Poor More Likely to Suffer During South Africa’s Dire Drought


Cape Town, South Africa is in the throes of a years-long drought that could earn it a truly alarming distinction: the first major city in the developed world to run out of water.

South Africa as a whole is experiencing its worst drought in a century. The six dams that supply Cape Town’s water have dropped to just 15.2 percent capacity of usable water, according to the Los Angeles Times, down from 77 percent in September 2015. Enforcement of strict water restrictions – which cut permitted daily consumption from 23 gallons per day to just 13.2 gallons – begin February 1.

Shravya K. Reddy, principal at Pegasys Strategy and Development and Climate Reality’s former director of science and solutions, lives in Cape Town and says that while several factors – including relatively rapid population growth, poor planning, and people ignoring previous water restrictions – have all contributed to this crisis, officials’ failure to recognize the role that climate change plays in exacerbating drought has made the situation even more dire.

“Decision-makers well-versed with climate science would have taken it seriously and would have started treating this drought, even in 2015 or 2016, as if it would last longer than usual,” Reddy tells Climate Reality. “Instead, they seemed to never escalate the preparations for additional water supplies or accelerate water augmentation projects in the belief that taking drastic action would be overkill, since the rains would come. If they had taken more concerted action two years ago or early last year, then they would not need to be on such war footing right now.”

Climate change worsens drought because as temperatures rise, evaporation increases. When this evaporation happens over land, soils dry out. Many places are also experiencing both decreases in annual precipitation and longer periods without significant rain, resulting in reduced water levels in streams, rivers, lakes, and (importantly) reservoirs. When rains do come, much of the water runs off the hard ground and is carried back to the ocean before it can fully replenish dams, reservoirs, or the water table.

All of Cape Town’s citizens are feeling the impact of the drought, but the city’s lower-income residents are already bearing the brunt. Should the city, which has a population of more than 4 million people in its greater metropolitan area, run out of water on April 21, as many are predicting, their plight will become truly desperate.

“Socio-economic disparity is evident in both peoples’ access to critical information, as well as in the measures people are taking to prepare for ‘Day Zero,’ the day when the city has to shut off municipal water and taps literally run dry,” Reddy says. “In speaking with people who typically have to work the longest hours just to financially survive, it seems to me that they simply don’t have access to the same levels of information we do, and thus are less empowered to make informed decisions about how they will cope and manage.”

This disparity, she adds, can often be traced back to a lack of computer and internet access among many of South Africa’s lower-income communities.

Another imbalance has become clear: Wealthier citizens have the resources to prepare and safeguard themselves from the worst of the water crisis’ impacts.

“Those with more disposable income can stock up on more bottled water. We can also invest in more water-saving devices,” Reddy explains. “Many of Cape Town’s most under-resourced residents live in what we call townships or informal settlements – what the West would call shanty towns or even slums – and they’re lucky if they have a communal water source amongst eight to 10 families. They certainly cannot buy and hoard bottled water.

“People with means – transportation as well as leisure time – can drive farther out of the city to areas where clean, potable water comes out of natural springs and can collect water to take home. Those who don’t have the luxury of a car and time to drive around are less able to take advantage of such natural springs hours away.”

She notes that some retailers are even taking advantage of the situation, increasing the price of common water conservation tools like buckets, pitchers, and other water storage units because of higher market demand, making them even less accessible to the people who may need them the most.

And beyond the obvious necessity of clean drinking water, Reddy worries that “significant public health challenges will emerge as a result of people not being able to maintain individual and institutional hygiene.” The risk of water-borne diseases and other bacterial infections may also rise sharply, elevating the risk of serious public health issues.


“Money buys other adaptation means too. The wealthy have greater ability to buy more new clothes as a response to less clothes washing, ordering takeout food as a response to less cooking and dishwashing, buying ‘chemical toilets,’ tons of wet-wipes, hand sanitizer, and leaving the city for long stretches of time to escape elsewhere – either by renting places in other cities or staying with friends and family who can afford to accommodate long-term guests,” she continues.

“Based on what several people in my circles have been saying, it is clear that some people will have the ability to temporarily leave the city and move to their second homes out in the countryside, to parts of the province that are not as water stressed. Some may even temporarily move to Johannesburg or leave the country until some semblance of normalcy is restored. The majority of the city’s residents do not have that immense privilege.”

Reddy concludes on a note that has become all too familiar for many already experiencing the climate crisis firsthand: “Certainly in the case of climate change adaptation in any community, anywhere in the world – those with greater means at their disposal will fare better.”

With each new natural disaster, the truth becomes clearer: The most vulnerable among us are on the front lines of a crisis they had the least to do with creating – and if we don’t act now to support solutions and end climate change, we may reach a point of no return.

HOMO NALEDI: NEW HUMAN ANCESTOR DISCOVERED


Within a deep and narrow cave in South Africa, paleoanthropologist Lee Berger and his team found fossil remains belonging to the newest member of our human family. The Homo naledi discovery adds another exciting chapter to the human evolution story by introducing an ancestor that was primitive but shared physical characteristics with modern humans.

