Referral to Food Security Services
The indicator can be interpreted to measure the extent to which referral
linkages are in place and active from clinical HIV services to food security services. The
indicator does not provide information about the extent to which clients are availing these
referrals, only the extent to which the referrals are occurring. Similarly, the indicator does not
inform about the quality or effectiveness of the food security services to which referrals are
made. Interpretation of the indicator should consider that there are multiple possible reasons
why referrals may not be happening, including a) lack of food security services in proximity to
clinical services, b) lack of awareness about food security services by clinical service providers,
or c) lack of referral systems between the two types of services.
Interpretation of the indicator should also consider that indicator values may change due to a
change in the number of food insecure clients (e.g., more clients need food security services) or due to changes in the referral system (e.g., better coverage with referrals). For this reason,
both number and percentage are collected.
Uses. At the global level the indicator can be used by donors and international organizations to
track the extent to which linkages and referral mechanisms are in place between clinical HIV
services and food security services and to identify countries or regions where gaps may exist.
To make such determinations, information from this indicator would likely need to be used in
combination with other information, such as the type, reach, and quality of food security
services. The indicator can also be used at the national level by governments to track linkages
and referral mechanisms. At the program level, the indicator can be used to assess and track
the extent to which mechanisms are in place to refer clients of HIV care and treatment services
to food security services, and the extent to which referrals are being made through such
mechanisms. This may be the most direct and valuable use of the indicator.
In many contexts HIV care and treatment clients are food insecure,
which can negatively affect their health, treatment adherence, nutritional status, and overall
well-being. While most clinical facilities do not offer services to strengthen food security,
presentation at clinical facilities does offer an opportunity for clients to be referred to such
services. Establishing effective referral mechanisms between clinical facilities and food security
services helps clients avail more comprehensive care and support services and can help sustain
nutritional improvements generated by clinical nutrition services. This indicator measures the
extent to which such referrals occur.
The number of HIV care and treatment clients identified as being vulnerable to food insecurity who are referred to food security services at any point during the reporting period
The number of HIV care and treatment clients identified as being vulnerable to food insecurity during the same
Numerator / Denominator
The indicator measures the number and percentage of HIV care and
treatment clients vulnerable to food insecurity who receive referrals to services to strengthen
food security. It is measured using clinic records documenting the number of clients receiving
HIV care and treatment services who are vulnerable to food insecurity and the number of these
clients who are referred to food security services. When the number of clients referred from
clinical facilities to food security services is being measured, the value of the indicator is the
number of clients who are identified as vulnerable to food insecurity and who receive a referral
to some type of food security service at any point during the reporting period.
When the percentage of clients is being measured, the numerator is the number of HIV care
and treatment clients identified as being vulnerable to food insecurity who are referred to food security services at any point during the reporting period. The denominator is the number of
HIV care and treatment clients identified as being vulnerable to food insecurity during the same
period. The duration of the reporting period is determined by the facility, program or country
reporting on the indicator.
Vulnerability to food insecurity is measured using a screening or assessment of food insecurity
administered to HIV care and treatment clients. The indicator does not recommend a specific
screening or assessment tool. The choice of tool is left up to the individual program, although it
is important that the program describe the tool and justify its use in the program context when
reporting the indicator. Depending on the time and resources available to health care workers
and lay workers, the process may range from a full assessment of food security using the
Household Hunger Scale or another food access assessment tool (which would require a
relatively greater time commitment), to a simple screening question such as whether the
household faces challenges in accessing sufficient food (which would require a smaller time
commitment). Where possible, managers of clinical facilities can contact nearby programs that
provide food security services to understand the eligibility criteria used for food security
services, which can help inform the screening or assessment process at the facility level.
Data collection method. Data for this indicator are collected at the clinic level. When food
security screening or assessment indicates vulnerability, this is documented on a record. When
clients are referred to food security services, the referral is documented. These data can be
tallied to calculate the number and percentage of clients vulnerable to food insecurity who are
referred to food security services.
Frequency of measurement and reporting. Data are recorded when referrals occur.
Compilation of the data and reporting of the indicator can occur as frequently as needed.
Generally, more frequent compilation is desirable so as to maintain up-to-date and accurate
records, while bi-annual or annual reporting of the indicator should be sufficient.
Disaggregation. Data can be disaggregated by client characteristics, e.g. gender, age groups,
ART and pre-ART clients, and PMTCT clients.
Gender: Male, Female
Strengths: A strength of this indicator is that it generally uses existing clinical records, in which
case no additional data collection is required. Another strength is that it measures linkages
between different services, which is an area rarely included in M&E systems, which often focus
on a particular type of service.
Weaknesses: The use of clinical records for data can be a weakness as well, because the data
will be only as good as the clinical records are. If the quality of clinical records is poor, this may
cause measurement error in the values reported. Also, the indicator does not provide
information about whether the referral was availed or about the quality of the food security
services provided. A final weakness is that different programs or countries are likely to use
different methods to measure vulnerability to food security, which potentially complicates
cross-program or cross-country comparisons.
Resources required. Because existing records can be used for this indicator, the resources
required are modest. In settings where referrals to food security services are not already
documented in clinical records, measuring this indicator will require some additional effort.
The primary resources required are the time needed to screen or assess for vulnerability to
food insecurity, and the time needed to record and tabulate referrals to food security services.
Ideally, providers screen or assess for vulnerability to food insecurity as part of program
services and referral, irrespective of the indicator, but in some settings the screening or
assessment process may need to be added as the indicator is introduced. Identifying and
linking to available food security services may also require resources, but this too would occur
as part of referral services, irrespective of whether the indicator is collected.
Information on screening and assessment of food security in clinical settings can be found in
Tumilowicz, Alison. Guide to Screening for Food and Nutrition Services Among Adolescents and Adults Living With HIV. Washington, DC: Food and Nutrition Technical Assistance II Project
(FANTA-2), Academy for Educational Development, 2010.