1414
Changing case-definition for AIDS SIR,-A new definition of AIDS has been announced by the US Centers for Disease Control (CDC) (Nov 7, p 1151) and is described in your Nov 13 editorial. By registering as AIDS cases all women with invasive carcinoma of the cervix who are seropositive to HIV, CDC will increase the cumulative prevalence since 1982 in the USA by more than 50% (from 250 000 to over 400 000). AIDS will cease overnight to be a mainly male disease. The expanded total will presume that women and their infants are at equal or greater risk by heterosexual transmission of HIV. Underlying this presumption is the reality that high-risk behaviour and risk groups for cancer of the cervix, and for infantile AIDS, coincide with those for transmission of HIV, genital herpes, and all other sexually transmissible infections, but this is not admitted and, for understandable reasons of confidentiality and management, will not be apparent. The expansion in enumeration will not stop there. The CDC will also register as AIDS cases all those with tuberculosis and recurrent bacterial pneumonia who happen to be seropositive for HIV, together with all symptom-free adolescents and adults who have a prescribed fall in CD4 T-lymphocytes as if, in the hundreds of thousands of patients in the wider world, these tests were feasible, accurate, and excluded all other diagnoses. This decision will lead to an immediate expansion in enumeration internationally because it coincides with the tenth revision’ of the International Classification of Disease (ICD), renaming AIDS as HIV disease and raising to 28 in Section B20-24 the list of formerly independent nosocomial entities that will now be classified as AIDS in individuals who are seropositive to HIV and in many who are not, irrespectively of CD4 counts. Section B21.0-9 includes 6 specified and 3 unspecified malignant diseases, to which cancer of the cervix can now conveniently be added. There is no way of showing that HIV causes cancer of the cervix or any other malignant disease, or that cancer is caused even indirectly by loss of CD4 T-lymphocytes. The logic of these decisions taken, according to your editorial, at the behest of AIDS activists and experts, is that reclassification of these other diseases as AIDS is in accordance with data emerging from surveillance. This conclusion is very doubtful, even in New York2°3 and urban California,4 and is certainly not applicable in the UK. The new definition is justified as a means of securing support under national programmes for the ethnic minorities in the USA who are majorities in the third world. Thus patients with AIDS, in addition to being uniquely exempt from contact-tracing and partnerprotection, have priorities and resources not available to those with tuberculosis, malnutrition, and many other diseases of gross deprivation. The new logistic for health services is that AIDS establishments and budgets (including activists and experts), already vastly greater than for any other disease, will also multiply. In the UK, the cost so far is over [,700 million. Further increase will inevitably be at the expense of individuals with these and other diseases who do not happen to have antibodies to antigens from HIV-1. If, as seems likely, the rest of the world must follow the US CDC in this latest demand, we should think now about what comes next. Shall any woman with cervicitis, any man with urethritis or prostatitis or genitourinary cancer, or any cancer (ICD B21.7-9), or perhaps any severe infection (B20.8-9), or any other unspecified or wasting or multiple disease (B22) who happens to be seropositive to HIV, and in many who are not, be diagnosed and registered as AIDS and treated for HIV disease because those in the business can expand their nosocomial domain across any diagnostic code and
scruple? Glenavon, Clifton Down, Bristol BS8 3HT, UK
GORDON T. STEWART
1. International Classification of Diseases, 10th ed. Geneva: WHO, 1992. 2. AIDS Surveillance updates, 1982-92. New York City, Department of Health, 1992. 3. Stoneburner RL, Chiasson MA, Weisfuse IB, Thomas PA. The epidemic of AIDS and HIV-1 infection among heterosexuals in New York City. AIDS 1990; 4: 99-106. 4. California morbidity 1984-92 biweekly reports. State of California: Health and Welfare Agency, 1992.
SiR,—I think all clinicians concerned with the management of
patients with HIV infection are agreed that the case definition for AIDS is unsatisfactory, the principal reason being that many patients have much HIV-related morbidity but do not fulfil the definition of AIDS. The proposed change by the Centers for Disease Control to define AIDS as all HIV patients with a CD4 lymphocyte count of less than 0-2 x 109/1 is a step in the opposite direction. It will not be long before clinicians will complain that their patients are given an AIDS diagnosis without any substantial morbidity. I suggest that AIDS as a definition should be scrapped altogether because it has outlived its useful purpose. I think the time has come for clinicians to speak wholly in terms of HIV infection and its
complications. King’s Cross Hospital,
A.
Dundee DD3 8EA, UK
J. FRANCE
Distinction awards and Cochrane SIR,-As a student of coincidence and a believer in destiny, I was reassured by your Nov 7 editorial about Cochrane’s legacy but saddened by Malcolm Dean’s report about distinction awards (Nov 7, p1150). It
seems
that the system for distinction awards is under threat.
