SOUTH AFRICA PUBLIC HEALTH JANUARY 27 2006 ISSUE

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: More Agreement Regarding AIDS Statistics;
Regular ARV Treatment Better than Intermittent Therapy; 2006
South African Health Issues; South African Gay Men Banned from
Giving Blood; Reactions; South Africans Show Genetic
Vulnerability to TB; Cancer Could be Notifiable Disease; Spread
of Disease by Rates Studied; Study Shows Clean Water's
Importance in Treating AIDS. End Summary.

More Agreement Regarding AIDS Statistics


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2. Two separate studies, using different techniques, have for
the first time reached a similar conclusion about how many
South Africans are infected with HIV. The research has raised
hopes of reconciling divergent estimates of HIV/AIDS
prevalence. The Actuarial Society of South Africa's (ASSA)
computer model using data from a wide variety of sources, and a
population survey by the Human Sciences Research Council
(HSRC), indicate that five million South Africans, or about
11%, carry the virus.



3. For the ASSA model, Rob Dorrington, of the Center for
Actuarial Research at University Cape Town, analyzed surveys of
HIV prevalence among pregnant women attending government
clinics, but factored in the first HSRC household survey in
2002, a youth survey, data from the most recent population
census, and death registration records. For the HSRC study,
fieldworkers surveyed the country, taking HIV blood tests from
15,800 of the nearly 23,300 people they interviewed. Their
work reveals widespread misunderstanding of the disease, with
many South Africans -- particularly those over 50 years of age
or in their early teens -- either uncertain of or denying any
connection between the virus and the disease.



4. Confusion over South Africa's infection rate arose from the
lack of information available at the start of the epidemic.
For years the only consistent and reliable data came from
government clinic blood tests on generally poor, pregnant
women, issued yearly since 1990. In 2005, Statistics SA
estimated that 4.5 million South Africans were infected, while
the Department of Health, has estimated that 6.3 million South
Africans are HIV-positive based on the 2004 antenatal survey.
Negotiations are under way to analyze the data and see if
additional agreement can be found. Source: Mail and Guardian,
January 20.

Regular ARV Treatment Better than Intermittent Therapy


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5. Findings from the Strategies for Management of Anti-
Retroviral Therapy (SMART) trial, using South African
participants, found that continuous anti-retroviral treatment
is better than intermittent therapy, as regular treatment
breaks can cause further health problems. Taking regular
breaks to avoid side effects and to save money was more than
twice as likely to make people ill. The study, conducted by
the U.S.'s National Institute for Allergy and Infectious
Diseases, compared levels of continuous ART with episodic drug
treatment guided by levels of CD4+ cells, an indicator of the
progression of AIDS. Enrollment was stopped because those
patients receiving episodic therapy had twice the risk of
disease progression.



6. HIV-positive volunteers were assigned at random to either a
viral suppression strategy, in which ART was taken on an
ongoing basis to suppress HIV viral load, or a drug
conservation strategy, in which ART was started only when the
levels of key immune cells, called CD4+ cells, dropped below
250 cells per cubic millimeter (mm3). Volunteers in the drug
conservation group were taken off ART with the aims of reducing
drug side effects and preserving treatment options whenever

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their CD4+ cells were above 350 cells/mm3. The average follow-
up was approximately 15 months.



7. The analysis showed that participants taking the treatment
breaks faced more than twice the risk of disease progression
than the participants on continuous ART. There was an increase
in major complications such as cardiovascular, kidney and liver
diseases in the participants on the drug conservation program.
These complications have been associated with ART, and it was
hoped that they would be seen less frequently in those patients
receiving less drugs. Follow up visits will continue for all
participants in the trial while the study team considers plans
for a longer follow-up. Source: Sapa, Mail and Guardian,
January 19.

2006 South African Health Issues


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8. Two new health initiatives starting in 2006 will have cost
implications for South African consumers: new tax treatments
for medical insurance contributions starting March 1 and
revised pricing of medicines. Only the first R500 ($83, using
6 rands per dollar) in monthly medical insurance contributions
will be tax exempt and those not covered by medical insurance
will get tax relief when medical expenses are more than 7.5% of
annual income, compared to the current tax threshold of 5%. In
addition, government is renegotiating the markups permitted on
medicine sales, with a new dispensing fee unlikely before mid-


2006.



