AIDS Slowdown in 3 Key Cities Seen : Cases Among White Gays Apparently Level Off in L.A., S.F. and N.Y. Areas

The growth of the AIDS epidemic appears to have slowed dramatically in Los Angeles County, San Francisco and New York City, the American metropolitan areas struck earliest and hardest by the acquired immune deficiency syndrome.

Since early 1987, there has been an apparent leveling off in the number of new cases being reported among white gay men in the three cities, according to an analysis by The Times of publicly available AIDS statistics.

While the exact reasons for the apparent leveling off have yet to be determined, some public health officials say the figures reflect the fact that many gay men have adopted safer sexual practices.

Increase in Drug Users

In contrast, the number of reported AIDS cases in intravenous drug users, many of whom are minority group members, and black and Latino gay men has continued to increase in these cities, as have AIDS cases among gay men and intravenous drug users in other areas in the country.

“It is possible that we may be seeing a plateau in cases in gay men in these cities,” said Dr. Harold W. Jaffe, chief of the AIDS epidemiology branch at the federal Centers for Disease Control in Atlanta. “It would make sense that the first population groups to plateau would be gay men in those cities which were hit first by the human immunodeficiency virus (HIV),” which causes AIDS. Jaffe said there has been “relatively little” new HIV infection in gay men, particularly whites, in the last several years.

Others are less circumspect. “We have hit the crest of the epidemic (among homosexuals),” said Dr. Alexander D. Langmuir of Chilmark, Mass., a retired Centers for Disease Control official who served as the agency’s chief epidemiologist from 1949 to 1970. “I believe this reflects the radical changes in behavior (to prevent HIV infections) that gays adopted even before there was a lot of publicity about AIDS.”

Together, Los Angeles, San Francisco and New York City account for more than a third of the 78,985 AIDS cases reported in the United States as of Nov. 21, including the majority of cases diagnosed in the early years of the epidemic.

Public health officials from around the country said the newly emerging data should be interpreted cautiously, but some acknowledged that these little-publicized trends may represent a glimmer of hope in the often frustrating AIDS fight. A slowing of the epidemic followed by a plateau in the number of cases is expected eventually. Several years ago, however, few experts expected to see possible indications of this slowing so soon.

Important Implications

The data may also have important implications for planning AIDS control programs and for projecting the number of AIDS cases that will occur.

Many public health officials have apparently been fearful of publicizing the recent data because of concerns that it will be seen as indicating that the AIDS epidemic is over among gay men or that it will lead to decreased funding for AIDS programs.

“Everybody seems very nervous about it,” one knowledgeable official said. “There is a concern that if we talk about this, it means (AIDS) is going away. It doesn’t mean that at all. It could be a plateau at a very high level for a very long period of time.”

Dr. Pauline Thomas, director of AIDS and HIV surveillance for the New York City Department of Public Health, said that there are “still lots and lots of (white gay men) getting sick. It is just not more and more every six months. . . . The virus is still out there in thousands and thousands of people.”

Public health officials want to make sure that the data is not just a statistical aberration. It is possible, for example, that the apparent leveling off may simply reflect greater delays and less completeness in reporting of AIDS cases among gay men than in the early years of the epidemic, according to Meade Morgan, chief of the statistics branch in the CDC’s AIDS program.

Dr. Ruth Berkelman, chief of the surveillance branch in the CDC’s AIDS program, said “the issue of reporting fatigue (among health care workers) or being overburdened with cases is a very real one,” particularly in New York City.

Other explanations of the trends are possible, but are considered less likely by many epidemiologists. They include significant under-reporting of cases because of concerns about AIDS-related discrimination and the potentially beneficial effects of experimental medications and life style changes in delaying the development of AIDS in asymptomatic individuals who are infected with the AIDS-causing human immunodeficiency virus. More gay men may also be seeking treatment outside the big cities struck first by the epidemic.

The trends among white gay men also may mean that an even higher percentage of AIDS cases than previously projected will occur in blacks, Latinos, intravenous drug users and individuals who acquire the virus through heterosexual intercourse. In addition, in August, 1987, the CDC broadened its definition of AIDS to include additional HIV-related illnesses, such as severe weight loss and mental confusion. One result of the expanded definition is that the number of cases being reported in minorities and intravenous drug users has increased out of proportion to cases in other risk groups.

More than half of all the AIDS cases reported to the CDC between September, 1987, and September, 1988, were diagnosed in blacks and Latinos, compared to 39% of the cases reported to the agency in the previous year. Over the same period, heterosexual contact cases increased from 2.6% of all AIDS cases reported to 3.6%.

