Decline in perinatal HIV transmission in New York State (1997-2000)

BACKGROUND: Perinatal HIV transmission has declined significantly in New York State (NYS) since implementation of a 3-part regimen of zidovudine prophylaxis in the antenatal, intrapartum, and newborn periods. This study describes the factors associated with perinatal transmission in NYS from 1997 to 2000, the first 4 years of NYS's comprehensive program in which all HIV-exposed newborns were identified through universal HIV testing of newborns. METHODS: This population-based observational study included all HIV-exposed newborns whose infection status was known and their mothers identified in NYS through the universal Newborn HIV Screening Program (NSP) from February 1997 to December 2000. Antepartum, intrapartum, newborn, and pediatric medical records of HIV-positive mothers/infants were reviewed for history of prenatal care, antiretroviral therapy (ART), and infant infection status. Risks associated with perinatal HIV transmission were examined. RESULTS: Perinatal HIV transmission declined significantly from 11.0% in 1997 to 3.7% in 2000 (P < 0.05). Prenatal ART was associated with a decline in perinatal HIV transmission both for monotherapy (5.8%, relative risk [RR] = 0.3, 95% confidence interval: 0.2%-0.5%) and combination therapy [2.4%, RR = 0.1, 95% confidence interval: 0.1%-0.2%) compared with no prenatal antiretroviral prophylaxis (P < 0.05). CONCLUSIONS: Public health policies to improve access to care for pregnant women and advances in clinical care, including receipt of appropriate preventive therapies, have contributed to declines in perinatal HIV transmission in NYS.     

Trends in AIDS incidence and survival among racial/ethnic minority men who have sex with men,United States, 1990-1999

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.     

Estimated number of children left motherless by AIDS in the United States, 1978-1998

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.     

"Informed altruism" and "partner restriction" in the reduction of HIV infection in injecting drug users entering detoxification treatment in New York City, 1990-2001

OBJECTIVE: To assess recent developments in the HIV epidemic in injecting drug users (IDUs) in New York City. With >50,000 cases of AIDS in IDUs, New York has experienced the largest HIV/AIDS epidemic in IDUs of any city in the world. METHODS: Serial cross-sectional surveys conducted continuously from 1990 to 2001 of IDUs entering the Beth Israel Medical Center (BIMC) drug detoxification program in New York City. HIV serostatus, use of prevention services, and risk behaviors were measured. Individuals were permitted to participate multiple times in the surveys but not more than once in any year. RESULTS: Two thousand eight hundred eighty-seven individuals contributed 3100 observations from 1990 to 2001. There was a substantial and consistent decline in the prevalence of HIV infection among IDUs entering the BIMC detoxification program, from 54% (165/304) in 1991 to 13% (39/303) in 2001 (P < 0.0001). The decline was highly linear, with r2 = 0.92 and a slope of -3.7% in seroprevalence per year. The decline occurred for both males and females, both short and long-term IDUs, and the three largest racial/ethnic subgroups (all P < 0.001 by Cochran-Armitage testing). Use of HIV prevention services increased substantially, particularly syringe exchange and voluntary HIV counseling and testing. General reductions in injection risk behaviors occurred, but substantial numbers of IDUs continued to engage in both receptive and distributive syringe sharing. Two conditional types of risk reduction not currently recommended by health authorities were reported: "informed altruism," in which persons who knew that they were HIV seropositive reduced transmission behavior, and "partner restriction," in which persons who shared needles and syringes primarily confined this sharing within small social networks. CONCLUSIONS: HIV infection continues to decline in this population of IDUs in New York City, suggesting the possibility of bringing very high prevalence epidemics under control. Risk elimination may not be required; rather, multiple forms of risk reduction may be effective in reducing HIV transmission within a local population of IDUs.     

Increasing proportion of late diagnosis of HIV infection among patients with AIDS in Italy following introduction of combination antiretroviral therapy

