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1 The AIDS Epidemic in the Second Decade In its first report, the Committee on AIDS Research and the Social, Be- havioral, and Statistical Sciences reviewed what was known about the distribution of cases of acquired immune deficiency syndrome (AIDS) in the United States and the behaviors that transmit infection by the human immunodeficiency virus (HIV). In addition, the committee looked at ra- tional strategies for preventing further spread of infection. Since issuing that report, the committee has continued to monitor the progression of the epidemic and the nation's response to what is now clearly seen as an evolving and enduring health problem. This report identifies several important changes that point toward new and developing issues to be addressed during the second decade of the epidemic, as well as contin- uing problems from the first decade that compel the nation's sustained attention. AIDS surveillance data indicate gradual changes in the loci of the epidemic in the U.S. population and the emergence of either new popula- tions at risk or segments within already at-nsk populations that appear to be at higher risk than was previously thought. Whereas AIDS case data provide a sense of the scope and nature of the current problem, however, data on HIV infection portend the future of the epidemic in the second decade. The future is likely to bring other changes as well, including decreased morbidity associated with HIV infection as new treatments become available. This change in the character of AIDS, with the be- ginnings of a shift away from an emphasis on the acuteness of infection toward a view of AIDS as a long-term illness, will have important impli- cations for treatment and care and for the design of intervention strategies to facilitate behavioral change, still the only available means to prevent 38

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STATE OF THE EPIDEMIC ~ 39 the spread of infection. This report considers the changing face of the epidemic and highlights recent data and research on several groups or populations whose risk for HIV transmission has emerged more clearly or changed over the past decade. It also presents an update on the im- plementation of prevention approaches discussed in the committee's first report and offers recommendations on directions for the future. INTRODUCTION In its earlier report, the committee noted that the AIDS epidemic is a social as well as a biomedical phenomenon. From a biomedical perspec- tive, AIDS is a disease caused by a virus, HIV-l, that is transmitted by anal or vaginal intercourse, by exposure to contaminated blood (either through shared injection equipment associated with intravenous drug use or transfusion), and from mother to fetus. Once it is acquired, HIV infection appears to persist for life. The AIDS virus destroys subpopu- lations of white blood cells that are crucial to normal functioning of the immune system. As the immune system deteriorates, infected individuals are no longer able to ward off infections, and some develop unusual cancers and other conditions that appear rarely among individuals with uncompromised immune functioning.) A sizable proportion of the people who were infected have, after variable periods of time, progressed to severe disease and death. At present, there is no cure for AIDS and no vaccine to prevent infection. In fact, the only means available to prevent further spread of the epidemic are strategies to alter the behaviors that transmit the virus. From a social perspective, AIDS is, for the most part, a preventable disease that is inextricably rooted in the behaviors that transmit HIV. Halting the progression of the epidemic will require a better understanding of the distribution of risk-associated behaviors, the social settings in which they are enacted, and the mechanisms that facilitate change in these behaviors. Like other epidemics in the past, AIDS will leave its mark on many aspects of the societies in which it be- comes prevalent.2 In the United States, the primary target of the disease is the nation's most productive population 20- to 40-year-old adults. As discussed below, however, the epidemic is moving in ever-widening circles to reach more people and geographic areas across the country. ~ For more information on the medical and biological aspects of AIDS and HIV infection, see Con- fronting AIDS: Directions for Public Health, Health Care, and Research, Washington, D.C.: National Academy Press, 1986; and Confronting AIDS: Update 1988, Washington, D.C.: National Academy Press, 1988. 2The committee's Panel on Monitoring the Social Impact of the AIDS Epidemic is currently exam- ining certain social consequences of the epidemic and will be preparing recommendations on specific methods to monitor these effects. The report is expected to be published in 1991.

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40 ~ AIDS: THE SECOND DECADE In this country, gay men still bear the burden of most of the illness re- lated to AIDS. But as the epidemic progresses and the number of persons who are at risk increases, changes in disease prevalence are becoming apparent. For example, extensive studies of gay men conducted in urban epicenters of the epidemic over a period of several years have consistently shown lower incidence rates of HIV infection, but this downward trend in new infections is not uniform across the country. Moreover, young gay men report less behavioral change to prevent infection than has been reported among older gay men, a phenomenon that leaves adolescents and young adults who engage in male-male sex at potentially increased risk. Shifts in membership in the population of men who have sex with men may also produce changes in incidence as individuals enter or leave this group. Thus, the risk of HIV infection among day men continues to be an important concern. Other populations are also feeling the effects of the disease. Increas- ingly, AIDS has become a problem of intravenous (IV) drug users and heterosexuals. Indeed, the proportion of AIDS cases in the United States attributable to heterosexual contact is growing, and a significant fraction of these cases report contact with a drug user. The rise in reported AIDS cases among females especially minority womenoccasions particular concern. As more women are infected, questions concerning the horizon- tal spread of the virus (to sexual and drug use partners) and its vertical transmission (from an infected mother to her unborn infant) have become prominent in national discussions on AIDS. In this chapter, the com- mittee presents data on AIDS and HIV infection among women as an example of an emerging problem that embraces a diverse subpopulation and that is likely to require new strategies for reaching the infected and for facilitating change in risky behaviors. Other epidemiological patterns show increasing geographic diffusion of the virus. Research in the first decade of the epidemic showed pockets of high seroprevalence in such cities as New York, Newark, San Fran- cisco, and Miami for a variety of populations. More recent data show increased numbers of AIDS cases in He central region of the country, malting the epidemic less a bicoastal phenomenon and more a prob- lem that may soon directly touch more and more individuals throughout this society. Data from U.S. military applicants support this finding of increasing geographic diffusion of HIV, showing increased rates of sero- prevalence among black and white applicants from nonepidemic regions of the country.3 Yet even though some patterns have changed, others Significant increases for the past 24 months are reported in California, Florida, Illinois, Ohio, and Texas (Gardner et al., 1989).

