World Food Day: You cannot treat HIV on an empty stomach
Today is World Food Day, a reminder that access to adequate nutrition is fundamental to health and survival. For children with advanced HIV disease (AHD), the stakes are particularly high. Malnutrition can further weaken an already compromised immune system, increase vulnerability to opportunistic infections (OIs), and undermine the effectiveness of HIV treatment. While antiretroviral therapy (ART) is essential to recovery, medication alone may not be enough when a child lacks the nutritional support needed to regain strength and rebuild immunity. For these children, integrating nutritional assessment and support into routine HIV care is not simply an added service; it is a critical component of effective treatment.
Many children living with HIV (CLHIV) who present late to care suffer from a dual disease burden. On one hand, they have AHD, which strips the immune system bare. On the other hand, they also suffer from malnutrition — wasting, stunting, and severe acute malnutrition (SAM) — which also lowers immunity through a different mechanism. When both arrive together, as they routinely do in children presenting to ART clinics across Nigeria, the combined damage is far greater than either condition alone.
Yet for much of Nigeria's HIV program history, these two crises have been managed separately. A child arriving at an ART clinic aged <5 years, or with CD4 percentage of <15%, a CD4 count below 200 cells/mm3, is started on antiretrovirals (ARVs). If visibly wasted, the child might be referred to a nutrition unit in a different building, a different facility, or a community program whose functionality may not be guaranteed. The next question should be (1) was the referral complete? (2) did the child receive the therapeutic food or the needed nutritional support? These questions were rarely asked by the healthcare workers (HCWs) and documented.
THRIVE was built on the understanding that this separation is not a minor administrative inconvenience. It is a clinical gap that affects the outcomes of CLHIV.
The weight of evidence
The link between malnutrition and HIV mortality is not new science. SAM in children is associated with dramatically elevated mortality risk, even in children on ART. Among children with AHD, malnutrition compounds the immunosuppression caused by HIV itself, accelerating the progression of opportunistic infections, reducing ARV drug absorption, and impairing the immune recovery that ART is supposed to deliver.
Before THRIVE, nutritional status rarely appeared in ART clinic records across pilot facilities. There was no field for it, no protocol that required it, and no referral pathway triggered by its absence. A child could present severely wasted, leave with ARVs, and return six months later in the same condition or not return at all. The THRIVE program is changing this practice.
Mapping what exists: findings from the nutrition support rapid assessment
Before THRIVE could build referral linkages for malnourished children, it had to answer a foundational question: what nutrition support actually exists in these states, and can children with AHD access it? In 2025, CHAI worked with State AIDS and STIs Control Programmes (SASCPs) in Anambra, Benue, Rivers, and Lagos to conduct a structured rapid survey to map available nutrition services at and near THRIVE sentinel facilities and co-develop facility-specific linkage pathways.
About THRIVE in Nigeria
THRIVE - Transforming Advanced HIV Disease CaRe in LMICs through ComprehensiVe and Equitable Access - is a government-led program funded by Unitaid and implemented across 21 public health facilities in four Nigerian states - Anambra, Benue, Rivers, and Lagos - with technical support from CHAI Nigeria and AFROCAB.
THRIVE strengthens delivery of the STOP AIDS package of care within routine HIV clinics, so that people presenting with AHD receive timely screening, diagnosis, treatment, and follow-up for life-threatening OIs such as tuberculosis and cryptococcal disease. Rather than creating a parallel program structure, THRIVE works within existing health systems.
Across all four states, the survey identified a functioning but deeply fragmented nutrition ecosystem. Support modalities documented include ready-to-use therapeutic food (RUTF), supplementary feeding, micronutrient supplementation, nutrition education and counseling, local food preparation and demonstration, and cash or food vouchers. Providers spanned government, international agencies, faith-based institutions, implementing partners, and private philanthropists. Notably, CLHIV were formally listed as beneficiary groups by a number of providers, most consistently in Anambra and Lagos.
The cross-cutting reality, however, was one of fragility. Coverage was concentrated in urban areas. In Benue, for example, nutrition support was documented across only five local government areas: Makurdi, Gboko, Guma, Gwer East, and Vandeikya, leaving rural communities largely unreached. Most programs operated on short, cyclical funding windows: six-month rounds, annual campaigns, or quarterly distributions that created predictable gaps between cycles.
Service delivery challenges were consistent across all four states: stock-outs of RUTF and micronutrient supplements; age-based eligibility restrictions limiting therapeutic food access for children over five; absence of basic anthropometric screening tools — mid-upper arm circumference (MUAC) tapes, height boards, Z-score charts at many primary health centers; no nutritionist present at PHC level; and inadequate physical space or demonstration tools for nutrition counseling.
