2 tables, 1 figure omitted
Injection-drug use is a risk factor for acquired immunodeficiency syndrome
(AIDS).1 Of the 765,559 cumulative AIDS
cases diagnosed as of December 2000, a total of 193,527 (25%) occurred among
injection-drug users (IDUs).2 IDUs become
infected with human immunodeficiency virus (HIV) through sharing injection-drug
equipment with HIV-infected persons or by engaging in other risk behaviors
such as having unprotected sex.3 Since 1995,
AIDS incidence among IDUs has declined.2,4 This
report presents data on initial HIV diagnoses among IDUs aged ≥13 years,
with and without AIDS at the time of HIV diagnosis, by year, during 1994-2000.
The findings indicate that HIV diagnoses among IDUs have leveled in the majority
of demographic groups during this period in the 25 states for which HIV surveillance
data are available.* Because IDUs and their sex partners represent approximately
one third of persons infected in the HIV epidemic and continue to be at risk
for transmitting HIV, prevention efforts targeting IDUs and their sex partners
should be enhanced.
Data were available from health departments in 25 states that have had
HIV-infection case reporting since 1993, the first year for which HIV surveillance
data were available. During 1993-2000, these states accounted for 516,939
(24%) AIDS case reports and 35,548 (7%) cases reported among IDUs. Data were
adjusted for reporting delays. Cases reported without risk information were
reclassified based on a probability formula.5 Annual
proportions of HIV diagnoses among IDUs during 1994-2000 were compared by
age, sex, and race/ethnicity, and 95% confidence intervals were computed for
During 1994-2000, a total of 21,687 HIV diagnoses reported in the 25
states were among IDUs; males accounted for 14,252 (66%) cases. HIV diagnoses
reported among IDUs declined 42% overall, compared with a 15% decrease among
men who have sex with men (MSM) and a 9% increase among persons with heterosexual
transmission during the same period. IDU-related HIV diagnoses declined from
4,226 cases in 1994 to 2,403 cases in 1999, and leveled to 2,514 from 1999
to 2000. Blacks continue to be represented disproportionately (65%) among
IDU-related HIV cases diagnosed.
During 1994-2000, IDU-related HIV diagnoses declined among persons aged
13-19 years and 30-39 years by 17% and 68%, respectively. Among persons aged
20-29 years and 40-49 years, diagnoses decreased 53% and 26%, respectively,
during 1994-1999, and leveled off during 1999-2000. IDU-related HIV diagnoses
among persons aged ≥50 years were level during 1994-1999 and increased
slightly during 1999-2000.
Among men, HIV diagnoses reported among IDUs declined 44%, from 2,819
in 1994 to 1,568 in 1999, and leveled to 1,628 in 2000. Among women, diagnoses
declined 41%, from 1,407 in 1994 to 835 in 1999, and leveled to 886 in 2000.
Trends were similar in all racial/ethnic groups. Among whites, IDU-related
HIV diagnoses decreased 40%, from 941 in 1994 to 563 in 1999, and leveled
to 590 in 2000. Among blacks, HIV diagnoses among IDUs decreased 46%, from
2,825 in 1994 to 1,535 in 1999, and leveled to 1,584 in 2000. Among Hispanics,
IDU-related HIV diagnoses decreased 43%, from 409 in 1994 to 238 in 1999,
and leveled to 243 in 2000. Asians/Pacific Islanders and American Indians/Alaska
Natives accounted for 205 (1%) cases diagnosed during 1994-2000.
Sex partners of IDUs accounted for 5,117 (4%) HIV infections diagnosed
in these 25 states during 1994-2000. Heterosexual men and women who reported
having sex with IDUs accounted for 1,849 (1%) and 3,268 (3%) cases, respectively.
MSM/IDUs accounted for 4,626 (5%) HIV diagnoses. All IDU-related HIV diagnoses,
including those among IDUs, sex partners of IDUs, and MSM/IDUs, accounted
for 31,428 (32%) diagnoses, compared with MSM (not IDUs) (39,184 [42%]) and
those reporting having heterosexual sex (not with an IDU) (23,674 [25%]).
