Update: AIDS Among Women -- United States, 1994

In 1993, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) was the fourth leading cause of death among women aged 25-44 years in the United States (1); in addition, the incidence of AIDS is increasing more rapidly among women than men (2). Women with AIDS reported in 1994 represented 13% of the cumulative total of 58,448 cases among women. This report presents characteristics of women and men reported with AIDS in 1994, summarizes trends in cases reported during 1985-1994, and describes findings of an HIV seroprevalence survey among childbearing women during 1989-1993. * AIDS Surveillance

In 1994, of the 79,674 persons aged greater than or equal to 13 years reported with AIDS, 14,081 (18%) occurred among women -- nearly threefold greater than the proportion (534 {7%} of 8153) reported in 1985; in addition, the proportion of cases among women has increased steadily since 1985 Figure_1. The median age of women reported with AIDS was 35 years, and women aged 15-44 years accounted for 84% of cases. More than three fourths (77%) of cases among women occurred among blacks and Hispanics, and rates for black and Hispanic women were 16 and seven times higher, respectively, than those for white women Table_1.

In 1994, the Northeast region accounted for the largest percentage of AIDS cases reported among women (44%), followed by the South (36%), West (9%), Midwest (7%), and Puerto Rico and U.S. territories (4%). In the Northeast, most cases among women occurred in urban areas; 1.4% of women with AIDS in the Northeast resided outside metropolitan statistical areas (MSAs) compared with 10.2% of women who resided outside MSAs in the South. Of all cases among women, 61% were reported from five states: New York (26%), Florida (13%), New Jersey (10%), California (7%), and Texas (5%).

In 1994, 59% of AIDS cases among women were reported based on criteria added in the 1993 expanded AIDS surveillance case definition (3). This total included 7181 women with severe HIV-related immunosuppression (CD4+ T-lymphocytes less than 200 cells/uL or percentage of total lymphocytes less than 14), 557 with pulmonary tuberculosis, 376 with recurrent pneumonia, and 164 with invasive cervical cancer.

In 1994, 41% of women with AIDS reported injecting-drug use; 38%, heterosexual contact with a partner at risk for or known to have HIV infection or AIDS; and 2%, receipt of contaminated blood or blood products; 19% had no specific HIV exposure reported. Of all women with AIDS who were initially reported without risk but who were later reclassified, most had heterosexual contact with an at-risk partner (66%) or a history of injecting-drug use (27%) (4). In 1994, of the 5353 women reported with AIDS attributed to heterosexual contact, 38% reported contact with a male partner who was an injecting-drug user; 7%, a bisexual male; 2%, a partner who had hemophilia or had received HIV-contaminated blood or blood products; and 53%, a partner who had documented HIV infection or AIDS but whose risk was unspecified. HIV Seroprevalence in Childbearing Women

Using findings from the HIV Survey in Childbearing Women (SCBW) (5), an estimated 7000 HIV-infected women delivered infants in the United States during 1993. Assuming a perinatal transmission rate of 15%-30%, approximately 1000-2000 infants were perinatally infected with HIV during 1993. From 1989 through 1993, the annual prevalence of HIV infection among childbearing women remained relatively stable (1.6-1.7 per 1000), although prevalence varied regionally: in the Northeast, prevalence decreased from 4.1 to 3.4 per 1000; in the South, prevalence increased from 1.6 in 1989 to 2.0 in 1991 and remained stable through 1993. Reported by: Local, state, and territorial health depts. Div of HIV/AIDS, National Center for Infectious Diseases; Office of Women's Health, Office of the Director; Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: In 1994, as in previous years, the AIDS epidemic among women continued to disproportionately affect racial/ethnic minorities, primarily in the Northeast and South. AIDS among women was primarily associated with two modes of HIV transmission: injecting-drug use and heterosexual contact with an at-risk partner. The proportion of women in 1994 with unreported risk will decrease substantially after investigation by local and state health departments because, after follow-up, most women are found to have a recognized risk for HIV. Heterosexual contact is the most rapidly increasing transmission category for women (6).

The disproportionate impact of HIV/AIDS among women in racial/ethnic minority groups reflects social and economic factors that have not been completely defined. Despite the methodologic limitations associated with use of race/ethnicity, these data have assisted in the development and implementation of community-based prevention efforts.

The increase in the proportion of cases associated with heterosexual transmission will complicate accurate ascertainment of mode of transmission. In particular, women are more likely than men to be reported initially without a risk for HIV because both women and their care providers may not recognize or report the risk behaviors of the woman or her partners (6). High rates of sexually transmitted diseases are associated with the use of noninjecting drugs and with the exchange of sex for drugs, money, or personal items that may account for increased heterosexual transmission among some women (7). In addition, some women who have sex with other women may be at risk for HIV infection if they inject drugs or have partners with high-risk behaviors (8).

