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Dr Paluku Bahwere Valid International

Ready to use therapeutic food and community treatment of endstage AIDS in Malawi: Benefits of community based nutrition care for malnourished adults with AIDS. Dr Paluku Bahwere Valid International. Content. Background Experiences in Malawi using RUTF in HBC programmes Research priorities.

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Dr Paluku Bahwere Valid International

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  1. Ready to use therapeutic food and community treatment of endstage AIDS in Malawi:Benefits of community based nutrition care for malnourished adults with AIDS Dr Paluku Bahwere Valid International

  2. Content • Background • Experiences in Malawi using RUTF in HBC programmes • Research priorities

  3. Background

  4. Important issues in Sub-Sahara • High HIV prevalence • Fast progression of condition • sero-conversion to stage 2 - 25.4 months • sero-conversion to stage 3 - 45.5 months • Progression from AIDS to death < 1 year • ART coverage low (11%) • Malnutrition common at ART commencement. • Not always related to AIDS stage • Very common first AIDS defining condition • Malnutrition related to survival time • High mortality in ART programs (>10%)

  5. Progression of HIV in Uganda: seroconversion to stage 3 Morgan D et al, 2002

  6. Survival time after first AIDS defining condition in a Uganda cohort Morgan D et al, 2000

  7. June 2005 6.5 million in need 970,000 (15%) accessing ARV. Sub-Saharan Africa only 500,000 accessing (11% ARV coverage) 3 by 5 progress

  8. Malnutrition at time of commencing ART reduce chance of survival Paton NI et al., HIV medicine 2006, 323-330 Paton NI et al., HIV medicine 2006, 323-330

  9. HIV in Malawi • Prevalence (DHS 2004): 12% (♀ 13% & ♂ 10%) • Very low VCT coverage • 83% adults untested • ART coverage very low • 160,000 people in need of ART (NAC, 2003) • Patients on ART = 13,183 (Dec 2004) – 37,640 (Dec 2005) • VCT and ART activities centralized • High mortality on ART • 10% in the first 3 months (National data) • 19% in 8.3 months (MSF-France cohort)

  10. Pilot programme in Malawi • Deliver Ready to Use Therapeutic Food (RUTF) to HIV positive adults • Through existing Home-Based Care networks (HBC) • Salima (SASO) & Nkhota Kota (NASO) • Study population • Malnourished HIV positive adults with stage 3 & 4 disease Programme supported by CWW

  11. Study questions • Will malnourished HIV positive adults eat RUTF? • What are the clinical effects of RUTF? • Nutritional status • Activity • Access to treatment Studies already showed RUT works for HIV+ve malnourished children (Bahwere P et al, unpublished)

  12. Characteristics at admission • Clinical WHO stages (n=60) • WHO stage 3 = 25% • WHO stage 4 = 75% • Nutritional status: means (SD) (n=60) • BMI = 16.1(1.7) • MUAC = 19.5(1.8) • CD4 count (n=51) • <200 = 28 (54.5%) • 20-350 = 12 (23.5%) • >=350 = 11 (21.6%)

  13. Study population and evolution Figure 1: Flowchart for the participation into the programme

  14. Intervention • 3 months nutritional support • 500 g /day of RUTF (Chickpea-Sesame recipe) • 2600 kcal/day • 70g protein/day • Routine cotrimoxazole

  15. RUTF Acceptability • 71 subjects referred by volunteers • 63 (89%) consumed RUTF (including 3 HIV-ve) • Average RUTF intake • 300 g/day • 1600 Kcal/day • 40 g of proteins

  16. Activity performance

  17. 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

  18. 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

  19. Weight gain closely related to RUTF intake

  20. Case study 1 Woman, 36 years, 2 girls , separated, stage 4 not on ARVs At inclusion in study: • Bedridden > 12 months • 39 kg • dependent on mother & 2 daughters for all daily care • Could not walk to clinic 3 months later: • 48 kg • Able to care for herself • Able to walk to clinic • Able to work on her house

  21. Case study 2 Woman, 28 years, 1 child (died), stage 4, on ARVs, 31 kg at admission Rates of weight gain: Month 1, (on ARVs but before RUTF) weight gain = 1 Kg Months 2 & 3, (on ARVs & RUTF) weight gain = 21 Kg Month 4, (on ARVs post RUTF) weight gain = 2 Kg

  22. Case study 2 body composition

  23. CSB + oil 10 $US/patient/month 40 $US/Household ration 50 $US/MT logistic costs CS-RUTF 37.5 $US/patient/month No household ration 50 $US/MT logistic costs COSTS

  24. Lessons learned • Chick-pea Sesame RUTF was acceptable • RUTF facilitated effective nutrition care to malnourished 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

  25. Future researches

  26. Mangochi District-Malawi programme

  27. Valid research priorities • Confirm and clarify results of the pilot programme. • body composition change • impact on physical performance using grip-strength • Use of RUTF/nutrition care in delaying HIV disease progression • Adaptation of RUTF composition to the need of HIV and AIDS patients

  28. Conclusion • Inclusion of RUTF can substantially improve HBC • HBC intervention impact • Motivation of community based workers/volunteers • Improvements in nutrition status associated with improved physical activity performance • Improved physical activity performance increases access other essential care including ART • Transforms a short term benefits into a long term benefits • Nutrition intervention with RUTF prior to ART may improve response to ART. • More research is required: • To confirm the benefit of RUTF in the management of malnutrition in PLWHA • To explore the use of RUTF in preventing malnutrition and delaying HIV disease progression

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