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

121357Z Aug 05

UNCLAS SECTION 01 OF 04 PRETORIA 003257 
 
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 DBIRX 
 
E.O.  12958: N/A 
TAGS: ECON KHIV SOCI TBIO EAID SF
SUBJECT:  SOUTH AFRICA PUBLIC HEALTH AUGUST 12 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:  Study shows later transmission of HIV to 
babies; increases in pregnant HIV-positive women; fewer people 
have medical insurance; men and HIV testing; Isoniazid may 
reduce risk of death for South Africans in first six months of 
ART; PEPFAR-funded NGOs present progress at 2nd South African 
AIDS Conference; Circumcision prevents three out of four female- 
to-male HIV infections.  End Summary. 
 
Study Shows Increased Later Transmission of HIV to Babies 
--------------------------------------------- ------------ 
 
¶2.  According to research presented at the South Africa 
National AIDS Conference, many of the babies given nevirapine 
at birth to prevent the transmission of HIV from their mothers 
are being infected with the virus later in communities where 
health systems are weak.  Research at three very different 
sites providing the prevention of mother to child HIV 
transmission (PMTCT) program showed that, after nine months, 
the site in the poorest area had almost double the transmission 
rate of the best resourced site.  Research on 665 mother-baby 
pairs in the PMTCT program found that, three weeks after birth, 
only 8.6 percent of babies born in Paarl in the Western Cape, 
11.9 percent in Umlazi in KwaZulu-Natal and 14.2 percent in 
Rietvlei in the Eastern Cape were HIV-positive.  But between 
three and 36 weeks of age, there was a jump in HIV transmission 
by almost 20 percent in Rietvlei, the site in the poorest area 
with the weakest health service.  This meant that almost 30 
percent of babies born to HIV-positive mothers in Rietvlei were 
HIV-positive by nine months.  This is almost the same 
proportion that would be infected without any drug treatment, 
meaning that at Rietvlei the benefits of the drug intervention 
were effectively cancelled out by the later HIV infections.  In 
comparison, the HIV transmission rate between three weeks and 
nine months in the relatively well-resourced Paarl was only 7.8 
percent, while 12.3 percent of babies in Umlazi had became HIV- 
positive in this time. 
 
¶3.  Most children infected after birth would have got HIV when 
their mothers mixed breastfeeding and formula feeding. 
Exclusive breastfeeding for six months or formula feeding are 
much safer options.  In Paarl, the health care system was able 
to offer a reliable supply of formula milk to those mothers who 
wanted it and more women chose this option than at the other 
sites.  It was also relatively easy for HIV-positive mothers to 
get child support grants and the environment seemed more 
accepting of HIV as 72 percent of the women had been able to 
disclose to family members that they had HIV.  Far fewer 
mothers in Rietvlei (39 percent) and Umlazi (53 percent) felt 
comfortable enough to disclose their HIV status.  To reduce the 
later HIV infection, the researchers proposed more effective 
counseling of mothers on safer feeding options for their 
babies, a consistent supply of formula milk and antiretroviral 
therapy for mothers with high viral loads.  An environment in 
which mothers felt able to disclose their HIV status is also 
very important.  Women who had disclosed to their families 
would be less likely to be pressured by their families to mix 
breast and formula feeding.  The Good Start research was 
produced by HST in collaboration with the University of the 
Western Cape, MRC, Cadre and the University of KwaZulu-Natal. 
Source:  hst.org.za, July 2005. 
 
Increases in Pregnant HIV-Positive Women 
---------------------------------------- 
 
¶4.  According to the 2004 National HIV and Syphilis Antenatal 
Sero-prevalence Survey, the percentage of pregnant women living 
with HIV in South Africa for the year 2004 is 29.5, about 1.5 
percent higher than in 2003.  HIV infection was higher among 
women in their late twenties and early thirties, and lower 
among teenagers.  The provinces of Free State, Mpumalanga and 
North West recorded slight decreases compared to 2003. 
Syphilis prevalence continues to decline in all age groups, 
suggesting prevention and treatment against the sexually 
transmitted infection are effective.  The report also estimated 
the total number of HIV positive people in the country at the 
end of 2004 to be between 6.29 million and 6.57 million.  The 
survey measures the HIV infection rate among 16,061 pregnant 
women seeking health care in the public sector. 
 
