SOUTH AFRICA PUBLIC HEALTH JANUARY 28 ISSUE

UNCLAS SECTION 01 OF 05 PRETORIA 000392

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
DEPT FOR USAID 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 28 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: Rationing ARV Treatment; Industry Anti-
retroviral Treatment Low; Two African Herbal Medicines Inhibit
Metabolism of Anti-HIV Drugs; Improving the Quality of Primary
Health Care: Public and Private Provision; Release of Mortality
Report Delayed; Draft Legislation Regulating Alternative
Medicines Likely to be Changed; and Aspen Approved by U.S. FDA.
End Summary.

Rationing ARV Treatment
--------------


2. Researchers from the Center for International Health and
Development and the Clinical HIV Research Unit at the
University of the Witwatersrand recently published an article
describing how rationing of antiretroviral therapy (ART) will
be necessary as long as demand exceeds supply. In Zambia, the
first-year target for treatment is 10,000 patients; while
100,000 Zambians have already reached the clinical threshold of
less than 200 CD4 cells. The most recent numbers of South
Africans receiving ART is 19,500 by October 2004, out of an
estimated 300,000 to 700,000 needing ART treatment (South
African government estimates). Kenya's target is 50 percent
coverage, as is the global target of WHO's 3X5 initiative.
Rationing is any policy that restricts consumption and can be
either a market-based (relying on prices) or non-market system.
As long as treatment targets represent less than total HIV/AIDS
patients, the rationing of treatment is inevitable.


3. The article discusses rationing options and evaluation of
rationing systems and recommends that governments should make
deliberate choices about rationing ART and then explain and
defend the choices to their constituencies. The most accepted
criterion for rationing ART is disease progression. WHO
guidelines call for ART when a patient has a CD4 cell count of
less than 200; although a recent study highlighted how changing
this criteria would impact demand in South Africa. If ART
treatment guidelines were changed to a CD4 count of 350 (the
guidelines used by the U.S. Department of Health and Human
Services),the proportion of HIV-positive people eligible for
therapy would increase from 9.5 percent to 56.3 percent.


4. The authors describe four types of rationing systems: two
explicit and two implicit. Explicit rationing systems use
specific socioeconomic criteria to define populations that
receive treatment. An example is the mother to child
transmission program that makes ART preferentially available to
HIV-positive mothers and their children. Other explicit
systems of rationing include either co-payment requirement or
geographic location, where clinics are concentrated in high HIV-
infected regions. Other systems ration ART implicitly, with
either a lack of medical facilities or drugs effectively
serving as rationing in particular areas. A system requiring
queues will be implicit rationing.
The authors provide seven criteria for assessing rationing
systems that could help governments decide on their
effectiveness. The criteria outlined include: (1) Does the
rationing system produce a high rate of successfully treated
patients; (2) Is the cost per patient relatively low; (3) Are
the human and infrastructural resources needed for program
implementation available; (4) To what extent does the system of
distributing treatment reduce the long-term effects of HIV/AIDS
on economic development; (5) Do all medically eligible patients
have equal access to treatment; (6) Can the system be
sustained; and (7) Does the treatment reduce the rate of HIV
infection. The authors recommend that governments make clear
that the treatment program chosen be clear in its explicit and
implicit means of rationing so people can debate the policy
choices. Source: Health-link Bulletin, January 14;
www.thelancet.com.

Industry Antiretroviral Treatment Low
--------------


5. A study, "Treatment of HIV/AIDS at SA's Largest Employers:
Myth or Reality" done by the Center for International Health
and Development, shows that 4 percent of employees in South
African's largest companies are on HIV/AIDS disease management
programs and 0.6 percent receive antiretroviral treatment
despite an HIV prevalence rate of 14.3 percent. Only 25 of
South Africa's 64 largest firms know how many employees are
enrolled in their HIV/AIDS disease management programs or are
receiving ARV treatment. Table 1 highlights treatment results
from the study by industrial sector. Only a few companies make
up the most of the 3,908 workers receiving ARV treatment. For
example, Anglo American has more than 1,000 of its South
African employees on treatment. Study authors attribute low
treatment numbers to stigma, and to new workplace programs. In
addition, companies have waited to see how the government
program prioritizes its treatment program, seeing if the
government's program would reach their employees. The mining
and financial services sectors lead in providing HIV/AIDS
services. All financial services and 75 percent of mining
firms surveyed offer ARV treatment to employees. Only 31
percent of retail firms and no construction companies offer ARV
treatment. Companies with in-house HIV/AIDS management
programs get more people into treatment than those companies
relying on medical insurance programs. Source: FM Focus,
January 14.

