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This study compared demographic characteristics of adults and adolescents who received an AIDS diagnosis in one state and died in a different state. We analyzed reports of deaths among persons (> or = 13 years old) with AIDS whose state of residence at diagnosis and state of occurrence of death were different (migrants). Between January 1993 and December 2001, 251,441 deaths of adults and adolescents with AIDS occurred. Of these, 13,860 (5.4%) migrated. Migrants were more likely to be male than female, white than black, and men who have sex with men than persons with heterosexual contact. A small proportion of persons with AIDS migrated between residence at AIDS diagnosis and place of death, suggesting that the effect of migration on destination health care services is likely to be small. [ABSTRACT FROM AUTHOR]

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 > or = 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. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The current status of and changes in the HIV epidemic in the United States are described. METHODS: Surveillance data were used to evaluate time trends in AIDS diagnoses and deaths. Estimates of HIV incidence were derived from studies done during the 1990s; time trends in recent HIV incidence were inferred from HIV diagnoses and seroprevalence rates among young persons. RESULTS: Numbers of deaths and AIDS diagnoses decreased dramatically during 1996 and 1997 but stabilized or declined only slightly during 1998 and 1999. Proportional decreases were smallest among African American women, women in the South, and persons infected through heterosexual contact, HIV incidence has been roughly constant since 1992 in most populations with time trend data, remains highest among men who have sex with men and injection drug users, and typically is higher among African Americans than other racial/ethnic groups. CONCLUSIONS: The epidemic increasingly affects women minorities, persons infected through heterosexual contact, and the poor. Renewed interest and investment in HIV and AIDS surveillance and surveillance of behaviors associated with HIV transmission are essential to direct resources for prevention to populations with greatest need and to evaluate intervention programs. [ABSTRACT FROM AUTHOR]

An increasing number of cases of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) among women is reported to state and territorial health departments without exposure risk information (i.e., no documented exposure to HIV through any of the recognized routes of HIV transmission). Because surveillance data are used to plan prevention and other services for HIV-infected persons, developing methods to accurately estimate exposure risk for HIV and AIDS cases initially reported without risk information and assisting states to analyze and interpret trends in the HIV epidemic by exposure risk category is important. In this report, a classification model using discriminant function analysis is described. The purpose of the classification model is to develop a proportionate distribution of exposure risk category for cases among women reported without risk information. The distribution was estimated based on behavioral and demographic data obtained from interviews with HIV-infected women; the interviews were conducted in 12 states during 1993-1996. Variables used in the analysis were alcohol abuse, noninjection-drug use, and crack use; year of HIV/AIDS diagnosis; age; employment; and region. As a result of the classification procedure, nearly all cases among women with no reported risk were classified into an exposure risk category: 81%, heterosexual contact; and 16%, injection-drug use. These proportions are higher than the current redistribution fractions (calculated from risk reclassification patterns and weighted by demographic characteristics) and reflect the increasing proportion of cases among women attributable to heterosexual contact with an infected partner. This report provides one method that could be applied to HIV surveillance data at the national level to estimate the proportion of cases in exposure risk categories. However, because the study in this report is limited in sample size and geographic representativeness, other models are also needed for adjusting risk exposure data at the national, state, and local levels. [ABSTRACT FROM AUTHOR]

In 1994, zidovudine (ZDV) was demonstrated to substantially reduce perinatal transmission of the human immunodeficiency virus (HIV). Guidelines regarding the use of ZDV to reduce transmission and regarding counseling and voluntary testing of pregnant women were issued in 1994 and 1995, respectively. Surveillance methods were used to evaluate the implementation of these guidelines and to understand reasons for continued perinatal transmission of HIV. Population-based enhanced perinatal surveillance was used in seven states to collect information regarding mother-infant pairs in 1993, 1995, and 1996. Birth registries and HIV/Acquired immunodeficiency virus (AIDS) registries were matched to determine the number of HIV-infected women with diagnosis before delivery. Supplemental epidemiologic information was collected for 1,321 pairs. The estimated total number of HIV-infected women giving birth each year was derived from the Survey of Childbearing Women, an anonymous serologic survey of the prevalence of HIV infection among women giving birth. From 1993 through 1996, the proportion of HIV-infected women with diagnosis before delivery increased from 70% to 80%. The proportion of women with a diagnosis who received ZDV prenatally increased from 27% to 83% and intrapartum, 6% to 75%; for neonates, the increase was from 8% to 77%. Overall, 14% of women received no or only one prenatal care visit. A total of 36% of women who used illicit drugs during pregnancy had not had prenatal care. Of the children who received any ZDV, 8% were infected compared with 16% of those who received no ZDV. ZDV, used for treating pregnant HIV-infected women, has been rapidly adopted in clinical practice and has reduced the transmission of HIV. To achieve continued declines in perinatal transmission of HIV infection, continued progress is needed in the following areas: a) increases in the proportion of women who receive prenatal care and an HIV diagnosis; and b) implementation of rapid testing methods (when licensed rapid tests are available) or rapid turnaround of standard tests (expedited EIA tests). [ABSTRACT FROM AUTHOR]

CDC recommends that all states and territories conduct case surveillance for human immunodeficiency virus (HIV) infection as an extension of current acquired immunodeficiency syndrome (AIDS) surveillance activities. The expansion of national surveillance to include both HIV infection and AIDS cases is a necessary response to the impact of advances in antiretroviral therapy, the implementation of new HIV treatment guidelines, and the increased need for epidemiologic data regarding persons at all stages of HIV disease. Expanded surveillance will provide additional data about HIV-infected populations to enhance local, state, and federal efforts to prevent HIV transmission, improve allocation of resources for treatment services, and assist in evaluating the impact of public health interventions. CDC will provide technical assistance to all state and territorial health departments to continue or establish HIV and AIDS case surveillance systems and to evaluate the performance of their surveillance programs. This report includes a revised case definition for HIV infection in adults and children, recommended program practices, and performance and security standards for conducting HIV/AIDS surveillance by local, state, and territorial health departments. The revised surveillance case definition and associated recommendations become effective January 1, 2000. [ABSTRACT FROM AUTHOR]

