in my first post, i referenced the lancet's series on health in south africa. the third article in this series explores the epidemics of HIV and TB in the country: "in 2007, south africa, with 0.7% of the world's population, had 17% of the global burden of HIV infection." when i talk about rounds at edendale and suggest most patients have HIV, i'm not exaggerating. particularly in kwazulu-natal province, the prevalence is astronomically high, and this has had major, major implications in all aspects of healthcare (including the previously discussed concomitant TB co-epidemic). the province of kwazulu-natal has been disproportionately affected which undoubtedly has much to do with the large population of black Africans here living in poverty, an unfortunate, ongoing after-effect of the apartheid government.
how did this happen? the early history of HIV in this country is not dissimilar from the US: although the early epidemic was focused in groups of men who have sex with men, IV drug users, and those requiring blood transfusions, in the late 1980s and early 1990s, there was an exponential increase by heterosexual transmission. in south africa, from 1990 to 1994 alone, the prevalence in pregnant women went from 0.8% to 7.6% -- which further climbed to 20.5% in 2000, 24.8% in 2001, and 30.2% in 2005. unfortunately, under the apartheid government (finally dissolved in 1994), HIV was stigmatized and labelled a "black disease." both the lack of education and the "migrant worker" lifestyle of much of the poorer black African population was implicated in the rapid spread (multiple partnerships). little was done by the south african government to control the epidemic during this time; their response has been described as being "marked by denial, lack of political will, and poor implementation of polices and programmes." it wasn't until 2003 that the government began to provide antiretroviral therapy in the public health sector. despite this, by 2006, mortality from HIV exceeded the incidence -- and south african life expectancy had decreased by almost 20 years.
despite all of this, efforts are underway in an attempt to make a dent in this epidemic. huge scale-ups in condom distribution and education, HIV testing and counseling, and education about and adherence to treatment have been prioritized. standardized regimens have been created and are available almost everywhere patients are seen. today i had the pleasure of spending time in the "communicable diseases center" or HIV clinic (the name remains from a time when the disease was much more stigmatized), where there were two doctors available to see the 128 patients scheduled for routine visits to have their ARVs refilled.
|these boxes with free packets of condoms can be found as frequently as purell dispensers at US hospitals.|
|clinics and hospitals (including edendale) are sites where people can get tested.|
|the standardized ARV regimens available for free through the government.|
so, back to the survey. one of the biggest headlines: prevalence in the overall population of south africa had climbed from 10.6% in 2008 to 12.2% in 2012. young black African women accounted for the highest burden of disease (in ages 30-34, 36% are infected) followed closely by their male counterparts (in ages 35-39, 28.8% are infected). you guys, this is essentially 1 in 3 people. the survey also turned up that self-reported condom use had significantly decreased since the prior survey in 2008 -- in fact, more than half of all respondents reported never having used a condom. again, the burden was found to be highest in kwazulu-natal province. despite all this discouragement, the increased prevalence of disease in the population was felt to be in part due to new infections, but also secondary to the scale-up of the ARV programs allowing for more people to live longer with the infection. the report cited that access to ARVs has actually doubled since 2008.
so what does this all mean? in short, south africa is drowning in HIV. it's no secret that years of apartheid, denialism, and lack of government initiative for controlling the spread has left the country and its most vulnerable population miserably behind in this battle. programs are now in place to better educate and treat those infected, however these are still far from adequate.
despite all i've said, i've had the pleasure of meeting and working alongside dozens of highly-motivated, compassionate health-care workers at edendale who focus on chipping away at the epidemic by taking care of one patient at a time. in HIV clinic today, i met two dedicated doctors and a handful of their nursing counterparts who work tirelessly not only to prescribe medications, but also to provide ongoing education. theoretically, we all expect this, however watching it play out in practice, especially against such a formidable epidemic, is absolutely inspiring. what an eye-opening, challenging, valuable experience this has been.
until next time,
Salim S Abdool Karim, Gavin J Churchyard, Quarraisha Abdool Karim, Stephen D Lawn. (2009) Health in South Africa 3: HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet; 374: 921–33.
Shisana, O, Rehle, T, Simbayi LC, Zuma, K, Jooste, S, Zungu N, Labadarios, D, Onoya, D et al. (2014) South African National HIV Prevalence, Incidence and Behaviour Survey, 2012. Cape Town, HSRC Press.