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HIV and NCDs: the need to build stronger health systems
Editorial
HIV and NCDs: the need to build stronger health systems
www.thelancet.com/diabetes-endocrinology Vol 4 July 2016
The availability of antiretroviral drugs means that people in Africa with HIV should be able to look forward to living into a healthy middle–old age. Unfortunately, lifestyle change, driven by urbanisation and Westernisation means that metabolic syndrome and its components rival HIV as a leading cause of illness in Africa. The result is that middle–old age in both those with and without HIV is marred by poor health due to non-communicable diseases (NCDs). For example, in people older than 55 years in South Africa, the prevalence of diabetes is astonishingly high, at nearly 14%, and 29% of deaths in the continent were estimated to be due to NCDs in 2012. Heath systems in Africa have already suffered from the perfect storm of donor-determined health priorities, resulting in silos of care aimed at achieving Millennium Development Goal priorities, and structural reforms demanded by the Bretton Woods institutions. They will be sorely tested by the double burden of HIV and NCDs. If there is a bright side to look on, it is that the hitherto lack of systems to care for chronic diseases means that many countries in Africa have a relatively clean slate on which they can draft plans to develop health systems that will care for patients with HIV as well as NCDs. But beneath this potential veneer of optimism lurks the question, how will this be achieved? World Bank data show that growth in gross domestic product (GDP) in sub-Saharan Africa slowed to 3·0%
Published Online June 8, 2016 http://dx.doi.org/10.1016/ S2213-8587(16)30110-3 For more on HIV and CVD see Review page 598 For more on HIV prevalence see http://data.worldbank.org/ indicator/SH.DYN.AIDS.ZS For more on Africa’s transition see Editorial Lancet Diabetes Endocrinol 2016; 4: 1 For more on diabetes prevalence in older people in Africa see Review Lancet Diabetes Endocrinol 2016; 4: 72–84 For more on Africa’s GDP see http://www.worldbank.org/en/ region/afr/publication/africaspulse-an-analysis-issuesshaping-africas-economicfuture-april-2016
Tony Camacho/Science Photo Library
One of the greatest health achievements of recent decades is turning HIV infection from a death sentence to a chronic disease. Widespread access to combination antiretroviral therapy means that people with HIV are now living near normal life spans—and thereby facing different health challenges. Cardiovascular disease (CVD) is now one of the leading causes of non-AIDS-related morbidity and mortality in people with HIV. In this issue of The Lancet Diabetes & Endocrinology, Eric Nou and colleagues review the current state of knowledge concerning CVD in people with HIV. Although traditional risk factors for CVD (diabetes, hypertension, hyperlipidaemia, and smoking) are more prevalent in people with HIV, evidence from epidemiological studies suggests a 50–100% increase in risk for CVD even after controlling for these factors. The consequences of HIV infection per se and the side-effects from antiretroviral drugs (especially older generations) probably contribute to this increased risk. Additionally, the stage at which treatment is started might affect CVD risk. It is also likely that there are differences in risk depending on the population with HIV under study. But, as the authors acknowledge, there are problems with the evidence presented in this Review. Studies are often small, cross-sectional, and use proxy measures for clinical outcomes. Little evidence comes from large-scale randomised trials. As a result, although it seems clear that traditional risk scores could be way off the mark in their ability to predict CVD outcomes in people living with HIV, translating findings to actionable health policy is difficult. The European Union and the USA have made a start in developing guidelines for monitoring risk factors in patients with HIV, but specific guidelines for treatment are lacking. Globally, there is an urgent need for research to inform health policy in this clinical area. That necessity is absolute in low-income and middle-income countries, which suffer from the double whammy of high prevalence of HIV and fragile health systems. Africa is arguably at the top of this list. AIDS-related deaths are estimated to have decreased by more than 50% in the past 10 years—a truly momentous achievement. But the overall prevalence of HIV in Africa remains high at 4·5%, and this statistic hides huge regional variation—for example, the prevalence in Swaziland is 27·4%.
