2004 Delaware Epidemiological Profile

HIV/AIDS Epidemiology
Health Promotion & Disease Prevention
DELAWARE HEALTH AND SOCIAL SERVICES
Division of Public Health

Special Thanks to the Following Individuals

Jaime H. Rivera, MD, FAAP
Director
Delaware Division of Public Health
 
Paul Silverman, Dr. P.H. 
Associate Deputy Director 
Health Information & Science

Jill Rogers
Section Chief
Health Promotion & Disease Prevention

Robert S. Jackson, MD
Chief
Communicable Disease Bureau

James C. Welch, RN, HN-C Director
HIV/AIDS, STD and Hepatitis C Program

Atmaram Nambiar, MD, MPH
HIV/AIDS Surveillance Program Manager

Robert Vella
Health Program Coordinator

HIV/AIDS Surveillance Staff
Bruce Levan 
Angela Miller 
John Miller 
Christina Melvin 
Amanda Yarnal



Delaware HIV/AIDS Epidemiologic Profile 2004

  

Executive Summary

Description of the State of Delaware: The estimated population of Delaware for 
2003 is   817,491 representing 0.3% of the United States population 
(290,809,777). Seventy percent of Delaware residents live within urban areas. Of 
Delaware’s residents, 75% are White, 19% are  African-American, 5% are Hispanic 
and 1% are self-identified as ‘other’. Delaware residents had higher incomes, a 
lower unemployment rate, and were more highly educated than United States 
residents as a whole.

Epidemiological Trends in HIV and AIDS in Delaware: By 2003, the cumulative 
number of AIDS cases (3,219) in Delaware represented 0.4% of all reported U.S. 
cases. Delaware ranks 33rd among states in the total cumulative number of 
reported AIDS cases and, despite being the 2nd  smallest state in the U.S., 
Delaware had the 5th highest rate of new AIDS cases per 100,000 population in 
2003 (26.1).

Gender.  While 49% of Delaware’s population is male, 71% of those infected 
with HIV/AIDS and reported through 2004 are male. As an artifact of the 2001 
implementation of HIV reporting, the difference between the percentage of HIV 
cases attributed to men and women is smaller than the difference between the 
percentage of AIDS cases attributed to men and women (24% and 48% respectively). 
This difference could be interpreted to mean that HIV was more prevalent than 
AIDS for women. If this was true, it would suggest that women were more 
resistant to progression of the disease.  However, the proportion of AIDS cases 
diagnosed among women has continued to grow from 15% of cases reported in the 
1985 to 1989 period to 36% of cases reported in the 2000-2004 period. In fact, 
national data suggest that women may progress from HIV to AIDS quicker than men 
do.

Race/Ethnicity. The proportion of HIV/AIDS cases reported among African-
Americans in Delaware is  disproportionately high, and the disparity is 
increasing. While African-Americans represent only 19% of Delawareans, the 
percentage of new cases attributed to African-Americans had increased  from 44% 
in years 1985-1989 to 67% in years 2000-2004. Currently, over 66% of the 
cumulative HIV/AIDS cases in the State are among African-Americans. The relative 
proportion of HIV cases reported since 2001 by ethnicity is very similar to the 
proportion of AIDS cases reported before 2001--66% of the cumulative AIDS cases 
since 1983 and 64% of the cumulative HIV cases since 2001 are reported amongst 
African-Americans.  Hispanics represent a relatively small percentage (about 5%) 
of the Delaware population, and are not disproportionately represented in 
reported HIV/AIDS rates/cases. Relative to the same periods of time mentioned 
above, HIV/AIDS rates among Hispanics have declined from 7% to 6% of new 
infections.  DPH is contracting with local agencies  to increase availability of 
HIV counseling and testing and other services to help ensure that the reported 
rates of HIV and AIDS in this community are not due to under-reporting.

Age. Those aged 30-49 account for more than 70% of AIDS cases reported in 
Delaware in 2003 and 2004, mirroring the national age distribution. This may be 
due to the relatively large number of infected people who do not present for 
testing or treatment until they are symptomatic, and, therefore, may have been 
infected much earlier than they were reported. However, the age distribution of 
those who are tested and reported prior to symptoms is very similar to those who 
present after symptoms and does not support this conclusion. Fewer than 3%  of  
HIV/AIDS cases reported in Delaware and nationally are among those 60 and older. 
Only 1% of Delaware and national reported HIV/AIDS cases are attributed to those 
under age 13, defined as pediatric HIV/AIDS cases. Pediatric cases are relatively 
rare, but occur disproportionately among minorities.

Mortality. AIDS cases have been monitored since 1981 and, until the mid-1990s, 
the number of those who died in a given year exceeded the number of those living 
with AIDS and by 2004, 1,815 Delaware  residents had  died with AIDS. However, 
with the advent of highly active anti-retroviral therapy (HAART), the number of 
Delaware residents living with AIDS has increased by 322%, from 550 cases in 1996 
to 1,578 in 2002 and 1,775 in 2004. Earlier diagnosis, better medical management 
of HIV, and the development of HAART led to this dramatic change. Similarly, 
people are living longer with HIV. In 2001, the first year HIV reporting began 
in Delaware, the state had 461 people living with the disease. By 2004, 1,070 
Delawareans were living with HIV and only 24 died with the disease.


Geography. Delaware’s HIV/AIDS cases when distributed by county (excluding the 
city of Wilmington) closely match population distributions. Wilmington 
(population 76,664) is disproportionately represented in the HIV/AIDS statistics,  
making up only 15% of the New Castle County population, but accounting for 60% 
of the County’s HIV/AIDS cases. Within Delaware, the mode of transmission of HIV 
varies from one area of the state to another. In New Castle County, cases are 
largely among African-American Injection drug users (IDUs), while in Sussex County 
cases are for the most part among White men who have sex with men (MSM). It should 
be noted that 40% of all HIV/AIDS cases in the state occur among minorities in the 
four central Wilmington zip codes 19801, 19802, 19805, and 19806.

2003-2004 Observations in Behavioral Risk Groups: The largest number of HIV/AIDS 
cases reported in Delaware in 2003-2004 are attributed to heterosexual 
transmission at 37% (n=240), men having sex with men (MSM) at 28% (n=183) and 
injection drug users (IDUs) 25% (n=164). An additional 2% are among those 
classified as both MSM and injection drug user (IDU). More than half, 59%, of 
injecting drug users and 53% of heterosexually infected women reported in 2003-
2004 are Wilmington residents. Thirty-four percent (n=64) of MSM cases reported 
in 2003-2004 were in the City of Wilmington, and another 33% (n=61) in New 
Castle County.

HIV/AIDS in other populations:  There are a number of populations on which 
adequate data to assess HIV risk are not available. These include smaller and 
hard-to-reach groups such as the homeless, trans-gendered, and mentally ill. 
There are also populations who are diagnosed through routine screening on whom 
we have little data (e.g., blood donors). Data indicates that 27 HIV- infected 
women gave birth to infants in  2004. All the infants served by Ryan White 
Title  IV programs and receiving prophylaxis tested negative for HIV infection.  
While there has been only one perinatally-infected infant in recent years 
(2002), trend data shows a decrease in perinatally-infected infants in 
Delaware.

Counseling and Testing Data: In 2004, one percent of people deciding to get 
tested at publicly funded counseling and testing sites in Delaware are HIV sero-
positive. Of those who test positive, 65% are men and 35% women. Racial groups 
showing the highest seroprevalence are African-Americans 69%, Whites 20% and 
Hispanics 11%. Thirty percent of positives are MSM while 23% self-reported 
having no risk other than a sex partner who was at risk for HIV. Heterosexual 
IDUs comprised 15% of the positive tests in 2004 followed closely by 
Heterosexual (no other risk) at 13%.

Background and Introduction

Delaware has tracked AIDS cases since 1981 and reported AIDS Surveillance 
information since the mid-1980s. The Division of Public Health, Delaware Health 
and Social Services began collecting information on the HIV infected population 
July 10, 2001 by compiling information from health care professionals, 
laboratories and physicians throughout the state. The ongoing analysis of 
current and cumulative AIDS case reporting and of the  more recent but 
developing HIV data is an important community and public health function of the 
Division of Public Health.

Data presented here are current through December 31, 2004. The Delaware HIV 
Planning Council, other 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 positive 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 state  HIV/AIDS Epidemiology Office. Forty-one 
months of HIV data collected through December 31, 2004 are now available to 
assist prevention and health planning groups with a relatively full scope of 
incidence, prevalence and related characteristics of the HIV epidemic in 
Delaware.

Methods

This Epidemiologic Profile describes the distribution, trends, and impact of 
human immunodeficiency virus (HIV) and acquired immune deficiency syndrome 
(AIDS) on the people of Delaware.

-HIV or Human Immunodeficiency Virus is the underlying agent that weakens the 
immune system in  many and thus is the cause of AIDS. Except for initial viral 
response, HIV may not manifest itself with symptoms for some time after 
infection.

-AIDS or Acquired Immune Deficiency Syndrome is the stage where the symptoms of 
the virus have  advanced to a state where a clinical diagnosis can be made by a 
licensed practioner. Symptoms include certain infections, cancers, and cellular 
changes in a person’s immune system.

This profile provides information for prevention and care planning and education 
programs  centered  on  HIV. It is an important but by no means the only 
component needed by the Delaware HIV Consortium and its Planning Council as 
input into its ongoing comprehensive strategy to  steer prevention and care 
planning and service efforts in Delaware, as called for by the Health Resources 
and Services Administration (HRSA) and the Centers for Disease Control and 
Prevention (CDC). The compiled data will help monitor overall progress and 
trends, and it will be an indicator in justifying and awarding future funding 
for prevention and medical/social services.


The four main questions used to outline data in this profile are:


1.  What are the socio-demographic characteristics of the State of Delaware?
2.  What is the scope of HIV/AIDS epidemic in Delaware?
3.  What are the indicators of risk for HIV/AIDS infection in Delaware?
4.  What are the patterns of utilization of services in people with HIV in 
    Delaware?

The data to address each question are presented in turn in the profile. 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 also addressed. Sources for data presented include:  AIDS 
surveillance activities, CDC national statistics on HIV/AIDS, HIV counseling and 
testing annual report, STD data, vital statistics annual report, United States 
Census Bureau Quick Facts, the Youth Risk Behavior Survey in Delaware, and Ryan 
White  Comprehensive AIDS Resource Emergency (CARE) Act Data Reports (CADR) from 
HRSA grantees. If the reader has specific questions, the State Surveillance 
Office can provide assistance locating  appropriate data sources.

Data quality varies among the sources. An overview of the strengths and 
limitations of data sources are provided below. HIV/AIDS surveillance includes 
case reports of all known HIV sero-positive and AIDS-defined cases in Delaware. 
The data provided on the HIV/AIDS case reports are only as good as the 
information provided by the reporting source.

Data Sources - Their Strengths and Limitations

The data source for Delaware demographic information is the United States Census 
Bureau1 located at http://quickfacts.census.gov/qfd/ on the Internet. Strengths:  
Data set is complete and standardized nationwide through 2000. Limitations: The 
best data estimates are for the Census  decades with estimates provided in the 
interim.

Delaware Vital Statistics Annual Report 2002 – produced by the Delaware Health 
Statistics Center, provides health statistical data on the morbidity and 
mortality of all residents of Delaware.  Doctors, hospitals, and clinics in 
Delaware are required to report birth and death certificate data. It can be 
accessed at www.state.de.us/dhss/dph/hp/2002.html

Strengths:  Data set is complete, and it is a good source for mortality data.

