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# 13 {#section .Chapter-#}

# HIV

Co-Lead Agencies: Centers for Disease Control and Prevention\
Health Resources and Services Administration

### Contents {#contents .Heading-Special}

[Goal Page 13-3](#goal)

[Overview Page 13-3](#overview)

[Issues Page 13-3](#issues)

[Trends Page 13-6](#trends)

[Disparities Page 13-8](#disparities)

[Opportunities Page 13-10](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
13-10](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
13-12](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
13-13](#healthy-people-2010-objectives)

[Related Objectives From Other Focus Areas Page
13-26](#related-objectives-from-other-focus-areas)

[Terminology Page 13-26](#terminology)

[References Page 13-27](#references)

## Goal

Prevent human immunodeficiency virus (HIV) infection and\
its related illness and death.

## Overview

In 1981, a new infectious disease, AIDS, or acquired immunodeficiency
syndrome, was identified in the United States.[^1] Several years later,
the causative agent of AIDS---human immunodeficiency virus (HIV)---was
discovered. This discovery coincided with the growing recognition of
AIDS in the United States as part of a global infectious disease
pandemic.

Currently, HIV/AIDS has been reported in virtually every racial and
ethnic population, every age group, and every socioeconomic group in
every State and most large cities in the United States.[^2] Initially
identified among men who have sex with men on the East and West
Coasts,[^3] the AIDS epidemic is composed of diverse multiple
subepidemics that vary by region and community. By the end of 1998, more
than 680,000 cases of AIDS had been reported, and nearly 410,800 people
had died from HIV disease or AIDS.Error: Reference source not found

### Issues 

Estimates of the number of people infected with HIV in the United States
range from 800,000 to 900,000.[^4] The HIV/AIDS subepidemics not only
vary by region and community but also may vary by population, risk
behavior, and geography. Elimination of disparities in the rate of
infection among certain racial and ethnic groups, particularly African
American and Hispanic populations, remains a challenge. Recently
introduced therapies for HIV/AIDS have reduced illness, disability, and
death due to HIV/AIDS; however, access to culturally and linguistically
appropriate testing and care may limit progress in this area.

In the United States, HIV/AIDS remains a significant cause of illness,
disability, and death, despite declines in 1996 and 1997.[^5]**^,^**
[^6] Current surveillance provides population-based HIV/AIDS data for
tracking trends in the epidemic, targeting and allocating resources for
prevention and treatment services, and planning and conducting program
evaluation activities. Since the early 1980s, surveillance studies have
identified four distinct populations and issues that have affected the
epidemic in these populations:

-   Men who have sex with men, facilitated by frequent changes of sex
    partners in highly infected sexual networks and by high-risk sexual
    practices.

-   Injection drug users, facilitated by the shared use of needles and\
    syringes contaminated with HIV-infected blood.

-   Heterosexual persons (principally in certain racial and ethnic
    populations), facilitated by (1) a high rate of HIV among drug-using
    populations that resulted in heterosexual transmission to some
    partners, (2) high rates of other sexually transmitted diseases
    (STDs) that can increase both susceptibility to and transmissibility
    of HIV infection, (3) high-risk sexual practices (mainly unprotected
    sex) associated with certain addictive substances, such as crack
    cocaine, and (4) sex in\
    exchange for drugs.

-   Perinatal transmission among infants, caused by undetected or\
    untreated HIV infection in pregnant females (although the number of
    perinatally infected infants has declined dramatically since the
    mid-1990s to a point where elimination of perinatal transmission in
    the United States may be possible).

The proportion of different population groups affected by HIV/AIDS has
changed over time. By 1998, 83 percent of the cumulative AIDS cases had
occurred in males, 16 percent in females, and 1 percent in
children.Error: Reference source not found The response to the epidemic
reflects these changes:

-   Comparing the 1980s to the 1990s, the proportion of AIDS cases in
    white men who have sex with men declined, whereas the proportion in
    females and males in other racial and ethnic populations increased,
    particularly among African Americans and Hispanics (see Disparities
    section). AIDS cases also appeared to be increasing among injection
    drug users and their sexual partners.Error: Reference source not
    found

-   Increases among women have occurred over time. By the mid-1980s, the
    majority of AIDS cases had been reported among males, with only 7
    percent reported among females in 1983.[^7] Reported AIDS cases in
    females have increased steadily since then and accounted for nearly
    23 percent of the cases reported in 1998.Error: Reference source not
    found

-   Monitoring and tracking of the current HIV/AIDS epidemic remains a
    challenge. Even though AIDS may occur much later than infection with
    HIV, only AIDS cases are currently reported by all State health
    departments. Because tracking HIV is more accurate for tracking the
    status of the epidemic and because States are making progress in
    reporting HIV infection, it is anticipated that key baseline data
    about HIV will be available by the early 2000s.Error: Reference
    source not found

-   Although a test for HIV was developed and made widely available in
    the early to mid-1980s, the lack of available treatment until 1995,
    negative implications of treatment (including concerns about lack of
    confidentiality), and possible discrimination and stigmatization\
    resulted in barriers to the reporting of HIV infection.

The lifetime costs of health care associated with HIV, in light of
recent advances in diagnostics and therapeutics, have grown from
\$55,000 to \$155,000 or more per person.[^8] These costs mean that HIV
prevention efforts may be even more cost-effective and even cost-saving
to society. Prevention efforts include availability of culturally and
linguistically appropriate HIV counseling and testing, partner
counseling, and referral systems for individuals at high risk for HIV
infection; needle and syringe exchange programs; and information,
education, treatment and counseling for injection drug
users.![](media/image2.wmf){width="4.502083333333333in"
height="7.478472222222222in"}

The true extent of the epidemic remains difficult to assess for several
reasons, including the following:

-   Because of the long period of time from initial HIV infection to
    AIDS and because highly active antiretroviral therapy (HAART) has
    slowed the progression to AIDS, new cases of AIDS no longer provide\
    accurate information about the current HIV epidemic in the United
    States.Error: Reference source not found

-   Because of a lack of awareness of HIV serostatus as well as delays
    in accessing counseling, testing, and care services by individuals
    who may be infected or are at risk of infection, some populations do
    not perceive themselves to be at risk. As a result, some
    HIV-infected\
    persons are not identified and provided care until late in the
    course of their infection.[^9]

### Trends

HIV infection rates appear to have stabilized since the early 1990s at
about 40,000 new infections per year, which represents a slowing from
growth rates experienced in the mid-1980s.[^10] At least 800,000 persons
are estimated to be infected with HIV, with over 200,000 to 250,000
persons who are not aware of their infection.[^11] About 335,000 persons
are estimated to be in treatment with new antiretroviral treatment
therapies, and another 215,000 are not currently in treatment.Error:
Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,^** [^12]

Significant changes in the epidemic have occurred over time. In 1992,
AIDS became a leading cause of death among persons aged 25 to 44 years,
but by 1997 had dropped to the eighth leading cause of death in this age
group. In 1997, however, HIV/AIDS remained the leading cause of death
only for African Americans among persons in this age group.[^13]**^,^**
[^14] Between 1992 and 1997, the number of persons reported living with
AIDS increased in all groups as a result of the 1993 expanded AIDS case
definition and, more recently, improved survival rates due to new HAART
treatment.

