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Current Trends Update: Public Health Surveillance for HIV Infection -- United States, 1989 and 1990

Since 1981, state and territorial health departments have provided reports of acquired immunodeficiency syndrome (AIDS) to CDC; AIDS cases are now reported by all 50 states and the District of Columbia. Persons with reported cases of AIDS represent approximately 10% of the estimated one million persons currently infected with human immunodeficiency virus (HIV) (1). Consequently, many states have enacted statutes or promulgated public health regulations that mandate the reporting of HIV-infected persons; these reports may assist with early medical intervention and partner notification activities, provide a minimum estimate of the number of infected persons who have been tested and identified, and facilitate planning for medical and social services. This report summarizes current HIV-reporting practices by state.

In telephone surveys conducted in 1989 and 1990, CDC requested all 50 states and the District of Columbia to provide information regarding current HIV-reporting practices. In most states, because of limited resources, reports of HIV infection are provided through passive surveillance systems; reports of HIV infection may originate from state public health laboratories, private laboratories, private physicians, or other health-care providers. However, because surveillance methods differ by state and are not yet standardized, data cannot be readily compared between states or to AIDS cases.

As of October 1990, 33 states required that HIV infection in persons who do not yet meet the criteria for CDC-defined AIDS be reported (Table 1); these states accounted for 34.4% of all AIDS cases reported in the United States through September 1990. As of October 1, 1990, 21 of the 33 states had enacted legislation or promulgated regulations that require reporting of HIV-infected persons by name to state or local health departments. These 21 states accounted for 12.6% of all reported AIDS cases. All 21 states require reported information to include the person's sex, age, and race/ethnicity; 19 states, the mode of transmission; six, the clinical status; and three, the CD4+ T-cell count. In 19 states, duplicate HIV reports are excluded. Sixteen of the 21 states with reporting by name also offer the option of anonymous HIV testing in some circumstances. Thus, patient names are not always provided.

In 12 of the 33 states, anonymous (i.e., without names or identifiers) individual reports of HIV infection must be provided to the state health department; these 12 states account for 21.8% of all reported AIDS cases. Eleven states require reporting of (Continued on page 859)sex and age; nine, race/ethnicity; and six, the mode of transmission. None require reports on clinical status or CD4+ T-cell count. Because reporting is anonymous, duplicate test reports cannot be excluded with certainty.

The CDC surveys did not collect detailed information on the variety of reporting practices among states that do not have legal requirements for the reporting of asymptomatic persons identified with HIV infection by public or private sector health-care providers. However, among the 17 remaining states and the District of Columbia, reports of HIV infections may be required only in selected cases (e.g., in some criminal cases or for incarcerated persons). Two states (Maryland and Washington) require reporting by name of symptomatic HIV-infected persons only. Several states are considering either implementing or changing existing HIV-reporting rules or regulations. Some states receive reports provided on a voluntary basis by state public health laboratories and/or health-care providers. Reported by: State health departments. Div of HIV/AIDS, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: In May 1989, the Council of State and Territorial Epidemiologists (CSTE) recommended that CDC provide technical assistance to states with required HIV-infection reporting to implement a standardized surveillance system for the reporting of HIV-infected persons. CSTE also recommended that states that require HIV reporting should provide data on HIV-infected persons (but without personal identifiers) to CDC. The recommended elements for a standardized HIV-reporting system include age, sex, race/ethnicity; transmission category; state of residence; laboratory test results and clinical status; and an identifier that can be used to exclude duplicate reports (2). A standardized HIV-infection reporting system that is similar to that used for national AIDS surveillance has been developed.

Twenty of the states that require reporting by name submit to CDC reports of HIV-infected persons who do not meet the CDC AIDS case definition; these reports to CDC do not contain names and other personal identifying information. All 50 states and the District of Columbia will continue to report persons who meet the AIDS case definition.

The standardized HIV report form includes the recommended elements as well as information on source of test report, referrals for medical treatment, and partner notification. Persons to be included are those determined to be infected with HIV based on the criteria defined jointly by CDC and the Association of State and Territorial Public Health Laboratory Directors for the interpretation and use of Western blot assays for HIV serodiagnosis (3).

At the local and state levels, reports of HIV-infected persons may be used to implement and evaluate the impact of partner notification for preventing transmission, to contact and counsel HIV-positive persons who have not returned for test results, and to provide access to medical follow-up including CD4 cell testing and therapy. The roles of private-sector providers and others in HIV-prevention activities can be monitored in states with HIV reporting with identifiers that also collect information on source of HIV report. In some states, CD4 cell testing is conducted in conjunction with HIV reporting. For example, in South Carolina, HIV-positive persons are routinely provided CD4 cell testing; HIV reporting may be used to monitor access to and use of treatment regimens. HIV reporting also may assist in monitoring trends in the HIV/AIDS epidemic by detecting at-risk segments of the population (e.g., adolescents) before the onset of AIDS (4). In some settings, HIV testing and reporting may provide an early indication of the spread of HIV among persons without recognized high-risk behaviors (5).

The implementation of HIV reporting has raised such concerns as whether HIV-infected persons may be less willing to be tested (6). Therefore, assessment of the public health usefulness of HIV reporting will require careful evaluation of the completeness of testing and reporting, the representativeness of infected persons who are reported, and the impact of HIV reporting on prevention goals, patient management, and AIDS case surveillance. CDC is initiating such evaluations in collaboration with five state health departments (Alabama, Arizona, Colorado, Mississippi, and Missouri). Reports of persons with HIV infection cannot be considered to accurately measure the prevalence of HIV nor represent the population of HIV-infected persons. Therefore, AIDS case surveillance data and blinded HIV-seroprevalence surveys will continue to be the primary means for HIV/AIDS surveillance (7).

Despite limitations in HIV reporting, assessment of the public health impact of the HIV/AIDS epidemic should be enhanced by surveillance of the entire spectrum of HIV-related disease through seroprevalence studies, HIV-infection reporting, and AIDS case surveillance. Moreover, by using measures to maintain confidentiality, the implementation of a standardized system for HIV reporting to state health departments can enhance the ability of local, state, and national agencies to project the levels of required resources. Public health surveillance for HIV infection is assisting in the establishment of a framework for providing partner notification and treatment services in some states.

References

  1. CDC. Estimates of HIV prevalence and projected AIDS cases: summary of a workshop, October 31-November 1, 1989. MMWR 1990;39:110-2,117-9.

  2. CDC. HIV infection reporting--United States. MMWR 1989;38:496-9.

  3. CDC. Interpretation and use of the Western blot assay for serodiagnosis of human immunodeficiency virus type 1 infections. MMWR 1989;38(no. S-7).

  4. MacDonald K, Danila R, Reier D, Heiser J, Stiepan D, Osterholm M. Surveillance for HIV infection in Minnesota: results from the first three years of operation (Abstract). V International Conference on AIDS. Montreal, June 4-9, 1989:59.

  5. Salamon R, Dabris F, Maurice S, Toulose C, Prost L, Tilly B. HIV monitoring in general practice (Letter). Lancet 1988;2:395.

  6. Fehrs L, Fleming D, Foster L, et al. Trial of anonymous versus confidential human immunodeficiency virus testing. Lancet 1988;2:379-82.

  7. Buehler J, Berkelman R, Curran J. Reporting of AIDS: tracking morbidity and mortality (Editorial). JAMA 1989;262:2896-7.



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