¶5.  When results of the 2004 antenatal survey were released, 
media coverage concentrated on trying to understand the 
discrepancy between the 4.5 million HIV-infected people 
provided by Stats SA and the more recent 6.3 to 6.6-million. 
AIDS experts seem to agree on about 5 million.  The 
discrepancies are due to different methodologies and data, and 
since there is no one methodology for HIV estimation, varying 
estimates will continue to be produced. 
 
¶6.  Contrary to earlier claims, HIV prevalence among young 
South African women has not fallen.  This survey shows that 
nearly 40 percent of young, pregnant women between 25 and 29 
years are infected, while women in their early twenties and 
early thirties show rates of around 30 percent.  Older women 
and importantly teenagers have prevalence rates of below 20 
percent.  More specifically the survey shows that over 16 
percent of teenage, expectant mothers were HIV positive.  Each 
age group from 15 to 24 shows a year-on-year increase.  One in 
10 15-year-olds were HIV positive, but by 24, over one in three 
women were HIV positive.  The increases are as follows: 10 
percent of 15 year-olds were HIV positive; 9.1 percent of 16 
year-olds; 12.3 percent of 17-year-olds; 19 percent of 18-year- 
olds; 19.9 percent of 19-year-olds; 25.1 percent of 20-year- 
olds; 28.5 percent of 21-year-olds; 31.1 percent of 22-year- 
olds; 34.7 percent of 23-year-olds; and 35.5 percent of 24-year- 
olds. 
¶7.  Some population-based surveys suggest that young women are 
delaying sexual debuts and using condoms more often when they 
have sex.  Analysts suggest that the pronounced rise in HIV 
prevalence among older women, all the way up to 40 years is 
unusual.  One possible explanation could be that women who 
forego protected sex (because they're in steady relations or 
marriages and trust their partners, or because they wish to 
become pregnant) are facing extremely high odds of being 
infected with HIV.  Another reason may be that women who have 
abstained from sex face very high odds of being infected once 
they do have sex because HIV infection is so prevalent. 
Similar trends in other southern African countries exist, where 
young women wait longer before having sex, but are then 
infected within a year or so of becoming sexually active. 
Source:  Health-e News Service and Sapa, July 2005. 
 
Fewer People Have Medical Insurance 
----------------------------------- 
 
¶8.  According to the 2004 General Household Survey released by 
Stats SA, only 15 percent of South Africans have any form of 
medical insurance, below the 18 percent level shown in 1995. 
Whites and those living in Gauteng and the Western Cape have 
the highest coverage.  Almost 70 percent of whites, 26.2 
percent of those in Gauteng and 25.9 percent of those in the 
Western Cape enrolled in medical insurance policies.  Limpopo 
residents had the lowest coverage (6.4 percent), followed by 
the Eastern Cape (9.6 percent).  Only 7.2 percent of black 
Africans are insured, totaling 2.7 million African people out 
of a total of 37 million.  Some 18.4 percent of coloureds and 
36 percent of Indians have medical insurance.  Over 39 million 
people out of the total population of almost 47 million have no 
medical insurance.  Source:  Health-e News, July 2005. 
 
Men and HIV Testing 
------------------- 
 
¶9.  A recent study by Andrew Levack, a consultant with Engender 
Health South Africa, of men's attitudes towards using voluntary 
HIV-tests highlights reasons why only one in five people tested 
for HIV are men.  The findings are grouped into three main 
themes - the personal, social and institutional.  Personal 
reasons include fear of the results.  The survey found that men 
tended to have their partners test for them, using negative 
results of their partners as reasons for not being tested. 
Social factors include issues of stigma and the fact that men 
are not socialized to test.  And finally, institutional factors 
include concerns about the kind of treatment and 
confidentiality offered to men.  The sample size of the study 
 
SIPDIS 
was small, with interviews and focus groups with just 69 
individuals, men and women from Soweto.  The individuals 
represented a range of communities in Soweto, which included 
Diepkloof, Meadowlands, Kliptown.  Source:  HST Newsletter, 
July 2005. 
 
