With more than 7 million people living with HIV, South Africa is home to the world’s largest
HIV epidemic. About 3.4 million people are on HIV treatment – the largest of any country in
the world – and as coverage continues to improve, this number will continue to grow.
The government’s decision to prioritise the roll out of anti-retroviral treatment over the last
15 years has been one of South Africa’s biggest success stories. For hundreds of thousands
of people living with HIV, it has meant that they are able to live longer, and continue to be
healthy for longer.
One of these is that people living with HIV are more susceptible to develop tuberculosis.
People who are infected with HIV are 20 to 30 times more likely to develop active TB. TB is
both curable and preventable.
In South Africa, the TB epidemic has been driven by high HIV co-infection rates, meaning
that many people who are HIV positive, also have TB. South Africa has one of the highest
burdens of TB in the world with more than 320 000 new infections in 2017. In the same year
there were 78 000 deaths from TB in the country – with about 56 000 of these people being
HIV-positive as well. TB was the leading cause of death in South Africa in 2015 and 2016.
Globally, TB is a leading killer of people living with HIV: in 2015, 35% of HIV deaths were due
For people who live with both HIV and TB, there are various risk factors that influence the
way their disease develops. Smoking is one.
For those with TB, smoking aggravates their symptoms and increases the severity of their
disease at a faster rate. Smokers with TB are more likely to develop coughs, lesions in their
lungs and positive sputum culture, which means that they are more likely to spread TB. They
may also become resistant to TB treatment drugs and therefore an increased likelihood of
having recurrent TB.
Smokers who are living with HIV have a higher risk of developing heart disease, high blood
pressure and strokes. They are also at a higher risk of developing lung cancer and cancer of
the cervix, as well as bacterial pneumonia, oral and esophageal thrush and osteoporosis.
Although researchers across the globe have been investigating the intersections between
HIV, TB and smoking for several years, until recently, little was known about the extent of
how smoking influences these two diseases in South Africa. Research released earlier this
year has filled this gap and provided South Africa with the first concrete statistics.
The study – which was done by the SA Medical Research Council, the University of
Witwatersrand’s Perinatal HIV Research Unit and the Johns Hopkins Centre for TB Research
in the US -- shows that the smoking rates among people with HIV in South Africa are much
higher than the rates among the general population. While 33% of South Africa’s men and
8% of the country’s women smoke, the 2018 study found that among people living with HIV,
smoking rates among people living with HIV was significantly higher. In this cohort of
people, 52% of men and 13% of women smoke. This is clearly an increased health risk.
In the last 15 years South Africa has made significant inroads to improve access to anti-
retroviral and TB medication. One of these initiatives is receiving both HIV and TB treatment
at the same clinic.
However, the South African government could provide more support to people living with
TB and HIV to help them to stop smoking. When patients visit these clinics for their
medication, they should be able to receive counselling to help them stop smoking. They
should also have the option of being able to join support groups where they can engage
with others patients who also wish to give up the habit. The health departments needs to
ensure that clinics provide materials in all nine official languages to educate patients about
the harms of smoking in general; and about the dangers of smoking when patients are living
with both HIV and TB in particularly. These materials should have tips that patients can
follow to help them stop smoking.
Ending both the TB and AIDS epidemic by 2030 is one of the United Nations’ Sustainable
Development Goals – which South Africa has agreed to work towards. For HIV this means
meeting the UNAIDS target of reducing the number of new infections globally to less than
200 000 by 2030. For TB, it means meeting the World Health Organization's target of
reducing the national incidence of TB to fewer than 20 cases for every 100 000 people by
2030. The World Health Organisation has extended this goal and set a 2035 target of a 95%
reduction in deaths and a 90% decline in TB incidence – similar to current levels in low TB
incidence countries today.
South Africa has a little over 12 years to meet the 2030 targets. Developing interventions
that reduce the prevalence of smoking among people living with HIV and TB would play a
significant role in being able to meet these targets.
*This article first appeared in The Star on November 30, 2018.