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New Pro-Circumcision Guidelines: Cutting Comments, Adolescent Choice

Preparing for a circumcision

Preparing for a circumcision (Cheskel Dovid/Wikimedia Commons)

Just days after the U.S. Centers for Disease Control and Prevention issued draft recommendations on male circumcision asserting that the health benefits outweigh the risks, more than 300 comments (and counting) have been posted on the agency’s website.

Surprise: The feedback overall reflects anger over mounting institutional support for what some call a “barbaric, outdated practice.” (The public comment period on the agency’s proposed recommendations ends on Jan. 16.)

Here are a few random comments:

When I was a little girl and discovered my little brothers had been cut, I was horrified for them and grateful I wasn’t born a boy.

The only benefit of infant circumcision is the fatter wallet of the circumciser. Wake up people! Condoms prevent sexually transmitted diseases, not circumcision. Males deserve the same protection from genital cuttings that females do. Shame on the CDC for condoning such a barbaric, outdated practice that nearly every other industrialized nation has refused to adopt!

Routine infant circumcision is morally wrong because it is non-essential cosmetic surgery performed on the body of a human being not yet old enough to give informed consent….

Your agenda clearly shows your primary purposes is for health insurance to pay for male genital mutilation. Please don’t continue to make the U.S. the continued laughing stock of the international medical community.

You get the picture.

The CDC stopped short of actually telling parents they must circumcise their baby boys; instead the agency offered guidelines — including a new recommendation that un-circumcised adolescent boys discuss the risks and benefits with their doctors — and laid out the latest research. Male circumcision, according to an AP report, can:

•Cut a man’s risk of getting HIV from an infected female partner by 50 to 60 percent.

•Reduce their risk of genital herpes and certain strains of human papillomavirus by 30 percent or more.

•Lower the risk of urinary tract infections during infancy, and cancer of the penis in adulthood.

Studies have not shown that circumcision will reduce an HIV-infected man’s chances of spreading the AIDS virus to women. And research has not found circumcision to be a help in stopping spread of HIV during gay sex.

The guidelines say circumcision is safer for newborns and infants than for older males, noting the complication rate rises from 0.5 percent in newborns to 9 percent in children ages 1 to 9, according to the CDC. Minor bleeding and pain are the most common problems, experts say.

CDC officials are recommending doctors tell parents of baby boys of the benefits and risks of circumcision…

These are the first federal guidelines on circumcision, a brief medical procedure that involves cutting away the foreskin around the tip of the penis. Germs can grow underneath the foreskin, and CDC officials say the procedure can lower a male’s risk of sexually-transmitted diseases, penile cancer and even urinary tract infections.

I asked circumcision expert Marvin Wang, co-director of the newborn nurseries at Massachusetts General Hospital (and someone who has performed thousands of circumcisions), about the new CDC draft recommendation, and he offered this thoughtful analysis:

First a little history:

For decades, the American Academy of Pediatrics (AAP) (which produces the majority of research-based policy for U.S. pediatric care) has led a relatively neutral stance on male neonatal circumcision, as the literature has shown that there is a relatively small health benefit by performing circumcision (there is huge debate on how one interprets the numbers on this, but overall, that conclusion is true). However, a game changer that tilted the balance towards claiming health benefits came in 2005-2007, when three separate World Health Organization clinical trials were performed in Africa demonstrating that circumcision among adult men in Sub-Saharan African settings reduced the acquisition of HIV by 50%.

With that, the AAP changed its recommendations in 2012 to reflect these studies. Their statement basically said that, yes, we know that there are health benefits now – enough to encourage parents to strongly consider circumcision for the newborn. However, the decision still lays with the parents, balanced by their beliefs (which may be influenced by religious, social or familial reasons). There are other tenets to the statement, but let’s just focus on this one topic, as this is most relevant to the recent CDC statement.

In light of the infectious disease issues involved, the medical community had been told that the CDC would make their recommendations regarding circumcision at about the same time as the AAP’s release. So, with this week’s statement, you are basically seeing a reaffirmation of the 2012 AAP statement. We don’t really see anything new. The health benefits touted in the CDC report have all been discussed before in the literature.

The only potentially new issue here is a topic that the 2012 AAP statement neglected: The idea of encouraging un-circumcised adolescents to discuss the option with their physician. Continue reading

Study: New Way To Hold Back Herpes, Keep Virus Latent

Fluorescent staining shows areas of the cornea affected by herpes virus that infected a man's eyes. (Photo: Wikipedia)

Fluorescent staining shows areas of the cornea affected by herpes virus that infected a man’s eyes. (Source: Wikipedia)

Chances are, you’ve got herpes, I’ve got herpes, we’ve all got herpes.

