food assistance in the context of hiv: ration design guide · i < food assistance in the context...

FoodAssistanceintheContextofHIV:RationDesignGuide>i

FoodAssistanceintheContextofHIV:

RationDesignGuide

July2008

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FoodAssistanceintheContextofHIV:

RationDesignGuide

i <FoodAssistanceintheContextofHIV:RationDesignGuide

TableofContents

Table of Contents ii

Acknowledgements iii

Acronyms iv

At a Glance 1

Introduction 2

Section 1: Food, Nutrition and HIV 5NutritionalrequirementsofpeoplelivingwithHIV....................................5

Sub-populationsaffectedbyHIVandAIDSthatcouldbetargetedthroughWFP’sprogrammes......................................8

Section 2: Ration Design–the Five Steps 15Step 1:Reviewthenutritionandfoodsecuritysituationofthetargetedpopulation......................................................15

Step 2:Reviewtheobjectivesoftheprogrammeandtheroleoftheration.....................................................................17

Step 3:Determinehowmuchfoodneedstobeprovidedandforhowlong...................................................................20

Step 4:Selectthemostappropriatefoodcommoditiesandtypeofrations..........................................................23

Step 5:Consideractivitiestoputinplacetoenhancetheproperuseofthefoodration............................................28

Section 3: Monitoring the Ration and Operational Considerations 31Monitoring.........................................................................................31

Operationalconsiderations..................................................................32

FoodAssistanceintheContextofHIV:RationDesignGuide>ii

Section 4: Food Aid Commodities 37Cereals..............................................................................................37

Pulses...............................................................................................37

Oil.....................................................................................................38

Fortifiedblendedfoods.......................................................................39

Sugar/salt..........................................................................................39

Animalproducts.................................................................................40

Driedskimmedmilk............................................................................41

Ready-to-UseTherapeuticFood...........................................................41

Micronutrientpowders........................................................................42

Breastmilksubstitute..........................................................................42

Otherspecializedproducts..................................................................43

Section 5: Examples of Ration Design Process 45HypotheticalCase:FoodAssistanceinResponsetoDroughtandConflictin‘Gotongo’.....................................45

Exercise1:RationdesignforPLHIVinIDPcamps.................................47

Exercise2:RationdesignforOVCinSouthernProvince........................49

References 52

iii <FoodAssistanceintheContextofHIV:RationDesignGuide

Acknowledgements

This guide was developed through extensive consultations with many WFPcolleaguesbasedinthefieldandinHeadquarters,whomwewishtothankfortheirvaluablecontributions.WewouldliketosingleoutthespecialcontributionsofFrancescaErdelmann(currentlywithWFPMozambique),whodevelopedtheearly draft of this guide, which was later restructured and retooled into thepresentguidethankstopainstakingworkbyWillyMpoyiwaMpoyi(HIVandAIDSService)andAndrewThorne-Lyman (NutritionService),whoalsocoordinatedandmanagedtheguidedevelopmentprocess.

Special thanks go to the following colleagues who provided specific input:JohnSsemakalu(WFPUganda),NeilBrandenandSimonSadler(WFPBangkokRegional Bureau), Thobias Bergmann, Laurence Bequet and Mary Njoroge(PDPH),SibiLawsonandKebbyMutale(WFPZambia),andOlivierNkakudulu(WFPDakarRegionalBureau).

Wewould like to thankDelphinDiasoluaNgudi (UniversityofGent,Belgium),who reviewed the draft and incorporated the substantive comments fromvariouscolleagues.

We would also like to thank Robin Landis for her sound advice and BrettShapiro,oureditorialconsultant,forhisefficientworkineditingandformattingthisguide.

Finally,wearethankfultoRobinJacksonandMartinBloem,respectivelyformerChief, and current Chief of the HIV andAIDS Service, for their support andleadership.

FoodAssistanceintheContextofHIV:RationDesignGuide>iv

Acronyms

ART Anti-retroviraltherapyARVs Anti-retroviraldrugsCDC USCentersforDiseaseControlandPreventionCSB corn-soyablendDOTS DirectlyObservedTreatment,short-courseDSM driedskimmilkEDP extendeddistributionpointFBF fortifiedblendedfoodFDP finaldistributionpointFFW foodforworkGFD GeneralFoodDistributionHBC home-basedcareIDP internally-displacedpersonLIFD low-incomefood-deficitMNP micronutrientpowdersODOC OtherDirectOperationalCostOVC orphansandothervulnerablechildrenPDPH HIVandAIDSServiceinWFPHeadquartersPLHIV peoplelivingwithHIVPMTCT preventionofmother-to-childtransmissionPRRO protractedreliefandrecoveryoperationRDA RecommendedDailyAllowanceRTUF ready-to-usefoodRUTF ready-to-usetherapeuticfoodTB tuberculosisTFD targetedfooddistributionWHO WorldHealthOrganizationWSB wheat-soyablend

1 <FoodAssistanceintheContextofHIV:RationDesignGuide

At a Glance

1. Mostofthecoreprinciplesofnutritionandrationplanningforpeopleliving

withHIVarethesameastheyareforpeoplewhoareuninfectedbythevirus.

2. Abalanced,healthydietthatprovidesforadequateintakeofenergy,protein,

fatandmicronutrientsisessentialforthehealthandsurvivalofallpeople,

regardlessofHIVstatus.

3. Auniversallyapplicable“HIVration”doesnotexist.

4. HIVbyitselfdoesnotmeanthatpeoplearefoodinsecure.Thefoodsecurity

assessmentdataofpotentialbeneficiariesmustbereviewedaspartofthe

rationdesignprocess.

5.The World Health Organization (WHO) recommends increasing energy

requirementsby10percenttomaintainbodyweightandphysicalactivity

inasymptomaticHIV-infectedadultsandgrowthinasymptomaticHIV-infected

children.ForsymptomaticHIV,energyrequirementsincreaseby20-30percent

foradultsandby50-100percentforchildrenexperiencingweightloss.

6. Unlesspotentialbeneficiariesaretotallydependentonfoodassistancefor

survival,thefoodprovidedshouldserveasanutritionalsupplementand/or

foodsecuritysupportthatcomplementsthebeneficiary’sdiet.

7. WhereWFPprovidesstaplefoodstopopulationswithhighHIVprevalence,

thesestaplefoodsshouldbemilledandfortifiedwherepossibletoprevent

micronutrientdeficiencies.

8. The food provided by WFP should be complemented with fresh foods

whereverpossible.

9. NutritioneducationshouldbeanessentialcomponentofHIV-relatedactivities,

as itcanhelpbeneficiariesdealwithsymptomsof thevirus,manageside

effectsofmedication,andpreventadversenutrient-medicineinteractions.

FoodAssistanceintheContextofHIV:RationDesignGuide>2

Introduction

“We’restartinganewactivityrelatedtoHIV… WhatrationshouldIgive?”

ThisquestionisoneofthemostfrequentlyaskedquestionsposedtotheNutritionandHIV/AIDSServicesinWFPheadquarters.PlanningafoodrationforapopulationthatisaffectedorinfectedbyHIVcanoftenbedaunting.StudiesofnutritionandHIVarerelativelynew,asarefood-basedprogrammesthataimtorespondtotheHIVpandemic.ThereislittleguidancetohelpplanrationsfortargetedfoodandnutritionactivitiesaimedatsupportingthecareandtreatmentofpeoplelivingwithHIV,orforpopulationsmadevulnerablebythepandemic.

This guide was developed to help ensure that the rations provided throughWFP’sprogrammesaredesignedthroughaprocess thatconsiders theneedsofthe beneficiaries as well as the practical concerns that dictate the feasibility ofimplementingprogrammes.Itisimportanttorememberthatplanningrationsisonlypartofalargerprocessofprogrammedesign.

This guide has been prepared primarily for WFP programme officers in thefield who are responsible for designing rations for HIV programmes. The guidewill also be helpful to other agencies, including WFP co-operating partners,to help them understand the rationale behind different WFP rations and tostrengthenpartnership.

Theguideisdividedintofivesections.Section1discussestheneedsofpopulationsaffectedbyHIVandtheirrelevancetoWFPprogramming.Section2presentsthestepstodesigningfoodrationsthat take intoaccount theHIVcontext.UsersareadvisedtofamiliarizethemselveswiththefivestepsdescribedinthissectionandapplythemtodesignrationsfortheirHIV-assistedprogrammes.Section3discussesoperationalconsiderationsofplanningandprovidingfoodrationsinanHIVcontext.Section4discussesfoodaidcommoditiesandsection5providesexamplesoftherationdesignprocess.Referencesandhyperlinksaregiventoprovideuserswithfurtherreadingmaterialsonthesubject.


Section1:Food,NutritionandHIV

Section 1: Food, Nutrition and HIV


Section1:Food,NutritionandHIV

Nutritional requirements of people living with HIV

“Adequatenutrition,whichisbestachievedthroughconsumptionofabalanced

healthydiet,isvitalforhealthandsurvivalofallindividualsregardlessofHIVstatus.”

–WHONutrientRequirementsforPeopleLivingwithHIV(PLHIV)

ScientificknowledgeaboutthespecificnutritionalrequirementsofPLHIVremainslimited,despiteamarked increase in thenumberofscientificstudiesconductedin recent years.2; 3; 4The table below presents the main conclusions of aWHOtechnical assistance group meeting convened in 2003 to examine the scientific

evidencebaseofnutritionalrequirementsforPLHIV.

Box 1: Macronutrient requirements of PLHIV

Nutrient Population Group Recommendation*

Energy AsymptomaticHIV+adults Increaseof~10%

AdultswithsymptomaticHIVinfectionorAIDS(includingpregnant/lactatingwomen)

Increaseof~20-30%

AsymptomaticHIV+children Increaseof~10%

Childrenexperiencingweightloss(regardlessofHIVstatus)

Increaseof~50-100%

Childrenwithsevereacutemalnutrition NochangefromWHOguidelines

Protein Allpopulationgroups Nochangeindicatedtodate(10-12%oftotalenergyintake)

Fat IndividualswhoareHIV-orHIV+butnottakingantiretroviraldrugs

Nochangeindicatedtodate(atleast17%oftotalenergyintake)

*ComparedwithnormaldietaryrequirementsfromWHO.Sources:WorldHealthOrganization(WHO).“NutrientrequirementsforPLHIV.”Geneva:WHO,2003;

WHO.“Executivesummaryofascientificreview.ConsultationonnutritionandHIV/AIDSinAfrica:evidence,lessonsandrecommendationsforaction”.Durban,SouthAfrica10–13April2005.WHO,Geneva,2005


Asnotedinthetable,thereisa10percentincreaseintheamountofenergyneededbypeoplelivingwithHIVwhohavenotyetbegunexperiencingsymptoms.Energyneedsincreaseby20-30percentforadultsdevelopingsymptomsandby50-100percentforchildrenexperiencingweightloss.Fromanutritionalperspective,havingadequateenergy intake (alongwithadequate intakeof cleanwater) is themostessentialthingthatPLHIVcandotomaintaintheirhealthandweight,andtoengagein normal activities.Although a lack of appetite and the symptomsof infections(suchasmouthsores)maymakeitdifficulttoeat,itisimportanttoincreaseenergyintakeoncenormalappetitehas returnedduring the recoveryphase fromacuteinfection.Currentevidence is insufficient to recommend increasedproteinor fatrequirementsduetoHIVinfection,althoughincreasingfoodconsumptiontomeetenergyneedsimpliesaproportionalincreaseinproteinandfatintake.

