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Progress Review

HIV

U.S. Department of Health & Human Services—Public Health Service

August 4, 2003

Healthy People 2010 logo
Acting Assistant Secretary for Health Cristina Beato chaired a focus area Progress Review on Human Immunodeficiency Virus (HIV), the 11th in a series of assessments of Healthy People 2010. In conducting the review, Dr. Beato was assisted by staff of the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA), which share the lead for this Healthy People 2010 focus area. Also participating were representatives of the Office of HIV/AIDS Policy and other offices and agencies within the Department of Health and Human Services.

The complete text for the HIV focus area of Healthy People 2010 is available at www.healthypeople.gov/document/html/volume1/13hiv.htm. The meeting agenda, data presentation (tables and charts), and other briefing materials for the Progress Review can be found at www.cdc.gov/nchs/about/otheract/hpdata2010/fa13/hiv13.htm.

Data Trends

In reporting on the status of focus area objectives, Richard Klein of CDC's National Center for Health Statistics provided an overview of the impact of HIV in the United States. He noted that an estimated 40,000 people are newly infected with HIV each year and that approximately 850,000 to 950,000 Americans were living with HIV in 2000. An estimated 180,000 to 280,000 of those infected are unaware of their status. At the end of 2001, 816,149 cumulative cases of aquired immunodeficiency syndrome (AIDS) and 467,910 deaths caused by HIV/AIDS had been reported to CDC. In 2001, CDC reported 43,158 new cases of AIDS and 14,477 deaths from HIV/AIDS. Among people aged 25 to 44, HIV infection ranked as the fifth leading cause of death for whites in 2000, the fourth for Hispanics, and the first for blacks. The cost of treating HIV/AIDS over a lifetime is estimated at $155,000 per person.

Overall, the incidence (new cases) of AIDS rose throughout the 1980s to peak at about 80,000 in 1993, then began a downward trend, which leveled off in the late 1990s (Obj. 13-1).

From 1985 to 2001, the percentage of new AIDS cases occurring in whites declined from 60 percent of the total to 31 percent. The percentage occurring in blacks increased from 25 percent to 49 percent and from 15 percent to 19 percent in Hispanics. In 2002, 75 percent of new AIDS cases diagnosed in people 25 years of age and older (about 95 percent of the total caseload) occurred in males and 25 percent in females. Among persons 13 to 19 years of age, the proportion of females diagnosed with AIDS in 2002 was roughly equal to that of males. Between 1985 and 2001, data for males show an increase from 16 percent to 24 percent in the proportion of males acquiring AIDS who were exposed to the virus via injecting drug use (IDU), while the proportion exposed from men having sex with men (MSM) decreased from 70 percent to 54 percent. (However, data from a limited number of States with stable HIV reporting suggest an upward trend in the MSM mode of exposure since 1999.) The proportion exposed through both modalities (IDU and MSM) was 10 percent in 1985, compared with 6 percent in 2001. For females, injecting drug use as a mode of exposure decreased from 55 percent of cases in 1985 to 32 percent in 2001, while heterosexual contact as the modality increased from 27 percent to 65 percent of cases. In 2001, heterosexual contact was the mode of exposure for 15 percent of males who had acquired AIDS (Objs. 13-2, 13-3, 13-4). The number of new perinatally acquired AIDS cases (mother-to-child transmission) increased in every year from 1982 (<30) to 1992 (≈900). With the widespread implementation of public health recommendations to prevent perinatal transmission, including use of zidovudine (AZT) by infected women during pregnancy and delivery, the number of new cases then declined dramatically year-by-year, from an estimated 800 in 1993 to approximately 100 in 2001 (Obj. 13-17).

In 2000, 75 percent of HIV-positive people aged 13 and older knew their serostatus (Obj. 13-7). A 2010 target has not yet been set. In 2002, 55 percent of substance treatment facilities offered HIV/AIDS counseling and education; the target is 70 percent (Obj. 13-8). In 2001, 58 percent of adults aged 25 to 44 years with tuberculosis had been tested for HIV, well short of the target of 85 percent (Obj. 13-11). In 2001, 85 percent of HIV-infected people received some form of antiretroviral therapy, and 66 percent received highly active antiretroviral therapy (HAART). These data are improvements over comparable 1997 percentages of 80 percent and 40 percent, respectively. The target is 95 percent for each of the six forms of therapy covered by Objective 13-13.

In 2001, preliminary data show that the age-adjusted rate of deaths from HIV/AIDS was 5.0 per 100,000 for the total population, compared with 5.3 in 1999. The population subgroups with the highest rates of death from HIV/AIDS in 2001 were blacks (23.2 deaths per 100,000), people with less than a high school education (18.4), high school graduates (12.6), males (7.5), and Hispanics (6.2). The target is 0.7 deaths per 100,000 (Obj. 13-14). Blacks accounted for 54 percent of HIV/AIDS deaths in 2001, compared with 29 percent in 1990. Whites made up 60 percent of the total in 1990, compared with 30 percent in 2001. In general, the southeastern and middle Atlantic States are the geographic areas with the highest death rates from HIV/AIDS reported in 2000.