549
Editorial
For UN human development indicators see http://hdr.undp. org/en/countries For more on the Chatham House recommendations see https://www.chathamhouse.org/ sites/files/chathamhouse/home/ chatham/public_html/sites/ default/files/20140300Domestic FundingHealthMcIntyreMeheus. pdf For the Ethiopian Health Sector Transformation Plan see http://www.moh.gov.et/ documents/26765/0/Health+Sec tor+Transformation+Plan/ 5542a23a-9bc7-46a2-8c1f8b32c2603208?version=1.0 For more on out-of-pocket payments in Africa see http:// data.worldbank.org/indicator/ SH.XPD.OOPC.TO.ZS For more on development assistance for health see Articles Lancet 2016; published online April 13. http://dx.doi. org/10.1016/S01406736(16)30168-4 For more on research capacity in Africa see Editorial Lancet Diabetes Endocrinol 2016; 4: 375
550
in 2015 from 4·5% in 2014. Additionally, 30 out of the 48 sub-Saharan African countries are classed by the UN as least developed—there are just 18 other countries on this list. A perusal of the most recent World Bank data for national GDP and the proportion of GDP spent on health will allow even a casual reader to realise that even for countries that achieve the Chatham Houserecommended 5% of GDP spent on health, that figure is unlikely to equate to a recommended primary healthcare spend of $86 per person. And this is without accounting for the financing of infrastructure. So, how to ensure that the successes seen in managing HIV thus far don’t stumble at the hurdle of NCDs? The Sustainable Development Goals (SDGs) have made a good start of highlighting NCDs, but achieving success in the SDGs will require strong in-country policy and implementation. Following the money is often a necessary course of action, but governments should stay firm in focussing on the needs of their populations and not be led by the interests of donors. Examples where diseases intersect clearly demonstrate the need for broad-based health system strengthening and a move away from single-disease prioritisation. Ethiopia has made good progress down this path, with an emphasis on community ownership and an echo of UNAIDS Three Ones principles (one framework, one coordinating authority, and one accountability and monitoring system) in its Health Sector Transformation Plan. A priority for all health systems should be to ensure that drugs for NCDs—which are mostly generic and fairly cheap to purchase—are as available to the entire population in need as antiretroviral therapy. Achieving this goal will entail looking closely at supply chains and eliminating import tariffs, taxes, and other mark-ups. In 2014, although HIV treatment was available freely to most patients, in sub-Saharan Africa, out-of- pocket payments made up 34·8% of total expenditure on health-care services (with highs of 71·7% in Nigeria and 75·5% in Sudan). Corresponding numbers for the UK and USA are 9·7% and 11%, respectively. In view of the rising costs of providing and accessing care for multiple chronic diseases, the necessity for governments to build resilient health systems, and
worrying economic prospects, it seems unfortunate that in the next few years, development assistance for health is predicted to decline. NCDs are a less tangible area than infectious diseases, and require investment in more complex systems, but this challenge should not provide an excuse for donors not to invest. The fact that people with HIV are highly likely to enter older age with multiple comorbidities should encourage donors to complete the work that they have started. They should also use the platforms that have been set up for HIV care to help to build health systems that care for all. The anecdotal cry of an NCD patient claiming they would have been better off with HIV should never be heard. Most importantly, where possible, donors should work with recipient governments to ensure that they are acting in concert to strengthen health systems that care for the entire patient. But effective action is not possible without knowledge. The lynchpin of a successful effort to grow health systems that can deal with communicable diseases and NCDs equally effectively is research. Governments, donors, and research funders have to work together to ensure that research capacity in Africa is strong, led by Africans, and is directed—at least initially—to countries’ priority areas. Currently there are clear and important gaps in knowledge with respect to the epidemiology of NCDs and their intersection with HIV; little knowledge about whether public health strategies that were effective for HIV will be useful for NCDs; hardly any trials investigating clinical outcomes and cost-effectiveness of treatments for patients with both HIV and NCDs outside of high-income countries; and a dire need for implementation research that looks at how best to develop and finance health systems and provide services to deal with infections and NCDs in low-income and middle-income settings. The solutions to achieve a response that allows good outcomes for people living with HIV and NCDs together or alone seem daunting. However, the global community joined forces to effectively turn the tide of the HIV epidemic. That community should use the valuable lessons learnt from dealing with HIV as a head start in the run to strengthen health systems for all in sub-Saharan Africa. ■ The Lancet Diabetes & Endocrinology
