Experts’ Grim 5-Year Forecast : AIDS Shock Wave Due to Sweep U.S.

Until recently, Joseph Zengerle’s only knowledge of AIDS had come from newspapers and television. Then Zengerle, a happily married Washington attorney and father of two young sons, learned to his astonishment that one of his clients, who had become a good friend, was dying from the disease.

“I’ve certainly been aware of AIDS, but never thought I would encounter it in my personal life,” Zengerle said. “Suddenly the disease became something real to me. This brought it next door.”

Zengerle’s experience is rare thus far, but experts say that within five years, as the number of AIDS cases explodes, many Americans who have been insulated from the burgeoning epidemic somehow will be touched by the disease.

And neither they nor many of the medical and social service institutions across the country that will be called upon to care for the afflicted, as well as many of the communities that will see their first cases of the invariably fatal disease, are prepared for the experience. Whether they will be ready in time is of intense concern to health officials.

“It’s a national problem, and every physician in the country is going to have to deal with it,” said Dr. Harold Jaffe, chief of epidemiological studies for the federal Centers for Disease Control’s AIDS program. “You’re looking at numbers that are really shocking.”

By 1991, the U.S. Public Health Service projects, the total number of Americans who will have contracted acquired immune deficiency syndrome will increase to 270,000, up from about 28,000 now. About 179,000 of them will have died.

That means the disease will have struck one of every 933 Americans. In 1991 alone, an estimated 74,000 new cases will be diagnosed and 54,000 individuals will die. That could put AIDS among the nation’s 10 chief causes of death.

The 270,000 cases projected by 1991 represent, for the most part, individuals who experts believe are already infected with the AIDS virus--and may have been for several years--but have not yet developed the disease’s symptoms. Federal health officials have estimated that 1.5 million or more Americans now carry the virus--many of them without knowing it--and increasing numbers of them will inevitably fall ill.

By 1991, “everyone’s going to start feeling it,” said Dr. Donald Francis, a federal disease centers epidemiologist on loan to the California Department of Health. “Everyone will know somebody who has died from AIDS, or is going to die from AIDS.”

AIDS, which is caused by a virus transmitted from individual to individual most often through sexual intercourse or the sharing of contaminated hypodermic needles, will begin to move outside the current high-risk groups in the United States--male homosexuals and intravenous drug users. Heterosexuals, particularly the young and sexually active, will confront a rising danger of contracting the disease.

Through infected bisexual men, intravenous drug users and transfusion recipients, the virus is already beginning to infiltrate the heterosexual population. Experts fear it will ultimately spread from sexual contact to sexual contact--in a chain effect--many times removed from the original source.

Detached Perceptions

“People read about AIDS and say: ‘Oh--that’s what gay men in San Francisco get,’ ” said the CDC’s Jaffe, who has been deeply involved in tracking the immunity-crippling disease since it was first identified in 1981. That perception may eventually be obsolete. “There is still a lot of denial out there,” he said. “I think that denial has got to change in the next five years.”

AIDS, now concentrated in major cities of the East and West coasts, will spread to all sections of the United States. California and New York City accounted for half of all AIDS cases through 1983 and 35% through this year, according to the CDC, but the experts say 80% of all cases will occur outside California and New York City by 1991.

“Other cities are catching up,” said Walter Dowdle, director of CDC’s center for infectious diseases. “We’re going to see a larger increase in a number of cities because the infection was acquired there at a later time than on the West Coast and in New York City.”

As the disease spreads across the country, many physicians and hospitals that have had no contact with the disease will begin to receive patients, and AIDS medical costs will spiral nationwide to more than $1 of every $100 spent for health care.

To be sure, AIDS does not yet compare to other devastating epidemics of the past or even to some of the current century. Just after World War I, for example, influenza cut a lethal path through the United States, killing 500,000 people and striking those of all ages and life styles. When the projection of 270,000 AIDS cases becomes a reality, however, the death toll from this newest killer will far surpass the polio epidemic that took 60,000 lives in the United States in the 1940s and 1950s.

The projection that AIDS will proliferate uncontrollably is based on the assumption that there will be no medical breakthroughs toward a treatment or a vaccine--missions that are absorbing scientists around the world and are expected to draw more than $400 million in federal funds in fiscal 1987. Another unknown factor in the potential spread of the virus is the effect of public education efforts aimed at persuading people to use precautions in their sexual and drug activity.

Experts believe that an acceleration in both spending and education may make a significant difference in slowing the epidemic, even in the absence of scientific advances.

The highly regarded Institute of Medicine, an affiliate of the National Academy of Sciences, recently called for an immediate escalation in education on all levels coupled with a fivefold increase in federal funds for research and education--at least $2 billion annually by the end of this decade. And Surgeon General C. Everett Koop, in his long-awaited report to the public on AIDS, called for comprehensive AIDS education at home and in the schools at the “lowest grade possible.”

Seen as Inevitable

But in the view of the experts, no amount of education will prevent the explosion of cases expected in the next five years.

“We know the problem is going to get a lot worse before it gets better--that’s the message that has to get out there,” said Meade Morgan, chief of the CDC’s statistics and data processing branch.