We analyzed trends over time and determinants of late diagnosis of HIV infection among people diagnosed with AIDS in 1986 to 1998 in a tertiary care center in Rome, Italy. Information on the date of a first HIV test was collected prospectively, in addition to data routinely collected for AIDS reporting. Patients with AIDS were defined as "late testers" if the time interval between first positive HIV test result and AIDS diagnosis was < or = 3 months. Overall, 503 people with AIDS of 1977 included in the analysis (25.4%) were late testers. the proportion of late testers decreased from 62.5% in 1986 to 16% in 1995. Thereafter, this proportion increased to 20.5% in 1996, 33.7% in 1997, and 36.6% in 1998. In multivariate analysis, the following variables were significantly associated with late testing: AIDS diagnosis in years 1986 to 1993 or 1997 to 1998 compared with 1995, male gender, age > or = 45 years, men who have sex with men, heterosexual contacts, or having unknown transmission mode compared with intravenous drug users, and being born outside Italy. Since 1996, the overall number of AIDS cases diagnosed at our center began to decrease whereas the number of late-testing AIDS patients did not decrease, resulting in an increasing proportion of late testers during the last 3 years of the study. This findings may reflect the effect of combination antiretroviral therapy in slowing progression to AIDS of HIV-infected persons aware of their status. A relevant number of people still discover their HIV infection late and may therefore miss treatment opportunities. New testing strategies are needed to reach more people who engage in high-risk behaviors, especially those at risk for sexual transmission, and those born outside Italy.     

Incidence of AIDS-defining cancers after AIDS diagnosis among people with AIDS in Italy, 1986-1998

A record linkage was carried out between the Italian National Registry of AIDS and 19 cancer registries. The aim was to evaluate the 1986 through 1998 trends in incidence rate (IR) of AIDS-defining cancers (ADCs) among persons with AIDS (PWA) in Italy overall and according to various characteristics. A steady decrease in IRs was found for Kaposi sarcoma (KS) in men between 1986-1992 (2.5 per 100 person-years [py]) and 1997-1998 (1.0 per 100 py). Conversely, the first decrease in IRs of KS in women (from 0.9 to 0.6 per 100 py) and of non-Hodgkin lymphoma in both genders (from 1.7 to 0.7 per 100 py) was seen between 1993-1996 and 1997-1998, thus pointing to a favorable impact of highly active antiretroviral therapies. The decline was consistent across different age and HIV transmission groups, but it was more marked in PWA with a CD4 count >50 cells/microL than in PWA with more severe immune suppression. As a proportion of AIDS cases, invasive cervical cancer increased from 1.5% in 1993-1996 to 2.4% in 1997-1998, but IRs after AIDS could not be evaluated. On account of the marked decline of KS in men in 1997-1998, the overall burden of ADCs in Italy became similar in both genders.     

Use of total lymphocyte count and hemoglobin concentration for monitoring progression of HIV infection

BACKGROUND: Prognostic markers for HIV monitoring are needed for resource-limited regions. Prior research has demonstrated rapid declines in total lymphocyte count (TLC) and hemoglobin levels before AIDS, but the prognostic accuracy of these declines has not been examined prospectively. METHODS: Longitudinal TLC and hemoglobin data from men in the Multicenter AIDS Cohort Study (MACS) before the introduction of potent HIV therapy were used to identify the first time when the TLC was 33% per year, and hemoglobin declined by >11.6% per year. The prognostic value of these declines for AIDS was evaluated by Cox regression models and Kaplan-Meier survival curves. RESULTS: Rapid declines in TLC or hemoglobin were associated with progression to AIDS (relative hazard [RH]=4.70, 95% confidence interval [CI]: 3.23-6.86 for TLC; RH=5.55, 95% CI: 3.69-8.36 for hemoglobin). The World Health Organization criterion for initiating therapy, a TLC1200 cells/mm, a rapid decline in TLC or hemoglobin was strongly associated with progression to AIDS (RH=2.53, 95% CI: 1.56-4.10 for TLC; RH=5.28, 95% CI: 3.11-8.97 for hemoglobin). CONCLUSIONS: In the MACS, rapid declines in TLC or hemoglobin concentration indicated an increased likelihood of progression of HIV infection to AIDS. These results support the potential utility of these markers for monitoring HIV-infected people in resource-limited regions, but critical levels and rates of decline of markers for such regions remain to be defined.     

Similarities and differences by race/ethnicity in changes of HIV seroprevalence and related behaviors among drug injectors in New York City, 1991-1996.

