Date: Thu, 8 Jun 1995 11:16:47 +0500 From: ghmcleaf{CONTRACTOR/ASPEN/ghmcleaf}%NAC-GATEWAY.ASPEN@ace.aspensys.com Subject: MMWR 06/02/95 CENTERS FOR DISEASE CONTROL AND PREVENTION Morbidity and Mortality Weekly Report June 2, 1995 Vol. 44, No. 21 Update -- Trends in AIDS Among Men Who Have Sex with Men -- United States, 1989-1994 During 1994, local, state, and territorial health departments reported to CDC 34,974 cases of acquired immunodeficiency syndrome (AIDS) among men whose only reported HIV exposure was sexual contact with other men. Although previous reports indicated progressively smaller annual increases in cases of AIDS among men who have sex with men (MSM) (1), male-to-male sexual contact continues to represent the most frequently reported mode of HIV transmission among persons with AIDS. This report summarizes trends during January 1989-June 1994 in the occurrence of AIDS among MSM aged greater than or equal to 13 years. * For this analysis, AIDS surveillance data were reported from the 50 states, the District of Columbia, and Puerto Rico for 6-month reporting periods (i.e., January-June and July-December). Because the AIDS surveillance case definition was expanded in 1993, trends in AIDS incidence are evaluated using the estimated incidence of AIDS-defining opportunistic illnesses (AIDS-OIs) (2). Estimated AIDS-OI incidence is the sum of the observed AIDS-OI incidence and the incidence based on estimated dates of AIDS-OI diagnosis for persons reported with AIDS based only on severe immunosuppression **; both incidences are adjusted for reporting delays and anticipated redistribution of cases initially reported with no identified risk. Because the estimated dates of AIDS-OI diagnosis are based on data from a longitudinal record review project of persons in care, these rates account for changes in AIDS-OI incidence reflecting the effects of antiretroviral therapy or prophylactic therapy for Pneumocystis carinii pneumonia (2). To calculate rates for 1989-1990, the denominators were derived from 1990 U.S. census population estimates; rates for 1991, from 1991 intercensal estimates; and rates for 1992-1994, from 1992 intercensal estimates. For analysis of data by metropolitan statistical area (MSA), denominators were derived from 1990 census data for the United States and Puerto Rico. From January-June 1989 through January-June 1994, rates of AIDS-OI for MSM increased 31%, from 12.1 to 15.9 cases per 100,000 males aged greater than or equal to 13 years (|Figure_1|). Rates varied subtantially by geographic region ***: in the Midwest and South, rates increased 51% (from 5.7 to 8.6) and 49% (from 11.6 to 17.3), respectively. Increases were smaller in the West (21%; mid-1994 rate: 21.7) and the Northeast (13%; mid-1994 rate: 15.0). Increases also varied by race/ethnicity (|Figure_1|), and during January-June 1989 and January-June 1994, rates were highest among black men (20.8 and 37.3, respectively); the largest proportionate increase in rate (79%) during January 1989-June 1994 also occurred among black men. Rates also increased among Hispanic men (61%, from 14.0 in mid-1989 to 22.6 in mid-1994), American Indian/Alaskan Native men (77%, from 3.9 to 6.9), Asian/Pacific Islander men (55%, from 4.0 to 6.2), and white men (14%, from 10.7 to 12.2). Among males in the youngest age group (13-24 years), rates increased for blacks (31%, from 5.2 to 6.8) and Hispanics (39%, from 2.3 to 3.2) but decreased (31%, from 1.6 to 1.1) for whites. By region, the largest race/ethnicity-specific increase in rate occurred among black men in the South (109%, from 16.0 to 33.4). The only decrease occurred among white men in the Northeast (7%, from 10.0 to 9.3). Differences in rates between white men and black and Hispanic men increased in all regions during the 5-year period. The increase in rates also varied substantially by size of MSA. Although rates during mid-1989 were lowest (2.6) in rural areas (i.e., population less than 50,000), the percentage increase in rate was highest in these areas (69%; mid-1994 rate: 4.4) and in MSAs with populations of 50,000-1 million (55%; mid-1994 rate: 10.2). In comparison, although rates during mid-1989 were highest (20.8) in the largest MSAs (i.e., population greater than 2.5 million), these MSAs were characterized by the smallest 5-year percentage increase (19%; mid-1994 rate: 24.8). Since June 1981, three MSAs (New York, Los Angeles, and San Francisco) have reported 27% of all AIDS cases among MSM. During the 5-year surveillance period, rates of AIDS-OI in these three MSAs increased 8%, 12%, and 7%, respectively, (mid-1994 rates: 44.4, 34.9, and 127.7, respectively). In all three MSAs, the rate for white men decreased (20%, 16%, and 3%, respectively), and the rate for black men increased (49%, 48%, and 53%, respectively). Reported by: Local, state, and territorial health departments. Div of HIV/AIDS Prevention, National Center for Prevention Svcs, CDC. Editorial Note: The findings in this report indicate a continuing increase