Public Health in the News

 Some 61 percent of staff working in the health service have experienced physical or psychological violence over the past year, costing the government R40-billion. This is according to a study conducted by Dr Mireille Kingma of the International Council of Nurses in Geneva, Switzerland, who found that nurses and ambulance staff were at the highest risk of encountering violent situations. Kingma carried out her research in several countries, including Brazil, Australia and Thailand, and South Africa with the help of Dr Susan Steinman, founder of South Africa's Work Trauma Foundation. The foundation deals with violence in the workplace. The findings showed a marked increase in such violence. Staff in the health services are 16 times more likely to be victims of violence. According to the survey, psychological violence - considered as, if not more, destructive than physical violence - was more prevalent between staff. With physical violence, the patient and family members were usually the perpetrators. Large hospitals in densely populated areas experienced higher crime and more violence than private health sectors, said Kingma. Steinman, a trained country-facilitator for the International Labour Organisation, assisted in the development of Stress, Tobacco, Alcohol & Drugs, HIV/Aids and Violence, or Solve, which aims to deal with violence at the workplace. (Source: The Cape Argus, 19 November) 2003  Some 61 percent of staff working in the health service have experienced physical or psychological violence over the past year, costing the government R40-billion.  The shocking increase in attacks in the workplace has also led to a loss in productivity.  This is according to a study conducted by Dr Mireille Kingma of the International Council of Nurses in Geneva, Switzerland, who found that nurses and ambulance staff were at the highest risk of encountering violent situations.  Kingma carried out her research in several countries, including Brazil, Australia and Thailand, and South Africa with the help of Dr Susan Steinman, founder of South Africa's Work Trauma Foundation. The foundation deals with violence in the workplace.  The findings showed a marked increase in such violence. Staff in the health services are 16 times more likely to be victims of violence. In Sweden, 24% of reported cases were in the health sector. More than half of the health workers surveyed had experienced at least one incident of workplace violence, said Kingma.  Although this research focused on health sectors it is adaptable to other sectors. What is worrying is the noted increase in violence which is highly destructive.  According to the survey, psychological violence - considered as, if not more, destructive than physical violence - was more prevalent between staff. With physical violence, the patient and family members were usually the perpetrators.  Large hospitals in densely populated areas experienced higher crime and more violence than private health sectors, said Kingma.  She was speaking at the Gauteng international conference on the management of psycho-social problems in the workplace.  Steinman, a trained country-facilitator for the International Labour Organisation, assisted in the development of Stress, Tobacco, Alcohol & Drugs, HIV/Aids and Violence, or Solve, which aims to deal with violence at the workplace. (Source: The Cape Argus, 19 November) 2003

 Honourable Minister, Dr Manto Tshabalala Msimang, MECs present, Heads of Department, senior managers in the national and provincial departments of health, ladies and gentlemen, I wish to refer to one of the famous quotes by our Minister of Finance, Mr Trevor Manuel which says: If you cant measure it, you cant manage it! This quote, probably said in a financial and budgeting context, succinctly captures the purpose of both the South African Health Review and the National Primary Health Care Facilities Survey: To provide a data-driven body of information against which progress in providing quality health care can be measured, and most importantly, by using information to better plan and manage our health services.  Todays launch coincides with the commemoration of South Africas 10 years of freedom. It is therefore not surprising that unlike previous editions, this edition provides a critical reflection on the performance of our health system over the past 10 years. The Reviews findings and conclusions are based on objective and rigorous analysis provided by independent researchers and reviewers. Its recommendations are however realistic to the practical challenges that face health services managers and their personnel. To that end, health personnel provided valuable data for which we are grateful and also co-authored the various chapters.  The funding provided by the Atlantic Philanthropies, a private Foundation, for the production and printing of the Review also helps ensure the publications financial sustainability and independence.  In keeping with the data-anchored focus of the Review, the fourth Facilities Survey gives a status report on our countrys PHC services points. By comparing this years findings with those of previous years, we have been able to generate long-term trends in improvements (or the lack thereof) in health care delivery in an informative manner than the usual snapshot-type surveys produced in other situations.  As usual, the publications show a mixed bag of successes and failures. There is danger that readers may choose to focus on either of the 2 extremes. We caution against this, and suggestthat all users of the publications, including policy makers, health services managers, front-line health workers, students, the media and international role players with an interest in South Africa should use the information provided in its totality, and not selectively.  We however wish to indicate that, notwithstanding the challenges that continue to face us as a nation, it will be disingenuous not to recognize that South Africa is better off from 10 years ago, and the information provided today attest to this. We can only grow stronger if we fully utilize the resources and tools at our disposal. To this end, we in the HST provide as our contribution to these efforts, the South African Health and the PHC Health Facilities Survey.(Orginal speech : 28 July 2004)  The SAHR and the Facilities Survey can be found on the HST web site. Press release  South African Health Review   Excecutive Summary SAHR  National Primary Health Care Facilities Survey  For more information contact: Ashnie Padarath: +27 31 3072954 or 083 314 5191. To order SAHR copies: contact Khululiwe Mfayela at the resource centre at +27 31 3072954 or e-mail: cynthia@hst.org.za or fill in the online order form.

