US embassy cable - 05PRETORIA1892

UNCLAS SECTION 01 OF 04 PRETORIA 001892 
 
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 KHILL 
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 MAY 13 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:  Rural Communities to Shape Own HIV/AIDS 
Programs; Asthma Rates Rise Among SA's Teens; Government Needs 
to Treat HIV-Positive People Sooner; Treatment of Children a 
Lower Priority ARV Treatment; Breastfeeding Reduces HIV 
Transmission; Health Department Proposes Reforms to Funding 
Public Health; South African Women More Likely to Know HIV 
Status; and Global Fund Grants 3 Months Behind Schedule.  End 
Summary. 
 
Rural Communities to Shape Own HIV/AIDS Programs 
--------------------------------------------- --- 
 
2.  A new project by South African NGO, the Center for HIV/AIDS 
Networking (HIVAN), will enable rural communities across the 
country to develop their own programs to deal with the impact 
of HIV/AIDS.  Since July 2003, the HIVAN team has been 
investigating how people in rural areas respond to HIV/AIDS 
despite inadequate resources, including a lack of basic 
infrastructure and access to health facilities, while suffering 
from high rates of unemployment and illiteracy.  The survey 
found that the involvement of local stakeholders was crucial in 
implementing prevention campaigns.  After preliminary research, 
HIVAN recently launched its pilot project, which will run over 
a three-year period in a deeply rural, poverty-stricken and 
isolated area in the Mtunzini district of northern KwaZulu- 
Natal.  Based on the information obtained from the pilot, a 
model of best practices will be created and implemented in 
other rural areas throughout the country.  HIVAN's program is 
based on extensive consultation with communal stakeholders, 
giving it support in the community.  The nearest health care 
facility to the project is the Empangeni Hospital, and few 
residents can afford the transport to get there. 
As a result, they have to rely on the services of a mobile 
clinic that visits the area once a month.  But when it rains, 
the potholed and sandy roads become inaccessible, and the sick 
have to wait even longer for assistance.  HIV testing is not 
offered by the mobile clinic either, so information on HIV 
prevalence figures in the community is sketchy, but an HIVAN 
survey conducted among 100 residents in the project locale, 
estimated that 35 percent of pregnant women and 16 percent of 
adults were HIV-positive.  Families and caregivers nursing 
terminally ill AIDS patients were isolated and received very 
little community support.  When HIVAN first started interacting 
with the community, it found that the only mobilized groups 
dealing with HIV/AIDS were the under-resourced community health 
and home-based workers, with none receiving HIV/AIDS-related 
training.  Subsequently, a committee consisting of faith-based 
organizations, traditional healers, community health workers, 
tribal authorities and local health officials was established. 
The communal committee will meet on a regular basis and, with 
the help of HIVAN, develop an HIV/AIDS program that corresponds 
to the specific needs of the area.  The NGO will also 
facilitate HIV/AIDS information sessions, and promote critical 
thinking about social roots and stigma.  Since the beginning of 
this year, HIVAN has provided 75 community health workers with 
HIV/AIDS-related education and 10 HIV/AIDS focus groups have 
been established in the area.  Over the next three years HIVAN 
will continue training community health workers and launch two 
AIDS peer-education programs - one targeting the youth, the 
other geared to the men in the village.  Source:  All- 
africa.com May 4. 
 