OBJECTIVE: To measure differences and similarities in the prevalence of HIV infection and of related risk and protective behaviors among New York City black, white, and Hispanic drug injectors during a period of decreasing HIV prevalence. METHODS: Drug injectors were interviewed at a drug detoxification clinic and a research storefront in New York City from 1990 to 1996. All subjects had injected drugs within the last six months. Phlebotomy for HIV testing was conducted after pretest counseling. Analysis compares the first half (period) of this recruitment interval with the second half. RESULTS: HIV seroprevalence declined among each racial/ethnic group. In each period, white drug injectors were significantly less likely to be infected than either blacks or Hispanics. Similar declines were found in separate analyses by gender, length of time since first injection, and by recruitment site. After adjustment for changes in sample composition over time, blacks and Hispanics remained significantly more likely to be infected than whites. Interactions indicate that the decline may be greatest among Hispanics and slowest among blacks. A wide variety of risk behaviors declined in each racial/ethnic group; and syringe exchange use increased in each group. Few respondents reported injecting with members of a different racial group at their last injection event. CONCLUSIONS: HIV prevalence and risk behaviors seem to be falling among each racial/ethnic group of drug injectors. Black and Hispanic injectors continue to be more likely to be infected. Declining prevalence among whites poses some risk of politically based decisions to reduce prevention efforts. Overall, these results show that risk reduction can be successful among all racial/ethnic groups of drug injectors and suggest that continued risk reduction programs may be able to attain further declines in infection rates in each group.     

Modeling trends in HIV incidence among homosexual men in Australia 1995-2006

BACKGROUND: Previous mathematical models have indicated that any decrease in HIV incidence in homosexual men due to decreased infectiousness from antiretroviral treatment (ARV) may be offset by modest increases in unsafe sex. The aims of this study were to assess the effects of ARV use and increasing unprotected anal intercourse with casual partners (UAIC) in homosexual men on HIV incidence during 1995-2001 and to project HIV incidence depending on trends in ARV use and UAIC. METHODS: A mathematical model of HIV transmission among homosexual men in Australia was developed. HIV incidence during 1995-2001 was estimated assuming that 70% of men in whom HIV was diagnosed received ARVs and assuming a 10% annual increase in UAIC. For 2001-2006, scenarios included ARV levels remaining at 70% or declining to 50% by 2006, combined with UAIC levels remaining at the 2001 level or continuing to increase annually by 10%. FINDINGS: The number of incident HIV cases per year was predicted to have declined during 1996-1998 due to the introduction of effective ARVs, with a slow increase during 1998-2001 due to increased levels of UAIC when use of therapies was fairly stable. From 2001, a continued increase in UAIC was predicted to lead to a rise in HIV incidence. A rise in UAIC combined with a moderate decline in ARV use could lead to a 50% increase in HIV incidence by 2006. INTERPRETATION: These models suggest that widespread ARV use has had some effect in reducing HIV incidence among homosexual men in Australia. However, if current trends in UAIC and ARV use continue, a resurgent HIV epidemic is predicted.     

Trends in HIV-related inpatient admissions from 1993 to 1997: a seven-state study

BACKGROUND AND OBJECTIVES: Reports of declining HIV-related inpatient use have typically been based on limited or local data. Using comprehensive hospital discharge data from seven states, this study examines trends in HIV-related inpatient admission rates and lengths of stay from 1993 through 1997. METHODS: We identified HIV-related admissions by the International Classification of Diseases, ninth edition (ICD-9-CM) diagnosis codes in the range 042 to 044. Analyses assessed effects of state, gender, race/ethnicity, insurance, and time period; they also examined differential patterns of change. RESULTS: HIV-related inpatient admission rates rose between 1993 and 1995 but began declining steadily starting in late 1995. This general pattern occurred for all states, demographic groups, and insurers. The magnitude of the decline varied; admissions for white males and for patients with private insurance showed the greatest decreases. Admission rates were highest for African-American males and lowest for white females. Lengths of stay declined steadily; trends did not differ by demographic group or payer. CONCLUSIONS: Results document the recent decline in HIV-related hospital admission rates. Relative declines in admissions parallel reported disparities in access to new antiretroviral therapies. Racial/ethnic disparities in inpatient use persist.     

Estimates of HIV incidence among persons testing for HIV using the sensitive/less sensitive enzyme immunoassy, New York City, 2001

BACKGROUND: Estimates of the incidence of HIV infection among persons testing for HIV can be derived by applying a newly available serologic test to the diagnostic specimen of HIV-positive persons. Such estimates would enhance the targeting of HIV prevention resources and provide a sensitive outcome measure for prevention program evaluation. The goal of this investigation was to estimate the incidence of HIV infection among persons testing for HIV in New York City. METHODS: The study population consisted of persons testing for HIV in public settings in New York City during 2001 (n = 114,703). We applied a less sensitive enzyme immunoassay (LS-EIA) (Vironostika, BioMerieux, Durham, NC) to the diagnostic blood specimen of 1022 persons in whom HIV (non-AIDS) had been diagnosed for the first time in 2001. The distribution of transmission risk among HIV-negative persons--men who have sex with men (MSM), injection drug users (IDUs), heterosexuals-from a large telephone health survey was used to generate denominators for transmission risk groups. RESULTS: The 1022 persons tested by the LS-EIA represented 27% of all persons in whom HIV (non-AIDS) had been diagnosed in New York City during 2001. The incidence of HIV was estimated to be 0.29% per year (95% CI: 0.20-0.38), and was significantly higher for men than women (rate ratio 3.6, 95% CI: 2.6-5.1), and HIV incidence increased with age. Male IDU and MSM testers had the highest HIV incidence rates: 2.7% per year (95% CI: 2.3-3.1) and 2.5% per year (95% CI: 2.1-2.8), respectively. CONCLUSIONS: Male IDUs and MSM may be good candidates for intensified targeting of HIV prevention resources in New York City.     

