Current Trends Update: Acquired Immunodeficiency Syndrome -- United States, 1994

During 1994, state, local, and territorial health departments reported to CDC 80,691 cases of acquired immunodeficiency syndrome (AIDS) among persons in the United States, which followed the 106,618 cases reported in 1993. The number of cases reported in each of these years was greater than that reported in 1992 (47,572) and followed the expansion of the AIDS surveillance case definition for adolescents and adults implemented on January 1, 1993 (1-3). Based on analyses using consistent definitions, the rate of AIDS-related illnesses increased 3% in 1993 compared with 1992; a similar increase is expected for 1994 compared with 1993 (3). This report summarizes the characteristics of AIDS cases reported in 1994 and compares these findings with those in 1993.

Of the total 80,691 reported cases, 79,674 (99%) occurred among adolescents and adults (i.e., persons aged greater than or equal to 13 years) and 1017 among children aged less than 13 years. Women, blacks and Hispanics, and persons in the South and Northeast accounted for higher percentages of reported cases during 1994 than during 1993 Table_1. Among cases for which risks were reported, the largest decline in the proportion of reported cases occurred among homosexual/bisexual men.

The number of cases reported among adolescents and adults for 1994 (79,674) was lower than that reported for 1993 (105,676). During 1993, the number of cases reported among adolescents and adults decreased by quarter year of report and included 36,208 during the first quarter, 25,548 during the second quarter, 25,509 during the third quarter, and 18,411 during the fourth quarter. In comparison, the number of cases reported during 1994 varied less by quarter year of report and included 20,682 during the first quarter, 19,566 during the second quarter, 21,924 during the third quarter, and 17,502 during the fourth quarter.

Of all AIDS cases reported among adolescents and adults during 1994, a total of 43,226 (54%) was reported based on the reporting criteria added to the definition in 1993. Of these, 39,513 (91%) persons had severe human immunodeficiency virus (HIV)-related immunodeficiency only (i.e., less than 200 CD4+ T-lymphocytes per uL or a CD4+ T-lymphocyte percentage of total lymphocytes less than 14), 2357 (5%) had pulmonary tuberculosis (TB), 1239 (3%) had recurrent pneumonia, and 164 ( less than 1%) had invasive cervical cancer; 47 persons were reported with greater than or equal to 2 of these clinical diseases. Of the 3713 persons reported with one of the three opportunistic illnesses (i.e., pulmonary TB, recurrent pneumonia, and invasive cervical cancer), 1097 (30%) were women, 2237 (60%) were black, and 1785 (48%) were injecting-drug users.

The AIDS surveillance definition for children aged less than 13 years did not change in 1993. The number of cases reported in children during 1994 (1017) increased 8% over those reported during 1993 (942). Of the 1017 children, 50% were female, most were black (62%) or Hispanic (23%), and 92% were infected through perinatal transmission. Reported by: Local, state, and territorial health depts. Div of HIV/AIDS, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: This report confirms the predicted decline in the number of AIDS cases reported in 1994 compared with 1993 (2). Following the expansion of the surveillance definition on January 1, 1993, a substantial increase occurred in the number of cases reported, predominantly reflecting the reporting of persons with conditions diagnosed before that date and who were not eligible for reporting until these conditions were added to the surveillance definition. However, after these cases had been reported, the number of reported cases began to decrease by quarter, and during 1994, the numbers of cases reported by quarter were relatively stable.

The findings for 1994 indicate a continuation of trends for certain population groups, including an increase in the proportion of cases accounted for by women and racial/ethnic minorities, a decrease in the proportion accounted for by homosexual/bisexual men, and an increase in the number of cases in children. These patterns may reflect the evolution of the HIV epidemic but also may have been influenced by the differential effects of the expansion of the surveillance definition among different populations and in different geographic areas (4). Studies are in progress to evaluate the effects of use of the 1993 criteria on AIDS case reporting.

The large increases in case reporting associated with the expansion of the AIDS surveillance definition have constrained the usefulness of analyses based on year of report as an approach for monitoring trends. Instead, analyses based on the year of diagnosis -- with adjustments for delays in reporting -- typically have been used to more precisely monitor temporal changes in AIDS trends. Because most HIV-infected persons develop severe immunosuppression before the onset of AIDS-defining opportunistic illnesses (AIDS-OIs), the inclusion of the CD4+ reporting criteria in the surveillance definition has required an additional adjustment to estimate when persons who were reported using the CD4+ criteria will develop an AIDS-OI. Based on these methods, the estimated number of persons with diagnosed AIDS-OIs in 1993 increased 3% over 1992 (3) and indicated disproportionate increases for women and racial/ethnic minorities and a leveling of cases diagnosed among homosexual/bisexual men (CDC, unpublished data, 1994). Initial analysis suggests that the number of AIDS-OI diagnoses in 1994 will increase at a rate similar to that estimated for 1993.