Isoniazid May Reduce Risk of Death for South Africans in first 
six months of ART 
--------------------------------------------- ------------------ 
 
¶10.  According to research reported at the Third International 
AIDS Society Conference on HIV Treatment and Pathogenesis in 
Brazil, South African miners receiving antiretroviral therapy 
(ART) are just as likely to die during the first six months of 
treatment as their untreated counterparts.  The reduction in 
death and illness associated with ART only begins after six 
months of treatment.  Many African clinicians have reported a 
high rate of mortality in patients starting ART in their 
clinics.  The observation has led some to argue that less sick 
patients should be prioritized for ART, and so the London 
School of Hygiene group also set out to determine whether there 
are factors that place individuals starting ART at higher risk 
of death during the early months of treatment.  Several factors 
have been suggested as especially problematic:  (1) late 
treatment, often with a CD4 cell count below 50 cells/mm3, (2) 
active opportunistic infections, especially tuberculosis, and 
(3) presence of immune reconstitution syndrome, particularly 
due to prior or current infection with tuberculosis (TB).  The 
study analyzed all individuals who had received ART through a 
workplace health program in a gold mining company in Kwa-Zulu 
Natal, comparing the risk of death with historical data from 
the same workplace treatment program prior to the introduction 
of ART.  The size of the cohorts was similar, with 649 on 
treatment and 679 untreated.  The median age was around 40 in 
both groups, and the median baseline CD4 cell count was 140 
cells/mm3 in the treated group and 188 cells/mm3 in the 
untreated group.  Median follow-up was approximately one year 
in each group.  There was no significant difference in the 
relative hazard of death during the first six months of 
treatment compared to the historical control group after 
adjustment for baseline CD4 cell count, but the risk of death 
fell dramatically between months 6 and 12, and after month 12 
in the treated group.  The reduction in mortality rate per 100 
person years of follow up was 1.8 deaths.  Source:  AIDSMAP, 
August 4. 
 
PEPFAR-Funded NGOs Present Progress at 2nd South African AIDS 
Conference 
--------------------------------------------- ---------------- 
 
¶11.  A diverse group of non-governmental organizations (NGOs), 
funded by the United States President's Emergency Plan for AIDS 
Relief (PEPFAR), presented their first year's progress at a 
satellite conference of the 2nd South African AIDS Conference 
in Durban.  Funded projects focused on providing aid to orphans 
and vulnerable children, faith-based HIV prevention services, 
voluntary counseling and testing services, collaborations with 
traditional healers, operational research into the long-term 
success of PMTCT programs, nurse-driven antiretroviral therapy, 
and antiretroviral treatment delivery in an antenatal clinic. 
PEPFAR provides funding to 76 primary partners and 153 sub- 
partners throughout South Africa's nine provinces.  The 
partners include faith-based, community-based and non- 
governmental organizations, government, academic institutions, 
as well as public/private partnerships.  The satellite 
conference showcased partnerships with the South African 
Government, including the Department of Defense, Department of 
Social Development and Department of Correctional Services. 
Several organizations reporting annual progress in their 
programs include:  Nurturing Orphans and AIDS for Humanity 
(NOAH); Hope Worldwide; New Start VCT Services; Good Start 
Study; The Vulindlela CAT Project; and Starting ART in an 
antenatal clinic.  Source:  AIDSMAP, June 2005. 
 
Circumcision Prevents Three out of Four Female-to-male HIV 
Infections 
--------------------------------------------- ------------- 
 
¶12.  Researchers reported at the Third International Conference 
on HIV Pathogenesis and Treatment in Brazil strong evidence 
that male circumcision prevented female-to-male HIV 
transmission.  The first ever randomized controlled trial (RCT) 
of male circumcision as an HIV prevention measure has been 
halted early and all participants have been offered 
circumcision.  There were only 35 percent as many infections in 
the circumcision group as opposed to the control, implying that 
circumcision can prevent at least six out of ten female-to-male 
HIV transmissions.  However, when the results were analyzed 
according to true circumcision status rather than by 
intervention group, the protective effect went up to 75 percent 
since there were crossovers between the intervention and 
control groups in that some men randomized to be circumcised 
were not, and some in the control group were.  The trial, the 
first of four RCTs of circumcision being conducted in Africa, 
randomized 3,273 men aged 16 to 24 to be circumcised at the 
start of the trial or to be offered circumcision at the end of 
it, 21 months later.  The men lived in the Orange Farm township 
near Johannesburg, South Africa.  Circumcisions in the 
intervention arm were carried out by a surgeon under local 
anesthesia and with post-operative pain relief given.  HIV 
incidence was measured at three and twelve months into the 
trial and finally at 21 months though the average follow-up 
period was in fact 20 months due to the premature termination 
of the trial.  Although all participants received intensive 
safer sex counseling and condoms, there were 51 HIV 
seroconversions in the control group versus 18 in the 
circumcision group.  This translates as HIV incidences of 2.2% 
and 0.77% a year respectively.  Circumcision studies are 
currently underway in other sites in Africa.  Source:  AIDSMap, 
July 27, 2005. 
 
 
FRAZER