SOUTH AFRICA PUBLIC HEALTH JANUARY 14 ISSUE

UNCLAS SECTION 01 OF 04 PRETORIA 000205

SIPDIS

DEPT FOR AF/S; AF/EPS; AF/EPS/SDRIANO
DEPT FOR S/OFFICE OF GLOBAL AIDS COORDINATOR
STATE PLEASE PASS TO USAID FOR GLOBAL BUREAU APETERSON
USAID ALSO FOR GH/OHA/CCARRINO AND RROGERS, AFR/SD/DOTT
ALSO FOR AA/EGAT SIMMONS, AA/DCHA WINTER
HHS FOR THE OFFICE OF THE SECRETARY,WSTEIGER AND NIH,HFRANCIS
CDC FOR SBLOUNT AND EMCCRAY

E.O. 12958: N/A
TAGS: ECON KHIV SOCI TBIO EAID SF
SUBJECT: SOUTH AFRICA PUBLIC HEALTH JANUARY 14 ISSUE


Summary
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1. Summary. Every two weeks, USEmbassy Pretoria publishes a
public health newsletter highlighting South African health
issues based on press reports and studies of South African
researchers. Comments and analysis do not necessarily reflect
the opinion of the U.S. Government. Topics of this week's
newsletter cover: HIV-Positive and Pregnant; Doctors to Help
Cut Cost of Health Care; Risk of TB Doubles in First Year of
HIV Infection; Monitoring the Effect of the New Rural Allowance
for Health Professionals; Health Department Makes Progress in
Filling Key Vacancies. End Summary.

HIV-Positive and Pregnant
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2. As anti-AIDS drugs become available to more South Africans,
a growing number of HIV-positive women are choosing to become
pregnant in spite of their status. There are risks involved.
In the absence of intervention, an estimated 15 to 30 percent
of mothers with HIV will transmit the infection to their baby
by the time it is born, according to the World Health
Organization. A single dose of Nevirapine, given to mother and
baby, halves the chances of infection during labor, when the
risk of transmission is highest. Initially people assumed that
if someone knew their HIV-positive status, then pregnancy was a
'no-no'. But the reality is that most of these people are young
women in their prime, who want to have babies, according to Dr
Pumla Lupondwana, a research doctor at Chris Hani Baragwanath
hospital in Johannesburg. Lupondwana is conducting a study on
resistance to Nevirapine at the perinatal HIV research unit
based at the hospital. She estimated that about a third of the
250 women participating in the trial had made a conscious
decision to fall pregnant. In fact, an increasing number of
women were second-time mothers who had been diagnosed HIV-
positive during their first pregnancy. They've been exposed to
Nevirapine, and they know all the risks involved, she said.
The reason for having a baby varies. According to Lupondwana,
some may want a child they can leave behind as some form of
legacy or reminder. For some women, a new partner might insist
on having a baby, with the woman too afraid to disclose her
status. Pressure from the community, and fear of stigma and
discrimination were other reasons. In a study presented at the
2004 International AIDS Conference in Bangkok, Thailand, South
African virologist Dr Lynn Morris showed that although there
was high resistance to Nevirapine six weeks after a woman had
taken a single dose, this dropped to 14 percent after six
months. Resistance to Nevirapine decreases the drug's
effectiveness and makes it difficult to treat the baby if it is
born HIV-positive. Most HIV-positive pregnancies are usually
trouble-free, unless the mother is at an advanced stage of the
disease and has a compromised immune system, Lupondwana said.


