Health Minister Manto Tshabalala-Msimang led the singing of ”Happy Birthday” at the opening of the first South African Tuberculosis Conference this week, while Treatment Action Campaign (TAC) activists stood quietly by holding low-visibility protest signs about government health policy.
A brief hesitation among the 2 000 international and local TB experts was followed by a dutiful mass serenading of the conference organiser, Refiloe Matji.
As the singing subsided, a security guard quietly moved the TAC protesters back to their seats and what appeared to be a ministerial bodyguard sat next to them.
Low key as it was, the TAC demonstration highlighted the grim fact that Aids and TB are fellow-travellers in South Africa. Roughly two-thirds of people with active TB also carry HIV, and national TB conferences alternate with national Aids indabas.
The four-day conference heard that co-infection with HIV meant that the TB pattern is changing.
Traditionally TB has been a lung disease transmitted by droplets in the air for several hours after a patient with active TB coughs or sneezes. It is estimated that a third of the world’s population has been infected.
But as HIV-positive patients become sicker, an increasing proportion get TB in other parts of the body, which can be harder to diagnose and test.
This exacerbates the difficulty in diagnosing people with advanced HIV who may not cough up the bacilli in sufficient quantities to be detected under a microscope.
However, a local innovation may improve matters. Professor Jan Verschoor of the University of Pretoria presented preliminary findings from a locally developed blood test that apparently detects TB even in the sickest Aids patients.
Currently undergoing validation, the test should allow rapid detection of disease, allowing HIV patients with TB to be treated appropriately and those not jointly infected to be given prophylaxis.
South Africa has the world’s fourth-highest TB burden and the national response is in many cases a shambles.
Recurrent themes at the conference were the failure to implement existing policies, lack of education, lack of prevention measures, lack of support for people living with TB and, above all, lack of information.
The full extent of drug resistant TB, both multi-drug resistant (MDR-TB) and extensively drug resistant (XDR-TB) is not known in South Africa, with many cases still going undiagnosed.
Professor Anton Stoltz, co-chair of the conference’s scientific committee, said there is no information on almost a third of TB patients nationally. Some clinics lack records on more than half their patients.
According to the government’s National Strategic Plan on TB, Mpumalanga has had no cases of XDR-TB. Given that the province has the lowest cure levels of TB, this is almost certainly due to lack of monitoring and testing. Only about 57% of South Africa’s TB patients are cured, even though more than 90% of the country is covered by Directly Observed Therapy, Short-Course (Dots), which includes patients being overseen as they take the medication.
The country once had 100% coverage, but this fell when Mpumalanga admitted it had no functioning Dots system. Unsuccessful or uncompleted TB treatment leads to the development of drug resistance.
Colleen Bamford of the National Health Laboratory Services reported on research among adult patients at Tygerberg Hospital in 2007, which found that it took an average of 33 days for patients to start receiving treatment for MDR-TB, with one patient waiting 187 days.
The good news at the conference was the announcement that the World Health Organisation had approved a one-day test for drug resistant TB for use in countries with high levels of the disease.