GUIDANCE NOTE | 2014
Nutrition assessment, counselling and support for
adolescents and adults living with HIV
a programmin...
UNAIDS / JC2628 (English original, July 2014.)
Copyright © 2014.
Joint United Nations Programme on HIV/AIDS (UNAIDS).
All ...
4 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV
ACKNOWLEDGEMENTS
The d...
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Foreword	8
Acronyms	10
...
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Micronutrient intake ...
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How can linkages be mad...
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FOREWORD
This programm...
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WFP’s recent work in th...
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ACRONYMS
AIDS acqui...
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INTRODUCTION
This prog...
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„„ donors, including ...
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clinical malnutrition....
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also addresses the ro...
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CHAPTER 1 HIV, AIDS AN...
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In a person living wi...
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symptoms, HIV-related ...
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What is TB?
TB is usu...
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patients, and should b...
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232 Consolidated guid...
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the early period of tr...
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The following barrier...
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Challenges with access...
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„„ Nutrition assessme...
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Mortality risk is part...
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CHAPTER 2	NUTRITION, ...
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with a combination of ...
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may increase their ri...
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The more advanced the ...
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balance or need to co...
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be different sources o...
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It is important to no...
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and livelihood followi...
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Compensation for real...
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CHAPTER 3	NUTRITION AS...
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Evidence shows that m...
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Fig. 6. A model of nut...
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„„ prevent food-relat...
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Where screening occurs...
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„„ when initiating or...
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Published on: Mar 3, 2016
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Transcripts - NACS guide

  • 1. GUIDANCE NOTE | 2014 Nutrition assessment, counselling and support for adolescents and adults living with HIV a programming guide FOOD AND NUTRITION IN THE CONTEXT OF HIV AND TB CLASSIFICATION | 2013 Nutrition assessment, counselling and support for adolescents and adults living with HIV Insert an image or a graphic that corresponds to the theme or issue of the publication. Consult the Photography section of the UNAIDS Brand Builder for guidance on selecting an appropriate image. A progrAmming guide FOOD AND NUTRITION IN THE CONTEXT OF HIV AND TB
  • 2. UNAIDS / JC2628 (English original, July 2014.) Copyright © 2014. Joint United Nations Programme on HIV/AIDS (UNAIDS). All rights reserved. Publications produced by UNAIDS can be obtained from the UNAIDS Information Production Unit. Reproduction of graphs, charts, maps and partial text is granted for educational, not-for-profit and commercial purposes as long as proper credit is granted to UNAIDS: UNAIDS + year. For photos, credit must appear as: UNAIDS/name of photographer + year. Reproduction permission or translation-related requests—whether for sale or for non-commercial distribution—should be addressed to the Information Production Unit by e-mail at: publicationpermissions@unaids.org. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of UNAIDS concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. UNAIDS does not warrant that the information published in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.
  • 3. 4 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV ACKNOWLEDGEMENTS The development of this programming guide was coordinated by Fatiha Terki, Saskia de Pee, Joan Manuel Claros, Quinn Marshall and Lydia DuRant from the World Food Programme (WFP) Policy Division, Nutrition and HIV Service. The programming guide was designed and written by the WFP, in close cooperation with staff from the Albion Centre, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR). In addition, Chris Duncombe (World Health Organization— WHO) and Pamela Fergusson (Food and Nutrition Technical Assistance II) made technical contributions. The Thai Red Cross AIDS Research Centre (TRCARC) provided case studies. Inputs were received from Amanda Justice, Belinda Meggitt, Charmaine Turton, Julian Gold, Lia Purnomo and Simon Sadler (Albion Centre); Praphan Phanuphak (TRCARC); and Eyerusalem Kebede Negussie, Francesco Branca and Maria del Carmen Casanovas (WHO). The programming guide benefited greatly from initial contributions from Nils Grede and Francesca Duffy (WFP), and from the vision and continued support of Martin Bloem (WFP).
  • 4. 5Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS Foreword 8 Acronyms 10 Introduction 11 Objectives and audience 11 A note on terminology 12 Background 12 Chapter 1 HIV, AIDS and TB 15 Key messages 15 What is HIV? 15 What is AIDS? 16 What is TB? 18 When should PLHIV begin antiretroviral therapy? 19 What is comprehensive HIV prevention, treatment, care and support? 21 What is the rationale for including nutrition and food support in comprehensive care programmes? 24 What is the role of food and nutrition support in achieving universal access and adherence in lifelong chronic HIV treatment and care? 25 Chapter 2 Nutrition, and HIV and TB 26 Key messages 26 Introduction 26 What is the evidence for the role of nutrition in TB incidence? 27 Why are food and nutrition interventions needed during HIV and TB treatment? 27 What interventions are required to restore health and nutritional status among adolescents and adults living with HIV and with active TB? 28 What are the nutritional needs of people living with hiv and patients with active TB? 29 Energy intake 29 Protein intake 30 Fat intake 31 TABLE OF CONTENTS
  • 5. 6 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV Micronutrient intake 31 General nutrient intake 31 What are the nutritional needs of acutely undernourished adults? 32 What kind of food and nutrition support should be provided to adolescents and adults on antiretroviral therapy or receiving tb treatment? 32 What is the role of nutrition support to enable access to health services? 33 Chapter 3 Nutrition assessment, counselling and support 35 Key messages 35 How does nacs fit into HIV or tb prevention, treatment, care and support services? 35 What are the objectives of NACS? 37 What is Nutrition Assessment? 38 What is Nutrition Screening? 38 What is a detailed Nutrition Assessment? 39 What are the objectives of Nutrition Assessment? 39 When is a Nutrition Assessment conducted? 39 What is involved in a Nutrition Assessment? 40 Which nutrition assessments are used for adolescents and adults? 42 What is Nutrition Counselling? 45 What is Nutrition Education? 46 What are the objectives of Nutrition Education? 46 What methods are used in Nutrition Education? 46 What is Individual Nutrition Counselling? 46 What are the objectives of Nutrition Counselling? 47 What are the key messages in Nutrition Counselling? 47 What are the general nutrition recommendations for plhiv and people receiving tb treatment? 47 How can Cutrition Counselling be made more effective? 49 How can nacs be integrated into treatment, care and support for hiv and tb? 50
  • 6. 7Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS How can linkages be made between health sectors and communities? 51 Who is responsible? What are the possible roles of the different stakeholders? (100) 52 Considerations for NACS interventions 54 What human resource capacity is needed? 55 What operations management capacity is needed? (102) 56 Chapter 4 provision of nutritious food 57 Key messages 57 Introduction 57 Who should receive a food supplement in addition to NACS? 59 For how long should a food supplement be given? 59 What supplements could be provided individually and programmatically? 60 Nutrient density 61 Practicality 61 Acceptability 61 Sharing 61 Cost-effectiveness 62 Should household members be included or just the patient? 63 How is household support targeted? How long should it last? 64 Annex I Stages of Change: A model for targeting nutrition counselling 67 Annex II Case studies by the Thai Red Cross AIDS Research Centre 68 Case study 1: Anaemia 68 Case study 2: Malnutrition, injecting drug use and TB 70 Case study 3: Dyslipidaemia 72 Case study 4: Overweight/obesity 74 References 77
  • 7. 8 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV FOREWORD This programming guide prepared by the World Food Programme (WFP), the United Nations Programme on HIV/AIDS (UNAIDS) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) provides practitioners with useful information for planning and imple- menting food and nutrition support as part of a comprehensive treatment, care and support programme for adults and adolescents living with HIV. It serves as a resource for govern- ments, UN organizations, donors, civil society, and other organizations providing support to countries. The AIDS response has provided an important benchmark for global leadership, highlighting what can be accomplished when strong partnerships involving governments, donors, multilat- eral organizations, the private sector, communities, people living with HIV, advocates, non- governmental organizations, and civil society are formed. PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), UNAIDS and WFP continue to play a key role in developing these critical partnerships. As a result of advances in access to antiretroviral therapy (ART), people living with HIV are now living longer and healthier lives. Research has indicated that HIV treatment, particularly the initiation of early treatment, is important for long-term survival and for HIV prevention. In 2013, almost 13 million of the approximately 35 million people living with HIV had access to life-saving treatment. However, only 37 percent of people living with HIV are on treatment. Sub-Saharan Africa is the most affected region, with approximately 70 percent of all people living with HIV residing there. Long term adherence will be important to individual health and decreasing transmission. Reported data from Low Middle Income Countries (LMIC) show a negative trend in ART adherence over time, wherein 81 percent of people initiating ART were still retained in care at 24 months and 73 percent at 60 months. Only 65 percent of people living with HIV in sub-Saharan Africa (SSA) who are enrolled on ART remain on treatment three years later. Despite comparable retention rate in high-income countries, there is still substantial room for improvement in adherence in LMIC/SSA. UNAIDS’ Treatment 2015 provides a framework for scaling up HIV treatment and identifies several challenges that impede treatment coverage and adherence. More than half of all people living with HIV are unaware of their status and a substantial number of people diagnosed with HIV are never assessed for ART. Additionally, due to low uptake of services and loss to follow-up between testing and treatment initiation, a significant proportion of people start treatment late or do not start treatment. Food and nutrition for people living with HIV plays a key role in improving retention and treatment outcomes. Most importantly, it reduces mortality risk among people living with HIV who are malnourished (body mass index <18.5). Currently, malnourished people living with HIV are two to six times more likely to die when starting ART compared to people with optimal nutritional status. Given that the HIV epidemic is often most severe in food-insecure settings, food and nutrition assistance provides critical support to people and helps promote access and adherence to treatment and care in these resource-constrained settings.
