INDICATOR GUIDE

FAN TA 2
FOOD AND NUTRITIO
N T E C H N I C AL A S S I S T
ANCE

Guide to Screening for

Food and Nutrition
Services among
Adolescents and Adults
Living with HIV
Alison Tumilowicz
2016

Food and Nutrition Technical Assistance III Project (FANTA)

FHI 360 1825 Connecticut Ave., NW Washington, DC 20009-5721
Tel: 202-884-8000 Fax: 202-884-8432 E-mail: [email protected] Website: www.fantaproject.org
 Guide to Screening for
Food and Nutrition Services
Among Adolescents and Adults
Living with HIV

Alison Tumilowicz

March 2016

Food and Nutrition Technical Assistance III Project (FANTA)

FHI 360 1825 Connecticut Avenue, NW Washington, DC 20009-5721
Tel: 202-884-8000 Fax: 202-884-8432 [email protected] www.fantaproject.org
This report is made possible by the generous Recommended Citation:
support of the American people through the
support of the Office of HIV/AIDS and the Office Tumilowicz, Alison. Guide to Screening for
Food of Health, Infectious Diseases, and Nutrition, and Nutrition Services Among Adolescents and
Bureau for Global Health, United States Agency Adults Living with HIV. Washington, DC: Food
for International Development (USAID), under and Nutrition Technical Assistance III Project
terms of Cooperative Agreement No. GHN-A-00- (FANTA), FHI 360, 2010.
08-00001-00, through the Food and Nutrition
Technical Assistance III Project (FANTA), Contact information:
managed by FHI 360.
Food and Nutrition Technical Assistance III
The contents are the responsibility of FHI 360 Project (FANTA)
and do not necessarily reflect the views of FHI 360
USAID or the United States Government. 1825 Connecticut Avenue, NW
Washington, D.C. 20009-5721
Published March 2010 Tel: 202-884-8000
Fax: 202-884-8432
Email: [email protected]
Website: www.fantaproject.org
Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living with HIV
Acknowledgments
Technical input and review of earlier drafts were provided by Eunyong Chung (USAID), Timothy Quick
(USAID), Randa Jarudi Saadeh, Micheline Diepart and Juan Pablo Pena-Rosas (WHO), and Tony
Castleman, Hedwige Deconinck, Megan Deitchler, Serigne Diene, Pamela Fergusson, Wendy Hammond,
Philip Moses, Sandra Remancus, Anne Swindale, Joan Whelan and Monica Woldt (FANTA-2).

ii
Acronyms and Abbreviations

ART Antiretroviral therapy

BBW Baseline body weight
BMI Body mass index
CSB Corn-soy blend
cm Centimeter(s)
FANTA-2 Food and Nutrition Technical Assistance II Project
FBF Fortified-blended food
HIV Human immunodeficiency virus
IOM Institute of Medicine at the United States National Academy of Sciences
IUGR Intrauterine growth retardation
kg Kilograms
LBW Low birth weight
m Meter(s)
MUAC Mid-upper arm circumference
OI Opportunistic infection
PEPFAR United States President’s Emergency Plan for AIDS Relief
PLHIV People living with HIV
RDA Recommended Daily Allowance
RUTF Ready-to-use therapeutic food
SD Standard deviation(s)
USAID United States Agency for International Development
WFP World Food Programme
WHO World Health Organization
> Greater than
≥ Greater than or equal to
< Less than
≤ Less than or equal to
Purpose and Scope of the Guide

The relationship between HIV and nutrition is bidirectional and multifaceted. HIV can cause or worsen
malnutrition due to increased energy requirements, reduced food intake and poor nutrient absorption.
Malnutrition, in turn, further weakens the immune system, increasing susceptibility to infections and
worsening the disease’s impact. Among those in antiretroviral therapy (ART), poor diet may also
increase digestive track and metabolic-adverse reactions, reducing treatment adherence and increasing
morbidity.

Recognizing the important role food and nutrition play in comprehensive care of people living with HIV
(PLHIV), countries and programs, such as those supported by the United States President’s Emergency
Plan for AIDS Relief (PEPFAR), the World Health Organization (WHO) and the World Food Programme
(WFP), are increasingly integrating food and nutrition services into HIV care and treatment programs. As
HIV care and treatment programs scale up food and nutrition services among PLHIV, implementing
agencies have expressed the need for guidance on how to screen PLHIV who need food and nutrition
services.
1
This guide provides direction on how to screen HIV-infected older adolescents and adults who need
food and nutrition services, including:

1. Nutrition assessment and counseling

2. Provision of specialized food products
2
3. Micronutrient supplementation
4. Food security and livelihood services

This guide is structured around the four services listed above and includes a section for each.

In the context of this guide, the objective of screening is to quickly classify clients into two groups: 1.
those with more need for food and nutrition services and 2. those with less need for food and nutrition
services. The screening criteria presented here are brief and simple, with clear cut-offs for referral or
action.

This guide does not provide information on nutrition assessment; designing nutrition assessment
protocols is outside the scope of this guide. The objective of nutrition assessment is to understand a
client’s nutritional status in order to develop a nutrition care plan consisting of nutrition goals, food and
nutrition services, and medical treatment. Nutrition assessment involves evaluating more factors (client
anthropometric measurements, biochemical lab tests, clinical characteristics and dietary patterns) and
is more comprehensive than screening, which is the focus of this guide.

Ideally, every PLHIV should receive individualized nutrition assessment and counseling. However, it is
not always possible for facilities to provide nutrition assessment and counseling for all clients because of
limited staffing. This guide describes conditions that can be used to screen PLHIV who need nutrition
assessment and counseling when prioritizing clients is necessary.

