Understanding the Intersecting Syndemics of Communicable and Non-Communicable

Understanding the Intersecting Syndemics of Communicable and Non-Communicable

Understanding the Intersecting Syndemics of Communicable and Non-Communicable Diseases Emily P. Hyle, MD MSc Division of Infectious Diseases Massachusetts General Hospital Harvard Medical School #AIDS2018 | @AIDS_conference | www.aids2018.org Financial disclosures I have no financial disclosures #AIDS2018 | @AIDS_conference | www.aids2018.org HIV and TB are synergistic HIV Adapted from Tsai et al. Soc Sci Med 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org TB Additional impact of diabetes (DM) DM HIV

Adapted from Tsai et al. Soc Sci Med 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org TB Influence of structural barriers to care DM HIV TB Economic instability Food insecurity Adapted from Tsai et al. Soc Sci Med 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Syndemics framework Health conditions co-occur due to adverse social conditions and interact synergistically A broad view of the challenges contributing to multimorbidity that includes social, behavioral,

and biologic interactions Singer et al. Med Anthropol Q 2003; Singer et al. Lancet 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org Road map 1. Challenges and successes of global HIV treatment scale-up 2. HIV co-exists with a wide range of other healthrelated issues 3. Syndemics framework suggests opportunities to maximize impact #AIDS2018 | @AIDS_conference | www.aids2018.org Road map 1. Challenges and successes of global HIV treatment scale-up 2. HIV co-exists with a wide range of other healthrelated issues 3. Syndemics framework suggests opportunities to maximize impact #AIDS2018 | @AIDS_conference | www.aids2018.org Challenges and successes in HIV/AIDS 940,000 AIDS-related deaths 1.8 million new infections

Rising HIV incidence in 50 countries UNAIDS Global AIDS Update 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Almost 60% of PWH on ART worldwide Antiretroviral therapy coverage (%) 100 80 ART coverage 60 40 20 0 00 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 0 2 2 2 2 2 2 2

2 2 2 2 2 2 2 2 2 2 2 UNAIDS Global AIDS Update 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Global HIV care cascade Percentage of people with HIV 100% 100% 80% 75% 60%

59% 47% 40% 20% 0% Prevalent Diagnosed UNAIDS Global AIDS Update 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Treated Controlled Life expectancy of PWH on ART In US, Canada, and Europe, a 20 yo PWH who achieves a CD4 >350/L within a year of starting L within a year of starting ART can expect to live to 78y In South Africa, the difference in life expectancies between PWH and HIV-uninfected has shrunk to 1.2y for men and 5.3y for women

ART-CC Lancet HIV 2017; Reniers et al. Lancet HIV 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org P W H w ith a g e - a s s o c ia te d c o n d itio n s PWH on ART have multimorbidity 6000% 5000% 4000% 3000% 2000% 1000% 0% 4+ conditions 3 conditions 2 conditions Wong et al. CID 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org 1 condition Road map

1. Challenges and successes of global HIV treatment scale-up 2. HIV co-exists with a wide range of other healthrelated issues 3. Syndemics framework suggests opportunities to maximize impact #AIDS2018 | @AIDS_conference | www.aids2018.org TB deaths have not declined steeply Millions of deaths per year 2 HIV deaths 1.5 TB deaths in people without HIV 1 0.5 TB deaths in people with HIV 0

2000 2008 WHO Global Tuberculosis Report 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org 2016 TB care cascade in India Percentage of people with TB 100% 100% 80% 60% 60% 53% 45% 40%

20% 0% Prevalent Diagnosed Subbaraman et al. PLoS Med 2016 #AIDS2018 | @AIDS_conference | www.aids2018.org Treated Controlled Hepatitis deaths are rising worldwide Millions of deaths per year 2 1.5 Hepatiti s TB HIV

1 0.5 0 2000 2005 2010 WHO Global Hepatitis Report 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org 2015 Most common causes of deaths globally Ischaemic heart disease Stroke COPD Lower respiratory infections Dementias Trachea, bronchus, lung cancers Diabetes mellitus Road injury Diarrhoeal diseases

