Loading...
HomeMy WebLinkAboutMINUTES - 12141993 - IO.4 TO: INTERNAL OPERATIONS COMMITTEE FROM: VAL ALEXEEFF, DIRECTOR GROWT14 MANAGEMENT& ECONOMIC DEVELOPMENT AGENCY DATE: DECEMBER 13, 1993 SUBJECT: INDUSTRIAL COMMITTEES SPECIFIC RE�QULST(S)OR RLCOMML•NDA'rION(S)E BACKGROUND AND JUSTIr'ICATION RECOMMENDATIONS: ESTABLISH ContraCosta WORKS Advisory Council and Industrial Advisory Committee as proposed in Attachment A. FISCAL IMPACT: Il' these committees are to be staffed by GMEDA, there will need to be a source of funds to reimburse the Agency for time and materials. BACKGROUND/REASONS FOR RECOMMENDATIONS: Last. August, the Board solicited letters of interest 1'rom a wide variety of sources to pa►ticipate on committees to provide focus and analysis on the condition of the County's industrial base. Interest in these committees has grown and questions have been raised regarding their specific function. The ContraCostaWORKS Advisory Council will address the issue of the future viability of industry in this County and will be composed of a cross section of interests and will make recommendations to the Board. The Industrial Advisory Committee will be composed of industry representatives and will be directed toward analyzing the effectiveness of the regulatory structure in place over industry. This committee will offer recommendations to the Board. Other committees may be formed through the Contra Costa Council, Mayors Conference, and staff will respond and participate as appropriate. Additional comment is provided in Attachment B. CON1INU1-0 ON AT7ACIiMi?NT: X YES SIGNIVIURE. VkA65��, R11COMMHNDA7170N OF COIJNI'Y ADMINIMIUVrOR RE'COMMENDA'TION OF BOARD COMMITI u APPROVE 0117Il?R SI(iNA'17JRIi(S): A(7170N OF BOARD ON�i l� lQq�j APPROVUD As RF.COMMENDIiI) 0'17II R_ VOTE OV SUPERVISORS I I111REBY CT"R'I I Y TI IAT '1'1IIS Is A '1'I(llli AND CORRIiCI' COPY OF AN A(MON TAKIiN AND UNANIMOUS(A13SI:NT ) 1?NTFRI?1) ON '1711: MINUTI S OF '1711: BOARD OF SUPERVISORS ON'1711i DA'I'li SITOWN. AYI!S: NO S: G A13SI?N'r- ABSTAIN: P1 III,13A7'C:IIIi1,OR,(:I.IiIiK OF'1711:BOARD OF S 'IiIiVISO1ZS ANI)C011N'I Y AD�KIIIA'IOIt 13Y ,Dlil'lPl Y VA:dg indusam.lx) Coulad: .Val Al xa:IT((A6 IG10) CC: County Adminislralor GMl?DA Departments ATTACHMENT A INTERNAL OPERATIONS INTERVIEWS On November 22, 1.993, the Internal Operations Committee held a group interview for individuals serving on its industrial committees. The proposed cornposition for the ContraCostaWORKS Advisory Council and the attendees were as follows: Industry Community Jim Simmons Lonna Coleman (Lafayette) Pat Serrill Lynn Leach (Walnut Creek) June Johnson (Richmond) Small Business Marvin Mizis (Alamo) Howard Adams (Crockett) Patrick Corr Ron Haskins Environment Michael Green A] McNabney Education Denny Larson Barbara Hockett Labor Mary Lou Lucas COMPOSITION OF CONTRACOSTAWORKS ADVISORY COUNCIL Board of Supervisors. Gayle Bishop and Tom Torlakson Industry: Pat Serrill (East County) Pat Chadwick (Central County) Dennis Spaniol (West County) Small Business. Patrick Corr (Alternates: Ron Haskins, Michael Green, Mary Horton) Community. West County June Johnson (Richmond) Alternate: Howard Adams (Crockett) East County Thomas Mello (Antioch) Alternate: Glenn Williams (Bay Point) Central County Lonna Coleman (Lafayette) Alternates: Lynn Leach (Walnut Creek) Marvin Mizis (Alamo) Labor.• Steve Roberti (Central Labor Council) Ronald Halloway (Oil, Chemical, Atomic) Environment: Bob Doyle (Alternate: Denny Larson) Education: Barbara Hockett Cities. Mayors Conference would like a minimum of 2 members and plans to take up the appointment on January 6, 1994. Several elected representatives have spoken to me and expressed interest. SELECTION CRITERIA Consensus building approach to its future. Many people have expressed interest in the committee. The easy response would have been to select everyone who showed up. However, experience has provided two observations. First, excessively large committees are not effective. Second, committee focus and structure change over time. Some individuals got too busy, others may lose interest or become frustrated that their agenda is not being served. Therefore, alternates will move up to membership. The guiding criteria for selection has been the extent to which the applicant is a stakeholder in the County. Does the individual work in Contra Costa County or is their employment dependent ont he viability of industry in Contra Costa County? Since the raison d'etre for the committee is the future of Contra Costa, this appears to be the crucial dimension. Participation will determine if the initial appointee stays in the slot or is replaced by an alternate. PURPOSE OF THE CONTRACOSTAWORKS ADVISORY COUNCIL The CCWAC will be considering issues and preparing a series of recommendations to the Board on the viability and compatibility of industry in Contra Costa County. Since Contra Costa County ranks second in industrial counties, industrial future is important. Contra Costa needs a pragmatic approach to industrial issues. It was hard to determine which community perspective should or should not be included. Community representatives stated their interest most eloquently at the IO interviews. Broad community representation will be needed for future dialogue. It is hoped that alternates will fully participate. COMPOSITION OF INDUSTRIAL ADVISORY COMMITTEE Board of Supervisors: Tom Powers and Jeff Smith WESPA: (Refinery Manager) COLAB: Mary Lou Lucas, Executive Director Industrial Association: Dale Kirkland, Executive Director Council of Industries: Dennis Spaniol Contra Costa Council Industrial Task Force: Chris Howe Industrial Chamber of Commerce. Brad Nail Building 'Prudes: Greg Feere Environment: Al McNabney SELECTION AND PURPOSE OF THE INDUSTRIAL ADVISORY COMMITTEE This committee was established at the request of industry groups before the Board. The concern of industry was to establish a dialogue with the Board on issues such as local requirements, State regulations, and similar technical issues. In its most recent correspondence, the committees indicated concern about the loss of this opportunity for dialogue due to the diversity of composition. The composition should be evaluated after three months of operation. Both committees are ad hoc at this time and should be reviewed yearly to determine whether they should continue. ATTACHMENT B INDUSTRIAL COMMITTEES WHY ARE WE DOING THIS? Contra Costa must determine the role of industry in its future and respond appropriately. There are many decisions on the local level that can be made to support or retard industry. No one wants to return to the spewing "satanic" mills described in the literature of the industrial revolution and we do not want to smugly dismantle our industrial base to find our schools and restaurants closing. Somewhere amidst the issues, there is a reasonable path that will give us the proper course. The following statements identify some of the issues before us. 1. The global economy is undergoing numerous shifts that have resulted in an exodus of thousand of manufacturing jobs from Contra Costa County since the 80's. 2. Industries are reluctant to invest in California and the Bay Area due to the CEQA process, the Air Quality process, the water quality process, other regulatory process, and a perceived anti-business climate. (Should an industry decide to locate in the South, they often get a parade in their honor --- imagine a parade in Contra Costa County on behalf of a new industry.) 3. Contra Costa's economy is split among its base industries, work involving out- commute employment to out-of-County locations, white collar office work in County offices, and services in support of the population. There is a need to evaluate the importance of industry as a sector of the economy and to treat it in an appropriate strategic manner. 4. There is a presumption that we want "clean industry" and we will treat clean industry better while "dirty industry" is treated in the manner it deserves, thereby driving away dirty industry and attracting clean industry. The regulatory laws and interpretation in California are driving the clean industries away, as well as the traditional heavy industry due to exactions, (local fees to make up for loss of other sources), traffic problems (due to lack of infrastructure caused by lack of funding and local opposition), lack of affordable housing, forcing up wages (due to NIMBYism and lack of infrastructure), and regulatory attitude (prohibitive conditions on expansion or diversification). 5. Local jurisdictions often have a love-hate relationship with their industries. The industries provide jobs, donations, campaign support, employment, indirect employment, and prestige while they have toxic incidents, neighbor complaints, unsightliness, and influence. How can communication be improved and resources directed most effectively? 6. Due to the rash of industrial release incidents, Contra Costa County is sensitive to an "apparent" lack of consideration for primary safety of residents. While the incidents are spread among industries, cumulatively the level of sensitivity is so high that any event in one industry carries the baggage of previous events in other industries. 7. The attractiveness of Contra Costa County is its quality of life. Does Contra Costa industry imperil the Bay and the air basin? What is the role of industry in quality of life? 8. There is a disproportionate burden of the impacts of industry on key communities. The charge has been raised that the effect is on poor and minority communities. Is this true" If so, is this a result of subtle racism or of residential encroachment into industrial areas`? 9. Contra Costa County and its cities have not needed to provide a coordinated effort to attract industry and business to the County in the past due to geographical advantages. Has this benefit diminished and must we now commit to a coordinated strategic effort? 10. The technological revolution will require rapid and continuous retraining throughout the industrial sector. Is our working population and educational sector capable of maintaining a competitive edge to the workforce? American Jola al Are HIV-Infected Injection Drug 10, Of Public Health Users Taking HIV Tests? Reprint Juan Reardon, MD, MPH, Nancy Warren, PHN, Rusty Kedch, MA, Dale Jenssen, RN, Francie Wise, PHN, MPH, and Wendel Brunner, MD, MPH Objectives. Knowledge.of infec= tion.is essential for human.immuno-. Introduction •What is the 1991 HIV-1 scroprev- . deficiency virus-type 1(MV-1)treat- alence for all injection drug users ment initiation and epidemic control.. Regardless of sexual orientation,in entering treatment in Contra Costa This study evaluates infection knowl jection drug users constitute 14.8% of County and for those accepting a edge among infected injection drug us- adult acquired immunodeficiency syn- voluntary test? ersand acceptance ofconfidential.test- drome (AIDS) cases in California' and *Are injection drug users entering ing among in ection drug users 19.3°/n of such cases in Contra Costa treatment accepting a confidential particularly those - antibody test? infectedwithHIV-i County, California (San Francisco Bay HTV-1 anti .. `A total of 810 injection •Are those who•re infected likely to Area),'where human immunodeficiency drug users entering treatment in Con- be aware of their infection? tra Costa:County,.Calif,were exam- virus type 1(HIV-1)seroprevalence rates 0 Are those who are infected and un- among these drug users appear to be par aware Clients were tested.with unlinked � aware likely to accept a test? (blinded) tests and simultaneously titularly high for African Americans.