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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2005.077461
RESEARCH AND PRACTICE |
Lorena Espinoza is with the Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, and the Epidemic Intelligence Service, Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Ga. H. Irene Hall, Felicia Hardnett, Richard M. Selik, Qiang Ling, and Lisa M. Lee are with the Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta.
Correspondence: Requests for reprints should be sent to Lorena Espinoza, Division of HIV/AIDS Prevention–Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail Stop E–47, Atlanta, GA 30333 (e-mail: lespinoza{at}cdc.gov).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. In the United States a growing proportion of cases of heterosexually acquired HIV infections occur in women and in persons of color. We analyzed the association between race/ethnicity, whether diagnoses of HIV infection and AIDS were made concurrently, and the survival after diagnosis of heterosexually acquired AIDS.
Methods. We used data from 29 states that report confidential name-based HIV/AIDS cases to the Centers for Disease Control and Prevention to calculate estimated annual percentage change in the number of actual diagnoses and analyzed the association between race/ethnicity and concurrent diagnoses of HIV and AIDS. We adjusted for reporting delays and absence of information about HIV risk factors.
Results. During 1999 to 2004, diagnoses of heterosexually acquired HIV were made for 52 569 persons in 29 states; 33 554 (64%) were women. Among men and women, 38 470 (73%) were non-Hispanic Black; 7761 (15%), non-Hispanic White; and 5383 (10%), Hispanic. The number of persons with heterosexually acquired HIV significantly increased: 6.1% among Hispanic men (95% confidence interval=2.7, 9.7) and 4.5% among Hispanic women (95% confidence interval=1.8, 7.3). The number significantly decreased (–2.9%) among non-Hispanic Black men. Concurrent HIV and AIDS diagnoses were slightly more common for non-Hispanic Whites (23%) and Hispanics (23%) than for non-Hispanic Blacks (20%).
Conclusions. To decrease the incidence of heterosexually acquired HIV infections, prevention and education programs should target all persons at risk, especially women, non-Hispanic Blacks, and Hispanics.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Worldwide, most HIV infections result from heterosexual transmission.1 In the United States, a growing proportion of cases of AIDS has been attributed to heterosexual contact. By contrast, the proportion of AIDS cases transmitted by male-to-male sexual contact and by injection drug use has decreased since the start of the HIV epidemic. In 2004, heterosexually acquired HIV infections accounted for a large proportion (33%) of new diagnoses of HIV infection reported to the Centers for Disease Control and Prevention (CDC), second only to the proportion acquired by male-to-male sexual contact (47%).2
Most HIV infections in women in the United States are heterosexually acquired.3 The proportion of heterosexually acquired cases of HIV infection is higher for younger women than for older women.4–6 The HIV epidemic continues to disproportionately affect persons from certain racial and ethnic groups.
Late diagnosis of HIV infection (near the time of AIDS diagnosis) has been shown to be more common for persons with heterosexually acquired HIV infections, non-Hispanic Blacks, and Hispanics than for persons in other transmission categories or belonging to other racial and ethnic groups.7 This has been attributed to the fact that non-Hispanic Blacks and Hispanics historically have had less access to treatment and prevention services.8
Important indicators of access to screening and testing services are the interval between HIV diagnosis and AIDS diagnosis and survival after an AIDS diagnosis. Few studies have reported on these indicators among persons with heterosexually acquired HIV. In addition, few studies have reported on survival rates for persons with heterosexually acquired AIDS.9,10
To clarify the characteristics of persons with heterosexually acquired HIV infection in the United States, we analyzed the association between race/ethnicity, whether diagnoses of HIV infection and AIDS were made concurrently, and survival after diagnosis of heterosexually acquired AIDS.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We analyzed cases in adults and adolescents, aged 13 years and older, for whom a diagnosis was made during 1999 to 2004 and reported to the CDC through June 2005 from 29 states (Alabama, Arizona, Arkansas, Colorado, Florida, Idaho, Indiana, Iowa, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Utah, Virginia, West Virginia, Wisconsin, and Wyoming). These states had conducted confidential, name-based HIV/AIDS surveillance at least since 1998, a period sufficient to allow for stabilization of data collection to monitor trends during the study period. We defined a case of HIV as a confirmed HIV infection classified as heterosexually acquired; that is, attributed to high-risk heterosexual contact with a sexual partner with a known risk factor (i.e., injection drug use, sexual intercourse with a bisexual man [for women only], or hemophilia), a transfusion or transplant recipient with documented HIV infection, or a person known to be HIV infected but whose risk factor (mode of exposure) was not specified. We defined a case of HIV/AIDS as a diagnosis of HIV infection that had not progressed to AIDS, a diagnosis of HIV infection followed by a diagnosis of AIDS, or concurrent diagnoses of HIV and AIDS infection (HIV and AIDS diagnoses in the same calendar month).
