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The intersection of HIV and Non-Communicable Diseases in Low R esource Settings

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?

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The intersection of HIV and Non-Communicable Diseases in Low R esource Settings

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  1. The intersection of HIV and Non-Communicable Diseases in Low Resource Settings Omar Sued, MD, MScFundación HuéspedArgentina

  2. 3 Simple Questions 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. Why? a) Global Ageing BRAZIL: Population Structure The proportion of older persons in the world will double by 2050 Changes are faster in middleincomecountries. UN 2009 2000 2050 China’s Population Structure Age 2050 2000 • 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 VilaçaMendes E, PAHO, 2012 In Braziltheproportion of >65y willincreasefrom 5.4% in 2000 to20% in 2050. 80% of thispeoplewillrequirechroniccare • Male • Female • Male • Female • Source: World Population Prospects: The 2004 Revision (2005) VilaçaMendes E, PAHO, 2012

  4. Why? b) Increasedsurvival of PLWHAs • In LMICs life expectancy for HIV adults initiating HAART now approaches life expectancy for all adults. Mills et al, AIM 2011 Comparedadultmortality in 9 African PEPFAR focuscountries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) vs. 18 Africannonfocuscountriesfrom 1998 to 2008. Bendavid et al, JAMA, 2012 • 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

  5. Why? c) Because HIV & NCDsoverlap NCD mortality HIV mortality • Poor countries are more vulnerable to risk factors and social determinants: • Urbanization • Globalization • Tobacco industry • Westernized diets • Lowphysicalactivity Countries without public smoking ban NCD Global report WHO 2011, HIV Progressreport 2011 WHO, UNICEF, UNAIDS. Tobaccouse: Wikipedia

  6. Riskfactors: tobacco 15% of global deaths WHO

  7. Riskfactors: overweight • 2.8 millionsof deatheveryyear • In Mexicoand Braziltheestimatedincrease of obesitybetween2010 and 2030 is 13-17%. • Theassociatedhealthcarecostwillbe US$ 400-600 /y. • Changes are beingincreasinglyshown in children Building a healthier future, PAHO, 2011, NCD Global Report WHO, 2011

  8. Markets move to countries with weaker regulations CENTRAL AMERICA Snack imports from the United States MEXICO INDIA FAO 2007

  9. Riskfactors: hypertension • High prevalence in African Countries Maher 2011

  10. Why? d) Burdenof NCDs in LMICs Ten leading causes of burden of disease, 2004 and 2030 Source: The global burden of disease, 2010, WHO

  11. Why? d) Burdenof NCDs in LMICs (cont.) Projected NCDs Deaths in 2015 and 2030 Inten. Injuries Unintentional Road traffic Other NCD Cancers CVD MTC Other ID HIV,TB,malaria NCD accounts globally for 36 of the 57 millions of deaths per year In addition, 1.8million of HIV related deaths UN 2005

  12. Why? d) Burdenof NCDs in LMICs (cont.) Projected NCDs Deaths in 2015 and 2030 Inten. Injuries Unintentional Road traffic Other NCD Cancers CVD MTC Other ID HIV,TB,malaria LMICs accounts for 80% of the 36 million NCDs deaths LMICs =80%of global NCDs deaths =98%of global HIV deaths UN 2005

  13. Why? d) Burdenof NCDs in LMICs (cont.) 2007: NCDs #1 cause of death in The Americas: 75% of the total deaths COPD Other NCDs Diabetes CVD 36% of deaths are below age 70 years Cancer

  14. Why? d) Burdenof NCDs in LMICs (cont.) Leading Causes of Death in Caribbean Countries by Sex, 2004 MALES FEMALES • Heart Disease • Cancers • Diabetes • Stroke • Hypertension • HIV/AIDS • Influenza/pneumonia • Injuries and violence • Heart Disease • Cancers • Injuries and violence • Stroke • Diabetes • HIV/AIDS • Hypertension • Influenza/pneumonia Resource: CAREC Mortality data

  15. 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

  16. 2)What is the current situation of HIV-NCDs in low resources setting?

  17. a) Evidence HIV= 240,900 Hypertension [ti] or “blood pressure”[ti] or cardiovascular[ti] = 780 Diabetes[ti] = 249 Cancer[ti] =1245 2274 LMICs FILTER: ("low income countries" OR "developing countries" OR "third world" OR Africa OR Asia OR “Latin America") HIV and Hypertension [ti] or “blood pressure”[ti] or cardiovascular[ti] and LMIC=43 HIV and Diabetes[ti] and LMIC= 31 HIV and Cancer[ti] and LMIC= 170 244 PubMed Search, Junio 2012

  18. b) Frequency of CV risk factors in HIVHigh prevalence among people on HAART 1) D:A:D Study

  19. Prevalence 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) c) Diabetes-HIV 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 AfricaIdemyor, 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

  20. d) Cancer and HIV • No Cancer-HIV registries • Very limited information • In Africa, 25–30% of all cancers are linked to infectious agents

  21. e) Cervical Cancer and HIV Cervical cancer cases are expected to increase in HIV women Atashili,PLoS ONE , 2011 Cervical lesions in Africa 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. Ferlay et al, Int Jour of Ca, 2010 Grulich, CurrOp HIV AIDS, 2009 Bower, CurrOp HIV AIDS, 2006 Aberg J, et al. Clin Infect Dis. 2009 British HIV Association, HIV Med, 2008

  22. 3) The HIV-NCDs in the real life

  23. HIV-NCD real life • HIV-HCW 45% • No HIV-HCW 23% • Community 21% • Policy maker 11% Online survey 260 participants from 90 countries 89% consider NCD a problem, in particular CVD, DBT and hypertension. Who should detect NCDs in HIV? Who should treat NCDs in HIV? (Sued,June 2012, unpublished)

  24. Need to integrate health promotion Do you consider general public has complete information about?: (mark all that apply) Risk factor for diabetes Obesity Safe sex None Tobaccorisks Cancerprevention Healthydiets

  25. Lack of resources for NCDs Tests and procedures free to patients Treatment free to patients

  26. NCDs were indicated as the third most likely and severe economical risk in 2009… Oil and gas price spike ….and havelessthan 1% of theinternationalhealthresources Retrenchment from globalization Asset price collapse NCDs Fiscal crisis Flu pandemic Food crisis NCDscostfor LMIC mightbe US$ 500 billions per year (4% GDP) Infectious disease http://www.weforum.org/pdf/globalrisk/globalrisks09/global_risks_2009.pdf

  27. 3) Conclusions &What needs to be done I have to restart my English class

  28. 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

  29. Whatneedsto be done • Advocacy, political commitment and multisectoralapproaches • 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

  30. Past and futureof Non–CommunicableDiseases

  31. Previously Non–ConsideredDiseases

  32. Currently Non–CoveredDiseases

  33. Let’stotransformitinto Now–ControlledDiseases !!!

  34. 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, YitadesGebre, 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…...

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