An assessment of capacity and needs for the implementation of nutrition rehabilitation services with RUTF of SUCCESS-CRS partners of 5 provinces: Lusaka, Central, Eastern, North-western, Southern
Dr Prosper Kabi Dibi Dibi
Dr Paluku Bahwere
VALID INTERNATIONAL
Content
1. Executive Summary / 22. Context, Objectives, Methodology / 3
3. Findings / 6
3.1 Characteristics / 6
3.2. Current nutrition interventions / 8
3.3 Consensus on the RUTF Program / 10
3.4 Potential beneficiaries of the RUTF program / 10
3.5 Capacity development need / 10
4. Comments and Recommendations / 11
4.1 Comments / 11
4.2 Recommendations / 14
Table 1: General characteristics of visited centres / 16
Table 2: Main services offered by the visited sites. / 17
Table 3: Characteristics of patients admitted in the visited centres / 18
Table 4: Current nutrition interventions for HIV patients in the visited centres / 20
Table 5: Nutrition indicators used in visited sites. / 21
Table 6: Estimated beneficiaries of RUTF program / 22
Table 7: expressed needs per visited site. / 23
List of appendix / 24
1. EXECUTIVE SUMMARY
Valid assisted Catholic Relief Services (CRS) in the design of their planned RUTF programme for people living with HIV/AIDS (PLWHA). This included theidentification of capacity assets and needs, design of an RUTF program, development of a monitoring plan and development of a community mobilisation and sensitization strategy. Assistance in these areas was developed through consultations and meetings with various stakeholders of the CRS-SUCCESS program both inLusaka and at 13 different field sites visited during the consultancy.
After a series of discussions and observations it is concluded that there are a number of enabling factors included firm conviction by all that maintenance of good nutrition and quick and timely correction of malnutrition are very important for HIV infected patients, experience with nutrition intervention like food distribution, feeding of very sick persons and nutrition counselling, motivated caretakers and caregivers and a good network of providers. However, the consultants are convinced that to achieve a maximum impact and ensure that the program is going to inform future programming, there is a need to promote the use of objective criteria for the identification of beneficiaries, supply the sites with the necessary for applying these criteria, standardizing tools for data collection and program monitoring, closely monitor selected sites to ensure that the quality of the program is optimal in sites to be used for informing future programmingand expand the as yet small body of knowledge on the care of malnourished adults and children living with HIV/AIDS and receiving ART. The consultants were impressed by the enthusiasm around the program and think that this enthusiasm has transformed to possible threats to be only challenges that all sites were prepared to face and overcome. The enthusiasm will allow the program to easily absorb the 727 adults and 295 children that consultants anticipate could be admitted within 3 months. Finally, the consultants would like to mention that they enjoyed the exercise as they did not face any major administrative or logistical problems and they are happy to have been part of the process of a program which is going to be another CRS-SUCESS achievement if all the recommendations made in this report are implemented. These recommendations include:
- Maintenance of a good working partnership with CRS-SUCCESS partners;
- RUTF should be distributed as a medicine to cure malnutrition in sick and malnourished individuals especially those with wasting or oedematous malnutrition;
- Use of objective entry and discharge criteria should be reinforced;
- The size of the program should be kept manageable by reducing the number of entry points to those accessing ART clinics or organising access to ARV;
- The treatment with RUTF should be started immediately at the recruitment of the patient without waiting for the completion of all the process for commencing ART.
- The implementation of the program should be preceded by a comprehensive training of providers;
- To closely document the outcomes with the aim of contributing to the development of the evidence of the effectiveness of the intervention.
2.Context, Objectives, Methodology
HIV-infection results in weight loss and wasting. This is the consequence of a combination of increased energy, protein, minerals and vitamin requirements together with the reduction of food intake, malabsorption and loss of nutrients, and disturbance in the utilisation of macronutrients.Indeed, resting energy expenditure is increased by ~10% in adults with asymptomatic HIV while energy requirements are increased by 20–50% during the convalescent catch-up period after an episode of opportunistic infection. Studies have shown that weight loss and malnutrition observed in HIV/AIDS have an impact on survival. Thus, the comprehensive care of HIV infected persons includes not only ARV provision but also nutritional support. Maintenance of good nutrition and timely improvement of nutritional status are very important to maintain a good quality of life and contribute to prolonging life.
Althoughfood shortage at the household level often contributes to the reduction in dietary intake of PLWHA, anorexia caused by the HIV disease and other systemic infections also play a very important role.For this reason, getting HIV infected adults and children to increase their energy intake through escalating the volume of what they eat is very challenging. Therefore, it is a priority to identify appropriate and sustainable ways of increasing energy intake in HIV/AIDS patients especially the malnourished ones.CRS-SUCCESS plans to evaluate the efficacy of RUTF in the Zambian context and provide RUTF in the treatment of severely malnourished adultsand children infected with HIV. Delivery of this support will occur through Home Based Care (HBC) programs, Hospices and ART clinics as a strategy to reinforce the impact of ART programs. This comprises part of the CRS program ‘Return to Life’ that aims at reducing HIV/AIDS impact through a multisectoral responseto improve care and support for people living with or affected by HIV/AIDS. This intervention will also contribute to the USAID PEPFAR objectives in Zambiain addition to the national objective of expanding treatment care and support.
