HIV rates falling overall – but not for everyone

HIV rates in Australia have dropped overall to a seven-year low, but a concerning increase in infection rates has been observed among heterosexual males and Aboriginal and Torres Strait Islander people.

According to the latest HIV surveillance report released by the Kirby Institute at UNSW, there were 963 new HIV diagnoses in Australia in 2017, representing a 7% decline over five years

The reductions were greatest among gay and bisexual men, with a 15% reduction in the past year alone.
Associate Professor Darryl O’Donnell, CEO of Australian Federation of AIDS Organisations, told doctorportal that “this is some really good news.”

“There have been strong increases in regular HIV testing in this population, along with incredible enthusiasm for the pre-exposure prophylaxis (PrEP) drug, and people taking treatment very early on in their diagnosis. All three things are really helping us get those diagnoses down.”

HIV rates among heterosexual males on the rise

The results of the report are not all good news, however. There was a 10% increase between 2013 and 2017 in HIV diagnoses among heterosexuals, with a 14% increase between 2016 and 2017 alone. In men, the number of diagnoses attributable to heterosexual sex has increased by 19% in the last five years yet has remained relatively stable in women.

Professor O’Donnell said that this data was concerning. “This is a much smaller proportion we’re talking about here – around 20-25% of all diagnoses are among heterosexuals – but we do want to keep an eye on this”

“It’s important for us to understand that not everyone who is a heterosexual is equally at risk for HIV. The sorts of things emerging from the data are that a person who is at relatively low risk in Australia might be at higher risk when they’re travelling overseas if they’re having sex with partners there.”

Another factor behind the rise in HIV among heterosexuals has been the increase in the number of people with HIV coming to Australia from countries with a high prevalence.

“The third category is people who are heterosexual whose partner is at high risk of HIV – maybe their partner is someone who injects drugs, or their partner is from a high risk country”, Professor O’Donnell said.

HIV among Indigenous Australians nearly double the rate of non-Indigenous Australians

HIV diagnoses among Aboriginal and Torres Strait Islander people have also increased in the past five years. In 2017 the notification rate was 1.6 times higher than the Australian‑born, non‑Indigenous population.

“The rate of HIV among Aboriginal and Torres Strait Islander people has been increasing since 2008. This is very concerning, because once HIV is established in these communities, it is much harder to achieve the type of outcomes we see elsewhere”, Professor O’Donnell said.

He added that for this reason, prevention and testing for early diagnosis are key. “We need to be sure that our workforce, including Aboriginal health workers and staff working within Aboriginal medical services, are fully supported to be able to offer HIV screening.”

Return to Grim Reaper-style campaigns not the answer

“We certainly don’t want to go back to the grim reaper. It certainly raised awareness, but also frightened people and made people think that HIV was about someone who wasn’t like them”, Professor O’Donnell said.

The goal of any HIV campaign should not be to make people fear each other, but instead build their understanding of their individual level of potential risk, and encourage them to take positive steps based on that.

“We need awareness and to intensify educational efforts with those most at risk and across the whole community. But we need to do it in a mature way, and work with people as adults who are confident and capable of making sensible choices.”

Vitamin D: a pseudo-vitamin for a pseudo-disease

We are still in love with vitamins a century after they were discovered, with half the US and UK population taking a supplement. Vitamin D – the sunshine vitamin – is the favourite and is believed to have the most proven benefits. Governments, including the UK government, have said that the evidence for vitamin D’s health benefits is so overwhelming that every adult should take it as a supplement for at least six months of the year.

It was first used to cure rickets in Victorian children living in urban poverty and is now routinely given to prevent and treat brittle bone disease (osteoporosis) and fractures. It has been associated with a reduced risk of over a hundred common diseases in observational studies, ranging from depression to cancer.

The largest ever clinical study on the benefits of vitamin D in preventing fractures is now reported in the BMJ, with over 500,000 people and around 188,000 fractures from 23 cohorts from many countries. As vitamin D levels are strongly influenced by genes, the researchers used genetic markers for vitamin D blood levels (called Mendelian randomisation or MR) to avoid the normal biases of observational studies, such as confusing cause and consequence of disease and the effects of other related health behaviours (so-called “confounders”).

The results showed no association between vitamin D levels over a lifetime and the risk of fracture. This latest study contradicts the UK government’s recent view, but not a host of earlier clinical trials.

