Integrating food and nutrition security interventions into AIDS care and

treatment: Fostering evidence based programming

TASO-RENEWAL-WFP- Concern Worldwide and other food and livelihood program partners

2 Years Ago: RENEWAL 3 Workshop 2007

HIV and Nutrition Security Theme Working group

Malnutrition and HIV disease progression

• Degree of malnutrition clearly linked with mortality risk in adults and children

• Compromises efficacy & increases toxicity of ARVs– Undesirable ARV side effects – Threats of decline in ARV adherence– Higher mortality in the first three months of ART initiation

• High levels of vitamin B, C, E, folate, Se slow the progression from HIV to AIDS (↑ CD 4 counts & ↓ viral load)– Role of Vitamin A and Zn not consistent across studies

Source: WHO 2005; Fawzi 204; Moore et al 2006; Zachariah et al 2007; Au et al 2008; and other sources

Impact of AIDS on Household Welfare

• Deterioration of food security due to chronic morbidity & mortality through – reduced income, increased expenditures – loss of labor productivity– time for care-giving

• Reduced human capital investments– Children's education – Child survival and growth

Source: Gillespie and Kadiyala 2005; Gillespie 2006; Chapoto and Jayne 2007; Yamauchi et al 2007; Kadiyala et al 2009 & other sources

Integrating nutrition security interventions

• A significant response of food assistance programming to people affected by HIV & AIDS (mostly by WFP, USAID programs incl. PEPFAR)

• Many organizations attempting to integrate livelihood programs to improve food security.– TASO partners with many such organizations

• Evidence base on these programs still weak:– If the programs are effective?– If not, why not? E.g. Quality of implementation?

Food and nutrition along the HIV timeline

Risk HIV AIDS Impacts

Prevention Care & treatment Mitigation

At each point, what are the key roles of food and nutrition research and programming?

Source: IFPRI/RENEWAL

RENEWAL 3 2007 Agenda

• What is the evidence of effectiveness and cost-effectiveness of relatively short-term interventions?

• How to integrate long-term sustainable interventions?

• How do we make use of the date we have to build the evidence base?

8

The AIDS Support Organization (TASO)

• TASO (www.tasouganda.org) was founded in 1987 to contribute to prevention of HIV, restoring hope and improving the quality of life of persons, families and communities affected by AIDS.

• It provides counseling, medical care, and social (including nutritional) support to PLWHA and their families; HIV education to the public , training and capacity building of other NGOs/CBOs.

• It has 11 branches and serves 80,000 clients annually following Government of Uganda service guidelines.

• It is a key play in the National (Uganda) response and works in partnership with various agencies.

Collection, Analysis, and Use of Programming Data in TASO

• TASO maintains databases on its clients and the services they receive.

• The data is routinely analyzed for purposes of improving service delivery and management.

• The data is also used in collaborative studies aimed at answering key strategic questions; the hence current partnership with IFPRI/ RENEWAL, & others.

• The interest in the studies is contribute to service improvement, the knowledge base, and to national and international policy development.

1. Utilizing the existing data

How does the provision of food assistance affect BMI and change in WHO staging?

– Preliminary Results:a) Food assistance had a positive impact on weight gainb) Food assistance helped slow transitions in WHO Stagec) Impacts varied by initial WHO stage at which food assistance is

provided (earlier is better)

(RENEWAL/IFPRI & Concern Worldwide, WFP, Univ. of Illinois and others )

2. Effectiveness of Food Supplementation Study(baseline recruitment ongoing)

To estimate the effectiveness (including cost-effectiveness) of food support (in the form of a WFP HH food basket) provided to HIV-infected individuals who are not yet on anti-retroviral therapy (ART)

• Individual welfare outcomes• Household welfare outcomes

(TASO, WFP, RENEWAL/IFPRI , Concern Worldwide & Univ. of Illinois)

Study Design

GULU(Receiving food aid for 12 mo.)

