Intensified Care Art Clinic Improves Treatment Outcome: The Case Of Nunu From Mangochi District, Malawi
Intensified Adherence counseling session with Nunu and her family.
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At only 26 years old, Nunu S. has led a difficult life, having lost four children before they reached the age of two years and losing her first husband to divorce when he learned she was HIV positive. Nunu was chronically ill and repeatedly defaulting from HIV care when a Tingathe CHW found her and her premature newborn baby on the Kangaroo mother care ward in June 2019 and linked her to ICAC (Intensified Care ART Clinic), saving the life of both Nunu and her baby.
The Tingathe program, implemented by Baylor College of Medicine Children’s Foundation-Malawi, has been implementing ICAC since 2019. ICAC is a differentiated service delivery model targeting clients who will benefit from intensified clinical care such as new ART initiates, children on ART, clients with TB-HIV coinfection, ART clients with high viral load, and clients on 3rd line ART. The goal of ICAC is to provide these relatively more complex clients with longer clinic visits to facilitate enhanced treatment to address client-specific challenges and curb disease progression. Through ICAC, clients receive treatment and adherence support, identification and management of ARV side effects, treatment of opportunistic infections and support for other emerging issues related to HIV care. |
In addition to aiming to improve the quality of care provided to clients, ICAC clinic presents a capacity-building opportunity for MOH staff. During these clinics, a Tingathe clinician or doctor provides on-job training and mentorship to MOH service providers to build their clinical capacity and confidence to manage complex/advanced HIV/AIDS cases. This is done through side by side review of ICAC patients, with the aim to ultimately transition the mentorship role from a Tingathe mentor to a qualified member of the district MOH clinical team who will then lead the process.
Diagnosed at Katuli Health Center in Mangochi district, Nunu was initiated on antiretroviral therapy (ART) in 2013 but stopped taking her medication in an effort to hide her illness from her new spouse upon re-marriage. She did not disclose her status, constant bouts of illness only made their destitute living conditions worse, and the 2 hours’ walk to the health facility presented yet another barrier.
In 2018, after several instances of ARV default, Nunu was pregnant with her fifth child and agreed to reinitiate ARVs. She had problems tolerating the medication, was poorly adherent and her side effects did not abate. Health care workers at the site found her case difficult to manage, without adequate time or clinical knowledge to address the psychosocial and clinical factors affecting her. The baby was born prematurely in June 2019, weighing only 1,300 grams. She was initiated on Kangaroo mother care but was too weak to breast feed, yet the facility discharged her. Again, Nunu fell ill and was readmitted back to the hospital’s postnatal ward.
Noting her absence from clinic, the community health worker (CHW) assigned to her for follow up, identified Nunu in the ward during routine screening of mothers not tested for HIV. The CHW discussed the importance and benefits of having Nunu’s case reviewed at the newly introduced ICAC. She was scheduled for immediate review in the next ICAC where a Tingathe medical doctor alongside the facility MOH clinician transferred her to Mangochi district hospital for assessment and treatment of presumed pulmonary TB, commencing her first trip on a journey to a healthy life. At the District hospital, her TB diagnosis was confirmed, she was started on TB treatment, diagnosed with ART treatment failure, and had her ARVs changed to a more effective second line regimen. The baby was enrolled in the early infant diagnosis (EID) program and infant feeding, testing, and prophyalxis was reviewed with Nunu. On discharge, she was advised to continue attending monthly ICAC for clinical reviews and drugs refills.
Nunu is grateful for the care she received at Katuli: “I was very sick and had no hope that my child will survive. She was so tiny and I had problems breastfeeding her since I was too sick. I appreciate the health workers at Katuli for having an interest in my condition. I am now healthy and my baby is well. The counselling I get here has encouraged me to continue taking my ARVs and TB drugs so that my child is protected and that I get better health.”
Three months have passed since Nunu attended the first ICAC. She has tolerated the new medication well, is healthier and happy. She is back on her feet and able to do household chores. Her child is healthy too. She attends monthly ICAC. Her husband, who also tested HIV positive, was linked to ART and they have become one another’s support partner for treatment adherence. The CHW follows up on them closely to provide support and answer any questions they may have.
“I can now eat food cooked by my wife and am happy that the child is healthy. I was afraid she (Nunu) will not survive but with these drugs our marriage too will survive. It was hard for me to do everything on my own, I have been solely fending for the family”, reckons Silaji, Nunu’s husband.
