May 2001

Substance Abuse in the United States:
An Update

The critical link between substance abuse and HIV infection continues to be reflected in the AIDS epidemic. Worldwide, approximately 5 percent of all HIV infections occur through injection drug use, according to the Joint United Nations Program on HIV/AIDS.1

In the United States a much higher proportion of AIDS cases are related to substance abuse.  It is estimated that injection drug use (IDU) was the HIV exposure category in 28.7 percent (12,230) of the 42,698 adolescent and adult AIDS cases reported in 1999; heterosexual contact with an injection drug user (HC/IDU) is estimated to have been the exposure category in an additional 4.1 percent of cases (2,741).2(pp28-29)   Thus, these two exposure categories account for approximately one-third of AIDS cases reported in 1999; yet they do not tell the whole story.  Substance abuse was certainly a factor in some of the 7,454 cases for which the exposure category was heterosexual contact with an individual for whom the risk factor has not been identified; likewise for the 1,982 cases in which the exposure category was men who have sex with men and inject drugs.2(pp28-29)  Finally, no one can know the number of AIDS cases that occurred because drug use—from alcohol to meth- amphetamines—influenced decisions about sexual activity.

The effect of substance abuse on the AIDS epidemic in the United States reaches still further: most pediatric AIDS cases are drug related.  As of June 30, 2000, a total of 8,804 pediatric AIDS cases had been reported in America; the leading exposure category was a mother with or at risk for HIV infection through:

    Injection drug use (35.6 percent);

    Sex with an injecting drug user (16.5 percent); or

    Sex with an HIV-infected person, risk not specified (13.7 percent).2(p22)

In 20.9 percent of cases, the mother's exposure category has not been identified.2(p22)


Substance Abuse, HIV Disease, and the Ryan White CARE Act

Organizations receiving Ryan White CARE Act funding are all too familiar with the added burden that substance abuse places on people with HIV and their families and providers.

AIDS First Reported 20 Years Ago


Experience provides ample evidence that abusers of alcohol and other drugs are much less likely than others with HIV to be in care and to stay there over time. Moreover, the period between the time substance abusers learn their serostatus and the time they first seek medical treatment may be especially long.3 Substance abuse is also associated with the need for additional services from CARE Act providers, such as substance abuse treatment, to which Title I Eligible Metropolitan Areas allocated $39.4 million in FY 2000. Substance abusers with HIV also may have a greater need for services such as mental health counseling and intensive case management. Finally, anticipating adverse drug interactions and adhering to treatment regimens present unique challenges for alcohol and other drug abusers.4  Although AIDS mortality has been declining in the past few years, the smaller decrease among people for whom the HIV exposure category was injection drug use (Chart 2) may be a reflection of the challenges facing IDUs and other substance abusers.


Clearly, an understanding of substance abuse is important for people involved in the treatment of HIV disease. This article summarizes the most recent data on the use of alcohol and illicit drugs, much of which comes from the 1999 National Household Survey on Drug Abuse (NHSDA),5 an annual survey administered by the Substance Abuse and Mental Health Services Administration (SAMHSA). 


Illicit Drug Use in the United States

The 1999 NHSDA* estimated that 14.8 million people in the United States were current users of illicit drugs in 1999—that is, they had used drugs at least once in the 30 days before the survey interview. An estimated 3.6 million of this group were dependent on illicit drugs; 8.2 million Americans were dependent on alcohol.**  Although the number of illicit drug users has decreased significantly from its peak of 25 million in 1979, the effects of drug abuse on society, personal health, and quality of life are substantial.

* Unless otherwise noted, all data on alcohol and drug use are from the 1999 NHSDA. A complete copy of the survey is available at www.samhsa.gov/hhsurvey/hhsurvey.htm.

** To assess AOD dependence, the 1999 NHSDA included a set of questions that were based on the criteria for dependence described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed., 1994).


Gender

The 1999 NHSDA found that men had a higher rate of current illicit drug use (8.7 percent) than did women (4.9 percent), a difference that has changed little from earlier years. An estimated 2 percent of all men are drug dependent, compared with 1.3 percent of women.

Among the survey respondents, 3.4 percent of pregnant women ages 15 to 44 reported use of an illicit drug during pregnancy; of that group, substance abuse was most prevalent among those ages 15 to 17 (7.5 percent) and ages 18 to 24 (6.5 percent). Substance abuse among women is associated with serious medical problems: one study found that women substance abusers are 42 percent more likely to have chronic medical problems and emergency room visits than are women who do not abuse illicit drugs.6

Race

White, black, and Hispanic youths ages 12 to 17 had similar rates of current illicit drug use in 1999; however, the rates differed for adults. The survey found that 6.6 percent of whites, 6.8 percent of Hispanics, and 7.7 percent of blacks age 18 and older were current illicit drug users. American Indians/Alaska Natives (10.6 percent) and people of multiple races (11.2 percent) had the highest rates of drug use;  Asians, at 3.2 percent, had the lowest rates.