Eligibility: 400 PLHIVCD4: 200-450

Not currently on food aid but eligible

SOROTI(Not receiving food aid)

Eligibiliy:400 PLHIVCD4: 200-450

Not currently on food aid but eligible

800 HIV-infected, ART ineligible TASO clientsw/ CD4 counts 200-450 & eligible for food assistance

Baseline clinic and household survey (July 2008-June 2009)12-month follow-up (September 2009- June 2010)

Outcomes

Individual

• Disease progression (CD4 count, WHO stage)

• Health –OIs and symptoms

• Nutritional status (BMI, MUAC, Hb)

• High risk behavior• Quality of Life• Disclosure• Stigma• Access to health care

Household• HH food security & dietary

diversity• Anthropometry (=<5yrs)• Health and quality of life• Economic activities and

employment• Assets, indebtedness• Expenditures (food & non

food)• Agriculture production• Intra-household labor

allocations

3. Operations Research to Improve Livelihood Programming (data collection complete)

OR, with livelihood program implementing partners (LP), to investigate – whether integrated livelihood and HIV/AIDS programs

share a clearly elucidated causal pathway to impact– the service delivery and utilization plans of programs to

realize the intended impact on food security– the household level determinants of program

effectiveness and sustainability • E.g. relevance, quality of programs, local participation

(TASO, RENEWAL/IFPRI, Concern Worldwide & 20 LPs )

RENEWAL-TASO Research Team

IFPRI/RENEWAL• Suneetha Kadiyala• Rahul Rawat (also CWW)• Terry Roopnaraine (consultant)• Stuart Gillespie

TASO• Robert Ochai• Frances Babirye• Dr. Christine Nabiryo• Tina Achilla • TASO Jinja, Mbale, Gulu, Soroti

Research Assistance Team

• Mulowooza, Fiona• Ssegujja, Eric• Kyohangirwe, Rossette• Achola, Elizabeth• Werikhe, Susan• Christopher, Omoding• Murisho Shafi• Okello Robert Bob• Sentamu Ismail• Alex Kagaha*

With active participation from TASO clients

Traditional Evaluation of Impact

BaselineSurvey

EndlineSurvey

Program Implementation

Baseline and Endline Measures of Indicators of Interest:

•Food Insecurity•Dietary Diversity•Nutritional Status (e.g. BMI, Hb)•HH level Indicators

This design determines IF there is impact

If there is NO IMPACT, this design does not answer WHY

How Programs Operate

Inputs Outputs Outcomes Impacts

Processes

Processes

Research Methods

• in-depth key informant interviewing with program staff from TASO and 20 LP implementing partner organizations

• in-depth, multiple-contact interviewing with TASO clients in 71 households

• 4 TASO catchment areas (Jinja, Mbale, Soroti and Gulu)• Interviews were taped and transcribed into English• Coding & analysis using Nvivo 8

Framework for Conducting Operations Research of Livelihood Programs Integrated with HIV/AIDS Care and Treatment

Services

Program Theory FrameworkImpact Theory

•Specifies impact pathways

•What are the steps by which a program intervention is expected to impact outcomes?

•Specifies causal pathways to achieving impact

Process Theory

•Shows steps by which intervention or program is implemented

•Includes steps related to organizational plan

•Also includes steps related to service utilization plan

Emerging Impact Theory Results

• Program staff asked what their programs were trying to achieve– Senor staff usually able to offer responses consistent with

objectives laid out in program documentation– Often not the case farther down the program chain

• Inconsistencies in explanation of program design– Staff emphasize wide range of program inputs, but clients

offer different opinion

Key Themes Addressed in Service Delivery and Utilization (Process Theory)

• Necessary client actions to optimize program benefits

• Necessary program actions to optimize program impact

Emerging Process Theory ResultsClient actions• Living positively:

– Disclosure & overcoming stigma– Non- fatalistic attitude

• Demonstrated commitment to the program:– Appropriate use of inputs– Peer training

• Joint monitoring & feedback with program staff:– Provide honest information

• Effective group management:– Group cohesion– Planning & management of

group resources – Fairness in resource allocation

Program actions• Integration of LP services with other

services: – medical, veterinary & extension

• Client and community involvement:– In choice of input & program design– Intensive mobilization– Monitoring & feedback– Involve family members in program– Creating a sense of ownership

• Working within local community structures:– Existing social capital

• Creating links :– Ensuring that support is provided

along the entire chain including processing and marketing

Operations Research in Practice

• Focus on process and delivery– Understanding the “how”

• Feedback into program design • Adaptable, if planned well• Challenges

– Requires human resource inputs– Requires monetary inputs– Requires careful planning at an early stage– Programs must be amenable to change

– Creating Program-Research Synergy