Because the cave system where the bones were located was extremely difficult to access, it could be speculated that these hominins practiced a behavior previously believed to be modern: that of deliberately disposing of their dead underground.

Watch the video. URL:https://youtu.be/oxgnlSbYLSc

South African Doctors Perform World’s First Penis Transplant


South African doctors have successfully performed the world’s first penis transplant on a young man who had his organ amputated after a botched circumcision ritual, a hospital said on Friday.

The nine-hour transplant, which occurred in December last year, was part of a pilot study by Tygerberg Hospital in Cape Town and the University of Stellenbosch to help scores of initiates who either die or lose their penises in botched circumcisions each year.

“This is a very serious situation. For a young man of 18 or 19 years the loss of his penis can be deeply traumatic,” said Andre van der Merwe, head of the university’s urology unit and who led the operation said in a statement.

The young patient had recovered full use of his manhood, doctors said, adding that the procedure could eventually be extended to men who have lost their penises to cancer or as a last resort for severe erectile dysfunction.

“There is a greater need in South Africa for this type of procedure than elsewhere in the world, as many young men lose their penises every year due to complications from traditional circumcision,” Van der Merwe said.

The patient, who is not being named for ethical reasons, was 21 years old when his penis was amputated three years ago after he developed severe complications due to a traditional circumcision as a rite of passage into manhood.

Finding a donor organ was one of the major challenges of the study, a statement by the university said.

The donor was a deceased person who donated his organs for transplant, doctors said without elaborating.

Each year thousands of young men, mainly from the Xhosa tribe in South Africa, have their foreskins removed in traditional rituals, with experts estimating around 250 losing their penises each year to medical complications.

Initiates are required to live in special huts away from the community for several weeks, have their heads shaved and smear white clay from head to toe and they move into adulthood.

Another nine patients will receive penile transplants as part of the study, doctors said, but it was not clear when the operations could be carried out.

Who next as the world’s elder statesman?


Mandela death: Who next as the world’s elder statesman?

Gandhi, Nelson Mandela and Aung San Suu Kyi

Nelson Mandela was often described as the “world’s elder statesman”, a father figure tackling global problems. His moral authority made him, in some people’s eyes, a successor to Gandhi. Who might play a similar role now?

Lockerbie, Burundi, DR Congo, Lesotho, Indonesia, Israel-Palestine, Kashmir, Stephen Lawrence murder, HIV awareness and World Cup football.

The list of subjects addressed in some way by Nelson Mandela is long and varied.

In some disputes, like Burundi’s long-running conflict, he was a mediator. On other intractable issues, like the stigma of HIV, he was the campaigner and bereaved father who tried to address prejudice.

Not all his contributions were successful or universally welcomed. He opposed intervention in Kosovo in 1999 and often strongly criticised US foreign policy, while his warm relations with Colonel Gaddafi and President Suharto raised eyebrows. Many thought he spoke out too late about the HIV crisis.

But even his critics would concede that he became a figure with unequalled status on the global stage.

“It seems to me that uniquely he negotiated his transformation from prisoner of conscience and iconic human rights leader to practical political leader who became in every single way the father of modern South Africa and then transformed again into elder statesman,” says Simon Marks, global affairs correspondent at Feature Story News based in Washington.

He had unquestioned legitimacy, someone that a very broad array of people looked up to, including pop singers and supermodels, says Marks.

Mandela on…

Mandela and Colonel Gaddafi
  • Lockerbie: Mediated between Libya and UK on transfer of suspects
  • Middle East: Criticised Israel for ‘narrow interests’
  • Lesotho: Ordered troops into country
  • DR Congo: Arranged key summit that led to peace accord
  • Kashmir: Urged India-Pakistan talks
  • Burundi: Closely involved in peace process
  • Indonesia: Visited East Timor politician in prison in Jakarta
  • Stephen Lawrence: Demanded urgency from police, two weeks after killing

Mandela had the capacity to operate as an honest broker in situations where others might not have been able to, says Christopher Alden of the London School of Economics, who points to Indonesia as an example. In 1997, Mandela’s two-hour visit to the imprisoned East Timorese politician Gusmao in Jakarta, against Suharto’s wishes, paved the way for a referendum and Gusmao’s release two years later.

“He accrued a moral authority that transcended the ordinary politics that guide the worst conduct of political actors.”

The unique feature of Mandela is that he was someone whose moral stature was truly worldwide, says Alden – a reflection of the globalised nature of the anti-apartheid struggle by the 1980s.

There have been other elder statesmen and women in recent years, he says, but they are generally figures whose activities are focused on internal politics or they are asked to act on behalf of a state.

“Jimmy Carter has been ‘deployed’ to North Korea to hold discussions on sensitive issues and has played an important role in democratisation efforts in Africa through the monitoring/training of elections but these are more functional – he lacks the emotive power that Mandela generates.

“Blair’s involvement in the Middle East was an attempt, I suppose, at this – and to burnish his post-Iraq reputation – but notably a failure.”

