US embassy cable - 04PRETORIA4800

UNCLAS SECTION 01 OF 04 PRETORIA 004800 
 
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 
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 EMCCRAY 
 
E.O.  12958: N/A 
TAGS: ECON, KHIV, SOCI, TBIO, EAID, SF 
SUBJECT:  SOUTH AFRICA PUBLIC HEALTH OCTOBER 29 ISSUE 
 
1.  Summary.  Every two weeks, this post 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:  a UNFPA report that projects population in 
South Africa to decline by 2050; a new survey on sexual 
violence; the increasing but largely ignored South African 
orphans; the Global Fund contribution of R430 million to the 
Western Cape; a large increase in South African child 
mortality; the withdrawal of Thembalami Pharmaceuticals' bid 
for government ARV contract; trends in HIV risk behavior in 
South African migrant workers; and the implementation of ARV 
treatment in all nine provinces.  End Summary. 
 
UNFPA Report Projects SA Population Decline 
------------------------------------------- 
 
2.  The latest United Nations Population Fund (UNFPA) report 
puts South Africa's population growth rate at 0.6 percent, 
indicating a concrete decline for the first time.  The report 
estimates that the country will have five million fewer people 
in 2050 with a little more than 40 million people, compared 
with previous projections of twice as many.  The world's 
population is expected to grow by a third (2.5 billion people) 
by 2050.  Statistics SA, projects a South African population 
growth rate of 1.8 percent primarily because of a higher 
assumed total fertility rate. The actuarial sciences department 
at the University of Cape Town said most population models 
based their calculations on an estimated growth of under 1 
percent, less than half of the South African official 
projections.  This is in line with other recent international 
reports such as that of the International Monetary Fund and the 
UN Development Program (UNDP), which projects a radical decline 
in life expectancy for South Africa to as low as 37 years by 
the end of the decade.  According to the latest UNFPA report, 
most of Africa's population is expected to grow by more than 2 
percent despite AIDS, with the exception of South Africa, 
Botswana (0.9 percent), Zimbabwe (0.5 percent), Namibia (1.4 
percent), Swaziland (0.8 percent) and Lesotho (0.1 percent). 
Five of these southern African countries were also rated by the 
UNDP as among the 10 most unequal societies, while they are 
also among those with the highest HIV and AIDS infection rate. 
70 percent of people in southern Africa live below the poverty 
line on less than $2 (R13) a day and 40 percent on less than $1 
a day.  The UNFPA report does not discuss the reasons for the 
decline in South Africa, but refers to AIDS as a prime cause. 
Professor Rob Dorrington, an actuarial scientist at the 
University of Cape Town, said that South Africa's fertility 
rate had been dropping since the 1980s and, along with AIDS, 
would be the main cause for the declining population rate, 
which he estimates to be 0.7 percent.  Source:  Sunday 
Independent, October 17. 
 
Survey Released on Sexual Violence 
---------------------------------- 
 
3.  A study published by the British Medical Journal found high 
incidents of sexual violence and perceptions of sexual violence 
in South African pupils.  The study, conducted in the last 
quarter of 2002 interviewed 269,000 South African students in 
1418 schools.  It found 8.6 percent were forced to have sex in 
the past year. A further 58 percent said forcing sex on 
"someone you know" was not sexual violence, 30 percent said 
girls had no right to refuse sex with boyfriends and 26 percent 
said girls enjoyed rape, with findings similar across race, 
religions and class boundaries.  The questionnaires were in 
nine languages, and used the term forced sexual violence 
because not all languages have a direct translation for the 
word rape.  The study, funded by the Canadian International 
Development and Research Center and the United Nations, 
highlighted an apparent expectation of sexual coercion among 
young people that contributed to a culture of sexual violence. 
About 11 percent of boys and 4 percent of girls claimed to have 
forced someone to have sex in the past year. A third of the 
boys and 71 percent of the girls had themselves been forced to 
have sex.  Almost 16 percent said they would have unprotected 
sex, and a similar number said they would spread HIV 
intentionally. These views were expressed most by older (15-19 
years) boys from rural areas. Only 60 percent of the pupils 
surveyed believed condoms prevented the spread of HIV. A third 
said they never spoke to anyone about sex.  Source: Business 
Day, October 20. 
 
South African Orphans Increasing but Largely Ignored 
--------------------------------------------- ------- 
 
4.  Around a quarter of a million South African children are 
orphaned but large numbers are falling through bureaucratic 
cracks. By mid-2004, according to the Actuarial Association of 
South Africa (ASSA) 2002 model, 250,000 children in South 
African had lost both parents but government departments tasked 
with the welfare of these vulnerable children are unable to 
confirm actual numbers who are being cared for in children's 
homes.   Department of Social Development statistics indicate 
that 2,238 children were adopted in 2000 compared to 2,320 in 
2003 with only 369 of these children classified as abandoned. 
Figures from 169 affiliates of the SA National Council for 
Child Welfare, a non-governmental organization that collects 
statistics from many child welfare societies, indicate that 
during 2003 there were already 1,803 abandoned children.  6,356 
children were added in 2003. This translates into about 8,000 
abandoned children reported to the Council.  Nationally, 
238,610 children access monthly foster grants, amounting to 
just over R126 million ($20 million, using 6.2 rands per 
dollar).  Government statistics reveal that of the 2 320 
children adopted last year, 371 were cross-cultural and 224 
were by parents outside the country's borders.   More than half 
of the cases were processed in Gauteng courts alone.  Source: 
Health-e News, October 20. 
 
