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HIV & AIDS Treatment in Practice
Issue 206 | 10 October 2013
In this issue:
Multi-disease prevention campaigns (part 1): integrating
HIV into wider public health campaigns; by Keith Alcorn page 2
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Key points
The need for comprehensive responses and more cost-efficient delivery
Vertical programmes or integrated disease campaigns?
Integrated disease campaigns: beyond HIV
Schistosomiasis, helminth interventions and HIV
Malaria and HIV
Waterborne infectious diseases and HIV
What is the difference between a campaign and a programme?
Putting it all together
Possible elements in integrated disease campaigns
Cost-effectiveness
Campaigns – the future
Conclusion
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HATiP | Issue 206 | 10 October 2013
Multi-disease prevention
campaigns (part 1):
integrating HIV into wider
public health campaigns
By Keith Alcorn
Key points
targets to achieve rapid increases in the coverage of
• Ambitious
HIV counselling and testing, and of antiretroviral therapy, require
•
•
•
•
•
•
•
•
•
innovative approaches to reaching people.
Offering HIV counselling and testing as part of larger public
health campaigns has shown promising potential in two
multi-disease prevention campaigns in western Kenya and
Uganda.
Integration of disease prevention campaigns has the potential to
save money and maximise the value of public health
investments.
Several neglected tropical diseases are already addressed
through integrated treatment campaigns, demonstrating that a
variety of disease control areas can work together successfully.
Integrated disease prevention campaigns are likely to have the
greatest impact when they tackle diseases that are synergistic,
such as malaria and HIV. These synergistic effects are likely to
vary according to the epidemiology of HIV, malaria and neglected
tropical diseases.
Integrated disease prevention campaigns may attract community
interest through the distribution of prevention commodities such
as mosquito nets and water filtration equipment. Campaigns
which offer testing for health conditions identified as local health
priorities by the community can also attract a high level of
community interest.
Both approaches have been proven to result in very high uptake
of HIV counselling and testing in rural areas, and diagnosis of
people living with HIV much earlier in the disease course.
Design of integrated disease prevention campaigns requires
community involvement in the setting of priorities to ensure
successful community mobilisation.
Integrated disease prevention campaigns offer an opportunity to
expand testing and linkage to care for non-communicable
diseases, as well as for HIV. Synergies between infectious
diseases and non-communicable diseases, such as between
diabetes and tuberculosis, may be worth exploring.
Male medical circumcision, syphilis screening and cervical
cancer screening are already being considered as elements of
future integrated disease prevention campaigns.
Reviewed by Gabriel Chamie, Vivek Jain (University of California
San Francisco), Reuben Granich (UNAIDS), Alexandre Doyen
(Vestergaard Frandsen) and Judd Walson (University of
Washington, Seattle).
This edition of HATIP was kindly supported by Vestergaard
Frandsen.
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tel +44 20 7837 6988 fax +44 20 7923 5949 email [email protected] web www.aidsmap.com
page 2
Ambitious targets to scale up the coverage of HIV counselling and
testing, and antiretroviral therapy, will require innovations in many
aspects of healthcare delivery. This edition of HATIP examines the
concept of multi-disease prevention campaigns which target a range
of public health issues in a concentrated burst of activity in a
locality.
The need for comprehensive responses and more
cost-efficient delivery
As international donor spending on health continues to be squeezed
there is growing pressure from donors for health programmes to
demonstrate greater returns on investment. In part this reflects the
growing difficulty that many governments face in justifying overseas
aid at a time of domestic budget cuts. But it also reflects the
recognition that past investments often missed opportunities for
action, and that the previous emphasis on rapid achievement of
disease-specific targets may have occurred at the expense of a
co-ordinated approach to health.
“Integrated disease prevention campaigns can reduce the costs
to donors while doing more with the money,” said Erin Bendavid of
Stanford University at an AIDS 2012 satellite meeting on integrated
campaigns.
