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Building on the HIV platform: tackling the challenge of noncommunicable diseases among persons living with HIV

El-Sadr, Wafaa M.a; Goosby, Ericb

doi: 10.1097/QAD.0000000000001886

The global HIV response has enabled access to prevention and treatment interventions for millions of people around the world. This investment has enabled the strengthening of health systems, which offers a remarkable opportunity to integrate care for noncommunicable diseases for persons living with HIV who are at risk for or have a noncommunicable disease.

aICAP at Columbia University, Mailman School of Public Health, New York, New York

bUniversity of California, San Francisco, California, USA.

Correspondence to Wafaa M. El-Sadr, ICAP at Columbia University, 722 West 168th Street, New York, NY 10032, USA. E-mail:

Received 8 November, 2017

Revised 24 April, 2018

Accepted 10 May, 2018

The global HIV response has been enormously successful. More than 20 million persons living with HIV (PLHIV) have accessed HIV treatment and evidence indicates that this has led to a decrease in morbidity and mortality and a reduction in the number of new infections in several of the most severely affected countries [1]. With millions of PLHIV now able to access HIV treatment, their life expectancy has increased substantially making them susceptible to noncommunicable diseases (NCDs) common in older individuals [2]. In addition, several studies have indicated that HIV infection itself may increase the risk of NCDs due to stimulation of inflammatory markers and adverse events associated with certain antiretroviral drugs [3,4]. This risk is compounded by evidence of high rates of NCDs overall in the general population in many low and middle-income countries, including in sub-Saharan Africa (SSA), due to the increasing prevalence of traditional risk factors for NCDs such as smoking, change in diet and adoption of sedentary life styles [5]. All of these factors compel serious attention to efforts to effectively prevent, diagnose and manage NCDs among PLHIV.

For many of the countries most severely affected by HIV, health systems have traditionally focused on the provision of acute care and maternal-child health services [6]. HIV programmes, on the contrary, helped chart a new path, representing the first large-scale, chronic care programmes in these countries [7]. The ability to rapidly scale-up such programmes was facilitated by the adoption of the public health approach to design, deliver and evaluate HIV programmes [8]. The latter centred on the use of consistent algorithmic approach for the management of HIV disease that enabled task shifting to nonphysician clinicians, utilization of uniform antiretroviral regimens as well as support for use of a single monitoring and evaluation system consistent with national systems. The successful scale-up was also enabled by the large investments made to strengthen health systems such as supply chains for medications, reagents and consumables, human resources for health, management resources, laboratories, strategic information systems, community resources and fortified partnerships with health facilities [9]. HIV also inspired the need to pay attention to psychosocial issues in recognition of the stigma and discrimination that PLHIV face, to the importance of preventing HIV transmission as well as the need for life-long adherence with medications. These challenges inspired the creation of multidisciplinary teams of providers and peer educator cadres to help tackle these issues [10].

The transformed health systems established through investment in HIV programming in SSA present a unique opportunity for countries to tackle the rapidly rising burden of NCDs [7] (Fig. 1). HIV, as a chronic communicable disease, has much in common with NCDs. Both require long-standing engagement with the health system, maintenance of robust drug procurement mechanisms and strong laboratory systems, a skilled and diverse workforce, and importantly, engagement of communities. Effective diagnosis and management of NCDs also requires attention to addressing behavioural risk factors, supporting self-management and adherence by recipients of care as well as garnering support from community groups that can complement the services provided at health facilities [11–13].

Fig. 1

Fig. 1

Recognizing the anticipated impact of NCDs on PLHIV, it becomes critically important to pursue models of integrated screening, prevention and care for PLHIV with or at risk for NCDs. These can capitalize on the platform already established for HIV through adoption of a public health approach to tackle NCDs, heeding the lessons learned from HIV and building on the systems and partnerships already established in many countries in SSA.

This supplement is dedicated to the issue of integrating HIV and NCD services for PLHIV and includes 11 articles focused on relevant areas in the SSA context. Each article presents a review of various elements needed for HIV/NCD integration and includes an assessment of the current evidence, lessons learned from HIV scale-up and unanswered research questions. Patel et al.[14] provide a systematic review of cardiovascular disease, cervical cancer, depression and type 2 diabetes mellitus among PLHIV in an attempt to understand the burden of these NCDs among PLHIV, while Mwagomba et al. describe the intersection between policy and evidence and the role each plays in four SSA countries [15]. Njuguna et al. outlines the lessons learned, evidence gaps and way forward in relation to various models of HIV/NCD care integration in SSA [16], while Rabkin et al.[17] describe a specific model for integration of CVD and HIV care in Swaziland. Pastakia et al.[18] focus on the lessons learned from HIV and evidence still needed to inform supply chain management for NCDs and Rabkin et al.[19] highlight key research issues related to strengthening the workforce to support integration of HIV and NCDs. Juma et al.[20] describe the lessons learned and further evidence needed from HIV prevention and care to improve health promotion for NCDs. Johnson et al.[21] highlight the importance of research partnerships and their sustainability in addressing NCD research needs. Nugent et al.[22] provide in their article an assessment of the currently available evidence and the studies needed to understand the costs and cost-efficiencies of HIV and NCD integration in SSA. Finally, Kemp et al.[23] describe the use of implementation science to identify evidence-based integration for HIV and NCDs, while Vorkoper et al.[24] offer a prioritized research agenda that researchers can utilize, as they pursue answers to critical questions that stand in the way of full utilization of the HIV chronic care platform to enable successful response to NCDs.

We trust that this Journal supplement will serve as a resource for all relevant stakeholders including funders, researchers, implementers and policy makers, as they aim to enhance the care of PLHIV with either NCD risk factors or co-existing NCD. We hope that the insights will also inform these same stakeholders, as they put in place the plans to tackle NCDs in the general population and as they conceptualize the elements of such care in the context of universal health coverage. As countries in SSA confront the looming NCD health crisis, it behooves them to look to the successful HIV programs they have established as a model for their NCD response. Integration of NCD services for PLHIV is critically important to address the needs of individuals with both HIV and NCDs and to prevent avoidable disease and suffering. Such efforts will also serve as a blueprint to shape the response to NCDs in the general population. Controlling NCDs, which represent some of the biggest killers in the world today, is feasible. HIV has taught us one indelible lesson: that the impossible is possible [25].

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We acknowledge Drs. John Onidoko and Robert Murphy who also served as guest editors for this supplement. We also thank Katherine Harripersaud for superb editorial assistance. Gratitude is also due to Linda Kupfer, Susan Vorkoper, Nalini Anand and Roger Glass for their commitment to this project.

Source of support: This article as part of the Research to Guide Practice: Enhancing HIV/AIDS Platform to Address Non-Communicable Diseases in sub-SSA was supported by the U.S. National Institutes of Health Fogarty International Center.

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Conflicts of interest

There are no conflicts of interest.

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health system strengthening; HIV; noncommunicable diseases

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