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STATE OF THE EPIDEMIC ~ 41 have endured. One pattern that has remained dauntingly constant is the disproportionate magnitude of HIV infection and AIDS among minority men and women, who are overrepresented in every transmission category. Changes are also being seen in the patterns of behavior that transmit the AIDS virus. Many gay men with AIDS acquired HIV infection through unprotected sexual contact. In addition, since the earliest days of the epidemic it has been clear that sharing injection equipment posed a risk for the acquisition and spread of HIV infection. Today, there is growing appreciation of other factors that may influence risk, including the role in risk taking played by drugs such as alcohol. Indeed, the use of noninfected drugs, such as crack and alcohol, has been linked with both high-nsk sexual behavior and HIV infection in a variety of populations. Another potential risk comes from recent increases in the use of drugs such as opiates and cocaine, which in many areas are taken primarily through smoking. These drugs offer the possibility of wider spread of HIV infection if the route of their administration should shift to injection. Getting ahead of the epidemic requires foresight to prevent infection in populations and regions that currently have a low prevalence of AIDS and HIV infection. Such opportunities should not be overlooked, for, once lost, they cannot be recaptured. The third chapter of this report considers the scope of the AIDS problem among adolescents. In it, the committee notes opportunities for intervention with this group and the characteristics of this population that put adolescents at risk and that require consideration in the design of intervention strategies. Keeping pace with the epidemic requires perseverance an enduring, long-term commitment to surveillance, research, and improved interven- tion. Short-term approaches that result in one study, one report, one intervention will not suffice. The type of commitment required is one that includes a range of strategies and techniques, behavioral as well as biomedical. The response of the U.S. blood supply system to the threat of AIDS, which is discussed in Chapter 5, offers an example of such a commitment. The blood supply system has combined biomed- ical techniques (e.g., HIV blood screening) and behavioral approaches (e.g., self-exclusion procedures for high-risk donors, training programs for physicians to alter transfusion-related practices) to reduce dramati- cally the risk of ~ansfusion-related transmission and the number of cases associated with exposure to contaminated blood products. Yet despite the success these reductions represent, problems remain. Although the current prevalence of HIV infection in the general population is believed to be Tow, as the virus spreads and more people become infected, some parts of the country may find that the pool of uninfected, "safe," and

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42 ~ AIDS: THE SECOND DECADE willing blood donors has shrunk to a point that could compromise the adequacy of the blood supply. The second decade of the epidemic thus brings continuing as well as new challenges in managing the effects of HIV infection and preventing its further spread. In its first report, the committee commented on the need for sys- tematic improvement of intervention strategies to facilitate change in the behaviors known to transmit HIV. It noted in particular that the interven- tion efforts described in that report had not resulted in data that offered a clear sense of which strategies worked best for specific subpopula- tions. The paucity of planned variations of intervention strategies and of information garnered through rigorous outcome evaluation that was cited by the committee has not been remedied. The gap is particularly problematic for innovative programs that have targeted groups such as {V drug users, in which infection has been shown to spread at an alarmingly fast rate in the absence of effective intervention efforts and in which potentially efficacious but politically sensitive efforts have come under attack. A year ago the committee recommended well-designed, carefully evaluated pilot tests of sterile needle exchange programs to ascertain the effectiveness of this strategy in preventing further infection among IV drug users. Although several programs were initiated, there are now crippling restrictions on the use of federal funds to support and evaluate these activities.4 This chapter relies extensively on counts of diagnosed AIDS cases reported to the Centers for Disease Control (CDC). In its last report, the committee noted some of the pitfalls that cause undercounting or misclassification of AIDS cases and deaths (Turner, Miller, and Moses, 1989:32-33~.5 It recommended that both vigilant quality control and spe- cial methodological studies be undertaken to improve our understanding of the errors and biases that affect the reporting of AIDS cases and deaths. The committee finds Hat the need for such methodological work continues, and it commends the Public Health Service for its plan to give pnonty to the funding of such research (PHS, 1988; CDC, 19891. As we embark on a second decade of understanding and coping with the AIDS epidemic, these efforts will provide needed attention to the quality of this key data system. More than 115,000 cases of AIDS have been reported in the United 4See Public Law 101-166 [H.R. 3566], Title General Provisions, Section 520. Depar~nents of La- bor, Health and Human Services, and Education and related agencies appropriations, 1990. November 21, 1989. Washington, D.C. 50ther reports have also looked at completeness of reporting of AIDS cases. See, for example, the estimates of Conway and colleagues (1989) and Modesitt, Hlllman, and Fleming (1990).

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STATE OF THE EPIDEMIC ~ 43 States, and more than half of the people reflected by this statistic have died. Moreover, AIDS has become the leading cause of death for 30- to 50-year-old males and 20- to 40-year-old females in New York City (New York State Department of Health, 19891. Despite advances in the medical treatment of AIDS and other sequellae of HIV infection,6 it is likely that HIV and AIDS will remain significant threats to individual and public health for the foreseeable future. The persistence of risk in the environment and the potential for relapse among those who have taken protective action mean that, as we enter the 1990s and the epidemic's second decade, it is important to reaffirm the nation's commitment to preventing further spread of infection. To be more successful in future prevention endeavors than we have been in the past, we must commit talent and resources to the rigorous outcome evaluation of well-designed interventions while developing new approaches based on current under- standing of the evolutionary and persistent aspects of the problem. The task of devising intervention strategies to fulfill this commitment rests on obtaining sound information about the populations at risk and the behav- iors transmitting the virus to guide program planners and policy makers. The section that follows discusses the current profile of the disease in the United States on the eve of the epidemic's second decade. THE CHANGING EPIDEMIOLOGY OF AIDS IN THE UNITED STATES As of December 1989, the CDC reported 117,781 cases of AIDS in the United States.7 Of the adult and adolescent cases, a significant majority (70,093) are attributed to male homosexual or bisexual contact, and an additional 8,117 are ascribed to bow homosexual contact and rv drug use (CDC, 1990a). Of all men with AIDS who report same-gender sexual contact, more than one-quarter (27 percent) are black or I-atino~ (CDC, 1990a); moreover, homosexual contact is the predominant AIDS risk category among black and Latino males, accounting for 45 and 47 percent of cases, respectively (CDC, 1990a). 6GaiL Rosenberg, and Goedert (1990), for example, recently presented evidence suggesting that pro- phylactic use of zidovudine among seropositive homosexual and bisexual men (particularly in New York City, San Francisco, and Los Angeles) may be responsible for the lower than expected incidence of AIDS cases reported in this population since the middle of 1987. 7 although the degree of underreporting of AIDS cases is not known with any certainty, recent studies have judged reporting to be between 83 and 100 percent complete (Chamberland et al., 1985; Hardy et al., 1987; Lafferty et al., 1988). A recent survey of hospital discharge billing records in South Car- olina, however, found that only 59.5 percent of cases meeting CDC diagnostic criteria were reported; underreporting was significantly worse among black patients than among whites (Conway et al., 1989). 8In this report the teIms Latino and Latina are used interchangeably with Hispanic.

