Cablegate: South Africa Public Health December 10 Issue

This record is a partial extract of the original cable. The full text of the original cable is not available.




E.O. 12958: N/A


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: South Africa's Response to HIV/AIDS Still
Includes Denial and Ignorance; HIV/AIDS Places Burden on
Elderly; Some Regions Fear HIV/AIDS, Others Cancer; Health
Department Reports Increase in Number of Patients on ARV;
Economic Cost of AIDS May Worsen; Telkom HIV/AIDS Prevalence
Rate Expected to Peak at 11.4 Percent; Correctional Services
Conducts HIV Survey in Prisons; HIV/AIDS Budgets for National
and Provincial Government; Provincial Progress on Implementing
Government's HIV/AIDS Treatment Plan; and SA's Labor Force
Declines with HIV/AIDS, Discouragement Impacts. End Summary.

SA's Response to HIV/AIDS Still Includes Denial and Ignorance
--------------------------------------------- ----------------

2. The latest figures from the Actuarial Society of South
Africa suggest that about one in nine South Africans is
infected with HIV, the virus that causes AIDS, and about 5
million people who are living with the disease, the largest
case load in the world. The Human Sciences Research Council's
2002 household survey estimated that 6.2 percent of white South
Africans were infected with HIV, the biggest middle class
epidemic in the world. By comparison, an estimated 12.9 percent
of black Africans were infected. Many health care
practitioners find that their patients know about HIV/AIDS but
few are changing their behavior. The same patients repeatedly
ask for HIV tests. These are not sex workers for whom HIV is a
hazard of their jobs, but people who refuse to accept that they
need to protect themselves with condoms. The point about an
HIV test is to have it once, and if you are negative to keep it
that way. "There's a mistaken belief among many middle- to
upper income professionals, particularly whites, that they are
not at risk," says Mark Heywood of the Treatment Action
Campaign. The fact that HIV has disproportionately affected
poor, black, young women is an indication that many of them
think it cannot affect them, says Jonathan Berger, of the AIDS
Law Project at the University of the Witwatersrand. That
denial is worsened by SA's HIV-prevention campaigns, which
focus almost exclusively on young people. "By telling part of
the story as if it were the entire story, the vulnerability
picture often painted is both inaccurate and misleading," he
says in a paper accepted for publication by the journal
Development Update. Berger argues that SA's limited public
education campaigns are deeply flawed, presenting a sanitized
view of sex that bears little relation to people's lives. They
focus on young men and women having heterosexual sex, and shy
away from anything vaguely taboo, he says. Very little
research investigates what kind of sex people are having. And
when research does shed light on potentially dangerous
practices, Berger states that the findings are not incorporated
in education campaigns. Despite the frustration expressed by
many HIV/AIDS experts, there is some encouraging evidence that
young people are waiting longer before they have their first
sexual encounters; are using condoms more consistently; and are
more conscious of the dangers of HIV, says loveLife CEO David
Harrision. Source: Business Day, December 1.

HIV/AIDS Places Burden on Elderly

3. The Human Sciences Research Council (HSRC) released a study
on the impact of HIV/AIDS on the elderly (aged 60 and older) in
Mpumalanga that highlights the particularly heavy financial and
care burden the elderly are paying. The study found that 72
percent of older people in the province are the main
breadwinners in multi-generational households, spending most of
their income on household necessities and the education of
grandchildren. Nine percent are caring for sick young adults
living in the household, 22 percent are staying with
grandchildren whose own parents are either dead or away in the
cities on a long-term basis, 20 percent take care of children
six years or younger, and 46 percent take care of children
between the ages of six and 18. With 60 percent of orphans in
South Africa being cared for by their grandparents, bringing up
a second generation weighed heavily on the elderly. Funerals
carry a substantial cost, often shouldered by the elderly as
the main breadwinner, or receiver of a state pension. The
majority of the elderly are female, according to census 2001
there are 34 males to 100 females in Mpumalanga. Most stay in
rural areas, with even those who worked in the cities returning
to rural areas when reaching retirement age to reunite with
their extended families. Source: SAPA, Mail and Guardian,
December 1.

