Comprehensive Overview of HIV/AIDS:
State of Kentucky Mandatory Training

Prevalence of HIV and AIDS

Global Update

Worldwide, at the end of 2007, approximately 33.2 million persons were living with HIV infection (CDC, 2008a; UNAIDS, 2008). HIV/AIDS continues to be a political as well as a medical disease. This is a decrease from the previous year's estimate of 39.5 million, attributing the decrease to more accurate data collection and analysis. 2.7 million people have become newly infected and 2 million people have died of AIDS (WHO, 2008a; UNAIDS, 2008).

In many ways it has evolved into two epidemics, divided by what one physician refers to as the "haves and have-nots" (Sepkowitz, 2006). In developing countries, even HIV testing may not be readily available, especially to the poor living in rural areas. This problem is compounded by the cost of HIV medications which remains well out of reach for many. Still, the outlook is not hopeless, but change will require political and financial cooperation among countries worldwide.

The global percentage of adults living with HIV has leveled off since 2000. In virtually all regions outside sub-Saharan Africa, HIV disproportionately affects people who inject drugs, men who have sex with men and sex workers (UNAIDS, 2008). Sub-Saharan Africa has two thirds (67%) of all people living with HIV worldwide (UNAIDS, 2008a).

Because HIV/AIDS most often affects adults in their child bearing years, countries have lost a whole generation of teachers, political leaders, and scientists. In many cases, HIV/AIDS has destroyed the family unit leaving older children and grandparents to raise younger children.

Reported HIV/AIDS Cases in the US

The World Health Organization estimates that the number of people living with HIV infection (prevalence) in the US is 1,200,000 (WHO, 2008a). The Centers for Disease Control and Prevention's (CDC) analysis reveals that there were more than a million people-an estimated 1,106,400 adults and adolescents-living with HIV infection in the United States at the end of 2006 (CDC, 2008a).

The NAMES Project AIDS quilt, representing people who have died of AIDS, in front of the Washington Monument. Courtesy of the National Institutes of Health.

For many years the CDC reported that there were 40,000 new HIV infections in the US annually. However, with the release of the first estimates from the nation's new HIV incidence surveillance system reveal that the HIV epidemic in the US-and has been-worse than previously estimated. CDC estimates that 56,300 new HIV infections occurred in the United States in 2006 (CDC, 2008b).

Table 1. Estimated United States AIDS Cases Cumulative through 2006 (5)

HIV Infections by Transmission Categories

Figure 1. Estimated Number of New HIV Infections, by Transmission Category, 2006 (CDC, 2008d)

Male-to-male sexual contact accounted for 53% (28,700) of estimated new HIV infections in 2006. CDC's historical trend analysis indicates that HIV incidence has been increasing steadily among men who have sex with men (MSM) since the early 1990s, confirming a trend suggested by other data showing increases in risk behavior, sexually transmitted diseases (STDs), and HIV diagnoses in this population (CDC, 2008d).

High-risk heterosexual (HRH) contact accounted for 31% (16,800) of estimated new HIV infections in 2006. The historical analysis suggests that the number of new infections in this population fluctuated somewhat throughout the 1990s and has declined in recent years (CDC, 2008d).

Injection drug use (IDU) accounted for 12% (6,600) of estimated new HIV infections. CDC's historical trend analysis indicates that new infections have declined dramatically in this population; between 1988-90 and 2003-06, HIV infections among injection drug users declined 80%. These declines confirm the success in reducing HIV infections among injection drug users (CDC, 2008d).

HIV Incidence by Race/Ethnicities

Populations of minority races/ethnicities are disproportionately affected by the HIV epidemic (CDC, 2008c). Of the 1.1 million persons living with HIV infection in the US, the majority were nonwhite (65.4%), and nearly half (48.1%) were men who have sex with men (MSM)(CDC, 2008c). African Americans and Hispanics specifically have disproportionately higher rates of AIDS cases in the US.

African American and Hispanic women make up less than 25% of the total US population, but account for 77% of all reported AIDS cases in women. African Americans make up about 12% of the population, but account for 37% of all AIDS cases in the US. Hispanics made up 13% of the population but accounted for 20% of reported AIDS cases (CDC, 2008c).

Blacks- In 2006, the rate of new infections among non-Hispanic blacks was 7 times the rate among whites (83.7 versus 11.5 new infections per 100,000 population). Blacks also accounted for the largest share of new infections (45%, or 24,900). Historical trend data show that the number of new infections among blacks peaked in the late 1980s and has exceeded the number of infections in whites since that time (CDC, 2008d).