In 2014, a review and meta-analysis of 31 vitamin D supplement trials found no effect on all fractures. Much of our strong belief in the benefits of vitamin D came from studies of supplements in care homes in the 1980s, which were never replicated and were probably flawed.

In a more recent meta-analysis of 33 randomised trials of over 50,000 older adults, supplementation with calcium or vitamin D had no effect on the incidence of fractures. There were also no clear benefits on muscle strength or mobility.

So, if all the data points to vitamin D failing to prevent fractures, why worry about all the people with low blood levels of the vitamin? Vitamin D deficiency has become a modern epidemic with a fifth of the UK and US populations reported to have low levels. Will they be more susceptible to other diseases and cancer?

No consensus on deficiency

There is little agreement on what vitamin D deficiency is. Deficiency levels are arbitrary with no international consensus and confusion caused by different units in the US. A “normal” level can vary from 50 to 80 nanomole per litre of blood, but recent studies suggest 30nmol is quite enough.

While clinical deficiency (<10nmol) is often clear cut, wrongly labelling millions of people as vitamin D deficient causes stress and over-medicalisation. Most people assume calcium and vitamin D are safe, and the more you take the better. My clinical practice changed when studies showed calcium supplements, as well as being ineffective against fractures, may cause heart disease. Prescriptions are now dropping.

Vitamin D is fat soluble, so high levels can build up in the body. While recommendations for supplements are usually with modest doses (10 micrograms or 400 international units (IU)), these will inevitably be overdone by some people taking other sources in cod liver oil tablets or in fortified milk, orange juice or bread. More worrying, people increasingly buy high-dose supplements of 4,000-20,000IU on the internet.

Patients with very high vitamin D blood levels (over 100nmol) are becoming routine in my clinic and elsewhere, and toxic overdoses are increasingly being reported. Several randomised trials have shown that patients with high blood levels or taking large doses of vitamin D (above 800IU) had an unexpected increased risk of falls and fractures. Vitamin D is far from safe.

It can no longer be recommended for use in other conditions; the vast majority of the positive published studies in 137 diseases were reviewed as spurious. It was widely believed that vitamin D supplements prevented cardiovascular disease, but meta-analyses and large-scale genetic MR studies have ruled this out.

Pseudo-disease

We have created another pseudo-disease that is encouraged by vitamin companies, patient groups, food manufacturers public health departments and charities. Everyone likes to believe in a miracle vitamin pill and feels “they are doing something”.

Vitamin D, despite its star status, would not be called a vitamin today, as the doses needed are too large, the body can synthesise it from skin, and it is a steroid precursor. Instead of relying on this impostor, healthy people should get vitamin D from small doses of sunshine every day as well as from food, such as fish, oil, mushrooms and dairy products.

We should also trust that thousands of years of evolution would cope with a natural drop in vitamin D levels in winter without us snapping our limbs. About half the population take vitamins daily, despite zero benefits, with increasing evidence of harm. The worldwide trend of adding unregulated vitamins to processed food has now to be seriously questioned.

While vitamin D treatment still has a rare medical role in severe deficiency, or those bed bound, the rest of us should avoid being “treated” with this steroid for this pseudo-disease and focus on having a healthy lifestyle, sunshine and importantly save your money and energy on eating a rich diversity of real food.

Tim Spector, Professor of Genetic Epidemiology, King’s College London

This article was originally published on The Conversation. Read the original article.

To keep patients safe in hospitals, the accreditation system needs an overhaul

Once a year, inspectors visit hospitals across the country to assess their performance on a range of measures, from medication safety to consumer engagement. But it’s not a secret shopper-type scenario. Hospital staff have known for months when the inspectors will arrive and what they will be looking for.

It’s no wonder doctors dismiss the process as irrelevant or a waste of their time. But most concerning is the process doesn’t identify the key safety issues in hospitals, nor propose ways to address them.

Almost every significant safety failure in Australian hospitals in recent decades has happened in a hospital that had passed accreditation with flying colours.

Bundaberg Hospital passed accreditation, despite allowing surgeon Jayant Patel (later dubbed Dr Death) to continue practising after complaints from patients and staff about his competence.

Bacchus Marsh Hospital, where seven babies died after receiving sub-optimal care, had regularly passed accreditation. The hospital was about to get a new accreditation certificate when the story broke.

And Bankstown-Lidcombe Hospital in New South Wales, where a gas mix-up left one baby dead and another brain-damaged, was accredited.

