Community treatment for HIV-related malnutrition in Malawi

HIV has led to an increase in both acute and chronic malnutrition. People with HIV are prone to infections and likely to become more financially, socially and psychologically vulnerable. Community care programmes offer an effective way of treating HIV-related malnutrition as well as other aspects of the disease.

The Community Care ResearchProgramme is a collaborative project between Valid International and ConcernWorldwide. Its research team has examined the potential of an approach calledCommunity-Based Therapeutic Care, or CTC, to address HIV-linked malnutrition.

CTC was initiated in Malawi inJuly 2000. Recovery rates from the first 12 programmes, which treated 9,020severely malnourished people, showed that outcomes were well withininternational standards for therapeutic feeding programmes.    

Instead of using therapeuticfeeding centres or rehabilitation units, the approach uses a ready-to-usetherapeutic food which patients can take home. The food is high-energy,contains an appropriate balance of nutrients and needs no cooking. The CTCmodel for severe malnutrition is similar to the home-based care which is seenas the best way to care for people with HIV and AIDS. It provides for physicalcare, reduction of stigma, building local capacities and promoting sustainablesupport for people with HIV. It could therefore be an effective way of treatingmalnutrition in people with HIV, although there are also some risks.  These include the potential effect ofhigh-fat, high-sugar food on the body’s uptake of antiretroviral drugs and apossibility of increasing the risk of some bacterial infections.

Findings include:

• In the first 12 programmes of CTC, recovery ratewas 76.5 percent, with a default rate of 10.6 percent and a death rate of4.8 percent.
• In Malawi, research has indicated that up to 35percent of severely malnourished children were HIV-positive.
• In the 2002-2003 hungry season in Malawi, 95percent of severely malnourished children receiving the therapeutic foodas outpatients reached their target weight, including 56 percent of theHIV-positive children.
• CTC combines medical and nutritional treatmentwith home and clinic-based support for carers, and links with a variety oflocal agencies and structures to address the wider causes of malnutrition.
• CTC decreases the barriers to treatment bydecentralising treatment sites and working with communities. Usingmalnutrition rather than HIV as the ‘entry point’ also reduces stigma.

The CTC model contains manyfeatures that are appropriate for the care of HIV-affected people. TheCommunity Care Research Programme is currently adapting the model to make itmore suitable for this purpose in the longer term. Policy implications include:

• By decentralising treatment, CTC can improveaccess, reduce the number of people who discontinue treatment and helpHIV-affected households and communities to remain economically productive.
• Implementing CTC requires decentralisedmonitoring and surveillance systems. These need a well planned andco-ordinated strategy linked to existing community-based programmes.
• Where possible CTC works through existing healthinfrastructure such as maternal and child health outpatients clinics.
• The trust, understanding and participation of thecommunity are key to providing affordable long-termsupport for the treatment of sick people at home.

Lowering the cost of the therapeuticfood is essential. Imported products are too expensive for nationalgovernments. Whilst local production with local ingredients could reduce thecosts, this remains a potential limitation for sustainable CTC.