Urgency for South Africa to prioritise cardiovascular disease management
Authors: Aletta E Schutte
Journal: The Lancet Global Health (2018)

Over the past few decades, the burden of high blood pressure has shifted from high-income to low-income and middle-income countries, including sub-Saharan Africa.1NCD Risk Factor CollaborationWorldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants.Lancet. 2017; 389: 37-55Summary Full Text Full Text PDF PubMed Scopus (1340) Google Scholar Raised blood pressure is accompanied by rising obesity trends, with 68% of South African women and 31% of men being overweight or obese.2National Department of HealthStatistics South AfricaSouth African Medical Research CouncilICFSouth Africa Demographic and Health Survey 2016: key indicators. Statistics South Africa, Pretoria2017Google Scholar In South Africa, the age-standardised death rates for non-communicable diseases (NCDs) are now higher than those of HIV/AIDS and tuberculosis combined,3Nojilana B Bradshaw D Pillay-van Wyk V et al.Persistent burden from non-communicable diseases in South Africa needs strong action.S Afr Med J. 2016; 106: 23-24Crossref PubMed Scopus (46) Google Scholar, 4Pillay-van Wyk V Msemburi W Laubscher R et al.Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study.Lancet Glob Health. 2016; 4: e642-e653Summary Full Text Full Text PDF PubMed Scopus (200) Google Scholar with cardiovascular disease being the leading category of NCDs. Despite this reality, South Africa faces a balancing act. As the country with the highest burden of HIV/AIDS, most health-care spending remains directed towards antiretroviral treatment, with limited finances available for NCDs, especially in primary health care. South Africa has therefore implemented an ambitious strategic plan to decrease premature mortality from NCDs by 25% by 2020.5National Department of HealthStrategic plan for the prevention and control of non-communicable diseases 2013–17. National Department of Health, Pretoria2013Google Scholar Population-based strategies to prevent NCDs are progressive and include legislation for the reduction of sodium in processed foods, taxation of sugar-sweetened beverages and alcohol, and continued tightening of anti-tobacco regulations. The crucial point, however, is individual-level strategies within the primary health-care sector where the detection, treatment, and control of cardiovascular disease risk factors should take place. In The Lancet Global Health, Sanjay Basu and colleagues6Basu S Wagner RG Sewpaul R Reddy P Davies J Implications of scaling-up cardiovascular disease treatment in South Africa: a microsimulation and cost-effectiveness analysis.Lancet Glob Health. 2018; (published online Dec 6.)http://dx.doi.org/10.1016/S2214-109X(18)30450-9Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar present a timely analysis on the implications of scaling up treatment of cardiovascular disease in South Africa. They base their analyses on risk factor statistics and treatment levels reported in the national 2012 SANHANES study, applying these data to create a demographically representative simulated population using the most recent census data (ie, 2011) and population projections. Unsurprisingly, they find cardiovascular risk factors to be common and disproportionate among socioeconomically disadvantaged populations and emphasise that targeting antihypertensive and statin treatment might need to be prioritised over blood glucose therapies. Importantly, Basu and colleagues emphasise that disadvantaged populations could disproportionately benefit from assertive treatment, as embodied by two alternative treatment guidelines: the WHO's package of essential non-communicable disease interventions (PEN) and South Africa's Primary Care 101 (SA PC 101) guidelines. A multicentre study7Mash B Fairall L Adejayan O et al.A morbidity survey of South African primary care.PLoS One. 2012; 7: e32358Crossref PubMed Scopus (94) Google Scholar on primary care in South Africa, including 18 856 consultations, showed that primary care is dominated by NCDs, with hypertension being the leading reason to attend primary care as well as the most common diagnosis. HIV ranked third. Furthermore, the vast majority of patients were seen by nurses.7Mash B Fairall L Adejayan O et al.A morbidity survey of South African primary care.PLoS One. 2012; 7: e32358Crossref PubMed Scopus (94) Google Scholar The importance of scaling up not only treatment of hypertension and dyslipidaemia6Basu S Wagner RG Sewpaul R Reddy P Davies J Implications of scaling-up cardiovascular disease treatment in South Africa: a microsimulation and cost-effectiveness analysis.Lancet Glob Health. 