Dual epidemics in a young Democracy

For many years, South Africa’s HIV/AIDS epidemic has been the focus of international attention. The state’s obstruction of a public roll-out of antiretroviral therapy (ART), due to AIDS dissidence within the highest echelons of government, drew international attention to the politicization of HIV in South Africa. Moreover, high rates of HIV infection elicited questions regarding the sexual culture, socio-economic conditions and biomedical realities of the so-called ‘rainbow nation’.

But while the attention focused on HIV was duly warranted, another epidemic has remained largely ignored. This is despite its intimate connections with HIV morbidity and mortality, and the important questions beggared by the interactions between the two diseases. HIV is a relatively new disease in South Africa, with the first deaths of citizens from AIDS taking place in 1982. But Tuberculosis (TB) has a much longer history, reflective of the industrial and demographic processes which shaped South Africa’s past and which continue to impact on the health of the population at large.

Why South Africa?

With its history of inequitable distribution of resources and health facilities, South Africa has long shouldered a heavy disease burden of TB.[1] The migrant labour system, in which miners lived and worked in cramped, unsanitary conditions in between visits to their home communities across South Africa, provided fertile conditions for the emergence and entrenchment of a national TB epidemic.

The interaction of TB and HIV in South Africa requires far greater attention and research. Put broadly, however, the rapid spread of HIV across South Africa during the early 1990s is partly attributable to the high national prevalence of TB, and its weakening impacts on the general immunity of the population. The confluence of these diseases also works in the opposite direction, with the biomedical effects of HIV resulting in higher TB caseloads, and more virulent TB infections. Approximately 53% of South Africans with TB are also HIV-positive,[2] with dual infection rates of up to 80% in some communities.[3] HIV infection increases the risk of developing TB by tenfold.

The Double Bind

Due to the Treatment Action Campaign’s court case victory to compel the state to implement a national ART programme, from 2003 the Department of Health was required to initiate a programme of public access to ART. As of November 2008, approximately 350 000 South Africans were accessing the treatment in the public sector, and a further 100 00 in the private sector. Due to expanding access to ART, many South Africans are living healthily with HIV. However, due to high rates of TB/HIV co-infection, TB/HIV is currently the primary cause of death in South Africa.[4] Recorded TB deaths have increased from approximately 25 600 in 1997 to 77 000 in 2006, accounting for 12% of all natural deaths in South Africa.[5] This is despite the fact that TB is curable and largely preventable through infection control measures and access to prophylaxis for high-risk populations (including healthcare workers and people living with HIV). National incidence rates are escalating, and in 2006, the World Health Organisation (WHO) estimated that there were 940 cases of TB for every 100 000 people in South Africa. The WHO recently ranked South Africa fourth among the world’s 22 high-burden TB countries in terms of absolute case numbers.[6]

State of Emergency

In 2005, the former Minister of Health, Dr. Manto Tshablala-Msimang, declared TB an emergency in South Africa. Despite the rhetoric of urgency, the state’s response to the TB/HIV co-epidemic has remained sluggish. Increases in expenditure and resource allocation, as well as the collective commitment of the sate, the private sector and civil society to addressing the TB epidemic, are essential in order to lower infection rates to manageable levels.

Earlier this month, the South African National AIDS Council (SANAC) included TB as an official priority to be incorporated into all of its work. This was a clear attempt to combine broad-based responses to HIV/TB. But despite this positive development, the TB strategic plan of the Southern African Development Community (SADC) for 2007 – 2015, has devoted only 1% of its budget to TB/HIV collaborative activities. By failing to establish closer ties between the treatment of HIV and TB, resources will be wasted and access to treatment for both diseases rendered more difficult. This will be to the detriment of patient convenience, treatment adherence and ultimately disease control. For instance, HIV and TB are frequently treated at different healthcare sites in Southern Africa, with patients having to travel vast distances between the HIV and TB facilities at which they may receive treatment.

