444 Postgrad Med J: first published as 10.1136/pmj.79.934.444 on 3 September 2003. Downloaded from REVIEW Is there an epidemic of HIV/AIDS among heterosexuals in the USA? H W Haverkos, R C Chung, L C Norville Perez ............................................................................................................................. Postgrad Med J 2003;79:444–448 The Centers for Disease Control and Prevention (CDC), includes all males over the age of 13 years at diag- Atlanta, reports HIV infections and AIDS cases in the nosis who reported any sex with males and includes those who also reported having injected United States biannually. Trends in the distribution of drugs not prescribed by a physician. Second, HIV/AIDS cases according to sex, race or ethnic group, injection drug users includes both men who deny and various categories of exposure to HIV were sex with men and females who reported ever injecting drugs not prescribed by a physician. analysed. The groups in which there were the greatest Third, blood transfusion recipients include adults percentage increases over time were the group with and adolescents who deny male homosexuality heterosexual contact and the group for whom the risk and injection drug abuse and have been a recipi- ent of whole blood, blood components, or tissues. factors were not reported or identified. The CDC should Blood recipients also included persons with be encouraged to provide additional information haemophilia and coagulation disorders who have regarding sexual and drug-using behaviours of those received fractionation proteins. Fourth, hetero- sexual contact cases are defined as those who patients listed as “undetermined”. deny male homosexuality, injection drug use, and .......................................................................... receipt of any blood products and reported heterosexual contact with a person with HIV/ ew issues related to AIDS have generated as AIDS or at increased “risk” for HIV/AIDS. “Risk” much interest and debate in the USA as het- is defined as men who have sex with men, injec- erosexual transmission of HIV and its poten- tion drug users, or blood recipients. Fifth, “unde- F termined” or risk not specified refers to all other tial importance to the epidemic. In the book Crisis: Heterosexual Behavior in the Age of AIDS published in patients whose mode is unknown or not clearly 1988, sex therapists Masters et al screened 3805 specified. This undetermined group includes men and women in Atlanta, Los Angeles, New patients under investigations, who died, were lost York, and St Louis, and observed that HIV had to follow up, or refused interview, and patients spread among heterosexual American adults.1 In not meeting a risk category definition listed above 1990, civil rights journalist Michael Fumento after interview. Heterosexual contact patients http://pmj.bmj.com/ published The Myth of Heterosexual AIDS and were further subdivided by the reported risk of suggested that the US Public Health Service was the identified sexual partner, or if a partner was exaggerating the epidemic among heterosexuals not identified as a bisexual man, injection drug to garner increased research funds.2 In a 1988 user, or blood transfusion recipient, those hetero- review article on the epidemiology of AIDS, the sexual contact patients are listed as having sex proportion of cases attributed to heterosexual with a partner of “undetermined risk” with HIV/ transmission had not increased relative to other AIDS. Children, all patients less than 13 years of risk groups.3 Where is the HIV/AIDS epidemic age at HIV or AIDS diagnosis are listed without on October 1, 2021 by guest. Protected copyright. going in the USA in the 21st century? What can regard to exposure category. We tabulated data by be learned from the Centers for Disease Control gender, racial or ethnic group, and exposure and Prevention (CDC) surveillance data for AIDS category for AIDS cases from 1981–2001, and HIV and HIV infection? infection from 1993–2001, charting the total numbers of reported patients and percentages of exposure categories. METHODS Since 1981, the CDC has tabulated and reported RESULTS AIDS cases in the USA and listed patients by Table 1 lists the number of patients with AIDS exposure categories. Since 1993, the CDC has reported each year from 1983–2001; the number See end of article for tabulated and reported HIV infection not AIDS, in of HIV infections, without AIDS, reported each authors’ affiliations those states and territories willing to report such year, and numbers of states/US territories report- ....................... data. We analysed CDC HIV/AIDS surveillance ing HIV infection from 1993–2001.4 The definition Correspondence: Dr Harry year end reports from 1983 to 2001, examining of AIDS for case reporting expanded several W Haverkos, HFD-530, changes in the definitions of exposure categories, times, including the inclusion of additional 5600 Fishers Lane, Rockville, MD, 20857, and trends in the incidence of AIDS cases and opportunistic infections in 1987 and to include 4 USA; haverkosh@ HIV infections as