Since the use of highly active antiretroviral therapy (HAART) in the United States became widespread during 1996, trends in AIDS incidence have become less reflective of underlying trends in HIV transmission. To better monitor the patterns of HIV diagnoses, most states have implemented HIV surveillance. The figure on the cover depicts the estimated number of cases of HIV/AIDS among adults and adolescents, from 2000 through 2003, by transmission category for persons residing in the 33 areas with integrated HIV and AIDS surveillance since at least 1999. The term HIV/AIDS is used to refer to persons with a diagnosis of HIV infection, regardless of their AIDS status at diagnosis. From 2000 through 2003, the total number of new cases of HIV/AIDS in the 33 areas increased slightly. HIV/ AIDS prevalence (i.e., the number of persons living with HIV/AIDS) also increased during this time: at the end of 2003, an estimated 351,614 persons in the 33 areas were living with HIV/AIDS. According to the number of reported AIDS cases, these 33 areas represent approximately 43% of the epidemic in the United States.

Some persons with a newly diagnosed case of HIV infection were infected recently; others were infected some time in the past. Therefore, new HIV diagnoses do not necessarily reflect trends in HIV incidence (i.e., new infections). One method for estimating HIV incidence is to apply the serologic testing algorithm for recent HIV seroconversion (STARHS) to the serum specimens from which recent HIV diagnoses were made. A total of 33 areas are using this method: 5 areas were funded in FY 2002 to pilot this method, 19 additional areas were funded in FY 2003, and another 9 areas were funded in FY 2004. The monitoring of HIV incidence will be critical in evaluating progress toward CDC’s HIV Prevention Strategic Plan goal of reducing the number of new HIV infections in the United States from 40,000 to 20,000 per year.

Surveillance data on HIV infection provide a more complete picture of the epidemic and the need for prevention and care services than does the picture provided by AIDS data alone. Such comprehensive information is needed to allocate resources and evaluate program effectiveness. The 2003 HIV/AIDS Surveillance Report presents data on cases of HIV/AIDS. For analyses of HIV/AIDS data, we used data from 33 areas (i.e., 32 states and the U.S. Virgin Islands) with mature HIV reporting systems (i.e., HIV reporting at least since 1999) to allow for stabilization of data collection and for adjustment of the data in order to monitor trends. Tables 1, 2, 8, and 9 summarize cases and prevalence of HIV/AIDS. For analyses of AIDS cases, we used data from the 50 states, the District of Columbia, U.S. dependencies, possessions, and associated nations.

This report is organized in 5 sections: (1) cases of HIV/AIDS and AIDS, (2) deaths of persons with AIDS, (3) persons living with HIV/AIDS, AIDS, or HIV infection (not AIDS), (4) length of survival after AIDS diagnosis, and (5) reports of cases of AIDS, HIV infection (not AIDS), and HIV/AIDS. In Sections 1–3, we present point estimates of case counts that have been adjusted for reporting delays and for redistribution of cases in persons initially reported without an identified risk factor. CDC routinely adjusts data for the presentation of trends in the epidemic. Data to estimate the number of cases of HIV/AIDS or AIDS; the number of persons living with HIV/AIDS, AIDS, or HIV infection (not AIDS); and the number of deaths among persons with AIDS have been statistically adjusted to correct for delays in the reporting of cases and deaths. To assess trends in cases, deaths, or prevalence, it is preferable to use adjusted data, presented by year of diagnosis instead of year of report, to eliminate artifacts of reporting in the surveillance system. Therefore, for trends, you are encouraged to use the tables in Sections 1, 2, 3 that present trends by year of diagnosis, year of death, or year-end prevalence. Section 4 presents estimates of survival for persons whose AIDS diagnosis was made during 1999 (Table 13) and for persons whose diagnosis was made during 1995–2002 (Figures 2,3,4). Proportions of persons who survived for various lengths of time after diagnosis are presented by year of diagnosis, age group, race/ethnicity, and HIV transmission category. Finally, Section 5 presents reports of cases of HIV infection (not AIDS) and cases of AIDS reported through 2003. The areas included in tabulations of reported cases of HIV infection (not AIDS) are based on the date that confidential name-based HIV infection reporting was implemented. For Tables 16, 18, 20, and 22, we used data from 41 areas to describe reports of HIV infection. These data have not been adjusted for delays in reporting and are presented by year of report to CDC. Tables that present cases by year of report represent the most up-to-date information reported to CDC; however, cases by year of report do not represent incident cases, the most recent diagnoses, trends, or deaths.

