Explosive Growth of Dual TB-HIV Infection in South Africa

UNCLAS SECTION 01 OF 04 PRETORIA 000756

SIPDIS

SIPDIS
SENSITIVE

DEPT. FOR AF/S; OES/IHB
STATE PLEASE PASS OGAC: BPATEL; WCOGGINS
STATE PLEASE PASS TO USAID/W FOR GH AND AFR/SA
HHS/PHS FOR OFFICE OF GLOBAL HEALTH AFFAIRS WSTEIGER
CDC FOR GLOBAL HEALTH OFFICE SBLOUNT

E.O. 12958: N/A
TAGS: SOCI TBIO SENV EAID PGOV KHIV KSCA ZU SF
SUBJECT: Explosive Growth of Dual TB-HIV Infection in South Africa
- An Emerging Public Health Crisis


1. (U) Summary: South Africa (SA) is experiencing explosive twin
epidemics of HIV/AIDS and tuberculosis (TB). The HIV epidemic in SA
is fuelling the rise of an exploding TB epidemic since individuals
infected with HIV are much more susceptible to TB and other serious
infections. Poor diagnosis and management of TB cases in SA has
led to increasing levels of TB, including Multi-Drug Resistant TB
(MDR-TB) and Extensively Drug Resistant TB (XDR-TB),with consequent
extraordinarily high mortality rates. Experts warn that HIV has
the potential to fast track XDR-TB into an uncontrollable epidemic
with serious public health consequences, not only for SA but for the
whole African region and globally. The USG is expanding efforts
supported by the US President's Emergency Plan for AIDS Relief
(PEPFAR) and USAID's GHCS account (formerly known as the Child
Survival and Health Account) to control these dual epidemics, by
providing extensive support to TB control programs in the crisis
areas, innovative models for integration of TB and HIV diagnosis,
treatment and care, and support for development of a National TB
Reference Lab. Experts have called for the South African Government
(SAG) to mount an immediate stepped up crisis response to the
emerging epidemics.

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TB Burden in South Africa
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2. (U) The scale of the TB epidemic in South Africa is staggering.
For 2006, SA ranked as the country with the fourth highest burden of
TB globally, in terms of absolute numbers of cases, deteriorating
from its number 7 ranking in 2005. According to the recently
released World Health Organization (WHO) statistics for 2006,
despite a global slowdown in new TB cases since 2003, SA recorded
the world's second highest rate of new cases per capita (incidence
rate) - 940 cases per 100,000 of population, topped only by
Swaziland. This reflects an increase of more than 300% since 1990
and more than 50% since 2005 (incidence rate of 600 per 100,000).


3. (U) A recent World Economic Forum Study reported that 85% of SA
business leaders who responded to a study on the business
community's response to TB expect TB-related impacts on their
businesses in the next five years, with 24% expecting serious
impacts. This is up sharply from the 2004 response where 55% of
respondents were expecting impacts, with 12% expecting serious
impacts. Three fourths of the people who fall sick and die are of
prime working age, and those that survive may miss months of work
due to TB. Workplaces can also be a fertile breeding ground for TB
due to continuous exposure to infected colleagues, and in certain
industries such as mining, the inhalation of dust and chemicals.
South African gold miners, for example, already had one of the
highest incidence rates of tuberculosis in the world before the HIV
epidemic, but rates remained stable between 1990 and 1999 among
HIV-negative miners. However, due to their increased
susceptibility, rates among HIV-positive miners increased by a
factor of 10.


4. (U) The 2006 WHO statistics reflect that SA was a country with:
one of the highest prevalence rates in the world, at 998 per 100,000
Qone of the highest prevalence rates in the world, at 998 per 100,000
of population (482,000 reported cases of TB); the second highest per
capita number of deaths due to TB at 218 per 100,000 of population
(105,179 deaths); and the highest total number of deaths due to HIV
associated TB (64,757 persons or 134 per 100,000 of population).
Approximately sixty percent of TB related deaths in SA were due to
HIV associated TB (HIV/TB) and represented about 28% of globally
reported deaths from HIV/TB. South Africa also represented almost
5% of global TB incidence and more than 6% of global TB deaths. The
recent WHO report noted that at current rates of progress, the
increase of TB in Africa and Europe will likely prevent the
achievement of Millennium Target 6 - to halt and reverse TB
incidence by 2015.


