Women's Nutrition and HIV

 

Welcome to the programmatic area on women’s nutrition and HIV within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. This is one of the subareas found in the health service integration section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. The HIV epidemic is primarily occurring in populations where malnutrition is already endemic. Because adequate nutrition helps maintain the immune system, sustain physical activity, and is essential for improving treatment outcomes with antiretroviral drugs, the World Health Organization (WHO) recommends that any comprehensive program for HIV and AIDS include nutritional support (WHO, 2003). Women of reproductive age with HIV are a critical population for health and nutrition interventions. The indicators cover topics ranging from national policy, training, quality and utilization of nutrition services, and prevalence of undernutrition, to implementation of care and feeding practices for HIV-exposed infants. Key indicators to monitor and evaluate women’s nutrition and HIV can be found in the links at left.   Full Text The HIV/AIDs epidemic is primarily occurring in populations where malnutrition is already endemic.  Because adequate nutrition helps maintain the immune system, sustain physical activity, and is essential for improving treatment outcomes with antiretroviral drugs, WHO recommends that any comprehensive program for HIV/AIDS include nutritional support (WHO, 2003).  Women of reproductive age with HIV are a critical population for health and nutrition interventions. According to UNAIDS data from 2009, women account for over 50 percent of global HIV infections and over 19.2 million women live with HIV. Programs addressing women’s nutrition and HIV/AIDS relate to four of the Millennium Development Goals: #1. reduce poverty and hunger; #4. reduce child mortality; #5. improve maternal health; and #6. combat HIV/AIDs.    The nutritional status of HIV-infected women before or during pregnancy and during lactation influences both the women’s health and the health and survival of their infants.  For women who are underweight to normal weight before pregnancy, adequate weight gain during pregnancy reduces the risks for low birth weight, stillbirth and perinatal mortality.  During the postpartum period, sufficient energy and nutrient intakes are necessary to support the demands of breastfeeding and for women to replenish their nutrient stores.  HIV infection increases energy requirements due to higher resting energy expenditures and increased nutritional needs from HIV-related infections and illnesses, thereby placing pregnant and lactating women at greater nutritional risk than their HIV-uninfected counterparts (WHO, 2004; Papathakis and Rollins, 2005; FANTA, 2010). However, for pregnant women living with HIV who are normal weight, they have higher frequency of pregnancy complications - particularly those related to hypertension and diabetes - than other pregnant women living with HIV who are normal weight (Tamayo et al., 2011). Plus, pre-pregnancy obesity and excess weight gain during pregnancy are risk factors for heavier babies (Li et al., 2013). But little emphasis is put on this population. Current evidence has clearly demonstrated that overweight and obesity and related non-communicable diseases have been exploding in low - and middle- income countries (Global Burden of Disease Report, 2012). The emerging challenges associated with the dual burden of over - and under - nutrition in the same population and often the same individuals may be associated with both quality and quantity of the diet as well as metabolic consequences of overweight/obesity. An overview of the recommended nutrient requirements for people living with HIV (PLHIV) and specifically for pregnant and lactating women can be found at FANTA-2 (2007).  Interventions aimed at the food and nutrition needs of PLHIV should be coordinated at multiple levels from international and country levels to districts and local communities and, to maximize efficiency and effectiveness, should involve an array of relevant partners.  The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) utilizes a coordinated approach partnering with government-wide agencies including the Office of the Global Aids Coordinator, USAID, USDA, HHS, the Peace Corps, in addition to UNAIDS and relevant UN agencies, the Global Fund for AIDS, TB, and Malaria, the World Bank, and private sector and non-governmental organizations. PEPFAR supports the development of national policies and guidelines and prioritizes meeting the nutritional needs of undernourished HIV-positive pregnant and lactating women, as well as orphaned and vulnerable children (OVC) born to HIV-positive parents (PEPFAR, 2006).  The following nutritional interventions are supported by PEPFAR for patient care: nutritional assessment; counseling and education; therapeutic and supplementary feeding; and preventing maternal to child transmission (PMTCT).  Each type of intervention entails curricula development, training, quality assurance measures, and establishing a system for monitoring and evaluation (ME).    In 2009, PEPFAR released a five-year strategy that outlines its contributions to the USAID’s Global Health Initiative and focuses on transitioning HIV/AIDS programs from an emergency response to sustainable, country-owned efforts (USAID, 2010).  Also in response to HIV/AIDS policy and programming at the global level, UN agencies such as WHO have been setting and disseminating policy guidelines based on the “Three Ones” principles: (1) one agreed upon HIV/AIDS action framework for all country-level partners; (2) one national AIDS coordinating authority; and (3) one accepted country-level ME system (PEPFAR, 2006).    The scaling-up of ongoing food and nutrition interventions, the development of new approaches, and the rapid expansion of this relatively new set of interventions requires harmonized approaches to effectively monitor and evaluate nutritional care and support for PLHIV. Information from ME can be used in designing and managing programs, assuring quality services, assessing outcomes and impacts of food and nutrition interventions, and in advocating for support and expansion of effective approaches. At the client level, collection of nutrition-related information is an important component of nutritional care and support that helps increase awareness among PLHIV, counselors and other service providers about clients’ diets and nutritional status, thereby supporting care, treatment and counseling processes.  The core indicators selected for this database have been developed and are being tested by the USAID Food and Technical Assistance (FANTA-2) program as part of the linked set of ‘Harmonized Indicators on Nutrition Care and HIV’ (FANTA, 2009), which have been developed to measure undernutrition in PLHIV and OVC (See FANTA 2008; 2010 for more background and details on these indicators). The indicators can be disaggregated for women of reproductive age and cover topics ranging from national policy, training, quality and utilization of nutrition services, and prevalence of undernutrition, to implementation of PMTCT care and feeding practices for HIV-exposed infants. Several of the indicators are also listed in the PEPFAR (2009) next generation indicators.  Additional sets of indicators are being tested by FANTA-2, specifically for PMTCT and for Food Security and HIV. __________  References: FANTA (Food and Nutrition Technical Assistance) Project.  2010.  A Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living With HIV . Washington, D.C.:  Academy for Educational Development.  FANTA (Food and Nutrition Technical Assistance) Project.  2009.  A Guide to Screening for Food and Nutrition Services Among People Living With HIV (Draft).  Washington, D.C.:  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.:  Academy for Educational Development.    FANTA (Food and Nutrition Technical Assistance) Project. 2007. Recommendation for the Nutrient Requirements for People Living with HIV/AIDS, Washington, DC: USAID. http://www.fantaproject.org/downloads/pdfs/Nutrient_Requirements_HIV_Feb07.pdf    FANTA (Food and Nutrition Technical Assistance Project.  2006.  Compilation of Monitoring and Evaluation (ME) Indicators Used for Food and Nutrition Interventions Addressing HIV/AIDS.  Washington, D.C.:  Academy for Educational Development.  Papathakis P. and Rollins N., ‘HIV and Nutrition: Pregnant and Lactating Women,’ Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and recommendations for action, Durban, South Africa, April 2005, Department of Nutrition for Health and Development, World Health Organization.  President’s Emergency Plan for AIDS Relief (PEPFAR), Report on food and nutrition for people living with HIV/AIDS, 2006, Washington, DC: Office of the U.S. Global AIDS Coordinator.  USAID, The Global Health Initiative (GHI). 2010. Implementation of the Global Health Initiative: Consultation Document, Washington, DC: USAID.  WHO. 2004, Nutrition Counseling, Care and Support for HIV-infected Women, Geneva, Switzerland: World Health Organization.   WHO, 2003, nutrient requirements for people living with HIV/AIDS: Report of a technical consultation, May 13-15, Geneva: WHO. Li, S., Rosenberg, L., Palmer, J. R., Phillips, G. S., Heffner, L. J. and Wise, L. A. (2013), Central adiposity and other anthropometric factors in relation to risk of macrosomia in an african american population. Obesity, 21: 178–184. doi: 10.1002/oby.20238 Tamayo et al. Presentation on 2011 Caribbean Conference.https://www.2011caribbeanhivconference.org/abstract/high-rates-obesity-among-pregnant-women-living-hiv-associated-pregnancy-complications-such-

National policy on nutrition and HIV, including a postnatal nutritional care and support policy

Definition:

The country has adopted policies, as demonstrated in frameworks, guidelines, and monitoring and evaluation (M&E) plans, that reflect the WHO and UNICEF recommendations on nutrition and HIV, including a postnatal nutritional care and support policy (WHO/UNICEF, 2003; WHO, 2004; FANTA, 2008).

