- Email: [email protected]
AIDS, CONDOMS, AND PRISONS
41
responders2 revealed no difference in psychiatric disorder between them and the responders. One correspondent suggests that the search for meaning could be dealt with by repeat interviews of women who had been depressed at the mitial interview, after they had recovered, to see whether they still reported abusive experience. Unfortunately the searching for meaning is a characteristic of all people, not only those who get depressed. Such an approach would not obviate the research problem that individuals react to adversity in different ways and’ explain their reactions differently. Our main finding stands: randomly selected women who were sexually abused as children or sexually and physically abused as adults have more psychiatric symptoms and psychiatric illness when studied in a cross-sectional manner.
Dr James suggests that reaction to abuse is culturally determined. We have shown that it is harmful to the mental health of New Zealand women for them to experience sexual or physical abuse. We would be most interested to learn of other well-designed studies with contradictory results. Most writers accept that female children are exposed more frequently to sexual abuse than male children and that adult females suffer more physical and sexual abuse than males. Our hypothesis is that this may account for at least some of the gender difference in psychiatric disorder. We deliberately avoided any discussion of the mechanisms by which abuses may be linked to outcome. To unravel these complex issues, a more clearly developed theory of the social causation of psychiatric illness is needed. We restricted ourselves to noting that the three types of abuse we studied separately explained more of the variance in psychiatric disorder than did traditionally investigated variables of social class and marital and employment status. Department of Psychological Medicine, University of Otago, Dunedin, New Zealand
SARAH ROMANS-CLARKSON* PAUL E. MULLEN VALERIE A. WALTON
*Present address: Department of Psychological Medicine, Medical Bartholomew’s Hospital, London EC1A 7BE.
College
of St
1. Finklehor U, Korbin J. Child abuse as an international issue. Child Abuse Neglect 1988; 12: 8-23 2 Romans-Clarkson SE, Walton VA, Herbison GP, Mullen PE. A study of women who refused to participate in a community survey of psychiatric disorder. Aust NZ J Psychiatry 1988; 28: 19-29.
Preventing the spread of HIV infection is the responsibility of all doctors.’ There is, however, little evidence that the profession has fully accepted this. A surveys of general practitioners in one area of England showed that the majority expressed little interest in health education about HIV and that only just over half of them had ever raised the question of AIDS with a patient unprompted. Glanz6 found that although large numbers of drug users present in primary-care settings, most general practitioners regarded opioid users as "beyond their competence to treat and less acceptable as patients than others in need of care". Robertson and Skidmore4 suggest that measures to prevent AID S in drug users should be divorced from the treatment for drug abuse, arguing that the drug clinics cater largely for "geriatric junkies who will either be HIV infected or not at risk" and that there is an ideological clash between treatment and harm reduction. Such a policy could lead to many opportunities for prevention being missed. Several drug units have established community drug teams which appear successful in reaching the younger drug user. In its first year of operation the Maudsley team saw over 180 clients, 47% of whom were under 25. Less than one-third had made previous contact with drug services and only one-fifth had sought help from their general practitioner. These are hardly "geriatric junkies". This community approach is now a victim of its own success and has a waiting list for new clients, despite the original intention to provide an immediate response. The community drug team is also an efficient way of spreading scarce skills on the management of drug problems to general practitioners, and in our experience it is possible to increase the proportion who are willing to provide such "shared care". The individual doctor has to abandon the notion that the threat posed by HIV is some other doctor’s problem. No single group within the profession can mount an adequate response. Those who fund and plan the National Health Service cannot wash their hands of the matter. Preventive measures may seem expensive but the financial and human costs of AIDS will be much higher. Our only choice is between spending a sizeable sum now in an attempt to slow the epidemic, or spending a great deal tomorrow treating the casualties of our inaction. Drug Dependence Clinical Research and Treatment Unit,
