Global mid-upper arm circumference cut-offs for adults: a call to action.

Since 2009, mid-upper arm circumference (MUAC) has become an accepted measure for screening children for acute malnutrition and determining eligibility for services to manage acute malnutrition. Use of MUAC has increased the reach and enhanced the quality of community-based management of acute malnutrition services. Increasingly, MUAC is also used to assess nutritional status and eligibility for nutrition support among adolescents and adults, including pregnant and lactating women and HIV and TB clients. However, globally recognised cut-offs have not been established to classify malnutrition among adults using MUAC. Therefore, different countries and programmes use different MUAC cut-offs to determine eligibility for programme services. Patient monitoring guidelines provided by WHO for country adaptation to support the integrated management of adult illness do not include MUAC, in part because guidance does not exist about what MUAC cut-off should trigger further action.

A 6-Country Collaborative Quality Improvement Initiative to Improve Nutrition and Decrease Mother-to-Child Transmission of HIV in Mother-Infant Pairs.

Despite advances in coverage and quality of prevention of mother-to-child transmission (PMTCT) programs, infant protection from postnatal HIV infection remains an issue in high HIV-burdened countries. We designed a quality improvement (QI) intervention-the Partnership for HIV-Free Survival (PHFS)-to improve infant survival. PHFS convened leaders in 6 sub-Saharan African nations to discover together the best strategies for implementing and scaling up existing PMTCT protocols to ensure optimal health of mother-baby pairs and HIV-free infant survival. We used 3 core technical components-rapid adaptive design, collaborative learning, and scale-up/sustainability designs-to test strategies for accelerating effective PMTCT programming in complex, resource-poor settings. Learning generated included the need for increased ownership and codesign of improvement initiatives with Ministries of Health, better integration of initiatives into existing programs, and the need to sustain QI capability throughout the system. PHFS can serve as a design prototype for future global networks aiming to accelerate improvement, learning, and results.

Reducing Mother-to-Child Transmission of HIV Using Quality Improvement Approaches.

Over half of mother-to-child HIV transmission (MTCT) occurs postdelivery. Keeping mother-infant pairs in care remains challenging. Health workers in 3 countries used quality improvement (QI) approaches to improve data systems, mother-infant retention, and facility-based care delivery. The number and proportion of infants with known HIV status at time of discharge from early infant diagnosis programs increased in Tanzania and Uganda. We analyzed data using statistical process control charts. Mother-to-child HIV transmission did not decrease in 15 Kenyan sites, decreased from 12.7% to 3.8% in 28 Tanzanian sites, and decreased from 17.2% to 1.5% in 10 Ugandan sites with baseline data. This improvement is likely due to the combination of option B+, service delivery improvements, and retention through QI approaches. Reaching the global MTCT elimination target and maximizing infant survival will require health systems to support mother-infant pairs to remain in care and support health workers to deliver care. Quality improvement approaches can support these changes.

Nutrition assessment, counseling, and support interventions to improve health-related outcomes in people living with HIV/AIDS: a systematic review of the literature.

BACKGROUND: Although numerous studies have shown that severe to moderate wasting at the time of antiretroviral therapy initiation is strongly predictive of mortality, it remains unclear whether nutritional interventions at or before antiretroviral therapy initiation will improve outcomes. This review examines data on nutrition assessment, counseling, and support interventions in resource-limited settings. METHODS: We identified articles published between 2005 and 2014 on the effectiveness of nutrition assessment, counseling, and support interventions, particularly its impact on 5 outcomes: mortality, morbidity, retention in care, quality of life, and/or prevention of ongoing HIV transmission. We rated the overall quality of individual articles and summarized the body of evidence and expected impact for each outcome. RESULTS: Twenty-one articles met all inclusion criteria. The overall quality of evidence was weak, predominantly because of few studies being designed to directly address the question of interest. Only 2 studies were randomized trials with no food support control groups. The remainder were randomized studies of one type of food support versus another, cohort (nonrandomized) studies, or single-arm studies. Ratings of individual study quality ranged from "medium" to "weak," and the quality of the overall body of evidence ranged from "fair" to "poor." We rated the expected impact on all outcomes as "uncertain." CONCLUSIONS: Rigorous better designed studies in resource-limited settings are urgently needed to understand the effectiveness of nutrition assessment and counseling alone, as well as studies to understand better modalities of food support (targeting, timing, composition, form, and duration) to improve both short- and long-term patient retention in care and treatment, and clinical outcomes.