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Food and Nutrition Activities in the President’s Emergency Plan for AIDS Relief (PEPFAR) CAPT Pamela Ching, RD/LD, MS, SD Nutrition Medical Officer Division.

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Presentation on theme: "Food and Nutrition Activities in the President’s Emergency Plan for AIDS Relief (PEPFAR) CAPT Pamela Ching, RD/LD, MS, SD Nutrition Medical Officer Division."— Presentation transcript:

1 Food and Nutrition Activities in the President’s Emergency Plan for AIDS Relief (PEPFAR) CAPT Pamela Ching, RD/LD, MS, SD Nutrition Medical Officer Division of Global HIV/AIDS Center for Global Health Centers for Disease Control and Prevention

2 Goals Background on food insecurity and undernutrition Background on food insecurity and undernutrition Overview Overview Global Health Initiative (GHI) Global Health Initiative (GHI) President’s Emergency Plan for AIDS Relief (PEPFAR) President’s Emergency Plan for AIDS Relief (PEPFAR) Food and Nutrition (F&N) activities Food and Nutrition (F&N) activities Assessments of food insecurity and malnutrition Assessments of food insecurity and malnutrition Provision of therapeutic and supplemental foods to eliminate macro- and micro-nutrient deficiencies Provision of therapeutic and supplemental foods to eliminate macro- and micro-nutrient deficiencies Training clinical and community-based personnel Training clinical and community-based personnel

3 Food Insecurity “The limited or uncertain availability of nutritionally adequate, safe foods or the inability to acquire personally acceptable foods in socially acceptable ways.” (American Institute of Nutrition) “The right to adequate food is realized when every man, woman and child, alone or in community with others, has physical and economic access at all times to adequate food or means for its procurement.” ( (United Nations Committee on Economic, Social, and Cultural Rights, 1999)

4 ~ 850 million people were food insecure last year Global Food Insecurity (World Food Programme)

5 Chronic Undernutrition,

6 Global Undernutrition

7 INTERVENTIONS - Breastfeeding - Complementary feeding - Vitamin A - Zinc - Hygiene INSTITUTIONS POLITICAL & IDEOLOGICAL FRAMEWORK ECONOMIC STRUCTURE Food/nutrient intake Health Water/ Sanitation health services Immediate Underlying causes at household/ family level Basic causes at societal level - Agriculture - Poverty Reduction - Income generation - Education - Women’s empowerment - Health Systems Strengthening Maternal and child- care practices Access to food RESOURCES ENVIRONMENT, TECHNOLOGY, PEOPLE CAUSES Undernutrition (Adapted from: United Nations Standing Committee on Nutrition News, 2008)

8 PEPFAR GHI US Efforts Undernutrition Department of State Breastfeeding Complementary feeding Vitamin A Zinc Hygiene INSTITUTIONS POLITICAL & IDEOLOGICAL FRAMEWORK ECONOMIC STRUCTURE Food/nutrient intake Health Water/ Sanitation health services Agriculture Poverty Reduction Education Health Systems Strengthening Income generation Women’s empowerment Maternal and child- care practices Access to food RESOURCES ENVIRONMENT, TECHNOLOGY, PEOPLE

9 “We cannot simply confront individual preventable illnesses in isolation. The world…demands an integrated approach to global health. We will not be successful in our efforts …unless we do more to improve health systems around the world…and ensure that best practices drive the funding for these programs.” President Barack Obama May 5, 2009

10 Global Health Initiative (GHI) Six-year, $63 billion commitment by the US government to assist developing countries in reducing morbidity and mortality from HIV/AIDS, tuberculosis, malaria, and neglected tropical diseases Six-year, $63 billion commitment by the US government to assist developing countries in reducing morbidity and mortality from HIV/AIDS, tuberculosis, malaria, and neglected tropical diseases Objectives: Objectives: Achieve significant health improvements Achieve significant health improvements Create an effective, efficient and sustainable platform for the delivery of essential health care and public health programs Create an effective, efficient and sustainable platform for the delivery of essential health care and public health programs

11 GHI Goals Nutrition: Reduce child undernutrition by 30% across assisted food insecure countries in conjunction with the President’s “Feed the Future” initiative. Nutrition: Reduce child undernutrition by 30% across assisted food insecure countries in conjunction with the President’s “Feed the Future” initiative. HIV/AIDS: PEPFAR will support: HIV/AIDS: PEPFAR will support: Treatment of > 3 million people with anti-retrovirals (ARVs) Treatment of > 3 million people with anti-retrovirals (ARVs) Prevention of > 12 million new HIV infections Prevention of > 12 million new HIV infections Care of > 12 million people, including 5 million orphans and vulnerable children Care of > 12 million people, including 5 million orphans and vulnerable children

