Date: Fri, 11 Mar 1994 11:21:00 -0500 (EST) From: "ANNE WILSON, CDC NAC" Subject: MORBIDITY AND MORTALITY WEEKLY REPORT 3/11/94 MORBIDITY AND MORTALITY WEEKLY REPORT Centers for Disease Control and Prevention March 11, 1993 Current Trends Heterosexually Acquired AIDS -- United States, 1993 From 1991 through 1992, persons with acquired immunodeficiency syndrome (AIDS) who were infected with human immunodeficiency virus (HIV) through heterosexual transmission accounted for the largest proportionate increase in reported AIDS cases in the United States (1). During 1993, a total of 103,500 persons aged greater than or equal to 13 years with AIDS were reported to CDC. This report summarizes the characteristics of persons reported with AIDS in the United States in 1993 attributed to heterosexual contact, compares data with those for 1992, and presents trends in heterosexual exposure categories.* From 1985 through 1993, the proportion of persons with AIDS who reported heterosexual contact with a partner at risk for or with documented HIV infection increased from 1.9% to 9.0%, respectively (Figure 1). During the same period, the proportion of cases attributed to male-to-male sexual contact decreased from 66.5% to 46.6%, while the proportion attributed to injecting-drug use among women and heterosexual men increased from 17.4% to 27.7%. In 1993, AIDS cases attributed to heterosexual contact (n=9288) increased 130% over 1992 (n=4045). Cases in all other exposure categories combined increased 109% in 1993, when the expanded AIDS surveillance case definition resulted in substantial increases in reported cases in all demographic and exposure categories (2,3). These reports include present AIDS cases diagnosed in 1993 and in earlier years. In 1993, most heterosexually acquired AIDS cases were attributed to heterosexual contact with an injecting-drug user (IDU) (42.3%) or with a partner with HIV infection or AIDS whose risk was unreported or unknown (49.7%) (Figure 2). Men were more likely than women to report contact with a partner with HIV infection or AIDS whose risk was unreported or unknown (60% versus 44%); this group may include persons whose sex partners were IDUs or bisexual men for whom risk was not known or reported and persons whose sex partners were themselves infected heterosexually. Compared with 1992, during 1993 the number of cases associated with heterosexual contact with an IDU (n=3916) increased 79%, and the number of cases associated with heterosexual contact with a partner with HIV infection or AIDS whose risk was unknown or unreported (n=4617) increased 195%. Increases also occurred in the number of cases associated with heterosexual contact with a bisexual man (171%), a person with hemophilia or other coagulation disorder (200%), or a transfusion or transplant recipient (132%). However, the number of cases in these latter three categories is small, and they represent a decreasing proportion of all heterosexual-contact cases (Figure 2). In 1993, heterosexual HIV transmission accounted for 6056 AIDS cases reported among women (median age: 33 years) and 3232 cases among men (median age: 38 years). In addition, 55% of men and 50% of women were non-Hispanic black, and 23% of men and 24% of women were Hispanic (Table 1). Rates were highest for non-Hispanic blacks (20 per 100,000 population) and Hispanics (10 per 100,000) than for non-Hispanic whites (1 per 100,000), Asians/Pacific Islanders (1 per 100,000), and American Indians/Alaskan Natives (2 per 100,000). During 1992 and 1993, persons aged 13-29 years accounted for 25% and 27%, respectively, of heterosexual-contact cases, while representing 18% of total adolescent and adult AIDS cases each year. The highest proportions of cases associated with heterosexual contact during 1993 were in the South** (42%) and Northeast*** (31%); these areas also accounted for 24% and 53%, respectively, of cases reported among heterosexual IDUs (n=28,687). States reporting the largest number of heterosexually acquired AIDS cases in 1993 were Florida (1772 cases), New York (1336), and New Jersey (855). As of December 31, 1993, of 34,952 persons with AIDS ever reported without a behavioral risk factor, 14,787 (42%) had been reclassified; of these, 10% of men and 63% of women were reclassified as having acquired AIDS through heterosexual transmission of HIV (Figure 3). By comparison, in 1993, 4% of men and 37% of women with AIDS were reported as having HIV infection associated with heterosexual transmission. Reported by: Local, state, and territorial health depts. Div of HIV/AIDS, National Center for Infectious Diseases, CDC. Editorial Note: This report documents the continued increase in the number and proportion of AIDS cases attributed to heterosexual HIV transmission. Persons at highest risk for heterosexually transmitted HIV infection include adolescents and adults with multiple sex partners, those with sexually transmitted diseases (STDs), and heterosexually active persons residing in areas with a high prevalence of HIV infection among IDUs (4). In addition, a disproportionate number of persons with AIDS who acquired HIV infection through heterosexual contact are black or Hispanic; monitoring HIV prevalence and AIDS incidence in different racial/ethnic populations can assist in developing culturally and linguistically appropriate HIV-prevention messages. Among heterosexuals at high risk for HIV infection (e.g., heterosexually active clients at STD clinics and drug-treatment