LM Lee, PhD, M McKenna, MD, Div of HIV/AIDS Prevention, National Center
for HIV, STD, and TB Prevention; TT Sharpe, PhD, EIS Officer, CDC.
The finding of overall declines in new HIV diagnoses among IDUs in the
25 states with HIV infection reporting is consistent with studies that suggest
a decline in new HIV infections among IDUs in other areas of the United States.6 Several factors probably account for the decline.
Because the peak of infections occurred in the early 1990s,2 the
decline during the late 1990s might reflect the natural decline in the epidemiologic
curve following the peak in the epidemic, which often is observed after the
onset of a disease in a population. The decline also might be attributable
in part to advances in antiretroviral therapy since 1995. In addition, the
HIV epidemic among IDUs is closely related to other risk behaviors such as
having unprotected sex, which frequently occurs in the context of illicit
substance use.7 Changes in HIV prevalence
among sex and needle-sharing partners or changes in risk behavior with such
partners might lead to changes in the risk for new infections.
The finding that IDU-related HIV diagnoses occurred disproportionately
in males and blacks is consistent with the disproportionate impact of the
HIV/AIDS epidemic on minority communities and the concentration of IDUs among
males.2 The leveling of IDU-related HIV
diagnoses during 1999-2000 for the majority of demographic groups might represent
a plateau in IDU-related HIV diagnoses or changes in testing behavior among
IDUs.6 In addition, the increase in IDU-related
HIV diagnoses among persons aged ≥50 years during 1999-2000 might represent
the aging of a cohort of IDUs who continue risk behaviors, acquire new infections,
or receive late testing and diagnosis.
IDUs who continue risk behaviors and sex partners of IDUs who contract
the disease might represent missed opportunities for HIV prevention. Approximately
25% of the estimated 850,000-950,000 persons living in the United States with
HIV are unaware of their infection,8 and
some transmit HIV infections to others. In 2003, CDC launched a new strategy
for prevention aimed at reducing the number of new infections in the United
States by increasing the proportion of infected persons who know their status
and by working with persons with HIV and their partners.9
The findings in this report are subject to at least three limitations.
First, the data are from 25 states with <10% of IDUs with AIDS and are
not generalizable to other states. Second, redistribution of risk is derived
by using an algorithm based on historical patterns of risk determination after
additional information is gathered; the summary might not account for current
patterns of risk redistribution. Finally, the data include new HIV diagnoses,
not new infections. Although testing patterns can change the number and trends
of new diagnoses, surveillance methods being developed by CDC will enable
estimation of patterns in HIV-infection incidence.10
CDC recommends that all states, especially those with high AIDS morbidity,
implement HIV case surveillance. In addition, procedures to reassign cases
reported without risk should be improved. CDC is piloting new methods to improve
risk ascertainment, including statistical sampling and inference.
Despite overall decreases, IDUs and their sex partners bear a substantial
burden of the disease. Expansion of efforts that include counseling and voluntary
HIV testing for IDUs and their sex partners is encouraged. Persons with HIV
should receive counseling to reduce risks associated with transmission to
others through drug use and sexual behaviors. Prevention programs targeting
minority communities should continue. Drug treatment for IDUs, medical treatment
for HIV-positive IDUs, and programs to prevent initiation of injection-drug
use should be enhanced to prevent HIV infection and transmission among IDUs
and their sex and drug-sharing partners.
*Alabama, Arizona, Arkansas, Colorado, Idaho, Indiana, Louisiana, Michigan,
Minnesota, Mississippi, Missouri, Nevada, New Jersey, North Carolina, North
Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Utah, Virginia,
West Virginia, Wisconsin, and Wyoming.
HIV Diagnoses Among Injection-Drug Users in States With HIV Surveillance—25 States, 1994-2000. JAMA. 2003;290(6):743-747. doi:10.1001/jama.290.6.743-a