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

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

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. Care for acutely ill AIDS patients and long-term provision of antiretroviral therapy 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, Abdool Karim and colleagues 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.

This paper is a ‘must read’ for anyone wishing to understand the historical response to the intertwined HIV and tuberculosis (TB) epidemics in South Africa against a political backdrop. From a concentrated subtype B epidemic among men who have sex with men and patients with haemophilia in the early 1980s, the South African HIV epidemic evolved into a predominantly heterosexual clade C epidemic as mini-epidemics coalesced into a country-wide generalised epidemic, the worst in the world. Tuberculosis, which was introduced in the 17 th century from Europe and gained a firm toehold in the 19 th century in South Africa’s mining industry, is the most common notified natural cause of death in South Africa, with multidrug resistant (MDR) TB and extensively drug-resistant (XDR) TB now major causes for concern. This paper includes a scorecard that rates the government’s response in comparison with 5 neighbouring countries, Brazil, and India. It then lays out the challenges clearly, highlighting achievements to build upon, and sets out the priority action steps to achieve HIV and tuberculosis control. Failure is clearly not an option.