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TB in South Africa – HIV, epidemics, National Strategic Plans

No account of TB in South Africa can be complete unless it includes discussion of the HIV epidemic. It is the effect of HIV infection on people with TB that has resulted, and indeed is still resulting, in enormous suffering and tremendous loss of life.

“HIV is driving the TB epidemic in South Africa, with a TB/HIV co-infection rate of above 60% it is clear that the war against TB will never be won unless we win the war against HIV.”

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

By contrast 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.

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.

Both President Mbeki and his health minister Dr Manto Tshabalala-Msimang publicly questioned the effectiveness of antiretrovirals as well as questioning the fact that HIV was the cause of AIDS.

TAC (The Treatment Action Campaign)

Zachie Achmat set up the Treatment Action Campaign

Zachie Achmat set up the Treatment Action Campaign

By  1998, researchers had shown that a short course of the drug AZT could significantly reduce the likelihood of HIV being passed from an HIV positive pregnant woman to her baby. The South African government however, had little interest in providing pregnant women with protection for their babies, it being argued that among other things AZT was too toxic and too expensive. The Treatment Action Campaign was started in 1998 with the aim of ensuring that people living with HIV, both adults and children, could get access to antiretrovirals.

In 2007 President Zuma took over the presidency of the ANC and finally AIDS denialism came to an end. The position of the ANC changed to one where they supported the use of antiretrovirals, and South Africa started to develop what was to become the largest antiretroviral programme in the world.

During this time there had continued to be an increase in the number of cases of TB, with relatively little attention being paid to the problem of TB and HIV co-infection.

South African Government response

However, when in 2009 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/

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”

National Strategic Plan

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

By 2011 South Africa was ranked the third highest in the world in terms of TB burden with an incidence that had increased by 400% over the previous 15 years. The number of cases for all forms of TB had increased from 148,164 in 2004 to 401,048 in 2010. The cure rate had gone from 54% in 2000 to 71.1% in 2009. The corresponding treatment success rate of new infectious TB cases was 77.1 % in 2009, although this was still below the global target of >85%.

South African prison cell &#169 Robin Wood

South African prison cell © Robin Wood

The HIV epidemic had stabilised but at a very high level with a national antenatal prevalence rate of around 30%. The incidence is the number of new infections in a population during a certain time period. The prevalence is the percentage of people in a population that have a certain condition at a given point in time.  For more statistics for South Africa see the HIV statistics for South Africa and the TB statistics for South Africa.

It was estimated that by this time some 80% of the South African population had latent TB. There were also certain populations who were at higher risk of TB infection and re-infection and these included health care workers, prisoners, prison officers, and household contacts of confirmed TB patients. There was an increased risk of TB among miners, and little action had been taken in this area in a number of Southern African countries.

In addition in South Africa there were certain groups of people that were particularly vulnerable to progressing from latent TB to TB disease. These included children, people living with HIV, diabetics, smokers, alcohol and substance users, people who are malnourished or have silicosis, mobile, migrant and refugee populations and people living and working in poorly ventilated environments.

There had however by this time been some notable achievements in the expansion of TB and  HIV control. By 2011 1.4 million people with HIV had started taking antiretroviral treatment and 250,000 men had undergone medical male circumcision. There had been an improvement in TB case detection and there had also been a rapid scale up of faster TB and MDR TB diagnosis.

Drug resistant TB

The number of multi drug resistant TB cases doubled  from 7,350 cases in 2007 to 14,161 in 2012. In addition about 4,700 new MDR-TB and 1,500 retreatment MDR-TB cases were estimated to have occurred among notified pulmonary TB cases in 2014. There is more about drug resistant TB in South Africa.

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

By 2012 it was time for another strategic plan. However, when it came to this plan there was no separate plan for TB, but rather one plan to cover HIV and all STIs as well as TB.2“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 particularly improve prevention efforts for both TB & HIV.

Four of the main goals were:

  • To have 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) do actually get it, and to ensure that 70% of these people do recover and remain alive and on treatment five years after initiation of ART;
  • To reduce by at least 50% the self reported stigma related to HIV & TB.
12 people living in one room in an informal settlement. Ideal conditions for the spread of TB&#169 NombuleloDambaHendrick Groundup

12 people living in one room in an informal settlement. Ideal conditions for the spread of TB © NombuleloDambaHendrick Groundup

The period of this strategic plan saw a considerable reduction in new cases of both TB and HIV, but the decrease in incidence did not reach the 50% target set in the NSP. The reduction in new HIV cases was mainly due to the fact that large number of people living with HIV were no longer infectious due to the fact that they were receiving antiretroviral therapy.

It was considered by some people that during this five year period South Africa  “turned a corner” in relation to TB. Pro-active identification of TB was introduced. TB testing with GeneXpert was introduced countrywide meaning that results were available within a couple of hours and that there was better detection of TB among people living with HIV.

Treatment success rates steadily improved and there were intensified efforts on providing services for high risk populations in correctional facilities, the mining industry and people in informal settlements. However an estimated 150,000 TB cases remained undiagnosed and 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”.

By 2016 the very significant achievements in respect of HIV and TB were said by the South African government to include:3“National Strategic Plan on HIV TB and STIs 2017 – 2022”, www.hst.org.za/publications/national-strategic-plan-hiv-tb-and-stis-2017-2022

  • Deaths due to HIV had dropped from 681,434 in 2006 to an estimated 150,375 in 2016.
  • 3.7 million people were taking antiretroviral treatment for HIV but this was only 53% of those eligible for treatment
  • Deaths due to TB had dropped from 69,916 in 2009 to 37,878 in 2015.
  • The number of new HIV and TB infections had fallen and a higher proportion of people living with these infections had been diagnosed and treated.
  • In 2016 an estimated 270,000 people became newly infected with HIV, and the 2015 estimate of new TB cases was 450,000.

What still needs to be done? The goals of the National Strategic Plan on HIV, TB and STIs 2017-2022

At the time of the launch of this latest National Strategic Plan in 2017 the South African Government said that:

“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. However, there is still a great deal to be done.”

The approach taken in this latest National Strategic Plan 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

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. “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
3. “National Strategic Plan on HIV TB and STIs 2017 – 2022”, www.hst.org.za/publications/national-strategic-plan-hiv-tb-and-stis-2017-2022