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(THE CONVERSATION) I mentioned to a friend, a gay man nearing 60, that World AIDS Day, which has been observed on Dec. 1 since 1988, was almost upon us. He had no idea that World AIDS Day still exists.
This lack of knowledge is a testament to the great accomplishments that have occurred since World AIDS Day was created 30 years ago. It is also due to an accident in the timing of his birth that my friend escaped the devastation wreaked by AIDS among gay men in the U.S., before there was antiretroviral therapy.
Many people have forgotten AIDS, but there are consequences to forgetting. The fight against AIDS is at a tipping point. Increasingly, there are signs that we may be heading in the wrong direction.
Many successes, yet the grand prize is elusive
I am a social epidemiologist with more than 20 years of research experience in HIV and STD prevention. I am also the founder of The Basics with Dr. Mo, a sex health communications project that translates prevention science directly for people who need it most.
Most recently, Pre-Exposure Prophylaxis (PrEP) – the use of antiretrovial drugs to prevent HIV infection among those exposed – has proved to be a successful prevention approach.
Yet the prize – a vaccine that can prevent HIV infection – remains elusive, and makes impossible the use of the only known strategy to have ever eradicated an infectious disease: widespread vaccination. That disease was smallpox, in 1980.
The seeds of unease
Despite the lack of a vaccine, in 2016 United Nations member states adopted a political declaration on ending the AIDS epidemic by 2030.
Prominent scientists have already begun to question the ability to eradicate AIDS by the 2030 deadline, and concede that the situation has stagnated. The attainment of eradication looks bleak, without the aid of either an effective vaccine or the immediate large-scale promotion and utilization of existing prevention tools (i.e., condoms, voluntary circumcision and potentially PrEP). Given that the vast majority of new HIV infections are sexually transmitted and that condoms have played a decisive role in the global control of HIV transmission, ongoing condom availability and use will be essential to future eradication.
Condoms – both male and female – remain a highly effective mechanism of HIV/AIDS prevention, as well as of other sexually transmitted infections that greatly enhance the risk of HIV transmission.
Condom availability is a different matter and varies greatly from country to country. Countries with the highest levels of HIV often rely heavily on donor support. According to the most recent data, in sub-Saharan Africa in 2013, only 10 condoms were availableannually for every man aged 15 to 64 (as compared with the recommended 50 to 60), and, on average, there was one female condom available for every eight women. Funding required to maintain – let alone scale up – HIV commitments, particularly those dedicated to prevention, are increasingly uncertain.
The hydra, sprouting new heads
Even though condoms are an extremely effective barrier method, it is usage that makes condoms efficacious in preventing HIV transmission. Reported condom use varies considerably around the world, and ranges from 80 percent use by men in Namibia and Cambodia to less than 40 percent usage by men and women in other countries, including some highly affected by HIV such as Sierra Leone and Mozambique.
Age plays a role, too. Among young people aged 15 to 24, condom use at last sex variesfrom more than 80 percent in some Latin American and European countries to less than 30 percent in some West African countries. In the U.S., condom use is at the lower end of the spectrum: Only one-third of the population uses condoms, a number that has not changed significantly over the past two decades.
The majority – 66 percent – of the world’s HIV/AIDS cases are in sub-Saharan Africa, where there has been much progress, particularly with the provision of antiretroviral therapy.
However, there are worrying signs in other parts of the world. There has been little change in new HIV infections in countries outside of sub-Saharan Africa between 1990 and 2017.
In fact, six of the 10 most populous countries in the world have experienced 10 percent to 45 percent increases in new HIV infections since 2010: Russia, China, Brazil, Pakistan, Mexico and Bangladesh. Even in countries such as the U.S., where new HIV infections have decreased by 8 percent overall, the rates of change are unevenly distributed. For example, young African-American men who have sex with men show no decrease in new infections; African-American gay and bisexual men represent the largest percentage of new HIV infections: more than one-quarter.
The increased provision of antiretroviral therapy to people living with AIDS has had a huge impact on extending life and in preventing new HIV infections. However, there remains 25 percent of the population who live with HIV, about 9 million people, who do not know their status.
While we have been necessarily focused on the head of the hydra in sub-Saharan Africa, other hydra heads are beginning to make their presence known, many in countries ill-prepared to deal with increases in the number of new HIV infections.