Some of these changes are reflected in the following:

-   Women accounted for just under 14 percent of persons over age 13
    years living with AIDS in 1992, compared with 20 percent in
    1998.Error: Reference source not found**^,^** [^15]

-   By the end of 1998, the number of African Americans living with
    AIDS, which increased from 33 percent of the AIDS population in 1992
    to 40 percent in 1998, was almost identical to the number of whites
    living with AIDS.Error: Reference source not found

-   Persons living in the South accounted for 34 percent of AIDS cases\
    in 1992 and 39 percent in 1998. Persons living in the Northeast\
    accounted for 28 percent in 1992 and 31 percent in 1998. The
    proportion living in the West declined from 24 percent to 21
    percent.Error: Reference source not found**^,^** [^16]

-   By December 1998, approximately 297,136 persons were reported to be
    living with AIDS, compared with 269,775 in 1997.Error: Reference
    source not found**^,\ 5^**

In late 1982, cases of AIDS attributed to blood transfusions were first
reported in the United States.[^17]**^,^** [^18] The publication,
dissemination, and implementation of specific guidelines and
recommendations to prevent HIV infection among health care workers and
to test donated blood for HIV[^19]**^,^** [^20]**^,^** [^21]**^,^**
[^22] have resulted in a reduction in transfusion-related AIDS and
increases in safety among health workers.

Another prevention success has been the 66 percent decline in perinatal
transmission from 1992 to 1997.[^23] With the finding that perinatal HIV
transmission rates could be reduced substantially with zidovudine
therapy during pregnancy, the U.S. Public Health Service issued
guidelines recommending that HIV counseling and voluntary testing become
a part of routine prenatal care for all pregnant women.Error: Reference
source not found This policy ensures that HIV-infected pregnant women
have access to important health care for themselves and also have the
opportunity to reduce the risk of HIV transmission to their infants.
Subsequent declines in new cases of AIDS among children demonstrate that
these strategies are showing success in reducing mother-to-infant HIV
transmission.[^24]**^,^** [^25]

However, initial declines in deaths from AIDS after the availability of
treatments have slowed. Deaths from AIDS continued to decline throughout
1997 and 1998 (down 42 percent and 20 percent, respectively, compared to
1996), and the number of persons living with AIDS (AIDS prevalence) in
1997 and 1998 increased by 12 percent and 10 percent,
respectively.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** If declines continue
in newly diagnosed AIDS cases in the coming years, an increasing number
of persons will be living with HIV infection. As HIV surveillance
extends to additional States, so will the ability to monitor HIV cases
and to direct prevention and treatment services to people with
asymptomatic infection or mild illness.

**Principal health determinants.** Behaviors (sexual practices,
substance abuse, and accessing prenatal care) and biomedical status
(having other STDs) are major determinants of HIV transmission.
Unprotected sexual contact, whether homosexual or heterosexual, with a
person infected with HIV and sharing drug-injection equipment with an
HIV-infected individual account for most HIV transmission in the United
States.[^26]**^,^** [^27] Increasing the number of people who know their
HIV serostatus is an important component of a national program to slow
or halt the transmission of HIV in the United States.

For persons infected with HIV, behavioral determinants also play an
important role in health maintenance. Although drugs are available
specifically to prevent and treat a number of opportunistic infections,
HIV-infected individuals also need to make lifestyle-related behavioral
changes to avoid many of these infections. The new HIV antiretroviral
drug therapies for HIV infection bring with them difficulties in
adhering to complex, expensive, and demanding medication schedules,
posing a significant challenge for many persons infected with HIV.

Because HIV infection weakens the immune system, people with
tuberculosis (TB) infection and HIV infection are at very high risk of
developing active TB disease.[^28]

**Interventions.** Interventions for combating HIV are behavioral as
well as biomedical. Recent advances in antiretroviral therapy have been
credited with dramatic declines in deaths associated with HIV/AIDS.
However, declines in overall AIDS cases, particularly in the early
epicenters of the epidemic such as San Francisco and New York City,
predate the advent of antiretroviral therapies and support the belief
that behavior-based prevention programs are effective. In San Francisco,
for example, new cases of AIDS among men who have sex with men began
dropping in 1992, suggesting that sustained, comprehensive prevention
activities begun in the 1980s succeeded in reducing HIV transmission in
this group.[^29]

Behavioral interventions to prevent HIV vary depending on the audience
for whom the program is designed, who designed it, and funds available.
Effective community-level prevention strategies in the United States
have included social marketing interventions to increase condom use and
messages about safer sex and needle-sharing that rely on popular opinion
leaders and role model stories. Effective small and large group
interventions have aimed at increasing safer sex practices for high-risk
HIV-infected men and women and have tended to employ cognitive
behavioral and skill-building methods.Error: Reference source not found

Several effective individual counseling or education interventions have
focused on increasing condom use and other safer sex practices for
HIV-infected persons. For example, at the individual level,
client-centered HIV counseling and testing appear to be effective in
preventing high-risk uninfected persons from becoming infected and in
helping HIV-infected persons prevent transmission to uninfected
partners. Intervention venues vary and include STD clinic waiting rooms,
drug treatment centers, schools, community agencies, street settings,
and community settings where HIV-infected and high-risk uninfected
persons congregate.Error: Reference source not found

While HIV testing in STD clinics is an important intervention, detection
and treatment of other STDs are also an important biomedical component
of an HIV prevention program that should include both behavioral and
biomedical interventions. STD prevention programs must address STD
concerns and their cofactor role in HIV transmission. Early STD
detection and treatment are a biomedical tool for lowering the risk for
sexual transmission of HIV infection. Behavioral interventions emphasize
reducing the number of sex partners, knowing the serostatus of one's
partner, using condoms consistently and correctly, and avoiding risky
sexual behaviors.Error: Reference source not found**^,^** [^30]**^,^**
[^31]

### Disparities

In the United States, African Americans and Hispanics have been affected
disproportionately by HIV and AIDS, compared to other racial and ethnic
groups. Through December 1998, 688,200 cases of AIDS had been reported
among persons of all ages and racial and ethnic groups, including
304,094 cases among whites, 251,408 cases among African Americans, and
124,841 cases among Hispanics. Although 55 percent of the reported AIDS
cases occurred among African Americans and Hispanics, these two
population groups represent an estimated 13 percent and 12 percent,
respectively, of the total U.S. population.Error: Reference source not
found

In 1997, AIDS remained the leading cause of death for all African
Americans aged 25 to 44 years---the second leading cause among African
American females and the leading cause among African American
males.Error: Reference source not found In 1996, for the first time,
African Americans accounted for a larger proportion of AIDS cases than
whites, and this trend has continued. The AIDS case rate among African
Americans in calendar year 1998 was 66.4 per 100,000 persons, or eight
times the rate for whites (8.2 per 100,000) and over twice the rate for
Hispanics (28.1 per 100,000).Error: Reference source not found