Table 1. Industrial Employees on ARV Treatment by Industry
-------------- --------------

Sector Number of Employees Employees on ARV Treatment
Mining 275,300 2,954
Financial 172,000 300
Transport, Construction
and Communication 119,000 6
Retail 44,900 52
Manufacturing 36,700 518
Agriculture 8,475 48
Total 656,375 3,908
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Two African Herbal Medicines Inhibit Metabolism of Anti-HIV
Drugs
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6. Two herbs widely used to treat individuals with HIV in
Africa have a significant interaction with anti-HIV medication,
potentially leading to poor metabolism of anti-retrovirals,
according to a study published in the January 3rd edition of
AIDS. Extreme caution should be taken if using herbal
medicines in the treatment of HIV, stress the investigators,
who also state that their study shows the importance of
undertaking pharmacokinetic studies to show the potential
interactions between herbal medication and antiretrovirals.


7. The South African government has accredited 27 facilities
to provide nutritional and micronutrients supplements and
complementary and traditional medicines to HIV-positive
patients so that the progression of HIV disease slows. Many
anti-HIV drugs, including protease inhibitors and non-
nucleoside reverse transcriptase inhibitors (NNRTIs) are
metabolized using the CYP3A4 pathway. Herbal medicines have
been shown to affect levels of anti-HIV because of their impact
on CYP3A4 and, in the case of protease inhibitors, P-
glycoprotein as well. Some herbal medications are also known to
interact with nuclear receptors such as the pregnane X receptor
(PXR),which modulates expression of CYP3A and P-glycoprotein.
In a laboratory study investigators examined the effects of
Hypoxis hemerocallidea (African potato) and Sutherlandia, two
herbs widely used against HIV in Africa, on the metabolism of
antiretroviral drugs. Capsules, tablets and teas of both herbs
were extracted and tested for their ability to inhibit CYP3A4.
The affect of the herbs on PXR and P-glycoprotein were also
assessed. African potato showed a significant inhibition of
CYP3A4 activity. Sutherlandia also inhibited CYP3A4. In
addition, African potato and Sutherlandia resulted in
significant activation of PXR. The investigators suggest that
using these herbal drugs with antiretroviral agents may result
in the early inhibition of drug metabolism and transport
followed by the induction of decreased drug exposure with more
prolonged therapy. The authors underscore the need for
appropriately designed pharmacokinetic studies to discover the
interaction potential of herbal drugs with antiretroviral
drugs. Failure to undertake such studies could result in drug
interactions, treatment failure, resistant HIV, and drug
toxicities. Source: Healthnet.org, Mills E et al. Impact of
African herbal medicines on antiretroviral metabolism, AIDS
2005, January 14.
Improving the Quality of Primary Health Care: Public and
Private Provision
-------------- --------------


8. Research from the London School of Hygiene and Tropical
Medicine, the University of Witwatersrand and the University of
Cape Town examines the performance of various types of public
health care (PHC) provision in South Africa. It attempts to
determine the strengths and weaknesses of private and public
provision of primary care and the potential for increased
arrangements between the public and private sectors. It
assesses whether private providers give good quality service at
a cost that is comparable to that of the public sector. The
different models considered were individual General
Practitioner (GP) contracts, commercial companies running PHC
clinics on contracts, physicians in independent or group
practices, commercial companies running clinic chains, and the
public integrated model of clinics. Performance was measured
by looking at the cost and quality of providers in terms of
their infrastructure, treatment given and acceptability to
patients.


9. The main findings of the report were the following: (1)
care delivered by two of the private provider models,
contracted GPs and the clinic chain, was comparable to public
sector care in terms of cost per patient; (2) there were no
private care provider models that consistently showed a better
overall technical quality of care than public clinics. Care by
GPs lacked standardization and the clinic chain failed to
deliver standardized chronic care; (3) users perceived the
quality of service of private providers, except for contracted
GPs, to be far superior to that of others; (4) the performance
of both models involving contracts was negatively impacted by
weak contract design and implementation.


10. The quality of PHC delivered to people in developing
countries is often poor and coverage is not yet universal.
This is despite a focus on the public delivery of comprehensive
PHC over the past 20 years. People frequently consult private
providers including qualified medical professionals and
unqualified health practitioners. A better use of private care
providers, therefore, might be a potential solution, including
contracting them to provide services on behalf of the public
sector. Performance was strongly influenced by the context of
each type of service provision and thus simply comparing public
with private providers was not helpful. Source:
Healthnet.org, January 14, "The performance of different models
of primary care provision in Southern Africa", Social Science &
Medicine, Vol. 59.

