US embassy cable - 05PRETORIA205

UNCLAS SECTION 01 OF 04 PRETORIA 000205 
 
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 JANUARY 14 ISSUE 
 
 
Summary 
------- 
 
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:  HIV-Positive and Pregnant; Doctors to Help 
Cut Cost of Health Care; Risk of TB Doubles in First Year of 
HIV Infection; Monitoring the Effect of the New Rural Allowance 
for Health Professionals; Health Department Makes Progress in 
Filling Key Vacancies.  End Summary. 
 
HIV-Positive and Pregnant 
------------------------- 
 
2.  As anti-AIDS drugs become available to more South Africans, 
a growing number of HIV-positive women are choosing to become 
pregnant in spite of their status.  There are risks involved. 
In the absence of intervention, an estimated 15 to 30 percent 
of mothers with HIV will transmit the infection to their baby 
by the time it is born, according to the World Health 
Organization. A single dose of Nevirapine, given to mother and 
baby, halves the chances of infection during labor, when the 
risk of transmission is highest.  Initially people assumed that 
if someone knew their HIV-positive status, then pregnancy was a 
'no-no'. But the reality is that most of these people are young 
women in their prime, who want to have babies, according to Dr 
Pumla Lupondwana, a research doctor at Chris Hani Baragwanath 
hospital in Johannesburg.  Lupondwana is conducting a study on 
resistance to Nevirapine at the perinatal HIV research unit 
based at the hospital. She estimated that about a third of the 
250 women participating in the trial had made a conscious 
decision to fall pregnant. In fact, an increasing number of 
women were second-time mothers who had been diagnosed HIV- 
positive during their first pregnancy.  They've been exposed to 
Nevirapine, and they know all the risks involved, she said. 
The reason for having a baby varies. According to Lupondwana, 
some may want a child they can leave behind as some form of 
legacy or reminder.  For some women, a new partner might insist 
on having a baby, with the woman too afraid to disclose her 
status.  Pressure from the community, and fear of stigma and 
discrimination were other reasons.  In a study presented at the 
2004 International AIDS Conference in Bangkok, Thailand, South 
African virologist Dr Lynn Morris showed that although there 
was high resistance to Nevirapine six weeks after a woman had 
taken a single dose, this dropped to 14 percent after six 
months.  Resistance to Nevirapine decreases the drug's 
effectiveness and makes it difficult to treat the baby if it is 
born HIV-positive.  Most HIV-positive pregnancies are usually 
trouble-free, unless the mother is at an advanced stage of the 
disease and has a compromised immune system, Lupondwana said. 
 
3.  Most of the women are practicing unsafe sex, despite 
receiving extensive family planning advice.  Some might have 
planned to have the babies, but most of these women are having 
unplanned pregnancies because they are not using any form of 
contraception, or their partners refuse to use condoms.  Sharon 
Ekambaram, an AIDS activist and former PMTCT coordinator of the 
lobby group, the Treatment Action Campaign, pointed out that 
the country's prevention of mother-to-child transmission of HIV 
(PMTCT) and antiretroviral (ARV) rollout programs had failed to 
take this into account.  These programs are not addressing the 
woman's inability to disclose to their spouse or partner and 
negotiate safer sex. These women are forced to hide the fact 
that they are on treatment, just to avoid disclosure, she said. 
Men don't want them to use condoms, and they are too scared to 
tell them about having HIV. When some women did gather the 
courage to disclose, the men would say 'if we both have it, 
then it doesn't matter - we don't have to use condoms.' 
 