Among women with AIDS, African Americans and Hispanics have been
especially affected, accounting for nearly 77 percent of cumulative
cases reported among women by 1998. Of the 109,311 AIDS cases in women
reported through December 1998, 61,874 cases occurred in African
American women and 21,937 occurred in Hispanic women.Error: Reference
source not found

For young adults aged 20 to 24 years, 24,437 cumulative AIDS cases were
reported through December 1998. Of this total, 10,107 (41 percent)
occurred among African Americans, 8,804 (36 percent) among whites, and
5,203 (21 percent) among Hispanics. Overall, 73 percent (17,797) of the
AIDS cases in this age group occurred among males and 27 (6,640) percent
among females. Among African Americans in this age group, 63 percent
were male, and 37 percent were female. Among Hispanics, 74 percent were
male, and 26 percent were female. Because the time from initial
infection with HIV to the development of AIDS is long and variable
(often 8 to 10 years or more), many of these young adults likely
acquired their infections while in their teens.Error: Reference source
not found

Among teenagers aged 13 to 19 years, 3,423 cumulative AIDS cases had
been reported through December 1998.Error: Reference source not found In
this age group, 1,047 cases (31 percent) occurred among whites, 1,654
(48 percent) among African Americans, and 668 (20 percent) among
Hispanics. Overall, males accounted for 61 percent of the AIDS cases in
this age group, and females accounted for 39 percent. Among African
American teenagers with AIDS, 46 percent were male, and 54 percent were
female. Among Hispanic teens, 67 percent of those with AIDS were male,
and 33 percent were female. Among white teenagers with AIDS, 79 percent
were male, and 21 percent were female.Error: Reference source not found

The disproportionate impact of HIV/AIDS on African Americans and
Hispanics underscores the importance of implementing and sustaining
effective prevention efforts for these racial and ethnic populations.
HIV prevention efforts must take into account not only the multiracial
and multicultural nature of society, but also other social and economic
factors---such as poverty, underemployment, and poor access to the
health care system. These factors affect health status and
disproportionately affect African American, Hispanic, Alaska Native, and
American Indian populations.

### Opportunities

In the 21st century, strategies for reducing HIV transmission will
continue to evolve and will require shifts from current efforts.[^32]
Future strategies should focus on:

-   Continuing to address the disproportionate impact of HIV/AIDS among
    certain racial and ethnic groups.

-   Enhancing prevention strategies for populations that are
    particularly high risk, such as injection drug users, homeless
    persons, runaway youth, mentally ill persons, and incarcerated
    persons. Some of these populations are also difficult to reach.

-   Increasing the number of people who learn their HIV status in order
    to detect HIV infection when the potential for transmission is
    greatest and the need for prevention, care, and treatment, including
    HAART, is greatest.

-   Reaching high-risk seronegative people to help them to stay
    uninfected.

-   Improving access to HAART, thereby reducing deaths and
    HIV-associated illness and, possibly, infection of others.

-   Increasing efforts and opportunities to provide counseling to
    prevent transmission and reinfection for all HIV-infected
    individuals who are receiving medical and supportive care.

-   Detecting and treating ulcerative and inflammatory STDs, especially
    in groups at risk for HIV infection.

-   Setting the discovery of a safe and effective HIV vaccine as a
    reachable goal, as a result of ongoing HIV vaccine testing. The
    development and testing of candidate microbicides may be important
    in enhancing prevention efforts until a vaccine is available.

## Interim Progress Toward Year 2000 Objectives

Data to assess progress are available for 13 of the 17 Healthy People
2000 HIV objectives. Two objectives have met or exceeded the year 2000
targets. The objective to lower the risk of transfusion-transmitted HIV
infection exceeded its target, and the objective to protect workers from
exposure to bloodborne infections was met with the Occupational Safety
and Health Administration's bloodborne pathogens standard in December
1991. Data show progress toward the year 2000 targets for objectives to
slow the rise in the rate of new AIDS cases, contain the rate of HIV
infection, and increase the proportion of sexually active females whose
partners used condoms at last sexual intercourse. The objective to
increase the proportion of HIV-positive people who know their serostatus
is moving away from its target, as are objectives for counseling,
outreach, and school-based AIDS education.

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### HIV {#hiv-1 .Heading-Special-Sub}

**Goal:** Prevent HIV infection and its related illness and death.

  ------------ --------------------------------------------------------------
  **Number**   **Objective Short Title**

  13-1         New AIDS cases

  13-2         AIDS among men who have sex with men

  13-3         AIDS among persons who inject drugs

  13-4         AIDS among men who have sex with men and who inject drugs

  13-5         New HIV cases

  13-6         Condom use

  13-7         Knowledge of serostatus

  13-8         HIV counseling and education for persons in substance abuse\
               treatment

  13-9         HIV/AIDS, STD, and TB education in State prisons

  13-10        HIV counseling and testing in State prisons

  13-11        HIV testing in TB patients

  13-12        Screening for STDs and immunization for hepatitis B

  13-13        Treatment according to guidelines

  13-14        HIV-infection deaths

  13-15        Interval between HIV infection and AIDS diagnosis

  13-16        Interval between AIDS diagnosis and death from AIDS

  13-17        Perinatally acquired HIV infection
  ------------ --------------------------------------------------------------

## Healthy People 2010 Objectives

13-1. Reduce AIDS among adolescents and adults.

**Target:** 1.0 new case per 100,000 persons.

**Baseline:** 19.5 cases of AIDS per 100,000 persons aged 13 years and
older\
in 1998. Data are estimated; adjusted for delays in reporting.

**Target setting method:** Better than the best.

**Data source:** HIV/AIDS Surveillance System, CDC, NCHSTP.

+--------------------------------+------------+------------+-----------+
| **Persons Aged 13 Years and    | **New AIDS |            |           |
| Older, 1998**                  | Cases**    |            |           |
+================================+============+============+===========+
|                                | **13-1.\   | **F        | **        |
|                                | Both\      | emales\*** | Males\*** |
|                                | Genders**  |            |           |
+--------------------------------+------------+------------+-----------+
|                                | Rate per   |            |           |
|                                | 100,000    |            |           |
+--------------------------------+------------+------------+-----------+
| > **TOTAL**                    | 19.5       | 8.8        | 30.8      |
+--------------------------------+------------+------------+-----------+
| **Race and ethnicity**         |            |            |           |
+--------------------------------+------------+------------+-----------+
| > American Indian or Alaska    | 9.4        | 4.5        | 14.5      |
| > Native                       |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Asian or Pacific Islander    | 4.3        | 1.2        | 7.8       |
+--------------------------------+------------+------------+-----------+
| > Asian                        | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > Native Hawaiian and other\   | DNC        | DNC        | DNC       |
| > Pacific Islander             |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Black or African American    | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > White                        | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
|                                |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Hispanic or Latino           | 33.0       | 13.8       | 52.2      |
+--------------------------------+------------+------------+-----------+
| > Not Hispanic or Latino       | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > Black or African American    | 82.9       | 48.5       | 122.9     |
+--------------------------------+------------+------------+-----------+
| > White                        | 8.5        | 2.2        | 15.2      |
+--------------------------------+------------+------------+-----------+
| **Family income level**        |            |            |           |
+--------------------------------+------------+------------+-----------+
| > Poor                         | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > Near poor                    | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| > Middle/high income           | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+
| ###### Sexual orientation      | DNC        | DNC        | DNC       |
+--------------------------------+------------+------------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for females and males are displayed to further characterize the
issue.

