REPUBLIC OF RWANDA

Ministry of Health
PREFACE

The HIV/AIDS pandemic affects approximately 3% of the Rwandan population (7.3% in the urban
area and 2.2% in the rural area, DHS 2005), with the greatest impact being on its most productive
members with consequences on the economic development of the country and household food
security. This situation is aggravated by poverty, which affects 60% of the population, and a high
prevalence (more than 30%) of malnutrition.

AIDS leads to malnutrition in affected individuals and reduces their immunity and ability to fight
opportunistic infections. As a consequence, household labour capacity is reduced, followed by a fall
in agricultural production and income generation. HIV/AIDS therefore limits the capacity of the
affected households to access quality and appropriate health and nutritional care. With the availability
of antiretrovirals, it is important to have food for drug efficacy and to improve adherence to drug
regimens. The interaction between the HIV/AIDS and nutrition is not a single vicious cycle, but
several vicious cycles which does not only result in misery or death, but worse – death in misery.

In addressing the problem of HIV/AIDS, the strategy of the Government of Rwanda places particular
emphasis on prevention, while at the same time providing prophylaxis and treatment for opportunistic
infections and antiretroviral therapy to all eligible people living with HIV/AIDS, irrespective of their
social status.

It is now important to include nutrition as an integral component of a comprehensive package of the

treatment and care strategy for people living with HIV/AIDS so as to break the vicious cycle caused
by the virus. For this reason, we highly appreciate the valuable multisectoral response of the Rwanda
Nutrition Technical Working Group, which, with these Guidelines and Protocol, has given direction
to the hitherto missing food and nutrition dimension of the package of treatment and care for people
infected with HIV/AIDS.

The Guidelines raise fundamental questions and address challenges, such as the issue of breast-
feeding vis-à-vis replacement feeding with breast milk substitutes for the baby born to an HIV
positive mother in a resource-limited environment. In addition to addressing essential questions, it is
important to recognize that the Guidelines are the first tool that integrates a nutritional dimension in
the treatment and care of people living with HIV/AIDS.

The Guidelines offer practical recommendations for healthy and balanced diets aimed at improving
the nutritional well being of PLWHA. The Guidelines are intended to be used by service providers,
mainly in the health and agricultural sectors, gender and social development, and the local
administration, as well as those providing home-based care.

The Ministry for Health is grateful for this valuable tool, which is the fruit of the effort of various
partners, and counts much on the users for their constructive feedback.

Lastly, it is our intention that the Guidelines and protocol fall under the Vision 2020 of the
Government whose objective is not only national development, but also to relieve the individual’s
pain and disease for a better health, a better education, a more productive and better life.

Dr. Innocent NYARUHIRIRA

Minister of State in Charge of HIV/AIDS and Other Epidemics,
Ministry of Health.

i
Acknowledgement
The Ministry of Health would like to express its sincere gratitude to the following agencies
for their financial and technical assistance: CIAT, FANTA/AED, FAO, UNICEF, USAID,
and WFP.

Special thanks go to the Nutrition and HIV/AIDS Working Group members:

HATEGEKIMANA Dassan, KALIGIRWA Christine, KAMPIRWA Rachel, KAYUMBA
Josephine, MIHIGO Jules, NGABO Fidel, NKUSI Debra, NYAGAYA Martha, OMWEGA
Abiud, OULARE Macoura, and RWAHUNGU Jumapili, for their technical input,
commitment and dedication, which contributed a great deal to the development of the
guidelines. This work is a result of their tireless work in compiling and reviewing the various
drafts. The Ministry of Health would also like to express its appreciation to all those persons
who in one way or another contributed to make the guidelines a reality.

ii
 TABLE OF CONTENTS

PREFACE ............................................................................................................................................................. I

ACKNOWLEDGEMENT ..................................................................................................................................II

ACRONYMS AND ABBREVIATIONS............................................................................................................ V

GLOSSARY ...................................................................................................................................................... VII

1 INTRODUCTION....................................................................................................................................... 1
1.1 BACKGROUND ...................................................................................................................................... 1
1.2 MALNUTRITION IN RWANDA ................................................................................................................ 1
1.3 NATIONAL RESPONSE TO HIV/AIDS AND MALNUTRITION .................................................................. 2
1.4 RATIONALE FOR THE GUIDELINES ........................................................................................................ 2
1.5 PURPOSE OF THE GUIDELINES .............................................................................................................. 3
1.6 TARGET GROUPS................................................................................................................................... 3
1.7 HOW TO USE THE GUIDELINES ............................................................................................................. 3
2 FOOD, NUTRITION AND HIV/AIDS ..................................................................................................... 3
2.1 BASIC INFORMATION ON FOOD AND NUTRITION .................................................................................. 3
2.2 NUTRITION AND DISEASE ..................................................................................................................... 4
2.2.1 HIV & AIDS.................................................................................................................................... 5
2.3 THE LINK BETWEEN FOOD, NUTRITION AND HIV/AIDS...................................................................... 6
2.4 REQUIRED NUTRIENTS FOR GOOD HEALTH AND NUTRITION ............................................................... 7
2.4.1 Balanced Diet ................................................................................................................................. 7
2.4.2 Consequences of nutrient deficiencies .......................................................................................... 10
2.4.3 Non-nutritive components of foods ............................................................................................... 11
3 NUTRITION COUNSELING FOR PEOPLE LIVING WITH HIV/AIDS......................................... 12
3.1 TIPS FOR EFFECTIVE COUNSELING ..................................................................................................... 13
3.2 COUNSELING PLWHA ON HOW TO TAKE CARE OF THEMSELVES ..................................................... 13
3.3 NUTRITIONAL COUNSELING FOR CAREGIVERS OF PLWHA ............................................................... 13
4 NUTRITIONAL CARE AND SUPPORT FOR ADOLESCENTS AND ADULTS WITH HIV/AIDS
15
4.1 OVERVIEW ......................................................................................................................................... 15
4.1.1 Assessing Body Weight ................................................................................................................. 16
4.1.2 Assessing Micronutrient Deficiencies........................................................................................... 17
A. CARE AND SUPPORT FOR ADULTS AND ADOLESCENTS WITH HIV/AIDS.................................................... 18
B. CARE AND SUPPORT FOR PREGNANT AND LACTATING MOTHERS WITH HIV/AIDS .................................... 20
5 FOOD AND NUTRITIONAL CARE AND SUPPORT FOR CHILDREN WITH HIV OR BORN
TO HIV-POSITIVE MOTHERS ...................................................................................................................... 21
5.1 RECOMMENDATIONS FOR FEEDING CHILDREN BORN TO HIV POSITIVE MOTHERS IN
RWANDA ....................................................................................................................................................... 21
5.2 FEEDING OPTIONS FOR INFANTS BORN TO HIV POSITIVE MOTHERS............................. 23
5.2.1 INFANTS 0 - 6 MONTHS ............................................................................................................. 23
5.2.2 Children aged 6 to 24 months....................................................................................................... 31
5.3 MANAGEMENT OF LACTATION PROBLEM S.......................................................................... 32
5.3.1 MECHANISM FOR MILK PRODUCTION.................................................................................. 32
5.3.2 Management of cracked nipples ................................................................................................... 32
5.3.3 Management of breast engorgement............................................................................................. 33
5.3.4 Management of mastitis or abscess .............................................................................................. 33
5.3.5 Management of “NOT ENOUGH MILK SYNDROME” .............................................................. 34
5.3.6 Management of a child who cries persistently.............................................................................. 34
5.3.7 Management of inverted nipples................................................................................................... 35
5.4 NUTRITION CARE AND SUPPORT FOR CHILDREN INFECTED WITH HIV/AIDS .............. 35

iii
 5.4.1 MAJOR NUTRITIONAL PROBLEMS OF HIV-INFECTED CHILDREN.................................... 35
6 FOOD AND NUTRITIONAL CARE AND SUPPORT FOR PLWHA TAKING MEDICATION .. 37
6.1 ANTIRETROVIRAL THERAPY, FOOD AND NUTRITION ......................................................................... 37
6.2 INTERACTIONS BETWEEN ARV AND OTHER DRUGS WITH FOOD AND NUTRITION .............................. 38
7 FOOD SECURITY FOR HOUSEHOLDS AFFECTED BY HIV/AIDS ............................................. 41

8 MONITORING AND EVALUATION OF THE IMPLEMENTATION OF GUIDELINES ............ 42

8.1 OBJECTIVES OF MONITORING AND EVALUATION ............................................................................... 42
9 REFERENCES AND RESOURCES....................................................................................................... 45

ANNEX I: ESSENTIAL NUTRIENTS, THEIR FUNCTIONS AND LOCAL FOOD ANNEX

SOURCES ................................................................................................................................... 48

ANNEX 2: MAINTAINING WEIGHT........................................................................................................ 51

ANNEX 3: NUTRITIONAL ASSESSMENT TOOL FOR PLWHA......................................................... 53

ANNEX 4: BODY MASS INDEX TABLE: ADULTS AND ADOLESCENTS........................................ 54

ANNEX 5: FOOD SAFETY AND PERSONAL HYGIENE ...................................................................... 55

ANNEX 6: NUTRITIONAL MANAGEMENT OF SYMPTOMS ASSOCIATED WITH HIV/AIDS .. 56

ANNEX 7 : COPING WITH COUGHS, COLD AND FEVER .................................................................. 57

ANNEX 8 : COPING WITH DIARRHEA ................................................................................................... 58

ANNEX 9: INDIVIDUAL EVALUATION FORM FOR REPLACEMENT FEEDING OPTIONS

FOR HIV-POSITIVE MOTHERS ........................................................................................... 59

ANNEX 10: ALGORITHM FOR COUNSELING OF HIV-POSITIVE MOTHERS ON INFANT

FEEDING .................................................................................................................................... 60

ANNEX 11: FOOD AND NUTRITION IMPLICATIONS AND SOME SIDE EFFECTS OF
MEDICATIONS USED TO TREAT COMMON INFECTIONS .......................................... 61

ANNEX 12: FOOD AND NUTRITION IMPLICATIONS AND SOME SIDE EFFECTS OF ARV
DRUGS ........................................................................................................................................ 62

ANNEX 13: SCHEMATIC PRESENTATION FOR FEEDING A CHILD AGED 0-24 MONTHS........ 64

ANNEX 14: PREPARATION OF ARTIFICIAL MILK .............................................................................. 65

ANNEX 15: FOLLOW-UP OF A HIV-POSITIVE WOMAN AND HER CHILD.................................... 66

ANNEX 16 : FOLLOW-UP PLAN FOR CHILD UNDER ARV TREATMENT. ...................................... 69

ANNEX 17. MINIMUM FOOD PACKAGE FOR NUTRITIONAL CARE AND SUPPORT OF
PEOPLE (INCLUDING CHILDREN) LIVING WITH HIV/AIDS IN FOOD INSECURE
HOUSEHOLDS .......................................................................................................................... 70

ANNEX 18: SOME RECIPE SUGGESTIONS ............................................................................................. 77

iv
ACRONYMS AND ABBREVIATIONS

ABC Abstain-Be Faithful-Use Condoms

AFASS Acceptable, Feasible, Affordable, Sustainable, and Safe
AIDS Acquired Immune Deficiency Syndrome
ANC Antenatal Care
ARI Acute Respiratory Infection
ART Antiretroviral Therapy
ARV Antiretroviral
BMI Body Mass Index
CIAT Centro Internacional de Agricultura Tropical
CNLS Commission Nationale de Lutte contre le SIDA
FANTA Food And Nutrition Technical Assistance Project
FAO Food and Agriculture Organization of the United Nations
FP Family planning
GAM Global Acute Malnutrition
GDP Gross Domestic Product
GoR Government of Rwanda
HAART Highly Active Antiretroviral Therapy
Hb Hemoglobin
HIV Human Immunodeficiency Virus
IDD Iodine Deficiency Disorders
IEC Information, Education, and Communication
IMCI Integrated Management of Childhood Illnesses
IU International Units
IYCF Infant and Young Child Feeding
M&E Monitoring and Evaluation
MAP World Bank Multi-country HIV/AIDS Program
MICS Multiple Indicator Cluster Survey
MINISANTE Ministère de la Santé (Ministry of Health)
MTCT Mother-to-child transmission (of HIV)
NGO Non-governmental organization
ORS Oral Rehydration Solution
PACFA Protection and Care of Families Against HIV/AIDS
PLWHA People Living with HIV/AIDS
PMTCT Prevention of mother-to-child transmission (of HIV)
PRSP Poverty Reduction Strategy Paper
RDA Recommended Daily Allowance
RCQHC Regional Center for Quality Health Care (Kampala, Uganda)
RDHS Rwanda Demographic and Health Survey
RNTWG Rwanda Nutrition Technical Working Group
SAM Severe Acute Malnutrition
STI Sexually Transmitted Infections
TB Tuberculosis
TBA Traditional Birth Attendants
TRAC Treatment and Research AIDS Centre
UNAIDS United Nations HIV/AIDS Program
UNDP United Nations Development Program
UNICEF United Nations Children’s Fund

v
USAID United States Agency for International Development
VCT Voluntary Counseling and Testing
WFP World Food Program
WHO World Health Organization

vi
GLOSSARY

Absorption The process by which nutrients cross the gastrointestinal cell

membranes into the blood system to be utilized by the body.
AIDS Acquired Immunodeficiency Syndrome. A group of diseases caused by
HIV.
Antiretroviral A treatment regime for HIV with antiretroviral drugs
Therapy (ART)
Antiretroviral The name given to a group of drugs that act on the HIV virus and
prevent it from reproducing itself in the body.
Candidiasis Also called candidosis. Infection with a fungus of the genus Candida
that usually occurs in the skin and mucous membranes of the mouth,
respiratory tract, or vagina but may invade the bloodstream, especially
in immuno-compromised individuals.
Constipation A condition when the bowels do not function properly and a person has
difficulty in passing stools (defecating). This may be caused by a diet
low in fiber or be a symptom of illness or a side-effect of medicines.
Counseling Counseling is a dialogue between a client and a care provider aimed at
enabling the client to cope with stress and take personal decisions
relating to their condition, i.e., HIV/AIDS. The counseling process
includes the evaluation of personal risk of HIV transmission and the
facilitation of preventive behavior
Dehydration The excessive unhealthy loss of water and salts from the body, often
during diarrhea.
Diarrhea The frequent passing of watery feces (stools) - at least three in a day
Digestion The process by which food is prepared (broken down or decomposed) in
the digestive tract releasing nutrients for absorption
Healthy and Consuming the required quantities and varieties of food in sufficient
balanced diet quantities to meet daily energy and nutrient needs. The food should
consist of staples (cereal), vegetables, legumes, animal products, fruits,
nuts and fats/oils.
Household Food A situation whereby every person, at all times, have physical, social and
Security economical access to sufficient, safe and nutritious food to meet their
nutrient needs for an active and healthy life.
Immune system All the mechanisms that act to defend the body against external agents,
particularly microbes (viruses, bacteria, fungi and parasites.
Malnutrition An abnormal physiological condition caused by deficiencies, excesses
or imbalances in energy, protein and/or other nutrients. Malnutrition in
this publication refers to: a) lack of food energy (undernutrition); and b)

vii
 lack of nutrients.
Micronutrients The vitamins, minerals and certain other substances that are required by
the body in small amounts.
Nausea A feeling of disquiet in the stomach.
Nutrients The nutritional substances contained in food and released during
digestion.
Nutrition The science of food and how it is utilized by the body for growth, work,
play, sustain health and resist diseases.
Nutrition The education of individuals, families and communities encouraging
education them to select the food they consume in order to achieve optimum
health.
Opportunistic An infection with a microorganism that does not ordinarily cause
infection disease, but that becomes pathogenic in a person whose immune system
is impaired, as by HIV infection.
Oral A liquid substance administered to people to restore fluids and mineral
rehydration salts lost during diarrhea. An ORS can be prepared by mixing salt, sugar
solution (ORS) and water or making some light porridge using cereals such as rice and
maize or diluting the ORS powder from a package in drinking.
Palliative drugs Drugs which moderate HIV symptoms and help a person to feel better
without treating the HIV infection itself.
PLWHA A general term for people infected with HIV, whether or not they are
showing any symptoms of infection.
Positive living An approach to life whereby people with HIV/AIDS maintain a positive
attitude towards themselves, take action to improve their situation,
continue to work and lead a normal life and approach the future
positively with hope and determination and not with despair,
depression, guilt and self pity.
Refined cereals Foods containing cereals such as wheat, rice or maize that have been
processed to remove all or part of the husks. Refined foods are low in
fiber and generally contain less micronutrients than whole foods.
Staple foods Foods that form the main part of the diet, usually cereals such as maize,
rice, wheat and millet or root crops, such as yams, cassava and potatoes.
Virus Infectious agent (microbe) responsible for numerous diseases in living
beings. It is an extremely small particle and, in contrast with bacteria,
can only survive and multiply within a living cell at the expense of that
cell.
Vitamins A group of naturally occurring substances that are needed in small
amounts (micronutrients) by the body to maintain health

viii
1 INTRODUCTION

1.1 Background

Magnitude of HIV/AIDS in Rwanda

According to DHS (2005) the sero-prevalence is 3% at the national level, with a 7.3%
prevalence in urban areas and a 2.2% prevalence in rural areas. The effect of HIV/AIDS has
been enormous on families, communities and the country. AIDS is expected to increase the
country’s already high under-five child mortality of 203 per 1000 live births (UNICEF 2005).
By 2001, an estimated 264,000 children orphaned by AIDS were living in Rwanda, and life
expectancy had declined from 54.9 to 37.6 years (USAID 2003). Table 1.1 highlights some of
the epidemiological statistics related to HIV/AIDS in Rwanda.
Table 1.1 HIV/AIDS Epidemiological Statistics
Indicator Statistic
HIV prevalence (number of cases) 906,000
Annual deaths from AIDS 49,000
New HIV cases annually 80,000
Annual pregnancies, HIV+ women 40,000
Perinatal HIV infections per year 11,904
% HIV+ persons with TB 60%
Children orphaned by AIDS 260,000
Source: Government of Rwanda (2003)

Key social and economic sectors have lost members of their prime labor force to HIV/AIDS,
and as infection rates rise, the effects of the pandemic are beginning to have a negative
impact on food security, nutrition, and household coping strategies. Food insecurity increases
vulnerability to diseases and malnutrition, and reduces the body’s immunity and ability to
fight opportunistic infections. HIV/AIDS, both a cause and consequence of food insecurity,
undermines the livelihoods and resilience of many people in the country.

1.2 Malnutrition in Rwanda

For the past two decades, malnutrition and micronutrient disorders have been problematic in
Rwanda, contributing to high levels of morbidity and mortality, particularly among children
and women, as well as to poor health and low work capacity, learning disabilities, mental
retardation, and blindness.

Since the 1994 war, the population has become increasingly mobile, with large segments of
the population moving to the cities, particularly Kigali. Women head approximately 38% of
households, and thousands of children are growing up with neighbors, relatives, or on the
street, where they may be vulnerable to sexual and other abuses, poor health and
malnutrition.

The results of various surveys undertaken in the country, show that the rate of chronic
malnutrition is 45% among children under five years old with a higher proportion (56%)
suffering from anemia (Hb<12g) (RDHS, 2005). These data suggest that malnutrition and
micronutrient deficiencies are public health problems in Rwanda.

1
Like HIV/AIDS, malnutrition also compromises the immune function and thus increases
susceptibility to severe illnesses and reduces survival. Since HIV/AIDS weakens infected
individuals, resulting in reduction of labor capacity, agricultural production and household
incomes, which in turn results in household food insecurity. In this way, HIV/AIDS limits the
capacity of affected households to acquire adequate food or quality care, and to adopt
appropriate health and nutritional responses to the disease. Consequently, providing quality
care and support for people living with HIV/AIDS (PLWHA) includes addressing their
nutritional needs. Providing nutritional care and support has been shown to be an effective
strategy in mitigating the effects of HIV/AIDS and should therefore be an integral component
of a comprehensive care package.

1.3 National Response to HIV/AIDS and Malnutrition

The GoR has demonstrated a strong commitment towards controlling the HIV/AIDS
pandemic. The National AIDS Control Commission (CNLS) released a new Strategic
Framework to Combat HIV/AIDS, 2002–2007, which addresses the full spectrum of
HIV/AIDS prevention, care, treatment and mitigation. This Strategic Framework was
prepared in a participatory manner, with input from public officials, NGOs, PLWHA, church
groups, youth clubs, women’s organizations and private sector groups.

In 2002, the CNLS and the Treatment and Research for AIDS Center (TRAC) assumed
responsibility for implementing the National HIV/AIDS Strategy. The CNLS is mandated by
the President to integrate all sectors in the national response to HIV/AIDS, whilst TRAC
focuses on HIV/AIDS surveillance, treatment, and clinical care and support. The National
Care and Treatment Plan for HIV/AIDS, developed in June 2003 with support from the
William J. Clinton Foundation, outlines a vision and objectives for a national comprehensive
treatment and care system for HIV/AIDS in Rwanda.

A wide range of bilateral, multilateral and NGO partners contribute resources, direct
assistance and capacity building in the field of HIV/AIDS in Rwanda. The GoR has secured
significant funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria and the
World Bank’s Multi-Country HIV/AIDS Program (MAP). Apart from the Global Fund and
MAP funds, the United States Government currently is the largest donor to HIV/AIDS
programs in Rwanda.

1.4 Rationale for the Guidelines

Rwanda has adopted policies and guidelines related to HIV/AIDS prevention and treatment
but these do not specifically address issues of nutritional care and support for PLWHA. To
date, initiatives to provide such care and support, such as those undertaken by NGOs and
AIDS service programs, are limited in scope and coverage and are not harmonized. As such,
additional guidance is needed to fill this gap. These Guidelines for Food and Nutritional
Support and Care for PLWHA will enable programs and services to provide consistent and
sound recommendations to PLWHA and their caretakers, and contribute to greater awareness
of the importance of nutritional care and support in mitigating the impact of HIV/AIDS.

