Since the COVID-19 pandemic devastated healthcare systems around the world, many countries have suffered significant human losses. South Africa is no exception – to date, almost three million confirmed cases and about 90 000 deaths have been officially recorded.
According to the South African Medical Research Council (SAMRC), 271 311 excess deaths were registered between 3 May 2020 and 6 November 2021. “Excess deaths” refer to the number of people who die from any natural cause in a given region and period compared with a recent historical baseline. Accordingly, over a quarter of a million more people have died from natural causes in SA than was predicted for that period. SA is estimated to have the 13th highest excess deaths per 100 000 people in the world and the highest in Africa.
Mortality statistics show that older populations have been disproportionately affected by COVID-19. There was early optimism that Africa, with its relatively young population, would be spared. Regrettably, this optimism was unfounded, and countries like SA were severely impacted due to the high incidence and prevalence of both communicable diseases, such as tuberculosis (TB) and the human immunodeficiency virus (HIV), and non-communicable diseases, most notably diabetes mellitus, hypertension and obesity, which are all known to increase COVID-19-related mortality.
While not all excess deaths are due to COVID-19, the SAMRC estimates that 85% to 95% of these deaths are in fact related to it. The remaining proportion reflects the collateral damage to the rest of the healthcare system. Clinics and hospitals were repurposed as specialised COVID-19 hospitals; healthcare personnel were diverted from management of chronic diseases to frontline care for COVID-19 cases; and community health workers were removed from HIV- and TB-related work, and deployed as “coronavirus hunters”.
The national lockdown further added to the devastation through a surge in interpersonal violence – especially gender-based violence – and unprecedented unemployment, which saw loss of livelihoods and food security, all in the context of decreased access to both preventative and curative healthcare services.
Despite significant advances in the prevention and treatment of HIV, it remains one of the leading causes of mortality in Africa, with more than 400 000 deaths occurring in 2019. SA has the largest number of people living with HIV (about 7.8 million in 2019). Based predominantly on South African data, the World Health Organisation (WHO) warned that HIV increases the risk of severe and critical COVID-19. The impact is unfortunately bidirectional: COVID-19 also impacts HIV care.
In SA, HIV testing declined by 22.3% between March and December 2020 compared with 2019, with 3.44 million fewer HIV tests performed. A large decrease in testing delays timeous access to treatment for infected people and increases the risk of virus transmission. These consequences are exacerbated by simultaneous COVID-19-related reductions in HIV-prevention services for key populations – such as sex workers, gay men, men who have sex with men, and drug users – as well as reduced medical male circumcision and condom distribution.
Studies modelling the potential impact of disruptions to HIV programmes by the COVID-19 pandemic estimate that interruption of antiretroviral therapy (ART) for six months for 50% of patients would result in a 1.63 times increase in HIV-related deaths over a one-year period. This would amount to 296 000 excess HIV-related deaths in sub-Saharan Africa. Fortunately, current trend data suggests that disruptions and their impact on AIDS-related mortality may be less than had been predicted. Unfortunately, SA is a notable exception, with about 300 000 people feared to have been lost to treatment because of the COVID-19 pandemic.
A particularly vulnerable population is HIV-positive pregnant women. According to data routinely collected from the South African District Health Information System (DHIS), the service most affected in the public health system was antenatal care. In fact, during the first wave of COVID-19, there was a 30% increase in institutional maternal mortality and a 4.8% increase in institutional neonatal mortality. It is further worrying to note an estimated 20% decrease in HIV testing during pregnancy and an estimated 25% decrease in women receiving ART during pregnancy in 2020. The cost in terms of increased perinatal transmission of HIV will only become evident in the years to come.
Prior to COVID-19, TB was the world’s leading infectious disease killer, especially among people living with HIV. Sub-Saharan Africa is home to 70% of all people living with HIV/TB co-infection, with SA as the epicentre, where about 59% of people with TB are co-infected with HIV.
Unfortunately, TB was also the disease most severely derailed by COVID-19. There is ample evidence from SA and elsewhere that a shift in focus to COVID-19 diverted resources away from TB-related preventative, diagnostic and curative care. At the same time, TB and COVID-19 could be confused due to patients presenting with similar symptoms, thereby decreasing the likelihood of seeking care and making an accurate diagnosis.
The WHO says that repurposing human, financial and other resources from TB care has resulted in TB case notification rates plummeting in more than 200 countries. In three countries with the highest TB burdens – India, Indonesia and the Philippines – case notifications decreased between 25% and 30% from January to June 2020 compared to 2019. The WHO has warned that if such reductions were to occur on a global scale for three months, TB-related deaths could increase by as much as 400 000 in 2020.
In SA, the National Institute for Communicable Diseases reported a reduction in GeneXpert TB testing by 48% between February and May 2020. Routine data from the DHIS revealed that the number of people screened for TB symptoms declined from 87.6 million in 2019 to 70.8 million in 2020. Provisional data from 84 countries indicate that an estimated 1.4 million fewer people received TB care in 2020 than in 2019. Untreated cases have a snowball effect with increased risks of additional spread, including of drug-resistant variants, as well as worse outcomes of COVID-19.
Fortunately, all is not lost. Trends indicate that HIV and TB services are resuming and that some have returned to pre-COVID-19 levels. Great innovations have also been born out of strained healthcare systems, and could be adapted to shape the future of HIV and TB programmes. Some of these include increased focus on self-testing; home- and community-based treatment initiation; innovative treatment delivery strategies like multi-month drug prescription for long-term use to reduce the number of visits to healthcare facilities; digitisation of screening services and virtual observation of treatment via smartphone applications; WhatsApp platforms for healthcare worker consultations; and workstations consisting of chip-based, real-time quantitative portable PCR systems that allow for point-of-care testing.
Ultimately, despite the devastation, the COVID-19 pandemic might in time become known as a catalyst for positive change that helped achieve the elimination of some of the most relentless infections of our time.
Professor Theresa Rossouw is Professor in the Department of Immunology in the Faculty of Health Sciences at the University of Pretoria (UP).
CBS News: ‘Why South Africa was able to deploy a ready-made army of coronavirus hunters’
CIDRAP: ‘WHO warns of COVID impact on TB services’
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