Despite the history of antagonism between the government and the intended beneficiaries of its AIDS control programme both during and after apartheid (), there have been significant accomplishments in the last 10 years. Five key accomplishments are highlighted in . National Strategic Plans for HIV (32
) and for TB (23
) have been developed through an inclusive process of consultation and have been broadly welcomed. Publication of these comprehensive documents highlights the fact that South Africa is not currently deficient in policy but rather lacks either the will or the capacity to deliver. Despite these clear deficiencies, the sheer magnitude of the TB and HIV epidemics has nevertheless stimulated the development of innovative means of delivering health care, the lessons of which might be harnessed to strengthen the overall health system.
Although belated, the scale-up of ART to the largest programme in the world is widely recognised as a major achievement in South Africa. Paradoxically, however, long-standing TB services have lagged behind and may benefit from incorporating key lessons from ART scale-up. Although TB and HIV treatment outcomes are not directly comparable, with TB treatment being for a defined period of 6–9 months whereas HIV treatment being lifelong, it is noteworthy that there is substantial disparity between the capacity to deliver treatment effectively. For example, the Western Cape, which has a good provincial TB programme, the sputum smear conversion rate at 2 months among new smear-positive TB cases was just 66.9% in 2005, the treatment default rate at 6 months was 11.1% and the TB cure rate (71.9%) fell well short of the WHO recommended goal of 85% (26
). In contrast, data for the ART programme in the Western Cape from the same period showed that among over 16,000 patients treated, 90.6% achieved viral load suppression <400 copies/mL at 6 months, the loss to follow-up rate was just 4.2% and 89.5% patients were alive and retained on treatment at 6 months (33
). Furthermore, even after four years of follow-up, immunological and virological outcomes were excellent and sentinel ART services within the province have among the lowest rates of mortality and loss to follow-up in sub-Saharan Africa (34
Many factors may underlie this apparent disparity, but a key factor underlying the high rates of patient retention and treatment compliance in the ART services may be the widespread use of treatment literacy training for patients, often delivered by lay or peer counsellors(36
). These education programmes provide patients with detailed information on HIV infection, how antiretrovirals work, the importance of adherence and how to incorporate pill taking within daily routines and address the many social implications of their disease. In this way patients are empowered to take responsibility for their health and treatment and have ready access to advice and care when needed. In marked contrast to this patient-centred approach, TB services typically fail to provide adequate treatment literacy and disempower patients by requiring daily observation and recording of treatment compliance, which is often facility-based.
Both the TB and HIV epidemics have served as key drivers of innovation in service delivery, monitoring and evaluation. The TB control programme has established of a national electronic register that facilitates standardized recording and reporting and evaluation of the national TB programme. HIV treatment programmes have taken this one step further to collect longitudinal data on the clinical status, drug switching, drug-related adverse events, treatment adherence, CD4 cell count and viral load measurements and treatment outcomes. While these data are not nationally standardised yet, they provide a wealth of data on the status of the ART rollout programme. Indeed the level of detail in the data collected in HIV treatment programmes has enabled a performance management approach, where ART roll-out programme indicators are used to provide feedback to health service managers.
Task shifting has been effective in TB services through the use of community health care workers, defaulter tracers and treatment supporters, thereby improving case detection and holding to ensure continuity of care from investigation to diagnosis and cure. Similarly, HIV treatment programmes, saddled with a burden beyond the capacity of currently available health care personnel have, in addition to task shifting, created new cadres of health care workers. These include lay counselors, lay AIDS educators and enrolling patients with good ART adherence to provide adherence counseling in HIV clinics and through community outreach. This concept has been even further extended to home-based daily care to provide treatment for patients with XDR-TB (28
To achieve the massive scaling up of HIV care in South Africa, millions of people had to access HIV testing and this was achieved through a number of innovative means. Testing was done through dedicated voluntary counseling and testing centres and community-based mobile clinics. Facility-based provider initiated testing especially focused on antenatal clinic attendees and TB patients. In addition, testing was facilitated through public sector partnerships with the private sector and non-governmental organisations. A major innovation that made this possible was the development of simple, reliable and cheap rapid HIV tests. To further enhance the reliability of HIV testing, algorithms have been developed where two different rapid tests are used to achieve diagnostic accuracy comparable to those available through laboratory testing.
While a similar rapid test is not available to diagnose TB, the growing burden of drug resistant TB has led to the evaluation and adoption of a rapid diagnostic for rifampicin and isoniazid resistance - the molecular line-probe assay (37
). In addition, algorithms have been developed for diagnosing smear-negative TB. The need to manage TB and HIV in the same patient is stimulating the integration of TB and HIV services, with best practice examples at the Church of Scotland Hospital in Tugela Ferry (38
), the CAPRISA eThekwini TB-HIV clinic in Durban (39
) and the Medicins Sans Frontieres clinic in Khayelitsha (40
These and other innovations in the TB and HIV treatment programmes, spawned by the sheer force of the burden these two infections place on the health system, are slowly trickling through to the rest of the health care service.