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

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.


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.


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


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.


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. 


nutrition, HIV/AIDS, adolescent

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.


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.

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