Limitations:  Data quality is limited to the information provided by physicians 
on the birth and death certificates and behavior risk data are unavailable.  
Many physicians do not note HIV/AIDS on death certificates. This may be due to 
family request,unawareness by physician of HIV status, or notation of primary 
cause of death only and not secondary causes or underlying disease status. 
Therefore, due to stigma, confidentiality concerns, failure to test for HIV 
infections and AIDS related diseases, death data may only reflect immediate 
cause of death and may not identify an underlying disease status such as 
HIV/AIDS. The Annual Report has also not been publicly updated since 2002. As 
mortality data has become better reported in the HIV/AIDS Surveillance 
mechanisms described below, the Vital Statistics Report has become much less 
vital to HIV/AIDS reporting. HIV/AIDS Reporting System3 (HARS) is the software 
system promulgated by the CDC and used nationwide for storing of HIV/AIDS data. 
Medical professionals throughout the state submit HIV  and AIDS case report 
forms to the State Surveillance Office. AIDS data is the only consistently 
reported data across the nation, resulting in population-wide statistics in all 
states. HIV data, on the other hand, is only reported to the CDC from some 
states with approved non-anonymous (confidential) reporting procedures (not yet 
approved in Delaware). 

Strengths:  Data set for AIDS is quite complete and provides a historical 
perspective on trends.

Limitations: Case report forms from medical professionals vary in completeness 
and timeliness.  AIDS data may not represent all AIDS-defined individuals due to 
delays in reporting and noncompliance with reporting policies. HIV data does not 
represent all people-testing positive in Delaware, as confidential results are 
the only tests reported and the availability and option for anonymous testing 
remains at specific testing sites in Delaware. The quality of HARS data has 
improved substantially in recent years through the proactive efforts of the 
Surveillance Office and its field workers.

The HIV/AIDS Surveillance Report4 through 2003, published by the Centers for 
Disease Control and Prevention, is used frequently in this Profile for national 
data and data from other states. This is the national and state by state summary 
database established by the CDC and is the reporting source for most national 
statistics. It is released periodically in printed form and updated more often 
on the Internet http://www.cdc.gov/hiv/dhap.htm.

Strengths:  National data. Great source for information and for updated slide 
presentations.

Limitations: Time delay in release of data. The report for the period ending 
2004 will not be available until after this profile is completed.

Supplement to HIV/AIDS Surveillance5 (SHAS) project is a federally funded grant 
initiative through which adult HIV/AIDS  patients are interviewed for additional 
information. Surveys address 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.

Questions regarding behavior and treatments allow investigators more detail on 
these topics than  from  other sources. 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 this profile reflects information collected from July 1991 to June 2004. 
This study has now ended.

Strengths: Confidential data set. SHAS data can be linked to HARS data by 
patient number.

Limitations: Since respondents’ self-report data can be subjective and from the 
patient’s perspective, it can  be biased. Responses may be what the  patient 
thinks the interviewer wants to hear rather than the  truth. Data may also be 
skewed toward those healthy enough to participate, and participation is 
voluntary so it is not fully representative of all clients.

HIV Counseling  and  Testing Annual  Report6 is based on data collected on a 
standardized data collection form from people seeking counseling and possible 
testing for HIV.

Strengths: Standardized data collection.

Limitations: Not a good source of prevalence data. Report is only for those who 
are tested in public clinic settings or are seeking specific HIV counseling and 
testing. Clients who are counseled/tested more than once will appear multiple 
times in the data but cannot be identified as such. Clients often defer to 
“sexual partner at risk,” rather than identifying specific risk behavior of 
sexual partner. Sexually Transmitted Infection and Disease Reports7 include the 
statistical data on sexually transmitted disease (STD) events of gonorrhea, 
chlamydia and syphilis in Delaware. STD case data are well reported in Delaware 
but are limited in that the collected data do not include information, such as 
gender of sexual partners or reports of drug use, important for HIV planning.

Strengths: Standard data collection. Patients at high risk for STDs are at high 
risk for HIV.

Limitations: Data may include duplicate cases (multiple events of infections in 
one person), and private providers may under-report.

2003 Youth Risk Behavior Survey8  (YRBS) is a self-administered, anonymous 
questionnaire for Delaware high school students administered in odd-numbered 
years. The privacy of the student is  assured by allowing for anonymous and 
voluntary participation (participation rates are very high  with less than  2% 
refusals). The YRBS is one component of the surveillance system developed by the 
Centers for Disease Control and Prevention in collaboration with state and local  
departments of education and health, federal agencies, and national education 
and health organizations. The YRBS was designed to focus the nation on behaviors 
among youth related to the leading causes of  mortality and morbidity among both 
youth and adults. The Delaware Department of Education assumes responsibility 
for the YRBS. More information may be obtained through the Department of 
Education’s Adolescent School Health section and on the web at 
www.state.de.us/drugfree/data.htm

Strengths:  Risk assessment ongoing with emphasis on prevention. It is a 
reasonably representative random survey of Delaware youth, and it provides 
information on the leading causes of morbidity and mortality for youth -- 
nutrition, substance use, accidents, sexual activity, sexual orientation, and 
delinquency. 

Limitations: Data are limited to high school students who voluntarily 
participate in the survey, and the accuracy relies upon self-reported 
information.

Ryan White CARE Act Data Reports9 (CADR) are used  to report information about 
provider and  program characteristics providing Ryan White CARE Act services. 
Data are collected and submitted by grantees of Title II through Title IV to 
Health Resource and Services Administration (HRSA). At the provider level, the 
CADR offers unduplicated aggregate counts of all clients served. At the Title II 
grantee level, the CADR data are duplicated. Utilization of medical and support 
services, prescription drugs and health insurance coverage are also collected as 
part of the CADR.

Strengths:  Standardized data instrument containing grouped data making it 
easier to report frequency count data for grouped categories.

Limitations:  Currently unable to perform analysis on data that cannot be 
completely unduplicated as clients may access services from multiple providers. 
Data are limited to those who access care, treatment or services for HIV.


Epidemiology

When investigating an epidemic, questions relating to person, place and time are 
important criteria to sort out pertinent information.

§   Person: Identifying how a person contracts infections or disease is the 
first step in the process of prevention. Surveillance staff help characterize a 
person’s mode of exposure to HIV  from case report forms, personal interviews 
and medical record reviews. The exposure is often identified as a risk.

§   Place: In this Epidemiological Profile, place generally refers to zip code 
of residence at time a person is reported as testing positive for HIV or an AIDS 
diagnosis is made. Every effort is made to collect unduplicated information, and 
in this process surveillance extends to other states. Whenever reporting sources 
indicate a patient may have been treated elsewhere or was diagnosed in another 
state or jurisdiction, surveillance 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 may be a time lag between when 
a patient is reported to the Division of Public Health (DPH) Surveillance Office 
and the actual date they first developed an AIDS-defining condition or tested 
positive for HIV. Therefore, date of report is used, unless otherwise stated in 
a statistical table or figure.

§   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.

Two noteworthy time specific changes in data collection related to HIV/AIDS 
affect the data in this profile nationally and locally. Increases in reporting 
are noted in both timelines.

§    In 1993, the Centers for Disease Control and Prevention (CDC) revised the 
AIDS case definition. An increase in cases, around 1993 -1994 due to the 
expanded  definition, is noted  nationally and locally. The new definition 
included persons previously unreported until several AIDS indicators were added 
to the case definition. These  ndicators include:  severe immune- compromised 
individuals with CD4 counts <200 µ/L or <14%; invasive cervical cancer; 
recurrent pneumonia;and pulmonary mycobacterium tuberculosis.

§    Delaware implemented HIV reporting on July  10, 2001. HIV data is combined 
with AIDS data  in 2001 through 2004, and the change in reporting is a 
contributing factor in the increased number of cases observed in most tables and 
figures in the profile. Unless otherwise stated, all tables and figures that 
have HIV/AIDS in the title, include HIV data reported from July 10, 2001 through 
December 2004 combined with AIDS data from 1981 through 2004.

All AIDS patient data are strictly confidential and are collected for 
epidemiological 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 Surveillance Office has extensive 
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 
HIV/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; when this is 
done the fact is generally identified in the footnote.

Definition of Terms

Adolescent: An individual between the ages of 13 and 19.

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 may be 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 of year when the disease event was first detected by 
medical personnel.

Year of report: Measure of year that the HIV/AIDS surveillance office received 
case report.

Abbreviations

AIDS                       Acquired Immune Deficiency Syndrome
A/PI                       Asian/Pacific Islander
CARE                       Comprehensive AIDS Resource Emergency
CADR                       CARE Act Data Report
CDC                        Centers for Disease Control and Prevention
C/T                        Counseling and Testing Services 
DHSS                       Delaware Health and Social Services 
DPH                        Division of Public Health
HAART                      Highly active anti-retroviral therapy
HARS                       HIV/AIDS Reporting System (software) 
HIV                        Human Immunodeficiency Virus
HRSA                       Health Resources and Services Administration
IDU(s)                     Injecting Drug User(s)
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
NRR                        No Risk Reported
PWH/A                      Person with HIV or AIDS 
PLWHA                      People living with HIV or AIDS 
SCBW                       Study of Childbearing Women
SHAS                       Supplement to HIV/AIDS Surveillance
STD (STI)                  Sexually Transmitted Disease (Infection)
YRBS                       Youth Risk Behavior Survey (both national and 
			   Delaware specific)



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 
state surveillance 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? Did a change in data collection procedures influence the trend data?

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, or as a case rate?

Question  1. What are the sociodemographic characteristics of the State of 
Delaware?


Description of the State of Delaware

Geography

Delaware is the second smallest state, in the U.S., measuring 100 miles from 
north to south and  30 miles from west to east. Land area accounts for 1,955 
square miles and 535 miles of Delaware are covered by water. The geographic 
center of Delaware is located 11 miles southwest of Dover, the state capital, in 
Kent County. The Interstate 95 corridor, running from Maine to Florida, crosses 
through Delaware’s northernmost county from Maryland to Pennsylvania, or 
alternately Interstate 295 to New Jersey and points north via the Delaware 
Memorial Bridge. The south-eastern portion of  Delaware’s coast-line with the 
Atlantic  Ocean provides the beach resorts that are the destination of many 
tourists and split-residency owners of summer homes from the mid-Atlantic 
region.

Delaware Demographics

Delaware’s total population estimate through July of 2003 is 817,491 according 
to the  U.S. Census Bureau. The proportion of the population, by county of 
residence, is 63% New Castle County, 16% Kent County and 21% Sussex as depicted 
in Table 1 on the next page. The race and ethnicity distribution in the state 
(see Table 2 on page 14) is 75% White, 19% Black, 4% of Hispanic origin and the 
remaining 1% a compilation of Asian, Native Hawaiian and other Pacific 
Islanders. Seventy percent of the population is urban. Women comprise 51% of the 
state total population, equivalent to the national distribution by gender. The 
median age of the Delaware resident is 36  years. Ten percent of Delaware 
residents report a language other than English is spoken in their home. Median 
household income of $47,381 and a per capita income of $23,305 in Delaware 
exceed the  U.S. incomes $41,994 and $21,587 respectively. Eighty-three percent 
of Delaware residents reported having a high school diploma and 25% a bachelor’s 
degree or higher compared to 80% and 20% for the U.S. respectively.

County Demographics

New Castle County is the smallest county in Delaware, registering 426 square 
miles according to Quick Facts of the U.S. Census Bureau, with 1,174 persons 
residing per square  mile. The July  2003 estimated population for New  Castle 
County is 515,074 or 63% of Delaware’s total  population. Fifteen percent 
(n=76,664) of New Castle County’s residents live within the City of Wilmington. 
The  racial distribution in New Castle County is 73% White, 20% Black, 5% 
Hispanic and 2% are of multiple/other origins. Gender-wise, New Castle County 
residents are 51% women and 49% men.

