WHO says: Male circumcision should be part of HIV prevention

Researchers have known for years that circumcision significantly reduces the spread of HIV virus in men, and that uncircumcised men are 3 times more likely to contract HIV. Male circumcision is the surgical removal of the foreskin from the penis. Researchers state that removal of the foreskin makes it more difficult for the virus to penetrate the skin of the penis. The underside of the foreskin has special immunological cells which are targets for the HIV virus. Male circumcision is associated with a lower risk of male genital diseases like cancer of the penis, balanitis and phimosis.
Some studies indicate that women partners of circumcised males have a lower risk of cervical cancer.

The World Health Organization (WHO) has announced that based on studies in Kenya, Uganda and South Africa, male circumcision reduces the risk of heterosexually transmitted HIV infection in men by 60%. Surprisingly, only 30% of men worldwide are estimated to be circumcised. Health experts recommend that circumcision be offered as part of safe sex promotion practices. They want to make clear that circumcision does not provide complete protection against HIV and other diseases, and all other practices such as use of condoms should be followed.

HIV/AIDS is the most serious health problem in much of Africa, including Uganda. Ugandan experts cite the tragic situation they face in losing a generation to whom the elderly would traditionally impart their wisdom. Circumcision rituals are an integral part of this wisdom. In many African cultures, the circumcision ritual takes place during puberty and marks the child's acceptance into the tribe as an adult. Boys are often circumcised in a group. During the period of recuperation after the ceremony, the newly circumcised are taught tribal history and traditions. Health care workers are calling for male circumcision services to be delivered in a manner that is culturally sensitive and adhere to medical ethics and human rights standards of informed consent, confidentiality and absence of coercion.

Getting the word out to populations who may not have access to this information will be the responsibility of every clinician. Make sure to talk to the sexually active males in your practice today. Find out if they are circumcised. Educate them and their partners about the health advantages of circumcision. Refer them for circumcision services and help stem the tide of HIV transmission.

Thank you JaxinCPT for use of your photo Makishi dancers wiping away footprints.

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Thank You MedViews For Grand Rounds 3.27!

Dr. Stuart Henochowicz has put together a fascinating array of articles in Grand Rounds 3.27 in his blog MedViews. Thank you so much for including my post:

Global HealthBeat: AIDS in India

For more posts on AIDS see,

AIDS: Why are people of color hit so hard?

For other global health posts see:

XDR-TB: Extremely Drug Resistant, Extremely Scary
World Water Day 2007: 4500 Children Die Daily

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Most Angioplasties Unneeded, According to New Study

Half a million patients a year with chest pain are getting unnecessarily or prematurely treated with stents to open blocked arteries when drugs are just as effective, according to an upcoming study in the New England Journal of Medicine.

Stenting is an increasingly common procedure where a tiny balloon is inserted into a severely blocked artery, and then removed, leaving the device to hold the artery open. Stents were developed to combat the tendency of many blood vessels to close quickly after an angioplasty. Angioplasty and stenting usually cost between $25,000 and $50,000.

The New York Times reports:

Since 2002, practice guidelines from the American Heart Association and the American College of Cardiology have called for using angioplasty and stenting — or bypass surgery, an even more invasive alternative — only after extensive efforts to treat the symptoms of such patients with drugs. But they have been increasingly ignored, cardiologists say, by patients and doctors choosing the more immediate and initially reliable relief provided by stenting.

Patients who received stents did not live longer or have fewer heart attacks than patients treated only with drugs. In both groups, 7 of 10 were free of chest pains after 5 years of treatment.

Previous studies have shown that stenting is recommended for patients who have poor blood flow to the heart during stress or exercise that isn't relieved by rest or medication. Stenting can also save lives when used during heart attacks.

But a half million Americans who get stents fall into the group in this study that isn't believed to be in danger of a heart attack despite accumulated plaque narrowing the coronary arteries by 70% or more.

"You are not putting yourself at risk of death or heart attack if you defer," and considering the safety worries about drug-coated stents putting patients at increased risk of blood clots, it may be wise to wait, said Dr. Steven Nissen, a Cleveland Clinic heart specialist and president of the College of Cardiology.

The study is not without its detractors - especially from companies who manufacture stents, which generate $3B in sales, and doctors who perform angioplasties.

One of those doctors spoke at a meeting sponsored by stent maker Boston Scientific Corp., and was responsible for the leak of the study's results, which weren't due out until Tuesday.

The study "was rigged to fail, and it did," said Dr. Martin B. Leon of Columbia University to several hundred of his colleagues Sunday night. "A lot of people have been taking shots at us, and we need to go on the offense for awhile." Columbia responded by saying that it was "extremely disappointed" that the study's results were released prematurely, and "will be considering strong sanctions againgst the individual or individuals involved."