  • 8. 9Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS WFP’s recent work in the AIDS response links clinical services with community-based food and nutrition services. These programme linkages aim to improve adherence and treatment effectiveness while enhancing prevention efforts. PEPFAR recognizes the linkages between clinical services and income, food and nutrition support, with care and treatment for people living with HIV/AIDS. Sustaining progress made and supporting the work toward a shared vision of “Zero new HIV infections, Zero discrimination and Zero AIDS-related deaths,” requires strong linkages with other sectors including social protection, nutrition and food security, and education. This programming guide is a resource for designing and imple- menting such comprehensive programs that integrate food and nutrition support as part of comprehensive treatment, care and support. U.S. Global AIDS Coordinator WFP Executive Director UNAIDS Executive Director
  • 9. 10 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV ACRONYMS AIDS acquired immunodeficiency syndrome BMI body mass index DOTS directly observed treatment, short course FANTA Food and Nutrition Technical Assistance FBF fortified blended flours HIV human immunodeficiency virus IEC information, education and communication IMAI Integrated Management of Adolescent and Adult Illness MUAC mid-upper arm circumference NAC nutrition assessment and counselling NACS nutrition assessment, counselling and support NGO nongovernmental organization PEPFAR United States President’s Emergency Plan for AIDS Relief PLHIV people living with HIV RNI recommended nutrient intake RUTF ready-to-use therapeutic food TB tuberculosis UNAIDS Joint United Nations Programme on HIV/AIDS WFP United Nations World Food Programme WHO United Nations World Health Organization
  • 10. 11Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS INTRODUCTION This programming guide provides practical guidance for the planning and implementation of food and nutrition support as part of treatment, care and support programmes for human immunodeficiency virus (HIV) and tuberculosis (TB). Food and nutrition support can be a component of programmes that address either HIV or TB . However, it is advisable for HIV and TB to be addressed at the same time and for linkages between the programmes to be formed, as the support is often being provided to the same individuals. Food and nutrition support includes nutrition assessment, counselling and support, collectively known as NACS. The programming guide also provides an overview of some aspects of food assistance. It aims to be a common resource for national governments; cooperating nongovernmental organiza- tions (NGOs); and staff of the World Food Programme (WFP), World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), United States President’s Emergency Plan for AIDS Relief (PEPFAR), Food and Nutrition Technical Assistance III (FANTA III) and other agencies providing technical assistance as part of HIV and TB preven- tion, treatment, care and support programmes. Because the areas of targeting, implementa- tion, and monitoring and evaluation have been addressed in the handbook Food assistance programming in the context of HIV (1) and the Monitoring and evaluation guide for HIV and TB programming (2), these topics will not be covered in depth here. 1 Objectives and audience This programming guide summarizes the biological, behavioural and contextual rationale for food and nutrition interventions as part of HIV and TB prevention, treatment, care and support programmes, and how these interventions can be implemented in a variety of settings. More specifically, the objectives of this programming guide are to: „„ increase understanding of the role of food and nutrition in the context of HIV and TB treatment in adolescents and adults; „„ help build the skills of policy-makers and programme managers in integrating food and nutrition support into the comprehensive response to HIV and TB; and „„ provide information on the implementation of food and nutrition support as part of HIV and TB programmes. This information may be useful to a broad audience, including: „„ national and subnational authorities (governments and policy-makers); „„ programme managers, and national and international organizations; „„ staff of WFP, WHO, UNAIDS and other United Nations cooperating partners; non-governmental organizations (NGOs); associations of people living with HIV (PLHIV); community members; and people working in HIV and TB treatment, care and support programmes; and 1 The WFP Strategic Plan 2014–2017 has been approved, and all changes relevant to HIV and AIDS will be incorporated into the monitoring and evaluation guidelines.
  • 11. 12 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV „„ donors, including PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria. A note on terminology Because many different organizations implement food and nutrition programmes in conjunction with HIV care and treatment services, terminology is not always used in a standardized way. This programming guide considers comprehensive food and nutrition interventions as comprising three main elements: nutrition assessment, counselling and support (NACS). Nutrition assessment—including anthropometry, biochemical, clinical, dietary and household food security—is key to informing clinical management of PLHIV or patients with TB, and determining the appropriate support for the individual and their household. Counselling, which may be provided to individuals or in group sessions, includes education linked to promotion of specific behaviours and actions. In some publications, NACS has been described as a combination of NAEC (nutrition assessment, education and counselling) and support; this programming guide considers education as an integral component of counsel- ling and therefore uses NACS without referring separately to education. Support consists of providing nutritious food to malnourished individuals, based on anthropometric entry and exit criteria (low body mass index or low mid-upper arm circumference). This is sometimes referred to as food by prescription, which emphasizes that therapeutic and supplementary feeding may be prescribed and provided to indi- vidual PLHIV or patients with TB as a critical component of comprehensive care and treatment, contributing to nutritional recovery and clinical improvement. Support can include additional nutrient supplementation (e.g. micronutrient supplements) and safe water treatment. It might also include transfers or other assistance to households that have undergone an income shock from the burden of caring for PLHIV, often coupled with the temporary or permanent loss of production, assets and income. Finally, support may include a variety of livelihood activities that aim to give affected households the tools to meet their basic needs, including food, so that they do not have to rely on long-term income transfers or food assistance. Background In many countries, national policy frameworks for HIV and tuberculosis (TB) have started to include food and nutrition support. Food and nutrition programmes are increas- ingly being developed and implemented as part of a comprehensive response to the HIV epidemic. Such programmes target the individual, but may also support households. For the individual, support is often in the form of prescription of specialized food products as medicine to treat people with acute malnutrition, or to supplement the diet of people with
  • 12. 13Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS clinical malnutrition. The aim of household support is to mitigate the impact of the illness on the household and ensure food security for the family. Support for households may be in the form of household food rations, often consisting of staple foods,2 cash or vouchers. Both individual and household support can increase adherence to care and treatment. Food and nutrition interventions are not stand-alone activities; they should be integrated as a key component of a minimum health-care package. They should empower people living with HIV (PLHIV) and patients with TB to manage, improve and maintain their nutritional status autonomously by giving them the knowledge and tools to do so. This requires broadly defined food and nutrition support, which encompasses not just support in the form of food supple- ments, but also nutrition assessment and counselling. National frameworks need to address the HIV epidemic and TB in a comprehensive manner. Among major donors, there is currently a shift away from traditional vertical funding focused on a single disease towards multidisease funding streams with broader objectives and strength- ening of health systems. Integrated HIV, TB, food and nutrition interventions can achieve both disease-specific and broader public health objectives. They should also be seen as ways of increasing investment return for existing HIV and TB treatment, care and support programmes. Food and nutrition support can reduce the risk of morbidity and mortality through its impact on uptake of treatment, retention in care and adherence to treatment, as well as through reducing malnutrition. Food and nutrition support is also important for PLHIV who are not yet eligible for antiretroviral therapy. The 2013 World Health Organization (WHO) consoli- dated guidelines on the use of antiretrovirals for treating and preventing HIV infection (3) provide detailed guidance on when to start antiretroviral therapy in adults and adolescents (see Table 1). Targeted food and nutrition support for PLHIV and TB should be accompanied by counselling to improve treatment knowledge and preparedness, as well as to mitigate the impact of HIV on the household. This programming guide provides comprehensive guidance on integrating food and nutrition support into HIV and TB programming, but it may need to be adapted to local context. The programming guide should enable appropriate decisions about planning and allocating available food and non-food resources to address the nutritional needs of PLHIV and TB patients in treatment, care and support programmes. The programming guide highlights the relevance of nutrition assessment, counselling and support (NACS), the often-neglected foundation on which food and nutrition support should be built. The main focus of this programming guide is food and nutrition interventions for PLHIV and patients with TB, or more specifically, the following three target groups: adolescents and adults living with HIV; adolescents and adults with active TB; and adolescents and adults with both conditions. In this programming guide, the term ‘ PLHIV’ refers to adolescents and adults living with HIV, and does not include children. Needs of other members of their households are also considered. Although it is not a central topic, this programming guide 2 Staple foods are foods that are regularly consumed in a community or society and from which people obtain most, or a significant proportion of, their calorie requirements—for example, rice, maize, wheat, tubers or lentils.
  • 13. 14 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV also addresses the role that food and nutrition support plays in a comprehensive response to the HIV epidemic and TB. The World Food Programme and the Albion Street Centre developed the programming guide in close collaboration with the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States President’s Emergency Plan for AIDS Relief. The Albion Centre is a WHO Collaborating Centre for Capacity Building and Health Care Worker Training in HIV/ AIDS Care, Treatment and Support. Development of the programming guide started in 2009, when WHO began a process to review the evidence for the role of food and nutrition support to prevent TB infections, and to improve the health status of TB patients and PLHIV. A guideline development group, the Nutrition Guidance Expert Advisory Group, was established for two years to review available evidence and draft guidelines for the nutritional care of patients with TB and PLHIV (including pregnant and breastfeeding women living with HIV), and for prevention of mother-to-child transmission of HIV. The guidelines for the nutritional care of patients with TB have been published (4). These provide guidance on the principles and evidence-informed recommendations for nutritional care and support for TB patients. Guidelines for an inte- grated approach to nutritional care of HIV-infected children (6 months – 14 years), and on HIV and infant feeding have also been published (5, 6), and systematic reviews of the evidence have been conducted to inform guidelines on the effects of nutrition interventions for PLHIV. Guidelines on the use of vitamin A supplementation during pregnancy for reducing the risk of mother-to-child transmission of HIV were also published; they noted that vitamin A supplementation as a public health intervention is not recommended for reducing the risk of mother-to-child transmission of HIV (7). The programming guide will require updates on an ongoing basis, and a revised version is expected when new WHO recommendations are published. Not all of the interventions described in this programming guide will be appropriate in every country and setting, and the guidance may need to be adapted to the local context. The scientific evidence provided in this programming guide is not exhaustive, nor is the list of suggested actions. Additional research on the continuum of implementation is required. This entails addressing the efficacy and safety of interventions (proof of concept), how these interventions work in real-world settings (proof of implementation), and how they can be integrated into health systems in a sustainable way (informing scaling up). Many programming guides already exist, particularly on the broader questions of nutrition assessment, education, counselling and support. This programming guide is not intended to replace them, but refers to and builds on them. The programming guide is divided into four chapters: „„ Chapter 1: HIV, AIDS and TB; „„ Chapter 2: Nutrition, and HIV and TB; „„ Chapter 3: Nutrition assessment, counselling and support; and „„ Chapter 4: Provision of nutritious food.