Key Challenges and Current Strategies

In the presentations that preceded and followed the data overview, the principal discussants were Administrator Elizabeth Duke and Deborah Parham of HRSA and F.E.Thompson, Jr., Harold Jaffee, and Ida Onorato of CDC. Participants in the review identified a number of obstacles to achieving the objectives and outlined activities under way to meet these challenges, including the following:

  • As of 2002, only 25 States, representing just 25 percent of total AIDS cases in the United States, had implemented HIV name-based reporting for a sufficient length of time to allow for stabilization of data collection and adjustment of the data to monitor trends.
  • Factors contributing to an apparent upturn in the incidence of HIV infection from the MSM mode of exposure include syphilis outbreaks, an increase in risky behaviors, excessive optimism about the efficacy of treatment, and possible "condom message fatigue."
  • Resistance to antiretroviral drugs is encountered in 10 to 20 percent of newly diagnosed cases of HIV/AIDS. The maximum benefit of current HAART regimens may already have been reached.
  • In correctional systems, there is a disincentive to testing for HIV, because if a person is diagnosed as positive, the systems are required to provide treatment at their expense.
  • Recent advances in HIV treatment that have contributed to a decline in AIDS incidence have at the same time diminished the ability of AIDS surveillance data to represent trends in HIV incidence and to quantify the impact of the epidemic on the healthcare system.
  • In 2001, 24 States, New York City, and the District of Columbia reported HIV test results for at least 75 percent of tuberculosis patients aged 25 to 44.
  • Currently, 86 percent of public school students receive education about HIV/AIDS.
  • The declining trend in perinatal AIDS cases is strongly associated with increasing use of zidovudine in pregnant women who are aware of their HIV status.
  • As part of a 5-year prevention strategy, CDC’s new initiative, Advancing HIV Prevention: New Strategies for a Changing Epidemic, focuses on making voluntary HIV testing, including prenatal screening, a routine part of medical care and on implementing new models for diagnosing HIV infections in nonclinical settings.
  • HRSA's HIV/AIDS Bureau administers the Ryan White CARE Act through hundreds of grantees that provide health care to around 533,000 HIV-infected or HIV-affected people each year who have low incomes and little or no insurance. Sixty percent of these are minorities.
  • Participation of the Substance Abuse and Mental Health Services Administration in the Minority AIDS Initiative has been instrumental in providing prevention, treatment, and mental health services programs for identified minority populations at risk for HIV or living with HIV/AIDS.
  • CDC is working with the Federal Bureau of Prisons to develop a curriculum for corrections staff and prisoners that includes descriptions of common sexually transmitted disease symptoms and advice on seeking treatment. After evaluation in the Federal system, the curriculum will be offered to State correction systems.

Approaches for Consideration

Among suggestions offered during the review for steps that could be taken to bring about further progress in achieving the HIV objectives include the following:

  • Ensure that every American with HIV infection has the opportunity to get tested and has access to state-of-the-art medical care and ongoing prevention services.
  • Promote adoption of simplified HIV-testing procedures in medical settings that do not require prevention counseling before testing.
  • Enhance intergovernmental collaboration to ensure that injecting drug users who are HIV positive or at high risk for HIV infection are referred into drug counseling and treatment programs that incorporate a component on responsible sexual behavior.
  • Intensify the targeting of evidence-based HIV prevention activities on high-risk populations to reduce the transmission of HIV.
  • Encourage State governments to factor in potential long-term savings to correctional systems and the community when they assess the cost of providing HIV/AIDS counseling and testing in correctional facilities.
  • To the extent possible, accelerate development of the next generation of antiretroviral therapies, which ideally should be potent, inexpensive, relatively nontoxic, active against viral strains resistant to currently available agents, and easy to administer.
  • Seek to reduce the current backlog in some States of HIV-infected people who are on the waiting list for primary care services.
  • Devote greater resources to the treatment needs of the increasing number of people living with HIV/AIDS.
  • Increase efforts to identify the estimated 180,000 to 280,000 people who are infected with HIV but unaware of their infection.
  • Accelerate the implementation of new models for diagnosing HIV infections, using rapid tests when appropriate, to increase the number of people who learn their test results.
  • Work more closely with Federal partners and prenatal care providers to make training in conducting prenatal HIV/AIDS testing more widely available.

Contacts for information about Healthy People 2010 focus area 13 – HIV:

  • Centers for Disease Control and Prevention-Gena Hill, gfh5@cdc.gov
  • Office of Disease Prevention and Health Promotion (coordinator of the Progress Reviews)-Miryam Granthon, mgranthon@osophs.dhhs.gov (liaison to the focus area 13 workgroup)

Cristina V. Beato
Cristina V. Beato, M.D.
Acting Assistant Secretary for Health

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