       Document 0241
 DOCN  MMWR0241
 TI    Current Trends AIDS Among Racial/Ethnic Minorities -- United
       States, 1993
 DT    940909
 SO    MMWR - September 09, 1994; Vol. 43, No. 35.
 AV    U.S. Government Printing Office, Superintendent of Documents,
       Washington, DC, 20402-9371, (202) 783-3238. U.S.  Department of
       Commerce, National Technical Information Service, 5285 Port
       Royal Rd., Springfield, VA, 22161, (703) 487-4650.
 TX    In 1993, local, state, and territorial health departments
       reported to CDC 58,538 cases of acquired immunodeficiency
       syndrome (AIDS) among racial/ethnic minorities (Table 1). A
       total of 38,544 (66%) cases were reported among blacks, 18,888
       (32%) among Hispanics, 767 (1%) among Asians/Pacific Islanders,
       and 339 (1%) among American Indians/Alaskan Natives*. These
       cases represented 55% of the 106,949 AIDS cases reported in the
       United States in 1993. Rates of AIDS and modes of human
       immunodeficiency virus (HIV) exposure varied substantially both
       among and within minority populations. This report describes
       these differences and summarizes the epidemiologic
       characteristics of AIDS cases reported among racial/ethnic
       minorities during 1993. In 1993, racial/ethnic minorities
       accounted for 45,039 (51%) of 89,165 AIDS cases reported among
       adult and adolescent males (aged greater than or equal to 13
       years) and 12,696 (75%) of 16,824 cases among adult and
       adolescent females. Of the 959 cases reported among children
       (aged less than 13 years), 803 (84%) were among minorities.

       In 1993, 111 AIDS cases per 100,000 adults and adolescents were
       reported among racial/ethnic minorities. Rates were highest
       among blacks and Hispanics (162 and 90, respectively) and
       lowest among American Indians/Alaskan Natives and
       Asians/Pacific Islanders (24 and 12, respectively). Blacks are
       disproportionately affected by the HIV epidemic: the AIDS rate
       for black females (73) was approximately 15 times greater than
       that for white females (5), and the rate for black males (266)
       was nearly five times greater than that for white males (57).
       AIDS rates for blacks and Hispanics varied substantially by
       geographic region (Figures 1 and 2).** Rates for both groups
       were generally highest in the Northeast.*** For blacks, rates
       were highest in Vermont (445****), New York (379), New Jersey
       (373), and Florida (366). AIDS rates for blacks were less than
       the overall adult and adolescent rate (50) in 11 (22%) of the
       50 states.

       For Hispanics, AIDS rates were highest in New York (293),
       Connecticut (271), Massachusetts (249), and Pennsylvania (246).
       Rates for Hispanics were less than the overall rate in 26 (52%)
       of the 50 states. In Arizona, California, Hawaii, Mississippi,
       New Mexico, Texas, Wyoming, and the District of Columbia, AIDS
       rates for Hispanics were lower than rates for whites. Among
       males who were racial/ethnic minorities, the most common modes
       of HIV exposure were male-male sex (39%) and injecting-drug use
       (IDU) (38%). Among females, the most common exposures were IDU
       (47%) and heterosexual contact (37%). However, the distribution
       of exposures differed substantially by race/ethnicity (Table 2)
       and geographic location. IDU was the principal HIV exposure
       among blacks and Hispanics; most (60%) IDU-associated cases
       among blacks and Hispanics were reported in the Northeast and
       Puerto Rico. Male-male sex was the primary exposure among
       Asians/Pacific Islanders and American Indians/Alaskan Natives.
       The proportion of AIDS cases with no reported risk for HIV
       infection was greater among racial/ethnic minorities than among
       whites.

