Friday, August 28, 2009

An Easy Fix for Tennis Elbow? -

In a medical advance inspired by recessionary thinking, researchers from the Nicholas Institute of Sports Medicine and Athletic Trauma at Lenox Hill Hospital in New York City announced last month that they've developed an effective and supremely cheap treatment for chronic tennis elbow. Huddling a while back to brainstorm about inexpensive methods for combating the injury, the scientists glanced around their offices and noticed a homely, low-tech rubber bar, about 8 inches long, which, at the time, was being used for general physical therapy programs. The researchers wondered whether the ribbed, pliable bars, available for less than $20, might be re-purposed to treat tennis elbow. The answer, it soon become clear, was a resounding yes.

To arrive at that conclusion, the researchers recruited 21 people with chronic, debilitating elbow pain. Ten of them were assigned to standard physical therapy treatment for tennis elbow; this was the control group. The other 11 also received physical therapy, but in addition were taught a choreographed exercise using the rubber bar that they practiced at home. After less than two months of treatment, the researchers terminated the experiment. The early results had been too unfair. The control group had showed little or no improvement. But the rubber-bar-using group effectively had been cured. Those patients reported an 81 percent improvement in their elbow pain and a 72 percent improvement in strength.

"We couldn't believe" how fast and well the therapy worked, says Timothy Tyler, PT, ATC, a clinical research associate at the Nicholas Institute and one of the authors of the study. "We were seeing improvements in five weeks, even three. It was crazy."

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Canadian health-care advocates fire back - The Globe and Mail

There are no death panels, no reference to "Obamacare" and no Shona Holmes. But vocal advocates of Canada's health-care system have shot back at American detractors with a tamer brand of YouTube video, intended to correct what they see as misconceptions about Canada's health resources being batted about in the heated United States health-care debate.

The eight-minute video clip features interview segments with former Saskatchewan premier Roy Romanow, the president of the Canadian Federation of Nurses Unions, members of Canadian Doctors for Medicare, and other physicians and researchers extolling Canada's "real" universal health-care system, and expressing bemusement that it could meet anything but praise and envy south of the border.

"The battle that's going on in the United States taps into Canadian emotions," Mr. Romanow, who headed the Royal Commission on the Future of Health Care in Canada, says in the clip.

"[Canadians] object to the misrepresentation, mischaracterization of the Canadian system by a lot of the American opponents."

Steven Lewis, Saskatoon-based health policy and research consultant, says Canadians are happier with their health-care system than they were 10 years ago, and they should be.

"If [Americans] want to use our system as a whipping boy in their own propaganda wars, it's mildly irritating. ... We should hope for our American brothers and sisters that they get it right, but I for one don't much care about what right-wing superstitions Americans want to put out there about our Canadian system because ultimately they're the ones who suffer from their own ignorance."

The clip, helpfully titled "Universal health-care message to Americans from Canadian doctors and health-care experts" has been viewed more than 26,000 times since it was posted Aug. 22.

Canadian health care has become a lightning rod in the debate over U.S. health care ignited by President Barack Obama's vow to reform the country's system.

Canada's role heated up when Shona Holmes of Waterdown, Ont., appeared in a commercial sponsored by the Americans for Prosperity Foundation, claiming she had to travel to the U.S. to seek medical treatment for her brain tumour, and would have died had she waited to obtain care in Canada. The clip sparked strident condemnation in Canada, where Ms. Holmes was branded a traitor, and further fuelled rhetoric decrying "socialized" health care in the U.S.

Wednesday, August 26, 2009

Real Choice? It’s Off-Limits in Health Bills -

Consider the following health insurance plan.

It refuses to pay for certain medical care and then doesn't offer a clear explanation. It does pay for unhelpful care that ends up raising premiums. Its customer service can be hard to reach or unhelpful. And the people who are covered by this insurer have no choice but to remain with it — or, at best, to choose from one or two other insurers that are about as bad.

In all likelihood, I have just described your insurance plan.

Health insurers often act like monopolies — like a cable company or the Department of Motor Vehicles — because they resemble monopolies. Consumers, instead of being able to choose freely among insurers, are restricted to the plans their employer offers. So insurers are spared the rigors of true competition, and they end up with high costs and spotty service.