Vitaminsandminerals(micronutrients)arevitalforallpeople,butareparticularlyessential for people with compromised immune systems. At the same time,micronutrientdeficienciesareverycommonamongPLHIV.RecentrecommendationsbyWHOconcerningintakeofmicronutrientsareprovidedinBox2.

Box 2: Micronutrient requirements of PLHIV

“HIV-infected adults and children should consume diets that ensure

micronutrient intakes at RDA levels. However, this may not be sufficient to

correctnutritionaldeficiencies inHIV-infected individuals…Safeupper limits

fordailymicronutrientintakesforPLHIVstillneedtobeestablished.”

Food insecurity and dietary diversity

LackofdietarydiversityisoneofthemainnutritionalchallengesfacedbypopulationsinthecountrieswhereWFPoperates.(Forexample,insub-SaharanAfrica,70-80percentofenergyconsumedcomesfromstaplesandtubers.)Thislackofdietarydiversityisamajorcauseoffoodinsecurityandmicronutrientdeficienciesingeneral,butmoresoforhouseholdsinwhichchronicillnesshasledtopovertyandchangesinagriculturalpractices.5BecauseHIVinfectionusuallyimpactsfoodconsumption


andutilization,itfurtherincreasestheriskofmicronutrientdeficiencies.Therefore,itisextremelyimportanttostrivetoensurethatbasicmicronutrientneedsaremet–throughadiversediet,fortifiedfoodsormicronutrientsupplements.

HIV and AIDS symptoms, opportunistic infections, and their effect on food consumption, absorption and nutritional status

AdvancedformsofHIVinfectionandAIDS,aswellasmedicaltreatmentitself,areoftenaccompaniedbyvarioussymptomsthatinterferewithfoodconsumptionandutilization,bothofwhichoftenleadto“wasting”.Wasting–thethinnessassociatedwith lossofbodyweight– isoneof themajorsymptomsofAIDS.6;7AIDS-related“wastingsyndrome”isdefinedbytheUSCentersforDiseaseControlandPrevention(CDC)8asa10percentweightlossfrombaselineinasix-monthperiodaccompaniedbydiarrhoeaorfeverformorethan30dayswithoutaknowncause.

TypicalsymptomsexperiencedbyPLHIVareshownintheboxthatfollows.9

Box 3: Symptoms commonly experienced by PLHIVDiarrhoeaDiarrhoeaisaproblemformanyPLHIV;itleadstolossofwaterandminerals

fromthebody.Inseverecases,diarrhoeacausesdehydration,poorabsorption

of food, significant weight loss and malnutrition, resulting in weakness and

furtherillness.

Lack of appetitePoorappetiteisoneofthemostcommonproblemsamongPLHIV.Itcanhave

manycauses,includinginfections,pain(particularlyinthemouthorabdomen),

depression,anxiety,fatigueorpoornutritionalintake.

Nausea and vomitingNausea reduces appetite and can be caused by certain foods, hunger,

infections,stressandlackofwater.Itcanalsobeaside-effectofmedicines.


Ifvomitingoccurs, thebodywill losewaterandmineralsandwilldehydrate

evenmorequickly.

Sore mouth or painful eatingSorenessof themouthand tongue iscommonamongPLHIV.Asmentioned

above,asoremouthcanmakeitdifficulttoeat,thusreducingfoodintake.

Digestive problemsPLHIVmayhaveproblemsdigestingcertainfoodsormaysufferfromconsti-

pationandbloating.Theseproblemsarecausedbydamageto thenaturally

occurring bacteria in the intestine, which are needed to digest food.

Thebacteriamaybedestroyedbyantibioticsorothermedicines.

Changes in taste of foodAsaresultofdrugside-effectsandinfections,peoplemayfindthattasteor

textureoffoodshaschangedfortheworse,thusdiminishingtheirappetite.

It is typical for PLHIV to experience repeated opportunistic infections (such aspneumonia,tuberculosis(TB)andcanceroustumors)contributingtomalnutrition.EffectivetreatmentofHIVinfectionorAIDSinvolvescarefulmonitoringandnutritionalmanagementoftheseconditions.VariousrecommendationshavebeendevelopedtohelphealthcarepractitionersimpartknowledgethatcanhelpfamilymembersandPLHIVmanagesymptoms.10;11Theserecommendationsarerelatedtothetypeoffoodstoconsume,fluidintake,mealfrequencyandsize,rest,andotherpracticesthatcanhelptodealwiththesymptoms.

Sub-populations affected by HIV and AIDS that could be targeted through WFP’s programmes

WFPprovides foodassistance to an array of beneficiaries that include refugeesand displaced persons during emergencies, vulnerable populations (such asmalnourishedchildrenorpregnantandlactatingwomen)toimprovenutritionandhealth,andspecificpopulationgroupstohelpthemrebuildtheirassetsandpromote


theirfoodsecurity.WFPfoodassistancealsotargetschildrenthroughschoolfeedingprogrammes.PopulationsinfectedoraffectedbyHIVshouldbeconsideredforWFPassistance if theyaremalnourishedor food insecure,provided thatall theotherlogisticalconsiderationsforfoodprocurementanddistributionaremet.

Persons on anti-retroviral treatment

“Adequatenutritionisrequiredtooptimizethebenefitsofantiretroviraldrugs

(ARVs),whichareessentialtoprolonglivesofHIV-infectedpeopleandprevent

HIVtransmissionfrommothertochild.”

–WHOParticipants’Statement,DurbanConsultation,2005

Anti-retroviral therapy (ART)consistsof theconsumptionofspecificmedicationsto reduce the replicationofHIV.Someanti-retroviraldrugs (ARVs)affectnutrientutilization throughchanges inmetabolism,distribution,excretion,andabsorptionof nutrients. Therefore, ART is a process of drug and nutrition management –monitoringweightchanges,CD4countandsideeffects,andadjustingtheregimetostabilizethepatient.Therearealsoknowninteractionsbetweencertainfoodsanddrugsthathavebeensummarizedinotherpublications.12

PeoplegoingontoARToftensufferfrommalnutrition–theresultofopportunisticinfections, metabolic changes, and often household food insecurity. Focusednutritioninterventionscan“transformthepreventionandmanagementofHIV/AIDSandhelpgetthehealthofchildrenandadults‘backontrack.’”13

Orphans and vulnerable children affected by HIV

TheimpactoftheHIVepidemiconchildreniswidelyacknowledged.Worldwide,14millionchildrenundertheageof15havelostoneorbothparentstoAIDS.By2010,this number is expected to exceed25million.There is thus a growing concernaboutcareandsupportoforphansandothervulnerablechildren(OVC).

It isgenerallypreferable toplaceorphansorunaccompaniedchildrenwith localfamiliesratherthanwithorphanages.Butcaringforanadditionalchildcanbecome


aburdenwhenthefosteringfamilyispoor,orisheadedbyanelderlyorillperson

who is food insecure.Asupplementary rationcanease theburdenofcaring for

thesechildrenandenablemorefamiliestotakethemin.

OVCexpertsbelievethattraditionalriskfactorsforchildmalnutritionamongnon-

HIVinfectedchildren,suchasinsufficientintakeofqualityfoodsanddiarrhea,are

alsomajorcontributorstopoorgrowthinHIV-infectedchildren.

Based on current evidence in malnourished HIV-infected children who are not

receivingART,energysupplementationaloneappearstoimproveweightgainbut

nottoreversedeficitsinheight.14

ThereisevidencefromMalawithatseverelymalnourishedchildrenwhoareHIV-

positiverespondwelltotherapeuticcarethatmakeuseofreadytoeatfoods.15

MuchisstilltobelearnedaboutthenutritionalimplicationsofARTonchildren.Like

adults, children with HIV/AIDS often experience wasting syndrome and frequent

infections. Unlike adults, the additional nutritional demands associated with

growthmeanthattheeffectsofHIV/AIDSareoftenmoredevastatingforchildren

thanadults.

Children born to HIV-infected mothers

In resource-poor settings, theoverall riskofmother-to-child transmissionofHIV

is 15-25 percent in non-breastfeeding populations and 20-45 percent in breast-

feedingpopulations.16;17

InthelatestguidelinesfromWHOonpreventionofmother-to-childtransmissionof

HIV,“HIV-infectedwomen,includingthoseonART,areadvisedtooptforexclusive

breastfeedingasopposedto‘mixedfeeding’withbottle-feeding,waterorformula

feeding.HIV-infectedwomenshouldavoidbreastfeedingonlyifreplacementfeeding

isacceptable,feasible,affordable,sustainableandsafe.”18Currentprotocolsalso

recommendearlycessationofbreastfeeding(atsixmonths)inordertoreducerisk

oftransmission.


Earlycessationofbreastfeedingpresentsasignificantnutritionalchallengetoyoungchildren,asbreastmilknormallyprovidesabouthalfoftheenergyconsumedbychildrenaged6-11months.Thelossofanimportantsourceofadditionalprotein,fats,mineralsandvitaminscanhaveserioushealthandnutritionalconsequences.

Pregnant and lactating women

Nutritionalrequirementsincreaseduringpregnancyandlactation,independentofHIVstatus.AnecdotalevidenceshowsthatpregnantwomenwhoareHIV-positivetendtobeintheearlystagesofHIVinfection,andthereforetendnottosufferextensivelyfromopportunisticinfections.LowbirthweightiscommonamongchildrenborntoHIV-infectedmothersandinaddition,thesechildrenoftensufferfrompoorgrowth.IrrespectiveofHIVstatus,targetedfoodassistancehasthepotentialtosignificantlyimprovethenutritionandfoodsecuritysituationofpregnantandlactatingmothersandtheirhouseholdmembers,especiallyinfantsandyoungchildren.

People supported through home-based care

According to WHO, home-based care (HBC) is the provision of comprehensiveservices(includinghealthandsocialservices)byformalandinformalcaregiversinthehome,inordertopromote,restoreandmaintainaperson’smaximumlevelofcomfort,functionandhealth.19Inmanyresource-limitedsettings,HBCistheonlywaytodelivercaretothepatient.Around50-60percentofPLHIVworldwidehavenoaccesstoprofessionalhealthcareworkerstoaddresstheirmedicalneeds,andthusrelyonHBCservices.

