Food and Nutrition Assistance Programs to HIV Infected and Affected Individuals

Rahul RawatResearch Fellow

Poverty Health and Nutrition DivisionRegional Network on AIDS, Livelihoods, and Food security (RENEWAL)

International Food Policy Research Institute (IFPRI) & Concern Worldwide

Rationale for Nutrition Programs

High geographic overlap between HIV prevalence, malnutrition, and chronic food insecurity; weight loss is a significant prognostic factor of mortality since the beginning of the AIDS epidemic

Despite improved access to ART, malnutrition complicates the provision of care in resource limited settings− low BMI at ART initiation is an independent predictor of early mortality

(Zambia, Malawi, Tanzania)

The proposed benefits of early weight gain serve as the theoretical basis for food supplementation programs

Limited evidence of impacts of nutrition interventions

Source: Zachariah et al (AIDS 2006); Johannessen et al. (BMC Infectious Disease 2008); Koethe et al. (JAIDS 2010)

Nutrition Program Responses

HIV services integrating food and nutrition components− Food by Prescription

• Specialized Food Products (RUFs, FBFs)

Food Assistance Programs− Delivery of food baskets (CSB, oil, maize meal, pulses etc.)− Title II, WFP

Livelihood Security Programs− Provision of agricultural inputs and training to promote local

food production

Evidence of Impact: Specialized Foods

Supplementary feeding to malnourished patients− Fortified spread compared vs. CSB

− No significant differences in mortality, immunological status, quality of life, or ART adherence

− Impacts were not sustained at 12 months

Outcome at 14 weeks

Fortified Spread

Corn Soy Blend

Difference (95% CI)

Gain in BMI 2.2 (1.9) 1.7 (1.7) 0.5 (0.2 - 0.8)

Gain in fat free body mass (kg)

2.9 (3.2) 2.2 (3.0) 0.7 (0.2 – 1.2)

Weight gain (kg) 5.6 (4.8) 4.3 (4.0) 1.3 (0.5 – 2.1)

Source: Ndekha et al. (BMJ 2009); Ndekha et al. (TMIH 2009)

Evidence of Impact: Food Assistance

Zambia (Prospective Design)

Pilot study of WFP food supplementation to food insecure adults initiating ART in ART sites in Lusaka

Food supplementation for 6 months to food insecure patients/HHs had no impact on weight gain or CD4 count

Impact on adherence: 70% of patients in experimental group achieved 95% MPR vs. 48% in control group

Source: Cantrell et al .(JAIDS 2008)

Evidence of Impact: Food Assistance

Uganda (Retrospective Evaluation of the TASO database)

TASO electronic monitoring data system− patient's intake registration form; medical visit summaries; counseling visit

summaries; ART initiation and other drug use; social support services

Between 2002-2007 TASO had 195,676 registered patients− Database for analysis had 14,481 patients

Examined changes over 12 months for patients and how the receipt of FA influences weight gain and disease progression

• Used PSM to match each FA recipient with similar non-FA recipients; uses the outcome of the non-FA recipients as a proxy for the outcome of the FA recipients if they had not received FA

Source: Rawat et al. (BMC Public Health 2010)

Impact of Food Assistance on Weight Gain

Change in Weight (kg)

Food assistance Recipients

(n)

Matched Controls

(n)

ATT a(absolute value of

t-statistic)

Overall 3202 11069 0.36(3.19)**

Conditional estimates

Without ART 2783 9661 0.48(2.14)*

With ART 546 1120 0.17(1.5)

Baseline WHO stage 1 327 1479 -0.2(0.55)

Baseline WHO stage 2 2329 7318 0.26(2.3)*

Baseline WHO stage 3 615 1807 0.2(1.8)+

Baseline WHO stage 4 58 129 1.9(1.9)+

** significant at 1% ; *significant at 5% ; + significant at 10%a Absolute value of t-statistics on ATT, in parentheses, are based on bootstrapped standard errors

Source: Rawat et al. (BMC Public Health 2010)

Impact of Food Assistance on Weight Gain

Change in Weight (kg)

Food assistance Recipients

(n)

Matched Controls

(n)

ATT a(absolute value of

t-statistic)

Overall 3202 11069 0.36(3.19)**

Conditional estimates

Without ART 2783 9661 0.48(2.14)*

With ART 546 1120 0.17(1.5)

