Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases

Blood pressure level impacts risk of death among HIV seropositive adults in Kenya: a retrospective analysis of electronic health records

BACKGROUND

Mortality among people with human immunodeficiency virus (HIV) infection is increasingly due to non-communicable causes. This has been observed mostly in developed countries and the routine care of HIV infected individuals has now expanded to include attention to cardiovascular risk factors. Cardiovascular risk factors such as high blood pressure are often overlooked among HIV seropositive (+) individuals in sub-Saharan Africa. We aimed to determine the effect of blood pressure on mortality among HIV+ adults in Kenya.

METHODS

We performed a retrospective analysis of electronic medical records of a large HIV treatment program in western Kenya between 2005 and 2010. All included individuals were HIV+. We excluded participants with AIDS, who were <16 or >80 years old, or had data out of acceptable ranges. Missing data for key covariates was addressed by inverse probability weighting. Primary outcome measures were crude mortality rate and mortality hazard ratio (HR) using Cox proportional hazards models adjusted for potential confounders including HIV stage.

RESULTS

There were 49,475 (74% women) HIV+ individuals who met inclusion and exclusion criteria. Mortality rates for men and women were 3.8 and 1.8/100 person-years, respectively, and highest among those with the lowest blood pressures. Low blood pressure was associated with the highest mortality incidence rate (IR) (systolic <100 mmHg IR 5.2 [4.8-5.7]; diastolic <60 mmHg IR 9.2 [8.3-10.2]). Mortality rate among men with high systolic blood pressure without advanced HIV (3.0, 95% CI: 1.6-5.5) was higher than men with normal systolic blood pressure (1.1, 95% CI: 0.7-1.7). In weighted proportional hazards regression models, men without advanced HIV disease and systolic blood pressure ≥140 mmHg carried a higher mortality risk than normotensive men (HR: 2.39, 95% CI: 0.94-6.08).

CONCLUSIONS

Although there has been little attention paid to high blood pressure among HIV+ Africans, we show that blood pressure level among HIV+ patients in Kenya is related to mortality. Low blood pressure carries the highest mortality risk. High systolic blood pressure is associated with mortality among patients whose disease is not advanced. Further investigation is needed into the cause of death for such patients.

Task-shifting and prioritization: a situational analysis examining the role and experiences of community health workers in Malawi

BACKGROUND

As low- and middle-income countries face continued shortages of human resources for health and the double burden of infectious and chronic diseases, there is renewed international interest in the potential for community health workers to assume a growing role in strengthening health systems. A growing list of tasks, some of them complex, is being shifted to community health workers' job descriptions. Health Surveillance Assistants (HSAs) - as the community health worker cadre in Malawi is known - play a vital role in providing essential health services and connecting the community with the formal health care sector. The objective of this study was to understand the performed versus documented roles of the HSAs, to examine how tasks were prioritized, and to understand HSAs' perspectives on their roles and responsibilities.

METHODS

A situational analysis of the HSA cadre and its contribution to the delivery of health services in Zomba district, Malawi was conducted. Focus groups and interviews were conducted with 70 HSAs. Observations of three HSAs performing duties and work diaries from five HSAs were collected. Lastly, six policy-maker and seven HSA supervisor interviews and a document review were used to further understand the cadre's role and to triangulate collected data.

RESULTS

HSAs performed a variety of tasks in addition to those outlined in the job description resulting in issues of overloading, specialization and competing demands existing in the context of task-shifting and prioritization. Not all HSAs were resistant to the expansion of their role despite role confusion and HSAs feeling they lacked adequate training, remuneration and supervision. HSAs also said that increasing workload was making completing their primary duties challenging. Considerations for policy-makers include the division of roles of HSAs in prevention versus curative care; community versus centre-based activities; and the potential specialization of HSAs.

CONCLUSION

This study provides insights into HSAs' perceptions of their work, their expanding role and their willingness to change the scope of their practice. There are clear decision points for policy-makers regarding future direction in policy and planning in order to maximize the cadre's effectiveness in addressing the country's health priorities.

