CDC-Funded HIV Testing Services Outcomes and Social Determinants of Health in Ending the HIV Epidemic in the U.S. Jurisdictions

We performed an ecological analysis to examine associations between CDC-funded HIV testing services outcomes and social determinants of health (SDOH) among Ending the HIV Epidemic in the U.S. jurisdictions. Using National HIV Prevention Program Monitoring & Evaluation (2020) and American Community Survey (2016-2020) data, we ran robust Poisson models (adjusted for race/ethnicity). In healthcare settings, a 10% absolute increase in percentage without health insurance was associated with a 40% lower prevalence of newly diagnosed positivity (aPR = 0.60, 95% CI: 0.43-0.83); a $5,000 increase in median household income (aPR = 1.04, 95% CI: 1.03-1.06) and a 10% absolute increase in percentage unemployed (aPR = 1.80, 95% CI: 1.31-2.46) were associated with 4% and 80%, respectively, higher prevalence of percentage linked to HIV medical care within 30 days of diagnosis (i.e., linkage). In non-healthcare settings, a 10% absolute increase in percentage with less than high school diploma (aPR = 0.53, 95% CI: 0.29-0.96) was associated with a 47% lower prevalence of newly diagnosed positivity, whereas a 10% absolute increase in percentage without health insurance (aPR = 1.92, 95% CI: 1.29-2.88) was associated with a 92% higher prevalence of newly diagnosed positivity; a 10% absolute increase in percentage with less than high school diploma was associated with a 35% lower prevalence of linkage (aPR = 0.65, 95% CI: 0.43-0.97). Addressing SDOH in HIV prevention programs will play an important role in ending the HIV epidemic.

CDC-Funded HIV Testing and Undiagnosed HIV Infection in Ending the HIV Epidemic in the U.S. Jurisdictions

BACKGROUND

Approximately 13% of persons with HIV (PWH) are unaware of their status. To help end HIV, it is important to understand the relationship between the rates of HIV testing and undiagnosed HIV infection.

SETTING

Ending the HIV in the U.S. (EHE) jurisdictions.

METHODS

Using 2021 data from the National HIV Surveillance System and the National HIV Prevention Program Monitoring and Evaluation system, we calculated estimated rates of undiagnosed HIV infections per 100,000 population and rates of CDC-funded HIV tests per 1,000 population. We assessed the association between the two rates using Spearman's rank correlation. We also calculated a rank difference between the two rates for each EHE jurisdiction to help identify jurisdictions with greater unfilled needs for HIV testing.

RESULTS

Overall, CDC-funded HIV tests per 1,000 population were positively associated with estimated rate of undiagnosed HIV infection per 100,000 population (rho=0.55, p<0.001). EHE jurisdictions with the greatest magnitude of negative rank differences (i.e., higher undiagnosed HIV infection per 100,000 population and lower CDC-funded HIV tests per 1,000 population) were Prince George's County, MD; Mecklenburg County, NC; Hudson County, NJ; Bronx County, NY, and Hamilton County, OH.

CONCLUSIONS

In general, CDC-funded HIV testing is being conducted in jurisdictions with the greatest needs. However, we also found large discrepancies between CDC-funded HIV testing and undiagnosed HIV infection rates for some jurisdictions. These jurisdictions may want to identify barriers to their HIV testing services and expand their programs to ensure that all PWH in their jurisdictions are diagnosed.

HIV Diagnoses Through Partner Services in the United States in 2019 and Opportunities for Improvement

Background:

HIV Partner Services (HIV PS) is an effective strategy for diagnosing HIV infection. Sex/needle-sharing partners of individuals diagnosed with HIV are notified about potential exposure and offered HIV testing and other services. We assessed the HIV PS contribution to HIV diagnoses in the U.S. and assessed priority areas for improvements.