Maudsley Hospital, London SE5 8AZ
DRUG USERS, AIDS, AND THE GOVERNMENT RESPONSE was used in the UK Government’s AIDS campaign. Yet this will be the fate of many, given the Government’s failure to back specialist advice on measures to curb the spread of HIV infection. The Advisory Council on the Misuse of Drugs recommends a substantial expansion in a range of drugs services,l to reduce HIV transmission by helping drug addicts move away from more risk-laden habits; but the Government has provided no extra money for this expansion. The Health Minister has argued that the Government’s main response to the misuse of drugs will be a combination of law enforcement and education.2 In the same month a US presidential report emphasised that education alone is not enough-it must be accompanied by assistance to effect the recommended changes. "Expansion of the treatment system and expansion to outreach efforts should be carried out in conjunction with one another. Outreach workers must have treatment programmes available to offer drug users who are willing to take action. Education without
SiR,—The slogan "Don’t die of ignorance"
recent
is not enough."3 The British response (or lack of it) is shortsighted. Incarceration is not widely regarded as therapeutic and drug users are not much bothered by legislative measures, nor readily influenced by information alone. The Government response seems founded on the hope that HIV infection will not spread beyond high-risk groups and that by implication the present services for drug users will )ust have to manage. The United States is planning for 3300 new drug treatment agencies with 32 000 new drug workers.3
treatment
ANDREW JOHNS MICHAEL GOSSOP PAUL GRIFFITHS JOHN STRANG
Advisory Council on the Misuse of Drugs. Aids and drug misuse: part 1. London: HMSO, 1988. 2. Health Circular HC(88)26 and accompanying annex: Services for drug misusers: Curbing the spread of AIDS and HIV infection. London: DHSS, 1988. 3. US Presidential Commission on the Human Immunodeficiency Virus Epidemic. Press release (Feb 24, 1988). 4. Robertson JR, Skidmore CA. Drug misuse strategies and AIDS prevention. Lancet 1
1988, ii: 422. 5. Milne GRG, Keen SM. Are general practitioners ready to prevent the spread of HIV? Br Med J 1988; 296: 533-37. 6. Glanz A. Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: Dealing with the opiate misuser. Br Med J 1986; 293: 486-88
AIDS, CONDOMS, AND PRISONS SIR,-Administrative resistance to a World Health Organisation recommendation that condoms be made available to prison inmates1 frequently shows a want of appreciation of the patterns of homosexual practice among prisoners. Apart from stable, mutually supportive partnerships, there are two common types. In one, an inmate of low social status, frequently mentally retarded, makes himself freely available to several other inmates as a casual sex object, for small favours. The number of men who might take advantage of this is large: in one incident where such an inmate was rumoured to be infected with HIV over fifty other prisoners inquired about testing for HIV. In the second form, older predatory homosexuals, often serving long sentences, maintain a sort of harem of one or more younger, sexually desirable inmates, often serving a shorter sentence, who are coerced by the offer of protection against
42
competing "wolves"
or "ring bandits". In neither form does the have free and the vast majority of those involved choice, exploited show a heterosexual preference when not incarcerated. Both forms of practice lend themselves to the rapid dissemination of HIV, and must represent a potentially significant route of infection into the heterosexual community outsider Under these circumstances, failure to provide condoms within prisons seems indefensible. Security concerns that condoms offer a means of packaging drugs and other high risk articles for carrying within body cavities ignore the fact that substitutes for packaging are readily available. Official fears that the administration, by providing condoms, might be seen to be condoning homosexual practice show a lack of appreciation of the reality of these practices and of the helplessness of most of those involved. The exploiting partner is often anxious to maintain the illusion that the exploited partner is a willing participant. The victim can use this wish to "bargain" for the use of precautionary measures, if measures are available. The provision of condoms in prisons represents one practical way to prevent the spread of AIDS. Another would be to make conjugal visits more freely available, thus reducing the pressures for homosexual activity in prisons.
337 Palace Road, Kingston, Ontario K7L 4T4, Canada
G. NEIL CONACHER
1. Anon. WHO consultation on prevention and control of AIDS in prisons. Lancet 1987; ii: 1263-64. 2. Harding TW. AIDS in prison. Lancet 1987; ii: 1260-63.
