Category Archives: Clinical conditions

The Socialist Health Association (SHA) published its first Blog on the COVID-19 pandemic last week (Blog 1 – 17th March 2020). A lot has happened over the past week and we will address some of these developments using the lens of socialism and health.

  1. Global crisis

This is a pandemic, which first showed its potential in Wuhan in China in early December 2019. The Chinese government were reluctant to disclose the SARS- like virus to the WHO and wider world to start with and we heard about the courageous whistle blower Dr Li Wenliang, an ophthalmologist in Wuhan, who was denounced and subsequently died from the virus. The Chinese government recognised the risk of a new SARS like virus and called in the WHO and announced the situation to the wider world on the 31st December 2019.

The starter pistols went off in China and their neighbouring countries and the risk of a global pandemic was communicated worldwide. The WHO embedded expert staff in China to train staff, guide the control measures and validate findings. Dr Li Wenliang who had contracted the virus, sadly died in early February and has now been exonerated by the State. Thanks to the Chinese authorities and their clinical and public health staff we have been able to learn about their control measures and the clinical findings and outcomes in scientific publications. This is a major achievement for science and evidence for public health control measures but….

Countries in the Far East had been sensitised by the original SARS-CoV outbreak, which originated in China in November 2002. The Chinese government at that time had been defensive and had not involved the WHO early enough or with sufficient openness. The virus spread to Hong Kong and then to many countries showing the ease of transmission particularly via air travel. The SARS pandemic was thankfully relatively limited leading to global spread but ‘only’ 8,000 confirmed cases and 774 deaths. This new Coronavirus COVID-19 has been met by robust public health control measures in South Korea, Taiwan, Hong Kong, Japan and Singapore. They have all shown that with early and extensive controls on travel, testing, isolating and quarantining that you can limit the spread and the subsequent toll on health services and fatalities. You will notice the widespread use of checkpoints where people are asked about contact with cases, any symptoms eg dry cough and then testing their temperature at arms length. All this is undertaken by non healthcare staff. Likely cases are referred on to diagnostic pods. In the West we do not seem to have put much focus on this at a population level – identifying possible cases, testing them and isolating positives.

To look at the global data the WHO and the John Hopkins University websites are good. For a coherent analysis globally the Tomas Peoyu’s review  ‘Coronavirus: The Hammer and the dance’ is a good independent source as is the game changing Imperial College groups review paper for the UK Scientific Advisory Group for Emergencies (SAGE). This was published in full by the Observer newspaper on the 23rd March. That China, with a population of 1.4bn people, have controlled the epidemic with 81,000 cases and 3,260 deaths is an extraordinary achievement. Deaths from COVID-19 in Italy now exceed this total.

The take away message is that we should have acted sooner following the New Year’s Eve news from Wuhan and learned and acted on the lessons of the successful public health control measures undertaken in China and the Far East countries, who are not all authoritarian Communist countries! Public Health is global and instead of Trump referring to the ‘Chinese’ virus he and our government should have acted earlier and more systematically than we have seen.

Europe is the new epicentre of the spread and Italy, Spain and France particularly badly affected at this point in time. The health services in Italy have been better staffed than the NHS in terms of doctors/1000 population (Italy 4 v UK 2.8) as well as ITU hospital beds/100,000 (Italy 12.5 v UK 6.6). As we said in Blog 1 governments cannot conjure up medical specialists and nurses at whim so we will suffer from historically low medical staffing. The limited investment in ITU capacity, despite the 2009 H1N1 pandemic which showed the weakness in our system, is going to harm us. It was great to see NHS Wales stopping elective surgical admissions early on and getting on with training staff and creating new high dependency beds in their hospitals. In England elective surgery is due to cease in mid April! We need to ramp up our surge capacity as we have maybe 2 weeks at best before the big wave hits us. The UK government must lift their heads from the computer model and take note of best practice from other countries and implement lockdown and ramp up HDU/ITU capacity.

In Blog 1 we mentioned that global health inequalities will continue to manifest themselves as the pandemic plays out and spare a thought for the Syrian refugee camps, people in Gaza, war torn Yemen and Sub Saharan Africa as the virus spreads down the African continent. Use gloves, wash your hands and self isolate in a shanty town? So let us not forget the Low Middle Income Countries (LMICs) with their weak health systems, low economic level, weak infrastructure and poor governance. International banking organisations, UNHCR, UNICEF, WHO and national government aid organisations such as DFID need to be resourced and activated to reach out to these countries and their people.

  1. The public health system

We are lucky to have an established public health system in the UK and it is responding well to this crisis. However we can detect the impact of the last 10 years of Tory Party austerity which has underfunded the public health specialist services such as Public Health England (PHE) and the equivalents in the devolved nations, public health in local government and public health embedded in laboratories and the NHS. PHE has been a world leader in developing the PCR test on nasal and throat samples as well as developing/testing the novel antibody blood test to demonstrate an immune response to the virus. The jury is out as to what has led to the lack of capacity for testing for C-19 as the UK, while undertaking a moderate number of tests, has not been able to sustain community based testing to help guide decisions about quarantining key workers and get intelligence about the level of community spread. Compare our rates of testing with South Korea!

We are lucky to have an infectious disease public health trained CMO leading the UK wide response who has had experience working in Africa. Decisions made at COBRA and announced by the Prime Minister are not simply based ‘on the science’ and no doubt there have been arguments on both sides. The CSO reports that SAGE has been subject to heated debate as you would expect but the message about herd immunity and stating to the Select Committee that 20,000 excess deaths was at this stage thought to be a good result was misjudged. The hand of Dominic Cummings is also emerging as an influencer on how Downing Street responds. Remember at present China with its 1.4bn population has reported 3,260 deaths. They used classic public health methods of identifying cases and isolating them and stopping community transmission as much as possible. Herd immunity and precision timing of control measures has not been used.

The public must remain focused on basic hygiene measures – self isolating, washing of hands, social distancing and not be misled about how fast a vaccine can be developed, clinically tested and manufactured at scale. Similarly hopes/expectations should not be placed on novel treatments although research and trials do need supporting. The CSO, who comes from a background in Big Pharma research, must be seen to reflect the advice of SAGE in an objective way and resist the many difficult political and business pressures that surround the process. His experience with GSK should mean that he knows about the timescales for bringing a novel vaccine or new drugs safely to market.

  1. Local government and social care

Local government (LAs) has been subject to year on year cuts and cost constraints since 2010, which have undermined their capability for the role now expected of them. The budget did not address this fundamental issue and we fully expect that in the crisis, central government will pass on the majority of local actions agreed at COBRA to them. During the national and international crisis LAs must be provided with the financial resources they need to build community hubs to support care in the community during this difficult time. The government need to support social care.

COVID-19 is particularly dangerous to our older population and those with underlying health conditions. This means that the government needs to work energetically with the social care sector to ensure that the public health control measures are applied effectively but sensitively to this vulnerable population. The health protection measures which have been announced is an understandable attempt to protect vulnerable people but it will require community mobilisation to support these folk.

Contingency plans need to be in place to support care and nursing homes when cases are identified and to ensure that they can call on medical and specialist nursing advice to manage cases who are judged not to require hospitalisation. They will also need to be prepared to take back people able to be discharged from acute hospital care to maintain capacity in the acute sector.

Apart from older people in need there are also many people with long term conditions needing home based support services, which will become stressed during this crisis. There will be nursing and care staff sickness and already fragile support systems are at risk. As the retail sector starts to shut down and there is competition for scarce resources we need to be building in supply pathways for community based people with health and social care needs. Primary health care will need to find smart ways of providing medical and nursing support.

  1. The NHS

In January and February when the gravity of the COVID pandemic was manifesting itself many of us were struck by the confident assertion that the NHS was well prepared. We know that the emergency plans will have been dusted down and the stockpile warehouses checked out. However, it now seems that there have not been the stress tests that you might have expected such as the supply and distribution of PPE equipment to both hospitals and community settings. The planning for COVID-19 testing also seems to have badly underestimated the need and we have been denied more accurate measures of community spread as well as the confirmation or otherwise of a definite case of COVID-19. This deficiency risks scarce NHS staff being quarantined at home for non COVID-19 symptoms.