The ‘3 I’s’

The new Health Minister, Barbara Hogan, and her Deputy, Dr. Molefi Sefularo, have focused greater attention on the TB epidemic in South Africa. However, what is needed is a massive budget scale-up for TB services in conjunction with the establishment and implementation of what is known in public health as the ‘3 I’s’. These are: Intensified Case Finding (ICF), an effective Infection Control Policy, and a roll-out of Isoniazid Preventative Therapy (IPT), a prophylactic measure that reduces the risk of developing TB by more than 65%.

Intensified Case Finding involves screening all HIV-positive patients for TB at least every six months. The Department of Health reports that around 40% of HIV patients are screened for TB, while the WHO estimates this to be at less than 1% for South Africa. Regardless of the alarming discrepancies in these statistics, what is certain is that screening must be dramatically increased if deaths from AIDS/TB are to be reduced.

In the realm of treatment, Isoniazid Preventative Therapy (IPT) has been prescribed to only four per cent of HIV-positive South Africas. The state is therefore failing to provide this essential prophylaxis. IPT has the potential to reduce the risk of HIV-positive people developing TB by 65%, thus sharply decreasing HIV/TB mortality.

Improving infection control is a third imperative, as nosocomial TB transmission is common at South African healthcare sites. As the public ART roll-out gains momentum, increasing attention is being paid to the interaction of HIV and TB, and of the effects of the ART roll-out on the latter. In their article on TB infection control in resource-limited settings, Bock et al. have outlined the ways in which the very treatment initiatives created by the scale-up of ART have created ‘unprecedented opportunities’ for immuno-suppressed patients to be exposed to TB within healthcare facilities.[7]

Healthcare workers may also be HIV-positive, thus putting their own health at risk in treating patients with active TB, and reducing the productivity of the healthcare facility if they become ill with the disease while simultaneously presenting a TB infection risk to their patients.

Infection Control and Drug Resistant Strains

A recent study showed that a relatively low number of South Africa’s health facilities pass international infection control norms and standards. Despite popular misconceptions, Drug Resistant (DR) TB is not mostly caused by poor management of TB, but rather by primary transmission of the disease through poor infection control. In illustration of this, WHO figures show that 2,442 more cases of Multi-Drug Resistant (MDR) TB in South Africa are in new cases of TB as opposed to ‘re-treatment’ cases of TB.[8] This means that more people are being infected with MDR TB than developing resistance through poor adherence to treatment.

The TB/HIV Working Group of the WHO Stop TB Partnership has drawn up a series of guidelines on ‘Essential Actions for Effective TB Infection Control’, with a special focus on promoting safety without stigma. Their first recommendation concerns the necessity of patients being informed about their rights to rapid TB diagnosis and treatment, and of infection control through mask wearing and ‘cough hygiene’ (the covering of mouth and nose in order to prevent the spread of TB-infected droplets into the surrounding air).These guidelines explain that healthcare workers and patients must be taught that a request to wear a mask or to give a sputum test in a well-ventilated area is not an act of prejudice but rather a means of ensuring a safer clinic for everyone.

As the ART roll-out drives the establishment of new primary healthcare facilities in resource-limited countries, new healthcare sites are being established. Building plans and renovations must consider TB infection control as integral to the construction of new healthcare facilities, so as to ensure optimal natural ventilation.

The ‘Ubuntu’ Clinic

The waiting room of the ‘Ubuntu’ clinic in Khayelitsha (an informal settlement in Cape Town) is a model of TB infection control. There is optimal natural ventilation as the waiting room is outdoors, with heaters, blankets and a roof to protect patients from the elements.The Ubuntu clinic was established in 2003 by Médecins Sans Frontières (MSF) working in conjunction with provincial health authorities.

MSF has a record of remarkable achievements in South African public health. In April 2000, three ART pilot programmes were started by MSF as an adjunct to its primary healthcare centres in Khayelitsha. The purpose of their establishment was to prove that indigent patients could adhere well to ART treatment, in spite of the treatment’s complexities.[9] Due to the emergence of AIDS dissidence within high-ranking political circles, in addition to a lack of political will to respond to the increasing challenges of South Africa’s growing HIV epidemic, it would take a further three years before the state finally committed to the establishment of a national ART roll-out. However, the adherence rates documented in the MSF clinical study on ART were the highest on record when the results were published, overturning the notion that patients adhered better in rich world contexts and highlighting the centrality of effective treatment literacy.[10] The study proved that poverty level and locale were irrelevant to treatment success, but that educating patients in the basic biology of HIV and the importance of treatment adherence were vital.

