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MSF in Malawi, 2003
All articles on Malawi »
MSF was present in Malawi from 1986 to 1990. In 1996 MSF returned to the country.
Paracetamol; first-line malaria treatment; oral rehydration salts; iron tablets; vitamins; condoms; disinfectant solutions; eye ointment; soap; adhesive tape; cotton; disposable gloves; gauze bandages and scissors.
These few basic items can be put into a little kit, carried around by bicycle from home to home, village to village. They might be small, they might be deceptively simple – but, in the right hands, they can mean a big difference in the daily life of a person living with the pandemic disease of the current age: HIV/AIDS. They can help forestall the untimely disappearance of one, two, ten, a hundred people. They can help prevent a part of humanity from slipping away, unnoticed.
In Thyolo district, a densely populated rural district in southern Malawi with a population of about 475,000 people, home-based care volunteers working with MSF carry these items (and others) when they visit their assigned patients. These volunteers are part of the great community web of care and compassion that has evolved in Malawi even as the deadly virus claims over 80,000 lives each year. Around 850,000 Malawians are living with the disease, including about 15% of the adult population.
Malawi's circle of care has many faces: doctors and nurses who treat patients in hospitals and clinics; nurses who zoom from village to village on their motorbikes, examining patients and supervising village volunteers; home-based care volunteers; "guardians," usually close friends or family members who look after one patient, who make sure that he or she has enough to eat, that medicine is taken on time and doctor's appointments are kept; sick people themselves, who meet together, offering one another support and encouragement. All of these people together are trying to hold on to lives the virus has put its claim on.
Since 1996, MSF has been working to fight HIV/AIDS in the district of Chiradzulu, in 1997 expanding work to Thyolo. Both programs are tackling the disease through a comprehensive range of prevention activities and services, medical care and patient support. And both program sites now offer antiretroviral (ARV) treatment, which can enhance and prolong the lives of people living with AIDS. In Thyolo, MSF's project is designed to root nearly every aspect of detection, support, care and ARV treatment for people with HIV/AIDS in a communitybased continuum of care network.
Evance Nikoma is a 40-year-old father living in Thyolo. Suffering from a fever and chronic diarrhea, Evance discovered he was HIV-positive. He now has a "guardian" – his brother – who takes care of him. Anne, a volunteer from Evance's village, also helps. Both his brother and Anne were trained by MSF to take care of Evance on a daily basis. An MSF nurse visits periodically, referring Evance to the HIV/AIDS clinic service in the nearby health center, or to the MSF HIV/AIDS clinic at the district hospital for treatment of opportunistic infections.
Modeled on community-based networks that already have strong roots in Malawi society, the MSF project in Thyolo is the product of collaboration with the Ministry of Health and Population and national and local health organizations to create an HIV/AIDS program centered in traditional community support systems. Through this "continuum of care" people with HIV/AIDS are integrated into a community health care network involving family members, volunteers, local organizations and health care professionals. People are referred to the program through a wide range of social groups, health structures and community outreach activities. Religious groups, traditional birth attendants and traditional healers help steer patients to MSF-supported facilities, while mobile clinics are organized monthly for commercial sex workers and their clients. MSF and local health staff provide voluntary counseling and testing and mother-to-child transmission prevention services (PMTCT) at seven health centers and two hospitals in the district (MSF also provides PMTCT in Chiradzulu). Currently, more than 1,500 men, women and children are being tested monthly, of whom 30-35% test positive for HIV infection. One-third of those newly identi. ed as HIV-positive can be integrated into the network of home-based care.
The tuberculosis connection
One of the most effective entries to treatment for HIV/AIDS is through offering routine voluntary counseling and testing to all tuberculosis (TB) patients. TB is one of the most common opportunistic infections associated with AIDS, and it is on the rise in Malawi. Countrywide, the annual number of cases increased three-fold between 1987 and 2001. In Thyolo, 75-80% of those with tuberculosis test positive for HIV. All of these HIV-positive TB patients are offered cotrimoxazole prophylaxis (which can help protect them against opportunistic infections) and are entered into the continuum of care network for home-based care and HIV/AIDS clinic services.
Medications for patients who are being treated for opportunistic infections such as tuberculosis can be complicated. To help patients and their loved ones understand and participate in the process, patients are required to keep a health "passport" recording treatments and medical visits. Care is individualized to each person's situation and often involves family and friends. Caregivers in the continuum of care program are trained to assist patients with chronic or terminal illness, alleviate pain and suffering and help improve their lives in other ways. As of July 2003, 4,000 people were receiving direct support through the continuum of care initiative in the district of Thyolo. However, over a five-year period (2003-2007) MSF hopes to extend access to the continuum of care network to at least 50% of the estimated 50,000 people living with HIV/AIDS in this district.