A new Grattan Institute report shows how accreditation needs to change. Australia’s one-size-fits-all system of assessing hospitals against centrally determined “standards” must be replaced with a system tailored to address the specific weaknesses of each hospital.

The report shows that a hospital’s performance in one specialty is unrelated to its performance in another – a hospital may have the lowest rate of surgical complications in orthopaedics, but the highest rate of medication complications in general medicine.

One size fits all system

Some 40 years ago, I evaluated Australia’s relatively new hospital accreditation system for my PhD. Back then, hospitals were expected to meet a set of standards. Inspectors visited a hospital to assess it against the standards. They produced a report, which remained secret.

An independent body would make an assessment of the report, and the assessment also remained secret. Then, in almost every case, the hospital was awarded “accreditation”.

Inexcusably, today the process remains the same (though we do have better standards and a better report). No other part of Australia’s hospital system has been so immune from fundamental change over those 40 years.

Back then it was difficult to measure a hospital’s performance on patient complications, and the quality of care. This was partly because we didn’t know whether a patient had a particular diagnosis when they were admitted to the hospital, or whether the diagnosis arose because of something that happened in hospital.

We couldn’t compare one hospital with another hospital, so we had to rely on independent qualitative judgements.

Not any more. Today we can measure hospital complication rates and other safety indicators to assess a hospital’s performance and compare them with others.

The dangers of a one-size-fits-all accreditation system can be illustrated by considering infection control, which is one of the current national standards for hospitals.

Hospital-acquired infections are widespread – more than one in every hundred patients contract one – and cost the hospital system almost A$1 billion each year.

The accreditation visit to the hospital with Australia’s lowest hospital-acquired infection rate will look very similar to the visit to the hospital with the highest rate. The same information will be read, people in the same roles will be interviewed, and the same boxes about identifying the problems and training staff will be ticked.

But the hospital with the worse infection record will have no way of learning from the best performer, and infection rates across the system will be unlikely to improve.

Tailoring accreditation

A new accreditation system needs to be tailored to each hospital’s situation.

All hospitals – public and private – should be given data about their complication rates and how they compare to other hospitals. The data provided to each hospital should be so specific that the hospital’s orthopaedic unit, for example, can compare its complication rates with its peers.

Hospitals and their clinical units should then develop plans to reduce their complications rates:

The proposed new accreditation cycle would focus on enhancing the safety and quality of patient care.
Grattan Institute

Under the plan, hospitals would no longer be spruced up for a scheduled, visit by accreditation inspectors every few years. Instead, surveyors would visit without notice. The surveyors would focus on providing feedback to the hospital on how it can strengthen its own safety processes.

After each visit, the survey report should be released publicly. That way, patients and their families and GPs could make better-informed decisions about which hospitals to go to.

The cycle of visit and report should be repeated every few years.

This dramatic change to the way Australia’s hospitals are accredited cannot occur overnight. Data has to be provided to hospitals in an actionable form, staff have to be trained in how to understand statistical variation and how to implement improvement strategies, and the new model needs to be piloted and evaluated.

But the sooner we make the transition, the better we’ll be able to care for Australians who have to go into hospital.

This article was originally published on The Conversation. Read the original article.

Is it time to remove the cancer label from low-risk conditions?

Over the past few decades, our understanding of cancer has changed. We now know some cancers don’t grow or grow so slowly that they’ll never cause medical problems.

But the way we label disease can harm. The use of more medicalised labels, including cancer, can increase levels of anxiety and the desire for more invasive treatments.

Given this growing evidence, my colleagues and I argue in The BMJ today that it may be time to stop telling people with very low-risk conditions that they have “cancer” if they’re unlikely to be harmed by it.

Our understanding of cancer has changed

Cancer screening for people who have no symptoms and the use of increasingly sensitive technologies can lead to overdiagnosis – a diagnosis that causes more harm than good. Overdiagnosis is most common in breast, prostate and thyroid cancer.

Thyroid cancer diagnoses, for example, have dramatically increased in developing countries. This has mainly been driven by an increase in the detection of papillary thyroid cancers. These are a sub-type of thyroid cancer which are often small (less than 2cm in size) and slow-growing.

But death rates from thyroid cancer remain largely unchanged. And tumour growth and spread in patients with small papillary thyroid cancer who choose surgery are similar to those who just monitor their condition.

In fact, autopsy studies spanning over 60 years show thyroid “cancers” have always been common but often went undetected and didn’t cause harm.