  • 14. 15Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS CHAPTER 1 HIV, AIDS AND TB Key messages „„ Comprehensive HIV and tuberculosis (TB) prevention, treatment, care and support programmes are needed to improve the well-being of infected individuals and affected households at all stages of infection. „„ As antiretroviral therapy coverage increases in many countries, focus will gradually shift from the urgent response of enrolling people for treatment to a chronic disease approach, focused on improving adherence to treatment and retention in care—losing a person to follow-up not only increases mortality risk but also means that the investment made to date in that person’s health is lost. „„ Undernutrition in adolescents and adults increases early mortality and delays recovery from HIV-related disease and TB. In the longer term, it may also result in the need to manage chronic diseases, such as high blood pressure, diabetes and dyslipidaemia. „„ As part of the continuum of care, nutrition assessment and counselling (NAC) should be included in the comprehensive package of treatment and care, to support nutritional status and health. In specific situations, support—in the form of nutritious food, and household and/or livelihood support—may also be required (NACS). „„ In resource-limited settings, food and nutrition support are key enablers of accessing health services, and can support returning to a productive, quality life in the community. „„ Countries need assistance with framing and subsequently implementing national policies and guidance for integrating NACS as part of HIV and TB programming among adolescents and adults. What is HIV? HIV mainly infects cells of the immune system—CD4 T-cells and macrophages, which are key components of the cellular immune system—and destroys or impairs their function. Infection with HIV results in the progressive deterioration of the immune system, leading to “immuno- deficiency” (8). The most common modes of transmission of HIV are (9): „„ unprotected vaginal or anal sex with an HIV-infected person; „„ sharing contaminated syringes, needles or other contaminated sharp instruments; „„ transmission from an HIV-infected woman to her child during pregnancy, childbirth or breastfeeding; and „„ blood transfusion with HIV-infected blood.
  • 15. 16 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV In a person living with HIV, the immune system is deficient when it can no longer fulfil its role of dealing with infections and diseases. Immunodeficient people are more susceptible to a wide range of illnesses, infections and diseases, most of which are rare or do not occur among immune-competent people, and they are also much more likely to develop TB. Illnesses associated with immunodeficiency are known as opportunistic infections because they take advantage of the weakened immune system (9). Tremendous success has been achieved in the response to HIV in the past decade. Nearly 10 million of the 35.3 million people living with HIV are receiving treatment today. This represents 34% of the 28.3 million people who were eligible for treatment in 2013. The overall number of new HIV infections decreased by 33% from 2001 to 2012, and the number of deaths from AIDS declined by 30% from 2005 to 2012 (10). 3 Enabling policy frameworks have accelerated progress in combatting the epidemic. However, HIV remains one of the great challenges of our times. Issues of access to services, utilization of services and continuum of care (including retention in care and adherence to treatment) need to be addressed. A large number of eligible people who are in need of antiretroviral therapy do not start treatment because of low uptake of HIV testing, and losses between testing and initiation of treatment (11). A systematic review from sub-Saharan Africa estimates that only 65% of people living with HIV (PLHIV) who start antiretroviral therapy remain on treatment after three years (12); therefore, programmes that achieve high retention rates and good long-term adherence are needed to provide models for other programmes in similar contexts (13). What is AIDS? AIDS is an epidemiological definition based on clinical signs and symptoms. It is caused by HIV, and, if it goes untreated, will ultimately lead to death. There are various symptoms associated with HIV infection, as well as an array of opportunistic infections at various stages of the disease (14). Many PLHIV have no obvious signs or symptoms of the disease (i.e. they are asymptomatic) for many years following HIV infection, and might not even know that they are HIV-positive. However, as HIV infection progresses, the immune system weakens, and the person is at an increased risk of developing serious illnesses, including opportunistic infections that affect the entire body with a wide array of symptoms (8). The natural history of HIV infection and its progression to AIDS are described in Figure 1. The World Health Organization’s (WHO’s) clinical staging system for HIV-related disease in adolescents and adults is described below. It uses clinical parameters, such as signs and 3 The 2013 UNAIDS Global Report (p. 4) states: “Globally, an estimated 35.3 (32.2–38.8) million people were living with HIV in 2012. An increase from previous years as more people are receiving the life-saving antiretroviral therapy. There were 2.3 (1.9–2.7) million new HIV infections globally, showing a 33% decline in the number of new infections from 3.4 (3.1–3.7) million in 2001. At the same time the number of AIDS deaths is also declining with 1.6 (1.4–1.9) million AIDS deaths in 2012, down from 2.3 (2.1–2.6) million in 2005”. Taking into account the 875 000 people receiving antiretroviral therapy in high-income countries, a total of 10.6 million people were receiving antiretroviral therapy as of December 2012.
  • 16. 17Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS symptoms, HIV-related opportunistic infections and associated conditions. In settings where CD4 testing is not routinely available, this system is used to guide clinical decision-making for the management of PLHIV (3). There are four WHO clinical stages (3): 4 „„ Clinical stage 1 involves asymptomatic or generalized swelling of the lymph nodes. „„ Clinical stage 2 includes unexplained weight loss of <10% of body weight, minor mucocutaneous manifestations and recurrent upper respiratory tract infections. „„ Clinical stage 3 includes weight loss of >10% of body weight, unexplained chronic diarrhoea, unexplained persistent fever, oral candidiasis, severe bacterial infections, pulmonary TB and acute necrotizing inflammation in the mouth; some people at clinical stage 3 have AIDS. „„ Clinical stage 4 includes some opportunistic infections or cancers related to HIV; everyone at clinical stage 4 has AIDS. 4 The clinical staging of HIV disease in adolescents and adults can be found in Annex 1 of WHO (3). 0 200 400 600 800 1000 1200 10 102 103 104 105 106 CD4lymphocytecount(cellspermm3 ) HIVRNAcopiespermLplasma 10 102 103 104 105 106 HIVRNAcopiespermLplasma A After ART HIV RNA CD4 blood CD4 GIT HIV RNA CD4 blood CD4 GIT Immune activation (eg, LPS, sCD14, andT-cell activation) HIV Ab HIV-specific CD8T cells 0 3 6 9 12 1 2 3 4 5 6 7 8 9 10 11 0 500 CD4lymphocytecount(cellspermm3 ) YearsWeeks B Immune activation (eg, LPS, sCD14) HIV Ab HIV-specific CD8T cells HIV-specific CD4T cells C Acute Asymptomatic AIDS After ART 0 3 6 9 12 1 2 3 4 5 6 7 8 9 10 11 0 YearsWeeks D Normal Limit of detection of commercial assays Normal 0 3 6 9 12 1 2 3 4 5 6 7 8 9 10 11 YearsWeeks Acute Asymptomatic AIDS 0 3 6 9 12 1 2 3 4 5 6 7 8 9 10 11 YearsWeeks Quasispecies diversity Latently infected cells Fig. 1. Natural history and progression of HIV infection (A): CD4 T cells are progressively lost in blood and the gut (rapidly depleted in the gut). The acute response to HIV infection causes a dramatic increase in markers of immune activation © and production of non-neutralising antibodies and HIV-specific CD4 and CD8 T cells that are associated temporally with a decrease in HIV RNA in blood. After antiretroviral therapy (B), HIV RNA decreases and CD4 T in blood cells increase while recovery of CD4 T cells in the gut is reduced. (D) With reduction of HIV RNA and viral antigens, HIV-specific T cells decrease after antiretroviral therapy and antibody persists in all patients. Immune activation decreases after antiretroviral therapy but in most patients remains significantly increased compared with healthy controls. GIT=gastrointestinal tract. LPS=lipopolysaccharide (15) Source: Maartens (15)
  • 17. 18 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV What is TB? TB is usually caused by the bacterium Mycobacterium tuberculosis. TB is the world’s leading bacterial cause of death in humans and the second leading cause of death from infectious disease after the HIV epidemic (16). Furthermore, TB is the leading cause of mortality among PLHIV (17). HIV and TB coinfection has become a significant burden and challenge in many countries. In 2012, an estimated 8.6 million people developed TB, and 1.3 million died from the disease (including 320 000 deaths among HIV-positive people) (18). An estimated 1.1 million (13%) of the 8.6 million people who developed TB in 2012 were HIV-positive. About 75% of these cases of coinfection were in Africa. Most TB cases and deaths occur in men, but TB is among the top three killers of women worldwide. There were an estimated 410 000 TB deaths among women in 2012, including 160 000 HIV-positive women. Half of the HIV-positive people who died from TB in 2012 were women. Of the estimated 8.6 million new TB cases worldwide in 2012, 2.9 million were women. TB is most often spread through contaminated droplets in the air when a person with pulmonary TB coughs or sneezes. Approximately one third of the world’s population is infected with TB, and 95% of them have the asymptomatic, noncontagious, latent form of TB (19). Around 5% of people will develop active, usually contagious, TB immediately after initial exposure. This is called primary progressive disease. The risk of developing primary progres- sive TB is higher in people who are undernourished or have a compromised immune system (due to HIV, for example). Undernutrition is both an important risk factor for, and a common consequence of, TB. It is therefore a common comorbid condition for people with active TB, and is associated with increased risk of mortality and poor treatment outcomes. Evidence shows that undernutrition is a risk factor for progression from TB infection to active TB. When present at the time of diagnosis of active TB, undernutrition is a predictor of increased risk of death and TB relapse (4). The 2013 WHO guideline on nutritional care and support for patients with tuberculosis recognizes the effect of undernutrition on TB, and acknowledges that nutrition assessment and care are critical components of improving rehabilitation and quality of life (4). Fifty percent of adults in sub-Saharan Africa, and South and South-East Asia are infected with latent TB. Although noncontagious, people with immune systems weakened by HIV are at a higher risk of the infection reactivating and causing active TB, so this is an enormous pool of individuals at risk (4). The situation is further complicated by widespread malnutrition, increased mobility of people, and the emergence of multidrug-resistant and extensively drug- resistant TB. Like HIV infection, undernutrition lowers immunity, increasing both the risks of activation of latent TB and primary progressive TB. Undernourished people or those with a recent weight loss of more than 10% of their body weight are at increased risk of reactivation of latent TB. Malnutrition is significantly associated with increased mortality among both PLHIV and TB