The WHO/UNICEF (2003) policy recommendation on nutrition and HIV counseling for mothers and their infants is stated as:  “All HIV-infected mothers should receive counseling, which includes provision of general information about meeting their own nutritional requirements and about the risks and benefits of various feeding options, and specific guidance in selecting the option most likely to be suitable for their situation.”

The following interventions are included in pre- and postnatal nutrition and HIV care and support guidelines: nutritional assessment; counseling and education; therapeutic and supplementary feeding; and preventing mother-to-child transmission (PMTCT) of HIV (PEPFAR, 2006; FANTA, 2008). Each type of intervention entails curricula development, training, quality assurance measures, and establishing a system for M&E.

Data Requirements:

Evidence of policies, frameworks, guidelines and M&E plans that include nutrition and HIV care and support.  Supporting documentation should include copies of the policy, framework, guidelines, M&E plans, where or by whom these were issued or published, and what the actual recommendations were.

Data Sources:

Surveys, reports, and interviews from Ministry of Health and collaborating programs (including private and non-governmental organizations) on written nutrition and HIV policies, frameworks, or guidelines.

Purpose:

In order for nutrition and HIV care and support recommendations to be fully integrated into HIV and reproductive health services and programs, they must be mainstreamed into polices, frameworks, guidelines, and plans for M&E.  This outcome indicator measures the success of advocacy efforts to increase nutrition and HIV awareness and education among policy makers leading to the adoption and formalization of recommendations at the national, provincial, and district levels.

WHO has recommended that any comprehensive program for HIV/AIDS include nutritional support (WHO, 2003). Adequate nutrition for people living with HIV helps maintain the immune system, sustain physical activity, and is essential for improving treatment outcomes with antiretroviral drugs.  Women of reproductive age with HIV are a critical population for health and nutrition interventions. According to UNAIDS data from 2009, women account for over 50 percent of global HIV infections and over 19.2 million women live with HIV. The nutritional status of HIV-infected women before or during pregnancy and during lactation influences both the women’s health and the health and survival of their infants. WHO and UNICEF (2003; 2007) have recommended the provision of postnatal nutritional care and support to minimize HIV transmission while at the same time maximizing child survival. For more background on recommendations, interventions and indicators for nutrition care and support, infant feeding and preventing mother-to-child transmission of HIV, see  FANTA (2007); FANTA (2008); WHO/UNICEF (2007); PEPFAR (2006); UNAIDS (2010); and WHO/UNICEF/UNAIDS (2011).  

Issue(s):

Evaluators may have difficulty obtaining evidence of nutrition and HIV care and support policies incorporated into government frameworks, guidance, and M&E documents.  Once nutrition and HIV policies have been formally adopted, evaluators need to follow-up to verify how these recommendations are being operationalized, which cannot be determined by this indicator.

References:

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. https://www.unscn.org/web/archives_resources/files/Nutrient_Requirements_HIV_Feb07.pdf

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.  http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.395.3455&rep=rep1&type=pdf 

PEPFAR, 2006, Report on food and Nutrition for People Living with HIV/AIDS, Washington, DC: USAID/PEPFAR. http://pdf.usaid.gov/pdf_docs/Pcaab509.pdf

UNAIDS, 2010, Prevention of Mother-To-Child Transmission of HIV (PMTCT): Technical Guidance Note for Global Fund HIV Proposals, Geneva: UNAIDS. http://www.who.int/hiv/pub/toolkits/PMTCT_Technical_guidance_GlobalFundR10_May2010.pdf

WHO, 2003, Nutrient requirements for people living with HIV/AIDS: Report of a technical consultation, May 13-15, Geneva: WHO. http://www.who.int/nutrition/publications/Content_nutrient_requirements.pdf

WHO, 2004, Nutrition Counseling, Care and Support for HIV-infected Women, Geneva, Switzerland: World Health Organization. http://www.who.int/hiv/pub/prev_care/en/nutri_eng.pdf

WHO/UNICEF, 2003, Global Strategy for Infant and Young Child Feeding, Geneva: WHO.  http://whqlibdoc.who.int/publications/2003/9241562218.pdf

WHO/UNICEF, 2007, Planning Guide for national implementation of the Global Strategy for Infant and Young Child Feeding, Geneva: WHO.  http://www.who.int/nutrition/publications/infantfeeding/gs_iycf_planning_guide.pdf

WHO/UNICEF/UNAIDS, 2011, A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS. Geneva: WHO. http://www.who.int/hiv/data/UA2011_indicator_guide_en.pdf

Number/percent of HIV care and treatment sites with at least one service provider trained in a ministry of health-approved course on nutrition and HIV

Definition:

The number or proportion of HIV care and treatment sites in a country or specified area that have at least one staff member (e.g., nurse, counselor, nutritionist) who have been trained in a ministry of health-approved course to provide nutrition assessment, education and counseling (NAEC) services to persons living with HIV (PLHIV) (Fanta 2008).

This indicator is calculated as:

(Number of HIV care/treatment sites with at least one staff member trained in a MOH-approved course for NEAC services for PLHIV /Total number of HIV care/treatment sites in a country or specified area) x 100

Data Requirements:

Surveys or reports from program sites provided by supervisors or evaluators on the presence of (or number of) staff trained to provide NAEC services using a census-based approach (i.e., from all program sites in the target area). The data collector should ask the manager at each site if any staff members have attended a MOH-approved course on nutrition and HIV and establish a list of names with their professional positions. Next, the data collector should follow up individually with the listed service providers to confirm that the information is correct. If at least one service provider at the site is confirmed to have attended a MOH-approved training, the site is recorded as meeting the requirements of the indicator.  Where the data are available, the indicator can be disaggregated by province or district, urban/rural location, type of facility (public, private, community-based), and client characteristics (age group, sex, most-at-risk populations).

Data Sources:

Surveys, reports, and interviews from program sites and staff trained in NEAC.

Purpose:

The availability of appropriately trained service providers helps ensure that NAEC is provided at HIV care and treatment sites, that staff perform NAEC appropriately and give clients comprehensive and correct information.  Given the growing recognition of the important role nutrition plays in the care and support of PLHIV and the scaling up NEAC services into HIV care and support programs, adequate training of providers and harmonized approaches to monitoring and evaluation specific for nutrition and HIV are essential.  This indicator can provide information on overall training coverage, distribution of trained providers, workload constraints, and future needs for training and funding. Additional background on NEAC, a conceptual framework, process for developing an M&E system, and related indicators can be found in FANTA (2008)

WHO has recommended that any comprehensive program for HIV/AIDS include nutritional support (WHO, 2003). Adequate nutrition helps maintain the immune system, sustain physical activity, and is essential for improving treatment outcomes with antiretroviral drugs. Women of reproductive age with HIV are a critical population for health and nutrition interventions. According to UNAIDS data from 2009, women account for over 50 percent of global HIV infections and over 19.2 million women live with HIV. The nutritional status of HIV-infected women before or during pregnancy and during lactation influences both the women’s health and the health and survival of their infants. An overview of the recommended nutrient requirements for people living with HIV (PLHIV) and specifically for pregnant and lactating women can be found at FANTA (2007).  For additional background and technical guidance on interventions and indicators for nutrition and HIV care and support and prevention of mother-to-child transmission of HIV, see WHO/UNICEF (2003); WHO (2004); UNAIDS (2010); and WHO/UNICEF/UNAIDS (2011)

Issue(s):

Counting the number or presence of NEAC-trained staff alone does not capture knowledge or how well the staff are able to integrate the training with their professional roles.  Added indicators for quality of training, such as knowledge and follow-up on skills retention can be useful. Furthermore, it cannot be determined from this indicator if there is an adequate number of trained providers (in nutrition and HIV) for a particular site based on that site’s HIV care and treatment client load.

