facturers are allowed to charge health authorities on the one hand and pharmaceutical wholesalers on the other. Through the Prescription Price Regulatory Scheme the government controls the overall profits made by pharmaceutical manufacturers that sell medicines to the NHS. The scheme does not seek to control the prices charged by manufacturers to different sectors of the NHS. For various reasons, not least the negotiating power of health authorities, the prices that drug companies charge regional health authorities are extremely low; the companies make up their profits by charging higher prices to wholesalers and community pharmacists. As long as there is a "Chinese wall" between primary and secondary health care this price differential does not matter, but as "seamlessness" approaches it becomes very relevant indeed. It is also necessary to remember that the fee that the NHS pays to community pharmacies is intended to reimburse the overheads that the pharmacists incur in providing a pharmaceutical service to the community. To compare prices fairly it is essential to add a substantial element to the basic cost of drugs in hospitals to take account of the overheads incurred there. T P ASTILIL
Director, National P'harmaceutical Association, St Albans, Hertfordshire ALl 3NP 1 Ash S. How to pay for ( 12 October.)
expensis'e drugs. BMJ 1991;303:926.
Counselling patients before an HIV test SIR,-The series of letters' in response to our paper2 illustrates the complex medical, psychological, and practical problems associated with HIV testing which may deter some doctors from counselling their patients about the test. K C Mohanty correctly points out that screening patients for other sexually transmitted diseases is important when discussing the pros and cons of the HIV test with patients. None the less, in a recent study of the same day HIV testing service at the Royal Free Hospital, London, we found that many patients choosing this clinic did so because it was not a clinic for sexually transmitted diseases.' We always encourage discussion about sexually transmitted diseases as a part of the counselling process and work, closely with our colleagues in genitourinary medicine. Testing for HIV is appropriate in a wide range of medical settings and it is illogical and impractical for all testing to take place in sexually transmitted disease clinics. C Timmis suggests that taking a detailed sexual history of patients before an HIV test is potentially inappropriate and an invasion of the patient's private life. Though this may be true of the life insurance medical examination for HIV tests, we addressed the clinical situations in which HIV infection is part of a differential diagnosis or the patient may be at risk of HIV infection. A sexual history is necessary to identify whether there has been any risk of HIV infection. Failure to counsel these patients is to collude with the denial of the problem and to place the lives of patients and others at risk. Mary Reynolds contends that people who have had a negative HIV test result are not necessarily penalised when applying for life insurance. Our experience is that some people do face restrictions as a result of their having had an HIV test. If negative test results are ignored by underwriters why ask the question about previous tests? Testing for HIV itself does not provide any information about the person's risk for HIV. Instead of making assumptions about risk or lifestyle, underwriters 1478
could ask applicants whether they have ever had a positive test result for HIV antibody. Fhis would be fairer to patients and be less damaging to doctorpatient relationships. ROBERT BOR RIVA MILLER Psychology Division,
City University, London EC IV OHB
MARGARET JOHNSON Royal Free Hampstead NHS Trust, London NW3 2QG 1 Correspondence. BMJ 1991;303:1133-4. (2 November.) 2 Bor R, Miller R, Johnson M. A testing time for doctors: counselling patients hefore an HIV test. BMJ 1991;303:905-7. (12 October.) 3 Squire SB, Elford J, Bor R, Tilsed G, Salt H, Bagdades EK, et al. Open access clinic providing HIV-I antibody results on dav of testing: the first twelve monthso*MJ 1991;302:1383-6.