Americans give lower marks to their health insurer than they do to their life insurer, their auto insurer or their bank, according to the American Customer Satisfaction Index. Even the Postal Service gets better marks. (Cable companies, however, get worse ones.) No wonder President Obama's favorite villain is health insurers.

You might think, then, that a central goal of health reform would be to offer people more choice. But it isn't.

Real choice is not part of the bills moving through the Democratic-led Congress; even if the much-debated government-run insurance plan was created, it would not be available to most people who already have coverage. Republicans, meanwhile, have shown no interest in making insurance choice part of a compromise they could accept. Both parties are protecting the insurers.

That's a reflection of the thorny politics of health care. On one hand, big interest groups are lobbying hard to keep some form of the status quo. Insurers don't want people to have more choice. Neither do employers and labor unions, which now control huge piles of money spent on health care. Nor do hospitals and drug makers, which benefit from all the waste now in the system.

On the other hand, the people who stand to benefit most from having more choice — all of us — are not agitating for change, because the costs of the system are hidden from us. A typical household spends $15,000 each year on health care. But most of it comes in the form of taxes or employer deductions from paychecks, which means insurance can seem practically free.

As a result, people may not like their insurer, but they don't hate it, either. If anything, they are more anxious about losing their insurance than they are eager to be given more choice. And that anxiety has driven the White House's decision to pursue a fairly conservative form of health reform.

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T.R. Reid's 'The Healing of America' (excerpt)

Health Expenditure as a percentage of GDP, 2005

USA 15.3

Switzerland 11.6

France 11.1

Germany 10.7

Canada 9.8

Sweden 9.1

UK 8.3

Japan 8.0

Mexico 6.4

Taiwan 6.2

Sources: OECD Health at a Glance, 2007; Government of Taiwan.

There's nothing particularly wrong with spending a lot of money on something important, as long as you get a decent return for what you spend. It's certainly not wasteful to spend money for effective medical treatment. If a dentist who was about to drill a tooth offered her patient a choice between listening to pleasant music for free to lessen the pain, or a shot of Novocain for $50, most people would pay for the shot and would probably get their money's worth. And there's nothing wrong with paying more for better performance. Those fifty-two-inch high-definition plasma televisions that people hang on the family room wall these days cost five times what a top-of-the-line set would have cost ten years ago, but buyers are willing to shell out the extra money because the enhanced viewing quality is worth the price.

When it comes to medical care, though, Americans are shelling out the big bucks without getting what we pay for. As we'll see shortly, the quality of medical care that Americans buy is often inferior to the treatment people get in other countries. And patients know it. Surveys show that Americans who see a doctor tend to be less satisfied with their treatment than Britons, Italians, Germans, Canadians, or the Japanese even though we pay the doctor much more than they do.

Twitter Being Used To Deliver Medical News -- InformationWeek

Twitter, the social networking tool, is emerging as a potentially valuable tool of real-time, healthcare information and medical alerts, U.S. researchers say.

Dr. Joseph C. Kvedar, director of the Center for Connected Health, says short messages, or "tweets," delivered via Twitter has obvious advantages for sharing time-critical information such as disaster alerts and drug safety warnings, tracking disease outbreaks such as H1N1 flu or disseminating healthcare information.

"One way to look at Twitter is as a method of mass communication," Kvedar says in a statement.

Twitter applications are also available to help patients find out about clinical trials, or to link brief news alerts from the Centers for Disease Control and Prevention.

However, the use of social media and Internet-based outlets such as Twitter to communicate medical information requires a high degree of caution, to preserve confidentiality and patient privacy and to ensure information sources are accurate, reliable, and current, the article said.

Tuesday, August 25, 2009

Prescription Drug Ratings Reports by Drug Type: Side Effects and Patient Comments

Jackson pleaded with doctor for powerful anesthetic, records show --

A sleepless Michael Jackson spent his last hours pleading for a dose of
a powerful anesthetic, his doctor told police, according to court
records unsealed Monday.

For six hours, Dr. Conrad Murray said he resisted -- fearful that the
pop star had developed a dangerous addiction to propofol.

Instead, Murray administered the sedatives Valium, lorazepam and
midazolam -- five times over six hours. But none put Jackson to sleep,
and he continued to demand his "milk," the word the pop star used for

Murray finally relented and at 10:40 a.m. added the drug to Jackson's
intravenous drip, according to the records.

