Growing Consensus : AIDS Threat to All--How Serious?

AIDS is not spreading at the anticipated rate among non-drug-using heterosexual Americans, and medical officials here at the Centers for Disease Control and elsewhere are generally agreed that they see no evidence the disease will reach epidemic proportions, except among homosexuals and intravenous drug users.

As a consequence, there is a growing consensus among leading medical scientists that the threat of AIDS to the wider population, while serious, has been exaggerated.

Doctors who share in this new consensus base their conclusions on recent reviews of statistical data, which show far fewer cases among American-born heterosexuals than earlier epidemiological predictions suggested. Moreover, according to the CDC, more careful study of widely publicized instances of heterosexual transmission--such as those that reportedly had occurred among new Army recruits--have been found to be unreliable.

CDC studies show also that in areas such as California and New York, where AIDS is epidemic among homosexuals and drug users, “very little crossover to the mainstream heterosexual population has occurred,” said Dr. Harold W. Jaffe, the centers’ chief of AIDS epidemiology.

“We don’t need to panic about heterosexual transmission,” said Dr. Robert C. Gallo, the National Cancer Institute researcher who was a co-discoverer of the AIDS virus. “It’s not going to run rampant . . . . Our greatest danger by far in this country is the drug addicts. If drug addiction goes up among people who are sexually active, then there is no predicting how bad this can get. But, if the drug addiction problem doesn’t get any worse, I doubt whether for heterosexuals at large this is going to be anywhere near the problem that it is in the homosexual population.”

Reluctant to Discuss Spread

Like Gallo, most of the health professionals monitoring the course of this disease hold government jobs and many were reluctant to discuss the spread of AIDS among heterosexuals for fear of contradicting statements by their political superiors. They pointed out that, although politicians from the President on down initially had discounted AIDS as primarily a homosexual affliction, the pendulum now has swung in the opposite direction toward an unwarranted alarm.

A number of specialists interviewed on a not-for-attribution basis said they felt that the potential for heterosexual spread was being exaggerated in order to obtain increased governmental funding.

“If this wasn’t seen as a heterosexual problem, the money wouldn’t be there for research,” said one top federal doctor working on AIDS.

Another federal physician put it more bluntly: “Everybody has got their own agenda, and the thing that fuels the resources for AIDS is the threat of heterosexual transmission. The people who are spending the money basically don’t care if a bunch of gay men and drug abusers get AIDS. They really don’t. So the thing that’s driving the money is the fear of heterosexual transmission. And the people who run the laboratories that get that money know that.”

One of the most influential scientists who believes public anxiety over heterosexual transmission has become disproportionate is the CDC’s Jaffe. He points out, for example, that statistically even sexually active heterosexuals are at greater risk from drunk driving and failure to wear seat belts than they are from AIDS.

Recently, in fact, he was asked whether he would first caution an average American heterosexual going out on a date about auto safety or condom use. Jaffe mulled the risk statistics for a few moments and answered: “Fasten your seat belt.”

Jaffe has lived with this epidemic for the last seven years and he does not minimize its risks; he believes people should use both condoms and seat belts. He is concerned, however, about what he sees as an exaggerated emphasis by educational and testing programs on the threat to mainstream America. In Jaffe’s view, such a preoccupation might draw resources away from the real risk groups.

Concern Over AIDS Hysteria

He believes there are two dangers. “One is the temptation to diffuse resources over the whole country rather than target them where they are most need,” he said. “The other is that, if concern about heterosexual transmission of the virus turns into hysteria, that hysteria could fuel repressive measures that have no public health basis. The best example would be quarantine.”

His concerns were endorsed by a recent CDC planning conference held to map out a public education campaign. There was a consensus among participants that exaggerating the risk of AIDS spread through heterosexual activity was leading to a counterproductive panic in low-risk communities.

AIDS remains primarily an affliction of homosexual men augmented by intravenous drug users, most of the latter in the New York-New Jersey metropolitan area. The disease can be passed through heterosexual intercourse, and all of those interviewed stressed the importance of safe-sex practices by both men and women. But they also believe that AIDS is not likely to reach epidemic proportions through this route because of the apparent difficulty of female-to-male transmission. Easier two-way transmission would be required for AIDS to reach epidemic proportions among heterosexuals.

Heterosexual Transmission

Among the 40,051 AIDS cases recorded nationally, there are 174 males, excluding immigrants from Haiti and Africa, who have been reported to the CDC as having contracted AIDS through heterosexual sex. However, the CDC merely collects these numbers from local health authorities. Although 40% of these 174 case were reported from New York City, subsequent screening by the city’s Health Department found only three men who appear to have contracted the disease from sex with women. Only seven Los Angeles men even claim to have caught the disease heterosexually. In San Francisco, the figures are eight women and seven men out of a total of 3,545 people with AIDS.

Earlier fears of rampant spread of the disease through heterosexual activity, as has been the case in central Africa and Haiti, have simply not materialized in this country. And the relevance of the experience of the world’s poorer regions with their vastly inferior medical and sanitary practices is now being widely questioned. AIDS is primarily transmitted by exchange of blood, and it seems that the prevalence of genital infections in Africa has contributed to the spread of the disease there, whereas such infections are far less frequent and severe in this country.

