HIV infection in Wisconsin: an overview of epidemiologic trends, 1983-1999.

A review of HIV case surveillance data shows that the number of persons reported with HIV infection in Wisconsin steadily increased during the 1980s, leveled in the early 1990s and since 1993 has tended to decline. Cases reported in 1999 represented a 44% decrease compared to the 1990-1993 average. The number of deaths among persons with HIV infection declined 64% from 1993 to 1999; as a result, the number of persons living with HIV infection nearly doubled during the 1990s. Comparing cases reported 1995-1999 with cases reported in the 1980s, a higher percentage was attributed to injection drug use and high-risk heterosexual contact. A higher percentage of HIV cases also occurred among females and racial and ethnic minorities.

HIV infection in Wisconsin: state and national resources for clinicians and patients.

The authors review state and national resources for clinicians and patients regarding HIV infection, high-lighting pertinent resources in the Wisconsin AIDS/HIV Program as well as select local and national resources.

HIV seroprevalence among male prison inmates in the Wisconsin Correctional System.

OBJECTIVE: To estimate HIV seroprevalence and the acceptance of voluntary HIV testing among male inmates entering the Wisconsin Correctional System during July 1, 1994-June 30, 1995, and compare these estimates with similar data obtained in 1987-1988. METHODS: A blinded HIV seroprevalence survey concurrent with a review of voluntary HIV antibody testing records. RESULTS: HIV test results were obtained for 3,681 (89%) male prison entrants during the study period; 26 (0.7%) were HIV-1 seropositive. Based on this estimate and the total number of male prison entrants (4,134), an estimated 29 HIV-1 seropositive male inmates entered the Wisconsin Correctional System during the study period. Eighty-four percent of all inmates were tested voluntarily. Among inmates testing HIV-1 seropositive, 69% were tested voluntarily. CONCLUSIONS: These data suggest that HIV-1 seroprevalence among male prison inmates in Wisconsin is low, and is unchanged from the late 1980s; however, a large increase in the prison population has resulted in a substantial increase in the absolute number of HIV-1 seropositive inmates entering the correctional system. Although overall acceptance of voluntary HIV testing is high, nearly one third of HIV-1 seropositive inmates declined voluntary HIV testing.

Wisconsin statutes regarding HIV testing in primary care: frequent questions and answers.

The authors review Wisconsin statutes related to human immunodeficiency virus (HIV) testing in primary care, including the areas of written informed consent, documentation of consent, testing without consent, testing of minors, disclosure of test results without the consent of the test subject, reporting requirements, discrimination, access by insurance companies and third-party payors to HIV test results, and civil liabilities and criminal penalties associated with violation of HIV-related state statutes. During the course of the HIV epidemic in Wisconsin, many individuals (service providers, legislators, consumers and advocates) supported the enactment of HIV-related legislation. Today, Wisconsin has some of the nation's most comprehensive HIV legislation. These laws have set a legal framework that balances the rights of individuals with protection of public's health. The relatively low seroprevalence of HIV infection in Wisconsin can be attributed, in part, to the state's HIV-related legislation. While Wisconsin HIV legislation is broadly focused, much of it is concerned with HIV testing. This article examines common questions as they pertain to HIV testing in primary care and to the following areas addressed by state statutes: counseling and referral for health and support services [Wisconsin statute s. 252 14(3)] informed consent for testing or disclosure [Wisconsin statute s. 252.15(2)] written consent to disclose [Wisconsin statute s. 252.15(3) & (4)] testing without consent of the test subject [Wisconsin statute s. 252.15(2)] confidentiality of an HIV test [Wisconsin statute s. 252.15(5)] reporting of positive test results [Wisconsin statute s. 252.15(7)] discrimination [Wisconsin statute s. 252.14(2)] civil and criminal liabilities [Wisconsin statute s. 252.14(4); 252.15(8) & (9)].

Meeting the challenge of early identification of HIV infection in primary care.

