Trends in encephalitis-associated deaths in the United States.

The United States national mortality statistics and HIV/AIDS surveillance data were analysed to determine trends in encephalitis-associated deaths and to assess the impact of HIV infection on those deaths during 1979-1998, a period when ICD-9 codes were used for coding deaths in the United States. A total of 25125 encephalitis deaths were reported; 4779 of them (19%) had concurrent HIV infection. Overall encephalitis death rates remained stable, but they increased for groups where HIV infection was common and declined or remained unchanged for others. For persons without HIV infection, the rates declined in all demographic groups. Encephalitis deaths in HIV-infected persons followed general trends for HIV deaths in the United States. The rates in the HIV-infected population were several hundred- to thousand-fold higher than in the HIV-uninfected population. HIV infection was largely responsible for the lack of overall decline in the considerable mortality associated with encephalitis in the United States during 1979-1998.

HIV/AIDS among African Americans: progress or progression?

OBJECTIVES: To review data on the extent of HIV infection and associated risk behaviors, the occurrence of AIDS, and HIV-related mortality in African Americans and to suggest what can be done to reduce HIV exposure and infection in this population. DESIGN/METHODS: Review of epidemiologic, published, multisite data on HIV infection in, and related behaviors of, African Americans. RESULTS: On every epidemiologic measure in common use, African Americans, compared with the four other federally recognized racial/ethnic groups, have the most severe epidemic. The trend data show continuing growth in the African American epidemic despite the availability of effective behavioral interventions and biomedical treatments. Few published intervention studies with African American populations have been adequately evaluated; nor have they focused proportionately on men who have sex with men, a group in the African American community with continuing high rates of infection. CONCLUSIONS: Rates of HIV transmission and disease among African Americans are high, disproportionate, and are not declining as significantly in response to effective interventions as they are among whites. Attention is urgently needed to increase our understanding of risk behaviors, social networks, and specific factors in the African American community that can be altered to reduce HIV infection. Macroenvironmental factors--poverty, social class, racism--need to be studied to suggest possible intervention components to reduce rates of HIV transmission and to increase the use of therapies that are more effectively slowing disease progression and lowering death rates among whites.

Years of potential life lost due to HIV infection in the United States.

OBJECTIVE: To compare premature mortality due to HIV infection with that from other causes of death in the United States, so as to provide a basis for allocating public health resources among causes of death that would be more useful than either total or age-specific mortality data. METHODS: Using death certificate data, we calculated years of potential life lost (YPLL) before age 65 years for each cause of death. We defined YPLL for an individual as the difference between 65 years and the age at death if the age was < 65 years, or zero if the age was > or = 65 years. The YPLL in the population was the sum of YPLL for individuals. RESULTS: In 1995, HIV infection was the fourth leading cause of YPLL nationally, accounting for 4.7 YPLL per 1000 population (all under age 65 years; 8.8% of the 53.9 YPLL from all causes per 1000 population). Among males, HIV infection ranked fourth (11.0% of YPLL) nationally and in 1994 was the top cause of YPLL in four states: New York (causing 22.7% of YPLL), Florida (18.1%), New Jersey (17.6%) and Maryland (13.9%); and in 51 cities of > or = 100,000 total population, where it caused 12.6-50.9% of YPLL. In 1995, among females, HIV ranked sixth (4.5% of YPLL) nationally and in 1994 was the leading cause of YPLL in 11 cities (11.6-31.4%). CONCLUSION: HIV infection has become the fourth leading cause of premature mortality, measured in terms of YPLL, in the United States and the leading cause in a sizeable number of United States cities.

Effect of the human immunodeficiency virus epidemic on mortality from opportunistic infections in the United States in 1993.

To measure the effect of the human immunodeficiency virus (HIV) epidemic on mortality from opportunistic infections (OIs) in 1993, national multiple-cause death certificate data were examined using two approaches. First, for each OI, the percentage of deaths with HIV infection reported as the underlying cause was calculated. Second, the age-adjusted rate of death per million population was compared with the rate predicted from a model of rates in 1970-1980 or 1979-1981, as available. The percentage of deaths with HIV as the underlying cause and the ratio of observed to predicted death rates were as follows: toxoplasmosis, 91% and 86 (5.24/0.06); cryptosporidiosis/isosporiasis, 90% and infinite (1.61/0.00); progressive multifocal leukoencephalopathy, 87% and 19 (2.58/0.13); pneumocystosis, 82% and 18 (15.44/0.87); cytomegalovirus disease, 82% and 17 (12.60/0.74); nontuberculous mycobacteriosis, 79% and 18 (15.51/0.84); cryptococcosis, 76% and 4 (5.80/1.35); and histoplasmosis, 68% and 6 (1.36/0.23). Thus, the HIV epidemic has greatly increased mortality from several OIs.

