The HIV/AIDs epidemic is primarily occurring in populations where malnutrition is already endemic.  Because adequate nutrition helps maintain the immune system, sustain physical activity, and is essential for improving treatment outcomes with antiretroviral drugs, WHO recommends that any comprehensive program for HIV/AIDS include nutritional support (WHO, 2003).  Women of reproductive age with HIV are a critical population for health and nutrition interventions. According to UNAIDS data from 2009, women account for over 50 percent of global HIV infections and over 19.2 million women live with HIV. Programs addressing women’s nutrition and HIV/AIDS relate to four of the Millennium Development Goals: #1. reduce poverty and hunger; #4. reduce child mortality; #5. improve maternal health; and #6. combat HIV/AIDs.

The nutritional status of HIV-infected women before or during pregnancy and during lactation influences both the women’s health and the health and survival of their infants.  For women who are underweight to normal weight before pregnancy, adequate weight gain during pregnancy reduces the risks for low birth weight, stillbirth and perinatal mortality.  During the postpartum period, sufficient energy and nutrient intakes are necessary to support the demands of breastfeeding and for women to replenish their nutrient stores.  HIV infection increases energy requirements due to higher resting energy expenditures and increased nutritional needs from HIV-related infections and illnesses, thereby placing pregnant and lactating women at greater nutritional risk than their HIV-uninfected counterparts (WHO, 2004; Papathakis and Rollins, 2005; FANTA, 2010). However, for pregnant women living with HIV who are normal weight, they have higher frequency of pregnancy complications – particularly those related to hypertension and diabetes – than other pregnant women living with HIV who are normal weight (Tamayo et al., 2011). Plus, pre-pregnancy obesity and excess weight gain during pregnancy are risk factors for heavier babies (Li et al., 2013). But little emphasis is put on this population. Current evidence has clearly demonstrated that overweight and obesity and related non-communicable diseases have been exploding in low – and middle- income countries (Global Burden of Disease Report, 2012). The emerging challenges associated with the dual burden of over – and under – nutrition in the same population and often the same individuals may be associated with both quality and quantity of the diet as well as metabolic consequences of overweight/obesity. An overview of the recommended nutrient requirements for people living with HIV (PLHIV) and specifically for pregnant and lactating women can be found at FANTA-2 (2007). 

Interventions aimed at the food and nutrition needs of PLHIV should be coordinated at multiple levels from international and country levels to districts and local communities and, to maximize efficiency and effectiveness, should involve an array of relevant partners.  The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) utilizes a coordinated approach partnering with government-wide agencies including the Office of the Global Aids Coordinator, USAID, USDA, HHS, the Peace Corps, in addition to UNAIDS and relevant UN agencies, the Global Fund for AIDS, TB, and Malaria, the World Bank, and private sector and non-governmental organizations. PEPFAR supports the development of national policies and guidelines and prioritizes meeting the nutritional needs of undernourished HIV-positive pregnant and lactating women, as well as orphaned and vulnerable children (OVC) born to HIV-positive parents (PEPFAR, 2006).  The following nutritional interventions are supported by PEPFAR for patient care: nutritional assessment; counseling and education; therapeutic and supplementary feeding; and preventing maternal to child transmission (PMTCT).  Each type of intervention entails curricula development, training, quality assurance measures, and establishing a system for monitoring and evaluation (M&E).

In 2009, PEPFAR released a five-year strategy that outlines its contributions to the USAID’s Global Health Initiative and focuses on transitioning HIV/AIDS programs from an emergency response to sustainable, country-owned efforts (USAID, 2010).  Also in response to HIV/AIDS policy and programming at the global level, UN agencies such as WHO have been setting and disseminating policy guidelines based on the “Three Ones” principles: (1) one agreed upon HIV/AIDS action framework for all country-level partners; (2) one national AIDS coordinating authority; and (3) one accepted country-level M&E system (PEPFAR, 2006).

