Current Trends Update: Acquired Immunodeficiency Syndrome Associated with Intravenous-Drug Use -- United States, 1988

In 1988, health departments of the 50 states and the District of Columbia reported 9752 cases, and U.S. territories reported 995 cases, of acquired immunodeficiency syndrome (AIDS) in intravenous-drug users (IVDUs), their sex partners, and children born to mothers who were IVDUs or sex partners of IVDUs. These IVDU-associated AIDS cases represented 33.3% of the 32,311 AIDS cases reported in 1988 and included 5789 (53.9%) male heterosexual IVDUs, 1742 (16.2%) female IVDUs, 2055 (19.1%) male homosexual/bisexual IVDUs, 227 (2.1%) men whose heterosexual partners were IVDUs, 620 (5.8%) women whose heterosexual partners were IVDUs, 231 (2.1%) children whose mothers were IVDUs, and 83 (0.8%) children whose mothers were sex partners of IVDUs. The 847 persons who were heterosexual partners of IVDUs accounted for 55.0% of the total 1541 cases associated with presumed heterosexual transmission of human immunodeficiency virus (HIV) (379 (54.6%) of the 694 other such cases occurred in persons born in countries where heterosexual contact is the predominant mode of HIV transmission). The 314 children whose mothers were IVDUs or sex partners of IVDUs accounted for 70.2% of the 447 cases associated with perinatal HIV transmission reported in 1988.

In 1988, 4.3 cases of IVDU-associated AIDS per 100,000 population were reported by the 50 states, District of Columbia, and U.S. territories combined. Rates for IVDU-associated AIDS varied widely by area; rates in Puerto Rico, New Jersey, New York, and the District of Columbia were greater than 10/100,000 population; in 22 states, rates were less than 1/100,000 population (Figure 1). Rates were higher in the Northeast census region than in other regions (Table 1), and 54.5% of IVDU-associated cases were reported from the Northeast*, which represents 19.7% of the population of the United States and its territories. In 1988, IVDU-associated cases accounted for 50.7% of all AIDS cases reported from the Northeast; 23.5%, from the South; 19.8%, from the Midwest; and 15.8%, from the West. Excluding states and territories with less than 10 reported cases in 1988, three states and one territory had more cases in heterosexual IVDUs than in homosexual/bisexual men who were not IVDUs (Table 2).

The rate of IVDU-associated AIDS continues to be higher for blacks and Hispanics than for whites (Table 1). Except for the West, where rates for whites and Hispanics were similar, this difference by race/ethnicity was observed for all regions of the country and was greatest in the Northeast (Table 1). IVDU-associated AIDS cases represented 16.3% of all AIDS cases in whites, 52.7% in blacks, 55.5% in Hispanics, 6.3% in Asians/Pacific Islanders, and 29.0% in American Indians/Alaskan Natives.

Although homosexual/bisexual male IVDUs represented approximately one fifth of all IVDU-associated cases, this proportion varied widely by region of the country. Male homosexual/bisexual IVDUs constituted 7.7% of IVDU-associated cases in the Northeast, 26.3% in the Midwest, 29.1% in the South, and 56.8% in the West. Similarities between homosexual/bisexual male IVDUs and other men with AIDS varied by demographic and disease characteristics (Table 3).

In August 1987, the CDC surveillance case definition for AIDS was expanded to include additional AIDS-indicator diseases (e.g., HIV dementia, wasting syndrome, extrapulmonary tuberculosis) and to accept presumptive diagnoses of some other indicator diseases (e.g., Pneumocystis carinii pneumonia, Kaposi's sarcoma, esophageal candidiasis) when tests for HIV infection are positive (1). Of IVDU-associated AIDS cases reported in 1988, 4682 (43.6%) met the case definition solely on the basis of criteria added in the 1987 revision of the case definition. Of these persons, 2616 (55.9%) had a presumptively diagnosed indicator disease, 1572 (33.6%) had wasting syndrome, and 501 (10.7%) had HIV dementia (diagnostic groups not mutually exclusive). In contrast, diagnoses of 23.3% of all other AIDS cases meeting the case definition were based on the additional 1987 revision criteria. Of all 1988 AIDS cases based on the new criteria, 48.2% were IVDU-associated.

Throughout the course of the HIV epidemic, the proportion of IVDU-associated AIDS cases has been higher in the Northeast than in other regions (Figures 2 and 3). The 1987 revision of the AIDS surveillance definition was associated with an increase in reported cases beginning in the last quarter of 1987, particularly for IVDU- associated cases in the Northeast, where total IVDU-associated cases surpassed the number of all other AIDS cases. Reported by: Local, state, and territorial health departments. AIDS Program, Center for Infectious Diseases, CDC. Editorial Note: AIDS cases occurring in association with IV-drug use involve not only IVDUs themselves but also their sex partners and children born to IVDUs or their sex partners. IVDU-associated AIDS accounts for most AIDS cases in heterosexual men, women, and children. Compared with the incidence in whites, the higher incidence of IVDU-associated AIDS in blacks and Hispanics contributes to their overall higher incidence of AIDS (2). This is most evident in the Northeast, where 1988 case rates for IVDU-associated AIDS were dramatically higher in blacks and Hispanics than in whites and where IVDU-associated AIDS cases exceeded all other AIDS cases.

Approximately one fifth of IVDU-associated AIDS cases are in homosexual/bisexual men. These cases may reflect HIV transmission through individual drug use or sexual activity.