Due to increased nutritional requirements of PLHIV mentioned on page 5, foodassistanceneedstobeprovidedtomalnourishedorfoodinsecurepeople,usingtheHBCnetworkofvolunteers.TheimplementationofHBCactivitiesvariesconsiderably.However,HBCteamsoftenofferongoingcounselingandsupport,assistancewithprovidingandpreparing food, cooking, cleaning,woundcare,hygiene, symptomassessment,painandsymptommanagement,identificationofspecificopportunisticinfections,treatmentofsomeofthem,supervisionofdrugtaking,andmonitoringfordrugsideeffects.


Recommended reading

1. Recommendation for the Nutrient Requirements for People Living withHIV/AIDS(FANTA,2007)

2. Consultation onNutrition andHIV/AIDS inAfrica: Evidence, lessons andrecommendationsforaction,ICC,Durban,SouthAfrica,10-13April2005

http://www.who.int/nutrition/topics/consultation_nutrition_and_hivaids/en/index.html

3. FawziWWetal.StudiesofvitaminsandmineralsandHIVtransmissionanddiseaseprogression.JNutr135:938-944,2005.

4. FawziWWetal.ArandomizedtrialofmultivitaminsupplementsandHIVdiseaseprogressionandmortality.NewEnglJMed351:23-32,2004.

5. Conducting a situation analysis of orphans and vulnerable childrenaffectedbyHIV/AIDS,Williamson,Jetal.USAID,BureauforAfrica,OfficeofSustainableDevelopment,2004

6. AIDSandfoodsecurity.EssaysbyPeterPiotandPerPinstrup-Andersenand by Stuart Gillespie and Lawrence Haddad. Reprinted from IFPRI’s2001-2002annualreport.

http://www.ifpri.org/pubs/books/ar2001/ar2001e.pdf

7. Antiretroviral drugs for treating pregnant women and preventing HIVinfection in infants inresource-limitedsettings.Recommendationsforapublichealthapproach.WHO,2006

8. TheWorldHealthReport2005:Makeeverymotherandchildcount.WHO,2005 http://www.who.int/whr/2005/whr2005_en.pdf

9. HIV and Infant Feeding Technical Consultation on Prevention of HIVInfectionsinPregnantWomen,MothersandtheirInfants.WHO,2006

http://www.who.int/reproductive-health/stis/mtct/infantfeedingconsensusstatement.pdf

Continuedonnextpage


10. KuhnLetal.“DoesSeverityofHIVDiseaseinHIVInfectedMothersAffectMortalityandMorbidityamongtheirUninfectedInfants?”ClinicalInfectiousDisease.41:1654-1661,December2005

http://www.journals.uchicago.edu/doi/pdf/10.1086/498029

11. IllifPJetal.EarlyExclusiveBreastfeedingReducesHIV-transmissionandIncreases HIV-free Survival. AIDS 2005, 19(7): 699-708and IncreasesHIV-freeSurvival.”AIDS2005,19:699-708

Continuedfrompreviouspage

Section2:RationDesign–theFiveSteps

Section 2: Ration Design —

the Five Steps


Section2:RationDesign–theFiveSteps

Thedesignof rations for foodassistanceprogrammesdependsonanumberoffactors.Thissectiondescribesfivestepstohelpguidethedecision-makingprocessrelatedtorationdesignforHIV/AIDSactivities:

➤ Step 1: Review the nutrition and food security situation of the targeted population

➤ Step 2: Review the objectives of the programme and the role of the ration

➤ Step 3: Determine how much food is needed to be provided and for how long

➤ Step 4: Select the most appropriate food commodities and type of rations

➤ Step 5: Consider activities to put in place to enhance the proper use of the food ration

Itisimportanttorealizethatfoodrationdesignisaniterativeprocess,inwhichthefivestepsmaybe repeated.Theprocessalso requiresconsultationwith variousstakeholders, including operational and technical partners, national counterpartsandpreferablybeneficiaryrepresentatives.Althoughtheprocessmainlytakesplaceatthestageofprojectformulationandpreparation,therecommendedrationanditssubsequentusemustbecarefullymonitoredandmodifiedifrequired.

Step 1: Review the nutrition and food security situation of the targeted population

Thefirststepinthedesignofarationistoreviewvulnerabilityandfoodsecuritysituationdataofthetargetedpopulation.Datatobereviewedinclude:

• Proportionofthedailyfoodrequirementsthatcanbemetbyhouseholdsources


• Householdfoodstocksandstorage

• Seasonalpatternsoffoodinsecurityandmalnutrition

• Dietarydiversity–thetypesoffoodcommoditiesthatareconsumedbythehousehold

• Nutritionalwell-being–thetypesofnutritionalproblemsfoundandthepercentageofpeople(childrenandadults)whosufferfrommalnutrition(bothmacro-andmicronutrients)

• Foodpreparationpractices

• Dependencyratios

• Healthproblems,includingfactorsthatmayinfluencefoodconsumptionandutilization

• Householdlivingconditions–accesstofuel,safewater,sanitation,cleanenvironment,shelter,etc.

• Characteristicsofparticulargroupswhomaybemorevulnerableormoreatrisk

Theabove information isnormallyavailableat thecountryofficethroughreportsof foodsecurityassessmentsandnutritional surveysof vulnerablecommunities.This informationcanalsobecomplementedby rapid foodsecurity andnutritionassessmentsofthetargetedpopulation.

In the case of care and treatment programmes, other factors may need to beconsidered,suchas:

• Enrolmentinoruptakeofhealthandcareservices(doesfoodinsecuritypreventthetargetgroupfromseekingservices?)

• Attendanceatservicesandactivities(whatarethebarrierstoregularattendance?)

• Adherencetothemedicalprotocol

• Speedofrecovery(towhatextentdoprovidersbelievethatrecoveryfromsicknessisbeinginhibitedbypoornutritionalstatusorinadequatefoodintake?)

Manyofthesefactorsmaybedirectlyorindirectlyrelatedtofoodconsumptionandnutritionalvulnerability.


Step 2: Review the objectives of the programme and the role of the ration

RationdesigninanHIVcontextwillbebasedontheprogrammeobjectivesandtheration’srole inachievingtheseobjectives. It isextremely important tobeable tojustifyandexplainthefoodbasketintermsofwhattheprogrammeaimstoachieve.Thefirststepinthisprocessistodefinetheroleofthefoodbasketinachievingtheobjective.Table1providessomeexamplesoftypicalobjectivesoffoodassistanceinHIVprogrammesandthepossiblecorrespondingroleofthefoodration.

Table 1: Examples of food assistance objectives in the HIV context

Food assistance objective Possible role of the ration in the HIV context

Maintainthenutritionalwell-beingofHIV+pregnantandlactatingwomen

Nutritionalsupplement,enablerforregularlyattendingPMTCTservices

ImproveadherencetoART Supportformanagingdrugside-effects,enablerforregularattendanceatARTsite

ProvideasafetynetforHIV-affectedhouseholds

Contributiontohouseholdfoodsupply,incometransfer,protectionofproductiveassets,reductioninadoptionofriskylivelihoods

EnhancelivelihoodsofolderOVCthroughlivelihoodtraining

Coverageofopportunitycostsfortimespentintraining,incentivetoattendandcompletetraining

Theobjective(s)offoodassistanceshouldbedirectlyrelatedtotheproblemsthathavebeenidentifiedandclearlydefined.InthecontextofHIVandAIDSactivities,theobjectivesmayberelatedtotheobjectivesoftheprogrammebeingsupported(forexample, increasingadherencetodrugtreatment)butalsomayrelatetothefoodandnutrition insecuritychallengesexperiencedbythetargetgroup.Severalexamplesfollow.


• When the role of a ration is to maintain or improve nutritional status,the ration should include commodities that are high in nutritional value andappealtothetargetedgroups.

• When the role of the ration is to increase or ensure participation in services or activities, commoditiesshouldbechosen for their incentiveormonetaryvalueaswellastheirnutritionalvalue.Insuchcases,theration’svaluemustbeequaltoorslightlygreaterthantheopportunitycostofparticipatingintheactivity.

• When the role of the ration is to act as a safety net,itmustbedesignedtoprovideprotectionfromtheriskstheprogrammehopestohelpbeneficiariesavoid, suchasofferingenough value toprevent saleofproductiveassetsorriskybehaviors.

Theobjectiveandtheplannedroleofthefoodrationinfluencethecompositionandsizeofthefoodbasketandmaydeterminewhethertherationswillbeanindividualration/supplementorahouseholdfoodbasket.

In general food assistance programmes (e.g. general food distribution (GFD),targeted fooddistribution (TFD), food forwork) (FFW)), theobjectivemaynotbedirectlyrelatedtoHIV.However,theenvironmentinwhichfoodassistanceisprovidedmaybehighlyimpactedbythepandemic.Insuchsituationsitmaybeappropriatetoadjust conventional rations toaccommodate thenutritionalanddietaryneedsassociatedwithHIV.

Box 4: HIV prevalence and its impact on general food assistance

TodetermineiftheHIVsituationinagivenpopulationwarrantsanadjustment

of the food basket in general food support activities (relief, recovery or

development),thesituationneedstobecarefullyinterpreted.

High prevalenceInhigh-prevalencecountries,suchas inEasternandSouthernAfrica,HIV is

sowidespreadthatitcanbesafelyassumedthatmanypeopleareaffectedin

somewayorotherandasaresultmayexperiencefoodsecuritychallenges.Continuedonnextpage


Continuedfrompreviouspage

Ofcourse,theactualleveloffoodinsecurityneedstobedeterminedthrough

appropriateassessmentandanalysis.

Furthermore,alargeportionofthetargetpopulationislikelytohaveparticular

nutritional needs associated with HIV and/or drug treatment. It is important

to remember that thenutritionalwell-beingofmanypeoplemayalreadybe

compromised by limitations in appropriate food, health and care that are

unrelated to the particular implications of HIV and AIDS. However, these

nutritional weaknesses are likely to have implications on the effect of the

diseaseonPLHIVaswellastheimpactonaffectedhouseholds.

Insuchcircumstancesitisimportantthatappropriateadjustmentstothefood

basketbecarefullyexplored,intermsofcommoditiesandpossiblythesize.

Low prevalenceIn (relatively) low-prevalence regions (for example in West Africa or Asia),

adjustmentoftherationstoaccommodateaverysmallnumberofuntargeted

individuals, many of whom may not be able to identify themselves as HIV-

positive,doesnotnormally result inpracticalandeffectiveresults.However,

whentargetingparticularlyhigh-riskgroupsorthosewithsuspectedorknown

elevatedprevalence,therationadjustmentcouldbeconsideredinlinewiththe

“highprevalence”situationdescribedabove.

