MONTREAL, July 27 – Scientists and health advocates are calling for better integration of non-communicable disease (NCD) care with HIV services for people living with HIV who are now living longer lives.
International AIDS Society (IAS) president Prof Dr Adeeba Kamarulzaman noted that the rollout of HIV antiretroviral drugs – which she described as one of the “scientific and logistical milestones” over the past half a century – saved millions of lives and “virtually transformed HIV from a death sentence to a chronically manageable disease”.
By the end of 2019, she said, about 67 per cent of the world’s estimated 38 million people living with HIV (PLHIV) had initiated antiretroviral therapy (ART), with 59 per cent achieving viral suppression.
The life expectancy of PLHIV who are diagnosed early and are able to take continuous ART, in fact, now approaches that of the general population. However, Dr Adeeba pointed out that despite viral suppression, PLHIV often report poor well-being and health-related quality of life.
“In the first instance, the fact of living longer means PLHIV are now faced with chronic disease challenges like the rest of society. The longer one lives, the more susceptible one is to developing chronic disease,” Dr Adeeba said in her keynote at the “Why is HIV/NCD integration important” pre-conference session at AIDS 2022, the 24th International AIDS Conference, organised by IAS in Montreal, Canada.
“Second, despite treatment advances, a higher burden of multimorbidity and poorer health-related quality of life are reported by many PLHIV in comparison to people without HIV.
“People living with HIV are faced with a double whammy in that they are at an increased risk of non-communicable disease comorbidities, including cardiovascular diseases, such as hypertension, depression, diabetes, cervical cancer, and several other cancers, and NCDs.”
Dr Adeeba called for better access to disease prevention to adapt to the growing comorbidities of PLHIV, such as scaling up HPV vaccination and testing to prevent cervical cancer.
“We really need to advance cervical cancer and HIV integration,” she said. “We have a cancer we can eliminate.”
The HIV expert also cited the impact of diabetes and obesity in South Africa, where about seven million people live with HIV, a fifth of the global total and higher than anywhere else in the world.
Today, diabetes kills more people than HIV in South Africa and is the second deadliest disease in the country. Diabetes prevalence nearly tripled from 4.5 per cent in 2010 to 12.7 per cent in 2019. South Africa is 16th highest globally for diabetes-related mortality.
“We´re clearly seeing a fundamental shift in the nature of the disease burden across South Africa, the region, and globally. Hypertension, cardiovascular disease, cancers, and mental health are all on steep upward trajectories.”
Twenty years ago, having HIV in South Africa meant early death, while chronic conditions like diabetes and obesity were barely present.
“Fast forward a few decades and we are faced with a perfect storm of a treatment-led long life for PLHIV and a growing national prevalence of diabetes.”
Dr Adeeba also highlighted problems with the non-integration of NCD with HIV care, noting that PLHIV often need to visit different clinics to get treated for HIV and other conditions like diabetes or tuberculosis.
“This is inconvenient in high-income countries. But in LMICs (low- and middle-income countries), where fewer clinics are spread further apart, public transportation takes much longer to travel from one place to another, and both treatment and transportation expenses can be prohibitively high, many people don’t complete their NCD treatment or even forego treatment altogether.”
The Universiti Malaya infectious disease physician acknowledged that even in her own clinic, HIV patients get four or five appointments on different days for treatment of HIV, diabetes, tuberculosis, and mental health.
“As health care providers, we need to do better at integrating and improving the quality of life of all our patients.”
Dr Adeeba called for screening for a range of infectious and non-infectious diseases in one spot, noting that the early HIV movement had made prevention, early diagnosis, and early treatment the bedrock of the disease’s global response, unlike the current “inertia” surrounding the early detection of chronic illness among PLHIV.
“We need a quiet revolution in health care that begins to reflect the current and emerging disease burdens, that reflects people’s lives.”
Covid Provided An Opportunity For Integration
Katie Dain – chief executive of the NCD Alliance, a global network on NCD policy and practice – pointed out that NCDs were never previously discussed in a pandemic response before Covid-19 came along.
The coronavirus turned out to be particularly severe on people with chronic conditions like diabetes.
“It was two complete separate silos,” she said at the panel discussion.
“Covid-19, in a sense, was an opportunity to emphasise the point around integration.”
She said health systems should reflect the new norm of comorbidities in which people are living with different multiple conditions.
Dr Meg Doherty – the director at the Department of Global HIV, Hepatitis and Sexually Transmitted Infectious Programmes at the World Health Organization (WHO) – said the global HIV response saw the demedicalisation of health service delivery, where many tasks could be performed by auxiliary health care workers.
Many of their trainings, she noted, could be done online.
“Between vertical and horizontal integration — we’re looking at diagonal. We hate the pitting of one against another, in many ways we need both,” Dr Doherty told the panel.
“Sometimes we need a vertical system that addresses something specifically, and you need health systems horizontally.”
She noted that some people fear losing the opportunity of ending AIDS by 2030 if focus turned towards integration with NCD and primary care.
“I’d like to see both happening well. That’s a huge challenge for all of us.”