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 Pamela Fergusson
2007 Cochrane review Eight trials (486 participants) Significantly No effect improved Energy intake Body weight Protein intake Fat-free mass CD4 countSmall number of participants, no reporting of morbidity or mortality, mostly resource-adequate settingCochrane Database Syst Rev. 2007 Jul 18;(3):CD004536. Nutritional interventions for reducing morbidity and mortality in people with HIV. Mahlungulu S et al
Review: macronutrient supplementation for HIV in resource constrained/adequate settings• BMI <16 = >2X RR of mortality (Malawi, Zambia, Tanzania)• Resource constrained settings: 2 trialsZambia: food insecurity entry, modest improvement in adherence, no difference in weight gain, CD4 count or mortalityMalawi: FBF vs RUFIncrease in BMI and LBM after 3 months in RUF groupno significant differences in survival, viral load, CD4, or quality of lifeAt 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 alJ 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 alBMJ. 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.
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).
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.
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.
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
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
Belief in the importance offood 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
NACS Nutrition To clients who meet criteria at sites where available Support .Nutrition Counseling Periodically to clients at all sitesNutrition Assessment Routinely to all clients at all sites
Integration of Nutrition into National HIV Responses• National Policy and Coordination• Capacity Strengthening• Service Delivery• Information systems and evidence base
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
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
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
Challenges: Linkages between HIV and other services CMAM Antenatal Food and <5 HIV security TB
Integrating with food security programmesGood 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 HIVIssues• Entry and exit criteria• Overlap of target population
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
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