The Interaction of HIV, Nutrition, and Poverty 2016/NOURISH...Prof. Archileo Kaaya, Dr. Gaston Ampe,MU, Dr. Christine Karungi, Dr. Fiona Kalinda, JCRC, Frances Nakakawa, Patrick Lubega,

The Interaction of HIV, Nutrition, and Poverty: Living with the Consequences

Moving from Research to Policy and Practice

Trinity College Dublin, 3rd November 2016

Please note that these are that these presentations contain preliminary findings from

the NOURISH Project - analysis of the data is ongoing

Contact NOURISH Project Manager Sarah Glavey [email protected] for

further information

mailto:[email protected]

Welcome and Overview

Time Session

9.30-9.45am “Welcome and Overview of NOURISH” Martina Hennessy, NOURISH Principal Investigator, Associate Dean of Research, TCD

Sarah Glavey, NOURISH Project Manager/Research Fellow

9.45-10.15am

“Information delivery and entrepreneurial skills sharing: evidence from two randomized field experiments on women living with HIV in Uganda”

Gaia Narciso, Professor of Economics, TCD

10.15-10.45am

“Investigating the connections between environment, agriculture and food and nutrition security in Karamoja”

Solomon Olum, NOURISH Researcher, Gulu University

10.45-11.15am

“Supplementary Feeding in Adults and Children living with HIV in and around Kampala”

Martina Hennessy, NOURISH P.I., Professor of Medical Education, TCD Derek Doherty, Professor of Immunology, TCD

11.15-11.30am

Coffee Break

11.30 – 12.45pm

“From Research to Policy and Practice” Elaine Collins, Finance Manager, Valid Nutrition

Breda Gahan, Global HIV and AIDS Programme Advisor, Concern Worldwide Edward Lahiff, Lecturer, Dept. Food Business and Development, University College Cork

Vincent Maher, HIV Policy Lead, Irish Aid, Department of Foreign Affairs and Trade Eoin Wrenn, Head of Region, Horn and East Africa, Trócaire

Chair: Connell Foley, Director of Strategy, Advocacy and Learning, Concern Worldwide

12.45- 1.00pm

“Next Steps for Research, Policy and Practice” Martina Hennessy, Principal Investigator

1.00pm Close and light lunch

4

“No one will be left behind”

Tackling Societal Challenges through Research

Irish Aid Research Strategy 2015-18: One World- One Future

2. FRAGILE STATES AND SITUATIONS

1

GLOBAL

HUNGER

3. CLIMATE CHANGE

4. TRADE AND ECONOMIC GROWTH

1. GLOBAL HUNGER

5. ESSENTIAL SERVICES

6. HUMAN RIGHTS AND ACCOUNTABILITY

7. HUMANITARIAN ASSISTANCE

Research Strategy Objectives •To build evidence, new and existing, on Irish Aid priorities for

poverty reduction.

•To strengthen communication and policy uptake of the findings

of Irish Aid funded and other research.

•To improve capacity to plan for, conduct and apply development

research within Irish Aid partner countries.

4. TRADE AND ECONOMIC GROWTH

The Role of the University

“No moral questions are ever abstract questions” Edmund Burke, 1839, TCD graduate

“If we still believe universities can actually change the world, then we must move beyond the conventional approach as our only way of finding answers to the most important issues of our time... Putting Global Research Questions on the agenda needs our explicit support if the questions are to become the focus of teams of academic researchers working smoothly across many disciplines… a new kind of global interdisciplinary collaboration needs to be promoted” Prendergast & Hennessy, 2015

How can a university respond?

Uganda and the Context for NOURISH

HIV: Sub-Saharan Africa had 25.8 million people living with HIV in 2014 and accounts for almost 70% of the global total of new HIV infections.

Food Security and Nutrition:

There is a need to understand the lived experience of people with HIV

HIV- Malnutrition Interactions

Social and

economic barriers

Impaired Host

response to HIV and treatment

Food Insecurity

Increased Resilience

Increased Responsiveness

Increased Empowerment

for health

Outcomes Work Package Objectives

WP4: Build Capacity Develop frameworks to measure nutritional health in HIV

Create a database for Public health and Policy and to generate new research

Increased risk of HIV Increased morbidity at presentation

Toxicity of ART Risk of relapse Sub-optimal immune response

WP2: Examine effect of Food insecurity on adaptive capacity in Karamoja

WP1.Investigate impact of nutrition on immune and

pharmacological responses in HIV

WP3: Investigate the role of nutrition and role modelling in empowering women with HIV

Work Package 2 Household survey (N=1000) + Focus Groups (N=80) Karamoja

Work Package 1 & 4 Clinical intervention, biomarkers + Public Health platform (N=250) Kampala

Work Package 3 Randomised controlled trial across Uganda (N=4,000)

WP1 Urban

WP2 Isolated

WP3 Rural

WP4 Database

Demographics x x x x

Household survey (income, health etc.)

