This global discussion series began this past May with a debate entitled “Test and Treat: Can We Treat Our Way Out of the HIV Epidemic?” which looked at testing and treating strategies with a focus on their role in Africa.

In June, a debate on “Behavior Change in HIV Prevention” took place looking at dynamics involved in behavior change approaches and their past ineffectiveness.

Check out these past debates and the ones still to come including theis week’s August 26th debate on “Discordant Couples and HIV Transmission” and continue to follow this debate series for future conversations.

62,000 – chemicals that were “grandfathered” in by the 1976 Toxic Substances Control Act (TSCA) and therefore unstudied as to their health and environmental safety.

200 – chemicals tested for their safety under TSCA.

1,000,000+ tons – amount of Bisphenol A (BPA) consumed in the US in 2004, before widespread recognition of its multiple adverse health impacts.

The US public, and now the outsourced manufacturing hubs in China, India and other places worldwide, are essentially participating in a giant experimental trial with the chemicals in our foods, our clothes, our cleaners, plastics, and virtually everything we use.  H.R. 5820 the Toxic Chemical Safety Act, currently under consideration in Congress would begin the process of re-assessing the safety of these chemicals on the loose and replace the ineffective Toxic Substances Control Act.

The new legislation marks a shift in the regulatory philosophy towards new chemicals. Historically, the US favored self-regulation of the industry and allowed the industry to innovate without much concern for long-term effects. This new legislation follows the lead of the Precautionary Principle by beginning to assess the safety of products before they are released into the market.

Perhaps most troubling from a health perspective, aside from the fact that many of these molecules have not been tested for their long term chronic exposure safety, but that even with those that have been tested, few, if any, have had their safety assessed in the context of the myriad of other chemicals that we use on a daily basis. While it has shortcomings, HR 5820 is a step in the right direction.

For more info and perspectives see:

House Panel Tackles Chemical Legislation | EHS Today.

http://www.huffingtonpost.com/rev-fletcher-harper/choose-life-the-religious_b_662234.html

http://www.opencongress.org/bill/111-h5820/show

http://blogs.edf.org/nanotechnology/2010/07/30/not-playing-nice-the-american-chemistry-council-solidifies-its-claim-to-being-the-industry-of-no/

http://mollyannaapproach.blogspot.com/2010/07/house-members-witnesses-clash-over.html

With the highest recorded global population growth rate and the most enormous demographic shift ever between the more developed and less developed regions, the century from 1950 to 2050 saw dramatic changes in global development. It is still unforeseen whether this pattern of human development will remain sustainable. This paper explores the ways in which policy could respond to unmet human needs, many of which have arisen from human choices rather than biophysical necessities.

In a recent article on Huffington Post, Dr. Ezekiel J. Emanuel, special advisor for health policy in the OMB, defends the Obama Administration’s decision to shift some of the funding away from successful AIDS treatment efforts:

This comprehensive and integrated approach is what the President’s Global Health Initiative is all about. It recognizes that we can’t treat our way out of the HIV-AIDS epidemic. The key to ending it is to reduce the number of those who become HIV-positive in the long-term – and that takes improving their overall health and the health systems around them. After all, patients don’t come to doctors with one disease or condition, and our response shouldn’t focus on one as well.

Dr. Emanuel writes in response to widespread criticism of the Obama Administration during the International AIDS Conference in Vienna, as well as to the July 20^th New York Times op-ed by Archbishop Desmond Tutu, who writes:

During my life, I’ve witnessed amazing advances in medical science. New treatments turn H.I.V. infection from a death sentence to a manageable illness. The cost of treating it is a small fraction of what it was 10 years ago. Meanwhile, more and more African nations have invested in the public health infrastructure needed to distribute AIDS drugs. I appreciate that tough financial times require the United States government to cut spending. But scaling back America’s financial commitments to AIDS programs could wipe away decades of progress in Africa.

