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Working Group on Nutrition and HIV/AIDS Contribution to Millennium Development Goalsheld during the ACC/SCN's 31st Session in New York, United States, 24 March 2004 Chair: Andrew Tomkins (Centre for International Child Health, Institute of
Child Health, London, UK) Presenters – Andrew Tomkins (Centre for International Child Health, Institute of Child Health, London, UK), Randa Saadeh (WHO), Moses Sinkala (Ministry of Health, Lusaka, Zambia), Lackson Kasonka (University Teaching Hospital, Lusaka, Zambia), John Mason (Department of International Health and Development, Tulane School of Public Health and Tropical Medicine, New Orleans, USA), Robert Mwadime (FANTA, Uganda) Working Group Co-Chair Andrew Tomkins opened the session by welcoming the participants and giving apologies from the Co-Chair (Jos Perriens of WHO) and Stuart Gillespie (IFPRI) who were unable to attend. He also thanked USAID and FANTA for supporting the attendance of Moses Sinkala and Lackson Kasonka, the UNU for supporting the attendance of Robert Mwadime and Jane Hedley of SCN for her considerable administrative help. The role of the SCN working group on Nutrition and HIV/AIDS – identifying interventions to assist achieving the Millenium Development Goals (MDGs) (Andrew Tomkins)The impact of HIV/AIDs on nutrition of the individual has been recognised for decades. However, several previously neglected aspects are now increasingly recognised. Firstly, sufficiently large numbers of adults are now infected in many countries that food production and earning capacity is often seriously affected. While there are anecdotal reports of families or entire communities being unable to farm traditional crops there seems little data on how much any agricultural policies or extension activities mitigate against the resultant food insecurity. Secondly there is now increased commitment to increasing the provision of anti-retroviral drugs to more people. The 3x5 strategy of WHO and the increased funding for RVs from the Global Fund are examples. Several nutritional factors will need to be included within ARV programmes for them to be effective. This will require the establishment of guidelines and improved skills and capacity of medical and nursing staff. Societal change to reduce the scale of stigma, which often prevents people taking VCT, is vital. It is not widely recognized that the majority of HIV infected individuals will not receive ARVs because their CD4 counts are above 200. Despite increasing information on the importance of nutritional interventions, guidelines have not been clarified or introduced sufficiently, either for those receiving ARVs or those not yet receiving them. Thirdly, there is now data showing decreased disease progression and increased survival among HIV infected individuals (not receiving ARVs) who recive high dose anti-oxidants. Fourthly the impact of HIV/AIDS is now having a range of effects on child nutrition and survival. While many communities are remarkably able to support increasing numbers of orphans, others have “collapsed” socially. Many NGOs are active in supporting Orphans and Vulnerable Children but the costs vary considerably and there has been little assessment of their impact. It is suggested that the following interventions are needed to achieve MDG 1:
It has been noted that school attendance is reducing in many HIV affected communities which are also poor and food insecure. Several factors contribute to declining attendance including the need to care for sick parents, farm, seek food or employment together with the declining quality of schools and absence of teachers because of illness or funerals. In addition the health and nutrition of school children is compromised by factors considered by the Working Group on Nutrition and School Age Children – including micronutrient deficiency and infections. It is suggested that the following interventions are needed to achieve MDG 2:
It has been noted that there are several factors affecting children’s lives which influence their susceptibility to HIV and its associated malnutrition. Lack of confidence in negotiating sex, stigma about discussing HIV or obtaining VCT or treatment all contribute. The lack of awareness of HIV/nutrition related issues and the low levels of parenting skills among boys are major problems and reflect inadequate discussion within the school curriculum and community groups. It is suggested that the following are necessary to achieve MDG 3:
It has been noted that Infant and Young Child Mortality rates are increasing among communities with a high prevalence of HIV/AIDS. It is estimated that there are around 700,000 new cases of paediatric HIV globally each year as a result of MTCT. The rates of child mortality are especially high if the mother is dead, seriously ill, absent or an adolescent. A current emerging concern is that infants who are born to an HIV infected mother may be at immunological risk even though they remain HIV free (uninfected/exposed). There is increasing evidence that micronutrient interventions improve pregnancy outcome of HIV infected mothers and they may improve infant health. It is suggested that the following are necessary to achieve MDG 4:
It is noted that maternal mortality rates are increasing in many HIV/AIDS affected communities. Whereas there is clear data from a single study in Asia that regular pre-pregnancy and intra pregnancy supplementation with beta carotene or vitamin A leads to reduced maternal mortality there is no data on the effect of nutritional supplementation of HIV infected women. There is however increasing evidence that HIV infected women have a higher prevalence of infections which cause mortality. HIV infected women also have worse nutritional status. It is suggested that the following is necessary to achieve MDG 5:
