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HIV and AIDS --- United States, 1981--2000
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The acquired immunodeficiency syndrome (AIDS) epidemic has had a substantial impact on the health and economy of many nations (1). Since the first AIDS cases were reported in the United States in June 1981, the number of cases and deaths among persons with AIDS increased rapidly during the 1980s followed by substantial declines in new cases and deaths in the late 1990s. This report describes the changes in the characteristics of persons with AIDS since 1981. The greatest impact of the epidemic is among men who have sex with men (MSM) and among racial/ethnic minorities, with increases in the number of cases among women and of cases attributed to heterosexual transmission. The number of persons living with AIDS has increased as deaths have declined. Controlling the epidemic requires sustained prevention programs in all of these affected communities, particularly programs targeting MSM, women, and injection drug users.
CDC analyzed reported AIDS cases from 1981 through 2000 from the 50 states, District of Columbia, and U.S. territories. Proportions by sex, age, race/ethnicity, region, and vital status (living or deceased) were computed over four time periods corresponding to changes in the AIDS case definition and the introduction of effective combination antiretroviral therapy (Table 1). Trends in estimated AIDS diagnoses and deaths of persons with AIDS were adjusted for reporting delays based on the number of cases reported to CDC through June 2000, and for anticipated reclassification of cases originally reported without human immunodeficiency virus (HIV) infection risk information. Estimated AIDS prevalence was calculated as the cumulative incidence of AIDS minus cumulative deaths adjusted for reporting delays (2).
As of December 31, 2000, 774,467 persons had been reported with AIDS in the United States; 448,060 of these had died; 3542 persons had unknown vital status. The number of persons living with AIDS (322,865) is the highest ever reported. Of these, 79% were men, 61% were black or Hispanic, and 41% were infected through male-to-male sex. Of the AIDS cases, approximately one third were reported during 1981--1992, 1993--1995, and 1996--2000 (Table 1).
AIDS incidence increased rapidly through the 1980s, peaked in the early 1990s, and then declined (Figure 1). The peak of new diagnoses was associated with the expansion of the AIDS surveillance case definition in 1993 (2). As of 1996, sharp declines were reported in AIDS incidence and deaths. From 1998 through June 2000, AIDS incidence and deaths leveled off and AIDS prevalence continued to increase. Throughout the epidemic, approximately 85% of persons diagnosed with AIDS were aged 20--49 years (Table 1).
In the early 1980s, most AIDS cases occurred among whites. However, cases among blacks increased steadily and by 1996, more cases occurred among blacks than any other racial/ethnic population. Cases among Hispanics, Asians/Pacific Islanders, and American Indians/Alaska Natives have increased also (Table 1).
Male-to-male sex has been the most common mode of exposure among persons reported with AIDS (46%), followed by injection drug use (25%) and heterosexual contact (11%). The incidence of AIDS increased rapidly in all three of these risk categories through the mid-1990s; however, since 1996, declines in new AIDS cases have been higher among MSM and injection drug users than among persons exposed through heterosexual contact (Figure 2).
Nearly all transmission of HIV through transfusion of blood or blood products occurred before screening of the blood supply for HIV antibody was initiated in 1985 (3). The number of persons reported with AIDS who were exposed through blood transfusions was 284 in 2000, down from a peak of 1098 in 1993. The number of perinatally acquired AIDS cases peaked in 1992 (901 cases), followed by a sharp decline through December 1999. In 1999, 144 cases of perinatally acquired AIDS were diagnosed.
Reported by: Surveillance Br, Div of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, CDC.
AIDS in the United States remains primarily an epidemic affecting MSM and racial/ethnic minorities. A new generation of MSM has replaced those who benefitted from early prevention strategies, and minority MSM have emerged as the population most affected by HIV. Socioeconomic factors (e.g., homophobia, high rates of poverty and unemployment, and lack of access to health care) are associated with high rates of HIV risk behaviors among minority MSM and are barriers to accessing HIV testing, diagnosis, and treatment (4). Minority MSM may not identify themselves as homosexual or bisexual because of the stigma attached to these activities and may be difficult to reach with HIV prevention messages. In addition, the proportion of AIDS cases attributed to heterosexual contact and among women is substantially greater than earlier in the epidemic.
Several public health successes have been achieved during the AIDS epidemic. Disease-monitoring systems were established following the first reports in 1981 (5). Data from these systems helped determine how AIDS was transmitted and provided a basis for the Public Health Service (PHS) to make prevention recommendations. The licensure of a blood test to screen the nation's blood supply and donor and self-deferral measures dramatically reduced the incidence of transfusion-associated HIV infections (6). Less than one in 450,000--660,000 screened blood donations are estimated to be contaminated with HIV (7).
In 1985, the first federal resources dedicated to HIV prevention were made available to all state and local health departments nationwide. In 1987, a national effort to educate the public about HIV and AIDS was launched and CDC created a comprehensive AIDS information resource, the CDC National AIDS Hotline and National AIDS Information Clearinghouse. Comprehensive school-based HIV education to inform and educate young persons began in 1987, and funding for national, regional, and community-based organizations began in 1988.
The first research on effective behavior interventions to reduce transmission of HIV among sex partners and injection drug users began in the early 1980s. Behavior interventions, including school-based programs, peer-to-peer interventions, strategies that limit needle sharing, strategies that use parent-to-child communication, client-centered counseling, and personalized risk-reduction strategies, are effective in promoting healthy behaviors that are protective for HIV (8).
PHS released guidelines in 1994 and 1995 for routinely counseling and voluntarily testing pregnant women for HIV and for offering zidovudine to infected women and their infants (9). Since this intervention, mother-to-child HIV transmission rates have decreased dramatically. During 1985--1999, AIDS cases among children declined 81%.
As a result of these and other HIV prevention efforts and increases in societal awareness of and response to the AIDS epidemic, new infections in the United States, which had risen rapidly to a peak of 150,000 per year in the mid-1980s, declined to an estimated 40,000 per year since 1992. With the advent of highly active antiretroviral therapy in the mid-1990s, the number of new AIDS cases and deaths declined dramatically and then stabilized in the United States and several other industrialized nations.
Despite the decline in HIV-related disease and death in the United States, major gaps exist in the tools needed to address HIV prevention. The development of an HIV vaccine is important to control the global epidemic. Development of a microbicide that is safe and effective in reducing HIV transmission through sexual intercourse may be key to controlling the epidemic among women. New behavior interventions, particularly targeting minority MSM, are needed.
Political, financial, and social barriers have often kept the most effective prevention and treatment strategies from reaching those at highest risk. In addition, HIV-related stigma continues to hinder prevention, testing, and treatment. Expanding HIV prevention programs remains an urgent priority in the United States. Reaching populations at risk to ensure early diagnosis and ensuring sustained access to preventive and treatment services for all at risk and HIV-infected persons can have a major impact on the HIV and AIDS epidemic (10).
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