x x x

Physical Measures: BMI, MUAC, Waist, Wt./ Ht

x x x x

Food Freq. Q’aire or 24hr dietary recall/ diversity

x x x x

Household food insecurity access scale

x

Coping Strategy Index x

Lab data (FBC, glucose, chol), Tanita, Urinary metabolomics

x

Biomarkers; DNA, RNA, PBMCs, PK x

Policy review x x x x

Key Informant Interviews x

Overview of NOURISH Research Methods

International Advisory Group

Prof. Kjetil Bjorvatn, Dr Alex Bambona, Dr Elizabeth Kiboneka, Prof. Jakob Svensson, Prof Robert Gilligan, Prof. Fiona Mulcahy

Partners: Dr. Anne Mullen, National Dairy Council

UK Dr. Helen Roche, University College Dublin

WP4 Advisory Group:

Prof. Christopher Orach, MUSPH, Dr. Jesca Nsungwa, MoH, Mr. Alex

Bambona, MAAIF, Dr. Fred Makumbi, MUSPH,

Dr. Simon Kasasa, MUSPH

jj WP4

Prof. Nazarius Tumwesigye, Dr. Pamela

Nasirumbi, Geraldine Agiraembabazi,MU

Prof. Joe Barry, Sarah Glavey, TCD

The NOURISH Consortium

WP1 Dr. Andrew Kambugu, Dr. Mohammed Lamorde, IDI, Prof. Martina Hennessy, Dr. Derek Doherty, Prof. Fiona Lithander, Dr. Paul Spiers, Dr. PJ Collins, TCD Ben Kikaire, Judy Tatwangire, TCD/IDI

WP2 Prof. Pen-Mogi, Prof. Okello-Umo, Dr. Basil Mugonola, Gulu Uni Prof. David Taylor, NUS, Gaston Tumuhimbise, Archileo Kaaya, MU Christopher Muggaga, Solomon Olum, GU

WP3 Prof. Carol Newman, Prof. Gaia Narciso TCD, Prof. Archileo Kaaya, Dr. Gaston Ampe,MU, Dr. Christine Karungi, Dr. Fiona Kalinda, JCRC, Frances Nakakawa, Patrick Lubega, MU

Panel 1: NOURISH Research

• Dr. Gaia Narciso, Assistant Professor of Economics, Trinity College Dublin

• Solomon Olum, NOURISH Researcher, Gulu University

• Dr. Martina Hennessy, Associate Professor of Medical Education

• Chair: Sarah Glavey, NOURISH Project Manger/Research Fellow

Information delivery and entrepreneurial skills sharing: evidence from two randomized field experiments on women living with HIV in Uganda

Patrick Lubegaa, Frances Nakakawaa, Gaia Narcisob and Carol Newmanb

aMakerere University, Uganda bTIME, Trinity College Dublin, Ireland

Trinity College Dublin, The University of Dublin

Information delivery, Nutrition and HIV Treatment: Evidence from a randomized field experiment on women living with HIV in Uganda



Background

• Little is known about how to trigger behavioral change in relation to nutrition, particularly among vulnerable groups

• In this paper, we test the effectiveness of a nutritional information campaign on improving the health and welfare outcomes of women living with HIV in Uganda using a large-scale RCT

• We explore whether the means of communication matters and uncover some of the underlying mechanisms at work

Motivation • In many settings, people are not well informed about the benefits

associated with certain types of behavior

• The use of mass information campaigns to improve the delivery of services has recently been advocated as an important mechanism for solving information failures (Mansuri and Rao, 2013)

• However, the extent to which such information reaches the most excluded groups has been questioned (Mansuri and Rao, 2013)

• Very little research has explored how information delivered through mass campaigns matters for outcomes

What we do…

• We examine alternative means of providing nutritional information to HIV positive women

• We design and test the impact of a nutrition information campaign and explore two different means of information delivery:

1) a standard nutritional information campaign involving the distribution of posters and flyers;

2) interactive and entertaining cookery demonstrations on how to produce a locally sourced home-made nutritious food.

Experimental design We randomly selected 4 sub-regions of Uganda;

We randomly selected 24 clinics, 6 in each of the four sub-regions;

At baseline each clinic was visited for two days during the HIV clinic to recruit participants;

On average 135 women recruited in each clinic (over 3,000 respondents at baseline);

Baseline survey instrument gathers information on: Personal characteristics of woman Personal characteristics of family members Food frequency questionnaire Income Agricultural production Enterprise activity Employment Housing Access to credit and savings behavior

Experimental Design

Two separate treatments are considered and randomization of baseline participants occurs at the clinic level;

Each group includes 8 clinics and are evenly distributed across each of the 4 sub-regions.

