Lisa M. Lee

Estimation of HIV Incidence in the United States

CONTEXT Incidence of human immunodeficiency virus (HIV) in the United States has not been directly measured. New assays that differentiate recent vs long-standing HIV infections allow improved estimation of HIV incidence. OBJECTIVE To estimate HIV incidence in the United States. DESIGN, SETTING, AND PATIENTS Remnant diagnostic serum specimens from patients 13 years or older and newly diagnosed with HIV during 2006 in 22 states were tested with the BED HIV-1 capture enzyme immunoassay to classify infections as recent or long-standing. Information on HIV cases was reported to the Centers for Disease Control and Prevention through June 2007. Incidence of HIV in the 22 states during 2006 was estimated using a statistical approach with adjustment for testing frequency and extrapolated to the United States. Results were corroborated with back-calculation of HIV incidence for 1977-2006 based on HIV diagnoses from 40 states and AIDS incidence from 50 states and the District of Columbia. MAIN OUTCOME MEASURE Estimated HIV incidence. RESULTS An estimated 39,400 persons were diagnosed with HIV in 2006 in the 22 states. Of 6864 diagnostic specimens tested using the BED assay, 2133 (31%) were classified as recent infections. Based on extrapolations from these data, the estimated number of new infections for the United States in 2006 was 56,300 (95% confidence interval [CI], 48,200-64,500); the estimated incidence rate was 22.8 per 100,000 population (95% CI, 19.5-26.1). Forty-five percent of infections were among black individuals and 53% among men who have sex with men. The back-calculation (n = 1.230 million HIV/AIDS cases reported by the end of 2006) yielded an estimate of 55,400 (95% CI, 50,000-60,800) new infections per year for 2003-2006 and indicated that HIV incidence increased in the mid-1990s, then slightly declined after 1999 and has been stable thereafter. CONCLUSIONS This study provides the first direct estimates of HIV incidence in the United States using laboratory technologies previously implemented only in clinic-based settings. New HIV infections in the United States remain concentrated among men who have sex with men and among black individuals.

CRACK COCAINE USE AND ADHERENCE TO ANTIRETROVIRAL TREATMENT AMONG HIV-INFECTED BLACK WOMEN

Since the appearance of crack cocaine in the 1980s, unprecedented numbers of women have become addicted. A disproportionate number of female crack users are Black and poor. We analyzed interview data of HIV-infected women ≥ 18 years of age reported to 12 health departments between July 1997 and December 2000 to ascertain if Black women reported crack use more than other HIV-infected women and to examine the relationship between crack use and antiretroviral treatment (ART) adherence among Black women. Of 1655 HIV-infected women, 585 (35%) were nonusers of drugs, 694 (42%) were users of other drugs and 376 (23%) were crack users. Of the 1196 (72%) Black women, 306 (26%) were crack users. We used logistic regression to examine the effect of crack use on adherence to ART, controlling for age and education among Black women. In multivariate analysis, crack users and users of other drugs were less likely than non-users to take their ART medicines exactly as prescribed (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.24–0.56), OR = 0.47; 95% CI = 0.36–0.68), respectively. HIV-infected Black women substance users, especially crack cocaine users, may require sustained treatment and counseling to help them reduce substance use and adhere to ART.

Window-period human immunodeficiency virus transmission to two recipients by an adolescent blood donor

BACKGROUND:  Pooled NAT and donor screening have reduced the diagnostic window period for HIV in the blood donor population to approximately 10 to 15 days. This report describes two cases of transfusion‐acquired HIV infection and verification of transmission from the donor to the recipients, and attempts to identify how the 18‐year‐old donor acquired her infection.

Characteristics of persons with heterosexually acquired HIV infection, United States 1999-2004.

OBJECTIVES In the United States a growing proportion of cases of heterosexually acquired HIV infections occur in women and in persons of color. We analyzed the association between race/ethnicity, whether diagnoses of HIV infection and AIDS were made concurrently, and the survival after diagnosis of heterosexually acquired AIDS. METHODS We used data from 29 states that report confidential name-based HIV/AIDS cases to the Centers for Disease Control and Prevention to calculate estimated annual percentage change in the number of actual diagnoses and analyzed the association between race/ethnicity and concurrent diagnoses of HIV and AIDS. We adjusted for reporting delays and absence of information about HIV risk factors. RESULTS During 1999 to 2004, diagnoses of heterosexually acquired HIV were made for 52 569 persons in 29 states; 33 554 (64%) were women. Among men and women, 38 470 (73%) were non-Hispanic Black; 7761 (15%), non-Hispanic White; and 5383 (10%), Hispanic. The number of persons with heterosexually acquired HIV significantly increased: 6.1% among Hispanic men (95% confidence interval=2.7, 9.7) and 4.5% among Hispanic women (95% confidence interval=1.8, 7.3). The number significantly decreased (-2.9%) among non-Hispanic Black men. Concurrent HIV and AIDS diagnoses were slightly more common for non-Hispanic Whites (23%) and Hispanics (23%) than for non-Hispanic Blacks (20%). CONCLUSIONS To decrease the incidence of heterosexually acquired HIV infections, prevention and education programs should target all persons at risk, especially women, non-Hispanic Blacks, and Hispanics.