In some cases, screening criteria may be sufficient to determine if a food or nutrition service should be
provided to a client. For example, screening clients for low body mass index (BMI) may provide sufficient
information to determine if a client should receive specialized food products. However, because
screening is brief, it generally results in referral for further nutrition assessment. For example, clients
screened for weight loss should be assessed for the causes of weight loss and an integrated medical
and nutrition care plan should be developed to reverse the weight loss. Clients screened for inadequate
household food access may need further assessment for eligibility for food security and livelihood
services.

Table 1 summarizes the differences between nutrition screening and nutrition assessment.

1
Table 1. Differences Between Nutrition Screening and Nutrition Assessment
Nutrition Screening Nutrition Assessment
Obtain information as a basis to assess
Identify clients who need food and
needs and develop a nutrition care plan
Purpose nutrition services and clients who
which includes nutrition goals, food and
need further assessment
nutrition services, and medical treatment
In depth medical, dietary and social
Brief, easy-to-complete information
history; anthropometric data; biochemical
Description collection with clear conditions for
data; and information on drug-nutrient
referral or action
interactions

Nutritional status changes over time, and clients who may not need food and nutrition services at one
point may need such services at a later date. Therefore, clients should be screened regularly during
clinical evaluation or visits by community-based service providers. Program managers must decide how
to screen clients most efficiently and effectively in their facilities and programs. The timing of screening
will differ depending on the set-up of services, capacity of service staff, client flow and services provided
to clients at a given site.

Table 2 lists conditions that indicate that clients need one or more food and nutrition services.

Table 2. Conditions That Indicate Need for Food and Nutrition Services
Service Conditions that Indicate Need for Service
Pregnancy or lactation
Symptoms that diet can help manage
Unintentional weight loss
Initiation of ART
1. Nutrition assessment and counseling
Consumption of specialized food products or micronutrient
supplements
Concern about or interest in nutrition
Never had nutrition education or counseling
Low BMI
Low BMI-for-age z-score
2. Provision of specialized food products Low mid-upper arm circumference (MUAC)
Unintentional weight loss
Inadequate weight gain during pregnancy
No consumption of fortified specialized food product or
3. Micronutrient supplementation micronutrient supplement (when micronutrient supplements are
routinely provided by health facility)
Fulfillment of eligibility criteria established by existing food
security and livelihood services
No household consumption of foods from at least one of the
4. Food security and livelihood services following food groups in the past 24 hours due to an inability to
access or buy these foods: a) vegetables and fruits; b) meat,
poultry, seafood and eggs; c) milk and milk products; d) oils and
fats

PLHIV may need one, several or all of the food and nutrition services. For example, clients screened for
weight loss may need nutrition assessment and counseling as well as the provision of specialized food
products. Clients may also have coexisting conditions, such as symptoms that diet can help manage
and weight loss, and may need more than one service.

The guide is designed for use by program managers, government officials, service providers, technical
assistance partners and others who are responsible for designing screening tools for food and nutrition
services for PLHIV and/or identifying and estimating the number of PLHIV who need a food and
nutrition service.

Figure 1 is a sample screening tool that can be adapted and integrated into facility- and community-
based care and treatment programs. It is meant for screening for food and nutrition services, not for
3
nutrition assessment.
Figure 1. Sample Screening Questionnaire for Nutrition Services
NUTRITION SCREENING TOOL
Date of screening (dd/mm/yy): Name of staff person completing screening:
Client name: Sex (M/F): Birthdate (dd/mm/yy):
1. NUTRITION ASSESSMENT AND COUNSELING
Is the client pregnant or lactating? Y N
In the past month, has the client experienced symptoms including
diarrhea, nausea, vomiting, thrush/mouth sores, anemia and lack of Y N
appetite that could be alleviated through diet?
In the past month, has the client felt that he or she has lost weight If the answer to any of these questions is
Y N
unintentionally? “yes,” refer the client to nutrition assessment
Has the client recently started or will soon start ART? Y N and counseling.

In the past month, has the client consumed specialized food products or
Y N
taken micronutrient supplements?
Does the client have any nutrition concerns or questions about his or her
Y N
diet?
Has the client ever received nutrition counseling since testing positive for If the answer to either of these questions is
Y N
HIV? “no,” refer to nutrition assessment and
Has the client ever received nutrition counseling since starting ART? Y N counseling.

2. PROVISION OF SPECIALIZED FOOD PRODUCTS

Weight in kilograms (kg) Height in meters (m) For adults > 18 years of age

Body mass index (BMI) If BMI < 16.0, refer for treatment of severe
(weight in kilograms) ÷ (height in meters)² malnutrition.
If BMI ≥ 16.0 and < 18.5, refer for treatment
If BMI-for-age < -3 SD, refer for treatment of
For adolescents 15-18 years of age severe malnutrition.
BMI-for-age z-score If BMI ≥ -3 and < -1 SD, refer for treatment of
mild to moderate malnutrition.
If MUAC < 19.0 cm, refer for treatment of
For pregnant or post-partum women up to 6 months after delivery severe malnutrition.
Mid-upper arm circumference (MUAC) in centimeters If MUAC ≥ 19.0 and < 22.0 cm, refer for
treatment of moderate malnutrition.
3. MICRONUTRIENT SUPPLEMENTATION
Is the client consuming fortified specialized food products designed for If the client is not consuming either a fortified
malnourished people or people living with HIV (PLHIV), such as ready- Y N specialized food product or micronutrient
to-use therapeutic food (RUTF) or fortified supplementary foods? supplement, refer for micronutrient
supplementation (only if facility provides MN
Is the client taking a micronutrient supplement? Y N supplements routinely).
4. FOOD SECURITY AND LIVELIHOOD SERVICES
Did the client or anyone in the household eat any of the following foods yesterday?
Vegetables or fruits Y N
Meat such as beef; pork; lamb; goat; rabbit wild game; chicken, duck or
other birds; liver, kidney, heart or other organ meats; fresh or dried fish Y N
or shellfish; eggs
Cheese, yogurt, milk or milk products Y N
Foods made with oil, fat or butter Y N
If the client or anyone in the household did NOT eat any of the foods from the food If the reason was inability to access or buy the
groups above, why not? foods, refer to food security and livelihood
services.
RESULT OF SCREENING
Referred to nutrition assessment and counseling? Y N
Provided with specialized food product? Y N
Provided with micronutrient supplement? Y N
Referred to food security and livelihood services? Y N
 1. Nutrition Assessment and Counseling

