The new epidemic of non-communicable disease in people living with the human immunodeficiency virus [Perspective

Abstract

The global focus on human immunodeficiency virus (HIV) infection in recent years has been on improving access to antiretroviral therapy (ART). World Health Organization (WHO) statistics indicate that in countries such as South Africa, Bangladesh, India and Malaysia, the uptake of ART is increasing rapidly. In South Africa, the country with the highest number of people globally on ART, the South African strategic plan on HIV has adopted a broad 20-year vision that at least 80% of eligible patients will be initiated on ART within this period.1 In 2007, the WHO estimated that 5.7 million people in South Africa were living with HIV. By the end of that year, only 27% of those eligible to receive ART had been commenced on antiretrovirals. Since then there has been significant scale-up in treatment, and by latest estimates, despite the introduction of a higher ART CD4 entry point of 350 cell/mm3, some 55% of eligible people are now on ART.2 This favourable situation in South Africa is not unique; it reflects the increasing coverage in ART in Latin America, the Caribbean and South-East Asia.2 The successful scale-up of ART has resulted in new challenges, including sustaining large numbers of people on treatment, ensuring high volume drug supplies and meeting the huge costs of treatment.3 The initial dire course of HIV disease has been modified, and millions of people in low- and middle-income countries are now able to live longer. However, living longer with HIV infection exposes patients to a new set of health issues. Opportunistic infections decrease on ART, but the potential for diseases of ageing, lifestyle-related disease and other non-communicable diseases (NCDs) increases. There is currently a global move to identify and target NCDs, which include cancers, chronic respiratory disease, heart disease, stroke and diabetes.4 This new approach was discussed at the recent United Nations high-level meeting on NCDs.5 It is evident that the majority of deaths related to these diseases occur in low- and middle-income countries. A recent positive step was the undertaking at the 65th World Health Assembly to target a 25% reduction in mortality due to NCDs by 2025 in all 194 member states.6 Interventions to help reach these targets include lifestyle modification, dietary interventions, smoking cessation and tobacco control. Considerable effort to achieve this goal will be required, from health policy makers and global advisory bodies to delivery at clinic level through non-governmental stakeholders and national policy roll-outs.