Demographic Characteristics
We examined the following characteristics of persons with heterosexually acquired HIV infection: gender, age group, race/ethnicity, and year of diagnosis. Race/ethnicity was categorized into non-Hispanic White, non-Hispanic Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native.
We adjusted the number of diagnoses for reporting delays (the time between case diagnosis and case report), which may vary by transmission category, region, race/ethnicity, age, gender, and vital status (alive or dead).2 We also adjusted the diagnoses by transmission category (e.g., injection drug use, male-to-male sexual contact, heterosexual contact) for cases initially reported without risk factor information. Redistribution of transmission categories was based on patterns of reclassification of cases originally reported with no risk factor to the national HIV/AIDS surveillance system that follow-up investigations later reclassified into other transmission categories.11
Trends
We calculated the estimated annual percentage change and 95% confidence intervals (CIs) in the number of annual diagnoses for each age and racial/ethnic group from 1999 through 2004 by fitting a linear regression line to the natural logarithm of the number of diagnoses, with calendar year of diagnosis as an independent variable. The significance of a trend was assessed by determining whether the 95% CI for the estimated annual percentage change included zero.12
Concurrent HIV and AIDS Diagnoses
We conducted multiple-variable logistic regression analysis with SAS version 8.2 (SAS Institute Inc, Cary, NC) to determine the association between race/ethnicity and whether diagnoses of HIV infection and AIDS were made concurrently, while adjusting for other covariates. The modeling process was a backward elimination procedure keeping higher-order interaction terms and their component lower-order terms. Cases without reported race/ethnicity (n=439) were excluded from this analysis. Cases in Asians/Pacific Islanders and American Indians/Alaska Natives (n=516), also were excluded because their numbers were too small to derive statistically stable estimates.
Survival Times After AIDS Diagnosis
We analyzed survival times after diagnosis of adults and adolescents for whom heterosexually acquired AIDS was diagnosed during 1996 to 2003 in the 50 states and the District of Columbia and reported through June 2005. We used data on deaths that occurred during 1996 to 2004 and were reported by June 2005. We adjusted for gender, age group, race/ethnicity, year of diagnosis, and CD4 lymphocyte count at diagnosis. We did not adjust for reporting delays. We excluded persons for whom AIDS diagnosis and death occurred during the same month because they contributed no measurable survival time, and an unknown proportion may have had a diagnosis date earlier than that reported. Significant differences between groups were assessed by determining whether the 95% CIs overlapped. We present the 12-month, 24-month, 36-month, and 48-month survival estimates for non-Hispanic Whites, non-Hispanic Blacks, and Hispanics derived from standardized Kaplan–Meier estimation.13
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Demographic Characteristics
Of the 144 818 HIV/AIDS cases diagnosed in the 29 states during 1999 to 2004, 52 569 (36%) were heterosexually acquired (Table 1
). Of the remaining 92 249 cases, risk classification was male-to-male sexual contact for 63 653 (44%), injection drug use for 21 886 (15%), male-to-male sexual contact and injection drug use for 5421 (4%), and other risk factors, such as transfusion of HIV-contaminated blood or blood products, for 1289 (1%). The percentage of all HIV/AIDS cases that were heterosexually acquired varied by state from 15% to 49% (median 28%).
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Of persons with heterosexually acquired HIV/AIDS, 33554 (64%) were women and 33% were aged 30 to 39 years (Table 1
). Most cases were diagnosed in non-Hispanic Blacks (73%), followed by non-Hispanic Whites (15%), Hispanics (10%), Asians/Pacific Islanders (<1%) and American Indians/Alaska Natives (<1%). Of cases in persons aged 13 to 19 years, 88% were in women. Women accounted for 68% of cases in non-Hispanic Whites, 64% in non-Hispanic Blacks, and 55% in Hispanics.
Trends
Overall, during 1999 to 2004 the annual number of heterosexually acquired HIV/AIDS cases did not significantly change (Table 1). There was a significant decrease (– 2.9%) in HIV/AIDS cases per year in non-Hispanic Black men, but a significant increase per year in non-Hispanic White men (5.5%) and Hispanic men (6.1%). The number of diagnosed cases per year among men aged 40 to 59 years significantly increased (Table 2).
