Re: [pronut-hiv] Nutrition Care and support for PLWHA and OVCs: Countries'experiences

["Grace Ettyang" <gaettyang@gmail.com>]

Hi Everyone ,

Just a thought. What sample size will 250 facilities cover?. What about
those with no access to INSTA? Is anyone thinking/interested
 in developing sustainable *home based* therapeutic foods that could be
linked to family/community livelihoods?.

Grace
- 
Grace A. Keverenge-Ettyang (PhD)
Dept. of Epidemiology and Nutrition
School of Public Health
Moi University
P O Box 4606
ELDORET 30100
Kenya
Cell: +254-722-609257


------ Tadayo Hanna wrote:

> Hi Everyone
>
> Thanks John for sharing the experiences from Kisumu Kenya.
> Initially, the USAID /INSTA support was being carried out on a pilot basis
> in 63 facilities through out kenya from 2006.
>
> I wish to  let the team know that due to the successful outcomes  from the
> pilot phase, USAID has awarded the program another 5 years upto 2013 and to
> scale up to 250 facilities . This will be implemented by the USAID/Nutrition
> HIV Program in collaboration with NASCOP. (INSTA and AED) through private
> public partneship will continue with the support for the vulnerable groups
> incliding Pregnant and Post Partum clients, malnourished  PLHIV with BMI
> less than 18.5, children above 6months as well as the OVCs.
>
> The program will also enhance the health facility - community linkages.
> The Program was officially launched on 15th August 2008 during the National
> Nutrition Day by the Ministry of Medical Services - Kenya  and USAID with
> support from NASCOP and other stakeholders( UNICEF, WHO etc).
>
> To note about the program is the point of use water treatment provision for
> the beneficiaries and supplements from 6 months and over. This means that
> none of the food products are recomended for children below six months as
> per  the set guidelines. The water treatment not only supports those who use
> ERF as a feeding option but also  support clean safe water for all epecially
> PLHIV and the vulnerable. This will reduce water borne illnesses!
>
> All stakeholders need to join hands to support policies and guidelines
> towards better health of the population.
>
> Below is a segment of the message from one of  the Government of Kenya
> officials - Ministry of medical Services as quoted in  one  the  Kenyan
> Newspapers newspapers on the day of the launch. The theme was " Nutrition is
> essential for Management of HIV"
>
> "Key components of this program include capacity building of health care
> providers, provision of therapeutic and supplemental food to treat
> malnourished PLHWA and OVCs. The supplemental food is in the form of
> nutrient-dense fortified blended foods and the first locally produced and
> distributed Ready-to-Use-Therapeutic Food (RUTF). This program will support
> scaling up of operations from the current 63 health facilities to 250 health
> facilities by 2013.
>
> NASCOP will partner with the Academy for Educational Development (an
> International non profit development organization) and Insta Products
> Limited (a Kenyan –owned food manufacturing company). These organizations
> will partner in the scale-up. "
>
>
> HANNA C. TADAYO
> USAID/Nutrition and HIV Program (NHP)
> Academy for Educational Development (AED)
> htadayo@aed.org
>
> --- Okanda, John wrote:
>
> Hi everyone,
> Thanks Hanna for answering Bill's question on thoughts about ways that
> malnourishment among mothers enrolled in PMTCT is being remedied.
>
> I want to add that in Kisumu-Kenya, USAID/INSTA PRODUCTS provides food
> supplements and waterguard for HIV positive pregnant mothers throughout
> pregnancy and for the first 6 months postpartum. They also provide weaning
> supplements for babies from 6 months through to 2 years.
>
> In our PMTCT study, we have seen reduction in the number of mothers
> complaining
> of insufficient production of milk due to lack of food, reduction in mix
> feeding
> cases and increase in number of mothers complying with cessation of
> breastfeeding at 6 months.
>
> Waterguard (dilute, locally-produced sodium hypochlorite solution) is used
> for
> water treatment in the homes. This has helped mothers and kids to have
> clean and
> safe drinking water. We have seen a reduction in Diarrhea morbidity in our
> study.
>
> The supplements are also provided for Orphans or Vulnerable Children (OVC)
> and
> malnourished PLWHAs. Thanks to USAID/INSTA.
>
> John Okanda
> Nutritionist,
> CDC/KEMRI,
> HIV-Research,