Cases of HIV/AIDS and cases of AIDS
Cases of HIV/AIDS
From 2000 through 2003, the estimated number of HIV/AIDS cases in the 33 areas with confidential name-based HIV infection reporting remained relatively stable. See Table 1 for data on persons in this category. The estimated number of HIV/AIDS cases increased approximately 1% from the end of 2002 (31,805) through the end of 2003 (32,048).

• Age group: From 2000 through 2003, the estimated number of HIV/AIDS cases decreased slightly among children less than 13 years of age and in the age group 25–34 years, remained stable in the age group 35–44 years, and increased in the following age groups: 13–14, 15–24, 45–54, 55–64, and 65 years and older. The age group 25–34 years represented 27% of all HIV/AIDS cases diagnosed in 2003.

• Race/ethnicity: From 2000 through 2003, the estimated number of HIV/AIDS cases increased among whites, Hispanics, and Asians/Pacific Islanders, remained stable among American Indians/Alaska Natives and decreased among blacks. Blacks accounted for 50% of all HIV/AIDS cases diagnosed in 2003.

• Sex: From 2000 through 2003, the estimated number of HIV/AIDS cases increased 5% among males and decreased 2% among females. In 2003, males accounted for 72% of all HIV/AIDS cases among adults and adolescents.

• Transmission category: From 2000 through 2003, the estimated number of HIV/AIDS cases increased each year among men who have sex with men (MSM) and among heterosexual adults and adolescents. In addition, the estimated number of HIV/AIDS cases decreased among injection drug users (IDUs), MSM who were also IDUs, and among children. MSM (45%) and persons exposed through heterosexual contact (34%) accounted for 79% of all HIV/AIDS cases diagnosed in 2003.

Of all HIV infections diagnosed in 2002, 38% progressed to AIDS within 12 months after HIV infection was diagnosed. AIDS was diagnosed within 12 months after the diagnosis of HIV infection for a larger proportion of persons aged 35 years and older, Hispanics, IDUs, and persons exposed through heterosexual contact (Table 2).

Cases of AIDS
During 1999–2001, decreases in the annual number of AIDS cases began to level; however, after 2001, the estimated number of AIDS cases increased each year (Table 3). In 2003, the estimated rate of AIDS cases in the United States was 14.5 per 100,000 population (Table 5).

• Age group: From 1999 through 2003, the estimated number of AIDS cases decreased 68% among children and 15% in the age group 25–34 years and remained stable in the age group 13–14 years (Table 3). The estimated number of AIDS cases increased in the following age groups: 15–24, 35–44, 45–54, 55–64, and 65 years and older. The age group 35–44 years represented 41% of all AIDS cases diagnosed in 2003.

• Race/ethnicity: From 1999 through 2003, the estimated number of AIDS cases decreased among whites and increased among blacks, Hispanics, Asians/Pacific Islanders, and among American Indians/Alaska Natives (Table 3). In 2003, rates of AIDS cases were 58.2 per 100,000 in the black population, 20.0 per 100,000 in the Hispanic population, 8.1 per 100,000 in the American Indian/Alaska Native population, 6.1 in the white population, and 4.0 per 100,000 in the Asian/Pacific Islander population (Table 5).

• Sex: From 1999 through 2003, the estimated number of AIDS cases increased 15% among females and 1% among males. Males accounted for 73% of all AIDS cases diagnosed in 2003 among adults and adolescents in the United States (Table 3). Rates of AIDS cases in 2003 were 26.6 per 100,000 among males and 9.2 per 100,000 among females (Table 5).

• Transmission category: From 1999 through 2003, the estimated number of AIDS cases decreased among IDUs and among MSM who were also IDUs (Table 3). From 1999 through 2000, the estimated number of AIDS cases decreased slightly among MSM; however, during 2001–2003, the estimated number of AIDS cases increased. Among persons exposed through heterosexual contact, the estimated number of AIDS cases increased each year from 1999 through 2003.

• Region: In 2003, compared with 2002, the estimated number of AIDS cases increased 9% in the Northeast, 6% in the South, and 4% in the Midwest and decreased 3% in the West.

Deaths
The estimated number of deaths among persons with AIDS remained relatively stable from 1999 through 2003 (Table 7).

• Age group: From 1999 through 2003, the estimated number of deaths decreased among children less than 13 years of age and in the age groups 13–14, 25–34 and 35–44 years. The estimated number of deaths increased in the age groups 45–54, 55–64, and 65 years and older, and remained stable in the age group 15–24 years.