Some Regions Fear HIV/AIDS, Others Cancer

4. A global survey has found that Africans, West Asians and
Latin Americans believe that HIV/AIDS is the most important
disease confronting them -- while people elsewhere fear cancer.
The Gallup International/Markinor poll interviewed more than
50,000 people in over 60 countries between June and August for
their annual Voice of the People survey. They were asked for
their views of the most important disease in their country.
Overall, four out of every 10 (42 percent) citizens in the
countries polled around the world mentioned cancer as the most
threatening disease -- a concern shared in most countries, but
not unanimously. Twenty-seven percent rated HIV/AIDS as the
top disease and 15 percent heart attacks and strokes. Three
percent rated tuberculosis highest, two percent malaria and one
percent Severe Acute Respiratory Syndrome, while eight percent
rated other illnesses and four percent did not know or would
not answer. All five African countries included in the survey
are amongst the first 11 that regard HIV/AIDS as the most
important disease. In the five African countries polled, two
thirds of interviewees believed that HIV/AIDS was the most
important disease facing them. Malaria was the second most
frequently mentioned disease in Africa and was of particular
concern for Nigerians (35 percent) and the people of Cameroon
(31 percent). Source: SAPA, December 1.

Health Department Reports Increase in Number of Patients on ARV
--------------------------------------------- ------------------

5. The number of people receiving anti-retroviral therapy in
accredited government facilities increased from 11,250 at the
end of August to 19,500 in October, Health Minister Manto
Tshabalala-Msimang reported. Treatment is available in at

least one facility in 50 of the 53 districts in the country. A
total of 103 facilities have been accredited and are providing
care and treatment for people with HIV and AIDS. Three centers
have been established to detect, assess, and prevent adverse
reaction to anti-retroviral drugs. A center at the Medical
University of SA focuses on the use of anti-retroviral drugs
and traditional medicine between adolescent and adults with HIV
and AIDS. The second center at the Free State University deals
with the use of anti-retroviral drugs among pregnant women and
infants. The University of Cape Town also serves as a
reference center for adverse reaction to all types of medicines
registered in the country. At least 67 percent of all public
health clinics were providing voluntary counseling and testing
(VCT) services, which had increased the coverage rate. The
number of people using VCT services had increased from 412,696
in 2002/2003 to 690,537 in 2003/4. The Health Department
reported that there were now 10,000 counselors at service
points throughout the country at the end of March 2004. Rapid
HIV test kits were widely available at the service points to
ensure people received results immediately. In addition, more
than R9.4 million ($1.6 million, using 5.7 rands per dollar)
had been spent on communication, including newspaper, radio and
billboard advertising, and production of information and
educational material to support the implementation of the
comprehensive plan. Source: SAPA, Health Dept Health News
Release, November 25.

Economic Costs of AIDS May Worsen

6. Although data on the extent of HIV/AIDS and its impact on
the South African economy vary, analysts agree that government
and businesses need to take urgent action to combat the virus.
Already HIV/AIDS is estimated to be reducing South Africa's
growth rate by a minimum of 0.3 to 0.4 percent per year.
Forecasts of future growth show large discrepancies, however,
as financial experts have created different mathematic models
to calculate the consequences. Analysts at Apt Associates
estimated that the country's gross domestic product (GDP) will
be 17 percent lower by 2010 than it would have been without
AIDS, leading to a loss of $22 billion. Financial analysts at
ABSA bank, in contrast, estimate the shrinkage of GDP at 9.6
percent by 2015, while ING Barings put the figure at only 2.8
percent. One of the paradoxes of the HIV epidemic in sub-
Saharan Africa is that in the past 10 years it has not made a
huge dent on standard macroeconomic yardsticks, such as GDP.
This is due, in part, to the labor situation in South Africa.
The country's labor surplus means that workers removed by AIDS
can be replaced without much loss of productivity. The World
Bank analysis emphasizes the long-term impact of the disease on
human capital, arguing that the damage in terms of accumulated
loss of GDP per capita will be large, if left untreated. This
suggests that a country like South Africa could face
progressive economic decline over several generations, unless
it combats its AIDS epidemic more urgently. By mainly taking
the lives of young adults, AIDS seriously weakens a country's
tax base; as a result, national finances will come under
increasing pressure. Less income from taxes will reduce the
government's ability to finance public expenditures, including
those aimed at accumulating human capital, such as education
and public health services. It will also have to handle severe
financial strain in other social spending categories, such as
grants for AIDS orphans. To balance these, the government is
likely to raise taxes. AIDS will create significant costs to
business. At the company level, the pandemic poses a serious
threat to profitability as well as competitiveness. Firms will
have to face increasing absenteeism due to illness, funeral
attendances and care taking of family members. Businesses will
also see rising expenditure on medical and pension benefits,
loss of skilled manpower leading to disruption of production,
as well as increases in training, recruitment and personnel
turnover costs. Old Mutual Healthcare, for example, estimated
that additional healthcare costs as a result of HIV/AIDS could
reach $3.8-billion per year by 2009. By 2010 life expectancy
will be 43 years, 17 years less than it would have been without
AIDS. Analysts estimate the South African labor force will
decline by up to 23.5 percent by 2015. To what degree
enterprises are affected varies between business sectors. The
mining sector has been worst hit by the pandemic, with an AIDS
prevalence rate among its workforce of 25 percent, closely
followed by manufacturing with a prevalence rate of up to 19
percent. Construction, retail and wholesale count as medium- to
low-risk sectors. The effects of AIDS on businesses will also
depend on a company's location. In provinces with high
prevalence rates, such as KwaZulu-Natal and Gauteng, close to
40 percent of firms indicated that AIDS already had a negative
impact on their profits, according to Bureau for Economic
Research. In the Western Cape and Eastern Cape, the numbers
were 25 percent and 27 percent respectively. HIV/AIDS is a
risk of doing business in South Africa, right next to asset
security, crime and exchange rate volatility, besides political
and infrastructural risk. Only about a quarter of the
country's businesses -- mainly large corporations -- have
workplace policies in place. Small and medium-sized firms often
the lack human and financial resources to implement an AIDS
plan. Source: Mail and Guardian, November 26.

