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The STD superbug

 

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For the last 60 years, we have enjoyed a period where most infections have been easy to treat. That time could be coming to an end.

I should know, I’ve worked in the area of antimicrobial drug resistance. It’s a constant race with the bugs. We develop a new antibiotic, and after a while, we see the first signs of resistance appearing. Then the resistance spreads, until finally that antibiotic becomes useless. Then it’s time to move to the next antibiotic, if one exists. Earlier this month the Herald reported that this is happening with Neisseria gonorrhoeae, the cause of gonorrhoea. And there are no more antibiotics left to treat it.

This is a concern because of the poor advice given about STDs. Often STDs are described as being easy to treat or cure. That’s not consistent with the advice about infectious diseases from outside the ‘sexual health’ area. How often do hospitals advise visitors to stay away if they are sick? Yet in the ‘sexual health’ area, the advice is to just use condoms. That would be like the hospital saying, ‘come at visit no matter how much you are coughing and sneezing, just wear a face mask”.

Anyone in public health would see that as irresponsible.

But the ‘just wear a condom’ advice is given particularly to young people who are consistently the worst at using condoms, and who are the most vulnerable to catching STDs.

The rates of gonorrhoea have been dropping for teenagers in NZ, as have been the rates chlamydia and abortions. This could well be because young people are having less sex and fewer partners. It’s a trend that should be encouraged. Living a chaste life is the best protection against all STDs. Not just gonorrhoea. That includes other STDs like HPV, which can continue to spread even with consistent condom use. Chaste living also protects against any STDs that we don’t yet know about.

Fighting microbes isn’t fighting a fixed target. New species of microbes turn up from time to time. New strains of the old bugs emerge all the time. Sometimes more virulent, sometimes less. The one constant feature is that the drugs that we use to treat them become useless in time.

With gonorrhoea, this started with penicillin and tetracycline, and then fluoroquinolones. Ceftriaxone is the last drug left. And last year there were reports of resistance to ceftriaxone in Auckland and Waikato. If one strain acquires high levels of resistance to all these drugs, it will become untreatable. It’s probably only a matter of time before that happens. Then our oldest protection against STDs will become our only protection: Chastity.

So why are there no more antibiotics left? One of the main reasons is economics. It costs a great deal of money to develop any drug. If the drug is a contraceptive, and going to be used daily for decades, the drug company can get its development costs back. If it’s an antibiotic, and only going to be used for a 2 week course, the chances are recovering development costs aren’t very good. So the forces that rubbish chastity and push contraceptives onto our society are the same forces that tolerate the harm done when a chaste life is abandoned.

It’s called the culture of death.

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Abortion and pre abortion visits

When the topic of liberalising abortion comes up, as it has recently, invariably there is talk about “increasing access” and reducing the number of visits required before a woman can have an abortion.

New Zealand law stipulates that the woman seeking an abortion must see two certifying consultants. Sometimes this can happen in one visit. Beyond this the law doesn’t specify anything about visits and appointments, but there is the need for a few more visits and procedures. The Abortion Supervisory Committee does have medical recommendations, but the extra visits and procedures are there more for medical reasons than legal.

Abortion providers generally want some basic tests done, and some information about when the woman became pregnant. This is important because different abortion procedures can only be used in some stages of pregnancy.

They want to know if there is an active sexually transmitted infection, as this can cause complications including chronic pelvic pain, infertility and increase risk of future ectopic pregnancy. One study of women presenting for an abortion found chlamydia at a rate of nearly 19% in one population group. Clearly it’s important to test and wait for the results before risking invasive surgery and all the risks of infection that can result.

One requirement that is very controversial overseas is ultrasound. There are some good reasons why it’s appropriate to do an ultrasound before an abortion. The first reason is to confirm that it’s a normal pregnancy, and not an ectopic or molar pregnancy. The recent case of “Dr N” highlights the risks or forgoing the ultrasound. She facilitated several of her patients to have medical abortions by providing the medication outside New Zealand’s current legal framework. One of these women had an ectopic pregnancy, which was not ended by the medical abortion. Later this patient was admitted to hospital for treatment due to a ruptured fallopian tube. Her outcome could have been much worse.

Ultrasound can confirm if the unborn child is healthy likely to survive to birth. There is an appreciable miscarriage rate in early pregnancy, and sometimes an ultrasound can predict a miscarriage before it happens. Clearly in these cases there is no need for the woman to be exposed to the additional trauma of an abortion. I’ve also heard that many women who have made up their mind to have an abortion, and then cry when they hear the news that their child has died, or will soon die.

An increasingly important feature of ultrasound is the ability to accurately estimate the age of the preborn baby. Many women are using forms of contraception that disrupt the normal menstrual cycle, which can make dating an unexpected pregnancy more difficult. The gestational age of the child is important information for abortion providers, as different methods of abortion are used as the gestational age of the child increases.

Blood tests are normally required. These indicate the health of the mother, and her rhesus blood group. If the mother is rhesus negative, and the baby is rhesus positive, after the abortion the mother may produce antibodies which could cause rhesus disease in her future babies. This can easily be prevented by an injection of ‘anti-D’ at the time of the abortion.

And then there is counselling. The Abortion Supervisory Committee strongly recommends counselling for all women wanting an abortion, both before and after abortion. This is universally optional, despite the growing evidence that abortion is harmful to a woman’s mental health.

It’s clear that the extra visits for a woman wanting an abortion in New Zealand are not because of some pro-life conspiracy, but are all justified on medical and evidence based grounds. They are certainly not hoops to be gotten through. They are there to protect the health of the woman and her future children.