Intervention

Group A Nutritional Information campaign

Group B Nutritional Information campaign + recipe demonstration

Group C Control group

Oct-Dec 2014 Intervention 1

Jan – Mar 2015 Intervention 2

Apr – May 2015 Intervention 3/Evaluation 1

July-Aug 2015 Evaluation 2

April-Sept 2014 Baseline

Details on Interventions

Nutritional Information Campaign

Delivered by clinic staff at each visit

Content of campaign:

» Information leaflets and posters

» Hands off approach

» Allow clinics to do as they please in attempt to mimic typical campaigns by Ministry of Health

Treatment 1: Nutritional Information Campaign

Treatment 2: Recipe Demonstration

Locally sourced Home-made Nutritious Foods

Nutritionists working in each region to establish locally sourced ingredients that can be used to prepare a Home-Made Nutritious Food.

Products tested at Makerere University for nutrient content, taste and aesthetic appeal – similar to bringing product to market

Intervention takes the form of cookery demonstrations


Treatment 2: Recipe Demonstration

Did the campaign lead to a behavioural change in relation to nutrition?

Obs: 6,200

Information campaign

Recipe demonstration

Access to information

+ +

Meals +

Snacks

Litres of Water

Treated Water

Did the campaign lead to improved health and education outcomes?



Sick -

% Child sick -

% Child absent school

- Midline

Child absent - School fees

-

Child absent - Sick

Did the campaign impact on income and livelihoods?

Obs: 6,200



Personal income +

Other household income

Wage income

Crop income

Livestock income

Enterprise income +

Operates an enterprise

+

Income and livelihoods

Question: What is different about the cookery clinics?

There are two possibilities:

i. Women in cookery clinics become better nourished because they are eating the recipes. In the information only clinics they are just following the guidelines on the brochure so they are not getting the full effect.

ii. There is something about the way the information is delivered that empowers women to work harder.

Anthropometrics and Nutritional intake



Anthropometrics

BMI -

Upper Arm Circumference

Waist circumference -

Nutritional intake (end-line data)

Calories +

Protein +

Fat +

Carbs

Fibre

Minerals +

Vitamins +

Empowerment

Control over.. Information campaign


Personal income - alone

+

Personal income – husband

Personal income – joint

-

Household income - alone

Household income - husband

Household income - joint

Conclusion

• The provision of basic information changes the nutritional intake of women and their health but has limited impact on other welfare outcomes

• In contrast, participation in the cookery campaigns has significant effects on incomes and female empowerment, with knock on effects for children’s school attendance

• Our results suggest that standard information campaign have limited impact on objectively measured outcomes. The participatory cookery demonstrations, on the other hand, have further-reaching effects.

• Positive impact on personal income and the decision to start an enterprise

• Payment of school fees and reduces the proportion of days that children are absent from school

• More empowered, exercising greater control over their own personal incomes

Conclusion

Cookery demonstrations could impact differently in two ways:

1) Demonstration of the recipe is more effective than a passive information campaign

…. both campaigns increased the nutritional content of women’s diets; some evidence that the cookery campaign impacted positively on the mineral and vitamin intake of women

2) the actual activity of bringing women together creates social ties that both empowers and enables the women to engage in more economic activity.

….no evidence that the cookery campaign impacted on the formation of social ties, but positive effects on empowerment

Overall, our results suggests that the medium through which information is delivered can be an empowering tool in itself to improve well-being for vulnerable populations.

Inspiring women: Experimental evidence on sharing entrepreneurial skills in rural Uganda




Motivation

– Role models and bottom-up knowledge sharing;

– Do role models and bottom-up knowledge sharing have an impact in the way in which discriminated individuals think and behave?

– Is this impact permanent or does it fade away over time?


Literature review

– Guyon and Huillery (2014): disadvantaged individuals perform worse when they are reminded of their group;

– Hoff and Pandey (2006, 2014): making identity salient can negatively affect performance of low-caste boys;

– Bernard et al. (2014): impact of screening documentaries about people who had succeeded in agriculture or small business in Ethiopia.

This project

• focuses on a specific group of individuals, who are discriminated and carry a substantial social stigma.

• spans over a longer time horizon

Experimental design We randomly selected 4 sub-regions of Uganda;

We randomly selected 16 clinics, 4 in each of the four sub-regions;

At baseline each clinic was visited for two days during the HIV clinic to recruit participants;

On average 135 women recruited in each clinic;

Baseline survey instrument gathers information on: Personal characteristics of woman Personal characteristics of family members Food frequency questionnaire Income Agricultural production Enterprise activity Employment Housing Access to credit and savings behavior

Experimental Design

One treatment is considered and randomization of baseline participants occurs at the clinic level

Each control and treatment group includes 8 clinics and is evenly distributed across each of the 4 sub-regions

Intervention

Group T Inspiring women videos

Group C Control group

April-Sept 2014 Baseline

Oct-Dec 2014 Intervention 1

Jan – Mar 2015 Intervention 2

Apr – May 2015 Intervention 3/Mid-evaluation

July-Aug 2015 Intervention 4

Sept-Dec 2015 Endline evaluation


Intervention

Video screening at HIV clinics;

One video for each round of intervention;

Four 3-minutes videos;

Group discussion during and after video screening;

Posters;

Casting: 4 inspiring women with business activities;

Video structure:

Background information

How they started their businesses

Challenges

Targets for the future

“I run my own businesses. I have done this and you too can do it”


Inspiring women

Sarah

Alice

Jovia

Mugenyi

https://vimeo.com/139188803




Outcomes

• Income and livelihoods

• Empowerment

• Health and education

• Savings and credit

Income and livelihoods

Obs: 3,600

Videos

Operates an enterprise +

Works for a wage

Personal income +

Household income

Wage income

Crop income

Livestock income +

Enterprise income +

Empowerment

Control over.. Videos

Personal income - alone

+ (Mid-line)

Personal income – husband

Personal income – joint

- (Mid-line)

Household income - alone

Household income - husband

Household income - joint

Did the campaign lead to a improved health and education outcomes?