Health of the nation SIR,-Can Hugh Tunstall-Pedoe diminish my pessimism that a 50% reduction in mortality from coronary heart disease by the year 2000 is attainable?' How can we assume that the decline in mortality that the United Kingdom has witnessed since the 1970s will continue at the same or a faster pace? As the cause for this decline is unclear (it may be related more to improvements in standards of living than to any health promotional intervention) is not that assumption questionable? Furthermore, as behaviour is modified in the population those people most resistant to change will probably be those with persistent risk factors for the last years of the decade. It is also a changing population, making predictions of mortality even more difficult. Is it appropriate to have a target that is the same for men and women, given the significant difference in mortality between the sexes and the fact that the incidence of coronary heart disease in women is more difficult to reduce? The various large cardiovascular intervention studies suggest that the percentage reduction achieved by such studies was small. The World Health Organisation's European collaborative study in the United Kingdom actually showed an increase in mortality in the intervention group,2 and I understand from the multiple risk factor intervention trial in men that the reduction in deaths from coronary heart disease was not significant.' A report of the British regional heart study suggested that benefits from stopping smoking are much more gradual and less than previously predicted and that reductions in mortality from coronary heart disease may take decades to occur after the reduction or removal of mutable risk factors.4 Ex-smokers carry the risk of coronary heart disease for some time. Also, after a coronary thrombosis conventional risk factors become relatively unimportant so that intervention with respect to mutable risk factors in these cases may be ineffective. In my district the mobility of the population creates the problem of a shifting denominator, making calculations difficult and the achievement of a local target reduction in mortality questionable. Mobile populations, many of them with high risk factors, are difficult to engage effectively in a health promotion strategy. The inner city also has a higher proportion of residents living a subsistence lifestyle, who are resistant to traditional health educational approaches to stopping smoking or altering their diet. I am impressed by Tunstall-Pedoe's development of a means of calculating cardiovascular risk.' This is of great potential use: even without seeing patients doctors can begin to establish a database from the records and to identify the high risk group. More attainable local targets for this district might be to record risk factors in a high percentage of cases and to use this database to
evaluate interventions. Is this pragmatic or have I overestimated the task? ANDREW IHARRIS Lainbeth, Southwark, and 1cwtsham l'amily Health Services Authority, London SEI 7NT 1 'l'unstall-Pedoe H. Coronary heart disease. BRH 1991;303: 701-4. (21 September.) 2 World Health Organisation Europeani Collaborative (;routp. Multifactorial trial in the prevFention of coronary heart disease. 1. Recruitment and initial fitadings. Fur leartj 1980;1:73-80. 3 MIRFIT Research Group. Multiple risk factor interventiolt trial: risk factor changes anid mortality results. JAMA 1982;248: 1465-77. 4 Shaper AG, Pocock SJ, Walker M, Phillips AM, Whitehead TP, Mlacfarlane PW. Risk factors for ischaemic heart discase: the prospective phase of the British regional heart study. J E;pidemiotl Community Health 1985;39:197-209. 5 'I'unstall-Pedoe H. The Dundee coronar) risk-disk for ntanagement of changc in risk factors. BMJ 1991;303:744-7. (28
September.)
AUTHOR'S reply,-I do not claim infallibility in predicting trends in mortalitv from coronary heart disease. In the words of St Paul, "We know in part, and we prophesy in part." Ten years ago a school of thought at the Office of Population Censuses and Surveys held that cardiovascular mortality in England and Wales had been stable for 20 years and would continue so for the next 20. I challenged it on the grounds that what America does Britain repeats half heartedly 10 years later. I was wrong. The rate of decline is now as great in England and Wales. If we use other English speaking countries as our role models there is no sign of their declines bottoming out for coronary heart disease, even where all cause mortality, as in the United States, may be levelling off. Having started near the top, we have a long way down to go. Andrew Harris enumerates some of the frustrations and disappointments of the multifactorial trials of prevention of coronary heart disease, in which differences between intervention and control groups can be difficult to achieve; both, however, are affected by national trends, which can result in low attack rates in the control group, as occurred in the multiple risk factor intervention trial.' Not all studies show a long lead time. Some have shown a fairly rapid change in the incidence of coronary heart disease after change in risk factors, and that the primary risk factors do seem to matter in those with evidence of coronary heart disease; the Belgian heart disease prevention study is an example of both.2 Although trends in mortality in women may occasionally diverge from those in men, on the whole there is a good correlation and common targets are sensible. Harris might shed some of his pessimism if he looked at the United States, which has gross inequalities in wealth and provision of health services. It is ethnically heterogeneous, and there is considerable population mobility. These factors have not prevented it from experiencing a large and continuing decline in mortality from coronary heart disease despite the problems of identifying and counselling high risk subjects in inner city
populations. Harris questions the appropriate use of the Dundee coronary risk-disk.' It can certainly be used, as he suggests, for classifying patients from their records, but in this respect it is rubbing shoulders with other systems.4 Feedback from the increasing numbers of users confirms that its main virtues are in showing to patients directly on its analogue scales, firstly, the input of their risk factors; secondly, the impact of these on their ranking in the "queue" for coronary heart disease; and, thirdly, how they may, if they wish, change their ranking through changing their risk factors. It is much easier to show these with the disk than with a microcomputer, although a software version for IBM compatible computers is available. In commenting on the disk G H Hall and W T Hamilton suggested that measures of absolute risk are more motivational6; experience in the United BMJ
VOLUME 303
7 DECEMBER 1991
Director, National P'harmaceutical Association, St Albans, Hertfordshire ALl 3NP 1 Ash S. How to pay for ( 12 October.)
