encourage voluntary testing and restore public confidence the Department of Health must foot the bill and pay HIV positive doctors to stay out of medicine if that is appropriate. I am lucky. I have no reason to suppose that I am HIV positive and am not in any high risk group. As things stand, if I thought that I was at risk I would keep very quiet about it and certainly not allow anyone to check my HIV status. LAURENCE COOK
Oldham, Lancashire OL4 SRT 1 Morris M. American legislation on AIDS. BMJ 1991;303:325-6. (10 August.)
Zidovudine after occupational exposure to HIV SIR,-With reference to Professor D J Jeffries's editorial on giving zidovudine after occupational exposure to HIV, we report a case of HIV seroconversion in a health care worker exposed to the
before the infecting dose of HIV. Furthermore, Professor Jeffries quotes two cases of accidental occupational needlestick exposure to HIV in which prophylaxis with zidovudine started within 45 minutes and six hours of the injury failed to protect the exposed employee. It seems unreasonable to advocate prophylaxis with zidovudine, especially when it is not without risk in itself. The clue to this course of action may lie in the comment that "there is nothing else to offer." Surely these must be the precise conditions in which caution should be exercised. We agree, however, that health care workers who have sustained such an accidental exposure should be counselled by someone who can put the risk in perspective for them. The training of occupational health professionals includes this type of counselling and assessment of risk. Because the overall infection rate after exposure to HIV is 0-31% zidovudine may be at best a placebo and at worst actually harmful.
D R TAIT
Department of Virology, D J PUDIFIN V GATHIRAM
Department of Medicine, University of Natal, PO Box 17039, Congella 4013, South Africa I M WINDSOR
Department of Serology, South African Institute for Medical Research, PO Box 1038, Johannesburg 2000, South Africa I Jeffries DJ. Zidovudine after occupational exposure to HIV. BMJ 1991;302:1349-51. (8 June.)
SIR,-Professor D J Jefferies suggests that, for health care workers who have been exposed to blood infected with HIV, "starting prophylaxis
[with zidovudine]
as soon as
BMJ
303
possible, preferably
within an hour of exposure, seems sensible." He goes on to say that "during the working week this is probably best arranged through occupational health departments in hospitals." As trainees in occupational medicine we question the validity of this advice. None of the evidence quoted shows the slightest indication that infection can be prevented as opposed to being just delayed for a few weeks, even when zidovudine is given VOLUME
7 SEPTEMBER 1991
H E KIRK M DOHERTY
Murray Royal Hospital, Perth PH2 5BH I Gunn J, Maddon A, Swinton S. Treatment needs of prisoners with psychiatric disorders. BMJ 1991;303:338-41. (10
August.) 2 Scottish Home and Health Department. Mental Health (Scotland) Act 1960: the treatment of mentally disordered inmates. Edinburgh: SHHD, 1980. (Circular No 6/1980 (criminal).)
J TAMIN
Occupational Health Department, Oldham and District General Hospital, Oldham OL I 2JH
D MENZIES D GILBERT
virus. The worker had a finger pulp injury from a lancet while attempting to obtain blood, for determination of the blood glucose concentration, from a patient whose HIV status was unknown. The health care worker started prophylaxis with zidovudine (200 mg four hourly) six hours after the injury when the patient's HIV status became known (despite our policy of administering zidovudine within one hour of any possible exposure). At this time the health care worker was shown to have had no prior exposure to HIV (that is, was HIV antibody negative) and denied any other risk factors for exposure. Three weeks after this injury the health care worker developed a mild illness characterised by lymphadenopathy, fever, diarrhoea, and malaise. A blood specimen taken at this time showed antibodies to HIV (confirmed by western blotting). We think that this case is important as seroconversion occurred after an injury that is considered to be minor; the injury was caused by a lancet, not a hollow bore needle; and seroconversion occurred after three weeks of the course of zidovudine (albeit started six hours after injury).
apparently little used informal option has been reassuring to staff in both the prison system and the NHS.2 Professor Gunn and colleagues estimate that 27% (14 of 52) of the prisoners identified as requiring hospital treatment could be managed by a local service. In practice, we found that 57% (32 of 56) of transfers from Tayside prisons were managed in a local setting. We wonder if the difference reflects diminishing inpatient resources available in local hospitals in England and Wales.