in the occurrence of AIDS-OI diagnosed among MSM during January 1989-June 1994, although increases during this period were smaller than earlier in the epidemic. This decline in the level of increase in AIDS cases among MSM began during the late 1980s (1) and may reflect, in part, decreases in high-risk sexual behaviors and HIV incidence among MSM during the mid- to late 1980s (3). However, the occurrence of AIDS among MSM is high (151,994 new AIDS cases were reported among MSM during the 5-year period), and cases of new infections continue to occur, especially among young MSM. For example, during 1992-1993, HIV seroprevalence was 4.8% among MSM aged 18-23 years in San Francisco (4) and, during 1990-1991, 9% among MSM aged 18-24 years in New York City (5). During the same periods, the overall rates of new HIV infections among MSM in San Francisco and New York City were 1.2% and 2%, respectively (4,5). Regardless of mode of transmission, the incidence of AIDS has been higher among black and Hispanic men than among white men (6). Factors potentially associated with the increased risk among racial/ethnic minorities include decreased access to HIV-prevention services, higher rates of sexually transmitted diseases (7), and culturally inappropriate HIV-prevention activities (8). This report documents the disproportionate occurrence of AIDS among black and Hispanic MSM compared with white MSM during January 1989-June 1994. This finding underscores the need for community planning groups to consider culturally appropriate prevention services when addressing the HIV-prevention needs of racial/ethnic minorities. The use of rates to evaluate trends in estimated AIDS-OI incidence allows comparison of the impact of the epidemic among persons in different racial/ethnic groups, geographic regions, and age groups. However, rates calculated with denominators comprised of all men underestimate the impact of the epidemic among MSM because the true denominator of MSM at risk is substantially smaller than census counts of all men aged greater than or equal to 13 years. Geographic differences in rates of AIDS attributed to male-to-male sexual contact may reflect variations in the prevalence of homosexual behavior and in the prevalence of HIV infection in different communities. For example, when compared with men living in rural areas, the prevalence of men who self-identified as homosexual was seven times greater among men in the 12 largest central cities (9). The AIDS epidemic among MSM should be viewed as a composite of multiple epidemics with different times of onset and patterns of spread. AIDS surveillance data collected by health departments should be used to characterize and track local epidemics and to assist community planning groups and providers in designing and implementing HIV-prevention programs at the community level (10). References 1. Karon JM, Berkelman RL. The geographic and ethnic diversity of AIDS incidence in homosexual/bisexual men in the United States. J Acquir Immune Defic Syndr 1991;4:1179-89. 2. CDC. Update: trends in AIDS diagnosis and reporting under the expanded surveillance definition for adolescents and adults -- United States, 1993. MMWR 1994;43:826-31. 3. Winkelstein W, Wiley JA, Padian NS, et al. The San Francisco Men's Health Study: continued decline in HIV seroconversion rates among homosexual/bisexual men. Am J Public Health 1988;78:1472-4. 4. Osmond DH, Page K, Wiley J, et al. HIV infection in homosexual and bisexual men 18 to 29 years of age: the San Francisco young men's health study. Am J Public Health 1994; 84:1933-7. 5. Dean L, Meyer I. HIV prevalence and sexual behavior in a cohort of New York City gay men (aged 18-24). J Acquir Immune Defic Syndr 1995;8:208-11. 6. CDC. AIDS among racial/ethnic minorities -- United States, 1993. MMWR 1994;43:644-7,653-5. 7. National Commission on AIDS. The challenge of HIV/AIDS in communities of color. Washington, DC: National Commission on AIDS, December 1992. 8. United States Conference of Mayors. Assessing the HIV-prevention needs of gay and bisexual men of color. Laurel, Maryland: Health Consultants International, December 1993. 9. Laumann EO, Gagnon JH, Michaels S. Homosexuality. In: The social organization of sexuality: sexual practices in the United States. Chicago, Illinois: University of Chicago Press, 1994:283-320. 