Videos

Sick -

% Child sick -

% Child absent school

-

Child absent - School fees

-

Child absent - Sick

Other outcomes

Videos lead to more informal savings

There may be much longer term effects associated with the video intervention

Conclusions

Roles models have a positive effect on probability of starting a business, personal income and income from enterprises and livestock.

The fact that other household income and income from other activities is not affected suggests that this is due to the message contained in the videos.

Conclusions

Some evidence of increase in control over personal resources in video clinics.

Decline in joint control of personal finances;

Videos lead to

» better health among women and their children

» lower proportion of children absent from school

» In particular they reduce the probability that children are absent from school because of school fees.

Videos lead to more informal savings

There may be much longer term effects associated with the video intervention

Thank You!

Acknowledgements • Collaborating partners:

• Joint Clinical Research Centre (JCRC) • Makerere University • Trinity College Dublin

• We are grateful to a number of people for their valuable comments and insights. These include:

• We are also grateful to the large team of research assistants who took part in the fieldwork component of this project for their dedication and commitment

• We also thank our scientific advisory team for their input and advice

• Prof Martina Hennessy, TCD

• Prof Nazarius Mbona, Makerere

• Dr Cissy Kityo, JCRC

• Prof Archileo Kaaya, , Makerere

• Dr Gaston Ampe, Makerere

• Ms Max Walusimbi, Makerere

• Dr Fiona Kalinda, JCRC

• Ms Christine Karungi, JCRC

• Prof Fiona Lithander, Bristol

• Prof Joe Barry, TCD

• Prof Ceppi Merry, TCD

• Sarah Glavey and Sarah O’Reilly, TCD

Investigating the connections between environment, agriculture and food and nutrition

security in Karamoja, Uganda

Solomon Olum, MSc, NOURISH Researcher, Gulu

University

NOURISH Project: Work Package 2 • Host partner: Gulu University, Uganda • Supervisors and project team

Prof. Taylor David (National University of Singapore, formerly TCD)

Prof. Duncan Ongeng (Gulu University) Prof. Okello-Uma (Gulu University) Dr. Basil Mugnola (Gulu University) Prof. Kaaya Anchileo, (Makerere University) Dr. Gaston A. Tumuhimbise, (Makerere University) Prof. J.H. Nyeko Pen-Mogi-PI, (Gulu University)

• 2 students

PhD: Christopher Mugagga MSc: Solomon Olum *Absorbed by Gulu University as lecturers *Gulu University is a community-oriented institution, with moto “for community transformation”

Background • Karamoja with highest food and nutrition insecurity

(UDHS, 2011)

• Lowest human development indicators

20% of the households food insecure and a further 38%

moderately food insecure (Gerlad & Jing, 2012).

45% U5 are stunted ; 70% U5 and 43% of WCBA are anemic (UBOS/IFC, 2012).

High childhood disease prevalence; Malaria (43.3%) (UNICEF/ACF, 2009), fever (40.9%) and diarrhea (20.3%) (UBOS/IFC,

2012).

• Ecologically; one planting season, highly sporadic rains

• Pastoral lifestyle

• Ethnically diverse with unique cultural features

Map of Karamoja: (5/7 districts studied)

Objectives of Work Package 2

Investigate:

The principal causes of nutritional stress and poor

health

Forms of food production and livelihoods that are

most vulnerable to chronic and transitory external

pressures.

Factors (including cultural determinants)

contributing to food and nutrition insecurity

Methodology • Households surveys

Food security—HFIAS

Dietary survey; FFQ, HDDS, 24-recall

Methodology • Focus groups

• Key Informants interview

Methodology

• Anthropometry

Number of respondents for household surveys

District First Visit Follow-up Visit

Abim 192 166

Amudat 186 146

Kaabong 190 168

Moroto 186/133 (319) 165

Kotido 140 -

TOTAL 1027 645

Key findings

• High household food insecurity

Household food insecurity score and coping strategy index

Sub-county

Mean±SD of food

insecurity score P value

Mean±SD of Coping

strategy index (CSI) P value

Nadunget 15.65±5.21 0.271 119.286±47.40a < 0.00

Tapac 15.11±3.07 122.264±30.94a

Nakapelimor

u 14.24±4.56 94.057±46.06b

Kacher 14.79±3.80 98.100±42.36b

Total 14.94±4.21 108.148±43.65

Key findings • Poor dietary practices Low number of meals

Low and infrequent consumption of animal foods

Low dietary diversity

Number of meals taken by households

Percent of households that took different

number of meals in 24 hours

Ethnic group No meal at all 1-2 meals

3 or more

meals

Jie 1.6 74.8 23.6

Labwor 0 50.0 50.0

Matheniko 0 93.9 6.1

Tepeth 3.0 68.2 28.8

Others (Acholi, Turkana) 0 62.5 37.5

Total 1.5% 77.3% 21.2%

Poor nutritional indices (WAZ,HAZ,WHZ)

