PRB

(September 2001) Two decades into the AIDS epidemic in North America, the face of AIDS is darker and increasingly female. Today, the face of AIDS is still largely that of a gay or bisexual man (though he is now more likely to be African American than white), a black or Hispanic injection drug user, or a black woman who has used injection drugs or who has been the partner of a man who uses them.

From the earliest years of the epidemic, AIDS advocates have worked hard to ensure that people with AIDS are seen as having faces, rather than as mere statistics. The numbers in North America, however, give us a sense of how the epidemic in the United States and Canada has evolved in 20 years, compared with other world regions.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates there are roughly 34 million people living with HIV or AIDS throughout the world; some 33 million are adults, 15.7 million of them women and another 1.3 million of them children under age 15. UNAIDS estimates that since the beginning of the epidemic, 18.8 million people have died from AIDS.¹

Over 900,000 North Americans Are Living With HIV

In the United States, the Centers for Disease Control and Prevention (CDC) estimates that as many as 900,000 Americans are living with HIV. Between 1981 and June 2000, a total of 753,907 cases of AIDS were reported in the country. During the same period, 438,795 Americans died from AIDS.² In Canada, the Centre for Infectious Disease Prevention and Control (CIDPC) reported a cumulative national total of 48,014 HIV infections and 17,594 AIDS cases since the early 1980s through December 2000. Of these, 12,419 Canadians have died from AIDS-related causes.³

Ninety-eight percent (745,103) of U.S. AIDS cases have been reported among adults and adolescents ages 13 and older; 8,804 cases have been reported among children under age 13. Between July 1999 and June 2000 alone, the most recent period for which data are available, nearly 33,000 new AIDS cases were reported in the United States.

As of 1999, an estimated 320,282 Americans were living with AIDS. The largest numbers of those living with HIV or AIDS were in California (43,286), Florida (50,957), New Jersey (27,165), New York (52,873), and Texas (27,608). AIDS cases have been reported in all 50 states, the District of Columbia, and the U.S. territories. Ten states (California, Florida, Georgia, Illinois, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, and Texas) and Puerto Rico account for 76 percent of all AIDS cases reported in the United States since the beginning of the epidemic. AIDS in the United States is largely concentrated in urban areas, though there are pockets of HIV infection in rural areas, particularly among poor African Americans in the South. In fact, 10 U.S. metropolitan areas account for nearly half (42 percent) of the nation’s cumulative reported AIDS cases, according to the CDC.

Men With HIV Outnumber Women With HIV

On every continent except Africa, the number of HIV infections is greater among men than among women.⁴ In the United States, men with HIV outnumber infected women nearly five to one. There have been 620,189 AIDS cases among males and 124,911 among females. Among the increasing number of Americans living with HIV but not diagnosed with AIDS, males outnumber females by only two to one. In fact, according to the CDC, the proportion of all AIDS cases reported among adult and adolescent women has more than tripled, from 7 percent in 1985 to 23 percent in 1999.

Among both males and females in the United States, AIDS and new HIV infections are most prevalent among persons 25 to 49 years old. Whites account for 43 percent (324,822) of the cumulative cases, while blacks make up 37 percent (282,720) of the cases even though they account for only 12 percent of the U.S. population. Hispanics account for another 18 percent (137,575) of the cumulative cases, with considerably smaller numbers among Asian/Pacific Islanders (5,546) and American Indian/Alaska Natives (2,234), according to the CDC.

Among American women with AIDS, it is striking to note that there have been more than two and a half times the number of black women with AIDS (74,331) as white women (27,889). Equally striking are figures for new HIV infections reported from the nation’s 36 areas with confidential HIV infection reporting. They show HIV to be spreading most rapidly among non-Hispanic blacks.

Same-Sex Relations Still a Prime Risk Factor in the United States

While the face of HIV/AIDS may have changed in terms of skin color and sex, the means by which HIV is transmitted have remained the same. For this reason, the so-called risk groups have merely varied in their proportions of the total new HIV infections and AIDS cases. In the United States, more than half (56 percent) of the males diagnosed with AIDS became infected through same-sex relations. Among white men diagnosed with AIDS since 1981, 74 percent have been men who have sex with men. Among black males, men who have sex with men account for 37 percent of AIDS cases — nearly equal to the 34 percent who became infected through injection drug use. The situation is similar among Hispanic males: some 42 percent of those with AIDS are men who have sex with men and 35 percent are injection drug users.