9. Another new health initiative likely to impact the health
industry is the proposed government employee health plan, GEMS.
GEMS is expected to consolidate the medical insurance industry
as civil servants change from their current insurance plans.
Unions representing civil servants will continue negotiating
with government on the fine details of GEMS' implementation,
hoping to postpone mandatory membership until the proposed plan
has proved to be value for money for civil servants.



10. Far-reaching industry talks will focus on negotiations for
the new health-care charter. Businesses were highly critical
of the initial approach to the charter in 2005. The second
draft of the health charter was more favorably received.



11. HIV/AIDS will continue to be a major health concern.
Doctors and AIDS activists are already on a collision course
with entrepreneur Matthias Rath over his anti-AIDS drug
campaign and controversial vitamin-based therapies, and have
drawn the Department of Health into their legal challenge to
his activities. Government is expected to come under renewed
pressure to improve the provision of AIDS drugs at its clinics
and hospitals.



12. The Health Department also has plans to finalize and
implement a human resources strategy. Without a plan to
recruit and retain adequate numbers of doctors, nurses and
other health professionals, health-care services are expected
to continue to deteriorate as staff emigrates for better jobs.



13. Implementing and finalizing already passed regulations
will be another priority for the Department of Health,
including implementing the Nursing Bill (once President Mbeki
has signed it), tightening legislation controlling tobacco and
alcohol, finalizing regulations for traditional and
complementary medicines, and implementing the most
controversial aspects of the National Health Act. Doctors and
private hospitals are awaiting the regulations spelling out how
government plans to introduce the "certificate of need", a new
system designed to control the location of doctors and
hospitals.



14. Finally, health experts say South Africa cannot afford to
focus all its attention on immediate health-care needs at the
expense of planning its response to a possible global avian flu
epidemic. Source: Business Day, January 11.

South African Gay Men Banned from Giving Blood


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15. South Africa's blood donor service has banned blood from
sexually active homosexual men due to a higher risk of HIV,
provoking an angry response from gay activists. A man who has
had sex with another man within the last five years, whether
oral or anal sex, with or without a condom is not permitted to
donate blood, according to the head of the South African
National Blood Service, Dr. Robert Crookes. The South African
Gay and Lesbian Rights Advocacy Group said blood donors should
be screened according to whether they used a condom, not their
sexuality. Crookes said the blood service's position was based
on international practice and research that showed sexually
active gay men were more likely to be infected with HIV than
their heterosexual counterparts. Source: Reuters, January 12.

Reactions


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16. The Gay and Lesbian Alliance's (GLA) claimed that it
recruited more than 100 gay men to donate blood to the SA
National Blood Services (SANBS) without disclosing their sexual
activities. However, SANBS Chief Executive Officer Anthon
Heyns said the organization was not able to find any record of
the people the GLA claimed had donated blood. The South
African Human Rights Commission (SAHRC) said that gay men could
not be excluded from donating blood based upon identity or
status, but rather on the basis of epidemiological data. The
SAHRC also said it had met with the SANBS previously to discuss
the possibility of SANBS undertaking an epidemiological study,
along with the Medical Research Council and the Council for
Scientific Industrial Research (CSIR), to determine if
homosexuals were a high-risk group for contracting HIV in South
Africa. According to SAHRC, negotiations broke down because
SANBS did not want to conduct the study under their auspices.
The SANBS asserts that it does not exclude gay men from
donating blood, just those who have sexual relations. SANBS
publicity manager Gail Nothard said the SANBS has just received
research about the gay male community in South Africa, which it
will examine in the next few months. For now the SANBS still
goes by available international data in order to "ensure the
safety of the blood supply," Nothard said.



17. This is the second time that SANBS has been accused of
discrimination. In 2005, the SANBS was asked to change its
blood exclusion policy that had been based upon information
that some races were perceived as a higher risk for HIV
contraction than others. After discussions with the Department
of Health, SANBS introduced a new blood-screening process
called Nucleic acid Amplification Testing (NAT), which can
detect the presence of the virus earlier.



18. On January 17, the Health Department announced that SANBS
will begin discussions with interested parties to resolve the
challenges posed by its policy of excluding gay male donors.
SANBS may modify their donor criteria to identify potential
donors who engage in anal sex, regardless of if they are
homosexual. Source: Sunday Independent, January 15; Sapa and
IOL, January 17; The Star January 21.

