Food and Nutrition Technical Assistance II Project (FANTA-2)AED 1825 Connecticut Ave NW Washington DC 20009Tel 202-884-8000 Fax 202-884-8432 E-mail fanta2aedorg Website wwwfanta-2org

Integrating nutrition into national HIV policies and

programsExperience from Africa

Pamela Fergusson PhDNutrition and HIV Advisor FANTA-2pfergussonaedorg

Outline

Scientific evidenceCritical reflectionProgrammatic experienceResearch gaps and priority actions

SCIENTIFIC EVIDENCE

2007 Cochrane review Eight trials (486 participants)

Small number of participants no reporting of morbidity or mortality mostly resource-adequate setting

Cochrane Database Syst Rev 2007 Jul 18(3)CD004536 Nutritional interventions for reducing morbidity and mortality in people with HIV Mahlungulu S et al

Significantly improved

No effect

Energy intake Body weight

Protein intake Fat-free mass

CD4 count

Outline

Scientific evidenceCritical reflectionProgrammatic experienceResearch gaps and priority actions

SCIENTIFIC EVIDENCE

2007 Cochrane review Eight trials (486 participants)

Small number of participants no reporting of morbidity or mortality mostly resource-adequate setting

Cochrane Database Syst Rev 2007 Jul 18(3)CD004536 Nutritional interventions for reducing morbidity and mortality in people with HIV Mahlungulu S et al

Significantly improved

No effect

Energy intake Body weight

Protein intake Fat-free mass

CD4 count

SCIENTIFIC EVIDENCE

2007 Cochrane review Eight trials (486 participants)

Small number of participants no reporting of morbidity or mortality mostly resource-adequate setting

Cochrane Database Syst Rev 2007 Jul 18(3)CD004536 Nutritional interventions for reducing morbidity and mortality in people with HIV Mahlungulu S et al

Significantly improved

No effect

Energy intake Body weight

Protein intake Fat-free mass

CD4 count

2007 Cochrane review Eight trials (486 participants)

Small number of participants no reporting of morbidity or mortality mostly resource-adequate setting

Cochrane Database Syst Rev 2007 Jul 18(3)CD004536 Nutritional interventions for reducing morbidity and mortality in people with HIV Mahlungulu S et al

Significantly improved

No effect

Energy intake Body weight

Protein intake Fat-free mass

CD4 count

Review macronutrient supplementation for HIV in resource constrainedadequate

settingsbull BMI lt16 = gt2X RR of mortality (Malawi Zambia Tanzania)bull Resource constrained settings 2 trials Zambia 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 149(5)787-98 Macronutrient supplementation for malnourished HIV-infected adults a review of the evidence in resource-adequate and resource-constrained settings KoetheJR et al

J Acquir Immune Defic Syndr 2008 Oct 149(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 al

BMJ 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

CSB vs RUFS for Adult ART Clients

Kenya KEMRI FBF vs No Food for HIV+ Adults

∆BMI (pre-ART N = 431 )

bull Differences significant through the 6th month

bull Food significant determinant of ∆BMI at 3 and 6 months in multivariate regression

bull Greater difference for women than men

bull After 6 months differences not significant (n quite low by then)

Kenya KEMRI FBF vs No Food for HIV+ Adults

∆BMI (ART N = 624)bull Differences significant

through the 3rd month

bull Food significant determinant of ∆BMI at 3 months in multivariate regression but not 6

bull Greater difference for women than men

bull Rapid weight gain 19 amp 10 kg in 1st month and 46 amp 34 kg by 3rd

month on food amp non-food respectively

Kenya KEMRI FBF vs No Food for HIV+ Adults

Loss to Follow-up (pre-ART)bull Loss to follow-up a

huge problem in Kenya

bull Among pre-ART clients LTF lower in food group during supplementation Difference not significant for ART

bull Food is significant independent predictor of clinic attendance at 6 months among both ART and pre-ART

Implications from Studiesbull RUF leads to faster weightlean body mass

gain than CSB among adults on ART

bull Impacts of food appear greater for pre-ART than ART clients

bull Improved adherence bull Impact of supplementation on CD4 and

mortality yet unprovenbull Most benefits occur during the period of food

supplementation and may not persist beyond

CRITICAL REFLECTION

Issues in quality of evidence base

bull Small sample sizebull High loss to follow-upbull Ethics comparing to a control group with no

supplementationbull Less evidence for interventions with PMTCT

and childrenadolescentsbull Few trials in African settingsbull Little research evidence evaluating

programmatic approaches

Belief in the importance of food

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 clinicsldquoClients were unanimous in saying that ldquofood rations were a life saverrdquo(GAIN working paper 2 FBP a Landscape Paper)

