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AIDS The Second Decade (1990) / Chapter Skim
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1 The AIDS Epidemic in the Second Decade
Pages 38-80

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From page 38...
... This change in the character of AIDS, with the beginnings of a shift away from an emphasis on the acuteness of infection toward a view of AIDS as a long-term illness, will have important implications for treatment and care and for the design of intervention strategies to facilitate behavioral change, still the only available means to prevent 38
From page 39...
... From a biomedical perspective, AIDS is a disease caused by a virus, HIV-l, that is transmitted by anal or vaginal intercourse, by exposure to contaminated blood (either through shared injection equipment associated with intravenous drug use or transfusion) , and from mother to fetus.
From page 40...
... drug users and heterosexuals. Indeed, the proportion of AIDS cases in the United States attributable to heterosexual contact is growing, and a significant fraction of these cases report contact with a drug user.
From page 41...
... Changes are also being seen in the patterns of behavior that transmit the AIDS virus. Many gay men with AIDS acquired HIV infection through unprotected sexual contact.
From page 42...
... The paucity of planned variations of intervention strategies and of information garnered through rigorous outcome evaluation that was cited by the committee has not been remedied. The gap is particularly problematic for innovative programs that have targeted groups such as {V drug users, in which infection has been shown to spread at an alarmingly fast rate in the absence of effective intervention efforts and in which potentially efficacious but politically sensitive efforts have come under attack.
From page 43...
... are attributed to male homosexual or bisexual contact, and an additional 8,117 are ascribed to bow homosexual contact and rv drug use (CDC, 1990a)
From page 45...
... In 1981 cases attributable to heterosexual transmission and {V drug use constituted 0.5 and 11.0 percent, respectively, of all reported cases; by 1989 these rates had increased to 5.0 and 23.2 percent (Table 1-1~. Among IV drug users, after several years of progressively worsening infection statistics, there is now evidence that HIV seroprevalence has stabilized in some areas, such as New York City (Des Jarlais et al., 1989; Stoneburner et al., 1990)
From page 46...
... in northeastern cities that have been attributed to homosexual contact or IV drug use, 1982-1989. (Cases reported as both IV drug use and homosexual/bisexual contact are not shown.)
From page 47...
... Small surveys of crack users have indicated an association between crack use and sexually transmitted diseases (STDs) (Fullilove et al., 1989)
From page 48...
... The majority of women represented by these statistics have a history of intravenous drug use; a subset report no drug use themselves but indicate a sexual relationship with an intravenous drug user in their risk profile. The range of women at risk for AIDS, however, goes beyond those involved through drug use.
From page 49...
... AIDS case data show that women are at greater risk than men of acqu~nng infection through heterosexual contacti4 and that the proportion of U.S. AIDS cases attributable to heterosexual contact is growing.is A majority of female heterosexual cases, however, are related to sexual contact with an infected intravenous drug user.l6 Thus, women are at risk for HIV infection both directly through their own drug use and indirectly through sexual exposure to partners who inject drugs.
From page 50...
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From page 52...
... This route of transmission accounts for only a small proportion of all AIDS cases, but it accounts for a greater proportion of AIDS cases among women than among men, a finding that is related to gender differences in the distribution of cases across transmission categories. Because all blood donors are now screened for risk factors and all rlonntinn~ urn.
From page 53...
... Small surveys of female sexual partners of hemophiliac men have found between O and 21 percent to be infected (Kim et al., 1988; Ragni et al., 1988; Smiley et al., 1988; Lawrence et al., 1989;19901. In addition, women who have received needle-stick injuries while helping to administer clotting factor treatments to an infected male partner may also be at risk (Smiley et al., 19881.~9 The AIDS case data thus present a picture of emerging risk for women, one that is strengthened by recently available seroprevaTence data on HIV infection ire this population.
From page 54...
... arnd neonatal seroprevalence rates reflect the differential risk of AIDS among minority women.24 Among births in New York City, racial and ethnic trends are spiking: 2.17 percent of black, 1.46 percent of Hispanic, arid 0.39 percent of white newborns were found to have antibodies to HIV (Novick et al., 19891.25 Disproportionate rates of infection among black arid Hispanic women have been seen in other parts of the country as well.26 An association has been noted between IV drug use and the risk of HIV infection for a substantial portion of pregnant women and their babies.27 In New York City, the neonatal seroprevalence rate was 2.2 Lambert reviewed the New York neonatal data for the New York Times (January 13, 1988, pp.
From page 55...
... The male-to-female ratio is approximately 1:1 in these countries, pennatal transmission is more common than in other areas, and intravenous drug use and homosexual transmission occur at a very low level. CThis category includes cases currently under investigation for which no history of exposure has yet been reported and cases for which no exposure mode could ever be detennined.
From page 56...
... Five of the six studies in Table 1-4 that report seroprevalence rates of 10 percent or greater are based on samples of female intravenous drug users.29 It is difficult to draw conclusions from these studies, however, because of venous methodological constra~nts.30 Seroprevalence studies of female applicants for military service and women on active and reserve duty in the U.S. Army provide another view of the pattern of infection in a large population of women.3i Since October 1985, 383,112 women have been tested by the military for antibodies to HIV.
From page 59...
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From page 60...
... For example, a subset of women injectors report a history of physical and sexual abuse (Weiner, Kaltenbach, and Finnegan, 1989; Worth et al., 1989~. hndeed, as Worth and her coworkers reported in art ethnographic study of 96 female intravenous drug users from the South Bronx, drug-related violence and illegal activities often characterize the relationships of these women with their sexual parmers.