In the absence of a vaccine, behavior change in the form of condom use promotion, acceptance and adoption, at a scale that many gay men utilized during the peak of the AIDS epidemic in the industrialized world, will need to occur. There are many challenges: continued stigma and gender inequality, not to mention issues of availability, distribution and proactive, nonjudgmental promotion.
We must not forget. Progress on reducing the rate of new HIV infection has been done before. It can be done again, but only if we take forceful, funded action now.
The chronic condition can feel overwhelming, so we asked some experts for their help and insight
Endometriosis affects one in 10 of us, and an estimated 1.5 million women in the UK alone. But despite it being so widespread, there’s little awareness of what the condition entails (it’s not just heavy, painful periods) and how it can be managed.
With this in mind, we grilled a couple of ‘endo experts’ to help you better understand the condition. So whether you think you may have endometriosis, have just been diagnosed or simply want to learn more, read on for an in-depth guide.
What is endometriosis?
‘Endometriosis is the growth of endometrial-like tissue (the lining of the womb/uterus) outside of the uterus,’ explains Dr Anita Mitra, aka the Gynae Geek. ‘This is commonly on the ovaries, bowel, bladder and – in rare cases – on the liver and lungs.
‘The tissue responds to female hormones throughout the menstrual cycle as it would if it were in the womb; it thickens and then begins to fall away as it would during a period. However, because it’s not inside the womb with an escape route, it causes irritation, inflammation and often excruciating pain.
‘Eventually, it can cause scar tissue to develop, which in turn causes the normally mobile internal organs of the pelvis to become stuck together, further adding to the pain. Endometriosis can be staged during surgery according to where it is, how much there is and how much scar tissue is present. Stage I – minimal, Stage II – mild, Stage III – moderate, and Stage IV severe.’
‘A lot of people think endometriosis is just heavy, painful periods; while that can be true, and it’s probably the most common symptom, it can be a whole lot more than that,’ explains Anita.
The most common symptoms include pain in your lower tummy or back, severe period pain that stops you doing normal activities and difficulty getting pregnant, according to the NHS.
‘Symptoms also depend on where exactly tissue is growing,’ Anita continues. ‘For example, excruciating pain on having your bowels open could be a sign that it’s growing on your bowel. Endometriosis also commonly causes bloating, diarrhoea and constipation, and the presence of scar tissue can make having sex painful.’
Diagnosing endometriosis can feel like a long process. After seeing your GP, you’ll be referred to a gynaecologist and will also need an ultrasound. ‘Endometriosis doesn’t show up on scans or blood tests, but it’s important to do a scan for other causes of pain,’ Anita explains. The scan can pick up other signs of the condition, such as a certain type of cyst with a classic appearance.
‘A normal scan doesn’t rule out the diagnosis however – the only definitive way to diagnose is endometriosis through a laparoscopy, keyhole surgery that involves putting a camera through your belly button to look directly inside your tummy.’
How to treat endometriosis
The good news is that the condition is completely treatable through medication and surgery. ‘Surgery will sometimes be performed at the time of diagnosis, and involves releasing adhesions [fibrous bands that form between organs and tissue] and removing or destroying deposits and cysts,’ Anita explains.
‘This should always be performed by a specialist in endometriosis surgery and, although many people will notice an improvement, there is a high rate of recurrence in symptoms post-surgery.
‘Many surgeons will advise some form of hormonal therapy, such as the contraceptive pill, Mirena coil, or injections of something called a GnRH analogue. This is also an option for people who don’t want or need surgery; the aim is to block the hormones that cause tissue to grow and shed every month, thus reducing the amount of pain and bleeding.’
Endometriosis pain management
Anita advises that painkillers can be used, but when endometriosis pain is at its worst they may not be that helpful. ‘But it’s definitely worth a try,’ she adds. ‘Hormonal medications are the next step because they stop the build up and shedding of endometriotic plaques, which is a cause of a lot of the pain.
‘One of the biggest problems I see is constipation, which is surprisingly common because a lot of us don’t drink enough water or eat enough fibre. Constipation can make endometriosis pain worse, as it can make your stomach quite bloated and pull on the scar tissue, but it also means you need to strain more to open your bowels – which for many women is already incredibly painful. So simple things like increasing fibre and fluid intake could see an improvement in symptoms.’