3. Most of the women are practicing unsafe sex, despite
receiving extensive family planning advice. Some might have
planned to have the babies, but most of these women are having
unplanned pregnancies because they are not using any form of
contraception, or their partners refuse to use condoms. Sharon
Ekambaram, an AIDS activist and former PMTCT coordinator of the
lobby group, the Treatment Action Campaign, pointed out that
the country's prevention of mother-to-child transmission of HIV
(PMTCT) and antiretroviral (ARV) rollout programs had failed to
take this into account. These programs are not addressing the
woman's inability to disclose to their spouse or partner and
negotiate safer sex. These women are forced to hide the fact
that they are on treatment, just to avoid disclosure, she said.
Men don't want them to use condoms, and they are too scared to
tell them about having HIV. When some women did gather the
courage to disclose, the men would say 'if we both have it,
then it doesn't matter - we don't have to use condoms.'


4. The latest UNAIDS report on the global AIDS epidemic
estimates that in South Africa the number of orphans is
expected to increase from 2.2 million in 2003 to 3.1 million by

2010. According to the latest numbers from the Joint Civil
Society Monitoring Forum, an NGO coalition set up to monitor
the ARV rollout, about 18,500 South Africans are accessing ARV
treatment. More and more HIV-positive women will want to have
kids - this is still a new issue that hasn't been adequately
dealt with in the public sector. Lupondwana cautioned that
becoming pregnant when HIV-positive still has its risks, as it
could compromise the woman's immune system. But, at the end of
the day, it is their choice to make. Source: PLUSNEWS, 17
December 2004; Health Systems Trust, January 7.
Doctors to Help Cut Cost of Health Care
--------------


5. More than 1,200 KwaZulu-Natal medical doctors have joined
hands for an ambitious program aimed at controlling the
escalating cost of healthcare delivery. The KwaZulu-Natal
Managed Care Coalition is an association of general
practitioners, including specialists, one of 20 regions all
affiliated to the national South African Managed Care
Coalition. The KwaZulu-Natal coalition's success, according to
the chairman and CEO, Dr Morgan Chetty, is due to its
monitoring of the healthcare process in the private sector of
the region. Some of its functions include a strict code of
conduct for the practitioners, managed medical aid and options
for medical aids. It also co-ordinates one of the best-
attended continuing medical education programs for its members,
highlighting new medical evidence-based information and
reviewing practice parameters. The coalition's successful
management program has led the University of KwaZulu-Natal's
medical school together with Net Partners, a national doctors'
investment group, to establish a department of managed care and
health services management at the university. Net Partners has
created a similar department at the University of Pretoria.
Traditionally, medical practitioners are taught pure clinical
medicine and not introduced to health care management issues.
According to Chetty, the goal for South Africa is to develop
doctors with the same management and clinical expertise that
can easily adapt to either the public or private sector.
Source: IOL, January 2.

Risk of TB Doubles in First Year of HIV Infection
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6. The risk of developing tuberculosis doubles within the
first year of testing HIV positive, according to a large
retrospective study published in the January 15th issue of The
Journal of Infectious Diseases (JID). This risk further
increased in subsequent years. Although HIV increases the risk
of TB it has long been assumed that this was primarily due to
falling CD4 cell counts seen with advancing HIV disease
progression. The early effect seen in the study, conducted by
researchers from the London School of Hygiene and Tropical
Medicine, was largely unexpected.


7. The retrospective study analyzed data drawn from the
medical records of 23,874 workers from four South African gold
mines. The mines provided the perfect opportunity to assess
how HIV affects the risk of tuberculosis over time. The mines
have a stable population, provide regular medical care and keep
good medical records. There is a well-established TB control
program and a confidential database of all HIV test results of
the mine workers has been kept since 1989. HIV test results
could therefore be linked to routinely collected TB and
demographic data. At the beginning of the study, 3371 miners
were HIV-positive (these are referred to as having prevalent
HIV) and 20,503 were HIV-negative. Over the course of several
years, many of the workers had subsequent HIV tests. Of these,
2,737 received positive HIV results (these cases are referred
to as having incident TB) 1,962 (72%) within two years or less
of a previous HIV negative result. A total of 740 cases of
pulmonary TB (first episode) were analyzed during a seven-year
period. TB was found to be at least three times more common in
those who were HIV-positive. The incidence of pulmonary TB was
2.9 cases per 100 patient years at risk in the HIV positive
workers and 0.8 cases/100 patient years at risk in the HIV
negative workers. Investigators then assessed the relative
risk (RR) of developing TB by age and calendar period (1991-92,
93-94, and 95-9) and according to when workers tested HIV
positive. Age and calendar were significantly associated with
an increased risk of TB. The incidence of TB per patient years
at risk doubled during the last time period, with an adjusted
case rate ratio of 2.21. This could reflect the impact that
the HIV pandemic was having on the overall incidence of TB in
the southern African region. The relative risk (RR) of
developing TB was greater in those who were HIV-positive when
the study began, which is to be expected as they had been
infected longer and their immune systems would be less able to
fight off TB. But what was not expected, as mentioned earlier,
was the increase in incidence of pulmonary TB so soon (within a
year) after seroconversion, with an adjusted case rate ratio of
2.11.


