Despite widely acknowledging that in some parts of the country like Khayelitsha in the Western Cape, about 73% of people with HIV also have Tuberculosis, Health Department programmes have failed to screen HIV-positive people for TB and to protect them from getting the bacterial infection.
Under the current national Health Counselling and Testing (HCT) campaign, just over seven million people have been tested for HIV. In comparison, less than half - a little over two million - have been screened for Tuberculosis infection.
"Out of the nine million South Africans that have been counseled for HIV, with seven million of them accepting to be tested, under 3 million of them have actually been screened for TB. There has been insufficient emphasis on TB in the HCT", head of the TB programme in the national Health Department, Dr David Mametja, admits.
According to Dr Nono Simelela, Chief Executive Officer of the South African National AIDS Council (SANAC), when the campaign started it lacked specific prescriptions to guide service providers on what to do.
"The first thing that I think went wrong, at least, from the feed-back we got from people who are doing the counselling and testing is that they were not sure whether they were supposed to be screening everybody who came for counselling and testing - whether they were positive or negative. So, you had situations where people were testing negative and walking away. So, we became much more clearer in our message, to say: 'Look, we want everybody to be screened'.", says Dr Nono Simelela.
Dr David Mametja added that "in theory, if nine million people have been counselled, you should be having nine million that have been screened for TB. In the beginning there wasn't that sufficient understanding by the health professionals who were doing this, that for every person they counsel, they should also screen for TB".
The campaign had to be re-designed in order to prevent people from leaving testing stations without being screened for TB.
"When the campaign started, we were screening for a lot more other chronic conditions. What we found is that it was time-consuming. People said that they wait for long hours in queues if we have to go through all of these. So, the directive from the Minister has been that even if we don't do the screens for the other chronic diseases, we must screen for Tuberculosis. So, we've been very, very clear that the minimum is that, at least, for all of those who test positive, they must be screened".
"Whilst you're waiting for the test results to come through, people should be asked whether or not they've been coughing for more than three weeks, they should be asked whether they are losing weight, they should be asked whether they are sweating at night, they should be asked if they are in the company of people who are also coughing and they should also be asked whether or not they are coughing up blood or something like that. If they say, 'yes', to any of those questions then, they must be referred for a proper screen", Dr Simelela explains.
The Health Department also has a policy that prescribes TB preventative therapy called IPT or INH Preventative Therapy in HIV-positive people. That means that if you are diagnosed with HIV and you do not have active Tuberculosis, you need to take medication known as INH or Isoniazid for six months to protect yourself against developing active TB. The drug is also widely used to treat TB in those who have active infection. However, implementation of the policy has been slow. The Health Department will not obtain its target to ensure that 600 000 HIV-positive people get access to Isoniazid by June this year, which is just two months away.
"A few months ago, we had only managed to put about 49 000 people on IPT. I think now we have exceeded 100 000 for the first time, but against a huge target of 600 000 that should be by June of this year", says Dr Mametja.
SANAC's Dr Nono Simelela described the figure as dismal.
"That's a dismal figure. We should be around 80/85%. We should have 100% of people who are positive for HIV who don't have active Tuberculosis taking prophylaxis for TB control. We're not doing as well as we should", she says.
Several factors have blocked implementation of the policy, including opposition by pockets of health workers to using INH or Isoniazid to prevent TB infection in people with HIV. Those opposing it argue that the use of the drug by people who don't have TB might result in them developing resistance to the medication in the event that they might need it in future should they acquire active TB infection. South Africa adopted the INH preventative therapy policy after it discovered that HIV/TB co-infection levels in the country are extremely high. According to the latest WHO figures about 58% of HIV-positive South Africans also have TB. In Khayelitsha, just outside Cape Town, about 73% of people with HIV are also TB-positive.