-•4 counseled and offered voluntary con- Voluntary HIV-1 antibody testing of in- fidential HIV l.antibody testing..Data jection drug users has been recommended Methods on confidentialtestingacceptance,pre as an effective approach to limiting the Unlinked HIV-1 serosurveys were vious testing, dru use; and demo= spread of HIV-1.5 For example,early in conducted conducted at two methadone clinics op graphic information were collected. tervention with zidovudine has been erating in Contra Costa County, Califor- Remdts.:Of.the 810 tested, 105 proven beneficial in postponing the occur ma,from January l to December 31,1991. (13.0%n)were infected. The current rence of illness in people infected with Standardized research protocols devel- confidential test was accepted by 507 HIV 1.6 Some people believe that drug oped by the Centers for Disease Control (62.6%). HN seroprevalence in the abuse treatment personnel can develop di- (CDC)were used.12 The study population unlinkedsurveywasfour times greater agnostic and therapeutic relationships consisted of drug users entering metha- than in the.voluntary survey(13%and with injection drug users more effectively done detoxification programs and of those 3.5%n, respectively)..H.N-1.infection than can practitioners in more traditional entering or continuing methadone mainte- was associated with refusal of a confi- settings.? The reluctance or inability of nance.A total of 810 consecutive injection dential:test:largely because most in- these drug users to become involved with drug users who entered methadone treat- : . fected injection..drug users:(n = 58;. traditional medical clinics may postpone ment and had their blood drawn for hep- 55.2%n)already knew of their infection. : HIV-j diagnosis until very late,deferring atitis screening were included. Excluded Ofthe47injecxion.druguserswhowere appropriate interventions. were clients retesting during the study pe- not aware oftheirinfection,12(25.5%) In previous work we reported that, riod(n = 294). accepted the test. Although African- of all injection drug users admitted to All clients received individualized American injection drug risers pre- treatment in 1990, 60.0% (614/1023) ac- HIV/AIDS counseling and were offered a sented with a higher infection rate cepted a confidential antibody test but confidential HIV-1 antibody test. Demo- (37.3%), they,were: three times less only 33.6%(36/107)of the infected users graphic data,drug use history,and infor- likely to know of their infection. (in unlinked surveys) accepted testing.8 mation regarding acceptance of confiden- Conelusions; "In clinic" 19V-1 Finding lower HIV seroprevalence rates testing is highly accepted;and most in- with voluntary testing surveys, com- fected clients in treatment will learn pared to unlinked.surveys,was reported The authors are with the Contra Costa County thein Status. Nevertheless, voluntary previously in other populations,e and Health Services Department,Public Health Di - testing data are likely.to yield eonsid- the 1990 data did not include whether re- vision,Martinez,Calif. erable underestimates of:the tete rate fusal of a test was owing to prior knowl- Requests for reprints should be sent to of infection. injection us- edge of positive status. Therefore our Juan Reardon, MD, MPH, Contra Costa . t� ] �. g P � County Health Services Department,597 Cen- erg. (Am J Public Health 1993;83: analysis of 1991 data intends to clarify the ter Ave,Suite 200,Martinez,CA 94553-4669. 14144417). following: This paper was accepted January 12,1993. 1414..American Journal of Public Health October 1993,Vol.83,No. 10 HIV among Injection Drug Users tial HN-1 testing were collected for each client tested with the unlinked method. TAB1. 9, titY-1.: ;.arnong.:t .;0rr ,USM ig Truett::; This information allowed grouping the 810 Ah Corte O.Odio CowtMy CWHornt ; t 9t Wd Unhmr Ctjnp isi . in'eetion drug users b HIV-1 status :,:::: ::;::af:Giroup:Sance J S Y knowledge of that status, and acceptance of testing.Repetitive reactive enzyme im- ".:.:::.:'. ::::.:`. . ::.:. ... .. . munoassay tests(at least two positive tests) JUI;Glirrtts;(unlit ! roey�;: :. 8IU 1p6 1.3.0 40...: 2.4;7.2. were confirmed Western blot.The As- Ctiwft tested..v r#a y:::: .:`.::::,507 .: i$::::: ::: 3;5:,:,, 1::; sociation of State and Territorial Public ..:.::....::.:.:..... .......:. Mai . .::::: ;..:.:.: 4 .. ..., : . Health Laboratory Directors/CDC criteria 70..:.... for a positive Western blot were used.13 217: 81 '37 3 180 ' 9733 7 Clients testing positive for HIV-1 ;8(f:.'::..::.: 6: 7:$' :.:... :':2.4: '': 08;.6.9': : with the voluntary test were given clinical L?tkt8r 40 1 .2Z08 fl.02 5.3 and support services referrals and prefer- a:: 468 ':::::;:1.8 :..:.. 3:2 ential admission to methadone mainte- 19: 5 28.3 2 5 nance treatment. The statistical signifi- Hiel. .... 784.:.: 99...:... canoe of associations was evaluated using . W46M Co t plink.::: 41? :.: : 71::: , :' 1�0::: 2.2:::::'.'A 3 4." chi-square and Fisher's Exact tests. fast County elf .. 393.:FfIV34 8 7 1 .: -1 seroprevalence group differences 13:8 %:..::.':: 3:0: ': 1:04;i1..5.:.: : and the likelihood of infected drug users ge:' :30: : 79':::. .::::. 4'. S 0' S .. . .... owing their status at admission were ialanionance:: :': 2 0';::: �7.,,: 19.:7.;: :' 2.#: ::.: :1:5;:3;7: ::: evaluated with crude odd ratios(ORs). aIctftlirila r::oiigerts t:and r vvns m�ssmg from fW:np.nh*ed.diem:and:.or�:infected:cUertE.::: Irit n"an on 9"wwal:-i n:rias missing froni:sk no iirdad d.c is ts:a�ri.:one:in .:ekent. ::'. . ...... ..... .. . . Ininrtilefl i.'on'a0e:. s;R00V ... suis.nad'rrfec�ed:i nt<Treatritara:moftWinb n::wm:. Seroprevalence levels are reported in msrng for 13:i1orarifecFed deft and fur infesed:es:and rued "iier:':for26 rKm*eected cleft Table 1.African-American drug users rep- resented 27.0% of the clinic population and 77.9% of the clients infected with HIV-1.The seroprevalence among clients Abce ice,. mang:In don:0 in methadone maintenance was higher tvw �m.T h 1diCo than that for those entering methadone detoxification.Injection drug users under No. 30 years of age were less likely to be in- n HIV fected than were older clients,and clients ......: ..... ..... ......: ..:. ......: .. at the West County clinic had higher rates 70&:.. :.' :: 489. 68:4 ':..':; .1E}9... of infection.Overall,a confidential HIV-1 Ir�fiected•users;, 106 18 171 1 test was largely accepted(62.6%),but in- ..`........: .........:..:.:..:.,......: ... .. ................... C a B SofHt im.: • : ....... fected clients were more likely to decline a confidential test(Table 2). Of the 105 infected drug users, 58 jection drug users infected with HIV-1 other hand, the West County clinic had (55.2%)already knew of their HIV infec- knew of their infection. most of the infected clients (67.6%) and tion and only 6 of those chose to test again. Only 12(25.5%)of the 47 who were most of the African-American clients There were 47 drug users (44.8%) who unaware of their infection accepted a con- (73.7%). African Americans constituted were infected and unaware of the infection fidential test upon admission to treatment 38.6%of the West County clinic popula- (Table 3). Infected users entering detoxi- in 1991 (Table 3).Of the 35 infected drug tion and only 14.6% of the East County fication programs were less likely to know users who were unaware of their infection clinic population.We found no significant of their infection than those entering or and declined a confidential test,27(77.1%) difference by clinic in the acceptance of an continuing in maintenance programs reported having had at least one such test HIV test among infected African-American (P< 0.001).The group less likely to take in the past,and 16(45.7%)had had a neg- clients who were unaware of their infection a confidential test were methadone main- ative test within the past 12 months,mark- (East County clinic = 28.6% vs West tenance clients from the West County ing recent seroconversions or infections. County clinic=20.6%). Also of some in- clinic(P= .054).Infected African Amer- Regarding clinic differences, with terest is the observation that injection drug icans were less likely overall to know of similar client population sizes, the East users who were aware of their infection re- their infection than White (OR = 0.15; County clinic, had clients more likely to ported using crack cocaine more often(12/ 95% confidence interval [CI] = 0.02, know of their infection(Table 4),was sig- 58,or 20.7%)than those who were unaware 0.74), but some clinic variation existed. nificantly more successful (P< .001) in (4/47,or 8.7%)(P= .07). Among infected African-American drug recruiting clients for an HN test than the users, those entering treatment in East West County clinic(76.3%vs 49.6%),and D&cusSiOn County, although fewer in number, also appeared more successful in recruit- seemed more likely than those entering ing among the infected who were not Contra Costa seroprevalence rates treatment in West County to know of their aware of their infection(40.0%vs 21.6%). for injection drug users are among the HN infection.All five gay or bisexual in- This difference was not significant.On the highest reported in California.The policy October 1993,Vol.83,No.10 American Journal of Public Health 1415 Reardon et al. TABLE 3 Aa txfe ct er :s:':: TABLE'4,-Knt d af:r�erostatuslrAecloed 1 R; Users: ......,,.e.............., .......3".::...:... ....... .:.::. ...:.'........Hf W ....... .......ie.... .......q 1:Test ;.... -:7neatrner�t �9.. Ca�a`Costa"Cou... `•`T 1 ........ ..........,....... ....... :: ............ .::.:. .. ...... .........: .. ............... ......w.........w........ :....:::..... :. ::�:F`...... ............. ...:.... ..... .�.y.,�y7.Calltott#1a,:1991,..::.::'::.:. 'n' %u:;:-.i`.:�:,.,,;;, :. .Wtw Were Not A**V of Oft " ................. .............................:....... .. East. C6r►IC.... ... . 24 . Y 34 ...:.:..:.....:::: WestGou Crmlc:: :.::.:::...:.:::.: `.:: '71 :...,: ..34..,..: :47.8 1 :':•F re..... ...a ...e...... ...:s..''