Nunu represents one of the many clients accessing quality care through ICAC. Katuli health center has an estimated 2,346 individuals on ART of whom 76 have been enrolled on ICAC (since commencement of the program in June 2019) as a result of complexities such as high viral load, poor adherence to ART, opportunistic infections and adverse drug side effects among others. Of the 76, 27 have been identified with treatment failure and successfully transitioned to more appropriate ART regimens. CHWs provide ongoing supportive counseling to those newly started on ARVs to ensure early retention on care. On job training and mentorship of MOH staff, coupled with provision of necessary SOPs and job aids, has enabled them to identify and competently manage clients eligible for ICAC thereby improving the quality of care given to patients.
Ms. Faith Kautsi, Katilu health center in-charge and only medical assistant states, “It is our sincere hope that these clinics will be sustained and be conducted more often. They are not only beneficial to clients, but we service providers, are also learning a lot and our skills are being improved.”
Tingathe program continues to scale up intensified care ART clinics across all districts of coverage with a two-pronged purpose; to improve treatment outcomes for enrolled clients and build sustained capacity of MOH staff to address complex HIV cases.
Diagnosed at Katuli Health Center in Mangochi district, Nunu was initiated on antiretroviral therapy (ART) in 2013 but stopped taking her medication in an effort to hide her illness from her new spouse upon re-marriage. She did not disclose her status, constant bouts of illness only made their destitute living conditions worse, and the 2 hours’ walk to the health facility presented yet another barrier.
In 2018, after several instances of ARV default, Nunu was pregnant with her fifth child and agreed to reinitiate ARVs. She had problems tolerating the medication, was poorly adherent and her side effects did not abate. Health care workers at the site found her case difficult to manage, without adequate time or clinical knowledge to address the psychosocial and clinical factors affecting her. The baby was born prematurely in June 2019, weighing only 1,300 grams. She was initiated on Kangaroo mother care but was too weak to breast feed, yet the facility discharged her. Again, Nunu fell ill and was readmitted back to the hospital’s postnatal ward.
Noting her absence from clinic, the community health worker (CHW) assigned to her for follow up, identified Nunu in the ward during routine screening of mothers not tested for HIV. The CHW discussed the importance and benefits of having Nunu’s case reviewed at the newly introduced ICAC. She was scheduled for immediate review in the next ICAC where a Tingathe medical doctor alongside the facility MOH clinician transferred her to Mangochi district hospital for assessment and treatment of presumed pulmonary TB, commencing her first trip on a journey to a healthy life. At the District hospital, her TB diagnosis was confirmed, she was started on TB treatment, diagnosed with ART treatment failure, and had her ARVs changed to a more effective second line regimen. The baby was enrolled in the early infant diagnosis (EID) program and infant feeding, testing, and prophyalxis was reviewed with Nunu. On discharge, she was advised to continue attending monthly ICAC for clinical reviews and drugs refills.
Nunu is grateful for the care she received at Katuli: “I was very sick and had no hope that my child will survive. She was so tiny and I had problems breastfeeding her since I was too sick. I appreciate the health workers at Katuli for having an interest in my condition. I am now healthy and my baby is well. The counselling I get here has encouraged me to continue taking my ARVs and TB drugs so that my child is protected and that I get better health.”
Three months have passed since Nunu attended the first ICAC. She has tolerated the new medication well, is healthier and happy. She is back on her feet and able to do household chores. Her child is healthy too. She attends monthly ICAC. Her husband, who also tested HIV positive, was linked to ART and they have become one another’s support partner for treatment adherence. The CHW follows up on them closely to provide support and answer any questions they may have.
“I can now eat food cooked by my wife and am happy that the child is healthy. I was afraid she (Nunu) will not survive but with these drugs our marriage too will survive. It was hard for me to do everything on my own, I have been solely fending for the family”, reckons Silaji, Nunu’s husband.
Nunu represents one of the many clients accessing quality care through ICAC. Katuli health center has an estimated 2,346 individuals on ART of whom 76 have been enrolled on ICAC (since commencement of the program in June 2019) as a result of complexities such as high viral load, poor adherence to ART, opportunistic infections and adverse drug side effects among others. Of the 76, 27 have been identified with treatment failure and successfully transitioned to more appropriate ART regimens. CHWs provide ongoing supportive counseling to those newly started on ARVs to ensure early retention on care. On job training and mentorship of MOH staff, coupled with provision of necessary SOPs and job aids, has enabled them to identify and competently manage clients eligible for ICAC thereby improving the quality of care given to patients.
Ms. Faith Kautsi, Katilu health center in-charge and only medical assistant states, “It is our sincere hope that these clinics will be sustained and be conducted more often. They are not only beneficial to clients, but we service providers, are also learning a lot and our skills are being improved.”
Tingathe program continues to scale up intensified care ART clinics across all districts of coverage with a two-pronged purpose; to improve treatment outcomes for enrolled clients and build sustained capacity of MOH staff to address complex HIV cases.