References:

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. https://www.unscn.org/web/archives_resources/files/Nutrient_Requirements_HIV_Feb07.pdf

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.   http://pdf.usaid.gov/pdf_docs/Pnadm260.pdf

UNAIDS, 2010, Prevention of Mother-To-Child Transmission of HIV (PMTCT): Technical Guidance Note for Global Fund HIV Proposals, Geneva: UNAIDS. http://www.who.int/hiv/pub/toolkits/PMTCT_Technical_guidance_GlobalFundR10_May2010.pdf

WHO, 2003, Nutrient requirements for people living with HIV/AIDS: Report of a technical consultation, May 13-15, Geneva: WHO. http://www.who.int/nutrition/publications/Content_nutrient_requirements.pdf

WHO, 2004, Nutrition Counseling, Care and Support for HIV-infected Women, Geneva, Switzerland: World Health Organization. http://www.who.int/hiv/pub/prev_care/en/nutri_eng.pdf

WHO/UNICEF, 2003, Global Strategy for Infant and Young Child Feeding, Geneva: WHO.  http://whqlibdoc.who.int/publications/2003/9241562218.pdf

WHO/UNICEF/UNAIDS, 2011, A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS. Geneva: WHO. http://www.who.int/hiv/data/UA2011_indicator_guide_en.pdf

Number/percent of HIV care and treatment sites providing individual nutrition counseling services

Definition:

The number or percent of HIV care and treatment sites that provide one-on-one nutrition counseling services to people living with HIV (PLHIV). 

As part of the recommended nutrition assessment, education and counseling (NAEC) services provided to PLHIV (FANTA, 2008), nutrition counseling services are defined as an individual, one-on-one counseling session during which a service provider discusses the client’s situation with her or him and provides information on topics related to diet and nutritional status. Group education and counseling on nutrition and HIV topics do not meet the criteria for this indicator.

This indicator is calculated as:

(Number of HIV care and treatment sites that provide individual nutrition counseling services for PLHIV/ Total number of HIV care and treatment sites in a country or specified area) x 100

Data Requirements:

Surveys or reports from program sites provided by supervisors or evaluators on whether individual nutrition counseling services are provided.  It is recommended that data are collected using a census-based approach (i.e., from all program sites in the target area).  For validation purposes, the data collector may choose to conduct brief follow-up interviews with a subset of clients.  Where the data are available, the indicator can be disaggregated by province and district, urban/rural location, type of facility (public, private, community-based), and client characteristics (age group, sex, most-at-risk populations).

Data Sources:

Surveys, reports, and interviews from program sites, staff, and clients.

Purpose:

WHO recommends that any comprehensive program for HIV/AIDS include nutritional support (WHO, 2003) and the provision of individual nutrition counseling is a key component of NAEC services provided to PLHIV (Fanta 2008). Adequate nutrition helps maintain the immune system, sustain physical activity, and is essential for improving treatment outcomes with antiretroviral drugs.  Women of reproductive age with HIV are a critical population for health and nutrition interventions. According to UNAIDS data from 2009, women account for over 50 percent of global HIV infections and over 19.2 million women live with HIV. The nutritional status of HIV-infected women before or during pregnancy and during lactation influences both the women’s health and the health and survival of their infants. An overview of the recommended nutrient requirements for people living with HIV (PLHIV) and specifically for pregnant and lactating women can be found at FANTA (2007).

Given the growing recognition of the important role nutrition plays in the care and support of PLHIV and the scaling up NEAC services into HIV care and support programs, harmonized approaches to monitoring and evaluation (M&E) specific for nutrition and HIV are essential.  This indicator can provide information on reach and coverage of nutrition counseling across program sites, help inform program design, resource allocation decisions, identify workload constraints (especially with scaling up of programs) and can be used for reporting to donors and stakeholders on key site-level outputs. Additional background on NEAC, a conceptual framework, process for developing an M&E system, and related indicators can be found in FANTA (2008).  For additional background and technical guidance on interventions and indicators for nutrition and HIV care and support and prevention of mother-to-child transmission of HIV, see WHO/UNICEF (2003); WHO (2004); UNAIDS (2010); and WHO/UNICEF/UNAIDS (2011)

Issue(s):

This indicator does not provide information about the quality of counseling services and cannot be used to measure the relative success of nutrition and HIV care and support interventions.  The FANTA (2008) resource has an indicator specific for measuring quality of counseling.

References:

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. https://www.unscn.org/web/archives_resources/files/Nutrient_Requirements_HIV_Feb07.pdf

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.  http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.395.3455&rep=rep1&type=pdf

UNAIDS, 2010, Prevention of Mother-To-Child Transmission of HIV (PMTCT): Technical Guidance Note for Global Fund HIV Proposals, Geneva: UNAIDS. http://www.who.int/hiv/pub/toolkits/PMTCT_Technical_guidance_GlobalFundR10_May2010.pdf

WHO, 2003, Nutrient requirements for people living with HIV/AIDS: Report of a technical consultation, May 13-15, Geneva: WHO. http://www.who.int/nutrition/publications/Content_nutrient_requirements.pdf

WHO, 2004, Nutrition Counseling, Care and Support for HIV-infected Women, Geneva, Switzerland: World Health Organization. http://www.who.int/hiv/pub/prev_care/en/nutri_eng.pdf

WHO/UNICEF, 2003, Global Strategy for Infant and Young Child Feeding, Geneva: WHO.  http://whqlibdoc.who.int/publications/2003/9241562218.pdf

WHO/UNICEF, 2007, Planning Guide for national implementation of the Global Strategy for Infant and Young Child Feeding, Geneva: WHO. http://whqlibdoc.who.int/publications/2007/9789241595193_eng.pdf

WHO/UNICEF/UNAIDS, 2011, A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS. Geneva: WHO. http://www.who.int/hiv/data/UA2011_indicator_guide_en.pdf

Number/percent of women (15-49) with HIV who were nutritionally assessed with anthropometric measurement during reporting period

Definition:

The number or proportion of women of reproductive age (WRA, i.e., ages 15 to 49 years) who are HIV positive and who were nutritionally assessed using anthropometric measurements during a specified reporting period.  These measurements include body mass index (BMI) for non-pregnant women and mid-upper arm circumference (MUAC) for pregnant women and for postpartum women with infants under six months of age.

This indicator is calculated as:

(Number women ages 15 to 49 with HIV who were nutritionally assessed using anthropometric measurements/Total number women ages 15 to 49 with HIV who received programs services during reporting period ) x 100

The numerator is the number of WRA with HIV who received nutrition assessment at some time during the reporting period using anthropometric measurement. The denominator is the number of WRA with HIV receiving program services during the same period.  Each woman who received program services at least once during the reporting period is counted once in the denominator (and once in the numerator if she received nutrition assessment at least once during the reporting period), irrespective of whether she received services once or several times during the reporting period.  The duration of the reporting period is determined by the facility/program gathering the data. 

Note: This indicator measures the subpopulation of WRA that can be disaggregated from the corresponding outcome indicator in the linked set of ‘Harmonized Indicators on Nutrition Care and HIV’ (FANTA, 2009), which have been developed to measure undernutrition in people living with HIV (PLHIV) and orphaned and vulnerable children (OVC) (See FANTA 2008; 2009; 2010 for more details on these indicators.)

Data Requirements:

The number of women with HIV who received anthropometric assessment at some time during the reporting period can be tabulated by program staff reviewing individual client and/or clinic records.  Data can be collected continuously at the facility/community level and information should be documented on program records each time a client is nutritionally assessed.  Tools for the measures mentioned above may include weight scales, MUAC measurement tapes, and stadiometers/height measuring devices. Data can be disaggregated by reproductive status (pregnant, postpartum up to six months, and non-pregnant, non-lactating), by treatment status for opportunistic infections and  antiretroviral treatment, and by age groups, parity, and other relevant factors such as urban/rural residence.

Data Sources:

Program/site records that document whether nutrition assessment of clients receiving program services has taken place.

Purpose:

This indicator monitors coverage for the number and proportion of WRA with HIV who are nutritionally assessed within a facility or geographic area.  Nutrition assessment including anthropometric measurements provides information on individual nutrition status and is an essential component of treatment, care and support for PLHIV and OVC.  It is important for women with HIV to be nutritionally assessed at regular intervals.  This indicator is a basic part of the linked set of ‘Harmonized Indicators for Nutrition and HIV Care’ (FANTA, 2009), which track and provide comparative and trend data on the number and proportion of nutritionally assessed undernourished individuals receiving various program services.