Opted-out hospitals and the Department of Health are the main adversaries. Critics point to the secrecy of the allocation process, the endemic bias in their distribution, and the vagueness of the criteria. There is a recognition that despite many attempts at change, the "main planks of the system remain in place". Dean concludes, and I agree, that "the long-term decline of the system looks inevitable". What should be the next step? It may be opportune to apply some of Cochrane’s principles to the system. I believe that the secrecy of the allocation process or the bias in the distribution are not great drawbacks. There are two major difficulties. First is the vagueness of the criteria required for distinction awards. Specific, defined criteria for the exercise will probably resolve all difficulties. The great advantage of the present system is that it is decided by the profession. Most consultants would also choose that performance-related pay should also be decided by the profession. Second, prejudice is emotional and should have no place in deciding distinction awards or performance-related pay. Award-holders should not have the ability to veto an award; this is wholly unacceptable. More than four years ago, I read Archie Cochrane’s self-written obituary, and I shall always remember his concluding sentence: "He was a man with severe porphyria who smoked too much and was without the consolation of a wife, a religious belief or a merit award-but he didn’t do so badly". Your editorial was of an objective man with social principles. A centre has been established in Oxford to promote his objectivity. Archie Cochrane should have been given a distinction award. If his objectivity could be applied to distinction awards or performance-related pay, the success of the system would be assured. Microbiology Department, Raigmore Hospital,
D. O HO-YEN
Inverness IV2 3UJ, UK 1. Cochrane AL.
Obituary. BMJ 1988; 297:
63.
Prohibition of alcohol in India SIR,—The trend that Ahbay and Rani Bang (Sept 19, p 720) record in Gadchiroli district is likely to follow in other places. I report the outcome of prohibition on alcohol in the state of Gujarat. Liquor is defined in the Prohibition Act as "spirits, denatured spirits, wine, beer, toddy and liquids consisting of or containing alcohol and any other intoxicating substance which the state government may by notification in the official gazette declare to be liquor for the purpose of this Act".* The rule is applicable to perfumed spirits and medicines containing alcohol above a certain level. It also prevents the entry to the state of anyone who is intoxicated. A licence is issued to individuals on health grounds if recommended by the district medical superintendant. Permits are
Changing case-definition for AIDS SIR,-A new definition of AIDS has been announced by the US Centers for Disease Control (CDC) (Nov 7, p 1151) and is described in your Nov 13 editorial. By registering as AIDS cases all women with invasive carcinoma of the cervix who are seropositive to HIV, CDC will increase the cumulative prevalence since 1982 in the USA by more than 50% (from 250 000 to over 400 000). AIDS will cease overnight to be a mainly male disease. The expanded total will presume that women and their infants are at equal or greater risk by heterosexual transmission of HIV. Underlying this presumption is the reality that high-risk behaviour and risk groups for cancer of the cervix, and for infantile AIDS, coincide with those for transmission of HIV, genital herpes, and all other sexually transmissible infections, but this is not admitted and, for understandable reasons of confidentiality and management, will not be apparent. The expansion in enumeration will not stop there. The CDC will also register as AIDS cases all those with tuberculosis and recurrent bacterial pneumonia who happen to be seropositive for HIV, together with all symptom-free adolescents and adults who have a prescribed fall in CD4 T-lymphocytes as if, in the hundreds of thousands of patients in the wider world, these tests were feasible, accurate, and excluded all other diagnoses. This decision will lead to an immediate expansion in enumeration internationally because it coincides with the tenth revision’ of the International Classification of Disease (ICD), renaming AIDS as HIV disease and raising to 28 in Section B20-24 the list of formerly independent nosocomial entities that will now be classified as AIDS in individuals who are seropositive to HIV and in many who are not, irrespectively of CD4 counts. Section B21.0-9 includes 6 specified and 3 unspecified malignant diseases, to which cancer of the cervix can now conveniently be added. There is no way of showing that HIV causes cancer of the cervix or any other malignant disease, or that cancer is caused even indirectly by loss of CD4 T-lymphocytes. The logic of these decisions taken, according to your editorial, at the behest of AIDS activists and experts, is that reclassification of these other diseases as AIDS is in accordance with data emerging from surveillance. This conclusion is very doubtful, even in New York2°3 and urban California,4 and is certainly not applicable in the UK. The new definition is justified as a means of securing support under national programmes for the ethnic minorities in the USA who are majorities in the third world. Thus patients with AIDS, in addition to being uniquely exempt from contact-tracing and partnerprotection, have priorities