Session 7:
Integrating Nutrition Assessment,
Counselling, and Education into HIV
and AIDS Care
Nutrition Management with HIV and AIDS:
Practical Tools for Health Workers
Objectives
• Appropriately assess and counsel patients
on nutrition and HIV
• Identify ways to integrate nutrition into HIV
and AIDS care
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 2
Nutrition at Each Stage of HIV:
Stage 1
• Symptoms
• No other infections
• Generalised fatigue
• Nutrition Considerations
• Healthy eating and hydration (drink fluids)
• Nutrition assessment and education
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 3
Nutrition at Each Stage of HIV:
Stage 2
• Symptoms:
• Some other infections, but still in good overall health
• Weight loss (less than 10 percent of normal weight)
• Nutrition Considerations:
•
•
•
•
•
Continue efforts for Stage 1
Follow-up nutrition assessment
Address nutrition-related side effects
Prevent weight loss
Prescribe micronutrient supplements, if indicated
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 4
Nutrition at Each Stage of HIV:
Stage 3
• Symptoms:
• More serious infections
• Severe weight loss (greater than 10% loss of usual
weight)
• Chronic, unexplained diarrhoea for > 1 month
• Unexplained anaemia
• Nutrition Considerations:
• Continue efforts for Stages 1 and 2
• Nutrition management for: weight loss/malnutrition,
ART, and infections
• Coping strategies
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 5
Nutrition at Each Stage of HIV:
Stage 4
• Symptoms:
• AIDS
• More serious infections with life-threatening
complications
• HIV Wasting Syndrome
• Nutrition Considerations:
• Continue nutrition management of side effects, as
appropriate for client’s prognosis
• Provide comfort and manage pain
• Fluids for hydration
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 6
Nutrition Assessment
•
•
•
•
•
•
Anthropometric
Biochemical
Clinical
Dietary
Environmental
Food Security
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 7
Anthropometrics
• Height (cm) at first visit for adults, at each
visit for children
• Weight (kg) at each visit
• Percent weight loss, if applicable
• Mid Upper Arm Circumference (MUAC) at
each visit
• Body Mass Index (BMI) at each visit
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 8
Weight Loss Calculation
•
•
•
•
Percent weight loss
UBW = Usual Body Weight
CBW = Current Body Weight
Formula:
% loss = UBW – CBW x 100
UBW
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 9
Mid Upper Arm Circumference
• Use measuring tape; measure in cm
• Estimates muscle loss
• If less than 23 cm, possible muscle
wasting  intervene with nutrition
counselling
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 10
Body Mass Index (BMI)
• BMI is used to assess an adult’s weight based
on their height.
• Not used for children or pregnant women
• A quick and easy way to estimate weight status
(e.g. underweight, normal weight, overweight).
Refer to BMI reference chart and calculation sheet
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 11
BMI Reference Chart
Underweight
BMI
2
(kg/m )
16
17
18
Normal Weight
19
20
21
22
23
Overweight
24
25
26
27
28
Height
(cm.)
Obese
29
30
31
32
33
34
35
36
37
38
39
40
41
42
Weight (kg.)
