The Wall Street Journal - May 6, 1996

The story further suggests that it was possible in 1987 to predict with confidence the ultimate course of this nation's AIDS epidemic -- predict it with such utter confidence, in fact, that one could dismiss as negligible the potential threat to tens of millions of Americans. What colossal irresponsibility that would have been, and yet your story suggests it would have been the proper course.

Obviously, in 1987 there were groups at particularly high risk for HIV infection, and any policy of prevention would have to take that seriously. But those at highest risk are neither readily distinguishable from the rest of the public nor hermetically sealed off from them. Moreover, there was already evidence from abroad of how HIV can spread from the highest risk groups to the public at large -- trends that continue to be seen in many countries today where heterosexual contact is responsible for the overwhelming majority of HIV transmissions. It is hard to conceive, in light of these circumstances, any responsible policy that does not embrace the broadest public as well as the groups at highest risk.

It seems likely, in fact, that the policy of broad public education adopted by the government has been an important factor in reducing the spread of HIV to a wider cross section of Americans. Although your story concedes that these efforts brought about major changes in people's sexual behavior, it never seems to occur to you that such changes may go a long way to account for the fact that "rates of new HIV infections appear to be declining from their peak in the mid-1980s," as the article itself points out.

There is actually good news to report about HIV prevention. The epidemic is stabilizing overall, and we are even reporting declines in AIDS incidence in some groups, including those initially at highest risk, such as older gay and bisexual men and injection drug users in some parts of the country. We certainly agree that more could have, and can, be done to reach these high-risk groups. As long as we report new infections, things could be done better.

As you noted in your article, a number of factors historically have made targeting direct prevention messages to those at greatest risk difficult. Even now, confronting the issues associated with preventing HIV among gay and bisexual men and injection drug users is challenging. Indeed, HIV prevention is challenging for all groups, because it makes us confront issues with which many people are uncomfortable. But we are making progress.

David Satcher, M.D. Director Centers for Disease Control and Prevention

Helene D. Gayle, M.D. Director National Center for HIV, STD and TB Prevention Atlanta

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Your seriously flawed article rewrote history. I want to set the record straight. In 1987, we could not know or predict with absolute certainty who was or would be at risk for HIV infection. The virus had already made significant inroads in the gay community. We had indications that it could spread easily to other groups. We knew that certain behaviors -- unprotected sex with multiple partners, primarily -- put people at risk. And we knew that certain biologic factors -- infection with another sexually transmitted disease -- also put people at risk. Those behavioral and biologic factors were not then and are not now limited to men who have sex with men.

Further, we knew that, world-wide, the virus was spreading predominantly among heterosexuals. In this context, we made the decision to deliver messages about HIV and AIDS to the broad public, to educate all Americans about the virus and what each person could do to prevent infection. That was the right decision, and it still is. We know that as each generation of young Americans comes of age they face an epidemic not unlike the generation before them. Prevention messages cannot be delivered only once. We must continue to educate all our children about HIV/AIDS to protect them from infection and early death.

At the same time, we must also deliver tailored messages for the groups at highest risk for infection. In 1987, every message -- even a general education message -- about HIV/AIDS was developed and delivered in defiance of the Reagan Administration's Domestic Policy Council. Despite this nearly insurmountable obstacle, we were able to get prevention messages out to those who needed them. But we were not able to do all we wanted, and all we knew was needed, for some populations, including gay and bisexual men and injecting drug users. Even now, there are those in Congress and elsewhere who oppose targeted, direct, lifesaving prevention messages.

Collectively, we must summon the will to put aside personal ideology and commit ourselves to doing whatever is needed to vanquish HIV. We must agree that any American who dies of AIDS is one who need not have. We must accept that we as a society bear the responsibility for ensuring that not one more needless infection or death occurs. It was the right thing to do in 1987. It is still the right thing to do.

C. Everett Koop, M.D. Surgeon General, 1981-1989 Bethesda, Md.

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Kudos to Amanda Bennett and Anita Sharpe for their outstanding article. Clearly, as you noted, the risks of transmitting the AIDS virus in the U.S. through the most common forms of heterosexual intercourse under most circumstances have been overstated by public health officials, health education programs and the media. Last year, I tried to explain this in my graduate course on lifestyle and disease at a large midwestern university by presenting data on the odds of transmitting HIV through coitus. Several students expressed outrage that I would characterize the risk as small. Some said I was "sending the wrong message," claiming that what I was saying couldn't possibly be true given all they had previously heard about AIDS. After they told my former colleague who specializes in AIDS education about my "blasphemy," she told me that I shouldn't teach about things I don't know about.

"Politically correct" propaganda about AIDS as an equal opportunity disease may have succeeded in convincing many Americans to support the funding of AIDS education activities for a wide variety of audiences. However, the reality of AIDS is that it is not and has never been an equal opportunity disease. Emphasizing depictions in the media of white, middle-class heterosexuals as persons at significant risk of AIDS did little to prevent blacks and Hispanics of low socio-economic status from becoming afflicted at disproportionate rates.

Sending the message that coitus presents a significant risk (in the absence of genital bleeding or lesions) has served to downplay the far greater risks of anal intercourse and of injecting drugs with syringes previously used by others. Thus there has been insufficient emphasis on AIDS prevention efforts targeted to the needs of people who find high-risk activities appealing and too much emphasis on promoting avoidance of low-risk, "unprotected" sexual contact.

Tragically, this has left us with widespread paranoia among middle-class heterosexuals along with numerous deaths that could have been averted among men who have sex with men, injecting drug users, their sexual partners, and their children. Anyone who really cares about preventing needless deaths should carefully consider your bold, perspicuous article.

William M. London Director of Public Health American Council on Science and Health New York

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As you show, the campaign to "democratize" AIDS arose from the perceived necessity of keeping the support of the public. As the epidemic progressed it became obvious that HIV was rarely if ever transmitted by the mere contact of the genital organs, but required access to the blood stream. In this context the wall of the rectum has proved to be an avenue and the wall of the vagina a barrier to the bloodstream. Semen carries to the blood whatever micro-organisms it may contain. Hepatitis B, Cytomegalovirus and HIV are introduced by this route.

Human beings are not supposed to have semen in the blood, and the immune system produces antibodies to its various constituents. Antibodies produced to combat the foreign white blood cells may attack the recipient's own white blood cells, a condition called auto-immunity, which can cause an immune-system crisis. Women do not ordinarily get semen antibodies. The gross abnormality of anal copulation should be clearly stated in AIDS education. But it is not. Young people are told instead that HIV is transmitted by "sexual intercourse."

Michael B. Flanagan, M.D. Carmel, Calif.

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Amanda Bennett and Anita Sharpe should be nominated for the Pulitzer Prize for their outstanding reporting. The government's fear campaign has not only siphoned precious medical research away from life-threatening diseases and viruses that affect all Americans, but has also effectively worked to further repress our already uptight puritanical society.

It took great courage for you to publish this story.

Gerald Celente Rhinebeck, N.Y.

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