Clinical malnutrition is a risk factor for HIV progression and mortality for pre-ART and ART patients, as well as for birth outcomes among HIV-positive women. Ethiopia is a chronically food insecure country with high levels of malnutrition. As HIV infection progresses, hyper-metabolism, mal-absorption of nutrients, diarrhea, and anorexia can all become severe challenges to maintenance of adequate nutritional status. In addition, poor nutritional status and inadequate dietary intake can adversely affect adherence to and efficacy of drug treatments. According to the World Health Organization (WHO), energy requirements are increased by 10% in asymptomatic adults, 20-30% in symptomatic adults and as much as 50-100% in infected children with growth faltering. The goal of the Food by Prescription (FBP) program is to provide food and nutritional support to malnourished HIV+ individuals in the form of therapeutic and supplementary feeding at health facility (hospital, health center) level. PEPFAR Ethiopia piloted an FBP program in FY 2007 in 20 hospitals and 25 health centers. In COP 2010, the program will expand to approximately 35 new health facilities and enroll severely malnourished PLWHAA, HIV-positive pregnant women in PMTCT programs, HIV-positive lactating women in the first six months post-partum, their infants, and OVC in Amhara, Oromia, SNNPR, Tigray and Addis Ababa.

The program involves the procurement and distribution of ready-to-use therapeutic foods (RUTF) and a nutrient-dense blended flour product to targeted health facilities for severely malnourished ART and pre-ART clients and to HIV-infected pregnant and lactating women. Anthropometric entry and exit criteria based on WHO classification of malnutrition are used. Beneficiaries will also receive nutritional counseling and education. The program is being implemented by partners in Ethiopia in coordination with the Ministry of Health (MOH)/HIV/AIDS Prevention and Control Office (HAPCO) and with technical assistance from the Food and Nutrition Technical Assistance (FANTA) Project. Procurement of RUTF is through PSCM.

A significant part of this program will focus on linkages and coordination with the MOH/HAPCO, UNICEF, WFP, and other implementing partners. Since the food can only be targeted to PLWHAPLWHAA, the FBP activity seeks to coordinate with other partners, where available, to help provide comprehensive food and nutritional services for beneficiaries not targeted by the FBP program. The program will provide food support to approximately 28,000 malnourished PLWHAPLWHAA at 80 HIV care and treatment facilities, contributing to improved ARV adherence and nutritional status which will ultimately lead to improved treatment outcomes of beneficiaries.

The program will also serve as a critical component of PEPFAR Ethiopia's broader effort to strengthen integration of nutrition into HIV services. The assessment and counseling services offered through this integration effort will be important components of the Food by Prescription program. Severely malnourished PLWHAPLWHAA (pre-ART and ART clients), and HIV-infected pregnant women will be reached with food support and complementary services at hospitals and health centers. Service providers will be trained to assess clients' eligibility for food, provide food by prescription, and counsel clients in use of the food and in related nutritional practices.

In order to reduce the cost associated with the importation of nutrients and food commodities, the program in collaboration with the public and private sector, will explore the possibility of local production for some of the required food commodities.

Program activities will need to be carefully assessed for their effectiveness in reaching target populations and achieving overall program impact. The partner will adapt or establish the necessary baseline and monitoring information systems to allow monitoring of progress towards anticipated results. This will require extensive collaboration with Regional Health Bureaus and USG partners. Data quality must be at a level sufficient to allow confident assessments of the effectiveness and coverage of food supplementation. The partner is expected to provide reports to USAID/Ethiopia on utilization, consumption and graduation data. These reports should meet PEPFAR reporting requirements. Intermediate outcomes and graduation rates should be monitored to assess the effectiveness of the FBP supplementary and therapeutic foods and the partner should help beneficiaries link to the continuum of care where they will be able to maintain their weight gain. This is to be coupled with annual technical analyses of program efficiencies, effectiveness and impact.

None

Ethiopia is categorized as a focus country for food and nutrition. PEPFAR Ethiopia has identified nutrition support as a priority to provide care and support services which are critical to improve ART adherence and treatment outcomes. PEPFAR Ethiopia will continue to implement therapeutic feeding in the form of food by prescription (FBP). The program will expand to more sites and enroll severely malnourished PLWHAA and OVC.