Problem/Condition: Acquired immunodeficiency syndrome (AIDS)-defining opportunistic illnesses (OIs) are the major cause of morbidity and mortality among persons infected with human immunodeficiency virus (HIV). As a result of new treatments that reduce mortality for persons with AIDS, the number of persons living with AIDS is increasing, and the incidence of AIDS is decreasing. In 1997, an estimated 271,245 persons were living with AIDS in the United States and thus were at high risk for OIs. In 1997, an estimated 21,909 HIV-infected persons died with AIDS, nearly all as a result of OIs. Reporting Period Covered: Aggregate data and trends for 1992-1997 were examined to determine a) the frequencies at which OIs occurred first; b) the incidence of OIs; c) the percentage of persons among those who have died who had had a given OI during their course of AIDS, and d) the frequency of prescriptions for antiretroviral therapy and prophylaxis for Pneumocystis carinii pneumonia (PCP) and for Mycobac-terium avium complex disease (MAC). Description of System: Data were analyzed from the Adult/Adolescent Spectrum of HIV Disease (ASD) sentinel surveillance project, a prospective medical record review of HIV-infected persons aged >/=13 years conducted in 11 U.S. cities. ASD data were standardized to national AIDS surveillance data for 1992-1997 by age; race; sex; country of birth; year of AIDS diagnosis; HIV exposure mode; and for incidence calculations, by CD4+ T-lymphocyte distribution. Results: The incidence declined significantly for each of 15 of the 26 specific AIDS-defining OIs (p<0.05). PCP was the most common AIDS-defining OI to occur first (PCP was the first OI to occur for 36% of HIV-infected persons), the most common incident AIDS-defining OI (274 cases per 1000 person-years), and the most common AIDS-defining OI to have occurred during the course of AIDS (53% of persons who died with AIDS had PCP diagnosed at some time during their course of AIDS). Of persons with CD4+ T-lymphocyte counts <500 cells/muL, the number with prescriptions for triple combination therapy increased from zero in 1992 to 40% in 1997, and 80% of persons had a prescription for any antiretroviral therapy in 1997. Of persons with CD4+ T-lymphocyte counts <200 cells/muL, the percentage with prescriptions for PCP prophylaxis remained stable from 1992 through 1997 (range: 75% to 80%). Of persons with CD4+ T-lymphocyte counts <50 cells/muL, the percentage with prescriptions for MAC prophylaxis increased from 9% in 1992 to 44% in 1997. Interpretations: The incidences of many OIs are decreasing primarily because of advances in HIV-related therapy. However, OIs are still occurring, especially when patients access care late during the course of disease. Even after accessing care, persons may develop OIs because of lack of prescription for prophylaxis, antiretroviral drug resistance, or poor adherence to therapy. During 1992-1997, most patients in need of PCP prophylaxis received a prescription for it; however, even in 1997, most patients in need of MAC prophylaxis did not receive a prescription for it. Actions Taken: These surveillance data are used by persons involved with developing guidelines for preventing OIs to determine the importance of and trends in OIs and preventive therapy. CDC is developing population-based approaches for surveillance of HIV disease progression, OIs, and therapies with the goal of making these data available in more geographic areas to help assess public health and health-care programs. [ABSTRACT FROM AUTHOR]

Context: The effect of the acquired immunodeficiency syndrome (AIDS) epidemic on women is substantial and warrants an updated analysis.Objective: To describe AIDS incidence trends in women.Design: We analyzed national surveillance data on women 13 years of age and older with AIDS reported through June 1996. Data were adjusted for reporting delay, unreported risk, and the 1993 change in AIDS surveillance case definition to assess overall trends and examine trends by age group and birth cohort.Setting: Surveillance conducted by the Centers for Disease Control and Prevention in collaboration with state and local health departments.Results: In 1995, women accounted for 19% of AIDS cases in adults; AIDS incidence rates per 100000 women were highest in black women (50.1), women in the Northeast (22.3), heterosexual contacts (5.5), and women living in metropolitan statistical areas with more than 1 million residents (15.9). Greatest increases in rates between 1991 and 1995 by region and mode of transmission were in the South and in heterosexual contacts. Greatest increases in AIDS incidence rates were observed in heterosexually infected women born between 1970 and 1974, ie, women who were 14 to 18 years old in 1988.Conclusions: These trends predict continued growth of the number of AIDS cases in women, especially in those in the South and those infected heterosexually, and suggest that successive cohorts of young women may be at risk for human immunodeficiency virus infection as they reach adolescence and young adulthood. Prevention programs must reach young women before they initiate sexual activity and drug use. [ABSTRACT FROM AUTHOR]

The early referral of HIV-exposed children and their mothers to coordinated medical and social services has become increasingly important. In July 1989, the Missouri Department of Health initiated the Service Coordination Program to provide individualized referral (case management) for Missouri, residents who were reported to have acquired immunodeficiency syndrome (AIDS) or HIV infection. The purpose of the Service Coordination Program is to assist persons in accessing medical and social services. The authors describe the characteristics of the 36 children (18 enrolled in the Service Coordination Program, and 18 not enrolled) reported to the Missouri Department of Health through September 1992. Although more detailed evaluations are necessary, preliminary data suggest that opportunities for early intervention may be facilitated by the Service Coordination Program if the child's HIV status is recognized early. [ABSTRACT FROM AUTHOR]

Background: After the first two cases of locally-acquired HIV infection were recognized in Chuuk State, Federated States of Micronesia (FSM), a public health response was initiated. The purpose of the response was to assess the need for HIV education and prevention services, to develop recommendations for controlling further spread of HIV in Chuuk, and to initiate some of the prevention measures., Methodology/principal Findings: A public health team conducted a survey and rapid HIV testing among a sample of residents on the outer islands in Chuuk. Local public health officials conducted contact tracing and testing of sex partners of the two locally-acquired cases of HIV infection. A total of 333 persons completed the survey. The majority knew that HIV is transmitted through unprotected sexual contact (81%), injection drug use (61%), or blood transfusion (64%). Sexual activity in the past 12 months was reported among 159 participants, including 90 females and 69 males. Compared to women, men were more likely to have had multiple sex partners, to have been drunk during sex, but less likely to have used a condom in the past 12 months. The two men with locally acquired HIV infection had unprotected anal sex with a third Chuukese man who likely contracted HIV while outside of Chuuk. All 370 persons who received voluntary, confidential HIV counseling and testing had HIV negative test results., Conclusions/significance: Despite the low HIV seroprevalence, risky sexual behaviors in this small isolated population raise concerns about the potential for rapid spread of HIV. The lack of knowledge about risks, along with stigmatizing attitudes towards persons infected with HIV and high risk sexual behaviors indicate the need for resources to be directed toward HIV prevention in Chuuk and on other Pacific Islands.

