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The intersection of HIV and Non-Communicable Diseases in Low R esource Settings. Omar Sued, MD, MSc Fundación Huésped Argentina. 3 Simple Questions. 1) Why are Non-Communicable Diseases (NCDs) being discussed in HIV conferences now? - PowerPoint PPT Presentation
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The intersection of HIV and Non-Communicable Diseases
in Low Resource Settings
Omar Sued, MD, MScFundación Huésped
Argentina
1) Why are Non-Communicable Diseases (NCDs) being discussed in HIV conferences now?
2) What is the current situation of HIV-NCDs in low resource settings?
3) What needs to be done?
3 Simple Questions
Why? a) Global AgeingThe proportion of older persons in the world will double by 2050 Changes are faster in middle income countries. UN 2009
15 10 5 0 5 10 15
China’s Population Structure
15 10 5 0 5 10 15
2000
Male FemaleSource: World Population Prospects: The 2004 Revision (2005)
80+ 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9
0-4
Age 2050
FemaleMaleVilaça Mendes E, PAHO, 2012
BRAZIL: Population Structure
2000 2050
In Brazil the proportion of >65y will increase from 5.4% in 2000 to 20% in 2050. 80% of this people will require chronic care
Vilaça Mendes E, PAHO, 2012
Compared adult mortality in 9 African PEPFAR focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) vs. 18 African nonfocus countries from 1998 to 2008. Bendavid et al, JAMA, 2012
Why? b) Increased survival of PLWHAs• In LMICs life expectancy for HIV adults initiating HAART
now approaches life expectancy for all adults. Mills et al, AIM 2011
• More than 50% of the PLWHA in the US will be 50 or older by 2015. Effros, Ageing and ID, 2008
• With the reduction of initial mortality, now the focus needs to be in the next phase of treatment programs. Hirnschall, Lancet, 2010
Why? c) Because HIV & NCDs overlapNCD mortality HIV mortality
Countries without public smoking banPoor countries are more vulnerable to risk factors and social determinants: • Urbanization• Globalization
• Tobacco industry• Westernized diets• Low physical activity
NCD Global report WHO 2011, HIV Progress report 2011 WHO, UNICEF, UNAIDS. Tobacco use: Wikipedia
15% of global deaths
WHO
Risk factors: tobacco
Building a healthier future, PAHO, 2011, NCD Global Report WHO, 2011
Risk factors: overweight • 2.8 millions of death every year • In Mexico and Brazil the estimated increase of obesity
between 2010 and 2030 is 13-17%.• The associated health care cost will be US$ 400-600 /y.• Changes are being increasingly shown in children
Markets move to countries with
weaker regulations
CENTRAL AMERICA
Snack imports from the United States
MEXICO
INDIA
FAO 2007
Maher 2011
Risk factors: hypertension High prevalence in African Countries
Ten leading causes of burden of disease, 2004 and 2030
Source: The global burden of disease, 2010, WHO
Why? d) Burden of NCDs in LMICs
NCD accounts globally for 36 of the 57 millions of deaths per year
Why? d) Burden of NCDs in LMICs (cont.)
0
5
10
15
20
25
30
2004 2015 2030 2004 2015 2030 2004 2015 2030
Dea
ths
(mill
ions
)
High income Middle income Low income
HIV,TB,malariaOther ID
MTC
CVD
Cancers
Other NCD
Road trafficUnintentionalInten. Injuries
Projected NCDs Deaths in 2015 and 2030
UN 2005
In addition, 1.8 million of HIV related deaths
Projected NCDs Deaths in 2015 and 2030
0
5
10
15
20
25
30
2004 2015 2030 2004 2015 2030 2004 2015 2030
Dea
ths
(mill
ions
)
High income Middle income Low income
HIV,TB,malariaOther ID
MTC
CVD
Cancers
Other NCD
Road trafficUnintentionalInten. Injuries
LMICs =80% of global NCDs deaths=98% of global HIV deaths
Why? d) Burden of NCDs in LMICs (cont.)
UN 2005
LMICs accounts for 80% of the 36 million NCDs deaths
45%
30%
8%
7%
10%
Diabetes
COPD
Cancer
CVD
Other NCDs
2007: NCDs #1 cause of death in The Americas:
36% of deaths are below age 70 years
75% of the total deaths
Why? d) Burden of NCDs in LMICs (cont.)
Leading Causes of Death in Caribbean Countries by Sex, 2004
1. Heart Disease2. Cancers3. Injuries and violence4. Stroke5. Diabetes6. HIV/AIDS7. Hypertension8. Influenza/pneumonia
1. Heart Disease2. Cancers3. Diabetes4. Stroke5. Hypertension6. HIV/AIDS7. Influenza/pneumonia8. Injuries and violence
MALES FEMALES
Resource: CAREC Mortality data
Why? d) Burden of NCDs in LMICs (cont.)
