US embassy cable - 05PRETORIA1161

UNCLAS SECTION 01 OF 05 PRETORIA 001161 
 
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 MARCH 18 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:  25% of Under-20s Using Drugs; Partial 
Victory for Dispensing Doctors; State to Supply AIDS Drugs for 
Less than R100; Debate in South Africa about Routine Testing; 
Survey Shows Durban Less Likely to Test for HIV; Survey Shows 
Youth Views of HIV/AIDS; AIDS Impacts on Agriculture; Another 
Study Confirms TB Increase; Constitutional Court will hear 
Medicine Pricing Case; The Impact of AIDS on Gauteng Province; 
MRC Points to Signs that HIV Pandemic might be abating.  End 
Summary. 
 
25% of Under-20s Using Drugs 
----------------------------- 
 
2.  A Medical Research Council (MRC) survey of the prevalence 
of drug abuse among people under 20 years of age shows that in 
1996, one youth in 20 in the Western Cape was taking drugs and 
that now the figure is one in four.  The MRC collected 
information from 25 substance abuse treatment centers in the 
Western Cape and found that between 1996 and 2004, the number 
of young people using drugs had increased dramatically.   The 
drug of choice also changed over the eight years.  The demand 
for treatment of dagga, Mandrax, cocaine and heroin as primary 
drugs increased from one percent in 1996 to nine percent in 
2004.  Methamphetamines (tik) became the most popular choice of 
drug, increasing from 121 treated cases in 2003 to 376 in the 
first half of 2004.  The number of people seeking treatment for 
the abuse of more than one drug had increased since the second 
half of 2003, with more than 10 percent of patients being 
reported as abusing four or more substances.  The length of 
time between a person's first using a drug and seeking 
treatment for abuse depends on the type of drug.  Treatment for 
tik begins, on average, 1.6 years after first use.  Heroin 
users enter treatment programs after three years on average, 
dagga users after 4.8 years, cocaine users after five years and 
Mandrax users after about 7.6 years.  Alcoholics tend to seek 
treatment much later.  Compared with other provinces, a greater 
proportion of young people in the Western Cape seem to have 
started drinking before the age of 13.  Half of the people 
whose unnatural deaths were recorded in Cape Town in 2003 had 
blood alcohol levels over the legal limit.   MRC researchers 
suggested a number of measures that could help curb drug and 
substance abuse.  These include:  (1) reducing the supply of 
drugs and taking steps to deter people from abusing alcohol, 
such as increasing the frequency of random breath tests for 
motorists; (2) passing provincial legislation on the retail 
sale of alcohol and bringing shebeens into the regulated 
market; (3) promoting and implementing effective prevention 
programs with community-based approaches; and (4) improving 
access to quality treatment by building strong partnerships 
between substance abuse treatment centers and mental health 
services.  Source:  The Cape Times, March 10. 
 
Partial Victory for Dispensing Doctors 
-------------------------------------- 
 
3.  The first constitutional challenge to new health laws left 
dispensing doctors and the Department of Health each claiming a 
partial victory.  In a unanimous judgment, the Constitution 
Court said that regulations that force doctors to get licenses 
to dispense drugs were not unconstitutional.  However, sections 
that tried to limit the number of pharmacies in an area were 
declared invalid.  The court said that laws requiring renewal 
of a dispensing license would stand.  The application to the 
Constitution Court was brought by a group of dispensing doctors 
under the umbrella of the Affordable Medicines Trust, which 
included the National Convention on Dispensing (NCD), and was 
opposed by the Department of Health.  NCD spokesperson Norman 
Mabasa said he did not consider it a partial victory. "It is a 
major victory," he said.  Mabasa claimed that NCD has never 
been against licenses and inspections, but was concerned about 
regulations that would have limited dispensing doctors on the 
basis of competition in an area.  Source:  Sapa, March 11. 
 