> Kisumu, Kenya.
>
>
> -----Tadayo Hanna wrote:
>
> Hi All,
>
> Thanks you Bill and Dorcas for highlighting some very important issues.
>
> To respond to Bill's question on what is being done for malnourished
> pregnant and lactating women, in Kenya, some programs are actually
> providing
> supplemental food to the PMTCT pregnant women and upto 6 months post
> partum.
>
> However, from field assessments in response to Dorca's concern and
> suggestion for expressing BM  by mothers to continue EBF when they return
> back
> to work before 6 months are over, some mothers mentioned that they do not
> get
> adequate support from care givers who are left to take care of their
> infants.
> Afew mentioned that some care givers do not like to "deal with human
> milk" hence the challenge for some to continue EBF through expressing BM.
>
> Pre -service training and in -service training is going on in other places
> but
> the question still remains " does this knowledge translate into
> practise?"
>
> It is indeed important to utilize all approaches whether through care
> givers at
> health facilities as well as the community linkages to advocate for optimal
> nutritional practices for all especially the vulnerable, malnourished and
> PLHIV.
>
>
> HANNA C. TADAYO
> USAID/Nutrition and HIV Program (NHP)
> Academy for Educational Development (AED)- Kenya
>
> ---William F Wulsin  wrote:
>
> This discussion forum is most remarkable!
>
> Dorcas, Hanna and Kate have brought us full circle in recognizing that a
> comprehensive approach that strengthens, integrates and systematizes each
> of
> the
> components of PMTCT will likely improve outcomes with a more tightly woven
> net
> of support for mothers.  Consistent access to health services, clean water,
> usable information, reliable counseling, community, family and  workplace
> support and access to nutritious food ALL are needed for
> effective/optimal ERF and EBF.
>
> Sounds similar to the familiar refrain
> that we know too well calling out the need for widespread and
> equitable access to primary health related care.  Hopefully this
> dialogue can bolster each of our individual efforts to improve PMTCT
> components while not losing site of their contribution to the whole.
>
> I often wonder if one issue might underly the effectiveness for each
> of the others when addressing HIV prevention and care.  The issue that
> comes to mind is systemic population wide malnutrition. It is
> difficult to conceive of any element of PMTCT (or HIV care!) that is
> not seriously impeded by chronic malnutrition.  I do not mean to imply
> that we must emphasize relieving hunger at the expense of individual
> programs.  Perhaps though, our efforts to improve those PMTCT
> component programs such as counseling, education, consistent messages,
> access to care, transportation, product development and delivery,
> clean water etc. will be strengthened by linking them with programs
> that promote sustained access to nutritious food.  With persistent
> malnutrition our PMTCT and related infectious disease prevention
> efforts might be likened to attempting to fill a bucket riddled with
> holes.
>
> Any thoughts about ways that malnourishment among mothers enrolled in
> PMTCT is being remedied?
>
> Best regards,
>
> Bill
>
> William F. Wulsin, ND, MA, MPH
> 753 North 35th Street
> Suite 302
> Seattle Washington, 98103, USA
>
> 206 283-9139 FAX
> 206 679 8500 cell
> skype: drbillwulsin
>
> wfwulsin@u.washington.edu
>
> -- Dorcas Lwanga wrote:
>
> > Thank you Hanna
> > You bring up some very critical points.
> >
> > At a recent regional  training on Essential Nutrition Actions in the
> > Southern African region, we visited a few hospitals and had a chance
> > to
> > talk to and counsel HIV positive mothers who were bringing their
> > infants
> > for a well baby visit. A number of mothers indicated that the reason
> > they were not able to EBF is because they had to go back to work and
> > where not sure how they could continue to EBF the baby. One solution
> > is
> > to express the breast milk but this message was received with some
> > hesitation.
> >
> > At the same training  it was made very clear to us that the best
> > option
> > is and remains EBF.  Most of the clients we saw did not meet AFASS for
> > ERF.  Nonetheless we did observe that the messages given whilst the
> > mother was attending antenatal visits and also during postnatal were
> > well received and in line with WHO guidelines, however, a number of