Note the shift in emphasis: Bendavid is talking about “disease
prevention” rather than HIV or TB treatment campaigns. In the HIV
field the growing emphasis on earlier access to testing and
treatment including 'test and treat', which aims to diagnose large
numbers of people and link these people to treatment and care
before they become severely ill, has fundamentally altered the
terms of the debate for low- and middle-income countries. The new
2013 World Health Organization guidelines recommend a move
towards earlier treatment at CD4 counts below 500, yet many
people with HIV continue to be diagnosed in clinical settings at low
CD4 cell counts as a result of presentation with clinical disease.
Prevention of HIV disease requires earlier treatment, as does
prevention of transmission. To reach people long before they
become sick, and to minimise onward transmission, earlier HIV
diagnosis requires more systematic approaches to making HIV
testing available in the community, outside clinical settings.
A recently published systematic review and meta-analysis of
community-based approaches to HIV testing and counselling found
that a range of approaches achieved a high rate of testing and
linkage to care, as well as diagnosing people at higher CD4 counts.1
These approaches included door-to-door testing, mobile testing
and site-specific testing at churches, workplaces and schools.
Door-to-door testing achieved an average uptake of 80%, so it is
clearly an effective strategy for achieving a good uptake of voluntary
counselling and testing, but is it the most cost-effective use of
resources?
A recent comparison of the costs of four different approaches to
HIV counselling and testing found costs-per-client (2007 USD) of
$19.26 for stand-alone HIV counselling and testing, $11.68 for
hospital-based counselling and testing, $13.85 for
household-member counselling and testing, and $8.29 for
door-to-door counselling and testing.2
So, door-to-door counselling and testing compares favourably
with the cost of other methods of offering HIV testing, but there are
other considerations regarding cost-efficiency. An integrated
disease prevention campaign in western Kenya was able to deliver
HATiP | Issue 206 | 10 October 2013
HIV counselling and testing, condoms, and CD4 cell testing for all
persons diagnosed HIV positive, at a cost-per-client of USD12.35
(this cost would fall to USD9.91 if the campaign was scaled up, the
researchers estimated).3 Furthermore, the campaign reached 83%
of eligible adults in the district in seven days, a very high level of
coverage that would not be achievable for door-to-door testing
without a substantially increased investment in community health
workers to carry it out.
A further limitation of single-disease campaigns relates to
incentives and risk perception. People need to be aware that they
are at risk in order to seek a diagnosis, and in the case of HIV, high
levels of awareness in the population may mask widespread
assumptions that HIV is something that happens to other people, or
to those in other places, and that absence of illness is proof of good
health. The stigma attached to HIV infection and the fear of an HIV
diagnosis may also discourage people from testing or from being
seen to seek testing.
On the other hand, people may be encouraged to learn their HIV
status as a result of free testing for high blood pressure (which may
be a paradoxical badge of higher economic status), or by the
distribution of long-lasting insecticide-treated nets to protect their
families, to give just two examples.
Finally, single-disease campaigns are unlikely to prove a viable
way of expanding access to antiretroviral treatment through testing
for the 28 million people who need it. Approaches to disease
prevention which keep diseases in separate silos fail to achieve
economies of scale and keep disease areas in competition, forcing
policy makers to choose between HIV, TB, malaria, neglected
tropical diseases, rather than exploring ways of using investments to
tackle all these areas.
“Multi-disease prevention campaigns provide real hope that with
our scarce resources we will be able to keep our promise to reach
millions of people with life-saving prevention interventions, said Dr
Reuben Granich, UNAIDS Treatment and Care Advisor. “In fact,
providing earlier HIV diagnosis and treatment as part of a campaign
could end up saving people and the health sector millions of
dollars.”
Vertical programmes or integrated disease
campaigns?
Almost without exception, the models of community testing
evaluated in the systematic review were part of vertical HIV
programmes that formed the emergency response in
resource-limited settings during the first decade of treatment scale
up.
But vertical programmes are increasingly viewed as a bad
investment by donors, according to Simon Wright, Head of Child
Survival at Save the Children UK, speaking at a recent conference
organised by the International Society for Neglected Tropical
Diseases (ISNTD). “Policy makers are getting increasingly fed up
with hearing from single-disease advocates, about single-disease
strategies, and who can’t think in a joined-up way,” he said.
There has been a growing emphasis on the need for integration
of HIV-related activities into other programmes, such as TB and
maternal-child health, in order to reach people with HIV infection
where they are most likely to present for medical care.