Hispanics- The rate of new HIV infections among Hispanics in 2006 was 3 times the rate among whites (29.3 versus 11.5 per 100,000), and Hispanics accounted for 17% of new infections (9,700). Historically, the number of new infections among Hispanics has been lower than the numbers among whites and blacks. Incidence trends among Hispanics over time have mirrored those among blacks (CDC, 2008d).

Whites- Whites accounted for 35% (19,600) of estimated new HIV infections in 2006. After declining significantly in the late 1980s, new infections among whites increased slightly during the 1990s and remained stable from 2000 through 2006.

Asians/Pacific Islanders and American Indians/Alaska Natives- Data suggest that Asians/Pacific Islanders accounted for roughly 2% of new infections, and American Indians/Alaska Natives accounted for roughly 1% of new infections in 2006. The relatively small number of infections in these populations makes it difficult to draw reliable conclusions about trends over time in these populations CDC, (2008d).

Figure 2. Estimated Rates of New HIV Infections, by Race/Ethnicity, 2006 (CDC, 2008d)

There is not one single reason that stands out as to why the disparities exist. One factor is health disparities, which are linked to socioeconomic conditions. Another factor is distrust of the healthcare system. Both legacies of the past and current issues of race mean that many people of color do not trust "the system" for a variety of reasons. Thus, even when income is not a barrier, access to early intervention and treatment may be limited. And HIV may be only one of a list of problems, which also include adequate housing, food, employment, etc.

Another factor may be the diversities within these populations. Diversity is evident in immigrant status, religion, languages, geographic locations and, again, socioeconomic conditions. Getting information out in appropriate ways to these diverse populations is challenging.

There is a significant amount of denial about HIV risk, which continues to exist in these communities. As with other groups, there may also be fear and stigmatization of those who have HIV. Prevention messages must be tailored and presented in a culturally and linguistically appropriate manner. The messages must be carried thorough channels that are appropriate for the individual community. These channels may include religious institutions or through respected elders in the community. Ironically, it may be these institutions or elders who, in the past, have contributed to the misinformation and stigma associated with HIV. Many HIV prevention programs are recognizing the importance of working with diverse communities. Input from these communities must be included in planning, delivering, and evaluating HIV prevention activities.

HIV Incidence by Gender

Men accounted for most of the estimated new HIV infections in the United States in 2006 (73%, or 41,400). CDC's historical analysis indicates that the number of infections among men has mirrored the overall trend in HIV incidence, peaking during 1984-85 and reaching a low point in the early 1990s. Among women, incidence rose gradually until the late 1980s, declined during the early 1990s, and remained relatively stable after that time (CDC, 2008d).

Figure 3. Estimated Number of New HIV Infections, Overall and by Gender, 2006 (CDC, 2008d)

Note: Because of rounding, estimates of subgroups do not add to total.

HIV Incidence By Age

More infections occurred among young people under 30 (aged 13-29) than any other age group (34%, or 19,200), followed by persons 30-39 (31% or 17,400). These data confirm that HIV is an epidemic primarily of young people and underscores the critical need to reach each new generation of young people with HIV prevention services. Persons over age 50 continue to account for a relatively small proportion of new infections (CDC, 2008d).

Figure 4. Estimated New HIV Infections, by Age, 2006 (CDC, 2008d)

Reported AIDS Cases in Kentucky

As of June 30, 2008, there have been a total of 4,890 AIDS cases reported in Kentucky to the Department for Public Health's HIV/AIDS Surveillance Program since 1982. Table 1 presents recent data regarding AIDS cases in Kentucky. The annual AIDS diagnosis rate among persons in Kentucky has remained fairly steady from 2000 to 2006 (KCHFS, 2008).

Table 2. Kentucky AIDS Cases Cumulative through June 30, 2008 (KCHFS, 2008)

Kentucky's distribution of AIDS cases by age at diagnosis (Table 2) closely parallels that of the U.S. distribution (Table 1). However, compared to U.S. data, the percentage of cases who are white is greater in Kentucky. This could be due to the greater percentage of white persons in Kentucky's general population compared to the U.S. population (KCHFS, 2008).

In addition, a greater percentage of Kentucky AIDS cases report their primary mode of exposure to be men having sex with men (MSM) (55%) as compared to U.S. AIDS cases (47%).

Kentucky ranks 37 in US States' annual rates of AIDS diagnosis. The US AIDS diagnosis rate is 12.7 per 100,000 persons. Kentucky's rate is 4.9, while the highest rate is in the District of Columbia with a rate of 146.7; the lowest rate was in Montana, with a rate of 0.7 (KCHFS, 2008).

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