Living dangerously

Making life safer encourages us to live more dangerously. That's the message (well known to risk analysts) of the article by Michael Cassell and colleagues in this week's BMJ (p 605). Risk compensation has been seen with sunscreens (encouraging more time in the sun) and seatbelts (bad driving), and is now a growing problem among people at risk of HIV. This “horse trading” in risk is most frighteningly illustrated by reports of people relying on pre-exposure or post-exposure use of antiretrovirals to protect them from infection.

Unless we link prevention with initiatives to change behaviour, as has been done successfully in Uganda and elsewhere, drug resistant HIV will continue to spread, say Cassell et al. Efforts to contain drug resistance include intensive laboratory monitoring of antiretroviral treatment. But this is beyond the means of health systems in developing countries—the very places where prolonging the usefulness of cheaper first line drugs is most critical. Serena Koenig and colleagues argue that this lack of resource for monitoring antiretroviral treatment should not delay us making the drugs more widely available (p 602). Instead they recommend focusing efforts on meticulous adherence to treatment, which has been shown to be the most important factor in delaying drug resistance.

Can public-private collaboration help? Puneet Dewan and colleagues conclude that it has been effective in improving control of tuberculosis in India (p 574). But Angus Wallace (p 614) is deeply troubled by what he sees happening with private provision in the NHS. He gives a measured account, recognising some of the benefits of this “much needed development” but then describing a catalogue of problems: inadequate supervision of junior surgeons in independent sector treatment centres (ISTCs); lack of training opportunities in routine surgical procedures in the NHS; the artificial divide between the two, aimed to prevent NHS surgeons working in ISTCs—all pushed through for political reasons. The news this week of the departure of Nigel Crisp, the chief executive of the NHS (p 565), must raise questions about the current direction and speed of travel of the NHS reforms.

Meanwhile, some things to divert you on bmj.com. There's learning, laughter, and inspiration from this year's TED (technology, entertainment, design) conference in Monterey, California. The world's “thought leaders” gathered to explore the future we will create, and Tony Delamothe was there to hear and report back (http://bmj.com/cgi/content/full/332/7540/DC1). You can also now see which content is freely available online (research articles) and should find it easier to get to articles published “online first” (ahead of print)—currently virtually all our research articles. Finally, we have listed of all of you who served as peer reviewers for us in 2005 (http://bmj.com/advice/reviewers.shtml). This is one way to thank you for undertaking what must often seem like a thankless task, but without which the BMJ could not survive.