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STATE OF THE EPIDEMIC ~ 45 Data from the Multicenter AIDS Cohort Studies (MACS) and the San Francisco Men's Health Study suggest that incidence rates among gay and bisexual men have stabilized (Winkelstein et al., 1987, 1988), and there is some evidence that the number of new cases of AIDS in this population appears to be leveling off in New York City and Los Angeles (Berkelman et al., 19891. Indeed, the proportion of all AIDS cases attributed to male homosexual and bisexual contact has dropped from 64.9 percent in 1981 to 55.3 percent in 1989.9 At the same time, the proportions of cases attributable to heterosexual contact and to IV drug use have grown. In 1981 cases attributable to heterosexual transmission and {V drug use constituted 0.5 and 11.0 percent, respectively, of all reported cases; by 1989 these rates had increased to 5.0 and 23.2 percent (Table 1-1~. Among IV drug users, after several years of progressively worsening infection statistics, there is now evidence that HIV seroprevalence has stabilized in some areas, such as New York City (Des Jarlais et al., 1989; Stoneburner et al., 1990), San Francisco (Moss et al., 1989), Detroit (Ognjan et al., 1989), Amsterdam (van Haastrecht, van den Hoek, and Coutinho, 1989), and Stockholm (Olin and Kall, 19891.~ However, this stabilization reflects lower rates of new cases of HIV infection within a dynamic population and should not be confused with elimination of viral transmission. In fact, the evidence of stabilization in some regions is offset by data on the recent, very rapid spread of the disease in other areas. The proportion of cases attributed to drug use is increasing in Louisiana (Atkinson et al., 1989) and Maryland (Horman and Hamidi, 1989), as well as throughout cities in the northeast region of the United States (see Figure 1-11. The population of IV Hug users is mobile and quite capable of carrying the virus from one geographic area to another (Comerford et al., 1989, McCoy, Chitwood, and Page, 19891. Such mobility is one factor that can contribute to the possibility of rapid rises in seroprevalence rates in venous parts of the country. There is some evidence that homosexual and bisexual IV drug users may play a role in introducing HIV infection to other IV drug users in areas with 9Decreasing proportions, however' do not indicate decreasing numbers of cases. This smaller propor- tion of an ever-increasing whole still continues lo result in increasing morbidity. 10For some groups at highest risk for HIV infection, stable rates may signify that all vulnerable indi- viduals are already infected, a phenomenon known as saturation. This phenomenon does not appear to explain stable rates in New York City, however, where approximately 50 percent of IV drug users are estimated to be infected. If saturation had occurred, one would expect to see higher seroprevalence rates. For example, approximately 90 percent of IV drug users in New York City have been infected with hepatitis, a virus that is transmitted in the same manner as HIV and appears to have reached saturation in this population.

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46 1 AIDS: THE SECOND DECADE 70 _ 60 __ ~ 50 an an C] o it G ILL 40 30 20' it 10 I- Homosexual- Bisexual - IV Drug Use O 1 1 1 1 1 1 1 1982 1983 1984 1985 1986 1987 19~ 1989 YEAR FIGURE 1-1 Percentages of reported AIDS cases among men (aged 13 and older) in northeastern cities that have been attributed to homosexual contact or IV drug use, 1982-1989. (Cases reported as both IV drug use and homosexual/bisexual contact are not shown.) NOTE: Cities in the Northeast region include the OMB Metropolitan Statistical Areas (or New England County Metropolitan Areas) of Bergen-Passaic, N.J.; Buffalo, N.Y.; Boston, Mass.; Hartford, Conn.; Nassau-Suffolk, N.J.; New York City; and Newark, N.J. SOURCE: Tabulated from CDC's AIDS Public Infonnation Data Set for AIDS cases reported through December 31, 1989. low prevalences of HIV infection (Battjes, Pickens, and Amsel, 1989). Although the distribution of cases in the IV drug-using population has shown considerable variation, one constant remains: the burden of AIDS related to IV drug use falls most heavily on minorities (Selik and Petersen, 19891. Nearly half (47.6 percent) of all males reporting IV drug use as their only risk factor for AIDS are black, and 32 percent are Latinos (CDC, 1990a). Addressing the problem of IV drug use in relation to AIDS remains a high priority, but a focus solely on drug injection will no longer suffice to prevent further spread of HIV infection among individuals who use drugs. The evolving nature of the epidemic also requires a broadened perspective to encompass what appear to be new patterns of risk associated with drug use. In particular, the emergence of "crack" cocaine use as a risk factor for the transmission of HIV infection is a new and disturbing development in the epidemiology of AIDS in the United States. The risks associated with the use of crack are indirect (crack use is not in itself a mode of HIV transmission). However, the tendency of those who use crack to engage in unsafe sexual activity offers the potential for viral transmission.

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STATE OF THE EPIDEMIC ~ 47 Unlike other forms of cocaine that are snorted or injected, crack is smoked.l1 It can produce a rapid, intense effect that for most users is a feeling of euphoria, including an increased sense of self-worth and power. The effect of the drug wears off rapidly, however, and may be followed by a craving to use more. As a result, some users will "binge," using crack every 10 to 20 minutes until they or their supply of drug is exhausted. Thus, the intensity and transience of the crack "high" encourage the development of dependence on the drug. For many males, crack is reported to produce intensified sensations of sexual arousal and sexual pleasure; indeed, in some places crack is marketed by highlighting the sexual effects of the drug. Some females who become dependent on crack show a willingness to exchange sex for the drug or for money to obtain the drug. (Chapter 4 discusses at greater length the relationship between crack use and female prostitution.) It is possible, of course, for crack users to practice safer sex, including condom use, but the effects of the drug and the perceived exigencies of repeating those effects reduce the likelihood that safer sex will be practiced consistently (Friedman et al., 19881. Small surveys of crack users have indicated an association between crack use and sexually transmitted diseases (STDs) (Fullilove et al., 1989), which supports the hypothesis that unprotected sex occurs in such settings. Because STDs appear to be cofactors in the acquisition of HIV infection, this association bodes ill for preventing the sexual transmission of HIV. Indeed, surveys of patients at STD clinics in New York have already found individuals with HIV infection whose only behavioral risk factor appears to be sexual activity associated with crack use (Chiasson et al., 1989; Hoegsberg et al., 1989~. The rapid emergence of crack as a risk factor for HIV infection highlights the need to be vigilant for signs of new patterns of nsk. Thus, the committee recommends that the Public Health Service establish mechanisms across its agencies for rapid identification and assessment of the relationship of new drug use problems to the spread of HIV. But changes in drug use are not the only new trends that are i 1 Usually, cocaine is sold as a hydrochloride Set; in this form it must be either "sniffed" and absorbed through the nasal mucosa or injected. To produce crack cocaine, the hydrochloride is removed; in this form the cocaine may be vaporized and thus inhaled. Inhaling any drug into the lungs permits it tO be absorbed into the blood stream rapidly and transported to the brain. Chemically, smoking crack is identical to "freebasing" the hydrochloride salt form of cocaine. Previously, persons who wanted tO freebase had to purchase cocaine hydrochloride and convert it themselves to the base form through a complicated and dangerous process that involved heating volatile chemicals that could easily catch fire. The rise in the use of crack has come from the development of new and safer methods for removing the hydrochloride so that the drug can be sold in its base fonn. 12 Some crack houses (the locations at which the drug is sold and used) employ women to provide sex to customers.

