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To the Editor. —Diverse cellular and immune factors in sexual fluids and the coital environment have been postulated to influence the sexual transmission of HIV type 1. 1 The differences between male-to-female and female-to-male transmission that were documented recently by Padian et al 2 suggest to us that an additional coital factor, vaginal pH, could also significantly influence the sexual transmission of HIV. Free virus and/or infected lymphocytes and macrophages (principal host cells for HIV) are thought to be the infectious unit(s) transmitted during coitus. Each can be found in semen and in vaginal secretions of HIV-infected individuals. Free virus and lymphocytes are both inactivated at low pH, as illustrated in the Figure. For free virus, inactivation occurs within minutes. 3 Vaginal secretions from healthy reproductive-aged women are characteristically acidic (pH values of 3.4 to 6.0) and thus present a hostile environment for HIV particles and infected lymphocytes. For this

In Reply. —Drs Rodrigues and Garcia Moreno do not define safe sex, and therefore, their recommendations are unclear. The risk of acquisition of HIV increases with increasing number of sex partners. We should teach our children that having intercourse with multiple partners is unhealthy and also how to protect themselves if they choose to have sex. Both messages are also essential for adults. Which one is emphasized may depend on the particular clinical situation, but neither message should be excluded.

To the Editor. —We are pleased to see a feature in the medical literature addressing the fact that the right health education message may not be enough to protect women against human immunodeficiency virus (HIV) infection. 1 The issue of women's ability to perceive themselves at risk and to negotiate safer sex and the role of society's perceptions of masculinity have been discussed, particularly in the sociological and anthropological literature, for some time. 2 We would, however, like to take issue with Dr Guinan's assertion that a comprehensive program to prevent HIV infection to women should emphasize "having one lifetime partner." 1 Health education campaigns aimed at heterosexual transmission of HIV infection have often centered on recommending monogamy, particularly in Africa, or at least have presented casual sex as the main risk. We believe that this is not an accurate reflection of risk of HIV transmission to women and may cause

THE HUMAN immunodeficiency virus (HIV) epidemic has moved into the heterosexual population in the United States. This probably started in the 1970s but was making significant inroads by 1982 as determined from a backcalculation model. 1 Given the methodologic difficulties in estimating HIV incidence, trend data may give the most reliable picture of the emerging epidemic. As of March 1992, a total of 12 881 patients with the acquired immunodeficiency syndrome (AIDS) had been reported who acquired their infection through heterosexual intercourse, 5100 men and 7781 women. 2 Women have outnumbered men in the heterosexual contact transmission category in the United States since the epidemic was recognized in 1981. 3 Four-year trends in reported AIDS cases show that women accounted for an increasing proportion of total cases between 1988 (10.4%) and 1991 (12.8%) and heterosexual contact accounted for a greater proportion of female cases each year from 1988 through 1991

To the Editor. —Heterosexual transmission of HIV is decidedly in one direction, according to recent data published and distributed by the AIDS Surveillance Unit of the New York City Department of Health. Among 26985 men with AIDS reported through March 1991, a history of acquiring the infection because of intercourse with women at risk was elicited in only 11 instances.1This is in contrast to 1148 (25%) of 4640 women with AIDS who reported having sex with men at risk (the report notes that data are not tabulated on intravenous drug users who also report high-risk heterosexual contact). It is probable that the pool of high-risk men exceeds the infected female population. For example, there are 9420 reported intravenous drug-user cases among men and 2623 among women. Thus, there would be a greater chance of a woman contracting HIV from any given sexual contact with a man than vice

To the Editor. —In a partner study on HIV transmission among heterosexual couples, Padian et al 1 observed only one case (1.4%) of male-to-female transmission of HIV in their study of 72 male partners of HIV-infected women. The observed case was in a couple described as unique in that vaginal and penile bleeding during intercourse was noted. However, since nearly half (32/72) of the couples studied used condoms, the risk of transmission may have been underestimated. On the other hand, male-to-female transmission was estimated to be 17.5 times more effective than female-to-male transmission (crude OR). Apart from the fact that the 90% CI for the OR given in the article is large (3.5 to 353), and the usual 95% CI would be still larger, the crude measurement of the relative efficiency of HIV transmission in both directions may be invalid for at least one reason: the authors did not take

