Food and nutrition at the 2009 HIV Implementers' Meeting

Additional reporting by Lance Sherriff

PEPFAR supports food and nutrition services for malnourished people in HIV care and treatment, PMTCT clients as well as orphans and vulnerable children. However, integrating nutritional support into HIV programmes poses great operational and logistical challenges — consequently, the provision of food supplements should be seen as a “short term fix” according to several experts speaking in a session on food and nutrition at the 2009 HIV Implementer’s Meeting in Windhoek. Finding more sustainable solutions that address the long-term food security needs of people with HIV, their families and communities will be critical.

“PEPFAR offers us an opportunity to better link activities through a development lens looking at economic growth, broader income generation, education and so forth,” said Dr Robert Clay, Director of the Office of Population, Health and Nutrition at USAID, who co-chaired the session. “It’s not just about food. There needs to be a whole package that goes into this.”

Notably, there has been a shift in policy within the Obama administration to focus on local agricultural development to provide increased food security — as evidenced by the recent announcement at the G8 meeting, of a $20 billion US-sponsored food security initiative over the next three years to boost agricultural investment in poorer countries and fight hunger by helping poor nations feed themselves — rather than relying on emergency food aid shipped from the US (see press release)

“"There is no reason why Africa cannot be self-sufficient when it comes to food,” said President Obama. “It has sufficient arable land. What's lacking is the right seeds, the right irrigation, but also the kinds of institutional mechanisms that ensure that a farmer is going to be able to grow crops, get them to market, get a fair price.”

How or whether these efforts will be linked into PEPFAR-supported projects is yet to be seen — however, a presentation by Wendy Hammond, a senior nutrition and HIV programme officer in FANTA2 suggests that these programmes will need to be well-coordinated.

Food by Prescription and Community-based Management of Acute Malnutrition

Already, according to Hammond, the implementation of two programme approaches to treating acute malnutrition in countries with high HIV prevalence: ‘Food by Prescription’ (FBP) and Community-based Management of Acute Malnutrition (CMAM), “being initiated simultaneously in many countries, is causing a lot of confusion - and in many cases at ministry level - about the differences between these two programmes because they are so similar. They have similar aims and they use similar methods.”

FBP includes nutrition assessment and counselling, provision of micronutrient supplements, point-of-use water purification means and specialised foods prescribed as part of clinic-based HIV services according to clinic entry and discharge or ‘graduation’ criteria. It is different from food assistance programmes such as that offered by the World Food Programme, because it integrates food and nutrition interventions into clinical HIV health services to improve ART adherence and outcomes.

The specialised foods for FBP include Ready to Use Therapeutic Foods (RUTF) and fortified blended foods, or FBFs, which are both meant to be eaten in addition to the normal diet for children and adults at risk of malnutrition.

The most common RUTF used is PlumpyNut a fortified peanut butter paste which is being produced locally in countries such as Zambia, Malawi and Kenya. (Another presentation at the conference on the use of PlumpyNut in malnourished Ugandan children with HIV reported greatly improved nutritional status, with 78/85  (92%) of the malnourished children reaching the 90% UNICEF weights/heights appropriate for their gender (Aweko). Research is being done on other RUTFs such as soy-based RUTFs for regions that are not used to eating peanut-based foods such as South-East Asia.

The FBFs are cereals fortified with micronutrients and sometimes other ingredients such as soya, beans, pulses, oil seeds and dried skimmed milk. These include corn soy blends and wheat soy blends that are mixed with water and cooked as a porridge. On average, FBFs are about five times cheaper than RUTFs, and for that reason the programme has tried to maximise their use and reserve the RUTFs for the more severe malnourished clients.

At the same time that PEPFAR-supported countries are poised to implement FBP, many are also rolling out CMAM, based upon the WHO treatment protocol to manage severe acute malnutrition (SAM) in children 6-59 months old in outpatient or inpatient care depending on the presence of medical complications.

