Shanti Devi Memorial Health Justice Lecture Series

Ensuring food security for people

with TB and/or HIV
Dr K S Sachdeva
DDG
NACO, MoHFW
New Delhi
 Structure of presentation

Food Security - Concept

Indian Scenario
Under-nutrition, TB & HIV

Importance of food security/nutrition for TB and

HIV programmes

Linkages between RNTCP, NACP and food

security programmes
Present Scenario
Opportunities
 Food Security

Food security is a situation that exists when all

people, at all times, have physical, social and
economic access to sufficient, safe and nutritious
food that meets their dietary needs and food
preferences for an active and healthy life

870 million people (out of which 852 million from

developing countries) are estimated to have been
undernourished in the period 2010-12
FAO. 2002. The State of Food Insecurity in the World 2001. Rome.
FAO, WFP, and IFAD (2012). The State of Food Insecurity in the World 2012 (PDF). Rome: FAO.
 Food Security

People are considered food secure when they

have availability and adequate access at all
times to sufficient, safe, nutritious food to
maintain a healthy and active life

World Food Programme . https://www.wfp.org/node/359289. Accessed on 25th June 2017

 Community Food Security

Community food security exists when all

citizens obtain a safe, personally acceptable,
nutritious diet through a sustainable food
system that maximizes healthy choices,
community self reliance and equal access for
everyone

Public Health Association of British Columbia (PHABC)

 Household Food Security

Household food security refers to the ability of

the household to secure, either from its own
production or through purchases, adequate
food for meeting the dietary needs of all
members of the household

Food and Agriculture Organization. http://www.fao.org/ag/agn/nutrition/household_en.stm

Indian Scenario
 Under Nutrition: Indian Scenario

Nearly one-fifth of the adult population is

malnourisheda
Women whose Body Mass Index (BMI) is below
normal - 22.9%
Men whose BMI is below normal - 20.2%
Proportion of under-nourished adults higher
in 15-19 age groups, in women and in those of
lower quintiles of incomeb

a- National Family Health Survey 4 (2015-16), International Institute of Population Sciences

b- National Family Health Survey 3 (2005-6), International Institute of Population Sciences
 Tuberculosis: Indian Scenario

India had the highest tuberculosis (TB) burden

with 28 lakh cases annually, which accounts for
27% of the global burdena
Nearly 4.8 lakh people die from TB annually,
which accounts for 34% of the global burdena
Slowly declining incidence over the past 10 years
socio-behavioral, economic and environmental
factors including under-nutrition, barriers to
complete elimination of TB

a - WHO Global TB Report 2016

 HIV: Indian Scenario

India had the 3rd largest HIV burden -21.2 lakha

National adult HIV prevalence is 0.26% (2015)a
It also has the 2nd largest number of PLHIV on
Anti-retroviral therapy (ART) 10.4 lakhb
An estimated 67,600 people died of AIDS-
related causes (2015) with a declining trend

a - India HIV Estimate,2015, Technical Report. National AIDS Control Organization

b - National Strategic Plan NACO, MoHW
Importance of food security/nutrition
for TB and HIV programmes
 Under-nutrition and Risk for TB
Under nutrition contributes to an estimated 55% of annual TB incidence in India*

Vicious cycle Under-

of under nutrition
nutrition and
TB

Anorexia, Impaired cell-

inflammation, mediated
cytokines immunity

Tuberculosis

* Bhargava A et al. Undernutrition and the incidence of tuberculosis in India: National and subnational estimates of the
population attributable fraction related to undernutrition. Natl Med J India 2014
 Under-nutrition and Risk for TB
Relationship between
TB incidence & BMI - risk
of TB increases by about
14% for each unit
reduction BMI a

Population based study from N. India b, distribution of

under nutrition was highest among women, villagers,
younger age groups, members of lower quintiles of
wealth index
a - Lonnroth K et al. A consistent log-linear relationship between tuberculosis incidence and body mass index
Int. J. Epidemiol. 2010
b - * Bhargava A et al. Undernutrition and the incidence of tuberculosis in India: National and subnational estimates of the
population attributable fraction related to undernutrition. Natl Med J India 2014
 Under-nutrition and TB treatment outcomes

Risk of relapse 4 times compared to those with

normal weight a

Only about 1/3rd of men & 1/4th of women had

normal range BMI after successful treatment b

Nutritional support to TB patients resulted in

better outcomes c
a - Awal Khan et al.Lack of Weight Gain and Relapse Risk in a Large Tuberculosis Treatment Trial.
American Journal of Respiratory and Critical Care Medicine Vol 174. pp. 344-348, (2006)x
b - Bhargava A et al. Nutrional status of adult patients with Pulmonary TB in rural central India and its association with
mortality. PLosONE 2013
c - Pandey A et al. Impact of nutritional support to patients on first line anti-TB treatment in India -a case control study.
(unpublsihed)
 Nutrition and HIV
Under nutrition accelerates progression from HIV to AIDS &
risk of transmission from mother to babies

