People living with HIV are at high risk of non-communicable diseases

The discovery and roll-out of HIV antiretroviral drugs is undoubtedly one of the scientific and logistical milestones of the past 50 years. Millions of people’s lives have been saved and the medicines have transformed HIV from a death sentence to a chronically manageable disease. The impact has been keenly felt in South Africa, where over seven million people live with HIV. In 15 years, Aids-related deaths in the country have been reduced to about 72 000 from 350 000, mirroring the global reduction in Aids-related mortality across the world. 

This transformation has meant people living with HIV are living longer, matching the life expectancy of most people in the community. But, paradoxically, this also means they are, like everybody, increasingly vulnerable to the dramatically rising prevalence of non-communicable diseases such as hypertension and diabetes. 

Non-communicable diseases are now the world’s biggest killers, accounting for 74% of all deaths globally, with most of them occurring in poor communities and countries. 

Diabetes kills more people in South Africa today than HIV does and is the second deadliest disease in the country. The country has seen a rapid increase in diabetes prevalence, almost tripling from 4.5% in 2010 to 12.7% in 2019. It was estimated that of the 4.58-million people between 20 and 79 years old with diabetes in South Africa in 2019, 52.4% were undiagnosed. South Africa is 16th on the world index of diabetes-related mortality and is joined by 14 other sub-Saharan African countries in the top 50. We´re clearly seeing a fundamental shift in the nature of the disease burden across South Africa, the region and globally. Hypertension, cardiovascular disease, cancers and mental health are all on steep upward trajectories.

However, people living with HIV are faced with a double whammy – in many instances their status means they are at much higher risk of non-communicable diseases. 

It is thought that HIV could be an inflammatory condition, increasing the likelihood of cardiovascular disease and a higher prevalence of metabolic conditions, increasing problems of diabetes. Traditionally, HIV and non-communicable diseases affected different generations, but as people living with HIV get older, the two age cohorts are beginning to overlap more.

The risk of cardiovascular disease is twice as high, as is the prevalence of depression and diabetes. Hypertension is also reported to be a common comorbidity in people living with HIV, with one study identifying almost 40% of participants having the condition.

Death rates from non-communicable diseases are nearly twice as high in low- and middle-income countries compared to high-income countries. Keeping people living with HIV healthy will require a new integrated approach to disease management that shifts the focus away from the single health crisis or condition and better reflects a life course approach. This will require a transformation of disease siloes into synergies. 

This emerging approach was given impetus for the first time at last year’s UN General Assembly’s high-level meeting on Aids where global leaders committed to ensure 90% of people living with HIV would have access to non-communicable disease and mental health care by 2025. It’s telling that both UNAids and the Global Fund to Fight Aids, Tuberculosis and Malaria have incorporated the idea into their own strategies. But it’s only the beginning of the journey — the reality on the ground in many low- and middle-income countries is very different.

We´ll need a revolution in healthcare and health systems in sub-Saharan Africa and beyond if we have any chance of meeting this important goal because, on the ground, the delivery of basic medical services does not reflect the current lived experience of people living with HIV. But that also implies a revolution in the way that global health is financed. At the moment, it is very much based on vertical funding models which also reinforces the status quo. 

This is not only a problem for ageing adults living with HIV. The documented chronic health conditions associated with adolescents who have lived their whole lives with HIV are, in most cases, not being picked up early enough.

A recent study undertaken in Cape Town reported that, despite high levels of diabetes, cardiovascular disease, osteoporosis, renal impairment, depression and neurocognitive disorders in a group of HIV adolescents, their knowledge about those conditions was almost non-existent, with the result that their symptoms were not being treated in many cases. Another study reported that half of a group of people living with HIV and diabetes in South Africa had not ever received treatment for the latter.

Once people living with HIV receive a diagnosis of a non-communicable disease, they face another set of challenges. Often, these involve travelling to separate clinics, for instance, to treat HIV, diabetes and tuberculosis. This is inconvenient in high-income countries but in low- and middle-income countries, where fewer clinics are spread further apart, public transport takes much longer to travel from one place to another, and both treatment and transport expenses can be prohibitively high, many people don’t complete their non-communicable disease treatment or even forego treatment.

A 2021 study showed people living with HIV were reluctant to seek healthcare for non-communicable diseases because they saw HIV care and chronic care as being fragmented and uncoordinated and HIV being beyond generalists’ scope of practice.

Too often people in these settings are forced to choose between health and survival. 

Cervical cancer, a preventable condition, provides a salient example. 

Cervical cancer is as much as six times more likely to occur in women living with HIV

We´ve long known about the cervical cancer risks associated with HIV. Yet, too often we expect women to access human papillomavirus screening services at distances from their routine HIV care. Tens of thousands of women aren’t even aware of the need for, or the benefit, of screening. If we are serious about preventing unnecessary suffering and death then HPV screening needs to be a fundamental service in any HIV service and vice versa.

Differentiated service delivery that puts the patient at the centre of the health system is urgently needed. Screening for a range of infectious and non-infectious diseases at one spot is surely the future.

We´ve been here before of course. Four decades ago, to be precise.

The current inertia around the early detection of chronic diseases of people living with HIV is an irony not lost on HIV advocates, who from the outset of the Aids pandemic, made prevention, early diagnosis and early treatment the bedrock of the global response to the disease. So, we do have the playbook and millions of lives are at stake. What are we waiting for?

Professor Linda-Gail Bekker is the director of the Desmond Tutu HIV Centre at the University of Cape Town. She is a past president of the International Aids Society.

Katie Dain is the chief executive of the NCD [Non-communicable Disease]

Alliance.

The views expressed are those of the author and do not reflect the official policy or position of the Mail & Guardian.

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Linda-Gail Bekker
Professor Linda-Gail Bekker is the director of the Desmond Tutu HIV Centre at the University of Cape Town. She is a past president of the International Aids Society.
Katie Dain
Katie Dain is the chief executive of the Noncommunicable Disease Alliance.

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