This document discusses HIV and TB in the Western Cape province of South Africa. It finds that 86% of HIV infections and 76% of TB cases are concentrated in 14 sub-districts, mainly due to factors like poverty, overcrowding and migration. Effective prevention and treatment requires multi-sectoral strategies including increasing access to testing, treatment and prevention tools, as well as addressing social and structural drivers of disease transmission at individual and community levels through normative and behavioral changes. An ideal approach combines biomedical, behavioral and structural interventions tailored to local epidemiology and risks.

1. HIV and TB
Prevention and treatment
What multi-sectoral strategies will
decrease the burden of infectious disease
amongst the people of the Western Cape?

2. A coherent strategy needs to be informed by the
answers to the following questions…
• What is the scale of the HIV/TB epidemic in the Western
Cape?
• Where is it prevalent?
• Why does it occur where it does?
• What tools do we have to either prevent infection or to
reduce disease severity, and how effective are they?

3. Scale and distribution of disease

4. HIV infected population in the Western Cape
+ ART coverage
District/Sub-district No. HIV infected
Proportion of
total infections No. on ART
Proportion of
total on ART
Khayelitsha 39 121 14.5% 19 708 19.1%
Cape Winelands 29 371 10.9% 10 477 10.1%
Klipfontein 29 205 10.8% 7 863 7.6%
Eastern 26 508 9.8% 9 506 9.2%
Western 22 894 8.5% 11 499 11.1%
Northern 22 862 8.5% 5 385 5.2%
Eden 22 271 8.2% 8 381 8.1%
Mitchells Plain 17 962 6.7% 11 273 10.9%
Southern 16 300 6.0% 5 764 5.6%
Tygerberg 16 193 6.0% 6 147 5.9%
Overberg 14 521 5.4% 3 268 3.2%
West Coast 9 114 3.4% 3 570 3.5%
Central Karoo 3 680 1.4% 508 0.5%
270 000 100.0% 103 349 100.0%

5. TB cases 2009
West Coast: 4,244 (8%)
Central Karoo: 700 (1%)
Eden: 7,204 (13%)
Cape Winelands: 9,892 (18%)
Cape Town: 30,820 (55%)
Overberg: 3,059 (5%)
0
5000
10000
15000
20000
25000
30000
35000
Cape
Town…
Cape
Winelands
Eden
West
Coast
Overberg
Central
Karoo
TB cases

6. TB is the face of HIV
• Being HIV-infected increases your risk of having TB by anywhere
from 30 to 100-fold (depends on the stage of the HIV disease)
• Proportionate to its population size, Western Cape is the province
worst affected by TB
TB is what is killing HIV-infected people

7. Recent HCT campaign
Sites with > 1000 HIV+ tests – Red
Sites with 400-1000 HIV+ tests - Yellow

11. Burden of HIV and TB
~270,000 HIV infected individuals
~50,000 diagnosed TB cases per annum
Of HIV-infected people, 86% are in 14 sub-districts
Of TB diagnoses, 76% are in the same 14 sub-districts
These two diseases account for +/- a quarter of the years of life lost in the province

12. Because they harbour many of the risk factors
associated with HIV1:
The ‘deprivation cluster’ of:
1. Poverty
2. Overcrowding
3. Malnutrition
4. Migration
Why do certain areas carry a disproportionate
burden of HIV disease?
Produce social vulnerability
1. Western Cape Burden of Disease report for major infectious diseases, 2007

13. By being strongly associated with the following risks1:
1. Not knowing one’s HIV status
2. Stigma and discrimination
3. Age mixing
4. Early sexual debut
5. Transactional sex
6. Partner turnover/concurrency
7. Alcohol misuse
Social vulnerability creates a high risk environment
for HIV transmission
*disempowerment
*compromised decision-making
*economic necessity
1. Western Cape Burden of Disease report for major infectious diseases, 2007

14. Viral transmission is a complex biological sequence of events that
starts with ‘permanent’ viral attachment to host epithelial tissue
Some people are more likely to transmit HIV and others are more vulnerable to acquire HIV
1. Sex & age
2. Viral load
3. Sexually transmitted infections
4. Lack of circumcision
5. Mother to child transmission
Despite the socio-structural environment creating a context of high risk
for HIV acquisition…
the final mediator of HIV transmission is biological

15. TB – another risky environment
Risk 1 = Risk of being exposed to the organism
(acquiring infection)
• The ‘deprivation cluster’ of: impoverishment, poor nutrition,
migration, overcrowded dwellings compounded by existing high TB
prevalence and incidence, poor education, ignorance of TB
transmission mechanisms and of TB symptoms, poor adherence to
treatment
“85-90% of those people with normal immunity who inhale TB do not develop disease”

16. Risk 2 = Risk of infection progressing to disease
TB infection can be longstanding and “reactivate”
or can be recently acquired and progressive
“50-90% of South Africans are likely to be latently infected with TB”
“by far the most powerful risk identified (for infection progressing to disease) is
concurrent HIV infection”
TB – another risky environment

17. Interventions
• We’re not only trying to prevent new HIV and new TB infections
• We also have a large population of people who are already HIV-
infected, and in whom we are trying to prevent premature death

