the epidemiology of hiv and aids worldwide, nationwide, and in la county jane neff rollins, msph

The Epidemiology of HIV and AIDSWorldwide, Nationwide, and in LA County

Jane Neff Rollins, MSPH

Initial HIV Infection

HIV Antibody

Test Positive

Laboratory Evidence of

Immuno-suppression

Clinical Symptoms

Opportunistic Disease(AIDS)

Death

6 weeks--6 months

Spectrum of HIV Disease

~10 years (without treatment)

Signs and Symptoms of Acute HIV Infection

• Fever

• Lymphadenopathy

• Sore throat

• Extreme fatigue

• Weight loss (more than 5 pounds in <2 weeks

• Night sweats

• Muscle and joint pain

• Nausea or vomiting or diarrhea

• Pain in feet or fingers

• Thrush (yeast infection in the mouth or throat)

• Red or dark, spotty, “measles-like” rash

• Oral, genital or rectal ulcers

Most Common

Less Common

Most Definitive Signs

Healthcare workers with documented and possible occupationally acquired AIDS/HIV infection, reported through June, 2001, United States

Occupation

Dental worker, including dentist 6Emergency med tech/paramedic --- 12Lab technician 19 17Nurse 24 35Physician 6 18Other 8 48

TOTAL 57 136

DocumentedOccupationalTransmission

PossibleOccupationalTransmission

Source: www.cdc.gov/hiv/pubs/facts/hcwsurv.htm

NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings, Publication # 2000-108

Available at www.cdc.gov/niosh or1-800-35-NIOSH

Recommendations for Prevention of HIV Transmission in Health Care Settings, MMWR, August 21, 1987, Vol 36: No 27,

Primary and Secondary HIV PreventionThrough Early Detection of HIV Infection

Early Identification Early Treatment

PRIMARY PREVENTION SECONDARY PREVENTION

Reproductive Choices AZT/HAART during

pregnancy

Decrease Vertical Transmission

Decreased Transmission to Sex & Needle-Sharing Partners

Altered Behaviors

Partner Notification

Decreased Progression to

AIDS

Decreased Mortality

Decreased Viral Load

?

A global view of HIV infection 36.1 million persons living with HIV/AIDS

As of year-end 2000

Adult prevalence rate

15.0% – 36.0% 5.0% – 15.0% 1.0% – 5.0% 0.5% – 1.0% 0.1% – 0.5% 0.0% – 0.1% not available

Spread of HIV over timein sub-Saharan Africa, 1984 to 1999

Estimated percentage of adults

(15–49) infected with HIV 20.0% – 36.0%10.0% – 20.0% 5.0% – 10.0% 1.0% – 5.0% 0.0% – 1.0%trend data unavailable

outside region

<55 - 14.915+

AIDS Rates per 100,000 PopulationReported in1999

Rate per 100,000

8.4VI 32.6PR 32.1

DE

MARICTNJ

MDDC

NH

VT3.4

3.8

25.124.7

17.9

23.510.8

29.5161.5

36.2

15.2

42.3

16.4

24.7

21.5

19.515.9

18.4

2.4

16.4 3.8

4.9

2.9

3.0

4.0

4.4

4.0

2.2

1.1

3.1

1.5

2.0

6.3

6.8

13.47.3

5.3

7.9 6.4

7.6

9.7

12.8

6.6

6.1

7.0

13.8

10.9

10.4

13.7

6.4

Centers for Disease Controland Prevention

CDC

HIV Infection (not AIDS) Reported in 1999N=21,419*

*Includes 361 persons who were residents of areas without HIV infection surveillance but who were reported by areas with HIV infection surveillance.

HIV surveillance initiated in July 1999†

NJCT

PR VI 153

1,330

56,402

464

717

9712,563

694

919

184

169

230

219

79

21

2

928

0

23264

145

325

214

472

499

301

897

519

1,017

87849287

†

ConfidentialHIV Reporting** Required

Pediatric only

**HIV cases reported by patient name

Source: CDC


CDC

Age at Diagnosis of HIV Infection or AIDS, Reported through 1999, United States

*Data from 34 areas with confidential HIV infection surveillance

HIV* AIDSNumber

2,0264,797

47,61341,178

20,263

122,6076,730

<1313-19

30-3920-29

40-4950+

Age Number

8,7183,725

329,066123,580

190,087

733,37478,198

Percent

24

3934

175

Percent

11

4517

2611


CDC

White not Hispanic

Black not Hispanic

Hispanic Asian/Pacific IslanderAmerican Indian/Alaska Native

AIDS Cases in 13- to 19-Year-Olds by Race/Ethnicity, United States

AIDS Cases 1999N=312

AIDS Cases 1981-1999N=3,725

U. S. Population N 27Million

2% 2%14%

60%

24%

29%

49%

20%

5%

67%

15%14%


CDC

Public Health Importance of HIV/AIDS in LA County

• LAC is second only to NYC in cumulative number of reported AIDS cases in metropolitan areas.

