58 129 (1.9)+ ** significant at 1% ; *significant at 5% ; + significant at 10% a Absolute value of t-statistics on ATT, in parentheses, are based on bootstrapped standard errorsSource: Rawat et al. (BMC Public Health 2010)
  9. 9. Outcomes of Interest in Programs Individual Household• Disease progression (CD4 count, • HH food security WHO stage) • Dietary diversity• Nutritional status (BMI, MUAC, • Child nutritional status (<5 yrs) Hb) • Economic activities and• High risk behavior employment• Labor activities • Asset ownership• Quality of life • Expenditure (food & non food)• Disclosure • Agriculture production• Stigma • Credit & savings
  10. 10. Determinants of Nutritional Status among Uganda HIV-infected Individuals Previous studies consistently show malnutrition as a strong predictor of mortality Determinants of malnutrition among PLHIVs are not well established − Do HH characteristics like dietary diversity and food insecurity influence nutritional status, independent of disease progression?
  11. 11. Dietary Diversity, Food Security and Nutritional Status Dietary diversity and HH Food Security are significantly associated with nutritional status (BMI & MUAC), independent of SES, and disease stage (CD4 count) Adjusted Mean BMI 21.5 Δ=0.96 kg/m2; p = 0.008 21 Δ=0.5 kg/m2; p = 0.031 20.5 20 19.5 Low (0-4 Med (5-8 High (9-12 Groups) Groups) Groups) Mean BMI values adjusted for CD4 count, sex, district, HH size, education, income Severely food insecure HHs (Category 4) had 3-times the odds of being malnourished (BMI<18.5 kg/m2; p=0.002)Source: Rawat et al. (in preparation); Kadiyala et al. (in preparation)
  12. 12. Summary of Impact of Nutrition Support Improvements in weight, possibly ART adherence No impact on immunological status Knowledge Gaps − Composition of support − Timing of support • pre ART vs. post ART • role in delaying progression − Pregnant and lactating women vs. OVCs vs. malnourished adults − Exit criteria − Impact on HH level characterisitcs
  13. 13. Livelihood Security Programs Livelihoods Programs − Objectives are to promote food and livelihood security − Provision of agricultural inputs and training to promote rural livelihoods and local food production; promotion of income generating activities • Widely implemented • Questions remain about sustainability and scale-up • Limited documented impact evaluation studies
  14. 14. Applying a Program Theory Framework to Examine Integrated HIV and Livelihood Interventions Critically examined 20 org. implementing livelihood interventions throughout Uganda, implemented by TASO partners Objectives 1. Examine the extent to which livelihood interventions integrated into HIV care and treatment programs (IHLPs), implemented by a wide set of organizations, present coherent and consistent causal pathways to improving food security of people afflicted by HIV 2. Identify critical components of IHLP processes necessary to achieve the intended outcomes 3. Investigate the approaches taken to adequately address the articulated challenges in IHLP processesSource: Kadiyala et al. (JDE 2009)
  15. 15. Operations Research to Examine Livelihoods Programs Integrated with HIV Care and Treatment Program theory identifies the processes by which a program is intended to achieve its impacts Impact Theory Process Theory •Specifies impact pathways •Shows steps by which intervention or program is implemented •Identifies the steps by which a program intervention is expected to •Includes steps related to impact outcomes organizational plan to deliver services •Identifies the hypothesized cause- and-effect pathways that connect a •Also includes assumptions of how program’s activities to its expected and why beneficiaries will actually outcomes utilize a service
  16. 16. General Findings Monitoring and evaluation frameworks need strengthening − Key process and impact indicators not well defined or collected The complex pathways to achieving impact need to be further defined Causal pathways are, in theory, plausible − However, program implementation activities need to be monitored Need to strengthen planning and implementation to integrate livelihood interventions with complementary services Program activities and inputs (material and intellectual) were consistent with, and appropriate to, program objectives − However, there are assumptions about practical implementation
  17. 17. PEPFAR Conceptual Framework for Food and Nutrition Support in HIV Services

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