2
1.5 Purpose of the Guidelines

The Guidelines present the actions that service providers need to take in order to provide
quality care for and support to PLWHA at various contact points. The Guidelines address the
specific needs of different populations of HIV/AIDS infected/affected people, such as adults,
adolescents, pregnant and lactating women, children and antiretroviral therapy (ART) clients.
The Guidelines do this by providing practical recommendations for food and nutritional
support within household, hospitals and health facilities.

The Guidelines also explain how to address the nutritional aspects of HIV-related conditions,
illnesses and infections. Food requirements of PLWHA are described, and recommendations
are provided on foods, feeding and eating practices to meet these requirements. Finally,
recommendations are provided for the use of food aid in home-based care, hospital setting
and health centers.

1.6 Target groups

The Guidelines are targeted at providers of care and services for PLWHA in Rwanda:
• Health service providers and extension workers, including those involved in
testing, counseling, diagnosis, treatment and home-based care;
• Community-based organizational staff working with PLWHA;
• Planners in health, social, educational and nutrition services, who will develop
local Guidelines for nutritional care and support for PLWHA;
• International and national agency staff, who support national and community-
based programs for PLWHA;
• Research and training institutions like the NUR, KHI, ISAE, ISAR, etc.).

1.7 How to Use the Guidelines

The Guidelines provide a general approach to meet a variety of situations found in Rwanda.
Each service provider will need to adapt the recommendations to the local context or to the
individuals to whom the services are being offered.

The Guidelines can be used to:

• Create messages that advocate good nutrition for all, but particularly for PLWHA;
• Develop more detailed and specific operational Guidelines and materials to
communicate to caregivers and PLWHA;
• Provide nutritional and dietary counseling to PLWHA;
• Design monitoring and evaluation systems for nutritional components of HIV/AIDS
programs/interventions.

2 FOOD, NUTRITION AND HIV/AIDS

2.1 Basic Information on Food and Nutrition

Food provides the energy and nutrients that humans need to stay alive, move and work; build
new cells and tissues for growth, maintenance and repair; resist and fight infections.

3
Nutrition refers to how food is utilized by the body for growth, energy, reproduction and
maintenance of health. Foods contain different nutrients (Annex 1).

Good nutrition is essential for:

• Growth, development, replacement and repair of cells and tissues;
• Production of energy for warmth, movement and work;
• Carrying out digestion, metabolism and maintenance;
• Protection against disease and recovery from disease.

Nutrients are essential for health and include water, macronutrients (carbohydrates, proteins,
and fats), and micronutrients (vitamins and minerals).

Water is a key nutrient, found in all foods. About two-thirds of the body is water.

Macronutrients are nutrients that are needed in large amounts, such as carbohydrates (found
in sweet potatoes, Irish potatoes, rice, maize, and cassava), proteins (found in meat, poultry,
fish, eggs and dried peas and beans) and fat or lipids (such as oil, butter, fatty cheese, and
avocadoes).

Micronutrients are essential nutrients which are needed in very small amounts. These are
the vitamins (found mainly in colourful fruits and vegetables, whole grains, meat and fish)
and minerals (found mainly in meat, fish, poultry, whole grains, dark green leafy vegetables,
and dried peas and beans). Both macro- and micro-nutrients are required in the right amounts
and combinations for the body to function properly.

Calories are the amounts of energy in food that provides the body with the fuel it requires to
function and fight disease.

2.2 Nutrition and Disease

An optimal diet plays a major role in
Nutrition is the science of food and how it is preventing disease and recovering from
utilized by the body for growth, work, play, many diseases. As with any illness, the body
and to sustain health and resist diseases. requirements for more energy are greater
than when the body is healthy.

4
 ‘A healthy lifestyle includes adopting
healthy and balanced dietary practices
necessary to lengthen & improve
quality of life.’

A healthy life style and nutritionally sound diet, early treatment of infections, and recovery
after infection can limit weight loss and reduce the negative effects of future infections.

2.2.1 HIV & AIDS

Acquired Immune Deficiency Syndrome (AIDS) is a disease caused by a retrovirus known as

the Human Immunodeficiency Virus (HIV), which attacks and impairs the body’s natural
defense system against disease and infection. Because an HIV-infected person’s defense
system is impaired, other viruses, bacteria and microorganisms can cause opportunistic
infections such as diarrhea, pneumonia, tuberculosis and oral thrush, which further weaken
the body.

As the body’s immune system weakens, the increased number and frequency of infections
place extra demands on the immune system and increase the body's need for energy and other
nutrients. As a result of frequent illnesses and malnutrition, the body gradually becomes
weaker; weight loss or wasting becomes a serious problem, and diarrhea and other infections
occur more often and last longer.

There is no cure for HIV/AIDS. Some therapies can prevent, treat or cure many of the
opportunistic infections and relieve the symptoms associated with them. Antiretroviral drugs
attack the virus and may slow the weakening of the body’s immune system, but they do not
cure the disease.

In Rwanda, as in most developing countries, HIV is mostly transmitted to adult through

sexual contact with an infected person. Women are more vulnerable to HIV infection than
men due to the physiology of their reproductive organs.

Children are also at risk because HIV can be transmitted from a mother to a child during
pregnancy, labour and delivery or through breastfeeding. Because the virus can be
transmitted from mother to child through breast milk and breastfeeding, HIV positive

5
mothers need information to make an informed choice about feeding their infants. The risks
to an infant from not breastfeeding, especially in resource-poor settings where there is limited
money to buy breast milk substitutes, inadequate hygiene and access to potable water, and
other constraints, must be weighed against the risks of HIV/AIDS transmission from mother
to child due to breastfeeding.

2.3 The Link between Food, Nutrition and HIV/AIDS

Nutrition and HIV/AIDS are strongly

An HIV infected individual is more at risk interdependent. Malnutrition can both
for malnutrition for the following reasons: contribute to and result from the progression
• Loss of appetite of HIV. This relationship between
• Poor food absorption malnutrition and HIV/AIDS creates a
• Chronic infections and illness vicious cycle: HIV weakens the immune
system, which in turn leads to more
infections (Figure 1). Infections increase energy needs and at the same time cause anorexia,
as indicated in Table 2. Heightened infections (in number and severity) lead to loss of
appetite, resulting in inadequate food intake, and eventually malnutrition. Malnourished
persons are at greater risk of infections, creating more vulnerability to HIV, and so the cycle
continues.

Figure 1: The Cycle of Malnutrition and Infection in the Context of HIV/AIDS

Poor Nutrition
(Weight loss, muscle wasting, weakness,
fatigue, and micronutrient deficiencies)

Increased Nutrition Needs

(Due to malabsorption & Impaired Immune
System
decreased food intake; to HIV (Poor ability to fight HIV
address infections and viral
and other infections)
replication)

Increased vulnerability to Infections

(Diarrhea, TB, colds, faster progress to
AIDS)

Source: FANTA, 2002.

Whilst HIV may take years to progress to AIDS, the negative effects of the virus on
nutritional status can occur early in the course of the disease. Weight loss, a decrease in lean
muscle tissue and damage to the immune system, are more common for adults but they are
also prevalent in children infected with HIV. A PLWHA is more at risk of malnutrition
because of reduced food intake, poor absorption, changes in the body’s metabolism, chronic
infections and illnesses, anorexia or loss of appetite, diarrhea, fever, nausea and frequent
vomiting, thrush, and anemia (see Annex 6 for advice on the nutritional management of these
symptoms).

6
Table 2. Energy needs by phase of disease
Population Group HIV phase Energy requirement

Adults Asymptomatic 10% increase

Symptomatic 20-30 % increase
Pregnant/lactating Asymptomatic 10% increase
women*
Symptomatic 20-30% increase
Children Asymptomatic 10% increase
Symptomatic (with no weight 20-30% increase
loss)
Symptomatic (with weight loss) 50-100% increase

* This is in addition to extra energy, protein and micronutrients required by pregnancy or lactation.
Source: WHO (2003).

Although treatment for opportunistic infections and ART may help a PLWHA to maintain
better health status, they may also influence eating practices and subsequently have a
negative effect on nutrition. Taking measures to ensure an adequate nutrient intake,
following sound hygiene practices, and treating illnesses quickly and effectively are
necessary to reinforce the positive effects of HIV/AIDS treatment.

2.4 Required Nutrients for Good Health and Nutrition

2.4.1 Balanced Diet

A well balanced diet, that is, a

correct combination of different No single food contains all the nutrients the body
kinds (energy-giving, body-building needs in the right quantities and combinations
and protective foods) and amounts of (except for breast milk, which contains the perfect
food and drink consumed, is the key combination of nutrients and ideal quantity needed
to a stronger immune system. for a baby during the first six months of life). A
nutritious diet provides a variety of foods in
Water is an important component of adequate quantities and combinations to supply
the body and necessary for many of essential nutrients on a daily basis.
its functions. A safe water supply is the most basic of all nutritional needs. Safe drinking
water should be boiled for three minutes, cooled, and stored in clean, covered containers. If
possible, drinking water should be filtered to prevent the transmission of illnesses.

7
) Energy-giving foods

Carbohydrates are mainly found in

staples and sugars. Staples form the
main part of the meal and are cheap
and readily available, provide
energy, they may also provide some
protein, vitamins and fiber. In
Rwanda, the main staples include
bananas (ibitoke), Irish potatoes
(ibirayi), sweet potatoes (ibijumba),
cassava (imyumbati), flour (amafu -
made from maize, sorghum and
millet), yams and rice.

Staples alone cannot provide enough of all the nutrients the body needs and should therefore
be eaten in combination with other foods.

Sugars and Sugary Foods are another source of energy, but usually lack other beneficial
nutrients. These foods include honey, jam, table/tea sugar, cakes and biscuits, which are
more common in urban centers of Rwanda, and are generally expensive. Sugary foods also
include most artificial fruit juices and sodas. Some fruit juices are too acidic and may be too
strong for the stomach of a sick person. Natural sugars in fruit and mild fruit juices are better
tolerated.

Fats and Oils are rich sources of energy. People generally need fats in smaller quantities than
carbohydrates. Fats also add flavour and taste to food, and thus stimulate the appetite. They
build body cells, help body processes, and are essential for absorption and utilization of fat-
soluble vitamins. Excessive consumption of fat, however, may contribute to diarrhea in
PLWHA. Vegetable oils are obtained from corn, simsim, sunflower, cottonseed, and palm.
Animal sources of oils and fats include lard, butter (including ghee), margarine, cheese, meat,
poultry and fish (including fish oil). Vegetable sources of oils and fats include avocados and
groundnuts.

8
) Body-building foods

Protein is essential for cell growth and

repair. Proteins support the function and
formation of the general structure of all
tissues, including muscles, bones, teeth,
skin and nails. Protein is also the basic
element of the substances that make up the
immune system. Unless the body receives
enough calories and protein in the diet, it
will break down its protein stores (usually
muscles) to make up for the lack of
calories. A balance of calories and protein,
along with other nutrients, is necessary to
maintain a strong defense against
Plant proteins include beans and peas of infections and weight loss.
different varieties, groundnuts, soyabeans and
some vegetables. Plant proteins also provide vitamins and minerals.

Animal proteins most commonly available in Rwanda are meat, poultry, milk (including
cheese, yogurt and fermented milks), fish and eggs. Others include isenene (grasshoppers)
and white ants. Animal proteins are sources of high quality protein, and also provide vitamins
and minerals. Animal products also provide additional energy.

) Protective foods

Vitamins and Minerals are required for the immune system to function optimally, and for
cell growth, maintenance and repair. Some vitamins are water-soluble (e.g., the vitamin B
group and vitamin C) and should be consumed regularly since the body does not store them
but excretes any excess intakes. Other vitamins (A, D, E, K) are fat soluble, and are stored for
longer periods in the body. Vegetables containing fat-soluble vitamins should be eaten or
prepared with some oil/fats to improve their absorption and use by the body. In terms of
public health, the important minerals include iron, selenium, zinc, iodine and calcium.

Vegetables add taste, flavor and

color to meals. Common
vegetables in Rwanda include:
dodo, cassava leaves, spinach,
pumpkin leaves, carrots,
isombe, and green peppers. Red
and yellow vegetables contain
pro-vitamin A substances called
beta-carotenes. In many cases,
vegetables are available
seasonally, which means that
quality and prices can vary
considerably throughout the
year. Vegetables provide
nutrients as listed in Annex 1[0].

9
 Fruits in Rwanda come in a variety of forms. Deep yellow or orange-colored fruits such
as banana, avocadoes, mangoes, and papayas are rich in vitamins, particularly beta-
carotenes, which are transformed into vitamin A in the body. Oranges, lemons, and other
citrus fruits, as well as strawberries, guava, maracuja, pineapple and gooseberries are rich
sources of vitamin C. Like vegetables, many fruits in Rwanda are seasonal.

In Rwanda, fruits and vegetables are considered as the most cost-effective and practical
means to improve availability and intake of micronutrient-rich foods for many communities.
PLWHA who are deficient in micronutrients can improve their nutritional status by
consuming larger amounts and varieties of micronutrient-rich foods or by taking special
supplements. Keeping small domestic animals (e.g., chickens, rabbits, goats) for household
consumption can improve the availability of foods rich in protein, fat, as well as
micronutrients such as iron and vitamin A.

Research on the impact of micronutrient supplements on HIV infection is still ongoing

especially with respect to zinc and selenium. At present, there is no conclusive evidence to
show that micronutrient supplementation effectively reduces morbidity and mortality among
HIV-infected adults. Therefore, health service providers should follow the current WHO
recommendations to promote and support adequate dietary intake of micronutrients at
recommended dietary allowance (RDA) level.

For TB clients being treated with isoniazid, Vitamin B6 (10 mg daily) supplementation is
recommended. Vitamin A supplementation for all children and especially for children of HIV
infected mothers reduces illness, particularly diarrhea. High dose vitamin A supplements are
also recommended for mothers immediately after delivery and for infants 6 months and older.

In Rwanda, regular access to micronutrient supplements may be difficult for PLWHA due to
lack of availability and associated high cost. For this reason, improving dietary intake of all
nutrients is the most practical solution, especially for PLWHA.

Dietary fiber is important for the digestive system, and to ensure the proper movement of the
bowels. Children or people with poor appetites should consume foods rich in fiber with
caution since too much fiber may fill up their stomachs quickly, before they have consumed
enough energy and other nutrients. The best sources of fiber are vegetables and fruits.

2.4.2 Consequences of nutrient deficiencies

a) Macronutrient deficiencies can be caused by reduced food intake, poor absorption of

nutrients, and changes in metabolism that affect cell growth and other processes and immune
system reactions. Known as Protein Energy Malnutrition (PEM), macronutrient deficiencies
are evidenced by weight loss and wasting. In order to avoid PEM, a PLWHA should consume
more food than persons who are not infected. (See Table 2).

b) Deficiencies in essential micronutrients can have devastating effects on health status,

resulting in impaired immune system which leads to inability to fight infections, and thus
placing a PLWHA at a much higher risk of infections. Current WHO recommendations to
promote and support adequate dietary intake of micronutrients at recommended dietary
allowance (RDA) level should be encouraged for all PLWHA.

10
2.4.3 Non-nutritive components of foods

There are some non-nutrient chemical substances in plants (phytochemicals) such as tannins
and phytates that may prevent or reduce the prevalence of some diseases such as cancer, but
also prevent absorption of some micronutrients (iron, zinc, etc.). They contain protective,
disease–preventing compounds, and thus help to protect the body from cell damage caused by
chronic disease. Although more is yet to be discovered about these phytochemicals, there is
strong evidence that consuming a wide variety of plant foods such as garlic, onions, leeks,
cabbage, tomatoes, peppers, carrots, celery, parsley, oranges, lemons, limes, grapefruits,
berries, watermelon, beans, whole grains, seeds, herbs and spices, and green tea, amongst
others, may be very beneficial for improving health.

Tea, coffee and other caffeinated drinks such as sodas should be avoided, or taken in
moderation since they can interfere with absorption of nutrients and may interact poorly with
medicines.

Alcohol should either be avoided or taken in small quantities since it can damage the ability
of the body to fight disease. Some alcoholic beverages like beer contain sugar and yeast that
may be harmful to a sick person. Alcohol can create dangerous side effects if consumed along
with medications.

ACTIONS FOR SERVICE PROVIDERS

Promoting Nutritious Foods

In all contacts with PLWHA, service providers should:

• Provide counselling on nutrition and healthy feeding/eating practices to ensure that
PLWHA consume a balanced diet, manage illnesses and monitor and maintain nutritional
status
ƒ Encourage PLWHA to increase the amount of food they eat to make sure they get
more calories for energy. The amount of food consumed should be greater than their
usual amount of food to increase energy intake.
ƒ Assist PLWHA to increase the frequency or number of times they eat during the day.
Eating small, frequent meals is easier on the digestive system than a few large, heavy
meals. Persons with poor appetites should be advised to eat as often as possible, even
if the amount at each meal is small.
ƒ Encourage PLWHA to increase nutrient-rich foods, especially fruits, vegetables,
beans and whole grains, in their meals.
ƒ Recommend the consumption of foods fortified with micronutrients (vitamin A,
vitamin C, iron, folic acid, the B vitamins, and vitamins K, and E), if they are
available and accessible.
ƒ For specific deficiencies, advise PLWHA to take nutritional supplements to
complement the diet.
• Work with their families/households to plan for lean periods or hungry season, when food
supplies may be lower than usual or non-existent. During these periods, some family
members may reduce portion sizes, skip meals or eat inferior foods.

11
• Investigate all options for obtaining sufficient amounts of foods, ensuring that all required
nutrients are available, and promoting eating habits that improve nutrition.
• If necessary, demonstrate to clients how to prepare foods.

3 NUTRITION COUNSELING FOR PEOPLE LIVING WITH

HIV/AIDS
Counseling is an integral part of nutritional care and support of PLWHA. Positive, effective
counseling can result in improvements in nutrition related behaviour and help improve the
quality of life of PLWHA. Since most service providers in Rwanda are not trained
counselors, they need to develop basic interviewing skills so as to meet the goal of
counseling.

The goal of counseling is to help the client to:

• Assess his/her nutrition and food needs clearly in the context of his/her living situation.
• Identify the alternatives s/he has for correcting a problem or meeting a need.
• Address the constraints that may affect choice of alternatives.
• Make the best choice depending on his/her circumstances.
• Understand the pros and cons of each option and take responsibility for choices made.
• Express his/her innermost fears/feelings or concerns and develop the confidence to
address them.
• Develop a positive attitude towards achieving behavioral change.

Counseling can be either

Individual (through one-to-one
contact) or Group (of value if
the HIV status of most members
of the group is unknown).

Interviews/assessments should
be conducted in a non-
judgmental manner to elicit
more accurate responses (e.g.,
be aware of body language, both
yours and the person you are
counseling). The service
provider should be an active
listener, sensitive to changes in
mood, and communicating
nutrition information according
to the client’s needs and in
Information for counseling on food choices, consideration of what s/he
maintaining weight, safe food handling and proper already knows.
hygiene can be found in the Annexes.

12
3.1 Tips for Effective Counseling

• Always treat the client with respect.

• Listen carefully and actively to the client's situation/concerns.
• Avoid insincere sympathy. Empathise with the client's situation.
• Ask open-ended questions to elicit detailed responses and dialogue with the client.
• Praise and affirm the things that the client is doing right.
• Allow the client the opportunity to make decisions on her/his choices on the way
forward.
• Maintain professional conduct and emotional stability during all counseling sessions.
• Maintain privacy and confidentiality.
• Always be conscious of issues that may require referral.

3.2 Counseling PLWHA on How to Take Care of Themselves

Counsel the client as follows:

• Your body needs extra rest. Try to sleep for eight hours every night. Rest
whenever you are tired.
• Try not to worry too much. Stress can harm the immune system. Relax more.
Relax with people you love, your family, your children and your friends. Do
things you enjoy, e.g., listen to music or read a newspaper or a book.
• Be kind to yourself. Try to keep a positive attitude. Feeling good is part of being
healthy.
• Take light exercise. Choose a form of exercise that you enjoy.
• Find support and get good advice. Ask for advice from health workers. Many
medical problems can be treated.
• Ask for help and accept help when it is offered.
• Stop smoking. It damages the lungs and many other parts of the body and makes it
easier for infections to attack your body.
• Alcohol is harmful to the body, especially the liver. It increases vulnerability to
infection and destroys vitamins in the body; under the influence of alcohol you
may forget to practice safe sex.
• Avoid unnecessary medicines. They often have unwanted side effects and can
interfere with food and nutrition. If you do take medicines, read the instructions
carefully.

3.3 Nutritional Counseling for Caregivers of PLWHA

The person caring for a PLWHA may be a member of the family or, if the person lives alone,
a neighbour, relative or friend. Caring for a PLWHA involves meeting the needs of the sick
person and balancing these with the needs of other members of the family. Too much help
may be overprotective and take away the dignity, independence and self-respect of the person
with HIV/AIDS while too little help may not provide the support that is needed to ensure that
the person eats well and has the strength to resist infection. Procuring, preparing, cooking and
serving food for a person with HIV/AIDS demands considerable time, energy and resources.

13
Counsel the caregiver as follows:
• Spend time with the PLWHA. Discuss the foods they need to maintain and gain
weight and manage their illness. Learn what kind of foods they like and do not like.
Involve them in planning their meals.
• Monitor their weight. If possible, weigh them regularly and keep a record. Look out
for signs of unexpected weight loss and take action.
• Check the medicines they are taking. Read the instructions to find out when they need
to be taken, what foods to be avoided and any side effects.
• Be encouraging and loving. If people want to have food of their choice at any time of
the day, try to get it for them. They may suddenly stop liking a food, refuse what has
been prepared and want something different. They are not trying to be difficult. These
sudden changes in taste are a result of their illness.
• Be firm about the importance of eating and encourage them to eat frequently, but do
not force them to eat. Giving them too much food at one time may cause them to
refuse or vomit.
• If they are too sick to leave their beds, make sure that they have something to drink
and a snack nearby.
• Keep a watchful eye. Look around to see if the house is clean, that there are no
hygiene problems and there is enough food.
• If the sick person lives alone, invite them to join your family for a meal. Encourage
others in the community to visit them and invite them out.
• Advise the caregiver to take care of him/herself, get enough rest and have the
appropriate information and support to carry out their difficult task.
• Inform the caregiver of the following:
• HIV/AIDS is not spread by food or water.
• HIV/AIDS cannot be spread by sharing food, dishes or cooking utensils such as
cups, plates, knives and forks with a person who is HIV positive.
• Touching another person, hugging, shaking hands or holding other people in a
normal way cannot spread HIV/AIDS. There is no need to avoid body contact
with a person living with HIV/AIDS.

