HIV/AIDS in Georgia 1993 [1993]

Georgia Department of Human Resources
Division of Public Health .................................................................................................................................................................. Patrick Meehan, M.D. Director
Epidemiology and Prevention Branch .............................................................................................................. Kathleen E. Toomey, M.D., M.P.H.
State Epidemiologist Director
HIVIAIDS Epidemiology Unit ............................................................................................................................ Harrison C. Stetler, M.D.
Director Rebecca T. East HIV Serosurveillance Director Brian 0.Williams, M.D. AIDS Surveillance Director
Graphics and Design
Janice M. Braswell Data Analyst
HIVIAIDS Epidemiology Unit
Charlene Reid Surveillance Technician HIVIAIDS Epidemiology Unit

Table of Contents
AIDS Surveillance ....................................................................................................................................................... I.17
Effect of the Expanded AIDS Surveillance Definition .......................................................................................................................................... 2 Cumulative Number of Reported AIDS Cases Among the Top Eight Reporting states. 1981-1993 ..................................................................3 Cumulative AIDS Cases by Health District. Georgia. 1981.1993 ......................................................................................................................... 4 Cumulative AIDS Case Rates per 100.000 Population by County. Georgia. 1981-1993 ....................................................................................5 AIDS Case Rates per 100.000 Population by Health District and Year of Diagnosis. 1989-1993 .................................................................... 6-9 Proportional Distribution of Georgia Adult/Adolescent AIDS Cases by Selected Risk Categories and Year of Diagnosis. 1989-1993 ............ 10 Proportional Distribution of Georgia Adult/Adolescent AIDS Cases by Race and Year of Diagnosis. 1989-1993 ............................................11 Proportion of AIDS Cases that are Female by Race and Year of Diagnosis. Georgia. 1984-1993......................................................................12 Male to Female Ratio of AIDS Cases by Year of Diagnosis. Georgia. 1984-1993.............................................................................................13 Proportional Distribution of All Reported AIDS Cases by Sex and Age Group. Georgia. 1981-1993................................................................14 Pediatric AIDS Cases by RaceIEthnicity and Year of Diagnosis. Georgia. 1982-1993 .......................................................................................15 Cumulative Pediatric AIDS Cases by Risk Category of Mother. Georgia. 1981-1993 .......................................................................................16 Projection of Future AIDS Cases. Georgia. 1994-2000 ....................................................................................................................................... 17
HIV Family of Surveys ...............................................................................................................................................18-35
Survey of Childbearing Women ..................................................................................................................................................................19-22
Seroprevalence of HIV Among Childbearing Women in Metropolitan Atlanta Health Districts ...........................................................20 Seroprevalence of HIV Among Childbearing Women by Health Districts Outside of Metropolitan Atanta .........................................21 Seroprevalence of HIV Among Childbearing Women by Health District and Race. Georgia. 1993 .....................................................22
Blinded Surveys ..........................................................................................................................................................................................23-35
HIV Seroprevalence Among All Sexually Transmitted Disease Clinic Patients by Testing Period ....................................................... 24 HIV Seroprevalence Among All Sexually Transmitted Disease Clinic Patients by Sexual Orientation and Testing Period .................25 HIV Seroprevalence Among All Sexually Transmitted Disease Clinic Patients by Sexual Orientation. Race and Testing Period .......26 HIV Seroprevalence Among Heterosexual Sexually Transmitted Disease Clinic Patients by Sex and Testing Period ........................27 Distribution of Sexually Transmitted Diseases Among HIV Positive Patients. Sexually Transmitted Disease Clinics. 10191.12/93 ...28 HIV Seroprevalence Among Drug Treatment Clinic Patients by Testing Period. Atlanta. Georgia .......................................................29 HIV Seroprevalence Among Intravenous Drug Users by Race. Sex and Testing Period .......................................................................30 HIV Seroprevalence Among Non-Intravenous Drug Users by Race. Sex and Testing Period ...............................................................31 Overall HIV Seroprevalence Among the Homeless by Testing Period ..................................................................................................32

Table of Contents (continued...)
HIV Seroprevalence Among the Homeless by Race. Sex and Testing Period ......................................................................................33 HIV Seroprevalence Among the Homess by Risk Category. 03/90 .12/93 ...........................................................................................34 Seroprevalence of HIV in Women's Health Clinics by Race and Testing Period ..................................................................................35
Rural Sentinel Hospital Survey .................................................................................................................................................................36-39
HIV Seroprevalence Among Patients in the Rural Sentinel Hospital Surveys by Race and Sex. 1993 .................................................37 HIV Seroprevalence Among Patients in the Rural Sentinel Hospital Surveys by Age Group. 1993 ..................................................... 38 Distribution of Patients and HIV Seroprevalence Rates in the Rural Sentinel Hospital Surveys by Hospital Service. 1993 ................39
Non-Blinded Surveys ................................................................................................................................................................................... 40-42
HIV Seroprevalence Among the Homeless by Testing Period ................................................................................................................41 HIV Seroprevalence Among the Homeless by Duration of Homelessness. 01191.12/93 ....................................................................4 2
HIV Counseling and Testing .......................................................................................................................................43-45
HIV Counseling and Testing at Public Health Sites. Georgia. 1993...............................................................................................................44 HIV Counseling and Testing at Public Health Sites by Demographics and Risk Exposure. Georgia. 1993 .......................................................45
HIV Seroprevalence Among Military Applicants .......................................................................................................46-48
Seroprevalence of HIV Among Civilian Applicants to the Military by Sex. Georgia. 1985-1992......................................................................47 Seroprevalence of HIV Among Civilian Applicants to the Military by Race. Georgia. 1985-1992....................................................................48
Sexually Transmitted Diseases. Tuberculosis and Adolescent Pregnancies by County ........................................ 49-53
Early Syphilis Case Rate per 100.000 Population by County. Georgia. 1993 .....................................................................................................50 Tuberculosis Case Rate per 100.000 Population by County. Georgia. 1993 .......................................................................................................51 Teenage Pregnancy Rates per 1.000 Female Population by County. Georgia. 1993 ...........................................................................................52 The 25 Counties With the Highest AIDS. Tuberculosis. Syphilis and Teenage Pregnancy Rates. Georgia. 1993 ..............................................53
Appendix .....................................................................................................................................................................54-64

