ENHANCING COMPREHENSIVE HIV CARE:Addressing Cardiovascular Disease (CVD) and other Noncommunicable Diseases (NCDs)

Kwasi Torpey MD PhD MPH FGCPDeputy Chief of Party, TechnicalFHI360/SIDHAS, Nigeria

Why integrate CVD into HIV services?

• Global burden of CVD

– CVD is a leading cause of morbidity and mortality globally, claiming 17.3 million lives per year

– CVD accounts for nearly 30% of deaths in low and middle income countries

• Link between CVD and HIV– HIV-positive individuals are at increased risk of CVD due to

effects of the virus itself and ART drugs • HIV is a chronic disease

– HIV health infrastructure can be leveraged for other chronic diseases

References: WHO. Global Atlas on Cardiovascular Disease Prevention and Control, 2011Connor et al. Burden of stroke in black populations in sub-Saharan Africa. Lancet Neurology 2007;6:269-78.IOM. Promoting Cardiovascular Health in Developing Countries: A critical challenge to achieve global health, 2010.

CVD Integration Models Across Various Contexts: Examples from FHI 360 HIV Programs

Kenya: CVD/HIV Pilot • CVD accounts for 12% of all deaths;

hypertension prevalence is 37%

Nigeria: CVD/HIV Pilot & Scale-up • CVD accounts for 12% of all deaths;

hypertension prevalence is 43%

Zambia: Integrated Chronic Care • CVD accounts for 12% of all deaths;

hypertension prevalence is 40%

Reference: WHO, Noncommunicable Disease Country Profiles, 2011.

Kenya CVD/HIV Integration PilotKey Components

• Partnership w/ MOH, Kenya Cardiac Society, and USAID

• CVD screening, treatment, & referral services integrated in five APHIA II HIV treatment sites

• Target population for behavioral and biomedical risk assessment

1) HIV counseling & testing clients

2) HIV-positive clients in care

3) ART clients

• Between Sept 09 – Sept 10, over 4,000 HIV clients were screened• Health care providers and clients valued the addition of CVD and

diabetes services • Integration of CVD and diabetes services allowed clients to receive

all services at the same location • Behavioral risk factors were highest among HIV-negative counseling

and testing clients

– Tobacco use, physical inactivity and alcohol use• Biological CVD risk factors were highest among ART clients

– Elevated blood pressure, high BMI, and high waist circumference

Kenya CVD/HIV Integration PilotFindings

Kenya CVD/HIV Integration PilotBiological CVD Risk Factors and Length on ART

Variable

Length on ART <1 year 1 – 3 years > 4 years

Blood pressure (n=92) (n=198) (n=115) Normal 87% 74% 76%

High 13% 26% 24% BMI (n=92) (n=198) (n=115)

Normal 78% 74% 78% High 22% 26% 22%

Waist Circumference (n=92) (n=198) (n=115) Normal 84% 86% 79%

High 16% 14% 21% Random blood sugar (RBS) (n=43) (n=117) (n=80)

Normal 98% 98% 99% High 2% 2% 1%

Total cholesterol (n=39) (n=118) (n=76) Normal 90% 68% 72%

High 10% 32% 28%

Nigeria CVD/HIV IntegrationThe Pilot

• Began as a small pilot within USAID-funded GHAIN Project

• CVD screening system was integrated within HIV care services at Murtala Mohammed Specialist Hospital in Kano

• WHO/ISH guidelines were adopted for the CVD risk assessment

• Risk factors assessed: age>40 yrs, male sex, BMI, history of smoking, hypertension, and diabetes – Lab investigations done for those identified with

risk factors• 1033 HIV-positive clients enrolled in the ART

clinic were screened

Nigeria CVD/HIV IntegrationPilot Findings

• Most common risk factors were:– age >40years (25.7%)– male sex (25.9%)– overweight/obese (21.8%) – blood pressure >140/90 mmHg (15.2%)

• Linear relationship found between the mean levels of serum total cholesterol and duration on ART

Total CholesterolDuration on ART N Mean p value< 1Yr 33 3.93

0.021-<3Yrs 52 4.49>=3Yrs 67 4.54

Nigeria CVD/HIV IntegrationScale-up within Strengthening Integrated Delivery of HIV/AIDS

• CVD integration being scaled up in all SIDHAS-supported sites

• Simplification of CVD screening based on level of health care facility and capacity

• CVD integration implemented within the context of a HIV chronic care model

Zambia Chronic Care Screening IntegrationKey Components

• Chronic care screening integration within USAID-funded ZPCTII project

• Screening provided in HIV counseling and testing, PMTCT, and ART • Chronic Care Screening Checklist includes

– CVD-related risk factors: BMI, hypertension, diabetes– Other health concerns: TB, gender-based violence, prevention w/ positives

• Implemented in all facilities regardless of level• Random blood sugar performed depending on capacity of the facility

Zambia Chronic Care Screening IntegrationSnapshot of Checklist

Key Messages

• CVD/HIV integration is feasible and acceptable in resource limited settings– It can be offered from

PHCs to tertiary facilities

• Leveraging the platform of an existing HIV program - funding, infrastructure, staffing, and commodity management - allows for smooth integration of CVD services

CVD/HIV integration site in Kenya:Comprehensive Care Center, Naivasha District Hospital

Key Messages (2)

• Integration strengthens the capacity of the health system to address the comprehensive needs of HIV patients, including their increased risk of CVD

• Integration services can be offered to clients regardless of HIV status

• Integration offers an opportunity for de-stigmatization by offering services to non HIV clients