Community Therapeutic Care for managing severe acute malnutrition-The effect of RUTF

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Community Therapeutic Care for managing severe
acute malnutrition-The effect of RUTF

• By Dr. Paluku Bahwere -Valid International
• 34th session of the SCN- WG on nutrition and
  HIV/AIDS
• February 28th 2007

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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

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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

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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 lt 1 year

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CTC entry point?
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Primary study questions outcomes

• Can CTC be used as an entry point for providing
  HIV testing and treatment referral?
• Outcome VCT uptake
• Are CTC protocols effective in HIV-positive
  children (or are modifications needed)?
• Outcomes weight gain/d, recovery, mortality,
  default

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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

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Summary of VCT uptake
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Nutritional Recovery in the Prospective Cohort
WHM gt 85
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Impact of CTC in HIV-positive and HIV-negative
children
RETROSPECTIVE RETROSPECTIVE PROSPECTIVE PROSPECTIVE
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 LOS 63 42 56 42
Default N/a N/a 22.7 14.2
Mortality N/a N/a 18.2 1.8
p lt0.05 Wt gain in RC may be
underestimate due to oedema at admission
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Nutritional Relapse in the Retrospective Cohort
HIV (N28) HIV- (N1102) p-value
losing WH 38.9 20.2 0.07
WHM lt 80 WHM lt 70 14.3 0 2.0 0.4 lt0.001
MUAC lt 125 MUAC lt 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 gt80
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Adult studyEffectiveness of RUTF delivered in
the community through CTC linked with HBC
organisations
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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

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Activity performance
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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

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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

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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

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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

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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

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Weight gain closely related to RUTF intake
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Mangochi programImpact on HIV testing
  n of the total
Tested prior to recruitment 9 4.1
Tested while in program 102 46.4
tested positive 98
tested negative 4
Not yet tested 109 49.5
Total 220 100.0
Counselling continuing
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Mangochi programImpact on ART access
  n of the total
Not yet on ART 160 72.7
ART prior to the recruitment 3 1.4
ART while in program 53 24.1
Tested negative 4 1.8
Total 220 100.0
Counselling continuing
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Livelihood integration
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• SC US Malawi supported farmers earn 355 from
  the sales of their products

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Improvement continues after discharge
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• 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

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Conclusions
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• 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

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Do we need of RUTF?
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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