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TB & HIV in South Africa – Epidemics, NSPs, mines & prisons

South Africa has made good progress over the last few years in combating the two epidemics of TB & HIV. There is however a great deal more that needs to be done.

The TB epidemic

TB was first identified in South Africa as long ago as the seventeenth century. It is however unclear exactly when TB began to spread so quickly that it became of epidemic proportions but the years between 1895 and 1910 seem to have been critical. In 1919 TB was made a notifiable disease throughout the entire country. There is more about the history of TB in South Africa.

The HIV & AIDS epidemic

HIV and AIDS were first identified in South Africa in gay men around the 1980s. By the late 1980s doctors had begun to warn of a significant HIV and AIDS epidemic and the first heterosexual AIDS cases were diagnosed in late 1987. The need for a community based HIV & AIDS program was first publicly acknowledged in 1990 by the Maputo statement on HIV & AIDS in Southern Africa, issued jointly by the banned and exiled ANC and a range of anti apartheid organisations.

There are epidemics of both TB & HIV in South Africa

There are epidemics of both TB & HIV in South Africa

In 1996 at the international AIDS conference South Africans learnt that for those that could afford the costly drugs AIDS could become a chronic manageable disease. But although the first antiretrovirals started to reach South Africa just a few months later, for those without the necessary money nothing had changed. Indeed when in 1999 Thabo Mbeki was elected president the situation in South Africa became worse with the arrival of “AIDS denialism”, the belief that HIV was not the cause of AIDS.

In 2007 Mbeki was defeated in the election for the presidency of the ANC and he was replaced by President Zuma. Finally “AIDS denialism” came to an end with the position of the ANC changing to one where they supported the use of antiretrovirals. South Africa then started to develop the largest antiretroviral drug treatment program in the world.

HIV & TB co-infection

The HIV epidemic in South Africa was and still is, fueling the TB epidemic. As far back as 2009, when the World Health Organisation (WHO) reviewed the South African TB program, they said that the biggest area of concern in South Africa remained the dual epidemics of HIV and TB. There were unacceptably high mortality rates.1“SA TB programme gets a cautious thumbs up”, health-e, July 2009 www.health-e.org.za/2009/07/20/sa-tb-programme-gets-a-cautious-thumbs-up/

South African Government response

Others had in 2009 referred to the initial South African government response to the two expanding epidemics as being marked by:

“denial, lack of political will, and poor implementation of policies and programmes”

There had however by this time been some notable achievements in the expansion of TB control efforts. There had also been improvements in access to condoms as well as the scale up of free antiretroviral therapy. The diagnosis of TB was to be improved by the use of the GeneXpert TB test.

The National Strategic Plan 2007 – 2011 then resulted in further scaling up of the antiretroviral treatment plan for HIV as well as decreasing the number of new HIV infections.

TB in the South African mines and the prisons

By 2011 it had been realised that there were certain places where TB was, as an airborne disease, more likely to be transmitted. In 2011 there were an estimated 760,000 new cases of TB related to South Africa’s mining sector, which was a third of all new cases in Africa that year, and a staggering 9% of all new cases worldwide.2“The ‘worst public health epidemic we’re facing today’? Tuberculosis in the Mining sector”, THINK AFRICA PRESS June 2013 www.health-e.org.za/2009/07/20/sa-tb-programme-gets-a-cautious-thumbs-up/

The incidence rate of TB among workers in South Africa’s mines is the highest in the world, somewhere between 3,000 and 7,000 cases per 100,000 people. As WHO classifies 250 cases per 100,000 people as a “health emergency” it is not surprising that the spread of TB in the mining sector has been described as “the worst public health epidemic that we’re facing today”. There is more about TB and Mining in South Africa.

South-African-Prison-Cell

South African prison cell © Robin Wood

At the same time in  the prisons TB had been described as “raging out of control”.3“The losing battle against TB in prisons”, Daily Maverick, July 2013 www.dailymaverick.co.za/article/2013-07-01-the-losing-battle-against-tb-in-prisons/#.UgJf5VM1eX0 However, the Constitutional Court ruled in December 2012 that the state had been negligent in its approach to TB in prisons. A prisoner, Dudley Lee, had sued the Department of Correctional Services (DCS) for his infection with TB whilst he was incarcerated in Pollsmoor prison. The Constitutional Court recognised that:

“the responsible authorities were aware that there was an appreciable risk of infection and contagion of TB in crowded living circumstance. Being aware of that risk, they had a duty to take reasonable measures.”