centers), the seroprevalence of HIV infection is higher among men than women (5). However, serosurveillance findings indicate that rates of HIV infection are increasing among women in some populations and geographic areas. For example, among disadvantaged young women who enter the Job Corps and among childbearing women in the South, seroprevalence rates were higher during 1991-1992 than during earlier years (5). Therefore, to understand the extent of heterosexual transmission and to develop targeted prevention programs, health officials must account for local variations in population characteristics and behaviors that may affect the risk for HIV transmission. Although some persons classified as having acquired HIV infection through heterosexual contact may have other unreported risk factors (6), the proportions of AIDS cases attributed to heterosexual contact (9% and 6%, respectively, of persons reported in 1993 and cumulatively) probably are a conservative estimate of heterosexual contact AIDS cases. The classification for heterosexual transmission requires a history of heterosexual contact with a partner who has HIV infection, AIDS, or risk factors for HIV infection (i.e., male-to-male sexual contact, injecting-drug use, or receipt of HIV-contaminated blood or blood products). In addition, persons whose origin is a country where heterosexual transmission was presumed to be the predominant mode of HIV transmission (i.e., formerly classified by the World Health Organization as Pattern II countries [7]) and persons who had sex with a person whose origin is such a country are no longer automatically classified as having acquired AIDS through heterosexual contact. To promote more consistent risk ascertainment among persons reported with AIDS, all persons who have no specific risks for HIV infection are classified as "no risk reported." Other persons with AIDS also may have become infected through heterosexual contact. For example, of the 86,961 persons cumulatively classified as IDUs, approximately 12,600 also reported heterosexual contact with a person at risk. In addition, after follow-up investigations are completed, some persons currently classified as "risk not reported" will be found to have risks for heterosexual transmission. To develop more accurate estimates of the proportion of AIDS cases resulting from heterosexual transmission, CDC is collaborating with six local and state health departments to evaluate the validity and accuracy of heterosexual risk information reported to surveillance programs. Compared with persons who acquired HIV infection through other modes of transmission, the number of persons infected through heterosexual transmission is increasing rapidly. Increased awareness of these trends and concerns about STDs and unintended pregnancies among adolescents and young adults should result in enhanced efforts to promote safer-sex behaviors. These behaviors include postponing sexual activity among youths, restricting sexual contact to a mutually monogamous relationship with an uninfected partner, and consistently and correctly using latex condoms during intercourse (8). Because promotion of such behavior change is influenced by community norms (9), CDC has expanded efforts to assist local and state health departments in planning HIV-prevention programs at the community level. References 1. CDC. Update: acquired immunodeficiency syndrome--United States, 1992. MMWR 1993; 42:547-51,557. 2. CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41(no. RR-17). 3. CDC. Update: impact of the expanded AIDS surveillance definition for adolescents and adults on case reporting--United States, 1993. MMWR 1994;43:160-1,170. 4. CDC. Update: heterosexual transmission of acquired immunodeficiency syndrome and human immunodeficiency virus infection--United States. MMWR 1989;38:423-4,429-34. 5. CDC. National HIV serosurveillance summary: results through 1992. Vol 3. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1993:29-30. 6. Nwanyanwu OC, Conti L, Ciesielski CA, et al. Increasing frequency of heterosexually transmitted AIDS in southern Florida: artifact or reality? Am J Public Health 1993;83:571-3. 7. Mertens TE, Burton T, Stoneburner R, et al. Global estimates and epidemiology of HIV infection and AIDS. AIDS: A Year in Review, 1993-1994 (in press). 8. CDC. Update: barrier protection against HIV infection and other sexually transmitted diseases. MMWR 1993;42:589-91,597. 9. National Commission on AIDS. Behavioral and social sciences and the HIV/AIDS epidemic. Washington, DC: National Commission on AIDS, July 1993:44-9. * Single copies of this report will be available free until March 11, 1995, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231. ** South Atlantic, East South Central, and West South Central regions. *** New England and Middle Atlantic regions. Current Trends Update: Impact of the Expanded AIDS Surveillance Case Definition for Adolescents and Adults on Case Reporting -- United States, 1993 During 1993, local, state, and territorial health departments reported 103,500 acquired immunodeficiency syndrome (AIDS) cases among persons aged greater than or equal to 13 years in the United States, an increase of 111% over the 49,016 reported in 1992 (Figure 1). This increase resulted from the expansion of the AIDS surveillance case definition in 1993*; in comparison, the number of cases based on the preexisting case definition decreased slightly. This report summarizes characteristics of persons reported with AIDS in 1993, compares these findings with data from 1992, and describes the impact of the change in the AIDS surveillance definition on AIDS case reporting.