Current Trends Update: Acquired Immunodeficiency Syndrome-- United States

As of December 8, 1986, physicians and health departments in the United States had reported 28,098 patients (27,704 adults and 394 children) meeting the acquired immunodeficiency syndrome (AIDS) case definition for national reportin) (1-3). Of these patients, 15,757 (56% of adults and 61% of children) are known to have died, including over 79% of those patients diagnosed before January 1985. Since the initial reports of AIDS in early 1981 (4-5), the number of cases reported for each 6-month period continues to increase. However, the increases are not exponential, as evidenced by the lengthening period of time required to double the number of cases (Table 1). During the past 3 months, an average of 58 AIDS cases have been reported to CDC daily. This compares with 35 cases reported during the same period in 1985, 20 cases in 1984, and 10 cases in 1983. Cases have been reported from all 50 states, the District of Columbia, and four U.S. Territories.

Adult patients. Among adult AIDS patients, 25,834 (93%) are men. There has been no significant change over time in distribution of male patients by age and race. Ninety percent of men with AIDS are 20 to 49 years of age (mean = 36.8 years); 63% are white; 22%, black; 14%, Hispanic; and 1%, other or unknown race/ethnicity.

Pneumocystis carinii pneumonia (PCP) continues to be the most common opportunistic disease reported among AIDS patients. Sixty-four percent of men had PCP; 21% had other opportunistic diseases without PCP; and 15% had Kaposi's sarcoma (KS) alone. Ninety-five percent of patients with KS have been homosexual or bisexual men.

Women with AIDS have been reported from 41 states, the District of Columbia, and three territories. The number of cases varies greatly by reporting area and ranges from one to 877 (median = 6); seventy-two percent of female cases were reported from Florida, New Jersey, and New York (42% of male cases were reported from these three states). Eighty-eight percent of women reported with AIDS are 20 to 49 years of age (mean = 34.9 years); 27% are white; 52%, black; 20%, Hispanic; and 1%, other or unknown race/ethnicity. Sixty-seven percent of women had PCP, 31% had other opportunistic diseases without PCP, and 2% had KS alone.

Ninety-seven percent of all adult AIDS patients can be placed in groups* that suggest a possible means of disease acquisition. Homosexual or bisexual men who are not known to have used intravenous (IV) drugs represent 66% of all reported cases (70% of male cases). Heterosexual IV drug users comprise 17% of all cases (15% of male cases and 51% of female cases). Homosexual or bisexual men who have used IV drugs comprise 8% of all cases (8% of males). Persons with hemophilia/coagulation disorders represent 1% of all cases (1% of males; 0.4% of females). Heterosexual sex partners of persons with AIDS or at risk for AIDS represent 4% of all cases (2% of males and 27% of females). This latter category includes persons without other identified risks who were born in countries in which heterosexual transmission is believed to play a major role. Recipients of transfused blood or blood components account for 2% of all cases (1% of males and 10% of females). For 3% of AIDS patients (3% of males and 11% of females), the possible means of disease acquisition is undetermined. Except for women with a coagulation disorder, the number of AIDS cases reported per year continues to increase in all patient groups (Table 2).

AIDS patients reported as not belonging to recognized risk groups are investigated by local health officials to determine if possible risk factors exist. Of all AIDS patients reported to CDC who were initially identified as not belonging to a risk group and who were available for followup, 72% have been reclassified because risk factors were identified or because the patient was found not to meet the surveillance case definition. Of the 853 AIDS patients currently listed as not belonging to recognized risk groups, information is incomplete on 206 due to: death (158), refusal to be interviewed (34), or loss to followup (14). Of the remaining 647 patients, 458 are currently under investigation. No risk was identified for 189 patients who were interviewed or for whom other followup information was obtained. However, of those patients responding to a standardized questionnaire, 40/125 (32%) gave histories of gonorrhea and/or syphilis, and 19 of the 70 men (27%) gave a history of prostitute contact, indicating that these AIDS patients were at potential risk for other sexually-transmitted infections.