8. An editorial accompanying the article in JID suggested that
there could have been a small bias in detecting TB in patients
with HIV because HIV-positive miners may present to medical
facilities more frequently because of the development of HIV-
related clinical symptoms of illness, thus potentially biasing
toward greater evaluation for, and detection of, TB among HIV-
positive miners. The editorial writers believe the study
provides sufficient data to demonstrate the doubling of the
incidence of TB within the first year of HIV seroconversion.
The editorial suggests two possible explanations for the
increased TB risk 1) the profound immune dysregulation that
occurs soon after [HIV] infection or 2) that those patients who
develop tuberculosis within the first year of HIV infection
have a rapidly progressing form of HIV disease. High levels of
HIV seen during acute seroconversion or the immune response to
HIV could also activate latent TB infections in some patients.
If TB is activated in this setting, HIV could quickly wipe out
any CD4 cell response. Investigators evaluated whether the
increased risk of TB early during the course of HIV infection
is due to reactivation or to a newly acquired M. tuberculosis
infection by performing molecular fingerprinting on available
isolates. Unique isolates are more likely to have been due to
reactivated TB acquired before working in the mines, while the
isolates of TB acquired in the mines would be the same. Among
HIV seroconverters, unique TB isolates were present in 57
percent of miners who developed TB within 2 years of HIV
seroconversion, compared with 20 percent who developed TB
later. The finding is intriguing though numbers are too small
to draw any firm conclusions. However, it suggests that
patients with latent TB are more likely to develop pulmonary TB
within the first year of seroconversion.


9. The study's findings have a number of major implications
for TB and HIV control programs. The editorial points out that
while current models for TB control do factor an increase in TB
incidence where there is a high adult HIV prevalence, they do
not account for the increased risk of TB early during the
course of HIV infection. TB that occurs later in HIV disease
is usually not centered in the lungs but is extrapulmonary.
This study showed a doubling in pulmonary TB, which is far more
infectious. Finally there is an immediate need to expand
reliable and affordable HIV testing services in areas where TB
is endemic and, conversely, to improve surveillance for TB
among patients testing positive for HIV. Source: Aidmap,
January 5; Health Systems Trust, January 7.

Monitoring the Effect of the New Rural Allowance for Health
Professionals
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10. A recent study by Professor S. Reid of the Center for
Rural Health, University of KwaZulu-Natal, published by the
Health Systems Trust, focuses on the impact of the rural
allowances in influencing where health care professionals
practiced. The unequal distribution of health professionals
between rural and urban areas in South Africa led to financial
and non-financial incentives to recruit and retain health
professionals in areas of need. In 1994, South Africa started
a rural recruitment allowance, granted only to medical doctors
and dentists, and remained at the same fixed rate since the
time of its inception. It was perceived to be ineffective as an
incentive for retention of professional staff, and despite the
introduction of community service for all health professionals
except nurses, it remains difficult to recruit and retain
professional staff at rural hospitals, health centers and
clinics.