Anand Reddi responds on Huffington Post and specifically counters the argument that “we can’t treat our way out” of the epidemic:

Results by Dr. Julio Montaner published in The Lancet demonstrated that provision of antiretroviral therapy in British Columbia halved the rate of new infections. The Economist writes the study by Montaner is “the strongest confirmation yet that treatment and prevention are two sides of the same coin.”  Treating our way out is indeed possible.  In our recent article in AIDS, Sarah Leeper and I demonstrated the unique dynamic-reciprocal relationship that HIV/AIDS, TB, and Malaria have on maternal and child health and vice-versa in the resource limited setting. I salute Dr. Emanuel for forwarding the dialogue on global health and advocating for comprehensive, integrated, cost-effective models of care that advance not just HIV/AIDS but other important health priorities including maternal and child health. Given that the provision of antiretroviral treatment can actually lead to prevention, eradication of new HIV infections is possible if the world community remains fully committed to funding cost-effective antiretroviral treatment initiatives.

Further reading:

• Anand Reddi’s previous article about AIDS funding on Huffington Post.
• The CID journal article by Rochelle Walensky and Daniel Kuritzkes, from the Center for AIDS Research at Harvard Medical School, that Archbishop Tutu references in his letter.

Over the course of my involvement in global health during medical school, I began to narrow my interests toward humanitarian assistance and global health delivery in post-conflict settings. Last year, during my fourth year of medical school, I participated in a new course on social medicine being taught in Gulu, northern Uganda, a region that is recently recovering from a 20 year civil conflict. This course, called Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness was very well organized, with didactics on a range of topics from the health consequences of internal displacement, to the portrayal of Africans in the Western media. We also were able to spend time on the wards seeing patients with a range of diseases and syndromes common in the region. The keystone of this course, however, is the international student body. Half of the medical students study at Gulu University and hailed from around Uganda. The other half were American and European. This enabled fantastic discussions with different perspectives on the issues we were studying, and planted the seeds of long-term friendships between colleagues from around the world. I enjoyed my time there so much that I went back to Gulu for another clinical rotation later that semester.

If you have any questions about the course or are interested in applying, please email the course directors at: social.medicine@yahoo.com. Applications are due July 30, 2010.

The architects of the Obama administration’s Global Health Initiative recommend funding the Mother and Child Campaign at the expense of future funding increases for PEPFAR. The idea that differing global health initiativesmust compete with each other lacks not only ethical legitimacy but also scientific merit. Confronting illness in isolation – whether by funding PEPFAR at the expense of programs that targetMCH or vice versa – cannot be our way forward. Policies that de-emphasize PEPFAR threaten to undermine,rather than support, MCH in countries with high HIV/AIDS prevalence [PubMed; full-text].

The strongest scientific-journal rebuttal yet to the Obama Administration’s proposal to shift resources to maternal and child health at the expense of HIV/AIDS treatment scale up comes from two medical students, who in a commentary just published in AIDS make a clear and convincing case that such a move would actually undermine the health of women and children around the globe, not improve it.

UNAIDS estimates that the cost needed to continue global HIV treatment in 2009 will be about US$9 billion.

Related reading:

• Denny CC and Emanuel EJ. “US Health Aid Beyond PEPFAR: The Mother & Child Campaign.” (JAMA,  11/2008.)
• “At Front Lines, AIDS War Is Falling Apart” (NYTimes, 05/05/2010)
• “Donor AIDS” (The Lancet Student, 05/14/2010)
• Jennifer Weinberg’s post on the Administration’s effort to address global maternal, newborn, and child health needs (GP Blog, 06/17/2010)
• “Obama ‘hurt’ by AIDS funding criticism” (The Guardian, 06/21/2010)

Selected sessions are webcast live each day with past sessions also available for viewing. Find the complete guide-to-coverage as well as the webcasts already available for viewing including the Opening Session, Monday’s plenary with former President Bill Clinton, and Tuesday’s session on the study which found Microbicides containing HIV drugs lower the infection risk in women.

