Elsevier

The Lancet

Volume 374, Issue 9693, 12–18 September 2009, Pages 921-933
The Lancet

Series
HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response

https://doi.org/10.1016/S0140-6736(09)60916-8Get rights and content

Summary

One of the greatest challenges facing post-apartheid South Africa is the control of the concomitant HIV and tuberculosis epidemics. HIV continues to spread relentlessly, and tuberculosis has been declared a national emergency. In 2007, South Africa, with 0·7% of the world's population, had 17% of the global burden of HIV infection, and one of the world's worst tuberculosis epidemics, compounded by rising drug resistance and HIV co-infection. Until recently, the South African Government's response to these diseases has been marked by denial, lack of political will, and poor implementation of policies and programmes. Nonetheless, there have been notable achievements in disease management, including substantial improvements in access to condoms, expansion of tuberculosis control efforts, and scale-up of free antiretroviral therapy (ART). Care for acutely ill AIDS patients and long-term provision of ART are two issues that dominate medical practice and the health-care system. Decisive action is needed to implement evidence-based priorities for the control of the HIV and tuberculosis epidemics. By use of the framework of the Strategic Plans for South Africa for tuberculosis and HIV/AIDS, we provide prioritised four-step approaches for tuberculosis control, HIV prevention, and HIV treatment. Strong leadership, political will, social mobilisation, adequate human and financial resources, and sustainable development of health-care services are needed for successful implementation of these approaches.

Introduction

The concomitant epidemics of HIV and tuberculosis present a major public health problem in South Africa. Despite constituting just 0·7% of the world's population, South Africa accounted for 17% (about 5·5 million people) of the global burden of HIV infection in 2007.1, 2 Furthermore, as a result of the convergence of a major pre-HIV-era tuberculosis epidemic, rising numbers of tuberculosis cases associated with the maturing HIV epidemic, and growing resistance to antituberculosis drugs, South Africa now has one of the most serious tuberculosis epidemics in the world (table 1).

The social, economic, and environmental conditions created by apartheid6—such as overcrowded squatter settlements, migrant labour, and deliberately underdeveloped health services for black people—provided a favourable environment for efficient transmission of HIV and tuberculosis.7 Hundreds of thousands of black people working in South Africa's cities were forced to live in overcrowded, poorly ventilated, single-sex hostels. These hostels were often served by sex workers (euphemistically referred to as “town wives”). The oscillatory migration lifestyle of these workers—ie, living temporarily in the cities and on the mines, with regular visits to wives and families in rural homelands—was key to the spread of tuberculosis8 and sexually transmitted infections9 in the first half of the 20th century.

Because these historical conditions continue to define the nature of the HIV and tuberculosis epidemics in South Africa, both diseases are crucial public health challenges in the post-apartheid era. Moreover, their control is fundamental to economic growth and development in the country's young democracy.10 Unfortunately, South Africa's response to the epidemics during the past decade has been marked by denialism, ineptitude, obtuseness, and deliberate efforts to undermine scientific evidence as the basis for action (panel 1 and figure 1).12, 13 The change in administration in 2008, and the subsequent elections in 2009, however, have created new hope that the country will rise to the challenges of HIV and tuberculosis. Obtaining the best evidence available and taking decisive action are key to controlling both diseases. This report provides a historical perspective and overview of South Africa's evolving HIV and tuberculosis epidemics and how the government has responded to them, and concludes with a prioritised set of strategic steps for HIV and tuberculosis control.

Key messages

  • Worldwide, South Africa has the highest number of people living with HIV/AIDS, representing a quarter of the disease burden in sub-Saharan Africa and a sixth of the global disease burden.

  • South Africa has one of the worst tuberculosis epidemics in the world, with high disease burden, incidence rates, and HIV co-infection rates, and growing epidemics of multidrug-resistant and extensively drug-resistant tuberculosis.

  • Although South Africa has well formulated and broadly accepted Strategic Plans for HIV/AIDS and tuberculosis, insufficient political will and inadequate capacity to deliver on many of the urgently needed health-care interventions are major deficiencies in the country's response to the epidemics.

  • The HIV/AIDS epidemic will continue to shape the South African health service. The successful scale-up of antiretroviral therapy provision, leading to the creation of the world's largest HIV/AIDS treatment programme, is key to stimulating innovation to strengthen the overall health service.

  • The newly elected South African Government has the opportunity to actively support and adequately resource the implementation of an evidence-based public health policy to effectively control the HIV and tuberculosis epidemics.

Section snippets

The evolving HIV epidemic in South Africa

The HIV epidemic in South Africa has been characterised by high prevalence rates in young women (figure 2). In 1992, HIV prevalence rose most rapidly in teenage girls while remaining low in teenage boys. Peak HIV prevalence in men occurred at an age 5–7 years older than it did in women.9 The age-differential partnering pattern, in which older men partner with younger women, was first reported in a community-based HIV survey in 1992 and has been one of the key drivers of high rates of HIV

The tuberculosis crisis in South Africa

Tuberculosis was introduced into South Africa in the 17th century by the arrival of European immigrants mainly from Britain and the Netherlands, many of whom had been infected with Mycobacterium tuberculosis during the epidemic that had swept through Europe.8 The development of South Africa's mining industries in the late 19th century led to the infection of large numbers of previously unexposed black South Africans as a result of poor working conditions, silica dust exposure, overcrowded

Achievements and innovations in the responses to HIV and tuberculosis

Despite the history of antagonism between the government and the intended beneficiaries of its HIV/AIDS control programme, both during and after apartheid (panel 1), there have been notable achievements in the past 10 years. Five key achievements are shown in panel 2. The HIV & AIDS and STI Strategic Plan for South Africa, 2007–201135 and the Tuberculosis Strategic Plan for South Africa, 2007–201111 have been broadly welcomed. The publication of these comprehensive documents highlights that

Public health action for HIV and tuberculosis control

South Africa is currently underperforming in its efforts to control HIV. An international HIV/AIDS scorecard of country-level HIV/AIDS programmes showed that South Africa was doing worse or no better than some of its neighbouring countries (table 2).44 South Africa needs to improve in almost all the ten elements used in this international rating. With regard to financing, this index is rated as the mean of three indicators: the total expenditure on the response per person living with HIV; the

Priority action steps to achieve tuberculosis control

The cornerstone of tuberculosis control remains the detection and cure of new infectious tuberculosis cases under a DOTS programme. Integration of HIV and tuberculosis services and rapid and appropriate management of drug-resistant tuberculosis are other crucial components of tuberculosis control. The following four steps outlined below prioritise these interventions to make the best use of limited resources.

Priority action steps to achieve HIV prevention

The priority steps for HIV prevention are founded on the urgent need to address risk factors and underlying vulnerability for infection, especially in young women and unborn children.

Step 1: scale-up HIV testing

HIV testing needs to be expanded because it is an essential entry point to ART programmes. In South Africa, an estimated 7% of the population are tested for HIV every year—this proportion needs to increase to 25% per year.35 To achieve this target, provider-initiated HIV testing should be the standard of care at all health-care facilities so that all those who come into contact with the health service are given the opportunity to find out their HIV status and access to treatment and prevention

Conclusion

South Africa has the world's worst HIV and tuberculosis epidemics. The current epidemic trajectory suggests that both epidemics will continue to worsen, leading to substantial increases in morbidity and mortality. The concomitant epidemics have exacerbated each other and have been further compounded by an increase in MDR tuberculosis and the emergence of XDR tuberculosis.

South Africa cannot afford to miss the window of opportunity created by the 2009 elections. Decisive action is needed to

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