Undernutrition in People Living with HIV (PLHIV)
1. Malnutrition significantly increases the mortality risk for
HIV-infected individuals, both those on treatment and those that are not.2 For case
management, nutrition assessment that includes anthropometric measurement can provide
data for clinical staging and can identify patients at higher mortality risk whose health status
may benefit from medical or nutrition interventions, such as counseling and therapeutic or
supplementary feeding. At the facility, regional, and national levels, monitoring the number and
proportion of undernourished individuals can be used to determine the extent to which PLHIV in care and treatment services may need nutrition care services.3 It also serves to inform the
development of strategies for nutrition interventions in care and support services. This
information can also be used for planning and resource allocation for food and nutrition
support. This indicator can also be used to determine whether the objective of integrating
nutrition care services to reduce malnutrition among PLHIV is being achieved.
Interpretation. While changes in the indicator may be interpreted as representing the impact of
nutrition and other interventions, other factors also need to be considered. Changes in the
client base, such as an influx of new clients or deaths of malnourished clients, can affect the
indicator. Seasonal factors, such as weather, and environmental factors that influence access to
food can also affect the nutritional status of clients. However, if the reporting period is long
(e.g., a year), the data being compared should be collected at the same time of year; seasonal
variations can be minimized and data collected will be comparable from one period to the next.
For shorter reporting periods (e.g., months or quarters), it is recommended that trend analysis
be used to compare data from the same time of year (e.g., the same month). Finally,
improvements in nutritional status should in general not be attributed to nutrition
interventions alone, as other factors, including ART, disease progression, and opportunistic
infections, can also influence nutritional status to a significant degree.
While, for the purposes of this indicator, we use the term “undernourished,” it is important to
note that this indicator captures only macronutrient undernutrition, due to insufficient caloric
intake. There are other forms of undernutrition, for example, vitamin and mineral deficiencies that may affect PLHIV in care and treatment, but they are not captured here. These would
require different assessment and data collection methods.
Finally, because it is possible that not all of the PLHIV receiving care and treatment services
receive a 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 as both a number
and a proportion.
Uses. The information provided by this indicator can be used at many levels and for many
purposes. At the global level, this indicator can be used by donors and international
organizations to track to extent to which program nutrition interventions are improving client
status and to identify countries or regions where more focused efforts may be required.
Similarly, this information can be used by national governments to track efforts and prioritize
needs at the sub-national level. Programs can use the information to assess the impact of their
interventions, to inform resource allocation and program management, to assess the scale of
planning resource needs (e.g., food commodities and staff training), and to report data to
donors. Finally, for case management, nutrition assessment can provide the clinician with
information about a patient’s mortality risk and disease progression and can identify patients in
need of nutrition interventions, which may improve the effectiveness of treatment (Cantrell et
The purpose of this indicator is to monitor the number and proportion
of PLHIV, including adults, children, and pregnant and lactating women, who are clinically
undernourished exhibited by thinness and weight loss. According to the WHO guidelines for
treatment of HIV-positive adults and adolescents, weight loss is one of the considerations used
to determine clinical staging of HIV.
The number of all PLHIV, including adults, children, and pregnant and lactating women, that were
undernourished at any point during the reporting period, using the above criteria (see Method of Measurement).
The number of PLHIV that received anthropometric assessment during the same
Numerator / Denominator
The primary source of data for this indicator is patient records,
which include information about the nutrition status of clients enrolled in care and treatment.
For adults greater than (>) 18 years of age who are not pregnant or within six months post-
partum, BMI is the preferred indicator of body thinness used to classify malnutrition. BMI is
calculated by dividing weight in kilograms (kg) by height in meters (m) squared (BMI = kg/m2).
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 indicator of body thinness used to classify
malnutrition. For adults, simple BMI can be used as an indicator of nutritional status because
most individuals older than 18 years of age have completed their physical development.
However, children and adolescents are still experiencing growth and development. Therefore it
is necessary to consider the age and sex of the child or adolescent when using BMI as an
indicator of nutritional status.
To identify undernourished children 6-59 months, weight-for-height (WFH) z-scores are used. A
z-score allows comparison of a child’s weight-height ratio to that of a reference population of
the same age, requiring 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
be plotted on a pre-printed graph, which allows health care providers to easily identify children
whose z-scores are less than −2.
MUAC is also recommended by WHO as an indicator of 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 to classify the nutritional status of 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).
