EXECUTIVE SUMMARY
Great strides have been made over the last 20 years in the long-term management of HIV infection in developing countries, resulting in improved immune function, reduced mortality, and prolonged survival. However, underlying malnutrition continues to impede positive health outcomes, and HIV infection in turn worsens malnutrition. The Ethiopia Food by Prescription (FBP) program, implemented by Save the Children US (SC US), USAID/Ethiopia, and the Ethiopian Ministry of Health since 2010, provides therapeutic food along with nutritional assessment and counseling to malnourished HIV+ individuals. The Tufts University Friedman School of Nutrition Science and Policy was contracted by SC US to research the effectiveness and cost-effectiveness of this intervention, in order to contribute much needed evidence to guide programming and policy, both in Ethiopia and worldwide.
Specifically, the study aimed to examine the effect on health and nutrition outcomes of food offered “by prescription” to malnourished adults living with HIV/AIDS who were at different stages of treatment. Stages of treatment included: pre-ART, ART for less than six months, and ART for more than six months. The food offered by prescription was “Plumpy’NutTM ,” a ready-to-use lipid-based therapeutic food.
Nutritional status at baseline of participants was classifi ed as either severe or moderate acute malnutrition, defi ned by BMI <= 16, and BMI > 16 < 18.5, respectively. Cost-effectiveness was assessed by measuring the marginal cost of incorporating the food supplement into the treatment program for HIV+ patients, and then relating it to the marginal benefits (specific health and nutrition outcomes) of this intervention. The study was designed as a quasi-experimental effectiveness evaluation, with a comparison group of clinics selected from a geographic area similar to those in which the intervention was being evaluated.
Key findings are noted below:
• Controlling for other factors, participants receiving the therapeutic food package (Food by Prescription/FBP) were 2.4 times more likely to meet the program criteria for graduation/recovery (i.e., to reach a BMI of 18.5 for two consecutive clinic visits within the defined time period) than similar patients who did not receive the additional food in their ART treatment regimen (comparison group).
• FBP participants were 3.1 times as likely to have ever reached a BMI of 18.5 as those not receiving food (comparison group). Among all participants, 32.6% achieved BMI >= 18.5 at least once during treatment in the FBP group, compared to 18.8% in the comparison group.
• Participants in the FBP group classified as SAM at baseline showed slightly larger increases in BMI than those with MAM (in the same group), though were less likely to recover. Thus for optimal recovery, this result underlines the importance of closely monitoring the nutritional status of HIV patients, treating malnutrition at early stages, and increasing early access to HIV/AIDS care.
• While nutrition outcomes in the intervention area were significantly better than those seen in the comparison area, recovery rates overall, as defined by the program, were low in both groups (11.3% in FBP vs. 7.4% in comparison).
• Recovery rates went up considerably (to 42% in the FBP group) if only those participants who complied with the FBP program protocol (i.e., did not default) were considered. This suggests that there is good potential to improve the impact and effectiveness of this type of nutritional program, if additional efforts are made to improve both patient adherence and health worker understanding of the protocol, program needs, and record-keeping approach.
• In the FBP group, factors associated with increased chance of recovery from malnutrition included being female, recent commencement of ART, being moderately rather than severely malnourished, having a CD4 count higher than 200 cells/microliter, and coming from a food insecure household. These findings could have important implications for the prioritization of resources for nutritional supplementation in ART programs.