12 President’s Emergency Plan for AIDS Relief (PEPFAR) 2003: Congress authorizes 5-year, $15 billion Program 2003: Congress authorizes 5-year, $15 billion Program A crucial component of US foreign policy A crucial component of US foreign policy Program focused on provision of comprehensive HIV/AIDS prevention, care, and treatment using a multi-sectoral approach in developing countries most affected by the epidemic Program focused on provision of comprehensive HIV/AIDS prevention, care, and treatment using a multi-sectoral approach in developing countries most affected by the epidemic 15 focus countries (12 in Sub-Sahara Africa; Haiti; Guyana; Vietnam) accounting for >50% global HIV/AIDS burden 15 focus countries (12 in Sub-Sahara Africa; Haiti; Guyana; Vietnam) accounting for >50% global HIV/AIDS burden 2009: 5-year reauthorization within GHI: $48 billion for HIV/AIDS, tuberculosis, and malaria 2009: 5-year reauthorization within GHI: $48 billion for HIV/AIDS, tuberculosis, and malaria

13 HIV/AIDS, Food, and Nutrition “Slim Disease” - People living with HIV/AIDS (PLWHA ) typically present with advanced AIDS after chronic illness and >10% weight loss “Slim Disease” - People living with HIV/AIDS (PLWHA ) typically present with advanced AIDS after chronic illness and >10% weight loss Strong correlation between wasting and mortality before and during treatment Strong correlation between wasting and mortality before and during treatment Food is often the most urgent need for PLWHA and their families Food is often the most urgent need for PLWHA and their families Anti-retroviral therapy (ART) and treatment for opportunistic infections improves appetite and nutritional status of most malnourished patients Anti-retroviral therapy (ART) and treatment for opportunistic infections improves appetite and nutritional status of most malnourished patients

14 Guiding Principles for PEPFAR F&N Programs Support PEPFAR “3/12/12” goals Support PEPFAR “3/12/12” goals Strive to integrate nutrition assessment, counseling, and support (NACS) services within clinical care and treatment Strive to integrate nutrition assessment, counseling, and support (NACS) services within clinical care and treatment Provide food and specialized nutritional supplements to target groups using defined eligibility criteria (“Food as Medicine”) Provide food and specialized nutritional supplements to target groups using defined eligibility criteria (“Food as Medicine”) Be linked with food assistance and security programs supported by other initiatives or “wrap-arounds” (e.g., UN World Food Programme; USAID’s Title II, Food for Peace Program) Be linked with food assistance and security programs supported by other initiatives or “wrap-arounds” (e.g., UN World Food Programme; USAID’s Title II, Food for Peace Program)

15 Target Groups for PEPFAR F&N Support Orphans and vulnerable children (OVC), especially those under 5 years of age Orphans and vulnerable children (OVC), especially those under 5 years of age HIV + pregnant and lactating women in prevention of mother to child transmission (PMTCT) programs HIV + pregnant and lactating women in prevention of mother to child transmission (PMTCT) programs People living with HIV/AIDS (PLWHA) in care and treatment programs People living with HIV/AIDS (PLWHA) in care and treatment programs

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17 Food by Prescription (FBP) Nutrition assessment, counseling, and support = NACS Nutrition assessment, counseling, and support = NACS FBP - program supporting NACS FBP - program supporting NACS Nutrition assessment: entry and “graduation” anthropometric and clinical criteria for malnourished and nutritionally vulnerable PLWHA, pregnant and lactating women and their infants enrolled in PMTCT programs, and OVC Nutrition assessment: entry and “graduation” anthropometric and clinical criteria for malnourished and nutritionally vulnerable PLWHA, pregnant and lactating women and their infants enrolled in PMTCT programs, and OVC Provision of nutrition education and counseling Provision of nutrition education and counseling

18 Food by Prescription (FBP) Therapeutic and supplementary feeding support Therapeutic and supplementary feeding support RUTF (Ready-to-use Therapeutic Food), e.g., Plumpy’nut RUTF (Ready-to-use Therapeutic Food), e.g., Plumpy’nut FBF (Fortified Blended Foods – grain and legume based flour/cereals FBF (Fortified Blended Foods – grain and legume based flour/cereals Sometimes: multi-micronutrient supplements Sometimes: multi-micronutrient supplements Instruction and supplies to support safe water treatment Instruction and supplies to support safe water treatment Referral and support for household food security and livelihood assistance Referral and support for household food security and livelihood assistance

