Epidemiologic Profile of HIV/AIDS in Delaware: 2001 Delaware AIDS Epidemiologic Profile: 2001 EXECUTIVE SUMMARY AIDS continues to impact the residents of Delaware. Over 2,800 cases of AIDS have been reported in Delaware since reporting began in 1981. Ongoing advances in medical treatment and combination therapies have individuals living longer with the disease. At the end of 2001, the number of people living with AIDS in the First State exceeds 1,350. In calendar year 2001, an average of 5 new Delaware AIDS cases were reported every week. The increase in the numbers of new AIDS cases in 2001 is attributed to the finding of unreported AIDS cases upon implementation of HIV reporting in July of 2001. Historically, the average number of cases reported per week peaked at 7.4 in 1993, when the AIDS case definition was expanded. A gradual decline in the number of new AIDS cases reported on a weekly basis continued until 2001. Over three quarters (76%) of Delaware AIDS cases are male. The distribution by transmission mode in men is now 41% in men who have sex with men and 40% are injecting drug users. About 24% of the AIDS cases are in women. More than half (51%) of the female cases are women who were exposed through intravenous drug use. Forty-three percent (n=288) of the women were infected heterosexually, with 167 (58%) infected through sex with an IDU. Thirty-eight percent (n=109) were identified as sex with a person with HIV/AIDS. A continued rise in the number of cases infected through heterosexual contact, defines the need to continue to provide AIDS education to all Delaware residents. A general alarm needs to be sounded that AIDS has not gone away and the treatments available are not yet a cure. Education regarding the spread of the virus to others and resistant strains of HIV is needed for individuals infected with HIV/AIDS. Delaware’s AIDS cases are racially disproportionate with the population. African American AIDS cases comprise about 66% of the cases, whereas 19% of the Delaware population is African American. Multiple outbreaks of sexually transmitted disease cases in 2001 points to continued engagement in risky behaviors among the population. Individuals can not be infected with HIV unless they are engaging in activity with an already infected partner. These individuals are engaging in high-risk behavior (sexual or drug use), which puts them at that much higher risk for HIV infection. Delaware implemented name-to-code based HIV reporting in July 2001. HIV case reports will be collected for one year before analysis is conducted. A report on the HIV data will be released in the fall of 2002. BACKGROUND AND INTRODUCTION Since 1984, Delaware has tracked AIDS cases by compiling information from health care professionals, laboratories and physicians. The early years of the epidemic indicated White men who had sex with men were the predominant population at risk and reported with AIDS. Examining recent data shows the trend is shifting to African Americans, heterosexual exposure, and female cases. Data presented here are current through December 31, 2001. Community prevention planning groups, health educators, and health planners may use the data to help guide risk reduction and public health interventions aimed at reducing the numbers of HIV- infected individuals in Delaware. Regulations for the Control of Communicable and Other Disease Conditions were revised in July 2001. The revision includes the reporting of HIV cases, through a name to code system, to the HIV/AIDS Epidemiology office. An ample amount of HIV data will need to be collected before it is analyzed and disseminated. Therefore, HIV data is not included in this report. METHODS The purposes of the epidemiologic profile are multi-focal. First, to describe the distributions, trends, and impact of acquired immunodeficiency syndrome (AIDS) in Delaware. Second, to provide information for planning, prevention and education programs centered on the human immunodeficiency virus (HIV). The last focus is to deliver an assessment of needs for those living with HIV/AIDS in Delaware. Because data are continually collected, updates are provided annually and on request. The five main questions used to outline data in this profile are: 1. What are the socio-demographic characteristics of the population? 2. What is the impact of HIV/AIDS on the population? 3. Who is at risk for becoming infected with HIV? 4. Who is infected and who is in care? 5. What is the geographic distribution of AIDS? Data from a variety of sources are combined, analyzed and presented in response to each of the main questions. Additional subtopics related to specific Delaware populations are addressed. Sources for data presented include: AIDS surveillance activities, CDC national statistics on HIV/AIDS, HIV counseling and testing data, BRFSS, STD data, and the vital statistics annual report. For analytic and publication purposes, Delaware data presented in this profile are current through December 31, 2001. If the reader has specific questions, the surveillance office can provide assistance locating appropriate data sources. DATA SOURCES Case report forms are submitted by medical professionals throughout the state and vary in completeness and timeliness. The software used nation-wide for storing of HIV/AIDS data is HARS (HIV/AIDS Reporting System)1. AIDS data are the only consistently reported data across the nation, resulting in population-wide statistics in all states. AIDS data may not represent all AIDS- defined individuals due to delays in reporting and noncompliance with reporting policies. The Supplement to HIV/AIDS Surveillance (SHAS)2 project is a federally funded grant initiative through which adult AIDS patients are interviewed for additional information. Interviews address a multitude of topics including: socio-demographic factors, sexual and medical history, drug and alcohol use, access to medical and social services, gynecological and reproductive histories (females), and preventive therapy. Due to the sensitivity of questions, criteria for inclusion in the study and lengthy interview session, a limited number of interviews have been completed since the study’s inception in 1991. Questions regarding behavior and treatments allow investigators more detail on these topics than from other sources. Since the project involves interviewing patients, data are subjective and from the patient’s perspective. Therefore, respondent bias is inherent in this data set. All data from SHAS interviews are confidential and linked to