Asthma Rates Rise Among SA's Teens 
---------------------------------- 
 
3.  Researchers at the Red Cross Children's Hospital have 
warned that asthma rates are rising among South African 
teenagers, and may dramatically increase among Xhosa-speakers 
as their families adopt western lifestyles.  The findings from 
two separate studies also highlight concerns about misdiagnosis 
and inappropriate treatment of asthma.  Symptoms of asthma, 
allergic rhinitis and eczema had increased markedly in Cape 
teenagers over the past seven years.  They repeated a survey 
conducted for the 1995 International Study of Asthma and 
Allergies in Childhood among more than 6000 13-to-14-year-olds 
from 53 Cape Town schools in 2002, and found the proportion of 
children reporting severe wheezing had risen from 5.2 percent 
to 7.6 percent.  Exercise-induced wheezing was reported by 32 
percent of the teenagers compared with 21.5 percent in the 
earlier study.  Scientists suspect that the worldwide rise in 
allergies is linked to the way people live, suggesting that 
bacteria-free homes and sterilized food make people more 
susceptible to hay fever, asthma and eczema.  A series of 
studies has found that children are less likely to get 
allergies if they are raised on farms, live in rural areas, or 
are exposed to plenty of infections when they are young. 
Western diets and a lack of exercise are also linked to the 
rise in allergies.  The 2002 study also found a drop in the 
proportion of children who had had their asthma diagnosed by a 
doctor.  SA has the fifth-highest asthma fatality rate in the 
world, although it ranks only 25th for asthma prevalence, 
according to the Global Initiative for Asthma.  A separate 
study found African teenagers appeared to be more genetically 
disposed to allergies than whites, suggesting the incidence of 
asthma and other allergies would rise "exponentially" among 
Xhosa speakers as they adopted western lifestyles.  Source: 
Business Day, May 3. 
 
Government Needs to Treat HIV-Positive People Sooner 
--------------------------------------------- ------- 
 
4.  Treating HIV positive people when their CD4 counts are 
above 200 is not only lifesaving, but also more cost effective, 
according to research conducted by Robin Wood of the University 
of Cape Town's Desmond Tutu HIV Research Center.  At present, 
people with a CD4 count (measure of immunity in the blood) of 
200 or less are eligible for ARV drugs at government clinics. 
Placing patients on ARV treatment when their CD4 cell counts 
are between 200 and 350 not only improved mortality, but was 
also cost effective.  According to calculations by Wood, life 
expectancy for an HIV positive person in the absence of 
antiretrovirals is around 6.3 years.  This goes up to an 
average of 17 years if a person with a CD4 count of less than 
200 starts ARV treatment.  Starting ARV treatment with the 
patient having a CD4 count of between 200 and 350 increases 
life expectancy by a further six years, extending life 
expectancy to 23 years.  Nine clinics forming part of the HIV 
Center's anti-retroviral program in Cape Town recorded a death 
rate of only 7.8 percent after 12 months of therapy.  The death 
rate was measured within the first 12 months of placing the 
patients on anti-retroviral therapy.  However, when Wood 
measured the death rates from the time of referral (from the 
clinic to the ARV site) the picture changed dramatically.  It 
was found that 28 percent of patients died from the time of 
referral until the time they are placed on treatment.  Many 
patients had died of wasting syndrome, a condition for which 
there is no specific treatment, while others died of 
tuberculosis, Kaposi's sarcoma and cryptococcosis.  The 
critical need is to find and treat patients early, and Wood 
said the tuberculosis program was a good place to start as 60 
percent of patients entering the ARV program had had TB in the 
past.  Source:  Health e-News, April 28. 
 
Treatment of Children a Lower Priority ARV Treatment 
--------------------------------------------- ------- 
 
5.  According to Dr Haroon Saloojee of Wits University's 
Community Pediatrics Division speaking at the first "Priorities 
in AIDS Care and Treatment (PACT)" conference, at best 3,000 
children are on antiretroviral (ARV) drugs countrywide, whereas 
between 30,000 and 45,000 of the country's 230,000 HIV-positive 
children needed the drugs.  Statistics showed child mortality 
had steadily increased since 1996, with AIDS-related diseases 
accounting for 40 percent of deaths of children under the age 
of five.  A further 10 percent died of diarrhea while around 11 
percent of deaths were due to low birth weight, both of which 
could be HIV-related.  Gauteng placed 1,319 children on ARVs, 
12 percent of those accessing the drugs in the province.  In 
Mpumalanga only 31 children, 1 percent of those on ARVs, were 
on the drugs and in KwaZulu-Natal, at best, 500 of its 9,000 
patients were children.  Dr Saloojee identified the following 
obstacles facing widespread treatment of HIV-positive children: 
(1) staffing shortage with up to one third of posts in the 
public health sector vacant; (2) pediatric guidelines on 
treatment have to be finalized; (3) too few sites accredited 
for pediatric anti-retroviral treatment: (4) reluctance by the 
clinics and hospitals to start treating children unless there 
is a pediatrician on the staff; (4) Parents being treated at 
different sites from their children; (5) failure and reluctance 
to test children; (6) A lack of pediatric drug formulas and 
their high prices; (7) complex dosages, foul tasting syrup, 
refrigeration requirements and quick expiry dates; (8) reliance 
on herbal medicine; and (9) sharing medicine with family. 
Saloojee called for the fast tracking of accredited sites, the 
urgent distribution of treatment guidelines, the incorporation 
of testing into primary healthcare services and the overall 
strengthening of the prevention of mother to children 
transmission program (where many children would be identified 
in the first place).  Source:  Health e-News, April 28. 
 
