An aggressive HIV prevention campaign was politically difficult, if not impossible, to initiate in the United States throughout the 1980s. Prevention of HIV requires detailed knowledge of who is at the greatest risk for disease; however, infected patients were threatened with loss of livelihood, health insurance, personal safety, and social support [3]. This social and political climate slowed our understanding of the spread of HIV and the scope of the epidemic. Although an HIV prevention campaign requires an effort to change sexual behavior, such a campaign would probably have offended and alienated some American voters. Efforts to promote condom education and use were frustrated at every level. Regardless of the clear-cut role of intravenous drug use in the HIV epidemic, drug rehabilitation programs were not expanded, and needle exchange programs were not federally funded. As a result of these and other problems, the public health community found itself constrained in its efforts to prevent HIV disease. These latter problems were summarized by Dr. Donald Francis in his farewell address to the Centers for Disease Control and Prevention [4] and dramatized by the book and movie And the Band Played On. Finally, the prevention of sexually transmitted diseases (STDs), which are now recognized to facilitate transmission of HIV, was not given high priority. Indeed, during the 1980s, the incidence and prevalence of all the treatable bacterial STDs (gonorrhea, chlamydial infection, syphilis, chancroid) and herpes simplex virus type 2 infection increased. By default, HIV control in the United States evolved to focus on the screening of blood donors and HIV testing and counseling.

Most other countries (both industrialized and developing) have implemented more comprehensive HIV control programs. These are best exemplified in developing countries by the World Health Organization's Global Program on AIDS and the U.S. Agency for International Development's AIDS Control and Prevention Program, which is coordinated by Family Health International in more than 30 countries. The Clinton administration is likely to support a comprehensive HIV prevention plan for the United States as well as programs similar to those advocated by the Global Program on AIDS and the U.S. Agency for International Development. Our purpose is to describe these programs and to suggest some fundamental changes in addressing the STD problem in the United States.

The Global Program on AIDS and the U.S. Agency for International Development strategies are designed to prevent sexual transmission of HIV with minimal dependence on technology and resources. The programs focus on three linked components: condom promotion and distribution, change in sexual behavior (delaying onset of intercourse by adolescents, avoidance of high-risk sexual practices, and partner number reduction), and control of those STDs that appear to facilitate the transmission of HIV [5]. Mathematical models of the AIDS pandemic strongly suggest that only concomitant implementation of these three strategies will maximally reduce the spread of HIV [6]. Accordingly, each of these goals deserves further discussion.

Condoms can help to reduce the spread of STDs, including HIV infection [7]. However, condom distribution has evoked concern about the "message" sent by their availability [8]. It has been argued that the very act of making condoms available endorses promiscuous sex, especially for less mature (and potentially more easily confused) adolescents. This notion contrasts with data suggesting that sex education can reduce risky behavior in some adolescent populations [9].

Sexual behavior is complex and poorly understood. Experiments designed to better understand ways to change sexual behavior are in progress, and the results are critically important to the war on AIDS. The sexual behavior of a population can probably be changed only very slowly. Further, all Americans do not share the same risk for STD and HIV infection [10]. The continued spread of many STDs is dependent on high-risk groups whose sexual behaviors appear to allow at least some of these diseases to flourish [11]. Different groups can be expected to respond differently to new information and to efforts to change behavior. Campaigns against HIV and STDs are now becoming more focused on high-risk groups, although such "targeting" has stimulated serious controversy [12].

Available data strongly suggest that STDs that cause skin ulcers (genital herpes, syphilis, and chancroid) or mucosal inflammation (gonorrhea, chlamydial infection, and trichomoniasis) greatly facilitate HIV transmission [5, 13]. This finding is now popularly referred to as epidemiologic synergy [5]. Prevention of these classic STDs has become a high priority. Unfortunately, in developing countries, drugs to treat STDs are often not available. In the United States, STD care is tremendously hindered by inadequate staffing and overcrowding of public health clinics, where STD care has traditionally been delivered, and the lack of STD education for health care workers in the private sector.

How did we get where we are? More than 30 years ago Surgeon General Thomas Parran helped to develop a U.S. public health infrastructure that shifted STD care and control to the public sector. These public health measures, combined with the use of effective antibiotics, led to a dramatic decrease in STDs. In 1954 the American Journal of Syphilis, Gonorrhoeae, and Venereal Diseases ceased publication after four successful decades, as a direct result of "reduced interest. of physicians and medical students" [14]. Changes in the 1950s led to at least two generations of physicians with little experience in STD treatment, risk assessment, or the public health aspects of STD case management. A 1982 survey of 127 medical schools in the United States and Canada showed that 87 offered no clinical teaching about STDs to students, and 96 offered no such training for residents [15].

We now anticipate the inception of a stronger and more comprehensive U.S. AIDS prevention program. This program offers a unique opportunity for practicing physicians. Given the movement toward managed care and preventive health care services, it appears likely that physicians in the private sector will play a greater role in the management of patients with STDs. Treatment of STDs must be comprehensive, and physicians will require more experience in treating STDs as well as strategies to work effectively with the public sector. The physician who recognizes one STD must look for others; he or she must treat partners and counsel the patient.

Who will provide the education for the proper management of STDs? Medical schools are under tremendous pressure to teach their students how to manage primary care problems in outpatient settings [16]. Sexually transmitted disease clinics have a high volume of outpatients with interesting and important problems. We have had excellent experience with students and residents who choose to work in our STD clinics and who evaluate this experience very positively. Even before the AIDS epidemic began, several expert panels recommended that medical schools establish affiliations with STD treatment facilities so that medical students and physicians in training would have the opportunity for supervised clinical experience treating STDs [15]. This education is even more imperative now; it will be essential to enable private sector physicians to play a leading role in the "new and improved" war on STDs and HIV.