If cases of the new coronavirus spread in South Africa, the country may be heading into uncharted territory — becoming the first country in the world to grapple with the new coronavirus and a high burden of HIV and TB.
HIV-positive people not on treatment and people with conditions such as hypertension and diabetes could be among the worst affected if cases of the new coronavirus spreads in South Africa.
On Tuesday, 10 March, Health Minister Zweli Mkhize confirmed South Africa now has 13 confirmed cases of the virus, officially named SARS Coronavirus 2 (SARS-CoV-2). The virus gets its name from its similarity to the virus responsible for the 2003 outbreak of severe acute respiratory syndrome in China. The World Health Organisation (WHO) has called the disease that SARS-CoV-2 causes COVID-19.
So far, eight of the country’s 13 COVID-19 cases are among a group of nine people who recently returned from an Italian skiing trip. The group is now in self isolation or quarantine and the health department is tracing anyone who might have been in contact with them.
The other five cases are from people who travelled back to South Africa from Germany, Austria, Portugal, Switzerland and Turkey.
Currently, the national health department doesn’t think the virus is spreading in South Africa but if in the future, it does, it may hit people with underlying health conditions such as HIV and TB, and who are not on treatment, the hardest — according to the heads of local HIV and TB research organisations. Similar risks may hold true for those living with other chronic illnesses.
HIV positive and on treatment? Then you have no cause for extra concern
Salim Abdool Karim is the director of the Durban-based Centre for the Aids Programme of Research in South Africa and a global health professor at Columbia University in the United States. Abdool Karim says that SARS-CoV-2 is too new to know much about its potential impact on people with HIV, but other viruses — such as measles or influenza — can give us a clue.
If those viruses are anything to go by, those with HIV, and who are not on treatment, will be among the most at risk.
“If an HIV-positive patient is on antiretrovirals, then their response will be pretty similar to what an HIV-negative patient’s response would be based on what we know from other infections,” he says.
“I think what we’re going to see is that the young people who have HIV and low CD4 counts will have… death rates similar to what we’re seeing in patients who are 60 years old and 70 years old.”
CD4 counts are a measure of the immune system’s strength.
Between 8 and almost 15% of people older than 70 who contracted the virus in China’s Hubei province died, according to a Chinese Center for Disease Control and Prevention analysis of more than 44 000 coronavirus cases released in February.
Today, about four out of every 10 people living with HIV in South Africa are still not on antiretrovirals, the latest HIV household survey by the Human Sciences Research Council revealed.
Now is the time to know your HIV status and start treatment’
In Johannesburg, the organisation Right to Care provides HIV services. CEO Ian Sanne agrees with Abdool Karim.
“People on antiretrovirals need to make sure they’re taking their antiretrovirals and then I think there’s no reason to worry more than the general population,” Sanne told Bhekisisa. “What we’re worried about are people who are HIV positive and not yet diagnosed.”
In a statement earlier this week, Sanne explained: “Now is the time to know your status and start treatment.”
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We know very little about what the new virus means for people with TB
South Africa is among 30 high burden countries that account for almost 90% of the world’s TB cases, according to the WHO’s 2019 TB report. In 2019, more than half of the country’s 301 000 TB cases were among people infected with HIV.
But Abdool Karim says it’s not clear how the new coronavirus will impact people co-infected with HIV and TB given that both TB and SARS-CoV-2 affect the lungs.
Statistics South Africa’s 2016 data shows TB was responsible for about 30 000 deaths in 2016 and the condition remains the leading cause of natural death in South Africa.
As of 10 March, 4 012 people had died globally as a result of the new coronavirus, the WHO reported.
Data from Wuhan: Why Chinese figures may only tell us so much
The virus’ death rate continues to be contentious, mostly because countries aren’t sure they’re catching every case of SARS-CoV-2.
But the WHO and the National Institute for Communicable Diseases have estimated that about 2 to 3.4% of people who reported contracting the virus have died.
Data from the Chinese Centers for Disease Control, however, reveals that your odds of dying from the virus depend on how healthy you are. In its February analysis, the government agency found a death rate of 2.3% among almost 45 000 confirmed cases in the Hubei province. But this rate rose steeply among those people with weaker immune systems due to, for instance, non-communicable diseases (NCDs).
An NCD is a disease that is not passed from person to person.
The agency admitted data on NCDs among coronavirus patients was not routinely collected. But among those infected with the virus who reported having diabetes, the death rate rose to about 7%. Meanwhile, an estimated 6% of Chinese coronavirus patients with high blood pressure died, the February data shows. This proportion increased to 11% among people with cardiovascular disease.
However, it’s unclear whether patients with NCDs also had any other risk factors, such as an older age, from the data.
Coronavirus and other chronic conditions
Nasheeta Peer is a senior specialist scientist with the South African Medical Research Council’s NCD Research Unit. She says it’s difficult to predict how people with NCDs such as diabetes, which weaken the immune system, might be impacted by the coronavirus.
Peer explains that people with diabetes will be at increased risk compared with the general population, “but if their diabetes is uncontrolled, which is possible even when taking medication for diabetes, then the risk may perhaps be greater”.
The International Diabetes Federation estimates that about 450-million adults were living with diabetes worldwide in 2017, but almost half these cases were undiagnosed.
Data from Stats SA notes how diabetes is the second leading cause of natural death in South Africa after TB, with about 25 000 people who died in 2016. People with diabetes are three to four times more likely to develop TB, a 2010 research review published in the journal Tropical Medicine & International Health showed. This is why the country’s latest national TB plan recommends increasing TB screening among people with diabetes.
But this may also be true the other way around, according to an article from 2000 published in the Indian Journal of Tuberculosis. TB can temporarily reduce the body’s ability to handle glucose, or sugar, leading to increased blood sugar levels — which is a risk factor for developing diabetes.
Director of the South African NCD Alliance, Vicki Pinkney-Atkinson, says if the new coronavirus begins to spread in South Africa, her main concern is people with NCDs
who need medication, but could potentially put themselves at risk of contracting the virus by queuing in long lines at public clinics to do this.
In 2012, the national health department introduced a system to deliver chronic medications to allow patients to pick up their medications at designated pick-up points outside of health facilities. About 3.1-million patients are now enrolled in the project, called the Centralised Chronic Medicine Dispensing and Distribution programme, according to presentations made before Parliament earlier this year. Patients can now pick up medication at more than 800 points around the country despite the programme’’s challenges with costs and patient tracking.
“For the moment I’m lucky enough that I don’t have to go and stand in a long queue [to get my medication]” Pinkney-Atkinson says. “What will happen for those people who have to do it and travel on buses to get there and taxis to get there?”