The scaling-up of ongoing food and nutrition interventions, the development of new approaches, and the rapid expansion of this relatively new set of interventions requires harmonized approaches to effectively monitor and evaluate nutritional care and support for PLHIV. Information from M&E can be used in designing and managing programs, assuring quality services, assessing outcomes and impacts of food and nutrition interventions, and in advocating for support and expansion of effective approaches. At the client level, collection of nutrition-related information is an important component of nutritional care and support that helps increase awareness among PLHIV, counselors and other service providers about clients’ diets and nutritional status, thereby supporting care, treatment and counseling processes.

The core indicators selected for this database have been developed and are being tested by the USAID Food and Technical Assistance (FANTA-2) program as part of the linked set of ‘Harmonized Indicators on Nutrition Care and HIV’ (FANTA, 2009), which have been developed to measure undernutrition in PLHIV and OVC (See FANTA 2008; 2010 for more background and details on these indicators). The indicators can be disaggregated for women of reproductive age and cover topics ranging from national policy, training, quality and utilization of nutrition services, and prevalence of undernutrition, to implementation of PMTCT care and feeding practices for HIV-exposed infants. Several of the indicators are also listed in the PEPFAR (2009) next generation indicators.  Additional sets of indicators are being tested by FANTA-2, specifically for PMTCT and for Food Security and HIV.

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References:

FANTA (Food and Nutrition Technical Assistance) Project.  2010.  A Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living With HIV . Washington, D.C.:  Academy for Educational Development. https://www.fantaproject.org/sites/default/files/resources/Nutrition_Interventions_Screening_Guide_Final.pdf

FANTA (Food and Nutrition Technical Assistance) Project.  2009.  A Guide to Screening for Food and Nutrition Services Among People Living With HIV (Draft).  Washington, D.C.:  Academy for Educational Development.

FANTA (Food and Nutrition Technical Assistance) Project.  2008.  A Guide To Monitoring and Evaluation of Nutrition Assessment, Education and Counseling of People Living with HIV.  Washington, D.C.:  Academy for Educational Development. http://www.hivpolicy.org/Library/HPP001508.pdf

FANTA (Food and Nutrition Technical Assistance) Project. 2007. Recommendation for the Nutrient Requirements for People Living with HIV/AIDS, Washington, DC: USAID. https://www.unscn.org/web/archives_resources/files/Nutrient_Requirements_HIV_Feb07.pdf

FANTA (Food and Nutrition Technical Assistance Project.  2006.  Compilation of Monitoring and Evaluation (M&E) Indicators Used for Food and Nutrition Interventions Addressing HIV/AIDS.  Washington, D.C.:  Academy for Educational Development.

Papathakis P. and Rollins N., ‘HIV and Nutrition: Pregnant and Lactating Women,’ Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and recommendations for action, Durban, South Africa, April 2005, Department of Nutrition for Health and Development, World Health Organization.

President’s Emergency Plan for AIDS Relief (PEPFAR), Report on food and nutrition for people living with HIV/AIDS, 2006, Washington, DC: Office of the U.S. Global AIDS Coordinator.

USAID, The Global Health Initiative (GHI). 2010. Implementation of the Global Health Initiative: Consultation Document, Washington, DC: USAID.

WHO. 2004, Nutrition Counseling, Care and Support for HIV-infected Women, Geneva, Switzerland: World Health Organization.  

WHO, 2003, nutrient requirements for people living with HIV/AIDS: Report of a technical consultation, May 13-15, Geneva: WHO.

Li, S., Rosenberg, L., Palmer, J. R., Phillips, G. S., Heffner, L. J. and Wise, L. A. (2013), Central adiposity and other anthropometric factors in relation to risk of macrosomia in an african american population. Obesity, 21: 178–184. doi: 10.1002/oby.20238

Tamayo et al. Presentation on 2011 Caribbean Conference. https://www.2011caribbeanhivconference.org/abstract/high-rates-obesity-among-pregnant-women-living-hiv-associated-pregnancy-complications-such-