The objective of nutrition assessment is to understand a client’s nutritional status to develop a nutrition
care plan, which includes nutrition goals, food and nutrition services and medical treatment. Nutrition
assessment involves collecting information about a client’s socioeconomic characteristics, medical
history, dietary patterns, anthropometric measurements, clinical and biochemical characteristics, and
current treatment including medications. Nutrition counseling refers to an interactive process between
service provider and client to interpret information generated during assessment; understand client
preferences, constraints and options; and plan a feasible course of actions that supports healthy dietary
4
practices and referral for services.

PLHIV who know dietary recommendations related to HIV and can consume a healthy diet are better
able to manage symptoms, maximize the benefit of medications, enhance their quality of life, and
maintain or improve their nutritional status. Clients who do not know about dietary recommendations –
especially if they are pregnant or lactating or at critical points in disease progression and treatment
initiation – may be at greater risk of suffering from the effects of malnutrition and HIV-related symptoms.

Ideally, every PLHIV should receive individualized nutrition assessment and counseling. However, it is
not always possible for facilities to provide nutrition assessment and counseling for all clients because of
limited staffing. When prioritization of clients is necessary, the following conditions identify PLHIV who
need nutrition assessment and counseling. Facilities and programs screening clients can add other
conditions as appropriate.

PREGNANCY OR LACTATION

HIV-infected pregnant and lactating women are especially vulnerable to malnutrition. In addition to
increased nutrient requirements as a result of pregnancy or lactation, HIV-infected pregnant and lactating
women have higher energy requirements than those who are not infected with HIV. Nutrition education
and counseling are especially important for this group of women to help them meet their overall nutrition
requirements and increased energy needs as a result of pregnancy, lactation and HIV. Pregnant and
lactating women also need counseling and support for infant feeding.

SYMPTOMS THAT DIET CAN HELP MANAGE

Healthy dietary practices learned through nutrition education and counseling can help manage HIV-
related symptoms and alleviate their effects on food intake and nutrient absorption. Common symptoms
that can be managed through diet include diarrhea, nausea, vomiting, thrush/mouth sores, anemia and
lack of appetite. Therefore, clients experiencing such symptoms can benefit from nutrition assessment
and counseling.

UNINTENTIONAL WEIGHT LOSS

“Unintentional” means the weight loss is not the result of a deliberate effort to lose weight. Weight loss
often indicates a decline in the nutritional and health status of PLHIV and is associated with mortality
5, 6
among PLHIV, regardless of treatment status. Clients may prevent or reverse weight loss by
following food and nutrition recommendations related to the frequency of meals, nutrient density of
foods and dietary management of symptoms.

INITIATION OF ART

Dietary practices can help manage food-drug interactions, minimize drug side effects, and improve ART
adherence and effectiveness. Nutrition assessment is also important to identify drug side effects
including anemia and lipodystrophy.
CONSUMPTION OF SPECIALIZED FOOD PRODUCTS OR MICRONUTRIENT
SUPPLEMENTS

Once clients have been prescribed specialized food products or micronutrient supplements, trained
clinicians should regularly complete nutrition assessments to determine a client’s continuing need for
them. In addition, trained clinicians should ascertain the adequacy and safety of the nutrient levels in
specialized food products and micronutrient supplements, especially if they are not prescribed by the
program.

Nutrition counseling can provide clients with guidance on the prescribed quantity and frequency of
specialized food products that should be consumed, as well as on how to prepare specialized food
products like corn-soy blend (CSB). Nutrition counseling can also provide clients with instruction on when
to consume micronutrient supplements in relation to meals and how to improve nutrient intake by eating
a diverse diet with foods rich in micronutrients.

CONCERN ABOUT OR INTEREST IN NUTRITION

Clients with immediate concerns or interest in learning more about nutrition are more receptive to
improving their dietary practices. Specific concerns about diet and nutrition may require consultation and
counseling with a service provider.

NEVER HAD NUTRITION EDUCATION OR COUNSELING

Clients who have never had the opportunity to discuss nutrition issues with a trained service provider
since testing positive for HIV or since initiating ART should be prioritized for nutrition assessment and
counseling. It is recommended that all PLHIV receive nutrition counseling at least once because
following dietary recommendations helps PLHIV improve, maintain or slow the decline of nutritional
status; manage symptoms; boost immune response; and improve adherence to ART.

