By Vivian Mugarisi
Harare, Zimbabwe – 51-year-old Kay Mabika** adheres to her HIV medication. Testing positive for HIV in 2006 added more weight and complexities onto the burden of living with diabetes, which she was diagnosed with 4 years earlier. Despite being strict in adhering to antiretroviral treatment (ART), Mabika struggles to manage her diabetic condition and is worried that she may not even be able to afford the medication when she retires.
Due to the diabetic condition, she lost her sight in her left eye and the right one is short sighted. This started when her treatment was changed before being put on insulin.
Infact, Mabika is worried more over her diabetes condition than she is over her HIV positive status, she says in an interview from her residence in Chitungwiza, about 30km south-east of Harare.
I do not fear HIV. I am scared of diabetes,” said Mabika, her voice trailing off into deep thought as she stood by the door waiting for me to pass after exchanging goodbyes.
“I fear the complications of diabetes……… as I head towards retirement,” she added handing over the parcel (fresh corn) she had packed for the road.
Zimbabwe’s HIV/AIDS programme is a model in sub-Saharan Africa with figures rarely seen in developing countries. The uptake of treatment is also very high by most standards, currently at 95,3%. But many of the people living with HIV are also living with diabetes, hypertension and cardiovascular diseases with often unaddressed mental health issues.
“Understanding the correlation between HIV, malaria, TB and NCDs should give health workers an opportunity to ensure that those in need of HIV services are given the opportunity for screening noncommunicable diseases and treated appropriately,” says the World Health Organization (WHO) Zimbabwe Team Lead for the Universal Health Coverage, Communicable and Non-Communicable Diseases Cluster Dr Anderson Chimusoro.
Mabika is one of these people experiencing multiple comorbidities. As if this was not enough, early this year she was prescribed with treatment for another silent killer, hypertension. Even then she is of the firm belief that for her and others in her situation, the worst lies ahead. For a schoolteacher, in a normal economy, Mabika should manage just fine but Zimbabwe is anything but normal. Her meager income is barely enough to sustain bare essentials, thanks to the downturn in the economy. It is this triple burden that has raised her fears that she may not be able to effectively manage the increasingly common comorbidity of living with HIV, diabetes and hypertension.
With the limited comprehensive care packages to manage these comorbidities, people like Mabika may be saved from dying of AIDS but lost to non-communicable diseases (NCDs).
NCDs, including diabetes, cancer, cardiovascular and chronic respiratory diseases, account for 41 million deaths globally each year. Yet, getting screened and treated for NCDs remains out of reach for many patients in low-middle income countries like Zimbabwe. Despite transitions in disease profiles with evidence showing the rising prevalence of NCDs and Mental Health conditions, investments towards health have been mainly focused on responding to communicable diseases such as HIV, Malaria and TB.
For instance, investments from the Global Fund have focused on HIV, TB and malaria, saving over 44 million lives over the past decades. In Zimbabwe, the National AIDS Trust Fund was set up in 1999, as a way of increasing domestic funding for HIV. While patients receive free HIV and TB drugs, costs for NCD diagnostics and medications are usually out-of-pocket expenditure with increased risk of defaulting and loss to follow-up. Further, the COVID-19 pandemic has shown how critical integration of mental health services is. People with TB and HIV often have unaddressed mental health conditions which has a direct impact on disease progression, treatment outcomes and adherence.
Speaking ahead of a Global Fund meeting held in Harare from 19-21 April 2023, the Director for HIV and TB in the Ministry of Health and Child Care, Dr Owen Mugurungi said responsive health systems should be patient-centred and not focused on diseases.
“…so we urgently need to be sensitive to the needs of our clients and accommodate treatment and management of NCDs and mental health conditions in one visit,” he said.
The meeting gave Ghana, Mozambique, Tanzania, Zambia and Zimbabwe, an opportunity to integrate NCDs and Mental Health components in their funding proposals to the Global Fund. Technical and financial support for this meeting was provided by WHO (AFRO and HQ), The Global Fund and UNAIDS.
The workshop marked a critical step towards achieving Universal Health Coverage (UHC) by ensuring improved health outcomes, well-being and quality of life, particularly of people living with and at risk of HIV and NCDs.
Integration provides an opportunity to leverage the infrastructure and platforms successfully set up to prevent, screen and treat HIV to deliver high-impact interventions for other diseases including mental health and NCD- related services at the primary health care level.
“HIV service continuum provides entry points for the integrated services,” said Dr Ani Shakarishvili – UNAIDS Team Lead, Integrated Systems and Services.
For integration to work, experts agree that there is need to increase funding to further invest in primary health care and make the services more accessible to communities.
According to Dr Tsitsi Apollo, Deputy Director for HIV in MoHCC, the reduction in the Global Fund contribution to Zimbabwe by nearly $10 million, “will hamper interventions,” with WHO Representative to Zimbabwe Professor Jean-Marie Dangou stressing the need to “push for increased prioritization in domestic budgets, capitalize on new opportunities around innovative financing and public-private partnerships, including further engagement with donors and private philanthropies.”
Investments in education and awareness is another necessary factor to increase demand for NCDs and Mental Health services particularly for women living with HIV. This will increase uptake of services such as cervical cancer screening which are not readily available at the facilities where they access their ART from. The double stigma of HIV and Mental Health, where communities still shy away from talking openly about the issues also requires awareness to create demand for services. The need to invest in the health workforce should also be high on the agenda, providing the necessary training and include people living with HIV, mental health conditions and NCDs such as diabetes and other NCDs in the planning and implementation processes to promote programme relevance.
“It’s important to prioritize interventions that contribute to making health systems and service delivery more equitable, efficient, effective, and sustainable in delivering integrated people-centred health services,” added The Global Fund Senior HIV Advisor Dr Lee Abdelfadil.
WHO will continue to support countries in the development of funding requests to the Global Fund and other donors as well as programme development and implementation. In these activities, WHO will also ensure that Ministries of Health consider the comorbidities between NCDs, Mental Health conditions and communicable diseases and guide countries in integrating them into communicable diseases programmes.
“With the increasing burden of NCDs and mental health conditions in People living with HIV, integration across these diseases is mutually beneficial. Focus therefore is on ensuring integration at primary health care level to achieve UHC,” noted Dr Prebo Barango, NCDs Programme Coordinator at the WHO Regional Office for Africa.
Addressing the barriers, promoting access to information and taking this step to integrate services within communities will make health for all a reality for Mabika and many others.
**Names have been changed to protect the identity of the individual.