The biggest move towards integration has been the shift towards
the delivery of HIV treatment and care as part of the package of
primary care. It is beyond the scope of this article to explore the
challenges and success of this approach, but one limitation is clear:
integration into primary care requires a functional primary care
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page 3
system with comprehensive population coverage and, even then,
there are things that primary care may not be able to achieve. These
include identifying people not currently engaged in care, and
promoting disease prevention measures such as condom use and
use of long-lasting insecticide-treated nets.
Accordingly, public health practitioners in a variety of settings
and disease areas have been considering how campaign
approaches to disease prevention might be integrated, in order to
achieve economies of scale and synergies of impact.
Integrated disease campaigns: beyond HIV
Integrated campaigns are already happening outside the HIV field
and form the core of efforts to tackle neglected tropical diseases.
Professor Alan Fenwick of Imperial College, London, director of the
Schistosomiasis Control Initiative, points out that in order to achieve
the 2020 targets for elimination of many neglected tropical
diseases, new strategies rather than new drugs will be needed in
order to achieve scale and synergies of action.
Integrated disease prevention campaigns are already a reality in
many countries where neglected tropical diseases are a public
health priority.
The Rapid-Impact Package for neglected tropical diseases
Disease
Vector
Treatment
Schistosomiasis
Water borne
Praziquantel
Onchocerciasis
Water borne
Ivermectin
Lymphatic
filariasis
Mosquito
Ivermectin or
Albendazole
Soil-based helminths
Soil
Albendazole
Mebendazole
Trachoma
Bacterial
Azithromycin
Schistosomiasis control is increasingly integrated into a package
of activities designed to deliver treatment and prevention against a
range of neglected tropical diseases that are co-endemic, supported
by drug donation programmes run by six pharmaceutical
companies. The other diseases are onchocerciasis (river blindness),
lymphatic filariasis, soil-transmitted helminths and trachoma.
Prevention of these diseases has become integrated through a
Rapid-Impact Package which delivers treatment with a combination
of four drugs on an annual basis at a cost of approximately US 50
cents per person.
Prevention of all these neglected tropical diseases needs to be
supported by vector-based strategies that address both the
immediate vectors of transmission – such as mosquitoes – and the
environmental and structural factors which give rise to a high
burden of disease. These might include clean water, sanitation and
hygiene (WASH) interventions as well as measures to reduce
mosquito infestation by indoor spraying.
Integrated vector management strategies may also mitigate the
unintended consequences of interfering in the very complex ecology
of tropical parasites. In the case of lymphatic filariasis, which is
spread by mosquitoes, we don’t know whether a reduction in filarae
(the parasitic cause) will result in a paradoxical increase in
mosquito survival, noted Louise Kelly Hope of the London School of
Hygiene and Tropical Medicine during the ISNTD event. “Is
elimination a sensible plan or are we removing one species only to
make room for another?” asked Dr Mark Booth of the Wolfson
HATiP | Issue 206 | 10 October 2013
Institute at the University of Durham. “Is elimination the best use of
resources or will these diseases always bounce back?”
The World Health Organization has recommended integrated
vector management for lymphatic filariasis and malaria where both
are co-endemic in sub-Saharan Africa and Asia (especially the
western Pacific).4 Integrated disease prevention requires both the
distribution of long-lasting insecticide-treated nets and treatment of
lymphatic filariasis. Mapping of co-endemic areas in order to target
areas for integrated intervention will be necessary. This approach of
disease mapping is still in its infancy but has huge potential as an
additional benefit of integrated disease prevention campaign
events.
There is limited evidence that a number of neglected tropical
diseases interact with HIV, either by increasing susceptibility to
infection or by accelerating disease progression. A systematic review
found that treatment of malaria and helminth infections had a
modest impact on HIV viral load, but the authors note that “even
small changes in plasma HIV-RNA concentrations have been shown
to slow HIV disease progression.”5
More importantly, neglected tropical diseases are often endemic
in areas where HIV prevalence is also high, and targeting a range of
diseases which impose a high burden on the local population is
likely to represent a more cost-effective use of resources in most
settings.
Several neglected tropical diseases offer potential synergies with
HIV and are reviewed in the following sections.
