| |
Working Group on Nutrition and HIV/AIDS
held during the ACC/SCN's 30th Session in Chennai, India, March 2003
Chaired by Andrew Tomkins (ICH, UK)
1. Background
1.1 The group is rather young and is still establishing its priorities
for action. While the HIV epidemic is well recognised in most African countries
there has been a disturbing pattern of delay in recognition of the reality of
the scale of the problem in other regions. In many countries there has been
denial that HIV/AIDS is a problem until sufficiently large numbers of people die
that opinion formers and/or politicians begin to take HIV seriously. There are
serious concerns that such “denial” is occurring in several Asian countries. The
scale of the problem globally is however increasingly documented, mostly using
sentinel site surveillance. This data, available on various web sites through
the www.unsystem.org, shows that no country is immune from the devastating
effects of the epidemic. The scale – in terms of proportion of the population
which is infected or in total numbers infected – is for many countries quite
terrifying. Members of the WG have communicated by e-mail and a briefing
document has been prepared which outlines the key elements and challenges which
face the WG as it seeks to produce guidelines to prevent and manage the
infection and mitigate the impact of the infection on individuals, families and
children.
1.2 During the Chennai meeting some of these elements were discussed
and specific recommendations were made for new work. This included the need to
establish new knowledge to enable the development of an evidence base, the need
to ensure that existing/recent knowledge is more widely disseminated, the need
to insert specific nutritional interventions into health, agriculture,
educational, economic and social policies, and the need to monitor and support
the efficient application of policies and programmes which impact on Nutrition
and HIV/AIDS. In order to achieve this range of activities it was recognised
that there are several steps which involve achieving agreement on:
- What is known? - And how can this be used to develop activities now?
- What is not known? - And how do we prioritise about which new pieces of
knowledge are needed the most urgently?
- What might work? - Make suggestions for novel interventions.
- How can new knowledge be used to modify existing policies?
- What are the resource costs of implementing policies?
- What is the experience of implementing policies and what lessons have been
learned about challenges/constraints?
- How can programme experience be fed back into modification on resource
allocation, training, management and evaluation?
1.3 Nutrition and HIV are inextricably linked. HIV causes repeated
illness which reduces the ability to produce or buy sufficient food. It also
affects the ability to eat and absorb food and leads to nutrient losses. The
resulting malnutrition leads to increased severity of infection, delayed
recovery from opportunistic infection and shortened life span. Each and all of
these problems lead to poverty which is itself a risk factor for increased
susceptibility to HIV. There are effective interventions ranging from clinical
and public health nutrition to agricultural, social and employment policies.
Many of these interventions require collaboration between agencies. Work is now
needed to identify these interventions more clearly and identify areas where
added value and greater impact can be achieved through more effective
collaboration. Identifying the different parts of the HIV/HFIS/Poverty cycle,
specific interventions need to be examined from three perspectives. Firstly, are
there any interventions with proven efficacy/effectiveness which have a strong
evidence base? Secondly, are there any interventions that seem likely to work
but further information is required before they are promoted on a strong
evidence base? Thirdly, are there any suggestions for new interventions that
need developing and evaluating?
2. Preventing Mother to Child Transmission (MTCT)
Anti retroviral regimes (ARVs) can make a
major contribution to reducing the rates of MTCT but for the majority of HIV
infected mothers globally, ARVs are unavailable and nutrition interventions play
a key role.
- What is known and advised on the evidence? The UNICEF/WHO guidelines on
infant feeding for HIV +ve mothers provide a range of recommendations for HIV
+ve mothers. There is a strong focus on the benefits of exclusive
breast-feeding.
- What is not yet known? It is not known what the relative risks are of one
feeding mode compared with another when ARVs are used. It is also not known
what the risks are of continuing breast-feeding after 6 months of age, when
mixed, complementary feeding is introduced.
- What might work? Pasteurisation of breast milk, boiling breast milk, use
of modified animal milks, other interventions? The role of micronutrient
interventions is not clear for 2 reasons. Firstly in the few studies published
different dose regimes have been used. Secondly few micronutrients only –
vitamin A, beta carotene and limited studies on vitamin E – have been
investigated. The role of zinc, selenium and other anti-oxidants known to be
crucial in other infections has not been investigated.
3. Delaying progression of HIV to AIDS
- What is known? There is an association between higher levels of
micronutrient intake and delayed development of AIDS but most studies are
observational.
- What is not yet known? – whether improving lean body mass and
micronutrient stores delays progression.
- What might work? – nutrient/micronutrient interventions in
individuals/communities with a high risk of acquiring HIV. Particular food
based guidelines.
4. Prevent Serious Infections in HIV+ve individuals
- What is known? There is evidence that nutritional interventions prevent
serious illness and promotes recovery. There is evidence that nutritional
interventions in subjects with HIV/AIDS improve immune status and clinical
response. Most of this evidence has come from intensive use of nutritional
therapy in industrialised countries.
- What is not known? Whether suitable nutritional interventions can be
introduced and sustained within resource poor settings and how much they
influence severity of infection.
- What might work? Sip feed macronutrient/food technologies to increase
nutrient intake of sick individuals. Micronutrient interventions might be
effective in HIV associated infection. Important to consider nutritional
interventions to overcome some of the side effects of ARVs (anorexia.
malabsorption, metabolic changes and increased requirements) and the
biochemical effects of certain ARVs. Nutritional supplements might enhance
immunity sufficiently to prevent HIV associated infections such as diarrhoea
and TB.
5. Nutritional Support during severe infection in somebody with HIV
- What is known? There is evidence that nutritional interventions alter
severity and outcome of infection and rate of recovery.
- What is not known? Whether appropriate sustainable nutritional supplements
can be used in resource poor settings.