Historically, AIDS incidence data have served as the basis for assessing
needs for prevention and treatment programs. However, because of the
effect of potent antiretroviral therapies, AIDS incidence no longer can
provide unbiased information on HIV incidence patterns; it is hoped that
AIDS will not develop in the growing number of HIV-infected persons as
they benefit from these new therapies. Persons reported with AIDS will
increasingly represent persons who were diagnosed too late for them to
benefit from treatments, persons who either did not seek or had no
access to care, or persons who failed treatment. This objective will be
modified to track HIV cases as additional States implement HIV
surveillance programs as an extension of their current AIDS case
surveillance systems.

13-2. Reduce the number of new AIDS cases among adolescent and adult men
who have sex with men.

**Target:** 13,385 new cases.

**Baseline:** 17,847 new cases of AIDS in 1998 among males aged 13 years
and older. Data are estimated; risk is redistributed; adjusted for
delays in reporting.

**Target setting method:** 25 percent improvement.

**Data source:** HIV/AIDS Surveillance System, CDC, NCHSTP.

In 1998, an estimated 17,847 AIDS cases were diagnosed among men having
sex with men. This was a decrease from 1997 and part of a continuing
trend. The decline is a result of prevention activities and the impact
of and access to potent antiretroviral therapies that are delaying
progression to AIDS in many HIV-infected individuals.

However, men who have sex with men (MSM) remains a population at risk
for HIV infection, and continued efforts to promote behavioral risk
reduction among at-risk youth are needed. Prevention programs for
adolescent and adult MSM need to focus on both HIV-infected and
uninfected populations. Challenges to HIV prevention programs for MSM
include (1) reaching MSM who may not identify themselves as homosexual
or bisexual, (2) representing MSM from certain racial and ethnic groups
in HIV prevention planning, (3) increasing knowledge about HIV risk, and
(4) improving access to HIV testing and health care.[^33] Serologic
surveys, HIV/AIDS case surveillance, and supplemental research and
evaluation studies of MSM from certain racial and ethnic groups and
other HIV-infected and at-risk populations also are needed to target
intervention programs.**^4^** This objective will be modified when
additional States implement HIV infection surveillance as an extension
of their current AIDS case surveillance systems.

13-3. Reduce the number of new AIDS cases among females and males who
inject drugs.

**Target:** 9,075 cases.

**Baseline:** 12,099 new cases of AIDS among injection drug users aged
13 years and older (females, 3,667; males, 8,432) in 1998. Data are
point estimates; risk redistributed; adjusted for delays in reporting.

**Target setting method:** 25 percent improvement.

**Data source:** HIV/AIDS Surveillance System, CDC, NCHSTP.

In 1998, an estimated 12,099 cases were diagnosed among adult men and
women who injected drugs. This was a decrease from the previous year and
part of a continuing trend. The decline is a result of prevention
activities and the impact of potent antiretroviral therapies that are
delaying progression to AIDS in many HIV-infected individuals.

Prevention measures for reducing the occurrence of AIDS associated with
injection drug users (IDUs) included: (1) preventing the initiation of
injecting-drug use, (2) increasing the number of IDUs in drug treatment,
(3) encouraging safer injecting practices among IDUs, and (4) promoting
safer sexual behavior among IDUs and their sex partners.[^34]**^,^**
[^35]**^,^** [^36] Persons who continue to inject drugs should be
screened periodically for HIV infection and advised of measures that may
reduce risks for infection.

13-4. Reduce the number of new AIDS cases among adolescent and adult men
who have sex with men and inject drugs.

**Target:** 1,592 cases.

**Baseline:** 2,122 new cases of AIDS among males aged 13 years and
older in 1998. Data are point estimates; risk redistributed; adjusted
for delays in reporting.

**Target setting method:** 25 percent improvement.

**Data source:** HIV/AIDS Surveillance System, CDC, NCHSTP.

In 1998, an estimated 2,122 AIDS cases were diagnosed among adult and
adolescent men who have sex with men and who inject drugs. This was a
decrease from 1997 and part of a continuing trend. The decline is a
result of prevention activities and the impact of potent antiretroviral
therapies which are delaying progression to AIDS in many HIV-infected
individuals.

Prevention programs for adolescent and adult MSM and IDUs need to focus
on both HIV-infected and uninfected populations. Challenges to the
design and implementation of HIV prevention programs among MSM and IDUs
include: (1) reaching MSM who may not identify themselves as homosexual
or bisexual, (2) representing MSM from certain racial and ethnic groups
in HIV prevention planning, (3) increasing knowledge about HIV risk, (4)
improving access to HIV testing and health care, (5) preventing the
initiation of injecting-drug use, (6) increasing the number of IDUs in
drug treatment, (7) encouraging safer injecting practices among IDUs,
and (8) promoting safer sexual behaviors among IDUs and their sex
partners.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found^**
This objective will be modified when additional States implement HIV
infection surveillance as an extension of their current AIDS case
surveillance systems.

13-5. (Developmental) Reduce the number of cases of HIV\
infection among adolescents and adults.

**Potential data source:** HIV/AIDS Surveillance System, CDC, NCHSTP.

Recent advances in HIV treatment have slowed the progression of HIV
disease for infected persons on treatment and contributed to a decline
in AIDS incidence. These advances in treatment have diminished the
ability of AIDS surveillance data to represent trends in HIV incidence
or to represent the impact of the epidemic on the health care system.
Once HIV case surveillance is implemented nationwide by 2001, the
Centers for Disease Control and Prevention (CDC) will be able to report
baseline data and progress toward the objective of "reducing the annual
incidence of HIV infection."

13-6. Increase the proportion of sexually active persons who use
condoms.

