Current Trends Acquired Immunodeficiency Syndrome -- Dade County, Florida, 1981 - 1990

In the United States, the impact of the epidemic of acquired immunodeficiency syndrome (AIDS) has been most substantial in urban areas. In addition, AIDS has differentially affected racial/ethnic minority groups. This report characterizes the epidemiology of AIDS through 1990 in Dade County (which includes incorporated Miami), Florida (1990 population: 1.937 million), an urban area with a diversity of racial/ethnic groups and cultures. The findings in this report are based on surveillance data from CDC's AIDS Public Information Data Set (1,2) and from the Florida Department of Health and Rehabilitative Services' (HRS) AIDS Program (3).

Through 1990, Dade County ranked seventh among U.S. metropolitan areas in cumulative total AIDS cases (4223) and in cases among adults/adolescents (i.e., persons greater than or equal to 13 years of age) (4060). In 1990, Dade County ranked fifth in annual incidence rate (54.7 cases per 100,000 population). The distribution of AIDS cases in Dade County by exposure category differed markedly from that of the nation (Figure 1). Dade County ranked highly in all exposure categories. Heterosexual Transmission

Through 1990, Dade County ranked second among U.S. metropolitan areas, with 706 cumulative cases attributed to heterosexual contact (HC) (Table 1). Dade County ranked second nationally in the proportion of HC cases (706/4060 (17%)) (JM Shultz, RS Tomchik, S Kumar, J Malecki, JR Simmons, unpublished data, 1991). Dade County accounted for 522 (26%) of all HC cases in the United States among persons born in Pattern II countries*; these 522 cases represented 74% of HC cases and 13% of cases among adults/adolescents in Dade County. The 184 HC cases among persons not born in Pattern II countries accounted for 5% of cases among adults/adolescents, a proportion comparable to national data (4%). The male-to-female ratio was 2.7:1 for Pattern II HC cases and 0.6:1 for non-Pattern II HC cases (5).

In addition to cases attributed to HC, cases also occurred among heterosexuals who are injectable-drug users (IDUs) and among persons currently identified as having no identified risk (6). The combined total of 706 HC cases and 771 cases among heterosexual IDUs accounted for 36% of Dade County's adult/adolescent cases. Heterosexual transmission risks were amplified by the high rates of sexually transmitted diseases in Dade County (7,8). AIDS Cases Among Women and Children

Through 1990, Dade County ranked third among U.S. metropolitan areas in cumulative AIDS cases among women. The high proportion of cases among women was directly related to the behavioral epidemiology of risk (Table 2). For the 628 adult/adolescent women, three exposure categories were prominent: IDU (255 (41% of cases among women)), Pattern II HC cases (141 (22%)), and non-Pattern II HC cases (112 (18%)). Of the 628 cases, 528 (84%) occurred among black women, of whom 141 (27%) were born in Pattern II countries (Table 2).

Dade County ranked second among U.S. metropolitan areas in pediatric (i.e., children less than 13 years of age) AIDS cases (163 cases); 150 (92%) of these resulted from perinatal (mother-to-child) transmission. Black children accounted for the majority of pediatric AIDS cases (142/163 (87%)). Racial/Ethnic Characteristics

Through 1990, the cumulative incidence rate for AIDS in Dade County was lowest for Hispanics and highest for blacks (Table 3). Annual incidence rates were highest for blacks (Figure 2). For non-Hispanic whites and Hispanics, more than three fourths of persons with AIDS were classified as having male homosexual/bisexual contact as a primary risk behavior. In contrast, blacks accounted for most of the HC cases (646/706 (92%)) and cases among male heterosexual and female IDUs (604/770 (78%)). Reported by: JM Shultz, PhD, L Elliott, MPH, CB McCoy, PhD, Dept of Epidemiology and Public Health, Univ of Miami School of Medicine, Miami; JR Simmons, MD, District XI, S Lieb, MPH, M LaLota, MPH, RS Hopkins, MD, State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs.