Why

Before and after ART

Photo credit httpwwwannielennoxsingcomabout-sing

INTEGRATING NUTRITION INTO HIV PROGRAMMATIC EXPERIENCE

NACS

Nutrition Assessment

Nutrition Counseling

Nutrition Support

To clients who meet criteria at sites where available

Periodically to clients at all sites

Routinely to all clients at all sites

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Kenya KEMRI FBF vs No Food for HIV+ Adults

∆BMI (pre-ART N = 431 )

bull Differences significant through the 6th month

bull Food significant determinant of ∆BMI at 3 and 6 months in multivariate regression

bull Greater difference for women than men

bull After 6 months differences not significant (n quite low by then)

Kenya KEMRI FBF vs No Food for HIV+ Adults

∆BMI (ART N = 624)bull Differences significant

through the 3rd month

bull Food significant determinant of ∆BMI at 3 months in multivariate regression but not 6

bull Greater difference for women than men

bull Rapid weight gain 19 amp 10 kg in 1st month and 46 amp 34 kg by 3rd

month on food amp non-food respectively

Kenya KEMRI FBF vs No Food for HIV+ Adults

Loss to Follow-up (pre-ART)bull Loss to follow-up a

huge problem in Kenya

bull Among pre-ART clients LTF lower in food group during supplementation Difference not significant for ART

bull Food is significant independent predictor of clinic attendance at 6 months among both ART and pre-ART

Implications from Studiesbull RUF leads to faster weightlean body mass

gain than CSB among adults on ART

bull Impacts of food appear greater for pre-ART than ART clients

bull Improved adherence bull Impact of supplementation on CD4 and

mortality yet unprovenbull Most benefits occur during the period of food

supplementation and may not persist beyond

CRITICAL REFLECTION

Issues in quality of evidence base

bull Small sample sizebull High loss to follow-upbull Ethics comparing to a control group with no

supplementationbull Less evidence for interventions with PMTCT

and childrenadolescentsbull Few trials in African settingsbull Little research evidence evaluating

programmatic approaches

Belief in the importance of food

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 clinicsldquoClients were unanimous in saying that ldquofood rations were a life saverrdquo(GAIN working paper 2 FBP a Landscape Paper)

Why

Before and after ART

Photo credit httpwwwannielennoxsingcomabout-sing

INTEGRATING NUTRITION INTO HIV PROGRAMMATIC EXPERIENCE

NACS

Nutrition Assessment

Nutrition Counseling

Nutrition Support

To clients who meet criteria at sites where available

Periodically to clients at all sites

Routinely to all clients at all sites

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Kenya KEMRI FBF vs No Food for HIV+ Adults

∆BMI (ART N = 624)bull Differences significant

through the 3rd month

bull Food significant determinant of ∆BMI at 3 months in multivariate regression but not 6

bull Greater difference for women than men

bull Rapid weight gain 19 amp 10 kg in 1st month and 46 amp 34 kg by 3rd

month on food amp non-food respectively

Kenya KEMRI FBF vs No Food for HIV+ Adults

Loss to Follow-up (pre-ART)bull Loss to follow-up a

huge problem in Kenya

bull Among pre-ART clients LTF lower in food group during supplementation Difference not significant for ART

bull Food is significant independent predictor of clinic attendance at 6 months among both ART and pre-ART

Implications from Studiesbull RUF leads to faster weightlean body mass

gain than CSB among adults on ART

bull Impacts of food appear greater for pre-ART than ART clients

bull Improved adherence bull Impact of supplementation on CD4 and

mortality yet unprovenbull Most benefits occur during the period of food

supplementation and may not persist beyond

CRITICAL REFLECTION

Issues in quality of evidence base

bull Small sample sizebull High loss to follow-upbull Ethics comparing to a control group with no

supplementationbull Less evidence for interventions with PMTCT

and childrenadolescentsbull Few trials in African settingsbull Little research evidence evaluating

programmatic approaches

Belief in the importance of food

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 clinicsldquoClients were unanimous in saying that ldquofood rations were a life saverrdquo(GAIN working paper 2 FBP a Landscape Paper)