The availability of laboratory tests to detect human T-cell lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV)** antibody made it possible to increase the sensitivity and specificity of the AIDS case definition used for national reporting (3). Of the AIDS case reports submitted to CDC, HTLV-III/LAV antibody test results were included for 6,897 (24.5%) of patients (6,558 with recognized risk factors and 339 for whom no risk has been identified). Eighty-nine (1.4%) of the tested patients with recognized risk factors, compared with 27 (8%) of those without identified risk factors were reported negative for HTLV-III/LAV antibody (p 0.001).

Pediatric patients. Among 394 AIDS patients 13 years of age, 347 (88%) are 5 years old. Of those, 20% are white; 57%, black; and 22%, Hispanic. Fifty-five percent are male. Fifty-two percent were diagnosed with PCP, 47% with other opportunistic diseases and no PCP, and 1% with KS alone. Three hundred and eleven (79%) pediatric patients came from families in which one or both parents had AIDS or were at increased risk for developing AIDS; 22 (6%) had hemophilia and 51 (13%) had received transfusions of blood or blood components before onset of illness. Risk factor information on the parents of the 10 (3%) remaining cases is incomplete. Pediatric patients have been reported from 29 states, the District of Columbia, and Puerto Rico; reported cases per area ranged from one to 141 (median = 4). Over 72% of the 311 pediatric patients who acquired infection perinatally are residents of Florida, New Jersey, and New York.

Other modes of transmission. There continues to be no evidence of nonspecific transmission through casual contact; insect bites; or foodborne, waterborne, or environmental spread among AIDS cases. The situation is most clear in the 5- to 15-year-old age group, which lies between the youngest children for whom perinatal transmission is the most important and the adult age groups where sexual and drug related transmission predominates. Five to 15 year olds, who include the majority of school children, comprise 16% of the U.S. population (6). However, only 62 AIDS cases (0.2% of total cases) have occurred in this large group, which is exposed like other groups to casual contact with HTLV-III/LAV-infected persons, insects, and environmental factors. Of these, 61 (98%) fit into established risk categories. The risk factor investigation is incomplete on the remaining case. Reported by State and Territorial Epidemiologists; AIDS Program, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The number of reported AIDS cases continues to increase. An analysis of past trends using empirical models projects a cumulative case total of 270,000 by 1991 (7,8). The proportion of AIDS cases among most transmission categories has remained relatively constant. The geographic distribution of men and women with AIDS differs significantly (p .001). Most reports of women with AIDS continue to come from Florida, New Jersey, and New York, while these states account for a much smaller proportion of male cases. Since most pediatric AIDS cases result from perinatal transmission of HTLV-III/LAV, the race/ethnicity and geographic distribution of pediatric AIDS patients is similar to that of reported AIDS cases among women.

The proportion of AIDS patients diagnosed with KS is declining (9-11), but most KS (95%) continues to be diagnosed among homosexual or bisexual men. KS alone is infrequently diagnosed among women (3% of cases) and children (4%) with AIDS. The reasons that certain patients develop KS remain unclear (12,13).

Numerous studies and continuing investigations of AIDS patients not belonging to recognized risk groups have not supported the existence of new modes of HTLV-III/LAV transmission (14-17). History of other sexually transmitted diseases among the "no identified risk" group as well as prostitute contact among male AIDS patients suggest that sexual contact with partners whose risk was unrecognized or unreported by the patient may be the mode of HTLV-III/LAV transmission for some of these patients. Given current epidemiologic data, AIDS patients who were born outside the United States and who do not have one of the predominant risk exposures have been moved from the "undetermined" transmission category to the "heterosexual contact" category. This move has increased the "heterosexual contact" category from 2% to 4% of adult cases and has decreased the "undetermined" category from 5% to 3%.

The HTLV-III/LAV antibody test allows further refinement of the case definition, especially in disease categories of lower

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