Oti, Samuel O.a,b
An increasing number of countries, mostly low income and middle income, are facing a double burden of infectious and noncommunicable diseases (NCDs) [1,2]. On one hand, the health systems in such countries continue to be placed under enormous strain by the huge burden of infectious disease such as HIV/AIDS, tuberculosis (TB) and malaria . On the other hand, such countries are also experiencing a rapid upsurge in the levels of NCDs such as stroke and cancer, as well as their risk factors including hypertension, diabetes, obesity, tobacco use, excessive alcohol consumption, inadequate physical activity and unhealthy diet . This upsurge in NCDs is believed to be driven largely by rapid urbanization and the consequent adoption of unhealthy lifestyles, as well as increased life expectancy (the risk of NCD increases with age) in many low and middle-income countries . Unfortunately, the health systems in such countries are simply incapable of adequately dealing with an increased burden of disease in their current state because they are mostly attuned to providing episodic care for acute conditions, given their historical disease patterns and resource limitations [5▪].
It is not all bad news, however. With regard to HIV/AIDS – the leading infectious disease globally – the world appears to be turning a corner in the fight to defeat the epidemic. For instance, HIV incidence has declined in 33 countries, 22 of them in sub-Saharan Africa . This success can be largely attributed to the global response to the epidemic, including the launch of UNAIDS in 1996, the targeting of HIV/AIDS as one of the Millennium Development Goals (MDGs) in 2000, the launch of the Global Fund to fight AIDS, TB and Malaria in 2002 and the announcement of U.S President's Emergency Plan for AIDS Relief (PEPFAR) by President Bush in 2003, to mention a few. At the same time, the world is also taking the fight to NCDs as evidenced by the launching of the WHO Action Plan on NCDs in May 2012 and the UN Resolution on the prevention and control of NCDs in September 2011.
Going forward, the current discourse in the global health arena centres on what the best approaches should be to reducing the burden of NCDs while at the same time not loosing focus on other important public health conditions such as HIV/AIDS. A number of recent publications highlight a need for a coordinated or integrated approach in dealing with the double burden of infectious and NCDs. For instance, a recent study [7▪▪] in the British Medical Journal stars the title ‘No more disease silos for sub Saharan Africa’. The authors’ main argument is that knowledge of the common determinants and links between infectious and NCDs should be used to spur the development of coordinated approaches to prevent and treat both.
The calls for coordinated approaches to preventing and treating infectious and NCDs are valid and timely. This is because going by previous experience with major infectious diseases such as HIV/AIDS, there could be a tendency for the initiation and implementation of ‘vertical’ approaches in the global response to reduce the burden of NCDs, as was the case with the global HIV/AIDS response. A vertical approach implies disease prevention and/or treatment programmes that are implemented either in whole or to a large extent by specialized health delivery services outside the confines of what is routinely available. Although there are strong justifications (and benefits) for vertical approaches to dealing with public health emergencies such as HIV, there remain doubts as to the long-term sustainability of such approaches. Moreover, questions have been raised as to whether or not vertical approaches strengthen or weaken existing health systems [8,9]. The aim of this review is to examine current calls for a coordinated global response to HIV and NCDs and make a case for health system building in resource-constrained settings.
TEXT OF REVIEW
Quite a number of recent publications address the issue of a coordinated global response to HIV and NCDs. This section highlights why a coordinated approach is imperative and how health systems could benefit from such an approach.
Why a coordinated approach is imperative
The proponents of a coordinated approach to prevent and treat HIV and NCDs make the following arguments.
There are significant overlaps between HIV infection and noncommunicable diseases
A number of recent publication make the case that there are significant similarities between HIV infection and NCDs [7▪▪,10▪▪]. First, they point to evidence that shows that many low and middle-income countries with a high burden of HIV also have ‘burgeoning epidemics’ of NCDs. For instance, three-fourths of all AIDS-related deaths globally occurred in low- and middle-income countries where an estimated 80% of NCD-related deaths also occurred. Further these studies point out that, at a biological level, there are inter-linkages between HIV and NCDs. On one hand, people living with HIV (PLHIV) are at an increased risk of NCDs such as diabetes and certain types of cancers. This increased risk may either be directly related to HIV infection itself or the side effects associated with the medication used to treat the infection. Indirectly, due to the availability of life-prolonging treatment, PLHIV are living longer and hence becoming more at a risk to NCD similar to the uninfected population. Moreover, some of the opportunistic infections associated with HIV infection are themselves NCDs such as cervical cancer and lymphomas, among others. Finally, HIV and NCD are similarly chronic diseases, that is diseases of insidious onset, long duration and slow progression. Therefore, to a large extent, chronic treatment and care programmes for HIV and NCD would usually involve the same elements such as promotion of healthy behaviour, long-term adherence to treatment, regular follow-up, to mention a few. Given these similarities, a coordinated approach to dealing with both HIV and NCDs makes a whole lot of sense. Indeed, the WHO and UNAIDS have recently signed what is being termed as a historic ‘letter of agreement’ signifying their commitment to integrate NCD and HIV programmes in low- and middle-income countries. Both agencies will aim to ‘maximize synergistic strategies’ in an integrated HIV and NCD response .
