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AIDS Among Racial/Ethnic Minorities -- United States, 1993

In 1993, local, state, and territorial health departments reported to CDC 58,538 cases of acquired immunodeficiency syndrome (AIDS) among racial/ethnic minorities (Table_1). A total of 38,544 (66%) cases were reported among blacks, 18,888 (32%) among Hispanics, 767 (1%) among Asians/Pacific Islanders, and 339 (1%) among American Indians/Alaskan Natives *. These cases represented 55% of the 106,949 AIDS cases reported in the United States in 1993. Rates of AIDS and modes of human immunodeficiency virus (HIV) exposure varied substantially both among and within minority populations. This report describes these differences and summarizes the epidemiologic characteristics of AIDS cases reported among racial/ethnic minorities during 1993.

In 1993, racial/ethnic minorities accounted for 45,039 (51%) of 89,165 AIDS cases reported among adult and adolescent males (aged greater than or equal to 13 years) and 12,696 (75%) of 16,824 cases among adult and adolescent females. Of the 959 cases reported among children (aged less than 13 years), 803 (84%) were among minorities.

In 1993, 111 AIDS cases per 100,000 adults and adolescents were reported among racial/ethnic minorities. Rates were highest among blacks and Hispanics (162 and 90, respectively) and lowest among American Indians/Alaskan Natives and Asians/Pacific Islanders (24 and 12, respectively). Blacks are disproportionately affected by the HIV epidemic: the AIDS rate for black females (73) was approximately 15 times greater than that for white females (5), and the rate for black males (266) was nearly five times greater than that for white males (57).

AIDS rates for blacks and Hispanics varied substantially by geographic region (Figure_1) and (Figure_2). ** Rates for both groups were generally highest in the Northeast. *** For blacks, rates were highest in Vermont (445 ****), New York (379), New Jersey (373), and Florida (366). AIDS rates for blacks were less than the overall adult and adolescent rate (50) in 11 (22%) of the 50 states.

For Hispanics, AIDS rates were highest in New York (293), Connecticut (271), Massachusetts (249), and Pennsylvania (246). Rates for Hispanics were less than the overall rate in 26 (52%) of the 50 states. In Arizona, California, Hawaii, Mississippi, New Mexico, Texas, Wyoming, and the District of Columbia, AIDS rates for Hispanics were lower than rates for whites.

Among males who were racial/ethnic minorities, the most common modes of HIV exposure were male-male sex (39%) and injecting-drug use (IDU) (38%). Among females, the most common exposures were IDU (47%) and heterosexual contact (37%). However, the distribution of exposures differed substantially by race/ethnicity (Table_2) and geographic location. IDU was the principal HIV exposure among blacks and Hispanics; most (60%) IDU-associated cases among blacks and Hispanics were reported in the Northeast and Puerto Rico. Male-male sex was the primary exposure among Asians/Pacific Islanders and American Indians/Alaskan Natives. The proportion of AIDS cases with no reported risk for HIV infection was greater among racial/ethnic minorities than among whites.

In geographic locations outside the Northeast, patterns of HIV exposure among blacks and Hispanics varied substantially. Among black males with AIDS, male-male sex was the most common mode of exposure in the District of Columbia, the U.S. Virgin Islands, and 32 (67%) of 48 states that reported AIDS cases among black males. Among Hispanic males, male-male sex was the most common exposure in the District of Columbia and 34 (71%) of 48 states that reported cases among Hispanic males. Among black females, IDU was the most common exposure in the District of Columbia and 23 (52%) of 44 states that reported AIDS cases among black females, and heterosexual contact was the leading exposure in 20 (45%) states. Among Hispanic females, heterosexual contact was the most common exposure in the District of Columbia, Puerto Rico, and 19 (54%) of 35 states that reported AIDS cases among Hispanic females, and IDU was the leading exposure in 10 (29%) states.

Reported by: Local, state, and territorial health depts. Div of HIV/AIDS, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Following the 1993 expansion of the AIDS surveillance case definition, the number of AIDS cases reported among racial/ethnic minorities in 1993 increased 135% over that in 1992, while the number among whites increased 114%. The greater increase in cases among racial/ethnic minorities is consistent with trends in the number of AIDS cases reported in previous years, representing a continued increase in the epidemic among certain minority populations. However, because the increase in cases reported in 1993 reflects a transient effect of the expansion of the AIDS surveillance case definition, the number of AIDS cases reported in 1994 is expected to be lower than that in 1993 (1).

AIDS surveillance may underestimate the number of AIDS cases reported among certain minority populations because of misclassification of race/ethnicity on medical records, which are the source for AIDS case reports. For example, a study conducted during June 1990-August 1992 that compared self-reported race/ethnicity with that listed on AIDS case reports indicated that AIDS cases among Asians/Pacific Islanders (12 cases), American Indians/Alaskan Natives (14), and Hispanics (249) were underreported by 25%, 21%, and 18%, respectively; in comparison, AIDS cases among whites and blacks were overreported by 4% and 2%, respectively (2).