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Although the annual number of heterosexually acquired HIV/AIDS cases in women did not change significantly, in Hispanic women the number significantly increased by 4.5% (Table 2
). The number of diagnosed cases per year among women aged 40 years and older also significantly increased.
Concurrent HIV and AIDS Diagnoses
Among the persons with heterosexually acquired HIV/AIDS, 20% had their diagnoses of AIDS made during the same month as their diagnosis of HIV infection. Such concurrent HIV and AIDS diagnoses were slightly more common for non-Hispanic Whites (23%) and Hispanics (23%) than for non-Hispanic Blacks (20%) (P 
.001).
Formal tests of interaction indicated that race modified the effect of gender (P .001) and age (P =.004) on the probability of concurrent HIV and AIDS diagnoses. Therefore, we conducted logistic regression analysis stratified by race/ethnicity. Concurrent HIV and AIDS diagnoses were more common for men than women and increased with age for all racial/ethnic groups (Table 3). Despite a decreasing trend over time of concurrent HIV and AIDS diagnoses overall (test for trend P =.003), among subgroups the trend was significant only for non-Hispanic Blacks (test for trend P .001).
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Survival Times After AIDS Diagnosis
Of 337670 cases of AIDS diagnosed during 1996 to 2003 in the 50 states and the District of Columbia, 86923 (26%) were reported to be heterosexually acquired. A comparison of these data with data from the 29 states found no differences in survival probabilities among persons with a diagnosis of heterosexually acquired AIDS. In each racial/ethnic group, as expected, the probability of survival decreased as time from AIDS diagnosis increased. At any time after diagnosis, the proportion of non-Hispanic Blacks surviving was lower than the proportion of non-Hispanic Whites and Hispanics. A lower proportion of non-Hispanic Black men survived after 36 months than did non-Hispanic White men and Hispanic men and women (Table 4
).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Overall, in the 29 states with sufficient data, most (64%) persons who had a diagnosis of heterosexually acquired HIV/AIDS during 1999 to 2004 were women. The finding that the proportion who were women was even higher (88%) among those aged 13 to 19 years supports earlier findings of a high proportion of women among teenagers with heterosexually acquired HIV.4 This finding may be related to the age at which younger women initiate sexual behaviors that may place them at increased risk for acquiring HIV.4 It also may be because they have sexual contact with older men, who are more likely to be HIV infected.14 Conversely, as our data represent diagnoses rather than all infections, these findings may result from the fact that young women may have more opportunities for HIV testing and diagnosis (e.g., routine family planning and gynecological services) than do young men, in whom HIV infection may remain undiagnosed longer.
The HIV epidemic has been concentrated in groups that traditionally have limited access to prevention services, medical care, and effective therapies.15,16 Among women, non-Hispanic Blacks and Hispanics accounted for 83% of the reported heterosexually acquired cases of HIV/AIDS. Contributing to the risk for HIV infection among non-Hispanic Blacks and Hispanics may be lack of HIV knowledge, lower perception of risk, drug or alcohol use, and different interpretations of safer sex.17 In addition, because of social mixing patterns, non-Hispanic Black and Hispanic women are more likely than other women to be exposed to HIV because of a higher prevalence of infection among non-Hispanic Black and Hispanic men.18 The increase in the number of heterosexually acquired HIV/AIDS cases among Hispanics may be partly explained by the increasing number of Hispanics. The Hispanic population is one of the fastest growing demographic groups in the United States, according to census data.19 Although the number of HIV cases in Hispanics is growing at the same rate as the Hispanic population, this increasing number reflects a growing need for HIV prevention and care services for this population.