. Othsr.ethntc. ......,. .................... -::.... QuP::: :':'::::4-:....::::;.:::4-a:.:':'.:::::23'.:'.::;:;;;':;;::x•18 .4............................3................. . ... .:9 ...... ...�................ ... ..............8..Atm..e:,e;.::.: ...... .......... ....... .......... ..1..;..:..:.:.. .�'.::.;.:..�:: Afrxt:AmenCan 81. .. 4{1;: 49.4" ;'1 ...::.:........... i4fiCan ., f.,........,.............. ... . ....... .. Amencan/Esst: . . .. ,..............sd..........f ............. . . ... ..... .....: ,.....�::-,:.......:,,.....,.,... ►h!,..;...:::::,.,;,;,.... .,.....;.4.,...............:•:::.: :.'s:€-.-�3 8.` 2.8-: < 0.99�9.8`:;.`.� ....: 47.::.:;;::12.:;:;:.;'-2r 5... AmetlptVWest .. .... : ...... .. .:. ..................................... ..31; -::` .;`.6.'''''';;:1.9:4:;.: Femelei ew t8'' . ' j6 37.5 AhiC�ti' `: All Injection Drug Users e2.6% 'Oei`eifut�G9ot�P: `' We COtIi11Tt:Cl :''':. Male ao.as ES :.Countydkk;: 10'.: ;::;'4:: Female ee.os African American .os �.:±i:'.:'; 14 ::.::;;1i':: ::::71:. Latino e.a• M�I18dQ(i@: ='s >:'• " = :: Other �.ee . ..:.................:....... White ...... ro.le illillillit Under age 30 ea.a• 'NiBgalivetest in?�St:''' [_ <s ..';;'' '` ..'. g ................:....... p:g,;::;:' Age 30 and over es.ee NO.n8g816Ve: n. -: '';,::..: '• East County Clinic I s.a• West County clinic .o.e. .. Infected 0::: : Not Infected 69.4%1 s`All'oi�iercGerlfs':' `. .- g :.:.: i Infected and aware +o.a+� j - - Infected and unawarone e Re.e• °s=it�se`cis:wlio-aooWad.theHiV,te tTreat 0% 20% 40% 60% 80% 100% ``mertt.ntiDda&ty.iri�rist8�0ii Vvtis;ti�ssiig for;thfe�s; ottieseinterned;c tYie,tl e@acaa adtl�ie.:: FIGURE 1—Acceptance of an HIVA antibody test by Injection drug users entering treatment in Contra Costa County,California.:::.. .........:.:.: ......:...:•:.:....::•:::,::....,.1411.,;-:.,.....,.,,4.......... My, 1991. of actively and preferentially admitting in- ents admitted to drug therapy(62.6%),and clinic.The East County clinic appears to fected clients to maintenance programs the availability of these programs has cer- have established a more accepting atmo- will likely result in a rising seroprevalence tainly contributed to infection awareness. sphere,which brings into testing more cli- among maintenance clients, which, it is Clearly,not all detoxification clients may ents of all groups, including the infected hoped,will be accompanied by a declining be ready for a confidential HIV-1 test at and unaware. Race distributions in each seroprevalence rate among detoxification the time of admission,and it may be better clinic may also be a factor in the difference clients. This will represent a successful for some to postpone the news of infection between clinics because African-Ameri- combination of the protective measures to facilitate the first steps of recovery.14 can clients entering treatment in both clin- implemented by those who are continuing Nevertheless,among infected clients un- ics were less likely than other clients to to inject drugs and the reduced probability aware of their status, the test was ac- accept a test,and the East County clinic of such drug users encountering a needle- cepted more often by those enrolling in had a smaller African-American clientele. sharing partner infected with HIV-1. But methadone detoxification than by those These observations suggest that the par- this public health goal has not been enrolling in or continuing methadone ticular environment created at the East reached yet.The 1991 seroprevalence for maintenance,who are likely further into County clinic made acceptance of the test detoxification clients was 9.3%—lower, recovery.In any event,the test must con- the norm (76.3%) and contributed to the but not significantly so,than the 9.8%rate tinue to be available to injection drug users test's acceptance by infected and unaware of 1990.It is hoped that continued efforts' and their sexual partners at any time after clients,but it was not enough to eliminate to reach,counsel,educate,and test injec- admission and upon request.Certain drug the general reluctance of African Ameri- tion drug users in Contra Costa County users who are infected and unaware of the can clients to test.Further research is also and to offer facilitated and preferential ad- infection may not feel at risk because they needed on drug abuse patterns(e.g.,abuse mission to methadone maintenance pro- have been in maintenance treatment for of crack cocaine) of injection drug users grams will be reflected in declining sero- some time,or they may have specific con- who learned of their HIV-1 infection. prevalence rates among drug users cerns about the test or its consequences. Additionally, our data confirmed that entering detoxification programs in future This group needs to be studied further. one-to-one education and testing alone is years. The acceptance of a confidential test not guaranteed to prevent all infections The programs for in-house HIV-1 by clients who are infected and unaware of among these users.15 Complementary ap- confidential testing at these clinics were their infection parallels the general level of proaches to counseling and treatment,in- successful in recruiting the majority of cli- acceptance of the test by all clients at each cluding programs to make clean needles 1416 American Journal of Public Health October 1993,Vol.83,No.10 HIV among Injection Drug Users ' available to those continuing to inject The authors acknowledge the profes- 8. Reardon J,Warren N, Keilch R,Jenssen drugs,are needed to reduce the incidence sional participation and assistance of Mary Jess D,Wise F,Brunner W.HIV serostatus and of HIV-1 in this population. Wilson, MD, MPH (California State Depart- confidential HIV antibody testing in meth- ment of Health Services, Office of AIDS); adone clinics in Contra Costa County,Cal- Our study shows the potential for bi- Charles Deutschman,MFCC,and Steve Lrve- ifomia,USA, 1990.Seventh International ased underestimation of HIV-1 preva- Seth(Contra Costa County Substance Abuse Conference on AIDS; June 16-21, 1991; lence in voluntary testing surveys. The Division); Rodney Smith,PhD(Contra Costa Florence,Italy.Abstract WC 3367. low rate of acceptance of voluntary con- County Public Health Laboratory); Emmett 9. Hull MF, Bettinger CJ, Gallaher MM, fidential HN-1 testis among those in Velten, PhD (Bay Area Addiction Research Keller MM,Wilson J,Mertz GJ.Compar- g g Treatment);and the San Francisco Bay Area ison of HIV-antibody prevalence in pa- fected resulted in a voluntary testing prev- HIV Seroprevalence Regional Coordinating tients consenting to and declining HIV- alence estimate(3.5%n)four times smaller Committee. antibody testing in an STD clinic.JAMA. than the estimate obtained by the unlinked 1988;260(7):935-938. survey(13.0%n),which included all clients References 10. Cabral-Evins DN, Stone S, Anderson L, admitted into treatment.In the study pop- 1. California Department of Health Services, Gaudino JA.Association of human immu- Office of AIDS.Calif HIV/AIDS Update. nodeficiency virus serostatus with confi- ulation, the main reason for the lack of 1993;6(1):7 dential and unlinked antibody testing in an acceptance of voluntary testing by the in- 2. Contra Costa County liealth Services De- STD clinic.Sixth International Conference fected clients seems to have been previous partment, Public Health Division. Quar- on AIDS:June 20-24,1990;San Francisco, knowledge of their infection. Hence the terly Rep HIV/AIDS Stat. April-June Calif.Abstract FC-684,vol.2. more successful the past voluntary testing 19922• 11. Hart G.Factors associated with requesting programs have been, the fewer infected 3. Yano E,Longshore D,Gorman M,Hughes and refusing human immunodeficiency vi- M,Anglin MD.HIV Infection among Lr rus antibody testing. Med J Australia. clients will accept the voluntary test in travenous Drag Users. California Depart- 1991;155(9):586-589. subsequent survey periods,and the lower ment of Health Services, UCLA Drug 12. Jones TS,Allen DM,Onorato IM,Peter- and more biased the estimates will be. In Abuse Research Group for the Office of sen LR,Dondero TJ,Pappaioanou M.HIV addition, lack of knowledge, misunder- AIDS; 1991:68. seroprevalence surveys in drug treatment 4. Watters JK, Cheng YT, Bluthenthal R, centers. Public Health Rep. 1990;105(2) standings, and fears may hinder specific Carison J, Lorvick J. Drug injectors and 125-130. racial or ethnic groups'acceptance of con- HIV-1 infection in the San Francisco Bay 13. Centers for Disease Control.Interpretation fidential testing. These areas of concern Area.Eighth International Conference on and use of the Western blot assay for se- must be adequately addressed by volun- AIDS,July 19-24,1992;Amsterdam,The rodiagnosis of human immunodeficiency tary testing programs. ❑ Netherlands.Abstract PoC 4700. virus type 1 infections. MMWR 1989;38 5. Brickner PW,Torres RA,Barves M.et al. (No S-7):1-7. Recommendations for control and preven- 14. Magura S, Grossman JI, Lipton DS, tion of human immunodeficiency virus Amann KR,Koger J,Gehan K.Correlates Acknowledgments (HIV)infection in intravenous drug users. of participation in AIDS education and Blinded seroprevalence surveys were funded Ann Intens Med. 1989;110:833--837. HIV antibody testing by methadone pa- by the CDC National HIV Seroprevalence Sur- 6. Volberding PA,Lagakos S,Koch MA,et tients.Public Health Rep. 104(3):231-240. veys through the California Department of al.Zidovudine in asymptomatic human im- 15. Calsyn DA, Saxon AJ, Freeman G Jr, Health Services,Office of AIDS.Confidential munodeficiency virus infection.N Engl J Whittaker S. Ineffectiveness of AIDS ed- testing for HIV-1 antibodies was funded by the Med. 1990;322:941-949. ucation and HIV antibody testing in reduc- CDC through the California State Department 7. Haverkos HW. Infectious diseases and ing high-risk behaviors among injection of Alcohol and Drug Program, Division of drug abuse.JSubstAbuseTreat. 1991;(8): drug users. Ann J Public Health. 1992; Drugs,AIDS Intervention Section. 269-275. 82(4):573-575. October 1993,Vol.83,No. 10 American Journal of Public Health 1417 X0. y Contra Costa County The Board of Supervisors HEALTH SERVICES DEPARTMENT OFFICE OF THE DIRECTOR Tom Powers, 1st District Jeff Smith,2nd District Mark Finucane, Director Gayle Bishop,3rd District :'d-'.r ". 20 Allen Street Sunne Wright McPeak,4th District = Martinez,California 94553 3191 Tom Torlakson,5th District ni - .