Noncommunicable diseases - including cardiovascular disease, diabetes, cancers and other diseases - will represent a major challenge for the care of HIV in low and middle income countries; and as the population of people in the treatment of HIV grows and ages it tends to increase, it was heard in the XXI International Conference on AIDS held in Durban July.
The development of models of care that can manage non-communicable diseases in people living with HIV and the general population, will be a key part of the development of a health system that can provide different standards of care for people with HIV according to your needs - so-called "differentiated".
Kara Wools-Kaloustian Indiana University School of Medicine, co-principal investigator for the international epidemiological database East-African cohort to evaluate AIDS (IeDEA), believes that the best answer would be to develop and strengthen systems supporting health in the general population, whether for HIV or noncommunicable diseases.
"A chronic disease integrated management model is probably the most effective in terms of cost and sustainable approach," she said.
Burden of noncommunicable diseases
According to the World Health Organization (WHO), NCDs kill 38 million people each year. Most of these deaths measure (28 million) are considered prone to occur in low and middle income countries, which have been slower to develop effective responses to detect, prevent and cure these diseases. Deaths from NCDs occur at earlier ages in these countries, with 82% in people under 70 years.
Most (56%) of deaths related to the DNC are caused by cardiovascular diseases such as hypertension, cerebrovascular disease including strokes, artery-coronary heart disease and heart disease mio. Cancers (essentially unrelated to AIDS) will be responsible for 26% of deaths, while respiratory diseases such as chronic obstructive pulmonary disease (COPD) and pulmonary hypertension represent 13% and diabetes around 5%. Other conditions including chronic kidney disease, liver disease, neurodegenerative diseases, osteoporosis and physical weakness also contribute to the mortality related to the DNC. In addition, accidental poisoning that can cause disease, disability, and very severe reduction in the quality of life of an even larger number of people.
However, to obtain an accurate estimate of the burden of noncommunicable diseases in some countries of low income or middle-income countries - and compare the burden of disease among people living with HIV and seronegative against the people, or between the treatment of new HIV-positive people on ART and those on antiretroviral therapy (HAART) - can be difficult due to a shortage of data. Moreover, it is limited laboratory capacity to assess the risk of non-communicable diseases and clinically limited the ability to diagnose them in many countries.
"Our HIV treatment programs usually do not collect information about risk factors or DNC or the occurrence of DNC," said Paula Munderi the Medical Research Council / Uganda Viral Research Institute of the AIDS unit. "Most of our countries do not make national HIV surveillance operations and research DNC, but these two surveys are not connected."
A 4 districts research in Uganda and Tanzania found a prevalence of hypertension in the general population ranging from 19 27% to% (depending on whether they lived in a rural or urban community). This was usually much greater than the HIV prevalence ranging from 6% to 12%. The prevalence of diabetes ranged from 2% to 4%, heart failure from 2% to 9% and COPD 2% to 6%.
Another much larger research hypertension which included 65.000 20 adults in rural communities in Uganda, with an HIV prevalence of 5% They found a prevalence of hypertension of 14%. Most (79%) these cases We had not been previously diagnosed and only 15% of those diagnosed with hypertension were actually seeking treatment.
Although the risk of noncommunicable diseases appear to be higher among people living with HIV compared to the general population in most industrialized countries, in these studies the prevalence of East Africa came about the same. But cases may be under DNC diagnosed or reported in installations where the assistance is for HIV infection or AIDS.
In addition, the group research in Uganda countries and Tanzania found that the diagnosis and management of NCDs were obtained only in hospitals and larger health centers and not in lower-level or dispensaries where most of the community lives and where are ongoing efforts to decentralize HIV treatment. health care providers to these smaller places told the researchers that there have been recent training on HIV but no training on DNC management.