There is no need to reinvent the wheel
The global response to the HIV epidemic over the past two decades has been phenomenal to say the least; there are declines in both the rate of new HIV infections and AIDS-related deaths. Also, unprecedented funding has been mobilized for HIV programmes. As a result, HIV/AIDS programmes have become the first large-scale chronic care programme implemented in low- and middle-income countries to date. Against this backdrop, and taking into consideration the overlaps and similarities between HIV and NCD, a strong case has been made for the leveraging of HIV programmes for NCD programmes [12▪▪,13▪,14▪▪]. Lessons learnt from HIV programmes could very well shorten the learning curve for NCD prevention and control [15▪].
Specifically, the HIV/AIDS experience can guide the linking of detection, prevention, treatment and integration of behavioural and biomedical approaches that are similarly applicable to NCD [15▪]. Some HIV programme approaches that can be reviewed and adapted by NCD programmes include but are not limited to peer educator programmes, family-focused care, defaulter tracing initiatives, support for adherence and retention, multidisciplinary teams, task shifting and sharing, demand creation for services, community engagement, tools (registers, charts, forms and medical records) and systems (monitoring and evaluation, improving quality, supply chain and procurement, referring people and processing specimen) [12▪▪,14▪▪]. Demand creation for services and community engagement are two shining examples of lessons that can be learned from the HIV experience [12▪▪]. With regard to demand creation, the extent to which PLHIV and civil society have championed the expansion and implementation of HIV programmes, and access to services, remains unprecedented . Community engagement, although not novel to HIV programmes, has been crucial to their success. This is because HIV programmes recognize that support for a lifelong treatment of a chronic disease such as HIV is more effective if provided at the community level [12▪▪]. Hence, HIV programmes typically engage community-based resources in the continuum of care from hospital to home . Overall, therefore, HIV programmes provide hands-on experience in the scale-up of chronic care to millions of people on the basis of their successes in resources mobilization, garnering of political will, engagement of civil society and establishment of human rights framework for HIV/AIDS victims [5▪].
The reverse is also true to some extent. That is, lessons learnt from NCD programmes can also be applied to HIV. For example, chronic care models usually used for NCDs are being applied in the care of HIV/AIDS in resource-constrained countries. In Zambia, ‘expert patients’ or PLHIV were trained to provide adherence and supportive counselling in response to a shortage of health professionals . The concept of ‘expert patients’ has been applied for many years in developed countries as part of Chronic Disease Self-Management Programmes . Overall, there is a strong case to be made for HIV and NCD programmes to learn and leverage from each other and explore avenues for coordinated approaches that could very well maximize limited resources without compromising on effectiveness.
How health systems could benefit from a coordinated approach
In its 2006 Framework for Action, Director-General of the WHO, Margaret Chan, describes the strategic importance of health systems strengthening as being ‘absolute’ . Her comments echo the increasing recognition of the key role of health systems strengthening in improving health outcomes. In fact, it is widely accepted that it will be impossible for countries and their development partners to achieve national and international goals – especially the MDGs – without greater and more effective investment in health systems and services. Similarly, it will be difficult to sustain the achievements in the fight against HIV or make sustainable progress in preventing an NCD epidemic if health systems are ignored, especially in low- and middle-income countries where existing systems are weak .
Proponents of a coordinated approach to HIV and NCD prevention and control argue that low- and middle-income countries need to have strong and dynamic health systems that can respond effectively to any changes in the epidemiological pattern of diseases whether infectious or noncommunicable [10▪▪]. They contend that countries can no longer afford to treat diseases in ‘silos’ or ‘turn by turn’ [7▪▪,10▪▪]. A model that is health-centred rather than disease-centred is crucial, as it is the only truly sustainable way to go. This they say calls for innovative approaches to expand the capacity of health systems, particularly in low- and middle-income countries to address multiple health challenges. Such approaches must capitalize on existing resources and capabilities by leveraging, for example, HIV resources, experience and models for the management of NCDs, and vice versa.
