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NCDs & HIV IN LOW AND MIDDLE-INCOME COUNTRIES
Prof. Gerald Yonga NCD Research to Policy Thematic Unit School of Medicine University of Nairobi
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CONFLICTS OF INTEREST NONE
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NCDs & HIV Interactions Interventions for NCDs in HIV
OUTLINE Rising NCD Burden NCDs & HIV Interactions Interventions for NCDs in HIV
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Annual Number of Deaths
Global NCD Threat NCDs responsible for 41 million death each year 71% of all deaths globally Each year, 15 million people between years of age die from an NCD OVER 85% OF THESE "PREMATURE" DEATHS OCCUR IN LMIC Four conditions account for over 80% of all premature NCD deaths Disease Annual Number of Deaths CVD 17.9 million Cancers 9 million Respiratory diseases 3.9 million Diabetes 1.6 million WHO - Noncommunicable diseases (NCDs) kill 41 million people each year, equivalent to 71% of all deaths globally. Each year, 15 million people die from a NCD between the ages of 30 and 69 years; over 85% of these "premature" deaths occur in low- and middle-income countries. Cardiovascular diseases account for most NCD deaths, or 17.9 million people annually, followed by cancers (9.0 million), respiratory diseases (3.9million), and diabetes (1.6 million). These 4 groups of diseases account for over 80% of all premature NCD deaths. Tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets all increase the risk of dying from a NCD. Detection, screening and treatment of NCDs, as well as palliative care, are key components of the response to NCDs. WHO 2018
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Non-communicable Diseases - Death trends (2006-2015)
2005 (cumulative) Geographical regions (WHO classification) Total deaths (millions) NCD deaths (millions) Trend: Death from infectious disease Trend: Death from NCD Africa 10.8 2.5 28 +6% +27% Americas 6.2 4.8 53 -8% +17% Eastern Mediterranean 4.3 2.2 25 -10% +25% Europe 9.8 8.5 88 +7% +4% South-East Asia 14.7 8.0 89 -16% +21% Western Pacific 12.4 9.7 105 +1 +20% Total 58.2 35.7 388 -3% (WHO Chronic Disease Report, 2005) 5
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NCDs rising as CDs drop (Kenya MOH Report)
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Main Cause of DALYs Lost in Sub-Saharan Africa by Main Cause of DALYs Lost in Sub-Saharan Africa by 2030 The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death Fig 1: Burden of disease (% of total disability adjusted life years (DALYs) lost) by groups of diseases and conditions, sub-Saharan Africa, 2008 and 2030
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PLHIV are at Increased Risk for NCDs
At risk due to prevalence of traditional NCD risk factors1,2 Increased risk of NCDs associated with certain antiretrovirals3 HIV infection associated with increase in inflammatory markers4 1 Rabkin et al. AIDS 2012 2 Dalal et al. Int J Epidemiol 2011 3 Deeks et al. Lancet 2013 4 Neuhaus et al. J Infect Dis 2010
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Chronic Inflammation and Increased Risk for Comorbidities in HIV-Positive Persons
Deeks SG. Annu Rev Med. 2011;62: ; Deeks SG et al. Lancet 2013; 382:
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CVD MORBIDITY IN HIV AIDS defining illnesses still account for majority of admissions to hospital, critical care admission & mortality (AKUHN closed chart audit 2014, Nduku Kiko et al) However, the proportions of HIV patients with non-AIDS defining Non-Communicable Diseases (NCDs) are rising especially in outpatient care settings with potential to being major causes of morbidity and mortality in HIV (Jay S et al, Kaittany F et al, Njenga E et al, Murbi N et al, - AKUHN ) Cardiovascular diseases (CVD) contribute the highest proportions to non AIDS defining illnesses seen in both in-patient and out-patient settings
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PAD AMONGST HIV NEGATIVE AND HIV POSITIVE PATIENTS IN AKUHN (Kaittany F et al 2012)
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METABOLIC SYNDROME AMONGST ART NAÏVE AND ART USERS (Njenga E et al)
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Changing face of CVD in HIV in Africa
Some form of CVD is demonstrable at autopsy in about 40% of HIV-related death, and by echocardiography in approximately 25% of patients with HIV. In Pre-HAART era in Africa, dilated cardiomyopathy affected 15.9 patients per 1000 HIV infected persons and pericardial effusion 11% of patients per year Cardiovascular risk factors have steadily increased in the HAART era and atherosclerotic disease is now significant cause of morbidity and mortality HIV infection doubles or trebles the relative risk of a major adverse cardiovascular event. Each year of exposure is thought to increase the risk of myocardial infarction by approximately 10%.
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HIV- CVD COMORBIDITY CVD patients who develop HIV ?
HIV patients who develop CVD? People diagnosed with both HIV and CVD? Does it matter which category?