Why

Before and after ART

Photo credit httpwwwannielennoxsingcomabout-sing

INTEGRATING NUTRITION INTO HIV PROGRAMMATIC EXPERIENCE

NACS

Nutrition Assessment

Nutrition Counseling

Nutrition Support

To clients who meet criteria at sites where available

Periodically to clients at all sites

Routinely to all clients at all sites

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Kenya KEMRI FBF vs No Food for HIV+ Adults

Loss to Follow-up (pre-ART)bull Loss to follow-up a

huge problem in Kenya

bull Among pre-ART clients LTF lower in food group during supplementation Difference not significant for ART

bull Food is significant independent predictor of clinic attendance at 6 months among both ART and pre-ART

Implications from Studiesbull RUF leads to faster weightlean body mass

gain than CSB among adults on ART

bull Impacts of food appear greater for pre-ART than ART clients

bull Improved adherence bull Impact of supplementation on CD4 and

mortality yet unprovenbull Most benefits occur during the period of food

supplementation and may not persist beyond

CRITICAL REFLECTION

Issues in quality of evidence base

bull Small sample sizebull High loss to follow-upbull Ethics comparing to a control group with no

supplementationbull Less evidence for interventions with PMTCT

and childrenadolescentsbull Few trials in African settingsbull Little research evidence evaluating

programmatic approaches

Belief in the importance of food

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 clinicsldquoClients were unanimous in saying that ldquofood rations were a life saverrdquo(GAIN working paper 2 FBP a Landscape Paper)

Why

Before and after ART

Photo credit httpwwwannielennoxsingcomabout-sing

INTEGRATING NUTRITION INTO HIV PROGRAMMATIC EXPERIENCE

NACS

Nutrition Assessment

Nutrition Counseling

Nutrition Support

To clients who meet criteria at sites where available

Periodically to clients at all sites

Routinely to all clients at all sites

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Implications from Studiesbull RUF leads to faster weightlean body mass

gain than CSB among adults on ART

bull Impacts of food appear greater for pre-ART than ART clients

bull Improved adherence bull Impact of supplementation on CD4 and

mortality yet unprovenbull Most benefits occur during the period of food

supplementation and may not persist beyond

CRITICAL REFLECTION

Issues in quality of evidence base

bull Small sample sizebull High loss to follow-upbull Ethics comparing to a control group with no

supplementationbull Less evidence for interventions with PMTCT

and childrenadolescentsbull Few trials in African settingsbull Little research evidence evaluating

programmatic approaches

Belief in the importance of food

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 clinicsldquoClients were unanimous in saying that ldquofood rations were a life saverrdquo(GAIN working paper 2 FBP a Landscape Paper)

Why

Before and after ART

Photo credit httpwwwannielennoxsingcomabout-sing

INTEGRATING NUTRITION INTO HIV PROGRAMMATIC EXPERIENCE

NACS

Nutrition Assessment

Nutrition Counseling

Nutrition Support

To clients who meet criteria at sites where available

Periodically to clients at all sites

Routinely to all clients at all sites

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

CRITICAL REFLECTION

Issues in quality of evidence base

bull Small sample sizebull High loss to follow-upbull Ethics comparing to a control group with no

supplementationbull Less evidence for interventions with PMTCT

and childrenadolescentsbull Few trials in African settingsbull Little research evidence evaluating

programmatic approaches

Belief in the importance of food

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 clinicsldquoClients were unanimous in saying that ldquofood rations were a life saverrdquo(GAIN working paper 2 FBP a Landscape Paper)

Why

Before and after ART

Photo credit httpwwwannielennoxsingcomabout-sing

INTEGRATING NUTRITION INTO HIV PROGRAMMATIC EXPERIENCE

NACS

Nutrition Assessment

Nutrition Counseling

Nutrition Support

To clients who meet criteria at sites where available

Periodically to clients at all sites

Routinely to all clients at all sites

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Issues in quality of evidence base

bull Small sample sizebull High loss to follow-upbull Ethics comparing to a control group with no

supplementationbull Less evidence for interventions with PMTCT

and childrenadolescentsbull Few trials in African settingsbull Little research evidence evaluating

programmatic approaches

Belief in the importance of food

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 clinicsldquoClients were unanimous in saying that ldquofood rations were a life saverrdquo(GAIN working paper 2 FBP a Landscape Paper)

