National Aids Conference: Spotlight back on HIV/TB – at last

With fear and stigma once again rampant, laboratory testing for TB, so often an HIV co-infection, dropped by over 50% – and has yet to return to pre-Covid levels.

These assertions were made by Dr Gloria Maimela, Program Director for SA’s 11th National AIDS Conference being held in Durban from June 20th to 23rd.

Maimela, also the chairperson of the Wits Reproductive Health Institute, RHI, spoke alongside Professor Koleka Mlisana, Head of Academic Affairs, Research and Quality Assurance at the National Health Laboratory Service, NHLS.

Both told 1 900 delegates at Durban’s International Convention Centre where 200 experts are due to speak and 223 poster presentations go up this week, that with eight million South Africans still living with HIV/AIDS, Covid had ‘exposed our fragility in responding to HIV.’

“We lost focus on an epidemic that continues unabated – Covid undermined our 2025 HIV, TB and STI prevention targets and we also lost key experts in prevention and treatment services,” lamented Maimela.

The Covid pandemic ‘exposed and widened inequality’ in society and created a breeding ground for HIV and TB, not to mention the full panoply of sexually transmitted infections, (STI’s).

Can HIV/AIDS/TB prevention survive another pandemic?

“However, as a society we remained resilient. It’s part of our DNA. We used the lessons from our AIDS experience to respond to Covid and get back on track. The big question is: are we prepared for another global health threat or pandemic? Can we afford for the HIV response to be derailed again? I think not, not with a child dying from HIV every five minutes around the world. That’s simply unacceptable,” she said.

Professor Mlisana said Covid had disrupted or limited health services, increased absenteeism and workload, aggravated fear and stigma, restricted movement and access to prevention and control programs, with major variability between provinces, districts, and sub districts.

Studies modelling the impact of Covid in low to middle income countries showed that deaths due to HIV increased by 10% while TB mortality increased by 20%, the former mainly due to untimely diagnosis and treatment of new cases.

The reallocation of healthcare resources impacted on the quality of HIV services while lockdown restrictions severely reduced access to healthcare facilities and support structures, increasing vulnerability and risking treatment disruption.

LGBT community-support bolstered

Speaker after speaker in the opening plenary hit out at the recent passing of anti LBGT laws in Uganda – and other sexually conservative African countries where discrimination against LBGT communities is legalized.

Several speakers also called for South Africa to speed up the amended Sexual Offences and Related Matters bill that decriminalizes sex work and hampers prevention efforts – to spontaneous applause from the crowded plenary hall.

Taking stock of the post-Covid-pandemic HIV/TB/STI response, Mlisana said South Africa had, “come a long way,” since the mid-1990s when thousands of funerals were being held daily while politicians debated whether HIV caused AIDS or not.

Changes in HIV/TB burden over time

HIV prevalence grew from 1,2% in 1990 to 19% by 2017. With the AIDS pandemic peaking at 270 000 deaths in 2005, civil society groups and activists joined the rest of the world in condemning President Thabo Mbeki’s refusal to roll out anti-retro-viral drugs.

By 2007 the first National Strategic Plan, (NSP) to address HIV/AIDS was finally launched – but ‘only when we realized we had a huge problem on our hands,” and civil society protest marches were a weekly occurrence.

In 2006 an estimated 681 434 people died of AIDS-related causes compared to 150 375 in 2016, a 78% decline.  The number of new HIV infections in 2010 was 401 608 compared to 198 311 in 2021, a 51% decline – both directly attributable to ARV’s and awareness and prevention campaigns unmatched globally.

TB and STI’s were added to the NSP in 2020 – and HIV and TB services were integrated, while efforts to reduce stigma and promote testing and treatment were redoubled.

TB prevalence surveys between 2017 and 2019 in SA revealed 852 cases per 100 000 population. However, by 2021 the incidence of TB in SA had dropped to 513 per 100 000 population, a 48% reduction compared to 2015 – but still above the global average of 134 per 100 000 people.

“Life expectancy in SA rose from 54 to 65 years within two years of ART starting, while earlier and earlier treatment initiation allowed near to normal life expectancy,” she said.

Mlisana warned that a syndromic management approach to STIs had resulted in limited diagnostic testing, potentially resulting in overtreating people with symptoms and gross undertreatment of asymptomatic infections, which were the majority.

She said the launch of the latest the NSP, (2023 to 2028), in March this year was, ‘a major improvement with a significant emphasis’ on STI’s and the development of a vaccine. It also scaled up prevention and expanded testing and care and focused on key population groups and improving adherence to ART, something Covid set back hugely.

Unique patient identifier

“With all CD 4 counts and viral loads now being done and ART work-up labs for all patients in SA’s public sector HIV program, wherever people go for treatment it gets recorded onto the system, so we have an unprecedented richness of data. We must use that to ensure we’re able to better look at trends and patterns. We need to tap into that and inform how we change policy and what the next steps are. Soon we’ll be able to use a unique patient identifier so we can translate this into even more effective programs,” she revealed.

The new NSP’s had four goals; to break down barriers to achieving solutions for HIV, TB and STI’s, maximize equitable and equal access to services and solutions, fully resource and sustain an efficient NSP led by ‘revitalized, inclusive and accountable’ institutions, and build resilient, integrated systems for health, social protection, and pandemic response.

Mlisana said key actions would be the integration of services, scaling up testing, increasing case findings, community engagement, enhancing surveillance – and optimizing gains made during the Covid pandemic. She added that vital boosters in the battle against HIV would be vaccine development and genomic sequencing, both of which ‘cried out,’ for better funding.