HIV/AIDS and tuberculosis are both "wasting diseases"- that is, diseases that cause significant weight loss through a variety of physiological mechanisms. Furthermore, severe, chronic diseases such as HIV/AIDS and TB may also cause food insecurity indirectly in both the patient and his/her immediate family, as illness impedes productivity in farming or other economic activities or as limited family resources are directed towards health care.

Adequate nutrition is a critical element in the management of HIV-positive patients. In addition to itself causing malnutrition, HIV immune suppression is exacerbated by poor nutritional status. Recent studies have shown that malnutrition at the time of starting antiretroviral therapy is significantly associated with decreased survival. Some medications cannot be taken on an empty stomach. For these reasons, at PIH we target our limited food assistance to HIV and TB patients and their families.

Planning considerations

• Explore possible partnerships with the local, national, or international agencies or programs that address nutrition assistance. Such programs generally provide time-limited nutritional support based on strict enrollment criteria. PIH has welcomed the support of the World Food Program, in particular, at several of our program sites.

• Collaborate with other organizations in the area working on food security and food assistance. These groups may be able to assist with local procurement of foods as well as with agricultural initiatives.

• Food assistance programming should be integrally linked with patient clinical care to be effective. PIH's food assistance program is integrated with patients' clinical care, involving all members of the clinic staff. It is important that patients understand that their food assistance is a critical component of their medical treatment.

• Define the clinical and socioeconomic criteria for enrollment in food assistance. Given the limited supply of food rations, beneficiary criteria should ensure that support is reaching the patients most in need. Community leaders, clinicians, community health workers, and local and national officials, as appropriate, should be consulted as to the best local indicators of need. Consistent, standardized enrollment criteria can help to reduce possible tensions within the community regarding differential receipt of food rations.
• Identify the clinical criteria upon which food assistance will be provided. PIH uses BMI, starting ART (CD4 count), HIV/TB co-infection, and pediatric malnutrition as its principal clinical indicators for food assistance. Some considerations: Will all patients on AIDS or TB treatment be eligible? If BMI and CD4 will be used, how will the numeric cut-off points be defined and monitored? How long will food be distributed to patients after their BMI, CD4 or nutritional status has normalized? What nutritional and/or agricultural support will be provided to patients upon exiting the food program?
• Integrate socioeconomic indicators into enrollment criteria to ensure that patients living in extreme poverty are eligible to receive food even if they would not qualify based on clinical criteria. Social workers and community health care workers are often best-placed to define local indicators of extreme need. Some factors PIH has considered are the total number of people in the household, housing quality, the number of children in the household, access to arable land, migration for work, etc.

• Create a system for collecting program data to ensure that beneficiary progress and clinical status can be tracked. Include information on weight, BMI, CD4 counts, visits to the health center, treatment adherence, and socioeconomic factors. In addition to tracking individual patients, regularly assess the program as a whole: keep good records on patients who have died, abandoned the program, or exited the program. This data will allow for meta-analysis of individual and community impact for program evaluation.

• Prioritize the recruitment and training of logistics and management personnel who can oversee the efficient receipt, tracking and delivery of food rations.

• Consider establishing long-term initiatives such as agricultural programs or other forms of socioeconomic assistance that will be available to patients when they no longer qualify for direct food assistance.

Suggested staffing

• Clinicians (nurses and doctors)
• Program manager
• Logistician
• Warehouse staff/manager
• Drivers
• Social workers
• Data clerks/manager
• Community health workers

As in all other aspects of PIH's community-based model of care, community health workers play an integral role in food assistance programs. They may help patients carry their food rations, monitor household food needs, and alert clinic staff to any local conditions that could exacerbate food insecurity.

Logistical requirements

The following transport, warehousing, and material needs ensure proper storage and the effective distribution of food staples and other supplies associated with food and nutrition programs:

• Delivery trucks
• Warehouses with appropriate climate and space to prevent spoilage and to allow for cleaning and sanitization
• Pallets to store food and materials off the ground
• Stock cards and/or database to track incoming and outgoing stock
• Registers for tracking patients
• Storage containers and bags for distribution of food and supplies
• Scales to weigh food rations
• Labels to properly identify ingredients and dosing

Implementation

PIH provides food support to HIV and TB patients based on an assessment of their clinical and socioeconomic status.

Monthly food package

Designing the scope, contents, and duration of food assistance packages is a complex exercise, requiring consideration of factors such as the baseline nutrition and food security situation of the targeted population, the immediate objectives of the food package in supporting HIV or TB treatment, the appropriate mix of nutrients, patients' ability to transport and prepare the foods provided, and local and individual food preferences and practices. In Haiti, Rwanda, and Lesotho, the World Food Program has predetermined the contents of the food packages, but debates continue as to the specifics. The typical monthly food package for a family is presented below:

Zanmi Lasante, Haiti

Inshuti Mu Buzima, Rwanda
Package is halved after 6 months

Bo-Mphato Litsebeletsong tsa Bophelo, Lesotho

Zanmi Lasante, Haiti

Large supplies are transported by truck monthly from Port-au-Prince to a central storage warehouse, where careful inventory is taken. From there, food is sent to each of the health centers, where it is redistributed into sacks that patients receive monthly. After patients' initial clinical assessment, social workers are charged with evaluating and monitoring patients' needs and determining which patients receive assistance.

Patients who qualify for food assistance are given voucher slips, which they present at the health center to receive their monthly ration; the food package thus acts as an incentive to encourage patients to attendtheir monthly check-ups. Severely ill patients who are not able to attend the health center have their food rations delivered to their homes.

PIH is currently conducting a research study to determine the impact of food assistance on HIV patients' clinical outcomes, food security, and quality of life.

Inshuti Mu Buzima Rwanda

Food is dispatched from a central warehouse to each health center, where program staff manage inventory (stock registration card) and distribute rations to patients every month. Patients starting ART and TB treatment are given a food package the day they start their treatment. They receive these packages each month for 10 months, with the package halved after 6 months.
For patients not receiving HIV or TB treatment, they may be evaluated by social workers and given a social case form documenting their need for food assistance. They receive a food package for 2 months. The food program staff maintains regular lists of food assistance recipients.

Bo-Mphato Litsebeletsong tsa Bophelo, Lesotho

Logistical challenges are particularly extreme at Lesotho's remote mountain sites. The roads are often washed out or impassable, while some health centers are not accessible at all by road. Food assistance arrives via a range of forms of transportation, including airplane, with the help of the Mission Aviation Fellowship; road with the help of the World Food Program; boat; and donkey. Food is distributed monthly.