2. Provision of Specialized Food Products

Studies have shown that malnutrition, manifested by thinness and weight loss, significantly increases the
7, 8, 9, 10
risk of mortality for PLHIV regardless of treatment status. There are multiple causes of
malnutrition among PLHIV. PLHIV are prone to opportunistic infections (OIs) that cause diarrhea,
vomiting and reduced appetite. These symptoms, as well as economic conditions, may reduce their
intake of food.
PLHIV also have an increased metabolic rate and malabsorption of nutrients because of fever and
metabolic changes, which can lead to malnutrition. Services to address the root causes of malnutrition,
such as nutrition assessment and counseling and treatment of OIs, should be part of all clients’ medical
care.

PLHIV can benefit from the provision of specialized food products as part of treatment for malnutrition.
Examples of specialized food products include energy- and nutrient-dense ready-to-use therapeutic food
®
(RUTF) such as Plumpy’Nut (a fortified peanut-based paste) and supplementary foods such as fortified-
blended food (FBF), which are commonly partially pre-cooked fortified cereal and legume products such
as CSB.

Anthropometric indicators that are used to screen PLHIV for malnutrition and the need for specialized
food products include BMI, mid-upper arm circumference (MUAC), weight gain during pregnancy and
11
unintentional weight loss. These indicators, described below, are often used without further
assessment
to determine eligibility for the provision of specialized food products. However, specialized food products
should not be given in isolation, and medical examination and care, as well as nutrition assessment and
counseling, are recommended for PLHIV with malnutrition. Furthermore, other clinical indicators of
malnutrition, such as bilateral pitting edema, should also be considered when determining the need for
treatment of malnutrition. Program implementers should follow existing eligibility criteria for specialized
food products established by national policies, implementing agencies or facilities.
BMI

For adults over 18 years of age who are not pregnant or within six months post-partum, BMI is the
preferred indicator of body thinness used to classify malnutrition. BMI is calculated by dividing weight in
kilograms (kg) by height in meters (m) squared (BMI = kg/m²).

Table 3 shows the BMI classification of malnutrition in adults over 18 years of age given in the WHO
12
guidance for the management of severe malnutrition.

Table 3. Classification of Nutritional Status of Non-Pregnant, Non-Post-Partum Adults, > 18 Years

of Age
BMI Classification
< 16.0 Severe malnutrition
≥16.0 and < 17.0 Moderate malnutrition
≥17.0 and < 18.5 Mild malnutrition
≥18.5 and < 25.0 Normal
Source: WHO. 1999. Management of Severe Malnutrition: A Manual
for Physicians and Other Senior Health Workers. Geneva: WHO.

BMI-FOR-AGE Z-SCORE

For adolescents 15-18 years of age who are not pregnant or within six months post-partum, BMI-for-age
z-score is the preferred indicator of body thinness used to classify malnutrition.

For adults, simple BMI can be used as an indicator of nutritional status because most individuals over
18 years have completed their physical development. However, adolescents are still experiencing
growth and development. Therefore, it is necessary to consider the age and sex of the adolescent
when using BMI as an indicator of nutritional status.

The z-score, or standard deviation unit (SD), is defined as the difference between the BMI value for an
individual and the median BMI value of the reference population for individuals of the same age and
sex, divided by the SD of the reference population. A BMI-for-age z-score calculated for an individual
tells exactly how many SDs an individual’s BMI value is away from the median BMI value of the
reference population. A positive BMI-for-age z-score means that the individual’s measurement is higher
than the median BMI value of the reference population and a negative BMI-for-age z-score means that
the measurement is lower than the median BMI value of the reference population. Annex 1 contains a
look-
up table for determining an individual 15-19 years of age’s BMI-for-age z-score based on the WHO
13
Reference 2007 for children and adolescents 5-19 years of age. Table 4 shows the BMI-for-age z-score
14
classification of malnutrition in adolescents between 15-18 years of age.

Table 4. Classification of Nutritional Status of Non-Pregnant, Non-Post-Partum Adolescents 15-18

Years of Age by BMI-for-Age
BMI-for-age Classification
< -3 SD Severe malnutrition
≥ -3 SD and < -2 SD Moderate malnutrition
≥ -2 SD and < -1 SD Mild malnutrition
≥ -1 SD Normal
Source: WHO. 2007. Growth reference data for 5-19 years.
http://www.who.int/growthref/en/ (accessed August 21, 2009).
MUAC

MUAC measures the circumference of the left upper arm in centimeters (cm). It is taken at a point
midway between the tip of the shoulder and the elbow. MUAC is a proxy measure of nutrient reserves in
muscle and fat that are not affected by pregnancy and are independent of height. It can be used to
classify the nutritional status of women who are pregnant or up to six months post-partum and of non-
pregnant/post-
partum adults whose height or weight cannot be measured (e.g., the client cannot stand, no weighing or
15
measuring equipment is available).

Because there are few data on the relationship between MUAC and mortality and other functional
measures in adults, WHO has not yet established standardized MUAC cutoffs to classify nutritional status
among adults. To date, most program experience using MUAC to determine PLHIV eligibility for
specialized food products has been with pregnant and post-partum HIV-infected women. The cutoffs in
16
Table 5 are suggestions based on current practice.

Table 5. Classifications of Nutritional Status of Women Who are Pregnant or Within Six Months
Post-Partum by MUAC
MUAC Classification
< 19 cm Severe malnutrition
≥ 19 and < 22.0 cm Moderate malnutrition
≥ 22 and < 23.0 cm Mild malnutrition
≥ 23.0 cm Normal

INADEQUATE WEIGHT GAIN DURING PREGNANCY

Birth weight is one of the most important determinants of a child's survival and is highly influenced by the
mother’s nutritional status before and during pregnancy. Low pre-pregnancy weight and inadequate
weight gain during pregnancy are the most significant predictors of intrauterine growth retardation
17
(IUGR) and low birth weight (LBW).