10. Valdiserri RO, Aultman TV, Curran JW. Community planning: a national strategy to improve HIV prevention programs. J Community Health 1995;20:87-99. * Single copies of this and the following report in this issue will be available free until June 1, 1996, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 217-0023. ** CD4+ count less than 200 T-lymphocytes/uL or a CD4+ T-lymphocyte percentage of total lymphocytes of less than 14. *** Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; and West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. HIV Transmission in a Dialysis Center -- Colombia, 1991-1993 Although never reported in the United States, previous reports of possible patient-to-patient transmission of human immunodeficiency virus (HIV) associated with hemodialysis (1,2) indicate the potential for this problem and the importance of infection-control measures in dialysis centers. In May 1994, CDC received a report of a cluster of HIV seroconversions among patients undergoing treatment at a dialysis center in Colombia. This report summarizes the findings of the epidemiologic and laboratory investigations of this cluster by the National Institute of Health in Colombia and CDC (3), which underscore the need for strict adherence to infection-control practices during dialysis (4,5). In May 1993, blood specimens from three patients of the dialysis center in Colombia were HIV-antibody-positive. This finding prompted the subsequent testing of blood specimens from all dialysis center patients that had been stored during January 1988-December 1993 transplant program. An epidemiologic investigation was initiated after these specimens were tested for HIV antibody by enzyme immunosorbent assay and confirmatory Western blot. A retrospective cohort study was conducted among all patients who were dialyzed in the dialysis center from January 1992 (approximately 6 months before the first seroconversion) through December 1993 (epidemic period). An HIV seroconverter was defined as any patient with a documented seroconversion from HIV-antibody-negative to positive during the epidemic period. An HIV seronegative patient was a patient whose most recent serum sample was HIV negative. To determine potential risk factors for HIV seroconversion, HIV seroconverters were compared with HIV seronegative patients. Medical, blood bank, and dialysis center records were reviewed, and confidential interviews were conducted with available patients or family members. Any potential exposures to HIV (e.g., surgical or dental procedures or behavioral risk factors) were included in the analysis if they had occurred less than or equal to 1 year before HIV seroconversion for seroconverters or less than or equal to 1 year before the epidemic period for HIV seronegative patients. In addition to the dialysis center, the endoscopy suite and dental clinic located within the hospital containing the dialysis center were inspected; infection-control practices in these settings were observed. Three isolates of HIV were analyzed from four seroconverters and four controls (controls included two HIV-infected persons from the same city but who had not been dialyzed at the dialysis center and two from a different city). Polymerase chain reaction was used to amplify a 480 nucleotide sequence of the HIV-1 gag gene, which encodes for p24 and p7; in addition, three isolates were analyzed for each HIV-infected person. Of the 84 dialysis center patients dialyzed during the study period (January 1988-December 1993), blood specimens were available for 59 patients. Of these, 13 (22%) were HIV seropositive, including 10 who were HIV seroconverters (nine of whom seroconverted during the epidemic period {January 1992-December 1993}). All HIV seroconverters had undergone greater than or equal to 10 dialysis sessions. Of the nine who seroconverted during the epidemic period, seven were male, two had a history of paying for sex, and five had received blood products (screened for HIV) less than or equal to 6 months before seroconversion; none reported intravenous or illicit drug use or receiving unscreened blood products, and none of the males reported having had sex with other men. None met clinical criteria for acquired immunodeficiency syndrome; four died following seroconversion, but none died because of HIV-related illness. The first HIV seropositive patient dialyzed during the epidemic period (patient A) tested positive 20 days after beginning care at the dialysis center in May 1992. The risk for seroconversion among patients who received dialysis during the 4-month period (May-August 1992) when patient A was dialyzed was significantly higher than for those who were dialyzed only during other months (i.e., nine of 10 versus none of nine; relative risk=infinity; exact 95% confidence interval=3.0-infinity). The only patient who received dialysis during the same period as patient A but who did not seroconvert was recorded to have always used separate patient-care equipment designated for patients known to be infected with hepatitis B virus (HBV); all other patients dialyzed during this period were recorded to have used common equipment. Risk for HIV seroconversion was not associated with other factors, including history of transfusions less than or equal to 6 months before seroconversion, a kidney transplant, or dental or endoscopic procedures. Nucleotide sequence comparison of HIV deoxyribonucleic acid indicated that isolates obtained from the four dialysis center seroconverters were genetically closer to each other (0.02%-0.05% variation) than to the four controls (0.06%-0.08% variation), suggesting a common source for infection in patients in the dialysis center (6). An HIV isolate from patient A, who died 4 months after beginning dialysis at the dialysis center, was not available for testing. Isolates from three of the four dialysis center seroconverters were 100% homologous at the amino acid level. This amino acid homology was not found for isolates from seroconverters compared with controls. The dialysis center had no written policies about reprocessing patient access needles, dialyzers, or blood lines. Interviews with staff nurses indicated that all dialyzers and blood lines were labeled appropriately and individually reprocessed with 5% formaldehyde while still attached to the machine, placed in separate labeled containers, and stored for reuse only on the same patient. In contrast, patient access needles were reprocessed through the use of a 0.16% solution of benzalkonium chloride; in this procedure, the pairs of access needles for two to four patients were placed unlabeled in a common soaking pan for disinfection, and the disinfectant was changed every 7 days. As a result of the investigation, changes in procedures implemented at the dialysis center included cessation of reprocessing patient-care equipment and providing HIV counseling to all infected patients. National surveillance was initiated for HIV infection among patients undergoing dialysis, and the Ministry of Health has banned the use of quaternary ammonium compounds for disinfecting intravascular devices. Reported by: M Velandia, MD, J Boshell, MD, A Iglesias, MD, G Ramirez, MD, National Institute of Health, Advanced Training Program in Applied Epidemiology, Ministry of Health, Bogata, Colombia. B Rengifo, MD, M Essex, DVM, Dept of Cancer Biology, Harvard School of Public Health, Boston, Massachusetts. V Cardenas, MD, Field Epidemiology Training Program, International Br, Div of Field Epidemiology, Epidemiology Program Office; Hospital Infections Program, National Center for Infectious Diseases, CDC. Editorial Note: The epidemiologic and laboratory findings from the investigation described in this report indicate that transmission of HIV in the dialysis center was associated with a common exposure or patient-to-patient transmission. In particular, the investigation implicated receipt of dialysis after an HIV-seropositive patient began dialysis as the most likely risk exposure for infection and suggested that cross-contaminated, inadequately disinfected patient access needles may have been inadvertently shared among HIV-infected and noninfected patients. Benzalkonium chloride, the disinfectant used for reprocessing the needles, is a chemical germicide with low-level activity and is not recommended in the United States for disinfection of intravascular devices (e.g., dialysis access needles) (7). Previous reports of possible patient-to-patient transmission indicate that potential routes for transmission of HIV in other health-care settings include inadequate reprocessing or inadvertent reuse of hypodermic needles and breaks in universal precautions (8,9). The outbreak in Colombia suggests that, in dialysis centers worldwide, reprocessing of patient-care equipment must conform to established infection-control practices (4,5,7). The global implementation of dialysis and other advanced medical technologies must be accompanied by rigorous adherence to infection-control practices. Standards and recommendations outlined by the Association for the Advancement of Medical Instrumentation (10) and CDC (4,5,7), including sterilization before reuse of all intravascular patient-care items (i.e., intravascular access devices), are essential for preventing transmission of bloodborne pathogens such as HBV and HIV. References 1. Dyer E. Argentinian doctors accused of spreading AIDS. Br Med J 1993;307:584. 2. Marcus R, Favero MS, Banerjee S, et al. Prevalence and incidence of human immunodeficiency virus among patients undergoing long-term hemodialysis. Am J Med 1991;90:614-9. 3. Velandia M, Fridkin SK, V Cardenas, et al. Transmission of HIV in a dialysis centre. Lancet 1995;345:1417-22. 4. Favero MS. Precautions for dialyzing human immunodeficiency virus-infected patients. In: Monkhouse PM, ed. Aspects of renal care. London: Balliere Tindall, 1989:55-61. 5. CDC. Recommendations for prevention of HIV transmission in health care settings. MMWR 1987;36 (no. 2S). 6. Myers G. Molecular investigation of HIV transmission {Editorial}. Ann Intern Med 1994; 121:889-90. 7. CDC. Guidelines for handwashing and hospital environmental control. Atlanta: US Department of Health and Human Services, Public Health Service, 1985. 8. Hersh BS, Popovici F, Apetrei RC, et al. Acquired immunodeficiency syndrome in Romania. Lancet 1991;338:645-9. 9. Chant K, Lowe D, Rubin G, et al. Patient-to-patient transmission of HIV in private surgical consulting rooms. Lancet 1994;342:1548-9. 10. Association for the Advancement of Medical Instrumentation, ed. Recommended practice for reuse of hemodialyzers. Arlington, Virginia: Association for the Advancement of Medical Instrumentation, 1993.