Methods:

National HIV Monitoring and Evaluation Partner Services and case surveillance data reported to the Centers for Disease Control and Prevention for 2019 were used for this analysis. The percentage of all new diagnoses that HIV PS programs reported are described nationally and by state. Linkage to HIV medical care among newly diagnosed partners is described. Potential increases in diagnosing HIV infection are assessed by HIV PS step to identify priority areas for improvement.

Results:

HIV PS contributed 1,214/35,164 (3.5%) of all diagnoses nationally in 2019, and contributions ranged 0-31.8% by state. Of partners tested with non-missing data, 22.7% were newly diagnosed. An estimated 1,692 new partner diagnoses were lost during HIV PS steps. Steps resulting in the highest losses included index patients not being interviewed, partners not being tested for HIV, and index patients not being located. Seventy-two percent of partners newly diagnosed with HIV were linked to HIV medical care.

Conclusions:

HIV PS is an effective strategy for diagnosing HIV, and a high percent of sex/needle-sharing partners were newly diagnosed with HIV. Expanded HIV PS in some states and targeted improvements in HIV PS steps can enhance the contribution of HIV PS toward achieving national goals.

HIV Partner Services in 2019 resulted in 1,214 diagnoses (3.5% of diagnoses in the United States) with 22.7% new positivity among partners without prior diagnosis. Areas for improvement are identified.

HIV Testing Services Outcomes in CDC-Funded Health Departments During COVID-19

BACKGROUND

Organizations offering HIV prevention services have reported interruptions during the COVID-19 pandemic. The national extent of these interruptions and their public health impact remain largely unexplored.

METHODS

Using data from 60 state and local health departments, we compared HIV testing services outcomes in calendar years 2019 and 2020, including the number of Centers for Disease Control and Prevention (CDC)-funded HIV tests conducted, the percentage of persons with newly diagnosed HIV infection (ie, HIV positivity), and the percentage linked to HIV medical care within 30 days after new diagnoses (ie, linkage to care) using χ2 and robust Poisson models. We also assessed the independent associations between the pandemic period (ie, March-December 2020) and the number of COVID-19 cases with monthly HIV testing services outcomes using multivariable robust Poisson models.

RESULTS

There was a 46.0% (P < 0.001) reduction in the number of CDC-funded HIV tests conducted in 2020 (n = 1,255,895) compared with 2019 (n = 2,324,421). Although there were fewer persons with newly diagnosed HIV in 2020 (n = 5581 vs. n = 7739 in 2019), HIV positivity was greater in 2020 (0.4% vs. 0.3% in 2019; adjusted prevalence ratio [aPR] = 1.33, 95% confidence interval [CI]: 1.05 to 1.69). When adjusting for the monthly number of COVID-19 cases, the pandemic period was associated with a 56% reduction in the number of monthly CDC-funded HIV tests (adjusted rate ratio = 0.44, 95% CI: 0.37 to 0.52) but 28% higher monthly HIV positivity (aPR = 1.28 95% CI: 1.16 to 1.41) and 10% higher linkage to care (aPR = 1.10, 95% CI: 1.02 to 1.18).

DISCUSSION

Despite increased HIV positivity, a drastic reduction in the number of CDC-funded HIV tests was observed in 2020, affecting the ability to identify persons with newly diagnosed HIV. CDC and health departments will need to expand testing strategies to cover tests not conducted in 2020 while adapting to the continuing pandemic.A visual abstract is available for this article at: http://links.lww.com/QAI/B941.

