Nutrition and HIV: Evidence, Promising Practices, and Emerging Issues

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Nutrition and HIV Evidence, Promising
Practices, and Emerging Issues
Nutrition and HIV Evidence, Promising
Practices, and Emerging Issues

• Amie N. Heap MPH, RD
• Nutrition Advisor, Monitoring and Evaluation
• Bureau of Global Health, Office of HIV/AIDS
• USAID

Amie N. Heap MPH, RD, USAID Tim Quick, PhD, MS,
USAID Tony Castleman, PhD
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Nutrition and Burden of Disease
Nutrition and Burden of Disease

• Maternal and child undernutrition
• 3.5 million deaths
• 35 of the disease burden in children under 5
• 11 of the total global DALYs
• Maternal short stature and iron deficiency anemia
• Increases the risk of death of the mother at
  delivery
• Accounts for at least 20 of maternal mortality
• Poor fetal growth in the first two years of life
• Lower attained schooling
• Reduced adult income
• Decreased offspring birthweight
• 
  
• 
  Lancet,
  Vol 371, 2008

• Maternal and child undernutrition
• 3.5 million deaths
• 35 of the disease burden in children under 5
• 11 of the total global DALYs
• Maternal short stature and iron deficiency anemia
• Increases the risk of death of the mother at
  delivery
• Accounts for at least 20 of maternal mortality
• Poor fetal growth in the first two years of life
• Lower attained schooling
• Reduced adult income
• Decreased offspring birthweight
• 
  
• 
  Lancet,
  Vol 371, 2008

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Nutrition and HIV
Nutrition and HIV

• Adequate nutrition, which is best achieved
  through consumption of a balanced healthy diet,
  is vital for health and survival of all
  individuals, regardless of HIV status
• Nutrition Requirements for People Living with
  HIV/AIDS
• Report of a Technical Consultation
• WHO, Geneva, Switzerland, May, 2003.
• Adequate nutrition cannot cure HIV infection,
  but is essential to maintain the immune system
  and sustain physical activity, and to achieve
  optimal quality of life.
• Participants Statement
• WHO Consultation on Nutrition and HIV/AIDS in
  Africa
• Durban, South Africa, April, 2005

Adequate nutrition, which is best achieved
through consumption of a balanced healthy diet,
is vital for health and survival of all
individuals, regardless of HIV status Nutrition
Requirements for People Living with
HIV/AIDS Report of a Technical Consultation WHO,
Geneva, Switzerland, May, 2003. Adequate
nutrition cannot cure HIV infection, but is
essential to maintain the immune system and
sustain physical activity, and to achieve optimal
quality of life. Participants Statement WHO
Consultation on Nutrition and HIV/AIDS in
Africa Durban, South Africa, April, 2005
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HIV as an Opportunity for Nutrition
HIV as an Opportunity for Nutrition

• HIV services reach nutritionally vulnerable
  populations (though not necessarily most
  vulnerable or most food insecure)
• Trainings, IEC materials for health care
  providers
• High attention and visibility on HIV services
• High level of resources allocated to HIV
• Services are entry points for nutrition

• HIV services reach nutritionally vulnerable
  populations (though not necessarily most
  vulnerable or most food insecure)
• Trainings, IEC materials for health care
  providers
• High attention and visibility on HIV services
• High level of resources allocated to HIV
• Services are entry points for nutrition

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Nutrition and HIV Links
Nutrition and HIV Links
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HIV Nutrition
HIV Nutrition

• Malnutrition HIV

• HIV Malnutrition

Malnutrition HIV
HIV Malnutrition

• Weakened immune system
• Increased susceptibility to OI
• Slower healing
• Poorer response to treatment
• Possibly more rapid disease progression

• Reduced food intake
• Increased nutrient needs
• Altered nutrient absorption
• Altered nutrient metabolism

• Weakened immune system
• Increased susceptibility to OI
• Slower healing
• Poorer response to treatment
• Possibly more rapid disease progression

• Reduced food intake
• Increased nutrient needs
• Altered nutrient absorption
• Altered nutrient metabolism