It is noted that HIV has deleterious effects on pregnancy outcome leading to prematurity and low birth weight in women with malnutrition. It is also known that malaria increases the progression of HIV/AIDS. Thus the combination of HIV and malaria on fetal and maternal health is of particular concern. The detrimental effects of malaria on fetal development are most well recognised in the first pregnancy but there is increasing evidence that among HIV infected women these risks may also occur in subsequent pregnancies. Thus improved protection against malaria becomes especially important in HIV infected individuals. Among the opportunistic infections affecting HIV infected individuals, TB is common. There is some evidence that nutritional interventions decrease susceptibility and improve rate of recovery from TB. It is increasingly recognised that ARVs have short and long term side effects. Short term effects relate to the timing and type of meals in relation to side effects and toxicity; they may also relate to underlying nutritional status. Longer terms problems include abnormalities of fat distribution, blood lipids, diabetes and severe metabolic disturbances. It is not known how much underlying malnutrition contributes to these. Guidelines for dietary intake while taking ARVs, management of opportunistic infections and improved management of the metabolic complications of ARVs have not been established. Similarly there are no guidelines for those (the majority) of HIV infected individuals whose immune status is still sufficiently good that they do not yet need ARVs. It is suggested that the following is necessary to achieve MDG 6:
It has been noted that HIV infected individuals are especially likely to acquire opportunistic infection such as intestinal infection (from water and food) and respiratory infection (often found in communities with crowding and poor housing). There is increasing evidence that community programmes have more sustainable effects on the environment. It is suggested that the following is necessary in order to achieve MDG 7:
It is noted that there are many activities in the area of nutrition and HIV/AIDS but the results are not widely known or appreciated. The importance of developing guidelines to assist national governments and agencies was recognised. It is suggested that the following is necessary in order to achieve MDG 8 :-
WHO activities on Nutrition and HIV/AIDS (Randa Saadeh)WHO seeks to alleviate the overall burden of malnutrition by reducing the severity and complexity of the impact that HIV/AIDS and nutrition have on each other. This will involve the development of a comprehensive strategic response and will require a global response to develop evidence-based guidance with regard to the role of nutrition in the prevention, care and treatment of HIV/AIDS as an essential care package within resource limited populations.
Specific planned activities include:
It is suggested that:
HIV/Nutrition and Pregnancy Outcome – a case study from Lusaka, Zambia (Lackson Kasonka)Over the last few years it has been recognised in Zambia, as elsewhere in sub-Saharan Africa (SSA), that HIV is having a devastating effect on pregnancy outcome. Increasing obstetric complications noted among HIV infected women include – TB, malaria, acute respiratory infection, postpartum sepsis and breast abscess. Maternal mortality rates have increased from 560/100,000 live births in 1990 to 729 in 2002. In other SSA countries rates of over 1000 are described in particularly affected areas. Most of the data on complications comes from hospital studies; there are remarkably few community based studies available on maternal health, nutrition or pregnancy outcome. For this reason the Breast Feeding and Postpartum Health Project was established in an urban community in Lusaka. Despite the availability of skilled, trained and dedicated staff, stigma within the community prevents widespread uptake of counselling and testing for HIV – only 36% of antenatal women agree to have an HIV test. Of these 32% are HIV infected. The community is relatively well educated – nearly 60% have attended secondary school and nearly half have a refrigerator at home. More than 80% have electricity in their homes. As in other studies, HIV infected women are older than uninfected (25.5years) and have been pregnant previously more often (70% vs 50%). HIV infected women are more anaemic than HIV uninfected (62% vs 53%). HIV infected women had a premature delivery (< 37 weeks) more frequently then uninfected women (23% vs 13%) and had a low birth weight baby more frequently than uninfected women (17% vs 10%). The perinatal mortality rates and neonatal mortality rates were higher in infected than uninfected women (50 vs 11 deaths/1000 births and 31 vs 5 deaths/1000 live births respectively). HIV infected women had higher levels of acute phase proteins inferring inflammation and lower plasma retinol and tocopherol levels than uninfected women. These women were not thin or particularly anaemic but they did not have low plasma micronutrient levels. The significance of these findings in women in relation to pregnancy outcome, and required dosage for anti-retrovirals, is not known in these resource poor settings. However the association between nutritional deficiencies and poor pregnancy outcomes infers that there be a causal relationship and the results of studies on nutritional interventions are needed. Infant feeding, HIV transmission and infant growth (Moses Sinkala)Mother to child transmission of HIV accounts for the infection of over 700,000 children each year. It is estimated that among infants of HIV infected mothers – 5% become infected in utero, 15% become infected in delivery and 10% become infected from breast milk. These transmission rates can be reduced, but certainly not eliminated by using antiretrovirals. In the light of the study showing the benefits of exclusive breast feeding (EBF) on post natal transmission of HIV there have been considerable activities to promote EBF among HIV infected populations. However there has been rather little appreciation of the nutritional problems faced by infants of infected mothers and of the difficulty facing mothers as their children can no longer be supported by breast feeding alone. The transition from EBF to non breast milk feeds is difficult. In the Breast Feeding and Post Partum Health Project referred to above several aspects of infant and maternal health and nutrition have been highlighted. It is now recognized that several factors increase the chance of a mother transmitting HIV in her breast milk. A subclinical level of inflammation of the breast (subclinical mastitis) is associated with higher levels of breast milk HIV. Local factors including poor lactational practices (such as poor attachment, infrequent feeding and failure