The intersection of HIV and Non-Communicable Diseases

in Low Resource Settings

Omar Sued, MD, MScFundación Huésped

Argentina

1) Why are Non-Communicable Diseases (NCDs) being discussed in HIV conferences now?

2) What is the current situation of HIV-NCDs in low resource settings?

3) What needs to be done?

3 Simple Questions

Why? a) Global AgeingThe proportion of older persons in the world will double by 2050 Changes are faster in middle income countries. UN 2009

15 10 5 0 5 10 15

China’s Population Structure

15 10 5 0 5 10 15

2000

Male FemaleSource: World Population Prospects: The 2004 Revision (2005)

80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9

0-4

Age 2050

FemaleMaleVilaça Mendes E, PAHO, 2012

BRAZIL: Population Structure

2000 2050

In Brazil the proportion of >65y will increase from 5.4% in 2000 to 20% in 2050. 80% of this people will require chronic care

Vilaça Mendes E, PAHO, 2012

Compared adult mortality in 9 African PEPFAR focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) vs. 18 African nonfocus countries from 1998 to 2008. Bendavid et al, JAMA, 2012

Why? b) Increased survival of PLWHAs• In LMICs life expectancy for HIV adults initiating HAART

now approaches life expectancy for all adults. Mills et al, AIM 2011

• More than 50% of the PLWHA in the US will be 50 or older by 2015. Effros, Ageing and ID, 2008

• With the reduction of initial mortality, now the focus needs to be in the next phase of treatment programs. Hirnschall, Lancet, 2010

Why? c) Because HIV & NCDs overlapNCD mortality HIV mortality

Countries without public smoking banPoor countries are more vulnerable to risk factors and social determinants: • Urbanization• Globalization

• Tobacco industry• Westernized diets• Low physical activity

NCD Global report WHO 2011, HIV Progress report 2011 WHO, UNICEF, UNAIDS. Tobacco use: Wikipedia

15% of global deaths

WHO

Risk factors: tobacco

Building a healthier future, PAHO, 2011, NCD Global Report WHO, 2011

Risk factors: overweight • 2.8 millions of death every year • In Mexico and Brazil the estimated increase of obesity

between 2010 and 2030 is 13-17%.• The associated health care cost will be US$ 400-600 /y.• Changes are being increasingly shown in children

Markets move to countries with

weaker regulations

CENTRAL AMERICA

Snack imports from the United States

MEXICO

INDIA

FAO 2007

Maher 2011

Risk factors: hypertension High prevalence in African Countries

Ten leading causes of burden of disease, 2004 and 2030

Source: The global burden of disease, 2010, WHO

Why? d) Burden of NCDs in LMICs

NCD accounts globally for 36 of the 57 millions of deaths per year

Why? d) Burden of NCDs in LMICs (cont.)

0

5

10

15

20

25

30

2004 2015 2030 2004 2015 2030 2004 2015 2030

Dea

ths

(mill

ions

)

High income Middle income Low income

HIV,TB,malariaOther ID

MTC

CVD

Cancers

Other NCD

Road trafficUnintentionalInten. Injuries

Projected NCDs Deaths in 2015 and 2030

UN 2005

In addition, 1.8 million of HIV related deaths

Projected NCDs Deaths in 2015 and 2030

0

5

10

15

20

25

30

2004 2015 2030 2004 2015 2030 2004 2015 2030

Dea

ths

(mill

ions

)

High income Middle income Low income

HIV,TB,malariaOther ID

MTC

CVD

Cancers

Other NCD

Road trafficUnintentionalInten. Injuries

LMICs =80% of global NCDs deaths=98% of global HIV deaths

Why? d) Burden of NCDs in LMICs (cont.)

UN 2005

LMICs accounts for 80% of the 36 million NCDs deaths

45%

30%

8%

7%

10%

Diabetes

COPD

Cancer

CVD

Other NCDs

2007: NCDs #1 cause of death in The Americas:

36% of deaths are below age 70 years

75% of the total deaths

Why? d) Burden of NCDs in LMICs (cont.)

Leading Causes of Death in Caribbean Countries by Sex, 2004

1. Heart Disease2. Cancers3. Injuries and violence4. Stroke5. Diabetes6. HIV/AIDS7. Hypertension8. Influenza/pneumonia

1. Heart Disease2. Cancers3. Diabetes4. Stroke5. Hypertension6. HIV/AIDS7. Influenza/pneumonia8. Injuries and violence

MALES FEMALES

Resource: CAREC Mortality data

Why? d) Burden of NCDs in LMICs (cont.)

