took a study of 2600 seafarers working with Belgian shipping companies. Of 336 screening tests, 15 (4-5%) yielded a positive result. This is extremely high, the average prevalence of HIV infection among Belgians being 0062%.3 Thus, like prisoners, seafarers require management, treatment, education, and information is tailored to their circumstances. They need to be targeted as they pose complex logistical problems with regard to decreasing their risk. J DHAR D J TIMMINS

University Department of Genitouirinary Medicine, Royal Liverpool Hospital, Liverpool L7 8XP I Smith R. Rcforming prisons. BM7

1991;303:737. (28

Septemher.) 2 Vuksanovic P, Goethe WHG, Burchard HU, Schmitz H, Backhaus A, Koeppen M. Seamen and AIDS. TravelMedicine

International 1988;6:18-9. 3 Van Damme J, Van Damme P'. Incidence of HIV in a seafarers' population. In: Consensus statement from the consultation on

AIDS and seafarers. Geneva: WHO Global Programme on AIDS, 1989:1-3.

Monkey business over AIDS vaccine SIR, -I was interested in the observation reported initially by Stott et al' and discussed by Robin Weiss2 that uninfected human T lymphocytes treated with formaldehyde conferred protection from infection with simian immunodeficiency virus (SIV) in macaques. I wish to suggest an explanation for this phenomenon. For some years we have been investigating the interesting finding that antibody directed against not only virus but also host cell antigens will inhibit release of virus from cells infected with the virus.'- Possibly, therefore, the release of SIV was reduced by immune interaction between host cell determinants on the human T lymphocytes and antibody stimulated in the macaques by inoculation of these human (as opposed to simian) cells; it would be interesting and quite straightforward to examine this possibility by laboratory experimentation. On a tangential issue, I agree that Stott's research group should not be criticised for initially excluding this control study. It is perfectly valid science to seek an effect and thereafter validate the effect by appropriately controlled experimentation; if, on the other hand, the initial result is negative no further experimentation is required, thereby economising on time, finance, and unnecessary experimentation on animal species.

virus to their offspring, or of their uninfected children being left motherless at an early age, "our job is to.... help her to enjoy the experience of motherhood as fully and as long as possible."' We cannot agree. Immediate sympathy for an infertile couple is natural. But treatment aimed at relieving them of the suffering of childlessness must not ignore potential suffering of the as yet unborn child, whose welfare must be given first priority. Indeed, such concern is a requirement of the Human Fertilisation and Embryology Act with respect to in vitro fertilisation, though the principle is the same for any infertility treatment.2 Recent epidemiological studies show that, as the mean time from initial infection with HIV-I to the development of AIDS is 10 years,' survival into the child's adolescent years might be considered to be optimistic. In addition, an estimated one woman in seven with HIV infection transmits the virus to her fetus in utero; for each of these women and her partner and child there will be the intense psychological as well as physical consequences. The prognosis for children infected in utero is poor, most dying before the age of 5 years, and the parents would be subjected to both the potential and the actual devastating trauma in addition to coping with the problems of the mother's illness. Would parents be able to cope with the knowledge of having infected their child created from their self centred desire to have a family "before it is too late"? A couple require counselling, certainly, but not simply so that they "can make [that is, exercise] an informed choice." We must surely consider our own responsibilities as medical practitioners in such cases and not merely act unthinkingly as technicians and commissioned providers of treatment. D J CAHILL P G WARDLE M G R HULL

University of Bristol, Department of Obstetrics and Gynaecology, St Michael's Hospital, Bristol BS2 8EG EE

O'SULLIVAN

Barrow Hospital, Barrow Gurnev, Bristol BS19 3SG I Huengsberg M, Bradbeer CS, Welch J. Routine testing for HIV at fertility clinics. BMJ 1991;303:645. (14 September.) 2 Human Fertilisation and Embryology Authority. Code ofpractice: assessing clients, donors and the welfare of the child. London: HFEA, 1991:3.10. 3 Moss AR, Bachetti P. Natural history of HIV infection. AIDS

1989;3:55-6 1.

GORDON R B SKINNER

Department of Medical Microbiology, Division for the Studv of Infection, University of Birmingham, Birmingham B 15 2TrTF

Counselling patients before an HIV test

1 Stott EJ, Kitchin PA, Page M, Flanagan B, Taffs LF, Chain WI, et al. Anti-cell antibiotics in macaques. Nature 1991353:393. 2 Weiss R. Mionkey business over AIDS vaccine. B.1MJ 1991;303: 872. (12 October.) 3 Skinner GRB, Mushi EZ, Whitney JE. Immune inhibition of virus release from herpex simplex virus infected cells. Intire'irologv 1976;6:296-308. 4 Shariff D, Hallworth J, I)esprbasques Mi, Buchan A, Skinner GRB. Immune inhibition of irus release from herpes simplex virus-infected cells by human sera. Intervirology 1988;29: 125-32. 5 Shariff DM, Davies J, l)esperbasqucs M, Billstrom Mt, Geerligs JH, W'elling GW, et al. Irnmtmune inhibition of virus released from human and non-human cells by antibody to viral and host cell determinants. Interrvirology 1991;32:28-36.