 More than half of all nurses polled report suffering at least one incident of physical or psychological violence in a single year, according to research by a health union grouping.And 80 percent of nurses questioned blamed abuse - largely by male doctors - in the private sector for nurses leaving the profession.  Almost half the respondents - 48 percent - of respondents cited abuse by patients as a reason for nurses leaving the profession.  The study was conducted by Christine Zondagh, of the Health and Other Service Personnel Trade Unions of South Africa (Hospersa), and published in the newly released Health Annals 2005 of the Hospital Association of South Africa.   In an article, Sharon Slabbert, the Hospital Association's client liaison executive officer, said that while nurses working in accident and emergency units were commonly exposed to a disturbing number of assault victims, violence against the nurses themselves was neither widely discussed nor acknowledged.  Employers, Slabbert wrote, usually stated that incidents of violence against nurses were rare, but the opposite was true.  The violence ranged from harassment and bullying to aggression and assault, both physical and psychological.  The perpetrators were patients, patients' families and visitors, other nurses and other healthcare professionals, such as doctors.  Racial and sexual harassment were also reported.    The Hospersa research was conducted in conjunction with Dr Susan Steinman, founder of the Work Trauma Foundation.  Slabbert wrote that it had shown that staff in health services were 16 times more likely to be the victims of violence than the average.  Psychological violence was the more likely kind, involving healthcare workers, and physical violence was usually perpetrated by patients and their relatives.  Quoting Zondagh's study of why professional nurses leave the profession, Slabbert said 80 percent of those surveyed suggested that abuse, largely by male doctors towards female nurses in the private sector specially, could be the reason.  Slabbert pointed out that the increase in violence against nurses in the British National Health Service was also well documented.  In six months of 2003, more than 400 cases of violence and aggression against healthcare workers at the Bradford Royal Infirmary were reported, and nearly 140 incidents by Airedale General Hospital staff.  The Massachusetts Nurses' Association in the United States reported that in 2002 more than 4 000 hospital employees were assaulted while working in accident and emergency units.  Slabbert quoted the US Department of Justice as saying nurses experienced violence and victimisation rates 72 percent higher than medical technicians, and twice that suffered by other health workers.  Nurses who were regularly subjected to verbal abuse, she said, experienced more stress, felt less job satisfaction and could take more days off work, so providing substandard care.  The areas she pinpointed in which abuse occurred most often included general wards, intensive care units and emergency departments - with emergency staff, unsurprisingly, taking the brunt of it.  Although nurses are committed to caring for their patients and their families, this does not include accepting abusive or violent behaviour, Slabbert said.  In addition, unless an actual assault occurred, the violence was often ignored, in spite of research having shown that a tolerance of less aggressive violence often resulted in worse acts of violence.  The only way to eradicate this problem is through a policy of zero tolerance, she said.

 Great strides have been made in improving maternal care in South Africa over the last decade. A record high of ninety percent of pregnant women attend antenatal care and 92% of deliveries of babies are conducted by skilled health workers. Despite such achievements in access to care, maternal deaths are on the increase, mostly fuelled the HIV and TB epidemics.  Many gains have been made in improving access to and quality of health care for children. However, gaps remain in delivery of key health promotion and disease prevention for children, and many children still fall ill and die from preventable and treatable conditions. Child mortality has also increased, fuelled largely by HIV, which is reversing gains made in child survival over the last decade. While the number of children receiving antiretroviral therapy is relatively low, this is gradually increasing.  Postnatal transmission of HIV from mother-to-child through breast milk remains a key challenge despite the availability of replacement feeds as part of the national PMTCT programme.  The co-existence of both under and over nutrition among South African children under nutrition combined with the effects of HIV is leading to a triple burden of disease requires innovative and sustainable responses.   These are some of the findings of the 11th edition of the widely acclaimed South African Health Review (SAHR) which was launched in Midrand today. This edition of the SAHR Review focuses on maternal, women's and child health and seeks to reflect on achievements made, challenges and gaps that impact on transformation and strengthening of the South African health system. Published annually since 1995, an important purpose of the South African Health Review (SAHR) is to serve as a knowledge resource on the development of the national health system, and to contribute to the assessment of the implementation of health policies. said CEO of the HST Dr Lilian Dudley.  This years SAHR confirms the indivisibility of maternal, womens and child health and reinforces the need for multi-sectoral, collaborative initiatives which take a more broader view of the determinants of health outcomes such as water, nutrition and education, all of which need to work together if the health of vulnerable populations is to improve remarked Dudley.  Dudley added that the release of the findings of the SAHR was timed to co-incide with the 16 days of activism against women and children and World Aids Day. HIV has been implicated in the causation and aggravation of many existing illnesses and has extracted a considerable toll on the human and financial resources of the health system she said. Women's social status and the effects of violence against women and children results in a variety of disabling mental conditions which have implications for the health system and society as a whole.  The Review which consists of 22 chapters also includes chapters on health care financing, health policy and legislation, the impact of international trade treaties on South Africas National Health Act and Health Management Information Systems. This years Review suggests that SA has made considerable progress in strengthening its health management information system which is a touchstone of an efficient health system she concluded. Ends  For more information contact: Ashnie Padarath, ashnie@hst.org.za, 031- 307 2954, 083 299 7129 or Petrida Ijumba, petrida@hst.org.za, 031-307 2954, 082 505 8598  Download the SAHR 2006 here

 The South African Health Review (SAHR) is an annual publication of the Health Systems Trust (HST), which has been published since 1995. The SAHR seeks to provide a South African perspective on prevailing international public health issues, to stimulate debate and critical dialogue and to provide a platform for assessing progress in the health sector.  Download the South African Health Review 2007 If you would like to order a copy of the SAHR 2007, please click here.   Statement by the Minister of Health: The Hon. Dr. Manto Shabalala-Msimang  Presentation: Highlights of the SAHR 2007 by Stephen Harrison, Guest Editor  Join the discussion forum on the SAHR 2007  Media Coverage of the SAHR 2007      The broad aims of the SAHR are to:    provide a comprehensive and independent review of developments in health sector  monitor trends and progress in the move towards transformation and equity within health care  report on key health status indicators coupled with in-depth analysis of policies and practices impacting on the provision of health services  identify and highlight gaps in policy implementation and  highlight policy implications and recommendations of research findings.   Of late, the SAHR has been produced on a thematic basis and the theme of the 2007 SAHR is The Role of the Private Sector within the South African Health System.  This edition will focus on broad areas with respect to the role of the private health sector i.e. oversight, pooling of resources and purchasing of health care, delivery of health care services and health and related indicators. Critical issues covered in the 2007 Review include:   Assessment of the stewardship role of the government in the overall transformation process of the health sector.  Policy and legislative review on the provision and funding of private health care.  Review of key elements around the ongoing debate of introducing some form of mandatory health insurance in South Africa.  Overview of the medical schemes industry including key debates and proposals on the Risk Equalisation Fund and Low Income Medical Schemes.  Review and analysis of health care financing and expenditure as well as recent trends in spending in the public and private health sectors.  Overview of health information systems and the role played by intermediaries in facilitating the flow of patient information.  Analysis of the health status of the South African workforce and health care provision in the workplace.  Analysis and developments in the market and regulatory environment impacting on medicine pricing and access to medicines.  Review of the impact of public-private partnerships on access to health care and health outcomes (a provincial case study is presented).  Analysis of the private hospital industry with specific focus on structure, ownership and market share per geographical region. The nature of relationships between private hospitals and providers is also reviewed.  Research and analysis on cost benefit analyses of traditional and complementary interventions relative to allopathic interventions.  Analysis of the private sectors response to HIV and AIDS, sexually transmitted infections and tuberculosis.   The 2007 SAHR was launched on 5 December 2007 in Cape Town.