State to Supply AIDS Drugs for less than R100 
--------------------------------------------- 
 
4. Government will be able to supply state patients with three 
antiretroviral drugs (triple therapy) for around R100 ($17, 
using 5.85 rands per dollar) a month, according to prices 
agreed in the government antiretroviral drug tender.  Local 
generic drug producer Aspen is the main beneficiary of the 
tender, while Indian generic producer Cipla will supply one of 
the drugs needed.  Brand name drugs from the large 
pharmaceutical companies, GlaxoSmithKline, Boehringer 
Ingleheim, Bristol Meyers Squibb, MerckSharpe&Dohme and 
Abbott, are only included where there are no generic 
alternatives.  Concern has been expressed about price increases 
during the tender period.  Boehringer Ingleheim is the only 
company to guarantee that it will not increase the price of the 
drug it is supplying, nevirapine, over the tender period. 
Aspen's prices rise by 6 percent after 18 months.  Abbott is 
providing its drug, lopinavir, to the state at the same price 
as in the private sector.  However, it has pegged its prices 
for Kaletra and Norvir at $500 per patient per year for the 
duration of the tender, which ends in August 2007.  It says 
increases will only come about in relation to currency 
fluctuation.  GlaxoSmithKline's price for 3TC is almost a third 
of the private sector cost, while AZT is almost half the 
private sector price.  First line treatment of the drugs d4T 
(stavudine), 3TC (Lamivudine) and nevirapine for an adult 
weighing 70kg will be about R97.26 a month.  Where efavirenz is 
substituted for nevirapine, the drug the price rises to R269.96 
($46).  Second line treatment of AZT, ddI and lopinavir will 
cost R534.98 ($91). This treatment will be resorted to if 
patients fail to respond to the first regimen, perhaps because 
they have been on antiretroviral drugs in the past and 
developed resistance, or because of side-effects.  Three 
different classes of antiretroviral drugs, called triple 
therapy, are needed because the virus mutates rapidly, and can 
develop resistance to a single drug with relative ease. Each of 
the three drugs is from a different class and interacts with 
the virus at a different stage of its lifecycle.  Source: 
Health E-News and Business Day, March 4. 
 
Debate in South Africa about Routine HIV Testing 
--------------------------------------------- --- 
 
5.  Only 850,000 South Africans have actually been tested for 
HIV in the past four years, while 1.2 million people have had 
pre-test counseling.  The low rate of testing is a common 
problem worldwide, which has led to countries such as Botswana 
and the US making the HIV test a routine service available at 
primary health facilities.  Debate about South Africa's 
voluntary approach to HIV Testing and Counseling involves 
government officials and interested community organizations. 
The article summarizes different viewpoints on testing.  The 
Department of Health has concerns about making HIV testing a 
routine practice, stating that they operate within the 
parameters of the Bill of Rights of the Constitution, whereby 
mandatory testing would violate the rights of those who are HIV- 
infected, so testing should be voluntary.  In addition, they 
feel that mandatory testing will increase stigma associated 
with the infection, saying that their approach is to educate 
communities about the importance of getting to know their 
status early, and also, educating them as to how to live 
positive, healthy, longer lives.  Jonathan Berger of the AIDS 
Law Project asserts that offering the HIV test as a routine 
service would not conflict with South Africa's human rights 
principles.  According to Berger, the routine offer of HIV 
testing should be introduced in South Africa as long as it is 
not introduced in a way that dispenses with the need for pre- 
and post-counseling and proper informed consent.  Advocates of 
routine testing emphasize that an environment where treatment 
is being offered as a real option to the patient and 
confidentiality is respected is essential.  Confidentiality is 
 
SIPDIS 
different from disclosure.  Disclosure is the choice of the 
patient.  In addition, legal and Constitutional guarantees of 
non-discrimination are essential as well.  With these 
guarantees in place, HIV testing can become routine.  Proposals 
for increased mandatory testing have been recently introduced, 
with the latest recommendation of pre-marital testing proposed 
by Ruth Rabinowitz, an IFP Member of Parliament.  Source: 
Health E-News, March 4, The Witness, March 14. 
 