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48 ~ AIDS: THE SECOND DECADE becoming apparent at the end of the first decade of the epidemic. There are also noticeable shifts in the groups being affected directly by the disease. Throughout its studies, the committee has been struck by the diversity of the populations now represented in the AIDS statistics. It has chosen to look at women and the risks HIV poses to them as an example of a heterogeneous population that will require considerably more attention in the second decade of this epidemic than it received in the first. Because most of the cases of AIDS reported in the early years of the epidemic were diagnosed in men, few women appreciated their potential risk of acquiring this disease. Yet as the epidemic has progressed, women of all races have begun to account for a greater proportion of cases. The majority of women represented by these statistics have a history of intravenous drug use; a subset report no drug use themselves but indicate a sexual relationship with an intravenous drug user in their risk profile. The range of women at risk for AIDS, however, goes beyond those involved through drug use. The sections that follow discuss the profile of risk among women in the United States, noting the varied subgroups of this population that are increasingly affected by the epidemic. A PICTURE OF EMERGING RISK: THE AIDS EPIDEMIC AMONG WOMEN Early in the epidemic, vertical or pennatal transmission of HIV infection (transmission from an infected pregnant woman to her offspring was of particular concern because the majority of female AIDS cases (75.4 per- cent) had been diagnosed in women between the ages of 20 and 39, prime childbearing years. Today, concerns about perinatal transmission must be joined with the recognition that the risk of HIV infection among women of all ages is increasing, and more and more women are confronting the disease in their own lives or in the lives of those around them. This increasing risk can be seen in the epidemiological data in Table 1-2, which show rising numbers of female AIDS cases over the past decade. By December 1989, a cumulative total of 10,611 cases of AIDS had been reported in women 13 years of age or older; however, this figure is likely to underestimate the scope of the problem owing to a failure to report cases and reporting delays. The upward trend shown in Table 1-2 is particularly ominous for minority women, who are disproportionately represented in almost every risk category (Table 1-31. In 1989 women also accounted for a larger proportion of all AIDS cases diagnosed in this

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70 ~ AIDS: THE SECOND DECADE transmission and the extent to which the incidence of these diseases can be controlled; and the extent to which crack users can adopt safer sexual prac- tices. It is clear that crack use and its associated unsafe sexual activity rep- resent a potentially important new wave of HIV transmission in the United States. What is unclear is how large a wave this might be. The commit- tee recommends that the Public Health Service support additional research on crack use, including its epidemiology, its relationship to sexual behavior, strategies to reduce its occurrence (both initiation of use and continuance among low- and high-frequency users), and methods for facilitating change in the sexual behavior of persons who continue to use crack. Understanding the use of crack and its role in the spread of HIV infection will require basic behavioral research, re- search on the social factors associated with initiating and sustaining crack use, biological research to determine effective treatment strategies, and demonstration projects to assess the effectiveness of intervention efforts. Collecting good data regarding AIDS and HIV infection is intnn- sically difficult because of the sensitivity of the subject matter and the difficulties involved in locating and studying some of the subgroups at highest risk. (The last chapter of the report is a more detailed discussion of how the quality of sensitive data can be improved.) Many researchers rely on secondary analyses of data collected by others, including agen- cies of the state and federal governments that are responsible for public health. Timely access to those data is sometimes constrained by policies pertaining to confidentiality as well as by other data release regulations. Moreover, it is often difficult to compare data across data sources. For example, in the CDC serologic survey of newborn infants, the data col- lected on the sociodemographic characteristics of the mother vary from state to state, precluding comparisons. In addition, in those states that only collect limited sociodemographic information, efforts by state and local public health agencies to design and implement programs and ser- vices may be constrained by a lack of data on the subgroups who need attention. Mathematical models hold some promise for improving our understanding of the course of the epidemic and thus for planning the delivery of programs and services. However, shortcomings in existing data on the prevalence and distribution of risk-associated behaviors and

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STATE OF THE EPIDEMIC ~ 71 HIV infection, on the natural history of the disease,53 and on other factors relevant to the spread of infection currently limit the use of such models. Improving data quality for ~] populations will require a wide range of additional efforts. In some instances (e.g., studies of adult gay men), improvement will demand that new and younger cohorts be recruited as part of ongoing efforts to understand the disease's natural history and changing patterns of risk. For drug users, improvements in data qual- ity will require innovative sampling strategies, modification of existing surveillance approaches, and attention to the appearance of new drugs whose use may pose additional risk to this population. Progress is needed in several other areas as well, including improving the quality of data from sites currently collecting information on the prevalence of infection and risk behaviors (e.g., STY clinics), resolving interjurisdictional prob- lems of confidentiality and data release, and establishing mechanisms for determining what information to obtain in each survey (e.g., how much detail to elicit concerning mothers in the neonatal surveys or patients in surveys conducted in STD clinics). Improving data quality is vital to improving our capacity to monitor the movement of the epidemic. It is also essential for evaluating the impact of intervention efforts to halt the spread of HIV infection. As the agency within the Public Health Service with primary responsibility for collecting surveillance data, CDC instituted data collection programs in the first decade of the epidemic, targeting diverse at-nsk populations. The dynamic nature of the epidemic, however, mandates continuing attention to these programs to ensure that relevant subgroups are being monitored. Thus, to facilitate the Centers for Disease Control's (CDC) ongoing efforts to improve its AIDS-related data collection systems, the com- mittee recommends that the agency initiate a systematic review of current programs. This effort should draw on the expertise of both CDC staff and outside experts. In summary, sound epiclemiologica] data are important in clevelop- ing accurate an] (3etallecl pictures of at-Hsk populations. The finer the grain of these pictures, the more useful they become. Depictions that Carl distinguish subgroups at Varying levels of risk and that Carl detect changing risk patterns are vital in cl~ectiDg intervention resources to those in greatest need; they ale also essential to the development of relevant intervention programs and to the evaluation of these programs.54 Having 53As noted earlier, prospective studies of large cohorts of gay men (e.g., the MACS) have provided valuable information on the natural history of the disease- for this population. Unfortunately, less is known about the natural history of the disease in other populations, such as adolescents and women. 54For more information on program evaluation, see the recent report of the committee's Panel on the