Women with HIV are a critical population for health and nutrition assessment and intervention.  According to UNAIDS data from 2009, women account for over 50 percent of global HIV infections and over 19.2 million women live with HIV. The nutritional status of HIV-infected women before or during pregnancy and during lactation influences both the women’s health and the health and survival of their infants. For women who are under- to normal weight pre-pregnancy, adequate weight gain during pregnancy reduces the risks for low birth weight, stillbirth and perinatal mortality.  In addition, sufficient energy and nutrient intakes are necessary postpartum to support the demands of breastfeeding and for women to replenish their nutrient stores.  HIV infection increases energy requirements due to higher resting energy expenditures and increased nutritional needs from HIV-related infections and illnesses, thereby placing pregnant and lactating women at greater nutritional risk than their HIV-uninfected counterparts (WHO, 2004; Papathakis and Rollins, 2005; FANTA, 2010). This indicator relates to four of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; #5. Improve maternal health; and #6. Combat HIV/AIDs. 

The information provided by this indicator can be used at many levels and for a variety of purposes. At the global level, this indicator can be used by donors and international organizations to track the extent to which program nutrition interventions are reaching women with HIV and to identify countries or regions where more focused efforts may be required.  This information can be used similarly by national governments to track efforts, identify gaps in service delivery, and prioritize needs within countries.  Programs can use the information to assess the reach of their services, to inform resource allocation and program management, to plan resource needs (e.g., commodities and staff training), and to report data to donors.  Data collected by this indicator would likely be reviewed annually at the national and global level and could be reviewed more frequently at the program level as needed.

Many countries are integrating nutrition assessment including the use of anthropometric measurements into national HIV programs and this indicator directly measures the coverage of these nutrition assessment services.  Acquiring tools for conducting anthropometric measures and developing systems for collecting, recording, and reporting such data are becoming priorities for national governments as well as international donors making collection and utilization of this indicator increasingly feasible.

Issue(s):

Accurate collection of data relies largely on flow of services at the clinic/program level and requires availability of standardized anthropometric measurement equipment, trained staff, and accurate record keeping within a program.  The indicator does not provide information about the quality of the nutritional assessment, and accordingly quality assurance systems should be established and indicators of quality collected to assess how effectively these services are being implemented.  The indicator may underestimate the number of HIV-infected women in an area and should not be used for this purpose.  Not all women with HIV will be able access to services, especially in remote areas or where women’s mobility is limited by cultural norms. 

Gender Implications:

Women’s ability to access HIV programs and services may be more limited than men’s in settings where women are particularly stigmatized for being HIV-positive or where cultural norms limit women’s ability to travel outside the home. 

References:

FANTA (Food and Nutrition Technical Assistance) Project.  2010.  A Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living With HIV . Washington, D.C.:  Academy for Educational Development.

FANTA (Food and Nutrition Technical Assistance) Project.  2009.  A Guide to Screening for Food and Nutrition Services Among People Living With HIV (Draft).  Washington, D.C.:  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.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance) Project. 2004. Food and Nutrition Implications of Antiretroviral Therapy in Resource Limited Settings, T. Castleman, E. Seumo-Fosso,and B. Cogill Washington, D.C.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance Project.  2006.  Compilation of Monitoring and Evaluation (M&E) Indicators Used for Food and Nutrition Interventions Addressing HIV/AIDS.  Washington, D.C.:  Academy for Educational Development.

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

Papathakis P. and Rollins N., ‘HIV and Nutrition: Pregnant and Lactating Women,’ Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and recommendations for action, Durban, South Africa, April 2005, Department of Nutrition for Health and Development, World Health Organization.

Number/percent of women (15-49) with HIV who were found to be undernourished during reporting period

Definition:

The number or proportion of women of reproductive age (WRA, i.e., ages 15 to 49) who are HIV positive and who were determined to be undernourished using anthropometric assessments during a specified reporting period.  These measurements and cutoffs include body mass index (BMI) <18.5 kg/m2 for non-pregnant women; mid-upper arm circumference (MUAC) <22 cm for pregnant women; and MUAC < 21 cm for postpartum women with infants under six months of age.

This indicator is calculated as:

(Number women ages 15 to 49 with BMI <18.5 (non-pregnant) or MUAC <22 (pregnant) or MUAC <21 (with infants <6 months of age)/Total number of women ages 15 to 49 with HIV who were nutritionally assessed using anthropometric measurements during reporting period ) x 100

The numerator is the number of WRA with HIV who were nutritionally assessed and found to be undernourished at some time during the reporting period.  The denominator is the number of WRA with HIV who were nutritionally assessed using anthropometric assessment during the same period.  Each woman who was assessed at least once during the reporting period is counted once in the denominator (and once in the numerator if she was also determined to be undernourished at least once during the reporting period), irrespective of whether she received services once or several times during the reporting period.  The duration of the reporting period is determined by the facility/program gathering the data.

Note: This indicator measures the subpopulation of WRA that can be disaggregated from the corresponding outcome indicator in the linked set of ‘Harmonized Indicators on Nutrition Care and HIV’ (FANTA, 2009), which have been developed to measure undernutrition in people living with HIV (PLHIV) and orphaned and vulnerable children (OVC) (See FANTA 2008; 2009; 2010 for more details on these indicators.)

 

BMI is calculated as:         

Weight in kilograms

(Height in meters)2

 

There are numerous tools (charts, websites, and computer applications) available to calculate BMI. For details on BMI categories and cutoffs, see WHO Global Database for BMI, 2011, http://apps.who.int/bmi/index.jsp?introPage=intro_3.html.

Data Requirements:

The number of women with HIV who were undernourished at some time during the reporting period based on the cutoffs for the relevant anthropometric measurements can be tabulated by program staff reviewing individual client and/or clinic records. Data can be collected continuously at the facility/community level and information should be documented on program records each time a client is nutritionally assessed. Tools for the measures mentioned above may include weight scales, MUAC measurement tapes, and stadiometers / height measuring devices.  Data can be disaggregated by reproductive status (pregnant, postpartum up to six months, and non-pregnant, non-lactating), by treatment status for opportunistic infections and antiretroviral (ARV) treatment, and by age groups, parity, and other relevant factors such as education, income, and urban/rural residence.

Data Sources:

Program and site records that document the HIV and nutritional status of clients receiving program services.

Purpose:

This indicator monitors the number and proportion of women with HIV who are clinically undernourished within a facility or geographic area.  Studies have shown that malnutrition significantly increases mortality risk for HIV-infected individuals, both those on treatment and those who are not on treatment. It is important for women with HIV to be nutritionally assessed at regular intervals.  This indicator is part of the linked set of ‘Harmonized Indicators for Nutrition and HIV Care’ (FANTA, 2009), which track and provide comparative and trend data on the number and proportion of undernourished individuals receiving various program services.

Women with HIV are a critical population for health and nutrition assessment and intervention.  According to UNAIDS data from 2009, women account for over 50 percent of global HIV infections and over 19.2 million women live with HIV. The nutritional status of HIV-infected women before or during pregnancy and during lactation influences both the women’s health and the health and survival of their infants. For women who are under- to normal weight pre-pregnancy, adequate weight gain during pregnancy reduces the risks for low birth weight, stillbirth and perinatal mortality.  In addition, sufficient energy and nutrient intakes are necessary postpartum to support the demands of breastfeeding and for women to replenish their nutrient stores.  HIV infection increases energy requirements due to higher resting energy expenditures and increased nutritional needs from HIV-related infections and illnesses, thereby placing pregnant and lactating women at greater nutritional risk than their HIV-uninfected counterparts (WHO, 2004; Papathakis and Rollins, 2005; FANTA, 2010). This indicator relates to four of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; #5. Improve maternal health; and #6. Combat HIV/AIDs. 

The information provided by this indicator can be used at many levels and for a variety of purposes. At the global level, this indicator can be used by donors and international organizations to track the extent to which program nutrition interventions are improving client status and to identify countries or regions where more focused efforts may be required.  This information can be used similarly by national governments to track efforts and prioritize needs within countries.  Programs can use the information to assess the impact of their interventions, to inform resource allocation and program management, to plan resource needs (e.g. food commodities and staff training), and to report data to donors. Data collected by this indicator would likely be reviewed annually at the national and global level and could be reviewed more frequently at the program level as needed.

Many countries are integrating nutrition assessment and related services into national HIV programs and this indicator directly measures the primary outcome that nutrition services aim to impact, i.e. undernutrition.  Acquiring tools for conducting anthropometric measures and developing systems for collecting, recording, and reporting such data are becoming priorities for national governments as well as international donors making collection and utilization of this indicator increasingly feasible.