Findings from the 1999 NHSDA indicate that rates of dependence on illicit drugs were highest among American Indians/Alaska Natives (4.7 percent), followed by people reporting multiple races (2.6 percent), blacks (2.3 percent), Hispanics (1.9 percent), whites (1.5 percent), and Asians (0.8 percent). However, 3.8 percent of whites were dependent on alcohol, compared with 3.1 percent for blacks. Rates of alcohol dependence were highest for people reporting multiple races (7.7 percent) and lowest for Asians (2.2 percent).

Age

Ages 12 to 17.   Illicit drug abuse poses a serious problem for youths in the United States. In 1999, 10.9 percent of adolescents ages 12 to 17 reported current use of illicit drugs. Drugs of choice for this group vary according to age. For instance, 2.2 percent of 12-year-old adolescents reported use of inhalants, and 1.4 percent reported use of psychotherapeutics; only 0.6 percent reported marijuana use. By age 14, however, marijuana is the most commonly used drug among adolescents (5.9 percent), although it is often used with inhalants and psychotherapeutics.

According to statistics made available by the American Medical Association, adolescents first experiment with alcohol at an average age of 12.8.7  Eighty-one percent of high school seniors have tried alcohol at least once, as have 70 percent of 10th graders and 53 percent of 8th graders. Of the estimated 5.4 million junior high and high school students who have ever consumed five or more drinks in a row, 39 percent say they drink alone, 58 percent drink when they are upset, 30 percent drink when they are bored, and 37 percent say they drink to get high.7 

The NHSDA has found a correlation between the age of first drug use and future abuse and addiction: adults who first used drugs at a young age were more likely to become dependent on drugs. Similar findings have been found for alcohol use: people who start drinking before age 15 are approximately four times as likely to become alcohol dependent as those who begin drinking at age 20 or older.8

Ages 18 and Older.   The highest rate of illicit drug use in 1999 was among young adults ages 18 to 20, with 20.5 percent reporting current use. Marijuana is the most common drug among people in that age group: 18 percent are current users. Among adults ages 30 to 39, approximately 6.0 percent reported current use of illicit drugs; however, a slightly higher proportion (8.6 percent) of those ages 40 to 44 reported current use. Researchers believe that members of the latter group have higher rates of drug use because they came of age in the 1970s, when drug use was sharply increasing. Illicit drug use among older survey respondents was significantly lower, at 1.7 percent for those ages 50 to 64 and a mere 0.6 percent for adults age 65 and older.

Substance Abuse in Urban and Rural Areas

The 1999 NHSDA found that use of illicit drugs is higher in metropolitan areas (7.1 percent) than in nonmetropolitan areas (5.2 percent). Prevalence also varies from State to State: Virginia (4.7 percent) has the lowest rates of illicit drug use, and Alaska (10.7 percent) has the highest. Alaska also has the highest dependency rate: 2.8 percent of its population age 12 and older are dependent on illicit drugs, and 7.3 percent are dependent on either illicit drugs or alcohol.

Injection Drug Use

In 1997, the United States was home to approximately 1.5 million IDUs 9; their drug-related health consequences range from blood-borne infections, such as hepatitis B and C, HIV, endocarditis, and malaria, to physical deterioration and death from overdose and untreated infections. 9

A wide range of substances can be injected. In addition to opiates (including heroin), IDUs most commonly use cocaine, amphetamines, tranquilizers, and barbiturates.  Many of these substances are available to the user in other forms, such as pills or powders. Cost, availability, and preferred mode of ingestion vary from area to area.
 

Drugs of Choice

Heroin

Preliminary findings from the Seropositive Urban Drug Injector's Study (SUDIS) conducted by the Center for AIDS Prevention Studies, indicate that heroin is the drug of choice among IDUs for both women (67 percent) and men (65 percent).10 The National Institute on Drug Abuse (NIDA) reports that the number of new heroin users jumped from 141,000 in 1995 to 216,000 in 1996, but notes that  "estimates of heroin incidence are subject to wide variability and usually do not show any clear trend."11  From 1996 through 1998, a total of 471,000 people in the United States used heroin for the first time, according to NHSDA estimates; one-quarter of all new users were under age 18.  Most new users sniff, snort, or smoke heroin but move on to injection because of nasal soreness, declined purity, and an increased tolerance.11

Heroin use is most prevalent in metropolitan areas, where the typical users are middle-class men; however, heroin use in suburban areas appears to be increasing, especially among middle-class, white women.11 Heroin is expensive, complicated to produce, and sometimes hard to find. The purity of heroin has declined or is inconsistent in some areas, causing price-cutting and aggressive marketing by dealers.11

Marijuana

Seventy-five percent of current illicit drug users use marijuana.  The number of Americans using marijuana for the first time rose substantially in the past decade—from 1.4 million in 1990 to 2.6 million in 1996—although the number of new users dropped to 2.3 million in 1998.   The growth in incidence (i.e., new users) in the 1990s was primarily fueled by the increasing number of users ages 12 to 17.

