Anti-HIV strategies in limited resource settings set the pattern for combating other diseases

HIV-specific interventions in poor regions of the world like sub-Saharan Africa may have benefits for their health systems that exceed the initial aims of those interventions (How should HIV-specific charitable interventions like PEPFAR be evaluated? (STI/blog)). This is the encouraging message coming out of a recent evaluation of treatment of rheumatoid heart disease (RHD) in Uganda (Longenecker & Okelleo) – a leading cause of disability both here and in other low-income countries. On the strategic level, we find here the application of approaches that have proved their worth in the area of sexual health – e.g. the ‘care cascade’. Also, on a more concrete level, there may be an enhanced medical infrastructure due to HIV interventions from which other kinds of interventions (e.g. RHD) can benefit – e.g. local care centres.

In the case of RHD, long-term treatment with injected benzathine penicillin G (BPG) maintains health and reduces mortality, just as cART does in the case of HIV/AIDS.  Longenecker & Okello observe that treating those suffering from RHD involves much the same sequential stages as HIV care, and they apply the ‘cascade’ model to evaluating the treatment of RHD. Though there appears to be – if anything – a negative correlation between HIV and RHD infection, the researchers discover that, for both conditions, blockages occur at the same sequential stage of the cascade. With RHD, only 56.9% of the living and diagnosed subjects were retained in care (defined as at least on in-person clinical visit in the past 56 months); whereas 91.6% of the retained are prescribed appropriate therapy, and 91.4% of the prescribed adhere to the regimen. Important correlates of retention – such as proximity to nearest treatment centre and attendance at regional (as opposed to metropolitan) centres – suggest that effective treatment of RHD may face some of the same barriers as treatment of HIV, and that these could be addressed by similar measures. (Adjusted analysis indicated the independence of these two correlates.) These results lead to authors to suggest a focus on such practical steps as weekly SMS reminders, enhanced counselling and more decentralized care. They also point to data from the  SEARCH (Sustainable East Africa Research on Community Health) study that advocates community-based testing and treatment, and recommend adapting these HIV initiatives to RHD care.

There is increasing recognition nowadays of the possibility of complex synergies between different interventions (of which F&O report a good example) (Heaton & Way (STI)).  Reynolds & Cates (STI) refer to the case of contraception interventions undertaken as a more cost-effective method than prenatal ART to prevent HIV positive births, and the 220,000 health-care workers funded through PEPFAR (President’s Emergency Plan for HIV Relief) HIV interventions may find their future role not restricted to the delivery of those interventions. This reinforces the case for moving from a ‘vertical’ (disease-specific) towards more ‘horizontal’ (non-disease specific) modes of health service evaluation in which there is more recognition of the possibility of non-disease specific benefits. On the other hand, there is also a need for quantitative non-disease-specific evaluations in order to justify continued financial support for the cause of fighting specific diseases like HIV (Baenighausen & Humair (STI)).