Valid is an experienced technical support agency which has the objective of increasing the impact of health and nutrition interventions in Africa and Asia. The primary focus of the organisation since it was established in 1999 has been to improve the impact of therapeutic feeding programs for severe malnutrition in children using the Community-based Therapeutic Care (CTC) approach. The results of this international program have been extremely positive. Recently, Valid extended the approach to the management of HIV infected individuals and has begun to accumulate evidence outlining the effectiveness of RUTF as nutritional support for HIV positive individuals. CRS therefore commissioned Valid to provide technical assistance for the set up of a pilot program in two provinces. This involved identification of capacity assets and needs, design of the program, development of a monitoring plan and development of a community mobilisation and sensitization strategy (see annex 1). The methodologies incorporated a desk review of available relevant documents, meetings with key managers of ART clinics, hospices and Home Based Care and physical assessment of storage capacity.A questionnaire was used to capture the information needed but all the questions in the questionnaire were open-ended to allow the interviewed people to completely express their views and contribute freely. A list of all documents reviewed and meetings conducted can be found in Appendix 2.
Site visits were conducted to assess technical capacity and capacity building needs of proposed providers. On site activities included interviews with key managers of the institution and visitsto the institution premises. Field visits were limited due to the number of institutions that needed to be visited during the consultancy time frame. Consequently the majority of data used to formulate recommendations and suggestions for program protocols are based on data extracted from the interviews. However, caution is advised regarding estimations of potential beneficiaries due to possible inflation of figures during interviews.
3.Findings
3.1.Characteristics
3.1.1.General characteristics
A pre-established list of sites to be visited was given to the Consultants (Table 1). Some of the general characteristics of these sites are summarised in table 1. The list comprised second level hospitals each one running an ART clinic, 9 hospices and home based care programs of 2 dioceses. SaintFrancisHospital which serves approximately 600,000 people was running an ART for more than 3 years. In comparisonMukingeHospital, serves a population of 120,000 and has recently commenced an ART. Both hospitals follow up their HIV patients in the community through outreach clinics and use of a network of caregivers based in the community to complement the care provided by medically trained staff in the community.
The hospice visited are either part of a hospital or stand alone hospices. Out of the 9 hospices visited, 3 have an ART clinic on site and an additional 2 organise enrolment and follow up of their patients througha nearby ART clinic. The catchment areas of the hospices vary with some of them covering the whole region. However every hospice has limited inpatient capacity not exceeding 30 beds. This means that there is a waiting list with some patients having to wait until a bed is free before benefiting from hospices care. All the hospices had medically trained staff, complemented by caregivers. Only one of the five HBC centres in Chipata District (at Lumezi) had a formal link with an ART clinic. However, each centre did have a number of HIV positive individuals and were providing care to a small number of critically ill patients. The Solwezi diocese HBC centres also don’t have a formal link with a particular ART clinic. Although, the Kasempa HBC has good capacity in terms of medically trained staff (28 nurses and 12 clinical officers) and a large number of caregivers (476),
3.1.2.Services offered
The main services offered by the centres visited are described in table 2. Two hospitals were providing various care and support free of charge to their HIV patients through ART clinics. This includes Voluntary Counselling and Testing (VCT), nursing, treatment of opportunistic infections, nutrition counselling, adherence counselling, ART monitoring at clinic level and follow up in the community and palliative care. Both hospitals have a child nutrition unit. In SaintFrancisHospital up to 50% of children admitted were HIV infected. SaintFrancisHospital provides a take home nutrition supplement to ART patients, however MukingeHospitaldoes not. Both provide meals to hospitalised patients including those commencing on ART. For MukingeHospital nutrition stabilisation was commencing before starting ART while there was no such policy at SaintFrancisHospital.
Hospices currently receiveboth terminally ill patients and those coming for treatment of acute diseases complementing traditional hospitals. Thus, they offer both palliative care and traditional medical care for short course diseases. Some hospices have an outpatient department where HIV positive patients can register for treatment and receive care for any other disease. They also have outreach clinics that do routine and regular monitoring of registered patients and management of minor conditions right in the community. Not all the patients admitted in the hospices are HIV positive. Four hospices do not have testing capacity and they only offer pre-test counselling and send the patients or a blood sample to the nearest VCT facility while 5 health facilities can perform the full process of counselling and testing. 5 hospices also admit patients commencing ART to monitor tolerance and side effects, provide required nutrition support, establish adherence to treatment, train and inform buddies concerning their role and responsibilities. Nutrition care is an important component of hospices’ interventions. All admitted patients are provided with 4 to 7 meals per day. However, when discharged from the hospice, nutrition support in the form of take home rations are only available in hospices with or linked to HBC which are able to refer those on ART or on TB treatment for monthly rations.
