Alessandro Sinicco and colleagues from the University of Turin studied the progression of the disease in 285 patients recruited between September 1985 and January 1995. They found that patients whose blood showed signs of infection after December 1989 had both a higher probability of decline in the immune system cells affected by the virus (CD4 cells) and a faster progression to AIDS than patients who had become infected before this date.

Although all patients had similar immunological status at entry into the study, CD4 cell counts started differing at early stages of the infection. The authors say that the first twelve months after infection are critical for the future course of HIV disease, and that repeated monitoring is needed during this period to identify those patients who would benefit from early drug treatment.

The emergence of more virulent strains of HIV, they conclude, may be responsible for the aggressive course of HIV in people who were recently infected.

Contact: Dr Alessandro Sinicco

University of Turin

Tel: 00 39 11 439 3980
Fax: 00 39 11 776 1757

Allyson Pollock and colleagues investigated 17 first-wave PFI hospital schemes, accounting for 5% of all acute beds in England and almost a quarter in Scotland. PFI schemes are no local issue, they say; they indicate the likely configuration of hospital services nationally if current policies continue. Dr. Pollock and colleagues forecast bed reductions of around 26% for England and 30% for Scotland over the next five years. They also carried out a detailed study of three hospital PFIs in three areas - Lothian, Calderdale, and Bromley - where plans are at an advanced stage.

Under the PFI the public sector buys services, rather than assets. NHS Trusts invite private contractors to meet an output specification' which states not the number of beds needed, but the expected level of clinical activity. Once a private sector consortium has been selected, there is scope for further bed reductions.

The data available publicly are incomplete either because Trusts have not carried out the necessary analyses or because the business plans have not been published during the consultation process, say the authors. Bed numbers and patient activity in all three areas studied in detail are out of line with national and local trends. Patient throughput on each site would have to increase to unrealistic levels over the next five years to cope with the proposed reductions in beds.

"Health authorities are not making adequate provision for need" say the authors. "There is no evidence of input from primary care, social services, or public health, let alone from hospital specialists. These schemes involve the sale of public assets and commitment of public funds for many years to come, so the information should be publicly available."

Contact: Dr. Allyson Pollock

St. George's Hospital Medical School

The Bentham Unit was set up in February 1994 to provide rapid assessment and transfer for male mentally disordered remand prisoners in the former North West Thames Regional Health Authority. Tim Weaver and colleagues at Imperial College School of Medicine at St.. Mary's Hospital, London, and the University of Kent at Canterbury, looked at the time lapse between remand, assessment and transfer. They found that intervention by the unit coincided with a significant decrease in the time that prisoners spent in prison and a doubling of the number of patients referred for assessment and those transferred to NHS care.

"The role of similar units with special skills in forensic psychiatry should be further assessed", say the authors. "Early transfer out of prison will deliver more timely treatment and enable local providers to engage with patients before they are finally relocated."

Contact: Tim Weaver

Imperial College School of St. Medicine at St. Mary's London

Tel: 0181 846 6568
Fax: 0181 846 6555

In a letter, Tom McClintock, lecturer in forensic psychiatry at Crozier Terrace Medium Secure Unit, Hackney Hospital, London, calls on a new government to consider the long term effects of its criminal justice policy and set up a royal commission to look at the treatment of offenders.

Since 1992 the prison population in England and Wales has increased by half to its current level of almost 60,000. Both Conservative and Labour seem committed to increasing custodial sentences despite an inevitable worsening of problems in prisons, he says.

"Prisons are damaging and violent places, with large numbers of inmates who are mentally ill, have personality disorders, or are inadequate. The triad of popular ignorance, demands for the control of crime, and the presence of violent crime go well together in prompting harsher sentences",says the author. With both of the two major political parties not wishing to be seen to be soft' on crime, research about the causes of crime is being ignored.

Contact: Tom McClintock

Hackney Hospital
London

Tel: 0181 919 8562
Fax: 0181 985 0278

A series of letters on the crisis in London's mental health service calls for better integration of community and hospital mental health teams.

Avon Health Authority serves nearly one million people, registered with 450 general practitioners in 147 practices. The authors, from the Department of Public Health Medicine, Avon Health Authority, Bristol, studied how well the objectives of locality commissioning had been met between April 1994 and November 1996. The majority of GPs surveyed believed that it had led to a more constructive relationship between themselves and the Health Authority, that there was useful development between practices in the locality, and that they felt more powerful about having a say on what services were available for their patients.

Although there were no restrictions as to what services could be worked in, primary care and community services were affected more than hospital services, with the emphasis on primary mental health and chronic disease care, guidelines, and outpatient access. The financial cost of GPs participation was small, although some contributed unpaid time to the schemes.

Lead general practitioners were frustrated by the lack of clear management framework and political impetus, and said that they would like to have more influence. But the vast majority of lead GPs enjoyed locality commissioning and believed that the benefits outweighed the costs.

Contact: Dr. Christine Hine

Avon Health Authority
Bristol

Tel: 0117 976 6648
Fax: 0117 976 6601

The GPs thought that the targets for the reduction of cancer were most likely to be achieved, and the reduction of suicides the least likely. Obstacles to pursuing the targets at a practice level were excessive workload, too ambitious targets, unrealistic time scales, patient apathy, and lack of funds.

"Effecting mass change in behaviour that is a risk to health and influencing factors such as personal motivation and socioeconomic conditions are beyond the remit of the primary healthcare team and possibly even beyond national campaigns" say the authors.

Contact: Dr. Philip Cheung