That dose -- mixed with the cocktail of other sedatives in the pop
star's system -- was enough to kill him, the Los Angeles County
coroner's office concluded in a preliminary toxicology report cited in a
search warrant affidavit unsealed Monday in Houston.

These documents address one of the central questions in the Jackson
death investigation: What killed him. The coroner's office said in a
preliminary report that it found "lethal levels" of propofol in
Jackson's system, the records show.

The records also lay out the first detailed chronology of Jackson's
final hours-- and reveal Murray's fateful decision to give Jackson the
drugs despite his suspicions that the pop star was becoming addicted to
them. The narrative is based largely on a three-hour interview Murray
gave to Los Angeles police detective two days after Jackson's death on
June 25.

Authorities still have not disclosed how Jackson or Murray obtained the
propofol, which is typically used in hospitals by anesthesiologists.
Another unanswered question is exactly when Jackson stopped breathing.
Both are crucial to the criminal investigation.

Police said Murray told them he found Jackson not breathing at 11 a.m.
-- a contention that Murray's attorney disputes -- but paramedics were
not called until nearly 90 minutes later. During that time, police
suspect that Murray made three cellphone calls totaling 47 minutes,
according to the affidavits filed last month when authorities sought
search warrants for Murray's Houston medical office and storage unit.

In addition, Murray failed to tell paramedics or emergency room doctors
that he had administered propofol, a critical omission that calls into
question his treatment and could bolster pursuit of an involuntary
manslaughter charge, authorities said.

"Michael Jackson was not the usual patient with the usual problems in
the usual circumstances," said Murray's attorney, Edward Chernoff, in
response to the court records. "Dr. Murray's overriding goal was to try
to help him. . . . To place negligence on him simply because he was
there, I don't think is fair."

Authorities have sought records from at least five different physicians
who treated Jackson as well as pharmacies in Las Vegas and Beverly
Hills, but Murray is the only one named in court documents as the target
of the manslaughter investigation. Jackson had specifically asked
concert promoter AEG Live to hire Murray as his $150,000-a-month
personal physician to travel with him to London, where he was scheduled
to perform 50 concerts.

At Jackson's request, Murray had been administering 50 milligrams of
propofol in the six weeks prior to his death using an intravenous line,
according to court records. But after weeks of use, Murray said he tried
to wean the pop star off the medication. Murray told detectives that he
lowered Jackson's dosage to 25 milligrams and mixed it with two other
sedatives, lorazepam and midazolam. Then, on June 23, he administered
those two medications and withheld the propofol -- and Jackson was able
to sleep.

On June 25, the day Jackson died, Murray once again tried to induce
sleep without resorting to propofol, according to the affidavit. He
first gave Jackson the three alternative sedatives at 1:30 a.m., 2 a.m.,
3 a.m., 5 a.m. and 7:30 a.m. But Jackson remained awake.

Finally, "after repeated demands/requests from Jackson," Murray relented
and gave Jackson 25 milligrams of propofol, diluted with another
sedative, records state.

Medical experts said that a 25-milligram dose for someone Jackson's size
should not have been enough to kill him. But combined with other drugs,
the propofol could have been more dangerous.

"You start giving a lot of drugs and don't know what the final effects
might be," said Dr. Scott Engwall, vice chairman of the Department of
Anesthesiology at UC Irvine School of Medicine. "When you give a little
bit of this and a little bit of that, it starts adding up."

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For Parents on NICU, Trauma May Last -

Kim Roscoe’s son, Jaxon, was born three months early, weighing two and a half pounds. But for nine days he did exceedingly well in the neonatal intensive care unit, and Ms. Roscoe felt little different from the other new mothers.

Her nightmare started on Day 10.

“I had left him late the night before, in my arms, tiny but perfect,” said Ms. Roscoe, now 30, of Monterey, Calif. But when she returned to the NICU the next day, Jaxon was in respiratory and kidney failure, and his body had swollen beyond recognition.

“He was hooked up to ventilators, his skin was turning black, the alarms kept dinging over and over,” Ms. Roscoe recalled.

Jaxon is 16 months old now, and home with his family. But he was in the NICU for 186 days, and his days and weeks were punctuated by near-death episodes.

