Nutrition Assessment for People Living with HIV (PLHIV)

Export Indicator

The number and proportion of PLHIV in care and treatment who were nutritionally assessed at any point during the reporting period. PLHIV include adults and children that have tested positive for HIV. This definition includes adults (including pregnant
What it measures

Nutrition assessment via anthropometric measurement can provide data for clinical staging and
can identify patients at higher mortality risk whose health status may benefit from additional
medical and/or nutrition interventions, such as counseling and therapeutic or supplementary
feeding. Performing nutrition assessment also provides information on the nutritional status of
PLHIV and creates a means for monitoring the number and proportion of undernourished
individuals at the facility, regional, and national levels. These data can inform the development of strategies addressing the need for nutrition interventions in care and support services. This
indicator is also critical because it is a companion to the indicators in this set that track the
number and proportion of PLHIV that are identified as undernourished during the reporting
period, as well as the number and proportion of undernourished PLHIV that received
therapeutic and supplementary feeding.

Interpretation. This indicator is interpreted to measure the extent to which nutrition
assessment services are reaching PLHIV within a facility or a geographic area. As such, it
provides valuable information about coverage of this service and where gaps in service delivery
may exist.

Uses. 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 PLHIV
and to identify countries or regions where more focused efforts may be required. This
information can be used by national governments to track efforts 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 assess the scale of need for planning
resource needs (e.g., staff training), and to report data to donors.

Rationale

The purpose of this indicator is to monitor the extent to which nutrition
interventions are included as a component of care and treatment services for PLHIV. Among
PLHIV, undernutrition is associated with faster progression to AIDS and higher risk of
mortality.1,2 Thus, nutrition assessment is an essential component of care and treatment for
HIV-infected individuals. Completion of a nutrition assessment assists health care providers to
determine whether clients are undernourished and to monitor individual nutritional status.

Numerator

The number of PLHIV, including adults, children, and pregnant and lactating women, who were nutritionally assessed via anthropometric measurement at any point during the reporting period

Denominator

The number of PLHIV receiving care and treatment services during the same reporting period. Since the indicator unit is PLHIV, every PLHIV who received care and treatment services at least once during the reporting period is counted once in the denominator (and once in the numerator if he or she received a nutrition assessment at any point during the reporting period), irrespective of whether he or she received services once or several times during the reporting period

Calculation

Numerator / Denominator

Method of measurement

The primary source of data for this indicator will be patient records
that document whether clients have received a nutrition assessment. Each time a client is
nutritionally assessed using anthropometric measurement, the measurement is recorded on
the client record and /or clinic register.

For adults greater than (>) 18 years of age who are not pregnant or within six months post-
partum, BMI is the preferred method of nutrition assessment. BMI is calculated by dividing
weight in kilograms (kg) by height in meters (m) squared (BMI = kg/m2). 3

For children and adolescents 5-18 years of age who are not pregnant or within six months post-
partum, BMI-for-age z-score is the preferred method of nutrition assessment. Because children
and adolescents are still experiencing growth and development, it is necessary to consider the
age and sex of the child or adolescent when using BMI as an assessment method for
determining nutrition status.4

For children 6-59 months, weight-for-height (WFH) z-scores is the preferred method of
nutrition assessment. A z-score allows comparison of a child’s weight-height ratio to that of a
reference population of the same age and requires data on height, weight, and age of the child.
Growth charts may be used to facilitate data collection and interpretation of z-scores. A child’s
weight and height can also be plotted on a pre-printed graph. 5

MUAC is also recommended by WHO as a method of assessment to for severe acute
malnutrition among children 6-59 months. MUAC measures the circumference of the left
upper arm in millimeters (mm). It is taken at a point midway between the tip of the shoulder
and the elbow. MUAC is a proxy measure of nutrient reserves in muscle and fat that are not
affected by pregnancy and are independent of height. It can be used as an assessment tool for
women who are pregnant or up to 6 months post-partum and of non-pregnant/post-partum
clients whose height or weight cannot be measured (e.g., the client cannot stand or no
weighing or measuring equipment is available). 6,7
To tabulate the number of PLHIV that were nutritionally assessed at any point during the
reporting period, program staff review individual client records and/or clinic registers to
determine the number of clients that received nutrition assessment. Clients that were assessed
multiple times during the reporting period should be counted only once.