Studies find that by age 60, virtually all adults carry herpes simplex virus 1 — best known for seeping cold sores but also potentially blinding when it hits the eyes. Herpes simplex virus 2, the sexually transmitted disease, infects more than a quarter of people by their forties, the CDC says.

While anti-viral medications can help, there is no cure for herpes viruses. Their wily ways of going latent between recurrences, hiding out in viral reservoirs in our bodies, make them supremely hard to eradicate.

So it’s welcome news that a study just out in the journal Science Translational Medicine describes a whole new strategy for beating down herpes viruses and keeping them down — at least in mice, rabbits and guinea pigs.

Far fewer of the mice died or had virus spreading throughout their bodies.

It’s a tactic that researchers say may also hold promise for attacking HIV, another virus whose habit of hiding out makes it hard to kill, and the herpes zoster virus that causes excruciating shingles.

The new method hinges on epigenetics — specifically, protein “packages” that determine how genes are turned off and on.

For a herpes virus to go from a latent state to an active state, it needs to unpackage or unbundle its genes so they can be “turned on” and begin to replicate and spread. But, the researchers found, if they block an enzyme called LSD1, those genes tend to stay bundled up and inactive.

It’s as if the viral DNA encoding the genes needed to reactivate the virus naturally carries a “Don’t open me!” sign on it, says the paper’s senior author, Dr. Thomas M. Kristie. The LSD1 enzyme can remove that sign. But block the enzyme and the “Don’t open me!” sign stays up. Continue reading

World AIDS Day: A Look At The Gains And Challenges In The Fight Against HIV

A woman adjusts a red ribbon, symbol of the fight against AIDS, during a demonstration on World AIDS Day in Spain on Dec. 1, 2014. (Alvaro Barrientos/AP)

A woman adjusts a red ribbon, symbol of the fight against AIDS, during a demonstration on World AIDS Day in Spain on Dec. 1, 2014. (Alvaro Barrientos/AP)

From ribbons to lights on buildings, you may have seen a lot of red Monday — it’s the symbolic color for World AIDS Day (Dec. 1), which raises awareness about HIV.

The day began in 1988, some years after the AIDS epidemic was first identified in the early ’80s. As the world marks the day with events and vigils, here is a look at the current state of HIV:

Continue reading

Doc: Lyme Underreporting ‘No Surprise’ But Big Problem

It was big news this week when the CDC announced that cases of Lyme disease were vastly underreported and that, in fact, about 300,000 Americans are diagnosed with the disease each year — 10 times its previous estimate. Lyme disease now has this distinction according to the public health authorities: It’s the most commonly reported tick-borne illness in the United States.

In the latest NEJM Journal Watch’s HIV and ID Observations blog post, Dr. Paul Sax, clinical director of the HIV Program and Division of Infectious Diseases at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, writes that he’s not at all surprised by the Lyme disease underreporting and offers a few theories on what’s behind it:

Go ahead, check my math — that’s a whopping 10:1 ratio of actual to reported patients with Lyme, highlighting that this reporting is something we clinicians just don’t do very well.
lymedisease

And it’s no surprise to me at all.

Here’s why:

–Clinicians are busy doing other stuff, most importantly taking care of their patients.
Lyme is one of many reportable diseases — take a look at this list!
–It’s annoying. If you asked 100 doctors and nurses what they like least about practicing medicine, 74.39% would say “the paperwork.”
–The forms can’t be completed quickly, as they request detailed information about dates of exposure and onset of illness, presence of diverse associated symptoms, and evaluations for ancillary diseases. Plus, they’re paper forms — a particular problem in an increasingly web-based and electronic medical record world. As for the specific dates of possible exposure and onset of symptoms? “I just lie,” one PCP told me.
–“Soft calls” won’t get reported at all. Think about the febrile, achy patient in the summer who’s just spent a weekend hiking in the woods, saying ticks were everywhere, then gets treated (appropriately) for suspected Lyme. That may be the billing code the clinician uses, but often as not, no Lyme test is sent.
–No one’s paying for these reports. Forgive the mercenary tone to the comment, but as these folks will tell you, humans are very predictable creatures — give them some incentive to do something, and they’ll often do it, even if the task is unpleasant.

Sax suggests that those seeking a fix for the underreporting problem might benefit from looking at the history of HIV, Continue reading

Advocates: End Of AIDS In Mass. Within Reach

Frank, a 21-year-old homeless man, takes in Cambridge Commons. (Photo: Martha Bebinger/WBUR)

Frank, a 21-year-old homeless man, on his favorite Cambridge Commons bench. (Martha Bebinger/WBUR)

Could Massachusetts stop — not just reduce but actually stop — the spread of HIV and new cases of AIDS?

Some activists say that with a little more money and a targeted plan, the end of AIDS is within reach here.

“It’s possible for us to end the AIDS epidemic in Massachusetts,” said Rebecca Haag, president and CEO of the AIDS Action Committee of Massachusetts. “This came on our watch and I believe we should put an end to it.”