And the ominous forecasts of the spread of AIDS does not include people suffering from an associated condition known as ARC, or AIDS-related complex, which is often as debilitating as AIDS and can also result in death. Even now, the number of ARC patients is estimated at up to 10 times that of AIDS patients.

AIDS will “deeply change America in the next few years,” creating “social dislocation unlike any event other than war,” predicted California Rep. Henry A. Waxman (D-Los Angeles), chairman of the House Energy and Commerce subcommittee on health.

“If AIDS claims as many lives as projected and costs the country the billions it appears it will, we can expect serious national stress and division,” Waxman said. “There will be fundamental changes in those institutions that middle-class Americans have come to take for granted: medical care, insurance, education, employment and, most of all, privacy.”

AIDS destroys the immune system, leaving the body vulnerable to otherwise rare diseases such as pneumocystis carinii pneumonia, a respiratory infection caused by a parasite, and Kaposi’s sarcoma, a cancer of the capillary system. The virus can also invade the central nervous system, causing serious neurological disorders such as dementia.

For the next five years, the period for which researchers have detailed projections, the dominant patterns of AIDS are not expected to change in fundamental ways, experts say. But the number of patients will soar.

The overwhelming majority will continue to be homosexual and bisexual men and intravenous drug users. Currently, an estimated 70% of AIDS cases are homosexuals and about 25% are intravenous drug users.

“Not much is going to change--most are young to middle-age adults who have already been infected,” said Dr. James Curran, director of AIDS activities within the CDC center for infectious diseases.

AIDS is believed to have begun in the homosexual population in this country and has largely remained confined to homosexual men. However, experts have repeatedly stressed that AIDS is a sexually transmitted disease that can be spread by both homosexual and heterosexual activity.

“I don’t think there is any doubt in anyone’s mind that heterosexual spread is a fact of life,” said Dr. Mervyn Silverman, executive director of the American Foundation for AIDS Research, at a recent meeting in New York on heterosexual transmission. “Exactly how far it’s spreading in the United States? Who knows?”

A Public Health Service report released in June predicts that the 1986 total of more than 1,000 cases among heterosexual men and women will climb to nearly 7,000 by 1991.

For now, most heterosexual cases are expected to occur only among those who have had sexual contact with a high-risk source--an intravenous drug user, a bisexual man, a recipient of a contaminated blood transfusion, or a hemophiliac who has been infected through tainted blood products. Currently, heterosexual transmission accounts for about 4% of the total number of cases. (Because of better screening, the chances of being infected with the AIDS virus by contaminated blood in a transfusion now are regarded as minuscule.)

Dowdle predicts that most of the heterosexual cases will begin among the heterosexual contacts of intravenous drug users.

“I would think that this would be the next group most threatened,” he said. “This is already a problem, showing up in younger women. The question is: What happens after that? What happens if the virus is passed from an intravenous drug-using male to a younger woman, who in turn passes it on to other men, who pass it on to other women? It may start from the intravenous drug abuse, but it could spread through fairly straightforward heterosexual contacts.”

Fears for the Children

Dr. Robert Redfield of the Walter Reed Army Institute of Research, who has been treating heterosexuals with AIDS said: “You can get it from a man, and you can get it from a woman. The people who will be the next generation of AIDS patients are those who are developing sexually now. I fear for my children.”

Recent studies presented at a conference on heterosexual transmission indicate that heterosexual transmission of the AIDS virus has taken place among the sexual partners of infected individuals.

Dr. Margaret Fischl, director of the clinical AIDS research unit at the University of Miami, said that vaginal intercourse was sufficient to transmit the virus to about half of 35 infected spouses or sexual partners of 58 AIDS or ARC patients she studied over a two-year period. Frequent and long-term sexual contact apparently increases the risk, she said, although the research also demonstrated that “couples can have repeated sexual contact without transmitting the virus.”

Fischl said that the use of condoms can also make a difference in preventing transmission. Among 38 spouses who were negative upon enrolling in the study, infection was “much lower” among those who used condoms, she said.

Dr. Neal Steigbigel, head of the division of infectious diseases at Montifiore Medical Center in the Bronx, N.Y., said that 44 steady sexual partners of 93 AIDS patients became infected with the virus after engaging in an average of more than 100 episodes of “the usual heterosexual activities,” including vaginal intercourse and oral sex.

Of the 93 AIDS patients studied, he said, 12 were men and 81 were women. Of the 44 partners who became infected, he said, 38 were women and six were men.

Within the next five years, health officials say, heterosexuals who want to avoid AIDS will have to change their sexual activities, particularly as they involve casual encounters. More than abstaining from sexual contact with bisexuals and intravenous drug users, they will have to steer clear of persons whose background and other sexual contacts are not known to them. Even then, they should follow measures that will protect them--such as using condoms.

“If a person is cheating in a relationship, he or she had better be careful,” Francis said. “You’re going to have 10 times as many cases. So there’s 10 times as many chances of knowing someone with AIDS.”