surveillance data through patient numbers and not identifying information. The SHAS survey instrument was revised in 2000 and the data in the 2002 profile reflects on information collected in the new Version 6. Sero-surveys in drug treatment centers, women's clinics, and hospitals are not currently funded. Data collection was completed in 1996 and is not presented in this profile. Through state funding, the study of childbearing women (SCBW)3 was re-started in 1999. Heel stick specimens are collected on all infants born in Delaware. The data are blinded and unbiased. Yet, it only represents women delivering live- born infants and provides no risk information. HIV counseling and testing data is collected on a standardized data collection form. Repeat tests can not be distinguished in this data set. Detailed information on risk behavior among test seekers is available and is published in the HIV Counseling and Testing Annual Report. The HIV/AIDS Surveillance Report through 2000, published by the Centers for Disease Control and Prevention, is used frequently in the profile for national data. The report for the period ending 2001 will not be available until approximately June 2002. The report is the compilation of HIV/AIDS surveillance information made available to the public via the Internet. The website: http://www.cdc.gov/hiv/dhap.htm can provide the reader with a wealth of information and slide presentations. Epidemiology When investigating an epidemic, questions relating to person, place and time are important to sort out pertinent information. Person: Mode of exposure is used to classify patients. A patient is characterized by the main mode of transmission of HIV infection. From personal interviews, case report forms, and medical record reviews, surveillance staff can help characterize the mode of exposure so a patient is categorized correctly. Place: In this epidemiologic profile, place refers to zip code of residence at time of diagnosis. There is always potential for a person to move either north or south in the state – but all information is based on reported zip code. Additionally, surveillance extends to other states. If a case resides elsewhere or was diagnosed elsewhere, staff will contact the other state for confidential data- sharing purposes. Time: Throughout the statistical presentation, date of report and date of diagnosis are used to define time periods. There can be a lag between date of diagnosis of an AIDS-defined person and the date the individual was reported to the Division of Public Health (DPH). Therefore, date of diagnosis is used, unless otherwise stated. Risk: Individuals are identified by behaviors that put them at risk of HIV infection. CDC established a hierarchy to classify a person’s most likely route of exposure, or HIV risk. Data collected allows a person to be classified by the risk that most likely exposed the individual.5 In 1993, the Centers for Disease Control and Prevention (CDC) revised the AIDS case definition. The United States saw an increase in cases around 1993-1994 due to the expanded definition. The new definition included persons previously unreported until several AIDS indicators were added to the case definition. These indicators include: severe immune-compromised individuals with CD4 counts <200 µ/L or <14%; invasive cervical cancer; recurrent pneumonia; and pulmonary mycobacterium tuberculosis. All AIDS patient data is strictly confidential and is collected for epidemiologic purposes. Confidentiality of HIV/AIDS case reports is important to maintain an effective HIV/AIDS surveillance system. The Delaware Division of Public Health's HIV/AIDS Epidemiology office has confidentiality and security protocols outlining physical, operational, and personnel security standards. These standards must be maintained to receive federal funding. Data-release policies guide the presentation of data to ensure AIDS data do not allow for individual identification. Tables must not present data in a manner that would allow for individual identification. Reporting small numbers, in a table, may inadvertently cause an individual to be identified. In these cases data in small cells may be combined but are generally identified in the footnote. DEFINITION OF TERMS Adult/Adolescent case: Patient is 13 years of age or greater at the time of diagnosis. Epidemiology: Study of factors (age, race, and gender) that affect disease distribution in the human population. Heterosexual: Persons with a history of sexual contact with a person of the opposite sex, and may include heterosexual relations with: injecting drug user; bisexual male; person who had a transplant or transfusion; or person with AIDS or undocumented HIV infection. Incidence: Number of new cases divided by the population at that specific time. NIR case: No identified risk – risk was unable to be ascertained through investigation to date. NIR cases are reclassified as information is obtained through a complete epidemiologic investigation. Pediatric case: Patient is less than 13 years of age at diagnosis. Prevalence: Number of existing cases per standard population. Rate: Number of cases divided by specific population of a given group. Rates allow for the direct comparison of different groups by taking into account the varying population size. Transfusion case: Person who acquired the virus as a result of receiving blood or blood products. Year of diagnosis: Measure when disease event occurred. Year of report: Measure of when the HIV/AIDS surveillance office received case report. 8 ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome A/PI Asian/Pacific Islander BRFSS Behavioral Risk Factor Surveillance Survey C/T Counseling and Testing Services DPH Division of Public Health HARS HIV/AIDS Reporting System (software) HIV Human Immunodeficiency Virus IDU Injecting Drug Users MSM Men who have Sex with Men MSM/IDU Men who have Sex with Men and Inject Drugs NA/AN Native American/Alaskan Native NIR No Identified Risk PLWA People living with AIDS SCBW Study of Childbearing Women SHAS Supplement to HIV/AIDS Surveillance STD Sexually Transmitted Disease CAUTIONS IN USING DATA Readers should use caution when reviewing data. Listed below are “hints” to help you understand the report. If you have further questions, please contact the epidemiology office. Case rate: A rate is a measure of the frequency of an event (disease) compared to the number of persons in the group in which it occurs. An example: if there are 700 White AIDS cases in Delaware and the White Delaware population