18. HIV prevention can and should be implemented at
different levels
Structural- seek to change the context that
contributes to vulnerability or risk
Behavioural- attempt to motivate behavioural
change within individuals or communities
Biomedical – attempt to block infection or reduce
infectiousness

19. Biomedical interventions need to be placed into the high risk environments - at scale
(and socio-structural barriers to their consistent and correct use need to be
overcome)
Level of
intervention
Risk No. Mode of action Effectiveness
1 Physical seperation 85-95%
2
Restore epithelial
integrity Variable
3
Reduce epithelial
vulnerabilty ~58%
Oral ART-
lifelong
Reduce hiv in body
fluids
theoretically
very high
Oral ART-
pre-coitally
Reduce hiv in body
fluids ~44%
Topical
antimicrobials
peri-coitally
Reduce probability
of viral 'attachment' ~39%
5 Boost immunity unclear
Vaccines
HIV in body fluids
coming into
contact with
epithelium of
sexual partner
Biomedical
4
Anti-
retroviral
medication
Prevention method
Barrier methods
STI treatment
Male circumcision

20. TB interventions
1. Reduce the probability of someone inhaling the
mycobacterium Tuberculosis
– Tackle the ‘deprivation cluster’ – overcrowding etc
– Reduce prevalent and incident TB (case-finding – ART work-up,
door-to-door community drives etc..)
– Reduce/prevent drug-resistant TB
– Reduce infectiousness of those with TB (case-treatment and case-
holding)
– Environmental infection control (applying not only to health
facilities but all areas where people congregate – transport, work,
church, bars etc)

21. TB interventions
2. Reduce the probability of inhaled (or latent) tuberculosis
progressing to active disease
– Early identification of high risk cases (HIV testing) and intensive
education of disease symptoms
– Regular routine monitoring of high risk cases
– ‘Bolster immunity’: ART where indicated
– IPT where appropriate

22. A word on Mother-to-child transmission
Pre-conception
Pre-partum
Intra-partum
Post-partum
Antiretroviral drugs (dual and triple therapy)
reduce viral load, reduce probability of
transmission. The earlier started, the better
Antriretroviral drugs and reducing birth trauma
(C/S)
Antiretroviral drugs for mother and child.
Breastfeeding choices and drug cover to
the child for the duration of breastfeeding
MTCT – effective contraception is a
powerful tool to prevent transmission of HIV from
mother to child. 100% effective

23. • In the absence of a ‘game-changing’ intervention, the Western Cape
will see approximately ~14,000 HIV infections in 2012 (~1,200 of
which will be from mother to child)
• We can identify the communities in which the ~14,000 transmission
events will occur
• We have the biomedical tools and knowledge to theoretically stop
almost every one of those transmission events…
We know the following about HIV infections in
the Western Cape…
But we’re missing a piece of the puzzle…
And it revolves around generating large scale demand for, and
consistent uptake of, proven biomedical interventions by high risk
communities

24. It’s not clear how we are going to solve this vexed problem,
but let’s try and picture the type of societal and community
norms that would be required to reduce HIV and TB
transmission…

25. What’s the “ideal world” scenario?
• Structural: to do away with the ‘deprivation cluster’
• Societal/behavioural:
An environment in which everybody…
• Is informed of the consequences of HIV infection, knows their HIV status,
checks it regularly and no stigma is attached to doing so
• Uses barrier protection consistently, and especially with casual sex; has
immediate access to condoms whenever they want them and their use of
condoms is positively re-enforced by their partner, their peer group and
their community
• Delays their sexual debut and avoids having multiple sexual partners
• Men present for circumcision routinely
• Women use contraception consistently and space their pregnancies well
• HIV-infected pregnant women know their HIV status and present very
early in their pregnancy for treatment

26. What’s the “ideal world” scenario?
• Societal/behavioural:
An environment in which every HIV-infected person…
• Knows that they are at unusually high risk of TB
• Knows how to recognise TB, knows simple household and community
infection control measures, knows the benefits of TB preventative therapy,
knows what to do and where to go if they think they have TB
• Who is HIV-infected is able to keep themselves well by routinely
undergoing monitoring (for TB, cervical cancer etc) and being rapidly
responsive to new symptoms

27. • Biomedical
An environment in which everybody…
• Has simple and rapid access to HIV and TB testing
• Has easy access to required medication
• Adheres to their prescribed treatment because they understand it benefits
them, are aware of the consequences of not doing so, and are supported
in doing so by their peers and their community
What’s the “ideal world” scenario?

28. • “Highly active HIV prevention inevitably must be combination prevention”
• “Nothing should be more important than a focus on young people”
• “investments should focus on promoting normative and social change to
reduce multiple and concurrent partnerships, and to greatly increase
availability of safe and affordable male circumcision services”
• “condoms (unlike contraception) have to be available immediately and thus a
continuous source of supply is needed”
• “The aggregate effect of radical and sustained behavioural changes in a
sufficient number of individuals potentially at risk is needed for successful
reductions in HIV transmission”
“ Understand but don’t overcomplicate.
Broad rapid brushstrokes are sufficient for action”
UNAIDS suggested high level strategies…