152
37
40
42
44
46
48
50
53
56
58
60
62
64
67
70
72
74
76
78
81
84
86
88
90
92
94
97
154
38
40
42
45
48
50
52
54
57
60
62
64
66
68
71
74
76
78
80
83
86
88
90
92
95
98
100
156
39
42
44
46
48
51
54
56
58
61
64
66
68
70
73
76
78
80
82
85
88
90
92
95
94
100
102
158
40
42
45
48
50
52
55
58
60
62
65
68
70
72
75
78
80
82
85
88
90
92
95
98
100
102
105
160
41
44
46
48
51
54
56
59
62
64
66
69
72
74
77
80
82
84
87
90
92
94
97
100
102
105
108
162
42
44
47
50
52
55
58
60
63
66
68
71
74
76
79
82
84
86
89
92
94
97
100
102
105
108
110
164
43
46
48
51
54
56
59
62
64
67
70
72
75
78
81
84
86
89
92
94
97
100
102
105
108
110
113
166
44
47
50
52
55
58
61
64
66
69
72
74
77
80
83
86
88
91
94
96
99
102
105
108
110
113
116
168
45
48
51
54
56
59
62
65
68
70
73
76
79
82
85
88
90
93
96
99
102
104
107
110
113
116
118
170
46
49
52
55
58
61
64
66
69
72
75
78
81
84
87
90
92
95
98
101
104
107
110
113
116
118
120
172
47
50
53
56
59
62
65
68
71
74
77
80
83
86
90
94
97
100
103
106
108
110
112
115
118
120
124
174
48
51
55
58
61
64
67
70
73
76
79
82
85
88
91
94
97
100
103
106
109
112
115
118
120
124
127
176
50
53
56
59
62
65
68
71
74
77
81
84
87
90
93
96
99
102
105
108
111
115
118
120
124
127
130
178
51
54
57
60
63
67
71
74
76
79
82
85
89
92
95
98
101
105
108
111
114
117
120
124
127
130
133
180
52
55
58
61
65
68
71
75
78
81
84
87
97
94
97
101
104
107
110
113
117
120
123
126
130
133
136
182
53
56
59
63
66
69
73
76
79
83
86
89
93
96
98
103
106
109
113
116
119
123
126
129
132
136
139
184
55
57
61
64
68
71
74
78
81
85
88
91
95
98
102
105
108
112
115
118
122
125
129
132
135
139
142
186
55
59
63
66
67
73
76
79
83
87
90
93
97
101
104
107
111
114
117
120
124
128
131
135
138
142
145
188
57
60
63
67
71
74
77
81
85
89
92
95
99
103
106
109
113
117
120
124
127
131
134
138
141
145
148
190
57
61
65
69
73
76
79
83
87
91
94
97
101
104
108
112
115
119
123
126
130
133
137
141
144
148
152
192
59
63
67
70
73
77
81
85
89
93
96
99
103
107
111
115
118
120
125
129
133
136
140
144
147
151
155
194
61
64
67
71
75
79
83
87
91
94
97
101
105
109
113
117
120
124
128
132
135
139
143
147
151
154
158
196
61
65
69
73
77
81
85
89
93
96
99
103
107
111
115
119
123
127
131
134
138
142
146
150
154
157
161
198
63
67
71
75
79
83
87
91
95
98
101
105
109
113
117
120
125
129
133
137
141
145
149
153
157
161
165
200
63
67
71
75
79
83
87
91
95
99
103
107
111
115
119
124
128
132
136
140
144
148
152
156
160
164
168
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Adapted from: RCQHC/FANTA
Slide 12
Biochemical
• Laboratory values as available
• CD4 count and all other routine values
with:
•
•
•
•
Blood cholesterol (fat)
Blood glucose (sugar)
Haemoglobin (blood iron)
Urine test, look for ketones
• Parasites (e.g. worms)
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 13
Clinical
• Assess and counsel on management of
complications
•
•
•
•
•
Diarrhoea
Nausea/vomiting
Poor appetite
Mouth sores
Changes in taste
• Medication Regimen
• Discuss food effects, interactions, and
herbal/traditional therapies
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 14
Dietary
• How many times a day does the client
eat?
• What does the client eat in a typical day?
• How does the client:
• Keep foods cold (refrigerator, freezer, other
methods)?
• Cook food (stove, open fire)?
• Keep dishes, utensils, and cooking areas
clean (soap, water)?
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 15
Environmental
• Assess hygiene and sanitation situation at
home and community
• Where does the family get water from?
• Is there a latrine in the home or communal
latrine? If so, how is it maintained?
• Is garbage removed often and safely?
• Are client and family aware of basic food
and water safety practices
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 16
Food Security
• Where does the food come from? Market,
supermarket, home garden?
• Are there community or village gardening
projects that client can be referred to?
