SOUTH AFRICA PUBLIC HEALTH April 21 2006 ISSUE

UNCLAS SECTION 01 OF 05 PRETORIA 001657 SIPDIS 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, NIH/HFRANCIS CDC FOR SBLOUNT AND DBIRX E.O. 12958: N/A TAGS: ECON KHIV SOCI TBIO EAID SF SUBJECT: SOUTH AFRICA PUBLIC HEALTH April 21 2006 ISSUE Summary -------------- ¶1. Summary. Every two weeks, Embassy 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: Monitoring South African AIDS Treatment Plan Difficult; Health Minister Emphasizes HIV Prevention; Business Conference Learns About Possible AIDS Impacts; Survey: AIDS Has no Major Impacts on Small and Medium Firms; TAC Representative Invited but will not Attend UN AIDS Conference; South African Women to test New Microbicides that Reduce HIV Transmission; South African Contributions to ARV Side Effects Research; South African Health Worker Shortage; Outline of Health Human Resource Plan; Eastern Cape Health MEC Replaced; South African Birth Defects; SA Highest Rate of Femicide; and SA to Develop new Malaria Drug. End Summary. Monitoring South African AIDS Treatment Plan Difficult -------------- -------------- ¶2. The Joint Civil Society Monitoring Forum (JCSMF) reports on obstacles towards successful implementation of South Africa's treatment plan. JCSMF considers that the most serious problems are: severe human resource shortages, provincial divergences in implementing the government's treatment plan, gaps in communication and information sharing, uneven treatment of children needing ARV treatment, no disaggregated HIV and AIDS expenditure reporting by provinces available, and lack of clarity on the extent to which provinces are using conditional grants allocated by National Treasury or using funds from provincial budgets (including equitable share funding) to implement the ARV treatment plan. The JCSMF has sponsored seven workshops starting in September 2004, with the latest on March 6, 2006. All meetings have identified information inaccessibility as being a major challenge to monitoring the Operational Plan. In addition, various JCSMF forums emphasized the lack of detailed provincial expenditure on HIV and AIDS activities as a major obstacle to evaluating the Operational Plan's success, especially in the areas of nutrition support and child services. JCSMF is an organization composed of civil society organizations, research institutes, health workers and private sector members and its aims are to monitor and support the implementation of the Operational Plan for Comprehensive HIV and AIDS Care for South Africa. Source: IDASA Budget Brief 161, Monitoring AIDS Treatment Rollout in South Africa: Lessons from the Joint Civil Society Monitoring Forum, April ¶13. Health Minister Emphasizes HIV Prevention -------------- ¶3. Speaking at the start of the African Union's Acceleration of Prevention of HIV Initiative, South African Health Minister Tshabalala-Msimang asserted that HIV prevention campaign has SIPDIS suffered at the expense of emphasis on treatment and that prevention has to be accelerated. According to the minister, policies addressing poverty, underdevelopment and gender inequalities which make women more vulnerable to HIV infection have to be implemented. She stressed the importance of condom distribution, basic health care, and nutrition and abstinence programs. Source: Business Day and The Star, April 12. Business Conference Learns About Possible AIDS Impacts -------------- -------------- ¶4. At a private sector conference on HIV/AIDS sponsored by Business Unity SA, various study results of HIV/AIDS impacts were used to illustrate the disease's possible negative impacts on South African business. According to an SA Business Coalition Against HIV/AIDS survey for July to September 2005, 40% of the manufacturing and transport companies, and 60% of the mining companies surveyed reported a tangible loss of experience and vital skills as a result of HIV/AIDS. Peter Doyle, the chief executive of Metropolitan, said that while treatment was important, it was equally important to halt new infections. Metropolitan is completing an extensive study on a 20-year outlook for HIV/AIDS. It expects to release the study to the public later in 2006. Of the four scenarios presented PRETORIA 00001657 002 OF 005 at the conference, the worst case showed about 8 million new infections by 2025. This could be reduced by 2.8 million, by 3.8 million, or by 5.9 million in the best case. Source: Business Report, April 6. Survey: AIDS has no Major Impacts on Small and Medium Firms -------------- -------------- ¶5. According to a report on a Joint Economic AIDS and Poverty Program commissioned study done by Patrick Connelly and Sydney Rosen, HIV/AIDS was ranked ninth among a list of 10 concerns affecting small and medium enterprises (SMEs). Productivity of workers, demand for product, cost of labor, cost of materials, regulations, crime, taxes and a shortage of