Clinical malnutrition is a risk factor for HIV progression and mortality for pre-ART and ART patients. As HIV infection progresses, hyper-metabolism, mal-absorption of nutrients, diarrhea, and anorexia increase, adversely affecting nutritional status. In addition, poor nutritional status and inadequate dietary intake affects adherence to and efficacy of drug treatments. According WHO, energy requirements are increased by 10% in asymptomatic adults, 20-30% in symptomatic adults and as much as 50-100% in infected children with growth faltering. Clinically malnourished PLWHAPLWHAA in care and treatment programs in Ethiopia have an immediate and critical need for nutrient-dense foods that can be readily and safely prepared and consumed to improve their nutritional and immunological status, especially as an adjunct to ART.

FBP was awarded in October 2009. The principal activities are to provide technical assistance in the delivery of therapeutic and supplementary food products; integration of nutritional assessment and counseling services through in-service training; support for local production, marketing and distribution of therapeutic foods through local commercial organization(s); and the creation of economic opportunities for beneficiaries along the value chain. Procurement and distribution of a ready-to-use therapeutic food (RUTF) and a nutrient-dense blended flour product will be done by the PSCM project. Anthropometric entry and exit criteria based on WHO classification of malnutrition will be used. Beneficiaries will also receive nutritional counseling and education. This activity will provide food support to approximately 18,000 malnourished PLWHAPLWHAA. Clients receiving FBP will be linked to WFP. A tool will be developed to track clinical outcomes and for supportive supervision activities.

HIV-infected children are among the most vulnerable population groups to malnutrition especially in resource-limited settings. They have relatively higher nutritional requirements that often can not be obtained through their regular diets. In response to this situation, PEPFAR will implement a therapeutic feeding program, in selected hospitals and health centers, for children with moderate-severe malnutrition who are HIV-exposed, pre-antiretroviral therapy, and for children on antiretroviral therapy (ART). This program will be part of a comprehensive pediatric care package.

The lead partner, Save the Children US, will work with Management Sciences for Health/ Supply Chain Management System (MSH/SCMS) to quantify, procure and distribute ready-to-use therapeutic food. To minimize costs and promote local ownership and sustainability, priority will be given to locally-produced food.

In collaboration with Food and Nutrition Technical Assistance/Academy for Education Development (FANTA/AED) and university partners, technical assistance will also be provided, including reviewing, developing, producing, and disseminating job aids and other resource materials; conducting didactic and on-the-job training; and providing supportive supervision. Health workers will be equipped with knowledge and skills in such areas as nutritional assessment, child nutritional education/counseling, and food prescription. Children eligible for therapeutic food will be identified using standard anthropometric parameters.

Quality of the services will be ensured through competence enhancement approaches, including training health workers; facilitation with job aids; use of standard nutritional protocols and tools; and regular quality assessment.

For effective quality, comprehensive, and integrated service delivery, linkages and coordination between the relevant partners will be encouraged. The Government of Ethiopia will be involved in all the phases of the program, which will promote local ownership and sustainability.

The Food by Prescription project is expected to improve nutritional status and ART adherence of the exposed/infected children resulting in better quality of life and treatment outcomes with increased child survival.

Food by Prescription (FBP) for pregnant and lactating women and exposed infants is a continuing activity with a target population of HIV-positive pregnant women and their infants over six months of age at health facilities in urban and peri-urban sites. FBP for PMTCT clients is part of comprehensive PMTCT services at health. In view of the low PMTCT uptake in the country, it is hoped that the initiation of the FBP program will play a key role in encouraging pregnant and lactating mothers to use health facility services by generating routine attendance at ANC, assisted delivery and postpartum follow-up. FBP program has the opportunity to decrease malnutrition rates among HIV-positive pregnant and lactating women.

The program is being implemented by partners in Ethiopia in coordination with the MOH and with technical assistance from the FANTA project. The program involves procurement and distribution of a ready-to-use therapeutic food and a nutrient-dense, blended flour product to targeted health facilities, from where the food is provided to severely malnourished ART and pre-ART clients and HIV-positive pregnant and lactating women.

Supplementary food will be provided on a monthly basis for women in select PMTCT programs during pregnancy until the infant is weaned at which time food will continue to be provided on a monthly basis for the infant until two years of age. FANTA will assist in establishing the product specifications and production standards for the low-cost, nutrient dense supplementary food(s) to be procured under this activity.

This activity will provide food support to over 8,000 HIV-positive women and their infants at HIV care and treatment facilities, contributing to improved functioning, quality of life, and treatment outcomes. The activity aims to improve ARV/for PMTCT adherence and the nutritional status of the beneficiaries.

A significant part of this activity will focus on linkages and coordination with the MOH/HAPCO, UNICEF, WFP, and other implementing partners to ensure that the FBP activity will not cause negative consequences in health facilities.