Routine testing for HIV infection at fertility clinics SIR,-M Huengsberg and colleagues conclude, in the context of infertility treatment, that despite the risks of women infected with HIV transmitting the BMJ

VOLUME 303

2 NOVEMBER

1991

SIR,-In my general practice most requests for HIV testing are part of a medical examination, for life assurance. In such cases the detailed sexual history suggested by Robert Bor and colleagues' in their article on counselling patients before the test not only is inappropriate but can be an invasion of the patient's private life. Moreover, total confidentiality may be hard to maintain in general practice. Further requests for medical reports may be received and must either be answered truthfully or be left partly unanswered. I therefore find it more appropriate to tell the patient in detail about the recognised high risk behaviours. He is counselled on the other aspects of the test and, in particular, on the importance of early diagnosis if he is HIV positive. The informed patient can then make his own decision on whether to proceed with the test without necessarily having to disclose his past exploits. Of course, I make it clear that the patient is welcome to discuss the details of his personal risks if he so wishes. Records of the consultation must be kept for

medicolegal purposes whether or not the patient discloses his sexual history. CHRISTOPHER TIMMIS

Devonshire Lodge Health Centre, Pinner, Middlesex HA5 ITG I Bor R, Miller R, Johnson M. A testing time for doctors: counselling patients before an HIV test. BMJ7 1991;303:905-7. (12 October.)

SIR,-In their article on counselling patients for an HIV test Robert Bor and colleagues fail to emphasise the most important aspect-that is, screening these patients for sexually transmitted diseases.' Of the three main modes of transmissionthat is, sexual (homosexual or heterosexual), bloodborne (in haemophilic patients and drug addicts), and maternofetal (resulting in paediatric AIDS)-sexual transmission is the most common. It is therefore important that all those who seek an HIV antibody test should be screened for all sexually transmitted diseases. In a study I found that 47% of 378 patients seeking only an HIV antibody test had various sexually transmitted diseases.' Counselling about HIV and AIDS can be done anywhere, but pretest counselling should ideally be done in a medical setting. Secondly, informed consent is difficult to define. Some clinics have a checklist so that counsellors can make sure that all the information needed has been given. Other clinics follow procedures such as obtaining patients' signed consent. Byrne et al showed that 47% of patients who had signed for various surgical procedures were unaware of the exact nature of those procedures.' In my opinion it should be left to the counsellor's judgment as to what information should be given before a patient has an HIV antibody test. K C MOHANTY

St Luke's Hospital, Bradford BD5 ONA I Bor R, Miller R, Johnson M. A testing time for doctors: counselling patients before an HIV test. BMJ 1991;303:905-7.

(12 October.) 2 Mohanty KC. Sexually transmitted diseases among patients seeking HIV antibody test for AIDS. International journal of STDsandAIDS 1990;1:207-8. 3 Byrne DJ, Napier A, Cuschieri A. How informed is signed consent?BM. 1988;296:839-40.

SIR,-As the chiefmedical officer of a life insurance company and chairman of the medical committee of the Association of British Insurers may I emphasise that the industry agrees with the BMA on the importance of ensuring that any person asked to have an HIV test for life insurance is given appropriate professional counselling before the test. I would, however, take issue with Robert Bor and colleagues' statement that people who have had a negative result of a test face difficulty over future applications for life insurance because of having had the test.' The life insurance industry treats an HIV test no differently from any other medical test-for example, liver function tests or electrocardiography-in that, even though the result may be negative, it is still necessary to know why a person has had the test. If an extra premium is charged or the application is declined it will be because of the risks present, not because the person has had a test. If there are no risk factors present or the risk has passed the applicant will be accepted at standard rates. Similarly, the "worried well" and those undergoing routine screening need have no fears. A recent survey carried out jointly by the Department of Health and the Association of British Insurers into the public's perception of HIV tests showed that only three out of 1400 members of the general public might be deterred from having an HIV test because of life insurance.2

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Monkey business over AIDS vaccine.

took a study of 2600 seafarers working with Belgian shipping companies. Of 336 screening tests, 15 (4-5%) yielded a positive result. This is extremely...
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