HIVIAIDS in Georgia
Through December, 1993,9,764 cases of AIDS have been reported to the Georgia AIDS case surveillance registry; 5,663 cases have been reported to have died. In January, 1993 the AIDS case definition was made more sensitive by including persons who test positive for HIV, and have a CD4 count under 200 or have pulmonary tuberculosis, recurrent pneumonia or invasive cervical cancer. A total of 1,945 AIDS cases were reported in 1993; of these, 915 cases would have been reported under the pre-1993 case definition and 1,030 only fulfilled the 1993 case definition. Georgia has the eighth highest cumulative number of reported AIDS cases among the 50 states.
The AIDS epidemic in Georgia has been changing gradually from primarily affecting metropolitan Atlanta to affecting smaller towns and rural areas. If AIDS cases are examined by year of diagnosis, the percentage of cases living outside the metropolitan Atlanta area at the time of their diagnosis has increased from 25% in 1986 to 36% in 1993. This trend is especially marked in south and central Georgia. From 1989 to 1993 many of the health districts in this part of Georgia have more than doubled their case rates; in some, over half of the reported cases list their place of residence at time of diagnosis as in rural counties, that is outside the county where the main town is located.
The epidemic in Georgia began in the early 1980's among white gay men. As the epidemic spread, the percentage of AIDS cases among men who have sex with men (MSM) has steadily decreased. In 1989,65% of diagnosed AIDS cases occurred among MSM, but by 1993 only 47% of cases were reported in this risk group. Over this same five year period, there has been a steady increase in cases among injecting drug users (IDUs) and heterosexuals.
The epidemic is increasing much more rapidly in blacks than in whites. In 1989,47% of reported cases were in blacks but by 1993 68% of reported cases were in blacks. Since only 29% of the Georgia population is black (from the 1992 population projections), reported AIDS case rates in 1993 were more than 5 times higher in blacks than whites. Much of this increase in HIV transmission in blacks is occurring outside the metropolitan Atlanta area.
The proportion of AIDS cases who are women has steadily increased over the past 10 years. Since 1984, the proportion of female AIDS cases has increased from 4% to 15%. In blacks, 20% of the reported cases in 1993 were in women.

Pediatric AIDS cases, although only a small proportion of total AIDS cases reported, are steadily increasing. Most (93%) are due to transmission from an infected pregnant women to the fetus or newborn. The survey of childbearing women (a survey that tests blood on all newborns in Georgia for HIV antibodies) showed a seroprevalence of 0.17% in 1992 (193 newborns) and 0.18% in 1993 (208 newborns), an increase of 8%. Approximately 20% of these newborns will eventually develop AIDS. This burden of pediatric AIDS will continue to increase as more women become infected.
Data from various seroprevalence surveys tend to confirm the trends seen in the analyses of the AIDS case data. The HIV seroprevalence data from selected STD clinics (not all were included) over the past five years show a slight but steady increase in the percent of heterosexuals testing positive, from 1.8% in 1989 to 2.2% in 1993. Over the same time period, the HIV seroprevalence in MSM has decreased from 54.6% in 1989 to 41.9% in 1993. The HIV seroprevalence in heterosexual females attending these clinics has increased from 1.2% to 1.8%.
The seroprevalence rate among injecting drug users (IDUs) has fluctuated between 13% and 19% over the past five years with no clear trend, while it has remained relatively constant at around 8% for non-injecting drug users. Seroprevalance rates were consistently higher among male drug users and black drug users.
In a surveyed homeless population, the HIV seroprevalence rate was 45% in MSM and 18% in IDUs. Although the overall seroprevalence has declined from 9.2% in 1990to 6.9% in 1993,this level of infection is very high when compared to the general population.
In summary, the HIVIAIDS epidemic in Georgia is continuing to affect the men who have sex with men population, but in the 1990's has increasingly affected IDUs and the heterosexual population. In addition, transmission is increasing among blacks and women, both in Metropolitan Atlanta and in Georgia's smaller towns and rural areas. The changing dynamics of this epidemic must be closely monitored so that effective prevention programs can be designed and focused on communities most at risk.

HIVIAIDS in Georgia
Through December, 1993,9,764 cases of AIDS have been reported to the Georgia AIDS case surveillance registry; 5,663 cases have been reported to have died. In January, 1993 the AIDS case definition was made more sensitive by including persons who test positive for HIV, and have a CD4 count under 200 or have pulmonary tuberculosis, recurrent pneumonia or invasive cervical cancer. A total of 1,945 AIDS cases were reported in 1993; of these, 9 15 cases would have been reported under the pre-1993 case definition and 1,030 only fulfilled the 1993 case definition. Georgia has the eighth highest cumulative number of reported AIDS cases among the 50 states.
The AIDS epidemic in Georgia has been changing gradually from primarily affecting metropolitan Atlanta to affecting smaller towns and rural areas. If AIDS cases are examined by year of diagnosis, the percentage of cases living outside the metropolitan Atlanta area at the time of their diagnosis has increased from 25% in 1986 to 36% in 1993. This trend is especially marked in south and central Georgia. From 1989 to 1993 many of the health districts in this part of Georgia have more than doubled their case rates; in some, over half of the reported cases list their place of residence at time of diagnosis as in rural counties, that is outside the county where the main town is located.
The epidemic in Georgia began in the early 1980's among white gay men. As the epidemic spread, the percentage of AIDS cases among men who have sex with men (MSM) has steadily decreased. In 1989,65% of diagnosed AIDS cases occurred among MSM, but by 1993 only 47% of cases were reported in this risk group. Over this same five year period, there has been a steady increase in cases among injecting drug users (IDUs) and heterosexuals.
The epidemic is increasing much more rapidly in blacks than in whites. In 1989,47% of reported cases were in blacks but by 1993 68% of reported cases were in blacks. Since only 29% of the Georgia population is black (from the 1992 population projections), reported AIDS case rates in 1993 were more than 5 times higher in blacks than whites. Much of this increase in HIV transmission in blacks is occurring outside the metropolitan Atlanta area.
The proportion of AIDS cases who are women has steadily increased over the past 10 years. Since 1984, the proportion of female AIDS cases has increased from 4% to 15%. In blacks, 20% of the reported cases in 1993 were in women.