Approximately 7% of the county’s residents are under the age of 5, with 19% 
between 5 and 17, the age group 18-64 comprises 62% and 12% are 65 years and 
older.

Kent County is the second smallest in landmass with 590 square miles and an 
estimated population in July of 2003 of 134,390. This represents 16% of the 
state’s entire population with 215 people per square  mile. Kent County is the 
home of Dover Air Force Base and of the State Capital, Dover.

The racial distribution in Kent county is 74% White, 21% Black, 3% are Hispanic 
or Latino and  the remaining 2% combines multiple/other origins. The gender 
distribution in Kent is 52% women and 48% men.

Approximately 7% of  the county’s residents are under the age of 5, with 20% 
between 5 and 17, the age group 18-64 comprises 61% and 12% are 65 years and 
older.

Sussex County is the fastest growing and largest county in landmass, measuring 
938 square miles,  with 167 persons per square  mile. Estimated population as of 
July 2003, based on Quick Facts of the U.S. Census Bureau, is 168,027 or 21% of 
the state population.

The racial distribution in Sussex is 80% White, 15% Black, 4% Hispanic and the 
remaining 1% combines multiple/other origins. The gender distribution in Sussex 
is 52% women and 48% men.

Approximately 6% ofthe county’s residents are under the age of 5, with 17% 
between 5 and 17, the age group 18-64 comprises 58% and 19% are 65 years and 
older.


Question 2.  What is  the scope  of the HIV/AIDS epidemic in Delaware?

Overview of HIV/AIDS Characteristics:

Unless otherwise specified, HIV/AIDS data is based on information from the 
Delaware HIV/AIDS Reporting System3 (HARS). It should be noted that HIV data is 
combined with AIDS data beginning in 2001, and this is a major contributing 
factor in the increased number of cases observed in most of the trend tables and 
figures in the profile. Through December 2004, a total of 4,343 people were 
reported to DPH with a diagnosis of HIV or AIDS. A total of 1,684 persons have 
died, representing 39% of the cases. The disproportionately large number of 
reported cases among Blacks continues to  be observed, as reported in previous 
profiles. This disparity and those related to gender and age group will be 
considered in detail later in the profile.  Table 3 below, provides a brief 
overview of demographic characteristics of all reported HIV/AIDS cases in 
Delaware through December 31, 2004.

National data are not yet available through 2004 so national comparisons with 
Delaware data are  comparing the Nation in 2003 with Delaware in 2004. National 
surveillance reports4 estimate that at the end of 2003, 902,223 persons have 
been diagnosed with AIDS since the beginning of the epidemic. An additional 
221,065 persons are reported to have HIV infection that has not progressed to 
AIDS. There are currently 351,614 persons living with HIV/AIDS in the 33 areas 
(not including Delaware) that practice confidential name based reporting of HIV 
infection. The  national cumulative case rate per 100,000 population was 127.8 
for HIV and 167.3 for AIDS at the end of 2003. Delaware’s cumulative AIDS rate 
per 100,000 population was 235.6 for 2004. The National annual rate for reported 
AIDS cases in 2003 was 15.0 per 100,000;  while Delaware’s 2004 rate  was 19.2.  
Delaware ranked 8th among states and the District of Columbia for annual case 
rates per 100,000 population in 2004.

Figure  1  on the next page compares the percentage of people surviving with 
AIDS who were diagnosed between 1992 and 2004 to the percentage of those who 
have died through 2004. The  graphic clearly illustrates the decrease in 
fatalities and the increase in the percentage of people living with AIDS. 
Factors contributing to survival in people diagnosed later in the epidemic are 
timeliness in referral into care, progress in the medical management of HIV, and  
the introduction of highly active anti-retroviral therapy (HAART). As 
encouraging as these trends are, they point out that the nature of the AIDS 
epidemic is changing. For the first decade and a half, AIDS was often an 
apparent death sentence with significant medical consequences and use of  
medical services only in the late stages of the disease. With the development of 
effective  anti-retroviral medicines, the prospect of living with and 
effectively managing HIV/AIDS has become the norm. The societal consequence over 
time will be the burden of disease and financial   strain associated with long 
term and expensive management of chronic illness. This dilemma will become even 
more apparent as states begin to address the yet undiagnosed and untreated 
prevalence of hepatitis (particularly Hepatitis C).

Data from the Delaware Health Statistics Center2 indicates an overall decline in 
deaths due to  HIV/AIDS.  In 1999-2000, HIV was listed as the fourth leading 
cause of death for residents of Delaware in the 25-44 year age group.  In 1999-
2003 HIV is the 5th leading cause of death in this age group.

At the end of 2004, there were 1,600 living AIDS cases in Delaware and an 
additional 1,059  persons living with HIV infection that had not progressed to 
AIDS. Living AIDS cases continue to increase across all demographic groups. In 
2004, the prevalence rate (living AIDS cases in Delaware) was 196 per 100,000 
population for AIDS and 130 per 100,000 for HIV infection. This represents a 13% 
increase in the survival rate from AIDS as compared to 2001 (when it had been 
173 per 100,000) and a 5% increase from 2002 (186 per 100,000 population).


HIV/AIDS by Gender and Race/Ethnicity:


The prevalence rate for female cases in Delaware through 2004 was 216 per 
100,000 population (HIV/AIDS living cases).  The prevalence rate for male cases 
in Delaware through 2004 was 441 per 100,000 (1,753 living HIV/AIDS cases).

Table 4 on the next page illustrates how the percentage of deaths in men 
attributed to AIDS has decreased gradually since the beginning of the epidemic 
and increased slowly in women.  By race, deaths have increased in the  Black 
population and decreased in the Hispanic and White  populations. A sharp decline 
is noted in the deaths of MSM cases over time compared to the gradual increase 
in deaths among IDUs and heterosexual cases.

Looking  at National data through 2003,4 the number of deaths declined in the 
Midwest and South and increased in the Northeast and West for year 2002 to 2003. 
The number of deaths related to AIDS declined among Whites and Asian/Pacific 
Islanders, increased among Hispanics, and remained stable among Blacks and 
American Indians/Alaskan Natives. By sex and risk, deaths declined in MSM, and 
male IDUs, while deaths among female IDUs remained stable. Heterosexual cases of 
both sexes experienced a decline from 1996 to 1998, then increased from 1999 
through 2001, decreased  slightly in 2002, and then increased in 2003. Delaware 
numbers are too small to talk about past year significant declines, but the 
trend is for declining percentages of male deaths and white deaths and an 
increased percentage for deaths among blacks.

Figure 2 on the next page illustrates the distribution of Delaware HIV/AIDS 
cases by gender and year of report for the time periods pre-1984, 1985–1989, 
1990-1994, 1995-1999 and 2000-2004.  The latest time period, 2000-2004 includes 
the collection of HIV case data implemented beginning in July 2001. A gradual 
decrease in male HIV/AIDS cases reported from 85% in the 1985-1989 period to
62% in the 2000-2004 period is reflected. The pre-1984 period is shown as a 
baseline, at which time there were only 3 cases in the state. Most cases, of 
course, are still among males, though the percentage of cases among females 
rises from 15% in 1985-1989 to 38% in 2000-2004. Looking at both Table 4 and 
Figure 2, the overall trend numbers mask what is happening among women, where 
there is: first, a steady increase in the percentage of female cases reported 
with HIV/AIDS; and second, an apparent increase in the number of deaths among 
women reported in Delaware.

Male HIV/AIDS cases continue to dominate case reports. Males represent 49% of 
Delaware’s population, yet 71% of the HIV/AIDS cases. Females represent 51% of 
Delaware’s population, and 29% of the HIV/AIDS cases. Figure 3 below provides a 
graphical depiction of both the gender and racial trends in Delaware. Black men 
represent the majority of cases, followed by Black women.  The increase in the 
year 2001, particularly for Blacks, is again attributed to the onset of HIV 
reporting.


Delaware’s HIV/AIDS epidemic continues to disproportionately affect the Black 
population. Blacks comprise 19% of the state population but 66% of AIDS cases 
and 64% of HIV cases.  Among females, 80% of AIDS cases and 69% of HIV cases are 
among Blacks, compared with 59% and 64% nationally. The national vs. Delaware 
comparison is even more striking among males where 62% of AIDS cases and 61% of 
HIV cases are in the Black population in Delaware, compared to the national 
percentages of 35% and 43%, respectively. For pediatric cases, 71% of both HIV 
and AIDS cases in Delaware are within the Black population. National data on 
gender/race breakdowns were unavailable for pediatric cases. Tables 5a and 5b 
and the accompanying chart provide an overview of the racial distribution of 
Delaware and National AIDS cases respectively. The “other” category in the table 
includes Asian/Pacific Islanders and Native American/Alaskan Natives.


HIV/AIDS by Age Group:

Age group refers to the age a person first tests positive for HIV or age at 
diagnosis of AIDS.    When compared by age group, Delaware’s HIV/AIDS statistics 
through 2004 are similar to the national statistics for 2003. As portrayed in 
Figure 5, on the next page, the percentages differ little. Delaware’s HIV/AIDS 
cases by age group are very similar to the national estimates. In both Delaware 
and nationally, over 70% of cases are for those 30 to 49 years of age. Fewer 
than 3% of HIV/AIDS cases in both Delaware and nationally are for those 60 and 
older. Only 1%  of  Delaware and national HIV/AIDS cases are for those under age 
13, defined as pediatric HIV/AIDS cases. Pediatric cases, although relatively 
rare, occur disproportionately among minorities.    Delaware pediatric HIV/AIDS 
cases are addressed separately in more detail beginning on page 39.

HIV/AIDS by Mode of Exposure:

For surveillance purposes,HIV/AIDS cases are counted only once in the hierarchy 
of exposure categories established by the CDC. 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 “sex partner at risk”
    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 HIV/AIDS; 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

Delaware HIV/AIDS Epidemiologic Profile 2004                                                                             
If a patient admits to certain sexual ordrug use behaviors, the patient is 
ranked along this continuum of possible exposures to HIV. Nationally,4  10% of 
the AIDS cases reported through December 2003 were “no identified risk” (NIR), 
while 28% of HIV cases had no identified risk.   Surveillance personnel in 
Delaware place a high priority on determining risk, and 6.6% HIV and 1.5% of 
AIDS cases in Delaware at the end of 2004 were classified as NIR. The NIR 
largely reflects cases where the reporting source does not have the risk 
information to report
(e.g., private laboratories, blood banks and lab tests conducted during 
inpatient hospitalizations where results came after discharge and cases were 
never linked). Surveillance staff attempt to resolve the “no risk reported” 
(NRR) cases when reviewing medical records. The difference in NIR percentages 
between HIV and AIDS, both nationally and in Delaware, is partly a function of 
time to investigate and collect data. Newer cases tend to be HIV reports, and, 
over time, the details are obtained by surveillance staff.