Findings from the SCBW indicate that approximately 7000 infants are born to HIV-infected women in the United States each year. Recent advances in the prevention of perinatal HIV transmission emphasize the need for women to know their HIV-infection status. Zidovudine therapy has been recommended for infected pregnant women and their newborns as an effective means for reducing the risk for perinatal HIV transmission (9). The Public Health Service is developing draft recommendations to establish policy regarding HIV counseling and testing of pregnant women to reduce vertical transmission and promote referrals for on-going health care.

Women at highest risk for heterosexually acquired HIV infection include those whose heterosexual partners have high-risk behaviors (e.g., injecting-drug use), adolescents and young adults with multiple sex partners, and those with sexually transmitted diseases. To reduce HIV transmission to women, prevention programs should emphasize consistent condom use, the need for substance-abuse prevention and treatment services, and counseling to support decisions by women and their partners to reduce risk behaviors. Efforts to improve the prevention of HIV transmission in women also should include the development and evaluation of additional measures such as the female condom and microbicides.

References

1. CDC. Annual summary of births, marriages, divorces, and deaths: United States, 1993. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994:18-20. (Monthly vital statistics report; vol 42, no. 13).

2. CDC. Update: acquired immunodeficiency syndrome -- United States, 1994. MMWR 1995;44:64-7.

3. CDC. 1993 Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR 1992;41:(no. RR-17).

4. CDC. HIV/AIDS surveillance report. Atlanta: US Department of Health and Human Services, Public Health Service, 1994;6(no. 1):20,25-7.

5. Gwinn M, Pappaioanou M, George JR, et al. Prevalence of HIV infection in childbearing women in the United States. JAMA 1991;265:1704-8.

6. CDC. Heterosexually acquired AIDS -- United States, 1993. MMWR 1994;43:155-60.

7. Edlin BR, Irwin KL, Faruque S, et al. Intersecting epidemics: crack cocaine use and HIV infection among inner-city young adults. N Engl J Med 1994;331:1422-7.

8. Chu SY, Hammett TA, Buehler JW. Update: epidemiology of reported cases of AIDS in women who report sex only with other women, 1980- 1991. AIDS 1992;6:518-9.

9. CDC. Recommendations of the U.S. Public Health Service Task Force on the Use of Zidovudine to Reduce Perinatal Transmission of Human Immunodeficiency Virus. MMWR 1994;43(no. RR-11).

• Single copies of this report will be available until Friday 10, 1996, from the CDC National AIDS Clearinghouse, P.O. Box 6005, Rockville, MD 20849-6003; telephone (800) 458-5231.

|------------------------------------------------------------------- --------| |             | | Erratum: Vol. 44, No. 5 | | ======================= | | SOURCE: MMWR 44(07);135 DATE: Feb 24, 1995 | |             | | In the article "Update: AIDS Among Women -- United States, | | 1994," on page 81, the sentence beginning on the fourth line was | | incorrect. The sentence should read, "Women with AIDS reported in | | 1994 represented 24% of the cumulative total of 58,428 cases among | | women."     | |------------------------------------------------------------------- --------|
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TABLE 1. Number, percentage, and rate * of AIDS cases among adolescents and adults + ,
by race/ethnicity and sex -- United States, 1994
===============================================================================================
                                    Men                   Women                 Total
                           ---------------------    ------------------   ----------------------
Race/Ethnicity              No.     (%)    Rate     No.     (%)   Rate    No.     (%)    Rate
-----------------------------------------------------------------------------------------------
White, non-Hispanic        29,910  (45.6)   38.9    3,148  (22.4)  3.8   33,058  (41.5)  20.8
Black, non-Hispanic        22,838  (34.8)  208.0    8,016  (56.9) 62.7   30,854  (38.7) 129.8
Hispanic                   12,016  (18.3)  109.8    2,814  (20.0) 26.0   14,830  (18.6)  68.2
Asian/
  Pacific Islander            518  ( 0.8)   15.3       49  ( 0.4)  1.3      567  ( 0.7)   8.0
American Indian/
  Alaskan Native              184  ( 0.3)   26.8       42  ( 0.3)  5.8      226  ( 0.3)  16.1

Total *                    65,591           63.7   14,081         12.8   79,674          37.4

* Per 100,000 population.
+ Persons aged >=13 years.
& Includes 137 persons whose race/ethnicity is unknown and two persons whose sex is unknown.
===============================================================================================

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