Better Practice in Targeted Food Assistance

Summary of published report¹

C-Safe, a consortium of non-governmental organisations (NGOs) for the southern Africa food security emergency, has recently completed its second year of implementation of a coordinated developmental and relief programme in Malawi, Zimbabwe and Zambia. Based upon a diverse set of programming experiences, C-SAFE has compiled a study on 'Better Practices in C-SAFE targeted food assistance in the context of HIV/AIDS'. The study examines programming through non-medical, as well as medical, interventions.

At its inception, the consortium identified four groups that would be prioritised for food assistance, namely:

• households affected by chronic illness
• pregnant and lactating women
• orphans and vulnerable children
• malnourished children under five years.

Chronic illness is used as a proxy indicator for AIDS throughout C-SAFE programming and literature.

The study is broken down into two key programming areas. The first area investigates targeted food assistance for non-medical programmes and looks at factors involved in establishing the programme, targeting, appropriate rations for the chronically ill, complementary activities and exit strategies. The second area reviews guidance on linking targeted food assistance with medical interventions, specifically tuberculosis, Prevention of Mother to Child transmission (PMTCT) and Antiretroviral Therapy (ART).

The following are among the key conclusions from the study.

Targeted food assistance for nonmedical programmes

Establishing the programme

Targeted food assistance programming has been more effective in reaching its goals when integrated into pre-existing relief and/or developmental programmes and infrastructures, as opposed to establishing an independent pipeline. Integration into pre-existing programming allows C-SAFE food to complement existing relief/developmental efforts, and can serve to strengthen current relationships with communities and local structures. It can also help to establish new relationships where C-SAFE expands a NGOs coverage area. Sensitisation is most effective in reducing duplicity and increasing collaboration when it reaches a broad audience of village leaders, local health centre staff, local NGO staff, community committee members, potential beneficiaries and non-beneficiaries.

Targeting

While stigma continues to hinder the transparent and direct targeting of AIDS-affected households, it does appear to be diminishing, especially in the rural areas where C-SAFE works. Targeting in the context of HIV/AIDS continues to require the use of refined proxies and other creative approaches to reach those marginalised by stigma. Staff sensitisation and training sessions have been very influential in breaking down stigma-related barriers and giving staff new skills and confidence with which to approach communities. The application of multiple vulnerability criteria (and weighting of criteria) ensures that from those referred, the most vulnerable within each group are served.

While admission and discharge criteria for food adjuncts to medical interventions are more easily standardised, C-SAFE encourages the establishing of both admission and discharge criteria for nonmedical interventions as well. By establishing clear discharge criteria (based on treatment completion or measurable improvement in food security status), individuals and households can, and do, graduate from direct food assistance to other food security and livelihood interventions, where these are available.

Conducting re-verification on a regular basis to re-assess the food security status of vulnerable households is an integral aspect of graduating beneficiaries from targeted food assistance. While safety nets are an essential feature of a self-reliant community, C-SAFEs HIV-positive beneficiaries (who overcome opportunistic infections and regain productivity), with the right support at household level, can graduate from a short-term food aid intervention to a long period of self-sufficiency and productivity, where a community-held safety net will not be required.

Appropriate rations for Chronic Illness (CI)

Given the dual crisis of food insecurity and HIV/AIDS, a comprehensive review of the traditional food basket ration choices, amount, and relative proportion of components is needed. A minimum increase of 10% more energy intake is required to maintain nutritional status and avoid weight loss in asymptomatic individuals living with HIV. Targeted food assistance often includes individuals with AIDS-related illnesses, whose nutritional needs include a minimum of 20% increase in energy intake, with as much as 50% higher protein requirements.

When chronic illness strikes the primary breadwinner and/or caregiver, other members of the household become susceptible to malnutrition. In areas affected by both food insecurity and high HIV prevalence, a household ration (which should include a nutrient dense commodity such as Corn Soya Blend) is preferable to individual supplementation.

Both NGOs and donors have failed to devote adequate time or resources to identifying, developing or sourcing appropriate commodities for chronically ill individuals and affected households. This is especially problematic where constraints exist to using genetically modified foods.

Complementary activities

Tapping into private (and other donor) funding has been an effective way of allowing C-SAFE to conduct complementary programming that was not allowable under C-SAFE's single donor funding source. Linking with partners, both local and international, has brought specialisations/expertise in various sectors and added value to C-SAFE's targeted food assistance programming.

Exit Strategies

A phase-over exit strategy will only be effective when the community is strong enough and motivated to care for itself and its vulnerable households. As C-SAFE approaches its final year, NGO members struggle to obtain adequate cash resources to ensure that community level institutions are sufficiently prepared and empowered to assume the responsibility of caring for the most vulnerable.

Targeted food assistance for medical interventions

Tuberculosis

C-SAFE has identified TB patients undergoing treatment for food assistance in its coverage areas. Based on stakeholder interviews, linking food programming with TB treatment has achieved several successes, including;

• very high TB adherence through the full DOT (Directly Observed Therapy) cycle
• reduced default rates
• increased case identification
• observed improvement in well-being includ ing weight gain
• improved return to work/productive activity.

Prevention of Mother to Child Transmission of HIV

An investment in mothers during this time is intended to assist them in delivering a normal birthweight infant, and to support the production of breastmilk through the duration of lactation. Many HIV positive women are the heads of households, and the survival of other household members depends on her well-being.

C-SAFE members are concerned that up to 20% of infants born to HIV-positive women acquire infection through breastfeeding. In resource poor environments, the WHO recommends that HIVpositive mothers practice exclusive breastfeeding during the first six months of life and discontinue as soon as is feasible. While this advice presents many challenges, C-SAFE experience has been that mothers struggle to implement these recommendations, not only because of inadequate knowledge and support but because of the lack of weaning foods that fully meet the nutritional requirements of a young infant.

Antiretrovirals (ARVs)

Many people on ARVs in resource-limited settings are not able to follow food and nutrition guidelines due to lack of access to the food required. This can lead to exacerbated drug side effects, reduced drug efficacy, and compromised adherence to treatment. For the purposes of establishing a food assistance protocol, C-SAFE categorises people on ARVs into the following two categories:

1. Those on ARVs with symptoms and related complications (at the early stages of treat ment) who require not only 20-30% addi tional energy intake, but probably need a nutrient-dense, palatable commodity while appetite and absorption are restored.
2. Those on ARVs without symptoms and related complications (well-established on treatment) who still have increased energy requirement (10%) and require a high-quality balanced diet.

Those without symptoms and/or complications would normally have responded well to treatment and other support. While nutritional support is still indicated in this group, these individuals would not fit in a C-SAFE food assistance programme. The key assumption here is that this group is essentially healthy and is engaged in, or has the potential to participate in, productive livelihood activities. Where applicable, these individuals should be directed to sustainable livelihoods/food security initiatives. On the other hand, those on ARVs with symptoms and related complications are often unable to participate in productive livelihood activities. This group would require immediate food assistance (in addition to other support).

In conclusion, targeted food assistance has the potential to fill a significant gap in the provision of comprehensive HIV/AIDS care and treatment, especially during the initial stage of ARV therapy.

¹C-SAFE (2004). Targeted Food Assistance in the Context of HIV/AIDS. Better practices in C-SAFE targeted food programming in Malawi, Zambia and Zimbabwe. A study published by the C-SAFE Learning Centre.