was 700,000; the case rate would be 100 per 100,000. That means for every 100,000 people, there would be 100 AIDS cases. Dates: Be careful interpreting trends over time. Though it may be enticing to jump to conclusions about changes over time – look carefully at the data. Are the changes over an extended period? Is it a small percentage change in one year? Graphs and tables: Examine the title. Does it indicate a time period? Does the graph represent all cases or just one group (men, women, IDU or MSM)? Are data represented as the number of cases, a percentage of cases or as a case rate? Data limitations: Does the author provide information on each data source? What type of data collection method was used? Does the data include repeat patients? QUESTION 1: WHAT ARE THE SOCIO-DEMOGRAPHIC CHARACTERISTICS OF DELAWARE? Delaware, the First State, ranks 49th in the nation for total area with 1,954 total square miles. Delaware’s population was estimated to be 783,600 in the 2000 Census. The population density is 401 persons per square mile. The US Census Bureau 6 provides current county estimates for 2000. Delaware’s population is 73% urban and 27% rural. The Census Bureau indicates the population of Delaware increased for 2000 by greater than 30,000 residents. More than half of the population growth was in “rural” Sussex County. As demonstrated in Table 2A, the majority of Delawareans live in New Castle County (64%). Dover, the state capitol, is in Kent County where approximately 16% of the population resides. Females comprise 51% of the population. Nineteen percent of Delawareans are Black. Kent County has the highest percentage of Black residents among the three counties. According to Delaware Health Statistics Center 7, there were 11,046 births in Delaware in 2001. Of these births, 7,889 were to White women, 2,634 were to Black women and 1,023 were to women of Hispanic ethnicity. Table 2B illustrates the race/ethnic population in each county. Delaware’s unemployment rate remains at or below national rates. In 2000, Delaware’s unemployment rate was 4%. In 2001, the unemployment rate in Delaware8 was 3.5%, while nationally the unemployment rate was 5.8%. According to the Delaware Department of Correction9, Correctional facilities in Delaware house approximately 6,350 inmates through the end of 2001. About 42% of Delaware citizens, over the age of 25, have a high school degree (or equivalent). Among the citizens over age 25, seventeen percent have some college and 12% are college graduates. Agriculture, fishing, mining, and the manufacturing industry support Delaware's economy. Among the items produced in Delaware are chemicals, food products, paper products, rubber and plastic products, and primary metals. The banking industry is the biggest private employer in the state. Delaware's largest private employer is MBNA America followed by Du Pont. The State of Delaware is the largest public employer. The Bureau of Economic Analysis, Department of Commerce10 reports, Delaware’s per capita personal income was $31,074 in 2000. In the second quarter of 2000, Delaware was one of the six states with the fastest growth in personal income (up 2.4%). Approximately 10% of Delawareans live below the poverty level. QUESTION 2: WHAT IS THE IMPACT OF HIV/AIDS ON THE POPULATION? As defined on page 10, the time a disease event occurs is the year of diagnosis. At times, there may be a significant delay between when the diagnosis is made and when the information is reported and received by surveillance. Table 3 illustrates the difference in the number of cases diagnosed and reported each year. Additional cases diagnosed in 2000 – 2001 may well be received. As the cumulative columns in Table 3 demonstrate, by 1990 more cases had been diagnosed than were reported to surveillance. These cases may have been reported at a later time. This trend continues through 2000, as a cumulative total of 2646 cases were diagnosed, yet only 2560 were reported. In Delaware, 2,820 persons have been diagnosed with AIDS. Approximately 1,462 persons have died, representing 52% of the cases. There is a racial disparity between the cases reported, as will be described later in the profile. The number of cases diagnosed each year appears to be decreasing since a high of 290 diagnosed cases in 1994. The large number diagnosed in 1993-94, and subsequently reported, may be due to an artificial increase as a result of the 1993 AIDS definition change. In 2000, however, 212 cases were diagnosed and 222 were reported. In 2001, 174 cases were diagnosed and 260 cases reported. This is the second year of an increase in cases. It may be due to the implementation of HIV reporting in July 2001, enhanced surveillance activities, or to the true picture of Delaware's epidemic taking shape. National surveillance efforts have reported 322,865 persons living with AIDS and 127,058 persons living with HIV through December 2000. The national annual case rate per 100,000 population was 14.3 for January 2000 – December 2000. Delaware’s rate per 100,000 population for the same time period was 28.0. Delaware continues to rank among the top ten states for case rates per 100,000 population. Delaware’s population is small compared to other states. Therefore, an increase of 10 cases will affect our case rate more than it would affect the case rate of more populous states. Data from the Delaware Health Statistics Center indicates a decline in deaths due to HIV/AIDS. In 1996, 132 deaths were due to HIV/AIDS, while in 1999 there were 65 deaths due to HIV/AIDS. Living cases are increasing across all demographic groups. In 2000, the prevalence rate (living cases in Delaware) was 156 per 100,000 population. There was a 10% increase in the prevalence rate in 2001, with a rate of 173 per 100,000 population. Overall, for all 2,820 reported cases, CD4 immune deficiency was reported in 79% of cases, PCP in 31%, wasting syndrome in 21%, esophageal candidiasis in 12%, and mycobacterium avium in 10% of cases. Patients may have more than one opportunistic infection, so the percentages will add to more than 100%. GENDER Male AIDS cases continue to dominate case reports. Males represent 49% of Delaware’s population, yet 76% of the AIDS cases. Females represent 51% of Delaware’s population, and 24% of the AIDS cases. Since 1985, when the first AIDS case was diagnosed in a Delaware female, AIDS cases have increased in the female population. Nationally, 43% of all cases reported through December 2000 were White, 38% were Black and 18% were Hispanic. However, when