ACTIONS FOR SERVICE PROVIDERS

Nutrition Counseling for PLWHA

I. Create an environment conducive for counseling.

• Make space available for counseling, taking care to guarantee privacy
• Develop a positive attitude. Remember people are able to make choices that fit
with their circumstances; they just need support.
• Set aside the time for counseling to avoid rushing
• Establish rapport with the client
• Welcome the person
• Greet the person in a kind and friendly way
• Introduce yourself and let the client also introduce him/herself
• Ask general questions about the client's feelings, health and welfare.
• Reassure clients of confidentiality

14
II. Assess the needs of the client, and provide information to help decision-making.
• Make the client feel comfortable to tell his/her story and express needs and wants
during the counseling session.
• Empathise with clients, especially those in shock, depressed or frightened.
• Pay attention to special needs or fears of some groups, e.g., pregnant women,
adolescents, and school children.

III. Help the client to make practical decisions.

• Request the client to use the information provided to make the correct decision.
• Help the client come up with a plan that will work given the context.
• Review cultural values, traditions and beliefs as well as any family or community
factors that may affect his/her decision.
• Help the client make informed decisions. For example, use a list of local,
affordable and accessible foods to show the client how much extra food he/she
needs to eat.
• Make sure the client understands who else is affected by his/her decisions and
what implications these decisions may have.
• When giving information that encourages behavioral change, suggest one change
at a time, and make sure that the recommendations are realistic given the client's
circumstances.

IV. Support the client to implement the decisions they have made to address
nutrition concerns.
• Help the client recall what has been discussed and agreed upon to ensure they
know exactly what they need to do. You may role-play if necessary.
• Help the client build confidence that they know how to implement the decisions
made.
• Help the client consider who else may support the decisions made.
• Praise and reaffirm those things that the client is doing right, to help build self-
confidence and motivation.
• Work out a follow-up plan with the client, including return dates and where to
seek support in case there is need.

4 NUTRITIONAL CARE AND SUPPORT FOR ADOLESCENTS AND

ADULTS WITH HIV/AIDS

4.1 Overview

Adults and adolescents with Weight loss and wasting are strongly associated with
HIV/AIDS may suffer from loss of poor health outcomes for PLWHA. Smaller amounts
appetite, difficulty in eating and of weight loss during short periods of time, or any
poor absorption of nutrients, which loss of important lean muscle tissue can increase a
may result in wasting, or the loss person’s risk for illness or other complications. Most
of body weight and lean tissues. wasting can be prevented or reduced by maintaining
The HIV/AIDS wasting a healthy, balanced diet that meets the body’s
syndrome, a major cause of changing needs. Maintaining weight is a key
morbidity and mortality in component of any health care plan for PLWHA.

15
PLWHA, refers to a loss of 10% or more of a person’s original weight before illness, plus
chronic diarrhea, weakness, or fever.

Good nutritional status is important for the well being of everyone, as well as the birth
outcomes of pregnant women, and for the survival and development of children. Because of
the increased energy demands of HIV/AIDS, pregnant and lactating mothers with HIV/AIDS
are at a higher risk of malnutrition. They will need nutritional advice and additional food to
minimize the negative impact of HIV/AIDS on their health, to delay disease progression, and
to maintain productivity.

Older adults have special nutritional problems due to the effects of aging, such as the loss of
teeth, fragile gums, poor absorption, poor appetite and chronic diseases. HIV/AIDS infection
makes these problems worse.

Adolescents’ nutrient needs are high because of their rapid growth and development. Young
girls who become pregnant are at particular risk of developing nutrient deficiencies if they
have HIV/AIDS. They need additional nutrients for their babies’ growth as well as their own
and to boost their immunity.

4.1.1 Assessing Body Weight

For adults and adolescents, measurements of weight and height give us important information
about a person’s nutritional status when considered together. There are several different
anthropometric measures, but the most common for adults are: BMI, and MUAC. For
adolescents, weight for height (W/H) is used. There are currently no specific anthropometric
measurements for PLWHA; consequently, these common measurements are used.

Symptomatic adults and adolescents with HIV/AIDS may display the following:
• Weight loss;
• Changes in body shape, e.g., changes in fat deposits and lean muscle;
• Frequent illnesses due loss of resistance to infection.

The best way to assess weight loss is by using a calibrated scale. However, if no scales are
available, weight loss can be recognized by changes in the fit of clothing or appearance. If
possible, PLWHA should be weighed every month and records of weight should be kept to
detect changes as quickly as possible. Weight should be assessed using the same scale, if
possible, wearing no shoes or heavy clothing. A form for monitoring weight over time is
found in Annex 3.

Body Mass Index (BMI) is an indicator of adult nutritional status that reflects thinness, by
adjusting bodyweight for height (Annex 4). BMI is calculated as shown below:

BMI =Weight (kg)/Height (m2)

Cut-off points for BMI for adults, including PLWHA:

• 18.5 – 25 : person is at healthy weight
• 16 – <18.5 : person is moderately malnourished
• < 16 : person is severely malnourished

16
Although the cut-off points are based on European populations, Rwanda has adopted BMI as
a method to assess nutritional status of adults. BMI can only be used in adults who have
reached full maturity but cannot be used for adolescents, who are still growing or for
pregnant women. For individual assessment and follow-up of adolescents and pregnant
women, weight gain or loss is the preferred indicator for nutritional status.

Measuring body composition involves measurements of different parts of the body with
skinfold caliper. Nutritional edema is swelling caused by an excessive amount of fluid in
the tissues of the body, often as a result of severe protein energy malnutrition. It’s occurrence
in adults and adolescents is rare, and will only occur in severe food shortages. A finding of
edema may also be due to other medical causes, and should therefore be interpreted with
caution.

PLWHA have should be weighed at least once a month with calibrated scales and record their
weight in order to detect changes as soon as possible. Table 3 provides the criteria for
classification of nutrition status that can be used by service providers when classifying their
clients.

Table 3: Criteria for classification of nutritional status

Severe malnutrition Moderate malnutrition
Adults Children and Adults Children and
Adolescents Adolescents
BMI < 16 16 - 18.5
W/H < 70% 70%-80%
MUAC
(children1-5 years) - < 11cm 11- 12.5cm
MUAC (pregnant and
breast- feeding women) < 16cm 16 - 18.5cm
Edema Yes Yes
Source: RCQHC/FANTA/LINKAGES (2003).

4.1.2 Assessing Micronutrient Deficiencies

Deficiencies in micronutrients can occur with or without other signs of malnutrition. The
outcomes of micronutrient deficiencies can be serious, increasing the risk of morbidity and in
severe cases, resulting in permanent disabilities (such as blindness) or death. Clinical signs of
deficiencies may not be evident for a long time after the deficiency has begun. However, an
analysis of the diet can give an indication of potential micronutrient deficiencies. Since
cooking and storage practices may also destroy micronutrients, or limit their availability in
foods, food preparation techniques and storage facilities should also be examined. Some signs
of key micronutrient deficiencies are provided in Annex 1. The main diagnosis criteria for
key micronutrients are shown below:

Vitamin A Deficiency (VAD)

• Low intake of vitamin A and pro-vitamin A rich foods for prolonged periods of time.
• In advanced cases, presence of disorders such as night blindness (reduced ability to see
in dim light) and xeropthalmia.
• Low plasma or serum concentration of retinal: <0.35 µmol/L.

17
Iron deficiency (ID)
Tests for assessing iron status include serum ferritin, transferrin receptor, zinc
protoporphyrin and Hb. Often, with exception of Hb, these tests are not available. Some
of the criteria for assessment and cut-off points include the following;
• Low bioavailable iron diet or marked blood loss.
• Low Hb: <10.5 g/dL and hematocrit value less that about 3 times the Hb value.
• Low red blood cell volume (MCV): <72 fL
• Low serum ferritin: <12 ng/mL.
• Low serum transferrin receptor <28.1 nmol/L.
• A large proportion of small red cells and generally pale red cells under the microscope.
• Large normal color red cells suggest deficiencies due to folate and/or vitamin B12.
• High zinc protoporphyrin (ZnPP): >40 µmol/mol of Heme.

Iodine deficiency disorders (IDD)

• Intake of non-iodized salt or poorly iodized salt
• High intake of goitrogens (e.g., foods that inhibit iodine absorption such as cassava).
• Low urinary iodine levels (iodine intake during the preceding meals): <50 µg/L.
• The presence of visible enlarged thyroid gland (goitre), which indicates a history of
previous or ongoing iodine deficiency.

Selenium deficiency
• Low intake and poor bioavailability diets.
• Low plasma or serum concentration of selenium: <0.58 µmol/L.

Zinc deficiency (ZID)

• Low intake and poor bioavailability diets,
• Functional improvement of taste following zinc supplementation.
• Suggestive clinical signs such as delayed sexual maturation and dermatitis;
• Low plasma zinc levels: <10.7 µmol/L.

ACTIONS FOR SERVICE PROVIDERS

A. Care and Support for Adults and Adolescents with HIV/AIDS

I. Support adults living with HIV/AIDS to access information on nutrition and

HIV/AIDS.

• Increase your own knowledge by attending HIV/AIDS related meetings/seminars

• Read latest guidance/reports materials on nutrition and HIV/AIDS for HIV/AIDS
infected adults.
• Refer adults with HIV/AIDS to support groups
• Assist in linking them to organizations/services where they can get food and
nutrition information or support depending on their situation.

II. Encourage adults with HIV/AIDS to periodically check their nutritional status.

• Monitor weight every month

18
 • Monitor anemia by assessing and recording hemoglobin levels
• Keep accurate personal health records for service providers
• Record complete diet over one week to assess nutritional needs

III. Support adults with HIV/AIDS to know how to eat balanced diets and maintain
or gain weight.

• Counsel PLWHA to increase their energy and nutrient intake, through:

o Increasing the amount and the frequency of eating meals rich in energy,
protein and micronutrients.
o Eating nutritious snacks between meals as often as possible
o Consuming foods that are fortified with essential micronutrients like vitamins
A, C, E, K and iron, zinc and selenium
• If a PLWHA has weight loss of more than 10% of their initial body weight,
complete the form to monitor food intake over one week, and review his/her
history of illness. Based on the findings, make recommendations for action for
gaining weight and preventing further weight loss
• If hemoglobin (Hb) levels are less than 11 mg/dl, encourage the client to seek
medical care immediately. S/he should be advised to eat a diversified diet and
consume micronutrient-rich foods
• Assist the client to make meal plans using a variety of locally available foods to
improve nutrient intake. Consider food accessibility, availability, affordability,
preservation and storage, tastes and preferences of the client, and whether the
client is taking medication or has symptoms that could interfere with eating
• Advise caregivers of PLWHA to regularly supervise their meals to ensure that
they are eating a balanced and nutritious diet.

IV. Support adults with HIV/AIDS to address conditions that may negatively affect
their physical health.

• Advise the client to seek prompt treatment for HIV-related conditions, particularly
those that affect eating such as fever, oral thrush, ulcers/sores in the mouth,
diarrhea, vomiting, nausea and loss of appetite
• Advise the client to avoid (or minimize) practices that may interfere with food
intake, absorption and utilization such as drinking alcohol, smoking or chewing
tobacco, using illegal drugs, and drinking too much tea, coffee or soda
• Ensure food and water safety, follow personal hygiene measures (wash hands with
soap and water before eating or handling food, thoroughly cook animal products,
boil drinking water, wash fresh fruits and vegetables in clean water and store food
appropriately (see Annex 5)
• Develop an exercise plan with the client, to make sure s/he has regular physical
activities to prevent loss of muscle tone, strengthen the body and stimulate
appetite. If loss of muscle tone persists despite regular exercises, the client should
be referred for medical help
• If taking ARV drugs, assess whether the changes in body shape or muscle tone are
a side effect of the drugs. Clients should seek medical advice
• Get de-worming treatment (for all household members, except women in the first
trimester of pregnancy) twice/year.

19
 • Always practice safer sex (ABC -Abstain, Be faithful, or use Condoms) to avoid
re-infection.
• Follow guidelines for the nutritional management of symptoms associated with
HIV/AIDS (see Annex 6, 7 and 8).

B. Care and Support for Pregnant and Lactating Mothers with HIV/AIDS

I. Ensure that pregnant and lactating mothers seek PMTCT counseling in health
facilities for early diagnosis of HIV infection.

• Counsel pregnant and lactating mothers to prevent infection or re-infection by

having safer sex
• Counsel women on the need to seek early and periodic antenatal and postnatal
care and to comply with antenatal care (e.g., frequent weight monitoring – ideally
once a month, micronutrient supplementation, STI and hemoglobin screening).
• Encourage them to use free PMTCT and ART services available in Rwanda.

II. Support pregnant and lactating mothers to monitor and improve their
nutritional status.

• Ensure that every pregnant mother has an antenatal health card to record weight
changes and other information during pregnancy
• Explain the importance of regular weighing to determine whether a mother is
gaining enough or losing weight
• Determine the nutrition and nutrition-related factors influencing loss or failure to
gain weight for pregnant and lactating mothers.
o Once the causes of weight loss have been identified, work together to identify
the best course of action to promote weight gain.
o Refer pregnant women gaining less than 1 kg per month from the second
trimester for appropriate care and treatment.
o Refer lactating mothers who loose >10% of their body weight (within a period
of six months) for appropriate care and treatment.
• Screen all HIV positive mothers for anemia (check paleness of inner eyelids and
palms or for hemoglobin levels).
o Refer women with any clinical signs of anemia (or Hb <11mg/dL) to a Health
Centre for appropriate intervention, including increased consumption of iron
rich and iron-absorption enhancing foods.

III. Support pregnant and lactating mothers to consume enough food to meet their
energy and nutrient needs.

• Seek nutritional support that is more specific to the needs of the client (see Table
2).
• Encourage pregnant and lactating mothers to consume a variety of micronutrient-
rich foods.
• Ensure that mothers receive 200,000 UI of vitamin A within six weeks after
delivery.

20
IV. Support pregnant and lactating mothers to address conditions that may
negatively affect their physical and nutritional health

• Advise pregnant and lactating mothers to:

o Prevent parasite infestation and food-borne illnesses by following
recommended food safety and hygiene practices such as washing hands
regularly with soap and water, safely disposing of feces, and drinking safe
water.
o Seek early treatment for any infections (fever and diarrhea) to minimize the
impact on nutritional status.
o Encourage pregnant and lactating mothers to take measures to prevent malaria
(always sleep under treated bed nets), and to get prompt treatment for malaria
o Maintain regular physical activity and exercise to improve appetite and to help
build body mass.
o Avoid overworking and stress. Heavy physical labor, worry and fatigue
increase susceptibility to illness, so mothers should have adequate rest, time
for relaxation, and assistance to carry out strenuous tasks.
o Use reproductive health services where mothers can get family planning
support as well as counseling on STI, HIV/AIDS prevention and infant
feeding.
o Always practice safe sex (ABC -Abstain, Be faithful, or use Condoms) to
avoid re-infection.

V. Partner support for pregnant and lactating mothers

• Encourage partner involvement during ante-natal consultations and counseling for
VCT/PMTCT
• Counsel couples on family planning and safe sex practices
• Counsel couples on infant feeding options and encourage them to make a choice
together on their preferred option
• Enlist partner involvement in adherence to the selected feeding option
• Enlist partner support to minimize overworking and assist to carry out strenuous
tasks and create or sustain a stress-free environment.

5 FOOD AND NUTRITIONAL CARE AND SUPPORT FOR

CHILDREN WITH HIV OR BORN TO HIV-POSITIVE MOTHERS

5.1 RECOMMENDATIONS FOR FEEDING CHILDREN BORN TO HIV

POSITIVE MOTHERS IN RWANDA

Breast milk is the best food for infants and young children. It supports optimal growth and
development and protects the child against diseases. Although breast-feeding is one of the
modes of transmission of HIV/AIDS from mother to child, the risks of death in children
related to malnutrition and infectious diseases (diarrhea, respiratory infections) are higher
than those related to HIV transmission to children through breast-feeding in developing
countries. Artificial feeding (animal milk, infant formula, or milk powder) predisposes
children under 5 to a greater risk of morbidity and mortality, particularly in Rwanda, where

21
more than 60% of the rural populations live under the poverty line, clean water is not easily
accessible, and prevalence of chronic malnutrition is 45%. In this context, the following
infant feeding recommendations are made for the care and support of children born to HIV
positive mothers in Rwanda.

HIV negative mothers and those whose HIV status is unknown must be encouraged to
practice exclusive breast-feeding from birth to the age of 6 months, continuing thereafter
with breastfeeding and appropriate complementary feeding up to 2 years.

For HIV infected mothers, the following infant feeding options are recommended:
• When replacement feeding is not acceptable, feasible, affordable, sustainable and safe,
exclusive breastfeeding is recommended for the first 6 months with early cessation at 6
months. At the fourth month, prepare the child for weaning by giving breast milk in a cup
up to 6 months. At age of 6 months, provide appropriate breast milk substitutes with safe
and appropriate complementary foods up to the age of 24 months.

• When replacement feeding is acceptable, feasible, affordable, sustainable and safe,

replacement feeding (infant formula or animal milk) is recommended for the first 6
months continuing thereafter with the addition of safe and appropriate complementary
foods. Supplement the child with 50,000 IU of vitamin A during the first 6 months after
birth.

• For a child of 6 to 24 months who has been exclusively breastfed in the first 6 months,
replace breast milk with other milk (infant formula, animal milk prepared at home or
heat-treated breast milk) and provide appropriate locally available complementary foods
(2-3 meals a day from 6 to 8 months, 3-4 meals a day plus snacks from 9-24 months).
Give the child 100,000 IU of vitamin A once every 6 months and other micronutrients
according to the needs.

• For a child of 6 to 24 months who has been on replacement feeding for the first 6 months,
continue replacement feeding with locally available complementary foods (2-3 meals a
day from 6 to 8 months, 3-4 meals a day plus snacks from 9-24 months). Provide 100,000
IU of vitamin A once every 6 months and other micronutrients according to needs.

All HIV infected mothers must receive counseling on available infant feeding options,
benefits and risks associated with each option and guidance in selection of the appropriate
choice. The mothers should make an informed choice based on full information about the
risks and benefits of each option. Support whatever option the mother chooses to prevent
malnutrition and psychological consequences between the mother and the child.

HIV positive mothers who don’t breast feed or have stopped breastfeeding before 6 months
must continue with medical and nutrition-specific follow-up with their children for at least
2 years, to ensure that the child receives appropriate care and support.

HIV positive women must have access to information, at the family planning services and
counseling, on safe sexual practices. HIV positive pregnant women should increase their
food intake by supplementing their meals with an extra meal and one snack in order to try to
meet the additional nutrient needs due to pregnancy and HIV infection.

22
For infected children with or without symptoms, increase the quantity, frequency and the
energy density of meals given every day. For children on antiretroviral treatment, provide
their caregivers with the knowledge and skills necessary for the nutritional management of
drug and food interactions in HIV/AIDS therapy and adjust the diet in accordance to type of
treatment and associated side effects (Annex 11 and 12).

Due to the difficulties in cleaning feeding bottles and teats, increased risk of death in children
related to poor preparation of artificial milk and economic constraints of rural households,
replacement feeding should be done with cups rather than bottles. Because of the risks related
to replacement feeding, demonstrations on replacement feeding must be done on an
individual, one-on-one basis.

5.2 FEEDING OPTIONS FOR INFANTS BORN TO HIV POSITIVE MOTHERS

5.2.1 INFANTS 0 - 6 MONTHS

Annex 13 gives a schematic diagram on the infant and young children feeding aged 0 to 24
months.

OPTION 1: EXCLUSIVE BREASTFEEDING

This is the practice of feeding an infant only breast milk, without adding any other food or
drink including water. The exception that is allowable is providing the infant with drops or
syrups consisting of vitamins, mineral supplements or medicine. Exclusive breastfeeding
must be initiated within 30 minutes of birth and continued for the first 6 months of life. At the
4th month, an HIV positive mother should prepare her child for early cessation by giving
breast milk in a cup until the child is 6 months old.

Advantages of exclusive breastfeeding

• Provides all the nutrients required by an infant of up to 6 months

• Protects the child against infections like diarrhea and acute respiratory infections;
• Decreases the risks of HIV transmission from breastfeeding
• Delays the return of fertility helping to space the next pregnancy
• Provides bonding and contact between the mother and the child
• Is less expensive than replacement feeding

Disadvantages of exclusive breastfeeding

• HIV/AIDS transmission risk through breast milk during the first 6 months. This risk
increases if the mouth, throat or the intestines of the child are irritated or if the mother’s
breasts are infected (abscess, cracked nipples, mastitis, and engorgement).

Appropriate attachment and positioning of baby to the breast

• The areola is more visible above the mouth of the child than below
• The mouth is largely open
• The lower lip is turned towards outside

23
• The chin of infant touches the breast
• The cheeks of infant are rounded or flattened against the breast
• The breast seems to be round during the suckling
• When the child takes the breast well, milk runs out easily in the mouth of the child
• The baby suckles slowly, deeply with pauses.

