Already, according to Hammond, the implementation of two programme approaches to treating acute malnutrition in countries with high HIV prevalence: ‘Food by Prescription’ (FBP) and Community-based Management of Acute Malnutrition (CMAM), “being initiated simultaneously in many countries, is causing a lot of confusion - and in many cases at ministry level - about the differences between these two programmes because they are so similar. They have similar aims and they use similar methods.”
FBP includes nutrition assessment and counselling, provision of micronutrient supplements, point-of-use water purification means and specialised foods prescribed as part of clinic-based HIV services according to clinic entry and discharge or ‘graduation’ criteria. It is different from food assistance programmes such as that offered by the World Food Programme, because it integrates food and nutrition interventions into clinical HIV health services to improve ART adherence and outcomes.
The specialised foods for FBP include Ready to Use Therapeutic Foods (RUTF) and fortified blended foods, or FBFs, which are both meant to be eaten in addition to the normal diet for children and adults at risk of malnutrition.
The most common RUTF used is PlumpyNut a fortified peanut butter paste which is being produced locally in countries such as Zambia, Malawi and Kenya. (Another presentation at the conference on the use of PlumpyNut in malnourished Ugandan children with HIV reported greatly improved nutritional status, with 78/85 (92%) of the malnourished children reaching the 90% UNICEF weights/heights appropriate for their gender (Aweko). Research is being done on other RUTFs such as soy-based RUTFs for regions that are not used to eating peanut-based foods such as South-East Asia.
The FBFs are cereals fortified with micronutrients and sometimes other ingredients such as soya, beans, pulses, oil seeds and dried skimmed milk. These include corn soy blends and wheat soy blends that are mixed with water and cooked as a porridge. On average, FBFs are about five times cheaper than RUTFs, and for that reason the programme has tried to maximise their use and reserve the RUTFs for the more severe malnourished clients.
At the same time that PEPFAR-supported countries are poised to implement FBP, many are also rolling out CMAM, based upon the WHO treatment protocol to manage severe acute malnutrition (SAM) in children 6-59 months old in outpatient or inpatient care depending on the presence of medical complications.
The two approaches have different objectives:
Food by Prescription
- Manage severe acute malnutrition and moderate acute malnutrition in PLHIV, OVC, and paediatric AIDS clients
- Provides supplemental feeding based on nutritional vulnerability, particularly for early weened infants up to two years old and HIV-positive women during pregnancy and lactation.
- Strengthen clinical HIV care and treatment, or rather, ART adherence and effectiveness and the survival of people living with HIV
Community-based Management of Acute Malnutrition
- Manage severe and acute malnutrition in children regardless of HIV status
- CMAM provides specialised foods, RUTF, only for children who are already identified as severely malnourished, or malnourished.
- Identify severe acute malnutrition in the community for early initiation of treatment
However, the programmes are complementary and share a number of things in common including treating severe or moderate acute malnutrition; both treat most cases on an out-patient basis and give them the food to take home; both use RUTF (which should be locally produced); both emphasise capacity and nutritional assessment, counseling, treatment, prevention and classification; both integrate nutrition assessment and counseling into existing health services; and Hammond stressed:
“Both ideally - although this is usually the last component to be developed - refer rehabilitation clients to livelihood assistance programs, or income generation programs, to prevent them relapsing into malnutrition,” she said.
To better coordinate the two approaches, there is a call to harmonise guidelines for managing SAM at the global and country levels (admission and discharge criteria, registers/monitoring and reporting tools, and service aspects such as counselling/education messages and job aids and tools and community outreach to refer malnourished children to therapeutic feeding and also to HIV counselling and testing). “Targeting can be coordinated to maximise coverage in countries for example where CMAM addresses children and FBP can then take care of the adults,” said Hammond.
Commodity procurement/management and distribution should also be harmonized, according to Hammond, which could simplify procedures for food procurement, storage, management, and distribution.
Coordination at this level is often quite difficult though. Food by Prescription and Community-based Management of Acute Malnutrition are usually under different ministry directorates or divisions and may run parallel to routine nutrition services), and supported by different donors/funding mechanisms (usually CMAM by UNICEF and FBP by PEPFAR) with different data collection systems for monitoring and reporting demands).
But, Hammond reiterated — the food should only be part of the programme. Unfortunately, “the food tends to overshadow the other elements, especially the nutritional assessment and counselling. In every country, when we start discussing initiating such a programme, the first thing that ministries are interested in - and sometimes missions - is ‘What foods are we going to use?’ ‘How are we going to procure them?’ ‘Who’s going to distribute them?’ when the nutritional assessment, counselling and training hasn’t even been contemplated. This is a real challenge,” she said.