Cablegate: South Africa Public Health May 13 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: 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

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- 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.


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