Food and nutritional support improve the nutritional status of children and their families and address community food security. Food support may be through direct food supplements or community or school feeding programs. Support can also be through social protection measures such as cash transfers to increase access to food or household economic strengthening activities. While food and nutritional support is often offered as a time-limited strategy to address food insecurity or malnourishment, combining direct food supplements with household economic strengthening may improve nutritional status for longer periods (PEPFAR, 2009).
Why is food and nutritional support important?
Good nutrition is essential for children’s physical growth and development, including full development of their immune systems. Certain groups of children are particularly vulnerable to malnutrition, including young children, children outside of family care and children living with HIV. Globally, in 2010, an estimated 171 million children under age 5 were stunted and 104 million were underweight (WHO, 2010).
Malnutrition prevents children from reaching their full developmental potential. Malnutrition weakens a child’s immune system and can contribute to diarrhea, pneumonia, malaria and other conditions. In 2010, about 20 million children worldwide were estimated to suffer from severe, acute malnutrition, leaving them more vulnerable to serious illness and early death. About one-third of all deaths in children under 5 are linked to malnutrition.
Food Security and HIV: HIV, nutrition and food security are intimately linked. Food availability and good nutrition are essential for keeping people with HIV healthy and able to resist opportunistic infections.
Food security involves:
- Availability: adequate production/import of nutritious foods.
- Access – access to food through food production, and the ability to purchase food or support from safety-net programs or other people.
- Utilization – adequate daily caloric intake and a diverse diet to meet nutritional needs.
- Resilience/Stability – adequate strategies and mechanisms for households to manage their risk to food security shocks.
Households and communities coping with HIV and AIDS often have greater food and nutritional needs yet decreased access to food. Illness may prevent HIV-infected family members from working, which in turn threatens their livelihood.
Food security is also important for HIV prevention, as food insecurity may contribute to:
- More sexual risk-taking behavior, particularly among women or adolescent girls (for example, transactional sex and intergenerational sex) to increase income for food for themselves or their children.
- Greater job mobility, which can lead to more exposure to HIV.
- Families taking children out of school so they can work, which may place children at greater risk of abuse.
- Further weakening of already stretched traditional support networks for children and their families in areas with a high prevalence of HIV.
Children Affected by AIDS and Other Vulnerable Children: HIV can affect a child or adult’s nutritional status in a variety of ways. HIV weakens the immune system and may lessen appetite and ability to eat. HIV affects the body’s uptake, absorption and use of nutrients. People living with HIV have higher energy requirements and are more likely to show signs of micronutrient deficiencies, such as vitamins A, C, E, zinc and selenium. Adolescent girls are at higher nutritional risk than boys, and pregnant adolescents are at particularly high nutritional risk, including higher risk for anemia. (WHO 2008).
Stunting and wasting is very common in children infected with HIV, and antiretroviral treatment in children can be more complex because many children with HIV are so malnourished. Children with HIV are estimated to have 50–100% higher than normal energy requirements. WHO recommends treating malnourished HIV-infected children in community or hospital settings. Where children have severe malnutrition, ready-to-use therapeutic food (RUTF) such as Plumpy Nut, a peanut-based paste high in energy and enriched with vitamins and minerals, is recommended until they gain weight.
How should food and nutritional support be delivered?
Using the NACS (Nutrition Assessment, Counseling and Support) approach, orphans and vulnerable children programs can strengthen coordination with National and District implementers of nutrition programming to ensure strategic targeting of vulnerable children and their families (NACS SOTA meeting report highlights, 2012). The NACS model can increase linkages between community and clinic-based programs with referrals from community-based nutrition counseling to clinic-based services and economic strengthening assistance programs.
Food support should be child-focused and family-centered, to include all family members. Programs should be integrated with community- and home-based programs including Early Child Development programs, schools-based feeding programs, child survival, HIV prevention, PMTCT, Treatment and other programs.
Food support should also be AIDS-sensitive and not AIDS-exclusive in targeting. Communities can help identify the most vulnerable households, regardless of HIV status, ensuring equitable distribution of food, strengthening support mechanisms for critically malnourished children and families and strengthening linkages between community- and clinic-based programs.
Food security and nutrition can be supported through broad social protection measures that strengthen systems and avoid creating dependency. Social Protection programs may provide families with access to cash transfers, savings and income promotion interventions to strengthen households. Community grain banks, school-based feeding programs, and junior farmer field programs can all provide safety nets for vulnerable children and their families.