Why

Before and after ART

Photo credit httpwwwannielennoxsingcomabout-sing

INTEGRATING NUTRITION INTO HIV PROGRAMMATIC EXPERIENCE

NACS

Nutrition Assessment

Nutrition Counseling

Nutrition Support

To clients who meet criteria at sites where available

Periodically to clients at all sites

Routinely to all clients at all sites

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Belief in the importance of food

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 clinicsldquoClients were unanimous in saying that ldquofood rations were a life saverrdquo(GAIN working paper 2 FBP a Landscape Paper)

Why

Before and after ART

Photo credit httpwwwannielennoxsingcomabout-sing

INTEGRATING NUTRITION INTO HIV PROGRAMMATIC EXPERIENCE

NACS

Nutrition Assessment

Nutrition Counseling

Nutrition Support

To clients who meet criteria at sites where available

Periodically to clients at all sites

Routinely to all clients at all sites

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

INTEGRATING NUTRITION INTO HIV PROGRAMMATIC EXPERIENCE

NACS

Nutrition Assessment

Nutrition Counseling

Nutrition Support

To clients who meet criteria at sites where available

Periodically to clients at all sites

Routinely to all clients at all sites

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

NACS

Nutrition Assessment

Nutrition Counseling

Nutrition Support

To clients who meet criteria at sites where available

Periodically to clients at all sites

Routinely to all clients at all sites

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Integration of Nutrition into National HIV Responses

bull National Policy and Coordinationbull Capacity Strengtheningbull Service Deliverybull Information systems and evidence base

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Challenges managing service provider time constraints

bull Ghana 2010 assessment nurses report 6 minpatient consultation

bull Emphasis on strong toolsjob aids SBCC

bull Sharing and harmonising across the region appropriately

bull Task shifting

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Challenges establishing national-level coordination

bull Establishing a nutrition and HIV technical advisory group

bull Ghana Importance of membership of group ndash coordination between HIVmedical and nutrition stakeholders

bull Ethiopia Updating guidelines and policy ndashworking with govrsquot and NGO stakeholders

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Challenges the importance of quality improvement

bull Training and materials are not sufficientbull Importance of harmonising indicators collected

and respecting staff timebull Kenya good practice electronic recordsbull Uganda challenges paper records means that

patients can be double or triple counted bull Namibia multiple stakeholders creating MampE

systems needs harmonisationbull Staff taking ownership of QI

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Challenges Linkages between HIV and other services

CMAM

Food security

TB

Antenatal and lt5 HIV

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Integrating with food security programmes

Good practicebull Ghana WFP exploring opportunities

working in harmony with FANTA-2 through GHS stakeholder consultation

bull Namibia MOHSS FANTA-2 and LIFT (AED) partnering to explore food security amp livelihoods opportunities in HIV

Issuesbull Entry and exit criteria bull Overlap of target population

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Challenges facility-to-community referral systems

bull CMAM (child)ndash Harmonising guidelinesndash Multiple service delivery pointsndash Loss to follow-up (resources) ndash HIV testing at community level

bull Adult MUAC community based screeningndash Opportunity to refer adults for testing and

follow-up

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

RESEARCH GAPS AND PRIORITY ACTIONS

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Research Gaps

bull Effectiveness studies with large enough sample size to report on mortality

bull Relative effectiveness and cost-effectiveness of various food products

bull How to harmonize food security and nutrition supplementation programs in HIV

bull Further exploration of impact on quality of life qualitative research

bull More evaluation research into programmatic approaches amp sharing best practice

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions

Questions

• Integrating nutrition into national HIV policies and programs
• Outline
• Scientific Evidence
• Slide Number 4
• Review macronutrient supplementation for HIV in resource constrainedadequate settings
• CSB vs RUFS for Adult ART Clients
• Kenya KEMRI FBF vs No Food for HIV+ AdultsDBMI (pre-ART N = 431 )
• Kenya KEMRI FBF vs No Food for HIV+ Adults DBMI (ART N = 624)
• Kenya KEMRI FBF vs No Food for HIV+ AdultsLoss to Follow-up (pre-ART)
• Implications from Studies
• Critical reflection
• Issues in quality of evidence base
• Slide Number 13
• Integrating Nutrition into HIV programmatic experience
• NACS
• Integration of Nutrition into National HIV Responses
• Challenges managing service provider time constraints
• Challenges establishing national-level coordination
• Challenges the importance of quality improvement
• Challenges Linkages between HIV and other services
• Integrating with food security programmes
• Challenges facility-to-community referral systems
• Research gaps and priority actions
• Research Gaps
• Questions