Par tners In Heal thAbwenzi Pa Za Umoyo (APZU)

Improv ing HIV and Nut r i t i on Outcomes in Rura l Ma lawi

CASE STUDY – The power of an integrated approach

IN WARD AFTER 2 WEEKS OUTPATIENThttp://www.pih.org/blog/entry/a-healthy-child-in-just-two-weeks/

Three innovative components of an integrated, community-based approach

1. Village Health Workers2. Community Engagement

3. Direct Nutritional Support At the Hospital/health Center

Village Health Workers- Case finding- Active follow-up and

monitoring of health status

- One-on-one health education

Community Engagement- Health education and outreach- Community reinforced emphasis

on positive living- Backbone of Support Groups

and Community-Based Organizations

NENO HOSPITALDirect Nutritional Support

- Corn/soy blend (Likuni Phala) and Ready to Use Therapeutic Food (RUTF)

- All HIV, TB, and malnourished patients- Mothers on PMTCT, exposed infants

IdentifyRefer

Relies on VHWs for monitoring and follow up

Relies on for CE education, community reinforced well-being, prevention

Community-based Integrated Model

Village Health Workers (VHWs)

• Trained and supervised by Partners In Health to identify and report cases of malnutrition within community.

• Assess all children for malnutrition and determine severity using MUAC and clinical indication (edema, etc.)

• Trained to monitor health status of EVERY community member including-PLHIV with an emphasis on nutrition.

Janet, a village health worker in remote Nsambe district.

VHWs and People Living With HIV (PLHIV)

• PLHIV identified at clinic – begin antiretroviral therapy (ART), VHW assigned.

• Visit from VHW every day, accompaniment to clinic

• Receive four months of direct nutritional support.

• Household Chart - a simple tool to monitor health status and track follow-up care.

• Data compiled quarterly for assessments of community health indicators.

VHW visiting patients at home in Lower Neno

Household Chart

SECTION1 OF HHC

• Name:_____________________________ Village:__________________ TA:___________________ HSA Name:__________________________ Date Chart Opened:_____________________

• SECTION 1 LIST ALL HOUSEHOLD MEMBERS AND FILL IN THE REQUESTED INFORMATION

• First Name Last Name Male/Female Date of Birth Over 15? Ever tested for HIV? ...in the past 6 months? Joined Household Left Household Died

• Male Female ________/________/________ Day Month Year __________/__________ Day Month __________/__________ Day Month

__________/__________ Day Month • Male Female ________/________/________ Day Month Year

__________/__________ Day Month __________/__________ Day Month __________/__________ Day Month

• Male Female

Household Chart – Data Assessment

Community Engagement• Nutrition Counseling

• Community events• Outpatient clinics• Inpatient

• Nutrition Health Education• By VHWs, ART Clerks, Health

Surveillance Assistants• Occurs at monthly patient meetings• Topics: causes of malnutrition,

early/late signs, six food groups, etc.• Biannual outreach campaigns assist

case finding.• Accompaniment to Community

Based Organizations, Support Groups.

A Community Based Organization

MUAC being measured at an outreach event.

Community Engagement for PLHIV

• Positive living education specific to PLHIV: • how to eat during different

malnutrition diagnoses• Opportunistic infections and

preventable diseases (malaria, diarrhea, cholera, etc.)

• Water and sanitation, prevention of waterborne diseases

• Personal nutrition• Crop diversification

Dramas, poetry, song, dance, and more are used to emphasize lessons on positive living at community events

Community members are trained to recognize signs of malnutrition on a doll.

Direct Nutritional Support• Malnutrition cases referred for Direct

Nutritional Support• Moderate – Corn Soy Blend (called Likuni Phala)• Severe – Ready-to-Use Therapeutic Food (RUTF)

• All patients with HIV and/or TB are provided with nutritional supported for four months• Mothers on PMTCT program supported throughout

and after pregnancy.• HIV-exposed children supported after six months

old.

DIRECT NUTRITION SUPPORT CONT….

• Partnerships with Private Sector – Two Degrees assists with Likuni Phala

• Program on Social and Economic Rights (POSER) assists underserved patients with non-clinical needs

• After support reliance on VHW, Community Engagement, POSER to monitor health status

• Prevents graduated and malnutrition cases from coming back to Direct Nutrition Support.

Scale up of Model in Neno since 2006

• 1000x increase in patients on ART.

• 10x increase in number of clinics managed by APZU

2006 2007 2008 2009 2010 20110

500

1000

1500

2000

2500

ART Patients on Food Support

June 2006, Neno ART clinic opened with 5 patients

November 2011, 4016 patients across 12 sites

Challenges of Scale Up• Logistics – complicated /uncertain supply chains

– Solution: finding corporate local partners- Rab Processors.

• Funding – Budget cuts force reduced support– Solution: finding/strengthening partnerships

• Human Resources – finding versatile, capable staff to manage many health centers over large, rural area.– Solution: utilizing local ART clerks at health centers

as food suppliers• Changing ministry guidelines = changing demand on

local resources

Looking forward

• Empowering local Likuni Phala production• Maintaining nutritional support all the way to

24 months for HIV-exposed children