The 2009 H1N1 flu pandemic highlighted the need for critical care networks and more capacity in ITU provision with clear plans for surge capacity creating High Dependency Units (HDUs) including ability to use ventilators. The step-up and step-down facilities need bed capacity and adequate staffing. In addition, there is a need for clarity on referral pathways and ambulance transfer capability for those requiring even more specialised care such as Extracorporeal Membrane Oxygenation (ECMO). The short window we now have needs to be used to sort some of these systems out and sadly the supply of critical equipment such as ventilators has not been addressed over the past 2 months. The Prime Minister at this point calls on F1 manufacturers to step in – we wasted 2 months.

News of the private sector being drawn into the whole system is obviously good for adding beds, staff and equipment. The contracts need to be scrutinised in a more competent way than the Brexit cross channel ferries due diligence was, to ensure that the State and financially starved NHS is not disadvantaged. We prefer to see these changes as requisitioning private hospitals and contractors into the NHS. 

  1. Maintaining people’s standard of living

We consider that the Chancellor has made some major steps toward ensuring that workers have some guarantees of sufficient income to maintain their health and wellbeing during this crisis. Clearly more work needs to be done to demonstrate that the self-employed and those on zero hours contracts are not more disadvantaged. The spotlight has shown that the levels of universal credit are quite inadequate to meet needs so now is the time to either introduce universal basic income or beef up the social security packages to provide a living wage. We also need to ensure that the homeless and rootless, those on the streets with chronic mental illness or substance misuse are catered for and we welcome the news that Sadiq Khan has requisitioned some hotels to provide hostel space. It has been good to see that the Trade Unions and TUC have been drawn into negotiations rather than ignored.

In political terms we saw in 2008 that the State could nationalise high street banks. Now we see that the State can go much further and take over the commanding heights of the economy! Imagine if these announcements had been made, not by Rishi Sunak, but by John McDonnell! The media would have been in meltdown about the socialist take over!

  1. Conclusion

At this stage of the pandemic we note with regret that the UK government did not act sooner to prepare for what is coming both in terms of public health measures as well as preparing the NHS and Local Government. It seems to the SHA that the government is playing catch up rather than being on the front foot. Many of the decisions have been rather late but we welcome the commitment to support the public health system, listen to independent voices in the scientific world through SAGE and to invest in the NHS. The country as a whole recognises the serious danger we are in and will help orchestrate the support and solidarity in the NHS and wider community. Perhaps a government of national unity should be created as we hear much of the WW2 experience. We need to have trust in the government to ensure that the people themselves benefit from these huge investment decisions.

24th March 2020

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COVID-19 Pandemic

The SHA wants to contribute to the tremendous national and international debate about controlling and mitigating the worst effects of the COVID-19 pandemic. We will base these thoughts through the lens of a socialist society, which advocated politically in the 1930s to create the NHS in the UK and for other socialist policies, which see the social determinants of health being as important as the provision of health and social care services as we strive for a healthier and fairer society.

This blog will be the first of a series and will cover

 

  1. A global crisis
  2. The Public Health system
  3. The NHS, Local Government and Social Care
  4. Funding for staff and facilities
  5. Staff training, welfare and support
  6. Vulnerable populations
  7. Assuring Universal Basic Income

 

  1. A global crisis

This COVID-19 pandemic has already been cited as the greatest public health crisis for at least a generation. The HIV/AIDS pandemic starting in the 1980s had a much slower spread between countries and is estimated to have caused an estimated 25-30m excess deaths so far.  The potential scale of this type of respiratory viral infection pandemic with a faster spread means we should probably look back to the 1957 Asian flu pandemic and indeed the 1918 post war ‘Spanish flu’. The 1918 pandemic led to an estimated 40-50m global deaths and was when there was also no effective vaccine or treatment for the new variant of flu. So basic public health hygiene (hand washing), identifying cases and quarantining (self isolation) are still important. We recognise this as a global challenge, which requires global solidarity and the sharing of knowledge/expertise and advice.

The WHO, which is part of the United Nations, needs our support and is performing a very beneficial role.  This will be especially important for those Low Middle Income Countries (LMICs) who often have unstable political environments and weak public health and health systems. Remember the Democratic Republic of the Congo who have only just seen off their Ebola epidemic, war torn Syria and the Yemen.

The USA and other high-income countries should be unambiguous about recognising this as a fundamental global pandemic requiring collaboration between countries along the principles of mutual aid. The UN and WHO need our support and funding and we look to international financial organisations such as the IMF/World Bank to rally around in the way that the world banking system showed they could in their own self inflicted 2008 financial crash. The WHO has recently referred to Europe as the epicentre of the pandemic and we urge the Government to put aside their ideological objections and co-operate fully with the EU and our European partners.

 

  1. The public health system

The UK itself is in a relatively strong position with a national public health service, which has focus at a UK level (CMO/PHE), scientific advisory structures (SAGE), devolved governments, municipalities and local government. The NHS too still has national lines of control from NHSE to the NHS in England and the equivalents in devolved countries. The Tory ‘Lansley’ reforms in England destroyed the health authority structure below national levels (remember the former Strategic and District Health Authorities) but at least PHE has a regional organisation and Local Government have Directors of Public Health. We regret the fact that the 10 years of Tory austerity has depleted the resources in PHE and Local Government through not funding the PHE budget adequately and not honouring the public health grant for local authorities. We hope that the recent budget will mean that the public health service and local government does receive the financial and other resources required to help lead the pandemic response. Pandemics have always been high up in the UK risk register.

 

  1. The NHS, Local Government and Social Care

We are grateful that despite the privatisation of many parts of the NHS in England we still have a recognisable system and a culture of service rather than profit within our one million or so staff and their NHS organisations. We were pleased to hear the open ended funding commitment from the Chancellor at the last budget and urge that leaders within the NHS in England and the devolved countries use this opportunity to try to mitigate the underfunding over the last 10 years and implement the emergency plans that exist and calibrate them to deal most effectively with this particular viral threat. Any debates about further privatisation of the NHS needs to be taken off the agenda and let’s not use the budget money to prop up the private sector but requisition capacity if that is what is needed and compensate usage on an NHS cost basis. We want to protect the NHS from the risk that the NHS Long Term Plan proposals for 44 Integrated Care Schemes opens up the risk of US styled private insurance schemes.

 

  1. Funding for staff and facilities.

It will of course be difficult as a result of the staffing crisis that has been allowed to drift over the past 10 years with shortages of NHS workforce of 100,000 of which 40,000 are nurse vacancies but also includes doctors and other key staff. We and our Labour Party colleagues have been reminding Tory Ministers  that it takes 10 years to train a medical specialist so you cannot whistle them up or poach them from other poorer countries. The government needs to abolish their proposed points based immigration regime and indeed the compulsory NHS insurance of £650 per adult which is a huge disincentive to come here and work in the health and social care system.

Hospitals and other health facilities in the UK take time to plan, build and commission. We can of course learn from Wuhan in China where they built a 1000 bedded hospital in weeks! Our own war preparation in the late 1930s when industry shifted production rapidly from civilian to military supplies is another exemplar. Despite the negative impact of 10 years of Tory austerity we urge the NHS to embrace this opportunity to invest in staff, supplies and facilities needed to manage the effects of the pandemic. Creating strategic regional NHS bodies will ensure that capital and revenue resources committed from the centre are used optimally and equitable to meet population needs in collaboration with local authorities.

 

  1. Staff training, welfare and support

Front line NHS and social care staff will need our support over this time. We must ensure that working practices protect staff as much as possible from the risks in the workplace. Training and provision of Personal Protective Equipment (PPE) is vital and employment practices will need to adapt to the changing situation. Lets not forget social care workers, dentists, optometrists and district nurses who are part of our front line. Staff will need retraining if doctors and nurses are to be diverted to unfamiliar roles as we will need A&E, pandemic pods and intensive care unit capacity to be enhanced. Sadly, we now have a significant workforce who work for private contractors as part of the Tory privatisation of the NHS. We need to ensure that they have the same employment safeguards, minimum pay levels, sick pay and the health and safety entitlements as NHS staff. This is the time to renationalise such services back into the fold.