When the proportion of individuals receiving nutrition assessment is being measured, the
numerator is the number of PLHIV, including adults, children, and pregnant and lactating
women, who were nutritionally assessed via anthropometric measurement at any point during
the reporting period. The denominator is the number of PLHIV receiving care and treatment services during the same reporting period. Since the indicator unit is PLHIV, every PLHIV who
received care and treatment services at least once during the reporting period is counted once
in the denominator (and once in the numerator if he or she received a nutrition assessment at
any point during the reporting period), irrespective of whether he or 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.

Data collection method. The measures associated with this indicator require collection of the
number of individuals that received a nutrition assessment at the facility or community level.
Each time the nutritional status of a PLHIV is measured, program staff record this information
on individual or clinic records. Tools for the measures may include weight scales, MUAC
measurement tapes, stadiometers/ height-measuring devices, and recumbent length devices,
among others.

Frequency of measurement and reporting. To measure number and proportion of HIV-positive
individuals receiving nutrition assessment, patient-level data can be collected continuously at
health facilities. At the health facility level, data on nutrition assessment could be transferred to
the patient registers to facilitate the aggregation and report to the national level, ideally
integrated into routine health information systems. Data collected by this indicator would likely
be reviewed annually at the national and global levels and could be reviewed more frequently
at the program level as needed.

The Three Interlinked Patient Monitoring Systems for HIV Care/ART, MCH/PMTCT and TB/HIV:
Standard minimum data set and illustrative tools, published by WHO in 2010, provides
examples of data collection tools that allow documentation of height and weight or MUAC on
patient cards for PLHIV in care and treatment programs. This would allow for aggregation of the
data at the health facility level for reporting.

Disaggregation. Disaggregation for this indicator is recommended at the following levels.
ART vs. no ART
Sex
Pregnancy status
Postpartum status
Age
• • 6-24 months
• 24–59 months
• 5–14 years
• 15-17 years
• > 18 years

Measurement frequency

Continuously

Disaggregation

Age group: (greater than) 18 years

Gender: Male, Female

Pregnancy status: Pregnant, Not Pregnant

Explanation of the numerator
Explanation of the denominator
Strengths and weaknesses

Strengths. A key strength of this indicator is that it directly measures the coverage of nutrition
assessment services among PLHIV. The fact that many countries are integrating nutrition
assessment into national HIV programs is a prominent strength of this indicator. The practice of
conducting nutrition assessment via anthropometric measurement is occurring more frequently
as part of HIV services. Therefore, 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.

Weaknesses. This indicator captures only the coverage of nutrition assessment using one
assessment method: anthropometric measurement. There are other valid nutrition assessment
methods, such as biochemical assessment, clinical assessment, and dietary assessment, that are
not covered by this indicator. This may result in underestimation of the coverage of nutrition
assessment, but the difference is expected to be small. Of the nutrition assessment methods
mentioned above, anthropometry is one of the most widely used and easiest to implement in
resource-limited settings. Furthermore, it is often used in conjunction with other methods.

Resources required. As an output indicator, the resources required to collect this information
via routine health information systems are tools that allow documentation of nutritional status
in the patient record. This provides evidence that a patient was assessed. In addition, registers,
tally sheets, and reporting forms to facilitate extraction, aggregation, and reporting of the data
will be needed.

Further information

Cogill, Bruce. Antrhopometric Indicators Measurement Guide. Food and Nutrition Technical
Assistance (FANTA) Project. Academy for Educational Development. Washington, D.C., 2003.

Maas, J et al. Body mass index course in asymptomatic HIV-infected homosexual men and
predictive value of a decrese of boddy mass index for progression to AIDS. Journal of Acquired
Immune Deficiency Syndromes and Human Retrovirology;19 (3), 1998, 254-259.

Liu, E. et al. Nutritional Status and Mortality among HIV-infected patients receiving anti-
retroviral therapy in Tanzania. Journal of Infectious Diseases; 2004 (2), 2011, 282-290.