Schistosomiasis, helminth interventions and HIV
Schistosomiasis (bilharzia) is caused by ingesting or bathing in
water containing the larvae of schistosoma worms. Subsequent
worm infestation can cause damage to the bowel, bladder, kidneys,
liver and spleen, and impaired growth in children. Schistosomiasis
may also increase the vulnerability of women to HIV infection as a
consequence of damage to the genital mucosa. Schistosomiasis
can be cleared by treatment with praziquantel in one or two oral
doses costing less than US 40 cents per treatment.
Eradication of schistomiasis requires environmental controls in
order to eliminate water-dwelling snails that form the natural
reservoir for the helminths which cause schistosomiasis.
Mass treatment is concentrated in areas where schistosomiasis
is endemic and where it causes a high frequency of symptoms in
children.
The Schistosomiasis Consortium for Operational Research and
Evaluation (SCORE) is currently evaluating further strategies for the
elimination of schistosomiasis.
A wide range of helminths (worm) are also present in the
populations affected by schistosomiasis. These may cause
anaemia, malnutrition and impaired cognitive development in
children. A 2009 Cochrane Review concluded that deworming was
associated with significant positive impacts on viral load and CD4
cell counts in adults, and a persuasive body of evidence from
population, animal and human studies show that helminth
infections reduce responses to childhood vaccines.6, 7 However, a
more recent randomised trial conducted in Kenya with support from
PEPFAR and US CDC Global AIDS Program failed to show an effect
of empiric deworming on HIV disease progression in adults not
receiving antiretroviral therapy.8
A different approach to integration of schistosomiasis and HIV
disease prevention might focus on the impact of reducing
schistosomiasis on HIV acquisition in women. A modelling study
using data from a Zimbabwean community intervention which
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tel +44 20 7837 6988 fax +44 20 7923 5949 email [email protected] web www.aidsmap.com
page 4
combined provision of clean water, sanitation, and health education
with administration of praziquantel to school-aged children
suggested that the intervention would be highly cost-effective over a
20-year period.9 “It is important to treat young girls before they
become sexually active,” said Professor Alan Fenwick of the
Schistosomiasis Control Initiative.
Malaria and HIV
HIV and malaria overlap as endemic diseases in many parts of
sub-Saharan Africa, and to a lesser extent in south-east Asia.
People living with HIV are more likely to become infected with
malaria,9,10 to suffer higher parasite burden,11 and to have a higher
risk of clinical malaria and a higher risk of recurrence, especially at
a CD4 count below 200.12, 13
In malaria-endemic settings, several observational cohort studies
have shown a significantly greater risk of parasitaemia and clinical
malaria among HIV-infected adults, especially among highly
immunosuppressed adults.14, 15, 16
In regions of unstable transmission where early immunity is not
established, HIV appears to increase the risk of severe malaria, and
it is in these regions that the interaction between HIV and malaria
may result in the greatest additional burden of disease.17
HIV may particularly exacerbate susceptibility to malaria during
pregnancy. A systematic review of the burden of co-infection in
pregnant women found that in settings with extremely high HIV
prevalence (25 or 40%), 12.7 and 18.8% of malaria cases
respectively were attributable to HIV infection.18 For sub-Saharan
Africa as a whole, HIV infection was estimated to lead to an
additional 505,000 cases of malaria during pregnancy, out of an
estimated 10.5 million malaria cases occurring in pregnant women.
Studies have reached varying conclusions about the impact of
HIV on malaria in infants and children. While a large cohort study in
Uganda failed to find any association between HIV infection or
perinatal exposure to HIV and incidence or severity of malaria in
children, another study in Uganda in a cohort of children who
received blood transfusions found that HIV infection was associated
with increased morbidity and all-cause and malaria-related mortality
in those children with malaria who developed severe anaemia.19, 20
The latter study highlights perhaps the key area of risk for
children: the risk of HIV acquisition as a consequence of a blood
transfusion to treat anaemia associated with malaria.
