The Portfolio Committee on Health hosted delegates of the South African Medical Research Council (MRC) for a briefing on violence, peace, injury and effort made on combating the Human Immunodeficiency Virus (HIV) epidemic.
The MRC explained that HIV remained the highest cause of death in South Africa but there was a decline in the rate of infection in children aged below less five years. Also, Mother to Child Transmission (MTCT) of the virus reduced from about 6.4% to 1.5%. However, infection of children below 18 months increased due to engagement in breastfeeding by infected mothers who did not achieve a suppressed viral load. MRC explained some of the efforts made in preventing new infections. It was stated that a comprehensive prevention method would involve the combination of bio-medical, structural and behavioural factors.
Some of the bio-medical interventions were several researches carried out on developing microbicides and vaccines to be used with existing interventions for preventing the acquisition of the virus. Although a lot of research was done on the microbicides and vaccines, it was not yet in use because more research was still being carried out on its usability and efficacy.
From the research conducted by MRC, death through injury was found to be one of the ten leading causes of death in South Africa. MRC complained about the data available on injury as insufficient and too generalized to profile death due to violence and injury. It recommended that the Committee should appeal to the Department of Home Affairs to work with the Department of Health to update the forms used in collecting information on the deceased to include a more detailed cause of death. MRC stated that the number of deaths due to gunshots declined since the Fire Arm Act but was on the rise since 2011. Also, there was an increase in the number of women killed by intimate partners and a general increase in the cases of violent against women. Other issues discussed were road traffic accidents and injuries due to different kinds of burns.
Committee Members engaged the delegates of MRC in a robust discussion, some of the questions asked related to if findings from the MRC research were communicated to appropriate authorities and how they were communicated, the impact of road traffic accidents on the budget of the National Department of Health, why 4.3% of children under 18 months were infected with HIV, and what were the best practices to avoid infection of babies. They also wanted to know how much external donor funds were received by MRC, the side effects of the Antiretroviral Treatment (ART) and if it related to physical changes and cancer in HIV infected patients.
The Chairperson welcomed the delegates and said that since the Medical Research Council (MRC) received the invitation on Thursday 2 November, she expected that it would forward the document to be presented to the Committee despite the late notice. She said that receiving the presentation during the meeting would not give room for Members to adequately read through it in preparation for the meeting. She hoped that the Committee would benefit from the presentation and be empowered through the information that would be provided. She said that the MRC had to bear in mind as it made its presentation that it was meant to empower the Committee in its oversight functions.
Professor Rachel Jewkes, Executive Director: Research Strategy, MRC, apologized for not providing the presentation document before the day of the meeting. She said that the notice was received on Monday and it did not consider rescheduling because it was the end of the year. She said that MRC would do better in the future. She said that the report originated from the presentation of the Annual Report in the month of October, where Committee Members asked for details of the works done by MRC. She said that there were two presentations for the day. She introduced the delegates and explained how the presentation would be conducted.
The Chairperson asked delegates to commence the presentation and put emphasis where necessary.
Presentation by South Africa Medical Research Council
Professor Debbie Bradshaw, Unit Director: Burden of Disease, MRC, explained that death from HIV/AIDS was declining since the introduction of the Antiretroviral Treatment (ART) in 2006. She said that HIV/AIDS was no longer the leading cause of death for children below 5 years of age, which was because of several MRC interventions for the prevention of HIV. Neonatal causes of death overtook death from HIV/AIDS in children below 5 years old.
Professor Jewkes said that HIV/AIDS and interpersonal injury were among the ten leading causes of death in South Africa. She stated that non-communicable diseases were on the increase. South Africa was the only country that had a National Survey that measured the impact of policies of Mother to Child Transmission (MTCT) of HIV on transmission rate. She said that MRC research showed that since 2009, when guidelines were introduced, the rate of MTCT dropped from 6.4% to 1.5% in 2015/16. The MTCT focused on the time of birth; there was an increase in the number of children within 0 and 18 months who were infected by HIV. She said that this was due to breastfeeding by infected parents.
She said that there were a lot of challenges because HIV/AIDS remained the leading cause of death overall. There was a need to strengthen prevention effort particularly among young women, the promotion of prevention of MTCT and promotion of exclusive breastfeeding and provision of maternal ART. She explained that there were multiple contributing factors for the acquisition of HIV which were divided into three types, namely the structural, biological, and behavioral factors. She emphasized that most of the work done on HIV focused on biological factors for acquiring HIV, yet it was necessary to focus on the behavioral and structural factors. She stated that MRC was involved in microbicide research for the past 25 years and after several years of research, incorporating the ART within the microbicide showed the ability to reduce the risk of contracting HIV by 39%. There was also an attempt to replicate the product. She said that Dapirivine vaginal rings was discovered to be safe and effective having the capability of between 27 and 31 percent to reduce risk of infection. She that said research was ongoing and if the ring was approved, it would join the few range of choices for women controlled HIV prevention method. The said application was made, and it was expected that by the middle of 2019 the approval should be received for the Dapirivine rings.
