Caring for AIDS patients at home in Malawi

Home-based care is crucial for people with AIDS, yet it is not often available for patients in African countries. As AIDS patients experience different health problems, it is important to develop an understanding of the occurrence and duration of common illnesses in order to determine the needs of the patient community.

The World HealthOrganization (WHO) and UNAIDS advocate home-based care for people living withAIDS as an important part of the health response to the disease. In Malawi, theBangwe home-based care project is run jointly by theSalvation Army and the College of Medicine and provides a service to thetownship’s population of 40,000 people. Since January 2003, data has beencollected simultaneously on patients’ health problems as well as how theyrespond to treatment and their nutritional status. During the course of thestudy, antiretroviral drugs became available free of charge.

A study by theCollege of Medicine, Malawi, looks at patient mortality, frequency of diseases, howsevere the symptoms are, recurrence rates, duration of the symptoms and whetheror not patients’ needs were met, measured over 18 months. The mortality ratewas high: 199 of the 358 patients studied died during this period, a third ofthem within four months of first assessment.

The study makesthe following findings:

• Patients’needs are high, with many of them already experiencing multiple symptoms atenrolment and some of the symptoms recurring.
• Whilesome patients die shortly after first being seen, many survive and requirelong-term clinical care and palliative treatment.
• Substantialpain is common among these patients, with 84 percent reporting medium to severepain at their first assessment.
• Basictreatment of opportunistic infections seems to be successful for most symptoms.
• Somepatients need an opioid or codeine phosphate for pain but these are expensiveand often not available. Morphine has limited success in Bangweas it is difficult to administer.

There is a greaterneed for home-based care in Malawi than that currently being provided. Onlyabout half of patients with chronic illness sought help from the home-basedcare team, thus better community volunteers are needed to improve coverage. Thestudy makes the following recommendations:

• Becauseof the difficulty in using morphine in Bangwe, a goodalternative would be a morphine modified release preparation (MST), when acheap version is available.
• Asmost symptoms occur for about two weeks at a time, the supply of prescribeddrugs needs to last for this period.
• Patientsneeding palliative care and those with severe infections need ongoing weeklyvisits until the symptoms have cleared up.
• Aftertreatment, repeat episodes tend to be shorter in duration. As recurrences occurin some patients, it is vital that community volunteers are able to identifythese patients.
• Foodsupplementation does not seem to improve patients’ survival rate, nutritionalstatus or symptoms, therefore other needs such as income relief may be moreappropriate.