Table 9 below illustrates the mode of exposure for all Delaware HIV/AIDS cases 
and compares the data from the beginning of the epidemic through 1999 to the 
information  available  from  2000   through  2004. The mode of exposure or 
transmission of HIV describes the behavioral characteristics of a person at risk 
for acquiring HIV infection. Injecting drug use (IDU) is the greatest percentage 
of cases through 1999 followed by men who have sex with men (MSM). The large 
increase in heterosexual contact with a person with HIV or AIDS (PWH/A) from 8% 
to 29% moves it into the most prevalent category in the 2000-2004 era. This 
rapid change in ranking, though, should be viewed with caution since it has much 
to do with the reporting of HIV beginning in  2001. Also in general, risk 
information on initial case report forms is often revised after medical record 
reviews reveal the “person with HIV or AIDS” is an IDU or bisexual. Other modes 
of exposure (*) include pediatric cases infected through mothers, transfusion 
recipients, and additional transmission modes that resulted in less than 2% of 
Delaware's HIV/AIDS cases in the 2000-2004 era. The increase in NIR cases in the 
2000-2004 period is largely a result of inclusion of HIV reporting in this era. 
Table 9. Comparison of all Delaware HIV/AIDS cases by mode of exposure diagnosed 
through 1999 (n=3,147) to cases diagnosed 2000-2004,(n=1,196) National 
statistics through 2003 for AIDS indicate the distribution of female cases by 
mode are 45%    heterosexual contact, 20% IDU and 1% blood transfusion 
recipient. The remaining 34% are related to other modes and cases with risk not 
identified.

National statistics through 2003 for HIV indicate the distribution of female 
cases by mode is 40% heterosexual contact, 14% IDU and 1%  blood transfusion 
recipient. The remaining 45% are related to other modes and cases with risk not 
identified.

Delaware had  1,259 cases of HIV/AIDS reported in women through 2004. Fifty 
percent (n=631) of  the women with HIV/AIDS in Delaware at the  end of 2004 were 
infected through heterosexual contact. Sex with a person with HIV comprises 61% 
(n=390) of the heterosexual cases and 38%
(n=220) are due to  sex with an injecting drug user. Injecting drug use accounts 
for the  transmission of HIV in  42% (n=529) of the remaining women while 8% 
(n=99) have risk not reported/identified or other.

The early years of the AIDS epidemic in Delaware (1981 -  1993) are quite a 
different picture than the more recent years (1994 - 2004). Table 10 on the next 
page compares the top six behavioral groups reported in the first ten-year 
period to the latter.  The number of cases reported in each time period is noted 
under the year of report.  The columns indicate the number of cases in each 
behavioral group, and the percentage is representative of the whole number 
reported.

As previously demonstrated, the data in Table 10 above illustrate again the 
decrease in cases of men who are MSM. By comparing the two eras of the epidemic, 
the percentages in MSM decreased from 43% in the early era to 25% in the second. 
The other obvious change is the increase in women with male sex partners at 
risk, where the heterosexual partners of the women were intravenous drug users, 
bisexual men and/or HIV infected. The percentage increased over three times, 
from 5% to 16%. The percentage of men with female sex partners who are at risk 
through injecting drug use and/or whose female partner is HIV infected tripled 
from  3% to 9% from the first decade to the second decade respectively.

The next portion of the profile continues to address modes of transmission in 
adult and adolescent cases of HIV/AIDS. To illustrate changes in the two “AIDS 
eras,” the  data are again separated into two periods in Table 11 below. An 
increase of close to 100% (from  18% to 32%) is noted in the percentage of 
female cases reported.

Adult/Adolescent Transmission Modes in Males: 

The modes of transmission for HIV/AIDS in Delaware adult/adolescent male cases 
have changed over time. At the end of 1992, 58% of the cases were MSM, 25% were 
IDU, and 10% MSM/IDU. Men infected through sex with a woman with HIV or sex with 
a woman who injected drugs comprised only 3% of the AIDS cases reported. Figure 
6 below shows the distribution of modes of transmission through 2004 and 
illustrates how the percentages have shifted away from MSM and MSM/IDU to 
increases in IDU and heterosexually infected men in Delaware.

Men who have sex with men represented 43% (n=414) of the 773 male 
adult/adolescent cases reported in the early period of the epidemic (through 
1993). From 1994 through 2004 the percentage of male cases attributed to MSM 
decreased to 25% (n=837) of the 2,287 cases reported in men in Delaware. The 
race and age groups for men who have sex with men are shown on the next page in 
Table 12 and are split into periods to compare any changes in the epidemic among 
the MSM population from the earlier to the later period.

An increase in the number of MSM cases in men of color is noted in the second 
time period compared to a decrease in the White population. Additional cases in 
all age groups from 1994 through 2004 are likely due to the 1993 change in case 
definition and the 2001 inclusion of HIV reporting data in the surveillance 
report. The presence of cases in the 13-19 age group and an increase of cases in 
most other age groups reflects the influence HIV reporting has on the portrait 
of the epidemic in Delaware.

As of December 31, 2004, a cumulative total of 992 MSM with AIDS had been 
reported in Delaware and 258 with HIV for a total of 1,251 with HIV/AIDS. Men 
who have sex with men represent 29% of  the cumulative HIV/AIDS cases reported 
in Delaware through 2004.

As illustrated in Figure 7 on the next page, the number of MSM cases reported by 
race and ethnicity has remained fairly level in men of Hispanic origin with 
minimal change over the twenty-year period. Though historically men who have sex 
with men appear to be most often in the White population on the chart, the 
number of MSM in the Black population equaled Whites in 2004.  The increase in 
all race/ethnic groups in ’93-‘94 and in ‘01-’02 are again the result of the 
1993 AIDS case definition change and implementation of HIV reporting 
respectively.

Men Who Inject Drugs

Men who inject drugs represented 31% (n=241) of the 773 male adult/adolescent 
cases reported in the early period of the epidemic. From 1994 through 2004 the 
proportion of male IDU cases increased to 40% (n=916) of the 2,287  cases 
reported in Delaware. The race and age groups for  men who inject drugs are 
shown below and are split into two periods to compare any changes in the 
epidemic among the IDU population from one decade to the other. The 
disproportionate number of IDUs in the Black male population is significant.

Figure 9 on the next page depicts the number of male IDU cases in 
adult/adolescent HIV/AIDS cases by year of report. Two periods, 1992 to 1993 and 
2000 to 2001 reflect nearly a 300% increase in  the  number of cases reported. 
Again, the increase is attributed to the change in the AIDS definition and 
implementation of HIV reporting occurring in the years respectively. Figure 10 
on page 32 represents the incidence of men who inject drugs by county.

Men Who Inject Drugs and Who Also Have Sex with Men (MSM/IDU) Male injection 
drug users who also have sex with men (MSM/IDU) are the fourth highest 
behavioral risk in Delaware’s HIV/AIDS population. A cumulative total of 219 
MSM/IDU cases have been reported through December 2004 representing 7% of the 
total number of male cases. Table 14 below reports the race and age breakdown of 
the MSM/IDU cases, and Figure 11, on the next page, reports the distribution by 
county.

Men Reported with Heterosexual Mode of Transmission Only

Nationally,4 19% of AIDS and 12% of HIV cases cumulatively through 2003 were 
exposed through heterosexual contact. Of the adult/adolescent males reported 
with AIDS through 2003 through  heterosexual contact, 27% were reported as 
infected through sex with a female injecting drug user. Among HIV cases, 18% of 
the heterosexual cases were from sex with a female injection drug user.

Table 15, on the next page, compares the demographics of race/ethnicity and age 
groups for two time periods of the Delaware epidemic in men who were 
heterosexually infected with HIV. Both eras indicate Black men and men in the 
30-39 year age group are most frequently reported with a   heterosexual 
transmission mode. In the early years of the epidemic prior to 1993, more than 
two-thirds (67%) of the heterosexual men were Black, and after 1993, more than 
three-quarters   (76%) were Black.  White men who were reported as 
heterosexually infected have decreased by nearly half, from 30% to 17%. The 
absence of any heterosexual Hispanic men in the first decade is more than likely 
attributed to lack of HIV education, treatment and/or early intervention in the 
population that would have aided in detection in the community.

Delaware  men infected through heterosexual  contact with a woman, represent 11% 
of the male  population reported cumulatively. Figure 12 below illustrates that 
sex with an injecting drug user was indicated in 33% (n=111) of the cases, and 
65% (n=217) had sex with a woman with HIV.  The remaining 2% (n=5) had sex with 
someone who had received a blood transfusion.

The distribution by county of residence in men reported as infected with HIV 
through heterosexual contact is shown in Figure 13. The vast majority, 71%, of 
the heterosexually infected men are  residents of New Castle County, 16% are 
from Sussex County and 13% from Kent County.

Adult/Adolescent Transmission Modes in Females:

Women Who Inject Drugs

Table 16 below again divides the epidemic into two periods, and shows female 
injecting drug users by race and age at year of report. The Black IDU female 
population is the most affected by the HIV/AIDS epidemic in both time periods, 
and the percentage of IDUs in White females more than doubled. And though the 
30-39 year age group is clearly the group most often affected in both decades, 
the increase in the 20-29 year age group and the finding of cases in the teenage 
group are significant as well.

Women with Male Sex Partners at Risk (Heterosexual Contact)

Table 17 on the next page compares women HIV-infected by a male partner in the 
periods 1983–1993 and 1994 –2004. In Black and White women the percentages 
remained remarkably stable over the two periods.

Table 17 also shows a decrease in the percentage of women in the 20-29 and the 
30-39 year age groups who were HIV-infected by a male partner. There was a 
corresponding increase in the   number of female cases attributed to 
heterosexual transmission in the 40-49 age group.

In Figure 16 below, the women reported with heterosexually acquired HIV are 
broken down by the risk of the partner thought to have exposed them. Sex with an 
injecting drug user was reported as the partner’s risk in 37% (n=241) of the 
cases, and 60% (n=389) had sex partners who were HIV positive.

Pediatric HIV/AIDS Cases:

Through 2004, Delaware had 47 pediatric cases of HIV/AIDS, a small number for 
statistical reporting. Sixteen have HIV infection and 31 are AIDS defined. 
Thirty-seven (79%) of the children are living and 10 (21%) have died. 
Race/Ethnicity distribution for pediatric cases  is 74% Black, 17% White and 9% 
Hispanic. Geographically, 75%  (n=35) were living in New  Castle  County at time 
of diagnosis of HIV/AIDS, 15% (n=7) in Kent County and 11% (n=5) in Sussex 
County.

Figure 18. Distribution of pediatric HIV/AIDS cases by mothers’ mode of 
transmission in Delaware through 2004, (n=47)

As depicted in Figure 18 above, forty-five percent of the pediatric cases were 
born to mothers with HIV disease who were injecting drug users and 23% to 
mothers who had sex with injecting drug users. Twenty-one percent of the 
pediatric cases were born to mothers who had sex with someone with HIV/AIDS, and 
5% were born to mothers with no identified risk. The perinatal exposures 
comprise 94% of the risk for pediatric cases in Delaware with hemophilia, 
transplant or transfusion risks associated to the remaining 6%. In Delaware, no 
new cases of perinatal exposure were reported to public health in 2003 or 2004. 
Nationally4 through December 2003, a total of 9,419 children (<13 years of age) 
had been reported as having  AIDS; of these pediatric cases, 5,103 (54%) had 
died. During 2003, 152 new cases of HIV/AIDS in children were reported. Of the
2003 cases, 86% (131) were transmitted from an HIV positive mother. Among those 
transmitted  from a mother, 35% (53) resulted from mother’s sex with an HIV 
positive male, 11% (17) from mother’s injection drug use, while 40% (61) 
resulted from a maternal transmission where the mother’s cause of infection was 
unidentified. Of note is the comparison with national data in mother’s IDU as a 
cause, which is 11% of national pediatric infections and 45% of Delaware 
infections.

Figure 19 below shows the national trend in AIDS (not HIV) cases diagnosed in 
children under the age of 13 from 1993 through 2003. As shown below, there has 
been a substantial decline in new AIDS cases among pediatric patients.