There is also the risk of noncommunicable diseases still not be as great in some of the poorest countries, where the diet and lifestyles differ from the richest countries. For example, a survey looking at cardiac risk factors and metabolic risk in Malawi showed that the overall prevalence of hypertension and diabetes did not differ among people who were HIV positive and negative. However, this definition, the risk of overweight was lower among HIV-positive individuals, possibly due to weight loss in people with advanced immunosuppression.
In contrast, in South Africa, where obesity is much more prevalent, systemic arterial hypertension is the most common reason for visits to primary health centers, but it also appears to be a substantial number of people with multiple diagnoses, according to a presentation by Tolu Oni University of Cape Town School of Public Health and Family Medicine.
Um recently published cross-sectional study with a direct look at the relationship between consultations for hypertension, diabetes, HIV and tuberculosis among people participating in the Michael Mapongwana Clinic, a primary health care facility in Khayelitsha near Cape Town, found that the burden of hypertension and diabetes was higher among HIV-positive patients of persons younger than 46 years of age, but this was not observed among the elderly close to medical care. Nearly a quarter of the multi-diagnosed population had HIV with systemic arterial hypertension or diabetes or both.
Oni noted that in South Africa, there may be differences as patients with priority for care for HIV infection versus hypertension or diabetes. This could lead to a notification of non-communicable diseases, as well as the results of treatment of the poorest people living with HIV can not afford to.
Pathophysiology of noncommunicable diseases
Data from the Danish cohort, which compares the expectation of average life of the average of 50 years old living with HIV in the modern treatment was that of an HIV-negative individuals in the general population, showed that about ten years ago it was less Life expectancy. This is true even when restricted to individuals who have no other comorbidities.
The general view is even worse among people who started HIV treatment with a CD4 count less than 350 cells / mm3, according to data from the AN ACCORD cohort, which suggested a life expectancy 20 years lower among individuals who start treatment late. Most of the causes of this mortality is attributed to the early onset of NCDs.
"This is particularly important, since the vast majority of 17 million people living with HIV worldwide, most of whom are low-income or middle-income countries, which started ART in low scores of CD4. And this is a problem that we see for a long time yet, "said Peter Hunt of the University of California at San Francisco, who made a presentation about why HIV appears to be associated with an increased risk of noncommunicable diseases over and above than could be explained by risk factors style.
The Hunt research focused mainly on the role of persistent inflammation that fails to normalize these levels relative to the levels seen in uninfected by HIV despite years of viral suppression on HAART. Possible causes for this inflammation include low level of viral replication of HIV from reservoirs, cytomegalovirus (CMV) and microbial translocation - where an etiological agent through hematologic barrier and allows bacteria chequem the bloodstream which can boost immune activation chronic. (To learn about the life of elite drivers from this perspective, click here)
Regardless of the cause, markers of inflammation and innate immune activation remain abnormal in people with HIV and predict morbidity and mortality strong enough. For example, a single measure of inflammatory cytokines IL-6 is highly predictive of severe subsequent events not related to AIDS - mainly accidental poisonings - and mortality in subsequent years in people on ART.
"This is not a phenomenon linked only to a high-income country; this is also occurring in low and middle income countries, "said Hunt.
For the time being, approaches to reducing DNC-related diseases and death are essentially limited to moderate exercise and reducing lifestyle, reducing or wiping out risk factors such as smoking and alcohol consumption and use of illicit drugs. However, Hunt is optimistic that the use of statins - which reduce monocytes and T-cell activation as well as lowering blood lipids - will play a role in the treatment.
This hypothesis can be confirmed by the great international Esrudo REPIEVEWhich is testing the new and better tolerated Pitavastatin in 6500 people with HIV. Unfortunately Pitavastatin is not yet available in all countries of low and middle income.
In the future, Hunt believes it may be possible to develop other treatments more effective in the common unit of immunological pathways than many noncommunicable diseases.
