The Role of CTC in HIV AIDS Programs

The Role of CTC in HIV/AIDS Programs: Issues and opportunities for operations research Ellen G. Piwoz, ScD Presentation at the Inter-Agency CTC Meeting March 2, 2005 Overview of the Presentation  Brief summary of nutrition and HIV/AIDS  Role of food and nutrition in HIV prevention, treatment, and care programs  Important research questions related to the use of food support in HIV/AIDS programs  Operations research questions specifically related to CTC HIV/AIDS and nutrition are synergistically interrelated, particularly in Africa • Malnutrition and food insecurity are endemic in Africa, where more than 30 million people are living with HIV Nearly 40% of African children < 5 are moderately or severely stunted (low height-for-age) – > 50% also suffer from micronutrient deficiency disorders • • Malnutrition is not limited to children. – – > 50% of all pregnant women are anemic Much of population is at risk of IDD Nutritional status affects immune system function and resistance to infections Micronutrients and host defence and resistance to infections in humans Antioxidant capacity A B C E Iron Zinc ↑ ↑ ↑↑↑ ↑↑↑ ↓ ↑↑↑ Immune system ↑↑↑ ↑ ↑ ↑↑ ↑ ↑↑↑ ↑/↓ ↑↑↑ Resistance to infections ↑↑↑ / ↓ Selenium ↑↑↑ ↑ ↑ ↑: increase, ↓: decrease, number of arrows indicate relative importance, arrows in both directions indicate conflicting findings Friis et al, WHO, 2005 The effects of malnutrition and HIV on the immune system are similar Malnutrition HIV CD4 T-lymphocyte cell number Delayed hypersensitivity to recall and new antigens B-cell responses Production of IL-1, IL-2, TNF-alpha Bacteria killing “Nutritionally Acquired Immune Deficiency Syndrome” HIV affects nutrition through multiple mechanisms • Increased energy requirements – 10% increase during asymptomatic infection – 20-30% increase during secondary infections – 50-100% increase for children (WHO, 2003) – Due to appetite loss, depression, oral sores – Food insecurity/loss of livelihoods – HIV-infection of GI cells – Diarrhea-related losses • Reductions in dietary intake • Nutrient malabsorption and loss • Metabolic changes – Cytokine-related changes affect appetite – Impaired transport, storage, utilization of some nutrients (e.g. protein) – Increased utilization of antioxidant vitamins and enzymes, resulting in oxidative stress – may increase viral replication Malnutrition is an independent risk factor for illness and death in HIV infection Low BMI (<18) was a significant predictor of risk of death in Gambian HIV+ adults, independent of immune deficiency, presence of TB, and other risk factors (N=1657) 4 3.6 2.6 2 1.9 2.5 Hazard ratio 0 < 200 200-500 Baseline CD4 > 500 Overall Adj Risk* *Each unit decrease in BMI ~ with 13% adjusted increased risk of death van der Sande et al, JAIDS, 2004 Role of food and nutrition in HIV/AIDS prevention, treatment, and care programs Suggested food and nutrition interventions for HIV programs  Food and nutrition assessment  Nutritional status  Food access/availability  Household and community coping capacity Prevention/preservation of health, body weight Prevention of food and water-borne diseases Symptom-based management Drug interactions/side-effects management Infant and young child nutrition (feeding options)  Counseling and care       Targeted food and nutrition support  Food rations for AIDS-affected HH  Supplements (MN or food) for high risk groups  Supplementary and therapeutic foods for moderately and severely malnourished The mix of interventions depends on local circumstances and the individual’s disease progression HIV+ asymptomatic HIV+ symptomatic AIDS After AIDSrelated Death Counseling/care Nutrition for “positive living” Nutrition management of HIV-related opportunistic infections (OI), symptoms, and medications For high risk groups including persons who are losing weight, do not respond to medications Therapeutic feeding for severely malnourished adults and children Nutrition management of ARV therapy (where available) Nutrition counseling in home-based care Therapeutic feeding for severely malnourished adults and children Counseling on special food and nutritional needs of OVC Targeted food and nutrition support For high risk groups – e.g., pregnant and lactating women, non-breastfed children For high risk OVC groups – e.g., nonbreastfed children < 2 yrs, and those with growth faltering Possible outcomes of integrating food and nutrition in HIV/AIDS Programs Documentation of impact is needed • Improved quality of life  Improved nutritional status, other QOL indicators  Reduction in exposure to food and water-borne infections  Better management of HIV-related illnesses and symptoms affecting nutrition • Increased adherence to ARV treatment  Increased efficacy (if adherence is improved) • Improved birth outcomes in HIV+ women  Reduced fetal death, increased BW, reduced transmission • Increased participation in programs  Incentive to come for follow-up visits  Improved quality of care What are the priority research questions related to CTC and HIV/AIDS? -clinical -behavioral -operational Important research questions related to the use of food support in HIV/AIDS programs (Dec 2004 meeting) • Does providing food support in HIV programs: (“hard outcomes”)  Slow HIV disease progression/prolong time to treatment?  Improve nutritional status and quality of life?  Improve adherence to ARV and/or OI treatment? • What types of food support have the greatest impact?  What type of food or foods (composition) are most appropriate/needed to show impact?  What are appropriate entry/exit criteria for receiving support?  Individual versus family rations (sharing)  What is the most effective context for providing support (e.g. CTC, HBC, or facility-based delivery)  How can stigma be minimized & equity maximized?  Many of these questions not unique to HIV Does providing food support have broader impacts (positive or negative) at the household or community levels? • Conceptual Framework of Malnutrition “Food, Health, Care” CTC Nutritional Status Manifestations Diet Health Immediate Causes Household Food Security Care of Mother and Child Environ. Health, Hygiene & Sanitation Underlying Causes Human, Economic, and Institutional Resources Political and Ideological Structure Ecological Conditions Adapted from UNICEF Root Causes Potential Resources Operations research on CTC in HIV prevention, treatment, and care programs • Can CTC be used as an entry point for HIV prevention and treatment activities?  High uptake of HIV testing by parents of CTC children in Malawi (Dowa study)  Low prevalence of HIV in children in community setting • Is CTC an effective intervention model for managing severe malnutrition in HIV+ adults and children?  How does CTC interface with other models such as PD Hearth, Home-based care?  Feasibility and impact of RUTF for replacement feeding of nonbreastfed children > 6 mo? (Less expensive than infant formula)  Use in ARV/TB treatment programs • What is the role of RUTF in HIV programs? • Will providing HIV-related CTC support affect community attitudes toward and uptake of CTC for acutely malnourished children?  Minimizing program stigma