With regards to vaccines, she said that the major work funded by MRC was on developing vaccines. She hoped that there would be positive outcomes. The vaccine did not need to have 100% efficacy rate and did not need to be administered on 100% of the population to be useful; if a vaccine had an efficacy rate of 30% and it was administered on 20% of the population, about 5.5 million South African could be prevented from acquiring HIV. She said that there was a demonstration project on pre-exposure prophylaxis by the National Department of Health (NDOH). It was found that the pre-exposure prophylaxis worked better for men than women. She said that the South African Demographic and Health Survey done by the SAMRC were used to assess the health and disease risk factors in the population.
Professor Catherine Mathews, Unit Director: Health Systems Research, MRC, said that 6.3% of infants born to infected mothers died and were infected with 18 months. She said that the MRC contributed to policies, dialogues and guidelines on infant feeding. There was currently a single guideline for HIV negative and positive women. She said that there was a low rate of exclusive breastfeeding in South Africa, though studies showed an improvement which had to be sustained. Studies showed that young people were at risk of infection because of early sex and inconsistent use of condoms. She said that most of the HIV prevention work focused on schools and was enrolled in designing, aligning and implementing supports for schools. She said that the Vuka family intervention focused on perinatally infected adolescents and was identified as the best practice example for HIV infections. Combination prevention which used the structural, behavioral and biological factors was recommended as the best practice. She emphasized that critical roles were played by Community Health Workers (CHWs).
Professor Mathews said that MRC conducted a home-based testing trial which used lay counselors, and key findings showed that there were increased HIV testing and gave a unique opportunity to reach couples and people who were never tested for HIV infection. There were findings that CHW’s had the ability to cover more areas in testing and increase adherence to treatment by use of ART. There was a need for wise investment on CHW’s. A well-resourced community based platform would save the country an enormous amount of money. The office was currently funding 55 projects. SAMRC was currently investing R45 million a year on the HIV portfolio.
The Chairperson asked if members would like to ask questions now or after both presentations
Ms S Kopane (DA) said questions should be asked by Members after the two presentations.
The Chairperson said the delegates should continue with the second presentation
Professor Rachel Jewkes introduced the second presentation which was on violence, peace and injuries.
Professor Bradshaw said that statistics on injuries were not readily available. She said that the MRC went through the mortuaries to get the needed information. There was a decline in death due to violence and injury; the number of incidence was reduced by half. She said that the next source of injury was road traffic injury while the suicide rate was steady over time. There were concerns around the availability of data for injury mortality. She said that data collected by SAMRC showed a large variance from the National data. She said that the reason for this was that the death notification form should be changed. There was a need for an agreement among the NDOH, Statistics South Africa and the Department of Home Affairs to include an additional field on the death notification form to show if it was suicide, homicide or accident. She requested the Committee to help in addressing that challenge.
She said that the number of deaths from gunshots reduced in line with the firearm Act. However, since 2011 gunshot deaths was on the rise. She said that observations were that availability of gun licenses and availability illicit guns contributed to the murder rate. She stated that there was a significant drop in the involvement of guns against women from 33% in 1999 to 19.5% in 2009. A surveillance system through the mortuary was set up in four cities which was operational in Mpumalanga and Gauteng to allow the collection of more detailed information. The information would help to profile the data and identify vulnerable groups.
Professor Naeemah Abrahams, Unit Director: Gender and Health Research Unit, MRC, said that South Africa never conducted a dedicated national study on violence against women until now. She explained the findings of the research in Gauteng on rape against non-intimate partners. She said that there were two national studies, in 1999 and 2009 on femicide. She said that four women were killed per day and in 1999, and it reduced to three femicides per day in 2009. However, there was an increase in the number of women killed by intimate partners. She said that for every 1 000 sexual offences reported in 2009, there were nine offences of sexual homicides. She said that in 2009, about four children a day were murdered. Most of them were male children, including neonates, which indicated a need for more work to be done on reproductive health. She said that there was an indirect link of gender based violence on HIV infection. In a study on sex workers in Soweto, 90% of the women exposed to violence, more than one sexual assault and more than 50% of them tested positive to HIV infection, and 60% of them had drug resistant HIV and was never on ART.
