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children). The guardian most conversant with
the child’s health/illness situation was interviewed.
Quantitative data was collected and
analysed from client records, monthly reports
and field visit reports. Variables of interest were
age, sex, weight, anthropometry on admission
and discharge, length of stay on treatment and
reason for discharge. Data were edited and
entered into Excel. Data were exported to
Statistical Application Systems (SAS) for
further cleaning and analysis. Analyses
involved descriptive and inferential statistical
analyses including frequencies and distributions
of all variables.
Structured individual interviews were then
held with 91 clients, ten administrators and 38
health care workers. Focus group discussions
(FGDs) of five to ten participants, drew further
information from clients (four groups) and
service providers (five groups) using openended
questions and scenario methods, led by a
moderator and recorded by a note-taker.
Qualitative data were analysed manually by the
evaluation team, who read through the interviews
to identify emerging themes.
Results
Integration – Clinical facilities: The majority of
ART clinics achieved integration of FBP and
ART services as intended in Figure 1. Facilities
with the weakest community outreach
programmes had the highest number of
defaulters.
Some facilities, having achieved competence
with FBP implementation, extended services to
satellite sites. These were significantly more
difficult to manage but reduced congestion at the
hospitals and greatly increased FBP enrolment.
Integration – HBC: HBC programmes provided
a decentralised, ‘one-stop’ service model.
Clients were assessed, counselled, prescribed
and dispensed rations by a trained caregiver at
the parish office. Home-based follow-up was
provided by assigned HBC providers whose
role was to support both FBP and ART adherence.
HBC service providers and clients
reported that integration was seamless.
Integration – Hospice: Service models varied
considerably among hospices, with hybrids of
centralised and decentralised models tried.
Success with integration varied, possibly due to
reliance on lay counsellors and volunteer caregivers
(in contrast to technical staff employed
by ART clinics) as well as less rigorous recordkeeping
(in many hospices), and less
management oversight in some cases.
Service provision: Anthropometric assessment
was often done selectively (on clients who
appeared malnourished) rather than as a
routine aspect of the standard of care. While
weighing and recording weight is a standardised
practice, BMI is rarely calculated and
MUAC is seldom used. FGD respondents at all
sites noted the need for additional training and
supervision to ensure adherence to admission/discharge
criteria and to improve skills
and consistency in nutrition assessment.
Respondents consistently reported that
active supervision positively influenced staff
commitment to providing nutrition assessment
and education, and improved accuracy of
record-keeping. Many staff requested incentives
for providing FBP services. The pilot,
however, was neither designed nor budgeted to
accommodate incentive requests.
Only 11% of clients reported that they were
linked to livelihood activities, illuminating the
enormity of the gap in this aspect of FBP
programming.
Food storage and dispensing: Lack of FBP
commodity storage space was cited as a significant
challenge. CRS generally disbursed
commodities every two months to accommodate
storage limitations. Some alternate storage
locations, such as kitchens, did not meet storage
standards for temperature and humidity. There
was no consensus among service providers
regarding the ideal location for food dispensing
but agreement that each setting should evaluate
its options with emphasis on creating the most
seamless, efficient pathway for clients.
Overall, supply chain management was a
significant challenge, with three primary difficulties
noted:
1. Month-to-month new enrolment numbers
varied considerably
2. Length of client enrolment varied
3. Short shelf-life of selected commodities
reduced prepositioning options.
Monitoring and Evaluation: The project sought
to align with ‘the 3 Ones’ 8 by contributing to a
single national reporting system, but was
obliged to create a parallel approach because
the existing system, SmartCare, did not allow
for the capture of comprehensive nutrition data
(e.g. BMI and WHZ). Lack of nutrition training,
combined with the lack of tools and systems for
data collection, have resulted in a nationwide
gap in the detection, tracking and treatment of
malnutrition among PLHIV, especially adults.
