The burden of heterosexually acquired HIV infection is borne disproportionately by women and blacks, according to an analysis of data from 29 states that conduct confidential name-based HIV and AIDS surveillance.1 Between 1999 and 2004 in these states, two-thirds of all those who acquired HIV through heterosexual contact (and nine in 10 such teenagers) were women; three-quarters were black. Furthermore, the prospects for long-term survival after an AIDS diagnosis were dimmer for blacks with heterosexually acquired HIV than for whites and Hispanics.
During the period 1999–2004, one-third of newly diagnosed HIV infections in the reporting states were attributable to heterosexual activity with a partner who was HIV-positive or had a known risk factor for infection. (The analyses included all HIV infections, whether or not the disease had progressed to AIDS.) Sixty-four percent of heterosexually acquired cases of HIV were found in women, and 60% in persons younger than 40. The vast majority of infections (73%) were among blacks; 15% were among whites, 10% among Hispanics and the remainder among members of other racial or ethnic groups. Women accounted for 55% of Hispanics, 64% of blacks and 68% of whites with HIV infection acquired through heterosexual behavior. They made up an even larger share of 13–19-year-olds with newly identified heterosexually acquired HIV infection—88%.
Overall, the annual number of heterosexually acquired HIV infections was constant throughout the period, but significant changes occurred in several subgroups. The annual number of diagnoses declined by 3–5% among men in their 20s and 30s, and by 3% among black men; however, it rose 2–5% among men in their 40s and 50s, and 5–6% among white and Hispanic men. The number dropped by 3–4% among women aged 13–39 and 1% among black women, but increased 4–7% among women older than 39 and among Hispanic women.
One-fifth of individuals in whom heterosexually acquired HIV infection was identified between 1999 and 2004 received an AIDS diagnosis within the same calendar month (i.e., a concurrent diagnosis). Multivariate analyses revealed that in every racial or ethnic group, men were significantly more likely than women to receive concurrent diagnoses (odds ratios, 1.6 for whites and Hispanics, and 1.2 for blacks). Teenagers consistently had the lowest likelihood of concurrent diagnoses, and the relative odds were higher in each successive 10-year age-group. Among blacks, concurrent diagnoses were significantly less common in every year from 2001 to 2004 than they were in 1999; among whites, reduced odds of concurrent diagnoses were observed for 2000–2002. For Hispanics, the likelihood of concurrent diagnoses did not vary through the study period.
Estimated probabilities of survival after an AIDS diagnosis associated with heterosexually acquired HIV for the 29 study states in 1999–2003 were similar to those for the nation as a whole in 1996–2003; therefore, the analysts used the national data to examine survival at one-year intervals. In each racial or ethnic group, men and women with heterosexually acquired HIV had an estimated 92–94% probability of surviving for one year after an AIDS diagnosis. However, the probability of survival fell and subgroup differences emerged with each succeeding year. By three years after diagnosis, survival probabilities for black men and women were significantly lower than those for whites and Hispanics; at four years, an estimated 79% and 76%, respectively, of black men and women would be expected to have survived, compared with 82–85% of men and 81–84% of women in the other racial subgroups.
As the analysts comment, the surveillance data are limited by the exclusion of 21 states, including ones with high levels of AIDS morbidity. "To more completely describe the epidemic," they note, "a national HIV infection reporting system is needed." Nevertheless, they conclude that the available data illustrate the continued need for culturally sensitive HIV prevention messages, interventions aimed at especially vulnerable groups, and improved access to services for racial and ethnic minorities, who are "disproportionately affected by HIV" and often face barriers to obtaining adequate care. —D. Hollander
1. Espinoza L et al., Characteristics of persons with heterosexually acquired HIV infection, United States, 1999–2004, American Journal of Public Health, 2007, 97(1):144–149.