skilled labor were all ranked as more important concerns than HIV/AIDS. Only the availability of capital or financing was ranked as being of less concern than HIV/AIDS by SMEs, with 62% of the companies surveyed confirming that they had never even discussed HIV/AIDS as a business issue. The study results were based on data collected through a survey of managers of 80 randomly selected SMEs in KwaZulu-Natal and Gauteng. The study found that about a quarter of the sampled companies were providing some HIV/AIDS service to employees, but fewer than half of them incurred any direct costs to provide these services, which were usually limited to condom distribution, education and awareness of HIV/AIDS, and the development of a workplace policy on HIV/AIDS. Employee turnover was about 13% annually but only 10% of this was due to illness or death. Roughly 29% of SMEs surveyed expected the epidemic to have a large impact, 25% a moderate impact and 43% little or no impact, with 4% not responding. Source: Business Report, April 13. TAC Representative Invited but will not be Official Representative at UN AIDS Conference -------------- -------------- ¶6. The Health Ministry issued a list of groups invited to take part in the United Nations General Assembly Special Session on Aids (UNGASS) which now includes a representative from the previously excluded Treatment Action Campaign (TAC). The Health Department extended an invitation to Sipho Mthathi, the secretary-general of TAC. Earlier the Health Department said SIPDIS that the TAC would not be invited because of a concern over TAC's position on the government's HIV program, sparking criticism from AIDS activists. TAC announced that it will not be part of the official South African delegation because of the exclusion of the Aids Law Project, another non-governmental organization associated with the University of Witwatersrand and focuses on human rights developments of HIV/AIDS in South Africa. The Health Department objected to the accreditation of both TAC and ALP because they felt that these organizations would only disparage government policies. Source: Reuters IOL April 13; The Sunday Independent, April 16; Cape Times and Cape Argus, April 20. South African Women to test New Microbicides that Reduce HIV Transmission -------------- -------------- ¶7. More than 5,000 Durban women have volunteered for the world's largest microbicides clinical trials that will test its efficacy. Microbicides are products that are applied to the vagina to reduce HIV transmission during sexual intercourse and can take the form of a gel, cream, suppository or sponge that contains an active ingredient which can kill or inactivate HIV cells. Six clinical efficacy trials are being conducted in Africa, India and the United States, four of which are underway in South Africa. Microbicides can help women who do not have the power to negotiate condom use with their partners. The major route of HIV transmission in sub-Saharan Africa is through heterosexual contact. The first set of results should be available by late 2008, and the second set of results by late 2009 or early 2010. Source: Health Systems Trust and The Mercury, April 12. South African Contributions to ARV Side Effects Research -------------- -------------- ¶8. Now that antiretroviral therapy is available on a large scale, and across a wide range of populations in Africa and Asia, evidence is beginning to emerge about the variations in PRETORIA 00001657 003 OF 005 side-effects and tolerability between different populations. Drug toxicity is one of the major obstacles to good adherence, so observation of toxicity, education of patients and timely response to their concerns is a necessary part of HIV management. Toxicities most commonly reported in cohort studies from resource-limited settings include: (1) Peripheral neuropathy (damage to the nerves in the feet and legs, caused by d4T, universally reported as the most common serious toxicity); (2) Lactic acidosis (a build-up of lactate in the body); (3) Rash (caused by nevirapine); (4) Anemia (caused by zidovudine (AZT)) and (4) Lipoatrophy (loss of fat from the limbs and face, chiefly caused by d4T, more prominently a problem in reports from Rwanda and India than from Uganda, South Africa or Kenya). South African Studies on Side Effects -------------- ¶9. Peripheral Neuropathy In Khayelitsha, South Africa, a study of 1,700 patients treated for up to 36 months found that the rate of switching from d4T due to peripheral neuropathy was 17 cases per 1,000 years of patient follow-up. These rates are similar to those seen in the developed world. Neuropathy may be more likely when d4T and isoniazid are used together - which is an argument for closer communication between the TB and HIV clinic, and also a cause for concern as more patients on ART are put on isoniazid preventative therapy for latent TB. ¶10. Lactic acidosis Lactic acidosis