Current Trends Quarterly Report to the Domestic Policy Council on the Prevalence and Rate of Spread of HIV and AIDS in the United States

On December 18, 1987, CDC published the first in a series of articles about the prevalence and rate of spread of human immunodeficiency virus (HIV) infection in the United States (1). The article summarized a report presented to the Domestic Policy Council on November 30, 1987. The full report, published as a supplement to the MMWR (2), contained an extensive review of published and unpublished data on the prevalence and incidence of HIV infection. To update that information, CDC plans to publish summaries of all future quarterly reports presented to the Domestic Policy Council.

The second report was delivered to the Domestic Policy Council on March 23, 1988. The major points from this report are summarized below.

1. Trends in Reported Cases of Acquired Immunodeficiency Syndrome

(AIDS)

By March 14, 1988, a total of 56,212 cases of AIDS had been reported in the United States; nearly 10,000 of these cases have been reported since the last report, on November 30, 1987. More than 31,400 cases have resulted in death.

In the past 12 months, 23,200 cases were reported. This total represents an increase of 58% over the previous year.

During the past 12 months, cases among adults continued to be reported mainly among homosexual and bisexual men (68%) and among heterosexual men and women with a history of intravenous drug abuse (19%). Approxi- mately 4% of cases were attributed to heterosexual transmission (e.g., partners of persons infected or at increased risk of acquiring AIDS; persons without other identified risk who were born in countries where AIDS is primarily transmitted heterosexually).

The 416 cases of AIDS reported during the past 12 months among children under 13 years of age represent an 85% increase over the total for the previous year; 75% of these children acquired their infection perinatally, probably before birth, from their infected mothers.

In September 1987, the CDC AIDS case definition was expanded to encompass additional life-threatening manifestations of HIV infection and to include cases that are diagnosed presumptively by physicians (3). As of March 4, 1988, 7.7% of all reported cases met only this revised portion of the definition. CDC is examining the implications of these revisions for projected trends of AIDS.

The number of cases reported in 1987 represents 92% of the number originally projected to occur in that year by the Public Health Service in 1986 (4). However, current case reporting for AIDS may be less complete, or at least slower, than in past years; for example, there were longer delays between diagnosis and case reporting in 1987 than in 1986. CDC is working with state and local health departments to improve reporting and to evaluate its completeness.

B. Trends in Prevalence and Incidence of Human Immunodeficiency Virus

Type 1 (HIV-1) Infection Accurate estimates of the prevalence and rate of spread of HIV-1 infection in the entire U.S. population are not possible at this time. More precise estimates are available only for certain subgroups of the general population such as blood donors and applicants for military service. Among active-duty U.S. Army personnel who have been tested more than once, 7.7/10,000 per year have become infected since their first test (Division of Preventive Medicine, Walter Reed Army Institute of Research, unpublished data). From surveys of specific groups, the highest prevalence of HIV-1 infection is found among persons with hemophilia, homosexual and bisexual men, intravenous drug abusers, heterosexual partners of persons infected with HIV-1, and children born to mothers infected with HIV-1. In general, males have higher prevalence rates than females, black and Hispanic minorities have higher prevalence rates than other minorities and whites, and persons between 20 and 45 years of age have higher prevalence rates than persons in other age groups.

The prevalence of HIV-1 infection among childbearing women varies considerably by geographic area. In blinded serologic screening of newborns, prevalence of infection was 0.2% in Massachusetts and 0.8% in the state of New York. In New York, rates were 0.2% outside New York City, 1.6% in New York City as a whole, and over 3.0% in some parts of the city (New York State Department of Health, unpublished data).

CDC's estimate of the total number of persons infected in the United States is 1 million to 1.5 million; no new data have become available to prompt a change of this estimate. The Public Health Service will reexamine estimates of the prevalence and rate of spread of HIV-1 infection and projected trends of AIDS in preparing subsequent quarterly reports as new test data and modeling techniques become available.

C. Status of HIV-1 Antibody Surveys

Implementation of the Comprehensive Family of HIV Surveys. Since November 30, 1987, plans to implement the family of HIV-1 antibody surveys have proceeded rapidly. Effective January 29, 1988, funds were awarded to support over 420 different surveys in 30 major metropolitan areas.

Childbearing Women. HIV-1 antibody prevalence for childbearing women has been measured by using blinded serologic testing of blood samples collected on filter paper from newborns to measure maternal antibody. In the state of New York, preliminary results of 52,326 tests indicate an overall HIV-1 antibody prevalence of 0.8%. In New York City, one woman in 61 giving birth had HIV-1 antibody. An estimated 40% of these women passed the infection to their newborns. This survey was instrumental in promoting the recent institution of a New York policy to encourage counseling all women of childbearing age and to offer both counseling and testing to women contemplating pregnancy or in the early stages of pregnancy.