  • 18. 19Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS patients, and should be treated concurrently with both HIV and TB (4). For both HIV and TB, treatment is a prerequisite for nutritional recovery, in addition to intake of nutrients required for rebuilding tissues, which is constrained in food-insecure households. When should PLHIV begin antiretroviral therapy? WHO currently recommends that adolescents and adults begin treatment based on clinical staging (described in the previous section) and the CD4 count (see Fig. 2). If the clinical signs and symptoms correspond to those of clinical stages 3 and 4, antiretroviral therapy is indicated regardless of the CD4 count (3). However, all pregnant and breastfeeding women with HIV should initiate treatment with a triple antiretroviral drug combination, and this should be maintained for at least the duration of the risk period for mother-to-child transmission. Standard antiretroviral therapy consists of at least three antiretroviral drugs to suppress viral replication and stop the progression of HIV (3). When a person knows that they are HIV-positive, clinical examination and specific blood tests can estimate the stage and progres- sion of the infection, and the extent to which antiretroviral therapy, if started, will be effective in controlling the virus. Two blood tests often used in HIV management are the CD4 cell count test and the HIV viral load test (3). The CD4 cell count test measures the number of CD4 T-cell lymphocytes in the bloodstream; these cells are vital for an effective immune response to infection. A normal CD4 count for an HIV-negative person will range between approximately 500 and 1200 cells per cubic milli- metre (mm3 ) of blood. A person with a CD4 count below 350 cells/mm3 is at greater risk of contracting HIV-related opportunistic infections and diseases (20, 21). The HIV viral load test estimates the number of copies of the HIV RNA per millilitre of blood. It is used to monitor treatment response; effective antiretroviral therapy should result in a lowering of viral load (viral suppression) to an “undetectable” level (e.g. less than 50 copies per millilitre) (3). In 2013, the threshold for CD4 count was raised from 350 to 500 cells/mm3 in light of evidence showing that earlier initiation of treatment can reduce long-term morbidity and mortality in PLHIV (3). Currently, many PLHIV are not tested until they show the first symptoms of advanced HIV infection or AIDS, with CD4 counts far below even the previous threshold of 350. As a result, many are underweight. As people start treatment at a higher CD4 count threshold (<500 cells/mm3 ), it is likely that most will not be symptomatic, and it can be anticipated that the predominant focus on malnutrition and nutrition support for PLHIV initiating antiretroviral therapy may need to change significantly. PLHIV are at increased risk of metabolic syndrome, diabetes or cardiovascular diseases. This is due to both the HIV infection itself and adverse events associated with some antiretroviral drugs (22). Nutrition assessment, counselling and support (NACS) are important during
  • 19. 20 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV 232 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection a Annex 1 lists the WHO clinical staging for HIV disease. b ART initiation in individuals with severe or advanced symptomatic disease (WHO clinical stage 3 or 4), regardless of CD4 cell count, or with CD4 count ≤350 cells/mm3 , regardless of clinical symptoms, should be prioritized. c Active TB disease refers to the time when TB breaks out of latency and causes disease. Latent TB infection refers to the period of time when the immune system has been successful in containing the Mycobacterium tuberculosis and preventing disease. d Severe chronic liver disease includes cirrhosis and end-stage liver disease and is categorized into compensated and decompensated stages. Decompensated cirrhosis is defined by the development of clinically evident complications of portal hypertension (ascites, variceal haemorrhage and hepatic encephalopathy) or liver insufficiency (jaundice). e For details on ARVs for pregnant and breastfeeding women with HIV (Option B and Option B+), see Annex 3 and sections 7.1.2, 7.1.3 and 7.2.2. f A HIV-serodiscordant couple is a couple in which one of the sexual partners is HIV-positive and one is HIV-negative. Although one partner is currently HIV-negative, this does not mean that this partner is immunized or protected against getting HIV in the future. g For adolescents weighing less than 35 kg, refer to the algorithm for children in annex 4 which indicates the appropriate first-line ARV regimen options. Do not initiate ART Do not initiate ART Clinical assessment Initiate one of the following ARV regimensg : Preferred option: • TDF + 3TC (or FTC) + EFV Alternative options: • TDF + 3TC (or FTC) + NVP • AZT + 3TC + EFV • AZT + 3TC + NVP ART-naive adults and adolescents with HIV Yes YesNo No Initiate ART WHO clinical stage 3 or 4?a b Active TB disease?c Severe chronic HBV liver disease?d Pregnancy or breastfeeding?e HIV+ in a serodiscordant relationship?f Symptomatic HIV disease or presence of CD4-independent conditions? Initiate ART WHO clinical stage 1 or 2?a CD4 cell count CD4 ≤ 500 cells/mm³?b Asymptomatic HIV infection?a WHENTOSTARTARTWHATFIRST-LINE ARTTOSTART Annex 2. Algorithm for the 2013 recommendations for adults and adolescents Fig. 2. WHO criteria for initiation of antiretroviral therapy in adolescents and adults Source: WHO (3).
  • 20. 21Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS the early period of treatment and in the long term. For PLHIV who start treatment with a low body mass index (BMI), the main focus is on rapid weight gain and return to normal BMI through a healthy, balanced diet and treatment, with the overall goal of reducing the risk of illness and death. As for people who are not infected with HIV, proper nutrition is important for managing chronic noncommunicable diseases such as insulin resistance and dyslipidaemia. In addition to the WHO key recommendations (20), several factors can be considered when initiating treatment: „„ Patient consent and understanding of what antiretroviral therapy is and its possible side effects. Not all PLHIV are eligible for antiretroviral therapy, and not all who are eligible choose to take antiretroviral therapy even when clinically indicated. Before consenting and starting antiretroviral therapy, patients need to understand what it is, its benefits and its side effects. „„ Adherence. Once begun, antiretroviral therapy should not be discontinued. It is therefore important that the person is ready to start such treatment and to adhere to it for life. „„ Support. PLHIV may sometimes face barriers to adhere to treatment because of forgetfulness, change in daily routine, treatment fatigue, pill burden and drug side effects. Patients benefit from support, especially during the initial stages of treatment, ideally from someone who is also on antiretroviral therapy and has experience with treatment. Family members and peers can play a supportive role if they are aware of the individual’s diagnosis. „„ Treatment follow-up. It is important to monitor treatment response, clinical improvement, weight gain and decline in viral load. The treatment regime may need to be changed as a result of adverse side effects or treatment failure. What are comprehensive HIV prevention, treatment, care and support? HIV prevention, treatment, care and support services are needed at all stages of infection. HIV care and support encompasses a comprehensive set of services, including nutritional, psychosocial, physical, socioeconomic and legal care and support. These are essential to the well-being of both PLHIV and other members of their households, and should be provided regardless of the infected person’s ability to access, and eligibility to start, antiretroviral therapy (23). The number of PLHIV accessing antiretroviral therapy is growing, and the number eligible for treatment is also increasing, with the change in the WHO eligibility criteria. However, important challenges remain in ensuring that people who start treatment stay on it. In resource-limited settings, several factors can prevent people from accessing treatment for both HIV and TB (see the box for country-specific examples) (24–28).
  • 21. 22 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV The following barrier categories have recently been proposed (29). Economic barriers—the resource situation of the individual, including: „„ food insecurity; „„ lack of physical access to testing and health-care services; and „„ cost of health care, including direct costs of medications, diagnostics and consultation fees; and indirect costs, such as transport and incidental costs. Social norms—interaction of the individual with household members and other members of society, including: „„ gender relations; 5 „„ lack of adequate communication with health professionals; „„ difficulty in disclosing HIV status or presence of active TB infection; „„ laws that create service barriers for PLHIV; and „„ HIV- and TB-related stigma and discrimination. Physiology—effects of illness and treatment on body function (e.g. side effects, appetite). Psychology—the psychological situation and knowledge of the individual, including personal interpretation of the above factors. 5 Evidence shows that men generally have limited access to HIV testing, care and treatment services; they are less retained in care than women. In some settings, AIDS-related mortality is higher among men living with HIV than among women living with HIV. At the same time, women and girls are in almost all contexts more susceptible to HIV infection, often as a result of unequal power relationships within society and the household, and/or greater economic dependency. Country examples from Ethiopia and Uganda on barriers to adherence to antiretroviral therapy A study conducted in Ethiopia (24) showed that lack of food and nutrition support was the second most cited reason for failure to continue treatment. A number of other studies have reported that food insecurity is an important barrier to drug and treatment adherence in underresourced settings in general, including for TB. Research in Uganda (26) showed that: „„ treatment increased appetite and led to “intolerable hunger in the absence of food” „„ side effects of antiretroviral therapy were exacerbated by the presence of underlying anaemia „„ participants believed “they should skip doses or not start on antiretroviral therapy at all if they could not afford the added nutritional burden” „„ costs of food and medical expenses led people either to default from treatment or to give up food and wages, and medication was sometimes forgotten while working in gardens or plots.