Good attachment position Poor attachment position

Good position Bad position

EARLY CESSATION

The following steps should be taken when making the transition from exclusive breast-
feeding to replacement feeding:
• Gradually reduce breast-feeding frequency and lengthen breastfeeding intervals
• Beginning the month before you are scheduled to wean your child, cut out one or more
night feeds
o Reduce the number of night feedings gradually so that by 4 months he or she is
not waking often to feed
• Lengthen the time interval between breastfeeds to once every 4-6 hours
• Teach your baby to drink breast milk from a cup
• Cup feed expressed milk in-between feeds
• Try not to breast feed the infant to sleep, lay the baby down, pat, calm, carry, or rock the
baby to sleep

24
Actions for healthcare providers

• Explain to the mother the disadvantages and risks associated with mixed feeding
• Help the mother to initiate breast feeding within 30 minutes of delivery
• Help the mother to adopt a good position for breast-feeding and good attachment
• Help the mother to manage issues related to breast-feeding
• Help the mother to increase and maintain production of milk by breastfeeding on demand
• Provide treatment for breast diseases and oral candidiasis of the child
• Refer mothers to counselors in case of the mother’s or child’s problems
• Counsel the mother to avoid risky behavior to prevent mother-to-child transmission
(prevent and treat opportunistic infections, STI and use condoms)
• Prepare the mother and child to for cessation between 4 to 6 months
• Provide recommended amount of vitamin A at 6 weeks post-partum
• When possible, combine appointments with those for immunization and post-natal care
• Provide family planning counseling and services

OPTION 2: Expressed, heat-treated breast milk

This is the method whereby breast milk coming from an HIV positive mother is treated by
heat to destroy the HIV virus in the milk. It is the same technique that is referred to as
pasteurization.

Advantages of the method

• Kills the virus in milk of an HIV positive mother

• Preserves the main nutrients in breast milk
• Allows the mother to continue with breast-feeding after 6 months
• Decreases the possibility of engorgement and mastitis
• Less expensive and risky than artificial milk
• Does not require laboratory equipment for preparation - requires simple jars, cup,
charcoal or wood

Disadvantages of the method

• Heat-treatment reduces the level of anti-infective factors in breast milk

• Requires a lot of time for the mother or the person in charge
• Creates stigma around the woman in the community
• Mothers require a lot of support and motivation to face difficulties
• Cool the milk for 10-20 minutes before giving to the child
• Require the availability of materials for preparation (e.g., wood, charcoal, cups)

Materials required

• Jar or container fit to express and store the breast milk (bottle with a cover, a cup with a
cover)
• Two sauce-pans (a small one to heat expressed milk and another to boil water)

25
• A cup and a spoon to feed the child
• Fuel to boil water
• Water, soap and a bucket to clean utensils

Techniques

• Expression of milk:
Milk expression is done with a manual breast pump, electric pump or with hand (manual
expression) for women without breast pumps. The latter is the one described and is
applicable for by women in the rural area.
o Wash both hands with soaps and clean water
o Sit or take a comfortable position
o Prepare a clean container near the breast
o Gently massage breast in a circular motion
o Position the thumb on the upper edge of the areola and the first two fingers on the
underside of the breast behind the areola (opposite the thumb). The other fingers
will support the breast
o Press the thumb and forefinger slightly from inside towards outside (don’t press
too far to avoid blocking lactiferous canals)
o Press on the lactiferous canals (feeling of peanuts) next to the areola on different
sides and press continually
o Express one breast for 3-10 minutes until the flow of milk diminishes, then go to
the other breast and vice versa
o Avoid sliding the fingers on the skin which may hurt the breast
o Avoid pressing the nipple by itself, for milk is not concentrated there
o If the expression of milk must be done by someone else, it is recommended to
wear a glove to avoid contamination

• Treatment of expressed breast milk by heating

o Find a jar or bottle of 50 to 150 ml (example of jar; bottle of mayonnaise) with
cover, two saucepans and wash properly
o Express milk into the jar/bottle and close tightly
o Boil clean water in the big saucepan

o Place the closed jar containing breast milk on the inner surface of the small
saucepan and add the boiled water

26
 o Leave the jar of milk in the hot water for 20-30
minutes (until it is not too hot (between 56-630C) to
put your fingers in the water)
o Remove and cool before giving milk to the child by
using a cup.

Actions for care providers

• Explain to the mother the advantages, disadvantages and risks and challenges related to
the method as well as other feeding options available
• Discuss the implications of this method on her and the child (stigma)
• Make available the necessary materials for demonstrations - show mothers how to
express breast milk manually or by using a pump and feeding on the cup
• Inform the mother about the complexity of expressing breast milk and probable
complications
• Show the mother how to express and heat breast milk;
• Handle promptly breast problems
• Refer the mother to a support group in the community for help;
• Record the problems faced by the mother and her child in a follow-up document;
• This milk can be stored for 4 to 6 hours in a covered container at room temperature or in
the refrigerator for 72 hours.

Option 3: WET NURSES

This method involves the breast-feeding of the child by a woman other than its own mother
(grandmother, close relative or other volunteer). Traditionally, this method was practiced by
grandmothers or aunts when the mother is dead or absent.

Advantages

• Ideal for feeding an infant, because it provides the same advantages as breastfeeding by
the biological mother
• Provides protection against many diseases for the child
• Culturally acceptable in many regions
• Is cheaper than replacement feeding

Disadvantages

• Can be source of HIV/AIDS transmission from the wet nurse to child in areas of high
HIV/AIDS prevalence and where VCT is not part of routine exams and the wet nurse is
not aware of her status
• Risk of unwanted pregnancy for the child’s biological mother
• Can be a source of stigma for the mother in the community

27
Action for care providers

• Inform the wet nurse about the risks of HIV transmission to child and encourage her to
take an obligatory HIV test before she breast-feeds the baby (repeat test every 3 months
during the breast-feeding period)
• If the woman (wet nurse) is married, provide education to the couple on HIV transmission
risks through sexual intercourse
• Help the wet nurse to access and manage issues related to breastfeeding (engorgement,
mastitis, cracks, etc)
• Help the wet nurse to adopt a good position for breastfeeding
• Help the wet nurse to ensure a good attachment of the child to the breast
• Help the wet nurse to increase and maintain milk production
• Treat problems of breast early and oral candidiasis in the child
• Give the wet nurse her dose of vitamin A in their first 6 weeks of breastfeeding
• When possible, combine appointments with those for immunization and post-natal care

OPTION 4: BREAST MILK BANK

This method involves collecting milk from HIV negative women and making it available in a
warehouse called a milk bank. Milk banks have traditionally been used to supply babies with
special needs (premature, light weights, etc.) for a short period of time.

OPTION 5: REPLACEMENT FEEDING

Feeding infants who are receiving no breast milk with a diet that provides the nutrients
infants need until the age at which they can be fully fed on family food. During the first 6
months of life, replacement feeding should be an appropriate breast milk substitute. After 6
months, the appropriate breast milk substitute should be complemented by other suitable
foods. Replacement feeding should not be encouraged without taking into consideration the
AFASS conditions.

Appropriate replacement foods include; commercial infant formula and modified animal
milk. The preparation of these products is described in Annex 14.

Advantages

• There is no risk of HIV transmission to the child

Disadvantages

• Commercial infant formula is less easily digested than breast milk and lacks breast milk
protective immune factors
• Modified animal milk is difficult for infants to digest, does not contain all of the needed
nutrients in the appropriate proportions and quality (e.g., the proteins and fats in modified

28
 animal milk are inferior to those in breast milk) and has a higher sodium and calcium
content compared to human breast milk
• It is expensive in comparison to breast milk
• It carries an additional risk of infection and malnutrition if not prepared and used
correctly
• Can have dilution errors leading to malnutrition of the child
• Can reduce the bonding opportunities between mother and child causing a delay of
psychosocial stimulation
• High risk of contamination if hygiene conditions are uncertain, hence a higher risk of
diarrhea, malnutrition and death of the child
• Risk of early pregnancy of the mother if there is no family planning
• Can be a source of stigma to the mother in her community

Home prepared animal milk

Animal milk can be prepared (modified) at home and adapted in accordance to the infant’s
nutrient needs. These milks include those from cow, goat, sheep, camel, etc. and can be:
o Modified by adding water, sugar and other nutrients
o Powder milk (whole milk, cream milk)
o Non-modified fresh milk (whole)
o Condensed milk: is not good for infants and storage is difficult

Preparation of modified milk for a child between 0 to 6 months

Cow milk: 100 ml of cow milk + 50 ml boiled water + 10 g of sugar (2 pieces of sugar or
two full coffee spoons) or 2 volumes of milk + 1 volume boiled water + 2
pieces of sugar or 2 two full coffee spoons).
The mixture must be boiled before being given to the infant.

Goat milk: Same preparation as cow milk, but requires folic acid supplementation.

Sheep milk: Richer in fats and proteins than cow milk. Thus dilute as follows:
50 ml milk + 50 ml boiled water + 5 g of sugar.
Boil the mixture.

Actions for care providers

• Explain to the mother the advantages, disadvantages and risks related to bad application
of the method as well as other feeding options available
• Discuss the implications of using this method for the mother and the child (stigma)
• Help the mother to monitor the production of urine by the child to avoid dehydration. A
normal child urinates 5 to 6 times a day
• Refer the mother to a support group in the community for help
• Provide family planning (FP) services and advise on feeding of the mother

OPTION 6: ARTIFICIAL MILK

The preparation of artificial milk is described in Annex 14.

29
INDUSTRIAL PREPARATIONS FOR INFANTS

These are milk-based products or proteins of soya enriched with micronutrients given to an
infant. Generally, they are available in powder form to be dissolved or reconstituted in water.
There are generic forms for normal children and special preparations for premature babies.

Advantages

• No risk of contamination of HIV/AIDS after birth

• It is an option if the family meets all the AFASS conditions

Disadvantages

• Very expensive for a majority of mothers in rural area

• Can have errors of dilution
• High risk of contamination if hygiene conditions are uncertain, hence a higher risk of
diarrhea, malnutrition and death of the child
• Can reduce the bonding opportunities between mother and child causing a delay of
psychosocial stimulation
• Risk of early pregnancy of the mother if there is no family planning
• Can be a source of stigma for the mother in the community

Preparation

• Follow preparation instructions provided on the package in terms of quantity and quality
• Practice using household measures (i.e., utensils) with the mother to measure milk and
water if mother can not read
• Encourage the mother to feed the child with a cup instead of a bottle and teat

Actions for care providers on artificial milk

• Explain to the mother the advantages, the disadvantages and risks and challenges related
to nutritional value and bad application of the method as well as other feeding options
available
• Never demonstrate preparation of artificial milk in a group which can be construed as a
promotion of the products
• Discuss the implications of this method on her and the child (stigma)
• Evaluate the feasibility, acceptability, durability and safety (AFASS) conditions for this
method with the mother
• Show to the mother or her family how to clean the materials used to prepare the milk
• Ask the mother to practice preparing the milk to ensure that she understands (has
mastered) the procedure
• Give a dosage of vitamin A to the mother and the child within the first 6 weeks after
delivery
• Provide family planning (FP) services and advise on feeding of the mother
• Respect the international or national code on breast milk substitutes

30
5.2.2 Children aged 6 to 24 months

Milk is an important part of a child’s diet even after first 6 months of life and should continue
to provide at least half of the nutritional needs of the child between 6 and 12 months of age,
and, up to 40% for a child between 12 and 24 months. For HIV infected mothers early
cessation (shortened duration) of breastfeeding is recommended (by 6 months) to reduce the
risk of MTCT after delivery.

The mother should continue replacement feeding with an appropriate breast milk substitute
until the child is 24 months of age. In addition, complementary foods must be properly
prepared and varied. Meals should be given 2-3 times a day from 6 to 8 months and 3-4 times
a day plus snacks from 9-24 months.

If there are no available, feasible, affordable, sustainable and safe (AFASS) substitutes for
breast milk, replacement feeding must be based on properly prepared foods. Provide a variety
of foods in order to get an adequate amount of energy, protein and micronutrients. If possible,
other derivatives of milk like non-modified animal milk, full cream (whole) milk in powder,
or yogurt should be given as a source of protein and calcium. Other products like meat, liver,
and fish should be given as sources of iron and zinc. Fruits and vegetables are a good source
of vitamins and minerals. Micronutrient supplements may be provided according to the
child’s needs.

Table 4 below gives a summary of nutritional care and support for asymptomatic and
symptomatic infected children.

Table 4: Summary of nutritional care and support for asymptomatic and symptomatic
infected children.

Age Asymptomatic Symptomatic children

children On ARV Not on ARV
0-6 months Assessment of the Assessment of the Assessment of the
nutritional status nutritional status nutritional status

Exclusive breastfeeding in Exclusive breastfeeding in Exclusive breastfeeding in

the first 6 months the first 6 months the first 6 months
6-12 months Continuing breastfeeding Continuing breastfeeding Continuing breastfeeding

A meal of cereal and/or A meal of cereal and/or A meal of cereal pulp and
enriched vegetable plus enriched vegetable and enriched vegetable and
fruits fruits fruits

Vitamin A twice a year Vitamin A twice a year Vitamin A twice a year

and, if necessary, add and, if necessary, add and, if necessary, add
other multivitamins other multivitamins others multivitamins
12-24 month Continuing breastfeeding; Continuing breastfeeding; Continuing breastfeeding;
4-6 meals per day 5-7 meals per day 6-8 meals per day,
including snakes food including snacks between including between meals
between the meals meals

Vitamin A twice a year - Multivitamins - Multivitamins

and if necessary add

31
 others multivitamins
3-5 year 5-7 meals per day 5-7 meals per day 4 meals split per day
including snacks between including snacks between including snacks between
meals meals meals

Vitamin A twice a year Vitamin A twice a year Vitamin A twice a year

and if necessary add and if necessary add and if necessary add
others multivitamins others multivitamins others multivitamins
Child above 5 6-8 meals per day
years including snacks between
meals

Vitamin A twice a year

and if necessary add other
multivitamins
Source: Rwanda nutrition working group.
NOTE: The proposals are based on the increase nutrients needs.

5.3 MANAGEMENT OF LACTATION PROBLEM S

5.3.1 MECHANISM FOR MILK PRODUCTION

Milk is produced in the breast from the milk ducts and

then drained outside by lactiferous channels. At the
level of the areola, these channels grow bigger and
become joined at the nipple where milk accumulates
for nursing. When a child suckles, it stimulates the
mother’s brain which produces milk. Sight of the
child, his tears or even thinking about the child can
produce the same effects (the woman develops a
feeling of milk discharge). If the child does not suckle
on a regular basis, the volume of milk produced
decreases and eventually the breasts dry up.

5.3.2 Management of cracked nipples

Cracks on nipples can cause open wounds at the end of the nipple and pain during
breastfeeding. This can be caused by poor attachment and suckling position.

Actions for the healthcare provider

• Help the mother put the child on the breast in a good position with more areola (dark area
around the nipple) visible above the baby’s mouth than below
• Leave nipples free to air for a few minutes after nursing
• Do not wear tight bras
• Apply a drop of milk to nipples at the end of nursing to lubricate the nipple and reduce
the pain
• Do not wash nipples with soap or aggressive products or apply drugs on it -- use only
water

32
5.3.3 Management of breast engorgement

Engorgement is manifested by a feeling of heaviness, heat and pain in the breasts. They
become hard and swollen. This should not be confused with the feeling of the breasts being
full of milk.

Actions for service providers

Hot bottle Method:

• Take a bottle of 700 to 1000 ml with
a broad neck
• Fill it with hot water and empty it
thereafter
• Insert the nipple into the opening of
this bottle to stretch the nipple
• Hold the bottle without moving it
for 5-10 minutes. As it cools, a
vacuum is created in the bottle, the nipple is pulled in and milk is ejected;
• Repeat the process if necessary until the milk ducts are completely opened. This is
easier than manual expression, is less painful and makes breastfeeding easier.

Some health-providers recommend putting frozen ice cubes near the armpits for 15-20
minutes, 4 times a day to cool down the pain and the heat.

b) Restoring normal nursing

• Let the baby suckle as frequently as possible or continue to regularly extract milk to
avoid additional engorgement
• Ensure proper suckling and attachment position
• Gently massage the engorged areas towards the nipple
• Change position in order to empty all of the breast, especially parts where milk is
accumulated
• Avoid leaning forward because this may increase gravity and increase engorgement

5.3.4 Management of mastitis or abscess

Mastitis is an inflammation of a woman’s breast, usually as a result of bacterial infection that

causes fever; pain and swelling of the breast. If mastitis is not treated, the breasts can get
swollen and pus can accumulate within. This is called a “breast abscess”.

Actions for service providers

• Empty the infected breast as described above under engorgement

• Check if the liquid coming from the nipple is milk or pus - press on a piece of cotton; if
the liquid soaks into the cotton easily, it is milk; if it remains on the surface, it is pus. If
the breast is infected, the milk should not be given to the child
• Continue breast-feeding on the non-infected breast
• Put the mother on antibiotics and antipyretics (e.g., aspirin)
• Show the mother how to gently apply a wet piece of cloth on the breast to decrease pain

33
• If the abscess is confirmed, take her to the hospital for abscess drainage
• If the abscess is on both breasts, unblock as described above, advice the mother to heat
treat and cup feed expressed breast milk
• Help the mother to continue breast-feeding after healing

5.3.5 Management of “NOT ENOUGH MILK SYNDROME”

The causes of the “not enough milk syndrome” are: late breast-feeding initiation after birth,
nursing irregularly or for short periods and at fixed times, no nursing at night, bad positioning
of the baby at the breast, use of feeding-bottles, teats, lollipops and early introduction of other
foods, drinks (water or infusions etc). Lack of milk can also be as a result of a psychological
problem encountered by some women.

A lack of milk is evidenced through: passing of a low volume of concentrated urine (less than
6 times per day, yellow and strong odor); poor weight gain of the infant (less than 500
g/month and birth weight not doubled at two weeks); milk that does not discharge when the
mother tries to express or when the baby is placed on the breast; and the child does not
defecate frequently (and when they do it is hard and in small quantity).

Actions for service providers

• Advise the mother to eat and drink sufficiently and rest and relax as much as possible
• Breastfeed frequently, longer and upon request
• Improve the baby’s latch on the breast by adopting a good position
• Let the baby empty each breasts completely
• Breast feed exclusively until 6 months; other than breast milk do not give other food or
drink to the baby
• Do not use a feeding-bottle, lollipop or teat
• Help the mother rebuild self-confidence to increase her production of milk

5.3.6 Management of a child who cries persistently

Children generally cry due to hunger, discomfort (dirty, hot, cold, etc.) and illness or pain
(colic, otitis). This can make the baby refuse to suckle and is unable to sleep properly.

Actions for service providers

• Change the baby’s clothes, keep them warm or reduce their clothing depending on the
discomfort
• Advice the mother to breastfeed the baby in a good position
• Examine the child and refer for treatment if/when necessary
• Try putting the child in a different position that might relieve its pains (i.e., lay the baby
on the back, on the mother’s stomach, etc)

34
5.3.7 Management of inverted nipples

Actions for service providers

• Reassure the mother that she can still breastfeed her baby
• Explain to the mother that the nipples will be extended after delivery when the baby
suckles
• During the antenatal clinic, counsel the mother to pull and roll (using her fingers) the
nipples frequently especially after birth. Maximum effect occurs during the first 2 weeks
after delivery
• Encourage partner support in correcting inverted nipples
• If the inversion persists, the nipples can be suctioned using a syringe if inversion persists -
- this should be done at the hospital or health center

5.4 NUTRITION CARE AND SUPPORT FOR CHILDREN INFECTED WITH

HIV/AIDS

Malnutrition is frequently a problem with children infected with HIV/AIDS, non-infected

children born to HIV infected mothers or those who are not infected but sick or do not
receive enough food.

Like any other infection, HIV increases demand for macronutrients (proteins, carbohydrates
and lipids) and micronutrients (vitamins and minerals). In general, in rural areas where more
than half of population lives under the poverty line, parents are not able to provide adequate
quantities and quality of food to their children.

The current recommendation (WHO, 2003) is for an energy increase of 10% above the
normal needs for infected asymptomatic children in order to ensure growth, and development.
For infected symptomatic children or those suffering from loss of weight increase energy
requirements by 50 to 100% above the normal needs.

5.4.1 MAJOR NUTRITIONAL PROBLEMS OF HIV-INFECTED CHILDREN

Low birth weight: This is due to the high prevalence of premature deliveries and
inadequate intra-uterine growth seen in HIV-infected women and is
related to the severity of AIDS in the mother and micronutrient
deficiencies (common in HIV infected women).

Growth faltering: Growth faltering is also a symptom of HIV/AIDS infection in children

and results in growth failure in terms of height and weight gain. Non-
infected children with low birth weight born to infected mothers tend
to rapidly gain weight after birth. On the other hand, infected children
do not gain adequate weight and height or they gain weight very
slowly after birth.

In addition to Table 3, the following information can be used to classify nutritional status of
children:

35
 For children under 5 years old, some possible clinical signs of malnutrition are:
underweight, stunting, edema, thinning hair, loss of weight, skin wrinkles, anemia. An
assessment and classification of their nutritional status can be done using the following
anthropometric indices:

¾ W/A:
• < 65%: severe malnutrition (red strip)
• 65 - 85%: moderate malnutrition (yellow strip)
• > 85% : good nutritional state (green strip)

¾ W/H:
• <70%: severe malnutrition
• Between 70 - 80%: moderate malnutrition

For children aged between 5 and 15 years, their nutritional status and classification can be
done using the W/H anthropometric index:

¾ W/H:
• < 70%: severe malnutrition
• between 70 - 80% : moderate malnutrition

Major causes of nutritional problems (malnutrition)

• High viral load

• Existence and persistence of other diseases, i.e., diarrhea; and opportunistic infections
• Insufficient intake and an poor quality diet
• Influence of medication on appetite, absorption, utilization and metabolism of food

Actions for service providers

Guidelines on monitoring HIV-positive mothers and their children are given in Annex 15.

