San Francisco Chronicle - Wednesday, July 19, 1989
Randy Shilts

The calls come in every day of every week, but this one will mark a watershed in the history of acquired immune deficiency syndrome: It will put the number of diagnosed AIDS cases in the United States over 100,000.

In the eight years since a bizarre array of seemingly unrelated rare diseases were identified among a handful of gay men, the acronym AIDS has become an integral part of our vocabulary and culture, emblematic of the worst of all possible fates.

And the disease rages still.

Although AIDS no longer inspires the frenzied headlines and public hysteria that heralded its arrival a few years ago, the number of cases continues to rise exponentially.

It took 6 1/2 years of the epidemic to get the first 50,000 cases in America; it took only 18 months to get the second 50,000 cases.

Now, the CDC calculates that it will take about 12 months for the next 50,000 and just 10 months for the 50,000 after that.

In November 1980, when an ailing advertising manager first walked into his Los Angeles office, Dr. Joel Weisman saw the strange immunological disorder as an intriguing medical mystery. That 30-year-old gay patient was soon to become the nation's first reported case of what we now call AIDS.

Because 100,000 others have come down with the same malady, however, the doctor who first noticed the new epidemic has lost much of his scientific fascination with the disease.

"All I can think of, day in and day out, is all the people who have died -- young people, all dead, in such a short period of time since I first saw that patient," Weisman said.

"It's like some story from science fiction."

But AIDS is far from fiction, and the evolving epidemic is a study in contrasts:

* Although heterosexual AIDS is emerging as a gargantuan problem for minorities in inner cities, the national heterosexual epidemic some experts feared several years ago -- a modern "Black Death" taking lives throughout the general population -- has not materialized.

* Although AIDS is turning into a disease of the underclass on the East Coast, it remains largely a disease of gay men in most other parts of the country, particularly in California.

* New cases of HIV infection among blood transfusion recipients are almost unheard of, but nearly 20,000 Americans are expected to be afflicted with AIDS in the next four years from transfusions administered before AIDS blood-screening started.

Although seemingly anomalous, these trends have yielded no surprises for the epidemiologists who have long charted the spread of AIDS through America.

"The science of epidemiology is very sophisticated and with the AIDS epidemic, it has proved itself to be precise," said Dr. June Osborn, a leading AIDS authority and dean of the School of Public Health at the University of Michigan.

No new vulnerable populations for the disease have been identified since sexual partners of intravenous drug users were reported to constitute a high-risk group for AIDS in early 1983.

There have been no novel, surprising outbreaks of the disease. Instead, the people who have tended to get AIDS are just getting it in far greater numbers.

Put simply, where AIDS has not been a problem in the past, it largely is not a problem today.

But among people where AIDS has been a problem, it is far worse now.

In no population is this trend borne out more tragically than among gay men, the group that remains the hardest hit by the disease.

With more than 6,800 cases in San Francisco, for example, nearly one in eight gay men already has been afflicted with AIDS, according to health department estimates.

A dramatic increase in reported AIDS cases among local gay men this year has mocked earlier predictions that the disease had somehow "leveled off" among the city's huge gay community.

And it looks as though the epidemic is only going to get worse.

According to city epidemiologists, more than 17,000 cases are expected locally by 1993. That means that about one in every 40 citizens of San Francisco by then will have been afflicted with AIDS.

Nationally, the gay proportion of AIDS sufferers is slowly decreasing, both because gay men moved in the mid-1980s to adapt safe sexual practices and because cases among drug addicts are soaring.

Still, men who contracted the disease through sex with other men account for 61 percent of the nation's AIDS cases. An additional 7 percent are gay men who also injected drugs.

Outside the Northeast, in fact, AIDS is largely a disease of gay men. This is strikingly true in California, where about one in five of the nation's AIDS sufferers live.

Despite the intensity of AIDS infection among gay men in these areas, there has been relatively little spillover into other population groups.