  • 22. 23Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS Challenges with access and adherence to treatment should be addressed through comprehen- sive care—sometimes referred to as the continuum of care—which includes various health- care, welfare and social support services. These should focus holistically on both the medical and socioeconomic determinants of access and adherence, and can combine health-service, community and household delivery platforms. Details of the components of comprehensive care are provided below. Key elements in HIV prevention, treatment, care and support services: „„ Prevention of HIV transmission, including prevention of mother-to-child transmission during pregnancy, delivery and breastfeeding. „„ Reproductive health services, particularly prenatal and antenatal care to assist pregnant and lactating women, provision of condoms, and treatment of sexually transmitted infections. „„ Access to HIV testing (including provider-initiated testing and counselling, and client-initiated testing and counselling), behaviour change programmes and antiretroviral therapy. „„ For people receiving care and treatment for HIV and TB who are clinically malnourished, especially in food-insecure contexts, food supplements may be required for a limited period in addition to antiretroviral therapy, to ensure that appropriate foods are consumed to support nutritional recovery (that is, food by prescription) (3, 30). Examples of social and economic support: „„ Food assistance for the households of PLHIV or TB patients who are on treatment, where appropriate, especially when the most productive members of the household are unable to manage their day-to-day activities owing to illness; nutritious food provided to individuals on treatment for nutritional recovery also acts as a “buffer” as they prepare to re-engage in income-generating activities. „„ Peer support and community-based support groups. „„ Livelihood support and training, microfinance, vocational training and programmes that help HIV-affected households maintain or rebuild their income, savings and overall livelihood security. Examples of clinical care and treatment (3): „„ Diagnosis and treatment of opportunistic infections, including diarrhoea, sexually transmitted infections, TB or malaria, which can all worsen nutritional status. „„ Provision of prophylaxis (prevention) for opportunistic infections, including cotrimoxazole prophylaxis (CPT) and isoniazid preventive therapy (IPT). „„ Provision of antiretroviral therapy, TB treatment and follow-up services. „„ Patient counselling and education.
  • 23. 24 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV „„ Nutrition assessment, counselling and support (NACS), including management of individuals who are malnourished. 6 What is the rationale for including nutrition and food support in comprehensive care programmes? HIV has dramatic consequences for entire communities, especially where malnutrition and food insecurity are already prevalent. Of the 2 billion people suffering from micronutrient deficiencies, many are in countries with high HIV and TB prevalence, and high levels of undernutrition. In resource-limited settings, where food insecurity affects many households, people are more vulnerable to high-risk sexual behaviour that may increase their risk of HIV transmission. HIV infection then increases vulnerability to undernutrition by exacerbating poverty and food insecurity, as a result of additional expenditures on accessing medical care, and the often simultaneous loss of income due to prolonged illness and stigma. Psychosocial factors—depression and alcohol use—may also have adverse effects on HIV-related outcomes (31). Individuals may resort to selling assets, leading to long-term damage to the household’s economic sustainability. Such asset erosion can also occur during the treatment phase, when the costs associated with accessing services, adhering to treatment and maintaining adequate food consumption have to be met. As income decreases, households will often purchase poorer quality, less nutritious foods, limiting the consumption of nutrients by all household members (32). The negative impacts of malnutrition, HIV and TB reinforce each other (33). This vicious cycle is described in more depth in Chapter 2. PLHIV require more calories than people who are HIV-negative. At the same time, HIV and associated opportunistic infections undermine the immune system, limiting nutrient intake, absorption and use. In the absence of treatment, undernutrition weakens the immune system even further, which increases susceptibility to infections, lowers quality of life and increases mortality risk. Because of the significant asso- ciation between low BMI and mortality among both PLHIV and TB patients (34–36), patients should be treated for all three conditions (HIV, TB and malnutrition) concurrently. Rationale for food and nutrition considerations in HIV care and treatment programmes: „„ Low BMI is associated with higher mortality during the early phases of antiretroviral therapy. „„ Food and nutrition can improve adherence to treatment and retention in care. „„ Food and nutrition can support recovery and return to a productive life. 6 While this programming guide focuses mostly on adults and adolescents, NACS would have be provided to children as well (i.e. growth monitoring and basic child health services to promote the health of infants and young children, and clinical management of severely malnourished children).
  • 24. 25Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS Mortality risk is particularly high during the first few months of treatment and is inversely proportional to BMI: PLHIV on antiretroviral therapy with a low BMI are more likely to die than PLHIV with a normal BMI (34–36). A BMI below 18.5 is a sign of undernutrition and an independent predictor of early mortality within six months of initiation of antiretroviral therapy. For this reason, nutritional recovery in the early phase of treatment is imperative. Some studies show an association between early weight gain when receiving antiretroviral therapy and improved treatment outcomes (37, 38). Improving nutritional status requires a combination of antiretroviral therapy; treatment and control of opportunistic infections, enabling the body to make good use of nutrients and re-establish appetite; and a diet that meets nutrient requirements in terms of energy needs and micronutrient content. Malnourished PLHIV, especially in food-insecure contexts, may require food supplements, in addition to antiretroviral therapy, to ensure that appropriate foods are consumed to support nutritional recovery (3). In studies among PLHIV in Haiti, food assistance was associated with improved food security, increased BMI and improved adherence to clinic visits at 6 and 12 months (39). Most studies have found that providing food to food-insecure patients when they initiate antiretroviral therapy or TB treatment improves adherence to antiretroviral therapy (40). Research on the clinical benefits of different types of food supplementation for PLHIV—that is, to treat undernutrition or support treatment adherence—is urgently needed to inform global policy (41). What is the role of food and nutrition support in achieving universal access and adherence in lifelong chronic HIV treatment and care? Access to antiretroviral therapy is increasing in resource-limited settings. As treatment coverage expands, focus of treatment will gradually shift from an urgent response of enrolling people for treatment to a chronic disease approach, which focuses on improved adherence to lifelong treatment and retention in care. Losing a patient to follow-up not only increases mortality risk but also means that the investment made to date in that patient’s recovery is lost. Appropriate dietary and nutrition management is essential for all people at all stages of HIV. In some settings, food and nutrition interventions are significantly connected with treatment uptake, making them essential components in attaining the goal of universal access to treatment and care. For PLHIV who are already on treatment, adequate nutrition counselling can greatly assist in controlling food and drug interactions (e.g. the bioavailability of certain medication might be altered by the type of food), and treatment side effects. PLHIV in food- insecure households might find it particularly difficult to take up or adhere to antiretroviral therapy if they have to choose between purchasing food and accessing treatment services that could involve significant transport costs. Additionally, individuals might not tolerate the side effects of antiretroviral therapy on an empty stomach, or may fear the return of an appetite that they might not be able to satisfy with the food they have available. In these cases, many PLHIV may require food supplements to complement their home diet and meet nutrient requirements.
  • 25. 26 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV CHAPTER 2 NUTRITION, AND HIV AND TB Key messages „„ Food and nutrition support is essential in managing HIV infection before and during antiretroviral therapy, as well as for managing tuberculosis (TB) infection and treatment. „„ Adequate calorie and nutrient intake, combined with treatment, is needed to manage malnutrition and maintain good nutritional status. „„ Food and nutrition support is provided to: –– enhance the impact of antiretroviral therapy, particularly for early recovery and return to a productive, quality life; –– enable adolescents and adults living with HIV and with active TB infection to seek earlier diagnosis and access treatment; and –– promote treatment adherence and retention in care. Introduction Nutrition is important at all stages of HIV and TB infection. The vicious cycle of undernutri- tion and HIV, which also applies to TB and other infections, is shown in Fig. 3. HIV affects the immune system, increasing the risk of opportunistic infections and diseases. In turn, infection increases nutritional needs while increasing nutrient losses, and reducing intake and absorption of nutrients. The ensuing deterioration of nutritional status affects the immune system and body strength, and the cycle continues with disease progression and further worsening of nutritional status. This chapter discusses the relationship between HIV or TB infection and nutrition. It also addresses ways to reduce and reverse this deteriorating cycle Fig. 3. The vicious cycle involving HIV infection and undernutrition Source: Adapted from Regional Centre for Quality of Healthcare (100).
