National Guidelines For HIV/AIDS And Nutrition

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The Federal Democratic Republic of EthiopiaMinistry of HealthNational Guidelinesfor HIV/AIDS and NutritionRevised September 2008ii

National Guidelines for HIV/AIDS and Nutrition in EthiopiaAcknowledgementsThe Family Health Department of the Ministry of Health wishes to express itsgratitude and appreciation to the many individuals and institutions whose dedicationand support have made possible the development of these guidelines.We wish to begin by thanking the United States Agency for InternationalDevelopment (USAID) and the United States President’s Emergency Plan forHIV/AIDS Relief for providing the required financial and technical assistance throughthe Food and Nutrition Technical Assistance Project at FHI 360. We also express ourappreciation to the Technical Working Group on Nutrition and HIV for providing theirguidance in the review of technical issues and identification of priority areas to beincluded in the guidelines.In addition, we are grateful for the support of many colleagues within theimplementing partners for their technical input, participation and leadership supportthroughout the review process.Dr. Neghist Tesfaye, HeadFamily Health DepartmentFederal Ministry of HealthDr. Yibeltal Assefa, HeadHealth Programs DepartmentFHAPCOi

National Guidelines for HIV/AIDS and Nutrition in EthiopiaThe Federal Ministry of Health (FMOH) would like to express its sincere gratitude tothe following organizations for their assistance in this effort: Dr. Belaynesh Yifru, FHD/FMOHDr. Mulugeta Workalemahu, FHAPCOAto. Samson Taffesse, FHAPCODr. Wondimu Teferi, CDC EthiopiaDr. Mengistu Tafesse, ICAPDr. Mehreteselassie Menbere, WFPDr. Habtamu Fekadu, FHD/FMOHDr. Robert Muadime, FANTA ProjectMr. Tony Castleman, FANTA ProjectDr. Hana Nekatebeb, FANTA ProjectSeptember 2008ii

National Guidelines for HIV/AIDS and Nutrition in EthiopiaTable of ContentsAcknowledgements . iiAbbreviations and Acronyms . ivGlossary of Food Terms.vi1. Introduction. 12. Background . 33. HIV Counseling and Testing . 84. Maternal and Child Health . 115. Antiretroviral Therapy . 166. Orphans and Vulnerable Children . 217. Home-Based Care . 268. Behavior Change Communication Tools . 299. Food Security . 3010. Monitoring and Evaluation . 37Annex 1. Daily Energy and Protein Requirements . 39Annex 2a. Essential Nutrition Actions for Pregnant and Lactating Women and Their ChildrenWho Are HIV-negative or of Unknown Status . 40Annex 2b. Additional Essential Nutrition Actions for HIV-positive Pregnant and LactatingWomen, Other Adults, and Their Children. 41Annex 3. Calculating Body Mass Index . 42Annex 4. Treatment of Anaemia . 44Annex 5. Energy Values of Meals, Snacks, and Foods Available in Ethiopia . 46Annex 6. Nutrition Management of Symptoms Associated with HIV/AIDS. 51Annex 7. How to Measure Mid-upper Arm Circumference . 54Annex 8. How to Exclusively Breastfeed Safely . 56Annex 9a. Algorithm for the Management of Malnutrition in Children . 58Annex 9b. Algorithm for the Management of Malnutrition in Adult PLHIV.62Annex 10. National Guidelines for the Management of Severe Acute Malnutrition 66Annex 11. Food-and-Antiretroviral Drug Interactions and Common Side Effects . 67Annex 12. Developing a Drug-and-Food Plan. 69Annex 13. Monitoring and Evaluation Indicators . 71References . 72iii

National Guidelines for HIV/AIDS and Nutrition in EthiopiaAbbreviations and DFMOHGMPHAARTHBHBCHCTHEWHIVICAPIFAddis Ababa UniversityAcceptable, feasible, affordable, sustainable, safeAcquired immune deficiency syndromeAntenatal careAntiretroviral therapyAntiretroviral drugsAzidothymidineBehavior change communicationBody mass indexCluster of differentiation 4Centers for Disease ControlClinton Foundation HIV/AIDS InitiativeChild Health CardDemographic and health surveyCommunity health workerCorn-soy blendExclusive breastfeedingEthiopian Health and Nutrition Research InstituteEssential Nutrition ActionsExclusive replacement feedingFood and Nutrition Technical Assistance Project; may also be writtenas “FANTA Project”Food and Agriculture Organization of the United NationsFortified blended foodsFood by prescriptionFederal Democratic Republic of EthiopiaFederal HIV/AIDS Prevention and Control ProgramFamily Health DepartmentFederal Ministry of HealthGrowth monitoring and promotionHighly active antiretroviral therapyHemoglobinHome-based careHIV counseling and testingHealth extension workerHuman immunodeficiency virusInternational Center for AIDS Care and Treatment ProgramsInfant feedingiv

National Guidelines for HIV/AIDS and Nutrition in ARUTFSCMSTBTFPThe GuidelinesUNICEFUSAIDWFAWFHWFPWHMWHZWHOIncome generating activitiesIntegrated Management of Childhood IllnessInsecticide treated net (particularly for mosquitoes)International unitsJohns Hopkins University/Technical Support for the Ethiopia HIV/AIDSART InitiativeKilocalorieLymphocytic interstitial pneumoniaMonitoring and evaluationMaternal and child healthManagement Sciences for HealthMaternal to child transmission of HIVMid-upper arm circumferenceNon-governmental organizationNational Nutrition ProgramNational Nutrition StrategyOpportunistic infectionOral rehydration solutionOutpatient therapeutic programOrphans and vulnerable childrenPneumocystis carinii pneumoniaPolymerase chain reactionPeople living with HIV and AIDSPrevention of maternal to child transmission of HIVPost-natal careRegional Centre for Quality of Health CareRecommended dietary allowanceReady-to-use therapeutic foodUSAID Supply Chain Management System ProjectTuberculosisTherapeutic feeding programNational Guidelines for HIV/AIDS and Nutrition in EthiopiaUnited National Children’s FundUnited States Agency for International DevelopmentWeight-for-ageWeight-for-heightWorld Food ProgrammeWeight-for-height as a percentage of the medianWeight-for-height z-scoreWorld Health Organizationv

