The South African National AIDS Council (SANAC) took a decision to include tuberculosis as part of its mandate after a World Health Organisation (WHO) review in 2009 of South Africa’s national TB Control programme. The review found that the levels of TB and HIV co-infection in South Africa were enormously high. About 70% or more of TB patients in some parts of the country were also found to be HIV-positive. Following that report, a decision was made that all the country’s collaborative responses to TB and HIV would fall under the oversight of the SANAC. That means that the SANAC will be responsible for developing and co-ordinating policy and practice to deal with the dual epidemic.
For example, ‘what we’ve got now is experts on TB represented on the SANAC structures, the Treatment Task Team of SANAC now includes the TB-HIV experts. In the last year what we also did was manage to get guidelines for the public sector on how to integrate TB and HIV collaborative activities. What we also have is (a) guideline that was approved by the International Labour Organisation on the management of TB and HIV in the workplace’, explains SANAC’s Chief Executive Officer, Dr Nono Simelela.
Simelela says TB has taken priority at SANAC, with suggestions being made that the South African National AIDS Council change its name to reflect the enormity of HIV and tuberculosis co-infection levels in South Africa.
‘There have been proposals at the plenary level to look at whether we shouldn’t actually be having a South African Council on HIV and Tuberculosis. And I really believe that that is the route we need to take. Our belief is that South Africa should consider itself having a TB-HIV epidemic instead of just AIDS because I think AIDS is something we are managing. We’re getting more and more people on treatment. We are increasing the number of people who are eligible for treatment. So, we will see less and less of AIDS. But we will see higher levels of co-infection between TB and HIV’, she says.
One of SANAC’s priorities is to prevent TB infection in HIV-positive people. Current policy is that HIV-infected individuals who don’t have TB be given six-month prophylactic treatment of Isoniazid or INH to prevent them getting the bacterial infection. Simelela is concerned that the distribution and uptake of the intervention has been very low.
‘At the moment we’re sitting at an uptake of, maybe, around 15% of people who are HIV-positive who are taking TB prophylaxis. That’s a dismal figure. We should be around 80% – 85%. We should have 100% of people who are positive for HIV who don’t have active tuberculosis taking prophylaxis for TB’.
She concedes that the service needs strengthening.
‘We’ve spoken to the Clinicians’ Society for HIV. We are speaking to the South African Medical Association to really promote this message and to really get all the doctors in South Africa and the nurses who are managing patients at the primary health care facility ‘ even in the private sector – to provide INH. There’s a huge awareness programme necessary, a huge training and up-skilling of providers and demand by people who are living with HIV to say ‘we know that we must be getting something from the clinic to stop us from getting TB’. And those things haven’t happened’, says Simelela.
On the issue of resources for TB in the face of high levels of co-infection with HIV, the SANAC CEO says:
‘If you look at the allocation of resources for the HIV programme, I don’t think it’s necessarily appropriate to compare. But there is no doubt that the TB control programme needs more resources. It’s only right for us to resource that in the same way that we are resourcing HIV because if you want to improve mortality for those who have got HIV you have to control the TB, you have to manage TB, you have to stop people from getting tuberculosis’.
Aside from TB being the most common opportunistic infection in people living with HIV in South Africa, the country has one of the highest TB burdens in the world ranking in the top five of the 22 high-burden countries. About 1% of the population or 500 000 South Africans get newly infected with tuberculosis annually, according to WHO estimates.