** Of cases in 1993, 55,432 (54%) were reported based on conditions added to the definition in 1993; and 48,068 (46%) were reported based on pre-1993 defined conditions--a 2% decrease from the number of cases reported in 1992 (Figure 1). Of the 55,432 cases reported based on 1993-added conditions, 50,061 persons (91%) had severe human immunodeficiency virus (HIV)-related immunosuppression only; 3988 (7%), pulmonary tuberculosis (TB); 1251 (2%), recurrent pneumonia; and 151 ( less than 1%), invasive cervical cancer (19 persons were reported with more than one of these opportunistic illnesses). The number of case reports was highest during the first quarter of 1993 (n=33,875, a 178% increase over the same period in 1992) and declined throughout the year: 18,957 cases were reported during the fourth quarter, a 67% increase over the same period in 1992. Comparing the same quarters of 1993, the median interval between date of diagnosis and date of report declined from 9 months to 4 months among persons reported with the newly added criteria but remained stable for persons reported using pre-1993 criteria. Of the cases reported in 1993, 56% had been diagnosed in earlier years, compared with 42% of cases reported in 1992. In 1993, substantial increases in the number of reported AIDS cases occurred in all regions of the United States (Table 1, page 168). Of areas reporting more than 250 cases, the proportion of cases based on the 1993-added criteria ranged from 35% in North Carolina (n=1353) to 71% in Colorado (n=1323). The increase in reported cases in 1993 was greater among females (151%) than among males (105%) (Table 1, page 168). Proportionate increases were greater among blacks and Hispanics than among whites. The largest increases in case reporting occurred among persons aged 13-19 years and 20-24 years; in these age groups, a greater proportion of cases were reported among women (35% and 29%, respectively) and were attributed to heterosexual transmission (22% and 18%, respectively). Compared with homosexual/bisexual men, proportionate increases in case reporting were greater among heterosexual injecting-drug users (IDUs) and among persons reportedly infected through heterosexual contact (Table 1). The largest proportionate increase in AIDS case reporting occurred among persons with hemophilia, although the total number of these cases was smaller than for the other HIV-exposure categories. Females, blacks, heterosexual IDUs, and persons with hemophilia were more likely than others to be reported with 1993-added conditions (Table 2). Most of these differences were attributable to reports of the three opportunistic illnesses added in 1993; of 5371 persons reported with a 1993-added opportunistic illness, 26% were women, 48% were heterosexual IDUs, and 63% were black. The number of Hispanics reported under the 1993-added criteria reflected reports from Puerto Rico: 38% of the 3173 reports from Puerto Rico were based on the 1993-added criteria, compared with 54% of the 15,145 cases among Hispanics from other areas. The pediatric AIDS surveillance case definition was not changed in 1993. During 1993, 968 children aged less than 13 years were reported with AIDS, an increase of 24% compared with the 783 cases reported in 1992. Of those 968 children, 50% were female, and most were either black (55%) or Hispanic (27%) and were infected through perinatal HIV transmission (93%). New York, Puerto Rico, and Florida reported 489 (51%) of the pediatric AIDS cases. Reported by: Local, state, and territorial health depts. Div of HIV/AIDS, National Center for Infectious Diseases, CDC. Editorial Note: The expansion of AIDS surveillance criteria in 1993 altered both the process of AIDS surveillance and the number of reported cases. The dramatic increase in the number of cases reported probably represents a one-time effect of the expanded reporting criteria that primarily results from reporting of persons who had newly added conditions diagnosed before 1993. The increase in the number of cases reported in 1993 (111%) exceeded the projected increase (75%) (1,2), indicating the rapid and efficient implementation of the revised AIDS surveillance criteria by many local and state health departments. Because the initial impact of the expanded case definition is likely to wane, the number of AIDS cases reported in 1994 is expected to be less than the number reported in 1993. During 1993, the number of reported cases meeting the pre-1993 AIDS surveillance definition decreased 2% from 1992. This reflects the rapid adoption of the CD4+ reporting criteria, which was used for 91% of AIDS case reports that were based on the 1993-added conditions. Therefore, the case count using pre-1993 criteria is not a precise measure of the number of cases that would have been reported if the definition had not been changed because the reporting of conditions meeting the pre-1993 criteria is affected by reporting using the CD4+ and other expanded criteria. For example, some cases reported under the expanded criteria may have had a concurrent or subsequent AIDS-defining condition in 1993 that was not reported; conversely, reporting of these pre-1993 conditions may have been enhanced by follow-up of cases initially reported with a newly added condition. In addition to active