High impactThe impact of HIV andAIDS on certain countries may be severe, although

prevalencemaybe lowordiminishing. Incountrieswhere thepandemichit

veryearlyon,theimpacthasprogressedfromincreasedHIVcasestoincreased

deathsandnumbersoforphanedchildren.Thisdelayedbutprofoundimpact

mayrequirethat thefoodbasketbeconsidered intermsof foodavailability,

access,preparation,etc.bytheaffectedpopulationratherthantheparticular

nutritionalrequirementsassociatedwithHIVandAIDS.Thetypicaldemographics

ofseverelyaffectedhouseholdsmayalsojustifyanadjustmentofcommodity

choicesand/orrationsize.


Step 3: Determine how much food needs to be provided and for how longInfoodassistanceprogramming,rationsizeshouldbebasedonspecificnutritional

needsofanindividualorhousehold.BasicnutritionalprinciplesapplytoPLHIVas

muchastoallotherpeople.WHOrecommendstoinclude12-15percentofprotein,

atleast17percentoffatandmineral,andvitaminintakesatRecommendedDaily

Allowance(RDA)levels.

Forfoodassistanceinthecontextofgeneralfooddistributionsandotherhousehold-

orientedfoodsupportprogrammes,theenergyrequirementisbasedonaweighted

averageofallageandgendergroupswithinapopulation.Theaveragerequirement

calculatedonthisbasisuses2100kilocalories(kcal)asaninitialplanningfigure,

andisthenadjustedbasedonfactorssuchasdemographiccomposition,ambient

temperature,healthandnutritionalstatus,andphysicalactivitylevel.20Fortargeted

feedingprogrammes,theinitialplanningfiguremaybehigherorlowerthan2100

kcalsdependingonthepopulationsub-groupsbeingtargeted.Insomecases,the

rationwillcomplementthedailydietbyofferinganutritionalsupplement;inothers,

itwilltaketheformofanentiremeal.Eitherway,itisimportanttoknowtheageand

sexdistributionofthetargetgroup.Forexample,therearesignificantdifferencesin

thenutritionalneedsofachildunderfiveyearsofageandthoseofanadultman.21

Fourfactorswillinfluencethedecisiononthesizeoftheration.

Increased energy requirements of PLHIV

WHOrecommendationsiforthenutritionalrequirementsofPLHIVcallforincreases

in energy.Theamount of this increasedependsonwhether the individual is an

adultorchild,asymptomaticorsymptomatic,andexperiencingweightlossorno

weightloss.

ItmaynotberealistictoassumePLHIVwillconsumetherecommendedamount

ofenergyfromatake-homeration,asoneneedstotakeintoaccountthefactthat

mostofthetimerationsaresharedamongthehouseholdmembers.


Box 5: Some basic calculationsTotal energy requirements for PLHIVAsindicatedinBox1,researchhasshownthatPLHIVhaveincreasedenergy

requirements depending on the stage of the progression from HIV toAIDS.

These increases are reflected as percentages of the basic requirement.

Inorder to judgehowmuchenergy this increase represents incontextofa

food aid ration, it is important to know the sex and age distribution of the

targetgroup.

Example:a20percentenergyincreaserequiredbyanHIV+womanintheage

category15-19yearsiscalculatedasfollows:20%x2120kcal=424kcal.The

amountformeninthesameagegroupis20%x2700kcal=540kcal.

Associated increases in protein and fat intakeForPLHIVtheproportionofproteinneeds(10-12percentoftotalenergy)do

notincrease.However,withtheincreasedenergyneeds,theabsoluteamount

ofproteinneededalsogoesup.Similarly,theproportionalcontributionoffat

to the totalenergyrequirementdoesnot increase forPLHIV.However,when

theenergyincreases,sodoestheamountoffatrequiredtomaintainthe17

percentbenchmark.

Example: a 20%energy increase required byHIV+men in the age group

20-59yearsaddsup to:20%x2460=492kcal.Of thisenergy,10-12%

shouldbeprovidedbyprotein=59kcal(at12%),andatleast17%shouldbe

providedbyfat=84kcal.Thistranslatesto15gramsofadditionalproteinand

9gramsofadditionalfattobeconsumed.

Total energy requirement: 2460 + 492 = 2952 kcalTotal protein requirement: 74 + 15 = 89 gramsTotal fat requirement: 46 + 9 = 55 grams


The nutritional value of the meal that the ration is assumed to replace or complement

In somecases, the ration isassumed tocomplement thebeneficiary’sdietwithkeynutrients. Inothercases, therationmaybeassumedtocovermostorallofthebeneficiary’snutritionalrequirements(forinstance,100percentifthetargetedpopulationreliesentirelyonfoodassistanceforsurvival,or40,50or80percent,accordingtothenutritionandfoodsecuritysituation).Steps1and2shouldprovidetherationplannerwithenoughinformationtohelphim/herdeterminethesizeoftherationaccordingtotheroleheorsheidentifiedforfoodassistance.

The value of an income transfer that serves as an incentive for participation in services/activities or as safety net

Inaccordancewiththefoodsecurityandvulnerabilitysituation(Step1)ofthetargetpopulation,therationplannershouldmakeacleardecisionontheincomevaluehe/shewantstotransferthroughfoodassistance.Theincomevalueoftherationistheactualmoneyvalueoftherationdistributedtoeachbeneficiary.Inthiscase,therationissupposedtofreeupincomethatwouldotherwisebeusedtobuyfood.TheoutcomeofSteps1and2willagaindeterminehowmuchincome(intermsoflocalcurrencyordollars)therationwouldtransfertothebeneficiaries.Thiswillplayasignificantroleindeterminingthesizeoftheration.

Duration of the ration

Thedurationforprovidingrationsshouldbebasedonconsiderationofobjectivesand,toacertainextent,trialanderror.HIV-inducedfoodsecurityshocksdifferfromotherfoodsecurityshocksandcannotbeaddressedinthesamewayasdroughtsandothernaturaldisasters.Forexample,theimpactofHIVandAIDSoncommunityandhouseholdresiliencymaybemoresevereandlongerlastingthantheimpactofothershocks,whichwillinfluencethedurationoftherations.


Table 2: Examples of duration of ration by beneficiary type and programme

Beneficiary Objective Duration of ration

ARTclients ✓ Improvednutritionalstatus

✓ StabilizationtobeginART

✓ Improvedadherence

✓ Managementofdrugsideeffects

✓ Untilaclientreachesaspecificanthropometrictarget(e.g.BMI=18.5)or

✓ Limitedtimeframe:6months

TBclients Improvedtreatmentcompletionrate

Durationoftreatment

PMTCT Maintainorimprovenutritionalstatus

✓ From6thmonthofpregnancythrough9-12monthsafterbirth

✓ Untilindicatorsoffoodaccessimproveor

✓ Limitedtimeframe,suchas6months

Affectedhousehold

Safetynet ✓ Untilindicatorsoffoodaccessimproveor

✓ Limitedtimeframe,suchas6months

OVC ✓ Safetynet

✓ Incentiveforparticipationinservices(e.g.school,lifeskills,etc.)

✓ Untilachildisnolongervulnerable

✓ Durationofservice

Step 4: Select the most appropriate food commodities and type of rations

Food commodities

There are several key considerations that help determine if the rationwillmeetbeneficiaryneedsandprogrammeobjectivesinanHIVcontext.


Processing requirements.Programmesshouldexploreopportunitiestoprovidemilledcerealsaswellasalreadyprocessed,fortifiedblendedfoods.MilledcerealstakelesstimeandenergyforPLHIVortheircaregiverstopreparebecauseprocessingcerealsoftenrequireslongwalkstomillingfacilities–iftheyareavailableatall–aswellasthestrengthtopoundthegrainintoflour.MilledandprocessedfoodscomeatahighercosttoWFPandassuchrequireadequateattentionintheprojectbudget.Itisimportanttonotethatifnon-milledornon-processedfoodsareprovided,thecostofmillingandprocessingisbornebythebeneficiariesratherthantheprojectbudget.Theactualfinancialcostofmillingcanbequantifiedandrationscanbeadjustedtocompensateforthiscost.However,thecostintermsofphysicalburdenandopportunitycostisdifficulttoexpressinmonetarytermsbutcan,particularlyinextremelyvulnerablehouseholds,create immensechallenges.Consumptionofwholegraincerealsisnotnormallyanacceptableoptionforchronicallyillpersonswhoexperiencevariousconsumptionanddigestionchallenges.

Preparation requirements. Chronically ill persons require a large number ofsmallmealsthroughouttheday,beyondthetwoorthreemealsnormallypreparedforfamilyconsumption.Inordertopreventcontamination,itisimportanttoavoidpreparinglargequantitiesoffoodthatwillbestoredandreheatedwhenmealsarerequired.Thus,inordertominimizetheburdenplacedonthecaregiverinchargeofmealpreparation,itisimportanttoconsiderfoodcommoditiesthatcanbecookedeasilyandquicklywithminimumwater,fuelwoodandtimerequirement.Cookingtimethatreducessoakingshouldalsobeconsideredwhereappropriate.Partiallyprecookedcommoditiessuchasfortifiedblendedfoods(e.g.corn-soyablend(CSB)andwheat-soyablend(WSB)),orready-to-usefoods(RTUFs)arepreferredchoices.Considering the susceptibility of PLHIV and particularly chronically ill persons toinfections, it is extremely important that foods be adequately cooked to kill anygermsandbacteria.Often thenatural response to thishygiene requirementwillbetocookfooditemsforextendedperiodsoftime.However,thismayalsohavenegative consequences as many micronutrients may be destroyed by excessiveheatandprolongedcooking.Thus,extensivecookingdefeatstheeffortsandcostsmadeinfortificationoffoodaidcommoditiessuchasmaizemeal,CSBandoil.

Palatability and digestibility. Palatabilityanddigestibilityareextremelyimportant,particularlywhenprovidingrationsforchronicallyillpeopleandPLHIV,whomayhave


reducedappetite,eatingdifficultiesorgastrointestinalproblems.Rationsshouldbedesignedtominimizediscomfortoraggravationofthesesymptoms.Milledcereals,adequatelysoaked/cookedpulsesandfortified-blendedfoodsthatcanbemadeintoporridgesoftenaremorepalatableandeasiertodigestforsickpersons,aswellassmallchildrenortheelderly.Childrenoftenneedtobeencouragedtoeatadequatelybyaddingtastetothemeal–sugarand/orsaltareusefulasflavorenhancers.

