Understanding the Intersecting Syndemics of Communicable and NonCommunicable
Understanding the Intersecting Syndemics of Communicable and Non-Communicable Diseases Emily P. Hyle, MD MSc Division of Infectious Diseases Massachusetts General Hospital Harvard Medical School #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Financial disclosures • I have no financial disclosures #AIDS 2018 | @AIDS_conference | www. aids 2018. org
HIV and TB are synergistic HIV Adapted from Tsai et al. Soc Sci Med 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org TB
Additional impact of diabetes (DM) DM HIV Adapted from Tsai et al. Soc Sci Med 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org TB
Influence of structural barriers to care DM HIV Economic instability Adapted from Tsai et al. Soc Sci Med 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org TB Food insecurity
Syndemics framework • Health conditions co-occur due to adverse social conditions and interact synergistically • A broad view of the challenges contributing to multimorbidity that includes social, behavioral, and biologic interactions Singer et al. Med Anthropol Q 2003; Singer et al. Lancet 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Road map 1. Challenges and successes of global HIV treatment scale-up 2. HIV co-exists with a wide range of other healthrelated issues 3. Syndemics framework suggests opportunities to maximize impact #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Road map 1. Challenges and successes of global HIV treatment scale-up 2. HIV co-exists with a wide range of other healthrelated issues 3. Syndemics framework suggests opportunities to maximize impact #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Challenges and successes in HIV/AIDS • 940, 000 AIDS-related deaths • 1. 8 million new infections – Rising HIV incidence in 50 countries UNAIDS Global AIDS Update 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Almost 60% of PWH on ART worldwide Antiretroviral therapy coverage (%) 100 80 ART coverage 60 40 20 0 00 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 0 2 2 2 2 2 UNAIDS Global AIDS Update 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Global HIV care cascade Percentage of people with HIV 100% 80% 75% 60% 59% 47% 40% 20% 0% Prevalent Diagnosed UNAIDS Global AIDS Update 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org Treated Controlled
Life expectancy of PWH on ART • In US, Canada, and Europe, a 20 yo PWH who achieves a CD 4 >350/μL within a year of starting ART can expect to live to 78 y • In South Africa, the difference in life expectancies between PWH and HIV-uninfected has shrunk to 1. 2 y for men and 5. 3 y for women ART-CC Lancet HIV 2017; Reniers et al. Lancet HIV 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
PWH with age-associated conditions PWH on ART have multimorbidity 60% 50% 40% 30% 20% 10% 0% 0 200 1 3 4 2 200 200 1 condition 2 conditions 5 6 200 3 conditions Wong et al. CID 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org 7 8 9 200 200 4+ conditions
Road map 1. Challenges and successes of global HIV treatment scale-up 2. HIV co-exists with a wide range of other healthrelated issues 3. Syndemics framework suggests opportunities to maximize impact #AIDS 2018 | @AIDS_conference | www. aids 2018. org
TB deaths have not declined steeply Millions of deaths per year 2 HIV deaths 1. 5 TB deaths in people without HIV 1 0. 5 TB deaths in people with HIV 0 2008 WHO Global Tuberculosis Report 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org 2016
TB care cascade in India Percentage of people with TB 100% 80% 60% 53% 45% 40% 20% 0% Prevalent Diagnosed Subbaraman et al. PLo. S Med 2016 #AIDS 2018 | @AIDS_conference | www. aids 2018. org Treated Controlled
Hepatitis deaths are rising worldwide Millions of deaths per year 2 1. 5 1 Hepatitis TB HIV 0. 5 0 2005 WHO Global Hepatitis Report 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org 2010 2015