Issue(s):

This indicator is not sensitive to improvements or declines in nutrition status if the change in data points does not cross the cutoff threshold (e.g., an improvement of BMI from 15.0 to 18.0).  While changes in the indicator may be interpreted as representing the impact of nutrition and other interventions, other factors need to be considered.  Changes in the client base, such as an influx of new clients or deaths of malnourished clients, can impact the indicator.  Seasonal, environmental, economic, and urban/rural residence factors that influence access to food can also impact the nutrition status of clients.  In general, improvements in nutrition status should not be attributed to nutrition interventions alone, as other factors including ARV treatment, disease progression, opportunistic infections, and changes in women’s reproductive status can significantly influence nutritional status.

Accurate collection of data relies largely on flow of services at the clinic/program level and requires availability of standardized anthropometric measurement equipment, trained staff, and accurate record keeping within a program. The indicator does not provide information about the quality of the nutritional assessment, and accordingly quality assurance systems should be established and indicators of quality collected to assess how effectively these services are being implemented.  The indicator may underestimate the number of HIV-infected and undernourished HIV-infected women in an area and should not be used for these purposes.  Not all women with HIV will be able access to services, especially in remote areas or where women’s mobility is limited by cultural norms. 

Gender Implications:

Women’s ability to access HIV programs and services may be more limited than men’s in settings where women are particularly stigmatized for being HIV-positive or where cultural norms limit women’s ability to travel outside the home.  Cultural gender norms may also affect women’s access to and utilization of food resources.  In settings such as South Asia where women often eat ‘last and least,’ even in households with adequate food available, adolescent and young women may be chronically undernourished and, where women are HIV-infected, these imbalances in food and resource allocation may be exacerbated.

References:

FANTA (Food and Nutrition Technical Assistance) Project.  2010.  A Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living With HIV . Washington, D.C.:  Academy for Educational Development.

FANTA (Food and Nutrition Technical Assistance) Project.  2009.  A Guide to Screening for Food and Nutrition Services Among People Living With HIV (Draft).  Washington, D.C.:  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.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance) Project. 2004. Food and Nutrition Implications of Antiretroviral Therapy in Resource Limited Settings, T. Castleman, E. Seumo-Fosso,and B. Cogill Washington, D.C.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance Project.  2006.  Compilation of Monitoring and Evaluation (M&E) Indicators Used for Food and Nutrition Interventions Addressing HIV/AIDS.  Washington, D.C.:  Academy for Educational Development.

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

Papathakis P. and Rollins N., ‘HIV and Nutrition: Pregnant and Lactating Women,’ Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and recommendations for action, Durban, South Africa, April 2005, Department of Nutrition for Health and Development, World Health Organization.

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

Definition:

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

Data Requirements:

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). 

Data Sources:

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.

Purpose:

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).

Issue(s):

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.

References:

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.  https://www.unscn.org/web/archives_resources/files/Nutrient_Requirements_HIV_Feb07.pdf

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.  http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.395.3455&rep=rep1&type=pdf

PEPFAR, 2006, Report on food and Nutrition for People Living with HIV/AIDS, Washington, DC: USAID/PEPFAR.  http://pdf.usaid.gov/pdf_docs/Pcaab509.pdf

UNAIDS, 2010, Prevention of Mother-To-Child Transmission of HIV (PMTCT): Technical Guidance Note for Global Fund HIV Proposals, Geneva: UNAIDS. http://www.who.int/hiv/pub/toolkits/PMTCT_Technical_guidance_GlobalFundR10_May2010.pdf

WHO, 2003, Nutrient requirements for people living with HIV/AIDS: Report of a technical consultation, May 13-15, Geneva: WHO. http://www.who.int/nutrition/publications/Content_nutrient_requirements.pdf

WHO, 2004, Nutrition Counseling, Care and Support for HIV-infected Women, Geneva, Switzerland: World Health Organization. http://www.who.int/hiv/pub/prev_care/en/nutri_eng.pdf

WHO/UNICEF, 2003, Global Strategy for Infant and Young Child Feeding, Geneva: WHO.  http://whqlibdoc.who.int/publications/2003/9241562218.pdf

WHO/UNICEF, 2007, Planning Guide for national implementation of the Global Strategy for Infant and Young Child Feeding, Geneva: WHO. http://whqlibdoc.who.int/publications/2007/9789241595193_eng.pdf

WHO/UNICEF/UNAIDS, 2011, A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS. Geneva: WHO. http://www.who.int/hiv/data/UA2011_indicator_guide_en.pdf

Number/percent of women of reproductive age with HIV who were assessed with anthropometric measurement and who also received therapeutic or supplementary food during the reporting period

Definition:

The number or proportion of women of reproductive age (WRA, i.e., ages 15 to 49 years) who were assessed using anthropometric assessments, found to be undernourished, and received therapeutic foods or supplementary foods during the reporting period.  The recommended measurements and respective cutoffs for undernutrition in WRA include body mass index (BMI) <18.5 kg/m2 for non-pregnant women; mid-upper arm circumference (MUAC) <22 cm for pregnant women; and MUAC < 21 cm for postpartum women with infants under six months of age.

This indicator is calculated as:

(Number women ages 15 to 49 with HIV who were undernourished based on anthropometric assessment and received therapeutic /supplementary foods/ Total number women ages 15 to 49 anthropometrically assessed  as undernourished during reporting period) x 100

The numerator is the number of WRA with HIV who were nutritionally assessed using anthropometric measurements, found to be undernourished, and received therapeutic or supplementary foods during the reporting period.  The denominator is the number of WRA with HIV who were nutritionally assessed using anthropometric assessment and found to be undernourished during the same period.  Each woman who was assessed at least once during the reporting period is counted once in the denominator (and once in the numerator if she also received therapeutic or supplementary foods at least once during the reporting period), irrespective of whether she received services once or several times during the reporting period.  The duration of the reporting period is determined by the facility/program gathering the data.

Therapeutic foods are defined as foods for the management of severe undernutrition and include ready-to-use therapeutic food (RUTF) products such as PlumpyNut, an energy dense, fortified peanut butter/milk powder-based paste, or other locally produced RUTFs (FANTA, 2010; 2007). Supplementary foods for continued treatment of severe undernutrition after an initial stabilization and weight recovery period and for patients who are mild-to-moderately undernourished at entry are primarily fortified, blended flours (e.g. corn-soya blend). Basic food commodities provided for household use or as a safety net do not meet the definition of therapeutic and supplementary food for this indicator (i.e., distribution of these foods is not based on anthropometric assessment of clinical undernutrition).

Note: This indicator measures the subpopulation of WRA that can be disaggregated from the corresponding outcome indicator in the linked set of ‘Harmonized Indicators on Nutrition Care and HIV’ (FANTA, 2009), which have been developed to measure undernutrition in people living with HIV (PLHIV) and orphaned and vulnerable children (OVC) (See FANTA 2008; 2009; 2010 for more details on these indicators.)

Data Requirements:

The number of women with HIV who were nutritionally assessed with anthropometry, found to be undernourished, and those who received therapeutic and supplementary foods during the reporting period can be tabulated by program staff reviewing individual client and/or clinic records. Data can be collected continuously at the facility/community level and information should be documented on program records each time a client is nutritionally assessed and/or provided foods. Tools for the measures mentioned above may include weight scales, MUAC measurement tapes, and stadiometers/height measuring devices. Data can be disaggregated by reproductive status (pregnant, postpartum up to six months, and non-pregnant, non-lactating), by treatment status for opportunistic infections and antiretroviral treatment, and by age groups, parity, and other relevant factors such as education, income, and urban/rural residence.

Data Sources:

Program and site records that document women’s HIV status and whether clients who have received anthropometric assessment and were found to be undernourished received therapeutic or supplemental foods.

Purpose:

This indicator monitors the number and proportion of clinically undernourished women with HIV receiving therapeutic or supplementary food within a facility or geographic area.  Provision of therapeutic and supplementary feeding to PLHIV who are nutritionally assessed as undernourished is a key component of treatment, care and support for HIV-infected individuals.  Several national programs provide food support to clinically undernourished clients, including therapeutic food products for the severely undernourished and supplementary food products for the moderately and mildly undernourished. This indicator is part of the linked set of ‘Harmonized Indicators for Nutrition and HIV Care’ (FANTA, 2009), which track and provide comparative and trend data on the number and proportion of undernourished individuals receiving various program services.