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INTEGRATION OF NCD IN TO HIV PREVENTION AND CARE
Rationale (shared risk factors and high comorbidity) Feasibility (resources and logistics) Acceptability (patients, community, HCP at various levels, health administrators) Sustainability (work-load on HCP, health system change/policies, resource allocation) NEED FOR RESEARCH ADDRESSING BEST WAYS TO SCALE NCD PREVENTION AND CARE IN HIGH HIV BURDEN SETTINGS
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Common Challenges Faced Across Health Threats
HIV/AIDS Diabetes CVD Chronic Lung Disease Cancers Mental Health Demand-side barriers + Inequitable availability Health worker shortages ++ Lack of adherence support Inadequate infrastructure and equipment Inconstant supplies of drugs and diagnostics Missing linkage and referral systems Need for client and community engagement Stigma and discrimination Adapted from Rabkin and El-Sadr, Global Public Health, 2011
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Leveraging the Lessons of HIV
Diagnosis and enrollment Identification of risk factors, early diagnosis, opportunistic case-finding, point-of-service diagnostics , standardized diagnostic protocols Retention and adherence Appointment systems, defaulter tracking, patient counseling, expert patients, secure medication supply chains, pharmacy support Multidisciplinary family-focused care A multidisciplinary team of healthcare providers and community members delivers care in partnership with the patient Longitudinal monitoring Health information systems have standardized and easily retrievable data Linkages and referrals Links within the health facility (to lab, pharmacy, others), between facilities, and between facility & community Self management An informed, motivated patient is an effective manager of his/her own health Community linkages and partnerships Need functional partnerships between health facility-based providers and community-based groups that facilitate access to services across the care continuum
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SILO HEALTHCARE SYSTEM IN AFRICA
NCD care MCH/HIV & FP care Same people, same behavior… Different doors
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CHVs, CHEWs & Peer Counselors integration in BCC for HIV and NCDs
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HIV-CVD Primary Care integration
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Stable and affordable supply of essential medicines & technologies for NCDs (? Lessons learnt from access to ARVs)
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Education and Awareness Treatment and Monitoring
HHA - A comprehensive set of interventions across the entire patient pathway – at both facility and community level Education and Awareness Screening Diagnosis Treatment and Monitoring NCD/HIV Patient journey
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CONTEXT: Integrated HIV-NCD Programs in SSA
Malawi 2007: Integrated Cervical cancer-HIV screening 2016: national ART guidelines include hypertension screening Only Pilot integrated HIV-NDC management; scale-up awaiting lessons from 4 integration model projects (LHT, DI, PIH, DREAM) Kenya Kenya Health Policy (2014 – 2030) promotes integration of NCD prevention into existing infectious disease programs Current ART guidelines include screening and management of hypertension, DM & depression as “Standard Package of Care” for PLHIV; pilot projects by Healthy Heart Africa (PATH) & MSF No Scale-up of integrated programs yet South Africa 2011: national-level pilot of Integrated Chronic Disease Management (ICDM) model, includes both CDs (HIV & TB) and NCDs with health promotion, screening & management - health systems strengthening and reform focused Phased scale-up of integrated programs in provinces; not yet nation-wide Swaziland Integrated screening, treatment & referral for diabetes, hypertension & cervical cancer into HIV programs; Adapted HIV chronic care models for NCD management & piloted in 6 HFs, in 2014, supported by ICAP and CDC No Scale-up of integrated models yet Location of the 4 countries used with their policy availability or process stages
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Explain the model. Initial Chronic Care Model (The MacColl Institue ® ACP-ASIM Journals and books.)
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APPROACHES TO HEALTH SYSTEM INTEGRATIONS
Horizontal blocks (e.g. HIV & TB, HIV &MCH/FP, HIV & CVD, HIV & Cancer….) Pan Horizontal (HIV and all NCDs, TB, MCH/FP….) Diagonal approaches (human resource development, financing, facility planning, drug supply and quality assurance) Total Integration (WHO model for ICC in countries in transition)
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TOTAL INTEGRATION:- SDG & MAINSTREAMING OF HEALTH IN ALL GOALS
Most upstream drivers of both NCDs and HIV lie outside the health sector These drivers involve multiple sectors; across the public and private sectors (health, agriculture, education, trade& industry, physical & economic planning…) Approach should to address the health of the population as a human development agenda rather than only “preventing and treating diseases” Mainstream health issues across all sectors and in human development agenda at national and global level
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Supplement Launch! (23rd July 2018)
Research to guide practice: enhancing HIV/AIDS platform to address non-communicable diseases in sub-Saharan Africa Supplement Launch! (23rd July 2018) July 1, Volume 32 - Supplement 1
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Asante! (Thank you!)
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