The grim demographics of AIDS have made Maryland one of the states hardest hit by the epidemic.
Though 19th in population, the state ranks in the top 10 for two important AIDS indicators: rate per 100,000 population and total cases since 1981.
Maryland has the nation's eighth-highest rate, 47.6 documented cases of acquired immune deficiency syndrome per 100,000 residents, according to the national Centers for Disease Control and Prevention.
And, with 7,420 Marylanders diagnosed with the fatal disease since 1981, Maryland ranks ninth in cumulative AIDS cases.
New York, with 64,981 cases, leads the nation, says the CDC. The rest of the top 10 by number of cases are California, Florida, Texas, New Jersey, Illinois, Georgia, Pennsylvania and Massachusetts.
The most recent AIDS rate tallied by the CDC is for the 12 months through September. The national leader is the District of Columbia, with 232.3 cases per 100,000 population.
Maryland's rate of 47.6 is nearly double last year's 24.5 cases per 100,000 residents.
"What does 47.6 mean? It shows the epidemic is having one of the largest adverse impacts on this state," says Dr. John W. Ward, chief of HIV/AIDS surveillance for the CDC.
New York, second in the nation in population, is No. 2 in AIDS cases per 100,000 residents, with a rate of 88.4. Florida, fourth in population, is third at 70.6; and California, No. 1 in population, is fourth at 56.4.
The rest of the top 10 in AIDS rate are: New Jersey (56.3), Connecticut (51.4), Delaware (49.9), Nevada (44.0) and Massachusetts (42.4).
Demographic factors associated with the epidemic, such as urbanization and drug abuse, help account for Maryland's relatively high rate.
The same factors abound from the nation's capital to Boston, giving the Northeast Corridor the highest concentration of AIDS in the country.
In the early 1980s, the vast majority of cases stemmed from homosexual sex, and AIDS cases therefore clustered in urban centers with large gay populations.
More recently, the percentage of people infected by needles shared by intravenous drug users has increased. As a result, densely populated areas with high intravenous drug abuse show high rates of AIDS.
"You are going to see the states with the higher number of AIDS cases along the East Coast and Florida, and then you jump to California," says Dr. Liza Solomon, an epidemiologist at the Johns Hopkins School of Hygiene and Public Health. "That's pretty much the way it has been throughout the epidemic."
In part, Maryland's caseload, like caseloads nationwide, has risen because of a change made last year in the definition of
AIDS used by the CDC, says Dr. Kathleen Edwards, director of the state AIDS Administration.
The new definition is broader, so the number of people diagnosed with AIDS automatically increased. "We have seen a XTC huge increase in the number of cases reported. We should see some leveling off next year," Dr. Edwards says.
As for drug use, it usually is "associated with poverty and disenfranchised populations," says Dr. Alfred Saah, an epidemiologist at the Hopkins public health school. In big cities, "there is going to be perhaps a larger amount of drug use, given the larger numbers of people who are poor, and that may explain the geographic distribution that we are seeing."
In Maryland, the highest rates of drug abuse are found in Baltimore, which has an estimated 30,000 to 40,000 intravenous drug users.
Slightly fewer than half the AIDS cases reported in Maryland this year have been in Baltimore, 427 out of 862.
The area in the state with the next highest incidence of AIDS is Prince George's County, which has an estimated 5,000 to 6,000 intravenous drug users and recorded 177 people with AIDS. Montgomery and Baltimore counties follow with the third- and fourth-highest numbers of AIDS cases.
D.C. rate highest
Washington has the seemingly astronomical rate of 232.3 cases of AIDS reported per 100,000 residents. However, that rate is skewed by the district's dense population and small geographic area compared with the states.
Since 1981, 5,309 residents have been diagnosed with AIDS in Washington, a city of 588,620. That contrasts with 7,420 diagnosed with AIDS since 1981 in Maryland, with 4,908,453 residents.
Proximity to Washington, where 1,370 people have been diagnosed with AIDS this year, might play a role in the high Maryland caseload, some health officials suggest.
"The ease of travel back and forth between the city and the county -- and people engaging in behaviors that put them at risk -- adds to the spread of the virus," says Maureen McCleary, HIV/AIDS director for the Prince George's County Health Department.
But drugs are not the only factor contributing to the spread of the human immunodeficiency virus, which causes AIDS.
"We need to recognize the pervasive nature of HIV. By pervasive I mean it is a sexually transmitted disease that eventually people can pick up as easily as gonorrhea, which is an extraordinarily easily transmitted disease," Dr. Saah says.
The AIDS epidemic is viewed by health professionals as consisting of three smaller epidemics, three "waves" of infection. The first wave is made up of HIV infection spread by homosexual sex; the second, by needles shared among intravenous drug users; the third, by heterosexual sex, says Dr. Ward of the CDC.
"In the case of the Northeast, these three aspects are present, which compounds the problem of prevention," he says. Prevention efforts must "address the gay community but be effective for IV drug users, their partners and the heterosexual community in general."
Risk is everywhere
North Dakota, with 0.6 AIDS cases per 100,000 population, has the lowest rate in the country. But health officials point out that the risk of HIV infection still exists there -- and everywhere.
"Saying that this is an [East Coast] disease doesn't make sense," says Dr. John Lewis, assistant commissioner for preventive medicine and epidemiology for the Baltimore Health Department.
"In the same way, people who sit in the suburbs and say, 'Oh, it's an inner-city disease,' don't make sense," says Dr. Lewis. "We don't have a cure. . . .
"Why should HIV spread any differently from syphilis or gonorrhea -- and they certainly spread in the suburbs."