Micronutrient needs/fortification.Micronutrientsarecriticalforallpeopleandarevitalinfightinginfection.PLHIVinparticularcanbenefitfromcommoditiesfortifiedwithmicronutrients.Therefore,itisveryimportantforfoodaidrationstoprovideaconsiderablecontributiontothedailyintakeofvitaminsandmineralstomakesurethatminimumrequirementsaremet.Manyfoodaidcommoditiesprovidedinkindcome in fortified form,suchascornmeal,wheatflour,CSBandoil.WhereCSBandoilarepurchasedbyWFP,standardspecificationsareusedtodeterminethefortificationlevels.Thefortificationlevelsinlocally/regionallyproducedcerealflourscouldbedeterminedlocally.Itisimportantinsuchcasesthatthedecision-makingprocess includes consultation with expert organizations and considers the localfortificationlegislation.AlthoughthereisatrendinthefortificationofcommerciallyavailablefoodsforPLHIVtoaddextremelyhighlevelsofmultiplemicronutrients,itis importanttoensuresafeconsumption:somemicronutrientscanbeharmful inhighdoses. It is importanttoensurethattheaddedmicronutrientsdonotcauseanyrisktothebeneficiaryortothehouseholdmemberswithwhomtheymaysharetheration.

Acceptability.Asinallfoodassistanceprogrammes,somecommoditiesaremorereadilyacceptedandconsumedbybeneficiariesthanothers.Factorsthatcaninfluenceacceptability include traditional and religious diet patterns and taste preferences.Forexample,commoditieslikeCSBmayhavehighacceptabilityinsomeareasbutmaybeconsidered“children’sfood”andrejectedbyadultsinotherareas.

Storage.Processedfoodsmaybesusceptibletospoilage(rancidity,contaminationorinfestation),particularlyifstoredinlargequantitiesunderunhygienicconditions.Similarlyitisextremelyimportanttoconsiderthequalityofwholegraincerealsandotherproductssuchasgroundnuts,particularlyintermsofafflatoxincontamination,which may be present in locally-stored produce. Salmonella contamination also


often occurs in foods handled and/or stored in unhygienicways and is amajorcause of diarrhoea. It is important to consider storage capacity and conditions,shelf-lifeofcommoditiesandthehygieneawarenessofpoorhouseholdsaffectedbyHIVandAIDSwhenexploringtheuseofcertainproducts.

Value.Whentherationservesasanincometransferorincentive,thecommoditiesmusthaveanappropriatevalueinlocalmarkets.Thesefactorsdeterminearation’sincometransfervalue:Whatdoesitcostthetargetpopulationtoparticipateintheprogramme (e.g. transportation, daily lost wages, daily wage rate)?What is thevalueofotherincentivesthatareoffered(e.g.training,healthservices)?Whatisthevalueofthecommoditiestotheparticipants?Itisimportanttokeepinmindthatfoodswithhighvaluesmaybegoodforincometransfersbutaremorelikelytobesoldratherthaneatenbybeneficiaries.

Type of rations

Inlinewiththeobjectiveoftheprogrammeandtherolefoodrationsaresupposedtoplay,therearedifferenttypesofrations,whicharedescribedbelow.

Individual nutritional supplements.Theserationsareprovidedwhentheobjectiveoftheprogrammeistoimprovethenutritionalstatusofthetargetedindividual.ThisisthecaseforpatientsonARVorTBtreatment(forexample,thefirsttwomonthsofdirectlyobservedtreatment,shortcourse–DOTS).Whennutritionalsupplementsareprovidedtotakehome,thequantityisnormallydoubledtoaccommodatetheinevitablesharingoftherationwithotherhouseholdmembers.Itisexpectedthatsupplements for adults will be shared with other family members, particularlychildren,toalargerextentthanwhensupplementsareprovidedforvulnerableormalnourishedchildren. Inaddition toor insteadofdoubling the rationsize, it ispossibletoprovideacomplementaryfoodpackagefor thehousehold inorder toreducesharingofthenutritionalsupplement,calleda“protectionration.”Individualsupplementsarelikelytobemoreeffectivewhencommoditiesarechosenthataredifferentfromthoseinthehouseholdfoodbasketandcanbepromotedashavingparticularbenefitsforthetargetedindividual.AtypicalcommodityoftenchoseninindividualsupplementsisCSB,orasimilarfortifiedblendedfood.Normally,75-100gofCSBareconsideredtobeoneadditionalsupplementforadults.Forchildren,this


quantitymaybereducedtoapproximately50gperadditionalmeal.Wherenutrientdensityisofimportance(particularlywhenprovidingsupporttomalnourishedand/orillindividuals),itmaybeappropriatetoincludeoilandsugarinthesupplement.Twotothreeadditionalmealscouldbeconsumedontopofthetwoorthreemealsnormallyincludedinthehouseholddiet.

Household rations.Householdrationsarenormallyprovidedinprogrammesthataimtoimprovenutritionalwell-being,copingcapacityandlivelihoodopportunitieswithin theentirehousehold.Thedecision toopt for this typeof rationshouldbebasedonthe foodsecuritysituationof thePLHIV’shousehold.Theserationsarebasedontheestimatedneedofthehousehold,includingfoodavailabilityandaccessconsiderationsaswellasfoodutilization,dietarydiversityandnutritionalbalance.The ration needs to make a realistic contribution to the household food basketwithoutaimingtoprovidethefullrequirement.Thefoodbasketnormallyincludesabalancedvarietyofcommodities.Ahouseholdrationprovidedtopersonsincareand treatment programmes may be accompanied by a nutritional supplement.Tofacilitatethedistributionofhouseholdrations,astandardhouseholdsizemaybedeterminedand thequantitiesof thecommodities in thehouseholdpackageadjustedtoeasilymanageableunits.

On-site meals.Inprogrammeswherepeopleareattendingservicesoractivitiesonaregularbasis,on-sitemealsmaybeprovided.Thepurposeandroleofthefoodassistancemayrelatetonutritionalbenefitsaswellasregularityofattendance.Thisisoftenthecase inprogrammesforOVCincommunitycentresandschools, forskillstrainingprogrammes,etc.Whenpeopleresideinboardingfacilities,suchasinboardingschools,orphanagesandclinicalfacilities,themealsshouldprovidetheentiredailyfoodneedandbecomplementedwithfreshfoods.

Take-home rations.Inmostsituationsitisrelevanttoprovideabasichouseholdcomplementasatake-homerationinordertosafeguardthenutritionalimprovementof the targeted individual. In thiscase, thehouseholdpackageserves toprotecttheindividualsupplementfromexcessivesharing.Take-homerationscanalsobeprovidedasanincentivetothehouseholdtoencourageandsupportthepatient/client.Thismay be the case inPMTCT,TB andARTprogrammes.A take-homerationmayconsistofonecommoditythatisconsideredattractivetothehousehold


membersintermsofcontributiontothedailyfoodintakeand/orincometransfer.Thisisoftenprovidedinsimplepackingunitssuchasabagofmaize(preferablymilled and fortified so as to make a contribution to micronutrient status of thehouseholdmembers)oracanofoil.

Step 5: Consider activities to put in place to enhance the proper use of the food ration

A number of activities should be considered to ensure that food rations areadequatelyusedtoachievetheobjectivessetout:

Nutrition counseling and education.Foodassistanceactivities in thecontextofHIVandAIDSshouldbeaccompaniedtotheextentpossiblebyeducationandcounselingactivitiesthathighlighttheimportanceofnutritioninoverallwell-beingand demonstrate the appropriate use of the food assistance package provided.Topics could include: household utilization and distribution of the food basket;sharingofindividualnutritionalsupplements;appropriatepreparationformaximumnutritionalvalue;andtheappropriateuseoflimitedhouseholdresourcestosupportabalancedanddiversifieddiet.

Improved storage and preservation. It should be kept in mind that peopleinfectedwithHIVareparticularlysusceptibletoinfectionscausedbyspoiledfood.AsmentionedinStep4,itisimportanttoconsiderstoragecapacityandconditions,shelf-lifeofcommoditiesandthehygieneawarenessofpoorhouseholdsaffectedbyHIVandAIDSwhenexploringtheuseofcertainproducts.

Fuel-saving strategies. Itshouldbeensuredthateveryfamilyisabletocookthereceivedfoodproperly.Foodcommoditiesshouldbeeasytopreparewithaminimumuseoffuel.Considerationsregardingfuel-savingstrategiesarenotdifferentforPLHIVthenforotherpeople.Themostusualfuel-savingstrategiesinclude:i)useoffuel-efficientstoves; ii) energy-savingcookingpractices suchaspre-soakingof beansandusingtightlyclosinglids;iii)collectivecookingarrangements;iv)usingalternativebiomassfuelratherthancharcoal;andv)usingnon-biomassfuelssuchaskeroseneorsolarstoves.

Gardening. As food rations are usually designed as a complement to locallyavailablefood,gardening isagoodopportunity to increaseaccesstofreshfood.Whereverpossible,gardeningshouldbeencouraged.


Recommended Reading

1. TargetedfoodassistanceincontextofHIV/AIDS.BetterPracticesinC-SAFETargetedFoodProgramminginMalawi,ZambiaandZimbabwe,USAID2004

http://wwww.reliefweb.int/rw/RWFiles2004.nsf/FilesByRWDocUnidFilename/EVIU-64VFPK-csafe-souafr-16sep.pdf/$File/csafe-souafr-16sep.pdf

2. TUFTSNutrition,ProgramGraduationandExitStrategies:TitleIIProgramExperiencesandrelatedResearch,DiscussionPapern◦25,April2004

http://nutrition.tufts.edu/docs/pdf/fpan/wp25-program_grad.pdf

3. FANTAandWFP.FoodAssistanceProgrammingintheContextofHIV,WashingtonDC:FANTAProject,AcademyforEducationalDevelopment,2007

http://www.wfp.org/food_aid/doc/Food_Assistance_Context_of_HIV_Oct_edits.pdf

4. CanahuatiJBasicPrinciplesforFoodAssistedProgramsinthecontextofHIV/AIDS(Powerpoint)November2004

www.fantaproject.org/downloads/pdfs/hfa04_3f.pdf

5. HIV/AIDS:A Guide for Nutritional Care and Support. 2nd Edition. Foodand Nutrition Technical Assistance Project, Academy for EducationalDevelopment,WashingtonDC,2004.

http://www.fantaproject.org/downloads/pdfs/HIVAIDS_Guide02.pdf

6. BatterhamMJet al.Calculatingenergy requirements inmenwithHIV/AIDSintheeraofhighlyactiveantiretroviraltherapy.EuropeanJournalofClinicalNutrition,2003,57:209–17.

http://www.nature.com/ejcn/journal/v57/n2/pdf/1601536a.pdf

7. GerriorJLetal.NutritionassessmentinHIVinfection.NutritioninClinicalCare,2005,8(1):6-15

8. GuidelinesforHIV/AIDSinterventionsinemergencysettings.Inter-AgencyStandingCommittee2003.

http://www.who.int/3by5/publications/documents/en/iasc_guidelines.pdf

9. IntegrationofHIV/AIDSactivitieswithfoodandnutritionsupportinrefugeesettings:specificprogrammestrategies.UNHCR/WFP2004

http://data.unaids.org/pub/Manual/2004/integration_hiv_nutrition_strategies_manual.pdf


Section3:MonitoringtheRationandOperationalConsiderations

Section 3: M&E and

Operational Considerations


Section3:MonitoringtheRationandOperationalConsiderations

Monitoring

Theaimofmonitoringistoassessonaregularbasiswhethertheobjectivesoffooddistributionarebeingachieved.Threetypesofmonitoringneedtotakeplacewithrespecttofoodrations.Theyaredescribedbelow.

