1. E NHANCING C OMPREHENSIVE HIV C ARE : Addressing Cardiovascular Disease (CVD) and other Noncommunicable Diseases (NCDs) Kwasi Torpey MD PhD MPH FGCP Deputy Chief of Party, Technical FHI360/SIDHAS, Nigeria

2. Why integrate CVD into HIV services? Global burden of CVD – CVD is a leading cause of morbidity and mortality globally, claiming 17.3 million lives per year – CVD accounts for nearly 30% of deaths in low and middle income countries Link between CVD and HIV – HIV-positive individuals are at increased risk of CVD due to effects of the virus itself and ART drugs HIV is a chronic disease – HIV health infrastructure can be leveraged for other chronic diseases References: WHO. Global Atlas on Cardiovascular Disease Prevention and Control, 2011 Connor et al. Burden of stroke in black populations in sub-Saharan Africa. Lancet Neurology 2007;6:269-78. IOM. Promoting Cardiovascular Health in Developing Countries: A critical challenge to achieve global health, 2010.

3. CVD Integration Models Across Various Contexts: Examples from FHI 360 HIV Programs Kenya: CVD/HIV Pilot CVD accounts for 12% of all deaths; hypertension prevalence is 37% Nigeria: CVD/HIV Pilot & Scale-up CVD accounts for 12% of all deaths; hypertension prevalence is 43% Zambia: Integrated Chronic Care CVD accounts for 12% of all deaths; hypertension prevalence is 40% Reference: WHO, Noncommunicable Disease Country Profiles, 2011.

4. Kenya CVD/HIV Integration Pilot Key Components Partnership w/ MOH, Kenya Cardiac Society, and USAID CVD screening, treatment, & referral services integrated in five APHIA II HIV treatment sites Target population for behavioral and biomedical risk assessment 1)HIV counseling & testing clients 2)HIV-positive clients in care 3)ART clients

5. Between Sept 09 – Sept 10, over 4,000 HIV clients were screened Health care providers and clients valued the addition of CVD and diabetes services Integration of CVD and diabetes services allowed clients to receive all services at the same location Behavioral risk factors were highest among HIV-negative counseling and testing clients – Tobacco use, physical inactivity and alcohol use Biological CVD risk factors were highest among ART clients – Elevated blood pressure, high BMI, and high waist circumference Kenya CVD/HIV Integration Pilot Findings

6. Kenya CVD/HIV Integration Pilot Biological CVD Risk Factors and Length on ART

7. Nigeria CVD/HIV Integration The Pilot Began as a small pilot within USAID-funded GHAIN Project CVD screening system was integrated within HIV care services at Murtala Mohammed Specialist Hospital in Kano WHO/ISH guidelines were adopted for the CVD risk assessment Risk factors assessed: age>40 yrs, male sex, BMI, history of smoking, hypertension, and diabetes – Lab investigations done for those identified with risk factors 1033 HIV-positive clients enrolled in the ART clinic were screened

8. Nigeria CVD/HIV Integration Pilot Findings Most common risk factors were: – age >40years (25.7%) – male sex (25.9%) – overweight/obese (21.8%) – blood pressure >140/90 mmHg (15.2%) Linear relationship found between the mean levels of serum total cholesterol and duration on ART Total Cholesterol Duration on ARTNMean p value < 1Yr333.93 0.02 1-<3Yrs524.49 >=3Yrs674.54

9. Nigeria CVD/HIV Integration Scale-up within Strengthening Integrated Delivery of HIV/AIDS CVD integration being scaled up in all SIDHAS- supported sites Simplification of CVD screening based on level of health care facility and capacity CVD integration implemented within the context of a HIV chronic care model

10. Zambia Chronic Care Screening Integration Key Components Chronic care screening integration within USAID-funded ZPCTII project Screening provided in HIV counseling and testing, PMTCT, and ART Chronic Care Screening Checklist includes – CVD-related risk factors: BMI, hypertension, diabetes – Other health concerns: TB, gender-based violence, prevention w/ positives Implemented in all facilities regardless of level Random blood sugar performed depending on capacity of the facility

11. Zambia Chronic Care Screening Integration Snapshot of Checklist

12. Key Messages CVD/HIV integration is feasible and acceptable in resource limited settings – It can be offered from PHCs to tertiary facilities Leveraging the platform of an existing HIV program - funding, infrastructure, staffing, and commodity management - allows for smooth integration of CVD services CVD/HIV integration site in Kenya: Comprehensive Care Center, Naivasha District Hospital

13. Key Messages (2) Integration strengthens the capacity of the health system to address the comprehensive needs of HIV patients, including their increased risk of CVD Integration services can be offered to clients regardless of HIV status Integration offers an opportunity for de-stigmatization by offering services to non HIV clients