www.thelancet.com/diabetes-endocrinology Vol 4 July 2016
HIV and NCDs: the need to build stronger health systems
www.thelancet.com/diabetes-endocrinology Vol 4 July 2016
The availability of antiretroviral drugs means that people in Africa with HIV should be able to look forward to living into a healthy middle–old age. Unfortunately, lifestyle change, driven by urbanisation and Westernisation means that metabolic syndrome and its components rival HIV as a leading cause of illness in Africa. The result is that middle–old age in both those with and without HIV is marred by poor health due to non-communicable diseases (NCDs). For example, in people older than 55 years in South Africa, the prevalence of diabetes is astonishingly high, at nearly 14%, and 29% of deaths in the continent were estimated to be due to NCDs in 2012. Heath systems in Africa have already suffered from the perfect storm of donor-determined health priorities, resulting in silos of care aimed at achieving Millennium Development Goal priorities, and structural reforms demanded by the Bretton Woods institutions. They will be sorely tested by the double burden of HIV and NCDs. If there is a bright side to look on, it is that the hitherto lack of systems to care for chronic diseases means that many countries in Africa have a relatively clean slate on which they can draft plans to develop health systems that will care for patients with HIV as well as NCDs. But beneath this potential veneer of optimism lurks the question, how will this be achieved? World Bank data show that growth in gross domestic product (GDP) in sub-Saharan Africa slowed to 3·0%
Published Online June 8, 2016 http://dx.doi.org/10.1016/ S2213-8587(16)30110-3 For more on HIV and CVD see Review page 598 For more on HIV prevalence see http://data.worldbank.org/ indicator/SH.DYN.AIDS.ZS For more on Africa’s transition see Editorial Lancet Diabetes Endocrinol 2016; 4: 1 For more on diabetes prevalence in older people in Africa see Review Lancet Diabetes Endocrinol 2016; 4: 72–84 For more on Africa’s GDP see http://www.worldbank.org/en/ region/afr/publication/africaspulse-an-analysis-issuesshaping-africas-economicfuture-april-2016
Tony Camacho/Science Photo Library
One of the greatest health achievements of recent decades is turning HIV infection from a death sentence to a chronic disease. Widespread access to combination antiretroviral therapy means that people with HIV are now living near normal life spans—and thereby facing different health challenges. Cardiovascular disease (CVD) is now one of the leading causes of non-AIDS-related morbidity and mortality in people with HIV. In this issue of The Lancet Diabetes & Endocrinology, Eric Nou and colleagues review the current state of knowledge concerning CVD in people with HIV. Although traditional risk factors for CVD (diabetes, hypertension, hyperlipidaemia, and smoking) are more prevalent in people with HIV, evidence from epidemiological studies suggests a 50–100% increase in risk for CVD even after controlling for these factors. The consequences of HIV infection per se and the side-effects from antiretroviral drugs (especially older generations) probably contribute to this increased risk. Additionally, the stage at which treatment is started might affect CVD risk. It is also likely that there are differences in risk depending on the population with HIV under study. But, as the authors acknowledge, there are problems with the evidence presented in this Review. Studies are often small, cross-sectional, and use proxy measures for clinical outcomes. Little evidence comes from large-scale randomised trials. As a result, although it seems clear that traditional risk scores could be way off the mark in their ability to predict CVD outcomes in people living with HIV, translating findings to actionable health policy is difficult. The European Union and the USA have made a start in developing guidelines for monitoring risk factors in patients with HIV, but specific guidelines for treatment are lacking. Globally, there is an urgent need for research to inform health policy in this clinical area. That necessity is absolute in low-income and middle-income countries, which suffer from the double whammy of high prevalence of HIV and fragile health systems. Africa is arguably at the top of this list. AIDS-related deaths are estimated to have decreased by more than 50% in the past 10 years—a truly momentous achievement. But the overall prevalence of HIV in Africa remains high at 4·5%, and this statistic hides huge regional variation—for example, the prevalence in Swaziland is 27·4%.