- (510)370-5003 ;¢ County Administrator FAX(510)370-5098 zy.,� 40 Phil Batchelor `Or, N� *~` County Administrator November 18, 1993 To: Internal Operations Committee From: Mark Finucane, Director, Health Services Department by Wendel Brunner, M.D., Assistant Health Service Director for Public Health Subject: Quarterly Report on Communicable Diseases AIDS CURRENT AIDS CASES IN CONTRA COSTA COUNTY As of November 11, 1993, a total of 1,236 residents of Contra Costa County have been diagnosed with AIDS. This number represents 77 new cases reported since our last report to this committee on August 4, 1993. The increase (5%) is primarily due to cases diagnosed under the new and expanded AIDS surveillance case definition. HIV/AIDS EPIDEMIOLOGY REPORT During recent months more than 2,500 copies of a report on the epidemiology of the HIV/AIDS epidemic in Contra Costa County have been distributed to health care providers, community organizations, city officials and others throughout the county. Data pertinent to Contra Costa County was gathered from different sources and made available to the community for information, education, planning and grant applications. In addition to HIV/AIDS incidence and prevalence data, information was included describing aspects of the local response funded by the Ryan White CARE Act in terms of services provided to people with HIV/AIDS, the financial status of the recipients of assistance and reports of unmet needs. Copies of the HIV/AIDS Epidemiology Report are included here. RESULTS OF THE 1992 HIV SURVEY OF CHILDBEARING WOMEN The California Department of Health Services has provided Contra Costa County with the results of the 1992 HIV Survey of Childbearing Women. Every year since 1988, the blood of all babies born during the third quarter of the year is tested for HIV to assess the prevalence of HIV among the mothers of these babies. The babies born to infected mothers have a 30% chance of being infected. Merrithew Memorial Hospital&Clinics Public Health • Mental Health • Substance Abuse Environmental Health Contra Costa Health Plan Emergency Medical Services • Home Health Agency Geriatrics A-345 (2/93) Report to the Internal Operations Committee Page 2 On Communicable Disease in Contra Costa County Contra Costa County has had higher rates of HIV than the State as a whole, a trend observed in other San Francisco Bay Area counties as well. During 1992, four women out of 3,258 delivering babies during the third quarter were found to be HIV infected. This is the same number of infected mothers found in 1990 and 1991. The rate for 1992 was 0.123%, which is equivalent to one women infected in every 815. In 1992, two (50%) of the infected women delivering babies were teenagers (19 years of age or younger). All four of the women were African American. HIV Seroprevalence Survey of Childbearing Women Contra Costa County 1988 1989 1990 1991 1992 1988-92 Number 3029 3261 3245 3406 3258: ::::::::: 16,199 Tested Positive 2 9 4 4 4 23 �!at,e per 6.60 27.60 12.33 11.74 12.28....:::::::: 14.19 0000 AMERICAN JOURNAL OF PUBLIC HEALTH ARTICLE ON HIV TESTING AMONG CONTRA COSTA COUNTY INJECTION DRUG USERS In the October 1993 issue of the American Journal of Public Health an article by members of the Public Health Division, Communicable Disease Control Programs reported findings on the success of voluntary, confidential HIV counseling and testing performed "in- house" by methadone clinic staff members, as measured by the acceptance of such tests and by the level of HIV infection awareness among HIV infected injection drug users. The information and experience gathered in Contra Costa County has been distributed through this publication to its more than 50,000 subscribers. Copies of this article are attached. HIV counseling and testing is not enough to prevent all new infections and the article makes reference to the evidence of new HIV infections among Contra Costa injection drug users, which has previously been reported to the Board of Supervisors. Nevertheless, HIV testing was largely accepted by injection drug users entering treatment, it facilitated access to early treatment for HIV complications and is potentially helpful in limiting the spread of HIV to non-infected partners. Report to the Internal Operations Committee Page 3 On Communicable Disease in Contra Costa County COMMUNICABLE DISEASE TUBERCULOsis Tuberculosis continues, as it has for the past five years, to be reported at high rates. In 1985 our rate of tuberculosis cases was 8.5/100,000, in 1992 our case rate was 12.6/100,000. Contra Costa County has reported 97 confirmed cases as of November 1, 1993, with four additional cases pending confirmation. We continue to see cases in younger people, 25-44 years of age, and in the minority populations. Additionally, the bulk of the cases, 80%, are occurring in West and East County. To control tuberculosis by rapidly finding new cases and preventing new infection the Health Services Department has been working in several areas: • TB/HIV Jail Project - The Public Health staff in cooperation with medical staff of the jail continue to test each entering inmate for tuberculosis infection. Those persons testing positive are examined by a physician after receiving a chest x ray. The additional service that has been added is that each inmate started on treatment is met by a Public Health worker who will follow the person after he/she is released in the Directly Observed Therapy program (DOT). This delivering of medication to the person at home two times a week until the six month therapy is completed will prevent infection from progressing to disease. • STD/HIV/TB Mobile Clinic - Each Friday our mobile clinic parks in the North Richmond area or in Pittsburg/Bay Point to provide STD diagnosis and treatment services. The original mission of this van was to see women at risk for STD and their partners. However, we have also added HIV testing and counseling and TB skin testing and referral. In cooperation with Neighborhood House of North Richmond (Northstar Drug Treatment) in the Richmond area and Pittsburg Pre School Coordinating Council in East County we do outreach before the clinic arrives to encourage the persons at highest risk for any of these diseases to be seen when the clinic is held. This has been very successful, with 15-30 people being seen at each four hour clinic. We plan to substantially increase the number by January 1994 and add immunization and family planning services. • Cross Training of Personnel - We have instituted a policy of cross training all of our field workers in the Communicable Disease Programs (STD, AIDS, TB, Immunizations) to be able to provide information and service to the public, in all areas of communicable disease control. They are able to give educational information, referral and assistance to people who have questions or need any Communicable Disease services. The program workers are now less program specific in their training and orientation to the patient. This has been an important change since many of these workers in the various programs were serving the same people. Change has been made in the utilization of funding. Although outside funding continues to be categorical, merging programs at the local level enables us to use TB, Immunization, AIDS and STD funds in a unified service delivery unit. Workers are often funded under more than one program. Report to the Internal Operations Committee Page 4 On Communicable Disease in Contra Costa County • TB/HIV Screening in the IDU Population - We have worked in cooperation with UCSF and Dr. John Watters to test people for HIV and TB, in West County, over the past two years. We have referred those people to services within the county who are HIV positive. For people who were TB skin test positive we have held several special clinics to obtain chest x rays and examine for signs of tuberculosis disease. Those infected, without disease, who agreed were places on preventive therapy. This out-of-treatment, drug using population is at very high risk for both HIV and tuberculosis. For the past five years the number of patients diagnosed with tuberculosis who use inject drugs or cocaine has increased substantially. This is a population that does not seek medical care. We experienced a major outbreak of tuberculosis in the cocaine using population of West County in 1989-90 due to poor medical care, close quarters and many other factors. The HIV rates in the drug injecting population continue to be very high, with 26.5% infection rate for those surveyed in Richmond in 1992. This year we hope to be working with this same project offering HIV and TB testing. In addition, follow up Directly Observed Therapy (DOT) for those study participants who are placed on preventive Tb therapy will be provided. INIMUMZATION Although we have increased our immunization clinics in the past four years by more 100% per month with the cost remaining very low or free, the youngest children in the county continue to be inadequately immunized. Last year more than 48% of the children under two years of age were under-immunized. We have again expanded services and have added Immuni- zation Services to other services where young children are seen in order to encourage appropriate immunization of this highest risk population. • Immunization Coupons - Even if the $5.00 fee is waived, on request, people do not want to ask. We have begun handing out coupons for Free Immunizations through our Immunization Outreach worker, WIC clinics and in any area where immunization levels are very poor. This has been very successful in the past when the coupons were handed out for Immunization Awareness Month. We hope it will continue with the high rate of return. • Immunization Outreach Worker - Through new State funding we have been able to place an outreach worker in the field to work with communities, families and organizations on immunization issues. He has been arranging clinics in high need areas such as housing developments, churches which serve mainly non English speaking populations and community centers. He will also be visiting medical care providers giving information on immunizations and clinic resources. The merging of service provision and cross training of workers has been a very rewarding experience. As we continue to serve greater numbers of high risk persons, the need to maximize each contact will grow. We will continue to expand the cross training of other outreach workers within the Health Services Department, such as prenatal and Child Health & Disability Prevention (CHDP) outreach workers to provide communicable disease information and referral at each contact. urnat Are HIV-Infected Injection Drug ,q Public I ea U `? Users Taking HIV Tests? F Juan Reardon, MD, MPH, Nancy Warren, PHN, Rusty Kedc/4 MA, Dale Jensse RN Francie Wise PHN MPH and Wendel Brunner n, , , MD, MPH Ohjecl m.".,KnOwleclge:of'irifeC iron is essentzal,.for,humart: muno: ::: Inb'oducdon •What is the 1991 HIV-1 seroprev- defic encyvuus=type 1(19Vl)treat- alence for all injection drug users merit""initiation and epidetiiic control; Regardless of sexual orientation,in- entering treatment in Contra Costa Tats study evaluates tnfectxut.knowl- jection drug users constitute 14.8% of County and for those accepting a : e onto.. ,,edg ... n8,.:ededmjecttm. ..... us- voluntary ersanda adult acquired immunodeficiency syn- test ce tial test.. .:':. drome (AIDS) cases in Californian and •Are injection drug users entering irtg among injection;drug:users;: 19.3% osuch cases f h in Contra Costa treatment accepting a confidential particularly. HN those cfeilwith -l. :;;:. HN-1 anti test? Merhorisi"A total c+f"g10.' `" County, California (San Francisco Bay body en Area),2 where human immunodeficiency •Are those who are infected like to teii°g freatzrrit m CQn"`` be aware of their infection? •.tra County, virus-type I(HN- )seroprevalence rates Calm were exam- :•:; 1 •Are those who are infected and un- :'.ineii Clieritsweretestedwitt utilii ced: among these drug users appear to be par- ticularl hi for African Americans.3•4 aware likely to accept a test? (Blinded)_tests,and simultaneously` Y high czriiriseFed and"offereti vatuntaty con=..:'_';` Voluntary HIV-1 antibody testing of in- ftderitial`HIV"1:an tes' Data" jection drug users has been recommended Methods }' � ;on•c rr, testingacoeptatuwe;Pie=: :: as an effective approach to limiting the "ous'testtng;:.. rise;"olid;deii]o- . sprea example,ear in- 0 of HN 1 For a �, Unlinkedserosurveys were hic tervention with zidovudine has been conducted at two methadone clinics op glop anon were`cxilleced:.:' erating in Contra Costa County,Califor- At ii ""'Of Ahe 810:tested; 105 proven beneficial in postponing the occur- nia,from January 1 to December 31,1991. 