Use of the expanded AIDS surveillance case definition has been associated with predicted changes (i.e., both anticipated increases and decreases) in AIDS case reporting during 1993-1994. However, the rate of reporting of AIDS remained high in 1994. The approximately 81,000 persons reported with AIDS represent 18% of the 441,528 cumulative AIDS cases reported since 1981. As a result of the expanding epidemic of severe HIV disease, in 1993 HIV became the leading cause of death among persons aged 25-44 years (5).

References

1. CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41(no. RR-17).

2. CDC. Update: impact of the expanded AIDS surveillance case definition for adolescents and adults on case reporting -- United States, 1993. MMWR 1994;43:160-1,167-70.

3. CDC. Update: trends in AIDS diagnosis and reporting under the expanded surveillance definition for adolescents and adults -- United States, 1993. MMWR 1994;43:826-31.

4. CDC. Assessment of laboratory reporting to supplement active AIDS surveillance -- Colorado. MMWR 1993;42:749-52.

5. NCHS. Annual summary of births, marriages, divorces, and deaths: United States, 1993. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994:18-20. (Monthly vital statistics report; vol 42, no. 13).

TABLE 1. Characteristics of persons with reported AIDS cases, by year of report
-- United States, 1993-1994
=================================================================================
                             1993 Reported cases      1994 Reported cases
                           ----------------------    ---------------------
Characteristics               No.           (%)        No.           (%)
---------------------------------------------------------------------------------
Sex *
  Male                      89,349       ( 83.8)      66,095       ( 81.9)
  Female                    17,269       ( 16.2)      14,594       ( 18.1)

Age group (yrs)
   0- 4                        728       (  0.7)         785       (  1.0)
   5-12                        214       (  0.2)         232       (  0.3)
  13-19                        586       (  0.6)         417       (  0.5)
  20-29                     19,202       ( 18.0)      13,198       ( 16.4)
  30-39                     48,380       ( 45.4)      36,527       ( 45.3)
  40-49                     27,235       ( 25.5)      21,259       ( 26.3)
  50-59                      7,596       (  7.1)       6,108       (  7.6)
   >=60                      2,677       (  2.5)       2,165       (  2.7)

Race/Ethnicity +
  White, non-Hispanic       48,058       ( 45.1)      33,193       ( 41.1)
  Black, non-Hispanic       38,455       ( 36.1)      31,487       ( 39.0)
  Hispanic                  18,847       ( 17.7)      15,066       ( 18.7)
  Asian/Pacific Islander       771       (  0.7)         577       (  0.7)
  American Indian/
    Alaskan Native             348       (  0.3)         227       (  0.3)

HIV-exposure category
  Male homosexual/
    bisexual contact        50,389       ( 47.3)      34,974       ( 43.3)
  History of
    injecting-drug use
    Women and
      heterosexual men      29,792       ( 28.0)      21,717       ( 27.0)
    Male homosexual/
      bisexual contact       6,651       (  6.2)       3,853       (  4.8)
  Persons with hemophilia    1,117       (  1.0)         513       (  0.6)
  Heterosexual contact &     9,793       (  9.2)       8,300       ( 10.3)
  Transfusion recipients     1,199       (  1.1)         779       (  1.0)
  Perinatal transmission       886       (  0.8)         933       (  1.2)
  No risk reported           6,791       (  6.4)       9,622       ( 11.9)

Region @
  Northeast                 31,094       ( 29.2)      25,301       ( 31.4)
  Northcentral              11,195       ( 10.5)       7,962       (  9.9)
  South                     35,611       ( 33.4)      28,627       ( 35.5)
  West                      25,328       ( 23.8)      16,236       ( 20.1)
  U.S. territories           3,258       (  3.1)       2,412       (  3.0)

Total                      106,618       (100.0)      80,691       (100.0)

* In 1994, two cases were reported in persons for whom sex was unknown.
+ Excludes persons with unspecified race/ethnicity (139 in 1993 and 141 in
  1994).
& Persons whose origin is or who had sex with a person whose origin is a country
  where heterosexual transmission was presumed to be the predominant mode of
  HIV transmission (i.e., formerly classified by the World Health Organization
  as Pattern II countries) are no longer automatically classified as having
  heterosexually acquired AIDS. These persons are classified as "no risk
  reported."
@ Northeast=New England and Middle Atlantic regions; Northcentral=East North
  Central and West North Central regions; South=South Atlantic, East South
  Central, and West South Central regions; West=Mountain and Pacific regions.
  Excludes persons for whom state of residence was unspecified (132 in 1993 and
  153 in 1994).
=================================================================================

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