Process monitoring

Theaimofprocessmonitoringistoensurethatfoodisdistributedtotheintendedbeneficiariesandthatlossesareminimizedandaccountedfor.Processmonitoringincludesmonitoringof:

• Foodsupplyanddelivery

• Foodstorageandhandling

• Quantityoffooddistributed,andthenumberofactualvs.plannedbeneficiaries

• Inequalitiesindistribution

Post-distribution monitoring

Thepurposeofpost-distributionmonitoringistoassesswhetherbeneficiariesweresatisfied with the quality of distributed food, if the correct amount of food wasreceived and if the distribution was timely. Information should also be collectedregarding the utilization of food, i.e. if the food was consumed by the targetedbeneficiaries.Itisnormallydoneonarandomsampleofthebeneficiaries.

Outcome monitoring

Theselectionofindicatorstobecollectedformonitoringtheoutcomewilldependontheobjectivesofthefoodassistance.ForTBprogrammes,outcomeindicators


havebeenwellestablished:i.e.percentageofTBpatientscuredaftercompletingtreatment,includingfoodassistance.ForactivitiesrelatedtoPMTCT,ARTandHBCprogrammes, indicatorsrelated tonutrition,qualityof lifeanduptakeofservicesneedtobelookedat.

Operational considerations

Because of the specific nature of HIV programmes, a number of operational considerations need to be taken into account when designing and preparing them. The most important considerations are highlighted below.

Shelf-life of food commodities

MostWFPcommoditiesneedtobetransportedandstoredoverextendedperiodsof time. It is therefore important toassurea reasonableshelf-lifesoas toavoidspoilageofthefood.

Whensuggestingtheuseofmilledcerealsit isimportanttoconsiderthatlocallymilledcerealsmayhaveashort-shelf-life (1-1.5months).Althoughtheseflours/mealsareofhighnutritionalvalue(duetohighextractionrate),itmaybedifficulttoincludetheminthefoodbasketduetotheirshortershelf-life.Theinclusionofsuchproductsrequiresfrequentdeliveryofcommoditiestotheextendeddistributionpoint(EDP)/finaldistributionpoint (FDP),high-qualitystorageandstockmanagement.ThishasenormousimplicationsforqualityassuranceandWFP’sabilitytomanagethefoodpipeline.Ifpossible,themillingofcerealsshouldtakeplaceasclosetotheenduseraspossible.

Commercially-produced flours, milled under superior hygienic conditions andresultinginalowextractionrateproduct,maybeuseduptothreeorfourmonthsaftermilling(maizemealofUSspecificationshasashelf-lifeofaboutoneyear).Locally-producedCSB-typeproductsnormallylastupto6-12months.

Although milling and processing of commodities may seem to complicate theoperationsassociatedwithHIVsupportactivities, theirbenefits to theclientsarevital. Staggered procurement contracts (releasing small quantities on a regular


basis)andpartnershipswithlocalmillingandfortificationfacilitiesareamongthefeasiblesolutionstohelpassurethequalityofthefoodbasket.

Distribution facilitation and pre-packing

Inordertosimplifydistributionproceduresandfacilitatethecumbersomescoopingexercise(useofmeasuresthatcorrespondtothecalculatedindividualration),WFP’spartnersoftensuggestpre-packingcommoditiesbefore the ration isdistributed.However, caution should be taken not to pre-pack the commodities too far inadvance and keep them exposed to potentially unhygienic conditions.This mayspeedupspoilageandcontaminationandputthebeneficiariesatrisk.

Anotheroptionwouldbetopre-packcommoditiesat industrial level inunitsizesthatarecompatiblewiththedistributionquantities.Thismaymeanadjustingtherationsizesslightlytoendupwithtotalquantitiesthatfitstandardpackaging.Wherelocaland/orregionalpurchaseismade,adjustedpackagingspecificationscouldbepursued.Commoditiesthataredeliveredinpredeterminedpackagingunitsmayberepacked/reconstituteduponarrival.Thisdoescomeatacosttotheproject,whichcouldbecoveredunderOtherDirectOperationalCosts(ODOC).

Theuseofspecialbagsforpre-packingmayoffertheopportunitytomarkthebagswithhealthmessagesaboutthecommodity,overallhealthandnutritionissues,HIVpreventioneducation,andthelike.

Pre-packingdoesrequireacompromise inhouseholdrationsizeas typically the“onesizefitsall”approachisadopted.

Pipeline coordination

Pipeline coordination comprises the management of the entire food supplychain,fromdonorstobeneficiaries.Itincludesassessmentandplanningoffoodrequirements,reportingonfoodprocurementneedsandthecorrespondingtimingandmeasuresforavertingpotentialpipelinebreaks.


Accurate stock-keeping is the first step in pipeline management, along with acontinualinventoryofthebeneficiarycaseloadsandsubsequentfoodrequirementfigures,inlinewithagreeddistributionfrequencyandmodalities.Goodknowledgeofleadtimesforfoodpurchase,shipping,landtransport,andhandlinganddeliveryarealsoimportant.

Pipelinecoordinationinvolvestimelycollection,organizationandanalysisofalltheinformationrelatedtothefoodsupplychain,inordertoensurethatsufficientandadequatefoodismadeavailableattherightplaceattherighttime.Incaseofapipelinebreak,programmemanagersshouldmakeeveryefforttoensurethatfoodsupport toHIVprogrammescontinues,asanabruptstopcouldhave irreversibleconsequencesontheoutcomesofcertaincareandtreatmentprogrammes(TBandART,forexample).

Cost

Mostrationsarebasedonacombinationofcereals,pulsesandoil.Somefoodaidcommodities (e.g.cannedmeat,fishandbiscuits)are relativelymoreexpensive,and their routine inclusion in theration isnotadvised.However,whendesigningrations for a targeted beneficiary group such as HIV-positive people with a lowBodyMassIndex,theinclusionofthesecommoditiesinthefoodbasketcouldbeconsidered.Furthermore, theprovisionofvegetableoil fortifiedwithvitaminAoriodizedsalt incursonlymarginaladditionalcosts.WFPspecifications require thefortificationoftheseitems.Asscientificknowledgeoftheeffectivenessofexistingand new commodities grows, the relative cost-effectiveness of different optionsfor specific programmes (especially those with nutritional objectives) should beconsideredratherthancostalone.


Section4:FoodAidCommodities

Section 4: Food Aid Com

modities


Section4:FoodAidCommodities

Cereals

Cereals include maize, rice, wheat, bulgur wheat, sorghum, millets, etc.

Cerealstypicallyprovidethebulkofthedailyfoodbasketandcontributemainlytotheconsumptionofcarbohydrates.Inpoorhouseholds,thedietislargelydominatedby cereals asmany people cannot afford to complement them with vegetables,pulses and animal products. This makes the diet very monotonous and largelydrivenbytheneedforenergyandvolume(tosatisfythehungerfeeling)ratherthanbalancednutritionalintake.

Where roots and tubers, such as cassava, yams and potatoes, are the staplefoods,theyplayasimilarroleinthedietascerealsdo.AsWFPdoesn’tnormallyprovidetheseproductsaspartofitsfoodbasket,theyaretypicallyreplacedbyorcomplementedwithcereals.

AlthoughitisimportantthatadequatecerealsbeconsideredinfoodaidrationsinthecontextofHIV/AIDS,thisshouldbedoneinacarefulbalancewithcommoditiesthat provide protein and fat, which are typically lacking in the household foodbasket.Wherecerealsareprovidedthisshouldpreferablybedone inmilledandfortifiedform.

Pulses

Pulses include green peas, yellow split peas, beans, lentils, etc.

Pulsesprovideanimportantcontributiontotheproteinintakeofpoorhouseholds.Togetherwiththeproteinsincerealstheyprovideanadequatebalanceofaminoacids(proteins).Inbetter-offhouseholds,proteinisalsoprovidedthroughtheconsumptionofanimalproductssuchasmeat,eggsandmilk.Althoughanimalproteinismoreeasilyandeffectivelyutilizedbythehumanbody,vegetableproteinsourcesareofgreatimportanceinthedietsofPLHIVandtheirfamilies.Foodaidrationsshould


respondtotheadequacyofproteinrichfoodswithinthehouseholdfoodbasketandcomplementthesewithpulsesinthefoodaidrationasnecessary.

Pulses requirecarefulpreparation tomake thempalatableanddigestible.Sometypesofpulsescanbepre-cooked,makingthemquickertoprepare.Theymustbesoaked,andthusrequiresafewater.Cookingcantakealongtimeandrequiresalotofcookingfuel.Cookingtimecanbereducedbyaddingashesorsalttothewater.Thesespecialcookingrequirementsmustbetakenintoaccountwhenconsideringthetypeandamountofpulsestobeincludedinthefoodbasketandwhendesigningcomplementaryeducationactivities.

Oil

Oil provided in food aid programmes is refined and comes from vegetable sources. It is fortified with vitamin A and sometimes vitamin D.

Oil is the main source of fats in the diet. It does not contain any protein orcarbohydrates. Cereals and pulses also provide some fat, and so do fortifiedblendedfoodssuchasCSB.Inbetter-offhouseholds,fatintakeisalsosupportedbyconsumptionofmeats,fishanddairyproducts.Somehouseholdsmayalsouseanimal fat sources such as butter.A vegetable source rich in oil is groundnuts.Insomecountries inAfrica,oil isderivedfrompalmnutsand isnaturally rich invitaminA.This type of oil tends to solidify at lower temperatures andmay thuscausesomechallengesinfooddistributions.

Oil is very important in providing energy without increasing the volume of themeal–itincreasesthe‘energydensity’.Fatsarealsoimportantinfacilitatingtheabsorptionofcertainvitaminsandtheymakethemealmorepalatable.Theseareimportantconsiderationswhenprovidingfoodrationstopeoplewhohavedifficultyeatingastheyneedtoconsumeasmanynutrientsandasmuchenergyaspossibleinfewandsmallmeals.

InPLHIV,fatconsumptionissometimesassociatedwithdiarrheaandoilshouldthusnotbeprovidedinlargequantities.Oneshouldalsokeepinmindthatoilisnormallyusedforfoodpreparationandmixedwithotheringredients.Itcannotbeeatenonitsown.Thus,thedailyconsumptionquantityislimited.


Fortified blended foods

Fortified blended foods (FBFs) used in food aid include CBS, corn-soya milk, wheat-soya blend, pea-wheat blend, etc. Local variations are available under various names: IndiaMix, Likuni Phala, UniMix, FaMix, etc.