Two factors are most likely responsible for the increased rates among youth. First, marijuana is now grown in forms that are more potent than in the past, making the drug's high more attractive. Second, marijuana is often used in combination with other drugs that have become more readily available to youths. For instance, marijuana is often combined with crack cocaine for an increased high. Trends also include using marijuana with certain forms of malt liquor to purify the drug. Another increasingly popular activity is to dip marijuana cigarettes in embalming fluid (known as "shermans") for an increased high.11

Cocaine

Cocaine and crack cocaine users total approximately 2 million in the United States, with an estimated 1.5 million cocaine and 413,000 crack cocaine users in 1999. Although the number of new users of any form of cocaine rose from 514,000 in 1994 to 934,000 in 1998, this level is still below the peak of 1.6 million new users in 1983. Most of the new users were adults ages 18 to 25. The number of new crack cocaine users in 1998 totaled 371,000.

Unlike heroin, cocaine is most popular in powder form, but an increasing number of users appear to be injecting it. According to SUDIS, 51 percent of female and 36 percent of male IDUs injected cocaine in the 30 days prior to interview.10

Methamphetamine

Like cocaine, methamphetamine can be ingested in four ways: Injecting, snorting, smoking, and swallowing in pill form.  The relative popularity of the different methods varies from user to user and from city to city. The SUDIS found that approximately 5 percent of female IDUs and 11 percent of male IDUs are current methamphetamine injectors.10

Methamphetamine is manufactured in clandestine laboratories; the drug's availability and use is sporadic around the country.  The drug is popular in rural areas, and data suggest that methamphetamine use has steadily increased, especially in the Midwest, although it has declined in certain cities, such as San Diego and Los Angeles.11

Abuse of Prescription Drugs

Often referred to as "middle-class America's silent epidemic" or "America's dirty little secret,"12 the incidence of prescription drug abuse in this country is rising. Data from the Drug Enforcement Agency suggest the magnitude of the problem.12 For example, in Cincinnati, the Police Pharmaceutical Diversion Squad determined that between October 1990 and June 30, 1999, more than 2 million dosage units of prescription medicine had been diverted through illegal means. In 1998, a special drug task force in Kentucky found that 800 of 1,300 drug cases involved prescription drugs.12

Statistics gathered by law enforcement agencies working together on local and national levels indicate that hydrocodone is the most commonly abused prescription drug, from the health care professional to the junkie on the street.12 The drug is popular for several reasons:

  • It is practically free. Hydrocodone is often obtained by prescription, and health insurance companies cover the costs;
     
  • Unlike heroine or cocaine, hydrocodone is pure.  As with other prescription medications, the user knows what is in the drug;  and
     
  • The drug is manufactured under several brand names (e.g., Vicodin) for various purposes and can be found in other forms (e.g., cough medications).

The 1999 NHSDA found that of the 6.4 million users of illicit drugs other than marijuana, 4 million were using psychotherapeutics nonmedically—more than 1.8 percent of the population age 12 and older. Psychotherapeutics include pain relievers (2.6 million abusers), tranquilizers (1.1 million abusers), stimulants (0.9 million abusers), and sedatives (0.2 million abusers). Most prescription drugs are ingested orally, but a trend toward injection of these substances is emerging. Estimates from the SUDIS indicate that 4 percent of male IDUs crush, liquefy, and inject prescription drugs.10

Prescription drug abusers commonly are middle-class women.  Jeff Dean, a detective with the San Diego Police Department, says of these abusers that "their credit cards are maxed out, they have no money in the bank, and they go from doctor's office to doctor's office and pharmacy to pharmacy all day long feeding the  Vicodin habit."12

Alcohol

Alcohol users are generally described according to one of three categories:

  1. Current Users: Had at least one drink in the 30 days prior to interview;
     
  2. Binge Users: Consumed five or more drinks on the same occasion at least once in the 30 days prior to interview;  and
     
  3. Heavy Users: Consumed five or more drinks on the same occasion at least five times in the 30 days prior to interview.

The 1999 NHSDA found that rates of current, binge, and heavy alcohol use remained unchanged between 1998 and 1999 for all age groups.