11. The new rural allowance started by the Minister of Health
is a national initiative aimed at improving recruitment of
health care professionals in rural areas. The impact of the
initial R500 million allocated by Treasury in July 2003 needs
to be measured. While the effect of the rural allowance may
eventually be seen in staffing patterns of rural hospitals, the
longer-term effect is likely to be diluted by the many other
factors that influence health professionals career choices
apart from financial benefits. The effect of the new allowance
was measured in the short term by direct questioning of those
receiving the allowance, in order to control these variables as
far as possible, and allow a more direct evaluation of the
effect. However, between the time that the rural allowance was
announced in May 2003, and its eventual implementation in March
2004, retroactive to July 2003, there was intense and lengthy
debate in the Public Service Bargaining Chamber (PSCBC)
regarding the exact nature of this allowance, who it would
benefit, and most importantly, who would be excluded.
Eventually two separate allowances were agreed upon, the Scarce
Skills Allowance (SSA) and the Rural Allowance (RA). The SSA
benefits certain categories of health professional regardless
of the place of work, whereas the RA benefits all health
professionals in certain health facilities that are designated
as rural. The latter areas include the nodes as defined by the
Integrated Sustainable Rural Development Strategy, as well as
rural areas as designated by the PSCBC based on the previous
recruitment allowance. In addition, provincial Heads of Health,
depending on available funds, from within provincial budgets,
could determine inhospitable areas. Negotiations within the
PSCBC continue up to the time of writing, and certain unions
are challenging the regulations.


12. The changing nature of the allowance made the planning of
the research project difficult, in that the data collected for
the baseline survey did not anticipate the simultaneous
introduction of the SSA, which was confused by some of the
respondents and their managers as the RA. Nevertheless, an
attempt was made to capture information as the process
unfolded, in order to have a baseline on record for future
evaluations. The study randomly chose 34 out of 159 rural
hospitals and obtained 243 questionnaire responses, with most
of the questionnaires coming from doctors with more than five
years of experience. The study reports that almost one-third
of health professionals working in rural areas say that they
have changed their career plans next year as a result of the
new allowance. It is difficult to assess whether this is the
effect of the RA alone, or in combination with the SSA. Further
evaluations will be necessary to assess the longer-term impact
of these strategies. Source: Health Systems Trust, January

11.

Health Department Makes Progress in Filling Key Vacancies
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13. The Department of Health has appointed a new Director-
General (DG). The previous DG was transferred to the
Department of Foreign Affairs in September 2003. The new DG,
Mr. Thamsanqa Dennis Mseleku, assumed office on January 1,

2005. Mr. Mseleku previously served as the Director-General of
the Department of Education. During his career Mseleku has
served as a teacher and head of Foreign Languages Department,
Zibukezulu High School, in Pietermaritzburg, and as a
researcher and English lecturer at the University of Natal. He
was later appointed as Chief Director for Human Resources and
Labour Relations at the Department of Education. At the
Education Department he served as Special Advisor to the
previous Minister of Education; Deputy Director-General for
Human Resources and Corporate Services; and finally as Director-
General. The Department appointed a new manager of the HIV
program, a position formerly held by Dr. Nono Simelela. The
new head of the HIV/AIDS and STIs program is Dr. Nomonde Xundu,
previously with the Gauteng Provincial Health Department. Dr.
Xundu has program experience in condom distribution, STIs,
PMTCT, Post Exposure Prophylaxis for Non-Occupational Exposure
to HIV, VCT and Workplace HIV Programs. A key Department of
Health position is now vacant, putting additional pressure to
fill important vacancies. The Registrar of Medicines and Chief
Director for Medicines Control Council in the Department of
Health, Mrs. Precious Matsoso, has resigned, effective January
21, 2005. Mrs. Matsoso has been appointed Director of the
WHO's department of technical cooperation for essential drugs
and traditional medicine at the WHO Headquarters, Geneva.

MILOVANOVIC