• Race/ethnicity: From 1999 through 2003, the estimated number of deaths among persons with AIDS decreased among whites and Asians/Pacific Islanders, increased among Hispanics, and remained stable among blacks and American Indians/Alaska Natives.

• Sex and transmission category: From 1999 through 2003, among males, the estimated number of deaths of MSM and IDUs decreased. Among females, the estimated number of deaths of IDUs remained stable. Among adults and adolescents of both sexes exposed through heterosexual contact, the estimated number of deaths increased from 1999 through 2001, decreased slightly in 2002, and then increased again in 2003.

• Region: The estimated number of deaths in 2003 compared with 2002 decreased in the Midwest; the South; and U.S. dependencies, possessions, and associated nations and increased in the Northeast and the West.

Persons living with HIV/AIDS, HIV infection (not AIDS), or AIDS

Persons living with HIV/AIDS
The estimated number of persons living with HIV/AIDS has increased steadily in the 33 areas with confidential name-based HIV infection reporting (Table 8). At the end of 2003, an estimated 351,614 persons were living with HIV/AIDS in the 33 areas with confidential name-based HIV infection reporting since 1999:

• By age group, 41% were in the age group 35–44 years.

• By race/ethnicity, 48% were black, 38% white, 12% Hispanic, and less than 1% each were American Indian/Alaska Native and Asian/Pacific Islander.

• By sex, 75% of adults and adolescents living with HIV/AIDS were male.

• Of the estimated 259,609 male adults and adolescents (13 years of age and older) living with HIV/AIDS, 62% were MSM, 16% were IDUs, 13% had been exposed through heterosexual contact, and 8% were MSM who also were IDUs. Of the estimated 87,940 female adults and adolescents living with HIV/AIDS, 73% had been exposed through heterosexual contact, and 25% had been exposed through injection drug use. Of the estimated 4,062 children living with HIV/AIDS, 92% had been exposed perinatally.

Prevalence rates of HIV infection (not AIDS)
In the 33 areas with confidential name-based HIV infection reporting, the prevalence rate of HIV infection (not AIDS) among adults and adolescents was estimated at 127.8 per 100,000 at the end of 2003 (Map 1). The rate for adults and adolescents living with HIV infection (not AIDS) ranged from an estimated 13.6 per 100,000 (North Dakota) to an estimated 282.5 per 100,000 (U.S. Virgin Islands). The prevalence rate of HIV infection (not AIDS) among children residing in the 33 areas was an estimated 5.6 per 100,000 at the end of 2003 (Map 2). The rate for children living with HIV infection (not AIDS) ranged from an estimated zero per 100,000 in Alaska and New Mexico to an estimated 19.0 per 100,000 in New Jersey.

Persons living with AIDS
AIDS prevalence has also increased steadily since 1999 (Table 10). At the end of 2003, an estimated 405,926 persons in the United States were living with AIDS:

• By age group, 41% were in the age group 35–44 years.
• By race/ethnicity, 42% were black, 36% white, 20% Hispanic, 1% Asian/Pacific Islander and less than 1% American Indian/Alaska Native.
• By sex, 77% of adults living with AIDS were men.
• By region, 39% resided in the South, 29% in the Northeast, 19% in the West, 10% in the Midwest, and 3% in the U.S. territories. Of the estimated 313,183 male adults and adolescents (13 years of age and older) living with AIDS, 58% were MSM, 22% were IDUs, 11% had been exposed through heterosexual contact, and 8% were MSM who were also IDUs.
• Of the estimated 88,815 female adults and adolescents living with AIDS, 63% had been exposed through heterosexual contact, and 35% had been exposed through injection drug use.

AIDS prevalence rates
In the United States, the prevalence rate of AIDS among adults and adolescents was estimated at 167.3 per 100,000 at the end of 2003 (Map 1). The rate for adults and adolescents living with AIDS ranged from an estimated 4.1 per 100,000 (U.S. Pacific Islands) to an estimated 1,833.2 per 100,000 (District of Columbia). The prevalence rate of AIDS among children in the United States was estimated at 3.7 per 100,000 at the end of 2003 (Map 2). The rate for children living with AIDS ranged from an estimated zero per 100,000 in Guam, Idaho, Montana, and the U.S. Pacific Islands to an estimated 74.5 per 100,000 in the District of Columbia.

Survival after AIDS diagnosis
Table 13 is limited to data on AIDS cases diagnosed in 1999 in order to describe the survival of persons whose diagnosis was made relatively recently, but far enough in the past to permit a meaningful measure of survival. Figures 2, 3, and 4 illustrate the proportion of surviving persons among persons whose diagnoses were made over a longer period, 1995 through 2002. 

