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
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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
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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
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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

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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
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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
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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
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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
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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

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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

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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
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16. According to a March of Dimes report on birth defects,

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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
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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