Re: [pronut-hiv] Nutrition Care and support for PLWHA and OVCs:Kenya's experience (6)

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

Thanks Sadia,

Well put. We certainly do not want to re-invent the wheel. Just to share a
historical fact in the early 70's we had ship loads of Dried Skim Milk
(DSM). As much as INSTA is used as a stop gap measure in a household food
insecurity situation,  other parts of the world are thinking of  home
formulated therapeutic foods coupled with behaviour change communication
(BCC). Should  we not be doing the same? Of course obligations to funders
and project deadline must be met.  But we need to broaden the way we look at
HIV and Nutrition. We could start by asking a simple question.  What are the
ingredients  used to produce INSTA ?

If their nutritional value is known – why would facilitation  of access to a community specific diversified diet not make it possible for households to be shown a combination  of foods that would provide the same or even better nutrients that INSTA provides. 

Scaling up means you have evidence of its impact not only on increase in body weight (?) but on specific micronutrients as well ( Vit A, Zinc, Selenium, B vitamins ?). If this information is in the public domain ( publications ?),the next logical thing would be a clinical trial comparing INSTA and the community specific home based therapeutic formulations. This is an ideas that is being considered for infant complementary feeding why not for HIV?.


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

-----Christine Sadia wrote:
>
> Dear Brian,
>
> I think you misunderstood Grace. I agree that food may be available within
> communities, but easy of access which includes affordability must  be part
> of programming in a comprehensive care of  PLHIV.  I personally  do not
> agree  on your approach  that let the people who do manufacture go on with
> it. They can only manufacture what is acceptable to the user and has value
> from the care provider. Grace has a wealth of experience on applied
> nutrition.
>
> Dr. Christine Sadia
>
>
>
> ----- Brian Micino wrote:
>
> Hi Grace,
>
> Just to shed some light on these issue. It should be noted that we have at
> least 531 Comprehensive care centres (CCCs) in Kenya,  the USAID| Nutrition
> and HIV Program ( Formerly USAID Insta Products ltd) will by the 5th year be
> in 250 of these CCCs. The USAID|NHP will be programmed such that patients
> will have access to nutrition care, this will be through enhancing
> coordination between partners on the ground to make sure that those in need
> are catered for adequately and effectively.
>
> Developing a sustainable "home based therapeutic foods" will not increase
> access; this will be re-inventing the wheel. Therapeutic foods are
> available. What needs to happen is for partners to work together to ensure
> that patients receive the best care possible. This can be done by
> sensitizing the communities on Nutrition and HIV; this is the starting
> point.
>
> Let us leave the business of food manufacture to those who are licensed to
> do it.
>
> Thanks.
>
> Brian.
> ----- "Grace Ettyang"
>
>
> 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
> > >
> >
> >
> >
> >
>
>