Prevention and control of noncommunicable diseases: lessons from the HIV experience

In many lowand middle-income countries, the challenges of scaling up successful localized projects to achieve national coverage are well recognized.1 However, because of the widely acknowledged success of national efforts to scale up interventions to prevent and control human immunodeficiency virus (HIV) infection, the disease is now largely managed as a chronic condition. The shift means that lessons from the HIV experience may be transferable to the rollout and scale-up of effective interventions for noncommunicable diseases in lowand middle-income countries.2 The scale-up of noncommunicable disease interventions is particularly important because coverage is still modest and the evidence base for implementation in lowand middle-income countries remains very limited.3 WHO’s best buys for reducing noncommunicable diseases in lowresource settings suggest several such interventions. The interventions include measures to improve tobacco control, increasing public awareness of the health benefits of physical activity, multidrug therapy for people at high risk of cardiovascular disease and the screening and treatment of cervical cancer.3 Lowand middle-income countries need to rapidly disseminate and implement effective noncommunicable disease interventions at a national scale, often in contexts of low resources and capacity. The risk of premature death (that is, of people younger than 70 years) from the four major noncommunicable diseases (cardiovascular diseases, cancers, chronic respiratory diseases and diabetes) decreased by 25.4% in high-income countries and by 24.4% in upper-middle-income countries between 2000 and 2015. However, such mortality only reduced by 7.8% in lowermiddle-income countries and increased by 6.0% in low-income countries.4 Lack of context-specific evidence to underpin adaptation and implementation of best buys in low-income and lower-middle-income countries exacerbates this difference, as the bulk of research evidence on innovations to address noncommunicable diseases is from high-income countries.3 Despite limited evidence and capacity for adaptation of these best-buy interventions in low-resource settings, policy-makers and implementers in many lowand middle-income countries are expected to adapt and implement interventions from high-income countries and to move from pilot to implementation at scale. Nonetheless, some of the models of service delivery that have enabled the delivery of long-term care at scale may be transferable from HIV intervention scale-up to noncommunicable disease interventions. Lessons from the HIV experience, relevant to governance, financing, human resources, service delivery, products and technologies, information systems and community mobilization, and their potential applications to noncommunicable diseases are summarized in Table 1. However, acknowledging that significant differences exist between HIV and noncommunicable diseases and that these differences influence implementation and scale-up is important. For instance, evidence for the scale up of HIV-care delivery was primarily generated and applied, and strategies for widespread implementation and scaleup were initially attempted, in lowand middle-income countries. The spread of innovation among lowand middleincome countries was therefore less constrained. Adopting interventions to prevent and control noncommunicable diseases also requires a contextual adaptation of strategies, as these were primarily developed in high-income countries. Ease of adoption and adaptation to local context is key to successful scale-up. For example, while integrated team-based care for people with complex lifelong chronic conditions is important, delivery of such care in a low-resource health system will be different to that in wellresourced health systems. Scale-up is not only technical; it is also political. Scale-up is about what gets on the agenda of governments, global health agencies or philanthropists. HIV was an infectious disease that highincome countries sought to keep outside their borders, hence stimulating support for scale-up of prevention and control measures in lowand middle-income countries. Upstream influences (for instance, the commercial determinants of health) that are driving the increase of noncommunicable diseases are outside the health system. HIV affected population groups whose strong identity fostered collective action, contributing to placing scale-up on the political agenda in many lowand middle-income countries. Movements such as NCDFREE and the NCD Alliance seek to build similar traction for noncommunicable diseases. Addressing noncommunicable diseases may require legal and fiscal measures that are unpopular for industries, such as taxes on tobacco, alcohol and sugarsweetened beverages, and regulation to reduce salt in processed food. In addition to the specific lessons gained from the HIV field, efforts to adopt lessons and innovations from the HIV experience to scale up noncommunicable disease interventions should be informed by several approaches. The first is to follow a structured approach to re-design innovations for scale. The WHO guide1 for scaling-up suggests that the most likely innovations have Prevention and control of noncommunicable diseases: lessons from the HIV experience Seye Abimbola, Emma Thomas, Stephen Jan, Barbara McPake, Kremlin Wickramasinghe & Brian Oldenburg