Reversing the tide of death and suffering

The hard work over the past few years is paying off in terms of a reduction in mortality, writes Aaron Motsoaledi

AS WE head towards World TB Day and the launch of the 2017-2022 National Strategic Plan for HIV, TB and STIs, it is important that we reflect on our achievements, especially over the past few years. Such reflections will also allow us to recommit ourselves to doing more to ensure that we are on track to eliminate HIV and TB as public health threats by 2030.

The most important public health story since the advent of democracy in 1994 has been the rise and fall of the impact of HIV. It has left an indelible mark in virtually every community. An estimated 7 million people are infected with HIV with many millions more affected. It is well known that HIV has also fuelled the TB epidemic.

The most important health indicators, including mortality rates and associated life expectancy, have risen sharply as the tide of the twin epidemics rose. But in the past decade it has been arguably the good news story.

On February 28 this year, Statistics SA released a report on the number and cause of deaths in 2015. There has been a rise and fall in the number of deaths. This mirrors the rise in the number of HIV-infected people and the subsequent numbers treated with antiretroviral therapy, which was made available since 2004 but with accelerated access since 2009. In 1997 there were 317 680 deaths, these rose to a peak of 614 158 in 2006; by 2015 the number of recorded deaths was 460 236. This number is similar to the number of deaths in 2001, before the HIV epidemic reached its peak.

The declines in mortality need to be viewed against the increasing number of people in our country, which has grown from 44.91 million in 2001 to 54.96 million in 2015 – a growth of 22.4%.

The hard work over the past few years is paying off in terms of a reduction in mortality – something that our icon, Nelson Mandela, made an impassioned plea for at the International Aids Conference in Durban in 2000:

“HIV/Aids is having a devastating impact on families, communities, societies and economies. Decades have been chopped from life expectancy and young child mortality is expected to more than double in the most severely affected countries of Africa. Aids is clearly a disaster, effectively wiping out the development gains of the past decades and sabotaging the future.”

As the data illustrates, since the period of denialism we have heeded Madiba’s wise words and done much to reverse the tide of death and suffering, but more needs to be done to eliminate avoidable mortality.

A Stats SA publication last year shows that life expectancy fell to a low of 53.8 years in 2005. This coincided with the peak number of infections from HIV. From this low point there has been an annual increase in overall life expectancy to 62.8 in 2015 (with women living to 67.7 years on average, which is approximately at the same level as it was in 1994, before the advent of the Aids epidemic. This gain of 8.4 years over 11 years represents a gain in life expectancy of 0.8 years a year.

To put this in perspective: “The adult life expectancy in Japan after World War II increased at an average rate of around 0.5 years per year for a total gain of 9.4 years between 1947 to 1949 and 1965 to 1969, and is one of the nations with the most rapid life expectancy increases on record”.

The national picture is mirrored at local level in the province most affected by the HIV epidemic. In a recent paper, Reniers et al compared the life expectancy of the HIV positive and the HIV-negative (non-infected) populations after the roll out of antiretroviral therapy (ART) in UMkhanyakude District in northern KwaZulu-Natal from 2004 to 2014.

During this time there was an unprecedented increase in adult life expectancy of more than 15 years for men and women. The difference between the two populations, that is the life-expectancy deficit, had decreased to 1.2 years for men and 5.3 years for women, with the bulk of the deficit (more than 80%) due to HIV and its Siamese twin TB. The authors further note that most of the deaths in HIV infected people occur before they have started on ART treatment.

From their analysis of death notifications Stats SA also showed that maternal, infant and under five mortality rates have all declined. Maternal mortality ratios have declined from 247/100 000 live births in 2010 to 119/100 000 in 2015; infant mortality rates declined from 29/1 000 live births to 19/1 000; and under five mortality declined from 40/1 000 to 26/1 000 in the same time frames. Our efforts in preventing HIV infection in infants as well as the treatment of mothers for HIV have contributed to these significant declines in five years.

Similarly, Stats SA data suggests that deaths from TB have also declined. This is good news as we know that many people living with HIV die from TB. In the last three years mortality from TB has declined from 48 506 (9.9% of all deaths) in 2012 to 33 063 (7.2%) in 2015. This represents a decline of 15 443 deaths or 32%. In an effort to decrease the number of deaths of patients with HIV from TB, we expanded access to TB prophylaxis – with South Africa having the largest number of HIV patients on isoniazid preventative therapy.

These facts and figures tell a good story. But it doesn’t end there.

New antiretroviral treatment (Art) guidelines were introduced on September 1 last year. These guidelines, known colloquially as “test and treat” or “test and start”, require health workers to recommend that any person diagnosed with HIV be put on ART immediately. With increased access to treatment upon diagnosis, it is likely that people infected with HIV will be put on treatment sooner and therefore will be will probably live long and healthy lives. This will probably result in a further narrowing of the life expectancy deficit between HIV negative people and those who are HIV infected. Thus the good news story regarding the decrease in mortality and consequent increase in life expectancy as a result of the roll-out and scale up of the ART programme will probably have another chapter in five years time where the differential in life expectancy due to HIV will be approaching zero.

This does not mean that we should be complacent as there are more than seven million people infected with HIV, another 300 000 are infected each year and there are more than 460 000 new TB infections each year.

We need to reduce new infections to zero as soon as possible and ensure that every infected person gets the lifelong treatment that will give them a good quality of life. The soon to be launched National Strategic Plan for HIV, TB and STIs provides a good platform for accelerated action by all sectors of society to do more so that we can eliminate HIV and TB as public health threats by 2030 or sooner.

Dr Aaron Motsoaledi is the Minister of Health