ATW1H%ASUACAD.BITNET@oac.ucla.edu (Dr David Dodell) (06/28/89)
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from sexually transmitted disease (STD) clinics indicate that HIV
seroprevalence is highest among IVDUs and their sex partners. In an ongoing
study begun in January 1988 of New York City STD clinic clients who consented
to be interviewed and tested for HIV, 63 (47%) of 134 IVDUs and 25 (13%) of
193 persons with a sex partner who used IV drugs were HIV-positive (4). In
addition, a 1987 survey of STD clinic attendees in Baltimore detected HIV
antibody in 34 (15%) of 224 men and 14 (22%) of 65 women with self-reported
histories of IV-drug use and 18 (11%) of 170 women who reported sexual contact
with men who were bisexual or used IV drugs (5). Among clinic patients who did
not report any risks for HIV infection, including male homosexual contact, IV-
drug use, or sexual contact with a partner at increased risk, HIV
seroprevalence was 4% (20/571) in men and 5% (9/196) in women in New York City
(4), 3% (56/2068) in men and 2% (20/1115) in women in Baltimore (5), and 0.2%
(4/1634) in men and 0 (0/940) in women in Denver (6).
HIV transmission among heterosexually active persons without known risks
in either partner also can be monitored by interviewing seropositive civilian
recruit applicants for military service and blood donors. HIV seropositivity
lower than that in comparable segments of the general population would be
expected because both groups are screened to exclude persons with histories of
male homosexual contact, IV-drug use, or hemophilia. Seropositive recruit
applicants and blood donors therefore might be expected to include a
relatively large proportion of persons with HIV infection acquired from
heterosexual partners who were not suspected or known to be infected.
Among approximately 1.5 million male and 253,547 female civilian recruit
applicants screened during October 1985-September 1988, 0.15% and 0.07%,
respectively, were HIV seropositive (2). In limited follow-up studies of
seropositive male recruit applicants, most had risk factors for HIV infection
other than heterosexual contact. In New York City and Denver, 19 (86%) of 22
and 10 (91%) of 11 seropositive male applicants, respectively, admitted male
homosexual contact or IV-drug use; the remaining four men reported contact
with a female prostitute (7,8). Too few seropositive women were available for
analysis.
Among 1.3 million male and 1.2 million female first-time blood donors
tested during April 1985-September 1988, 0.067% and 0.014%, respectively, were
HIV-seropositive (2). In an ongoing follow-up study of seropositive blood
Health InfoCom Network News Page 20
Volume 2, Number 26 June 26, 1989
donors in 16 cities, 50% of interviewed donors reported male homosexual
contact or IV-drug use; 18 (8%) of 228 interviewed seropositive males and 43
(57%) of 76 women reported heterosexual contact with a partner at risk for HIV
infection; women were more likely than men (36% and 29%, respectively) to have
no risk identified (9).
Reported by: Local, state, and territorial health departments. AIDS Program,
Center for Infectious Diseases, CDC.
Editorial Note: In general, a person's risk of acquiring HIV infection through
sexual contact depends on 1) the number of different partners, 2) the
likelihood (prevalence) of HIV infection in these partners, and 3) the
probability of virus transmission during sexual contact with an infected
partner (10). Virus transmission, in turn, may be affected by biologic
factors, such as concurrent STD infections in either partner (e.g., genital
ulcer disease); behavioral factors, such as type of sex practice and use of
condoms; or varying levels of infectivity in the source partner related to
clinical stage of disease (11). Based on these factors, the risk for HIV
infection is highest for a regular partner of an HIV-infected person. Persons
who have sex partners with risk factors for HIV infection or who themselves
have multiple partners from urban settings with high rates of IV-drug and
"crack" cocaine use (4,12), prostitution, and other STDs are also at increased
risk.
Surveillance data for heterosexual transmission of HIV infection need to
be interpreted cautiously. The actual number of AIDS cases reported to be
associated with heterosexual transmission probably underestimates the role of
this mode of spread. Nearly 3000 persons classified as bisexual men and IVDUs
and persons with hemophilia also reported heterosexual contact with a person
at risk. Therefore, some of these persons may have acquired HIV through
heterosexual contact rather than through these other routes. Similarly, some
persons with an undetermined risk may have become infected through
heterosexual contact. Persons with an undetermined risk are demographically
similar to AIDS patients who report IV-drug use or sexual contact with a
partner at risk. Nearly 40% of persons with an undetermined risk have self-
reported histories of an STD, and one third of men reported sexual contact
with a female prostitute (13). Conversely, some persons with AIDS attributed
to heterosexual transmission may have other unacknowledged or undetermined
risk factors. For example, inconsistencies in the geographic distribution of
men who reported sexual contact with a female IVDU, as well as the tendency of
men to have partners with an unknown risk, suggests that some of these men may
be misclassified. Underascertainment of heterosexual transmission among men
probably exists in other areas.
Compared with AIDS case data, seroprevalence surveys reflect more recent
patterns of HIV infection. However, only limited information regarding the
spread of heterosexually acquired HIV infection is available from current
surveys because relatively few collect information about risk factors.
Additional follow-up studies of STD clinic patients, seropositive blood
donors, and civilian recruit applicants are now under way or being implemented
to aid in monitoring the level and trends of heterosexual transmission (14).