2018; (published online Dec 6.)http://dx.doi.org/10.1016/S2214-109X(18)30450-9Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar but also training of nurses on the correct measurement and aggressive management of NCDs seems paramount. By investing in active detection, prevention, and control of cardiovascular diseases, large-scale health-care expenses on hospitalisations could be averted. In their simulated population, Basu and colleagues6Basu S Wagner RG Sewpaul R Reddy P Davies J Implications of scaling-up cardiovascular disease treatment in South Africa: a microsimulation and cost-effectiveness analysis.Lancet Glob Health. 2018; (published online Dec 6.)http://dx.doi.org/10.1016/S2214-109X(18)30450-9Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar evaluate possible treatment recommendations as per the WHO PEN and SA PC 101 guidelines. They show that with current treatment levels, South Africans experience a burden of 40 DALYs (95% CI 29·5–52·0) per 1000 people per year, but if the SA PC 101 guidelines were implemented, these DALYs would lower to 32·5 (24·4–44·8), thereby saving almost US$25 000 per DALY averted.6Basu S Wagner RG Sewpaul R Reddy P Davies J Implications of scaling-up cardiovascular disease treatment in South Africa: a microsimulation and cost-effectiveness analysis.Lancet Glob Health. 2018; (published online Dec 6.)http://dx.doi.org/10.1016/S2214-109X(18)30450-9Summary Full Text Full Text PDF PubMed Scopus (30) Google Scholar The simulation, however, is based on the SANHANES treatment and control rates for hypertension of 71·4% and 70·6%, respectively, which differ substantially from other reports from SANHANES (22·4% and 8·9%, respectively)8Berry KM Parker WA McHiza ZJ et al.Quantifying unmet need for hypertension care in South Africa through a care cascade: evidence from the SANHANES, 2011–2012.BMJ Glob Health. 2017; 2: e000348Crossref PubMed Scopus (73) Google Scholar and the South African Demographic and Health Survey 2016 (control of 9·2% in women and 5·5% in men).2National Department of HealthStatistics South AfricaSouth African Medical Research CouncilICFSouth Africa Demographic and Health Survey 2016: key indicators. Statistics South Africa, Pretoria2017Google Scholar Notwithstanding this discrepancy, Basu and colleagues show that the cost-effectiveness of blood pressure and lipid therapies become more pronounced at lower levels of baseline treatment. To conclude, more aggressive approaches are required to manage NCDs in South Africa and other developing countries. These include scaling up treatment of hypertension and dyslipidaemia and empowering nurses by effective training on NCD management. The 2018 European Hypertension Guidelines9Williams B Mancia G Spiering W et al.2018 ESC/ESH Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension.J Hypertens. 2018; 36: 1953-2041Crossref PubMed Scopus (1527) Google Scholar reiterate these actions as new concepts. The guidelines firstly suggest aggressive treatment of hypertension—namely the preferred use of a single-pill, two-drug combination therapy for the initial treatment of most people with hypertension. This should substantially improve blood pressure control. The guidelines also recognise the key role of nurses in the long-term management of hypertension. I have received support from Servier and Novartis, outside of the submitted work. Implications of scaling up cardiovascular disease treatment in South Africa: a microsimulation and cost-effectiveness analysisCardiovascular risk factors are common and disproportionate among disadvantaged populations in South Africa. Treatment with blood pressure agents and statins might need greater prioritisation than blood glucose therapies, which contrasts with observed treatment levels despite a lower monthly cost of blood pressure or statin treatment than of sulfonylurea or insulin treatment. Full-Text PDF Open Access