US embassy cable - 05PRETORIA3917

UNCLAS SECTION 01 OF 05 PRETORIA 003917 
 
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, NIH/HFRANCIS 
CDC FOR SBLOUNT AND DBIRX 
STATE FOR AID 
 
E.O.  12958: N/A 
TAGS: ECON, KHIV, SOCI, TBIO, EAID, SF 
SUBJECT:  SOUTH AFRICA PUBLIC HEALTH SEPTEMBER 23 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:  Delmas Still Suffering with Typhoid; 
University Helps Search for Typhoid Source; Report Shows Few 
Towns Test Water; Durban Tries to Substitute Chocolate for 
Glue; Khayelitsha Trials Set to Continue; South Africa Health 
Review Highlights Health Statistics; Staff Shortage Constraint 
on ARV Plan; Common Vaginal Infection may Double HIV Infection 
Risk; and HIV Disproportionately Affects Young Women in South 
Africa.  End Summary. 
 
Delmas Still Suffering with Typhoid 
----------------------------------- 
 
2.  In Delmas, Mpumalanga, poor planning by local government 
authorities has been cited as a reason for the recent typhoid 
outbreak.  By September 14, two Delmas residents had died, more 
than 400 had symptoms of typhoid and health facilities were 
treating at least 400 cases of diarrhea a day.  The figures are 
expected to rise in the next three to six weeks because of the 
incubation period of the disease.  Minister of Health Manto 
Tshabalala-Msimang has blamed the typhoid outbreak in Delmas on 
 
SIPDIS 
local authorities, and Democratic Alliance MP Dan Maluleke says 
evidence points to poor planning on the municipality's part. 
The outbreak has occurred in the middle of a massive transfer 
program of water services schemes to municipalities by the 
national Department of Water Affairs and Forestry.  Minister 
Buyelwa Sonjica told the National Council of Provinces (NCOP) 
earlier this year that she expected all water services to be in 
the hands of municipal authorities by March 2006.  Helgard 
Muller, Executive Manager of water services in the Water 
Affairs and Forestry Department, cited poor management of 
sewage works spilling into underground water as well as 
inadequate disinfection of water supplies as reasons for the 
outbreak.  Overloading of the sewage system and the bucket 
system used by Botleng township residents have also been 
blamed.  An estimated 16 million people in South Africa still 
live without basic sanitation and 231,000 households across the 
country use the bucket system.  At least 800,000 household 
sanitation units have to be introduced every year in order to 
reach the government target of wiping out the backlog by 2010. 
Meanwhile, residents of Delmas are demanding to know why this 
is the second typhoid outbreak they have experienced in the 
past 12 years.  The last typhoid outbreak was caused by the 
overloaded sewage system seeping into the ground water that 
people are using.  Residents of Delmas protested about the lack 
of municipal oversight and handed a protest memorandum to 
Mpumalanga premier Thabang Makwetla outlining their concerns. 
Source:  IOL, The Star, Mail and Guardian, September 16. 
 
University Helps Search for Typhoid Source 
------------------------------------------ 
 
3.  A team from Free State University will use a method similar 
to that of forensic police to establish whether water in Delmas 
has the bacteria that causes typhoid.  Polimerase chain 
reaction technology will pick up traces of Salmonella Typhi's 
DNA even if the bacteria is no longer present in the water, and 
results should be available by September 26.  If there was no 
evidence of the bacteria, typhoid would most likely have come 
to Delmas through another route, probably related to personal 
hygiene.  Previous sampling by the University of Port 
Elizabeth's virology institute showed that water in Delmas had 
been responsible for typhoid and diarrhea in the minority of 
cases.  There were multiple routes the infection could take and 
that these could vary from household to household.  Salmonella 
Typhi only lives in humans.  Persons with typhoid fever carry 
the bacteria in their bloodstream and intestinal tract. 
Source:  SAPA, IOL, September 20. 
 
