AIDS Detective’s Grim Conclusion: Worst of Epidemic Is Yet to Come
During the 1970s, as the nation lived through its drug and sexual revolutions, Dr. James Curran of the Centers for Disease Control in Atlanta was tracking mini-epidemics of genital herpes, resistant strains of gonorrhea, hepatitis B, genital warts, chlamydia and other forms of pelvic inflammatory disease. In May, 1981, when the first five puzzling cases of what would turn out to be acquired immune deficiency syndrome were reported to CDC from three Los Angeles hospitals, Curran was assigned to the mystery. Subsequent cases among young homosexual men predominantly from New York involved Kaposi’s sarcoma, a rare cancer previously confined to elderly men of Mediterranean heritage. The task force Curran was by then heading became known as the “Kaposi’s Task Force.”
In this interview, Curran, one of the world’s leading experts on AIDS, talks about the future of the disease as a threat to us all.
“Kaposi himself is a strange case,” Curran said. “He was a Hungarian Jew named Morris Cohn who was very ambitious and who became a dermatologist and married the daughter of the chairman of dermatology at the University of Vienna Medical School. The chairman suggested to him he might do better with a different name, so he became Morris Kaposi. In 1867, he discovered ‘Kaposi’s sarcoma.’ ”
That rare cancer and many others are among those afflicting AIDS patients.
“The epidemic will get much worse before it gets better, both here and throughout the world,” Curran said.
Question: What is the future of AIDS?
Curran: The question comes in two parts: Where is the epidemic headed in this country and where is it headed throughout the world? Currently, we have much more information about what is going on here than we do elsewhere in the world.
For the U.S., the outlook is very sobering, and we must conclude that AIDS is endemic to the United States. During the last 12 months, there have been 20,000 new cases of AIDS reported to CDC, for an overall total of almost 50,000 (48,574 as of Dec. 14, 1987), and statistics show that 60% of all patients will die within 1 1/2 years of diagnosis and upwards of 90% within three years. We can expect that the number of American AIDS cases will increase for the rest of this decade and that the problem will be with us for the rest of this century.
Our best estimate is that 1 million to 1.5 million Americans have been infected with the human immunodeficiency virus (HIV), and I am confident that this figure is neither too high nor too low. Our data show that within 7.5 years, 35% of all those now infected with the virus will progress to full-blown AIDS and that another 40-45% will progress to AIDS-related complex (ARC) or have lymphadenopathy or other signs of immunological abnormality. Just 20% will remain asymptomatic, and these patients, too, will probably in time become ill.
Our surveillance provides little hope that this is a benign infection. So we are looking at hundreds of thousands of AIDS patients who in the near future will require lifetime care and counseling.
It is an enormous problem, and AIDS continues to spread through sex, through needles and through childbirth.
The good news is that middle-aged gay men appear to have listened to our message, and we are seeing a dramatic drop of new cases among gay men.
The bad news is that the intravenous drug abusers appear not to have listened to our message, and they are our biggest concern. The epidemic of intravenous drug abuse is absolutely central to the spread of AIDS among heterosexuals and children.
The risk to heterosexuals remains unknown, but clearly it is more of a problem in areas like the inner city, where the drug abusers cluster.
Worldwide, there is less data available, but it appears that AIDS is less of a problem in Asia and Europe than in America. It is a growing problem in the Caribbean, and it is a much greater problem in Africa than anywhere else in the world. The World Health Organization estimates that there are 5 million to 10 million AIDS cases worldwide, and I am inclined to accept this estimate, with the caveat that less is known about the world picture than the American picture.
Q: There seems to be a backlash in the news media and a smugness in the general population, suggesting that there is little, if any, risk to heterosexuals who do not abuse intravenous drugs. What is the real risk to heterosexuals who have no acknowledged risk factors?
Curran: There has always been a waxing and a waning of concern about the risk of AIDS to heterosexuals. People want simple answers--like AIDS is going to kill everybody or heterosexuals do not have to worry. The truth, of course, is in the middle, and we can’t give many people what they want--to be told, “It won’t happen to me!”
On the other hand, some people want to think that if everyone’s behavior does not fit their norm of what is acceptable, then everybody should die, and this is not the case, either.
Clearly, the risk to the average non-drug-abusing heterosexual is much, much lower than to people with recognized risk factors, so the best advice a heterosexual can follow is to avoid having sex with either someone with AIDS or someone who has a risk factor--a gay or bisexual male, a hemophiliac or an IV drug abuser.
The most efficient form for spreading the virus appears to be receptive anal intercourse among gay men, although vaginal intercourse is also a reasonably efficient form of transmitting the virus.
However, our studies show a very low incidence of HIV among heterosexuals. The most likely subpopulation of heterosexuals in which to observe HIV infection is exclusively heterosexual, non-IV-drug-using patients at clinics that treat other sexually transmitted diseases. This is where we would expect to see the highest prevalence of HIV among heterosexuals.
The AIDS epidemic is forcing all of us to take a hard look at what our behaviors are really like. Is it that easy for heterosexuals to distance themselves from the AIDS crisis? I don’t think so. And if the epidemic ever hits heterosexuals in a major way, it will be because of this nation’s epidemic of drug abuse.
Q: How serious is the problem of IV drug abuse?
Curran: It is the key to controlling the widening of the epidemic. Three of every five heterosexuals with AIDS acquired it because they abuse IV drugs, and three of every four acquired it either because they abuse drugs themselves or are sexual partners of someone who does. Four of every five babies with AIDS are born to mothers who abuse IV drugs. Three of every four female prostitutes with AIDS acquired it from IV drug abuse.
Of the total 1,920 heterosexual cases of AIDS reported to CDC through Dec. 14, 1,086 (241 men, 845 women) have had heterosexual contact either with someone with AIDS or at risk for AIDS, and the overwhelming majority of these cases are from IV drug abuse. The other 834 heterosexual cases of AIDS (645 men, 189 women) without other identified risk factors were born in countries in which heterosexual transmission is believed to play a major role, although precise means of transmission have not yet been fully defined.
Since heroin abuse is central to the spread of AIDS among heterosexuals and children, our two key goals for the future are to reach and treat the heroin addicts and to provide family planning services for infected women to prevent them from giving birth to kids with AIDS.
Q: What would you like to know about AIDS that you don’t know?
Curran: We know quite a bit about AIDS. We know that it is not spread by insects or mosquitoes. We know that the risk of casual transmission is extraordinarily rare, if at all. We know that the risk to health workers is rare and that this risk, like the greater risk posed by hepatitis B, can be minimized by following the precautions recommended by CDC.
We would like to know more about the actual prevalence of HIV infection.
We would like to know more about how to motivate people, like the heroin addicts, to take the steps they have to take to protect both themselves and their sexual partners and children.
We would like to know why some people appear to be more efficient at spreading the virus than others.
Q: When will the epidemic level off?
Curran: Not anytime in the near future. One crude way of defining a “leveling off” is when the number of new infections each year is equal only to the number of deaths that same year. Well, during the last 12 months, 15,000 people died of AIDS, 20,000 new cases were diagnosed with full-blown AIDS, and many, many more were undoubtedly infected and seroconverted to positive for HIV, although the precise figure is not known.
