Understanding of the Quadruple Burden of Diseases in South African, its’ management and its’ relation to ongoing burdening of the Health Care System.

South Africa’s burden of disease consists of maternal, newborn and child health, HIV/AIDS and TB, non-communicable diseases, and interpersonal violence (South African Medical Research Council, 2022). Disability Adjusted Years, also called DALYs, is able to quantify the premature mortality and morbidity that these burdens of diseases cause in South Africa. DALYs means one lost year of "healthy" life. When DALYs for a population or burden of disease are added it puts into perspective the difference between the ideal standard for the health of the population, e.g. living to old age, without disease and disability, and the current health status of the population or affect that the burden of disease is having. Disability adjected years can be calculated with the following equation:

DALY=YLL+YLD

Where:

DALY- Disability adjusted years.

YLL- years of life lost

YLD- years lived with disability.

South Africa had HIV/AIDS, diarrheal disease, and interpersonal violence, as the top causes of Disability adjusted years in 2010. This illustrated the link between the burden of diseases and the decreased quality of life or life span of an individual. Globally there was a general trend of declining communicable, maternal, neonatal, and nutritional causes for DALYs, while non-communicable disease and injuries have continued to increase. We can now look at each quadruple burden of disease individually.

Communicable diseases:

These are illnesses which are the result of biological agents or their products and can easily be transmitted from one person to another. There are two types of communicable diseases, acute and chronic communicable diseases. HIV/AIDS and TB both fall under chronic communicable diseases.

HIV/AIDS

Globally there was a decrease in the incidence of HIV and deaths caused by HIV, while the number of people who are living with HIV has increased this is a testament to the success of antiretroviral treatment worldwide. From the 1980s to mid-1990s there was an exponential increase in the number of people with HIV and those dying from AIDS. There was a plateau with a similar amount of people being infected for the second half the 1990s. Due to the creation of effective drugs and its continued development infections have continued to decrease as well as deaths.

In South Africa young people who do not have access to health care services and thus prevention and treatment contribute to the high infection rates and women who have low socioeconomic in the country and experience gender-based violence which impacts their access.

They are considered key populations because these groups face stigma, discrimination. abuse and social economic status issues which impacts access to treatment and education of prevention methods. There is a group missing which is migrants, migrants into the country with HIV (or those who contract the disease while in the country) may struggle with accessing treatment and may be contribute to the spread of HIV due to their social economic status.

South Africa conforms to the UNAIDS 95-95-95 guidelines, it has referenced this when compiling the 2023 ART Clinical Guidelines. South Africa has the largest ART programme in the world. In 2018, UNAIDS reported that 4.4 million people were receiving treatment in South Africa. This equates to 61% of the people living with HIV in the country.

The timing of initiating antiretroviral therapy (ART) promptly, along with continuation of treatment, is the most effective approach for achieving long-lasting viral suppression and restoring immune function. This strategy can lead to better clinical outcomes and reduce the risk of transmission to negative partners.

Management of HIV/AIDS:

Clinical Manifestation of HIV

• Acute HIV infection may present as a mononucleosis type of syndrome with a constellation of nonspecific symptoms.

• Without a high degree of suspicion, the diagnosis can frequently be missed by clinicians.

• In some cases, early HIV infection may be asymptomatic.

• Good history taking and clinical examination are the keys (skin, mouth, anogenital region and lymph nodes)

• WHO HIV Classification (WHO TEAM Global HIV, Hepatitis and STIs Programmes (HHS), Global Tuberculosis Programme (GTB), Guidelines Review Committee, 2016)

Clinical stage 1	Clinical stage 2	Clinical stage 3	Clinical stage 4
Asymptomatic Persistent generalized lymphadenopathy	Moderate unexplained weight loss (<10% of presumed or measured body weight) Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis) Herpes zoster Angular cheilitis Recurrent oral ulceration Papular pruritic eruption Fungal nail infections Seborrhoeic dermatitis	Unexplained severe weight loss (>10% of presumed or measured body weight) Unexplained chronic diarrhoea for longer than 1 month Unexplained persistent fever (intermittent or constant for longer than 1 month) Persistent oral candidiasis Oral hairy leukoplakia Pulmonary tuberculosis Severe bacterial infections (such as pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteraemia) Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis Unexplained anaemia (<8 g/dl), neutropaenia (<0.5 × 109/L) and/or chronic thrombocytopaenia (<50 × 109/L)	HIV wasting syndrome Pneumocystis (jirovecii) pneumonia Recurrent severe bacterial pneumonia Chronic herpes simplex infection (orolabial, genital or anorectal of more than one month in duration or visceral at any site) Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs) Extrapulmonary tuberculosis Kaposi sarcoma Cytomegalovirus infection (retinitis or infection of other organs) Central nervous system toxoplasmosis HIV encephalopathy Extrapulmonary cryptococcosis, including meningitis Disseminated nontuberculous mycobacterial infection Progressive multifocal leukoencephalopathy Chronic cryptosporidiosis Chronic isosporiasis Disseminated mycosis (extrapulmonary histoplasmosis, coccidioidomycosis) Lymphoma (cerebral or B-cell non-Hodgkin) Symptomatic HIV-associated nephropathy or cardiomyopathy Recurrent septicaemia (including nontyphoidal Salmonella) Invasive cervical carcinomaAtypical disseminated leishmaniasis