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Clinical Picture for PLHIV
Clinical Picture for PLHIV

• Nausea, oral thrush, altered taste, and depressed
  appetite
• Malabsorption, diarrhea, and hypermetabolism
• Multiple micronutrient deficiencies pre-existing
  and precipitated by infection and Tx

• Nausea, oral thrush, altered taste, and depressed
  appetite
• Malabsorption, diarrhea, and hypermetabolism
• Multiple micronutrient deficiencies pre-existing
  and precipitated by infection and Tx

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WHO PLHIV Nutrient Requirements
WHO PLHIV Nutrient Requirements

• Energy
• 10 increase for asymptomatic
• 20-30 increase for symptomatic
• 50-100 increase for children with growth
  faltering
• Protein
• -12-15 of energy intake to maintain and/or
  recover lean body mass
• Micronutrients
• Essential micronutrients _at_ 1 RDA
• High energy, nutrient dense food is required to
  meet needsnot just more of the same!

• Energy
• 10 increase for asymptomatic
• 20-30 increase for symptomatic
• 50-100 increase for children with growth
  faltering
• Protein
• -12-15 of energy intake to maintain and/or
  recover lean body mass
• Micronutrients
• Essential micronutrients _at_ 1 RDA
• High energy, nutrient dense food is required to
  meet needsnot just more of the same!

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Nutrition and HIV Evidence
Nutrition and HIV Evidence
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Evidence Nutrition and Mortality
Evidence Nutrition and Mortality

• Among PLHIV not on ART, lower BMI at time of
  diagnosis is associated with higher mortality
• Each unit decrease in BMI associated with a 13
  increase risk of death after controlling for
  baseline immune status (CD4 count)
• 
  Van der Sande et al, JAIDS 2004

• Among PLHIV not on ART, lower BMI at time of
  diagnosis is associated with higher mortality
• Each unit decrease in BMI associated with a 13
  increase risk of death after controlling for
  baseline immune status (CD4 count)
• 
  Van der Sande et al, JAIDS 2004

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Evidence Nutrition and Mortality
Evidence Nutrition and Mortality

• Among PLHIV receiving ART, moderate to severe
  malnutrition at the start of ART more than
  doubled the risk of death
• Differences in CD4 counts were not statistically
  significant between those with lower and higher
  baseline BMI
• 
  Paton et al, HIV Med, 2006

• Among PLHIV receiving ART, moderate to severe
  malnutrition at the start of ART more than
  doubled the risk of death
• Differences in CD4 counts were not statistically
  significant between those with lower and higher
  baseline BMI
• 
  Paton et al, HIV Med, 2006

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Evidence Nutrition Interventions
Evidence Nutrition Interventions

• Evidence on impacts of various nutrition
  interventions on PLHIV is still emerging,
  including recent or ongoing studies on food
  supplementation
• Many of these services are relatively new, so
  opportunities for randomized controlled trials in
  many settings were limited in the past but are
  expanding.

• Evidence on impacts of various nutrition
  interventions on PLHIV is still emerging,
  including recent or ongoing studies on food
  supplementation
• Many of these services are relatively new, so
  opportunities for randomized controlled trials in
  many settings were limited in the past but are
  expanding.

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Nutrition and HIV Strategy
Nutrition and HIV Strategy
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Target Vulnerable Populations
Target Vulnerable Populations

• PEPFAR funded programs focus on
• Orphans and vulnerable children (OVC)
• HIV pregnant and lactating women in PMTCT
  programs
• Clinically malnourished PLHIV in care and
  treatment programs

• PEPFAR funded programs focus on
• Orphans and vulnerable children (OVC)
• HIV pregnant and lactating women in PMTCT
  programs
• Clinically malnourished PLHIV in care and
  treatment programs

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Program Approaches
Program Approaches

• Food assistance programs
• Interventions to improve food security for
  HIV-affected populations
• Primary objective is usually food security
• Examples
• Title II
• PLHIV feeding
• School feeding
• Food for assets
• WFP