 


Substance Abuse Facts and Trends
  1. Age of first use is an indicator of dependency.
    Adults who first use drugs at a young age are more likely to become dependent on drugs than are adults who initiate use at a later age.
     
  2. Men are more likely to be dependent on illicit drugs and alcohol than are women.
     
  3. Illicit drug use is highly correlated with educational status.
    As of 1999, college graduates had the lowest rate of current use despite the fact that they were more likely to have tried illicit substances in their lifetime.
     
  4. Employment status is highly correlated with illicit drug use.
    In 1999, an estimated 16.5 percent of all unemployed individuals were illicit drug users, compared with 6.5 percent of employed adults. Despite the high prevalence rate among the unemployed, most drug users are employed: an estimated 77 percent of illicit drug users had jobs in 1999.
     
  5. The percentage of the illicit drug user population age 12 and older did not change significantly from 1998 to 1999.
     
  6. The rate of illicit drug use among adults ages 18 to 25 increased between 1997 and 1999.
    Rates have not significantly changed among other age groups.
     
  7. Rates of current alcohol use remained unchanged from 1998 to 1999 for all age groups, continuing a leveling trend seen throughout the 1990s.
     
  8. Estimates show that illicit drug use is less prevalent in rural areas than in metropolitan areas. However, cigarette use continues to be higher in rural areas than in metropolitan areas.

SOURCE: Substance Abuse and Mental Health Services Administration (SAMHSA). Summary of Findings from the 1999 National Household Survey on Drug Abuse. Rockville, Md: Office of Applied Studies, SAMHSA, US Dept of Health and Human Services; August 2000.

 

Almost one half of U.S. residents age 12 and older reported being current drinkers of alcohol in 1999. The prevalence of alcohol use increases by age group: 3.9 percent of 12-year-olds are current drinkers, and prevalence peaks at 66.6 percent for people ages 21 to 25. Current alcohol use declines to 59.5 percent for people ages 26 to 29 and to 47.2 percent for people ages 50 to 64, reaching 32.7 percent for those age 65 and older.

According to the 1999 NHSDA, approximately one-fifth of the population age 12 and older participated in binge drinking in 1999, representing 20.2 percent of the population, or 45 million people. The survey estimates that 43 percent of all current drinkers are binge drinkers. Binge drinking and heavy drinking are highly correlated with illicit drug use: approximately 14.8 percent of the binge drinkers surveyed (representing 4.8 million people) reported current illicit drug use.  Of the approximately 12.4 million heavy drinkers in 1999, 30.5 percent are estimated to be current users of illicit drugs.

Conclusion

No substantial decrease in the interplay between substance abuse and HIV infection appears to be on the horizon; indeed, evidence points to the contrary. Although use patterns of some drugs fluctuated from 1997 through 1999, the use of all drugs for which data are gathered has increased substantially since 1990.

The phenomenon of increased substance abuse among young people parallels evidence of increased sexual activity at younger ages, particularly the rising incidence of unprotected sexual encounters among men who have sex with men. These double warning signs could coalesce to have an upward effect on HIV incidence.

AIDS surveillance data do not indicate any increase in the proportion of new AIDS cases for which the HIV exposure category was injection drug use, heterosexual contact with an IDU, or men who have sex with men and inject drugs.  In fact, the proportion of cases attributable to injection drug use actually decreased by 1.5 percentage points, from 30.1 percent in 1997 to 28.6 percent in 1999 (Chart 4). However, this decrease was more than negated by an increase in cases attributable to heterosexual contact with an HIV-infected person, risk not specified, which grew from 15.8 percent in 1997 to 18.4 percent in 1999.2,13  It is certain that the proportion of new cases in which substance abuse is a factor remains substantial.

Moreover, HIV incidence remains steady at approximately 40,000 infections annually, and the decrease in AIDS incidence has slowed considerably in recent years, with a drop of just 6.9 percent in the 12-month period from July 1999 to June 2000 (from 46,775 cases to 43,517 cases).2(p6) Among women, the decline was only from 10,841 to 10,469 cases—a difference of just 372 cases, or 3.4 percent.2(p12);13

Experience shows that entering and staying in care over time holds special challenges for substance abusers, as does adherence to treatment regimens. Other factors suggest the continuation of a challenging landscape for health care and other service providers: High levels of illicit drug use; the interaction of drug use, lack of awareness of HIV disease, and increased levels of sexual activity among young people; the slowing decline in AIDS prevalence; and steady HIV incidence. More importantly, these developments portend a substantial level of need for services for HIV-positive patients who are current or former alcohol and other drug abusers—to say nothing of the enormous unmet need among those not yet in care.