The two approaches have different objectives:      

Food by Prescription

• Manage severe acute malnutrition and moderate acute malnutrition in PLHIV, OVC, and paediatric AIDS clients
• Provides supplemental feeding based on nutritional vulnerability, particularly for early weened infants up to two years old and HIV-positive women during pregnancy and lactation.  
• Strengthen clinical HIV care and treatment, or rather, ART adherence and effectiveness and the survival of people living with HIV

Community-based Management of Acute Malnutrition

• Manage severe and acute malnutrition in children regardless of HIV status
• CMAM provides specialised foods, RUTF, only for children who are already identified as severely malnourished, or malnourished.
• Identify severe acute malnutrition in the community for early initiation of treatment

However, the programmes are complementary and share a number of things in common including treating severe or moderate acute malnutrition; both treat most cases on an out-patient basis and give them the food to take home; both use RUTF (which should be locally produced); both emphasise capacity and nutritional assessment, counseling, treatment, prevention and classification; both integrate nutrition assessment and counseling into existing health services; and Hammond stressed:

“Both ideally - although this is usually the last component to be developed - refer rehabilitation clients to livelihood assistance programs, or income generation programs, to prevent them relapsing into malnutrition,” she said.

To better coordinate the two approaches, there is a call to harmonise guidelines for managing SAM at the global and country levels (admission and discharge criteria, registers/monitoring and reporting tools, and service aspects such as counselling/education messages and job aids and tools and community outreach to refer malnourished children to therapeutic feeding and also to HIV counselling and testing). “Targeting can be coordinated to maximise coverage in countries for example where CMAM addresses children and FBP can then take care of the adults,” said Hammond.

Commodity procurement/management and distribution should also be harmonized, according to Hammond, which could simplify procedures for food procurement, storage, management, and distribution.

Coordination at this level is often quite difficult though. Food by Prescription and Community-based Management of Acute Malnutrition are usually under different ministry directorates or divisions and may run parallel to routine nutrition services), and supported by different donors/funding mechanisms (usually CMAM by UNICEF and FBP by PEPFAR) with different data collection systems for monitoring and reporting demands).

But, Hammond reiterated — the food should only be part of the programme. Unfortunately, “the food tends to overshadow the other elements, especially the nutritional assessment and counselling.  In every country, when we start discussing initiating such a programme, the first thing that ministries are interested in - and sometimes missions - is ‘What foods are we going to use?’ ‘How are we going to procure them?’ ‘Who’s going to distribute them?’ when the nutritional assessment, counselling and training hasn’t even been contemplated. This is a real challenge,” she said.

Leveraging supply chain best practices for Food by Prescription programmes

But the addition of food support to the PEPFAR programme in 2008 has created complex logistical challenges, according to Ssanyu Nyinondi of Supply Chain Management Systems (SCMS).

First SCMS had to do considerable market research to see what is available in the market and identify the suppliers, then they had to evaluate the quality of the product to see whether it fitted the standards of each country that is being worked in. Then, they had to meet with all the various stakeholders to try to determine how much product would be needed.

“In addition to all of that we also have to go through an analysis of port freight and logistics costs — and it was very important to have this information beforehand so we could provide to the countries to incorporate into their budgets,” said Nyinondi. “All of this work is done in coordination with different partners in each of the countries that we are working in.”

Then there are activities related to procurement, storage and distribution.

“In this particular project one of the major challenges we have to face is the diversity in policy and regulations among countries - not only in the three different countries but within country itself - Registration of products [for importation] can be lengthy and requirements are different in each country. We had a situation in a country where the regulatory authority did not have an idea how to handle this product - it’s a FBP and should it be handled like a mineral supplement or is it food?” she said.

While SCMS might be dealing with one manufacturer, each country has specific requirements for packaging and labelling. This means the manufacturer has to go through a process of changing the labels to suit a particular country, which means more cost involved and it takes longer to have the food imported into the particular country.

“We also need to understand distinct storage requirements for these specialised products, especially like in the case of fortified blended flour. Which is to say, site assessments are very important. And fortified blended flour is food and attracts rodents and other pests whilst in storage,” she said. This caused problems for storage in some settings where they had initially been putting the food supplements with the medical supplies. “But you would not really like to store the food products with pharmaceuticals because they do not want rodents attacking the pharmaceutical products,” she said

In other situations, she said that SCMS had imported products into countries before it was clear which partner would distribute them. As a result, products just sat in storage until their shelf-life expired.

According to Nyinondi, several practices are needed to carry forward Food by Prescription programmes in-country and globally:

• Establish technical working groups to make decisions and coordinate with all of the stakeholders that are working in FBP programs to design and carry forward activities, including MoH, IPs, USG.
• Coordination among the different stakeholders Learn from what has already been happening in these countries where the products will be launched;
• Designing logistics systems for efficient distribution of these nutrition commodities is very important. As time goes on, more accurate estimations of the quantities needed will allow better procurement and planning of supply. Logistics systems can show consumption and allow for more informed decisions.

