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Clinical news

Sexual health this week…chlamydia, female circumcision, WHO and America’s future

1 Feb, 11 | by Leslie Goode, Blogmaster

Better access to reproductive health care in the US: a promise stillborn?
A Step Forward. Obama’s health reform (PL111-148), while conceding nothing to the pro-choice lobby, offers genuine promise of better access to sexual health care. This is thanks to Barbara Mikuski’s provision requiring all new health insurance plans to cover preventive services for women with no out-of-pocket cost to patients. The general terms of the provision leave open the question of which services should be included. The matter is currently before an expert committee due to report in August.

Two Steps Back. This promise of better access may be stifled, and even existing levels of access imperilled, as healthcare reform becomes a battleground for Congress and many State legislatures, now dominated, thanks to the recent electoral sea-change, by opposition to “Obamacare” and undiscriminating conservative hostility towards any institution that could be remotely linked to a pro-choice position. According to author, Sharon Lerner, anti-abortion moderates, formerly favourable to family planning, have been voted out, or are susceptible to intense pressure, with a resulting polarization towards extreme positions.
The abortion issue is being deployed as a means of attacking the Obama reform. The Senate’s Democratic majority has pledged to block the repeal bill. But the lower House will then take up a resolution, calling on key committees to draft bills to replace elements of the reform law. The resolution (H.Res 9) calls for these efforts to include “provisions that prohibit taxpayer funding of abortions and provide conscience protections for health care providers”. The Mikulski provision, and any gains to be derived from it, will be especially vulnerable.
Anti-abortion measures could also pose a threat to sexual health provision, quite independently of their impact on the health reform law. The strongly conservative composition of Congress may be the ideal opportunity for the kind of anti-abortion legislation, such as the recently tabled bill by Representative Mike Pence, which failed to pass in 2007 and 2009). Pence’s bill would block federal funding to organizations that perform abortions, so that groups such as Planned Parenthood would no longer receive federal money for family planning. Already, at state level, with many conservative-dominated State legislatures strapped for cash, funding for reproductive health services is on the block. The outlook for reproductive healthcare provision has ceased to look so good.

See Sharon Lerner, “Does Contraception Count as Prevention?” The Nation, 18.01.11

Muslim leaders move against female circumcision
In Mauretania a meeting of 34 religious leaders convened by the Forum of Islamic Thought have issued a fatwa condemning female genital mutilation. Female circumcision is common in areas of Mauretania, as it is in other Islamic countries in Africa, notably Egypt, Sudan, Somalia and Eritrea (where it is now banned). In Egypt surveys have indicated that as many as 80% of women may have undergone a form of circumcision.
Fatwas are published opinions by Muslim religious scholars. They are non-binding in law, but Muslim believers are expected to follow them. Three recent fatwas relating to female circumcision have been issued in Egypt (1949, 1951, 1981), the two most recent being favourable to the practice. More recently (2007), the Grand Mufti issued a prohibition. Female circumcision is still far from being a thing of the past. The hope is that, in the words of Dr Sheiky Ould Zein Ould Imam of the Forum: (the fatwa) “removes the mask such practices were hiding behind”.

See Mohamed Yahya Ould Abdel Wedoud for Magharebia, 15.01.11

Ethnicity bias in the screening for Chlamydia: is it really so irrational?

Chlamydia testing is recommended for adolescents by the US Preventive Services Task Force, though take-up is known to be low (about half of eligible women). But why should it be so much lower for eligible women who are white (45%) than for black women (65%) or Hispanics (72%)? A recent US longitudinal cohort study, based on computerized data deriving from 3 hospitals and 30 clinics (Indiana), provocatively raises the question of ethnic stereotyping behaviour among responsible health practitioners. It also contends that these biases in Chlamydia screening may contribute to higher reported rates among ethnic minorities.
Given this suggestion of medical prejudice feeding off itself, it is surprising to find that differential rates of positivity on screening for ethnic groups are not given – even for patients in the study group. Low rates of positivity for the screened Hispanics would presumably have clinched the argument nicely. And why are rates of positivity not deemed relevant to the authors’ extended discussion of stereotyping behaviour? The perception of risk by patients and practitioners is surely a factor which should enter into any genuine attempt to account for the dynamics of their interaction.
Should we conclude that practitioner behaviour is necessarily irrational where it does not accord with official screening guidelines?