South Africans Show Genetic Vulnerability to TB


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19. South African blood samples have helped identify a new
genetic link to people's susceptibility to tuberculosis (TB).
Tuberculosis is caused by a bacterium that is so widespread in
South Africa that most people have been exposed to it. Yet,
only ten per cent of those infected develop the disease.
Researchers at South Africa's Stellenbosch University spent
years collecting blood samples from local communities. The
study revealed that people who had been exposed to the virus
but did not fall ill were more likely to have a variant of one
particular gene than those who did become ill. The gene
produces a chemical called DC-SIGN, which is known to affect
other diseases including HIV/AIDS, Ebola, hepatitis C and
dengue fever. But, until now, variation in DC-SIGN had never
been linked to TB. The study director, Eileen Hoal, stated
that additional research on the immunological response to the
TB bacteria is needed since the immune system's response is
important to developing a more effective TB treatment. The
research is published in January 2006's issue of PLoS Medicine.

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Source: SciDev.Net, January 11.

Cancer Could be Notifiable Disease


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20. In order to improve data collection, the Health Department
wants to make cancer a `notifiable' disease, with health
institutions required to submit cancer diagnosis to the Health
Department. Currently, incidents of cancer are voluntarily
supplied to the National Cancer Registry (NCR) by pathology
laboratories. Officials from the NCR, Health Department,
pathology laboratories, medical schools and the South African
Oncology Society agreed to set up a working group assigned to
develop a way of collecting accurate data on cancer without
compromising patient confidentiality. NCR figures for 1999
(the most recent available) show that 30,000 cases of cancer
were diagnosed among South African women, mostly breast,
cervical and colorectal cancer. The leading cancers among the
29,000 newly diagnosed men that year were prostate, lung and
esophageal cancer. Source: Business Day, January 24.

Spread of Disease by Rats Studied


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21. Nearly 200 blood samples from Durban shack dwellers are
being analyzed amid fears that rats are spreading potentially
fatal diseases to humans. Because some of the symptoms are
similar to flu, fever and malaria, officials say that cases of
rat-borne illness could go untreated because of misdiagnosis by
clinic staff and poor public awareness of the risks. Blood and
tissue samples from four species of rats and mice collected in
Durban during the past two years all came up negative for
bubonic plague, but in some parts of the city more than 30% of
rats were found to be carrying leptospirosis and about 10% were
carrying toxoplasmosis. Both diseases can be passed from rats
to humans. Newborn infants and developing embryos also face
very grave risks if the mother contracts toxoplasmosis during
pregnancy. As a follow-up to the rat blood tests, more than
200 human blood samples were taken from volunteers in the Cato
Crest informal settlement late 2005. The results are expected
to be published soon. The recent surveys would be very useful
to prepare more effective treatment and control strategies in
Durban, other South African cities and the rest of Africa.
This research project is part of a larger international study
investigating rodent-related disease hot spots in four African
countries. Known as "Ratzooman", the project is being funded
by the European Union to check the re-emergence of zoonotic
diseases (sicknesses which can be spread from animals to
humans). Source: The Mercury, January 23.

Study Shows Clean Water's Importance in Treating AIDS


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22. Researchers from Denmark and Zimbabwe found evidence that
treating bilharzias or schistosoma (microscopic worms usually
in stagnant water) can improve the immune systems of HIV/AIDS
patients. The study used two groups of patients, some of whom
also had HIV. One group was immediately treated for bilharzias
and the other had to wait three months for treatment. In HIV-
infected patients, the number of CD4 cells rose. In those HIV
patients waiting for treatment, the CD4 count did not improve
and the amount of HIV increased. The results suggest that the
parasitic worm suppresses the immune system, leaving people
more vulnerable to viral infections such as HIV. The precise
extent to which bilharzias increased the development of AIDS is
still unknown. Bilharzias is responsible for 2.5 million
people being ill in South Africa, with approximately 10%
developing severe infections. Bilharzias contributes to slow
mental and physical growth in children as well as anemia in
adults. It is found primarily in the eastern half of South
Africa and is particularly prevalent in the KwaZulu-Natal
province. Source: The Witness, January 23.

TEITELBAUM