South Africa’s health challenges: An elephant in the room

Perhaps surprisingly, HIV/AIDS is not the leading infectious disease killer of South Africans: that distinction belongs to tuberculousis (TB). And despite the epidemiologic, biologic, and medical links between TB and HIV, the disease receives far less attention and fewer resources. There are several reasons why this somewhat startling situation should be addressed.

First, South Africa has a lot of TB. About 80 percent of the South African population is thought to have latent TB, a form of inactive TB infection that occurs in most people soon after they are exposed to – and infected by – TB bacteria. Many people with latent TB, which is not contagious, go through their entire life without becoming ill with TB disease. Those who do become ill with active TB disease usually do so only because their immune system has been weakened by some other disease process such as malnutrition, cancer, or HIV infection.    

Second, South Africa has a lot of people living with HIV/AIDS.  It’s clear that being infected with HIV leads to a very large increase in a person’s risk that their latent TB infection will progress to active TB disease. Because numbers of HIV-infected South Africans have skyrocketed over the last 20 years, it’s not surprising to learn that the country’s annual numbers of people developing new active TB disease cases has increased by 400% over roughly that same period.    

In fact, globally, South Africa is said to be behind only India and China in its number of new cases of active TB disease every year. 

Third, TB is the most common killer of people living with HIV/AIDS. People with active TB disease experience accelerated progression of their HIV/AIDS.  Although access to anti-retroviral drugs, which many HIV-infected South Africans have begun taking, reduces the mortality risk of HIV-infected people, many HIV-infected South Africans have yet to gain access to those life-saving drugs. Although their overall TB-related risk is lower, TB remains as the single greatest mortality risk even among HIV-infected people taking antiretroviral drugs. 

Fourth, many TB infections among South Africans are caused by TB bacteria that have become resistant to many of the drugs traditionally used to treat TB. These overlapping challenges of multi-drug resistant TB (MDR-TB) and the even more extreme extensively drug resistant TB (XDR-TB) seem to be a particular problem among people infected with HIV. (The latter XDR-TB group of TB bacteria is defined as being resistant to all primary TB drugs and most “second line” TB drugs).  In one astonishing South African TB outbreak reported in 2006, 52 (98%) of the 53 patients infected with XDR-TB died within 30 days of their diagnosis, despite receiving the best available TB treatment. Among that group, all 44 patients who were tested for HIV were found to be HIV-infected. Because none of the 53 patients had any family members sick with TB, the conclusion was that these patients had become infected with TB from other patients being cared for at the same clinic, where antiretroviral drugs for HIV/AIDS were being distributed. The combination of MDR-TB and HIV has been called “the perfect storm”.

There has been some progress by the South African Department of Health and other groups in creating useful policies and programs for TB control, including plans and initial efforts to integrate HIV and TB programs. In addition, the TB cure rate improved from 54% of those treated for TB in 2000 to 71% in 2009.  Numbers of HIV-infected people receiving preventive TB medication to keep their latent TB infection from progressing to active TB disease are rising.  Greater attention is being given to TB transmission in prisons and in mines, both locations where crowding has led to high rates of new TB infections. Moreover, South Africa is the site of first-rate research on TB, TB/HIV co-infection, MDR-TB, and TB vaccine research.

However, a number of challenges remain. Beyond the health system, the country has domestic budget troubles such as slow GDP growth and high unemployment rates.  These are likely to limit the resources available to address current and future health challenges. The ongoing HIV/AIDS epidemic – South Africa has more new HIV infections annually than any other country – suggests that growing proportions of future health budgets will need to be allocated to providing antiretroviral drugs to the millions living with HIV infection, leaving fewer resources for other diseases.

The South African health system is also struggling with a number of structural problems related to TB control, including shortages of trained primary care staff, shortages of well-trained middle managers, challenges in providing quality services in rural areas, drug stock-outs, etc. To date, the U.S. PEPFAR program has been highly supportive of various activities to further strengthen the South African health system in ways required to successfully address these and other systemic gaps.

TB has been – and remains – a very large challenge for South Africa, and will continue to kill large numbers of South Africans unless more is done. The South African government and its international partners need to work to address the structural and budgetary problems that inhibit progress against TB. And it is critical that policy changes – such as the coming PEPFAR transition – not add to the challenges being faced by the country’s already fragile TB control programs.  Saving people from HIV only to have them die of TB should not be considered a success.

Source: SmartGlobalHealth.org