> > the
> > mothers we saw were very young and it was obvious that even though
> > they
> > had made the decision to EBF and could explain the benefits of EBF and
> > what it mean't,  what happened at home was different because they
> > had no
> > bargaining power in the home on the feeding of the baby...hence there
> > was a lot of mixed feeding happening. One nurse did voice a concern
> > she
> > had over the number of infants that were dying.She attributed it to
> > mixed feeding despite the counselling provided.
> >
> > Reaching out to the community is very very critical step in making BF
> > safe. Commitment to strengthen community involvement and support for
> > BF
> > is necessary  to making BF safe.
> >
> > I do agree that we have to figure out how to advocate for increased
> > maternity leave as one of the solutions to help increase EBF for all
> > women. In line with this there needs to be more emphasis on training
> > health workers to counsel, train and support mothers, especially those
> > that have to return to work prior to 6 months, on how to express their
> > breast milk if that is an option, so that someone else can feed the
> > baby
> > and in that way ensure that EBF is maintained.
> >
> > In changing the attitude of the health care provider and counsellors
> > and ensuring that the messages used are clear,  there has to be a
> > greater emphasis on Pre-service training on BF and replacement
> > feeding.
> > A lot of training on BF is done in  in-service programs which is okay
> > but you are working to change an attitude that has been established
> > for
> > a while. Having a cadre of health workers coming out of training
> > institutions with the know how I believe will produce a much better
> > outcome.
> >
> > Furthermore, the training on Breast feeding and Replacement
> > feeding should be done at all levels/stages of the program and not
> > concentrated in the first, second, third or final year of study. Each
> > year should build on to the next. It maybe time to take a good look at
> > the training curricula at all levels/years of training for all the
> > different health cadre to ensure that the correct information and
> > messages on BF and replacement feeding are taught.
> >
> > cheers
> >
> > Dorcas
> >
> > Dorcas Lwanga MSc., RD
> > Nutritionist
> > Africa's Health in 2010 Project
> > Academy for Educational Development
> > 1825 Connecticut Ave. NW
> > Washington, DC 20009-5721 USA
> > Tel. (202) 884-8815
> > Fax. (202) 884-8447
> > When there's nothing left but God, that's when you know that God
> is
> > all
> > you need. Unknown
> > " Where love is there God is also"   Mahtma Gandhi
> >
> >
> >
> >>>> "Tadayo Hanna" wrote:
> >
> > Dear All,
> >
> > EBF has always been  and will always be the best option for feeding
> > infants because as we all know most of our clients in resource
> > challenged settings do not meet AFASS for ERF.
> >
> > How to strengthen EBF is by first changing the attitute of health Care
> > Providers  and counsellors who despite knowing EBF as the Gold
> > Standard
> > continue to recommend RF.
> >
> > Governments /programs and all stakeholders need to seriously consider
> > the type of counseling and training being passed on so that clear
> > messages reach the mothers/clients.
> >
> > Committment to  strengthen Reproductive health training   and
> > intergrate Infant feeding counseling at all levels of care ( FP
> > clinics,
> > MCH, PMTCT , CCC,Support groups etc) will go a long way in creating
> > awareness and supporting all clients  epecially those on ARVS to make
> > the proper choices for feeding their infants.
> >
> > Increasing maternity leave to accommodate all women to practice EBF
> > for
> > 6 months will also help as well as providing clients on ARVS with
> > adequate knowledge and support  for them to make informed decisions/
> > choices on how to feed their infants as per the set policies and
> > guidelines.
> >
> > Stigma continues to affect most of our clients who opt for ERF due to
> > cultural and other social related isues hence some clients practicing
> > mixed feeding.
> >
> > Disclosure and adherence counseling need to be strengthened and  be
> > made part and parcel of "compehensive management of HIV"
> >
> >
> > Hanna
> >
> >
> >
> > HANNA C. TADAYO
> > USAID/Nutrition and HIV Program (NHP)-Kenya
> > Academy for Educational Development( AED)
> >
> > --- Jean Tshiula wrote:
> >
> > Dear all,
> >
> > WHO recommendations 2006 say:
