Cablegate: South Africa Public Health March 18 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: 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

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

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

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)


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