Overview of the 29th Session Symposium - Nutrition and HIV/AIDS

The Minister for Public Health, the Honorable Professor Sam K. Ongeri welcomed participants to the Symposium, outlined the history of the development of HIV/AIDS in Kenya, provided a picture of the current situation and enunciated Kenya’s pragmatic policy to concentrate efforts on HIV prevention. In 1990 the prevalence of HIV in Kenya was 3.9%; in 1998/99 it was 14% nationally, while several age groups have much higher rates. Amongst teenagers, 24% are HIV-positive in the year after first sexual contact; this increases to 46-50% five years after first sexual contact. In total, about 2.1 million Kenyans are infected with HIV and this number is increasing daily. About one million children are orphaned in Kenya because of HIV/AIDS. Interventions have focused on prevention through behavioural change; without these programmes in place Kenya may have seen a national rate of close to 30% by now.

One area of serious concern for the health sector is bed occupancy in hospitals. AIDS patients occupy 50% of beds in some district and provincial hospitals in Kenya. This has enormous implications for staffing and the quality of care. Minister Ongeri explained that if all AIDS patients were to receive appropriate treatment, the cost would amount to close to KShs 12 billion per year; whereas the budget of the Ministry of Health for all preventive and curative services is about KSh 9 billion. HIV/AIDS in Kenya, as elsewhere in Sub-Saharan Africa, co-exists with malaria, tuberculosis and other infectious diseases.

Kenya has adopted a strategic plan to combat the spread of HIV infection and to give priority to a comprehensive care services package for those with AIDS. Nutritional care is very much part of this strategic approach. Minister Ongeri argued that large-scale campaigns to promote healthy behaviours and good nutrition can be effective in poor populations. However, these efforts need to be flexible, adapted to the real needs of the people, and coupled with poverty reduction strategies. In Kenya, the role of the family and the community is emphasized in programme design and implementation. Minister Ongeri also stressed that breastfeeding promotion, support and protection takes on a new significance and importance in the face of the HIV/AIDS epidemic. Existing programmes need strengthening, as stigma and misinformation erode past gains.

In his keynote address Dr. Peter Piot, Executive Director of UNAIDS, stressed that HIV/AIDS is most often one additional burden on top of many others. In Sub-Saharan Africa in particular, AIDS emerged against a backdrop of poverty, conflict and inadequate infrastructure. By eroding social capital, its effect has been to make those problems and their consequences far worse. HIV/AIDS has decimated the very generation of young adults poised to take Africa’s future into their own hands. There are over 25 million people living with HIV in Sub-Saharan Africa; in some countries over one in three adults is living with HIV/AIDS. AIDS is not a disease of poverty, and often those first affected by the epidemic are the better educated and more mobile sections of a population. However, over time AIDS and poverty cement their relationship.

Dr. Piot went on to discuss the relationship between nutrition and HIV. Like poverty and HIV, nutrition and HIV operate in tandem, both at the level of the individual and the society. For individuals, nutrition deficits make people with HIV more susceptible to disease and infection. Indeed, malnutrition is one of the major clinical manifestations resulting from HIV infection both in children and in adults. At the social level, food insecurity is a major cause of vulnerability to HIV. The impact of HIV is felt in reduced agricultural production as well as in increased fragility of affected households. However, Dr. Piot emphasized, we are not powerless in the face of AIDS. We know what works to turn the epidemic back. Effective responses to the HIV epidemic come from unified national planning, access to essential prevention and care commodities, and a public environment where people with HIV and those most at risk are not excluded, but considered part of the community and part of the solution.

Dr. Piot said that the nutrition voice needs to be heard louder and stronger in the HIV field. He called upon the nutrition community to assist with applying proven strategies on a scale commensurate with the epidemic. The time for pilot projects is over. Mainstreaming and decentralizing our work are all important. Success comes from long-term sustained commitment. Moving to specific challenges, these areas were identified as needing intensive work.

· Emergencies, including food emergencies, need to be the focus for interventions to reduce HIV risk. When populations are on the move, basic security is threatened and HIV risk rises.

· We must pay attention to sustainability and overcoming long-term vulnerability, while dealing with the immediate impacts of AIDS. Two examples are cultivating less labour intensive crops which may not be good food sources and keeping children in school while adults are ill and dying.

· There is a need to assess the impact of rural development on the spread of HIV. Will agricultural development plans add to HIV risk? Will new transport routes increase the spread of HIV? These questions, and others, need to built into the World Bank’s poverty reduction strategies.

· Nutrition must be brought into the essential care package. “Care” has somehow been narrowed to the cost of anti-retrovirals and this is counter productive.

· Women need to be supported in their infant feeding choices, and this should be coupled with confidential testing and counselling. Testing is all too rare amongst poor African women. Unless women know their sero-status they are unable to determine their risks.