Today’s schedule includes:

The WHO is calling for earlier treatment of those infected with the HIV virus, suggesting that if people are treated before their immune systems become weakened by the virus, HIV-related mortality can be reduced by 20% between 2010 and 2015. In addition, early therapy also has a benefit in preventing transmission of the virus. These new guidelines expand the number of people eligible for antiretroviral therapy from around 10 million to about 15 million people. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that the cost needed for HIV treatment in 2010 will be about US$ 9 billion.

Figure 1.

For the first time in the 15 year-long search for an HIV prevention method that women can control, a vaginal microbicide gel called Viread has been shown to decrease the risk of HIV infection by as much as 54%.  Even though the microbicide does not prevent transmission in every woman who uses it, this is the first promising tool that women are able to use without the cooperation of the male partner.  This is an important consideration most of the new HIV infections in women living in Africa were acquired through forced sex with infected men who refuse to wear condoms. Women and girls represent 60 percent of the 22 million people infected with HIV living in Africa.

The gel was developed by Conrad, a nonprofit organization based in Arlington, Virginia, and funded by the U.S. and South African governments under royalty-free license from Foster City, California-based Gilead, the world’s biggest maker of AIDS medicines. The Bill Gates Foundation also helped fund the trial.

In the clinical trial, coordinated by scientists at the Centre for the AIDS Program Research in South Africa (CAPRISA), the use of the microbicide was compared to a placebo in a group totaling 889 women located in either the urban setting of Durban or the  rural setting of Pietermaritzburg in the KwaZulu-Natal province of South Africa.

The main active ingredient of Viread was a 1% vaginal gel formulation of the nucleotide reverse transcriptase inhibitor tenofivir. The pill form of tenofivir is already used in combination with other antiretroviral agents for the treatment of HIV and works  by slowing HIV’s spread through a patient’s body.  The secret to tenofovir’s success as a topical agent may be that it absorbs into the vaginal wall and into the cells targeted by HIV. Other gels have had to be sufficiently spread around and present in the vagina during intercourse in order to work.

Participants of the clinical trial were instructed to apply the gel 12 hours before and up to 12 hours after intercourse. Participants were told that the gel was experimental and were also counseled to use condoms or another means of HIV prevention. According to the trial results, when compared with the placebo group, women in the tenofovir group showed 39 percent fewer HIV infections. Within the tenofovir group, women who used the gel more than 80 percent of the time had 54 percent fewer infections than women who used the placebo gel .  For women who did not use the gel regulalrly ( less than 80 percent of the time) there was a 28 percent reduction.

Some theories as to why the gel did not perform better:

The net impact seen in the study reflects the combined effect of many variables, only one of them the action of tenofovir, which penetrates into the vaginal tissue, protecting the cells that HIV targets for infection. Other variables include the prevalence of HIV infection in the male population; the number of sexual partners a woman had; the amount of AIDS virus (“viral load”) in an infected man’s semen; concurrent use of condoms; and, most important, the consistency with which a woman used the gel.

For that reason, the researchers said, it’s impossible to say how much protection this microbicide might afford any woman.

“We can only approximate it,” said Salim Abdool Karim of the University of KwaZulu-Natal in Durban, South Africa, who helped lead the study. “What you see is a mixture of the efficacy of the product mixed with the ability to use the product. It is fundamentally dependent on human behavior.”

Other scientists speculated that some women who became infected despite using the tenofovir gel might have been exposed to men with very high HIV load (which occurs soon after infection).

“My most likely explanation is that you have to go up on the dose,” said Anthony S. Fauci, who heads the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. “You may have maxed out on 1 percent,” he said, meaning a more concentrated gel might produce greater protection.

Over the past 15 years, six other microbicides were tested in 11 clinical trials, with none showing a protective effect.  Previous gels relied on drugs that weren’t specifically designed to target HIV.

