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

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.

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.

PNC registers; client records

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.

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.


nutrition, HIV/AIDS

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.

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.

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