Breastfeeding Reduces HIV-Transmission 
-------------------------------------- 
 
6.  Exclusive breastfeeding substantially reduces the 
transmission of HIV from mother to baby as well as infant 
death, compared with partial breastfeeding, a study in Zimbabwe 
has confirmed.  Breastfeeding causes nearly 40 percent of all 
pediatric HIV infections, yet also prevents millions of child 
deaths every year by protecting infants from diarrhea and other 
infections.  A study conducted by the Johns Hopkins Bloomberg 
School of Public Health, the University of Zimbabwe and Harare 
City Health Department found that exclusive breastfeeding 
substantially reduces the transmission of HIV from mother to 
infant as well as infant mortality, compared with partial 
breastfeeding.  Infants who were introduced to solid foods or 
animal milk within the first three months were at four times 
greater risk of contracting HIV through breastfeeding compared 
to those who were exclusively breastfed.  International 
guidelines currently recommend that HIV-infected mothers should 
avoid all breastfeeding, but only if replacement feeding is 
acceptable, feasible, affordable, sustainable and safe.  For 
the large majority of African women, this isn't the case and 
breastfeeding is the only choice.  The study was conducted 
among 14,000 pairs of mothers and newborns who were part of the 
ZVITAMBO project, which examined the effects of vitamin A 
supplementation in Zimbabwe.  From this group, the researchers 
followed 2,060 infants from birth to age 2 who were born to HIV- 
positive mothers.  Information about infant feeding was 
collected at ages six weeks, three months and six months.  All 
infants were breast fed, but were categorized as exclusive 
(breast milk only), predominant (breast milk and non-milk 
liquids) or mixed (breast milk and animal milk or solids) 
breastfeeding.  In their analysis, the researchers found that 
mixed breast feeding quadrupled mother-to-infant HIV 
transmission and was associated with a three times greater risk 
of transmission and death by age 6 months when compared to 
exclusive breast feeding.  Predominant breastfeeding was 
associated with a 2.6-fold increase in HIV transmission as 
compared to exclusive breastfeeding.  The study is published in 
the latest issue of the AIDS journal.  Source:  Health e-news, 
April 28. 
 
Health Department Proposes Reforms to Funding Public Health 
--------------------------------------------- -------------- 
 