Pediatric AIDS cases, although only a small proportion of total AIDS cases reported, are steadily increasing. Most (93%) are due to transmission from an infected pregnant women to the fetus or newborn. The survey of childbearing women (a survey that tests blood on all newborns in Georgia for HIV antibodies) showed a seroprevalence of 0.17% in 1992 (193 newborns) and 0.18% in 1993 (208 newborns), an increase of 8%. Approximately 20% of these newborns will eventually develop AIDS. This burden of pediatric AIDS will continue to increase as more women become infected.
Data from various seroprevalence surveys tend to confirm the trends seen in the analyses of the AIDS case data. The HIV seroprevalence data from selected STD clinics (not all were included) over the past five years show a slight but steady increase in the percent of heterosexuals testing positive, from 1.8% in 1989 to 2.2% in 1993. Over the same time period, the HIV seroprevalence in MSM has decreased from 54.6% in 1989 to 41.9% in 1993. The HIV seroprevalence in heterosexual females attending these clinics has increased from 1.2% to 1.8%.
The seroprevalence rate among injecting drug users (IDUs) has fluctuated between 13% and 19% over the past five years with no clear trend, while it has remained relatively constant at around 8% for non-injecting drug users. Seroprevalance rates were consistently higher among male drug users and black drug users.
In a surveyed homeless population, the HIV seroprevalence rate was 45% in MSM and 18% in IDUs. Although the overall seroprevalence has declined from 9.2% in 1990to 6.9% in 1993,this level of infection is very high when compared to the general population.
In summary, the HIVIAIDS epidemic in Georgia is continuing to affect the men who have sex with men population, but in the 1990's has increasingly affected IDUs and the heterosexual population. In addition, transmission is increasing among blacks and women, both in Metropolitan Atlanta and in Georgia's smaller towns and rural areas. The changing dynamics of this epidemic must be closely monitored so that effective prevention programs can be designed and focused on communities most at risk.

AIDS S ~ ~ vllaenice
9,764 AIDS cases were reported in Georgia between 1981 and 1993; 59% of these individuals have died.
29% of the total reported AIDS cases to date lived outside of the metropolitan Atlanta area at the time of their diagnosis. This has increased from 25% in 1986 to 36% in 1993.
54% of all cases have been among men who have sex with men (MSM). The proportion of diagnosed AIDS cases in MSM has decreased from 65% in 1989 to 47% in 1993. Over the same time period there has been a steady increase in the proportion of AIDS cases among IDUs and heterosexuals.
An increasing proportion of AIDS cases are among blacks, from 29% of cases diagnosed in 1986 to 68% in 1993. Eighty-one percent of women with AIDS in Georgia are black.
AIDS has been the leading cause of death in Georgia in the 20-44 year age group since 1991. In 1993, it was the leading cause of death in white males, black males and black females in this age group in Georgia.
Women accounted for one in five Georgians reported with AIDS in 1993, up from one in 19 in 1985, nearly a 400% increase.

Effect of the Expanded AIDS Surveillance Definition
The Centers for Disease Control and Prevention (CDC) implemented an expanded AIDS surveillance case definition on January 1, 1993. Under the new definition, adults and adolescents with documented HIV infection who have CD4+ T-lymphocyte counts <200/yL or % of total lymphocytes <14 % are reportable as AIDS cases. In addition to the 23 clinical conditions in the previous (1987) case definition, three additional clinical conditions are now AIDS-defining in persons with documented HIV infection (pulmonary tuberculosis, recurrent pneumonia, and invasive cervical cancer).
The expanded AIDS surveillance case definition has had a substantial impact on the number of reported cases. The immediate increase in case reporting was attributable to the addition of severe immunosuppression to the definition; fewer additional cases were included due to the inclusion of the three additional clinical conditions. Under the previous AIDS surveillance criteria, 915 AIDS cases were reported in 1993; an additional 1,030 cases were reported due to the revised case definition.
The following pages give a graphical description of the epidemic in Georgia, with emphasis on trends. All data are based on reports received through December 31, 1993; therefore, 1993 data are provisional. Data reported in the CDC Surveillance Report may differ from those published by individual states due to a delay in the receipt of case reports by CDC. Some of the percent columns on the tables that follow may not add up to 100% due to rounding.

Year of Rcport
Because of anticipation of the addition of severe immunosuppression to the AIDS case definition, Georgia began having these cases reported in late 1991. However, these cases were not added to the Georgia case count until 1993.
1,932 and 1,945 cases were reported in 1992 and 1993 respectively.

Year of Diagnosis
If cases are distributed by year of diagnosis, many cases diagnosed in 1993 will not be reported until 1994 or later.

Cumulative Number of Reported AIDS Cases Among the Top Eight Reporting States, 1981-1993

New York California Florida Texas New Jersey Illinois Pennsylvania Georgia

9,906

Since the beginning of the AIDS epidemic, the Centers for Disease Control and Prevention (CDC) has recorded over 360,000 reported cases of AIDS through December 1993. Georgia has consistently remained among the top reporting states in the United States and now ranks eighth in the cumulative number of reported cases of AIDS.
The above data are based on cases reported to CDC as of December 1993. These CDC data differ from those published in other areas of this report because of subsequent changes in the status of previously reported Georgia cases.

Cumulative AIDS Cases by Health District
Georgia, 1981 - 1993
Metropolitan Atlanta Area
29% of reported AIDS cases to date live outside Metropolitan Atlanta; this proportion has increased from 25%

Cumulative AIDS Case Rates per 100,000 Population by County
Georgia, 1981 - 1993
Cases Per 100,000 <lo
10 - 29
30 - 49
50-100 >I00

AIDS Case Rates per 100,000 Population by Health District
and Year of Diagnosis, 1989 - 1993

Fulton

DeKalb

1989

1990 1991 1992 Year of Diagnosis

1993

Year of Diagnosis

The high case rates in Fulton and Dekalb counties are continuing.
NOTE: The case rate scale changes for the graphs presented on each of the next four pages. The health districts are presented in order of descending average case rates. Since these data are presented by year of diagnosis, the data for recent years are incomplete (Cases diagnosed in 1992 and 1993 will continue to be reported in 1994 and later).