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72 ~ AIDS: THE SECOND DECADE identified and charactenzed the problem, insofar as the data permit, the committee tutus to the question of what should be done. The next chapter reviews intervention strategies for populations at risk arid discusses the barriers that may impede their implementation. REFERENCES Abramowitz, A., Guydish, J., Woods, W., and Clark, W. (1989) Increasing crack use among drug users in an AIDS epicenter: San Francisco. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Altman, R., Grant, C. M., Brandon, D., Shahied, S., Rappaport, E., et al. (1989) Statewide HIV-1 serologic survey of newborns with resultant changes in screening and delivery system policy. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Araneta, M. R. G., Thomas, P. A., Ramirez, L. L., Weisfuse, I., and Schultz, S. (1989) No change in HIV-1 seroprevalence among parturients and women having induced abortions in New York City, 1987-1988. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Arguelles, L., Rivero, A. M., Reback, C. J., and Corby, N. H. (1989) Female sex partners of IV drug users: A study of socio-psychological characteristics and needs. Presented at the Fifth International AIDS Conference, Montreal, June =9. Armson, B. A., Mennuti, M. T., and Talbot, G. H. (1988) Seroprevalence of human immunodeficiency virus (HIV) in an obstetric population. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Atkinson, W., Troxler, S., Dal Corso, M., and McFarland, L. (1989) Intravenous drug use as a risk factor for AIDS and HIV infection in Louisiana, 1981-1988. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Barbacci, M., Chaisson, R., Anderson, J., and Horn, J. (1989) Knowledge of HIV serostatus and pregnancy decisions. Presented at the Fifth International AIDS Conference, Montreal, June ~9. Battjes, R. J., Pickens, R. W., and Amsel, Z. (1989) Introduction of HIV infection among intravenous drugabusers in low prevalence areas. Journal of Acquired Immune Deficiency Syndromes 2:533-539. Berkelman, R., Karon, J., Thomas, P., Ker7ldt, P., Rutherford, G., and Stehr-Green, J. (1989) Are AIDS cases among homosexual males leveling? Presented at the Fifth International Conferenceon AIDS, Montreal, Juneau. Brettler, D. B., Forsberg, A. D., Levine, P. H., Andrews, C. A., Baker, S., and Sullivan, J. L. (1988) Human immllnodeficiency virus isolation studies and antibody testing. Archives of Internal Medicine 148:1299-1301. Brondum, J., Debuono, B., Dondero, L., Hodge, J., and Johnson, A. (1987) The alternative test site (ATS) in Rhode Island. Presented at the Third International Conference on AIDS, Washington, D.C., June 1-5. Evaluation of AIDS Interventions (Coyle, Boruch, and Turner, 1990). In this report, the panel lays out specific strategies for assessing the effectiveness of three of CDC's major AIDS prevention programs: the national media campaign, testing and counseling, and the health education projects sponsored by its group of funded community-based organizations.

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STATE OF THE EPIDEMIC ~ 73 Brown, L. S., Mitchell, J. L., DeVore, S. L., and Primm, B. J. (1989) Female intravenous drug users and pennatal HIV transmission. New England Journal of Medicine 320: 1493-1494. Castro, K. G., Lieb, S., Calisher, C., Witte, J., and Jaffe, H. W. (1987) AIDS and HIV infection in Belle Glade, Florida. Presented at the Third International Conference on AIDS, Washington, D.C., June 1-5. Castro, K. G., Lifson, A. R., White, C. R., Bush, T. J., Chamberland, M. E., et al. (1988) Investigations of AIDS patients with no previously identified risk factors. Journal of the American Medical Association 259:1338-1342. Centers for Disease Control (CDC). (1987) Human immunodeficiency virus infection in the United States. Morbidity and Mortality Weekly Report 36:801-804. Centers for Disease Control (CDC). (1989) HIV/AIDS Projections Workshop October 31-November 1, 1989: Draft Working Group Reports and Summary (December 3, 1989~. Atlanta, Gal: Centers for Disease Control. Centers for Disease Control (CDC). (1990a) HIVIAIDS Surveillance: U.S. AIDS Cases Reported Through December 1989. Atlanta, Gal: Centers for Disease Control. Centers for Disease Control (CDC). (1990b) Publicly funded HIV counseling and testing-United States, 1985-1989. Morbidity and Mortality Weekly Report 39:137- 140. Charnberland, M. E., Allen, J. R., Monroe, J. M., Garcia, N., Morgan, C., et al. (1985) Acquired immunodeficiency syndrome in New York City: Evaluation of an active surveillance system. Journal of the American Medical Association 254:383-387. Chambers, C. D., and Moffitt, A. (1970) Negro opiate addiction. In J. C. Ball and C. D. Chambers, eds., The Epidemiology of Opiate Addiction in the United States. Springfield, Ill.: Thomas. Chambers, C. D., Hinesley, R. K., and Moldestad, M. (1970) Narcotics addiction in females: A race comparison. International Journal of the Addictions 5:257-278. Chandrasekar, P. H., Matthews, M., and Chandrasekar, M. C. (1988) Risk factors for HIV infection among parenteral drug abusers (PDA) in a low-prevalence area. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Chiasson, M. A., Stoneburner, R. L., Telzak, E., Hildebrandt, D, Schultz, S., et al. (1989) Risk factors for HIV-1 infection in STD clinic patients: Evidence for crack-related heterosexual transmission. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Chiasson, M. A., Stoneburner, R. L., Lifson, A. R., Hildebrandt, D. S., Ewing, W. E., et al. (1990) Risk factors for human immunodeficiency virus type 1 (HIV-1) infection in patients at a sexually transmitted disease clinic in New York City. American Journal of Epidemiology 131:208-220. Cohn, D., Douglas, J., Koleis, J., Feeney, F., and Judson, F. (1989) Companson of prevalence of HIV infection in IV drug users (IVDU) from four different test~ng and treatment programs. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Comerford, M., Chitwood, D. D., McCoy, C. B., and Trapido, E. J. (1989) Association between fo~mer place of residence and serostatus of IVDUs in south Florida. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Connor, E, Denny, T., Goode, L., Niven, P., Oxtoby, M., et al. (1989) Seroprevalence of HIV-1 and HTLV-1 among pregnant women in Newark, N.J. Presented at the Fifth International Conference on AIDS, Montreal, June 09.