4. The latest UNAIDS report on the global AIDS epidemic 
estimates that in South Africa the number of orphans is 
expected to increase from 2.2 million in 2003 to 3.1 million by 
2010.  According to the latest numbers from the Joint Civil 
Society Monitoring Forum, an NGO coalition set up to monitor 
the ARV rollout, about 18,500 South Africans are accessing ARV 
treatment.  More and more HIV-positive women will want to have 
kids - this is still a new issue that hasn't been adequately 
dealt with in the public sector.  Lupondwana cautioned that 
becoming pregnant when HIV-positive still has its risks, as it 
could compromise the woman's immune system. But, at the end of 
the day, it is their choice to make.  Source:  PLUSNEWS, 17 
December 2004; Health Systems Trust, January 7. 
Doctors to Help Cut Cost of Health Care 
--------------------------------------- 
 
5.  More than 1,200 KwaZulu-Natal medical doctors have joined 
hands for an ambitious program aimed at controlling the 
escalating cost of healthcare delivery.  The KwaZulu-Natal 
Managed Care Coalition is an association of general 
practitioners, including specialists, one of 20 regions all 
affiliated to the national South African Managed Care 
Coalition.  The KwaZulu-Natal coalition's success, according to 
the chairman and CEO, Dr Morgan Chetty, is due to its 
monitoring of the healthcare process in the private sector of 
the region. Some of its functions include a strict code of 
conduct for the practitioners, managed medical aid and options 
for medical aids.  It also co-ordinates one of the best- 
attended continuing medical education programs for its members, 
highlighting new medical evidence-based information and 
reviewing practice parameters.  The coalition's successful 
management program has led the University of KwaZulu-Natal's 
medical school together with Net Partners, a national doctors' 
investment group, to establish a department of managed care and 
health services management at the university.  Net Partners has 
created a similar department at the University of Pretoria. 
Traditionally, medical practitioners are taught pure clinical 
medicine and not introduced to health care management issues. 
According to Chetty, the goal for South Africa is to develop 
doctors with the same management and clinical expertise that 
can easily adapt to either the public or private sector. 
Source: IOL, January 2. 
 
Risk of TB Doubles in First Year of HIV Infection 
--------------------------------------------- ---- 
 
6.  The risk of developing tuberculosis doubles within the 
first year of testing HIV positive, according to a large 
retrospective study published in the January 15th issue of The 
Journal of Infectious Diseases (JID). This risk further 
increased in subsequent years.  Although HIV increases the risk 
of TB it has long been assumed that this was primarily due to 
falling CD4 cell counts seen with advancing HIV disease 
progression. The early effect seen in the study, conducted by 
researchers from the London School of Hygiene and Tropical 
Medicine, was largely unexpected. 
 
7.  The retrospective study analyzed data drawn from the 
medical records of 23,874 workers from four South African gold 
mines.  The mines provided the perfect opportunity to assess 
how HIV affects the risk of tuberculosis over time.  The mines 
have a stable population, provide regular medical care and keep 
good medical records.  There is a well-established TB control 
program and a confidential database of all HIV test results of 
the mine workers has been kept since 1989. HIV test results 
could therefore be linked to routinely collected TB and 
demographic data.  At the beginning of the study, 3371 miners 
were HIV-positive (these are referred to as having prevalent 
HIV) and 20,503 were HIV-negative.  Over the course of several 
years, many of the workers had subsequent HIV tests.  Of these, 
2,737 received positive HIV results (these cases are referred 
to as having incident TB) 1,962 (72%) within two years or less 
of a previous HIV negative result.  A total of 740 cases of 
pulmonary TB (first episode) were analyzed during a seven-year 
period.  TB was found to be at least three times more common in 
those who were HIV-positive.  The incidence of pulmonary TB was 
2.9 cases per 100 patient years at risk in the HIV positive 
workers and 0.8 cases/100 patient years at risk in the HIV 
negative workers.  Investigators then assessed the relative 
risk (RR) of developing TB by age and calendar period (1991-92, 
93-94, and 95-9) and according to when workers tested HIV 
positive. Age and calendar were significantly associated with 
an increased risk of TB.  The incidence of TB per patient years 
at risk doubled during the last time period, with an adjusted 
case rate ratio of 2.21.  This could reflect the impact that 
the HIV pandemic was having on the overall incidence of TB in 
the southern African region.  The relative risk (RR) of 
developing TB was greater in those who were HIV-positive when 
the study began, which is to be expected as they had been 
infected longer and their immune systems would be less able to 
fight off TB. But what was not expected, as mentioned earlier, 
was the increase in incidence of pulmonary TB so soon (within a 
year) after seroconversion, with an adjusted case rate ratio of 
2.11. 
 
