Commentary

   Since the use of highly active antiretroviral therapy (HAART) became widespread during 1996, trends in AIDS incidence have become less reflective of underlying trends in HIV transmission. AIDS incidence increased throughout the 1980s, declined from the mid-1990s through 2001, and increased 2% in 2002 (compared with 2001). The number of deaths among persons with AIDS continued to decline. During 1998–2002, the estimated number of deaths among persons with AIDS declined 14%. AIDS prevalence (i.e., the number of persons living with AIDS) continued to increase. At the end of 2002, an estimated 384,906 persons in the United States were known to be living with AIDS (see cover).

   To better monitor the patterns of HIV diagnosis, most states have implemented HIV surveillance. Many states in which the HIV surveillance system allowed the reporting of previously diagnosed cases received a large number of HIV case reports during the initial implementation period. However, once most of the previously diagnosed cases had been reported, the number of cases reported in later reporting periods decreased, better reflecting newly diagnosed cases. Some of the persons with a newly diagnosed case had been infected recently; others had been infected some time in the past. Therefore, new HIV diagnoses do not necessarily reflect HIV incidence (i.e., new infections). One method for estimating HIV incidence is to apply the serologic testing algorithm for recent HIV seroconversion (STARHS) to the serum specimens from which recent HIV diagnoses were made. Five areas were funded in FY 2002 to pilot this method, and 19 additional areas were funded in FY 2003. The monitoring of HIV incidence will be critical in evaluating progress toward CDC’s goal of reducing the number of new HIV infections in the United States from 40,000 to 20,000 per year by the year 2005.

Since 1994, CDC has supported uniform HIV surveillance for all 50 states and territories. The 2002 HIV/AIDS Surveillance Report has been revised to present data on persons with HIV infection, including those in whom HIV infection has progressed to AIDS. Surveillance data on HIV infection provide a more complete picture of the epidemic and the need for prevention and care services than that provided by AIDS data alone. Such comprehensive information is needed to allocate resources and evaluate program effectiveness.

In this report, the term HIV/AIDS is used to refer to three categories of cases: (1) new diagnoses of HIV infection only, (2) new diagnoses of HIV infection with later diagnoses of AIDS, and (3) concurrent diagnoses of HIV infection and AIDS. For analyses of HIV/AIDS data, we used data from 30 areas (i.e., 29 states and the U.S. Virgin Islands) that have had HIV infection reporting for a sufficient length of time (i.e., at least since 1998) to allow for stabilization of data collection and for adjustment of the data in order to monitor trends. Tables 1, 2, 8, and 9 summarize diagnoses and prevalence of HIV/AIDS. For analysis of diagnoses of AIDS, we used data from the 50 states, the District of Columbia, U.S. territories and other associated nations.

This report is organized in five sections: (1) diagnoses of HIV/AIDS and AIDS, (2) deaths of persons with AIDS, (3) persons living with HIV/AIDS, AIDS, or HIV infection (not AIDS), (4) length of survival after AIDS diagnosis, and (5) reports of cases of AIDS, HIV infection (not AIDS), and HIV/AIDS. Sections 1 through 3 present point estimates of cases that have been adjusted for reporting delays and for redistribution of cases initially reported without a mode of HIV exposure. CDC routinely adjusts data for the presentation of trends in the epidemic. Data to estimate the number of persons with diagnoses of HIV/AIDS or AIDS, the number of persons living with HIV/AIDS, AIDS, or HIV infection (not AIDS), and the number of deaths among persons with AIDS have been statistically adjusted to correct for delays in the reporting of cases and deaths. To assess trends in diagnoses, deaths, or prevalence, it is preferable to use adjusted data, presented by year of diagnosis instead of year of report, to eliminate artifacts of reporting in the surveillance system. Therefore, readers are encouraged to use tables that present trends by year of diagnosis, year of death, or year-end prevalence. Section 4 presents estimates of survival for persons whose AIDS diagnosis was made during 1998 (Table 13) and persons whose diagnosis was made during 1994–2001 (Figures 2-4). Estimates of the proportion of persons surviving various lengths of time after diagnosis are presented by year of diagnosis, age group, race/ethnicity, and HIV exposure category. Finally, Section 5 presents reports of cases of HIV infection (not AIDS) and cases of AIDS reported through 2002. Areas included in tabulations of reported cases of HIV infection (not AIDS) are based on the date of implementation of name-based HIV infection reporting. For this report, data from 39 areas were used in Tables 15 and 17 to describe reports of HIV infection (not AIDS). These data have not been adjusted for delays in reporting and are presented by year of report to CDC. Tables that present cases by year of report represent the most up-to-date information reported to CDC; however, cases by year of report do not represent incident cases, the most recent diagnoses, trends, or deaths.