The grassroots education of volunteers, nurses and family members involved in implementing and maintaining this successful program has helped to mobilize the community to respond to HIV/AIDS and raised consciousness about the disease and its transmission. This awareness-raising and education is important in both Chiradzulu and Thyolo. "When AIDS first appeared in Malawi, no one wanted to talk about it," explains George Maruwo, an MSF health worker in Chiradzulu. "It was totally taboo. Many people got infected because there was no information and no prevention." Other educational activities include plays and songs presented by People Living With AIDS (PLWA) support groups. Members of PLWA support groups meet monthly to talk about their experiences, supported by MSF counselors. Psychosocial care for people with AIDS and their families is critical.
ARV therapy – offering the future
"I feel like I have a future" – Fred Minandi, Chiradzulu, receiving antiretroviral treatment since 2001
Fred Minandi is expressing a feeling that is commonly found among those who begin antiretroviral treatment. An expanding part of MSF's work in many countries, ARV therapy can suppress the disease and help the patient's immune system recover, transforming AIDS from a fatal disease into a chronic and manageable illness. People managing HIV/ AIDS with ARVs can often live long, healthy lives. Since May 2001 in Chiradzulu and April 2003 in Thyolo, antiretroviral medicines, or ARVs, have extended the care available to those with AIDS and helped many people see a future where there was none before.
In a country where health facilities often lack even basic supplies, the idea of implementing quality HIV/AIDS care which includes ARV therapy was resisted by some. Maryline Mulemba, Head of Mission in Chiradzulu explains, "Two years ago, when we made the rounds of donors, everyone treated us like we were aliens from outer space who didn't understand anything about the local situation. How could ARVs be introduced when there weren't even oral rehydration salts? Today, no one criticizes us and everyone agrees that treatment is necessary."
MSF nurse Helle Poulsen-Dobbyns notes the amazing difference ARVs can make for patients with HIV/AIDS. Six years ago she worked with children in Malawi. "As one by one I watched the children die, I became increasingly frustrated and angry," she remembers. After ARV drugs were introduced in Chiradzulu in 2001, Poulsen- Dobbyns decided to return, and was amazed to see patients begin to feel better after only a few weeks of ARV therapy. "We've come a long way," she concluded.
In Thyolo, MSF nurses select HIV-positive people already integrated in the home-based care program as potential candidates for ARV treatment, depending on their medical status and the availability of a family member, friend or neighbor to support them with their ARV treatment. Once accepted into the program, patients select a guardian (if they don't have one already) who is responsible for helping supervise their doctor visits and medication regime. Usually a friend or family member, the guardian is an essential part of the program, providing individualized support to each participant, and helping alert MSF staff to individual needs or problems. By July 2003, nearly 150 people had begun ARV therapy in Thyolo district through the MSF HIV/ARV clinic at Thyolo district hospital, and 1,000 others had been identi. ed as eligible for treatment. Plans are underway to open a new HIV/AIDS clinic at the Malamulo 7th Day Adventist Hospital by late 2003. The ambitious five-year goal is to provide access to ARV treatment to at least 50% of the estimated 7-8,000 people in the area continuously suffering and dying of AIDS.
Finding sustainable ways to extend ARV therapy to as many people as possible is currently at the center of discussion within the MSF movement. "Our real challenge is providing services to all the patients knocking on our door," states Maryline Mulemba. People living with HIV/AIDS in Chiradzulu are eligible to participate in the ARV program if their disease has progressed to a particular stage and they have selected a guardian to help them with the treatment. By July 2003, nearly 1,000 people were undergoing ARV treatment in Chiradzulu.
In addition to providing direct access to essential medications, working to implement change at the level of national policy and fighting to diminish international barriers to affordable drugs are high priorities.
Other projects – emergency preparedness and nutritional monitoring
Since the late 1990s, there have been yearly outbreaks of cholera in Malawi during the rainy season. In 12 districts in the southern part of the country, MSF works with the Ministry of Health and Population and several missionary health centers and hospitals on refresher training for health staff, pre-positioning medical supplies and materials and construction or rehabilitation of cholera treatment facilities. During outbreaks, MSF supports case management, supplies medical materials and disinfectants, and works on outbreak control.
In August 2002, MSF carried out an independent assessment of food security in Malawi. While international reports of impending famine in southern Africa were widespread, MSF teams found the nutritional levels of the population to be similar to previous years. MSF continues to monitor the nutritional situation in Malawi in 2003.