The national Department of Health estimates that 5.54 million South Africans were living with HIV in 2005, an estimated prevalence of 10.8%. Partly as a result of HIV, South Africa is one of 22 high burden TB countries and has the fifth highest number of notified TB cases in the world. The number of TB cases reported annually has quadrupled from 61 486 in 1988 to 279 260 in 2004. TB is the most common opportunistic infection and is the most significant cause of mortality in people living with HIV in developing countries where access to ART is limited. Obtaining good TB treatment outcomes is critical to decreasing HIV-related morbidity and mortality. Likewise, access to appropriate treatment and care for HIV is essential to containing TB.
Collaborative care that engages the interconnectedness of these infections is critical to controlling these epidemics. In 1997, the National HIV/AIDS/STI review recommended improved collaboration between the TB and HIV/AIDS programmes. Whilst there has been progress in TB/HIV collaboration, it appears to have been slow (although assessing progress is made difficult by a lack of implemented standardised reporting systems). Progress is hampered by a range of factors including constraints in access to essential medicines and antiretroviral therapy as well as community adherence support and mobilisation around TB and antiretroviral treatments.
The promotion and strengthening of integrated care should be pursued and other models for scale-up explored. Integrated care should include HIV counselling and testing and routine TB case finding at every HIV clinical visit. Initiatives to increase treatment adherence such as dedicated community adherence workers and simplified drug regimens, especially for paediatrics are critical. The intransigent dilemmas of improving staffing levels and morale need to be addressed as well as task-shifting explored as components of integrated HIV and TB care.
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