 

Trends in Sexually Transmitted Disease
Infection Rates:  An Update

Millions of Americans are infected with sexually transmitted diseases (STDs).  Many STDs, including HIV, can remain asymptomatic for long periods, leading to late diagnoses, negative effects on physical well-being, and increased potential for transmission to others.  Moreover, the presence of some STDs increases risk of HIV transmission and can complicate the treatment of HIV disease.   

The latest estimates indicate that 15 million Americans become newly infected with an STD each year, yet STDs remain one of the least recognized health threats. Although gonorrhea and syphilis are now primarily limited to local outbreaks, other diseases such as chlamydia, herpes, and human papillomavirus (HPV), remain widespread. Concurrent infections of HIV and other STDs are common, but may remain undiagnosed until symptoms develop.

The incidence (i.e., number of new cases in a 12-month period) of most STDs appears to be highest among young people, a finding that is cause for pessimism regarding reduction of HIV incidence among this population, which accounts for up to 25 percent of all new HIV infections, according to some estimates. Young women are particularly likely to become infected with some STDs and, like people with HIV who are unaware of their serostatus, can experience long-term effects from infections that they do not yet know they have. 

Thus, the links between HIV infection and other STDs remain significant, in terms of both the risk for new HIV infections and the treatment of HIV disease. Given the increased emphasis on early intervention services, outreach, and collaboration with organizations defined in the CARE Act Amendments of 2000 as "key points of access," CARE Act providers are likely to see more new clients who are living with HIV infection and another STD.  Therefore, familiarity with STD surveillance trends, summarized below, is important for all CARE Act providers.

Chlamydia

Chlamydia may be one of the most dangerous STDs for women today. "While chlamydia can easily be treated and cured, the disease can lead to severe health consequences, including infertility, potentially fatal tubal pregnancies, and increased risk of HIV infection, if not detected early," says Judith Wasserheit, M.D., M.P.H., director of the CDC's STD program. "In areas where people cannot easily access screening and treatment services, chlamydia remains a significant and unacceptable health threat, especially among adolescent and young adults." Women often do not know that they have the disease, and estimates are that as many as 75 percent of women with chlamydia have no symptoms.

Currently, 3 million men and women are estimated to become infected with chlamydia each year in the United States.   Although the number of cases has declined since the early 1980s, when well over 4 million people were believed to contract the disease each year, the number of reported cases increased from 607,752 in 1998 to 659,441 in 1999—an increase of 8.5 percent. From 1995 to 1999, the reported rates for chlamydia increased from 190.4 to 254.1 cases per 100,000 persons (Chart 1); the rate in the Southern United States was higher than in any other part of the country.  Increases in reported cases represent expansion of screening for the disease as well as the use of more sensitive screening tests.


In 1999, the reported rate of chlamydia infection among women was four times higher than the reported rate among men. This statistic reflects the larger number of women screened for the disease and suggests that cases among the male partners of women with chlamydia are not being diagnosed or reported.  Now that new, highly sensitive tests are available, however, both symptomatic and asymptomatic men increasingly are being diagnosed, although under-screening remains a problem.  From 1995 to 1999 the reported chlamydial infection rates for men increased from 57.7 to 94.7 cases per 100,000; the reported rate for women increased from 316.3 to 404.5 cases per 100,000 (a 27.9 percent increase) over the same period.

Chlamydia is widespread throughout the sexually active population, regardless of race, ethnicity, age, or gender. However, it is more concentrated among adolescents than any other STD. For both men and women in 1999, the highest chlamydia infection rates occurred among those between ages 15 and 24.

Gonorrhea

Between 1975 and 1997, the national gonorrhea rate (number of new infections per year per 100,000 adolescents and adults) declined almost 75 percent, from 467.7 to 122.0.  However, the gonorrhea rate in the United States increased from 122.0 cases to 133.2 cases between 1997 and 1999, raising concerns that steady declines in the disease over the past 2 decades could be reversing. "It is too soon to say that successes in gonorrhea control of the past 2 decades will be reversed, but these new statistics are cause for serious concern," says Helene Gayle, M.D., M.P.H., director of CDC's National Center for HIV, STD, and TB Prevention. "In the past 2 years, we have seen signs that gonorrhea is increasing among gay and bisexual men in a number of U.S. cities, and these trends may now be extending to the overall population," Gayle adds.

 

The gonorrhea rate in the United States remains the highest of any industrialized nation. In 1999, a total of 360,076 cases were reported in the United States, but those are feared to represent only about one-half of all annual infections.