During the six-month ordeal, Ms. Roscoe had constant nightmares. She slept with her shoes on, expecting a call from the hospital at any moment. She became angry at the world, and so jumpy she thought a supermarket scanner was one of Jaxon’s monitors going off. Her husband, Scott, immersed himself in projects, took care of their daughter, Logan, now 6, and held things together emotionally.

About three months after her son’s birth, Ms. Roscoe asked to see a psychiatrist. She was given a diagnosis of post-traumatic stress disorder, or P.T.S.D. — a mental illness more often associated with surviving war, car accidents and assaults, but now being recognized in parents of premature infants in prolonged intensive care.

A new study from Stanford University School of Medicine, published in the journal Psychosomatics, followed 18 such parents, both men and women. After four months, three had diagnoses of P.T.S.D. and seven were considered at high risk for the disorder.

In another study, researchers from Duke University interviewed parents six months after their baby’s due date and scored them on three post-traumatic stress symptoms: avoidance, hyperarousal, and flashbacks or nightmares. Of the 30 parents, 29 had two or three of the symptoms, and 16 had all three.

“The NICU was very much like a war zone, with the alarms, the noises, and death and sickness,” Ms. Roscoe said. “You don’t know who’s going to die and who will go home healthy.”

Experts say parents of NICU infants experience multiple traumas, beginning with the early delivery, which is often unexpected.

“The second trauma is seeing their own infant having traumatic medical procedures and life-threatening events, and also witnessing other infants going through similar experiences,” said the author of the Stanford study, Dr. Richard J. Shaw, an associate professor of child psychiatry at Stanford and the Lucile Packard Children’s Hospital.

“And third, they often are given serial bad news,” he continued. “The bad news keeps coming. It’s different from a car accident or an assault or rape, where you get a single trauma and it’s over and you have to deal with it. With a preemie, every time you see your baby the experience comes up again.”

Abby Schrader and her partner, Sharon Eble, delivered twins at 23 weeks. Both girls, born at 1 pound 5 ounces each, were having continuous near-death events. “We were constantly being asked whether we wanted to remove support,” said Ms. Schrader, of Philadelphia.

Eighteen days after the girls’ birth, the couple did withdraw support from one baby, whose health had badly deteriorated. The surviving twin, Hallie, now 3, was in the NICU for 121 days and continued to have medical problems once home. “From the moment of their birth, and still to this day, we feel like we’re triaging everything and just hanging on,” Ms. Schrader said.

The Stanford study found that although none of the fathers experienced acute stress symptoms while their child was in the NICU, they actually had higher rates of post-traumatic stress than the mothers when they were followed up later. “At four months, 33 percent of fathers and 9 percent of mothers had P.T.S.D.,” Dr. Shaw said.

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Bioethicist Becomes a Lightning Rod for Criticism -

Few people hold a more uncomfortable place at the health care debate’s intersection between nuanced policy and cable-ready political rhetoric than President Obama’s special health care adviser, Dr. Ezekiel J. Emanuel.

Largely quoting his past writings out of context this summer, Betsy McCaughey, a former lieutenant governor of New York, labeled Dr. Emanuel a “deadly doctor” who believes health care should be “reserved for the nondisabled” — a false assertion that Representative Michele Bachmann, Republican of Minnesota, repeated on the House floor.

Former Gov. Sarah Palin of Alaska has asserted that Dr. Emanuel’s “Orwellian” approach to health care would “refuse to allocate medical resources to the elderly, the infirm and the disabled who have less economic potential,” accusations similarly made by the political provocateur Lyndon H. LaRouche Jr.

In fact, Dr. Emanuel has written more than a million words on health care, some of which form the philosophical underpinnings of the Obama administration plan and some of which have enough free-market elements to win grudging respect from some conservative opponents.

The debate over Dr. Emanuel shows how subtle philosophical arguments that have long bedeviled bioethicists are being condensed, oversimplified and distorted in the griddle-hot health care debate. His writings grapple with some of the most complex issues of medical ethics, like who should get the kidney transplant, the younger patient or the one who is older and sicker?

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Monday, August 24, 2009

Status-Quo Anxiety : The New Yorker

There are times when Americans’ attitude toward health-care reform seems a bit like St. Augustine’s take on chastity: Give it to us, Lord, but not yet. In theory, the public overwhelmingly supports reform—earlier this year, polls showed big majorities in favor of fundamental change. But, when it comes to actually making fundamental change, people go all wobbly. Just about half of all Americans now disapprove of the way the Obama Administration is handling health care.

