US embassy cable - 05PRETORIA392

UNCLAS SECTION 01 OF 05 PRETORIA 000392 
 
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 
DEPT FOR USAID 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 28 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:  Rationing ARV Treatment; Industry Anti- 
retroviral Treatment Low; Two African Herbal Medicines Inhibit 
Metabolism of Anti-HIV Drugs; Improving the Quality of Primary 
Health Care: Public and Private Provision; Release of Mortality 
Report Delayed; Draft Legislation Regulating Alternative 
Medicines Likely to be Changed; and Aspen Approved by U.S. FDA. 
End Summary. 
 
Rationing ARV Treatment 
----------------------- 
 
2.  Researchers from the Center for International Health and 
Development and the Clinical HIV Research Unit at the 
University of the Witwatersrand recently published an article 
describing how rationing of antiretroviral therapy (ART) will 
be necessary as long as demand exceeds supply.  In Zambia, the 
first-year target for treatment is 10,000 patients; while 
100,000 Zambians have already reached the clinical threshold of 
less than 200 CD4 cells.  The most recent numbers of South 
Africans receiving ART is 19,500 by October 2004, out of an 
estimated 300,000 to 700,000 needing ART treatment (South 
African government estimates).  Kenya's target is 50 percent 
coverage, as is the global target of WHO's 3X5 initiative. 
Rationing is any policy that restricts consumption and can be 
either a market-based (relying on prices) or non-market system. 
As long as treatment targets represent less than total HIV/AIDS 
patients, the rationing of treatment is inevitable. 
 
3.  The article discusses rationing options and evaluation of 
rationing systems and recommends that governments should make 
deliberate choices about rationing ART and then explain and 
defend the choices to their constituencies.  The most accepted 
criterion for rationing ART is disease progression.  WHO 
guidelines call for ART when a patient has a CD4 cell count of 
less than 200; although a recent study highlighted how changing 
this criteria would impact demand in South Africa.  If ART 
treatment guidelines were changed to a CD4 count of 350 (the 
guidelines used by the U.S. Department of Health and Human 
Services), the proportion of HIV-positive people eligible for 
therapy would increase from 9.5 percent to 56.3 percent. 
 
4. The authors describe four types of rationing systems:  two 
explicit and two implicit.  Explicit rationing systems use 
specific socioeconomic criteria to define populations that 
receive treatment.  An example is the mother to child 
transmission program that makes ART preferentially available to 
HIV-positive mothers and their children.  Other explicit 
systems of rationing include either co-payment requirement or 
geographic location, where clinics are concentrated in high HIV- 
infected regions.  Other systems ration ART implicitly, with 
either a lack of medical facilities or drugs effectively 
serving as rationing in particular areas.  A system requiring 
queues will be implicit rationing. 
The authors provide seven criteria for assessing rationing 
systems that could help governments decide on their 
effectiveness.  The criteria outlined include:  (1) Does the 
rationing system produce a high rate of successfully treated 
patients; (2) Is the cost per patient relatively low; (3) Are 
the human and infrastructural resources needed for program 
implementation available; (4) To what extent does the system of 
distributing treatment reduce the long-term effects of HIV/AIDS 
on economic development; (5) Do all medically eligible patients 
have equal access to treatment; (6) Can the system be 
sustained; and (7) Does the treatment reduce the rate of HIV 
infection.  The authors recommend that governments make clear 
that the treatment program chosen be clear in its explicit and 
implicit means of rationing so people can debate the policy 
choices.  Source:  Health-link Bulletin, January 14; 
www.thelancet.com. 
 
