What research is needed to address the co-epidemics of ... - The Lancet

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What research is needed to address the co-epidemics of HIV and cardiometabolic disease in sub-Saharan Africa? HIV-positive populations in sub-Saharan Africa are both growing and ageing.1 These population changes are due in large part to the massive scale-up of antiretroviral therapy and its success in averting HIV-related mortality. One result of this scale-up has been a surge in the number of people living with HIV in the region.2 Mass HIV treatment has therefore contributed to a striking change in population structure; for example, average adult life expectancy in rural KwaZulu-Natal, South Africa, increased by 11·3 years between antiretroviral therapy roll-out in 2003 and 2011.3 This population ageing has conspired with the socioeconomic transition to increase the burden of cardiometabolic diseases in sub-Saharan Africa.4 As such, the epidemics of HIV and cardiometabolic disease in the region are increasingly intertwined. With the shift in development policy towards commitments to achieving universal health coverage, the health-care and research communities urgently need to better understand the HIV and cardiometabolic disease co-epidemics, and how to address them through health systems interventions. It is also essential to ensure that resultant evidence can be applicable to those with cardiometabolic disease alone and those with both HIV and cardiometabolic disease.5 Applying evidence and strategies wholesale from highincome countries is unlikely to bear fruit. Programmes that were successfully implemented in comparatively well-resourced health systems might not be feasible to implement in the vastly under-resourced health systems of sub-Saharan Africa. Another important difference is that the HIV epidemic in sub-Saharan Africa is generalised, whereas in high-income countries, HIV infections are largely restricted to high-risk groups2—men who have sex with men, sex workers, and intravenous drug users. These high-risk groups differ from the general population with respect to their risk factors for cardiometabolic disease6 and their treatment outcomes in chronic disease care.7 In view of these differences, research into useful approaches to deliver care for cardiometabolic disease to HIV-positive and HIV-negative individuals in sub-Saharan Africa is urgently needed. Too little research currently goes into testing the most effective ways to deploy efficacious

prevention and management strategies in real-life settings. However, in our view, successful deployment of the effective and inexpensive approaches that already exist for the prevention and management of HIV and cardiometabolic disease, including improving access to screening—especially for high-risk populations—and drug therapy, could lead to large population health benefits. On this basis, we believe that three priority research areas have the potential to rapidly advance effective policy for addressing the growing burden of cardiometabolic disease in people living with HIV in sub-Saharan Africa, and to ensure that research findings will benefit all people with cardiometabolic diseases in the region. These research areas are population epidemiology, behavioural research, and health systems research. Studies in population epidemiology are urgently needed to better understand the dynamics of cardiometabolic disease in the HIV-positive and HIVnegative populations in sub-Saharan Africa to enable development of health systems that can successfully address the HIV and cardiometabolic disease coepidemics. Data from population-based epidemiological studies could also further clarify the effect of different antiretroviral therapy regimens on the incidence of cardiometabolic disease.8 This question is of vast importance to population health, in view of the high HIV prevalence and antiretroviral therapy coverage in many countries in sub-Saharan Africa.2 A second key field of research to help alleviate the burden of cardiometabolic disease, including in people living with HIV, is behavioural science. Successfully influencing human behaviour has tremendous potential to avert new HIV infections and delay or avoid cardiometabolic disease onset, while also improving treatment outcomes for both conditions. The existing evidence for interventions to improve antiretroviral therapy adherence is just one example of the potential that behavioural science holds for improving chronic disease care at low cost.9 Unfortunately, only a few studies in sub-Saharan Africa have assessed interventions in real-life health systems, at large scale, and over extended time horizons. Yet, it is precisely these types of studies that are most relevant to policy makers.

www.thelancet.com/diabetes-endocrinology Published online March 17, 2017 http://dx.doi.org/10.1016/S2213-8587(17)30091-8

Lancet Diabetes Endocrinol 2017 Published Online March 17, 2017 http://dx.doi.org/10.1016/ S2213-8587(17)30091-8

