The present study involved 336 HIV care and treatment sites from nine sub-Saharan African countries (Kenya, Tanzania, Ethiopia, Rwanda, Mozambique, South Africa, Nigeria, Lesotho and Cote d’Ivoire) that were receiving technical support from the International Center for AIDS Care and Treatment Programs (ICAP; www.columbia-icap.org) at Columbia University’s Mailman School of Public Health.

Table 1 describes the location, site characteristics and prevalence of the reported availability of nutritional support services in the sample of 336 HIV care and treatment sites in the nine sub-Saharan African countries. Of these, 185 (55 %) were situated in urban areas and 151 (45 %) in rural areas. By July 2008, these sites had cumulatively enrolled 467 175 patients in HIV care and treatment (including 40 430 (9 %) children and 429 745 adults (91 %)), of whom 210 019 individuals (45 %) had initiated ART (including 16 507 (8 %) children and 193 512 (92 %) adults). Of the 336 sites surveyed, 303 (90 %) reported the availability of at least one form of nutritional support service.

Among the 303 HIV care and treatment sites for which at least one form of nutritional support service was available, 140 (46 %) were primary care sites, 152 (50 %) were secondary care sites and eleven (4 %) were tertiary care sites; twenty-one sites (7 %) had a nutritionist onsite and weight-for-height evaluation was available at 282 (93 %) sites. Among these 303 HIV care and treatment sites, the extent of availability of specific nutritional support services varied substantially (Fig. 1). Nutritional counselling was reported to be available at 98% of sites (range across countries (RAC): 94–100 %). Nutritional counselling for adults was reported to be available at 95% of sites (RAC: 75–100 %) and infant feeding counselling for mothers with infants at 91% (RAC: 81–100 %) of sites. Micronutrient supplementation was reported to be available at 64% of sites (RAC: 2–100 %) and multivitamin and mineral supplementation at 25% (RAC: 0–97 %) of sites. Vitamin A supplementation to infants, postpartum women and other adults/non-infant children was reported to be available at 52% (RAC: 2–89 %), 41% (RAC: 0–77 %) and 19% (RAC: 0–58 %) of sites, respectively, and Fe supplementation was reported to be available at 47% (RAC: 0–89 %) of sites. Treatment for severe malnutrition was reported to be available at 36% of sites (RAC: 0–72%). Treatment for severely malnourished adults was reported to be available at 23% (RAC: 0–72 %) of sites and services for infants and children aged <5 years were available at 33% (RAC: 0–69 %) of sites. Food rations were reported to be available at 31% (RAC: 2–97%) of sites, including rations for adults to promote medication adherence and household food security at 18% (RAC: 0–87 %) and 4% (RAC: 0–13 %) of sites, respectively. Food rations were reported to be available for children aged <5 years to promote medication adherence and household food security at 13% (RAC: 0–77 %) and 7% (RAC: 0–22 %) of sites, respectively.

In bivariate analysis (Table 2), nutritional counselling was more commonly reported to be available at secondary or tertiary care sites compared with primary care sites (93% v. 85%, P = 0·026) and at sites where weight-for-height evaluation was available (98% v. 39%, P < 0·001). Micronutrient supplementation was more commonly reported to be available in rural compared with urban sites (65% v. 52%, P < 0·016) and at sites where weight-for-height evaluation was available (65% v. 17 %, P < 0·001). Treatment for severe malnutrition was more commonly reported to be available at sites providing ART services for over 2 years (50% v. 21%, P < 0·001), at sites that reported a nutritionist on staff (57% v. 31%, P = 0·013) and at sites where weight-for-height evaluation was reported to be available (38% v. 4%, P < 0·001). The reported availability of food rations was higher at sites providing ART for at least 2 years (45% v. 18%, P < 0·001) and at sites where weight-for-height evaluation was reported to be available (33% v. 2%, P < 0·001).

In multivariate analysis (Table 3), secondary or tertiary care sites were associated with a higher odds of nutritional counselling availability (adjusted OR (AOR) AOR_{secondary/tertiary v. primary} : 2·2, 95% CI 1·1, 4·5). Rural sites (AOR_{rural v. urban} : 2·3, 95% CI 1·4, 3·8) and sites where weight-for-height evaluation was available (AOR_{weight-for-height v. none} : 11·0, 95% CI 5·0, 24·0) reported higher odds of micronutrient supplementation availability. Sites that had provided ART for at least 2 years had a higher odds of having treatment for severe malnutrition (AOR_{≥2 years v. <2 years} : 2·4, 95% CI 1·4, 4·1). Sites that had provided ART for a minimum of 2 years (AOR_{≥2 years v. <2 years} : 1·6, 95% CI 1·3, 1·9) and rural sites (AOR_{rural v. urban} : 2·4, 95% CI 1·4, 4·4) had greater odds of reported availability of food rations.

