Addressing Africa’s Dual Disease Burden: Designing Trials for Infectious Diseases Alongside Rising Non-Communicable Diseases

Africa faces a critical epidemiological transition. Infectious diseases such as HIV, tuberculosis (TB), and malaria now coexist with rapidly rising non-communicable diseases (NCDs), including cardiovascular disease, diabetes, hypertension, and cancers. This dual disease burden strains health systems and demands a fundamental shift in how clinical trials are designed, conducted, and integrated into care.

Cardiovascular diseases, diabetes, cancer, chronic kidney disease and inherited conditions such as sickle cell disease are becoming increasingly important contributors to morbidity and mortality across the continent.

This newsletter examines the scale of the challenge, the limitations of traditional siloed research, and practical strategies for designing trials that address multimorbidity, leverage existing infrastructure, and generate actionable evidence for African populations.

Understanding Africa’s Dual Disease Burden

Historically, African health systems and global research funding prioritized infectious diseases. Progress against HIV (through antiretroviral therapy scale-up), malaria, and TB has extended life expectancy. As populations age and urbanize, lifestyle-related risk factors unhealthy diets, physical inactivity, tobacco use, and air pollution have driven a sharp rise in NCDs.

In the WHO African Region, NCDs accounted for 37% of all deaths in 2019, up from 24% in 2000. Nearly two-thirds of these NCD deaths are premature (occurring between ages 30–70), far higher than the global average. Cardiovascular diseases lead NCD mortality, followed by cancers, diabetes, and chronic respiratory diseases. Hypertension prevalence among adults has climbed toward 30–36% in many settings, while diabetes cases are projected to more than double by 2045.

Infectious diseases remain formidable. Africa still carries a disproportionate share of global HIV, TB, and malaria burden. Critically, these conditions frequently overlap: people living with HIV experience higher rates of hypertension, diabetes, and cardiovascular risk, partly due to aging on treatment, chronic inflammation, and shared socioeconomic drivers. Studies in rural South Africa and elsewhere document high multimorbidity, with many individuals carrying at least one infectious disease and one NCD, often poorly controlled.

The result is a “syndemic” in which diseases interact biologically and socially, amplifying morbidity, mortality, and health-system costs. Vertical programs optimized for single diseases struggle when patients present with multiple conditions requiring lifelong management.

How do we design clinical trials that are responsive to Africa’s evolving disease burden?

Moving Beyond a Single-Disease Approach

Africa’s health challenges cannot always be separated neatly into communicable and non-communicable diseases.

Patients may live with multiple conditions simultaneously. An individual participating in an infectious disease trial may also have hypertension, diabetes, kidney disease or an underlying haematological condition. Likewise, patients living with chronic diseases may face increased vulnerability to infectious diseases.

This means clinical development programmes must increasingly account for comorbidities, patient diversity, local disease patterns and the realities of healthcare delivery across African settings.

For sponsors and research organisations, this creates both a challenge and an opportunity: to develop trial strategies that reflect the patients and healthcare systems in which medicines will ultimately be used.

Principles for Designing Trials That Address Both Infectious Diseases and NCDs

Effective trials must be pragmatic, adaptive, and embedded in health systems. Clinical trials conducted in Africa must be built around the realities of African populations.

This includes thoughtful site selection, robust patient recruitment strategies, strong investigator networks, appropriate endpoint selection, patient retention and follow-up, as well as consideration of the clinical conditions that may influence treatment outcomes.

It also requires therapeutic-area expertise.