 Patients with existing long-term conditions remain in need of continuing care as will patients presenting with new life-threatening conditions such as cancers, diabetes and circulatory diseases. NHS managers will need support to organise these different services and decisions to postpone non-urgent elective surgery to free up resources. What also makes sense is testing novel ways of supporting people digitally and by teleconferencing to reduce attendance at NHS premises. This can be rolled out for Out Patient provision as well as GP surgeries. The NHS 111 service, and other online services  and the equivalents in the devolved nations can easily be overwhelmed so pushing out good health information and advice is being done and needs to continue. The public and patient engagement has always been at the heart of our policies and can be rolled out in this emergency utilising the third sector more imaginatively.

 

  1. Vulnerable populations.

In our assessment of what needs to be done we must not bypass the urgent needs of some of our most vulnerable populations. The homeless and rootless populations, many of whom have longstanding mental health conditions and/or substance dependency, are particularly at risk. They need urgent attention working closely with the extensive voluntary sector. Also those populations with long term conditions who will feel at risk if services are withdrawn due to staff redeployment or staff sickness need planning for. Primary care needs to be the service we support to flag up those in need and ensure that their medications and personal care needs continue to be met even if we need to involve volunteers and good neighbours to help out with daily needs such as shopping/providing meals and other tasks.

Undocumented workers such as migrants and refugees are often frightened to use health services for fear of police intrusion. The government needs to make it clear that there will be no barriers to care for this population during this crisis and beyond.

Social care is in need of particular attention. It was virtually ignored in the budget. This sector is at risk in terms of problems with recruiting and retaining staff as well as the needs of the recipients of care and support.. While business continuity plans may be in place there is no question that this sector needs investment and generous support at the time of such an emergency. They will be a vital cog in the wheel alongside home-based carers in supporting the NHS and wider social care system. Those most at risk seem to be the most neglected. Disabled people with care needs have received little advice and no support. Already carers are going off sick and can be replaced only with great difficulty. Those paying for their own care with Direct Payments seem to get no support at all.

With the COVID-19 virus we are seeing that the older population and those with so called ‘underlying conditions’ are at particular risk. We must ensure that this large population do not feel stigmatised and become isolated. Rapid assembly of local support groups should be encouraged which has been referred to as ‘local COBRA groups’. Local government can play a key role in establishing local neighbourhood centres for information and advice on accessing support as we move toward increasing quarantining and isolated households. Again wherever possible the use of IT and telephone connectivity to share information and provide remote support will make this more manageable.

 

  1. Assuring universal basic income.

Finally the SHA recognises that the economy will be damaged by the pandemic, organisations will go to the wall and staff will lose their jobs and income stream. We have always recognised that the fundamental inequalities arise from the lack of income, adequate housing and the means to provide for everyday life. This pandemic will last for months and we think that the Government needs to ensure that we have systems in place to ensure that every citizen has access to an adequate income through this crisis. We pay particular attention to the 2m part time workers and those on zero hours contracts as well as the 5m self-employed. There have been welcome changes in the timely access to the insufficient Statutory Sick Pay but this is not going to be the answer. People will be losing their jobs as different parts of the economy go under as we are already seeing with aviation, the retail sector and café/restaurants. The government needs to reassure those fearful of losing their jobs that they will stand by them during the pandemic. It may be the time to test the Universal Basic Income concept to give all citizens a guarantee that they will have enough income for healthy living. We already have unacceptable health inequalities so we must not allow this to get worse.

 

  1. Conclusion

The SHA stands ready to support the national and international efforts to tackle this pandemic. We assert our belief that a socialist approach sees universal health and social care as an essential part of society. That these systems should be funded by all according to a progressive taxation system and meet peoples needs being free at the point of use.  We believe that a thriving state owned and operated NHS and a complimentary not for profit care sector is essential to achieve a situation where rich and poor, young and old and citizens in towns, cities and in rural areas have equal access to the best care.

We recognise that the social determinants of health underpin our health. We agree with Marmot who reminds us that health and wellbeing is reflected by ‘the conditions that people are born, grow, live, work and age and by the inequities in power, money and resources that influence these conditions’.

The pandemic is global and is a major threat to people’s health and wellbeing. Universal health and public health services offer the best means of meeting this challenge nationally and globally. Populism and inward looking nationalism needs to be challenged as we work to reduce the human suffering that is unfolding and direct resources to meet the needs of the people at this time.

On behalf of officers and vice chairs

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The Conference on Retroviruses and Opportunistic Infections (CROI) in Boston is the most important yearly scientific meeting for HIV doctors and the global community of people living with HIV.

However, this year – and at the very last minute because of the new coronavirus outbreak – the organisers replaced it with a ‘virtual’ conference.

HIV i-Base, the London-based HIV Treatment Information charity, regularly attends this conference. Simon Collins and Polly Clayden at i-Base always report on the latest scientific research, including on new drugs for both treatment and prevention of HIV.

But importantly his year, CROI have given open access to a special session on COVID-19 and SARS-CoV-2.

Here is Simon Collins’ report for i-Base. This includes a link to the special session which contains up-to-date information about the outbreak that can be of interest to all, and not just to people who are HIV positive:

The special session on coronavirus at CROI yesterday is posted for open-access on the CROI website. [1]

The 75-minute overview includes four talks and a Q&A at the end.

A few selected key points include:

  • The highest risk of more serious illness and outcomes (risk of dying) are older age (80>70>60 years old), and having other health conditions (heart, lung/breathing, diabetes, cancer). The risk of the most serious outcomes is 5 to 30 times higher than with seasonal influenza (‘flu’).
  • Implications for people living with HIV are not currently known, other than as for the general population. One speaker included low CD4 as a possible caution. [Note: Due to lack of evidence so far a low CD4 count has not been included as a risk in the recent UK (BHIVA) statement]. [2]
  • Transmission is largely from microdroplets in air from someone during the infectious period (generally from 1 day before symptoms to average 5 days, but up to 14 days after). These can remain infectious on hard surfaces for an unknown time (possibly hours) which is why hand-washing and not touching your face is important.
  • Best ways to minimise risk of infection include washing your hands more carefully and frequently and not touching your face.
  • Soap and water is better than hand sanitisers (and more readily available).
  • Best candidate treatment (so far) is remdesivir (a Gilead compound). This has good activity against a range of viruses in in-vitro studies and is already in at least four large randomised studies.
  • Studies with candidate vaccines are expected shortly – within two months of the virus being isolated – fastest time for vaccine development.
  • The response in China after the first cases were reported was probably much faster than it would have been in the UK. This included:
    –  Within four days of the first reported cases, the suspect source was identified and closed (a seafood market).
    –  Within a week, the new virus was identified (SARS-CoV-2).
    –  The viral sequence was then shared with WHO and on databases in the public domain for other global scientists to use.
    –  Within three weeks of the first confirmed cases, Wuhan and 15 other large cities in China were shut down as part of containment measures.
  • One of the questions after the main talks asked whether SARS was now extinct. The answer explained that SARS is a bat virus, and only 50 out of about 1300 species of bats have been studied so far. So SARS is very likely still around.

COMMENT

Currently, the most important things for people living with HIV are:

  1. To make sure people have enough medications – including at least one month spare. If travelling where there might be a risk of quarantine, to take additional meds with you to cover this.

  2. As recommended by BHIVA, sensible hygiene precautions (hand washing and not touching your face etc). [2]

  3. Avoid or delay any non-essential or non-urgent hospital visits.

  4. Special caution for those who are older or who have multimorbidities – which are prevalent in HIV.

References

  1. Special session on COVID-19. CROI 2020, 8–11 March 2020.
    https://special.croi.capitalreach.com
  2. BHIVA. Comment on COVID-19 from the British HIV Association. 27 February 2020.
    https://www.bhiva.org/comment-on-COVID-19-from-BHIVA
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“Like everyone else, we feel helplessness, anxiety, and fear.”

by Dan Robitzski / 8 hours ago

As they try to fight the COVID-19 outbreak, medical staff in China are suffering from the seemingly endless slog of work, new cases, and the coronavirus itself.