• Know which local, nutritious foods are
available in the community, and promote
these instead of expensive foods from
shops
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 17
Additional Information
• Other illness or opportunistic infections
• E.g. Tuberculosis, malaria, pneumonia, or skin
problems
• Lifestyle practices (smoking, alcohol use, and
unsafe sex)
• Family/community support system
• Educational level
• Living environment (housing, income, and
number of members per household)
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 18
Anthropometric
Measurement and BMI
Calculation Practice
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 19
Nutrition Assessment Action Plan
Assessment
Nutrition Assessment
Weight, Height, BMI,
Record nutrition
symptoms
Diagnosis
Action Plan
Severe Malnutrition
BMI <16kg/m2, weight loss
> 10%, persistent diarrhoea,
fever, with or without other
symptoms
Consider hospitalization with
enteral, parenteral or supplemental
feedings, treat infections, rehydrate,
and promote weight gain with high
calorie foods.
Moderate Malnutrition
BMI 16.5 – 18.5 kg/m2, weight
loss < 10%, mild symptoms
Treat symptoms/infection and
prevent further weight loss and
infections with high energy,
protein, vitamin and mineral foods.
Follow up
in 1 month
Follow up in
1-2 months
Well Nourished
BMI > 19 kg/m2, no weight loss
or symptoms
Praise good eating behaviours.
Encourage continued healthy eating
and weight maintenance
Regular follow up
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 20
Integration of Nutrition into HIV
and AIDS Care
• Begin at VCT services
• Address food availability and access
• Weight loss prevention can improve
survival
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 21
First HIV Visit
• Complete full nutrition assessment
• Obtain baseline height and weight, calculate
BMI, and measure MUAC
• Ask about recent weight loss or inability to eat
(due to illness)
• Ask about food availability, food storage, and
cooking facilities in home
• Provide nutrition counselling on healthy eating
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 22
Follow-up Visits
• Continue with nutrition assessment
• Obtain height (if not already done), weight,
calculate BMI, MUAC and % weight loss, if
necessary
• Ask if any problems eating
• Ask if any change in food availability,
storage or cooking facilities at home
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 23
For Patients in the Hospital
• Take note of whether the patient is eating and
how much
• If the patient needs help and family members
are not there, provide help with eating
• Weigh patients
• Counsel patient on adjusting food intake for
management of side effects
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 24
Integration into ART Programme
• Before ART, assess food availability and intake
situation
• Assess weight status
• Use Food and Medication Time Table when
discussing medication schedule
• At each follow-up, obtain current weight and side
effects
• Counsel appropriately on side effect
management and good nutrition
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 25
Integration into PMTCT and
Ongoing Paediatric Care
• Counsel mothers and partners on all infant
feeding options for PMTCT
• Support infant feeding choice
• Educate on dangers of mixed feeding
• Monitor growth and feeding of infant
• For infants on replacement feeding,
educate on and monitor formula/milk
supply and preparation
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 26
Nutrition Counselling
• Listen to client; assess individual situation
• Ask open-ended questions (who, what, when,
where, why, how?)
• Be realistic and practical with counselling; set
realistic goals with client
• Encourage good eating habits
• Be a role model for clients
• Maintain confidentiality always
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 27
Making Suggestions, not
Commands
• Commands use the imperative form of
verbs (give, do, bring) and words like
always, never, must, should
• Suggestions include:
•
•
•
•
Have you considered …?
Would it be possible …?
What about trying … to see if it works for you?
Would you be able to …?
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 28
Making Suggestions, not
Commands
• Suggestions include:
• Have you thought about …? Instead of …?
• You could choose between … and … and …
• It may not suit you, but some mothers … a
few women …
• Perhaps … might work
• Usually … Sometimes … Often …
• Follow-up with open-ended questions
using: who, what, when, where, how, why
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 29
Counselling Role Play
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 30
Integration Case Study
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 31
Key Points
1. All persons with HIV and AIDS need
nutrition counselling and assessment
2. Obtain weight and calculate body mass
index
3. Integrate nutrition and food security
assessment into regular HIV care
Session 7: Integrating Nutrition into HIV and AIDS Care
Nutrition Management with HIV and AIDS Training
Slide 32