HIV-infection and pregnancy: Mothers need to be well nourished for their own health and for the health and development of their babies. Mother-and-child health and early child development services and referrals should be an integral part of orphans and vulnerable children’s programs. Lack of nutrition in pregnant mothers can pose an increased risk of HIV transmission to the child.
Breastfeeding and weaning: The role of breastfeeding in a child’s growth and development is very important. Breastfeeding protects children against many diseases and greatly increases their chances of survival. Lack of appropriate breastfeeding or complementary feeding practices are main causes of undernutrition (WHO, 2008). However, in HIV-infected women, breastfeeding carries the risk of transmitting HIV infection. Determining the safest way to breastfeed an infant can be difficult for HIV-infected parents and choices may depend on several factors.
WHO 2010 guidelines highlight the important impact of ARVs during breastfeeding and recommend that national authorities in each country decide which infant feeding practice, (i.e. breastfeeding with an ARV intervention to reduce transmission or avoidance of all breastfeeding) should be promoted and supported by their maternal and child health services.
Evidence shows that ARV interventions to an HIV-infected mother or HIV-exposed infant can significantly reduce the risk of postnatal transmission of HIV through breastfeeding. This evidence has major implications for how women living with HIV might feed their infants and how health counselors should counsel these mothers. Together, breastfeeding and ARV interventions have the potential to significantly improve infant’s chances of surviving while remaining HIV-uninfected.
Where national guidelines promote breastfeeding and ARVs, HIV-infected mothers are now recommended to breastfeed their infants until 12 months of age, introducing appropriate foods at 6 months of age, while continuing to breastfeed. Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided. (WHO, 2010).
Recognizing that ARVs will not be available everywhere immediately, WHO recommends that mothers be counseled to exclusively breastfeed for the first 6 months of life and continue breastfeeding unless environmental and social circumstances are safe for, and supportive of, replacement feeding. Replacement feeding should not be used unless it is acceptable, feasible, affordable, sustainable and safe.
Mothers known to be HIV-infected who decide to stop breastfeeding at any time should stop gradually within one month. Mothers or infants who have been receiving ARVs should continue ARVs for one week after breastfeeding is fully stopped. Stopping breastfeeding abruptly is not recommended.
Starting at 6 months, all children should receive complementary foods. At 6 months, WHO recommends complementary foods such as boiled animal milk or yogurt and a diet adequate in micronutrients.
For more information on HIV and breastfeeding, please check the WHO website for Infant Feeding Recommendations.
Anti-retroviral therapy (ART) and nutrition: The integration of HIV and nutrition programming is imperative for successful HIV treatment outcomes. Nutritional interventions are critical for pregnant and lactating women living with HIV as well as for women and children on ART. WHO guidelines recommend treating malnutrition and starting HIV treatment in children at the same time. Please see the links below to the latest World Health Organization (WHO) and World Food Program (WFP) guidance on food support in ART programs.
Key Food and Nutrition Activities and Messages
- Maternal and newborn health, nutrition and hygiene interventions during the first “1000 days” are critical to a child’s survival and to a child’s lifelong health and development. Nutrition interventions must support HIV-positive pregnant women and their children.
- Promote the NACS (Nutrition Assessment, Counseling and Support) Approach and coordinate with National and District level nutrition program implementers to strengthen linkages between community and clinic-based services and to ensure strategic targeting of vulnerable children and families for food and nutrition interventions.
- Integrate nutritional support into Early Childhood Development (ECD), school-based programs and ART. Children and youth have different nutritional needs at different ages. Adolescent girls are at higher risk for anemia and other nutritional issues.
- Integrate growth monitoring and nutrition interventions into child-focused community- and home-based programs including child survival, PMTCT, Treatment and others.
- Ensure that nutrition and food security are key components of HIV prevention, care and treatment strategies for children and their families. Nutrition, food security and HIV are intimately linked.
- Establish linkages and referral systems between community- and clinic-based programs.
- ARV interventions for an infected mother or child can significantly reduce risk of postnatal transmission of HIV through breastfeeding. (WHO, 2010)
- Where national guidelines promote breastfeeding and ARVs, HIV-infected mothers are recommended to breastfeed their children for 12 months. Where ARVs are not available, HIV-infected mothers should be counseled to breastfeed their children for at least 6 months and to continue after 6 months unless circumstances are safe for, and supportive of, replacement feeding. (WHO 2010).