13.0% ,were inf66ted::'I'lie current: ':.:' rence of illness in people infected with Standardized research protocols Bevel tesf`was ed Sf37 HN-1 a Same people believe that drug oped by the Centers for Disease Control confidettttal:..;. ... , (62.6%).HN.seroptevalei ce,`in the. : abuse treatment personnel can develop di- (CDC)were used.12Tbe study population i itiiiked"sutveywasfour times`gieater:',:,: agnostic and therapeutic relationships consisted of drug users entering metha- thah in.t2te.vdtia sono 13%arid :`."`' with in'ection drug users more effective g g .M • '( 1 g n' done detoxification programs and of those HIV 1 utfectton than can practitioners to more traditional 3:5%,.respeca ..: p entering or continuing methadone mainte- was`assocaated.i i refusal:vf a ocmfr: settings 7 T'he reluctance or inability of Hance.A total of 810 consecutive injection dential;test 4 ,..largely„.tiecause.;most:m=. .;; these drug users to become involved with drug users who entered methadone treat- ;: , :fected in'ectton: users` ri: :58; traditional medical clinics may postpone J,. . `. ..:.. it Y Poste ment and had their blood drawn for hep- their% knewof. infectictti::` .:' HN-1 di osil . ., s untive�'late deferrin g atitis screening were included. Excluded Ofthe47irijet�ondrttgiiserswhowerea ; ppronate interventions. st he study pe- not aware of Their utfectiari,`32(Z S%) In previous work we reported that, riod(n ! ) =:acgepted:xlieaest.,'AlihaughAfiicaii-`;,' ” of all injection drug users admitted to All clients received individualized ,..American.injection. drug users:grey; ; treatment in 1990, 60.0% (614/1W. ) ac- �V/SDS counseling and were offered a ... :. ::. . sentes3.,<:with:.a. higher,itifection rate. ..: ce ted a confidential antibody test but p confidential HN-1 antibody test. Demo- .(37:3% they::were.three times:less:.'. ;; only 33.6%(36/10')of the infected users graphic data,drug use history,and rnfor- ,.•:<.1lcely to:kr6w:of;their,iiifersion;:,:; . .:. in unlinked surveys) accepted test ing.$ oration regarding acceptance of confiden- Gctrrcltcsions:;:'"hi Finding lower HIV seroprevalence rates testutgtshtghlyaovepted,.andptosfiit- °:g; with voluntary testing surveys, com- # 'clieatts in treatYrtent will;lea;rt;.j`.::; pared to unlinked surveys,was reported The authors are with the Contra Costa County theu.:status. Nevertheless;vpluntary:; :: previously in other populations,%i r and Health Services Department,Public Health Di- tem%data are.irkeis+`to yield cqh!4d- the 1990 data did not include whether re- vision,Martinez,Calif. eralile:trr�erestimates of the_trine rete : fusal of a test was owing to prior knowl- Requests for reprints should be sent to Of irifeti iii us edge of positive status. Therefore, our loan Reardon, MD, MPH, Contra Costa J County Health Services Department,597 Cen- ers:{Am:J Publrc.Healtls`"1993;83: : :": analysis of 1991 data intends to clarify the ter Ave,Suite 200,Martinez,CA 94553-4669. 1414=41n.'?'_ following: Thisrrwasa ted Jan ] ]993.pape accepted January 2, 14i4,Arneticari Journal of Public Health:,;:"'w; October 2993,Vol.83,Na. 10 IUV among IWection nt„g Users tial HIV-1 testing were collected for each client tested with the unlinked method. TABLE:17HIY-1.Seroprevalence arnmV Infection pru8 Uasts EnW"Treattttertt This information allowed grouping the 810 in Contra Coater County,Callfomta,1991;and 11r>fvar�dEis Cort>parUons injection drug users by HIV-1 status, GIGrow1gropma '�' :..... :'. . :`.::. ...:. `.. knowledge of that status,and acceptance of testing.Repetitive reactive enzyme im- n... . .... .HIV+: ..:::: %;�::;:. ;:: OR .::.. . 9596 Cl munoassay tests(at least two positive tests) were confirmed Western blot.The As- A8 di 11s{ur>tiilked survey)... ....810 - .105 13A.:.:. . ::.::4.0 '.2:4;7.2 Merits tasted lrohcre +:'.: ` . .. • ::. 18 3.5 sociation of State and Territorial Public 47t) 85::.'-.' ::;13.8 1.2:... ©8,1.9 Health Laboratory DirectoNCDC criteria emale. .: : for a positive Western blot were used.13 Clients testing positive for HIV-1 Ahican Ari�ericart . : :.;. 217.: ::: :. 81 :. 37.3. 18.0:..::::..,9.7,33.7 ..... Latno:.:..:. :.: 80:....:.. . : 6. 7.5:.''::",.2-4...:;':,. :0.8,.6.9:. :.':. with the voluntarytest were en clinical given CIter ":.. f::::. .`<:'; '40. '1 2.5..:..: 0.8..':::`:::.0.02,.5.3.... and support services referrals and prefer- White .::..:: .:. :.::.::........ 468:.: :. 15 32..;` 1•'.::::;r.: ential admission to methadone mainte- . . :..:. . .... ...:... .. ,. Ibiseoa�.',::. :..•:.:;. : : : 19 ..: ':` ; ;.•5.: ::.: 28.3 : . : .::2.8..:-;'::':.:U.7,7.5 : nance treatment. The statistical signifi- 171e00Meoaaal:... 784.. ;. :':. :. 99.::. 12.6.: canoe of associations was evaluated using Wast Gocrnty .. 417. 71 17.0 22. 1.4,3.4 chi-square and Fisher's Exact tests. East Courdy conk,� ..393 HIV-1 seroprevalence group differences roPt tP P Age 30 and:ovW:... `:'::: .::: ... 730 101 : 13 8 . 3.0: IX 11.5. : and the likelihood of infected drug users ;.::.Age under 30: :: ...... 79 4:' : 5.0....: 1 knowing their status at admission were Ma�roenar>ce:. ... �. .290: ,: :.57.;:;..: `19.7.`:,; .::...24.:::..,...:.1.6.3.7% evaluated with crude odd ratios(ORs). tc+firation . 4M. :: 44: : : ::...9.3:::::.:.. 1, °li�tonrrabori 06.096(w and nye was mis lg dram tour rl( w tided and one ir�t%edclient , Rent& &rfarrnabon on sexual o fs was ming tram sk nonnfected and ore.We.cded.ckenc Irtiorndori on age-w.as.missngIMm om.nomr�ted cleft Treaftwt modit irtk�rination was Seroprevalence levels are reported in ++fie for 13 rrors tied aeras and tar RibeWd.cants and ieponsd as'atm-,form norg tad.ed `..: Table 1.African-American drug users rep- resented 27.0% of the clinic population and 77.9% of the clients infected with HIV-1.The seroprevalence among clients in methadone maintenance was higher TABLE 2-A i ,�+g. in deers of a Cgrinderrtlal HN Teat. upon to Treadrtertt;Contra CosEa County,Cafl�ort+la;'t991` than that for those entering methadone detoxification.Injection drug users under ..: 30 years of age were less likely to be in- n: NN.:TestAct fected than were older clients,and clients at the West County clinic had higher rates t f ed users:.: :::':::.705. , . . of infection.Overall,a confidential HIV-1 Irifec ted users: 105..':.:.. .' ::'`:::..18. 17:1 test was largely accepted(62.6%),but in- IM d * regardless ct.M-1'siatt� fected clients were more likely to decline a confidential test(Table 2). Of the 105 infected drug users, 58 jection drug users infected with HIV-1 other hand, the West County clinic had (55.2%)already knew of their HIV infec- knew of their infection. most of the infected clients (67.6%) and tion and only 6 of those chose to test again. Only 12(25.5%)of the 47 who were most of the African-American clients There were 47 drug users (44.8%) who unaware of their infection accepted a con- (73.7%). African Americans constituted were infected and unaware of the infection fidential test upon admission to treatment 38.6%of the West County clinic popula- (Table 3). Infected users entering detoxi- in 1991(Table 3).Of the 35 infected drug tion and only 14.6% of the East County fication programs were less likely to know users who were unaware of their infection clinic population.We found no significant of their infection than those entering or and declined a confidential test,27(77.1%) difference by clinic in the acceptance of an continuing in maintenance programs reported having had at least one such test HIV test among infected African-American (P<0.001).The group less likely to take in the past,and 16(45.7%)had had a neg- clients who were unaware of their infection a confidential test were methadone main- ative test within the past 12 months;mark- (East County clinic = 28.6% vs West tenance clients from the West County ing recent seroconversions or infections. County clinic=20.6%).Also of some in- clinic(P= .054).Infected African Amer- Regarding clinic differences, with terest is the observation that injection drug icans were less likely overall to know of similar client population sizes, the East users who were aware of their infection re- their infection than White (OR =0.15; County clinic, had clients more likely to ported using crack cocaine more often(12/ 95% confidence interval [CI] = 0.02, know of their infection(Table 4),was sig- 58,or 20.7%)than those whowere unaware 0.74), but some clinic variation existed. nificantly more successful (P< .001) in (4/47,or 8.7%)(P= .07). Among infected African-American drug recruiting clients for an HIV test than the users, those entering treatment in East West County clinic(76.3%vs 49.6%),and LkwuSSion County, although fewer in number, also appeared more successful in recruit- seemed more likely than those entering ing among the infected who were not Contra Costa seroprevalence rates treatment in West County to know of their aware of their infection(40.0%vs 21.6%). for injection drug users are among the HN infection.All five gay or bisexual in- This difference was not significant.On the highest reported in California.The policy October 1993,Vol.83,No.10 American Journal of Public Health 1415 Reardon et al. r" TABLE 3—,Acceptance of a C00101d0i" „ TABLE 4---Kttowiedge of riercWtatus fAtwng Infected 1018ctionPrug titters ardor KV-1 Tact st€�xV k*eWon . ii lvntra :Ca1100MI t991 Dng Users ErtWing Tnsabrtterrt In CcrbaCosb. , No.Who � n . . N%Cl Who Were,W Awlire of 24. 