Tina Lloren & Habtamu Fekadu
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  • For this brief presentation (15 minutes), I want to describe how Mozambique has approached nutrition assessment, counseling and support (NACS) for the HIV population within the broader community-based management of acute malnutrition (CMAM) program. I will start by telling you the story of how an integrated program came to be. I will then discuss some of the successes and challenges with integrating HIV into CMAM. And I’ll finish with a few topics that are being discussed as a learning agenda.
  • Until 2004, the standard treatment for severe acute malnutritionamong children in Mozambique had been inpatient care using adaptations of the WHO guidelines for the inpatient treatment of SAM. Recognizing the limitations with treating acute malnutrition through inpatient services, the Mozambique Ministry of Health (MOH) introduced the community-based management of acute malnutrition (CMAM) program, known locally as the Programa de ReabilitaçãoNutricional (PRN), to expand the coverage of services and improve the outcomes. The CMAM/PRN program was introduced in 2004 in services treating children with HIV – it was known as the “Plumpynut program” and was seen as an HIV intervention. The draft protocols at that time focused on treatment of SAM for those with HIV, but quickly expanded to include all under-fives regardless of HIV status. In 2007, the MOH PRN technical working group redirected the focus to treatment of acute malnutrition as a starting point – with special attention to HIV. The CMAM/PRN program expanded beyond HIV services and was integrated into general health services. In 2008, a comprehensive Manual for Nutrition Treatment and Rehabilitation (Manual de Tratamento e Reabilitação Nutritional in Portuguese) was drafted and provided treatment protocols for the treatment of acute malnutrition among children with and withoutHIV, and including both inpatient and outpatient treatment. In 2009, the MOH PRN technical working group, which included FANTA-2, SC and UNICEF, updated the protocols in accordance with newinternational recommendations published by WHO of that same year. The content of the Manual was also expanded to include adolescents age 5-15 years.
  • In 2007, the MOH PRN technical working group redirected the focus to treatment of acute malnutrition as a starting point – with special attention to HIV. The CMAM/PRN program expanded beyond HIV services and was integrated into general health services. In 2008, a comprehensive Manual for Nutrition Treatment and Rehabilitation (Manual de Tratamento e Reabilitação Nutritional in Portuguese) was drafted and provided treatment protocols for the treatment of acute malnutrition among children with and withoutHIV, and including both inpatient and outpatient treatment. In 2009, the MOH PRN technical working group, which included FANTA-2, SC and UNICEF, updated the protocols in accordance with newinternational recommendations published by WHO of that same year. The content of the Manual was also expanded to include adolescents age 5-15 years.
  • Until 2004, the standard treatment for severe acute malnutritionamong children in Mozambique had been inpatient care using adaptations of the WHO guidelines for the inpatient treatment of SAM. Recognizing the limitations with treating acute malnutrition through inpatient services, the Mozambique Ministry of Health (MOH) introduced the community-based management of acute malnutrition (CMAM) program, known locally as the Programa de ReabilitaçãoNutricional (PRN), to expand the coverage of services and improve the outcomes. The CMAM/PRN program was introduced in 2004 in services treating children with HIV – it was known as the “Plumpynut program” and was seen as an HIV intervention. The draft protocols at that time focused on treatment of SAM for those with HIV, but quickly expanded to include all under-fives regardless of HIV status. In 2007, the MOH PRN technical working group redirected the focus to treatment of acute malnutrition as a starting point – with special attention to HIV. The CMAM/PRN program expanded beyond HIV services and was integrated into general health services. In 2008, a comprehensive Manual for Nutrition Treatment and Rehabilitation (Manual de Tratamento e Reabilitação Nutritional in Portuguese) was drafted and provided treatment protocols for the treatment of acute malnutrition among children with and withoutHIV, and including both inpatient and outpatient treatment. In 2009, the MOH PRN technical working group, which included FANTA-2, SC and UNICEF, updated the protocols in accordance with newinternational recommendations published by WHO of that same year. The content of the Manual was also expanded to include adolescents age 5-15 years.
  • There have been many benefits of implementing a NACS program that starts with malnutrition as the base and HIV as a special focus within the program:Partners and donors have been able to collaborate more effectively, e.g. collaboration between PEPFAR-funded projects focused on HIV care and treatment and SC’s UNICEF-funded project focused on the CMAM/PRN roll out has meant cost-sharing of (for example) trainings and supervision visits and equipment needed for NACS. It has also contributed to the success of HIV as a focus of PRN/CMAM. Without the HIV partners at the table, the HIV focus would become more diluted.
