CHAPTER 5

The Epidemiology of AIDS

Epidemiology
WHO definition:
Epidemiology is the study of the distribution and
determinants of health-related states or events (including
disease), and the application of this study to the control of
diseases and other health problems.
Various methods can be used to carry out epidemiological
investigations: surveillance and descriptive studies can be
used to study distribution; analytical studies are used to
study determinants.

AIDS and Epidemiology

In June 1981, doctors at the CDC:
Described five cases of Pneumocystis pneumonia in homosexual men in
Los Angeles.
Received several requests for pentamidine isethionate, which is used to
treat Pneumocystis pneumonia.
Received reports of an unusual number of cases of Kaposis sarcoma and
suppressed immune systems in patients.

By the end of 1982, epidemiologists had named the disease

acquired immune deficiency syndrome (AIDS).
Surmised that there was a common denominator among cases in separate
populations.
As data on the long incubation period emerged, they guessed a larger
group was infected and would manifest symptoms in the future.
Used case control studies to gather additional data.

A case-control study is an analytical study which compares

individuals who have a specific disease ("cases") with a
group of individuals without the disease ("controls"). The
proportion of each group having a history of a particular
exposure or characteristic of interest is then compared.

Case control studies enabled epidemiologists to show:

Number and frequency of sexual partners among
homosexual men were factors in the incidence of AIDS.
Sexual partners of homosexual and bisexual men were
at risk and that more than 20% of cases occurred in
men who had a sexual relationship with an infected
person.
Epidemiologists gathered enough data to prepare a case
definition for AIDS in 1983.
Made recommendations for avoiding the disease.
Physician reporting pointed to blood and semen as
principal sources of the disease agent.

HIV virus.
Disintegrates outside the body.
Cannot resist environmental pressures.
Transmission requires exchange of body fluids to spread
A large number of viral particles must be passed during
transmission.
Particle counts in saliva, tears, and sweat are too low to
affect HIV transmission.
Semen and blood remain the major
transferring substances of HIV.
Other contributing risk factors:
Volume of fluid introduced into
the recipient.
General state of health of
the recipient.
Inoculation site of the fluid.

Global summary of the AIDS epidemic 2012

Number of people living
with HIV

People newly infected

with HIV in 2012

Total
Adults
Women
Children (<15 years)

million [32.2 million 38.8 million] 35.3

million [29.1 million 35.3 million] 32.1
million [16.4 million 19.3 million] 17.7
million [3.0 million 3.7 million] 3.3

Total million [1.9 million 2.7 million] 2.3

Adults 2.0 million [1.7 million 2.4 million]
Children (<15 years) [000 320 000 230] 000 260

AIDS deaths in 2012

Total million [1.4 million 1.9 million] 1.6
Adults 1.4 million [1.2 million 1.7 million]
Children (<15 years) [000 250 000 190] 000 210
WHO, UNAIDS, UNICEF 2014

Adults and children estimated to be living with HIV 2012

Eastern Europe
& Central Asia

& Western
Central Europe

million 1.3

000 860

[000 930 000 800]]million 1.7 million 1.0[

North America

million 1.3

East Asia

]million 1.9 000 980[

000 880

Middle East & North Africa

Caribbean

000 250

[000 280 000 220]

Latin America

million 1.5

]million 1.9 million 1.2[

]million 1.2 000 650[

000 260

[000 380 000 200]

South & South-East Asia

million 3.9

Sub-Saharan Africa

million 25.0

]million 26.6 million 23.5[

]million 5.2 million 2.9[

Oceania

000 51

[000 59 000 43]

Total: 35.3 million [32.2 million 38.8 million]

WHO, UNAIDS, UNICEF 2014

Epidemic in the United States

CDC MMWR June 15, 2012: Estimated number of persons aged 13 years living
with diagnosed and undiagnosed HIV infection* and percentage with undiagnosed
HIV infection National HIV Surveillance System, United States, 19852008

* HIV prevalence estimates were based on national HIV surveillance data for persons aged 13 years at diagnosis
reported through June 2010 using extended back-calculation.
The number of undiagnosed HIV infections was calculated by subtracting the estimated number of diagnosed HIV
infections in living persons from the estimated overall HIV prevalence.

Epidemic in the United States

1.3 million
Americans had been
diagnosed with
AIDS or found to be
HIV-positive in
2006.
Rates of new HIV
infections and deaths
from AIDS have not
significantly
changed in the U.S.
since 1998.
Gradual shift away
from sexually active
homosexual men and
toward blacks,
Hispanics, and
women.