AIDS Case Rates per 100,000 Population by Health District
and Year of Diagnosis, 1989 - 1993

Savannah

Augusta

Albany

Colurr7bus

1989 1990 1991 199' Year of Diagnosis

1993
Brunsurick

Year 01' Diagnocis

Year of Diagnosis

Year of Dtagnosis

Substantial increases in case rates have occurred in Savannah and Albany; smaller increases have occurred in the other health districts shown.

AIDS Case Rates per 100,000 Population by Health District
and Year of Diagnosis, 1989 - 1993

Clayton

Macon

Waycross

1989 1990 1991 1992 1993 Year of Diagnosis
Cobb

1989 1990 1991 1992 1993 Year of Diagnosis
Gwinnett

1989 1990 1991 1992 1993 Year of Diagnosis

Year of Diagnos~s

Ycar of Diagnosis

Most of the above health districts show moderate but level case rates.

Year of Diagnosis

AIDS Case Rates per 100,000 Population by Health District
and Year of Diagnosis, 1989 - 1993

Athens

Dublin

Dalton

1989 1990 1991 1992 1993 Year of Diagnosis
Gainesville

1989

1990 1991 1992 Year of D~agnosis

1993

Valdosta

1989

1990 1991 1992 Year of Diagnos~s
Korne

1993

Year of Diagnos~s

Year of Diagnosis

The above health districts have the lowest overall case rates and show no clear trend.

Year of Diagnosii

Proportional Distribution of Georgia Adult/Adolescent AIDS Cases
by Selected Risk Categories and Year of Diagnosis, 1989 - 1993
0 MSM IDU IIHetero

1989

1990

1991

1992

1993

Year of Diagnosis

Over the past 5 years the proportion of diagnosed AIDS cases in MSM has decreased from 65% in 1989 to 48% in 1993. Over the same time period there have been increases in the proportion of diagnosed AIDS cases among IDUs and heterosexuals.
NOTE: "MSM/IDU" and "Other Risk" categories not shown.
MSM = Men who have sex with men IDU = Injecting drug users Hetero = Heterosexual

Proportional Distribution of Georgia Adult/Adolescent AIDS Cases
- by Race and Year of Diagnosis, 1989 1993

1989

1990

1991

1992

1993

Year of Diagnosis

The percentage o f diagnosed AIDS cases in blacks has increased from 47% in 1989 to 68% in 1993.
Even though blacks make up only 29% of Georgia's population, twice as many blacks as whites are now being diagnosed with AIDS; the AIDS case rate is therefore 5 times greater among blacks than among whites.

Proportion of AIDS Cases that are Female
by Race and Year of Diagnosis, Georgia, 1984 - 1993
Year of Diagnosis The proportion of AIDS cases that are female has steadily increased over the past 10 years, from 4% in 1984 to 15% in 1993. In 1993, 20% of AIDS cases among blacks were female.

Male to Female Ratio of AIDS Cases by Year of Diagnosis,
Georgia, 1984 - 1993
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 Year of Diagnosis
The ma1e:female ratio continues to decrease; this is due to increasing HIV transmission in IDUs and heterosexuals.

Proportional Distribution of All Reported AIDS Cases by Sex
and Age Group, Georgia, 1981 - 1993

13-19

20-29

30-39

40-49

>49

Age Group

The greatest proportion of reported AIDS cases occurred in the 30-39 year age group in both sexes.

Pediatric AIDS Cases By RaceIEthnicity and Year of Diagnosis
- Georgia, 1982 1993

Year

White

Black

Other

Total

Number ot Cd\es 16

TOTAL

23

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 199: Ye- of Diagnosis

The number of pediatric AIDS cases is expected to increase as the number of HIV-infected women of childbearing age increases. NOTE: Most of the cases diagnosed in 1993 will not be reported until 1994 or later.

Cumulative Pediatric AIDS Cases by Risk Category of Mother,
Georgia, 1981 - 1993

Mother HIV infcctc.d/Risk not specified

Mother an IDU Mother sex partner of a male IDU

Mother's sex partner known HIV infected

Mother sex partner of MSM Mother has no identified risk

Mother a transfusion recipient Mother's sex partner had blood transfusion

Mother from Pattern I1 country "Pediatric transfusion

"Hemophilia

0%

5%

"Child's Exposure

10% 15% 20% 25%

3 3 !'i

I

30%

30% 35% 40%

83 (93%) of the 89 pediatric AIDS cases were due to perinatal transmission.

Projection of Future AIDS Cases
Georgia, 1994 - 2000

In 1987, the Georgia Department of Human Resources (DHR) developed a five year plan for the management of AIDS in Georgia. At that time, 937 cases of AIDS had been reported to DHR. According to mathematical projections at that time, between 5,800 and 6,000 cumulative cases would be reported by the end of 1991. The actual data demonstrate that a total of 6,863 cases were reported through 1991.
Based on the number of reported AIDS cases through December 1993, further mathematical projections were calculated. The model that results in the best fit of existing data is one using linear regression. This model suggests that 11,967 cases of AIDS will be reported to Georgiaby the end of 1994and 14,366by the end of 1995. Although changes in therapy and behavior may cause marked shifts in actual cases reported, these projections can be used to predict future needs for HIV prevention and intervention.

Cumulative Cascs (Thousands) 15
10
15
20
15
10
5
0 XI 82 83 84 85 86 87 88 89 90 91 92 93 91 95 96 97 08 99 20 Year of Diagnosis