The increase in infection rates from 1997 to 1999 for men and women are similar; the rate increased by 8.8 percent for men (from 124.9 to 136.0 cases per 100,000) and by more than 9 percent for women (from 119.0 to 129.9 cases per 100,000). Seventy-seven percent of the reported cases of gonorrhea were among African Americans.  Between 1998 and 1999, the reported rate of gonorrhea in 15- to 19-year-olds decreased by 2.4 percent (from 547.0 to 534.0 cases per 100,000), but among people ages 20 to 24, the rate grew by 1.56 percent (from 605.2 to 614.7 cases per 100,000).

Syphilis

Unlike gonorrhea, the incidence of syphilis has continued its steady decline since its most recent peak in 1990, falling to 2.5 cases per 100,000 in 1999. "The continued decline in syphilis rates overall is very encouraging and indicates that the National Plan to Eliminate Syphilis in the United States remains a realistic goal," says Ronald O. Valdiserri, M.D., M.P.H., deputy director of CDC's HIV, STD, and TB programs. Valdiserri attributes most of the progress to successful efforts to reach African  Americans, but he added that remaining high-risk populations must be reached.


Thanks to the introduction of penicillin and a national STD control program in the 1940s, syphilis was nearly
completely eradicated in 1957.  Since then, however, cyclic national epidemics have occurred about every 7 to 10 years. The most recent epidemic peaked in 1990, with a reported rate of 20.3 cases per 100,000 people. In 1999, the rate dropped to 2.5 cases per 100,000, its lowest since reporting started in 1941; 79 percent of the 3,115 counties in the United States reported no cases of syphilis in 1999.

Despite improvements in reaching African Americans, syphilis continues to affect this group disproportionately. In 1999, 75 percent of all primary and secondary cases of syphilis reported occurred among African Americans, a rate 30 times greater than for non-Hispanic whites.

Human Papillomavirus

Human papillomavirus (HPV) can cause genital warts, but more often exists without any noticeable symptoms. It is of increasing public health importance because recent studies have shown that some types of the disease can cause cervical, penile, and anal cancer. Current estimates indicate that 5.5 million people in the United States become infected with HPV each year and that 20 million people currently are  infected. An estimated 75 percent of the reproductive-age population has been infected with sexually transmitted HPV.

Most HPV infections seem to be temporary and are eliminated by the body's natural immune defenses; the disease may therefore pose even greater problem for HIV-positive men and women. "HPV is likely the most common STD among young, sexually active people," says Wasserheit. "Given the health consequences of this infection, there is a tremendous need for us to better understand how to prevent HPV infection and why it either persists or is cleared up by the body's immune system, so people do not go on to develop life-threatening complications like cervical cancer."

Genital Herpes Simplex Virus Type 2

Genital herpes simplex virus type 2 (HSV-2) infects as many as one million people each year in the United States, making it one of the most common STDs. In the late 1980s and 1990s, the disease spread dramatically among teenagers and young adults. HSV-2 is potentially fatal in newborns and is a particular threat to the HIV-positive population.

Currently, about 45 million people are infected with HSV-2—more than 1 in 5 Americans.  Prevalence increased from the late 1970s to the early 1990s by 30 percent, but preliminary data from the 1999 National Health and Nutrition Examination Survey (NHANES) indicate that the prevalence of HSV-2 has remained stable since then. Many people do not know they have the disease, as highlighted by a survey in which only 10 percent of those diagnosed with HPV-2 knew they were infected.

Other Sexually Transmitted Diseases

    Reported cases of chancroid, a bacterium that produces genital ulcers, have steadily declined since hitting a peak of 4,986 cases in 1987 and are currently confined to local outbreaks. In 1999, only 143 cases were reported in the United States, 72 percent of which were reported in Texas, New York, and South Carolina. However, because the disease is difficult to diagnose without a specific laboratory test that is beyond the capability of most health care providers and labs, chancroid is believed to be substantially under-diagnosed and under-reported.

    No national surveillance statistics are compiled for trichomoniasis and bacterial vaginosis (BV), but they are considered to be the most common conditions found in women in health care settings. If not treated, BV can cause pelvic inflammatory disease, and both BV and trichomoniasis can increase the risk of HIV infection. About 5 million cases of trichomoniasis are estimated to occur each year in the United States, and as many as 16 percent of pregnant women have BV.

    The Third National Health and Nutrition Examination Survey (conducted between 1988 and 1994), found that about 5 percent of all Americans have been infected with hepatitis B at some point in their lives. In 1997, the CDC received reports of 10,416 hepatitis B cases, but reported cases dramatically underestimate the actual number of people infected with the disease each year. Results from the 1999 Survey indicate that 200,000 infections occur each year and that roughly 120,000 of those infections are sexually transmitted. An estimated 417,000 people are currently living with chronic sexually acquired hepatitis B.