According to the Institute of Medicine at the United States National Academy of Sciences (IOM), women
who begin their pregnancy with a BMI < 18.5 must increase their daily energy intake to gain at least 12.5
18
kg during pregnancy. Table 6 shows recommended total weight gain during singleton pregnancy and
recommended weekly and monthly weight gain during the second and third trimesters by BMI at the
beginning of pregnancy. Weekly or monthly weight gain less than that recommended by the IOM could be
19
used as a criterion to screen pregnant women for need of specialized food products.

Table 6. Recommended Weight Gain During Singleton Pregnancy According to Pre-Pregnancy

BMI
Recommended weekly Recommended monthly
Pre-pregnancy category
Recommended total gain weight gain, second and weight gain, second and
BMI
third trimesters third trimesters
< 18.5 12.7 – 19.5 kg 0.5 kg 2.0 kg
18.5 – 24.9 11.3 – 17.1 kg 0.5 kg 2.0 kg
25.0 – 29.9 6.8 – 12.2 kg 0.3 kg 1.2 kg
≥ 30.0 5.0 – 9.8 kg 0.2 kg 0.8 kg
Source: IOM. May 2009. Resource Sheet: Weight Gain During Pregnancy: Reexamining the Guidelines. Washington,
DC: IOM.
UNINTENTIONAL WEIGHT LOSS

Unintentional weight loss, regardless of treatment status, is a strong predictor of mortality among
20, 21,22
PLHIV. As little as 5 percent unintentional weight loss from a baseline body weight (BBW), or
weight first recorded in the medical record, has been associated with significantly increased risk of OIs
and death. Unintentional weight loss could therefore be used as a criterion to screen for the need of
specialized food products. However, weight loss alone should not be used to prescribe specialized food,
products as patients who are losing subcutaneous fat with preservation of muscle mass may not benefit
23
from increased energy intake.

Unintentional weight loss is measured as the percentage of weight lost from the BBW, using the following
formula:

% of weight lost = [(BBW – current body weight)/BBW] x 100

The cutoff for percentage of weight lost could be set at 5 percent on the basis of the association between
a 5 percent weight loss and adverse outcomes. For example, for a woman with a BBW of 50 kg currently
weighing 46 kg, the formula above would calculate an 8 percent weight loss from BBW. Assuming a cut-
off of 5 percent weight loss, the woman would be eligible for specialized food products.

3. Micronutrient Supplementation

PLHIV are at high risk of micronutrient deficiencies as a result of decreased food intake, nutrient
malabsorption and increased metabolic rate. The inherent risk of malnutrition among PLHIV is further
complicated by underlying micronutrient deficiencies common in countries where HIV is prevalent.
Micronutrient deficiencies have been associated with higher risks of HIV disease progression and
mortality, and supplementation with selected micronutrients has been shown to improve outcomes.
However, conflicting results from several studies have raised concerns about the safety of micronutrient
24, 25, 26, 27, 28
supplementation of PLHIV.

According to the current WHO recommendations, PLHIV should consume diets that ensure micronutrient
29
intake at one Recommended Dietary Allowance (RDA). Eating a diverse diet with foods rich in
30
micronutrients is the best way to meet the RDA. However, micronutrient supplements may be
necessary to help PLHIV meet the RDA. If micronutrient deficiencies are suspected, trained staff or
31
nutritionists should complete individualized dietary assessments before prescribing supplements. In
settings with a high prevalence of micronutrient deficiencies, however, programs or health facilities may
have a policy of providing micronutrient supplements routinely to all PLHIV clients without completing
individualized nutrition assessments.

Specialized food products are formulated to provide micronutrients. Because of the risk of adverse
effects from some micronutrients in large doses, clients should consult the service provider before
consuming specialized food products or taking micronutrient supplements in addition to those
prescribed. If clients are already consuming specialized food products or micronutrient supplements,
service providers should first complete individualized nutrition assessments to determine the adequacy
and safety of the micronutrient levels before prescribing any additional supplementation. Whenever
service providers give clients micronutrient supplements, they should advise them not to consume
additional specialized food products or supplements without first consulting the service provider.

Facilities that have a policy to routinely provide all PLHIV with micronutrient supplements should restrict
those supplements to clients who are not currently consuming either specialized food products or
micronutrient supplements. They should provide individualized nutrition assessment and counseling to
clients who are already consuming specialized food products or micronutrient supplements to determine
the necessity and safety of additional micronutrient supplementation.
 4. Food Security and Livelihood Services

Food insecurity occurs when people do not have continued access to a sufficient quantity and quality of
food to meet their physiological needs. USAID defines food security as a situation in which “all people at
all times have physical and economic access to sufficient food to meet their dietary needs for a
32
productive and healthy life.” This definition of food security consists of three components: food
availability, food access and food utilization/consumption.

Food availability is achieved when sufficient quantities of food are consistently available to all people in a
country, region or household through domestic production, commercial imports and/or food assistance.

Food access is achieved when households have adequate resources to obtain a sufficient quantity and
quality of food for a nutritious diet and depends on available household income, distribution of household
income and the price of food.

Food utilization/consumption is the proper biological use of food by the body, influenced by the efficiency
of the body’s physiological processes and the availability of clean and safe water, adequate sanitation, a
diet that provides sufficient levels of essential nutrients, proper child care, illness management, and
household food storage and preparation techniques.

PLHIV’s loss of productivity and income as well as the time and money caregivers must spend to care for
PLHIV often compromise the capacity of households affected by HIV to produce or access a variety of
33
foods. Services to strengthen household food security commonly aim to sustain or improve productive
activities and livelihoods and mitigate the negative impacts of HIV.