8.  An editorial accompanying the article in JID suggested that 
there could have been a small bias in detecting TB in patients 
with HIV because HIV-positive miners may present to medical 
facilities more frequently because of the development of HIV- 
related clinical symptoms of illness, thus potentially biasing 
toward greater evaluation for, and detection of, TB among HIV- 
positive miners.  The editorial writers believe the study 
provides sufficient data to demonstrate the doubling of the 
incidence of TB within the first year of HIV seroconversion. 
The editorial suggests two possible explanations for the 
increased TB risk 1) the profound immune dysregulation that 
occurs soon after [HIV] infection or 2) that those patients who 
develop tuberculosis within the first year of HIV infection 
have a rapidly progressing form of HIV disease.  High levels of 
HIV seen during acute seroconversion or the immune response to 
HIV could also activate latent TB infections in some patients. 
If TB is activated in this setting, HIV could quickly wipe out 
any CD4 cell response.  Investigators evaluated whether the 
increased risk of TB early during the course of HIV infection 
is due to reactivation or to a newly acquired M. tuberculosis 
infection by performing molecular fingerprinting on available 
isolates. Unique isolates are more likely to have been due to 
reactivated TB acquired before working in the mines, while the 
isolates of TB acquired in the mines would be the same.  Among 
HIV seroconverters, unique TB isolates were present in 57 
percent of miners who developed TB within 2 years of HIV 
seroconversion, compared with 20 percent who developed TB 
later. The finding is intriguing though numbers are too small 
to draw any firm conclusions.  However, it suggests that 
patients with latent TB are more likely to develop pulmonary TB 
within the first year of seroconversion. 
 
9.  The study's findings have a number of major implications 
for TB and HIV control programs. The editorial points out that 
while current models for TB control do factor an increase in TB 
incidence where there is a high adult HIV prevalence, they do 
not account for the increased risk of TB early during the 
course of HIV infection.  TB that occurs later in HIV disease 
is usually not centered in the lungs but is extrapulmonary. 
This study showed a doubling in pulmonary TB, which is far more 
infectious.  Finally there is an immediate need to expand 
reliable and affordable HIV testing services in areas where TB 
is endemic and, conversely, to improve surveillance for TB 
among patients testing positive for HIV.  Source: Aidmap, 
January 5; Health Systems Trust, January 7. 
 
Monitoring the Effect of the New Rural Allowance for Health 
Professionals 
--------------------------------------------- --------------- 
 
10.  A recent study by Professor S. Reid of the Center for 
Rural Health, University of KwaZulu-Natal, published by the 
Health Systems Trust, focuses on the impact of the rural 
allowances in influencing where health care professionals 
practiced.  The unequal distribution of health professionals 
between rural and urban areas in South Africa led to financial 
and non-financial incentives to recruit and retain health 
professionals in areas of need.  In 1994, South Africa started 
a rural recruitment allowance, granted only to medical doctors 
and dentists, and remained at the same fixed rate since the 
time of its inception. It was perceived to be ineffective as an 
incentive for retention of professional staff, and despite the 
introduction of community service for all health professionals 
except nurses, it remains difficult to recruit and retain 
professional staff at rural hospitals, health centers and 
clinics. 
 
