MONTREAL – South Africa is home to the biggest community of people with HIV, but more of its citizens are now dying of diabetes than HIV and the country is grappling with how to integrate treatment for non-communicable diseases (NCDs) into HIV care.
This is something that all African countries with large communities of people are grappling with as the disease burden on the continent shifts from infectious diseases to NCDs and people with HIV get older and become more vulnerable to hypertension, diabetes, cancer and other NCDs.
A good place to start is by expanding the HIV infrastructure built by years of solid investment in clinics, hospitals, data collection and drug supply chains to include treatment for key NCDs, advised Dr Zipporah Ali, chair of the NCD Alliance of Kenya.
“But we need to look at supply chains, cost and the availability of NCD medicines,” Ali cautioned at an event hosted by the NCD Alliance (NCDA) in Montreal on Wednesday ahead of the international AIDS conference that starts on Friday.
Last year’s United Nations High-Level Meeting on HIV resolved that 90% of people with HIV should have access to NCD treatment and mental health services and this has accelerated countries’ motivation to integrate care, according to Jose Luis Castro, CEO of Vital Strategies.
Castro added that TB and HIV had been treated together for many years and could provide a model for integrated care.
Putting integration into practice
In Tanzania, six hospital sites are starting to integrate diabetes and hypertension into HIV programmes. But Dr Kaushik Ramaiya, CEO of Shree Hindu Mandal Hospital in Tanzania, stressed that, while a lot of money has been invested in HIV, the same was not true for NCDs.
“HIV drugs are free, TB drugs are free, but NCD drugs are not free and most of them have to come from out-of-pocket expenditure,” said Ramaiya. “With the HIV/AIDS and TB programme, you’re able to track each and every individual. Unfortunately, NCDs do not have that system in place, and service providers might be doing multiple accountings and lose track of your clients.”
Dr Kim Green, global program director of primary health care at the health provider, PATH, also cautioned that the supply of NCD was not nearly as stable as that of ARVs in many countries. – mostly because more money had been invested in ensuring a stable supply of HIV medication.
“In Kenya, PATH is integrating NCD and HIV services so that people living with HIV are able to access medicines for hypertension and diabetes, with their ARVs. But the challenge is, the ARVs are there and they’re pretty consistently always there but the NCD meds are not,” said Green.
Dr Kiyali Ouattara, Cote d’Ivoire Director of health non-profit Jhpiego, said that his organization had been training HIV healthcare providers in conditions like diabetes and hypertension as well as HIV.
“Instead of having the siloed HIV program looking at HIV-positive clients only at the health facility level, we have an integrated chronic disease platform. All patients with chronic conditions are now seen by the same provider,” said Ouattara.
Minding mental health
Professor Pamela Collins from the Department of Global Health at the University of Washington made a special plea for mental health services.
“If there’s anything COVID has taught us, it’s about the importance of mental health,” said Collins.
“Around 970 million people around the world have an identifiable mental disorder in any given year, and we know that these conditions disproportionately affect the 38 million people living with HIV,” said Collins, adding that about half of mental disorders started by the age of 14 and could be disabling if not treated early.
Professor Linda-Gail Bekker, Director of the Desmond Tutu Health Center in South Africa and former chair of the International AIDS Society, said that each country would have different priorities.
“Which NCDs are we going to prioritize? That may depend from setting to setting. But undoubtedly, the emphasis now needs to be on the implementation, and how we actually put all of this together – from prevention, to demand creation through to the clinical aspects, laboratory work and the medicine supply chain.”
Alignment of global plans
Dr Meg Doherty, director of HIV at the World Health Organization (WHO), said this year was a crucial time for service integration.
“There are so many opportunities and innovations coming forward,” said Doherty, listing the new Global Fund replenishment and new PEPFAR funding models.
“As we go to the next UN high-level meeting on NCDs [in 2025]it’s critical that we bring those together because the implementation will be based upon political leadership and ensuring that there’s funding and focus.”
Starting with communities
Concluding the session, NCDA CEO Katie Dain appealed for countries to collect data about integration models that worked and were cost-effective to present to Ministers of Finance.
“Multiple speakers have spoken about the fact that the stars have aligned around the global policy frameworks, the Global Fund’s new strategy, the UNAIDS strategy, as well as COVID-19 really reinforcing the importance of integration,” said Dain.
“We absolutely need to start with communities and make this about people-centred care, and in order to do that, we need to understand patient needs. We need to be shaping policies and services with people living with HIV and NCDs.”
The event was co-hosted by the Quality of Life partnership (including GNP+, STOPAIDS, and Frontline AIDS), UNAIDS, International AIDS Society, the Leona M and Harry B Helmsley Charitable Trust, and the Norwegian Agency for Development Cooperation.
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