The Elders
Mandela’s organisation, The Elders, drew together some of the world’s leading statesmen and women

Possibly Mandela’s most noteworthy intervention came early in 2005, following the death of his son, Makgatho. With the Aids epidemic still a taboo subject in parts of Africa, Mandela urged South Africans to be more open about the illness.

Biographer David James Smith believes Mandela’s personality was a key factor in his rise to international father figure – a quality few can match.

“There was a purity about Mandela, a simplicity about him like a farm boy looking after sheep, although he was capable of achieving things in immensely complex situations.

“He talked to commoners and kings in the same way. Everyone loves that he remembered names and took time to talk to everyone. He had all those great human qualities that people admire.”

The EldersFormed by Mandela in 2007, it’s an independent group of leaders working for peace

  • Martti Ahtisaari
  • Kofi Annan (chairman)
  • Ela Bhatt
  • Lakhdar Brahimi
  • Gro Harlem Brundtland
  • Fernando H Cardoso
  • Jimmy Carter
  • Hina Jilani
  • Graca Machel
  • Mary Robinson
  • Ernesto Zedillo
  • Desmond Tutu (honorary)

You could go anywhere in the world and show his face and people would know his name, says Smith, and there’s not anyone alive now who you could say that for.

“I can’t think of anyone else who will set the same example. Aung San Suu Kyi embodies some of the values that he had but you can’t say that she would be recognised in the same way.”

The Burmese prisoner turned politician is a really interesting character, says Marks. “Could she become that person? Maybe, except we don’t yet know how the political story will turn out. She has this amazing moral authority because of her experience as a prisoner of conscience but now playing an active political role and there are a lot of things putting her in a tough position.

“And when you take a leadership role you inevitably rub people up the wrong way. Therefore it’s not axiomatic that she fills those shoes, once the brutal world of politics has finished with her.”

Gandhi, Mandela and Suu Kyi were all political prisoners and this personal sacrifice is an important part of the role, says Marks, but there are other prisoners of conscience, in places like China and North Korea, who are not household names.

“They might at some point emerge as the agent of change in these countries. It requires a combination of personal sacrifice and – cynical though it is to say so – personal sacrifice at the right moment, because when the right moment is there politically, and you can capitalise on it as a result of personal sacrifice, you have more of a chance to effect change.”

But it may be that these extraordinary figures only emerge from time to time, says Marks. In the age of social media, it is perhaps more difficult to establish a long-term reputation because judgments are cast so quickly.

On his 89th birthday, Mandela formed The Elders, a group of leading world figures, to offer their expertise and guidance to – according to their website – “tackle some of the world’s toughest problems”.

“It remains to be seen whether an organisation of senior statesmen and women will be able to do what an individual like this has,” says Alden. “It is a one-in-a-generation person. It may work but it’s a novel experiment.

“Humankind needs this kind of person. Without them, the possibility of descending into brutish conflict we are capable of is accentuated. Hopefully there’s cometh the hour, cometh the man or woman. But I scan the horizon and I don’t see anyone of his ilk.”

Nelson Mandela: Aids campaigner


Nelson Mandela in October 2003
Like many others, Nelson Mandela did not at first realise the dangers of HIV

Though at first muted in his approach to the issues surrounding HIV/Aids, Nelson Mandela eventually became a dedicated and extremely effective advocate for a more vigorous approach to the disease.

When Mr Mandela was released from prison in February 1990, HIV/Aids had yet to make its full impact on South Africa.

“Start Quote

We are facing a silent and invisible enemy that is threatening the very fabric of our society”

Nelson Mandela

Following his election as president four years later, Mr Mandela faced huge challenges and – like so many other world leaders at the time – failed to fully understand the depth of the problem and did little to help those with Aids.

At the time, the African National Congress (ANC) was gripped by an ongoing debate about both the causes of, and treatment for, Aids.

Some figures, like Thabo Mbeki, Mr Mandela’s successor as president, openly questioned whether Aids was caused by HIV.

After Mr Mandela left office in 1999, he campaigned for more research into HIV/Aids, for education about safe sex and for better treatment for those affected. However, most South Africans still did not mention the disease in public.

Controversy within ANC

According to UN figures, the rate of HIV infection among adult South Africans rose from less than 1% in 1990 to about 17.9% by 2012.

Aids activists demonstrate outside the US consulate in Johannesburg - 17 June 2010South Africa has one of the highest HIV rates in the world

South Africa is currently home to more people with the virus than any other country – 6.1 million of its citizens were infected with HIV in 2012, including 410,000 children (aged 0-14), out of a population of just over 51 million.

The causes of an epidemic on this scale have been many – primarily poverty, but also economic migration, the poor status of women, and unsafe sexual practices, have all contributed to the rapid spread of the disease.

Apart from the human misery caused by Aids, its economic impact has been huge, with South African economic growth rates badly affected.

Having put the issue of Aids on the back burner when in office, Mr Mandela began to make strong pronouncements on the subject after he stepped down in 1999.