You may be shaking your head and asking, “Really?”

Well, Haag says, think about this figure: 657. That’s the total number of new HIV cases reported to the state Department of Public Health in 2011. Compare that with the many hundreds of Massachusetts residents who were dying of AIDS every year from the mid-1980s through the mid-1990s.

In 1994, the worst year, 1,156 died. Overall, nearly 13,000 Massachusetts residents died of the disease, and more than 18,000 are now living with it.

But recent years have seen major progress.

“In Massachusetts, we have been successful in dramatically reducing new incidence of HIV infection and are approaching levels that start to look like an unsustainable epidemic, over the long term,” said Kevin Cranston, who directs the Bureau of Infectious Disease at the Department of Public Health.

When might there be so few new cases that HIV dies out? Cranston says it’s hard to predict, in part because Massachusetts is down to the hardest-to-reach cases. Most of them are young gay men in poor city neighborhoods.

Like Frank. When his dad found out he was gay, he was kicked out of the house. Frank, who’s 21, turned to prostitution. Continue reading

How An AIDS Specialist Read Recent News Of A ‘Breakthrough’

HIV particles, yellow, infect an immune cell, blue. (NIAID_Flickr)

HIV particles, yellow, infect an immune cell, blue. (NIAID_Flickr)

By Paul E. Sax, MD
Guest contributor

There it is, right in your daily paper, on your tablet or computer screen, or wherever you get your news today — a headline about a great medical breakthrough everyone’s been waiting for:

Scientists On Brink Of HIV Cure
Researchers believe that there will be a breakthrough in finding a cure for HIV ‘within months’

Yes, I read this exact headline recently. Here’s the full article, published in the English newspaper the Daily Telegraph. It details how some Danish researchers have figured out a way for “the HIV virus to be stripped from human DNA and destroyed permanently by the immune system.”

Dr. Paul Sax (Courtesy BWH)

Dr. Paul Sax (Courtesy BWH)

Furthermore, they are “expecting results that will show that finding a mass-distributable and affordable cure to HIV is possible.”

By all means, go ahead and read the full piece; you’ve got 20 free reads on the Telegraph website. As a treat, there’s a colorful stock photo too, showing red blood cells floating through some blood vessels, along with a few HIV virions glowing bright green — it’s very Fantastic Voyage-esque, minus Raquel Welch in her scuba gear.

But return here for a moment, please. I’m going to recommend three simple steps to getting the most from this — and other medical breakthroughs — in the mainstream media.

Step 1: Be a skeptic. As exciting as curing HIV would be, and no matter how much you’d like this to happen, just think for a moment about the plausibility of this story. Are scientists really on the “brink” of curing HIV? If so, why is this only appearing in the U.K. Telegraph? Trust me, this brink-of-cure has not yet appeared in peer-reviewed medical journals or at scientific meetings.

And wouldn’t you expect this kind of advance, if real, to show up everywhere in media land? Fire up that Google machine, and see what you can find about it elsewhere — lo, it’s the great following herd, all stampeding after that same U.K. Telegraph story. And importantly, here’s a New York Times piece on the very same general subject — HIV cure — and they don’t even mention these Danish researchers. Sure, the Times misses some stories, but it’s got some pretty impressive Health and Science sections — could they miss this, researchers on the brink of curing HIV, no less? I think not. So perhaps Mr. U.K. Telegraph Science Reporter is exaggerating a bit, for the sake of his story, of course.

Step 2: Don’t be a complete snob — give the story a chance. Continue reading

What Does A Possibly Cured Baby Mean For Adult HIV?

HIV particles, yellow, infect an immune cell, blue. (NIAID_Flickr)

HIV particles, yellow, infect an immune cell, blue. (NIAID_Flickr)

It broke Sunday, the big news that a baby with HIV had apparently been cured by intensive anti-retroviral therapy immediately after birth. NPR’s Richard Knox did a bang-up job on the story here, including our local angle, contributions by pediatric AIDS researcher Dr. Katherine Luzuriaga of the University of Massachusetts.

But given that pediatric HIV and AIDS are — thankfully — rare, in American babies at least, the news seemed to beg the question: So what implications does this have for adults? I put it to Dr. Daniel Kuritzkes, chief of infectious diseases at Brigham and Women’s Hospital. He’s currently at the Atlanta conference where the baby’s case was presented. His response, lightly edited:

I think the implication for adults are not certain, because the difference with children is that we know exactly when they may have been exposed, and have an opportunity to test them immediately after birth or very shortly after birth. Whereas the typical adult may be exposed to HIV and not know it, and come in later when they start having symptoms. So the opportunities to intervene very, very early are much harder to produce in adults.

