While HIV and TB rates in South Africa are slowly declining, cases of non-communicable diseases (NCDs) like hypertension and diabetes are climbing, particularly the former, with experts suggesting that using some of the strategies employed in combatting HIV might be effective, writes Elri Voigt for Spotlight.
For much of the past decade, UNAIDS’s 90-90-90 targets have been central to how governments have kept track of their HIV responses. The first 90 measured the success of testing programmes, the second 90 measured the success of efforts to get people on to treatment, and the third 90 provided information on how well people are doing once on treatment.
South Africa’s National Strategic Plan (NSP) for the prevention and control of NCDs (2022-2027) sets out similar targets for hypertension and diabetes. As with HIV, the three hypertension indicators will paint a picture of how the country is doing on testing, getting people on treatment, and finally, how well they are doing once on treatment.
The hypertension targets are as follows:
• 90% of people over 18 will know whether they have raised blood pressure (BP).
• 60% of people with raised BP will receive interventions.
• 50% of people receiving interventions for hypertension will have controlled BP levels.
Implementation will be key
Experts interviewed by Spotlight agree the NSP is a step in the right direction but say it’s clear more will be needed.
Professor Brian Rayner, Emeritus Professor in the Division of Nephrology and Hypertension at the University of Cape Town, says he finds the NSP lacking in practical details of how the targets will be achieved. “I’d love the government to have the plan for how it can achieve this – it needs to actually say how we are going to do this,” he says.
Professor Angela Woodiwiss of the School of Physiology at the University of the Witwatersrand, and member of the board of the Southern African Hypertension Society, has similar concerns. She says the objectives and deliverables in the NSP are sound, but short on details regarding implementation.
She suggests that addressing this could include “cost-effective practical approaches like setting up cardiovascular screening centres at all district clinics where measurements of BP are done; monthly screening drives at community centres over weekends for those who work during the week; (and) awareness campaigns at malls”. Another suggestion is for hypertension awareness and education campaigns on TV and radio.
“To reduce the burden of disease, this target needs to be raised. I would suggest 90-80-70 as the proportions,” she adds.
Professor Andre Kengne, director of NCD research at the South African Medical Research Council, who was also part of the planning committee for this version of the NSP, says the plan is only a starting point. “The plan says these (NSP targets) are the entry point, so it’s going to be a catalyst,” he says. “We just need to start somewhere and then improve on that … I think that’s exactly the approach the plan is taking: let’s start small but with the aim of actually progressing.”
Screening: 90% of people over 18 will know if they have raised BP
A major challenge with NCDs like hypertension and diabetes is there are no good epidemiological data in South Africa. Experts referred Spotlight to data from two sources.
Kengne says based on data collected by the NCD Risk Factor Collaboration, a global network of health scientists providing data on NCDs, of which he is part, about 40% of men and about 42% of women in South Africa had hypertension in 2019. Only about 38.5% of men with hypertension were diagnosed at the time and 61.5% of women.
Woodiwiss cites data collected through May Measure Month (MMM) SA, where she is a principal investigator. MMM is a global campaign run by the International Society of Hypertension to raise awareness. She cites data collected from screenings conducted from 2017 to 2022.
“The proportion of hypertensive adults aware that they have hypertension ranged from 42.5% to 56.7%,” she says.
Looking at the South African population as a whole, Woodiwiss calculates that this means only around 13.6% to 19.6% of everyone over 18 is aware of whether they have hypertension or not. “So we have a long way to go to achieve the target of 90% of all adults being aware of whether they have raised BP or not.”
Whichever of the two data sources you look at, South Africa falls well short of the 90% target.
To improve the performance, experts said there should be greater awareness of hypertension (including the importance of checking BP regularly) and better opportunities for screening.
“There will be no other way of actually improving numbers without screening people,” Kengne says.
“The current approach is essentially hospital-based, and it’s not even comprehensive, meaning only those in contact with the health system are likely to get their BP measured and then eventually get diagnosed with hypertension. The first focus is to optimise that hospital-based screening, to ensure everything is in place to measure the BP of whoever gets in contact with the system.”
Ultimately, Kengne suggests implementing community-based approaches to blood pressure screening. One way would be to couple HIV community screening efforts with hypertension screening, and empowering community healthcare workers to check BP when doing household visits, before referring people with elevated blood pressure to clinics if needed.
“There should be national awareness campaigns on TV and radio that encourage people to have their BP measured at free screening sites like community centres, malls, and university campuses, as is done as part of the May Measure Month campaign.”
Treatment: 60% of people with raised BP receive interventions
“About 85% of those (men) diagnosed (with hypertension) are on treatment. In women, it’s about 86%,” Kengne says.
This, he adds, is where the NSP targets are not as ambitious as they could be because looking at the data of everyone with hypertension (not just those with diagnosed hypertension), only 33% of men and 53% of women are on treatment.
In Woodiwiss’ data, the proportion of hypertensive adults receiving medication for hypertension ranged from 36.1% to 49.2%.
One of the biggest challenges to getting people on treatment is diagnosing them in the first place. The question, however, is whether the health system will be able to cope with the increased treatment load if diagnosis improves.
Kengne said public health sector facilities might not cope, that task-shifting might be part of the solution. This was critical to the scaling up of SA’s HIV treatment programme, for example, by allowing qualifying nurses to prescribe antiretroviral treatment.
Similarly, more staff, including community healthcare workers, nurses, and field workers, can be trained to screen for and treat hypertension.
Reducing the pill burden on hypertension patients in the public sector is also critical. While medication is relatively cheap, there has not been a move towards combining multiple blood pressure drugs into a single pill, making patient adherence easier.
The prescribing of BP medication in the private sector needs to be simplified, suggests Rayner, and allowing nurses to prescribe medication for straightforward hypertension cases would be a cost-effective way to treat the problem.
Control: 50% of people receiving interventions are controlled
About 43% of men with hypertension and who are on treatment have controlled BP compared with 54.6% of women, says Kengne.
“Taken as a proportion of all those with hypertension, our target of 50% controlled will narrow down to about 27% of all people with hypertension (being controlled),” he says.
“Using that as the estimate among men, currently only 14% of all those with hypertension are controlled and among women, 29% are controlled.”
Data from Woodiwiss suggested “the proportion of treated individuals with controlled blood pressure ranges from 49.6% to 57.5%”.
For this target then, the country isn’t too far off the 50% target.
But Kengne says BP control is not straightforward. “Diagnosing, it’s not that difficult. Starting treatment is not difficult, but treating to target it’s a challenge, with various factors coming into play. Some can be linked to healthcare providers and the health system.”
For patients, issues like adherence to treatment can be difficult. He suggests using mobile technology, like text messages, to remind patients to take their medication, and reducing the pill burden by investing in combination medications.
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Spotlight article – 90-60-50: Can SA reach its hypertension targets? (Creative Commons Licence)
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