A SMALL OUTBREAK OF HIV INFECTION AMONG COMMERCIAL PLASMA DONORS
SIR,-During the past year we have studied seven patients with HIV infection who did not have any of the generally accepted risk factors. All seven gave blood, for money, to private blood banks in Valencia. Investigations revealed that infection had happened via equipment contaminated with blood that probably carried HIV-ie, the mechanism resembled that observed in intravenous drug abusers. All seven patients were men, aged 37-57, who, lacking economic support, sold their plasma. They denied belonging to any established risk group. All had antibodies to HIV (Abbott EIA, western blot). This table summarises the clinical characteristics. Epidemiological data suggest that the only way in which these men could have become infected by HIV was through selling plasma to private blood banks. Investigations by public health authorities revealed incorrect handling of the equipment used in plasma extraction. The same possibly contaminated material (intravenous
lines, bottles, and so on) had been used several times. Screening of donated blood and blood products for antibodies to HIV began in 1985 in Spain, so these men were presumably infected before that date. The long incubation period of HIV infection means that further clinical cases of HIV infection, acquired in this way, may present in future. PABLO ROIG ANGEL NIETO JUAN JIMENEZ CONCEPCIÓN TUSET LUIS TUSET RAFAEL NAVARRO GUSTAVO JUAN VICENTE NAVARRO Infectious Diseases Unit,
Hospital General de Valencia, Valencia 46014, Spain
BREAST FEEDING AND PREMATURE BABIES
SIR,-Your March 19 editorial entitled Breast not Necessarily (for premature babies) recommends milk manufactured semi artificially and concludes that some studies have shown no Best
difference in growth while others have revealed significant improvements for low-birthweight formulas versus the premature baby’s own mother’s milk. I note that one reference (ref 13) in favour and one (ref 5) against were published in the same issue of a journal and one author is common to both articles. You state that "extremely premature infants are not capable of feeding directly from their mother’s breast so milk has to be mechanically processed in some way". You then mention pasteurisation. Milk expressed from the breast may have to be fed by tube whether mother’s milk or not. Is this what you mean by "mechanically processed"? You claim that "time spent on a neonatal unit may be significantly reduced" in premature babies fed artificially, but let us not forget about "mother-kangaroo" systems, which have rescued babies very near to the 1750 g birthweight you refer to. No mechanical processing was needed to save them and the time spent in the nursery was even less than with "optimum artificial feeding". Many people will be in total disagreement with your view that in developing countries breast milk does not confer significant additional immunological protection to premature babies. The theoretical considerations about calcium, phosphorus, and sodium are only suggestions of inadequate bone mineralisation, and, as you say, evidence for longer-term advantages of breast and formula
feeds for premature infants is awaited. "Breast not necessarily best" is, as a generalisation, most dangerous, especially for underdeveloped countries and may jeopardise the efforts of health workers all over the world to increase breast feeding. For the first time I find myself hoping that an issue of The Lancet will not be widely read. Nutritional Research Institute, Lima 18, Peru
JAIME FREUNDT-THURNE
CLINICAL CHARACTERISTICS
COAGULATION FACTOR VIII CONCENTRATES AND THE MARKETPLACE
SIR,-It is most unfortunate that Dr Cash (June 4, 1270) should assume that possible price increases related to the production of high-technology concentrates are automatically linked to profit motives in a falling market. Over the years predictions of rises or falls in the demand for clotting fractions have been notoriously unreliable and, despite the tragedy of HIV infection, the fall Cash forecasts may not take place--indeed, recent evidence points to a rise. Cash, from his research and work on plasma fractionation, must know the heavy commitments, in time and money, that are involved in the development of high-technology blood products. Increased safety, convenience, and efficacy of these products have been demanded by physicians and patients alike for many years. To pretend that these advances are potentially valueless and that the p
T" T,
=
T
helper
T suppressor cell ratio.
