AIDS, the deadly disease, today moves relentlessly into its second decade and those who combat it in Baltimore and Maryland find themselves facing cuts in funding, a critical shortage of acute medical care for children and a dearth of innovative programs for hard-to-reach victims such as women, intravenous drug users and adolescents.
Doctors, people with AIDS and activists battling the spread of the epidemic also say that key advisory groups are stalled and mute on controversial issues such as wider AIDS testing programs.
There is no end in sight to the suffering caused by acquired immune deficiency syndrome, a disease that destroys the immune system. But while the disease, which is most often sexually transmitted, is not abating, experts say it is not spreading as quickly as it once did.
Federal Centers for Disease Control officials in Atlanta say that by the end of the year, AIDS deaths since 1981 will top 150,000, and that more than 250,000 cases will have been diagnosed. It is estimated another 1 million to 1.5 million people carry the human immunodeficiency virus, or HIV, which develops into AIDS after an average 10-year incubation period.
In Maryland, state AIDS Administration officials are girding for about 750 to 825 cases in the year ahead.
At the start of the second decade of AIDS there is still no vaccine or cure. But patients are living longer and better thanks to improved drugs and treatments.
The predominance of homosexual sex as the method of infection is also changing. Homosexual men still make up the largest percentage of new cases. But in Maryland, the percentage of new cases of those infected through intravenous drug use or through sex with intravenous drug abusers has nearly caught up with homosexual sex as the leading cause.
Increasingly, AIDS is an epidemic of poor blacks and Hispanics, particularly IV drug users, their sex partners and their children.
This year, AIDS is expected to become the fifth leading cause of death among women, according to the CDC, making women the fastest growing segment of the population infected with AIDS.
The state AIDS Administration will be forced to operate with $1.4 million less in fiscal 1992 than in fiscal 1991, down to $11.3 million from $12.7 million.
Of that, $4 million will come from state general funds, which is $400,000 less than last year, and $7.2 million in federal funds, which is $1 million less than last year. Grants and gifts add about $100,000.
The Ryan White Care Act of 1990, which is designed to improve care of persons with HIV, will change the way the state gets some of its money, says Dr. Eric Fine, deputy director of the AIDS Administration.
In October, Baltimore will become one of two cities that will qualify for this special assistance to cities that have an unusual number of AIDS cases. Sixteen cities across the nation, including San Francisco, Los Angeles and New York, already get this federal support.
"At this point, they're talking in terms of roughly $1 million to $2 million," said Fine. "The money will go directly to Mayor [Kurt L.] Schmoke's office and is earmarked for programs that will benefit minorities and women."
The kinds of things the Ryan White Act requires are central medical services, which includes case management, and central support services, which in the case of women and children have to do with day care, respite care, foster care and residential care.
Although at first blush this sounds like good news, Dr. Kathleen Edwards, director of the AIDS Administration warns, "We don't want people to think we have new money because we really don't. It's not totally all good news."
She said that while the government was adding money under this new program, it was taking money away from other programs.
"Money continues to be a critical factor," Edwards says. "We can't be discouraged about these money problems. We have to stay up and we have to keep working hard."
"We're facing a crisis in the acute medical care of children with HIV infection or at risk for the infection," says Dr. John P. Johnson, the head of pediatric AIDS at the University of Maryland Medical Center.
"Our numbers have swelled tremendously in our clinical operation. We now have gone from operating the clinic a half-day week to three days a week. We're following close to 250 children who are at risk, have HIV disease or AIDS. That is close to a four-fold increase in the last couple of years."
Johnson expects the figures to keep rising. UM data show a steady increase of children on a monthly basis, he says.
The only way hospitals are going to be able to cope with this problem in the future, he believes, is to train general pediatricians to take care of children with HIV disease.
"We have to move away from having these children cared for at one or two institutions in the city," Johnson says. In Baltimore, UM and Johns Hopkins Hospital are shouldering the task, taking care of the majority of children who are already ill with this disease or at high risk for developing it.
"Pediatricians in the community should be taking care of HIV infected kids, using us for consultation only when they need it," he says. "It's going to be too much for single programs to handle. We are now being overwhelmed by the demands of the clinical care of these children and, of course, we have other duties like research and teaching."
Since the start of the epidemic in 1981, a total of 75 Maryland children, 66 of them under five years of age, have been diagnosed with AIDS. Most of the children, 62 of them, have been black. Most of the babies, 40 of them, were born to mothers who were intravenous drug users.
Nationwide, 1,141 babies under five years of age and 308 children between the ages of 5 and 14 have succumbed to the deadly disease.
One of the key concerns of the Mayor's AIDS Coordinating Council is adolescents because the problem of teen pregnancy and sexually transmitted disease, "both of which are on the rise . . ." says Dr. Janet Horn, the chairman.
Last October, the 40-member committee presented Schmoke with a two-pronged plan to address what were seen as "gaps" in efforts to reach teen-agers with better AIDS prevention-education methods in the schools and places they hang out and to provide them with easy access to treatment if they became HIV-infected.
"Since the city runs very good sexually-transmitted disease clinics downtown that work on both STD treatment and teen pregnancy, birth control and contraception, our recommendation was to integrate HIV testing and, eventually, care in that group," Horn says. "A lot of the kids show up there before anywhere else."
The mayor has wholeheartedly endorsed the plan, she said.
Yesterday, Schmoke told the council that "AIDS is still the number one priority" of his administration and city health officials promised to begin full implementation of the plan.
"The STD clinics in Baltimore were one of the first in the country to offer contraceptive counseling," Horn says. "We used to send teens to places like Planned Parenthood. But, all the studies show the best way to hit these kids is in one fell swoop."
The HIV counseling was started a year ago, but until now, only a few patients have had treatment.
The growing numbers of pediatric AIDS cases leads to a number of other implications for pregnant women and adolescents, say UM's Johnson.
"We need more effective education and prevention programs, particularly for women," he stressed.
Greater presence of educators and trainers, provided by the city and health departments, is needed in the neighborhoods, Johnson says. It's just not happening now.
John Stuban, the founder and a spokesman for the activist group known as ACT-UP Baltimore, an acronym for AIDS Coalition To Unleash Power, says that "it has been proven over and over again in the gay community that education has to be repeated, repeated, repeated and has to be continually reinforced.
"There is no city effort in AIDS education in the gay community . . . and only a minimal effort within the HIV drug community. In the schools, it's sporadic at best and it's inconsistent."
ACT-UP, which is a branch of the national group that was founded in San Francisco, has tried to launch a strong effort to try to address the question of women and HIV.
"It is an uphill battle because if you broaden the need for more money, there is no money to pay for people," Stuban explains.
"We see in Baltimore growing needs for women with HIV infection and the problems that follow because they have children. These children are not all infected but they are children of women who are sick and will eventually die. And they will need services. Right now, for example, there are no housing slots for women with AIDS who have families."
Stuban said he would like to see churches take in whole families and care for them.