 Health Systems Trust publishes its 13th edition of the South African Health Review PRIMARY HEALTH CARE IN SOUTH AFRICA: A REVIEW OF 30 YEARS SINCE ALMA ATA  Download the SAHR 2008 here Order your copy of the SAHR 2008  Press Release  Since Alma Ata, with its call for Health for All by the year 2000, governments of the world, including South Africa, have signed up to the Millennium Development Goals (MDGs). These ambitious MDGs include a number of key health related targets, which are dependent on Primary Health Care (PHC) for their achievement. It has become increasingly clear that South Africa will not achieve the goals in relation to child and maternal mortality, nor in relation to goals set in relation to HIV and TB.  Some of the key factors, which impact on PHC and the achievement of the MDGs are outside the scope of the health sector and are collectively known as the social determinants of health. There has been a significant improvement in access to water from 59% in 1994 to 94% in 2007. Improvements in the delivery of sanitation have been slower. Despite these improvements, isolated outbreaks of cholera, typhoid and diarrhea in many provinces serve as a reminder that more needs to be done. Additionally, there are inter-provincial inequities with KwaZulu-Natal, Limpopo and the Eastern Cape having the lowest levels of access to water and sanitation.  There has been increased provision of social grants especially in the area of child grants. Despite this, there are still extreme wealth inequalities and high levels of unemployment, which play an important role in poor health outcomes. The nutritional status of most South Africans has not improved in the last 14 years and malnutrition continues to affect the lives of millions of children in South Africa. Nationally, the percentage of children who are underweight has remained relatively static at 9% since 1994.  There has been an unprecedented threat to the health sector brought about by the twin diseases of HIV and TB. Over the past 20 years there has been a massive rise in these diseases, which have directly impacted on the MDGs. They are currently compartmentalised into separate boxes, but need to be seen as two sides of the same coin with interventions against them needing to be holistic and integrated.  Within the formal health sector there have been a number of factors which impact on PHC. Substantial resources have been moved into PHC and spending on public sector PHC services amounted to R297 per capita uninsured in 2006/07 and Treasury budgets indicate an increase to R395 per capita by 2010/11. The health workforce is now substantially weaker in some areas than it was in the mid 1990s, despite a range of excellent health policies. In 1994, there were approximately 2.5 nurses for every 1000 persons, while in 2007 there were only 1.1 nurses available for every 1000 persons. In addition, the nursing profession faces a serious shortage as the professional nursing population ages, because production to keep pace with attrition and retirement has lagged behind.  Outside the public sector there has been increased activity within both the private for-profit and not-for-profit sectors in PHC. However, there is a need for a greater co-ordination of resources and activities within this growing sector, particularly with regard to the geographical spread of activities.  These are some of the findings of the 2008 South African Health Review (SAHR).  The 13th edition of the widely acclaimed SAHR was launched in Pretoria today (10 December 2008). This edition of the SAHR focuses on PHC in South Africa, 30 years after the historic Alma Ata Declaration, which famously linked health and health status to broader social determinants of health. At Alma Ata delegates affirmed that health is a fundamental human right and that the attainment of the highest possible levels of health requires action from social and economic sectors in addition to the health sector.  The 2008 SAHR focuses on critical issues in PHC. The Review includes a national and international perspective of PHC and focuses on areas such as policy and legislation, determinants of health, lifestyle, infectious diseases, mental health, maternal and child health, nutrition and environmental health. The SAHR also reviews issues around human resources, finance, and information and concludes with the Indicators chapter which presents a selection of the best available data on the functioning and performance of the South African health system.  This years Review reflects on the policies of the past and some of the major components of PHC and attempts to learn from the lessons and mistakes of the past so that there is improved implementation in the future, said the CEO of the Health Systems Trust, Dr Thobile Mbengashe.  Dr Mbengashe added that, the release of the findings of the SAHR was timed to co-incide with the 40th anniversary of the Universal Declaration of Human Rights. This years SAHR confirms the indivisibility of health as a human right and reinforces the need for multi-sectoral, collaborative initiatives which take a more broader view of the determinants of health outcomes such as water, nutrition and education, all of which need to work together if the health of vulnerable populations is to improve remarked Dr Mbengashe.  We commit ourselves to assisting the Department of Health to strengthen and support the health system in South Africa so that the goal of Health for All is not merely a hollow battle cry concluded Dr Mbengashe.  Ends  For more information please contact: Fiorenza Monticelli (083 299 3899) Ashnie Padarath (031 307 2954 or 083 299 7129)