Sources:
National Health and Nutrition Examination Survey
CDC  STD Surveillance, 1999
CDC Biennial Report, Tracking the Hidden Epidemics: Trends in STDs in the
      United States, December 2000

 

TITLE II FY 2001 AWARDS TOTAL $845.7 MILLION

In April, HHS Secretary Tommy G. Thompson announced the award of $845.7 million in CARE Act Title II funds to help poor and uninsured individuals with HIV/AIDS obtain primary care, support services and life-sustaining medications through the AIDS Drug Assistance Program (ADAP).

All 50 States, the District of Columbia, Puerto Rico, the Virgin Islands, and Guam will receive awards. The new grants include a $267 million base award; $571.3 million to buy medications through State-run ADAPs; and $7 million under the Congressional Black Caucus (CBC) Initiative to support educational and outreach services to help disproportionately impacted communities of color improve their participation in ADAPs.

Also in April, the Secretary  announced first-time, $50,000 awards to each of five U.S. Pacific Territories and Associated Jurisdictions to provide Title II services.  These include the U.S. Pacific Territories of American Samoa and the Commonwealth of the Northern Mariana Islands; and the Associated Jurisdictions of the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau.  The 2000 reauthorized CARE Act legislation increased the number of territories eligible to receive CARE Act funding.

In announcing the new funding, Secretary Thompson commented:  "AIDS is of increasing concern in the Pacific because of mobility among island communities and the Pacific Rim countries, as well as substance use and other lifestyle issues.  This new funding recognizes the emerging needs of these Pacific regions for more and improved HIV/AIDS care and services."

Title II grants are based on a calculation of the estimated number of people living with AIDS in the State or territory.  Since FY 1996, separate funds have been earmarked under Title II to help State ADAPs purchase pharmaceuticals for people living with HIV/AIDS.  States also may designate a portion of their base grant to support ADAPs.  Approximately 125,800 people received medications through ADAPs in FY 2000.

Since the CARE Act was first funded in FY 1991, $4.1 billion has been awarded for Title II grants, including $2.1 billion in ADAP funding.  A list of the FY 2001 Title II grant awards is available on the HIV/AIDS Bureau Web site at http://hab.hrsa.gov.  It is estimated that more than 500,000 individuals access CARE Act services every year.

 

 

CARE Act Providers Reaching
Minorities and Women

Recently released FY 1999 data on use of CARE Act services reveal that almost one-third of clients receiving services represent women, and more than two-thirds represent minorities.  CARE Act Title I and II grantees report data at the end of each fiscal year through the Annual Administrative Report (AAR).

Program data for 1999 were submitted by 1,445 organizations providing services in the 51 Title I Eligible Metropolitan Areas (EMAs), and 1,288 service providers in Title II States.  Some overlap occurs in these two groups, as many providers receive funds from both programs.

According to the 1999 data, Title I service providers served 584,614 "duplicated clients" in 1999, and Title II providers reached 383,009 individuals.

The AAR provides demographic information on duplicated clients—clients that receive services from multiple providers within an EMA or State.   When the data are tabulated at the EMA or State level, client demographic characteristics are included more than once.  However, these duplicated counts, as well as program data from other CARE Act programs, are used to estimate the total number of people reached by the CARE Act each year.  

Overall, the HIV/AIDS Bureau estimates that 500,000 individuals receive services from CARE Act-funded providers each year.  Despite the duplicated counts, the AAR is a valuable tool for understanding more about clients reached through  Title I and Title II programs:

  • Almost one-third of both Title I (32 percent) and Title  II (31.2 percent) clients represented in the 1999 AAR  were female.
     
  • More than two-thirds of the clients represented in the report were racial or ethnic minorities. At 45.7 percent for Title I and 46.2 percent for Title II, African Americans are the most frequently represented, followed by whites, at 31.1 percent for Title I and 33.6 percent for Title II.  Hispanics represent approximately one-fifth of the duplicated clients in the report: 20.9 percent for Title I and 18 percent for Title II.
     
  • More than two-thirds of the individuals represented in the report—70.4 percent of those from Title I and 71.7 percent from Title II—were ages 20 through 44; 23.6 percent  and 23.1 percent of Title I and II clients, respectively, were at least 45 years old.

 

For more information on the 1999 Annual Administrative Report, please consult the HIV/AIDS Bureau Web site at http://hab.hrsa.gov. 

