SOUTH AFRICA PUBLIC HEALTH AUGUST 12 ISSUE

UNCLAS SECTION 01 OF 04 PRETORIA 003257

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 KHILL
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 DBIRX

E.O. 12958: N/A
TAGS: ECON KHIV SOCI TBIO EAID SF
SUBJECT: SOUTH AFRICA PUBLIC HEALTH AUGUST 12 ISSUE


Summary
--------------


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: Study shows later transmission of HIV to
babies; increases in pregnant HIV-positive women; fewer people
have medical insurance; men and HIV testing; Isoniazid may
reduce risk of death for South Africans in first six months of
ART; PEPFAR-funded NGOs present progress at 2nd South African
AIDS Conference; Circumcision prevents three out of four female-
to-male HIV infections. End Summary.

Study Shows Increased Later Transmission of HIV to Babies
-------------- --------------


2. According to research presented at the South Africa
National AIDS Conference, many of the babies given nevirapine
at birth to prevent the transmission of HIV from their mothers
are being infected with the virus later in communities where
health systems are weak. Research at three very different
sites providing the prevention of mother to child HIV
transmission (PMTCT) program showed that, after nine months,
the site in the poorest area had almost double the transmission
rate of the best resourced site. Research on 665 mother-baby
pairs in the PMTCT program found that, three weeks after birth,
only 8.6 percent of babies born in Paarl in the Western Cape,
11.9 percent in Umlazi in KwaZulu-Natal and 14.2 percent in
Rietvlei in the Eastern Cape were HIV-positive. But between
three and 36 weeks of age, there was a jump in HIV transmission
by almost 20 percent in Rietvlei, the site in the poorest area
with the weakest health service. This meant that almost 30
percent of babies born to HIV-positive mothers in Rietvlei were
HIV-positive by nine months. This is almost the same
proportion that would be infected without any drug treatment,
meaning that at Rietvlei the benefits of the drug intervention
were effectively cancelled out by the later HIV infections. In
comparison, the HIV transmission rate between three weeks and
nine months in the relatively well-resourced Paarl was only 7.8
percent, while 12.3 percent of babies in Umlazi had became HIV-
positive in this time.


3. Most children infected after birth would have got HIV when
their mothers mixed breastfeeding and formula feeding.
Exclusive breastfeeding for six months or formula feeding are
much safer options. In Paarl, the health care system was able
to offer a reliable supply of formula milk to those mothers who
wanted it and more women chose this option than at the other
sites. It was also relatively easy for HIV-positive mothers to
get child support grants and the environment seemed more
accepting of HIV as 72 percent of the women had been able to
disclose to family members that they had HIV. Far fewer
mothers in Rietvlei (39 percent) and Umlazi (53 percent) felt
comfortable enough to disclose their HIV status. To reduce the
later HIV infection, the researchers proposed more effective
counseling of mothers on safer feeding options for their
babies, a consistent supply of formula milk and antiretroviral
therapy for mothers with high viral loads. An environment in
which mothers felt able to disclose their HIV status is also
very important. Women who had disclosed to their families
would be less likely to be pressured by their families to mix
breast and formula feeding. The Good Start research was
produced by HST in collaboration with the University of the
Western Cape, MRC, Cadre and the University of KwaZulu-Natal.
Source: hst.org.za, July 2005.

Increases in Pregnant HIV-Positive Women
--------------


4. According to the 2004 National HIV and Syphilis Antenatal
Sero-prevalence Survey, the percentage of pregnant women living
with HIV in South Africa for the year 2004 is 29.5, about 1.5
percent higher than in 2003. HIV infection was higher among
women in their late twenties and early thirties, and lower
among teenagers. The provinces of Free State, Mpumalanga and
North West recorded slight decreases compared to 2003.
Syphilis prevalence continues to decline in all age groups,
suggesting prevention and treatment against the sexually
transmitted infection are effective. The report also estimated
the total number of HIV positive people in the country at the
end of 2004 to be between 6.29 million and 6.57 million. The
survey measures the HIV infection rate among 16,061 pregnant
women seeking health care in the public sector.