This article describes a conceptual framework for HIV behavioral surveillance in the United States. The framework includes types of behaviors to monitor, such as risk behaviors, HIV testing behaviors, adherence to HIV treatment, and care-seeking for HIV/AIDS. The framework also describes the population groups in which specific behaviors should be monitored. Because the framework is multifaceted in terms of behaviors and populations, behavioral data from multiple surveillance systems are integrated to achieve HIV behavioral surveillance program objectives. Defining surveillance activities more broadly to include behavioral surveillance in multiple populations will provide more comprehensive data for prevention planning, and lead to a more effective response to HIV/AIDS in the 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.

Objectives: The goals of this study were two-fold: (1) to describe methods for drawing a population-based sample of individuals in care for HIV infection and (2) to compare data from the sample with data from existing surveillance systems that describe care for HIV., Methods: The authors implemented a two-stage sampling method, using local HIV/AIDS surveillance data as a sampling frame of HIV care providers in three states. At selected providers, medical records of a random sample of patients were abstracted., Results: The medical records of a number of patients, ranging from 253 to 374 individuals per state, were abstracted. The demographics of sampled individuals and of individuals reported to the local HIV/AIDS surveillance program were similar; however, differences existed in the proportion of individuals receiving HIV care consistent with treatment guidelines between the sample and a contemporary facility-based supplemental surveillance project. The median design effect for outcomes collected in the sample was 1.8 (range=0.5-29.6)., Conclusions: This survey method is feasible for collecting population-based data on patients in care for HIV. Sample size and some design elements should be changed in future studies to increase precision of estimates and usefulness of data for local planning and evaluation.

Objectives: To describe HIV and AIDS among American Indians/Alaska Natives (AI/ AN) in the USA through 2000., Design: An epidemiologic profile was constructed using HIV/AIDS surveillance, sexually transmitted disease (STD), and seroprevalence data., Results: Although AIDS among AI/AN represents < 1% of cumulative AIDS cases in the USA, in 2000 the AIDS incidence rate (cases per 100,000 population) for AI/AN (11.9) was higher than that for whites (7.3). AI/AN had high rates of chlamydia, gonorrhea, and syphilis from 1996 through 2000; among all females, AI/AN females had the second highest rates of chlamydia, gonorrhea, and syphilis reported during this time period. Of all AIDS cases among AI/AN, 70% were reported by 10 states., Conclusions: These data demonstrate that the impact of STDs and the potential for an impact of HIV/AIDS among AI/AN are greater than indicated by the relatively small number of AIDS cases in this population. Additional mechanisms are needed to fill gaps in the available data. Coordination among the complex network of healthcare providers, tribes, and federal, state, and local health agencies is needed to improve delivery of information about HIV/AIDS to AI/AN and to ensure access to HIV prevention and treatment programs for AI/AN.

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.

We determined incidence and risk factors for acute and chronic hepatitis B virus (HBV) infection and HBV vaccination rates among human immunodeficiency virus (HIV)-infected subjects from the Adult/Adolescent Spectrum of HIV Disease Project, during 1998-2001. Among 16,248 HIV-infected patients receiving care, the incidence of acute HBV was 12.2 cases/1000 person-years (316 cases), was higher among black subjects (rate ratio [RR], 1.4; 95% confidence interval [CI], 1.0-2.0), subjects with alcoholism (RR, 1.7; 95% CI, 1.2-2.3), subjects who had recently injected drugs (RR, 1.6; 95% CI, 1.1-2.4), and subjects with a history of AIDS-defining conditions (RR, 1.5; 95% CI, 1.2-1.9) and was lower in those taking either antiretroviral therapy (ART) with lamivudine (RR, 0.5; 95% CI, 0.4-0.6), ART without lamivudine (RR, 0.5; 95% CI, 0.3-0.7), or >/=1 dose of HBV vaccine (14% of subjects) (RR, 0.6; 95% CI, 0.4-0.9). Prevalence of chronic HBV was 7.6% among unvaccinated subjects. HBV rates in this population were much higher than those in the general population, and vaccination levels were low. HBV remains an important cause of comorbidity in HIV-infected persons, but ART and vaccination are associated with decreased disease.

Objective: To characterize occupationally acquired human immunodeficiency virus (HIV) infection detected through case surveillance efforts in the United States., Design: National surveillance systems, based on voluntary case reporting., Setting: Healthcare or laboratory (clinical or research) settings., Patients: Healthcare workers, defined as individuals employed in healthcare or laboratory settings (including students and trainees), who are infected with HIV., Methods: Review of data reported through December 2001 in the HIV/AIDS Reporting System and the National Surveillance for Occupationally Acquired HIV Infection., Results: Of 57 healthcare workers with documented occupationally acquired HIV infection, most (86%) were exposed to blood, and most (88%) had percutaneous injuries. The circumstances varied among 51 percutaneous injuries, with the largest proportion (41%) occurring after a procedure, 35% occurring during a procedure, and 20% occurring during disposal of sharp objects. Unexpected circumstances difficult to anticipate during or after procedures accounted for 20% of all injuries. Of 55 known source patients, most (69%) had acquired immunodeficiency syndrome (AIDS) at the time of occupational exposure, but some (11%) had asymptomatic HIV infection. Eight (14%) of the healthcare workers were infected despite receiving postexposure prophylaxis (PEP)., Conclusions: Prevention strategies for occupationally acquired HIV infection should continue to emphasize avoiding blood exposures. Healthcare workers should be educated about both the benefits and the limitations of PEP, which does not always prevent HIV infection following an exposure. Technologic advances (eg, safety-engineered devices) may further enhance safety in the healthcare workplace.

We review the HIV/AIDS reporting system, including the legal basis for reporting, the methods and infrastructure for reporting, evaluation of the completeness and quality of the data, and analysis and dissemination of reports. Other information systems (e.g., seroprevalence surveys and behavioral surveys) that collect useful information for HIV prevention and care programs are also described. Multiple data collections systems are needed to monitor the HIV/AIDS epidemic in the United States and to collect the information needed to plan, implement, and evaluate prevention and care programs.