Baseline WHO stage 1 327 1479 -0.2(0.55)

Baseline WHO stage 2 2329 7318 0.26(2.3)*

Baseline WHO stage 3 615 1807 0.2(1.8)+

Baseline WHO stage 4 58 129 1.9(1.9)+

** significant at 1% ; *significant at 5% ; + significant at 10%a Absolute value of t-statistics on ATT, in parentheses, are based on bootstrapped standard errors

Source: Rawat et al. (BMC Public Health 2010)

Outcomes of Interest in Programs

Individual

• Disease progression (CD4 count, WHO stage)

• Nutritional status (BMI, MUAC, Hb)

• High risk behavior• Labor activities• Quality of life• Disclosure• Stigma

Household

• HH food security • Dietary diversity• Child nutritional status (<5 yrs)• Economic activities and

employment• Asset ownership• Expenditure (food & non food)• Agriculture production• Credit & savings

Determinants of Nutritional Status among Uganda HIV-infected Individuals

Previous studies consistently show malnutrition as a strong predictor of mortality

Determinants of malnutrition among PLHIVs are not well established− Do HH characteristics like dietary diversity and food insecurity influence

nutritional status, independent of disease progression?

Dietary Diversity, Food Security and Nutritional Status

Dietary diversity and HH Food Security are significantly associated with nutritional status (BMI & MUAC), independent of SES, and disease stage (CD4 count)

Severely food insecure HHs (Category 4) had 3-times the odds of being malnourished (BMI<18.5 kg/m2; p=0.002)

19.5

20

20.5

21

21.5

Low (0-4 Groups)

Med (5-8 Groups)

High (9-12 Groups)

Adjusted Mean BMI

Δ=0.96 kg/m2; p = 0.008

Δ=0.5 kg/m2; p = 0.031

Mean BMI values adjusted for CD4 count, sex, district, HH size, education, income

Source: Rawat et al. (in preparation); Kadiyala et al. (in preparation)

Summary of Impact of Nutrition Support

Improvements in weight, possibly ART adherence No impact on immunological status

Knowledge Gaps− Composition of support− Timing of support

• pre ART vs. post ART• role in delaying progression

− Pregnant and lactating women vs. OVCs vs. malnourished adults− Exit criteria− Impact on HH level characterisitcs

Livelihood Security Programs

Livelihoods Programs− Objectives are to promote food and livelihood security

− Provision of agricultural inputs and training to promote rural livelihoods and local food production; promotion of income generating activities

• Widely implemented• Questions remain about sustainability and scale-up• Limited documented impact evaluation studies

Applying a Program Theory Framework to Examine Integrated HIV and Livelihood Interventions

Critically examined 20 org. implementing livelihood interventions throughout Uganda, implemented by TASO partners

Objectives

1. Examine the extent to which livelihood interventions integrated into HIV care and treatment programs (IHLPs), implemented by a wide set of organizations, present coherent and consistent causal pathways to improving food security of people afflicted by HIV

2. Identify critical components of IHLP processes necessary to achieve the intended outcomes

3. Investigate the approaches taken to adequately address the articulated challenges in IHLP processes

Source: Kadiyala et al. (JDE 2009)

Operations Research to Examine Livelihoods Programs Integrated with HIV Care and Treatment

Program theory identifies the processes by which a program is intended to achieve its impacts

Impact Theory

•Specifies impact pathways

•Identifies the steps by which a program intervention is expected to impact outcomes

•Identifies the hypothesized cause-and-effect pathways that connect a program’s activities to its expected outcomes

Process Theory

•Shows steps by which intervention or program is implemented

•Includes steps related to organizational plan to deliver services

•Also includes assumptions of how and why beneficiaries will actually utilize a service

General Findings

Monitoring and evaluation frameworks need strengthening− Key process and impact indicators not well defined or collected

The complex pathways to achieving impact need to be further defined

Causal pathways are, in theory, plausible− However, program implementation activities need to be monitored

Need to strengthen planning and implementation to integrate livelihood interventions with complementary services

Program activities and inputs (material and intellectual) were consistent with, and appropriate to, program objectives − However, there are assumptions about practical implementation

PEPFAR Conceptual Framework for Food and Nutrition Support in HIV Services