TB remains the leading cause of death in South Africa. (TB Alliance)

As the country with the highest number of people living with HIV and amongst the countries with a high TB burden, South Africa’s response to the COVID-19 pandemic must include a recovery plan to get HIV and TB responses back on track to achieve the National Strategic Plan 2017–2022 commitments.


Following a call to action that was developed by Frontline Aids, the Aids and Rights Alliance for Southern Africa, the Global Coalition of TB Activists and TB People, alongside community organisations on the frontline of the HIV and TB responses, and national, regional and global civil society groups committed to ending Aids and TB, the South African National Aids Council (Sanac) civil society is heading the call to the South African government, donors and United Nations (UN) partners to support our efforts, by committing to ensuring the mitigation of the impact of COVID-19 on HIV and TB programmes and addressing the secondary impact of COVID-19 in communities most impacted by Aids and TB.

South Africa with over 7.7 million people living with HIV, has the highest number of HIV-positive people globally and is also amongst countries with a high TB burden. The estimated number of incident TB cases in SA for 2018 was 301 000 while the estimated number of deaths due to TB in the same year was 63 000. TB remains the leading cause of death in the country. The country has the highest number of confirmed COVID-19 cases in the African continent. 

Wider spread of COVID‐19 in Africa may result in millions of PLHIV being exposed to, and potentially infected with, SARS‐CoV‐2. There is uncertainty about its impact on this population and health systems directed to them. The World Health Organisation recently projected up to 3.6–5.5 million hospitalisations and 190 000 deaths in Africa from COVID‐19 over the course of one year, while modelling by the Stop TB Partnership has also shown that an additional 1.4-million people could die due to the impact of lockdown on TB programmes, if control measures are inadequate.

As South Africa’s COVID-19 lockdown moved to alert level one on Monday 21 September, allowing most social and economic activity to resume, containment and mitigation measures continue to be implemented, as these are essential for the control of the COVID-19 pandemic. After years of progress in fighting HIV and TB, these measures have had an unintended impact on existing programmes of other important public health problems. 

Although most patients received additional medicines to continue their treatment at home amid the COVID-19 outbreak, national data still showed that there was a decrease in the number of patients who visited healthcare facilities to get tested for HIV and TB, as well a decrease in the number of people with HIV and TB who received treatment. The socio-economic impact of COVID-19 has exposed vulnerable populations because basic, first line defences such as water and sanitation are lacking in many communities. As these three epidemics now collide it is critical that public health programmes, that have taken tremendous efforts and years to optimise, remain uninterrupted. 

There is an urgent need for a recovery plan to get HIV and TB responses back on track to achieve the National Strategic Plan (NSP) 2017–2022 commitments. COVID-19 has demonstrated the important role that affected communities play in responding to health crises, reporting barriers to access and supporting peers and filling gaps in services. The pandemic is an opportunity for national HIV and TB responses to become more people-centred and to involve communities.

As the Sanac civil society forum we are asking the South African government, donors and UN partners to support our efforts, by committing to the following actions during level one  lockdown of the COVID-19 pandemic response:

  • Adapt HIV and TB programmes to mitigate the impact of COVID-19 and safeguard progress; 
  • Support innovative, fast-tracked and emergency policies for full implementation of decentralised and multi-month dispensing of antiretroviral treatment (ART) as recommended by theJoint United Nations Programme on HIV and Aids to allow clients to maintain ART adherence;
  • Protect frontline health workers through the provision of personal protective equipment and the training of frontline health staff, including community health workers; 
  • Reinforce systems for health so they don’t collapse by supporting urgent enhancements, including to supply chains, laboratory networks and community-led response systems; 
  • Provide psychosocial support services delivered through virtual platforms such as phone calls and social media platforms (e.g. Facebook and WhatsApp), replacing in‐person services while reducing the risk of SARS‐CoV‐2 transmission to clients and staff;
  • Prioritise orphans, vulnerable children, adolescent girls and young women to receive virtual risk screening and linkage to essential services, including referrals if at risk for, or experiencing abuse, neglect or violence;
  • Create demand and capacity for HIV pre‐exposure prophylaxis, voluntary male medical circumcision, testing and rapid linkage to treatment. 

As a partnership between governments, technical partners, the private sector, civil society, health organisations and communities, Sanac has continued to bring diverse players together, building off each other’s strengths to deliver health solutions quickly and at scale. Lessons from the HIV and TB pandemics have shown that supporting community engagement and community-led responses will be critical in the fight against COVID-19. This was evident in the collaboration in screening for COVID-19 and the follow-up programme for contacts which saw the government announcing support for more than 50 000 community health care workers who were deployed in communities, resulting in millions of people being screened for COVID-19. 

During the COVID-19 pandemic response we have noted an absolute devastation for our quest to end HIV and TB. If we were climbing a mountain before COVID-19, that mountain has now become Mount Everest. We need to work extra hard to mitigate the damage and stay focused on HIV and TB for the long haul. Collaboration and solidarity within the HIV and TB communities are critical if we are to have any hope of getting back on track to reach the NSP and sustainable development goals.

Mitigating the impact of COVID-19 on the communities most affected by HIV and TB will require swift action, extraordinary levels of leadership and collaboration and significant extra resources. We must recognise that this is not just a fight against a single virus, but a fight to protect and save lives from multiple infectious diseases. We must fight this new fight and we must sustain the unfinished fight against HIV and TB. Moreover, as in the fight against HIV and TB, in the fight against COVID-19, we must leave no one behind. 

It may not be possible to meet the 2020 target of fewer than 500 000 AIDS-related deaths globally, but gains in South Africa’s HIV and TB responses must not be reversed.

Steve Letsike is a human rights advocate who founded Access Chapter 2 (AC2), a human rights organisation that focuses on LGBTI people, women and girls in their diversities. Letsike has recently been appointed a member of the Ministerial Advisory Committee on social and behaviour aspects of the COVID-19 response in South Africa.