Procedures Needed for South African Adoption 
------------------------------------------ 
 
5.  Generally, a child is available for adoption once the 
mother has been counseled by a social worker in an adoption 
agency or an accredited adoption social worker in private 
practice.  Once the mother has decided, the social worker 
identifies approved adopters.   When a child is abandoned, the 
procedures are more complex.  First the police will take the 
child to a place of safety pending a decision by the children's 
court. This may be a state Place of Safety, an NGO-run 
children's home, a foster family or a temporary "safe house" 
(basically an emergency foster home).  If the child is left at 
a hospital, the matter will immediately be referred to the 
Department of Social Development, a Child and Family Welfare 
agency or sometimes directly to a children's home.  In some 
regions abandoned children will remain in institutions because 
the local commissioner of child welfare insists on a two-year 
"police search" before the child is declared abandoned and 
released for adoption. There is no legal basis for this 
requirement.  Some agencies will place abandoned children with 
foster families (if they are available) until the children's 
situation is clarified but many babies will wait out this phase 
in institutional care.  Another scenario arises if a child has 
been abused or neglected and is placed by the court in foster 
care or a children's home. Accepted practice is for intensive 
services to be rendered immediately to the family in question, 
with a view to restoring the child to their care if at all 
possible, or to finding an alternative permanent family if 
there is no prospect of reunification. Because of extremely 
poor pay and stressful working conditions the Department of 
Social Development and many family welfare agencies are unable 
to hold onto experienced staff. The children are served by a 
constant procession of new recruits who often take months to 
catch up with their caseloads.  Once they do, the numbers and 
the rapid inflow of new cases make it impossible for them to 
give more than token attention to children who do, at least, 
have roofs over their heads and are not known to be suffering 
active abuse.  If the system worked properly, intensive 
services would be delivered to these families from the outset, 
assessments would be made at short and regular intervals as to 
whether or not they were responding, and in the absence of 
progress, prospective adoptive parents could apply to adopt the 
child.  Where appropriate, such adopters could be foster 
parents who are already caring for the child. The court would 
then decide whether or not to use its power to dispense with 
the consent of the parents.  There is at present no compulsory 
training for commissioners of child welfare, and provisions 
which had been made by the SA Law Commission in its draft 
Children's Bill for specialized training of children's court 
personnel have since been removed, a decision currently 
contested by non-government organizations.  Source:  Health-e 
News, October 20. 
 
Western Cape Receives R430 Million from Global Fund 
--------------------------------------------- ------ 
 
6.  The Global Fund's R430 million ($69 million, using 6.2 
rands per dollar) grant to the Western Cape will accelerate 
AIDS programs and ensure that everyone who needs anti- 
retrovirals will get them by the end of next year. Two-thirds 
of the grant - the biggest to any department in the province's 
history - will go to treatment.  Currently, in the Western Cape 
approximately five thousand people are receiving anti- 
retroviral treatment.  New funding meant that all of the 
estimated 12,000 people who need the ARV drugs could be treated 
by the end of next year.  In addition, the funding will support 
(1) increased peer education programs; (2) additional hospices; 
and (3) more community-based and non-governmental 
organizations' initiatives.  The R430 million will be spread 
over the next five years, with R100 million for the first two 
years.  The money also comes directly to the province, the 
first time that has happened in South Africa.  Twenty-eight 
implementing partners will be involved in the program including 
Nazareth House, Medecins Sans Frontieres, Lovelife and the 
Desmond Tutu HIV Foundation.  Source:  Cape Argus, October 21; 
Cape Times, October 22. 
 