Both AIDS surveillance and HIV seroprevalence follow-up studies indicate
that an appreciable proportion of HIV infection among women in the United
States is acquired through heterosexual contact. Because HIV seroprevalence is
greater in men, a woman is more likely than a man to have an infected
heterosexual partner. Women may also be unaware of the infection status of
their male partners, as suggested by data on civilian recruit applicants. HIV
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Volume 2, Number 26 June 26, 1989
seroprevalence rates among male recruit applicants have declined since 1985;
in contrast, rates among female applicants have remained stable, suggesting
that women may be less likely to self-defer because they do not know or
suspect they are infected (2). The predominance of heterosexually acquired HIV
infections in women of reproductive age has important implications for
perinatal HIV transmission; nearly 30% of children with AIDS were infected by
their mothers who acquired infection through heterosexual contact.
Recent increases in syphilis among heterosexuals, particularly among
prostitutes, drug users, and their sexual contacts (15,16), indicate the need
for more intensive application of recommended measures (17,18) to interrupt
sexual and drug-use- related transmission of HIV infection. These measures
include: --development of community health education programs aimed at
populations at increased risk; !participation in mutually monogamous
relationships or reduction of the number of sex partners; --use of condoms to
prevent exposure to semen and infected lymphocytes; --enrollment of drug users
in programs to eliminate use of IV-drugs; and --increased voluntary HIV
testing and counseling of persons at increased risk in settings such as STD
and family planning clinics and drug-treatment programs.
References
1. CDC. Human immunodeficiency virus infection in the United States: a review
of current knowledge. MMWR 1987;36(suppl S-6).
2. CDC. AIDS and human immunodeficiency virus infection in the United
States: 1988 update. MMWR 1989:38(suppl S-4).
3. Darrow WW, Bigler W, Deppe D, et al. HIV antibody in 640 U.S. prostitutes
with no evidence of intravenous (IV)-drug abuse (Abstract). IV International
Conference on AIDS. Book 1. Stockholm, June 12-16, 1988:273.
4. Chiasson MA, Stoneburner RL, Telzak E, Hildebrandt D, Schultz S, Jaffe HW.
Risk factors for HIV-1 infection in STD clinic patients: evidence for crack-
related heterosexual transmission (Abstract). V International Conference on
AIDS. Montreal, June 4-9, 1989:117.
5. Quinn TC, Glasser D, Cannon RO, et al. Human immunodeficiency virus
infection among patients attending clinics for sexually transmitted diseases.
N Engl J Med 1988;318:197-203.
6. Judson F, Cohn D, Douglas J. HIV seroprevalence in heterosexual men and
women, Denver Metro STD Clinic, 1985-1988 (Abstract). V International
Conference on AIDS. Montreal, June 4-9, 1989:87.
7. Stoneburner RL, Chiasson MA, Solomon K, Rosenthal S. Risk factors in
military recruits positive for HIV antibody (Letter). N Engl J Med
1986;315:1355.
8. Dillon BA, Spencer N. Follow-up counseling and risk behavior assessment of
HIV antibody positive military recruits (Abstract). III International
Conference on AIDS. Washington, DC, June 1-5, 1987:42.
9. Peterson L and the HIV Blood Donor Study Group. Surveillance for unusual
modes of HIV transmission in the USA--a 5-year multicenter study of blood
donors (Abstract). V International Conference on AIDS. Montreal, June 4-9,
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Volume 2, Number 26 June 26, 1989
1989:83.
10. Peterman TA, Curran JW. Sexual transmission of human immunodeficiency
virus. JAMA 1986;256:2222-6.
11. Holmes KK, Kreiss J. Heterosexual transmission of human immunodeficiency
virus: overview of a neglected aspect of the AIDS epidemic. J Acquired Immune
Deficiency Syndromes 1988;1:602-10.
12. Chaisson RE, Bacchetti P, Osmond D, Brodie B, Sande MA, Moss AR. Cocaine
use and HIV infection in intravenous drug users in San Francisco. JAMA
1989;261:561-5.
13. Castro KG, Lifson AR, White CR, et al. Investigations of AIDS patients
with no previously identified risk factors. JAMA 1988;259:1338-42.
14. Dondero TJ, Jr, Pappaioanou M, Curran JW. Monitoring the levels and trends
of HIV infection: the Public Health Service's HIV surveillance program. Public
Health Rep 1988;103:213-20.
15. CDC. Continuing increase in infectious syphilis--United States. MMWR
1988;37:35-8.
16. CDC. Relationship of syphilis to drug use and prostitution--Connecticut
and Philadelphia, Pennsylvania. MMWR 1988;37:755-8,764.
17. CDC. Additional recommendations to reduce sexual and drug abuse-related
transmission of human T-lymphotropic virus type III/lymphadenopathy-associated
virus. MMWR 1986;35:152-5.
18. CDC. Public Health Service guidelines for counseling and antibody testing
to prevent HIV infection and AIDS. MMWR 1987;36:509-15,521-2.
#####
Notice to Readers
MMWR Recommendations and Reports
A new component in the MMWR series of publications, Recommendations and
Reports, has been developed. The purposes of this publication are to permit
increased access to recommendations and guidelines by consolidating them under
one cover and to accommodate other reports more lengthy than articles that
typically appear in the weekly MMWR. The first issue of Recommendations and
Reports, published June 16, 1989, contains guidelines for prophylaxis against
Pnemocystis carinii pneumonia(1). Subscribers to the MMWR will receive the
Recommendations and Reports.
Reference
1. CDC. Guidelines for prophylaxis against Pneumocystis carinii pneumonia for
persons infected with human immunodeficiency virus. MMWR 1989;38 (S-5).
Health InfoCom Network News Page 23
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