Another important finding in the trial was that the gel prevented the transmission of genital herpes (caused by the herpes simplex virus-HSV) by 51%.  A genital herpes infection increases the susceptibility to HIV infection because the HSV virus can cause open lesions to form.

If further development and testing continues to be successful, more potent formulations combined with marketing that makes the product more appealing to women could lead to increased prevention of HIV transmission.

A product could be ready as early as 2013 if the results are confirmed by a second study known as Voice that is enrolling patients.

Gilead, which donated the active ingredient in the gel, won’t participate in the commercialization of the product in developing nations. They are unsure of whether or not will market the gel in the U.S. and Europe. Conrad gave the rights to manufacture the gel to the government of South Africa to get the product to women in the country most affected by the disease as quickly as possible.

The findings of the study were described at the 18th International AIDS Conference in Vienna, Austria and the research article was published in Science magazine.

For More Info:

1. Sciencenews
2. Businessweek
3. WashingtonPost

In order to create prosperity for the average Haitian citizen, innovative solutions are needed to develop “attractive export market segments to serve with unique products, building new distribution systems, lowering energy costs, and providing skills to Haitian citizens who will be compensated for the high value they create” according to Pierre Marie Boisson, a Harvard-educated, Haitian international banker.

This is not the first time that Slim and Gates have partnered up.  They have been working together at Prodigy MSN, which has just celebrated its 10^th anniversary.

In order to achieve such coverage for only two dollars a year, the government of Rwanda must receive supplemental help from outside organizations such as Partners in Health, The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US government. Additionally, the plan requires co-pays which can be cost prohibitive for many patients. For example, a Caesarean section requires a five dollar co-pay which many patients cannot afford.

For more on this issue check out the New York Time’s recent article, this info sheet from the World Bank and this article in the bulletin of the World Health Organization.

A related webcast and fact sheets on maternal and child health and family planning are also available.

http://apps.nlm.nih.gov/againsttheodds/exhibit/index.cfm

The effects of Afghanistan’s 375 ton per year opium and heroin export are also felt at home through direct use and passive exposure such as  second-hand and third-hand exposure.  A new study that will be finalized this summer is expected to show that in Afghanistan 1.5 million people out of a total population of 30 million are addicts and that a quarter of those users are thought to be women and children.

Another study funded by the International Demand Reduction Program sought to determine if there were unwilling addicts exposed to opium by evaluating the indoor environment of the homes of known opium users.  Air, surface, and hair samples from all the inhabitants living in the homes of the opium users tested positive for opium products.  Direct contact and hand-to-mouth transfer from items such as eating utensils, toys, pillows, and bedding may be a significant route of exposure to opium for children.  The long term consequences of this passive exposure on mental, physical and emotional development to the children are unknown.   We should not wait to see what these long-term effects will be and something should be done immediately to put an end to this abuse.

Another theory as to why and how early these addictions begin suggests that the easily accessible opium fills a void that results from lack of access to doctors and medicines. Opium is used to treat physical pains and ailments as well as the psychological pains brought on by decades of war and poverty. One mother described how her children became addicted:

“When my son was born, he had earache. We couldn’t get to a doctor, so I gave him opium to help him get rid of the pain. After my daughter was born, she got stomach aches, and I only had opium to give to her for medicine, so now they’re both addicted.”

Other factors leading to increased use are the high unemployment rate throughout the country and the return of refugees from Iran and Pakistan who became addicts while abroad.

The disagreement about how much criminal groups, insurgents and terrorists are funded by the drug trade has made it more difficult to develop and follow a unified plan to end this problem.  I agree with President Medvedev’s sense of urgency, but how do we begin to put an end the destruction resulting from the opium trade?  Is it better to start from scratch or to work on coordinating the existing agencies that are evaluating the damage and setting up interventions?

Check out their website to register and access related materials.

It can be argued that health care providers who neglect to report illegal immigrants under their care will violate the law and be considered criminals. The bill provides physicians with no guidance as to what constitutes “reasonable grounds” to suspect that somebody is in the country illegally, leaving the particulars of such scrutiny to anyone’s imagination (although the fact that Arizona shares a border with Mexico rather than a European country suggests that whites will not be “reasonable” suspects).

