Provision of Therapeutic or Supplementary Food to Undernourished PLHIV
Export Indicator
The purpose of this indicator is to assess progress toward providing
therapeutic and supplementary food to clinically undernourished PLHIV that receive
therapeutic or supplementary food. Provision of therapeutic and supplementary food to
undernourished PLHIV is a key component of treatment, care, and support for PLHIV.
Undernutrition significantly increases mortality risk for HIV-infected individuals, both those on
treatment and those not on treatment.12 Therapeutic and supplementary foods are essential
and proven interventions to manage and treat undernutrition, recommended and supported by
WHO, UNICEF, WFP, and other global authorities, as well as by PEPFAR. Programs in several
countries provide food support to clinically undernourished clients, including therapeutic food
products for severely undernourished PLHIV and supplementary food products for moderately
and mildly undernourished PLHIV. The indicator enables the scale and coverage of these
services to be tracked and monitors the extent to which these services are reaching those that
need them. Provision of therapeutic and supplementary food is generally accompanied by
other nutrition services, such as nutrition assessment and counseling, and measuring coverage
of therapeutic and supplementary food is a strong indicator of the extent to which the larger
package of nutrition care services is reaching PLHIV.
The structure of the indicator is very similar to existing UNGASS indicators that monitor
coverage of services, such as ART for adults and children with advanced HIV infection, ART to
prevent mother-to-child transmission, and treatment for TB and HIV among co-infected
individuals.
Interpretation. To address undernutrition and strengthen care and support for PLHIV, a
number of countries have introduced therapeutic and supplementary food provision in their
HIV programs. Results from the indicator provide information about the extent to which
therapeutic and supplementary food support is reaching eligible PLHIV and where gaps may
exist. Because this is a commodity-based intervention, data from other sources, such as stock
data, can be used to triangulate data collected at the point of service delivery.
When the proportion of undernourished PLHIV receiving food support is measured, the
indicator result will be affected by how many and which clients are anthropometrically
assessed. If there are changes in the population receiving anthropometric assessments (e.g.,
introduction of nutrition assessment services in new geographic areas where therapeutic and
supplementary food products are not yet provided), the denominator may change significantly
without any commensurate change in the numerator. Interpretation of changes in this indicator
need to consider these factors so changes in the indicator may reflect a combination of
program impacts and the influx (or exit) of populations to (or from) the indicator’s
measurement universe.
Uses. By measuring the coverage achieved for food support to clinically undernourished PLHIV,
the indicator can be used at the global level to gauge the extent to which nutrition support
services are reaching the PLHIV that require them as part of treatment, care, and support,
globally and in specific countries. At the national and program levels, the indicator can also be
used to monitor and track progress in the implementation of nutrition components of
comprehensive HIV care and support. This information can support national governments and
programs to identify strengths and gaps, plan interventions, and determine allocation of
resources for food and nutrition as needed. At the facility level as well, information from the
indicator can inform service providers and managers about coverage within the facility, and
measurement of the indicator can serve as an incentive and reminder to assess the nutritional
status of clients and provide therapeutic and supplementary foods to those who are
undernourished.
The number of clinically undernourished PLHIV that received therapeutic or supplementary food at any point during the reporting period
The number of PLHIV that were nutritionally assessed and found to be clinically undernourished
Numerator / Denominator
The source of data for this indicator is program and site records that
document whether clients have received therapeutic or supplementary food. Each time a client
is nutritionally assessed using anthropometric measurement, the measurement is recorded on
the client record and/or clinic register indicating whether the client is undernourished or not.
Each time therapeutic or supplementary food is provided to a client, this is also recorded in the
clinic register or program records.
To tabulate the number of clinically undernourished PLHIV receiving therapeutic or
supplementary food, program staff review individual client records, clinic registers, or program
records to tally the number of clinically undernourished clients that received nutrition
therapeutic or supplementary feeding at any point during the reporting period.
When the proportion of individuals receiving therapeutic or supplementary food is being
measured, the numerator is the number of clinically undernourished PLHIV that received
therapeutic or supplementary food at any point during the reporting period. The denominator
is the number of PLHIV that were nutritionally assessed and found to be clinically
undernourished. Since the measurement unit is PLHIV, every clinically undernourished PLHIV
who was nutritionally assessed and found to be clinically undernourished at any point during the reporting period is counted once in the denominator (and once in the numerator if he or
she received therapeutic or supplementary food at least once 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 likely to be a year at the national level.