Industry Antiretroviral Treatment Low 
------------------------------------- 
 
5.  A study, "Treatment of HIV/AIDS at SA's Largest Employers: 
Myth or Reality" done by the Center for International Health 
and Development, shows that 4 percent of employees in South 
African's largest companies are on HIV/AIDS disease management 
programs and 0.6 percent receive antiretroviral treatment 
despite an HIV prevalence rate of 14.3 percent.  Only 25 of 
South Africa's 64 largest firms know how many employees are 
enrolled in their HIV/AIDS disease management programs or are 
receiving ARV treatment.  Table 1 highlights treatment results 
from the study by industrial sector.  Only a few companies make 
up the most of the 3,908 workers receiving ARV treatment.  For 
example, Anglo American has more than 1,000 of its South 
African employees on treatment.  Study authors attribute low 
treatment numbers to stigma, and to new workplace programs.  In 
addition, companies have waited to see how the government 
program prioritizes its treatment program, seeing if the 
government's program would reach their employees.  The mining 
and financial services sectors lead in providing HIV/AIDS 
services.  All financial services and 75 percent of mining 
firms surveyed offer ARV treatment to employees.  Only 31 
percent of retail firms and no construction companies offer ARV 
treatment.  Companies with in-house HIV/AIDS management 
programs get more people into treatment than those companies 
relying on medical insurance programs.  Source:  FM Focus, 
January 14. 
 
Table 1.  Industrial Employees on ARV Treatment by Industry 
--------------------------------------------- -------------- 
 
Sector    Number of Employees      Employees on ARV Treatment 
Mining              275,300                            2,954 
Financial           172,000                            300 
Transport, Construction 
and Communication   119,000                            6 
Retail              44,900                             52 
Manufacturing       36,700                             518 
Agriculture         8,475                              48 
Total               656,375                            3,908 
--------------------------------------------- ------------------ 
 
Two African Herbal Medicines Inhibit Metabolism of Anti-HIV 
Drugs 
--------------------------------------------- -------------- 
 
6.  Two herbs widely used to treat individuals with HIV in 
Africa have a significant interaction with anti-HIV medication, 
potentially leading to poor metabolism of anti-retrovirals, 
according to a study published in the January 3rd edition of 
AIDS.  Extreme caution should be taken if using herbal 
medicines in the treatment of HIV, stress the investigators, 
who also state that their study shows the importance of 
undertaking pharmacokinetic studies to show the potential 
interactions between herbal medication and antiretrovirals. 
 
7.  The South African government has accredited 27 facilities 
to provide nutritional and micronutrients supplements and 
complementary and traditional medicines to HIV-positive 
patients so that the progression of HIV disease slows.  Many 
anti-HIV drugs, including protease inhibitors and non- 
nucleoside reverse transcriptase inhibitors (NNRTIs) are 
metabolized using the CYP3A4 pathway.  Herbal medicines have 
been shown to affect levels of anti-HIV because of their impact 
on CYP3A4 and, in the case of protease inhibitors, P- 
glycoprotein as well. Some herbal medications are also known to 
interact with nuclear receptors such as the pregnane X receptor 
(PXR), which modulates expression of CYP3A and P-glycoprotein. 
In a laboratory study investigators examined the effects of 
Hypoxis hemerocallidea (African potato) and Sutherlandia, two 
herbs widely used against HIV in Africa, on the metabolism of 
antiretroviral drugs.  Capsules, tablets and teas of both herbs 
were extracted and tested for their ability to inhibit CYP3A4. 
The affect of the herbs on PXR and P-glycoprotein were also 
assessed.  African potato showed a significant inhibition of 
CYP3A4 activity.  Sutherlandia also inhibited CYP3A4.  In 
addition, African potato and Sutherlandia resulted in 
significant activation of PXR.  The investigators suggest that 
using these herbal drugs with antiretroviral agents may result 
in the early inhibition of drug metabolism and transport 
followed by the induction of decreased drug exposure with more 
prolonged therapy.  The authors underscore the need for 
appropriately designed pharmacokinetic studies to discover the 
interaction potential of herbal drugs with antiretroviral 
drugs.  Failure to undertake such studies could result in drug 
interactions, treatment failure, resistant HIV, and drug 
toxicities.  Source:  Healthnet.org, Mills E et al. Impact of 
African herbal medicines on antiretroviral metabolism, AIDS 
2005, January 14. 
Improving the Quality of Primary Health Care: Public and 
Private Provision 
--------------------------------------------- ----------- 
 