cost of research does not need to be recovered in the first years of use is illogical and perhaps reflects a parochial concern for the relatively low-purity products produced by the Scottish National Blood Transfusion Service and UK Blood Products Laboratory. Haemophiliacs, like diabetics, suffer from a single definable deficiency. It does not seem good clinical practice to bombard the
responders2 revealed no difference in psychiatric disorder between them and the responders. One correspondent suggests that the search for meaning could be dealt with by repeat interviews of women who had been depressed at the mitial interview, after they had recovered, to see whether they still reported abusive experience. Unfortunately the searching for meaning is a characteristic of all people, not only those who get depressed. Such an approach would not obviate the research problem that individuals react to adversity in different ways and’ explain their reactions differently. Our main finding stands: randomly selected women who were sexually abused as children or sexually and physically abused as adults have more psychiatric symptoms and psychiatric illness when studied in a cross-sectional manner.
Dr James suggests that reaction to abuse is culturally determined. We have shown that it is harmful to the mental health of New Zealand women for them to experience sexual or physical abuse. We would be most interested to learn of other well-designed studies with contradictory results. Most writers accept that female children are exposed more frequently to sexual abuse than male children and that adult females suffer more physical and sexual abuse than males. Our hypothesis is that this may account for at least some of the gender difference in psychiatric disorder. We deliberately avoided any discussion of the mechanisms by which abuses may be linked to outcome. To unravel these complex issues, a more clearly developed theory of the social causation of psychiatric illness is needed. We restricted ourselves to noting that the three types of abuse we studied separately explained more of the variance in psychiatric disorder than did traditionally investigated variables of social class and marital and employment status. Department of Psychological Medicine, University of Otago, Dunedin, New Zealand
SARAH ROMANS-CLARKSON* PAUL E. MULLEN VALERIE A. WALTON
*Present address: Department of Psychological Medicine, Medical Bartholomew’s Hospital, London EC1A 7BE.
College
of St
1. Finklehor U, Korbin J. Child abuse as an international issue. Child Abuse Neglect 1988; 12: 8-23 2 Romans-Clarkson SE, Walton VA, Herbison GP, Mullen PE. A study of women who refused to participate in a community survey of psychiatric disorder. Aust NZ J Psychiatry 1988; 28: 19-29.
Preventing the spread of HIV infection is the responsibility of all doctors.’ There is, however, little evidence that the profession has fully accepted this. A surveys of general practitioners in one area of England showed that the majority expressed little interest in health education about HIV and that only just over half of them had ever raised the question of AIDS with a patient unprompted. Glanz6 found that although large numbers of drug users present in primary-care settings, most general practitioners regarded opioid users as "beyond their competence to treat and less acceptable as patients than others in need of care". Robertson and Skidmore4 suggest that measures to prevent AID S in drug users should be divorced from the treatment for drug abuse, arguing that the drug clinics cater largely for "geriatric junkies who will either be HIV infected or not at risk" and that there is an ideological clash between treatment and harm reduction. Such a policy could lead to many opportunities for prevention being missed. Several drug units have established community drug teams which appear successful in reaching the younger drug user. In its first year of operation the Maudsley team saw over 180 clients, 47% of whom were under 25. Less than one-third had made previous contact with drug services and only one-fifth had sought help from their general practitioner. These are hardly "geriatric junkies". This community approach is now a victim of its own success and has a waiting list for new clients, despite the original intention to provide an immediate response. The community drug team is also an efficient way of spreading scarce skills on the management of drug problems to general practitioners, and in our experience it is possible to increase the proportion who are willing to provide such "shared care". The individual doctor has to abandon the notion that the threat posed by HIV is some other doctor’s problem. No single group within the profession can mount an adequate response. Those who fund and plan the National Health Service cannot wash their hands of the matter. Preventive measures may seem expensive but the financial and human costs of AIDS will be much higher. Our only choice is between spending a sizeable sum now in an attempt to slow the epidemic, or spending a great deal tomorrow treating the casualties of our inaction. Drug Dependence Clinical Research and Treatment Unit,
