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