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74 ~ AIDS: THE SECOND DECADE Conway, G. A., Colley-Niemeyer, B., Pursley, C., Cruz, C., Burt, S., and Heath, C. W. (1989) Underreporting of AIDS cases in South Carolina, 1986 and 1987. Journal of the American Medical Association 262:2859-2863. Corby, N. H., Rhodes, F., and Wolitski, R. J. (1989) HIV serostatus and risk behaviors of street IVOUs. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Cowan, D. N., Brundage, J., Miller, R., Goldenbaum, M., Pomerantz, R., and Wann, F. (1989) Prevalence of HIV infection among U.S. army reserve component personnel. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Coyle, S. C., Boruch, R. B., and Turner, C. F., eds. (1990) Evaluating AIDS Prevention Programs, Expanded Edition. Washington, D.C.: National Academy Press. Cozen, W., Mascola, L., Giles, M., Bauch, S., Finn, M., and Heneman, C. (1989) Routine HIV antibody screening in Los Angeles county prenatal clinics: A demonstration project. Presented at the Fifth International Conference on AIDS, Montreal, June 4-9. Curran, J. W., Jaffe, H. W., Hardy, A. M., Morgan, W. M., Selik, R. M., and Dondero, T. J. (1988) Epidemiology of HIV infection and AIDS in the United States. Science 239:610 616. Danila, R. N., Shultz, J. M., Osterholm, M. T., MacDonald, K. L., Henry, K., and Simpson, M. (1987) Minnesota counseling and testing sites: Analysis of trends over time. Presented at the Third International Conference on AIDS, Washington, D.C., June 1-5. Del Tempelis, C. D., Shell, G., Hoffman, M., Benjamin, R. A., Chandler, A., and Francis, D. (1987) lIuman immunodeficiency virus infection in women in the San Francisco Bay area. Journal of the American Medical Association 258:474 475. Des Jarlais, D. C., Friedman, S. R., and Strug, D. (1986) AIDS and needle sharing within IV-drug use subculture. In P. A. Feldman and T. M. Johnson, eds., The Social Dimensions of AIDS: Method and Theory. New York: Praeger Press. Des Jarlais, D. C., Chamberland, M. E., Yancovitz, S. R., Weinberg, P., and Fned- man, S. R. (1984) Heterosexual partners: A large risk group for AIDS. Lancet 2(8415):134~1347. Des Jarlais, D. C., Friedman, S. R., Novick, D. M., Sotheran, J. L., Thomas, P., et al. (1989) HIV-1 infection among intravenous drug users in Manhattan, New York City, from 1977 through 1987. Journal of the American Medical Association 261 :1008-1012. Eldred, C. A., and Washington, M. N. (1976) Interpersonal relationships in heroin use by men and women and their role in treatment outcome. International Journal of the Addictions 17:117-130. Ernst, J. A., Bauer, S., Amaral, L., St. Louis, M., and Falco, I. (1989) HIV seropreva- lence at the Bronx Lebanon Hospital Center A CDC sentinel hospital. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Fehrs, L., Hill, D., Kerndt, P., Rose, T., and Henneman, C. (1989) HIV screening program at a Los Angeles prenatal/family planning center. Presented at the Fifth International Conference on AIDS, Montreal, June =9.

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STATE OF THE EPIDEMIC ~ 75 Forsberg, A. D., Sullivan, J. L., Willitts, D. L., Kraus, E., and Brettler, D. B. (1989) Results of HIV antibody testing in sexual partners of seropositive hemophiliacs over a 5-year penod. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Friedman, S. R., Dozier, C., Sterk, C., Williams, T., Sotheran, J. L., et al. (1988) Crack use puts women at risk for heterosexual transmission of HIV from intravenous drug users. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Frutchey, C., and Walsh, K. (1989) Marginalization of gay men in AIDS funding and programs. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Fullilove, R. E., Fullilove, M. T., Bowser, B. P., and Gross, S. A. (1989) Crack use and risk for AIDS among black adolescents. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Gail, M. H., Rosenberg, P. S., and Goedert, J. L. (1990) Therapy may explain recent deficits in AIDS incidence. Journal of Acquired Immune Deficiency Syndromes 4:296-306. Gardner, L. I., Brundage, J. F., Burke, D. S., McNeil, J. G., Visintine, R., and Miller, R. N. (1989) Evidence for spread of the human immunodeficiency virus epidemic into low-prevalence areas of the United States. Journal of Acquired Immune Deficiency Syndromes 2:521-532. Gerstein, D. R., Judd, L. L., and Rovner, S. A. (1979) Career dynamics of female heroin addicts. American Journal of Drug and Alcohol Abuse 6:1-23. Goedert, J. J., Eyster, M. E., Biggar, R. J., and Blattner, W. A. (1987) Heterosexual transmission of human immunodeficiency virus: Association with severe depletion of T-helper lymphocytes in men with hemophilia. AIDS Research and Human Retroviruses 3:355-361. Guinan, M. E., and Hardy, A. (1987) Epidemiology of AIDS in women in the United States: 1981 through 1986. Journal of the American Medical Association 257:2039-2042. Hardy, A. M., Starcher, E. T., Morgan, W. M., Druker, J., Kristal, A., et al. (1987) Review of death certificates to assess completeness of AIDS case reporting. Public Health Reports 102:38~391. Harrison, W. O., and Moore, T. A. (1988) Prenatal HIV screening in a low-risk population. Presented at the Fourth International Conference on AIDS, Stockholm, June 13-16. Hill, D., Kerndt, P., Frenkel, L. M., Settlage, R., Lee, M., et al. (1989) HIV seroprevalence among parturients in Los Angeles County, 1988. Presented at the Fifth Intemational Conference on AIDS, Montreal, June =9. Hoegsberg, B., Dotson, T., Abulafia, O., Tross, S., Des Jarlais, D., et al. (1989) Social, sexual and drug use profile of HIV-positive and HIV-negative women with PID. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Horman, J., and Hamidi, C. (1989) The epidemiology of AIDS in Maryland, 1981-1987. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Horton, J., Alexander, L., and Brundage, J. (1989) HIV prevalence among military women: An examination of military applicant, active duty, and reserve testing data. Presented at the Fifth International Conference on AIDS, Montreal, June =9.

