Implementation of postnatal nutritional care and support policy at PMTCT sites.

The number or percent of sites in a country or specified area delivering prevention of mother-to-child-transmission (PMTCT) of HIV care that provide postnatal nutritional counseling to HIV positive mothers according to national HIV and infant feeding policy. For WHO and UNICEF recommendations on postnatal nutrition and HIV care and support and PMTCT, see WHO (2003); WHO (2004); and WHO/UNICEF (2003).

PMTCT sites may be defined differently, but minimum services should include testing and counseling for pregnant women at or near an antenatal care facility or labor and delivery facility. 

This indicator is calculated as:

(Number of PMTCT sites that provide postnatal nutritional care and support in accordance with national policy/ Total number of PMTCT sites in a country or specified area ) x 100

A list will be compiled for all PMTCT sites that provide nutritional care and support to HIV-positive mothers in a country or specified area.  Investigators and study staff will visit each site to determine whether or not postnatal nutritional care and support services are being provided according to national policy. In order to achieve accurate and reliable results that can be compared across sites, study staff will need to develop a set of criteria that can be used to judge whether the content of counseling provided by staff complies with national HIV and infant feeding policy. The indicator may be disaggregated by sites that provide the following services: (1) nutritional care services - nutritional assessment and counseling; (2) nutritional support services – supplementary and therapeutic feeding; or (3) both nutritional care and support services. Where the data are available, the indicator can be disaggregated by province and district, urban/rural location, and type of facility (public, private, community-based). 

National or district level listings of PMTCT sites.  Surveys, reports, interviews and/or observations from program sites and staff regarding provision of postnatal nutritional care and support to HIV-positive mothers.

This indicator measures the level of policy implementation from the national government or ministry of health through to the PMTCT site-level provision of nutritional care and support.  It serves as a proxy for the extent to which PMTCT and nutritional care and support have been operationalized at the facility level and can be used to identify sites or areas in need of inputs, such as added staffing, in-service training, and/or ongoing monitoring.  If country-level nutritional policies are changed, this indicator can be used measure roll out of the new guidelines. 

WHO and UNICEF have recommended the provision of postnatal nutritional care and support to maintain or improve nutritional status of HIV-positive mothers and to minimize mother-to-child transmission (MTCT) of HIV, while at the same time maximizing child survival (WHO/UNICEF, 2003; 2007). Sufficient energy and nutrient intakes are necessary for women to replenish their nutrient stores and to support the demands of breastfeeding. Infants born to HIV-positive mothers are at a substantially higher risk of low birth weight, early malnutrition, and mortality in the first two years of life compared with children born to mothers without HIV. Where breastfeeding is common and prolonged, HIV transmission through breast milk may account for up to half the infections in infants and young children (PEPFAR, 2006). MTCT can take place even in settings where 100 percent of HIV-positive women are receiving either lifelong antiretroviral (ARV) therapy or a prophylactic course of ARVs for prevention of mother-to-child transmission (PMTCT).  Given the nutritional and immunological benefits of breast milk and the finding that, compared with exclusive breastfeeding, mixed feeding before six months increases risk for MTCT, WHO and UNICEF (2003) have recommended exclusive breastfeeding for the first few months of life where safe and affordable alternatives are not feasible. For more background on recommendations, interventions and indicators for nutrition care and support, infant feeding and PMTCT, see WHO/UNICEF (2007); PEPFAR (2006), UNAIDS (2010), and WHO/UNICEF/UNAIDS (2011).

While the indicator quantifies the number of sites that provide the recommended content of nutritional care and support for postnatal HIV-positive mothers and their infants, it does not provide information on the quality of the counseling.  The interviewer’s assessment of the counseling with respect to policy guidelines and criteria requires subjective interpretation and results are subject to observer bias.  The indicator cannot be used to measure the relative success or failure of the nutritional care and support interventions.

quality, integration, access, HIV/AIDS, health system strengthening (HSS), policy, newborn (NB)

FANTA (Food and Nutrition Technical Assistance) Project. 2007. Recommendation for the Nutrient Requirements for People Living with HIV/AIDS, Washington, DC: USAID/Academy for Educational Development.

FANTA (Food and Nutrition Technical Assistance) Project.  2008.  A Guide To Monitoring and Evaluation of Nutrition Assessment, Education and Counseling of People Living with HIV.  Washington, D.C.: USAID/Academy for Educational Development.

PEPFAR, 2006, Report on food and Nutrition for People Living with HIV/AIDS, Washington, DC: USAID/PEPFAR.

UNAIDS, 2010, Prevention of Mother-To-Child Transmission of HIV (PMTCT): Technical Guidance Note for Global Fund HIV Proposals, Geneva: UNAIDS.

WHO, 2003, Nutrient requirements for people living with HIV/AIDS: Report of a technical consultation, May 13-15, Geneva: WHO.

WHO, 2004, Nutrition Counseling, Care and Support for HIV-infected Women, Geneva, Switzerland: World Health Organization.

WHO/UNICEF, 2003, Global Strategy for Infant and Young Child Feeding, Geneva: WHO.

WHO/UNICEF, 2007, Planning Guide for national implementation of the Global Strategy for Infant and Young Child Feeding, Geneva: WHO.

WHO/UNICEF/UNAIDS, 2011, A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS. Geneva: WHO.