Women with HIV are a critical population for health and nutrition assessment and intervention.  According to UNAIDS data from 2009, women account for over 50 percent of global HIV infections and over 19.2 million women live with HIV. The nutritional status of HIV-infected women before or during pregnancy and during lactation influences both the women’s health and the health and survival of their infants. For women who are under- to normal weight pre-pregnancy, adequate weight gain during pregnancy reduces the risks for low birth weight, stillbirth and perinatal mortality.  In addition, sufficient energy and nutrient intakes are necessary postpartum to support the demands of breastfeeding and for women to replenish their nutrient stores.  HIV infection increases energy requirements due to higher resting energy expenditures and increased nutritional needs from HIV-related infections and illnesses, thereby placing pregnant and lactating women at greater nutritional risk than their HIV-uninfected counterparts (WHO, 2004; Papathakis and Rollins, 2005; FANTA, 2010). This indicator relates to four of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; #5. Improve maternal health; and #6. Combat HIV/AIDs. 

The information provided by this indicator can be used at many levels and for a variety of purposes. At the global level, this indicator can be used by donors and international organizations to track the extent to which program nutrition interventions are reaching women with HIV and to identify countries or regions where more focused efforts may be required.  This information can be used similarly by national governments to track efforts, identify gaps in service delivery, and prioritize needs within countries.  Programs can use the information to assess the reach of their services, to inform resource allocation and program management, to plan resource needs (e.g., commodities and staff training), and to report data to donors.  Data collected by this indicator would likely be reviewed annually at the national and global level and could be reviewed more frequently at the program level as needed.

Many countries are integrating nutrition assessment, counseling and provision of therapeutic and supplemental foods into national HIV programs.  Acquiring tools for conducting anthropometric measures, training counseling staff, and developing systems for collecting, recording, and reporting data are becoming priorities for national governments as well as international donors making collection and utilization of this indicator increasingly feasible. 

Issue(s):

There are some possible constraints in comparing this indicator across countries. It is important to note that different countries and programs may use different types of food products and possibly even different entry and exit criteria for food eligibility. Also, the indicator provides information about coverage, but not about the duration of food support provided, drop-out rates, quality of the foods, or existence of complementary interventions with the food.

Accurate collection of data relies largely on flow of services at the clinic/program level and requires availability of standardized anthropometric measurement equipment, trained staff, and accurate record keeping within a program.  The indicator may underestimate the number of HIV-infected women in an area and should not be used for these purposes.  Not all women with HIV will be able access to services, especially in remote areas or where women’s mobility is limited by cultural norms. 

Gender Implications:

Women’s ability to access HIV programs and services may be more limited than men’s in settings where women are particularly stigmatized for being HIV-positive or where cultural norms limit women’s ability to travel outside the home. 

References:

FANTA (Food and Nutrition Technical Assistance) Project.  2010.  A Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living With HIV . Washington, D.C.:  Academy for Educational Development.

FANTA (Food and Nutrition Technical Assistance) Project.  2009.  A Guide to Screening for Food and Nutrition Services Among People Living With HIV (Draft).  Washington, D.C.:  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.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance) Project. 2007, Nutrition and HIV/AIDS: A Toolkit for Service Providers in the Comprehensive Care Centres. Washington, D.C.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance Project.  2006.  Compilation of Monitoring and Evaluation (M&E) Indicators Used for Food and Nutrition Interventions Addressing HIV/AIDS.  Washington, D.C.:  Academy for Educational Development.

FANTA (Food and Nutrition Technical Assistance) Project. 2004. Food and Nutrition Implications of Antiretroviral Therapy in Resource Limited Settings, T. Castleman, E. Seumo-Fosso,and B. Cogill. Washington, D.C.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance) Project. 2004, HIV/AIDS: A Guide for Nutritional Care and Support. Washington, D.C.:  Academy for Educational Development. 

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

Papathakis P. and Rollins N., ‘HIV and Nutrition: Pregnant and Lactating Women,’ Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and recommendations for action, Durban, South Africa, April 2005, Department of Nutrition for Health and Development, World Health Organization.

Number/percent of women of reproductive age with HIV who were assessed with anthropometric measurement and who also received nutrition counseling during the reporting period

Definition:

The number and proportion of women or reproductive age (WRA, i.e., ages 15 to 49 years) who were HIV positive and were nutritionally assessed using anthropometric assessments during a specified reporting period and received nutrition counseling at the same time.  The recommended anthropometric nutrition assessment measurements include body mass index (BMI) for non-pregnant women and mid-upper arm circumference (MUAC) for pregnant women and for postpartum women with infants under six months of age.

This indicator is calculated as:

(Number women ages 15 to 49 with HIV who were assessed with anthropometric measurements and received nutrition counseling at the same time/ Total number women ages 15-49 with HIV who were assessed with anthropometry during reporting period ) x 100

The numerator is the number of WRA with HIV who were nutritionally assessed using anthropometric measurements and received nutrition counseling at the same time during the reporting period.  The denominator is the number of WRA with HIV who were nutritionally assessed using anthropometric assessment during the same period.  Each woman who was assessed at least once during the reporting period is counted once in the denominator (and once in the numerator if she was also counseled at the same time she was assessed at least once during the reporting period), irrespective of whether she received services once or several times during the reporting period.  The duration of the reporting period is determined by the facility/program gathering the data.

Nutrition counseling refers to an interactive process between trained nutrition service providers and the clients to interpret information gained from assessments; understand clients’ preferences, needs, constraints, and options, and to plan a realistic course of actions that supports health dietary practices and referrals for services (FANTA, 2010).  For more information on nutrition counseling, see FANTA 2004, HIV/AIDS: A Guide for Nutritional Care and Support; FANTA, 2007, Nutrition and HIV/AIDS: A Toolkit for Service Providers in the Comprehensive Care Centres.

Note: This indicator measures the subpopulation of WRA that can be disaggregated from the corresponding outcome indicator in the linked set of ‘Harmonized Indicators on Nutrition Care and HIV’ (FANTA, 2009), which have been developed to measure undernutrition in people living with HIV (PLHIV) and orphaned and vulnerable children (OVC) (See FANTA 2008; 2009; 2010 for more details on these indicators. 

Data Requirements:

The number of women with HIV who were nutritionally assessed with anthropometry and those who received nutrition counseling at the same time during the reporting period can be tabulated by program staff reviewing individual client and/or clinic records. Data can be collected continuously at the facility/community level and information should be documented on program records each time a client is nutritionally assessed and/or counseled.  Tools for the measures mentioned above may include weight scales, MUAC measurement tapes, and stadiometers/height measuring devices. Data can be disaggregated by reproductive status (pregnant, postpartum up to six months, and non-pregnant, non-lactating), by treatment status for opportunistic infections and antiretroviral treatment, and by age groups, parity, and other relevant factors such as education, income, and urban/rural residence.

If targeting and/or linking to inequity, classify outlets where counseling is taking place by location (poor/not poor) and disaggregate by area served.  Exit interviews can be conducted with clients to determine client's poverty status.

Data Sources:

Program and site records that document women’s HIV status and whether clients who have received anthropometric assessment were provided nutrition counseling.

Purpose:

This indicator monitors the number and proportion of women with HIV who are nutritionally assessed and receive nutrition counseling within a facility or geographic area. It is important for women with HIV to be nutritionally assessed at regular intervals and nutritional counseling helps clients understand nutritional needs, identify constraints and options for improved diet, and plan feasible dietary actions to improve nutritional status. Ideally, nutrition counseling should be based on an assessment of nutritional status. This indicator is part of the linked set of ‘Harmonized Indicators for Nutrition and HIV Care’ (FANTA, 2009), which track and provide comparative and trend data on the number and proportion of undernourished individuals receiving various program services.