Occupational Health Department, Stepping Hill Hospital, Stockport,
Cheshire SK2 7JE G PARKER Lancaster Health Authority, Royal Lancaster Infirmary, Lancaster LAI 4RP E HUI North Manchester General Hospital,
Manchester M8 6RB I Jeffries DJ. Zidovudine after occupational exposure to HIV. BMJ 1991;302:1349-51. (8 June.)
Prisoners with psychiatric disorders SIR,-Professor John Gunn and his colleagues estimate that 3% of male prisoners in England and Wales require treatment in a mental hospital.' They reckon that of the 52 men so identified in their survey, 17 should go to special hospitals, 21 to regional secure units, and 14 to district psychiatric services. In Scotland there are no regional secure units. Options for transfer are limited to the State Hospital at Carstairs (maximum security) or local mental hospitals (low security). Since 1 February 1985 prisoners in the Tayside area, which contains three prisons and a young offenders' institution catering for up to 800 male offenders from all over Scotland, have been transferred from prison to hospital on 56 occasions. Twenty four transfers were to the State Hospital and 32 to local mental hospitals (27 to the Murray Royal Hospital, Perth, and five to local hospitals elsewhere). Altogether 49 prisoners were transferred for treatment, seven being transferred on two occasions. The 25 prisoners transferred to the Murray Royal Hospital were suffering predominantly from psychotic illnesses. The mixed sex locked admission ward to which they came has no special facilities. These transfers have become increasingly accepted by the hospital staff for several reasons. The area forensic psychiatrist, having both prison commitments and NHS beds in the Murray Royal Hospital, provides valuable continuity. Exposure of NHS nursing staff, in the prison setting, to the plight of mentally disordered inmates has engendered positive and rational attitudes towards "criminal" patients. Furthermore, being asked to cope with a slow trickle of transfers has helped to build up the confidence of staff. Finally, the ease and speed of transfer back and forth under the
SIR, - Dr John Gunn and colleagues' study into the prevalence of psychiatric disorders in prisoners is long overdue.' I would, however, like more details about the method of diagnosing personality disorder. The authors state that they used clinical criteria and believe that they identified severe disorder, but they do not break down the diagnoses further according to specific diagnoses in the ICD (ninth revision), such as predominantly sociopathic, explosive, or paranoid. A diagnosis of disorder rather than trait depends on the severity of the effect on social functioning. Tyrer et al developed the personality assessment schedule,2 which specifically addresses the issue of the severity of the disorder and can give a diagnosis of personality disorder according to the criteria of either the ICD (ninth revision) or the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R).' It also depends on a reliable informant who knows the person well giving a rating behaviour. There is also the standardised assessment of personality,4 a similar interview. I note that table II refers to the primary diagnosis. It is important to consider dual diagnoses as with personality disorders there is often a considerable overlap. Which is the primary diagnosis in someone with severe sociopathic personality disorder and appreciable substance misuse? In terms of treatment we do not treat one and not the other. DSM-III-R clearly separates personality disorder into axis II and all other psychiatric diagnoses into axis I to encourage personality disorder to be identified when psychiatric illness has been treated. JANET BRUCE
Mapperley Hospital, Nottingham NG3 6AA 1 Gunn J, Maden M, Swinton M. Treatment needs of prisoners with psychiatricdisorders. BMJ 1991;303:338-41. (10 August.) 2 Tyrer P, Alexander J, Ferguson B. Personality assessment schedule (PAS). In: Tyrer P, ed'. Personality disorders: diagnosis, management and course. Bristol: Wright, 1988. 3 American Psychiatric Association. Diagnostic and statistical manual of mental disorders, third edition, revised (DSM-III-R). Washington, DC: APA, 1987. 4 Mann AH, Jenkins R, Cutting C, Cowen PJ. rhe development and use of a standardized assessment of abnormal personality. PsvcholMed 1981;11:839-47.