Weight for Height-Kaabong

Causes of food and nutrition insecurity and poor health

• Low calorie and nutrient intake

• Cultural aversion to nutritious foods (e.g. ASFs)

• Poor food insecurity coping strategies

• Poor housing predisposes to poor health

• Big family sizes (majority >10 members)

• Low educational attainment

Proportion of households with adequate intake of calorie and nutrients

Percentage of households that took at least the minimum RDA

Age

group

19-30 years 31-50 years 51-70 Years Above 70 years

District Kotido Moroto Kotido Moroto Kotido Moroto Kotido Moroto RDA

Calorie 20.8 7.1 25.9 3.9 12.5 0 0 0 2000-

2200Kcal

Water 27.1 21.4 10.3 39.2 9.4 32.6 N/A 38.5 2.7 litre

Proteins 58.3 14.3 63.8 21.6 53.1 14 N/A 23.1 46g

Carbohyd 81.2 64.3 75.9 60.8 75.0 41.9 N/A 46.2 130g

Fiber 45.8 39.3 46.6 35.3 62.5 37.2 N/A 38.5 21-25g

Calcium 12.5 0 8.6 0 0 2.3 0 0 1000mg

Iron 41.7 10.7 43.1 13.7 84.4 51.2 N/A 46.2 8-18g

Zinc 43.8 10.7 43.1 5.9 40.6 7.0 0 0 8g

Proportion (%) of Pregnant women with adequate energy and nutrient intake

Districts

Season

/

visits

n

Percentage of Pregnant women with adequate Energy and

Nutrient Intake

Energy Protein

Carbohy

drates Fibre Calcium Iron Zinc

Abim 1 65 15.4 12.3 61.5 32.3 7.7 6.2 7.7

2 20 25 25 85 45 15 25 25

Kaabong 1 63 9.5 15.9 81 33.3 7.9 4.8 11.1

2 19 63.2 31.6 100 31.6 31.6 21.1 36.8

Moroto 1 63 30.2 20.6 74.6 38.1 7.9 11.1 15.9

2 14 57.1 35.7 71.4 64.3 0 14.3 28.6

Amudat 1 62 35.5 14.5 88.7 30.6 54.8 0 32.3

2 20 65 30 100 75 50 5 50

Foods prohibited by culture to be eaten by women and children

Name of the food item (local name) Reason (s) for prohibiting

Offals/animal intestine (Ngamolteng) - First women who ate spoilt it.

- Pregnant women will get miscarriage

Liver (Emany) - Expecting woman will fail to deliver or her baby

dies

Pancreas (Ecid) - Woman continues bleeding/over bleed after

delivery

Animal ribs (Ngamarang) - When a woman delivers, the placenta will fail to

come out

Testis of animal (Nyito) - Young women will not produce if they eat

Spinal cord/Vertebrae bone - If a child eats, his/her uncle will die

Chicken which lack feather on the

neck (Congolese chicken): Lokulas

- The child will not have good luck in most things

Sharing water from same source - Girls of the same family who are married in one

area do not share water from the same source

unless a ritual is performed or they die

Food insecurity coping strategies for Karamoja

Coping strategy Weight assigned

Rely on less preferred and less expensive foods 3

Borrow food or money to buy food 3

Rely on help from friends/relatives 2

Limit portions at meal time 3

Limit intake to ensure children get enough 3

Reduce number of meals eaten in a day 4

Skip whole days without eating 3

Gather unusual amounts of wild foods 4

Harvest immature crops 2

Rely on casual labour for food 4

Send household members to eat elsewhere 2

Sell assest e.g. animals 2

Eat unconventional foods e.g. local brew residue,

wild foods 4

Poor housing predisposes to poor health

Educational attainment of household caregivers

District No formal education

Primary level Secondary level

Tertiary

Abim 26 56 18 1

Kaabong 63 37 1 0

Moroto 92 8 0 0

Amudat 95 4 0 0

Kotido 92.9 5.7 1.4 0

Forms of food production and livelihoods that make occupants vulnerable

• Food production generally low to support food and nutrition security

• Pastoral life style*

• Charcoal burning and cutting down trees for fuel wood

• Poor occupation (casual laboring and gardening)

• Brewing of cereals for alcohol

Household 12 month crop production value (in US dollars) segregated by sub-county (mean)

Key Recommendations

• Nutrition education to: Demystify cultural aversion to nutritious foods Raise knowledge and awareness of nutritious foods Increase calorie and nutrient intake (link food intake and

levels of activity) Minimize nutrient loss during food preparation Behaviour change communication to address cultural

food restriction and high alcohol consumption

• Natural resource management

Emphasis on conservation of wild plants to sustainably reap benefits (Vegetable, fruits, roots, medicine, fuel wood).

