By Elizabeth Radin, Miriam Rabkin, and Wafaa El-Sadr/New York
Global health is once again in the spotlight. In September, the United Nations General Assembly convened two high-level meetings – one on ending tuberculosis (TB), and the other on fighting noncommunicable diseases (NCDs). It was the first time ever that the UN featured two health crises so prominently on its annual agenda.
But with these discussions now over, the global health community must focus on securing the necessary political commitments to sustain international co-ordination and planning. One model worth emulating in the fight against both TB and NCDs is the approach taken to confront the HIV epidemic.
Since 2001, when the UN General Assembly hosted its first meeting on HIV/Aids, the trajectory of the disease has shifted dramatically. Today, some 22mn people living with HIV are receiving treatment. As a result, annual Aids deaths have fallen by half – from 1.9mn in 2003 to 940,000 in 2017 – while the rate of new infection has decreased by nearly half in several of the hardest-hit countries. Efforts to control TB and NCDs – which, like HIV/Aids, place a heavy burden on low- and middle-income countries – can leverage the lessons learned from the response to HIV.
Three lessons in particular stand out. First, as the global Aids response expanded, it faced the dual challenge of including hard-to-reach communities while continuing to support a growing number of patients receiving treatment. In response, HIV programmes have evolved to offer services shaped by the preferences of patients. Such novel models of care also relieve the burden of large numbers of patients on health facilities and health workers.
For example, in several countries, stable patients who prefer to visit their health-care provider less often receive multi-month supplies of medications. In South Africa, where as many as 4.3mn people with HIV are receiving treatment, prescriptions can be refilled at pharmacist-managed vending machines. In Lesotho, where people may live hours from a health facility, HIV testing is offered in the home and, for those found to have HIV infection, community treatment is supported by local health workers.
A similar approach could be taken for TB and NCDs. For TB, this might mean longer gaps between checkups for patients who adhere to treatment and show no signs of drug resistance, while those experiencing side effects or who require more complex treatments could receive more intensive care. Likewise, patients with well-controlled NCDs who show no symptoms and are doing well on medications may need only occasional visits to a health-care provider, while those with more complicated cases could benefit from closer medical monitoring and counselling.
Second, HIV programmes succeeded in part because they established goals for the entire “cascade of care” – from diagnosis to treatment.
For example, the “90-90-90” targets set by the Joint United Nations Programme on HIV/Aids (UNAIDS) – in which 90% of people living with HIV have been diagnosed, 90% of those diagnosed with HIV are on treatment, and 90% of those on treatment are virally suppressed – helped focus the global Aids response. In fact, models suggest that if these targets are achieved, HIV will no longer be a public-health threat by the year 2030.
Setting targets is useful for benchmarking progress and identifying coverage gaps. For example, in many countries, the largest gap in the coverage of HIV services is in diagnosis, particularly of men and young people. As a result, many programmes now offer new options to reach these groups, such as confidential workplace testing and self-testing. Another gap is among populations that are disenfranchised and stigmatised in some countries, such as men who have sex with men.
Targets along the cascade could be similarly beneficial for controlling TB and NCDs. The Stop TB Partnership, for example, has proposed 90-(90)-90 treatment goals for the disease, although they have yet to be widely adopted. For NCDs, the focus is on achieving UN Sustainable Development Goal 3.4, which calls for a one-third reduction in premature deaths from such illnesses by 2030. But the latter goal is not disaggregated along the NCD care cascade of diagnosis and treatment. For example, it would be useful for programmes to monitor how many people with high blood pressure have been diagnosed and placed on treatment, what proportion of those on treatment have achieved blood-pressure control, and what treatment level would be required to reduce premature deaths by the desired target.
Finally, the Aids effort was able to expand as a result of strong advocacy and collaborations that reshaped markets for diagnostic and treatment programmes. By forecasting medication needs, aggregating orders, and promoting competition, in combination with intense advocacy, policymakers and providers were able to secure market efficiencies. The resulting economies of scale allowed suppliers to shift from low-volume, high-margin solutions to high-volume, low-margin profit models. As a result, these efforts reduced the cost of annual HIV treatments from more than $10,000 per patient in 2001 to less than $100 in 2016.
Likewise, controlling TB and NCDs will require making medications more convenient and affordable. While the TB response has leveraged strategic partnerships to expand coverage, large gaps remain, the largest being treatments for children and patients with drug-resistant TB. For NCDs, companies like Novartis, Pfizer, and the Indian drug maker Cipla have made efforts to bring affordable medicines to patients in Africa. But while donations may help stimulate initial demand, a more deliberate market approach will be needed to achieve price reductions. A multisectoral coalition launched in 2017 could help drive efficiencies, but it will need additional support to succeed.
Tedros Adhanom Ghebreyesus, Director-General of the World Health Organisation, recently called on governments to increase their leadership and investments in health systems to fight TB and NCDs. But while more resources are no doubt needed, they must be accompanied by sound strategies that engage communities, guide programming, and scale up prevention and care. Best of all, with the Aids response blueprint already in hand, there is no need to reinvent the wheel. – Project Syndicate
* Elizabeth Radin is Lecturer in Epidemiology and Technical Director of the PHIA Project at ICAP at Columbia University. Miriam Rabkin is a professor of medicine and epidemiology and Director of Health Systems Strategies at ICAP at Columbia University. Wafaa El-Sadr is Professor of Epidemiology and Medicine and Director of ICAP at Columbia University.
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