The epidemiology of HIV/AIDS in women in the southern United States.

Objective: We reviewed data from multiple sources to examine distinguishing features of the HIV epidemic among women in the South. Goal: The goal of this study was to identify HIV and sexually transmitted disease (STD) prevention research priorities in the South. Study Design: Cases of HIV/AIDS and STDs were analyzed to compare rates by region and rates in urban versus rural areas. Data from interviews of persons reported with HIV/AIDS from rural areas in 4 southern states compared social and behavioral characteristics of men versus women. Results: The South is characterized by high AIDS and STD rates. The epidemic among southern women is distinguished by the predominance of heterosexually acquired infection, the disproportionate impact on blacks, the high proportion residing in rural areas, and multiple high-risk behaviors. Conclusions: Research to identify determinants of high-risk sex and drug-using behaviors among poor, minority men and women in less urban and rural southern regions is needed.

Monitoring the incidence of HIV infection in the United States

The Centers for Disease Control and Prevention maintains a national surveillance system that provides data about the HIV/AIDS epidemic for program planning and resource allocation. Until recently, incidence of HIV infection (i.e., the number of individuals recently infected with HIV) has not been directly measured. New serologic testing methods make it possible to distinguish between recent and long-standing HIV-1 infection on a population level. This article describes the new National HIV Incidence Surveillance System.

The Status of National HIV Case Surveillance, United States 2006

Since the height of HIV incidence in the mid-1980s, advances in treatment have delayed progression of HIV infection. As a result, surveillance of AIDS cases alone is no longer sufficient to monitor the current status of the HIV epidemic. At the national level, new HIV diagnoses and progression of these cases to AIDS are used to describe the epidemic. The capacity to monitor the national HIV epidemic has consistently improved over the last several years. An increasing number of states report diagnosed HIV cases to the national surveillance system, allowing data from this system to better represent the national picture. Monitoring the national HIV epidemic depends on a nationwide system using standardized methods of data collection, and establishing such a comprehensive system remains one of the highest priorities for national HIV case surveillance.

Validation of Race/Ethnicity and Transmission Mode in the US HIV/AIDS Reporting System

Since 1981, the national HIV/AIDS reporting system (HARS) has provided data to track the progression of the AIDS epidemic, detect patterns of transmission, assess prevention programs, provide an epidemiological basis for planning, and allocate federal resources.1 The Centers for Disease Control and Prevention actively evaluate the quality of the data to ensure that the objectives of the system are based on accurate and complete information.2–5 The HARS relies on medical record reviews by health care providers or trained health department personnel for completion of case reports. Validity studies of medical record data have shown that accuracy and reliability vary according to the type of information and the diagnoses examined.2,4,6 To assess the accuracy of 2 HARS variables on which data are frequently stratified, we compared HARS data on race/ethnicity and transmission mode to self-reported data collected during a survey of people with AIDS.

Accurate monitoring of the HIV epidemic in the United States: case duplication in the national HIV/AIDS surveillance system.

Objective:To assess the degree of duplicate reporting in the US HIV/AIDS surveillance system as compared with a performance standard of <5%, and to assess the effect of duplicate removal on epidemiologic trends. Methods:Multistate evaluation of HIV/AIDS case surveillance. Potential duplicate HIV or AIDS case reports in the national surveillance system matched on Soundex, birth date, and sex were assessed for duplication by state and territorial health departments. Results:Of the 990,175 cases of HIV infection and AIDS in the surveillance system on December 31, 2001, 44,945 (4.5%) were identified as duplicate reports. The duplication rate was higher for HIV cases (8.2%) than for AIDS cases (3.8%). The median of 322 duplicate AIDS reports per area (range: 1 to 3947) represented a median of 5% of all AIDS reports per area (range: 1% to 11%). The median of 369 duplicate HIV reports per area (range: 1 to 1247) represented a median of 11% of all HIV reports per area (range: 1% to 30%). Discussion:The overall duplication rate was within acceptable limits in the national HIV/AIDS surveillance system but did not meet the standard for HIV cases. Ongoing centrally coordinated efforts are necessary to minimize duplicate reporting in the future.

Estimated number of children left motherless by AIDS in the United States, 1978-1998.

When a mother dies of AIDS, basic needs of her children may be left unmet. To estimate the number and characteristics of maternal AIDS orphans in the United States, demographic techniques were applied to data from several sources. From the national HIV/AIDS surveillance system, reporting delays were adjusted for the number of deaths among women aged 15-44 diagnosed with AIDS through 1998 and reported as deceased by December 1999. No fertility was assumed in the year preceding death. To the adjusted number of deaths the annual age- and race-specific cumulative fertility and infant mortality rates from national vital statistics were applied. A perinatal infection rate of 25% was assumed among children born through 1994, and 10% among children born after 1994. Through 1998, 51,473 women died leaving 97,376 children motherless. Of the estimated 76,661-87,0018 uninfected children, 83% were younger than 21 years when orphaned. After increasing each year, the annual number of orphaned children younger than 21 years peaked in 1995. In 1998, between 4252-4489 uninfected youth were added to 47,863-54,025 existing orphans younger than age 21. Due to declines in AIDS deaths, the annual number of children orphaned by AIDS has declined. Nevertheless, each year thousands of youth are orphaned.