 Theme: REFLECTIONS ON THE MDGs AND PERSPECTIVES ON A NATIONAL HEALTH INSURANCE  In only five more years we will reach the target date for achieving the United Nations Millennium Development Goals (MDGs). In the year 2000 a total of 189 countries agreed on targets to reduce poverty and improve health by 2015. How is South Africa faring in this ambitious challenge?  Download the SAHR 2010 from here  Health Systems Trusts (HST) much-acclaimed publication, the South African Health Review (SAHR), presents the opinions of experts in their respective fields as they assess the countrys progress towards the MDGs. The 2010 Health Review, the 14th since 1995, was launched in Pretoria on 8 December.  This years SAHR also explores the currently topical issue of Universal Health Coverage. A National Health Insurance scheme is envisaged as the mechanism to achieve this similarly ambitious, but necessary, goal. In the absence of an official policy document the authors use available information to debate the plans and illustrate various options. The Review contributes much to ensuring that the NHI debate does improve the countrys health system for all South Africans.  HSTs Chief Executive Officer, Jeanette Hunter said, The release of this years Review is timely in that it corresponds with the release of the World Health Report 2010, which deals with universal health coverage. The Director-General of the World Health Organization explains that, this is an argument for solidarity. In solidarity with the countrys health needs, we in HST are committed to improving the health system for all South Africans and have thus sought to provide a wide range of perspectives on universal coverage and on NHI so that we can develop a common understanding of where we need to go as a country and how we are going to get there.  The South African Health Review has rapidly become a flagship product that is widely read and quoted as an authoritative reference source. It provides a South African perspective on prevailing local and international public health issues. This edition again promises to be a useful resource for public health practitioners both nationally and locally as they grapple with the issues of the day.  With over 40 authors and 21 chapters, some of the highlights of this years Review relating to the achievement of the MDGs are as follows:   In MDG 5 (maternal health) it appears that South Africa is not on track to meet the goal, namely to decrease the maternal mortality ratio by 75%. A particular feature of maternal mortality in South Africa is that non-pregnancy-related infections, mainly HIV-related, are a significant cause of maternal deaths in South Africa.  MDG 4 deals with child mortality and the authors have found that after five successive years of increasing childhood mortality, the under-5 mortality rate (using 2007 data) appears to have levelling off at an estimated 62.1 deaths per 1000 live births. They caution, however, that poor data quality could be influencing the picture.  The Review has found that South Africans face challenges and obstacles in accessing comprehensive treatment, prevention and care for sexually transmitted infections, including HIV, and in sexual and reproductive health, family planning, pregnancy and delivery.  The intertwining of HIV and TB has seriously affected the countrys ability to make progress towards achieving the MDGs. The Review locates health and health outcomes within a broader socio-economic context and depicts the social gradient upon which health and illness are located. The average TB cure rate, for example, is 55% in the most deprived districts while it is 71% in the least deprived districts.     The latest World Health Report highlights the need to move towards universal coverage. In exploring options for introducing National Health Insurance, South Africa is in keeping with international trends.  The envisaged reform of the health system towards universal coverage of health services is necessary, albeit ambitious. The reform must be accompanied by improvements in the general management of the public health system. Changes could include increasing staffing at primary health care clinics, introducing task-shifting and improving the capacity of hospital managers.  The Review shows that there is neither doubt nor dispute that the South African health system is in need of significant reform. Private sector perspectives on national health insurance reflect the sectors willingness to engage in developing a NHI for the country. The theme is reiterated in a civil society contribution suggesting that a NHI policy that increases access to quality health care will be welcomed and supported. An issue in recent media debates, albeit in the absence of an official policy document, was the affordability of a universal system to the country. One commentator in the Review points out, however, that it is not the universality of a health system that makes it unaffordable but rather inappropriate design and inefficiencies. Another chapter considers the financial feasibility of implementing NHI in South Africa.  The Review has endeavoured to put together a compendium of arguments and counter-arguments on the NHI. As HSTs Chairman correctly reflects in the Foreword, for to listen only to the voices that affirm one viewpoint, is to deny the fundamental contradictions that exist in our society and, indeed, in our health system. Improved health care for all South Africans remains both a prerogative and a responsibility of every citizen of the country.  Ends For more information contact: Ashnie Padarath 031 266 9090 or 083 299 7129 Ashnie@hst.org.za

 Combining reflections on South Africas progress towards achieving the Millennium Development Goals and perspectives on a National Health Insurance for South Africa, the 14th edition of the SAHR promises to provide a useful resource for public health practitioners in both nationally and locally.     Produced since 1995, the SAHR an annual publication of Health Systems Trust and provides a South African perspective on prevailing local and international public health issues. It has rapidly become a flagship product that is widely read, used and quoted as an authoritative reference source.  Delivering the keynote address at the launch, Deputy Minister of Health, Dr Gwen Ramokgopa commented as follows:  This launch of the SAHR is a great achievement not only for the HST, but for all of us who appreciate excellence. On behalf of our people and those who benefit from our services, the Ministry of Health of the Republic of South Africa and the Department of Health, we note with appreciation the launch of this report.  The South African Health Review (SAHR) is a very valuable resource, especially for academics, students, researchers, scientists, policy makers, health activists and leaders in South Africa and abroad. Since 1995 when the first SAHR was published, it has developed into a user-friendly and authoritative reference manual for those who need well researched information about the South African National Health System. The Board and staff of the Health Systems Trust (HST) is highly commended for the consistency that it has displayed in compiling these reports and also the high quality of work that year-after-year is dedicated to the production of this publication.  This publication of the HST has gained a reputation of being an independent assessment of the performance of the South African national health system. Every year the SA Health Review provides its compilers an opportunity to analyze new and existing data, make informed conclusions about the pace of progress made and recommend to decision makers and implementers what needs to be done in order to reach the targets. The SAHR also provides invaluable yearly statistical updates on a compendium of health and development indicators.   Your decision to sharply focus in the 2010 SA Health Review the MDGs and the National Health Insurance (NHI) indicates the value that you put on health outcomes and ongoing health policy reform. This edition therefore provides the reader with an in-depth analysis of health MDGs and their linkages to other development goals and health interventions being implemented in our country.   The launch was attended by a variety of stakeholders in the health field and included Department of Health staff, academics, parliamentarians, donors and the media.  Download the SAHR 2010 from here Order your copy of the SAHR 2010 from here

 By Kamini Padayachee  The KwaZulu-Natal Health Department is not liable for damages claimed by a Gauteng woman, who alleged that she contracted HIV/Aids because of the negligence of paramedics, the Supreme Court of Appeal has ruled.  The woman, who cannot be identified according to law, said she contracted the virus after she was treated by paramedics at an accident scene on the N3 highway near Mooi River in August, 2000.  The woman was a passenger in a vehicle which knocked down a pedestrian. The pedestrian, Mandla Mthalane, died at the scene.  She claimed that paramedics attended to HIV-positive Mthalane and then assisted her with her wounds.  She sued the KZN health MEC for more than R2 million in damages.  In January last year, Judge Chiman Patel ruled that the MEC, as head of the department, was liable for the paramedics, from the provincial ambulance services, having transmitted HIV/Aids to the woman.  Judge Patel did not rule on the amount of money to be awarded to the woman as that was to be dealt with on another date.  However, on Friday, the Supreme Court of Appeal ruled there was no evidence to prove that the virus had been transmitted to the woman at the crash scene or that Mthalane had been HIV-positive.  During the trial, the woman’s counsel did not have proof of Mthalane’s HIV status, but admitted into evidence his diary and notes in which he had written the telephone number for an Aids helpline.  Judge Patel found that there was prima facie evidence to draw the inference that Mthalane was HIV-positive because the Aids helpline number was in his diary, there was no other explanation to explain why he had recorded the telephone number and there was a high incidence of the virus in the province.  He rejected the paramedics’ testimonies that they had treated the woman first before attending to Mthalane.  But he accepted the evidence of another passenger in the vehicle who said the paramedics worked on Mthalane before assisting the woman and found that the paramedics had transferred Mthalane’s blood to the woman.  However, appeal court Judge Suretta Snyders, with Judges Leona Theron, Visvanathan Ponnan, Mohamed Navsa, and Shenaaz Meer (acting appeal judge) found that the conclusion that Mthalane was HIV-positive was pure speculation and that other inferences could have been drawn from his possession of the Aids helpline telephone number.  They also found there was no evidence to support the finding that the woman was infected with the virus by the paramedics.  The judges said the paramedics had corroborated each other’s version of events but found that the passenger’s evidence had been fraught with inconsistencies.  The case was dismissed with costs. – The Mercury