Embedding nutrition into the HIV encounter
The THRIVE approach to nutrition was not to build a separate nutrition program. It was to make nutritional assessment a necessary and permanent step in the existing HIV care continuum, as routine as a temperature check.
At all 21 THRIVE sentinel sites, over 40 nurses and adherence counselors were trained and equipped to complete a brief MUAC and weight/height assessment at every AHD enrollment and follow-up visit. The assessment adds less than five minutes to the standard clinical encounter. Children identified with acute or moderate acute malnutrition are referred to supplementary or therapeutic feeding program linked to the national or non-governmental nutrition systems, with the referral documented in the AHD case management record.
Within months of implementation, nutritional assessment was documented for 75% of children living with AHD from Q1 2025 through the Q2 2026. Across the cohort, 61 children with AHD were identified with malnutrition through clinical assessment, presenting with MUAC measurements in the SAM range, weight-for-age, and BMI below threshold. Screening has kept climbing as the practice took hold.
35%
documented malnutrition screening among children under 5 in Q1 2025
50%
documented malnutrition screening among children aged 5-14 in Q1 2025
91%
documented malnutrition screening among children under 5 in Q2 2026
100%
documented malnutrition screening among children aged 5-14 in Q2 2026
Of those diagnosed with malnutrition, 92% have been linked to orphans and vulnerable children (OVC) nutrition support services, reflecting the intensive case management and referral tracking that THRIVE's community facilitators and adherence counselors maintain for enrolled children.
children with AHD diagnosed with malnutrition across THRIVE sentinel sites
of those children successfully linked to OVC nutrition support services
Nutrition counseling was integrated into adherence counseling sessions with THRIVE teams working with facilities across all four states to formalize linkage pathways and documented referral routes with tracking mechanisms, ensuring that children identified reach the nutrition services they need, and that the outcome is recorded and followed up.
Filling the gap: procurement, supplies, and community food demonstrations
When the 2025 USG funding disruption hit Nigeria's HIV commodity supply chain, nutrition services were among the first casualties. OVC programs funded by the US Government were halted in 75% of implementation facilities.
CHAI procured anthropometric tools including weighing scales, bassinet, MUAC Measuring Tape and Stadiometer to support nutritional assessment in these facilities; and have procured dedicated RUTF specifically targeting children with AHD enrolled at THRIVE sentinel sites. 13,650 packs of RUTF and anthropometric equipment have been directly delivered to the four THRIVE states. The goal is to ensure that children identified as malnourished do not face a supply gap at the point of referral.
On the community side, AFROCAB's AHD champions are bridging the gap that clinical referral alone cannot: direct nutritional engagement at the household level. In Anambra and Benue states, community facilitators are conducting structured food preparation and demonstration sessions with caregivers of CLHIV on how to prepare locally available, nutrient-dense meals using accessible, affordable ingredients. The response from caregivers has been instructive. For many families, the demonstration sessions have been the first time a health program acknowledged that the challenge is not simply treating HIV, it is finding enough nutritious food to keep a child strong enough to tolerate treatment. That acknowledgement, delivered by community facilitators who share the same communities and face the same economic pressures, lands differently from advice delivered across a clinical consultation desk.
What it will take to finish the work
The 56 children successfully linked to nutritional support represent a genuine achievement. They also represent a fraction of the children across Nigeria's HIV program who need the same. The gap between identifying a malnourished child with AHD and ensuring they receive therapeutic food and return to the clinic with improved nutritional status remains the most consequential unresolved challenge in THRIVE's nutrition workstream.
Documentation rates are improving. Referral pathways are being formalized. Bridge procurement is addressing the most acute commodity gaps. AFROCAB's food demonstrations are reaching caregivers who have never been engaged by the nutrition system before. But the structural constraints; inconsistent availability of RUTF and supplementary feeding commodities, the absence of nutritionists at primary health center level, and the unpredictable funding cycles that cause well-designed programs to disappear mid-year cannot be resolved through project-level interventions alone. This will require a robust advocacy agenda. Nutritional status must be embedded as a mandatory variable in national AHD reporting tools. CLHIV must be formally recognized as a priority group for nutritional commodity allocation at state level. And the out-of-pocket costs that make therapeutic feeding inaccessible to the most vulnerable families must be addressed through health financing mechanisms that actually reach them.
Through the generous support of Unitaid, the Clinton Health Access Initiative (CHAI)-led THRIVE Project is enabling access to critical prevention, screening, and treatment commodities for advanced HIV disease to dramatically reduce mortality among adults and children living with HIV. The THRIVE project is conducted in partnership with AFROCAB and Penta.
Disclaimer: The views expressed are those of CHAI and do not necessarily reflect those of Unitaid or other partners.