8.  Research from the London School of Hygiene and Tropical 
Medicine, the University of Witwatersrand and the University of 
Cape Town examines the performance of various types of public 
health care (PHC) provision in South Africa.  It attempts to 
determine the strengths and weaknesses of private and public 
provision of primary care and the potential for increased 
arrangements between the public and private sectors.  It 
assesses whether private providers give good quality service at 
a cost that is comparable to that of the public sector.  The 
different models considered were individual General 
Practitioner (GP) contracts, commercial companies running PHC 
clinics on contracts, physicians in independent or group 
practices, commercial companies running clinic chains, and the 
public integrated model of clinics.   Performance was measured 
by looking at the cost and quality of providers in terms of 
their infrastructure, treatment given and acceptability to 
patients. 
 
9.  The main findings of the report were the following:  (1) 
care delivered by two of the private provider models, 
contracted GPs and the clinic chain, was comparable to public 
sector care in terms of cost per patient; (2) there were no 
private care provider models that consistently showed a better 
overall technical quality of care than public clinics.  Care by 
GPs lacked standardization and the clinic chain failed to 
deliver standardized chronic care; (3) users perceived the 
quality of service of private providers, except for contracted 
GPs, to be far superior to that of others; (4) the performance 
of both models involving contracts was negatively impacted by 
weak contract design and implementation. 
 
10.  The quality of PHC delivered to people in developing 
countries is often poor and coverage is not yet universal. 
This is despite a focus on the public delivery of comprehensive 
PHC over the past 20 years.  People frequently consult private 
providers including qualified medical professionals and 
unqualified health practitioners.  A better use of private care 
providers, therefore, might be a potential solution, including 
contracting them to provide services on behalf of the public 
sector.  Performance was strongly influenced by the context of 
each type of service provision and thus simply comparing public 
with private providers was not helpful.  Source: 
Healthnet.org, January 14, "The performance of different models 
of primary care provision in Southern Africa", Social Science & 
Medicine, Vol. 59. 
 
Release of Mortality Report Delayed 
----------------------------------- 
 
11.  The release of a mortality report by Statistics SA (Stats 
SA) has been delayed to ensure it is "a good and useful product 
", a senior agency official said yesterday, but would not 
specify when it would be made public.  The report, detailing 
causes of deaths between 1997 and 2003, was due for release on 
January 12, but was postponed at the last minute without 
explanation, fuelling speculation of political interference. 
The report will include AIDS deaths figures, which has sparked 
controversy in the past between government, Stats SA and the 
Medical Research Council.  Stats SA had said the report was 
based on all death notification forms received from home 
affairs from 1997 to 2003.  Stats SA's last report in 2001 was 
based on a 12 percent sample of forms from 1997 to 2001. It 
said "basic information" on causes of deaths would be presented 
for 1997 to 2003, and a more detailed analysis for 1997, 1999 
and 2001.  In 2001, Stats SA released a report showing a sharp 
increase in deaths among sexually active youths over the 
previous 15 years, saying this was largely due to AIDS, which, 
it said, was responsible for the deaths of an estimated 40 
percent of people aged 15 to 49.  At that time, the report was 
widely criticized by the Health Department and the Presidency 
saying that no proof that AIDS was responsible for the rise in 
deaths.  Stricter coding procedures and more efficient methods 
were used for the upcoming study to determine underlying causes 
of death, ranked according to frequency, and 10 leading causes 
presented for various populations and sub-populations. 
Source:  Business Day, January 20. 
 