Maudsley Hospital, London SE5 8AZ
DRUG USERS, AIDS, AND THE GOVERNMENT RESPONSE was used in the UK Government’s AIDS campaign. Yet this will be the fate of many, given the Government’s failure to back specialist advice on measures to curb the spread of HIV infection. The Advisory Council on the Misuse of Drugs recommends a substantial expansion in a range of drugs services,l to reduce HIV transmission by helping drug addicts move away from more risk-laden habits; but the Government has provided no extra money for this expansion. The Health Minister has argued that the Government’s main response to the misuse of drugs will be a combination of law enforcement and education.2 In the same month a US presidential report emphasised that education alone is not enough-it must be accompanied by assistance to effect the recommended changes. "Expansion of the treatment system and expansion to outreach efforts should be carried out in conjunction with one another. Outreach workers must have treatment programmes available to offer drug users who are willing to take action. Education without
SiR,—The slogan "Don’t die of ignorance"
recent
is not enough."3 The British response (or lack of it) is shortsighted. Incarceration is not widely regarded as therapeutic and drug users are not much bothered by legislative measures, nor readily influenced by information alone. The Government response seems founded on the hope that HIV infection will not spread beyond high-risk groups and that by implication the present services for drug users will )ust have to manage. The United States is planning for 3300 new drug treatment agencies with 32 000 new drug workers.3
treatment
ANDREW JOHNS MICHAEL GOSSOP PAUL GRIFFITHS JOHN STRANG
Advisory Council on the Misuse of Drugs. Aids and drug misuse: part 1. London: HMSO, 1988. 2. Health Circular HC(88)26 and accompanying annex: Services for drug misusers: Curbing the spread of AIDS and HIV infection. London: DHSS, 1988. 3. US Presidential Commission on the Human Immunodeficiency Virus Epidemic. Press release (Feb 24, 1988). 4. Robertson JR, Skidmore CA. Drug misuse strategies and AIDS prevention. Lancet 1
1988, ii: 422. 5. Milne GRG, Keen SM. Are general practitioners ready to prevent the spread of HIV? Br Med J 1988; 296: 533-37. 6. Glanz A. Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: Dealing with the opiate misuser. Br Med J 1986; 293: 486-88
AIDS, CONDOMS, AND PRISONS SIR,-Administrative resistance to a World Health Organisation recommendation that condoms be made available to prison inmates1 frequently shows a want of appreciation of the patterns of homosexual practice among prisoners. Apart from stable, mutually supportive partnerships, there are two common types. In one, an inmate of low social status, frequently mentally retarded, makes himself freely available to several other inmates as a casual sex object, for small favours. The number of men who might take advantage of this is large: in one incident where such an inmate was rumoured to be infected with HIV over fifty other prisoners inquired about testing for HIV. In the second form, older predatory homosexuals, often serving long sentences, maintain a sort of harem of one or more younger, sexually desirable inmates, often serving a shorter sentence, who are coerced by the offer of protection against
42
competing "wolves"
or "ring bandits". In neither form does the have free and the vast majority of those involved choice, exploited show a heterosexual preference when not incarcerated. Both forms of practice lend themselves to the rapid dissemination of HIV, and must represent a potentially significant route of infection into the heterosexual community outsider Under these circumstances, failure to provide condoms within prisons seems indefensible. Security concerns that condoms offer a means of packaging drugs and other high risk articles for carrying within body cavities ignore the fact that substitutes for packaging are readily available. Official fears that the administration, by providing condoms, might be seen to be condoning homosexual practice show a lack of appreciation of the reality of these practices and of the helplessness of most of those involved. The exploiting partner is often anxious to maintain the illusion that the exploited partner is a willing participant. The victim can use this wish to "bargain" for the use of precautionary measures, if measures are available. The provision of condoms in prisons represents one practical way to prevent the spread of AIDS. Another would be to make conjugal visits more freely available, thus reducing the pressures for homosexual activity in prisons.
337 Palace Road, Kingston, Ontario K7L 4T4, Canada
G. NEIL CONACHER
1. Anon. WHO consultation on prevention and control of AIDS in prisons. Lancet 1987; ii: 1263-64. 2. Harding TW. AIDS in prison. Lancet 1987; ii: 1260-63.