Comparisons to Africa

“We are not the same as the particular regions of Central Africa where AIDS is epidemic,” Gallo said. “In Africa we can say that a major co-factor in the spread of AIDS is venereal disease. There are lessons to learn from the African situation, but we cannot predict parallel phenomena here.”

Gallo’s observations are part of a growing awareness that heterosexual activity in this country rarely involves the necessary co-factors--wounds permitting blood or blood/semen exchange--for easy transmission of AIDS.

By contrast, in the high-risk groups, blood contact is common. Most of the homosexual spread has been accounted for by anal intercourse, which often involves torn tissue and rectal bleeding, providing an entry for the virus, which is carried in the blood that makes up part of semen. And IV drug users exchange the virus through blood on shared needles, a practice common in the so-called “shooting galleries” frequented by drug addicts in New York and New Jersey. Such needle-sharing is far less frequent in the rest of the nation.

Indeed, the main threat of heterosexual spread is from IV drug use involving needle-sharing. As Dr. Timothy J. Dondero, the head of AIDS surveillance for the CDC, notes: “Seventy percent of the sources of infection for heterosexuals have been drug users--either through infecting their babies or their lovers. For tackling the problems of heterosexual transmission you have to tackle drug use, yet there is a six-month wait for a methadone clinic. It’s scandalous. Whatever happened to the war on drugs?”

Focus on Drug Use

“Dealing with drugs,” Dondero added, “getting people into clinics, screening and counseling of people in drug treatment centers to try to get them not to pass on the infection, that should be a prominent part of the attack on heterosexual transmission. There maybe other things that are showier, like premarital screening, but how about where the problem is stemming from?”

“There’s no doubt in my mind we should be focusing on the high-risk groups, particularly the addict problem,” Gallo said. “That and Africa make everything else seem trivial by comparison. The drug problem is a mess. It’s a national and international disgrace of the first order.”

Dondero and Gallo’s views were echoed by CDC epidemiologist Jaffe: “For anybody who has a son in college, I think the first question ought to be: Is my son gay? If your son is gay or bisexual, then he ought to know a lot about AIDS. Then you ought to ask: Is my son or daughter shooting drugs? It’s not likely, but if it happened, that’s a real problem. But, beyond that, while it’s a good idea to wear rubbers and it’s a good idea not to have sex with everybody you meet, is there a big risk? I think the answer is no; there is not a big risk. The risk is very small.”

Consensus Over Spread

Epidemiologists argue that, if AIDS were spreading rapidly through heterosexual sex, there would already be a far higher incidence of AIDS cases and AIDS-positive tests in the heterosexual population than there currently is. There is a sense among the epidemiologists who professionally chart the course of the disease that alarmists are ignoring the statistics.

“In New York City, which has the highest number of heterosexual cases, the statistics do not show significant heterosexual spread through sexual contact, but rather through primarily poorer people’s use of IV drugs,” reported Dr. Pauline Ann Thomas, the epidemiologist in charge of the city’s AIDS surveillance program. She added that “it’s not a case of the middle-class johns of prostitutes taking it back to their wives in the suburbs. Heterosexual spread is a drug problem--period.”

Some AIDS’s experts, like Harvard virologist William A. Haseltine, still argue the case for a rampant heterosexual spread. In an interview last month, Haseltine cited the experience in Africa, where AIDS is primarily a heterosexual disease, and the results of the U.S. military’s testing of new recruits.

But most of the epidemiologists who have studied the African data insist, as Gallo does, that the circumstances on that continent and in the United States are different in crucial ways. They state also that, if this were not the case and heterosexual transmission were comparable here, the number of AIDS-infected heterosexuals would already be much higher.

Still Relatively New

Haseltine’s answer is that in this country AIDS is still relatively new to the heterosexual population, and he cited the military study to confirm that large numbers of heterosexuals are now testing positive.

But the military statistics have not held up well. Critics charge that military recruits who tested positive were reluctant in many cases to admit to homosexual practices or intravenous drug use, because both are grounds for exclusion from the military, and the former is a crime in some states and the latter in all.

In Colorado, county health workers near the military bases of Colorado Springs were able to re-interview 20 active duty persons who had tested positive. Of that group, 14 ultimately admitted to homosexual contact, whereas only four had admitted it to Army interviewers; three others were in fact IV drug users, whereas the Army had found only one. The civilian researchers, who specialize in investigating sexually transmitted diseases, found that only one of the original 20 fell clearly into the heterosexual transmission category.

A similar re-evaluation of the data in New York City also called into question the military statistics. The largest number of AIDS-positive recruits were in that area, and 25% of them, or 23, subsequently called the city Health Department’s hot line for advice.