Women with HIV are a critical population for health and nutrition assessment and intervention.  According to UNAIDS data from 2009, women account for over 50 percent of global HIV infections and over 19.2 million women live with HIV. The nutritional status of HIV-infected women before or during pregnancy and during lactation influences both the women’s health and the health and survival of their infants. For women who are under- to normal weight pre-pregnancy, adequate weight gain during pregnancy reduces the risks for low birth weight, stillbirth and perinatal mortality.  In addition, sufficient energy and nutrient intakes are necessary postpartum to support the demands of breastfeeding and for women to replenish their nutrient stores.  HIV infection increases energy requirements due to higher resting energy expenditures and increased nutritional needs from HIV-related infections and illnesses, thereby placing pregnant and lactating women at greater nutritional risk than their HIV-uninfected counterparts (WHO, 2004; Papathakis and Rollins, 2005; FANTA, 2010). This indicator relates to four of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; #5. Improve maternal health; and #6. Combat HIV/AIDs. 

The information provided by this indicator can be used at many levels and for a variety of purposes. At the global level, this indicator can be used by donors and international organizations to track the extent to which program nutrition interventions are reaching women with HIV and to identify countries or regions where more focused efforts may be required.  This information can be used similarly by national governments to track efforts, identify gaps in service delivery, and prioritize needs within countries.  Programs can use the information to assess the reach of their services, to inform resource allocation and program management, to plan resource needs (e.g., commodities and staff training), and to report data to donors.  Data collected by this indicator would likely be reviewed annually at the national and global level and could be reviewed more frequently at the program level as needed.

Many countries are integrating nutrition assessment using anthropometric measurements and nutrition counseling into national HIV programs. Acquiring tools for conducting anthropometric measures, training counseling staff, and developing systems for collecting, recording, and reporting data are becoming priorities for national governments as well as international donors making collection and utilization of this indicator increasingly feasible. 

Issue(s):

This indicator only measures the number of clients who received both nutrition assessment and nutrition counseling at the same time.  Therefore, the indicator should not be interpreted as measuring total coverage of assessment and counseling, rather as measuring coverage of assessed clients with counseling. The indicator does not provide information about the quality of the assessment and counseling, and accordingly quality assurance systems should be established and indicators of quality collected to assess how effectively these services are being implemented. 

Accurate collection of data relies largely on flow of services at the clinic/program level and requires availability of standardized anthropometric measurement equipment, trained staff, and accurate record keeping within a program.  The indicator may underestimate the number of HIV-infected women in an area and should not be used for these purposes.  Not all women with HIV will be able access to services, especially in remote areas or where women’s mobility is limited by cultural norms. 

Gender Implications:

Women’s ability to access HIV programs and services may be more limited than men’s in settings where women are particularly stigmatized for being HIV-positive or where cultural norms limit women’s ability to travel outside the home. 

References:

FANTA (Food and Nutrition Technical Assistance) Project.  2010.  A Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living With HIV . Washington, D.C.:  Academy for Educational Development.

FANTA (Food and Nutrition Technical Assistance) Project.  2009.  A Guide to Screening for Food and Nutrition Services Among People Living With HIV (Draft).  Washington, D.C.:  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.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance) Project. 2007, Nutrition and HIV/AIDS: A Toolkit for Service Providers in the Comprehensive Care Centres. Washington, D.C.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance Project.  2006.  Compilation of Monitoring and Evaluation (M&E) Indicators Used for Food and Nutrition Interventions Addressing HIV/AIDS.  Washington, D.C.:  Academy for Educational Development.

FANTA (Food and Nutrition Technical Assistance) Project. 2004. Food and Nutrition Implications of Antiretroviral Therapy in Resource Limited Settings, T. Castleman, E. Seumo-Fosso,and B. Cogill. Washington, D.C.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance) Project. 2004, HIV/AIDS: A Guide for Nutritional Care and Support. Washington, D.C.:  Academy for Educational Development. 

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

Papathakis P. and Rollins N., ‘HIV and Nutrition: Pregnant and Lactating Women,’ Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and recommendations for action, Durban, South Africa, April 2005, Department of Nutrition for Health and Development, World Health Organization.

Percent HIV positive women who have MUAC <21 at first postnatal visit within 6 weeks of delivery

Definition:

The proportion of HIV positive women who have a mid-upper arm circumference (MUAC) of less than 21cm at first postnatal visit within six weeks of delivery and, given this low MUAC level, are considered to be undernourished.   

This indicator is calculated as:

(Number of women with HIV who have MUAC <21cm at first postnatal visit within 6 weeks of delivery/ Total number of women with HIV who had a MUAC assessment  at first postnatal visit within 6 weeks of delivery ) x 100

The numerator for this indicator will include the number of HIV positive women who have a MUAC <21cm at the first postnatal visit within 6 weeks of delivery. The denominator will include all HIV positive women who had a MUAC assessment at their first postnatal visit within 6 weeks of delivery.

Data Requirements:

Postnatal care (PNC) registers should have columns indicating maternal HIV status and whether or not the MUAC is <21cm.  This indicator should be collected on a quarterly or semi-annual basis to ensure high data quality and to allow for review if there is a question about the data validity.  For country level reporting, this indicator should be reported annually. Data can be disaggregated by lactation status, by treatment status for opportunistic infections and antiretroviral (ARV) treatment, and by age groups, parity, and other relevant factors such as education, income, and urban/rural residence.

Data Sources:

PNC registers; client records

Purpose:

MUAC provides a measure of acute nutrition status in adults and this indicator monitors the proportion of women with HIV who are undernourished at their first postpartum visit by facility and geographic area.  Studies have shown that malnutrition significantly increases mortality risk for HIV-infected individuals regardless of treatment status and it is important for women with HIV to be nutritionally assessed at regular intervals, including after delivery.  This indicator is part of the linked set of ‘Harmonized Indicators for Nutrition and HIV Care’ (FANTA, 2009 Eilene’s Note – Add Link when available), which track and provide comparative and trend data on the number and proportion of undernourished individuals receiving various program services.

Maternal nutrition status following delivery is assumed to reflect the mother’s nutritional experience during pregnancy, her general health and well-being, and her physical preparedness to breastfeed and care for a baby. HIV infection increases women’s energy requirements due to higher resting energy expenditures and increased nutritional needs from HIV-related infections and illnesses, thereby placing pregnant and lactating women at greater nutritional risk than their HIV-uninfected counterparts (WHO, 2004; Papathakis and Rollins, 2005; FANTA, 2010). This indicator relates to four of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; #5. Improve maternal health; and #6. Combat HIV/AIDs. 

Where nutrition interventions for HIV-infected women during pregnancy are in place, this indicator can measure the impact of nutritional support services.  A reduction in the prevalence of acute undernutrition following pregnancy among HIV-infected mothers indicates that nutritional support has been effective in preventing malnutrition during pregnancy, whereas, an increase in prevalence may call for program reviews and adjustments.  For example, nutrition program managers may need to work with other programming areas to ensure that HIV-positive pregnant women are getting nutritional support services earlier in their pregnancy, ramp up service provision, or improve counseling or training for clinic staff.  With regard to individual clients, this indicator can inform service providers if HIV-positive mothers need additional nutritional support after delivery of their infant. Regardless of the method of infant feeding, both mother and infant stand to gain if the mother is in good nutritional status.  The indicator is also meaningful for tracking individual women in comparison with prior assessments.  

At the global level, this indicator can be used by donors and international organizations to track the extent to which nutrition interventions are improving client status and to identify countries or regions where more focused efforts may be required.  This information can be used similarly by national governments to track efforts and prioritize needs within countries.  Programs can use the information to assess the impact of their interventions, to inform resource allocation, program management, to plan resource needs (e.g., food commodities and staff training), and to report data to donors.  Many countries are integrating nutrition assessment and related services into national HIV programs.  Acquiring tools for conducting anthropometric measures and developing systems for collecting, recording, and reporting such data are becoming priorities for national governments and for international donors making collection and utilization of this indicator increasingly feasible.

Issue(s):

Some conditions, such as the redistribution of fat tissue (lipodystrophy) associated with ARV treatment, may alter an individual’s normal fat distribution and affect the validity of MUAC measurements for determining nutritional status (WHO, 2004; FANTA, 2010). Another consideration is that use of a cutoff (i.e., MUAC<21cm) for assessing nutritional status prevents measurement of nutritional improvement below the cutoff level. A low MUAC value following pregnancy does not necessarily mean that the individual did not benefit from nutritional care and support, since the individual mother’s nutritional status may have improved with nutritional care and support even if that improvement was not sufficient to produce a normal MUAC value. While changes in the indicator may be interpreted as representing the impact of nutrition and other interventions, other factors need to be considered.  Seasonal, environmental, economic, and urban/rural residence factors that influence access to food can also impact the nutrition status of clients.  In general, improvements in nutrition status should not be attributed to nutrition interventions alone, as other factors including ARV treatment, disease progression, opportunistic infections, and breastfeeding status can influence nutritional status.

