JOHANNESBURG, 27 August 2009 (PlusNews) - 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
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
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
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."