A very common worry is that there’s a link between endometriosis and cancer, or even that it is a type of cancer – possibly because pain is such a red flag for so many of us – but that’s not the case.
‘While there are a few small studies suggesting a possible link, there are no large, robust studies confirming a causal link between endometriosis and endometrial cancer,’ Anita says.
Endometriosis and diet
First things first: there is no need to eliminate entire food groups from your diet. ‘There are a lot of people who have read about cutting out dairy and gluten, although there’s no solid evidence that these worsen endometriosis’ Anita says.
‘But I think everyone should be treated as an individual – what might work for one person may not work for another. If you want to try it, by all means go ahead and try to keep a symptoms diary. But if this doesn’t improve your symptoms, there’s no need to cut things out of your diet for fear it’s making your endometriosis worse.’
Nutritionist Henrietta Norton is not only an expert in nutritional female health, but also on what it’s like to live with endometriosis, having been diagnosed in her twenties. After her laparotomy and laser treatment, she sought the help of a nutritional therapist, which she says changed her life.
‘Research continues to prove that nutrition and diet can be fundamental to managing the condition,’ she says. ‘Studies show that taking the right nutrients through supplements can reduce symptoms significantly – 98% of the women in one study experienced improvements.’
So, what is it worth trying to consume more of in your diet? ‘Zinc and magnesium are used in abundance during states of both physical and mental stress; as endometriosis is a state of physical stress, the demand is even greater than normal,’ Henrietta continues. ‘Women can actually lose up to half their magnesium supply during menstruation.
‘Endometriosis sufferers often experience heavy bleeding during their period, significantly reducing stores of iron. This, along with the trace mineral molybdenum, is required for the elimination of oestrogen (it’s thought that endometriosis is characterised by a dominance of oestrogen), and without adequate iron stores the pain management process can also be affected.’
‘Women with endometriosis have also been reported to have a lower intake of carotenoids (found in vegetables like carrots, kale and spinach) and D-glucarate (found in cruciferous vegetables, which blocks beta-glucoronidase) than women without endometriosis.’
Wild Nutrition’s Endometriosis Complex was created with the latest research in mind to use as part of a multi-disciplinary approach to managing the condition, Henrietta says. ‘Using natural forms of nutrients that are efficiently absorbed and used by the body in combination with organic herbs [magnesium, methionine, probiotics and more], the curated formulation addresses the complex condition affecting the immune and digestive systems and hormonal stability.’
Can you get pregnant with endometriosis?
A common worry is that an endometriosis diagnosis means pregnancy is unlikely or even impossible. But is this actually the case? ‘Not always,’ says Anita. ‘Generally it depends on the severity, but saying that, we do see a lot of women with severe endometriosis on the labour ward delivering their babies, so it’s not impossible.’
Case in point: Despite being told that she would never have children, Henrietta now has three sons, all of whom were natural conceptions and healthy pregnancies.
‘I also see a lot of patients being diagnosed with endometriosis during the investigative process for infertility,’ Anita continues. ‘On further questioning, the vast majority report a long-standing history of the common symptoms, which is saddening to hear as they often say they thought it was normal, or something they just had to tolerate as part of being a woman.
‘This is why we need to get more comfortable with talking to our friends and families about periods and women’s health – to know what is normal and what might require further investigation. And it’s also a reason we shouldn’t leave potential gynae issues right up until trying to get pregnant.’
As part of her mission to educate women everywhere about their reproductive health, Anita is about to publish her first book, which you can pre-order now. The Gynae Geek: Your No-Nonsense Guide to ‘Down There’ Healthcare tackles all of your burning gynae-related questions, from periods to smear tests to PCOS – it’s the definition of essential reading.
As with any condition, it’s important to listen to your body and know when it’s telling you to take it easy. ‘I have become acutely aware of how the foods I choose to eat and my lifestyle affect my symptoms,’ Henrietta says.
‘I understand the importance of slowing down, taking time to restore and just “be” in everyday life, which has a profound affect. I now use my symptoms as gentle reminders signalling me to slow down and to rest and digest.’
Things may feel very overwhelming – especially at first – but there are a number of support groups, helplines and online forums you can visit to get more advice and emotional support. Head to endometriosis-uk.org (Anita’s go-to patient resource) for more information.
Note that the purpose of this feature is to inform, not replace one-to-one medical consultations. For advice tailored specifically to you, always discuss your health with a doctor.
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