Nurses in Wuhan, the city where the outbreak began, are fainting on the job, developing painful rashes, sores, hypoglycemia, and psychological exhaustion — and that’s why two of them published an impassioned plea for help from the rest of the world in the journal The Lancet on Sunday.

“While we are professional nurses, we are also human. Like everyone else, we feel helplessness, anxiety, and fear,” the authors, Yingchun Zeng and Yan Zhen, both from hospitals in Guangzhou, wrote. “Experienced nurses occasionally find the time to comfort colleagues and try to relieve our anxiety. But even experienced nurses may also cry, possibly because we do not know how long we need to stay here and we are the highest-risk group for COVID-19 infection.”

Nearly 2,000 medical workers helping COVID-19 patients in China have been infected, and at least nine have died. Meanwhile, the nurses write that the safety measures they have to follow, like quadruple-layering gloves and constantly wearing and washing tight respirators that are giving them bedsores, are simultaneously making them sick and rendering them useless as caregivers.

For instance, unpackaging medical supplies and giving a patient a shot while wearing four layers of latex gloves is particularly difficult.

“Due to an extreme shortage of health-care professionals in Wuhan, 14,000 nurses from across China have voluntarily come to Wuhan to support local medical health-care professionals,” the nurses wrote. “But we need much more help. We are asking nurses and medical staff from countries around the world to come to China now, to help us in this battle.”

 

 

 

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Today the Mail on Sunday published an article headlined ‘HIV treatment now costs NHS as much as breast cancer – Fears £606m annual bill for sexually transmitted disease is fuelled by flood of foreign health tourists‘.

The only views to ‘balance’ the diatribe published in the paper and online was a short rebuttal from BHIVA  (British HIV Association) and NAT (National AIDS Trust) as well as a short statement from NHS England on how costs for HIV treatment are actually reducing:

A spokesman for the BHIVA said: ‘In the UK, new diagnoses of HIV are now falling because of the success of testing and treatment.’

An NHS England spokesman said the cost of HIV treatment had fallen £28 million from £634 million in 2017/18 to £606 million in 2018/19.

A Department of Health spokesman said: ‘We’ve seen a decline of almost a third in new HIV diagnoses in the UK in recent years.

‘As with all other serious infectious diseases, we do not charge overseas visitors for treatment for HIV as, if left untreated, there is a significant risk to others in this country.’

Deborah Gold, chief executive of the NAT, said: ‘The concept of health tourism for HIV treatment is an outdated myth.

‘It is actually a problem that we have such long average delays, usually years, between migrants’ arrival in the UK and them accessing HIV testing and care.

‘Universal availability of HIV treatment is a cornerstone of the response in the UK. Any suggestion this is a poor use of NHS money, or that access to treatment should be limited for anyone, is outrageous. In fact, it is evidence of the NHS at its best: saving lives and preventing ill-health.’

UK-CAB (the UK Community Advisory Board) responded to the article via this tweet with the following statement:

“The UK is a world leader in reducing the numbers of new HIV diagnoses and one of only six countries to have already met the UNAIDS 90-90-90 targets. This achievement would not have been possible without upscaling HIV testing and providing immediate antiretroviral treatment to all people living with HIV in the UK.

People with HIV on effective antiretroviral treatment cannot pass the virus on to their sexual partners or to their unborn child during birth and pregnancy. The investment in free HIV treatment for everyone with HIV is fundamental to meeting the Government’s commitment to end new transmissions by 2030.

Stigmatising information like that reported in today’s Mail on Sunday only serves to hinder the UK’s response to the HIV epidemic. Whilst we have made huge strides in reducing new diagnoses by an incredible 28% between 2015 and 2017, the numbers of people diagnosed late is still too high.

Late diagnosis not only increases the chances of premature death but also heightens the risk of HIV being unknowingly transmitted to sexual partners. We cannot tolerate attitudes which put people off testing and finding out their HIV status.

People living with HIV should not be pitted against other patient groups or conditions.

Access to treatment and care for all people living with HIV ensures that individuals can live well and in good health and also stops transmission of the virus to others. Any insinuation that denying HIV treatment to those without ‘settled’ status would be a benefit to the nation’s public health or NHS budgets is nonsense.”

Please circulate this as widely as possible.

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Nick Bostock reports at GPonline that:

Under-pressure GPs are delivering ‘remarkable outcomes’ on cancer

You can read the complete article here. Nick reports:

GPs ‘can take a lot of credit’ for marked improvements in early cancer diagnosis and reductions in the proportion of cases detected as an emergency, according to a cancer expert.

In the year to March 2018, the proportion of cancer patients who first presented at hospital as an emergency fell to 18.8% – down from 21% in the year to December 2012.

Over roughly the same period, cancers detected at an early stage increased significantly – rising from 46% in 2013 to 52% by mid-2017, according to figures from the National Cancer Intelligence Network (NCIN).

However: GPonline reported earlier this year on research showing that GPs were as good as consultants at making appropriate use of cancer diagnostic tests – and yet pledges to give GPs direct access to four key diagnostic tests – blood tests, chest X-ray, ultrasound and endoscopy – have not been delivered in many areas.

Isn’t it about time that GPs were also given access to the new technology for GP consultations via mobile and Skype? This is currently being ‘rolled out’ by GP at Hand. Here’s a transcript of the R4 Today programme 13 September at 6 mins to 9:00 am (I made this transcript and I believe it’s a fairly accurate job – but any mistakes are mine):

(Int) Interviewer

AP (Ali Parsa, CEO Babylon – parent company that runs GP at Hand)

RV (Dr Richard Vautrey, Chair GP Committee, British Medical Association)

SoS = Secretary of State

 

(Int): So Ali Parsa just explain to us how your App works.

(AP): So, we have a very simple service. So, what it does is allow patients to check their symptoms whenever they want. To make an appointment with a doctor within seconds, to be able to see a doctor within minutes. In fact, I was just checking my App and it says that if I want to see a doctor I can see one at 9 o’clock today, in the next few minutes.

(Int): You mean ‘see’ over the phone?

(AP): Over the phone. And if you want to see somebody physically then, you can go see them that very same day. It is open 24hrs a day, 365 days of the year. And it is available for the same price the National Health Service pays any other GP. What we have done is to solve the problem of accessibility and the continuity of healthcare – using technology and what the SoS and the NHS is doing today is celebrating that and promising it for the whole country.

(Int): And Richard Vautrey, this is something which patients complain about again and again, isn’t it, access to their GP, so is this kind of App the solution?

(RV): We have real concerns, as well as patients do, about the inability of many practices to be able to offer enough appointments and that’s simply because we haven’t had the funding over the last decade to support the expansion of the health service to be able to meet the growing needs of our patients. What General Practices are doing right now is seeing thousands and thousands – if not a million – patients today offering, you know, face-to-face consultations and seeing them in their surgeries, so that’s when patients approach them today. So that’s happening right now. What we haven’t got is the resources to be able to offer some of the IT technologies in every single practice. And the SoS’s commitment to IT is welcome, but we need to see that commitment translated into resources provided to enable every practice to offer this type of consultation.

(Int): But could this kind of technological approach actually help some of the pressure on GPs because people would consult a doctor over the phone rather than going to the surgery.

(AP): Well many practices, if not most practices, already offer telephone consultations. What they haven’t got is the IT kit to be able to offer smart phone consultations, or Skype-phone computer consultations, any many would like to be able to do that, if the technology was provided to them. But the other big difference is that every Practice that is open today will see any and every patient who lives within their area, and we have concerns about the model of which GP Hand has been built, which is primarily about looking at some of the relatively mobile healthy patients and not accepting every single patient who lives within their area.