The increase in the number of persons with AIDS has greatly affected death rates for racial/ethnic minorities, particularly young adults. In 1991, among males aged 25-44 years, HIV infection was the leading cause of death for blacks and Hispanics and the sixth leading cause for Asians/Pacific Islanders and American Indians/Alaskan Natives. Among females in this age group, HIV infection was the third leading cause of death for blacks and Hispanics, the seventh for American Indians/Alaskan Natives, and the ninth for Asians/Pacific Islanders. Provisional mortality data for 1992 ***** indicate that HIV infection was the second leading cause of death among black females aged 25-44 years (3); in 1991, the HIV/AIDS death rate for all black females was approximately 10 times the rate for white females (4).

Most AIDS cases classified as having no reported risk for HIV infection will be reclassified into one of the known exposure groups after additional follow-up. A greater proportion of racial/ethnic minorities than whites may be initially classified without an HIV risk because of unrecognized heterosexual transmission, the diagnosis of AIDS at or near death, and language and cultural differences that make risk ascertainment more difficult.

Although race and ethnicity are not risk factors for HIV transmission, they are markers for underlying social, economic, and cultural factors and personal behaviors that affect health (5). Socioeconomic status in particular is associated with morbidity and premature mortality (6); unemployment, poverty, and illiteracy are correlated with decreased access to health education, preventive services, and medical care, resulting in an increased risk for disease (5). In 1992, 33% of blacks and 29% of Hispanics lived below the federal poverty level, ****** compared with 13% of Asians/ Pacific Islanders and 10% of whites (7). Therefore, the social, economic, and cultural context of HIV infection should be considered when designing and implementing prevention programs for diverse populations.

Although IDUs in the Northeast and Puerto Rico accounted for 24% of all AIDS cases reported among racial/ethnic minorities, AIDS rates and modes of HIV exposure varied greatly among minority populations in other areas of the country. HIV serosurveillance studies have demonstrated similar patterns (8). In addition, the incidence of AIDS and the distribution of HIV exposures among Hispanics and Asians/Pacific Islanders vary in relation to their place of birth (9,10). These geographic and racial/ethnic differences are directly related to variations in the prevalence of HIV infection, the type and frequency of behaviors associated with HIV transmission, and the time of introduction of HIV into the specific communities; and indirectly related to the social, economic, and cultural influences within those communities.

Because the epidemiology of HIV infection varies considerably by geographic region and among racial/ethnic populations, preventive interventions should be developed at the local level to ensure that they reflect the language, culture, and behavioral norms of the targeted community. CDC is collaborating with local, state, and territorial health departments to establish planning groups composed of community representatives, epidemiologists, behavioral scientists, and other public health practitioners who will participate in the development and implementation of HIV-prevention programs.

References

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

  2. Kelly JJ, Chu SY, Diaz T, Leary LS, Buehler JW. Race/ethnicity misclassification of persons reported with AIDS. Ethn Dis (in press).

  3. CDC. Update: mortality attributable to HIV infection among persons aged 25-44 years -- United States, 1991 and 1992. MMWR 1993;42:869-72.

  4. NCHS. Excess deaths and other mortality measures for the black population, 1979-81 and 1991. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994.

  5. National Commission on AIDS. The challenge of HIV/AIDS in communities of color. Washington, DC: National Commission on AIDS, December 1992.

  6. Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health. JAMA 1993;269:3140-5.

  7. Bureau of the Census. Poverty in the United States, 1992. Washington, DC: US Department of Commerce, Economics and Statistics Administration, Bureau of the Census, September 1993.

  8. CDC. National HIV serosurveillance summary: results through 1992. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, November 1993.

  9. Diaz T, Buehler JW, Castro KG, Ward JW. AIDS trends among Hispanics in the United States. Am J Public Health 1993;83:504-9.

  10. Metler R, Hu DJ, Fleming PL, Ward JW. AIDS among Asians and Pacific Islanders (A/PI) reported in the U.S.A. {Abstract no. PCO325}. Vol 2. Xth International Conference on AIDS/International Conference on STD. Yokohama, Japan, August 10-11, 1994:241.

* The racial/ethnic categories used in federal statistics are specified in the Office of Management and Budget's Directive 15, Race and Ethnic Standards for Federal Statistics and Administrative Reporting (1978).

** The numbers of AIDS cases reported among Asians/Pacific Islanders and American Indians/ Alaskan Natives were insufficient to analyze by state. 

*** New England and Middle Atlantic regions. 

**** Based on six reported AIDS cases in 1993. 

***** Provisional data were available only for blacks and whites without stratification by Hispanic ethnicity. 

****** Poverty statistics are based on definitions originated by the Social Security Administration in 1964, subsequently modified by the federal interagency committees in 1969 and 1980, and prescribed by the Office of Management and Budget as the standard to be used by federal agencies for statistical purposes.