A systematic review of the literature on self-management interventions and discussion of their potential relevance for people living with HIV in sub-Saharan Africa

OBJECTIVE

This study systematically reviews the literature on self-management interventions provided by health care teams, community partners, patients and families and discusses the potential relevance of these interventions for people living with HIV in sub-Saharan Africa.

METHODS

We searched major databases for literature published between 1995 and 2012. 52 studies were included in this review.

RESULTS

The review found very few studies covering people living with HIV and generally inconclusive evidence to inform the development of chronic care policy and practice in sub-Saharan Africa.

CONCLUSION

Chronic care models and self-management interventions for sub-Saharan Africa has not been a research priority. Furthermore, the results question the applicability of these models and interventions in sub-Saharan Africa. There is a need for studies to fill this gap in view of the rapidly increasing number of people needing chronic care services in Africa.

PRACTICE IMPLICATIONS

The established practices for long-term support for HIV patients are still the most valid basis for promoting self-management. This will be the case until there are more studies which assess those practices and their effect on self-management outcomes and other studies which assess the utility and feasibility of applying chronic care models that have been developed in high-income countries.

Optimizing linkage and retention to hypertension care in rural Kenya (LARK hypertension study): study protocol for a randomized controlled trial

Background

Hypertension is the leading global risk factor for mortality. Hypertension treatment and control rates are low worldwide, and delays in seeking care are associated with increased mortality. Thus, a critical component of hypertension management is to optimize linkage and retention to care.

Methods/Design

This study investigates whether community health workers, equipped with a tailored behavioral communication strategy and smartphone technology, can increase linkage and retention of hypertensive individuals to a hypertension care program and significantly reduce blood pressure among them. The study will be conducted in the Kosirai and Turbo Divisions of western Kenya. An initial phase of qualitative inquiry will assess facilitators and barriers of linkage and retention to care using a modified Health Belief Model as a conceptual framework. Subsequently, we will conduct a cluster randomized controlled trial with three arms: 1) usual care (community health workers with the standard level of hypertension care training); 2) community health workers with an additional tailored behavioral communication strategy; and 3) community health workers with a tailored behavioral communication strategy who are also equipped with smartphone technology. The co-primary outcome measures are: 1) linkage to hypertension care, and 2) one-year change in systolic blood pressure among hypertensive individuals. Cost-effectiveness analysis will be conducted in terms of costs per unit decrease in blood pressure and costs per disability-adjusted life year gained.

Discussion

This study will provide evidence regarding the effectiveness and cost-effectiveness of strategies to optimize linkage and retention to hypertension care that can be applicable to non-communicable disease management in low- and middle-income countries.

Trial registration

This trial is registered with (NCT01844596) on 30 April 2013.

Hypertension prevalence and Framingham risk score stratification in a large HIV-positive cohort in Uganda

BACKGROUND

To report the prevalence of hypertension and projected 10-year absolute risk of acute cardiovascular disease in a large prospectively followed cohort of HIV-positive youth and adults beginning antiretroviral therapy in sub-Saharan Africa.

METHODS

HIV-positive individuals seeking HIV treatment, ages 13 years and older, were assessed for repeated blood pressure measurements over the first year following initiation of antiretroviral therapy, including serum total cholesterol, high-density lipoprotein, CD4 cell count and related clinical and laboratory measurements. Outcomes include hypertension, defined according to the 7th Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure categories, and Framingham Risk Score based 10-year cardiovascular disease risk estimates.

