Public Health Uses of HIV-Infection Reports -- South Carolina, 1986-1991

In the United States, public health officials use acquired immunodeficiency syndrome (AIDS) surveillance data to monitor trends, manage resources within communities, and identify specific needs of special populations (1). In addition to AIDS surveillance, 24 states require confidential reporting by name of HIV-infected persons to the local/state health department (Figure 1). This report summarizes public health uses for HIV-infection report data by one of these states -- South Carolina Department of Health and Environmental Control (SCDHEC) -- in guiding prevention and treatment programs.

AIDS has been reportable to the SCDHEC since 1982; cases of HIV infection have been reported to SCDHEC since February 1986. SCDHEC uses HIV-infection reports to 1) target health education/risk reduction and early intervention programs; 2) provide counseling, testing, referral, and partner-notification services; 3) offer testing for CD4+ T-lymphocytes and screening for other diseases; 4) expand HIV surveillance data collection; and 5) assist legislators and policy makers in targeting resources. In South Carolina, although 93% of AIDS cases among hospitalized persons have been reported (2), the completeness of HIV testing and reporting is not known. As of December 31, 1991, SCDHEC had received 5787 HIV reports and 1599 AIDS reports. Of all reported cases of HIV infection in South Carolina in 1991, 52% were from SCDHEC counseling and testing sites and clinics, and 48% were from other sources. Targeting Health Education/Risk Reduction and Early Intervention Programs

To identify groups in need of HIV/AIDS services, SCDHEC compared HIV-infection and AIDS reports for the state and the United States by person's sex, race/ethnicity, and HIV-transmission category (Table 1). During 1990, a higher percentage of persons with HIV infection were women and blacks than were persons reported with AIDS. From 1986 through 1990, the proportion of HIV-infection reports (from all sources) for women in South Carolina increased 4.5-fold (from 6% to 27%), while the proportion of health department testing of women increased less than twofold (from 28% to 54%). These data were used to target persons with high-risk behaviors with HIV-prevention messages through peer-directed health education and street outreach programs. Counseling, Testing, Referral, and Partner-Notification Services

SCDHEC uses HIV-infection reports to target counseling and testing to persons with high-risk behaviors: following each HIV-infection report, either the patient or personal physician is contacted to develop a plan to counsel the infected person and for voluntary partner notification. Without disclosing the identity of the HIV-infected persons, named sex partners and/or persons with whom they shared needles during the previous 3 years are notified and offered counseling and testing. During 1990, of 1235 persons reported with HIV infection, SCDHEC attempted follow-up of 1139 (92%). Staff located 837 (73%) who named 1856 partners (mean: 2.2 partners named per index client); of the 1856 persons, 1336 (72%) were counseled and tested, and 263 (20%) persons with HIV infection were newly identified. CD4+ T-Lymphocyte Testing and Screening for Other Diseases

Since March 1989, SCDHEC has offered an initial CD4+ T-lymphocyte test free to all persons newly identified as infected with HIV by SCDHEC counseling and testing sites or who were referred by personal physicians. In addition, subsequent CD4+ T-lymphocyte count monitoring is offered free to persons using health department services and for patients who were referred by personal physicians and who lack a source of payment for this test. From March 1989 through August 1991, the SCDHEC performed 4180 CD4+ tests for 2562 persons infected with HIV.

SCDHEC uses CD4+ T-lymphocyte counts to determine the priority of referral of HIV-infected persons to physicians for care and to refer HIV-infected persons to entitlement programs (i.e., state Medicaid AIDS waivers require a CD4+ count less than 500 cells/uL). Persons are also offered screening for tuberculosis and syphilis, and during return visits for follow-up CD4+ T-lymphocyte counts, clients are counseled on risk reduction and behavior changes; clients have reduced high-risk behavior as a result of this counseling (3).

From March 1989 through October 1990, SCDHEC evaluated a sample of persons newly identified as infected with HIV who had a CD4+ T-lymphocyte test performed within 90 days of their HIV-antibody-positive test results; of 422 persons, 12% had CD4+ less than 200 cells/uL, and 46% had less than 500 cells/uL. These findings were used to assess the need for prophylaxis for Pneumocystis carinii pneumonia and zidovudine treatment. Expanding Surveillance for HIV Infection and AIDS

In collaboration with CDC, SCDHEC is obtaining additional health-related information from persons newly reported with HIV infection or AIDS in urban (Charleston County) and rural (Edisto Health District) areas of the state. Persons who consent to be interviewed provide information about their economic status, access to health care, reproductive history, and detailed sex and drug-use behaviors. Data from this supplemental surveillance are used to improve prevention and treatment services for HIV-infected persons. Assisting Legislators and Policy Makers