Figure 20 below shows pediatric AIDS cases diagnosed in Delaware through 2004. 
The state ranks fourth in the Nation (behind Washington DC, Florida and New 
York) in rate per 100,000 persons in terms of pediatric AIDS cases with a rate 
of 8.7 per 100,000. The national rate in 2003 was 3.7 per 100,000.

HIV/AIDS by Geographical Location:

Although Kent County appears to have the largest percentage of heterosexual 
cases compared to the other four areas throughout the state, it is because New 
Castle and Sussex Counties were further broken down by zip codes to depict 
epicenters of HIV disease.


In Sussex County, the beach area (Zip Codes: 19930, 19944, 19970, 19971 and 
19958) HIV/AIDS statistics show cases are 94% male, 87% White and 85% men who 
have sex with men. The statistics represented in Table 16 above may under-
represent the presence of known and diagnosed HIV in   these communities. The 
estimates do not incorporate the men who have sex with men diagnosed elsewhere 
who have retired and established permanent residency on the shore, or those  
with dual residencies in Philadelphia, Baltimore and the District of Columbia. 
The beach area is a much  different population than the remainder of Sussex 
County, and that is reflected in the cases  residing throughout the remaining 
zip codes in Sussex County where three-quarters (76%) are male, 59% are Black 
and modes of transmission are, for the most part, evenly distributed over MSM, 
IDU and heterosexual contact.

Question 3.  What are the indicators of risk for HIV/AIDS infection in Delaware?

To assist community planning groups address populations at risk for HIV 
infection, this portion of the profile looks at data collected in other 
databases. Limitations of the data sets were addressed starting on page 5.

*    As an extension of HIV/AIDS surveillance, the Supplement to HIV/AIDS 
Surveillance5 (SHAS)  project collects risk behavioral information on adults 
living with HIV/AIDS.

*    HIV Counseling and Testing data is collected at all DPH publicly funded 
test sites.  Counselors assess risk behaviors for HIV infection in pre-test and 
post-test counseling sessions.

*    People seeking treatment for sexually transmitted infection (STI) or 
disease (STD) share  one or more risk factors with persons diagnosed with HIV 
infection. The existence of an STD  indicates the individual has had unprotected 
sex. Sex with someone who has HIV could increase  the possibility of 
transmission of HIV through a sore and into bloodstream.


Supplement to HIV/AIDS Surveillance5 (SHAS) Project Data:

Delaware began involvement in the SHAS project as a pilot state in 1991 through 
supplemental funding from the CDC. Through December 31, 2002, SHAS interviews 
were only conducted with clients diagnosed with AIDS. Upon implementation of HIV 
reporting in July 2001, subsequent application was made to the Human Subjects 
Review Board (HSRB) to include people diagnosed with HIV. Approval was granted 
in the fall of 2002 and inclusion of HIV positive clients into the SHAS project 
was initiated in January 2003. Application to interview incarcerated people with 
HIV and AIDS was made in the winter of 2002. The Delaware HSRB accepted the 
application and approval was granted at the federal level from the Office of 
Human Research Protection (OHRP) in March 2003. Delaware
is the first surveillance office in the nation to interview subjects in 
correctional facilities. Though little information collected on prison 
interviews is included in this profile, the information collected through June 
30, 2004 may prove valuable to prevention and treatment program planning for the 
Department of Correction.

Most questions relating to behavioral risk in SHAS ask the patient to answer the 
question in relationship to a time period. One of the following three time 
periods is used in the data that follows:
Questions asked of the participants in SHAS that may be used to assess the risk 
behaviors for the transmission of HIV include:

*    Number of sex partners
*    Frequency of condom use or unprotected sex
*    Exchange of money or drugs for sex
*    Injecting drug or other substance use
*    Needle sharing or preventive measures with needle use


SHAS in Injecting Drug Users (IDUs)

Forty-five percent (n=618) of the SHAS participants interviewed in the period 
July 1991 through June 2003 were identified by the reporting source as IDU. Of 
the IDUs interviewed, 84% (n=518)  were Black, 11% (n=67) were White and 5% 
(n=33) were Hispanic/Other. By gender the IDUs were 66% (n=407) male and 34% 
(n=211) female.

In male injecting drug users, 66% (n=269) had sex in the 12 months prior to the 
interview. In female injecting drug users, 61% (n=129) had sex in the 12 months 
prior to the interview.

Male IDU SHAS Participants 

Four-hundred seven of the male SHAS participants were identified by the 
reporting source as an IDU. One-hundred thirty four (33%) did not have sex in 
the 12 months prior to the interview. Seventy-seven (19%) had sex but no steady 
sex partner. Of the 196 who had a steady partner, 40 (10%) knew their steady 
partner was positive, 151 (38%) knew their steady partner was negative and 5 
(1%) did not know their partner’s HIV status and isn’t illustrated in Figure 21. 
Seventy-nine percent (n=119) of the 151 men with HIV negative partners used 
condoms during vaginal intercourse.

Female IDU SHAS Participants

Two-hundred eleven (54%) of 388 female SHAS participants were identified by 
reporting sources as IDU. Eighty-four (40%) did not have sex in the 12 months 
prior to the interview. One hundred twenty-seven (60%) of the 211 female IDU 
SHAS participants had sex in the 12 months prior to the interview. Of the 127 
women who had sex in the time frame, 21 (10%) did not have a “steady partner” 
and 106 (50%) had a “steady partner”.
*         38 women knew their "steady partner" was positive and
*         67 women knew their "steady partner" was negative or did not know 
status
Sixty-nine  percent  of  the  105  women  with  “steady  partners”  used  
condoms regardless of the “steady partner’s” HIV status.

One hundred sixty-seven (27%) of the 618 SHAS participants identified by 
reporting sources as an IDU at time of report denied ever injecting drugs. 
Fifty-seven (34%) of those who denied ever injecting a drug also denied ever 
using any non-injecting drugs as well.

Four hundred fifty-one (73%) of the 618 SHAS participants identified by 
reporting sources as an IDU at time of report responded they had injected a 
drug. Two hundred fifty-three (56%) said  the drug they injected most often was 
cocaine followed by 117 (26%) who chose heroin as their  most often used drug. 
In addition, more than half (51%) of the injecting drug users had used  crack in 
a crack house and 39% (n=176) had sex in a crack house.

Three hundred sixty-five (81%) of those 451 SHAS participants who claimed to 
have injected drugs had shared needles and 42% (n=153) cleaned their syringes 
“every time” while 11% (n=40) “never” cleaned their syringes. Of the 365 who 
have shared needles, forty-four (12%) have used in the 12 months prior to the 
interview and the needle was obtained “off the street” by 29 participants and 15 
other participants got their needle “from a friend”, “from a drug dealer” or 
“refused to answer.”

Two hundred eighty-one (77%) of the participants, who used a needle in the 12 
months prior to the interview, have been in drug treatment. Eighty-four (30%) 
had been enrolled in a drug treatment program in the 12 months prior to the 
interview.

SHAS in Men Who Have Sex with Men (MSM)

Twenty-seven percent (n=369) of the SHAS participants interviewed in the period 
July 1991 through June 2003 were identified by the reporting source as MSM. Of 
the MSM interviewed, 52% were White, 44% were Black and 4% were Hispanic or 
other.

Of the 369 MSM SHAS participants, 11% (n=41) had been treated for an STD in the 
12 months prior to the interview date.

Sixty-three (17%) of the MSM said they had been given drugs or money for sex, 
while 70 (19%) responded they had given someone money or drugs for sex in the 12 
months prior to the interview date.

The 369 men reported in HARS as MSM self-identified their sexual orientation as:
*    258 (70%) Homosexual/Gay
*    74 (20%) Heterosexual/Straight
*    37 (10%) selected Bisexual/Other

Of the 369 MSM participants, 284 (77%) said they had sex in the 12 months prior 
to the interview date and 85 (23%) had not had sex during the time frame.

Data from the SHAS database, not mutually exclusive, on the 284 MSM who had sex 
in the time frame:
*    Two hundred forty-four (86%) identified their sex partners as male only;
*    Nine (3%) had both a male and female sex partner;
*    Thirty-one (11%) identified their sex partners as female only;
*    One hundred fifty-nine (56%) were in a “steady and monogamous 
     relationship”;
*    Ninety-one (32%) had fewer than 5 sex partners in the time frame; and
*    Forty (14%) had more than 5 partners in the 12 months prior to the 
     interview.

One hundred-nineteen (47%) of the 253 MSMs who had sex in the time frame engaged 
in sex where they were an anal receptor of their partner the last time they had 
intercourse. Eighty-nine (75%) of these 119 men used condoms the last time they 
received anal sex. Ninety-one (36%) of the 253 MSM who had sex in the time frame 
engaged in sex where they penetrated their partners anally the last time they 
had sex. Of the 91 men who anally penetrated their partners, the last time they 
had sex, 77 (85%) used a condom.

One hundred-eleven (30%) of the 369 MSM participants identified their sexual 
orientation as  heterosexual or bisexual. Thirty-three (30%) of the 111 men 
responded they had sex with a woman in the 12 months prior to the interview. 
Forty-three percent (n=14) of these 33 said the woman was a “new partner” or 
someone they had sex with for the first time in the 12 months prior to the SHAS 
interview. All 33 of the men who had sex with a woman in the past 12 months 
claimed  their  partner was either negative or they did not know the female 
partner’s HIV status. When vaginal and oral intercourse took place, condoms were 
used less than 10% of the time. The 33 MSM participants who had sex with a 
female denied anal intercourse with their female partners.

Of the 85 (23%)participants who claimed not to have had sex in the twelve months 
prior to the  interview date the main reason for not having sex was identified 
as “sexual drive had decreased”  in 47 (55%). Thirty-eight (45%) responded they 
“were afraid of infecting someone else with HIV 
or other STD.”

Heterosexual SHAS Participants

From July 1991 through June 2004, heterosexual SHAS participants comprised 19% 
(n=260) of those  interviewed. Heterosexuals in this portion of the profile 
include: sex with an IDU, sex with a bisexual man, sex with a person who 
received a blood transfusion and sex with a person with HIV/AIDS. Due to the 
small number of those who had sex with bisexual men and those who had sex with a 
person who received a blood transfusion they are combined with the participants 
who had  sex with someone who is HIV positive or AIDS defined. Their risk is not 
associated with injecting drug use and their partners are HIV positive or AIDS 
defined. With the merger, 42% (n=110) are heterosexuals who had sex with a 
person with HIV/AIDS and 58% (n=150) are heterosexuals who had sex with an IDU.

More detailed information regarding sexual activity and condom usage in 
heterosexual SHAS participants may be found in Appendix A of profile.


The demographic information in Table 20, on the previous page, indicates in 
2003, the clients seeking HIV counseling and testing services (n=11,672) are:
*       51% women;
*       52% Black, 34% White, and 14% Hispanic, other, or unknown races.
*       41% in the age group 20-29, 21% are 30-39 and 20% are 13-19 years of 
	age.


The demographics for clients deciding to be tested (n=10,365) are:
*       52% women;
*       51% Black, 36% White, and 13% Hispanic or other race/ethnicities;
*       40% in the age group 20-29, 21% are 30-39 and 21% are 13-19 years of 
	age.


The demographics for clients testing positive for HIV (n=129) are:
*       66% are men;
*       71% are Black, 19% are White, and 10% Hispanic or other 
	race/ethnicities;
*       33% in the age group 30-39, 36% are 40-49 and 19% are 20-29 years of 
	age;
*       25% of the positives self-identified as MSM.

For 2004, the clients seeking HIV counseling and testing services (n=15,029) 
are:
*       51% men;
*       50% Black, 32% White, and 18% Hispanic, other, or unknown races.
*       39% in the age group 20-29, 20% are 30-39 and 17% are 13-19 years of 
	age.


