A qualitative investigation of adherence to nutritional therapy in malnourished adult AIDS patients in Kenya

Objective: To understand factors affecting the compliance of malnourished, HIV-positive adults with a nutritional protocol using ready-to-use therapeutic food (RUTF; Plumpy'nut (R)). Design: Qualitative study using key informant interviews, focus group discussions and direct observations. Setting: Ministry of Health HIV/programme supported by Medecins Sans Frontiers (MSF) in Nyanza Province, Kenya. Subjects: Adult patients (n 46) currently or previously affected by HIV-associated wasting and receiving anti-retroviral therapy, their caregivers (n 2) and MoH/MSF medical employees (n 8). Results: Thirty-four out of forty-six patients were receiving RUTF (8360 kJ/d) at the time of the study and nineteen of them were wasted (BMI < 17 kg/m(2)). Six of the thirteen wasted out-patients came to the clinic without a caregiver and were unable to carry their monthly provision (12 kg) of RUTF home because of physical frailty. Despite the patients' enthusiasm about their weight gain and rapid resumption of labour activities, the taste of the product, diet monotony and clinical conditions associated with HIV made it impossible for half of them to consume the daily prescription. Sharing the RUTF with other household members and mixing with other foods were common. Staff training did not include therapeutic dietetic counselling. Conclusions: The level of reported compliance with the prescribed close of RUTF was low. An improved approach to treating malnourished HIV-positive adults in limited resource contexts is needed and must consider strategies to support patients without a caregiver, development of therapeutic foods more suited to adult taste, specific dietetic training for health staff and the provision of liquid therapeutic foods for severely ill patients.