The expanding regional diversity of the acquired immunodeficiency syndrome epidemic in the United States.

BACKGROUND: The geographic spread of the human immunodeficiency virus (HIV) epidemic reflects multiple subepidemics in different regions and population groups. METHODS: To describe regional trends in the acquired immunodeficiency syndrome (AIDS) in the United States, we analyzed national surveillance data for persons with AIDS diagnosed from 1988 through 1991. RESULTS: Highest annual AIDS incidence rates were in the US territories (52.7 per 100,000) and the Northeast (27.7 per 100,000). The greatest percentage increases were in the US territories (68.8%), the South (60.1%), and the Midwest (52.4%). Men who have sex with men constituted the majority of AIDS cases nationally (54.6%), as well as in the Midwest (67.8%), the South (57.4%), and the West (75.3%). Among injecting drug users, the greatest rates of increase in AIDS cases were observed among blacks in the South. Although large increases in the number of persons with HIV transmitted through heterosexual contact were reported from almost all regions, the largest increase was in the South. CONCLUSION: High rates of increase in AIDS cases from the Midwest, South, and US territories probably reflect later entry of HIV into these regions compared with the earlier HIV epidemics in large metropolitan areas of the Northeast and West. In particular, because the South has the largest population of the regions, and sexually transmitted disease surveillance data suggest that substantial populations in the South are at risk, the marked increase in AIDS incidence in this region suggests that the major impact of the epidemic may yet be seen. The continuing spread of HIV and AIDS in different communities and regions demonstrates the need to expand preventive and therapeutic services.

Epidemiology of AIDS in incarcerated persons in the United States, 1994-1996.

OBJECTIVE: To compare demographic, behavioral, and geographic characteristics of incarcerated persons with AIDS and those of all persons with AIDS reported from January 1994 through December 1996. DESIGN: Population-based surveillance. SETTING: Medical records of persons for whom AIDS diagnosis was made in hospitals, clinics, and other settings (e.g., prisons) in the United States. PATIENTS: Adults (13 years or older) with AIDS reported from January 1994 through December 1996. RESULTS: Of the 220000 AIDS cases in adults, 4% were reported in incarcerated persons. Compared with all persons with AIDS, a higher proportion were male (89% versus 82%), black (58% versus 39%), younger at time of diagnosis (35 versus 37 years), had injected drugs (61% versus 27%), and were reported on the basis of the 1993 immunologic criteria (71% versus 50%). Fewer cases in incarcerated persons were diagnosed at death (3% versus 10%). The South (38%) and the Northeast (37%) United States accounted for the largest proportion of incarcerated persons. The 1996 AIDS rate for incarcerated persons (199 per 100000) was six times the national rate of 31 per 100000. Among persons incarcerated at time of diagnosis, rates for women were higher than for men (287 versus 185 per 100000) and higher for blacks and Hispanics than for whites (253, 313, and 100 per 100000, respectively). By state of report, Connecticut had the highest rate among incarcerated persons (1348 per 100000). CONCLUSION: These data illustrate differences in demographic, behavioral, and geographic characteristics of incarcerated persons compared with all persons with AIDS. However, they reflect only the minimum numbers of incarcerated persons with AIDS in the United States. Our results highlight the need for state health departments to work with correctional systems to ensure accurate and timely reporting of AIDS cases and to develop HIV prevention, education, and treatment both in prison and on release into the community.

Changes in AIDS incidence for men who have sex with men, United States 1990-1995.