• Food assistance programs
• Interventions to improve food security for
  HIV-affected populations
• Primary objective is usually food security
• Examples
• Title II
• PLHIV feeding
• School feeding
• Food for assets
• WFP

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Program Approaches
Program Approaches

• HIV services integrating food and nutrition
  components
• Primary objective is usually HIV-related
• Examples
• Food by Prescription
• National nutrition programs

• HIV services integrating food and nutrition
  components
• Primary objective is usually HIV-related
• Examples
• Food by Prescription
• National nutrition programs

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Nutrition and HIV Integration
Nutrition and HIV Integration

• National Policy and Coordination
• National guidelines on nutrition and HIV
• National strategy on nutrition and HIV
• Incorporation of nutrition into HIV policies (and
  vice versa)
• Coordinating technical group
• Nutrition focal point in the National AIDS
  Control Program

• National Policy and Coordination
• National guidelines on nutrition and HIV
• National strategy on nutrition and HIV
• Incorporation of nutrition into HIV policies (and
  vice versa)
• Coordinating technical group
• Nutrition focal point in the National AIDS
  Control Program

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Nutrition and HIV Integration
Nutrition and HIV Integration

• Capacity Strengthening
• Training of health care workers (in-service and
  pre-service)
• Job aids, IEC materials, anthropometric equipment
• Mentoring, QI/QA supervision, ME

• Capacity Strengthening
• Training of health care workers (in-service
• and pre-service)
• Job aids, IEC materials, anthropometric equipment
• Mentoring, QI/QA supervision, ME

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Nutrition and HIV Integration
Nutrition and HIV Integration

• Service Delivery
• Nutrition assessment
• Nutrition education and counseling
• Specialized food products
• Micronutrient supplementation
• Water purification and hygiene
• Food security support

• Service Delivery
• Nutrition assessment
• Nutrition education and counseling
• Specialized food products
• Micronutrient supplementation
• Water purification and hygiene
• Food security support

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Package of Nutrition Services at Clinical HIV
Care and Tx Sites
Package of Nutrition Services at Clinical HIV
Care and Tx Sites
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Food By Prescription
Food By Prescription

• What is it?
• A program approach for delivering the package of
  nutrition services (assessment, counseling, food,
  water purification)
• PEPFARs primary approach to providing nutrition
  interventions in clinical settings

• What is it?
• A program approach for delivering the package of
  nutrition services (assessment, counseling, food,
  water purification)
• PEPFARs primary approach to providing nutrition
  interventions in clinical settings

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Food By Prescription Approach
Food By Prescription Approach

• Core components
• Provision of set of nutrition services at
  clinical facilities as part of HIV care and Tx
• Clearly defined entry and graduation criteria for
  specialized food products
• Prescriptions used for take-home food packages
• Food packaged in daily consumption doses and
  aimed at improving individual nutrition and
  health status

• Core components
• Provision of set of nutrition services at
  clinical facilities as part of HIV care and Tx
• Clearly defined entry and graduation criteria for
  specialized food products
• Prescriptions used for take-home food packages
• Food packaged in daily consumption doses and
  aimed at improving individual nutrition and
  health status

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Food-by-Prescription
Food-by-Prescription
VCT
VCT
Hospital / Clinic

• Food Company
• Food Production
• Direct Delivery to Hospital/Clinic

Hospital / Clinic

• Food Company
• Food Production
• Direct Delivery to Hospital/Clinic

• Physician/Nurse
• Symptom Diagnosis
• Integrated Symptom Tx/Management

• Physician/Nurse
• Symptom Diagnosis
• Integrated Symptom Tx/Management

• Nutritionist/Health Worker
• Assessment
• Counseling
• MN Supplement Food Prescription
• Referral to Clinical Care Household Food
  Security

• Nutritionist/Health Worker
• Assessment
• Counseling
• MN Supplement Food Prescription
• Referral to Clinical Care Household Food
  Security

