The Global Fund embraces integration of chronic diseases

For the Global Fund to Fight AIDS, Tuberculosis and Malaria, the funding priorities are in the name. But links between AIDS and TB, in particular, and noncommunicable diseases, have driven calls for the financier to expand its focus to offer more funding for services that integrate NCDs such as cardiovascular disease and diabetes. “The awareness is coming from people living with HIV about multiple morbidities and the problems they’re facing,” Alison Cox, the advocacy and policy director at the NCD Alliance, told Devex. “It’s just a cruel irony that the success of HIV treatment and investment in it means that people are living long enough to die of NCDs. That is what we need to address.” In response, the Global Fund is shifting more explicitly in the direction of financing for integrated programs that include NCDs. The fund’s current five-year strategy, beginning this year, explicitly endorses integrating services to prevent, identify, and treat HIV comorbidities, including NCDs, and supports TB services that manage diabetes and other conditions. The fund is also encouraging countries to integrate services for NCDs into a pool of funding it is offering to build resilient and sustainable systems for health, or RSSH. Many countries participating in the current Global Fund grantmaking round are seizing on the opportunity, looking to integrate NCD coverage into HIV, TB, and RSSH into their current proposals, which are still being completed and evaluated, with the latest grant window closing in August. If they are approved, NCD advocates said it could be a watershed as funds from an institution focused on HIV, TB, and malaria would allow countries to begin recalibrating their broader health systems. It is a growing need. The NCD Alliance reports that people living with HIV and TB, who live mostly in low- and middle-income countries, are more susceptible to many NCDs, including diabetes and cardiovascular disease, than the rest of the population. There are multiple factors driving this link, including the fact that HIV treatment has dramatically extended people’s lives. That means, like any population, as people living with HIV age, they are at increased risk of developing an NCD. Then there is the complex interplay between the different diseases — and their treatments — which has researchers scrambling to understand how contracting one might increase the likelihood of developing another. There are indications that some antiretroviral therapies, the treatment for HIV, might also contribute to the development of some NCDs, including cardiovascular disease. HIV patients are at higher risk for certain types of cancer, including women living with HIV who are six times more likely to develop cervical cancer than women who are HIV-negative. And there is evidence that diabetes, which causes immunosuppression, is a risk factor for developing TB. What all of this adds up to, Cox said, “are a lot of good reasons epidemiologically for wanting to see a more joined-up approach. Contact with the health systems could be an opportunity for screening for hypertension, diabetes, cervical and breast cancer. It’s more efficient for health care services and costs.” But the opportunities haven’t necessarily translated into increased donor funds specifically to improve service integration. That led the NCD Alliance to organize a pre-conference event at last year’s International AIDS Conference in Montreal to highlight the importance of integrated NCD and HIV coverage and to issue an open letter to the Global Fund. In it, the signatories called for the institution to prioritize the inclusion of NCD interventions into its upcoming five-year work program and to “ensure the promotion of integrated, people-centered, quality care services for the Global Fund target groups who are currently strongly affected and dying from NCDs.” The Global Fund has done more than include NCD integration in its five-year strategy. In an information note published last year, the fund encouraged countries applying for HIV financing during this round to “support health and longevity among people living with HIV,” which included proposing investments in integrated care delivery for comorbidities, specifically cardiovascular disease, hypertension, diabetes, obesity, and mental health conditions. Similarly, countries applying for TB grants were directed to consider the management of mental health and chronic conditions, including diabetes. And the RSSH information note spelled out a focus on “delivering integrated, people-centered health services” as an “opportunity to catalyze the integration of HIV, TB and malaria with additional services like mental health, non-communicable diseases and neglected tropical diseases.” Siobhan Crowley, the head of HIV at the Global Fund, told Devex the latest strategy does not signal a sea change, but is part of an evolution that has been underway for almost a decade. “We had a policy that comorbidities could be considered eligible for funding in our 2015 strategy,” she said. However, the previous five-year strategy was not as explicit in promoting integrated programs for NCDs. “The future of HIV is not to be stand-alone,” Crowley emphasized, though she said it will be up to each country to determine how they want to integrate their health services. That means more than including NCD services, she cautioned, but also figuring out how to expand coverage of sexually transmitted infections and other programs. And the Global Fund is encouraging countries to do that with a “level of money that looks roughly the same [as the last funding round], but with the cost of everything higher at this point,” she cautioned. “Countries are really having to make tough tradeoffs.” Nevertheless, she said countries that want to prioritize NCD integration should be able to do so even with the current funding restraints. Some diabetes diagnoses are manageable with diet and weight loss and “hypertension is not very expensive,” she said. “National programs should be procuring and offering their populations these services, anyway. But they can start by making sure it happens in HIV services and [primary health care] to get to whatever blend makes sense.” Several countries have latched onto just that approach, spotting an opportunity in the current grant round to scale up flailing NCD services while breaking out of siloed health care systems built around the diseases that receive the most donor attention. But to utilize Global Fund funding for that process, Cox said countries are “needing to make strong investment cases.” That means understanding the burden of NCDs in their countries and identifying any gaps in coverage while demonstrating how aligning their strategies for addressing multiple diseases could help overcome those shortages. With the support of the World Health Organization and UNAIDS, Zimbabwe hosted a workshop on integrating NCDs and mental health components into HIV-focused Global Fund grants in April. It drew representatives from Ghana, Mozambique, Tanzania, and Zambia. The NCD Alliance also supported teams from Malawi, Tanzania, and Rwanda as they scoped out opportunities last year to make the case for integration. In Zimbabwe, which featured some NCD integration in previous grant rounds — including funding for training — officials and civil society intensively researched the intersection between HIV and aging women in preparation for the current Global Fund grant proposals. Gemma Oberth, who led the drafting of the country’s latest HIV proposal, told Devex that as a result the team “really increased what they’re going to do here” in their latest application. That includes requests to procure high-volume diagnostics, with a focus on screening, diagnosing, and managing hypertension, diabetes, mental health, and cervical cancer among people with HIV. Zimbabwe, like most countries that have submitted their grants, is now waiting on feedback from the technical review panel to see if their NCD integration plans will move forward. Overall, Cox said a “great outcome in this round would be that care is taken to generate good evidence, which is used to get the ball rolling, to build momentum for more of this going forward.” She is hopeful it could be the funding round that truly jumpstarts integration of the traditional Global Fund diseases and NCDs. “We want investments in [antiretroviral therapy] to have impact,” Oberth said. “We can’t have impact if people living with HIV are dying from another disease.”