  By David Brown, Published: May 30  The AIDS epidemic turns 30 next month. What began as a fatal new plague has become a treatable, if still incurable, chronic illness. That change counts as a triumph by any measure, but it also poses an unusually difficult question for the next 30 years:  How many people do we want to save from a death by AIDS — and who’s going to pay for it?  The global AIDS community now has tools that prolong the lives of people infected with the virus and prevent others from acquiring it. They range from antiretroviral therapy (ART), to circumcision and campaigns to reduce promiscuity. On the horizon are gels and pills that protect against infection during intercourse. Even the outlook for an AIDS vaccine is no longer as bleak as it used to be.  At least 6 million people in the developing world are now receiving life-extending ART. While that is less than half the 14.6 million HIV-infected people who should be getting treatment under the World Health Organization’s latest guidelines, it nevertheless represents an accomplishment that was inconceivable when the epidemic turned 20 in 2001. That number is likely to grow in the wake of a recent study showing that ART dramatically cuts a person’s infectiousness, and thus is itself a tool for prevention.  Bringing those tools to the people needing them — 90 percent of whom are in developing countries — requires lots of money. Last year, the world spent $16 billion on the task, half of which was donated by rich countries and charities.  A recent projection estimated that, by 2031, global AIDS costs could reach the equivalent of $35 billion a year. A recent United Nations report declared frankly: “The trajectory of costs is wholly unsustainable.”  Peaked but far from over  The disease eventually named AIDS first came to public attention on June 5, 1981 in a report on a rare type of pneumonia in five gay men, but scientists now believe the virus entered human beings early in the 20th century. In Africa, where the epidemic began and has had the most devastating effect, the rate of new infections — incidence — peaked in the late 1990s.  Today, the epidemic is an astonishing mixture of good news and hard-to-excuse failure. About 33.3 million people around the world are infected with HIV, the virus that causes AIDS. In 2009, the last year for which there are complete statistics, 2.6 million people became infected and 1.8 million people died. Those numbers are down from previous peaks.  The decline reflects great progress in the hardest-hit regions, especially in Africa. During the last decade, the HIV incidence declined in 33 countries, and HIV prevalence among young people fell in 15 countries — in both cases, by an astonishing 25 percent — largely due to safer sexual practices.  Nevertheless, the number of people living with HIV is still on the increase. Part of the reason is that AIDS patients are surviving longer, thanks to the expansion of antiretroviral therapy in the developing world, where 200 times as many people are getting it now than were just eight years ago. But for every person who starts treatment, two others become infected.  Without more progress in preventing new infections, HIV incidence will eventually start rising again. By 2031 when the epidemic turns 50, about 3.2 million adults will become infected each year, according to a recent projection. By the middle of the century, there could be 70 million people living with HIV in Africa alone.  Without question, a big reason for the progress made in the last decade is the sums of money brought to bear by the President’s Emergency Plan for AIDS Relief (PEPFAR), created by George W. Bush in 2003 and expanded by President Obama, and by the Global Fund to Fight AIDS, Tuberculosis and Malaria, a free-standing institution in Geneva that gets money from rich countries (including the United States) to fund grants to needy countries. PEPFAR spent $6.7 billion last year on AIDS treatment and prevention, the Global Fund $1.6 billion. Together, the two provide antiretroviral therapy to about 85 percent of the people receiving it in the developing world — about 4.7 million people in all.  Faced with budgetary concerns, both are now seeing the amount of money they have to spend on the problem level off. Everyone agrees that, from now on, low-income countries will have to devote more of their budgets to AIDS. But some fear they will be asked to shoulder too much too soon.  “It defies imagination to think that it’s time for donors to pass the hot potato to the government of one of the poorest countries on Earth,” said Asia Russell, who works in Uganda with the activist group Health Global Access Project.  Sharing the bill  Nearly everyone agrees the first thing that needs to be done is to get more bang for the billions of bucks now being spent.  “Money is important, but money alone will not make it,” said Michel Sidibe, director of UNAIDS, the United Nations AIDS program. “We need to have a solidarity around issues which are going beyond money. The solution will be found through a genuinely shared responsibility.”  The most important step in bringing AIDS treatment to people in the developing world has been the huge decline in the cost of antiretroviral drugs over the last 15 years. Three-drug ART combinations cost $10,000 to $12,000 a year in 1996 when they became standard AIDS therapy in the United States. The Clinton Health Access Initiative, one of former president Bill Clinton’s charities, recently announced a new schedule of brokered prices in which a three-drug combination, which includes the highly favored drug tenofovir, runs $159 a year. The price of an older, less desirable triple combination is $79 a year — less than 1 percent of what it used to be.  The initiative has helped create a more sustainable market by bringing drug buyers (often national governments) and drugmakers (usually generics companies) together to encourage more rational, long-term planning. Recently, it has also begun helping manufacturers find cheaper sources of the chemical raw materials they need to make their products.  The result has been a proliferation of firms making AIDS drugs for poor countries (although not for rich countries, where patent restrictions forbid the sales). In 2003, four companies in India made generic AIDS drugs. Today 10 do, and Indian companies supply more than 80 percent of AIDS drugs used in developing countries.  “Prices are rock-bottom now for a lot of the older drugs. We can’t keep squeezing, because it will become an unattractive market,” said Brenda Waning, a health economist at the World Health Organization, in Geneva. For newer drugs, she said, “there is still a lot of room for price reductions.”  Lowering drug prices is just one of several strategies to make money go further. A researcher from Boston University working in PEPFAR-funded programs in Africa reported recently that when hospital clinics staffed mostly by doctors handed stable patients over to community clinics run mostly by nurses, the cost of care fell 9 percent in South Africa and 21 percent in Zambia. A physician from Columbia recounted that when Rwanda merged its HIV and tuberculosis programs, the number of TB patients being tested for HIV went way up, and the time it took to get someone on TB treatment went way down.  “We’re still mining for those efficiencies,” Eric Goosby, the physician who runs PEPFAR at the State Department, said recently. But he added, “My guess is that in the next 18 months to two years we will have found them all.”  What happens then is a big question.  Recently, a group of economists and epidemiologists convened a project called aids2031 that examined four scenarios for what might happen between now and the epidemic’s 50th anniversary.  The most expensive one, costing $722 billion over that period, would ramp up to provide treatment and prevention services for 80 percent of people by 2015. It would prevent 33 million new infections, although 1.3 million a year would still be occurring in 2031, according to modeling done by the Washington-based Results for Development Institute. The cheapest scenario would put almost the same number of people on AIDS drugs but would target prevention services only at high-risk groups, such as uncircumcised African men, infected pregnant women and drug users. It would cost much less — $397 billion — but 1.7 million people would still be getting infected each year 20 years from now.  All of the scenarios make clear that, without much better success at preventing infections, the problem of not enough money will go on for decades.  “Prevention is the sine qua non for turning off the tap and reducing the need for treatment,” said Robert Hecht, head of the institute.  ‘Innovative financing’  Is there a way to get lots of money for AIDS painlessly? Some people think so.  Since 2006, a charity based in Geneva, UNITAID, has collected $1.5 billion and used it for AIDS, malaria and tuberculosis projects. About two-thirds of the money comes from a small fee that is added to the price of airline tickets in eight countries.  A campaign called (RED) has raised $170 million since 2006 by partnering with companies that give the Global Fund a share of profits from the sale of computers, mobile phones, baby strollers and other products.  That’s all small change in the face of what’s needed.  However, there is one “innovative financing” scheme that could raise as much as $50 billion a year.  It’s called a “financial transaction tax.” It would collect a fixed amount — perhaps .05 or .005 percent — on stock purchases, currency trades or other specified activities. A group of 1,001 economists this spring signed a letter to the finance ministers of the G20 countries saying the tax “is an idea that has come of age . . . [and] is morally right.”  At least 23 countries have transaction taxes. In the United States such a tax supports the budget of the Securities and Exchange Commission.  But in recent decades there’s been a trend away from transaction taxes, experts say, because trading tends to move to places where a tax doesn’t exist, and because the cost of the tax is easily passed on to consumers.  “I have never seen a proposal that I think would generate significant revenues that is politically viable internationally and wouldn’t generate substantial distortions in the market,” said Adam LaVier, an official in the domestic finance office of the Treasury Department.  The global AIDS epidemic is out of its youth. It seems unlikely that there will be easy ways to avoid hard decisions as it heads toward middle age.          © The Washington Post Company