Tuberculosis 0 1 2 3 4 Deaths (millions) WHO Global Health Estimates 2016 #AIDS2018 | @AIDS_conference | www.aids2018.org 5 6 7 8 9 10

Most common causes of deaths globally Ischaemic heart disease Stroke COPD Lower respiratory infections Dementias Trachea, bronchus, lung cancers Diabetes mellitus Road injury Diarrhoeal diseases Tuberculosis 0 1 2 3 4 Deaths (millions) WHO Global Health Estimates 2016 #AIDS2018 | @AIDS_conference | www.aids2018.org 5

6 7 8 9 10 High-income countries (GNI per capita > $12,056) Ischaemic heart disease Stroke Dementias Trachea, bronchus, lung cancers COPD Lower respiratory infections Colon and rectum cancers Diabetes mellitus Kidney diseases Breast cancer 0 20 40

60 80 Crude death rate (per 100,000 population) WHO Global Health Estimates 2016, World Bank 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org 100 120 140 High-income countries (GNI per capita > $12,056) Ischaemic heart disease Stroke Dementias Trachea, bronchus, lung cancers COPD Lower respiratory infections Colon and rectum cancers Diabetes mellitus Kidney diseases Breast cancer

0 20 40 60 80 100 120 140 Crude death rate (per 100,000 population) WHO Global Health Estimates 2016, World Bank 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org Upper middle-income countries (GNI per capita $3,896-$12,055) High-income countries (GNI per capita > $12,056)

Ischaemic heart disease Stroke COPD Trachea, bronchus, lung cancers Dementias Lower respiratory infections Diabetes mellitus Road injury Liver cancer Stomach cancer Ischaemic heart disease Stroke Dementias Trachea, bronchus, lung cancers COPD Lower respiratory infections Colon and rectum cancers Diabetes mellitus Kidney diseases Breast cancer 0 20 40

60 80 100 120 140 Lower middle-income countries (GNI per capita $966-$3,895) Ischaemic heart disease Stroke Lower respiratory infections COPD Tuberculosis Diarrhoeal diseases Diabetes mellitus Preterm birth complications Cirrhosis of the liver Road injury 20 40 60

80 20 40 60 80 Crude death rate (per 100,000 population) Crude death rate (per 100,000 population) 0 0 100 120 140 Crude death rate (per 100,000 population)

WHO Global Health Estimates 2016, World Bank 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org 100 120 140 Upper middle-income countries (GNI per capita $3,896-$12,055) High-income countries (GNI per capita > $12,056) Ischaemic heart disease Stroke COPD Trachea, bronchus, lung cancers Dementias Lower respiratory infections Diabetes mellitus Road injury Liver cancer Stomach cancer Ischaemic heart disease

Stroke Dementias Trachea, bronchus, lung cancers COPD Lower respiratory infections Colon and rectum cancers Diabetes mellitus Kidney diseases Breast cancer 0 20 40 60 80 100 120 0 140

40 60 80 100 120 140 100 120 140 Crude death rate (per 100,000 population) Crude death rate (per 100,000 population) Lower middle-income countries (GNI per capita $966-$3,895) Low-income countries (GNI per capita $995)

Ischaemic heart disease Stroke Lower respiratory infections COPD Tuberculosis Diarrhoeal diseases Diabetes mellitus Preterm birth complications Cirrhosis of the liver Road injury 0 20 Lower respiratory infections Diarrhoeal diseases Ischaemic heart disease HIV/AIDS Stroke Malaria Tuberculosis Preterm birth complications Birth trauma Road injury 20

40 60 80 100 120 140 Crude death rate (per 100,000 population) WHO Global Health Estimates 2016, World Bank 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org 0 20 40 60 80

Crude death rate (per 100,000 population) Pollution is a major contributor to mortality 10000000 Global estimated deaths (millions) 8000000 6000000 4000000 2000000 0 Landrigan et al. Lancet 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Too many deaths from tobacco 10000000 Global estimated deaths (millions) 8000000 6000000 4000000 2000000 0

