[Articles] Convergence of infectious and non-communicable disease epidemics in rural South Africa: a cross-sectional, population-based multimorbidity study

Research in context

Evidence before this study

Across sub-Saharan Africa, mortality related to HIV is dropping because of widespread antiretroviral therapy use over the last 15 years. This change is driving increasing life expectancy and decreasing rates of tuberculosis. However, morbidity and mortality from non-communicable diseases, including cardiovascular disease, diabetes, and chronic post-tuberculosis lung disease, are rising in the region. In this context, there is an increasing concern about the effect of multimorbidity or the overlap of two or more chronic conditions on health in African settings. Data from large systematic sources, including the Global Burden of Disease studies, have shown these trends. More granular and localised data are available through health systems data, but these sources do not capture members of the population who have not accessed the health system. Large population-based studies of HIV and non-communicable diseases in Kenya, Uganda, and Karonga, Malawi, have shown the high prevalence of uncontrolled high blood pressure and diabetes in populations with a high HIV prevalence. To date, population-based surveys that include the characterisation of HIV and non-communicable disease in South Africa, the country with the world's largest HIV epidemic, have been limited to either specific conditions or specific age categories, or have not included tuberculosis. To inform the design of the protocol, we searched PubMed for original reports or reviews using the search terms “HIV” OR “HIV infections”, “TB” OR “tuberculosis”, “noncommunicable diseases”, “Africa”, and “multimorbidity” (search done between Nov 1, 2016, and April 27, 2017).

Added value of this study

In a population in rural KwaZulu-Natal, South Africa that has been under continuous demographic surveillance for 20 years, we used mobile health camps to measure blood pressure, glycosylated haemoglobin, HIV serology, and HIV viral load, and used a digital chest x-ray and sputum tests for Mycobacterium tuberculosis, to simultaneously define HIV, active and lifetime tuberculosis, elevated blood glucose, and elevated blood pressure in more than 17 000 adolescents and adults. On the basis of knowledge of the underlying population structure, we estimated age-specific and sex-specific population prevalence rates of each disease, the extent to which each disease was optimally diagnosed and treated, and the prevalence of multimorbidity using a scale that combined the number of simultaneous diseases and their state of control. Geospatial and lifespan analysis of individual diseases and multimorbidity showed distinct prevalence patterns for HIV and multimorbidity.

Implications of all the available evidence

In this population and others in sub-Saharan Africa, although HIV diagnosis and the uptake of antiretroviral therapy has not reached the Joint United Nations Programme on HIV and AIDS's 90–90–90 goals (that by 2020, 90% of individuals positive for HIV will be diagnosed, 90% of individuals diagnosed will be on antiretroviral therapy, and 90% of people on antiretroviral therapy will be virally suppressed), the majority of HIV-positive individuals are on effective chronic treatment. In contrast, most people with active tuberculosis, elevated blood pressure, and elevated blood glucose have undiagnosed or suboptimally treated disease. Women bear a particularly high burden of HIV, elevated blood pressure, and elevated blood glucose. Men have higher rates of active and lifetime tuberculosis, putting them at risk for chronic lung disease. In the absence of a rapid improvement of public health systems to prevent, diagnose, and treat these diseases, the burden of multimorbidity will worsen as the cohort of men and women with the highest rates of HIV infection (currently in their fourth and fifth decades of life) get older over the next several decades. Population-based studies of the convergence of infectious and non-communicable diseases are needed to inform the design of interventions to address multimorbidity in sub-Saharan Africa and other low-income and middle-income settings.

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