Trends in infectious diseases and cancers among persons dying of HIV infection in the United States from 1987 to 1992.

OBJECTIVE: To determine trends in the relative frequency of infectious diseases and cancers among U.S. residents dying of human immunodeficiency virus (HIV) infection. DATA SOURCE: National multiple-cause mortality data for 1987 to 1992 compiled from death certificates. SUBJECTS: Deaths reported with HIV infection as the underlying cause and with nonunderlying causes that could be secondary to HIV infection. DATA ANALYSIS: Trends in the annual percentage of deaths associated with each infectious disease or cancer that accounted for at least 1.0% of all HIV-related deaths. RESULTS: From 1987 to 1992, the percentage of HIV-related deaths associated with the following diseases decreased: pneumocystosis, from 32.5% to 13.8%; cryptococcosis, from 7.7% to 5.0%; and candidiasis, from 2.3% to 1.7%. The percentage of deaths associated with the following diseases increased: nontuberculous mycobacteriosis, from 6.7% to 12.2%; cytomegalovirus disease, from 5.2% to 9.9%; bacterial septicemia, from 9.0% to 11.5%; non-Hodgkin lymphoma, from 3.9% to 5.7%; tuberculosis, from 2.9% to 4.1%; progressive multifocal leukoencephalopathy, from 0.8% to 1.9%; bacterial pneumonia, from 1.2% to 2.1%; and cryptosporidiosis or isosporiasis, from 0.7% to 1.2%. The percentages of deaths associated with toxoplasmosis, Kaposi sarcoma, and pneumonia caused by unspecified organisms had no significant linear trends (ranges from 4.9% to 5.5%, 10.4% to 12.1%, and 17.6% to 18.6%, respectively). CONCLUSIONS: The percentage of HIV-related deaths associated with pneumocystosis has decreased dramatically, probably because of chemoprophylaxis and improved treatment. Pneumonia caused by unspecified organisms has now become the leading secondary cause of death among persons dying of HIV infection. Decreases in the percentages of HIV-related deaths associated with cryptococcosis and candidiasis may reflect the use of new antifungal agents such as fluconazole.

Demographic differences in cumulative incidence rates of transfusion-associated acquired immunodeficiency syndrome.

To describe the demographic patterns of blood transfusion in the United States, the authors analyzed the cumulative incidence rate of transfusion-associated acquired immunodeficiency syndrome (AIDS) (total cases reported from June 1981 through May 1993 per million population) by sex, race/ethnicity, age (at transfusion), and geographic area. Except for a high rate in infants, the rate increased with age, peaking at ages 55-64 years in men and at 65-74 years in women. Overall, the rate in males was 1.7 times that in females. By age, the rate in males was significantly higher than that in females only at ages 0-4 years and 45-84 years, when the rate in males was 2-3 times that in females. Overall, the rates in blacks and Hispanics were twice the rate in non-Hispanic whites. By age, the rates in blacks and Hispanics were significantly higher only at ages 0-4 years and 15-54 years, when they were 2-5 times those in whites, respectively. By state of residence, the incidence of transfusion-associated AIDS was correlated with the rate of all other AIDS cases (Spearman correlation coefficient, 0.83; p = 0.0001). Most of these demographic differences probably reflect differences in exposure to blood transfusion and in the incidence of conditions requiring transfusions.

Trends in transfusion-associated acquired immune deficiency syndrome in the United States, 1982 through 1991.

To evaluate the efficacy of measures for preventing the transmission of human immunodeficiency virus (HIV) by blood transfusion, trends in transfusion-associated cases of acquired immune deficiency syndrome (AIDS) reported through June 1992 were analyzed. By year of transfusion, cases rose from 56 in 1978 to 714 in 1984, dropped sharply to 288 in 1985 when screening of donated blood for HIV antibody began, and fell below 20 per year from 1986 through 1991. Reinvestigation of a sample of cases suggested that only one-fourth of those attributed in the trends analysis to post-1985 United States transfusions actually were due to that source. By year of AIDS diagnosis, cases climbed from 14 in 1982 to 824 in 1987 and subsequently remained relatively level. Of cases diagnosed in 1991 with known transfusion dates, almost all resulted from transfusions received before 1986. Cases in persons aged > or = 65 years at diagnosis fell steeply after 1987, while those in persons aged 45 to 64 years leveled and those in persons aged 25 to 44 years continued to increase; this caused the median age to decrease from 59 in 1986 to 47 in 1991. Thus, screening and other measures have almost completely prevented transmission, but, because of infections acquired before screening began, many cases continue to be diagnosed among increasingly younger persons.

HIV infection as leading cause of death among young adults in US cities and states.