Food security and livelihood services base eligibility criteria on household economic characteristics (e.g.,
income, assets), agricultural production, food consumption (e.g., dietary diversity, meal frequency), client
functional status or dependency ratios (e.g., number of income earners/caretakers versus number of
dependents). If possible, the best option for screening criteria is to use the eligibility criteria that
programs use for services. However, sometimes it is not possible to use the eligibility criteria for
screening, for example if the eligibility criteria are lengthy or require a home visit.

Currently, no indicator of household food access has been validated for screening at the household level
34, 35, 36
across different populations. However, household consumption of foods from food groups that are
often relatively more expensive may be an indication of household food access. Based on this approach,
food group screening questions are proposed below for classifying households with more or less difficulty
with food access and need for food security and livelihood services. Note that health facilities and
programs should evaluate the validity of the food group screening questions or the capacity of the
questions to correctly classify households.

FOOD GROUP SCREENING QUESTIONS FOR HOUSEHOLD FOOD ACCESS

Clients’ answers to the food group screening questions will allow classification of their households as
having adequate or inadequate food access. Classification of inadequate access to food is based on
reported non-consumption of foods from at least one of the four food groups (1. vegetables and fruits; 2.
meat, poultry, seafood and eggs; 3. milk and milk products; and 4. oils and fats) in the previous 24 hours
because of inability to access or buy those foods. Table 7 provides examples of foods in each of these
four food groups.
Table 7. Food Groups Used for Screening for Household Food Access
37
Food group Examples
Vegetables and All vegetables and fruits, including dark green leafy vegetables such as cassava leaves, bean
fruits leaves and kale, carrots, and squash and sweet potatoes that are yellow or orange inside
Meat, poultry, Beef, pork, lamb, goat, rabbit, wild game, chicken, duck, organ meats, fresh or dried fish or
seafood and eggs shellfish, eggs
Milk and milk
Cheese, yogurt, milk or other milk products
products
Oils and fats Foods made with oil, butter or fat

During screening, service providers should first ask clients whether they or anyone in their households
consumed foods from each of the four food groups in the previous 24 hours. The client should be
instructed to include the foods consumed by household members at home or outside the home. The
previous 24 hours is used as the recall period because it provides the most accurate information.
Service providers should determine whether the previous 24-hour period was “usual” or “normal” for
the household. If it included a special occasion such as a funeral or a feast or if most household
members were absent, another day (e.g., the day before yesterday) should be selected for the
screening.

If the client responds that no one in their household consumed any foods from a specific group, service
providers should ask, “What was the reason that no one consumed [food group not consumed]?”
Service providers should refer clients for food security and livelihood services if neither the clients nor
anyone in their household ate foods from at least one of the groups because they were unable to
access or buy them.

The question about why a food group was not consumed is qualitative and open-ended and could result
in many possible responses. Service providers using the food group screening questions should be
trained to probe for information using non-leading questions that do not influence clients’ responses. For
example, “Did no one consume milk or milk products because you could not afford to buy it?” is a
leading question because it proposes a possible answer and therefore should not be used. A non-
leading question such as “What is the reason that you and no one in the household consumed milk or
milk products?” elicits information without leading clients to an answer. Service providers also need to
be trained to interpret responses so they can correctly identify clients with inadequate household food
access. Table 8 shows examples of answers that would and would not warrant referral to food security
and livelihood services.

Table 8. Reasons for Not Eating Certain Foods That Warrant or Do Not Warrant Referral to Food
Security and Livelihood Services
Referral No Referral
 We did not have enough money to buy the  The food was not available in the market.
food.  The food is not in season.
 We don’t like the food.
 Harvest of the food was not sufficient and we
cannot afford to buy it.  We did not eat the food for religious or cultural
reasons (e.g., fasting).
 We ate something else because that food is
too expensive.
 We did not have enough to trade in exchange
Endnotes