 Crucial time to turn commitments into action  NEW YORK, 3 June 2011 - Global efforts to improve the lives of children affected by HIV and AIDS are increasing but still fall short of the growing needs of millions. At the end of 2010, an estimated 16.6 million children lost one or both parents to AIDS – 14.9 million of these in sub-Saharan Africa.  This year’s Global Partners Forum on children affected by AIDS, under the heading of ‘Taking Evidence to Impact’, jointly hosted by UNICEF, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and UNAIDS, has brought together 100 high level representatives from governments, civil society, donors, international organisations and academic institutions in an effort to promote evidence based approaches to improve the lives of children affected by AIDS. The two-day Forum which starts today will review:   Lessons learned at country level to support HIV affected children and their families;  Mechanisms that protect children affected by AIDS from marginalization and discrimination, and increase their access to key social services;  How to overcome barriers and increase access to HIV prevention, treatment and care services;  How to increase the impact of our investments and achieve greater results for those in greatest need.   Many HIV-affected children continue to face enormous challenges, including the burden of care for sick relatives, trauma from the loss of parents, economic distress due to declining household incomes and high health costs, and the risk of early sexual debut and abuse, which in turn can make children – particularly girls – more susceptible to HIV infection.  “These children have already experienced the tragedy of losing a parent or a loved one to AIDS – only to be subjected to stigma, discrimination and exclusion from school and social services,” said UNICEF Director Anthony Lake. “To help these children reach their full potential, we urgently need to invest in national social protection programmes that fight poverty and stigma, and which address the special needs of HIV-affected families."  Equity analysis also shows that the poorest households are often least resilient to the impacts of HIV, and that HIV is in itself impoverishing.  In settings where epidemics are still relatively concentrated, HIV-affected children often have parents who are highly stigmatized. In addition disability, displacement, ethnicity and punitive laws often make children affected by AIDS more vulnerable. Access to social services and progressive legislation to reduce social exclusion are all essential in improving the lives of children and communities affected by HIV and AIDS.  “The U.S. Government is the largest supporter of programs targeting orphans and vulnerable children, and we remain firm in our commitment,” said Ambassador Eric Goosby, U.S. Global AIDS Coordinator. “Failure to address the needs of orphans and vulnerable children will have a long-term impact on both individuals and society. Moving forward, we have a shared responsibility to make smart investments that will ultimately ensure a positive future for children affected by HIV/AIDS.”  Families and Communities are integral to improving HIV responses. Early childhood development centres and community based child protection committees can serve as referral and entry points for linking vulnerable children and their families to social care and health services.  Efforts to prevent HIV transmission from mother to child (PMTCT) are also critical and can serve as an entry point for care and support for the whole family, particularly through better integration of couples testing and counselling; HIV treatment, care and support; and linkages with HIV testing and treatment within child health services.  “Every mother, father and child should have access to comprehensive health care which includes HIV prevention and treatment,” said Michel Sidibé, Executive Director of UNAIDS. “Parents should be given the chance to protect their children from HIV and access life-saving antiretroviral medicine for their own health.”  Given that the effects of HIV and AIDS will be felt for generations, building stronger, sustainable health and social care systems is essential as part of a comprehensive national response. To anchor this response, improved human resources are often needed to connect the most vulnerable households and families impacted by AIDS to the necessary services.  Evidence show that in generalized epidemic settings, social protection along with cash transfers, livelihood programmes – such as microfinancing, savings and loans, and the provision of agricultural inputs – can have a significant impact on poor households affected by AIDS. The recommendations from the  Global Partners Forum are taken forward by a global Inter-Agency Task Team on children affected by AIDS and will be reflected in discussions during the UN High Level Meeting in New York from 8-9 June 2011.