Survey Shows Durban less likely to Test for HIV 
--------------------------------------------- -- 
 
6.  According to a survey by Khulisa Management Services, 
people living in Durban are less likely to test for HIV than 
people in Cape Town and Johannesburg.  The survey of 892 
households in the Durban area found that 72 percent of 
respondents had no intention of getting tested for HIV in the 
next 12 months, compared with 42 percent of people in Cape Town 
and 53 percent of Johannesburg residents.  Overall, 33 percent 
of the respondents aged between 18 and 35 had been tested for 
HIV and 43 percent intended to go for tests in the next 12 
months.  Walk-in centers, independent of any established clinic 
or hospital are being established by the government and U.S. 
Center for Disease Control, to serve people who prefer not to 
use government testing facilities.  According to Treasury's 
estimated 2005 expenditure, 3,369 public health care facilities 
are already providing voluntary counseling and testing, with 
the number expected to increase to 5,000 by the end of 2005. 
KwaZulu-Natal province has the highest estimated HIV prevalence 
in South Africa.  Source:  Business Day, March 7. 
 
Survey Shows Youth Views of HIV/AIDS 
------------------------------------ 
 
7.  The University of Cape Town's Center for Social Research's 
AIDS and Society Research Unit recently published a study 
"Measuring HIV/AIDS Stigma" based on a survey of 4,800 Cape 
Town youths aged 14 to 22.  Respondents in the Cape Area Panel 
Study were interviewed repeatedly between 2002 and late 2003. 
The study will track the youths' changing circumstances and 
views until 2008.  Initial results highlight the importance of 
awareness campaigns in reducing stigma, showing that the more 
adolescents know about how HIV/AIDS is transmitted, the less 
likely they are to stigmatize people living with the virus. 
Fear of infection is the dominant cause of discrimination among 
81 percent of respondents, followed by `some negative moral 
judgments' cited by 73 percent of survey participants.  Almost 
all respondents believed HIV-positive people should be treated 
equally with regard to government services such as free health 
services, job training, and welfare grants.  The research also 
found that respondents aged 15 to 18 are more likely to 
stigmatize people living with HIV/AIDS than the older 
participants.  Males are more likely to be prejudiced than 
women, while coloured youths are more likely to discriminate 
against those with the virus and African youths the least 
likely to discriminate.  Christian and Muslim youth are more 
likely to discriminate against HIV-infected people than those 
with no religious affiliation.  Source:  Mail&Guardian, March 
11. 
 
AIDS Impacts on Agriculture 
--------------------------- 
 
8.  Based on forecasts of Agri AIDS, an HIV/AIDS awareness 
initiative directed at farm workers, between 35 and 40 percent 
of South Africa's agricultural workers are infected with the 
HIV/AIDS virus.  The pilot program of Agri AIDS brings AIDS 
treatment to agricultural workers, with 200 treatment centers 
treating 1000 workers.  According to the latest Statistics SA 
employment report, the agricultural sector employs 
approximately 1 million workers and more severe impacts on the 
agricultural sector production would be felt in the next 
several years.  Source:  Business Day, March 15. 
 
Another Study Confirms TB Increase 
---------------------------------- 
 
9.  A National Tuberculosis Control Program (NTBCP) study shows 
that the prevalence of TB has increased from 188,695 patients 
diagnosed in 2001 to 256,000 diagnosed in 2003.  In addition, 
an estimated 55 percent of TB patients are also HIV-positive. 
On a provincial level, KwaZulu-Natal showed the highest TB and 
HIV prevalence, with almost 80,000 TB cases recorded in 2003 
and 37.5 percent of its population infected with HIV. 
Statistics SA, in its 2005 Mortality Report, found that TB 
accounted for 11.3 percent of all deaths in 2001.  NTBCP cited 
a cure success rate of nearly 54 percent although multi-drug 
resistant cases had increased by almost 2 percent and re- 
treatment cases by about 7 percent.  The NTBCP estimates that 
about 10,000 patients currently suffered from multi-drug 
resistant TB.  Source:  Pretoria News, March 15. 
 