The presentation of the data in tables has also been changed to show trends in diagnoses of HIV/AIDS for the most recent 5-year period and cumulatively. For trends in AIDS diagnoses, we present annual estimates for the most recent 5 years (i.e., 1998 through 2002) and cumulative totals through 2002. For trends in diagnoses of HIV/AIDS, we also present annual estimates of the most recent 4 years (i.e., 1999 through 2002) in 30 areas with confidential HIV infection reporting since 1998, as well as cumulative totals through 2002.

Highlights of Analyses

Diagnoses of HIV/AIDS and AIDS

Diagnoses of HIV/AIDS

From 1999 through 2002, the number of diagnoses of HIV/AIDS in the 30 areas with confidential-name-based HIV infection reporting increased steadily. Table 1 includes data on persons in this category. Diagnoses of HIV/AIDS increased 3.2% from 2001 (25,643) through 2002 (26,464) (Table 1). For the 30 areas, the rate of HIV/AIDS diagnoses in 2002 was 19.1 per 100,000 population.

• By age group, diagnoses of HIV/AIDS decreased among children and in the age group 25–34 years and increased in all other age groups. In 2002, the age group 25–34 years represented 28% of all new diagnoses of HIV/AIDS.
• By race/ethnicity, increases occurred among whites, Hispanics, and Asians/Pacific Islanders and remained stable among blacks. In 2002, blacks accounted for 54% of all new diagnoses of HIV/AIDS.
• By sex, from 1999 through 2002, the number of diagnoses of HIV/AIDS increased 7% among men and remained stable among women. In 2002, men accounted for 71% of all new HIV/AIDS diagnoses among adults in the 30 areas.
• By exposure category, diagnoses of HIV/AIDS increased each year during 1999–2002 among men who have sex with men (MSM) and, to a lesser degree, among heterosexuals. In addition, diagnoses decreased among injection drug users (IDUs), MSM who were also IDUs, and among children. In 2002, MSM (44%) and persons exposed through heterosexual contact (35%) accounted for 79% of all new diagnoses of HIV/AIDS.
  

Of all HIV infections in 2001, 39% progressed to AIDS within 12 months after the diagnosis of HIV infection. AIDS was diagnosed within 12 months after the diagnosis of HIV infection for a larger proportion of older persons (35 and older), Hispanics, Asians/Pacific Islanders, American Indians/Alaska Natives, IDUs, and persons exposed through heterosexual contact (Table 2).

Diagnoses of AIDS

During 1998–1999, declines in AIDS incidence began to level, and essentially no change occurred from 1999 through 2001. In 2002, AIDS diagnoses increased 2% (Table 3). The rate of AIDS diagnoses in the United States was 14.1 per 100,000 population (Table 5).

• By age group, from 1998 through 2002, AIDS incidence decreased 61% among children and 24% in the age group 25–34 years, and remained stable in the age group 35–44 years. AIDS incidence increased in the following age groups: 13–14, 15–24, 45–54, 55–64, and 65 years and older. In 2002, the age group 35–44 years represented 41% of all new diagnoses of AIDS.
• By race/ethnicity, from 1998 through 2002, AIDS incidence declined among whites and Hispanics; incidence increased among blacks, Asians/Pacific Islanders, and among American Indians/Alaska Natives. In 2002, rates of AIDS diagnoses ranged from 58.7 per 100,000 of the black population to 4.0 per 100,000 of the Asian/Pacific Islander population.
• By sex, from 1998 through 2002, the number of AIDS diagnoses increased 7% among women and decreased 5% among men. In 2002, men accounted for 74% of all new AIDS diagnoses among adults in the United States. Rates of AIDS diagnoses in 2002 were 26.4 per 100,000 among men and 8.8 per 100,000 among women.
• By exposure category, from 1998 through 2001, AIDS incidence declined among MSM, IDUs, and MSM who were also IDUs. In 2002, incidence among MSM increased slightly. Among persons exposed through heterosexual contact, incidence increased each year from 1998 through 2002.
• By region, AIDS incidence declined in the Northeast and the U.S. territories from 1998 through 2002, the South through 2000, and the West through 2001. In 2002, compared with 2001, incidence increased 9% in the Midwest, 5% in the South, and 5% in the West.