 Global AIDS response continues to show results as a record number of people access treatment and rates of new HIV infections fall by nearly 25%  As the world marks 30 years of AIDS, UNAIDS estimates 34 million [30.9 million–36.9 million] people are living with HIV and nearly 30 million [25 million–33 million] people have died of AIDS-related causes since the first case of AIDS was reported on 5 June 1981  NEW YORK/GENEVA, 3 June 2011—About 6.6 million people were receiving antiretroviral therapy in low- and middle-income countries at the end of 2010, a nearly 22-fold increase since 2001, according to a new report AIDS at 30: Nations at the crossroads, released today by the Joint United Nations Programme on HIV/AIDS (UNAIDS).  A record 1.4 million people started lifesaving treatment in 2010—more than any year before. According to the report, at least 420 000 children were receiving antiretroviral therapy at the end of 2010, a more than 50% increase since 2008, when 275 000 children were on treatment.  “Access to treatment will transform the AIDS response in the next decade. We must invest in accelerating access and finding new treatment options,” said Michel Sidibé, UNAIDS Executive Director. “Antiretroviral therapy is a bigger game-changer than ever before—it not only stops people from dying, but also prevents transmission of HIV to women, men and children.”  His statement follows the recent HPTN052 trial results which found that if a person living with HIV adheres to an effective antiretroviral regimen, the risk of transmitting the virus to his or her uninfected sexual partner can be reduced by 96%.  “Countries must use the best of what science can offer to stop new HIV infections and AIDS-related deaths,” said UN Deputy Secretary-General Asha-Rose Migiro. “We are at a turning point in the AIDS response. The goal towards achieving universal access to HIV prevention, treatment, care and support must become a reality by 2015.”  HIV prevention efforts showing results   According to the report, the global rate of new HIV infections declined by nearly 25% between 2001 and 2009. In India, the rate of new HIV infections fell by more than 50% and in South Africa by more than 35%; both countries have the largest number of people living with HIV on their continents.  The report found that in the third decade of the epidemic, people were starting to adopt safer sexual behaviors, reflecting the impact of HIV prevention and awareness efforts. However, there are still important gaps. Young men are more likely to be informed about HIV prevention than young women. Recent Demographic Health Surveys found that an estimated 74% of young men know that condoms are effective in preventing HIV infection, compared to just 49% of young women.  In recent years, there has been significant progress in preventing new HIV infections among children as increasing numbers of pregnant women living with HIV have gained access to antiretroviral prophylaxis during pregnancy, delivery and breastfeeding. The number of children newly infected with HIV in 2009 was 26% lower than in 2001.  About 115 low- and middle-income countries are providing optimal treatment regimens for pregnant women living with HIV as recommended by the World Health Organization (WHO). There are 31 countries that still use sub-optimal regimens in many of their HIV prevention programmes. UNAIDS urges all countries using sub-optimal regimens to revise their treatment guidelines and make the transition to optimal WHO recommended regimens.  AIDS is not over—significant challenges remain  According to the latest estimates from UNAIDS, 34 million [30.9 million–36.9 million] people were living with HIV at the end of 2010 and nearly 30 million [25 million–33 million] have died from AIDS-related causes since AIDS was first reported 30 years ago.  Despite expanded access to antiretroviral therapy, a major treatment gap remains. At the end of 2010, 9 million people who were eligible for treatment did not have access. Treatment access for children is lower than for adults—only 28% of eligible children were receiving antiretroviral therapy in 2009, compared to 36% coverage for people of all ages.  While the rate of new HIV infections has declined globally, the total number of HIV infections remains high, at about 7000 per day. The global reduction in the rate of new HIV infections hides regional variations. According to the report, above-average declines in new HIV infections were recorded in sub-Saharan Africa and in South-East Asia, while Latin America and the Caribbean experienced more modest reductions of less than 25%. There has been an increase in the rate of new HIV infections in Eastern Europe and in the Middle East and North Africa.  In virtually all countries, HIV prevalence among populations at increased risk of HIV infection—men who have sex with men, people who inject drugs, sex workers and their clients, and transgender people—is higher than among other populations. Access to HIV prevention and treatment for populations at higher risk of infection is generally lower due to punitive and discriminatory laws, and stigma and discrimination. As of April 2011, 79 countries, territories and areas criminalize consensual same-sex relations; 116 countries, territories and areas criminalize some aspect of sex work; and 32 countries have laws that allow for the death penalty for drug-related offences.  According to the report, gender inequalities remain a major barrier to effective HIV responses. HIV is the leading cause of death among women of reproductive age, and more than a quarter (26%) of all new global HIV infections are among young women aged 15-24.  AIDS resources declining   According to the report, investments in the HIV response in low- and middle-income countries rose nearly 10-fold between 2001 and 2009, from US$ 1.6 billion to US$ 15.9 billion. However, in 2010, international resources for HIV declined. Many low-income countries remain heavily dependant on external financing. In 56 countries, international donors account for at least 70% of HIV resources.  “I am worried that international investments are falling at a time when the AIDS response is delivering results for people,” said Mr Sidibé. “If we do not invest now, we will have to pay several times more in the future.”  A 2011 investment framework proposed by UNAIDS and partners found that an investment of at least US$ 22 billion is needed by the year 2015, US$ 6 billion more than is available today. When these investments are directed towards a set of priority programmes that are based on a country’s epidemic type, the impact is greatest. It is estimated that the return on such an investment would be 12 million new HIV infections averted and 7.4 million AIDS-related deaths averted by the year 2020. The number of new infections would decline from about 2.5 million in 2009 to about 1 million in 2015.  Perspectives on AIDS from leaders around the world  The report features commentaries from 15 leaders in the global AIDS response, including South Africa’s President Jacob Zuma, former United States President Bill Clinton, former President of Brasil Luiz Inácio Lula da Silva, the President of Mali, Amadou Toumani Touré, and Jean Ping, Chairperson of the African Union Commission. The commentaries cover a range of areas, such as AIDS funding, South-South cooperation, youth leadership, the empowerment of women, key affected populations, injecting drug use, human rights, stigma and discrimination and systems integration.  Young people leading the HIV prevention revolution  AIDS at 30: Nations at the crossroads also includes an article on a recent event held on Robben Island, South Africa, where Archbishop Desmond Tutu, Co-chair of the UNAIDS High Level Commission on HIV Prevention, passed the baton of leadership in the AIDS response to a new generation of young leaders.  According to the report, some of the most important HIV prevention successes have been led by young people. Data indicate that young people in many heavily affected countries are increasingly adopting safer sexual behaviours.