In Reply. —We did not attempt to examine gender-specific transmission rates by anal intercourse because we did not believe it to be a risk factor for female-to-male transmission. Anal intercourse among the uninfected male partners of infected women seems analogous to insertive anal intercourse between uninfected male partners of infected men, which poses far less risk than receptive anal intercourse.1There is no evidence that anal intercourse is prevalent in pattern II countries where bidirectional heterosexual transmission is common (areas of central, eastern, and southern Africa and in some Caribbean countries). Nevertheless, Dr Godfrey poses an interesting hypothesis: male-to-female transmission in our study could largely be attributed to anal intercourse, and once this practice is controlled for, rates of female-to-male transmission might approximate rates of male-to-female transmission. Overall, we observed that 20% of 307 female partners of infected males were infected. One hundred ninety-three (37%) of these couples practiced

To the Editor. —The study by Padian et al 1 of female-to-male transmission of human immunodeficiency virus (HIV) unfortunately did not consider specific sexual behavioral practices among the comparative cases of male-to-female transmission, even though examination of associated risk factors was said to be an objective. The only mention of anal intercourse was with regard to the one possible case of female-to-male transmission reported. The reader was left with the inference that all the comparative cases of male-to-female transmission occurred through vaginal intercourse because it was not stated otherwise. However, Dr Padian herself was the lead author in an earlier report 2 in JAMA on male-to-female transmission of HIV in which anal intercourse specifically was considered and was found to discriminate significantly between seronegative and seropositive women to the extent that women who engaged in this practice were 2.3 times more likely to acquire infection than women who did not.

To the Editor.— Because there are no data to indicate that "soldiers are more likely to lie (about homosexuality or IV drug use) than civilians," Redfield et al 1 conclude that they are telling the truth. Unfortunately, the mere absence of data to the contrary does not by itself make the opposite assertion true; if it did, science would be a much simpler thing. And yet the authors cite their observation (which is what it is) of acquired immunodeficiency syndrome (AIDS) among ten married servicemen, who claim contact with European prostitutes as their only risk factor, as evidence helping to substantiate the idea that human T-cell lymphotropic virus type III (HTLV-III) can be transmitted sexually from women to men. We are given the conclusion that "HTLV-III is a bidirectional sexually transmitted disease [ sic ]," which the authors find in "non-drug-using, strictly heterosexual men." While it is true that in Africa, the

To the Editor.— A number of articles in a recent issue ofThe Journalconcerned heterosexual transmission of human T-cell lymphotropic virus type III (HTLV-III). 1-3 While HTLV-III transmission from semen donor to semen recipient (either male to female or male to male) is well documented, the reverse route of transmission (female to male) is not. The evidence, to date, to support such transmission remains entirely based on untested epidemiologic observations. Dr Redfield and his colleagues are to be congratulated for their continued efforts to provide "evidence for both male-to-female and female-to-male transmission of infection and disease."1 I am not convinced, however, that they have yet completely succeeded in their goal. They report on ten men with HTLV-III-associated diseases who denied traditional risk factors. Eight of the ten reported multiple sexual contacts (>50 in the past five years), including, in most, a history of sex with prostitutes. They report, in

In Reply.— The major purpose of our prospective study was to evaluate the efficiency of and the potential mechanisms associated with the heterosexual transmission of HIV among spouses and monogamous heterosexual couples, as well as to evaluate any potential household transmission of HIV. Due to the broad scope of the study, our data analysis and presentation focused on these particular issues. Spouses with other potential risk factors for HIV infection were excluded from the study. However, it became apparent during the course of the study that heterosexual contact with other partners, particularly prostitutes, could also represent a risk factor for HIV infection. In analyzing our data, it was noted that male spouses of Haitian ancestry had a higher seroprevalence rate of HIV antibody at entry into the study. Correlation between a history of other heterosexual partners, in particular sexual contact with female prostitutes, gonorrhea, and syphilis, and antibody to HIV