Most common causes of deaths globally Ischaemic heart disease Stroke COPD Lower respiratory infections Dementias Trachea, bronchus, lung cancers Diabetes mellitus Road injury Diarrhoeal diseases Tuberculosis 0 1 2 3 WHO Global Health Estimates 2016 #AIDS 2018 | @AIDS_conference | www. aids 2018. org 4 5 6 7 Deaths (millions) 8 9 10
Most common causes of deaths globally Ischaemic heart disease Stroke COPD Lower respiratory infections Dementias Trachea, bronchus, lung cancers Diabetes mellitus Road injury Diarrhoeal diseases Tuberculosis 0 1 2 3 WHO Global Health Estimates 2016 #AIDS 2018 | @AIDS_conference | www. aids 2018. org 4 5 6 7 Deaths (millions) 8 9 10
High-income countries (GNI per capita > $12, 056) Ischaemic heart disease Stroke Dementias Trachea, bronchus, lung cancers COPD Lower respiratory infections Colon and rectum cancers Diabetes mellitus Kidney diseases Breast cancer 0 20 40 60 80 100 120 140 Crude death rate (per 100, 000 population) WHO Global Health Estimates 2016, World Bank 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
High-income countries (GNI per capita > $12, 056) Ischaemic heart disease Stroke Dementias Trachea, bronchus, lung cancers COPD Lower respiratory infections Colon and rectum cancers Diabetes mellitus Kidney diseases Breast cancer 0 20 40 60 80 100 120 140 Crude death rate (per 100, 000 population) WHO Global Health Estimates 2016, World Bank 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
High-income countries (GNI per capita > $12, 056) Ischaemic heart disease Stroke Dementias Trachea, bronchus, lung cancers COPD Lower respiratory infections Colon and rectum cancers Diabetes mellitus Kidney diseases Breast cancer Upper middle-income countries (GNI per capita $3, 896 -$12, 055) Ischaemic heart disease Stroke COPD Trachea, bronchus, lung cancers Dementias Lower respiratory infections Diabetes mellitus Road injury Liver cancer Stomach cancer 0 20 40 60 80 100 120 140 Crude death rate (per 100, 000 population) Lower middle-income countries (GNI per capita $966 -$3, 895) Ischaemic heart disease Stroke Lower respiratory infections COPD Tuberculosis Diarrhoeal diseases Diabetes mellitus Preterm birth complications Cirrhosis of the liver Road injury 0 20 40 60 80 100 120 140 Crude death rate (per 100, 000 population) WHO Global Health Estimates 2016, World Bank 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org 0 20 40 60 80 100 120 140 Crude death rate (per 100, 000 population)
High-income countries (GNI per capita > $12, 056) Ischaemic heart disease Stroke Dementias Trachea, bronchus, lung cancers COPD Lower respiratory infections Colon and rectum cancers Diabetes mellitus Kidney diseases Breast cancer Upper middle-income countries (GNI per capita $3, 896 -$12, 055) Ischaemic heart disease Stroke COPD Trachea, bronchus, lung cancers Dementias Lower respiratory infections Diabetes mellitus Road injury Liver cancer Stomach cancer 0 20 40 60 80 100 120 140 Crude death rate (per 100, 000 population) 0 Lower middle-income countries (GNI per capita $966 -$3, 895) Ischaemic heart disease Stroke Lower respiratory infections COPD Tuberculosis Diarrhoeal diseases Diabetes mellitus Preterm birth complications Cirrhosis of the liver Road injury 20 40 60 80 100 120 140 Crude death rate (per 100, 000 population) Low-income countries (GNI per capita ≤ $995) Lower respiratory infections Diarrhoeal diseases Ischaemic heart disease HIV/AIDS Stroke Malaria Tuberculosis Preterm birth complications Birth trauma Road injury 0 20 40 60 80 100 120 140 Crude death rate (per 100, 000 population) WHO Global Health Estimates 2016, World Bank 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org 0 20 40 60 80 100 120 140 Crude death rate (per 100, 000 population)
Pollution is a major contributor to mortality Global estimated deaths (millions) 10 8 6 4 2 0 Total pollution Tobacco smoking AIDS, malaria, and TB Alcohol use Malnutrition Road (child and accidents maternal) Landrigan et al. Lancet 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org Drug use War and murder (2015) Ebola (2015)
