Integrated PMTCT Services in a Rural Setting in Malawi
By Gertrude Kara, WFP and Mary Corbett, ENN
Gertrude Kara is the Programme Officer responsible for HIV/AIDS programmes in WFP Malawi. She has wide experience in the area of sexual and reproductive health, population issues, HIV/AIDS, nutrition and food security.
The authors would like to acknowledge the contributions of Dr. Athanase Kiromera, Medical Director, St. Gabriel's Hospital, and Miss Hilda Kamera, Matron, St Gabriel's Hospital, to this article.
This article is based on interviews by Mary Corbett with Matron Hilda Kamera and Dr Athnase Kiromera, and a project visit by Mary, accompanied by Gertrude Kara, WFP.
St Gabriel's Mission Hospital is situated in Lilongwe district, about 45 minutes by vehicle west of Lilongwe, the capital. Although just off the main road and reasonably close to the city, it is a very rural location. The hospital services a catchment area of 15km radius and a population of 200,000 people who rely mainly on subsistence farming. Maize is the staple food, while tobacco is the main source of cash and is mostly cultivated in big estates where the majority of the poor work as tenants. Most of the people have inadequate land and cannot afford agricultural inputs and are thus, potentially more food insecure. In Malawi, health care is supported through a combination of facilities run by the MOH (Ministry of Health) and the CHAM (Christian Health Association of Malawi) - approximately 40% of the health care is primarily supported by CHAM, working closely with the MOH.
PMTCT in Malawi
Mother-to-child transmission (MTCT) is the second major mode of transmission of HIV in Malawi. Recent estimates show that MTCT accounts for 8 to 10 % of all HIV cases in the country. Although 10 to 15% of perinatal HIV infections occur through breast milk, women, particularly from rural areas, regard breastfeeding as the natural and preferred means of feeding their infants due to high poverty levels.
The health staff at St Gabriel's felt that there was a need to support pregnant/ lactating women living with HIV/AIDS. In particular, the health personnel were concerned at the outcome of mothers diagnosed with HIV/AIDS, especially those with borderline nutrition status, and the impact this would have on breast milk output. Astudy in Kenya had indicated that reduced nutritional intake leading to catabolism increased the speed of the disease process - it is clear that the death of a mother substantially increases the risk of death of the young infant.
Thus, following discussions with WFP, a proposal was developed with a very specific objective to support HIV-positive pregnant and lactating women and their families with nutrition support. In October 2003, in collaboration with WFP, a pilot nutrition intervention to support pregnant/lactating women with HIV/AIDS and their families was commenced.
All pregnant women during antenatal visits were offered VCT (voluntary counselling and testing). Women tested positive for HIV/AIDS were admitted to the PMTCT programme and benefited from the nutrition support programme. On a monthly basis, the family received 50kg maize, 4 litres oil, 7.5kg pulses and the mother received 9kg Corn Soya Blend (CSB) or Lukini Phala (locally produced fortified blend) to be mixed with one litre of oil, which was specifically targeted for her consumption. It was decided that by including a family basket, it might reduce sharing of the CSB/Lukini Phala. The mother received this food ration for all of the remainder of the pregnancy (normally 4-5 months) and then for eighteen months after delivery. The rationale for the long length of support following delivery was based on the following reasons:
- To encourage compliance, so the health team could monitor the mother at antenatal visits and mother/infant pairs closely at post-natal visits
- To offer medical and psychological support to the mother living with HIV/AIDS
- To facilitate ongoing educational support
- To support the mother with abrupt weaning when the infant reaches six months, so as to reduce risk of the infant becoming HIV infected through prolonged breast feeding (see box)
- To monitor routinely the nutritional status of the mother and infant
- To ensure the infant is fully immunised
- To offer VCT on behalf of the infant at eighteen months of age
- To target opportunistically this group for activities such as group support, income generation (rabbit distribution, kitchen gardens, agriculture) and education on breastfeeding.
UN infant feeding recommendations
relating to HIV/AIDS
HIV-negative mothers and for mothers
unaware of their HIV status
Infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Afterwards, they should receive nutritionally adequate and safe complementary foods, while breastfeeding continues for up to two years of age or beyond.