HIV/Aids in South Africa

  • People living with HIV: 6.1 million
  • Rate of infection in adults aged 15-49: 17.9%
  • Children aged 0-14 living with HIV: 410,000
  • Deaths due to Aids in 2012: 240,000
  • Orphans due to Aids aged 0-17: 2.5 million

Source: UNAids 2012

On World Aids Day in 2000, he sent out a hard-hitting message, saying: “Our country is facing a disaster of immeasurable proportions from HIV/Aids.

“We are facing a silent and invisible enemy that is threatening the very fabric of our society.

“Be faithful to one partner and use a condom… Give a child love, laughter and peace, not Aids.”

Mr Mandela said his country should promote abstinence, the use of condoms, early treatment, counselling and drugs to reduce mother-to-child transmission.

Urgency

At the time, there was a marked reluctance on the part of the South African government to fund anti-retroviral drugs for those with HIV.

Nelson Mandela with Makgatho (R) in 2003
Mr Mandela’s son, Makgatho (R) died from Aids-related illness in 2005

The then President Mbeki outraged many people when he told a US journalist that “personally, I don’t know anybody who has died of Aids” and that he did not know if he had ever met anyone infected with HIV.

One of his ministers suggested that people with HIV eat garlic and beetroot to combat the infection.

In November 2003, Mr Mandela – and his Nelson Mandela Foundation – stepped up the campaign, launching an HIV/Aids fundraising campaign called 46664, after his prison number on Robben Island.


Nelson Mandela

1918 Born in the Eastern Cape

1943 Joined African National Congress

1956 Charged with high treason, but charges dropped after a four-year trial

1962 Arrested, convicted of incitement and leaving country without a passport, sentenced to five years in prison

1964 Charged with sabotage, sentenced to life

1990 Freed from prison

1993 Wins Nobel Peace Prize

1994 Elected first black president

1999 Steps down as leader

2001 Diagnosed with prostate cancer

2004 Retires from public life

2010 Last major public appearance at football World Cup in Johannesburg

He compared the urgency and drama of his country’s struggle against HIV/Aids to the fight against apartheid.

Pop stars like Beyonce, Youssou N’Dour and Dave Stewart supported the campaign, and a star-studded concert, held in Cape Town in 2003, was seen by a worldwide television audience of two billion.

The money raised by Mr Mandela’s initiatives has been used to fund research projects and provide practical support for South Africans with HIV/Aids.

The campaign received a further boost in 2005, when Mr Mandela shocked the nation by announcing that his son, Makgatho, had died of Aids.

He urged people to talk about HIV/Aids “to make it appear like a normal illness”.

It was a significant move, which had a huge impact, said Michel Sidibe, head of the UN’s Aids agency Unaids.

“The country has become a leader in the Aids response because of Mr Mandela, and is moving towards an Aids-free generation thanks to his campaigning,” he said.

Mr Mandela also became a central figure in the African and global Aids movement, Mr Sidibe said.

“He was instrumental in laying the foundations of the modern Aids response and his influence helped save millions of lives and transformed health in Africa,” he said.

“He was a statesman who had Aids at the top of his agenda and he used his stature and presence on the global stage to persuade world leaders to act decisively on Aids. His legacy will be felt by generations.”

How do S Africans rate Mandela film?


South Africans are flocking to the cinemas to watch a film about their former President, Nelson Mandela. The movie Mandela: Long Walk To Freedom, starring British actor Idris Elba, is based on the former political prisoner’s autobiography of the same title and seems to be hitting the right notes.

I went to watch the epic 146-minute film in one of Johannesburg’s busiest economic hubs, Rosebank, and I found very few critics of the film among the general public.

Almost everyone I spoke to expressed their pleasant surprise at how well the film came across. A big thumbs-up for the lead actor, given that he is not South African, let alone not being Xhosa, Mr Mandela’s tribe. Some sang Elba’s praises because they felt that he got the accent right – not exactly like Mr Mandela, but close enough.

Part of the legacy of the apartheid system is that two decades since the introduction of democracy, the minds of South Africans are still very much defined along racial lines. So inevitably I must tell you what the white people thought and what the black majority said.

Mandela’s key dates

  • 1918: Born in the Eastern Cape
  • 1944: Joins African National Congress
  • 1962: Arrested, convicted of sabotage, sentenced to five years in prison
  • 1964: Charged again, sentenced to life
  • 1990: Freed from prison
  • 1993: Wins Nobel Peace Prize
  • 1994: Elected president
  • 1999: Steps down as leader
  • 2004: Retires from public life
  • 2010: Appears at football World Cup

In 1994, no-one thought we would still be talking about the colour of our skins in 2013 – especially considering the fact that we are just reviewing a film. However, that’s the reality of today’s South Africa.

Take Karabo Nkabinde, a teenage girl who can be best described as a born-free – the label attached to those who were born after the country was liberated from racial oppression and Nelson Mandela was elected president in the country’s first multi-racial election.

Clad in a fashionable small black hat and thick-framed spectacles, she told me that she had loved the film because it reminded her of the sacrifices Mr Mandela had endured.

“He’s actually been through a lot for us South Africans… for the youth and it is our job to make him proud,” she said.