  • 26. 27Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS with a combination of medical treatment and good nutrition. The focus is on resource-limited settings. What is the evidence for the role of nutrition in TB incidence? Approximately one third of the world’s population and one half of all adults in sub-Saharan Africa, and South and South-East Asia are infected with TB and therefore at risk of developing active TB. Undernutrition, in addition to HIV infection, increases the risk of active TB in people with latent TB infection. Good nutrition is therefore important, especially for people who are in contact with someone with active TB (including health workers and members of patients’ households). Observational studies from World War I, before TB drugs were available, show how TB incidence in Denmark fell when the quality of the diet improved after food exports ceased. This was also seen in British prisoners of war who received extra food from the Red Cross, compared with Russian prisoners of war who did not (38). In both cases, a lower TB incidence was observed when the consumption of dairy foods, vegetables, fruits and meat, in particular, was higher. This illustrates that nutrition, and specific nutrients in particular, support the immune system, preventing people from developing common colds and influenza, and also active TB. Similarly, good nutrition helps maintain good health among people living with HIV (PLHIV) who are not yet eligible for antiretroviral therapy (42). Why are food and nutrition interventions needed during HIV and TB treatment? In resource-limited settings, the HIV epidemic and TB infections are often highest where undernutrition is already prevalent. Many patients first present to the clinic undernourished and in an advanced stage of disease, and undernutrition is associated with high mortality in the early months of treatment (34–36). The faster that nutritional recovery can be achieved through nutritional support, in combination with antiretroviral therapy or TB treatment, the better. For food-insecure families, receiving food or other support (vouchers, cash or transport) can be very important in compensating for lost income and alleviating costs related to seeking care, including a diagnosis. Awareness of HIV status is linked with prevention, accessing treatment and care, and adherence to treatment. Receiving food and other support is particu- larly important at the beginning of treatment when people are still recovering from opportu- nistic infections and undernutrition, and regaining the ability to earn an income. As adolescents and adults living with HIV stay on treatment for life, adequate nutrition remains important, but the nature of nutrition challenges changes. After many years of treatment, they may face an increased risk of high blood pressure, diabetes, heart disease, reduced bone density and/or dyslipidaemia. Many may have been at risk of these conditions irrespective of their HIV infection, and the HIV infection, as well as its ongoing treatment,
  • 27. 28 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV may increase their risk (22). A healthy diet can contribute to managing these conditions, and regular monitoring is important. Although TB patients, whose treatment is finite, do not face the same longer term health issues, they often struggle to rebuild lean body mass (mostly muscle tissue) while on treatment and shortly afterwards; this phenomenon is also observed among people recovering from long periods of other illnesses (43). For both HIV and TB, nutrition plays an important role in maintaining or improving health. What interventions are required to restore health and nutritional status among adolescents and adults living with HIV and with active TB? Fig. 4 summarizes how HIV and malnutrition reinforce each other, and how malnutrition is a consequence of poverty and food insecurity, both of which are very common in resource- limited settings. It also shows the different pathways through which HIV affects nutrition, including food intake, nutrient absorption and metabolism. It is important to remember that, in PLHIV and TB patients, it is the combination of medical treatment and improved food intake that allows for nutritional recovery. Medical treatment is required for HIV infection and opportunistic infections. Treatment of infections improves nutrient absorption and metabolism, although it may also have adverse metabolic conse- quences. Treatment thereby paves the way for food and nutrition support to have a greater impact on rebuilding tissues and improving nutritional and health status. Fig. 4. Relationship between HIV and malnutrition Source: De Pee S, Semba RD (38). Context in resource-limited settings: – Pre-existing malnutrition, food insecurity, low dietary quality – High infection pressure (malaria, TB, parasitoses) – Higher susceptibility to HIV infection: – Higher HIV prevalence
 – Lower epithelial integrity
 – Risk behavior Loss of appetite Difficulty swallowing Diarrhoea Malnutrition: Low BMI
 Weight loss Micronutrient deficiencies Poverty, food insecurity Low food intake (micronutrients, energy) Malabsorption (fat, carbohydrates, micronutrients): Gut functioning Diarrhoea HIV infection and opportunistic infections Altered metabolism: – Increased nutrient needs due to infection – From 10% higher resting energy expenditure when asymptomatic to 30% higher when symptomatic – Increased losses of micronutrients due to infection – Inefficient nutrient utilization – Changes of hormone production (glucagon, insulin, cortisol, epinephrine) affecting carbohydrate, protein, fat metabolism – Hypogonadism and adrenal insufficiency Affecting progression and outcome Loss of appetite Difficulty swallowing Diarrhoea Malabsorption (fat, carbohydrates, micronutrients): Gut functioning Diarrhoea Malnutrition: Low BMI
 Weight loss Micronutrient deficiencies Low food intake (micronutrients, energy) Context in resource-limited settings: – Pre-existing malnutrition, food insecurity, low dietary quality – High infection pressure (malaria, TB, parasitoses) – Higher susceptibility to HIV infection: – Higher HIV prevalence
 – Lower epithelial integrity
 – Risk behavior Altered metabolism: – Increased nutrient needs due to infection – From 10% higher resting energy expenditure when asymptom- atic to 30% higher when symptomatic – Increased losses of micronutrients due to infection – Inefficient nutrient utilization – Changes of hormone production (glucagon, insulin, cortisol, epinephrine) affecting carbohydrate, protein, fat metabolism – Hypogonadism and adrenal insufficiency
  • 28. 29Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS The more advanced the disease stage, the more challenging it is to manage HIV (including opportunistic infections and other diseases), to treat factors that affect food intake (such as mouth ulcers and loss of appetite) and to restore nutritional status. What are the nutritional needs of people living with HIV and patients with active TB? To provide effective nutrition counselling and support, health providers need to be aware of the increased nutritional needs of adolescents and adults living with HIV and TB infection who are receiving treatment. Table 1 shows the macronutrient intake guidance from the World Health Organization. Energy intake A 10% increase in energy intake is recommended during asymptomatic HIV infection to make up for increased resting energy expenditure (44). However, it is important to note that weight loss during HIV infection is mainly a result of reduced food intake as a consequence of reduced appetite (45). Careful study (in developed countries) of the energy balance of asymp- tomatic PLHIV has shown that reduced physical activity often compensates for the increased energy needs of resting metabolism (46), meaning that there may not be a negative energy Table 1. WHO recommended macronutrient intake for adolescents and adults living with HIV Nutrient/population groupa Recommendationb Energy Asymptomatic HIV+ adults Increase of ~10% Adults with symptomatic HIV infection or AIDS (including pregnant/lactating women) Increase of ~20–30% Asymptomatic HIV+ children Increase of ~10% Children experiencing weight loss (regardless of HIV status) Increase of ~50–100% Children with severe acute malnutrition No change from WHO guidelines Protein All population groups No change indicated in the relative propor- tion of protein, although absolute quantities would increase with increased energy intake (10–12% of total energy intake) Fat Individuals who are HIV or HIV+ but not taking ARVs No change indicated (17%of total energy intake) ARV: antiretroviral drug; HIV+: HIV-positive; HIV–: HIV-negative. a Although this programming guide does not address children, we have left the recommendations for children here for completeness. b Compared with normal dietary requirements recommended by WHO. Source: WHO (44).
  • 29. 30 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV balance or need to consume more energy. In other words, once physical activity is reduced, energy intakes may not need to be much higher than when the person was not infected with HIV. Monitoring weight changes is the best indication, at the individual level, of whether energy needs and intake are aligned. However, if people are involved in physical labour and unable to afford a reduction in physical activity, and if meeting normal energy requirements is already difficult, increasing energy intake by 10% during asymptomatic infections is reasonable advice. During periods of symp- tomatic infection, energy expenditure increases by 20–30%, and therefore the recommenda- tion is to increase energy intake by 20–30% during symptomatic infection and shortly after it (during the convalescence period) (45). Energy requirements of PLHIV on antiretroviral therapy are not well known and are likely to vary according to clinical condition. However, they are very unlikely to be lower than for people without HIV infection or higher than during symptomatic infection. Monitoring weight is the best way to determine whether an individual is meeting their energy needs. It is important to note that certain life stages have increased recommended energy intakes that need to be added to the increased requirement due to HIV infection. In adolescence, require- ments for energy are highest during the period of peak growth, particularly in boys, who gain a greater amount of height and lean body mass than girls (47). The recommendations for increased energy intake at different life stages are shown in Table 2 (48). Protein intake The recommended percentage of energy intake from protein is the same for PLHIV as for HIV-negative people. However, when energy intake is increased, the total amount of protein should also be higher for PLHIV. Furthermore, to treat undernutrition, it is important that the protein sources provide enough of the essential amino acids. This means that there should Life stage Increased energy requirements (kcal/day) Pregnancy, first trimester a 85 Pregnancy, second trimester a 285 Pregnancy, third trimester a 475 Lactation (first 6 months),b well nourished, good gestational weight gain 505 Lactation (first 6 months),b undernourished, poor gestational weight gain 675 Table 2. Increased energy requirements at various life stages a Additional energy will be required for adolescent and undernourished pregnant women; these requirements should be reduced if pregnant women are overweight or obese. b Energy requirements for milk production after six months are highly variable but should be considered.
  • 30. 31Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS be different sources of protein in the diet, including some with a high protein digestibility corrected amino acid score, such as soybeans or animal source foods, including dairy. Fat intake Recommendations for fat intake are the same for PLHIV as for people who are HIV-negative: 15–30% of energy intake should be from fat (49). Some PLHIV may have to increase their fat intake to achieve this level. To increase energy intake during convalescence, eating energy- dense foods, such as fatty foods and foods with a higher sugar content (e.g. fruit), may help to keep bulk relatively low so that energy intake can be higher. It is important to note that PLHIV should preferentially consume unsaturated rather than saturated fats. As a rule of thumb, oils and fats that are liquid at room temperature (20–25 °C) have a lower content of saturated fat. PLHIV should eat foods that are dense in a range of nutrients, including micronutrients. Micronutrient intake Because micronutrients are important for the immune system and other body functions, maintaining an adequate intake is very important for adolescents and adults living with HIV or with active TB. Although several studies have assessed the impact of micronutrient supple- ments among PLHIV, the composition of these supplements has varied widely. As a result, there is currently no definitive evidence on whether PLHIV should increase (or reduce) their micronutrient intake; which micronutrients they should consume more or less of; or which ‘cocktail’ of micronutrients would be best (38, 50). Therefore, the WHO recommendation to ensure consumption of 1 recommended nutrient intake (RNI) per day is still valid (44, 45). (RNI values are established by WHO and the Food and Agriculture Organization of the United Nations.). The South African Academy of Science recommends an intake of 1–2 RNI per day because of higher needs during infection and the likelihood of pre-existing deficien- cies. Ensuring that these recommendations are met is particularly important for PLHIV because of the role of micronutrients in supporting the immune system and other body functions. Many people are unlikely to achieve the recommended intakes, especially when their diets lack diversity and do not include many animal source foods, fortified foods, fruits or vegetables. Micronutrient supplements may therefore be required. General nutrient intake Recommended nutrient intake depends on disease stage, age, physiological status (pregnancy or lactation) and physical activity. Furthermore, people consume foods rather than nutrients. To translate nutrient needs into food-based guidance, food preferences, as well as access to food, must be taken into account. Where undernutrition is widely prevalent, food insecurity and poor dietary diversity are likely to be problems, and meeting food-based guidance is often difficult. This is the reality for many people in resource-limited settings. Therefore, the sections below focus on the goal and form of possible food and nutrition support.