Objectives: We describe trends in AIDS incidence, survival, and deaths among racial/ethnic minority men who have sex with men (MSM)., Methods: We examined AIDS surveillance data for men diagnosed with AIDS from 1990 through 1999, survival trends from 1993 through 1997, and trends in AIDS incidence and deaths from 1996 to 1999, when highly active antiretroviral therapy (HAART) was introduced., Results: The percentage of racial/ethnic minority MSM with AIDS increased from 33% of 26,930 men in 1990 to 54% of 17,162 men in 1999. From 1996 through 1998, declines in AIDS incidence were smallest among black MSM (25%, from 66.2 to 49.5 per 100,000) and Hispanic MSM (29%, from 39.3 to 27.8), compared with white MSM (41%, from 17.9 to 10.5). Declines in deaths of MSM with AIDS were also smallest among black MSM (53%, from 39.7 to 18.6 deaths per 100,000) and Hispanic MSM (61%, 21.6 to 8.4), compared with white MSM (63%, 12.3 to 4.5). Survival improved each year for all racial/ethnic groups but was poorest for black MSM in all years., Conclusions: Since the introduction of HAART, a combination of factors that include relatively higher infection rates in more recent years and differences in survival following AIDS diagnosis contribute to observed differences in trends in AIDS incidence and deaths among racial/ethnic minority MSM. Increased development of culturally sensitive HIV prevention services, and improved access to testing and care early in the course of disease are needed to further reduce HIV-related morbidity in racial/ethnic minority MSM.

Through sequential cross-sectional surveys, we examined intent to use home HIV test collection kits, actual use and barriers to use among persons at high risk for HIV infection. Interest in kits was assessed in the 1995-96 HIV Testing Survey (HITS, n=1683). Kit use, knowledge of kits and barriers to use were assessed in the 1998-99 HITS (n=1788), after kits had become widely available. When asked to choose among future testing options, 19% of 1995-96 participants intended to use kits. Untested participants were more likely than previously tested HIV-negative participants to choose kits for their next HIV test (p < 0.001). Among 1998-99 participants, only 24 (1%) had used kits; 46% had never heard of kits. Predictors of not knowing about kits included never having been HIV tested and black or Latino race. Common reasons for not using kits among participants aware of home test kits were concerns about accuracy, lack of in-person counselling and cost. Despite high rates of anticipated use, kits have had minimal impact on the testing behaviour of persons at high risk for HIV infection. Increasing awareness of kits, reducing price and addressing concerns about kit testing procedures may increase kit use, leading to more HIV testing by at-risk individuals.

In the United States, monitoring the HIV/AIDS epidemic among the incarcerated population is done by (a) conducting a census of persons in prisons and jails reported to be infected with HIV or diagnosed with AIDS, (b) seroprevalence surveys in selected correctional facilities, and (c) population-based HIV/AIDS case surveillance by state health departments. We describe methods for HIV/AIDS case surveillance in correctional settings and present data from the HIV/AIDS Reporting System (HARS) and the Supplement to HIV and AIDS Surveillance (SHAS) to describe the demographic, behavioral, and clinical characteristics of HIV-infected persons who were incarcerated at the time of diagnosis. HARS data showed a higher proportion of females and a lower proportion of injection drug users for incarcerated persons diagnosed with HIV (not AIDS) compared to those initially diagnosed with AIDS. The SHAS data showed a high prevalence of injection drug use, crack use, alcohol abuse, and exchanging sex for money or drugs. Together, HARS and SHAS collect fairly comprehensive information of risk behaviors from persons with HIV infection and AIDS. Advances in HIV prevention and care for the incarcerated community will require an accurate and timely description of the magnitude of the HIV epidemic in correctional settings. These data are needed to guide programmatic efforts to reduce HIV transmission in prisons and jails and in the general community upon release and ensure needed risk reduction and health care services for incarcerated persons.

Purpose: To assess the completeness, validity, and timeliness of the AIDS surveillance system after the 1993 change in the surveillance case definition., Methods: To assess completeness of AIDS case reporting, three study sites conducted a comparison of their AIDS surveillance registries with an independent source of information. To evaluate validity, the same sites conducted record reviews on a sample of reported AIDS cases, we then compared agreement between the original report and the record review for sex, race, and mode of transmission. To evaluate timeliness, we calculated the median delay from time of diagnosis to case report, before and after the change in case definition, in each of the three study sites., Results: After expansion of the case definition, completeness of AIDS case reporting in hospitals (> or = 93%) and outpatient settings (> or = 90%) was high. Agreement between the information provided on the original case report and the medical record was > 98% for sex, > 83% for each race/ethnicity group; and > 67% for each risk group. The median reporting delay after the change was four months, but varied by site from three to six months., Conclusions: The completeness, validity, and timeliness of the AIDS surveillance system remains high after the 1993 change in the surveillance case definition. These findings might be useful for programs implementing integrated HIV and AIDS surveillance systems.

Objective: Since the introduction of combination antiretroviral therapy in 1996, acquired immune deficiency syndrome (AIDS) data no longer provide information about trends in human immunodeficiency virus (HIV) incidence; therefore, we used HIV surveillance data to describe recent trends in HIV diagnoses among women., Methods: Using HIV cases reported from 25 states with confidential HIV reporting, we examined new HIV diagnoses from 1994 to 1998 among women born between 1950 and 1979 by five-year birth cohorts. We adjusted for reporting delays and anticipated reclassification of cases reported without exposure risk., Results: During the period, 24 171 cases of HIV infection were diagnosed among women. The annual number increased 4% from 1994 to 1995, then declined 12% from 1995 to 1998. The annual number of diagnoses attributed to heterosexual contact (HC) among women age 15 to 19 in 1994 (born 1975-1979) increased 117% from 1994 to 1998. Among older women, HC-related diagnoses remained stable or declined. The annual number of diagnoses attributed to injection drug use (IDU) among women age 15 to 19 in 1994 increased 90% from 1994 to 1998. The number of IDU-related diagnoses among older women declined between 31% and 59%. Diagnosis rates were higher among HC-related cases than among IDU cases. The rate for IDU-related diagnoses declined by nearly half over the period, but remained stable for HC-related diagnoses., Conclusions: HIV diagnoses among women decreased slightly between 1994 and 1998. As the youngest cohort of women reached the age where risk behaviors are initiated, however, the number of diagnoses attributed to IDU increased and the number of diagnoses attributed to HC more than doubled. It is in this youngest cohort, where risk behaviors have only recently been initiated, that HIV diagnoses most closely approximate trends in HIV incidence.