The authors review the role of human immunodeficiency virus (HIV) testing in primary care, including an overview of epidemiologic trends of the HIV epidemic; avenues for HIV counseling and testing; HIV testing assays; guidelines for HIV test counseling in primary care; special situations involving testing of pregnant women, infants, and young children; post-exposure prophylaxis; and related resources available to Wisconsin primary care clinicians. HIV disease is a major cause of premature death and disability in the United States. Advances in the understanding of the pathogenesis of HIV and developments of newer antiretroviral therapies have resulted in dramatic changes in the management of HIV disease. Combination antiretroviral drug therapy has resulted in prolonged and near complete suppression of detectable HIV replication in many HIV-infected persons. These clinical developments underscore the importance of early identification and intervention in HIV disease. Intervention during primary HIV infection, the time when the viral burden "set point" is achieved, may present a special window of opportunity to effectively intervene in limiting viral replication in an infected individual. This earliest intervention may have major benefits for infected persons and society at large. Decreasing viral load during primary HIV infection may decrease an individual's infectiousness and thereby decrease the overall rate of transmission of infection to others. Primary care clinicians play a critical role in diagnosing, managing, and preventing HIV infection. Because of the ongoing relationship between patient and health care provider, the primary health care clinician is in the best position to provide HIV risk assessment, testing, related prevention education, and coordination of needed health care. This article presents guidelines for conducting HIV counseling and testing in primary care for purposes of furthering the public health objective of early identification of HIV infection. Clinicians can achieve this objective by including HIV risk assessment during the initial history and physical exam of every patient.

Setting standards for the Wisconsin HIV Counseling and Testing Program: an application of threshold analysis.

Human immunodeficiency virus (HIV) counseling and testing (CT) services are an important component of any comprehensive HIV prevention program. Because resources are limited and must be used wisely, it is important to determine if the expenditures on CT services are sufficiently effective that they might be considered cost-saving or cost-effective to society. The policy analysis technique of "threshold analysis" was employed to determine how many HIV infections the publicly funded Wisconsin CT program would have to prevent in order to be considered cost-saving or cost-effective. Depending on the calculation method used, the threshold for the minimum number of HIV infections that must be averted ranges between approximately 1 and 18 (for the year 1994). Although the exact number of HIV infections prevented by these services in Wisconsin in unknown, the best estimate of this number is well over the required threshold. Hence, HIV CT services in the state of Wisconsin appear to be cost-saving to society.

Cryptosporidiosis-associated mortality following a massive waterborne outbreak in Milwaukee, Wisconsin.

OBJECTIVES: This study estimated the magnitude of cryptosporidiosis-associated mortality in the Milwaukee vicinity for 2 years following a massive waterborne outbreak. METHODS: Death certificates were reviewed. RESULTS: During approximately 2 years before the outbreak, cryptosporidiosis was listed as an underlying or contributing cause of death on the death certificates of four Milwaukee-vicinity residents. In the approximately 2 years after the outbreak, this number was 54, of whom 85% had acquired immunodeficiency syndrome (AIDS) listed as the underlying cause of death. In the first 6 months after the outbreak, the number of death certificates indicating AIDS, but not cryptosporidiosis, as a cause of death was 19 (95% confidence interval = 12.26) higher than preoutbreak trends would have predicted. CONCLUSIONS: Waterborne outbreaks of cryptosporidium infection can result in significant mortality, particularly among immunocompromised populations. Any discussion of policies to ensure safe drinking water must consider the potential fatal consequences of waterborne cryptosporidiosis among immunocompromised populations.

Clinical and epidemiologic features of a massive waterborne outbreak of cryptosporidiosis in persons with HIV infection.

During March and April 1993, a massive outbreak of Cryptosporidium infection resulted from contamination of the public water supply in Milwaukee, Wisconsin. The health impact of this outbreak in HIV-infected persons was unknown but was perceived as severe. We surveyed HIV-infected persons who resided in the greater Milwaukee area to examine the acute health impact of cryptosporidiosis on this population. Data from a random-digit dialing survey in the general population residing in the same area were used for comparison. The attack rate of watery diarrhea suggestive of cryptosporidiosis was lower in HIV-infected persons (32%) than in the general population (51%). There was no significant difference in attack rate in HIV-infected persons based on CD4+ T-lymphocyte count. In persons with watery diarrhea, HIV-infected persons were more likely to experience cough (42%), fever (52%), and dehydration (55%). In HIV-infected persons with watery diarrhea, persons with CD4+ T-lymphocyte counts <200/microl had longer duration of diarrhea and were more likely to seek medical attention and be hospitalized. During this massive waterborne outbreak, HIV-infected persons were not more likely to experience symptomatic Cryptosporidium infection than the general population. However, once infected, the duration and severity of illness was greater in HIV-infected persons, especially if the CD4+ T-lymphocyte count was <200/microl.

HIV seroprevalence among patients attending a Milwaukee clinic for sexually transmitted diseases: findings from four annual surveys, 1988-1991.