Landrigan et al. Lancet 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Tobacco use increases mortality Increased risk of TB, cancers, COPD, CVD, and stroke In 2015, 6.4 million deaths (11.5%) were attributable to smoking worldwide In Asia, 2 million deaths of adults 45 years or older were attributable to smoking in 2014 19.1% of all deaths in Asia that year GBD 2015 Tobacco Collaborators Lancet 2017; Zheng et al. PLoS Medicine 2014 #AIDS2018 | @AIDS_conference | www.aids2018.org Impact of tobacco on PWH mortality -X Age in years Life expectancy (men) 80.0 Never smokers Former smokers

71.9 70.9 65.0 60.0 Current smokers -1.0 75.0 70.0 =Years of life lost, compared to never smokers -6.7 65.2 Enter care at age 40 Reddy et al. JID 2016 #AIDS2018 | @AIDS_conference | www.aids2018.org Cancer cases are increasing worldwide 28% more cancer cases in 2016 compared to 2006

Global Burden of Diseases Cancer Collaboration JAMA Oncology 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Disparities in cancer deaths Cancer deaths are rising in LMIC Global Burden of Diseases Cancer Collaboration JAMA Oncology 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org N u m b e r o f a d u lts w ith d ia b e te s ( m illio n s Diabetes prevalence worldwide is rising 500 400 300 Africa Middle East Asia Latin America US Europe 200 100

0 1980 1985 1990 1995 2000 NCD Risk Factor Collaboration Lancet 2016 #AIDS2018 | @AIDS_conference | www.aids2018.org 2005 2010 2014 Diabetes care cascade in South Africa Percentage of people with diabetes 100% 100%

80% 60% 55% 40% 40% 38% 20% 0% 19% Prevalent Screened Diagnosed Stokes et al. PLoS One 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org Treated

Controlled Diabetes care cascade in the US Percentage of people with diabetes 100% 100% 80% 72% 60% 40% 40% 20% 0% Prevalent Diagnosed Ali et al. Ann Int Med 2014 #AIDS2018 | @AIDS_conference | www.aids2018.org

Controlled Hypertension leads to serious disease Kidney disease Stroke CVD Hypertension #AIDS2018 | @AIDS_conference | www.aids2018.org N u m b e r o f h y p e rte n s iv e s ( m illio n s ) Hypertension prevalence globally 300 250 200 150 100 50 0 Mills et al. Circulation 2016

#AIDS2018 | @AIDS_conference | www.aids2018.org Men Women Hypertension care cascade in Malawi Percentage of people with hypertension 100% 100% 80% 60% 56% 40% 42% 29% 20% 11% 0% Prevalent

Screened Diagnosed Price et al. Lancet Diabetes Endocrinol 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Treated Controlled Depression care cascade in the US Percentage of people with depression 100% 100% 80% 60% 47% 40% 24%

20% 6% 0% Prevalent Diagnosed Pence et al. Curr Psychiatry Rep 2012 #AIDS2018 | @AIDS_conference | www.aids2018.org Treated Controlled P e r c e n t a g e o f p e o p le w it h d is e a s e Care cascades must be improved 100%Prevalent; Prevalent; 100% Prevalent; Prevalent;

1 100% Prevalent; 100% 100% HIV Tuberculosis Diabetes Hypertension Depression 80% 0.69 60% 0.6 53% 0.53 47% 40% 44%

40% 0.45 40% 28% 20% 22% 24% 19% 9% 0% Prevalent Diagnosed Treated #AIDS2018 | @AIDS_conference | www.aids2018.org Controlled

6% Strengthening health systems is essential Tobacco use, diabetes, hypertension, and depression have intervenable targets to improve outcomes and quality of life As a model of chronic disease treatment, global HIV care suggests innovations to increase diagnosis, linkage, treatment, and retention #AIDS2018 | @AIDS_conference | www.aids2018.org Medications are too often not available Availability of anti-hypertensives 100% 98% 98% 97% 95% 94%

87% 80% 87% 86% 79% 72% 71% 60% 72% 61% 47% 40% 40% 20% 13% 0%

High income Upper middle income One Two Lower middle income Three Attaei et al. Lancet Public Health 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org Four Low income Medications are too often not available Availability of anti-hypertensives 100%