Racial disparities in sexual risk behaviors and drug use among older gay/bisexual and heterosexual men living with HIV/AIDS

Adults over age 50 comprise 11% of yearly AIDS cases, yet little is known about their sexual risk behaviors and drug use following diagnosis with HIV/AIDS. The present questionnaire study examines potential racial differences in sexual risk and drug use behaviors among 59 HIV-infected gay/bisexual and heterosexual men over age 50 who were recruited from HIV-related organizations in New York City between 1996-1998. The majority (59%) of older men reported unprotected sex since diagnosis, and 36% had done so in the past six months. African-American gay/bisexual men (n=12) were significantly more likely than white gay/bisexual men (n=32) to report unprotected vaginal/anal sex in the past six months (67% versus 22%, p<0.01), since diagnosis (42% versus 9%, p<0.05), and to report a history of intravenous drug use (50% versus 3%, p<0.01), but did not differ from heterosexual African-American men (n=15). No differences were found in reports of unprotected oral sex or recent use of hard drugs (i.e., crack, cocaine, heroin). These findings suggest that interventions targeting older African-American men (both gay/bisexual and heterosexual) with HIV/AIDS are needed to reduce risk behaviors and prevent HIV transmission in this population.     

Autopsy patterns in patients dying of acquired immunodeficiency syndrome in New York City

The autopsy rate was examined for patients dying of acquired immunodeficiency syndrome (AIDS) in New York City from 1982 through 1986 to determine if individuals dying of AIDS had autopsy rates that differed from the general population. Using data from death certificates, verified by hospital records, autopsy rates for various diseases and causes of death were examined in persons aged 25 to 44 years, which represents the age group with the majority of AIDS deaths. The hospital autopsy rate for those patients dying of AIDS dropped from 46% in 1982 to 17% in 1986, while the rate for non-AIDS autopsies went from 23% in 1982 to 15% in 1986. These declines have occurred despite the continued presence of a major epidemic in which the pathophysiology is still under active investigation. The low autopsy rate for patients with AIDS is of concern to both epidemiologists and clinical researchers: the autopsy is vital to a better understanding of the spectrum of human immunodeficiency virus infection.     

Cardiopulmonary hospitalizations during influenza season in adults and adolescents with advanced HIV infection

The etiologic role of influenza in hospitalizations and deaths among persons infected with HIV since the introduction of highly active antiretroviral therapy (HAART) is not known. A retrospective cohort study was performed of all persons aged 15 to 50 years with AIDS or advanced HIV infection enrolled in the Tennessee Medicaid program from 1995 through 1999, representing 7368 person-years of follow-up. The influenza season was defined based on local virus surveillance, and hospitalizations were measured for acute cardiopulmonary causes and deaths from any cause throughout the year. From 1995 through 1999, cardiopulmonary hospitalization rates in HIV-infected patients declined by 53% and death rates declined by 77%. The influenza-attributable hospitalization rate was 48 (95% confidence interval [CI]: 16-91) per 1000 persons in 1995 and 5 (95% CI: -0.5-11) per 1000 persons per year during 1996 through 1999, after the introduction of HAART. Influenza-associated hospitalizations have declined in patients with HIV infection in the post-HAART era. Rates remain comparable to rates in other high-risk groups for which annual influenza vaccination is recommended, however.     