and resources not available to those with tuberculosis, malnutrition, and many other diseases of gross deprivation. The new logistic for health services is that AIDS establishments and budgets (including activists and experts), already vastly greater than for any other disease, will also multiply. In the UK, the cost so far is over [,700 million. Further increase will inevitably be at the expense of individuals with these and other diseases who do not happen to have antibodies to antigens from HIV-1. If, as seems likely, the rest of the world must follow the US CDC in this latest demand, we should think now about what comes next. Shall any woman with cervicitis, any man with urethritis or prostatitis or genitourinary cancer, or any cancer (ICD B21.7-9), or perhaps any severe infection (B20.8-9), or any other unspecified or wasting or multiple disease (B22) who happens to be seropositive to HIV, and in many who are not, be diagnosed and registered as AIDS and treated for HIV disease because those in the business can expand their nosocomial domain across any diagnostic code and
scruple? Glenavon, Clifton Down, Bristol BS8 3HT, UK
GORDON T. STEWART
1. International Classification of Diseases, 10th ed. Geneva: WHO, 1992. 2. AIDS Surveillance updates, 1982-92. New York City, Department of Health, 1992. 3. Stoneburner RL, Chiasson MA, Weisfuse IB, Thomas PA. The epidemic of AIDS and HIV-1 infection among heterosexuals in New York City. AIDS 1990; 4: 99-106. 4. California morbidity 1984-92 biweekly reports. State of California: Health and Welfare Agency, 1992.
SiR,—I think all clinicians concerned with the management of
patients with HIV infection are agreed that the case definition for AIDS is unsatisfactory, the principal reason being that many patients have much HIV-related morbidity but do not fulfil the definition of AIDS. The proposed change by the Centers for Disease Control to define AIDS as all HIV patients with a CD4 lymphocyte count of less than 0-2 x 109/1 is a step in the opposite direction. It will not be long before clinicians will complain that their patients are given an AIDS diagnosis without any substantial morbidity. I suggest that AIDS as a definition should be scrapped altogether because it has outlived its useful purpose. I think the time has come for clinicians to speak wholly in terms of HIV infection and its
complications. King’s Cross Hospital,
A.
Dundee DD3 8EA, UK
J. FRANCE
Distinction awards and Cochrane SIR,-As a student of coincidence and a believer in destiny, I was reassured by your Nov 7 editorial about Cochrane’s legacy but saddened by Malcolm Dean’s report about distinction awards (Nov 7, p1150). It
seems
that the system for distinction awards is under threat.
Opted-out hospitals and the Department of Health are the main adversaries. Critics point to the secrecy of the allocation process, the endemic bias in their distribution, and the vagueness of the criteria. There is a recognition that despite many attempts at change, the "main planks of the system remain in place". Dean concludes, and I agree, that "the long-term decline of the system looks inevitable". What should be the next step? It may be opportune to apply some of Cochrane’s principles to the system. I believe that the secrecy of the allocation process or the bias in the distribution are not great drawbacks. There are two major difficulties. First is the vagueness of the criteria required for distinction awards. Specific, defined criteria for the exercise will probably resolve all difficulties. The great advantage of the present system is that it is decided by the profession. Most consultants would also choose that performance-related pay should also be decided by the profession. Second, prejudice is emotional and should have no place in deciding distinction awards or performance-related pay. Award-holders should not have the ability to veto an award; this is wholly unacceptable. More than four years ago, I read Archie Cochrane’s self-written obituary, and I shall always remember his concluding sentence: "He was a man with severe porphyria who smoked too much and was without the consolation of a wife, a religious belief or a merit award-but he didn’t do so badly". Your editorial was of an objective man with social principles. A centre has been established in Oxford to promote his objectivity. Archie Cochrane should have been given a distinction award. If his objectivity could be applied to distinction awards or performance-related pay, the success of the system would be assured. Microbiology Department, Raigmore Hospital,
D. O HO-YEN
Inverness IV2 3UJ, UK 1. Cochrane AL.
Obituary. BMJ 1988; 297:
63.
Prohibition of alcohol in India SIR,—The trend that Ahbay and Rani Bang (Sept 19, p 720) record in Gadchiroli district is likely to follow in other places. I report the outcome of prohibition on alcohol in the state of Gujarat. Liquor is defined in the Prohibition Act as "spirits, denatured spirits, wine, beer, toddy and liquids consisting of or containing alcohol and any other intoxicating substance which the state government may by notification in the official gazette declare to be liquor for the purpose of this Act".* The rule is applicable to perfumed spirits and medicines containing alcohol above a certain level. It also prevents the entry to the state of anyone who is intoxicated. A licence is issued to individuals on health grounds if recommended by the district medical superintendant. Permits are
