RE: [pronut-hiv] Topic 1: Promising Approaches in Nutrition-HIV Integration

["Dr. Robert Mwadime" <rmwadime@rcqhc.org>]

Friends

It was a pleasure last week to have the discussions on guidelines. Many
wonderful responses; Many of which you have seen and some you have not. Two
of you have written to me directly (want to remain anonymous), expressing
frustrations in your governments on the way guidelines were developed or are
being disseminated. Six people (interestingly 3 from the same country) want
this discussion documented and recommendations made to senior government
persons. One person from the beautiful land of Mozambique send (very useful
related) materials to my private mail. One person send me a private message
in French (I have since had it summarized). Whatever the case the discussion
on guidelines is coming to an end; we start on some other issue on
integration this week. Let me summarize the issues so far...I pretend NOT to
be the expert.

Summary of the Discussion

I. We have seen that we need guidelines on nutrition and HIV. However,
while most countries have developed separate guidelines on the issue, this
is not always necessary. We can adapt existing guidelines and policies
related to aspects of care, e.g. guidelines on IMCI, ART, PMTCT, management
of acute malnutrition, etc. to reflect key technical and operational issues
on nutrition and HIV. As we talk most countries in the region (Ethiopia,
Kenya, Uganda, Tanzania, Rwanda, Zambia, Namibia, RSA, Zimbabwe, Lesotho,
Botswana) have separate guidelines, BUT Malawi has integrate the nutrition
and HIV aspects into existing guidelines.

As Ndosi, Hana and Alice indicated, the process of development of guidelines and the mandate of the institution doing so, is as important as the product. YES Hana made it clear that there is need for a forum or a mechanism to ensure that we can question the content and discuss lessons in the operationalization of the guidelines.

Governments in Kenya and Ethiopia (and soon in Zambia) have a mechanism (a
technical working on nutrition and HIV) where stakeholders report on the
operationlization of the guidelines but also discuss coordination issues. To
answer my sister Stella, some countries did have a situational assessment
before writing their guidelines (Kenya was one of them---see report by Faith
Thuita in fantaproject.org); other countries had very elaborate national
consultative process (RSA, Ethiopia, Rwanda, Tanzania). Others
adapted/adopted existing guidelines with a lot of national (or external)
reviews. Most countries are however doing assessments (and formative
reviews) in the process of development of BCC/IEC materials.


II. Guidelines by themselves are not enough, service providers need
training, the content of the guidelines, and the support to implement the
guidelines are paramount. In 2005 Uganda's Paul Orikushaba did an assessment
on the use of national guidelines 18-24 months after dissemination of
guidelines in the country (MSc thesis). He reported that, while facilities
had the guidelines, few of the service providers had read the guidelines or
used them (similar detriments have been expressed in this
discussion).Service providers need orientation on the use of the guidelines.
As Alice, Stella and others have shown this can be done through pre-service
(working to change curriculum---done in Uganda, Kenya, Malawi? And RSA) or
systematic coordinated training of different cadres of health workers (Hana
explained this for Kenya). Fanice and others still think that the "casketed
training" Hana talks about has not reached many. Government resources cannot
be expected to reach the scale needed to feel the impact of the guidelines
(as put well by Titus). Development partners MUST support the dissemination
of guidelines (through orientation of health workers) if accelerated
integration is to be realized (Titus, Fanice). However, Paul in his study
observed that knowledge was not associated to implementation of the
guidelines..YES training was key in "creating interest" but as also
expressed in the discussions this week, availability of nutritional
assessment equipment, demand for the service by supervisors (surprisingly
not patients) were the key drivers. Therefore, as Hana puts it, "senior
government officials (the director general/permanent secretary of health,
for example) MUST make a policy statement: making nutritional care and
support a mandatory component of care for people with HIV. Supervisors must
ask questions and M&E teams must seek for the data. Then clinical staff will
be supportive and do the activities. Malawi and Kenya have succeeded in
implementing national nutritional programs because the country's' leadership
have promoted nutrition in HIV management by establishing a favorable
policy. In addition, the care/treatment delivery systems have to be
modified/reviewed in order to accommodate nutritional care, e.g. the client
flow, the data collection tools and the reporting systems must accommodate
nutrition (Charlotte; private communication). MANY TIMES where the nutrition
cadre is not well established there must be someone(or people) in the flow
of clients mandated to provide the various nutritional care and support
activities (Margaret Benjamin). We can't leave the responsibility of
nutritional assessment, counseling/education (which might include
demonstrations), prescription for food supplements (where these are
available), etc to NO BODY or TO EVERYBODY because no one will do it. Where
there are no nutritionists/dieticians, NO one likes doing nutrition work.
Someone must be given that responsibility!!! 

III. The Operationalization of the technical content (see attachment to
see the internationally agreed technical knowledge/guidelines): JeanT in RSA
asked how to operationalize these recommendations. Clearly only "field
experts" working with PLHIV can answer this question. Many countries have
developed counseling materials (counseling cards; posters; brochures) that
translate these recommendations to local recipes or equivalents. In Kenya
and Uganda for instance, they say "a cup of porridge made of maize/millet
flour and enriched with sugar and/or margarine taken as a snack between
meals will provide an equivalent (approximately) of the 10% additional
energy needed by asymptomatic PLHIV. Ethiopia instead just gives examples of
snacks commonly eaten that would provide equivalent amount of energy. The
recommendation on micronutrient is based on consuming variety of foods in
ones diet, deworming, and supplementation only if indicated to be deficit or
at the risk of deficiency. Some countries (e.g. Namibia) provide a
multivitamin supplement to all PLHIV. Most food supplements are fortified
and they (together with diversified family diets) would be sufficient to
provide the needed micronutrients for the period one is taking them.

IV. Uniformity among the partners/programs is facilitated through task
groups on nutrition and HIV (as in Kenya and Zambia) or through sharing of
promising practices in the use of the guidelines. Supervision and quality
assurance of programs implemented by different partners by the lead
government department would also go a long way to ensure uniformity in
observing the guidelines. Guidelines are not mandatory but just, as the name
goes, "guidelines". 

V. Are there indicators to monitor implementation of guidelines? Yes.
Most guidelines (Uganda, Kenya, Ethiopia, Tanzania, etc) provide the
indicators for monitoring access and use of guidelines, but also changes in
behavior and nutritional outcomes expected from use of the guidelines. Few
countries have actually done assessments on use of guidelines. WE SHALL BE
DISCUSSING THESE ON THE FINAL WEEK OF THIS DISCUSSIONS. (we shall respond on
the indicator question later----there are good materials on the way!!!)

Keep well and let us continue to bless each other with our experiences and
knowledge.

Robert Mwadime (Ph.D).