1. HIV and Tuberculosis in South Africa Prof Allen Herman Dean, National School of Public Health Phidisa Conference Richards Bay 28 th July 2004

2. Harlem What happens to a dream deferred? Does it dry up Like a raisin in the sun? Or does it fester like a sore – And then run? Does it stink like rotten meat? Or crust and sugar over – Like a syrupy sweet? Maybe it just sags Like a heavy load Or does it explode? Langston Hughes

6. Source: Tuberculosis Commission Report, 1914: 113-114 Prevalence of TB Infection in New Recruits compared to Workers with previous experience NyasalandMozambiqueNot Specified New Recruits6/129 (4.7%)7/415 (1.7%) End of First Year of Contract 26/121 (19.7%) Re-employed10/52 (19.2%)11/63 (17.2%)

7. Survival of mine workers repatriated from Witwatersrand to the Transkei and Ciskei CategoriesYears of Repatriation 1926192719281929 Number Repatriated132148186237 Follow-up period3 yrs2 yrs1 yr6 mo Number Traced85122141127 Number Died49767151 % Died at follow-up57.662.350.440.2

9. Tuberculosis Incidence Rates (per 100,000)

18. Estimated Burden of Tuberculosis and TB/HIV in South Africa (1999)

24. Summary (1) Tuberculosis is a series of very old epidemics in South Africa It has its onset in the second half of the 19 th century when tuberculosis naïve populations of the western and northern Cape were exposed to Europeans coming to the TB Sanatoria in the semi-desert of the Kgalakgadi (Kalahari) It accelerated to the north and east by the two South African Wars and the discovery of diamonds (in the Northern Cape) and then gold in the Witwatersrand in the late 19 th century

25. Summary (2) Rapid urbanization and the creation of slums associated with mining increased the probability of infection in the new South African cities Migrant labor successfully seeded the epidemic in rural areas (especially, Zululand, the Transkei, and the eastern Highveld) The epidemic was aggravated by the absence of a country-wide Public Health Law until 1919

26. Summary (3) The first epidemic of the twentieth century was attenuated by the advent of triple therapy in 1953 The second epidemic started in the 1970s and it may be associated with the de- institutionalization of therapy. The epidemic curve has accelerated during the late 1990s in association with the HIV epidemic