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