  • 31. 32 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV It is important to note that nutrient intake recommendations will be revised to take into account relevant new evidence. What are the nutritional needs of acutely undernourished adults? WHO recommendations for treatment of malnutrition in adults are not specific to PLHIV. However, severely malnourished adults (body mass index—BMI—of less than 16) should receive a therapeutic food that is nutritionally equivalent to F100 therapeutic milk. For initial treatment, people 19–75 years old should consume 40 kcal/kg/day of this therapeutic food, and people 15–18 years old should consume 50 kcal/kg/day. According to WHO, moderately malnourished adults can be given supplementary foods such as fortified blended foods, compressed bars, biscuits or lipid-based nutrient supple- ments (51–53). Most specialized food products for treating severe acute malnutrition were formulated for children. For adults, it is best to use a product that is adapted to their taste preferences and has a reduced content of some nutrients (in particular, iron, zinc, copper and vitamin A) because adults with severe acute malnutrition have higher energy needs than children and therefore have to consume a higher absolute amount of the product. What kind of food and nutrition support should be provided to adolescents and adults on antiretroviral therapy or receiving TB treatment? As discussed above, good nutrition, composed of adequate calories and nutrients, is essential to all PLHIV (before and during antiretroviral therapy) and to people on TB treatment. This applies both to resource-adequate and to resource-limited settings. Nutrition assessment, counselling and support (NACS) should be universal. It should be tailored to the nutritional needs and circumstances of the individual patient receiving antiretroviral therapy, before and during different stages of treatment (early, later and stabilized), or TB treatment.7 Some patients may not put nutrition counselling advice into practice because they lack access to appropriate foods for economic or availability reasons. In these cases, food support might be provided, with a specific focus on nutritious foods, including fortified foods that can be added to the usual diet. Most nutrition support programmes for adolescents and adults living with HIV and with active TB provide food and nutrition support when treatment is initiated, usually to support the recovery of lost body weight. To recover weight, patients need to eat specific foods that provide the nutrients required for rebuilding tissues (muscle mass and fat mass) and restoring body functions. Support for treatment initiation and adherence may require specific foods to manage side effects, including nausea and lack of appetite. PLHIV may also require support to offset the opportunity costs of accessing treatment, and compensate for their loss of income 7 Approximately half of all adults in sub-Saharan Africa and South and South-East Asia are infected with TB, making it imperative that the nutritional status of the general population is also prioritized.
  • 32. 33Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS and livelihood following prolonged illness. This support can be in the form of food, as well as cash or vouchers (e.g. for transport or food) (54). Ready-to-use therapeutic food (RUTF) is often prescribed for severely malnourished adults (BMI 16), but many adults are unable to consume large amounts of RUTF. Some programmes therefore prescribe RUTF in combination with a fortified blended food such as corn–soya blend )(CSB) (54). When specialized food products are provided to help people recover lost weight and return to a normal BMI (18.5–25.0), this support is usually stopped when BMI has become normal. Antiretroviral therapy is a lifelong treatment, whereas TB treatment lasts for six months, depending on national guidelines and treatment response to a first- or second-line treatment regimen. The impact of food and nutrition support on treatment success depends on many factors (see Fig. 5). It is important that these factors are taken into account when programme impact on undernutrition and treatment outcome is being evaluated. What is the role of nutrition support to enable access to health services? As mentioned above, food support also enables access to diagnosis, especially for TB, and treatment initiation and adherence. This is mainly because it offsets the opportunity costs, such as transport costs, of gaining access to treatment (55). Fig. 5. Factors affecting the impact of food support interventions on malnutrition and HIV disease outcome Source: De Pee S, Semba RD (38). Characteristics of food supplement: – Content of supplement – Nutrients: macro- and micronutrients, protein quality, essential amino acids, essential fatty acids – Anti-nutrients – Energy density
 – Amount provided per day – Form of the food (palatability, preparation required) – Ingredients
 – Packaging – Setting in which the food is provided (clinic, community) Starting point of patients and context: – Baseline nutritional status – Target group (children, women, men, etc.)
 – Food security situation
 – Basic diet to which food supplement is added – HIV-disease stage Total food and nutrient intake: – What information and counselling are provided to the patient? – How much of the food supplement does the patient con- sume per day, and for how long? – What else does the patient consume? Treatment adherence and progression of HIV disease during the study period Impact of food intervention on malnutrition and HIV disease (mortality, viral load, CD4 count)
  • 33. 34 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV Compensation for real and opportunity costs can be very important in helping people to access health care. This compensation can be provided in different forms, including cash, vouchers for food or transport, and a family ration. For PLHIV, such support may focus on the initial treatment phase, when they may need to make frequent visits to clinics and their clinical condition makes it difficult to work steadily to earn income. In some settings, TB patients receive such support throughout the treatment period to improve access to services, because treatment takes place over a much shorter period. For equity and clinical reasons, specialized food products are prescribed to treat malnutrition on the basis of strict anthropometric entry and exit criteria (low BMI or low mid-upper arm circumference). Without these criteria, food-insecure people who are not malnourished might argue that they should also be eligible for this kind of food support. At the same time, special- ized food products provided to treat malnutrition may serve as incentives for initiating or adhering to treatment, as can other household food support. While incentives play an important role in increasing uptake of antiretroviral therapy and initial adherence, they are also important for promoting universal access to treatment. On the service provision side, health systems need to bring quality and reliable care closer to people. On the demand side, people need to seek services. How long food support is provided depends on improvement in nutritional status (in the case of specialized food products), the patients’ ability to earn a living and the opportunity costs of accessing treatment.
  • 34. 35Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS CHAPTER 3 NUTRITION ASSESSMENT, COUNSELLING AND SUPPORT8 Key messages „„ Nutrition assessment, counselling and support (NACS) is an organizing framework of comprehensive nutrition services. It emphasizes the strengthening of health systems and the linking of nutrition with other relevant sectors and stakeholders along a continuum of care. „„ NACS improves the quality of care and aims to decrease morbidity and mortality associated with HIV and tuberculosis (TB) by improving or maintaining nutritional status, improving treatment adherence and helping to prevent nutrition-related chronic diseases, such as metabolic syndrome, cardiovascular disease and diabetes. „„ The NACS approach can be integrated into the continuum of care, and engage people living with HIV (PLHIV) and patients with TB in the delivery of nutrition services. „„ Countries should adopt policies and procedures that clearly outline how NACS services are to be delivered within each national context as an integral part of health services. The range and nature of service needs to be adjusted to each context, as appropriate. „„ Staff who deliver nutrition services should be adequately trained and mentored to give clear, tailored and effective messages to address the person’s individual nutritional needs. Chapters 3 and 4 address the incorporation of nutrition into programme design, specifically focusing on the NACS framework. NACS aims to decrease HIV- and TB-related morbidity and mortality, while improving the quality of care at each stage of the continuum of care. Chapter 3 discusses the different components of NACS and how they fit within comprehensive HIV and TB care programmes, as well as the broader policy framework of nutrition interven- tions. It also considers the programme requirements and supportive interventions that are needed to integrate NACS into treatment, care and support. Chapter 4 covers the provision of food support interventions (the “S“ in NACS). How does NACS fit into HIV or TB prevention, treatment, care and support services? NACS should be considered an integral part of HIV and TB treatment, care and support. It has the potential to support treatment, promote adherence to therapy and improve overall health. The use of nutrition interventions contributes to increased adherence to antiretroviral therapy and can support recovery of PLHIV and patients with active TB, and improve the prognosis of TB (56, 57). NACS programmes assist individuals and their families with making dietary changes that promote long-term health and improve quality of life (58, 59). The introduction of safety- net schemes, including travel vouchers, cash transfers and food support, can reduce the cost for patients with HIV and/or TB and their families (57). 8 This chapter was prepared by the Albion Centre. It has been added in part from Family Health International (85), to which Albion Centre staff contributed their technical expertise. Readers with a nutrition background wishing to apply this informa- tion are referred to this text as a guide.