Impact of the cancer label

Many people associate the word cancer with major illness or death. It can be frightening to hear. This association has been ingrained by public health messaging that cancer screening saves lives.

Although this promotion has had the best of intentions, it has also induced feelings of fear and vulnerability in the population. It has then offered hope, through screening.

After decades, this messaging has resulted in highly positive attitudes towards cancer screening and early treatment. It has also led to an increased, sometimes unwarranted, desire for surgery.

Several studies show the cancer label, and the use of medicalised labels in various other conditions, leads to higher levels of anxiety and perceived severity of the condition, as well as a greater preference for invasive treatments.

The increased desire for more aggressive treatments has been shown clinically in ductal carcinoma in situ (DCIS) of the breast (sometimes known as stage O breast cancer). Women are increasingly choosing mastectomy and bilateral mastectomy (removal of one or both breasts) rather than lumpectomy (removal of the lump), even though these treatments do not change their odds of dying of breast cancer.

Similarly, in localised prostate cancer, active surveillance has been a recommended management option for a number of years, which means monitoring the condition and not providing immediate treatment. But men are only beginning to avoid immediate treatment and follow active surveillance at similar rates to men who choose surgery or radiation.

There is also evidence and informed speculation that melanoma in situ (also called stage 0 melanoma), small lung cancers, and some small kidney cancers may similarly be considered low risk and subject to overdiagnosis and overtreatment.

A strategy to reduce overdiagnosis and overtreatment

Removing the cancer label is one strategy that has been proposed in recent years by international cancer experts to reduce overdiagnosis and overtreatment in some low-risk conditions.

The cancer label has previously been removed when there was clear evidence the condition was low-risk and very unlikely to cause harm. In 1998, “papilloma and grade 1 carcinoma of the bladder” was re-labelled to “papillary urothelial neoplasia of low malignant potential”. The word carcinoma, which is another way of saying cancer, was dropped.

More recently, reference to “cancer” was removed from a sub-type of papillary thyroid cancer, which is identified after surgery. This was done to eliminate the need for ongoing follow-up and reduce any potential patient anxiety.

It’s vital we learn from these past examples. We also need to establish a formal evaluation of the impact that removing the cancer label will have on clinical practice and patient outcomes, to drive effective reform.

Ultimately, removing the cancer label will create controversy and take time. But the end result should better support appropriate evidence-based care for both future and current patients.

Brooke Nickel, PhD Candidate, University of Sydney

This article was originally published on The Conversation. Read the original article.

[Editorial] Tackling inequalities to improve wellbeing in New Zealand

In May, 2018, Jacinda Ardern’s New Zealand Government announced their first budget and, in a world first, extended the measures of success to include the nation’s wellbeing alongside financial measures. Providing a baseline on which success of the government’s future wellness budgets can be measured, the Health and Independence Report 2017, published by the New Zealand Ministry of Health on July 16, outlines the current state of the nation’s health. The report references Te Whare Tapa Whā, a Māori philosophy towards health based on a holistic model of health and wellbeing, and acknowledges the role of social determinants and environmental factors to sustain both good and poor health.

[Correspondence] Regional population structures at a glance

Population ageing is a major demographic challenge for humanity. Since population structures evolve slowly and predictably, the demographic, economic, environmental, and social problems of ageing have been anticipated and discussed for many decades.1 Yet the focus of these discussions has always been the elderly population, with elderly people often defined as those older than a threshold—eg, 65 years or age at retirement—or with a certain number of estimated remaining years of life.2 Such a focus is quite reasonable and understandable but not entirely correct.

[Correspondence] Reducing NCDs globally: the under-recognised role of environmental risk factors

This month, the WHO Independent High-Level Commission on Non-Communicable Diseases (NCDs) published a set of recommendations to accelerate progress towards achieving the Sustainable Development Goals Target 3.4 for reducing NCDs by 2030.1 Unfortunately, this globally important report had a major omission: recognising the detrimental role of environmental risk factors, beyond the conventional behavioural factors (tobacco and alcohol use, physical inactivity, and unhealthy diet), in enhancing global NCD burden and health inequality.

Code Green

BY DR TESSA KENNEDY, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING

When we talk about sustainability in health we are usually talking about spending and workforce. But what of the physical environment?

Existing AMA policy acknowledges that: “Human health is ultimately dependent on the health of the planet and its ecosystem. Climate policies can have public health benefits beyond their intended impact on the climate. These health benefits should be promoted as a public health opportunity, with significant potential to offset some costs associated with addressing climate change.”