the national numbers are viewed by gender, the proportion of cases by race/ethnicity depicts a growing epidemic in Black women nationally. Through the end of 2000, female AIDS cases reported nation-wide were 58% Black, 21% White, and 20% Hispanic. The male AIDS cases, reported to CDC through December 2000, were 47% White, 34% Black and 18% Hispanic. This data correlates with national data provided by CDC. In absolute numbers, Blacks have outnumbered Whites in new AIDS diagnoses and deaths since 1996 and in the number of people living with AIDS since 1998. AGE The majority of Delaware’s cases were diagnosed between ages 30-39 (47%). The age distribution of AIDS cases in Delaware is similar to the national distribution. Delaware AIDS cases are getting diagnosed at older ages. This may be due to increasing effectiveness of medications prolonging the period between HIV infection and AIDS diagnosis. Table 5 compares cases reported through December 1991 with all cases reported through December 2001. As demonstrated, an increasing number of cases are diagnosed in age group 40-49 years. MODE OF EXPOSURE For surveillance purposes, AIDS cases are counted only once in a hierarchy of exposure categories. Persons with more than one reported mode of exposure to HIV are classified in the category listed first in the hierarchy, except for men with both a history of sexual contact with other men and injecting drug use. They comprise a separate exposure category. This hierarchy of exposure categories in adult/adolescent cases is as follows: 1. Men who have sex with men 2. Injecting drug user 3. Men who have sex with men and inject drugs 4. Heterosexual contact a. sex with an injecting drug user b. sex with a bisexual male c. sex with a person with hemophilia d. sex with a transfusion recipient with HIV e. sex with a transplant recipient with HIV f. sex with a person with AIDS/HIV; with a risk unspecified 5. Transfusion of blood/blood components 6. Transplant of tissue/organs or artificial insemination 7. Worked in a health care or laboratory setting If a patient admits to certain sexual or drug use behaviors, the patient is ranked along this continuum of possible exposures to HIV. Nationally, 9% of the cases reported through December 2000 were without risk identified. Surveillance personnel place high priority on determining risk for these patients and 2% of Delaware’s cases at the end of 2001 are currently classified as “no identified risks” (NIR). Male cases Men who have sex with men (MSM) remain the most affected group among men in Delaware. Forty-one percent of male cases acquired HIV through having sex with other men. Injecting drug use (IDU) account for 40% of Delaware’s male AIDS cases. A third group combines men who have sex with men and inject drugs (MSM/IDU). This group accounts for 8% of Delaware’s male cases and is often treated separately. Nationally, 56% of male cases are MSM, 22% IDU and 8% MSM/IDU. Heterosexual cases and other modes comprise 8% of male cases in Delaware and 15% nationally. With the 1993 definition change, the main mode of transmission went from MSM to IDU in Delaware. Figure 5 illustrates the increase among male IDU cases. However, tentative data from 1999 - 2000 indicate a slight increase in the MSM cases, in addition to a decrease in IDU cases. Because 2001 data are not complete, this is provisional. Female cases Female cases in Delaware are primarily infected through injecting drug use (51%). Heterosexual contact is noted as the mode of exposure for 43% of the female cases. Nationally, 40% of the female cases are heterosexual contact and 41% are injecting drug use. Slightly more than half (58%) of the women exposed to HIV through heterosexual contact indicated heterosexual contact with an injecting drug user. Other modes of transmission in this sub-population were heterosexual contact with a bisexual male (4%) and heterosexual contact with a person with HIV/AIDS (38%). Figure 6 describes the distribution of all female AIDS cases in Delaware. New Castle County cases are mostly Black (70%) and male (75%). Injecting drug use accounts for 56% of the female New Castle County cases and 46% of the male New Castle County cases. Kent County has 253 AIDS cases, 56% of which are Black. Female Kent County cases are largely infected through heterosexual contact (57%). Male Kent County cases are mostly men who have sex with men (43%). Sussex County has reported 380 AIDS cases. These cases are almost evenly divided among two racial groups (46% Black and 51% White). Men who have sex with men account for 64% of the male Sussex AIDS cases. Injecting drug use accounts for 18% of the Sussex male cases and 32% of the Sussex female cases. More than half of the female AIDS cases in Sussex were infected through heterosexual contact (59%). Of the 250 cases reported from corrections, 88% are in New Castle County facilities and 11% in Sussex facilities. Eighty-eight percent of the inmates are Black and injecting drug use is the primary mode of transmission (70%) Additional information on the geographic distribution of AIDS cases in Delaware can be found under Question 4. QUESTION 3: WHO IS AT RISK FOR BECOMING INFECTED WITH HIV? Community planning groups rely on data describing modes of transmission to help prioritize populations and identify groups affected in the region. Information on mode of transmission (also called mode of exposure) provides insight into groups that may be at increased risk in the future. As mentioned previously, individuals are identified by behaviors that put them at risk of HIV infection. MEN WHO HAVE SEX WITH MEN (MSM) Through December 2001, eight hundred eighty four MSM cases have been reported in Delaware. MSM cases comprise 40% of Delaware’s male cases. From a national perspective, 355,409 MSM cases reported through December 31, 2000, representing 56% of the male AIDS cases nationally. In the “early” years of the epidemic (1981-1990), the majority of MSM cases were White (72%). In more recent years (1991-2001), the MSM epidemic is distributed among White males (59%) and Black males (37%). Figure 9 demonstrates the general decrease in White MSM AIDS cases. Data from 2001 can not be considered as complete as additional cases are sure to be reported. Therefore, any trends that may appear to be descending may not reveal the true picture in this population. In Delaware, geographical differences are evident in the MSM population. Sussex County has reported 220 MSM cases. Seventy-two percent of the Sussex MSM cases are