Support for PLWHAs in Malawi

By Mary Corbett

Mary Corbett is a food security and nutrition consultant who visited the region on behalf of ENN in early 2005.

This article is based on interviews with a number of individuals within the Ministry of Health, in particular Dr Michael O Carroll and Mrs Teresa Banda.

The HIV/AIDS pandemic has seriously impacted negatively on all sectors of life in Malawi, irrespective of social class, and has reduced adult life expectancy considerably. With a population of around 10 million and a HIV/AIDS prevalence rate of 14%, it is estimated that around 180,000 people are at stages 3 or 4 in the progression of the disease. As the country grapples with the enormous strain of this pandemic, the Ministry of Health (MOH) has put together a strategy to deal with HIV/AIDS and its impact, with a concerted campaign to scale up access to antiretroviral drugs (ARVs) countrywide. Fifty-nine sites have been identified within the country to support ARV distribution. It is planned to have 40,000 people on ARVs by the end of 2005 and a further 40,000 by the end of the 2006.

Low CD4 count is one of the measurements for deciding when to start patients on ARVs. However as the equipment for measuring CD4 count is only available in six centres, the WHO algorithm (see box 1) is being used for identifying symptomatic HIV/AIDS patients. The Malawi MOH has added severe wasting based on Body Mass Index (BMI<16) as one of the main criteria for diagnosis of clinical HIV/AIDS, which is also indicative of severe malnutrition or severe wasting. Recent studies have shown the benefits of nutrition support in conjunction with TB treatment, reducing mortality and improving compliance. It has been recognised that around 70% of TB patients are HIV positive.

Nutrition Status

The challenge to impact on nutritional status is daunting, as many of the patients that start ARV treatment are very ill and severely malnourished. It is planned that these patients will be nutritionally rehabilitated in a similar manner to the severely malnourished children in the NRUs (nutrition rehabilitation units), using F75 and F100 therapeutic milks initially and later, using a Ready to Use Therapeutic Food (RUTF). It is not planned to rehabilitate adult patients completely (as is currently the case with malnourished children) but rather to stabilise their condition within a week to ten days and send them home with RUTF and nutrition counselling.

The treatment of severe malnutrition in adults is not as well researched and guidelines are less well defined internationally, compared to management of children. Consequently there are many unknowns. Many severely wasted adult patients may not want to consume large volumes of milk. It is also possible that a BMI of <16 is, in fact, too high and will lead to an excessive case load of malnourished people.

Staffing and health infrastructure capacity

Although training has been conducted with health personnel around ARVs, the training in associated nutritional care has not yet been carried out. The task is not easy, as human resource capacity within hospitals is severely stretched. Large hospitals requiring around 175 qualified trained nurses have, in reality, a staff of only 25 nurses. During the recent food security emergency, it took a considerable time to introduce the guidelines on treatment of severe malnutrition in children in the NRU's, both in terms of substantial initial training and then ongoing monitoring.

The attrition of health staff is due to many factors, which include poor morale and working conditions, long working hours, low pay, lack of resources, such as equipment, and lack of uniforms. There is also, like many other countries, a depletion of human resources due to emigration (brain drain to other African countries, Europe and the States) and the HIV/AIDS pandemic. It is generally recognised that the health infrastructure in Malawi is at near collapse. A proposal has provisionally been funded by the Department for International Development (DFID-UK) to support reform of the health system, dependant on other funding from the global fund.

Bearing all this in mind, it is difficult to see how, with the best will in the world, the many challenges around the health/nutrition care of PLWHA'S will be managed.

PMTCT programme

The PMTCT programme is an integrated approach, working through the ante and postnatal clinics and offers a range of services. Alarge component of this is good nutrition education for all women attending the clinics. At present, not all facilities have the capacity to do voluntary counselling and testing (VCT), but where these exist, women are encouraged to be tested - particularly if symptomatic. However, as it is voluntary testing, the wishes of patients are respected.

Women who test positive for HIV/AIDS receive further counselling on nutrition for themselves and on infant feeding. As 70-80% of Malawians live in rural areas with little access to clean water and electricity and lack resources and purchasing power to obtain breastmilk substitutes, exclusive breast-feeding for six months is recommended as the safest option. Furthermore, 90% of women choose to breastfeed as it is the cultural norm and there is stigma attached to not breast-feeding. It is proving difficult to get women to abruptly wean the infant off breast-feeding at six months. One compromise may be to support mothers to wean infants within a 2-3 week period, once the child has reached six months. As complementary foods are renowned for their poor quality in Malawi, and in the absence of breastmilk, a study is being conducted into the use of a RUTF as part of the complementary diet of infants over six months of age. Preliminary results suggest that young children are growing very well with this type of nutritional support.

