Presentation on theme: "Is Plumpynut® accepted by HIV-infected malnourished adults on ART? By Filippo Dibari *, ** Presented by Andrew Seal Supervision: Andrew Seal* & Paluku."— Presentation transcript:
Is Plumpynut® accepted by HIV-infected malnourished adults on ART? By Filippo Dibari *, ** Presented by Andrew Seal Supervision: Andrew Seal* & Paluku Bahwere** Field supervision: Isabelle Le Galle*** and Ali 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 *** MSF-F/Homa Bay, Kenya Funding provided by Valid International MSF Scientific Day London - 2008
Objectives 1) To understand and describe the acceptability, compliance and adherence to prescribed doses of Plumpynut® 2) To determine key barriers to compliance with Plumpynut® consumption ….among malnourished adults living with HIV, starting ART treatment, in the MoH/MSF HIV Programme in Homa Bay
Background and Methods Is Plumpynut® accepted by HIV-infected malnourished adults commencing ART?
Homa Bay MoH/MSF-F Hospital 3 HIV decentralized clinics Background:location
Background: the project MoH/MSF HIV Outpatient Programme in Homa Bay, Nyanza Province (Jan 2006 to present): Afya® and/or Plumpynut® Important? Cost in MSF/Homa Bay: 30,000 USD/year (estimation)
Research Design Focus group discussions (FG) Key informant interviews (KI) Direct unobtrusive observations (DO)* * 2 weeks
Participants 56 participants ◦28 HIV+ ◦18 HIV/TB co-infected ◦2 carers ◦8 health staff Characteristics ◦All were adults (>15 years) ◦Of the patients, 29% were recovered and 72% under treatment ◦Patients under nutritional treatment were receiving Plumpynut only Research activities: ◦Focus Groups (5) ◦Direct Observations (6) ◦Key Informant Interviews (22)
The results Is Plumpynut® accepted by HIV-infected malnourished adults commencing ART?
Results Part 1: Acceptability/compliance with Plumpynut® Part 2 : Key barriers to compliance with Plumpynut® Part 3 : Other issues
Results – Part 1: Acceptability & Compliance KI = key informants FG = focus groupsDO = direct observations
Results – Part 1: Acceptability & Compliance Sharing practices: ◦Household food insecurity ◦“children like it” ◦Sharing with HIV+, not malnourished, partner ◦Health Staff FG: probably more sharing in the Outpatient Programme 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; ingredients separation
Results – Part 1: Acceptability & Compliance Counselling: ◦Health staff: uncertain about effectiveness; but also “I do not know what to counsel about severe cases…” ◦General nutrition (“protein from meat, eggs, etc.”) – OK but… ◦Plumpynut®: how to consume it? How often a day? KI = key informants FG = focus groupsDO = direct observations
Results – Part 2: Key barriers Supply-related problems: ◦Only about 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
Results – Part 2: Key barriers Carer very important (1)(2)
Results – Part 2: Key barriers Buddy very important (1) (2) (3) (4) (5)
Results – Part 3: Other issues Malnourished patients are also prescribed: ◦Micronutrient supplements ◦“Foundation +” (mixed) Risk of exceeding the safe upper limits for micronutrient intake? Admission criteria: ◦Height not reliable with gross weakness
Conclusions Is Plumpynut® accepted by HIV-infected malnourished adults commencing ART?
Stigma Sharing practices Will/motivation (novel) RUTF efficacy Supply distribution system ART & RUTF calendars matching Counselling Buddy care Costs (e.g. transport) Food Insecurity Acceptability, compliance and adherence in therapeutic feeding programs in HIV+ adults under ART (source: adaptation from Dr. Mwaniki, KEMRI)
Recommendations Is Plumpynut® accepted by HIV-infected malnourished adults commencing ART?
Recommendations 1. Criteria for micronutrient prescriptions 2. Guidelines for Plumpynut® use: ◦ Assess swallowing capacity ◦ Inform patients about side-effects ◦ Advice how & how often to consume ◦ Encourage presence of the carer 3.Collection of second two weeks supply: ◦Carer comes to collect the second two weeks ◦Community Based Organization involvement ◦Other arrangements? 4.FAQ booklet (Luo & Swahili) 5.Education sessions 6.Workshops on Dietetics / Nutrition & HIV 7.Anonymous containers 8.Admission criteria (span/demi-span or MUAC)
Recommendations a.Visual estimate of oral sores + treatment b.If oesophageal candidiasis 2. Guidelines for Plumpynut®: (a) Assess swallowing capacity [ swallowing test ] Thrush present but bearable Impossible to swallow Specific dietetic guidelines Out-Patient Programme In-Patient Programme (NG; F-75 / F-100)
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