Incorporating combination polypharmacy into national or provincial CVD control strategies: An African perspective

Global Summit on Combination Polypharmacy for CVD 2012, Hamilton, Ontario, Canada Incorporating combination polypharmacy into national or provincial CVD control strategies: An African perspective Kengne AP NCRP Cardiovascular & Metabolic Disease Medical Research Council, Cape Town, South Africa

Outline The context Opportunities Challenges

Ethnicity - Diversity 2nd largest continent ~ 1 billion inhabitants ~ 1000 ethnic groups/languages > 50 nations Between and within countries socio-economic disparities

Modifiable risk factors among African Stroke survivors Blood pressure Mean 158/92 mmhg Any hypertension: 84% Known hypertension: 71% 8% on anti-htn Mean BP 172/96 mmhg Only 1 patient at target levels Other risk factors: Diabetes: 12% Probable CHD: 11% Current smoker: 9% Other treatments Statin None Aspirin - None SASPI investigators: WHO Bulletin 2004;82:503-508

Barriers to care among stroke survivors in Africa Reluctance to use pills Patients feel they are useless Stopped after the initial amount prescribed ran out Availability of drugs Issues with drug supply particularly at primary care level Late of insufficient drug delivery Cost Drug cost Consultation fees Transport fees SASPI investigators: WHO Bulletin 2004;82:503-508

Clustering of cardiometabolic RF in urban diabetes cohort in Africa Study Country N Age Duration syndrome (%) Criteria Overall Men Women Ogbera Nigeria 601 60 7.0 JIS 2009 60 - - Ogbera Nigeria 973 59 6.9 JIS 2009 86 83 87 Alshkri Libya 99 56 9.4 ATP III 92 82 97 IDF 81 68 88 Kengne Cameroon 308 56 3.0 IDF 72 58 86 ATP III 60 43 79 Kalk SA (Black) 500 48 2.0 IDF 50 46 74 SA (white) 254 54 6.0 IDF 74 53 73 Unadike Nigeria 240 51 - ATP III 62 41 79 Adediran Nigeria 408 56 - WHO 51 44 56 Isezua Nigeria 254 52 6.1 WHO 59 - - Alebiosu Nigeria 218 53 8.5 WHO 25 25 26 Puepet Nigeria 634 54 - IDF 64 74 55 Kengne et al, Unpublished review

CVD risk factor control among people with diabetes in Africa Study Country Age Dur SBP HTN Treate ACE/ Statin ASA Smok- BMI CVD d HTN ARB ing Chinenye Nigeria 57.1 8.8 142 60.9 81.9 66.6/3.1 12.6 65 27.2 4.7 Gudina Ethiopia 48.4 7.4 124 44.4 89.0 84.6 2.7 14.0 11.1 Dzudie Cameroon 56.7 4 142 50.2 88.1 68.2 7.1 7.6 28.5 3.6 Ondoua Cameroon 57 8.3 136 55.6 88.6 54.4 4.9 7.4 5.9 Sobngwi 6 countries 53 8.0 139 65.3 100 77.1 12.9 5.5 27.6 Kengne Cameroon 55.8 3 143 44.8 100 1 1.3 4.9 27.9 Isezuo Nigeria 52 6.1 135 54.3 28.4 25.8 2.2

Available guidelines for cardiovascular risk reduction in diabetes in Sub-Saharan Africa Variables SEMDA1(SEMDA 2002) IDF(IDF Clinical Guidelines 2005) Risk evaluation Single factor Single factor and Global risk (UKPDS risk engine) Fist line BP lowering medications Lipid modifying therapy ACE inhibitors Any except alphaadrenergic blockers IDF Afro (2006) Single factor ACEI or diuretics Based on lipid levels 40 years, CVD, high risk Based on lipid levels Aspirin prescription Secondary prevention High risk individual or CVD Secondary prevention, 40y + other risk factor Smoking cessation Complete cessation Complete cessation Complete cessation Kengne et al, Clinical Medicine Cardiology 2008

Awareness, treatment and control of Hypertension around the world Country Sample Prevalence Awareness Treatment Control Developed world Developing world Africa Men 40.2% 48.4% 28.8% 33.1% Women 32.2% 61.1% 40.5% 38.5% Men 33.4% 42.1% 29.9% 29.7% Women 32.0% 53.6% 40.6% 33.8% Men 40.5% 39.4% 34.5% 21.3% Women 40.3% 55.8% 49.0% 24.7% Journal of Hypertension 2009, 27:963 975

Standards of care for hypertension in selected African countries Country Author Year published Monotherapy (Step-up approach) Nigeria MoH 2008 Yes Yes Uganda MoH 2010 Yes No South Africa DoH 2006 Yes No South Africa DOH/SAHS 2006 Yes Yes South Africa SAHS 2011 Yes No Fixed combination Kenya DoH 2002 Yes Severe HTN Tanzania DoH 2007 Yes No SSA IFHA 2003 Yes No