Concurrent diagnoses of HIV and AIDS may reflect HIV diagnosis late in the course of infection, possibly because of testing for HIV infection being delayed until symptoms have developed. Concurrent HIV and AIDS diagnoses were more common among men than among women and may be explained by variability between men and women in HIV testing. However, 1 study found that women aged 45 years and older were less likely than men to have ever had an HIV test.20
The timing of the diagnosis of HIV infection in relation to the diagnosis of AIDS varied by race/ethnicity. Concurrent HIV and AIDS diagnoses were slightly more common among non-Hispanic Whites and Hispanics than among non-Hispanic Blacks. Although 1 study reported that non-Hispanic Blacks were more likely to receive concurrent AIDS and HIV diagnoses, a different definition of concurrent diagnosis and a different study methodology were used.7 The findings in this report may be the result of more use of testing services by non-Hispanic Blacks. Several studies have demonstrated that non-Hispanic Blacks were more likely to report having been tested for HIV than were non-Hispanic Whites and Hispanics.21,22 Reasons for not being tested included denial of HIV risk factors and fear of being HIV positive.23 The proportion of concurrent HIV and AIDS diagnoses increased with age, which may be explained by the fact that HIV disease progression tends to occur more rapidly among older persons. Another possible explanation is that older persons are assumed to not be at risk and are therefore not the focus of testing programs. As suggested by this study and others, for older non-Hispanic Whites, a diagnosis of HIV was more often made during times of symptomatic illness.24
The findings in this report indicate that rates of survival after diagnosis of heterosexually acquired AIDS differ among racial/ethnic groups. Although non-Hispanic Blacks were least likely to have concurrent HIV and AIDS diagnoses, their lower survival after a diagnosis of AIDS, compared with non-Hispanic Whites and Hispanics, suggests that timely treatment or adherence to antiretroviral therapy may not necessarily follow a diagnosis of AIDS. One explanation may be that, in comparison with non-Hispanic Whites, non-Hispanic Blacks use fewer scheduled outpatient medical services and receive a greater proportion of care in emergency rooms,15 where they are unlikely to receive comprehensive care.25 Non-Hispanic Blacks are more likely to be uninsured, and those who are uninsured are more likely to delay or not receive medical care because of cost.15 Another possible explanation is that the treatment of AIDS is more difficult as a result of the emergence of drug resistance during HIV infection.26 In addition, the lack of social support structures among drug users, the homeless, and those who trade sex for drugs may complicate compliance with antiretroviral therapy.27
HIV surveillance data are subject to at least 4 limitations. First, the national HIV infection surveillance system does not include data from all states. Although our data were from the largest set of population-based data currently available for persons infected with HIV, the 29 states used in this analysis may not be nationally representative, because they reported only 39% of all AIDS cases diagnosed among adults and adolescents in the United States during 1999 to 2004. Data from states with high AIDS morbidity (e.g., California and New York) were not included, which may have resulted in an underrepresentation of cases among non-Hispanic Blacks and Hispanics. However, in a validation study of race/ethnicity and transmission mode in the national HIV/AIDS reporting system, self-reported and AIDS surveillance system classification of race/ethnicity agreed well.28 To more completely describe the epidemic and improve estimates of the size of the HIV-infected population, a national HIV infection reporting system is needed.
Second, although the first known date of HIV diagnosis is reported to the surveillance system, an earlier diagnosis date may have been reported outside of the 29 states used in this analysis. Third, the assumptions on which we based reclassification of cases reported without risk factors may no longer be valid and are being reevaluated. Last, risk behavior information about partners is limited; therefore, surveillance data cannot effectively evaluate the effect of sexual behaviors (e.g., bisexuality) on transmission of heterosexually acquired HIV.
In summary, racial and ethnic disparities continue to exist among persons with HIV infection. To reach those groups most affected by the epidemic, HIV prevention messages should be culturally sensitive. To decrease the incidence of new HIV infections in heterosexually active adolescents, especially young women and Blacks and Hispanics, prevention and education programs for these groups should be continued. In addition, Hispanic and non-Hispanic Black populations, who historically have had less access to treatment and prevention services, are disproportionately affected by HIV. New strategies are needed to remove barriers to access to these services by those populations. In addition, because concurrent AIDS and HIV diagnoses imply missed opportunities for early treatment of HIV, it is important to facilitate earlier diagnosis and entry into care if prognosis and survival rates are to be improved. Access to testing does not necessarily imply access to care, so it is important to link HIV prevention and testing services with care and treatment. As outlined in the CDC’s initiative in 2003 to advance HIV prevention,29 knowledge of HIV status and access to care and prevention services are needed for all groups affected by the epidemic.
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Acknowledgments |
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We thank M. Kathleen Glynn, Matthew T. McKenna, and P. Lynn Stockton for their reviews and editorial suggestions on improving this article.
Human Participant Protection
No protocol approval was needed for this study.
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Footnotes |
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Peer Reviewed
Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Contributors
L. Espinoza conducted the analyses and interpretation of findings and led the writing. H.I. Hall assisted with the study, contributed to the study design, and supervised all aspects of its implementation. F. Hardnett and Q. Ling assisted with analyses. L.M. Lee originated and assisted with the study.
Accepted for publication February 18, 2006.
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References |
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