Table_1
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TABLE 1. Number, percentage, and rates * of AIDS cases, by race/ethnicity -- United States, reported in 1993
===============================================================================================================
                                                          Adult/Adolescent +
                            -------------------------------------------------------------
                                   Male                 Female               Total              Children &
                            -------------------   ------------------   ------------------  ------------------
Race/Ethnicity               No.    (%)    Rate    No.    (%)   Rate    No.    (%)   Rate  No.    (%)    Rate
-------------------------------------------------------------------------------------------------------------
White, non-Hispanic         43,987 ( 49)    57     4,103 ( 24)    5    48,090 ( 45)   30   150   ( 16)   0.4
Black, non-Hispanic         28,792 ( 32)   266     9,220 ( 55)   73    38,012 ( 36)  162   532   ( 55)   7.2
Hispanic                    15,301 ( 17)   146     3,324 ( 20)   32    18,625 ( 18)   90   263   ( 27)   3.6
Asian/Pacific Islander         665 (  1)    21        97 (  1)    3       762 (  1)   12     5   (  1)   0.3
American Indian/
  Alaskan Native               281 ( <1)    41        55 ( <1)    8       336 ( <1)   24     3   ( <1)   0.6
Total minorities            45,039 ( 51)   179    12,696 ( 75)   47    57,735 ( 54)  111   803   ( 84)   4.8

Total @                     89,165 (100)    88    16,824 (100)   15   105,990 (100)   50   959   (100)   1.9
-------------------------------------------------------------------------------------------------------------
* Per 100,000 population. Population counts for 1993 were estimated from 1990 U.S. census data.
+ Age >=3 years.
& Age <13 years.
@ Includes 171 persons for whom race/ethnicity was unknown and one person for whom sex was unknown.
===============================================================================================================

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Figure_1

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Figure_2

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Table_2
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TABLE 2. Number and percentage of AIDS cases among adults and adolescents, by race/ethnicity and exposure category --
United States, reported in 1993
============================================================================================================================================
                                                                  Race/Ethnicity
                                  ----------------------------------------------------------------------------------------
                                    White,             Black,                             Asian/          American Indian/
                                  non-Hispanic      non-Hispanic        Hispanic     Pacific Islander      Alaskan Native        Total *
                                  ------------      ------------      ------------   ----------------     ----------------    ------------
Exposure category                  No.    (%)        No.    (%)        No.    (%)        No.    (%)          No.    (%)        No.    (%)
------------------------------------------------------------------------------------------------------------------------------------------
Male
  Male-male sexual contact        32,188 ( 73)      10,509 ( 36)       6,519 ( 43)       509   ( 77)         177   ( 63)      49,963 ( 56)
  Injecting-drug use               4,634 ( 11)      10,961 ( 38)       5,872 ( 38)        33   (  5)          27   ( 10)      21,571 ( 24)
  Male-male sexual contact and
    injecting-drug use             3,296 (  7)       1,871 (  6)         853 (  6)        24   (  4)          46   ( 16)       6,098 (  7)
  Persons with hemophilia            868 (  2)         110 ( <1)          71 ( <1)        12   (  2)           8   (  3)       1,069 (  1)
  Heterosexual contact               707 (  2)       1,833 (  6)         752 (  5)        16   (  2)           6   (  2)       3,317 (  4)
  Transfusion recipients             408 (  1)         178 (  1)          83 (  1)        13   (  2)           1   ( <1)         686 (  1)
  Risk not reported                1,886 (  4)       3,330 ( 12)       1,151 (  8)        58   (  9)          16   (  6)       6,461 (  7)

  Total                           43,987 (100)      28,792 (100)      15,301 (100)       665   (100)         281   (100)      89,165 (100)

Female
  Injecting-drug use               1,889 ( 46)       4,428 ( 48)       1,458 ( 44)        17   ( 18)          18   ( 33)       7,827 ( 47)
  Persons with hemophilia             16 ( <1)           7 ( <1)           3 ( <1)         1   (  1)          --    --            27 ( <1)
  Heterosexual contact             1,557 ( 38)       3,139 ( 34)       1,474 ( 44)        54   ( 56)          24   ( 44)       6,253 ( 37)
  Transfusion recipients             235 (  6)         187 (  2)          90 (  3)        13   ( 13)           3   (  5)         529 (  3)
  Risk not reported                  406 ( 10)       1,459 ( 16)         299 (  9)        12   ( 12)          10   ( 18)       2,188 ( 13)

  Total                            4,103 (100)       9,220 (100)       3,324 (100)        97   (100)          55   (100)      16,824 (100)
------------------------------------------------------------------------------------------------------------------------------------------
* Includes 164 persons for whom race/ethnicity was unknown.
============================================================================================================================================

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