National protocols should be used as the criteria for undernutrition for this indicator. Most
countries have adopted the criteria and cutoffs established and published by WHO (WHO,
1999; WHO, 2007; WHO, 2010), which are summarized in the table below. A few countries have
slightly modified the cutoff values. In all countries, accepted national protocols should be used
to identify the undernourished, based on the following criteria.
Non-pregnant adults ≥ 18 years of age3 BMI < 18.5 kg/m2
Pregnant women and women with infants < 6
months of age4 MUAC < 220 mm
Children 6-59 months of age5 WFH < −2 z-score or MUAC < 125 mm or
presence of bilateral pitting oedema
Children 5–9 years of age6 BMI-for-age < −2 z-score
Children 10–14 years of age7 BMI-for-age < −2 z-score
Children 15–17 years of age8 BMI-for-age < −2 z-score
Data collection method. The measures associated with this indicator require collection of the
number of individuals that were found to be undernourished using anthropometric assessment
and the number of these clients that received therapeutic or supplementary food. Each time a
PLHIV is nutritionally assessed and found to be undernourished, clinic or program staff record
this information on individual, clinic, or program records. And each time the client is provided
with therapeutic or supplementary food, clinic or program staff record this information. Tools
needed for nutrition assessment may include weight scales, MUAC measurement tapes,
stadiometers/height-measuring devices, and recumbent length devices, among others.
Maintenance of records about nutritional status and food provision is required.
Since the indicator includes ART and pre-ART clients, PMTCT clients, and pediatric HIV clients, in
some settings information will be drawn from multiple record systems, such as routine health
information systems and reporting systems for large-scale food distribution programs,
especially those that target PLHIV. This may require aggregation at the district or national level. Frequency of measurement and reporting. Data should be collected continuously at the facility
or program level by documenting on program records each time a client is assessed to be
undernourished and each time a client receives therapeutic or supplementary food. Data
should be aggregated periodically, and would be reviewed and reported annually at national
and global levels. It could be reviewed and reported more frequently at the program level as
needed.
Disaggregation. Disaggregation for this indicator is recommended for the following categories.
ART vs. no ART
Sex
Pregnancy status
Postpartum status
Age
• < 6months
• 6-24months
• 24-59 months
• 5-14years
• 15-17 years
• > 18 years
Continuously
Age group: < (less than) 6 months, 6 months - 24 months, 24 months - 59 months, 5 years - 14 years, 15 years - 17 years, > (greater than) 18 years
Gender: Male, Female
Pregnancy status: Pregnant, Not Pregnant
Strengths and Weaknesses.
Strengths. The indicator directly measures the number and proportion of undernourished PLHIV
receiving therapeutic or supplementary food, which is a critical care and support service for
undernourished clients. Provision of therapeutic and supplementary food is widely seen as the
most powerful and impactful nutrition intervention provided to undernourished individuals.
Furthermore, because most programs providing such food also provide other complementary
nutrition services, this indicator can be interpreted as indicating the extent to which the fuller
package of nutrition services is provided. By measuring both the number and the proportion,
the indicator provides information about the overall scale of these services as well as
information about coverage among clients needing such food support. The indicator is quite
straightforward to measure, especially since most facilities and programs measuring nutritional
status already record the result of this measurement, and most programs providing therapeutic
and supplementary foods maintain records of the food provision.
Weaknesses. There are limitations to comparing results for this indicator across countries.
Different countries and programs may use different types of food products, may provide the
food for different durations, and possibly even apply different entry and exit criteria for food
eligibility. Also, the indicator provides information about coverage, but not about the impact of
the food support, quality of the foods, duration of food support, or adherence and drop-out
rates.
As described in the “Interpretation” section above, changes in the proportion measure of the
indicator may be caused by changes in the number or population of clients being assessed, in
addition to changes in the number receiving therapeutic or supplementary food support. For
this reason, it is recommended to collect the indicator as both a number and a proportion.
Resources required. As an output indicator, the resources required to collect this data for this
indicator are tools that document the provision of therapeutic or supplementary foods, either
in a patient record or within programs. Additional tools to facilitate the extraction from patient
records and aggregation at the site or program level, such as registers, tally sheets, and
reporting forms, will also be required.