INTEGRATION OF NUTRITION INTO
HIV AND OTHER INFECTIOUS
DISEASES :THE NACS APPROACH
Serigne M. DIENE, PhD, Senior Nutrition and HIV Advisor
AIDS 2012 Communications-Hosted Satellite Session
July, 22, 2012
Food and Nutrition Technical Assistance III Project (FANTA)
FHI 360 1825 Connecticut Ave., NW Washington, DC 20009
Tel: 202-884-8000 Fax: 202-884-8432 Email: fantamail@fhi360.org Website: www.fantaproject.org
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Presentation Outline
• Evidence Supporting NACS
• NACS’s overview
• Elements of the NACS approach
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Emerging evidence
• Evidence is emerging on the impact of various nutrition
interventions on the health and wellbeing of PLHIV.
• Opportunities for randomized controlled trials were limited in
the past but are expanding with the increased adoption of
NACS.
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EVIDENCE SUPPORTING
NACS
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Supplementary Feeding and Nutritional Status
Outcome Findings
Other Comments
Kenya - Food Supplementation v Control (n=1058)1
ART Group
1.9kg v 1.0kg at 1/12
4.6kg v 3.4kg at 3/12
Pre-ART Group
Food Supp significant in
change in BMI at 3/12 & 6/12
* CD4 ↑ int. at 3/12 and CD4 ↓
control at 3/12. Not signif. at 6 or
12/12
* Food predictor of attendance at
6/12 in both
Malawi - Fortified Spread (FS) v Corn Soy Blend (CSB) (n=491) 2
Greater anthropometric ↑ FS group v CSB group at 14/52
BMI change (2.2 v 1.7), weight change (5.6kg v 4.3kg),
FFM (2.9kg v 2.2kg), and MUAC (2.2cm v 1.6cm)
* BMI at enrollment 16.5.
* Mortality rate 27% for FS and 26%
for CSB
* Spread 3x more expensive
* No differences in CD4 count, VL,
QoL, or adherence
Zambia – CSB/Oil/Beans v Control (n=636)3
No differences were not found for weight gain
*Food supplementation assoc. with
better adherence
* No difference in CD4 change
India – Fortified Blended Food (Indiamix) v Control (n=636)4
Food supplementation did not result in increased weight
compared with nutrition counseling and standard care
* ↑ in weight, BMI, MUAC, FFM, and
BCM in both groups
All results reported in findings are significant unless indicated
III
1.
2.
3.
4.
KEMRI, FANTA Project - Report June 2011
Ndekha MJ et al.. BMJ. 2009 May 22;338:b1867
Cantrell RA,. J Acquir Immune Defic Syndr. 2008
Swaminathan S,et al. Clin Infect Dis. 2010 Jul 1;
Micronutrient Supplementation and Disease Progression
Outcome Findings
Other Comments
Tanzania – MMVM v MMVM/Vit A v Vit A v Placebo (n=1078)1
•24.7% MMVM progressed to WHO stage 4 or died
•31.1% placebo progressed to WHO stage 4 or died
•MMVM group had reduced risk of AIDS related death
•MMVM and MMVM/Vit A group had fewer people progress
HIV stage 3 or higher.
•The MMVM and MMVM/Vit A had slight increases in CD4+
•MMVM group had slight reduction in viral loads.
USA – MMVM v Placebo (n=40)2
• MMVM group – CD4 ↑ 65 cells/mL (↑ 24%) at 12/52
•Placebo group - CD4 ↓ 6 cells/mL (↓ 0%) at 12/52
•Study period was over 6 years
•>1000 pregnant women enrolled
•Vit A group had similar results to
placebo
•MVM group also had reduced
incidence of complications
•No change in any other biochemical
parameters e.g. blood lipids and glucose
•42% improvement in neuropathy
symptoms in MMVM group,
•33% improvement in neuropathy
symptoms in placebo group – result not
statistically significant but clinically
significant.
All results reported in findings are significant unless indicated
III
1.
2.
Fawzi WW, et al. A N Engl J Med. 2004 Jul
Kaiser, JD.. J Acquir Immune Defic Syndr. 2006 Aug 15
OVERVIEW OF NACS
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What is NACS?
• Nutrition assessment, counseling, and support (NACS) is an
approach that aims to improve the nutritional status of
individuals and populations by integrating prevention and
treatment of malnutrition into policies, programs, and health
service delivery infrastructure.
• The NACS approach strengthen the capacity of facility- and
community-based health care providers to deliver nutritionspecific services while linking clients to nutrition-sensitive
interventions provided by the health, agriculture, food security,
social protection, education, and rural development sectors.