In part, of course, this is because of the non-stop demonization of the Obama plan. But the public’s skittishness about overhauling the system also reflects something else: the deep-seated psychological biases that make people resistant to change. Most of us, for instance, are prey to the so-called “endowment effect”: the mere fact that you own something leads you to overvalue it. A simple demonstration of this was an experiment in which some students in a class were given coffee mugs emblazoned with their school’s logo and asked how much they would demand to sell them, while others in the class were asked how much they would pay to buy them. Instead of valuing the mugs similarly, the new owners of the mugs demanded more than twice as much as the buyers were willing to pay. The academics Ziv Carmon and Dan Ariely showed the same thing in a real-world experiment: posing as ticket scalpers, they phoned people who had entered a raffle to win tickets to a Duke basketball game. People who hadn’t won tickets were willing to pay, on average, a hundred and seventy dollars to get into the game. But those who had won tickets wanted twenty-four hundred dollars to part with them. In other words, those who had, by pure luck, won the tickets thought the ducats were fourteen times as valuable as those who hadn’t.

What this suggests about health care is that, if people have insurance, most will value it highly, no matter how flawed the current system. And, in fact, more than seventy per cent of Americans say they’re satisfied with their current coverage. More strikingly, talk of changing the system may actually accentuate the endowment effect. Last year, a Rasmussen poll found that only twenty-nine percent of likely voters rated the U.S. health-care system good or excellent. Yet when Americans were asked the very same question last month, forty-eight per cent rated it that highly. The American health-care system didn’t suddenly improve over the past eleven months. People just feel it’s working better because they’re being asked to contemplate changing it.

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Experiencing Life, Briefly, Inside a Nursing Home -

For 10 days in June, Kristen Murphy chose to live somewhere she and many others fear: a nursing home.

Ms. Murphy, who is in perfect health, had to learn the best way to navigate a wheelchair around her small room, endure the humiliation that comes with being helped in the bathroom, try to sleep through night checks and become attuned to the emotions of her fellow residents.

And Ms. Murphy, 38, had to explain to friends, family and fellow patients why she was there.

Ms. Murphy, a medical student at the University of New England in Biddeford, Me., who is interested in geriatric medicine, came to New York for a novel program that allowed her to experience life as a nursing home patient.

Students are given a "diagnosis" of an ailment and expected to live as someone with the condition does. They keep a daily journal chronicling their experiences and, in most cases, debunking their preconceived notions.

The program started in 2005 after a student approached Dr. Marilyn Gugliucci, the director of geriatrics education at the medical school. " 'Dr. G,' " she recalled the student saying, " 'I would like to learn how to speak with institutionalized elders.' What came out of my mouth was, 'Will you live in a nursing home for two weeks?' "

To Dr. Gugliucci's surprise, she found nursing homes in the region that were willing to participate and students who were willing to volunteer. No money is exchanged between the school and nursing homes, and the homes agree to treat students like regular patients.

"My motivation is really to have somebody from the inside tell us what it's like to be a resident," said Rita Morgan, administrator of the Sarah Neuman Center for Healthcare and Rehabilitation here, one of the four campuses of Jewish Home Lifecare.

"But she is really there to study herself, her own feelings about living in a nursing home," Ms. Morgan added, referring to Ms. Murphy.

Geriatric specialists hope the program and others like it help generate interest in the profession, one of the most underrepresented fields in medicine. Medical schools and residencies require little to no geriatric training, and many students are reluctant to get into the field because it is among the lowest paid in medicine.

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Officials Weigh Circumcision to Fight H.I.V. Risk -

Public health officials are considering promoting routine circumcision for all baby boys born in the United States to reduce the spread of H.I.V., the virus that causes AIDS.

The topic is a delicate one that has already generated controversy, even though a formal draft of the proposed recommendations, due out from the Centers for Disease Control and Prevention by the end of the year, has yet to be released.

Experts are also considering whether the surgery should be offered to adult heterosexual men whose sexual practices put them at high risk of infection. But they acknowledge that a circumcision drive in the United States would be unlikely to have a drastic impact: the procedure does not seem to protect those at greatest risk here, men who have sex with men.