       In geographic locations outside the Northeast, patterns of HIV
       exposure among blacks and Hispanics varied substantially. Among
       black males with AIDS, male-male sex was the most common mode
       of exposure in the District of Columbia, the U.S. Virgin
       Islands, and 32 (67%) of 48 states that reported AIDS cases
       among black males. Among Hispanic males, male-male sex was the
       most common exposure in the District of Columbia and 34 (71%)
       of 48 states that reported cases among Hispanic males. Among
       black females, IDU was the most common exposure in the District
       of Columbia and 23 (52%) of 44 states that reported AIDS cases
       among black females, and heterosexual contact was the leading
       exposure in 20 (45%) states. Among Hispanic females,
       heterosexual contact was the most common exposure in the
       District of Columbia, Puerto Rico, and 19 (54%) of 35 states
       that reported AIDS cases among Hispanic females, and IDU was
       the leading exposure in 10 (29%) states. Reported by: Local,
       state, and territorial health depts. Div of HIV/AIDS, National
       Center for Infectious Diseases, CDC. Editorial Note: Following
       the 1993 expansion of the AIDS surveillance case definition,
       the number of AIDS cases reported among racial/ethnic
       minorities in 1993 increased 135% over that in 1992, while the
       number among whites increased 114%. The greater increase in
       cases among racial/ethnic minorities is consistent with trends
       in the number of AIDS cases reported in previous years,
       representing a continued increase in the epidemic among certain
       minority populations. However, because the increase in cases
       reported in 1993 reflects a transient effect of the expansion
       of the AIDS surveillance case definition, the number of AIDS
       cases reported in 1994 is expected to be lower than that in
       1993 (1).

       AIDS surveillance may underestimate the number of AIDS cases
       reported among certain minority populations because of
       misclassification of race/ethnicity on medical records, which
       are the source for AIDS case reports. For example, a study
       conducted during June 1990-August 1992 that compared
       self-reported race/ethnicity with that listed on AIDS case
       reports indicated that AIDS cases among Asians/Pacific
       Islanders (12 cases), American Indians/Alaskan Natives (14),
       and Hispanics (249) were underreported by 25%, 21%, and 18%,
       respectively; in comparison, AIDS cases among whites and blacks
       were overreported by 4% and 2%, respectively (2).

       The increase in the number of persons with AIDS has greatly
       affected death rates for racial/ethnic minorities, particularly
       young adults. In 1991, among males aged 25-44 years, HIV
       infection was the leading cause of death for blacks and
       Hispanics and the sixth leading cause for Asians/Pacific
       Islanders and American Indians/Alaskan Natives. Among females
       in this age group, HIV infection was the third leading cause of
       death for blacks and Hispanics, the seventh for American
       Indians/Alaskan Natives, and the ninth for Asians/Pacific
       Islanders. Provisional mortality data for 1992***** indicate
       that HIV infection was the second leading cause of death among
       black females aged 25-44 years (3); in 1991, the HIV/AIDS death
       rate for all black females was approximately 10 times the rate
       for white females (4).

       Most AIDS cases classified as having no reported risk for HIV
       infection will be reclassified into one of the known exposure
       groups after additional follow-up. A greater proportion of
       racial/ethnic minorities than whites may be initially
       classified without an HIV risk because of unrecognized
       heterosexual transmission, the diagnosis of AIDS at or near
       death, and language and cultural differences that make risk
       ascertainment more difficult.

       Although race and ethnicity are not risk factors for HIV
       transmission, they are markers for underlying social, economic,
       and cultural factors and personal behaviors that affect health
       (5). Socioeconomic status in particular is associated with
       morbidity and premature mortality (6); unemployment, poverty,
       and illiteracy are correlated with decreased access to health
       education, preventive services, and medical care, resulting in
       an increased risk for disease (5). In 1992, 33% of blacks and
       29% of Hispanics lived below the federal poverty level,******
       compared with 13% of Asians/ Pacific Islanders and 10% of
       whites (7). Therefore, the social, economic, and cultural
       context of HIV infection should be considered when designing
       and implementing prevention programs for diverse populations.