Initial Claims

At first, many claimed they had contracted AIDS from heterosexual contact with prostitutes, but later changed their story. Of the 20 who agreed to come into the Health Department office for counseling, 18 fell into the high-risk categories, with 10 admitting to intravenous drug use and eight to homosexual activity. The one woman in the group said she had sex with an IV drug user. The one man who might have contracted it from heterosexual sex alone turned out, on retesting, not to be AIDS positive.

Rand L. Stoneburner, the physician who reported on the New York experience, feels that, while AIDS can be heterosexually transmitted, female-to-male transmission, in this country, has so far proved very unlikely. And such transmission is a vital link for the illness to reach epidemic proportions among non-IV-using heterosexuals.

Stoneburner, a veteran of the CDC who now heads the AIDS research program in New York City, is emboldened in this view by the results of a massive study based in that area’s sexually transmitted disease clinic. The study attempted to isolate a group of heterosexuals who were very sexually active in an area where AIDS was widespread.

Few Cases Turned Up

Yet, despite the fact that these people had contracted other sexually transmitted diseases and often had contact with prostitutes in a neighborhood where bisexual men and IV drug users were common, very few cases of AIDS-positive males have turned up among the heterosexuals.

In the first group of 236 sexually active males, only one of those who tested positive denied being in one of the high-risk groups. The sample is now twice as large and the proportion of non-high-risk sex transmissions has remained the same--very low, two or three men and women. This study is considered especially significant in that it measures for positive test results rather than relying on actual cases of the disease. Although the disease may take as long as 10 years to manifest itself, exposure to the virus itself--which is what the test shows--can be detected within weeks of contact.

Half of the females in the country who are infected are in the New York area, yet only 5% of the males who claim they got AIDS from a woman reside there. This makes no logical sense, because the larger the pool of infected women, the greater the risk for males, and it leaves Stoneburner suspicious of the reporting in other communities. He surmises that there is more pressure to hide drug use or homosexual activity in areas outside of New York and that perhaps investigators there are less experienced or thorough.

Tendency to Over-Report

When one looks at the CDC’s statistics for reported AIDS cases, as opposed to surveys of those who test positive, there may be a similar tendency to over-report the national number of cases of heterosexual transmission.

The CDC’s heterosexual figures look suspicious in the eyes of epidemiologist Thomas, who runs the AIDS surveillance program in New York, where one-third of the nation’s total AIDS cases have been reported. It is suspicious because in that city, where one-third of all AIDS patients live, only five males have claimed they got the disease from heterosexual contact and two of them were drug users.

Thomas reports that 40% of the new cases in New York City are among intravenous drug users, that 80% of women with AIDS are IV drug users and 80% of children with AIDS are the children of IV drug users.

“It’s not the yuppies who are getting AIDS. We don’t want to go to the extreme and say there’s isn’t going to be any heterosexual spread or that people are never infected from prostitutes because it probably has happened. But this idea that prostitutes are going around infecting men, who infect their wives, is not generally true. If it were, we would be seeing more white middle-class men from Scarsdale. But we don’t. It’s the IV community, and that’s where we ought to be putting our efforts.”

Political Realism

But then she added a note of political realism: “IV drug users are not the most popular people in the world. People don’t care so much about black and Hispanic IV drug users.”

Thomas noted that heterosexual spread is not new and that retrospective testing demonstrated that three babies were born with AIDS in New York 10 years ago. Their parents were IV drug users. Knowledge that AIDS is spread in this manner is now several years old, yet New York City still does not have a program of AIDS education targeting drug-using potential mothers.

“This is where we have to pour in resources,” Thomas said. “We have lots of women delivering babies in New York City--120,000 births a year. We’ve known for a year and a half that it would be a good idea to counsel every women when she comes to prenatal care, but that’s not happening yet in New York. We have the highest incidence of AIDS infection in women in the country, yet we don’t give those potential mothers basic information: like do you know what AIDS is and how you get it? And, if it’s before 20 weeks of pregnancy, would she consider an abortion after knowing she’s infected and knowing that 20% to 50% pass it on to babies?” (Although mother-to-child transmission can occur in the uterus, the primary mode appears to be through the milk.)

Distribution of Free Needles

Or should free needles be distributed to IV drug users to discourage needle-sharing? A New York City Health Department proposal to do just that has been languishing for several years pending state approval.

Obviously, such questions play differently politically than do calls for sexual abstinence or widespread testing, but an increasing number of health officials are arguing that they are more relevant.

“Why aren’t we just selling needles in the drugstore?” Stoneburner of the New York City Health Department wondered out loud. “Who are we kidding? Drug use is the problem and everyone is dragging their feet failing to address it.”

In his cluttered cubicle in the crowded building where the New York City Health Department resides and the grimy walls bear witness to bureaucratic inefficiency and timidity, Stoneburner mused that it was easier for the media and politicians to focus on the yuppie bars in Denver, where the virus might spread, than on the black and Hispanic ghettos of New York and New Jersey, where it is now virulent.

“There’s pressure out there for a heterosexual epidemic in mid-America, and maybe if you don’t have a heterosexual epidemic no one is going to do anything about it. If that’s true, we have a bigger problem than AIDS.”

Researcher Nina Green contributed to this story.