National Health Insurance
The Interaction between HIV and Other Diseases
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The epidemics of HIV and tuberculosis (TB) are interlinked. The ANC Health Plan of 1994 said: “Tuberculosis is by far the most frequently occurring notifiable disease. The annual case load increased by 4% between 1987 and 1988. In 1988 the prevalence rate was 489 per 100,000 population, with the Western Cape having the highest rates in the country. The incidence in 1990 was 229 per 100,000.” By 2006, the Department of Health found that the incidence of TB had increased to 720 per 100,000.
The WHO said: “Globally, 700 000 people living with HIV had TB in 2006. ... Sub-Saharan Africa accounts for 85% of the people with both TB and HIV, with a disproportionately heavy burden in some countries. South Africa ... has 0.7% of the world’s population but accounts for 28% of the world’s people with both HIV and TB and 33% of the cases in sub-Saharan Africa.”
The National Strategic Plan for HIV/AIDS says: “In southern Africa, between 50% and 80% of TB patients are HIV positive. Whilst a primary risk factor for TB infection is overcrowding, the development of TB disease is significantly more likely where there is co-infection with HIV as a product of immunosuppression”.
A recent review of the history and treatment of TB in the Lancet warns “Tuberculosis is at least as old as recorded human history ... Regrettably, there are currently more cases of tuberculosis in the world than at any previous time in history.” “When WHO declared tuberculosis a global emergency in 1993, the initial response from the international community was sluggish and inadequate. A resurgence of the disease, the emergence of multidrug-resistant [MDR-TB] and extensively drug-resistant [XDR-TB] strains, and the detrimental effect of the concurrent tuberculosis and HIV/AIDS epidemics on national control programmes in sub-Saharan Africa have all occurred despite the availability of effective combination treatment regimens. On the positive side, funding agencies and donor governments are at long last taking a serious interest in investing in tuberculosis research priorities defined by the Stop TB Partnership.”
The SAHR 2007 describes the delivery of TB treatment in South Africa: “Whilst the public health sector is predominant in the provision of TB care across the country, there are private providers of TB treatment. These providers can be classified into three main groups:
- Employer-based private providers (e.g. the mining industry TB services provided either in-house or contracted out to managed health care companies);
- Private for-profit providers; and
- Private not-for-profit providers (e.g. the NGOs providing community-based TB treatment).
The Department of Health found “There are marked provincial variations in the treatment outcomes [for TB] ... The best performing province [in 2005], the Western Cape, achieved a cure rate of 71.9% .... The KwaZulu-Natal province, which appears to be experiencing significantly more challenges than the other provinces, reported a cure rate of 45.2%.
The SAHR 2007 found that “Public-private partnerships involving some of the private providers are an important component of TB care”. Problems of co-ordination remain and many medical scheme members still receive treatment in the public sector for TB. Medical schemes should be engaged in the provision of TB treatment in order to ensure proper co-ordination of treatment for the patient.
A new WHO report says that multidrug-resistant tuberculosis (MDR-TB) has been recorded “at the highest rates ever”. The report is based on information collected between 2002 and 2006 on 90 000 TB patients in 81 countries. It found that extensively drug-resistant tuberculosis (XDR-TB), a virtually untreatable form of the respiratory disease, has been recorded in 45 countries.
The WHO report found a link between HIV infection and MDR-TB: surveys in Ukraine found nearly twice the level of MDR-TB among TB patients living with HIV compared with TB patients without HIV. The report provides valuable epidemiological information which might be used to estimate the likely cases in South Africa as the HIV epidemic develops. For example, “thirty six countries reported data on age and sex of cases by any resistance and MDR-TB”.
The interaction between HIV and other sexually-transmitted infections (STI) has been modelled by Dr Leigh Johnson. He identified “a number of forms of STI treatment that could achieve significant reductions in HIV incidence over the next decade”. Further research is needed to determine the costs of treatment and the cost-effectiveness of the treatment.
Dr Leon Regensberg provides evidence that “some 5% of people living with HIV in Sub-Saharan Africa are co-infected with Hepatitis B. Certain first-line antiretroviral therapy options (Tenofovir and lamivudine) can successfully suppress both infections.”
As the epidemic progresses and people with HIV live longer, so the issue of co-morbidities with other chronic diseases becomes more of a concern.
Figure 7 : Proportion of Multiple Disease and HIV by Age and Gender in Medical Schemes
Using data from the REF Study 2005, it was found that of those on treatment for HIV, 24.4% are on treatment for one or more of the other chronic CDL diseases. This is lower than the multiple disease rate found in people who are not on treatment for HIV. For those on treatment for any of the CDL diseases (but excluding HIV), 38.0% are receiving treatment for more than one disease.
There is however a strong effect by age and overall numbers always need to be treated with caution as the HIV population is generally younger. Figure 7 shows that even by age and gender, there seems to be less multiple chronic disease in those being treated for HIV. These early findings need to be discussed with administrators and clinicians in more detail and more research is needed on how this overlap might progress over time and with an expansion of health insurance to a larger proportion of the population.
The graph below from the data used for the REF Study 2005 provides information on the multiple Chronic Disease List (CDL) diseases that co-exist with HIV in medical schemes.
Figure 8: Multiple Chronic Conditions occurring together with HIV/AIDS in Medical Schemes in 2005
It seems that HIV may also have a reverse impact on the experience of chronic disease in those that are not HIV positive. Steyn and Schneider argue29 that the “most striking feature of the AIDS pandemic in South Africa is the tremendous increase in the mortality of young adults (citing Dorrington). As a consequence, the older and poorer people not only have to care for their adult children who suffer from AIDS, but also for their grandchildren who are orphaned when their parents die. Although not yet formally evaluated, the impact this has on the quality of chronic diseases care for the elderly must be extensive. They are emotionally drained as a result of the changing family structure and through the premature loss of their children, who traditionally would have cared for them in their old age (citing Adjetaye-Sorsey). The impact that the AIDS epidemic has on chronic diseases and chronic diseases care in older persons must surely aggravate the position of the poor.”
One in three people in the world is infected with dormant TB bacteria (Mycobacterium tuberculosis). Only when the bacteria become active do people become ill with TB. Bacteria become active as a result of anything that can reduce immunity, such as HIV, advancing age, or some medical conditions. TB can usually be treated with a course of four standard, or first-line, anti-TB drugs. If these drugs are misused or mismanaged, multidrug-resistant TB (MDR-TB) can develop. MDR-TB takes longer to treat with second-line drugs, which are more expensive and have more side-effects. Extensively drug-resistant tuberculosis (XDR-TB) can develop when these second-line drugs are also misused or mismanaged and therefore also become ineffective. Because XDR-TB is resistant to first- and second-line drugs, treatment options are seriously limited. It is therefore vital that TB control is managed properly. Source: WHO: http://www.who.int/topics/tuberculosis/en/
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