An increasing number of cases of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) among women is reported to state and territorial health departments without exposure risk information (i.e., no documented exposure to HIV through any of the recognized routes of HIV transmission). Because surveillance data are used to plan prevention and other services for HIV-infected persons, developing methods to accurately estimate exposure risk for HIV and AIDS cases initially reported without risk information and assisting states to analyze and interpret trends in the HIV epidemic by exposure risk category is important. In this report, a classification model using discriminant function analysis is described. The purpose of the classification model is to develop a proportionate distribution of exposure risk category for cases among women reported without risk information. The distribution was estimated based on behavioral and demographic data obtained from interviews with HIV-infected women; the interviews were conducted in 12 states during 1993-1996. Variables used in the analysis were alcohol abuse, noninjection-drug use, and crack use; year of HIV/AIDS diagnosis; age; employment; and region. As a result of the classification procedure, nearly all cases among women with no reported risk were classified into an exposure risk category: 81%, heterosexual contact; and 16%, injection-drug use. These proportions are higher than the current redistribution fractions (calculated from risk reclassification patterns and weighted by demographic characteristics) and reflect the increasing proportion of cases among women attributable to heterosexual contact with an infected partner. This report provides one method that could be applied to HIV surveillance data at the national level to estimate the proportion of cases in exposure risk categories. However, because the study in this report is limited in sample size and geographic representativeness, other models are also needed for adjusting risk exposure data at the national, state, and local levels.

Background: The number and proportion of people living longer with HIV and the proportion of people infected heterosexually have increased. We measured the frequency with which people with heterosexually acquired AIDS knew their partners' risk behaviors, the extent of secondary heterosexual transmission of HIV, and characterized people at risk for secondary heterosexual transmission., Methods: For each of five sites (Alabama, California, Florida, New Jersey, and Texas) and for New York City, a sample of adults with AIDS was interviewed. Primary heterosexual transmission was contact with a partner who had a known risk factor for HIV infection. Secondary transmission was contact with an HIV-positive partner not known to have a risk for HIV., Results: Among men, 35% knew that a sexual partner was HIV infected, 56% of women knew that a sexual partner was HIV infected. Among women, 12% knew that a partner was bisexual. Overall, 79% (460 of 581) reported a partner with a primary risk for HIV; among men, 236 of 293 (81%), and among women, 224 of 288 (78%) reported a partner with a primary risk. People categorized with secondary transmission were significantly more likely to be black and never married. People categorized with secondary transmission were more frequently women (53%), had less than a high school education (48%), and a history of drug use (52%). Men categorized with secondary transmission of HIV had a mean of 22 heterosexual partners; women had a mean of 16 partners., Conclusions: We found that many heterosexuals with AIDS did not know their sexual partners' risk for HIV, and that secondary heterosexual transmission probably results in a small proportion of all AIDS cases in the U.S.

Context: Declines in the number of acquired immunodeficiency syndrome (AIDS) deaths were first observed in 1996, attributed to improvements in antiretroviral therapy and an increase in the proportion of persons receiving therapy., Objective: To examine national trends in survival time among persons diagnosed as having AIDS in 1984-1997., Design, Setting, and Subjects: Retrospective cohort study using data from a population-based registry of AIDS cases and deaths reported in the United States., Main Outcome Measure: Months of survival after AIDS diagnosis through December 31, 1998, compared by year of diagnosis., Results: Among 394 705 persons with an AIDS-defining opportunistic illness (OI) diagnosed in 1984-1997, median survival time improved from 11 months for 1984 diagnoses to 46 months for 1995 diagnoses. Among persons with an OI diagnosed in 1996 and 1997, 67% were alive at least 36 months after diagnosis and 77% were alive at least 24 months after diagnosis, respectively. Among 296 621 AIDS cases diagnosed during 1993-1997, 65% were based on immunologic criteria and 35% on OI criteria; 80% were among men; and 42% were among non-Hispanic blacks, 40% among non-Hispanic whites, 17% among Hispanics, 1% among Asians/Pacific islanders, and less than 1% among American Indians/Alaska natives. The probability of surviving at least 24 months increased from 67% for those with immunologic diagnoses in 1993 to 90% in 1997 and from 49% for those with OI diagnoses in 1993 to 80% in 1997. Survival time increased with each year of diagnosis from 1984 to 1997 for blacks, whites, and Hispanics. The greatest annual survival gains occurred among persons receiving an AIDS diagnosis in 1995 and 1996., Conclusions: Survival time after AIDS diagnosis improved from 1984 to 1997. While AIDS incidence is declining, improved survival times present a growing public health challenge as the number of persons living with chronic human immunodeficiency virus disease/AIDS increases.

HIV surveillance and diagnostic testing for HIV infection share elements in common, yet differ notably in context. Clinical testing provides vital information for individual medical and behavioral decisions, whereas surveillance, which focuses on populations, provides information to develop policy, direct resources, and plan services. HIV/AIDS surveillance has evolved over the course of the epidemic, reflecting changes in scientific knowledge, populations affected, and information needs. Likewise, the benefits of early diagnosis of HIV have become increasingly apparent with advances in HIV treatment. This article examines the changing context of HIV/AIDS surveillance and discusses the potential impact of HIV surveillance practices and policies on HIV testing behaviors. Special emphasis is placed on the importance of protecting the confidentiality of HIV/AIDS surveillance data and on the role of health department in monitoring the impact of surveillance policies on test-seeking patterns and behaviors.

The emergence of a new infectious disease, AIDS, in the early 1980s resulted in the development of a national AIDS surveillance system. AIDS surveillance data provided an understanding of transmission risks and characterized communities affected by the epidemic. Later, these data provided the basis for allocating resources for prevention and treatment programs. New treatments have dramatically improved survival. Resulting declines in AIDS incidence and deaths offer hope that HIV disease can be successfully managed. However, to prevent and control HIV/AIDS in the coming decades, the public health community must address new challenges. These include the defining of the role of treatment in reducing infectiousness; the potential for an epidemic of treatment-resistant HIV; side effects of treatment; complacency that leads to relapses to high-risk behaviors; and inadequate surveillance and research capacity at state and local levels to guide the development of health interventions. Meeting these challenges will require reinvesting in the public health capacity of state and local health departments, restructuring HIV/AIDS surveillance programs to collect the data needed to guide the response to the epidemic, and providing timely answers to emerging epidemiologic questions.