98% 98% 97% 95% 94% 87% 80% 87% 86% 79% 72% 71% 60% 72% 61%

47% 40% 40% 20% 13% 0% High income Upper middle income One Two Lower middle income Three Attaei et al. Lancet Public Health 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org

Four Low income H o u s e h o ld s u n a b le to a ffo r d m e d ic a tio Medications are often not affordable 100% 80% 60% One anti-hypertensive Two anti-hypertensives Two plus metformin Two plus metformin and statin 40% 31% 20% 0%

80% 1% 3% 0% 0% High income 6% 19% 12% Upper middle income 25% 5% 6% 11% Lower middle income Attaei et al. Lancet Public Health 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org 39%

31% 17% Low income H o u s e h o ld s u n a b le to a ffo r d m e d ic a tio Medications are often not affordable 100% 80% 60% One anti-hypertensive Two anti-hypertensives Two plus metformin Two plus metformin and statin 40% 31% 20% 0%

80% 1% 3% 0% 0% High income 6% 19% 12% Upper middle income 25% 5% 6% 11% Lower middle income Attaei et al. Lancet Public Health 2017 #AIDS2018 | @AIDS_conference | www.aids2018.org 39%

31% 17% Low income Road map 1. Challenges and successes of global HIV treatment scale-up 2. HIV co-exists with a wide range of other healthrelated issues 3. Syndemics framework suggests opportunities to maximize impact #AIDS2018 | @AIDS_conference | www.aids2018.org Syndemics worsen health outcomes An increase in the number of syndemic risk factors has been associated with worse outcomes Can we use the syndemics framework to generate innovative solutions that leverage these synergies? Friedman et al. AIDS 2015; Byg et al. J Community Health 2016; Tomori et al. Soc Sci Med 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org

Syndemics: platform for innovation DM HIV TB Economic instability Food insecurity Adapted from Tsai et al. Soc Sci Med 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Cash transfers DM HIV TB Economic instability Food

insecurity Adapted from Tsai et al. Soc Sci Med 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Decrease economic instability & food insecurity DM HIV TB Economic instability Food insecurity Adapted from Tsai et al. Soc Sci Med 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Improve diagnosis, treatment, retention DM HIV

TB Economic instability Food insecurity Adapted from Tsai et al. Soc Sci Med 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org Prevent new cases & reduce illness and death DM HIV TB Economic instability Food insecurity Adapted from Tsai et al. Soc Sci Med 2018 #AIDS2018 | @AIDS_conference | www.aids2018.org

Turning ideas into reality Syndemics framework is a theoretical structure to consider real-life challenges but requires ongoing research and outreach to understand synergies better: Qualitative assessment regarding needs and barriers Measurements of outcomes: HIV and TB, and also other health outcomes causing morbidity and death Innovative health care delivery for scale up and sustainability that target syndemics #AIDS2018 | @AIDS_conference | www.aids2018.org Conclusions HIV is one among many major health issues; PWH face multimorbidities intertwined with the health of all Innovative approaches are essential to address communicable and non-communicable diseases Syndemics highlight opportunities to address underlying needs by targeting high-impact synergies #AIDS2018 | @AIDS_conference | www.aids2018.org Thank you Ingrid Bassett, MD MPH

Linda-Gail Bekker, MBChB PhD Andrea Ciaranello, MD MPH Sydney Costantini Caitlin Dugdale, MD Simone Frank Kenneth Freedberg, MD MSc Louise Ivers, MD Elena Losina, PhD Emily Martey Lucia Millham Anne Neilan, MD MPH Robert Parker, ScD Krishna Reddy, MD Justine Scott, MPH Madeline Stern Alexander Tsai, MD Rochelle Walensky, MD MPH Milton Weinstein, PhD Acknowledgments: National Institutes of Health (K01 HL123349) Our fight against HIV and AIDS is indebted to people living with HIV both past and present #AIDS2018 | @AIDS_conference | www.aids2018.org

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