HIV Family of Surveys
In 1988, Georgia was one of the sites selected by the Centers for Disease Control and Prevention (CDC) to participate in the HIV Family of Surveys. The HIV Family of Surveys (HFS) include blinded (no identifying or epidemiologic information collected with the blood samples) and non-blinded (identifying information and risk behavior collected along with the blood samples) testing for antibodies to HIV-1. This report will include all data collected from both the blinded and non-blinded surveys through the end of 1993.
Blinded Surveys
The purpose of the blinded surveys was to establish a baseline of HIV seroprevalence and to monitor trends over time in selected populations. The blinded surveys are conducted in several different types of clinics in the metropolitan area including two sexually transmitted disease (STD) clinics, two drug treatment centers (DTC), five adolescent clinics, two women's health clinics, and in mobile clinics serving the homeless. For a clinic to be eligible to participate in the HFS survey, they must obtain blood from clients as part of normal clinic procedures. At all clinics participating in the blinded survey, after routine tests are completed on the blood specimens, all identifiers are removed from the specimen and HIV testing is carried out. Each survey has a minimum sample size that must be obtained within a 12 month period.
The survey of childbearing women is also considered to be a blinded survey because no identifiers remain on the specimen when the HIV test is conducted. In order to link demographic information with test results, each specimen is assigned a survey identification number. The survey of childbearing women is the only population-based HIV seroprevalence survey in Georgia.
Rural Sentinel HIV Survey
Due to increased reporting of AIDS cases from outside Metropolitan Atlanta, five hospitals in south Georgia were selected as sentinel sites to monitor trends in HIV seroprevalence. Testing began in 1993 and was conducted in two six week intervals.
Non-Blinded Surveys
Non-blinded HIV testing and collection of risk behavior information began in 1989 and was conducted in two tuberculosis clinics, two STD clinics, two DTC's, and among the homeless. The purpose of these surveys was to obtain detailed information on the risk behaviors associated with HIV. Questionnaires were administered in conjunction with HIV counseling and testing; therefore, a clinic must offer HIV counseling and testing before they are eligible to participate in the survey. After several years of testing, these surveys were discontinued effective December 31, 1992, with the exception of mobile clinics serving the homeless population; in this report, only data on the homeless population will be presented.

Childbearing Women

In Georgia, all newborn infants have several blood spots absorbed onto filter paper within 48 hours of birth to test for a variety of metabolic abnormalities. After the metabolic screening is completed, identifying information on the mother and infant are removed and the remaining blood spot samples are tested for antibodies to HIV, therefore, results cannot be reported back to the mothers.

A sample that tests positive indicates that the newborn infant has antibodies to HIV in their blood. These passively transferred antibodies from the mother may last as long as 15-18 months before they are no longer present (about 20% of these infants are HIV-infected and will continue to be HIV antibody positive beyond 18 months of age). Hence, measurement of newborn infants' antibody status is really measuring the HIV infection status of their mothers.

The survey among child bearing women has completed six periods of testing. The following pages include charts and maps representing the data by health district and by race. The overall seroprevalence rate in 1993 was 0.18%, an 8% increase over 1992.

The testing periods are:
First period of testing - 09/88 - 12/88 [33,288 tested, 53 (0.16%) positive]

Fourth period of testing - 01/91 - 12191 [96,201 tested, 149 (0.15%) positive]

Second period of testing - 01/89 - 12/89 [51,621 tested, 68 (0.13%) positive]

Fifth period of testing - 01/92 - 12/92 [114,095 tested, 193 (0.17%) positive]

Third period of testing - 01/90 - 12/90 [78,765 tested, 133 (0.17%) positive]

Sixth period of testing - 01/93 - 12/93 [117,223 tested, 208 (0.18%) positive]

Seroprevalence of HIV Among Childbearing Women in Metropolitan Atlanta Health Districts
Horizontal Axis - Testing Periods 1-6, (1988 - 1993) Vertical Axis - Percent HIV Positive

Clayton

Cobb

DeKalb

Fulton

Gwinnett

Fulton health district has the highest HIV seroprevalence among childbearing women; about 1in 250 are HIV positive.

Seroprevalence of HIV Among Childbearing Women by Health Districts Outside of Metropolitan Atlanta
Horizontal Axis - Testing Periods 1-6, (1988 - 1993) Vertical Axis - Percent HZV Positive

Athens

0.5

0.5

0.5

0.5

0.4

0.4

0.4

0.4

0.3

0.3

0.3

0.3

0.2

0.2

0.2

0.2

0.1

0.1

0.1

0. t

n

n II

n

n

0.5 0.4 0.3 0.2 0. i
0 88 89 90 91 92 93

Dalton
0.5 0.4 0.3 0.2 0.1
0 88 89 90 91 92 93

Dublin
0.5 0.4 0.3 0.2 0.1
0 88 89 90 91 92 93

Gainesville
0.5 0.4 0.3 0.2 0.1
0 88 89 90 91 92 93

LaGrange
0.5 0.4 0.3 0.2 0. I
0 88 89 90 91 92 93

Macon

Rome

Savannah

Valdosta

Way cross

0.5

0.5

0.5

0.5

0.5

0.4

0.4

0.4

0.4

0.4

0.3

0.3

0.3

0.3

0.3

0.2

0.2

0.2

0.2

0.2

0.1

0.1

0.1

0.1

0.1

0

0

88 89 90 91 92 93

8% 89 90 91 92 93

0 88 89 90 91 92 93

0 88 89 90 91 92 93

0 88 89 90 91 92 93

The highest HIV seroprevalence rates outside metropolitan Atlanta are in Albany, Columbus, and Savannah.

Seroprevalence of HIV Among Childbearing Women by Health District and Race Georgia, 1993

Black Females
N = 35,039

White Females
N = 57,018

Blinded HIV testing began in 1988 in selected sexually transmitted diseases clinics, drug treatment clinics, women's health clinics and among the homeless. Each clinic enrolls clients consecutively until a pre-determined sample size has been met.
The seroprevalence rate among heterosexuals attending selected sexually transmitted diseases clinics has increased slightly over six testing periods from 1.8% to 2.2%. The seroprevalence rate among men who have sex with men (MSM) decreased over six testing periods from 55% to 42%
The seroprevalence rate among intravenous drug users at selected sites has fluctuated between 13% and 19% over six testing periods with no clear trend, while it has remained around 8% over five testing period for non-intravenous drug users.
The seroprevalence rate among the homeless population has decreased slightly from 9% to 7% over four testing periods. This level of infection is high when compared to the general population.

HIV Seroprevalence Among All Sexually Transmitted Disease Clinic Patients by Testing Period

Period 2
N =4,123

Period 3
N = 3.940

Period 4
N = 3.585

Period 5
N = 3.503

Period 6
t~ = 2,493

During the first testing period, an oversampling of homosexual/bisexual males occurred causing an inflated overall seroprevalence rate in that period. This data point is therefore not included.
Over the next 5 testing periods seroprevalence was about 3% with no clear trend.
Period 1 - 07/88 - 04/89 Period 4 - 10191 - 04/92 Period 2 - 10189 - 03/90 Period 5 - 09/92 - 12/92 Period 3 - 10190 - 02/91 Period 6 - 09/93 - 12/93

HIV Seroprevalence Among All Sexually Transmitted Disease Clinic Patients by Sexual Orientation and Testing Period

Heterosexuals (Male and Female)

MSM Only

From 1988 to 1993 HIV seroprevalence among heterosexuals who attend STD clinics has increased from 1.8% to 2.2%.

