Peter Lamptey

The Global HIV/AIDS Pandemic

Progress has been achieved in reducing the spread of HIV infection in some developing countries. Certain populations in industrialized countries are also showing a decline in HIV incidence. However the HIV epidemic continues to spread in most developing countries as well as in European countries undergoing political stress and upheaval. Aggravating the issue is the increase of the social economic demographic and health impacts of the epidemic. In developing countries a spread of HIV in young adults adolescents and children is noted; while HIV is found to be increasing in the minority populations of industrialized countries. Heterosexual transmission extensive commercial sex industries the high prevalence of sexually transmitted diseases and injecting drug use provide the potential for explosive epidemics in several countries. Globally the HIV/AIDS pandemic is composed of multiple epidemics in different stages of development that have become increasingly diverse and fragmented each with their own features.

Global prevention and control of NCDs: Limitations of the standard approach.

The five-target ‘25 × 25’ strategy for tackling the emerging global epidemic of non-communicable diseases (NCDs) focuses on four diseases (CVD, diabetes, cancer, and chronic respiratory disease), four risk factors (tobacco, diet and physical activity, dietary salt, and alcohol), and one cardiovascular preventive drug treatment. The goal is to decrease mortality from NCDs by 25 per cent by the year 2025. The ‘standard approach’ to the ‘25 × 25’ strategy has the benefit of simplicity, but also has major weaknesses. These include lack of recognition of: (i) the fundamental drivers of the NCD epidemic; (ii) the ‘missing NCDs’, which are major causes of morbidity; (iii) the ‘missing causes’ and the ‘causes of the causes’; and (iv) the role of health care and the need for integration of interventions.

Informing the 2011 UN Session on Noncommunicable Diseases: Applying Lessons from the AIDS Response

In advance of the September 2011 UN Summit on non-communicable diseases (NCDs), Rebecca Dirks and colleagues identify lessons from the AIDS epidemic that can inform the response to the growing epidemic of NCDs.

The path to longer and healthier lives for all Africans by 2030: the Lancet Commission on the future of health in sub-Saharan Africa.

Sub-Saharan Africa’s health challenges are numerous and wide-ranging. Most sub-Saharan African countries face a double burden of traditional, persisting health challenges, such as infectious diseases, malnutrition, and child and maternal mortality, and emerging challenges from an increasing prevalence of chronic conditions, mental health disorders, injuries, and health problems related to climate change and environmental degradation. Although there has been real progress on many health indicators, life expectancy and most population health indicators remain behind most low-income and middle-income countries in other parts of the world. Our Commission was prompted by sub-Saharan Africa’s potential to improve health on its own terms, and largely with its own resources. The spirit of this Commission is one of evidence-based optimism, with caution. We recognise that major health inequities exist and that health outcomes are worst in fragile countries, rural areas, urban slums, and conflict zones, and among the poor, disabled, and marginalised. Moreover, sub- Saharan Africa is facing the challenges and opportunities of the largest cohort of young people in history, with the youth population aged under 25 years predicted to almost double from 230 million to 450 million by 2050. The future of health in Africa is bright, but only if no one is left behind.

Towards a comprehensive global approach to prevention and control of NCDs

BackgroundThe “25×25” strategy to tackle the global challenge of non-communicable diseases takes a traditional approach, concentrating on a few diseases and their immediate risk factors.DiscussionWe propose elements of a comprehensive strategy to address NCDs that takes account of the evolving social, economic, environmental and health care contexts, while developing mechanisms to respond effectively to local patterns of disease. Principles that underpin the comprehensive strategy include: (a) a balance between measures that address health at the individual and population level; (b) the need to identify evidence-based feasible and effective approaches tailored to low and middle income countries rather than exporting questionable strategies developed in high income countries; (c) developing primary health care as a universal framework to support prevention and treatment; (d) ensuring the ability to respond in real time to the complex adaptive behaviours of the global food, tobacco, alcohol and transport industries; (e) integrating evidence-based, cost-effective, and affordable approaches within the post-2015 sustainable development agenda; (f) determination of a set of priorities based on the NCD burden within each country, taking account of what it can afford, including the level of available development assistance; and (g) change from a universal “one-size fits all” approach of relatively simple prevention oriented approaches to more comprehensive multi-sectoral and development-oriented approaches which address both health systems and the determinants of NCD risk factors.SummaryThe 25×25 is approach is absolutely necessary but insufficient to tackle the the NCD disease burden of mortality and morbidity. A more comprehensive approach is recommended.

Do the benefits of breastfeeding outweigh the risk of postnatal transmission of HIV via breastmilk

Conflicting recommendations have been offered about whether HIV+ mothers should breastfeed. Since there is a strong precedent for US infant feeding practices to be imitated in developing countries, a model was constructed to estimate infant mortality if the CDC admonition for HIV + mothers not to breastfeed were upheld in less developed settings. Estimates are given for infant mortality in the presence and absence of breastfeeding across several baseline levels of infant mortality and across several theoretical rates of transmission through breastfeeding. The infant mortality associated with HIV infection acquired through breastfeeding is estimated to be lower than the mortality associated with the diseases of infancy that would result if breastmilk were withheld. The difference in these estimates is greater in areas with high baseline levels of infant mortality.

An Overview of Aids Interventions in High-Risk Groups: Commercial Sex Workers and Their Clients

Although the epidemiological features of the AIDS epidemic vary throughout the world, HIV infection has followed a set pattern (1). Initially, HIV infection is introduced into a relatively small group of people who are at most risk of getting infected because of their behavior. This group spreads the infection to other groups. In time, the epidemic is a risk to everyone in the population.