Co-infection with malaria causes a transient but substantial
increase in HIV viral load lasting for several months after malaria
treatment is successfully concluded.21 In a Ugandan cohort of
people living with HIV, people who experienced three or more
episodes of malaria in a year had much greater declines in CD4 cell
count than people who remained free of malaria (-142 cells).22
Systematic review found conflicting results regarding the impact of
malaria on HIV transmission during pregnancy.23 The extent to
which malaria contributes to sexual transmission is unclear, but the
magnitude of the increase in viral load observed during malarial
co-infection is consistent with an increased risk of transmission in
people not receiving antiretroviral treatment.
Interventions
A number of interventions in various populations of people living
with HIV in east Africa have shown positive benefits of preventing
malaria on HIV disease progression and positive benefits of
antiretroviral therapy and cotrimoxazole prophylaxis on malaria
incidence.
HATiP | Issue 206 | 10 October 2013
Distribution of long-lasting insecticide-treated nets was
associated with a reduced incidence of malaria symptoms and
clinical malaria in a prospective study of people with HIV infection
not yet eligible for antiretroviral therapy in Kenya, as well as a
reduced risk of HIV disease progression as measured by CD4 cell
count. Recipients of nets and a water purification device were
significantly less likely to reach the CD4 cell threshold for starting
treatment (350) during a two-year follow-up period.24
Cotrimoxazole, recommended as prophylaxis against pneumonia
and bacterial infections in people with HIV, also protects against
malaria, and has been shown to reduce the incidence of malaria by
around 70% and mortality by around 40% in HIV-positive adults in a
Ugandan cohort study.25
If cotrimoxazole is discontinued in people taking antiretroviral
treatment the risk of malaria increases very substantially – a
randomised study in Uganda found that after just 120 days off
cotrimoxazole, people with HIV had a 28-fold higher risk of
developing malaria, indicating the need not only for continuous
cotrimoxazole prophylaxis, but also the need for consistent drug
supplies and healthcare worker and patient education on the need
to use cotrimoxazole consistently in endemic areas.26
Antiretroviral therapy is also strongly associated with a reduced
risk of malaria, due in part to improved immunity over time. A cohort
study in Uganda found the incidence of malaria was 70% lower in
people who received ARVs and cotrimoxazole compared to
cotrimoxazole alone. Use of both interventions together with
insecticide-treated nets was associated with a 95% reduction in
malaria incidence compared to no intervention.27
The use of both cotrimoxazole and insecticide-treated nets
combined reduced the risk of malaria in children with HIV by 97% in
Uganda.28
In the light of this evidence, there is a strong case for integrating
malaria prevention and treatment activities into any community
campaign to promote HIV counselling and testing, wherever malaria
is present.
Waterborne infectious diseases and HIV
Diarrhoea caused by waterborne infections is a frequent cause of
illness in people living with HIV in resource-limited settings,
particularly in children (see HATIP 157, April 2010, for a review of
the management of diarrhoea in children with HIV). A cohort study
conducted in Uganda in the mid-1990s among 1213 people with
HIV found that frequency of diarrhoea was strongly associated with
lower CD4 cell counts, but failed to show a strong association
between diarrhoea and the presence of bacteria or protozoa in the
stools of those diagnosed. Cryptosporidial infection was associated
with low CD4 cell count.29
However, a randomised study conducted in Uganda by the US
Centers for Disease Control Global AIDS Program in 2001-2002
found that a home-based safe water intervention significantly
reduced diarrhoea frequency regardless of whether cotrimoxazole
prophylaxis was provided, and also reduced the numbers of days of
work or school lost due to diarrhoea.30 A subsequent systematic
review identified eight studies which measured the effect of water
quality interventions on diarrhoea in people living with HIV. Water
quality interventions were associated with a 43% reduction in
diarrhoea (RR = 0.57, 95% CI 0.38-0.86).31 The authors concluded
that the studies were of mixed quality however, with small sample
sizes and little measurement of intervention adherence.
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tel +44 20 7837 6988 fax +44 20 7923 5949 email [email protected] web www.aidsmap.com
page 5
A literature review on water safety and the health of people living
with HIV published by USAID’s Hygiene Improvement Project in 2007
recommended that:
treatment kits (including sodium hypochlorite and water
• Water
storage equipment) should be distributed alongside
•
•
•
antiretrovirals.
Home-based care programmes should provide covered water
vessels with spigots.