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III
N
A
C
S
Nutrition Assessment, Counseling, & Support
N
A
C
S
NACS
Establishing a Nutrition Standard of Care
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GOAL: Improved health and quality of life
•
•
•
•
Nutrition care
& support
OBJECTIVES:
Improve nutritional status
Improve infant survival
Reduce food insecurity
Strengthen health systems
HIV-Free Survival
Economic
strengthening,
livelihoods & food
security
Health system
strengthening
NACS: A platform for integrating nutrition into the continuum of care
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NACS: A Life Cycle Approach
NACS
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C&T
ART & ARV
Prophylaxis
Tx of
Malnutrition
Maternal
Nutrition &
IYCF
Counseling
Photos: Wendy Hammond
Pregnancy
Birth
III Infancy
Childhood
Adolescence
Photo: Wendy
Hammond
Adulthood
ART & ARV
Prophylaxis
Peri-/Postnatal
Care
Maternal
Nutrition &
IYCF Counseling
Pregnancy
Birth
III Infancy
Photo: Wendy Hammond
Childhood
Adolescence
Adulthood
Postnatal Care
Deworming
Micronutrients
IYCF/GMP
CMAM
Tracking/Follow-Up of
Mother-Infant Pairs
Photos: Save the Children Federation
Pregnancy
Birth
III Infancy
Childhood
Adolescence
Adulthood
Pediatric Care
Nutrition
Surveillance/GMP &
Referral
Micronutrients
CMAM
Photo of Plumpy’nut® from
Valid International; all others:
Save the Children Federation
Pregnancy
Birth
III Infancy
Childhood
Adolescence
Adulthood
Nutrition
Surveillance,
Referral, Assessment
& Counseling
Deworming
Micronutrients
CMAM
Nutrition
Surveillance,
Referral, Assessment
& Counseling
Micronutrients
Tx of malnutrition
Photo: LINKAGES Project
Pregnancy
Birth
III Infancy
Childhood
Adolescence
Adulthood
Why NACS?
• Evolved in HIV, specifically from model of Food By
Prescription
• Links vulnerable to clinical services -- reciprocal impact
between health & nutrition
• Continuum of Care from rehabilitation to chronic nutrition
management
• Link patients to support groups & community services
• Referrals for economic strengthening, livelihood & food
security (ES/L/FS) support
• Contributed to overall health system strengthening
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NACS Hinges on Nutrition Assessment
1. Routine Comprehensive Assessment
• Anthropometry
• Biochemical
• Clinical
• Dietary
• Household Food security
2. Analyze/interpret data using evidence-based standards
3. Identify nutrition problems
4. Determine causes/contributing risk factors
5. Cluster signs/symptoms and defining characteristics
6. Determine an appropriate Nutrition Care Plan
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Nutrition Counseling
1. Understanding of client preferences, constraints & options
2. Nutrition Care Plans
3. Optimal diet
4. Dietary management of symptoms
5. Dietary management of drug side-effects
6. Adherence to medications & clinical visits
7. Chronic disease management
8. Exercise
9. Water, sanitation, and hygiene (WASH)
10. Referral to community services, including household
ES/L/FS support
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Nutrition Support
Treatment of
Malnutrition
Prevention of
Malnutrition
Economic
Strengthening,
Livelihood & Food
Security Support
Water, Sanitation, &
Hygiene (WASH)
• Corrective
Medical Care &
Treatment
• Food by
Prescription
• Provision of MN
Supplements
• Routine Medical
Care & Tx
• Provision of MN
Supplements
• Provision of
Complementary
Foods/Dietary
Supplements
• Savings
• Microcredit
• Incomegenerating
activities
• Household food
production
• Food assistance
• Distribution of
POU water
treatment
products or
vouchers
• Latrine
construction
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NUTRITION
SUPPORT
NUTRITION
COUNSELING
Exercise
IYCF/GMP
Maternal Nutrition
Nutrition
Care Plan
Clinic
Food by
Prompt
Prescription: treatment of
Therapeutic,
infections
Supplementary &
Complementary Adherence to
medications
Foods
NUTRITION
ASSESSMENT
Anthropometry
Clinical
Dietary
Biochemical
Support
Groups
Household
food
rations
Community
Community Health Workers
Food
security
Dietary management
of symptoms, drug
side-effects and drugfood interactions
Economic
Strengthening,
Livelihoods &
Food Security
WASH
Point-of-use water treatment
Micronutrient supplements
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Enabling Environment
SUN/
1000
Days
Feed
the
Future
Policies, Strategies &
Guidelines
Training
Supply Chain Management
Funding/Financing
PEPFAR
Research/M&E
Community
Demand
Mapping/
Strengthening
Services
Referral Links &
Tracking
NACS
Global
Health
Initiative
Human Resources
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Quality Improvement
Title II
COMMUNITY
Service
Gaps
Pre-NACS….
CLINIC
Limited
linkages
and
referrals
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The NACS Approach….
COMMUNITY
CLINIC
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Along the continuum of care, in a way that is client
centered that includes assessment, counseling, and
support with referrals and effective coordination
for optimal quality and impact
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Phased Implementation of NACS in HIV
Early Planning & Implementation
South Africa, Mozambique, Vietnam
Program Expansion
Côte d’Ivoire, Ghana, Ethiopia,
Uganda, Tanzania, Namibia,
Zambia, Haiti
Implemented at National Scale
Malawi and Kenya
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Elements of the NACS
Approach
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Integrating Nutrition
into National HIV Responses (1)
• National Policy and Coordination
– National nutrition and HIV guidelines
– National nutrition and HIV strategy
– Nutrition incorporated into HIV policies and vice versa
– Technical coordinating group
– Nutrition focal point in National AIDS Control Program
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Integrating Nutrition
into National HIV Responses (2)
• Capacity Strengthening
– In-service and pre-service training of health care providers
(linking the two ?)
– Job aids
– SBCC materials
– Anthropometric equipment
– Mentoring and supervision
– QA/QI
– M&E
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Integrating Nutrition
into National HIV Responses (3)
• Service delivery
– Nutrition assessment
– Nutrition education and counseling
– Specialized food products
– Micronutrient supplementation
– Water , sanitation, and hygiene (WASH)
– Food security support
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THANK YOU
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