As for why angioplasty doesn't help more, experts point out that it treats only one affected artery at a time, while drug therapies work on all arteries. Also, the kinds of blockages treated by angioplasty tend to be less lethal.

"Even though it goes against intuition, the blockages that are severe that cause chest pain are less likely to be the source of a heart attack than segments in the artery that are not severely blocked," said Dr. David Maron, a Vanderbilt University cardiologist who helped lead the new study.

"Often I think that patients are under the impression that unless they have [a stenting] procedure done, they're not getting the best of care and are at increased risk of having a heart attack and die," continued Dr. Maron. "This study shows that is not true."

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XDR-TB: Extremely Drug Resistant, Extremely Scary

Tuberculosis has likely plagued humanity since the origin of our species. In 460 B.C., Hippocrates identified Phthisis (Greek for wasting) as a fatal disease that was most prevalent in the population at that time. Throughout human history, tuberculosis has killed millions, more than any other pathogenic organism. Tuberculosis flourishes wherever poor living conditions exist - poor ventilation, crowding as in densely populated urban areas and prisons. During the Industrial Revolution, tuberculosis decimated the urban poor and in 19th century England, it was the cause of one in four deaths. The unknown and the famous: poet John Keats, Frederick Chopin, Dr. Anton Checkov, George Orwell, Emily Bronte, Robert Louis Stevenson were all victims of the disease. Dr. Robert Koch stunned audiences in 1882, identifying Mycobacterium tuberculosis (Mtb) as the bacterium causing TB. He won a Nobel Prize in Physiology or Medicine in 1905 for his discoveries about TB. A vaccine was developed in 1908, but by the 1940's, antibiotics like streptomycin were the drug of choice. The big three; isoniazid, rifampin and ethambutol were soon introduced and by the 1960's, it seemed the epidemic was controlled.

Today, one hundred and twenty five years after Dr. Koch identified the organism, public health officials believe that one third of humans, or 2 billion people, are infected with TB. 1.6 million people died of TB each year in 2004 and 2005 and 85% of the victims resided in Africa and Asia. Of the 1.6 million who died of TB, 195,00 were co-infected with HIV. Public health officials describe a "deadly synergy" between HIV/AIDS and TB which has contributed to the spread of the disease and resistance to drug treatment. TB is now the leading cause of death for people with HIV/AIDS. The ICRC (International Red Cross) reports that TB is 100 times more prevalent in prisons than in the general public, and prisons in Central Asia, Africa and the Caucasus are seeing an increase in drug-resistant cases. TB is an airborne illness that is treatable, but if not diagnosed early, it can mutate into drug-resistant strains. Africa's large AIDS population has been hit by a virulent strain: XDR-TB. This strain is now found in the US and Canada, in all 35 countries world-wide. What is frightening about the outbreaks is that they are not transmitted person to person but seem to be a progression of mutation independent of geographic barriers.

MDR-TB (Multi-drug Resistant TB) is a strain of the disease that is resistant to isoniazid and rifampicin. XDR-TB is resistant to 3 or more of the 6 classes of second line drugs. XDR-TB was first found in South Africa in the HIV/AIDS population. It is thought that resistance to drugs is the result of poorly managed care--incorrect prescribing practices, non-compliance with prescription therapy, and poor quality drugs with erratic supply. When people are given enough medication to allay symptoms but not kill the organism, the organism mutates to resist the drug. Additionally, there are significant problems with drug interactions between anti-tuberculosis and anti-HIV medications that may make compliance difficult for patients. There is no known cure.

Clinicians may want to participate in the on-line eForum, One-in-Ten Campaign.
The Tuberculosis Coalition for Technical Assistance (TBCTA), a partnership of WHO, CDC, USAID and others has published an on-line resource: International Standards for Tuberculosis Care.

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World Water Day 2007: 4500 Children Die Daily

The UN General Assembly designated March 22 as World Water Day to draw attention to the critical lack of clean drinking water worldwide. The world water crisis is one of our most pressing public health issues, with 20% of the world's population (or 1.1 billion people) lacking access to safe drinking water and nearly two thirds of those people live in Asia. 2.2 million people died from drinking unsafe water in 2004 and 90% of those were children.

Given the technological advances much of the world is enjoying, this is an appalling situation.

• Clean drinking water and basic sanitation are prerequisites for health and human rights.
  
