Impact Nutrition intervention Byron

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Information about Impact Nutrition intervention Byron

Published on January 12, 2008

Author: Manuele


Linking Nutritional Support with ARV Treatment: Lessons being Learned in Kenya:  Linking Nutritional Support with ARV Treatment: Lessons being Learned in Kenya Elizabeth Byron Stuart Gillespie and Mabel Nangami International Food Policy Research Institute School of Public Health, Moi University Study Objectives:  Study Objectives Examine ability of a nutrition intervention to improve both the nutritional status of patients on ARV treatment and their household resilience. Identify constraints and future challenges facing program implementers and beneficiaries. Provide practical lessons for modifying program delivery and informing future initiatives that link nutrition support to treatment and care. Contribute to growing evidence base on interactions between nutrition and ARV treatment. Nutritional Intervention for People Living with HIV:  Nutritional Intervention for People Living with HIV Individual-level HIV infection often leads to nutritional deficiencies through decreased food intake and malabsorption Increased caloric requirements for HIV-positive individuals (higher for symptomatic individuals) Undesirable side effects of treatment that can be worsened by malnutrition Threats of declines in adherence and increased drug resistance Household-level Deterioration of food security when chronically ill adult member through reduced income, increased expenditures, loss of labor productivity, time for care-giving Academic Model for Prevention and Treatment of HIV/AIDS (AMPATH):  Academic Model for Prevention and Treatment of HIV/AIDS (AMPATH) Provision of free ARV treatment and care First patient in 2000, today… 14 clinics in western Kenya Over 20,000 HIV positive individuals enrolled Over 9,700 individuals on ARV treatment Mosoriot Rural Health Center (first rural clinic) Female patients in initial treatment cohort Widowed, markedly undernourished No food in their homes, small children at home HIV prevalence 7% Food insecurity 15-20% AMPATH’s Nutrition Intervention:  AMPATH’s Nutrition Intervention HAART and Harvest Initiative (HHI) - 2002 4 production farms established Purchase of additional food Nutrition education to all patients on ART Agricultural skills training, income security program World Food Program (WFP) - 2005 June 2005, 50% daily requirement for 2200 mouths Maize, pulses, oil, and CSB (Maize-Soy blend to <5, patient, and pregnant or lactating women) Target new ARV patients meeting enrollment criteria January 2006  scale-up to 15,000 mouths USAID (Instamix) – 2006 1 clinic site, blended flour to index patient Eligibility Criteria for Supplements:  Eligibility Criteria for Supplements Targeting patients: Insufficient access to food to support patient recovery Household income less than 3,000 Ksh/month ($41/month) Advanced disease, CD4 < 200 BMI < 19 Food prescription: Written by the nutritionist for patient and household Types of food at discretion of nutritionist Duration (initial 6 months), weaning or transition Strategies to assist in post-intervention Methodology:  Methodology Qualitative Data Collection (Dec. ‘05 – Feb. ’06) Key Informant Interviews with program and community stakeholders (18) Focus Group Discussions (9) In-depth Interviews (79) In-depth Sample Groups New ARV patients on food supplements (WFP/HHI) New ARV patients not eligible for supplements Current ARV patients on food supplements (HHI) Current ARV patients never on supplements Key Issues Examined:  Key Issues Examined Eligibility criteria Use of food supplements Appropriateness of food Seasonal changes in demand for food assistance Opportunity costs Individual and household-level benefits Transition off food supplementation Long-term strategies for meeting needs General Lessons Learned:  General Lessons Learned Supplemental foods are reaching intended beneficiaries and provide an important source of support. Enabled patients and households to access food otherwise unavailable, alleviating food insecurity to some extent. Foods are shared among household with some preferential allocation to the HIV positive individual. Types of foods distributed are widely accepted, especially fresh farm foods. Unfamiliar foods require initial education and demonstration. Individual-level Benefits:  Individual-level Benefits Self-reported health outcomes while in food program and on ARV treatment: Weight gain Recovery of strength Resumption of labor activities Self-reported greater adherence to treatment: Fewer side effects Ability to satisfy increased appetites Increased dietary diversity through food collections and nutrition education. Emotional well-being of patients, lowered stress caused by insufficient access to