The objective of this study was to examine the effect of duration of human immunodeficiency virus (HIV) infection on a woman's likelihood of giving birth. Using longitudinal data from the Maryland state Human Immunodeficiency Virus Information System and a retrospective cohort design, the authors compared 1,642 women with acquired immunodeficiency syndrome (AIDS) to 8,443 uninfected women enrolled in the Medicaid program between 1985 and 1995. The decade before AIDS diagnosis was divided into four 2.5-year periods. Proximity to AIDS diagnosis served as a proxy for duration of infection. An extension of the Cox model was used to estimate the relative risk for giving birth, with adjustment for covariates and repeated outcomes. The average number of births per 100 person-years was 6.0 for HIV-infected women and 11.1 for uninfected women (adjusted relative risk = 0.63; 95% confidence interval (CI): 0.57, 0.68). Accounting for duration of infection, the adjusted relative risks for birth among HIV-infected women, as compared with uninfected women, were 0.85 (95% CI: 0.71, 1.03), 0.74 (95% CI: 0.63, 0.86), 0.55 (95% CI: 0.47, 0.64), and 0.45 (95% CI: 0.38, 0.55) for successive 2.5-year periods before AIDS diagnosis. Demographic characteristics, contraception, abortion, fetal loss, or drug use could not fully explain the reductions. These results suggest that HIV-infected women experience a progressive reduction in births years before the onset of AIDS. This may compromise estimation of HIV prevalence and interpretation of time trends from serosurveillance of pregnant women.

Objective: To characterize Asians and Pacific Islanders in the United States with reported acquired immunodeficiency syndrome (AIDS)., Methods: AIDS surveillance data reported through June 1998 were analyzed. Characteristics of cumulative case patients, rates of AIDS incidence in 1996 through 1997, and trends from 1982 through 1996 were analyzed., Results: Through December 1998, 4,928 Asian and Pacific Islander adults and 46 Asian and Pacific Islander children with AIDS were reported in the United States. Of the total cases, 89% were in men, and 79% of those were in men who have sex with men (MSM). Five states, which account for 63% of the Asian and Pacific Islander population in the United States, reported 78% of the cases: California (45%), Hawaii (12%), New York (15%), Texas (3%), and Washington (3%). Of the 92% of Asian and Pacific Islander patients with country of birth information, 59% were foreign-born, a percentage that corresponds to the distribution in the general population. The overall incidence rate per 100,000 for 1996 through 1997 was 12.8 (21.3 for men; 3.3 for women). The highest rate was in the Northeast (15.9), followed by the West (13.8), South (10.6), and Midwest (5.7). Tuberculosis, reported for 6% of Asians and Pacific Islanders, was higher among foreign-born than among U.S.-born Asians and Pacific Islanders (8% and 4%, respectively). Between 1982 and 1996, AIDS incidence among MSM increased and peaked in 1994. Among heterosexual contacts and injection drug users, incidence has increased but remained low., Conclusions: The AIDS epidemic among Asians and Pacific Islanders in the United States has primarily affected MSM and is concentrated in a few states where most Asians and Pacific Islanders reside. Prevention activities should include consideration of cultural diversity and an understanding of cultural norms regarding sexuality. Additional information on risk behaviors and seroprevalence among Asian and Pacific Islander MSM is needed to better guide prevention planning.

Objective: To compare demographic, behavioral, and geographic characteristics of incarcerated persons with AIDS and those of all persons with AIDS reported from January 1994 through December 1996., Design: Population-based surveillance., Setting: Medical records of persons for whom AIDS diagnosis was made in hospitals, clinics, and other settings (e.g., prisons) in the United States., Patients: Adults (13 years or older) with AIDS reported from January 1994 through December 1996., Results: Of the 220000 AIDS cases in adults, 4% were reported in incarcerated persons. Compared with all persons with AIDS, a higher proportion were male (89% versus 82%), black (58% versus 39%), younger at time of diagnosis (35 versus 37 years), had injected drugs (61% versus 27%), and were reported on the basis of the 1993 immunologic criteria (71% versus 50%). Fewer cases in incarcerated persons were diagnosed at death (3% versus 10%). The South (38%) and the Northeast (37%) United States accounted for the largest proportion of incarcerated persons. The 1996 AIDS rate for incarcerated persons (199 per 100000) was six times the national rate of 31 per 100000. Among persons incarcerated at time of diagnosis, rates for women were higher than for men (287 versus 185 per 100000) and higher for blacks and Hispanics than for whites (253, 313, and 100 per 100000, respectively). By state of report, Connecticut had the highest rate among incarcerated persons (1348 per 100000)., Conclusion: These data illustrate differences in demographic, behavioral, and geographic characteristics of incarcerated persons compared with all persons with AIDS. However, they reflect only the minimum numbers of incarcerated persons with AIDS in the United States. Our results highlight the need for state health departments to work with correctional systems to ensure accurate and timely reporting of AIDS cases and to develop HIV prevention, education, and treatment both in prison and on release into the community.

To better estimate the distribution of AIDS cases after the 1993 change in the case definition, we assessed the proportion of persons whose AIDS diagnosis was based on laboratory criteria for severe immunosuppression (CD4 count <200 cells/microl or <14%) and who also had an unreported opportunistic illness (OI) at the time of the CD4 report. Five U.S. reporting sites (Arizona; Los Angeles County, California; New Jersey; Oregon; and Washington State) reviewed AIDS cases reported between January 1 and June 30, 1993. From these sites, 3289 immunologic cases were reported; of these cases, 322 (9.8%; range, 1.6%-16.1%) were in persons who had an unreported OI. More of those who had an unreported OI were male, members of racial groups other than white, injection drug users, and had a CD4 count of <50 cells/microl at AIDS diagnosis. Because of recent advances in OI prophylaxis and treatment of HIV infection, studies monitoring HIV-related morbidity should assess the occurrence of OIs in a sample of persons reported with HIV and severe immunosuppression. Such assessment will ensure representative ascertainment of initial AIDS-defining OIs and thus improve the usefulness of the data for public health planning and the allocation of resources for patient care.