Recently, studies showed that in African countries hit hard by AIDS, men who were circumcised reduced their infection risk by half. But the clinical trials in Africa focused on heterosexual men who are at risk of getting H.I.V. from infected female partners.

For now, the focus of public health officials in this country appears to be on making recommendations for newborns, a prevention strategy that would only pay off many years from now. Critics say it subjects baby boys to medically unnecessary surgery without their consent.

But Dr. Peter Kilmarx, chief of epidemiology for the division of H.I.V./AIDS prevention at the C.D.C., said that any step that could thwart the spread of H.I.V. must be given serious consideration.

"We have a significant H.I.V. epidemic in this country, and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address the epidemic," Dr. Kilmarx said. "What we've heard from our consultants is that there would be a benefit for infants from infant circumcision, and that the benefits outweigh the risks."

He and other experts acknowledged that although the clinical trials of circumcision in Africa had dramatic results, the effects of circumcision in the United States were likely to be more muted because the disease is less prevalent here, because it spreads through different routes and because the health systems are so disparate as to be incomparable.

Clinical trials in Kenya, South Africa and Uganda found that heterosexual men who were circumcised were up to 60 percent less likely to become infected with H.I.V. over the course of the trials than those who were not circumcised.

There is little to no evidence that circumcision protects men who have sex with men from infection.

Another reason circumcision would have less of an impact in the United States is that some 79 percent of adult American men are already circumcised, public health officials say.

But newborn circumcision rates have dropped in recent decades, to about 65 percent of newborns in 1999 from a high of about 80 percent after World War II, according to C.D.C. figures. And blacks and Hispanics, who have been affected disproportionately by AIDS, are less likely than whites to circumcise their baby boys, according to the agency.

Circumcision rates have fallen in part because the American Academy of Pediatrics, which sets the guidelines for infant care, does not endorse routine circumcision. Its policy says that circumcision is "not essential to the child's current well-being," and as a result, many state Medicaid programs do not cover the operation.

The academy is revising its guidelines, however, and is likely to do away with the neutral tone in favor of a more encouraging policy stating that circumcision has health benefits even beyond H.I.V. prevention, like reducing urinary tract infections for baby boys, said Dr. Michael Brady, a consultant to the American Academy of Pediatrics.

He said the academy would probably stop short of recommending routine surgery, however. "We do have evidence to suggest there are health benefits, and families should be given an opportunity to know what they are," he said. But, he said, the value of circumcision for H.I.V. protection in the United States is difficult to assess, adding, "Our biggest struggle is trying to figure out how to understand the true value for Americans."

Circumcision will be discussed this week at the C.D.C.'s National H.I.V. Prevention Conference in Atlanta, which will be attended by thousands of health professionals and H.I.V. service providers.

Among the speakers is a physician from Operation Abraham, an organization based in Israel and named after the biblical figure who was circumcised at an advanced age, according to the book of Genesis. The group trains doctors in Africa to perform circumcisions on adult men to reduce the spread of H.I.V.

Members of Intact America, a group that opposes newborn circumcision, have rented mobile billboards that will drive around Atlanta carrying their message that "circumcising babies doesn't prevent H.I.V.," said Georganne Chapin, who leads the organization.

Although the group's members oppose circumcision on broad philosophical and medical grounds, Ms. Chapin argued that the studies in Africa found only that circumcision reduces H.I.V. infection risk, not that it prevents infection. "Men still need to use condoms," Ms. Chapin said.

In fact, while the clinical trials in Africa found that circumcision reduced the risk of a man's acquiring H.I.V., it was not clear whether it would reduce the risk to women from an infected man, several experts said.

"There's mixed data on that," Dr. Kilmarx said. But, he said, "If we have a partially successful intervention for men, it will ultimately lower the prevalence of H.I.V. in the population, and ultimately lower the risk to women."

Circumcision is believed to protect men from infection with H.I.V. because the mucosal tissue of the foreskin is more susceptible to H.I.V. and can be an entry portal for the virus. Observational studies have found that uncircumcised men have higher rates of other sexually transmitted diseases like herpes and syphilis, and a recent study in Baltimore found that heterosexual men were less likely to have become infected with H.I.V. from infected partners if they were circumcised.