RESULTS

Five thousand, five hundred and sixty-three patients had at least two blood pressure measurements on at least two separate occasions during the first year of antiretroviral therapy [median age of therapy initiation 34, first and third quartile (Q1-Q3) 28-40 years, 1841 (33.1%) men, baseline CD4 cell count 161 cells/μl (Q1-Q3 72-231 cells/μl]. Hypertension was diagnosed in 1551 patients [27.9%, 95% confidence interval (CI) 26.7- 29.1] including 786 (14.1%, 95% CI 13.2-15.1) who met criteria for stage 2 hypertension. The age-standardized prevalence for Ugandans aged 13 or more was 24.8% (95% CI 23.8-26.1). Among those with complete laboratory studies (n=1102), nearly all women were in the 10% or less 10-year Framingham Risk Score category, but 20% of men were at at least 10% or more long-term risk of acute cardiovascular disease.

CONCLUSION

Efforts to combine HIV treatment with vascular disease risk factor prevention and management are urgently needed to address noncommunicable disease multimorbidity in HIV-positive persons in sub-Saharan Africa, particularly in men.

Nurse management of hypertension in rural western Kenya: implementation research to optimize delivery

BACKGROUND

Hypertension is the leading global risk factor for mortality. Hypertension treatment and control rates are low worldwide, and insufficient human resource capacity is among the contributing factors. Thus, a critical component of hypertension management is to develop novel and effective solutions to the human resources challenge. One potential solution is task redistribution and nurse management of hypertension in these settings.

OBJECTIVES

The aim of this study is to investigate whether nurses can effectively reduce blood pressure in hypertensive patients in rural western Kenya and, by extension, throughout sub-Saharan Africa.

METHODS

An initial phase of qualitative inquiry will assess facilitators and barriers of nurse management of hypertension. In addition, we will perform usability and feasibility testing of a novel, electronic tablet-based integrated decision-support and record-keeping tool for the nurses. An impact evaluation of a pilot program for nurse-based management of hypertension will be performed. Finally, a needs-based workforce estimation model will be used to estimate the nurse workforce requirements for stable, long-term treatment of hypertension throughout western Kenya.

FINDINGS

The primary outcome measure of the impact evaluation will be the change in systolic blood pressure of hypertensive individuals assigned to nurse-based management after 1 year of follow-up. The workforce estimation modeling output will be the full-time equivalents of nurses.

CONCLUSIONS

This study will provide evidence regarding the effectiveness of strategies to optimize task redistribution and nurse-based management of hypertension that can be applicable to noncommunicable disease management in low- and middle-income countries.

Point-of-Care Diagnostics in Low-Resource Settings and Their Impact on Care in the Age of the Noncommunicable and Chronic Disease Epidemic

The emergence of point-of-care (POC) diagnostics specifically designed for low-resource settings coupled with the rapid increase in need for routine care of patients with chronic diseases should prompt reconsideration of how health care can be delivered most beneficially and cost-effectively in developing countries. Bolstering support for primary care to provide rapid and appropriate integrated acute and chronic care treatment may be a possible solution. POC diagnostics can empower local and primary care providers and enable them to make better clinical decisions. This article explores the opportunity for POC diagnostics to strengthen primary care and chronic disease diagnosis and management in a low-resource setting (LRS) to deliver appropriate, consistent, and integrated care. We analyze the requirements of resource-appropriate chronic disease care, the characteristics of POC diagnostics in LRS versus the developed world, the many roles of diagnostics in the care continuum in LRS, and the process and economics of developing LRS-compatible POC diagnostics.

Baseline assessment of adult and adolescent primary care delivery in Rwanda: an opportunity for quality improvement

BACKGROUND

As resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda.

METHODS

Patients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard.

RESULTS

Four hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (p = 0.03 and p = 0.04, respectively).

CONCLUSION

Fundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.

Antiretroviral therapy for prevention is a combination strategy

In the past several years, the debate of "treatment vs prevention" has shifted with the introduction of the concept of "treatment as prevention," (TasP), stemming from a series of compelling observational, ecological, and modeling studies as well as HPTN 052, a randomized clinical trial, demonstrating that use of ART is associated with a decrease in HIV transmission. In addition to TasP being viewed as 1 intervention in a combination strategy for HIV Prevention, TasP is, in and of itself, a combination of multiple interventions that need to be implemented with high coverage in order to achieve its potential impact.