  • 35. 36 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV Evidence shows that mortality during the early months of treatment is inversely proportional to nutritional status, measured by body mass index (BMI). Although no specific studies have been undertaken, indirect evidence suggests that accelerating nutritional recovery may reduce early mortality (34, 35). NACS is particularly important in resource-limited settings, where undernutrition and food insecurity are more prevalent (3, 60). The specific NACS model can be tailored to the nutritional needs of the adolescent and adult population, the implementation environment, and available financial and human resources. Nutritional assessment (anthropometry, and clinical and dietary assessment), counselling and support should be an integral component of HIV care; it should be conducted at enrolment in care and monitored during all HIV care and treatment. Malnourished HIV patients, especially in food-insecure contexts, may require food supplements for a finite period, in addition to antiretroviral therapy (3). Sometimes support in the form of food, cash or voucher transfer can support treatment adherence and help the household recover from the economic shock of having a chronically ill member (see Chapter 4 for further details). Depending on the model, NACS is often initiated briefly by health-care providers in an ad hoc manner; however, comprehensive nutrition assessment and interventions are integral to the standard treatment, care and support approach. Following good clinical practices, individuals are first screened for nutritional concerns and then referred for further assessment by a nurse- nutritionist, nutritionist or dietician. In a country lacking sufficient nutritionists, a variety of health workers and health volunteers, such as peer educators, can be trained to perform effective nutrition assessment and counselling. Peer educators or health workers can perform screening during the initial visit. Tools and techniques that may be helpful when commu- nicating with recipients include visual tools, using a variety of venues and opportunities to deliver promotional information, and mass media campaigns that repeat the promotional messages delivered by lay health workers (61). Lay health workers who provide promotional services need training in counselling and communication. Fig. 6 outlines a model of interventions for the nutrition management of adolescents and adults living with HIV or with active TB infection. The model shows the significance of nutrition screening to identify people at risk of poor nutritional health. The nutrition assess- ment can provide the basis for nutrition counselling and determine whether food assistance is required. NACS is important at all stages of HIV infection and TB (42, 63), although the type of nutri- tional problems addressed tends to change over time. In a clinically stable person living with HIV, before the start of treatment, good nutrition helps to maintain good health (42). Once treatment has started, NACS can focus on restoring nutritional status—this is a high priority because of the increased risk of mortality among patients with low BMI during the early phase of treatment (37). For PLHIV on long-term antiretroviral therapy, NACS may be useful in the prevention and/or management of conditions such as diabetes and cardiovascular disease (64).
  • 36. 37Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS Fig. 6. A model of nutrition interventions in treatment, care and support for adolescents and adults living with HIV and TB (62) Source: Family Health International (62). Targeted nutrition strategies are designed by assessing the individual’s needs and tailoring an intervention to suit their specific requirements. NACS can be curative and/or preventive. For clients whose clinical, biochemical or anthropometric status shows nutritional issues, the objective is to improve nutritional status. For those with no nutritional issues on initial assessment, the goal is to reinforce or develop healthy eating habits to prevent nutritional issues from developing. What are the objectives of NACS? The objectives of NACS are to assist the individual to: „„ achieve and maintain a healthy weight; „„ achieve and maintain adequate macro- and micronutrient intake; Nutrition issues identified: � Nutrition counselling � Receive treatment for acute malnutrition � Food transfer for the household � Economic strengthening and livelihood support No nutrition issues identified: Undernourished and food secure: � Nutrition counselling � Receive support for management of malnutrition if they cannot adequately modify diet on their own (if micronutrients and energy density are problems) Not undernourished: �Nutrition counselling �Does not need support Regular nutrition screening Nutrition management and follow-up Basic nutrition education Nutrition assessment Undernourished and food insecure:
  • 37. 38 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV „„ prevent food-related illness, including foodborne infections and contamination; „„ identify and manage undernutrition-related conditions; and „„ increase overall quality of life. What is nutrition assessment? A nutrition assessment is an interpretation of information obtained from dietary, biochemical, anthropometric and clinical studies. Nutrition assessment systems are made up of surveys, surveillance or screening. In clinical practice, all of these systems have been used. Most commonly, nutrition screening is used to identify clients at risk, followed by a detailed assess- ment (65). What is nutrition screening? Nutrition screening is a generalized tool that identifies PLHIV and patients with active TB who should receive NACS (42, 66). It involves questionnaires, checklists or scaled instruments, which compare an individual’s measurement with predetermined risk levels of “cut-off” points (65). If people at risk of undernutrition or already undernourished can be identified, early interventions may prevent the onset or worsening of undernutrition (42). Screening tools can be integrated into both inpatient and outpatient clinical procedures, or offered in the home by trained health workers, community and home-based care workers, or peer educators. In the inpatient setting, the tool is administered on admission; in the outpa- tient setting, it is administered as part of an initial consultation, often by a trained volunteer or clinic receptionist (47). Alternatively, it is implemented during a field visit, where it forms the basis of a referral for a detailed nutrition assessment. The screening tool generally identifies symptoms associated with undernutrition, such as weight loss, diarrhoea and loss of appetite. The tool also addresses issues such as food insecurity, and pregnancy or lactation. Depending on the target population, it may include identification of people at risk of chronic conditions, such as metabolic syndrome. Most tools attempt to identify unintended weight loss, impaired food intake, increased nutritional losses and current body weight (47). A well designed screening tool is a quick, reliable and cost-effective way of identifying people who are nutritionally at risk (67). The outcome of the screening will be influenced by the validity9 and reliability10 of the screening tool. The tool is designed in consultation with the people who will be implementing it, to ensure that it is appropriate to the nutritional risks of the target population, does not cause additional stigma and discrimination, and is simple to administer. Language and literacy level of the client are considered during the design of the tool. Ideally, a tool is validated in the population where it will be used (66). Currently, few validated HIV screening tools have been developed for resource-limited settings. 9 Validity measures how closely the tool answers the questions it was designed to answer. 10 Reliability measures the consistency of the tool—in other words, when measured again, will the answer be the same?
  • 38. 39Nutrition assessment, counselling and support for adolescents and adults living with HIV | UNAIDS Where screening occurs, it is important to ensure that procedures are in place to refer people for a detailed nutrition assessment. If no additional services are available, the screening tool is not used unless staff are trained in how to administer the tool and proceed with the next steps. In many cases, nutrition screening is not performed, and the treating doctor or health worker will refer the client directly for NACS. Although many people would benefit from a detailed nutrition assessment and counselling, where resources are limited, screening can help to identify individuals with nutritional issues (or at risk for nutritional issues) and those who need immediate attention to reduce the burden on the health-care system. What is a detailed nutrition assessment? A detailed nutrition assessment is a comprehensive analysis of the nutrition status and assess- ment of the biological, physiological, social and psychosocial factors that may contribute to the client’s current or long-term health. A detailed assessment allows the health worker to determine if there truly is a nutrition problem, to name the problem and to determine its severity (68). Nurse-nutritionists, nutritionists, dieticians or other health workers or volun- teers trained in nutrition usually perform the nutrition assessment. What are the objectives of nutrition assessment? The objectives of nutrition assessment are to: „„ determine the nutritional status of an individual; „„ develop an individualized nutrition care plan to support the clinical management of PLHIV and patients with TB; „„ identify whether a specific nutrition intervention, beyond general nutrition education, is needed and, if so, what type; and „„ determine eligibility for nutrition and food assistance for undernourished PLHIV or patients with TB. When is a nutrition assessment conducted? A nutrition assessment is conducted: „„ when a risk factor, such as low BMI or food insecurity, is identified during a nutrition screening; „„ soon after a diagnosis of HIV infection, if nutrition screening is not available; „„ at periodic intervals, depending on the stage of a person’s HIV infection; 11 and 11 Asymptomatic PLHIV: 1–2 times per year; symptomatic PLHIV: 2–6 times per year (85).
  • 39. 40 UNAIDS | Nutrition assessment, counselling and support for adolescents and adults living with HIV „„ when initiating or changing antiretroviral therapy and/or directly observed treatment, short course (DOTS) regimens. What is involved in a nutrition assessment? One method used to assess nutritional status is the “ABCDEF” approach (63, 69), which involves the following components: „„ Anthropometry: includes measures of body composition, height, weight, weight change, BMI, mid-upper arm circumference (MUAC), waist circumference, waist-to-hip ratio, and lean and fat tissue. In children, it includes measurements of length/height, weight and MUAC (70). (See the section on nutrition assessments of adolescents and adults, below.) „„ Biochemical: identifies deficiencies and abnormalities in the blood, including anaemia, and indicators of lipid, protein and glucose metabolism. These measures include haemoglobin, albumin, triglyceride, total cholesterol, low-density lipoprotein, high-density lipoprotein, iron and biomarkers of micronutrients. A biochemical assessment also may include screening for diseases such as diabetes and cardiovascular problems. Many of these tests are expensive, and results need to be interpreted by a trained health worker. Where resources are limited, these tests are not essential to nutrition assessment. „„ Clinical: involves a clinical assessment of the client to examine signs and symptoms of abnormalities such as dehydration, oedema,12 undernutrition and ascites; 13 taste changes and swallowing difficulties (71); the condition of the skin, fingernails and hair; fatigue; and whether a woman is pregnant or breastfeeding. The client’s medical history—including stage of disease, medication and treatments—is also essential information to be collected at this time (71). „„ Dietary intake: involves an assessment of an individual’s or family intake of particular foods, nutrients, herbal preparations and other supplements. The assessment looks at patterns of food consumption, dietary diversity and specific dietary preferences. If human resources allow, mental health should be considered in this component. A variety of methods are used to assess dietary intake; they vary in their accuracy and difficulty, in terms of client recall and recording. These approaches include (47): –– 24-hour recall—the client is asked to recall all the foods and liquids consumed in the previous 24-hour period. This method is highly subjective because of the variability of an individual’s diet from day to day, and season to season. –– Usual food intake—the clinician asks clients to recount the range of food “usually” eaten at various times during the day. Although this method captures more foods than the 24-hour recall, it can be unreliable because of inaccuracies in clients’ recall. Good questioning skills are needed to obtain useful information. 12 Swelling. 13 Swelling in the abdomen.

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