Of the 336 sites, 174 (52 %) had information available from the three consecutive PFaCTS surveys (January 2007, July 2007 and July 2008) and were included in the time-trend analysis. Over the 18-month period, micronutrient supplementation and treatment for severe malnutrition became increasingly more common. The percentage of sites with availability of micronutrient supplementation increased from 19% in January 2007 to 56% in July 2008 (P < 0·001). Similarly, the percentage of sites with availability of treatment for severely malnourished individuals also increased significantly (from 24% in January 2007 to 40% in July 2008, P = 0·001). No significant trend was detected in the availability of nutritional counselling (P = 0·86) or food rations (P = 0·08), although the prevalence of the former was already high (87 %) in January 2007. In order to verify that no bias resulted from the exclusion of sites without three consecutive surveys, we re-ran the time-trend analysis including all sites. This analysis similarly found a significant increase in the availabilities of micronutrient supplementation (P < 0·001) and treatment for severe malnutrition (P = 0·006) and no significant trend for other nutritional support services.

This investigation evaluated the prevalence and correlates of the reported availability of different types of nutritional support services in HIV care and treatment sites in multiple sub-Saharan African countries. Ninety per cent of sites had at least one form of nutritional support service. However, the type of nutritional support services reported to be available varied substantially, including by country, geographical context (urban/rural) and site-level characteristics (type of site, age of programme, reported presence of a nutritionist on staff).

The fact that nutritional counselling to adults and to pregnant and lactating mothers was reported to be available at 95% and 91% of sites, respectively, is encouraging. Nutritional counselling is considered to be a cornerstone of HIV treatment support, recommended by multiple international guidelines^(36,39,40). Nutritional counselling is also important for supporting HIV-affected households. Studies in sub-Saharan Africa have found that HIV-exposed but uninfected children have poorer growth compared with HIV-uninfected children, possibly because of reduced breast-feeding practices by HIV-infected mothers⁽⁴¹⁾. Exposure to nutritional counselling and education about safe breast-feeding practices is associated with increased weight gain and a reduced risk of postnatally acquired HIV infection among HIV-exposed infants, respectively ^(42,43). Sustained programme efforts and optimization of general and infant feeding counselling are critical, particularly as rates of exclusive breast-feeding among HIV-infected mothers remain low in many settings where it is recommended⁽⁴⁴⁾.

Although some type of micronutrient supplementation was reported to be available at 64% of sites, this mostly included vitamin A and Fe supplementation. The fact that multivitamin and mineral supplementation was reported to be available at only 25% of HIV care and treatment sites suggests that there is room for improvement. Studies have found that many people living with HIV/AIDS suffer various micronutrient deficiencies and have increased micronutrient needs⁽⁴⁵⁾. However, evidence of the effectiveness of micronutrient supplementation on HIV-infected adults and children remains limited, and findings have been heterogeneous. Supplementation of specific vitamins and minerals has been associated with several clinical benefits among people living with HIV/AIDS, including reduced risk of hospitalization⁽⁴⁶⁾, increased CD4 cell count levels⁽⁴⁷⁾ and reductions in all-cause mortality⁽⁴⁸⁾. Among individuals receiving ART, micronutrient supplementation has been variously correlated with improved immunological, virological and clinical status and may facilitate decreases in mitochondrial dysfunction, oxidative stress and metabolic complexities⁽⁴⁹⁾. A recent meta-analysis found that periodic vitamin A supplementation of HIV-positive children aged >6 months was associated with reduced all-cause mortality, but additional research is required to determine the impact on HIV-infected adults⁽⁴⁸⁾. Results from studies evaluating the impact of other specific micronutrients, such as vitamin E, Se, Zn and Fe, on HIV-infected individuals remain inconclusive⁽⁴⁵⁾. Although the reported availability of micronutrient supplementation at some of the HIV care and treatment sites in our sample is encouraging, the expansion of access to micronutrient supplementation must be evidence-informed via research studies, with scale-up, safety and adherence carefully monitored at site and patient levels to ensure optimal outcomes.

Food rations were reported to be available at 31% of HIV care and treatment sites. Macronutrient supplementation, commonly comprising corn–soya blend, fortified blended foods and high-energy ready-to-use therapeutic foods (RUTF), is often used as a replacement of, or complement to, regular staple foods⁽⁵⁰⁾. Supplemental feeding is often used to mitigate the impacts of mild and moderate malnutrition and to prevent further deterioration of nutritional status to severe acute malnutrition.

Studies have noted that provision of food rations may be associated with improved medication adherence and retention in HIV care and treatment in sub-Saharan Africa, which is both a major and persistent challenge of scale-up in the region^(51,52). In a qualitative programme evaluation from Kenya, provision of household food rations to food-insecure individuals on ART improved treatment adherence, reduced drug-related side effects and increased appetite satisfaction, weight gain and physical strength⁽⁵³⁾. A randomized controlled trial involving 636 food-insecure adults starting ART in Zambia found that individuals who received home-based WFP rations were 1·5 times more likely to achieve 95% ART adherence, compared with the control group⁽⁵⁴⁾. Finally, we reported in a previous ecological analysis of 108 056 individuals initiating ART across ten sub-Saharan African countries that the reported availability of food supplementation was significantly associated with higher retention in HIV care and treatment ⁽⁵⁵⁾. The impact of fortified food supplementation on HIV-affected individuals is varied. A randomized controlled trial in Zambia comparing the impact of a basal v. micronutrient-fortified infant porridge in Zambia found that micronutrient supplementation did not reduce stunting or hospital referrals among HIV-exposed children but did improve Fe status and anaemia⁽⁵⁶⁾. Given the high burden of food insecurity in sub-Saharan Africa⁽⁶⁾, availability of food supplementation in HIV care and treatment sites to HIV-infected and -affected individuals could promote individual and household food security and clinical outcomes.