In the epidemic's earlier days, some experts feared that bisexuals would be conduits for HIV into middle-class heterosexuals.

No such trend has emerged, and only 10 percent of heterosexually contracted cases of AIDS have been linked to bisexual men.

But the so-called second wave of AIDS among intravenous drug users, their sexual partners and their children represents another scenario in which a bad situation has gotten unthinkably worse.

New studies on the prevalence of AIDS in cities with high concentrations of intravenous drug abusers are finding levels of infection that are nothing short of awesome.

In one study at Lebanon Hospital in the Bronx, New York City's most impoverished borough, researchers tested the blood of patients who were not checking in for AIDS or for any infectious disease.

Eighteen percent of all men in the study between the ages of 25 and 44 were HIV-infected. Of all black men checking into the hospital, one in 11 were HIV positive.

Most of these men probably acquired the virus through intravenous drug use.

More important, however, is that they represent huge numbers of men in the prime of their sexual lives and are causing significant increases in the numbers of women who are contracting the disease sexually.

"Over the last couple of years, we've seen women increase from being 7 percent of all AIDS cases to about 10 percent," said Dr. Ruth Berkleman, chief of the surveillance branch of the Center for Disease Control's AIDS Program.

"Most of them are partners of drug users."

At Mount Sinai Hospital in New York, one in seven women seeking treatment for pelvic inflammatory disease recently tested HIV positive.

A recent study found that a new, major risk factor for AIDS among adolescent girls in New York City was not drug use but heterosexual sex, the cause of 52 percent of such cases.

"Now, we have plenty of evidence that this virus is well into the adolescent population here," said Dr. Karen Hein, director of the Adolescent AIDS Program at Montefiore Medical Center in the Bronx.

HIV infection rates in Baltimore, Newark, Miami, Washington, D.C., and San Juan, Puerto Rico, also are reaching levels comparable to those of central Africa, where AIDS is pandemic.

Higher rates of AIDS among adults has translated to more cases among newborns who are infected by their mothers' blood in the womb.

Even more striking are the new cases being found among children who were born to drug-addicted parents before it was widely known that AIDS was a problem for needle users.

"We're finding older children who were infected at birth -- children who are 6 and 7 -- and we're only finding out now they were infected," Berkleman said. "We'll see whether they'll get to be 8 or 9."

The severe heterosexual epidemic of AIDS in the inner cities, however, has not meant that AIDS is exploding all over America.

In 1985, some experts feared that prostitutes might provide the link for viral spread from drug addicts to society's mainstream, but the sex industry does not appear to be playing any significant role.

The bulk of white heterosexual cases in the coming years will be less likely to come from sexual contact than from blood transfusions dating back to the early 1980s.

By 1992, the CDC projects, 20,000 AIDS cases nationally will have been diagnosed in those who had blood transfusions before HIV screening started for blood donations in early 1985.

"Because of the very long incubation periods, these cases won't peak for some time," says the CDC's Dr. Martha Rodgers.

"This reflects old donations. New infections have been virtually eliminated by the screening."

Despite these cases, which will account still for only about 5.5 percent of the nation's total, the epidemic's current epidemiology bodes for a fairly clear portrait of AIDS in the 1990s.

Without effective treatments, gay men will continue to be afflicted with AIDS by the tens of thousands in the years ahead.

They will be joined by growing numbers of drug addicts and their sex partners, most of whom will be poor blacks and Hispanics from mid-Atlantic states.

Although this trend might come as a relief for white, affluent heterosexuals who spent the 1970s in singles bars, it offers troubling political implications to experts who will struggle with future AIDS policy issues.

"The bleakest nightmare I've heard is that the epidemic would settle out at 40,000 new cases a year, but that it would be sufficiently concentrated in the underclass (so) that we'd accept it," says Dr. Osborn, who recently was appointed to the new National AIDS Commission, which will oversee federal AIDS policy in the years ahead.

"I see us moving in that direction already," she says, "and I find it very troubling."

CAPTION: PHOTO AIDS demonstration

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