Why we need to treat other chronic diseases alongside HIV/Aids
by Dr Robert Newman
Executive Director, AMP Health
This article was first published in Business Day on 30 November 2024. To view the original, click here.
This World Aids Day, Sunday December 1, the International Aids Society has called on people everywhere to rally around the theme Unite to Reach All. While this is laudable, it falls short by continuing to focus on HIV and Aids rather than creating accessible services for the prevention and treatment of chronic diseases more broadly.
In 2015 I was the director of the US Centres for Disease Control office in Cambodia. I received a charge from the US global Aids co-ordinator to begin planning for the end of US government support for HIV efforts in Cambodia. New infections had dropped dramatically, and I was told to find ways for the HIV programme to be rolled into chronic disease services.
I discovered that no chronic disease delivery programme existed except for HIV. This is the case in most lower-income countries. The reason, of course, is that only HIV had received the international funding and attention that made it possible to develop and implement a programme to detect, diagnose and treat a lifelong condition.
In contrast, public services for other chronic conditions such as diabetes, hypertension and heart disease, were nearly nonexistent. One recent study in Cambodia revealed that patients presenting at rural health facilities with new-onset hypertension were receiving about 18 days of antihypertensive medication, and no follow-up appointment — inadequate for the management of a lifelong condition. While there was angst at the highest levels of government about the ballooning burden of noncommunicable diseases (NCDs), health officials seemed paralysed and unable to design a feasible approach to tackling the problem.
When I suggested that the HIV programme could be the platform on which to build integrated and comprehensive services for chronic disease, my team and government officials looked at me as if I had lost my mind. HIV was an “untouchable” programme. And how could a programme addressing an infectious disease be the foundation for delivering services for a host of NCDs?
In reality, it matters little from a health system perspective whether a disease is infectious or non-infectious. What does matter is whether the condition being addressed is acute and resolvable with a short course of treatment, or chronic and requiring years of treatment.
The HIV service delivery platform built in most countries over the past 20-plus years shows it is possible to offer healthcare services for a lifelong condition at a population level. The main requirements? Community awareness and activism, political will (often a product of the former), and resources.
If it was deemed urgent to create an HIV service delivery platform 20 years ago, it should now be deemed equally urgent to expand that platform to meet the public health threat posed by other chronic diseases. To save someone from HIV, and to have them, or someone else, die prematurely from untreated hypertension, is a true tragedy.
This is no theoretical threat. One morning when I was living and working in Cambodia I received a call from the wonderful man I had hired to drive me through the traffic-choked streets of Phnom Penh. He told me he had a headache. I suggested he drive home and take the day off. When he informed me that he did not feel well enough to drive, I realised something was seriously wrong.
Though he was seen right away and diagnosed with hypertension, it was too late to prevent him, aged 40, from suffering a stroke. With top notch care and intensive rehabilitation, he was able to regain most of his speech and motor function and resume his career as a driver. Most Cambodians who suffer from chronic diseases are not so fortunate.
During my time there, ministry of health officials warmed to the idea of transforming the HIV service delivery platform into an integrated chronic disease service. The ministry recently developed a standard operating procedure for the integration of antiretroviral therapy and NCD clinics in referral hospitals. Breaking down political, programmatic and funding silos is not easy. Doing so requires ministry of health teams equipped with a range of skills, including vision setting, strategic planning, partnership brokering, stakeholder management, communication, influencing without authority, use of data for decision-making, innovation uptake and change management.
Over the past few years the SA-based nonprofit I lead, AMP Health, has supported NCD teams in Liberia, Malawi and Mozambique by building durable leadership and management capabilities. At one of the intercountry workshops in 2023, these teams focused on innovative thinking to achieve results and how to develop an investment case for NCD services. The team from Liberia was inspired to develop a proposal for the delivery of diabetes and cancer services using the HIV and TB service delivery platform.
Liberia submitted this proposal to the Global Fund, which was later accepted and funded. This is a major step forward, not only in terms of resources to address key chronic diseases, but also in building a robust foundation for integrated service delivery.
One of the benefits of developing an integrated chronic disease delivery platform is the further destigmatisation of HIV, which remains stubbornly high. By treating HIV as one of any number of chronic diseases affecting people that can be treated, we have an opportunity to change thinking about HIV as some unique curse, and recast it as a treatable and manageable lifelong health challenge — like many others.
Given that one of the goals of World Aids Day 2024 is the continued destigmatisation of HIV and Aids, I hope public health leaders will build on the examples of countries such as Cambodia and Liberia to advocate for a shift from focus on HIV alone to a broader focus on the delivery of quality chronic care services that are accessible for all who need them, regardless of the condition with which they are living.