Epidemiology and awareness of hypertension in a rural Ugandan community: a cross-sectional study

BACKGROUND

Hypertension is one of the largest causes of preventable morbidity and mortality worldwide. There are few population-based studies on hypertension epidemiology to guide public health strategies in sub-Saharan Africa. Using a community-based strategy that integrated screening for HIV and non-communicable diseases, we determined the prevalence, awareness, treatment rates, and sociodemographic factors associated with hypertension in rural Uganda.

METHODS

A household census was performed to enumerate the population in Kakyerere parish in Mbarara district, Uganda. A multi-disease community-based screening campaign for hypertension, diabetes, and HIV was then conducted. During the campaign, all adults received a blood pressure (BP) measurement and completed a survey examining sociodemographic factors. Hypertension was defined as elevated BP (≥ 140/≥ 90 mmHg) on the lowest of three BP measurements or current use of antihypertensives. Prevalence was calculated and standardized to age distribution. Sociodemographic factors associated with hypertension were evaluated using a log-link Poisson regression model with robust standard errors.

RESULTS

Community participation in the screening campaign was 65%, including 1245 women and 1007 men. The prevalence of hypertension was 14.6%; awareness of diagnosis (38.1%) and current receipt of treatment (20.6%) were both low. Age-standardized to the WHO world standard population, hypertension prevalence was 19.8%, which is comparable to 21.6% in the US and 18.4% in the UK. Sociodemographic factors associated with hypertension included increasing age, male gender, overweight, obesity, diabetes, alcohol consumption, and family history. Prevalence of modifiable factors was high: 28.3% women were overweight/obese and 24.1% men consumed ≥ 10 alcoholic drinks per month.

CONCLUSIONS

We found a substantial burden of hypertension in rural Uganda. Awareness and treatment of hypertension is low in this region. Enhanced community-based education and prevention efforts tailored to addressing modifiable factors are needed.

Linkage to HIV, TB and non-communicable disease care from a mobile testing unit in Cape Town, South Africa

BACKGROUND

HIV counseling and testing may serve as an entry point for non-communicable disease screening.

OBJECTIVES

To determine the yield of newly-diagnosed HIV, tuberculosis (TB) symptoms, diabetes and hypertension, and to assess CD4 count testing, linkage to care as well as correlates of linkage and barriers to care from a mobile testing unit.

METHODS

A mobile unit provided screening for HIV, TB symptoms, diabetes and hypertension in Cape Town, South Africa between March 2010 and September 2011. The yield of newly-diagnosed cases of these conditions was measured and clients were followed-up between January and November 2011 to assess linkage. Linkage to care was defined as accessing care within one, three or six months post-HIV diagnosis (dependent on CD4 count) and one month post-diagnosis for other conditions. Clinical and socio-demographic correlates of linkage to care were evaluated using Poisson regression and barriers to care were determined.

RESULTS

Of 9,806 clients screened, the yield of new diagnoses was: HIV (5.5%), TB suspects (10.1%), diabetes (0.8%) and hypertension (58.1%). Linkage to care for HIV-infected clients, TB suspects, diabetics and hypertensives was: 51.3%, 56.7%, 74.1% and 50.0%. Only disclosure of HIV-positive status to family members or partners (RR=2.6, 95% CI: 1.04-6.3, p=0.04) was independently associated with linkage to HIV care. The main barrier to care reported by all groups was lack of time to access a clinic.

CONCLUSION

Screening for HIV, TB symptoms and hypertension at mobile units in South Africa has a high yield but inadequate linkage. After-hours and weekend clinics may overcome a major barrier to accessing care.

Diabetic ketoacidosis: an overlooked child killer in sub-Saharan Africa?