From 1988 to 1993 HIV seroprevalence among MSM who attend STD clinics has declined from 55% to 42%.

Period 1 - 07/88 - 04/89 Period 4 - 10191 - 04/92 Period 2 - 10189 - 03/90 Period 5 - 09/92 - 12/92 Period 3 - 10190 - 02/91 Period 6 - 09/93 - 12/93

HIV Seroprevalence Among All Sexually Transmitted Disease Clinic Patients by Sexual Orientation, Race and Testing Period

10%

Heterosexuals (Male and Female)

MSM Only

0% Period 1
N = 3,075

Period2
N-3.895

-Period3
N 3,694

-Period4
N 3.407

Period5
N = 3,336

-Period6 N 2,379

From 1988 to 1993 HIV seroprevalence has risen slightly in both white and black heterosexuals.

0%
-Period 1 N 430

-Period2 N 140

Period3
N = 144

Period4
N = 90

Period5
N=79

Period6
N = 61

Over the past 6 years, white MSM have had a marked decrease in HIV seroprevalence while black MSM have maintained a high seroprevalence.

- - Period 1 - 07/88 04/89 i Period 4- 10191 04/92 - - Period 2 - 10189 03/90 I Period 5 - 09/92 12/92 - - Period 3 - 10190 02/91 \ Period 6 - 09/93 12/93

HIV Seroprevalence Among Heterosexual Sexually Transmitted Disease Clinic Patients by Sex and Testing Period

0% Period 1
N = 3,149

Period 2
N = 3,979

Period 3
N = 3,794

Period 4
N = 3,493

Period 5
N = 3,422

Period 6
N = 2,432

HIV seroprevalencehas remained about 2.4%from 1988 to 1993 in heterosexualmales. HIV seroprevalencehas increased fiom 1.2%to 1.8%fiom 1988to 1993 in heterosexual females.
Period 1 -07188 - 04/89 Period 4 - 10191 - 04/92
- - Period 2 10189 03/90 Period 5 - 09/92 - 12/92 - - Period 3 10190 - 02/91 Period 6 -09193 12/93

Distribution of Sexually Transmitted Diseases Among HIV Positive Patients,
Sexually Transmitted Disease Clinics, 10191 - 12/93

Males N = 233

OthcdUnknown 28 Multiple STDs 8%
Gonorrhea 25%:

STD Contact" 5 % Genital Warts 2%

Multiple STUS 10%)

Genital Ulcers 5%
cother Lhan syphili,l

G o n o ~ ~ l - ~8e%a

Females N = 60
STD Contact* 17% Genital Ulcers 5%)
(orkrer than syphili<)
Syphilis 5%
Vaginal or Pelvic Infections 35%

* STD Contact -person had a sex partner with a diagnosed or reported sexually transmitted disease

HIV Seroprevalence Among Drug Treatment Clinic Patients by Testing Period, Atlanta, Georgia

25%

20%

Q)
>....1
.-C mo 15%
PI

k

I

C
10%
0
8
PI

5%

0% Period 1
N = 374

Period 2
N = 2,414

Period 3
N = 2,685

Period 4
N = 2,549

Period 5
N = 1,902

From 1988 to 1993 HIV seroprevalenceamongIDUs has fluctuated between 13%and 19%.
From 1989to 1993 HIV seroprevalenceamongnon-IDUs'has remained stable at an average of 7.7%.

* Not included during thefirst period oftesting

- - - Period 1 -08188 07/89 j Period 4 10191 09192 - - - / Period 2 10189 09/90 Period 5 10192 - 09/93 - - Period 3 10190 0919 1

HIV Seroprevalence Among Intravenous Drug Users by Race, Sex and Testing Period

BYRace

BY Sex

0% Period 1
N-357

Period 2
N = 2,197

Period 3
N= 2.432

-Period 4
N 2,3n

Period 5
N = 1,819

HIV seroprevalence rates have been consistently three or more times higher in blacks compared to whites.

HIV seroprevalencerateshave increased fiom 16%in period 1to 22% in period 5 among blacks, while rates have slowly declined in whites.

OYo
Period 1
N = 374

-Period 2
N 419

Period 3
N= 302

Period 4
N = 266

Period 5 N = 239

HIV seroprevalence rates have been higher among male IDUs.

- - Period 1 - 08/88- 07/89 Period 4 10191 09/92 - - - - Period 2 10189 09/90 Period 5 10192 09/93 - Period3 10190-09/91

HIV Seroprevalence Among Non-Intravenous Drug Users* by Race, Sex and Testing Period

BYRace

BY Sex

0%
-Period 2
N 1.986

Period 3
N = 2,369

Period 4
N = 2.276

Period 5
N = 1,657

0% Period 2
N = 1.995

-Period 3
N f 383

Period 4
N-2.283

-Period 5
N 1,663

HIV seroprevalence rates have risen slowly among black but declined slowly among white non-IDUs.

HIV seroprevalence rates have been consistently higher in male non-IDUs.

* Not included during thefirst period of testing

- - / - Period 2 10/89 09/90 Period 4 10/91 - 09/92 - - Period 3 - 10190 09/91 Period 5 - 10/92 09/93

Overall HIV Seroprevalence Among the Homeless by Testing Period
20%

15%
6)
.>z.c,r-1.l
a
>
10%
c1
8 8
e,
5%

0% Period I
N=683

Period 2
N = 568

Period 3
N = 385

Period 4
N = 404

HIV seroprevalence among homeless persons tested has declined from 9.2% to 6.9%. However, this level of infection is still very high when compared to the general population.

HIV Seroprevalence Among the Homeless by Race, Sex and Testing Period

Bv Race

Bv Sex

5%
0%
Period 1
N = 676

Period 2
N = 564

Period 3
N = 384

Period 4
N = 398

5%
4
0%
Period 1
N = 683

Period 2
N = 568

Period 3 N = 384

Period 4
N = 398

HIV seroprevalenceis consistentlyhigher in the black as comparedto thewhite homelesspopulationsampled.