OBJECTIVE: To describe the extent to which human immunodeficiency virus (HIV) infection has become the leading cause of death among young adults (25 to 44 years of age) in US states and cities of at least 100,000 population. DESIGN: Analysis of underlying causes of death using national vital statistics for 1990 by state and city. Deaths caused by HIV were defined as those with underlying cause assigned a code number of 042, 043, or 044, as established by the National Center for Health Statistics. RESULTS: Infection with HIV was the leading cause of death among young men in five states, causing 29% of their deaths in New York, 28% in New Jersey, 24% in California and Florida, and 16% in Massachusetts. Among young women, HIV was not the leading cause of death in any state. Among young men, HIV infection was the leading cause of death in 64 cities, with the proportion of deaths due to HIV ranging from 16% in Bridgeport, Conn, to 61% in San Francisco, Calif. Among young women, HIV infection was the leading cause of death in nine cities, with the proportion of deaths due to HIV ranging from 15% in Baltimore, Md, to 43% in Newark, NJ. CONCLUSION: In many US communities, HIV infection is the leading cause of death among young men and women, causing a large proportion of deaths in this age group.

Epidemiology of human immunodeficiency virus encephalopathy in the United States.

To investigate the epidemiology of human immunodeficiency virus (HIV) encephalopathy, we analyzed cases of acquired immunodeficiency syndrome (AIDS) reported to the Centers for Disease Control (CDC) from September 1, 1987, through August 31, 1991. Of 144,184 persons with AIDS (PWAs), 10,553 (7.3%) were reported to have HIV encephalopathy. The proportion of PWAs with HIV encephalopathy was highest at the extremes of age: in PWAs less than 15 years old the proportion was 13%, and in PWAs greater than or equal to 15 years old the proportion progressively increased with age, from 6% in PWAs 15 to 34 years old to 19% in PWAs greater than or equal to 75 years old (p = 0.00001, chi 2 test for linear trend in proportions). The reported annual incidence of HIV encephalopathy per 100,000 population aged 20 to 59 years was 1.4 in 1988, 1.5 in 1989, and 1.9 in 1990. This analysis best provides estimates for HIV encephalopathy as the initial manifestation of AIDS because the CDC AIDS reporting system often does not ascertain diagnoses after the initial AIDS report. These data suggest that age (very young or old) is associated with the development of HIV encephalopathy and that HIV encephalopathy is a common cause of dementia in adults less than 60 years old in the United States.

Epidemiology of acquired immune deficiency syndrome in persons aged 50 years or older.

Acquired immune deficiency syndrome (AIDS) has afflicted persons of all ages, yet only recently has attention been devoted to AIDS in older persons. To examine the epidemiology of AIDS in persons greater than or equal to 50 years old in the United States, we analyzed cases reported to the Centers for Disease Control. The number reported annually in persons greater than or equal to 50 years old increased from 13 in 1981 to 3,562 in 1989. Through December 1989, 11,984 had been reported, representing 10% of all cases. Although male homosexual contact accounted for most cases in persons aged 50-69, blood transfusion became a more common means of exposure with increasing age, accounting for 28% of cases in persons aged 60-69 and 64% of cases in individuals aged greater than or equal to 70. The proportion of women increased from 6.1% in persons with AIDS aged 50-59 to 28.7% of those aged greater than or equal to 70. The proportion of AIDS diagnoses made in the same month as death increased from 16% in persons aged 50-59 to 37% in those aged greater than or equal to 80, suggesting either more rapid progression of disease or increasing delay in diagnosis. As the incidence in older persons continues to increase, clinicians caring for older patients must become more familiar with AIDS.

Surveillance for AIDS and HIV infection among black and Hispanic children and women of childbearing age, 1981-1989.

Surveillance systems indicate that the most documented human immunodeficiency virus (HIV) infections and acquired immunodeficiency syndrome (AIDS) cases among children and women of childbearing age in the United States occur among black and Hispanic populations. Intravenous-drug use (IVDU) is the presumptive origin of HIV infection for most of these cases, through direct IVDU, sexual contact with an intravenous (IV)-drug user, or birth to women with either mode of exposure. These data confirm the need for HIV-prevention programs directed to the racial, ethnic, age, and reproductive concerns of black and Hispanic women of childbearing age and their children. Services should be available for those who are HIV infected, as well as for those who are not infected with HIV, to prevent the further spread of HIV. Services for prevention and treatment of drug abuse are an integral part of HIV prevention and treatment for these groups.

Impact of the 1987 revision of the case definition of acquired immune deficiency syndrome in the United States.