A SMALL OUTBREAK OF HIV INFECTION AMONG COMMERCIAL PLASMA DONORS
SIR,-During the past year we have studied seven patients with HIV infection who did not have any of the generally accepted risk factors. All seven gave blood, for money, to private blood banks in Valencia. Investigations revealed that infection had happened via equipment contaminated with blood that probably carried HIV-ie, the mechanism resembled that observed in intravenous drug abusers. All seven patients were men, aged 37-57, who, lacking economic support, sold their plasma. They denied belonging to any established risk group. All had antibodies to HIV (Abbott EIA, western blot). This table summarises the clinical characteristics. Epidemiological data suggest that the only way in which these men could have become infected by HIV was through selling plasma to private blood banks. Investigations by public health authorities revealed incorrect handling of the equipment used in plasma extraction. The same possibly contaminated material (intravenous
lines, bottles, and so on) had been used several times. Screening of donated blood and blood products for antibodies to HIV began in 1985 in Spain, so these men were presumably infected before that date. The long incubation period of HIV infection means that further clinical cases of HIV infection, acquired in this way, may present in future. PABLO ROIG ANGEL NIETO JUAN JIMENEZ CONCEPCIÓN TUSET LUIS TUSET RAFAEL NAVARRO GUSTAVO JUAN VICENTE NAVARRO Infectious Diseases Unit,
Hospital General de Valencia, Valencia 46014, Spain
BREAST FEEDING AND PREMATURE BABIES
SIR,-Your March 19 editorial entitled Breast not Necessarily (for premature babies) recommends milk manufactured semi artificially and concludes that some studies have shown no Best
difference in growth while others have revealed significant improvements for low-birthweight formulas versus the premature baby’s own mother’s milk. I note that one reference (ref 13) in favour and one (ref 5) against were published in the same issue of a journal and one author is common to both articles. You state that "extremely premature infants are not capable of feeding directly from their mother’s breast so milk has to be mechanically processed in some way". You then mention pasteurisation. Milk expressed from the breast may have to be fed by tube whether mother’s milk or not. Is this what you mean by "mechanically processed"? You claim that "time spent on a neonatal unit may be significantly reduced" in premature babies fed artificially, but let us not forget about "mother-kangaroo" systems, which have rescued babies very near to the 1750 g birthweight you refer to. No mechanical processing was needed to save them and the time spent in the nursery was even less than with "optimum artificial feeding". Many people will be in total disagreement with your view that in developing countries breast milk does not confer significant additional immunological protection to premature babies. The theoretical considerations about calcium, phosphorus, and sodium are only suggestions of inadequate bone mineralisation, and, as you say, evidence for longer-term advantages of breast and formula
feeds for premature infants is awaited. "Breast not necessarily best" is, as a generalisation, most dangerous, especially for underdeveloped countries and may jeopardise the efforts of health workers all over the world to increase breast feeding. For the first time I find myself hoping that an issue of The Lancet will not be widely read. Nutritional Research Institute, Lima 18, Peru
JAIME FREUNDT-THURNE
CLINICAL CHARACTERISTICS
COAGULATION FACTOR VIII CONCENTRATES AND THE MARKETPLACE
SIR,-It is most unfortunate that Dr Cash (June 4, 1270) should assume that possible price increases related to the production of high-technology concentrates are automatically linked to profit motives in a falling market. Over the years predictions of rises or falls in the demand for clotting fractions have been notoriously unreliable and, despite the tragedy of HIV infection, the fall Cash forecasts may not take place--indeed, recent evidence points to a rise. Cash, from his research and work on plasma fractionation, must know the heavy commitments, in time and money, that are involved in the development of high-technology blood products. Increased safety, convenience, and efficacy of these products have been demanded by physicians and patients alike for many years. To pretend that these advances are potentially valueless and that the p
T" T,
=
T
helper
T suppressor cell ratio.
cost of research does not need to be recovered in the first years of use is illogical and perhaps reflects a parochial concern for the relatively low-purity products produced by the Scottish National Blood Transfusion Service and UK Blood Products Laboratory. Haemophiliacs, like diabetics, suffer from a single definable deficiency. It does not seem good clinical practice to bombard the