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20 Food by Prescription (FBP) Physician/Nurse Symptom diagnosis Integrated symptom treatment/management Pharmacy Food dispensing Inventory control Record keeping Lay Counselor Nutrition education/ counseling Peer support Nutritionist/Health Worker Assessment Counseling MN supplement & food prescription Referral to clinical care & household food security HBC/Community Referral Hospital / Clinic Inpatient VCT Community Programs Food security Livelihood assistance MCH Food Company Food production Delivery to hospital/clinic

21 PEPFAR-Supported F&N Efforts Basic FBP program implementation: Basic FBP program implementation: In operation: Malawi, Zambia, Haiti In operation: Malawi, Zambia, Haiti Starting: Namibia, Ghana Starting: Namibia, Ghana Planning: Cote d’Ivoire, Mozambique, Vietnam Planning: Cote d’Ivoire, Mozambique, Vietnam FBP with quality assessment and improvement evaluation activities: FBP with quality assessment and improvement evaluation activities: Kenya, Tanzania, Ethiopia, Uganda Kenya, Tanzania, Ethiopia, Uganda

22 PEPFAR-Supported F&N Efforts LIFT (LIvelihoods & Food Security Technical Assistance) Project LIFT (LIvelihoods & Food Security Technical Assistance) Project Provide household economic strengthening and livelihood assistance to food-insecure HIV/AIDS-affected families, including OVC Provide household economic strengthening and livelihood assistance to food-insecure HIV/AIDS-affected families, including OVC Technical assistance in Nigeria, Malawi, Kenya, Ethiopia, Rwanda, Mozambique, South Africa and Namibia. Technical assistance in Nigeria, Malawi, Kenya, Ethiopia, Rwanda, Mozambique, South Africa and Namibia.

23 Future PEPFAR-Supported F&N Efforts PMTCT programs: greater emphasis on infant feeding practices which promote infant HIV-free survival in addition to prevention of peri-natal HIV transmission PMTCT programs: greater emphasis on infant feeding practices which promote infant HIV-free survival in addition to prevention of peri-natal HIV transmission Promote prolonged breastfeeding in conjunction with use of ART Promote prolonged breastfeeding in conjunction with use of ART Counseling on appropriate and timely weaning from breastfeeding and introduction of complementary foods Counseling on appropriate and timely weaning from breastfeeding and introduction of complementary foods Establish local capacity to produce therapeutic and supplementary foods (e.g., RUTF; FBF; urban and rural gardens) Establish local capacity to produce therapeutic and supplementary foods (e.g., RUTF; FBF; urban and rural gardens) Establish globally-accepted food security and nutritional status indicators which are harmonized with HIV/AIDS status indicators Establish globally-accepted food security and nutritional status indicators which are harmonized with HIV/AIDS status indicators

24 Acknowledgements Nicholas Vogenthaler - Emory University Nicholas Vogenthaler - Emory University Roshelle Payes and Eunyong Chung - USAID, Washington Roshelle Payes and Eunyong Chung - USAID, Washington Tonya Himelfarb – Office of the Global AIDS Coordinator, US Department of State Tonya Himelfarb – Office of the Global AIDS Coordinator, US Department of State Tim Quick and Amie Heap – USAID, Washington Tim Quick and Amie Heap – USAID, Washington

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26 AVAILABILITY: sufficient quantities of food from household production, other domestic output, commercial imports or food assistance ACCESS: adequate resources to obtain appropriate foods for a nutritious diet, which depends on income available to the household, on the distribution of income within the household and on the price of food UTILIZATION/CONSUMPTION: proper biological use of food, requiring a diet providing sufficient energy and essential nutrients, potable water and adequate sanitation, as well as knowledge within the household of food storage and processing techniques, principles of nutrition and proper child care and illness management Food Security Food security = all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life.

27 Global Undernutrition Stunting remains a greater problem than underweight or wasting. More than 1/3 of children in Africa & Asia are underweight.

