Massive twin burden of HIV and TB
But, note authors Professor Salim Abdool Karim and others, ‘until recently, the South African government’s response to these diseases has been marked by denial, lack of political will, and poor implementation of policies and programmes’.
In six short years, between 1994 and 2000, HIV prevalence among pregnant women went from 7.6% to 20.5%.
Tuberculosis arrived in South Africa with the 17th century settlers, and spread rapidly amongst black mineworkers particularly, working underground and living in overcrowded hostels.
However, the HIV epidemic undermined people’s ability to fight TB, and the co-infection rate of the two diseases is estimated at 70% in 2005.
In 1986, 163 people per 100,000 were infected with TB but by 2006, this figure was 628 per 100,000. Only India, China and Indonesia have more TB cases than South Africa, and all have substantially bigger populations.
‘Poor performance of control programmes and low cure rates over many years’ has resulted an explosion of drug-resistant TB. Extensively drug-resistant (XDR) TB, fist identified in rural northern KwaZulu-Natal, has been identified in some 60 facilities in the province and in all nine provinces. The fatality rate is 84%.
In contrast to TB control, the country has the biggest HIV/AIDS treatment programme in the world, and ‘longstanding tuberculosis services have lagged behind and could benefit from the incorporation of some of the key lessons of the antiretroviral therapy scale-up’.
A key factor that make the ARV programme have better outcomes than the TB programme is that patients are giving treatment literacy to understand their condition and their treatment.
‘In marked contrast with this patient-centred approach, TB services typically fail to provide adequate literacy and dis-empower patients because of the need for daily observation of treatment compliance’.
The authors detail the priority actions needed to control tuberculosis, including improving the cure rate (which varies greatly from province to province); improving detection rates (currently at 62%), integrating tuberculosis and HIV services, and identifying and treating drug resistant TB. They recommend that 85% of people with recurrent TB should be tested for drug-resistant TB.
South Africa’s spending on HIV — measured by spending per HIV positive person, spending on HIV prevention per person and as a proportion of gross national product — is on a par with our poorest neighbours, Mozambique and Zimbabwe. We are outstripped even by Malawi, Namibia and Botwana
Although the new National Strategic Plan on HIV/AIDS has set ambitious targets, Zuma’s government needs to show ‘unwavering commitment’ to dealing with HIV and TB.
The authors’ priorities for HIV treatment include: scaling up HIV testing, starting ARV treatment in all patients with a CD4 count of below 350 cells(instead of the current 250); maintaining viral suppression in patients on ARVs (which makes them less infectious) and integrating HIV prevention and treatment services.
‘Ninety percent of HIV positive patients [should be] screened for active TB and 90% of patients with TB [should be] offered an HIV test,’ they recommend.
The break with the AIDS denialism of former president Thabo Mbeki and the election of Zuma’s government opens ‘a window of opportunity’ that South Africa ‘cannot afford to miss’.
‘South Africa still awaits the opportunity to enjoy its newfound political freedoms without the overhanging threat of the HIV and tuberculosis epidemics.’ ‘ Health-e News.
* Paper is written by Professor Salim S Abdool Karim, PRO Deputy Vice-Chancellor at the University of KwaZulu-Natal, Gavin Churchyard, Quarraisha Abdool Karim an Stephen Lawn. http://press.thelancet.com/saser3.pdf
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