Estimating Gains in HIV Testing by Expanding HIV Screening at Routine Checkups

Objectives. To estimate gains in the prevalence of individuals who had ever been tested for HIV overall and by subpopulations from increases in the percentage of persons who had a routine checkup and were tested. Methods. We used data from the 2019 Behavioral Risk Factor Surveillance System to determine the prevalence of individuals who were ever tested for HIV and the prevalence of missed opportunities for HIV testing among those never tested in the United States. We assessed the effect of absolute percentage increases in having ever been tested among those who had a past-year routine checkup on increasing the overall prevalence of having ever been tested. Results. In 2019, 49.5% of US adults had ever been tested for HIV; 34.5% had a missed opportunity. A 50% increase in testing at routine checkups would increase the prevalence of having ever been tested to 84.0%. Increases in the prevalence of having ever been tested (≥ 85%) was highest among persons aged 35 to 54 years, Black persons, persons who were female at birth, persons with health insurance, and persons reporting HIV risk behaviors. Conclusions. Fully incorporating HIV screening into primary care would greatly increase the proportion of US adults who have been tested for HIV. Public Health Implications. Continued efforts to promote HIV testing, including implementing routine screening in clinical settings, will help ensure that all US adults know their HIV status.

Factors Associated with State Variation in Mortality Among Persons Living with Diagnosed HIV Infection

In the United States, the all-cause mortality rate among persons living with diagnosed HIV infection (PLWH) is almost twice as high as among the general population. We aimed to identify amendable factors that state public health programs can influence to reduce mortality among PLWH. Using generalized estimating equations (GEE), we estimated age-group-specific models (24-34, 35-54, ≥ 55 years) to assess the association between state-level mortality rates among PLWH during 2010-2014 (National HIV Surveillance System) and amendable factors (percentage of Ryan White HIV/AIDS Program (RWHAP) clients with viral suppression, percentage of residents with healthcare coverage, state-enacted anti-discrimination laws index) while controlling for sociodemographic nonamendable factors. Controlling for nonamendable factors, states with 5% higher viral suppression among RWHAP clients had a 3-5% lower mortality rates across all age groups [adjusted Risk Ratio (aRR): 0.95, 95% Confidence Interval (CI): 0.92-0.99 for 24-34 years, aRR: 0.97, 95%CI: 0.94-0.99 for 35-54 years, aRR: 0.96, 95%CI: 0.94-0.99 for ≥ 55 years]; states with 5% higher health care coverage had 4-11% lower mortality rate among older age groups (aRR: 0.96, 95%CI: 0.93-0.99 for 34-54 years; aRR: 0.89, 95%CI: 0.81-0.97 for ≥ 55 years); and having laws that address one additional area of anti-discrimination was associated with a 2-3% lower mortality rate among older age groups (aRR: 0.98, 95%CI: 0.95-1.00 for 34-54 years; aRR: 0.97, 95%CI: 0.94-0.99 for ≥ 55 years). The mortality rate among PLWH was lower in states with higher levels of residents with healthcare coverage, anti-discrimination laws, and viral suppression among RWHAP clients. States can influence these factors through programs and policies.

HIV Testing, Access to HIV-Related Services, and Late-Stage HIV Diagnoses Across US States, 2013-2016

Objectives. To examine state-level factors associated with late-stage HIV diagnoses in the United States.Methods. We examined state-level factors associated with late-stage diagnoses by estimating negative binomial regression models. We used 2013 to 2016 data from the National HIV Surveillance System (late-stage diagnoses), the Behavioral Risk Factor Surveillance System (HIV testing), and the American Community Survey (sociodemographics).Results. Among individuals 25 to 44 years old, a 5% increase in the percentage of the state population tested for HIV in the preceding 12 months was associated with a 3% decrease in late-stage diagnoses. Among both individuals 25 to 44 years of age and those aged 45 years and older, a 5% increase in the percentage of the population living in a rural area was associated with a 2% to 3% increase in late-stage diagnoses.Conclusions. Increasing HIV testing may lower late-stage HIV diagnoses among younger individuals. Increasing HIV-related services may benefit both younger and older people in rural areas.

