The most recent HIV/AIDS Program update has just been published.1 The document contains some 75 figures and tables and provides information current through December 31, 1999. I want to review for physicians in San Bernardino County the major changes taking place in HIV/AIDS and related diseases/issues. Overall, the AIDS epidemic peaked in 1993, accentuated by the change in definition to include HIV infected individuals with CD-4 counts < 200. These cases were moved forward in time as reportable which helped create an accentuated decline over the next few years when these individuals with severe immune deficiency would presumably have acquired one or more AIDS defining illnesses.
Although the decline in AIDS rates following 1993 affected all race-ethnic groups, rates in whites have fallen continuously while among African-Americans, with the highest rates initially, they have not fallen as consistently.
HIV REPORTING
The State of California is preparing to implement a requirement for all HIV
affected individuals to be reported to local public health authorities. The
reporting will be mandatory, but in the absence of an AIDS diagnosis, those
infected with HIV will be reported using a unique identifier or non-name code
generated from information specific to the individual (including his/her name).
A series of coded numbers based on the letters of the last name (Soundex code) will be included in the identifier as will date of birth, sex and the last four digits of the social security number. Although the proposed reporting process is still being reviewed following receipt of extensive public comments, it is likely that the basic elements will remain as initially proposed.
One important implication of the proposed new reporting requirements has to do with the wording of informed consent documents used when testing a patient for HIV antibodies or other evidence of infection. This would be an opportune time to review all such documents in use to be sure that they are not in conflict with new reporting requirements, which might be problematic with such statements as, "I further understand that no additional release of the results will be made without my written authorization."
Related Diseases
We can learn something more about the past and present impact of HIV/AIDS by studying changes in related diseases and conditions. For example, there has been a substantial decline in reported cases of gonorrhea and primary and secondary syphilis cases. In 1989 3,455 gonorrhea cases were diagnosed and reported to Public Health. By contrast, in 1999 only 738 cases were reported. Similarly, in 1990, there were 196 primary and secondary syphilis cases reported to Public Health compared to seven in 1998, 12 in 1999, and 10 in 2000.
As reassuring as these figures may be, in the year 2000 there were 1,073 cases of gonorrhea reported and through the first 21 weeks of 2001, more cases have been reported than for the same period last year. To be consistent with our view of the decline, it may be that reduced fear of AIDS has led to a reoccurrence of high risk behaviors. This hypothesis is reinforced by the documentation of a prolonged outbreak of syphilis in the LA, Orange County and Long Beach areas which included many young gay men, some of whom were HIV-infected as well.
If changes in the frequency of occurrence of gonorrhea and syphilis have been driven by fear of HIV/AIDS, it is possible that births to teenagers might follow a similar pattern. In fact, there has been a steady decline in teen births since 1991 when the birth rates reached 90.3/1000 women aged 15-19 to a rate of 63.1 in 1999 with no evidence of resurgence in the year 2000.
Recent changes in the number of diagnosed and reported cases of tuberculosis provide a different insight into disease occurrence and transmission. After years of decline, reported tuberculosis cases hit the lowest level in 1987 with 68 cases. Increases followed annually to a peak of 151 cases in 1993, corresponding to the peak among AIDS cases. This was followed by an unsteady decline to 101 cases in 1998, 113 cases in 1999, and 104 cases in 2000. Although there have never been enough cases with both tuberculosis and AIDS to account for all of the increase, the presence of large numbers of immune deficient individuals (with HIV/AIDS) increases the chance that they will 1) acquire tuberculosis infection and progress to communicable tuberculosis disease, 2) transmit tuberculosis to other immune deficient individuals with whom they come in contact, an illustration of which was a 17 case tuberculosis case outbreak among HIV-infected incarcerated individuals, and 3) transmit tuberculosis to contacts who are not immune deficient with some potential for spread in the larger population of those not HIV infected.
Improved treatment for those with HIV/AIDS has reduced death rates and hastened the decline in reported AIDS cases. While this is a remarkable achievement, it is tempered by the concern that this limited good news might lead to a relaxation in the behavioral restraints which appear to have been responsible for the peak of AIDS cases reported in 1993 and the decline in other STDs and blood borne infections (like acute hepatitis B which has also declined dramatically since peaking in the late 1980s).
Anyone wishing to receive a copy of the complete Year 2000 report of HIV/AIDS data can contact the HIV/AIDS Program epidemiologist at (909) 383-3051 and request a copy. A more detailed report and discussion of other reportable conditions in San Bernardino can be obtained by calling (909) 383-3050 and asking for the Year 1999 or Year 2000 Communicable Disease Summary Report.2 Questions or comments about reporting, case trends in AIDS or related diseases or other issues can be directed to the Health Officer's office at (909) 387-6219.
