Chicago Tribune (CT) - SUNDAY May 31, 1987 Edition: FINAL EDITION Section: NEWS Page: 1 Word Count: 3,859
John Crewdson, Chicago Tribune

The AIDS crisis. Six years after the first reported AIDS case, scientists are trying to determine how widespread the disease is and how it will affect our future. The first of two articles. AIDS

MONDAY: A look at AIDS incidence.

TEXT:

LOS ANGELES - The item appeared in the Morbidity and Mortality Weekly Report, a grim little publication put out by the federal government that tracks the course of every communicable disease from aseptic meningitis to flea-borne typhus fever.

"A previously healthy 33-year-old man," it began, "developed P. carinii pneumonia and oral mucosal candidiasis in March, 1981, after a 2-month history of fever associated with elevated liver enzymes, leukopenia and CMV viruria. The patient's condition deteriorated despite courses of treatment. . . . He died May 3."

It will be six years this week since the first puzzling case of what the world later would call AIDS was thus reported by researchers at the UCLA School of Medicine in Los Angeles.

Since then the nation has become transfixed by a fear of deadly disease not seen since the polio epidemic of the 1940s and 1950s, possibly not since a half-million Americans lost their lives to influenza during the dark winter of 1918.

Largely because of the deaths from AIDS of such well-known people as Rock Hudson, Liberace, designer Perry Ellis and Connecticut Rep. Stewart McKinney, public opinion polls show that 95 percent of all Americans have heard of the disease.

Though cancer kills 50 times as many people each year, the same polls show that as many Americans now fear dying from AIDS as from cancer. Nor has there been any shortage of predictions about the ways in which AIDS will alter permanently the shape and texture of American society.

Dr. C. Everett Koop, the U.S. surgeon general, has warned that "the changes in our society will be economic and political and will affect our social institutions, our educational practices and our health care."

Dr. Otis R. Bowen, the secretary of health and human services, has suggested that "the dreadful prospect of a worldwide death toll in the tens of millions" may require the sacrifice of some individual rights in order to conquer the disease.

Despite appeals by civil libertarians that the rights of AIDS victims be respected and preserved, public officials have met such expressions of concern with a variety of responses.

U.S. Education Secretary William J. Bennett and other Reagan administration officials, reportedly including the President himself, favor the mandatory testing of couples who apply for marriage licenses, pregnant women, hospital patients and prison inmates.

A bill before Congress, sponsored by Reps. Danny L. Burton (R., Ind.) and William Dannemeyer (D., Calif.), would go even further, requiring all American citizens to be tested for AIDS.

In California, public health officials are drafting guidelines for the forced isolation of "recalcitrant" AIDS patients. Legislation pending in Colorado would make the transmission of AIDS from one person to another punishable by four years in prison. A bill before the West Virginia legislature would make it first-degree murder. The Illinois legislature, too, has worked on its own package of AIDS bills.

Against the backdrop of official concern are the wrenching stories of pain and anguish told by AIDS victims, most of them young homosexual men ravaged by a disease that no one has yet beaten.

Gay rights groups claim that hundreds of AIDS victims have been denied housing, schooling, medical and dental treatment, health insurance and jobs because of their disease. In New York City, which has more than three times as many reported cases of AIDS as any other city in the country, 314 discrimination complaints were filed by AIDS victims in 1986 alone.

Public health officials, accused by homosexual organizations of having been slow to respond to the AIDS threat, are making up for lost time. AIDS- related spending by the federal government, which totaled just $5.5 million in 1982, since has risen nearly a hundredfold, to $530 million.

At the Centers for Disease Control, the federal facility on the outskirts of Atlanta where the progress of AIDS is being monitored, so many new researchers have been hired that office space is at a premium. Construction of the CDC's new $5 million virology building, which will be used in part for the study of AIDS, will be completed later this year.

Such a commitment of resources is undoubtedly justified. AIDS--the acronym stands for Acquired Immunodeficiency Syndrome--is a public health nightmare, an infectious disease for which there is no certain prevention and no cure, which can go undetected for years and which apparently leaves each person it infects permanently capable of passing it along to others.

President Reagan has declared the AIDS epidemic "public health enemy No. 1," and those Americans already infected with the virus continue to sicken and die at a rapid pace. But if one way to measure the scope of an epidemic is by its death toll, AIDS still ranks as one of the rarest of all diseases.

Deaths from AIDS are far less frequent than the various forms of heart disease that kill more than a million Americans each year, rarer even than deaths from alcohol-related liver disease, diabetes, atherosclerosis, influenza and pneumonia, motor vehicle accidents, homicide, suicide, or accidental falls in the home.

When other current trends are examined, it becomes clear that AIDS is still far from the all-encompassing plague that many authorities say they fear. There is some fresh evidence that it may never become a pandemic, a general epidemic in which all Americans are equally at risk.