**Target and baseline:**

+----------+-----------------------------------+-----------+---------+
| O        | Increase in Sexually Active       | 1995\     | 2010\   |
| bjective | Persons\                          | Baseline  | Target  |
|          | Using Condoms                     |           |         |
+----------+-----------------------------------+-----------+---------+
|          |                                   | ######    |         |
|          |                                   | # Percent |         |
+----------+-----------------------------------+-----------+---------+
| **       | Females aged 18 to 44 years       | 23        | 50      |
| 13-6a.** |                                   |           |         |
+----------+-----------------------------------+-----------+---------+
| **       | Males aged 18 to 49 years         | Deve      |         |
| 13-6b.** |                                   | lopmental |         |
+----------+-----------------------------------+-----------+---------+

**Target setting method:** Better than the best.

**Data source:** National Survey of Family Growth (NSFG), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------+---------------------------+
| **Unmarried Females 18 to 44 years,      | **13-6a.\                 |
| 1995**                                   | Reported Condom\          |
|                                          | Use by Partners\***       |
+==========================================+===========================+
|                                          | Percent                   |
+------------------------------------------+---------------------------+
| **TOTAL**                                | 23                        |
+------------------------------------------+---------------------------+
| **Race and ethnicity**                   |                           |
+------------------------------------------+---------------------------+
| > American Indian or Alaska Native       | DSU                       |
+------------------------------------------+---------------------------+
| > Asian or Pacific Islander              | DSU                       |
+------------------------------------------+---------------------------+
| > Asian                                  | DNC                       |
+------------------------------------------+---------------------------+
| > Native Hawaiian and other Pacific      | DNC                       |
| > Islander                               |                           |
+------------------------------------------+---------------------------+
| > Black or African American              | 22                        |
+------------------------------------------+---------------------------+
| > White                                  | 23                        |
+------------------------------------------+---------------------------+
|                                          |                           |
+------------------------------------------+---------------------------+
| > Hispanic or Latino                     | 17                        |
+------------------------------------------+---------------------------+
| > Aged 18 to 19 years                    | 16                        |
+------------------------------------------+---------------------------+
| > Aged 20 to 24 years                    | 18                        |
+------------------------------------------+---------------------------+
| > Aged 25 to 29 years                    | 19                        |
+------------------------------------------+---------------------------+
| > Aged 30 to 34 years                    | 22                        |
+------------------------------------------+---------------------------+
| > Aged 35 to 44 years                    | 9                         |
+------------------------------------------+---------------------------+
| > Not Hispanic or Latino                 | 24                        |
+------------------------------------------+---------------------------+
| > Black or African American              | 22                        |
+------------------------------------------+---------------------------+
| > Aged 18 to 19 years                    | 31                        |
+------------------------------------------+---------------------------+
| > Aged 20 to 24 years                    | 35                        |
+------------------------------------------+---------------------------+
| > Aged 25 to 29 years                    | 23                        |
+------------------------------------------+---------------------------+
| > Aged 30 to 34 years                    | 17                        |
+------------------------------------------+---------------------------+
| > Aged 35 to 44 years                    | 12                        |
+------------------------------------------+---------------------------+
| > White                                  | 24                        |
+------------------------------------------+---------------------------+
| Aged 18 to 19 years                      | 39                        |
+------------------------------------------+---------------------------+
| Aged 20 to 24 years                      | 29                        |
+------------------------------------------+---------------------------+
| Aged 25 to 29 years                      | 24                        |
+------------------------------------------+---------------------------+
| Aged 30 to 34 years                      | 14                        |
+------------------------------------------+---------------------------+
| Aged 35 to 44 years                      | 18                        |
+------------------------------------------+---------------------------+
| **Family income level**                  |                           |
+------------------------------------------+---------------------------+
| > Poor                                   | 16                        |
+------------------------------------------+---------------------------+
| > Near poor                              | 21                        |
+------------------------------------------+---------------------------+
| > Middle/high income                     | 27                        |
+------------------------------------------+---------------------------+
| **Education level** (aged 25 to 44       |                           |
| years)                                   |                           |
+------------------------------------------+---------------------------+
| > Less than high school                  | 7                         |
+------------------------------------------+---------------------------+
| > High school                            | 15                        |
+------------------------------------------+---------------------------+
| > At least some college                  | 25                        |
+------------------------------------------+---------------------------+
| **Geographic location**                  |                           |
+------------------------------------------+---------------------------+
| > Urban                                  | 24                        |
+------------------------------------------+---------------------------+
| > Rural                                  | 18                        |
+------------------------------------------+---------------------------+
| ###### Sexual orientation                | DNC                       |
+------------------------------------------+---------------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for both genders and for males currently are not collected.

Note: The table above may have continued from the previous page.

When used consistently and correctly, latex condoms are highly effective
in preventing HIV transmission. Increased use of latex condoms is
essential for slowing the spread of HIV infection. Carefully designed
studies among heterosexual couples in which one partner is HIV positive
and the other is not demonstrate that latex condoms provide a high level
of protection against HIV.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^**

Persons in some populations, especially sexually active young persons,
may experience problems in obtaining access to condoms because of
several factors, including cost, convenience, and
embarrassment.[^37]**^,^** [^38] The lack of readily accessible condoms
may also be a significant barrier to consistent use. To eliminate this
barrier, many local communities actively support programs that make
condoms available to populations most vulnerable to HIV infection,
including sexually active young persons.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** Research shows that
providing access to condoms can increase their use among sexually active
young persons.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** Research also
clearly demonstrates that---despite fears to the contrary---young
persons who participate in comprehensive HIV prevention programs that
include approaches to ensure access to condoms are no more likely to
initiate or increase sexual activity than other young persons.Error:
Reference source not found**^,\ Error:\ Reference\ source\ not\ found^**

In addition to access, the correct and consistent use of condoms is an
issue for many young females, some of whom are having intercourse with
older males. Young females often are limited by intimidation or threats
of mistrust by their partners if they suggest condom use.Error:
Reference source not found Knowledge of effective negotiating skills is
another critical element of increased condom use.Error: Reference source
not found

13-7. (Developmental) Increase the number of HIV-positive\
persons who know their serostatus.

**Potential data source:** HIV/AIDS Surveillance System, CDC, NCHSTP.

Advances in HIV prevention and treatment increase the importance of
persons learning their HIV status.Error: Reference source not found
Estimates are that approximately 250,000 persons in the United States
are unaware they were infected with HIV in 1998.Error: Reference source
not found HIV testing provides a critical avenue to reach persons at
risk with prevention counseling and services as well as to link infected
individuals with needed care and treatment services. Clearly, infected
persons should be counseled about ways they can protect their own health
and keep from infecting others. New treatments offer infected persons
the promise of a longer, healthier life. For HIV-infected pregnant
females, therapy is available to reduce the chance of transmitting HIV
to their babies. Although the evidence still is not entirely clear,
persons who are being treated successfully for HIV may be less likely to
transmit the virus. Because the science is evolving, communicating the
continuing need for infected persons, even those in treatment, to take
steps to protect their partners is essential.Error: Reference source not
found

13-8. Increase the proportion of substance abuse treatment\
facilities that offer HIV/AIDS education, counseling, and support.

**Target:** 70 percent.

**Baseline:** 58 percent of substance abuse treatment facilities offered
HIV/AIDS education, counseling, and support in 1997.