The ruling effectively obliged the government to curb the spread of TB in correctional facilities, and the DCS and the Department of Health had drafted policy guidelines for the Management of Tuberculosis in Correctional Centres. However, it was unclear whether these guidelines would have much effect or whether they would simply be more policy documentation. Instead some people had called for the DCS to firstly respect it’s own regulations in the area of cell occupancy and related issues, before it introduced more paperwork.4“The losing battle against TB in prisons”, Daily Maverick, July 2013 www.dailymaverick.co.za/article/2013-07-01-the-losing-battle-against-tb-in-prisons/#.UgJf5VM1eX0

The National Strategic Plan on HIV, STIs and TB 2012 – 2016

It was now time for another strategic plan. However, when it came to the next strategic plan there was no separate plan for TB, but rather one plan to cover HIV and all STIs as well as TB.5“National Strategic Plan on HIV,  STIs and TB 2012 – 2016”, SANAC, 2011 www.gov.za/documents/national-strategic-plan-hiv-stis-and-tb-2012_2016 The aim was to improve on the achievements of the previous plan and to particularly improve prevention efforts for both TB & HIV.

Three of the main goals were:

  • To reduce by half the number of new infections and deaths caused by TB
  • To reduce by half the number of new HIV infections
  • To ensure that 80% of all people who need antiretroviral treatment (ART) actually do get it, and to ensure that 70% of these people do recover and remain alive and on treatment five years after initiation of ART.

Although by 2016 there had been a number of achievements in respect of HIV, it was also said by the South African National AIDS Council (SANAC) that:

We need to give TB and indeed sexually transmitted diseases the same attention that we give to HIV.

Achievements by 2017

By 2017 the country was on to the next NSP for 2017 – 2022, and the achievements in respect of HIV and TB were said by the South African government to be:6“National Strategic Plan on HIV TB and STIs 2017 – 2022”, www.hst.org.za/publications/national-strategic-plan-hiv-tb-and-stis-2017-2022

“We have made major gains in terms of treating millions of people living with HIV & TB, slashing the death toll due to these infections, and reducing the number of new infections. For example:

  • Deaths due to HIV dropped from 681,434 in 2006 to an estimated 150,375 in 2016.
  • Deaths due to TB dropped from 69,916 in 2009 to 37,878 in 2015.
  • The number of new HIV and TB infections has fallen and a higher proportion of people living with these infections have been diagnosed and treated.

However, it was also acknowledged that:

  • In 2016 an estimated 270,000 became newly infected with HIV, and the 2015 estimate of new TB cases was 450,000
  • 3.7 million people were taking antiretroviral treatment for HIV but this was only 53% of those eligible for treatment
  • The number of deaths due to HIV and TB is still massive.

The approach taken in this latest NSP is to intensify efforts in the geographic areas that are most affected. In addition the highest impact interventions are to be used in these areas.

You can read more about TB & HIV in South Africa by looking at

Drug resistant TB in South Africa

& TB statistics South Africa

References

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1. “SA TB programme gets a cautious thumbs up”, health-e, July 2009 www.health-e.org.za/2009/07/20/sa-tb-programme-gets-a-cautious-thumbs-up/
2. “The ‘worst public health epidemic we’re facing today’? Tuberculosis in the Mining sector”, THINK AFRICA PRESS June 2013 www.health-e.org.za/2009/07/20/sa-tb-programme-gets-a-cautious-thumbs-up/
3. “The losing battle against TB in prisons”, Daily Maverick, July 2013 www.dailymaverick.co.za/article/2013-07-01-the-losing-battle-against-tb-in-prisons/#.UgJf5VM1eX0
4. “The losing battle against TB in prisons”, Daily Maverick, July 2013 www.dailymaverick.co.za/article/2013-07-01-the-losing-battle-against-tb-in-prisons/#.UgJf5VM1eX0
5. “National Strategic Plan on HIV,  STIs and TB 2012 – 2016”, SANAC, 2011 www.gov.za/documents/national-strategic-plan-hiv-stis-and-tb-2012_2016
6. “National Strategic Plan on HIV TB and STIs 2017 – 2022”, www.hst.org.za/publications/national-strategic-plan-hiv-tb-and-stis-2017-2022