Yet the health sector itself contributes around seven per cent of all greenhouse gas emissions. Our own resource rich settings create an enormous amount of plastic and other waste which take a direct toll on patient health and our environment. The way we run our hospitals is also increasingly unsustainable from an environmental perspective.

Health facilities and workers should promote a holistic approach to health, including its social and environmental determinants. We are increasingly acknowledging this: hospitals are non-smoking areas, because tobacco is a significant risk to health. There have been efforts to improve food options and exclude sugar sweetened beverages from hospital canteens because obesity is a significant risk to health.

Yet every time I place a cannula, suture a chest drain, resuscitate a baby, I generate a large amount of disposable, non biodegradeable waste, including plastics and instruments that have barely touched a patient. When I wash my hands tens of times a day, paper towels are co-mingled with nonrecyclable rubbish. Many of us will drive to work because of lack of public transport options to suburban hospitals, especially when working shifts, and a lack of showering and changing facilities required to encourage active self-transport options like cycling or jogging.

Disposable coffee cups, choice of volatile anaesthetic gases, computers and lights left on overnight – there are many environment degrading and wasteful practices that would take little effort to change.

Nonetheless, I’m sure like me, many of you have felt like the threat of climate change is more of an existential one than of direct relevance to your every day. Even with good intentions it just feels too big, too far beyond our reach to change. Like any efforts we make are just a drop in a warming ocean.

But what if we could see the impact of our actions in the community we treat? To measure the impact of our efforts to change in terms of patient outcomes and cost savings that could be reinvested in our insatiable health budget? It would be a lot easier to stay motivated.

Luckily, we not only have a fantastic opportunity of many low hanging fruit to improve sustainability due to the current lack of priority it is afforded, but a proven model of how to go about achieving change from the UK NHS Sustainable Development Unit. This dedicated unit has coordinated research, policy and action to improve the sustainability of health care. They succeeded in cutting NHS greenhouse gas emissions by 11 per cent between 2007 and 2017, despite an 18 per cent increase in health service activity.

If we are sincere in acknowledging climate change and environmental degradation as one of the most significant threats to human health in our time, we must acknowledge our part in addressing it in how we work. As Associate Professor Forbes McGain of the University of Sydney and Doctors for the Environment Australia has said: “The [Australian] health-care system can’t become low carbon and low waste without leadership, incentives and direction.”

Being aware of the environmental impact of our work practices and changing our individual actions are a great way to bring the issue front of mind and help start a conversation with others. But to achieve sizeable change we need to issue a triage category upgrade for environmental sustainability, and we need the whole system to respond.

So, bring your Keep Cup. But also ask the coffee shop whether they would give discounts to everyone who brings one. Choose the instruments that go back to the sterilizer, not into the sharps bin. But also question whether the marginal cost saving of procuring single use plastic items offsets the clinical waste disposal and other environmental costs. Factor environmental impact into your choices and practices at work every day, and write to your chief executive to ask them to do the same. Improve patient outcomes locally, globally, and save money doing so – it’s a no-brainer.

The science is clear – we’ve been issued a Code Green. And if we are serious about safeguarding human health, we must respond.

[Correspondence] Cerro Matoso mine, chemical mixtures, and environmental justice in Colombia

On March 16, 2018, a milestone event in the history of environmental health in Colombia occurred; the Colombian Constitutional Court decided that the Cerro Matoso ferronickel mine in Montelibano, Córdoba, had caused irreparable damage to the environment and health of people living in the surrounding area.1 Cerro Matoso mine, controlled by the multinational company BHP Billiton, is one of the largest open-pit ferronickel mines in the world, and has been an important source of income for Colombia since the mining and metallurgy processes began in 1982.

[Perspectives] Sophie Neuburg: building a movement of health professionals

Seasoned campaigner Sophie Neuburg is not one to shirk a challenge. Appointed as Executive Director of Medact, the UK charity for health professionals, in 2017, she has set herself the mission of tackling the social and environmental inequities that underlie many of the national and global public health problems. “My biggest frustration is that the prevailing political narrative is still around people’s individual ability to pick themselves up and sort their lives out”, she says. “Yet so many determinants of health are massively influenced by social and power structures which individuals don’t have the power to change by themselves.” At the heart of Neuburg’s ambition is galvanising the health community to campaign for systemic change.