food. Household-level Benefits:  Household-level Benefits Spillover effect – self-reported improved health status of other household members, especially children. Improved in both diet quality and quantity. Household labor supply increased as patient recuperated. Reallocation of resources previously used for food toward education, rent, clothing and transport. Temporarily relieved demand for informal support from social network. Opportunity Costs to Food Collection:  Opportunity Costs to Food Collection Stigma Collection - Many clients keep collection secret from family and friends due to fear of discrimination, esp. when have not disclosed their HIV status. - Visibility of distribution points – initial gossip, stigma, appears to be declining Fermented Milk Packets - Labeled with AIDS awareness messages - Does not respect confidentiality “Let food be food.” 2. Transport costs Average roundtrip transport cost = $2.15 Impact on frequency of food collection Program Challenges:  Program Challenges Determining program eligibility for cases that fall near enrollment guideline cut-offs, yet limited human resources to verify borderline candidates Seasonal vulnerability to food security Duration of Support – dependency vs. weaning Transition from short to long-term strategies – client’s ability to meet own food needs post-intervention Recommendations:  Recommendations Transition off supplementation: Constraints to meeting needs persist even after some recovery Six months may be too short to make longer-term plans Weaning should ideally occur when secure strategies for meeting needs are in place, either Patient’s return to productive activities or Household’s generation or food or income AMPATH should strengthen investment in process of transitioning off food supplementation Programmers, clinical care providers, and researchers should collaborate in determining what constitutes an appropriate duration of food supplementation Translate these guidelines to donors to ensure appropriate timelines for supplying food resources Recommendations (con’t):  Recommendations (con’t) 2. Program Monitoring and Evaluation Necessary to meet long-term objectives Possibility of patients requiring reintroduction to food supplementation should be considered in program design. Anthropometrics and clinical indicators should be coupled with assessments of ability to meet needs. Use data to determine when patient experiences a decline in nutritional status that necessitates additional food supplementation. Recommendations (con’t):  Recommendations (con’t) 3. Seasonal shifts in demand for food supplementation Available number of food rations should take into account seasonal patterns in food insecurity and adjust to increased needs for assistance. 4. Reduce stigma associated with food collection Labeling of any supplemental foods with AIDS-identifying messages, even when intended for educational purposes is inappropriate in population that has not widely disclosed their HIV status to family and friends. Consider removing messages from milk Incorporate initiatives to reduce stigma in program objectives Recommendations (con’t):  Recommendations (con’t) 5. Build linkages with partners AMPATH, while a comprehensive model, can’t do it all. Promote linkages with external partners based on comparative advantage in long-term sustainable rural livelihood strategies. Income security program – (i.e. Imani Craft Workshop) Majority of clients depend on agriculture and greater linkages with local and national institutions may be necessary to achieve long-term goals. Recommendations (con’t):  Recommendations (con’t) 6. Initiation of Supplementation “When” to initiate nutrition interventions? – future research needed. Limited resources and increasing demand. Universal provision of nutrition education to all patients regardless of whether they are on ARV treatment or not, may be one strategy. 7. Economic sustainability Economic evaluation of cost-effectiveness of AMPATH’s nutrition intervention needed to allow for future planning. How to ensure that this service can continue to meet demand. Further Research Areas:  Further Research Areas Transition from short to long-term strategies for nutrition security Post-intervention and weaning process Economic viability of programs Acknowledgements:  Acknowledgements Collaborators Mabel Nangami, Ph.D. (Moi University) Stuart Gillespie, Ph.D. (IFPRI – Director RENEWAL) Kara Wools-Kaloustian, MD (Indiana Univ. School of Med.) Markus Goldstein, Ph.D (The World Bank) Josh Graff-Zivin, Ph.D. (Columbia University.) Cristian Pop-Eleches , Ph.D. (Columbia University) Abraham Siika, MD (AMAPTH, Moi University) Funding for this study was provided by Regional Network on HIV/AIDS, Rural Livelihoods and Food Security (RENEWAL) USAID Office of Food For Peace

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