Opinion: HIV and TB are losing out in the drive to stop COVID-19
The government mass screening and testing campaign to detect COVID-19 (coronavirus disease 2019) was developed, drawn up and executed within a matter of weeks following the confirmation of the first COVID-19 case in South Africa in March 2020. The threat of the disease, which currently has no vaccine or cure, meant that lightning quick action was required, and implemented.
As of 25 May, the total number of reported tests conducted stands at 583 855.
Teams of healthcare workers are going out to test and screen in public areas, door-to-door and at walk-in clinics. Some people are presenting for testing. Others are too afraid to test because of associated stigma and fear of being quarantined.
But have we forgotten about HIV and TB?
HIV has no vaccine. No cure. We have never had to lock down because of the spread of HIV. The national response has varied wildly following the first cases of HIV/AIDS diagnosed in the 1980s. Not at any point in the early 2000s, as new HIV infections were approaching its peak, was there remotely the level of response needed from government to slow the spread of HIV. Many doctors and researchers, some of whom are now prominently featuring in the COVID-19 response, wanted to expand HIV testing and treatment, but they were up against a government that dragged its feet and rejected scientific evidence.
The cost of this was staggering. The sluggish and half-hearted efforts of the South African government to roll out antiretroviral treatment timeously and at scale under the Thabo Mbeki presidency resulted in an estimated 330 000 preventable HIV related deaths and 35 000 needless cases of mother to child HIV transmission.
It was only due to immense pressure from civil society and the work of the Treatment Action Campaign and its allies that the government eventually acquiesced to a large-scale rollout of ART across the country. The 2002 Constitutional Court ruling forced the government to provide anti-retroviral drugs to prevent transmission of HIV from mothers to their babies during birth. In the years following the judgment, the TAC’s campaigns helped to secure a universal government-provided AIDS treatment programme, which has since become the world’s largest.
Over the last decade or so we have become experts at large scale HIV and TB testing. The tests are easy to conduct, and the results are ready within a short period. We know how to do these tests – and it is critical that we keep doing them since both HIV and TB still often goes undiagnosed.
Unfortunately, it seems HIV and TB are falling by the wayside in the drive to stop the spread of COVID-19.
This is not just hearsay.
A communique released by the Gauteng Department of Health on 19 May 2020 indicates that there has been an increase in the number of patients who have defaulted on their TB and HIV medication and a document published on the website of the National Institute for Communicable Diseases (NICD) shows a dramatic decrease in TB testing numbers. (See Spotlight reporting on the impact of COVID-19 and the lockdown on TB here.)
But it is not just that the existing HIV and TB response is being harmed by the COVID-19 pandemic and the measures to stem it, there are also new opportunities that are being missed.
The COVID-19 community screening programme has given healthcare workers unprecedented access to communities. But, we are not utilising these valuable opportunities to educate people on HIV and TB, provide family planning and deliver HIV and TB testing in a controlled environment while we have this access.
For example, a large part of the COVID testing in KwaZulu-Natal is conducted in a private, secure environment in testing vehicles. The option should be given to patients to test for HIV and TB as well since they are already there and since these vehicles offer privacy that may not be available when visiting a local clinic.
Reducing clinic visits to reduce COVID-19 transmission makes sense up to a point, but the impact of this on services such HIV and TB testing and condom distribution cannot be ignored. And, given that people are understandably fearful of visiting clinics, it seems clear that government must ramp up efforts to reach people through alternative means. In this light, having a COVID-19-only screening programme in communities seems misguided.
It is not just a matter of immediate opportunities being missed, an overly narrow response to the containment of COVID could have long-term consequences for the HIV and TB epidemics, creating years’ worth of extra burden on the South African healthcare system – not to mention the impact on people’s lives.
Yet, despite some comments to the contrary, it seems that both the Department of Health and some funders are allowing their focus on COVID-19 to push HIV and TB services to the side.
There are still screening processes happening, but it would appear that the focus is no longer on actively testing for HIV and TB due to risk of exposure to COVID. Staff are being sent to the COVID frontlines, where they risk of being exposed to TB.
It is welcome that President Cyril Ramaphosa has acknowledged at least part of the problem. “As we mobilise our health resources to meet the expected surge of coronavirus cases, we must make sure that we do not create the space for the emergence of other health crises,” he said. “Routine health services should therefore be fully opened and continue to provide services with attention to childhood immunisation, contraceptive services, antenatal care, diagnosis and treatment of tuberculosis and HIV, management of chronic diseases and support for survivors of gender-based violence.”.
It is also welcome that Health Minister Zweli Mkhize has echoed the sentiment.
But saying so is one thing. In the short term, integrating TB and HIV screening into the COVID-19 screening programme will be the test of how serious government really is about not dropping the ball on HIV and TB. Further down the line, it will be telling to see if the same energy and capacity is brought to bear on contact tracing for TB as for COVID-19.
Ultimately, combining testing for all three diseases would make logical sense and be the best utilisation of resources and the reach we have with our screening programmes. Testing for HIV and TB, using correct social distancing measures and sanitation and using mobile vans would make the most sense.
Waiting for people with TB or HIV to present to clinics was not a sufficient strategy before COVID-19.
It is even less so now.
We have to sit up and pay attention
We cannot afford to undo the gains we have made over the last decades in stopping the spread of HIV and TB, which is what could happen if we focus too narrowly on COVID-19.
Instead, where we can we must minimise the harm to the HIV and TB response, and maybe more importantly, we need to see the opportunity to address all three diseases together.
Around seven and a half million people in South Africa are living with HIV and in the region of 300 000 people in the country become sick with TB every year. Many thousands will become sick with COVID-19.
We cannot let any of these people down.
*Penfold is an independent communications consultant, writing in her personal capacity.