Current Trends Characteristics of, and HIV Infection among, Women Served by Publicly Funded HIV Counseling and Testing Services -- United States, 1989-1990

In 1990, the number of reported acquired immunodeficiency syndrome (AIDS) cases among women in the United States exceeded 15,000, an increase of 34% from 1989 (1). Public health surveillance of the human immunodeficiency virus (HIV)/AIDS epidemic has included monitoring of publicly funded voluntary counseling and testing (CT) programs, such as the voluntary client record system (representing 43% of all reported CT visits) that collects detailed information for each CT visit. This report summarizes findings based on information from the client record system for women who received public CT services during 1989 and 1990.

During 1989 and 1990, women accounted for approximately 1 million (48%) of the 2.2 million tests reported by all CT programs. Of these, 47% of tests were from white women; 35%, black women; and 16%, Hispanic women; in comparison, these groups account for 79%, 11%, and 6%, respectively, of the U.S. female population (2). Approximately 20,000 (2%) tests were positive for HIV antibody, including 0.9% among whites, 3.3% among blacks, and 3.7% among Hispanics.

Nearly all CT visits by women occurred in either sexually transmitted disease (STD) clinics (29%), HIV CT sites (29%), or women's (family planning and prenatal) clinics (28%). Of seropositive tests, 40% were from CT sites, 29% from STD clinics, and 8% from women's clinics. Drug-treatment centers accounted for 4% of all tests and 7% of all positive tests; however, the seropositivity rate among tests from drug-treatment centers (3.7%) was higher than tests from other sites (CT sites, 3.0%; STD clinics, 2.2%; and women's clinics, 0.7%) (Table 1).

Most (80%) women who were tested did not report HIV risk behavior (including 81% of blacks, 76% of Hispanics, and 69% of whites) (Figure 1, page 203). Of women who did not report HIV risk behavior, 1.0% were seropositive; however, seropositivity varied by race and ethnicity (1.9%, 1.0%, and 0.3% in black, Hispanic, and white women, respectively). Of seropositive women, 65% reported a specific risk behavior; 35% reported no risk behavior (22% among whites; 24%, Hispanics; and 44%, blacks).

Intravenous (IV)-drug use was reported by 8% of all women, compared with 31% of those who were seropositive. Among black, Hispanic, and white women who identified themselves as IV-drug users, seropositivity was 16.7%, 15.0%, and 3.8%, respectively. Of seropositive women, IV-drug use was reported by 43% and 32% of white and Hispanic women, respectively, compared with 26% of black women.

Women who were sex partners of persons at risk accounted for 13% of those tested, but 27% of all seropositive tests (20%, 30%, and 40% of all seropositive black, white, and Hispanic women, respectively). The overall seropositivity among women who were sex partners of persons at risk was 4.3% (1.5%, 8.2%, and 3.6% for whites, blacks, and Hispanics, respectively). Reported by: HIV prevention programs of state and local health depts. Program Development/Technical Support Section, Div of STD/HIV Prevention and Office of the Deputy Director (HIV), Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: This assessment of findings at CT sites underscores the disproportionate impact of the HIV epidemic on minority populations in the United States (1). However, because these data reflect characteristics of women who receive services at public clinics (Table 1), they cannot be considered representative of all U.S. women. In addition, because these data are collected in service delivery settings, data regarding risk may be less reliable than those obtained during epidemiologic investigations, particularly for persons who initially report no HIV risk behavior.

Nearly half the HIV tests reported by publicly funded CT programs are from women, among whom blacks and Hispanics are disproportionately represented. Although 17% of all women in the United States are black or Hispanic (2), blacks and Hispanics accounted for 73% (52% and 21%, respectively) of reported AIDS cases among women (1). Because of the high prevalence of HIV infection and AIDS among these groups, community-based outreach programs should actively encourage women--especially minority women--to seek HIV-prevention services.

Sexual transmission of HIV is associated with certain STDs. In the United States, syphilis incidence is 50-fold greater among black women and 10-fold greater among Hispanic women than among white women (3). HIV infection and transmission have been epidemiologically linked with genital ulcer disease, including syphilis (3-5), suggesting that genital ulcer disease facilitates HIV transmission.

Previous documentation of the association between syphilis and transmission of HIV (3-5) suggests that syphilis contributes to heterosexual transmission of HIV in selected U.S. populations. However, because many women at risk for syphilis may not be aware of the associated risk for HIV, they may have reported no risk behaviors during pretest counseling. Accordingly, STD and HIV control programs should direct efforts to diagnosing and treating women who have syphilis or who are reported as sex partners of syphilis patients (6) and should ensure that these persons receive HIV CT.

STD and HIV prevention programs need to maximize the proportion of high-risk women who receive comprehensive HIV risk assessment, accept pretest counseling, accept HIV testing, return for their test results, and receive posttest counseling. Based on the data in this report, a substantial proportion of women who seek HIV CT services at selected public sites may be at risk for HIV infection; however, many of these women may be unaware of, or unwilling to report, a specific risk behavior. Therefore, CT sites that serve women in areas with high prevalence of HIV seropositivity should routinely offer all clients HIV counseling and testing. In areas with low prevalence of HIV seropositivity, standardized, thorough risk assessments may assist in identifying a person's risks for HIV infection, and recommendations for HIV testing can be made based on the results of each assessment.

References

1. CDC. HIV/AIDS surveillance. Atlanta: US Department of Health and Human Services, Public Health Service, January 1991:9-14.

2. Department of Commerce. Census of population, general population characteristics, United States summary. Washington, DC: US Department of Commerce, Bureau of the Census, May 1983:1-21.

3. Rolfs RT, Nakashima AK. Epidemiology of primary and secondary syphilis in the United States, 1981 through 1989. JAMA;264:1432-7.

4. Cameron DW, Simonsen JN, D'Costa LJ, et al. Female to male transmission of human immunodeficiency virus type I: risk factor for seroconversion in men. Lancet 1989;2:403-7.

5. Quinn TC, Cannon RO, Glasser D, et al. The association of syphilis with risk of human immunodeficiency virus infection in patients attending sexually transmitted disease clinics. Arch Intern Med 1990;150:1297-302.

6. Toomey KE, Cates W Jr. Partner notification for the prevention of HIV infection. AIDS 1989;3(suppl 1):S57-62.

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