Nutrition Counseling for People Living with HIV (PLHIV)

Export Indicator

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

Undernutrition significantly increases mortality risk for HIV-infected
individuals, for both those on treatment and those not on treatment .1,2 The purpose of this
indicator is to monitor the number and proportion of all PLHIV, including adults, children, and
pregnant and lactating women, who are nutritionally assessed and received nutrition
counseling. Nutritional counseling, when informed by nutrition assessment, assists clients to
understand nutritional needs, identify constraints and options for improved diet, and plan
feasible dietary actions to achieve or maintain good nutritional status. Ideally, nutrition
counseling should be based on a nutrition assessment. 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 medical and/or nutrition
interventions, such as nutrition counseling. Nutrition assessment also helps health care
providers understand client nutritional status and dietary habits, identify nutritional problems
that clients face, and gauge changes and progress in nutritional status. To maximize treatment efficacy, it is essential for PLHIV to be nutritionally assessed and receive nutrition counseling at
regular intervals. This indicator measures the coverage of clients who were nutritionally
assessed and then received nutrition counseling at any point during the reporting period.

Interpretation. This indicator as a proportion is interpreted to measure the coverage of
nutrition counseling among clients receiving nutrition assessment in care and treatment.
Results for this indicator as a number should be interpreted as measuring the number of clients
that received both nutrition assessment and nutrition counseling. As such, it provides valuable
information about the services being provided to clients within care and treatment programs.

Because it is possible that not all of the PLHIV receiving care and treatment services will receive
nutrition assessment, interpretation of trends in the indicator, when expressed as a proportion,
will be sensitive to changes in the denominator (i.e., the number of PLHIV that were assessed).
For this reason, we recommend that the indicator be expressed both as a number and a
proportion. It is also recommended that this indicator be interpreted along with another
indicator proposed in this set that measures the number and proportion of PLHIV in care and
treatment that were nutritionally assessed. In this way, the fluctuations in the denominator and
how they affect the level of the indicator (when using proportion) can be considered to
determine whether trend comparisons are valid. This joint interpretation of indicators also
allows for a better understanding of the extent to which different components of nutrition care
are provided to PLHIV in care and treatment.

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. The indicator provides
information about the extent that nutrition assessment and counseling is reaching PLHIV in
treatment, care, and support and where gaps in service delivery may exist.

Rationale

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. The indicator provides
information about the extent that nutrition assessment and counseling is reaching PLHIV in
treatment, care, and support and where gaps in service delivery may exist.

Numerator

The number of PLHIV, including adults, children, and pregnant and lactating
women, who were nutritionally assessed and received nutritional counseling at any point
during the reporting period

Denominator

The number of PLHIV that were nutritionally assessed during the same reporting period

Calculation

Numerator / Denominator

Method of measurement

The primary source of data for this indicator will be patient records,
which include information about the services, including nutrition assessment, provided to
patients enrolled in care and treatment. Each time a client is nutritionally assessed using
anthropometric measurement, the measurement is recorded on the client record and/or the
clinic register. Similarly, each time nutrition counseling is provided, this should be recorded on
the client record.

To tabulate the number of PLHIV that were nutritionally assessed and received nutrition
counseling at any time during the reporting period, program staff review individual client
records and/or clinic records to determine the number of clients who were nutritionally
assessed and received nutrition counseling.

When the proportion of individuals receiving nutrition counseling is being measured, the
numerator is the number of PLHIV, including adults, children, and pregnant and lactating
women, who were nutritionally assessed and received nutritional counseling at any point
during the reporting period. The denominator is the number of PLHIV that were nutritionally
assessed during the same reporting period. Since the indicator unit is PLHIV, every PLHIV who
was nutritionally assessed at least once during the reporting period is counted once in the
denominator (and once in the numerator if he or she was nutritionally assessed and received
nutritional counseling at least once during the reporting period), irrespective of whether he or
she received services once or several times during the reporting period. Persons receiving
nutrition counseling more than once during the reporting period should be included only once
in the calculation of the indicator. 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 were nutritionally assessed and who received nutrition counseling at
the facility/community level. Each time a PLHIV receives a nutrition assessment and nutrition
counseling, program staff record this information on individual and/or clinic records.

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. With small modifications, the patient
registers could be adapted to document the number of clients receiving nutrition assessment
that also received nutrition counseling. This would allow for aggregation of the data at the
health facility level for reporting.

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

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 and Weaknesses.
Strengths. A key strength of this indicator is that it directly measures the coverage of nutrition
assessment and counseling services among PLHIV. The fact that many countries are integrating
nutrition assessment and counseling into national HIV programs attests to the relevance of this
indicator. The practice of conducting nutrition assessment and counseling is occurring more
frequently at the facility level. Therefore, 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. The prominent weakness of this indicator is that when the proportion is used, the
indicator measures the proportion of assessed clients that also receive counseling (not the
proportion of all clients that receive assessment and counseling). The indicator should
therefore not be interpreted as measuring total coverage of assessment and counseling, but
rather as measuring coverage of assessed clients with counseling.

Additionally, this indicator does not provide information about the quality of the assessment
and counseling beyond meeting the requirements listed above. Quality assurance and
supportive supervision systems should be established and indicators of quality collected to
assess how effectively these services are being implemented. Also, because the intensity of
assessment and counseling and the type of anthropometric assessment applied may vary across
programs, comparisons across programs or countries using this indicator should be interpreted
as comparing coverage of assessment and counseling services, but not necessarily the same
specific services.

Resources required. As an output indicator, the resources required to collect this information
via routine health information systems are tools that allow documentation of the counseling
intervention in the patient record as well as registers, tally sheets, and reporting forms to
facilitate extraction, aggregation, and reporting of the data.

Further information