Mr Aziel Gangerdine, Head: Corporate and Marketing Communications, MRC, said that the MRC was involved in research with many partners. He said that South Africa had a high rate of burn mortality, young adult and older adult, infants and toddlers were affected respectively. About 3% of South Africans may suffer burns, 40% of which were children and about 20% of the 3% may be hospitalized. Burns were primarily due to hot liquids and some from open flames and hot surfaces. Majority of the burns were due to accident and a few cases due to violence. Three major forms of burn phenomenon and major losses were due to informal settlement fires and spills from hot liquids at home. He said that most burns were because of the resolution to using unsafe types of energy due to high rate of poverty. Fire incidence due to paraffin stove cost the country about R40 billion per annum. He said that of all the types of illnesses, the burn had the longest hospital stay. He highlighted the need to revisit the policy on the use of paraffin stoves.
He said that there were more injuries from road traffic accidents. Fatal road traffic accident rates increased in the evenings, weekends and more in the month of December, due to alcohol consumption. Also, a finding showed a correlation between rain and road accidents and SAMRC was working on how to manage interventions for the rainy days.
Professor Jewkes said that the MRC was conducting research to know what happened to opened rape cases. Findings showed that, of all rape cases opened, only 55.7% went for prosecution because in most cases police were unable to make an arrest. She said that sometimes the victims decided not to press charges. Overall, only 18% went to the trial of suspects and only 8.6% ended with a guilty charge. There was no improvement over a nine-year period in the way rape cases were investigated. Also, she stated that there were several complications around the prosecution of rape perpetrators. She highlighted the need for good policing and improved medical research. She said that the structural drivers of violence against women were the same for increasing HIV infections. There was a need to prevent violence by starting with early childhood violence prevention. She explained the link between masculinity and gun involvement with violence.
The Chairperson said that Member should ask a maximum of three question and not repeat questions already asked by other Members, to save time.
Ms C Ndaba (ANC) thanked the Chairperson and welcomed the presentation. She asked a question concerning the cumulative HIV incidence within 18 months. She asked why 4.3% of children under 18 months were infected with HIV. What was the best practice to avoid infection of babies?
Mr S Jafta (AIC) said that he did not want to sound xenophobic, but wanted to know if foreign nationals were involved in spreading violence and the spread of HIV/AIDS.
Ms S Kopane (DA) said that it was unfortunate that Members did not get the documents earlier and noted that it would have improved participation of Members in the meeting. She asked how much funding came from external donors. She appreciated the research done on Community Health Workers, because Community Health Workers were often not appreciated. She appreciated the cumulative savings of the country if CHWs were used. She asked how well the findings were communicated to different government departments; NDOH and Department of Social Development. She asked if there was research carried out on the capabilities of the CHWs. Also, was there was any research done by the violence, injury and peace research unit, especially in the Western Cape where violence was high. She said that the research showed that much had to be done about poverty which was a baseline factor for violence and HIV infection.
Dr P Maesela (ANC) said that the economy and socializing factors might be the major drivers of HIV and violence. He reasoned that if the two factors were addressed by the research, especially the economic factor, there might be a reduction in HIV infection and violence.
Ms L James (DA) said that she wanted to understand if there was evidence of breastfeeding preventing HIV infection in babies and what type of breastfeeding provided this advantage, if it was exclusive or breastfeeding combined with baby formula. She asked if there were short term advices on the death due to violence and injuries, especially as they escalated during December which was soon approaching. She asked what the impact of road accidents was on the budget of the NDOH.
The Chairperson said that she expected that MRC would reflect that the country was a violent society, not because of its own doing, but because of the system. She said that citizens were not yet psychologically demobilized of the assumption that things had to be done through violence. She noted that the presentation was general, because the other classes of citizens had to be concerned. She asked if findings were referred to the Departments of Justice, Social Works and Basic Education. She said that the report had to reflect that there were women that were abusive. She was worried that the research on burns was only done in Cape Town. She said that violence from acid burns was excluded from the presentation. She said that the presentation should talk about pedestrians that caused accidents due to their drunkenness. The presentation was empowering but it was a little bit too technical; it had to be easy to understand because it was a public document. She said that places within the Provinces where certain research was conducted should be specified.
Mr T Nkonzo (ANC) asked the MRC to explain the implications of toxins in pills taken to prevent pregnancy.
Chairperson said that Mr Nkonzo’s question would be answered towards the end of the discussion
Professor Mathews said that exclusive breastfeeding was required by all nursing mothers but would be ideal in nursing mothers who were HIV positive only when they achieve a suppressed viral load. The 4.3% infant infection was driven by breastfeeding with high viral load drives. A combination of suppressed viral load and exclusive breastfeeding prevented HIV infections and other neonatal problems. She stated that the investment was commissioned by government and it was shared with the Department of Health and National Treasury. She did not know the capability of the home-based care workers but the use of home base care workers for keeping patients out of hospitals was based on research evidence.