Accurate collection of data relies largely on flow of services at the clinic/program level and requires availability of standardized anthropometric measurement equipment, trained staff, and accurate record keeping within a program. The indicator does not provide information about the quality of the nutritional assessment, and accordingly quality assurance systems should be established and indicators of quality collected to assess how effectively these services are being implemented.  Finally, this indicator only measures those women who come to their postnatal care visit within the first six weeks and it thus is likely to suffer from selection bias. The indicator will underestimate the number of early postpartum undernourished HIV-infected women in an area and should not be used for these purposes. The attendance rate of these early postpartum visits also varies between countries and within countries so the size of this bias is likely to vary respectively.  The usefulness of this indicator for inter- and intra-country comparisons is limited.

 

Gender Implications:

Women’s ability to access HIV programs and services may be more limited than men’s in settings where women are particularly stigmatized for being HIV-positive or where cultural norms limit women’s ability to travel outside the home.  HIV services that have been integrated with antenatal care and PNC may be more accessible for women with HIV. Cultural gender norms may also affect women’s access to and utilization of food resources.  In settings such as South Asia where women often eat ‘last and least,’ even in households with adequate food available, adolescent and young women may be chronically undernourished and, where women are HIV-infected, these imbalances in food and resource allocation may be exacerbated.

References:

FANTA (Food and Nutrition Technical Assistance) Project.  2010.  A Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living With HIV . Washington, D.C.:  Academy for Educational Development.

FANTA (Food and Nutrition Technical Assistance) Project.  2009.  A Guide to Screening for Food and Nutrition Services Among People Living With HIV (Draft).  Washington, D.C.:  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.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance) Project. 2007, Nutrition and HIV/AIDS: A Toolkit for Service Providers in the Comprehensive Care Centres. Washington, D.C.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance Project.  2006.  Compilation of Monitoring and Evaluation (M&E) Indicators Used for Food and Nutrition Interventions Addressing HIV/AIDS.  Washington, D.C.:  Academy for Educational Development.

FANTA (Food and Nutrition Technical Assistance) Project. 2004. Food and Nutrition Implications of Antiretroviral Therapy in Resource Limited Settings, T. Castleman, E. Seumo-Fosso,and B. Cogill. Washington, D.C.:  Academy for Educational Development. 

FANTA (Food and Nutrition Technical Assistance) Project. 2004, HIV/AIDS: A Guide for Nutritional Care and Support. Washington, D.C.:  Academy for Educational Development. 

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

Papathakis P. and Rollins N., ‘HIV and Nutrition: Pregnant and Lactating Women,’ Consultation on Nutrition and HIV/AIDS in Africa: Evidence, lessons and recommendations for action, Durban, South Africa, April 2005, Department of Nutrition for Health and Development, World Health Organization.

Infant feeding in three specific areas: 1. Percent HIV-exposed infants who are exclusively BF at 3 months 2. Percent HIV-exposed infants who are replacement feeding at 3 months 3. Percent HIV-exposed infants who are mixed feeding at 3 months

Definition:

The percentages of HIV-exposed infants who are receiving each of three specific types of infant feeding at three months of age (i.e., at time of third dose of diphtheria, pertussis, and tetanus (DPT3) vaccine given at 14 weeks or at the closest visit after 3 months). The three types of feeding are: (1) exclusively breastfeeding; (2) replacement feeding receiving no breast milk; or (3) mixed feeding with breast milk and replacement feeding.

Exclusive breastfeeding is defined as receiving only breast milk and no other liquids or solids except drops of syrups consisting of vitamins, minerals, or medicines.  Breast milk can include mother’s expressed milk or milk from a wet nurse.

Replacement feeding is defined as the infant receives no breast milk and is being fed suitable breast milk substitutes in the form of commercial infant formula since animal milk is no longer recommended for feeding infants during the first 6 months of life, except as an emergency measure.

Mixed feeding is defined as both breast milk and breast milk substitutes (i.e., commercial infant formula).

This indicator is calculated in three levels as:

(Number of HIV-exposed infants who are exclusively breastfed at 3 months/ Total number of known HIV-exposed infants whose feeding practice was assessed) x 100

(Number of HIV-exposed infants who are replacement feeding at 3 months/ Total number of known HIV-exposed infants whose feeding practice was assessed) x 100

(Number of HIV-exposed infants who are mixed feeding at 3 months/ Total number of known HIV-exposed infants whose feeding practice was assessed) x100

Data Requirements:

During each visit, the health provider should inquire about infant-feeding practices during the previous 24 hours and record the response as one of three types - exclusively breastfeeding, replacement feeding, or mixed feeding. While this information should be recorded at each visit, only the DPT3 vaccination visit at about 14 weeks postpartum or the closest visit after the infant is at least 3 months old should be used to calculate this indicator.  The denominator is calculated from the total number of HIV-exposed infants whose infant feeding practices were assessed. Where the data are available, the indicator can be disaggregated by province and district, urban/rural location, and type of facility (e.g., public, private, community-based).

Data Sources:

Ideally data can be aggregated from sites and registers, such as stand-alone sites or integrated HIV service facility infant registers, depending on where the services are located and where data are recorded. Efforts should be made to include data from public, private, non-governmental, and community-based health facilities that provide HIV-exposed infant follow-up services.

Purpose:

This indicator allows the monitoring of program or country progress toward safer infant feeding practices among HIV-positive mothers and their exposed infants. It can be used as a proxy of the quality of infant feeding counseling with low rates of mixed feeding (the least healthy form) as a likely indicator of adequate counseling and support.  The information can be compared with population-based surveys, such as DHS which monitor infant-feeding in the general population. The indicator is included in the PEPFAR list of new generation indicators (PEPFAR, 2009) and the WHO/UNICEF/UNAIDS (2011) guide on indicators for monitoring the health sector response to HIV/AIDS.  

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). Mother-to-child transmission (MTCT) of HIV 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) of HIV. 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; 2007) 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 infant feeding and PMTCT, see WHO/UNICEF (2007), PEPFAR (2006), UNAIDS (2010), and WHO/UNICEF/UNAIDS (2011)).  

Issue(s):

The indicator does not provide information about the quality of replacement feeds or the impact of infant-feeding practices on child survival. Using a 24-hour recall period to measure current status may slightly overestimate the proportion of exclusively breast-fed infants because some infants who are given other liquids or foods irregularly may not have received them in the 24 hours before the survey. The indicator may not reflect the actual feeding patterns for HIV-exposed infants at national or district levels since it does not include infants who may have already died, whose HIV status is unknown, or infants whose mothers did not attend a facility with their infants for DPT3 or at around 3 months. 

References:

PEPFAR, 2009, The President’s Emergency Plan for AIDS Relief: Next Generation Indicators Reference Guide, Washington, DC: USAID/PEPFAR.  https://www.k4health.org/toolkits/igwg-gender/president%E2%80%99s-emergency-plan-aids-relief-next-generation-indicators-reference

PEPFAR, 2006, Report on food and Nutrition for People Living with HIV/AIDS, Washington, DC: USAID/PEPFAR. http://pdf.usaid.gov/pdf_docs/Pcaab509.pdf

UNAIDS, 2010, Prevention of Mother-To-Child Transmission of HIV (PMTCT): Technical Guidance Note for Global Fund HIV Proposals, Geneva: UNAIDS. http://www.who.int/hiv/pub/toolkits/PMTCT_Technical_guidance_GlobalFundR10_May2010.pdf

WHO/UNICEF/UNAIDS, 2011, A Guide on Indicators for Monitoring and Reporting on the Health Sector Response to HIV/AIDS. Geneva: WHO. http://www.who.int/hiv/data/UA2011_indicator_guide_en.pdf

WHO/UNICEF, 2003, Global Strategy for Infant and Young Child Feeding, Geneva: WHO.  http://whqlibdoc.who.int/publications/2003/9241562218.pdf

WHO/UNICEF, 2007, Planning Guide for national implementation of the Global Strategy for Infant and Young Child Feeding, Geneva: WHO. http://whqlibdoc.who.int/publications/2007/9789241595193_eng.pdf