Dr Tolu Oni
WHAT: Evolution of the HIV epidemic
Over the years, HIV and the ensuing global epidemic has resulted in millions of deaths. With the advent of antiretroviral therapy, and the advocacy efforts of civil society, HIV-related mortality has significantly decreased, as has mother-to-child transmission.
Consequently, a worldwide epidemic, characterised by fear, illness and death, has been transformed – with HIV-infected patients now able to live longer in good health in settings where antiretroviral therapy (ART) is equitably accessible and initiated early.
The global burden of HIV continues to vary considerably, with a disproportionally high prevalence in sub-Saharan African countries and other low- and middle-income countries (LMIC).
In these settings, HIV-related deaths remain unacceptably high, with delays in diagnosis and access to treatment. However, in many LMIC, sustained and expanding provision of ART, at increasingly higher CD4 cut-off values, has resulted in increasing life expectancy and decreasing incidence of new infections.
There is therefore a need to move from a system designed as an emergency response to one of chronic disease management, with an accompanying shift from a predominant mortality focus to focusing on morbidity (living with HIV and other diseases) and the improvement of quality of life.
WHY: Changing patterns of disease in countries with significant HIV burden
This ongoing evolution of the HIV epidemic towards being considered a chronic disease is occurring against a background of population transition. Many low and middle-income countries are experiencing rapid, unplanned urbanisation, resulting in a significant proportion of urban dwellers living in informal settlements.
This changing environment is associated with changing behaviour with decreased physical activity, increased consumption of processed high salt/high sugar foods, increased rates of tobacco smoking and alcohol/substance abuse. This is resulting in an accompanying rise in non-communicable diseases (NCD) such as diabetes and heart disease, and NCD risk factors like obesity and high blood pressure.
Of note, this rise in NCDs is considerably higher in low and middle-income countries. A recent study showed that in South Africa, almost four out of every five people over the age of 50 years has high blood pressure. Another research study conducted in South Africa found that three to four out of every five women are overweight or obese. One research study in South Africa found that among HIV-infected patients attending a clinic for ART, one in five were also on treatment for another chronic disease, predominantly treatment for diabetes and/or high blood pressure.
Given that less than 50% of people with high blood pressure are aware of their diagnosis, this figure is likely to be a gross underestimate, and is on the rise as a greater number of HIV-infected individuals age. The increase in NCD and NCD risk factors is even more pronounced in socio-economically disadvantaged populations, the same populations with a high prevalence of HIV. This trend is set to continue across LMIC as countries continue to urbanise and undergo epidemiological transition.
But in addition to simply co-existing in the same populations, these diseases are also known to interact with some ART drugs known to increase the risk of insulin resistance associated with diabetes. In addition, some ART drugs are known to interact with drugs for the treatment of diabetes and high cholesterol. These data highlight the existing overlap between HIV/NCD co-morbidity, and the different pattern of multi-morbidity to that described in high-income countries emerging. This multi-morbidity – the presence of two or more chronic diseases (including HIV) – has been shown in South Africa, and results in greater difficulty of patients to self-manage.
Where there is a mismatch between the workload (including clinic visits, behaviour change, taking long term medication and so on) and the capacity to meet these demands, this may result in poor adherence and could undo the health outcomes and quality of life advances achieved through ART roll-out. Therefore a holistic, coordinated and coherent approach to integrated management is needed.
The roll-out of ART across high-burden settings was accompanied by a mobilisation of global funds to finance these efforts. In these countries, parallel health systems were set up to facilitate the diagnosis, initiation of treatment and monitoring of disease control. These programs have been largely effective at reaching a wide population and rolling out ART access. Many lessons have been learnt in the establishment of HIV programmes, including the importance of prevention, screening and early detection, early treatment and treatment monitoring. With a strong focus on viral-load suppression once ART is initiated, these programmes were designed with a strong focus on monitoring disease control, with systems in place to address sub-optimal disease control – and they have resulted in significant gains in HIV mortality.
The recognition of tuberculosis as an important co-morbidity led to integration service delivery, including screening and co-management, as well as integration of healthcare workers providing care for HIV and TB, resulting in improved HIV and TB outcomes in co-infected patients. These lessons are highly relevant for the control of NCDs and there is a need for a systems approach to integrating chronic infectious and non-communicable disease prevention, screening, diagnosis and management.
Successes notwithstanding, there are common challenges faced by both HIV and NCD programmes that could benefit from a combined effort.
Advocacy by civil society movements was key to achieving affordable equitable access to ART. There is a need for all role players including patient and civil society groups, non-governmental organisations, clinicians and researchers to combine forces and bolster advocacy efforts to address common HIV and NCD challenges including:
improving access to, and uptake of, services by hard to reach and vulnerable populations such as adolescents, migrants, and incarcerated persons.
the need to adopt a Health-in-All-Policies approach to address socio-environmental determinants of these diseases with a stronger focus on prevention
the need to address shared risk factors such as alcohol/substance use through intersectoral collaboration
access to newer medication and advocacy for development of better combinations of drugs
access to palliative care for these conditions
WHEN? Right now
A Global Health Film Festival held at the University of Cape Town in April 2016 screened “Fire in the Blood”, a documentary about access to ART.
The documentary could have been entitled: “When the world realised they should care about HIV”, as it showed effectively how slow the world was to mobilise to respond to the need for access for all and the consequences of the slow response. The last frame of the documentary had the statement: “Help prevent a sequel”.
We welcome the news of a change in treatment policy towards treating all who test positive as this will ensure HIV is a manageable chronic condition (in addition to contributing to prevention efforts). But without a concerted effort right now to address NCD in the general population, the sequel is already playing albeit in slow motion.
From a patient and health system perspective, this conversation must include HIV-infected persons and the HIV programmes in the health system. With the recent announcement of the test and treat policy, we can celebrate the remarkable journey to achieving ART access to all HIV-infected persons. But alongside these achievements must be a shift to improving morbidity, as well as mortality.
Addressing the NCD epidemic in this, and the general population is key to achieving this goal to prevent a reversal of the gains in mortality and morbidity achieved.
DR Tolu Oni is a Senior Lecturer, School of Public Health and Family Medicine, University of Cape Town.