Evaluation of an HIV prevention intervention for women living with HIV

It is estimated that 23% of the adults and adolescents living with HIV in the United States are female. The Division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention (CDC) funds evidence-based interventions (EBIs) to reduce HIV risk behaviors, including HIV prevention programs for people living with HIV and their partners. While EBIs have been shown to be effective in controlled research environments, there are limited data on intervention implementation in real-world settings. Women Involved in Life Learning from Other Women (WILLOW) is a four-session small-group intervention that targets heterosexual women aged 18-50 who are living with HIV. This evaluation assessed changes in participants' HIV knowledge, attitudes, beliefs and risk behaviors. A repeated measures design was used to collect participant risk behaviors at baseline, and again at three and six months post-intervention. Changes in attitudes, beliefs, and risk behaviors were assessed using generalized estimating equations. After participation in WILLOW, participants reported increased HIV knowledge, attitudes and beliefs, being more supportive of condom use, and reduced prevalence of HIV risk behaviors. Findings suggest that the WILLOW intervention can be successfully delivered by community-based organizations to reduce HIV risk behaviors among members of this high-risk population.

Evaluating a Culturally Tailored HIV Risk Reduction Intervention Among Hispanic Women Delivered in a Real-World Setting by Community Agency Personnel

PURPOSE

To evaluate the effectiveness of Salud, Educación, Prevención, y Autocuidad/Health, Education, Prevention and Self-care (SEPA) to increase human immunodeficiency virus (HIV)/sexually transmitted infections (STI) prevention behaviors for Hispanic women delivered in a real-world setting.

DESIGN

Randomized controlled trial.

SETTING

Participants were recruited from the Miami Refugee Center, the Florida Department of Health, and public locations in Miami.

PARTICIPANTS

Three hundred twenty Hispanic women.

INTERVENTION

The SEPA is a culturally tailored intervention developed to address HIV/STI risk behaviors among Hispanic women. The SEPA intervention consisted of three 2.5 hour sessions per week conducted with small groups. The SEPA sessions consisted of group discussions, role playing, negotiation skills, partner communication, and skills building as part of the methodology.

MEASURES

Acculturation, HIV/STI risk behaviors, HIV knowledge, partner communication, intimate partner violence, drug/alcohol use, condom use.

ANALYSIS

Differences at baseline by group were assessed using Wilcoxon rank sum test, χ², and a negative-binomial model. Changes in dependent variables, compared to baseline, were analyzed in separate models. Log-binomial models and negative binomial models were used for dichotomous and count/rate-type dependent variables.

RESULTS

Significant outcome improvements were observed in the SEPA group at 6 and 12 months follow-up. The adjusted prevalence of any condom use was 30% and 37% higher at each follow-up. The adjusted prevalence of answering 10/12 HIV knowledge questions correctly rose by 57% and 63% at each follow-up. Intimate partner violence was significantly lower at each subsequent time point (62% and 41% of baseline). Moderate depressive symptoms were reduced to 50% and 42%, getting drunk was reduced to 20% and 30%, and condom use self-efficacy was significantly higher (84% and 96%).

CONCLUSION

The SEPA intervention reduced HIV/STI risk-related behaviors when delivered in a real-world setting. The results suggest that SEPA can be implemented in various settings to reach Hispanic women, and that SEPA could reach large numbers of women in an efficient, cost-effective way.

Characteristics of community health organizations and decision-makers considering the adoption of motivational interviewing

Research related to the adoption of comparative effectiveness research (CER) in mental health practice is limited. This study explores the factors that influence decisions to adopt motivational interviewing (MI)-an evidence-based practice (EBP) grounded in CER-among decision-makers (n = 311) in community health organizations (n = 92). Descriptive analyses focus on organization and decision-maker characteristics and processes that may influence the decision to adopt an EBP, including demographics, structure and operations, readiness, attitudes, barriers, and facilitators. Within-group agreement is examined to determine the degree to which participants within each organization gave similar responses. Results show characteristics differed according to type of organization (community health versus community behavioral health) and position (directors versus staff). Within-group agreement was also influenced by position. These findings indicate different strategies may be needed to best disseminate CER to the two groups.