Draft Legislation Regulating Alternative Medicines Likely to be 
Changed 
--------------------------------------------- ------------------ 
 
12.  Current draft regulations state that alternative medicines 
should be regulated in the same way as patented conventional 
drugs.  Health Minister Manto Tshabalala-Msimang recently 
suggested that this draft legislation is likely to be changed, 
meaning that African traditional medicines, homoeopathic 
remedies, Chinese and Ayurvedic medicines and others would not 
have to go through the rigorous testing as pharmaceutical 
drugs.  If this draft were passed into law, alternative 
medicines would have to undergo trials designed for Western 
medicines and a pharmacist would have had to oversee their 
manufacture.  Experts say complementary medicine cannot afford 
expensive, large-scale trials because alternative medicines are 
not patented.  At least 80 percent of South Africans used 
African, Chinese, Ayurvedic or South American traditional 
medicines, she said. The proportion would be greater if 
homoeopathic and other complementary medicines were included. 
South Africans spent R3-billion a year on complementary 
medicines.  Tshabalala-Msimang said the study of indigenous 
knowledge was "an opportunity to reclaim Africa's scientific 
and socio-cultural heritage, which was stigmatized and 
discredited as primitive rituals and witchcraft by colonialism 
and apartheid".  The Health Department has spent R6 million ($1 
million, using 6 rands per dollar) into the testing of the 
safety, efficacy and quality of traditional medicines that are 
used as immune boosters by people with HIV and Aids.  The first 
phase of testing the safety of one of these medicines was 
completed late in 2004 and the research had shown promising 
results, the health minister said. The government also funds 
research at universities and science councils into the efficacy 
of traditional medicines used to treat tuberculosis, malaria, 
asthma, cancer, diabetes, anxiety, stress and musculoskeletal 
disorders.  (The Mercury, January 17) 
 
Aspen Approved by U.S. FDA 
-------------------------- 
 
13.  Aspen Pharmacare had won U.S. Federal Drug Administration 
(FDA) regulatory approval for its AIDS drugs to be included in 
the U.S.'s $15 billion AIDS program.  "The approval is for the 
co-packed and most widely used triple cocktail combination of 
Lamivudine/Zidovudine and Nevirapine tablets in conventional 
adult dosages and Aspen stated that the drugs would be priced 
at affordable levels.   Aspen is the first accredited generic 
supplier to the U.S. AIDS program.  Production would soon begin 
at factory in Port Elizabeth, approved by the FDA in December. 
The triple combination drug would not be immediately available 
in South Africa, as it was still awaiting approval from the 
Medicines Control Council, which was expected soon.  While the 
result of the South African Health Department's first anti- 
retroviral bid has not been released, Aspen officials believe 
that the company is well positioned to win the bid.  About 25.4 
million people live with HIV in Africa - where just three 
percent of those infected had access to life-prolonging ARV 
drugs. At least 2.3 million people died from the disease in sub- 
Saharan Africa in 2004.  Aspen's pioneering of ARVs on the 
African continent and its world first generic ARV recognition 
by the FDA was achieved after getting voluntary licenses from 
the original drug manufacturers.  These include 
GlaxoSmithKline, the world's leading supplier of HIV and AIDS 
drugs, German drug maker Boehringer Ingelheim and Bristol-Myers 
Squibb.  By close of business on January 25, shares in Aspen 
increased 4.4 percent to R19.84 per share.  Source:  Business 
Day; Business Report; The Star; allAfrica.com; January 26. 
 
AIDS Treatment Numbers Released 
------------------------------- 
 
14. As of September 2004, 155,000 people received anti- 
retroviral treatment under the Presidential Emergency Plan for 
AIDS Relief, a program begun in 2003.  South Africa is one of 
15 focus nations, with over 12,000 receiving anti-retroviral 
treatment.  World Health Organization released estimates of 
people receiving anti-retroviral treatment and those aged 15-49 
needing treatment.  In Sub-Saharan Africa there were 310,000 
receiving therapy while 4 million need it.  According to WHO, 
700,000 receive therapy globally while 5.8 million need it. 
Source:  The Citizen, January 27; U.S. Embassy Pretoria PAS 
Press Release, January 26. 
 
MILOVANOVIC