Download Module 18: HIV & AIDS Nutrition

HIV/AIDS and Nutrition
Module 18
Learning objectives
• Be able to identify the changing nutritional requirements of people
living with HIV and how these could be managed in emergencies
• Be aware of the complex issues surrounding targeting of people
living with HIV in emergencies
• Understand the issues linked to breastfeeding for HIV-positive
mothers in emergencies
• Have enough knowledge to understand the importance of key
services for the treatment and care of people living with HIV in
emergencies to maintain nutritional status
• Understand the importance of good hygiene, water and sanitation
for people living with HIV.
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The Global AIDS epidemic
• Since the beginning of the epidemic, almost 60 million people have
been infected with HIV and 25 million people have died of HIVrelated causes
• In 2008, some 33.4 million people living with HIV, 2.7 million new
infections and 2 million AIDS-related deaths
• In 2008, around 430 000 children were born with HIV, bringing to 2.1
million the total number of children under 15 living with HIV
• Young people account for around 40% of all new adult (15+) HIV
infections worldwide
• Sub-Saharan Africa is the region most affected and is home to 67%
of all people living with HIV worldwide and 91% of all new infections
among children
• In sub-Saharan Africa the epidemic has orphaned more than 14
million children.
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Humanitarian crises and HIV and AIDS
• Factors that may accelerate the spread of HIV in
emergencies include:
– Rape and sexual violence
– Mass displacement of people
– Severe impoverishment leading to transactional sex for
survival
– Breakdown in normal health and social services leading to
reduction in the availability of:
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•
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Voluntary counselling and testing for HIV
Reproductive health options
Treatment for Sexually Transmitted Infections (STIs)
Antenatal care
Antiretroviral treatments for breastfeeding HIV+ve women
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HIV and AIDS programming
• The challenges faced by humanitarian workers,
governments and civil society fall within all the 3 pillars of
HIV/AIDS programming, namely:
– Prevention
– Health care and treatment
– Support and care
• Prevention – condoms, counselling, infant and young child
feeding counselling and support, etc
• Health care and treatment - ARTs, opportunistic infections
treatment, nutritional support including micronutrient
supplements
• Support and care – psychosocial support, family and
community support, etc
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2010 Inter-Agency Standing Committee Guidelines
• The 2010 IASC guidelines for addressing HIV in humanitarian
settings action framework lists 9 sectors into which HIV should be
integrated:
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–
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–
–
–
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Awareness raising
Health
Protection
Food security
Education
Shelter
Camp coordination
Water, sanitation, and hygiene
The workplace
• Earlier guidelines focused on avoiding stigmatisation
• The 2010 guidelines emphasise the need for coordination of
existing and fragmented HIV support groups to provide targeted
nutritional support, food security, and livelihood support.
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What is the link between HIV and AIDS and Nutrition?
• One of the most common signs of HIV progression is
weight loss
– Unexplained weight loss (>10% of body weight) is one
of the signs used to indicate that a patient is moving
from the asymptomatic phase towards AIDS
• There are 2 patterns of weight loss:
– First pattern is a slow gradual decline in weight over time
with HIV infection
– Second pattern is a rapid and drastic weight loss often
associated with a serious infection
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Link between HIV and AIDS and Nutrition
• Early detection of HIV provides an opportunity to build up good
nutritional status and healthy eating habits
• Good nutrition is a form of immune protection, especially important in
the presence of HIV
• People living with HIV may reduce the amount of food they consume due
to the following factors:
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Sores in the mouth, throat, and digestive tract
Persistent nausea, vomiting, diarrhoea, or stomach pains
Depression which reduces appetite
Economic problems due to loss of income or lack of access to adequate food
Tiredness making food preparation slow or difficult
• People living with HIV may also have poor absorption of nutrients from
food consumed due to:
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–
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Diarrhoea
Intestinal tract infection
Medications side effects
(Anaemia)
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Link between HIV and AIDS and Nutrition (2)
• The metabolism of a person living with HIV is altered
• In the asymptomatic phase an additional 10% of energy is
required
• As a person moves into the symptomatic phases, the
energy requirement goes up 20-30% more
• Children in symptomatic phases require 50-100% more
energy than expected by age and weight
• If nutritional needs are not met, the body is more
susceptible to infections and may take longer to recover
from minor illnesses
• This leads to a cycle of more weight loss, more
vulnerability, and worsening illness
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Nutrient requirements for HIV+ in relation to
Normal Dietary Requirements
Nutrient
Population Group
Recommendations*
Energy
• Asymptomatic HIV+ Adults
• Adults with symptomatic HIV infections
(including pregnant and lactating women)
• Asymptomatic HIV+ children
• Children experiencing weight loss
regardless of HIV status
• Children with severe acute malnutrition
• Increase of ~10%
• Increase ~20%
Protein
All population groups
Fat
Individuals who are HIV- or HIV+ but not