Increase access of local people to areas with wild plants

Key recommendations • Improvement on agricultural production

Diversification of production for both crops and animals Provision of early maturing and drought resistant varieties Encourage small animal (goats and poultry) production to cushion

against transitory food insecurity

• Improvement on WASH Increase on latrine coverage and lower open defecation Increase coverage of safe water sources

• Empowerment of households Economic empowering (IGAs) of households to cushion in hunger

periods Combat high illiteracy levels—government & development agencies Health education on family planning and benefits of small size

households

Acknowledgements

• Irish Aid/HEA-for funding the research • TCD Team- overall coordination • Makerere University- supervision, MSc study, country

coordination • Gulu University – PhD study, supervision, coordination • Professor David Taylor (NUS)- WP2 Supervision and

Sponsorship of visit to NUS (PhD and MSc Students) • All the collaborators in NOURISH project • Karamoja district local government (RDCs, CAOs, sub-

county officials, LCs) • Locally sourced RAs

Thank you for listening

Solomon Olum, MSc, NOURISH Researcher, Gulu

University

Supplementary Feeding in Adults and Children in and around Kampala

Dr. Martina Hennessy, TCD

Aims

• To investigate the role of nutrition as a determinant of treatment outcome for HIV infected adults and children in Uganda, by examining clinical, pharmacological and immunological responses to food supplementation in patients with and without malnutrition

WP1

Screened 420 or more, 300 proceed, lost 30% early on further loss at F/U , 95 remaining enough to reveal the lived experience of adults with HIV in Uganda

Adults with HIV initiating ARVs

MAM

BMI 16.5-18.5

ARVs Plus supplementary

feeding

ARVs only

SAM

BMI<16.5 ARVs Plus

supplementary feeding

WN

BMI >18) ARVs only

MAM ARV

Experienced BMI <18

Nourish participants underwent a comprehensive nutrition assessment

• Food and Nutrition Related History

• Anthropometry

• Biochemical Data and Medical tests

• Nutrition Focused Physical Findings

• Client History

78

Adult Baseline Characteristics

CHARACTERISTIC

GROUP

Well nourished

N=23

Severely

Malnourished

N=17

Moderately

Malnourished

N=32

Malnourished

On ART

N=26

Mean Age in years (sd) 32.42 (8.39) 32.36 (6.53) 34.69 (11.77) 46.00 (8.31)

WHO STAGE at

ART initiation

I 4 0 1 0

II 15 1 6 3

III 3 2 15 18

IV 1 14 10 5

Mean Weight in Kg (Sd)

Time to ARV (mths)

58.4 (8.6)

2

44.2 (5.1)

13.8

49.5 (4.7)

8.7

45.1 (3.5)

3yrs on ARVs

Mean BMI (sd) 22.3 (1.8) 15.88 (0.7) 17.86 (0.5) 17.3 (1.1)

Mean CD4 cells/ul (sd) 299.61

(183.64)

125.8

(161.08)

205.65

(135.78)

492.69

(247.1)

Median Viral Load

(Copies/ml), (range)

0.6^105

(489- 28.5^105)

1.3^105

(1250-12.4^105)

1.8^105

(0-86^105 )

0

(0-35.6^105)

Baseline Daily Work activities lost through

illness all groups

*

Understanding The Adult Diet

HIV Positive, Moderately Acutely Malnourished (MAM) Naïve Patients. Randomised to Plumpy Nut or not x12 weeks

Group A Treated vs Untreated patients (PN) showed a significant increase in 3month BMI compared with patients own baseline BMI, but no difference between groups

Gain of approx. 5kg weight and +1 unit of BMI

Weight Change (Kg) and BMI change (Kg/M2 ) in Adult ARV experienced HIV malnourished Patients

Patients with BMI < 18.5Kg/ M2 were randomised to receive Plumpy Nut ( 2 sachets/ day) or not for 12 weeks

The effect of PN on ARV drug levels

Body Composition Analysis Moderately malnourished Severely

malnourished Well nourished

Baseline combined

Follow up with

Plumpy nut

Follow up No

Plumpynut

Baseline Follow up with

Plumpy nut

Baseline Follow up no Plumpy

nut

Age, y 35 33 38 33 33 33 33

Weight, kg

49.5

54 55 44 49 57 59

Height, cm 166

166 167 166 166 161 161

BMI, kg/m2

17.9

19 19 16 18 22 23

% fat 9.7 15.79 12 7 12 21 21

Fat mass, kg

5.9

8.9 6.3 3.1 6 11 12.6

TBW, kg 33 33.5 34.9 30 31 33 34

How do we usefully measure total body protein ?

