First 500,000 AIDS Cases -- United States, 1995

As of October 31, 1995, a total of 501,310 persons with acquired immunodeficiency syndrome (AIDS) had been reported to CDC by state and territorial health departments; 311,381 (62%) had been reported as having died. The AIDS surveillance case definition was substantially expanded in late 1987 and again in 1993 to reflect increased knowledge of the natural history of human immunodeficiency virus (HIV) and to remain consistent with the clinical management of HIV disease (1,2). This report presents rates of reported AIDS cases for 1994 and describes the temporal changes in the characteristics of persons reported with AIDS during three periods corresponding to changes in the AIDS case definition -- 1981-1987, 1988- 1992, and 1993-October 1995 -- and how this information can be used to plan local, state, and national prevention programs. *

Of the cumulative AIDS cases, 50,352 (10%) were reported during 1981-1987, 203,217 (41%) during 1988-1992, and 247,741 (49%) during 1993-October 1995. The proportion of AIDS cases among females increased from 8% of cases reported during 1981-1987 to 18% during 1993-October 1995 (Table_1). The proportion of cases among whites decreased from 60% to 43%, and the proportion among blacks and Hispanics increased from 25% to 38% and from 14% to 18%, respectively. During 1994, the rates per 100,000 population for blacks and Hispanics (101 and 51, respectively) were substantially higher than rates for whites (17), American Indians/Alaskan Natives (12), and Asians/Pacific Islanders (6).

The proportion of cases among persons who reported injecting-drug use increased from 17% during 1981-1987 to 27% during 1993-October 1995, and the proportion of cases attributed to heterosexual transmission increased from 3% to 10%. Cases among men who have sex with men decreased from 64% to 45%.

During 1994, the rates per 100,000 population for reported AIDS cases were 48 in the Northeast, 31 in the South, 29 in the West, and 13 in the Midwest. ** However, during 1988-1992 and 1993-October 1995, the largest numbers of cases (65,926 and 86,462, respectively) were reported from the South, which also accounted for the largest proportionate increase of reported cases (31%). The proportionate increases in reported cases from 1988-1992 to 1993-October 1995 for the Midwest, Northeast, and West were 22%, 20%, and 15%, respectively.

During 1993-October 1995 in the South and Midwest, higher proportions of cases among adolescents and young adults (aged 13-29 years) occurred in small (50,000-499,999 population) metropolitan statistical areas (MSAs) and non-MSAs (rural areas) (27% and 24%, respectively) compared with 9% in the Northeast and 11% in the West. During this time period, among cases in adolescent and young adult men who have sex with men, 25% of 8481 cases in the South occurred in persons who resided in small MSAs and rural areas, 21% of 2870 in the Midwest, 9% of 3311 in the Northeast, and 9% of 5706 in the West. Among adolescent and young adult injecting-drug users, 30% of 531 cases in the Midwest occurred among persons residing in small MSAs and rural areas, 23% of 2370 in the South, 17% of 930 in the West, and 8% of 3304 in the Northeast. The proportion of cases among adolescents and young adults residing in small MSAs and rural areas that resulted from heterosexual transmission was highest in the South (32% of 2842), followed by the Midwest (22% of 678), the West (18% of 691), and the Northeast (7% of 1745).

During 1993-October 1995, most AIDS cases among adolescent and young adult men who have sex with men occurred among whites in all four regions (Midwest, 57%; West, 56%; South, 49%; and Northeast, 42%). Black adolescent and young adult men who have sex with men accounted for 39% of cases in the South, 37% in the Midwest, 36% in the Northeast, and 14% in the West. These proportions were higher than those for cases among black adolescent and young adult men who have sex with men reported during 1988-1992 (South, 31%; Midwest, 30%; Northeast, 31%; and West, 12%).

Reported by: Div of HIV/AIDS Prevention, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The World Health Organization estimates that 18 million adults and 1.5 million children have been infected with HIV, resulting in approximately 4.5 million AIDS cases worldwide (3). The theme for the 1995 World AIDS Day (December 1) is "Shared Rights, Shared Responsibilities." The findings in this report document both the magnitude and evolving nature of the AIDS epidemic in the United States, and underscore that HIV-prevention programs must be planned and implemented collaboratively by persons with diverse skills, training, and experience.