Telkom HIV/AIDS Prevalence Rate Expected to Peak at 11.4
--------------------------------------------- ------------

7. Telkom, the telecommunications parastatal, expects its
HIV/AIDS rate among employees to peak at 11.4 percent in 2006,
with the company's current HIV/AIDS prevalence rate at 9.6
percent. Telkom's introduction of antiretroviral treatment,
which started in October, is part of an integrated health
management strategy to manage health risks and invest in human
capital. Telkom had allocated R8 million ($1.4 million) in the
current financial year for the management of HIV/AIDS. The
company is offering a voluntary counseling, testing and
treatment (VCT) program, which offers employees around the
country access to a range of HIV/AIDS related services in
absolute privacy and confidentiality. Telkom does not have
access to details of an employee's HIV and AIDS status unless
he or she voluntarily discloses the information. The first
phase of Telkom's VCT program ended in October, during which
2,504 employees were tested. The second phase is currently
running until March next year with a target of 10,000. Source:
SAPA, December 1.

Correctional Services Conducts HIV Survey in Prisons
--------------------------------------------- -------

8. The Department of Correctional Services announced that a
national survey of prison inmates to determine HIV/AIDS
prevalence is now in the preparation phase, with a task team
and steering committee established. The prevalence of HIV/AIDS
will be ascertained by extrapolation from a sample. The 2003/04
annual report of the judicial inspectorate of prisons,
described HIV/AIDS in prisons as a "major problem". The report
noted that about 58 percent of prisoners were men below the age
of 30, who were more sexually active and prone to take risks
than older men. The report found that natural deaths were
rising and the increase could be "fairly attributed" to
HIV/AIDS and the opportunistic diseases that followed. Natural
deaths rose by 584 percent from 1995 to 2000, with 1087 deaths
in 2000 and 1683 in 2003. Seven months ago an AIDS directorate
was established focusing on care and support, prevention and
treatment. The Department of Correctional Services was
conducting a baseline study of the number of offenders
currently using ARVs in prisons, with preliminary results
expected in early December. Source: SAPA, December 1.

HIV/AIDS Budgets for National and Provincial Government
--------------------------------------------- ----------

9. Government commitment to HIV/AIDS funding only really
materialized in 2000 with the introduction of special
conditional grants, according to Alison Hickey, manager of
Idasa's AIDS Budget Unit. Before 2000, the AIDS budget was
minimal. The 2004/5 national budget shows a serious commitment
to making financial resources available for the new ARV
treatment programs. National Treasury has specifically
allocated R1.439 billion ($250 million) for HIV/AIDS programs
and services in this year. This is seven times what was set
aside to fight HIV/AIDS in 2000/1. However, HIV/AIDS funds
still constitute less than 1 percent of the total budget.
Money for ARV treatment is sent to provinces via conditional
grants. However, Hickey is concerned that provinces such as the
Eastern Cape and Mpumalanga may struggle to spend their grants.
"For those provinces with weaker financial and project
management skills, absorption capacity could well be the
primary obstacle to roll-out," she says. One of the weaknesses
in the national Department of Health identified by the Auditor
General is its inability to monitor conditional grants
properly. A new clause in the Division of Revenue Bill allows
unspent HIV/AIDS grants to be relocated to better-performing
provinces. Researcher Hein Marais found that the Western Cape,
Eastern Cape and Mpumalanga did not allocate any funds
specifically for HIV/AIDS in 1998. Gauteng was the only
province to allocate a substantial sum, with R49 million
allocated across all its departments and R4 million set aside
for NGOs. Source: Health E-News, November 28.