Areas with the highest estimated rates of persons

living with diagnosed HIV infection at the end of
2010 were the District of Columbia (2,704.3), New
York (810.0), the U.S. Virgin Islands (667.1),
Maryland (632.9), Florida (592.7), Puerto Rico
(584.3), New Jersey (488.2), Louisiana (451.7),
and Georgia (428.8).

Estimated New HIV Infections in the United States, 2010, for

the Most Affected Subpopulations (CDC)
Estimated new AIDS diagnoses as of
2011 by geographic distribution :

South 45%
Northeast 24%
West 19%
Midwest 13%

Annual Prevalence of Adults Living with HIV Disease,

1995-2012, Florida

As a result of declining deaths, annual HIV/AIDS diagnoses have exceeded deaths since 1995,
and the number of persons reported with HIV/AIDS that are presumed to be alive has been
increasing. Since the year 1995, prevalent cases have increased by 468%. In 2012,
the prevalence increased by 4.7% from the previous year.

Adults Living with HIV Disease, and

State Population*, by Race/Ethnicity,
Reported through 2012, Florida
Living Adult HIV/AIDS Cases

Population Estimates

N=98,291

N=16,190,842

Note: In this snapshot of living adult HIV/AIDS cases through 2012, 49% are black, whereas
only 14% of Floridas adult population are black. This indicates a disparity of HIV/AIDS in the black
population.
*Source: Population estimates are provided by FloridaCHARTS
**Other includes Asian/Pacific Islanders and Native Alaskans/American Indians.

Persons Living with HIV Disease

by Selected Demographics and Risk Factors
U.S. (2010)* and Florida (2012)

Note: M:F ratio: U.S., 3.0:1. FL, 2.4:1

Source: U.S. data: HIV Surveillance Report, 2011 (most recent available) Vol. 23, Table 15a (HIV
data for all 50 states) http://www.cdc.gov/hiv/topics/surveillance/resources/reports/index.htm
Florida data: FL Department of Health, HIV/AIDS and Hepatitis Section, alive and reported through
2012, as of 06/30/13.

HIV and AIDS in women

Women represent 20% of all diagnoses of HIV infection in the
United States .
Spread of HIV through high-risk heterosexual contact is on the rise because
women are more susceptible than men to the spread of HIV through
heterosexual activity, and most sex events in the human population are
heterosexual.
Suggests that HIV distribution in the U.S. may become
predominantly heterosexual and female.
Prevention challenges for women
Unaware of partners risk factors for HIV infection.
Relationship dynamics (fear of physical abuse or abandonment if they
insist on condom use)
History of sexual abuse may lead to the use of drugs as a coping
mechanism.
May exchange sex for drugs or engage in high-risk sexual activities.

HIV and AIDS in women

Vaginal infections
Bacterial vaginosis increases a womans susceptibility to HIV infection
because it interferes with the normal metabolism of cells lining the vaginal
cavity.
Opportunistic diseases are equally prevalent in HIV-infected women and
men (except for cervical cancer and Kaposis sarcoma)
Gynecological
associated with STDs require special attention
HIV
infectioncomplications
and pregnancy
HAART or even AZT intervention can interrupt viral passage to the fetus.
During delivery, an obstetrician will postpone rupture of the amniotic
membranes or other potentially invasive procedures that might encourage
HIV transmission.

HIV and AIDS in injection drug users

Sharing of bloodstained needles and syringes
Rinsing the syringe and needle in a bleach solution can eliminate the
virus and interrupt transmission.
Sharing needles and syringes that contain a drug-blood mixture that is not
entirely removed before use by the next person.
In 2010, 9% of HIV infections were attributable to the use of injection
drugs.
Legal needle exchange programs
Not available in all states.
Needles and syringes may still be hard to come by.
Participation draws attention to illegal behavior.
HIV infections by injection drug use alone disproportionately affect
blacks/African Americans.
AIDS epidemic is gradually taking on sociological, political, and
economic overtones that differ from those of the past.

The Spreading Epidemic in the United States

* Early high prevalence of HIV in the active homosexual
population suggests that HIV entered the U.S. homosexual
population very early in the epidemic here.
* Gay and bisexual men are still the most severely affected by
HIV in the U.S.
* CDC recommends annual HIV testing for men who have sex
with men.
* Transgender communities in the U.S. are among the groups at highest risk
for HIV infection.
Transgender refers to individuals who do not conform to the traditional
definition of gender based on external genitalia or their sex assigned at
birth.
Identifying transgender people can be challenging.
High levels of HIV risk behavior have been reported among transgender
people.