From page 61...
... 3~.36 Preliminary data from the NIDA-sponsored multisite study of female {V drug users indicate that the majority of women who report injecting drugs have shared injection equipment and rented or borrowed equipment in the past (Sowder, 340f the women (N = 1,229) participating in a NIDA demonstration projects on which Sowder, Weissman, and Young ( 1989)
From page 62...
... In interviews with 736 female injectors who are participating in the NIDA demonstration project, 38 percent reported two or more sex partners who injected drugs, and 83 percent stated that they never or rarely used condoms (Sowder, Weissman, and Young, 19891. A separate survey of IV drug users recruited from the streets of Long Beach, California (110 of whom were women)
From page 63...
... As is true for any woman of childbearing age who is at risk of becoming infected, women who inject drugs have the potential to transmit HIV vertically to their offspring. Stereotypical depictions of IV drug users do not usually include a family and children.
From page 64...
... Although there has been only limited research on this group, service providers, law enforcement officials, and the drug users themselves indicate that the population is quite diverse with respect to race, ethnicity, education, and income (Arguelles et al., 19891. Some researchers have suggested that many female sexual partners of men who inject drugs do not themselves use drugs intravenously (Des JarIais et al., 1984; Murphy, 1987~42 and therefore are not at direct risk of acquiring HIV from this mode of transmission.
From page 65...
... Female Sexual Partners of Male Hemophiliacs and Transfusion Recipients Women who engage in unprotected intercourse with men who have become infected through exposure to contaminated blood are themselves at risk of acquiring HIV infection, although the exact extent of the risk is not known. As of December 1989, 48 current or foyer heterosexual partners of hemophilic men had been diagnosed with AIDS; an additional 59 reported cases among women were ascribed to sexual contact with a transfusion recipient (CDC, l990a)
From page 66...
... When the only reported risk factor is unprotected vaginal intercourse, it appears that seroconversion rates among the female sexual parmers of infected hemophiliacs are generally Tow (Brettler et al., 1988; Kim et al., 1988; Ragni et al., 1988; Jackson et al., 19891. Yet despite the incomplete understanding of the association between risk and infection in this population, the committee would emphasize that repeated exposure through unprotected intercourse can and does lead to infection among female sex partners of infected men (Lawrence et al., 1990~.
From page 67...
... Seroprevalence estimates for IV drug users, for example, often come from samples of convenience recruited through treatment programs or criminal justice agencies. Seroprevalence data for the gay male population come from a variety of sources, including smaller studies of patient populations recruited through STD clinics and HIV testing and counseling facilities.
From page 68...
... As discussed earlier, CDC's population-based serologic survey of newborn infants has generated some new and very valuable data on infection rates among childbearing women. This effort is only one of several systematic inqu~nes~DC's "family" of surveys intended to measure the prevalence of infection in potentially high-risk locations and subpopulations (e.g., clients at STD clinics, patients at certain "sentinel hospitals," college students)
From page 69...
... At present it is not possible to predict how rapidly HIV will spread among crack users. Factors that affect the rate and extent of spread and that require monitoring include the following: · the number of people who use crack, the frequency with which it is used, and the contexts in which it is used; · the efficiency of heterosexual transmission of HIV from males to females and from females to males; · the number of already-infected persons who may bring the virus to locations where sex is exchanged for crack; · the rates of partner change among different groups of crack users; · the extent to which syphilis and other STDs facilitate HIV 52Several studies from New York City indicate that many of the IV drug users who are dying from HIVrelated illnesses have never developed Kaposi's sarcoma or an opportunistic infection, the previous criteria of the case surveillance definition of AIDS (Selwyn et al., 1988; Stoneburner et al., 1988)
From page 70...
... , and methods for facilitating change in the sexual behavior of persons who continue to use crack. Understanding the use of crack and its role in the spread of HIV infection will require basic behavioral research, research on the social factors associated with initiating and sustaining crack use, biological research to determine effective treatment strategies, and demonstration projects to assess the effectiveness of intervention efforts.
From page 71...
... , improvement will demand that new and younger cohorts be recruited as part of ongoing efforts to understand the disease's natural history and changing patterns of risk. For drug users, improvements in data quality will require innovative sampling strategies, modification of existing surveillance approaches, and attention to the appearance of new drugs whose use may pose additional risk to this population.
From page 72...
... (1989) Female sex partners of IV drug users: A study of socio-psychological characteristics and needs.
From page 73...
... (1989) Female intravenous drug users and pennatal HIV transmission.
From page 74...
... (1989) HIV-1 infection among intravenous drug users in Manhattan, New York City, from 1977 through 1987.
From page 75...
... (1988) Crack use puts women at risk for heterosexual transmission of HIV from intravenous drug users.
From page 76...
... (1989) Sex practice correlates of human immunodeficiency virus transmission and acquired immunodeficiency syndrome incidence in heterosexual parmers and offspring of U.S.
From page 77...
... (1987) Heterosexual contacts of intravenous drug users: Implications for the next spread of the AIDS epidemic.
From page 78...
... (1989) Risk factors for human immunodeficiency virus infection in intravenous drug users.
From page 79...
... (1989) Perception of AIDS risk among women sexual partners of intravenous drug users in San Francisco.
From page 80...
... (1989) HIV infection in female intravenous drug users in San Francisco.


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