28 Issues to Address Concerning Undernutrition  Stunting and iron deficiency anemia have not been adequately addressed  Stunting and iron deficiency anemia have not been adequately addressed  Poor growth in many countries related to inadequate breastfeeding, complementary feeding, and infectious disease  Refocus on dietary quality, high levels of morbidity, and possibly intergenerational factors affecting linear growth.  Targeting of pregnant women and children under 2 – ‘window of opportunity’ – especially in communities with highest prevalence of stunting  Gross inequities throughout region and within countries: Rural vs. urban; indigenous vs. non-indigenous  Human resources and capacity constraints for health and nutrition

29 PEPFAR Five-Year Strategy (FY ) Transition from an emergency response to promotion of sustainable country programs. Transition from an emergency response to promotion of sustainable country programs. Strengthen partner government capacity to lead the response to this epidemic and other health demands. Strengthen partner government capacity to lead the response to this epidemic and other health demands. Expand prevention, care, and treatment in both concentrated and generalized epidemics. Expand prevention, care, and treatment in both concentrated and generalized epidemics. Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems. Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems. Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes. Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes. (Executive summary of PEPFAR’s strategy: )

30 Nutrition Implications of HIV/AIDS Daily caloric needs: Daily caloric needs: Asymptomatic: 10% increase Asymptomatic: 10% increase Symptomatic: 20-30% increase Symptomatic: 20-30% increase Children with weight loss: % increase Children with weight loss: % increase Daily protein needs: Daily protein needs: Maintain at 12-15% of daily caloric intake (typically at least twice that of cereal- and tuber- based diets common in developing countries) Maintain at 12-15% of daily caloric intake (typically at least twice that of cereal- and tuber- based diets common in developing countries) Micronutrients (essential vitamins/minerals) Micronutrients (essential vitamins/minerals) At least daily recommended level s for non-HIV-infected individuals (which many such individuals as well s HIV/AIDS patients do not yet achieve) At least daily recommended level s for non-HIV-infected individuals (which many such individuals as well s HIV/AIDS patients do not yet achieve) Require high-energy, nutrient-dense foods Require high-energy, nutrient-dense foods

31 Recommended Elements for PEPFAR F&N Programs Nutrition Care – Goal: Improved/Adequate Nutrition Status Nutrition Care – Goal: Improved/Adequate Nutrition Status Nutrition Assessment, Counseling & Support (NACS) Nutrition Assessment, Counseling & Support (NACS) Assessment: Assessment: Anthropometric; Clinical; Dietary; Environmental (i.e., household food security) Anthropometric; Clinical; Dietary; Environmental (i.e., household food security) Counseling: Counseling: Clinical (adherence to ART ) Clinical (adherence to ART ) Dietary (use of special therapeutic and supplemental foods; adherence to WASH and food safety practices) Dietary (use of special therapeutic and supplemental foods; adherence to WASH and food safety practices) Psychosocial Psychosocial Support: Support: Food by Prescription; commodity support Food by Prescription; commodity support Safe Water Treatment Safe Water Treatment Multi-micronutrient supplements Multi-micronutrient supplements Referral to social services for livelihood and food security Referral to social services for livelihood and food security

32 Recommended Elements for PEPFAR F&N Programs PMTCT – Goal: HIV-Free Survival PMTCT – Goal: HIV-Free Survival ART: HAART; Maternal/Infant Prophylaxis ART: HAART; Maternal/Infant Prophylaxis Infant Feeding Counseling & Support Infant Feeding Counseling & Support Postnatal Care: Postnatal Care: Growth monitoring; Growth monitoring; Basic child survival package (immunizations; routine micronutrient supplementation; insecticide-treated bednets; Basic child survival package (immunizations; routine micronutrient supplementation; insecticide-treated bednets; Opportunistic infections: Cotrimoxizole; clinic referral) Opportunistic infections: Cotrimoxizole; clinic referral) Feeding Support Feeding Support Maternal Maternal Infant Infant Complementary Complementary Replacement Replacement Community Management of Acute Malnutrition (CMAM) Community Management of Acute Malnutrition (CMAM)

33 Recommended Elements for PEPFAR F&N Programs Livelihoods and Food Security – Goal: Household Food Security Livelihoods and Food Security – Goal: Household Food Security Food Production Food Production (Re-) Employment (Re-) Employment Involvement in income-generating activities Involvement in income-generating activities Vocational Training Vocational Training Food Commodity Affordability Food Commodity Affordability