HIV and AIDS in gay and bisexual men and

transgender individuals
Primary mechanism of HIV transfer for homosexual men is anal intercourse >
Rectum is highly susceptible to abrasions and bleeding because it is rich in
blood capillaries.
Danger to the receptive partner:
If the insertive partner is infected with HIV and the virus is present in the
semen, the viruses can easily penetrate the rectal lining.
Danger to the insertive partner:
HIV-infected T-lymphocytes accumulate within the rectum, so during
anal intercourse, they can enter the insertive partners urethra.
Any lesions on the insertive partners penis can also act as points of entry
for HIV.
Recommendations to reduce the transmission risk:
Use condoms.
Reduce the number of sexual partners.

HIV and AIDS in heterosexuals

For heterosexuals, the risk of contracting AIDS can be substantial, depending
on circumstances.
HIV risks from heterosexual intercourse: females
Wounds, lesions, or abrasions along the vaginal lining.
Virus can pass through the lining of the uterus if vaginal intercourse
occurs at the beginning of or during a womans menstrual period.
Macrophages may also be able to pass through the tissue of the cervix.
HIV risks from heterosexual intercourse: males
Lesions on the outside surface of the penis.
Viruses or infected T-lymphocytes can enter the urethra at the conclusion
of ejaculation.
Abstinence is the most sensible and efficient method of preventing HIV
transmission.
Condom use and limiting the number of sexual partners are also recommended.

HIV and AIDS in seniors

Risk factors for seniors
Far less likely to practice safer sex methods.
Weaker immune systems.
Age-related vaginal thinning and dryness during sex.
HIV infection less likely to be diagnosed because the symptoms are often related
to illnesses associated with aging.
Older males represented 24% of new HIV/AIDS diagnoses in 2010.

Estimated numbers of cases of

HIV/AIDS by age, 2005.

In the 1980s, most diagnosed older Americans contracted HIV as a result

of a contaminated blood transfusion.
Currently, the vast majority have become infected as a result of
heterosexual contact.
Number of cases and deaths in this group is expected to increase because of
new treatments that prolong life.
Obstacles include overcoming denial and stigma.

Annual Prevalence of Adult Males

Living with HIV Disease, by
Current Age, 1995-2012, Florida

HIV and AIDS in correctional

facilities
Incarcerated men and women are
often first diagnosed with HIV in a
correctional setting.
CDC recommends HIV screening
upon entry into prison and before
release, in addition to voluntary HIV
testing periodically during
incarceration.
Testing hesitancy is common due to
the stigma associated with a positive
diagnosis and concern that
confidentiality will not be
maintained.

HIV and AIDS in schools and colleges

Incidence in school-age children and teenagers is relatively low, but the potential
for exposure exists.
Experimenting with drugs and sexuality is common.
Obstacles
Ignorance and feelings of invincibility.
CDC is working on a multifaceted approach to interventions, including the use of
prevention messages on cell phones, gaming systems, websites, and social media.

Young people aged 13 to 19 in the

U.S. are at high risk for HIV
infection (CDC 2011).

HIV and AIDS in newborns

Women can pass HIV to their babies:
During pregnancy.
During delivery.
Through breast-feeding.
By 2006, the CDC had reports of more than 9,000 cumulative
confirmed cases of pediatric AIDS in US.
Testing of newborns became possible with the development of
the viral load test.
New HIV infections among children have declined since 2003.
More than 90% of the children who acquired HIV in 2011 live
in sub-Saharan Africa.

Studies show that rapid implementation of AZT treatment

can block transmission to the fetus.
Led to a steep decline of prenatally acquired AIDS.
Unclear why these drugs are more effective in blocking
the spread to the infant compared with the effect on the
adult.
Some newborns appeared to neutralize HIV before it became
entrenched in the tissues > Now attributed to maternal antibodies
that eventually cleared the neonnates system, not genuine HIV
infection.

Pediatric AIDS
Symptoms
* Failure to thrive
Do not demonstrate expected growth patterns after birth.
Do not respond to aggressive nutritional therapy.
Experience weight loss that does not reverse itself.
Decreased cognitive skills.
* Candidiasis
* Lymphadenopathy
* Swollen salivary glands
* Opportunistic diseases
Usually have a bacterial source.
Salmonella species (intestinal infections)
Streptococci (respiratory infections)
Staphylococci (skin and blood infections)
* Only common denominator is a compromised immune system.