Sarah E. Wiehe et al., “Chlamydia Screening Among Young Women: Individual- and Provider-Level Differences in Testing”, Pediatrics, Jan. 2011

Developing sexual health programmes: a framework for action, WHO, 2010
The framework itself occupies two pages; the bulk of the document concerns the development of a “programme-based approach” based on the framework. An appealing feature of the report is the range of real life examples from around the world which are used to illustrate what has been – and can be – achieved by elements of this approach.
The unspoken assumptions underlying the report are that a value neutral standpoint is possible, and that this value neutral standpoint is the one adopted by the report. Such assumptions may be integral to the hegemonic ambitions of a “holistic” approach (reinforcing contestable abstractions like “sexual health”); but they contrast disconcertingly with the contended realities currently afflicting US politics (see above). A more open, less “holistic” discourse might be more plausible in this difficult area.

WHO report

STI news

18 Jan, 11 | by Jackie Cassell, Editor of STI

The cost of Pelvic Inflammatory Disease: a case for the promotion of outpatient services?
A US study on the financial implications of PID in adolescents draws attention to patients’ under-use of appropriate outpatient services and the enormous cost of cases requiring hospitalization. The adolescents in the study, from black, low-income backgrounds, were mostly first seen for care in Emergency Departments. The authors, who favour a “strategic approach to adolescent care”, point out that the care provision by EDs may often be “suboptimal” as compared to outpatient clinics, i.e. general pediatric adolescent medicine and gynaecology clinics. The study evaluates the direct financial costs of existing, apparently very un-strategic, care arrangements: estimated charge for patients treated in outpatient clinics or emergency departments is $7440 lower than the charge for those requiring to be treated as inpatients.
Reference: Maria Trent et al., “Estimating the Direct Costs of Pelvic Inflammatory Disease in Adolescents: A Within-System Analysis”, Sexually Transmitted Diseases, Volume 37, Number 12, December 2010.

Solid evidence for the reproductive sequelae of Chlamydia – especially ectopic pregnancy?
Tubal ectopic pregnancy accounts for 1-2% of all pregnancies in Europe and the US, and is the most common cause of maternal mortality in these countries. Its association with Chlamydia has been demonstrated by epidemiological studies. But there is nothing like fingering the pathological mechanism, when it comes to bringing home the reality and importance of such an association.
The mechanisms of tubal damage are believed to be immunologically mediated, rather than a consequence of tissue destruction. A recent study reported in the American Journal of Pathology seeks to cast light on these mechanisms, thus corroborating the epidemiological link. Alterations in PROK signalling have previously been shown to promote a micro-environment conducive to embryo implantation. This study postulates that Chlamydia infection increases Fallopian Tube PROKR2 via TLR2 and NF?B activation.
Does this add new justification for screening programmes?
Reference: Jule L.V. Shaw et al., “Chlamydia trachomatis Infection Increases Fallopian Tube PROKR2 via TLR2 and NF?B Activiation Resulting in a Microenvironment Predisposed to Ectopic Pregnancy”, The American Journal of Pathology, Volume 178, no. 1, January 2011.

Russia and Ukraine adopt an “ostrich policy” on HIV.
As regards its impact on HIV transmission the benefits of what health-care professionals term the “harm-reduction package” for intravenous drug users (i.e. opiate substitution, and supply of clean needles) is taken for granted in many Western countries. And not just in the West. Last July, harm-reduction was endorsed by the “Vienna Declaration” at the 18th International AIDS Conference. But in Russia and the Ukraine, home to 90% of those infected in HIV in central and eastern Europe, it is quite another story – according to Jon Cohen, author of Shots in the Dark, in a recent opinion piece. Partly, this is due to the government’s failure to bankroll the harm-reduction effort until recently assured by Global Fund money, partly the outright ban on methadone.
Organizers of the Vienna Conference held the meeting in Vienna specifically because “it is the gateway to Eastern Europe”. For the first time, all proceedings were translated into Russian. But no high-level Russian or Ukraininan official attended.
Project Syndicate

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