Primary health care in AIDS

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The Lancet 2008; 372:866-868. DOI:10.1016/S0140-6736(08)61373-2

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From Alma-Ata to Agincourt: primary health care in AIDS

Hoosen Coovadia a and Ruth Bland b

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The often accompanying crises in serious epidemics—food, energy, and water—are dramatic reminders of failures to invest wisely in communities and respond effectively to a changing global landscape. We need fresh solutions to prevent disease and sustain life. Tollman and colleagues,1 in today's Lancet, provide a rare glimpse into changing patterns of death in Agincourt, a rural South African community. In doing so, they draw attention to the need to re-organise services for primary health care to respond to these emerging epidemics: an important challenge for many low-income settings that are experiencing the double burden of infectious and non-communicable diseases.

The Agincourt population faces a tide of HIV and tuberculosis, together with an increasing burden of non-communicable diseases—the twin scourges of many developing countries. By presenting causes of death, Tollman and colleagues document a mortality transition over a 13-year period. Although the prevalence of non-communicable diseases was generally low in those aged younger than 65 years in the study, there was evidence that such diseases are being detected at a younger age. The major strengths of the study are its quality of longitudinal data, population size, use of a validated instrument for verbal autopsy, and rigorous data management.

Tollman and colleagues' key findings suggest that models of primary health care introduced almost 40 years ago, and derived from the Alma-Ata Declaration, are now no longer valid. These early recommendations promoted, among other things, delivery of primary health care that was appropriate for acute infectious and nutritional diseases. Yet, in much of contemporary Africa, chronic infectious diseases coexist with chronic non-communicable diseases2–4 (although HIV is still largely managed as an acute illness), with reliance on physician-led diagnosis and management. This approach is overwhelming already overburdened health systems and is not sustainable much longer.

New thinking is needed to develop decentralised models of primary health-care services that integrate management of chronic infectious diseases with that of chronic non-communicable diseases. Tollman illustrates this approach by showing how the management of HIV/AIDS and cardiovascular and metabolic disorders potentially overlaps. The approach in primary health care of integrating the management of chronic infectious diseases with that of chronic non-communicable diseases will find supporters among those who favour a diagonal approach to health care, in which the response to an urgent problem is facilitated to improve services for other disorders.5

Mortality data, which are the main thrust of Tollman and colleagues' paper, do not fully reflect health and disease. Previous findings from Agincourt6 revealed important information about risk factors for non-communicable disease and morbidity, including hypertension, female obesity, male smoking, subclinical atheroma, and a stroke prevalence double that seen in other parts of Africa. Details of risk and morbidity data are provided in a webtable in Tollman's paper. Together these data imply a later stage in the health transition than elsewhere in Africa, but show similarities to another rural area of South Africa where a population-based survey has also shown a high prevalence of overweight people, obesity, and hypertension in the adult population, especially those without HIV.4

This burden of non-communicable diseases will be further uncovered as scaled-up treatment programmes lead to reduced mortality from HIV/AIDS.

Tollman and colleagues' expectation that integrated primary chronic care will be better than the current system does not entirely follow from their data. They do, however, provide some support for their argument by showing that stratification of health problems in Agincourt according to types of health-service needs would favour chronic care. A Cochrane review, which assessed strategies for integrating primary health-care services in low-income and middle-income countries, found few studies of good quality and no consistent pattern.7 Tollman, rightfully circumspect, points out that integration will have to be carefully shown in properly conducted trials that could explore novel ways of integrating primary health care. The health transition they describe spans an unprecedented number of transitions8 in the country, which are epidemiological, demographic, political, migratory, and socioeconomic. Welfare services for previously disadvantaged people have expanded enormously since South African independence in 1994.9

The extent to which the Agincourt experience can be directly translated to other regions in Africa depends on variations in context,10–12 which will affect the configuration of primary health-care services. The challenge for policy makers is how to integrate health systems, which are currently fragmented, based on a series of vertical programmes, and dependent on physicians. Integration on a small scale can be achieved with relatively little effort.

For example, in an attempt to further coordinate the integration of tuberculosis and HIV services in a subdistrict, a new daily cough clinic was established at Hlabisa Hospital, northern KwaZulu-Natal, South Africa. The clinic operates from a portacabin adjacent to the antretroviral clinic (figure).

Patients with a cough, or referred from the antretroviral clinic are screened for tuberculosis by a nurse who takes a history and arranges for an immediate chest radiograph. Every patient is then seen by a physician (20 patients daily). All patients are offered HIV testing on the same day in an adjacent portacabin, and uptake is over 80%.

Click to enlarge image

Figure. Integration of tuberculosis and antiretroviral services at Hlabisa Hospital, northern KwaZulu-Natal, South Africa

ART=antiretroviral.

Tom Heller

On a larger scale, however, re-organisation of primary health-care services, extending from those envisaged by Alma-Ata to the integrated management of chronic diseases, requires a major shift.

On the basis of our experiences in KwaZulu-Natal in dealing, at different locations, with either fragmented or unified services for tuberculosis and HIV, such shifts include the need for changes in the current legal framework to allow more tasks to be done by alternative cadres of health workers, and careful assessment.

We declare that we have no conflict of interest.

References

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9. Bhorat H, Kanbur R. Poverty and well-being in post apartheid South Africa: an overview of data, outcomes and policy. September, 2005: http://www.arts.cornell.edu/poverty/kanbur/BhoratKanbur...(accessed Aug 8, 2008)..

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Affiliationsa. University of KwaZulu-Natal, Durban, KwaZulu-Natal 4013, South Africab. Africa Centre, Mtubatuba, KwaZulu-Natal, South Africa

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