Editorial Note

Editorial Note: In Dade County, surveillance findings suggest that the AIDS epidemic is a composite of behaviorally, culturally, and geographically distinct subepidemics. Consequently, in this setting, prevention programs must target risk behaviors that also reflect prevalent cultures. For example, in Dade County, efforts to address homosexual/bisexual risk behaviors may be focused on subpopulations of white and Hispanic men; for IDUs and their sexual contacts, U.S.-born black men and women; and for cases associated with heterosexual contact with bisexual men and with persons from Pattern II countries, Caribbean-born black men and women. Each of these groups may be further defined in terms of specific residential neighborhoods, language, immigration history, cultural heritage, venues for high-risk activities, and social networks.

The principal public-sector efforts to curb the AIDS epidemic have included collaboration between HRS and the University of Miami. During the 1980s, HRS staff at the district and state levels conducted AIDS case surveillance, sentinel surveillance of human immunodeficiency virus (HIV) infection, and HIV-antibody testing and counseling and provided prevention services. Clinicians and researchers at the University of Miami School of Medicine conducted large-scale clinical trials of antiviral medications and special studies of high-risk populations, including IDUs, female prostitutes, and heterosexual partners of HIV-infected persons. Innovative research designs and strategies were developed to recruit IDUs, crack cocaine users, and sex partners of IDUs into intervention programs aimed at reducing high-risk behaviors associated with transmission of HIV (9-11). Research on school-based HIV/AIDS education is under way, and additional studies are planned.

Sentinel surveillance data for Dade County indicate that current and increasing HIV infection rates will sustain a high incidence rate of AIDS cases throughout the 1990s (12). Consequently, case-management of persons with currently diagnosed AIDS and HIV infection, as well as prevention and intervention efforts, need to be intensified. This process, based on links between HRS and university-based researchers, will include expansion of community-focused epidemiologic research involving the University of Miami's Department of Epidemiology and Public Health and the HRS Dade County Public Health Unit.

References

1. CDC. AIDS public information data set--December, 1990. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1991.

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

3. Florida Department of Health and Rehabilitative Services. The Florida HIV/AIDS surveillance report. Tallahassee: State Health Office, Disease Control, AIDS Program, January 1991.

4. Chin J, Mann JM. The global patterns and prevalence of AIDS and HIV infection. AIDS 1988;2(suppl):S247-52.

5. Shultz JM, Pierre L, Antoine LB. Heterosexual transmission of HIV in the USA: male-to-female ratios among immigrants from Pattern II countries compared with American-born heterosexual cases (Letter). AIDS 1990;4:1298-9.

6. Stoneburner RL, Chiasson MA, Weisfuse IB, Thomas PA. The epidemic of AIDS and HIV-1 among heterosexuals in New York City. AIDS 1990;4:99-106.

7. Rolfs RT, Nakashima AK. Epidemiology of primary and secondary syphilis in the United States, 1981 through 1989. JAMA 1990:264:1432-7.

8. Florida Department of Health and Rehabillative Services. Florida sexually transmitted disease statistics, 1989. Tallahassee: Sexually Transmitted Disease Program, Disease Control and AIDS Prevention, Health and Rehabilitative Services, 1990.

9. CDC. Update: reducing HIV transmission in intravenous-drug users not in drug treatment--United States. MMWR 1990;39:529,535-8. 10. McCoy CB, Khoury EL. Drug use and the risk of AIDS. American Behavioral Scientist 1990;33:419-31. 11. McCoy HV, McCoy CB, Trapido E, Chitwood D, McKay C, Vogel J. AIDS risk behavior change in female sexual partners of IVDUs (Abstract). VI International Conference on AIDS, 1990;2:272. 12. Shultz JM, Beach R, Elliott L, Lieb S. Dynamics of the AIDS epidemic in Florida, USA/Focus on Miami (Abstract). VII International Conference on AIDS, 1991;1:362. *According to the World Health Organization's classification of the global epidemiology of AIDS, Pattern II transmission occurs in several Caribbean countries and areas of sub-Saharan Africa; in these countries, most of the reported cases occur among heterosexuals and the male-to-female ratio approaches 1:1 (4).

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