1
In this guide, “older adolescents” are people between 15 to 18 years old. “Adults” are people over 18
years old. For information regarding nutrition assessment for children, refer to: WHO. 2009. Guidelines
for an Integrated Approach to the Nutritional Care of HIV-infected children (6 months-14 years)
Handbook.
Geneva: WHO.
2
“Micronutrient” refers to vitamins and minerals.
3
Guidance on nutrition assessment for PLHIV can be found in: Fields-Gardner, C, C Thomson, and CM
Capozza. 1997. Clinician’s Guide to Nutrition and HIV and AIDS. Chicago: American Dietetic
Association.
4
For additional information on nutrition counseling for PLHIV, see: Food and Nutrition Technical
Assistance (FANTA) Project. 2004. HIV/AIDS: A Guide for Nutritional Care and Support. Second
edition. Washington, DC: FANTA at 360; Republic of Kenya Ministry of Health, United States Agency
for International Development (USAID), United Nations Children’s Fund (UNICEF) and FANTA. 2007.
Nutrition and HIV/AIDS: A Toolkit for Service Providers in the Comprehensive Care Centres. Nairobi.
Both can be found at http://www.fantaproject.org/.
5
Wheeler, DA, CL Gilbert, CA Launer, N Muurahainen, RA Elion, DI Abrams, and GE Bartsch. 1998.
Weight Loss as a Predictor of Survival and Disease Progression in HIV Infection. Terry Beirn Community
Programs for Clinical Research on AIDS. Journal of Acquired Immune Deficiency Syndrome 18: 80–85.
6
Tang, AM, J Forrester, D Spiegelman, TA Knox, E Tchetgen, and SL Gorbach. 2002. Weight Loss and
Survival in HIV-Positive Patients in the Era of Highly Active Antiretroviral Therapy. Journal of Acquired
Immune Deficiency Syndromes 31: 230–36.
7
Wheeler, DA et al, op cit.
8
Tang, AM et al, op cit.
9
Paton, N, S Sangeetha, A Earnest, and R. Bellamy. 2006. The Impact of Malnutrition on Survival and
the CD4 Count Response in HIV-Infected Patients Starting AntiretroviralTherapy. HIV Medicine 7: 323–
30.
10
Van der Sande, M, AB Maarten, F Schim van der Loeff, AA Aveika, S Sabally, T Togun, R Sarge-Njie,
AS Alabi, A Jaye, T Corrah, and HC Whittle. 2004. Body Mass Index at Time of HIV Diagnosis: A Strong
and Independent Predictor of Survival. Journal of Acquired Immune Deficiency Syndrome 37: 1,288–94.
11
For more information on procedures to measure height, weight and MUAC, refer to: Cogill, B. 2003.
Anthropometric Indicators Measurement Guide. Washington, DC: FANTA at FHI 360.
12
PEPFAR-supported care and treatment programs may provide food support to non-pregnant and non-
lactating adult patients with a BMI < 18.5. PEPFAR Policy Change in Food and Nutrition Programming.
http://www.pepfar.gov/pepfar/guidance/98836.htm (accessed September 18, 2008).
13
The WHO Reference 2007 for Children and Adolescents 5 to 19 years is available on the WHO
website: http://www.who.int/growthref/en/.
14
PEPFAR policy guidance as of 2009 states that PEPFAR resources may be used to support food for
HIV-positive adolescents until age 17 years regardless of nutritional status if programs choose to provide
food accordingly. However, for programs that choose to screen adolescents for provision of specialized
food products based on nutritional status, BMI-for-age z-score can be used to classify malnutrition.
15
WHO. 1995. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert
Committee. Technical Report Series No. 854. Geneva: WHO.
16
PEPFAR policy guidance as of 2009 states that PEPFAR resources may be used for food support for
HIV-positive pregnant and post-partum women regardless of nutritional status. Programs that choose to
screen pregnant and post-partum women for provision of specialized food products based on nutritional
status could use MUAC as an eligibility criterion.
17
For additional information on nutrition and HIV during pregnancy, see: FANTA. 2004. HIV/AIDS: A
Guide for Nutritional Care and Support. Second edition. Washington, DC: FANTA at FHI 360.
18
IOM. May 2009. Resource Sheet, Weight Gain During Pregnancy: Reexamining the Guidelines.
Washington, DC: National Academies Press. http://www.iom.edu/CMS/3788/48191/68004.aspx.
19
PEPFAR policy guidance as of 2009 states that PEPFAR resources may be used for food support for
HIV-positive pregnant women regardless of nutritional status. Programs that choose to screen pregnant
women for provision of specialized food products based on nutritional status could use inadequate weight
gain as an eligibility criterion.
20
Wheeler, David A, et al, op cit.
21
Tang, Alice M, et al, op cit.
22
Wanke, C, D Kotler, and the HIV Wasting Collabortive Consensus Committee. 2004. Collaborative
recommendations: the approach to diagnosis and treatment of HIV wasting. Journal of Acquired
Immune Deficiency Syndrome 37 (Suppl 5): S284–S291.
23
PEPFAR has not established unintentional weight loss cutoffs for eligibility for specialized food
products. BMI should be used to determine the eligibility of non-pregnant/post-partum adults for PEPFAR-
supported specialized food products.
24
Fawzi, W, G Msamanga, D Spiegelman, and D Hunter. 2005. Studies of Vitamins and Minerals and HIV
Transmission and Disease Progression. Journal of Nutrition 135: 938–44.
25
Friis, H. 2005. Micronutrients and HIV Infection: A Review of Current Evidence. Geneva: WHO.
26
Drain, PK, R Kupka, F Mugusi, and WW Fawzi. 2007. Micronutrients in HIV-Positive Persons Receiving
Highly Active Antiretroviral Therapy. American Journal of Clinical Nutrition 85: 333–45.
27
Fawzi, WW, et al. 2000. Randomized Trial of Vitamin Supplements in Relation to Vertical
Transmission of HIV-1 in Tanzania. Journal of Acquired Immune Deficiency Syndrome 23 (3): 246–54.
28
McDermid, JM, J Assan, M Schim van der Loeff, J Todd, et al. 2007. Elevated Iron Status Strongly
Predicts Mortality in West African Adults with HIV Infection. Journal of Acquired Immune Deficiency
Syndrome 46 (4): 498–507.
29
WHO. 2003. Nutrient Requirements for People Living with HIV/AIDS. Report of a technical consultation.
May 13-15, 2003. Geneva: WHO.
30
IOM. 2004. Dietary Reference Tables: The Complete Set. Washington, DC: National Academies Press.
http://www.iom.edu/?id=21381 (accessed May 8, 2008).
31
For more information on micronutrient deficiencies, refer to WHO and the Food and Agriculture
Organization of the United Nations (FAO). 2004. Vitamin and Mineral Requirements for Human Nutrition.
Second edition. Geneva: WHO and Rome: FAO.
32
USAID Policy Determination, Definition of Food Security, April 13, 1992.
33
FANTA and WFP. 2007. Food Assistance Programming in the Context of HIV. Washington, DC:
FANTA at FHI 360.
34
Hoddinott, J, and Y Yohannes. 2002. Diversity as a Household Food Security Indicator. Washington,
DC: FANTA at FHI 360.
35
The Household Dietary Diversity Score (HDDS) has been validated and demonstrated to be associated
with food expenditures and consumption at the population level but not for household-level screening. For
example, no cutoff for the score value to determine whether a household has adequate or inadequate
access to food has been established. For more information, refer to: Swindale, A, and P Bilinsky. 2006.
Household Dietary Diversity Score (HDDS) for Measurement of Household Food Access: Indicator Guide
(v.2). Washington, DC: FANTA at FHI 360.
36
The Household Hunger Scale (HHS) has been validated as a culturally invariant measure of household
hunger for use at the population level in food insecure settings. For more information, refer to: Deitchler,
M, T Ballard, A Swindale, and J Coates. Forthcoming 2010. Validation of a measure of household
hunger for cross cultural use. Washington, DC: FANTA-2 at FHI 360.
37
As appropriate, locally available foods should be added to the food groups.
Annex 1. BMI-for-Age Look-Up Table for Adolescents 15-19 Years,
WHO 2007 Growth Reference
Boys' BMI-for-age Year: Girls' BMI-for-age

