VZCZCXRO8645
RR RUEHDU RUEHJO
DE RUEHSA #0756/01 1011316
ZNR UUUUU ZZH
R 101316Z APR 08
FM AMEMBASSY PRETORIA
TO RUEHC/SECSTATE WASHDC 4106
INFO RUEHTN/AMCONSUL CAPE TOWN 5500
RUEHJO/AMCONSUL JOHANNESBURG 7984
RUEHDU/AMCONSUL DURBAN 9724
RUEAUSA/DEPT OF HHS WASHDC
RUEHPH/CDC ATLANTA GA 2325

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. 
 
------------------------- 
TB Burden in South Africa 
------------------------- 
 
¶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 
 
PRETORIA 00000756  002 OF 004 
 
 
equipment necessary to test for TB. 
 
------------------------------- 
HIV and TB - the Dual Epidemics 
------------------------------- 
 
¶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. 
 
----------------------------------------- 
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 
 
PRETORIA 00000756  003 OF 004 
 
 
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. 
 
------------------------------ 
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. 
 
---------------------- 
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, 
 
PRETORIA 00000756  004 OF 004 
 
 
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. 
 
------- 
COMMENT 
------- 
 
¶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