Home based care centres are very active in providing pre-test counselling and setting up positive survivors clubs. They provide medical care for minor diseases, psychosocial and spiritual counselling, counselling for positive living, adherence support and nutrition counselling. All are obliged to provide palliative care in the absence of a hospice in the catchment area or when the referral hospice or hospital is overcrowded. HBC also provide food supplements and other items to vulnerable members of the community and HIV sensitization to the whole community.
3.1.3.Characteristics of patients
Table 1 (page 16) explains the characteristics of patients admitted in the different sites visited. Two ART clinics provide a comprehensive package of HIV services including care and follow up of patients on ART and those not yet on ART. Only Saint Francis hospital could estimate a proportion of 25% of the patients with a BMI<18.5 at the time of commencing ART. However, it was mentioned that at Saint Francis up to 60% of HIV positive patients diagnosed while hospitalised for an opportunistic infection are malnourished and probably have a BMI<18.5%.
Patients’ characteristics for the hospices variedaccording to the type of hospice. The majority of stand alone hospices were predominantly admitting critically ill patients with terminal illnesses, and/or severely malnourished and bedridden. Other areas of the hospice receive transferred patients to provide continued treatment, including provision of intensive nutrition support. The proportion of patients who are in a critical condition or bedridden can be as low as 10%. However, all hospices admit a majority of HIV patients. Other patients frequently admitted in hospices are those with TB or cancer. In terms of nutrition status, the majority of patients present in the hospices at the time of our visit had a MUAC< 22 cm meaning that they had a BMI below17kg/m2.
3.2.Current nutrition interventions
3.2.1.Types of interventions
The different types of nutrition support currently provided are described in table 4. In general the stand alone hospices provide an average of 5 meals per day paying attention to the quality of food and menus. Hospices that are part of the hospital provide an additional 1 to 2 extra meals to improve quality and quantity. Most hospices providea take home ration to discharged ART and TB patients. Feedingpatients during hospital and hospice stay aims to cure underlying malnutrition while the take home ration intervention is aimed at sustaining good nutrition, supporting adherence to ART and alleviating the impact of the disease for the whole household.
Although it did not appear that HIV specific EIC material are used in the sensitization of all HIV and AIDS patients on the importance of good nutrition, all the care providers mentioned that they offer nutrition counselling to their patients or clients.
3.2.2.Targeting strategy: entry and discharge criteria
Clinical signs (general appearance) and weight were the main criteria used to define the nutritional status of patients (table 5). BMI was used in the past at Saint Francis hospital but is no longer routinely used. Mid Upper Arm Circumference (MUAC) is currently used only by the Solwezi HBCs. The Solwezi HBCs are also the only sites routinely measuring the height of patients (table 5).
Discharge from the hospice or the hospital and transfer to a supplementary feeding program or discharge from the nutrition program is also based on the general appearance and weight gain but no clear predefined discharge criteria are used.
For children, admission to the nutrition unit is based on the presence of bilateral pitting oedema or clinical signs of malnutrition (Minga and Lumezi), weight for age chart and oedema (MukingeHospital) and Weight for Height chart and oedema (SaintFrancisHospital).At SaintFrancisHospital where the World Health Organisation protocols are used, there are no clearly defined discharge criteria. In the other sites dealing with children, subjective impressions are used to discharge children.
3.2.3.Monitoring and evaluation of nutrition interventions
The impact of the current nutrition interventions are considered satisfactory at all sites visited. However, it was mentioned at Mother Marie Therese Linsen Hospice that nutrition improvements in patients on ART was slow, only becoming visible after 6 months of nutrition support and 2 weeks wet feeding in hospital and through take home rations. A similar opinion was expressed at Saint Francis Hospital-Katete, although a shorter time of 3 months was mentioned. At Our Lady’s Hospice 3 patterns of nutrition recovery were described: fast recovery (70% of patients on ART), slower recovery (20% of patients on ART) and very slow recovery (10% of patients commencing on ART).
At Mother Marie Therese Linsen Hospice (Mpansshya) and MukingeHospital there was a strong conviction that stabilisation of patients including nutrition improvement enhance the outcome of the ART. However, all the other sites provided ART were not stabilising patients prior to commencing ART.
The opinions expressed above on the timing of nutritional improvements are based on patients’ physical appearance and weight gain. For the beneficial effect of a nutritional improvement prior to ART commencement and not in terms of a quantified reduction in the mortality over time, the adoption of a strategy of stabilizing patients prior to ART commencementwas predominantly supported by those interviewed. These confirm that at some sites the impact of the program is assessed. This is not the case in all sites where, although some indicators that could be used were calculated every month for reporting purpose, there was no utilisation of the data for internal evaluation and decision making. Nevertheless, at Minga Hospice and Lumezi Hospice it was mentioned that regular auto-evaluations of hospital activities are carried out using the national auto-assessment tools.
3.2.4.Accountability mechanisms
It was observed that all visited sites had an acceptable accountability system which indicates that misuse of food commodities is reduced in the program they are implementing. All sites agreed with the idea of implementing an accountability system for the RUTF program.