Growing problem of HIV and NCDs

Three-quarters of people on antiretroviral treatment at a clinic in Khayelitsha were also being treated for hypertension. Yet there is not enough information about how HIV and common NCDs such as hypertension and diabetes interact, or how medicines to treat them interact.

This is according to Dr Tolu Oni from the University of Cape Town, who is investigating the “collision” between HIV and NCDs.

“As people living with HIV are living longer, we are facing a new challenge. NCDs pose a new threat to people with HIV but there are many unanswered questions,” Oni told the international AIDS conference.

These questions include the extent of NCD co-infection, medicine interactions and how to co-diagnose and co-treat these.

Fattest nation

Aside from having the largest HIV population in the world, South Africa is the fattest nation on the continent.

Up to 70% of South African women and a third of men are overweight or obese, while a quarter of girls and one in five boys between the ages of 2 and 14 years are overweight or obese. Obesity is associated with type 2 diabetes, heart disease, stroke, hypertension, joint pain and certain cancers.

“Some NCDS are related to HIV infection itself and to the side effects of some of the medicines used to treat HIV infection,” according to UNAIDS. “Several of the opportunistic illnesses associated with HIV infection are NCDs in their own right, such as HIV-associated lymphoma and cervical cancer.”

Australian Professor Andrew Grulich reported that “the pattern of cancer and HIV is beginning to collide” as the population of people with HIV ages.

“There is an exponential increase in cancer as a person ages,” said Grulich.

A skin cancer called Kaposi’s Sarcoma was common in people with low immunity, but could be treated once a person was on ARVs. However, lymphoma was the most common cancer in people with HIV with mildly suppressed immunity, he said.

Californian epidemiologist Dr Melissa Frasco reported that two classes of ARVs were associated with an increase in diabetes, while “untreated HIV could lead to metabolic syndrome” (including obesity), which put patients at risk of heart attacks and strokes.

Supporting this, a Kenyan study has shown that HIV positive people who were not on treatment had significantly higher rates of hypertension than HIV negative people.

“Ageing with HIV is a huge issue in Europe, where people started ARV treatment earlier. Addressing this needs both a medical and psycho-social approach,” said Tamas Bereczky, who is both living with HIV and a researcher with the European AIDS Treatment Group. – Health-e News.

Show us the money for NCDs – draft health budget

Numbers don’t lie, especially if you take a look at the place of NCDs in the draft health budget. The words about NCDs imply commitment to solving a huge health problem.   That is superficial though when it comes to NCDs. There a heaps of great sounding words (policies and plans) but a clear lack of money. Especially for screening and treatment. Words, even printed ones, are cheap. Little has changed:

Whilst the Minister in the preamble of the Annual Performance Plan highlights importance of tackling non-communicable diseases (NCDs) there doesn’t appear to be any dramatic shift in budget allocation over the Medium Term. Can the department provide reasons for this?
Issues for consideration Parliament Research Unit. Vote15: Health Budget 2014/15 p.6

Health is allocated less than 5% of the proposed national budget (Figure 1). Defense get more yet SA loses more people to NCDs each day than in armed conflicts. Where are our national priorities?


Figure 1:

Looking at the details of the health budget

health budges

The smallest by far is Programme 4 for Primary Health Care (PHC) services (R 225 -million)
Most People Living With NCDs  get care at primary health care (PHC) clinics and this appears to be the reasoning why NCDs are placed within Prog 4 . People living with HIV/AIDS

Our information comes from the draft Annual Performance Plan (APP) and its accompanying budget.  – see pages 61-63. Click here to download the draft APP 2015/2016-2017/8

Fast facts stacking up Programme 4 vs other NDoH Programmes 2015/16

Smallest programme
budget by far
See Figure 2
1st place people costs Programme 4 cost of PEOPLE EMPLOYED R186.2 million = ↓ money available for implementation
2nd largest # people
458 by only 10 people short of no 1 placed Programme 1 (p. 27)
Only programme to increase personnel costs Leaving less to spend on implementing programmes/ plans

3 NCDs issues related to HIV/AIDS and Maternal Child health appear in Prog 3 budget (cancer cervix, breast cancer policy, immunizations.) Cancer of the prostate does not warrant a mention in the APP.
The key to the APP is words not allocation of funds. Again NCDs screening and treatment is left high and dry.

