Session 7: Integrating Nutrition Assessment, Counselling, and Education into HIV and AIDS Care Nutrition Management with HIV and AIDS: Practical Tools for Health Workers Session 7 should take approximately 3 hours, 20 minutes Step 1: Overview and Objectives (Slides 1-2) – 5 minutes Step 2: Stages of HIV and Nutrition (Slides 3-6) – 15 minutes Step 3: Nutrition Assessment (Slides 7-18) – 20 minutes Step 4: BMI Calculation Practice (Slide 19) – 20 minutes Step 5: Nutrition Assessment and Action Plan (Slide 20) – 5 minutes Step 6: Integration (Slides 21-26) – 15 minutes Step 7: Nutrition Counselling (Slides 27-29) – 10 minutes Step 8: Counselling Role Play (Slide 30) – 60 minutes Step 9: Integration Case Study (Slide 31) – 45 minutes Step 10: Key Points (Slide 32) – 5 minutes Introduce the final session for this training and explain that it incorporates all of the previous sessions into how to conduct nutrition assessment and integrating nutrition into HIV and AIDS care.

Objectives Appropriately assess and counsel patients on nutrition and HIV Identify ways to integrate nutrition into HIV and AIDS care Review the session objectives and ask if there are any questions

Nutrition at Each Stage of HIV: Stage 1 Symptoms No other infections Generalised fatigue Nutrition Considerations Healthy eating and hydration (drink fluids) Nutrition assessment and education Step 2: Stages of HIV and Nutrition (Slides 3-6) – 15 minutes We can look at integrating nutrition care with HIV care through each stage of HIV. At the first stage, the individual has not developed any other infections yet, but feels generally fatigued. During this stage, the client is generally healthy with few complications thus we want to promote healthy, balanced eating with a variety of locally available foods and hydration with fluids. All clients should be assessed and provided nutrition education to prevent malnutrition and wasting.

Nutrition at Each Stage of HIV: Stage 2 Symptoms: Some other infections, but still in good overall health Weight loss (less than 10 percent of normal weight) Nutrition Considerations: Continue efforts for Stage 1 Follow-up nutrition assessment Address nutrition-related side effects Prevent weight loss Prescribe micronutrient supplements, if indicated In stage 2, there may be some other infections, and some weight loss, but overall the individual is still in good health. However, the weight loss should be addressed. Nutrition considerations during this stages would be to continue efforts from stage 1, follow-up with nutrition assessment, address nutrition side-effects, such as weight loss or diarrhoea, prevent further weight loss, and provide micronutrient supplement if indicated and available. Other Stage 2 Symptoms: Recurrent respiratory tract infections Herpes zoster Seborrhoeic dermatitis Recurrent oral ulcerations

Nutrition at Each Stage of HIV: Stage 3 Symptoms: More serious infections Severe weight loss (greater than 10% loss of usual weight) Chronic, unexplained diarrhoea for > 1 month Unexplained anaemia Nutrition Considerations: Continue efforts for Stages 1 and 2 Nutrition management for: weight loss/malnutrition, ART, and infections Coping strategies In stage 3 we see more serious infections, wasting syndrome (severe weight loss of greater than 10% of usual weight, unexplained diarrhoea), and anaemia. Considerations during this stages are to more aggressively provide nutrition care in terms of treatment for weight loss and malnutrition, ART management and treatment of infections. Coping strategies are also essential at this stage to explore psychosocial support systems available. Other symptoms of stage 3: Unexplained, persistent fevers for > 1 month Oral candidiasis (thrush) Nutrition management for Side effects: nausea, diarrhoea, dehydration, mouth sores, infections (wound healing), anaemia and prevention of malnutrition. Increase protein intake if infections persist or if untreated

Nutrition at Each Stage of HIV: Stage 4 Symptoms: AIDS More serious infections with life-threatening complications HIV Wasting Syndrome Nutrition Considerations: Continue nutrition management of side effects, as appropriate for client’s prognosis Provide comfort and manage pain Fluids for hydration Stage 4 is often quite severe with the client at full-blown AIDS with more serious complications and wasting syndrome. However, with proper treatment and support, an individual can reach this stage and recover to where they can live longer. Nutrition considerations include providing management for side effects, as appropriate for prognosis, comfort and pain management, and hydration with fluids. Other Stage 4 symptoms: Pneumocystis pneumonia Recurrent OI’s compromising food intake If the patient is co-infected with another STI, TB, malaria, hepatitis A, B, or C, or other illnesses not associated with HIV their need for nutritional care and support is increased.