Too many deaths from tobacco Global estimated deaths (millions) 10 8 6 4 2 0 Total pollution Tobacco smoking AIDS, malaria, and TB Alcohol use Malnutrition Road (child and accidents maternal) Landrigan et al. Lancet 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org Drug use War and murder (2015) Ebola (2015)
Tobacco use increases mortality • Increased risk of TB, cancers, COPD, CVD, and stroke • In 2015, 6. 4 million deaths (11. 5%) were attributable to smoking worldwide • In Asia, 2 million deaths of adults 45 years or older were attributable to smoking in 2014 – 19. 1% of all deaths in Asia that year GBD 2015 Tobacco Collaborators Lancet 2017; Zheng et al. PLo. S Medicine 2014 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Impact of tobacco on PWH mortality Life expectancy (men) 80. 0 -X Never smokers Age in years Former smokers Current smokers -1. 0 75. 0 70. 0 =Years of life lost, compared to never smokers 71. 9 70. 9 65. 0 -6. 7 65. 2 60. 0 Enter care at age 40 Reddy et al. JID 2016 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Cancer cases are increasing worldwide 28% more cancer cases in 2016 compared to 2006 Global Burden of Diseases Cancer Collaboration JAMA Oncology 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Disparities in cancer deaths Cancer deaths are rising in LMIC Global Burden of Diseases Cancer Collaboration JAMA Oncology 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Diabetes prevalence worldwide is rising Number of adults with diabetes (millions) 500 400 300 Europe US Latin America Asia Middle East Africa 200 100 0 1985 1990 1995 NCD Risk Factor Collaboration Lancet 2016 #AIDS 2018 | @AIDS_conference | www. aids 2018. org 2000 2005 2010 2014
Diabetes care cascade in South Africa Percentage of people with diabetes 100% 80% 60% 55% 40% 38% 20% 19% 0% Prevalent Screened Diagnosed Stokes et al. PLo. S One 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org Treated Controlled
Diabetes care cascade in the US Percentage of people with diabetes 100% 80% 72% 60% 40% 20% 0% Prevalent Diagnosed Ali et al. Ann Int Med 2014 #AIDS 2018 | @AIDS_conference | www. aids 2018. org Controlled
Hypertension leads to serious disease Kidney disease Stroke CVD Hypertension #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Hypertension prevalence globally Number of hypertensives (millions) 300 Men Women 250 200 150 100 50 0 East Asia and Pacific Europe Central Middle East and and Central Asia South America North Africa Mills et al. Circulation 2016 #AIDS 2018 | @AIDS_conference | www. aids 2018. org South Asia Sub-Saharan Africa
Hypertension care cascade in Malawi Percentage of people with hypertension 100% 80% 60% 56% 40% 42% 29% 20% 11% 0% Prevalent Screened Diagnosed Price et al. Lancet Diabetes Endocrinol 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org Treated Controlled
Depression care cascade in the US Percentage of people with depression 100% 80% 60% 47% 40% 24% 20% 6% 0% Prevalent Diagnosed Pence et al. Curr Psychiatry Rep 2012 #AIDS 2018 | @AIDS_conference | www. aids 2018. org Treated Controlled
Care cascades must be improved Percentage of people with disease 100% HIV Tuberculosis Diabetes Hypertension Depression 80% 69 60% 60 47 40% 40 44 45 40 28 20% 53 53 22 24 19 9 6 0% Prevalent Diagnosed #AIDS 2018 | @AIDS_conference | www. aids 2018. org Treated Controlled
Strengthening health systems is essential • Tobacco use, diabetes, hypertension, and depression have intervenable targets to improve outcomes and quality of life • As a model of chronic disease treatment, global HIV care suggests innovations to increase diagnosis, linkage, treatment, and retention #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Medications are too often not available Availability of anti-hypertensives 100% 98 98 97 94 95 87 87 80% 86 79 72 71 60% 72 61 47 40% 40 20% 13 0% High income Upper middle income ≥ One ≥ Two Lower middle income ≥ Three Attaei et al. Lancet Public Health 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org Four Low income