(AP): I’m afraid Richard that is simply factually not true. We will ask when patients started the service, to ask patients to seek advice if they want to change their GP Practice to our Practice, if they have any clinical issues. Most patients seek advice and join us – we look after them, young, old, sick, healthy, our patients are across the border, and we don’t do that just in Britain, remember we look after one third of the population in Rwanda, and we do so in the United States, we do this in Canada. . .

(Int): But specifically, on this idea of whether you cherry pick patients, it’s likely that patients who don’t have very serious health problems, and maybe younger, are more likely to want to use an App on their mobile.

(AP) . . . but, why is that? If the patient is not very mobile, if the patient is very old, if the patient can’t wait a few weeks to see their GP, they’re significantly more likely to use a service that is continuously available. Many of our patients have mental health issues – they can’t wait for a few days or a few weeks to see their GP. That’s why they switch to us. A thousand patients today will choose to apply to GP at Hand, and then switch their GP Practice – one every three minutes.

(Int): Richard Vautrey, some GP Practices are worried about the fact that if their patients sign up to GP at Hand they then lose that funding, don’t they?

(RV): That’s exactly right. And the way that General Practice is funded at the moment is a balanced mechanism, so those patients who use the service less, and there are many patients that use the service more, and that overall, that compensates one for another. What we have concerns about is that this would effectively replace a personal service with an anonymous call centre and patients don’t want that.

(Int): And finally, Ali Parsa, this was something that commissioning groups in Birmingham were worried about and that was clinical safety – isn’t it better to see a doctor the next day.

(AP): No, it wasn’t clinical safety, you do see a doctor, not a call centre, face-to-face on your mobile and then see one in one of our surgeries. We will open up across the country physical surgeries, their issue was not that. It was an IT hitch that doesn’t allow its screening to be done with your local hospital and that IT hitch has been fixed. This is the future, and I encourage more and more patients to join it.

(Int): Okay thank you both, we’ll leave it there, let us know what your think via twitter.

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Surveys of members of the British Association of Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) provide new evidence of pressure on over stretched sexual health services and a sector at ‘breaking point’

 

Access to sexual health and HIV services has been dramatically reduced as a result of changes to the funding and organisation of sexual health services since 2013, according to the medical professionals providing care. Over half (54%) of respondents to a survey of members of the British Association of Sexual Health and HIV (BASHH) reported decreases in the overall level of service access to patients over the past year, with a further 16 per cent saying that access had significantly decreased. In a parallel survey of members of the British HIV Association (BHIVA), three quarters (76%) of respondents said that care delivered to patients in their HIV service had worsened.

With Public Health England (PHE) data showing a 13 per cent increase in attendance of sexual health services between 2013 and 2017 (PHE, June 2018,) it is not surprising that nearly 80 per cent of BASHH respondents (79%) said that they had seen an increased demand for services in the past 12 months. Budgetary pressure means that this demand cannot always be met: more patients are now either turned away or redirected to other parts of the health system.  Six in ten (63%) per cent of BASHH respondents said that they had to turn away patients each week, with 19 per cent saying that they were having to turn away more than 50 patients on a weekly basis. While most were offered the next available appointment, 13 per cent said that patients were referred to another sexual health provider and four per cent that they were redirected to primary care. Clinicians responding to the survey report that many of the patients who are being turned away have symptoms of potential infection.

 

Reduction in prevention, cytology and mental health services

Both surveys revealed significant reductions in services such as the delivery of HIV prevention activities, outreach to vulnerable populations, cervical cytology and psychosexual health services. Three quarters of BHIVA members (75%) said that there had been an impact on access to HIV prevention advice and condoms, with 63 per cent saying access had been reduced; 44 per cent of BASHH members said that HIV prevention services had decreased. Almost half (47%) of BASHH members reported reductions in the provision of cervical cytology functions, reflected by BHIVA members, who also said that cervical screening had been halved (reduced access reported by 49.5%).  This is of particular concern in the context of a fall in national cervical screening coverage and the higher risk of HPV related cancer in women with HIV.

More than 40 per cent (42%) of BASHH respondents reported reduced provision of psychosexual health care, mirrored by a similar number (41%) of BHIVA members, who said that access to psychology input for HIV related mental health problems had been reduced. This is despite the higher risk of mental health issues the HIV population faces. Nearly half of BASHH members (47%) also said that care for vulnerable populations had reduced.

 

STI screening and HIV testing

More than 40 per cent (41%) of BHIVA members said that access to sexual health screening had been reduced, despite HIV positive people being at greater overall risk of sexually transmitted infections.  BASHH members gave a mixed response, with 29 per cent of respondents reporting reductions in STI testing in the past year and 27 per cent increased testing.  The BASHH response regarding HIV testing was similarly mixed, with 21 per cent saying there was a decrease and 26 per cent an increase.

The BHIVA survey showed that it is becoming more difficult for people to test for HIV, with 35 per cent of respondents reporting that there is now reduced access to testing in their own location.  Although 58 per cent of services offered outreach testing, with a quarter of respondents (26%) saying that it was offered locally in another service, more than half (52%) said access to testing in outreach settings was also reduced.  Almost half (47%) of BASHH respondents reported increases in access to online testing in the last 12 months, but it is not yet available in all locations. Although some respondents were optimistic about its role in helping to manage the growing demand for services, others expressed concerns about poor implementation, and suggested it was taking the focus away from face-to-face services.

Funding cuts have also drastically reduced the output of third sector organisations, such as charities and community groups, who have traditionally helped to plug gaps in services with HIV testing, advice and peer support. Nearly 40 per cent of BHIVA respondents said that peer support was no longer offered by their service, with 28 per cent of those that still do saying access to it had been reduced. 70 per cent said that overall the remaining third sector support had worsened, with services stripped back to basics or simply closed down completely.

 

PrEP availability and reproductive health

The roll-out of the PrEP programme through the IMPACT trial has led to increased availability.   Over 70 per cent (71%) of BHIVA respondents said that PrEP is now either available from their service or offered locally by another service (17%) and over 70 per cent (74%) of BASHH respondents reported increased delivery. However, provision remains mixed with 28 per cent of BHIVA respondents saying access is improving, 25 per cent saying it had been reduced, and 11 per cent saying PrEP was not currently on offer locally.

At the same time almost a third (32%) of BASHH respondents reported decreased provision of reproductive health and contraception and a similar percentage (34%) of BHIVA respondents also reported reduced access to these services.

 

Impact of separation of HIV and GUM on staff and services

Changes since 2013 have in many areas led to previously fully integrated clinics that were able to provide a range of services from a single location now being divided between differently funded suppliers.  Patients, particularly people living with HIV, may not be willing or able to travel elsewhere and staff may not be able to access records from other services.

Funding cuts have led to staff not being replaced with a knock-on effect to those remaining and to the level of service they can offer. For example, the loss of Health Advisers and nursing staff can limit support for patients.  More than a quarter (27%) of BHIVA respondents reported that access to partner notification has been affected, yet this is a key method of increasing testing of people at a higher risk of HIV transmission.  Although the majority of services (64%) still maintain counselling for the newly diagnosed, close to 30 per cent said that access is reduced.

Staff morale has been affected, with more than 80 per cent (81%) of BASHH survey respondents saying that staff morale had decreased in the last year, with almost half (49%) reporting it had greatly decreased.  Respondents to both surveys cited the damaging impact sustained budget cuts were having on staff, as well as the pressures and stresses experienced by retendering, restructuring and the loss of experienced colleagues. Some describe the situation as being “at breaking point” and nearly all are worried about the future:  more than 90 per cent (92%) of BASHH respondents said that they were worried, or extremely worried, about the future delivery of sexual health care in England.

