This is a new activity using Plus-up funds to provide "food by prescription" for severely malnourished ART clients and home-based care clients awaiting ART.

This new activity is funded with FY 2007 plus-up funding. This activity links to ART service delivery providers (CIDRZ#9000, AIDS-Relief#8827, and ZPCT#8885) and to Palliative Care services (for RAPIDS#8946, SUCCESS#9180, PCI/ZDF #9720, ZPCT#8884 and #8888, and others).

The goal of this activity is to improve ART patient outcomes by introducing nutritional assessment, nutritional counseling, and therapeutic feeding for severely malnourished ART clients. Severely malnourished palliative care clients who have not yet initiated ART will also be eligible for therapeutic foods. This approach is in line with OGAC Guidance issues in September 2006. This activity will address clinical malnutrition, a medical condition common in individuals with HIV/AIDS, and will not be used to address food security -a broader, non-clinical problem.

This activity will be modeled on the successful USAID Kenya "Food by Prescription" program, and will carefully target nutrition interventions to improve clinical outcomes in malnourished PLWHA. The program will screen and target clinically malnourished adults and children with HIV, following Zambian guidelines on treatment of malnutrition and will have strict client "entry and exit" criteria as recommended by OGAC. The "Food by Prescription" initiative will follow WHO recommendations and will be evidence-based.

The proposed partner for this Activity is an AID centrally-funded project specialized in nutrition and food, known as Food and Nutrition Technical Assistance (FANTA). FANTA will work with a sub-partner called VALID International, which specializes in community based therapeutic feeding. Both organizations have previous experience in Zambia. FANTA helped the National Food and Nutrition Commission (NFNC) to design and gain approval of National Guidelines for Nutrition for PLWHA, as well as to design nutrition counseling materials for PLWHA, and carry out training of trainers in early 2007.

FANTA will work with USG partners to develop guidelines to integrate nutrition and therapeutic feeding into ART and palliative care services. An initial regimen of therapeutic feeding, with a timely transition to supplementary food and then to a regular diet, corresponds to the need for clients who have experienced the "wasting" effect associated with the onset of ARC, to: rebuild lost body mass; enabling them to resume a normal, active life as they respond to ART, rebuild their immune systems; and go back to work.

FANTA will build capacity to provide nutritional assessment, nutritional counseling, and nutritional support (therapeutic and then supplementary foods) for 7,500 or more severely malnourished PLWHA who are either ART clients, or eligible HBC clients waiting for ART. FANTA will provide training and technical assistance to clinical staff and community-based health workers and volunteer home based caregivers at a number of selected sites. FANTA will also provide funding to support the cost of producing, distributing, monitoring and reporting on therapeutic and supplementary foods.

VALID has experience working with the Lusaka District Health Medical Team (DHMT) to provide community therapeutic feeding for malnourished children at outlying clinics in Lusaka District. VALID and the DHMT diagnosed and treated malnutrition earlier and closer to the home, and thereby reduced late admissions for severe malnutrition to the University Teaching Hospital (UTH), which historically experience 40% mortality among these late admissions. The VALID activity has been very successful, with extremely low mortality at clinic level.

VALID has already established production capability for its "Ready-to-Use-Therapeutic-Food" (RUTF) in Lusaka. In addition, other partners/projects, such as CRS SUCCESS and RAPIDS, as well as WFP, have successfully produced and distributed supplementary foods such as High Energy Protein Supplements (HEPS) to both ART clients (with CIDRZ) or to HBC clients. One important difference in the approach to be used under this Activity, compared to earlier nutritional supplementation efforts in Zambia, is that the "Food by Prescription" method targets the HIV-positive, severely malnourished ART or Palliative Care client only, not the family. This approach "medicalizes" therapeutic food (RUTF) or supplementary

food (HEPS) by packaging them in small, daily "doses" which are "dispensed" in clinic settings or through pharmacies. (In family-oriented supplementary ration schemes, clients receive monthly rations in standard bulk commodity bags, which may be indistinguishable from other food supplies in the family setting) Therefore, the Food by Prescription model is much more carefully targeted, and economical, than family-oriented food supplements. In Kenya, for example, Food by Prescription packets cost only about 25 cents per day. However, family members of severely malnourished PLWHA are likely to be food insecure as well, since one or more family "breadwinners" may be unable to earn money for food, or to farm and produce food themselves. As directed by OGAC, this Activity will also seek to link families of client PLWHA with Income Generating Activities (IGAs), "wrap-arounds" or other food-nutrition leveraging opportunities to address broader family food insecurity issues, While this Activity will link client PLWHA and their families to other sources of food and nutrition, the Activity will use PEPFAR funding requested here strictly according to OGAC Food and Nutrition Guidelines, in order to address clinical malnutrition.

The main purpose of this Activity will be to provide the training and technical assistance in treating malnutrition to clinic and community based health workers, as well as to support the production, distribution, and monitoring of RUTF and HEPS to severely malnourished PLWHA. FANTA and its partner VALID will address sustainability concerns by working with local food processing plants to produce the RUTF and HEPS products, as well as by using a training of trainers model. By using existing local food processing which have the requisite quality control, the USG does not have to pay for plant or equipment. Furthermore, local food processors have demonstrated that they can produce a consistent, quality product while adhering to strict cost control as well. This may allow the processors to market therapeutic and supplementary foods of high quality through the private sector, positioning them for sale in pharmacies and doctors' practices. In cases where clients cannot afford to buy them at retail prices, the USG could use "social marketing" price schemes to reduce the cost, or could provide them at no cost to truly destitute clients.

FANTA will use the TOT model of training to allow USG partners as well as the GRZ to train trainers who will be available to train others on an ongoing basis, as well as to supervise and guide other health workers to develop and maintain nutrition assessment and counseling skills. FANTA will produce assessment and counseling materials locally, and local printers and suppliers will make them available on an ongoing basis for re-production or re-printing as local organizations need them.

FANTA will build local capacity and strengthen local institutions. There are also possibilities for Public-Private Partnerships, leveraging and wrap-arounds. For example, Land O'Lakes has PPP funding to work with a local food processor to produce three fortified food products for malnourished PLWHA. FANTA can link with LOL to explore economies of scale or joint marketing efforts. Also, there may be multiple leveraging opportunities with RAPIDS project to use its ability to mobilize corporate donations that might reduce the cost of production, or provide some free constituents for food products.