Integrating Nutrition into HIV Treatment and Care Programs Evidence, Experience and Suggested Action

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Integrating Nutrition into HIV Treatment and Care
ProgramsEvidence, Experience and Suggested
Actions (Part II)World Bank Presentation,
April 27, 2004 Tony Castleman, FANTA Project/AED
(funded by U.S. Agency for International
Development)
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• OUTLINE
• I. ART-Nutrition Interactions
• II. Service Provider Actions to Manage
  ART-Nutrition Interactions
• III. Nutritional Care and Support Program Entry
  Points and Approaches
• IV. Tools and Country Experience

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I. ART-Nutrition Interactions

• Impacts of Interactions
• Adherence to ART
• ART efficacy
• Nutritional status

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• FOUR INTERACTIONS BETWEEN
• ART AND FOOD AND NUTRITION
• Food Can Affect ARV Efficacy
• ARV Can Affect Nutrient Utilization
• ARV Side Effect Can Affect Food Consumption or
  Nutrient Utilization
• Combination of ARV and Certain Foods Can Create
  Unhealthy Side Effects

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1. FOOD ARV EFFICACY
Affects

• Example A high fat meal
• increases absorption of efavirenz,
• decreases bioavailability of indinavir.

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2. ARV NUTRIENT UTILIZATION
Affects
Example Ritonavir affects metabolism of lipids,
resulting in elevated cholesterol or triglyceride
levels.

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3. ARV SIDE FOOD CONSUMPTION EFFECT
NUTRIENT ABSORPTION Affects
Example Zidovudine can cause anorexia, nausea,
and vomiting.

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4. ARV FOOD UNHEALTHY COMBINATION
SIDE EFFECT Creates
Example Consumption of alcohol with didanosine
can cause inflammation of the pancreas.

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• Service Provider Actions to
• Manage ART-Nutrition Interactions

• Information
• Identification of Food and Nutrition
  Responses
• Implementation
• and Follow-up

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• Information
• - Drugs, drug-nutrition interactions, multiple
  drug effects
• - Diet, available foods
• - Constraints to food access, stigma
• - Pre-existing nutritional issues
• - Individual reactions, preferences

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• Identification of Food and Nutrition Responses
• - Drug, meal timing increase/decrease certain
  foods, nutrients changes in food preparation,
  allocation responses to side effects
• - Feasibility, constraints (2nd best)
• - Build on what client is already doing

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• Implementation and Follow-up
• - Feedback and adjustments
• - Involvement of caregivers in the household
• - Linkages to other services for support

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III. Nutritional Care and Support Program Entry
Points and Approaches
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• Objectives of Nutritional Care and Support
• Maintain adequate diet and nutritional care
  practices
• Meet special nutritional needs
• Manage opportunistic infections and symptoms
• Manage interactions between drugs and food and
  nutrition

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• Nutritional Care Support Interventions
• Counseling (clinic-based, home-based,
  community-based)
• Awareness generation, IEC, mass media
• Provision of food aid or other resources
• Nutrition assessments
• BCC interventions

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Program Entry Points

• General Nutritional Care and Support
• Home-based care services
• - counseling, household constraints/situation
• - capacity issues (materials, training)
• Clinical services
• - practitioner time, opportunities
• - training of doctors, nurses hiring
  nutritionists
• Counseling services (e.g., TASO)

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• Program Entry Points (contd)
• General Nutritional Care and Support (contd)
• Non-HIV programs
• - MCH
• - community health, nutrition
• - food aid
• PLWHA networks
• VCT
• OVC programs School-based services

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Program Entry Points (contd)

• ART-Nutrition
• ART services
• - during medicine provision
• - during follow-up (clinic- and home-based)
• - counseling, IEC, simple aids (meal planner)
• - time and capacity issues (doctors, nurses)
• Non-ART services
• - home-based care (follow-up)
• - counseling services
• - PLWHA networks
• - links to food aid and nutrition programs

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Priority Approaches for Integrating Nutrition
into HIV/AIDS Programs

• Create enabling environment
• - Guidelines, policies, strategies (Rwanda)
• - Advocacy (Uganda)
• - Awareness national, district, community
• Strengthen capacity of providers - Training,
  orientations (integrated vs. separate)
• - Communication materials, job aids, counseling
  materials, mass media, posters, references

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Uganda National Guidelines
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Priority Approaches for Integrating Nutrition
into HIV/AIDS Programs (contd)

• Establish program systems supporting
  nutrition - Include nutrition as component of
  supervision - Assessments of food and nutrition
  situations - Referrals to other food or
  livelihood services
• Incorporate into existing services
• Identify and disseminate promising
  implementation practices

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Priority Approaches for Integrating Nutrition
into HIV/AIDS Programs (contd)

• Forge linkages between programs
• - HIV care nutrition education, hygiene
• - ART non-ART
• - HIV care livelihood
• Involve other household and community members.
  Consider stigma issues.
• Monitor and evaluate

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• Tools and Country Experience

Technical Guidance - Literature Review -
Nutritional Care Support Guides - Food
Nutrition Implications of ART

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National Guidelines- Regional workshops-
Handbook- National Guidelines Uganda, S.
Africa, Namibia (Zambia, Kenya, Rwanda,
others)
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Training Materials- Pre-service training manual
(region)- Training for nurses/midwives
(region)- National/district/ community training
(Rwanda)
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Counseling Materials - Counseling cards, job
aids, fact sheets - Uganda, Zambia, Kenya,
regional adaptation
Specialized Foods for PLWHA - Community
Therapeutic Care Study - Review of Specialized
Foods Food Aid and HIV/AIDS - Programming guide
- Regional workshop

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Country Approaches
Uganda multi-sectoral advocacy, national
guidelines, PLWHA pamphlet, counseling
materials Rwanda national strategy, national
guidelines, national and district training, ART
program materials, training Zambia national
guidelines, assessment of specialized foods,
counseling materials Kenya national
guidelines, formative research on nutrition needs
of ART clients

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Integrating Nutrition into HIV Treatment and Care
ProgramsEvidence, Experience and Suggested
Actions (Part II)World Bank Presentation,
April 27, 2004 Tony Castleman, FANTA Project/AED
(funded by U.S. Agency for International
Development)