Fast facts about NCDs Prog 4 budget

Where is the money for implementation of the NCDs plan in this budget?

89.37%  for people working on projects – personnel, contractors and consultants
0           for screening of target of 8 million people for high BP and blood glucose OR
NCDs Commission/ Health Commission
(more next week on this)
1.3 %       NGOs or non-profits  (< R 3-million) > 50% goes to 2 of 6 NGOs
National Council Against Smoking & SA National Council for the Blind.

prog 4 sub prog allocation

NCDs prevention and treatment cross cuts all Programmes especially at the PHC level. So we need to look at inside other programmes. However, without exception there is no separate financial allocation for stated NCDs targets like for example breast cancer policy development and cancer of the cervix screening in Programme 3 (HIV/AIDS & TB.)  Innovations like “ideal clinics” which are supposed to include NCDs take place without consulting NCDs civil society organisations.

Examples from Programme 2: NHI

  • Drug procurement and stock out management (all drugs including ARVs)
  • National Cancer Registry (words no money)

Programme 3: HIV/AIDS & TB

  • Cervical cancer screening
  • Breast cancer policy (more words no money)
  • Vaccinations against hepatitis & human papilloma virus
  • Obesity policy (more words no money)

Watchdogs must bark. An NCDs advocacy series. This is the first in a series on NCDs in policy documents.

Quick summary: NCDs in the Department of Health Strategic Plan 2014/15 – 2018/9

A quick review of where issues related to NCDs may be found in the National Department of Health’s (NDoH’s) strategic plan 2014/15- 2018/19.

What is missing?

  • We might have been too quick and missed the National Health Commission. Can you find it? Please let us know if you do.

What is in it?

Page 13: NCDs burden of disease

Page 14: NDoH goal to prevent disease and reduce its burden, & promote health. Relate to National Development Plan goal 2030 ↓ prevalence of NCDs.

Page 19: Programme 2: NHI, planning & enablement

Develop and implement integrated monitoring & evaluation plan.

Sector-wide procurement very important for essential medicine and equipment access. EDL are revised on a 3 year cycle and available via book, web and cell phone application format available. The material is also peer reviewed. Medicines availability; a central chronic medicines dispensing and distribution network availability in order to improve access.

Page 24: Programme 3: HIV/AIDS, TB, Maternal & Child Health (includes child, youth and school Health sub-programme)

  • HPV target by 2018/19 = >70% coverage.
  • Strategic objective indicator cervical cancer screening 2013/14 baseline 55% coverage 2018/19 >70% coverage

Page 27: Primary health care (PHC) services (also includes district health services and communicable diseases.)

Health promotion subprogramme focus on implementing a mass mobilization strategy on healthy options.
NCDs subprogramme includes mental health focus points:

  • ↓ NCDs risk factors
  • ↑ health systems and services for the detection and control of NCDs
  • ↑ service delivery platform for PHC focused eye care, oral health, care of elderly, rehabilitation, disability and mental health
  • Mental health ↑ awareness of- & ↓ stigmatization by sectoral collaboration
  • ↑ services to prevent disability by co-ordinated interdisciplinary services
  • decentralised integrated PHC services at clinic, community and district hospital level.

Page 29 & 30: Indicators and targets (2018/19)

  • NCDs % ↓ of obesity. Target: ↓ by 10% men to 21% and women to 55%
  • No. people counselled & screened & for high blood pressure & raised blood glucose with 5 million people target. Baseline not available.
  • No. people screened & treated for mental disorders. Target: 35%  prevalent population
  • No. districts implementing the framework and model for rehabilitation services. Target: 52 districts implementing (draft framework and model available 2013/14)
  • Cataract surgery rate. Target: 1700 cataract surgeries per million uninsured population (increase from 1000 2013/14)

Page 30: Resource considerations.  The “spending focus (for this period)… will be on health promotion and the prevention of NCDs such as diabetes and hypertension.”

Page 31: Risk management Risk: under-resourced District Health System with mitigation strategy to ring fence the funding for district management and service provision.

Download the strategic plan: SA DoH Strategic Plan 2014 to 2019