1. Community Therapeutic Care for managing severe acute malnutrition- The effect of RUTF By Dr. Paluku Bahwere -Valid International 34 th session of the SCN- WG on nutrition and HIV/AIDS February 28 th 2007

2. Presentation overview Introduction Management of HIV infected children in CTC CTC and the management of HIV malnourished adults in the community Local RUTF production and linkage with livelihood programmes Conclusions

3. Introduction: Important background issues in Africa High HIV prevalence –High mortality prior to ART and in ART programmes –Affect country and community in many sectors Malnutrition common among HIV infected individuals –In Therapeutic feeding programmes –Very common first AIDS defining condition –Common at ART commencement. –Not always related to AIDS stage –Malnutrition related to survival time

4. Introduction: Important background issues in Africa (cont) Very low VCT coverage –83% adults untested in Malawi (2004MDHS) Fast progression of HIV –sero-conversion to stage 2 - 25.4 months –sero-conversion to stage 3 - 45.5 months –Progression from AIDS to death < 1 year Picture removed

5. CTC entry point? CTC VCTHIV care Livelihood programmes

6. Primary study questions & outcomes 1. Can CTC be used as an entry point for providing HIV testing and treatment referral? Outcome: VCT uptake 2. Are CTC protocols effective in HIV-positive children (or are modifications needed)? Outcomes: weight gain/d, recovery, mortality, default

7. CTC protocols for children CTC provided 200 kcal/kg/d locally produced RUTF for OTP in weekly take home rations Per CTC protocols, children given Vitamin A, de- worming, antibiotics for bacterial infection, anemia treatment as needed, malaria prophylaxis HIV+ children referred to Lighthouse Clinic for further evaluation, and adults referred to Dowa District ART clinic

8. Summary of VCT uptake

9. Nutritional Recovery in the Prospective Cohort: WHM > 85%

10. Impact of CTC in HIV-positive and HIV-negative children RETROSPECTIVEPROSPECTIVE HIV+HIV-HIV+HIV- Median wt gain # (g/kg/d) [IQR] 2.2 [1.6-4.0] 3.1 [1.1-5.9] 2.8 [1.3-3.9] 4.7* [2.9-6.7] Median LOS6342*5642 Default %N/a 22.714.2* Mortality %N/a 18.21.8* * p <0.05 # Wt gain in RC may be underestimate due to oedema at admission

11. Nutritional Relapse in the Retrospective Cohort HIV+ (N=28) HIV- (N=1102) p-value % losing WH38.920.20.07 % WHM < 80% % WHM < 70% 14.3 0 2.0 0.4 <0.001 % MUAC < 125 % MUAC < 110 32.1 7.1 7.8 1.2 0.02 0.05 Median timing of follow-up 15.5 months post discharge (SD: 12.8) ~ 86% of HIV+ children had WHM >80%

12. Adult study Effectiveness of RUTF delivered in the community through CTC linked with HBC organisations

13. Intervention 3 months nutritional support –500 g /day of RUTF (Chickpea-Sesame recipe) –2600 kcal/day –70g protein/day Routine cotrimoxazole Delivered through existing HBC structures Picture removed

14. Activity performance

15. Access to clinics  26/60 (43.3%) able to walk to the clinic at admission  22/34 (73.5%) able to walk to the clinic after intervention  In total, 47/60 (78.3%) resumed productive activity 25 bedridden Completed 3 months 22 Resumed activity 3 Absence of improvement

16. Eager to restart some activities At admission –Can just walk out of the house –Only support= HBC volunteer After 2 weeks –Walk long distance (to the river to bath) –Prepare instrument to restart some activities After 1 month –Active –Need of social life Picture removed

17. Eager to restart some activities At admission –Can just walk out of the house –Only support= HBC volunteer After 2 weeks –Walk long distance (to the river to bath) –Prepare instrument to restart some activities After 1 month –Active –Need of social life Picture removed

18. She is going to harvest Maize Beddriden before admission and staying alone with her baby Admitted in the programme in Oct 06 November 06 started farming Picture removed

19. Median (IQR) weight gain in Kg After 1 month : 2.0 (0.0-3.5) kg After 2 months: 2.5 (0.0 -6.0) kg After 3 months: 3.0 (2.0-7.0) kg

20. Weight gain closely related to RUTF intake

21. Mangochi program: Impact on HIV testing n % of the total Tested prior to recruitment94.1% Tested while in program10246.4% tested positive98 tested negative4 Not yet tested10949.5% Total220100.0 Counselling continuing

22. Mangochi program: Impact on ART access n% of the total Not yet on ART16072.7% ART prior to the recruitment31.4% ART while in program5324.1% Tested negative41.8% Total220100.0 Counselling continuing

23. Livelihood integration SC US Malawi supported farmers earn 355$ from the sales of their products Picture removed

24. Improvement continues after discharge 04/2005: 41 kg and 17.3 cm at admission 07/2005: 47 kg and 20.5 cm after 3 months in programme 12/2006: 55 kg and 24.6 –Not yet on ARV Picture removed

25. Conclusions

26. RUTF facilitated effective nutrition care to malnourished children and chronically sick PLWHA. –Nutrition stabilisation –Improved physical activity performance –Improved quality of life Improved physical activity performance restoration of hope improved access to care including ART willingness to undergo HIV testing

27. Do we need of RUTF? Picture removed

28. Thanks to all organisations and experts who provided supports and advises SARA/AED FANTA Concern Worldwide Save Children US Valid International Government of Malawi SASO and NASO Professor Andrew Tomkins