The true incidence of diabetic ketoacidosis (DKA) in sub-Saharan Africa is unknown but unlike in the Western countries, DKA is also uniquely frequent among type 2 diabetes patients of African origin. Increased hyperglycaemia and hepatic ketogenesis lead to osmotic diuresis, dehydration and tissue hypoxia. Acute complications of DKA include cerebral oedema, which may be compounded by malnutrition, parasitic and microbial infections with rampant tuberculosis and HIV. Overlapping symptoms of these conditions and misdiagnosis of DKA contribute to increased morbidity and mortality. Inability of the patients to afford insulin treatment leads to poor glycemic control as some patients seek alternative treatment from traditional healers or use herbal remedies further complicating the disease process. Standard treatment guidelines for DKA currently used may not be ideal as they are adapted from those of the developed world. Children presenting with suspected DKA should be screened for comorbidities which may complicate fluid and electrolyte replacement therapy protocol. Patient rehabilitation should take into account concurrent treatment for infectious conditions to avoid possible life-threatening drug interactions. We recommend that health systems in sub-Saharan Africa leverage the Expanded Immunization Programme or TB/HIV/AIDS programmes, which are fairly well entrenched to support diabetes services.

Airborne Outreach

There is a paucity of research demonstrating how HIV-funded services in Africa have improved equity and access to non-HIV services for both HIV-infected and uninfected patients. In this short communication, we describe the impact of an airborne outreach program to provide HIV services to high-HIV burden health facilities in rural Botswana. The analysis demonstrates how this HIV-funded program enhanced access to essential subspecialist services at several rural health facilities across Botswana.

HIV and noncommunicable diseases: a case for health system building

PURPOSE OF REVIEW

Many low- and middle-income countries face a double burden of disease from infectious diseases such as HIV/AIDS and noncommunicable diseases (NCDs) such as diabetes, stroke and cancers. The health systems in such countries are weak and are severely challenged by the weight of a double burden of disease. The aim of this review is to examine current calls for a coordinated global response to HIV and NCDs and make a case for health system building in resource-constrained settings.

RECENT FINDINGS

The main argument in favour of a coordinated approach is that HIV and NCDs share many similarities that make them ideal candidates for a coordinated approach. Therefore, there is no need to reinvent the wheel, as experiences with HIV programmes can be leveraged to NCD programmes, and vice versa. Critics, however, worry that coordinated approaches could among other things adversely affect the gains of HIV programmes.

SUMMARY

Going forward, the overall benefit of a coordinated approach will be that health systems could be strengthened in a sustainable manner. However, such approaches must carefully weigh the benefits against risks to existing structures and must consider all the relevant stakeholders in their implementation.

First-line antiretroviral therapy and changes in lipid levels over 3 years among HIV-infected adults in Tanzania

BACKGROUND

With the rapid rollout of antiretroviral therapy (ART) in sub-Saharan Africa (SSA), there has been an increasing concern about cardiovascular risks related to ART. However, data from human immunodeficiency virus (HIV)-infected populations from this region are very limited.

METHODS

Among 6385 HIV-infected adults in Dar es Salaam, Tanzania, we investigated the nonfasting lipid changes over 3 years following ART initiation and their associations with different first-line ART agents that are commonly used in SSA.

RESULTS

In the first 6 months of ART, the prevalence of dyslipidemia decreased from 69% to 54%, with triglyceride (TG) decreasing from 127 mg/dL to 113 mg/dL and high-density lipoprotein (HDL) cholesterol increasing from 39 mg/dL to 52 mg/dL. After 6 months, TG returned to its baseline level and increased to 139 mg/dL at 3 years; total cholesterol and low-density lipoprotein cholesterol continued to increase whereas HDL cholesterol leveled off. The prevalence of dyslipidemia increased to 73% after a 3-year follow-up. In multivariate analyses, patients on zidovudine-containing regimens had a greater reduction in TG levels at 6 months (-16.0 vs -6.3 mg/dL), and a lower increase at 3 years compared to patients on stavudine-containing regimens (2.1 vs 11.7 mg/dL, P < .001); patients on nevirapine-based regimens had a higher increase in HDL cholesterol levels at 3 years compared to those on efavirenz-based regimens (13.6 vs 9.5 mg/dL, P = .01).

