Agricultural and finance intervention increased dietary intake and weight of children living in HIV-affected households in Western Kenya

We tested whether a multisectoral household agricultural and finance intervention increased the dietary intake and improved the nutritional status of HIV-affected children. Two hospitals in rural Kenya were randomly assigned to be either the intervention or the control arm. The intervention comprised a human-powered water pump, microfinance loan for farm commodities, and training in sustainable farming practices and financial management. In each arm, 100 children (0-59 mo of age) were enrolled from households with HIV-infected adults 18-49 y old. Children were assessed beginning in April 2012 and every 3 mo for 1 y for dietary intake and anthropometry. Children in the intervention arm had a larger increase in weight (β: 0.025 kg/mo, P = 0.030), overall frequency of food consumption (β: 0.610 times · wk-1 · mo-1, P = 0.048), and intakes of staples (β: 0.222, P = 0.024), fruits and vegetables (β: 0.425, P = 0.005), meat (β: 0.074, P < 0.001), and fat (β: 0.057, P = 0.041). Livelihood interventions have potential to improve the nutrition of HIV-affected children. The study ({"type":"clinical-trial","attrs":{"text":"NCT01548599","term_id":"NCT01548599"}}NCT01548599) was conducted in Rongo sub-County (intervention arm) and Migori County (control arm) government hospitals located in Migori County in the Nyanza region of western Kenya. The population is mostly rural, ethnically homogeneous (>95% members are Luo), and living in dispersed settlements. The major livelihood is subsistence farming and/or fishing, with the major crops for consumption being maize, sorghum, and cassava. The Nyanza region is one of Kenya’s most vulnerable regions to food insecurity because rural poor people do not have enough land and irrigation facilities to do subsistence farming (24). The study design is detailed elsewhere (21, 22). Two rural government district hospitals supported by Family AIDS Care & Education Services were randomly assigned as either intervention or control. The hospitals had similar inpatient, outpatient, emergency, maternal, child, and HIV Care and Treatment services. Both had adequate and similar numbers of adults receiving antiretroviral therapy (2394 in the intervention hospital and 2718 in the control hospital in 2012) with nonoverlapping catchment areas, mitigating contamination; the 2 locations were similar in terms of rainfall patterns, health, topography, water access, soil composition, and socioeconomic status. The intervention had 3 components: 1) the KickStart Water pump and required farm commodities, 2) training in sustainable farming and financial management provided by the Kenyan Ministry of Agriculture, and 3) a small loan ($150) to purchase the water pump and farming implements provided by AdokTimo, a microfinance institution. Control participants received no intervention; they were eligible for the intervention at the end of the 1-y follow-up period. We enrolled through clinic announcements adults who were receiving antiretroviral therapy, aged 18–49 y, with access to farmland and surface water, with moderate-to-severe food insecurity at enrollment or malnutrition during the preceding year, and willing to save the down payment for the loan. A total of 140 HIV-infected adults (72 intervention, 68 control) were enrolled from April to July 2012. The present study recruited all children aged 0–59 mo (biological or legally fostered) living within the households of index adult participants in the parent study (22). We followed children for 1 y every 3 mo, assessing dietary intake, weight, height, and midupper arm circumference (MUAC). In each arm, we enrolled 100 children aged 0–59 mo and their primary caregiver (biological parent or legal guardian aged 18–49 y) living within the households of index adult participants in the parent study. We excluded children with severe acute malnutrition (<−3 z scores of the Standards median) and referred them for immediate care if they were not already in care. We obtained written informed consent from the adult participants for their and for their children's participation. Dietary intake and nutritional status of children were the primary outcomes. Frequency of consumption of food groups was assessed using a questionnaire adapted from the World Food Programme Food Consumption Score. Mothers or caretakers were asked how often the child drank or ate in the past 3 mo each of 63 food items provided in a list. Response options were “every day,” “5–6 times a week,” “3–4 times a week,” “1–2 times a week,” “2–3 times a month,” “once a month,” “less than once a month,” and “never.” Ten food groups were created based on major nutrients present in the food items, adapting guidelines for individual dietary diversity developed by the FAO: staples, legumes, fruits and vegetables, meat, dairy, eggs, fat, sugary foods, condiments (spices, chili, garlic, and royco, which were usually served in small quantities), and tea/coffee (25). Each food group was represented as number of times consumed per week. The frequencies of consumption of all food groups were summed to obtain the overall frequency of consumption. Child nutritional status was assessed as weight, height, and MUAC. Three consecutive weights were measured using a SECA portable electronic scale, which can be adjusted to 0 and weigh quickly and accurately. Three consecutive measurements of standing height for children ≥24 mo of age and length for children <24 mo of age were taken using a length board. Three MUAC measurements using a measuring tape were taken. If the difference between the first 2 measurements was <0.3 kg or <0.3 cm, the mean of the first 2 measurements was used for the analysis; if the difference was ≥0.3 kg or ≥0.3 cm, the mean of all 3 measurements was used. In the intervention and control arms, over the 5 visits (i.e., 12 mo) weight of the children had 4.8% and 3.4% missing values, respectively. Missing values of height and MUAC were 4.6% and 5.8% in the intervention arm compared with 3.4% and 4.2% in the control arm, respectively. Missing values for overall frequency of food consumption were 20.8% in the intervention arm and 21.4% in the control arm, with similar percentages for specific food groups. The study was approved by the Committee on Human Research at the University of California San Francisco and the Ethical Review Committee at the Kenya Medical Research Institute. The study's purpose was explained to participants and written informed consent was obtained from each adult participant before conducting the survey. Intention-to-treat, repeated-measures analyses were done in Stata version 13 (StataCorp LP), with child as a random effect and arm, month of visit, and their interaction as fixed effects. Month of visit was continuous. All available data were analyzed assuming missingness at random. We estimated the difference between arms in the linear trends over months (i.e., fitting a straight line over months for each arm) using the interaction between arm and month. Because we hypothesized that children in the intervention arm would have a higher slope for the trend over visits in anthropometry and diet (except for condiments and tea/coffee, which would have a lower slope) than children in the control arm, we report 1-tailed P values. In sensitivity analyses for dietary intake without 22 children aged <6 mo, inferences were unchanged, with differences in the trends between arms being slightly larger; most of the 22 children consumed some complementary foods by visit 2.