Presented at the Regional RENEWAL 3 Workshop at the Glenburn Lodge, South Africa.

1. Integrating food and nutrition security
interventions into AIDS care and
treatment: Fostering evidence based
programming
TASO-RENEWAL-WFP- Concern Worldwide and other
food and livelihood program partners

2. 2 Years Ago: RENEWAL 3
Workshop 2007
HIV and Nutrition Security Theme
Working group

3. 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 studies
Source: WHO 2005; Fawzi 204; Moore et al 2006; Zachariah et al 2007; Au et al 2008; and other
sources

4. 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
– Children's education
– Child survival and growth
Source: Gillespie and Kadiyala 2005; Gillespie 2006; Chapoto and Jayne 2007; Yamauchi et al
2007; Kadiyala et al 2009 & other sources

5. 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?

6. Food and nutrition along the HIV timeline
Risk 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

7. 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?

8. 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

9. 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.

10. 1. Utilizing the existing data
How 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 )

11. 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)

12. 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: 200-450
Not 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)

13. Outcomes
Individual 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

14. 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 )

15. RENEWAL-TASO Research Team
IFPRI/RENEWAL Research Assistance Team
• Suneetha Kadiyala
• Rahul Rawat (also CWW) • Mulowooza, Fiona
• Terry Roopnaraine (consultant) • Ssegujja, Eric
• Stuart Gillespie • Kyohangirwe, Rossette
• Achola, Elizabeth
TASO • 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

16. Traditional Evaluation of Impact
Program Implementation
Baseline 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

17. How Programs Operate
Processes
Inputs Outputs Outcomes Impacts
Processes

18. 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

19. 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

20. 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

21. Key Themes Addressed in Service Delivery and
Utilization (Process Theory)
• Necessary client actions to optimize program
benefits
• Necessary program actions to optimize
program impact

22. Emerging Process Theory Results
Client 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

23. 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