HIV seroprevalenceis consistentlytwice ashigh inthe male as comparedto thefemalehomelesspopulation sampled.

- Period 1 -03190 - 09-90 Period 3 -07192 - 06/93
Period 2 -07191 06/92 Period 4 -07193 - 06/94

HIV Seroprevalence Among the Homeless
by Risk Category, 03/90 - 12/93

MSM N = 60

MSI\.1-IDU
N = 31

Hetero IDU
N = 245

Hetero I N = 167

Risk Category

Hetero 2
N = 1.218

UnMUnd
N = 114

MSM

= Men who have sex with men

MSM-IDU = Men who have sex with men and are

injecting drug users

Hetero IDU = Heterosexual injecting drug user

Hetero 1 = Heterosexual, partner at risk for HIV

Hetero 2 = Heterosexual

UnkIUnd = UnknownIUndetermined

Seroprevalence of HIV in Women's Health Clinics by Race and Testing Period

Black White Other Total

Period 1

Period 2

Period 3

Tested 1 10189- 09/90

10190 - 0919 1 Tested Positive (%)

Period 4
10191 - 09/92 Tested Positive (%)

Period 5
Tested Positive (%)

The HIV seroprevalence rate in black women has fluctuated between 0.5% and 1.2% with no clear trend. No HIV positive individuals have been identified in the white or "Other" groups, but numbers tested are small.

Data from two testing periods were aggregated. Subsequent years will include trend analysis.
HIV seroprevalence was higher among males and blacks
HIV seroprevalence was highest in persons admitted to the general medical service when compared to surgical services and the emergency room.

HIV Seroprevalence Among Patients in the Rural Sentinel Hospital Surveys by Race and Sex, 1993

Black Males N = 639

Black Females N = 1,916

White Males N = 1,227

White Feinaler N = 2,791

Total *
N = 6.646

HIV Seroprevalence was higher among blacks than whites and was higher among males than females.

* 73persons were of other races

HIV Seroprevalence Among Patients in the Rural Sentinel Hospital Surveys by Age Group, 1993
Age Group
HIV Seroprevalence rates are highest in the 25-34 year age group.

Distribution of Patients and HIV Seroprevalence Rates in the Rural Sentinel Hospital Surveys by Hospital Service, 1993

Distribution of Patients
In~atient

Distribution of HIV Seroprevalence Rates

Emergency Room

Emergency Room

Testing began in the Atlanta area in 1991 among the homeless. These surveys are conducted to obtain risk information associated with HIV in addition to standard demographic information collected in the blinded surveys.
Over the three testing periods, the HIV seroprevalence has declined from 11.5% to 6.0%.
HIV seroprevalence has increased with the duration of homelessness.

HIV Seroprevalence Among the Homeless by Testing Period

20%

15%

d)
.' L
.c& d 1

a

2
EC

10%

+ E

ki

ct

5%

0% Period 1
N = 174

Period 2
N = 183
Period 1 - 01/91 - 12/91 Period 2 - 01/92 - 12/92 Period 3 - 01/93 - 12/93

Period 3
N = 184

HIV Seroprevalence Among the Homeless
by Duration of Homelessness, 01/91 - 12/93

< 6 months
N = 258

6 mo.- 1 yr.
N = 104

1-3 yrs.
N = 82

> 3 yrs.
N = 60

Duration of Homelessness

Missing/Unk.
N=Z7

The HIV seroprevalence rate increases with increasing duration of homelessness.

82,677 tests were performed at publicly funded HIV counseling and
testing sites in Georgia in 1993.
45% of all tests were performed in STD clinics; 11% in
HIV counseling and testing sites; 6% in drug treatment centers;
1%in county jails.
31% of all positive tests were among individuals whose only identified risk was heterosexual sexual activity; 33% were among homosexual/bisexual males.

HIV Counseling and Testing at Public Health Sites, Georgia, 1993

Total Tested

Total Positive

Percent Positive

Percent Total Tested

Percent Total
Positive

STD Drug Treatment Family Planning

Other Health Dept. County Jails College Grady Mem. Hosp.
OB Clinic Private M.D./Clinic Other Unknown
TOTAL

HIV Counseling and Testing at Public Health Sites by Demographics and Risk Exposure, Georgia, 1993

Total Total Tested Positive

Percent Positive

Percent Percent Total Total Tested Positive

Male Female Missing

33,191 49,46 1
25

1,171 443 2

TOTAL

82,677 1,616

Ape Group
d 5-12 13-19 20-29 30-39 40-49 >49 Missing

TOTAL

82,677 1,616

Total Total Tested Positive

Percent Positive

Percent Percent Total Total Tested Positive

White

33,494

Black

44,285

Hispanic

1,932

AsianIPac Is1

484

Am InIAk Native 58

Missing

2,424

TOTAL

82,677

Risk Factors

MSM-IDU

412

MSM

3,746

IDU

2,132

Hern/Blood Received747

Hetero

29,617

Other

43,779

Missing

2,244

TOTAL

82,677

70 53 1 154
9 500 33 1 21
1,616

Seroprevalence of HIV Among Civilian Applicants to the Military
by Sex, Georgia, 1985 - 1992

Males

Females

Number Number Percent Number Number Percent Tested Positive Positive Tested Positive Positive

TOTAL 95,847 178

(0.19)

Among Georgiamilitary applicants, males are about two times more likely to be infected than females.

Seroprevalence of HIV Among Civilian Applicants to the Military
by Race, Georgia, 1985 - 1992

Black

White

Other*

Number Number % i Number Number * ! Number Number ./. Tested Pos Pos j Tested Pos Pos Tested Pos Pos

0

1988 1989 lggO 1991 1992 lgg3

1 TOTAL 52,188 135 (0.26) 60,866 59 (0.10) 1,794

4 (0.22)

Over the past 3 years, HIV seroprevalencerates have decreased among Georgia military applicants. This may be due to persons of lower risk for HIV infection applying to the military services. Among Georgiamilitary applicants, blacks are aboutthree times morelikelyto be infected than whites.
* .IncludesHispanics, American IndiandAlaska Natives,Asians and Pacific Islanders

s e x mI1y Tvanscnitted Diseases,
TibevcMlosis and f\clolescent
Behavioral factors that contribute to an increased risk for disease are not equally distributed among all communities and all populations. The factors that contribute to an increased risk for one disease often contribute to an increased risk for other diseases. Usually these risk factors are focused in the same populations. An integrated approach to data collection -- looking across different diseases and conditions -- will identify those populations in need of prevention and clinical services.
To emphasize this integrated approach, this section allows comparison of different public health problems. The behavioral factors that put an individual at risk for syphilis and gonorrhea are the same factors that contribute to sexual transmission of HIV; furthermore, the presence of an STD may increase the likelihood of HIV transmission. Tuberculosis has re-emerged as a public health problem, and is increasing in areas with high rates of HIVIAIDS. High adolescent pregnancy rates in an area indicates risk behavior conducive to HIVISTD transmission. Interpretation of HIVIAIDS data will be more meaningful for policy and program planning if evaluated in the context of these other conditions.