Only 2% fall in Cholesterol

(meta-analysis of community studies (Ramsay. BMJ;1991:303:953)

Dietician = Leaflet = GP advice

(BMJ:1995:310:569)

Changes in Blood lipids with Plumpy Nut and ARVs

Chol LDL HDL Trig HB crp

MAM +PN baseline vs F/U

3.58 vs 4.38 2.0 vs 2.75 0.88 vs 1.3 1.21 vs 1.24 11.9 vs -13 26 vs 26

MAM - PN baseline vs F/U

4.06 vs 4.33 2.44 vs 2.6 1.98 vs 1.55 1.46 vs 1.42 13.4 vs -13.9 26 vs 10

SAM +PN baseline vs F/U

3.1 vs 4.3 1.63 vs 2.2

0.65 vs 1.45 1.64 vs 1.88 10.86 vs 13.1 46 vs 15

WN baseline vs F/U

3.85 vs 4.22 2.23 vs 2.8 1.0 vs 1.4 1.57 vs 1.5 12.9 vs 12.8 2.9 vs 1.8

Dietary data under analysis includes CHO Fat protein and micronutrients folate iron magnesium calcium zinc and vits

Work Package 1- Main findings The presence of MAM or SAM status at initiation of ART is associated with worse presentation, micronutrient deficiency, more days lost due to illness and delay in starting ART. Generally food intake and dietary diversity if poor even when food is plentiful There is a significant cohort of adults ( 25%) and children (44%) already engaged in care that continue to be malnourished despite ART. This group responds well to RUTF For MAM patients starting treatment, there was no difference in change in BMI /weight for those given ART +RUTF compared with ART alone. Perhaps resources best used elsewhere? Preliminary results suggest that innate immune response (gamma delta expansion) to HIV treatment is affected by malnutrition

Additional Findings and Further Analysis

• Patients were compliant with ARV and PN where it was given • Degree of food insecurity and serious lack of dietary diversity ( as in

WP2) • All gained weight and some of that is attributable to the ARV

treatment PN • The effects of PN on BFC were remarkable does it have LT

significance • A sig no of patients on ARV are MN while engaged in care - a

forgotten group what can we learn from this group how should we treat them (? Not with PN)

• What about protein and metabolomics? The 24 hr dietary recall analysis will add information

• How will it affect drug handling

The Children's Study

Transdisciplinary research for global challenges is about making a different future for mankind

because the future will

be different

Naïve children n=66 (%) Exp children n=89 (%)

Male 31(47) 43 (48)

Female 35(53) 46 (52)

Nutrition status

malnourished 41(62) 44(49)

Well nourished 25(38) 45(51)

Next of Kin as mother 48(73) 65(73)

Mother on ART 34(69) 70(93)

Mother alive 53(88) 79(88)

Mother aware of HIV sero-status of father

22 (58) 56(67)

Immunization status 43(73) 74(83)

Socio-demographic characteristics of children

70% of malnourished children were between 5-12yrs, remainder between 1-5yrs, none were infants - “ The forgotten child”

Common reasons for exclusion Reasons for not being recruited Numbers Percentages

1. Suspected or confirmed malignancy 2 1.83

2. Vomiting 5 4.62

3. Congenital disorders 3 2.75

4. Cerebral palsy 2 1.83

5. ART naïve critically ill children 6 5.50

6. Odematous malnutrition 2 1.83

7. Recent RUTF use in the last 3 months 1 0.92

8. Stunted 9 8.26

9. Controversial HIV tests 2 1.83

10. Mild malnutrition 35 32.11

11. Minor with minor 3 2.75

13. HIV exposed 31 28.44

14. Doctor busy 6 5.50

15. Age range 2 1.83

Total 109 100

What are children Eating?

Change in viral load in ARV experienced children after receiving Plumpy nut

MAM SAM

BL 3 Mo BL 3 Mo

<20 22.5 37.9 6.67 18.2

20-1000 30.6 41.4 13.3 27.3

>1000 46.9 20.7 80 54.6

Pharmacology: ART Regimen Profile

Type of ART regimen Percentage

ABC+3TC+EFV

30.77

ABC+3TC+NVP

23.08

ABC +3TC+ AZT

23.08

ABC +3TC+ LPV/r

15.38

AZT +3TC+ NVP 7.69

Nevirapine paired samples from ARV experienced MAM and SAM children at baseline and 3months post PN

NVP levels are high relative to normal values at baseline

But return to normal values with PN

Flow cytometric analysis of circulating lymphocytes

To determine the frequencies of the following cell types in PBMC • CD4+ T cells - depleted in HIV infection • CD8+ T cells • CD4-CD8- T cells • B cells • Natural killer (NK) cells • Natural T (NT) cells • Invariant natural killer T (iNKT) cells • Vδ1+ γδ T cells – expanded in HIV infection • Vδ2+ γδ T cells – depleted in HIV infection • Vδ3+ γδ T cells

Immunophenotype (Vδ3) of HIV infected children categorised by nutritional & ART status