Wilks R, Younger N, Tulloch-Reid M, McFarlane S & Francis D; Jamaica health and Lifestyle Survey 2007-8; Epidemiology Research Unit, Tropical Medicine Research Institute, University of the West Indies, Mona
2)What is the current situation of HIV-NCDs in low resources
setting?
a) Evidence
HIV= 240,900
Diabetes[ti] = 249 Hypertension [ti] or “blood pressure”[ti] or cardiovascular[ti] = 780
Cancer[ti] =1245
LMICs FILTER: ("low income countries" OR "developing countries" OR "third world" OR Africa OR Asia OR “Latin America")
HIV and Diabetes[ti] and LMIC= 31
HIV and Hypertension [ti] or “blood pressure”[ti] or cardiovascular[ti] and LMIC= 43
HIV and Cancer[ti] and LMIC= 170
PubMed Search, Junio 2012
2274
244
b) Frequency of CV risk factors in HIVHigh prevalence among people on HAART
Hypertensio
n
Hyperglyc
HTGHch
olLD
F
Tobacco
use
Abdom obesity
Low physi
cal ac
tivity0%
10%
20%
30%
40%
50%
60%
46%
1%
31%27%
13%7%
24%
47%
13%
31%32%
3%
56%
32%
23%
6%
53%
Malawi. Muronya 2011Thailandia. Jackson 2011LAC. Cahn, 2010
1) D:A:D Study
c) Diabetes-HIVPrevalence in PLWHA Africa: 6% (n1606) Mwamjemi et al
Incidence in PLWHA Taiwan: 13.1/1000 pts-year Lo, HIV Med, 2009
Risk Factors (824/50 patients):– Familiar history of DM OR 2.6 (95%CI 1.2–5.8) – Zidovudine exposure OR 3.1 (95% CI 1.1–8.6) – Current use of PIs OR 2.5 (95% CI 1.1–5.3)
Diabetes cases will increase globally in general population • From 153M in 1980 to 472M in 2030 Danaei, Lancet 2011. • In 2015, will surpass HIV in Sub Saharan Africa Idemyor, JNMA, 2010
• 40% of global cases in India and China. Ramachandran, Lancet 2010
2-3 times risk of TB, TB relapse and TB death. Harris, IJTLD, 2011
d) Cancer and HIV • No Cancer-HIV registries• Very limited information• In Africa, 25–30% of all cancers are linked to infectious agents
Cancer Cause Prevention
Cervix, Anal, SCCC HPV Vaccine
Liver HBV-aflatoxine Vaccine-safe food
Non Hodking Limphoma EBV-HIV ART
Kaposi Sarcoma HHS8-HIV ART
Stomach H pylori HP treatment
Bladder S haematobium SH treatment
Ferlay et al, Int Jour of Ca, 2010Grulich, Curr Op HIV AIDS, 2009Bower, Curr Op HIV AIDS, 2006
Kenya, 2011
Cote d'Ivoire
, 2012
Mozambique, 2
012
Zambia, 2
011
Botswana, 2
012 0%5%
10%15%20%25%30%35%40%
7.1% 7.6% 8.2%
38.0% 38.1%
N
VIA is highly cost effective and feasible in LRS
HPV vaccine: Through PAHO Argentina, Panama, Mexico, Surinam, Brazil and Peru are including HPV for all the population.
Cervical lesions in Africa
e) Cervical Cancer and HIV
Aberg J, et al. Clin Infect Dis. 2009British HIV Association, HIV Med, 2008
Cervical cancer cases are expected to increase in HIV women Atashili ,PLoS ONE , 2011
3) The HIV-NCDs in the real life
Online survey 260 participants from 90 countries
• HIV-HCW45%
• No HIV-HCW23%
• Community21%
• Policy maker11%
HIV-NCD real life
89% consider NCD a problem, in particular CVD, DBT and hypertension.
HIV HCW General care
NCD HCW0
102030405060 54
30
16
HIV HCW General care NCD HCW0
10
20
30
40
50
33
23
44Who should treat NCDs in HIV?Who should detect NCDs in HIV?
(Sued,June 2012, unpublished)
Need to integrate health promotion
Healthy diets
Tobacco risks
Cancer prevention
Safe sex Risk factor for diabetes
Obesity None
Do you consider general public has complete information about?: (mark all that apply)
Tests and procedures free to patients Treatment free to patients
Lack of resources for NCDs
Asset price collapseRetrenchment from globalization
Oil and gas price spike
NCDs
Flu pandemicFiscal crisis
Food crisis
Infectious disease
http://www.weforum.org/pdf/globalrisk/globalrisks09/global_risks_2009.pdf
NCDs were indicated as the third most likely and severe economical risk in 2009…….and have less than 1% of the international health resources
NCDs cost for LMIC might be US$ 500 billions per year (4% GDP)
3) Conclusions &
What needs to be done
I have to restart my English class
Conclusions• NCDs are expected to increase in the near future,
in particular in LMICs• The longer HIV survival will increase the burden
of NCDs in HIV population• If not addressed, it will have a serious negative
impact on human development: – reduction of productivity– contribution to poverty– increased burden over health systems and economies
What needs to be done• Advocacy, political commitment and
multisectoral approaches• Information and evidence• Promotion and prevention: reduction of risk
factors, vaccines and safer ARV treatments• Equitable access to health care services,
including diagnosis and essential medicines
Past and future of
Non–Communicable Diseases
Previously
Non–Considered Diseases
Currently
Non–Covered Diseases
Let’s to transform it into
Now–Controlled Diseases !!!
Acknowledgements
Pedro Cahn, Esteban Martinez, Miriam Rabkim, Carina Cesar, Valeria Fink, Patricia Patterson, José Luis Castro, , Elisa Prieto
Eugenia Socías, Alberto Barceló, Noreen Jack, Rosalinda Hernandez, Yitades Gebre, James Hospedales, Mario Cruz
Penate, Kathleen Page, Freddy Perez, Raúl Gonzalez, Marco Vitoria, slides from Janet Voute, to all who disseminated and
responded the HIV-NCDs survey and many others…...