Sentinel Hospitals. HIV-1 antibody prevalence among hospital patients without AIDS or associated conditions is measured in CDC's blinded surveys in sentinel hospitals. In the first four institutions enrolled (all from the Midwest), overall prevalence was 0.3% for the first 12,000 individuals tested. HIV-1 antibody prevalence was highest for adults in the 25- to 44-year age group, higher for black and Hispanic minorities than for whites, and higher for men than for women. A total of 40 sentinel hospitals in 30 cities is expected to be enrolled by September 1988.

Prison Surveys. The Federal Bureau of Prisons implemented an HIV-1 testing program in June 1987. Of 29,193 inmates tested, 843 (2.9%) were positive for HIV-1. CDC and the National Institute of Justice are contracting with a major university to conduct a serosurvey of 10,000 inmates in ten state prisons beginning in June 1988.

College Students. A cooperative agreement was awarded on April 1, 1988, to enable 15 private and public colleges each to perform blinded tests on approximately 1,000 blood specimens drawn for routine diagnostic purposes at college health clinics. Testing is expected to begin in April 1988.

National Household Seroprevalence Survey. A contract will be awarded by the end of April to initiate a nationwide household-based sample survey. The survey will be conducted in two phases, a pilot phase followed by a national survey, if the pilot phase indicates that this would be feasible. Results of the first of the pilot studies are projected to be available by October 1, 1988, and results from the second and third pilot studies, by February 1 and June 1, 1989, respectively. The pilot studies will begin with a sample of 800 persons in one community, followed by two samples of 1,500 persons. If the national survey is conducted, it will start in June 1989, and results would be expected in June 1990.

An evaluation of the level of public participation and potential self-selection bias is being undertaken. Provisional data from the AIDS information questionnaire administered as part of the National Health Interview Survey in August and September 1987 indicate that 71% of the 3,097 adults queried were willing to have their blood tested with assurances of privacy of test results (5). Other surveys have shown that a high percentage of infected persons is concentrated in the minority of persons who are not willing to be tested. A recent study of childbearing women in New York City found that voluntary testing failed to detect 86% of the women who were infected with HIV-1 (6).

D. Human Immunodeficiency Virus Type 2 (HIV-2)

The first reported case of AIDS caused by HIV-2 in the United States was diagnosed in December 1987 (7). The patient was a recent visitor from West Africa, where HIV-2 was originally described, and denied sexual intercourse, use of nonsterile needles, or donation of blood while in the United States.

Since 1987, CDC, the Food and Drug Administration, and others have tested nearly 23,000 specimens from 8,500 blood donors and 14,500 persons at increased risk for HIV infection. No evidence of HIV-2 infection has been found. Because the modes of transmission are the same as those for HIV-1, the same preventive measures have been recommended.

E. Comparison of AIDS Mortality and Years of Potential Life Lost

(YPLL) with Other Major Diseases 1986 data on heart disease, all cancers, and cerebrovascular diseases (including stroke) show that these conditions each killed 10 to 50 times as many Americans as AIDS (8). However, AIDS is the only major disease in the United States where mortality is substantially increasing; the impact on mortality for men 25-44 years of age, for minorities, and for selected cities is much higher than the national average. In YPLL before age 65 years, AIDS increased in rank among diseases from 13th in 1984 to 8th in 1986, a change that reflects the young age of those it kills and the increasing number of deaths. Reported by: AIDS Program, Center for Infectious Diseases, CDC. References

1. Centers for Disease Control. Human immunodeficiency virus infection in the United States. MMWR 1987;36:801-4.

2. Centers for Disease Control. Human immunodeficiency virus infection in the United States: a review of current knowledge. MMWR 1987;36(suppl S-6).

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

4. Morgan WM, Curran JW. Acquired immunodeficiency syndrome: current and future trends. Public Health Rep 1986;101:459-65.

5. Dawson DA, Cynamon M, Fitti JE, National Center for Health Statistics. AIDS knowledge and attitudes for September 1987: provisional data from the National Health Interview Survey. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1988; DHHS publication no. (PHS)88-1250. (Advance data from vital and health statistics; no. 148).

6. Krasinski K, Borkowski W, Bebenroth D, Moore T. Failure of voluntary testing for human immunodeficiency virus to identify infected parturient women in a high-risk population (Letter). N Engl J Med 1988;318:185.

7. Centers for Disease Control. AIDS due to HIV-2 infection--New Jersey. MMWR 1988;37:33-5.

8. Centers for Disease Control. Table V. Estimated years of potential life lost (YPLL) before age 65 and cause-specific mortality, by cause of death--United States, 1986. MMWR 1988;37:163.

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