Florence Smith: NCDs and HIV—where’s the intersection?

florence_smithAt first glance, NCDs (non-communicable diseases) and HIV/AIDS seem to have little in common. However, a recent symposium, organised by the London School of Hygiene and Tropical Medicine and FHI360, showed that there is great scope for those working on these two big issues in global health to learn from each other.

HIV/AIDS has caused around 36 million deaths worldwide over the last three decades, but with new treatments mortality rates have dropped dramatically, and it now accounts for around 1.6 million deaths a year. NCDs kill just over 36 million people annually, with 80% of those deaths occurring in low and middle income countries. The World Health Organization has set a target to reduce deaths from NCDs, in those aged under 70, by 25% by 2025.

Many of the speakers at the symposium spoke about the need for integrated care—patients being able to see one doctor, or being able to go to a single clinic to receive care for all their health issues. Currently, in many low and middle income settings, patients have to go to separate clinics for their different diseases. This move towards more integrated care is becoming even more important as patients with HIV are living longer and developing other conditions—particularly NCDs. Receiving all your healthcare under one roof should not be a luxury offered only to those in high income settings.

Screening and offering prevention for NCDs was agreed to be simple and effective. For example, patients with HIV should be offered a blood sugar test. Peter Godfrey-Faussett, of UNAIDS, suggested that the symptoms of diabetes and HIV can seem similar, and that in some low income countries—for example in rural Africa—the only easily accessible way to differentiate between the two diseases is by testing urine: if urine attracts ants it has a high sugar content and the patient may have diabetes. Diabetes is directly linked to HIV because protease inhibitors, a treatment for HIV, lead to insulin resistance in 80% of patients, making type 2 diabetes more likely.

Godfrey-Faussett suggested that competing interests are a problem when governments come to constructing policies and initiatives to address the NCD burden. The food, alcohol, and tobacco industries may create opposition and lobby governments against policies that could reduce their revenues. In contrast, for HIV there has never been any powerful lobbyists against research into, and widespread use of, HIV treatments. Peter Piot, director of LSHTM, said he believed we will never be able to change policies on NCDs when academics, public health campaigners, and experts cannot reach a consensus on what should be done and what impact it could have. He called for greater uniformity.

Evaluation is essential for building consensus among experts. Without useful and rigorous assessments of NCD policies and initiatives in low and middle income countries, we cannot know if they are having an impact. If moves are made towards a more integrated system of care, then evaluation should be built in. Tricia Petruney, of FHI360, spoke about the evaluation of multisectoral approaches to combating NCDs, emphasising that we need to be careful about how the assessment is carried out. Many studies lack rigour because they compare multisectoral approaches with nothing, rather than comparisons with approaches that use only one sector.

The nature of the NCD burden is unlike that of HIV. Both Godfrey-Faussett and Tim Mastro, of FHI360, described the “exceptional” nature of HIV: how it arrived in a sudden, terrifying flash and caught the attention of the world. This has not, of course, been the case with NCDs. There were suggestions that “exceptionalising” the NCD burden could help get it more onto the global, political agenda, but it’s not clear how this might be done.

Sally Cowal, of the American Cancer Society, argued that one other way they were linked was the stigma surrounding both types of disease. Specifically, Cowal noted that mental illness and cancer are as stigmatised as HIV. Might reducing stigma save lives?

It’s surely useful for those worried about NCDs to try to learn from the successes and failures of the HIV epidemic. The lessons seem to be: to integrate care as much as possible; to evaluate the effectiveness of policies and programmes; to remain aware of the competing interests of governments; and to work together as a scientific, academic, and social community to agree on what we can do to help.

Florence Smith is a research assistant at C3 Collaborating for Health, a London based, global NGO that works to prevent NCDs.

I declare that I have read and understood the BMJ Group policy on declaration of interests and I hereby declare the following interests: employment at an NGO concerned with NCD prevention.