Insufficient dietary intake,

Malabsorption, Diarrhea,
altered metabolism and
nutrient storage

Increased HIV replication

Hastened disease Nutritional
progression deficiencies
Increased morbidity

Increased oxidative stress

Immune suppression

Complex interaction of under nutrition and HIV

 WHA resolution: Nutrition and HIV/AIDS

Resolution on Nutrition & HIV/AIDS passed in

59th World Health Assembly (WHA) in 2006
The resolution recommends:
making nutrition an integral part of the
response to HIV/AIDS
to strengthen, revise or establish guidelines
and assessment tools
support advocacy to raise awareness
of the urgent need to address
nutrition in HIV/AIDS response
 Guidelines on providing Nutritional Care and
Support for Adults Living with HIV & AIDS
Based on WHO Report of a Technical consultation on
Nutrient requirements of PLHIV
Guidelines provide practical recommendations for
institutionalizing nutritional support within health
facilities
Orient service providers to nutritional requirements of the
PLHIV at different stages of infection
Orient service providers to the various strategies
which can be used to address the nutritional
requirements of PLHIV
 SDG 2: Zero Hunger
UN General Assembly adopted Sustainable
Development Goals (SDGs) in 2015
SDG 2: End hunger, achieve food security and
improved nutrition, and promote sustainable
agriculture
India and other 190+ nations have promised
SDGs by 2030 - ensuring food security
and ending hunger (SDG-2) are among
the promises for all with no one left
behind principle
Sustainable Development Goals (SDGs) 2015.
https://sustainabledevelopment.un.org/?menu=1300 Accessed on 20th June 2017
 Guideline: Nutritional care and support
for patients with TB in India
Released by Health Minister on World TB Day 2017
Guiding principles for providing nutritional care and
support for TB patients from WHO guidelines (2013)
adapted to Indian context
Objective of the document includes
To provide guidance on nutritional assessment and
counselling of patients with active TB and their contact in
India
To provide guidance on management of under-nutrition in
patients with active TB in India
To provide operational guidelines for implementation
of nutritional support to households with patients
with active TB in India
Linkages between RNTCP, NACP
and food security programmes
 Linkages mechanisms - Process

Clinical assessment of nutritional status

Nutritional Anthropometric measurements &
assessment classification of nutritional status

Concept of healthy balanced diet

Nutritional Understanding foods and practices to avoid
counseling Use of locally available nutrient-rich food

Recommended energy, protein &

micronutrient intake
Nutritional
Management of moderate to severe under-
management nutrition in patients with enhanced family PDS
ration and a food basket
Linkages between RNTCP and food security
programmes: Present Scenario
Antyodya Anna Yojana
Support for food security

(Ministry of Food and Civil Supplies)

ICDS
(Integrated Child Development Services)

Food security Act 2013

(implemented in 11 states)

TB specific schemes
(Chhattisgarh, Mumbai, Karnataka, Kerala, Tamil Nadu)
 Linkages between RNTCP and food security
programmes: Opportunities
Scheme to provide monthly cash incentive for TB patients through DBT proposed in
National Strategic Plan for TB Elimination 2017-25

Resource
mobilization
(PRI/CSR/Inter-
sectoral)

Inpatient
Food basket
RNTCP & nutritional
procurement
food support
security
programmes

NGO Enhanced
schemes ration
(PDS)
 Linkages between NACP and food security
programmes: Present Scenario
1,64,435 patients linked to existing nutritional schemes (Dec 2016)
1,90,022 indirectly benefited through Livelihood scheme, Palanhar
Yojana & pension schemes.
Support for food security

Antyodya Anna Yojana

(22 states)

ICDS
38,578 beneficiaries

Nutritional support schemes

Double nutrition (8 states)
Linkages between NACP and food security
programmes: Opportunities
Emphasis on social protection package for PLHIV in National Strategic Plan
for HIV/AIDS and STI 2017 2024

Evolve basic Strengthening

minimum social District level
protection mechanisms for
package for PLHIV enrolment

NACP & food

security
programmes

Extension of Establishing
benefits of mechanisms of
schemes to uptake of
PLHIV schemes
 Conclusion
Institutionalize
nutrition
education
Synergy of inputs Improve access
from other to nutritional
departments
Food counselling
Security for
HIV & TB Scale up
Strengthen community
VHSNC based nutrition
interventions
Expand scope of
Reproductive &
sexual health
 Adequate nutrition cannot cure HIV infection,
but is essential to maintain the immune system
and sustain physical activity, and to achieve
optimal quality off life

Thank you

WHO Consultation of Nutrition and HIV/AIDS in Africa, Durban, South Africa, April, 2005