CONCLUSIONS

Our findings support the latest World Health Organization guidelines on the substitution of stavudine in first-line ART in resource-limited settings, and provide further evidence for selection of lipid-friendly ART for patients in SSA.

PEPFAR programs linked to more deliveries in health facilities by African women who are not infected with HIV

HIV programs in lower-income countries have provided lifesaving care and treatment to millions of people, but their expansion has raised concerns that these programs may have diverted health workers, management attention, and infrastructure investments from other health priorities, such as high maternal mortality in sub-Saharan Africa. We assessed the effect of HIV programs supported by the President's Emergency Plan for AIDS Relief (PEPFAR) on maternal health services for women not infected with HIV in 257 health facilities in eight African countries in 2007-11. Controlling for other variables, we found that having more patients on antiretroviral treatment and HIV-related infrastructure investments, such as on-site laboratories at health clinics, were associated with more deliveries at health facilities by women not infected with HIV. This association is consistent with the hypothesis that PEPFAR-funded infrastructure may also support other health services and that the program may have laid the foundation for improving health system performance in maternal health overall. We recommend that lessons learned from the rapid expansion of HIV services in sub-Saharan Africa should be drawn on to increase the provision of maternal and newborn health care and other high-priority health services, such as the treatment of diabetes, hypertension, and other chronic, noncommunicable diseases.

Counting the cost of not costing HIV health facilities accurately: pay now, or pay more later

The HIV pandemic continues to be one of our greatest contemporary public health threats. Policy makers in many middle- and low-income countries are in the process of scaling up HIV prevention, treatment and care services in the context of a reduction in international HIV funding due to the global economic downturn. In order to scale up services that are sustainable in the long term, policy makers and implementers need to have access to robust and contemporary strategic information, including financial information on expenditure and cost, in order to be able to plan, implement, monitor and evaluate HIV services. A major problem in middle- and low-income countries continues to be a lack of basic information on the use of services, their cost, outcome and impact, while those few costing studies that have been performed were often not done in a standardized fashion. Some researchers handle this by transposing information from one country to another, developing mathematical or statistical models that rest on assumptions or information that may not be applicable, or using top-down costing methods that only provide global financial costs rather than using bottom-up ingredients-based costing. While these methods provide answers in the short term, countries should develop systematic data collection systems to store, transfer and produce robust and contemporary strategic financial information for stakeholders at local, sub-national and national levels. National aggregated information should act as the main source of financial data for international donors, agencies or other organizations involved with the global HIV response. This paper describes the financial information required by policy makers and other stakeholders to enable them to make evidence-informed decisions and reviews the quantity and quality of the financial information available, as indicated by cost studies published between 1981 and 2008. Among the lessons learned from reviewing these studies, a need was identified for providing countries with practical guidance to produce reliable and standardized costing data to monitor performance, as countries want to improve programmes and services, and have to demonstrate an efficient use of resources. Finally, the issues raised in this paper relate to the provision of all areas of healthcare in countries and it is going to be increasingly important to leverage the lessons learned from the HIV experience and use resources more effectively and efficiently to improve health systems in general.

Strengthening Health Systems for Chronic Care: Leveraging HIV Programs to Support Diabetes Services in Ethiopia and Swaziland

The scale-up of HIV services in sub-Saharan Africa has catalyzed the development of highly effective chronic care systems. The strategies, systems, and tools developed to support life-long HIV care and treatment are locally owned contextually appropriate resources, many of which could be adapted to support continuity care for noncommunicable chronic diseases (NCD), such as diabetes mellitus (DM). We conducted two proof-of-concept studies to further the understanding of the status of NCD programs and the feasibility and effectiveness of adapting HIV program-related tools and systems for patients with DM. In Swaziland, a rapid assessment illustrated gaps in the approaches used to support DM services at 15 health facilities, despite the existence of chronic care systems at HIV clinics in the same hospitals, health centers, and clinics. In Ethiopia, a pilot study found similar gaps in DM services at baseline and illustrated the potential to rapidly improve the quality of care and treatment for DM by adapting HIV-specific policies, systems, and tools.