Wilks R, Younger N, Tulloch-Reid M, McFarlane S & Francis D; Jamaica health and Lifestyle Survey 2007-8; Epidemiology Research Unit, Tropical Medicine Research Institute, University of the West Indies, Mona

2)What is the current situation of HIV-NCDs in low resources

setting?

a) Evidence

HIV= 240,900

Diabetes[ti] = 249 Hypertension [ti] or “blood pressure”[ti] or cardiovascular[ti] = 780

Cancer[ti] =1245

LMICs FILTER: ("low income countries" OR "developing countries" OR "third world" OR Africa OR Asia OR “Latin America")

HIV and Diabetes[ti] and LMIC= 31

HIV and Hypertension [ti] or “blood pressure”[ti] or cardiovascular[ti] and LMIC= 43

HIV and Cancer[ti] and LMIC= 170

PubMed Search, Junio 2012

2274

244

b) Frequency of CV risk factors in HIVHigh prevalence among people on HAART

Hypertensio

n

Hyperglyc

HTGHch

olLD

F

Tobacco

use

Abdom obesity

Low physi

cal ac

tivity0%

10%

20%

30%

40%

50%

60%

46%

1%

31%27%

13%7%

24%

47%

13%

31%32%

3%

56%

32%

23%

6%

53%

Malawi. Muronya 2011Thailandia. Jackson 2011LAC. Cahn, 2010

1) D:A:D Study

c) Diabetes-HIVPrevalence in PLWHA Africa: 6% (n1606) Mwamjemi et al

Incidence in PLWHA Taiwan: 13.1/1000 pts-year Lo, HIV Med, 2009

Risk Factors (824/50 patients):– Familiar history of DM OR 2.6 (95%CI 1.2–5.8) – Zidovudine exposure OR 3.1 (95% CI 1.1–8.6) – Current use of PIs OR 2.5 (95% CI 1.1–5.3)

Diabetes cases will increase globally in general population • From 153M in 1980 to 472M in 2030 Danaei, Lancet 2011. • In 2015, will surpass HIV in Sub Saharan Africa Idemyor, JNMA, 2010

• 40% of global cases in India and China. Ramachandran, Lancet 2010

2-3 times risk of TB, TB relapse and TB death. Harris, IJTLD, 2011

d) Cancer and HIV • No Cancer-HIV registries• Very limited information• In Africa, 25–30% of all cancers are linked to infectious agents

Cancer Cause Prevention

Cervix, Anal, SCCC HPV Vaccine

Liver HBV-aflatoxine Vaccine-safe food

Non Hodking Limphoma EBV-HIV ART

Kaposi Sarcoma HHS8-HIV ART

Stomach H pylori HP treatment

Bladder S haematobium SH treatment

Ferlay et al, Int Jour of Ca, 2010Grulich, Curr Op HIV AIDS, 2009Bower, Curr Op HIV AIDS, 2006

Kenya, 2011

Cote d'Ivoire

, 2012

Mozambique, 2

012

Zambia, 2

011

Botswana, 2

012 0%5%

10%15%20%25%30%35%40%

7.1% 7.6% 8.2%

38.0% 38.1%

N

VIA is highly cost effective and feasible in LRS

HPV vaccine: Through PAHO Argentina, Panama, Mexico, Surinam, Brazil and Peru are including HPV for all the population.

Cervical lesions in Africa

e) Cervical Cancer and HIV

Aberg J, et al. Clin Infect Dis. 2009British HIV Association, HIV Med, 2008

Cervical cancer cases are expected to increase in HIV women Atashili ,PLoS ONE , 2011

3) The HIV-NCDs in the real life

Online survey 260 participants from 90 countries

• HIV-HCW45%

• No HIV-HCW23%

• Community21%

• Policy maker11%

HIV-NCD real life

89% consider NCD a problem, in particular CVD, DBT and hypertension.

HIV HCW General care

NCD HCW0

102030405060 54

30

16

HIV HCW General care NCD HCW0

10

20

30

40

50

33

23

44Who should treat NCDs in HIV?Who should detect NCDs in HIV?

(Sued,June 2012, unpublished)

Need to integrate health promotion

Healthy diets

Tobacco risks

Cancer prevention

Safe sex Risk factor for diabetes

Obesity None

Do you consider general public has complete information about?: (mark all that apply)

Tests and procedures free to patients Treatment free to patients

Lack of resources for NCDs

Asset price collapseRetrenchment from globalization

Oil and gas price spike

NCDs

Flu pandemicFiscal crisis

Food crisis

Infectious disease

http://www.weforum.org/pdf/globalrisk/globalrisks09/global_risks_2009.pdf

NCDs were indicated as the third most likely and severe economical risk in 2009…….and have less than 1% of the international health resources

NCDs cost for LMIC might be US$ 500 billions per year (4% GDP)

3) Conclusions &

What needs to be done

I have to restart my English class

Conclusions• NCDs are expected to increase in the near future,

in particular in LMICs• The longer HIV survival will increase the burden

of NCDs in HIV population• If not addressed, it will have a serious negative

impact on human development: – reduction of productivity– contribution to poverty– increased burden over health systems and economies

What needs to be done• Advocacy, political commitment and

multisectoral approaches• Information and evidence• Promotion and prevention: reduction of risk

factors, vaccines and safer ARV treatments• Equitable access to health care services,

including diagnosis and essential medicines

Past and future of

Non–Communicable Diseases

Previously

Non–Considered Diseases

Currently

Non–Covered Diseases

Let’s to transform it into

Now–Controlled Diseases !!!

Acknowledgements

Pedro Cahn, Esteban Martinez, Miriam Rabkim, Carina Cesar, Valeria Fink, Patricia Patterson, José Luis Castro, , Elisa Prieto

Eugenia Socías, Alberto Barceló, Noreen Jack, Rosalinda Hernandez, Yitades Gebre, James Hospedales, Mario Cruz

Penate, Kathleen Page, Freddy Perez, Raúl Gonzalez, Marco Vitoria, slides from Janet Voute, to all who disseminated and

responded the HIV-NCDs survey and many others…...