Tuberculosis and Nutrition Experiences from the Integration of

Tuberculosis and Nutrition Experiences from the Integration of Food and Nutrition in Care and Treatment Programmes GBC Workshop on Increasing Corporate Engagement on Tuberculosis 23 February 2010 Cape Town, South Africa

WHY WFP • 100% voluntary funded • Low overhead costs • Mandated to respond globally to – Emergency aid – Recovery assistance – Chronic hunger reduction Cost estimates • US$0. 25 - Feed a hungry school child per day • US$0. 31 – Feed Orphan and/or vulnerable child per day • US$0. 66 – to provide nutrition support to an AIDS patient plus family per day

UNAIDS Cosponsors – – – – – UNHCR UNICEF WFP UNDP UNFPA UNODC ILO UNESCO WHO WORLD BANK WFP’s lead role is dietary and nutritional support

Background • Southern Africa has the world's highest HIV infection rates • About one third of PLHIV in the region are co-infected with TB - TB is the leading cause of death among PLHIV • Severe malnutrition, Body Mass Index (BMI)<16, is associated with an increased risk of death in the first 4 weeks of TB treatment • Drug side effects reduce TB treatment compliance • WFP and partners’ support treatment programmes in 14 countries in the region (pre-ART/OI, ART, TB) • Align with national systems for greater ownership and replication Need to use ongoing programmes as platforms for services model development and national strategic guidance!

WFP Food Assistance Programmes HIV, Social Care & AIDS, Safety TB, Nets Treatment Drugs, Livelihoods Malnutrition, promotion Poverty “Drugs alone are not enough. Food and nutritional support should be an essential part of the care package for people with HIV/AIDS or tuberculosis” ‘The Lancet’, March 2007

Programme Objectives Programmes are designed to achieve one or more (often closely related) objectives, including: • Nutritional rehabilitation and/or nutrition support to improve individual well-being and treatment success • Social safety nets mechanisms to support treatment adherence and protect the household structure • Livelihood activities to encourage a productive recovery and sustain long-term adherence.

Types of Commodities • Corn Soya Blend and oil for nutrition rehabilitation • Cereals, pulses, oil, salt for household • Other specialized products – RUTF supplied by partner agencies Judy Pudlowski, International Medical Corps

Quality Assurance TAG = Technical Advisory Group: • External, independent • Composed of experts in field of nutrition, food safety, food legislation, consumer acceptability • Reviews all ‘new’ products offered to WFP and advises WFP on their appropriateness for use in WFP programmes

Operational Challenges Product choices and associated operational considerations are driven by technical and services delivery parameters i. e. protocols All operational considerations are closely linked to design decisions and vice versa • Commodities • Staff capacity • Infrastructure • Supply chain management

Operational Challenges: Commodities • Nutritional supplements versus staple commodities (volume, packaging) • Purpose of food reflected in product type - Food as ‘medicine’ or food for social welfare • Number of specialized products for advanced care protocol – elaboration complicates product handling Specialized nutritional supplements easier accepted as health products & facilitation of integration in health protocols and supply management Implication of care protocols for product choice

Operational Challenges: Staff Capacity • Integration in job description of doctors, nurses, pharmacists • Requirement for additional staff cadre • Need for integration within curriculum or on-the-job training • Encourage perspective of food as health product • Integration of nutritional care within treatment protocol Disconnect between nutritional care, ‘prescription’ and commodity handling discourages full responsibility by ‘medical’ staff Food and nutrition support perceived as parallel/add-on service

Operational Challenges: Infrastructure • Staple foods often stored and handled outside the clinic due to bulk (storage volume, spillage), so as specialized nutritional supplements • Requirement for weighing or measuring equipment to determine individual and/or HH entitlements • Location and timing of food distributions do not always match clinic visits (opportunity costs) ‘Distance’ between health trigger and food support purpose and handling location dilutes the health messaging on the use of food products Client perception of role of food!

Operational Challenges: Supply Chain Management • Integration in medical supply chain (Proportioned supplies by manufacturers/suppliers ) • High cost of supplies to sites with limited clients (high cost/volume) • Explore commercial supply managers, including retailers (cash/voucher) Integration is the way forward for national programming Products need to be adjusted to medical supply chain parameters

Operational Suggestions Products for individual nutritional support: • Needs to be provided based on prescription • Should be integrated in routine patient care and case management - clinicians role and responsibility • Need formalized protocols and training (including NAEC) • Product development (apart from specialized ‘recipe’), shelf life, portions, packaging • Product supply managed within medical supply chain • Procurement through local industries for easier access and sustainability • Quality assurance and oversight - Food standards, national/regional regulation regarding health claims

Operational suggestions, cont. Products for household support: • Distinguish purpose from specialized supplements • Handle food products (staples) outside the health sector infrastructure – civil society, retail • Consider the use of innovative social transfer modalities (cash, vouchers) • Consider linkages to livelihood enhancing activities and existing social welfare schemes • Consider (semi)-conditionality to encourage ‘graduation’

Lessons Learnt Food and nutrition assistance • Improves nutritional status of patients • Enhances treatment adherence • Decreases treatment default rates, as food acts as an incentive for the patient to visit the health facility • Increases patients’ access to health services including HIV counseling and testing • RUTF more effective in severe malnutrition • CSB more appropriate for mild to moderate malnutrition

Thank you