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HIV/AIDS treatment must lead transformation of primary health care
Keith Alcorn, AIDSmap
September 16, 2008

http://www.aidsmap.com/en/news/B4BAECF1-98DE-4031-9A17-DE08EB158FBC.asp

The scaled-up delivery of antiretroviral drugs through primary healthcare offers an important opportunity for health care systems to manage the transition towards caring for people with chronic i llnesses as populations age and cancers and cardiovascular disease become more common, according to the authors of a South African study looking at causes of death over 13 years in rural South Africa. The study, published in the September 13th edition of The Lancet, shows a two-and-a-half-fold increase in health problems requiring chronic long-term care, a six-fold increase in deaths from infectious diseases (predominantly AIDS and TB) and a doubling of deaths due to cancer in those over 65 years old.

The authors of the study, from the University of Witwatersrand School of Public Health in Johannesburg, say that rural communities in South Africa are now going through a health transition already witnessed in urban areas, with hypertension and cardiovascular problems becoming the predominant causes of illness and death in older people. Unless health systems in sub-Saharan Africa can harness the opportunity of scaling up antiretroviral therapy to develop a primary healthcare sector that can cope with managing chronic conditions, they argue, long-term population health will suffer and health services will continue to deteriorate.

In an accompanying comment article Professor Hoosen Coovadia of the University of Kwazulu-Natal and Ruth Bland of the Africa Centre note that the "burden of non-communicable diseases will be further uncovered as scaled-up treatment programmes lead to reduced mortality from HIV/AIDS." The findings come at a critical time for HIV treatment scale-up and health systems in southern Africa, as some argue that too much attention has been paid to HIV treatment and that investments in HIV are undermining other health system priorities such as child mortality.

AIDS advocates on the other hand have argued that investment in a primary care system that can deliver antiretroviral drugs will be essential in order to achieve universal access to HIV treatment and care, since hospitals are inaccessible to many people with HIV, especially in rural areas. Researchers from the MRC/Wits Rural Public Health and Health Transitions Research Unit analysed death records from the Agincourt health district in Limpopo province, a rural district close to the Mozambique border. The research programme has been tracking health trends in the area since 1992. Like all parts of South Africa the district has seen a substantial decline in life expectancy due to HIV/AIDS since 1992 (a 12-year decline in women and a 14-year decline in men).

When the researchers compared all-cause mortality across four periods (1992-94, 1995-97, 1998-2001, 2002-2005) they found a significant increase in deaths through infectious disease and a significant increase in the utilisation of all forms of health care. However, the use of chronic care - health care lasting more than one month or care for an incurable illness - had expanded substantially more than the need for acute care (relative change 2.63-fold, p < 0.0001). That increase in chronic care utilisation was driven chiefly by HIV/AIDS, which was the most common cause of death in adults aged 15-64 from 1995 onwards, and the most common cause of infant mortality from 1998 onwards.

By 2002-2005 no other cause came close to HIV/AIDS as an explanation for death in the district. In those aged 50-64 for example, HIV and tuberculosis caused four times as many deaths as vascular disease during that period, accounting for 28% of all deaths, and more deaths in that age group than all forms of cardiovascular disease and other non-communicable diseases put together. In infants aged 0-4, HIV and tuberculosis caused more deaths than diarrhoea, acute respiratory infection, malnutrition and perinatal disorders combined, accounting for 34% of infant deaths.

Nevertheless, deaths from non-communicable diseases such as cancer and cardiovascular disease did rise during the entire study period, both as a proportion of all deaths and in absolute numbers, and the increase was statistically significant in those over 30 (relative risk 1.22, p = 0.026). The researchers note that complementary research in the district has shown a variety of indicators of rising cardiovascular risk in the population aged 35 and over. More than two-fifths of adults aged over 35 have hypertension, the mean body mass index is 27.2 in women over 35, and there is substantial evidence of sub-clinical peripheral atheroma in this age group, all portending a growing burden of ischaemic heart disease in decades to come as the Agincourt district completes a health transition towards an increasingly urban disease profile.

The researchers go on to highlight the fact that despite the AIDS epidemic in sub-Saharan Africa, the number of people aged 60 and over is expected to grow from 34 million in 2005 to over 67 million in 2030 - higher than the expected growth rate in developed countries. How will this generation, already over-burdened by caring for children and grandchildren with AIDS, cope with diabetes, hypertension, cardiovascular disease, cancer and other chronic health problems if health systems have not adapted to a chronic healthcare model, they ask?

Efforts to scale up antiretroviral treatment in order to reduce mortality could paradoxically accelerate this health systems crisis by prolonging lives. People living with successfully treated HIV might eventually die of non-communicable diseases.

"Public health leadership is at a crossroads," the authors say, noting that exploiting the potential of antiretroviral treatment scale-up to strengthen health systems will need a different outlook from health service leaders and donors, as well as sustained efforts to achieve full integration of efforts at the primary healthcare level.

Accompanying articles in a special edition of The Lancet focus on the international movement to revitalise primary health care along the lines first agreed in the 1978 Alma-Ata 'Health for All' declaration, which envisaged an international move towards community-level health care i n the context of a wider push for development in the poorer nations of the world. The primary healthcare movement was undermined by the growing trend of the 1980s and 1990s towards neo-liberal economic policies that cut public services, imposed user fees and hiring freezes on health systems and led to significant growth in poverty and inequity in developing countries.

In order to revitalise primary health care and make the Alma-Ata goals a reality, say an international group of health systems experts writing in the same edition of The Lancet, health service infrastructure must be strengthened, community health worker cadres linked to primary health care need to be developed and a continuum of care needs to emerge, based on evidence of successful interventions. Investment in implementation research is essential, and should be embedded in the emerging integrated primary healthcare systems so that results inform local planning and development.

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