taking antiretroviral drugs
Micronutrients
All population groups
• Increase of ~10%
•Increase of 50-100%
• No change from WHO
guidelines
No change indicated to date
(10-12% of total energy
intake)
No change indicated to date
(at least 17% of total energy
intake)
No change indicated to
date. Micro-nutrient intake
at RDA is recommended
*Adapted from WHO, 2003: Nutrient requirements for People Living with HIV/AIDS, Report of technical consultation. Geneva,
WHO. Refer to this document for details and discussions on nutrient requirements
Vicious Cycle of Malnutrition and HIV
Source: Adapted from RCQHC and FANTA 2003
Poor Nutrition
resulting in weight loss,
muscle wasting, weakness,
nutrient deficiencies
Increased Nutritional
needs
Reduced food intake
and increased loss of
nutrients
HIV
Increased vulnerability to
infections e.g. Enteric
infections, flu, TB hence
Increased HIV replication,
Hastened disease progression
Increased morbidity
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Impaired Immune System
Poor ability to fight HIV
and other infections,
Increased oxidative
stress
Nutrition during pregnancy and early infancy for
those affected by HIV
• Condoms and ART supplies particularly for pregnant
women are an important part of integrated HIV and
nutrition planning
• PLW with HIV require the same increase in foods and
added micronutrients as HIV-ve pregnant women,
plus an additional 10% to maintain their health in the
context of HIV infection
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Nutrition during pregnancy and early infancy for
those affected by HIV (WHO, 2010)
• The best way to approach nutritional care and prevent
mother-to-child transmission of HIV:
– Appropriate health care during pregnancy (with ART)
– Breastfeeding exclusively in the first 6 months and
continue up to at least a year
– Replacement feeding if acceptable, feasible, affordable,
sustainable and safe (AFASS)
• Asymptomatic HIV positive lactating women require the
same increase in rations and micronutrients as HIV-ve
lactating women, plus an additional 10% for maintaining
health in the context of HIV
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Nutrition during childhood for those affected by HIV
• After the first year of life, HIV exposed but uninfected
children should transition to family foods with animal
protein, particularly milk
• Beyond the first year of life, children known to have
contracted HIV should continue to breastfeed up to 24
months of age and beyond
– In this case, breast milk offers no additional risk, and
provides the best source of nutrition
• Complementary foods should be added to the diet at 6
months to provide energy, nutrients, and dietary
diversity.
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HIV/AIDS and Nutrition in emergencies
• 8 critical HIV/AIDS and nutrition-related activities in
emergencies
1.
2.
3.
4.
5.
6.
7.
8.
Integration of HIV into all aspects of emergency care –
prevention, education, health, basic services, planning and
management
Targeted food support
Maternal and infant health and feeding
Treatment and care of HIV
Treatment of severe acute malnutrition
Support networks, including livelihood support and HBC
Food hygiene, sanitation, water, shelter
Protection
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HIV/AIDS and Nutrition in emergencies
1. Integration of HIV into all aspects of emergency care –
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prevention, education, health, basic services, planning and
management
Mainstreaming HIV programming into emergency
coordination and management can help to prevent the
transmission of HIV and uphold the human rights of those
living with HIV
The type of emergency and the stage of the emergency will
influence the HIV/AIDS and nutrition interventions that need
to be undertaken (analysis to be conducted)
The ideal is to integrate HIV into existing food assistance and
livelihood support, and integrate food assistance, security,
nutrition, and livelihood support into HIV-related projects and
activities.
» The 2 programming activities can strengthen one another.
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HIV/AIDS and Nutrition in emergencies
2. Targeted food support
• Household food insecurity should be the main (initial) targeting
principle, regardless of whether HIV status is known
• HIV prevention and sensitization activities should be linked to
large-scale food distribution
• Particular attention should be given to the identification of
households that may be vulnerable because of the presence of
HIV or AIDS:
• child or elderly headed HH
• orphans hosting HH
• HH with sick members, etc.
• Targeting people living with HIV/AIDS directly may be possible
• if there is no stigma or discrimination;
• if the targeting does not increase stigma;
• if the targeting does not unjustly exclude non affected households.
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HIV/AIDS and Nutrition in emergencies
2. Targeted food support
• Food rations should be specially designed and distribution
should consider issues such as distance to cover, capacity to
cook, to eat, etc.
• Quality- balanced diet particularly important
(preparation, consumption and digestibility)
• Quantity- increase of 10% in energy required to maintain
body weight
– in asymptomatic HIV infected adults, can rise to 20-30%
– for symptomatic adults and 50-100% for children with acute
weight loss and infection
• Safe access to food- women and girls should have direct
access to food distributions and rations - protection
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HIV/AIDS and Nutrition in emergencies
3. Maternal and infant health and feeding
• Continuation of breastfeeding recommended
• ART reduce rate of transmission from mother-to-child
during pregnancy from 40% to 10%, and also reduce
the risk of transmission through breastfeeding
• HIV testing should then be offered to all mothers:
• to determine status
• to obtain and dispense appropriate ART treatments to
breastfeeding mothers as a complement to
breastfeeding
• (testing of infants only reliable after 18 months)
• Guidelines available for feeding non breastfed infants.
