With all the spotlight on HIV and AIDS, it is in fact tuberculosis (TB) that is our biggest killer. Globally TB took 1.7 million lives in 2016 – and for the past five years has been one of the world’s leading causes of death. It is South Africa’s leading cause of death amongst men, amongst women it is the third largest killer according to Stats SA. Unlike HIV, TB is curable with antibiotics. Treatment is free at any health facility. Recent data from the District Health Barometer show that the TB cure rate now stands at 81% – the highest it has been since 2005.
This is good news for people who know they have TB. The bad news is that an estimated one in five South Africans with TB are not on treatment which means that they are inadvertently transmitting TB. We need to get better at helping people with TB to get diagnosed and onto treatment so that they can be cured.
To get on top of TB, here are three important things we need to be aware of. Firstly, TB is viewed as a disease of poverty and a great deal of stigma surrounds it. This makes people reluctant to visit a clinic with TB symptoms and ask to be tested. If you, or anyone you know has TB symptoms (persistent cough, weight loss, fatigue, chest pains and fever or night sweats), you should go to the clinic immediately and ask for a diagnosis. You will not immediately receive the result and will be told when to come back to get it.
Secondly, patients need to go back to the clinic to see if they have TB. If they have TB, they need to start treatment immediately as it will save their life. Whilst this may seem obvious, less than half of those diagnosed with TB in the North West province were put on treatment. This is compounded by the fact that many health practitioners communicate badly with their patients about the need to return for test results, what medication they will need to take and how to take it.
Finally, TB patients must finish the full course of treatment exactly as directed by the clinic or hospital. The drugs used to treat TB are strong and can cause unpleasant side-effects. This contributes to people stopping their treatment, as does not having enough food to take the medicine properly. Once on treatment, a person with active TB will often start to feel better within weeks and this can also lead to them stopping treatment because they think they are cured, when in fact they are not. Because of stigma, many people with TB don’t tell their families, work colleagues or friends that they are taking TB treatment and so they are not well supported through their treatment. Delays in treatment or interrupting treatment can make people very ill and also gives rise to drug-resistant strains of TB.
Resistance to tuberculosis drugs is another major obstacle to effective TB care and prevention. Multidrug-resistant TB (MDR-TB) is fuelled by improper treatment of patients, poor management of supply and quality of drugs, and airborne transmission of MDR-TB bacteria. MDR-TB is hard to manage and only half the people with MDR-TB are cured. One-third of MDR-TB patients died in the Eastern Cape and North West while in the JT Gaetsewe district in the Northern Cape, almost 60% of MDR-TB patients died. Patients who are living with HIV or who are underweight are found to be at more risk of dying.
It is unsurprising that South Africa’s TB burden is so high. According to the World Health Organization, people living with HIV are 17 to 22 times more likely to develop TB and we have the highest number of people living with HIV in the world – over 7 million. TB is the most common illness among people living with HIV and it is the leading killer of people living with HIV, causing 20% of AIDS-related deaths. In South Africa, 60% of TB patients are also living with HIV. However, people living with HIV who are successfully on anti-retroviral treatment are less likely to develop active TB disease and less likely to die from it if they do get it. Without treatment, an estimated 90% of people living with HIV will die within months of contracting TB.
TB is also prevalent in mining communities. South Africa draws miners from across Southern Africa with some two million ex-miners returning to their home countries. It is estimated that the mining industry is responsible for 760,000 TB cases annually across the region. The mining community in South Africa has long been associated with significantly high TB rates. Reasons for this include high prevalence of silicosis resulting from prolonged occupational exposure to silica dust in mine shafts (especially in gold mines); high prevalence of HIV; confined, humid, poorly ventilated working areas and often crowded and poorly ventilated living conditions. Incidence of TB in miners continues to rise, with reports of MDR and XDR-TB and TB incidence rates significantly higher than in the general population.
Although men are more at risk of contracting and dying from TB than women, TB can have particularly severe consequences for women, especially during their reproductive years and during pregnancy. TB in pregnant women living with HIV increases the risk of maternal and infant mortality by almost 300% and TB among mothers is associated with a six-fold increase in perinatal deaths and a two-fold risk of premature birth and low birth-weight. TB is one of the top five killers of adult women worldwide. Cultural and financial barriers can act as major obstacles for women seeking care resulting in delays and more severe illness.
It is not all bad news when it comes to TB though: South Africa is starting to make progress against the disease. A National Institute of Communicable Diseases (NICD) study published in 2017 found that TB cases have dropped between 4% and 6% year-on-year. This is thought to be linked to South Africa’s HIV treatment programme which has massively scaled up the number of people on antiretroviral treatment since 2004.
What we can learn from this is that TB and HIV must be tackled together for us to be successful in reducing the burden of both diseases on South Africans. And community engagement is critical if we are to bring down the barriers to screening, testing and treatment. Having state-of-the-art diagnostic facilities and comprehensive treatment regimens are not enough if people are not getting tested, returning for their results or finishing their treatment.
Without communities being aware of and engaged in the fight against TB, there is little hope of improving our treatment and cure rates.
Caroline Wills is NACOSA’s Deputy Programme Director and holds a Bachelor Degree in Social Work and a Masters in Public Health from the University of Cape Town