**Target setting method:** 21 percent improvement.

**Data source:** Uniform Facility Data Set (UFDS), SAMHSA.

To date, more than one-third of all reported AIDS cases in the United
States have occurred among injection drug users, their heterosexual sex
partners, and children whose mothers were injection drug users or sex
partners of injection drug users.Error: Reference source not found

Preventing drug use and providing treatment to stop drug use among
persons already using drugs are the best ways to prevent drug-associated
transmission of HIV. Among persons who inject drugs, reusing or sharing
blood-contaminated injection equipment (particularly syringes) continues
to play a substantial role in HIV transmission, as well as the
transmission of hepatitis B and C and other bloodborne infections.Error:
Reference source not found

Needle and syringe exchange programs (NSEPs) can be an effective
component of comprehensive community‑based HIV prevention efforts.Error:
Reference source not found Additionally, NSEPs can provide a pathway for
linking injection drug users to other important services, such as
risk-reduction counseling, drug treatment, and support services.

13-9. (Developmental) Increase the number of State prison\
systems that provide comprehensive HIV/AIDS, sexually transmitted
diseases, and tuberculosis (TB) education.

**Potential data source:** Survey of HIV, STD, and TB Prevention in
Correctional Facilities, CDC/National Institute of Justice.

Incarceration provides an environment in which early interventions and
risk-reduction behaviors can be taught and reinforced over time. It also
represents an opportunity to provide the education, support, and
continuity of care needed when incarcerated persons are released and
return to their home communities.

13-10. (Developmental) Increase the proportion of inmates\
in State prison systems who receive voluntary HIV\
counseling and testing during incarceration.

**Potential data source:** Survey of HIV, STD, and TB Prevention in
Correctional Facilities, CDC and National Institute of Justice.

Although not standardized, State prison systems can provide access to
treatment and care for persons infected with HIV. Early access to care
reduces both immediate and long-term health care costs for correctional
institutions and the community. This objective focuses on State systems
because, in accordance with the Federal Bureau of Prisons guidance, all
Federal correctional facilities are required to provide HIV testing to
all inmates at some time prior to discharge.[^39] Continuing this
practice is important. It is also important to provide HIV testing to
inmates upon intake to allow for sufficient medical care and necessary
followup. In addition, discharge planning and formal linkages with
community-based HIV care should be offered to all HIV-positive inmates
just prior to or upon release.

13-11. Increase the proportion of adults with tuberculosis (TB) who have
been tested for HIV.

**Target:** 85 percent.

**Baseline:** 55 percent of adults aged 25 to 44 years with TB were
tested for HIV\
in 1998.

**Target setting method:** Better than the best.

**Data source:** National TB Surveillance System, CDC, DTBE.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Adults Aged 25 to 44 Years With TB, 1998**   | **Tested for HIV**  |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 55                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 39                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 29                  |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 76                  |
+------------------------------------------------+---------------------+
| > White                                        | 50                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 46                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 58                  |
+------------------------------------------------+---------------------+
| > Black or African American                    | 76                  |
+------------------------------------------------+---------------------+
| > White                                        | 58                  |
+------------------------------------------------+---------------------+
| ###### Gender                                  |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 51                  |
+------------------------------------------------+---------------------+
| > Male                                         | 58                  |
+------------------------------------------------+---------------------+
| ###### Family income level                     |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The rapid rate of progression from infection with TB bacteria to active
TB disease among HIV-positive patients with *Mycobacterium tuberculosis*
has been well documented.[^40]**^,^** [^41] When State health
departments compared their TB and AIDS registries, 27 percent of the TB
cases reported in 1993--94 in adults aged 25 to 44 years had a match in
the AIDS registry. However, estimates based on registry matches provide
only a minimum estimate of coinfection.Error: Reference source not found

Early detection of HIV in TB patients also allows for early intervention
and treatment that may prevent or delay the development of other
HIV-related illnesses and AIDS. It is possible that many persons
diagnosed with TB have immune system problems caused by HIV and are
unaware of their HIV status. In 1998, 55 percent of TB case reports for
persons aged 15 to 44 years included information about HIV status. Among
the States with information for 75 percent or more of the cases in this
age group, the proportion of TB cases in HIV-infected patients ranged
from 0 to 47 percent.[^42] Because testing is voluntary, some patients
may decline HIV testing.

13-12. (Developmental) Increase the proportion of adults in\
publicly funded HIV counseling and testing sites who are screened for
common bacterial sexually transmitted\
diseases (STDs) (chlamydia, gonorrhea, and syphilis) and are immunized
against hepatitis B virus.

**Potential data source:** HIV Counseling and Testing Data System (CTS),
CDC, NCHSTP.

Data indicate that the presence of other STDs substantially increases
the risk of HIV transmission by making it easier both to get and to give
HIV infection.Error: Reference source not found**^,^** [^43] Treating
other STDs reduces the spread of HIV. STD rates in the United States are
high, and STD clinical services are inadequate in the face of a changing
HIV epidemic.[^44]

STD vaccines can minimize the probability of infection. While vaccines
for some STDs are in various stages of development, an effective vaccine
for hepatitis B is widely available. Unfortunately, hepatitis B vaccine
coverage remains low, especially in high-risk groups. The main reasons
are a lack of awareness among health care providers, limited opportunity
to reach high-risk youth in traditional health care settings, and
limited financial support for widescale implementation of this
intervention.[^45] Many persons requesting HIV counseling and testing,
although not HIV infected, are nonetheless at high risk for acquiring
sexually transmitted infections.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^** Offering hepatitis B
vaccine at sites screening for common STDs would take advantage of
reaching high-risk persons who otherwise may not have access to
immunization services.

13-13. Increase the proportion of HIV-infected adolescents and adults
who receive testing, treatment, and prophylaxis consistent with current
Public Health Service treatment guidelines.

Target and baseline:

+----------+-----------------------------------+-----------+---------+
| O        | Increase in HIV-Infected Persons  | 1997\     | 2010\   |
| bjective | Aged 13 Years and Older Receiving | Baseline  | Target  |
|          | Testing, Treatment, and           |           |         |
|          | Prophylaxis Consistent With       |           |         |
|          | Current Public Health Service\    |           |         |
|          | Guidelines                        |           |         |
+----------+-----------------------------------+-----------+---------+
|          |                                   | ######    |         |
|          |                                   | # Percent |         |
+----------+-----------------------------------+-----------+---------+
|          | **Testing**                       |           |         |
+----------+-----------------------------------+-----------+---------+
| **1      | Viral load testing                | Deve      |         |
| 3-13a.** |                                   | lopmental |         |
+----------+-----------------------------------+-----------+---------+
| **1      | Tuberculin skin testing (TST)     | Deve      |         |
| 3-13b.** |                                   | lopmental |         |
+----------+-----------------------------------+-----------+---------+
|          | **Treatment**                     |           |         |
+----------+-----------------------------------+-----------+---------+
| **1      | Any antiretroviral therapy        | 80        | 95      |
| 3-13c.** |                                   |           |         |
+----------+-----------------------------------+-----------+---------+
| **1      | Highly active antiretroviral      | 40        | 95      |
| 3-13d.** | therapy (HAART)                   |           |         |
+----------+-----------------------------------+-----------+---------+
|          | **Prophylaxis**                   | #######   |         |
+----------+-----------------------------------+-----------+---------+
| **1      | *Pneumocystis carinii* pneumonia  | 80        | 95      |
| 3-13e.** | (PCP) prophylaxis                 |           |         |
+----------+-----------------------------------+-----------+---------+
| **1      | *Mycobacterium avium* complex     | 44        | 95      |
| 3-13f.** | (MAC) prophylaxis                 |           |         |
+----------+-----------------------------------+-----------+---------+

Note: Data from 11 cities and 9 States.

