South Africa

Tuberculosis (TB) is a major public heath problem in South Africa. South Africa ranked fourth on the list of 22 high-burden tuberculosis (TB) countries in the world. According to the World Health Organization’s (WHO’s) Global TB Report 2008, South Africa had nearly 453,929 new TB cases in 2006, with an incidence rate of an estimated 940 cases per 100,000 population – a major increase from 338 per 100,000 population in 1998. Since South Africa adopted DOTS (directly observed treatment, short course) in 1996, all districts have implemented the core DOTS components, although coverage varies widely within and among districts. Despite South Africa’s investments in TB control, progress toward reaching program objectives has been slow; however, new data suggest that for the first time, in 2006, South Africa reached (and surpassed) the DOTS case detection target of 70 percent. DOTS treatment success increased from 65 percent in 2001 to 71 percent in 2005, though it still remains low compared with other African countries that have high HIV/AIDS prevalence rates and few resources.

Progress against the TB epidemic in South Africa is likely to be constrained over the next few years due to HIV/AIDS. The TB-HIV/AIDS co-infection rate is high, with 44 percent of new TB patients testing positive for HIV. Multidrug-resistant (MDR) TB, largely caused by non-adherence to drug regimens or inappropriate drug regimens, is further exacerbating the epidemic. The number of laboratory- confirmed cases of MDR-TB more than tripled from 2,000 cases in 2005 to 6,716 in 2006 and 7,369 in 2007. Since 2007, South Africa has increasingly reported patients with extensively drug-resistant (XDR) TB. A recent study that examined MDR isolates collected from 2004–2007 showed that 5.6 percent (986) of 17,615 TB cases were XDR-TB ¹. The actual reported cases of XDR-TB have also increased from 74 in 2004 to 536 in 2007 ². The most critical factor in addressing MDR-TB is primary prevention through excellent basic DOTS management (still poor in many areas) and excellent management of patients requiring re-treatment and treatment with second-line medicines. An unprecedented strengthening of overall TB control (diagnosis, treatment, and caseholding) is needed to ensure success in addressing the epidemic.

USAID Approach and Key Activities

USAID support for South Africa’s National TB Control Program (NTCP) began in 1998 through the EQUITY Project in Eastern Cape Province and expanded to nationwide coverage in 1999. USAID-supported activities are being implemented in 12 districts, 31 subdistricts, and 659 facilities in five provinces. While USAID assistance focuses primarily on the community, district, and provincial levels, it also helps the national health system confront the pressures exerted by HIV/AIDS by strengthening critical health systems, such as information, supervision, and TB management systems. Through the University Research Corporation, its subpartners, and the Tuberculosis Control Assistance Program (TB CAP), USAID’s assistance addresses capacity building, sustainability, quality of care, integration, and coordination. USAID provided $3 million for TB programs in South Africa in fiscal year (FY) 2007 and approximately $6 million in FY08. USAID assistance includes support for the following activities:

• Developing and piloting models for public-private mix DOTS with the private medical sector
• Participating in the childhood TB training initiative of the Desmond Tutu TB Centre, in cooperation with the NTCP
• Increasing efforts to improve infection control and reduce and contain MDR-TB and XDR-TB through training and technical assistance and by enhancing the capacity of laboratories treating MDR-TB and XDR-TB patients, resulting in the reduction of the default rate
• Supporting human resource development (HRD) and management by improving staff skills and knowledge, improving the distribution staff, and developing a national strategic plan for HRD
• Conducting advocacy, communication, and social mobilization activities in the mining industry and in two regions to sensitize the stakeholders and workers about the symptoms of TB, diagnosis, and treatment options

USAID Program Achievements

• Supported the treatment of nearly 84,000 people in five targeted provinces in FY 2008
• Assisted the government in establishing and implementing TB policies and protocols that are in-line with WHO standards, including policies on MDR-TB, infection control, and the National Strategic Plan for TB Control for 2007– 2011, which was approved in FY 2007
• Developed MDR-TB training tools and infection control (IC) training and risk assessment tools
• Trained more than 2,600 health service providers and program managers at the national, provincial, and service delivery levels to build their capacities in DOTS and TB management
• Continued to train service providers on data reporting and recording to improve treatment and follow-up of TB patients and reduce the number of defaulters and the probability of additional MDR-TB and XDR-TB cases
• Trained 34 laboratory managers to improve quality assurance systems for smear microscopy and improve TB lab management and surveillance system
• Continued to work with the government to align an electronic national register with information collected at the district level, including TB treatment outcomes by HIV status
• Continued to support the development of a National Reference Laboratory to improve the diagnosis of TB among people living with HIV/AIDS
• Supported IC and advocacy, communication, and social mobilization symposia at the first South African national TB conference
• Held a national seminar on TB-HIV/AIDS for key stakeholders in the country, including researchers and academics, clinicians and national and provincial level program managers
• Developed a national strategic plan for human resource development

Case Detection and Treatment Success Rates Under DOTS

Note: DOTS treatment success rate for 2006 will be reported in the 2009 Global Report. Source: Global Tuberculosis Control: Surveillance, planning, financing:WHO Report 2008.

Partnerships

Partnerships are one of the most important elements in combating TB in South Africa. The KNCV Tuberculosis Foundation manages TB CAP, in collaboration with other partners in the Tuberculosis Coalition for Technical Assistance. The University Research Corporation and its civil society partners and universities, the U.S. CDC, the International Union Against Tuberculosis and Lung Disease, the South African Medical Research Council, and WHO are also providing technical support to the government.

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1 Anti-Tuberculosis Drug Resistance in the World Report 2008: Fourth Global Report. WHO, 2008.
2 National Department of Health Report 2008

January 2009

Related Links

• USAID Overview of South Africa