       Although IDUs in the Northeast and Puerto Rico accounted for
       24% of all AIDS cases reported among racial/ethnic minorities,
       AIDS rates and modes of HIV exposure varied greatly among
       minority populations in other areas of the country. HIV
       serosurveillance studies have demonstrated similar patterns
       (8). In addition, the incidence of AIDS and the distribution of
       HIV exposures among Hispanics and Asians/Pacific Islanders vary
       in relation to their place of birth (9,10). These geographic
       and racial/ethnic differences are directly related to
       variations in the prevalence of HIV infection, the type and
       frequency of behaviors associated with HIV transmission, and
       the time of introduction of HIV into the specific communities;
       and indirectly related to the social, economic, and cultural
       influences within those communities.

       Because the epidemiology of HIV infection varies considerably
       by geographic region and among racial/ethnic populations,
       preventive interventions should be developed at the local level
       to ensure that they reflect the language, culture, and
       behavioral norms of the targeted community. CDC is
       collaborating with local, state, and territorial health
       departments to establish planning groups composed of community
       representatives, epidemiologists, behavioral scientists, and
       other public health practitioners who will participate in the
       development and implementation of HIV-prevention programs.

       References

              1. CDC. Update: impact of the expanded AIDS surveillance
       case definition for adolescents and adults on case
       reporting--United States, 1993. MMWR 1994;43:160-1,167-70.

              2. Kelly JJ, Chu SY, Diaz T, Leary LS, Buehler JW.
       Race/ethnicity misclassification of persons reported with AIDS.
       Ethn Dis (in press).

              3. CDC. Update: mortality attributable to HIV infection
       among persons aged 25-44 years--United States, 1991 and 1992.
       MMWR 1993;42:869-72.

              4. NCHS. Excess deaths and other mortality measures for
       the black population, 1979-81 and 1991. Hyattsville, Maryland:
       US Department of Health and Human Services, Public Health
       Service, CDC, 1994.

              5. National Commission on AIDS. The challenge of
       HIV/AIDS in communities of color. Washington, DC: National
       Commission on AIDS, December 1992.

              6. Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL.
       Socioeconomic inequalities in health. JAMA 1993;269:3140-5.

              7. Bureau of the Census. Poverty in the United States,
       1992. Washington, DC: US Department of Commerce, Economics and
       Statistics Administration, Bureau of the Census, September
       1993.

              8. CDC. National HIV serosurveillance summary: results
       through 1992. Atlanta: US Department of Health and Human
       Services, Public Health Service, CDC, November 1993.

              9. Diaz T, Buehler JW, Castro KG, Ward JW. AIDS trends
       among Hispanics in the United States. Am J Public Health
       1993;83:504-9.

              10. Metler R, Hu DJ, Fleming PL, Ward JW. AIDS among
       Asians and Pacific Islanders (A/PI) reported in the U.S.A.
       [Abstract no. PCO325]. Vol 2. Xth International Conference on
       AIDS/International Conference on STD. Yokohama, Japan, August
       10-11, 1994:241.

            * The racial/ethnic categories used in federal statistics
              are specified in the Office of Management and Budget's
              Directive 15, Race and Ethnic Standards for Federal
              Statistics and Administrative Reporting (1978).

           ** The numbers of AIDS cases reported among Asians/Pacific
              Islanders and American Indians/ Alaskan Natives were
              insufficient to analyze by state.

          *** New England and Middle Atlantic regions.

         **** Based on six reported AIDS cases in 1993.

        ***** Provisional data were available only for blacks and
              whites without stratification by Hispanic ethnicity.

       ****** Poverty statistics are based on definitions originated
              by the Social Security Administration in 1964,
              subsequently modified by the federal interagency
              committees in 1969 and 1980, and prescribed by the
              Office of Management and Budget as the standard to be
              used by federal agencies for statistical purposes.
 DE    Ethnic groups.  Epidemiological reporting.  Statistics.

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