The demographics for clients deciding to be tested (n=13,604) are:
*       51% men;
*       48% Black, 34% White, and 18% Hispanic, other, or unknown races.
*       39% in the age group 20-29, 20% are 30-39 and 17% are 13-19 years of 
	age.


The demographics for clients testing positive for HIV (n=142) are:
*       65% are men;
*       69% are Black, 20% are White, and 11% Hispanic or other 
	race/ethnicities;
*       32% in the age group 30-39, 27% are 40-49 and 27% are 20-29 years of 
	age;
*       30% of the positives self-identified as MSM.

The data shown above illustrates that in 2003 and 2004, men and women sought HIV 
counseling and testing services at nearly the same rate. Although African 
Americans represent 19% of Delaware’s  population, roughly 50% of clients 
counseled/tested were black. Positive tests coming out of our state funded sites 
have been  consistent over the past two years;  two out of three positive  tests 
were attributed to men. In 2003, 71% of the positive HIV tests were among 
Blacks; in 2004, the percentage slightly dropped to 69%. Roughly 40% of those 
tested in Delaware were between the ages of 20-29 followed by the 30-39 age 
group with 20%. Finally in 2003 and 2004, men having sex with men were self-
identified as the leading mode of HIV transmission among those testing positive.

Sexually Transmitted Infection (STI) and Disease

In Delaware information on individuals diagnosed with gonorrhea, chlamydia, 
primary and  secondary syphilis is collected at the local level in sexually 
transmitted disease (STD) clinics, private physician offices, correctional 
facilities, outpatient facilities and reported to a centralized office within 
the Division of Public Health. HIV can be spread through the same unprotected 
sexual contact that spreads STDs. The presence of an STD can facilitate HIV 
transmission both by increasing viral load and by providing ulcerations through 
which HIV can pass. People diagnosed with a STD are at increased risk of 
contracting or spreading HIV.

Due to continued unprotected sexual practices an individual may contract or be 
diagnosed more than one time in a reporting year. The recurrence of infection or 
disease, referred to as  disease events, may therefore include duplicate 
diagnoses. According to the Delaware Annual Sexually Transmitted Disease 
Report7, more than 2,600 chlamydia disease events, have  occurred  every 
reporting year from 1996 through 2002. Figure 30 above, illustrates the minimal 
rise and fall in chlamydia and gonorrhea events over a five year period. Each of 
the events represents  behavior that potentially exposes the client to HIV 
infection.

The figure on the next page shows chlamydia diagnoses by gender. For every male 
diagnosis,  close to four times as many females were diagnosed with chlamydia 
each year.

2003 Youth Risk Behavior Survey8 (YRBS) Data

During the spring of 2003, 3,048  students in 32 Delaware public high schools, 
participated in the Youth Risk Behavior Survey8 (YRBS). The school response rate 
was 100%, the student response rate was 77%, and the overall response rate was 
77%. The results are representative of all students in grades 9-12. The weighted 
demographic characteristics of the sample are as follows:

The YRBS is one component of the Youth Risk Behavior Surveillance System 
developed by the Centers for Disease Control and Prevention in collaboration 
with representatives from 71  state and local departments of education and 
health, 19 other federal agencies, and national   education and health 
organizations. The Youth Risk Behavior Surveillance System was designed to focus 
the nation on behaviors among youth related to the leading causes of mortality 
and morbidity among both youth and adults and to assess how these risk behaviors 
change over time.  The Youth Risk Behavior Surveillance System measures 
behaviors that fall into six categories:


1.  Behaviors that result in unintentional injuries and violence;
2.  Tobacco use;
3.  Alcohol and other drug use;
4.  Sexual behaviors that result in HIV infection, other sexually transmitted 
    diseases, and unintended pregnancies;
5.  Dietary behaviors; and
6.  Physical activity.


For this profile, highlights from questions three and four will be addressed.

If you are interested in more information about the Youth Risk Behavior 
Surveillance System you may contact Janet Ray; Health Education Associate at the 
Department of Education at 302-857-3320.

Of the students surveyed:


*       78.5% had at least one drink of alcohol on one or more days during their 
	life;
*       30.3% had their first drink of alcohol other than a few sips before age 
	13;
*       45.4% had at least one drink of alcohol on one or more of the past 30 
	days;
*       26.6% had five or more drinks of alcohol in a row, that is, within a 
	couple of hours, 
	on one or more of the past 30 days;
*       48.9% used marijuana one or more times during their life;
*       13.4% tried marijuana for the first time before age 13;
*       27.3% used marijuana one or more times during the past 30 days;
*       7.4% used any form of cocaine, including powder, crack, or freebase one 
	or more times during their life;
*       3.8% used any form of cocaine, including powder, crack, or freebase one 
	or more times during the past 30 days;
*       11.4% sniffed glue, breathed the contents of aerosol spray cans, or 
	inhaled any paints or sprays to get high one or more times during their life;
*       4.1% sniffed glue, breathed the contents of aerosol spray cans, or 
	inhaled any paints or sprays to get high one or more times during the 
	past 30 days;
*       2.3% used heroin one or more times during their life;
*       6.2% used methamphetamines one or more times during their life;
*       1.7% used a needle to inject any illegal drug into their body one or 
	more times during their life;
*       27.9% were offered, sold, or given an illegal drug on school property by 
	someone during 	the past 12 months;
*       57.7% had sexual intercourse;
*       20.6% had sexual intercourse with four or more people during their life;
*       42.7% had sexual intercourse with one or more people during the past 
	three months;
*       25.4% had sexual intercourse but have not had sexual intercourse during 
	the past three 	months;
*       Of students who had sexual intercourse during the past three months, 
	23.9% drank alcohol or used drugs during last sexual intercourse;
*       Of students who had sexual intercourse during the past three months, 
	62.2% used a condom during last sexual intercourse;
*       Of students who had sexual intercourse during the past three months, 
	17.9% used birth control pills during last sexual intercourse;
*       7.7% had been pregnant or gotten someone pregnant one or more times.

Question 4.  What are the patterns of utilization of services in people with HIV 
in Delaware?

The reference data for service utilization are for the most part based upon data 
provided to Health Resources and Service Administration (HRSA), by grantees in 
Delaware receiving funding through multiple title programs.

Title II funding is awarded to improve the quality, availability, and 
coordination of health care and support services for people and families with or 
affected by HIV disease. The funding also assists with access to recommended 
pharmaceuticals through the AIDS Drug Assistance Program (ADAP).

In 2003, a total of 3,772 clients received services funded through all Ryan 
White funding and 981 of them were new clients. Of the 3,772 clients, 94% 
(n=3,546) were HIV-infected and 226 were HIV-affected. HIV-affected counts the 
children, spouses and significant other people in the lives of an HIV-infected 
person that are not themselves infected with HIV. The service provided to  HIV-
affected individuals was case management.

In 2004, a total of 3,821 clients received services funded through all Ryan 
White funding and 223 of them were new clients. Of the 3,821 clients, 94% 
(n=3,593) were HIV-infected and 228 were HIV-affected. HIV-affected counts the 
children, spouses and significant other people in the lives of an HIV-infected 
person that are not themselves infected with HIV. The service provided to HIV-
affected individuals was case management.

Table 22, on the next page, compares the demographic characteristics of the 
duplicated HIV-infected clients receiving services that are funded by Ryan White 
Care Act Title II Programs in 2003 and 2004 to the distribution of living 
HIV/AIDS cases in Delaware through 2004.

More often than not a client may have received multiple services so the numbers 
are not mutually exclusive.

Table 22. Demographic characteristics of client visits funded by Ryan White Care 
Act Title  II programs in 2003 and 2004 compared to Delaware living HIV/AIDS 
cases.

The following table illustrates the five most frequently accessed Ryan White 
Title II services funded in Delaware. The unduplicated number of clients 
accessing the services is 3,546 in 2003 and 3,593 in 2004. Medical services do 
not include medications dispensed; medications are found  exclusively under the 
ADAP category.

Additional services provided with CARE Act funds for 2003 and 2004 are shown 
below.

2003 data

*	1,213 people were provided Health Education and Risk Reduction
*	  993 people were referred for psychosocial\supportive services
*	  596 food-bank or home delivery connections were made
*	  490 treatment adherence counseling session were held
*	  382 people were provided with transportation
*	  217 people received emergency financial assistance
*	   16 referrals to clinical research were arranged
*	  535 client advocacy incidents were reported
*	   29 assisted housing connections were arranged


2004 data

*	1,454 people were provided Health Education and Risk Reduction
*	1,079 people were referred for psychosocial\supportive services
*	  752 food-bank or home delivery connections were made
*	  639 treatment adherence counseling session were held
*	  388 people were provided with transportation
*	  272 people received emergency financial assistance
*	  100 referrals to clinical research were arranged
*	  582 client advocacy incidents were reported
*	  120 assisted housing connections were arranged

In Delaware, Ryan White CARE Act Title II funding was awarded to three provider 
types.  The provider types are:

1.  Hospital-Based Clinics that include:
*    DuPont Hospital for Children north of Wilmington
*    Christiana Care Health Services and Division of Public Health jointly 
sponsored clinics

2.  Community Based Organizations that include:
*    AIDS Delaware
*    American Red Cross
*    Beautiful Gate Outreach Center
*    Brandywine Counseling Incorporated
*    Case Management Services
*    Catholic Charities
*    Delaware Center for Justice
*    Delaware HIV Consortium
*    Kent/Sussex County Counseling
*    Ministry of Caring
*    Sussex County AIDS Council
*    Generations Home Health Care Inc.

3.  Public Health entities that include:
*    Division of Public Health, Delaware Department of Health and Social Services
*    Cecil County Health Department, Maryland

Table 25 below illustrates the demographic characteristics of clients in the 
ADAP program in 2003/2004 compared to the demographics of living HIV/AIDS cases 
in the HARS database for the same period. The percentages appear similar in most 
characteristics with the exception of race.

In this category, Blacks represent 71% of the living cases in HARS compared to 
59% enrolled in ADAP. The difference may be due to the number of clients in the 
ADAP program designated to the “Unknown\More than one race” category.

Table 25.  Demographic characteristics of clients served in 2003/2004 AIDS Drug  
Assistance Program (ADAP) compared to living Delaware HIV/AIDS reported cases in 
2003 and 2004

Of 1,213 clients, 637 (53%) attended an ID-Wellness clinic on Highly Active 
Antiretroviral Therapy (HAART) at the end of 2003. Of the 1,224 clients in 2004, 
513 (42%) attended an ID-Wellness clinic on HAART therapy. When the demographics 
are compared to the number of living  HIV/AIDS cases in the HARS database the 
similarities are significant. The data infers that HIV-infected people in 
Delaware are being equally served regardless of race, age or gender.

Table 26 below, illustrates the demographic characteristics on the 13% (n=161) 
of the 1,213 clients attending an ID-Wellness clinic who had an undetectable 
viral load at the end of 2003.  Also in 2004, 12% (n=145) of 1,224 clients had 
an undetectable viral load. When the characteristics of the clinic clients on 
ADAP are compared to the living HIV/AIDS cases in the HARS database, there is a 
direct correlation between the percentages. For example, 62% of Delaware’s ADAP 
dollars are being utilized by African-Americans which represents 64% of those 
currently living with HIV disease.