Nutrition Assessment Anthropometric Biochemical Clinical Dietary Environmental Food Security Step 3: Nutrition Assessment (Slides 7-18) – 20 minutes Refer participants to Handout 7.1 to follow along a sample assessment form. Listed are the key areas of nutrition assessment. Ask participants to try and define each. Use the following notes for discussion: Anthropometric is the collection of physical measurements such as weight, height, head circumference Biochemical refers to lab values Clinical refers to medical history, side effects, and/or medications Dietary refers to all considerations around eating habits, food availability and storage.

Anthropometrics Height (cm) at first visit for adults, at each visit for children Weight (kg) at each visit Percent weight loss, if applicable Mid Upper Arm Circumference (MUAC) at each visit Body Mass Index (BMI) at each visit Listed are the indicators commonly used for anthropometric measurements. These will each be discussed in detail

Weight Loss Calculation Percent weight loss UBW = Usual Body Weight CBW = Current Body Weight Formula: % loss = UBW – CBW x 100 UBW Body weight can be correlated to nutrition status and medication tolerance, therefore is necessary to be measured at each visit. When a person loses weight, it is important to know how much they lost. We assess this by looking at percent weight loss. This is because, for example, losing 5 kilograms would be more serious for someone who weighs only 50 kg verses someone who weighs 80 kg. Therefore we want to know the percent weight they lost relative to their usual weight. We consider usual weight to be baseline, or the most consistent weight recorded for a client. The formula is as listed on the Slide. Provide an example for participants using the flip chart. For example a person who usually weighed 65 kg now comes to the clinic and weighs 60 kg. Complete the calculation with the help of participants so that they see how it is calculated. 65 minus 60 divided by 65 multiplied by 100 = 7.7% weight loss. Take a few minutes to do this so that everyone understands the calculation. Provide participants with calculators if available, or they can use calculators on their cell phones.

Mid Upper Arm Circumference Use measuring tape; measure in cm Estimates muscle loss If less than 23 cm, possible muscle wasting  intervene with nutrition counselling Mid upper arm circumference is sometimes used as a way to see if a client who is losing weight is losing too much muscle. It has many limitations, but can be useful when looked at in combination with other anthropometric measurements. To measure MUAC, find the center part of the upper arm – between the shoulder and elbow. Measure around the arm at that spot with a measuring tape. If this measurement is less than 23 cm for an adult, there could be possible muscle loss. This measurement is best used when done repeatedly, even as a patient is trying to gain weight.

Body Mass Index (BMI) BMI is used to assess an adult’s weight based on their height. Not used for children or pregnant women A quick and easy way to estimate weight status (e.g. underweight, normal weight, overweight). Refer to BMI reference chart and calculation sheet Refer participants to Handouts 7.2. The body mass index is used to assess an individual’s weight based on their height. Although this measurement has limitations as it does not take into account age or sex, it is useful in determining if someone is underweight, which has been linked to shortened survival in HIV-positive individuals. It is also quick and easy for clinicians to use in assessing height and weight.

BMI Reference Chart Adapted from: RCQHC/FANTA Explain the BMI reference chart. Let participants know that they will get to practice this later on in the session BMI reference chart and calculation sheet: Adapted from BMI resources from the Regional Centre for Quality of Health Care, Makerere University Medical School, Kampala, Uganda. Technical support by FANTA (Food and Nutrition Technical Assistance) and LINKAGES and Bray, GA, Gray, DS. Obesity, Part I, Pathogenesis, Western Journal of Medicine. 1988 Oct;149(4):429-41. Adapted from: RCQHC/FANTA

Biochemical Laboratory values as available CD4 count and all other routine values with: Blood cholesterol (fat) Blood glucose (sugar) Haemoglobin (blood iron) Urine test, look for ketones Parasites (e.g. worms) Ask participants what lab values are routinely taken for patients. For urine test, high level of ketones can be one indication of undernutrition or protein deficiency Routine labs should be assessed when doing a nutrition assessment, and addition of lipids and glucose could help detect metabolic changes. If a client continues to lose weight or malabsorb food, then have parasites tested to detect for worms.