In the three main hospitals in Malawi, WFP supports the families of HIV positive pregnant women, with a family ration of 50 kg of maize, 7.5 kg of pulses and 2.5 kg of vegetable oil. Mothers receive a ration of 9kg of CSB (Corn Soya blend) and 900g 900g of vegetable oil. It is believed that HIV positive pregnant women are particularly vulnerable, owing to the extra nutritional needs due to being HIV positive, coupled with the additional nutritional requirements of pregnancy. The WFP ration continues up to 18 months after delivery, to support the well being of the child as well as the mother. During this time, the infant is closely monitored, ensuring immunisations (EPI) are completed. If deemed necessary, testing for HIV takes place. This programme is a collaborative approach between the MOH and CHAM (Christian Health Association of Malawi) - the main implementers, UNICEF, WFP and NGO's such as MSF-France and MSF-Luxembourg. Currently, WFP is supporting 3450 women and their families in this programme (Jan 2005).

As stigma remains a major issue in Malawi, it was interesting to see how this was being addressed. As targeting certain individuals with food would draw attention to these beneficiaries, in some clinics, women who have tested positive for HIV attend the clinic on a different day to the main caseload of clients. This appeared to get round the problem of stigma.

Home Based Care (HBC)

General support to the chronically ill in the community falls under the umbrella of home based care (HBC). These initiatives are supported by a variety of NGO's, community based organisations (CBOs) and church organisations. The degree of linkage to health infrastructure varies significantly. In an ideal HBC scenario, patients receive food (during crucial periods), health care and psychosocial care as necessary, and support to improve longer-term household food security through diversification and income generating activities.

Food insecure households taking care of chronically ill patients are targeted for support, as are people living with HIV/AIDS (PLWHAs) in recognition of their higher nutritional requirements, particularly with regard to the need for adequate intake of high quality protein and increased energy. The food basket is the same as that under the PMTCT programme and includes a household ration of 50kg of maize, 7.5kg of pulses, 2.5kg of vegetable oil, an individual patient ration consisting of 9Kg of CSB and 900 grams vegetable oil.

In Malawi, WFP is working in partnership with NGOs in 11 districts targeting PLWHAs and chronically ill patients. The project is implemented through NGO's, Community HBC volunteers and associations of PLWHA, who already have a close link with chronically ill patients and PLWHAs.

Regional resources

Due to collaboration and co-operation with other country programmes, resources that have already been developed are being modified for the specific context of Malawi. These include nutrition guidelines for PLWHAs and leaflets on topics such as positive living, diseases such as diabetes, etc. Incountry material is also being developed for use at 'grass roots' level, such as 'counselling cards'.

Conclusions and issues

Major initiatives are underway to address some of the issues around HIV/AIDS and nutrition support. However as it is early in the process, there is little evidence of impact of these interventions. Anecdotal evidence suggests that food aid/nutrition support, leading to longterm food security programmes, have a positive impact. There is good evidence to suggest that supporting TB patients with food aid reduces mortality and increases compliance. Many of the TB patients are also HIV positive (an estimated 70%).

In a country where food insecurity has been a major issue for many years, addressing the nutritional needs of PLWHA is a considerable challenge, particularly as their nutritional needs are increased due to the illness. A recent study indicated that households with PLWHA's and households with orphans and vulnerable children are more food insecure.

Internationally, nutrition in the context of HIV/AIDS has been seriously neglected. This is also evident at a country level, where training around ARV's has already taken place but training in associated nutrition activities is planned at some future point.

It is unclear if a BMI <16 is the most appropriate marker for admission to hospital of suspected HIV positive patients (based on clinical signs and symptoms) for therapeutic nutrition support, as all these extra admissions may completely overwhelm an already fragile health infrastructure. Imported nutrition products, such as Plumpy'nut and therapeutic milk are extremely expensive commodities in the context of an already extremely overstretched national health budget. Is this the most appropriate use of scarce resources?

Large volumes of milk as a stand-alone nutrition support may not be accepted by adults, and in some countries, milk is considered as food for children only. A combination of foods may need to be considered, however there is limited research on the treatment of adult malnutrition in these settings and it is unclear if there are budgets at hospital/clinic level to support nutrition through the use of such food commodities.

Malawi is probably one of the most advanced countries with regard to strategic plans and guidelines related to HIV/AIDS programming for different contexts. However, at a grass roots level where implementation occurs, there are significant constraints, in particular around human resource capacity and availability of equipment and materials. The major concern is the capacity at ground level to support this huge initiative, particularly as the health infrastructure is already completely overwhelmed.

For further information, contact Mary Corbett, email: corbettmary@eircom.net

¹Body Mass Index (BMI) calculated as weight (kg) divided by height (metres) squared

²Plumpy'nut, produced by Nutriset

³See field article, Integrated PMTCT services in a rural setting in Malawi, in this issue for experiences from St Gabriels Hospital, Malawi

⁴See research article, Impact of HIV/AIDS on household food security and quality of life in Malawi, in this issue of Field Exchange