An observational study of this sought provides clear outcome data based on the realities of the real world and not on the results of an artificially designed clinical trial. Food supplementation seems to have no effect on survival although it does on the nutritional status of those home based care patients who survive to one of the follow up weighing surveys. The result is not surprising considering the late stage in presentation of the disease in many patients. Another possible reason for the absence of effect on survival could that little food reaches the terminally ill patient due to problems of distribution in an urban area of Malawi to families who may have no one to carry food home from the distribution point and where many neighbours are hungry.
Oil, however, may have an effect in those patients who survive six months. This can be explained by some of the oil being eaten by the patient so providing a concentrated source of energy for those patients who are not terminally ill. An alternative suggestion is that oil is a saleable commodity and money so realised may be used to purchase essential commodities such as water and charcoal. This possible explanation fits with the result of oil having no demonstrable effect on nutritional status. There is a slight suggestion which is not statistically significant, as seen in the survival curves for clinical stage 4 patients that food may prolong survival after the first three months. No such difference is found in stage 3 patients.
Food supplementation has not helped to maintain body mass in household members of home based care patients. This apparently disappointing result needs interpretation. The reduction in mean BMI of household members may be attributable to the socio-financial catastrophe brought on by loss of income and increase in expenditure due to the chronic ill health of one or two of the adults in the family. The longer the adult remains alive and ill, the longer the loss of earnings, drain on resources and ensuing poverty. This may account for the reduction in BMI of PLWA households some of whose patients have survived for 12 months or more. Perhaps food supplementation has alleviated this tendency to malnutrition. It could have been worse without the food.
An observational study of this sort is difficult to interpret. Bias can confuse interpretation if the groups which are compared are not similar. The severity of case mix has been compared using discriminant analysis of the presence and severity of presenting symptoms. The before and after food groups have similar case mix. Their BMIs are similar. The main difference is the preponderance of females in the before-food group. It may be that males tend not to seek home based care until it is known that food is available. However, the severity of disease of these patients does not seem to be different from the severity of disease of those presenting before the food handouts started. It appears that the two groups at first presentation are comparable.
Disease progression without antiretroviral drugs is usually inevitable and insidious. Some patients who present with terminal illnesses require palliative care such as opiates and soon die. Others do stabilise with the majority needing continuous or intermittent treatment to provide palliation of symptoms. But should food supplementation be considered one such intervention?
The benefits of food, if they exist, may be outweighed by the costs, not just to donor organisations, but to the patients and their families. Food distribution in urban areas has problems and food may not get to the people intended. Indeed the WFP were hesitant about initiating the programme because of the problems likely to be encountered in Bangwe. The social disruption and animosities produced by the free but selective distribution of food in a community with slender food security may be substantial. The difficulty of families where the adults are unable to get out of the house to collect the food is real. Food is only one of the needs of the family. The catastrophe brought on by terminal illness in one or both caring adults is economic not famine. A more direct help would be the replacement of lost income. It is money in an urban area which is wanted, and not just food. Money is easier to distribute and replaces the actual loss experienced by such a family. The WFP has been reviewing the place of non-food responses to food insecurity and the value of targeting food insecure households . Their review notes the lack of empirical experience of non-food aid interventions.
The possible role of oil in increasing survival requires further study. Not only does oil provide highly concentrated energy but it is also far easier to distribute to PLWA families. Oil is also an easily saleable commodity, with the income from such sales available to purchase other necessities. Two small trials in Bangkok and Tanzania suggest that vitamins may delay progression of AIDS. While a large scale trail is needed to confirm the potential of this, one possibility is to dispense ready to use food (RTUF) which has been found to be useful in the treatment of severely malnourished children in Malawi . The locally produced high energy, high protein, vitamin fortified food which does not need cooking or keeping cool may be an ideal preparation to dispense with other palliative care drugs.