The 1987 revision of the AIDS case definition appears to have increased the number of IVDU-associated cases reported in 1988. The new criteria may have resulted in the identification of some persons earlier in the course of their disease (e.g., persons who eventually would progress to meet the previous definition) or of persons who never would have met the previous definition. The latter is particularly important for IVDUs who may use health-care services for HIV-related illness later or less often than other persons with AIDS and may be more likely to have presumptive rather than definitive diagnoses of their HIV-related diseases. In addition, some states collected surveillance data on cases that met the new criteria before the criteria were implemented and later reported those cases. For these reasons, a temporary surge in reported cases may be expected until trends reach a new equilibrium. A longer period of observation and improved understanding of the course of disease in persons with cases diagnosed under new definition criteria are needed to assess the full impact of the revision on trends.

In addition to illnesses included in the AIDS case definition, there is increasing recognition of an even broader spectrum of severe HIV-associated disease, particularly among IVDUs. For example, studies in New York City indicate that deaths due to infections such as pneumonia, endocarditis, and pulmonary tuberculosis occur more frequently among IVDUs with HIV infection than among IVDUs without HIV infection and that the increased number of pneumonia-related deaths among IVDUs has paralleled the HIV epidemic (3,4). In addition, pneumonia-associated deaths have recently increased among young adults in other cities that have a high incidence of AIDS among IVDUs (5).

Rates of IVDU-associated AIDS presented here are based on the total population, not on numbers of drug users. Consequently, these rates reflect the combined effect of both the prevalence of IV-drug use and the prevalence of HIV infection among IVDUs in different groups or geographic areas. Geographic variations in the rate of IVDU-associated AIDS cases also reflect differences in HIV seroprevalence rates among IVDUs; for IVDUs enrolled in drug-treatment programs, HIV seroprevalence rates have ranged from 50%-60% in areas such as New York City, northern New Jersey, and Puerto Rico to less than 5% in most other areas (6). The observation that the number of cases in IVDUs exceeds those in homosexual men in several Northeastern states and Puerto Rico highlights the magnitude of the problem of IVDU-associated AIDS. In addition, the lower HIV seroprevalence rates in most other parts of the country, where IVDU-associated cases constitute a smaller proportion of the HIV epidemic, emphasize the need to prevent extension of the epidemic of IVDU- associated HIV infection and AIDS.

The changing epidemiology of IV-drug use challenges efforts to prevent and control HIV infection and AIDS among IVDUs. Data on IVDUs suggest that most persons who use IV heroin began use in the mid-1960s to mid-1970s (7); many of the current AIDS cases among IVDUs may reflect the HIV epidemic among this cohort of heroin users. Increasingly, cocaine and other drugs are being used intravenously (8). Prevention of HIV infection in IV-cocaine users is further complicated because those persons engage in more frequent injection and needle sharing than do other IVDUs and because, unlike methadone for treatment of heroin dependence, there is no specific therapy for treating cocaine dependence (9,10). Controlling the epidemic of HIV infections and AIDS among IVDUs will require intense efforts to prevent and reduce IV-drug use and measures to prevent HIV transmission among IVDUs. In addition, the association between use of illicit drugs and recent increases in syphilis and between non-IV use of cocaine (e.g., "crack") and sexual activity links illicit drug use to an increased potential for sexual HIV transmission (11,12). References

1. CDC. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987;36(suppl S-1):3S-15S. 2.Selik RM, Castro KG, Pappaioanou M. Racial/ethnic differences in the risk of AIDS in the United States. Am J Public Health 1988;78:1539-45. 3.Stoneburner RL, Des Jarlais DC, Benezra D, et al. A larger spectrum of severe HIV-1-related disease in intravenous drug users in New York City. Science 1988;242:916-9. 4.Selwyn PA, Feingold AR, Hartel D, et al. Increased risk of bacterial pneumonia in HIV-infected intravenous drug users without AIDS. AIDS 1988;2:267-72. 5.CDC. Increase in pneumonia mortality among young adults and the HIV epidemic--New York City, United States. MMWR 1988;37:593-6. 6.CDC. Human immunodeficiency virus infection in the United States: a review of current knowledge. MMWR 1987;36(suppl S-6):24S-6S. 7.Kozel NJ, Adams EH. Epidemiology of drug abuse: an overview. Science 1986;234:970-4. 8.National Institute on Drug Abuse. Demographic characteristics and patterns of drug use of clients admitted to drug abuse treatment programs in selected states: annual data, 1985. Rockville, Maryland: US Department of Health and Human Services, Public Health Service. 9.Chaisson RE, Bacchetti P, Osmond D, Brodie B, Sande MA, Moss AR. Cocaine use and HIV infection in intravenous drug users in San Francisco. JAMA 1989;261:561-5. 10.Weiss SH. Links between cocaine and retroviral infection (Editorial). JAMA 1989;261:607-9. 11.CDC. Relationship of syphilis to drug use and prostitution--Connecticut and Philadelphia, Pennsylvania. MMWR 1988;37:755-8,764. 12.National Research Council. AIDS: sexual behavior and intravenous drug use. Washington, DC: National Academy Press, 1989. *The Northeast census region includes states in the New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) and Middle Atlantic (New Jersey, New York, Pennsylvania) districts; the Midwest includes the East North Central (Illinois, Indiana, Michigan, Ohio, Wisconsin) and West North Central (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) districts; the South includes the South Atlantic (Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia), East South Central (Alabama, Kentucky, Mississippi, Tennessee), and West South Central (Arkansas, Louisiana, Oklahoma, Texas) districts; and the West includes the Mountain (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) and Pacific (Alaska, California, Hawaii, Oregon, Washington) districts. Territories are not included in tabulations by region.

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