In addition to describing the overall magnitude of the epidemic -- approximately one half million cases, nearly half of which have been reported since 1993 -- this report highlights changes in the epidemiologic patterns during 1993-October 1995 compared with those during earlier periods. In particular, although men who have sex with men continue to account for the largest proportion of cases, the AIDS epidemic is increasing more rapidly among injecting-drug users and persons infected through heterosexual contact with a partner at risk for or known to have HIV infection or AIDS (4,5). The increase in AIDS cases resulting from heterosexual transmission also is reflected in the increase in cases reported among women. The proportions of AIDS cases reported during 1993-October 1995 that are attributed to these risk behaviors will increase as records of persons who were reported initially without risk are reviewed and the risk is identified (6). Geographic patterns also have changed, as reflected by increases occurring among persons in the South. Finally, regardless of transmission mode or region, the epidemic continues to affect blacks and Hispanics disproportionately.

Although the AIDS epidemic in the United States was recognized initially in the Northeast and West (7), and rates remain highest in the Northeast, the findings from AIDS surveillance document that the greatest proportionate increases in the HIV epidemic have occurred in the South and Midwest -- areas that account for the largest proportion of the total U.S. population. These regional variations, especially in adolescents and young adults, underscore the importance of developing HIV-prevention programs based on local trends in the epidemiology of HIV transmission. In the South and Midwest, more detailed characterization of the epidemiologic patterns in small cities and rural areas is particularly important for developing effective regionwide prevention programs.

The disproportionate impact of the epidemic among racial/ethnic minorities is reflected by rates of reported AIDS cases that are six and three times higher for blacks and Hispanics, respectively, than for whites. Rates for HIV infection and the proportions of men who have sex with men and injecting-drug users with AIDS who are black and Hispanic also vary substantially by region (8). For example, Hispanics account for lower proportions of reported cases of AIDS among adolescents and young adult men who have sex with men in the Midwest and South than in the Northeast and West. Because race and ethnicity are not risk factors for HIV transmission, programs to prevent HIV transmission among racial/ethnic minorities should be based on underlying social, economic, and cultural factors that influence risk behaviors (8).

Because of the regional and local variations in the AIDS epidemic in the United States, HIV-prevention efforts must be directed at the local level. In 1993, a CDC advisory committee review of HIV-prevention programs emphasized the importance of 1) enhancing the capacity of local and state agencies to collect and analyze information relevant to the specific and unique aspects of HIV transmission in their communities, 2) strengthening the behavioral and social science bases of HIV-prevention activities, and 3) ensuring that HIV-prevention strategies and interventions reflect the preferences and needs of the affected communities for whom they are intended (9). As a result, in 1994, CDC initiated the HIV Prevention Community Planning process (10) that has provided resources for collaboration between health departments and planning groups that are representative of the local communities. These resources facilitate HIV-prevention programs that are based on scientific data (including data from HIV/AIDS surveillance, seroprevalence surveys, vital statistics, and behavioral research) and knowledge of the community norms and practices. This approach is consistent with the focus of World AIDS Day and emphasizes the necessity of shared participation in HIV-prevention planning and program implementation.

References

1. CDC. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987;36(suppl 1).

2. CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41(no. RR-17).

3. World Health Organization. The current global situation of the HIV/AIDS pandemic. Geneva, Switzerland: World Health Organization, 1995.

4. CDC. Update: trends in AIDS among men who have sex with men -- United States, 1989-1994. MMWR 1995;44:401-4.

5. CDC. Update: trends in AIDS diagnosis and reporting under the expanded surveillance definition for adolescents and adults -- United States, 1993. MMWR 1994;43:826-31.

6. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1995:3-4,30-4. (Vol 7, no. 1).

7. CDC. Follow-up on Kaposi's sarcoma and Pneumocystis pneumonia. MMWR 30:409-10.

8. CDC. AIDS among racial/ethnic minorities -- United States, 1993. MMWR 1994;43:644-7,653-5.

9. CDC. External review of CDC's HIV prevention strategies by the CDC Advisory Committee on the Prevention of HIV Infection. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, 1994.

10. Valdiserri RO, Aultman TV, Curran JW. Community planning: a national strategy to improve HIV prevention programs. J Community Health 1995; 20:87-100.

Single copies of this report will be available free until November 22, 1996, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231 or (301) 217-0023.

** Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

TABLE 1. Number and percentage of persons with AIDS, by selected characteristics
and period of report -- United States, 1981-October 1995
=============================================================================================================
                                                                          1993-
                              1981-1987            1988-1992           October 1995          Cumulative
                          ------------------   ------------------   ------------------   ------------------
Characteristic              No.        (%)       No.        (%)       No.        (%)       No.        (%)
-----------------------------------------------------------------------------------------------------------
Sex
 Male                      46,317    ( 92.0)   177,807    ( 87.5)   204,356    ( 82.5)   428,480    ( 85.5)
 Female                     4,035    (  8.0)    25,410    ( 12.5)    43,383    ( 17.5)    72,828    ( 14.5)

Age group (yrs)
  0- 4                        653    (  1.3)     2,766    (  1.4)     2,013    (  0.8)     5,432    (  1.1)
  5-12                        100    (  0.2)       669    (  0.3)       616    (  0.2)     1,385    (  0.3)
 13-19                        199    (  0.4)       758    (  0.4)     1,343    (  0.5)     2,300    (  0.5)
 20-29                     10,531    ( 20.9)    38,662    ( 19.0)    41,861    ( 16.9)    91,054    ( 18.2)
 30-39                     23,269    ( 46.2)    92,493    ( 45.5)   111,992    ( 45.3)   227,754    ( 45.4)
 40-49                     10,491    ( 20.8)    47,088    ( 23.1)    64,990    ( 26.2)   122,569    ( 24.4)
 50-59                      3,690    (  7.3)    14,537    (  7.2)    18,413    (  7.5)    36,640    (  7.3)
  >=60                      1,419    (  2.8)     6,244    (  3.1)     6,513    (  2.6)    14,176    (  2.8)

Race/Ethnicity
 White, non-Hispanic       30,104    ( 59.8)   102,551    ( 50.5)   105,516    ( 42.6)   238,171    ( 47.5)
 Black, non-Hispanic       12,794    ( 25.4)    63,319    ( 31.2)    94,158    ( 38.0)   170,271    ( 34.0)
 Hispanic*                  7,039    ( 14.0)    35,213    ( 17.3)    45,135    ( 18.2)    87,387    ( 17.4)
 Asian/Pacific Islander       309    (  0.6)     1,339    (  0.7)     1,809    (  0.7)     3,457    (  0.7)
 American Indian/
  Alaskan Native               67    (  0.1)       433    (  0.2)       783    (  0.3)     1,283    (  0.3)

HIV-exposure category
 Men who have sex
  with men                 32,246    ( 64.0)   110,934    ( 54.6)   111,257    ( 44.9)   254,437    ( 50.8)
 Injecting-drug use         8,639    ( 17.2)    49,093    ( 24.2)    67,708    ( 27.3)   125,440    ( 25.0)
 Men who have sex
  with men and
  inject drugs              4,193    (  8.3)    14,252    (  7.0)    13,984    (  5.6)    32,429    (  6.5)
 Hemophilia                   505    (  1.0)     1,744    (  0.9)     2,009    (  0.8)     4,258    (  0.8)
 Heterosexual contact       1,248    (  2.5)    12,335    (  6.1)    24,958    ( 10.1)    38,541    (  7.7)
 Transfusion recipients     1,285    (  2.6)     3,894    (  1.9)     2,521    (  1.0)     7,700    (  1.6)
 Perinatal transmission       608    (  1.2)     3,084    (  1.5)     2,432    (  1.0)     6,124    (  1.2)
 No risk reported           1,628    (  3.2)     7,881    (  3.9)    22,872    (  9.2)    32,381    (  6.4)

Region +
 Northeast                 19,544    ( 38.8)    62,282    ( 30.6)    74,769    ( 30.2)   156,595    ( 31.2)
 Midwest                    3,770    (  7.5)    20,352    ( 10.0)    24,914    ( 10.1)    49,036    (  9.8)
 South                     12,960    ( 25.7)    65,926    ( 32.4)    86,462    ( 34.9)   165,348    ( 33.0)
 West                      13,550    ( 26.9)    46,675    ( 23.0)    53,729    ( 21.7)   113,954    ( 22.7)
 U.S. territories             516    (  1.0)     7,889    (  3.9)     7,566    (  3.1)    15,971    (  3.2)

Vital status
 Living                     2,779    (  5.5)    32,144    ( 15.8)   155,006    ( 62.6)   189,929    ( 37.9)
 Deceased                  47,573    ( 94.5)   171,073    ( 84.2)    92,735    ( 37.4)   311,381    ( 62.1)

Total &                    50,352    (100.0)   203,217    (100.0)   247,741    (100.0)   501,310    (100.0)
-----------------------------------------------------------------------------------------------------------
* Persons of Hispanic origin may be of any race.
+ Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Penn-
  sylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana, Iowa, Kansas, Michigan,
  Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South=-
  Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana,
  Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia,
  and West Virginia; West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Ne-
  vada, New Mexico, Oregon, Utah, Washington, and Wyoming,
& Includes persons for whom sex, race/ethnicity, or region are missing
=============================================================================================================

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