According to reports the CDC compiles each week from figures supplied by state and local health departments, 35,268 adult and adolescent Americans are known so far to have fallen ill from AIDS and more than 20,000 have died. The numbers are not small, and they continue to rise by the week.

But the time it takes for the number of AIDS cases to double is also on the rise, from 5 months in January, 1982, to nearly 14 months today--a sign that the spread of AIDS is not, despite some news reports to the contrary, an exponential one.

In recent weeks, the rates of increase for two other key measurements have begun to slow: the average number of deaths from AIDS recorded each day, and the percentage of Americans with AIDS who have died.

Most encouraging are recent indications that the rate at which AIDS is spreading is at last beginning to slow.

In March, 1986, an average of 29 new cases among adults were being recorded in this country every day. By last September that figure had risen by 8, to 37 new cases a day. But at the end of March it had climbed to 42, an increase of only 5.

If that trend continues, there eventually will come a month in which there are no more new cases of AIDS than there were the month before, and, sooner or later, there will be a month in which there are fewer.

Because of the delays in reporting and posting cases of AIDS as they are diagnosed around the country, and because the trends such figures reflect are only a few months old, the hope they offer--that the distant boundaries of the AIDS epidemic may be within sight--is still fragile at best.

And because of the long incubation period--most of those who have died or fallen ill from the disease contracted the virus some years before--the picture painted by current caseloads and death tolls is largely a portrait of the past.

How best to care for AIDS sufferers is an urgent social question. But since most current concerns have to do with the future, the eventual magnitude of the AIDS tragedy will depend ultimately on the answers to two fundamental questions:

-- How many Americans are infected with the spherical virus scientists now label HIV, for Human Immunodeficiency Virus, the microscopic thread of protein-coated ribonucleic acid that causes AIDS?

-- Of those who become infected, how many will become ill and die?

Nobody can answer those questions for sure, but estimates, predictions and projections abound. Time and Newsweek magazines both have reported that as many as 2 million Americans may carry the virus, while U.S. News & World Report has suggested the number may be 4 million.

The official estimate put forward by CDC researchers is that about 1.5 million Americans--a number equivalent to the combined populations of Wyoming, Vermont and South Dakota--now carry the AIDS virus in their bloodstreams.

The statistic is familiar to the readers of newspapers and watchers of television. It has been repeated so often by public officials that it now is practically engraved in stone.

Dr. James Mason, the CDC chief, has described the estimate as "the best number we have," and the prospect of so many illnesses and deaths is truly alarming. But some of Dr. Mason's colleagues are not as comfortable with the figure or the publicity it has been accorded.

"It's just a guess," says E. Thomas Starcher, the CDC official who compiles AIDS case reports from around the country.

"I think it's too high," says Timothy Dondero, the CDC epidemiologist who heads the center's AIDS surveillance program.

"It should be treated as a very soft number," says Warren Winkelstein, a professor of epidemiology at the University of California, Berkeley, and a prominent AIDS researcher.

Though the CDC estimate has been broadly employed as a basis for predicting everything from the decimation of the nation's inner cities to the eventual trillion-dollar cost of AIDS to the health care and medical insurance systems, its origins are not entirely clear-cut.

According to interviews with AIDS researchers around the country and a survey of the recent medical literature, the first attempt to predict the potential scope of the AIDS epidemic was made in a 1985 article in the prestigious magazine Science. The article was signed by James W. Curran, the CDC's AIDS program director; W. Meade Morgan, the program's statistical chief; and several other members of the center's AIDS branch.

In arriving at their conclusion, the authors relied mainly on a continuing study of male homosexuals in San Francisco.

As with any study of AIDS, the one in San Francisco was complicated by the fact that, unlike most infectious diseases, AIDS itself is never a direct cause of illness or death.

Through a process that is not yet fully understood, the AIDS virus enters the human bloodstream and attacks white blood cells that, as part of the body's immune system, form a protective barrier against invading disease.

The cells, known as T-4 lymphocytes, have been aptly described as "the conductors of the immune orchestra."

As the immune system is progressively weakened, the body becomes more vulnerable to other diseases, especially to a particular category of "opportunistic" infections that ordinarily cannot get past a healthy immune system.

The two opportunistic diseases most common in AIDS patients are an unusual form of pneumonia and an equally rare kind of cancer. But the AIDS patient's weakened immune system also may open the door to infections that result in other, more familiar symptoms--fatigue, diarrhea, unintentional weight loss and fever--that have been lumped together under the category of AIDS-related complex, or ARC.

A few people have fallen ill within weeks, or even days, after having been infected with HIV. In some others, the virus has existed for more than seven years without producing any overt physical symptoms. The incubation times for most of those with AIDS fall somewhere in between.