OBJECTIVES: To describe changes in AIDS incidence for men who have sex with men (MSM) from 1990 to 1995, by demographic and geographic groups. METHODS: We examined national AIDS surveillance data reported up to 30 September 1996, for men who received AIDS diagnoses in the years 1990-1995 and whose only reported risk behavior was sex with men. We evaluated trends in AIDS rates by estimating the incidence of clinical AIDS (AIDS defined by opportunistic illnesses), and report clinical AIDS incidence rates for MSM (AIDS rates) and proportional change in rates from 1990 to 1995. RESULTS: Clinical AIDS rates (MSM per 100,000 men per year) increased by 12% from 25.5% in 1990 to 28.5% in 1995. Significant variations in AIDS rates and 5-year changes in AIDS rates were observed in various subgroups of MSM. Five-year increases in AIDS rates were highest for American-Indian/Alaskan native (53%), black (45%), and Hispanic (23%) MSM; the only decrease occurred for white MSM (-2%). Incidence for black MSM increased from twofold (in 1990) to threefold (in 1995) the rate for white MSM. Large increases in AIDS rates were observed for MSM in rural areas (34%) and areas with 50,000 to 249,999 residents (34%) and for MSM aged over 60 years (32%). CONCLUSIONS: The high national AIDS rate for MSM continued to rise, but more slowly than earlier in the epidemic. Racial/ethnic minority MSM had consistently large increases in AIDS rates; AIDS rates decreased only slightly for white MSM. The AIDS epidemic among MSM is not homogenous, and AIDS rates continue to increase for minority MSM, and MSM living in rural areas. HIV prevention remains a high priority for all MSM, especially black and Hispanic MSM.

Surveillance of AIDS-defining conditions in the United States. Adult/Adolescent Spectrum of HIV Disease Project Group.

OBJECTIVE: To examine the reporting of AIDS-defining illnesses using two national surveillance systems. METHODS: Comparison of AIDS indicator diseases reported to the national AIDS reporting system (ARS) for AIDS cases diagnosed from January 1990-December 1992 among individuals aged > 13 years in 10 metropolitan areas, with that observed in the Adult/Adolescent Spectrum of HIV Disease (ASD) project, a surveillance project that monitors the clinical diagnoses of HIV-infected individuals receiving medical care. RESULTS: In the 10 metropolitan areas, 39,265 individuals with AIDS were reported to ARS, and 5969 with AIDS had medical record reviews as part of ASD. At initial AIDS diagnosis, the number of indicator diseases reported to ARS was almost identical to the number observed in ASD (mean number of diagnoses, ARS 1.3; ASD 1.2). However, ASD recorded a greater number of diagnoses over time than ARS (mean number of indicator diagnoses > 12 months after initial diagnosis, ASD 2.3; ARS 1.4). Conditions that typically occur late in the course of AIDS such as Mycobacterium avium infection and cytomegalovirus disease, were more frequently recorded by ASD than by ARS. CONCLUSION: ARS provides complete, population-based information on the frequency of AIDS-defining conditions at initial diagnosis. However, specialized surveillance projects such as ASD are needed to accurately describe subsequent AIDS-defining conditions.

Selected public health observations derived from Multicenter AIDS Cohort Study.

Selected findings from the Multicenter AIDS Cohort Study (MACS) of homosexual/bisexual men are reviewed. High risk sexual behaviors, the use of drugs/alcohol, condom use, and behavior change are addressed in a public health context. The potential significance of education/behavior modification programs as strategies for public health intervention emerges from these findings. Until there is a realistic timetable for vaccine availability and more effective chemotherapy, the MACS provides the opportunity to continue to study the effects of behavior change on the AIDS epidemic.

The completeness, validity, and timeliness of AIDS surveillance data.

PURPOSE: To assess the completeness, validity, and timeliness of the AIDS surveillance system after the 1993 change in the surveillance case definition. METHODS: To assess completeness of AIDS case reporting, three study sites conducted a comparison of their AIDS surveillance registries with an independent source of information. To evaluate validity, the same sites conducted record reviews on a sample of reported AIDS cases, we then compared agreement between the original report and the record review for sex, race, and mode of transmission. To evaluate timeliness, we calculated the median delay from time of diagnosis to case report, before and after the change in case definition, in each of the three study sites. RESULTS: After expansion of the case definition, completeness of AIDS case reporting in hospitals (> or = 93%) and outpatient settings (> or = 90%) was high. Agreement between the information provided on the original case report and the medical record was > 98% for sex, > 83% for each race/ethnicity group; and > 67% for each risk group. The median reporting delay after the change was four months, but varied by site from three to six months. CONCLUSIONS: The completeness, validity, and timeliness of the AIDS surveillance system remains high after the 1993 change in the surveillance case definition. These findings might be useful for programs implementing integrated HIV and AIDS surveillance systems.