Reduced sexual risk behaviors among people living with HIV: Results from the Healthy Relationships Outcome Monitoring Project

In 2006, the Centers for Disease Control and Prevention funded seven community-based organizations (CBOs) to conduct outcome monitoring of Healthy Relationships. Healthy Relationships is an evidence-based behavioral intervention for people living with HIV. Demographic and sexual risk behaviors recalled by participants with a time referent of the past 90 days were collected over a 17-month project period using a repeated measures design. Data were collected at baseline, and at 3 and 6 months after the intervention. Generalized estimating equations were used to assess the changes in sexual risk behaviors after participation in Healthy Relationships. Our findings show that participants (n = 474) in the outcome monitoring project reported decreased sexual risk behaviors over time, such as fewer number of partners (RR = 0.55; 95% CI 0.41-0.73, P < 0.001) and any unprotected sex events (OR = 0.44; 95% CI 0.36-0.54, P < 0.001) at 6 months after the intervention. Additionally, this project demonstrates that CBOs can successfully collect and report longitudinal outcome monitoring data.

Equine West Nile encephalitis, United States

After the 1999 outbreak of West Nile (WN) encephalitis in New York horses, a case definition was developed that specified the clinical signs, coupled with laboratory test results, required to classify cases of WN encephalitis in equines as either probable or confirmed. In 2000, 60 horses from seven states met the criteria for a confirmed case. The cumulative experience from clinical observations and diagnostic testing during the 1999 and 2000 outbreaks of WN encephalitis in horses will contribute to further refinement of diagnostic criteria.

Effects of countercurrent scalding and postscald spray on the bacteriologic profile of raw chicken carcasses

In June and September 1988, the USDA Food Safety and Inspection Service sampled raw chicken carcasses at a federally inspected slaughter establishment in Puerto Rico to determine the effects of changing the scalding equipment on bacterial contents of raw poultry products. The scalding equipment was changed to a countercurrent configuration, with a postscald hot-water rinse cabinet that sprayed carcasses as they exited the scalder. Analysis of 250 carcass-rinse samples collected at preevisceration, prechill, and postchill sites over 7 days indicated that carcasses had mean aerobe plate counts of log(10)3.73 before evisceration, 3.18 before chilling, and 2.87 after chilling; Enterobacteriaceae counts of log(10)2.70 before evisceration, 2.25 before chilling, and 1.56 after chilling; and Escherichia coli counts of log(10)2.09 before evisceration, 1.61 before chilling, and 0.89 after chilling. Salmonellae were found on 24% of the carcasses before evisceration, on 28% before chilling, and on 49% after chilling. Although bacterial count reductions were significant at all 3 sites, the proportion of carcasses contaminated with salmonellae in this study was higher at the postchill than prechill site (49 vs 28%). This no doubt was caused by cross-contamination in the chiller. These percentages indicated that although simple scalder changes contributed substantially to the improvement of the bacterial quality of chicken carcasses, additional interventions in the chilling process (such as chlorination of chill water) are important to control cross-contamination and to preserve the positive effects obtained by the scalder changes.

Effects of chlorination of chill water on the bacteriologic profile of raw chicken carcasses and giblets

In March 1989, the USDA Food Safety and Inspection Service sampled raw chicken carcasses and giblets at a federally inspected slaughter establishment in Puerto Rico to determine the effects of adding chlorine to carcass and giblet chill water on bacterial contents of raw poultry products. Over four 8-hour workdays, 200 carcass rinse samples were collected at 3 sites in the establishment; 39 giblet rinse samples were collected at 1 site. Analyses of the carcass rinse samples indicated that carcasses had average aerobe plate counts of log10 3.20 before chilling and 2.51 after chilling; Enterobacteriaceae counts of log10 2.57 before chilling and 1.75 after chilling; and Escherichia coli counts of log10 2.04 before chilling and 1.20 after chilling. Salmonellae were found on 43% of the carcasses before chilling and on 46% after chilling. Analyses of the giblet and neck rinse samples indicated that raw giblets and necks after chilling had average aerobe plate count of log10 3.49, Enterobacteriaceae count of log10 2.57, and E coli count of log10 1.06. Salmonellae were found on 12% of the giblets and necks sampled. Results compared favorably with giblet and neck rinse sample results obtained during a baseline sampling study in November and December 1987. The baseline results indicated aerobe plate count of log10 3.72; Enterobacteriaceae count of log10 2.90; E coli count of log10 1.14; and salmonellae on 69% of the giblets and necks sampled. Placing raw chicken carcasses in chlorinated chill water reduced aerobe, Enterobacteriaceae, and E coli plate counts. Prevalence of carcasses with salmonellae remained nearly the same.(ABSTRACT TRUNCATED AT 250 WORDS)

