1. NCDs & HIV IN LOW AND MIDDLE-INCOME COUNTRIES
Prof. Gerald Yonga
NCD Research to Policy Thematic Unit School of Medicine
University of Nairobi

2. CONFLICTS OF INTEREST
NONE

3. NCDs & HIV Interactions Interventions for NCDs in HIV
OUTLINE
Rising NCD Burden
NCDs & HIV Interactions
Interventions for NCDs in HIV

4. 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

5. 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

6. NCDs rising as CDs drop (Kenya MOH Report)

7. 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

8. 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

9. 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:

10. 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

11. PAD AMONGST HIV NEGATIVE AND HIV POSITIVE PATIENTS IN AKUHN (Kaittany F et al 2012)

12. METABOLIC SYNDROME AMONGST ART NAÏVE AND ART USERS (Njenga E et al)

13. 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%.

14. 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?

15. 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

16. 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

17. 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

18. SILO HEALTHCARE SYSTEM IN AFRICA
NCD care
MCH/HIV & FP care
Same people, same behavior…
Different doors

19. CHVs, CHEWs & Peer Counselors integration in BCC for HIV and NCDs

20. HIV-CVD Primary Care integration

21. Stable and affordable supply of essential medicines & technologies for NCDs (? Lessons learnt from access to ARVs)

22. 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

23. 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

24. Explain the model.
Initial Chronic Care Model (The MacColl Institue ® ACP-ASIM Journals and books.)

25. 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)

26. 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

27. 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

28. Asante! (Thank you!)