Specifically, the successes of the HIV programmes can be characterized by their focus on key building blocks of the health system, specifically, technologies and products viz-a-viz supply chain management of drugs, health information systems (data management) and on the health workforce [12▪▪,20▪]. This so-called vertical approach adopted by HIV programmes has been criticized for aggravating weak health systems by diverting resources from ‘horizontal’ or more comprehensive approaches. However, critics must consider the glowing achievements of HIV/AIDS programmes in terms of meeting their goals, as well as the circumstances under which they were conceived; HIV was declared by political leaders of the world to be an emergency that required out-of-the-box measures. Moreover, there is a school of thought [21–23] that proposes a very sensible approach that aims to ‘bridge the traditional divide between the vertical approach, which focus on technical interventions for specific disease priorities and the horizontal approach, aimed at strengthening the overall structure and functions of the health system but without a clear sense of priorities’ . This school of thought proposes ‘a diagonal approach, whereby explicit intervention priorities are used to drive improvements of the health system’ .
A diagonal approach touches the core of making a case for health system building through a coordinated approach to HIV and NCDs. For instance, existing intervention priorities of HIV/AIDS programmes can be drawn upon to re-energize and re-align the health system for chronic care for NCDs. A case in point is a pilot study  in Cambodia that demonstrated the effectiveness of a ‘chronic disease clinic’ that integrated services for HIV, diabetes and hypertension. Such a coordinated or integrated approach ensures that resources are shared and maximized, bringing an overall improvement to the health system.
There appears to be a strong case for a coordinated or ‘diagonal’ approach to HIV and NCD prevention and control. Such an approach will provide a path to a win–win situation if implemented with the overall aim of building health systems, especially in resource-constrained settings. This is not to say that vertical programmes will not be required in such settings to develop context-specific models of care and generate evidence for appropriate NCD interventions [20▪]. Generating evidence is very important, as wealthier nations are cautious about making long-term commitments to NCD prevention and control in low and middle-income countries partly due to the uncertainty about what interventions should be prioritized [20▪]. However, the case has been made that a coordinated approach will ensure that lessons learnt from existing programmes, either HIV or NCD-based, can be shared and cross-pollinated where applicable.
There are concerns that attempts to coordinate HIV and NCD programmes could undermine existing programmes by diluting their effectiveness so to say. Such concerns, if left unaddressed, could lead to antagonism of coordination efforts [25▪]. Therefore, it is important to recognize the interests of key stakeholders [7▪▪]. Moreover, context is crucial. There is no one-size-fits-all approach to coordination of HIV and NCD programmes. For instance, a point of care integration approach as found in the chronic care clinics in Cambodia may be appropriate in some contexts. Whereas in other contexts, it might be more appropriate to apply upstream coordination involving, for example, unified approaches to the development of treatment and care guidelines, and monitoring and evaluation, to mention a few [14▪▪]. What is important, according to the 2011 UNAIDS Report on Chronic Care for HIV and NCD, is to ‘ensure that lessons are shared, systems are harmonized and efficiency is recognized’. Finally, any coordinated approach must be careful not to antagonize parallel global health efforts to strengthen health systems in resource-constrained settings. Therefore, health planners and policymakers together with their development partners should carefully weigh the potential benefits and risks of any such coordinated approaches.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
▪ of special interest
▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 81–82).
1. de-Graft Aikins A, Unwin N, Agyemang C, et al. Tackling Africa's chronic disease burden: from the local to the global. Global Health 2010; 6:5.
2. Marshall SJ. Developing countries face double burden of disease. Bull World Health Organ 2004; 82:556.
3. World Health Organization. Global burden of disease. Geneva: WHO Press; 2008.
4. WHO. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.
5▪. Rabkin M, Kruk ME, El-Sadr W. HIV, aging and continuity care: strengthening health systems to support services for noncommunicable diseases in low-income countries. AIDS 2012; 26 (Suppl 1):S77–S83.
This study demonstrates that older PLHIV are also more likely to have other NCDs, including hypertension, diabetes, cancers, to mention a few. And, as populations in low-income countries age, enhanced chronic care systems such as those developed for HIV will be required to optimize their health and wellbeing. Thus, the authors propose that the lessons and resources learned from HIV programmes can also be leveraged to support the increasing numbers of non-HIV infected individuals with NCD who are in need of ongoing chronic care.
6. UNAIDS. Global report: UNAIDS report on the global AIDS epidemic. Geneva: UNAIDS; 2010.
7▪▪. Marquez PV, Farrington JL. No more disease silos for sub-Saharan Africa. BMJ 2012; 345:e5812.
In this study, the authors highlight the common determinants of infectious and NCD. They then describe how links between infectious and NCDs should be used to spur the development of coordinated programmes to prevent and treat both.