Prevalence of HIV and chronic comorbidities among older adults

OBJECTIVES

Limited evidence is available on HIV, aging and comorbidities in sub-Saharan Africa. This article describes the prevalence of HIV and chronic comorbidities among those aged 50 years and older in South Africa using nationally representative data.

DESIGN

The WHO's Study of global AGEing and adult health (SAGE) was conducted in South Africa in 2007-2008. SAGE includes nationally representative cohorts of persons aged 50 years and older, with comparison samples of those aged 18-49 years, which aims to study health and its determinants.

METHODS

Logistic and linear regression models were applied to data from respondents aged 50 years and older to determine associations between age, sex and HIV status and various outcome variables including prevalence of seven chronic conditions.

RESULTS

HIV prevalence among adults aged 50 and older in South Africa was 6.4% and was particularly elevated among Africans, women aged 50-59 and those living in rural areas. Rates of chronic disease were higher among all older adults compared with those aged 18-49. Of those aged 50 years and older, 29.6% had two or more of the seven chronic conditions compared with 8.8% of those aged 18-49 years (P < 0.0001). When controlling for age and sex among those aged 50 and older, BMI was lower among HIV-infected older adults aged 50 and older (27.5 kg/m2) than in HIV-uninfected individuals of the same age (30.6) (P < 0.0001). Grip strength among HIV-infected older adults was significantly (P=0.004) weaker than among similarly-aged HIV-uninfected individuals.

CONCLUSION

HIV-infected older adults in South Africa have high rates of chronic disease and weakness. Studies are required to examine HIV diagnostics and treatment instigation rates among older adults to ensure equity of access to quality care, as the number and percentage of older adults living with HIV is likely to increase.

Toward a systemic research agenda for addressing the joint epidemics of HIV/AIDS and noncommunicable diseases

A growing proportion of people living with HIV/AIDS also struggle to cope with one or several noncommunicable diseases (NCDs), particularly as they age. The two epidemics being intertwined, there is increasing recognition that that there should be closer advocacy, policy and programmatic links between HIV and NCDs. The objective of this paper is to discuss the development of a research agenda geared towards informing the design and implementation of programs and policies truly grounded in a co-benefits approach. Tackling the joint epidemics of HIV/AIDS and NCDs in Africa will require for research funders and private and foreign aid donors to be bold, visionary and to commit to long-term research investments in order to evaluate the effects of natural policy experiments and complex interventions.

HIV, aging and continuity care: strengthening health systems to support services for noncommunicable diseases in low-income countries

Although health systems in most low-income countries largely provide episodic care for acute symptomatic conditions, many HIV programs have developed effective, locally owned and contextually appropriate policies, systems and tools to support chronic care services for persons living with HIV (PLWH). The continuity of care provided by such programs may be especially critical for older PLWH, who are at risk for more rapid progression of disease and are more likely to have complications of HIV and its treatment than their younger counterparts. Older PLWH are also more likely to have other chronic noncommunicable diseases (NCDs), including hypertension, diabetes, cancers and chronic lung disease. As the number of older PLWH rises, enhanced chronic care systems will be required to optimize their health and wellbeing. These systems, lessons and resources can also be leveraged to support the burgeoning numbers of HIV-negative individuals with chronic NCD in need of ongoing care.

