Several HIV management efforts in African groups have developed differentiated service delivery models for people living with HIV who also have noncommunicable diseases, offering diagnostic and management strategies that can treat HIV patients holistically and address their range of health issues.
These efforts allow “countries with effective HIV programs to leverage lessons learned and best practices to enhance chronic noncommunicable disease” management, Miriam Rabkin, MD, said at the virtual meeting of the International AIDS conference. This approach aims to address the “growing prevalence of chronic noncommunicable diseases in low- and middle-income countries,” and the recognition that ”people living with HIV have the same or higher prevalence” of chronic noncommunicable diseases as that of others in the region where they live, said Dr. Rabkin, an epidemiologist at Columbia University in New York and director for health systems strengthening at ICAP, an international AIDS care program run at Columbia. The differentiated service delivery model derived from the premise that “one size does not fit all,” and that effective interventions must be “tailored” to the social and clinical circumstances of specific regions, she explained.
One program has focused on introducing more contemporary methods for diagnosing leukemias, lymphomas, and melanomas using flow cytometry at the Uganda National Health Laboratory Service in Kampala. This change in testing, which became available to patients starting in February 2019, has allowed diagnostics with fresh specimens that require minimal processing and results returned to referring physicians within 48 hours, a significant upgrade from the 1- to 4-week delay that was typical in the past, said Steven J. Kussick, MD, a hematopathologist and associate medical director of PhenoPath, a commercial pathology laboratory in Seattle.
The idea was to “leverage existing HIV laboratory capabilities to transform cancer diagnosis in sub-Saharan Africa,” he said during his talk at the conference. The flow cytometry approach allows an experienced pathologist like Dr. Kussick to diagnose clearcut cases in “5 seconds,” he said. The lab has already run specimens from more than 200 patients, and estimates an ability to handle specimens from about 250 patients per year at a total annual cost of roughly $60,000, an apparently sustainable operating model, said Dr. Kussick, who serves as a full-time consultant to the operation and was also instrumental in the 5-year process that created the diagnostic program. Future improvements planned for this program include bringing on-line a higher complexity diagnostic assay that’s closer to what is currently standard U.S. testing, digital imaging to facilitate consultation with remote experts, adding immunochemistry assays to allow diagnosis of solid tumors, and opening of a second laboratory in Kenya.
Another noncommunicable disease intervention in Africa that’s building on existing infrastructure for dealing with HIV infection is targeting hypertension, the most lethal risk factor globally for preventable deaths, said Jennifer Cohn, MD, senior vice president for cardiovascular health at the New York–based Resolve to Save Lives initiative. “We need to learn from what’s been done for HIV to rapidly incorporate and scale differentiated service models,” she said.
HIV and hypertension, along with diabetes, “are beginning to be recognized as ‘syndemics,’ ”synergistic pandemics, that need a holistic approach. A recent review of the topic reported that in the seven sub-Saharan countries with the highest HIV infection prevalence the percentage of adults with hypertension ranged from 20% to 24% (Curr Opin HIV AIDS. 2020 Jul;15[4]:356-60). Projections call for a “dramatic” increase in the prevalence of hypertension in both the general population and among people living with HIV, Dr. Cohn said.
As an example of the potential for combining HIV and antihypertensive care into a one-stop protocol, she cited a model program launched at Makarere University in Kampala, Uganda, that integrates HIV and antihypertensive treatment. Recent data from the program showed that among HIV-infected individuals 24% also had hypertension, and while the program lagged in putting only 28% of these hypertensive patients on a blood pressure-lowering regimen, more than three quarters of these patients on treatment successfully reached their goal blood pressure, proving the feasibility of the combined approach, Dr. Cohn said.
“Starting and scaling with differentiated service delivery models for noncommunicable diseases can help overcome barriers to uptake of care,” concluded Dr. Cohn. “As HIV cohorts age, we have to adapt and ensure we are providing quality, holistic care, including care for high impact noncommunicable diseases such as hypertension.”
Dr. Rabkin and Dr. Cohn had no disclosures.