Characteristics of women with AIDS and invasive cervical cancer.

OBJECTIVE: To characterize women reported with AIDS and invasive cervical cancer in the first year of the expanded AIDS surveillance case definition. METHODS: Using X2 testing and logistic regression, we compared women with invasive cervical cancer with those having other AIDS-defining illnesses. RESULTS: Of the 16,794 women 13 years old or older and reported with AIDS in 1993, 217 (1.3%) had invasive cervical cancer and 9113 (54.3%) had other opportunistic illnesses; the remaining 7464 (44.4%) had no opportunistic illnesses and were reported based on immunologic criteria. Women with invasive cervical cancer were more likely to have had AIDS diagnosed before 1993 (73 and 56%, respectively; P < .01), to be younger (median age 33 and 35 years; P < .001), to be white (31 and 21%; P < .01), and to reside in the south (41 and 34%; P < .05). Among women reported with CD4+ counts, the median value was higher in 149 women with invasive cervical cancer than in the 5993 with other opportunistic illnesses (153 and 50 cells/microL, respectively). Women with invasive cervical cancer were more likely to report injection drug use (57 and 48%; P < .05). In multivariate analysis, Hispanic women were 0.6 times less likely to be reported with invasive cervical cancer than were white women (P < .05). Among women infected through injecting drug use, black women were 0.5 times less likely to be reported with invasive cervical cancer (P < .001). CONCLUSION: Hispanic and black women infected with HIV were less likely to be reported with invasive cervical cancer, a finding that may be associated with inadequate access to health care services. Women with invasive cervical cancer were less severely immunosuppressed than women with other AIDS opportunistic illnesses.

Donor insemination and human immunodeficiency virus transmission.

OBJECTIVE: To describe cases of AIDS attributed to donor insemination identified through national human immunodeficiency virus (HIV)/AIDS surveillance and to compare the number identified through surveillance with our estimate of the number of women infected as a result of donor insemination before the initiation of donor screening. METHODS: We reviewed national HIV/AIDS surveillance data on women reported through December 1996 and described characteristics of documented and possible cases attributed to donor insemination. We estimated the number of women infected before the initiation of widespread screening of donors using assumptions about the number of women inseminated each year, the average number of inseminations, the proportion of donors who were men who had sex with men, the prevalence of HIV among such men, and the rate of transmission per HIV-infected exposure. RESULTS: A total of six documented and two possible cases of donor insemination-associated AIDS have been reported to the Centers for Disease Control and Prevention as of December 1996. An estimated eight to 141 women were infected through donor insemination in the United States between 1980 and 1984. Reasons for this discrepancy are discussed. CONCLUSION: Based on surveillance case reports and on our estimate, the total number of women infected as a result of donor insemination before screening was recommended is low. Current sperm bank practices to prevent HIV infection will be strengthened further by a pending proposal from the Food and Drug Administration requiring infectious disease screening and testing of semen donors. The most likely source of risk of new infections associated with donor insemination is self-insemination.

Characteristics of persons with late AIDS diagnosis in the United States.