Her friend Kgomotso Maloka, wearing a glamorous maroon lip gloss, said that she was pleased that, as a young black person, she could watch a film about Mr Mandela in a climate of peace where both black and white lived together in harmony.

“My favourite part was the ending, when he got freed and so did everybody else. Freed from fear and from the past! The movie is very touching and it could get you crying!” she said.

I then met a young white couple just as they walked out from Cinema One at Rosebank’s Ster Kinekor movie house holding hands. The man told me that he thought it was a very moving film which reminded him both of the liberation struggle and that there was still a long way to go to redress the imbalance of the past. They were shy to reveal their names.

After watching the film myself, I thought it was hard to squeeze such a rich life – including a 27-year prison sentence – into two hours without leaving out some key historical moments. And given that challenge, the film, in my view, captured the spirit of the man and his people in their desire to free themselves from the shackles of a brutal racist system.

While clearly the film was about Mandela the man, it also left me with a sense of the struggle of an entire people. When I asked a middle-aged white lady what she thought about the portrayal of the cigarette-smoking white men who ran the country under apartheid, she told me: “They were adequately portrayed, just as they were.”

Box-office records

I personally thought the death of Chris Hani ought to have been marked, even if it meant doing it with one single frame. I mention Chris Hani because his assassination on that fateful Saturday morning on 10 April 1993 delivered what is today celebrated as the nation’s biggest public holiday – Freedom Day on 27 April.

At the time of his death, Hani was the second most popular leader in the African National Congress after Nelson Mandela. He was shot by a Polish immigrant, Janusz Walus, in a killing ordered by right-wing politician Clive Derby-Lewis.

Nelson Mandela in a file photo from 2010
A film about an icon, but is it an iconic film?

They are both serving life sentences for killing Hani, with the sole purpose of starting a racial conflagration – something Mr Mandela prevented, and which was the primary reason he won the Nobel Peace Prize.

There were reports that, in some cinemas near Soweto, people took a day off work to watch the film. One cinema manager was quoted as saying that attendance was “unusually high”.

The film has broken box-office records for a non-holiday movie in South Africa, opening at number one.

However, even though it is about a much-loved figure like Mr Mandela, there has been some sharp criticism of Anant Singh’s production.

Writing in The Times, a national daily newspaper, Tymon Smith said: “If you want to really get to grips with the man though, you can do better by reading the books. One day someone will make a film that says something new and interesting about Mandela, but this is not that film and it seems a wasted opportunity rather than the fulfilment of a dream.

“It is also unfortunate that, because of all the power, money and influence behind it, all future films will have to struggle in its undeservedly long shadow.”

So, clearly not everybody is singing from the same hymn sheet. However, even Smith agrees in part that the actors are a class act: “The film certainly looks as good as any other epic and you can see the money on the screen.”

I should mention here the local cast of stars is also something that could not go unnoticed. Take the Walter Sisulu character, the man who recruited Nelson Mandela into the ANC, played by the talented Tony Kgoroge.

He was just brilliant alongside Elba and another British actor, Naomie Harris, who plays Winnie Mandela. And there are many other local talents like him in this biopic.

Considering that Mr Mandela is recuperating from a long illness at home just a few blocks away from the cinema, I was struck by the reality of it all. We have become accustomed to watching big Hollywood blockbusters on our local screens and listening to stories about others, so how refreshing it is to see characters of the very people I had drinks with just a week ago.

This story is not just about Mr Mandela but is a story of the people through the life of one man.

That’s what I take away from it. And with the current levels of poverty, inequality and unemployment which are in essence the legacy of apartheid, the story of the people continues where the film ends.

South Africa’s HIV treatment challenge .


The country with the highest number of HIV/AIDS patients struggles to provide medication to its most remote areas.


Earlier this year, when the Pilani health clinic suffered a shortage of the medication used to treat HIV, patients in the village of Ntshilini had to take an hour-long bus ride on a bumpy, mountainous road to the nearest hospital.

“We ended up paying so the nurse could get someone to go and fetch our drugs,” said Boniwe Gxala, a 36-year-old HIV patient from Ntshilini, who had to go weeks without her supply of the life-prolonging drug.

The shortage reportedly occurred because of delayed deliveries from the provincial department of health in South Africa‘s Eastern Cape region.

People are dying here and we have to say, ‘Sorry, we have no medicine’.

– Selena Arends, assistant nurse at Pilani clinic, Ntshilini village

Improving access to treatment and care is the World Health Organization’s focus for the campaign marking the 2013 World AIDS Day, which takes place on December 1. Nowhere is that message more relevant than in South Africa, a country with the one of the highest rates of HIV/AIDS infection in the world.

More than 5.5 million South Africans are living with the disease, comprising 11 percent of the population. Among women of reproductive age, a staggering 20 percent are HIV-positive.

Public health facilities throughout the Eastern Cape, one of the country’s least developed areas, have experienced severe shortages of essential medicines and medical supplies in the past year. A report published on November 5 by the Eastern Cape Health Crisis Action Coalition details what it calls the “crisis in healthcare” in the region.