Report Shows Few Towns Test Water 
--------------------------------- 
 
4.  According to an unpublished report commissioned by the 
Water Affairs and Forestry Department, half of the local water- 
service authorities in Mpumalanga believe they comply with 
government standards for drinking-water quality, but only a 
quarter of them actually monitor it.  Water-service authorities 
are responsible for providing safe drinking water to the 
country.  The water-service authorities' survey suggests the 
lack of monitoring of drinking water is not confined to 
Mpumalanga, and many more people may be at risk of waterborne 
diseases.  Officials have not ruled out contaminated water as 
the cause of the deadly typhoid outbreak that has rocked Delmas 
in Mpumalanga Province, claiming at least four lives.  Many 
other towns are struggling to maintain safe water supplies. 
Earlier the town of Chrissiesmeer in Mpumalanga Province cut 
off drinking water to 8000 inhabitants following the discovery 
of e.coli bacteria, which cause diarrhea, in one of the town's 
reservoirs.  Delmas reported in the survey that it considered 
its water to be up to standard, and said it regularly monitored 
and tested the quality of its drinking water with the 
assistance of an accredited laboratory.  But this was not 
independently assessed by external auditors.  The survey was 
alluded to by Water Affairs Minister Buyelwa Sonjica during her 
budget speech in May, when she said that 63 percent of 
municipalities could not confirm that they met guidelines for 
drinking-water quality, but at the time neither she nor her 
officials provided further details.  The survey, based on the 
self- assessed performance of South Africa's 170 water-service 
authorities, found 61 percent of them perceived their drinking 
water to be of "good" or "ideal" standard, yet only 58 percent 
regularly monitored it.  Only half met the South African Bureau 
of Standards quality guidelines for drinking water. 
 
5.  The provinces with the worst drinking water were Eastern 
Cape, KwaZulu-Natal, Limpopo, Mpumalanga, Northern Cape and 
North West, which all performed below the national average, 
according to the survey.  In the Eastern Cape, six out of 17 
authorities said they monitored the quality of drinking water. 
By contrast, in the Free State, 20 out of 21 said they 
regularly tested drinking water.  The problems were largely 
confined to rural areas, with Ekhurhuleni (east Johannesburg) 
the only metropolitan area failing to regularly test water. 
The report cites insufficient monitoring and evaluation 
systems, a lack of effective water treatment and a poor 
management culture, as weaknesses in the water delivery 
program.  Source:  Business Day, September 22. 
 
Durban Tries to Substitute Chocolate for Glue 
--------------------------------------------- 
 
6.  Durban's street children are being weaned off glue by 
chocolate although the eThekwini Municipality may run out of it 
soon.  Religious and other groups are being urged to donate 
chocolate to increase supplies.  There is a substance in 
chocolate which substantially reduces the craving for glue and 
street children are giving glue bottles in exchange for 
chocolate.  A bottle of glue costs R5 and is usually shared 
among friends.  The effect of glue sniffing lasts about six 
minutes and the urge to have more becomes very overpowering 
within a short space of time.  Source:  IOL, Daily News, 
September 19. 
 
Khayelitsha Trials Set to Continue 
---------------------------------- 
 
7.  Top government health officials seem poised to let the Dr 
Rath Health Foundation continue clinical trials on people with 
HIV in Khayelitsha.  Health director general Thami Mseleku 
stated that a preliminary report submitted to his office by the 
Health Department's Law Enforcement Directorate had not found 
anything wrong with what is happening in Khayelitsha.  Mseleku 
said it was now up to the Medicines Control Council (MCC), 
which he said was an independent body, to investigate the 
matter further.  However, the Health Department's Director of 
Nutrition, Lynne Moeng, criticized the inadequate labeling on 
Vita Cell, one of the Rath Foundation products, as well as the 
high dosages being prescribed.  Moeng said taking high doses of 
vitamins would among others cause nausea and vomiting and 
impair liver function.  Moeng said that there were regulations 
stipulating that a high dose vitamin should be registered with 
the MCC, however, a complementary product does not have to get 
MCC approval.  The Treatment Action Campaign (TAC) is preparing 
a legal action against the Health Minister and MCC after both 
failed to act against Rath and his foundation.  TAC 
spokesperson Nathan Geffen says no response has been received 
two weeks after their stated deadline.  MCC registrar Dr 
Humphrey Zokufa declined to comment on the MCC's investigation 
into the Rath Foundation's activities, claiming that the Health 
Department Law Enforcement Directorate's investigation was not 
yet complete.  Source:  Health e-News, September 15. 
 
