Date: Thu, 25 Apr 1996 16:51:51 -0400 From: "Flynn Mclean" Subject: Introduction to CDC 1995 Year-End Surveillance Report HIV/AIDS Surveillance Report U.S. HIV and AIDS Cases Reported Through December 1995 Year-End Edition Vol. 7, No. 2 U.S. Department of Health and Human Services Public Health Service Centers for Disease Control and Prevention National Center for HIV, STD, and TB Prevention Atlanta, GA 30333 The HIV/AIDS Surveillance Report is published semiannually by the Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention,* Centers for Disease Control and Prevention (CDC), Atlanta, GA 30333. The year-end edition contains additional tables and graphs. All data contained in the Report are provisional. Suggested Citation: Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 1995;7(no.2):[inclusive page numbers]. Centers for Disease Control and Prevention David Satcher, M.D., Ph.D. Director National Center for HIV, STD, and TB Prevention* Helene D. Gayle, M.D., M.P.H. Director Division of HIV/AIDS Prevention Helene D. Gayle, M.D., M.P.H. Acting Director Surveillance Branch John W. Ward, M.D. Chief Reporting and Analysis Section Patricia L. Fleming, Ph.D. Chief Russ P. Metler, R.N., M.S.P.H. Surveillance Report Coordinator Statistics and Data Management Branch W. Meade Morgan, Ph.D. Chief Xenophon M. Santas Assistant Chief for Operations Technical Information Activity Sara T. McGaughey, M.L.I.S. Chief Acquired immunodeficiency syndrome (AIDS) is a specific group of diseases or conditions which are indicative of severe immunosuppression related to infection with the human immunodeficiency virus (HIV). Single copies of the HIV/AIDS Surveillance Report are available free from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone 1 800 458 5231 or 1 301 217 0023. Individuals or organizations can be added to the mailing list by writing to MASO/MSB/IDS, CDC, Mailstop A-22, 1600 Clifton Rd., N.E., Atlanta, GA 30333. Internet users may view an electronic copy of the Report by visiting CDC's home page (http://www.cdc.gov) and selecting the topic "More Publications, Products, and Subscription Services." Confidential information, referrals, and educational material on AIDS are available from the CDC National AIDS Hotline: 1 800 342 2437, 1 800 344 7432 (Spanish access), and 1 800 243 7889 (TTY, deaf access). The HIV/AIDS logo on the cover is used with permission of the American Red Cross. *Pending approval by the Department of Health and Human Services. Contents Percent of AIDS cases by race/ethnicity and year of report, 1985-1995 [graph on cover; not included in text-only edition] Commentary AIDS tables Table 1. AIDS cases and annual rates per 100,000 population, by state Table 2. AIDS cases and annual rates per 100,000 population, by metropolitan area with 500,000 or more population Table 3. AIDS cases by age group, exposure category, and sex Table 4. Male adult/adolescent AIDS cases by exposure category and race/ethnicity Table 5. Female adult/adolescent AIDS cases by exposure category and race/ethnicity Table 6. Pediatric AIDS cases by exposure category and race/ethnicity Table 7. AIDS cases in adolescents and adults under age 25, by sex and exposure category Table 8. AIDS cases by age at diagnosis and exposure category Table 9. AIDS cases by sex, age at diagnosis, and race/ethnicity Table 10. AIDS cases and annual rates per 100,000 population, by race/ethnicity, age group, and sex Table 11. AIDS cases by year of diagnosis and definition category Table 12. AIDS-indicator conditions, by age group Table 13. AIDS cases, case-fatality rates, and deaths, by half-year and age group Table 14. Deaths in persons with AIDS, by race/ethnicity, age at death, and sex Table 15. Adult/adolescent AIDS cases among Hispanics, by exposure category and place of birth Table 16. Health care workers with documented and possible occupationally acquired AIDS/HIV infection, by occupation Table 17. Adult/adolescent AIDS cases by single and multiple exposure categories AIDS figures [not included in text-only edition] Figure 1. Male adult/adolescent AIDS annual rates per 100,000 population Figure 2. Female adult/adolescent AIDS annual rates per 100,000 population Figure 3. Male adult/adolescent AIDS cases Figure 4. Female adult/adolescent AIDS cases Figure 5. Pediatric AIDS cases Figure 6. AIDS cases by quarter-year of report and age group Figure 7. Investigations of adult/adolescent AIDS cases ever classified as risk not reported or identified Estimated AIDS-opportunistic illness tables Table 18. Estimated AIDS-opportunistic illness incidence, by region of residence and year of diagnosis Table 19. Estimated AIDS-opportunistic illness incidence, by race/ethnicity and year of diagnosis Table 20. Estimated AIDS-opportunistic illness incidence, by age group, sex, exposure category, and year of diagnosis HIV infection (not AIDS) tables Table 21. HIV infection cases (not AIDS), by state Table 22. Male adult/adolescent HIV infection cases (not AIDS), by exposure category and race/ethnicity Table 23. Female adult/adolescent HIV infection cases (not AIDS), by exposure category and race/ethnicity Table 24. Pediatric