WP1 Team - Acknowledgments Ben Kikaire, Judy OrikiriizaTatwangire, IDI/TCD Andrew Kambugu, Mohammed Lamorde, IDI

Nazarius Tumwesigye, MUSPH Martina Hennessy, Derek Doherty, Fiona Lithander, Paul Spiers, PJ Collins, Ceppie Merry, Fiona Mulcahy, Carol Newman, Gaia Narciso, Sarah Glavey, Joe Barry, TCD

Aifric O’ Sullivan, Helen Roche, UCD Anne Mullen, Kings College London/National Dairy Council UK

Pietro Pala, Jane Achan, Grace Ndeezi, Paula Munderi, MRC




Panel Q&A

• Audience Q&A (15 mins)

Summary

• Themes Arising: – Partnership among different development

stakeholders

– Research coherence: challenges and opportunities of doing multi-disciplinary research

– Research Impact

• After the break we will move from researcher to policy and practice, gaining responses and perspectives from our panel of discussants

Panel 2: From Research To Policy and Practice

Time Session

9.30-9.45am “Welcome and Overview of NOURISH” Martina Hennessy, NOURISH Principal Investigator, Associate Dean of Research, TCD

Sarah Glavey, NOURISH Project Manager/Research Fellow

9.45-10.15am

“Information delivery and entrepreneurial skills sharing: evidence from two randomized field experiments on women living with HIV in Uganda”

Gaia Narciso, Professor of Economics, TCD

10.15-10.45am

“Investigating the connections between environment, agriculture and food and nutrition security in Karamoja”

Solomon Olum, NOURISH Researcher, Gulu University

10.45-11.15am

“Supplementary Feeding in Adults and Children living with HIV in and around Kampala”

Martina Hennessy, NOURISH P.I., Professor of Medical Education, TCD Derek Doherty, Professor of Immunology, TCD

11.15-11.30am

Coffee Break

11.30 – 12.45pm

“From Research to Policy and Practice” Elaine Collins, Finance Manager, Valid Nutrition

Breda Gahan, Global HIV and AIDS Programme Advisor, Concern Worldwide Edward Lahiff, Lecturer, Dept. Food Business and Development, University College Cork

Vincent Maher, HIV Policy Lead, Irish Aid, Department of Foreign Affairs and Trade Eoin Wrenn, Head of Region, Horn and East Africa, Trócaire

Chair: Connell Foley, Director of Strategy, Advocacy and Learning, Concern Worldwide

12.45- 1.00pm

“Next Steps for Research, Policy and Practice” Martina Hennessy, Principal Investigator

1.00pm Close and light lunch

Panel 2: From Research to Policy and

Practice • Elaine Collins, Finance Manager, Valid Nutrition

• Breda Gahan, Global HIV and AIDS Programme Advisor, Concern Worldwide

• Edward Lahiff, Lecturer, Dept. Food Business and Development, University College Cork

• Vincent Maher, HIV Policy Lead, Irish Aid, Department of Foreign Affairs and Trade

• Eoin Wrenn, Head of Region, Horn and East Africa, Trócaire

• Chair: Connell Foley, Director of Strategy, Advocacy and Learning

Breda Gahan, Global HIV and AIDS Programme

Advisor, Concern Worldwide


Burden of HIV in Uganda (2015)

107

Impacts of HIV and AIDS on Food and Nutrition Security

Household member

ill with HIV and AIDS

Healthcare costs

Need for care

Productivity

Household Nutrition

Security

Savings, purchasing power

Partner becomes ill

Child care Hygiene

Food processing/

preparation Food Security

-Availability

Stability

Access to food

HIV and Malnutrition

Ref. In-Country Guidelines

Text

20080200880

2009

*Be Country, Culture, Context conscious in terms of national guidelines & implementation

Panel 2: From Research to Policy and Practice

• Short report to follow

Wrap-Up - What Next?

• Key themes emerging from the discussions today

• Next steps for NOURISH and partnerships – Work package 4 - Policy review and report

– Disseminate research findings as they are developed

– Consult widely to expand partnerships

– Make large dataset accessible

• Updates will be posted to https://www.tcd.ie/tidi/nourish/

• Check out Trinity Development Research Week by TIDI!

https://www.tcd.ie/tidi/news-events/tidi/#drw

112

“No one will be left behind”

Platform

Language Partnership

Defining

Challenge Approach

Outcome

Identification of Scale &

partnership

Research Design and performance

metrics for impact

Implementation

&

Timing

Impact

dissemination

Evidence into use

Transdisciplinary Ecosystem to address Global Challenges

Compromise Collegiality

Consistency Creativity

Academic Social Responsibility



All feedback and questions welcome to NOURISH Project Manager/Research Fellow, Sarah Glavey [email protected]

mailto:[email protected]

Documents

The Interaction of HIV, Nutrition, and Poverty 2016/NOURISH...Prof. Archileo Kaaya, Dr. Gaston Ampe,MU, Dr. Christine Karungi, Dr. Fiona Kalinda, JCRC, Frances Nakakawa, Patrick Lubega,