Treatment for severe malnutrition was reported to be available at 36% of HIV care and treatment sites and was more likely to be reported to be available at sites that had been providing ART for more than 2 years. This may be because longer established ART sites have increased logistic capacity, compared with more recently established ART sites⁽⁵⁷⁾. Interestingly, the likelihood of reported availability of treatment for severe malnutrition was similar at primary, secondary and tertiary care sites. This finding is surprising given that, until recently, the WHO clinical guidelines recommended in-patient hospital admission and prescription of high-energy milk products for the treatment for severe acute malnutrition. Operations research in sub-Saharan Africa now suggests that community-based distribution of RUTF is just as feasible and safe as, and more cost-effective than, hospital-based rehabilitation⁽⁵⁸⁾. Our findings that availability of treatment for severe malnutrition has expanded significantly even over a 1·5-year period suggest that ART treatment and care sites may be distributing RUTF products. These findings are promising given that RUTF use has been associated with rapid weight gain, improvements in physical activity and increased uptake of VCT and ART services among HIV-positive individuals with severe acute malnutrition^(59,60).

Our study has several strengths and limitations. The strengths of our study include the large number of sites, which allowed us to conduct an analysis of the reported availability of nutritional support services in scale-up programmes across several sub-Saharan African countries and settings. We were also able to include rural sites and primary health centres, increasing the generalizability of the findings. All PEPFAR-supported HIV care and treatment sites are situated within the public sector and as such are representative of African countries’ national efforts to scale-up ART access. Although the sites included in our sample are likely not representative of all HIV clinics in the region or within each country, they represent primary, secondary and tertiary scale-up sites from a diverse array of settings and contexts. These sites represent a substantial proportion of all patients initiating ART in sub-Saharan Africa, including over 7% of the estimated 2·925 million people receiving ART in the continent in 2008⁽⁶¹⁾.

The study survey tool was formally tested for reliability and accuracy and was found to have a good level of reliability between staff- and supervisory-completed responses. The following data management systems likely contributed to this high level of agreement, and additionally contributed to consistency of data quality across study sites and countries: (i) responses to surveys were recorded following a process of discussion and consensus among site staff; (ii) surveys were administered at sites using standard operating procedures, with reference to clearly defined indicators; and (iii) all data were computer-recorded using automated data entry controls and logic checks, followed by systematic data cleaning.

A major limitation is that site surveys solicited information only about the availability of different types of services and did not ascertain the access, quality, comprehensiveness or coverage of the indicated services at the sites. Thus, no information is available on the actual number, proportion or subsets of patients who utilized these services. For example, although the proportion of sites that reported availability of nutritional counselling or weight-for-height evaluation was high, we could not assess the proportion of patients who actually received these services at the sites in our sample⁽⁶²⁾. The amount of micronutrient supplementation available to clients at each site was unknown, and likely varied given the differences between the WHO and regional recommendations for recommended nutrient intake⁽⁴⁵⁾. We were unable to assess what types of food rations were available and whether these were intended for use by all HIV-positive individuals, by specific groups of HIV-infected groups or by HIV-affected households. Finally, we were unable to ascertain the types of treatment that were available for severe malnutrition and the extent to which RUTF products may have contributed to rapid increases in availability. Consequently, these data are most useful for macro-level policy and programmatic planning.

Our study is in alignment with the United Nations General Assembly Special Session (UNGASS) Declaration of Commitment on HIV/AIDS’ goal of monitoring and evaluating process outputs from HIV treatment and care facilities⁽⁶³⁾. These findings can directly assist national Ministries of Health and their partners’ efforts to monitor the rollout of HIV-related support services in accordance with national policies, to identify time-bound national goals for improving support to people living with HIV/AIDS and to track changes in the availability of these services over time⁽⁶³⁾. UNGASS 2010 Guidelines on the Construction of Core Indicators failed to explicitly recommend the collection of national programme indicators on nutritional support to adults and children living with HIV/AIDS and their affected households⁽⁶⁴⁾. Cross-national health facility data on the availability of nutritional support services are essential to effectively monitor and evaluate global HIV treatment and care outcomes.

Basic nutritional support services were reported to be available at a large number of public sector HIV care and treatment sites across urban and rural settings in several sub-Saharan African countries. Reported availability of specific nutritional support services varies by country, geographical context and clinical or programme characteristics. These findings can inform Ministries of Health and their partners in their efforts to make these services available at sites that provide HIV care and treatment in accordance with national policies⁽⁶³⁾. Expansion of availability of nutritional services is of critical importance. Further efforts are urgently needed to determine, in addition to availability, the uptake, quality and effectiveness of these services and their impact on programme outcomes such as adherence to ART, retention in care and survival.