Presented at RENEWAL’s Satellite Session "Nutrition Security, Social Protection and HIV: Operationalizing Evidence for Programs in Africa" at the XVIII International AIDS Conference. By Rahul Rawat

1. Food and Nutrition Assistance Programs to
HIV Infected and Affected Individuals
Rahul Rawat
Research Fellow
Poverty Health and Nutrition Division
Regional Network on AIDS, Livelihoods, and Food security (RENEWAL)
International Food Policy Research Institute (IFPRI) & Concern Worldwide

2. Rationale for Nutrition Programs
 High geographic overlap between HIV prevalence, malnutrition, and
chronic food insecurity; weight loss is a significant prognostic factor of
mortality since the beginning of the AIDS epidemic
 Despite improved access to ART, malnutrition complicates the
provision of care in resource limited settings
− low BMI at ART initiation is an independent predictor of early mortality
(Zambia, Malawi, Tanzania)
 The proposed benefits of early weight gain serve as the theoretical
basis for food supplementation programs
 Limited evidence of impacts of nutrition interventions
Source: Zachariah et al (AIDS 2006); Johannessen et al. (BMC Infectious Disease 2008); Koethe et al. (JAIDS 2010)

3. Nutrition Program Responses
 HIV services integrating food and nutrition components
− Food by Prescription
• Specialized Food Products (RUFs, FBFs)
 Food Assistance Programs
− Delivery of food baskets (CSB, oil, maize meal, pulses etc.)
− Title II, WFP
 Livelihood Security Programs
− Provision of agricultural inputs and training to promote local
food production

4. Evidence of Impact: Specialized Foods
 Supplementary feeding to malnourished patients
− Fortified spread compared vs. CSB
Outcome at 14 Fortified Corn Soy Difference
weeks Spread Blend (95% CI)
Gain in BMI 2.2 (1.9) 1.7 (1.7) 0.5 (0.2 - 0.8)
Gain in fat free 2.9 (3.2) 2.2 (3.0) 0.7 (0.2 – 1.2)
body mass (kg)
Weight gain (kg) 5.6 (4.8) 4.3 (4.0) 1.3 (0.5 – 2.1)
− No significant differences in mortality, immunological status,
quality of life, or ART adherence
− Impacts were not sustained at 12 months
Source: Ndekha et al. (BMJ 2009); Ndekha et al. (TMIH 2009)

5. Evidence of Impact: Food Assistance
 Zambia (Prospective Design)
 Pilot study of WFP food supplementation to food insecure adults
initiating ART in ART sites in Lusaka
 Food supplementation for 6 months to food insecure patients/HHs
had no impact on weight gain or CD4 count
 Impact on adherence: 70% of patients in experimental group
achieved 95% MPR vs. 48% in control group
Source: Cantrell et al .(JAIDS 2008)

6. Evidence of Impact: Food Assistance
 Uganda (Retrospective Evaluation of the TASO database)
 TASO electronic monitoring data system
− patient's intake registration form; medical visit summaries; counseling visit
summaries; ART initiation and other drug use; social support services
 Between 2002-2007 TASO had 195,676 registered patients
− Database for analysis had 14,481 patients
 Examined changes over 12 months for patients and how the receipt
of FA influences weight gain and disease progression
• Used PSM to match each FA recipient with similar non-FA recipients;
uses the outcome of the non-FA recipients as a proxy for the
outcome of the FA recipients if they had not received FA
Source: Rawat et al. (BMC Public Health 2010)

7. Impact of Food Assistance on Weight Gain
Food assistance Matched ATT a
Recipients Controls (absolute value of
Change in Weight (kg)
(n) (n) t-statistic)
0.36
Overall 3202 11069
(3.19)**
Conditional estimates
0.48
Without ART 2783 9661
(2.14)*
0.17
With ART 546 1120
(1.5)
-0.2
Baseline WHO stage 1 327 1479
(0.55)
0.26
Baseline WHO stage 2 2329 7318
(2.3)*
0.2
Baseline WHO stage 3 615 1807
(1.8)+
1.9
Baseline WHO stage 4 58 129
(1.9)+
** significant at 1% ; *significant at 5% ; + significant at 10%
a Absolute value of t-statistics on ATT, in parentheses, are based on bootstrapped standard errors
Source: Rawat et al. (BMC Public Health 2010)