Because San Francisco had a large and active homosexual population during the late 1970s and early 1980s, the period during which the AIDS virus first began to spread, the CDC researchers assumed that homosexual men in that city were among the first Americans to be infected with AIDS. If that were the case, the researchers thought, then the percentage of infected men in the San Francisco study who had gotten sick from AIDS must be greater than for the rest of the country.

At the time the Science article was published, for every man in the San Francisco study who was sick with AIDS there were 28 others who were infected with the virus but were otherwise healthy.

In assuming that San Francisco was two years ahead of the rest of the nation, the researchers also assumed that the national infection-to-AIDS ratio ought to be the same as the ratio in San Francisco two years before, or about 50 people infected for each one who was ill.

Even though the infection-to-AIDS ratio among the San Francisco men has since dropped to eight to one, and even though all the men in the study had sought treatment initially for other sexually transmitted diseases, and were therefore less than representative of the nation as a whole or even most homosexual men, the notion has persisted that there are about 50 times as many Americans infected with the AIDS virus as have fallen ill from AIDS.

As the number of confirmed AIDS cases reported from around the country has climbed past the 30,000 level in recent months, some public health officials have continued to estimate the number of Americans infected with AIDS by multiplying the current caseload by 50, for a rough total of 1.5 million.

A second, and somewhat more sophisticated, attempt to estimate the size of the AIDS "infection pool" was made last summer, when researchers from the CDC and elsewhere around the country gathered in West Virginia to ponder the future course of the epidemic.

The approach involved estimating the sizes of the two largest groups known to be at risk for AIDS and which together account for 90 percent of all cases--male homosexuals and intravenous drug users--and then guessing what percentage of each group might be infected with AIDS.

"I was at the meeting," said one researcher who spoke on condition that his name not be used. "We were a subcommittee, and we were supposed to make these predictions. It was really just off the tops of our heads. We tried to estimate the number of homosexual men in the country. We'd fool around with those kinds of numbers, and then we'd debate what the infection rate would be.

"We talked about these ratios, and we'd turn these things around and around. It seems to me we came up with a figure like a million infected people, but I don't know how we got it exactly. The main problem we had is that there are no good data. The data do not exist."

In estimating the number of homosexual males, the researchers turned to Alfred C. Kinsey's "Sexual Behavior in the Human Male," the landmark study of American sexuality published in 1948 and based on confidential interviews with 5,300 men.

Applied to the current population, Kinsey's figures suggest that about 2.5 million American men are exclusively homosexual and that an additional 2.5 million to 7.5 million are more or less homosexual for at least three years of their lives.

While the researchers had no idea what percentage of American homosexuals might be infected with AIDS, they settled on 15 percent, which produced an estimate of between 700,000 and 1.2 million male homosexuals who are infected with AIDS. Another participant referred to the estimate as "a committee decision."

In calculating the number of intravenous drug users, the group relied on estimates that the CDC said were supplied by the National Institute on Drug Abuse (NIDA). These reports said that there were about 750,000 regular users of intravenously injected drugs in the U.S. and another 750,000 less frequent users.

The rate of infection was presumed to be 25 percent among the hard-core intravenous drug users and 10 percent among the less frequent users, for an estimated total of 262,500 drug users who were infected with AIDS.

When the estimates for the two groups were added together, along with an extra 10 percent for Haitian immigrants, hemophiliacs and transfusion recipients, the other three groups who run a higher-than-usual risk of AIDS, the estimated "infection pool" totaled between 1 million and 1.5 million.

Though the new estimate was not out of line with the old one, the principal problem with the second set of calculations is that no one knows with any precision how many homosexuals or intravenous drug users there are.

Since all of the men interviewed by Kinsey and his associates were volunteers and not randomly selected, there is no assurance that they represent a true cross section of American society--especially since all of Kinsey's subjects were white, while a quarter of the homosexuals known to be sick from AIDS are either black or Hispanic.

Estimates of the true number of intravenous drug users are equally problematic. The official estimate supplied by NIDA is 1.28 million--not 1.5 million, as the CDC reported--and an institute spokeswoman acknowledged that "it's a real rough estimate."

Another NIDA official, who referred to the number as a "guesstimate," said the nationwide total had been obtained largely by pooling other estimates filed annually by each of the states to support their requests for federal antidrug funds.

In calculating the number of homosexual males and intravenous drug users who may be infected with AIDS, it is not enough to simply estimate their raw numbers, since in each instance the risk of acquiring AIDS may depend on myriad other factors.

One factor is age. Nearly half of all those who have fallen ill from AIDS are men in their early to middle 30s, which considering the incubation periods involved suggests that the various high-risk behaviors that contribute to AIDS infection are most likely to occur during the late 20s and early 30s.