Table 26. Characteristics of HIV-Infected patients who are ADAP clients with 
undetectable viral loads in CCHS\DPH ID-Wellness clinics throughout Delaware in 
2003 and 2004

In 2003, 1,213 HIV-infected clients attending ID-Wellness clinics also received 
the following preventive therapies:
*	1,100 (91%) had a TB skin test (PPD Mantoux), 9 who were treated 
	secondary to positive TB skin test.
*	  856 (71%) had screening/testing for syphilis and 3 were positive and 
	  treated.
*	   75 (6%) had screening/testing for any treatable sexually transmitted 
	  infection (STI) other than syphilis and HIV and 41 were treated for an 
	  STI other than syphilis and HIV.
*	  143 (12%) had screening/testing for hepatitis C and 17 received 
	  treatment for hepatitis C.

The 468 HIV-infected females attending ID-Wellness clinics also received the 
following gynecological\obstetric interventions in 2003:

?	335 (72%) received a pelvic examination and Pap smear during 2003.
?	 23 (5%) of the women were pregnant in 2003.
?	 13 entered care in the first trimester
?	  6 entered care in the second trimester
?	  3 entered care in the third trimester
?	  1 entered care at the time of delivery
?	 23 (100%) of the pregnant women received antiretroviral medication to 
	 prevent transmission of HIV to their children.

Fourteen children were delivered to 23 pregnant HIV-positive women. None of the 
14 children were HIV positive.

Figure 33a. on the next page, illustrates 39% (n=471) of the clients attending 
an ID-Wellness clinic in Delaware in 2003 are clients infected with HIV through 
heterosexual contact, 32% (n=388) are injecting drug users and 21% (n=258) are 
MSM.

In 2004, 1,224 HIV-infected clients attended ID-Wellness clinics and received 
the following preventive therapies:

*	1,187 (97%) had a TB skin test (PPD Mantoux), 15 who were treated 
	secondary to positive TB skin test.
*	  986 (81%) had screening/testing for syphilis and 11 were positive and 
	  treated.
*	  109 (9%) had screening/testing for any treatable sexually transmitted 
	  infection (STI) other than syphilis and HIV and 34 were treated for an STI 
	  other than syphilis and HIV.
*	  127 (10%) had screening/testing for hepatitis C and 39 received 
	  treatment for hepatitis C.

The 464 HIV-infected females attending ID-Wellness clinics also received the 
following gynecological\obstetric interventions in 2004:

?	250 (54%) received a pelvic examination and Pap smear during 2004.
?	 27 (6%) of the women were pregnant in 2004.
?	 22 entered care in the first trimester
?	  3 entered care in the second trimester
?	  2 entered care in the third trimester
?	 27 (100%) of the pregnant women received antiretroviral medication to 
	 prevent transmission of HIV to their children.

Fourteen children were delivered to 27 pregnant HIV-positive women. None of the 
14 children was HIV positive.

Figure 33b. below illustrates 39% (n=490) of the clients attending an ID-
Wellness clinic in Delaware in 2004 are clients infected with HIV through 
heterosexual contact, 32% (n=355) are injecting drug users and 21% (n=286) are 
MSM.

Figure 33b. Distribution of clients attending ID-Wellness clinics by risk factor 
for transmission of HIV in 2004, (n=1,224)

Of the 3,546 HIV-infected Delawareans in 2003 receiving services through Ryan 
White CARE Act funding, 43% (n=1,540) have income levels equal to or less than 
the Federal Poverty Level. Thirty-six percent (n=1,259) have income levels 
between 101% and 200% of the Federal Poverty Level.

Of the 3,593 HIV-infected Delawareans in 2004 receiving services through Ryan 
White CARE Act funding, 48% (n=1,734) have income levels equal to or less than 
the Federal Poverty Level. Thirty-nine percent (n=1,399) have income levels 
between 101% and 200% of the Federal Poverty Level.

HIV/AIDS Reporting System (HARS) Data

The HIV/AIDS Reporting System provides the states with the capability of 
collecting user specified data at the local level. Delaware has for several 
years collected information on where HIV-infected people are getting their 
health care. The data is generally collected from laboratory results that 
indicate the requesting providers name or treatment facility, through line 
reviews with private physicians, ID and Wellness clinic coordinators, case 
managers, correctional facilities and through case report forms. The 
information has become more frequently available since the implementation 
of HIV reporting in July 2001. Laboratory data is updated as the information 
becomes available and is generally received no less than twice a year. Due 
to enhanced laboratory reporting the information on treatment location 
is considered current for at the least the past 12 months. Anecdotally, to 
receive no data on a client in a 12-18 month time frame may indicate the client 
has moved to another state, moved to a treatment facility that is out of state, 
is receiving care through a health care provider who is not requesting CD4 or 
viral load testing or the provider is using a laboratory that is not reporting 
results to DPH.  The final determination that may be made is that the client has 
dropped out of care.

The following graphs show the utilization of treatment services in Delaware as 
collected in HARS and extracted for the current profile. Treatment locations are 
fixed for years ending in 2003 and 2004.

Figure  35a. Distribution by treatment location of all living HIV clients 
residing in Delaware at time of diagnosis through December 2003, (n=923)
 
Figures 35a (on page 70), 35b (on page 71), 36a (on page 71) and 36b above 
indicates over half of all HIV and AIDS patients are receiving care through a 
wellness clinic, with approximately one-quarter being treated by private 
doctors. A slightly higher percentage of HIV clients are being treated in a 
correctional facility when compared to AIDS clients.

Figures 37a and b on the next page illustrates the county of residence and 
treatment location of living cases as of December 31, 2003. This figure includes 
273 non-residents (cases that were diagnosed in a state other than Delaware but 
are now residing in Delaware) who received care in 2003.  There are also 17 
clients  residing in Delaware who go outside our state to receive their medical 
care and they are included in with the Veteran’s (VA) or other clinic category. 
In Delaware, the “other clinic” category includes sites like A.I. duPont 
Hospital for Children and the Henrietta Johnson Medical Center. As is 
illustrated in figure 37a on the next page, 538 (55%) HIV-infected clients and 
964 (59%) AIDS-infected clients living in Delaware attended an ID/Wellness 
clinic in each of the three counties in 2003.

Figures 38a and b on page 74 ooked at the same data, but for calendar year 2004. 
One noticeable change is the number of clients seeking care at a private doctor. 
For HIV-infected clients, this rate jumped from 20% in 2003 to 25% in 2004. 
Another increase between 2003 and 2004 is the number of clients whose treatment 
location is unknown. This rate jumped from 11% to 15% among HIV- infected 
clients and 3% to 5% among clients who progressed to AIDS.

Supplemental HIV/AIDS Surveillance (SHAS) Data

The SHAS interview process collected data through 13 questions regarding HIV 
Testing and  Medical Therapy, 32 questions on Preventive Therapy and 29 
questions on Health and Social Services. Information regarding availability and 
utilization of services in the state is collected through the survey. The 
results of 1363 participants interviewed through the SHAS process from July 1991 
through June 30, 2004 are found below.

The answers to the following SHAS questions are shown in percentages.

HIV Testing and Medical Therapy

All participants were asked:

Where were you tested when you had your first positive HIV test?
?   33% Hospital inpatient, outpatient and emergency room;
?   21% in Public Health clinics or “AIDS” clinics;
?   14% in private physician’s office;
?   10% in HIV counseling and testing site or mobile access;
?   8% in a community clinic;
?   8% in a correctional facility;
?   3% in a drug clinic;
?   2% at a blood bank;
?   1% in other types of clinic.

When you first tested positive for HIV, what was the main reason you were 
tested?
?   50% due to illness;
?   26% identified a risk behavior for HIV;
?   7% would not identify reason;
?   5% just wanted to know;
?   3% offered at the clinic;
?   3% insurance pre-requisite, entrance to military, started new relationship;
?   3% surgical pre-requisite;
?   3% pregnancy.

When you first tested positive for HIV, what type of test did you have?
?   15% anonymous
?   66% confidential
?   19% do not know

Has anyone (for example, from the health department or a health care provider) 
ever offered to tell your sex (or drug using) partners that they may have been 
exposed to HIV so they can be tested?
?   67% responded “no” no one ever offered help with notifying partners
?   32% responded “yes” someone had offered to help notify partners
?   1% responded “don’t remember”

The 32% (n=436) who answered “yes” to the preceding question were asked:

What was your response when they offered to tell your partners?
?   72% client chose to notify partners;
?   12% asked the health department or other person to help with notifying 
    partners;
?   9%  did not want partners told or refused to respond to questions;
?   5%  asked for help with some partners and said they would tell the 
    others;
?   2% answered with an “other” response.

The 9% (n=39) who did not want their partners told were asked:

What was the main reason you chose not to tell your partners?
?   31% responded they were “afraid of what the partner(s) would do me”;
?   13% responded they “didn’t trust the health department/person who 
    offered to tell my partners”;
?   13% responded they were “afraid my partner(s) would find out it was me who 
    may have infected them”;
?   43% responded with an “other” answer that did not fit any of the offered     
    responses in the survey.


All participants were asked:

When did you first get medical care after learning you had HIV/AIDS? This 
includes examinations and viral load or CD4 testing, even if you are not 
currently taking any anti-HIV medications?
?   53% received care within 1 month of learning their HIV status;
?   12% received care within 3 months;
?    3% received care within 12 months;
?    2% received care within 36 months;
?    6% waited more than 36 months;
?   24% were unable to provide both a month and year of first care 
    that is required to calculate the variable.

During the past 12 months where did you go most often to get medical care for 
your HIV infection?
?   83% receive their HIV medical care through a HRSA funded clinic,
?   11% through private physician,
?    2% through Veteran’s Administration Medical Center,
?    3% through another facility type not specified,
?    1% received no care in the last year.

Not counting payment for HIV medicines, about how much did you pay out-of- 
pocket for health care for your HIV infection in the past 12 months? This 
includes insurance premiums, deductibles, co-payments, and any other money you 
may have paid for your HIV care. (out-of-pocket meaning money you pay out that 
doesn’t get reimbursed).
?   80% paid no out-of-pocket money in the last 12 months;
?    6% paid between $1 and $100;
?    2% paid between $101 and $200;
?    3% paid between $201 and $300;
?    4% paid between $301 and $999;
?    5% paid more than $999.

Has a doctor or health care provider ever told you that your HIV infection had 
progressed to AIDS?

In the 1,216 surveys completed with AIDS diagnosed clients the responses were:
?   45% responded “no”, they had not been told they had progressed to AIDS;
?   52% responded “yes”, they had been told they had progressed to AIDS;
?    3% responded they “did not know or were not sure”.


In the 147 surveys completed with clients whose medical/diagnostic status was 
HIV positive at the time of interview the responses were:
?   98% responded “no”, they had not been told they had progressed to AIDS;
?    2% responded “yes”, they had been told they had progressed to AIDS.


Has your doctor or health care provider ever told you that you had hepatitis?
?   64% responded “no” they had not been told they had hepatitis;
?   36% responded “yes” that they had been told they had hepatitis.

The 36% (n=436) who responded “yes” to having been told they had hepatitis were 
asked:

What type of hepatitis was it? (multiple types were recorded where indicated)
?    8% of the participants said they had hepatitis A;
?   32% of the participants said they had hepatitis B;
?   50% of the participants said they had hepatitis C;
?   10% of the participants said they did not know the type of hepatitis they had.

Have you ever had the vaccination to protect against Hepatitis B?
?   51% participants said they had not received the Hepatitis B vaccine;
?   35% participants said they had received the vaccine preventative for hepatitis B;
?   14% participants did not know if they had received the hepatitis B vaccine.

Preventive Therapy

Have you ever taken antiretroviral medicines (an extensive list of 
antiretrovirals along with generic names is provided to the SHAS participant) to 
treat your HIV infection?
?   81% responded “yes” they had taken an antiretroviral medication;
?   18% responded “no” they had not taken an antiretroviral medication;
?   1% responded “they did not know or were unsure”.

