Doctors and nurses with HIV and AIDS in sub-Saharan Africa

Much has been written about the impact of the HIV and AIDS pandemic on the healthcare delivery systems and resources in central and southern Africa. The unremitting pressure on hospitals and other healthcare facilities,¹ and the disproportionate use of healthcare resources by the ever increasing numbers of patients, are threatening to undermine the capacity of countries such as South Africa to provide a comprehensive health safety net for the rest of the population.²

An additional threat that has received little or no attention in the literature is the possible impact of illness and death due to the pandemic specifically among healthcare professionals in countries with high HIV prevalence rates. A Medline search on this topic by using a variety of keyword combinations proved unproductive. Therefore the findings a 30% mortality over 20 years largely attributed to HIV infection among a cohort of Ugandan doctors in the article by Dambisya in this issue represent an important contribution in spite of the small numbers and the largely presumptive nature of the evidence (p 600).³

In South Africa, a country that carries 10% of the world's burden of HIV and AIDS while only 1% of the world population lives there,⁴ the potentially devastating impact of HIV and AIDS among health professionals on the capacity and integrity of the healthcare system is acknowledged, but only preliminary and sketchy data exist in this regard. A shortage of nurses is critical as many emigrate or succumb to AIDS related illness. Nothing is known about HIV and AIDS among doctors.

Olive Shisana and her group at the South African Human Sciences Research Council have conducted the only population based survey to date into the epidemiology of HIV in South Africa, which pegs South Africa's overall HIV prevalence in the general population (defined as those aged 2 years and older) at 11.4% (95% confidence interval 10.0 to 12.7).⁵ These findings are in accord with the estimates by other researchers derived from computer modelling, from the extrapolation of data from sentinel antenatal surveys, and from the national mortality registry.⁶ Notably, the prevalence in the study rises to 15.5% (13.5 to 17.5) for the adult population defined as those aged 25 years and older.

In a separate investigation commissioned by the South African health ministry in 2002 looking at the impact of HIV and AIDS on the health sector, the South African Human Sciences Research Council's team found an alarming HIV seroprevalence among professional healthcare workers of 15.7% (12.2 to 19.9).⁷ Although based on a relatively small sample of 595 subjects, the results show that the prevalence among health professionals is not dissimilar to that of the general adult population. The study does not provide a differential breakdown of the prevalence among the various professionals but notes that “African health workers had a much higher prevalence of HIV than other race groups.”

The investigators conclude that “the HIV/AIDS epidemic will have an impact on the health system through loss of staff due to illness, absenteeism, low staff morale, and also through the increased burden of patient load.”

The impact is already with us—the nursing profession is the most affected—but secrecy and silence continue to prevent us from getting the facts. A recent report from McCord Hospital, well regarded for its community orientation and as a teaching facility, records how an initiative to reach out and to create a supportive work environment for HIV affected staff following the death of four staff members in four months was met with denial, fear, hopelessness, and an unwillingness to be tested or treated.⁸ The hospital subsequently succeeded in establishing a trusted and well used diagnostic and treatment programme for its staff.

Three waves have been described in the natural course of the HIV epidemic,⁹ the depth and duration of which can of course be moderated by the effectiveness (or lack thereof) of interventions for modifying sexual behavioural and antiretroviral treatment: firstly, an expanding incidence of new cases, which in South Africa is deemed to have peaked around 1998; secondly, increasing prevalence thought to be peaking around now; and finally, increasing mortality.

In South Africa, and much of sub-Saharan Africa, mortality is currently spiralling upwards. Ironically, a stronger health system is necessary for more effective prevention and care of HIV and AIDS,¹⁰ which the attrition among health professionals will only serve to undermine. Holly Burkhalter, of Physicians for Human Rights, writes in the Washington Post of 12 June 2004 about the brain drain in Africa that “today's biggest limiting factor for AIDS treatment in the developing world is the paucity of trained health workers...We're going to run out of people before we run out of money.”¹¹ The same might well be said of AIDS related mortality among health professionals.