Hygiene education for people living with HIV and home-based
care programmes should include comprehensive information on
water safety and storage, handwashing and disposal of waste
water and faeces.
Access to sufficient quantities of water should be addressed.32
A study of a multi-disease prevention campaign conducted in
western Kenya showed that among people living with HIV who
received a LifeStraw water filter for home use, the incidence of
diarrhoea was reduced by 35%. Furthermore, receipt of a water filter
and a long-lasting insecticide-treated net was associated with a
significant delay in the need to start antiretroviral treatment among
those with CD4 cell counts above 350. This finding suggests that by
reducing exposure to waterborne infections, water filtration limits
exposure to infectious agents that cause immune activation or
infections that cause immunological harm.33
What is the difference between a campaign and
a programme?
Campaigns are time-limited events that occur within a specific area
as part of a larger public health programme.
“It’s important to understand that campaigns are one modality
that can be employed to reach people,” Professor Judd Walson of
the University of Washington, Seattle, told HATIP. “We have a
successful facility-based intervention – HIV treatment and care –
which is very successful. Campaigns are another model.”
Yet facility-based interventions depend on people visiting the
facility, and have little reach into the community. Facility-based
interventions may work for curative and some preventive
interventions, but will have limited preventive impact for endemic
infectious diseases like HIV and malaria.
Large community campaigns for diagnosis and disease
prevention have a long history, but chiefly as single-disease
campaigns. Vaccination campaigns date back to the early 19th
century in the form of local and national smallpox vaccination
drives.34
One of the first large-scale public health campaigns occurred in
the field of tuberculosis. Following the introduction of streptomycin
for TB treatment, for example, mass X-ray screening began to be
used from the late 1940s to identify people with TB early. One of the
largest concentrated campaigns took place in Glasgow in 1957,
where 714,915 people were screened in five weeks in a campaign
employing 37 mobile X-ray vans, identifying 2842 new TB cases. At
the time the city had the highest rate of TB in Western Europe. (See
this British Pathé newsreel for further information on the impressive
scale of community mobilisation.)
Community campaigns for smallpox eradication provide another
important template. Smallpox eradication campaigns “necessarily
had to function within existing health service structures and had to
take advantage of available resources,” Professor Donald
Henderson of Johns Hopkins University Medical School reflected in
Mortality and Morbidity Weekly Report in 1999, considering the
lessons of previous eradication campaigns. More recently,
HATiP | Issue 206 | 10 October 2013
large-scale campaigns have promoted the distribution and use of
insecticide-treated bed nets for malaria prevention.
The World Health Organization and UNICEF have endorsed the
strategy of integrating bed net distribution into measles vaccination
campaigns. Insecticide-treated bed net distribution has also been
integrated with childhood nutrition campaigns. (See this Alliance for
Malaria Prevention toolkit for further information on how integrated
campaigns have been developed to support distribution of
long-lasting insecticide-treated nets.)
Integration of treatment and prevention campaigns against other
neglected tropical diseases is less advanced.
In the HIV field, campaign approaches to HIV awareness and
prevention, and to HIV counselling and testing, have become
widespread. It is not the purpose of this article to review
single-disease interventions, beyond noting that HIV testing drives
and HIV testing weeks have become a commonplace means of
raising awareness of HIV and identifying people with HIV infection.
The weakness of this approach is that HIV testing events are by their
nature vertical programmes, and as already noted, will only attract
people who want to know their HIV status.
Putting it all together
Integration with neglected tropical disease prevention activities is
one approach, but many countries are also paying increasing
attention to non-communicable diseases. These diseases – heart
disease, diabetes, high blood pressure (hypertension), for example
– are beginning to impose a large burden on health systems in
Africa and Asia, and will eclipse infectious diseases as the main
causes of morbidity and mortality in some countries within the next
20 years. (See HATIP 182, October 2011, for a review of the
interaction between HIV and non-communicable diseases).
The second edition of this series on integrated disease
prevention campaigns will examine how diagnosis and monitoring of
diabetes and hypertension were incorporated into a community
disease prevention campaign that also involved large-scale HIV
testing in Uganda.