 

Commented BASHH President, Dr Olwen Williams: “Providing high-quality free and open-access care for all those that need it has been the bedrock of sexual health in this country for over a century. Whilst we are doing our utmost to maintain standards in the face of record demand and dramatic increases in infections, such as syphilis and gonorrhoea in recent years, these surveys clearly show that continued cuts to funding are taking their toll. Current levels of sexual health funding are quite simply not sustainable and the pressures they are generating are having a seriously detrimental impact on the morale and wellbeing of staff. Without increased support to match the huge growth in demand, the consequences will likely be disastrous for individuals and our public health as a whole.”

Added BHIVA Chair, Professor Chloe Orkin:“Despite the stated ambition of policy makers to reduce health inequalities this will not be possible without robustly funded, sustainable services. Our survey results provide clear evidence that we need to upgrade, not reduce, services if we are to support and protect vulnerable populations. We have made huge strides in the control of HIV, so it is particularly worrying to see that important aspects of HIV care, such as access to prevention services, testing and mental health support, have been reduced. Public Health England (PHE) figures show a 17 per cent fall in new diagnoses, which it attributes to large increases in HIV testing (PHE, September 2018.) It therefore makes no sense to make it more difficult for people to test, as shown by the reduced access to testing in clinics and outreach locations our members report.”

ENDS

Editor’s notes:

  1. Survey responses: The BASHH and BHIVA surveys were both conducted in August and September 2018. BASHH received 291 responses in total, of which 264 respondents were based in England. This press release summarises the responses provided by those members based in England.  BHIVA received 98 responses to the survey, 97 of which were from respondents based in England, which are summarised in this press release.
  2. The British Association for Sexual Health and HIV (BASHH)is the lead professional representative body for those managing sexually transmitted infections (STIs) and HIV in the UK. It has a prime role in education and training, in determining, monitoring and maintaining standards of governance in sexual health and HIV care. BASHH also works to further the advancement of public health in relation to STIs, HIV and other sexual health problems and acts as a champion in promoting good sexual health and providing education to the public.
  3. The British HIV Association (BHIVA)is the leading UK association representing professionals in HIV care. Since 1995, it has been committed to providing excellent care for people living with and affected by HIV. BHIVA is a national advisory body on all aspects of HIV care and provides a national platform for HIV care issues. Its representatives contribute to international, national and local committees dealing with HIV care. It promotes undergraduate, postgraduate and continuing medical education within HIV care.

For further information, please contact either: Simon Whalley, BASHH on 07506 723 324 or simon.whalley@mandfhealth.com or Jo Josh, BHIVA, on 07787 530 922 or jo@commsbiz.com.

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On 15 April 2018 Doctors of the World (DOTW) and the National AIDS Trust (NAT) issued a joint statement that called on NHS Digital to immediately stop sharing patient details with Home Office immigration authorities.

DOTW and NAT believe that sharing confidential patient information with the Home Office will deter vulnerable migrant groups from seeking antenatal care or urgent care for infectious diseases.

Here is the DOTW statement:

MPs repeat demand for an end to NHS Digital sharing patient data

The House of Commons Health & Social Care Committee has, for a second time, called on NHS Digital to immediately stop sharing patient details with the immigration authorities. Expressing deep concern about the Government’s approach to sharing confidential patient information, a report released by the Committee on 15 April stated: ‘we believe that patients’ addresses, collected for the purposes of health and social care, should continue to be regarded as confidential.’

The report also states the Committee’s lack of confidence in the leadership of NHS Digital, citing the failure of NHS Digital to act independently of Government and its disregard for the underlying ethical implications of this data-sharing.

Currently, the Home Office receives information about patients from NHS Digital, the body charged with safeguarding patient data. The data is used to trace migrants, which creates a climate of fear where vulnerable people – including pregnant women and those who have been trafficked – are too afraid to access healthcare.

DOTW (Doctors of the World) UK and NAT (National AIDS Trust) have been campaigning for an end to this practice since it came to light in 2014. Both charities gave evidence in the Health & Social Care Committee’s initial hearing on the issue.

Lucy Jones, Director of Programmes at DOTW, said: “In our clinic, day in day out, we see the incredibly harmful impact the data-sharing deal has on our patients. It has reached a point where people do not want to give the NHS their contact information out of pure fear. While confidentiality is in such a precarious state, mothers are not accessing the antenatal care they need, public health is put at risk, and we fear this is only going to get worse”.

“Doctors of the World UK stand with the Health Select and Social Care Committee in opposing this dangerous information-sharing deal between NHS Digital and the Home Office, and are thrilled the Committee has taken such a strong stance. This view is also shared by the British Medical Association[1] and the Royal College of GPs[2]. As a healthcare charity, we believe in the right to healthcare for all. Yet this immoral deal works to scare some of the most vulnerable people in society from seeing a doctor.”

Deborah Gold, Chief Executive of NAT said: “It is scandalous that our data is being shared and our privacy corroded with less and less justification. As an HIV charity, we understand the importance of treating infectious conditions and limiting the spread of epidemics. When people can’t trust the NHS with their data, that good work is undone and we face a public health risk. There is nothing to be said for this practice, which deters people from accessing healthcare.

“Data sharing should have been stopped when the Health & Social Care Committee first called for it, and it certainly should stop now they have, for a second time, demanded an end to this short-sighted and unethical practice.”

Sign our #StopSharing petition to support our NHS Doctors and tell NHS Digital they are NOT Border Guards:

https://www.doctorsoftheworld.org.uk/stopsharing-campaign

[1]https://www.bma.org.uk/news/2018/january/patient-information-shared-with-immigration-officials

[2]http://www.rcgp.org.uk/-/media/Files/News/2018/RCGP-letter-to-NHS-digital-from-chair-march-2018.ashx?la=en

The Commons Health Select Committee says:

Dr Sarah Wollaston MP (Chair): NHS Digital are an organisation that the public need to have absolute confidence will respect and understand the ethical principles behind data-sharing [and they] have not shown us at all that this is part of what [they] are considering’.

Dr Paul Williams, MP for Stockton South and a practicing GP, questioned “what advice would you give to clinicians about what they should inform their patients so that this information is classed “with consent”?’

Luciana Berger, the MP for Liverpool, Wavertree urged NHS Digital to reconsider, calling the deal ‘a matter of life and death’ for an extremely marginalised and vulnerable patient group. 

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This article was first published at HIV i-Base on 25 April 2018.

The revised BHIVA Standards of Care for people living with HIV are primarily produced as a reference for commissioning HIV services. It also describes a minimum standard of care that HIV positive people can use as a reference.

These 90-page guidelines were last updated in 2013 and this third edition was launched at the 4th Joint BHIVA/BASHH Conference in Edinburgh.

The Standards was produced by a writing group of more than 90 individual doctors, health workers and people living with HIV. It was a collaboration with numerous professional associations, commissioners and community groups.

The main changes to this edition include:

  • Reducing the number of standards from 12 to 8, but with each one covering broader themes.
  • A new section is included on person-centred care. This includes wider aspects of social circumstances, including stigma and discrimination, self-management, peer support and general well-being. The importance of these issues are emphasised by this being an early chapter.
  • Recognising the new U=U consensus: an undetectable viral load means HIV cannot be sexually transmitted – with or without a condom (although some sections of the document have inconsistent information on U=U that will hopefully be quickly updated).
  • The section on complex care has been broadened with more detail about access to specialist non-HIV treatment.
  • Another new section covers HIV across the life course covers HIV treatment and care from adolescence to end of life. This includes palliative care in the context that ART might continue to work well to the very end of life.

There are now eight chapters covering major themes. Each chapter and subsection includes quality statements and auditable targets.

Standard 1 covers testing, diagnosis and prevention and the 90:90:90 goals to eradicate HIV. All three areas are ways to maintain and develop combination prevention. This includes increased testing, early treatment, viral suppression and PrEP. Combination prevention helped bring about the dramatic reduction in HIV transmission seen recently in the UK. HIV positive people are important partners in combination prevention.

Standard 2 is about person-centred care. This has been described as “the fourth 90” and focusses on the whole person, not just HIV. BHIVA say it considers, “desires, values, family situations, social circumstances, and lifestyles. And in so doing, the needs and preferences of HIV positive people can be responded to in humane and holistic ways.” It challenges HIV stigma and discrimination and works towards equality in health and social care. Social inclusion and well-being – crucially aided by peer support – are key to person-centred care.