-3 SD -2 SD -1 SD Median Month Median -1 SD -2 SD -3 SD

14.7 16.0 17.6 19.8 15:0 20.2 17.8 15.9 14.4
14.7 16.1 17.7 19.8 15:1 20.3 17.8 15.9 14.4
14.8 16.1 17.8 19.9 15:2 20.3 17.8 15.9 14.4
14.8 16.1 17.8 20.0 15:3 20.4 17.9 16.0 14.4
14.8 16.2 17.9 20.0 15:4 20.4 17.9 16.0 14.5
14.9 16.2 17.9 20.1 15:5 20.4 17.9 16.0 14.5
14.9 16.3 18.0 20.1 15:6 20.5 18.0 16.0 14.5
15.0 16.3 18.0 20.2 15:7 20.5 18.0 16.1 14.5
15.0 16.3 18.1 20.3 15:8 20.6 18.0 16.1 14.5
15.0 16.4 18.1 20.3 15:9 20.6 18.1 16.1 14.5
15.0 16.4 18.2 20.4 15:10 20.6 18.1 16.1 14.6
15.1 16.5 18.2 20.4 15:11 20.7 18.1 16.2 14.6
15.1 16.5 18.2 20.5 16:0 20.7 18.2 16.2 14.6
15.1 16.5 18.3 20.6 16:1 20.7 18.2 16.2 14.6
15.2 16.6 18.3 20.6 16:2 20.8 18.2 16.2 14.6
15.2 16.6 18.4 20.7 16:3 20.8 18.2 16.2 14.6
15.2 16.7 18.4 20.7 16:4 20.8 18.3 16.2 14.6
15.3 16.7 18.5 20.8 16:5 20.9 18.3 16.3 14.6
15.3 16.7 18.5 20.8 16:6 20.9 18.3 16.3 14.7
15.3 16.8 18.6 20.9 16:7 20.9 18.3 16.3 14.7
15.3 16.8 18.6 20.9 16:8 20.9 18.3 16.3 14.7
15.4 16.8 18.7 21.0 16:9 21.0 18.4 16.3 14.7
15.4 16.9 18.7 21.0 16:10 21.0 18.4 16.3 14.7
15.4 16.9 18.7 21.1 16:11 21.0 18.4 16.3 14.7
15.4 16.9 18.8 21.1 17:0 21.0 18.4 16.4 14.7
15.5 17.0 18.8 21.2 17:1 21.1 18.4 16.4 14.7
15.5 17.0 18.9 21.2 17:2 21.1 18.4 16.4 14.7
15.5 17.0 18.9 21.3 17:3 21.1 18.5 16.4 14.7
15.5 17.1 18.9 21.3 17:4 21.1 18.5 16.4 14.7
15.6 17.1 19.0 21.4 17:5 21.1 18.5 16.4 14.7
15.6 17.1 19.0 21.4 17:6 21.2 18.5 16.4 14.7
15.6 17.1 19.1 21.5 17:7 21.2 18.5 16.4 14.7
15.6 17.2 19.1 21.5 17:8 21.2 18.5 16.4 14.7
15.6 17.2 19.1 21.6 17:9 21.2 18.5 16.4 14.7
15.7 17.2 19.2 21.6 17:10 21.2 18.5 16.4 14.7
15.7 17.3 19.2 21.7 17:11 21.2 18.6 16.4 14.7
15.7 17.3 19.2 21.7 18:0 21.3 18.6 16.4 14.7
15.7 17.3 19.3 21.8 18:1 21.3 18.6 16.5 14.7
15.7 17.3 19.3 21.8 18:2 21.3 18.6 16.5 14.7
15.7 17.4 19.3 21.8 18:3 21.3 18.6 16.5 14.7
15.8 17.4 19.4 21.9 18:4 21.3 18.6 16.5 14.7
15.8 17.4 19.4 21.9 18:5 21.3 18.6 16.5 14.7
15.8 17.4 19.4 22.0 18:6 21.3 18.6 16.5 14.7
15.8 17.5 19.5 22.0 18:7 21.4 18.6 16.5 14.7
15.8 17.5 19.5 22.0 18:8 21.4 18.6 16.5 14.7
15.8 17.5 19.5 22.1 18:9 21.4 18.7 16.5 14.7
15.8 17.5 19.6 22.1 18:10 21.4 18.7 16.5 14.7
15.8 17.5 19.6 22.2 18:11 21.4 18.7 16.5 14.7
15.9 17.6 19.6 22.2 19:0 21.4 18.7 16.5 14.7