Injection drug use and heterosexual relations with an injection drug user have continued to be the primary means by which U.S. women are infected with HIV.⁵ AIDS cases among U.S. women have been concentrated largely in the Northeast and South. The CDC estimates that between 120,000 and 160,000 adult and adolescent women are now living with HIV, including those with AIDS. Among white adult and adolescent females, 42 percent were infected via injection drug use; another 40 percent were infected heterosexually. Forty-two percent of newly infected black females contracted the virus through injection drug use, while 38 percent were infected by a male sexual partner. Forty percent of new infections among Hispanic females were from injection drug use and 47 percent from heterosexual contact.

Major Trends of the Epidemic in Canada

Although Canada has a markedly smaller population (30.8 million) and a correspondingly smaller AIDS epidemic, the demographics of the epidemic as well as the declining numbers of those newly infected or who progress to AIDS have mirrored their U.S. neighbors. New HIV infections in Canada have fallen from a high of 2,983 HIV-positive reports in 1995 to 2,240 in 1999. The number of those who progress to AIDS has likewise declined. Canadian public health authorities, like their U.S. counterparts, attribute the drop to the use of highly active antiretroviral therapy (HAART) since 1996 when protease inhibitors and drug “cocktails” first came into wide use.⁶

The largest proportion of positive HIV tests in Canada are consistently among persons 30 to 39 years old. Men who have sex with men accounted for a high of 75 percent of all Canada’s HIV cases during the period 1985 to 1994. But in 2000, their percentage of the total dropped to 42 percent. On the other hand, the number of injection drug users with HIV jumped from only 9 percent of all HIV infections during 1985 to 1994 to 26 percent in 2000. There was a nearly 400 percent increase in the number of males and females infected through heterosexual relations between 1985 and 2000, from nearly 8 percent of all positive test reports to roughly 25 percent.⁷

Major Trends of the Epidemic in the United States

The CDC estimates that each year 40,000 more Americans are infected with HIV. Half of all new HIV infections are believed to be among people under age 25, the majority infected sexually. In 1999, 1,813 young people ages 13 to 24 were reported with AIDS. Half the 13- to 19-year-old males and 56 percent of those 20 to 24 years old were infected through same-sex activity. Forty-nine percent and 46 percent of females in those respective age groups were infected via heterosexual contact.

Among gay and bisexual males of all races, recent studies have found increased risk behavior and sexually transmitted diseases. These trends suggest a resurgent HIV epidemic among young men who have sex with men, particularly in young, gay, black men.⁸ In fact, African American men who have sex with men now account for an estimated 60 percent of new infections among gay and bisexual males, according to the CDC. The same is true in Canada, where the proportion of new HIV infections among men who have sex with men increased from a low of 30 percent in 1996 to 38 percent in 1999.

Although the HIV/AIDS epidemic among injection drug users seems to have slowed in the northeast, where it had been concentrated, the CDC notes that, as for young, gay, and bisexual men, there are “worrisome trends.” Recent studies indicate an increase in the proportion of heroin users who are now injecting rather than snorting heroin. The agency suggests this may be related to a possible substantial increase in heroin use among young people, particularly among suburban youth.

Bolstering Prevention Efforts

Prevention efforts over the last 20 years have had tremendous benefits in altering the face of the overall AIDS epidemic. In the United States, for example, mother-to-child HIV transmission has been dramatically reduced, from a high of 2,500 perinatal HIV infections in 1992 to an estimated 300 to 400 annual infections in recent years. The reduction is due to the widespread use of HIV counseling and testing for pregnant women and the availability of zidovudine (ZDV, more commonly known as AZT) and other drugs to prevent so-called vertical transmission of the virus.