7fl.1_. .3.7. :`.1:4;:10:1..:: No W�Coui�rty 71 34: 47 81. C vwr ethnic.grcx>It° 23 1$ .. 76.3... 3,7 ;till/TestAtnencan..,:. 61 40 African.Am�sst Couftty dinto 22 7,_ 31.8,'' 2:9 0.94.9.6 . Tim. A7.:...:.:.12::..: .:25 5:.. Air art AmericrattlWe t County d�iC. ",.59:. ..: ..: .25 424 #. :..:.6 '. :19.4.. ' 37.5 All `A1iariArrieiicail 41` .,...8 : ,.'.225` Ali ser Drug Injection j in e U Users �� a ,2. : :40.0 . WW County C : 37 $ 21.6" Male 110.0+ Female EssfCo�'d1►.c�c::;::'i1t) ,`..:.-.4 °4flfl.., aa.oa k :. African American nta itertartoe. Latino 14 : 1.. Other P7e11 White rx.J11 W.7 tinder age 30 110.011 . Age 30 and over .,4 s:.e11 NoneW"tog. l.,. : .. :::.:.'. ::: East County clinic West County clinic II 40.0111 1 YilestC clihic, infected nom. 11 ' 00 Not Infected IlIllIllf 00.411 AD adwr ::... 33 ;: : .::9 .. . 27.3 . Infected and aware ,osa d a r Infected an un ora a NOW.ht�onzisiogn ori race was mis�g fi'orti ono�: - g� who aooWWd ft ilest Treat-:. 0% 20% 40% 80% 80% 100% "W11 modeJty lr*rrrie6W waS ha hires.. of two Wa6led the flee awspled the FIGURE 1•--Acceptance of an NIV-1 antibody test by Injection drug users entering . treatment in Contra Costa County California 1991. of actively and preferentially admitting in- ents admitted to drug therapy(62.6%),and clinic.The East County clinic appears to fected clients to maintenance programs the availability of these programs has cer- have established a more accepting atmo- wili likely result in a rising seroprevalence tainly contributed to infection awareness. sphere,which brings into testing more ch- among maintenance clients, which, it is Clearly,not all detoxification clients may ents of all groups,including the infected hoped,will be accompanied by a declining be ready for a confidential HIV-1 test at and unaware. Race distributions in each seroprevalence rate among detoxification the time of admission,and it may be better clinic may also be a factor in the difference clients. This will represent a successful for some to postpone the news of infection between clinics because African-Ameri- combination of the protective measures to facilitate the first steps of recovery.14 can clients entering treatment in both clin- implemented by those who are continuing Nevertheless,among infected clients un- ics were less likely than other clients to to inject drugs and the reduced probability aware of their status, the test was ac- accept a test,and the East County clinic of such drug users encountering a needle- cepted more often by those enrolling in had a smaller African-American clientele. sharing partner infected with HIV-1.But methadone detoxification than by those These observations suggest that the par- this public health goal has not been enrolling in or continuing methadone ticular environment created at the East reached yet.The 1991 seroprevalence for maintenance,who are likely further into County clinic made acceptance of the test detoxification clients was 9.30/&-4ower, recovery.In any event,the test must con- the norm(76.3%)and contributed to the but not significantly so,than the 9.8%rate tinue to be available to injection drug users test's acceptance by infected and unaware of 1990.It is hoped that continued efforts and their sexual partners at any time after clients,but it was not enough to eliminate to reach,counsel,educate,and test injec- admission and upon request.Certain drug the general reluctance of African Ameri- tion drug users in Contra Costa County users who are infected and unaware of the can clients to test.Further research is also and to offer facilitated and preferential ad- infection may not feel at risk because they needed on drug abuse patterns(e.g.,abuse mission to methadone maintenance pro- have been in maintenance treatment for of crack cocaine)of injection drug users grams will be reflected in declining sero- some time,or they may have specific con- who learned of their HIV-1 infection. prevalence rates among drug users cern about the test or its consequences. Additionally, our data confirmed that entering detoxification programs in future This group needs to be studied further. one-to-one education and testing alone is years; The acceptance of a confidential test not guaranteed to prevent all infections The programs for in-house HIV-1 by clients who are infected and unaware of among these users.15 Complementary ap- confidential testing at these clinics were their infection parallels the general level of preaches to counseling and treatment,in- successful in recruiting the majority of cli- acceptance of the test by all clients at each eluding programs to make clean needles 1416 American Journal of Public Health October 1993,Vol.83,No.10 HIV among Weclion Dnrg Users ' available to those continuing to inject The authors acknowledge the profes- 8. Reardon J,Warren N,Keilch R,Jenssen drugs,are needed to reduce the incidence sional participation and assistance of Mary Jess D,Wise F,Brunner W.HIV serostatus and of HN-1 in this population. Wilson, MD, MPH (California State Depart- confidential HIV antibody testing in meth- ment of Health Services, Office of AIDS); adone clinics in Contra Costa County,Cal- Our study shows the potential for bi- Charles Deutschman,MFCC,and Steve Love- ifomia,USA, 1990.Seventh International ased underestimation of HIV-1 preva- seth(Contra Costa County Substance Abuse Conference on AIDS; June 16-21, 1991; lence in voluntary testing surveys. The Division);Rodney Smith,PhD(Contra Costa Florence,Italy.Abstract WC 3367. low rate of acceptance of voluntary con- County Public Health Laboratory); Emmett 9. Hull MF, Bettinger CJ, Gallaher MM, fidential HN-1 testing anion those in Velten, PhD (Bay Area Addiction Research Keller MM,Wilson J,Mertz GJ.Compar- g g Treatment);and the San Francisco Bay Area ison of HIV-antibody prevalence in pa- fected resulted in a voluntary testing prev- HIV Seroprevalence Regional Coordinating tients consenting to and declining HIV- alence estimate(3.5%)four times smaller Committee. antibody testing in an STD clinic.JAMA. than the estimate obtained by the unlinked 1988;260(7):935-938. survey(13.0%),which included all clients References 10. Cabral-Evins DN, Stone S,Anderson L, admitted into treatment.In the study pop 1. California Department of Health Services, Gaudino JA.Association of human immu- ulation, the main reason for the lack of Office of AIDS.Calif HIVk4IDS Update. nodeficiency virus serostatus with confi- 1993;6(1):7. dential and unlinked antibody testing in an acceptance of voluntary testing by the in- 2. Contra Costa County Health Services De- STD clinic.Sixth International Conference fected clients seems to have been previous partment, Public Health Division. Quar- on AIDS;June 20-24,1990;San Francisco, knowledge of their infection. Hence the terly Rep HIV/AIDS Stat. April-June Calif.Abstract FC-684,vol.2. more successful the past voluntary testing 1992:2. 11. Hart G.Factors associated with requesting have been, the fewer infected 3. fano E,Longshore D,Gorman M,Hughes and refusing human immunodeficiency vi- programsM,Anglin MD.HIV Infection among In- rus antibody testing. Med J Australia. clients will accept the voluntary test in travenous Drug Users. California Depart- 1991;155(9):586-589. subsequent survey periods,and the lower ment of Health Services, UCLA Drug 12. Jones TS,Allen DM,Onorato IM,Peter- and more biased the estimates will be.In Abuse Research Group for the Office of sen LR,Dondero TJ,Pappaioanou M.HIV addition, lack of knowledge, misunder- AIDS; 1991:68. seroprevalence surveys in drug treatment standings, and fears may hinders c 4. Watters JK, Cheng YT, Bluthenthal R, centers. Public Health Rep. 1990;105(2): Y specific Carison J, Lorvick J. Drug injectors and 125-130. racial or ethnic groups'acceptance of con- HIV-1 infection in the San Francisco Bay 13. Centers for Disease Control.Interpretation fidential testing. These areas of concern Area.Eighth International Conference on and use of the Western blot assay for se- must be adequately addressed by volun- AIDS;July 19-24,1992;Amsterdam,The rodiagnosis of human immunodeficiency tary testing programs. ❑ Netherlands.Abstract PoC 4700. virus type 1 infections. MMWR 1989;38 5. Brickner PW,Torres RA,Barves M,et al. (No S-7):1-7. Recommendations for control and preven- 14. Magura S, Grossman JI, Lipton DS, tion of human immunodeficiency virus Amann KR,Koger J,Gehan K.Correlates Acknowledgments (HIV)infection in intravenous drug users. of participation in AIDS education and Blinded seroprevalence surveys were funded Ann Intem Med. 1989;110:833-837. HIV antibody testing by methadone pa- by the CDC National HIV Seroprevalence Sur- 6. Volberding PA,Lagakos S,Koch MA,et tients.Public Health Rep. 104(3):231-240. veys through the California Department of al.Zidovudine in asymptomatic human im- 15. Calsyn DA, Saxon AJ, Freeman G Jr, Health Services,Office of AIDS.Confidential munodeficiency virus infection.N Engl J Whittaker S. Ineffectiveness of AIDS ed- testing for HIV-1 antibodies was funded by the Med. 1990;322:941-949. ucation and HIV antibody testing in reduc- CDC through the California State Department 7. Haverkos HW. Infectious diseases and ing high-risk behaviors among injection ! of Alcohol and Drug Program, Division of drug abuse.J SubstAbuse Treat. 1991;(8): drug users.Am J Public Health. 1992; Drugs,AIDS Intervention Section. 269-275. 82(4):573-575. 