Professor Ib Christian Bygbjerg of the University of Copenhagen,
who recently highlighted the growing burden of non-communicable
diseases in developing countries,35 suggests that integrated
disease prevention activities which combine management of
infectious and non-communicable diseases should look at the
resources and skills required for management when looking at how
to effectively combine interventions.
For example, infectious and non-communicable diseases that
require long-term monitoring and management, such as HIV and
diabetes or leprosy and diabetes, might be managed together.
Similarly, direct observation might be employed concurrently in TB
treatment programmes to treat TB and to achieve glycaemic control
in TB patients diagnosed with diabetes. People with diabetes have
an approximately 2.5-fold higher risk of developing active TB.
Bi-directional screening programmes have found an elevated
prevalence of TB in people diagnosed with diabetes and an elevated
prevalence of diabetes in people diagnosed with TB, suggesting
opportunities for enhanced case finding of the two diseases.36
Health promotion interventions might also address the fact that
smoking is a risk factor for both diseases.
But investigators on both the large multi-disease prevention
campaigns incorporating HIV were cautious about the feasibility of
incorporating intensified case finding for TB, for reasons that will be
explored in more detail in the second article in this series.
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tel +44 20 7837 6988 fax +44 20 7923 5949 email [email protected] web www.aidsmap.com
page 6
Possible elements in integrated disease
campaigns
Disease
Intervention
Schistosomiasis
Praziquantel
Water filter or treatment kit
Malaria
Longlasting insecticide-treated nets
Cotrimoxazole prophylaxis for HIV+
Treatment of malaria
Waterborne infectious diseases
Water filter or treatment kit
Drug treatment for
schistosomiasis and
onchocerciasis
Rotavirus vaccine for infants
HIV
Counselling and testing
Condom distribution
If HIV+: CD4 count and linkage to care
If HIV+ and CD4<200 – 250: rapid
initiation of ART
If HIV+: TB screening
If HIV+: cotrimoxazole
prophylaxis
Medical male circumcision
Cervical cancer
Screening (visual acetic acid / VIA)
Noncommunicable diseases
Blood sugar screening for diabetes
Blood pressure monitoring
Childhood vaccination
Delivery of catch-up immunisations
Introduction of new vaccines eg
rotavirus or pneumococcal vaccine,
especially where a single-dose vaccine is
available
For programmers who want to achieve economies of scale and
promote efficiencies in the health system, thinking about how to
combine disease prevention interventions inevitably focuses on the
questions of cost and organisational efficiency.
“We often think about it from a costing perspective – for
example, insecticide-treated nets can be delivered every three
years, and so can water filters, so what else can be delivered on the
same cycle?” asks Judd Walson of the University of Washington. He
is working on a matrix of interventions that can help programmers
to identify cycles and potential target populations for combined
interventions.
Nevertheless he acknowledges a possible shortcoming of this
approach.
“On the flipside, what is going to drive use most effectively?
When we asked communities in Western Kenya what they wanted, it
was deworming for their kids and bednets. Doing a campaign in a
way that makes the community view it as a health benefit may not
HATiP | Issue 206 | 10 October 2013
always align with Ministry of Health programming priorities,” he
observed.
“The consumer isn’t the market in terms of paying for these
goods, but they are the market in terms of uptake.”
“In an ideal world we would take an approach that I’ve called the
public health bazaar, in which we ask the Ministry of Health to come
up with five to ten priority interventions, and then go to the
community and ask the community about their priorities, and then
come up with a list that meets both groups’ needs,” Walson told
HATIP.
“If you erode the confidence of the community [by delivering
unwanted interventions] then you undermine the future success of
subsequent campaigns. It is a prerequisite to work with the
community to be successful,” he went on.
Gabriel Chamie of University of California San Francisco, who led
the SEARCH Collaboration campaign combining HIV testing with
screening for diabetes and hypertension, agreed that the quality of
community consultation is essential to the success of campaign
approaches.
“We see community health campaigns as a platform to begin
engaging the community as to what they need and to promote
community ownership of public health interventions,” he said.
