representative) sample of the general population in Europe or the US will contain an equal number of males and females, but neither HIV infection nor AIDS is prevalent among the general population in the developed world. Like syphilis, gonorrhoea, and hepatitis B, HIV is prevalent among subsets of the population that happen to be made up mainly of men. A random sample of males would thus contain only males. Duesberg said that HIV infection does follow Farr’s law because the incidence of HIV is in the general population (Farr’s law predicts an increase in the epidemic curve followed by an even more rapid descent). However, AIDS does not seem to affect the general population in the developed world. Whether Farr’s law is applicable to chronic diseases such as TB or AIDS may be questioned. In any case, Coutinho presented convincing evidence that both AIDS and HIV have followed Farr’s law within the risk group (homosexual men).5 Duesberg’s last argument was that HIV did not fulfil Koch’s postulates. That HIV can be isolated in every AIDS case fulfils the first postulate. The second postulate requires that HIV is not isolated in any other disease and that, as Evans4added in 1973, virus-specific antibody appears after onset of illness. As Duesberg pointed out, many individuals positive for HIV and antibody to the virus have no clinical signs of immunodeficiency or AIDS-defining illnesses. Miedema argued that this postulate could be fulfilled when AIDS was defined as a functional immunodeficiency but accepted that it could not with the clinical definition of AIDS. There is no convincing evidence that AIDS occurs in the absence of HIV, except in the case of Kaposi’s sarcoma, where there is the possibility that the tumour may be caused by a different faeces-derived agent. Coutinho presented the best data to support HIV as a cause of AIDS: the Amsterdam cohort studies have shown that within 90 months of follow-up no AID S-defming illness has occurred among 655 HIV seronegatives, 30 cases of AIDS defining illnesses have occurred among 110 seroconverters after virus transmission, and 97 cases of AIDS have occurred among 370 individuals HIV seropositive at entry to the study. But is an HIV infection sufficient to cause AIDS? This question concerns Koch’s third postulate, which has not been fulfilled by HIV but has for another primate lentivirus (SIV) that uses the same CD4 receptor as HIV. Montagnier, referred to the experiments of Desrosiers at the New England Primate Center that virus derived from a single molecule of the complete genome of SIV causes AIDS in rhesus macaques. Although AIDS has developed in man after a single inoculation with a minuscule amount of blood containing HIV, it has not done so in any of the laboratory workers accidentally infected with purified HIV. Duesberg’s final point was that AIDS was not caused by HIV but by recreational drugs used by a subset of homosexual men. However, Coutinho presented evidence that there were no significant differences in AIDS progression rates among HIV-infected individuals belonging to different AIDS risk groups (homosexual men, intravenous drug users and haemophiliacs) after correction for age. On the basis of careful analysis of risk factors for disease progression among HIV seroconverters and seropositives,6 CoutiÍlho concluded that HIV was necessary and sufficient to cause AIDS, but Montagnier did not exclude the possibility that other co-factors, such as not
1. Duesberg PH. Human immunodeficiency virus and acquired immunodeficiency syndrome: correlation but not causation. Proc Natl Acad Sci USA 1989; 86: 755-64. F, Tersmette M, Lier van L. AIDS pathogenesis: a dynamic interaction between HIV and the immune system. Immunol Today
1990; 11,8: 293-97.
L, et al. Introduction of human T lymphotropic virus homosexual community in Amsterdam. Genitourin Med 1986; 62: 38-43. 4. Evans AS. Causation and disease: the Henk-Koch postulates revisited. 3. Coutinho RA,
Human Retrovirus Laboratory, University of Amsterdam
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mycoplasma proteins might act as superantigens.
lymphadenopathy associated virus or (LAV/HTLV-III) into the male
5. Evans AS. Causation and disease: a chronical journey. Am J Epidemiol 1978; 108: 249-58. 6. Griensven van GJP, Vroome de EMM, Wolf de F, Goudsmit J, Roos M, Coutinho RA. Risk factors for progression of human immunodeficiency virus (HIV) infection among seroconverted
seropositive homosexual men. Am J Epidemiol 1990; 132,2: 203-10.
Noticeboard GMC remedy for poor performance The General Medical Council has approved a draft consultation on proposals for dealing with doctors whose professional performance is seriously deficient, a group against which they can at present take no action. The GMC has powers to deal with doctors whose fitness to practise is seriously impaired by ill-health, those convicted of a criminal offence, or those guilty of serious professional misconduct. The serious professional misconduct charge has to be specific and clearly defmed. The hearing has to be conducted very much in the way a case would be heard in a court of law. And a verdict cannot be interpreted to mean that the doctor is generally incompetent. The new proposals are intended to be remedial and to cover not only standards of professional knowledge and skill but also attitudes towards patients and colleagues. All four broad stages in the proposed performance procedures will include lay participation. At the first stage, the GMC preliminary screener will, with expert help if necessary, decide whether the case should proceed to the assessment of performance stage; a decision not to proceed would require the agreement of a lay screener. Assessment of performance-by review of records, third-party inquiries, and extended interview with the doctor-will be done by at least two medically qualified specialists and a lay person. The third stage will consist of counselling, retraining, and reassessment, to be followed by further counselling and retraining if required. A doctor who refuses to undergo assessment would be referred to an assessment referral panel, which could impose a condition on the doctor’s registration (ie, a requirement to undergo assessment within a set time) if they deemed the refusal unjustified. Doctors appearing before the panel would be entitled to legal representation. The fourth stage, referral to a GMC professional committee, may take place when a doctor refuses to accept or does not comply with the assessor’s recommendations, does not comply with the referral panel’s condition, or does not improve despite counselling and retraining. The proposal is that, to maintain the position of the medical profession as a self-regulated profession, the GMC should bear the costs of screening, assessment, and referral panel or performance committee hearings. At current prices the annual retention fee of 80 would have to increase by [,8to 10. The GMC is discussing with the departments of health the possibility of government funds for retraining and counselling for doctors in NHS practice. It is inviting comments on the suggestions that NHS doctors contribute to these costs and that doctors in the private sector bear the full costs of retraining. Parliamentary time for a change in the Medical Act will be sought probably in early 1993. According to the GMC implementation of the proposals would be the biggest change in the way that the medical profession is regulated since the inception of the Council in 1858. paper