Provincial Progress on Implementing Government's HIV/AIDS
Treatment Plan
--------------------------------------------- -----------

10. North West Province
Provincial Health Department has allocated close to R50 million
for voluntary counseling and testing (VCT), prevention of
mother-to-child transmission (PMTCT) and sexually transmitted
infections. The high AIDS prevalence rate (29.9 percent) has
led to more rapid implementation of the treatment plan, with
more than 5,000 new patients coming to the 3 available service
points and more than 1,000 patients being treated. The
provincial health department was allocated R70 million for the
HIV/AIDS program, including R29 million for ARVs.
Nineteen hospitals in the province are now providing ARV drugs
and the province plans to expand the program to 80 facilities
by 2009. By November 5, 49,268 people have been assessed, of
whom 5,588 adult and 800 children received ARVs. 2002 records
indicate that 54 percent of people between 15 and 34 years of
age admitted to state hospitals were infected with HIV.
Limpopo has the third lowest (17.5 percent) HIV prevalence rate
in the country. Since October, more than 2,000 patients have
been assessed, with 300 adults and 40 children on ARV
treatment. The province has eight treatment sites and by April
2005, will introduce the ARV treatment program to 30 district
hospitals and 22 community health centers. The province has
R80 million for the AIDS program during the 2004 financial year
and R120 million for next year.
Northern Cape
The provincial treatment program started three months ago and
now has 1,200 patients qualified for ARV treatment with 250
patients registered for treatment. Approximately 500 patients
with more than a CD4-count of 200 have been assessed. R31.8
billion has been allocated for the AIDS program this year.
Eastern Cape
The province launched its treatment program in May and 2,000
patients, 135 of them children, are receiving treatment at 11
sites. R40 million has been allocated and about R22.6 million
has been spent on ARV treatment in the 2004 fiscal year. A
regional training center, funded by the Department of Health,
Columbia University and CDC, provides HIV/AIDS training to
health care professionals. So far, 1,000 have received
Western Cape
The province has 31 treatment sites, a total HIV/AIDS budget of
R119 million, of which R29 million is a grant from the Global
Fund. The province estimates that about 12,000 people need ARV
treatment and so far about 5,500, of which 1,000 are children,
are receiving ARVs. The Western Cape has the lowest HIV/AIDS
prevalence rate of 13.1 percent.
Free State
In October, the number of patients on treatment was 250, much
lower than the March 2005 target of 2,127; however its goals of
providing 5 treatment sites have been reached. A budget of R30
million has been allocated for 2004 and R50 million for next
year. For next year, an additional 16 sites providing ARV
treatment are planned.
The province currently has eight ARV treatment sites, though
the national Department of Health declared in October that the
province had 12. R 67 million was allocated to the AIDS
program this financial year and the province will likely not
reach its target of 1,934 patients on ARV treatment by March
2005. Currently Mpumalanga is treating 378 patients compared
to 130 patients in July.
KZN has the highest AIDS prevalence rate at 38 percent and will
likely not meet its March 2005 target of 20,000 patients on
treatment. The province is currently treating 3,247 adults and
167 children at 31 sites. A further 16 sites have been
recommended for accreditation by the national advisers. A
conditional grant of R64 million is available for the ARV
treatment program. Source: Mail&Guardian, November 26 to
December 2.

SA's Labor Force Declines with HIV/AIDS, Discouragement Impacts
--------------------------------------------- ------------------

10. South Africa's labor force has declined over the past few
years, probably because more people have given up looking for
work or are infected with HIV, says a new report in the South
African Reserve Bank's Labor Market Frontiers report. South
Africa's labor force participation rate, which counts the
number of people working and actively seeking work as a
proportion of the total population, has dropped to 54.1 percent
in September 2003, down from 58.9 percent in September 2000.
Official figures from Statistics SA show that unemployment
dropped to 4.6 million in September 2003 from 5.3 million in
March 2003, based on the narrow definition of unemployment,
where an individual had been actively seeking work prior to the
survey. The drop in unemployment was not matched by an
increase in total employment over that period, with more people
dropping out of the labor market. The number of discouraged
job seekers increased the unemployed figure to more than 8
million. The Bank's report stated that job seekers were
discouraged because of the slim chances of finding a job, or
because they lacked funds to search actively for work. Another
likely cause for a drop in labor market participation was the
effect of HIV/AIDS. The report points to research that shows a
drop in HIV/AIDS prevalence among younger people in their
twenties, and an increase in higher age groups, making up most
of the labor force. The report also assesses whether social
grants have a negative incentive on labor force participation,
but found mixed results. Some studies show that pension
payments cause an indirect effect of withdrawal from the labor
market. However, other studies show that a child support grant
could result in higher labor force participation. Source:
Business Day, December 3.


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