FANTA Ethiopia_briefing 7 24 08.pdf

Briefing on Nutrition and HIV Globally and in Ethiopia

Tony Castleman Dr. Hana Nekatebeb FANTA Project, AED

July 24, 2008

Outline

1. Nutrition and HIV Globally

a. Emerging Evidence

b. Specialized Food Products

c. Food by Prescription Programs

d. Monitoring and Evaluation

2. FANTA Nutrition and HIV Activities in Ethiopia

EMERGING EVIDENCE

CSB vs. RUFS for Adult ART Clients:

Research Question

For malnourished adults starting ART, does supplementation with ready-to-use fortified spread (RUFS) improve nutritional and clinical status more than supplementation with corn-soy blend (CSB) does?

Design

• Randomized, investigator-blinded effectiveness trial.

• Implemented at Queen Elizabeth Hospital, Malawi by Washington Univ. at St. Louis (Mark Manary, PI).

• Non-pregnant adults starting ART with BMI < 18.5 kg/m2 (average baseline 16.5 kg/m2).

374 g./day CSB (1,360 kcal/day) for 3 months n=246

Enrollment n=491

Randomization

CSB vs. RUFS for Adult ART Clients:

Design

260 g./day RUFS (1,360 kcal/day) for 3 months n=245

Results

Results

Results

• After 3 months of supplementation, differences in gains in weight (1.3 kg), lean body mass (0.7 kg), & BMI (0.5) were statistically significant.

• At 3, 6, 9 months after food ended, there were no significant differences in any outcomes.

• Differences in CD4 counts, survival, QOL, adherence were not significant.

Summary

• Among malnourished, adult, new ART clients, supplementation with RUFS led to greater weight gain than CSB but the difference did not persist beyond the period of supplementation and there were no differences in immune response or survival.

FBF vs. No Food for HIV+ Adults:

Research Question

Does provision of fortified blended food (FBF) to malnourished HIV-infected adult ART and pre-ART clients improve nutritional status, clinical outcomes, and drug adherence?

Design

• Randomized effectiveness trial.

• Implemented at 6 HIV treatment sites in Kenya by Kenya Medical Research Institute (KEMRI) .

• 6 months intervention + 6 months follow-up.

• Malnourished adult (non-pregnant) ART clients and pre-ART clients.

Nutrition counseling n=~389

ART

enrollment n=~718

Randomization

FBF vs. No Food for HIV+ Adults: Design

300 g./day

FBF +

counseling n=~329

Nutrition counseling n=~239

Pre-ART enrollment n=~431

Randomization

300 g./day

FBF +

counseling n=~192

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

3-month Results - ΔBMI (pre-ART)

0.2

0.4

0.6

0.8

1.2

Baseline Month 1 Month 2 Month 3 food+couns.

3-month Results - ΔBMI (ART)

0.2

0.4

0.6

0.8

1.2

1.4

1.6

1.8

Baseline Month 1 Month 2 Month 3 food+couns.

3-month Results - ΔBMI

• Pre-ART clients

– Differences in BMI were statistically significant.

– In multivariate regression, food was a significant independent predictor of increased BMI.

• ART clients

– Differences in BMI not statistically significant, but were significant among women.

– In multivariate regression, food was not a significant predictor of increased BMI.

3-month Results – ΔCD4 count

0.888

0.023 p-value

-32.416.5Pre-ART

72.870.3ART

CounselingFood + Counseling

In multivariate regressions, food was significant for pre-ART but not for ART.

Summary

• Food supplementation improves nutritional status and immune response of pre-ART clients. The benefits were less for ART clients, with greater benefits for women than men.

• Remaining results (at 6 and 12 months, and QOL other clinical outcomes) will be available in August/September.

SPECIALIZED FOOD

PRODUCTS

Specialized Food Products:

Recent Developments

• Increases in food costs

– Implications for client coverage.

– Modifying ingredients, e.g. removing milk/whey: Malawi RUF, Kenya FBF

• Lipid-based Nutrient Supplements

(LNS)

(RUSF; RUFS; use soy instead of milk)

Specialized Food Products

(enhanced FBFs)

Food Products:

Procurement, Logistics, QA

• OGAC and USAID discussions on systems for food procurement, logistics, and QA for FBP programs

• SCMS, UNICEF, WFP, direct contracts

• Possible global guidance, as well as country-specific collaborations:

Ethiopia first for SCMS

FOOD BY PRESCRIPTION

PROGRAMS

Expanding Beneficiaries & Countries

• October 2007 modification of PEPFAR guidance: moderately/mildly malnourished adults included.

• FBP Countries Existing: Kenya, Uganda, (Malawi) Planned: Ethiopia, Haiti, Zambia Considering: Cote d’Ivoire, Mozambique, Namibia, Tanzania

Review of Kenya FBP Program

• Focus on client graduation, loss-to-follow-up, changes in nutritional status, use of food, integration into health system

• Quantitative data from facility records and program database

• Qualitative data from interviews, focus group discussions, and direct observations

Nutritional Status, Graduation

• Average increase in BMI during food supplementation is 1.7 kg/m2

• High correlation between BMI and CD4 counts in both ART and pre-ART

• On average adults require 4-6 months of food supplementation to graduate

Loss-to-Follow-up

• High loss-to-follow-up rate

– Especially high in first 1-2 months

– Broader problem for HIV treatment in Kenya

– Higher for men, for pre-ART clients, and for severely malnourished

• Reasons include:

– Poor access to facilities (transport cost, carrying food, employment, transfer)

– Mortality (untracked)

– Stigma

Integration in Health System

• Implemented through health system staff

• Greater alignment with ART services needed, e.g. appointment dates

• Sometimes viewed as parallel “nutritionists program”

Use of Food

• High degree of sharing food with other household members

• 300 g./day of fortified blended food

• Clients and service providers very favorable towards the program

MONITORING AND

EVALUATION

PEPFAR Next Generation Indicators:

COP 2010

Proposed indicators for OGAC decision

• % of clients who are malnourished

• No. of clients receiving food support

• % of malnourished clients receiving food support

Possible additions?

• No. of clients nutritionally assessed

• No. of clients receiving nutrition

FANTA M&E Guide for Nutrition-HIV