8. Impact of Food Assistance on Weight Gain
Food assistance Matched ATT a
Recipients Controls (absolute value of
Change in Weight (kg)
(n) (n) t-statistic)
0.36
Overall 3202 11069
(3.19)**
Conditional estimates
0.48
Without ART 2783 9661
(2.14)*
0.17
With ART 546 1120
(1.5)
-0.2
Baseline WHO stage 1 327 1479
(0.55)
0.26
Baseline WHO stage 2 2329 7318
(2.3)*
0.2
Baseline WHO stage 3 615 1807
(1.8)+
1.9
Baseline WHO stage 4 58 129
(1.9)+
** significant at 1% ; *significant at 5% ; + significant at 10%
a Absolute value of t-statistics on ATT, in parentheses, are based on bootstrapped standard errors
Source: Rawat et al. (BMC Public Health 2010)

9. Outcomes of Interest in Programs
Individual Household
• Disease progression (CD4 count, • HH food security
WHO stage) • Dietary diversity
• Nutritional status (BMI, MUAC, • Child nutritional status (<5 yrs)
Hb) • Economic activities and
• High risk behavior employment
• Labor activities • Asset ownership
• Quality of life • Expenditure (food & non food)
• Disclosure • Agriculture production
• Stigma • Credit & savings

10. Determinants of Nutritional Status among
Uganda HIV-infected Individuals
 Previous studies consistently show malnutrition as a strong
predictor of mortality
 Determinants of malnutrition among PLHIVs are not well
established
− Do HH characteristics like dietary diversity and food insecurity influence
nutritional status, independent of disease progression?

11. Dietary Diversity, Food Security and
Nutritional Status
 Dietary diversity and HH Food Security are significantly associated with
nutritional status (BMI & MUAC), independent of SES, and disease stage (CD4
count)
Adjusted Mean BMI
21.5 Δ=0.96 kg/m2; p = 0.008
21 Δ=0.5 kg/m2; p = 0.031
20.5
20
19.5
Low (0-4 Med (5-8 High (9-12
Groups) Groups) Groups)
Mean BMI values adjusted for CD4 count, sex, district, HH size, education, income
 Severely food insecure HHs (Category 4) had 3-times the odds of being
malnourished (BMI<18.5 kg/m2; p=0.002)
Source: Rawat et al. (in preparation); Kadiyala et al. (in preparation)

12. Summary of Impact of Nutrition Support
 Improvements in weight, possibly ART adherence
 No impact on immunological status
 Knowledge Gaps
− Composition of support
− Timing of support
• pre ART vs. post ART
• role in delaying progression
− Pregnant and lactating women vs. OVCs vs. malnourished adults
− Exit criteria
− Impact on HH level characterisitcs

13. Livelihood Security Programs
 Livelihoods Programs
− Objectives are to promote food and livelihood security
− Provision of agricultural inputs and training to promote rural livelihoods
and local food production; promotion of income generating activities
• Widely implemented
• Questions remain about sustainability and scale-up
• Limited documented impact evaluation studies

14. Applying a Program Theory Framework to Examine
Integrated HIV and Livelihood Interventions
Critically examined 20 org. implementing livelihood interventions
throughout Uganda, implemented by TASO partners
Objectives
1. Examine the extent to which livelihood interventions integrated into HIV
care and treatment programs (IHLPs), implemented by a wide set of
organizations, present coherent and consistent causal pathways to
improving food security of people afflicted by HIV
2. Identify critical components of IHLP processes necessary to achieve the
intended outcomes
3. Investigate the approaches taken to adequately address the articulated
challenges in IHLP processes
Source: Kadiyala et al. (JDE 2009)

15. Operations Research to Examine Livelihoods Programs
Integrated with HIV Care and Treatment
Program theory identifies the processes by which a program is
intended to achieve its impacts
Impact Theory Process Theory
•Specifies impact pathways •Shows steps by which intervention
or program is implemented
•Identifies the steps by which a
program intervention is expected to •Includes steps related to
impact outcomes organizational plan to deliver
services
•Identifies the hypothesized cause-
and-effect pathways that connect a •Also includes assumptions of how
program’s activities to its expected and why beneficiaries will actually
outcomes utilize a service

16. General Findings
 Monitoring and evaluation frameworks need strengthening
− Key process and impact indicators not well defined or collected
 The complex pathways to achieving impact need to be further
defined
 Causal pathways are, in theory, plausible
− However, program implementation activities need to be monitored
 Need to strengthen planning and implementation to integrate
livelihood interventions with complementary services
 Program activities and inputs (material and intellectual) were
consistent with, and appropriate to, program objectives
− However, there are assumptions about practical implementation

17. PEPFAR Conceptual Framework for Food and Nutrition
Support in HIV Services