Release of Mortality Report Delayed
--------------


11. The release of a mortality report by Statistics SA (Stats
SA) has been delayed to ensure it is "a good and useful product
", a senior agency official said yesterday, but would not
specify when it would be made public. The report, detailing
causes of deaths between 1997 and 2003, was due for release on
January 12, but was postponed at the last minute without
explanation, fuelling speculation of political interference.
The report will include AIDS deaths figures, which has sparked
controversy in the past between government, Stats SA and the
Medical Research Council. Stats SA had said the report was
based on all death notification forms received from home
affairs from 1997 to 2003. Stats SA's last report in 2001 was
based on a 12 percent sample of forms from 1997 to 2001. It
said "basic information" on causes of deaths would be presented
for 1997 to 2003, and a more detailed analysis for 1997, 1999
and 2001. In 2001, Stats SA released a report showing a sharp
increase in deaths among sexually active youths over the
previous 15 years, saying this was largely due to AIDS, which,
it said, was responsible for the deaths of an estimated 40
percent of people aged 15 to 49. At that time, the report was
widely criticized by the Health Department and the Presidency
saying that no proof that AIDS was responsible for the rise in
deaths. Stricter coding procedures and more efficient methods
were used for the upcoming study to determine underlying causes
of death, ranked according to frequency, and 10 leading causes
presented for various populations and sub-populations.
Source: Business Day, January 20.

Draft Legislation Regulating Alternative Medicines Likely to be
Changed
-------------- --------------


12. Current draft regulations state that alternative medicines
should be regulated in the same way as patented conventional
drugs. Health Minister Manto Tshabalala-Msimang recently
suggested that this draft legislation is likely to be changed,
meaning that African traditional medicines, homoeopathic
remedies, Chinese and Ayurvedic medicines and others would not
have to go through the rigorous testing as pharmaceutical
drugs. If this draft were passed into law, alternative
medicines would have to undergo trials designed for Western
medicines and a pharmacist would have had to oversee their
manufacture. Experts say complementary medicine cannot afford
expensive, large-scale trials because alternative medicines are
not patented. At least 80 percent of South Africans used
African, Chinese, Ayurvedic or South American traditional
medicines, she said. The proportion would be greater if
homoeopathic and other complementary medicines were included.
South Africans spent R3-billion a year on complementary
medicines. Tshabalala-Msimang said the study of indigenous
knowledge was "an opportunity to reclaim Africa's scientific
and socio-cultural heritage, which was stigmatized and
discredited as primitive rituals and witchcraft by colonialism
and apartheid". The Health Department has spent R6 million ($1
million, using 6 rands per dollar) into the testing of the
safety, efficacy and quality of traditional medicines that are
used as immune boosters by people with HIV and Aids. The first
phase of testing the safety of one of these medicines was
completed late in 2004 and the research had shown promising
results, the health minister said. The government also funds
research at universities and science councils into the efficacy
of traditional medicines used to treat tuberculosis, malaria,
asthma, cancer, diabetes, anxiety, stress and musculoskeletal
disorders. (The Mercury, January 17)

Aspen Approved by U.S. FDA
--------------


13. Aspen Pharmacare had won U.S. Federal Drug Administration
(FDA) regulatory approval for its AIDS drugs to be included in
the U.S.'s $15 billion AIDS program. "The approval is for the
co-packed and most widely used triple cocktail combination of
Lamivudine/Zidovudine and Nevirapine tablets in conventional
adult dosages and Aspen stated that the drugs would be priced
at affordable levels. Aspen is the first accredited generic
supplier to the U.S. AIDS program. Production would soon begin
at factory in Port Elizabeth, approved by the FDA in December.
The triple combination drug would not be immediately available
in South Africa, as it was still awaiting approval from the
Medicines Control Council, which was expected soon. While the
result of the South African Health Department's first anti-
retroviral bid has not been released, Aspen officials believe
that the company is well positioned to win the bid. About 25.4
million people live with HIV in Africa - where just three
percent of those infected had access to life-prolonging ARV
drugs. At least 2.3 million people died from the disease in sub-
Saharan Africa in 2004. Aspen's pioneering of ARVs on the
African continent and its world first generic ARV recognition
by the FDA was achieved after getting voluntary licenses from
the original drug manufacturers. These include
GlaxoSmithKline, the world's leading supplier of HIV and AIDS
drugs, German drug maker Boehringer Ingelheim and Bristol-Myers
Squibb. By close of business on January 25, shares in Aspen
increased 4.4 percent to R19.84 per share. Source: Business
Day; Business Report; The Star; allAfrica.com; January 26.

AIDS Treatment Numbers Released
--------------


14. As of September 2004, 155,000 people received anti-
retroviral treatment under the Presidential Emergency Plan for
AIDS Relief, a program begun in 2003. South Africa is one of
15 focus nations, with over 12,000 receiving anti-retroviral
treatment. World Health Organization released estimates of
people receiving anti-retroviral treatment and those aged 15-49
needing treatment. In Sub-Saharan Africa there were 310,000
receiving therapy while 4 million need it. According to WHO,
700,000 receive therapy globally while 5.8 million need it.
Source: The Citizen, January 27; U.S. Embassy Pretoria PAS
Press Release, January 26.

MILOVANOVIC