4 October 1993,Vol.83,No.10 American Journal of Public Health 1417 1048 Concise Communications JID 1993;168(October) Discrepancies in Tuberculin Skin Test Results with Two Commercial Products in a Population of Intravenous Drug Users Alan R. Lifson,John K. Watters, Suzanne Thompson, Departments of Epidemiology and Biostatistics and of Tamil v and Charles M.Crane,and Francie Wise Community Medicine.School of Medicine,and Urban Health Studv, institute for Health Policy Studies. Universit v of California, San Francisco;Communicable Disease Control, Public Health Division, Contra Costa County Health Services Department,Martine:.California Screening for tuberculosis(using the Mantoux test)and human immunodeficiency virus(HIV) was conducted among intravenous drug users(IVDUs)recruited from a San Francisco Bay Area neighborhood.Of 178 IVDUs skin-tested with one commercial purified protein derivative(PPD) preparation,a reaction of>_5 mm of induration occurred in 62(47%)of 133 HIV-negative and 13 (29%)of 45 HIV-positive IVDUs(P=.037).Forty-two IVDUs with an initial PPD reaction>_5 mm were retested with a second commercial preparation; 11 (26%)had no reaction(0 mm)on retesting.These 1 I were 5(56%)of 9 HIV-positive and 6(18%)of 33 HIV-negative persons(P= .038).These discrepancies may be unique to specific lots of product or may reflect more general differences. A degree of caution in evaluating unexpected tuberculin skin test results may be indicated.Response to different tuberculin products by HIV status should be further evaluated. Screening of high-risk populations for infection with Myco- tant component of the national plan to combat tuberculosis bacterium tuberculosis has been recommended as an impor- (TB)[1,21.Such screening is commonly done with the Man- Received 23 March 1993:revised 7 June 1993. toux tuberculin skin test,with intracutaneous injection of 5 Presented: IX International Conference on AIDS/IV STD World Con- tuberculin units (TU) of purified protein derivative (PPD) gress.Berlin,6-11 June 1993. [3]. For certain persons who have a positive skin test without Informed consent was obtained from study subjects,using guidelines of evidence of active TB, therapy with isoniazid is recom- the University of California Committee on Human Research.Participants in this study received a small monetary reimbursement. mended [2] to prevent latent TB infection•from progressing Grant support: National Institutes of Health (DA-06908); Centers for to active disease. Disease Control and Prevention(U62-CCU902017),Office of AIDS.San TB represents a significant cause of morbidity and mortal- Francisco Department of Public Health(83-07069). Reprints or correspondence(present address): Dr.Alan R.Lifson.Divi- ity among intravenous drug users(IVDUs)[4, 51. IVDUs are sion of Epidemiology. School of Public Health. University of Minnesota, also at risk for infection with human immunodeficiency virus 1300 S.Second St..Suite 300,Minneapolis,MN 55454-1015. (HIV), which may increase the likelihood of developing ac- The Journal of infectious Diseases 1993;168:1048-51 tive TB: in one study, the incidence of active TB among 0 1993 by The University of Chicago.All rights reserved. 0022-1899/93/6804-D039S01.00 - HIV-positive PPD-positive IVDUs was 7.9 cases/100 per- JID 1993;168(October) Concise Communications 1049 son-years[4]. IVDUs are therefore an important population interpretation.Trained staff measured the size of induration for for whom TB screening is recommended[1].Preventive ther- skin test antigens by both palpation and the ballpoint pen apy with isoniazid is recommended for all IVDUs with a method [7]: results were recorded on standard forms. For this PPD skin test of>10 mm of induration and for certain per- analysis, we defined anergy as a reaction to PPD of 0 mm of sons with induration >5 mm. including those infected with induration and a reaction to both controls 4 1 mm. HIV 111. Retesting. Seventy-five IVDUs had a reaction,5 mm on the As part of a study of IVDUs recruited from community- initial screening with product A.Attempts were made to contact based settings, we conducted screening for TB and HIV in these subjects by letters. phone calls, or outreach workers to offer a repeat skin test. Forty-three persons (579) agreed to a one San-Francisco Bay Area neighborhood. Our initial TB second skin test with product B (Tubersol, lot 233422), of screening was done with one commercial tuberculin prepara- whom 42 returned 2 days later for skin test reading. Retesting tion (PPD product A, Aplisol: Parke-Davis. Morris Plains. was done 2 months after the initial screening. NJ). After this testing, we became aware of a number of Statistics. Discrete variables were compared by using the X2 employees of the University of California, San Francisco or Fisher's exact test: continuous variables were compared by (UCSF)who had a positive skin test reaction with product A using Student's t test.Confidence intervals(CI)were calculated and who were retested with a different commercial prepara- about proportions. Statistical analyses comparing initial PPD tion(PPD product B.Tubersol.Connaught.Swiftwater,PA). measurements with retest measurements on the same persons On retesting, most of these employees were skin test—nega- are not presented because,by definition,retesting was done only tive(R. Harrison,personal communication).Preliminary in- on persons who had an initial induration,5 mm.This selection formation indicated that employees with discrepant results for retesting based on exceeding a certain threshold of a mea- sured characteristic may result in a "regression toward the had been tested with the same lot of product A used in our mean"effect at the time of the next measurement. initial screening of IVDUs. Because we were concerned about these discrepancies and possible inappropriate referral of subjects for isoniazid ther- Results apy,we attempted to contact all subjects who had a reaction Initial shin testing. During the initial screening. 192 _>5 mm with product A to offer retesting with product B. IVDUs had PPD skin tests with product A. 178 (93%) re- This report summarizes our findings. turned 48-72 h later for evaluation. Of the 178 who re- turned, 75 (42%) had a reaction >5 mm. Induration of>5 Methods mm was present in 62 (47%) of 133 HIV-negative and 13 (29%)of 45 HIV-positive IVDUs(P= .037):a reaction>10 Study subjects. The Urban Health Study evaluates IVDUs mm was present in 48 (36%) of 133 HIV-negative and 12 recruited from San Francisco Bay Area neighborhoods with a (27%)of 45 HIV-positive IVDUs(P> .10). Of 166 IVDUs high prevalence of drug use. In these communities, a targeted who received both control skin tests as well as PPD and who sample of IVDUs are recruited by experienced outreach workers returned for evaluation, 6% of HIV-negative and 20% of [6]. All participants must be current IVDUs and have visible HIV-positive persons were classified as anergic (P = .012). signs of recent venipuncture.The study described here was con- After those who were anergic were excluded, a reaction >5 ducted in Richmond.California. mm was present in 48% of HIV-negative and 39% of HIV- IVDUs who agree to participate undergo an interview and positive IVDUs (P> .10). IVDUs with induration >5 mm HIV antibody testing. Screening for HIV antibody is done by were referred to the county health department for further EIA with confirmation by Western blot.Minimum criteria for a positive Western blot are the presence of bands at at least two of evaluation and possible isoniazid therapy. the following: p24, p41,and gp120/160. Repeat PPD tests. Of 42 IVDUs who were skin-tested Skin tests. IVDUs who had already agreed to HIV testing with both products A and B. 29 (69%) were male and 13 were asked if they would also be willing to receive a TB skin test. (31%)were female. Thirty-eight(90%)were African-Ameri- Exclusion criteria for TB testing included a history of active TB, can and 4(10%)of other race/ethnicity, reflecting the study a positive TB skin test resulting in further workup or institution population evaluated at this site. The mean age was 42.7 of preventive therapy,and a severe or allergic reaction to the TB years; 9 persons(21%)were HIV-antibody positive. Among skin test. the 75 persons who initially had a reaction >5 mm, those Screening for M. tuberculosis was done using an intradermal who returned for a second skin test reading did not differ injection of 0.1 mL of 5 TU of PPD stabilized with Tween 80 significantly from those who did not by sex, age, race/ (Mantoux test),administered through a single-dose syringe by a ethnicity, or HIV antibody status(P> .10). trained staff member.The initial skin tests were done with prod- uct A (Aplisol, lot 00952P). Subjects were also evaluated for Of those tested with both products A and B. the median anergy by using two controls: 1:100 dermatophytin "O." Can- skin test reactions were 16.0 and 12.5 mm,respectively.Ta- dida antigen (Hollister-Steir, Spokane, WA) and mumps skin ble 1 categorizes subjects by their initial and repeat skin test test antigen (Connaught). The location of skin test placement results.Of IVDUs retested. 11 (26`c)had no reaction(0 mm) on the arms was recorded on a standard form. Participants were with product B.No reaction on retesting occurred in 5(561r) asked to return 48-72 h after the initial placement for skin test of 9 HIV-positive and 6(18%)of 33 HIV-negative persons(11 1050 Concise Communications JID 1993.168(October) Table 1. Categorization of 42 intravenous drug users by indura- 91. For example,one report described 16 school district em- tion response on initial and repeat tuberculin skin tests. ployees who had a positive skin test with product A. 13 Initial results(product A) persons were retested with product B and were PPD- negative[8]. 5-9 mm 10-14 mm a 15 mm Between any two tuberculin tests there may be some vari- Repeat results ability in skin test response or interpretation,even if subjects (product B) HIV- HIV* HIV- HIV* HIV- HIV* Total are tested with the same product [101.To improve accuracy 0 mm 4 1 0 3 2 1 11 and reduce variability, skin tests were administered and in- 1-4 mm 2 0 1 0 0 0 3 terpreted using standard criteria by trained staff, many of 5-9 mm 1 0 1 0 0 0 2 whom participated in both screenings. Although we cannot 10-14 mm 1 0 3 0 1 1 6 exclude variability as a partial explanation for our findings,if ;1�15 mm 0 0 1 0 16 3 20 the discrepancies we identified were entirely due to variabil- NOTE. HIV- or HIV*, negative or positive for human immunodefi- ity in skin test response, this raises significant questions ciency virus. about the reliability of tuberculin skin test results. : If the discrepancies we identified were not entirely due to variability,then some IVDUs may have had either false-po- _ .038). Of the 1 1 IVDUs with no reaction to product B, 8 sitive skin test with product A or a false-negative test with reacted to at least one of the two skin test controls,2 had no product B. False-positive tuberculin tests may be due to hy- reaction to either control, and I did not receive mumps but persensitivity to other mycobacteria[11],including Mvcobac- had no reaction to the Candida control. The two persons Cerium avium complex, an important cause of disease in who did not react to either control or to product B were both HIV-infected persons. Among those retested, discrepant re- HIV-infected. Of 31 IVDUs who had some reaction (>0 sults were more common in HIV-infected IVDUs. Dissemi- mm) with product B, 30 reacted to at least one of the con- nated infection and disease due to M. avium complex tends trols.and 1 had no reaction to either control. to occur in HIV-infected persons with severe immunosup- By design,all 42.persons had induration>5 mm with prod- pression [12]. However, it is possible that HIV-infected per- uct A.in contrast,28(67%.959 CI,50%-80%)had a skin test sons in this study(even in the absence of disease)were more reaction to product B >5 mm. Thirty-three (799; 959 Cl, likely than HIV-negative persons to be infected with atypical 639-899)of those tested with product A