Another round in the battle to end HIV/AIDS began on June 10, 2016, at United Nations (UN) headquarters in New York, when the HIV community adopted targets and actions to end the AIDS epidemic by 2030. For Sub-Saharan Africa (SSA), which bears the largest burden of HIV deaths (800,000 in 2015), this is the promise of a new dawn.
However, this ambitious goal to improve health for people with HIV will not be fully realized unless health systems in sub-Saharan Africa address another threat that looms large on the horizon: the growing epidemic of chronic noncommunicable diseases (NCDs). These include heart disease, respiratory and mental health conditions, cancers, and diabetes. In 2008, SSA accounted for about 10 percent of the low- and middle-income countries' deaths due to NCDs and NCDs are expected to be the leading cause of deaths in SSA by 2030, outnumbering deaths due to maternal, perinatal, nutritional, AIDS, and other infectious diseases combined.
How can the international community seize on this opportunity to collaborate to end AIDS by 2030 and also address NCDs in SSA?
Traditionally, HIV/AIDS and NCDs have been "siloed" in communicable or noncommunicable disease camps. Therefore, in SSA, health systems deliver the response to HIV and NCDs through programs that operate separately. However, due to better access to antiretroviral therapy, HIV patients will soon have near-normal life expectancy and HIV infection will soon be considered a chronic disease.
Indeed, the HIV response's engagement of stakeholders, patients, and civil society is considered innovative, and its strengthening of broader health systems makes it an efficient approach. The model may hold lessons for efforts to improve NCD prevention, treatment, and care. However, aside from a few pilot projects, the two responses still remain highly separate.
This traditional partition should stop. A "marriage of convenience" between HIV and NCDs will be highly advantageous in SSA. Here are six reasons we have derived from our experiences as an HIV researcher and as a diabetes researcher.
1. A win-win partnership for the patients
In SSA, those affected by NCDs have reduced access to prevention, treatment, and palliative care. At the same time, patients affected by HIV and accessing HIV care in SSA may well develop NCDs, both because they are living longer, due to the side effects of their lifesaving medications, and possibly due to the virus itself, which can increase the risk of some cancers.
HIV patients will need to have access to NCD health services, but little is known about how to do this. Some studies are in progress. The NIH and PEPFAR-NCD program is exploring the integration of stroke prevention and care programs in existing HIV platforms. In some countries, evidence shows that offering comprehensive care to both types of patients in the same place is feasible and can achieve success. For example, in an HIV and diabetes project in Cambodia, the retention of patients in care was high after three years (80-90 percent).
2. A solution to the scarcity of financial resources for NCDs response at global and domestic level
Health financing and access are major issues in SSA where most countries are classified as low-income (58 percent). Despite commitments in 2011 from African Union countries to allocate 15 percent of their annual budgets to the health sector, very few of them have met this target five years later. Globally, NCDs have been a chronically underfunded group of health conditions. Advocacy and coordination with the HIV response may be an efficient way to support the response to NCDs in SSA.
3. An efficient way to tackle the lack of human resources in health
Addressing both HIV and NCDs requires human resources to achieve ambitious targets. The HIV response is seeking to offer testing and treatment to 90 percent of eligible groups in SSA by 2020, while the NCD community wants to provide drugs and counseling to 50 percent of eligible people by 2025.
The shortages in the health workforce could hinder these achievements. SSA bears 70 percent of HIV infection burdens but is home to only 3 percent of the global health workforce. That said, task shifting and task sharing in primary health care settings to address HIV have been hailed as successful models of chronic care delivery.
Nurses, community health workers, civil society, and people living with HIV/AIDS were important actors in these successes. Within multi-disciplinary teams, they contribute to a better continuum of care by providing support for adherence to medication, retention in care, and patient and community education. There is a leverage opportunity here, to expand the NCD response by piggy-backing on the HIV program's human resources and decentralized care delivery.
4. An excellent way to gather data regarding NCD's in SSA
Few data are available on NCDs in SSA while HIV research is more developed and provides timely and proper strategic information. A partnership such as this would bring in more technical expertise, lab equipment, and global technical assistance that could contribute to better knowledge of the NCD epidemic in SSA.
5. Better access to NCD essential medicines and adherence support
Cancer drugs are expensive and their prices limit access to care. This situation shares similarities with the early days of the HIV epidemic. Due to the strong leadership of actors, patients' activism, market size, and some innovative drug access initiatives, the price of one year of HIV first line treatment dropped from US $10,000 (2000) to $100 per person (2012) in SSA. Furthermore, the HIV response was an opportunity to improve drug forecasting, procurement, supply chain management, and adherence management in SSA. Therefore, an association of the two programs will be win-win for countries, corporations, and patients alike.
6. A good way to reduce HIV-related stigma in SSA
The stigma toward HIV remains high and may be associated with delays in access to testing and care. It is one of the most significant barriers for ending the epidemic in SSA. A pilot project that integrated HIV and NCDs services in Cambodia reported a reduction in perceptions of HIV stigma and self-stigma. The results showed increased patient attendance despite an "initial concern about HIV-related stigma."
Despite these compelling reasons, change will not be easy. Beyond the traditional division between NCDs and infectious diseases, there are other aspects that deserve consideration. NCDs are a very heterogeneous group of conditions. Unlike infectious diseases, there is no single vector of disease, but instead, a myriad of individual, environmental, and social risk factors. Also, without more evidence about how to address NCDs and HIV together, program integration may lead to suboptimal or even negative outcomes.
That is why SSA governments need to urgently take the lead on program integration and invest in operations research to develop a strong evidence base. We must go beyond speeches and actually test and implement.
In the words of Nelson Mandela, "It always seems impossible, until it is done."
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2aDTzzI
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