The 18% (n=245) who responded “no” to the preceding question were asked:

What is the main reason you havent taken antiretroviral medications?
?   18% responded “I recently got into care and haven’t had time to start taking 
    any medications yet”;
?   37% responded “My doctor said I should wait until later to take medications”;
?   13% responded “I feel good, I don’t think I need them”;
?   16% responded “My CD4 count is still high (or viral load is low) so I
    decided not to take them”;
?   11% responded “I’m worried about medication side effects”;
?    5% responded “I never got around to getting into care/never took the time” 
     or “other” answer.

The 81% (n=1,104) who responded “yes” to having taken an antiretroviral were 
asked:

In the past 12 months, have you taken a "drug holiday" from your antiretroviral 
medications?  That is, did you not take any doses of one or more of your 
antiretroviral medications for at least two whole days in a row?
?   29% (n=320) said “yes” they had taken a “drug holiday” in the past 12 
    months.

When the 320 were asked:

What was the main reason you took a drug holiday from your antiretroviral 
medications?

The top four responses were:
?   19% said “I just got tired of taking them and needed a break”;
?   15% said “Medication has side effects and makes me feel bad”;
?   15%  said “I was someplace where I couldn’t get my  medications 
    (on vacation or out of town)”;
?   13% said “I felt good and I didn’t think it would hurt not to take them”.

Have you ever been told you have Pneumocystis carinii pneumonia (PCP)?
?    4%  responded that  they “did  not know” if they had been told they had PCP;
?   15% responded “yes” that they had been told they had PCP;
?   81% responded “no” that they had not been told they had PCP.

Conclusion

Back in 1994, just ten short years ago, 3,282 AIDS cases were reported to the 
Division of Public Health and only forty-eight percent (n=1,585) were living. At 
the end of 2004, 4,343 HIV/AIDS cases have been reported to DPH and sixty-six 
percent (n=2,869) are living.

At the end of 2004, the majority, 39% (n=1,123), of the living cases reside in 
the City of Wilmington’s zip codes 19801, 19802, 19805, and 19806. Thirty 
percent (n=848) reside in other zip codes in New Castle County, 17% (n=478) 
reside in Sussex County and 9% (n=268) reside in Kent County. Four percent of 
those living with HIV/AIDS are incarcerated (n=124). 1% (n=28) of people living 
with HIV/AIDS have no county of residence on record.

The disproportionate impact of the HIV/AIDS epidemic on African-American 
Delawareans continues to present prevention providers with ever growing need for 
early intervention through education, outreach and behaviorally-based 
interventions. In the City of Wilmington, 82% of those living with HIV (not 
AIDS) are African-American and of those living with HIV (not AIDS) in New Castle 
County (outside Wilmington), 59% are African-American. As of the end of 2004, 
sixty five percent  (n=1,097) of Delawareans who have died of HIV/AIDS were 
African-American and 74% (n=812) of the African-American cases that have died 
were men.

Nearly two-thirds (62%) of the cumulative male cases n Delaware are African- 
American and more than three-quarters (76%) of the cumulative female cases are 
African-American. In Kent County, 61% of those living with HIV (not AIDS) are 
African-American. In Sussex County, 53% of those living with HIV (not AIDS) are 
White.

It is our hope that the data contained in this epidemiological report will help 
to prevent further cases of HIV/AIDS in the State of Delaware by better focusing 
resources and programs to those most at risk. Today, more Delawareans are living 
with HIV disease than ever before.  Recent data from Christiana Care Health Systems 
shows that 59% of people presenting for care, seek care only after experiencing 
symptoms of HIV illness and/or receive a diagnosis of AIDS before or at intake for 
clinic care. The need to reach people earlier in HIV illness has never been more 
urgent. Interventions must address at-risk populations, as communities and as 
individuals, and must be tailored, as much as is practical and fundable, to each 
population’s unique cultural, racial, ethnic, economic, religious and sexual 
mores and practices. HIV testing, partner services, active referral to care, and the 
responsibility to not pass the virus must be emphasized appropriately and effectively 
– in tune with the unique needs of each population.


Support
Grant funding through Cooperative Agreement 00005 from the Centers for Disease 
Control and Prevention (CDC) supported this publication. 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.

Acknowledgements
Many thanks goes out to the HIV/AIDS Surveillance staff for their hard work and 
dedication. Our surveillance staff includes John Miller, Christina Melvin, 
Bob Vella, Angela Miller, Bruce Levan and Doug Trader.

We  also would  like to thank the following individuals: Ryan White CARE Act 
grantees and Delaware Ryan White Program Administrator Lucy Luta and staff— 
Marge Brittingham, Jeanette Killen and Jean McAdams;  STD Program Administrator, 
Cathy Mosley and staff member Sheri Swackhammer, for their assistance with STD data 
and Amy Edwards for her assistance with the printing of the profile.

We also appreciate the efforts of Steve Martin and Dan O’Connell from the 
University of Delaware and Susan Tanner from the Delaware HIV Consortium for 
their assistance in the preparation of this report.

Finally, a special thanks to Dr. Robert Jackson and James C. Welch for their 
support, guidance, patience and mentoring.

References
1.  United States Census Bureau from website: http://quickfacts.census.gov/qfd/
2.  Delaware Division of Public Health, Health Statistics Center, Delaware Vital
    Statistics Annual Report 2002
3.  HIV/AIDS Reporting System (HARS), HIV/AIDS Surveillance, DPH
4.  Center for  Disease Control and  Prevention,  HIV/AIDS Surveillance Report
    2003, Year-end edition Volume 13, No. 2, U.S. HIV and AIDS cases reported 
    through December 2001, http://www.cdc.gov/hivdhap.htm
5.  Supplemental HIV/AIDS Surveillance (SHAS), HIV/AIDS Surveillance, DPH
6.  Division of Public Health, Disease Prevention and Control, HIV/STD/Hepatitis 
    C Section, HIV Counseling and Testing Annual Report 2002, internal document 
7.  Division of Public Health, Disease Prevention and Control, HIV/STD/Hepatitis 
    C Section, Sexually Transmitted Disease Annual Report 2002, internal document.
8.  Department of Education, Division of Adolescent and School Health (DASH), 
    Youth Risk Behavior Survey (YRBS), 2003 from website:
    http://www.cdc.gov/nccdphp/dash/yrbs/results.htm
9.  Health Resource and Services Administration (HRSA), Ryan White CARE Act Data 
    Reports (CADR) 2003 and 2004.

APPENDIX A

Heterosexual SHAS Participant Sexual Activity and Condom Use


Of the 14 heterosexual men who were infected with HIV through sex with an IDU, 3 
abstained from sex and eleven (79%) had sex with a woman in the 12 months prior 
to the interview.  Eight (73%) of the men, who had sex with a woman, had a 
single partner only. Two men had between 4 and 6  female partners and one male 
stated he had sex with 30 women in the 12 months prior to the interview.

Seven (67%) of the 11 men who had sex with a woman, in the time frame, 
identified themselves as having a “steady sex partner”. Of the seven, 86% (n=6) 
used a condom when engaging in vaginal intercourse with their partner.

Of the four men who did not have a steady sex partner, 3 (75%) used a condom 
when engaging in vaginal intercourse. None of the four men had anal sex with 
their female partner or had given the women oral sex. Three (75%) of the four 
men had received oral sex from a female partner and 2 (67%) used a condom.

Of the 20 female heterosexuals who were infected through sex with an IDU and 
interviewed with SHAS, 8 had abstained from sex in the 12 months prior to the 
interview date.

Of the 44 heterosexuals who had sex with a person with HIV/AIDS, 73% (n=32) are 
female and 27% (n=12) are male.

Within the female participants, 81% (n=26) had sex with a man in the 12 months 
prior to the interview date and 77% (n=20) of the 26 had a single partner in the 
time frame.  Five participants had sex with 2-3 male partners and one with 50 or 
more. Eight (25%) of the 32 women interviewed had a sexually transmitted disease 
in the 12 months prior to the interview date.

Four (13%) of the 32 participants who had sex with a person with HIV/AIDS had 
received  drugs or money for sex but only one in the 12 months prior to the 
interview. Only one of the females had ever paid for sex and not within the 12 
months prior to the interview.

Thirteen (68%) of the 19 women, who had a steady sex partner in the 12 months 
prior to the interview date, had vaginal intercourse with their steady sex 
partner and used a condom. Five (26%) of the 19 females were recipients of oral 
sex and one (5%) used a barrier or dental dam. Seven (37%) of the 19 women had 
given their partners oral sex and 3 (16%) of the 7 had used a condom. None of 
the 19 females engaged in anal intercourse.

Of the seven women  who did not have a steady sex partner in the 12 months prior 
to the interview date, the number of sex partners ranged from 1 to 3. Of the 
seven women, 4 (57%) had  vaginal intercourse and used a condom, 3 (43%) were 
recipients of oral sex and only one use a barrier or dental dam. Two (29%) of 
the 7 women without steady sex partners had given oral sex to a man and did not 
use a condom. None of the seven women had engaged in anal intercourse in the 12 
months prior to the interview date.

Within the 12 heterosexual males who participated in a SHAS interview and had 
sex with a person with HIV/AIDS, 10 (83%) had sex with a woman in the 12 months 
prior to the interview date.  Eight (80%) of the 10 had a steady female sex 
partner in the time frame. When having vaginal intercourse with their steady 
female partner, 70% (n=7) used a condom.

Of the 12 male heterosexual SHAS participants, two (17%) had been treated for a 
sexually transmitted disease in the 12 months prior to the interview  period.

APPENDIX B

Delaware Epidemiologic Profile Feedback

The purpose of this form is to provide the writers of HIV/AIDS epidemiologic 
profiles feedback from their end-users regarding the ease of use and 
applicability of the profile to prevention care planning activities.

Please complete this feedback form and send it to the HIV/AIDS Surveillance 
Office, Delaware Division of Public Health, Blue Hen Corporate Center, 255 South 
Bay Road, Suite 218, Dover, DE 19901


1.  Of which planning group are you a member?


c Delaware HIV Planning Council  c Formulary Committee c Policy Committee


2.  Was the epidemiologic profile easy to read?


c Yes   c No    c Somewhat


3.  How were the findings of the epidemiological profile communicated to you?


c Print Copy Only
c Profile Writers presented epidemiologic profile to planning group
c Other ____________________________________________________


4.  Were the findings of the epidemiologic profile clear to you?


c Yes   c No       c Somewhat


If not, explain why.


          ___________________________________________________________


          ___________________________________________________________


          ___________________________________________________________


5.  Was the epidemiologic profile useful to your planning process?


c Yes   c No       c Somewhat


If not, explain why.


          ___________________________________________________________                                                           

          ___________________________________________________________


          ___________________________________________________________




6.  Describe how you used the epidemiologic profile in your planning activities?


	  ______________________________________________________________




7.  How can next year’s profile be improved?


	  ______________________________________________________________


	  ______________________________________________________________


7a: What specific questions could be included in the next profile?


	  ______________________________________________________________


  	  ______________________________________________________________


8.  Do you want to receive the quarterly HIV/AIDS statistical report?


c No


c Yes, I already receive the report


c Yes, please send the report to me by:
Include your contact information, as appropriate

c Email _________________ c Fax _________________ c Mail ________________


9.  Data from this epidemiological profile is helpful to me as I conduct my job.


c Yes                      c No


If yes, how do you use the data?

c Grant writing


c Proposal development


c Resource for presentations


c Other, _________________