As the disease burden in developing countries shifts from infectious to non-communicable diseases (NCDs), governments and patient advocates are grappling with how to re-engineer healthcare systems to address both.

The extraordinary global focus on HIV has resulted in a siloed network of HIV clinics to treat the virus – but there is growing acknowledgement that countries’ HIV gains will be lost if they don’t get NCDs under control.

“People living with HIV are disproportionately affected with NCDs. It is estimated that one in three people living with HIV have either hypertension or other NCDs,” says Professor Kaushik Ramaiya, General Secretary of the Tanzania NCD Alliance and a member of the NCD Alliance Board.

“People living with HIV (PLHIV) have an increased incidence for more than 20 non-AIDS defining cancers, while women living with HIV are up to six times more likely to develop cervical cancer,” he told an event organised by the NCD Alliance at the International AIDS Conference in Munich last week.

There are almost 40 million people with HIV, mostly in developing countries, and many are succumbing prematurely to heart disease, diabetes, strokes and other NCDs. This is often because HIV programmes are so focused on their patients’ HIV that they don’t diagnose and treat these other conditions early enough.

‘I could take ARVS well and die of high blood’

South African Dudu Dlamini lives with HIV, hypertension and diabetes. As a sex worker and the advocacy officer for Sex Workers Education and Advocacy Taskforce (SWEAT), Dlamini knows what marginalisation means.

“We are criminalised,” Dlamini told the meeting. “It is not easy for me to identify as a sex worker. Our doctors don’t know about us. For my HIV, I am treated in one place. For my high blood, another place and for my blood sugar, somewhere else.”

Having three different treatment sites costs time and transport money, and sex workers default on medication “because we are not able to keep all the appointments”, says Dlamini.

“My vision is for sex workers to be helped for all the conditions at the same time; a place where we can identify freely as sex workers and get treated –  for STIs, and all other conditions – in one place. I need one folder with all my medical history and background because I might be taking antiretrovirals well but tomorrow I die from high blood.”

Her experience echoes that of several other people living with HIV and NCDs, as captured by the NCD Alliance in a collection of testimonies that makes the case for integrated care.

Global commitment to integration made back in 2021

At the 2021 United Nations High-Level Meeting on HIV and AIDS, global leaders committed to ensuring that “90% of people living with and affected by HIV have access to people-centred and context-specific, integrated services for HIV and other diseases, including NCDs and mental health by 2025”, NCD Alliance CEO Katie Dain told the meeting.

“This, in many ways, is one of the real frontiers of the global HIV response, recognising that people living with HIV are living longer thanks to advancements in antiretroviral antiretroviral therapy,” she added.

Ntombifuthi Ginindza, from Eswatini Ministry of Health in southern Africa, knowledges the urgency of “integrating NCD treatment into HIV setting”.

Eswatini has an estimated HIV prevalence rate of 25% in people aged 15 to 49, one of the highest rates in the world. 

It has made remarkable progress, achieving a 72% decline in HIV infections and a 55% decline in AIDS-related deaths since 2010. But its premature mortality for NCDs in moving in the opposite direction, growing from 27% in 2015 to 35% currently.

“We are integrating NCDs into HIV setting. In the spirit of client-centredness, we’re working on an integrated chronic disease framework, which is mainly focusing on integration at primary level facilities,” said Ginindza.

“We are trying to sustain the gains that we have made on HIV. There is a lot that we have achieved through HIV, so we want to leverage the resources that we have in place for HIV as we are transitioning HIV clinics to chronic disease clinics.”

Four different models of integration

Dr Nicholas Odiyo, Senior Technical Advisor for PATH Kenya, says his non-profit healthcare group has implemented various different models for HIV and NCD integration in Kenya, India, the Democratic Republic of the Congo (DRC) and Vietnam. 

One model involves screening for certain NCDs at HIV clinics, based on the patients’ assessed risk factors, particularly hypertension, diabetes and cervical cancer, said Odiyo.

The second involves community-based screening, mainly run by community health promoters with blood pressure machines and glucometers to test for hypertension and diabetes.

The third model is integrating “continuous screening for hypertension and diabetes” into HIV programmes, while the final model involves comprehensive care for all, with NCD and HIV screening for the entire population in universal healthcare.

Some donors are on board

HIV donors are also increasingly accepting that they need to incorporate NCD care to safeguard people living with HIV.

The US President’s Emergency Plan for AIDS Relief (PEPFAR) supports the integration of hypertension in five countries that are doing well with HIV, Botswana, Eswatini, Lesotho, Namibia and Rwanda, said PEPFAR ensior advisor Ritu Pati.

“PEPFAR’s HIV hypertension integration initiative was launched in response to  Ambassador [John Nkengasong’s] keen interest to address the very high rates of uncontrolled blood pressure amongst people living with HIV (PLHIV,” said Pati.

The five countries have received supplementary funding of $5 million for a year to improve  hypertension control in PLHIV, although this funding cannot be used to buy anti-hypertensive medication. 

“Close to 30% of men and women in sub-Saharan Africa over the age of 30 have hypertension, and at the same time, only a small proportion of them have controlled blood pressure. So the idea is, is that if we can proactively address hypertension in the populations that we serve, we can then reduce the incidence of cardiovascular events and thereby reduce mortality.

‘It’s become increasingly clear that we need to address hypertension amongst PLHIV to improve their health outcomes and preserve the gains of our PEPFAR programs.”

Pati adds that the integrated service delivery model has many benefits:  “It reduces the number of clinic appointments for PLHIV, promotes early diagnosis and treatment of co-morbidities, minimises service duplication, which really may lead to cost savings, and allows [healthcare] providers to have a comprehensive view of their patients history and offer them patient-centred care.”

Better still, PEPFAR has evidence that the integration of HIV services with primary health care “can actually improve HIV clinical outcomes such as continuity of treatment and viral load suppression”.

The Global Fund includes “integrated people-centred health services” in its strategy for 2023-2028, said Vindi Singh, the fund’s senior disease advisor on HIV treatment

HIV funding in some countries incorporates cervical cancer and hypertension services, Singh noted. Kenya and South Africa have also included HIV and NCD integration in their national strategic plans for HIV.

Stigma and competition

But as Ramaiya notes, the stigma associated with HIV means that is far easier for people living with HIV to accept NCD integration than HIV clinics than it is to integrate HIV services into non-HIV clinics.

“You need a policy cohesion that starts from the Ministry of Health and local government, because HIV is a vertical program and TB is a vertical program. So when you are trying to integrate an NCD programme within HIV, you need to have a cross communications with those other programs.”

STOPAids CEO Mike Podmore concluded the event by noting that “with a projected 71% of people living with HIV having at least one NCD by 2035”, the focus on “trailblazing quality integration is necessary and compelling”. 

But Podmore warned that “it is essential that we do not allow HIV and other health issues like NCDs to be in competition to each other in a zero-sum game of flatlined resources”.

“We need to champion quality integration and synergies across health issues that build greater equality across diseases. 

‘It is also essential that the global health community restructures and recalibrates itself to ensure that inequalities of the COVID pandemic response cannot be repeated again, and that there is much stronger coordination of external actors at country level, led by country stakeholders.”

Image Credits: Dischem.