Infant-feeding recommendations for HIV-positive women
Given the need to reduce HIV transmission to infants while at the same time not increasing their risk of morbidity and mortality from other causes, UN guidelines state "when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIVinfected mothers is recommended. Otherwise, exclusive breastfeeding is recommended during the first months of life" and should then be discontinued as soon as the above conditions are met.
Source, and for further details: HIV and infant feeding: A guide for health-care managers and supervisors. UNICEF, UNAIDS, WHO, UNFPA. WHO, 2003.
This and additional resources available online, at http://www.who.int/child-adolescent-health/
At present, there are around 150 women who tested positive for HIV/AIDS in this programme and who are receiving nutritional support. As the programme has only been in existence for around fifteen months, beneficiaries are only now starting to be discharged from the programme. Due to the huge burden of work by the health staff, they have been unable to analyse data from the previous fifteen months but, anecdotally, feel that the programme has had major benefits for these women and their families. It is felt that most of the women have gained weight. For those women who lost weight, it has triggered alarm bells as it was felt there was "something going wrong", such as opportunistic infections or other problems. Due to the nutritional support and improvement in health/nutritional status, many of the women have gone back to their daily activities such as farming. This has many positive implications, in particular improving food security within the household.
Abrupt weaning from breastfeeding was a major issue initially, with mothers finding it difficult to accept and not complying. However, with much sensitisation and ongoing education, women now accept that this is safer for their babies and reduces the risk of them becoming infected with HIV/AIDS. Following on from this, there are now forty-five clients (mothers and husbands) in this programme on ARV therapy. Initially it was difficult to get the husbands to go for VCT. However, as they were attending the clinic to help with taking home the food, over time they decided to be tested. At this stage, all the husbands of the positive women in the programme have been tested.
HIV/AIDS counselling session
It appears that there has been a major change in attitude to VCT within this programme area over the last couple of years. At the last antenatal clinic day, one hundred and twenty new patients were admitted to the antenatal programme and of these, 109 agreed to be tested for HIV/AIDS, i.e. 91% of all new admissions. There appears to be a number of reasons for this. First, in St. Gabriel's hospital catchment area, prevalence of HIV/AIDS (at 4%) is lower that in urban areas, and significantly lower than in the southern region. It may be that the fear of being positive has reduced and people are keener to know their status. Also, the communities are working well in some areas, openly supporting PLWHA with community gardens, among many other activities. Finally, public testimonies have helped reduce the stigma around HIV/AIDS.
In general, the health staff feel the nutritional support to HIV/AIDS women and their families is very beneficial for many reasons, including improvement of nutritional status and well being. However, due to huge work load, the staff have been unable to evaluate their data to be able to support this hypothesis. WFP plan to support the staff to address this issue.
an antenatal clinic
Although abrupt weaning is now more acceptable to HIV positive mothers, there is a major issue around complementary infant foods. Lukini Phala is the recommended food for these children (only available food) apart from foods from the main family pot. Animal milk, in general, is not available and, if so, is not affordable. There is a concern that this food is not nutritiously adequate at the early stage of abrupt weaning and it is felt that a more appropriate food is required. The health staff debated on the appropriateness of the use of the locally produced 'Plumpy nut' for this age group. There was also a concern voiced that stopping the food assistance at eighteen months may also create problems for some of the beneficiaries, particularly where they are particularly food insecure.
Although women appeared to be willing to be tested for HIV/AIDS in this community, men were, in general, much more reluctant. Where women were positive, some men felt they would also be positive and hence there was no need for them to be tested. As it is a polygamous society, in some cases the men left the women and moved to the other wife. With the possibility of ARV drugs, this trend may change in the future.
In conclusion, the nutritional wellbeing of a woman plays a key role in the overall status of her own and her baby's health. Food support improves the energy and protein intake of mothers, helps build their reserves and reduces their vulnerability to opportunistic infections. Integration of a well-targeted nutritional support increases mothers' and babies' access to health services. Food support enhances male involvement in the programme and empowers women to face their HIV status positively.
For further information, contact: Gertrude Masautso Kara, World Food Programme, PO Box 30571, Capital City, Lilongwe 3, Malawi. Tel: +265 1 774 666, email: Gertrude.email@example.com
Taken from Field Exchange Issue 25, May 2005