Deaths

The estimated number of deaths among persons with AIDS in 2002 represented a 14% decline since 1998 (Table 7).

• By age group, the number of deaths declined among most age groups but increased slightly among the age group 45-54.
• By race/ethnicity, the number of deaths among persons with AIDS declined in all racial/ethnic groups.
• By sex and exposure category, the number of deaths declined among MSM, IDUs, and MSM who were also IDUs. Among adults and adolescents exposed through heterosexual contact, the number of deaths leveled from 1998 through 2000, increased in 2001, and then declined in 2002.
• By region, the number of deaths in 2002 (compared with 2001) declined in the Midwest, the South, the West, and U.S. territories and increased slightly in the Northeast.

Persons Living with HIV/AIDS, HIV infection (not AIDS), or AIDS

Persons living with HIV/AIDS

The prevalence of diagnosed HIV/AIDS has increased steadily in the 30 areas with confidential name-based HIV infection reporting (Table 8). At the end of 2002, approximately 281,931 persons were known to be living with HIV/AIDS in the 30 areas with confidential name-based HIV infection reporting since 1998:

• By age group, 42% were in the age group 35–44 years.
• By race/ethnicity, 50% were black, 38% white, 10% Hispanic, and <1% each were American Indian/Alaska Native and Asian/Pacific Islander.
• By sex, 73% of adults with HIV/AIDS were men.
• Of the estimated 206,557 male adults and adolescents (>13 years of age) living with HIV/AIDS, 61% were MSM, 17% were IDUs, 13% had been exposed through heterosexual contact, and 8% were MSM who also were IDUs. Of the 71,996 female adults and adolescents living with HIV/AIDS, 72% had been exposed through heterosexual contact, and 26% had been exposed through injection drug use. Of the 3,374 children living with HIV/AIDS, 92% had been exposed perinatally.

Prevalence rates of HIV infection (not AIDS)

In the 30 areas with confidential HIV infection reporting, the prevalence rate of HIV infection (not AIDS) among adults was 125.7 per 100,000 at the end of 2002 (Map 1). The rate for adults living with HIV infection (not AIDS) ranged from 12.8 per 100,000 (North Dakota) to 229.7 per 100,000 (Virgin Islands). The prevalence rate of HIV infection (not AIDS) among children was 5.6 per 100,000 population (Map 2). The rate for children living with HIV infection (not AIDS) ranged from 0.4 per 100,000 in Idaho to 20.0 per 100,000 in New Jersey.

Persons living with AIDS

AIDS prevalence has also increased steadily (Table 10). At the end of 2002, approximately 384,906 persons in the United States were living with AIDS:

• By age group, 43% were in the age group 35–44 years.
• By race/ethnicity, 42% were black, 37% white, 20% Hispanic, and <1% each were Asian/Pacific Islander and American Indian/Alaska Native.
• By sex, 77% of adults living with AIDS were men.
• By region, 39% resided in the South, 29% in the Northeast, 19% in the West, 10% in the Midwest, and 3% in the U.S. territories.
• Of the 298,248 male adults and adolescents (>13 years of age) living with AIDS, 58% were MSM, 23% were IDUs, 10% had been exposed through heterosexual contact, and 8% were MSM who were also IDUs. Of the 82,764 female adults and adolescents living with AIDS, 61% had been exposed through heterosexual contact, and 36% had been exposed through injection drug use.

AIDS prevalence rates

• In the United States, at the end of 2002, the AIDS prevalence rate among adults was 160.5 per 100,000 (Map 1). The rate ranged from 2.2 per 100,000 (Pacific Islands) to 1,685.8 per 100,000 (District of Columbia). The rate among children was 4.2 per 100,000 population. The rate among children ranged from 0.4 per 100,000 in Arizona, Colorado, Kansas, and Utah to 80.8 per 100,000 in the District of Columbia.

Survival after AIDS Diagnosis

Table 13 is limited to data for AIDS cases diagnosed in 1998 to describe the survival of persons whose diagnosis was made relatively recently, but far enough in the past to permit a meaningful measure of survival. Figures 2, 3, and 4 illustrate the proportion of surviving persons among persons whose diagnoses were made over a longer period, 1994 through 2001.

