Cox: AIDS Booklet Update

Updated AIDS Data: Centers for Disease Control HIV/AIDS
July 2000

These five cities account for 31% of all U.S. cases

*There is a slight variance in data due to reporting method differences.

Commentary

During the 1990s, the epidemic shifted steadily toward a growing proportion of AIDS cases in blacks, Hispanics, and women; the epidemic shifted toward a decreasing proportion in MSM, although this group remains the largest single exposure group. Blacks and Hispanics, among whom AIDS rates have been markedly higher than among whites, have been disproportionately affected since the early years of the epidemic. In absolute numbers, blacks have outnumbered whites in new AIDS diagnoses and deaths since 1996 and in the number of persons living with AIDS since 1998.

The proportion of women with AIDS increased steadily, reaching 23% in 1999. The proportion infected heterosexually also increased, and in 1994 it surpassed the proportion infected through injection drug use.

Midway through the 1990s, effective therapies became available. As early as 1996, their effects of decreasing AIDS incidence and AIDS deaths were detected through surveillance at the population level. As deaths have decreased, AIDS prevalence has steadily increased year to year- a trend that will continue as long as the number of persons with a new AIDS diagnosis exceeds the number of persons dying each year.

The steep decline in perinatally acquired AIDS has been one of the dramatic changes of the 1990s, resulting from the rapid implementation of the use of zidovudine (ZDV) to prevent perinatal transmission. The increased use of ZDV took place after publication of the findings of the AIDS Clinical Trial 076 and of the Public Health Service guidelines on the use of ZDV to reduce HIV transmission. More recently, part of the decline in perinatal AIDS can be ascribed to improved treatments for HIV-infected children. These treatments delay the onset of AIDS-defining illnesses. The rate of perinatal transmission is expected to continue to decline as a result of more aggressive courses of treatment (e.g., combination therapy) and more obstetric procedures, such as elective cesarean sections, which reduce transmission.

The mid-year edition of the HIV-AIDS Surveillance Report presents the first opportunity to examine trends in the estimated incidence of AIDS during 1999 compared with earlier years. Sufficient time has elapsed to allow statistical adjustments for delays in reporting of AIDS cases that were diagnosed during 1999. Likewise, trends in estimated deaths among persons with AIDS, and in the prevalence of AIDS, that is the number of persons who are living with AIDS, are presented. In recent years, marked declines in AIDS incidence and deaths began in 1996 and continued into 1998 in association with the widespread use of potent combination antiretroviral therapies. However, the rates of decline in AIDS incidence and deaths slowed during the latter part of 1998 and 1999. In 1999, the numbers of cases and deaths each quarter have stabilized or are fluctuating slightly in most populations and geographic areas. AIDS prevalence continues to rise with approximately 320,000 persons living with AIDS at the end of 1999, although the rate of increase has slowed.

There are undoubtedly multiple reasons for these changing trends. These may include: reaching the limits of therapy in extending survival; failing therapies due to treatment-resistant viral strains; late HIV testing; inadequate access to and adherence to treatment in some populations; or recent increases in HIV incidence in some risk groups. Which among these factors contributes to the observed trends cannot be discerned from case reports of AIDS or deaths alone.

Source: Vol. 12, No. 1, HIV/AIDS Surveillance Report (July 1, 2000)

Report on the global HIV/AIDS epidemic- June 2000

Global estimates of the HIV/AIDS epidemic as of end 1999¹

Total number of AIDS orphans² since the beginning of the epidemic: 13.2 million

1. This summary supersedes the one published in the December 1999 Update on the global HIV/AIDS epidemic.
2. Defined as children who lost their mother or both parents to AIDS when they were under the age of 15.

North America	900,000
Caribbean	360,000
Latin America	1.3 million
Western Europe	520,000
North Africa & Middle East	220,000
Sub-Saharan Africa	24.5 million
Eastern Europe & Central Asia	420,000
East Asia & Pacific	530,000
South & South-East Asia	5.6 million
Australia & New Zealand	15,000
Adults and children living with HIV/AIDS- total	34.3 million