> >
> > "Feeding option for an HIV-infected mother depends on her individual
> > circumstances and local situation
> >
> > EBF is recommended for the first 6 months of life unless replacement
> > feeding is
> > AFASS
> >
> > When replacement feeding is AFASS avoidance of all breastfeeding by
> > HIV-infected mothers is recommended
> >
> > At 6 months if replacement feeding is still not AFASS  continuation of
> >
> > breastfeeding with additional complementary foods is recommended
> >
> > All HIV-infected mothers should receive counselling which includes
> > provision of
> > general information about risks and benefits of feeding options"
> >
> > It means that the first option is EBF unless if replacement feeding is
> >
> > AFASS! Therefore, the question will be how do we make BF safe.
> >
> > Jean Tshiula (AED/CAP SA)
> >
> >
> > -----
> >
> >> Dear Toumzghi,
> >>
> >> Do not feel guilty for your concern/question. You, like many workers
> > in
> >> the
> >> field, have a very relevant concern: "How do we make exclusive
> > replacement
> >> feeding (ERF)--which is actually only infant formula--safe?" In
> > fact,
> >> according to the spirit of the WHO recommendation, the first option
> > is
> >> "replacement feeds=infant formula" unless the mother (and
> her
> > family)
> >> cannot
> >> meet AFASS conditions, then exclusive breastfeeding (EBF) (until when
> >
> >> AFASS
> >> conditions are met). At all cost you and I would go for replacement
> >> feeding--since we could easily meet AFASS conditions with the right
> >> support.
> >>
> >> But what Silvia is saying is that "with the levels of poverty and
> > cultural
> >> environment in most of our countries, AFASS conditions are almost
> >> impossible
> >> for the majority of our clients" ...........Note also that EBF
> for 6
> >
> >> months
> >> has never been the easier option for the mother. It is difficult for
> > most
> >> of
> >> our clients (mixed feeding is the easier option). BUT EBF is the
> > safest
> >> option when you actually start to think about a baby born to a HIV+
> > woman.
> >>
> >> Maybe we need to segment clients to those a) among whom we support to
> > make
> >> EBF safer and possible, and b) among whom we support to make ERF
> > safer and
> >> possible. We have done a lot on making EBF safe BUT very little in
> > sought
> >> for ways to support families meet the AFASS conditions: Clean water?
> >> Sanitation/hygiene education? Free formula? Family planning? Or is
> > it
> >> through other innovation(s) we have not as yet identified?
> >>
> >>
> >> Robert Mwadime (FANTA)
> >
> >>
> >> -----Toumzghi sengal
> >>
> >> May be I was too concerned about the children ( to consider it a
> > crime) to
> >> go through the process of getting infected after birth. And 3 to 4
> > years
> >> down the road we tell the care givers how the child got it. Any body
> > ready
> >> to sue??? will they understand the logic why it   seems the easiest
> >> solution
> >> to take the breastfeeding route.
> >>
> >> Toumzghi
> >>
> >> ------Sylvia magezi  wrote:
> >>>
> >>> Dear Readers,
> >>>
> >>> I think it is easy to think breastfeeding an HIV positive baby a
> > crime,
> >>> if
> >>> you have not seen mothers struggling not to breastfeed a
> > malnourished
> >> infant
> >>> and giving the baby diluted milk that does not adequately give the
> > infant
> >>> the nourishment she needs.
> >>>
> >>> I once studied feeding characteristics of infants in a PMTCT ward
> > in
> >>> Kampala and saw several mothers that had decided not to breastfeed
> > but
> >> could
> >>> not afford infant formula and their infants were malnourished.  I
> >>> wondered
> >>> what kind of future they had.  The mothers were very stressed
> > trying
> > to
> >> feed
> >>> them and the babies either rejected the milk or had stomach
> upsets.
> >
> > The
> >>> reality is people are very poor, cannot afford infant formula yet
> > they
> >> still
> >>> give birth.  They are forced to have children for reasons you
> > cannot
> >>> control, the men believe that with anti retroviral therapy they
> > should
> >>> continue having children and mothers have to comply. Sanitation in
> > many
> >>> places is poor and the numbers dying of diarrhoea are very high.
> > So
> >> health
> >>> workers are forced to make those decisions. What would you
> > recommend
> > in
> >> such
> >>> a scenario?
> >>>
> >>>
> >>> Sylvia Magezi
> >
>
>
>
>



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