• Survival (the estimated proportion of persons surviving a given length of time after diagnosis) increased with the year of diagnosis for diagnoses made during 1995–2002. Year-to-year differences were small during 1998–2002 (Figure 2).
• Survival decreased as age at diagnosis increased among persons at least 35 years old at diagnosis and in comparison with persons younger than 35. Survival was similar for the age groups less than 35 years (Figure 3).
• Survival was greatest among MSM and among children with perinatally acquired HIV infection (Table 13). Survival was intermediate among men and women who had heterosexual contact with someone known to be HIV infected or at high risk for HIV infection, as well as among MSM who also were IDUs. Survival was lowest among men and women who were IDUs.
• Survival, particularly at more than 48 months after diagnosis, was greater among Hispanics, non-Hispanic whites, and Asians/Pacific Islanders than among non-Hispanic blacks (Figure 4). Results were unstable or inconsistent for American Indians/Alaska Natives because the numbers of persons in this racial/ethnic category were small.

Reports of Cases of AIDS, HIV infection (not AIDS), and HIV/AIDS
Tables 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23 describe reports of cases of AIDS, HIV infection (not AIDS), and of HIV/AIDS. Tables 16, 18, 20, and 22 are based on reports of cases of HIV infection (not AIDS) through 2003 from the 41 areas that had implemented name-based HIV infection reporting. Note that not all cases of HIV infection (not AIDS) or AIDS reported in 2003 reflected new diagnoses; rather, the reported cases include cases diagnosed during earlier years.

Reports of cases of HIV infection (not AIDS)
Through 2003, a total of 221,065 persons were reported as having HIV infection (not AIDS) in the 41 areas with confidential name-based HIV infection reporting (Table 16). Five states (New York, Florida, New Jersey, Texas, and North Carolina) reported 115,348 (52%) of the 221,065 cumulative cases of HIV infection (not AIDS) reported to CDC. In 2003, 3 states (Florida, New York, and Texas) reported 18,162 (55%) of the 33,301 cases of HIV infection (not AIDS). 

• By sex, in 2003, 69% of the 32,842 reported cases of HIV infection (not AIDS) among adults and adolescents were in males, and 31% were in females (Table 18).
• In 2003, 459 cases of HIV infection (not AIDS) in children were reported.

• By sex, in 2003, males accounted for 74% and females for 26% of 44,811 reported AIDS cases among adults and adolescents (Table 17).
• In 2003, 152 AIDS cases in children were reported.

Additional Resources

The following were prepared by using HIV/AIDS surveillance data:

• Selected MMWR articles at www.cdc.gov/hiv/resources/reports/mmwr/index.htm
• Public-use slides at www.cdc.gov/hiv/topics/surveillance/resources/
  slides/index.htm
• Other surveillance reports at www.cdc.gov/hiv/topics/surveillance/resources/
  reports/index.htm
• Public-use version of the AIDS surveillance data set (AIDS Public Information Data Set [APIDS]) at www.cdc.gov/hiv/topics/surveillance/resources/
  software/apids/

Suggested Readings

CDC. Advancing HIV prevention: new strategies for a changing epidemic―United States, 2003. MMWR 2003;52:329-332.

CDC. Diagnosis and reporting of HIV and AIDS in 25 states―United States, 1994–2000. MMWR 2002;51:595-598.

CDC. Guidelines for national HIV case surveillance, including monitoring for HIV infection and AIDS. MMWR 1999;48(No. RR-13):1-31.

CDC. HIV Prevention Strategic Plan Through 2005. Atlanta: U.S. Department of Health and Human Services, CDC; 2001. Available at http://www.cdc.gov/hiv/resources/reports/psp.

CDC. Increases in HIV diagnoses—29 states, 1999–2002. MMWR 2003;52:1145-1148.

CDC. Update: the AIDS epidemic in the United States, 2001. MMWR 2002;51:592-595.

Janssen RS, Satten GA, Stramer SL, et al. New testing strategy to detect early HIV-1 infection for use in incidence estimates and for clinical and prevention purposes. JAMA 1998;280:42-48.

Karon JM, Fleming PL, Steketee RW, De Cock KM. HIV in the United States at the turn of the century: an epidemic in transition. Am J Public Health 2001;91:1060-1068.

Nakashima AK, Fleming PL. HIV/AIDS surveillance in the United States, 1981–2001. J Acquir Immune Defic Syndr 2003;32:68-85.