reported. additional diagnoses and laboratory indicators of cder.fda.gov Using the CDC hierarchical definition of expo- immunodeficiency in 1993.5–8 The 1993 change in sure categories, we constructed five mutually the case definition of AIDS, the increasing use of Submitted 13 August 2002 Accepted 8 April 2003 exclusive categories among adults/adolescents. highly active antiretroviral therapy for HIV ....................... First, “gay” men or men who have sex with men infected persons, and the increasing number of www.postgradmedj.com HIV/AIDS among heterosexuals in the USA 445 Postgrad Med J: first published as 10.1136/pmj.79.934.444 on 3 September 2003. Downloaded from Table 1 AIDS and HIV cases reported by the CDC from 1981 to December 2001, United States No with HIV infection, not No of states/territories reporting Year No with AIDS AIDS HIV infection 1981–1983 3064 0 0 1984 4530 0 0 1985 8354 0 0 1986 13097 0 0 1987 20620 0 0 1988 32311 0 0 1989 35238 0 0 1990 43339 0 0 1991 45506 0 0 1992 47106 0 0 1993 106949 15047 26 1994 80691 18598 27 1995 74180 15206 28 1996 69151 13769 30 1997 60634 14514 30 1998 48269 19391 33 1999 46400 21417 34 2000 42156 21704 36 2001 43150 35575 39 Total 816149 174026 – Source: reference 4. Table 2 Cases of AIDS reported in USA in 1986, 1991, 1996, and 2001 according to category of exposure Exposure category 1986 1991 1996 2001 % Change* Adult/adolescent 1. Gay men 9416 (72) 26326 (58) 30283 (44) 14767 (34) −38 2. Injecting drug users 2136 (16) 11155 (25) 17027 (25) 7473 (17) +1 3. Blood recipients 405 (3) 1030 (2) 869 (1) 324 (1) −2 4. Heterosexual contact 485 (4) 3387 (8) 8821 (13) 6904 (16) +12 5. Undetermined 468 (4) 2925 (7) 11473 (17) 13515 (31) +27 Children 187 (1) 683 (2) 678 (1) 175 (0) −1 Total 13097 (100) 45506 (100) 69151 (100) 43158 (100) – Source: reference 4. *Percent change calculated by subtracting % in 1986 from % in 2001. http://pmj.bmj.com/ Notes: See text for definitions of exposure categories. 1. Gay men include all men who report sex with men and those men who also report injecting drug use. 2. Injecting drug users excluding men who have sex with men. 3. Blood recipients include adults/adolescents who deny male homosexual behaviour and injecting drug use, and are haemophiliac or transfusion recipients of blood or blood components. 4. Heterosexual contact include adults/adolescent who deny male homosexual behaviour, injecting drug use, haemophilia, and previous blood or blood components, and report heterosexual contact with a person with HIV or AIDS, a bisexual male, injecting drug user or blood recipient. 5. Undetermined includes patients who do not meet any of the definitions above (see text). Children include all those under age 13 years at time of diagnosis regardless of exposure category. on October 1, 2021 by guest. Protected copyright. states/territories reporting HIV infection complicate the above/other”/“as persons born in countries in which most interpretation of surveillance data. AIDS cases have not been associated with known risk The classification schema to count AIDS patients by factors”.4 In 1986, the “None of the above/other” category was exposure categories has been modified by CDC as clinicians renamed “Undetermined”. Undetermined included “patients and epidemiologists learned more about the epidemiology of on whom risk information is incomplete (due to death, refusal HIV transmission, however exposure categories have always to be interviewed, or loss to follow up), patients still under been listed hierarchically. Patients with multiple characteris- investigation, men reported only [italics added] to have had tics are tabulated in the group listed first. The definition of heterosexual contact with a prostitute, and interviewed heterosexual contact and undetermined patients changed patients for whom no specific risk was identified”. In 1989, the several times between 1984 and 1989, and has remained the CDC acknowledged that some of these “undetermined” same since 1989. Heterosexual contact patients were first patients may represent “unrecognised” heterosexual trans- reported in 1984 and included those who denied male homo- mission of HIV.9 sexuality, intravenous drug use, Haitian origin, or haemophilia Table 2 lists the reported patients with AIDS according to and reported heterosexual contact with a person with AIDS or exposure categories in 1986, 1991, 1996, and 2001. Homo- at risk for AIDS. In 1985, the Haitian category was sexual or bisexual men, including those gay men who injected incorporated into heterosexual contact patients if such drugs, accounted for 72% of all cases reported in 1986 and 34% patients reported sex with a person with AIDS or at risk for in 2001. The groups in which there were the greatest percent- AIDS. Haitian patients not reporting sex with a person with age increases over time were the group with heterosexual AIDS or at risk for AIDS were listed as “None of the contact category (4%–16%) and the group for whom risk www.postgradmedj.com 446 Haverkos, Chung, Norville Perez Postgrad Med J: first published as 10.1136/pmj.79.934.444 on 3 September 2003.