  • 2. One national protocol means that health center staff are more clear on the protocols and the MOH already sees the importance of keeping a focus on HIV within malnutrition programs. 3. In Mozambique RUTF is associated with malnutrition, and nutritional assessment, counseling and support are a routine part of the health care system. There is no HIV stigma for receiving RUTF, for example.4. For any child or adolescent (and soon, adult) that is acute malnourished, the standard protocol is to offer HIV testing. In this way, we hope to identify more people who are HIV positive and refer them to treatment and support services. Caretakers can opt-out of the test, but anecdotal evidence so far shows that many agree to be tested.5. The CMAM community materials geared toward community health workers includes a module on HIV and nutrition, thus highlighting the important link between the two. Cadres of HIV workers, e.g. home-based care workers, and health and nutrition workers, are jointly involved in malnutrition screening.
  • Of course, challenges do arise in an integrated system. For example:The referral system between malnutrition services (in the at-risk child consultation) and pediatric HIV services vary in implementation. For example, in some places a health worker or peer educator accompanies the caregiver and child to the HIV services from the at-risk child consultation if he/she has tested positive for HIV. In other health centers, caregivers and children are not accompanied to pediatric HIV services which increases the risk that caregivers and children do not follow through with the referral. Another challenge is the lack of a formalized system to verify if referrals actually reported to the next place and follow-up with home visits if necessary.2. Compared to programs such as the “Food by Prescription” program in Ethiopia that you heard about, the HIV focus within CMAM in Mozambique is more diluted because it is subsumed under the broader malnutrition approach as opposed to the stand-alone approach. 3. For every data point that we want to collect for CMAM, for example the percentage and number of people who have been cured, if we disaggregate by HIV, the fields double. This makes the forms more complicated and time consuming for the health staff.However, even with these challenges, the successes/advantage of the integrated program far outweigh the challenges.
  • Because this is an integrated system, we have an opportunity to test out some theories, for example:Can screening for malnutrition within CMAM improve earlier diagnosis of HIV? Intuitively, we think that if we find cases of acute malnutrition and test them for HIV, we’ll be able to identify cases of HIV earlier than in the absence of the malnutrition screening. But is this true?2. What are the most effective referral systems given the realities in the field? The health system is already overwhelmed and understaffed, and defaulting from CMAM and HIV programs is already a problem. What referral systems can truly be implemented at a large scale with limited inputs given the realities of the field?3. With a strong community component, can we decrease defaulting from either service? And if yes, what are the costs and inputs involved?4. Can CMAM be an effective platform for improving IYCF in HIV+ and – populations? Some countries have integrated IYCF into CMAM programs. In this national-level CMAM program, can we include a focus on IYCF for both HIV and non-HIV populations successfully?5. What is the profile of children admitted to CMAM, e.g. HIV+, HIV-? What is causing the SAM/MAM? The at-risk child registers and the pediatric ARV registers allow us to see the profile of the children being admitted, e.g. Are they breastfed? Have they had diarrhea? Are there times of the year when case loads go up, e.g. during the hunger season or high malaria season? With this information, we can better target preventive interventions. What portion of children admitted to CMAM are HIV+? In some urban health centers where we have good data, around 50% of the children who have acute malnutrition are also HIV positive. What is the situation in other health centers, in other parts of the country, in rural versus urban areas?

