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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
SUPPLEMENT ARTICLE
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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: wme1@cumc.columbia.edu

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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Acknowledgements

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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References

1. UNAIDS. People living with HIV on antiretroviral therapy (July 2017). http://www.unaids.org/en2018. [cited 27 March 2008]. [Accessed 24 August 2017].
2. Rabkin M, Kruk ME, El-Sadr WM. 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.
3. Neuhaus J, Jacobs DR Jr, Baker JV, Calmy A, Duprez D, La Rosa A, et al. Markers of inflammation, coagulation, and renal function are elevated in adults with HIV infection. J Infect Dis 2010; 201:1788–1795.
4. Deeks SG, Lewin SR, Havlir DV. The end of AIDS: HIV infection as a chronic disease. Lancet (London, England) 2013; 382:1525–1533.
5. Dalal S, Beunza JJ, Volmink J, Adebamowo C, Bajunirwe F, Njelekela M, et al. Noncommunicable diseases in sub-Saharan Africa: what we know now. Int J Epidemiol 2011; 40:885–901.
6. De Cock KM, El-Sadr WM, Ghebreyesus TA. Game changers: why did the scale-up of HIV treatment work despite weak health systems?. J Acquir Immune Defic Syndr 2011; 57 (Suppl 2):S61–S63.
7. Rabkin M, El-Sadr WM. Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront noncommunicable diseases. Global Public Health 2011; 6:247–256.
8. Gilks CF, Crowley S, Ekpini R, Gove S, Perriens J, Souteyrand Y, et al. The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings. Lancet (London, England) 2006; 368:505–510.
9. Palma AM, Rabkin M, Nuwagaba-Biribonwoha H, Bongomin P, Lukhele N, Dlamini X, et al. Can the success of HIV scale-up advance the global chronic NCD agenda?. Global Heart 2016; 11:403–408.
10. Toro PL, Rabkin M, Flam R, El-Sadr W, Donahue M, Chadwick E, et al. Training multidisciplinary teams to deliver high-quality HIV care to families in resource-limited settings: the MTCT-Plus initiative experience. J Assoc Nurses AIDS Care 2012; 23:548–554.
11. Sudhir PM. Advances in psychological interventions for lifestyle disorders: overview of interventions in cardiovascular disorder and type 2 diabetes mellitus. Curr Opin Psychiatry 2017; 30:346–351.
12. Funnell MM, Anderson RM. Empowerment and self-management of diabetes. Clin Diabetes 2004; 22:123–127.
13. Parker DR, Assaf AR. Community interventions for cardiovascular disease. Primary Care 2005; 32:865–881.
14. Patel P, Rose CE, Collins PY, Nuche-Berenguer B, Sahasrabuddhe VV, Peprah E, et al. for the NIH HIV/NCD Project Disease Condition Technical Operating Group. Noncommunicable diseases among HIV-infected persons in low-income and middle-income countries: a systematic review and meta-analysis. AIDS 2018; 32 (Suppl 1):S5–S20.
15. Mwagomba BLM, Ameh S, Bongomin P, Juma PA, MacKenzie RK, Kyobutungi C, et al. Opportunities and challenges for evidence-informed HIV-noncommunicable disease integrated care policies and programs: lessons from Malawi, South Africa, Swaziland and Kenya. AIDS 2018; 32 (Suppl 1):S21–S32.
16. Njuguna B, Vorkoper S, Patel P, Reid MJA, Vedanthan R, Pfaff C, et al. Models of integration of HIV and noncommunicable disease care in sub-Saharan Africa: lessons learned and evidence gaps. AIDS 2018; 32 (Suppl 1):S33–S42.
17. Rabkin M, Palma A, McNairy ML, Gachuhi AB, Simelane S, Nuwagaba-Biribonwoha H, et al. Integrating cardiovascular disease risk factor screening into HIV services in Swaziland: lessons from an implementation science study. AIDS 2018; 32 (Suppl 1):S43–S46.
18. Pastakia SD, Tran DN, Manji I, Wells C, Kinderknect K, Ferris R. Building reliable supply chains for noncommunicable disease commodities: lessons learned from HIV and evidence needs. AIDS 2018; 32 (Suppl 1):S55–S62.
19. Rabkin M, de Pinho H, Michaels-Strasser S, Naitore D, Rawat A, Topp SM. Strengthening the health workforce to support integration of HIV and noncommunicable disease services in sub-Saharan Africa. AIDS 2018; 32 (Suppl 1):S47–S54.
20. Juma K, Reid M, Roy M, Vorkoper S, Temu TM, Levitt NS, et al. From HIV prevention to non-communicable disease health promotion efforts in sub-Saharan Africa: A Narrative Review. AIDS 2018; 32 (Suppl 1):S63–S73.
21. Johnson M, Wilkinson J, Gardner A, Kupfer LE, Kimaiyo S, Von Zinkernagel D. Global partnerships to support noncommunicable disease care in low and middle-income countries: lessons from HIV/AIDS. AIDS 2018; 32 (Suppl 1):S75–S82.
22. Nugent R, Barnabas RV, Golovaty I, Osetinsky B, Roberts DA, Bisson C, et al. Costs and cost-effectiveness of HIV/noncommunicable disease integration in Africa: from theory to practice. AIDS 2018; 32 (Suppl 1):S83–S92.
23. Kemp CG, Weiner BJ, Sherr KH, Kupfer LE, Cherutich PK, Wilson D. Implementation science for integration of HIV and non-communicable disease services in sub-Saharan Africa: a systematic review. AIDS 2018; 32 (Suppl 1):S93–S105.
24. Vorkoper S, Kupfer LE, Anand N, Patel P, Beecroft B, Tierney WM. on behalf of the HIV/NCD Project. Building on the HIV chronic care platform to address noncommunicable diseases in sub-Saharan Africa: a research agenda. AIDS 2018; 32 (Suppl 1):S107–S113.
25. Horton R. Offline: NCDs – why are we failing?. Lancet 2017; 390:346.
Keywords:

health system strengthening; HIV; noncommunicable diseases

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