· Leadership, commitment and compassion are needed to attack stigma and discrimination, two of the major barriers to effective responses to the epidemic.

· HIV poses gender challenges, and these need to be faced. Addressing relationships between men and women is at the core of successful behavioural change to prevent the spread of HIV.

Mrs. Sophia Mukasa Monico, Director of The AIDS Support Organization (TASO), picked up on many of these issues in her presentation of the work of TASO, a grassroots organization in Uganda. AIDS was first recognized as a new disease in Uganda in 1982. In 1986 a national AIDS control programme was established and the government called for collective action. By 1990, an estimated 1.5 million adults and children were infected with HIV, and, by 1992, 16% of military recruits were sero-positive. However, by June 1995, the incidence of HIV in Uganda was already falling, and the prevalence started to fall by 1997. HIV infection rates are declining in antenatal clinics in Uganda; for the country as a whole, the infection rate has declined from an estimated 24% in 1992 to 8.3% by the end of 2000. This decline has been especially evident in youth between 15 and 25 years.

TASO has played a key role in the fight against the spread of HIV/AIDS, starting in 1986 as a group of 16 family members of people living with HIV/AIDS. At this time in Uganda, hospitals were not receptive to HIV/AIDS patients, and one of the main actions of the group was to sensitize hospital staff. TASO was legally incorporated in November 1987, to provide care and support for persons with HIV/AIDS and their families at Mulago Hospital, the biggest referral hospital in Kampala. TASO was thus founded to contribute to the process of restoring hope and improving the quality of life of persons and communities infected and affected by HIV/AIDS.

TASO offers support at the individual, family, community and national and international levels. One-to-one counselling which empowers people living with HIV and AIDS to make informed decisions that improve the quality of life and facilitate a balance between rights and responsibilities, is a key area for TASO. At the personal level, TASO also provides compassionate care, early diagnosis and treatment of opportunistic infections to encourage positive living and dying with dignity. At the family level, TASO counsels family members to dispel fears of contracting HIV through casual contact. TASO also facilitates community-planned responses, community evaluation of the responses and mobilization of community resources.

Mrs. Monico discussed the role of food assistance as an incentive for clients to seek services. In TASO’s experience, distributing food attracts people living with HIV/AIDS to access services. Nutrition counselling and education are important components in the TASO package of care services and help clients to use locally-available food resources wisely. The nutrition education component also aims to encourage clients to try new foods. Nutrition counselling helps clients understand that living with HIV/AIDS means living with higher protein and energy needs.

TASO shares the national outlook of the “good enough care” strategy for people living with HIV/AIDS that Uganda has adopted. This strategy includes management of opportunistic infections using readily available and affordable diagnostic and treatment strategies. Good enough care encompasses promotion and practice of positive living including good nutritional habits. TASO’s view is that people have more control over their diets than nearly any other factor affecting their health.

In his presentation on HIV/AIDS and development, Professor Oliver Saasa, said that national HIV prevalence in Zambia is about 20%, considerably higher than in Uganda. Sentinel site surveys carried out amongst women attending clinics in major urban centers show that 27% of antenatal women are sero-positive. Similar survey findings from rural areas indicate a rate of around 14%. The epidemic is imposing an unsustainable and mounting burden on households, firms and the public sector. Long periods of illness of skilled personnel in employment result in considerable loss to employers. The AIDS epidemic needs to be viewed, Professor Saasa said, as an immense challenge to capacity building and development. Impacts at the macro-level include increased costs of production, as the quantity and quality of the labour force diminish. Impacts on industry due to working hours lost poses a serious threat to sustainable productivity. One study of impacts on the petroleum industry in Zambia showed that the economic impact of the pandemic, the cost of medical care, salary compensation for the families of deceased employees and funeral grants more than doubled in a two-year period in the early 90s. In the education sector, deaths among school teachers will exceed total output from all primary teacher-training colleges in the country. The HIV/AIDS fight must be placed at the center of each African country’s capacity-building agenda, he concluded.

In a review of generic principles for maximizing the contributions of food and nutrition programming to mitigate the impacts of HIV/AIDS, Dr. Stuart Gillespie developed the notion of the “HIV lens”. This means taking a hard look that the role that existing interventions and policies play, or could play, in HIV/AIDS mitigation before completely new capacity-straining interventions are developed. These questions need to asked: when do governments, NGOs, communities and development agencies need to a) improve the performance of existing efforts, b) view HIV-prevention and mitigation interventions through a poverty lens and modify appropriately, or c) design completely new interventions to address HIV/AIDS? Dr Gillespie noted that food security programming per se is very weak in many countries. This is coupled with the fact that many countries do not include extensive food security policies and programmes in their overall poverty reduction strategy, which marginalizes the issue further.