Finally, “we cannot stress enough to do proper site assessments just to make sure that the sites will be able to accommodate the food,” she said.

Operational challenges of integrating food assistance in health care programmes

In another presentation, Gertrude Kara from the WFP described the findings of a review of their activities implemented in 14 countries in the East and Southern Africa regions — which largely expanded upon the challenges that Nyinondi described.

One issue is that storage poses challenges for the patient as well — and affects how food can be distributed to them. Another issue is how it is perceived.

“The way the food is packaged and also the objective of the programme determines what type of food or how the patient perceives the food. For example with PlumpyNut, it is perceived as medicine so it is provided in a very big ration to the patient only. Whereas the food support to the household is associated with social welfare because it’s basically just to improve the food security of the household,” she said.

The products like ‘plumpy nut’ are easier to store and distribute because it can be stored in the pharmacy area. But the FBFs like corn soy blend present a challenge.

“Most people don’t have enough storage space for it and the packaging is also a challenge because for instance a 25 kg bag of corn-soy-blend — the patient only requires 10 kg per month it means scooping (measuring) and spilling and thus presents a challenge,” she said. As a result these supplies are often housed separately from the clinic, which poses a burden upon the patient especially whe timing of food distributions do not match clinic visits.

Likewise, clinic staff do not perceive food supplement provision as a clinical activity.

“I was attending the TB session this afternoon and nobody mentioned nutrition in terms of care and support. Which means that doctors and nurses, nobody, considers nutrition as part of their responsibilities when they are treating these patients. Since it is being considered as an added responsibility it is really a challenge to get people to implement the nutrition programmes,” she said.

Increased training is needed to address this issue, but the nutritional protocols should also be incorporated into the HIV care programmes.

“We are also trying to say this nutrition care should be integrated into the treatment protocol. When they are trying to do blood pressure, they should also consider weight, height as part of that protocol so that it becomes part and parcel of the treatment, care and support,” she said.

Finally, there are supply chain logistics — it can be especially difficult to keep small remote clinics consistently stocked when they only serve a small number of clients.

Sustainability and cost effectiveness

Kara believes that these logistics suggest there must be a better way of providing for the support of the household:

“We need to distinguish this from the specialised supplements because this is just for welfare, just to increase the security for the household. So these should be handled outside the health sector and it can be handled by volunteers, civil society and people outside the health infrastructure. Although the patient may be the entry point for identifying the vulnerability of the household.  We also should consider the use of other social transfer modalities like cash or vouchers and create bridges to existing social welfare schemes that could be inclusive or exclusive services but at least they have to be part in that,” she said.

While food supplementation programmes are very well-meaning, another representative of the WFP, Gideon Cohen of the World Food Program (WFP) in Ethiopia said that it is also important to assess the relative cost-effectiveness of these programmes.

“It’s very important that we have effective cost-benefit analysis tools for the whole issue of providing food and nutrition support to people living with HIV/AIDS. This is a major gap and it’s particularly important in our efforts to integrate the very high impact - but very high cost -  Food By Prescription approach with the kind of supplementary food that the World Food Programme Is also providing to people living with HIV/AIDS. We should recognise that these two types of food, which we’re giving to people living with HIV/AIDS, are inherently complementary and that it’s very important to see how we integrate them. It is not only important for us to see what the clinical outcomes are, but we have to look beyond that and we also have to see where we should be putting the money. I’m not saying that either type of food should be given preference but it’s very important for us to see where we should put the money and where we have the high impact. I don’t think we have an adequate evidence-base to answer those questions yet.”

Finally, he said that partners need to very careful in how we target food toward people living with HIV/AIDS.

“We should make sure that if we give food to people living with HIV/AIDS, this should be a short-term investment for other long-term gains like ART enrollment and ART adherence. And we should definitely be making sure that we use food assistance, whatever type of food it is, as a bridge and make sure that we are giving people enough information so that after that they can look after their own nutritional needs. The long term solution for people living with HIV/AIDS must be that we improve the quality of their diet and that people take responsibility for having a healthy diet themselves,” he concluded.