180 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 8, NO.4, 1995

5 to 6 minutes and after 30 cycles one target DNA fragment infrequent to isolate either M. tuberculosis or Mycobacterium can be magnified one million times and is then detected by avium-intracellulare from blood. Since 6 of the 8 patients less sensitive methods such as hybridization with DNA were HIV-positive, the results are not unexpected. probes. While the detection level of DNA hybridization is It is interesting that 1 of the 8 patients was not immuno- 50 pg which is contained in about 10000 bacilli (the detection compromised and had no clinical feature of disseminated sensitivity of Ziehl-Neelsen staining is also 10 000 bacilli}, tuberculosis but was still positive by PCR. If this finding is using PCR it is possible to obtain a positive signal even when borne out by testing in a larger number of immunocompetent one bacterial genome is present. I patients it may offer a method for definitive diagnosis in The insertion sequence (IS) 6110 is a transposon which is patients where the site is inaccessible or where the relevant present in multiple copy numbers (varying from 1 to 15) in sample is difficult to obtain. members of the M. tuberculosis complex and has not been reported in any other mycobacterial species. However, PCR REFERENCES has been reported to give false-positive results (due to carry Saiki RK, Gelfand DH, Stoffel S, Scharf S1, Higuchi R, Horn GT, et at. over of amplicons) as well as false-negative (due to presence Primer-directed enzymatic amplification of DNA with a thermostable DNA polymerase. Science 1988;239:487-91. of inhibitory substancesj.? 2 van Soolingen D, Hermans PWM, de Haas PEW, Soli DR, van Embden 10. On chest radiography, 3 patients who were sputum Occurrence and stability of insertion sequences in Mycobacterium tuberculosis culture-positive had a cavitary lesion while 4 had a non-cavity complex strains: Evaluation of an insertion sequence dependent DNA infiltrate. None showed either miliary tuberculosis or clinical polymorphism as a tool in the epidemiology of tuberculosis. J Clin Microbial 1991 ;29:2578-86. or laboratory evidence of disseminated or extrapulmonary tuberculosis. Six were infected with HIV while the 2 not ASH OK RATTAN infected with HIV had a history of alcohol abuse. Department of Microbiology Before the AIDS era, blood cultures for mycobacteria All India Institute of Medical Sciences were rarely done but in patients with HIV infection, it is not New Delhi