Treatment of HIV/AIDS:

-          Prevention of mother to child transmission

-          Post exposure prophylaxis (PEP)

-          Secondary prevention of HIV transmission

-          Primary prevention (PrEP)

-          Clinical management of patients with HIV/AIDS:

1. Reduce HIV Replication

2. Increase or maintain CD4 count.

3. Maintain “less fit” mutated HIV.

-          All HIV positive patients regardless of CD4 count will be offered ART

-          treatment ,prioritizing those with CD4 less than 350

-          TEST AND TREAT 90-90-90 (2030): Timing of ART initiation;

1. ART should be started as soon as the patient is ready,

2. TB co-infection, start with TB treatment first, followed by ART as soon as possible and within 8 weeks

3. If CD4 <50 cells/μl initiate ART within 2 weeks of starting TB treatment,

4. If CD4> 50 cells initiate Art within 2-8 weeks after starting TB Rx

5. If Cryptococcus or TB meningitis 4-6 weeks

6. IMMEDIATE PRIORITY: All HIV-positive pregnant or breastfeeding women, with no active TB or contradiction being done

7. FAST TRACKING : HIV stage 4/CD4 <200 cells/μlFirst Line Treatment

Critical issues in the management of HIV:

• TB

The risk of this diseases is increased when coupled HIV. HIV weakens the immune systems which gives rise to the increased probability of acquiring TB. Because of the weakened immune system, people with HIV may pass away from TB quicker than patients without HIV.

• Adherence

Antiretroviral medication increases the life expectancy of HIV infected individuals, it enables them to live long lives without developing AIDS. If patients are unable to adhere to  antiretroviral medication prescriptions, there will be a increase in the number of deaths caused by HIV/AIDS.

• Side effects

Experiencing debilitating side effects is a deterrent to adherence to antiretroviral medication.

• Mental & sexual health

Patients which experience metal health struggles are less likely to care about their health, they may neglect taking the necessary medications.  People with unsafe sexual practice are more likely to contract and spread HIV.

• Pregnancy

There is a risk of the mother transmitting the disease to the child during birth.

• Others opportunistic infections

May lead to the death of HIV patients.

HIV/AIDS relation to ongoing burdening of the Health Care System:

South Arica has the biggest HIV treatment programme in the world which majority of the funding is internal funding. While the short-term financing of South Africa's HIV epidemic is secure, in the longer term, the government needs to explore other strategies in order to sustain and expand its progress.

The South African government does not have access to sufficient resources to renovate the public health sytem It lacks the resources for an overhaul of the public health infrastructure and to scale up and increase coverage of prevention programs like PrEP and broader programs to address the needs of young adults. In addition, health worker shortages and a rising non-communicable disease (NCD) burden are crippling already overstretched health facilities, and the decentralized health system requires political will at the provincial and district levels to implement services effectively. (Allinder and Fleischman, 2019)

Tuberculosis

There are 30 high burden tuberculosis (TB) countries in the world which contribute to approximately 87% of the reported TB cases globally. South Africa is one of these countries and contributes to about 3% of the 87%. Additionally, South Africa is part of the top 14 countries of the 30 high burden tuberculosis countries which have a high burden of patients with either TB, TB and HIV or multi-drug resistant TB (MDR-TB). Low socioeconomic statuses and high HIV rates are a big contributor to this. Delayed health-seeking behaviour and a large amount of undiagnosed diseased individuals in communities further exacerbate the TB epidemic (South African National Department of Health, 2021).

Key populations that are at risk adults who are in their reproductive years, individuals who are suffering with illnesses which case a weakened immune system and children because of their immature system (World Health Organization, 2018).

Tuberculosis is a notifiable disease in South Africa, all cases whether old or new must be reported. Information that is gathered should be the incidence of MDR/XDR TB cases, special case such as pregnant women, children, prisoners, etc, and immunisation levels. Compared to Global metrics, South Africa has a high TB prevalence because of AIDS epidemic

Direct Observed Treatment is a short course program which is used manage Tuberculosis in South Africa. The roll out of DOTs for TB and XDR-TB in SA occurred between 1995  and 2005 DOTS (directly observed treatment, short-course) The World Health Organisation explains this strategy as  strategy the most cost-effective way to stop the spread of TB in communities with a high incidence is by curing it. It further emphasises that the best curative method for TB is known as DOTS.