Profile of selected bacterial counts and Salmonella prevalence on raw poultry in a poultry slaughter establishment

The USDA Food Safety and Inspection Service determined populations of bacteria on poultry during processing at a slaughter plant in Puerto Rico in November and December 1987. The plant was selected because of its management's willingness to support important changes in equipment and processing procedures. The plant was representative of modern slaughter facilities. Eight-hundred samples were collected over 20 consecutive 8-hour days of operation from 5 sites in the processing plant. Results indicated that slaughter, dressing, and chilling practices significantly decreased the bacterial contamination on poultry carcasses, as determined by counts of aerobic bacteria, Enterobacteriaceae, and Escherichia coli. Salmonella was not enumerated; rather, it was determined to be present or absent by culturing almost the entire rinse. The prevalence of Salmonella in the study decreased during evisceration, then increased during immersion chilling.

A survey of doctorates by thesis among general practitioners in the British Isles from 1973 to 1988

Doctors who were general practitioners in the period 1973-88 and had written a successful MD or PhD thesis were identified. Of 96 doctorates, 64 were MDs and 32 PhDs. Fourteen doctors had obtained their MD before becoming general practitioners and the remaining 50 after becoming general practitioners. Twenty of the 64 doctors were full time or part time members of a university department of general practice; six of these were professors. In this 16 year study the mean annual number of MDs written by doctors while in general practice was three, compared with five in the previous 15 years. Of the PhDs, 11 were obtained before starting a medical course, six during the pre-clinical period, three after qualifying but before entry into general practice and 12 after entry into general practice. Ninety two per cent of the 50 doctors who obtained their MDs while in general practice and 84% of all the doctors with MDs continued to do research afterwards. Further research was carried out by 81% of doctors with a PhD. The best way of producing good researchers in general practice is to encourage doctors to accept the challenge of writing a PhD or an MD thesis. This study has shown that writing such a thesis encourages rather than discourages a doctor to undertake further research.

A purely mechanical theory of muscular contraction

A simple mathematic model is constructed for the cross-bridge dynamics that govern muscular contraction, based on ideas introduced by Huxley and Simmons. The model differs from earlier ones in that it is based on distributions over time rather than displacement and uses a sharp disengagement rule. The constitutive functions of the model are set using classical experimental results and its predictions for the length-step experiment of Ford, Huxley, and Simmons are examined.

Medical researchers in general practice

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Bordetella pertussis isolation in general practice: 1977-79 whooping cough epidemic in West Glamorgan

Some of the factors influencing the isolation rate of Bordetella pertussis during a whooping cough epidemic in West Glamorgan, Wales, are reported. The organism was isolated from 39% of patients with clinical whooping cough, pernasal swabbing being much more successful than cough plates. Isolation rates were increased in the non-immunized, particularly in the first year of life. Erythromycin and co-trimoxazole significantly reduced the isolation rate of B. pertussis but this did not occur with penicillin. In this study 20% of patients were culture positive 6 weeks after the onset of their infection. It is suggested that the Department of Health and Social Security recommendation of a minimum period of three weeks exclusion of children from school is inadequate. During the epidemic, the proportion of strains of B. pertussis containing antigen 2 more than doubled.