The risk of infection among many gay and bisexual men, injection drug users, and women also has been reduced through strong community-level interventions aimed at helping people to choose healthy, protective behaviors. Thanks to effective prevention, HIV seroprevalence among white men who have sex with men in the United States declined by 50 percent between 1988 and 1993. It dropped more than 40 percent among injection drug users in New York City during the 1990s, according to the CDC.⁹

But prevention has not been as successful in reaching other populations at greatest risk, particularly people of color, women, and younger men who have sex with men. The CDC has set a goal of reducing new HIV infections in the United States from what it calls the “unacceptably high” estimated 40,000 to 20,000 per year by 2005. Canada likewise calls its estimated annual 4,200 new HIV infections an unacceptably high level. One of the CDC’s key strategies is to use voluntary testing and counseling to increase from the current estimated 70 percent to 95 percent the proportion of Americans with HIV who know they are infected. The agency also aims to increase from an estimated 50 percent to 80 percent the proportion of HIV-infected people who are linked to appropriate prevention, care, and treatment services.

Although AIDS diagnoses offer information that can be used to improve testing and care programs, they no longer provide sufficient information to characterize recent trends in the HIV epidemic because of the impact of new treatments on the progression to AIDS. As Canada’s CIDPC puts it, AIDS cases now represent a failure of either HIV diagnosis or treatment. In the United States, the CDC has urged all states to begin reporting new HIV infections in addition to AIDS cases within the next one to two years. Effective counseling and testing inform those at greatest risk of their HIV status and provide the opportunity to link them to care and treatment that will keep them well as long as possible and reduce their infectiousness to others by keeping the amount of virus in their bodies as low as possible.

Two decades into the AIDS epidemic in North America, the rise and fall in numbers tell an ongoing story of individuals, communities, provinces, states, and nations sorting out and addressing the greatest health threat of our time.

John-Manuel Andriote is acting director of information programs for Family Health International’s HIV/AIDS Prevention and Care Department and author of Victory Deferred: How AIDS Changed Gay Life in America (University of Chicago Press, 1999).

References

1. United Nations Global Programme on AIDS (UNAIDS), Report on the Global HIV/AIDS epidemic — June 2000 (Geneva: UNAIDS, June 2000).
2. U.S. Centers for Disease Control and Prevention (CDC), HIV/AIDS Surveillance Report 2000 12, no. 1.
3. Division of HIV/AIDS Epidemiology and Surveillance, Bureau of HIV/AIDS, STD and TB, Centre for Infectious Disease Prevention and Control, “HIV and AIDS in Canada: Surveillance Report to December 31, 2000,” Health Canada, April 2001.
4. UNAIDS, Men and AIDS — A Gendered Approach. 2000 World AIDS Campaign (Geneva: UNAIDS, March 2000).
5. CDC, “HIV/AIDS Among U.S. Women: Minority and Young Women at Continuing Risk,” Face Sheet, available at www.cdc.gov/hiv/pubs/facts/women.htm (January 31, 2001).
6. Centre for Infectious Disease Prevention and Control, “National trends of AIDS and HIV in Canada,” Canada Communicable Disease Report 2000 26, no. 23.
7. CIDPC, “HIV and AIDS in Canada. Surveillance Report to December 31, 2000.”
8. Valleroy LA, DA MacKellar, JM Karon, et al., “HIV prevalence and associated risks in young men who have sex with men,” JAMA 284: 198-204. Woltiski RJ, Valdiserri RO, Denning PH, Levine WC, “Are we headed for a resurgence in the HIV epidemic among men who have sex with men?” Am J Public Health 91: 883-8.
9. CDC, HIV Prevention Strategic Plan Through 2005 (Atlanta: CDC, January 2001).

Additional Resources

U.S. Centers for Disease Control and Prevention: www.cdc.gov/hiv

Canadian Centre for Infectious Disease Prevention and Control:
www.hc-sc.gc.ca/dc-ma/aids-sida/index_e.html

Center for AIDS Prevention Studies (CAPS): www.caps.ucsf.edu

Joint United Nations Programme on HIV/AIDS (UNAIDS): www.unaids.org

Kaiser Family Foundation: www.kff.org