African governments are urgently facing a range of policy and programme challenges related to food, nutrition, and scaling-up programmes to accelerate access to life-saving antiretroviral therapy (ART) and HIV care. To address these issues, the World Health Organization held a Consultation on Nutrition and HIV/AIDS in Africa, in Durban South Africa from the 10-13 of April.
The meeting involved 230 participants from 20 countries, six UN agencies, eight Regional Groups and 21 NGOs — with representatives from bilateral organisations, research groups and institutions, donors and people living with HIV and AIDS.
The participants were divided into five working groups to discuss the latest evidence on nutrition and HIV/AIDS and to develop strategies to help improve the health status of people living with HIV/AIDS in southern and eastern African countries. The deliberations to help produce a meeting statement, a series of action points for implementation, and recommendations at the conclusion of the consultation, were at times difficult.
Processing evidence into action
This was a challenging process because the relationship between nutrition and HIV/AIDS is complex— particularly in settings with chronic malnutrition and food security. Furthermore, evidence on which to base programmatic action was often lacking.
Also, even though each working group had the same set of questions to consider, they approached the questions differently. The participants in this meeting came from diverse cultures, work environments and academic disciplines and thus viewed several of the key issues from various perspectives. At times, they seemed to speak past each other.
For example, some of those (often from a development or emergency relief background) found calls to monitor and evaluate food-based interventions distasteful. “Conducting clinical research of food-based interventions is unethical” declared one working group. They had concerns, perhaps justifiable, that the addition of a clinical monitoring component (and accountability) to development and food relief programmes could jeopardise the timely and efficient delivery of aid — and increase parallel overhead costs.
In contrast, many of those coming from a clinical AIDS treatment background often wanted to know whether specific nutritional interventions, such as food packages, offered clinical benefit above and beyond ameliorating hunger and increasing weight. In fact, another working group concluded that monitoring and evaluation of integration of food and nutrition into HIV/AIDS control programmes was absolutely essential.
Said Dr. Andrew Tomkins of the Institute of Child Health: “I do not feel it is responsible for any individual or organisation to use their resources – which are not their resources, since they are paid for by governments, national or international agencies — unless there is an evaluation of it. I do feel that we would never get away with this in medicine. We will never be able to know whether an antibiotic worked without a proper trial and a proper evaluation…
“But time after time we hear of worthy people doing worthy things with food. And all I would say is that we can design studies in which it is possible to know whether food supplements, programmes that increase household food security make a difference. It is not impossible to [1st] compare the impact of extra food for HIV, or TB-associated HIV, to see whether it makes an effect on body weight, or more importantly, body composition. — as there is some suggestion that the weight gain may actually be preferentially fat rather than lean body mass in some of the nutritional supplementary regimes; and 2nd to see what actually happens to communities and families affected."
Dr. Tomkins urged the groups to work out their differences.
While the participant’s final statement and recommendations are still being edited, and will be presented to WHO Executive Board in one month, here are the preliminary action points.
Conduct advocacy to strengthen political commitment and improve the positioning of nutrition in national policies and programmes
- Use existing advocacy tools, and develop news ones, as needed, to sensitise decision-makers about the urgency of the problem and impact on development targets.
- Such advocacy should be to increase commitment and support for improved nutrition, in general, and for addressing the nutritional needs of HIV-affected and infected populations, in particular.
Develop practical nutrition assessment tools and guidelines for home, community, health facility-based and emergency programmes
- Validate simple tools that can be used by front line workers to assess diet, nutritional status, and food security so that nutrition support provided within HIV programs is appropriate to individual needs.
- Develop standard operating procedures to define the nutrition actions that should be taken at health-facility and community levels and improve quality of care (who, what, when, and for how long).
- Review and update existing treatment protocols to include nutrition/HIV considerations (e.g., integrated management of adult illness, ARV treatment, nutrition in emergencies).
Implement at scale existing interventions for improving nutrition in the context of HIV
- Accelerate implementation of the Global Strategy for Infant and Young Child Feeding.
- Renew support for the Baby Friendly Hospital Initiative.
- Accelerate training and use of guidelines and tools for infant feeding counselling and maternal nutrition in PMTCT programmes.
- Expand access to HIV counselling and testing so that individuals can make informed decisions and receive appropriate advice and support on nutrition, including in emergency settings.
- Implement WHO protocols for vitamin A, iron-folate, zinc, multiple micronutrient supplementation and management of severe malnutrition.
Build a learning environment at all levels, through operations research and information sharing, to facilitate evidence-based programming
- Develop and implement operations research to identify effective interventions and strategies for improving nutrition of HIV infected and affected adults and children.
- Document results, publish findings in journals, and ensure access to lessons learned at all levels.
Develop human capacity and skills to ensure that nutrition is appropriately implemented in HIV prevention, treatment, and care programs
- Include funding for nutrition capacity development in HIV scale up plans.
- Incorporate nutrition into training of front line health, community and home-based care workers. Specific skills such as nutritional assessment and counselling, and program monitoring and evaluation should be included. Such training should be not favour particular commercial interests.
- Strengthen the capacity of government and civil society to develop and monitor regulatory systems to prevent commercial marketing of untested diets, remedies, and therapies for HIV-infected adults and children.
Incorporate nutrition indicators into HIV/AIDS monitoring and evaluation plans
- Include appropriate nutrition process and impact indicators for community surveillance, and national, regional, and international progress reporting.
For more info
More in depth coverage of this meeting will be presented in upcoming issues of HIV & AIDS Treatment in Practice, NAM's electronic newsletter on HIV treatment in resource-limited settings.