Clinical Assess and counsel on management of complications Diarrhoea Nausea/vomiting Poor appetite Mouth sores Changes in taste Medication Regimen Discuss food effects, interactions, and herbal/traditional therapies In terms of clinical assessment, we want to assess potential nutrition complications, as discussed in Session 3. Refer participants back to Handouts 2.1 (Symptom Management Guide) and 3.2 (Food Effects of ART) for information on common side effects. Medication regimen is considered here, as well as traditional therapies.

Dietary How many times a day does the client eat? What does the client eat in a typical day? How does the client: Keep foods cold (refrigerator, freezer, other methods)? Cook food (stove, open fire)? Keep dishes, utensils, and cooking areas clean (soap, water)? The dietary assessment involves asking open-ended questions to obtain a record of a client’s usual eating habits, where they obtain food from, and the type of storage they may have.

Environmental Assess hygiene and sanitation situation at home and community Where does the family get water from? Is there a latrine in the home or communal latrine? If so, how is it maintained? Is garbage removed often and safely? Are client and family aware of basic food and water safety practices

Food Security Where does the food come from? Market, supermarket, home garden? Are there community or village gardening projects that client can be referred to? Know which local, nutritious foods are available in the community, and promote these instead of expensive foods from shops

Additional Information Other illness or opportunistic infections E.g. Tuberculosis, malaria, pneumonia, or skin problems Lifestyle practices (smoking, alcohol use, and unsafe sex) Family/community support system Educational level Living environment (housing, income, and number of members per household) These factors may or may not already be included in HIV counselling – want to emphasise them, however.

Anthropometric Measurement and BMI Calculation Practice Step 4: Anthropometric Measurement and BMI Calculation Practice (Slide 19) – 40 minutes Use scales, measuring tape and/or stadiometers to do the anthropometric measurement activity. This is best done in pairs or small groups so that each person has a chance to practice on at least one person. Each participant should measure weight and height correctly on at least one other person. For the next activity, break participants into pairs. Ask participants to refer to Handout 7.2 again and to Worksheet 7.1. Explain that they will take the measurement of weight and height in pairs, using height and weight scales. Calculate one example for participants before they start their work in pairs Allow participants 10-15 minutes to calculate in pairs. Bring group back together and ask if there is any confusion or outstanding questions surrounding this process. Emphasise how quickly this measurement can be obtained.

Nutrition Assessment Action Plan Step 5: Nutrition Assessment and Action Plan (Slide 20) – 5 minutes Refer participants to Handout 7.3 This scheme is a nutrition assessment action plan for treating nutrition at various stages. Once an assessment is done, the client is diagnosed as one of three broad categories based on the assessment: severe malnutrition, moderate malnutrition, or well nourished. Then based on the diagnosis, we need to formulate an action plan for either treating malnutrition or praising good eating habits. All action plans must involve follow-up care, where the cycle begins again with nutrition assessment, diagnosis, and action plan.

Integration of Nutrition into HIV and AIDS Care Begin at VCT services Address food availability and access Weight loss prevention can improve survival Step 6: Integration (Slides 21-26) – 15 minutes When integrating nutrition into HIV and AIDS care, we must begin at voluntary counselling and testing services. Issues such as food availability and prevention of side effects like weight loss can be discussed here.

First HIV Visit Complete full nutrition assessment Obtain baseline height and weight, calculate BMI, and measure MUAC Ask about recent weight loss or inability to eat (due to illness) Ask about food availability, food storage, and cooking facilities in home Provide nutrition counselling on healthy eating At the first HIV visit, health workers should complete a full nutrition assessment to obtain a baseline height and weight, calculate BMI and measure MUAC. Consider their stage of HIV at diagnosis – many clients are only tested once they’ve progressed into later stages. Ask about recent weight loss or inability to eat (due to illness) Ask about food availability, food storage, and cooking facilities in home Provide nutrition counselling on healthy eating

Follow-up Visits Continue with nutrition assessment Obtain height (if not already done), weight, calculate BMI, MUAC and % weight loss, if necessary Ask if any problems eating Ask if any change in food availability, storage or cooking facilities at home At each follow-up visit, nutrition assessment should be completed again, to assess any changes in the client’s condition. This includes obtaining weight, calculating BMI and MUAC again, and assessing weight loss if applicable. Side effects and problems with eating should be addressed at this time, as well as food availability, storage, and cooking facilities.