According to the report, mismanagement by the municipal health department has resulted in stacks of the antiretroviral (ARV) drugs used to treat HIV infection lying in storage while patients are turned away from clinics. “People are dying here and we have to say, ‘Sorry, we have no medicine’,” said Selena Arends, an assistant nurse at the Pilani clinic.

“The impact on [HIV] patients from not taking their medication is huge,” said Marcus Louw of the Treatment and Action Campaign, an NGO that is part of the Eastern Cape Health Crisis Action Coalition. “If you do not take your ARV pills for weeks, your body develops resistance to the drug and you are also at a high risk of HIV-opportunistic illnesses.”

South Africa’s Department of Health said it is unfair to compare the situation in rural parts of the Eastern Cape to the rest of the country. Minister of Health Aaron Motsoaledi pointed out that South Africa distributes more ARV drugs than any other country, with more than 600,000 people per year registering to receive the medication.

“Our health facilities and supplies systems are exploding,” said Motsoaledi. “The yearly increase [of people registering for ARV] cannot come without any problems, so we will see logistical problems.”

According to South Africa’s National Treasury, the government spent 22.2bn rand ($2.17bn) on HIV in 2012/13. Five billion rand ($491m) came from donors.

Some data show that South Africa’s ARV distribution programme is improving. For instance, according to the National Antenatal Survey, the number of people receiving ARV drugs has increased in the past four years from 923,000 to 2.4 million people, while the number of clinics and hospitals offering the medication has climbed from 490 to 3,540 facilities countrywide.

Yet distributing the drugs has been a challenge. In one case, corrupt health officials at the Esselen Street clinic in Johannesburg stole ARV pills – which are meant to be available to patients at no cost – and sold the medication to them instead.

The HIV medication has also been used as an ingredient in a street drug called “nyaope” or “whoonga”. This cheap, potent mixture of heroin, marijuana and crushed ARV pills has become popular in impoverished townships, according to some accounts. Recently, armed heroin addicts broke into a doctor’s office in Soweto to steal ARVs.

“Two men came in with guns, ordered me to close my eyes, kneel down, emptied my pockets and they said they do not want my car – all they want is the key to the medication cabinet,” said Dr Mngoma Zulu, adding that he is not the only doctor in the area to have such an experience.

However, Cathy Vos of the South African National Council on Alcoholism and Drug Dependence said the story of people getting high on ARVs has been blown out of proportion, and that heroin use is a much bigger problem.

Drug addicts are not the only ones trying to get their hands on ARVs for illicit purposes. Smugglers are on the prowl, too. Cross-border syndicates deal in a variety of medications, including ARVs, selling them in neighbouring countries such as Mozambique, Lesotho and Zimbabwe, according to a spokesman for the premier of Kwazulu Natal province.

The South African government has made major investments to provide ARV pills to the many people who rely on the drug for their survival. Progress has been achieved, but as the international community marks another World AIDS Day, there are still many HIV patients who cannot be sure that next month they will have their medication.

Tuberculosis: Test Speeds Diagnosis, Time to Treatment.


The Xpert MTB/RIF (Cepheid) test improved tuberculosis (TB) diagnosis and reduced time to treatment, but not long-term TB-related morbidity, according to the results of a multicenter, randomized, controlled trial.

“Despite already being rolled-out in many countries, our study is the first to look at the feasibility of the Xpert test in a real-life clinical setting in southern Africa,” lead author Keertan Dheda, MBBcH, from the Department of Medicine, University of Cape Town, South Africa, said in a news release. The study results were published online October 28 in the Lancet.

The researchers enrolled adult patients with symptoms suggestive of active TB at 5 primary care facilities in South Africa, Zimbabwe, Zambia, and Tanzania. They randomly assigned patients to either Xpert MTB/RIF testing, performed at the clinic by a nurse who received 1 day of training, or to sputum smear microscopy. On the basis of local World Health Organization–compliant guidelines, participants with a negative test result were managed empirically.

The main study endpoint, analyzed by intention to treat, was TB-related morbidity, measured with the TB score and Karnofsky performance score at 2 months and 6 months after randomization in culture-positive patients who had started anti-TB treatment.

Of 758 assigned patients to smear microscopy between April 12, 2011, and March 30, 2012, 182 were culture positive, as were 185 of 744 patients assigned to Xpert MTB/RIF. Among culture-positive patients, median TB score and median Karnofsky performance score in culture-positive patients did not differ between groups at 2 or at 6 months.

Diagnostic Performance of Point-of-Care MTB/RIF

Compared with microscopy, point-of-care MTB/RIF had higher sensitivity (83% vs 50%; P = .0001), but similar specificity (95% vs 96%; P = .25). Compared with laboratory-based MTB/RIF, point-of-care MTB/RIF had similar sensitivity (83%; P = .99), but higher specificity (92%; P = .0173).

Of 744 tests with point-of-care MTB/RIF, 34 (5%) failed, as did 82 (6%) of 1411 with laboratory-based MTB/RIF (P = .22). More patients in the MTB/RIF group than in the microscopy group had a same-day diagnosis (24% vs 13%; P < .0001) and same-day treatment initiation (23% vs 15%; P = .0002).