At the Ubuntu clinic, MSF has applied the sound principles of patient education through treatment literacy, rapid initiation of patients onto the necessary therapies, and the decentralization of healthcare through increased reliance on nurses rather than doctors. The Ubuntu clinic, named after the African philosophical term which translates as ‘a person is only a person through other people’, is a model of integrated HIV/TB services in a resource-limited setting. Its popularity is illustrated by the fact that it is the busiest TB/HIV clinic with the highest TB cure rates in the Cape Town Metro region.[11] This model proves that, with good investments in interventions that result in the best patient outcomes, TB can be reversed.

TAC and TB

The Treatment Action Campaign (TAC) is an HIV activist organization which has won international acclaim for to its efforts in winning public access to ART in South Africa. TAC fights for the health and human rights of citizens, as enshrined in the Constitution. One of the TAC’s primary projects is its treatment literacy programme, whereby communities are educated about diseases through workshops and trainings, using materials which are understandable and accessible to South Africans from a broad range of educational backgrounds. TAC’s treatment literacy programmes also include information about TB, its symptoms, prevention and treatment.

At present, TAC is strongly advocating for better infection control at healthcare sites. TB is entirely curable and, in a properly functioning system, could be eliminated. However, this will take high-level commitment from government, healthcare workers, the private sector and partners in civil society to implement the strategies that will reverse the effects of the dual HIV/TB epidemics.

NOTES
1. S. Benatar, ‘Health care reform and the crisis of HIV and AIDS in South Africa’, New England Journal of Medicine (Vol. 351, No. 1, July, 2004), pp. 82, 85, 89 – 90.
2. Profile, South Africa, World Health Organisation, Available at http://www.who.int/globalatlas/predefinedReports/TB/PDF_Files/zaf.pdf
3. Gandhi, N.R; Moll, A.; Pawinski, R.; Sturm, A.W.; Lalloo, U.; Zeller, K.; Andrews, J.; Friedland, J.; High Prevalence and Mortality from Extensively-Drug Resistant (XDR) TB in TB/HIV Coinfected Patients in Rural South Africa, XVI International AIDS Conference, Toronto Canada. Available at http://www.aids2006.org/PAG/Abstracts.aspx?AID=51350
4. ‘Mortality and causes of death in South Africa’, 2005: Findings from death notification. P0309.3. Available at http://www.statssa.gov.za/publications/P03093/P030932005.pdf
5. ‘Mortality and causes of death in South Africa’, 2006: Findings from death notification. P0309.3. Available at http://www.statssa.gov.za/publications/P03093/P03093.pdf
6. WHO report 2008, ‘Global tuberculosis control - surveillance, planning, financing’. Available at http://www.who.int/tb/publications/global_report/2008/key_points/en/index.html
7. N. Bock, P. Jensen, B. Miller and E. Nardell, Tuberculosis Infection Control in Resource-Limited Settings in the Era of Expanding HIV Care and Treatment, Journal of Infectious Diseases (2007. 196, Supplement 1).
8. Anti-tuberculosis Drug-Resistance in the World, Report no. 4, World Health Organisation, 2008
9. Médecins Sans Frontières South Africa, the Department of Public Health at the University of Cape Town and the Provincial Administration of the Western Cape, South Africa, Antiretroviral therapy in primary heath care: the experience of the Khayelitsha programme in South Africa (WHO, Geneva, 2003), p. 2.
10. Médecins Sans Frontières South Africa, the Department of Public Health at the University of Cape Town and the Provincial Administration of the Western Cape, South Africa, Antiretroviral therapy in primary heath care: the experience of the Khayelitsha programme in South Africa (WHO, Geneva, 2003) p. 7; S. Power, ‘The AIDS rebel’, The New Yorker, 19 May 2003. Available at [email protected] or comment online at http://www.pambazuka.org/