HIV infection, if it remains uncontrolled, has the potential to swamp progress made in tuberculosis (TB) control, according to the South African Health Review released today.

“This is because it is the most important risk factor for the progression from latent to active disease in people infected with TB,” said Samson Kironde, author of the Health Review chapter dealing with TB.

The SA Health Review, produced annually by the Health Systems Trust, aims to provide a combination of detailed information on health status and health care coupled with in-depth analysis of policies and practices affecting the provision of health services in the country.

According to the Health Review, the Western Cape carried a caseload of 34 211 TB cases last year of which 31,6% were HIV positive.

Kironde revealed that up to 40% of TB patients in South Africa were being co-infected with HIV. HIV-affected individuals also have a 30 times higher probability of acquiring TB than non-HIV infected people.

The Medical Research Council estimates that this year, HIV co-infection will lead to an excess of 123 616 new cases of TB which would otherwise not have occurred. This will contribute 42% of the expected caseload for the year.

“Despite the constraints posed by the HIV epidemic, cure rates for new TB patients have generally improved,” Kironde said.

Figures from June last year revealed that the Western Cape managed to maintain a cure rate of 69%, but Kironde warned that HIV could affect cure rates in future.

He pointed out that where there had been a decline in cure rates, it could not be directly and wholly attributed to the impact of the HIV epidemic.

“Rather the death rate of TB patients where contributory factors to the cause of death are stated is a more accurate indicator.

“However, this information is not easily obtainable from registration data as HIV is not routinely tested for in TB patients,” he said.

Kironde said provincial health departments have agreed to promote the management of TB and HIV as a joint epidemic.

With this in mind four TB/HIV integrated management pilot sites were established in the country during 1999.

The Western Cape site is situated within the Langa Central district.

The Health Review revealed that this year, South Africa is expected to contribute at least 15% of the total TB caseload for Africa yet it accounts for only about 7% of the continent’€™s total population.

Currently, it is estimated that South Africa has a TB/HIV co-infection rate of 2 540 per 100 000 and a TB case fatality rate (death from TB) of 166 per 100 000.

TB in South Africa mainly affects the economically active age group with 86,6% of the TB patients reported in 1999 in the age group of 20 to 59 years.

The review stated that while efforts to contain the TB epidemic in the country over the last five years had been notable, the following areas still required especially sustained attention in order to achieve the objectives of the TB Control Programme:

• Expansion and sustainability of DOTS: It ought to be fully functional at primary health care and community level with sustained commitment by health care providers, NGOs and civic leaders to educate and advocate for the expansion of community-based supervision of TB.  
• Further progress in the integration of HIV/TB management: TB treatment services should offer voluntary counselling and testing for HIV infection, education on HIV/AIDS, condoms and management of opportunistic infections for HIV patients. HIV services should offer education on TB, diagnostic facilities for TB, TB prophylactic treatment for HIV patients at high risk and directly observed treatment for HIV patients with TB.
• Improving the monitoring and reporting system: It is important that a uniform, computerised data collection system be established for the whole country.
• Sustained prevention and management of Mult-Drug Resistant TB: Should be prevented by ensuring improved compliance to anti-TB medication through effective patient treatment support systems and provision of combination drugs.