39th Union World Conference on Lung

g Health
18th October 2008 - Paris

Operational aspects of therapeutic nutritional

rehabilitation for HIV/TB patients:
the use of READY TO USE THERAPEUTIC FOODS

By Filippo Dibari *, ** - PH Nutritionist (MSc), Food Technologist (MSc)

Supervision: Andrew Seal* & Paluku Bahwere**

Field supervision: Isabelle Le Galle***
Galle and Ali Ouattara***
Ouattara
Support in method design: Saul Guerrero**

*Centre of International Health and Development, Institute of Child Health, UCL, University of London
** Valid International – United Kingdom
g
*** MSF-F/Homa Bay, Kenya

Funding provided by Valid International

Objectives

y 1) To describe the acceptability, compliance and

adherence to the nutritional rehabilitation

y 2) To determine key barriers to compliance with

the nutritional rehabilitation

….among malnourished adults living with HIV,

starting ART treatment/TB drugs,
drugs
in an MoH/MSF programme in Homa Bay, Kenya

3) To describe the ready to use therapeutic foods

(RUTF) for such rehabilitation
Summary

y Background
y Research design
y Participants
y Results/conclusions
y Recommendations
y Next steps
p
Background
g
 WHO / WFP / UN-SCN / UNICEF 2007

Ready to Use Therapeutic Food (RUTF)

WHO 1999

Nutritional
N t iti l rehabilitation
h bilit ti in
i severe
PRIMARY malnutrition
Background:
SECONDARY malnutrition studies
In HIV+ adults

y Plumpynut® y Weight gain >5%

increases weight gain increases survival
but not survival (n=8701*; BMI<17) Madec et
(n=450*; BMI<18.5) - al., 2007
Ndheka et al., 2006
y Plumpynut®-type
Plumpynut® type
y Afya® maybe has no leads improvement of
benefit physical
p y activity
y
(n=329*; BMI<17) - performance,
MSF/Epicentre, 2007 nutritional status and
survival
(n=50**; BMI<18.5) –
Bahwere et al., 2007
* starting ART
** not under ART
Background:
g
location

• Homa Bay MoH/MSF-F Hospital

• 3 HIV/TB decentralized clinics
Number of adults (>15 years) in the MoH/MSF
HIV/TB programme

In August 2008 :

Æ11,624 patients are HIV and/or TB infected

Æ 9,786
9 786 are TB iinfected
f t d
ÆTB+ and HIV+ and BMI<17 are 311

(MSF/Epicentre 2008)

Backround
Background:
th project
the j t

MoH/MSF HIV OutPatient Programme

in Homa Bay
Bay, Nyanza Province (Jan 2006 to
present):

y Afya® and/or Plumpynut®

y Weight gain (g/kg/day):

◦ Average : 118 (MSF data; n=22)
◦ Standard Deviation: 98

y Important? Cost in MSF/Homa Bay: 30,000

USD/year (estimation)
Research Design: qualitative
Key Informant
I t i
Interviews
y Focus group
discussions (FG)

Focus Groups Direct

y Key informant Observations

interviews (KI)

y Direct unobtrusive
observations (DO)*

* 2 weeks
The Participants
Participants
y 56 participants
◦ 28 HIV+
◦ 18 HIV/TB co-infected
i f t d
◦ 2 carers
◦ 8 health staff
y Characteristics
◦ All were adults (>15 years)
◦ Of the patients, 29% were recovered and 72% under
treatment
◦ Patients under nutritional
treatment were receiving
Plumpynut only
The results
Results – Part 1: Acceptability &
Compliance
Compliance:

• 8/22
/ KI declared to be “non compliant”
p with 4 sachets/day
/ y
• 2/6 DO died because in severe conditions (no compliance at all)

Positive factors associated to Compliance:

• “bring strength”; “soon back to work”; “weight gain”; “less
hungry”; “increasing happiness”; etc.
• Smell & packaging
p g g
• Possibility to mix Plumpynut® with other foods

Negative factors for Compliance:

• Nausea and/or vomit

• Taste: “too sweet”; “too oily”; “too salty”; diet boredom

KI = key informants FG = focus groups DO = direct observations

Results – Part 1: Acceptability &
Compliance
y Sh i
Sharing practices:
i
◦ Household food insecurity
◦ “children
children like it
it”
◦ Sharing with HIV+, not malnourished, partner

• Mixing with other foods (“once you start mixing,

hard to go back”):

◦ (1) porridge, (2) bread, (3) vegetables, (4) tea, (5)

chapatti

◦ Reasons for mixing: Boredom; nausea/vomit

 Results – Part 1: Acceptability &
Compliance

y Counselling:
◦ Health staff: uncertain about effectiveness;; but also “I do
not know what to counsel about severe cases…”
◦ General nut info (“protein from meat, eggs, etc.”) - useful?
◦ Plumpynut®: how to consume it? How often a day?

KI = key informants FG = focus groups DO = direct observations

Results – Part 2: Key barriers
y Supply-related
pp y problems:
p

◦ Only half of the patients under treatment come

with a carer

◦ Max supply that can generally be carried

is 6 kg (approx. gross weight for 2 weeks)
This compares to the approx. 12 kg
required for 4 week gap in between
ART appointment

◦ Stigma : Plumpynut® > ART

◦ Carer very important

 (1) (2)

Results – Part 2: Key barriers

Carer very important
 (1)
(3)

(2)

(4)

Results – Part 2: Key barriers

Buddy very important
(5)
Results – Part 3: Other issues

y Malnourished patients
are also prescribed:
◦ Micronutrient supplements
◦ “Fortified porridge” (mixed)
◦ Risk of exceeding the safe upper limits for
micronutrient intake?

y Admission criteria:
◦ Height
g not reliable with gross
g weakness – BMI
not used for entry criteria
Recommendations
Recommendations
1. Criteria for micronutrient prescriptions

2. Guidelines for Plumpynut® use:

a) Assess swallowing capacity
b) Inform patients about side-effects
c) Advice how & how often to consume
d) Encourage presence of the carer
Recommendations
2. Guidelines for Plumpynut®:
(a) Assess swallowing capacity
a. Visual estimate of oral sores + treatment
b. If oesophageal
p g candidiasis

[ swallowing test ]

Thrush p
present but bearable impossible to swallow

Specific dietetic guidelines

Out-Patient Programme In-Patient Programme

(NG; F-75 / F-100)
 Recommendations
3. Collection of second two weeks supply:
◦ Carer comes to collect the second two weeks
◦ Community Based Organization involvement

4. Education sessions
5. Anonymous
y containers
6. Admission criteria
◦ Height
g issue Æ arm span
p & demi-span*
p ((in-patients)
p ) or
MUAC (out-patient)

* Ethnicity specific - De Lucia et al. (2002)

 What is next?
R d
Randomized
i dC Controlled
ll d T
Trial
i l
Slide 1/3

4.5 USD/Kg ~2.0 USD/Kg

The subjects (n=610) of this study are:
• age > 18 yrs
• malnourished : BMI<17 and/or MUAC<185
• starting ART
Total duration : 2 ~ 2.5 years
((inc. data analysis
y /reporting,
p g, p
publication))

Starting in January 2009

α error = 5%
βerror = 80%
ε = acceptable difference = 0.9 kg/month
 Pictures : MSF project in Homa Bay, Kenya

…thanks for your attention!

For more information on

Ready to Use Therapeutic Foods
(or collaborations on new
research topics):

www.validinternational.org

filippo@validinternational.org