SCDHEC uses HIV-infection surveillance data to assist legislators and policy makers in assessing the economic impact of the HIV epidemic and in targeting funds for prevention activities and medical services. For example, for each person newly identified with HIV infection (approximately 100 reported per month) in South Carolina, an estimated $50,000 will be expended for HIV-related health-care costs (4). Based on these projections, the partner-notification program during 1990 could result in an estimated cost savings of $13 million if program efforts prevented transmission of HIV to one other person during the lifetime of each of the 263 persons newly identified with HIV infection.

Reported by: L Kettinger, MPH, J Jones, MD, State Epidemiologist, South Carolina Dept of Health and Environmental Control. Div of HIV/AIDS, National Center for Infectious Diseases; National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The activities of the SCDHEC illustrate how states can use HIV-infection reports to strengthen efforts to prevent HIV infection and enhance access to services for persons infected with HIV. Although HIV reports may not be representative of all HIV-infected persons, they provide a minimum estimate of those in need of health care and services. The findings in this report (i.e., a higher proportion of HIV infections among women and blacks in South Carolina during 1990) are consistent with trends reported for AIDS cases in South Carolina and HIV seroprevalence and AIDS data for the United States (5-7). South Carolina has used these data to target priority geographic areas within the state and direct the funding for education, prevention, and early intervention activities.

Although these activities can occur in the absence of HIV reporting, states with confidential HIV reporting by name can ensure that treatment services are offered to eligible persons with high-risk behaviors. For example, the findings in this report show the effectiveness of targeting counseling and testing to persons at high risk for HIV infection (e.g., named partners of HIV-infected persons); 20% of partners who were counseled and tested were HIV-antibody-positive compared with a 3% seropositive rate among all HIV-antibody tests in South Carolina county health departments in 1990.

Some of the other states that have implemented HIV surveillance use these data in similar ways. For example, in Missouri, approximately 25% of persons infected with HIV who were reported to the health department had been enrolled in a state-funded case-management plan that offers CD4+ testing, a medical evaluation, and zidovudine and other medications. Patients reported by personal physicians are offered care-coordination services and, for those who are eligible, provided insurance co-payments. In Minnesota, all persons reported with HIV infection are offered counseling and partner-notification assistance by the health department; in addition, funding for education and prevention services targeted to adolescents has resulted directly from HIV-report data that demonstrated the need for intervention among this age group. Similarly, in Arizona, services available through the health department to HIV-infected persons include counseling, psychosocial and physician referrals, and zidovudine treatment.

States also use HIV-infection reports in combination with AIDS case reporting and seroprevalence surveys to monitor the epidemic and are collaborating with CDC to develop a standardized HIV surveillance system (8). To maintain confidentiality, state health departments have implemented various measures to ensure the security of personal data maintained through HIV/AIDS surveillance (9).

For HIV-infected persons who are identified in either public or private health-care settings, HIV reporting provides the opportunity for health departments to offer counseling, medical referrals, and partner-notification and prevention services. Health departments can also use HIV-infection report data to develop public health strategies that link surveillance with prevention and treatment services.

References

1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

2. Jones JL, Rion P, Hermann P, et al. Improvement in AIDS case reporting, South Carolina (letter). JAMA 1991;265:356.

3. Wykoff RF, Jones JL, Longshore ST, et al. Notification of the sex and needle-sharing partners of individuals with human immunodeficiency virus in rural South Carolina: 30-month experience. Sex Transm Dis 1991;18:217-22

4. Conway GA, Colley-Niemeyer B, Burt S, et al. Costs of AIDS and HIV-related disease in South Carolina: a comprehensive study (abstract). Vol 2. IV International Conference on AIDS. Stockholm, June 12-16, 1988.

5. CDC. AIDS in women -- United States. MMWR 1990;39:845-6.

6. CDC. The HIV/AIDS epidemic: the first 10 years. MMWR 1991;40:357-63,69.

7. St. Louis ME, Conway GA, Hayman CR, et al. Human immunodeficiency virus infection in disadvantaged adolescents. JAMA 1991;266:2387-91.

8. CDC. Update: public health surveillance for HIV infection -- United States, 1989 and 1990. MMWR 1990;39:853,859-61.

9. Torres CG, Turner ME, Harkess JR, Istre GR. Security measures for AIDS and HIV. Am J Public Health 1991;81:210-11.

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