Dr. Restrepo and colleagues also published a letter in the Arizona Republic earlier:

As physicians, we are concerned about the immigration bill signed by Gov. Jan Brewer. We care for many patients who may appear foreign based on superficial impressions. It is unclear whether health-care professionals like ourselves will infringe on the law if we don’t report patients or their families to the police or immigration authorities based on a vague suspicion of illegality. . . . Senate Bill 1070 tacitly prescribes a break with one of the oldest traditions of medicine: Physicians shall protect patients regardless of nationality or race [emph. added].

In a statement released on May 18, the National Physicians Alliance and CIR/SEIU-Healthcare condemn the law as “an affront to human rights and a devastating step backwards for the health and well being of the entire nation,” and warn that it will “create new obstacles to obtaining needed health care.”

More on Arizona SB 1070:

• Some 50,000 protesters gather in Phoenix on May 29 to demonstrate against the law
• Immigrant groups and workers’ organizations (Hispanic and not) urge a boycott of Arizona
• The Sound Strike, a group of musicians and performers headed by Zach de la Rocha, boycotts AZ

Does Arizona’s law go too far? Do you think it is likely to affect the practice of medicine in the state? Do doctors have a role to play in this debate? Join the discussion by leaving a comment!

During the white-coat advocacy day on Tuesday, the medical student group conducted over 25 meetings with lawmakers and staff, met with the bill’s sponsors, and hand-delivered copies of the petition signed by hundreds of their peers and fellow New York State residents. They also conveyed the support of state and national professional organizations for this landmark legislation…(more)

The medical student action event was also mentioned on the Huffington Post and on PHR’s Health Rights Advocate blog. Since then, NYCAT has also released a letter of support for the Gottfried-Duane Bill signed by prominent leaders of medicine in New York state, including medical school deans, hospital CEOs, and Nobel Prize laureates.

Medical students and NYCAT members with Assemblyman Gottfried in Albany

Related reading:

• ACLU’s resources on torture
• The National Religious Campaign Against Torture (NRCAT)
• NRCAT, ACLU, and PHR: Working together against inhumane detention conditions at home?

UPDATE [06-08-2010]: PHR’s newest report, Experiments In Torture, raises concerns that the actions of CIA doctors who participated in waterboarding and other methods amounted to illegal human experimentation. Read coverage of the report in The New York Times and commentary at The Washington Post and The Atlantic.

Looking for ways to get involved closer to home? NRCAT has a list of events across the country for the month of June.

Related: China bans the use of torture in extracting confessions.

An article written in the Wall Street Journal discusses the process used to create the cell:

To begin, they wrote out the creature’s entire genetic code as a digital computer file, documenting more than one million base pairs of DNA in a biochemical alphabet of adenine, cytosine, guanine and thymine. They edited that file, adding new code, and then sent that electronic data to a DNA sequencing company called Blue Heron Bio in Bothell, Wash., where it was transformed into hundreds of small pieces of chemical DNA, they reported.

To assemble the strips of DNA, the researchers said they took advantage of the natural capacities of yeast and other bacteria to meld genes and chromosomes in order to stitch those short sequences into ever-longer fragments until they had assembled the complete genome, as the entire set of an organism’s genetic instructions is called.

They transplanted that master set of genes into an emptied cell, where it converted the cell into a different species”

It may be possible for this new field, called synthetic biology, to one day provide alternatives to standard practices in many different industries. For example, the industrial life forms can be used to produce renewable fuels as well as vaccines.

This development also raises questions about concerning the ethics, law and public safety of artificial life. So I ask you all, what are some specific issues do you see needing to be addressed concerning synthetic life?

The CEOs of the American Heart Association, the American Cancer Society, and the American Diabetes Association comment on this issue in a recent (5/13) CNN opinion article.