Impact of HIV/Aids on Acute Malnutrition in Malawi

By Susan Thurstans, AAH and Mary Corbett, ENN

Susan Thurstans is HIV Adviser with Action Against Hunger, based in Malawi

This article developed from an interview by Mary Corbett (ENN) with Susan Thurstans, Action Against Hunger, Malawi.

The authors would like to acknowledge the support of AAH and the contributions of the AAH staff in Malawi, the Ministry of Health and Queen Elizabeth Central Hospital, Malawi to the ongoing work.

In Malawi, chronic malnutrition (stunting) is estimated at around 50%, although recent studies suggest this has increased substantially and, in some districts, is now around 65%. Rates of underweight are at 25% and acute wasting around 6%. During the dry season, admissions to the nutrition rehabilitation units (NRUs) average between 20-25 children a month. During the hunger gap, this peaks at 40-60 children, with higher numbers in the southern region. Action Against Hunger (AAH) became operational in Malawi in 2002, in response to the food crisis. Initially the main programming focus for AAH was supporting the treatment of severe acute malnutrition, targeting the under five's population through the Ministry of Health (MOH) supported NRUs. AAH are now operational in 48 NRUs scattered through northern, central and southern regions of the country.

Education session on World Aids Day

Through a collaborative process between the MOH, UNICEF and many NGOs, national guidelines for the treatment of severe acute malnutrition have been developed in line with international guidelines. These include protocols on nutrition and medical care to deal with acute malnutrition. As part of the development process, admission criteria were changed from admission using weight-for-age (a measurement of chronic malnutrition), to weightfor- height, a measure of acute malnutrition. Training of the NRU health staff was one of the main components of this programme. Another key element was sensitisation of senior staff at district level regarding the importance of appropriate treatment and resources for this vulnerable group. Ongoing supervision in the NRUs was also a major component. In a short period, extraordinary gains were made in Malawi in standardising nutrition guidelines, due to extensive co-operation among all the players and an openness of the MOH towards changing practice.

Context of HIV/AIDS

NRU garden

As a result of the compliance with the new guidelines, training, availability of special diets (F75 and F100) and availability of medicines, the treatment of acute malnutrition improved significantly. With the use of weight for height as admission criteria, only acutely malnourished children were admitted, so that length of stay in the NRU decreased and better weight gains were achieved. However, as seen from figure 1, the mortality rate remained high. A high prevalence of HIV among those admitted to the NRU was suspected as a cause - two small studies, conducted in Malawi, indicated prevalences of 18.9%¹ and 34%². Given this, a comprehensive study was undertaken to determine the prevalence of HIV in children admitted to the NRUs.

Method

The objectives of the study were:

• To establish the point prevalence of HIV sero- prevalence of children admitted to NRUs in Malawi
• To describe seasonal and regional variations in the proportions of HIV sero-positive children receiving care in NRUs in Malawi
• To describe clinical outcomes of HIV positive and negative children admitted with malnutrition
• To improve linkages with services providing support to PLWHA

The study was conducted in collaboration with AAH, the Malawi College of Medicine, MOH Malawi and UNICEF. It was a two-part study, carried out during both the dry and wet seasons in order to assess seasonal variations in HIV prevalence.

Twelve sites were identified, four from each region, in addition to the referral hospital from each region, and three rural hospitals. All mothers and children in the NRU over a two-week period were asked to participate in the study. Children less than 15 months were excluded, due to the unreliability of results in the absence of Polymerase Chain Reaction (PCR) testing methods. Of those mothers approached, 145 children were eligible and 143 mothers consented to Voluntary Counselling and Testing (VCT) for their children.

Results

Staff and beneficiaries in Matendu NRU

The preliminary findings from the first part of the study, carried out during the dry season, indicate a prevalence of 30% (CI 22%-37%) countrywide. However, there were significant regional differences, with the highest prevalence rates in the southern region at 42%, 16% in the central region and 32% in the northern region. The study is being repeated in February 2005 (hunger gap) to provide a seasonal comparison.

Out of the sero-positive sample, 58% were admitted with marasmus, 30% with kwashiorkor and 12% with marasmic kwashiorkor. Weight for height z scores on admission are presented in figure 2. Of those enrolled in the study, 40% of HIV positive had been previously admitted to a NRU, compared with 29% of HIV negative children (p=0.18, not significant). Clinical condition on admission to NRU is shown in figure 3.
As can be seen from table 1, the outcome for children admitted to the NRU who were HIV positive is poor, with almost half discharged as failing to respond (discharged at below the target weight). This group also had a higher rate of defaulters compared to those who were not HIV positive.

Conclusions

Although these results are not altogether surprising, it is extremely important to confirm the high HIV prevalence rates amongst this malnourished population group. Given this, specific nutritional and medical requirements need to be better addressed within the context of NRU and community programming. However, there remain many unknowns with regard to the treatment of severe acute malnutrition in conjunction with HIV positive status - particularly in children. Child friendly services are not available in many situations to deal with the issues around HIV/AIDS and children, particularly in the context of HBC programming.

The uptake of testing was high. However, it appeared that on occasion, health staff over-sensitivity regarding HIV/AIDS testing, particularly in relation to stigmatisation, may have adversely affected uptake of VCT. Following on from this study, AAH plans to try to use the NRU as an entry point for the care of children with HIV/AIDS. Areferral system is being set up to link the NRU to services providing care and support to people living with HIV, in order to provide a more holistic form of care. Services will include, VCT, PMTCT for mothers, ART (mainly for adults) and opportunistic infections (OI) treatment where available, family planning and community home based care (CHBC). To support the role of NRUs, there is a need to;

• train NRU health staff to identify HIV symptoms and provide more appropri ate support to VCT
• strengthen linkages with paediatric units and paediatric ARV provision as, presently, some NRUs are separate from paediatric wards, and
• improve NRU kitchen garden programmes so that these better support training in crop diversification and use of herbs, as well as improved food security activities for households of NRU patients.

The current Malawi nutrition guidelines for the treatment of severe acute malnutrition may need to be revised to address the special needs of children admitted with HIV/AIDS. AAH are currently conducting research to monitor the response of children to therapeutic feeding according to sero-status, in order to determine if there is a need to modify current guidelines.

Finally, nutrition guidelines relating to HBC and children need to be re-examined, in particular with regard to 'positive living with HIV/Aids.' A number of initiatives are afoot with regard to this.

For further information, contact: Action Against Hunger, PO Box 145, Lilongwe, Malawi, email: aah@globemw.net

¹Rogerson et al (2000) conducted a study whereby new admissions to an NRU (Queen Elizabeth Central Hospital) were tested over a two week period. Of these, 18.9% were found to be HIV positive and almost 30% of these children died.

²Kessler et al (2000), found a HIV prevalence of 34.4%, from a sample of 250 malnourished children. The overall mortality for this study was 28%.