South Africa Health Review Highlights Health Statistics 
--------------------------------------------- ---------- 
 
8.  The latest South Africa Health Review highlights health 
figures by province, showing significant health staffing and 
spending differences.  The North West province has the least 
doctors and professional nurses per capita in the country, with 
21 doctors and 90 nurses for every 100,000 people and spends 
the least on health, R771 per person.  The Western Cape almost 
doubles this amount at R1383 per person.  There are not enough 
medical specialists in Mpumalanga, having a total of 15 
specialists, or one for every 200, 000 people), while there are 
serious shortages in Limpopo and North West.  KwaZulu-Natal has 
the least dentists per capita in the country, followed by the 
Eastern Cape and Limpopo.  There are only seven psychologists, 
15 physiotherapists and 35 pharmacists in the whole of the 
Northern Cape.  Nurses in the province also have one of the 
heaviest workloads, seeing an average of 47 patients a day. 
Over the past few years, nurses' workloads have steadily 
increased from 23.5 patients a day to 29.4, undoubtedly because 
there are now 109 professional nurses per 100,000 people 
whereas five years ago, there were 120.  But there has been an 
improvement in vacancies.  Whereas in 2003, 31 percent of posts 
were vacant, this year the number has dropped to 27 percent. 
Almost 40 million of the country's 46.8 million people depend 
on the public health sector.  In 2004, there were 100,000 
hospital beds available, a decrease of 7,000 since 1998.  While 
malaria cases have dropped by two-thirds over the past four 
years, measles cases have tripled over the same period, 
indicating that not enough children are being immunized against 
the disease.  TB cases have jumped from 349 per 100,000 people 
in 2000 to 550 in 2003, with the worst affected provinces being 
the Northern Cape, Western Cape and KwaZulu-Natal.  Almost 30 
percent of pregnant women are testing HIV positive in antenatal 
clinics, with 38.5 percent of women aged 25 to 29 testing 
positive.  KZN has the highest rate by far (40.7 percent), 
followed by Gauteng and Mpumalanga.  It is estimated that 16 
percent of South Africa's total population is infected with 
HIV.  Source:  Health e-News, September 14. 
 
Staff Shortage Constraint on ARV Plan 
------------------------------------- 
 
9.  According to the South Africa Health Review, the ARV 
treatment plan is drawing health staff away from other 
services, while at the same time needs more staff to expand. 
Over the next five years, government's HIV/AIDS care, support 
and treatment plan will need about 13,800 more staff if it is 
to be implemented properly.  Approximately 3,200 doctors, 2,400 
nurses, 765 social workers, 765 dieticians, 112 pharmacists and 
2,000 data workers will be needed by 2009 to implement the full 
roll out of the antiretroviral component of the plan.  By 
April, over 1,000 health professionals had been recruited and 
more than 7 600 trained.  An estimated 100,000 people are now 
getting ARV treatment at government sites, although accurate 
figures are hard to come by as the national monitoring system 
is not yet operating.  Both the Western Cape and Gauteng have 
exceeded their patient enrolment targets, while KwaZulu-Natal 
has the most ARV sites.  Source:  Health e-News, September 14. 
 
Common Vaginal Infection may Double HIV Infection Risk 
--------------------------------------------- --------- 
 
10.  Researchers at the University of Cape Town found that 
bacterial vaginosis (BV), the most common vaginal infection in 
women of childbearing age, may double a woman's susceptibility 
to HIV infection, according to the results of a South African 
study published in the October 15th edition of The Journal of 
Infectious Diseases.  Bacterial vaginosis (BV) is a condition 
in women where the normal balance of bacteria in the vagina is 
disrupted, resulting in a change from an acidic to an alkaline 
environment.  Although it is sometimes accompanied by symptoms 
such as discharge, odor, pain, itching, or burning, it is often 
asymptomatic.  Although no pathogen has been isolated as the 
cause, it is considered to be a sexually transmitted infection 
(STI), and, since it affects between 20 - 25 percent of the 
general population, and up to 50 percent of women attending 
sexual health clinics, it is the most common STI worldwide. 
Several - but not all - epidemiological and prospective studies 
have found an association between BV and HIV infection.  In 
addition, in vitro studies suggest that BV has the potential to 
increase susceptibility to HIV infection, possibly through 
increased production of interleukin (IL)-10 and/or increased 
secretion of tumour necrosis factor-alpha (TNF-) and IL-1a. 
 