7.  Trying to address the inequities in health care spending, 
the Council for Medical Aid Schemes (CMS) has proposed to 
introduce a social health insurance system by 2010 where all in 
formal employment would have to buy medical insurance, which 
would double the number with insurance to about 14 million and 
reduce those relying on public health care facilities from 85 
percent to 65 percent.  The proposed health reforms have four 
phases.  Phase 1 (2003-2007) would limit private sector health 
care cost increases and improve the quality of public 
hospitals.  Phase 2 (2004-2008) would introduce a risk 
equalization fund and risk adjustment subsidy to medical 
insurance companies as well as sponsoring a state-sponsored 
medical insurance program requiring civil service 
participation.  Phase 3 (2005-2008) would require medical 
insurance for middle-to-high income workers and would encourage 
voluntary insurance for low-income workers.  Phase 4 (2008- 
2009) would require workers to contribute through a 5 percent 
payroll tax to a National Health Insurance fund, with higher 
income earners able to contribute more in order to receive more 
comprehensive health care coverage.  By 2010, the poor would 
receive free basic public health care coverage.  CMS, reporting 
to the Department of Health, acknowledged resistance from trade 
unions and other governmental departments (mainly Treasury), 
and suggested that membership of the state medical insurance 
program might be mandatory for new employees only.  The 
Department of Treasury favors a limit on the amount of medical 
aid contributions that are tax deductible rather than imposing 
a new 5 percent payroll tax and wants the Department of Health 
to improve its financial management and collection services 
before imposing additional taxes.  Public hospitals currently 
charge an income-based fee, now generating less than R300 
million ($50 million, using 6 rands per dollar) from R500 
million in 1996.  In March, the Health Department announced fee 
increases in public hospitals.  For example, patients earning 
less than R3,000 per month ($500) will have to pay R55 for a 
consultation, compared to R20 previously.  The Department of 
Health also mandated prescribed minimum benefits (PMBs), a list 
of diseases and conditions for which all medical insurance 
policies must insure, and increased the cost of entry for 
poorer people to private health care.  A medical insurance 
package just covering the PMBs costs approximately R200 per 
month.  Agreement with labor unions and other governmental 
agencies will be required if the proposed plan becomes 
operational.  Source:  Financial Mail, May 6; Mail and 
Guardian, May 2-6. 
 
South African Women More Likely to Know HIV Status 
--------------------------------------------- ----- 
 
8.  A survey, HIV and sexual behavior among young South 
Africans, found that 10 percent of 15-24-year-olds have HIV but 
the prevalence rate for women was more than three times that of 
men.  The research, by the University of Witwatersrand's 
Reproductive Health Research Unit, loveLife and the Medical 
Research Council, found that 77 percent of patients who tested 
positive were women.  Seventy percent of people getting tested 
at government voluntary counseling and testing centers are 
women.  The survey reported significant gender differences, 
finding that 25 percent of females surveyed said that they had 
been tested while only 15 percent of males did.  A recent 
Nelson Mandela study of HIV/AIDS showed that 13 percent more 
South African women than men know their status.  Source:  Cape 
Times, May 10. 
 
Average Global Fund Grants 3 Months Behind Schedule 
--------------------------------------------- ------ 
 
9.  Global Fund grants are, on average, three months behind 
schedule, according to an analysis conducted by Aidspan, a non- 
governmental organization (NGO) that monitors Global Fund 
activities.  The study compares each Global fund grant's 
planned disbursement schedule with the actual disbursement 
schedule and determines whether the grant is on time or ahead 
of schedule, up to 3 months behind schedule, between 3-6 months 
behind schedule, over 6 months behind, or too new for rating. 
Of the 311 grants, 45 (14 percent of the total) have an Aidspan 
rating of "A: On or ahead of schedule"; 140 grants (45 percent) 
are rated "B: Up to 3 months behind schedule";    61 grants (20 
percent) are rated "C: 3 to 6 months behind schedule"; 60 
grants (19 percent) are rated "D: Over 6 months behind 
schedule"; and 5 grants (2 percent) are rated "N: Too new for 
rating".  Grants to Eastern Europe and Central Asia currently 
have the highest average rating; they are on average 1.2 months 
behind schedule.  Grants to North Africa and the Middle East 
come next, being on average 2.0 months behind schedule.  Grants 
to each of the four remaining regions of the world are on 
average between 3 and 4 months behind schedule.  There is no 
statistically significant difference in performance between 
grants for HIV/AIDS, malaria, or TB.  Global Fund grants to 
PEPFAR (Presidential Emergency Plan for AIDS Relief) countries 
are on average 3.3 months behind schedule, and grants to non- 
PEPFAR countries are on average 3.0 months behind schedule, not 
a statistically significant difference.  For Sub-Saharan 
Africa, the average grant delay was 3.4 months while South 
Africa's average reached 7.88 months.  Source:  Global Fund 
Observer Newsletter, issue 44, May 5. 
 
FRAZER