The intersection of HIV and Non-Communicable Diseases in Low
Resource Settings Omar Sued, MD, MSc Fundacin Husped Argentina
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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
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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
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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
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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
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15% of global deaths WHO Risk factors: tobacco
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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
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Markets move to countries with weaker regulations CENTRAL
AMERICA Snack imports from the United States MEXICO INDIA FAO
2007
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Maher 2011 Risk factors: hypertension High prevalence in
African Countries
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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
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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
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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
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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.)
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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.)
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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
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2)What is the current situation of HIV- NCDs in low resources
setting?
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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
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b) Frequency of CV risk factors in HIV High prevalence among
people on HAART 1) D:A:D Study
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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
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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
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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
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3) The HIV-NCDs in the real life
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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)
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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)
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Tests and procedures free to patientsTreatment free to patients
Lack of resources for NCDs
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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)
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3) Conclusions & What needs to be done I have to restart my
English class
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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
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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
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Past and future of NonCommunicable Diseases
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Previously NonConsideredDiseases
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Currently NonCoveredDiseases
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Lets to transform it into NowControlledDiseases !!!
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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...