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Letter from South Africa

At the time of writing this ‘Letter from South Africa’, the country was gearing itself towards the festive season and the very popular summer holidays. My family and I had taken a short break earlier and used the opportunity to visit the Pilanesberg National Park to view and photograph the animals we so enjoying seeing (Fig. 1). Staying in Johannesburg (as I usually do), during the festive season, is a pleasure and a wellguarded secret. With many foreign citizens returning home for the holiday break, local citizens returning to their rural villages and others going down to the coast for their annual holiday, travelling to and from work every day becomes a pleasure, as there is considerably less traffic. In addition, finding a table at a restaurant, even without a booking, becomes highly possible. The students have finished their year, patient loads become much lighter and many colleagues are away, leaving one time to reflect on the factors that impact respiratory health and its research in the country. South Africa has the largest human immunodeficiency virus (HIV) epidemic in the world, with the complications of HIV infection weighing heavily on the respiratory system. HIV has an impact, at least partly, on a number of respiratory disorders, including both communicable and non-communicable conditions. Yet, recent data suggest that the country is making great strides in the fight against HIV infection. Furthermore, the challenge of managing an overwhelming epidemic has been juxtaposed against tremendous opportunities for researchers, with many investigators, too many to identify individually, producing worldleading research in the field of HIV infection. The fifth South African National HIV Prevalence, Incidence, Behaviour and Communications Survey conducted in 2017 by the Human Sciences Research Council was released this year. This was a large population-based cross-sectional survey of households in South Africa to assess the prevalence and trends in various HIV-related indicators and produced some interesting statistics, which made for interesting reading. In 2017, approximately 7.9 million people were living with HIV in South Africa, with the prevalence varying among the different population groups, in different geographical areas of the country, and in the different age groups. The prevalence was highest in the age group 15–49 years and especially high among females. The annual incidence of HIV among those aged 14–59 years was high at 0.79%, corresponding to approximately 199 700 new infections in that age group in 2017, but down by 44% since the previous survey in 2012. UNAIDS had set targets for HIV management, the so-called 90-90-90 targets, indicating that by 2020, 90% of people living with acquired immune deficiency syndrome (AIDS) should know their status, 90% of those diagnosed should be receiving antiretroviral therapy (ART) and 90% of people on ART should be virally suppressed. By 2017, South Africa had reached targets of 85-71-86, with 84.9% of people living with AIDS in the age group 15–64 years knowing their HIV status, 70.6% being on ART and 87.5% being virally suppressed. At the current time, South Africa has the largest ART programme in the world, but the President has directed the Health Department to diagnose and start an additional 2 million on treatment by 2020, an enormous challenge. The greatest impact of HIV on the lung is on the occurrence of respiratory infections, with the big three being tuberculosis (TB), community-acquired pneumonia (CAP) and Pneumocystis jirovecii pneumonia (PJP). For a considerable period of time, South Africa has been recognized to have one of the worst TB epidemics in the world, much of this being HIV-associated. With escalating numbers of infection and growing drug resistance, it is not surprising that TB became the number one overall cause of death in South Africa during the period 2014–2016. However, it is, perhaps, heartening to note that the proportion of deaths from TB has progressively decreased over the 3-year period, directly in tandem with the expansion of ART coverage. It is certainly important also to recognize that other innovations and achievements in this field have taken place, which include the development of a National Strategic Plan for TB and HIV, constantly being updated, and the upscale of the ART programme to the largest in the world, and self-funded, this being a significant achievement for South Africa.