34 Nutrition Assessment, Counseling, and Support (NACS) Clinical care and treatment services and F&N support are linked for PLWHA and OVC Clinical care and treatment services and F&N support are linked for PLWHA and OVC Reciprocal impact between health & nutrition Reciprocal impact between health & nutrition Therapeutic and corrective model  Preventive and chronic nutrition management model Therapeutic and corrective model  Preventive and chronic nutrition management model PLWHA and women in PMTCT are linked to groups for treatment and F&N support, education, and counseling PLWHA and women in PMTCT are linked to groups for treatment and F&N support, education, and counseling Referrals for livelihood (income-generating) and food security support Referrals for livelihood (income-generating) and food security support Health system strengthening -- strengthens capacity of clinics and communities to provide NACS for all individuals, not just HIV/AIDS infected and affected Health system strengthening -- strengthens capacity of clinics and communities to provide NACS for all individuals, not just HIV/AIDS infected and affected

35 Food Assistance for PLWHA & Families PEPFARWrap-around IndividualsOVC/PMTCT WomenHouseholds Hospital/Clinic LevelClinic/CommunityCommunity Clinical MalnutritionAny nutritional statusFood insecurity Severely malnourished adults Moderately malnourished adults Any nutritional statusHousehold food security assessment Therapeutic foods Supplementary foods Supplemental, supplementary & therapeutic foods Food aid commodities F-100, F-75, and ready-to- use therapeutic foods (RUTF) Fortified blended foods and ready-to- use supplementary foods (RUSF) Fortified foods, RUTF, RUSF. Fortified blended foods, grains, legumes, oil

36 Nutrition and HIV Indicators

37 Lessons Learned Clinics where NACS is initiated are understaffed and overstretched. Quality Improvement (QI) efforts will be critical to finding efficiencies that allow integration of NACS within clinical services Clinics where NACS is initiated are understaffed and overstretched. Quality Improvement (QI) efforts will be critical to finding efficiencies that allow integration of NACS within clinical services Training of healthcare workers are necessary, but not sufficient –all training should be linked to QI efforts and the realities of Human Resources (HR) Training of healthcare workers are necessary, but not sufficient –all training should be linked to QI efforts and the realities of Human Resources (HR) Training should be decentralized, and individualized to the needs of each of the different types of healthcare workers Training should be decentralized, and individualized to the needs of each of the different types of healthcare workers

38 Lessons Learned Prioritize provision of F&N program and services to the most vulnerable: Prioritize provision of F&N program and services to the most vulnerable: #1 - Infants and young children #1 - Infants and young children #2 - Pregnant and lactating women in PMTCT programs #2 - Pregnant and lactating women in PMTCT programs #3 - Adult PLWHA #3 - Adult PLWHA Roll-out of NACS should precede initiation of FBP programs -- build ability to carry out NACS and secure commodities Roll-out of NACS should precede initiation of FBP programs -- build ability to carry out NACS and secure commodities Counseling of “Food as Medicine” in FBP leads to limited sharing of food by patient within his/her household, resulting in good weight recovery Counseling of “Food as Medicine” in FBP leads to limited sharing of food by patient within his/her household, resulting in good weight recovery Assessment and counseling, even without provision of therapeutic foods and supplemental food commodities improves nutritional status of patients Assessment and counseling, even without provision of therapeutic foods and supplemental food commodities improves nutritional status of patients Linkage of F&N support to other community programs and public health surveillance results in improved nutritional and health outcomes at lower costs Linkage of F&N support to other community programs and public health surveillance results in improved nutritional and health outcomes at lower costs

39 Challenges in F&N Programming Integration and expansion of comprehensive NACS into other public health initiatives Integration and expansion of comprehensive NACS into other public health initiatives Linking clinical services with referral and support for food and livelihood assistance so as to produce sustainable food security among HIV/AIDS patients Linking clinical services with referral and support for food and livelihood assistance so as to produce sustainable food security among HIV/AIDS patients Balancing programming emphasis and resources for nutritional assessment and counseling with those needed for provision of food and feeding support Balancing programming emphasis and resources for nutritional assessment and counseling with those needed for provision of food and feeding support

40 Challenges in F&N Programming Balancing efforts to support food production among patients with support for (re-)employment, income generating activities, and other livelihood assistance Balancing efforts to support food production among patients with support for (re-)employment, income generating activities, and other livelihood assistance Balancing support and resources equitably among three vulnerable population groups: adult patients in care and treatment programs, women and infants supported in PMTCT programs, OVC Balancing support and resources equitably among three vulnerable population groups: adult patients in care and treatment programs, women and infants supported in PMTCT programs, OVC


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