Blendedfoodsarenormallyamixtureofcerealsandpulsesthathasbeenprecookedthroughroastingorindustrialcooking(extrusion).Insomecasesthemixisfurtherenrichedbyaddingmilkpowderand/orsugar.Animportantbenefitistheadditionofavitaminandmineralmixwhichboostthemicronutrientvalue.Blendedfoodsarenormallyusedtoprovideappropriatesupplementsfor infantandyoungchildfeedingandfortherehabilitationofmalnourishedchildren.Inreliefrationstheyarenormallyusedasameanstoprovidebasicmicronutrientstothetargetpopulationandparticularlytovulnerableindividualssuchaschildren,pregnantandlactatingwomenandthesick.InthecontextofHIVandAIDS,FBFsprovideavaluableadditiontothefoodbasketforthefollowingreasons:

• Shortcookingtimeandreducedburdenforcaregivers,enablingmorefrequentmeals

• Highpalatabilityduetosmoothtextureandsalt/sweettaste

• Easilydigestedduetoprecooking(particularlyrelatedtothepulses)

• High-energydensity(rightbalanceofingredientsandhighfatcontent)

• Balancedmixofmacro-andmicronutrientsduetopre-blendingandfortification

FBFscanbeusedasthemainfoodinnutritionalsupplementsbutarealsoavaluablecomponentofabalancedfoodbasket.

Sugar/salt

Sugar and salt are often included in food aid rations as they provide taste to the meals and thus increase the palatability of the food. This is very important when providing food support to people with eating difficulties, particularly those who need to gain weight.


Sugar provides energy through carbohydrates. It does not provide any othermacronutrient. Innatural formitalsodoesnot includeanymicronutrients,but insomecountriessugar is industrially fortifiedwithvitaminsandminerals (typicallyvitaminA)duringtherefinementprocess.Justlikeoil,sugarprovidesenergywithoutincreasingthevolumeof themealmuch.This isan importantconsiderationthatmaybetakenintoaccountwhendesigningmealsforpeoplewitheatingproblems.Oilandsugarareoftenmixed inmeals formalnourishedpeople to increase theenergyintake.

SugarisarefinedproductandcancausevariouscomplicationsinPLHIVwhoarefaradvanced in theprogression toAIDS.Forexample,candida (oral thrush)canbeworsenedbytheconsumptionofrefinedsugar.ItisthusimportanttocarefullyconsultwithexpertcounterpartsbeforeincludingsugarinfoodaidrationsthatarefocusedonPLHIV.

Salt does not provide any energy. It is normally included in the food basket forpurposes of taste, electrolyte balance in warm climates (making up for loss ofmineralsduetosweating)and,veryimportantly,asacarrierforiodine.Asamatterofprocurementpolicy,WFPrequiresthatall thesalt itprocuresbe iodized. Saltprovidedforfoodaidpurposesshouldalwaysbefortifiedwithiodine.Althoughmanycountrieshaveagreedtouniversallyfortifysaltwithiodine,notallconsumedsaltisfortified,particularlywherenaturalsaltsourcesareusedinsteadofcommerciallyrefinedsalt.Adeficiencyof iodinecan lead tophysicalproblemssuchasgoiter(enlargedthyroid)andcretinism(impairedphysicalandmentaldevelopment).Theseproblemsmaybeprevalent incertainpopulationsandaredangerousforwomenandsmallchildren.Itisthusimportanttoconsidertheiodinedeficiencylevelsinthetargetpopulationwhenmakingajudgmentabouttheinclusionofsalt.

Animal products

In food aid animal products are normally provided as canned fish, beef and cheese, and dried fish.

Animal products play an important role in providing protein, fat and a varietyof micronutrients. Unfortunately such products are not often available in poor


households.Wherepossible,householdsshouldbeencouraged toprovidesomeofthesefoodstopeoplewithparticularnutritionalvulnerabilities,includingPLHIV.Animalproductsshouldbecarefullypreparedtomakesuretheyaresafetoeat.

Canned meat, fish and cheese are expensive and rarely available in sufficientquantitiestobeusedinlarge-scalefoodaidprogrammes.Astheyareindustriallyprocessed,usingheattreatment,theyareconsideredsafe.Driedfishissometimesusedinfoodaidprogrammes.

Sourcesofvegetableproteinaremuchcheaperthansourcesofanimalprotein,andcandramaticallyreducethecostofprogrammes.

Dried skimmed milkDriedskimmedmilk(DSM)issometimesavailableforfoodaidactivitiesandcanbe a valuable ingredient for drinks and porridges used in nutrition rehabilitationprogrammes (often mixed with sugar, oil and/or combined with FBFs). Thereconstitutionofthemilkpowderrequiresmixingwithsafewater,preferablyboiled.Astheonlywaytoascertainthesafeuseofmilkpowderistosupervisethemixing,DSM is not used in household or individual take-home rations as a standalonecommodity. However, it can be premixed with cereal flour or FBFs and as suchenrichthefoodbasket.Premixingshouldbedoneinhygienicconditionssoasnottoexposetheproducttocontaminantsorspeedupthespoilage(rancidity)process.

It is strongly recommended thatDSMnot beusedas a stand-alone commodityunless required for specific nutritional purposes and prepared and consumedundersupervision.

Ready-to-Use Therapeutic FoodReady-to-UseTherapeuticFood(RUTF)isaspecializedfooddevelopedspecificallyforthenutritionalrehabilitationofmalnourishedindividuals.Althoughmainlyknownunderthecommercialname‘PlumpyNut’,variouslocalproductioninitiativesaredevelopingappropriaterecipesforlocalvarietiesbasedonthesameprinciple.RUTFistypicallymadeofpeanutpaste(variationsusingbeansalsoexist),oil,sugarandDSMandarefortifiedwithaspecialmicronutrientmix.


RUTFissufficientlydifferentinappearance,texture,tasteandsmellfromregularhouseholdfoodcommoditiestobesuccessfullytargetedtovulnerableindividualsasaspecialnutritionalsupplement.Whereasitwasoriginallydevelopedtosupportcommunity-based therapeutic care for severely malnourished children, it iscurrentlybeingtriedinMalawiandothercountriesforthenutritionalrehabilitationofseverelymalnourishedadultAIDSpatientsonART.Preliminaryfindingssuggesthigh acceptability rates of RUTF, and impressive changes in both weight gainandincreasedmobilityofpatients,indicatingthatRUTFholdsgreatpromiseasatherapeuticcomponentofHIVtreatment.However,thepreliminaryfindingsneedtobereplicatedonalargerscale.

RUTF’sdohaveasignificantlyhighercostthanthecommoditiesthatWFPnormallyuses. For example, locally produced RUTF in Malawi is estimated to cost aboutUS$3000-4000perton(possiblyloweronceitismassproduced)ascomparedtoUS$410pertonforCSB.

Duetothelackofevidenceofthebenefitofspecializedproductsoverlower-costcommodityoptionscurrentlyusedinWFP’sprogrammes,themostprudentoptionisforWFPtocontinuetouseexistingcommodities(suchasstaples,pulses,oil,andFBFs) in itsprogrammes tomeet thenutritionalneedsofPLHIVand tocarefullymonitornewstudiesoftheeffectivenessofnewcommodities.

Micronutrient powders

Micronutrientpowders(MNP)forhome-basedfortificationareincreasinglyusedasawayofaddressingmicronutrientdeficiencies.Oftendistributedinsmallsachets,theyaresprinkledonthefoodormixedinaftercookingbutbeforeeating.WFPiscurrentlypilotingtheuseofMNP inschool feedingprogrammesandemergencyprogrammes, and in the future there may be opportunities to use them inHIVprogrammes.

Breast milk substitute

The decision thatHIV-positivemothersmustmake aboutwhether to breastfeedorformulafeedtheirchildrenisadifficultonethatinvolvesbalancingtwosetsofrisks:theriskoftransmittingthevirustotheirchildrenagainstthesignificanthealth


risksassociatedwithformulafeedinginunsafecontexts.WFPandotheragenciesrecognizetherightofHIV-positivemotherstomakethisdecision.CurrentguidancefromWHO/UNICEFstatesthatreplacementfeedingmayberecommendedwhereitis“acceptable,feasible,affordable,sustainableandsafe.”

WhilesomePMTCTprogrammessupportedbyWFPmayprovideformulaaspartoftheservicesbeingoffered,WFPhasapolicynottoprovideinfantformula.Thispolicyisbasedon:(i)concernsthattheconditionsoutlinedaboveforsafereplacementfeedingdonotexistamongthepopulationssupportedbyWFP;and(ii)thehighcostofinfantformula.WFP’sMemorandaofUnderstandingwithUNICEFandUNHCRforemergencysettingsplacestheresponsibilityofprovidingformulawiththosepartneragencies.

Other specialized products

WFPisfrequentlyapproachedbycompaniesofferingspecializedfoodcommoditiesproduced and marketed for PLHIV. Most of these commodities have not beentestedforeffectivenessoradequatelyevaluatedforsafety.ToensurethatWFPfoodcommoditiesaresafeforbeneficiaries,allnewproductsproposedforusebyWFPmustfirstbeapprovedbytheTechnicalAssistanceGroup,whichisanindependentpanelcomposedofexpertsonfoodtechnology,nutritionandfoodsafety.Furtherdetailscanbeobtainedbywritingtotag@wfp.org.

Section5:ExamplesofRationDesignProcess

Section 5: Examples of

Ration Design Process


Section5:ExamplesofRationDesignProcess

Hypothetical case: food assistance in response to drought and conflict in ‘Gotongo’

Context

‘Gotongo,’with an estimatedpopulation of 7.4million (2005), is classifiedas aleast developed, low-income food-deficit country (LIFDC) and ranked as one ofthemostfoodinsecurecountriesintheworld. It isalsoparticularlyvulnerabletorecurringnaturaldisasters (floods,droughtandanimaldiseaseepidemics),whileHIVprevalenceisat9.5percent,making‘Gotongo’oneofthehardesthitcountriesin the region. Moreover, the region has been subject to conflicts for 15 years(1991-2005),andthepresenceof largenumbersof internallydisplacedpersons(IDPs)andrefugeescontinuestoincreasethepressureonalreadyover-stretchednatural,socialandeconomicresources.Atpresent,thesituationhasbeenfurtheraggravatedbyexceptionallysevereandprolongeddroughtsandpoorrainsoverthepastfouryears.Inmanypartsofthecountry,pastoralistshavelost50percentormoreoftheirlivestockherds;destitution,especiallyinthesouth,isontheincrease.Among the coping mechanisms are over-fishing and cutting trees for charcoal,leadingtosevereenvironmentaldegradationthroughoutthecountry.