Ms Jayajothi Moodley, Senior Scientist, MRC, said that the World Health Organisation (WHO) technical team met in 2012 to review observations and studies around DMPA and HIV infection. They developed a set of contraception guidelines which was included in the National Contraception guidelines by the National Department of Health (NDOH). There was currently an ongoing process to compare the vulnerability caused by different contraceptives such as DMPA, the implant and IUCD and the result of this would be communicated to the Committee when it was completed. She said that the vaccine research was currently at its infancy stage and MRC was working out a vaccine that had the longest efficacy, however this might take some time. She said that all clinical research had a collection on reactions and possible side effects, which were included in the investigators brochure. This might influence excluding people that were vulnerable to toxicity or use a detailed safety profiling to address the safety of users.
Mr Gangerdine said that the intervention work done by violence, injury and peace research unit was focused on strengthening relationships in the community although this was not the specialty of the entity. He said that the prevalence of violent attacks using burns was about 20% in Western Cape and 10% in Mpumalanga. Although acid burn was not considered by MRC earlier, it would work on isolating the data for acid burns. The advice offered by MRC on the road traffic injury problem was very useful. It was taken up by the Department of Transport. The MRC was a part of the campaigns for reducing accidents. He said that children who walked long distances were vulnerable to road accidents. There were discussions around infrastructure and the mass transport system. The rate of the accident did not go down because structural changes were needed to drive reduction in the number of road accidents; however, some of these changes were already taking place.
The Chairperson asked MRC to state the contributions of the pedestrians, especially drunk pedestrians to accidents.
Ms James asked what the impact of road accidents was on the budget.
Mr Gangerdine said that the impact of attending to about 250 000 road accidents per year was high on the budget. He said that when a drunken person walked on a road that lacked pedestrian pavements at night; the danger of road accidents became higher. He said that one of the interventions for pedestrian was the provision of school bags made with reflective clothing for young children as a visibility aid.
Professor Bradshaw said that MRC did not carry out any research on the contributions of foreign nationals to violence and HIV/AIDS infection. She was not aware of any research in that direction, but MRC just launched the initiative to strengthen the demographic and health surveillance site. She said that there was existing research, about 25 years old, which gave information on Mozambican refugees; their living situation and health. More of this would be created in urban centers which could provide in-depth information on foreigners.
Professor said that the alcohol research unit would be able to give more information on the fatalities on the road. There was a need to improve suburban planning to include the safety of pedestrians. She said that most of the solutions were multi-sectoral and did not lie primarily with the health sector. She said that the gender and health unit was highest funded unit with above R300 million, the HIV/AIDS prevention unit had about R150 million, health systems had R30 million, burden of disease units R6 million or R7 million, all external donor funded contracts. All the units received co-funding from the MRC. The funds from the National Treasury were not enough to fund all the activities of MRC. She said that there were social norms on gender and an overlapping highly connected social norm on the use of violence. Some women were also abusive towards children and neighbors and a few times towards their husbands. She said that research showed that men with power used the power to sexually abuse women. Research in Eastern Cape showed that powerful men had the tendency to abuse women. There was a major challenge with the abuse of power, but intimate partner violence was associated with poverty. She said that addressing women vulnerability was important. She added that the criminal justice finding was presented to the National Prosecuting Authority (NPA).
The Chairperson said that she would like to contest three areas of the presentation. There was violence in some white areas, so she resisted the impression that black poor people were violent. She said that she did not agree that women that were violent were retaliating abuse by men because she was sure that there were violent women, albeit a small fraction of the community. She cited having come across men that were abused by their wives. She requested for a well-balanced report. She said that MRC was silent about opportunistic diseases such as Tuberculosis and Meningitis. She noticed that some of the people on ARTs were disfigured and asked if the ART had this side effect and wanted MRC to discuss the challenges associated with the use of ART. She said that the understanding with people about nutrition also had to be addressed. She said that there was an impression that it was a race that was responsible for violence which should not be so. She said that she would write MRC on the areas that the Committee needed more information.
Ms Ndaba said that she was triggered by the Chairperson’s discussion on the side effects of ARTs. She said that most women known to her, who were on ARTs, ended up with breast and cervical cancer; she felt that cancer was not prevalent in the black communities before now. She said that there was a need to do research on the side effects of ART drugs on the health of HIV positive people, checking to see if there was a relationship between ART and the prevalence of cancer.
The Chairperson said that the Committee would expect a response next year. She also pleaded with the MRC to simplify the research in a way that it would be reader friendly because it was a public document. She informed the Committee of a joint meeting with Basic Education and Social Development which was slated for next week and another meeting with the Portfolio Committee on Agriculture on the same day. She said that the Committee would likely share Members between the two meetings. She requested that Members should attend the meetings.
The meeting was adjourned.