Prevention would be better than cure, and part of Oni's presentation focused on opportunities to integrate HIV and DNC prevention that she believes are being lost in adolescents, such as many risk factors such as smoking, unhealthy diet and lack of activity physiques often develop in adolescence, lifestyles that, as a rule, lead to DNCs.
Models for delivery
In many ways, the introduction of antiretroviral therapy in low- and middle-income was precursor of a trail that could show as a means of responding more effectively to NCDs. HIV and NCDs require health infrastructure to support continuity of care, the incorporation of community education, prevention, treatment and palliation.
"The most important thing is the political commitment to sustained funding, because we can not care for HIV, nor can we care for chronic diseases without commitment and funding," said Wools-Kaloustian. This can be a challenge as noncommunicable diseases do not benefit from the same degree of grassroots activism that led to the HIV response. (Translator's note: I've never seen people interdict the Avenida Paulistas the 12: 30 demanding a better treatment. Everything that came after, how to bless these people with DNC is, in some way, the result of the campaign that we, for them so-called "AIDS patients" -Ugh- that we have obtained, not only for us, a wide range of medications for DNC that, in one way or another, we have obtained for our needs, yes, people living with HIV and AIDS are that we end up by "table" reaching the right medicines and medical procedures that these other groups, completely apathetic would end up benefiting from our activism. I remember, in the past, been treated as public enemy No. 1 of people living with Hepatitis C, because they wanted me to take it from MY SITE, a story that informed them, I had them raise chickens and I went ahead and I take advantage of the moment to reinforce, you who had sex, or sex without a condom, AIDS is not the only problem with which you have to worry, since hepatitis C can have a response to the exam for up to five months (click here opens in another tab)! Yes! Yes Yes Yes!)
Wools-Kaloustian noted that the HIV field has learned to use the alternative structures and mobile and standardized services and simplified means of treatment approaches that have allowed the address change task for the shortage of providers. Best point of care diagnostics are available for the management of diabetes, but can be a challenge for some other non-communicable diseases, such as, for example, cancer. Access to cheap generic medicines has been accelerated and government procurement systems were strengthened, which will be critical to make the DNC accessible and affordable treatment.
During the debate at the meeting had doubts about whether the services should be DNC "a thing apart" or integrated with treatment services for HIV infection.
"My personal sense is that the conditions are perfectly integrated into the patient - and is that we seem to disintegrate things in our way of thinking," Munderi said.
However, concerns about trying to CHANGE were expressed in too much of the burden of care for groups with parity DNC and health workers from the community.
"Community health workers are wonderful tools, but can not do everything - and they can not do anything without being paid," Wools-Kaloustian said. "We can not expect the community health workers should be doctors and more, put on your plate, the more there is the need for formal education. We need more doctors and nurses and the need to encourage to stay in their countries after they have been trained. "
Managing non-communicable diseases among people living with HIV. Written by Theo Smart
Translated by Original Claudio Souza in managing non-communicable diseases Among people living with HIV Reviewed by Mara Macedo in 18 September 2016.
References19303IV as a Chronic Condition: an Opportunity to Integrate Prevention and Treatment of Non-communicable Disease (NCD) HIV Co-morbidities in Low and Middle-Income Countries. 21st International AIDS Conference. Durban, July 18-22, 2016. Symposium TUSY05.
P Munderi. Non-communicable disease (NCD) in PLWH in low and middle income settings: burden of disease and epidemiology. Presentation TUSY0502.
P Hunt. Pathophysiology of different NCD in treated PLWH: is there a common pathway? 21st International AIDS Conference. Durban, July 18-22, 2016. Presentation TUSY0503.
K Wools-Kaloustian. Health system strengthening for prevention and treatment of NCDs: lessons learned from HIV. 21st International AIDS Conference. Durban, July 18-22, 2016. Presentation TUSY0505.
T Oni. Models of integration of HIV and NCD treatment and the role of chronic disease prevention.21st International AIDS Conference. Durban, July 18-22, 2016. Presentation TUSY0506.