Effects of the conflict and drought on agriculture and food availability

Foodavailabilityvariesgreatlyamongthefourareasintowhich‘Gotongo’isdivided.

IntheNorthern Province,nomadiclivestockrearingandsomerain-fedsubsistenceagriculturearetheprincipaleconomicactivities.

In Pokolo, which covers the regions in eastern ‘Gotongo,’ livestock rearing andfishingarethemainfoodproductionactivities.Pokoloistheareaofthecountrythat


hassufferedthemostfromthelongdroughtcycleof2001-2004,compoundedbytheeffectsoftheAIDSepidemic.

In the Central Region, good rains in 2004/2005 led to improved range-land,increasedwateravailabilityandlivestockrecovery.Consequently,livestockproductionandtheavailabilityoflivestockproducts,particularlymilk,havegenerallyimprovedthroughouttheregion.Therecoveryprocessalsocontinuestobeconstrainedbypocketsofdrought,localizedconflictsandinsecurity.

Southern Provincehassufferedthemostfromcivilconflict.Since1991,extensionservices, credit, pest control and agricultural inputs have not been available tofarmers.Asa result, overall productionof staple food (sorghumandmaize) hasfallenbyasmuchas50percentinmostoftheagriculturallyimportantregions.Theoutputofmajorexportcrops(bananas,grapefruit,andwatermelons)hasdroppeddramatically.

Nutrition and health

IntheNorthernProvinceandPokolo,whichalreadyhadhighacutemalnutritionastheresultoffailed2005rains,thecurrentrateofacutemalnutritionisestimatedtobeover20percent.Foodinsecurityandmalnutritionhavebeenexacerbatedbylackof health care, poor infant-feedingpracticesand inadequate sanitationandpublic hygiene. Recent data available from sentinel sites have estimated acutemalnutritionratestobehigherthan15percent inthesouthwesternareasofthecountry.Also,UNICEFisoftheopinionthatmicronutrientdeficiencies–includingiron-deficiencyanaemia,vitaminAdeficiencyandiodinedeficiency–areserioushealth issues facing“Gotonguese” population.Anaemia is suspected to be highamongwomenandadolescents,andiodinedeficiencyisapublichealthconcern,asaccesstoiodizedsaltisextremelylow.

Objectives of WFP assistance

Theoverallgoalofthisprotractedreliefandrecoveryoperation(PRRO)istosavelivesandprotectlivelihoodswhilecontributingtonationalstabilityandthehouseholdfoodsecurityofIDPs,returnees,affectedhostcommunitiesandothervulnerablegroups


throughfoodaidinterventionsthatencouragethelong-termrecoveryofpeoplewhohavesufferedasaresultoftheconflictandrecurrentnaturaldisasters.

Objectives

The immediate objectives and corresponding WFP strategic objectives of thisPRROareto:

• savelivesofpeopleaffectedbyconflictanddisaster;

• protectandrecoverpeople’slivelihoods;

• improvethenutritionandhealthstatusofchildren,mothers,includingthoseinPMTCTprogrammes,PLHIVandothervulnerablepeople;and

• supportaccesstobasiceducation,particularlyforgirls.

Based on this scenario, two ration designs are presented on the pagesthatfollow.

Exercise 1: Ration design for PLHIV in IDP camps

Thereareanestimated2500PLHIVamongtheIDPs,concentratedmostlyinPokoloprovince.ARTservicesarenotorganizedinthecamp,butmostofthePLHIVreceivetreatmentfortheirchronicillnessesthroughhome-basedcareservicesadministeredbyvolunteers.Asisthecasewithallpeoplelivinginthecamps,PLHIVreceivethegeneralfooddistribution(GFD)rationcomprisedofmaizemeal,beans,vegetableoil,andiodizedsalt(2100kcalstotal).Supplementaryandtherapeuticfeedingareorganized for moderately malnourished and malnourished children. Moderatelymalnourishedchildrenandvulnerablepregnantandbreastfeedingwomenreceiveadryrationof1200kcalscomposedofCSB,sugarandoil.


Thisstepisaccomplishedbyreviewingallinformationfromassessments,surveysandvulnerabilitystudies.Basedonthereview,weknowthat:


• LikeotherIDPs,PLHIVlivingincampsarefoodinsecureandreceivefoodrationsthroughGFD

• Acutemalnutritionrateisveryhigh

• Healthandsanitationconditionsareverypoor

• HBCservicesareavailableinthecamp

• IDPs,includingPLHIV,engageinnegativecopingmechanismssuchassellingtheirassets(property,cattle)withdrawingchildrenfromschools,andeatingonlyonemeal

• Pokole,theregionhostingmostofthe2500PLHIVwashitbydrought

In conclusion, PLHIV are vulnerable and would benefit from a supplementary ration that would complement the ration they receive through GFD and allow them to take up HBC services.


Accordingtotheinformationprovidedabove,theobjectiveoftheprogrammehereistoimprove/maintainthenutritionalwellbeingofPLHIVandtoincreasetheuptakeofHBCservicesinthecamp.ThefoodaidwouldplaytheroleofnutritionalsupplementandenablerforHBCservicesinthecamp.

Step 3: Determine how much food needs to be provided and for how long

WeknowthattheencampedpopulationreceivesGFDrationsthatnormallyprovide2100kcalsperperson.TakingintoconsiderationtheincreasedenergyrequirementsofPLHIV(seeBox5),weshouldincreasetherationofPLHIVby500kcal(equivalentto a 20 percent increase), which can be doubled to take into consideration theintra-householdrationsharing.Ideally,therationshouldbegivenuntilindicatorsofqualityoflife(primarilyweightgain)improve,butshouldbelimitedtoanaverageofsixmonths.


In conclusion, a supplementary ration of 1000 kcal should be given for a limited period of time, to be determined by periodic assessments.


Among the many considerations that should help decide on the choice offood commodities and type of ration, the most important in this context areprobably palatability and digestibility, fortification and micronutrient content.ThecomplementaryfoodbasketshouldconsistofCSB,oilandsugarastheyarealreadyprovidedthroughthegeneraldistributiontotheencampedpopulation.

In line with guidance beginning on page 23, the obvious solution here would be to give complementary rations as take-home rations to PLHIV through HBC services.

Step 5: Consider activities to put in place to enhance the expected benefits of the food rations

Potentialcomplementaryactivitiescould includenutritioneducation,hygieneandsanitationsensitizationand,ifclimacticconditionsallowit,gardening.

Exercise 2: Ration design for OVC in Southern Province

TheSouthernProvinceishosttoanestimated35,000OVC,includingsome12,000attendingschoolssupportedbyWFP.MostoftheOVCliveinfosterfamilies,despitetheincreasingreluctanceofsomefamiliestotakeinOVCduetosocio-economicconstraints.With theongoingmulti-sectoralcrisis, it is feared thatmore familieswillbeforcedtowithdrawOVCfromschoolsandevenworse,abandonOVCwhoarealreadyhosted.



Areviewofvulnerabilityandfoodsecuritydatarevealsthat:

• Theregion,hosttomostOVC,istheonethathassufferedthemostfromthecivilwar, leading toacollapseof theeconomy,weakened livelihoodsamongfamilies,andincreaseddestitution

• FamilieswhotakeinOVCareverypoorandfoodinsecure

• OVCaredroppingoutofschoolbecause foster familiescannotafford topayschoolfees

In conclusion, families hosting OVC need a livelihood support to encourage them to continue to take in OVC and keep them in school.


TheobjectiveoftheprogrammewouldbetoprovideasafetynetforfosterfamiliesandincreasethenumberoffamilieswhotakeinOVC.Anotherobjectivecouldbetomaintainor improveOVCschoolattendance.The roleof foodaidcouldbe tocontributetohouseholdfoodsupplyorincometransfer.

Step 3: Determine how much food needs to be provided and for how long

Inlinewiththeobjectivesandtheroleoffoodaidoutlinedabove,andinlinewiththefindingsfromtheassessments,let’sassumethatitwasdecidedthattherationshould aim to transfer an equivalent of US$4 per day (4000 ‘Gotongo’ Francs(GF))toassistedhouseholds.ThecompositionofthisrationwillbedeterminedatStep4.Therationshouldbegiveninprincipleuntilfoodsecurityindicatorsimprove;butforpracticalreasons,itmaybedecidedthatfoodsupportwillbeprovidedfor


12months,atwhichtimeanassessmentwilldeterminewhetherfoodsupportcanbecontinuedorthehouseholdcanbetransferredtoanotherprogramme,suchasafoodsecurityorsocialprotectionprogramme.


Inthecontextof‘Gotongo,’theagreedtransferof4,000GFperbeneficiaryperday(seeabove)wouldbeequivalentto10kgofcereal,1.2kgofpulses,600gofoiland600gofoilpermonthperbeneficiary.Thiswouldtranslateinto50kgofcereals,6kgofpulsesand3kgofoilperassistedhouseholdoffivebeneficiariespermonth.

Step 5: Consider activities to put in place to enhance the expected benefits of the food rations

Nutrition counseling and education should be emphasized, along with improvedstorageandpreservation,andgardening(seeguidanceonpages28and29).


References

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http://www.who.int/nutrition/topics/Paper_1_Macronutrients_bangkok.pdf

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13. TomkinsAMetal.EvidencebasednutritioninterventionsforthecontrolofHIV/AIDS,SouthAfricanJournalofClinicalNutrition,Volume18Issue22005

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http://www.who.int/nutrition/topics/Paper_4_Growth_failure_bangkok.pdf

15. ManaryM.Jetal.Homebasedtherapyforseveremalnutritionwithready-to-usefood.ArchivesofDiseaseinChildhood.89(6):557-561,June2004.

16. SaadehRJetal.InfantfeedingandHIVtransmission:AReviewofCurrentEvidence.ConsultationonNutritionandHIV/AIDSinAfrica:Evidence,lessonsandrecommendationsforaction.Durban,SouthAfrica,WHO2005.

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17. DunnDTetal.Mother-to-childtransmissionofHIV:implicationsofvariationinmaternalinfectivityofHIV.AIDS,1998,12:2211-22.

18. HIVandInfantFeedingTechnicalConsultationonPreventionofHIVInfectionsinPregnantWomen,MothersandtheirInfants.WHO,2006

http://www.who.int/reproductive-health/stis/mtct/infantfeedingconsensusstatement.pdf

19. Communityhomebasedcareinresource–limitedsettings.Aframeworkforaction,WHO2002. http://www.who.int/hiv/pub/prev_care/isbn9241562137.pdf

20. GuidelinesforHIV/AIDSinterventionsinemergencysettings.Inter-AgencyStandingCommittee2003.

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21. FANTAandWFP.FoodAssistanceProgrammingintheContextofHIV,WashingtonDC:FANTAProject,AcademyforEducationalDevelopment,2007

http://www.wfp.org/food_aid/doc/Food_Assistance_Context_of_HIV_Oct_edits.pdf

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