This document describes Partners in Health's integrated community-based model for improving HIV and nutrition outcomes in rural Malawi. The key components are: 1) Village health workers who monitor community health and refer malnutrition cases. 2) Community engagement through nutrition education, support groups, and outreach. 3) Direct nutritional support at health centers for malnourished and HIV/TB patients using corn soy blend and therapeutic food. The model has expanded from serving 5 ART patients in 2006 to over 4,000 across 12 sites in 2011. Challenges include logistics, funding, and human resources which the program addresses through partnerships.

1. Partners In Health
Abwenzi Pa Za Umoyo (APZU)
Improving HIV and Nutrition
Outcomes in Rural Malawi

2. CASE STUDY – The power of an
integrated approach
http://www.pih.org/blog/entry/a-healthy-child-in-just-two-weeks/

3. Three innovative components of an
integrated, community-based approach
1. Village Health Workers
2. Community Engagement
3. Direct Nutritional Support At the
Hospital/health Center

4. Community-based Integrated Model
NENO HOSPITAL
Direct 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
Relies on Relies on for CE
VHWs for Identify education, community
monitoring Refer reinforced well-
and follow up being, prevention
Village Health Workers Community Engagement
- Case finding - Health education and outreach
- Active follow-up and - Community reinforced emphasis
monitoring of health on positive living
status - Backbone of Support Groups
- One-on-one health and Community-Based
education Organizations

5. 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
Janet, a village health worker on nutrition.
in remote Nsambe district.

6. 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 VHW visiting patients at home in
health indicators. Lower Neno

7. Household Chart

8. 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

9. Household Chart – Data Assessment

10. Community Engagement
• Nutrition Counseling
• Community events
• Outpatient clinics
• Inpatient
• Nutrition Health Education
• By VHWs, ART Clerks, Health
Surveillance Assistants
A Community Based Organization
• 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 MUAC being measured at an outreach
Groups. event.

11. Community Engagement for PLHIV
• Positive living education
specific to PLHIV:
• how to eat during different
malnutrition diagnoses
• Opportunistic infections and
Dramas, poetry, song, dance, and more are
used to emphasize lessons on positive living
preventable diseases
at community events (malaria, diarrhea, cholera, et
c.)
• Water and
sanitation, prevention of
waterborne diseases
• Personal nutrition
• Crop diversification
Community members are trained to
recognize signs of malnutrition on a doll.

12. 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.

13. 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.

14. Scale up of Model in Neno since 2006
• 1000x increase in 2500
ART Patients on Food Support
patients on ART.
• 10x increase in 2000
number of clinics 1500
managed by APZU
1000
500
0
2006 2007 2008 2009 2010 2011

15. June 2006, Neno ART clinic opened with 5 patients

16. November 2011, 4016 patients across 12 sites

17. 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

18. Looking forward
• Empowering local Likuni Phala production
• Maintaining nutritional support all the way to
24 months for HIV-exposed children