• No diseases that plague the world today can be adequately controlled if people do not have clean water and sanitation.
• While the number of people with access to clean water has increased since 1990, the absolute number is impacted by the increase in the global population
  
• Industry accounts for 21% of world water uses. Corporations have an opportunity to partner with governments and civil society to be advocates and providers of clean water.
• Lack of clean water for people hurts businesses because it negatively impacts human resources: increased illness, absenteeism and reduced productivity and labor supply.
• Go to Maplecroft Maps for a comprehensive tutorial about water resources.
  
• Women and girls in rural parts of the world must walk as much as 6 miles a day to provide water for the household.

Join a Walk for Water on March 24, 2007, inspired by the women who walk for water for their families in water stressed countries. For a list of Walk for Water participants, go to
World Water Day 2007.

Thank you Demosh for use of your beautiful photo, Women.

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Global Healthbeat: AIDS in India

The first case of AIDS reported in India was in 1986. Today, 5.7 million people in India are living with HIV/AIDS, and all but 500,000 of those are 15-49 years old. A few global NGO’s are stepping forward to help stem the tide. The Kaiser Family Foundation reports that India, the world’s second most populated country, is at a critical point in this epidemic. HIV could explode, but if large-scale prevention and other interventions are implemented, the expansion could be curtailed.The Bill and Melinda Gates Foundation report that multiple issues make the India epidemic unique: multiple local epidemics, high risk behavior groups are dispersed and mobile and an environment of apathy and denial make a publicly coordinated approach to prevention challenging. UNAIDS in India has coordinated an interagency action plan and reports progress in prevention as a result of building a comprehensive, multi-faceted response.

One third of India’s HIV/AIDS cases are women, and the predominant route of transmission in India is via unprotected heterosexual sex.One third of India’s HIV/AIDS victims are under the age of 30. Both the Kaiser Family Foundation and The Gates Foundation’s Avahan Program has partnered with Heroes in Action, a national initiative seeking to decrease the stigma and silence of AIDS and increase education and awareness. Banning HIV positive children from school is just one problem they have reported.

NACO is India’s Ministry of Health Department dedicated to seeing that AIDS victims are treated with dignity and have access to quality care. In 2006, NACO conducted a comprehensive study of tribal people and HIV/AIDS. Nearly ten percent of India’s population are tribal and tribal states lack an adequate health infrastructure. They find that tribal populations are particularly vulnerable due to illiteracy, mobility and women are sexually active at an early age. A Tribal Action Plan has been implemented to increase awareness and understanding of the disease and improve access to health services.

India, with a growing base of middle-class consumers, is increasing its global clout as a business and economic leader, yet it struggles with serious social, environmental and equity problems. HIV/AIDS seems to be one thorny issue the country is getting right , as a study last year reports a decline in new cases in some areas of India.

Thank you Calumar, for use of the photo.

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Obese Boy Almost Taken into Protective Custody

An 8 year-old boy in Britain narrowly missed being taken into protective custody today due to concerns about his weight. Connor McCreaddie has been on a regimen of improved diet and exercise over the past six weeks, after his mother sought the help of government health workers. At the time, the 8 year-old weighed 218 pounds.

The government intervened, recommending lifestyle changes, and monitoring Connor's progress closely. He has lost over 20 pounds in the past six weeks, and in doing so has avoided being taken into state custody for his own wellfare. He has trouble washing and dressing, misses school regularly because the five minute walk leaves him breathless and sometimes vomiting, and is targeted by bullies.

Poor diet and sedentary lifestyle are the primary causes of Connor's condition. His diet consists of burgers, steaks, buttered toast, sausages, and fast food. He has snacks every 20 minutes, eating four bags of potato chips, three packets of biscuits and several chocolate bars each day, which he eats in front of the TV. He refuses to eat fruits or vegetables.

Obvious parenting issues aside, Connor's tragic condition is indicative of worldwide trends that should concern us all.

An article in the Archives of Internal medicine said succinctly:

"Obesity and sedentary lifestyle are escalating national and global epidemics that warrant increased attention by physicians and other health care professionals. These intricately linked conditions are responsible for an enormous burden of chronic disease, impaired physical function and quality of life, at least 300 000 premature deaths, and at least $90 billion in direct health care costs annually in the United States alone."

The World Health Organization (WHO) estimates that 1.6 billion people around the world are overweight or obese, and calls sedentary lifestyle "one of the ten leading causes of death and disability in the world", and what's even more frightening is how many people are affected:

"Data gathered on health surveys from around the world is remarkably consistent. The proportion of adults who are sedentary or nearly so ranges from 60 to 85%."

These statistics scare me, as do heart disease, diabetes, oseoarthritis, and depression, which commonly result from obesity.

The nice thing about these issues is that it's easy for me, you, and everyone we know to make an impact. Choose the turkey sandwich instead of the cheeseburger. Walk to the store instead of driving. You can vote with your feet, and your food.

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