To describe characteristics of persons with late (at or after death) acquired immunodeficiency syndrome (AIDS) diagnosis, we analyzed national surveillance data among all persons with AIDS diagnosed through December 1991 under the pre-1993 AIDS case definition and with a known date of death. Late diagnosis was present in 15.8% of 163,202 decreased persons with AIDS and in 15.3% of decreased men with AIDS, 20.6% of women, 12.1% of whites, 20.0% of blacks, 21.1% of Hispanics, 12.3% of men who have sex with men (MSM), 21.9% of injecting drug users (IDU), and 19.6% of persons exposed to human immunodeficiency virus (HIV) through heterosexual contact. When age, race/ethnicity, sex, geographic region, and transmission mode were included in logistic regression analyses, among adults/adolescents, late diagnosis was more likely among persons 40 years or older than among those 13-39 years old, among blacks and Hispanics than among whites, and among IDU and persons exposed to HIV through heterosexual contact than among MSM. Although children (less than 13 years of age) were more likely to have late diagnosis than adults and adolescents, late diagnoses among children did not differ significantly by race/ethnicity, sex, geographic region, or transmission mode. Late AIDS diagnosis, especially among ethnic minorities and IDU and their sex partners, may represent delays in HIV diagnosis and care. In addition to not receiving early clinical intervention, persons who are diagnosed later in the course of HIV disease represent missed opportunities for receiving prevention efforts such as education, counseling, and substance abuse treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Knowledge of partner risk and secondary transmission of HIV.

BACKGROUND: The number and proportion of people living longer with HIV and the proportion of people infected heterosexually have increased. We measured the frequency with which people with heterosexually acquired AIDS knew their partners' risk behaviors, the extent of secondary heterosexual transmission of HIV, and characterized people at risk for secondary heterosexual transmission. METHODS: For each of five sites (Alabama, California, Florida, New Jersey, and Texas) and for New York City, a sample of adults with AIDS was interviewed. Primary heterosexual transmission was contact with a partner who had a known risk factor for HIV infection. Secondary transmission was contact with an HIV-positive partner not known to have a risk for HIV. RESULTS: Among men, 35% knew that a sexual partner was HIV infected, 56% of women knew that a sexual partner was HIV infected. Among women, 12% knew that a partner was bisexual. Overall, 79% (460 of 581) reported a partner with a primary risk for HIV; among men, 236 of 293 (81%), and among women, 224 of 288 (78%) reported a partner with a primary risk. People categorized with secondary transmission were significantly more likely to be black and never married. People categorized with secondary transmission were more frequently women (53%), had less than a high school education (48%), and a history of drug use (52%). Men categorized with secondary transmission of HIV had a mean of 22 heterosexual partners; women had a mean of 16 partners. CONCLUSIONS: We found that many heterosexuals with AIDS did not know their sexual partners' risk for HIV, and that secondary heterosexual transmission probably results in a small proportion of all AIDS cases in the U.S.

AIDS among Asians and Pacific Islanders in the United States.

OBJECTIVE: To characterize Asians and Pacific Islanders in the United States with reported acquired immunodeficiency syndrome (AIDS). METHODS: AIDS surveillance data reported through June 1998 were analyzed. Characteristics of cumulative case patients, rates of AIDS incidence in 1996 through 1997, and trends from 1982 through 1996 were analyzed. RESULTS: Through December 1998, 4,928 Asian and Pacific Islander adults and 46 Asian and Pacific Islander children with AIDS were reported in the United States. Of the total cases, 89% were in men, and 79% of those were in men who have sex with men (MSM). Five states, which account for 63% of the Asian and Pacific Islander population in the United States, reported 78% of the cases: California (45%), Hawaii (12%), New York (15%), Texas (3%), and Washington (3%). Of the 92% of Asian and Pacific Islander patients with country of birth information, 59% were foreign-born, a percentage that corresponds to the distribution in the general population. The overall incidence rate per 100,000 for 1996 through 1997 was 12.8 (21.3 for men; 3.3 for women). The highest rate was in the Northeast (15.9), followed by the West (13.8), South (10.6), and Midwest (5.7). Tuberculosis, reported for 6% of Asians and Pacific Islanders, was higher among foreign-born than among U.S.-born Asians and Pacific Islanders (8% and 4%, respectively). Between 1982 and 1996, AIDS incidence among MSM increased and peaked in 1994. Among heterosexual contacts and injection drug users, incidence has increased but remained low. CONCLUSIONS: The AIDS epidemic among Asians and Pacific Islanders in the United States has primarily affected MSM and is concentrated in a few states where most Asians and Pacific Islanders reside. Prevention activities should include consideration of cultural diversity and an understanding of cultural norms regarding sexuality. Additional information on risk behaviors and seroprevalence among Asian and Pacific Islander MSM is needed to better guide prevention planning.