A five-year study of influenza in families. Joint Public Health Laboratory Service/Royal College of General Practitioners working group

A five year collaborative study of influenza in volunteer families from 1973-78 covered a period in which there were outbreaks every year but no major epidemics of influenza. Volunteers over the age of 15 years were bled before and after each of the five winters, and virus isolation was attempted from as many as possible when they reported episodes of illness. Children under 15 in the volunteer families were also swabbed when they were ill. Although most families experienced one or more attacks by influenza viruses, there was little transmission within families.

Whooping cough in nursery school children

This paper describes an outbreak of whooping cough in a nursery school during a large epidemic in West Glamorgan. Explosive outbreaks of whooping cough occurred in nursery schools in the area when the majority of children had not been vaccinated. It is recommended that the period of quarantine for whooping cough should be four weeks.

Validation of sources of pertussis immunisation data

In this paper we describe the validation of three sources of immunisation data in a study of whooping cough in West Glamorgan. The least reliable source was that of the general practitioners and the best was that of the parents, but the area health authority source should be used in future studies provided that sufficient time is allowed for the relevant information to reach the computer.

Urinary MHPG levels and tricyclic antidepressant drug selection. A preliminary communication on improved drug selection in clinical practice

The 24-hour urinary 3-methoxy-4-hydroxyphenylethyleneglycol (MHPG) output was used as the basis for selection of tricyclic antidepressant drug therapy for the depressed patient population treated by one psychiatrist over a period of ten months in a psychiatric clinic. Use of MHPG output level as the criterion for drug selection resulted in significantly better clinical results than had been obtained previously by the same psychiatrist using more traditional selection methods on a similar depressed patient population. A correlation was noted between patients' pretreatment MHPG output levels and three symptoms of depression (guilt, agitation, and diurnal variation) as measured on the Hamilton Rating Scale for Depression.

A randomized controlled trial of aspirin in the prevention of early mortality in myocardial infarction

A randomized controlled trial is reported in which a single dose of aspirin (300 mg) was given to patients with myocardial infarction on first contact with a general practitioner. A total of 1,705 patients with confirmed infarction were studied, and survival ascertained. There was no evidence of benefit from the aspirin.

The changing pattern of general practitioner drug prescribing in the National Health Service in England from 1970 to 1975

We describe the changing pattern of general practitioner prescribing in the National Health Service in England between 1970 and 1975.The percentage increase in items of prescriptions had increased 10 times as much as the percentage increase in the population in the same period. One of the reasons given is that there may be a growing tendency to give a prescription when it would be better to give advice.The evidence seems to support other findings that the profession responds much more widely to reports on the good effects of a drug than it does to its adverse effects.

General practitioners and their staff

We describe the practices and staff of a random sample of 158 doctors. There has been a significant increase in ancillary staff since the Doctors' Charter of 1966. The study showed that there was no economy in staff as the number of doctors in a practice increased. In the selection of receptionists, doctors preferred married women over 35 with children, and were in favour of good personal qualities rather than good academic attainments. However, a high standard of work is important as well as a good understanding of human behaviour.

The assessment by doctors of the effectiveness of drugs

There was no significant difference between the assessments by two groups of randomly-selected general practitioners on the effectiveness of the drug treatment for 19 common clinical conditions. The treatment of simple iron deficiency anaemia was considered the most effective and gained the highest consensus. Least effective, but not matched by worst consensus, was the drug treatment for obesity. The most widespread disagreement among the practitioners was for the effectiveness of the drug treatment of gastroenteritis.

Aspects of the use of lithium for the non-psychiatrist

Lithium carbonate is commonly used in psychiatry, particularly in the management of the manic-depressive syndrome. It is also being increasingly tried in a variety of physical disorders. This essentially practical article summarizes important non-psychiatric aspects of the use of the drug, including its less common actions. Contra-indications to the use of lithium are discussed, and the management of lithium intoxication is outlined.