Open letter to The Global Fund to Fight AIDS, Tuberculosis and Malaria Strategies Committee

July 2022

Dear Esteemed Board and Members of The Global Fund to Fight AIDS, Tuberculosis and Malaria Strategy Committee, 

The Global Fund strategy 2023-2028 presents a unique opportunity for the inclusion of noncommunicable disease (NCD) and co-morbidities in the organisation’s programming. Due to the bidirectional relationship between NCDs, and HIV, tuberculosis (TB), and malaria, the incorporation of NCD programing could lead to improved quality of life and treatment outcomes, and to reduced premature mortality. Action now would build on the recommendations of the Global Fund Board’s approval of the framework for financing co-infections and co-morbidities of HIV/AIDS, TB and malaria, as set forth in GF/B33/11, on 1 April 2015.

Given the growing focus on universal health coverage (UHC), health system strengthening and the clear evidence of NCD comorbidities with HIV/AIDS, TB, and malaria, a bold approach to health services integration is needed to both protect the hard-earned gains for the three diseases over the last few decades and to ensure a better quality of life for people with these diseases. 

Increased risks of co-morbidities

It has been clearly demonstrated that people living with HIV have a significantly higher risk of cardiovascular disease, including hypertension, and cancers. It is estimated that one in three people living with HIV have hypertension and HIV-infected individuals have an increased incidence for at least 20 non-AIDS-defining cancers. HIV is also associated with as high as 100 times standardized incidence ratio for AIDS-defining cancers such as Kaposi’s sarcoma, with women living with HIV being up to six times more likely to develop cervical cancer. 
Additionally, people living with HIV and TB are much more susceptible to diabetes, and vice-versa. Approximately 370,000 new TB cases in 2020 were attributed to diabetes and in 2019, just over 15% of people with TB were estimated to have diabetes globally, compared with 9.3% among the general adult population (aged 20-79 years) resulting in an estimated 1.5 million people with TB and diabetes requiring coordinated care and follow-up to optimise the management of both conditions. 
Addressing the co-morbidities of NCDs with HIV, TB, and malaria will improve patient outcomes and reduce premature mortality globally, supporting progress towards Universal Health Coverage. 

Commitments to improving and integrating health services

Significant shifts at the global strategic and policy levels have been witnessed in support of integrated health systems and services, founded on the aspiration of achieving UHC. The fundamental 2019 Political Declaration of the UN General Assembly on UHC, saw Heads of State and Governments commit to “progressively cover 1 billion additional people by 2023 with quality essential health services and quality, safe, effective, affordable and essential medicines, vaccines, diagnostics and health technologies, with a view to covering all people by 2030.” 
In addition:
  • The 2011 Political Declaration of the first UN General Assembly on the Prevention and Control of NCDs, the 2014 Outcome Document of the second UN General Assembly on the Prevention and Control of NCDs and the 2018 Political Declaration of the third UN General Assembly on the Prevention and Control of NCDs, Heads of State and Governments committed to “integration, as appropriate of responses to HIV/AIDS and non-communicable diseases”.
  • The 2021 United Nations Political Declaration on HIV/AIDS also pledged to ensure that 90% of people living with or at risk of HIV can access the full range of essential health services, specifically including NCD and mental health care by 2025. 

Integrating investment

To benefit the poorest people living with HIV, TB, and malaria, the Global Fund should adopt an integrative approach where funding eligibility could be inclusive of hypertension, diabetes, and cancer. The Global Fund has a valuable opportunity to accelerate achievement of targets, while simultaneously addressing evolving community needs through cost-effective, evidence-based health interventions for NCDs. 
Implementation of the best-buy interventions for NCDs will give tangible and measurable results when integrated with interventions for HIV, TB and other target areas for the Global Fund. Investing in primary health care (PHC) is the cornerstone of enabling health systems to respond to the healthcare needs of people with HIV and NCDs. It will be critical to improving the coverage of services for early diagnosis, screening and appropriate treatment of the Global Fund focus diseases and NCDs. This urgent need was clearly demonstrated during COVID-19 and will be the foundation for achieving UHC. 

We therefore call on the Global Fund to:

  • Prioritize the inclusion of NCD interventions into the work program of the 2023-2028 Global Fund strategy 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.
  • Create financial and technical support to for activities relating to HIV and NCD prevention and care integration as a path towards UHC.
  • Ensure meaningful engagement of people living with and affected by Global Fund target diseases who also live with other chronic conditions, such as NCDs, in Global Fund’s strategic decision-making and accountability processes at global and country level, including in Global Fund’s country funding proposal development and implementation. So, to understand their full health care needs to improve quality of life and physical and financial barriers to access, including in accountability for progress towards UHC.
  • Provide financial and technical support for integrated services in PHC to develop more resilient and sustainable health systems. Support could include the mandatory consideration of NCD prevention and care within PHC-level Global Fund supported programmes and funding proposals, and supporting communities to conduct community-led monitoring of the quality of integrated services at PHC level. 
  • Provide financial and technical support for data collection, monitoring, and evaluation of access to care and quality of life for people living with Global Fund target diseases and NCDs to advance the evidence base on: 1) current gaps in secondary and tertiary health care for these patient groups; 2) equitable, impactful, cost-effective, gender-sensitive and age-responsive integration strategies at secondary or tertiary level.
Now is the time for the Global Fund to act on the growing impact of NCDs on the physical and mental health and wellbeing of people living with and at risk of HIV, TB, and malaria, and on the sustainability and resilience of health systems.  The price on action to address the comorbidities of HIV, TB, and malaria with NCDs is far outweighed by the human cost of inaction. 
We stand by ready to provide our full support for your efforts in promoting integrated, people centered quality care services. 
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