**Target setting method:** An improvement to the same percentage as
that\
projected for *Pneumocystis carinii* pneumonia prophylaxis.

**Data source:** Adult Spectrum of Disease (ASD) Surveillance Project,
CDC, NCHSTP.

> **Data for population groups currently are not collected.**

Estimated new cases of AIDS in adults and adolescents declined by 15
percent from 1996 to 1997.[^46] As new therapies continue to be
developed and as people with HIV/AIDS live longer, HIV-infected persons
need access to these life-enhancing treatments. Once individuals access
care, they need to receive the most beneficial treatment possible. The
survival benefits of antiretroviral therapy, *Pneumocystis carinii*
pneumonia (PCP) and *Mycobacterium avium* complex (MAC) prophylaxis, and
TB prophylaxis have been demonstrated for persons with HIV/AIDS who meet
the criteria for these preventive therapies. (CD4+ testing is included
as a standard of care in the Public Health Service treatment guidelines
but is not included here because it already is provided to nearly 100
percent of individuals measured by this objective.)Error: Reference
source not found

Data from HIV and AIDS case surveillance continue to reflect the
disproportionate impact of the epidemic on select populations,
especially females, youth, and children. Everyone needs equal access to
appropriate care and treatment services necessary to maintain a healthy
life.

13-14. Reduce deaths from HIV infection.

**Target:** 0.7 deaths per 100,000 persons.

**Baseline:** 4.9 deaths from HIV infection per 100,000 persons in 1998
(age\
adjusted to the year 2000 population).

**Target setting method:** Better than the best.

**Data source:** National Vital Statistics System, CDC, NCHS.

Note: The table below may continue to the following page.

+---------------------------------+------------+-----------+-----------+
| **Total Population, 1998**      | **Deaths   |           |           |
|                                 | Due to HIV |           |           |
|                                 | I          |           |           |
|                                 | nfection** |           |           |
+=================================+============+===========+===========+
|                                 | **13-14.\  | **Fe      | **        |
|                                 | Both\      | males\*** | Males**\* |
|                                 | Genders**  |           |           |
+---------------------------------+------------+-----------+-----------+
|                                 | Rate per   |           |           |
|                                 | 100,000    |           |           |
+---------------------------------+------------+-----------+-----------+
| > **TOTAL**                     | 4.9        | 2.3       | 7.7       |
+---------------------------------+------------+-----------+-----------+
| **Race and ethnicity**          |            |           |           |
+---------------------------------+------------+-----------+-----------+
| > American Indian or Alaska     | 2.3        | DSU       | 4.0       |
| > Native                        |            |           |           |
+---------------------------------+------------+-----------+-----------+
| > Asian or Pacific Islander     | 0.8        | DSU       | 1.4       |
+---------------------------------+------------+-----------+-----------+
| > Asian                         | DNC        | DNC       | DNC       |
+---------------------------------+------------+-----------+-----------+
| > Native Hawaiian and other     | DNC        | DNC       | DNC       |
| > Pacific Islander              |            |           |           |
+---------------------------------+------------+-----------+-----------+
| > Black or African American     | 22.1       | 12.2      | 34.0      |
+---------------------------------+------------+-----------+-----------+
| > White                         | 2.7        | 0.8       | 4.6       |
+---------------------------------+------------+-----------+-----------+
|                                 |            |           |           |
+---------------------------------+------------+-----------+-----------+
| > Hispanic or Latino            | 6.7        | 2.8       | 10.7      |
+---------------------------------+------------+-----------+-----------+
| > Not Hispanic or Latino        | 4.7        | 2.2       | 7.3       |
+---------------------------------+------------+-----------+-----------+
| > Black or African American     | 22.8       | 12.6      | 35.1      |
+---------------------------------+------------+-----------+-----------+
| > White                         | 2.1        | 0.5       | 3.8       |
+---------------------------------+------------+-----------+-----------+
| **Education level** (aged 25 to |            |           |           |
| 64 years)                       |            |           |           |
+---------------------------------+------------+-----------+-----------+
| > Less than high school         | 17.3       | 10.6      | 23.4      |
+---------------------------------+------------+-----------+-----------+
| > High school graduate          | 11.7       | 5.6       | 18.3      |
+---------------------------------+------------+-----------+-----------+
| > At least some college         | 4.3        | 1.1       | 7.5       |
+---------------------------------+------------+-----------+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*Data for females and males are displayed to further characterize the
issue.

Note: The table above may have continued from the previous page.

The impact of new combination drug therapies first was reported in 1997
when deaths attributable to HIV infection were down 44 percent from the
first 6 months of 1996, compared with the first 6 months of 1997.Error:
Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,\ Error:\ Reference\ source\ not\ found,^**
[^47]**^,^** [^48] These surveillance data suggest that not only are new
therapies delaying progression from AIDS to death, but, with early
diagnosis and treatment, these therapies also are helping to delay the
progression from HIV infection to an AIDS diagnosis for many persons.

13-15. (Developmental) Extend the interval of time between an initial
diagnosis of HIV infection and AIDS diagnosis in\
order to increase years of life of an individual infected\
with HIV.

**Potential data source:** HIV/AIDS Surveillance System, CDC, NCHSTP.

This objective is meant to identify which populations are not benefiting
from current treatment therapies and where to direct resources.
HIV-infected persons should be identified at the earliest possible
opportunity and referred to appropriate medical, social, and preventive
services that may preserve their health, help them avoid opportunistic
illnesses, reduce sexual and drug-use behaviors that may spread HIV, and
generally extend the quality of their lives. For HIV-infected persons to
benefit from treatment advances, HIV counseling and testing programs
must facilitate an early diagnosis of HIV infection. All persons should
have equal access to appropriate care and treatment services necessary
for maintaining a healthy life.

13-16. (Developmental) Increase years of life of an HIV-infected person
by extending the interval of time between an AIDS diagnosis and death.

**Potential data source:** HIV/AIDS Surveillance System, CDC, NCHSTP.

This objective provides insight into which population groups lack or
fail to respond to treatment. To sustain reductions in deaths due to HIV
infection, access to treatment and care is necessary. Targeting
prevention efforts at groups disproportionately affected also is
important.

13-17. (Developmental) Reduce new cases of perinatally acquired HIV
infection.

