Burden of NCDs including Mental Health and Comorbidities with HIV and TB – WHO Response

DR. SHARON KAPAMBWE

TECHNICAL OFFICER

WHO AFRO

BRAZZAVILLE

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Increasing burden of NCDs among PLWHIV

• The global burden of NCDs has risen rapidly, causing 15 million premature deaths each year among people aged 30–69 years, with 85% of these deaths occurring in low-income and middle-income countries.
• NCD-related deaths are projected to increase at a higher rate in Africa compared with worldwide trends and could exceed deaths from infectious diseases by 2030.
• Antiretroviral therapy (ART) for PLHIV has increased their life expectancy
• Increased their risk of acquiring NCDs as they age
• In addition to known risk factors for NCDs, effects of HIV along with the adverse effects of ART increases risk
• Among PLHIV, the four most common conditions are CVDs, cervical cancer, diabetes, and depression

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Prevalence of Conditions Among PLWHIV

eClinicalMedicine 2023 65DOI: (10.1016/j.eclinm.2023.102255)

Burden of Cardiovascular diseases

• Women and girls living with HIV have: 
• Higher risk of getting HPV infection
• Lower chances of clearing the infection
• Faster progression from infection to cancer
• Lower regression of pre-cancer lesions
• Higher recurrence following treatment 
• Younger age at presentation

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Source: Stelzle D, Tanaka LF, Lee KK, et al. Estimates of the global burden of cervical cancer associated with HIV. Lancet Glob Health 2020; published online Nov 16.

Population attributable fraction of women with cervical cancer living with HIV, 2018

Burden of NCD comorbidities including HIV and TB

Integrated service delivery refers to:

• “the re-organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, to achieve the desired results and provide value for money”

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• Waddington C, Egger D. Integrated Health Services - What and Why? Geneva, Switzerland, 2008.

Integration of services for prevention and management of comorbidities mutually beneficial

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• Reduction in loss to follow up
• Reduction in morbidity and mortality – Increase in life expectancy
• Better compliance
• Health system strengthening
• Better outcome across all programme areas
• Efficient use of finite resources

Integration of NCD prevention and control in HIV and TB strategies/platforms through facility, PHC and community approaches

Integration of NCD prevention and control in HIV and TB strategies/platforms through facility, PHC and community approaches

HEARTS: Promote cardiovascular health

Eliminate cervical cancer

Increase childhood cancer survival rates

Increase access to affordable treatment for diabetes

Promote breast health

Promote lung health

End childhood caries 

Improve data & strategic information on SDG 3.4

Integrate rehabilitation in health services

Integrate NCD services into PHC and UHC

Current efforts at integrating NCDs and MH in HIV and TB

• Integrating MH into HIV, TB, Sexual and Reproductive Health programme
• Integrating mental Health into HIV interventions
• Framework for collaborative action of tuberculosis and comorbidities
• WHO Operational Handbook for tuberculosis and comorbidities
• Framework to Implement the Comprehensive MH Action Plan in the WHO African Region
• Framework for implementing the Intersectoral Global Action on Epilepsy and Other Neurological Disorders in the WHO African Region​
• WHO Package of Essential NCDs interventions at the PHC level
• PEN Plus regional strategy for chronic and severe NCDs through an integrated people-centered approach at the first level referral health facilities

Noncommunicable disease facility-based monitoring guidance

• Comprehensive monitoring for essential noncommunicable disease interventions at primary care settings
• Cardiovascular diseases including hypertension
• Diabetes
• Asthma and chronic obstructive pulmonary disease
• Breast cancer, cervical cancer, childhood cancers and general cancers
• Domains aligned with WHO primary health care measurement framework and indicators: monitoring health systems through a primary health care lens
• Programme determinants (health system capacity and management)
• Service delivery (early detection and diagnosis, treatment and complication assessment)
• Programme objectives (disease control)

Barriers/bottlenecks to HIV/NCD integration

• Disease centric rather than patient centered
• Limited of policy guidance and tools at country level
• Knowledge and practice gaps
• Limited operational evidence and success stories
• Concerns around finances and quality of care
• May result in an increased workload for HIV or NCD programme
• The fear that if poorly done, HIV-NCD integration carries the fear of reducing the quality and success of the current HIV services without improving NCD care.
• There is also a risk that stigma may influence the uptake of services for NCD care

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Enablers for NCD integration

• Both amenable to the chronic care models spanning- Detection, screening, treatment, retention in care and follow-up as well as palliative care
• Pathophysiologic coherence – Multimorbidity is the predominant disease pattern in the Sub Sahara region
• Both have similar demand and supply side challenges
• reduction in duplication, redudancy and fragmentation of services, which would increase efficiency of resource use and help patients remain in care by reducing costs and inconvenience for patients with multiple morbidities.
• Contribution to Sustainable Development Goals and Universal Health Coverage.
• Integration makes policy sense to develop efficient and cost-effective ways to deliver their HIV programmes as external funding for HIV programmes decreases.

Current Policy & program implementation

• Support ministries of health in adopting guidelines
• Increase country-level impact to reduce cervical cancer incidence and mortality across the 3 pillars (detection, screening, treatment)

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• Bi-directional integration of HIV and NCDs
• Improve service provision in settings with high ce 
• Facilitate referrals between programs
• Strengthen facility-based monitoring of Noncommunicable Diseases
• Further strengthen links with the community 
• Advocate for better counselling, patient education, availability of treatment and screening tests
• Involve community of women, men and community of PLHIV in all aspects of programme development
• Address knowledge gaps with living guidelines and implementation science

Way forward

• Tailor existing national health policies towards integration comorbidities into strategies, funding and service provision platforms
• Establish a high-level multisectoral coordination mechanisms
• Foster collaboration, partnership and coordination
• Build adequate and sustainable multitask health workforce
• Apply integrated-patient centered approach at all levels, in a continuum of care.
• Invest on information technology and innovations to give process solutions.
• Promote implementation science research on NCD and comorbidities with HIV and TB in an integrated approaches

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