549
Editorial
For UN human development indicators see http://hdr.undp. org/en/countries For more on the Chatham House recommendations see https://www.chathamhouse.org/ sites/files/chathamhouse/home/ chatham/public_html/sites/ default/files/20140300Domestic FundingHealthMcIntyreMeheus. pdf For the Ethiopian Health Sector Transformation Plan see http://www.moh.gov.et/ documents/26765/0/Health+Sec tor+Transformation+Plan/ 5542a23a-9bc7-46a2-8c1f8b32c2603208?version=1.0 For more on out-of-pocket payments in Africa see http:// data.worldbank.org/indicator/ SH.XPD.OOPC.TO.ZS For more on development assistance for health see Articles Lancet 2016; published online April 13. http://dx.doi. org/10.1016/S01406736(16)30168-4 For more on research capacity in Africa see Editorial Lancet Diabetes Endocrinol 2016; 4: 375
550
in 2015 from 4·5% in 2014. Additionally, 30 out of the 48 sub-Saharan African countries are classed by the UN as least developed—there are just 18 other countries on this list. A perusal of the most recent World Bank data for national GDP and the proportion of GDP spent on health will allow even a casual reader to realise that even for countries that achieve the Chatham Houserecommended 5% of GDP spent on health, that figure is unlikely to equate to a recommended primary healthcare spend of $86 per person. And this is without accounting for the financing of infrastructure. So, how to ensure that the successes seen in managing HIV thus far don’t stumble at the hurdle of NCDs? The Sustainable Development Goals (SDGs) have made a good start of highlighting NCDs, but achieving success in the SDGs will require strong in-country policy and implementation. Following the money is often a necessary course of action, but governments should stay firm in focussing on the needs of their populations and not be led by the interests of donors. Examples where diseases intersect clearly demonstrate the need for broad-based health system strengthening and a move away from single-disease prioritisation. Ethiopia has made good progress down this path, with an emphasis on community ownership and an echo of UNAIDS Three Ones principles (one framework, one coordinating authority, and one accountability and monitoring system) in its Health Sector Transformation Plan. A priority for all health systems should be to ensure that drugs for NCDs—which are mostly generic and fairly cheap to purchase—are as available to the entire population in need as antiretroviral therapy. Achieving this goal will entail looking closely at supply chains and eliminating import tariffs, taxes, and other mark-ups. In 2014, although HIV treatment was available freely to most patients, in sub-Saharan Africa, out-of- pocket payments made up 34·8% of total expenditure on health-care services (with highs of 71·7% in Nigeria and 75·5% in Sudan). Corresponding numbers for the UK and USA are 9·7% and 11%, respectively. In view of the rising costs of providing and accessing care for multiple chronic diseases, the necessity for governments to build resilient health systems, and
worrying economic prospects, it seems unfortunate that in the next few years, development assistance for health is predicted to decline. NCDs are a less tangible area than infectious diseases, and require investment in more complex systems, but this challenge should not provide an excuse for donors not to invest. The fact that people with HIV are highly likely to enter older age with multiple comorbidities should encourage donors to complete the work that they have started. They should also use the platforms that have been set up for HIV care to help to build health systems that care for all. The anecdotal cry of an NCD patient claiming they would have been better off with HIV should never be heard. Most importantly, where possible, donors should work with recipient governments to ensure that they are acting in concert to strengthen health systems that care for the entire patient. But effective action is not possible without knowledge. The lynchpin of a successful effort to grow health systems that can deal with communicable diseases and NCDs equally effectively is research. Governments, donors, and research funders have to work together to ensure that research capacity in Africa is strong, led by Africans, and is directed—at least initially—to countries’ priority areas. Currently there are clear and important gaps in knowledge with respect to the epidemiology of NCDs and their intersection with HIV; little knowledge about whether public health strategies that were effective for HIV will be useful for NCDs; hardly any trials investigating clinical outcomes and cost-effectiveness of treatments for patients with both HIV and NCDs outside of high-income countries; and a dire need for implementation research that looks at how best to develop and finance health systems and provide services to deal with infections and NCDs in low-income and middle-income settings. The solutions to achieve a response that allows good outcomes for people living with HIV and NCDs together or alone seem daunting. However, the global community joined forces to effectively turn the tide of the HIV epidemic. That community should use the valuable lessons learnt from dealing with HIV as a head start in the run to strengthen health systems for all in sub-Saharan Africa. ■ The Lancet Diabetes & Endocrinology
www.thelancet.com/diabetes-endocrinology Vol 4 July 2016