5. When results of the 2004 antenatal survey were released,
media coverage concentrated on trying to understand the
discrepancy between the 4.5 million HIV-infected people
provided by Stats SA and the more recent 6.3 to 6.6-million.
AIDS experts seem to agree on about 5 million. The
discrepancies are due to different methodologies and data, and
since there is no one methodology for HIV estimation, varying
estimates will continue to be produced.


6. Contrary to earlier claims, HIV prevalence among young
South African women has not fallen. This survey shows that
nearly 40 percent of young, pregnant women between 25 and 29
years are infected, while women in their early twenties and
early thirties show rates of around 30 percent. Older women
and importantly teenagers have prevalence rates of below 20
percent. More specifically the survey shows that over 16
percent of teenage, expectant mothers were HIV positive. Each
age group from 15 to 24 shows a year-on-year increase. One in
10 15-year-olds were HIV positive, but by 24, over one in three
women were HIV positive. The increases are as follows: 10
percent of 15 year-olds were HIV positive; 9.1 percent of 16
year-olds; 12.3 percent of 17-year-olds; 19 percent of 18-year-
olds; 19.9 percent of 19-year-olds; 25.1 percent of 20-year-
olds; 28.5 percent of 21-year-olds; 31.1 percent of 22-year-
olds; 34.7 percent of 23-year-olds; and 35.5 percent of 24-year-
olds.

7. Some population-based surveys suggest that young women are
delaying sexual debuts and using condoms more often when they
have sex. Analysts suggest that the pronounced rise in HIV
prevalence among older women, all the way up to 40 years is
unusual. One possible explanation could be that women who
forego protected sex (because they're in steady relations or
marriages and trust their partners, or because they wish to
become pregnant) are facing extremely high odds of being
infected with HIV. Another reason may be that women who have
abstained from sex face very high odds of being infected once
they do have sex because HIV infection is so prevalent.
Similar trends in other southern African countries exist, where
young women wait longer before having sex, but are then
infected within a year or so of becoming sexually active.
Source: Health-e News Service and Sapa, July 2005.

Fewer People Have Medical Insurance
--------------


8. According to the 2004 General Household Survey released by
Stats SA, only 15 percent of South Africans have any form of
medical insurance, below the 18 percent level shown in 1995.
Whites and those living in Gauteng and the Western Cape have
the highest coverage. Almost 70 percent of whites, 26.2
percent of those in Gauteng and 25.9 percent of those in the
Western Cape enrolled in medical insurance policies. Limpopo
residents had the lowest coverage (6.4 percent),followed by
the Eastern Cape (9.6 percent). Only 7.2 percent of black
Africans are insured, totaling 2.7 million African people out
of a total of 37 million. Some 18.4 percent of coloureds and
36 percent of Indians have medical insurance. Over 39 million
people out of the total population of almost 47 million have no
medical insurance. Source: Health-e News, July 2005.

Men and HIV Testing
--------------


9. A recent study by Andrew Levack, a consultant with Engender
Health South Africa, of men's attitudes towards using voluntary
HIV-tests highlights reasons why only one in five people tested
for HIV are men. The findings are grouped into three main
themes - the personal, social and institutional. Personal
reasons include fear of the results. The survey found that men
tended to have their partners test for them, using negative
results of their partners as reasons for not being tested.
Social factors include issues of stigma and the fact that men
are not socialized to test. And finally, institutional factors
include concerns about the kind of treatment and
confidentiality offered to men. The sample size of the study

SIPDIS
was small, with interviews and focus groups with just 69
individuals, men and women from Soweto. The individuals
represented a range of communities in Soweto, which included
Diepkloof, Meadowlands, Kliptown. Source: HST Newsletter,
July 2005.

