Nutritional Support Through HBC in Malawi

By Mieke Moens, MSF

Mieke Moens is a paediatric nurse, and is responsible for the PMTCT and nutrition programme for MSF Thyolo, Malawi

The author would like to acknowledge the contributions of Dr. Roger Teck, Head of mission, Thyolo, Malawi and Pascale Delchevalerie, nutritionist at MSF-Belgium headquarters.

In common with other countries in southern Africa, the Malawian population is heavily affected by the HIV/AIDS epidemic. The most recent sentinel surveillance report¹ revealed a national HIV prevalence level of 19.8% among antenatal care (ANC) attendants. Projecting these findings, the prevalence level for HIV infection in the adult population (15-49 years) is estimated at 14.4% (12-17%)². Approximately 110,000 new HIV infections occur annually. In 2003, about 900,000 people were estimated to be living with HIV/AIDS in the country, of whom close to 170,000 had advanced HIV/AIDS disease and were in need of life-saving antiretroviral treatment (ART). Of these, 10% are children, the majority having been infected through mother to child transmission. With an estimated 80,000 adult and child HIV/AIDS related deaths annually, HIV/AIDS has become the most significant cause of death amongst adults - average life expectancy in Malawi has now dropped to below 40 years. Moreover, Malawi has, at present, approximately 840,000 orphans³, 45% of whom have lost one or both of their parents because of AIDS.

Fuelled by this epidemic, the annual case notification of tuberculosis has increased from 5,334 new cases (82/100,000) in 1985, to nearly 30,000 new cases (257/100,000) in 2003. This is coupled with a significant increase in mortality, to more than 20 %, among tuberculosis (TB) patients under TB treatment. The situation is further complicated by food shortages, which Malawi is increasingly confronted with during the yearly hunger gap periods. It is feared that this precarious food security situation will lead eventually to a nutritional crisis situation, with high levels of acute malnutrition during the annual 'lean' season (rainy season) before the harvest.

MSF in Malawi

MSF has worked in Malawi for many years, first in the refugee camps during the Mozambican war and later, since 1997, focusing on the HIV/AIDS pandemic. The current MSF programme is based in Thyolo district, Malawi and comprises a number of components including:

• Prevention of HIV transmission
• Support to the district tuberculosis control programme
• Home based care (HBC) and social support for people living with HIV/AIDS and/or TB.
• Hospital based care for patients for HIV/AIDS and/or TB
• Integrated antiretroviral treatment programme since April 2003
• Emergency preparedness and response to cholera outbreaks for the five most southern districts in the southern region of Malawi.
• Nutrition programme, whose key activities include:
  • Running a Nutrition Rehabilitation Unit (NRU) in Thyolo District Hospital
  • Supervising the Supplementary Feeding Centres (SFC) of Thyolo District
  • Orphan's programme for infants up to 1 year of age
  • Integrated nutrition support to malnourished patients in the HBC network
  • Nutrition support to TB patients during the first month of treatment
  • Nutrition support to malnourished patients registered with the 'Continuum Care' (HIV/ARV) Clinic
  • Nutrition supplementation of malnourished patients hospitalised in Thyolo District Hospital
• Operational research to document and adjust approaches, to prove feasibility and to provide evidence for dissemination and advocacy at national and international level.

The HIV/AIDS related targets (2003-2007) for Thyolo district are, access to a 'continuum of care' for at least half of the estimated 50,000 people living with HIV/AIDS, and access to ART for at least 50% of the estimated 7,000 - 8,000 people living with AIDS. The target groups are malnourished people with HIV/AIDS and/or TB, and people with a poor medical condition.

Height being measured by trained HBC volunteers

Integrating HBC and nutrition

MSF currently coordinates and integrates HBC and nutrition programmes in the district. The objectives of the programme are to reduce malnutrition amongst the chronically ill and to support malnourished AIDS patients during initiation of ART. MSF currently have 550 patients registered through HBC activities and 33 through the antiretroviral (ARV) clinic (Jan 2005).

Integrated activities have been taking place monthly over five days - a period that has recently been extended to 10 days a month. Each month, the nutrition team joins the HBC team and the patients are screened in their community (or the nearest community where this activity takes place), while they are waiting for treatment from the HBC nurse. Screening is carried out by trained HBC volunteers. The results (height, weight and MUAC) are written up in their individual health passport. The nutritional team then evaluates each individual by calculating the Body Mass Index (BMI), checking for oedema and evaluating the general health condition. Where individuals meet the entry criteria, the patient is admitted onto the programme (70% are admitted on the basis of BMI<17). Each patient receives a monthly ration of 10kg of Likuni Phala (Malawian fortified blended food).

Some of the ARV patients are not supported through HBC but by the nutrition team in Thyolo District Hospital. The same entry criteria apply for hospital nutrition support but patients are provided with Plumpy'nut (Nutriset) instead of Likuni Phala.

Team writing up individual 'health passports'

Initially discharge criteria were established as a weight gain of more than 10% during two consecutive visits⁴ , a BMI >17 (or MUAC > 185) and good general health condition. However these proved impractical, both in terms of calculating the 10% weight gain and the degree of weight gain, which sometimes took too long to reach. The criteria were subsequently revised to achieving a BMI >18.5 for two consecutive visits and a good general health condition. Generally, patients remain for a considerable time on the programme (average stay in 2004 was 5.5 months). Table 1 shows progress of patients in a one year period.

ARVs for children

MSF has recently started an ARV clinic for children. It has been a challenge to establish appropriate entry criteria for children and nutrition support, especially for those aged between 7 and 18 years. Since MUAC is not an accurate measure for this group, weight-for-height or BMI and the general health status is used. For smaller children, existing entry criteria for NRUs and SFCs are applied. These criteria are open to change, if experience leads us to believe that they are not appropriate.

The MSF team strongly believe that nutritional support for this vulnerable group is necessary, although it is difficult to measure the impact. Implementation of a double blind control study would be ethically difficult. The programme is also shifting slowly to using Plumpy'nut instead of Likuni Phala, as it is a more nutritionally complete supplement, more manageable in terms of carriage and storage, and is easier for beneficiaries to use.

Distributing the monthly ration of Likuni Phala

This programme has many challenges. For example, there is currently a low attendance rate in some areas, especially when the weather is poor or when there is a planting or harvesting period. People who send relatives, instead of attending themselves, for three consecutive visits are now visited by the team or through HBC workers, to establish the reason.

It is important that the objectives of this type of nutritional support are realistically defined in relation to access to medical care and treatment. In Thyolo district, people often live far away from the health structures, so that transport is difficult. Consequently, monthly attendance is not always realistic. On the positive side, nutritional screening can contribute to the identification of HIV positive patients eligible for ART (a wasting syndrome occurs at stage 4 in AIDS). In conclusion, through this programme experience, we have demonstrated that integration of well targeted nutritional support for malnourished people with HIV/AIDS is feasible in a setting with community home based care.

For further information, contact: Mieke Moens, PMTCT and Nutrition programme, MSF Thyolo, email: MSFL-Blantyre@Luxembourg.msf.org

¹At time of writing, the most recent report was HIV Sentinel Surveillance Report 2003. Malawi Ministry of Health & Population and National AIDS Commission, November 2003.

²HIV and AIDS in Malawi, 2003. Estimates and Implications. National AIDS Commission. January 2004.

³In Malawi, orphans are defined as children who have lost one or both parents (because of death) and who are still under 18 years old.

⁴Visits take place once a month.