Current Trends Update: Acquired Immunodeficiency Syndrome -- United States, 1989

During 1989, state and territorial health departments reported 35,238 cases (14.0 per 100,000 population) of acquired immunodeficiency syndrome (AIDS) to CDC. Rates (reported cases per 100,000 population) were highest for blacks and Hispanics; for persons 30-39 years of age; in the Northeast region and in U.S. territories (primarily reflecting rates in Puerto Rico); in the largest metropolitan areas; and for men (Table 1). Rates varied widely among states (Figure 1).* As in previous years, most reported cases occurred among men who had had sex with other men (homosexual/bisexual men) (56%) and among heterosexual intravenous-drug users (IVDUs) (23%).

The number of AIDS cases in 1989 can be compared with those in 1988 in two ways: 1) by using cases reported during these two periods, although these cases may have been diagnosed in earlier periods, and 2) by using cases diagnosed in these two periods and adjusting for reporting delays (1). These two comparisons yield different results for some categories of AIDS cases primarily because of changes in surveillance criteria, which were implemented in late 1987 (2).

Surveillance based on date of report. Compared with the 32,196 cases reported in 1988, AIDS cases reported in 1989 increased 9%. Large proportional increases occurred for cases reported in the South, in metropolitan areas with populations less than 500,000, and for persons exposed to human immunodeficiency virus (HIV) through heterosexual contact or perinatal transmission (Table 1). The largest proportional declines occurred among children infected with HIV through receipt of transfusions or clotting factors; smaller proportional declines occurred for adults who had received transfusions (Table 1).

Surveillance based on date of diagnosis. When 1989 and 1988 were compared based on cases diagnosed in comparable 1-year periods (October 1-September 30 (adjustments for reporting delays cannot be done reliably for the most recent quarter)), cases increased 14%. Other differences were: proportional increases among both blacks and Hispanics exceeded the increase for whites; cases increased in the Northeast, although proportionately less than elsewhere; the percentage increase for women was substantially greater than that for men; the percentage increase for heterosexual IVDUs exceeded that for homosexual/bisexual men; and cases due to perinatal HIV transmission had the largest increase among HIV exposure groups (Table 1).

Long-term trends. In mid-1987, trends in AIDS cases by date of diagnosis (adjusted for reporting delays) shifted--primarily reflecting a shift in trends for homosexual/bisexual men (Figure 2a). Cases among adult transfusion recipients and persons with hemophilia did not increase as rapidly as in earlier years and may have reached or neared their peaks (Figure 2b). Cases associated with heterosexual IV-drug use (Figure 2a), heterosexual contact (Figure 2c), and perinatal transmission (Figure 2d) continued to increase. Reported by: Local, state, and territorial health departments. Div of HIV/AIDS, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Analysis of surveillance data for AIDS cases elucidates trends in the characteristics of persons with severe HIV disease. Varying trends for different categories of AIDS patients in 1989 highlight the increasing complexity and extent of the HIV/AIDS epidemic.

Interpretation of these trends is complex because of the expansion of AIDS surveillance criteria in late 1987 (2), which extended the usefulness of surveillance in describing severe HIV disease. The new criteria led to greater increases in reporting for cases in IVDUs, blacks and Hispanics, and persons living in the Northeast (4) than for AIDS cases in other persons. Also, some areas retrospectively reported cases that met the new criteria but were diagnosed before the new criteria were implemented (2289 such cases were reported in 1988 and 623 in 1989). There are also other temporal and geographic variations in reporting delays; thus, comparisons between 1988 and 1989 differ depending on whether date of diagnosis or date of report is used.

Cases diagnosed among homosexual/bisexual men continued to increase but not as rapidly as in previous years; this change is most apparent in cities such as New York, San Francisco, and Los Angeles (5). Possible reasons for this observation include actual declines in the incidence of HIV infection, perhaps due to the success of prevention programs; the effect of treatments that delay progression of HIV disease; and a decrease in the completeness of reporting (5,6).

Since routine screening of donated blood for HIV antibody began in 1985, transmission of HIV through blood transfusions has become rare (7). Transfusion-associated AIDS now occurs predominantly among persons who received transfusions before screening began. Occurrence of such cases has leveled or possibly begun to decline, demonstrating the effectiveness of screening.

Increases in diagnosed cases were greatest for groups with little or no evidence of reductions in HIV incidence, such as IVDUs and associated groups (i.e., persons infected with HIV by heterosexual contact and perinatal transmission). Even though AIDS cases are heavily concentrated in the largest cities, the epidemic is increasingly affecting smaller communities.

References

1. Karon JM, Devine OJ, Morgan WM. Predicting AIDS incidence by extrapolating from recent trends. In: Castielo-Chavez C, ed. Mathematical and statistical approaches to AIDS epi demiology: lecture notes in biomathematics. Vol 83. Berlin: Springer-Verlag, 1989.

2. CDC. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987;36(no. 1S).

3. Chambers JM, Cleveland WS, Kleiner B, Tukey PA. Graphical methods for data analysis. Belmont, California: Wadsworth International Group, 1983:91-104,121-3.

4. Selik RM, Buehler JW, Karon JM, et al. Impact of the 1987 revision of the case definition of acquired immune deficiency syndrome in the United States. J AIDS 1990;3:73-82.

5. Berkelman R, Karon J, Thomas P, Kerndt P, Rutherford G, Stehr-Green J. Are AIDS cases among homosexual males leveling? (Abstract). V International Conference on AIDS. Montreal, June 4-9, 1989:66.

6. Gail MH, Rosenberg PS, Goedert JJ. Therapy may explain recent deficits in AIDS incidence. J AIDS 1990 (in press).

7. Ward JW, Holmberg SD, Allen JR, et al. Transmission of human immunodeficiency virus (HIV) by blood screened as negative for HIV antibody. N Engl J Med 1988;318:473-8. *The U.S. map will appear quarterly in the MMWR. More detailed information on AIDS cases is provided in the monthly HIV/AIDS Surveillance Report, including an expanded 1989 year-end summary issued January 1990; single copies are available free from the National AIDS Information Clearinghouse, P.O. Box 6003, Rockville, MD 20850.

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