Because of the lower dropout rate, more culture-positive patients in the MTB/RIF group were receiving treatment by study end (8% untreated in the MTB/RIF group vs 15% in the microscopy group; P = .0302). By day 56, however, the proportions of all patients receiving treatment were similar (43% vs 42%, respectively; P = .6408).

“Although earlier diagnosis by the Xpert test did not reduce overall severity of TB-related illness, and moreover did not reduce the overall number TB cases treated over the course of the study, it has substantial benefits over smear microscopy including improved rates of same-day diagnosis and reducing treatment drop-out,” Dr. Dheda said in the release.

Cost-Effectiveness May Be a Concern

Limitations of this study include about 20% loss to follow-up of patients with culture-confirmed TB, mostly resulting from staffing problems at 1 site, and possible lack of generalizability to seriously ill patients or those with extrapulmonary TB.

“Whilst Xpert may not be the ideal point of care TB test in particularly poorly resourced settings, in countries like South Africa where the clinic infrastructure is relatively good, rates of drug-resistant TB are high, and patient drop-out are significant problems, within clinic placement of Xpert in TB hotspots might be appropriate and enable earlier diagnosis of drug-resistant TB thus likely reducing community-based transmission,” Dr. Dheda noted. “Nevertheless, prevention of TB and adherence to TB treatment is critical and remains a major priority.”

In an accompanying comment, Christian Wejse, MD, PhD, associate professor, GloHAU, Center for Global Health, Department of Public Health, Aarhus University, Denmark, wonders about the cost-effectiveness of Xpert testing.

“At a cassette cost of US$10 (reduced price for low-resource settings), testing large numbers of people with suspected tuberculosis will put substantial pressure on already resource-limited tuberculosis programmes in which the drugs for treatment might not always be available,” Dr. Wejse writes. “Hence, the provocative question raised by this study is whether tuberculosis elimination is most likely to be advanced by distributing GeneXpert machines to all peripheral health facilities in the world, or by investing the same amount in ensuring that health facilities have the set-up available in this study—ie, well trained and paid staff, electricity, and reagents.”

Tuberculosis: Test Speeds Diagnosis, Time to Treatment.


The Xpert MTB/RIF (Cepheid) test improved tuberculosis (TB) diagnosis and reduced time to treatment, but not long-term TB-related morbidity, according to the results of a multicenter, randomized, controlled trial.

“Despite already being rolled-out in many countries, our study is the first to look at the feasibility of the Xpert test in a real-life clinical setting in southern Africa,” lead author Keertan Dheda, MBBcH, from the Department of Medicine, University of Cape Town, South Africa, said in a news release. The study results were published online October 28 in the Lancet.

The researchers enrolled adult patients with symptoms suggestive of active TB at 5 primary care facilities in South Africa, Zimbabwe, Zambia, and Tanzania. They randomly assigned patients to either Xpert MTB/RIF testing, performed at the clinic by a nurse who received 1 day of training, or to sputum smear microscopy. On the basis of local World Health Organization–compliant guidelines, participants with a negative test result were managed empirically.

The main study endpoint, analyzed by intention to treat, was TB-related morbidity, measured with the TB score and Karnofsky performance score at 2 months and 6 months after randomization in culture-positive patients who had started anti-TB treatment.

Of 758 assigned patients to smear microscopy between April 12, 2011, and March 30, 2012, 182 were culture positive, as were 185 of 744 patients assigned to Xpert MTB/RIF. Among culture-positive patients, median TB score and median Karnofsky performance score in culture-positive patients did not differ between groups at 2 or at 6 months.

Diagnostic Performance of Point-of-Care MTB/RIF

Compared with microscopy, point-of-care MTB/RIF had higher sensitivity (83% vs 50%; P = .0001), but similar specificity (95% vs 96%; P = .25). Compared with laboratory-based MTB/RIF, point-of-care MTB/RIF had similar sensitivity (83%; P = .99), but higher specificity (92%; P = .0173).

Of 744 tests with point-of-care MTB/RIF, 34 (5%) failed, as did 82 (6%) of 1411 with laboratory-based MTB/RIF (P = .22). More patients in the MTB/RIF group than in the microscopy group had a same-day diagnosis (24% vs 13%; P < .0001) and same-day treatment initiation (23% vs 15%; P = .0002).

Because of the lower dropout rate, more culture-positive patients in the MTB/RIF group were receiving treatment by study end (8% untreated in the MTB/RIF group vs 15% in the microscopy group; P = .0302). By day 56, however, the proportions of all patients receiving treatment were similar (43% vs 42%, respectively; P = .6408).

“Although earlier diagnosis by the Xpert test did not reduce overall severity of TB-related illness, and moreover did not reduce the overall number TB cases treated over the course of the study, it has substantial benefits over smear microscopy including improved rates of same-day diagnosis and reducing treatment drop-out,” Dr. Dheda said in the release.

Cost-Effectiveness May Be a Concern

Limitations of this study include about 20% loss to follow-up of patients with culture-confirmed TB, mostly resulting from staffing problems at 1 site, and possible lack of generalizability to seriously ill patients or those with extrapulmonary TB.

