Trends in the HIV and AIDS Epidemic, 1998

Because the dynamics of the HIV epidemic are different in each population, multiple data sets must be used to compile a complete picture of the epidemic in the U.S. While local subepidemics may vary, the HIV and AIDS data described above, combined with data from select studies in high-risk populations, come together to give us a clear indication of where our greatest challenges lie.

Prevention efforts have helped slow the epidemic from a period of rapid growth to an overall stabilization.

Yet, we have not achieved the same level of success in all communities. The epidemic -- which initially most heavily affected white gay men -- has increasingly settled among minority populations.

Looking at select seroprevalence studies among high-risk populations gives an even clearer picture of why the epidemic continues to spread in communities of color. The data suggest that three interrelated issues play a role -- the continued health disparities between economic classes, our nation's inability to successfully deal with substance abuse, and the intersection between substance abuse and the epidemic of HIV and other sexually transmitted diseases.

The same populations disproportionately impacted by HIV are also disproportionately impacted by other STDs. And recognizing that other STDs like gonorrhea, syphilis, and chlamydia make people 2-5 times as likely to both spread and acquire HIV, it is clear that the HIV epidemic can not be adequately addressed without also combating the epidemic of other STDs.

• A study of more than 31,000 repeat attenders at STD clinics in 7 U.S. cities shows high incidence rates among both gay and bisexual men (1.5 to 8.2 HIV infections per 100 person years) and heterosexuals (.06 to 1.1 per 100 person years).

• In these STD clinics, both heterosexuals and gay men were much more likely to become infected with HIV if they had other STDs.

For prevention efforts to succeed we must address the dangerous intersection of drug-related and sexual risk. There is no question that drug use is fueling the spread of the epidemic among African-American and Hispanic populations. In addition to the direct impact of injection drug use on the spread of HIV, many people infected heterosexually are infected through sex with an injection drug user or sex in exchange for drugs or money. Studies of seroprevalence in STD clinics and drug treatment centers continue to demonstrate the combined impact of drug use and STDs.

• Among heterosexuals treated in STD clinics, drug use -- both the use of illicit drugs and the exchange of sex for drugs or money -- are common risk factors for people who become infected with HIV.

Studies of HIV prevalence among patients in drug treatment centers and among childbearing women demonstrate that the heterosexual spread of HIV in women closely parallels the spread of HIV among injection drug users. The highest prevalence rate in both groups have been observed along the East Coast and in the South.

• All of the prevalence studies in high-risk populations find the rates of HIV among African-American and Hispanic populations to be dramatically higher than those among whites, indicating that the disproportionate toll of the epidemic among minorities continues.

In addition to improving prevention efforts for emerging communities at risk, we must sustain efforts for gay men. Continued high rates of HIV prevalence among young gay men demonstrate that it is critical to reach each generation of young gay and bisexual men with the information, skills, and support to change behavior.

• In a sample of young men who have sex with men (ages 15-22) in 6 urban counties, researchers found that between 5% and 8% percent were infected with HIV. A higher percentage of African Americans (13%) and Hispanics (5%) were infected than whites (4%).

We now have more knowledge than ever before about what biomedical and behavioral approaches work best in HIV prevention. Our challenge is to apply what we've learned to designing even more effective tools for prevention and to ensure that our successes are extended to all populations. Despite the dramatic slowing in the epidemic overall, approximately 40,000 new infections continue to occur in the U.S. each year. We must continue to pay attention to prevention. We can and must do even better.

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