‘We continue to see evidence that it is possible to eradicate HIV from infected patients — maybe still in very unique and unusual circumstances, but the more of these cases we see, the more impetus it provides for ongoing research.’

Strikingly, there was a presentation just before [the baby’s case] by a Thai investigator working with the US military research program, where they were doing pooled HIV testing of people coming in to testing centers in Thailand, and had the opportunity to identify some people very early on, and show that those who did get on treatment very early on subsequently had either undetectable or very, very low levels of HIV. That suggests that if you could get to people early enough, you might in fact prevent the establishment of the reservoir. [NPR’s Knox explains that viral reservoirs are “hideouts for the virus within the immune cells.”]

Those patients all remain on antiretroviral therapy, so they’re not claiming that the patients are cured, but the timing here is really critical. Between the first group, who are really within the first week or so of infection, and the next group, who were a few days beyond, there was a big difference in what happened with the reservoir. Continue reading

Pulling Back The Curtain On The AAP’s New Pro-Circumcision Stance

For some excellent context and more backstory on the American Academy of Pediatrics’ new recommendations on circumcision, listen to Radio Boston today featuring the very knowledgeable Marvin Wang, co-director of the newborn nurseries at MassGeneral Hospital for Children. (As for his credentials, when asked how many circumcisions he’s done, Dr. Wang said he stopped counting after the first thousand.)

The AAP on Monday updated its 1999 circumcision policy statement (which said the data weren’t sufficient to recommend routine neonatal circumcision) and now asserts that the health benefits of newborn male circumcision outweigh the risks and insurers should cover the procedure. However, the influential pediatrician’s group stopped short of recommending universal circumcision for all baby boys and said the ultimate decision should be left to parents.

Wang says that much of the push for the new AAP recommendations came from clinical studies in sub-Saharan Africa that showed male circumcision reduces the risk of heterosexually acquired HIV infection in men by approximately 60%. Wang also put circumcision in a global context, noting that while the rate of hospital circumcision in the U.S. has dropped from about 79 percent two decades ago to about 55 percent today, in the U.K only about 9 percent of men are circumcised. Continue reading

Influential AAP Says Health Benefits Of Circumcision Trump Risk

(afagen/flickr)

The American Academy of Pediatrics new policy statement today asserting that the health benefits of male circumcision outweigh the risks will inevitably set off a firestorm of reaction. Even while the pediatrics group continued to reiterate in their paper that circumcision is a personal family decision best left up to “parents in consultation with their child’s doctor” folks who oppose the procedure and equate it with genital mutilation will certainly not be pleased.

Carey’s earlier post on the increased health costs associated with declining circumcision rates triggered scary and intense online outrage.

All I can say is I’m glad I have daughters.

Here’s the abstract from the AAP paper today:

Male circumcision is a common procedure, generally performed during the newborn period in the United States. In 2007, the American Academy of Pediatrics (AAP) formed a multidisciplinary task force of AAP members and other stakeholders to evaluate the recent evidence on male circumcision and update the Academy’s 1999 recommendations in this area. Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks and that the procedure’s benefits justify access to this procedure for families who choose it. Specific benefits identified included prevention of urinary tract infections, penile cancer, and transmission of some sexually transmitted infections, including HIV. Continue reading

As Of Today In Mass., You Can Just Say Yes To The HIV Test

Dr. Paul Sax (Courtesy of BWH)

As of today in Massachusetts, you can get an HIV test without having to sign a written consent form. That means you can also skip that potentially embarrassing walk down to the lab to hand over your consent paperwork. You can just say yes.

Massachusetts is a leader in HIV care and research, but it is the last — yes, the very last — state to switch from written to verbal consent for HIV tests, said Dr. Paul Sax, clinical director of the Infectious Disease Department at Brigham and Women’s Hospital.

In other states that switched to verbal consent, experience has borne out the rationale for making HIV testing easier, he said: More people get tested, so more people know their HIV status, and those who find out they’re positive can get treatment and avoid spreading the virus to others.

How will the new Massachusetts law play out in the clinic? Dr. Sax says that typically, a medical staffer recommends an HIV test to a patient — “For example, you could say, ‘The CDC recommends everyone in the US get at least one HIV test, so I recommend you get one.'” Then the clinician should ask if the patient has any questions about accuracy or other implications of the test. If the patient says yes to the test, that should be noted in the medical record.

(Speaking of the CDC, how cool is this little tool? They have the public-health equivalent of a storefinder: You type in your zipcode and it gives you the addresses of clinics where you can get tested for HIV and other sexually transmitted diseases in your area. It’s here.)

Why is Massachusetts so late on this when we’re normally out front on public health? Dr. Sax theorizes that the existing law also included privacy protections that no one wanted to lose. Testing and privacy were “very entangled, and it was very hard to change one without changing the other.” All previous privacy protections have in fact been preserved.