Large Increase in South African Child Mortality Rate 
--------------------------------------------- ------- 
 
7.  A study released in 2003 by the Burden of Disease Research 
Unit of the Medical Research Council (MRC), has shown that the 
below-five mortality rate in 2000 was estimated at 95 per 1,000 
children.  Infant mortality has risen to 60 per 1,000 live 
births, compared to the 1998 figure of 45 per 1,000.  HIV/AIDS 
is the largest cause of fatalities in children younger than 
five, accounting for 40 percent of deaths.  Lower respiratory 
infections, diarrhea, low birth weight and protein energy 
malnutrition, all associated with poor socio-economic 
conditions, were responsible for 30 percent of childhood 
deaths.  The study indicated that HIV and AIDS resulted in the 
deaths of 42,749 children under the age of five in 2000, with 
32,636 fatalities recorded for the above four causes.   As 
children get older, the leading causes of death shift away from 
HIV/AIDS, with road traffic accidents accounting for about 50 
percent of deaths in the five to nine-year-old age group. Girls 
in this age group are still vulnerable to HIV and AIDS, which 
accounts for 33 percent of fatalities.  For 10-14 year olds, 
traffic accidents and homicide are responsible for 33 and 15 
percent of deaths respectively.   MRC researcher Nadine Nannan 
points out that although the data between 1992-2002 shows an 
increase in child mortality; there is no comparative data yet 
available for post 2002.  Leading causes of death in South 
African children under five in 2000:  (1) HIV/AIDS (40 
percent), (2) Low birth weight (11 percent), (3) Diarrhea 
diseases (10 percent), (4) Lower respiratory infections (5.8 
percent), and (5) Protein-energy malnutrition (4.3 percent). 
Source:  Pretoria News, October 26. 
 
Thembalami Pharmaceuticals Withdraws Bid 
---------------------------------------- 
 
8.  Thembalami Pharmaceuticals has withdrawn its bid for a 
slice of government's multimillion-rand AIDS drug tender, due 
to problems with the drugs made by its Indian partner, Ranbaxy 
Laboratories.  Thembalami is a joint venture between Adcock 
Ingram and Ranbaxy and was specifically established to supply 
generic AIDS medicines to the South African market.  Ranbaxy SA 
has voluntarily recalled its entire portfolio of AIDS drugs 
marketed in South Africa, citing problems with the research 
company, which conducted studies to determine whether the drugs 
offered the same therapeutic benefits as the originals.  As a 
result, only seven companies, two of which can provide 
generics, remain on government's short list for the tender to 
supply antiretroviral medicines needed to treat South Africa's 
millions of HIV sufferers.  The remaining bidders on the short 
list are Abbot, Bohringer Ingelheim, Bristol Meyers Squibb, 
GlaxoSmithKline, Merck Sharpe Dohme's South African subsidiary 
MSD, and generic manufacturers Aspen Pharmacare and Cipla- 
Medpro.  A report to the World Health Organization highlighted 
problems with the bioequivalence studies for Avocomb tablets, 
and subsequent investigations by Ranbaxy Laboratories 
identified similar problems with Lamaid, Nevran, and Zidaid. 
Ranbaxy SA CEO Desmond Brothers said the recall was confined to 
South Africa, in consultation with the Medicines Control 
Council.  Source:  Business Day, October 26. 
 
Trends in HIV Risk Behavior in South African Migrant Workers 
--------------------------------------------- --------------- 
 
9.  A study presented at the 11th Reproductive Health Research 
Priorities Conference October 5-8 found an increase in the 
number of South African migrant workers who report multiple 
partners (3-20) in the last six months.   Migrant workers from 
rural KZN province were interviewed over a three-year period 
(2000-2003).  Over the three years, the proportion who reported 
having two sexual partners remained constant at 39 percent; the 
proportion reported having three to 20 sexual partners within 
the past six months increased from 8 to 12 percent.  80 percent 
of the respondents thought they had little risk of contracting 
HIV, unchanged over three years.  The proportion of migrants 
reporting drug use increased significantly between 2000 (5 
percent) and 2003 (13 percent) as did the proportion who 
reported being intoxicated between five and 30 times during the 
past month (5 to 34 percent respectively from 2000 to 2003). 
Between 2000-2003, increased accessibility and availability of 
condoms were reported; the proportion that used condoms 
increased from 48 to 59 percent.  The proportion of migrants 
who reported trying to prevent pregnancy in partners increased 
significantly from 2000 (69 percent) to 2003 (81 percent), 
however the respondents who reported using a method for 
pregnancy prevention remained constant at 20 percent.  Source: 
Abstract from Trends in HIV/STD Related Risk Behavior Among 
South African Male Migrant Workers, Authors:  Nzwaki Mosery, 
Arthi Ramkissoon, Anne Moys, and Mags Beksinska, Reproductive 
Health Research Unit, University of Witwatersrand. 
 
All Nine Provinces are Implementing ARV Treatment 
--------------------------------------------- ---- 
 
10.  The Health Department reports that all nine provinces have 
begun implementing the HIV/AIDS treatment plan using 
antiretroviral drugs, although the number of people on 
treatment is lower than planned.  11,253 people received ARV 
treatment by the end of September falling short of target of 
53,000 patients by March 2005.  All but one of the country's 53 
health districts have at least one ARV service point which 
provides a comprehensive service to people living with 
HIV/AIDS.  The Department also reports that there is improved 
infrastructure, improved training and retention of staff, 
certification of 250 laboratories and the establishment of a 24- 
hour helpline in place.  Source:  Business Day, October 21; The 
Star, October 22. 
 
FRAZER