Slide 1

The intersection of HIV and Non-Communicable Diseases in Low Resource Settings Omar Sued, MD, MSc Fundacin Husped Argentina

Slide 2

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

Slide 3

Why? a) Global Ageing The proportion of older persons in the world will double by 2050 Changes are faster in middle income countries. UN 2009 Chinas Population Structure 2000 MaleFemale Source: 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 FemaleMale Vilaa Mendes E, PAHO, 2012 BRAZIL: Population Structure 20002050 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 Vilaa Mendes E, PAHO, 2012

Slide 4

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

Slide 5

Why? c ) Because HIV & NCDs overlap NCD mortalityHIV mortality Countries without public smoking ban Poor 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

Slide 6

15% of global deaths WHO Risk factors: tobacco

Slide 7

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

Slide 8

Markets move to countries with weaker regulations CENTRAL AMERICA Snack imports from the United States MEXICO INDIA FAO 2007

Slide 9

Maher 2011 Risk factors: hypertension High prevalence in African Countries

Slide 10

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

Slide 11

NCD accounts globally for 36 of the 57 millions of deaths per year Why? d) Burden of NCDs in LMICs (cont.) HIV,TB,malaria Other ID MTC CVD Cancers Other NCD Road traffic Unintentional Inten. Injuries Projected NCDs Deaths in 2015 and 2030 UN 2005 In addition, 1.8 million of HIV related deaths

Slide 12

Projected NCDs Deaths in 2015 and 2030 HIV,TB,malaria Other ID MTC CVD Cancers Other NCD Road traffic Unintentional Inten. 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

Slide 13

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.)

Slide 14

Leading Causes of Death in Caribbean Countries by Sex, 2004 1. Heart Disease 2. Cancers 3. Injuries and violence 4. Stroke 5. Diabetes 6. HIV/AIDS 7. Hypertension 8. Influenza/pneumonia 1. Heart Disease 2. Cancers 3. Diabetes 4. Stroke 5. Hypertension 6. HIV/AIDS 7. Influenza/pneumonia 8. Injuries and violence MALES FEMALES Resource: CAREC Mortality data Why? d) Burden of NCDs in LMICs (cont.)

Slide 15

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

Slide 16

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

Slide 17

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

Slide 18

b) Frequency of CV risk factors in HIV High prevalence among people on HAART 1) D:A:D Study

Slide 19

c) Diabetes-HIV Prevalence 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 1.25.8) Zidovudine exposure OR 3.1 (95% CI 1.18.6) Current use of PIsOR 2.5 (95% CI 1.15.3) 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

Slide 20

d) Cancer and HIV No Cancer-HIV registries Very limited information In Africa, 2530% of all cancers are linked to infectious agents CancerCausePrevention Cervix, Anal, SCCCHPVVaccine LiverHBV-aflatoxineVaccine-safe food Non Hodking LimphomaEBV-HIVART Kaposi SarcomaHHS8-HIVART StomachH pyloriHP treatment BladderS haematobiumSH treatment

Slide 21

Ferlay et al, Int Jour of Ca, 2010 Grulich, Curr Op HIV AIDS, 2009 Bower, Curr Op HIV AIDS, 2006 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. 2009 British HIV Association, HIV Med, 2008 Cervical cancer cases are expected to increase in HIV women Atashili,PLoS ONE, 2011

Slide 22

3) The HIV-NCDs in the real life

Slide 23

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. Who should treat NCDs in HIV? Who should detect NCDs in HIV? (Sued,June 2012, unpublished)

Slide 24

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)

Slide 25

Tests and procedures free to patientsTreatment free to patients Lack of resources for NCDs

Slide 26

Asset price collapse Retrenchment from globalization Oil and gas price spike NCDs Flu pandemic Fiscal 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)

Slide 27

3) Conclusions & What needs to be done I have to restart my English class

Slide 28

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

Slide 29

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

Slide 30

Past and future of NonCommunicable Diseases

Slide 31

Previously NonConsideredDiseases

Slide 32

Currently NonCoveredDiseases

Slide 33

Lets to transform it into NowControlledDiseases !!!

Slide 34

Acknowledgements Pedro Cahn, Esteban Martinez, Miriam Rabkim, Carina Cesar, Valeria Fink, Patricia Patterson, Jos Luis Castro,, Elisa Prieto Eugenia Socas, Alberto Barcel, Noreen Jack, Rosalinda Hernandez, Yitades Gebre, James Hospedales, Mario Cruz Penate, Kathleen Page, Freddy Perez, Ral Gonzalez, Marco Vitoria, slides from Janet Voute, to all who disseminated and responded the HIV-NCDs survey and many others...