It's estimated that 1.5 million Americans are infected with the AIDS virus but show no clinical signs of the disease. Most of these carriers are homosexual or bisexual men or persons who intravenously use illicit drugs. All carriers, no matter how healthy they appear to be, are contagious via intimate sexual contact or blood. And there's recent evidence that carriers may become more infectious with time; that is, they are increasingly able to pass on the virus to others by means of sex or blood.
A 36-page report on AIDS prepared by the surgeon general, Dr. C. Everett Koop, focuses on prevention. The report, released last October, has been widely distributed to the public. For example, Rep. Gerry Studds (D-Mass.) recently obtained 268,000 copies for mailing to all households in his district. Public Health officials are contemplating a national mailing of a smaller booklet.
In view of the widespread circulation of the surgeon general's message, it's important to determine how adequately the report handles such vital concerns as what constitutes "safe sex."
In a section headed "AIDS: You Can Protect Yourself From Infection," the surgeon general advises confirmed or likely AIDS carriers:
"If your test is positive or if you engage in high-risk activities and choose not to have a test, you should tell your sexual partner. If you jointly decide to have sex, you must protect your partner by always using a rubber (condom) during (start to finish) sexual intercourse (vagina or rectum)." Similar advice on use of condoms is addressed to those whose partners are known to carry the AIDS virus or to engage in high-risk behaviors. The report labels these recommendations as "adequate to safely protect yourself and others from infection by the AIDS virus."
The surgeon general is apparently putting his seal of "adequate protection" on intercourse, vaginal or anal, between an AIDS carrier and someone who is free of AIDS, if the carrier informs the partner of his or her carrier status and uses a condom. No warning is given about (1) condom failure, (2) the relatively high risk of receptive anal sex, and (3) the risk an AIDS-free person incurs by having intercourse with a carrier.
The surgeon general's statements on these points contrast greatly with more recent reports by other medical authorities. Dr. James J. Goedert, chief of the AIDS Working Group of the National Cancer Institute, in the May 21 issue of the New England Journal of Medicine, points out that among 18 heterosexual couples in which one parter was infected, the virus was transmitted in three cases despite the use of condoms. Dr. Goedert speculates that this failure rate may be because of slippage, which can sometimes occur even when people are reasonably conscientious.
Moreover, a May 1 report in the Journal of the American Medical Association indicates that the rate of condom tearing may be quite high with anal intercourse. Dr. Warren Winkelstein and colleagues at the University of California at Berkeley in the Jan. 16 JAMA report the results of a survey implicating receptive anal intercourse as being related to elevated risk of AIDS infection in a large group of homosexual or bisexual men.
Dr. Goedert concluded that the primary emphasis of education for AIDS carriers must be on eliminating any sexual contact with those who are known to be free of AIDS or whose AIDS status hasn't been tested. In other words, carriers should limit themselves to intimacy with another carrier; in cases of heterosexual couples carrying AIDS, birth control should be used to prevent AIDS infection of babies. (Another reason is that pregnancy may increase a carrier's own likelihood of developing AIDS.)
Dr. Theresa Crenshaw, president of the American Association of Sex Educators, Counselors and Therapists, makes an even more stringent recommendation: AIDS carriers should abstain from sex. Period. She holds these views even though she has always been a supporter of sexual expression. Dr. Crenshaw points out that intimacy between two AIDS carriers poses a danger to each of them since constant reinoculations may accelerate the disease's progress.
It's also instructive to note advice columnist Ann Landers' guidelines in an answer to AIDS carriers in a June column. After presumably consulting with medical advisers, she wrote:
"Practice safe sex. By safe sex I mean protect your partner by using condoms. One must be aware that they are not 100 percent safe. (The failure rate can be as high as 8 percent. Condoms can break and they can come off.) Oral sex is out. Anal sex is out. There can be no exposure to urine or feces from sexual partners. The AIDS virus is contained in both."
In view of the more stringent recommendations by such medical authorities as Dr. Goedert, I hope that revision of the surgeon general's guidelines is being considered. In the absence of a cure or a vaccine, one of the principal strategies for stemming the spread of AIDS will remain education designed to persuade the sexually active to adopt protective measures.
However, the usefulness of mass mailings of sex guidelines is called into question by the British experience in their recent educational drive, which included press, billboard and TV advertisements publicizing a one-page AIDS leaflet mailed to every household. As reported at the Third International Conference on AIDS, recently held in Washington, the British campaign considerably raised anxieties in the lowest risk groups and had little impact in groups with the highest rates of infection. I therefore recommend that the Public Health Service closely study the British campaign to learn from its mistakes. If such a campaign is planned, pilot tests should be done to determine the usefulness of unsolicited mailed material before the government spends large sums on mass mailings.
Shirley Petchel Damrosch is an associate professor at the University of Maryland's Center for Nursing and Health Services Research in Baltimore. She reported on a national survey on public concerns about AIDS at the recent conference.
Second Opinion is a forum for points of view on health policy issues.