Applications of the marketing perspective in nutrition education.

The marketing paradigm is based on the premise of exchange of value, that is, value received for value given. The role of the nutrition educator as a marketer is to facilitate exchanges of value with consumers. To carry out this role, a strong orientation to the consumer, what she or he wants and needs and is willing to "pay," guides the development of the nutrition education mission, objectives, and strategies. The marketing paradigm calls for a marketing information system that includes internal record keeping, marketing intelligence gathering, and marketing research. The information is used in the marketing audit, which identifies organizational strengths and weaknesses and marketplace opportunities and barriers. Marketing objectives are formulated, and strategies for segmenting, positioning, and developing the marketing mix follow. These are translated in the marketing plan to an action plan, a budget, and profit and loss projections. Use of the marketing paradigm in nutrition education is not a panacea for organizational ills and marketplace problems. Instead, the paradigm raises issues to which nutrition educators must bring their expertise, commitment, ingenuity, and creativity.

Case management of HIV-infected children in Missouri.

The early referral of HIV-exposed children and their mothers to coordinated medical and social services has become increasingly important. In July 1989, the Missouri Department of Health initiated the Service Coordination Program to provide individualized referral (case management) for Missouri residents who were reported to have acquired immunodeficiency syndrome (AIDS) or HIV infection. The purpose of the Service Coordination Program is to assist persons in accessing medical and social services. The authors describe the characteristics of the 36 children (18 enrolled in the Service Coordination Program, and 18 not enrolled) reported to the Missouri Department of Health through September 1992. Although more detailed evaluations are necessary, preliminary data suggest that opportunities for early intervention may be facilitated by the Service Coordination Program if the child's HIV status is recognized early.

Effects of a health careers program and family support for a health career on eighth graders' career interest.

The separate and combined effects of participation in a health careers program and of parental support for a health career on young people's interest in a health career were examined. Twenty-seven eighth graders participating in a health careers orientation program were matched by sex, race, and parental education with 27 eighth grade nonparticipants, and personal interviews were then conducted with students in both groups. Both program participation and parental support were found to be significantly related to two measures of the students' interest in a health career. One measure was of the students' interest in general health-related careers. When program participation and parental support were each studied with the other factor controlled, it was found that parental support had a greater effect when program participation was absent. An analysis of various participation-support combinations revealed that when neither participation nor parental support was present, the students' interest in a health career was considerably less than if one or both were present.

AIDS in women in the United States. Recent trends.

CONTEXT: The effect of the acquired immunodeficiency syndrome (AIDS) epidemic on women is substantial and warrants an updated analysis. OBJECTIVE: To describe AIDS incidence trends in women. DESIGN: We analyzed national surveillance data on women 13 years of age and older with AIDS reported through June 1996. Data were adjusted for reporting delay, unreported risk, and the 1993 change in AIDS surveillance case definition to assess overall trends and examine trends by age group and birth cohort. SETTING: Surveillance conducted by the Centers for Disease Control and Prevention in collaboration with state and local health departments. RESULTS: In 1995, women accounted for 19% of AIDS cases in adults; AIDS incidence rates per 100000 women were highest in black women (50.1), women in the Northeast (22.3), heterosexual contacts (5.5), and women living in metropolitan statistical areas with more than 1 million residents (15.9). Greatest increases in rates between 1991 and 1995 by region and mode of transmission were in the South and in heterosexual contacts. Greatest increases in AIDS incidence rates were observed in heterosexually infected women born between 1970 and 1974, ie, women who were 14 to 18 years old in 1988. CONCLUSIONS: These trends predict continued growth of the number of AIDS cases in women, especially in those in the South and those infected heterosexually, and suggest that successive cohorts of young women may be at risk for human immunodeficiency virus infection as they reach adolescence and young adulthood. Prevention programs must reach young women before they initiate sexual activity and drug use.