SIPDIS 
 
11.  Investigators, at the University of Cape Town, conducted a 
case-control study, nested within a randomized controlled trial 
evaluating cervical cancer screening in Khayelitsha, near Cape 
Town.  Of the 5,110 women who were HIV-negative at enrollment 
(between June 2000 and December 2002), the investigators 
selected all women who had seroconverted by December 2003 for 
this study.  The majority of seroconversions (64 percent) were 
identified at the 6-month follow-up visit, although the 
investigators report that risk of seroconversion remained 
constant throughout the 36-month follow-up period.  A further 
324 age-matched women were selected at random from the cohort 
as controls. 
Women who seroconverted were significantly more likely to be 
unmarried, to report having had more than one sex partner in 
the month before enrolment, and to report having a new sex 
partner at the 6-month follow-up visit.  In multivariate 
analysis, after adjusting for demographic characteristics, 
other STIs and sexual behaviors, women with BV were 
significantly more likely to seroconvert than women with normal 
vaginal flora. 
 
12.  The investigators point out several limitations to their 
study, including the fact that BV was assessed only once and 
HIV seroconversions were identified over three years. During 
this time, vaginal flora may have changed, and a baseline BV 
assessment may not accurately reflect presence of BV at the 
time of seroconversion.  The investigators also did not assess 
the presence of ulcerative STIs, including herpes simplex virus 
2 (HSV-2), which have been found to increase HIV acquisition 
risk.  It is also possible that other unknown confounding 
measures may have inflated the association between BV and HIV 
acquisition.  Source:  AIDSMAP, September 16. 
 
HIV Disproportionately Affects Young Women in South Africa 
--------------------------------------------- ------------- 
 
13.  Fifteen percent of young South African women, aged between 
15 and 24 are HIV-positive, compared to only 5 percent of South 
African males in the same age group, according to a study 
published in the September 23rd edition of AIDS.  The 
investigators found that older sexual partners, sexually 
transmitted infections and inconsistent condom use were amongst 
the risk factors for HIV infection, but they also found that 
young people who had participated in South Africa's loveLife 
HIV prevention activities were less likely to be HIV-infected. 
In 2003 investigators conducted a nationally representative 
survey of young South Africans and collected data on HIV 
prevalence, HIV-risk factors, and knowledge of and 
participation in national HIV prevention campaigns.  Almost 
12,000 young people from across South Africa were interviewed 
for the study and had a voluntary HIV test.  The majority of 
individuals participating in the study were black (82 percent). 
Just under half (47 percent) of the total study population were 
living in townships or in informal rural settlements, a quarter 
reported living in households without electricity and only 38 
percent of 20 - 24-year-olds had completed high school 
education.  HIV prevalence was 16 percent in young females 
compared to 5 percent in young males.  HIV prevalence increased 
with age.  Whereas only 4 percent of 15 and 16-year-old females 
were HIV-infected, by the age of 21 this had increased to 31 
percent.  A similar pattern was present among young males, with 
HIV prevalence being between 2- 3 percent amongst 15- and 16- 
year- olds, increasing to 12 percent in 21-24-year-olds. 
 
14.  Of the individuals who reported ever having sex, a quarter 
of men and 45 percent of women reported having more than one 
sexual partner.  Inconsistent condom use was reported by 61 
percent of sexually active men and 71 percent of sexually 
active women.  Circumcision was reported by a third of men. 
Males reported that their sexual partners were an average of 
one year older than them whereas females reported that their 
sexual partners were on average four years older.  There was a 
high level of knowledge about national HIV prevention 
campaigns, with 85 percent reporting having heard of the 
loveLife campaign and 25 percent of women and 15 percent of men 
reported ever having had an HIV test. 
15.  The investigators emphasized the gender inequality of HIV, 
with young South African females being many times more likely 
to be HIV-infected than young males.  The study found that 15- 
to 19-year-old females in their study had sexual partners an 
average of one to four years older.  The researchers noted 
study limitations, in particular the self-report of sexual risk 
activities, commenting that 3 percent of men and 4 percent 
women who reported never having had sex tested HIV-positive. 
Source:  Aidsmap, September 16. 
 
TEITELBAUM