THE ILLNESSES referred to collectively as acquired immunodeficiency syndrome (AIDS) (now often terme d human immunodeficiency virus [HIV] disease) were identified in 1981. Over the succeeding six years, HIV infection and AIDS have become an epidemic in this country, principally within the male homosexual and bisexual communities and among intravenous drug abusers. By January 1986, almost 30 000 cases of AIDS had been reported in the United States and at least 1 to 2 million persons were thought to be infected with HIV. The Institute of Medicine predicts that 270 000 cases of AIDS will be diagnosed by 1991, with 74 000 cases identified in that year alone. Deaths caused by AIDS are expected to reach 179 000, with 54 000 occurring in 1991. During the next four years, pediatric cases of AIDS will increase tenfold to a total of 3000 cases, and cases that result from heterosexual transmission of

To the Editor.— In the Oct 18, 1985, issue of JAMA , Redfield et al 1 present evidence for heterosexual transmission of the human T-cell lymphotropic virus type III (HTLV-III). Male-to-female transmission has been documented previously, but female-to-male transmission has yet to be demonstrated. Approximately one tenth of 1% of all US cases of acquired immunodeficiency syndrome (AIDS) (18/14,125) have been attributed to female-to-male sexual transmission (Centers for Disease Control, national surveillance data, 1981 through October 1985). Therefore, any study supporting this mode of transmission must be rigorous. We feel that the study by Redfield et al is based on questionable data and unsound epidemiologic reasoning and that the evidence presented for female-to-male transmission is unconvincing. Our first criticism is that the means used to exclude persons with known AIDS risks were not sensitive and were subject to considerable bias. Risk factors for HTLV-III infection were ascertained through self-reporting by cases

To the Editor.— Dr Redfield and colleagues 1 have provided documentation of male-to-female transmission of human T-cell lymphotropic virus type III/Lymphadenopathy-associated virus (HTLV-III/LAV). 1 Their data and the data of others reviewed below indicate that female-to-male transmission is also occurring. Female-to-male transmission, in fact, could account for an appreciable amount of the acquired immunodeficiency syndrome (AIDS) among nonrisk group members. Although the Centers for Disease Control properly claims that, "the importance of female-to-male transmission in the spread of AIDS in the United States and the role, if any, of female prostitutes in this transmission have not been established, 2 " we believe that female-to-male transmission is highly likely. We argue that heterosexual transmission of AIDS in both directions has occurred in Zaire and Haiti. 3,4 Although the Centers for Disease Control reports only six cases in the United States where men acquired AIDS from heterosexual contact with women who used intravenous drugs or

To the Editor.— Fischl and colleagues 1 are to be commended for their study, which provides compelling evidence that use of condoms protects against the transmission of human immunodeficiency virus (HIV) in sexually active heterosexual couples. However, the authors' data suggest an additional conclusion that is of major potential significance to heterosexual couples but that is not clearly delineated in their report or given the emphasis I believe it deserves. It can be inferred from the authors' discussion that the seven male spouses who had a history of other heterosexual partners were all seropositive for HIV at entry into the study. It is also stated that after elimination of these seven subjects from the analyses, gonorrhea and syphilis were no longer significantly associated with seropositivity in men. Thus, it can be suspected that the presence of gonorrhea or syphilis in male spouses was probably a marker for having other heterosexual

Few issues related to acquired immunodeficiency syndrome (AIDS) have generated as much interest and debate as heterosexual transmission of human immunodeficiency virus (HIV) and its potential contribution to maintenance and growth of the epidemic. Some have suggested that the growing interest in heterosexual transmission has prejudicial elements, that funding for research and control of AIDS depends on its impact on "us" more than the welfare of "them." But the potential for epidemic spread of any communicable disease beyond its recognized bounds is always cause for concern, and the interest in heterosexual transmission in no way detracts from the importance of understanding and controlling the spread of HIV by homosexual contact or the use of intravenous drugs. Moreover, the modes of transmission and the populations at risk are distinguished not by sharp lines but by broad shades of gray. Elsewhere in this issue, Haverkos and Edelman 1 present an excellent comprehensive