Standard 3 covers HIV outpatient care and treatment. Anyone newly diagnosed must be seen by a specialist HIV doctor within two weeks and given access to psychological and peer support. In some cases this referral needs to be within 24 hours. There is no gold standard for measuring engagement in care, but transfer of care should be seamless whether a person moves home, is incarcerated or simply moves to another clinic. Increasing numbers of children living with HIV from birth are now becoming adolescents. Management by interdisciplinary teams must ensure successful transition to adult HIV services. A qualified doctor must prescribe ARVs and monitoring according to current national guidelines.

Standard 4 is about complex HIV care. Inpatient care must ensure that an HIV specialist is included in the hospital multidisciplinary team. HIV positive people are living longer and often go into hospital for non-HIV related problems. They may be cared for safely and appropriately in a local ward or clinic. But they must also be supported by immediate and continued HIV expertise and advice. HIV positive people must have access to specialist services for other conditions such as cancer. But clear protocols and agreed pathways are essential for safe delivery of services. This section also includes supporting people with higher levels of need. It includes successful management of multiple long-term conditions, poor mental health, poor sexual health, and problems with alcohol or substance use.

Standard 5 is on sexual and reproductive health. It is important that HIV positive people are supported in maintaining healthy sexual lives for themselves and their partners. In addition, anyone at risk of other STIs and infectious hepatitis, perhaps through drug use, should be supported and given advice. Care should be given for contraception, fertility services, pregnancy planning, and access to abortion services. Care must ensure that babies are born healthy and HIV negative. Care for the mother’s health is key to giving birth to a healthy baby.

Standard 6 is on psychological care. HIV positive people should receive care and support that assesses, manages and promotes their emotional, mental and cognitive wellbeing and health. This should be sensitive to the unique aspects of living with HIV. HIV positive people have higher rates of depression, anxiety, addictions, self harm, and other mental health issues than the general population. Mental health needs must be screened on an annual basis. This includes screening for poor cognitive function that can cause memory problems and reduce ability to perform simple tasks.

Standard 7 covers HIV across the life course. This section looks at standards of care for everyone who is HIV positive. Management of ART should be individualised at every age. It starts with adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). Education and personal development – as well as achieving healthy sex lives and relationships – should be supported by experienced sexual health advisers and specialist nurses.

The years from 25 to 65 are described as early to middle adulthood. Most people in this age group are diagnosed as adults. Care for early diagnosis and treatment should include peer support as well as psychological support. HIV positive people should be supported in having healthy and fulfilling sex lives and engaged in treatment as prevention (U=U).

The over 65s – whether newly diagnosed or long-time positive – should be given access to treatment for complex comorbidities. This is an area of significant emerging knowledge and will likely develop over the course of these standards. Successful care may be achieved through co-speciality clinics, mentoring schemes, or by identified experts in advice and guidance. Palliative care is now included here. Palliative care ensures that the individual and their family are supported, receive appropriate care that meets their needs and preferences, and do not experience unnecessary suffering

Standard 8 covers developing and maintaining excellent care. This standard covers knowledge and training to ensure specialist services are provided. It sets standards for monitoring, auditing, research and commissioning. It also sets standards for public health surveillance, confidentiality and information governance.

Roy Trevelion was a community representative on the Standards writing group.

COMMENT

These comprehensive Standards are very welcome.

The community was involved at every stage from planning to the final draft, with at least one community representative on each chapter and more than 15 UK-CAB members collaborating overall.

The result is a comprehensive benchmark for health and wellbeing for HIV positive people.

All sections provide bullet points for measurable and auditable outcomes and must be promoted in primary and secondary care, health & social care, public health, and local authority healthcare provision.

As bureaucratic and structural changes affect the structure of HIV services, these Standards should be a reference for ensuring that high-quality care for HIV positive people is maintained.

The inconsistent messaging over undetectable viral load and HIV transmission will hopefully be corrected. As the publication is only available in PDF format, this should be relatively easy. Several formatting problems, including difficult legibility (light font, justified text) would benefit from being revised. 

It is good to see the inclusion of HIV positive people in the photographs throughout the report, supported by the UK-CAB and Positively UK.

Reference

BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.
http://www.bhiva.org/standards-of-care-2018.aspx

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A new study examining breast cancer awareness in India has found that a lack of early diagnosis is leading the country towards an epidemic.

The research, which is the first of its kind to look at breast cancer awareness in India, found that cultural and religious issues mean that women don’t access health services, are reluctant to consult male doctors, neglect their own health due to family obligations and are over-dependent on other family members to seek medical help, all of which causes delay in diagnosis.

The study found that traditional marketing campaigns don’t work for raising awareness of the disease and that community nurses are the most effective channel. A a greater understanding by men is also key to tackling early diagnosis. The study is published this week in the Journal of Business Research.

The research highlights the significance of the country’s rapid economic development, leading to greater urbanisation, which is leading some women towards a western lifestyle resulting in a rise of breast cancer rates. It describes the issue as one of the biggest health threats facing India today.

Judith Fletcher-Brown, from the University of Portsmouth, visited the country to explore the unique social, economic, cultural and institutional challenges in this emerging economy. She learned that in India’s cities and urban areas, breast cancer is the most commonly diagnosed type of cancer among women. 70,218 Indian women died of breast cancer in 2012 and deaths from the disease are predicted to increase to 76,000 in 2020 with an average age of incidence shifting to 30 years from 50 years. Yet women seek medical care extremely late due to lack of awareness about self-examination and cultural barriers.

Judith interviewed several women by email about their experiences in order to elicit the most open answers to her questions. One participant said that even among friends they are too shy, although there is more openness between mothers and daughters.

Judith said: “India is still a patriarchal society and while women are now in responsible jobs and earning for their families, it’s the men who are still the head of the household. Even educated professional women do not discuss private matters about their bodies with their husbands, fathers or brothers so it’s essential to direct health messages towards men to increase their awareness of and willingness to discuss the problem. Their understanding is pivotal in enabling female family members to access medical help at the earliest stage.”

She also ran focus groups with experts from various breast cancer medical practitioners.
“They told us that in India the subject is taboo and rarely discussed within the family, between men and women or even between husband and wife.”

She found that community health nurses had the greatest impact in raising awareness of early breast cancer symptoms with both men and women. These Accredited Social Health Activists (ASHAs) are embedded in the community and are far more effective than national advertising campaigns in overcoming cultural barriers because they have the trust of husbands and fathers as well as the women at risk.

The study showed that schools are the second best channel through which to raise awareness in young women, and in third place was the media, which has seen some success in raising awareness through charity initiatives in the country. Traditional marketing campaigns were one of the least effective channels.

Judith, from the Department of Marketing and Sales, highlighted the Westernisation of Indian women as a key issue caused by the country’s burgeoning economy: “Women are having fewer children later in life and breast feeding them less which increases their chance of developing the disease. Working women in urban India often have a more western diet leading to obesity which also increases the risk alongside a lack of infrastructure for early diagnosis.

“The emerging economy of India has presented women with new found economic independence and career opportunities but the lack of breast cancer awareness campaigns puts even these educated women at risk.”

The Indian government recognises the problem and has invested money in marketing campaigns via non-governmental organisations (NGOs). But the research indicated that such campaigns are not reaching the target audience.

India’s crisis especially manifests in the thriving cities of Mumbai, Delhi, Bengaluru, Bhopal, Kolkata, Chennai and Ahmedabad, where employment opportunities for women are increasing. A recent report identified the significance of employing more women in India could add $2.9 trillion to India’s annual GDP by 2025. A healthy female Indian workforce is crucial if the country is to benefit from its demographic advantage and sustain its thriving economy.

Professor Vijay Pereira, second author on the paper, said that the magnitude of the problem is enormous and has major policy implications for the Indian government, who he is urging to tackle the problem with better targeted campaigns:

He said: “Our findings reveal complex challenges at national, state and community levels. What is clear is that the state healthcare sector must transform itself to deliver quality breast cancer healthcare and awareness underpinned by effective use of social marketing campaigns. This research presents several proposals that would assist health marketers working in India’s emerging economy.”