“Whilst Xpert may not be the ideal point of care TB test in particularly poorly resourced settings, in countries like South Africa where the clinic infrastructure is relatively good, rates of drug-resistant TB are high, and patient drop-out are significant problems, within clinic placement of Xpert in TB hotspots might be appropriate and enable earlier diagnosis of drug-resistant TB thus likely reducing community-based transmission,” Dr. Dheda noted. “Nevertheless, prevention of TB and adherence to TB treatment is critical and remains a major priority.”

In an accompanying comment, Christian Wejse, MD, PhD, associate professor, GloHAU, Center for Global Health, Department of Public Health, Aarhus University, Denmark, wonders about the cost-effectiveness of Xpert testing.

“At a cassette cost of US$10 (reduced price for low-resource settings), testing large numbers of people with suspected tuberculosis will put substantial pressure on already resource-limited tuberculosis programmes in which the drugs for treatment might not always be available,” Dr. Wejse writes. “Hence, the provocative question raised by this study is whether tuberculosis elimination is most likely to be advanced by distributing GeneXpert machines to all peripheral health facilities in the world, or by investing the same amount in ensuring that health facilities have the set-up available in this study—ie, well trained and paid staff, electricity, and reagents.”

Source: Lancet

Nutritional interventions for reducing morbidity and mortality in people with HIV.


HIV/AIDS has long been synonymous with wasting and weight loss. For example, in South Africa, it was known as “slims” disease. Coupled with this, it’s known that adequate nutrition is important for optimal immune and metabolic function and, so, one might expect that dietary support would improve clinical outcomes in HIV-infected individuals by reducing HIV-related complications and attenuating progression of HIV disease. This should lead to better quality of life and, ultimately, less disease-related mortality. Therefore, this Cochrane Review from February 2013 examines the experimental evidence for the effects of nutritional interventions given orally on important clinical outcomes for adults and children with HIV infection and finds that there is relatively little research to help decision makers.

The authors searched many databases, trawled through references and contacted people working in the area. However, only 14 relatively small, randomized trials came to light, which met their inclusion criteria. Just three of these reported on mortality, two that had recruited adults and the other, from South Africa, had recruited children.

A wide range of macronutrient supplements were studied with just two of the trials (one in adults and one in children) studying the same one, a food supplement called Spirulina. There was also wide variation in other aspects of the trials, including the outcomes that were measured and reported and the types of people who took part, in relation to stage of HIV, HIV treatment status and general nutrient status. When the authors assessed the quality of the trials, none of the trials were graded as providing strong evidence. This was mostly because the trials were small and had a high risk of bias due to a lack of blinding and the large proportion of people who left the trials early.

The latest version of the review is an update of the earlier review from 2007, which had included 8 trials from high-income countries, with fewer than 500 HIV+ adults in total. Patients with confirmed secondary infections or other signs and symptoms of infection, such as fever, chills, or persistent diarrhea, were not eligible for any of those trials. This made it difficult to determine the applicability of the findings to the types of people who are most likely to need effective macronutrient supplementation. Six new studies have been added in the update, bringing the number of participants to more than 1700 adults and nearly 300 children. Four of the new trials are from Africa, and there is one from Brazil and one from India. The new trials also include two trials that had recruited participants with opportunistic infections (tuberculosis and persistent diarrhea).

Bringing the evidence together and, where possible, combining the findings of similar trials in meta-analyses identified no significant benefits for supplementary food, daily supplement of Spirulina or a nutritional supplement enhanced with protein with respect to death in HIV+ adults and children. In HIV+ adults with weight loss, nutritionally balanced macronutrient supplements aimed at improving energy intake by 600-960 kcal/day increased intakes of energy and protein compared with no supplement or nutrition counselling alone, but had no effect on other anthropometric or immunologic parameters. From the meta-analyses, supplementation with macronutrient formulas given to provide protein, energy or both and fortified with micronutrients, in conjunction with nutrition counselling, significantly improved energy intake (3 trials; n=131; MD 394 kcal/day; 95% CI: 225 to 562; p<0.00001) and protein intake (2 trials; n=81; MD 23.5 g/day; 95% CI: 12.7 to 34.0; p<0.00001) compared with no nutritional supplementation or nutrition counselling alone.

The authors conclude that supplementation with specific macronutrients such as amino acids, whey protein concentrate or Spirulina did not significantly alter clinical, anthropometric or immunological outcomes in HIV-infected adults and children. They call for future research that takes better account of the needs and resources of the HIV+ individual, the clinician treating them and the people caring for them. They highlight areas of ongoing uncertainty, including the choice between using resources for antiretroviral treatment for HIV+ people or nutritional interventions, the populations that might benefit most (e.g. malnourished HIV+ people, HIV+ people with uncontrolled weight loss, HIV+ people with opportunistic infections or HIV+ lactating mothers), the role of nutritional counseling compared to nutritional interventions in well-resourced settings, and how the use of anti-retroviral therapy might make it difficult to detect the effects of nutritional interventions.

Soure: Cochrane Library