Blinded HIV seroprevalence surveys were conducted annually from 1988 through 1991 among patients at a Milwaukee sexually transmitted disease (STD) clinic. Among 5,295 patients tested, 70 (1.3%) were HIV-1 Western blot positive. HIV seroprevalence rates were higher among male patients (1.7%) than among female patients (0.5%). HIV seroprevalence increased progressively with age and the number of prior STD episodes. During the four survey periods, HIV seroprevalence increased among teenage STD patients, patients who reported no prior STD, and patients without determined risk exposures. Selective voluntary HIV testing of patients who reported high risk exposures failed to detect 80% of all HIV seropositive patients. Because STD clinic patients are at high risk of HIV infection, HIV antibody testing, with appropriate referral of patients who test positive, and risk reduction education should be made routinely available to all STD patients with or without HIV-associated risk exposures.

Improving estimates of HIV-1 seroprevalence among childbearing women: use of smaller blood spots.

OBJECTIVES: Nationwide, human immunodeficiency virus type 1 (HIV-1) seroprevalence surveys using dried neonatal blood specimens are critical to estimating HIV-1 seroprevalence among childbearing women. However, the noninclusion of blood specimens deemed "quantity not sufficient" (QNS) for HIV-1 antibody testing potentially introduces bias. In Wisconsin beginning in 1990, we modified the survey protocol to reduce QNS rates and assess bias introduced by QNS specimens. METHODS: The HIV-1 antibody assay was modified to use four 1/8-in blood spots when a single 1/4-in blood spot could not be obtained. Both methods obtain identical blood volumes for testing. RESULTS: During a 27-month period, 7396 (4.8%) of 154,683 specimens were deemed QNS using 1/4-in blood spots. Of these, 6590 (89%) were of sufficient quantity to be tested using four 1/8-in blood spots; 6 (0.09%) specimens tested with 1/8-in blood spots were HIV-1 Western blot assay positive compared with 44 (0.03%) of 147,287 1/4-in specimens (odds ratio = 3.0; 95% confidence interval = 1.2, 7.4). CONCLUSIONS: Because noninclusion of QNS specimens potentially introduces bias, incorporating the results of HIV-1 antibody testing of QNS specimens using four 1/8-in blood spots can improve the accuracy of HIV-1 seroprevalence estimates in these serologic surveys.

HIV-1 among childbearing women and newborns in Wisconsin.

To estimate the prevalence of antibody to human immunodeficiency virus-type 1 (HIV-1) among Wisconsin childbearing women (CBW), a continuous blinded HIV-1 seroprevalence survey is being conducted. This survey uses dried blood specimens obtained from infants as part of the Wisconsin Newborn Screening Program. From February 1989 through March 1990, 79,546 specimens from Wisconsin residents were tested for HIV-1 antibody, 21 (0.026%) were HIV-1 seropositive. Among specimens obtained from Milwaukee County CBW, 15 (0.076%) of 19,781 were HIV-1 seropositive compared to 6 (0.010%) of 59,765 obtained from other Wisconsin counties. After adjusting for maternal residence, Wisconsin minority CBW were six times more likely to be HIV-1 seropositive when compared to white CBW. The survey results underscore the need for strategies to prevent HIV-1 infection that focus on women of childbearing age in Wisconsin.

HIV seroprevalence and the acceptance of voluntary HIV testing among newly incarcerated male prison inmates in Wisconsin.

In 1986-88, voluntary and blinded HIV testing was conducted among Wisconsin male prison entrants. The HIV seroprevalence was 0.30 percent in 1986, 0.53 percent in 1987, and 0.56 percent in 1988. The seroprevalence rates among entrants tested voluntarily did not differ from those tested blindly. Voluntary HIV testing was accepted by 71 percent of male prison entrants in 1988; among entrants reporting intravenous drug use 83 percent consented to voluntary HIV testing. Voluntary HIV testing of entrants appears to be an effective screening strategy in Wisconsin prisons.

AIDS and HIV in Wisconsin: projections for the decade.

Based on a projection model developed by the Wisconsin AIDS/HIV Program, at the beginning of 1990 there were between 7,143 and 11,957 HIV-infected persons in Wisconsin. During the 1990s the cumulative number of HIV-infected persons in the state may more than double to between 16,471 and 25,932. We project that between 6,329 and 9,489 new cases of acquired immunodeficiency syndrome (AIDS), and between 3,577 and 5,365 AIDS deaths will occur in Wisconsin in next ten years. This is a greater than 13-fold increase in AIDS cases over the 1980s. By the end of the 1990s, the number of persons living with AIDS is projected to be ten-fold greater than the currently estimated number. To make plans for the future, policy makers need to be aware of this expected large increase in HIV-related morbidity and mortality.

