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
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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.
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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.
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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.
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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.
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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.