All states require AIDS cases to be reported to public health officials. Typically, health care workers do not get around to reporting AIDS cases until several months after they are first diagnosed. In perhaps 5% to 10% of cases the delay may be one year or more. Some cases are never reported.

As a result, epidemiologists are more confident about discussing trends seen in the early years of the AIDS epidemic--when the number of AIDS cases increased rapidly in Los Angeles, San Francisco and New York City--than trends based on more recent data.

Nevertheless, public health officials in all three cities acknowledged that they have seen a slowing in the growth of the epidemic.

In Los Angeles County, more AIDS cases were diagnosed in the first half of 1987 than in the second half of the year, according to county statistics compiled at the end of October. Among white gay men, 488 AIDS cases were diagnosed in Los Angeles in the first half of 1987 and 469 in the second half of 1987. Only 345 AIDS case reports have been received for the first half of 1988, although more are expected, according to data compiled by the California Department of Health Services. Cases in white gay men account for about three-fifths of the city’s AIDS cases.

“We see a leveling off beginning in the second, third and fourth quarters of 1987” that is not accounted for by a lag in reporting cases, said Dr. Peter Kerndt, medical director of the AIDS epidemiology program for the Los Angeles County Department of Health Services. “It is definitely a real thing. I am not sure what the explanation is.” Kerndt said an intensive review of the county’s AIDS surveillance data is in progress.

New York City counted 1,015 AIDS cases in gay men and 770 in whites during the second half of 1986, but only 926 in gay men and 713 in whites during the second half of 1987, according to CDC statistics. Over the same time interval, reported AIDS cases increased markedly in intravenous drug users, a group that now accounts for nearly half of the city’s cases, and minority group members, who now account for about two-thirds of the city’s cases (the two groups overlap substantially). These conflicting trends resulted in about a 10% increase in the overall number of AIDS cases.

Thomas, of New York City’s health department, said there had been “not a decrease but at least a leveling” of cases in white gay men over the last 18 months. A key concern is under-reporting of cases diagnosed in patients who are treated in doctors’ offices, not in the hospital. “People are aware of this trend but are hesitant to be real self-assured about it, because we really want to prove that (it is not due to under-reporting),” she said.

In San Francisco, the total number of diagnosed AIDS cases for the second half of 1986 is similar to that for the first and second half of 1987. Cases in white gay men--which account for about three-quarters of the city’s AIDS cases--totaled 445 in the second half of 1986, 465 in the first half of 1987 and 434 in the second half of last year, according to the state Department of Health Services.

The number of new HIV infections among gay men in San Francisco has also declined sharply, presumably as a result of changes in sexual behavior. In 1987, only about 1% of uninfected gay men became infected with HIV, according to a report from the San Francisco Men’s Health Study published in the November issue of the American Journal of Public Health. In 1986, the comparable figure was 4%.

Dr. George Rutherford of the San Francisco Department of Public Health said “there are differential rates of growth in the epidemic” with “more rapid growth in non-whites compared to whites and non-white gay and bisexual men compared to white bisexual men.” But he declined to interpret the city’s recent data as showing “any kind of plateau” in the epidemic.

“We have something on the order of 26,000 to 27,000 infected gay men, 20% of whom have developed AIDS six to seven years into the epidemic,” Rutherford said. Even if few new HIV infections occur, Rutherford expects many of the men already infected with the virus to develop AIDS over the next several years.

It is unclear what effect the recent data will have on CDC estimates that 1 million to 1.5 million Americans are currently infected with the AIDS virus and that, by the end of 1992, a total of 365,000 AIDS cases will have developed.

The CDC projects a steady increase in AIDS cases for each of the next four years, but the actual predictions are very imprecise. For example, while the CDC estimates 49,000 new AIDS cases for 1989, the agency is, in statistical parlance, only “68% confident” that the actual number of AIDS cases will be between 32,000 and 56,000, according to a copy of the projections made available by Morgan.

According to Morgan, the current projections, based on AIDS cases diagnosed before June, 1987, and reported to CDC by March, 1988, are “holding up very well.”

But Langmuir, who is preparing a medical journal article that argues that the CDC’s AIDS projections are too high, takes a different view. “We have seen the crest in homosexual cases in 1988,” he said in a telephone interview. “Next year, I expect the total cases in homosexuals to be down, not markedly down, but down by maybe 10% to 15% below the level in 1988.”

TRENDS IN REPORTED AIDS CASES

The rate of growth of the AIDS epidemic appears to have slowed markedly during 1987 in Los Angeles County, San Francisco and New York City, the three areas hit earliest and hardest by the disease. These are the number of AIDS cases reported nationally and in these areas through the end of 1987. Statistics for 1988 are included in the total number of cases but are too incomplete to be interpreted by themselves.