But how much more could we protect women and children if we recognised the harm abortion does to them, and supported them in pregnancy and beyond? Then no unexpected pregnancy would be a crisis pregnancy, and every child could be born into a society which loves and affirms them.

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Condoms and HIV

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It is frequently stated that condoms are the solution to the AIDS epidemic. We have had condoms for a long time, and they are plentiful, cheap, and their use is advocated to virtually every school student in the country many times before they leave school.

In addition to this, we now have very effective medications for HIV positive people. They are capable of reducing the amount of the HIV in their blood to levels so low that they become undetectable. And when the viral load in their blood reduces to these levels, these people are considered to be virtually non infective.

So you could be forgiven for thinking that the AIDS epidemic is a problem solved, and it will soon just be another entry in the history books.

Except that in 2011 (the last year we have records for) the number of people newly diagnosed with HIV was higher than for any year during the 1990’s. And that number is a substantial drop from 2010. So why isn’t condom promotion stopping the epidemic in New Zealand and around the world? After all, it’s regularly said that condom use reduces the risk of becoming infected with HIV by 85%.

One answer to this question can be found in the same research papers that give us the efficacy of condoms.

There are some serious ethical (and moral) issues with medical testing. The standard method is to divide a sample of people randomly into 2 groups, and only treat one group. Then compare the disease or condition between the group that received treatment or intervention, to the other, or control group. But if the intervention is potentially life saving, then there are serious ethical issues in withholding that intervention from the control group.

As HIV was (and still is) a terminal disease, so if a researcher thinks using condoms will save the lives of people in the study, they ethically can’t withhold them from anyone. So they need an ‘ethical’ way of testing condom effectiveness. The standard method is to find a group of people that are going to be exposed to HIV infection, train them in condom use, and then record the condom usage and infection rates.

The usual group to study are couples where one has tested HIV positive, and one has tested HIV negative. These couples must be mutually monogamous, heterosexual, not be using intravenous drugs, and have not received unscreened blood products. They are all given intensive ‘safer sex’ instruction, usually on a regular basis. These studies frequently supply condoms too. Not surprisingly, a large number of couples simply stop having sex. The risk is too great. It’s the ones who continue that interest the researchers the most.

The researchers regularly survey condom use of the people in their study, and compare HIV infection rates of those who consistently use condoms to those who use them inconsistently or not at all.

Did you read that bit right? There are couples in the studies who don’t use condoms consistently or at all. And that is after receiving intensive and ongoing ‘safer sex’ education. It’s not just a small minority. Frequently those who do not use condoms at all or inconsistently number 50% or more of those taking part in the study. It’s hard to think of a group of people who might be more motivated to use “safer sex”, and yet this ‘safer sex’ approach isn’t keeping the majority ‘safe’. Add to that the real world failure rate of condoms, and you have a ‘safer sex’ strategy that isn’t that safe.

The condom and lube promotion is the main strategy here in New Zealand, and in many places around the world.

The sad irony is that although half of these people in these studies wouldn’t use condoms, all of them were prepared to be a faithful couple. If only this was advocated from the start, none of those people in the studies would have ever been infected with HIV.

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Sexually Transmitted Infections Rising in NZ

It appears that the incidence of sexually transmitted infections has been rising in New Zealand over the last few years.  These figures may be levelling out, but they are not going down.  Is the overall level out just a coincidence?  According to an article published on Stuff on Christmas Day “In the three months to September, rates of chlamydia, gonorrhoea and syphilis all increased on the quarter before.”  Obviously certain types of infections are becoming more prevalent in the non-monogamous sexually active population.

1202 cases of chlamydia were reported over the three months to September 2012 (up 5%).  The incidence of gonorrhea climbed from 16 cases to 27 in that same three month period (up around 68%).

These figures are alarming.  Both chlamydia and gonorrhea have the potential to cause irreparable damage to a woman’s reproductive system, possibly rendering her infertile.  If over 1200 cases of chlamydia were reported in such a short space of time, how many more have it and don’t even know?  It is astounding to think that so many women are walking around not even knowing that when they finally decide it is time for children, those children may never come.

Are these increases in sexually transmitted infections the result of the hard push by the New Zealand Family Planning Association and government agencies for women of all ages to use long-term contraception such as Jadelle, Depo Provera and IUDs?  Does it have anything to do with the easy attitude our society has regarding promiscuious sexual activity, and the practice of “serial monogamy” (where a couple are exclusively sexually active for the term of their relationship – whether that be one month or three years).

Dr Christine Roke, medical advisor to the Family Planning Association says “We are seeing people get checked more regularly and to a certain extent the numbers are reflective of the fact we’re picking up more.”  It might well be that people are getting checked more often, but I do believe that societal attitudes have become extremely permissive, and this permissivemess is being rewarded by free and cheap contraception.

Christine Roke’s answer to the madness of the “silly season” is “What we would recommend to people is to designate a person, in much the same way you would a sober driver, and that person should keep an eye on the group and make sure they don’t get into any trouble.”  Advice that is hardly going to ensure a person doesn’t contract a sexually transmitted infection.

Somehow we need to change society’s attitude towards promiscuous sex.  Young people especially need to learn that it is okay to enjoy the company of the opposite sex without engaging in sexual intercourse.  However we manage to convey this message, handing out free or inexpensive contraception and telling people to designate a person to keep watch is hardly going to work in decreasing the incidence of sexually transmitted infections.