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Chronic diseases in HIV Francois Venter Wits Reproductive Health & HIV Institute fventer@wrhi.ac.za

Chronic diseases in HIV Francois Venter Wits Reproductive Health & HIV Institute fventer@wrhi.ac.za. Which are the common chronic diseases in South Africa?. Chronic illness…. SA mortality data AIDS kills 50% (TB, pneumonia, gastro - #1-3) #4: Hypertension #6: Diabetes.

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Chronic diseases in HIV Francois Venter Wits Reproductive Health & HIV Institute fventer@wrhi.ac.za

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  1. Chronic diseases in HIVFrancois VenterWits Reproductive Health & HIV Institutefventer@wrhi.ac.za

  2. Which are the common chronic diseases in South Africa?

  3. Chronic illness… • SA mortality data • AIDS kills 50% (TB, pneumonia, gastro - #1-3) • #4: Hypertension • #6: Diabetes

  4. Why would life expectancy be higher in HIV?

  5. Why are South Africans so fat?

  6. BMJ 1990 • “Type 2 DM will be the commonest cause of death in South Africa” • Lancet 2013: same?

  7. 2 Overlapping Epidemics HIV infection Obesity

  8. …Over the past decade, it has become widely accepted that inflammation is a driving force behind chronic diseases that will kill nearly all of us (Cancer. Diabetes and obesity. Alzheimer’s disease.Atherosclerosis.)… …Mediating inflammation in chronic diseases is a new frontier, its success still uncertain… Science , 2010

  9. Traditional risk factors (age, gender, DM, HTN) are major predictors for MI (D:A:D) DAD Study Group. N Engl J Med 2007; 356:1723

  10. Fatter may be better…

  11. The 11 Keys to Healthy Aging in HIV Viral suppression after early diagnosis Control blood pressure Regulate blood glucose Lipids Stop smoking Be active Participate in cancer screenings Get regular immunizations Prevent bone loss and muscle weakness Combat depression Maintain social contact

  12. What can you tell your patients BEFORE starting ART?

  13. Population survival curves • Increase in average life expectancy but not life span • Disease vs. aging effects Life span Life Expectancy 1900 -1970’s

  14. Therapy for Early HIV Infection Clinical Symptoms Symptomatic (Stages 3 & 4) Asymptomatic (Stages 1 & 2) < 200 500 200 350 CD4 Count (cell/mm3)

  15. Effectsof HIV, Host and ART (Currier,WHEAX0102 ) HIV Replication ART Effects Immune Activation Inflammation Altered Lipid Effects Endothelial Function Macrophage recruitment Insulin Resistance HIV Diabetes Smoking Hypertension Genetics

  16. Vision… chronic care Minimal hospitalisation Diagnosis and staging, good primary care that suits patients Good ARV access CD4 8 to 10 years 40 years prevention

  17. The Health System Appears to Be Weak Across a Multitude of Dimensions • Healthcare Worker Issues • Administrative Issues • Patient Issues • Substandard management • Problem with recognition / diagnosis • Delay in referring patient • Initial assessment • Managed at inappropriate level • Infrequently monitored • Incorrect management • Prolonged abnormal monitoring without action • Lack of appropriately trained staff • Lack of specific health care facilities • Transport between institutions • Lack of blood for transfusion • Communication problems • Transport home to institution • Lack of accessibility • Barriers to entry • Delay in seeking medical help • Unsafe abortion • No antenatal care • Infrequent antenatal care Failing Healthcare System* System-wide causes – not a ‘one problem issue’ Note: *Modifiable Factors contributing to Maternal death used as a barometer of state of healthcare system, Approximately 3000 Maternal Deaths were assessed and 9000 errors were noted Source: Saving Mothers, Medical Research Council 7

  18. Treatment as prevention • Can reducing the viral load earlier have a public health impact? • Convenient convergence!

  19. The 10 Keys to Healthy Aging Control blood pressure Regulate blood glucose Lipids Stop smoking Be active Participate in cancer screenings Get regular immunizations Prevent bone loss and muscle weakness Combat depression Maintain social contact

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