For infected children, actions should lead to:

• Improved nutritional status as shown by maintenance of weight, avoidance of weight loss,
and maintenance of muscular mass
• Reinforced immunity for resistance to infection and healing upon treatment
• Management of symptoms that could interfere with food intake

Care and support for severely malnourished children is a more complex situation. It
requires therapeutic feeding and should be done at a therapeutic nutrition service center by
qualified personnel. The therapeutic regimen should conform to the national protocol for care
and support for severe malnutrition or the WHO guidelines for management of severe
malnutrition. The steps of the protocol are summarized in the Rwanda National Protocol for
Food and Nutrition Care and Support for PLWHA.

36
6 FOOD AND NUTRITIONAL CARE AND SUPPORT FOR PLWHA
TAKING MEDICATION
6.1 Antiretroviral Therapy, Food and Nutrition

Increased access to ART by PLWHA in Rwanda is being achieved through a combination of

local, national and international efforts. Antiretroviral drugs have been shown to significantly
reduce the rate of replication of HIV in the body. However, ART is not required by all
PLWHA at all stages of infection, research is ongoing but most often ARVs are prescribed
when the virus has begun to cause damage to the immune system. WHO recommends ARV
treatment programs in resource limited settings to start ARV therapy for HIV infected
adolescents and adults when they have:

• WHO Stage IV of HIV disease (clinical AIDS), regardless of CD4 count;

• WHO Stages I, II, or III of HIV disease, with a CD4 count below 200/m3; or
• WHO Stages II or III of HIV disease with TLC below 1200/mm3.

ARVs are normally given to HIV

positive people based on CD4 decline
and a high viral load and clinical
symptoms of AIDS. These
medications do not cure the HIV
virus, but work to reduce the amount
of virus in the blood and help delay
the progress of the disease and
increases life expectancy improving
the quality of life. If the medications
are able to raise the CD4 count, it
means that they are working.

There are two classes1 of ARV drugs that are

commonly used:
1. Reverse transcriptase inhibitors (RTIs),
and
2. Protease inhibitors (PIs).

Each class of drug acts at a different stage in the replication of HIV. When HIV infects a cell,
the viral RNA converts to viral DNA and is copied into the host cell’s DNA by an enzyme
called reverse transcriptase. Then the viral DNA instructs the cell to make copies of HIV
genetic material. The protease enzyme assembles this copied viral genetic material into new
viruses, after which they are released from the cell to infect other cells.

RTIs operate early in the HIV life cycle to stop viral replication after HIV has infected a cell.
Two types of these drugs exist: non-nucleoside reverse transcriptase inhibitors (NNRTIs) and
nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) also called nucleoside
analogues. NNRTIs bind onto the reverse transcriptase enzyme and prevent the HIV RNA
1
A third class of ARV, fusion inhibitors, is seldom used in resource-limited settings; no fusion inhibitors are
included in the list of ARVs published by the World Health Organization (WHO) for resource limited settings.

37
from converting into DNA, thereby preventing it from being copied into the cell’s DNA.
NRTIs incorporate into the viral DNA and prevent it from producing copies of HIV. On the
other hand, PIs operate later in the life cycle of HIV, stopping the protease enzyme from
assembling new HIV material to be released to infect other cells.

In most cases, one ARV drug alone cannot stop replication of the virus. To optimize efficacy
and reduce the chances of drug resistance, ART usually involves the administration of more
than one ARV drug, a practice known as combination therapy or highly active
antiretroviral therapy (HAART). In Rwanda, the first-line HAART regimen for adults
and adolescents consists of stavudine, lamivudine, and nevirapine.

PLWHA must strictly follow treatment schedules for ART and other medications in order to
maintain the best possible health status. Non-adherence to treatment can have grave negative
implications for both individuals and their communities. For an HIV-infected individual,
interrupting ART or taking it incorrectly may lead to a substantial decline in health, increased
frequency of opportunistic infections, and faster progression of the disease. For the
community, non-adherence to treatment may lead to the development of drug-resistant strains
of HIV, which creates a greater number of PLWHA who cannot be effectively treated against
the disease.

Because ART usually involves a lengthy period of treatment and because side effects are
common, the risk of non-adherence to ART is high. Food and nutrition interactions with
ARV drugs can also affect PLWHA’s adherence to drug regimens resulting in difficulties to
follow drug schedules, taking incorrect doses, failure to follow other drug directions, or
stopping consumption of the drug altogether.

6.2 Interactions between ARV and other Drugs with Food and Nutrition

Interactions between ART and food can significantly influence the success of ART by
affecting drug efficacy, adherence to drug regimens, and the nutritional status of PLWHA.
Therefore, managing ART and food interactions is a critical factor in the extent to which
ART is effective in slowing the progression of HIV/AIDS and improving the quality of life of
the PLWHA.

Annex 12 provides information about food implications of the 13 approved ARVs and their
side effects.

1) Food can affect medication absorption,

Four principles for interactions between
metabolism, distribution, and excretion.
ARV drugs and food:
• Food can affect medication
Certain foods affect the efficacy of some
absorption, metabolism,
ARV drugs by affecting their absorption,
distribution, and excretion.
metabolism, distribution, or excretion. Food
enhances the efficacy of some drugs and • Medications can affect nutrient
inhibits the efficacy of others. Consequently, absorption, metabolism,
some ARV drugs should be taken with food, distribution, and excretion.
others on an empty stomach, and others with • The side effects of medication can
or without specific types of foods. negatively affect food consumption
and nutrient absorption.
• Combination of medication and
certain foods can produce
unhealthy side effects.
38
2) Medications can affect nutrient absorption, metabolism, distribution and excretion.

Certain ARV drugs influence the body’s use of nutrients by affecting absorption, metabolism,
distribution, or excretion. Elevated blood cholesterol and triglyceride levels can increase the
risk of coronary heart disease. Such interactions may call for nutritional responses, such as
reduced consumption of saturated fats, if other food options are available.

3) Medication side effects can negatively affect food consumption and nutrient absorption.

Side effects of some medications can lead to reduced food intake or nutrient absorption that
worsens weight loss and nutritional problems experienced by PLWHA. Nausea, taste
changes, and loss of appetite may reduce food consumption, while diarrhea and vomiting
may increase nutrient losses.

Changing the diet may help PLWHA to manage certain ARV side effects and reduce negative
effects on their nutritional status. For example, if a particular medication causes nausea, it can
be taken with a light meal or with dry, salty foods. If it causes diarrhea, a PLWHA can drink
plenty of fluids and eat foods rich in energy and other nutrients to reduce the impact of
diarrhea on health and nutritional status (Annex 6, 7 and 8).

ARVs can also have unhealthy side effects that are not related to food consumption or
nutrient absorption but call for food and nutritional responses.

4) Combinations of medication and certain foods can produce unhealthy side effects.

PLWHA need to be made aware of the foods contra-indicated with the drugs they are taking
so that these foods can be avoided. For example, consuming alcoholic drinks while taking
ARV medication can cause pancreatitis, an inflammation of the pancreas that can be serious
and even fatal. In some cases, the food interactions of ARV combinations are different from
those of the individual drugs (Annex 12).

All combination ART regimens have food and nutrition implications, though the specifics
and the severity of ART-food interactions vary. Food and nutrition interactions of each drug
in the regimen must be considered separately, as well as any interactions that may be
different due to the drug combination. For those taking multiple ARV drugs (combination
therapy), one ARV may need to be taken with food and one without food, requiring the drugs
to be taken at separate times. Drug and food timetables need to be established to meet these
requirements.

When planning management of drug-food interactions, service providers must obtain

complete and up-to-date information from drug product information, medical facilities,
publications, or other sources. Table 5 shows the interactions that can occur between drugs
in Rwanda’s First Line HAART regiment, and food and nutrition, and offers
recommendations to manage them.

39
Table 5: Recommendations for managing food and nutrition interactions of Rwanda’s First
Line ARV Combination Regimen: stavudine (d4T), lamivudine (3TC), and
nevirapine (NVP).

Medication Food Foods to Possible Side Effects

(abbreviation) Recommendations avoid
Stavudine Can be taken Limit the Nausea, vomiting, diarrhea,
(d4T) without regard to consumption peripheral neuropathy, chills and
food of alcohol fever, anorexia, stomatitis, anemia,
headaches, rash, bone marrow
suppression, pancreatitis. May
increase the risk of lipodystrophy.
Lamivudine Can be taken alcohol Nausea, vomiting, headache,
(3TC) without regard to dizziness, diarrhea, abdominal
food pain, nasal symptoms, cough,
fatigue, pancreatitis, anaemia,
insomnia, muscle pain, rash
Nevirapine Can be taken alcohol Nausea, vomiting, rash, fever
(NVP) without regard to headache skin reactions, fatigue,
food stomatitis, abdominal pain,
drowsiness, paresthesia. High
hepatotoxicity, Steven Johnson
syndrome
Source: Adapted from FANTA, 2001.

ACTIONS FOR SERVICE PROVIDERS

I. Support PLWHA with information to prevent food-drug interactions and to mitigate the
side effects of medications and herbal remedies.
• Keep up-to-date about information on food and drug interactions;
• Provide informative materials related to food, nutrition and medication;
• Create awareness on nutrition concerns related to HIV/AIDS treatment.

II. Support PLWHA to meet their drug and food obligations to prevent negative effects of
food-drug interactions and to mitigate harmful side effects.
• Advise on the drugs that should be taken with or without food (See Annex 12 for
specific food-drug interactions);
• Devise a meal plan/drugs timetable to minimize the side effects of medications;
• Follow instructions for medications and continue the full course;
• Monitor the effects of medication on client’s health and nutritional status;
• Not all symptoms are necessarily due to side effects of drugs;
• Advise clients to seek prompt treatment for any infections, allergies and other
conditions;
• Inquire about side effects and actions taken regarding these side effects;
• Counsel the client on the use of herbal remedies.

The above recommendations also apply to older children and adolescents on ART and others
medications. Annex 16 shows the biological and laboratory monitoring plan.

40
7 FOOD SECURITY FOR HOUSEHOLDS AFFECTED BY HIV/AIDS

Household food security implies a situation whereby every person, at all times, have physical,
social and economical access to sufficient, safe and nutritious food to meet their nutrient
needs for an active and healthy life. To achieve this, households have the ability to produce
and/or purchase and preserve food and have adequate knowledge on how to use the food.

HIV/AIDS increases the risk of food insecurity through its impact on household productive
labor, income, food stores and dependency ratios. HIV/AIDS affects all three elements of
food security: availability, accessibility, and utilization.

Food insecurity may lead people to adopt risky behaviors (i.e., sex for food/money), which in
turn, may increase the spread of HIV/AIDS. As such, improving food security is a
prerequisite to improving livelihoods and preventing risky behaviors.

ACTIONS FOR SERVICE PROVIDERS

Service providers include associations of PLWHA, community development committees,

agricultural extension services, health facilities, NGOs, bi- and multi-lateral organizations.

I. Assess the dietary practices and factors that might prevent PLWHA from improving
their food security.
• Understand the following areas specific to the community:
o HIV/AIDS burden in the community;
o Food production patterns;
o Access to health, social and financial services;
o Division of labor in households of PLWHA;
o Use of food available to the households;
o Food consumption patterns;
o Food preservation methods;
o Coping mechanisms for food insecurity;
• Evaluate food security in HIV/AIDS affected households. Specific community
factors should be developed in collaboration with social workers and local leaders
to identify with food insecure households including some of the following:
o Households that report to have had less than 2 meals per day, prior to the
interview;
o Households that have been forced to reduce food portions;
o Households that have been obliged to borrow or exchange food in the course
of the week preceding the interview;
• Assess constraints and challenges met in adopting recommended practices.

II. Support households, in collaboration with partners, affected by HIV/AIDS to

implement effective and sustainable food security strategies, such as:
• Using new crop breeds and new technologies that reduce labor requirements
• Initiate income generating activities;
• Reallocating food expenditures to increase purchase of nutritious foods;

41
 • Adjusting tasks within the household to accommodate nutritional care and support
for PLWHA;
• Identify services to strengthen food access/availability among households affected
by HIV/AIDS
o Growing a variety of foods and rearing of animals (i.e., chickens, goats, etc).
• Refer eligible beneficiaries to services/institutions that provide food support and
on-site or take-home rations for HIV/AIDS.
• Combine or link food aid to other services such as:
o Nutrition education and counseling;
o Growth promotion, breastfeeding and basic child health services;
o Management/treatment of infections, which can worsen malnutrition;
o Reproductive health services, particularly pre- and post-natal care;
o Psychosocial support for PLWHA and family members;
o Economic/social support for HIV-affected households maintain their income,
savings and overall livelihood security;
• Inform patients about food security social networks in the community.

Annex 17 gives the Minimum Household Food Package for Nutritional Care and
Support of PLWHA in food insecure households while Annex 18 presents some
suggested recipes.

8 MONITORING AND EVALUATION OF THE IMPLEMENTATION

OF GUIDELINES
8.1 Objectives of Monitoring and Evaluation

Monitoring and evaluation (M&E) will generate information regarding the extent to which
the main objectives of the Guide for Food and Nutritional Support and Care for PLWHA are
being met, and improve efficiency of the users. Systematic assessment, analysis and
documentation of progress of activities related to nutritional care and support are essential to
ensure successful implementation.
Benefits of monitoring and evaluation are that it:
• Allows for improvements in interventions;
• Provides stakeholders with information on progress in use of food and nutrition as a
component in comprehensive care and support for PLWHA;
• Permits the sharing of results and lessons learned with other programs and supplies
the information to advocate for increased support for nutritional care and support
programs;
• Creates awareness about improvements in nutritional status that can be achieved
through behavior change as recommended by the Guidelines.

What to monitor?
• The number of people trained;
• The number of copies of guidelines distributed.

42
Who does the monitoring?
• National level: Ministry of Health (Nutrition Division, TRAC);
• District level: Health district (Medistrict);
• Health center level: Nutritionists, PMTCT/VCT heads;
• Community level: Health animators, PLWHA networks, NGOs, community-based
organizations, other partners;

How to do the monitoring:

• Develop a monitoring tool in a participatory manner;
• Interview people living with HIV/AIDS to assess at what level the service providers
were able to utilize and implement the guidelines.
• Hold a follow-up meeting with key persons in agencies using the guidelines in order
to evaluate their experience with its use.
• Set up a system of periodic reporting to assess progress on the use of the guidelines.

Follow –up
• Utilization of feedback and lessons learnt by relevant staff on the implementation and
(possible) revision of the guidelines.
• Documentation of best practices on the experience in implementation of the
guidelines.

43
Table 6: Activities, indicators and sources of data for monitoring and evaluation

ACTIVITY INDICATORS SOURCE OF INFORMATION

Evaluation of nutritional % of children <5 years with W/A <65% Growth chart
status % of children <5 years with W/A between 65%-85% Growth chart
% of children <5 years with W/A < 85%
Growth chart
Nutritional counseling % counselors trained Service providers’ reports
Topics covered for different groups (children,
mothers…)
Duration of counseling sessions
Number of sessions held
% of people followed up at home
% of people followed up at health centers
% of people followed up at the offices of
associations
Nutritional rehabilitation % of children <5 years with W/H < 70% Rehabilitation centre register
% of children <5 years with W/H between 70% and Rehabilitation centre register
80%
% of children between 5-15 years with W/H <70 Rehabilitation centre register
% of children of 5-15 years with W/H between 70% Rehabilitation centre register
and 80%
% adults with BMI <16 Rehabilitation centre register
% adults with BMI between 16-18.5 Rehabilitation centre register
Number of admitted cases Rehabilitation centre register
% cured Rehabilitation centre register
% abandoned Rehabilitation centre register
% died Rehabilitation centre register
% transferred Rehabilitation centre register
Average length of stay Rehabilitation centre register
Average weight gain Rehabilitation centre register
% children having receive Vitamin A Rehabilitation centre register
% children vaccinated against measles Rehabilitation centre register
% children dewormed Rehabilitation centre register
% women having received Iron Rehabilitation centre register
% breast feeding women having received Iron Rehabilitation centre register
Food Security % identified food insecure households
% household having benefited from IGAs
% PLWHA having received food aid Reports from service providers
% PLWHA having joined associations
% PLWHA having gained weight as a result of food
aid

Source: Nutrition working group in Rwanda (2005).

44
9 REFERENCES AND RESOURCES
American Dietetc Association : Manual of Clinical Dietetics. Chicago, 2000.
Antiretroviral Treatment: Swiss HIV Cohort Study.” The Lancet. October 20, 2001.
358:1322-27.
Bonnard, P. HIV/AIDS Mitigation: Using What We Already Know. Washington DC : Food
and Nutrition Technical Assistance Project, Academy for Educational Development, 2002.
Cadman, J, and C. Arboleda. Once or Twice : A Guide to Medication Dosing for HIV
infection. Washington DC: National Minority AIDS Council, 2001.
Carr, A., and D. Cooper. “Adverse Effects of Antiretroviral Therapy.” The Lancet. 2000. 356
: 1423-30.
Castleman, tony, Seumo-Fosso, Eleonore, and Cogill, Bruce, FANTA Technical Note No. 7:
Food and Nutrition Implications of Antiretroviral therapy in Resource Limited Settings,
FANTA-AED, and Washington, DC: 2003.
Centers for Disease Control Website: www.cdc.gov
Clinical Infectious Diseases. Supplement to April 2003 Issue. 2003:36 (Supplement 2).
Infectious Diseases Society of America, 2003.
Currier, J. “Metabolic Complications of Antiretroviral Therapy and HIV infection.”
HIV/AIDS: Annual Update 2001. Imed Options, 2001. Medscape.
Dobkin, J.F. “Tenofovir: the First Nucleotide for HIV Infection.” Infections Medicine. 19(1):
11, 38, 2002.
Dresbach, Sereana Howard, and Rossi, Ami, Ohio State University Fact Sheet,
Phytochemicals – Vitamins of the Future ? Ohio State University Extension, Family and
Consumer Sciences, http//ohioline.ag.ohio.state.edu:2004.
Fan, H., R.F. Conner, and L.P. Villarreal. The Biology of AIDS. Fourth Edition. Boston: Jones
and Bartlett Publishers International, 2000.
FANTA, 2001. HIV/AIDS: A Guide for Nutrition, Care and Support. Food and Nutrition
Technical Assistance Project, Academy for Educational Development Washington DC.
www.fantaproject.org (French and English versions)
FAO – Rwanda, Improvement of Food and Nutrition Status of Vulnerable households by
using Ubudehe approach, Kigali : December 2003
FAO – Rwanda, Protection and improvement of food and nutrition security of orphans and
HIV/AIDS affected children in Umutara province, Kigali : March 2004
FAO/WHO, 2002. Living Well with HIV/AIDS : Nutritional Care and Support for People
Living with HIV/AIDS. Food and Agriculture Organization and Word Health Organization,
Rome/Geneva. www.fao.org
Felly J., K. Boubaker, B. Ledergerber, E. Bernasconi, H. Furrer, M. Battegay, B. Hirschel, P.
Vernazza, P. Francioli, G. Greub, M. Flepp, and A. Telenti, for the Swiss HIV Cohort
Study. “Prevalence of Adverse Events Associated with Potent.
Fields-Gardner C., C. Thomson, and S. Rhodes. A Clinician’s Guide to Nutrition in HIV and
AIDS. Chicago: American Dietetic Association, 1997.
Fields-Gardner, Cade, Salomon, and Davis, Margaret, Living Well with HIV and AIDS : A
Guide to Nutrition, American Dietetic Association, USA : 2003.
Gelato, M. “Insulin and Carbohydrate Dysregulation”. Clinical Infectious Diseases. 2003.
36 :S91-5.
GoR/FAO – Rwanda, Strategy Paper : Agriculture sector response to mitigate the impacts on
HIV/AIDS in Rwanda, Kigali : May 2004Food and Nutrition Technical Assistance
Project. HIV/AIDS: A Guide for Nutritional Care and Support. Food and Nutrition

45
 Technical Assistance Project, Academy for Educational Development, Washington DC,
2001.
Hsu, A., G.R. Granneman, M. Heath-Chiozzi, E. Ashbrenner, L. Manning, R. Brooks, P.
Bryan, K. Erdman, and E. Sun. “Indinavir Can Be Taken with Regular Meals when
Administered with Ritonavir.” Abbot Laboratories. 12th World AIDS Conference, 1998.
Linkages, FAQ Sheet 1 : Breastfeeding and HIV/AIDS : Frequently Asked Questions,
Linkages Project- AED, Washington, DC: Updated April 2004. (French and English).
Linkages, Infant Feeding Options in the Context of HIV, the Linkages Project, AED,
Washington, DC: April 2004.
MAAIF, 1997 Nutrition and HIV/AIDS: A Handbook for Field Extension Agents. Ministry of
Agriculture, Animal Industry and Fisheries, Entebbe, Uganda.
Ministry of Health, Kampala, Uganda. Mondy, K., S. Lassa-Claxon, M. Hoffman, K.
Yarasheski, W. Powderly, and P. Tebas. “Longitudinal Evolution of Bone Mineral
Density (BMD) and Bone Markets in HIV Infected Individuals.” Paper presented at the 9th
Conference of Retroviruses and Opportunistic Infections, Seattle, WA, February 2002.
MOH (2003) Nutritional Care and Support for People Living with HIV/AIDS in Uganda:
Guidelines for Service Providers, Ministry of Health, Kampala, Uganda (2003).
MOH, 1999. The Management of Severe Malnutrition in Uganda: A Guide for Health
Workers.
MOH, 2001. Policy for the Reduction of the Mother-to-Cheld HIV Transmission in Uganda,
Ministry of Health, Kampala, Uganda
MOH, 2001. Policy Guidelines on Feeding of Infants and Young Children in the Context of
HIV/AIDS. Ministry of Health, Kampala, Uganda.
MOH/RSA, 2001. South African National Guidelines on Nutrition for People Living with
TB, HIV/AIDS and other chronic Debilitating Conditions. Ministry of Health, South
Africa.
Monday, K., and P. Tebas. “Emerging Bone Problems in Patients Infected with Human
Immunodeficiency Virus.” Clinical Infectious Diseases. 2003. 36 :S101-5.
MSF 1995 Nutrition Guidelines, Médecin Sans Frontières, Paris, France: 1995.
National Institutes of Health. “Structured Intermittent Therapy May Prove Feasible, Garlic
Can Impede HIV Medication.” AIDS Read 12. (2): 60, 2002.
NPA+2002. Food for People Living with HIV/AIDS. Network for African People Living with
HIV/AIDS. Nairobi, Kenya.
“Optimizing Anti-HIV Medications.” The Cutting Edge, 2001. www.tceconsult.org. Nerad,
J., M. Romeyn, E. Silverman, J. Allen-Reid, D. Dietrich, J. Merchant, V. Pelletier, D.
Tinnerello, and M. Fenon. “General Nutrition Management in Patients Infected with
Human Immunodeficiency Virus.” Clinical Infectious Diseases. 2003. 36.
Piscitelli, S.C., A.H. Burstein, N. Welden, K.D. Gallicano, and J. Falloon. « The Effect of
Garlic Supplements on the Pharmacokinetics of Saquinavir. » Clinical Infectious Diseases.
2002. 34:234-8.
Piwoz, E. G., and E.A. Preble. HIV/AIDS and Nutrition : A Review of the Literature and
Recommendations for Nutritional Care and Support in Africa. Washington, DC: Academy
for Educational Development, November 2000.
Pronsky, Z., S. A. Meyer, and C. Fields-Gardner. HIV Medications Food Interactions,
Second Edition. Birchrunville, PA: 2001.
RCQHC/FANTA, 2003. Handbook : Developing and Applying National Guidelines on
Nutrition and HIV/AIDS. Regional Center for Quality of Health Care, Kampala, Uganda.
www.fantaproject.org
RCQHC/FANTA/LINKAGES, 2003. Nutrition and HIV/AIDS: A Training Manual. Regional
Center for Quality of Health Care, Kampala, Uganda. www.fantaproject.org