- What might work? Opportunities for work by food industry to develop new
affordable products which are palatable/acceptable/affordable for a range of
ages. These could include nutrient dense powders/sachets. Will need
clarification of nutrient (energy/protein/micronutrients) requirements during
infection.
6. Nutritional Support of infants/children 6 – 24 months whose mothers are
HIV +ve
- What is known? There are dietary approaches/household food
technologies/industrial processes for improving the quality of complementary
foods. These include fermentation and germination as means of improving
nutrient density and bio availability. They are especially important in
settings where breast milk is not provided or breast feeding is stopped early
because of fears of transmitting HIV.
- What is not known? Whether promotion of improved complementary feeding,
especially for children of HIV +ve mothers actually results in better intake
- What might work? Household food technologies/industrial processes.
Advocacy for improved food provision for HIV +ve mothers in order to benefit
themselves and their children.
7. Promoting Household Food Security in families affected by HIV/AIDS
- What is known? That there are many community caring and coping strategies,
especially in traditional societies, that support families as parents become
ill and die and children are adopted into a wide range of family/community
groups. Greater understanding and support of community caring capacity limits
the detrimental impact of HIV on nutrition. Provision of social support, by
paying school fees, giving food and psycho-social support are all ways of
improving nutrition.
- What is not known? How such interventions can be supported and provisions
supplied without damaging the strong community structures and mechanisms that
provide sustainability.
- What might work? New forms of agricultural development/income generation
that can assist families affected by HIV/AIDS. These might include change in
cropping patterns to less energy intensive cereals/roots and support in
vegetable production. School feeding programmes have considerable potential
for encouraging children back into school. Certain companies have made
predictions on how many of their staff will be permanently on sick leave or
even die and what implications this has for profitability and employment
policies. Food provision may be part of welfare schemes. That “privatisation”
(decreasing role for government) of many industries is accompanied by
guidelines for employment, contract, training, welfare, housing and sick leave
policies.
8. Promoting the Nutrition, Health and Development of School Age Children
- What is known? That school attendance is dropping in many countries as a
result of HIV/AIDS in poor communities. That support of OVC through
combination support of food and school fees makes it possible to encourage
children back into school on a report/anecdotal basis
- What is not known? How effective are such programmes when scaled up? How
much food needs to be provided to children/families in “food for school”
programmes in order for OVC to return to school? How effective are the various
programmes including support of family and community level activities which
promote nutrition, health, learning capacity, school achievement, and social
development and life skills in situations where parental support is absent.
What is the effectiveness of local initiatives (e.g. faith based groups) and
how are these enhanced/suppressed by large donor activities. What to do when
so many are infected/affected that the scale reaches “emergency proportions”?
What are the effects and appropriate interventions in relation to land tenure
issues where children have land taken from them?
- What might work? A range of social development activities in which
community caring capacity is supported by some resource provision.
9. Maternal Nutrition
- What is known? There are effective interventions which improve nutrition
such that pregnancy outcome is affected. Multiple micronutrient interventions
improve rates of low birth weight and prematurity among HIV +ve mothers.
- What is not known? Whether nutritional interventions enhance women’s
survival from HIV, especially among lactating women. The formulation, dose
frequency and duration of micronutrient supplementation that is optimal in
relation to pregnancy outcome. How effective are such interventions in
reducing morbidity (however defined) and productivity (however defined)?
Having identified which ways that HIV will affect dietary intake for women,
what are the key, sustainable interventions that could be established?
- What might work? Novel methods of improving maternal nutrition earlier in
the life cycle.
10. Emergency Relief and Nutritional Rehabilitation
- What is known? Not a lot.
- What is not known? How prevalent is HIV and its impact in populations
requiring emergency relief? How does HIV affect the rate of nutritional
recovery in response to therapeutic feeding? What are effective programmatic
means by which agencies can improve the management of malnutrition in
populations affected by emergency and HIV? How can agencies modify their
response in terms of intervention, use of commodities, use of home care as
opposed to centre based nutritional care for the severely malnourished?
- What might work? Need some innovative approaches.
11. Antiretrovirals; their availability and interaction with nutrition
- What is known? That ARVs have a beneficial effect on the clinical and
nutritional outcome of HIV. That there are considerable nutritional side
effects of ARVs. A recent concern has been the development of lipodystrophy
and associated metabolic disorders in patients on ling terms ARVs. These
appear to more marked in those with poor nutritional status.
- What is not known? How much will underlying malnutrition affect the
efficacy and side effects of ARVs? What is the effect of meal timing in
relation to side effects of ARVs? How can S/E be minimised in communities
where meal patterns are different from industrialised countries?
- What might work? Establishment of studies to examine how nutritional
interventions might enhance clinical effectiveness of ARVs and reduce their
toxicity
12. Other interventions which should be added to the above?
13. Collaborative Work and Priorities for the coming year
- In June 2002 a meeting was held at FAO Rome attended by key UN agencies to
outline some of the key issues and ways in which action can be facilitated.
- Work has begun on a new section on the SCN website to display new
knowledge and reports of how this has been incorporated into new policies and
programmes. The web site aims to share information on activities of
governments, agencies, NGOs and civil society
- A small meeting is planned in Geneva in May 2003 to identify new knowledge
which could be used for policy development/change, identify knowledge gaps and
how new, essential knowledge can be obtained. This will be facilitated by
commissioning review papers on knowledge and how it has been applied.
- This will form the basis for a larger meeting in which reviews will be
commissioned about how knowledge can be most effectively used to develop cost
effective nutritional interventions.
- The WG on Nutrition and HIV/AIDS will collaborate as widely as possible
with other related WG and in particular will interact with the UNU African
Nutrition Leadership Development Programme which has taken Nutrition and
HIV/AIDS as one of its key activities
|
United Nations System