The New York Times

The New York Times, Feb 17, 2004 pF5(L) col 01 (31 col in)

Nationwide H.I.V. Reporting To Bring Trends Into Focus. (Health & Fitness) Lawrence K. Altman.

Now that all states are reporting newly identified H.I.V. infections in addition to AIDS cases, the picture of this country's AIDS epidemic could change significantly. On Jan. 1, Georgia became the last state to start reporting H.I.V. infections.

H.I.V. reporting is expected to provide a clearer and more accurate view of the most recent trends in the transmission of the virus. The information will help direct taxpayer dollars to the most effective programs in controlling the epidemic and may also affect allocations for the care of patients, health officials say.

For many years, the national reporting system focused principally on the AIDS cases that states reported to the Centers for Disease Control and Prevention, the federal agency that tracks the epidemic. AIDS cases represent the end stage, or trailing edge, of the epidemic because it takes about 10 years on average for H.I.V. to progress to AIDS in people who go untreated.

Compared with AIDS reporting, an initial but incomplete picture from H.I.V. reports puts a younger face on the epidemic, as expected, said Dr. Harold W. Jaffe, the director of the AIDS program at the agency. There are higher proportions of women and racial minorities in the H.I.V. group, he said, ''and that gives us an indication of where infections are occurring.''

Because AIDS case reporting reflected what happened years earlier, it produced a picture that told epidemiologists little about where, how many and how rapidly, new infections were occurring.

Dr. Matthew T. McKenna, an AIDS epidemiologist at the disease centers, said H.I.V. reporting would help the authorities identify groups that were being infected and find effective actions to stem the spread of the virus. The focus on H.I.V. will also help health officials learn how well the measures are working.

Because H.I.V. reporting is based on standard tests, health workers cannot determine when someone became infected. Some health departments, however, use an extra test that can determine if infection occurred in the previous six months.

Many health workers had long complained that their efforts to control AIDS lacked the same type of information that they received in a timely manner to battle every other infectious disease.

The disease centers estimate that one million Americans are infected with H.I.V., but that 25 percent are unaware they have the disease because they have not been tested for it. The agency also estimates that 40,000 Americans have become infected each year over the last decade.

The AIDS epidemic has changed in many ways since 1981, when it was first identified. It has shifted from one that primarily affected white gay men in New York City, San Francisco and Los Angeles to one that affects growing numbers of women and minority populations in many other areas. In developing nations, H.I.V. is causing one of history's worst epidemics.

The biggest factor in the decision of the states to report H.I.V. cases was the success in treating the infection. Powerful combinations of antiretroviral drugs have lowered the number of deaths and are allowing many people to live in better health and longer.

That development has lengthened the average time of progression from infection to the signs and symptoms of AIDS among treated patients. But the progress has made it difficult for statisticians to calculate backward to estimate time of infection.

''AIDS case reporting now has become much more of an indicator of who is getting treated, who is not getting tested early, and how effective therapy is,'' Dr. McKenna said.

Another factor in the greater reliance on H.I.V. reporting is that many patients have moved from the state where their infection was diagnosed. That development underscores the need for the disease centers to check identifying characteristics from reported cases to avoid duplications, Dr. McKenna said.

The C.D.C. long pushed for national reporting of H.I.V. cases that included patients' names. It took years to happen because groups representing gay men opposed the efforts out of fears that breaches in confidentiality could lead to discrimination.

In part for that reason, some states use codes, which, the agency says, are not as accurate as reporting by name.

The names of H.I.V. patients, which are known only to a small number of trained workers in local and state health departments, are not sent to the disease control centers, in keeping with the practice for all other reportable diseases.

State reporting of H.I.V. cases began with Colorado, Minnesota and Wisconsin in 1986. By 1995, 30 states were providing the reports.

But New York and California, which together have reported one-third of the nation's 859,000 AIDS cases in the epidemic, did not come aboard until 2000 and 2002, respectively. Although Pennsylvania adopted H.I.V. reporting in 2002, Philadelphia chose not to do so.

''In New York City, we have a very old, continuously evolving epidemic and a brand new H.I.V. surveillance system'' that ''allows us to understand not only who is acquiring H.I.V. but who is transmitting it,'' said Dr. Lucia V. Torian, who directs the city's H.I.V. monitoring.

A New York law required H.I.V. reporting to begin on June 1, 2000. At the 11th annual Conference on Retroviruses and Opportunistic Infections here, Dr. Denis Nash, formerly of the city health department and now with the New York Academy of Medicine, reported New York City data on new H.I.V. cases for 2001. About two-thirds were men and one-third women. Blacks and Hispanics were 5 and 2.5 times, respectively, as likely to become infected with H.I.V. as non-Hispanic whites in the city. The numbers have been stable since then.

Although New York City has analyzed H.I.V. reporting through the first quarter of 2003, that period is too brief to provide a clear picture of any trends, Dr. Torian said. Usually, about six years are needed, Dr. McKenna said.

Dr. Torian's team has found that 80,862 New Yorkers, or about 1 percent of the city's population, were living with H.I.V. or AIDS as of Dec. 31, 2002. Of the total, H.I.V. was diagnosed in 17,983 people since such reporting began.

The cumulative total for New York City since AIDS case reporting began is 135,837. Of those, 83,398, or 62 percent, have died.

In 2002, 1,429, or 26 percent, of New York City's 5,417 new cases -- people who were not only H.I.V. positive but also had infections that had advanced enough to meet the diagnostic criteria for AIDS -- learned of their infections on the day they learned they had AIDS.

''They missed an opportunity of taking advantage of the primary care that is available through the city,'' Dr. Torian said.

Also, these people may have unknowingly transmitted H.I.V. to sexual and needle-sharing partners over the years when they were unaware of their infection status.

Those whose H.I.V. infections were diagnosed in late stages tended to be men, non-Hispanic blacks and residents of boroughs outside of Manhattan. The health department has identified neighborhood hot spots in each of the city's five boroughs.

Increasing proportions of new H.I.V. diagnoses in New York City are among women, blacks and people ages 30 to 39. Of the 1,784 H.I.V. diagnoses of women in 2002, 1,203 were black.

In 2002, gay men accounted for 1,030 H.I.V. cases in New York City.

The health department estimates that about 2.5 percent of gay men in the city are infected each year.

In repeated surveys, more than half of the city's infected gay men said they usually engaged in anal intercourse without using condoms.

As of 2002, about 2.9 percent of all men in Manhattan are H.I.V. infected and 4.2 percent of men ages 40 to 49 in all five boroughs of New York City are infected. About 2.5 percent of all black men in the city are infected. Nationally, the estimated infection rate for males is 0.5 percent.

The 2.9 percent figure is ''very concerning'' because in countries like Thailand, described as having a serious AIDS problem, ''the numbers are not that much different,'' the C.D.C.'s Dr. Jaffe said.

He went on:

''If you stood on a street corner in Manhattan and watched men walk by, would it occur to you that this percent were infected? What if Manhattan were its own country and someone from the World Health Organization went into the country of Manhattan to assess the AIDS epidemic, how would they describe it?''

Article CJ113320177