46
RCQHC/LINKAGES, 2002. Nutrition Job Aids: Regions with High HIV Prevalence.
Regional Center for Quality of Health Care, Kampala, Uganda. www.linkagesproject.org
RCQHC/USAID, 2003: Counseling Mothers on infant Feeding for the Prevention of Mother-
to-Child Transmission of HIV : A Job Aid for Primary Health Care Workers Regional
Center for Quality of Health Care, Kampala, Uganda.
RDHS, 2001. Rwanda Demographic and Health Survey, 2000/2001, GoR, Kigali, Rwanda
Stone, V.E. “Enhancing Adherence to Antiretrovirals: Strategies and Regimens.” Medscape,
General Medicine 4(3), 2002.
Tawfik, Y., S. Kinoti, and C. Blain. Introducing Antiretroviral Therapy (ART) on a Large
Scale: Hope and Caution. Washington, DC: Academy for Educational Development,
November 2002.
Tebas, P., W.G. Powderly, S. Claxton, D. Marin, W. Tantisiriwat, S.L. Teitelbaum, et
al.AIDSmeds.com.U.S. Food and Drug Administration, and National Consumers League.
“Food and Drug Interactions.” Pamphlet. 1998.
U. S. Public Health Service and Infectious Diseases Society of America. 2001 USPS/IDSA
Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV.
November 2001.
WHO/BASICS/UNICEF, 1999. Nutrition Essentials: A Guide for Health Managers.
BASICS II, Washington DC.
World Food Program. Food and Nutrition Handbook, WFP, Rome : 2002 www.wfp.org
World Health Organization (WHO) Nutrient Requirements for People Living with
HIV/Consultation, WHO Geneva : 13-15May 2003.
World Health Organization (WHO) Scaling Up Antiretroviral Therapy in Resource-Limited
Settings: Guidelines for a Public Health Approach. Geneva, June 2002.
World Health Organization (WHO). New Data on the Prevention of Mother-to-Child
Transmission of HIV and their Policy Implications: Conclusions and Recommendations.
Geneva, 2001.
World Health Organization (WHO, UNAIDS). Safe and Effective Use of Antiretroviral
Treatments in Adults with Particular References to Resources Limited Settings. Geneva:
2000.
Zeman, F. Clinical Nutrition and Dietetics. Second Edition. New York: Macmillan
Publishing Company, 1991.

47
ANNEX I: ESSENTIAL NUTRIENTS, THEIR FUNCTIONS AND
LOCAL FOOD SOURCES

SPECIFIC ROLE DIETARY SOURCES DEFICIENCY SYMPTOMS

NUTRIENT
Provide energy and Cereals such as maize and
Carbohydrates
promote body rice
(Sugars and
function
Starches)
Starchy roots such as
cassava, sweet potatoes,
Irish potatoes and yams

Starchy fruits such as ibitoke

Sugars from sugarcane, ripe

fruit, milk, and honey

Cooking oil, Margarine,

Fats and Oils
Provide a fatty animal foods such as
concentrated source meat, chicken, milk, fish,
of energy fatty vegetable foods, such
as peanuts and soybeans

PLANT: legumes and

Form a part of the pulses (such as beans,
Proteins
essential structure of cowpeas garden peas,
cells pigeon-peas and
groundnuts).

ANIMAL: milk and milk

products like yogurt and
cheese

48
SPECIFIC ROLE DIETARY SOURCES DEFICIENCY
NUTRIENT SYMPTOMS
VITAMINS Promote cell growth and Yellow and orange fruits and
repair, maintenance of vegetables (sweet potatoes, mangoes,
epithelial cells, mucous papaya, carrot, etc).
membranes.
Vitamin A Health and integrity of the Dark green leafy vegetables Xeropthalmia,
skin; supports immune (DGLVs) (including doodo), milk, Bitot’s spots (dry or
system and provides eggs, liver, full cream milk, foamy white patches
resistance to infections. margarine on the conjunctive or
Promotes growth white of the eye)
Ensures good vision Night blindness
(inability to see
clearly at night)

Vitamin B1 Involved in producing Whole grain cereal, such as roasted Beriberi is the most
(Thiamine) energy for the body and cooked maize, legumes and oil obvious clinical sign
Supports appetite & central seed. of Vitamin B1
nervous system functions deficiency, and
Fish, liver, milk and eggs presents in two
Contributes to energy forms:
production in the body “Dry” – bilateral
peripheral
polyneuritis, with
evolution to flaccid
paralysis
“Wet” – cardio-
vascular syndrome
with oedema and
heart failure. Early
deficiency symptoms
are less specific:
fatigue, anorexia, and
abdominal discomfort

Vitamin B2 Enables energy production Fish, liver, meat, milk and eggs
(Riboflavin) in the body, supports Whole grain cereals (maize) and
appetite and central nervous legumes
system functions

Vitamin B3 Facilitates metabolism& DGLVs, whole grain cereals, fish, Angular stomatitis
(Niacin) absorption of fat and meat, chicken & eggs and other muco-
proteins. Promotes Red cutaneous symptoms
blood cell (RBC) formation

Vitamin B6 Contributes to synthesis of Legumes (especially white beans), Pellagra: dematisi,

new cells and maintains avocado and DGLVs, Maize, dementia and
nervous system potatoes, and water melons diarrhea. Typical skin
Fish, meat and chicken lesions (dark and dry)
are on sun-exposed
parts (neck, face and
arms).

Vitamin B12 Contributes to bone Fish, meat, eggs and milk

formation. Improves the
absorption of non-heme iron

49
Vitamin C Improves the absorption of Citrus fruits such as guavas, lemon Scurvy: painful
non-heme iron. Improves and oranges tomatoes, red and green joints, swollen,
the resistance to infections eppers, Irish potatoes, yams, matoke, bleeding gums, and
Serves as an anti-oxidant and fresh milk possible or
Helps protein metabolism. hemorrhages

Vitamin D Required for mineralization Produced by the skin on exposure to

of bone and teeth. sunlight, milk, cheese, butter, eggs,
& liver.

Folic acid (folate) Supports synthesis of new Margarine, fatty fish, especially
cells, especially RBCs and ijanga, isambaza, capitaine, tilapia,
gastro-intestinal cells liver and fish, DGLVs, legumes, oil
seeds, groundnuts.

Vitamin E Acts as an anti-oxidant by DGLVs, legumes and pulses, whole

preventing the breakdown cereals, and oil seeds (such as
of fat and other cells. groundnuts), butter, liver, egg yolk,
and milk
MINERALS
Zinc Supports immune system DGLVs, legumes and pulses, whole
function and resistance to cereals (maize), and oil seeds (such
infections and promotes as peanuts), garlic, butter, liver, egg
wound healing. yolk, milk, meat, chicken, and fish.

Selenium Metabolized vitamin A (as Liver, egg yolk, meat, and milk
an antioxidant) and serves Roasted and boiled maize, brown
as an antioxidant preventing rice, and brown maize flour, DGLVs,
the breakdown of fat and legumes and pulses, whole cereals,
other body cells. nuts, avocado and potato leaves.

Magnesium Assists muscle and nerve Meat, liver, kidney, eggs and milk
function and release of
energy.

Iron Promotes oxygen exchange DGLVs, legumes and pulses, whole

in the blood and serves as a cereals, nuts, avocado, Irish potatoes,
coenzyme. and fish.

Fibre Makes food bulky, gives Unrefined or unprocessed plant foods

feeling of fullness, aids in (whole grain- maize, leafy vegetables
rapid transit of food in – spinach, cabbage).
intestines, assists bowel
movements.
Adapted from UGANDA Guidelines, 2003.

50
ANNEX 2: MAINTAINING WEIGHT
If you are sick with HIV/AIDS you need more food to recover from illness. When your body
does not get enough food it uses energy and protein stored in fat and muscles. This leads to
weight loss, muscle weakness and malnutrition from which it takes longer to recover. Once
weight has been lost it is difficult to regain it.

Why do people with HIV/AIDS not eat enough food?

• Illness and medicines reduce appetite, modify the taste of food and prevent the body
from absorbing it.
• Symptoms such as a sore mouth, nausea and vomiting make it difficult to eat.
• Tiredness, isolation and depression reduce the appetite and the willingness to make an
effort to prepare food and eat regularly.
• There is not enough money to buy food.

To gain or maintain weight

• Eat an adequate amount of staple foods such as rice, maize, millet, sorghum, wheat,
bread, potatoes, sweet potatoes, yams and bananas.
• Increase your intake of beans, soy products, lentils, peas, groundnuts, peanut butter
and seeds, such as sunflower and sesame.
• Eat meat, fish and eggs as often as you can afford them.
• Eat an adequate amount of fat by using fats and oils when preparing food, as well as
eating fatty foods - oilseeds such as groundnuts, soy and sesame, avocados and fatty
meat. If problems with fat intake are experienced (especially diarrhea), reduce the fat
intake until symptoms are over and then gradually increase it to a level the body can
tolerate.
• Add dry milk powder to foods such as porridge, cereals, sauces and mashed potatoes.
However, avoid using coffee and tea whiteners, which do not have the same
nutritional benefits as milk. Note that some people may find milk difficult to digest. It
should be avoided if it causes cramps, a feeling of being full or skin rashes.
• Eat snacks regularly between meals.
Good snacks are nuts, seeds, fruit,
avocados, yogurt, carrots, cassava
chips, crab chips and peanut butter
sandwiches.

Try to eat three good meals daily with

frequent snacks in-between.

Keep active and stay fit. Exercise helps you to maintain muscle mass.
• Regular exercise strengthens the muscles, makes you feel energetic, helps to relieve
stress and increases appetite.

51
 • Cleaning, working in the field and collecting firewood and water may provide enough
exercise.
• Find an exercise that you enjoy and can fit into your daily life.
• Walking, running, swimming or dancing are all suitable exercise.

Increase your intake of vitamins and minerals

• Your immune system needs vitamins and minerals to function properly. You should
maintain an adequate intake of vitamins and minerals when HIV-positive.
• Eat a variety of vegetables and fruit every day, as these are a valuable source of
vitamins and minerals.
• Take care not to lose vitamins and minerals when cooking your food. Boil, steam and
fry vegetables only for a short time.
• Multivitamin and mineral supplements, usually in the form of pills, can help but they
are expensive and leave less money for food.
• Too many vitamins and minerals can harm you. If you take supplements, follow the
instructions on the label.

During infection
• It is very important to try to eat, even though you may not feel like eating, to avoid
weight loss.
• Treat infection as early as possible. If you are ill for more than a couple of days see a
health worker.

52
ANNEX 3: NUTRITIONAL ASSESSMENT TOOL FOR PLWHA

Form to Monitor Nutrition Status Over Time

Name:_________________________ Age _______ Sex ___________

In the form below, write down when patient was weighed. Take weight without shoes and
wearing similar light clothes each time. Note any events, illnesses, or changes in eating habits
and amount of foods eaten, etc. that might have caused weight loss. Where possible also note
CD4 counts and hemoglobin (Hb).

BMI is calculated as weight (kg)/height (meters²).

Date of Height Weight Amount BMI CD4 Hb Remarks

visit (cm) (kg) weight (specify
Increase↑ or any
Decrease↓ changes)

Adapted from FAO, Living Well with AIDS, Rome: 2002.

53
ANNEX 4: BODY MASS INDEX TABLE: ADULTS AND ADOLESCENTS
Weig
ht ( round to the closest number in the table )
KG 60 61 62 63 64 65 66 67 68 69 70 72.5 75 77.5 80 82.5
Height Lb 132 134.2 136.4 139 141 143 145.2 147.4 149.6 152 154 160 165 170.5 176 182
CM In
150 59 26.7 27.1 27.6 28 28.4 28.9 29.3 29.8 30.2 30.7 31.1 32.2 33.3 34.4 35.6 36.7
152 59.8 26 26.4 26.8 27.3 27.7 28.1 28.6 29 29.4 29.9 30.3 31.4 32.5 33.5 34.6 35.7
154 60.6 25.3 25.7 26.1 26.6 27 27.4 27.8 28.3 28.7 29.1 29.5 30.6 31.6 32.7 33.7 34.8
156 61.4 24.7 25.1 25.5 25.9 26.3 26.7 27.1 27.5 27.9 28.4 28.8 29.8 30.8 31.8 32.9 33.9
158 62.2 24 24.4 24.8 25.2 25.6 26 26.4 26.8 27.2 28 29 30 31 32 32 33
160 63 23.4 23.8 24.2 24.6 25 25.4 25.8 26.2 26.6 27 27.3 28.3 29.3 30.3 31.2 32.2
162 63.8 22.9 23.2 23.6 24 24.4 24.8 25.1 25.5 25.9 26.3 26.7 27.6 28.6 29.5 30.5 31.4
164 64.6 22.3 22.7 23.1 23.4 23.8 24.2 24.5 24.9 25.3 25.7 26 27 27.9 28.8 29.7 30.7
166 65.4 21.8 22.1 22.5 22.9 23.2 23.6 24 24.3 24.7 25 25.4 26.3 27.2 28.1 29 29.9
168 66.1 21.3 21.6 22 22.3 22.7 23 23.4 23.7 24.1 24.4 24.8 25.7 26.6 27.5 28.3 29.2
170 66.9 20.8 21.1 21.5 21.8 22.1 22.5 22.8 23.2 23.5 23.9 24.2 25.1 26 26.8 27.7 28.5
172 67.7 20.3 20.6 21 21.3 21.6 22 22.3 22.6 23 23.3 23.7 24.5 25.4 26.2 27 27.9
174 68.5 19.8 20.1 20.5 20.8 21.1 21.5 21.8 22.1 22.5 22.8 23.1 23.9 24.8 25.6 26.4 27.2
176 69.3 19.4 19.7 20 20.3 20.7 21 21.3 21.6 22 22.3 22.6 23.4 24.2 25 25.8 26.6
178 70.1 18.9 19.3 19.6 19.9 20.2 20.5 20.8 21.1 21.5 21.8 22.1 22.9 23.7 24.5 25.2 26
180 70.9 18.5 18.8 19.1 19.4 19.8 20.1 20.4 20.7 21 21.3 21.6 22.4 23.1 23.9 24.7 25.5
182 71.6 18.1 18.4 18.7 19 19.3 19.6 19.9 20.2 20.5 20.8 21.1 21.9 22.6 23.4 24.2 24.9
184 72.4 17.7 18 18.3 18.6 18.9 19.2 19.5 19.8 20.1 20.4 20.7 21.4 22.2 22.9 23.6 24.4
186 73.2 17.3 17.6 17.9 18.2 18.5 18.8 19.1 19.4 19.7 19.9 20.2 21 21.7 22.4 23.1 23.8
188 74 17 17.3 17.5 17.8 18.1 18.4 18.7 19 19.2 19.5 19.8 20.5 21.2 21.9 22.6 23.3
190 74.8 16.6 16.9 17.2 17.5 17.7 18 18.3 18.6 18.8 19.1 19.4 20.1 20.8 21.5 22.2 22.9

54
ANNEX 5: FOOD SAFETY AND PERSONAL HYGIENE

Keep the home free from feces

• Use a latrine and keep it clean and free from flies.
• Keep the home environment clean.
• Wash clothes, bedding and surfaces that might have been contaminated with feces in
hot water with soap.

Personal hygiene
• Always wash hands with water and soap or ashes
before, during and after preparing food or eating,
and after visiting the toilet.
• Cover all wounds to prevent contamination of
food during preparation and handling.
• Use clean water. If the water is not from a
protected source, it should be boiled for ten
minutes or treated with Sure Eau.

Storage of drinking-water
• Keep drinking water in a cleaned covered
container
• Do not dip hands or cups into the container.

Hygiene in the kitchen

• Keep all food preparation surfaces clean. Use clean dishes and utensils to store,
prepare, serve and eat food.
• Wash vegetables and fruit with clean water.

Cooking and storage of food

• Clean all cooking and eating surfaces, utensils and dishes.
• Wash all fruit and vegetables with clean water before eating or cooking.
• Thoroughly wash or peel raw fruits and vegetables with skin that may hold soil
particles, such as potatoes and carrots.
• Avoid letting raw meat come into contact with cooked food. Cut meat, poultry and
fish on a separate cutting board than food that has been cooked or will be eaten raw.
• Ensure that all food is cooked well, especially meat, poultry and fish.
• Avoid storing cooked food unless one has access to a refrigerator.
• Reheat left over foods well to avoid contamination
• Keep food covered.
• Avoid eating moldy or spoiled foods.
• Avoid eating raw eggs or foods that contain raw eggs.

55
ANNEX 6: NUTRITIONAL MANAGEMENT OF SYMPTOMS
ASSOCIATED WITH HIV/AIDS

Illness Food Care and Nutrition Practices

Muscle Wasting Increase the amount and frequency of food Eat an adequate amount of starchy foods,
consumption protein, vitamins and minerals and fat.
Improve the quality of food intake by eating Eat fortified foods where available.
a variety of foods Exercise regularly.
Constipation Increase consumption of foods that are high Avoid using cleansing practices, such as
in fiber content, such as millet, whole-wheat enemas.
bread, green vegetables and washed fruits Drink plenty of fluids, particularly clean,
with the peel remaining. boiled water.
Avoid processed or refined foods. Exercise regularly.
Bloatedness/ Eat small frequent meals Do not lie down or sleep immediately
Heartburn Avoid gas-forming foods, such as beans, after eating.
cabbage, broccoli, cauliflower, and soda.
Drink fluids.
Tuberculosis Consume foods high in protein, energy, iron Seek medical attention immediately
and vitamins Consult medical personnel about taking
food with medications
If taking isoniazid for treatment, take a
Vitamin B6 supplement to avoid
deficiency of this micronutrient.
Loss of Taste Use flavor enhancers, e.g. salt, spices, herbs Chew food well and move around mouth
and/or Abnormal and lemon. to stimulate taste buds.
Taste
Anorexia Eat small and frequent meals. Eat in a relaxed, happy setting.
Eat favourite foods. Try to eat with others.
Select foods that are energy dense. Avoid
strong smelling foods.
Diarrhea Drink plenty of fluids. Prepare and drink rehydration solution as
Continue eating during and following needed.
illness.
Avoid fried or fatty foods.
Flatulence Avoid gas-forming foods, such as beans,
cabbage, broccoli, cauliflower and soda.
High Blood Eat a low fat diet and limit intake of foods Exercise regularly.
Cholesterol rich in cholesterol and saturated fat.
Eat fruits and vegetables daily.
High Limit sweets and excessive carbohydrate Avoid alcohol and smoking.
Triglycerides and saturated fat intake. Exercise regularly.
Eat fruits, vegetables, and whole grains
daily.
Nausea or Eat small quantities of food at frequent Avoid having an empty stomach.
Vomiting intervals. Avoid lying down immediately after
Drink after meals and limit intake of fluids eating.
with meals. Rest between meals.
Eat lightly salty and dry foods to calm the
stomach.
Fever Drink plenty of fluids. Drink plenty of fluids including boiled
Eat energy and nutrient dense foods. water.
Adapted from FANTA, 2003

56
ANNEX 7: COPING WITH COUGHS, COLD AND FEVER
Cough is how the body cleans the lungs and throat by getting rid of mucus and germs.

Actions to Take:
Advise Patients/caregivers to take the following actions for cough:
• Crush some fresh gum tree, mint or thyme leaves and place them in boiling water. Place a
cloth over the person’s head and lean over the pot to breathe the vapors. Breathe deeply
for 10 minutes, twice a day.
• Place 3-4 dried gum tree leaves in a cup of hot water and boil for 10 minutes. Let the tea
cool slightly before drinking. Drink this tea 2-3 times a day. Tea can also be made with
lemon or guava leaves.
• Inform Patients when to seek medical help if the cough lasts more than two weeks, if the
person is coughing blood or bad-smelling sputum or mucous

Fever means that the body temperature is higher than normal (37°C). Fever is common in
people with HIV/AIDS, and does not necessarily indicate a serious illness. Fever may result
in increased nutrient requirements.