Kristine Gebbie, who heads the AIDS task force for the American Assn. of State and Territorial Health Officials, believes that “sooner or later, we will start finding cases like the nice suburban family where the wife believes the husband is monogamous. She’s never been concerned with AIDS. But he goes on business trips, where he is bisexual or has contact with a prostitute. He comes home and infects his wife. She might never know. But what if she decides to become pregnant?”

Some experts cite what they call “disturbing” evidence from military testing of recruits that the AIDS virus may already be moving into the heterosexual community faster than expected among the young, and particularly among minorities. The Pentagon’s statistical review of AIDS antibody blood testing of recruits from October, 1985, through June, 1986, showed an average of 1.5 cases of infection per 1,000 individuals tested.

Redfield, who views full-blown AIDS as the “end stage” of a disease that begins with infection, believes the level suggests AIDS has already begun to move outside the known high-risk groups. “The evidence is that it’s much greater than we thought,” Redfield said. “It is still a relatively uncommon virus in young heterosexuals, but it’s changing.”

Redfield believes that the data reflect the extent of “new” infection in the country--exposure to the virus that is occurring now. Particularly alarming is the fact that 17- to 20-year-old recruits, who were not likely to have been infected many years ago, are testing positive for the AIDS virus. There were 0.5 cases per 1,000 among 17- to 20-year-olds; 2.4 per 1,000 in the 21- to 25-year-old group and 4.2 per 1,000 among those 26 and older.

Also, among the recruits tested, the infection rates were four times higher among black recruits than among whites, which is consistent with the rates of fully developed AIDS cases among blacks.

Some researchers insist that conclusions cannot be drawn on the military data until it is known whether the recruits who tested positive had engaged in homosexual behavior or intravenous drug use. Health officials in New York said recently that many of the recruits who had tested positive were later found to have engaged in some high-risk behavior, including intravenous drug use and homosexual activity. Furthermore, regions of the country where military testing found a high prevalence of AIDS incidence are also areas of the country where the disease is most often found among the general population.

But Dr. Ed Gomperts, a member of the Los Angeles City-County AIDS Task Force, although stressing that the data is not adequately refined, said he is concerned by its possible implications.

“Adolescents go through a phase of sex exploration,” he said. “There is experimentation. Even from the point of view of finding an ultimate life partner, there are multiple contacts. So, if the virus is present in this group, the group is at risk.”

Dr. Karen Hein, associate professor of pediatrics at Albert Einstein College of Medicine in New York, added: “We have very little data about adolescents, but the feeling is that we ought to be doing more. Adolescents have not yet been identified as a high-risk group--but heterosexual transmission is a reason to be concerned. We feel that adolescents are the youngest members of what we consider high-risk groups. We feel they will form one of the bridges to heterosexual transmission--and will be a high-risk group.”

Jaffe of the CDC said health officials should concentrate on educating teen-agers where the AIDS risk among the heterosexual population is greatest--where intravenous drug use is common. “I would not be spending money on (educating) middle-class white girls at Vassar--I’d be spending money in the Bronx, Harlem and Liberty City (in Miami), because that’s where it’s going to happen.”

But Gomperts said middle- and upper-class whites could take little comfort. “The fact that it (prevalence of infection) is lower among white kids doesn’t mean they are protected,” he said, “It simply means the virus will move into that population a little later. Nobody is safe.”

The threat of contracting AIDS could become perilously real for all Americans, experts say, if the pool of infection begins to widen beyond high-risk sources and if individuals ignore precautions that would protect them from exposure. At that point, they say, it might be impossible to know who is infected--and almost anyone who is sexually active could be vulnerable to the deadly disease.

“The lines will get less distinct as more heterosexuals get involved,” Francis said. “We’ve got to take heterosexual transmission out of the closet. . . As long as this is a gay risk, it’s convenient for us. We as a society do not want this to be a heterosexual disease. We don’t want it to threaten us, or our children.”

Said Jaffe: “In 1983, the risk to heterosexuals was extremely small. Now, it’s still extremely small. But it’s larger than it was.”

Although no one predicts widespread infections across the full range of the American population in the immediate future, the mere expectation of 270,000 AIDS cases by 1991 will present a tremendous burden to schools and hospitals.

How the financial burdens will be borne and how the emotional issues and torment from the epidemic will be handled by both individuals and institutions are problems that await solutions.

AIDS AS A MAJOR CAUSE OF DEATHThe National Center for Health Statistics, the Centers for Disease Control, lists these major causes of death among Americans for 1984.

1. Heart Disease 765,114 2. Cancer 453,492 3. Stroke 154,327 4. Accidents 92,911 (Auto, air, boat) 5. Chronic Lung Disease 69,100 (Emphysema, bronchitis) 6. Pneumonia 58,894 7. Diabetes 35,787 8. Suicide 29,286 9. Liver Disease 27,317 10. Arteriosclerosis 24,462 THE AIDS FACTOR: 1984 2,829 deaths 1991 (est.) 54,000 deaths

The federal Department of Public Health Service projects that--assuming that the rates of other major killers will remain roughly stable--AIDS could become the seventh-leading cause of death among Americans by 1991.

The U.S. surgeon general’s report on AIDS is reprinted in a special section in today’s Times.