The paper is published in the Journal of Business Research, entitled: Health marketing in an emerging market: The critical role of signalling theory in breast cancer awareness. The authors are Judith Fletcher-Brown from the University of Portsmouth and Professor Vijay Pereira and Dr Munyar Nyadzayo from the University of Wollongong in Dubai.

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One of the prime concerns in almost every household is altered blood pressure. Every person craves for a sheer normality in blood pressure, but it is not always the case. As they age, more and more alterations and complications in the blood pressure levels emerges. It can go down resulting in low blood pressure or can also go up to a high level. Although there are no medications prescribed for treating low blood pressure, there are prescribed medicines for treating high blood pressure.

The effects of changes in blood pressure are rapid; sudden changes results in initial conditions like dizziness, nausea, lack of energy to extreme cases like heart attacks. Therefore it is extremely important to keep a constant and strict vigilance on the levels of blood pressure all the time. Gone are the days when you have to rush to the doctor every time you need to check your blood pressure levels. Now you can directly monitor these levels by technologically enhanced equipment from home. These blood pressure monitors are highly efficient and accurate in measuring and depicting the current health status of the body. To choose the best blood pressure monitor for you, you need to consider the following points:

Ensure that your monitor is working properly

One of the most important parts of the entire blood pressure monitor system is the monitor itself. You should look into the validation documents concerning the working of the monitor. It should have the ‘clinically validated’ status granted by the concerned authorities of the country. Such a badge will ensure that the machine has gone through a series of tests and validation procedures and have passed and gained trust from doctors all around the world.

Check whether you have the right cuff size

Another important aspect of every blood pressure monitor system is the cuff that is adjusted around your upper arm. You should ensure that the cuff fits properly onto your arm. If the cuff does not fit properly, it will give faulty readings. The cuff should be adjustable for all arm sizes. You should measure the diameter of your arm and then look into the details of the product to ensure that the cuff fits onto your arm.

The concern over budget

One of the important concerns regarding the purchase of any product is the price of it. Blood pressure monitors also vary in price depending on the features and the validation procedures. You can opt for such extra features like the built-in memory. However, you can cut down on the expenditure by only restricting yourself to the basic needs and features.

Proper calibration of the monitor

An important consideration for any medical device is its calibration. You need to check whether your blood pressure monitor is calibrated or not. Moreover, you need to get it calibrated at least for once in every two years. Look into the procedure of calibration and how easily you can go about it.

These are some of the important considerations that you have to take while choosing the best blood pressure monitor for you. following this set of advice will certainly land you with the best monitor system to check your blood pressure efficiently.

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Traumatic brain injuries, as the name clearly points out, are caused by a trauma to the brain. This often presents itself in the form of an external force, applied with violence at the level of the brain. Despite being protected by the sturdy cranial cavity, the brain can be easily damaged in such cases, its overall functioning being affected. Depending on the type of trauma, the injury can be closed or it can penetrate the cranial cavity. The symptoms of such traumatic injuries depend on the area of the brain that has been affected; the type of injury will also dictate the chosen course of treatment.

Brain injuries

Symptoms

The symptoms of traumatic brain injuries, as it has already been mentioned above, depend on the actual type of injury and the damaged area of the brain. Many people deal with brain injury and memory loss, especially after violent accidents. However, it is important to understand that the cognitive functioning can be affected as well; one can exhibit a wide range of other symptoms, related to the emotional, social and behavioral functions of the brain. The more severe the injury to the brain was the more diverse and intense the consequent symptoms are going to be.

Right after the actual trauma, one can lose consciousness or experience life-threatening symptoms, such as lethargy, inability to move or speak. One can experience moderate to intense headaches, blurred vision and inadequate coordination. Nausea and vomiting are frequent, as well as loss of balance, dizziness and tinnitus. If the cognitive functioning has been affected, one will have difficulties responding, speaking or concentrating.

The speech can be affected as well, with patients exhibiting slurred speech, aphasia or dysarthria. They may lose their ability to move and coordinate, especially when balance problems are associated (damage to the cerebellum). Patients who have suffered from traumatic brain injuries may exhibit personality changes, not to mention experience confusion, social behavioral problems and constant agitation.

If the intracranial pressure reaches high levels, life-threatening symptoms can appear. The patient can lose consciousness, experience an abnormally low heart rate or enter in a state of respiratory depression. In such situations, emergency intervention is necessary, in order to prevent sudden death.

Causes

The brain is protected by the tough cranial cavity and it does not become easily damaged. However, in case of trauma, things change. A violent force can cause a lot of damage to the brain, especially in case of vehicle accidents. Traumatic brain injuries are also common in those who engage in contact sports or those who have been involved in work-related accidents (constructions in particular).

Regular sports can lead to traumatic brain injuries as well, especially when violent force is involved. Other recreational activities are responsible for such health problems, especially in children. They are more fragile, as their bones are still developing and, thus, more vulnerable to such injuries. Traffic accidents, involving any kind of motor vehicle, are often responsible for traumatic brain injuries, including in the pediatric population.

Physical violence is one of the most common causes of traumatic brain injuries, not only in children but also in adults. Child abuse and domestic violence are two main causes of such injuries, leading to life-threatening complications and even death. Industrial accidents, such as the ones that occur on oil platforms, as a result of explosions or due to chemical products, are responsible for traumatic brain injuries (more commonly in men). Traumatic brain injuries are often encountered in war zones, being often caused by explosive projectiles, gun attacks and open-fire combat.

Treatment

In all traumatic brain injuries, emergency treatment is essential, in order to prevent life-threatening complications and death. Depending on the severity of the injury, the patient might need intubation (respiratory support). Emergency surgical interventions are performed, in order to reduce the intracranial pressure and avoid the excess swelling of the brain. Surgery is also recommended in case of brain hemorrhages, for the prevention of further complications.

Before administering any kind of treatment, the patient will undergo imaging investigations. This will determine what part of the brain has been affected and also guide the further treatment measures. The patient will receive analgesics or sedatives, in order to relieve the pain. Hypertonic saline solutions are administered to reduce the swelling at the level of the brain and also the electrolyte imbalances that might cause heart failure.

Fluids are administered intravenously, in order to maintain the blood pressure at a stable level. Medication, such as benzodiazepines, is administered in order to protect the brain against seizures and further damage. Craniotomy might be performed in case of excessive brain swelling or to reduce the intracranial pressure.

Once the acute phase has passed, the treatment will be concentrated on the rehabilitation of the patient. Physiotherapy is essential in the chronic phase, as it can improve the functional outcome and guarantee the best possible recovery from the trauma. Patients can also benefit from speech and language therapy, especially if they have suffered injuries to the parts of the brain responsible for speech. Other treatments include occupational therapy, psychological counseling and NeuroGum supplement.

It is important to understand that the recovery from a traumatic brain injury can spread over several years. In some cases, the recovery is not possible and the patient has to learn how to live with the remaining functioning potential. The support of family and other caregivers is essential for these patients.

Conclusion

Traumatic brain injuries can lead to permanent disabilities, affecting a person’s overall quality of life. The faster one receives treatment in the acute phase, the better the overall prognosis is going to be. Additional therapies, such as the ones mentioned above, can guarantee a faster and better recovery from the respective injury. The living environment often has to be adapted to the needs of the patient, with occupational therapy playing a very important role in the matter. Moreover, the patient has to benefit from regular counseling, in order to deal with feelings of anger, symptoms of depression and frustration in an effective manner.

AUTHOR BIO

Katleen Brown is a health, beauty and fitness writer. She loves to publish her articles on various health related websites. In her spare time, likes to do research to bring awareness.

Recognizing the unity of body, mind, and outlook, she helps empower women to tune into their innate & inner wisdom to transform their health and truly flourish.

Get in touch with her on Google+, Pinterest and Twitter.

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