Tackling HIV and TB - where there's a will, there's a way

One in six HIV-positive people in the world live in South Africa, which is also experiencing a parallel tuberculosis (TB) epidemic, but years of weak leadership, poor policy implementation and inadequate resources have undermined efforts to control the twin health emergencies.



These are the findings of several leading local researchers and epidemiologists, who chronicle the history of the HIV and TB epidemics in "Health in South Africa", a new series published in the UK-based medical journal, The Lancet.



The evolution of South Africa's HIV epidemic began with a concentration of cases mainly among gay men in the 1980s, spread rapidly via heterosexual transmission spurred by the migrant labour system in the 1990s, and peaked with a prevalence rate of 30.2 percent among pregnant women in 2005.



Since then the level of new HIV infections has remained high, but prevalence has stabilized or even declined in some age groups, largely as a result of HIV-related mortality.



Despite the belated roll-out of an antiretroviral (ARV) treatment programme, which started in 2004 and is now the largest in the world, average life expectancy has declined to 48.4 years for men and 51.6 years for women.



Starting in the late 1990s, the HIV epidemic has fuelled a sharp rise in TB incidence: 50 percent of new TB cases occur in patients co-infected with HIV, making TB the most common natural cause of death in the country.



The poor performance of TB control programmes and many years of low cure rates have seen the emergence of drug-resistant strains of the disease that are more difficult and costly to diagnose and treat - the caseload of drug-resistant TB now puts South Africa among the world's top 10 countries.



Strong leadership needed



These are grim statistics, yet The Lancet authors describe the government's response to the two epidemics in the past decade as marked by "denialism, ineptitude, obtuseness and deliberate efforts to undermine scientific evidence as the basis for action."



Important achievements, such as a vastly increased distribution of male condoms, the scale up of the ARV programme, and the development of well-formulated national strategic plans for HIV/AIDS and TB have not been enough to overcome a lack of high-level political commitment to controlling the health crises.



An international HIV/AIDS scorecard various elements in country-level programmes found South Africa's performance worse than many of its lower-income neighbours.



The authors note that the change of administration in 2008 has provided a potential "window of opportunity" to tackle HIV and TB, and suggest a number of priority actions. In the area of TB control, they recommend improving case detection and cure rates, and integrating HIV and TB services.



The first step in strengthening HIV prevention efforts should be using all available data to generate a clearer picture of the demographic features and key drivers of the epidemic, followed by scaling up prevention of mother-to-child transmission, targeted behaviour-change programmes, and making male circumcision widely available.



HIV treatment efforts could be boosted by routinely offering testing at all health care facilities, and raising the threshold for starting ARV treatment to a CD4 cell count of 350.



Treatment programmes play an important part in prevention: studies show that patients who start ARV treatment early are less likely to transmit the virus, and more likely to access sexual and reproductive health services.



However, the authors note that successful implementation of these approaches will require "strong leadership, political will, social mobilisation, adequate human and financial resources, and sustainable development of health care services."



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