There are five main components of DOTS:

• Government commitment (including political will at all levels, and establishment of a centralized and prioritized system of TB monitoring, recording and training).

• Case detection by sputum smear microscopy.

• Standardized treatment regimen directly of six to nine months observed by a healthcare worker or community health worker for at least the first two months.

• A drug supply.

• A standardized recording and reporting system that allows assessment of treatment results

Management of TB:

Clinical Manifestation of TB:

• Prolonged cough

• Chest pain

• Weakness or fatigue

• Weight loss

• Fever

• Night sweats

Treatment of TB:

Tuberculosis (TB) is a curable disease treated with a standard 6-month course of four antibiotics, including rifampicin and isoniazid. However, drug-resistant TB can occur when the standard drugs are ineffective. Treating drug-resistant TB is more complex and requires longer treatment. Health workers or trained volunteers provide support during treatment to ensure adherence. Additionally, for TB infection (when a person is infected but not yet ill), preventive treatment using the same drugs is given for a shorter duration (1 or 3 months) compared to the previous 6-month regimen (World Health Organization, 2018).

Critical issues in the management of TB:

• HIV:

The risk of TB is increased when coupled HIV. HIV weakens the immune systems which gives rise to the increased probability of acquiring TB. Because of the weakened immune system, people with HIV may pass away from TB quicker than patients without HIV.

• Health-seeking behaviour:

Delayed health access which leads to an increase in the incidence of TB in a community along with worsened health outcomes for the individual is infected.

TB relation to ongoing burdening of the Health Care System:

Tuberculosis (TB) imposes a substantial burden on South Africa’s health system and population. South Africa’s 2019 TB incidence rate was exceptionally high compared to the global average . Approximately 58% of TB cases remain undetected in the community (Murdoch et al., 2021). The health system in South Africa is understaffed, the high number of TB CASES can lead to staff burnout and therefore a decrease in the quality of care.

Non-communicable diseases:

Those diseases or illnesses that cannot be transmitted from an infected person to a susceptible, healthy one.  Several, or even many, factors may contribute to the development of a given non-communicable health condition. The contributing factors may be genetic, environmental, or behavioural in nature. Globally, non-communicable diseases are the leading cause of death in 1st world, killing more than 36 million people yearly. In low- & middle-income countries 80% deaths can be attributed to non-communicable diseases.

There are four groups of diseases that account for around 80% of all NCD deaths. Cardiovascular disease, Diabetes, Cancer, and Chronic respiratory disease.

These four conditions share four main risk factors: Tobacco use, physical inactivity, harmful use of alcohol, and Unhealthy diets.

FACTORS TO CONSIDER IN SA

• The burden of non-communicable diseases is rising in rural communities, and it disproportionately affects poor people living in urban settings, and is resulting in an increase in the demand for care for chronic diseases.

• As with CDs, NCDs are also associated with underdevelopment

• Trends show that exposure to risk factors for NCDs has been increasing.

• The rising demand for chronic care for communicable and non-communicable diseases needs an integrated model of care at all levels of the health system, supported by a robust surveillance system.

Management of Non-communicable diseases:

South Africa implements interventions to decrease the prevalence of NCDs. To put measures in place against non-communicable diseases South-Africa spends R150 million for population-based interventions and R1.25 billion for individual-based measures. This is unsustainable, so better intervention strategies need to be generated to decrease the prevalence of NCDs.

CHALLENGES WITH INTERVENTIONS

• Awareness campaigns for non-communicable diseases do not reach the target audiences, especially the rural population, due to poor infrastructure and inadequate communication facilities

• Routine screening for risk factors in all individuals in the health services is poor

• Annual physical examinations are not routine in health facilities, and the public is not well informed about the need for routine physical examination to detect disease early and initiate appropriate care

IMPLEMENTATION CHALLENGES

• A lack of integration within vertical programmes by the health sector

• There is also lack of involvement of other sectors (i.e. lack of intersectoral collaboration)

• There is limited community participation in chronic disease programmes within the health system

• Poor management of patients with chronic disease at PHC facilities is due to various barriers in the health system

• Missing and incomplete records often prevent continuity of patientcare

• Limited training of health personnel in a comprehensive approach to chronic diseases

Non-communicable diseases relation to ongoing burdening of the Health Care System:

Poverty or low socioeconomic status is linked to non-communicable disease. Many South Africans are of low socioeconomic status, this mean that many people access care through the public health system. The public heath system is already financially strained and the increase of non-communicable diseases would further cripple the financial capability of the healthcare system.