AUTHOR'S REPLY,-The diagnosis of personality disorder is doubly problematic in prisoners. Informants are not available. Standardised interviews yield DSM-III-R diagnoses but avoid dependence on biographical information only by giving added weight to factors such as criminality and substance misuse. Prison studies that use such interviews find rates of personality disorder of up to 78%' and seem to sacrifice validity in the name of reliability. We aimed at describing the treatment 581
Oldham, Lancashire OL4 SRT 1 Morris M. American legislation on AIDS. BMJ 1991;303:325-6. (10 August.)
Zidovudine after occupational exposure to HIV SIR,-With reference to Professor D J Jeffries's editorial on giving zidovudine after occupational exposure to HIV, we report a case of HIV seroconversion in a health care worker exposed to the
before the infecting dose of HIV. Furthermore, Professor Jeffries quotes two cases of accidental occupational needlestick exposure to HIV in which prophylaxis with zidovudine started within 45 minutes and six hours of the injury failed to protect the exposed employee. It seems unreasonable to advocate prophylaxis with zidovudine, especially when it is not without risk in itself. The clue to this course of action may lie in the comment that "there is nothing else to offer." Surely these must be the precise conditions in which caution should be exercised. We agree, however, that health care workers who have sustained such an accidental exposure should be counselled by someone who can put the risk in perspective for them. The training of occupational health professionals includes this type of counselling and assessment of risk. Because the overall infection rate after exposure to HIV is 0-31% zidovudine may be at best a placebo and at worst actually harmful.
D R TAIT
Department of Virology, D J PUDIFIN V GATHIRAM
Department of Medicine, University of Natal, PO Box 17039, Congella 4013, South Africa I M WINDSOR
Department of Serology, South African Institute for Medical Research, PO Box 1038, Johannesburg 2000, South Africa I Jeffries DJ. Zidovudine after occupational exposure to HIV. BMJ 1991;302:1349-51. (8 June.)
SIR,-Professor D J Jefferies suggests that, for health care workers who have been exposed to blood infected with HIV, "starting prophylaxis
[with zidovudine]
as soon as
BMJ
303
possible, preferably
within an hour of exposure, seems sensible." He goes on to say that "during the working week this is probably best arranged through occupational health departments in hospitals." As trainees in occupational medicine we question the validity of this advice. None of the evidence quoted shows the slightest indication that infection can be prevented as opposed to being just delayed for a few weeks, even when zidovudine is given VOLUME
7 SEPTEMBER 1991
H E KIRK M DOHERTY
Murray Royal Hospital, Perth PH2 5BH I Gunn J, Maddon A, Swinton S. Treatment needs of prisoners with psychiatric disorders. BMJ 1991;303:338-41. (10
August.) 2 Scottish Home and Health Department. Mental Health (Scotland) Act 1960: the treatment of mentally disordered inmates. Edinburgh: SHHD, 1980. (Circular No 6/1980 (criminal).)
J TAMIN
Occupational Health Department, Oldham and District General Hospital, Oldham OL I 2JH
D MENZIES D GILBERT
virus. The worker had a finger pulp injury from a lancet while attempting to obtain blood, for determination of the blood glucose concentration, from a patient whose HIV status was unknown. The health care worker started prophylaxis with zidovudine (200 mg four hourly) six hours after the injury when the patient's HIV status became known (despite our policy of administering zidovudine within one hour of any possible exposure). At this time the health care worker was shown to have had no prior exposure to HIV (that is, was HIV antibody negative) and denied any other risk factors for exposure. Three weeks after this injury the health care worker developed a mild illness characterised by lymphadenopathy, fever, diarrhoea, and malaise. A blood specimen taken at this time showed antibodies to HIV (confirmed by western blotting). We think that this case is important as seroconversion occurred after an injury that is considered to be minor; the injury was caused by a lancet, not a hollow bore needle; and seroconversion occurred after three weeks of the course of zidovudine (albeit started six hours after injury).
apparently little used informal option has been reassuring to staff in both the prison system and the NHS.2 Professor Gunn and colleagues estimate that 27% (14 of 52) of the prisoners identified as requiring hospital treatment could be managed by a local service. In practice, we found that 57% (32 of 56) of transfers from Tayside prisons were managed in a local setting. We wonder if the difference reflects diminishing inpatient resources available in local hospitals in England and Wales.