White. Compared to New Castle County, Sussex has a more defined epidemic among White MSM. New Castle County has reported 583 MSM cases, with 55% among Whites and 40% among Blacks. Kent County has the smallest number of MSM cases (n=81). Just over half of Kent County MSM cases are White and 44% are Black. Through the end of December 2001, forty-one percent (n=362) of the MSM diagnosed while residents of Delaware, were known to be alive. The treatment location field of the HIV/AIDS Reporting System (HARS) shows 94% of the living AIDS- defined MSM are in treatment and accessing care as depicted in Figure 10. Data shows 168 clients attend an ID or Wellness clinic, and 138 are seeking their care through private physicians. Other clinics include HIV specialty clinics in Maryland, Pennsylvania, Veteran’s Hospitals and prison infirmaries and are attended by approximately 30 cases. There is no information provided or known on the treatment location for 23 (6%) of the cases. BISEXUAL (SEX WITH A PERSON OF THE SAME SEX AND OPPOSITE SEX) As mentioned on page 14, the mode of transmission or exposure, is used to classify patients along a risk hierarchy. If a patient admits to certain sexual or drug use behaviors, the patient is ranked along a continuum of possible exposures to HIV. Though bisexuality is not an assigned risk in the HARS database, the capability exists for the bisexual population to be identified and analyzed. Bisexuals are identified by extracting the number of cases who are reported to have had sex with someone of the opposite sex as well as with a person of the same sex. Of the adult/adolescent cases reported through the end of the 2001, thirty nine women were reported as having sex with both a male and female. The number of men reported as having sex with a woman in addition to sex with another man totaled 385. The majority of the bisexual women, 82% (n=32), are African American with 10% White and 8% Hispanic. Setting aside their sex with women, 85% (n=33) of the 39 women are classified as IDU. Thirteen percent (n=5) had sex with a man with HIV/AIDS. The remaining 2% are other risks not identified due to small cell sizes. Of the 385 men who had sex with other men and with women, 227 (59%) are African American. Thirty seven percent (n=142) are White. Hispanic men account for 16 (4%) of the cases. Prior to identifying the men as having had sex with women as well, they are reported as 76% (n=292) MSM and 24% (n=93) as IDU. The information provided on bisexual activities, in the adult/adolescent Delaware AIDS population, is anecdotal. The information serves to identify co-contributors to the spread of HIV to the CPG. INJECTING DRUG USE (IDU) Delaware has reported 1,204 AIDS cases contracted through injecting drug use, 857 male and 347 female. IDU cases represent 40% of total male cases and 51% of total female cases. The majority of IDU cases are Black (82%). The IDU AIDS epidemic affects a wide range of ages, with the largest group being diagnosed between 30-39 (47%). The age range for age at diagnosis of IDU cases is 19 to 80 years. Eighty-six percent of the IDU cases are located in New Castle County. Supplement to HIV/AIDS Surveillance (SHAS) interview data about persons who inject drugs and use non-injection drugs allows prevention planning groups additional insight into the community. One hundred twenty SHAS interviews were conducted in 2000-2001. Of those interviewed 48% (n=57) stated they had at sometime in their lifetime injected drugs. The IDUs were 74% male (n=42) and 26% female (n=15). The age the SHAS participant first injected drugs range from 15-44 in men and 13-40 in women interviewed. Fifty-two (91%) denied injecting drugs in the past year (12 months). Detailed demographics on the IDU population interviewed in 2000 and 2001. Non-injection drug use continues to be high among SHAS participants. Marijuana is the most commonly used non-injection drug, followed closely by cocaine. More than half,55% (n=66), of the 2000-2001 SHAS participants have used crack. Sixty-one percent(n=40) of the crack users acknowledged that they had used crack in a crack house and 33% (n=13) stated they had sex in a crack house. The distribution of those having sex in a crack house by gender is 69% (n=9) male and 31% (n=4) female. MEN WHO HAVE SEX WITH MEN AND INJECT DRUGS (MSM/IDU) As previously noted, men having sex with men who also inject drugs (MSM/IDU), presents a unique opportunity for prevention outreach work. There have been 169 AIDS case reports submitted with the risk identified as MSM/IDU. African- Americans represent 67% (n=114) of the MSM/IDU cases. The age range at diagnosis is 24 to 69 years, though 57% (n=97) were diagnosed between 30-39 years of age. Seventy-nine percent of the MSM/IDU cases were diagnosed in New Castle County. Of the living MSM/IDU cases, 81% (n=56) are currently residing in New Castle County. Thirty-eight (68%) of the 56 cases in New Castle County, were also reported as having had sex with a female (bisexual). Twenty-eight (74%) of the bisexual/IDU cases are African-American. Five MSM/IDU cases were reported as not having had sex with a female and whether the man had sex with a woman was documented as unknown in 13 cases. HETEROSEXUAL The heterosexual AIDS epidemic affects more women than men in Delaware. There are 439 heterosexual cases in Delaware, of which almost 67% are female. Seventy- eight percent of those infected through heterosexual contact are Black. Seventy-two percent of the heterosexual cases were diagnosed in New Castle County. The age distribution of heterosexual cases is widely dispersed. The range in age at diagnosis is 16-74 years for heterosexual cases. Forty-one percent of the cases were diagnosed between ages 30 and 39. Figure 14 shows age distribution by gender. Heterosexual contact cases include individuals who had heterosexual relations with injecting drug users, bisexual males, hemophiliacs, transfusion recipients, and/or persons infected with HIV/AIDS. In Delaware, 57% of the heterosexual cases indicated heterosexual contact with an IDU. Forty percent indicated heterosexual contact with a person living with HIV/AIDS. Similar proportions hold across both genders as indicated in Figure 15. Nationally, 10% of all AIDS cases are reported as heterosexual contact. Fifty- seven percent noted sex with an HIV-infected person and 37% indicated sex with an injecting drug user. Treatment locations for the living heterosexual AIDS cases diagnosed through 2001 are illustrated in Figure 16. Participants in the revised