Updates to The Aids Booklet

• July 9-15, 2000, the XIIIth International Conference on HIV/AIDS was held in Durban, South Africa. The venue was complex because South Africa's Democratic President, Thabo Mkebi, had reasonable doubts concerning the truth and applicability of "mainstream" concepts of HIV/AIDS causes, transmission, and drug treatment, especially as applied to the affordable control of heterosexual spread in his nation. Two issues came to the fore:
  1. Is cell-free HIV-1 the cause of AIDS, or is AIDS a result of drugs, nutritional, and behavioral factors? Possibly, both sides of this argument are correct, especially if gene expression varies widely in individuals, if personal genes are variably susceptible, and if the signs and symptoms depend on the variable integration and extent of retroviral RNA into lymphocyte DNA, along with age of the individual when infected.
  2. Are reverse transcriptase inhibitors practical for preventing AIDS in African newborns? HAART having failed to cure AIDS in adults, the "main stream" and manufacturers of reverse transcriptase inhibitors have focused on the prevention of HIV/AIDS in the offspring of HIV-1+ mothers. Statistically, 25-35% of the offspring develop AIDS. If mother and child are given short courses of zidovudine or nevirapene at term and one to two days after birth, the number of HIV-infected are halved, especially if their mothers abstain from breast-feeding- a factor which increases total risk by approximately ten percent. The downsides to this approach are that if such RTIs do not cure the mother, 100% of the offspring may expect to be motherless within five to ten years, and 65-75% of the offspring will have been treated unnecessarily with necleoside analogs whose long term side-effects remain in doubt. The South African government declined to sponsor use of RTIs for preventing AIDS in the newborn even though the cost of nevirapine is extremely low, and it might be offered for free by the manufacturer. The bottom line remains that no RTI, operative intervention, or refusal to nurse, singly or in combination, has statistically reduced preinatal AIDS transmission to 0%. Nevertheless, infants are loved persons, not statistics.
• Despite such differences of opinion, the consensus at the Durban meeting was that the worldwide spread of HIV/AIDS between adults and to children must be reduced by improved education and all affordable as well as tolerable means. Education directed toward sexual abstinence, monogamy, and use of condoms has statistically reduced the incidence of teenage pregnancies in the USA, but it has not stemmed the tide of HIV/AIDS progression in women and young adults. Some believe that HIV-1, 2; HTLV-I, II; HPV, HSV, Chlamydiosis, and gonorrhea are commonly spread by means of infected motile cells, such as lymphocytes, monocytes, macrophages, and poplymorphonuclear prepuce. For those who agree with the former statement, there is virtue in female choices for stemming the tide of AIDS and other STDs, as well as overpopulating parts of this earth. Recent studies on the contraceptive effectiveness of various female choices (see JAMA 1999; 282: 1405-1407) ranked failure rates after one year of use as follows: progesterone implants- two to four percent; the pill- nine percent; uterine cervical caps and vaginal diaphragms- 13%; male condoms- 15%; periodic abstinence- 22%; penile withdrawal- 26%; and vaginal spermicides (N-9)- 28%. Cervical caps, diaphragms, and N-9 have been well tolerated by women and sexual partners for almost 50 years. Motile lymphocytes in semen are 50 to 100 times more sensitive than sperm are to the immobilizing and killing effects of N-9 (American Journal of Obs Gyn 1992; 16: 720-726). Therefore, use of N-9 in conjunction with a hidden reusable cervical cap or diaphragm would seem at least as effective as use of a disposable condom for preventing AIDS as well as pregnancy. This method would also cost five to seven times less per coitus than a condom.
• For those advocating circumcision for preventing HIV/AIDS during vaginal coitus, surgical removal of the penile foreskin thickens the thin and delicate frenulum, the "Achilles heel" of the penis. Thus, the male is less vulnerable to invasion by provirus-infected "Trojan horse" lymphocytes in uterine cervical secretions.
• Finally, little progress has been made in the USA or worldwide for stemming the tide of HIV/AIDS emanating from IV drug abuse or shared nasal secretions from cotton-tipped swabs used to sniff coke. In order to protect health care workers (HCWs) at high risk for transmission of HIV, HBV and HCV resulting from accidental needle sticks, on November 5, 1999, the US Department of Occupational Safety and Health (OSHA) directed the use of gloves and safety-engineered needles in all health care facilities. Problem areas included inadequate hand-washing and routine use of unsterile exam gloves in conjunction with needleless systems having recesses prone to colonization with skin-borne bacteria and IV injection of colonies with repeated use. These practices can be expected to increase the numbers of hospital-acquired blood stream infections with skin-borne bacteria. Such infections are now occurring at the rate of 400,000 annually with a 25% mortality rate and an average cost of $33,000 per infection (See FDA MAUDE access numbers 4002710 to 4002714 and American Journal of Infect Control 2000; 28: 321-322). Annual deaths from blood stream infections in the USA currently exceed those from HIV, HBV, and HCV combined. Thus, we need needles safer for patients and HCWs, as well as injection drug users.