Tina Lloren & Habtamu Fekadu Presentation Transcript

  • 1. Integration beyond HIV: Building on CMAM and MNCH Part 1: Ethiopia case studyLinking Food by Prescription with CMAM & other MNCH in Ethiopia: opportunities, challenges and lessons learned
  • 2. Outline •Overview of NACS/FBP •Achievements and progress toward Integration •Challenges •Lesson Learned •Next steps
  • 3. Ethiopia USAID/FBP Overview• Started in October 2009• Technical assistance program• Purpose is to integrate NACS into heath facilities with ART and Pre- ART services and other services (MNCH,CMAM)• Target beneficiaries: • Adults attending pre-ART and ART services; • Pregnant and post-partum HIV positive women • Malnourished OVC (irrespective of HIV status)• Health facilities: health centres and hospitals• Covering four big regions of Ethiopia: Oromia, Amhara, Tigray, and SNNPR
  • 4. Achievements• Scaled to a lot of facilities and reached a lot of clients in a short period of time: • 206 Health centers and hospitals in two years • >150,000 Assessed and Counseled • > 50,000 malnourished OVC and PLHIV provided RUTF• Capacity of health facilities to implement NACS strengthened: • 6- 8 health workers per facility trained (1,259 trained) • NACS materials produced: Flip charts, job aids, radio programs, Anthropometric equipments• NACS is partially integrated to MNCH and comprehensive HIV care services
  • 5. Achievements Number of clients and facility scale up for NACS, Sept 2010 to Dec 2011 140000 250 124810 120000 200 No of Facilities 100000 80000 150 68125 60525 60000 100 40000 27732 14727 50 20000 13448 1301 0 0 0 Mar-11 Sep-10 Dec-10 Sep-11 Dec-11 Jun-11 Assesed & Counseled
  • 6. Progress toward integration• Integration of NACS and CMAM for under five children • Same protocol • Same register • Same follow up mechanism• Integrated with ICCM (integrated Community Case management) for SAM cases but the counseling is weak• RUTF distribution to health facilities integrated into government supply and logistic system (PFSA)• Demand for NACS services created among beneficiaries and health facilities/regional health bureaus
  • 7. ChallengesSeparate guidelines are confusing I’m so confused!for health staff Which protocol should I use?!?(Nutrition and HIV, CMAM, MAM)
  • 8. Challenges• Comprehensive NACS is still a challenge: assessment and support scale up faster than the counseling because of high case load and health workers find it easier to treat than counsel• Different classification and eligibility criteria for children above five years and adults for NACS and CMAM/MNCH• NACS targets only HIV-positive pregnant and lactating women (PLW) where as ANC is for all PLW• The community component is less well developed and referral linkages are weak (contract limited the program to health facilities and relied on other CMAM and HIV partners at the community)
  • 9. Challenges• High loss to Hey wait…. don’t follow forget to come back! up/defaulter rate (20%) and long stay in the program (graduation rate 20-30%)
  • 10. Challenges• No consensus on how to manage MAM at health facilities under CMAM/MNCH programs• Separate supply chains for RUTF for NACS and CMAM/MNCH• Information system: • Already had heavy burden of HIV indicators in the HMIS • Nutrition/HIV indicators are not integrated into HMIS
  • 11. Lesson Learned• NACS is potentially scalable and the demand is high• Assessment and Support scale up faster than Counseling: • Initiate all NACS services together, not just assessment and support • Counseling should be targeted • Task shifting to case managers and lay counselors• Harmonize guidelines of NACS and MNCH/CMAM from the outset• NACS should have a strong community component from the beginning• Economic Strengthening interventions should be part of the NACS continuum but has its challenges• Simplify and harmonize the information to be collected by busy health providers
  • 12. Question for discussion in countries like Ethiopia where CMAM is already scaled up:For children under five years where CMAM is already in place, do we roll out “NACS” to the community, or just build on the existing CMAM and MNCH programming?
  • 13. Integration beyond HIV: Building on CMAM and MNCH Part 2: Mozambique Case StudyPresented by Tina Lloren, Regional Nutrition Advisor, Save the Children NACS SOTA workshop, February 22-23, 2012, Washington, DC
  • 14. Overview of Mozambique’s CMAM program withan integrated focus on HIV1. The starting point as CMAM (HIV integration vs stand-alone NACS project)2. Benefits and challenges3. Learning agenda going forward
  • 15. History of integration Plumpynut Program for HIV+ children CMAM covering all under fives
  • 16. Let’s have one national protocol to treat malnutrition where HIV is integrated! Andinfants, adole scents, and adults MOH TWG
  • 17. History of integration Plumpynut Program for HIV+ children CMAM covering all under fives CMAM covering: • Infants through adults • HIV+, exposed and negative • SAM and MAM
  • 18. Benefits of integrated approach: Increased collaborationamong partners, donors, and funds
  • 19. Benefits of integrated approach• One national protocol• No stigma associated with RUTF and NACS – “it’s for everyone”• HIV testing is standard part of the CMAM package (caretakers can opt-out)• HIV and nutrition is included as a topic for community cadres
  • 20. Challenges of integrated approach• Referral systems need to be set up• HIV focus is more diluted when it is subsumed under broader malnutrition as opposed to the stand-alone approach• Adding HIV to CMAM reporting forms makes them more complicated
  • 21. Learning agenda What are the most potential Can screening for malnutrition within CMAM effective referral systems improve earlier diagnosis given the realities in the of HIV? field? Can CMAM be anWith a strong community effective platform forcomponent, can we improving IYCF in HIV+decrease defaulting? and – populations? What is the profile of children admitted to CMAM, e.g. HIV+, HIV-?