Options for action were then presented at three levels: nutrition policies and programmes, programming food aid, and agricultural policies and programmes. For people living with HIV/AIDS, nutritional care and support is critically important in preventing nutritional depletion. The specific objectives might include improving the quantity and quality of the diet, to build or replenish body stores of micronutrients, to prevent or stabilize weight loss, to preserve muscle mass, to prevent diarrhoea, to speed recuperation from HIV-related infections, and to prepare for and manage AIDS-related symptoms that affect food consumption and dietary intake. Nutritional support has the potential to prolong life, an impact which will be greatest if interventions take place early in the coarse of the disease. Unfortunately, relatively few people know they are infected at this time.

In applying the “HIV lens” it becomes clear that breastfeeding promotion and complementary feeding programmes will need to further emphasize the dissemination of clear information to policy makers, health providers and communities about mother-to-child transmission facts. This includes risks and benefits of breastfeeding. Programmes will need to anticipate that households affected by HIV/AIDS will have even greater time and economic constraints to the provision, preparation and feeding of appropriate complementary foods. Programmes to address women’s nutrition may not require substantial content changes, but need much greater support all around, especially for breastfeeding women. All nutrition programming should be community driven, not just community based.

Dr. Gillespie noted that the role of food aid in HIV/AIDS mitigation and care has just begun to explored by field-based organizations. The biggest challenge for food-assisted interventions is to provide food to meet needs but also to programme interventions so that family members and communities are left with a means to improve their food and nutrition security after the food assistance stops. There is a role for food aid in both care and mitigation packages, however, good programming principles need to be followed. Dr. Gillespie suggested four principles: a) there needs to be a clear need for food, b) food should be provided as part of a larger package of assistance, c) food can be combined with training or income generating activities to improve food access and to increase self-sufficiency, and, finally d) close consultation with affected communities on how to target and deliver food assistance needs to be an integral part of the programme.

In her presentation on nutrition and the care package, Dr. Phetsile Dlamini, Minister for Health and Social Welfare of Swaziland said that in the wave of excitement about anti-retrovirals some of the practical and affordable solutions, including good nutrition, have been forgotten. Also, policies and programmes offering improved care for people living with HIV/AIDS have neglected issues of nutrition. Likening good nutrition to the strong foundation and walls of a house, Dr. Dlamini called attention to the need for programmes to promote indigenous foods, some of which are rich in micronutrients, especially anti-oxidant nutrients. The focus of nutrition work should be on sustainable community solutions such as small gardens near the home and advice on what foods to grow. Dr. Dlamini cautioned that although anti-retrovirals need to be made affordable and available, these treatment regimes may not work optimally in a vacuum. On the role of nutrient supplementation, Dr. Dlamini suggested that making supplements available to all may help to destigmatize HIV disease. Finally, there is a need for nutrition counselling to be practical, feasible, and for materials to be published in the local language.

Dr. Dlamini then joined a distinguished panel to discuss the implications of HIV/AIDS for nutrition programmes in the region. She was accompanied by Dr. Elizabeth Marum of the Center for Disease Control and Prevention, Nairobi, Dr. Ruth Nduati of the University of Nairobi, and Dr. Phillip Mwalari of Kenya’s National AIDS Control Council. Dr. Elizabeth Marum opened the discussion by presenting the findings of an assessment of home-based care programmes in Malawi. The findings relate to the issue of hunger among people living with HIV/AIDS, and the problem of home-based care programmes, in general, which are often not well designed. Fifty patients or their caregivers were interviewed. The needs and requests articulated by the interviewees were very simple: food, painkilling medications, soap, bed clothes and help with household tasks. Sadly, these basic needs were not being met by the home-based care programmes. While 86% of the patients reported needing food, only one patient was receiving food on a regular basis. The home-based care programmes, some of which were well funded by external donors, did not provide any food supplements. Volunteer caregivers were providing food from their own homes. Here, and elsewhere, in the region Dr. Marum said that she had observed an excessive dependence upon volunteers in care programmes. She suggested that food aid could be used to compensate the volunteers for their time.

Dr. Ruth Nduati discussed HIV and nutrition of women, and explained why energy requirements are elevated during HIV disease. She went on to pose a series of questions about the impact of increased nutritional demands of pregnancy and lactation on HIV disease progression in mothers. The co-existence of lactation and HIV is a very significant metabolic challenge. The requirements of increased resting energy expenditure, plus energy needed to support exclusive breastfeeding, are equivalent to one whole extra meal per day, providing at least 750 kcals. Dr. Nduati drew attention to the special needs of HIV-infected women who have experienced child death. These women tend to have shorter birth intervals because they try to replace the child who has died. The role of micronutrient supplementation was touched upon: one study carried out in Tanzania amongst HIV-positive, pregnant women showed that use of vitamins reduced low birthweight by 44%.