Medications are too often not available Availability of anti-hypertensives 100% 98 98 97 94 95 87 87 80% 86 79 72 71 60% 72 61 47 40% 40 20% 13 0% High income Upper middle income ≥ One ≥ Two Lower middle income ≥ Three Attaei et al. Lancet Public Health 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org Four Low income
Households unable to afford medication Medications are often not affordable 100% One anti-hypertensive Two anti-hypertensives 80% 80 Two plus metformin and statin 60% 39 40% 31 0% 25 19 20% 0 0 1 High income 3 6 12 Upper middle income Attaei et al. Lancet Public Health 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org 31 5 6 11 Lower middle income 17 Low income
Households unable to afford medication Medications are often not affordable 100% One anti-hypertensive Two anti-hypertensives 80% 80 Two plus metformin and statin 60% 39 40% 31 0% 25 19 20% 0 0 1 High income 3 6 12 Upper middle income Attaei et al. Lancet Public Health 2017 #AIDS 2018 | @AIDS_conference | www. aids 2018. org 31 5 6 11 Lower middle income 17 Low income
Road map 1. Challenges and successes of global HIV treatment scale-up 2. HIV co-exists with a wide range of other healthrelated issues 3. Syndemics framework suggests opportunities to maximize impact #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Syndemics worsen health outcomes • An increase in the number of “syndemic risk factors” has been associated with worse outcomes • Can we use the syndemics framework to generate innovative solutions that leverage these synergies? Friedman et al. AIDS 2015; Byg et al. J Community Health 2016; Tomori et al. Soc Sci Med 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Syndemics: platform for innovation DM HIV Economic instability Adapted from Tsai et al. Soc Sci Med 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org TB Food insecurity
Cash transfers DM HIV Economic instability Adapted from Tsai et al. Soc Sci Med 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org TB Food insecurity
Decrease economic instability & food insecurity DM HIV Economic instability Adapted from Tsai et al. Soc Sci Med 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org TB Food insecurity
Improve diagnosis, treatment, retention DM HIV Economic instability Adapted from Tsai et al. Soc Sci Med 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org TB Food insecurity
Prevent new cases & reduce illness and death DM HIV Economic instability Adapted from Tsai et al. Soc Sci Med 2018 #AIDS 2018 | @AIDS_conference | www. aids 2018. org TB Food insecurity
Turning ideas into reality • Syndemics framework is a theoretical structure to consider real-life challenges but requires ongoing research and outreach to understand synergies better: – Qualitative assessment regarding needs and barriers – Measurements of outcomes: HIV and TB, and also other health outcomes causing morbidity and death – Innovative health care delivery for scale up and sustainability that target syndemics #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Conclusions • HIV is one among many major health issues; PWH face multimorbidities intertwined with the health of all • Innovative approaches are essential to address communicable and non-communicable diseases • Syndemics highlight opportunities to address underlying needs by targeting high-impact synergies #AIDS 2018 | @AIDS_conference | www. aids 2018. org
Thank you Ingrid Bassett, MD MPH Linda-Gail Bekker, MBCh. B Ph. D Andrea Ciaranello, MD MPH Sydney Costantini Caitlin Dugdale, MD Simone Frank Kenneth Freedberg, MD MSc Louise Ivers, MD Elena Losina, Ph. D Emily Martey Lucia Millham Anne Neilan, MD MPH Robert Parker, Sc. D Krishna Reddy, MD Justine Scott, MPH Madeline Stern Alexander Tsai, MD Rochelle Walensky, MD MPH Milton Weinstein, Ph. D Acknowledgments: National Institutes of Health (K 01 HL 123349) Our fight against HIV and AIDS is indebted to people living with HIV both past and present #AIDS 2018 | @AIDS_conference | www. aids 2018. org
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