**Potential data source:** HIV/AIDS Surveillance System, CDC, NCHSTP.

Perinatal transmission of HIV accounts for virtually all new HIV
infections in children. Through 1993, an estimated 15,000 HIV-infected
children were born to HIV-positive women in the United States. As of
June 1998, 8,280 AIDS cases had been reported in children under age 13
years in the United States. Perinatally acquired AIDS cases have been
reported from 48 States, the District of Columbia, Puerto Rico, and the
U.S. Virgin Islands.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found^**

The National Institutes of Health sponsored an AIDS clinical trial,
ACTG-076, after demonstrating that the risk of perinatal HIV
transmission could be reduced by as much as two-thirds with the use of
zidovudine therapy. This therapy was given to HIV-positive pregnant
females during pregnancy and childbirth and to their newborns for 6
weeks after birth.Error: Reference source not found Additional research
confirmed that routine and universal counseling and voluntary testing,
combined with zidovudine therapy, are highly effective in preventing
HIV.Error: Reference source not found In addition, recently completed
and ongoing research suggests that other antiretroviral agents also can
reduce significantly maternal-infant HIV transmission. These additional
therapeutic options should increase the opportunity to intervene to
reduce perinatal HIV transmission. Substantial declines in perinatal
AIDS cases have been reported. Estimated new cases of pediatric AIDS
declined from 947 in 1992 to 225 in 1998.Error: Reference source not
found

Even though these prevention efforts are proving to be effective in
reducing perinatal HIV transmission, the continued number of new cases
of perinatally acquired HIV infection among infants indicates an ongoing
risk of perinatal transmission and underscores the need for strategies
to ensure that HIV-infected females have access to and receive adequate
prenatal care, timely HIV counseling, and voluntary testing; gain access
to HIV-related care and services; receive chemoprophylaxis to reduce
perinatal transmission; and avoid breastfeeding. In 1998, the Institute
of Medicine (IOM) completed a study to assess the impact of current
approaches for reducing perinatal HIV transmission. IOM recommended that
the United States adopt a national policy of universal HIV testing, with
patient notification, as a routine component of prenatal care.[^49] The
U.S. Public Health Service currently is revising its guidelines to
assure voluntary screening of all pregnant women. This objective will
remain developmental until all States extend their surveillance systems
to include HIV.

## Related Objectives From Other Focus Areas

7\. Educational and Community-Based Programs

7-2. School health education

9\. Family Planning

9-10. Pregnancy prevention and sexually transmitted disease (STD)
protection

14\. Immunization and Infectious Diseases

14-11. Tuberculosis

14-13. Treatment for high-risk persons with latent tuberculosis
infection

20\. Occupational Safety and Health

20-10. Needlestick injuries

25\. Sexually Transmitted Diseases

25-8. Heterosexually transmitted HIV infection in women

25-11. Responsible adolescent sexual behavior

25-17. Screening of pregnant women

## Terminology

(A listing of acronyms and abbreviations used in this publication
appears in Appendix H.)

**AIDS:** Acquired immunodeficiency syndrome, the most severe phase of
infection with the human immunodeficiency virus (HIV). Persons infected
with HIV are said to have AIDS when they get certain opportunistic
infections or when their CD4+ cell count drops below 200.

**CD4+ cell (also known as T helper cell):** A type of T cell found in
the blood that is involved in protecting the body against infections.
CD4+ cells normally orchestrate the immune response, signaling other
cells in the immune system to perform their special disease-fighting
functions.

**CD4+ cell count:** A measure of the number of CD4+ cells present in
the blood. Because HIV infection kills CD4+ cells, CD4+ cell count is
used to track the progress of HIV infection.

**Cost-effective:** Indicates that the cost of a particular intervention
compares favorably to life-saving interventions associated with other
diseases.

**Cost-saving:** Indicates that a particular intervention averts health
care costs in excess of the cost of the intervention.

**HAART (highly active antiretroviral therapy):** Aggressive anti-HIV
treatment usually including a combination of drugs called protease
inhibitors and reverse transcriptase inhibitors whose purpose is to
reduce viral load infection to undetectable levels.

**HIV (human immunodeficiency virus):** A virus that infects and takes
over certain cells of the immune system that are important in fighting
disease.

**HIV antiretrovirals:** Drugs, such as zidovudine (AZT) and saquinavir,
designed to attack HIV and prevent it from multiplying.

***Mycobacterium avium* complex (MAC):** Bacteria that cause disease in
individuals who have weakened immune systems and one of the
opportunistic infections that define AIDS.

**Opportunistic infections:** Infections that take advantage of the
opportunity offered when a person's immune system has been weakened by
HIV infection. At least 25 medical conditions, including bacterial,
fungal, and viral infections and certain types of cancer, are associated
with HIV infection.

**Pandemic:** An epidemic over a large area or country.

***Pneumocystis carinii* pneumonia (PCP):** A type of pneumonia that
strikes individuals who have weakened immune systems.

**Prevalence:** A proportion of persons in a population who are
infected, at a specified point in time or over a specified period of
time, with HIV.

**Prophylactic:** Something that guards against or prevents disease.

**Prophylaxis:** Measures designed to prevent the spread of disease and
preserve health; protective or preventive treatment.

**Protease:** An enzyme that triggers the breakdown of proteins in the
body. HIV's protease enzyme breaks apart long strands of viral protein
into the separate proteins constituting the viral core and the enzymes
it contains. HIV protease acts as new virus particles are budding off a
cell membrane.

**Protease inhibitor:** A drug that binds to and blocks HIV protease
from working, thus preventing the production of new functional viral
particles.

**Serostatus:** The result of a blood test for the antibodies that the
immune system creates to fight specific diseases.

> **Seronegative:** Indicates that a person's blood lacks antibodies to
> a specific infectious agent, such as HIV.
>
> **Seropositive:** Indicates that a person's blood contains antibodies
> to infections, such as HIV.

**Subepidemic:** The morbidity that occurs within a proportion of the
population infected by the epidemic.

**Universal infection control precautions:** Guidelines and procedures
to protect health care workers from exposure to infection from blood and
other body fluids.

## References

[^1]: Centers for Disease Control. Kaposi's sarcoma and pneumocystis
    pneumonia among homosexual men---New York City and California.
    *Morbidity and Mortality Weekly Report* 30(25):305-308, 1981.

[^2]: Centers for Disease Control and Prevention (CDC). *HIV/AIDS
    Surveillance Report* 10(2), 1998.

[^3]: Centers for Disease Control. Update on acquired immune deficiency
    syndrome (AIDS)---United States. *Morbidity and Mortality Weekly
    Report* 31(37):507-514, 1982.

[^4]: CDC. CDC guidelines for national human immunodeficiency virus case
    surveillance, including monitoring for human immunodeficiency virus
    infection and acquired immunodeficiency syndrome. *Morbidity and
    Mortality Weekly Report* 48(RR-13), 1999.

[^5]: CDC. Update: Trends in AIDS incidence, deaths, and
    prevention---United States, 1996. *Morbidity and Mortality Weekly
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