expensis'e drugs. BMJ 1991;303:926.
Counselling patients before an HIV test SIR,-The series of letters' in response to our paper2 illustrates the complex medical, psychological, and practical problems associated with HIV testing which may deter some doctors from counselling their patients about the test. K C Mohanty correctly points out that screening patients for other sexually transmitted diseases is important when discussing the pros and cons of the HIV test with patients. None the less, in a recent study of the same day HIV testing service at the Royal Free Hospital, London, we found that many patients choosing this clinic did so because it was not a clinic for sexually transmitted diseases.' We always encourage discussion about sexually transmitted diseases as a part of the counselling process and work, closely with our colleagues in genitourinary medicine. Testing for HIV is appropriate in a wide range of medical settings and it is illogical and impractical for all testing to take place in sexually transmitted disease clinics. C Timmis suggests that taking a detailed sexual history of patients before an HIV test is potentially inappropriate and an invasion of the patient's private life. Though this may be true of the life insurance medical examination for HIV tests, we addressed the clinical situations in which HIV infection is part of a differential diagnosis or the patient may be at risk of HIV infection. A sexual history is necessary to identify whether there has been any risk of HIV infection. Failure to counsel these patients is to collude with the denial of the problem and to place the lives of patients and others at risk. Mary Reynolds contends that people who have had a negative HIV test result are not necessarily penalised when applying for life insurance. Our experience is that some people do face restrictions as a result of their having had an HIV test. If negative test results are ignored by underwriters why ask the question about previous tests? Testing for HIV itself does not provide any information about the person's risk for HIV. Instead of making assumptions about risk or lifestyle, underwriters 1478
could ask applicants whether they have ever had a positive test result for HIV antibody. Fhis would be fairer to patients and be less damaging to doctorpatient relationships. ROBERT BOR RIVA MILLER Psychology Division,
City University, London EC IV OHB
MARGARET JOHNSON Royal Free Hampstead NHS Trust, London NW3 2QG 1 Correspondence. BMJ 1991;303:1133-4. (2 November.) 2 Bor R, Miller R, Johnson M. A testing time for doctors: counselling patients hefore an HIV test. BMJ 1991;303:905-7. (12 October.) 3 Squire SB, Elford J, Bor R, Tilsed G, Salt H, Bagdades EK, et al. Open access clinic providing HIV-I antibody results on dav of testing: the first twelve monthso*MJ 1991;302:1383-6.
