TAC/TAG Africa TB/HIV Workshop
19-21 June 2006
Over 70 activists from 22 African countries met in Cape Town for a workshop on HIV and tuberculosis (TB) advocacy from 19 to 21 June 2006.
Many countries in sub-Saharan Africa have large HIV epidemics. TB though treatable is a leading causes of deaths in people with HIV, more so than any other opportunistic infection. Africa has many of the high TB burden countries in the world. The meeting heard that in countries with TB epidemics, people with HIV have a 10% chance of developing TB each year, compared to 10% in a life time for people who do not have HIV. Consequently most countries with large HIV epidemics also have large TB epidemics.
There are several challenges to the successful management of TB epidemics in developing countries. Key among these is that TB is difficult to diagnose, especially in people with advanced HIV-disease. Nearly two thirds of people with HIV who have TB have extra pulmonary or smear negative TB which will be missed by the most commonly used diagnostic tool. The more accurate TB diagnostics using culture technology take up to two months to deliver results, during which time many people with TB and HIV will die without being diagnosed. The current treatment is cumbersome and requires four drugs for two months and two for six months at a minimum. The additional challenge is that the most powerful TB drug cannot be used with many HIV medications. These challenges in TB treatment lead to lack of adherence which can lead to multi-drug resistant TB. The prices of medicines for multi-drug resistant TB, which is a growing problem and ever present threat, are more than 100 times more expensive than first line TB drugs.
There are however technologies that accurately diagnose TB quickly. However they are not easily accessible due to cost. There are new drugs, diagnostics, and vaccines in the pipeline but due to lack of political will and underfunding, these new technologies might not be realised. The current gap for TB programs and research for the next ten years is estimated at 31 billion USD (approx. R217 billion).
Directly observed treatment support (DOTS) is the standard mechanism for monitoring medication adherence in TB patients. However it is our view that DOTS is inadequate. In contrast to the adherence model for HIV in which patients are treated autonomously and with dignity, TB patients have their autonomy reduced by DOTS. Yet adherence rates are much better for HIV patients than TB ones. The World Health Organisation has, with activist pressure, slowly realised that DOTS is an inadequate adherence model and that the management of TB should move towards a similar model to HIV. At country level however, there has been little progress to integrate HIV and TB treatment and move away from the DOTS model.
In South Africa, TB is the biggest recorded cause of death. On 31 May 2006 Statistics South Africa released an updated mortality report. The new report includes all recorded deaths for 2003 and a partial record of the recorded deaths for 2004. We learn the following from the report:
There were over 67,000 deaths recorded as TB in 2003, making this disease by far the biggest cause of death in South Africa. Given the substantial increase in TB deaths since 1997, when there were approximately 22,000 recorded TB deaths, it is almost certain that the vast majority of these deaths are HIV-related.
Recorded deaths in South Africa have risen from approximately 317,000 in 1997 to 553,000 in 2003, a 74% increase. Less than 20 percentage points of the increase can be explained by population growth and improved death registration. The increase in deaths between 2002 and 2003 is over 10%. The vast majority of the increase in deaths can only be explained by the HIV epidemic. Furthermore, the number of non-natural deaths (e.g. murders, car accidents etc.) declined between 1997 and 2003 (from 54,050 to 52,487). Natural deaths have increased by 91% over this seven year period. In a country experiencing normal development, mortality, once population growth and better death registration is accounted for, should be decreasing with time, not increasing at an alarming rate.
The death certificates demonstrate a continuing increase in registered infant deaths (0-4) from less than 35,000 in 1997 to over 55,000 in 2004, a year for which not all death certificates have yet been incorporated. While child death certificates have historically been less complete than adult ones, the massive increase in child deaths can only partially be explained by improved death registration and population growth. The remainder must be due to the HIV epidemic.
There is also a changing gender pattern in deaths. Recorded male deaths have increased by 60% from 1997 to 2003 (from 176,399 to 282,043). Female deaths have increased by 93% (from 139,088 to 268,861). This is also a feature of the HIV epidemic.
The changing age pattern of deaths in South Africa is the most remarkable aspect of the mortality data. In a normal population, the majority of adults would die at older ages such as after the age of 60. In 1997, this was the case in the South African mortality data although there were already clear signs of a changing age pattern of mortality. In 2003, there were more recorded deaths in the age group 30-34 (55,148) than any other age group, including children. By comparison there were only 30,535 recorded deaths in the age group 60-64 and 30,740 deaths in the age group 70-74. This feature of mortality, where most people who die are young adults, can only be explained by a massive HIV epidemic. Neither poverty nor anything else can explain this. The following graph powerfully depicts what is happening to the age-pattern of death in South Africa:
Graph taken from Statistics South Africa Changing age-pattern of death in South Africa â€“ 1997-2004 (not all 2004 death certificates have yet been processed) P0309.3, May 2006 update
We have a crisis of death in South Africa. This crisis is caused by the HIV epidemic which has resulted in deaths due to TB and other opportunistic infections spiralling. We therefore call on President Mbeki to lead us through this crisis by recognising that the HIV epidemic is an emergency.