Addressing the growing burden of non-communicable disease by leveraging lessons from infectious disease management.

In recent decades, low– and middle–income countries (LMICs) have achieved decreased morbidity and mortality associated with infectious diseases and poor maternal– and child–health (MCH). However, despite these advances, LMICs now face an additional burden with the inexorable rise of non–communicable diseases (NCDs). Deaths due to NCDs in LMICs are expected to increase from 30.8 million in 2015 to 41.8 million by 2030 [1]. While improvements in life expectancy, lifestyle and urbanisation go some way to explaining why more people in LMICs are affected by NCDs, it is less clear why these populations are contracting NCDs at a younger age and with worse outcomes than in high–income countries (HICs) [2]. Despite having a lower cardiovascular disease risk factor burden, LMIC populations have a four–fold higher mortality rate from cardiovascular events than HIC populations [3] in part due to a lack of access to quality, integrated health services and the poor availability of early interventions and effective NCD prevention programmes. The HIV/AIDS epidemic was the last time the world confronted a global health challenge that so disproportionately caused premature adult deaths in LMICs. The conclusion is unavoidable: the time to act is now. Prevention of NCDs at a population and an individual level is key and requires policy and structural changes. We have a unique opportunity to learn from the successes of infectious disease control programmes in LMICs and leverage these to address the growing NCD burden. Translatable learnings include: 1) emphasizing primary prevention, particularly in those at highest risk; 2) targeting service delivery to high–risk populations; 3) enabling access to adequate, affordable care at community level; 4) engendering patient empowerment and involving people affected by chronic conditions; 5) enabling access to quality drugs and adherence programmes; 6) regularly measuring the effectiveness and impact of programmes to ensure their appropriateness and improvement; and 7) creating an environment of health financing for universal coverage. Innovations to counter the emerging NCD epidemic must encompass both prevention and the delivery of care. Infectious disease programmes have used task–shifting, where less skilled health workers and community members are involved in delivery of health services. In India, we have seen this used for NCDs in the Arogya Kiran model where the existing health workforce was overstretched. Volunteers and teachers successfully delivered diabetes and hypertension screening and management to over 600 000 people [4]. Patient empowerment, and community involvement in health care delivery and governance, will be critical in tackling NCDs, since most are chronic conditions, which initially present silently and require long–term management [5]. In Malawi, recognizing the close relationship of HIV infection and cardiovascular diseases has led to screening for hypertension being integrated into HIV care [6]. In Ghana, decentralised community–based hypertension care, using digital technology, is helping to empower patients to manage their own disease: a model that is again adapted from HIV management [7]. We are also starting to see examples in India of MCH care coupled with life–long NCD screening and awareness programmes [8]. While these examples of managing the dual burden of infectious diseases and NCDs are encouraging, more needs to be done. The largest gap is in NCD prevention. Tackling the obesity epidemic and wrestling with the issues around curbing tobacco sales and smoking are rightly high on the NCD prevention agenda. The greatest opportunity is preventing a tobacco–related epidemic in sub–Saharan Africa where smoking levels are still low. Health budgets and development assistance for health must allocate resources commensurate with the dual disease burden. Health spending of governments in LMICs has tripled over the past 20 years, but remains low [9]. In addition, more health care models should consider diversified revenue streams or hybrid financing (eg, tiered payment schemes) to ensure sustainability. If equity is to be improved, patients need access to quality health care, through sustainable health–financing systems for universal health coverage, while reducing out–of–pocket expenditure for the under–served population. Photo:

Building on the AIDS response to tackle noncommunicable disease.

In September 2011, world leaders at the first-ever UN High-Level Meeting on Non-Communicable Diseases unanimously approved a Political Declaration to stem a rising tide of noncommunicable diseases (NCD), now the world’s leading killer [1]. This declaration called for governments, industry, and civil society to develop multipronged plans to curb the risk factors behind the four main NCD: cardiovascular diseases; cancers; chronic respiratory diseases; and diabetes [2]. The document highlighted the need for universal national health coverage and called for strengthened international cooperation to provide technical assistance and capacity-building to developing countries to effectively tackle NCD. The rising global burden of NCD requires an urgent response to prevent new disease, manage existing morbidities, and control the devastating health, social, and economic impacts. Particularly troubling is that lowand middle-income countries (LMIC) are disproportionally affected by NCD. Approximately 80% of NCD deaths occur in LMIC, and in many cases, these countries are facing a continuing burden of infectious disease [3]. There is an urgent need for programs to specifically provide evidence-based primary and secondary prevention of NCD risk factors, deliver accessible and affordable clinical care for NCD, and mitigate the impact of the NCD burden. The complex and multidisciplinary aspects of NCD will require a comprehensive coordinated multisectoral response.

HIV Prevention for the General Population

This paper discusses interventions that are primarily directed at reaching large segments of the general population. These include mass education campaigns improvement of sexually transmitted infections STI/HIV services social marketing programs and contextual interventions. Qualitative and quantitative evaluations were conducted for each of these programs. Overall results showed that mass media campaigns focusing on education/information exchange can increase levels of knowledge and programs presenting real-life situations can contribute to behavior change. Improved HIV/sexually transmitted infections (STIs) services for the general population are also known to be effective in reducing STI and HIV and to complement behavior change interventions. In addition interpersonal communication provided by well trained or outreach workers can facilitate and support behavior change. Active promotion of condoms can be acceptable within all environments. Finally prevention programs take place in a specific cultural social and economic situation and success can be facilitated by creating an enabling environment through legal action engaging gatekeepers and changing cultural and social norms.