Isoniazid May Reduce Risk of Death for South Africans in first
six months of ART
-------------- --------------


10. According to research reported at the Third International
AIDS Society Conference on HIV Treatment and Pathogenesis in
Brazil, South African miners receiving antiretroviral therapy
(ART) are just as likely to die during the first six months of
treatment as their untreated counterparts. The reduction in
death and illness associated with ART only begins after six
months of treatment. Many African clinicians have reported a
high rate of mortality in patients starting ART in their
clinics. The observation has led some to argue that less sick
patients should be prioritized for ART, and so the London
School of Hygiene group also set out to determine whether there
are factors that place individuals starting ART at higher risk
of death during the early months of treatment. Several factors
have been suggested as especially problematic: (1) late
treatment, often with a CD4 cell count below 50 cells/mm3, (2)
active opportunistic infections, especially tuberculosis, and
(3) presence of immune reconstitution syndrome, particularly
due to prior or current infection with tuberculosis (TB). The
study analyzed all individuals who had received ART through a
workplace health program in a gold mining company in Kwa-Zulu
Natal, comparing the risk of death with historical data from
the same workplace treatment program prior to the introduction
of ART. The size of the cohorts was similar, with 649 on
treatment and 679 untreated. The median age was around 40 in
both groups, and the median baseline CD4 cell count was 140
cells/mm3 in the treated group and 188 cells/mm3 in the
untreated group. Median follow-up was approximately one year
in each group. There was no significant difference in the
relative hazard of death during the first six months of
treatment compared to the historical control group after
adjustment for baseline CD4 cell count, but the risk of death
fell dramatically between months 6 and 12, and after month 12
in the treated group. The reduction in mortality rate per 100
person years of follow up was 1.8 deaths. Source: AIDSMAP,
August 4.

PEPFAR-Funded NGOs Present Progress at 2nd South African AIDS
Conference
-------------- --------------


11. A diverse group of non-governmental organizations (NGOs),
funded by the United States President's Emergency Plan for AIDS
Relief (PEPFAR),presented their first year's progress at a
satellite conference of the 2nd South African AIDS Conference
in Durban. Funded projects focused on providing aid to orphans
and vulnerable children, faith-based HIV prevention services,
voluntary counseling and testing services, collaborations with
traditional healers, operational research into the long-term
success of PMTCT programs, nurse-driven antiretroviral therapy,
and antiretroviral treatment delivery in an antenatal clinic.
PEPFAR provides funding to 76 primary partners and 153 sub-
partners throughout South Africa's nine provinces. The
partners include faith-based, community-based and non-
governmental organizations, government, academic institutions,
as well as public/private partnerships. The satellite
conference showcased partnerships with the South African
Government, including the Department of Defense, Department of
Social Development and Department of Correctional Services.
Several organizations reporting annual progress in their
programs include: Nurturing Orphans and AIDS for Humanity
(NOAH); Hope Worldwide; New Start VCT Services; Good Start
Study; The Vulindlela CAT Project; and Starting ART in an
antenatal clinic. Source: AIDSMAP, June 2005.

Circumcision Prevents Three out of Four Female-to-male HIV
Infections
-------------- --------------


12. Researchers reported at the Third International Conference
on HIV Pathogenesis and Treatment in Brazil strong evidence
that male circumcision prevented female-to-male HIV
transmission. The first ever randomized controlled trial (RCT)
of male circumcision as an HIV prevention measure has been
halted early and all participants have been offered
circumcision. There were only 35 percent as many infections in
the circumcision group as opposed to the control, implying that
circumcision can prevent at least six out of ten female-to-male
HIV transmissions. However, when the results were analyzed
according to true circumcision status rather than by
intervention group, the protective effect went up to 75 percent
since there were crossovers between the intervention and
control groups in that some men randomized to be circumcised
were not, and some in the control group were. The trial, the
first of four RCTs of circumcision being conducted in Africa,
randomized 3,273 men aged 16 to 24 to be circumcised at the
start of the trial or to be offered circumcision at the end of
it, 21 months later. The men lived in the ORANGE Farm township
near Johannesburg, South Africa. Circumcisions in the
intervention arm were carried out by a surgeon under local
anesthesia and with post-operative pain relief given. HIV
incidence was measured at three and twelve months into the
trial and finally at 21 months though the average follow-up
period was in fact 20 months due to the premature termination
of the trial. Although all participants received intensive
safer sex counseling and condoms, there were 51 HIV
seroconversions in the control group versus 18 in the
circumcision group. This translates as HIV incidences of 2.2%
and 0.77% a year respectively. Circumcision studies are
currently underway in other sites in Africa. Source: AIDSMap,
July 27, 2005.


FRAZER