SHAS project who had sex with a person of the opposite sex in the “past 12 months” numbered 65 (54%%) in 2000 and 2001. The revision to the questionnaire expanded the information available on condom use. It is now possible to compare the use of condoms as a barrier to transmission and protection from re- infection. Participants were asked: 1. “Have you had sex with a man (or woman respectively) in the past 12 months? ” Those who responded yes were additionally asked: 2. “Have you been in a steady relationship with a man (or woman respectively) in the past 12 months? By steady relationship I mean a relationship with a man (or woman respectively) where you feel committed to him above anyone else AND where you have sex together. Those who responded yes were additionally asked 3. “The last time you had sex with your steady partner, did you have vaginal sex?” Those who responded yes were asked: 4. “Was a condom used?” The participants were then asked questions 3 and 4 in regards to sex with “a man (or woman respectively) other than your steady sex partner?” Figure 17 compares the use of condoms with a steady partner to use with “other” partner(s) in men. Participants with steady partners are not excluded from having “other” partners. HISPANIC Delaware's Hispanic population is hard to quantify. Through December 2001, 147 AIDS cases have been reported among Hispanics. This represents just 5% of the total AIDS cases reported in Delaware. WOMEN Delaware has received 677 AIDS case reports for women. The majority are Black (80%). The female epidemic in Delaware appears centered in New Castle County (81%). The age range for female cases is 0-76 years; average age at diagnosis was 36 years. Just under half (48%) of all female cases were diagnosed between ages 30-39. Injecting drug use accounts for 347 female AIDS cases (51%). Heterosexual contact with an injecting drug user adds 166 female AIDS cases (25%). Thirteen female pediatric cases were exposed to HIV/AIDS through their mother being an IDU or having sex with an IDU. Therefore, drug use is associated with over three-quarters of the female cases. Of the 677 female cases diagnosed fifty-eight percent (n=392) are living. Reproductive history data from SHAS indicate that of the 31 women interviewed in 2000–2001, thirteen (42%) had abstained from sexual intercourse in the past 12 months. Eighteen (58%) stated they had sexual intercourse in the past 12 months. COMMERCIALIZED SEX Questions in Version 6 of the Supplement to HIV/AIDS Surveillance (SHAS) booklet regarding the commercializing of sex are: 1. Has anyone ever given you money or drugs to have sex with them? 2. In the past 12 months, has anyone given you money or drugs to have sex with them? 3. Have you ever paid money or given drugs to have sex with you? 4. In the past 12 months, have you paid or given drugs to anyone to have sex with you? Of the 120 SHAS participants interviewed in 2000-2001, thirty-one (26%) related having received money or drugs from a person for sex. Less than 3% of the 31 had accepted drugs or money for sex in the past 12 months. Of the same 120 participants, 40 (33%) related having paid someone drugs or money to have sex with them. Four percent of the 40 paid drugs or money for sex in the past 12 months. More than 80% of the participants who exchanged drugs or money for sex are male. African-Americans accounted for 82% of the participants who exchanged money or drugs for sex. YOUTH The first enzyme immunoassay (EIA) for the detection of HIV-1 antibody was available in the U.S. in 1985. Even so, HARS allows for the analysis of adolescent cases where an age at first positive HIV test is known. The data in Figure 24 are retrospective, as it was not available until an AIDS diagnosis was determined. The 33 cases represented are those where it was documented the patient tested positive for HIV when they were greater than 12 years of age and less than 20 years of age. QUESTION 4: WHAT IS THE GEOGRAPHIC DISTRIBUTION OF AIDS? As previously stated the majority of AIDS cases in Delaware are diagnosed in New Castle County. New Castle County has reported 2157 out of the total 2820 cases reported through December 31, 2001. The City of Wilmington (defined as zip codes 19801, 19802, 19805, and 19806) has reported 1,297 cases. Table 9 shows the 'top five' zip codes for New Castle County where the epidemic has hit. WILMINGTON The Centers for Disease Control and Prevention (CDC) calculates the AIDS case rate for metropolitan areas with populations greater than 500,000. CDC calculated the case rate for Wilmington, January 2001 – December 2001, as 33.6 per 100,000 population. 4 The majority the 1206 Wilmington AIDS cases are male 71% (n=851). More than half (51%) of the men are IDU. MSM account for 31% of the male cases. Of the 851 men, 662 (78%) are Black. Among the 355 female cases reported from Wilmington, 89% (n=317) are Black. The most frequent mode of transmission among women is IDU with 217 (61%) and 35% were exposed through heterosexual contact.Seventeen pediatric cases have been reported from Wilmington. Ten of the thirteen were Black, and the remaining were Hispanic. KENT COUNTY has reported 255 AIDS cases. Sixty-one percent of these cases were reported with Dover zip codes. The remaining cases were reported from across the county, with few zip codes reporting more than 10 cases. DOVER Through December 2001, Dover had reported 155 AIDS cases. The majority (66%) are Black. Approximately 42% of the male cases are MSM, and 30% are IDU. Heterosexual contact was the mode of exposure for 64% of the female cases, and IDU accounted for approximately 32% of the female cases. SUSSEX COUNTY reported 408 AIDS cases. The majority were reported from zip code 19971 (Rehoboth/ Dewey Beach). Table 10 lists the 'top five' zip codes in Sussex County. Sussex County has an AIDS epicenter in the beach area. The HIV/AIDS Epidemiology office defines the beach as zip codes 19930 (Bethany), 19971 (Dewey, Rehoboth), 19944 (Fenwick), 19968 (Milton), 19969 (Nassau), and 19958 (Lewes). One hundred forty-two cases have been reported from the beach. The majority of these cases are White (82%) and male (96%). Table 11 presents a comparison of the beach area to the western part of Sussex County (remaining zip codes in Sussex). QUESTION 5. WHO IS INFECTED AND WHO IS IN CARE? Who is infected and who is in care is addressed in the mode of transmission section, though interspersed throughout the profile. The treatment locations for living Delawareans, in the four major modes of