To measure the impact of the 1987 expansion of the definition of acquired immune deficiency syndrome on the number and characteristics of cases in the United States, we reviewed the 28,920 cases diagnosed since the revision and reported through 1988. The proportion meeting only new criteria was 28% overall, with a range of 0 to 82% in different states and territories. This proportion was 26% in the last quarter of 1987 and increased to 31% in the last quarter of 1988. It was higher in heterosexual intravenous drug abusers (IVDAs) (43%) and lower in homosexual male non-IVDAs (21%) than in other groups. The new criteria, but not earlier (pre-1985) criteria, generally require a positive test for human immunodeficiency virus (HIV) infection; however, use of HIV testing varies among states, as demonstrated by differences in the percentage of pre-1985-criteria cases with a reported HIV test (39 to greater than 95%). The revision has changed the distribution of characteristics of cases (e.g., heterosexual IVDAs composed 18% of cases meeting old criteria, 35% of cases meeting only new criteria, and 23% of all cases). Interpretation of trends in both the number and characteristics of cases should take into account the variable impact of the revision on reporting.

Birthplace and the risk of AIDS among Hispanics in the United States.

To extend previous work showing that the risk of AIDS (acquired immunodeficiency syndrome) is higher in US Hispanics than in Whites who are not Hispanic, we compared US residents born in different Latin American countries. We computed the cumulative incidence (CI) of AIDS and the distribution of cases by mode of exposure. Cases were those reported to the Centers for Disease Control between June 1, 1981 and December 12, 1988, and populations specific for birthplace were from the 1980 census. The reference group was the White population that was not Hispanic, CI 25.7/100,000. We estimated a similar rate in Mexican-born persons (25.3/100,000). In the South and West, the rate in Mexican-born Hispanics was half the reference rate. In each US region, the CI of AIDS in heterosexual intravenous drug abusers (IVDAs) in Puerto Rican-born persons was several times greater than that in other Latin American-born persons. Puerto Rican-born persons were the only Latin American-born persons in whom most cases were in heterosexual IVDAs. The data suggest that resources for preventing AIDS in Hispanics are needed most in those of Puerto Rican ethnicity for AIDS related to intravenous drug abuse.

The epidemiology of disseminated nontuberculous mycobacterial infection in the acquired immunodeficiency syndrome (AIDS).

We analyzed cases of disseminated nontuberculous mycobacterial infection (DNTM) in patients with AIDS reported to the Centers for Disease Control. Between 1981 and 1987, 2,269 cases were reported. In 96% of cases, infection was caused by M. avium complex (MAC). The number of cases has risen steadily since 1981, but the rate as a percentage of AIDS cases has remained stable at 5.5%. DNTM was seen less frequently in AIDS cases with Kaposi's sarcoma than in other AIDS cases (p less than 0.01). Rates of DNTM were lower in Hispanics and declined with age but were not significantly different by patient sex or means of acquiring HIV infection. Rates of disseminated MAC varied by geographic region from 3.9% to 7.8% (p less than 0.0001). As assessed by helper/suppressor T-cell ratios, AIDS patients with DNTM were not more immunologically impaired than those with other opportunistic infections. Life table analysis revealed that AIDS patients with DNTM survived a shorter time (median, 7.4 months) than did other AIDS patients (median, 13.3 months; p less than 0.0001). We conclude that DNTM is acquired by unpreventable environmental exposures. Because DNTM adversely affects survival of AIDS patients, effective therapeutic agents must be vigorously sought.

Racial/ethnic differences in the risk of AIDS in the United States.

We analyzed the variation in the risk of AIDS in US Blacks, Hispanics, and other racial/ethnic groups relative to that in Whites (non-Hispanic) by geographic area and mode of acquiring HIV infection, based on data reported between June 1, 1981 and January 18, 1988 to the Centers for Disease Control and 1980 US census data. Relative risks (RRs) in Blacks and Hispanics were highest in the northeast region, and higher in suburbs than in central cities of metropolitan areas. RRs in Blacks and Hispanics were greatest for AIDS directly or indirectly associated with intravenous-drug abuse by heterosexuals (range: 5.7-26.9) and were also high for AIDS associated with male bisexuality (range: 2.5-4.8), suggesting that these behaviors may be more prevalent in Blacks and Hispanics than in Whites. Prevention strategies should take into account these racial/ethnic differences.

[The definition of acquired immunodeficiency syndrome (AIDS)]. / Definition des Acquired-Immunodeficiency-Syndroms (AIDS).

The new, revised CDC case definition of AIDS (1) specifies precisely, which laboratory results and which diseases may indicate HIV-infection. The indicator diseases are divided into those with HIV-positive and HIV-not positive laboratory findings. The latter group is subdivided into diseases diagnosed definitely and diagnosed presumptively. Appendices contain directions for the interpretation of results of laboratory examinations indicating, under which circumstances the diagnosis of AIDS can be excluded or can definitely be established or which findings must be considered inconclusive. Further, the methods are listed, which have to be employed in order to provide a definitive diagnosis of an indicator disease and under which conditions a presumptive diagnosis of a disease, indicative of AIDS, is admitted.