11.  The new rural allowance started by the Minister of Health 
is a national initiative aimed at improving recruitment of 
health care professionals in rural areas.  The impact of the 
initial R500 million allocated by Treasury in July 2003 needs 
to be measured.  While the effect of the rural allowance may 
eventually be seen in staffing patterns of rural hospitals, the 
longer-term effect is likely to be diluted by the many other 
factors that influence health professionals career choices 
apart from financial benefits.  The effect of the new allowance 
was measured in the short term by direct questioning of those 
receiving the allowance, in order to control these variables as 
far as possible, and allow a more direct evaluation of the 
effect.  However, between the time that the rural allowance was 
announced in May 2003, and its eventual implementation in March 
2004, retroactive to July 2003, there was intense and lengthy 
debate in the Public Service Bargaining Chamber (PSCBC) 
regarding the exact nature of this allowance, who it would 
benefit, and most importantly, who would be excluded. 
Eventually two separate allowances were agreed upon, the Scarce 
Skills Allowance (SSA) and the Rural Allowance (RA). The SSA 
benefits certain categories of health professional regardless 
of the place of work, whereas the RA benefits all health 
professionals in certain health facilities that are designated 
as rural. The latter areas include the nodes as defined by the 
Integrated Sustainable Rural Development Strategy, as well as 
rural areas as designated by the PSCBC based on the previous 
recruitment allowance. In addition, provincial Heads of Health, 
depending on available funds, from within provincial budgets, 
could determine inhospitable areas. Negotiations within the 
PSCBC continue up to the time of writing, and certain unions 
are challenging the regulations. 
 
12.  The changing nature of the allowance made the planning of 
the research project difficult, in that the data collected for 
the baseline survey did not anticipate the simultaneous 
introduction of the SSA, which was confused by some of the 
respondents and their managers as the RA. Nevertheless, an 
attempt was made to capture information as the process 
unfolded, in order to have a baseline on record for future 
evaluations.  The study randomly chose 34 out of 159 rural 
hospitals and obtained 243 questionnaire responses, with most 
of the questionnaires coming from doctors with more than five 
years of experience.  The study reports that almost one-third 
of health professionals working in rural areas say that they 
have changed their career plans next year as a result of the 
new allowance. It is difficult to assess whether this is the 
effect of the RA alone, or in combination with the SSA. Further 
evaluations will be necessary to assess the longer-term impact 
of these strategies.  Source:  Health Systems Trust, January 
11. 
 
Health Department Makes Progress in Filling Key Vacancies 
--------------------------------------------- ------------ 
 
13.  The Department of Health has appointed a new Director- 
General (DG).  The previous DG was transferred to the 
Department of Foreign Affairs in September 2003.  The new DG, 
Mr. Thamsanqa Dennis Mseleku, assumed office on January 1, 
2005.  Mr. Mseleku previously served as the Director-General of 
the Department of Education.  During his career Mseleku has 
served as a teacher and head of Foreign Languages Department, 
Zibukezulu High School, in Pietermaritzburg, and as a 
researcher and English lecturer at the University of Natal.  He 
was later appointed as Chief Director for Human Resources and 
Labour Relations at the Department of Education.  At the 
Education Department he served as Special Advisor to the 
previous Minister of Education; Deputy Director-General for 
Human Resources and Corporate Services; and finally as Director- 
General.  The Department appointed a new manager of the HIV 
program, a position formerly held by Dr. Nono Simelela.  The 
new head of the HIV/AIDS and STIs program is Dr. Nomonde Xundu, 
previously with the Gauteng Provincial Health Department.  Dr. 
Xundu has program experience in condom distribution, STIs, 
PMTCT, Post Exposure Prophylaxis for Non-Occupational Exposure 
to HIV, VCT and Workplace HIV Programs.  A key Department of 
Health position is now vacant, putting additional pressure to 
fill important vacancies.  The Registrar of Medicines and Chief 
Director for Medicines Control Council in the Department of 
Health, Mrs. Precious Matsoso, has resigned, effective January 
21, 2005.  Mrs. Matsoso has been appointed Director of the 
WHO's department of technical cooperation for essential drugs 
and traditional medicine at the WHO Headquarters, Geneva. 
 
MILOVANOVIC