• Survival (the estimated proportion of persons surviving a given length of time after diagnosis) increased with the year of diagnosis for diagnosis during 1994–1997, but year-to-year differences were small during 1997–2001.
• Survival decreased as age at diagnosis increased among persons at least 35 years old at diagnosis, and in comparison with persons less than 35 years, but did not differ significantly among the age groups less than 35 years.
• Survival was greatest among MSM and among children with perinatally acquired HIV infection. Survival was intermediate among men and women who had heterosexual contact with someone known to be HIV infected or at high risk for HIV infection, as well as among MSM who also were IDUs. Survival was shortest among men and among women who were IDUs (Table 13).
• Survival was greater among Hispanics, non-Hispanic whites, and Asians/Pacific Islanders than among non-Hispanic blacks, particularly for more than 60 months after diagnosis (Figure 4). Results were unstable or inconsistent for American Indians/Alaska Natives because numbers of persons in this racial/ethnic category were small.

Reports of Cases of AIDS, HIV infection (not AIDS), and HIV/AIDS

Tables 14 through 18 describe reports of cases of AIDS, HIV infection (not AIDS), and of HIV/AIDS. Tables 15 and 17 are based on reports of cases of HIV infection (not AIDS) through 2002 from the 39 areas that had implemented name-based HIV infection reporting. Readers should note that not all cases of HIV infection (not AIDS) or AIDS reported in 2002 reflected new diagnoses; rather, the reported cases include cases diagnosed during earlier years.

Reports of cases of HIV infection (not AIDS)

Through 2002, a total of 199,759 persons were reported as having HIV infection (not AIDS) in the 39 areas with confidential name-based HIV infection reporting. Five states (New York, Florida, New Jersey, Texas, and North Carolina) reported 35% of the cumulative cases of HIV infection (not AIDS) reported to CDC. In 2002, three states (Florida, New York, and Texas) reported 22,608 (64%) of the 35,147 cases of HIV infection (not AIDS).

• By sex, in 2002, 68% of the 35,147 reported cases of HIV infection (not AIDS) were in men, and 32% were in women.
• In 2002, 420 cases of HIV infection (not AIDS) in children were reported.

Reports of AIDS cases

Through 2002, a total of 859,000 persons had been reported as having AIDS in the United States, dependencies, possessions, and associated nations. Three states (California, Florida, and New York) reported 44% of the cumulative AIDS cases and 38% of AIDS cases reported to CDC in 2002. In the United States, the rate of reported AIDS cases in 2002 was 14.8 per 100,000 population. The rate of reported AIDS cases ranged from 0.5 per 100,000 population (North Dakota) to 162.4 per 100,000 population (District of Columbia).

• By sex, in 2002, men accounted for 74% and women for 26% of 43,950 reported AIDS cases.
• In 2002, 158 AIDS cases in children were reported.

Additional Resources

The following were prepared with HIV/AIDS surveillance data:

• Selected MMWR articles at www.cdc.gov/hiv/pubs/mmwr.htm
• Public-use slides at www.cdc.gov/hiv/graphics.htm
• Other surveillance reports at www.cdc.gov/hiv/stats/hasrlink.htm
• Public-use version of the AIDS surveillance data set (AIDS Public Information Data Set [APIDS]) at www.cdc.gov/hiv/software/apids.htm

Suggested Readings

CDC. Advancing HIV prevention: new strategies for a changing epidemic?United States, 2003. MMWR 2003;52:329-332.

CDC. Diagnosis and reporting of HIV and AIDS in 25 states?United States, 1994–2000. MMWR 2002:51:595-598.

CDC. Guidelines for national HIV case surveillance, including monitoring for HIV infection and AIDS. MMWR 1999;48(No. RR-13):1-31.

CDC. HIV Prevention Strategic Plan Through 2005. Atlanta: U.S. Department of Health and Human Services, CDC; 2001. Available at www.cdc.gov/hiv/partners/psp.htm.

CDC. Trends in HIV diagnoses in 29 states - United States, 1999–2002. In press.

CDC. Update: the AIDS epidemic in the United States, 2001. MMWR 2002:51:592-595.

Janssen RS, Satten GA, Stramer SL, et al. New testing strategy to detect early HIV-1 infection for use in incidence estimates and for clinical and prevention purposes. JAMA 1998;280:42-48.

Karon JM, Fleming PL, Steketee RW, De Cock KM. HIV in the United States at the turn of the century: an epidemic in transition. Am J Public Health 2001;91:1060-1068.

Nakashima AK, Fleming PL. HIV/AIDS surveillance in the United States, 1981–2001. J Acquir Immune Defic Syndr 2003;32:68-85.