• Pharmacy
• Food Dispensing
• Inventory Control
• Record Keeping

• Pharmacy
• Food Dispensing
• Inventory Control
• Record Keeping

• Lay Counselor
• Nutrition Education/Counseling
• Peer Support

• Lay Counselor
• Nutrition Education/Counseling
• Peer Support

• Community Programs
• Food Security
• Livelihood Assistance
• MCH

Patient Follow-Up

• Community Programs
• Food Security
• Livelihood Assistance
• MCH

Patient Follow-Up
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Countries Implementing FBP
Countries Implementing FBP

• In operation
• Haiti, Kenya, Malawi, Uganda Zambia
• Starting soon
• Ethiopia, Rwanda, Tanzania
• Under consideration
• Cote dIvoire, Namibia, Vietnam, Mozambique

• In operation
• Haiti, Kenya, Malawi, Uganda, Zambia
• Starting soon
• Ethiopia, Rwanda, Tanzania
• Under consideration
• Cote dIvoire, Namibia, Vietnam, Mozambique

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Specialized Food Products
Specialized Food Products

• Fortified Blended Foods (FBP)

• Ready to Use Foods (RUTF)

Fortified Blended Foods (FBP)
Ready to Use Foods (RUTF)

• CSB has a long history of use in a range of
  programs with various objectives
• In many settings it is a more nutritious form of
  commonly used staple foods
• Questions have been raised about its
  effectiveness rehabilitating the malnourished
• Efforts to improve the formulation of CSB are
  underway
• U.S. 0.13 per 1000 kcals

• Ready-to-use therapeutic food (RUTF) was
  developed and is very effective for treating
  children with severe acute malnutrition
• Recent expansion to other populations HIV
  adults, moderately malnourished children
• May not be optimal for all groups adaptations
  and alternative formulations are underway
• RUTF is relatively expensive cost-effectiveness
  is a consideration
• U.S. 0.39 per 1000 kcals

• CSB has a long history of use in a range of
  programs with various objectives
• In many settings it is a more nutritious form of
  commonly used staple foods
• Questions have been raised about its
  effectiveness rehabilitating the malnourished
• Efforts to improve the formulation of CSB are
  underway
• U.S. 0.13 per 1000 kcals

• Ready-to-use therapeutic food (RUTF) was
  developed and is very effective for treating
  children with severe acute malnutrition
• Recent expansion to other populations HIV
  adults, moderately malnourished children
• May not be optimal for all groups adaptations
  and alternative formulations are underway
• RUTF is relatively expensive cost-effectiveness
  is a consideration
• U.S. 0.39 per 1000 kcals

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Research Question
Research Question

• FBP vs. No Food for HIV Adults
• Does provision of supplementary food to
• malnourished HIV-infected adult ART and pre
• ART clients improve nutritional status, clinical
• outcomes, and drug adherence?

FBP vs. No Food for HIV Adults Does provision
of supplementary food to malnourished
HIV-infected adult ART and pre ART clients
improve nutritional status?
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Design
Design

• Randomized effectiveness trial.
• Implemented at 6 HIV treatment sites in Kenya by
  Kenya Medical Research Institute.
• 6 months intervention 6 months follow-up.
• Adult (non-pregnant) ART clients with BMI lt 18.5
  kg/m2.
• Pre-ART adults clients taking cotrimoxazole with
  BMI lt 18.5, or 18.5-20 with weight loss.

• Randomized effectiveness trial.
• Implemented at 6 HIV treatment sites in Kenya by
  Kenya Medical Research Institute.
• 6 months intervention 6 months follow-up.
• Adult (non-pregnant) ART clients with BMI lt 18.5
  kg/m2.
• Pre-ART adults clients taking cotrimoxazole with
  BMI lt 18.5, or 18.5-20 with weight loss.

