TB & HIV in South Africa
Any discussion of TB in South Africa needs to include discussion of HIV because:
"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."
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.
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.
In 1996 at the international AIDS conference South Africans learnt that for those that could afford the costly drugs AIDS could be a chronic manageable disease. But although the first ARVs 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.
TAC (The Treatment Action Campaign)
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 ARVs.
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 ARVs. South Africa started to develop what was to become the largest HIV & ARV program 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
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 Plans for HIV & TB
The National Strategic Plans (NSPs) are a series of government plans that initially set out South Africa’s response to HIV & AIDS. The National Strategic Plan for 2007 - 2011 was the third such plan and it has been said that:
“it broke the back of AIDS denialism. It was ambitious and expansive, it set a target of appropriate packages of treatment care and support to 80% of HIV positive people and their families by 2011, it strengthened programmes to prevent mother to child transmission, it introduced the idea of a program of voluntary male circumcision.”
“It was strategically necessary to pack it with every programme we knew had some efficacy because AIDS denialism had placed us seven years behind the AIDS epidemic.”
By 2011 the HIV epidemic had stabilised but at a very high level with a national antenatal prevalence rate of around 30%. South Africa was also 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.
There had however by the end of this period 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.
The National Strategic Plan on HIV, STIs and TB 2012 - 2016
When it came to the next five year 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
https://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 halve 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 ARV 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.
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 ARV 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 in 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”,
- Deaths due to HIV had dropped from 681,434 in 2006 to an estimated 150,375 in 2016.
- 3.7 million people were taking ARV 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.
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.
There is very little mention of drug resistant TB although there is a very ambitious target that the treatment of drug resistant TB in South Africa should be 75% successful.