5. (SBU) Although these numbers are sobering, many experts believe
that the real incidence and prevalence rates are actually much
higher, since many HIV-positive individuals do not get tested for
TB. At a recent CDC-organized conference of organizations supported
by the President's Emergency Plan for AIDS Relief (PEPFAR) and
working on TB, doctors commented that although doctors treating
HIV-infected persons are legally required to perform TB-screening in
SA, two-thirds of doctors do not. Similarly, WHO reported that in
2006 only one-third of TB patients were tested for HIV. Conference
participants speculated that this is probably due to doctors being
over-burdened, inadequate training of doctors with regard to the
high correlation between HIV and TB, and a lack of skills and

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equipment necessary to test for TB.

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HIV and TB - the Dual Epidemics
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6. (U) A lethal combination of TB and HIV is fuelling the TB
epidemic in many parts of the world, including SA. TB is one of the
leading causes of death in HIV-infected people. HIV/AIDS and TB are
so closely connected that the term "co-epidemic" or "dual epidemic"
is often used to describe their relationship (denoted as TB/HIV or
HIV/TB). In 2006 in SA, 44% of new TB patients who were tested for
HIV were HIV positive. However, about 80% of patients presenting
with active tuberculosis in the Province of KwaZulu Natal (KZN),the
South African province with the highest HIV prevalence, are
co-infected with HIV. Each disease speeds up the progress of the
other and TB considerably shortens the survival of people with
HIV/AIDS. People who are HIV positive and infected with TB are up
to 50 times more likely to develop active TB in a given year than
HIV-negative people. HIV's impact on the immune system also
increases the likelihood of people acquiring new TB infection and
promotes both the progression of latent TB infection to active
disease and relapse of the disease in previously treated patients.



7. (U) There are many challenges facing effective treatment of
HIV/TB in SA. TB services in South Africa are frequently
administered separately from HIV services. As a result, the
dually-infected TB patient often has difficulty in getting
appropriate HIV care. Traditionally, anti-retroviral treatment is
administered at hospitals, while TB is treated at local clinics. TB
treatment is therefore ordinarily not available in the ARV clinic
setting and vice versa. Even if treatment is available at the same
facility, there is frequently no coordination that would allow a
rural patient to visit both TB and HIV treatment centers on the same
day. This poses great financial hardships and transportation
problems for poor rural patients who must often travel great
distances to hospitals. Ultimately, these obstacles decrease the
chances of a patient successfully completing a treatment regime.
The HIV and AIDS and STI Strategic Plan for South Africa 2007-2011
(NSP) advocates for the treatment of HIV within a clinical setting
in an attempt to integrate TB and HIV treatment; however, this
unfortunately is still not the norm in SA.


8. (U) TB treatment success rates in South Africa remain low, with
death and default the most frequent negative outcomes. The Global
TB cure rate for 2006 was 78%, while SA's cure rate was only 58%;
the overall successful completion rate in SA was 71%, compared to
the global rate of 85%. Rates of default from treatment were still
high at 10%. Patients are usually not infectious within a few
weeks of TB treatment and may feel much better. This can encourage
some to stop their treatment, allowing drug-resistant strains of TB
to emerge. Tuberculosis kills 30 to 40% of co-infected adults and
one in five children. Routine monitoring and evaluation (M&E)
systems in HIV clinics to monitor TB treatment are weak.