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76 ~ AIDS: THE SECOND DECADE Hull, H. F., Bettinger, C. J., Gallaher, M. M., Keller, N. M., Wilson, J., and Mertz, G. J. (1988) Comparison of HIV-antibody prevalence in patients consenting to and declining HIV-antibody testing in an STD clinic. Journal of the American Medical Association 260:935-938. Jackson, J. B., Sannerud, K. J., Hopsicker, J. S., Kwok, S. Y., Edson, J. R., and Balfour, H. H. (1988) Hemophiliacs with HIV antibody are actively infected. Journal of the American Medical Association 260:223~2239. Jackson, J. B., Kwok, S. Y., Hopsicker, J. S., Sannerud, K. J., Sninsky, J. J., et al. (1989) Absence of HIV-1 infection in antibody-negative sexual partners of HIV-1 infected hemophiliacs. Transfusion 29:265-267. Johnson, J. P., Alger, L., Nair, P., Watkins, S., 3ett, K., and Alexander, S. (1987) HIV screening in the high-risk obstetric population and infant serologic analysis. Presented at the Third International Conference on AIDS, Washington, D.C., June 1-5. Kaunitz, A. M., Brewer, J. L., Paryani, S. G., de Sausure, L., Sanchez-Ramos, L., et al. (1987) Prenatal care and HIV screening. Journal of the American Medical Association 258:2693. Kim, H. C., Raska, K. III, Clemow, L., Eisele, J., Marts, L., et al. (1988) Human immunodeficiency virus infection in sexually active wives of infected hemophiliac men. American Journal of Medicine 85:472~76. Krasinski, K., Burkowsky, W., Beber~oth, D., and Moore, T. (1988) Failure of voluntary testing for HIV to identify infected parturient women in a high-risk population. New England Journal of Medicine 318:185. Lafferty, W. E., Hopkins, S. G., Honey, J., Harwell, J. D., Shoemaker, P. C., and Kobayashi, J. M. (1988) Hospital charges for people win AIDS in Washington State: Utilization of a statewide hospital discharge data base. American Journal of Public Health 78:949-957. Landesman, S. H., Minkoff, H., Holman, S., McCalla, S., and Sijin, O. (1987) Serosurvey of human irnmunodeficiency virus infection in parturients: Implications for human immunodeficiency virus testing programs of pregnant women. Journal of the American Medical Association 258:2701-2703. Landis, S., Schoenbach, V., Weber, D., Mittal, M., Koch, G., and Levine, P. (1989) HIV-1 seroprevalence in sexually transmitted disease (STD) clinic patients in central North Carolina. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Laurian, Y., Peynet, J., and Verroust, F. (1989) HIV infection in sexual parmers of HIV seropositive patients with hemophilia. New England Journal of Medicine 320:183. Lawrence, D. N., Jason, J. M., Holman, R. C., Heine, P., Evatt, B. L., and the Hemophilia Study Group. (1989) Sex practice correlates of human immunodeficiency virus transmission and acquired immunodeficiency syndrome incidence in heterosexual parmers and offspring of U.S. hemophilic men. American Journal of Hematology 30:68-76. Lawrence, D. N., Jason, J. M., Holman, R. C., and Murphy, J. J. (1990) Human iITlmunodeficiency virus transmission from hemophilic men to their heterosexual parmers. In N. J. Alexander, H. L. Gabelnick, and J. M. Spieler, eds., The Heterosexual Transmission of AIDS. New York: Alan R. Liss.

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STATE OF THE EPIDEMIC 77 Lindsay, M. K., Peterson, H. B., Mundy, D. C., Slade, B. A., Feng, T., et al. (1989) Seroprevalence of human immunodeficiency virus infection in a prenatal population at high risk for HIV infection. Southern Medical Journal 82:825-828. Mandell, W., Vlahov, D., and Cohn, S. (1989) IVDU characteristics associated with needle sharing. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Mason, P. J., Olson, R. A., and Parish, K. L. (1988) AIDS, hemophilia, and prevention efforts within a comprehensive care program. American Psychologist 43:971-976. McCoy, C. B., Chitwood, D. D., and Page, J. B. (1989) Mobility, risk cities, risk behavior, and HIV status of IV drug users. Presented at the Fifth International Conference on AIDS, Montreal, June =9. McFarland, L., Dean, H., Trahan, B., and Muirhead, L. (1989) HIV infection in pregnant women at a public hospital in New Orleans, Louisiana. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Modesitt, S.K., Hulman, S., and Fleming, D. (1990) Evaluation of active versus passive AIDS surveillance in Oregon. American Journal of Public Health 80:463~64. Moss, A. R., Bachetti, P., Osmond, D., Meakin, R., Keffelew, A., and Gorter, R. (1989) Seroconversion for HIV in intravenous drug users in San Francisco. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Murphy, D. L. (1987) Heterosexual contacts of intravenous drug users: Implications for the next spread of the AIDS epidemic. Advances in Alcohol and Substance Abuse 7:89-97. National Hemophilia Foundation. (1988) What you should know about hemophilia (brochure). National Hemophilia Foundation, New York. New York State Department of Health. (1989) AIDS in New York State through 1988. Albany: New York State Department of Health. Novick, L. F., Berns, D., Stricof, R., Stevens, R., Pass, K., and Wethers, J. (1989) HIV seroprevalence in newborns in New York State. Journal of the American Medical Association 261: 1745-1750. Ognjan, A., Markowitz, N., Pohlod, D., Lee, H., Belian, B., and Saravolatz, L. D. (1989) HIV-1 and HTLV-1 infections in intravenous drug users (IVDUs) in Detroit, 1985-1989. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Olin, R., and Kall, K. (1989) HIV status and changes in risk behavior among arrested and detained intravenous drug abusers in Stockholm, 1987-88. Presented at the Fifth International Conference on AIDS, Montreal, June =9. O'SulIivan, M. J., Fajardo, A., Ferron, P., Efantis, J., Senk, C., and Duthely, M. (1989) Seroprevalence in a pregnant multiethnic population. Presented at the Fifth Internatior~al Conference on AIDS, Montreal, June =9. Padian, N., Moreno, A., Glass, S., Shiboski, S., and Maisonet, G. (1989) Ethnic differences in the heterosexual transmission of HIV in California. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Pappaioanou, M., George, R., Hannon, H., Hoff, R., Willoughby, A., et al. (1989) National surveys of HIV seroprevalence in women delivering live children in the United States. Presented at the Fifth International Conference on AIDS, Montreal, June =9.