Health of the nation SIR,-Can Hugh Tunstall-Pedoe diminish my pessimism that a 50% reduction in mortality from coronary heart disease by the year 2000 is attainable?' How can we assume that the decline in mortality that the United Kingdom has witnessed since the 1970s will continue at the same or a faster pace? As the cause for this decline is unclear (it may be related more to improvements in standards of living than to any health promotional intervention) is not that assumption questionable? Furthermore, as behaviour is modified in the population those people most resistant to change will probably be those with persistent risk factors for the last years of the decade. It is also a changing population, making predictions of mortality even more difficult. Is it appropriate to have a target that is the same for men and women, given the significant difference in mortality between the sexes and the fact that the incidence of coronary heart disease in women is more difficult to reduce? The various large cardiovascular intervention studies suggest that the percentage reduction achieved by such studies was small. The World Health Organisation's European collaborative study in the United Kingdom actually showed an increase in mortality in the intervention group,2 and I understand from the multiple risk factor intervention trial in men that the reduction in deaths from coronary heart disease was not significant.' A report of the British regional heart study suggested that benefits from stopping smoking are much more gradual and less than previously predicted and that reductions in mortality from coronary heart disease may take decades to occur after the reduction or removal of mutable risk factors.4 Ex-smokers carry the risk of coronary heart disease for some time. Also, after a coronary thrombosis conventional risk factors become relatively unimportant so that intervention with respect to mutable risk factors in these cases may be ineffective. In my district the mobility of the population creates the problem of a shifting denominator, making calculations difficult and the achievement of a local target reduction in mortality questionable. Mobile populations, many of them with high risk factors, are difficult to engage effectively in a health promotion strategy. The inner city also has a higher proportion of residents living a subsistence lifestyle, who are resistant to traditional health educational approaches to stopping smoking or altering their diet. I am impressed by Tunstall-Pedoe's development of a means of calculating cardiovascular risk.' This is of great potential use: even without seeing patients doctors can begin to establish a database from the records and to identify the high risk group. More attainable local targets for this district might be to record risk factors in a high percentage of cases and to use this database to
evaluate interventions. Is this pragmatic or have I overestimated the task? ANDREW IHARRIS Lainbeth, Southwark, and 1cwtsham l'amily Health Services Authority, London SEI 7NT 1 'l'unstall-Pedoe H. Coronary heart disease. BRH 1991;303: 701-4. (21 September.) 2 World Health Organisation Europeani Collaborative (;routp. Multifactorial trial in the prevFention of coronary heart disease. 1. Recruitment and initial fitadings. Fur leartj 1980;1:73-80. 3 MIRFIT Research Group. Multiple risk factor interventiolt trial: risk factor changes anid mortality results. JAMA 1982;248: 1465-77. 4 Shaper AG, Pocock SJ, Walker M, Phillips AM, Whitehead TP, Mlacfarlane PW. Risk factors for ischaemic heart discase: the prospective phase of the British regional heart study. J E;pidemiotl Community Health 1985;39:197-209. 5 'I'unstall-Pedoe H. The Dundee coronar) risk-disk for ntanagement of changc in risk factors. BMJ 1991;303:744-7. (28
September.)
AUTHOR'S reply,-I do not claim infallibility in predicting trends in mortalitv from coronary heart disease. In the words of St Paul, "We know in part, and we prophesy in part." Ten years ago a school of thought at the Office of Population Censuses and Surveys held that cardiovascular mortality in England and Wales had been stable for 20 years and would continue so for the next 20. I challenged it on the grounds that what America does Britain repeats half heartedly 10 years later. I was wrong. The rate of decline is now as great in England and Wales. If we use other English speaking countries as our role models there is no sign of their declines bottoming out for coronary heart disease, even where all cause mortality, as in the United States, may be levelling off. Having started near the top, we have a long way down to go. Andrew Harris enumerates some of the frustrations and disappointments of the multifactorial trials of prevention of coronary heart disease, in which differences between intervention and control groups can be difficult to achieve; both, however, are affected by national trends, which can result in low attack rates in the control group, as occurred in the multiple risk factor intervention trial.' Not all studies show a long lead time. Some have shown a fairly rapid change in the incidence of coronary heart disease after change in risk factors, and that the primary risk factors do seem to matter in those with evidence of coronary heart disease; the Belgian heart disease prevention study is an example of both.2 Although trends in mortality in women may occasionally diverge from those in men, on the whole there is a good correlation and common targets are sensible. Harris might shed some of his pessimism if he looked at the United States, which has gross inequalities in wealth and provision of health services. It is ethnically heterogeneous, and there is considerable population mobility. These factors have not prevented it from experiencing a large and continuing decline in mortality from coronary heart disease despite the problems of identifying and counselling high risk subjects in inner city
populations. Harris questions the appropriate use of the Dundee coronary risk-disk.' It can certainly be used, as he suggests, for classifying patients from their records, but in this respect it is rubbing shoulders with other systems.4 Feedback from the increasing numbers of users confirms that its main virtues are in showing to patients directly on its analogue scales, firstly, the input of their risk factors; secondly, the impact of these on their ranking in the "queue" for coronary heart disease; and, thirdly, how they may, if they wish, change their ranking through changing their risk factors. It is much easier to show these with the disk than with a microcomputer, although a software version for IBM compatible computers is available. In commenting on the disk G H Hall and W T Hamilton suggested that measures of absolute risk are more motivational6; experience in the United BMJ
VOLUME 303
7 DECEMBER 1991