Country capacity to address CVD MOROCCO TUNISIA Mediterranean Sea WESTERN SAHARA ALGERIA LIBYA EGYPT MAURITANIA Red Sea SENEGAL THE GAMBIA GUINEA GUINEA BISSAU SIERRA LEONE LIBERIA COTE DTVOIRE MALI BURKINA BENIN TOGO GHANA NIGERIA NIGER CAMEROON CHAD CENTRAL AFRICAN REPUBLIC SUDAN ERITREA ETHIOPIA DJIBOUTI SOMALIA U-F-P U-F EQUATORIAL GUINEA SAO TOME GABON REP. OF THE CONGO DEMOCRATIC REPUBLIC OF THE CONGO (ZAIRE) RWANDA BURUNDI UGANDA U-F KENYA Indian Ocean U F P NONE Atlantic Ocean ANGOLA ANGOLA F NAMIBIA MALAWI ZAMBIA U-F-P TANZANIA MOZAMBIQUE ZIMBABWE COMOROS MAYOTTE SEYCHELLES GLORIOSO ISLANDS MADAGASCAR MAURITIUS U, unit available within the ministry of Health for NCDs BOTSWANA REUNION ISLAND F, Funding available for NCD treatment and control P, Existing operational programme for CVD SOUTH AFRICA LESOTHO SWAZILAND Indian Ocean NCDs Country profile 2010

Standards of care for hypertension in selected African countries Country Author Year published Monotherapy (Step-up approach) Nigeria MoH 2008 Yes Yes Uganda MoH 2010 Yes No South Africa DoH 2006 Yes No South Africa DOH/SAHS 2006 Yes Yes South Africa SAHS 2011 Yes No Fixed combination Kenya DoH 2002 Yes Severe HTN Tanzania DoH 2007 Yes No SSA IFHA 2003 Yes No

WHAT WILL THE COMBINATION PILL NOT DO?

Underdiagnosis of CVD in Africa Country Sample Prevalence Awareness Treatment Control Developed world Developing world Africa Men 40.2% 48.4% 28.8% 33.1% Women 32.2% 61.1% 40.5% 38.5% Men 33.4% 42.1% 29.9% 29.7% Women 32.0% 53.6% 40.6% 33.8% Men 40.5% 39.4% 34.5% 21.3% Women 40.3% 55.8% 49.0% 24.7% Journal of Hypertension 2009, 27:963 975

Current density of physicians, nurses required rate of workforce growth according to population growth rates Country Density of physicians, nurses and midwives per 1000 population Scenario I b Annual net rate of growth Scenario II c Population growth rate % Required workforce growth per annum % Central Africa 0.52 0.7 2.3 1.8 13.4 Côte d Ivoire 0.73 7.5 5.9 2.2 10.4 DR Congo 0.64 1.3 2.9 2.5 11.6 Ethiopia 0.24 8.7 7.1 2.6 20.4 Kenya 1.28 2.5 4.1 2.4 5.2 Liberia 0.33 4.6 3.0 4.6 17.7 Madagascar 0.61 4.0 2.4 3.0 12.0 Rwanda 0.48 1.0 2.6 4.9 14.2 Sierra Leone 0.39 1.7 0.1 2.6 16.1 Uganda 0.81 2.3 3.9 2.3 9.4 Tanzania 0.37 4.1 2.5 3.2 16.4 Zambia 2.15 3.8 5.4 2.1 0.5 Total 0.64 3.2 1.6 2.7 11.6 Kinfu et. WHO Bulletin 2009; 3: 225-230

Health service utilisation among screen-detected HTN 9254 adults (25-64 y) screened in Dar es Salaam 540 with HBP at the first visit 245 (47) confirmed after 4 visits 208 untreated advised to seek medical care 161 of them interviewed after 1 year (23% lost to follow-up) 34% had attend a formal health care with 12 month 29% took BP control medications at some point 5% took BP control medication for at least 1 month Only 3% on BP medications at 12 months. Bovet et al, BMC Public Health 2008, 8:407

Retention in care among patients with CVD in Africa Study Country N Condition Follow-up Percent retained Labhardt Cameroon 221 HTN & DM 1 year 49.3% Kengne SSA 41 studies Several 0.5-20 years 72% (64-80%) Kengne Cameroon 351 HTN 26 months 77.3% Kengne Cameroon 225 Diabetes 26 months 84%

Cost of care Personal interventions for CVD in sub-saharan Africa Strategy Cost/DALY ACE-inhibitor (CHF) Cost saving Aspirin/β-blocker (post MI) Cost saving ASA/BB (AMI) 11 ACEI/BB (CHF) 218 Four-drug regimen secondary prevention 350 Streptokinase (AMI) 634 Four-drug regimen primary prevention (10-year risk >15%) 900 Diabetes (intensive glycaemic control HbA1c >8.0) 1810 Diabetes screening 3870 tpa (AMI) 15 900 CABG (post-mi) 27 000 Gaziano Heart. 2008;94:140-4.

Strength of Belief in Cameroonian Causal Web for Sugar Illness (Diabetes) BEHAVIOURAL FACTORS A SSOCIA T ED W IT H M EN NO SPORTS/ LACK OF EXERCISE IN T HE BLOOD NOT SWEATING FAILED PANCREAS INSULIIN GOD IN T HE BODY FROM THE BLOOD T OO M U CH A LCOH OL TOO M UCH SUGAR OVERW EIGH T PHYSICAL FACTORS SUPERNATURAL FACTORS DIET & CONSUM PTION CARELESS EATING TOO LITTLE SUGAR INDIVIDUAL FACTORS INHERIT ED SWEET THINGS SOCIA L FA CTORS sugar illness POVERT Y W EA LT H