Children (<15 years) estimated to be living with HIV 2012

North America

4500

& Western
Central Europe

Eastern Europe
& Central Asia

[2000 1300]

[000 24 000 16]

1600

East Asia

[5800 4000]

8200

Middle East & North Africa

Caribbean

000 16

[000 19 000 14]

Latin America

000 40

[000 52 000 32]

000 19

[000 11 5800]

000 20

[000 31 000 14]

South & South-East Asia

000 200

Sub-Saharan Africa

million 2.9

]million 3.3 million 2.7[

[000 270 000 170]

Oceania

3100

[4100 2400]

Total: 3.3 million [3.0 million 3.7 million]

WHO, UNAIDS, UNICEF 2014

Elimination efforts
In 2009, the Joint United Nations Programme
on HIV/AIDS called for the virtual elimination
of mother-to-child transmission (MTCT) of
HIV.
In 2010, the World Health Organization (WHO)
published a set of guidelines for best scientific,
programmatic tools, and new advice for safer
infant feed to eliminate MTCT.

HIV and AIDS in Africa

Dramatic increases in antiretroviral therapy coverage have
occurred in sub-Saharan Africa.
Africa remains the hardest-hit continent.
As much as 68% of the 35 million people with HIV
infection or AIDS are living in sub-Saharan Africa
Claims 1 million lives annually in sub-Saharan Africa.
Different pattern of spread than in Western Europe and the
United States > Most transmissions take place during
heterosexual vaginal intercourse.
Attributed in part to lesions and sores from STDs.
Refusal to circumcise males also a contributing factor.
Cultural practice of dry sex in certain communities.
Traditional attitudes against condom use.

Adults and children estimated to be living with HIV 2012

& Western
Central Europe

Eastern Europe
& Central Asia

000 860

million 1.3

[000 930 000 800]]million 1.7 million 1.0[

North America

million 1.3

East Asia

]million 1.9 000 980[

000 880

Middle East & North Africa

Caribbean

000 250

[000 280 000 220]

Latin America

million 1.5

]million 1.9 million 1.2[

]million 1.2 000 650[

000 260

[000 380 000 200]

South & South-East Asia

million 3.9

Sub-Saharan Africa

million 25.0

]million 26.6 million 23.5[

]million 5.2 million 2.9[

Oceania

000 51

[000 59 000 43]

Total: 35.3 million [32.2 million 38.8 million]

Slim disease
Symptoms include rapid weight loss, intractable diarrhea, fever, and loss
of appetite.
Many patients are infected with the protozoal parasites Cryptosporidium
and Isospora.
HIV has also been located in intestinal macrophages, which may reduce the
bodys natural defenses.

Other conditions
Tuberculosis is the most prevalent opportunistic disease in Africa.
Kaposis sarcoma is found in both infected and noninfected individuals.
Pneumocystis pneumonia is relatively rare.

The epidemic is largely confined to urban

centers, where malaria is also widespread.

World Health Organization (WHO) and the United

Nations Program on AIDS (UNAIDS)
Work to promote physical, mental, and social health in
peoples of the world.
Collect and distribute data on epidemics.
Establish international programs for dealing with epidemics.

Statistics

35 million people worldwide live with HIV.

269 countries are involved in the pandemic.
Annual new HIV infections fell 21% between 1997 and 2010.
Proportion of women living with HIV has remained stable at 50% globally.
Rapid scale-up of access to antiretroviral therapy averted 700,000 AIDS
deaths in 2010.

HIV and AIDS in the World

Several countries do not fit the declining trend.
Sub-Saharan Africa
Eastern Europe
Central Asia
The Caribbean has the second highest HIV prevalence,
but the epidemic there has slowed significantly since
the mid-1990s.
In Asia, prevalence of HIV is among populations at
higher risk of infection.

Three major patterns of transmission

Central Europe
Similar to that in the United States, with the
majority of cases occurring in homosexual men
and injection drug users.
Eastern Europe, the Russian Federation, and Ukraine
Injection drug use is the leading cause.
Latin America and sub-Saharan Africa
Primarily transmitted by heterosexual contact.

India
Second to South Africa in the total number of cases of
HIV infection as of 2003.
Disease is highly stigmatized.
China
Low incidence, primarily from injection drug use.
Concerns are related to the growing sex industry and
disdain for condoms, as well as contaminated blood
obtained at commercial collection centers.

WHO and UNAIDS

Committed to preventing new HIV infections
through:
Education
Blood screening
Treatment for injection drug users
Seek to bring support and care to the afflicted while
linking together national and international efforts to
break the chains of transmission.