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78 ~ AIDS: THE SECOND DECADE Pansh, K. L., Mandel, J., Thomas, J., and Gomperts, E. (1989) Prediction of safer sex practice and psychosocial distress in adults with hemophilia at risk for AIDS. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Prendergast, T. J., Maxwell, R., Greenwood, J. R., Burrell, P., and Swatzel, C. (1989) Incidence and prevalence of HIV infection during 44 months of testing prostitutes/IVDUs in the women's prison, Orange County, California. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Public Health Service (PHS). (1988) Report of the Second Public Health Service AIDS Prevention and Control Conference. Public Health Reports 103 (Supplement No. 11:1-98. Quinn, T. C., Glasser, D., Cannon, R. O., Matuszak, D. L., Dunning, R. W., et al. (1988) Human immunodeficiency virus infection among patients attending clinics for sexually transmitted diseases. New England Journal of Medicine 318:197-203. Ragni, M. V., Gupta, P., Rinaldo, C. R., Kingsley, L. A., Spero, J. A., and Lewis, J. H. (1988) HIV transmission to female sexual partners of HIV antibody-positive hemophiliacs. Public Health Reports 103:5~58. Ralph, N., and Spigner, C. (1986) Contraceptive practices among female heroin addicts. American Journal of Public Health 76:101~1017. Rosenbaum, M. (1981) When drugs come into the picture, love flies out the win- dow: Women addicts' love relationships. International Journal of the Addictions 16:1197-1206. Schoenbaum, E. E., Hartel, D., Selwyn, P. A., Klein, R. S., Davenny, K., et al. (1989) Risk factors for human immunodeficiency virus infection in intravenous drug users. New England Journal of Medicine 321:87~879. Selik, R., and Petersen, L. (1989) Epidemiology of AIDS associated with intravenous drug use, United States, 1979-1988. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Selwyn, P. A., Schoenbaum, E. E., Hartel, D., Klein, R. S., Davenny, K., et al. (1988) AIDS and HIV-related mortality ire intravenous drug users (IVDUs). Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Smiley, M. L., White, G. C. IL Becherer, P., Macik, G., Matthews, T. J., et al. (1988) Transmission of human immunodeficiency virus to sexual partners of hemophiliacs. American Journal of Hematology 28:27-32. Snyder, F., and Myers, M. (1989) Risk-taking behaviors of intravenous drug abusers. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Sowder, B., Weissman, G., and Young, P. (1989) Working with women at risk in a national AIDS prevention program. Photocopied materials distributed at the Fifth International Conference on AIDS, Montreal, June ~9. Sperling, R. S., Sacks, H. S., Mayer, L., Joyr~er, M., and Berkowitz, R. L. (1989) Umbilical cord blood serosurvey for human immunodeficiency virus in parturient women in a voluntary hospital in New York City. Obstetrics and Gynecology 73:179-181. Stoneburner, R. L., Des Jarlais, D. C., Benezra, D., Gorelkin, L., Sotheran, J. L., et al. (1988) A larger spectrum of severe HIV-1 related disease in intravenous drug users in New York City. Science 242:91~919. Stoneburner, R. L., Chiasson, M. A., Weisfuse, I. B., and Thomas, P. A. (1990) The epidemic of AIDS and HIV-1 infection among heterosexuals in New York City. AIDS 4:99-106.

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STATE OF THE EPIDEMIC ~ 79 Thompson, E. G., Suarez, L., Reed, C. M., Buchanan, B. K., and Therrell, B. L. (1989) Serosurvey of women of childbearing age in Texas, U.S.A. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Tross, S., Abdul-Quader, A. S., Des Jarlais, D. C., Kouzi, A. C., and Friedman, S. R. (1989) Determinants of sexual risk reduction in street-recruited female IV drug users. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Turner, C. F. (1989) Research on sexual behaviors that transmit HIV: Progress and problems. AIDS 3:S63-S71. Turner, C. F., Miller, H. G., and Barker, L. (1989) AIDS research and the behavioral and social sciences. In R. Kulstad, ea., AIDS, 1988: AAAS Symposium Papers. Washington, D.C.: American Association for the Advancement of Science. Tumer, C. F., Miller, H. G., and Moses, L. E., eds. (1989) AIDS, Sexual Behavior, and Intravenous Drug Use. Washington, D.C.: National Academy Press. U.S. Bureau of the Census. (1987) Statistical Abstract of the United States: 1988. 108th ed. Washington, D.C.: U.S. Government Printing Office. Valdiserri, R. O., Bonati, F. A., Proctor, D., and Glaser, D. A. (1988) HIV antibody testing in a family planning clinic setting. New York State Journal of Medicine 88:623-625. Valdiserri, R. O., Arena, V. C., Proctor, D., and Bonati, F. A. (1989) The relationship between women's attitudes about condoms and their use: Implications for condom promotion programs. American Journal of Public Health 79:499-501. van Haastrecht, H. J. A., van den Hock, J. A. R., and Coutinho, R. A. (1989) No trend in yearly HIV seroprevalence rates among IVDU in Amsterdam: 198~1988. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Watters, J. K. (1988) Meaning and context: The social facts of intravenous drug use and HIV transmission in the inner city. Journal of Psychoactive Drugs 20:173-177. Weiner, S. M., Kaltenbach, K. A., and Finnegan, L. P. (1989) Drug abuse and pregnancy: Concomitant risk factors for HIV infection. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Weissman, G. (1988) Community outreach and prevention: A national demonstration project. Presented at the 116th annual meeting of the American Public Health Association, Boston, November. Wermuth, L., and Ham, J. (1989) Perception of AIDS risk among women sexual partners of intravenous drug users in San Francisco. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Whittaker, S., Calsyn, D., Saxon, A., and Freeman, G. (1989) Sexual behaviors of intravenous drug users. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Wilson, P. A., and Wasserman, K. (1989) Psychosocial responses to the threat of HIV exposure among people with bleeding disorders. Health and Social Work August: 17~183. Winkelstein, W., Samuel, M., Padian, N. S., Wiley, 3. A., Lang, W., et al. (1987) The San Francisco Men's Health Study: IlI. Reduction in human immunodeficiency virus transmission among homosexual/bisexual men' 1982-1986. American Journal of Public Health 77(91:685~89.

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80 ~ AIDS: THE SECOND DECADE Winkelstein, W., Wiley, J. A., Padian, N. S., Samuel, M., Shiboski, S., et al. (1988) The San Francisco Men's Health Study: Continued decline in HIV seroconversion rates among homosexual/bisexual men. American Journal of Public Heals 78:1472- 1474. Withum, D. G., LaLota, M., Holtzman, D., Bum, E. E., Chan, M. S., et al. (1989) Prevalence of HIV antibodies in childbearing women in Florida. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Wolfe, H., Keffelew, A., Bacchetti, P., Meakin, R., Brodie, B., and Moss, A. R. (1989) HIV infection in female intravenous drug users in San Francisco. Photocopied materials distributed at the Fifth International Conference on AIDS, Montreal, June =9. Worth, D., and Rodriguez, R. (1987) Latina women and AIDS. Siecus Report January/February: 5-7. Worth, D., Drucker, E., Eric, K., Chabon, B., Pivnick, A., and Cochrane, K. (1989) An ethnographic study of high-nsk sexual behavior in 96 women using IV heroin, cocaine, and crack in the South Bronx. Presented at the Fifth International Conference on AIDS, Montreal, June =9.