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Innovative Activities Supported by PEPFAR
QInnovative Activities Supported by PEPFAR
--------------


9. (U) The USG, through PEPFAR, is supporting innovative programs
working to curb the growth of the HIV/TB epidemic. One such program
is THAT'S IT (Tuberculosis, HIV & AIDS Treatment Support and
Integrated Therapy),which is designed to ensure that patients
suffering from TB and HIV receive a full range of services to
effectively address both conditions. THAT'S IT is a unique
partnership between the South African Medical Research Council
(MRC),the Foundation for Professional Development (FPD) and the
Department of Health. It represents a best-practice approach to a
one-stop service for TB patients with HIV co-infection. The MRC
reports that results from the integrated approach show a dramatic
decrease in TB mortality (from 40% down to 12%) and an increase in
TB case findings by up to 20% in clients presenting for HIV care.


10. (U) Another important program supported with PEPFAR funds is
development of the TB/HIV African Centre for Integrated Laboratory
Training (ACILT),which has the goal of accelerating the scale up of
HIV/AIDS/TB diagnosis and strengthening laboratory capacity
throughout the region. Establishment of a national reference
laboratory is a key goal of South Africa's National Strategic Plan
for Tuberculosis 2007-2011. In all of Africa, South Africa is one

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of only two countries that have the diagnostic tools to identify
XDR-TB disease, highlighting the crucial need for the center. ACILT
will also be critical to the training and deployment of rapid
diagnostic tests for TB that will give results in days, rather than
months. Many HIV infected patients die from XDR-TB while waiting
for TB test results. PEPFAR has additionally supported TB/HIV and
MDR surveillance efforts, including enhancements in the electronic
TB register software to permit the ability to measure TB treatment
outcomes by HIV status. TB/HIV and MDR data collection tools have
been revised to help reduce barriers to more widespread TB/HIV and
MDR surveillance.

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Emergence of Drug Resistant TB
--------------


11. (U) A troubling aspect of the resurgence of TB is the emergence
of drug-resistant strains. Drug-resistant cases, especially those
diagnosed with the extensively drug-resistant (XDR) strain, create
many challenges. Resistance to TB drugs can develop when patients
fail to take their medication as prescribed and through direct
transmission from person to person. MDR-TB fails to respond to the
two most powerful anti-TB drugs, while XDR-TB is resistant to these
and at least two others. The national cure rate in South Africa for
MDR-TB stands at 50%, falling far short of international targets of
80%. The MDR strains are much more difficult and costly to treat
than non-drug resistant TB. MDR-TB is often fatal, with mortality
rates comparable to those for TB in the days before development of
antibiotics. While six months of out-patient treatment for non-drug
resistant TB costs about R400 (approximately $50),XDR-TB drugs cost
around R100,000 (approximately $12,000) and patients are required to
stay up to 24 months in the hospital.


12. (U) The National Department of Health reported 419 cases of
XDR-TB for 2006 and 221 cases for the first quarter of 2007,
compared to 74 in all 2004. More than 60% of all XDR-TB cases
reported are from KZN Province. Dr. Karin Weyer, tuberculosis
research director at the South Africa Medical Research Council
(MRC),commented that nobody really knows the true number of cases
due to laboratory and diagnostics constraints and inconsistencies in
reporting. Dr. Weyer estimates that the rate of treatment failure
for MDR-TB is about 10 percent and assumes that most failures are
due to the XDR-TB form. (Note: WHO 2006 statistics reflect 6,716
cases of confirmed MDR-TB, which would translate to more than 600
cases of XDR-TB in SA each year. End Note) Dr. Weyer has warned
that "HIV has the potential to fast track XDR-TB into an
uncontrollable epidemic."