transmission and the female population, are reintroduced here for ease of review. In the interest of resource planning and allocation of funding, it is of definite interest to note where vulnerable populations choose to receive their care. In the case of patients who are IDU or MSM/IDU, a full 20% more attend an HIV Community Program Clinic, also called ID/Wellness Clinics, for their care. Proximity to the populations served and the general need to access affordable and cutting edge care are attributed to their choices. ADDITIONAL DATA SOURCES COUNSELING AND TESTING (C/T) DATA Counseling and testing data from the Annual HIV Counseling and Testing Report released March 2002 indicates over 13,500 tests were conducted in 2001. The following tables and graphs were compiled from data extracted from the CTS database for the time frame January 1, 1995 to December 31, 2001. The data utilized is the Counseling and Testing database compiled by the State of Delaware Division of Public Health and courtesy of Disease Prevention and Control Statistician, Carylon S. Comegys. The Supplemental HIV/AIDS Surveillance (SHAS) provides insight into the participants ways and means of testing and finding out about their HIV antibody status. In response to the following questions it is found: 1. Where were you tested when you had your first positive HIV test? a. 35 (29%) were in a hospital, b. 17 (14%) were in a private physician’s office, c. 13 (11%) were in a STD clinic, d. 12 (10%) in a correctional facility, e. 11 (9%) at a HIV C/T site f. and the remaining 19 (16%) were in a wide variety of other clinics. 2. When you first tested positive for HIV, did someone else recommend you get tested, did you decide to get tested yourself, or was the test required? a. 71 (62%) had the test recommended b. 43 (36%) decided on their own c. 3 (2%) said the test was required 3. When you first tested positive for HIV, what was the main reason you were tested? a. 69 (58%) said it was due to illness, b. 18 (15%) said because they were an MSM or IDU c. 9 (8%) said it was because they had sex with someone with HIV d. the remaining 24 (19%) had various reasons from “just curious” to “new relationship” to “don’t know”. 4. When you first tested positive for HIV, what type of test did you have? a. 83 (69%) indicated confidential b. 14 (15%) indicated anonymous c. 23 (19%) indicated they didn’t know what type of test was done BRFSS Behavioral Risk Factor Surveillance Survey11 for 2000, indicates 17% of the adult Delaware population, age 18-24 believed that their chances of chances of HIV infection were “medium to high”. In the age range 25-34, 5.7% of the adults believed their chances of HIV infection were “medium to high”. In 2000, a question was added to the survey regarding reason for HIV testing. Responses to the question are as follows: 23.7% - “to see if infected” 19% - “routine physical exam” 13.6% - “pregnancy test” 7.6% - “employment” 6.5% - “hospitalization” 6.5% - “military induction/service YRBS Data on the sexual behaviors in Delaware teens are assessed through the Youth Risk Behavior Survey12,13. The survey is conducted every two years in high schools around the state and measures six behavioral categories through 87 questions. A summary of information from 1999 and 2001 shows some notable changes in the sexual behavior of youth. TEEN HOPE Teen Hope programs are conducted through several School Based Health Centers and gather data around sexual behavior of participants. The survey completed on the student’s initial visit to the program is denoted by “1st update”. Once the student has participated in the program long enough to have completed 3 additional surveys, the responses to the last survey are compared to the first denoted as “4th update”. Table 13 illustrates the comparison of data gathered 1999-2001 for questions specific to abstinence and condom use13. TEEN PREGNANCY Teenage pregnancy rates can provide a glimpse into adolescent sexual activity. The United States spends at least $7 billion annually on costs associated with teenage pregnancy. In 1999, there were 2,157 teenage pregnancies in Delaware among 15-19 year-olds. Table 14 illustrates the gradual but consistent decline in teenage live birth rates in Delaware (highlighted). Teenage live birth rates represent the number of live births in a specific age group (e.g., 15-19) per 1,000 women in that age group13. AAPP, the Alliance for Adolescent Pregnancy Prevention, is a state-wide teen pregnancy prevention initiative with activities managed and administered by Christiana Care, Eugene duPont, Preventive Medicine & Rehabilitation Institute under contract from the Department of Health and Social Services, Division of Public Health13. Now in its 6th year, AAPP has had a major influence in the promotion of community programs and increased awareness of teen pregnancy throughout Delaware. AAPP accomplishments include: - Targeted Community Programs focused on teen pregnancy prevention - Mini-Grant Awards resulting in service provision to approximately 850 adults and youth. - Sexuality Education to support community-based programs focusing on sexual responsibility and postponement of sexual activity. - Media Campaign Initiatives featured award-winning advertising for messages like, “A Teen Parent’s New Set of Wheels” and “If You Think Homework Stinks, Try Changing Diapers”. - Resource Centers distributed more than 10,000 brochures, videos, pencils, pens, magnets and posters, secondary to written requests, telephone calls and in-person visits to the centers - Public Information Activities including the toll-free information and resource line (800-499-WAIT). SEXUALLY TRANSMITTED INFECTION/DISEASE (STI/STD) The STD database collects information on patients diagnosed with an STI or STD are helpful as indicators of high-risk activity in the population. Delaware collects data on gonorrhea, chlamydia, and primary and secondary syphilis. Supplemental projects, like the gonorrhea urine-screening project (GUSP), provide behavioral data. Delaware’s chlamydia case rate has continued to rise and move into a national ranking of 4th in 2000. With a case rate of 379 per 100,000 population, Delaware far surpasses the US case rate of 262 per 100,000 population15. The majority, 79% of cases reported in 2000, were between the ages of 15-24 (n=2267). Eighty percent of the chlamydia cases in 2000 were in women (n=2271). African American females (n=1414) accounted for 62% of the 2000 chlamydia cases. Table 15 describes the increasing chlamydia case rate for