Context: Since 1994, the US Public Health Service (PHS) has recommended routine, voluntary prenatal human immunodeficiency virus (HIV) testing and zidovudine therapy to reduce perinatal HIV transmission., Objective: To describe trends in incidence of perinatal AIDS and factors contributing to these trends, particularly the effect of PHS perinatal HIV recommendations., Design, Setting, and Participants: Analysis of nationwide AIDS surveillance data and data from HIV-reporting states through June 1998., Main Outcome Measures: Trends in AIDS by year of diagnosis, incidence rates of AIDS and Pneumocystis carinii pneumonia (PCP) among infants younger than 1 year from US natality data for birth cohorts 1988 to 1996; expected number of infants with AIDS from national serosurvey data; and zidovudine use data from selected HIV-reporting states., Results: Perinatal AIDS cases peaked in 1992 and then declined 67% from 1992 through 1997, including an 80% decline in infants and a 66% decline in children aged 1 to 5 years. Rates of AIDS among infants (per 100000 births) declined 69%, from 8.9 in 1992 to 2.8 in 1996 compared with a 17% decline in births to HIV-infected women from 1992 (n = 6990) to 1995 (n = 5797). Among infants, PCP rates per 100000 declined 67% (from 4.5 in 1992 to 1.5 in 1996), similar to the decline in other AIDS conditions. The percentage of perinatally exposed children born from 1993 through 1997 whose mothers were tested for HIV before giving birth increased from 70% to 94%; the percentage who received zidovudine increased from 7% to 91%., Conclusions: According to these data, substantial declines in AIDS incidence were temporally associated with an increase in zidovudine use to reduce perinatal HIV transmission, demonstrating substantial success in implementing PHS guidelines. Reductions in the numbers of births and effects of therapy in delaying AIDS do not explain the decline.

Objectives: This article describes recent trends in AIDS among US Hispanics., Methods: Incidence rates were calculated from AIDS surveillance data for persons diagnosed from 1991 through 1996. Increases in the number of cases among Hispanics were calculated by linear regression., Results: Of the 415,864 persons diagnosed with AIDS from 1991 through 1996, 19% were Hispanic. Among Hispanics with AIDS, 67% were born in the United States or Puerto Rico. The relative risk (RR) of AIDS for Hispanics compared with Whites was highest for women (RR = 7.0), followed by children (RR = 6.2) and men (RR = 2.8). Increases in the number of cases were higher among foreign-born Hispanics., Conclusions: An understanding of which Hispanic subgroups are at greatest risk for HIV infection is important for prevention efforts.

The objective of this study was to verify the mode of exposure to the human immunodeficiency virus (HIV) among cases who obtained acquired immunodeficiency syndrome (AIDS) through heterosexual contact and to determine the proportion of cases initially reported with no risk but whose exposure may have been heterosexual. Adults aged > or = 13 years with AIDS, diagnosed from 1992 through 1995 with heterosexual risk or no risk at six US study sites (Alabama, California, Florida, New Jersey, New York City, and Texas), were eligible. Heterosexual risk was validated in 82% (1,610/1,952) of the heterosexual cases. Men were more likely than women to have a risk other than heterosexual (24% vs. 13%, chi2 p < 0.01). An HIV risk was identified for 351 (55%) of those cases with no risk, and men were more likely than women to remain without risk (48% vs. 38%, chi2 P = 0.02). Of the 415 men with no risk, 215 (52%) were reclassified: 94 (44%) were men who had sex with men, 61 (28%) were injection drug users, 48 (22%) had a heterosexual risk, and 12 (6%) had other exposures. Of the 219 women with no risk, 136 (62%) were reclassified: 82 (60%) had a heterosexual risk, 47 (35%) were injection drug users, and 6 (4%) had infection associated with transfusion. In conclusion, most cases reported with heterosexually acquired AIDS had valid heterosexual risk exposures.

Context: Policies requiring confidential reporting by name to state health departments of persons infected with the human immunodeficiency virus (HIV) have potential to cause some of them to avoid HIV testing., Objective: To describe trends in use of HIV testing services at publicly funded HIV counseling and testing sites before and after the implementation of HIV reporting policies., Design and Setting: Analysis of service provision data from 6 state health departments (Louisiana, Michigan, Nebraska, Nevada, New Jersey, and Tennessee) 12 months before and 12 months after HIV reporting was introduced., Main Outcome Measure: Percent change in numbers of persons tested at publicly funded HIV counseling and testing sites after implementation of confidential HIV reporting by risk group., Results: No significant declines in the total number of HIV tests provided at counseling and testing sites in the months immediately after implementation of HIV reporting occurred in any state, other than those expected from trends present before HIV reporting. Increases occurred in Nebraska (15.8%), Nevada (48.4%), New Jersey (21.3%), and Tennessee (62.8%). Predicted decreases occurred in Louisiana (10.5%) and Michigan (2.0%). In all areas, testing of at-risk heterosexuals increased in the year after HIV reporting was implemented (Louisiana, 10.5%; Michigan, 225.1 %; Nebraska, 5.7%; Nevada, 303.3%; New Jersey, 462.9%; Tennessee, 603.8%). Declines in testing occurred among men who have sex with men in Louisiana (4.3%) and Tennessee (4.1%) after HIV reporting; testing increased for this group in Michigan (5.3%), Nebraska (19.6%), Nevada (12.5%), and New Jersey (22.4%). Among injection drug users, testing declined in Louisiana (15%), Michigan (34.3%), and New Jersey (0.6%) and increased in Nebraska (1.7%), Nevada (18.9%), and Tennessee (16.6%)., Conclusions: Confidential HIV reporting by name did not appear to affect use of HIV testing in publicly funded counseling and testing programs.

Objective: Sexual transmission of human immunodeficiency virus (HIV) is the predominant risk exposure among adolescents and adults reported with HIV infection and acquired immunodeficiency syndrome (AIDS). Although perinatal transmission accounts for the majority of HIV infection in children, there have been reports of HIV transmission through sexual abuse of children. We characterized children <13 years of age who may have acquired HIV infection through sexual abuse., Methods: All reports by state and local health departments to the national HIV/AIDS surveillance system of children with HIV infection not AIDS (n = 1507) and AIDS (n = 7629) through December 1996 were reviewed for history of sexual abuse. Information was ascertained from data recorded on the case report form as well as investigations of children with no risk for HIV infection reported or identified on initial investigation. For children with a possible history of sexual abuse, additional data were collected, including how sexual abuse was diagnosed; characteristics of the perpetrator(s) (ie, HIV status and HIV risks); and other possible risk factors for the child's HIV infection., Results: Of 9136 children reported with HIV or AIDS, 26 were sexually abused with confirmed (n = 17) or suspected (n = 9) exposure to HIV infection; mean age of these children at diagnosis of HIV infection was 8.8 years (range, 3 to 12 years). There were 14 females and 3 males who had confirmed sexual exposure to an adult male perpetrator at risk for or infected with HIV; of these, 14 had no other risk for HIV infection, and 3 had multiple risks for HIV infection (ie, through sexual abuse, perinatal exposure, and physical abuse through drug injection). The other 9 children (8 females, 1 male) had no other risk factors for HIV infection and were suspected to have been infected through sexual abuse, but the identity, HIV risk, or HIV status of all the perpetrator(s) was not known. All cases of sexual abuse had been reported to local children's protective agencies. Sexual abuse was established on the basis of physician diagnosis or physical examination (n = 20), child disclosure (n = 15), previous or concurrent noncongenital sexually transmitted disease (n = 9), and for confirmed cases, criminal prosecution of the HIV-infected or at-risk perpetrator (n = 8). For the 17 children with confirmed sexual exposure to HIV infection, 19 male perpetrators were identified who were either known to be HIV infected (n = 18) or had risk factors for HIV infection (n = 17), most of whom were a parent or relative., Conclusions: These 26 cases highlight the tragic intersection of child sexual abuse and the HIV epidemic. Although the number of reported cases of sexual transmission of HIV infection among children is small, it is a minimum estimate based on population-based surveillance and is an important and likely underrecognized public health problem. Health care providers should consider sexual abuse as a possible means of HIV transmission, particularly among children whose mothers are HIV-antibody negative and also among older HIV-infected children. The intersection of child abuse with the HIV epidemic highlights the critical need for clinicians and public health professionals to be aware of the risk for HIV transmission among children who have been sexually abused, and of guidelines for HIV testing among sexually abused children, and to evaluate and report such cases.