Actions to Take
Advise caregivers to take the following actions for fever:
• Provide citrus (lemon, orange) juice several times throughout the day.
• Pound lemon or orange peel with a small amount of water. Rub on the patient’s back or
add to bathwater before bathing.
• Pound gum/eucalyptus leaves with a small amount of oil. Rub the oil onto the patient’s
chest. Or place a large number of gum leaves in a pot of boiling water. Leave the pot in
the patient’s room so the vapors can be inhaled.
• Drink plenty of fluids.
• Try to bring down the fever by sponging the body with a cool wet cloth
• Cut a fresh twig from a neem tree (Azadirachta indica). Remove the leaves, and have the
patient chew the bark; or boil some water with the bark and have the patient drink the tea.

Inform patients when to seek medical help:

• If fever lasts more than 24 hours.
• If fever is accompanied by other signs of serious illness.

57
ANNEX 8: COPING WITH DIARRHEA

Diarrhea
Diarrhea occurs when a person has several watery or loose bowel movements in a day.
Diarrhea results in losses of water and essential nutrients, and leaves a person at greater risk
of dehydration, which can be life threatening. Diarrhea also reduces appetite and interferes
with nutrient absorption. If diarrhea is persists or continues for a prolonged period, severe
malnutrition results. Diarrhea has serious nutritional implications for people with HIV
infection.

Actions to Take

Advise patients to do the following:

• Drink plenty of fluids to prevent dehydration.
• Drink soups, fruit juice diluted with water or an oral rehydration solution (ORS)
• Avoid spicy foods and fatty foods.

Inform Patients when to seek medical help:

• If there is blood in the diarrhea.
• If the diarrhea persists for more 24 hours
• If diarrhea is accompanied by fever or vomiting.

Methods of preparing an oral rehydration drink

From packets
Follow the instructions and dissolve the contents of the packet in
1 L of clean water as stated on the packet.

With sugar and salt

To 1L clean water, add 1/2 teaspoon of salt and 8 teaspoons of
sugar. Stir or shake well.

With powdered cereals

To 1L of clean water, add ½ a teaspoon of salt and 8 teaspoons of
a powdered cereal. Rice is best, but wheat, maize, sorghum flour,
or cooked mashed potatoes can be used. Boil for five to seven
minutes to make a liquid soup or watery porridge. Cool and drink.

58
ANNEX 9: INDIVIDUAL EVALUATION FORM FOR REPLACEMENT
FEEDING OPTIONS FOR HIV-POSTIVE MOTHERS

Evaluation of AFASS
NO YES YES YES

Will
Willyou
you Are
Areyouyouable
ableto
to Can
Canyou
youbebe DoDoyou
youhave
have
have
haveaa prepare
prepare Can
Canyouyoubebe able
ableto
toaccess
access access
accesstotoclean
clean
problem
problemwith
with feedings
feedings forthe
for the able
ableto
toaccess
access enough
enoughcow’s
cow’s safe
safewater,
water,
your
yourrelatives
relatives child
childevery
every enough
enoughcow’s
cow’s milk
milkororbuy
buy keep
keeputensils
utensils
or
orfriends
friendsifif three
threehours
hours milk
milkor orbuy
buy baby
babyformula
formula clean,
clean,can
canuse
use
you
youdodoNOT
NOT both
bothday
dayand
and baby
babyformula
formula for
for12
12months
months cup
cup& &spoon?
spoon?
breastfeed?
breastfeed? night?
night?
YES
YES NO NO NO NO

Counsel
Counsel mother
mother on
on options
options of
of breastfeeding?
breastfeeding? Support
Support for
for
Promote
Promote exclusive
exclusive breast
breast milk
milk replacement
replacement
feeding
feeding with
with
formula
formula or
or
animal
animal milk
milk

For the mother to be allowed to practice replacement feeding, she should fulfill the following
condition (in bold). If any one of these conditions is not fulfilled, the mother is NOT eligible
for replacement feeding.

Criteria for Replacement Feeding YES NO Total

(1) (0) points
ACCEPTABLE means that : (1) point)
• The mother perceives no barrier to choosing replacement feeding for x
cultural or social reasons, or for fear of stigma and discrimination.

FEASIBLE means that: (1 point)

• The mother (or family) has adequate time, knowledge, skills, resources, x
and support to correctly prepare breastmilk substitutes and feed the infant
8 to 12 times in 24 hours.
AFFORDABLE means that: (1 point)
• The mother and family, with available community/or health system x
support, can pay for the cost associated with the purchase/production,
storage and use of replacement feeds without compromising the health and
nutrition of the family.

SUSTAINABLE means that: (1 point)

• A continuous, uninterrupted supply and a dependable system for x
distribution of all ingredients (for example micronutrient supplements,
fuel) and products needed to safely practice replacement feeding are
available for as long as needed.

SAFE means that: ( 3 points)

• Replacement are correctly and hygienically stored and prepared and fed
with clean hands using clean cups and utensils – no bottles or teats:
o Safe source of portable water for household use; x
o Replacement foods should be stored in secure places or prepared x
at each meals;
o Other persons (care-givers) should have skills in case mother is
x
not available

59
 ANNEX 10: ALGORITHM FOR COUNSELING OF HIV-POSITIVE MOTHERS ON INFANT FEEDING

NO Counsel mother :
FADU -- 1. Exclusively breastfeed for up to 6
Is mother HIV- months ;
• Frequency,
positives ? 2. followed by continued
• Amount breastfeeding for up to 24
• Density, DO NOT months ;
• Utilization. KNOW 3. Plus complimentary feeding
YES from 6 to 24 months.

NO YES
Is the mother willing
to breastfeed?
Is the mother able and willing Is the mother able and willing to
to use replacement feeding use cow’s milk or other animal
(AFASS). milk after early cessation?

YES NO

YES NO
Counsel the mother to: Counsel the mother to:
1. Exclusively breastfeed for up to 6 1. Exclusively breastfeed for up to 6 months;
Counsel mother: Counsel the mother: months; 2. Followed by replacement feeding or heat-treated
1) Utilize replacement feeding for the 1st 6 4) Give home animal modified milk for 2. Plus complimentary feeding from 6 to breast milk for up to 24 months ;
month; the 1st 6 months; 24 months (FADU). 3. Plus complimentary feeding from 6 to 24 months
2) Followed by replacement feeding up to 5) followed by replacement feeding for (FADU).
24 months; up to 24 months ;
3) Plus complimentary feeding from 6 to 24 6) Plus complimentary feeding from 6 to
months (FADU). 24 months (FADU). 60
ANNEX 11: FOOD AND NUTRITION IMPLICATIONS AND SOME SIDE
EFFECTS OF MEDICATIONS USED TO TREAT COMMON
INFECTIONS

Medication Purpose Recommended to be Potential side effects

taken
Sulfanamides: Antibiotic for With food Nausea, vomiting,
Sulfamethoxazole treatment of abdominal pain
Cotrimoxazole, pneumonia and
(Bactrim, Spectra) toxoplasmosis
Rifampin Treatment of TB On am empty stomach Nausea, vomiting,
at least 1-2 hrs before diarrhea and loss of
meals appetite
Isoniazid Treatment of TB On an empty stomach May cause reactions with
at least 1-2 hrs before foods such as bananas,
meals beer, avocados,
caffeinated beverages,
chocolate, sausage, liver,
smoked fish, yeast and
yogurt.
May interfere with
vitamin B6 metabolism
and therefore require
vitamin B6 supplement.
Quinine Treatment of With food Abdominal or stomach
malaria pain, diarrhea, nausea,
vomiting, lower blood
sugar
Sulfadoxine and Treatment of With food and Nausea, vomiting.
pyrimethamine malaria continuously drink Not recommended if
(Fansidar*) clean boiled water folate deficient.
Not recommended for
women who are
breastfeeding.
Chloroquine Treatment of With food Stomach pain, diarrhea,
malaria loss of appetite, nausea,
vomiting. Not
recommended for women
who are breastfeeding.
Fluconazole Treatment of With food Nausea, vomiting,
candida (thrush) diarrhea. Can be used
during breastfeeding.
Nystatin Treatment of thrush With food Infrequent occurrence of
diarrhea, vomiting,
nausea.
Zidovudine Antiretroviral With food Anaemia, nausea,
vomiting.
Lamivudine Antiretroviral Avoid alcohol Can be Nausea, vomiting,
taken without regard to headache, dizziness,
food diarrhea, abdominal pain,
nasal symptoms, cough,
fatigue, pancreatitis,
anaemia, insomnia,
muscle pain, rash
Nevirapine Antiretroviral With food Sedative effect, diarrhea,
nausea, rash.
Adapted from FANTA, 2003

61
ANNEX 12: FOOD AND NUTRITION IMPLICATIONS AND SOME
SIDE EFFECTS OF ARV DRUGS

ARV Class: REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

ARV Type: Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI)
Medication Generic Food Avoid Possible Side Effects
Name (abbreviation) Recommendations
efavirenz (EFZ) Can be taken without Alcohol Elevated blood cholesterol levels,
regard to meals, elevated triglyceride levels, rash,
except do not take dizziness, anorexia, nausea,
with a high fat meal. vomiting, diarrhea,
(A high fat meal Dyspepsia, abdominal pain,
increases drug flatulence.
absorption to
potentially harmful
levels).
Nevirapine (NVP) Can be taken without St. John’s wort Nausea, vomiting, rash, fever
regard to food (Igikakarubamba headache skin reactions, fatigue,
) stomatitis, abdominal pain,
drowsiness, paresthesia. High
hepatotoxicity.
ARV Class: Reverse Transcriptase Inhibitors (RTI)
ARV Type: Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTI)
Medication Generic Food Avoid Possible Side Effects
Name (abbreviation) Recommendations
abacavir (ABC) Can be taken without Nausea, vomiting, fever, allergic
regard to food reaction, anorexia, abdominal pain,
diarrhea, anaemia, rash,
hypotension, pancreatitis, dyspnoea,
weakness, insomnia, cough,
headache.
didanosine (ddl) Take on an empty Alcohol. Do Anorexia, diarrhea, nausea,
stomach (at least 30 not take with vomiting, pain, headache,
minutes before or two juice. Do not weakness, insomnia, rash, dry
hours after eating). take with mouth, loss of taste, constipation,
Take with water only. antacids stomatitis, anaemia, fever,
(Taking with food containing dizziness, pancreatitis.
reduces absorption). Aluminium or
Magnesium
lamivudine (3TC) Can be taken without Alcohol. Nausea, vomiting, headache,
regard to food dizziness, diarrhea, abdominal pain,
nasal symptoms, cough, fatigue,
pancreatitis, anaemia, insomnia,
muscle pain, rash
stavudine (d4T) Can be taken without Limit the Nausea, vomiting, diarrhea,
regard to food consumption of peripheral neuropathy, chills and
alcohol fever, anorexia, stomatitis, anaemia,
headaches, rash, bone marrow
suppression, pancreatitis. May
increase the risk of lipodystrophy.

62
tenofovir (TDF) Take with a meal Abdominal pain, headache, fatigue,
dizziness
zidovudine Better to take without Alcohol Anorexia, anaemia, nausea,
(ZDV/AZT) food, but if it causes vomiting bone marrow suppression,
nausea or stomach headache, fatigue, constipation,
problems, take with a dyspepsia, fever, dizziness,
low-fat meal. Do not dyspnoea, insomnia, muscle pain,
take with a high-fat rash.
meal. May require zinc
and copper
supplementation
ARV Class: PROTEASE INHIBITORS (PI)

Medication Generic Food Avoid Possible Side Effects

Name (abbreviation) Recommendations (nutritional management of side
effects is given in Table 4)
indivavir Take on an empty Grapefruit Nausea, abdominal pain, headache,
(IDV) stomach, one hour St John’s wort kidney stones, taste changes,
before or two hours (Igikakarubam vomiting, regurgitation, diarrhea,
after a meal. ba) insomnia, ascites, weak-ness,
Or take with a light, dizziness. May increase the risk of
non-fat meal. Lipodystrophy (increased blood
Take with plenty of fats)
water, Drink at least
1500 ml of fluids daily
to prevent kidney
stones
lopinavir (LPV) Can be taken without St John’s wort Abdominal pain, diarrhea,
regard to food (Igikakaruba headache, weakness, nausea. May
mba) increase the risk of Lipodystrophy.
May increase the risk of diabetes.
nelfinavir Take with a meal or St John’s wort Diarrhea, flatulence, nausea,
(NFV) light snack (Igikakarubam abdominal pain, rash. May increase
Taking with acidic ba) the risk of Lipodystrophy.
food or drink will
cause a bitter taste.
To increase absorption,
take with meal
containing >15 g. of fat
ritonavir (RTV) Take with a meal if St John’s wort Nausea, vomiting, diarrhea,
possible (Igikakarubam hepatitis, jaundice, weakness,
ba) anorexia, abdominal pain, fever,
diabetes, headache, dizziness. May
increase the risk of Lipodystrophy.
saquiravir (SQV) Take with a meal or Garlic Mouth ulceration, taste changes,
light snack. supplements. nausea, vomiting, abdominal pain,
Take within two hours St John’s wort. diarrhea, constipation, flatulence,
of a high fat and high- (Igikakarubam weakness, rash, headache,
calcium meal ba) insomnia. May increase the risk of
Lipodystrophy.
Adapted from FANTA, 2003

63
 ANNEX 13: SCHEMATIC PRESENTATION FOR FEEDING A CHILD AGED 0-24 MONTHS.

0- 6 MONTHS

Exclusive breast feeding:

• Initiation 30 – 60 min after delivery/birth;
REPLACEMENT FEEDING • Feed on demand;
• No botle feeding and pacify or teats ;
• Supplement mother’s meals;
• Micronutrient supplementation for the mother.

• Artificial milk substitute;

• Modified animal milk or other articial milk; Between 4-6 months, prepare for early cessation:
• Micronutrient supplements (i.e., Vitamin A) for the infant and • Teach the mother how to express her milk ;
the mother ; • Train the infant to take breast milk from a cup or any
• Supplement mother’s meals. other suitable container (NOT bottle) ;
• Assist the infant to sleep throughout the night without
feeding ;
Stop breastfeeding by 6 months.

FORM 6 – 24 MONTHS

• Stop breastfeeding and replace breastmilk with

• Continue replacement feeding ; other milk ;
• Complement replacement feed with other foods for up to 24 • Complement replacement feed with other foods for
months ; up to 24 months ;
• Give micronutrient supplements (i.e., Vitamin A). • Give micronutrient supplements (i.e., Vitamin A).

64
ANNEX 14: PREPARATION OF ARTIFICIAL MILK

Age of infant Quantity of milk over 24 Number of feeds per day

hours
1 week 240 ml 8 x 30 ml
1 month 450 ml 8x 60 ml
2 months 600 ml 7 x 90 ml
3 months 750 ml 6x 120 ml
4 months 750 ml 6 x 120 ml
5 months 900 ml 6 x 150 ml
6 months 900 ml 6 x 150 ml
7-12 months 900 ml 6 x 150 ml

Detailed preparation of fresh whole milk (cow or goat)

Age of Quantity Quantity Sugar to Quantity Number of Total

infant of milk per of water to add of mixture feed per quantity of
feed add to the per feed day fresh milk
milk required
per day
1week 20 ml 10 ml 2g 30 ml 8 160
2-4 weeks 40 ml 20 ml 4g 60 ml 8 620
2 months 60 ml 30 ml 6g 90 ml 7 420
3-4 months 120 ml 0 ml 12 g 120 ml 6 720
5-12 150 ml 0 ml 15 g 150 ml 6 900
months

Reconstitution of powder milk

RECONSTITUTION PREPARATION DES REPAS DE

LAIT
Age of Quantity of water Quantity of Quantity of Quantity Amount
infant needed to milk powder milk per feed water added of sugar
prepare milk feed added to water to the milk added
per day per a feed per
day
1 week 160 ml 20 g 20 ml 10 ml 2g
2-4 weeks 320 ml 40 g 40 ml 20 ml 4g
2 months 420 ml 60 g 60 ml 30 ml 6g
3-4 months 720 ml 90 g 120 ml 0 ml 12 g
5-12 months 900 ml 115 g 150 ml 0 ml 15 g

65
ANNEX 15: NUTRITION FOLLOW-UP OF AN HIV-POSITIVE
WOMAN AND HER CHILD

Period Activities
Antenatal • Discuss the various feeding options, their disadvantages and
consultation and advantages, and their implications for woman and her family
counseling (ANC) • Help the woman to choose the best feeding option for her and her child
• Answer questions concerning the management of problems related to
breast feeding or other feeding options chosen
• If breast feeding is chosen, examine the breast for signs of potential
problems, such as retracted nipples
• If a feeding option other than breastfeeding is selected, evaluate the
conditions of acceptability, feasibility, accessibility, sustainability and
safety
• Provide individual demonstrations of the infant feeding method chosen
• Ask woman to practice the techniques immediately to ensure her
comprehension before she leaves

Other areas for discussion and follow-up include:

• Tetanus toxoid vaccination for the mother
• Iron folic acid supplementation
• ARVs where appropriate
• Information on risks related to home delivery and options
Delivery • Confirm the infant feeding choice of the mother

If the mother chose to breastfeed:

• Put the child in contact with his/her mother directly after delivery
• Show the mother how to put the infant to her breast, in a good position
to suckle
• Initiate breast feeding within 30 minutes of delivery
• Don’t give other liquids or food in addition to the breast milk

If the mother chose to replacement feeding:

• Put the child in contact with his/her mother directly after delivery
• Initiate feeding
• Provide information on the method chosen and its implications for the
mother and child

Other areas for discussion and follow-up include:

• Check the antenatal care card
• Check if the woman took its dose of Nevirapine, if prescribed
• Follow the delivery using a partogram
• Give Nevirapine to the child., if recommended
Before the mother • If the mother has chosen to breastfeed, examine the breast of the
leaves the health mother for any signs of cracks, abscess or inflammation
center • Reemphasize to the mother the importance of exclusive breastfeeding
and explain how to prevent problems related to poor breastfeeding
techniques
• Give one dose of 200,000 IU of Vitamin A to the woman and 50,000
IU to the child
• Prepare the woman to breastfeed on demand

66
 • Provide advice on maternal nutrition to the mother
• Refer the woman to an HIV support group, if available

Other areas for discussion and follow-up include:

• Make sure that the child has received Nevirapine, if appropriate
• Give the BCG and the polio vaccine
• Set up a time for the next appointment.
Week 1 after delivery • Check to see if the mother has difficulties with the selected infant
feeding method and help the mother to solve identified problems
• Continue to provide individual demonstrations of the feeding option
chosen
• For mother’s who have opted to exclusively breastfeed, check on
breast health
• Provide IFA supplementation and advice on maternal nutrition to the
mother
• Provide vitamin A to the mother if it wasn’t done at delivery

Other areas for discussion and follow-up include:

• Provide vaccinations that weren’t provided at delivery
• Set next appointment at 6 weeks post-partum
Week 6 after delivery • Follow-up on child’s growth, including weighing and measuring
length
• Check to see if the mother has difficulties with the selected infant
feeding method and help the mother to solve identified problems
• Continue to provide individual demonstrations of the feeding option
chosen, if necessary
• For mother’s who have opted to exclusively breastfeed, check on
breast health
• Provide IFA supplementation and advice on maternal nutrition to the
mother

Other areas for discussion and follow-up include:

• Follow-up on child’s vaccination status and umbilical cord
• Provide a medical follow-up for the mother (uterine involution,
episiotomy healing)
• Discuss family planning options
• Set next appointment at 10 and 14 weeks post-partum
Weeks 10 and 14 • Follow-up on child’s growth, including weighing and measuring
after delivery length
• Continue to monitor infant feeding
• Continue to provide IFA supplementation and advice on maternal
nutrition to the mother

Other areas for discussion and follow-up include

• Provide vaccinations
• Discuss family planning options
• Set next appointment for ANC at the 4th, 5th, 6th,7th and 8th month
post-partum
Month 4-8 • Follow-up on child’s growth, including weighing and measuring
once per month length
• Prepare mothers who have opted to exclusively breastfeed for early
cessation, including how to express and heat treat breastmilk and feed

67
 their infant from a cup
• Discuss access to and the preparation of replacement feeds and
complementary foods with the mother and provide individual
demonstrations, where possible
• Discuss the need to continue to feed sick children, particularly when
they are suffering from diarrhea
• Provide 100,000 IU of vitamin A orally to children between the ages
of 6-11 months once
• Continue to provide IFA supplementation and advise on maternal
nutrition to the mother

Other areas for discussion and follow-up include:

• Provide vaccinations
• Discus family planning options
• Set next appointment for ANC at the 9th month post-partum
Month 9 -24 • Discuss any problems or concerns the mother has about the
once per quarter preparation of replacement feeds and complementary feeding
• Follow-up on child’s growth, including weighing and measuring
length
• Provide 200,000 IU of vitamin A orally to children 12 months and
older every 4-6 months

Other areas for discussion and follow-up include:

• Provide vaccinations
• Discus family planning options
• Discuss HIV testing of the child at 15 months
• Set next appointment for consultation at 12-15 months post-partum
Beyond 24 months • Continue to monitor child growth until 5 years of age
once per quarter • Continue with child supplementation with vitamin A every 4-6 months
until 5 years of age
• Continue to set appointments for quarterly follow-up until 5 years of
age.

68
ANNEX 16 : FOLLOW-UP PLAN FOR CHILDREN UNDER ARV
TREATMENT
Date Clinical Laboratory
J0 + CD4, NFS, transaminases, creatinine
J 15 + NFS if AZT, transaminases if NVP
M1 + NFS if AZT, transaminases if NVP
M2 + Nothing
M3 + NFS if AZT, transaminases
M4 + Nothing
M5 + Nothing
M6 + CD4, NFS, transaminases, CV *
Beyond the sixth month
Monthly during 1 + CD4: every 6 months
year Transaminases: M 9 and M 12, stop has to start from
M 12
Certain examinations will be directed by clinical data

69
ANNEX 17.MINIMUM FOOD PACKAGE FOR NUTRITIONAL CARE
AND SUPPORT OF PEOPLE (including children) LIVING
WITH HIV/AIDS IN FOOD INSECURE HOUSEHOLDS
This package is part of the GOR process of evaluating its options for the integration of
nutrition into the essential package of care, treatment and support of people living with
HIV/AIDS and efforts to prevent infection. This is in recognition of the fact that adequate
nutrition may delay progression of HIV, decrease clinical symptoms and optimize the
benefits of ARVs, hence the need to design interventions for improving nutrition by
accelerating the training and use of guidelines and tools for infant feeding counseling and
maternal nutrition in PMTCT and related programs and also by implementing the Global
Strategy for Infant and Young Child Feeding.