 GSMA says the NHI will offer business opportunities to cellphone companies.  CAPE TOWN — The government’s plans for National Health Insurance (NHI) offers business opportunities to cellphone companies, the international mobile operator industry association GSMA said on Friday.  GSMA, which represents the interests of mobile operators in 219 countries, is hosting a mobile health conference in Cape Town this week which will focus on the role technology can play in addressing the healthcare needs of developed and emerging economies.  Research by GSMA on the South African market concluded that there were opportunities for mobile operators to introduce medical insurance and medical services for low-income groups.  While details of the government’s plans for NHI remain sketchy, the study found there was scope for mobile operators to enter into public-private partnerships with the state to reduce the cost of healthcare and increase access to health.  "Current infrastructure is not at a scale where it can meet the market’s needs. That presents an opportunity for thinking about different ways of delivering primary healthcare and reducing the number of patients in clinics and hospitals," GSMA head of health Gavin Krugel said.  "We see an opportunity in NHI. We can offer more cost-effective ways to provide primary healthcare and reduce the burden on the state," Mr Krugel said in a telephone interview on Friday.  The summit is expected to showcase a range of products, such as mobile technology that allows doctors to monitor patients from afar, so more people who are unwell can be cared for at home.  SA is already using mobile technology to combat HIV/AIDS in a variety of ways, including sending patients reminders to take their medication and providing information on where to get help.  GSMA’s study found private health expenditure amounted to 21 times the total combined revenue of all the South African mobile network operators, and concluded there was an opportunity for mobile companies to access a share of this revenue while providing a service.  This week’s GSMA mobile health summit is expected to tackle some of the tough issues that have plagued the industry, including the challenge of expanding promising projects into sustainable businesses.  "We identified over 100 point solutions around the world, but most are donor funded or philanthropic. Once the donor funding is used up, there isn’t sustainability in the projects," Mr Krugel said.  The African National Congress views NHI as a measure to close the gap between the quality of healthcare available to rich and poor in SA.

 The potential of mobile communication technologies to improve SA's healthcare service delivery is huge, according to Deputy Minister of Communications Obed Bapela, though he warned that the government would have to look at the possible pitfalls of eHealth before rolling out such solutions on a large scale.     "SA embraces the potential of information and communications solutions when it comes to improving the healthcare service delivery in our country," the deputy minister said on Tuesday in his keynote address at the 2011 Mobile Health Summit, which is taking place in Cape Town this week. The conference aims to examine how mobile communication technologies can increase the effectiveness of healthcare service delivery in developing countries.  "Mobile and internet health technologies can play a significant role in realising the health department's service delivery strategy, which aims to address the HIV/TB co-epidemic, reduce child and maternal mortality, fight non-communicable diseases and strengthen the effectiveness of our health system," he added.   "Currently, the Department of Health is looking at technology strategies that rest on the high mobile phone penetration as one of the key components," Bapela noted.   SA, with a population of 48 million, has about 42 million active simcards.  A simple example of a successful mobile healthcare initiative is the policy at the Themba Lethu clinic in Johannesburg. This facility sends out text messages to HIV and TB patients, including moms and pregnant women, to remind them about appointments and medication.  According to the health department's strategic health programmes' division, the number of missed appointments has dropped from 15% to 7% over the past four years.  "There are some questions that still need to be answered," Bapela stressed. "There is the issue of affordability, for instance. Communication costs in SA remain very high. eHealth solutions should also comply with the National Health Act when it comes to, for instance, privacy and confidentiality regulations, as well as doctors' liability. It should also comply with ethical rules and guidelines, and the user should be protected."  Bapela said private partnerships were vital in the adoption of eHealth solutions.

 Since the discovery last year that a vaginal gel containing an antiretroviral called tenofovir can protect women from HIV, scientists have been working hard to support and fast-track the results. - Kerry Cullinan  This was revealed yesterday by Professor Quarraisha Abdool Karim, one of the researchers who conducted the trial of the microbicide gel under the banner of the Centre for the AIDS programme of Research in SA (Caprisa)  A factory site to manufacture tenofovir gel has already been identified on the KwaZulu-Natal south coast by a public-private company, Professor Abdool Karim told a high level scientific meeting convened in Durban to assess Caprisa’s scientific outputs.  A number of trials are also planned to support the first trial, which found that the infection rate among the women who received the tenofovir microbicide was 39% lower than those who did not get the gel.  A large trial currently underway in a number of African countries will compare the efficacy of tenofovir gel with tenofovir tablets, as well as comparing tenofovir with another ARV called Truvada.  Caprisa is also waiting for permission to run an implentation trial to see how the tenofovir microbicide can be integrated into normal family planning services.  It also aims to run a trial to look at whether women who have used the tenofovir gel will develop resistance to the medicine, which would have implications for them should they become HIV positive.  However, an interrogation of the results by Caprisa scientists over the past year has raised even more questions.  Dr Vivek Naranbhai reported that the women who became infected with HIV during the trial had a relatively high level of vaginal inflammation. He suggested that it would be important to see whether anti-inflammatories could assist to reduce HIV transmission.  His colleague, Dr Sengeziwe Sibeko reported that it was possible that the tenofovir gel had only protected women if their partners had relatively low viral load in their semen.  “Certainly we urgently need further research to see whether this is the case, but unfortunately we don’t have the funds yet to do so,” said Sibeko.  Meanwhile, Science and Technology Minister Naledi Pandor complimented Caprisa for its research prowess.   “I am so tired of Africa being a recipient of things,” said Pandor. “We need to become a source of solutions. We need to move beyond being a resource-based to a knowledge-based economy.”  She added that she was working to encourage a bio-technology economy in South Africa along the lines of India and Brazil.  “We have set aside land in the Western Cape for a biotechnology park, supported by government,” said Pandor.