Objective: To describe cases of AIDS attributed to donor insemination identified through national human immunodeficiency virus (HIV)/AIDS surveillance and to compare the number identified through surveillance with our estimate of the number of women infected as a result of donor insemination before the initiation of donor screening., Methods: We reviewed national HIV/AIDS surveillance data on women reported through December 1996 and described characteristics of documented and possible cases attributed to donor insemination. We estimated the number of women infected before the initiation of widespread screening of donors using assumptions about the number of women inseminated each year, the average number of inseminations, the proportion of donors who were men who had sex with men, the prevalence of HIV among such men, and the rate of transmission per HIV-infected exposure., Results: A total of six documented and two possible cases of donor insemination-associated AIDS have been reported to the Centers for Disease Control and Prevention as of December 1996. An estimated eight to 141 women were infected through donor insemination in the United States between 1980 and 1984. Reasons for this discrepancy are discussed., Conclusion: Based on surveillance case reports and on our estimate, the total number of women infected as a result of donor insemination before screening was recommended is low. Current sperm bank practices to prevent HIV infection will be strengthened further by a pending proposal from the Food and Drug Administration requiring infectious disease screening and testing of semen donors. The most likely source of risk of new infections associated with donor insemination is self-insemination.

Objectives: To describe changes in AIDS incidence for men who have sex with men (MSM) from 1990 to 1995, by demographic and geographic groups., Methods: We examined national AIDS surveillance data reported up to 30 September 1996, for men who received AIDS diagnoses in the years 1990-1995 and whose only reported risk behavior was sex with men. We evaluated trends in AIDS rates by estimating the incidence of clinical AIDS (AIDS defined by opportunistic illnesses), and report clinical AIDS incidence rates for MSM (AIDS rates) and proportional change in rates from 1990 to 1995., Results: Clinical AIDS rates (MSM per 100,000 men per year) increased by 12% from 25.5% in 1990 to 28.5% in 1995. Significant variations in AIDS rates and 5-year changes in AIDS rates were observed in various subgroups of MSM. Five-year increases in AIDS rates were highest for American-Indian/Alaskan native (53%), black (45%), and Hispanic (23%) MSM; the only decrease occurred for white MSM (-2%). Incidence for black MSM increased from twofold (in 1990) to threefold (in 1995) the rate for white MSM. Large increases in AIDS rates were observed for MSM in rural areas (34%) and areas with 50,000 to 249,999 residents (34%) and for MSM aged over 60 years (32%)., Conclusions: The high national AIDS rate for MSM continued to rise, but more slowly than earlier in the epidemic. Racial/ethnic minority MSM had consistently large increases in AIDS rates; AIDS rates decreased only slightly for white MSM. The AIDS epidemic among MSM is not homogenous, and AIDS rates continue to increase for minority MSM, and MSM living in rural areas. HIV prevention remains a high priority for all MSM, especially black and Hispanic MSM.

We used national AIDS surveillance data to characterize trends in the numbers and proportions of heterosexually acquired AIDS cases diagnosed from January 1988 through December 1995 among adults and adolescents. We adjusted for expansion of the 1993 AIDS surveillance case definition and for delays in reporting, and we redistributed cases initially reported without risk. The chi-square test for linear trend was used to analyze trends at the p < 0.01 level by half-year of diagnosis and by sex, age, race or ethnicity, geographic region of residence at diagnosis, and partner's HIV exposure risk. From 1988 through 1995, heterosexual contact accounted for 10% of all AIDS cases. Heterosexual contact increased the most rapidly of all HIV exposure modes, with increases found among men and women in all age groups; among blacks, whites, and Hispanics: and among persons living in all geographic regions of the country. Blacks and Hispanics accounted for 75% of all persons reported with AIDS attributed to heterosexual contact. Although heterosexual contact with an injection drug user (IDU) accounted for most cases until 1993, cases increased most rapidly among persons reporting heterosexual contact with an HIV-infected partner whose risk was not specified. Findings suggest continued growth of the heterosexual AIDS epidemic. Because of the disproportionate and increasing number of heterosexually acquired AIDS cases among blacks and Hispanics, black and Hispanic communities at risk for HIV infection should be considered a high priority for prevention and education programs specifically targeting heterosexually active adolescents and adults. Epidemiologic and behavioral research and prevention program evaluation are urgent public health priorities to better control and prevent the further spread of HIV among heterosexually active adults and adolescents.

To evaluate the impact of the 1993 expansion of the acquired immunodeficiency syndrome (AIDS) surveillance definition on reporting of persons with no HIV risk exposure information, we compared persons reported with and without risk in 1992 and 1993. The expanded case definition resulted in a large increase in both the number of persons reported with risk (121% increase) and without risk (167% increase). The changes in demographic characteristics for each group were similar from 1992 to 1993. Persons reported based on immunologic criteria were more likely and persons with pulmonary tuberculosis (PTB) less likely than those meeting the pre-1993 definition criteria to be reported with risk. Many persons with PTB were retrospectively identified from tuberculosis registries that do not systematically include HIV risk information. Ascertainment of risk information continues to be an essential part of AIDS surveillance with >90% of reports including risk exposure.