is the condition caused by over accumulation of lactate in the bloodstream and tissues, which the body is unable to clear. In South Africa, lactic acidosis is more common. A South African study found that lactic acidosis is occurring at an unusually high frequency in patients receiving either d4T or AZT-based antiretroviral therapy. The South African study found an incidence of 15 cases per 1000 years of patient follow-up (almost as high a frequency as that reported for peripheral neuropathy in the same study). The risk of developing lactic acidosis seemed to be greater in women with a higher body weight - which is much more common in South Africa than in most other settings. Multivariate analysis found that women weighing 75 kilograms or more had an adjusted hazard ratio (AHR) of 25 for lactic acidosis when compared with males, while women weighing between 60 and 75 kilograms had an AHR of 5.6 for lactic acidosis. ¶11. Rash Severe rash is a potential side effect of nevirapine. It occurs during the first month of treatment in 16-20% of patients, but is usually mild and self-limiting, passing within a few weeks. Its frequency does not appear to be any greater in African populations than in developed world cohorts. In the Khayelitsha study, 8.9% of patients had switched from nevirapine after 24 months of treatment. Most switches from nevirapine occurred in the first six months of treatment. ¶12. Anemia Anemia is a frequent condition in resource-limited settings and is a major risk factor for death in the first year of treatment. Anemia can also be caused or worsened by AZT. The Khayelitsha study, in which AZT was used as the basis of a first-line regimen in the early years of treatment, found that 8.2% of AZT-treated patients had switched from the drug after 24 months of treatment, 82% of whom switched due to anemia. Source: HIV &AIDS Treatment in Practice, April 13. South African Health Worker Shortage -------------- ¶13. The World Health Organization's World Health Report 2006 revealed that 37% of doctors trained in South Africa are working in either Australia, Canada, Finland, France, Germany, Portugal, the United Kingdom or America. South African trained nurses working in these countries made up 13,496 of the local workforce of 184,459. Both the South African doctor and nurse migration figures were higher that any of the other sub-Saharan countries. The report also revealed that South Africa has 35,000 registered nurses who are either inactive or unemployed despite 32,000 vacancies. Many of these nurses are thought to be working in non-nursing occupations. According to the WHO PRETORIA 00001657 004 OF 005 report, more than four million additional doctors, nurses, midwives, managers and public health workers are urgently needed to fill the gap in 57 countries, 36 of which are in sub- Saharan Africa. According to South African research, nurses working in maternal health services were asked about the most important characteristics of the workplace and presented with 16 theoretical workplace profiles. The most significant finding was that nurses ranked good management, including clearly defined responsibilities, supportive attitude when mistakes are made and reward for ability, not length of service, higher than improved salaries, unless the remuneration was dramatically higher. A recent study from Cameroon, South Africa, Uganda and Zimbabwe points to both push and pull factors being significant. Workers' concerns about lack of promotion prospects, poor management, heavy workload, lack of facilities, a declining health service, inadequate living conditions and high levels of violence and crime are among the push factors for migration. Prospects for better remuneration, upgrading qualification, gaining experience, a safer environment and family-related matters are among the pull factors. Source: Health E-News, April 10. Outline of Health Human Resource Plan -------------- ¶14. The Health Department released its human resource plan designed to address the shortage of health care workers in South Africa. The human resource plan focuses attention on training and has set targets for increased health professionals working in the public sector by areas of specialization. By 2009, the planned targets are: (1) to double the number of clinical psychologists to 150; (2) to almost double the number of professional nurses to 3,000, up from 1,896; (3) to increase the number of nursing assistants to 10,000 from 7,368. By 2010, the number of pharmacists trained annually should reach 600 from 400 trained currently. By 2014, the number of trained doctors should reach 2,400. In addition, a staff retention policy based on better pay, a package of incentives and improved working conditions will help prevent trained health professionals from taking better jobs overseas after graduation. Foreign health professionals will be used as a last resort. The Health Department plans