Programs that currently include anthropometric assessment may continue to use whichever of
these methods is currently in use. Resources are available to guide the collection of
anthropometric data (see references section). To tabulate the number of PLHIV that were
undernourished at some time during the reporting period, program staff review individual
client records and/or clinic records to determine the number of clients that were malnourished
based on the following criteria to facilitate comparisons of the indicator across programs,
geographic areas, and/or sub-groups.
Non-pregnant adults ≥ 18 years of age4 BMI < 18.5 kg/m2
Pregnant women and women with infants < 6
months of age5 MUAC < 220 mm
Children 6-59 months of age of age6 WFH < −2 z-score or MUAC < 125 mm or
presence of bilateral pitting oedema
Children 5–9 years of age7 BMI-for-age < −2 z-score
Adolescents 10–14 years of age8 BMI-for-age < −2 z-score
Adolescents 15–17 years of age9 BMI-for-age < −2 z-score
When the proportion of undernourished individuals is being measured, the numerator is the
number of all PLHIV, including adults, children, and pregnant and lactating women, that were
undernourished at any point during the reporting period, using the above criteria. The
denominator is the number of PLHIV that received anthropometric assessment during the same
reporting period. Since the indicator unit is PLHIV, every PLHIV who received care and
treatment services and was anthropometrically assessed at least once during the reporting
period is counted once in the denominator (and once in the numerator if he or she was
assessed to be undernourished at any point during the reporting period), irrespective of
whether he or she received nutrition services. Persons assessed 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
anthropometric data that will be obtained via nutrition assessment at the facility/community
level. Each time the nutritional status of a PLHIV is measured, program staff record this
information on individual records. Tools for the measures mentioned above may include weight
scales, MUAC measurement tapes, stadiometers/height measuring devices, and recumbent
length devices, among others. Data collection tools such as registers or tally sheets will be
necessary to transfer data from individual records and aggregate data for calculation of the
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 one small modification, the
patient registers could be adapted to document the number identified as undernourished to
allow for aggregation of the data at the health facility level for reporting.
Frequency of measurement and reporting. To measure number and proportion of HIV-positive
individuals that are undernourished, patient-level data can be collected continuously at health
facilities. For non-pregnant adult patients, height should be measured once on enrollment in
the program, and the patient should be weighed and a BMI calculated (or a MUAC measurement taken) at every visit or as often as is feasible at the facility. Pregnant women and
those with infants less than 6 months old can be assessed using MUAC. Children 6-59 months of
age can be assessed using either weight-for-height or MUAC at every visit. Older children and
adolescents should be assessed using BMI-for-age with weight and height measured at every
visit. All anthropometric measurements should be documented on patient records. At the
health facility level, data on nutrition assessment and nutritional status 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 and global levels and could be reviewed more frequently
at the program level as needed.
Disaggregation for this indicator is recommended at the following levels.
ART vs. no ART
• < 6months
• 24-59 months
• 15-17 years
• > 18 years
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. A key strength of this indicator is that it directly measures the primary outcome that
nutrition services aim to affect, i.e., undernutrition. 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 assessments via anthropometric measurement is
occurring more frequently at the facility and community levels. 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.
Another strength of this indicator is that the data elements required to construct the indicator
are minimal. Height, weight, and/or MUAC are already included in the minimum data set
recommended by WHO. WHO has also already included these data elements in the generic
tools for patient monitoring systems, which, at the time of this writing, have been adapted for
use by 10 counties, and many other countries have expressed interest in implementing these
Weaknesses. The prominent weakness of this indicator is the number of factors that affect
nutritional status, but that are not attributable to nutrition interventions. Improvements or
declines in nutritional status can be associated with multiple factors, including changes in client
base and seasonal determinants.
Resources required. Collection of data for this indicator requires the availability of
measurement tools, such as growth charts for children under 5 or reference tables to asses
weight-for-height, BMI and BMI-for-age, scales, stadiometers, MUAC tapes, and height boards;
trained staff to conduct the nutrition assessment; and data collection tools to allow extraction
of the data from individuals records and site-level aggregation of data. The equipment and
trained staff to collect anthropometric data are critical for the delivery of NACS, regardless of
whether this indicator is collected. Thus, for programs that already provide nutrition services,
the only additional resources required would be the data collection tools and the staff
resources to complete them.
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Evaluation of Nutrition Assessment, Education and Counseling of People Living with HIV.
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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.
Tumilowicz, Alison. Guide to Screening for Food and Nutrition Services Among Adolescents and
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(FANTA-2), Academy for Educational Development, 2010.
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