NUTRITION SUPPORT TO NUTRITION SUPPORT TO PEOPLE LIVING WITH HIV/AIDS PEOPLE LIVING WITH HIV/AIDS

THROUGH COMMUNITY THROUGH COMMUNITY THERAPEUTIC CARETHERAPEUTIC CARE

Stanley V. MwaseStanley V. MwaseCASCAS

Overview of the presentationOverview of the presentation

Food Insecurity and Malnutrition in MalawiFood Insecurity and Malnutrition in MalawiCommunity Therapeutic Care (CTC)Community Therapeutic Care (CTC)The CTC Advisory Service The CTC Advisory Service Effects of CTC on Effects of CTC on PLWHAsPLWHAs in Malawiin MalawiChallenges of CTC implementation in MalawiChallenges of CTC implementation in Malawi

General Indicators for Malawi General Indicators for Malawi Total population: 13.2 million*People living below the poverty line: 52% (Integrated Household Survey 2005)Population in need of food: 833000 (MVAC June 2006)Under-five mortality rate: 118/10000 Multiple Indicator Cluster Survey 2006)48% of under fives are stunted* 48% of under fives are stunted* Maternal Mortality Rate = 984/100,000Maternal Mortality Rate = 984/100,000(Multiple Indicator Cluster Survey 2006)(Multiple Indicator Cluster Survey 2006)National HIV prevalence: 14%*

*Source MDHS 2004

An approach to delivering care to children with An approach to delivering care to children with severe acute malnutrition within their severe acute malnutrition within their communitiescommunities

A change in approach from the inA change in approach from the in--patient based patient based programmesprogrammes

It is based on public health principles of access, It is based on public health principles of access, coverage and community participationcoverage and community participation

What is Community Therapeutic What is Community Therapeutic Care (CTC)?Care (CTC)?

Acute malnutrition

Severe malnutrition with complications

Severe uncomplicated malnutrition

Moderate malnutrition

The CTC approachThe CTC approach

Inpatient using IMCI / WHO

protocols

Outpatient Therapeutic Programme

Supplementary Feeding

Programme

50 kms

Dowa District, MalawiStabilisation centre/NRU

50 kms

Dowa district, MalawiStabilisation centre/NRU

Outpatient treatment programme (OTP)

CTC results in:CTC results in:Increased access and coverage of servicesIncreased access and coverage of servicesFewer cases with complications due to early Fewer cases with complications due to early presentation presentation Communities participation and have increased Communities participation and have increased capacity capacity to prevent, recognise and manage to prevent, recognise and manage malnutritionmalnutritionReduced opportunity cost of time spent in Reduced opportunity cost of time spent in hospital by caregivers/ children hospital by caregivers/ children Reduced congestion and risk of crossReduced congestion and risk of cross--infection infection in hospitals/ inpatient feeding centresin hospitals/ inpatient feeding centres

Outcomes Concern Worldwide Outcomes Concern Worldwide supported CTC programs (2006)supported CTC programs (2006)

1%1%

1%1%

8%8%

3%3%

88%88%

3,6773,677

DowaDowa

00

3%3%

15%15%

2%2%

80%80%

1,7361,736

NKKNKK

1%1%

2%2%

12%12%

4%4%

80%80%

1,5221,522

NsanjeNsanje

00

1%1%

10%10%

2%2%

87%87%

13,17313,173

TotalTotal

1%1%Non recoveredNon recovered

Transferred to hospitalTransferred to hospital

DefaultDefault

DeathDeath

RecoveredRecovered

Total AdmissionsTotal Admissions

00

9%9%

1%1%

89%89%

6,2386,238

LilongweLilongwe

CTC ADVISORY SERVICECTC ADVISORY SERVICE

Advocated for CTC adoption by Advocated for CTC adoption by MoHMoHDeveloped national CTC guidelines and training Developed national CTC guidelines and training materialsmaterialsSupported CTC implementation in 11 districts Supported CTC implementation in 11 districts through training and mentoring through training and mentoring Districts planning and implementing CTC Districts planning and implementing CTC activities through their district budgets activities through their district budgets Streamlining tools and materials for CTC Streamlining tools and materials for CTC integration into the PHCintegration into the PHC

IMPACT OF CTC ON PLWHA IMPACT OF CTC ON PLWHA IN MALAWIIN MALAWI

HIV testing and prevalenceHIV testing and prevalenceHigh uptake of counseling and testing:High uptake of counseling and testing:

Dowa CTC program: 60.5% in adults and Dowa CTC program: 60.5% in adults and 94.4% in children94.4% in childrenThyoloThyolo District Hospital: 79.1% (694/877)District Hospital: 79.1% (694/877)

Prevalence varies according to areaPrevalence varies according to areaCentral: 6.6%, Central: 6.6%, North: 22.5% North: 22.5% South: 38.8%South: 38.8%ThyoloThyolo district hospital: district hospital: Inpatients=32% and Inpatients=32% and Outpatients =24%Outpatients =24%

Impact of CTC on HIVImpact of CTC on HIV--positive and HIVpositive and HIV--negative childrennegative children

83.483.459.159.1Recovery %Recovery %

14.214.222.722.7Default %Default %

1.81.818.218.2Mortality %Mortality %

42425656Median Length of stayMedian Length of stay

4.74.7[2.9[2.9--6.7]6.7]

2.82.8[1.3[1.3--3.9]3.9]

Median wt gainMedian wt gain## ((g/kg/dg/kg/d))

HIVHIV--HIV+HIV+IndicatorIndicator

Case study 1Case study 1•• Woman, 36 years, 2 girls , separated, stage 4 Woman, 36 years, 2 girls , separated, stage 4

not on not on ARVsARVs

•• Bedridden for > 12 months, 39 kg Bedridden for > 12 months, 39 kg

•• 3 months later: Weighed 48 kg3 months later: Weighed 48 kg

•• Able to care for herselfAble to care for herself

•• Able to walk to clinicAble to walk to clinic

•• Able to do some minor activities in her houseAble to do some minor activities in her house

Integration of CTC and HIV/AIDS Integration of CTC and HIV/AIDS ServicesServices

Promotion of routine VCT to all caregivers Promotion of routine VCT to all caregivers severely malnourishedseverely malnourishedIncreased target group from 6 to 11 yearsIncreased target group from 6 to 11 yearsModification of the antibiotic protocol to include Modification of the antibiotic protocol to include CotriCotri--moxazolemoxazoleModification of OTP admission protocols to Modification of OTP admission protocols to include moderately HIVinclude moderately HIV--positive childrenpositive childrenReferral of HIVReferral of HIV--positive children for appropriate positive children for appropriate care and support care and support

Challenges with CTC implementation in Challenges with CTC implementation in MalawiMalawi

Lack of resources by the Lack of resources by the MoHMoH to fully fund CTC to fully fund CTC programsprogramsThe lack of a national scaleThe lack of a national scale--up strategy for CTC up strategy for CTC has resulted in a scalehas resulted in a scale--up approach that is up approach that is primarily reactive, rather than plannedprimarily reactive, rather than plannedLack of longLack of long--term plans for most partners and term plans for most partners and donorsdonorsHigh prevalence of HIV/AIDS among severely High prevalence of HIV/AIDS among severely malnourished childrenmalnourished children