National Guidelines for HIV/AIDS and Nutrition in EthiopiaGlossary of Food Terms*†* See Annex 5. Tables 1 and 2. for the nutrition value of specific common Ethiopian meals and snacks.†See Annex 5. Table 3. for a list of common Ethiopian bulk foods, their local names, and specific nutrition values.AlichaAmbasha/DaboAshukAter kickBesoBeso firfirBozeno ShiroChechebsaEnjera ShiroSigaSauce made of vegitable, lentils, pea powder, meat, chicken oretc without pepperLocal fermented breadSnack consisting of roasted and boiled beansSplit PeaMildly Roasted Barley flourMildly Roasted Barley flour mixed with butterRoasted Legumes powder sauce with MeatChopped bread with oil or butter with bit of pepperChopped Enjera mixed with any type of sauceKaleFermented dough pan cake“Split wheat/oats/barley”; snack consisting of wheat, butter, andsaltUnfermented breadSnack consisting of roasted cereals and legumesLocal name for “snacks”LentilSnack consisting of boiled cereals and legumesRoasted legumes powder sauceMeatvi

National Guidelines for HIV/AIDS and Nutrition in Ethiopia1. INTRODUCTION1.1 Objectives of the GuidelinesThe National Guidelines for HIV/AIDS and Nutrition in Ethiopia (hereafter referred toas the Guidelines) define the nutrition actions for service providers to take inproviding quality care and support to people living with HIV and AIDS (PLHIV) atsites that provide HIV counseling and testing (HCT), maternal and child health(MCH) care, antiretroviral therapy (ART), services for orphans and vulnerablechildren (OVC), and home-based care (HBC). The Guidelines seek to assist thevarious categories of people infected with and/or affected by HIV: adults, pregnantand lactating women, adolescents, severely malnourished adults and children, andpeople on medication.As more and more partners (e.g., ministries, donor agencies, non-governmentalorganizations [NGOs]) become involved in HIV and AIDS support, the Guidelines willalso provide a framework by which interventions can be harmonized across Ethiopia.Also, additional clinical guidelines and a training course will likely be developed fromthis document in the future.1.2. Commitment of Government and Coordination of PartnersThe Federal Democratic Republic of Ethiopia (FDRE) recognizes that HIV andmalnutrition exacerbate one another and conversely that adequate nutrition mayslow disease progression, increase the effectiveness of antiretroviral (ARV) andother drugs, and improve the overall quality of life. Though many advances in thefight against HIV have been made in Ethiopia, sufficient effort has not been put intopromoting adequate nutrition for PLHIV. The FDRE therefore sees a crucialopportunity to endorse nutrition care and support as a cost-effective strategy in themanagement of HIV/AIDS. Moreover the FMOH has developed and launched theNational Nutrition strategy and the National Nutrition Program (NNP) whicharticulated nutrition and HIV/AIDS as one of the components of the program. Theroles and responsibilities of different partners supporting the implementation of thenutrition and HIV/AIDS program is outlined in the National Implementation ReferenceManual on Nutrition and HIV/AIDS. This is the second edition of the Guidelines, fromthe first edition developed in 2006, with updates based on recent scientific andprogrammatic advances in the field of nutrition and HIV/AIDS.1.3. Target AudienceThe Guidelines are targeted to PLHIV service providers, which include counselors,health extension workers (HEWs), teachers and trainers, and policymakers. Theyare intended for practical application as well as policy formulation andimplementation.1

National Guidelines for HIV/AIDS and Nutrition in Ethiopia1.4. Overview of the GuidelinesThe Guidelines provide a standardized approach to nutrition care and support forPLHIV in diverse conditions in Ethiopia. Each service provider needs to adapt therecommendations to her/his context and client population.The Guidelines can be used to: Provide dietary counseling and nutrition care to people living with and/oraffected by HIVCreate messages and materials that advocate for adequate nutrition forPLHIV and othersDevelop more detailed and specific operational guidelines and materials forservice providers and PLHIVDesign monitoring and evaluation (M&E) systems for nutrition components ofHIV/AIDS programs and interventionsThe Guidelines are organized around “contact points”—locations where or timeswhen the population encounters health care providers and related professionals.Contact points are likewise organized around the following health services: HCT, ART, and/or HBCMCH and prevention of mother-to-child transmission of HIV (PMTCT)OVC care and supportKey counseling messages, instructions for assessing nutritional status, and actionsfor the provider to take are given for each contact point.The following inputs are strongly recommended in order to implement qualitynutrition care and support in each of the above contact points: Staff trained in nutrition care and supportCounseling cards, behavior change communication (BCC) materials, copiesof the Guidelines, referral cards, and MCH cardsScales, mid-upper arm circumference (MUAC) tapes, height meters, etcMultiple micronutrients and other routine micronutrient supplements (e.g.,vitamin A, iron/folic acid, zinc)Demonstration modelsFood supplementsThe Guidelines also include information about food security. Guidance is provided onmonitoring the impact of the Guidelines. Corresponding BCC materials—including acounseling card, body mass index (BMI) chart, posters, and leaflets for patients—arebeing developed and will be made available to provid