to EBF) and systemic factors such as high viral load, low CD4 count, micronutrient malnutrition and opportunistic infection (including postpartum sepsis) all combine to increase the transmission of HIV. Infants of HIV infected mothers may be of lower birth weight in poor nourished communities; indeed the children of infected mothers in the Zambian BFPH study were 60g lighter than those of uninfected mothers. Furthermore, these infants of infected mothers failed to catch up and remained lighter and shorter by age 4 months. Several reasons appear possible – some infants are HIV infected (but as mothers received Nevirapine and mostly practised EBF this % is probably < 15%), some were exposed but uninfected (there is now increasing evidence that these infants are at risk), some were premature or had intra uterine growth retardation, maternal milk may be of inadequate volume in HIV infected mothers, and maternal milk may have a high Na level (known to be associated with poor infant growth) or maternal morbidity (physical/mental) leading to poor care. All these are possible explanations but the relative importance of each is unknown at the present time. Nutrition, Food Security and HIV in Southern Africa – UNICEF Southern Africa Nutrition Analysis Project – preliminary analysis (John Mason)
Implications for Policies and Programmes:
Further analysis is being conducted on the interactions between mortality, drought, food access, HIV trends, child nutrition and food aid. The presentation in powerpoint is available at www.tulane.edu/~internut (and in future also on the UNICEF/RIACSO site). Information Systems for Exchange of Information on Programmes on Nutrition and HIV (Robert Mwadime)A clearer understanding of the interaction between nutrition and HIV is evolving and the right information needs to get to the right user at the right time. This involves a careful review of the existing systems and concerns about their strengths and weaknesses. There are various information types :
Electronic or printed materials (newsletters, brochures, reports and articles, data sheets):
Resource Centers – such as NICUS, AIC (in Uganda), District resource units in Kenya. It is vital that stakeholders are more involved in the management of these information resources. What is there for them? Issues of confidentiality and use of information. Ownership of information. Credibility of information. Accessibility of tools and technology to target certain group of users Information needs to be:- Up-to-date (some are overtaken by events), Not tagged to individualsà institutional memory, know the users (who, characteristics); users change overtime adjust mechanisms and format. Have priority topics (these also change over time)à immediate needs. Information also needs to recognize scientific and international standards, consider the difficulties they may have with information (localizing, timeliness, reliability, confidentiality), benefits to senior decision- and policy-makers, self-financing or have legislation backing. Key issues raised during discussion included: Does nutrition affect vulnerability to HIV? – Possibly not directly in terms of primary infection, but severity of illness and possibly rate of disease progression might be delayed by improving nutrition. Further, hunger and destitution (which cause malnutrition) lead to an increase in high risk behaviour, thus indirectly increasing vulnerability; moreover, as malnutrition reduces immunocompetence generally, thus infection with STIs, it increases risk by this mechanism also. There is a manual on nutrition for people living with HIV/AIDS. FAO is working closely with UNICEF and WFP. It is important to see how the food security and nutrition of families/household affected by HIV/AIDS can be protected. There are videos and publications on food livelihoods and HIV. Also WHO and FAO have been involved in HIV and emergencies. Is there any Global Fund supported work on nutrition? WHO are working with some governments to get nutrition interventions into country proposals. Could some of the findings in the UNICEF Southern Africa Nutrition Analysis be due to migration in response to drought? Migration is an important factor; but the results shown were from ANC surveillance for HIV rates, and child nutrition, so these particular associations were probably not much related to migration. Problem of establishing national programmes. It is known that ARV and some nutrition interventions are efficacious but difficult to implement. More careful review of human resource issues is needed. CORE child survival group is writing a guide for PVOs that work in restricted resource settings. They are assuming that not breastfeeding is not an option. Is there an algorithm that can guide health workers? Yes, there are a lot of materials available, especially by UNICEF and WHO. Recommended that SCN working group should work, with others, to produce guidelines for nutrition interventions for the individual with HIV who is not yet on ARVs, the individual who is on ARVs, the family of an infected individual and the communities where there are many individuals infected and/or affected by HIV/AIDS. HIV affected households often seem to be left out of development initiatives – What is the basis of the HIV/nutrition MGD interventions? These are laid out in the suggestions for inclusion in the responses from the Nutrition/HIV/AIDS group above. How can the issues of stigma be overcome? Zambia is piloting a family-centered HIV care programme. This will include nutrition intervention components of MTCT- “The 3 by 5 initiative of WHO” – at present there is little emphasis on nutrition. Other initiatives such as the Clinton Foundation also have little evident focus on nutrition. There is a key role for SCN to make sure that nutrition is included within guidelines. On the positive side the US Presidential Initiative does include nutrition in several of its country programmes with technical assistance being provided by LINKAGES and FANTA. AcknowledgementsThe authors thank the organizations that shared their information, especially Suzanne Filteau of the Centre for International Child Health and the Wellcome Trust. In addition speakers were grateful for support from USAID, FANTA, the UNU, Danida and UNICEF. Key Recommendations
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