surveillance in hospitals and outpatient clinics, local health departments have employed different methods and sources to implement the expanded reporting criteria; these include laboratory-initiated surveillance for HIV antibody and CD4+ measurements (in states that require such reporting) and for AIDS-defining opportunistic infections and information obtained from TB and cancer surveillance registries (3,4). Group-specific differences may exist in the incidence of 1993-added conditions and in access to and use of HIV testing and clinical-care services. For example, the large increase in AIDS reporting among persons with hemophilia may reflect high levels of HIV testing and immunologic monitoring in this population in which new HIV infections have been rare since 1985. Females, IDUs, and blacks were most likely to be reported with new AIDS-defining opportunistic illnesses. This difference largely reflects the population coinfected with Mycobacterium tuberculosis and HIV (5). In 1993, the rate of increase in case reporting was greatest for women, racial/ethnic minorities, adolescents, IDUs, and persons infected through heterosexual contact. These trends in AIDS case reporting are similar to those observed in previous reporting years and suggest that changes in 1993 reflect, in part, underlying changes in the epidemic. Because race and ethnicity are not risk factors for HIV infection, an assessment of risk behaviors is necessary to properly target prevention efforts. The higher incidence of AIDS among non-Hispanic blacks and Hispanics than among non-Hispanic whites emphasizes the need for culturally sensitive and appropriate prevention messages. Although the pediatric case definition remained unchanged in 1993, the number of children reported with AIDS increased and paralleled the increase in AIDS among women. The surveillance information available as a result of the expanded AIDS reporting criteria provides a representative and more complete estimate of the number and distribution of persons with severe HIV-related immunosuppression and three major HIV-related illnesses that are particularly important among groups in whom the growth of the AIDS epidemic has been greatest. In general, persons with 1993-added conditions had higher CD4+ counts than other persons with AIDS. The ability to conduct surveillance for persons in earlier stages of HIV infection should result in more prompt recognition of changes in the trends of HIV transmission and disease. The expanded reporting criteria also have made reporting more complete because persons with 1993-added conditions who had died would not have been reported if the AIDS surveillance definition had not been changed. The addition of the pulmonary TB reporting criteria has more than doubled the number of persons with AIDS reported with TB. Although the number of HIV-infected women reported with invasive cervical cancer is relatively small, the inclusion of this potentially preventable and life-threatening condition in AIDS surveillance efforts provides an opportunity to monitor gynecologic care for HIV-infected women. The expanded AIDS surveillance information should facilitate community efforts to plan, direct, and evaluate HIV-prevention and HIV-care programs. References 1. CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41(no. RR-17). 2. CDC. Impact of the expanded AIDS surveillance case definition on AIDS case reporting--United States, first quarter, 1993. MMWR 1993;42:308-10. 3. CDC. Assessment of laboratory reporting to supplement active AIDS surveillance--Colorado. MMWR 1993;42:749-52. 4. Trino R, McAnaney J, Fife D. Laboratory-based reporting of AIDS. J Acquir Immune Defic Syndr 1993;6:1057-61. 5. Slutsker L, Castro KG, Ward JW, Dooley SW. Epidemiology of extrapulmonary tuberculosis among persons with AIDS in the United States. Clin Infect Dis 1993;16:513-8. * On January 1, 1993, the AIDS surveillance case definition for adolescents and adults was expanded beyond the definition published in 1987 to include all human immunodeficiency virus-infected persons with severe immunosuppression ( less than 200 CD4+ T-lymphocytes/uL or a CD4+ T-lymphocyte percentage of total lymphocytes of less than 14), pulmonary tuberculosis, recurrent pneumonia, or invasive cervical cancer (1). ** Single copies of this report will be available free until March 11, 1995, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231. Notice to Readers International EIS Course CDC and Emory University will cosponsor a course designed for practicing health professionals in international public health. This course, "The International EIS [Epidemic Intelligence Service] Course," will be held at CDC October 3-28, 1994. It emphasizes the practical application of epidemiology to international public health problems and will consist of lectures, discussions, workshops, classroom exercises (including actual epidemiologic case studies), and an on-site community survey. The topics covered will include descriptive epidemiology and biostatistics, analytic epidemiology, epidemic investigations, public health surveillance, surveys and sampling, computers and computer software, and discussions of selected prevalent diseases. There is a tuition charge. Applications must be received by June 15. Additional information and applications are available from Department PSB, Emory University, School of Public Health, 1599 Clifton Road, NE, Atlanta, GA 30329; telephone (404) 727-3485 or 727-0199; fax (404) 727-4590.