Integrating HIV treatment with primary care outpatient services: opportunities and challenges from a scaled-up model in Zambia

Background Integration of HIV treatment with other primary care services has been argued to potentially improve effectiveness, efficiency and equity. However, outside the field of reproductive health, there is limited empirical evidence regarding the scope or depth of integrated HIV programmes or their relative benefits. Moreover, the body of work describing operational models of integrated service-delivery in context remains thin. Between 2008 and 2011, the Lusaka District Health Management Team piloted and scaled-up a model of integrated HIV and general outpatient department (OPD) services in 12 primary health care clinics. This paper examines the effect of the integrated model on the organization of clinic services, and explores service providers’ perceptions of the integrated model.

Methods We used a mixed methods approach incorporating facility surveys and key informant interviews with clinic managers and district officials. On-site facility surveys were carried out in 12 integrated facilities to collect data on the scope of integrated services, and 15 semi-structured interviews were carried out with 12 clinic managers and three district officials to explore strengths and weaknesses of the model. Quantitative and qualitative data were triangulated to inform overall analysis.

Findings Implementation of the integrated model substantially changed the organization of service delivery across a range of clinic systems. Organizational and managerial advantages were identified, including more efficient use of staff time and clinic space, improved teamwork and accountability, and more equitable delivery of care to HIV and non-HIV patients. However, integration did not solve ongoing human resource shortages or inadequate infrastructure, which limited the efficacy of the model and were perceived to undermine service delivery.

Conclusion While resource and allocative efficiencies are associated with this model of integration, a more important finding was the model’s demonstrated potential for strengthening organizational culture and staff relationships, in turn facilitating more collaborative and motivated service delivery in chronically under-resourced primary healthcare clinics.

Scaling up chronic care systems: leveraging HIV programs to support noncommunicable disease services

The scale-up of HIV services in lower-income countries has created the first large-scale continuity care program in many settings. Although HIV and chronic noncommunicable diseases are thought of as quite different challenges and tend to be "siloed" throughout the health system, the availability of treatment has transformed HIV into a chronic condition-and HIV programs have developed the systems, tools, and approaches needed to support continuity care in the local context. In many cases, HIV programs have developed practical and contextually appropriate resources that might be used to support nascent noncommunicable diseases programs.

No need for apologies

The expansion of access to antiretroviral therapy for millions of persons living with HIV in low-income countries has been lauded by many. However, the investment in such programs has at the same time been criticized by others, who claim diversion of resources from HIV prevention efforts and from other important health threats in these same countries. Yet, the time is right to recommit to the goal of universal access to HIV prevention and treatment while garnering the lessons learned from HIV programming and building on the platform it has established in confronting other health threats.

HIV/AIDS, chronic diseases and globalisation

HIV/AIDS has always been one of the most thoroughly global of diseases. In the era of widely available anti-retroviral therapy (ART), it is also commonly recognised as a chronic disease that can be successfully managed on a long-term basis. This article examines the chronic character of the HIV/AIDS pandemic and highlights some of the changes we might expect to see at the global level as HIV is increasingly normalised as "just another chronic disease". The article also addresses the use of this language of chronicity to interpret the HIV/AIDS pandemic and calls into question some of the consequences of an uncritical acceptance of concepts of chronicity.

UN High-Level Meeting on Non-Communicable Diseases: addressing four questions

Non-communicable diseases (NCDs), principally heart disease, stroke, cancer, diabetes, and chronic respiratory diseases, are a global crisis and require a global response. Despite the threat to human development, and the availability of affordable, cost-effective, and feasible interventions, most countries, development agencies, and foundations neglect the crisis. The UN High-Level Meeting (UN HLM) on NCDs in September, 2011, is an opportunity to stimulate a coordinated global response to NCDs that is commensurate with their health and economic burdens. To achieve the promise of the UN HLM, several questions must be addressed. In this report, we present the realities of the situation by answering four questions: is there really a global crisis of NCDs; how is NCD a development issue; are affordable and cost-effective interventions available; and do we really need high-level leadership and accountability? Action against NCDs will support other global health and development priorities. A successful outcome of the UN HLM depends on the heads of states and governments attending the meeting, and endorsing and implementing the commitments to action. Long-term success requires inspired and committed national and international leadership.