PEPFAR funding was provided by USAID to CRS-Zambia under the SUCCESS Return to Life grant to pilot the Food by Prescription model in Zambia.Technical support provided by National Food and Nutrition Commission of Zambia as well as FANTA.
Before the FBP pilot, ART facilities only offered nutrition services through MCH clinics, specifically targeting under-five children, and facilities had no nutritional programs targeting PLHIV.8 ART clinics (mix of GRZ, mission, mine, private)10 hospices (3 at mission hospitals, 7 stand-alone F/NGO)2 home-based care programs (Diocese)
Time for training – national curriculum is 5 daysTailored trainings – e.g. not all staff used pharmacists to dispense. Most ART clinics adhered to the recommended client flow model using various cadres of staff, and decentralized services within ART outreach programs.HBC programs provided “one-stop” integrated services at parishes supported by household care, but required caregivers with a higher grasp of the technical criteria.Hospices provided FBP integrated into both inpatient and community programs. Community integration had varying success; in some cases M&E documentation greatly suffered.
All sites had been providing ART care and/or treatment since 2005, if not earlier.Training – issue of rotating staff into ART clinic – do you have to train every nurse as a result?
Supply chains:-ART clinics use government supply chains, but government stores does not stock RUTF/HEPS.HBC programs and stand-alone hospices mainly procure their own medications.Cadres:pharmacists, caregivers, stores clerk, nurse
Hospice, HBC and OVC access:they are separate from the government supply chainThere is no access to a national sales outlet.Possible idea: access through clinics. For example, they access VCT reagent-supervision from clinics, and report up through the clinics
Assessment:Initial assessment was visual. Assessment with MUAC and height not routinely done on everyone who walked into the site.Counseling: Not provided to clients, regardless of nutritional status.Smartcare – no place for BMI, W/H z-score score, nutrition counselingDecentralization – Sites insisted. Requires more robust system. ART clinics – proved to be fine. Hospices – community outreach could not keep accurate records.
Benefits of Routine-izeEliminates the “people are hungry” over-estimationBenefit: Assessment data will enable more accurate amount of commodities sent to sitesAssessment tools:Give all your HBC and OVC caregivers MUAC tape.Make height boards standard equipmentEvery nurses station to have a BMI chart
62% of clients in the pilot were admitted with SAM.This woman was visited by adherence counselors at home regularly for months. She was not brought into the ART clinic for FBP until she was at SAM, with BMI of 12. She died before completing nutrition treatment.MonitoringEarly detection of risksEarly detection of MAM before SAMEngagement of community programs
Only 5% of clients were HIV-exposed children between 6-24 months.Catherine was abruptly weaned from breastmilk during the final stages of her mother’s illness, when she was 1 year old, and it was right at the start of the “hunger period” in the community where people only have nshima and pumpkin leaves. She was a classic case of SAM last February.Upon arriving at her auntie’s, she was enrolled in a community OVC program in the catchment area of a FBP program in an ART clinic.The OVC program did not know about food by prescription, and the guardians being HIV-negative also were not aware.Her guardian happens to be my best friend from Peace Corps, and when I went to visit them I immediately sent the guardian with her to the ART clinic.Message: it has to be a national program that everyone knows about. People are falling through the cracks.
Not just another food program:Integrating Food by Prescription into HIV care Elizabeth Jere MPH CORE NACS State of the Art “Getting the Knack of NACS” Washington DC , February 22-23 2012
Food by Prescription Pilot in ZambiaTimeframe: Each site had a matureSept 2008 – March 2010 HIV program. – Embedded routines# served: 5360 clients – No regular nutrition services – Large staffSites: 8 ART clinics, – Little physical space 10 hospices , and – Decentralized 2 home-based care locations programs 2
Integration Issue #1: Busy clinics, with busy staff.+ Integration of NACS services into regular routine worked.+ Some hospices used task-shifting, which had varying success.- Identifying time for staff training in FBP was challenging.- Large number of people to be trained.- Trainings needed to be tailored to reach the different cadres doing same tasks across sites. 3
Issue #1 -> Recommendations Management involvement was a key success factor.• Assess degree of leadership buy-in and supervision structures. Explore opportunities for systematizing NACS skills:• Integration into national policies, guidelines and curricula: IYCN, ART, PMTCT• Pre-service education for (clinical) staff• Integration into HBC and OVC minimum standards, and care curricula• Incorporate into CME (stagger topics over weeks)• Distance learning certification? 4
Integration Issue #2: RUTF and HEPS fall outside the supply chain systems.- Pilot used a stand- alone system for commodities.+ Sites improvised storage.+ Dispensing was managed by different cadres. 5
Issue #2: Recommendations RUTF: • Integration into government medical stores, similar to F-100/F-75. • Ensure packaging doesn’t leak. • How will OVC/HBC/hospice access? HEPS: • Not appropriate for government stores? • Private sector/vouchers? (packaging by dose possible? quality control?) 6
Integration Issue #3: Making NACS routine practice- Assessment was not routine for every client.- Nutrition counseling was not routine for every client, regardless of nutrition status.- Standardized M&E forms did not capture important nutrition indicators.+ FBP services integrated into the decentralized ART services. 7
Issue #3: Recommendations• “Routine-ize” assessment and counseling first, then introduce food• Get assessment tools into facilities.• Advocate for nutrition indicators to be in M&E tools.• Use community programs! 8
What we wish we knew…Suggestions for Operations Research• What is the prevalence of SAM and MAM in HIV-positive adults?• Do pregnant women need a different eligibility cut-off than non-pregnant women?• What does it take to make task-shifting successful?• What in-service training models are most effective to integrate NACS? 9
ConclusionsFocus NACS service delivery toward prevention of malnutrition, and less about treatment. 10
ConclusionsApproachesneed to look atsystemization, rather thantemporary fixesfor time-boundprograms. 11