Dr. Phillip Mwalari presented some of the approaches of the National AIDS Control Council in Kenya. The Council has set up a network that takes messages to the grassroots level. At the provincial level the Provincial HIV/AIDS Coordinating Committee has HIV/AIDS coordinating units in the public and private sectors. With this approach the Council hopes to transfer as much as 60% of the available resources to the community. Dr. Mwalari emphasized that a strong multi-sectoral approach is needed in both nutrition and HIV/AIDS work.

In introducing the ACC/SCN Dr. Abraham Horwitz Memorial Lecturer, the chair noted that Ms. Lucy Thairu was selected from amongst eight finalists in an essay competition administered annually by the ACC/SCN Secretariat. Ms. Thairu, a graduate student at Cornell University, based her paper on field work carried out in Kiambu district, Kenya, on infant feeding options for mothers with HIV/AIDS. In introducing her research Ms. Thairu stressed the importance of dialogue with mothers and using women’s insights to guide policies. Although breastfeeding accounts for only part of mother-to-child transmission of HIV, in countries where both fertility and rates of HIV infection among pregnant women are high, the issue of HIV transmission through breastfeeding is of public health importance. For poor women living in developing countries the choice not to breastfeed is, obviously, much more problematic than for affluent women in northern countries.

Ms. Thairu first reviewed the literature on informed choice. By far the majority of pregnant women in Sub-Saharan Africa are not tested for HIV, so their status is unknown both to themselves and the health worker. Even where women get tested, some studies show that health care providers do not have accurate information to share with HIV-positive mothers, and may convey a lesser risk for formula feeding than for breastfeeding. Also, the widespread belief that all babies of HIV-positive mothers will be born infected needs to be countered with accurate information on the rate of mother-to-child transmission and current understanding of the risk of transmission through various routes. Regarding how infant feeding choices are made, in some communities a woman’s authority to make infant feeding decisions may receive scant respect. Early detection of HIV will enable mothers to recognize their role in infant feeding decision-making. Ms. Thairu argued that women should receive this information as early as possible, either prior to pregnancy or during antenatal care, allowing time for reflection.

There are relatively few reports, and even fewer published studies, on women’s views of infant feeding options, including exclusive breast-feeding, animal milks, wet nursing, heat treating expressed breastmilk and others. There is a paucity of data on the perceptions of mothers as decision-makers in guiding policies and counsellors’ advice. Knowledge about women’s ideas, opinions, feelings and experiences suggests specific ways in which health care providers can facilitate informed decision-making. Providing information about infant feeding options needs to be individualized, and must be unbiased and accurate to help women make a decision that is in keeping with personal values and beliefs.

In Ms. Thairu’s field study, women were asked what alternative they would choose if they hypothetically tested positive for HIV. A set of infant feeding options was presented to them. These included: expressed and heat-treated breast milk, milk banks, goat’s milk, wet nursing, infant formula and cow’s milk. Women were requested to give their opinion on all of the options presented.

Only 34% of the women stated that they were willing to breastfeed exclusively for three months if they tested positive for HIV. Only nine percent would choose to heat-treat expressed breast milk. About one quarter of women said they did not believe that heat treatment could inactivate the virus. Only 12% of women would consider banked milk. More than one half (56%) said they would consider infant formula, and some women perceived its composition as being close to that of breastmilk. A large majority of women (86%) said they would use cow’s milk because it is widely available and believed to be fresh, compared with infant formula.

In conclusion, Ms. Thairu discussed her findings in the context of informed decision-making. In the case of a mother who opts to use cow’s milk in early infancy, according to the purely informed decision-making model, if she is accurately informed, she should not be persuaded to change her mind. However, she should be taught how to modify cow’s milk to make it nutritionally adequate and safe. According to the shared informed decision-making model, such a mother could be educated on how to modify cow’s milk and supplement it with micronutrients.

In summing up the main themes emerging from the papers and the discussion that followed, Dr. Badara Samb of UNAIDS identified priority areas for action for the ACC/SCN Working Group on Nutrition and HIV/AIDS. These are:

· developing, testing and disseminating guidelines for incorporating nutrition into essential care packages for people living with HIV/AIDS

· strengthening the promotion, protection and support of exclusive breastfeeding, especially in countries with high HIV prevalence rates

· updating tables of food composition for micronutrient-rich African indigenous foods, especially those that are not labour intensive and can be grown near the home throughout the year

· monitoring the food and nutrient composition of commercially-marketed food supplements aimed at adults living with HIV/AIDS

· at the strategic and policy level, incorporating nutrition and HIV/AIDS programming into poverty reduction strategies.