8. Garret L. The challenge of global health. Foreign Affairs 2007; 86:14–38.
9. Shakarishvili G, Atun R, Berman P, et al. Converging health systems frameworks: towards a concepts-to-actions roadmap for health systems strengthening in low and middle income countries. Global Health Governance 2010; III.
10▪▪. Nigatu T. Integration of HIV and noncommunicable diseases in healthcare delivery in low- and middle-income countries. Prev Chronic Dis 2012; 9:E93.
In this study, the author describes HIV/AIDS programmes as probably the largest chronic care programmes ever implemented in most low- and middle-income countries. The author argues that HIV programmes involve the same elements of management of NCDs, and that given these similarities, the models, tools and approaches developed in the implementation of HIV programmes could be adapted to address NCDs.
11. Horton R. Offline: the rights and wrongs of ‘an AIDS-free generation’. Lancet 2012; 380:324.
12▪▪. Rabkin M, El-Sadr WM. Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront noncommunicable diseases. Glob Public Health 2011; 6:247–256.
The authors make the case that lessons learned from the scale-up of HIV programmes can be leveraged to strengthen health systems using chronic diseases as an entry point. Specifically, tools and approaches developed for HIV/AIDS programme such as service delivery models, M&E strategies, to mention a few can be adapted for other chronic conditions and as components of comprehensive preventive and primary care services.
13▪. Rabkin M, Nishtar S. Scaling up chronic care systems: leveraging HIV programs to support noncommunicable disease services. J Acquir Immune Defic Syndr 2011; 57 (Suppl 2):S87–S90.
The authors argue that the scaling up of HIV services in low-income countries has created the first large-scale continuity care programme in such settings. These programmes, they say, have developed resources that might be used to support initiatives for the prevention and control of NCDs.
14▪▪. UNAIDS. Chronic care of HIV and noncommunicable diseases. How to leverage the HIV experience. Geneva: UNAIDS; 2011.
This UNAIDS report presents similarities in the epidemiology of HIV and NCD, respectively, as well as the similarities in approaches for the management of both conditions. The report provides examples of lessons learned from HIV programmes that can be leveraged for NCDs, and makes a case for point of care and/or upstream integration of HIV and NCD services.
15▪. Venkat Narayan KM, Ali MK, del Rio C, et al. Global noncommunicable diseases – lessons from the HIV–AIDS experience. N Engl J Med 2011; 365:10.
This study describes historical landmark events in the global HIV response and how these could provide lessons that can be applied to NCDs. The authors suggest that though the challenges for a global NCD response are many, the experience from HIV shows that solutions are feasible.
17. Jaffar S, Amuron B, Foster S, et al. Rates of virological failure in patients treated in a home-based versus a facility-based HIV-care model in Jinja, southeast Uganda: a cluster-randomised equivalence trial. Lancet 2009; 374:2080–2089.
18. Kober K, Damme WV. Expert patients and AIDS care. A literature review on expert patient programmes in high-income countries, and an exploration of their relevance for HIV/AIDS care in low-income countries with severe human resources shortages. Antwerp: Institute of Tropical Medicine; 2006.
19. WHO. Everybody's business: strengthening health systems to improve health outcomes. Geneva: WHO; 2006.
20▪. Mills EJ, Ford N. Political lessons from the global HIV/AIDS response to inform a rapid noncommunicable disease response. AIDS 2011; 26:1171–1173.
In this study, the authors draw parallels between the ongoing political debates about NCDs and those that took place at the onset of the HIV epidemic. They suggest that the successes of the rapid scale-up of HIV programmes could not have occurred without activism and the high-level support of political leaders. Similar high-level support is needed for NCDs, but the challenge will be in ensuring that any political commitment translates into sustainable programmes that outlive political tenures.
21. Atun R, de Jongh T, Secci F, et al. Integration of targeted health interventions into health systems: a conceptual framework for analysis. Health Policy Plan 2010; 25:104–111.
22. Frenk J. The global health system: strengthening national health systems as the next step for global progress. PLoS Med 2010; 7:e1000089.
23. Ooms G, Van Damme W, Baker BK, et al. The ‘diagonal’ approach to Global Fund financing: a cure for the broader malaise of health systems? Global Health 2008; 4:6.
24. Janssens B, Van Damme W, Raleigh B, et al. Offering integrated care for HIV/AIDS, diabetes and hypertension within chronic disease clinics in Cambodia. Bull World Health Organ 2007; 85:880–885.
25▪. Grepin KA. Leveraging HIV programs to deliver an integrated package of health services: some words of caution. J Acquir Immune Defic Syndr 2011; 57 (Suppl 2):S77–S79.
The author highlights some of the challenges of integrating other health services into HIV care and advises that relevant stakeholders must carefully weigh the merits and demerits of any integration efforts before embarking upon them.
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