Development of long-term specific cellular immunity after acute Blastomyces dermatitidis infection: assessments following a large point-source outbreak in Wisconsin.

Ninety-five persons exposed to a point-source of Blastomyces dermatitidis in Wisconsin in 1984 were evaluated 3 months after exposure for the development of specific cellular immunity, and the 48 infected persons were again evaluated 7 and 21 months after exposure. The immune response was assessed by an assay of [3H]thymidine uptake by lymphocytes proliferating in response to stimulation with Blastomyces alkali- and water-soluble antigen (B-ASWS) or blastomycin and by skin testing with blastomycin. At 3 months, 36 (84%) of 43 patients demonstrated a proliferative response to B-ASWS (mean value of experimental [E]-control [C] counts, 16,852 +/- 2664, and of E/C, 42.2 +/- 5.3). None of the patients demonstrated a proliferative response to blastomycin, and only 19 (41%) of 45 patients tested had a positive blastomycin skin test. By 21 months, 47 (98%) of the 48 patients demonstrated a proliferative response to B-ASWS on at least one testing date. Of those initially positive, 82% had a persistently positive proliferative response at 21 months; mean E-C and E/C values were comparable to those seen at 3 months. None of the 47 uninfected persons demonstrated a proliferative response to B-ASWS: 7 with positive histoplasmin skin tests had a mean E-C value of 1094 +/- 432, and the 40 others, a mean value of 1139 +/- 212. A proliferative response to B-ASWS in exposed individuals is a reliable marker of specific cellular immunity in blastomycosis and the response persists in most patients for up to at least 2 years.

Human immunodeficiency virus seroprevalence and drug-using behavior in Milwaukee intravenous drug abusers.

We assessed human immunodeficiency virus (HIV) antibody prevalence and drug-using behaviors among intravenous drug abusers (IVDAs) enrolled in Milwaukee drug treatment programs. Six (2.3%) of 266 study participants were positive for HIV antibody by Western blot assay. A history of needlesharing was reported by 91% of participants, injection of drugs within the past 6 months by 76%, visits to a shooting gallery by 34%, and drug injection outside of Wisconsin by 41%. Nonwhite participants were more likely than white participants to share needles greater than 5 times per month (odds ratio of 2.0) and more likely to have visited a shooting gallery greater than 5 times (odds ratio of 2.7). The average frequency of injection did not differ significantly by race or gender. Pharmacies were the most frequently listed source of sterile needles, and the most common reason for sharing needles was convenience. We conclude that as of late 1987, HIV seroprevalence in Milwaukee IVDAs remained relatively low compared to that of IVDAs in the northeastern United States. There may be racial differences in drug-using behaviors that define distinct subpopulations of IVDAs. These differences should be assessed further, since they have important implications for the success of AIDS education efforts.

Two outbreaks of blastomycosis along rivers in Wisconsin. Isolation of Blastomyces dermatitidis from riverbank soil and evidence of its transmission along waterways.

Blastomycosis cannot yet be prevented or controlled, in part because the natural habitat of the causative fungus, Blastomyces dermatitidis, remains ill defined. In investigating 2 outbreaks of blastomycosis that occurred in the summer of 1985 among persons engaged in activities along rivers in contiguous central Wisconsin counties, we isolated B. dermatitidis from soil at one of the riverbanks. Blastomycosis developed in 7 (58%) of 12 residents and guests who had gathered at a pheasant farm on the Tomorrow River in early May, and in 7 (88%) of 8 boys and 1 adult who had visited a site on the Crystal River in early June. Of the 14 patients, 13 (93%) were symptomatic. Two patients visiting the sites only once became ill 23 and 78 days after exposure, respectively. We traced one outbreak to fishing from the bank of the Tomorrow River, and the other to climbing into an underground timber fort along the Crystal River. A culture of soil and organic debris from the fishing site yielded B. dermatitidis. From these and other outbreaks, and studies of endemic disease, we conclude that riverbanks can be a natural habitat of B. dermatitidis, and that the environment around waterways represents the most important site yet identified for transmission of B. dermatitidis.