HIV infection cases (not AIDS), by exposure category and race/ethnicity Table 25. HIV infection cases (not AIDS) in adolescents and adults under age 25, by sex and exposure category Table 26. HIV infection cases (not AIDS), by sex, age at diagnosis, and race/ethnicity Table 27. Persons living with HIV infection (not AIDS) and with AIDS, by state and age group Technical Notes Commentary The HIV/AIDS surveillance data in this report characterize the populations affected by HIV-related illness and death and provide a current profile of HIV/AIDS at the national level. The epidemic's impact on the nation's health was highlighted during 1995, when the cumulative number of reported AIDS cases surpassed one-half million. Of 513,486 persons with AIDS reported through December 1995, over 62 percent have died. Among persons ages 25 to 44 years, HIV infection is now the leading cause of death in men and the third leading cause in women. As expected, the number of cases reported during 1995 (74,180) was lower than the numbers reported during 1994 (79,897, Table 1) and 1993 (105,828), reflecting the waning effect of the expanded 1993 AIDS surveillance case definition. However, in 1995 the number of cases reported was 56 percent higher than in 1992 (47,453), before the case definition was expanded. Because the numbers of cases reported annually during the period 1992 through 1995 have fluctuated, and because persons reported with AIDS during a calendar year had AIDS diagnosed during that year or prior years, CDC has developed statistical methods to examine temporal trends in the epidemic (see Technical Notes). These methods estimate the incidence of AIDS opportunistic illnesses (AIDS-OIs) by taking into account the change in the case definition and lags in reporting of cases to CDC. Results show that from 1992 through 1994, the estimated incidence of AIDS-OIs increased by 8 percent overall. Trends in the incidence of AIDS-OIs varied by region, race/ethnicity, sex, and mode of exposure (Tables 18, 19, 20). From 1992 through 1994, the incidence of AIDS-OIs increased in the South (13 percent) and the Northeast (11 percent), and among blacks (17 percent), Hispanics (13 percent), men (5 percent), and women (26 percent). Increases also occurred among Asians/Pacific Islanders and American Indians/Alaska Natives; however, these populations each account for less than 1 percent of estimated AIDS-OIs. By mode of HIV exposure, the largest increases occurred among heterosexual men and women who acquired HIV through injecting drug use (men 11 percent; women 12 percent) or through heterosexual contact (men 38 percent; women 46 percent). Although the incidence of estimated AIDS-OIs is increasing most rapidly among persons infected heterosexually, men who have sex with men continue to represent the largest number and proportion of persons estimated to have AIDS-OIs. The demographic characteristics, behavioral risks, and geographic distribution of persons with AIDS reported during 1995 reflect shifts in the populations at risk for HIV/ AIDS, most notably the changing racial/ethnic profile shown on the cover of this report. The cover illustrates a shift in the epidemic from whites to minorities, especially blacks and Hispanics. In 1995, for the first time, the proportion of persons reported with AIDS who are black was equal to the proportion who are white (40 percent). In 1995, blacks and Hispanics represented the majority of cases among men (54 percent) and women (76 percent). The reported AIDS incidence rate per 100,000 among blacks (92.6) was 6 times higher than that among whites (15.4) and 2 times higher than that among Hispanics (46.2). Rates were lowest among American Indians/ Alaska Natives (12.3) and Asians/Pacific Islanders (6.2). However, HIV/AIDS surveillance data collected from medical records do not include measures of socioeco-nomic status such as education and income that may more accurately predict risk of HIV than demographic factors such as race/ethnicity. Case report information obtained by health care providers through routine patient history-taking may include one or more risk behaviors or potential modes of exposure to HIV (Table 17). Efforts to prevent HIV infections through community-based prevention pro-grams are enhanced by knowledge of HIV risk behaviors in the local community. Most adults/adolescents reported with AIDS have risk information recorded (93 percent, Table 3). Although persons most recently reported with AIDS are more likely to have unreported risk information because medical record reviews are incomplete or pending, most persons are ultimately identified as having a recognized risk factor (Figure 7). HIV reports provide a minimum estimate of the number and characteristics of persons in the community who have been tested for HIV; however, a higher proportion of HIV than AIDS reports has incomplete HIV exposure information. Persons reported with HIV (not AIDS) are younger, more likely to be women and black or Hispanic minorities, and more recently infected than persons reported with AIDS (Tables 22 through 26). HIV surveillance data should be interpreted with knowledge of local