 

Guide on Housing and the CARE Act Released

A new guide on implementing the HIV/AIDS Bureau's housing policy regarding use of CARE Act funds for housing-related services was released in May.  Housing is Health Care explains the flexibility of HAB Policy 99-02, "Use of CARE Act Funds for Housing Referral Services and Short-term or Emergency Housing Needs." The guide explains three implementation areas: housing categories to use in allocations and applications; record-keeping/ documentation; and funding/program changes.  Case studies on integrating housing funds under the CARE Act and HOPWA (Housing Opportunities for People with AIDS) are also featured.

Additional resources in the guide include a history of HIV/AIDS housing in the United States; the planning process under the CARE Act and HOPWA; a statement from HAB Associate Administrator Joseph F. O'Neill, M.D., M.P.H., on the role of housing in a changed epidemic; and technical resources available on housing.  Produced in partnership with AIDS Housing of Washington, the guide may be obtained from the HAB Web site "Tools" page (http://hab.hrsa.gov) or the HRSA Information Center at 1-888-ASK-HRSA.  To learn more, contact Harold Phillips, Deputy Chief of the Eastern Services Branch, HAB's Division of Service Systems, at 301-443-0654 or hphillips@hrsa.gov.

HAB Policy Amendment on Use of ADAP Funds

The HIV/AIDS Bureau (HAB) has issued an amendment to its existing policy on the use of AIDS Drug Assistance Program (ADAP) funds for access, adherence, and monitoring services. This amendment implements a provision in the reauthorized Ryan White CARE Act (P.L. 106-345) that placed limits on the use of ADAP funds for these purposes.   The amendment stipulates that no more than 5 percent of ADAP funds may be used for these services.  Under extraordinary circumstances, however, this amount may increase up to, but not exceed, 10 percent of ADAP funds, including carryover funds.

Note:  This amendment to Policy Notice 00-02 has been mailed to all CARE Act grantees and may be downloaded from HAB's Web site at: http://hab.hrsa.gov/mission.html. 

20 Years Since the First Reported U.S. AIDS Cases: June 5, 2001

Twenty years ago on June 5, 1981, the first U.S. AIDS cases were reported among five gay men in Los Angeles in the Morbidity and Mortality Weekly (MMWR) Report, a publication of the Centers for Disease Control and Prevention (CDC).  For more information on observances of this date, contact the Office of Minority Health Resource Center at http://www.omhrc.gov/omhrc/index.htm or the HIV/AIDS Bureau Web site at http://hab.hrsa.gov.

On June 5, there is a unique opportunity to highlight HIV/AIDS around the Nation by reviewing the struggles and successes, and mobilizing to address future challenges presented by the HIV epidemic.  To assist communities in coordinating activities in observance of this date, the Office of Minority Health will be posting on their Web site a "Tool Kit on 20 Years of AIDS."The tool kit includes materials to conduct public education and media outreach, such as sample letters to media (letter to the editor, media advisory), Web-based Public Service Announcements from the Surgeon General, and HIV/AIDS statistics.  The tool kit and other resources may be obtained at http://www.omhrc.gov/omhrc/index.htm.

 

SAVE THE DATE
Ryan White CARE Act
Grantee Meeting
August 20-23, 2002
Marriott Wardman Park Hotel
Washington, D.C.

 

 

 

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2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report.  2000;12(1):6,12, 22, 28-29.

3. Samet JH, et al. Trillion virion delay: time from testing positive for HIV to presentation for primary care. Arch Intern Med. 1998;158:734-740.

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5. Substance Abuse and Mental Health Services Administration (SAMHSA). Summary of Findings from the 1999 National Household Survey on Drug Abuse. Rockville, Md: Office of Applied Studies, SAMHSA, US Dept of Health and Human Services; August 2000.

6. Liebschutz J, et al. Victimization among substance-abusing women. Arch Intern Med. 1997;157:1093-1097.

7. American Medical Association. Youth, Young Adults, and Alcohol: Key Facts and Strategies. July 1997.  Available on the web at www.ama-assn.org. 
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9. Gostin L. Prevention of HIV/AIDS and other blood-borne diseases among injection drug users.  JAMA . 1997;277.

10. Seropositive Urban Drug Injector's Study. Injection Drugs of Choice. March 3, 2000. Gomez, Cynthia; Dawson-Rose, Carol; Knight, Kelly Ray. Center for AIDS Prevention Studies.

11.National Institute on Drug Abuse. Nationwide Trends. 1996. Bethesda, MD.  

12.Mitka, M. Abuse of prescription drugs: Is a patient ailing or addicted? JAMA. 2000;283: Available at: http://jama.ama-assn.org/issues/v283n9/ffull/jmn0301-2html.  Accessed March 2001.

13.Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. 1999;11(1):12.