to use foreign workers primarily through government-to-government agreements as it had with Cuba, and it will not actively recruit people from African countries. In addition, employment contracts for foreign health professionals will be a maximum of three years and be non-renewable. Source: Health-e News and Pretoria News, April 7. Eastern Cape MEC Replaced -------------- ¶15. Eastern Cape Health MEC Dr Bevan Goqwana was fired as a result of long standing inadequacies in the Eastern Cape health system. Under his tenure, the provincial health department failed to properly account for R18.1 billion out of a total budget of R22.6 billion. The Public Service Accountability Monitor (PSAM),an independent monitoring and research institute based at Rhodes University, cited critical staff shortages, severe under spending, dilapidated hospitals and crumbling infrastructure, corruption charges, shortages of essential medical equipment and medicine as some of the characteristics of Goqwana's tenure as Eastern Cape's Health MEC since 1999. Under Goqwana the health department has received five audit disclaimers between 2000 and 2005. During his tenure, Goqwana was involved in corruption charges leading to nine months fully paid leave. He was investigated by the Public Protector over allegations that he owned a private specialist practice and an ambulance service while in public office. He faced over a thousand fraud charges in 2002. He was found not guilty on all charges. In the last study that PSAM conducted it indicated that the Eastern Cape had one medical specialist for every 47,529 people, one professional nurse for every 1,278 patients, one pharmacist for every 53,662 people and one occupational therapist for every 554,507 people. Source: Health E-News, April 10; Business Day, April 12. South African Birth Defects -------------- ¶16. According to a March of Dimes report on birth defects, PRETORIA 00001657 005 OF 005 58,000 South African children are born with a serious genetic birth defect and another 14,000 born with fetal alcohol syndrome. Professor Christianson, a clinical geneticist at Wits University, was the co-author of the "March of Dimes global report, and views teaching and training of primary care practitioners as the major challenge to reducing overall South African birth defects, as most defects in South Africa may be prevented. According to Christianson, for children or people with birth defects, care is an absolute, prevention is the ideal. Syphilis and fetal alcohol syndrome can be prevented. Increased education of primary health care workers as well as the population is needed. Source: Health E News, April 13. SA Highest Rate of Femicide -------------- ¶17. South Africa has the world's highest rate of female homicide (femicide) by an intimate partner, with a woman being killed every six hours by her partner, according to a Medical Research Council (MRC) report. According to Dr Naeemah Abrahams from the MRC, females accounted for a third of all homicides globally, with a rate of four deaths per population of 100,000. In 50.3% of cases the perpetrator was found to be an intimate partner. The femicide rate in South Africa was much higher, with about 28 such cases per 100,000, compared to about three per 100,000 in the U.S. Statistics showed that the Western Cape had the highest number of femicide cases per 100,000, with about 37 deaths, and KZN the lowest, with 21 deaths. Women between the ages of 14 and 29 accounted for about 39% of femicides, and African women accounted for about 78%. Almost 61% of femicides took place at the women's homes. Of those women killed in 1999, 33% were killed with a firearm, and about 50% were at the hands of an intimate partner. About 11% of the perpetrators died after the murder, most commonly by suicide. Source: IOL, April 5. SA to Develop New Malaria Drug -------------- ¶18. The Medical Research Council (MRC) has developed a drug to treat malaria using extracts from an indigenous plant of the Asteraceae family and is now seeking a partner to commercialize the drug. Gilbert Matsabisa, the MRC's director of indigenous knowledge systems, said tests had shown promising results, indicating that the drug could eradicate the malaria infection from the bloodstream. Matsabisa said the plant was indigenous to sub-Saharan Africa and was concentrated in central South Africa up to Zimbabwe and Zambia. The Asteraceae family has more than 25,000 species worldwide with more than 2,300 species in southern Africa. It is commonly known as the aster, daisy or sunflower family. Well-known medicinal plants in this family include the African wormwood and the wild camphor bush. The MRC will not issue licenses but intends to retain the intellectual property in South Africa. Matsabisa said the MRC had applied for a worldwide patent on the drug and wanted to develop it in South Africa. Source: Business Report, April ¶19. TEITELBAUM