Cost-effectiveness
At AIDS 2012, Stéphane Verguet of the University of Washington
presented a cost modelling of the impact of the multi-disease
prevention interventions studied in Kenya, assuming they were
rolled out to the entire population living with HIV in sub-Saharan
Africa. This modelling exercise showed that substantial savings
could be achieved in a number of countries as a result of the
deferral of antiretroviral therapy.37
Using data from the Kenyan study of the impact of malaria and
waterborne disease prevention on HIV disease progression, Verguet
and colleagues in the University of Washington Department of
Global Health applied these data to a model that incorporated
epidemiological and costing data from sub-Saharan Africa.
Antiretroviral treatment was estimated to cost US$722 per year and
the intervention package was costed at $22 a year.
The model found that for Kenya, a nationwide integrated disease
prevention campaign costing $7 million might save $28 million a
year in antiretroviral costs, and save 2200 lives from HIV-related
death. The model did not incorporate the impact of a nationwide
integrated disease prevention campaign on deaths from either
malaria or waterborne diseases in the HIV-negative population.
A subsequent publication showed that the intervention was
highly cost-effective. The cost per death averted was US$3100 and
the cost per disability-adjusted life year (DALY) averted was US$99,
making the intervention very affordable for a country like Kenya. 38
A nationwide campaign would achieve a similar impact in
Mozambique, while in Nigeria, with a much larger population, and a
larger numerical HIV burden, a campaign costing $16.7 million
would save $67.3 million.
Modelled across the whole of sub-Saharan Africa, universal
implementation of an integrated disease prevention campaign
would save $402 million in antiretroviral costs, around 8% of the
PEPFAR antiretroviral drug budget, Verguet and colleagues
estimated.
Furthermore, Stéphane Verguet observed, the implementation of
campaigns in rural areas underserved by health services had the
potential to reduce inequities in access to services and health care,
and to reach the poorest section of the population.
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page 7
Campaigns – the future
“In the next two years we will have $9 billion available for
re-programming. That allows countries to move funds to high-impact
interventions,” said Dr Ade Fakoya, Senior Advisor (HIV & AIDS) at
the Global Fund, speaking at the satellite meeting on integrated
disease prevention campaigns at AIDS 2012.
Lara Starbinski of the Office of the Global AIDS Coordinator, US
State Department, suggested that integrated disease prevention
campaign planners ought to look at how circumcision might be
integrated into future campaigns. Dr Gabriel Chamie, co-investigator
with the SEARCH Collaboration study in Uganda, told HATIP that
syphilis screening and referral for circumcision were already being
considered for future waves of campaign activity.
“We could go back and do different interventions each year
according to the local community’s needs. We need a draw for
people to come back each year for repeat testing,” said Gabriel
Chamie.
Mikkel Vestergaard, chief executive of Vestergaard Frandsen,
manufacturer of the commodities used in the Kenyan disease
prevention campaign, said that his team was already looking at how
screening for cervical cancer might be integrated into future
campaigns.
“When people in the public sector talk about innovation, it’s
about innovation in technology rather than innovation in delivery,”
he said.
Without innovations in ways of delivering preventive interventions
that can achieve large-scale coverage, investments in technological
innovations like vaccines, medicines or or other prevention
technologies are likely to create a public health landscape of white
elephants: expensive projects that fail to make a difference to public
health.
Conclusion
“We’re already thinking about 26 or more million people needing
treatment so I think you’re going to be hearing a lot more about
these approaches,” said Dr Reuben Granich, now Senior Advisor for
Care and Treatment at UNAIDS.
“The individual interventions – safe water, insecticide-treated
nets, HIV counselling and testing, cotrimoxazole, antiretroviral
therapy – are already recommended by WHO. What’s new is putting
them together like this. What’s needed is co-ordination and delivery
on a much larger scale,” said Dr Granich.
The next edition of HATIP will review two large multi-disease
prevention campaigns, conducted in western Kenya and in Uganda.
These campaigns incorporated HIV counselling and testing, but in
other respects they differed. What can be learnt from these models,
and what do they suggest about the practicalities of combining
various interventions?
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© Copyright NAM — All rights reserved. Please photocopy and pass on.
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NAM, Acorn House, 314-320 Gray’s Inn Road, London, WC1X 8DP, UK
tel +44 20 7837 6988 fax +44 20 7923 5949 email [email protected] web www.aidsmap.com
page 8
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