Occupational Health Department, Stepping Hill Hospital, Stockport,
Cheshire SK2 7JE G PARKER Lancaster Health Authority, Royal Lancaster Infirmary, Lancaster LAI 4RP E HUI North Manchester General Hospital,
Manchester M8 6RB I Jeffries DJ. Zidovudine after occupational exposure to HIV. BMJ 1991;302:1349-51. (8 June.)
Prisoners with psychiatric disorders SIR,-Professor John Gunn and his colleagues estimate that 3% of male prisoners in England and Wales require treatment in a mental hospital.' They reckon that of the 52 men so identified in their survey, 17 should go to special hospitals, 21 to regional secure units, and 14 to district psychiatric services. In Scotland there are no regional secure units. Options for transfer are limited to the State Hospital at Carstairs (maximum security) or local mental hospitals (low security). Since 1 February 1985 prisoners in the Tayside area, which contains three prisons and a young offenders' institution catering for up to 800 male offenders from all over Scotland, have been transferred from prison to hospital on 56 occasions. Twenty four transfers were to the State Hospital and 32 to local mental hospitals (27 to the Murray Royal Hospital, Perth, and five to local hospitals elsewhere). Altogether 49 prisoners were transferred for treatment, seven being transferred on two occasions. The 25 prisoners transferred to the Murray Royal Hospital were suffering predominantly from psychotic illnesses. The mixed sex locked admission ward to which they came has no special facilities. These transfers have become increasingly accepted by the hospital staff for several reasons. The area forensic psychiatrist, having both prison commitments and NHS beds in the Murray Royal Hospital, provides valuable continuity. Exposure of NHS nursing staff, in the prison setting, to the plight of mentally disordered inmates has engendered positive and rational attitudes towards "criminal" patients. Furthermore, being asked to cope with a slow trickle of transfers has helped to build up the confidence of staff. Finally, the ease and speed of transfer back and forth under the
SIR, - Dr John Gunn and colleagues' study into the prevalence of psychiatric disorders in prisoners is long overdue.' I would, however, like more details about the method of diagnosing personality disorder. The authors state that they used clinical criteria and believe that they identified severe disorder, but they do not break down the diagnoses further according to specific diagnoses in the ICD (ninth revision), such as predominantly sociopathic, explosive, or paranoid. A diagnosis of disorder rather than trait depends on the severity of the effect on social functioning. Tyrer et al developed the personality assessment schedule,2 which specifically addresses the issue of the severity of the disorder and can give a diagnosis of personality disorder according to the criteria of either the ICD (ninth revision) or the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R).' It also depends on a reliable informant who knows the person well giving a rating behaviour. There is also the standardised assessment of personality,4 a similar interview. I note that table II refers to the primary diagnosis. It is important to consider dual diagnoses as with personality disorders there is often a considerable overlap. Which is the primary diagnosis in someone with severe sociopathic personality disorder and appreciable substance misuse? In terms of treatment we do not treat one and not the other. DSM-III-R clearly separates personality disorder into axis II and all other psychiatric diagnoses into axis I to encourage personality disorder to be identified when psychiatric illness has been treated. JANET BRUCE
Mapperley Hospital, Nottingham NG3 6AA 1 Gunn J, Maden M, Swinton M. Treatment needs of prisoners with psychiatricdisorders. BMJ 1991;303:338-41. (10 August.) 2 Tyrer P, Alexander J, Ferguson B. Personality assessment schedule (PAS). In: Tyrer P, ed'. Personality disorders: diagnosis, management and course. Bristol: Wright, 1988. 3 American Psychiatric Association. Diagnostic and statistical manual of mental disorders, third edition, revised (DSM-III-R). Washington, DC: APA, 1987. 4 Mann AH, Jenkins R, Cutting C, Cowen PJ. rhe development and use of a standardized assessment of abnormal personality. PsvcholMed 1981;11:839-47.
AUTHOR'S REPLY,-The diagnosis of personality disorder is doubly problematic in prisoners. Informants are not available. Standardised interviews yield DSM-III-R diagnoses but avoid dependence on biographical information only by giving added weight to factors such as criminality and substance misuse. Prison studies that use such interviews find rates of personality disorder of up to 78%' and seem to sacrifice validity in the name of reliability. We aimed at describing the treatment 581