Date of Diagnosis National Los Angeles San Francisco New York City Pre Jan. 1982 372 26 31 174 Jan.-June 82 386 19 34 164 July-Dec. 82 666 56 57 286 Jan.-June 83 1,272 113 130 472 July-Dec. 83 1,623 148 159 535 Jan.-June 84 2,522 196 232 784 July-Dec. 84 3,298 267 333 937 Jan.-June 85 4,679 405 402 1,226 July-Dec. 85 6,037 489 440 1,393 Jan.-June 86 7,749 654 552 1,708 July-Dec. 86 9,297 747 694 1,953 Jan.-June 87 11,415 881 695 2,077 July-Dec. 87 12,355 836 689 2,143 TOTAL 78,985 5,897 5,456 17,417

CASES FOR RISK GROUPS AND BY RACE

The slowing in the rate of growth of the epidemic appears to be most pronounced among gay men and whites. White gay men as a group were among the earliest individuals to be infected with the human immunodeficiency virus. Cases in intravenous drug users, heterosexuals and minority group members are increasing at a faster rate. These are the number of AIDS cases reported nationally and in California for key risk groups and by race through the end of 1987. Statistics for 1988 are included in the total number of cases but are too incomplete to be interpreted by themselves.

UNITED STATES

Date Gay IV Trans- Hetero- Whites Blacks of Diagnosis Men Drug Users fusion sexuals Pre Jan. 82 244 43 * * 219 95 Jan.-June 82 234 67 * * 213 123 July-Dec. 82 404 116 8 8 373 193 Jan.-June 83 780 218 14 13 720 347 July-Dec. 83 995 297 28 14 952 416 Jan.-June 84 1,608 419 45 36 1,533 614 July-Dec. 84 2,120 560 53 47 1,970 855 Jan.-June 85 3,037 799 123 84 2,846 1,123 July-Dec. 85 3,848 1,097 129 125 3,516 1,567 Jan.-June 86 4,852 1,432 207 178 4,573 1,958 July-Dec. 86 5,928 1,613 242 230 5,564 2,288 Jan.-June 87 7,110 2,082 345 324 6,723 2,922 July-Dec. 87 7,209 2,663 337 424 6,969 3,413 TOTAL 48,154 15,374 1,958 2,200 45,456 20,916

Date Latinos of Diagnosis Pre Jan. 82 55 Jan.-June 82 49 July-Dec. 82 96 Jan.-June 83 195 July-Dec. 83 241 Jan.-June 84 352 July-Dec. 84 460 Jan.-June 85 679 July-Dec. 85 897 Jan.-June 86 1,138 July-Dec. 86 1,362 Jan.-June 87 1,660 July-Dec. 87 1,850 TOTAL 11,877

CALIFORNIA

Date Gay IV Trans- Hetero- Whites Blacks of Diagnosis Men Drug Users fusion sexuals Pre Jan.-82 59 * * * 53 7 Jan.-June 82 62 * * * 63 * July-Dec. 82 117 * * * 109 17 Jan.-June 83 238 * * * 240 31 July-Dec. 83 313 8 * * 314 34 Jan.-June 84 451 13 6 * 471 39 July-Dec. 84 583 13 11 * 610 71 Jan.-June 85 858 30 31 8 862 85 July-Dec. 85 1,080 35 30 6 984 134 Jan.-June 86 1,363 48 48 19 1,286 181 July-Dec. 86 1,639 47 51 20 1,571 187 Jan.-June 87 1,860 77 56 34 1,748 262 July-Dec. 87 1,808 106 65 42 1,726 265 TOTAL 12,902 562 371 185 12,311 1,739

Date Latinos of Diagnosis Pre Jan.-82 9 Jan.-June 82 * July-Dec. 82 11 Jan.-June 83 23 July-Dec. 83 38 Jan.-June 84 42 July-Dec. 84 75 Jan.-June 85 113 July-Dec. 85 153 Jan.-June 86 180 July-Dec. 86 223 Jan.-June 87 269 July-Dec. 87 307 TOTAL 1,870

* Five or fewer cases

National statistics as well as those for San Francisco and New York City include cases reported to the CDC through the end of November. California and Los Angeles County statistics include cases reported through the end of October. Other groups not listed include gay men who also use intravenous drugs (5,600 cases nationally), children 12 years of age or younger (1,257 cases nationally) and heterosexual contact cases in individuals born in foreign countries (1,217 cases nationally).

Sources: Meade Morgan, Statistics Branch, AIDS Program, Centers for Disease Control; Donald Wooten, Dr. Alan I. Trachtenberg, Office of AIDS, California Department of Health Services; Los Angeles County Department of Health Services.