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HIV/AIDS and Nutrition in emergencies
4. Treatment and care of HIV
• The treatment based on ART and cotrimoxazole (for
opportunistic infections) helps nutrition by:
– improving appetite
– utilisation of nutrients by the body
– reduction of opportunistic infections
• Medication often combined with Food by Prescription
(FBP) programmes to increase adherence
• Protection and prevention is to be ensured with safe
procedures at health facility level, access to condoms,
access to post exposure prophylaxis, etc.
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HIV/AIDS and Nutrition in emergencies
5. Treatment of severe acute malnutrition
• Treatment remains the same as for non HIV children,
with addition of cotrimoxazole
• SAM cases and their caregivers should be encouraged
to take voluntary testing and counseling on HIV
• 3 care plans for HIV positive children include:
• for those growing well (review every 2-3 months)
• for those with poor weight gain (regular visit and support)
• for the severely malnourished ones (treatment)
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HIV/AIDS and Nutrition in emergencies
6. Support networks, including livelihood support and Home
based care (HBC)
• A functioning HBC system provides a safe channel for
resources to households with chronically sick members and
provide:
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Blended fortified foods or fortified cereals ± food basket
RUF or LNS to decrease the preparation time for people with
limited appetite
Cash benefits for the purchase of additional foodstuffs
Or the provision of services:
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Monitoring of weight and health status
Individual nutritional assessments
HBC limits the risk of opportunistic infections when people with
weakened immune systems are not required to wait in health
care centres
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HIV/AIDS and Nutrition in emergencies
6. Support networks, including livelihood support and
Home based care (HBC)
• HBC can also be used for provision of livelihood
support such as:
– Dietary diversity support with availability and access to
tools, fertilisers, and improved variety seeds
– Labour-saving tools adapted to local conditions
– Alternative income-generating activities compatible
with new activity constraints
– Skill building programmes such as junior farmer fields
and life school programmes to combine livelihood
support with skills education for children who are
unaccompanied, orphaned, or made vulnerable by the
illness of family members.
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HIV/AIDS and Nutrition in emergencies
7. Food hygiene, sanitation, water, shelter
• These are critical in emergency:
– Food Hygiene: avoid contamination during
cooking or storage
– Sanitation and water availability: latrine
construction, control of stagnant water,
promotion of hand washing, quality and quantity
of water supplies, distance to water
– Shelter: safety and security of sites, integration
of HIV prevention into shelter programmes
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HIV/AIDS and Nutrition in emergencies
8. Protection
• Gender inequalities are common in emergencies,
increasing the vulnerability of women to HIV
• Vulnerable households are also common in high HIV
prevalence contexts:
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Child-headed households
Households with no adult male members
Elderly headed households
Orphans without family
Households hosting orphans
HIV-positive people who are suffering from discrimination or
alienation
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HIV/AIDS and Nutrition in emergencies
8. Protection (2)
• Important policy points that should be in place to ensure
the rights of individuals and families living with HIV:
1.
2.
3.
4.
5.
6.
Monitor allegations of HIV-related rights violations (and change
program if violence associated to its design)
Ensure HIV service provision respects human rights, including
the right to privacy. Use of alternative vulnerability criteria for
programmes is recommended
HIV testing should not be mandatory, and all HIV testing should
be under confidential conditions, with informed consent and
counseling according to international standards
Establish protection for women and girls.
Protect orphans and unaccompanied, separated, and other
vulnerable children and youth.
Develop programmes addressing gender based violence.
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Key messages
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HIV should be integrated into all aspects of the emergency management planning
and response.
People living with HIV have increased nutritional needs in terms of energy
requirements.
People living with HIV should be monitored regularly for weight loss which may be
a sign of decreased intake or disease progression.
Steps can be taken to reduce the rate of transmission of HIV from mother to child
with counselling on infant feeding and ART (antiretroviral therapy). Food/nutrition
support may be needed.
Services for HIV care should be established as a priority. These include provision of
ART and cotrimoxazole and VCT (voluntary counselling and testing) facilities.
All severely malnourished children require therapeutic care. HIV positive children
should be regularly assessed and assigned to appropriate nutritional care plans.
Home based care (HBC) programmes and livelihood support programmes are
important for improving the long-term food security status of HIV affected
families.
People living with HIV are prone to infections, so access to clean water,
appropriate food hygiene and sanitation are a key part of the emergency response
for these people/families.
Targeted policies and practices are required to protect the rights and ensure the
safety of people living with HIV as well as those at risk of contracting HIV.
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