Constitutional Court Will Hear Medicine Pricing Case 
--------------------------------------------- ------- 
 
10.  The Constitutional Court will hear an application by the 
Department of Health relating to its controversial medicine 
pricing regulations.  Part of the regulations, which were 
introduced last May to make medicines more affordable and 
accessible, includes formulas to set the manufacturer price of 
medicine and cap the amount that pharmacists may make from 
selling the medicines.  Pharmacists believe this will put them 
out of business and have waged a prolonged court battle with 
the Department of Health to alter the dispensing fee maximum of 
R26 or 26 percent of the cost of the medicine.  While waiting 
for word of an appeal of a Cape High Court ruling in favor of 
the Department of Health, the pharmacists decided to approach 
the Supreme Court of Appeal (SCA) directly.  The SCA declared 
the regulations invalid and the Department of Health will ask 
the Constitutional Court for leave to appeal this.  The court 
is also expected to be asked to make a declaratory order on 
which laws are currently in force.  The Health Department 
believes their application to the Constitutional Court revives 
the regulations, but the pharmacists believe that because there 
is no clear rule over what happens to an order when it is 
appealed from the SCA, the SCA order stands until the 
Constitutional Court makes a ruling.  Meanwhile, pharmacists 
have chosen their own pricing structures pending the outcome of 
the application.  Source:  Sapa, March 14. 
 
The Impacts of AIDS on Gauteng Province 
--------------------------------------- 
 
11.  Gauteng commissioned a study in 2003/04 to investigate the 
impact of the HIV epidemic on hospitals in 2002.  In 2002, 64 
percent of hospital admissions for the age group 25 to 34 were 
people with HIV, with the most common cause of admission being 
TB.  The major costs for the province's hospitals in HIV/AIDS- 
related illnesses were antibiotic drugs and laboratory 
investigations.  The province has had a sharp rise in the 
prevalence of HIV among pregnant women during the period from 
1997 to 2001.  About 80 percent of the population of the 
province does not have medical insurance and depends on public 
health facilities for health services.  To date, 20 health care 
facilities are providing HIV/AIDS treatment in the province, 
with a total of 88,415 people tested, and 9,413 adults and 
1,308 children receiving ARV treatment.  In 2004/05, the total 
provincial HIV/AIDS budget allocation is R334.231 million 
($57.6 million) of which R200 million is from the provincial 
budget and an additional R134.231 million is from a conditional 
grant from the national Department of Health.  Source: 
Mail&Guardian, March 11. 
 
MRC Points to Signs that HIV Pandemic Might be Abating 
--------------------------------------------- --------- 
 
12.  According to Medical Research Council (MRC) interim 
president Dr. Anthony Mbewu, recent surveys signal that the 
demographic impact of HIV/AIDS might be changing.   Using data 
from the annual HIV-prevalence survey of pregnant women 
attending government clinics, Mbewu said there were indications 
that the pandemic was reaching a plateau.  The survey, 
conducted every year since 1990, found that 28 percent of the 
pregnant women surveyed in 2003 were HIV-positive; in 1990 the 
figure was just 0.7 percent.  The prevalence rate rose sharply 
during the mid-1990s, but year-on-year increases have slowed 
since 2000.  In earlier surveys, the highest prevalence rates 
were seen among women aged between 15 and 25, but in 2003 the 
survey showed the highest HIV burden among those aged 25-35. 
In addition, a decline in other sexually transmitted diseases 
such as syphilis, and the increased use of condoms, had helped 
limit the spread of HIV/AIDS.  The prevalence of syphilis among 
pregnant women attending government clinics declined from 8 
percent in 1998 to about 2 percent in 2000.   The MRC estimated 
that HIV was the leading cause of death in 2000, responsible 
for 29.8 percent of all reported deaths.  Cardiovascular 
disease was also a major problem in SA, and Mbewu suggested 
that its economic repercussions might be of the same order as 
those of HIV/AIDS. Referring to Statistics SA's latest 
mortality report, released last month, he said AIDS-related 
deaths were clearly under-reported.   The report detailed the 
causes of deaths recorded on death certificates between 1997 
and 2003, and found that only 2.8 percent of reported deaths in 
2001 were described as being due to HIV.  On the impact of the 
disease on the local economy, Mbewu cited most studies 
predicted a reduction in GDP of between 0.3 percent and 0.6 
percent, based on a decline in the population growth rate of 
1.3 percent.  However, he emphasized the uncertainties in the 
capability of the health system and the extent of the reduction 
in labor force due to HIV/AIDS and suggested that econometric 
models used to estimate HIV/AIDS impacts be refined.  Source: 
Sapa, Business Day, March 16) 
 
 
FRAZER