(about the risks of sharing injecting equipment) and testing (for hepatitis Band HIV) for inmates over a two-week period. This HIV and prisons initiative also aimed to introduce measures to prevent the spread of infection. During this exercise, the prison was isolated with no movement of inmates. Of the 636 inmates, 66 had been released and 192 had been transferred to other prisons. Of the Taylor A, Goldberg D, Emslie J, Wrench J, Gruer L, remainder (378), 227 (60%) accepted the offer of counselling, Cameron S, Black J, Davis B, McGregor J, Follett E, with younger inmates (aged 21-29 years) accepting the offer Harvey J, Basson J, McGavigan J. (Scottish Centre for more readily. The study also indicates that of the 151 inmates Infection and Environmental Health, Ruchill Hospital, who declined counselling, many were from a part of the prison Glasgow; Forth Valley Health Board, Stirling; HIV and where injecting was known to be prevalent. Of the 227counselled, Addictions Resource Centre, Ruchill Hospital, Glasgow; 162 (71%) were tested for HIV. Seventy-six (33%) had injected Regional Virus Laboratory, Ruchill Hospital, Glasgow; drugs, 33 of them while in Glenochil. Of these, 6 refused testing, HIV Counselling Clinic, HIV and Addictions Clinical 15 were seronegative (with eight in the window period of Directorate, Ruchill Hospital, Glasgow; Health Centre, less than three months since the last high-risk exposure) and Marshill, Alloa; Forth Valley Health Board, Falkirk and 12 were seropositive. District Royal Infirmary, Major's Loan, Falkirk; Scottish There were no infected men in the 34 tested injectors Home and Health Department, St Andrew's House, (who had never injected in Glenochil) or among the tested Edinburgh; Royal Infirmary, Stirling, UK.) Outbreak of HIV non-injectors. The evidence, even on incomplete testing of the infection in a Scottish prison. BM] 1995;310:289-92. prison population showed a strong association between inmates becoming infected with HIV and injecting in Glenochil in early SUMMARY 1993. Analysis of the admission of inmates and previous test results indicate that of the 12 seropositive men, 8 transmissions The study describes the first recorded outbreak of HIV infection in a prison setting, although several other reports have definitely occurred in Glenochil in the first part of 1993. Inmates did attempt to clean their injecting equipment in prison but suggested that the sharing of drug injecting equipment (needles these were mostly ineffective. Further, given the lack of clean and syringes) have resulted in the spread of HIV in prisons. In injecting equipment, a greater proportion of inmates shared the spring of 1993, 8 symptomatic cases of hepatitis B infection injecting equipment compared to when they were outside and 2 seroconversions to HIV were detected at Glenochil Prison prison. Only 1 (a non-injector) of the 227 inmates counselled (for adult male inmates) in central Scotland. It was known that admitted to sex with another man in Glenochil. drug injecting, with the sharing of injecting equipment, was prevalent within the prison. This information led to the offer COMMENT of HIV counselling and testing to all 636 inmates who had been in Glenochil in the six-month period starting from 1 January This study has demonstrated what other reports merely 1993. The principal aim was to provide intensive counselling suggested; 1,2 that HIV and other infections can be spread SELECTED SUMMARIES 181 in prisons by inmates injecting intravenous drugs and sharing One of the major issues with regard to prevention of the their injecting equipment. Although there is some evidence spread of HIV in prison is that people are sent to prison that imprisonment may reduce the overall risk of HIV trans- for, amongst other reasons, punishment and rehabilitation mission;' spread of HIV infection could potentially occur with very clear limitations on the freedom of inmates' very rapidly among injectors in prisons, where random activities. Therefore, it becomes very difficult for prison sharing occurs due to lack of access to sterile injecting authorities to deal with illicit activities since nothing should equipment. be done that may seem to be condoning these activities or From an epidemiological perspective, it is unfortunate challenging prison authority. The authors do not discuss the that a large proportion of the inmates did not take up the wider health promotion issues arising from the outbreak in offer of counselling and testing but this is understandable this paper. Health professionals cannot ignore the high-risk given the problems associated with being tested for HIV. activities prevalent in prisons and must come up with some The evidence for an association between HIV positivity and innovative ways of reducing these. Prison authorities need injecting whilst in prison was strong, but the issue of sexual to be persuaded to adopt a pragmatic approach to these practices in Glenochil was not fully investigated. Although problems. The Scottish Ministerial Task Force report" states only one inmate admitted to sex with another man in prison; that HIV education in prisons is important and should begin it is likely that this was an underestimate. This study excluded at the time of admission of the prisoner and that 'advice on sexual intercourse between men as an important risk factor the sterilization of drug injecting equipment should also be for the outbreak of HIV infection. However, sexual activity given early in the prisoner's sentence'. between men in prisons does occur with a high probability HIV is an issue which affects everyone and every country of practising unsafe sex due to the lack of condoms. The in some way. Its spread has demanded research in all dis- study provides no information on the transmission of ciplines of medicine including molecular biology, virology, hepatitis B in the prison which was the first indication of immunology, therapeutics, epidemiology, health care, high-risk activities and the possibility of HIV transmission. sociology, psychology, social anthropology and social Certainly information on this would be important in support- services. HIV in prisons is a big challenge and strategies to ing the conclusions. prevent its spread 'could have a substantial impact on the Overall, the study appears to be a well-thought and well- reservoir of blood borne infections in the population'. 5 implemented investigation of an outbreak. The fact that it is the first such recorded outbreak of HIV in a prison adds to its importance. The information about the population REFERENCES studied is clearly described and the reasoning and data support the conclusions. I Covell RG, Frischer M, Taylor A, Goldberg D, Green S, McKeganey N, et al. Prison experience of injecting drug users in Glasgow. Drug Alcohol The study highlights issues important for public health in Depend 1993;32:9-14. the investigation of an outbreak. These include awareness 2 Carvell AL. Hart GJ. Risk behaviours for H IV infection among drug users of potential problems (the first indication of an HIV out- in prison. 8M] 1990;300:1383-4. 3 McKee KJ, Power KG. HIV/AIDS in prisons. Scott Med ! 1992;37:132-7. break was transmission of hepatitis B among inmates) and 4 Scottish Office Home and Health Department. Ministerial Task Force the resources to undertake a comprehensive investigation Report-HIV and AIDS in Scotland: Prevention the key. Edinburgh: (availability of adequately trained staff for counselling and SOHHD, 1992. 5 Gill ON, Noone A, Heptonstall J. Imprisonment, injecting drug use, and testing as well as public health doctors, epidemiologists, blood borne viruses. 8M] 1995;310:275~. prison doctors and nursing staff, and microbiologists). It also emphasizes the need for inter-agency cooperation and between different health care staff. Lastly, it shows the H. S. KOHLI importance of careful documentation: the fact that this out- Department of Public Health break has been published has contributed to the debate on University of Glasgow what should be done to develop harm reduction activities Glasgow in prison. Scotland

SUMMARY HIV-control programme in Thailand Since 1988, when very few Thais had HIV the infection has spread so rapidly that by 19934% of army recruits and 1.4% of urban women in antenatal clinics tested positive. Commercial sex workers were considered to be the main agents for Hanenberg RS, Rojanapithayakorn W, Kunasol P, heterosexual transmission. In 1985 the Thai government started Sokal DC. (Family Health International, Research a programme to enforce condom use in commercial sex. Triangle Park, North Carolina, USA; and Department of It distributed a sufficient number of condoms to protect much Communicable Disease Control, Ministry of Public Health, of the commercial sex in the country, and sanctions were Thailand.) Impact of Thailand's HIV-control programme as brought against establishments where condoms were not used indicated by the decline of sexually transmitted diseases. consistently. (There is very little prostitution outside commercial Lancet 1994;344:243-5. sex establishments.)