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Study Design
Study Design
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FBF vs. No Food for HIV Adults Food Product
FBF vs. No Food for HIV Adults Food Product

• Locally manufactured
• 1,320 kcal/day FBF
• Corn, soy, vegetable oil, sugar, whey protein
  concentrate
• MN fortified to about 1 RDA
• US 0.23 per 1,000 kcal (2007 price)

• Locally manufactured
• 1,320 kcal/day FBF
• Corn, soy, vegetable oil, sugar, whey protein
  concentrate
• MN fortified to about 1 RDA
• US 0.23 per 1,000 kcal (2007 price)

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FBFFBP vs. No Food for HIV Adult Results DBMI
(pre-ART)
FBFFBP vs. No Food for HIV Adult Results DBMI
(pre-ART)

• Differences significant through the 6th month.
• Food significant determinant of DBMI at 3 and 6
  months in multivariate regression.
• Greater difference for women than men.
• After 6 months differences not significant (n
  quite low by then).

• Differences significant through the 6th month.
• Food significant determinant of DBMI at 3 and 6
  months in multivariate regression.
• Greater difference for women than men.
• After 6 months differences not significant (n
  quite low by then).

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FBP vs. No Food for HIV Adult Results DBMI (ART)
FBP vs. No Food for HIV Adult Results DBMI (ART)

• Differences significant through the 3rd month.
• Food significant determinant of DBMI at 3 months
  in multivariate regression but not 6.
• Greater difference for women than men.
• Rapid weight gain 1.9 1.0 kg in 1st month and
  4.6 3.4 kg. by 3rd month on food non-food
  respectively.

• Differences significant through the 3rd month.
• Food significant determinant of DBMI at 3 months
  in multivariate regression but not 6.
• Greater difference for women than men.
• Rapid weight gain 1.9 1.0 kg in 1st month and
  4.6 3.4 kg. by 3rd month on food non-food
  respectively.

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FBP vs. No Food for HIV Adult Results Loss to
Follow-up (pre-ART)
FBP vs. No Food for HIV Adult Results Loss to
Follow-up (pre-ART)

• Loss to follow-up is a huge problem in Kenya,
• Among pre-ART clients, LTF lower in food group
  during supplementation. Difference not
  significant for ART.
• Food is significant independent predictor of
  clinic attendance at 6 months among both ART and
  pre-ART.

• Loss to follow-up is a huge problem in Kenya,
• Among pre-ART clients, LTF lower in food group
  during supplementation. Difference not
  significant for ART.
• Food is significant independent predictor of
  clinic attendance at 6 months among both ART and
  pre-ART.

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Study Conclusions Future Directions
Study Conclusions Future Directions

• Food supplementation benefits malnourished adult
  PLHIV, with greater benefits for pre-ART than ART
  clients and for women than men.
• Most benefits occur during the period of food
  supplementation and may not persist beyond then
  (sample size issues).
• Food supplementation can improve nutritional
  status, reduce attrition, and possibly enhance
  immune response of pre-ART clients.

• Food supplementation benefits malnourished adult
  PLHIV, with greater benefits for pre-ART than ART
  clients and for women than men.
• Most benefits occur during the period of food
  supplementation and may not persist beyond then
  (sample size issues).
• Food supplementation can improve nutritional
  status and reduce attrition.

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Challenges
Challenges
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FOOD and nutrition
FOOD and nutrition
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Challenges
Challenges

• Food and nutrition needs of non-HIV-affected
  populations ethical and practical
  considerations
• Overstretched health systems, service provider
  time constraints
• Limited scale and geographic overlap for broader
  food security services

• Food and nutrition needs of non-HIV-affected
  populations ethical and practical
  considerations
• Overstretched health systems, service provider
  time constraints
• Limited scale and geographic overlap for broader
  food security services

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Challenges
Challenges

• Clinical facilities a good entry point for PLHIV
  nutrition services. But also need to integrate
  into community services and establish two-way
  referral mechanisms between facility and
  community services.
• Importance of integration into existing system
  patient flow, information flow, etc. Ownership
  by medical stakeholders
• Monitoring and evaluation capturing data and
  disseminating practices

• Clinical facilities a good entry point for PLHIV
  nutrition services. But also need to integrate
  into community services and establish two-way
  referral mechanisms between facility and
  community services.
• Importance of integration into existing system
  patient flow, information flow, etc. Ownership
  by medical stakeholders
• Monitoring and evaluation capturing data and
  disseminating practices

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Thank-You