Maternal, newborn and child health:

Maternal, newborn and child health refers to the health outcomes of mothers and babies within the first 28 days of life. As well as children under the age of 5. Over the past two decades, there has been a remarkable decline in child mortality rates. The most recent data indicates that the number of children who died before their fifth birthday reached an all-time low of 4.9 million in 2022. This positive trend reflects significant progress in healthcare and child well-being (UNICEF, 2022).

Management of Maternal, newborn and child health:

There are policies and strategies which are implemented in South Africa decrease the incidence of Maternal, newborn and child and ensure good health. Some of these polices are listed below:

1. South African MATERNAL, PERINATAL, and NEONATAL Health Policy:

This policy provides a framework for delivering quality, comprehensive, and integrated maternal, newborn, and child health (MNH) services. It guides the development of guidelines, strengthens service delivery, and ensures accountability for MNH services.

2. Managing Maternal, Neonatal, and Child Health During COVID-19:

These guidelines offer advice to healthcare workers and managers on managing pregnant women, newborns, and children in the context of COVID-19.

3. Factors Associated with MNH Continuum of Care:

Factors influencing MNH continuum of care include women's autonomy, partners' education levels, health insurance coverage, early antenatal care initiation, exposure to radio, and residing in Southern Africa.

Maternal, newborn and child health relation to ongoing burdening of the Health Care System:

Poor management maternal, newborn and child health will lead to an increase in critical mothers, newborns and children who require expensive care. This is straining on health systems which do not have the necessary finances to run effectively.

Interpersonal violence:

Mercy et al. (2017) defines interpersonal violence as, "Interpersonal violence involves the intentional use of physical force or power against other persons by an individual or small group of individuals. Interpersonal violence may be physical, sexual, or psychological (also called emotional violence), and it may involve deprivation and neglect."

In South Africa Interpersonal violence is the second highest burden of diseases. Additionally, most of the interpersonal violence is aimed at women (Gordon, 2016).

Management of Interpersonal violence:

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Interpersonal violence relation to ongoing burdening of the Health Care System:

According to Mercy et al. (2017) sexual and physical violence can be linked to infectious diseases, more specifically sexually transmitted infections and HIV/AIDS. The increase of communicable diseases requires an increase in financial resources which can strain health systems.

Reference list:

•  South African Medical Research Council (2022). South African Medical Research Council. [online] South African Medical Research Council. Available at: https://www.samrc.ac.za/ [Accessed 5 Jun. 2024].

• Allinder, S.M. and Fleischman, J. (2019). The World’s Largest HIV Epidemic in Crisis: HIV in South Africa. [online] Csis.org. Available at: https://www.csis.org/analysis/worlds-largest-hiv-epidemic-crisis-hiv-south-africa [Accessed 7 Jun. 2024].

• Gordon, C. (2016). Intimate partner violence is everyone’s problem, but how should we approach it in a clinical setting? South African Medical Journal, [online] 106(10), p.962. doi:https://doi.org/10.7196/samj.2016.v106i10.11408.

• Mercy, J.A., Hillis, S.D., Butchart, A., Bellis, M.A., Ward, C.L., Fang, X. and Rosenberg, M.L. (2017). Interpersonal Violence: Global Impact and Paths to Prevention. 3rd ed. [online] PubMed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK525208/#:~:text=Interpersonal%20violence%20involves%20the%20intentional [Accessed 10 Jun. 2024].

• Murdoch, J., Curran, R., van Rensburg, A.J., Awotiwon, A., Dube, A., Bachmann, M., Petersen, I. and Fairall, L. (2021). Identifying contextual determinants of problems in tuberculosis care provision in South Africa: a theory-generating case study. Infectious Diseases of Poverty, [online] 10(1). doi:https://doi.org/10.1186/s40249-021-00840-5.

• South African National Department of Health (2021). The First National TB Prevalence Survey - South Africa 2018 | Department of Health Knowledge Hub. [online] knowledgehub.health.gov.za. National Department of Health. Available at: https://knowledgehub.health.gov.za/elibrary/first-national-tb-prevalence-survey-south-africa-2018 [Accessed 11 Jun. 2024].

• UNICEF (2022). Maternal, Newborn and Child Survival. [online] Unicef.org. Available at: https://www.unicef.org/health/maternal-newborn-and-child-survival [Accessed 10 Jun. 2024].

• WHO TEAM Global HIV, Hepatitis and STIs Programmes (HHS), Global Tuberculosis Programme (GTB), Guidelines Review Committee (2016). Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection: Recommendations for a Public Health Approach. 2nd ed. [online] www.ncbi.nlm.nih.gov. World Health Organization. Available at: https://www.ncbi.nlm.nih.gov/books/NBK374293/ [Accessed 7 Jun. 2024].

• World Health Organization (2018). Tuberculosis (TB). [online] WHO | Regional Office for Africa. Available at: https://www.afro.who.int/health-topics/tuberculosis-tb [Accessed 10 Jun. 2024].