practices because they are influenced by the availability of HIV test facilities and the proportion of HIV-infected persons who seek or defer HIV testing. Among men reported with AIDS in 1995, male-to-male sexual contact again accounted for the largest proportion of cases (51 percent), followed by injecting drug use (24 percent, Table 4). These proportions will increase slightly as exposure information is completed for persons initially reported without a risk for HIV infection (13 percent). Among young men (ages 20 to 24 years), male-to-male sexual contact and/or injecting drug use accounted for 76 percent of AIDS cases and 63 percent of HIV infection cases reported in 1995 (Tables 7 and 25, respectively). Women accounted for 19 percent of adult/adolescent AIDS cases in 1995, the highest proportion yet reported among women. Most women acquired HIV infection through injecting drug use (38 percent) or sexual contact with a man with or at risk for HIV infection (38 percent, Table 5). The injecting drug use-associated epidemic among men is reflected in the heterosexual epidemic among women. Women may not recognize or report the risk behaviors of their partners, and health care providers may only record the HIV/AIDS status of a woman's male partners and not her partners' risk behaviors. Therefore, an increasing proportion of women are likely to be classified in the exposure category "sex with HIV-infected person, risk not specified." The epidemic in women is reflected in the epidemic in children, nearly all of whom acquired HIV infection perinatally. In 1995, 84 percent of children reported with AIDS were black or Hispanic, and AIDS rates per 100,000 population among black and Hispanic children were 16 and 6 times higher (6.4 and 2.3, respectively) than among white children (0.4, Table 10). The number of children reported with AIDS in 1995 (800) was lower than that reported in 1994 (1,034). Changes in surveillance practices, the number of infected women giving birth, and the clinical management of women and children may each have contributed to this decline. Studies are underway to determine the relative contributions of each of these factors. In 1995, the 28 states that reported HIV infection (not AIDS) among children reported 229 pediatric AIDS cases and 342 pediatric HIV cases (Table 24). In these states, reports of children perinatally exposed to HIV (with subsequent follow-up to determine infection status) will be useful in evaluating the impact of Public Health Service guidelines on preventing perinatal transmission (see Suggested Reading). The 1993 expansion of the AIDS surveillance case definition has caused fluctuations in the numbers of reported AIDS cases during the past 3 years. However, reporting trends are gradually stabilizing. Each year since 1993, a larger proportion of persons with AIDS was reported based on immunologic criteria added to the case definition. State-to-state fluctuations in reporting patterns may reflect a number of factors, including use of laboratory-initiated reporting of severe immunosuppres-sion, enhanced surveillance efforts in some states, and increases in AIDS incidence in some geographic areas. In many of the states (Table 1) and metropolitan areas (Table 2) that reported more cases in 1995 than in 1994,HIV was introduced later than in the bicoastal epicenters, where the epidemic emerged early in the 1980s. However, reported AIDS incidence rates per 100,000 population remained highest in Puerto Rico, New York, Florida, New Jersey, Maryland, and Connecticut, and in heavily affected metropolitan areas, many of which are in these same states (e.g., Jersey City, San Francisco, West Palm Beach, San Juan, Baltimore, New Haven, Orlando, and Hartford). To promote the uses of national HIV/AIDS surveillance data for tracking the epidemic, for program planning and evaluation, and for facilitating comparisons to state and local surveillance data, the HIV/AIDS Surveillance Report is now available through the Internet. See page 2 of this report for the address of CDC's home page. Suggested Reading 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. CDC. Recommendations of the U.S. Public Health Service Task Force on the use of zidovudine to reduce perinatal transmission of human immunodeficiency virus. MMWR 1994;43(RR-11): 1-20. CDC. Update: acquired immunodeficiency syndrome United States, 1994. MMWR 1995;44:64-67. CDC. Update: AIDS among women United States, 1994. MMWR 1995;44:81-84. Erratum: MMWR 1995;44:135. CDC. Update: trends in AIDS among men who have sex with men United States, 1989-1994. MMWR 1995;44:401-04. CDC. First 500,000 AIDS cases United States, 1995. MMWR 1995;44:849-53. CDC. 1995 revised guidelines for prophylaxis against Pneumocystis carinii pneumonia for children infected with or perinatally exposed to human immunodeficiency virus. MMWR 1995;44(RR-4):1-11. CDC. U.S. Public Health Service recommendations for human immunodeficiency virus counseling and voluntary testing for pregnant women. MMWR 1995;44(RR-7):1-15. CDC. Update: mortality attributable to HIV infection among persons aged 25-44 years United States, 1994. MMWR 1996;45:121-25.