Client weight gain and BMI: All sites showed
an increase in client BMI between admission
and discharge. Among adult clients, the average
BMI on admission was 17.6 kg/m 2 and the
average BMI on discharge was 20.5 kg/m 2 . The
overall average increase in BMI pre-FBP to
post-FBP was 2.9 kg/m 2 . Most clients required
three to six months of nutrition rehabilitation to
qualify for discharge.
Of the 22% of clients already discharged
from the programme at the time of the evaluation,
997 (84%) met discharge criteria, 127 (11%)
died from various causes, 45 (4%) were
unknown or lost to follow-up and 18 (1%) were
removed from treatment because of medical
complications.
Client health status: Clients were asked to rate
their pre- and post-intervention health status
using the Eastern Cooperative Oncology Group
(ECOG) performance scale 9 . The percentage of
clients who were ‘fully active’ went from 5%
pre-FBP to 51%, post-FBP. Only 1% of clients
remained ‘completely disabled’ post-FBP,
compared to 17% pre-FBP.
Limitations
Site records and quantitative datasets had
numerous missing anthropometric data which
limited the scope of analysis. Geographic
distance, communications challenges, delayed
project start-up and time constraints resulted in
a disproportionate number of enrolled clients
(thus fewer-than-planned rehabilitated and
discharged) represented in the evaluation
sample.
The short six-month project implementation
period was sufficient to measure integration
activity but necessitated pooling of clients
across several sites in order to obtain a sufficient
sample, which may have masked
site-specific patterns.
It should be noted that weight gain, BMI and
ECOG performance cannot be attributed exclusively
to a FBP intervention. It is understood
that nutritional status and activity level are
likely to improve with ART only, or with some
other combination of ART and nutrition.
Conclusions and recommendations
Integration of FBP into existing HIV care and
treatment was successfully adapted to facility,
home-based care (HBC) and hospice service
delivery settings. Integration did not interrupt
existing service delivery and can be accomplished
using available human and material
resources. The ‘medicalisation’ concept was
appreciated and understood by both clients and
service providers and the selected rations were
successful in treating malnutrition. Weight gain
and body mass index (BMI) improved while
percentage of discharges cured (i.e. nutritionally
rehabilitated) exceeded standards. In
addition, activity levels and perception of wellness
improved dramatically.
The keys to success were on-going support
for application of nutrition concepts and careful
record-keeping, and the identification of site
coordinators who brought both technical nutrition
knowledge and a high level of commitment
to the pilot project. However, on-going training
is required in nutrition, record-keeping and
reporting. Future implementers would benefit
from formal incorporation of new (FBP) tasks
through either scopes of work for key staff, or
the full integration of FBP responsibilities into
standard job descriptions. These additional
tasks may have implications for remuneration.
Furthermore, integration of FBP commodities
into the medical stores procurement and distribution
system would reduce duplication of
effort and promote national ownership.
The national ART M&E systems must be
expanded to capture nutrition data. To foster
timely discharge, linkages to wrap-around food
security and livelihood programmes should be
designed from the early stages of project
conceptualisation.
Children and pregnant/lactating women
were under-represented, suggesting that
Maternal & Child Health (MCH) and
Prevention of Mother to Child Transmission
(PMTCT) programmes should be more intentionally
included in scale-up plans. With regard
to the use of MUAC, it was suggested that it be
used for screening only, applying an increased
cut-off to trigger referral of potential clients for
assessment by a clinician.
For more information, contact Kate Greenaway,
email: kate.greenaway@crs.org
8
The ‘3 Ones’ is a set of three key elements that underpin a
coordinated national response: One agreed HIV/AIDS
Action Framework that provides the basis for coordinating
the work of all partners. One National AIDS Coordinating
Authority, with a broad-based multi-sectoral mandate; and
One agreed country-level Monitoring and Evaluation
System. (UNAIDS, 2004)
9
Oken, MM, Creech, RH, Tormey, DC, Horton, J, Davis, TE,
McFadden, ET, Carbone, PP: Toxicity And Response Criteria
Of The Eastern Cooperative Oncology Group. Am J Clin
Oncol 1982, 5(6):649-655.
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