THE CHANGING FACE OF AIDS.

Abstract

The human immunodeficiency virus (HIV) epidemic has had a profound effect on the nation's health. Nearly 700 000 people in the United States were reported to the Centers for Disease Control and Prevention (CDC) to have contracted acquired immunodeficiency syndrome (AIDS) through 1998. We summarize data on the disproportionate impact that HIV infection and AIDS have had on certain segments of American society.

HIV/AIDS began in the United States as a disease of mainly middle-class white homosexual men. In the past few years, the impact of the epidemic has shifted to primarily persons of color, injection drug users, and those with low socioeconomic status. There's new evidence that certain genetic factors can protect against HIV infection and disease progression. While these genetic factors appear to be more prevalent in white than in African American and Hispanic populations, they most likely play only a minor role in the epidemiology of HIV/AIDS. More significant is the differential access to care that accounts for much of the large differences in outcomes. Targeted interventions are needed to decrease barriers to care and enhance prevention efforts for high-risk populations. Policies and programs designed to help control the HIV epidemic need to address cofactors, such as injection drug use, prevalence of sexually transmitted diseases, and low literacy levels in these populations.

Introduction

The HIV / AIDS epidemic has had such a profound effect on American society that it now seems difficult to recall that AIDS was first recognized only in mid1981 [1-2] In 1983 a cytopathic retrovirus was first isolated from persons with AIDS. In the United States, the first 100 000 AIDS cases were reported between 1981 and 1989, an 8-year period. It took 2 more years for the second 100 000 cases to be reported. [3] By 1993, HIV / AIDS was the leading cause of death in the United States among all adults 25 to 44 years old. [4] It has been estimated that by the end of 1998, more than 688 000 persons were reported to have AIDS. At least 60% of them have died. [5-6] It is estimated that more than 335 000 HIV-infected adults are receiving care in the United States. [7] Expenditures in 1996 for the treatment of HIV / AIDS were estimated at $6.7 billion, or approximately $20 000 per patient per year. [7]

Currently, a large percentage of patients with HIV infection in the United States are members of racial and ethnic minorities, and a growing proportion are women. [8-11] In 1998, the incidence of AIDS among adult/adolescent African Americans was 8.5 times the rate of whites in the United States. AIDS incidence among Latinos was 3.8 times that of whites. [5] The increases in prevalence of HIV infection and AIDS among women have disproportionately affected African Americans, Latinos, and Caribbean blacks. [8-13] Now, more than half of males, and four fifths of females with AIDS, are persons of color. [5-6] This racial/ethnic disparity is even more pronounced in children with AIDS. In 1998, the pediatric AIDS incidence rate among African Americans was 16 times the rate of whites in the United States. Among Latinos, the rate was 4.5 times that of whites. [5]

The evidence is contradictory concerning differences in survival time, use of antiretroviral therapy, and use of prophylactic medication in HIV-infected persons of color as compared to whites. [14-16] Differences in provision of care are significant because antiretroviral and prophylactic medications significantly delay the onset of opportunistic infections and increase survival time. [17-20] There is also emerging evidence of differential racial prevalence of genetic factors that protect against HIV infection and disease progression. Is the differential use of medical therapies the underlying cause of observed inequalities in survival time in HIV-infected persons? Does race serve as a marker for access to medical care? Could biologic differences account for inequities in morbidity and mortality in HIV infection?