13. (U) In KZN Province, half the XDR cases in patients with HIV
infection were acquired in hospitals or clinics, and several
occurred in health care workers. Mortality exceeded 95%. XDR and
MDR-TB in three years have killed eight medical staff and 250
patients in just one hospital - Tugela Ferry's Church of Scotland
Hospital, the epicenter of the epidemic in KZN Province. Dr. Tony
Moll, principal medical officer at the hospital has reported that
all of the XDR-TB patients tested were HIV positive, most had not
Qall of the XDR-TB patients tested were HIV positive, most had not
received treatment for TB, and none had been exposed to the
second-line TB drugs to which they were resistant. This would mean
that their disease was not a result of poor adherence to TB
treatment. Dr. Moll was one of the authors of a study published in
the Lancet that used a mathematical model to simulate TB
transmission in a rural, high HIV prevalence area such as Tugela
Ferry. He reported that in KZN the rate of MDR-TB in new patients
was reported at 1.7% between 2000 and 2002; whereas, the rate was 9%
in a study integrating treatment for TB and HIV from 2003 to 2006 in
that region. The computer model calculated that more than 1,300
cases of XDR-TB could arise in the Tugela Ferry region by the end of

2012. However, the study concluded that implementation of a
combination of infection control strategies appropriate in limited
resource settings could avert nearly half of XDR-TB cases over the
next 5 years. Addressing infection control is also an important
priority for PEPFAR supported partners throughout SA.

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Frontal Assault Needed
--------------


14. (U) Dr. Weyer has commented that drug resistant TB forms
represent an unfortunate failure of TB control. "The low TB cure
rates and high rates of default from first-line TB treatment create
a fertile environment for the development of MDR-TB and, eventually,

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XDR-TB. TB drug resistance needs a frontal assault; infection
control precautions are needed now and must be scaled-up without
delay in settings where HIV patients are brought together," she
said. According to Dr. Mario Raviglione, director of the WHO Stop
TB Department, "If countries and the international community fail to
address it aggressively now, we will lose this battle."


15. (U) Experts are calling on the SAG to take immediate actions
aimed at: improving infection control, getting more people living
with HIV tested for TB, testing those living with TB for HIV,
integrating and decentralizing TB and HIV services, and preventing
and treating drug-resistant TB. According to Dr. Weyer, three
actions should immediately begin: TB patients need to be cured the
first time around to prevent the emergence of drug resistance, cases
must be much more rapidly diagnosed - with intensified surveillance
in each of the provinces in South Africa, and existing cases that
are being diagnosed must be quickly and appropriately treated.
Joining these calls for urgent action, the National Education Health
& Allied Workers Union (NEHAWU) recently issued a press release
expressing its concerns with the perennial weakness of SA's response
to TB. NEWAHU stated, "With the current shortage of trained and
qualified staff in SA, the mortality rate could plunge the country
into a serious pandemic."


16. (U) In 2006, the SAG developed the TB Crisis Plan, which
focuses on social mobilization and multi-sectoral engagement. It
initially targets three provinces and four districts with high
caseloads and unsatisfactory performance. In 2007, the SAG adopted
the Tuberculosis Strategic Plan for South Africa 2007-2011. In its
forward, the Minister of Health acknowledges the negative effects of
TB on the labor force and on GDP. The plan cites many of the
challenges faced and calls for a multi-sectoral approach to tackle
TB. NEHAWU, however, has commented that the TB strategic plan is
inadequate and is calling for enactment of an emergency plan with
short term measures to contain MDR and XDR-TB. In the coming year,
the MOH will roll out new TB testing systems and equipment across
SA's nine provinces to improve the accuracy and reliability of
tests. Further, the SAG is planning on a dramatic increase in
funding for 2007 and 2008, principally for investment in
infrastructure associated with MDR and XDR-TB.

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COMMENT
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17. (SBU) In September 2006, the WHO said a response akin to recent
global efforts to control SARS and bird flu was needed to curb
XDR-TB disease in South Africa. This has not yet materialized. The
coming year will be a crucial test of the SAG's commitment and
ability to gear up to control this disease and its potentially
devastating impacts on South Africa and beyond. Priorities for the
USG South Africa PEPFAR team in the coming year will include
increasing HIV testing for TB patients and TB screening for HIV
patients; strengthening labs and the ability to perform rapid
diagnostic testing; improving infection control; diagnosis and
management of MDR and XDR-TB; and enhancing surveillance for TB/HIV.


BOST