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Comment

Health system research is the final part of this trio. In 2015, an estimated 42% of people living with HIV in sub-Saharan Africa were on antiretroviral therapy.2 Although this level of antiretroviral therapy coverage points to the great challenges ahead, and would not have been possible without external funding, it also shows that health systems in the region can successfully provide long-term care to millions of people. By contrast, care coverage for patients with cardiometabolic diseases, such as diabetes, is currently very low in sub-Saharan Africa.10 For the large proportion of people living with HIV who are already in long-term care, however, providing cardiometabolic disease care as part of existing and functioning HIV care systems could be logistically simple and fairly inexpensive, and could provide a framework for expanding care to all people with cardiometabolic disease. As part of expanding care, the development of an evidencebased minimum package for cardiometabolic disease prevention and management will also be essential. Unfortunately, however, it is currently unknown how HIV and cardiometabolic disease care can be most effectively integrated, and which strategies will lead to the broadest access to care and highest patient satisfaction.11 In this regard, quantitative health system evaluations are crucial and should be paired with qualitative evaluations to establish which approaches to HIV-cardiometabolic disease care integration work best. Such research would not only allow for examination of the effects of integrated care programmes on health outcomes, costs to the health system, and patients’ healthcare expenditures, but also of the mechanisms underlying successful care delivery. Knowledge of these mechanisms could in turn inform care frameworks and how they can be adopted and adapted in other settings. An example of the value of qualitative research in this field is a study of a medication adherence club in Kenya that brought together patients with HIV, diabetes, and hypertension. The qualitative evaluation showed that an effect of the scheme might be a reduction in HIV stigma: club members reported that managing people living with HIV in the same way as patients with diabetes and hypertension reduced the impression that HIV was somehow an especially problematic disease.12 Unfortunately, the study did not report the perceptions of people without HIV attending the combined clinic. Studying such integrated care models could provide 2

important lessons for a wider integration of chronic disease care in sub-Saharan Africa—one that would also benefit HIV-negative populations. A high proportion of people living with HIV suffer from cardiometabolic diseases.13 To meet the healthcare needs of populations and hence achieve the targets of the Sustainable Development Goals, we call for the research community to refocus their efforts. Epidemiological research at the population level, behavioural science, and health systems research could help to ensure that the past investments into building functioning HIV care systems in sub-Saharan Africa are rapidly leveraged to increase the chances of healthy ageing in people living with HIV—and can be translated into improved care for everyone afflicted with chronic diseases in the region. †Pascal Geldsetzer, †Jennifer Manne-Goehler, ‡Till Bärnighausen, *‡Justine Ina Davies Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA (PG, JM-G, TB); Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA (JM-G); Institute of Public Health, Heidelberg University, Heidelberg, Germany (TB); Africa Health Research Institute, Mtubatuba, South Africa (TB); Centre for Global Health, King’s College London, London, UK (JID); School of Public Health, University of Witwatersrand, Johannesburg, South Africa (JID); and The Lancet Diabetes & Endocrinology, London, UK (JID) [email protected] †Contributed equally. ‡Co-senior authors. JID is Editor of The Lancet Diabetes & Endocrinology and currently on sabbatical from this role. PG, JMG, and TB declare no competing interests. 1

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Chaiyachati KH, Ogbuoji O, Price M, Suthar AB, Negussie EK, Bärnighausen T. Interventions to improve adherence to antiretroviral therapy: a rapid systematic review. AIDS 2014; 28 (suppl 2): S187–204. 10 Manne-Goehler J, Atun R, Stokes A, et al. Diabetes diagnosis and care in sub-Saharan Africa: pooled analysis of individual data from 12 countries. Lancet Diabetes Endocrinol 2016; 4: 903–12. 11 Hyle EP, Naidoo K, Su AE, El-Sadr WM, Freedberg KA. HIV, tuberculosis, and noncommunicable diseases: what is known about the costs, effects, and cost-effectiveness of integrated care? J Acquir Immune Defic Syndr 2014; 67 (suppl 1): S87–95.

12 Venables E, Edwards JK, Baert S, Etienne W, Khabala K, Bygrave H. “They just come, pick and go.” The acceptability of integrated medication adherence clubs for HIV and non communicable disease (NCD) patients in Kibera, Kenya. PLoS One 2016; 11: e0164634. 13 Geldsetzer P, Feigl AB, Tanser F, Gareta D, Pillay D, Bärnighausen T. Population-level decline in BMI and systolic blood pressure following mass HIV treatment: evidence from rural KwaZulu-Natal. Obesity (Silver Spring) 2016; published online Dec 7. DOI:10.1002/oby.21663.


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