• 35% of all California AIDS cases are reported from LAC.

• Only 4 states (CA, TX, NY, FL) have reported more AIDS cases than LAC.

Source: HIV Epidemiology Program, LAC/DHS, as of 12/31/99

MSM

IDU

MSM/IDU

Hetero

Transfusion

Other/undetermined

Source: HIV Epidemiology Program, LAC/DHS, and NYC Department of Health, as of 03/00

Mode of HIV Exposure (%) of Cumulative AIDS CasesLos Angeles County vs. New York City

Male Female Male Female

Los Angeles County New York City

78 --

6 26

7 --

1 46

1 8

7 19

41 --

44 52

n/a --

3 31

<1 1

11 16

HIV DISEASE IN LOS ANGELES COUNTY

AIDS

~15,000 Persons Living with AIDS

~25,000 Persons Living with HIV

HIV Infection Recognized

HIV Infection Unrecognized

Estimated 40,000 individuals living with HIV Infection, both early and advanced (AIDS)

AIDS Cases Reported in 1996-1999By Gender, Race/Ethnicity, Exposure Category and Percentage Change

1996 1997 1998 1999 % change % change % change No. No. No. No. 96 to 97 97 to 98 98 to 99

GENDER Male 3165 2139 1813 1745 -32% -15% - 4% Female 342 269 221 212 -21% -18% - 4%RACE/ETHNICITY White 1672 919 663 667 -45% -28% + 1% AA 679 544 516 479 -20% - 5% - 7% Latino 1066 876 799 750 -18% - 9% - 6% Asian 71 50 49 50 -30% - 2% + 2% AI/AN 10 15 5 8 +50% -67% +60%EXPOSURE CATEGORY MSM 2448 1518 1125 1031 -38% -26% - 8% MSM/IDU 180 96 100 83 -47% + 4% -17% Male IDU 197 139 124 91 -29% -11% -27% Female IDU 96 71 37 34 -26% -48% - 8% Male Hetero 50 57 53 31 +14% - 7% -42% Female Hetero 167 128 94 76 -23% -27% -19%

TOTAL 3507 2408 2034 1957 -31% -16% - 4%


AIDS Deaths Reported in 1996-1999By Gender, Race/Ethnicity, Exposure Category and Percentage Change

1996 1997 1998 1999 % change % change % change No. No. No. No. 96 to 97 97 to 98 98 to 99

GENDER Male 2038 965 623 518 -53% -35% -17% Female 175 100 84 75 -43% -16% -11%RACE/ETHNICITY White 1051 480 295 240 -54% -39% -19% AA 482 236 168 152 -51% -29% -10% Latino 623 317 236 182 -49% -26% - 23% Asian 50 24 5 14 -52% -79% +180 AI/AN 2 6 1 2 +200 -83% +100EXPOSURE CATEGORY MSM 1565 691 420 336 -56% -39% -20% MSM/IDU 152 72 40 35 -53% -44% -13% Male IDU 146 75 45 40 -49% -40% -11% Female IDU 46 28 19 29 -39% -32% +53% Male Hetero 39 13 18 12 -67% +38% -33% Female Hetero 77 44 36 31 -43% -18% -14%

TOTAL 2213 1065 707 593 -52% -34% -16%


Racial/Ethnic Distribution of Adult/Adolescent AIDS Cases by Year of Diagnosis

Los Angeles County, 1986-2001

0

20

40

60

80

86 87 88 89 90 91 92 93 94 95 96 97 98 99

Year of AIDS Diagnosis

Percent of total cases

White Latino African-American Asian/Other

Source: HIV Epidemiology Program, LAC/ DHS, as of December, 2001

00 01

Male Adolescent/Adult AIDS Rates1

By Race/Ethnicity and Year of DiagnosisLos Angeles County, 1990-2001

0

50

100

150

200

250

300

90 91 92 93 94 95 96 97 98 99 1

White African-American Latino Other

1 Data are adjusted for reporting delay only.


Rat

e p

er 1

00,0

0 0


1993 AIDS case definition change

00 0

Female Adolescent/Adult AIDS Rates1

By Race/Ethnicity and Year of DiagnosisLos Angeles County, 1990-2001

0

10

20

30

40

50

90 91 92 93 94 95 96 97 98 99 0 1

White African-American Latino1 Data are adjusted for reporting delay only.


