Nutritional status is an important determinant of HIV disease progression. Access to adequate food and nutrition services, including counseling, can improve nutritional status of HIV patients, improve immune response to opportunistic infections, and improve adherence to medical treatment.  One of the challenges in integrating nutrition and HIV care is that in a busy HIV clinic, it can be hard to find time to properly assess nutrition issues.  In Uganda, the USAID-funded NuLife and Health Care Improvement projects teamed up to support 54 health facilities to integrate nutrition care into their HIV/AIDS services.  This report describes the key activities carried out by these teams to incorporate nutrition interventions into HIV care and presents the results in terms of increased nutritional assessment using mid-upper arm circumference (MUAC) tapes and counseling on ready-to-use therapeutic food (RUTF).

Counseling Cards
The counseling cards are intended for health workers to use during sessions with HIV-positive prenatal and postpartum women. Published in English and Swahili, the cards are tools that health workers can use to explain: the risk of transmission of HIV from mother to child when no preventive actions are taken; infant feeding options for HIV-positive mothers; the concept of acceptable, feasible, affordable, sustainable and safe (AFASS) replacement feeding; and how to safely practice their chosen infant feeding method.

Risk of Passing HIV from Mother to Baby
Using this counseling card as a guide, the health worker can show the client a graphic depiction of the risk of passing HIV from HIV-positive women to their babies when NO preventive actions are taken. The card shows that most babies are infected with HIV during pregnancy and birth (approximately 20%). It also depicts the rate of babies who become infected with HIV through breastfeeding (approximately 15%) The health worker can use the card to illustrate that the majority of babies (approximately 65%) are not infected with HIV, but should be protected through the use of ARVs and safer infant feeding.

Infant Feeding Options
This counseling card is intended to assist healthcare providers counsel women who have tested HIV-positive. It offers graphic depictions of three of the most common methods being actively promoted for feeding infants of HIV-positive women in Tanzania so that the healthcare worker can guide the mother in determining the safest option for feeding her baby.

Infant Formula or Modified Cow's Milk as a Safe Option
This counseling card is directed to women who have tested HIV-positive and who are exploring their infant feeding options.This graphic job aid enables counselors to discuss whether using infant formula or modified cow’s milk presents a safe and secure alternative to breastfeeding, following AFASS criteria.

Risk of HIV passing from mother to baby if mother and baby take Nevirapine
Using this counseling card as a guide, the health worker can show the client that the risk of mother passing HIV to baby decreases the mother practices exclusive breastfeeding and mother and baby take Nevirapine.

How to Breastfeed
This job aid is intended to assist the counselor to give clear instructions to pregnant women on how to breastfeed. Illustrated, step-by-step instructions are presented to promote good positioning of the baby to prevent breast problems which can increase the transition of HIV through breastfeeding.

How to Hand Express Breast Milk
This counseling card graphically depicts the steps for the mother to follow to hand express breast milk, an important skill for all mothers to have, no matter what their status. It encourages the use of a cup rather than a bottle for feeding the baby.

Many Ways to Position and Attach Baby
Using this counseling card as a guide, the healthcare worker can show the mother a range of ways to position and attach the baby.

During the first 6 months, baby needs only breast milk
This card illustrates that during the first six months, the baby should be given only breast milk.The mother should avoid giving water, glucose water, and all other foods and drinks.

Danger Signs
Danger signs indicating that the baby should be immediately taken to the nearest health facility are illustrated.

Six take-home brochures provide illustrated and easy-to-follow guidelines to enable prenatal and postpartum women to make informed decisions about which infant feeding option is the most acceptable, feasible, affordable, sustainable, and safe (AFASS) for each individual's situation and to help women safely practice the option selected. The brochures graphically depict the step-by-step procedures for women to use in carrying out each of the four infant feeding options.

How to Breastfeed Your Baby
This take-home brochure provides mothers with an illustrated guide and detailed step-by-step instructions on how to start and continue breast feeding. It provides information on how to recognize and prevent problems, lists signs to look out for, and identifies what mothers need to remember and know.

How to Hand Express Breast Milk
This illustrated brochure graphically depicts and provides mothers with instructions on how to hand express. It includes points to remember and tells mothers how to safely store and feed the milk to the baby. This method is being promoted for use by HIV-positive mothers during the transition from exclusive breastfeeding to replacement feeding in order to minimize the dangerous period of mixed feeding.

How to Heat Treat Breast Milk
An insert to the above brochure shows how to safely heat breast milk.

How to Feed Your Baby Fresh Cow's Milk
HIV-positive mothers who opt to feed fresh cow's milk to their babies are given a complete list of steps and ingredients needed for safely modifying and feeding fresh cow’s milk to babies. The brochure outlines how to make fresh cow’s milk more nutritionally appropriate for infants. It visually presents the preparation process, stresses the importance of hygiene, and encourages the use of cup feeding. Additional points to remember are covered.

How to Feed Your Baby Infant Formula
HIV-positive mothers who opt to use commercial infant formula to feed their babies are given a complete list of steps needed to safely prepare formula and feed their babies. The brochure visually presents the preparation process, stresses the importance of hygiene and encourages the use of cup feeding. Additional points to remember are covered.

Nutrition: During Pregnancy and Breastfeeding
Pregnant and breastfeeding women are reminded of the importance of taking a test to determine HIV-status. By becoming aware of their status, HIV-positive women are then able to consult their healthcare providers to determine an appropriate course of action for antiretroviral therapy and nutrition. The brochure points out that good nutrition is especially important to HIV-positive mothers and their infants and gives illustrated pointers on safely preparing foods and planning balanced meals. General points covering meal frequency, water consumption, and diet supplementation are given, and women are reminded to follow their healthcare providers' instructions.

Feeding a Baby: After Six Months
This brochure addresses questions that mothers may have regarding how to feed babies who, after six months, are beginning to eat semi-solid foods. HIV-positive women, the brochure notes, should consult a healthcare provider to determine whether it would be best to give another type of milk in place of breast milk. It points out that after 6 months, babies need to gradually begin eating a variety of foods and gives information on types of foods, as well as correct consistency and amounts, to give to babies aged 6, 7-8, 9-12, and 12-24 months. The brochure gives instructions for safe food preparation and storage and covers a range of other points.