For Patients in the Hospital Take note of whether the patient is eating and how much If the patient needs help and family members are not there, provide help with eating Weigh patients Counsel patient on adjusting food intake for management of side effects When people are ill, they often do not feel like eating or cannot physically feed themselves. These are times when people need extra support from family or community members to ensure they eat enough. Terminally ill clients should be cared for with extra comfort to manage pain. In terms of food, they should not be forced to eat, but encouraged to eat small amounts of food and drink plenty of fluids as tolerated as part of comfort care. Patients in the hospital may need assistance with eating, as family members may not always be available to assist. This should be considered by health workers in wards where patients are often too ill to eat. Patients can recover much faster if they are able to eat well. As with patients in the hospital, those who are at home may also need assistance with eating. Home based care and other support systems should be considered to provide assistance. Ask participants who are working in-patient whether there are people in the wards to assist patients with eating.

Integration into ART Programme Before ART, assess food availability and intake situation Assess weight status Use Food and Medication Time Table when discussing medication schedule At each follow-up, obtain current weight and side effects Counsel appropriately on side effect management and good nutrition Integration into the ART services at a health facility include assessing food availability and intake before ART begins. This also includes assessing weight status Use Food and Medication Time Table when discussing medication schedule and provide suggestion on food or medication adjustment to best fit the client’s situation At each follow-up, obtain current weight and side effects Counsel appropriately on side effect management and good nutrition

Integration into PMTCT and Ongoing Paediatric Care Counsel mothers and partners on all infant feeding options for PMTCT Support infant feeding choice Educate on dangers of mixed feeding Monitor growth and feeding of infant For infants on replacement feeding, educate on and monitor formula/milk supply and preparation To integrate into PMTCT, mothers and partners need to be counselled on all feeding options and supported in their infant feeding choice. Important information to share includes the dangers of mixed feeding for HIV transmission and growth monitoring and promotion. Infants on replacement feeding need to be monitored for adequate growth and correct preparation, steady supply of milk.

Nutrition Counselling Listen to client; assess individual situation Ask open-ended questions (who, what, when, where, why, how?) Be realistic and practical with counselling; set realistic goals with client Encourage good eating habits Be a role model for clients Maintain confidentiality always Step 7: Nutrition Counselling (Slides 27-29) – 10 minutes When we provide any type of counselling we must always listen to the client and take their individual situation into account. Ask open-ended questions (who, what, when, where, why, how?) Provide some examples of closed-questions and ask participants to rephrase them to be open-ended. For example: Instead of “Do you eat every day?”…try “What did you eat yesterday morning, afternoon, evening, in between…?” Be realistic and practical with counselling; set realistic goals with client Encourage good eating habits Be a role model for clients Maintain confidentiality always

Making Suggestions, not Commands Commands use the imperative form of verbs (give, do, bring) and words like always, never, must, should Suggestions include: Have you considered …? Would it be possible …? What about trying … to see if it works for you? Would you be able to …? Commands use the imperative form of verbs (give, do, bring) and words like always, never, must, should. Suggestions include: Have you considered …? Would it be possible …? What about trying … to see if it works for you? Would you be able to …? Give examples of good phrasing and poor phrasing for counselling.

Making Suggestions, not Commands Suggestions include: Have you thought about …? Instead of …? You could choose between … and … and … It may not suit you, but some mothers … a few women … Perhaps … might work Usually … Sometimes … Often … Follow-up with open-ended questions using: who, what, when, where, how, why Suggestions include: Have you thought about …? Instead of …? You could choose between … and … and … It may not suit you, but some mothers … a few women … Perhaps … might work Usually … Sometimes … Often … Follow-up with open-ended questions using: who, what, when, where, how, why

Counselling Role Play Step 8: Counselling Role Play (Slide 30) – 60 minutes Refer participants to Worksheet 7.3. Divide class into groups of 3 and ask groups to assign one role to each group member: client, health worker, observer. Allow 30-40 minutes for the role plays, then 20-30 minutes for large group discussion. Use the instructions in the facilitator guide and Worksheet as needed.

Integration Case Study Step 9: Integration Case Study (Slide 31) – 45 minutes This case study incorporates all that was discussed in this unit and allows participants to put it into practice. Refer participants to Worksheet 7.4 Divide class into 2-3 groups to work through the case study. Allow about 20 minutes for groups to work on the case and about 20 minutes for discussion Use the instructions in the facilitator guide and Worksheet as needed.

Key Points All persons with HIV and AIDS need nutrition counselling and assessment Obtain weight and calculate body mass index Integrate nutrition and food security assessment into regular HIV care Step 10: Key Points (Slide 32) – 5 minutes List the key points on the Slide and ask if there are any final questions