Delaware. Gonorrhea remains a large problem in Delaware. Delaware ranked sixth for 2000 reported cases (n=1735). Delaware’s case rate was 230 per 100,000 population, compared to the national rate of 131 per 100,000 population. In 2000, Delaware reported 748 male and 987 female gonorrhea cases. Table 16 depicts the distribution of Delaware gonorrhea cases by year of report and gender. Delaware’s primary and secondary syphilis rates are decreasing minimally. The 2000 case rate was 1.2 per 100,000 population, resulting in Delaware’s moving up one place within the state ranking from 22nd to 21st. Our rate continues to be below the national rate of 2.2 per 100,000 population15. The Supplement to HIV/AIDS Surveillance (SHAS) interview includes questions on past history of sexually transmitted diseases. Clients are asked to indicate all the sexually transmitted diseases that have been diagnosed. Persons infected with a STD are more susceptible to recurrent infection and are likely engaging in risky sexual behavior. This population needs increased attention and education about safe sexual practices. More than half, 56% of the SHAS clients, interviewed in 2000-2001, reported having had a diagnosis with genital, oral or rectal gonorrhea. Other sexually transmitted diseases, including syphilis, genital warts, herpes, and chlamydia were reported by at least 15% of the SHAS clients. Seven (6%) of the 120 SHAS participants, attested to being treated for a STD in the last 12 months. SURVEY OF CHILDBEARING WOMEN (SCBW) Delaware HIV/AIDS Epidemiology participated in HIV seroprevalence surveys between 1989 and 1993. The Centers for Disease Control and Prevention (CDC) funded the early studies on selected Delaware populations. State funds were used to re-institute the survey of childbearing women in 1999. During the period June 1999 through July 2000, a total of 12,650 specimens were tested through the Survey of Childbearing Women16. A total of nineteen specimens were positive for HIV (0.15%). Twelve of the nineteen positive tests were among African-American women. Fifty-three percent of positive women were younger than 24 years. Eleven of nineteen reside in New Castle County. None of the positive women were Hispanic, according to survey results. The SCBW indicates the HIV epidemic is hitting hard among young African-American females, especially in Wilmington and New Castle County. CONCLUSIONS The State of Delaware has had 2,820 resident cases reported since reporting began in 1981 through the end of 2001. Almost half of Delaware’s AIDS cases are living with the virus. New Castle County, more directly Wilmington, continues to be home to 77% of the AIDS cases reported cumulatively through 2001. Those primarily affected are African- American, IDU and male. There appears to be an increase in the number of Black men being reported as MSM, though more time is needed to measure whether the increase proves to be a trend. Eighty-one percent of the male AIDS cases statewide are either men who have sex with men or intravenous drug users. Sixty-one percent of the men are African- American and 75% of the males live in New Castle County. The female cases in Delaware are predominately African-American (80%). County of residence at AIDS diagnosis is 81% New Castle County. Fifty-one percent of the female cases are IDU. When combined with heterosexual contact with an IDU the percentage of women in Delaware who are IDU or IDU associated soars to 75%. Through the end of 2001, ninety percent of the people living with AIDS were known to be receiving their HIV care here in Delaware. The remaining 10% have no treatment location documented and may or may not be in treatment for their HIV. It is of major significance to note that 60% of those in care are documented as attending a clinic associated with the HIV Community Program through Christiana Care Health Services. Of further interest, patients attending CCHS clinics are Delaware’s most vulnerable populations. Private physicians and the Veteran’s Administration Medical Center are treating another 38% and 2% percent are in a correctional facility or other clinic setting. ACKNOWLEDGEMENTS Surveillance officers collected data provided in this Epidemiologic Profile. With a grateful heart, I thank them for their diligence and persistence in collecting the quality data. New Castle County medical providers report cases to John Miller. Kent and Sussex County providers report cases to Carolyn Blessing. John and Carolyn are also responsible for recruiting and interviewing SHAS clients. Case managers, public and private agencies, and clinic staff provided assistance recruiting SHAS clients. Our appreciation to all involved in recruiting SHAS participants. Thank you to Ainbint Munn, Secretary, for her assistance in unsnarling my charts and tables. A special thanks to my mentor, Judith Gendler Epstein. Clearly a hard act to follow, Judy’s support and guidance was never lacking. Thanks Judy! SUPPORT This publication was supported by Grant/ Cooperative Agreement 99005 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention (CDC). REFERENCES 1. HIV/AIDS Reporting System (HARS) 2. Supplement to HIV/AIDS Surveillance (SHAS) 3. Study of Childbearing Women (SCBW) 4. HIV Counseling and Testing Annual Report – 2001 5. Center for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2000, Yearend edition Volume 12 (No.2) http://www.cdc.gov/hiv/dhap.htm 6. US Census Bureau. www.census.gov 7. Delaware Division of Public Health, Health Statistics Center 8. Delaware Department of Labor 9. Delaware Department of Correction 10. Department of Commerce, Bureau of Economic Analysis 11. Fred Breukelman, Behavioral Risk Factor Surveillance data. DPH internal document 12. Department of Education, Division of Adolescent and School Health (DASH) Youth Risk Behavior Survey (YRBS), 2000 data. DPH internal document 13. Greg Trollan, Adolescent Health Director, CHCA, DPH internal document 14. Delaware Division of Public Health, DP&C, STD internal document 15. Division of STD Prevention. Sexually Transmitted Disease Surveillance, 2000, CDC, December 2001 16. Survey of Childbearing Women, DPH internal document Delaware AIDS Epidemiologic Profile: 2002 Ulder Tillman, MD, Director of Public Health Paul Silverman, Dr. PH, Bureau Chief James C Welch, RN, HNC, HIV/AIDS/HepC Director Judith Gendler Epstein, MS HIV/AIDS Surveillance Staff 302-744-4542 Kathryn J. Widdowson, Coordinator John Miller, Surveillance Officer Carolyn Blessing, Surveillance Officer Ainbint Munn, Program Secretary