“Triple trouble”: Malnutrition, TB and HIV - CORE Group

Integration of Nutrition into NationalHIV ResponsesService Delivery• Nutrition assessment• Nutrition education and counseling• Specialized food products• Micronutrient supplementation• Water purification and hygiene• Food security support5

Package of Nutrition Services at ClinicalHIV Care and Tx SitesMicronutrientsupplementation6

Food-by-Prescription ApproachCore components• Provision of set of nutrition services at clinicalfacilities as part of HIV care and Tx• Clearly defined entry and graduation criteria forspecialized food products• Prescriptions used for take-home foodpackages• Food packaged in daily consumption “doses”and aimed at improving individual nutrition andhealth status7

Lessons• Clinical facilities a good entry point forPLHIV nutrition services. But also need tointegrate into community services andestablish two-way referral mechanismsbetween facility and community services.• Importance of integration into existingsystem – patient flow, information flow,etc. Ownership by medical stakeholders.8

Nutrition and TBNutritionalsupportMalnutritionNutritionalsupportLatent TB Active TB Malnutrition9

Malnutrition as a risk factor forTB• General malnutrition reduces expressionof mycobactericidal substances maycompromise cell-mediated immunityleading to active TB– Intervention: Nutritional support to at-riskpopulations (where latent TB is common)?• Challenging to study relationship betweenmalnutrition and incidence of TB—limiteddata10

Malnutrition as a consequenceof TB• Active TB associated with:– Wasting: both fat and fat-free mass reduced• Multiple factors involved: poor appetite, increasedenergy expenditure (due to infection), alteredprotein metabolism– Micronutrient deficiencies (retinol, vitamins Cand E, zinc, iron and selenium)– Anemia11

TB treatment and nutritionalstatus• TB treatment improves nutritional status, butlimited to gains in fat mass– Alterations in protein metabolism may continue duringtreatment– Typical diet may be inadequate to support lean massrepletion• Randomized controlled trial that provided an energy-protein supplement toTB patients receiving treatment showed gains in lean mass, and greater gripstrength (Paton et al, 2004)• Role for nutritional support during and after TBtreatment, but limited data exist on mosteffective (and cost-effective) approach andneeded duration of support12

Incorporating nutrition into TBprograms (1)• Limited programmatic evidence of nutritionalsupport for TB prevents firm recommendations• Limited documentation on the role of nutritionalsupport in TB programs• Some recommendations* include:– Nutritional assessment for determination of nutritionalstatus and referrals– Nutritional counseling/education on symptommanagement and improved dietary intake during/afterTB treatment*Source: Africa’s Health in 2010, Nutrition and Tuberculosis: A review of theliterature and considerations for TB control programs. 200813

Incorporating nutrition into TBprograms (2)• Recommendations (cont’d)– Targeted micronutrient supplementation: vitamin B6,vitamin D– Food support for treatment of malnutrition in TB andTB/HIV co-infected patients– Food support to increase treatment adherence14

WHO Consultation• “Scoping meeting for the development ofguidelines on nutritional/food support to preventTB and improve health status among TBpatients”– Nov. 2-4 2009– Convened by WHO Nutrition department, incollaboration with WHO Stop TB, UNAIDS and theWorld Food Programme– Invited participants: scientists, partner organizationswith experience in food support to TB patients,selected countries with TB/food support experience,WHO guideline review committee 15

WHO Consultation: Objectives• Review evidence base on TB and nutrition• Review potential for collaboration betweenTB and HIV programs and nutrition• Identify knowledge and research gaps andidentify questions to be answered withsystematic reviews of existing research• Agree on a scope of guidelines on nutritionand TB, and establish a guideline group16

WHO Consultation: Review ofevidence• Undernutrition as a risk factor for TB infectionand active TB disease• Effectiveness, cost and cost-effectiveness ofnutritional support for:– improvement of TB treatment outcomes– improvement of TB treatment adherence– nutritional rehabilitation of TB patients– reducing TB incidence• Special considerations for TB patients with HIV,MDR-TB, diabetes, and children17• Lessons learned from Nutrition-HIV

Discussion (1)• Drawing on your own experience…– What nutritional/food support are beingprovided to TB patients? What is the objectiveof the nutritional/food support (e.g., treatmentadherence, rehabilitation)?– What challenges and opportunities exist tointegrating nutrition support into TBprograms? Or integrating nutrition, TB andHIV programs?18

Discussion (2)– What key research questions related to TBand nutrition are needed to improveprogramming?– What lessons from nutrition and HIVprograms can be transferred to thedevelopment of nutrition support in TBprograms?– What about using nutrition to prevent activeTB? Is that feasible? A priority? What are theprogram platforms for doing this?19

Discussion (3)– What type of guidance, or for which specialgroups of TB patients (e.g., TB/HIV coinfected,children) is guidance most critical?20

This presentation is made possible by the generous support of theAmerican people through the support of the Office of Health, InfectiousDisease, and Nutrition, Bureau for Global Health, and the Sub-SaharanAfrica Bureau, United States Agency for International Development(USAID) , under terms of Cooperative Agreement No. GHN-A-00-08-00001-00, through the Food and Nutrition Technical Assistance IIProject (FANTA-2), managed by the Academy for EducationalDevelopment (AED). The contents are the responsibility of AED and donot necessarily reflect the views of USAID or the United StatesGovernment.Food and Nutrition Technical Assistance II Project (FANTA-2)Academy for Educational Development 1825 Connecticut Ave., NW Washington, DC 20009Tel: 202-884-8000 Fax: 202-884-8432 E-mail: fanta@aed.org Website: www.fanta-2.org21