The challenge that Africa has of dealing with multiple burdens of disease, characterised by high rates of infectious diseases such as HIV, AIDS, and tuberculosis, alongside non-communicable diseases such as cardiovascular diseases and diabetes, is well documented.1de-Graft Aikins A Unwin N Agyemang C Allotey P Campbell C Arhinful D Tackling Africa's chronic disease burden: from the local to the global. This challenge is also apparent in South Africa, and the country continues to live through a quadruple burden of disease resulting from infectious and non-communicable diseases emerging in both rural and urban areas, in addition to maternal and child mortality, and injuries,2The converging burdens of infectious and non-communicable diseases in rural-to-urban migrant Sub-Saharan African populations: a focus on HIV/AIDS, tuberculosis and cardio-metabolic diseases., 3Mayosi BM Flisher AJ Lalloo UG Sitas F Tollman SM Bradshaw D The burden of non-communicable diseases in South Africa. all of which are attributed to the rapid and complex health transition over the past two decades.3Mayosi BM Flisher AJ Lalloo UG Sitas F Tollman SM Bradshaw D The burden of non-communicable diseases in South Africa. Although the introduction of antiretroviral therapy has reduced the morbidity of people living with HIV, new challenges in the management of HIV have emerged, aggravated by treatment of HIV-related cardio-metabolic disorders, particularly hypertension and diabetes.2The converging burdens of infectious and non-communicable diseases in rural-to-urban migrant Sub-Saharan African populations: a focus on HIV/AIDS, tuberculosis and cardio-metabolic diseases. However, antiretroviral therapy increases cardio-metabolic risk.4Kazooba P Kasamba I Mayanja BN et al.Cardiometabolic risk among HIV-positive Ugandan adults: prevalence, predictors and effect of long-term antiretroviral therapy.A study by Emily Wong and colleagues5Wong EB Olivier S Gunda R et al.Convergence of infectious and non-communicable disease epidemics in rural South Africa: a cross-sectional, population-based multimorbidity study. in the Lancet Global Health is timely and notable. Their study established the prevalence and overlap of four common and treatable infectious and non-communicable diseases (HIV, tuberculosis, elevated blood pressure, and elevated blood glucose) in a HIV endemic population. The researchers found out the degree to which individual diseases and multimorbidity were diagnosed and optimally managed in the population. First, Wong and colleagues highlighted a 52·1% prevalence of at least one active disease and 11·8% prevalence of two or more active diseases among participants from the Africa Health Research Institute demographic surveillance area in the rural uMkhanyakude district of KwaZulu-Natal, South Africa. Second, the study showed evidence of the presence of infectious diseases, such as HIV (34·2%) and active (1·4%) and lifetime tuberculosis (21·8%), coexisting with elevated blood glucose (8·5%) and blood pressure (23·0%). Third, the study further showed that appropriate treatment and control of disease was the highest for HIV (76·3%), and lower for elevated blood pressure (40·0%), active tuberculosis (31·3%), and elevated blood glucose (6·9%). Lastly, the variations of disease prevalence were observed by sex, across age groups, and geospatially, with tuberculosis being high among men, and middle age women having a high prevalence of HIV and multiple non-communicable diseases that were poorly controlled in those older than 50 years.These findings support the evidence of a rising trend in the prevalence of multimorbidity in low-income and middle-income countries, which poses a major challenge to health-care systems.6The Richmond Group of Charities
Just one thing after another: living with multiple conditions. A report from the Taskforce on Multiple Conditions. This is because the management of multimorbidity is more complex and demanding for health systems and patients, compared with patients having only one chronic condition.6The Richmond Group of Charities
Just one thing after another: living with multiple conditions. A report from the Taskforce on Multiple Conditions., 7Future of multimorbidity research: how should understanding of multimorbidity inform health system design?. Rather than designing a model of care for the possible co-occurrence of chronic conditions, health systems in low-income and middle-income countries are largely constructed with chronic disease care that is one-size-fits-all, leading to ineffective care.8Barnett K Mercer SW Norbury M Watt G Wyke S Guthrie B Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study., 9Heide IVD Snoeijs S Melchiorre MG et al.Innovating care for people with multiple chronic conditions in Europe. However, data on the magnitude and type of multimorbidity (ie, concordant or discordant) affecting a patient's progression along the continuum of care in low-income and middle-income countries are few.10Abebe F Schneider M Asrat B Ambaw F Multimorbidity of chronic non-communicable diseases in low- and middle-income countries: a scoping review., 11Chang AY Gómez-Olivé FX Manne-Goehler J et al.Multimorbidity and care for hypertension, diabetes and HIV among older adults in rural South Africa. It is documented that people living with multimorbidity are predisposed to a lower quality of life, disability, premature mortality, greater use of health-care service resources, and unforeseen hospital admissions.12Multimorbidity. Understanding the challenge. A report for the Richmond Group of Charities., 13Care coordination of multimorbidity: a scoping study. Also, a paucity of data on the care of patients with HIV and multimorbidity has been reported in South Africa,11Chang AY Gómez-Olivé FX Manne-Goehler J et al.Multimorbidity and care for hypertension, diabetes and HIV among older adults in rural South Africa. whereas research in developed countries (ie, the USA) has reported that patients with HIV receive poorer care for their coexisting conditions than patients who do not have HIV.14Burkholder GA Tamhane AR Salinas JL et al.Underutilization of aspirin for primary prevention of cardiovascular disease among HIV-infected patients.Furthermore, the study by Wong and colleagues5Wong EB Olivier S Gunda R et al.Convergence of infectious and non-communicable disease epidemics in rural South Africa: a cross-sectional, population-based multimorbidity study. has contributed knowledge on a high and overlapping prevalence of HIV, tuberculosis, elevated blood glucose, and elevated blood pressure in rural South Africa. The study observed a convergence of infectious and non-communicable disease epidemics, instead of the classic epidemiological transition in which societies shift from predominantly infectious to predominantly non-communicable diseases over time. With a high prevalence of well managed and controlled HIV, the study further showed that despite the success of the HIV programme, the current health-care system does not address the burden of multimorbidity in this population. It seems that health facilities are attempting to provide more than acute services to treat long-term HIV, and health systems designed to manage HIV and AIDS are under the strain of managing patients with additional comorbidities of non-communicable diseases. No doubt that the effect of multimorbidity might further overwhelm health systems.15WHO
Multimorbidity: technical series on safer primary care.It is also worth mentioning that in settings with a high HIV burden, multimorbidity is occurring among younger people and adolescents with a higher amount of risk for non-communicable diseases attributed to HIV infection, making this an important target group for the prevention of non-communicable diseases and multimorbidity with a chronic condition such as HIV.16Kamkuemah M Gausi B Oni T Missed opportunities for NCD multimorbidity prevention in adolescents and youth living with HIV in urban South Africa. I commend Wong and colleagues for including adolescents in their study. I further support their call for research needed to understand the epidemiology of multimorbidity and define the best possible interventions to improve the outcomes of patients in various population groups with multimorbidity in South Africa, both rural and urban. The issue of including all categories of non-communicable diseases, such as cancer, chronic respiratory disease, mental health, and child health, and of studying their coexistence with HIV to improve proper management, needs urgent attention.

I declare no competing interests.

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DOI: https://doi.org/10.1016/S2214-109X(21)00271-0

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