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

["Kaviiri Dentons" <kdentons@yahoo.co.uk>]

Dear Dr Robert Mwadime,

I must say thank you for your all round summary
of views and your guiding opinion. Nothing can be far
from the truth.

Best regards to you all.

Dentons


--- "Dr. Robert  Mwadime"  wrote:

> 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
>