Another factor is geography. Most AIDS cases still are concentrated within a few metropolitan areas. More than half the known cases, for example, have been reported by doctors in California, where the victims are principally homosexuals, and New York, where both homosexuals and intravenous drug users are the chief victims. Most victims in Newark are drug users.

In other places, AIDS cases are practically nonexistent. Idaho, for example, has only nine reported cases and South Dakota only four. Clearly, the infection rates for the various groups at risk for AIDS, and thus the degree of risk itself, can vary substantially from place to place.

"One would expect that homosexual men in Minnesota probably have substantially lower rates of AIDS infection than do those in San Francisco, Los Angeles and New York," one researcher says, and variations have been found even within the same city. Half of one group of male homosexuals tested in Denver were found to be infected with AIDS, compared with only one-quarter of another group of homosexuals tested there.

A third factor concerns the nuances of individual behavior. As numerous studies have shown, those homosexual men most at risk for AIDS are the ones who practiced receptive anal sex during the late 1970s and early 1980s. The risk for those among them who also used intravenous drugs or received blood transfusions is greater still.

Of the 22,000 homosexual men known thus far to have become sick from AIDS, more than one-third have acknowledged to public health authorities at least one other factor besides their homosexuality that places them at a greater-than-average risk for contracting AIDS.

By the same token, those men whose homosexual experiences stopped before the late 1970s, or did not begin until recently, or which did not include receptive anal sex and were not accompanied by the use of intravenous drugs, or who did not live in California or New York, run a far lower risk of acquiring AIDS.

The average incidence of AIDS infection among intravenous drug users is similarly unclear. In various studies across the country, drug addicts have tested from 71 percent positive for AIDS (chronic drug users in a New York City methadone clinic) to zero percent positive (occasional users tested at drug treatment centers in six California counties).

As with homosexuals, the risk for intravenous drug users of contracting the AIDS virus depends not just on how old they are and on where they live but on when, and how often, they have used intravenous drugs, which drugs they use and even how affluent they are.

The NIDA estimate of 1.28 million intravenous drug users included 385,000 occasional heroin addicts and 400,000 people thought to have injected a liquid form of cocaine, leaving fewer than 500,000 hard-core heroin addicts.

Though the NIDA data reflect none of these distinctions, in most cases the hard-core addict, who injects heroin several times each day, runs a far greater risk of sharing a needle that has been infected with the AIDS virus by another addict than does the occasional user of heroin. A poor addict also is far more likely to share a needle and to be oblivious to the hazards of sharing.

Most dubious of all are the NIDA figures for intravenous cocaine use, taken from a nationwide household survey conducted in 1985 in which people were asked whether they had recently used cocaine, and if so how. Based on the survey's results, NIDA estimated that in 1985 some 4.3 million Americans had used cocaine, 8 percent of them, or about 400,000, intravenously. But the survey counted one-time users along with habitual ones, and there is reason to believe that the incidence of cocaine use in general, and intravenous cocaine use in particular, were both far higher in 1985 than during the years when the AIDS virus first began to spread.

As the concept of a household survey itself suggests, cocaine use is also apt to be more prevalent among those affluent users most likely to be knowledgeable about the hazards of needle-sharing with respect to AIDS.

Finally, since five out of six intravenous drug users with AIDS have acknowledged at least one other form of behavior that places them at risk for the disease, any estimate of incidence would have to separate out the other known co-factors.

As more potential co-factors are identified, some researchers have begun suggesting that merely acquiring the AIDS virus may not be enough by itself to cause AIDS.

"I still think there's a lot we don't know about this infection," says Berkeley's Winkelstein. "I really don't know what's going to happen."

CAPTION: Graphic:(color) New AIDS cases. Percent change from previous six- month period in average number of new cases per day (9/26/83 thru 3/30/87). Chicago Tribune Graphic; Source: Tribune analysis of data from National Centers for Disease Control. Photo: Deaths from AIDS Average deaths per day Percent change from previous six-month period

9/26/83 - -0.4%

3/26/84 - 51.9

9/24/84 - 40.6

3/25/85 - 46.4

9/30/85 - 70.6

3/31/86 - 15.9

9/29/86 - 51.4

3/30/87 - 11.4

Cumulative total deaths Percent change from previous six-month period

9/26/83 - 99.5%

3/26/84 - 75.8

9/24/84 - 60.6

3/25/85 - 55.2

9/30/85 - 60.7

3/31/86 - 43.8

9/29/86 - 46.1

3/30/87 - 35.1

Chicago Tribune Graphic; Source: Tribune analysis of data from National Centers or Disease Control.

Photo: Photo by Steve Ringman, San Francisco Chronicle. Deotis McMather rests in the AIDS ward, 5B, at San Francisco General Hospital. The picture, part of a photo essay, was taken only a few days before McMather died in 1983. Public fear has spread even faster than the disease since then.

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