Early Syphilis Case Rate per 100,000 Population by County, Georgia, 1993

Tuberculosis Case Rate per 100,000 Population by County, Georgia, 1993
No Tuberculosis (54 counties) 1 - 10 (50 counties)
C] 11 - 20 (41 counties)
21 - 30 (9 counties)

Teenage Pregnancy Rates per 1,000 Female Population by County, Georgia, 1993
- 100 (70 countiesf 01 - 125 (56 counties) 26 - 150 (25 counties)

The 25 Counties With the Highest AIDS, Tuberculosis, Syphilis and Teenage Pregnancy Rates, Georgia, 1993
* Tuberculosis

AIDS Cases by Year of Diagnosis, Race/Ethnicity and Sex
Georgia, 1981 - 1993

Male Subtotal

1989 1990 1991 1992 1993 Female Subtotal
TOTAL

25

82

0

3 7

126

3

32

197

2

37

214

5

23

152

1

200

878

12

4,501

5,103

148

* Other includes Asians, PacrJic Islanders, and American Indians/Alaska Natives

0

107

0

166

0

23 1

1

257

0

176

3

1,093

12

9,764

AdultIAdolescent AIDS Cases among Whites by Exposure Category, Sex and Year of Diagnosis,
Georgia, 1989 - 1993

Undetermined

* Total is cumulative from 1981 through December, 1993

MSM

= Men who have sex with men

IDU

= Injecting drug users

MSMIIDU = Men who have sex with men and are

injecting drug users

Adult/Adolescent AIDS Cases among Blacks by Exposure Category, Sex and Year of Diagnosis,
Georgia, 1989 - 1993

Transfusion recipient
Injection Drug User (IDU) 3 Heterosexual contact

* Total is cumulative from 1981 through December, 1993

MSM

= Men who have sex with men

IDU

= Injecting drug users

MSMADU = Men who have sex with men and ate

injecting drug users

Adult/Adolescent AIDS Cases among Hispanics by Exposure Category, Sex and Year of Diagnosis
Georgia, 1989 - 1993

Transfusion recipient Undetermined
Heterosexual contact

* ~ o t ails cumulativefrom 1981 through December, 1993

MSM

= Men who have sex with men

IDU

= Injecting drug users

MSMIIDU = Men who have sex with men and are

injecting drug users

AIDS Cases and Their Proportional Distribution
- by Race and Year of Diagnosis, Georgia, 1989 1993
ATLANTA GEORGIA TOTAL
* Includes the health districts of Fulton, Dekalb, Cobb, Gwinnett and Clayton
** Includes Hispanics, American Indians/Alaska Natives, Asians, and Pacijic Islanders

Cumulative AIDS Cases by Age Group, RaceIEthnicity and Sex
Georgia, 1981 - 1993
" Includes American Indians/Alaska Natives, Asians, and Pacific Islanders

Adult/Adolescent AIDS Cases by Exposure Category, Sex and Year of Diagnosis,
Georgia, 1989 - 1993

Heterosexual contact Transfusion recipient Undetermined
Injection Drug User (IDU) 45 Heterosexual contact Undetermined

*Totalis cumulativefrorn 1981 through Decembel; 1993

MSM

= Men who have sex with nnlen

IDU

= Injecting drug users

MSMADU = Men who have sex with men and are

AIDS Cases and Annual Rates Per 100,000 Population
by Health District and by Year of Diagnosis, Georgia, 1989 - 1993
Health District
1-1 Rome 1-2 Dalton 2 Gainesville 3-1 Cobb 3-2 Fulton 3-3 Clayton 3-4 Gwinnett 3-5 Dekalb 4 LaGrange 5-1 Dublin 5-2 Macon 6 Augusta 7 Columbus 8-1 Valdosta 8-2 Albany 9-1 Savannah 9-2 Waycross 9-3 Brunswick 10 Athens
TOTAL
*Totalis cumulativefrom 1981 through Decembel; 1993

AIDS Cases and Annual Rates Per 100,000 Population
by Health District and by Year of Report, Georgia, 1989 - 1993
Health District
1-1 Rome 1-2 Dalton 2 Gainesville 3-1 Cobb 3-2 Fulton 3-3 Clayton 3-4 Gwinnett 3-5 Dekalb 4 LaGrange 5-1 Dublin 5-2 Macon 6 Augusta 7 Columbus 8-1 Valdosta 8-2 Albany 9-1 Savannah 9-2 Waycross 9-3 Brunswick 10 Athens
TOTAL
*Totalis cumulativefrom 1981 through Decembel; 1993

Seroprevalence of HIV in the Survey of Childbearing Women
by Health District, Georgia, 1988 - 1993

Rome

(1-1)

Dalton

(1-2)

Gainesville (2-0)

Cobb

(3-1)

Fulton

(3-2)

Clayton

(3-3)

Gwinnett (3-4)

Dekalb

(3-5)

LaGrange (4-0)

Dublin

(5-1)

Macon

(5-2)

Augusta (6-0)

Columbus (7-0)

Valdosta (8-1)

Albany

(8-2)

Savannah (9-1)

Waycross (9-2)

Brunswick (9-3)

Athens

(10)

MissingIOut of State

Total

1988
Number (%)

1989
Number (%)

1990
Number (%)

1991
Number (%)

1992
Number (%)

1993
Number (%)

33,288 (0.16) 51,621 (0.13) 78,765 (0.17) 96,201 (0.15) 114,095 (0.17) 117,223 (0.18)