Trends in HIV seroprevalence and needle sharing among Puerto Rican drug injectors in Puerto Rico and New York: 1992-1999

This study assessed trends in HIV seroprevalence and needle-sharing behaviors among Puerto Rican injection drug users (IDUs) in Puerto Rico and New York. Data from two studies of IDUs conducted from 1992 through 1995 and 1998 through 1999 in Bayamón, Puerto Rico, and East Harlem, New York, were examined to assess trends over this period. Separate analyses were conducted for IDUs who were current crack smokers. Significant decreasing trends in seroprevalence were found among IDUs in the New York and Puerto Rico samples (p <.001). Significant decreasing trends in receptive and distributive needle sharing were found in the New York sample, and a significant decline in receptive sharing was found in the Puerto Rico sample. Overall, higher levels of needle-sharing behaviors were reported in Puerto Rico compared with New York. Decreasing trends in needle sharing and seroprevalence in both communities are an encouraging finding. Ongoing epidemiologic studies to monitor the epidemic and continued prevention efforts to help maintain or further these declines are needed, particularly to address the higher rates of needle sharing in Puerto Rico.     

Analysis of infectious disease mortality in Italy

Our research aimed to describe infectious disease mortality in Italy between 1969 and 1999, with particular emphasis on sex, age, and geographic differences. Using mortality data provided by the Italian Central Institute for Statistics (ISTAT), we evaluated all codes of the ICD8 and ICD9 classifications to identify each cause of death attributable to infectious agents. Deaths for HIV/AIDS were excluded. Infectious diseases accounted for 1.7% of overall mortality between 1969-1999, and our approach identified 57.5% of all deaths from infections not included in the ICD8 and ICD9 infectious disease codes. Up to 1994, the mortality for all infectious diseases showed a very strong downward trend, with a 6-fold decline. This trend levelled off in 1995-1999, mainly due to increasing deaths due to septicaemias, heart infections and hepatitis. An increasing proportion of deaths due to infectious diseases occurred in the elderly, from 48.1% in 1969-1979 to 77.3% in 1990-1999. Mortality rates were consistently higher in men than in women and showed a substantial geographic heterogeneity. In the newborn, mortality rates declined 10-fold and an inverse north-south geographic gradient persisted during the study period. This exhaustive methodological approach to identifying infectious causes of deaths allows us to better define the burden of infections on mortality and register downward trends similar to those found in other industrialized countries.     

Death decline slows

The Centers for Disease Control and Prevention (CDC) reports that AIDS deaths declined by 20 percent between 1997 and 1998. This figure represents a marked drop from the previous year's 42 percent decrease. AIDS Action attributes the decline to limited access to proper healthcare, and currently available treatments that are not effective for everyone, and may not represent a cure.     

HIV/AIDS surveillance in Germany

In Germany, since 1982, information on AIDS cases has been collected at the AIDS Center of the Robert Koch Institute. Since 1987, all laboratories performing HIV confirmatory testing have been required to report positive results anonymously. AIDS incidence peaked at about 2000 cases per year in 1993 and began to decline in 1995 following the widespread use of highly effective antiretroviral treatment. Current data indicate that the AIDS incidence has stabilized at a level of 750 cases per year since 1998. The number of newly diagnosed HIV infections has remained fairly stable at approximately 2000 to 2500 per year since 1993. Unlinked anonymous testing of dried blood spots from newborns is carried out in two federal states. The average prevalence of HIV seropositivity from 1993 to 1997 among women bearing children was 0.57 per 1000 in Berlin and 0.14 per 1000 in Lower Saxony.     

HIV-1 incidence among male workers at a sugar estate in rural Malawi

OBJECTIVES: To determine incidence of HIV and associated risk factors in two cohorts of men working at a sugar estate in rural Malawi. DESIGN: Prospective studies. METHODS: After counseling and obtaining informed consent, male workers were tested for HIV-1 and syphilis. Baseline HIV-seronegative men were enrolled in two follow-up studies in 1994 and 1998, and were retested for HIV and syphilis at 6-month follow-up visits. Demographic, behavioral, and medical history was collected at baseline. Cumulative HIV incidence based on Kaplan-Meier methods was estimated. HIV incidence was also estimated per 100 person-years (p-y). Crude and adjusted rate ratios for the association of risk factors with incident HIV infection were obtained using Cox proportional hazards models. RESULTS: HIV prevalence was 24.3% among 1692 men screened in 1994 and 21.0% among 1349 men screened in 1998 (p <.03). HIV incidence was extremely high during 1994 to 1995 (17.1% for that 1-year period). Incidence dramatically declined in 1996, averaging about 3.5% per year from 1996 through 1999. Among men enrolled in the 1998 cohort, HIV incidence during 1998 to 1999 was 3.8%. After controlling for potential confounders reactive syphilis was associated with a twofold risk of HIV acquisition in each cohort. CONCLUSIONS: Urgent preventive measures are needed to control the spread of HIV in this economically important occupational cohort. In addition to conventional educational messages to reduce risky sexual behavior, treatment of other sexually transmitted diseases should be considered.