This package is in two Parts: Part I presents a minimum household food package; while Part
II presents a replacement feeding package for both HIV-exposed and infected children in
food insecure households (HH).

PART I: Minimum Household Food Package for Nutritional Care and Support of
PLWHA in food insecure households.

Basis: Adult RDAs for energy were considered and are given below for the various
groups. However, considering that the minimum food package is being proposed
for PLWHA, the best option is to base our recommendations on a ration that
would take into consideration the increased energy needs of PLWHA. As such,
the Rwanda Nutrition Working Group agreed to use the HIV+ pregnant woman
as the basis for this recommendation.

Table 1. Recommended (WHO) RDAs for Engery

Target Normal Asymptomatic PLWHA Symptomatic PLWHA

(+10%) (+20%)
Adult 2100 2300 2500
Pregnant woman 2400 2600 2900
Lactating woman 2600 2800 3100

Target groups: Malnourished PLWHA and HIV-positive pregnant and lactating women
from households that are determined to be food insecure or households with an
HIV-exposed child Screening is done using the following criteria:
o BMI for adults (≤ 18.5) 2 or
o Weight loss of 5% or more of body weight or
o HIV-positive pregnant and lactating women or
o HIV-exposed children between the ages of 0-24 months (or beginning at
the time their mother ceased exclusive breastfeeding) and HIV-infected
children between the ages of 6-24 months.

2
This is the standard used in most countries to identify malnourished, non-pregnant adults and is based on the
1996 recommendations of the WHO Expert Committee on Physical Status to determine underweight.

70
 Inclusion should be based on indicators of food insecurity. These indicators can
include community specific factors developed with local community social
workers/leaders for the identification of food insecure households. These
indicators can include such things as reportedly having eaten less than 2 meals
on the day preceding the interview, having reduced the portion (size) of food
served or resorted to borrowing/bartering for food in the week preceding the
interview.

Ration composition: The recommended ration is based on 60% of the WFP PMTCT ration
because it is the most comprehensive, complete and balanced ration currently
being given in the country (Table 2). This ration is based on the assumption that
target HHs source 40% of their RDAs from own resources (own
production/family support/purchase, etc).

Table 2. Minimum Household Food Package for Nutritional Care and Support of PLWHA
in food insecure households.

Quantity per Unit Monthly Annual

Target Food Item HH/month cost/MT Cost/HH Cost/HH
Group (Commodity) (Kg) Kcal/pp/day in US$ in US$ in US$
Maize meal 15.0 230 3.45 41.40
Pulses 15.0 440 6.60 79.20
PLWHA SOSOMA 3.0 290 0.87 10.44
1572
& HH**. Sugar 1.8 380 0.68 8.16
Oil 2.2 liters 800 1.76 21.12
Total 13.36 160.32
** Household size is assumed to be 5 persons.

Duration of Intervention: The duration of the intervention will be 6 months for

malnourished PLWHA and HIV+ lactating women from food insecure
household to give them a chance to rehabilitate their nutritional status,
possibly delay the time when they will need to be on ART and to provide an
income transfer for the food insecure household, which might help them get
back on their feet. If the malnourished PLWHA from a food insecure
household is also beginning ART, then the food package may help them better
adhere to the medication regiment.

Pregnant or lactating HIV+ women from food insecure households might

be screened at anytime during the pregnancy, but ideally should be given the
food package from the third trimester through 6 months of lactation (i.e., a
maximum of 9 months).

Sustainability: Food and nutrition interventions should be undertaken within the National
Nutrition Policy context. That is, for this intervention to succeed and be
sustainable, it will require the implementation of the activities detailed in the
National Nutrition Strategy by relevant stakeholders.

PART II: Replacement Feeding and Complementary Feeding Packages for

Nutritional Care and Support for HIV-exposed and infected children
aged between 0 to 24 months in food insecure households.

71
Basis: Children’s RDAs for energy (WHO 2005 – Table 3) were considered in the
proposal of this replacement feeding package and are given below (Tables 4 to
6) for various age groups. However, considering that the target beneficiaries
are HIV-exposed and infected children, the best option is to base the
recommendations on a ration that would take into consideration the increased
needs related to HIV/AIDS infection. As such, the Nutrition Working Group
adopted the normal child RDAs for energy as the basis for this
recommendation and added on energy increases for asymptomatic and
symptomatic children.

Table 3: Recommended Daily Requirements for energy (WHO, 2005) for children
(under 24 months) exposed to or infected with HIV/AIDS.

Target group Energy needs Asymptomatic Symptomatic From From From

for normal or children children breast replacement complementary
HIV-negative (+10%) (+50%) milk milk food
children
Infant 0-6
months old
exclusively 585 644 878 100% 0% 0%
breastfed3
Infant 0-6
months old on
exclusive 585 644 878 0% 100 % 0%
replacement
feeding
Infant 6-8
months old 680 748 1020 0% 60% 40 %
Infant 9-11
months old 830 913 1245 0% 45 % 55 %
Children 12-
23 months old 1090 1199 1635 0% 31 % 69 %

Eligibility: Assess the AFASS conditions for mother (household) before recommending
replacement feeding for HIV-exposed children between 0-6 months of age.

Inclusion should be based on indicators of food insecurity. These indicators can

include community specific factors developed with local community social
workers/leaders for the identification of food insecure households and/or such
indicators as reportedly having eaten less than 2 meals on the day preceding the
interview, having reduced the portion (size) of food served or having resorted to
borrowing/bartering for food in the week preceding the interview.

Ration composition: For HIV-exposed children below 6 months, breastmilk or replacement

milk or infant formula (according to AFASS conditions) should be the only food
given. From 6-24 months, besides replacement milk or infant formula,
complementary feeding should be provided. For HIV-infected children the
recommendation is to continue breastfeeding until 24 months or longer. The
complementary package would be made available for the infant from 6-24
months.
3
HIV-infected infants should be exclusively breastfed until 6 month, with breastfeeding continuing until 24
months or longer

72
The total package for HIV-exposed and infected children in food insecure households
includes the following:

1. The household of a child of an HIV infected mother who is food insecure and who
chooses to exclusively breastfeed will receive:
a. The Minimum Household Food Package for PLWHA to support the mother in
exclusive breastfeeding and to provide complementary food for the child
after 6 months;
b. Replacement milk or infant formula from the time a replacement food is
introduced (no later than from 6 months) until the child is 24 months old
according to age specific requirements to cover the child’s RDA coming from
milk;
c. Nutrition counseling
d. A follow-up plan to support the mother in her feeding option choice.

2. The household of an HIV infected mother who chooses to exclusively feed with
replacement feeding will receive:,
a. Replacement milk or infant formula from birth to 24 months according to
age specific requirement to cover the child age specific RDA coming from
milk;
b. The Minimum Household Food Package for PLWHA to provide
complementary food for the child after 6 months;
c. Nutrition counseling
d. A follow up plan to support the mother in her choice.

3. For HIV infected children

a. The Minimum Household Food Package for PLWHA to provide
complementary food for the child after 6 months
b. Nutrition counseling
c. A follow up plan to support the mother with breastfeeding

Duration of Intervention: The targeted children will receive the replacement feeding
package beginning from birth or when the mother opts to stop exclusive
breastfeeding up to 24 months. The households of these children will also be
qualified for the Minimum Household Food Package for 24months. However,
these food packages still need to be complemented by foods obtained through the
households’ own resources to cover the child specific RDA requirements.

Sustainability: Food and nutrition interventions should be undertaken within the National
Nutrition Policy context. That is, for food and nutrition interventions to succeed
and be sustainable, it will require the implementation of the activities detailed in
the National Nutrition Strategy by relevant stakeholders.

73
Table 4. Replacement Feeding and Complementary Feeding Packages for HIV-exposed
children between 0-24 months
Quantity per Monthly Annual
Food Item child/month Cost/Child Cost/Child
Target Group (Commodity) (L/tins) Kcal/day in US$ in US$ Remarks
Infant 0-6 months Breastmilk 585 Breastfeeding on
who are demand, or at least
exclusively 8 feeds per day,
breastfed including night
feeding
Infant 0-6 months Replacement 585 Counseling
who are milk provided on safe
exclusively on replacement
replacement feed feeding
Cow’s Milk Preparation: Dilution ratio: 1 water + 2 milk + sugar to taste
22.5 Liters 495 9.9 118.8 Average of 750 ml
(85%) per day
Sugar 1.5 kg 1.8 21.6 700 RFW/Kg; 50 g
per day
Option 1 Safe (boiled or 11.5 liters 10.1 121.2 RFW 500/Liter
portable) water
Feeding Cup 2 2 6.0 3 cups/year
Flask 1 4 8.0 2 flask per year
Miscellaneous 5 5.0 Soap, etc…
Sub-Total 35.8 292.6
Infant Formula
Commercial 7 585 43 516.0 40 tins of
formula 500g/year; an
average of 7
tins/month; and
Option 2 RFW 3500/tin
Potable water 11.5 liters 10.1 121.2 RFW 500/Liter
Feeding Cup 2 2 6.0 3 cups/year
Flask 1 4 8.0 2 flasks/year
Miscellaneous 5 5.0 Soap, etc…
Sub-Total 64.1 656.2
Average energy
830
requirements for
age
Average of 900 ml
6-12 months Cow’s Milk 374 per day (150 ml x 6
27.0 11.8 141.6
(Litre) (45%) feeds) ; 250 RWF
per liter of milk
456 127 g/day, + other
**SOMA (Kg) 3.8 3.3 39.7
(55%) snacks to complete.
Subtotal 15.1 181.3
Average energy
1090
intake between age
12-24 months
Average of 900 ml
12-24 months Cow’s Milk per day (150 ml x 6
27.0 11.8 141.6
(Litre) 338 (31 feeds) ; 250 RWF
%) per litre of milk
752 (69 208 g/day, + other
SOMA (Kg) 6.2 5.4 64.8
%) snacks to complete.
Subtotal 15.4 206.4
**SOMA composition (WFP Rwanda Specifications: 800Kg of maize meal & 200Kg of soya flour plus Vitamin/mineral mix (per 100g of
flour mix (finished product) of Vit A (1,664.0 IU), Vit B1 (0.128mg), Vit B2 (0.448), Vit B3 (4.8mg), Folate (60.00μg), Vit C (48.0mg), Vit
B12 (1.2μg), Iron - as ferrous fumerate (8.0mg), Calcium – as calcium carbonate (100.0mg), Zinc – as zinc sulphate (5.0mg). Energy

74
content ≅ 380 Kcal/100g. SOMA is WFP’s locally purchased from the Duhamic/Adri with WFP specifications for fortification and is similar
to the common SOSOMA sorghum product.

Table 5: Complementary Feeding package for HIV-infected, asymptomatic children

between 0-24 months in food insecure households.
Food Item Monthly Annual
(Commodity Quantity Cost/Chil Cost/Chil
Target Group ) per month Kcal/day d in US$ d in US$ Remarks
Breastfeeding on
demand, or at least 8
feeds per day, including
night feeding
Infant 0-6
Breastmilk 644
months Provide the qualifying
mother with the
Household Food
Package to support
breastfeeding.
Average daily
913
requirement for this age
Breastmilk 411 (45%)
Average of 3Kg (90
From 6-12 SOMA (Kg) 2.7 502 (55%) 2.4 28 g/day x 30 days) @
months $0.87 per Kg
Feeding Cup 2 2 6.0 3 cups/year
Flask 1 4 8.0 2 flasks/year
Miscellaneou
5 5.0 Soap, etc…
s
Sub-Total 13.4 47
Average daily
1199 requirement for this age
372 (31
From 12 -24 Breastmilk
%)
months
Average of 6.6 (218
827 (69
SOMA (Kg) 5.7 5.7 68 g/day x 30 days) x 0.87
%)
$ per Kg
Sub-Total 5.7 68

75
Table 6: Complementary Feeding Package for HIV-infected, symptomatic children
between 0-24 months in food insecure households.

Food Item Monthly Annual

Target Group (Commodity Quantity Cost/Child Cost/Chil
(age) ) per month Kcal/day in US$ d in US$ Remarks
Breastfeeding on
demand, or at least 8
Infant 0-6
Breastmilk 878 feeds per day,
months
including night
feeding
Average daily
1245 requirement for this
age.
560 (45
Breastmilk
%)
Average of 5.4 (180 g
6-12 months SOMA (Kg) 5.4 5 60.0 per day x 30 days) x
685 (55%)
0.87 $ per Kg
Feeding Cup 2 2 6.0 3 cups/year
Flask 1 4 8.0 2 flasks/year
Miscellaneou
5 5.0 Soap, etc…
s
Sub-Total 16.0 79.0
Average daily
1635 requirement for this
age
12-24 months Breastmilk 736(45 %)
Average of 7.1 (237 g
SOMA (Kg) 7.1 6.2 74.1 per day x 30 days) x
899 (55%)
0.87 $ per Kg
Sub-Total 6.2 74.1

76
ANNEX 18: SOME RECIPE SUGGESTIONS
Below are suggestions for foods and drinks that may help to address some of the common
complications arising from HIV/AIDS? All recipes may be adapted to locally available foods
and taste preferences.

Garlic/ Onions

Garlic and onions strengthens the immune system and can be eaten both raw and cooked.
Garlic can be crushed, stored in oil and used for cooking
Place a slice of onions in hot water for a few minutes and then drink the water

Lemons

Lemons stimulate the liver, clean the digestive tract and help prevent infections. They aid
digestion of proteins and fats. The peel of lemons and oranges contains pectin which helps
the body to absorb fats and oils.

Gamatungu (Alfalfa)

Gamatungu is grown as livestock feed. It contains almost every vitamin and mineral. Add
finely chopped alfalfa leaves to soups, salads and stews as a spice.

Ginger

Chew fresh ginger or use ginger powder or crushed ginger in soups, stews and tea. (See
below)

Cultured milk (Ikivuguto)

Cultured milk products such as yogurt, sour milk (Ikivuguto) have friendly bacteria that fight
a range of micro- organisms that can cause diseases.

Pumpkin seeds

Remove the outer shell and eat the seeds raw or steamed to provide zinc, essential fatty acids.
It also aids in expelling worms.

Sour water

Drink regularly to prevent digestive infections. To make sour water, you can use any grain –
millet, sorghum, rice or maize. It is best to use sprouted grain.

Recipe is for sorghum: (Sorghum; potable water )

• Wash the sorghum

• Soak 1-cup sorghum in 3 cups water
• Cover tightly and leave for 2-3 days

77
 • Strain the water from the sorghum. Store the sour water in a cool place or in the
fridge.
• Drink ½ cup, 3 times a day for all digestive problems.

The sorghum water is ready to drink when it starts to form bubbles. The warmer the weather,
the sooner it will be ready. The water can be mixed with lemon, fruit juice or spice tea for
better taste and smell.

Avocado drink

Mashed avocado; sour milk or lemon juice; finely chopped raw onion, garlic and tomato.
Mix all the ingredients together.
Drink with bread, green beans (imiteja), carrots, green pepper or pumpkin.

Peanut (ubunyobwa) sauce

High protein sauce to eat with ugali and raw or steamed vegetables.

Use onions, garlic, oil, water, pounded peanut, lemon, ginger (Use whatever combination that
is available)
Fry the onions and garlic in oil until brown
Stir in all the other ingredients and cook the sauce at medium heat until it is smooth

Ndagala (dried fish) stew

Ndagala, onions, tomatoes, oil, water, salt, green pepper

Thoroughly wash the fish, boil until cooked

Fry onions, tomatoes, and green pepper.
Add water and put in ndagala. Boil for 5 minutes.

Ndagala can also be cooked in a groundnut sauce.

Isombe

Cassava leaves (mashed), palm oil, tomatoes, groundnuts, broth (meat or fish), leek and
garlic. Cook mashed cassava leaves until smooth. Add other ingredients and cook again and
add groundnut and palm oil. Cook the mixture for few hours.

Bean broth (amamininwa)

Beans, water, salt
Boil the beans in more water than usual until they are well cooked. Drink the broth or use it
to make other soups. You can also boil rice, maize meal or millet with the broth to add
carbohydrates for more energy.

Beef and beans

Minced beef, onion, oil, beans (soaked overnight), carrots, salt, water, spinach or other green
leaves, lemon juice, (pepper optional)

78
Sauté beef and chopped onion. When meat is brown add beans, chopped carrots, salt and
pepper. Add water, cover and cook until beans are tender (about 30 minutes). Add chopped
green leaves and boil another ten minutes. Add a bit of lemon juice.

Vegetable stew
Greens or other vegetables (such as cabbage, pumpkin, squash, green beans, sprouted beans
or peas), onions, garlic, ginger, cinnamon, coriander or mild curry powder, pili-pili (if you
like a hot taste), oil, chopped meat (optional; use bones or mince), water, carrots, tomatoes,
potatoes, lemon juice
Boil the meat and water until tender. Chop and add the vegetables except the greens. Cover
and simmer until the vegetables are soft. Add the chopped greens ten minutes before the dish
is ready.

Maize/sorghum/millet/rice/wheat porridge
Maize meal, milk, margarine, salt, sugar
Mix maize/sorghum/millet flour with cold water. Cook the mixture with milk or water for
about 15 minutes. Add a little oil and a pinch of salt and sugar to taste. Serve warm.

Sweet potato soup

Sweet potatoes, water, salt, ikivuguto (sour milk).
Peel sweet potatoes, cut them in pieces and cook in a little water until soft. Mash them and
add more water to make a soup. Add salt, and sour milk; Serve.

Vegetable stew with meat

Meat, onion, leeks, carrots, potatoes, oil, water, garlic, salt, pepper
Cut meat and vegetables in small pieces. Boil or fry meat until brown, add onion and leek.
Then add the other vegetables, water and chopped garlic and cook until soft. Serve

Pumpkin stew
Pumpkin, meat
Boil meat with chopped pumpkin until very soft. Mash the pumpkin. Cut the meat into small
pieces and add to the pumpkin.

Rice porridge
Rice, salt, cinnamon, sugar
Add one cup of rice to three cups of salted water. Cover the pot, bring to the boil and cook
slowly for one hour. Add cinnamon and sugar when serving.

Banana and papaya drink

Banana, papaya, milk, sour milk or yoghurt
Mash fruit together and mix with milk, sour milk or yoghurt.

Sour cabbage water

Chopped raw cabbage, water
Wash the cabbage and soak one-cup cabbage in three cups water. Cover tightly and leave for
two to three days. Strain the water from the cabbage, throw the cabbage away and store the
water in a cool place or refrigerator. It is ready to drink when it starts to bubble. Drink 1/2
cup three times a day for all digestive problems.

79
HERBAL DRINKS FOR COLDS, COUGHS, SORE THROATS AND FLU

For the teas below to have the greatest impact, it is best to prepare them fresh three times a
day and drink them hot. However, if this is not possible, prepare them in the morning and
heat them up or even drink them cold during the day.

Garlic tea (for sore throats)

Chop 3-4 cloves garlic. Add to one cup boiling water. Boil for ten minutes. Cover and allow
to cool. Add honey or sugar to taste. Drink one cup three times a day.

Ginger drink
8 cups clean water, 3 teaspoons fresh crashed ginger, 2 teaspoons sugar, 1 small chopped
pineapple
Mix all the ingredients and leave in a warm place for a day in a clean and covered container.
Drink the ginger juice.

Ginger tea
Ginger, water
Crush ginger in cold water and boil in water for ten minutes. Place in a covered container,
strain the ginger and drink three cups of the liquid per day before meals.

Ginger and cinnamon tea (for chesty colds or coughs)

Add 1/2 teaspoon chopped fresh ginger to one cup boiling water. Boil slowly for ten minutes.
Add 1/4-teaspoon ground cinnamon. Cover and allow standing for five minutes. Strain. Drink
one cup three times a day. Start drinking the tea as soon as you feel a cold coming.

Guava tea (for a persistent cold)

Add a chopped guava, a slice lemon, and a eucalyptus leaf to a cup of boiling water. Cover
and allow to stand for five minutes. Drink three times a day.

Lemon tea (for flu)

Squeeze a lemon. Add the juice to 1/2-cup water that has boiled and cooled slightly. Add
sugar or honey to taste. Drink one cup as hot as possible three times a day.

Onion tea (for a blocked and runny nose)

Put 1/4 onion into a cup of boiling water. Cover and leave for five minutes. Strain. Throw the
onion away. Drink one cup three times a day.

Thyme tea (for dry coughs)

Add 1/4 teaspoon dried thyme leaves to one cup boiling water. Cover and leave for five
minutes. Strain. Drink one cup three times a day.

COUGH SYRUPS

Cough syrup for adults or children

Mix one part honey with one part lemon juice, one part crushed ginger (but not for children)
and one part water. Stir well and bring to the boil. Cool, and take one teaspoon three times a
day.

80
(An alternative is to mix one part honey with one part lemon juice. Add two finely chopped
garlic cloves. Shake or stir well. Take one teaspoon three times a day.)

FEVER

Neem tea
Cut a fresh twig from a neem tree. Remove the leaves and boil the bark in water; the bark can
also be chewed.
Traditional foods can give you a healthy diet. To eat healthy diets avoid eating the following
foods.

Avoid as much as possible refined foods or highly processed foods, alcohol. Alcohol prevents
the body from using the nutrients in food, stresses the digestive system and stops the immune
system from working properly.

81