Rat

e p

er 1

00,0

0 0


1993 AIDS case definition change

Other Females

0

1

2

3

90 92 94 96 98 0

Year of Diagnosis

Rate per 100,000

0 0

AIDS Prevalence Rate (per 100,000)* for MalesBy Race/Ethnicity, 1986-1997,

Los Angeles County

* Prevalence Rate is the number of persons living with AIDS at any time during the year divided by the population in that year ( multiplied by 100,000)

Source: HIV Epidemiology Program, LAC/ DHS, as of May 31, 1999

AIDS Prevalence Rate (per 100,000)* for FemalesBy Race/Ethnicity, 1986-1997,

Los Angeles County

* Prevalence Rate is the number of persons living at any time during the year divided by the population in that year multiplied by 100,000

Source: HIV Epidemiology Program, LAC/ DHS, as of May 31, 1999

Cases, Deaths and Case Fatality Rate of Advanced HIV Disease (AIDS) by Year , Reported

by December 31, 2001, Los Angeles County Year Number of Cases Number of Deaths Case Fatality

Diagnosed Occurred Rate

19881989199019911992199319941995199619971998199920002001

2354280433184015417039443694346027062088181315951357

799

22292549294333753197260519651206

631406303219184

89

Source: HIV Epidemiology Program, LAC/DHS, as of 12/01

43541 27114

95%91%89%84%77%66%53%35%23%19%17%14%14%11%

AZT Treatment for HIV+ Pregnant Women

Source: NEJM, 331,1173-1180, November 3, 1994

AZT No AZT

Number of births 180 183

Probability of HIV 8.3 25.5Transmission (%)

Median interval from first positive HIV test to AIDS diagnosis among a sample of persons reported with

AIDS, 01/90-08/98Los Angeles County, SHAS Interview project (N=2,377)

Sex Male FemaleRace/Ethnicity White Black Latino Asian Native-American

2002 (89.2) 14 375 (10.8) 14

881 (39.9) 32 433 (15.9) 81005 (41.0) 8 49 ( 2.6) 2 6 ( 0.5) 11

Characteristics No. (%) Median Interval (months)

Source: HIV Epidemiology Program, LAC/DHS

Conclusions

• Although Los Angeles is an area of high HIV prevalence, our findings indicate an overall low level of early HIV detection.

• Major sociodemographic and behavioral disparities exist in the likelihood of early detection of HIV infection.• minorities, women, heterosexuals, young adults and persons

of lower educational level are less likely have HIV detected early.

• The low level of early HIV detection promotes transmission of HIV and may help explain the current local dynamics of HIV transmission in Los Angeles.


Background

HIV/AIDS and Tuberculosis

• Increases in TB worldwide in recent years have been attributed in large part to the HIV epidemic

• Immunocompromised persons such as those infected with HIV are at increased risk for tuberculosis


The U.S. Centers for Disease Control and Prevention recommends that all persons with TB be tested for HIV so that:

1) HIV infections among persons with TB can be identified early to ensure the provision of high-quality medical care that considers the comanagement of both infections.

2) the extent of comorbidity of TB and HIV in the general population can be accurately assessed.

Source: HIV Epidemiology Program, LAC-DHS

HIV/AIDS and Tuberculosis

The Los Angeles Syphilis Outbreak, 2000*

• Of 111 cases of syphilis identified, 108 (97%) were from LAC, and 3 cases were from Long Beach

– 13 primary, 43 secondary, 55 early latent stage

• 103 (93%) identified as MSM, 7 (7%) as transgender

• 58 (52%) were HIV positive

– Among those, 42 (72%) were in care for HIV infection

• The average age was 36 years of age (range 20-50)

• 45% Latino, 41% white, 13% African-American, and 2% A/PI

• Outbreak is suggestive evidence that there may be recent increases in high-risk behaviors for some MSM

* Data of of 9/29/00

Source: Sexually Transmitted Disease (STD) Program, Los Angeles County Department of Health Services

Young Men’s Survey

HIV prevalence P

erc

en

t H

IV+


YMS: Risk behaviorsRisk behaviorsMSM-W(n=92)

MSM(n=456)

Anal sex w/o cond (6 mo) 39% 52%

Exchange sex (6 mo) 29% 14%

High during last sex 29% 23%

History of STD 13% 15%

9+ male partners (life) 46% 48%

3+ male partners (6 mo) 54% 51%


YMS:Risk behaviors (cont.)Risk behaviors (cont.)

MSM-W(n=92)

MSM(n=456)

Injected drugs 7% 7%

Run away from home 52% 41%

Ever forced to have sex 48% 39%

Oral sex before 12 14% 17%

Anal sex before 12 7% 6%


Jane Neff Rollins, MSPH

[email protected]

the epidemiology of hiv and aids worldwide, nationwide, and in la county jane neff rollins, msph

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