and 26(629; 959 mycobacteria or to be colonized with greater numbers of or- CI, 469-769)of those tested with product B had a reaction ganisms.Another theoretical explanation for a false-positive 10 mm. Isoniazid preventive therapy is recommended for result with product A is a reaction to a different, nonmyco- all IVDUs with a reaction to PPD>10 mm and for HIV-posi- bacterial antigen. tive IVDUs with induration >5 mm [1]. Of those who were False-negative skin test reactions may be due to a number retested,on the basis of only PPD result and HIV status, 34 of factors related to the tuberculin used,method of adminis- IVDUs would have been referred for isoniazid therapy ac- tration, test interpretation, or person being tested [3, 1 1]. cording to product A results and 26 according to product B Although HIV-induced immunodeficiency may lead to fail- results. ure to respond to diagnostic skin tests[13],it seems unlikely Thirty-six IVDUs indicated that they had received a pre- that more than half the HIV-infected IVDUs with a positive vious TB skin test (prior to our studies), of whom 4 (119) initial skin test would become anergic at the time of repeat reported that the most recent skin test preceding our initial testing only 2 months later. Furthermore,even among HIV- screening was positive,this lower rate reflects our exclusion negative IVDUs, 189 had no reaction on retesting. criteria. The previous skin test was not positive in 8 IVDUs There may be more than one explanation for our results. with induration of 0 mm on retesting(product B), I IVDU However, several factors suggest that at least some propor- with a reaction 1-4 mm on retest,and 23 of 27 IVDUs with a tion of..the initial PPD results represent false-positive re- retest reaction >5 mm. sponses.Our retesting was initiated because of anecdotal re- ports of discordant PPD results in some health care workers: in this setting, the single positive result(with the same lot of Discussion product A as in our initial screening) was believed most likely to represent a false-positive skin test. In addition, the Of 42 IVDUs who had a PPD skin test reaction >5 mm rates of PPD positivity identified in our initial screening were with one commercial product, 269 had no reaction when somewhat higher than we expected on the basis of studies in retested 2 months later with a different product. Whether other cities[4, 141 and our own studies of IVDUs.For exam- these differences were unique to a particular lot of PPD prod- ple.in another San Francisco neighborhood characterized by uct or represent a more general problem is unknown. How- high rates of drug use and TB. 259 of HIV-negative IVDUs ever, discordant results with use of products A and B have had induration >-10 mm and 209 of HIV-positive 1VDUs been previously described in health department bulletins[8, had induration >5 mm [151. JiD 1993;168(October) Concise Communications 1051 Whether the discrepancies we observed are due to differ- Harris, Jennifer Lorvick, Charles Richardson, Bernadine San- ent concentrations of tuberculin in the two commercial skin tana, and Tia Wagner for help with the study: James Carlson test preparations or to some other factor, both false-positive and the UCSF AIDS Tissue Bank for assistance with HIV anti- and false-negative responses are of concern. False negatives body testing or specimen storage:and Denise Koo,Sarah Royce, could result in failure to initiate preventive therapy in a per- George Rutherford,and Mark Segal for helpful suggestions. son infected with M. tuberculosis. False positives may result in inappropriate initiation of isoniazid(with the potential for hepatotoxicity or other adverse effects)as well as diversion of References health care resources toward following such patients. Incor- I. Centers for Disease Control.Screening for tuberculosis and tuberculous rectly identifying an individual as having a positive PPD skin infection in high-risk populations,and the use of preventive therapy test will also make it more difficult to detect a true skin test for tuberculous infection in the United States:recommendations of conversion if it subsequently develops. the Advisory Committee for Elimination of Tuberculosis. MMWR Quantitating the sensitivity and specificity of specific PPD 1990:39(RR-8):1-12. skin test products is difficult for several reasons. Because 2. American Thoracic Society. Control of tuberculosis in the United States.Am Rev Respir Dis 1992:146:1623-33. there was no conclusive reference standard for latent M. tu- 3. American Thoracic Society.Diagnostic standards and classification of berculosis infection, a definitive interpretation of discordant tuberculosis.Am Rev Respir Dis 1990.142:725-35. skin test results was not possible. In our retesting,we evalu- 4. Selwyn PA,Hanel D.Lewis VA,et al.A prospective study of the risk of ated only IVDUs who had a reaction-_5 mm with product A. tuberculosis among intravenous drug users with human immunodefi- with the previously noted potential for a "regression to the ciency virus infection.N Engl J Med 1989:320:545-50. 5. Stonebumer RL,Des Jarlais DC,Benezra D,et al.A larger spectrum of mean" effect. We did not detect persons who theoretically severe HIV-I-related disease in intravenous drug users in New York could have had a negative skin test with product A and posi- City.Science 1988:242:916-9. tive results with product B. To identify the specificity of one 6. Watters JK. Biemacki P.Targeted sampling:options for the study of skin test product, it would also be necessary to know the hidden populations.Soc Probl 1989:36:416-30. 7. Longfield JN,Margileth AM,Golden SM,Lazoritz S.Bohan JS,Cruess number of subjects who were free of M.tuberculosis infection DF.Interobserver and method variability in tuberculin skin testing. with negative skin test results. For these reasons,our discus- Pediatr infect Dis 1984:3:323-6. Sion focuses on certain discrepancies in results between the 8. Infectious Disease Branch,California Department of Health Services. two PPD products. False positive tuberculin skin test reactions and product variability. The existence of such discrepancies, for whatever reason, California Morbidity 1989:28(July 21):1. raises questions that warrant additional investigation. A de- 9. Section of Epidemiology,Alaska Department of Health and Social Ser- vices.False-positive Aplisol PPD reactions.State Alaska Epidemiol gree of caution in the interpretation of specific skin test re- Bull 1992.9(Mav 12):1. sults may be indicated in certain situations, particularly if 10. ChaParas SD,Vandiviere HM,Melvin 1,Koch G,Becker C.Tuberculin such results are inconsistent with epidemiologic data or ex- test: variability with the Mantoux procedure. Am Rev Respir Dis pectation of M. tuberculosis infection. Additional studies si- 1985;132:175-7. 11. American Thoracic Society.The tuberculin skin test.Am Rev Respir multaneously evaluating different PPD products in the same Dis 1981:124:356-63. persons, including those who are HIV-infected, may help to 12. Horsburgh CR. Mmobacterium avium complex infection in the ac- further evaluate issues raised here. If significant discrepan- quired immunodeficiency syndrome.N Engl J Med 1991:324:1332- cies between skin test products are noted, particularly in 8. high-risk subjects such as IVDUs, this raises important issues 13. Centers for Disease Control.Purified protein derivative(PPD}tubercu- lin anergy and HIV infection:guidelines for anergy testing and man- for TB control programs and lends support to refinement of agement of anergic persons at risk of tuberculosis. MMWR current assays and development of additional diagnostic 1991;40(RR-5):27-33. measures to identify M. tuberculosis infection in those with- 14. Graham NMH.Nelson KE,Solomon L.et al.Prevalence oftuberculin out active disease. positivity and skin test anergy in HIV-l-seropositive and-seronega- tive intravenous drug users.JAMA 1992:267:369-73. Acknowledgments 15. Lifson AR. Watters JK, Thompson SM, Crane CM, Schecter GF. Screening for tuberculosis(TB)among injection drug users(IDUs) We thank Ricky Bluthenthal, Jose Carrasco, Myrto Conto- recruited from street-based settings.Presented:IX International Con- gouris, Michelle Estilo, Daryl Gault, Sauda Garrett, Charles ference on AIDS/IV STD World Congress,Berlin,June 1993. HIV/AIDS EPIDEMIOLOGY REPORT CONTRA COSTA COUNTY 1 IQ S COij� August, 1993 Mark Finucane, Health Services Director Wendel Brunner, M.D., Assistant Director for Public Health Francie Wise, Communicable Disease Control Director Rusty Keilch, AIDS Program Director Prepared by: Juan Reardon, M.D. Derrick A. Green Denise Johnson Ethel Alderete Nancy Warren Table of Contents Reported cases of AIDS in Contra Costa County . . . . . . . . . . . . . . . . . . . . . 1 Total cases reported (1982-1993) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I Mode of infection and gender distribution of all AIDS cases (1982-1993) . . . . . . . 1 RacelEthnicity distribution of all AIDS cases (1982-1993) . . . . . . . . . . . . . . . . 2 Age distribution of all AIDS cases (1982-1993) . . . . . . . . . . . . . . . . . . . . . . . 2 Year of diagnosis of all AIDS cases (1982-1993) . . . . . . . . . . . . . . . . . . . . . . 2 Cases under new CDC expanded AIDS case definition (1993) . . . . . . . . . . . . . . 3 Deaths among people with AIDS and people living with AIDS . . . . . . . . . . . . . . 4 Geographic distribution of AIDS cases (by city) : . . . . . . . . . . . . . . . . . . . . . S Global view: World, US, California and Bay Area cases . . . . . . . . . . . . . . . . 6 Estimate of Contra Costa residents infected with HIV . . . . . . . . . . . . . . . . . . 6 The local HIVIAIDS epidemic in injection drug users (IDUs) . . . . . . . . . . . . . 7 Percent of heterosexual IDUs among new AIDS cases over time . . . . . . . . . . . . 7 HIV seroprevalence among IDUs entering treatment . . . . . . . . . . . . . . . . . . . . 7 Street surveys in West County . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 New infections among IDUs ? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Diseases reported among Contra Costa residents with AIDS . . . . . . . . . . . . . . 9 The AIDS epidemic in Contra Costa County: Fact sheet . . . . . . . . . . . . . . . 10-11 77te local HIVIAIDS epidemic among gay and bisexual men . . . . . . . . . . . . . 12 Percent of gay/bisexual men among new AIDS cases over time . . . . . . . . . . . . . 12 HIV prevalence in non-IDU gay/bisexual men tested voluntarily . . . . . . . . . . . . 12 77te local HIVIAIDS epidemic among childbearing women, 1989-1991 . . . . . . . 13 Women of reproductive years with AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 HIV in female prostitutes and female IDUs . . . . . . . . . . . . . . . . . . . . . . . . . 14 HIV infection in women attending pre-natal clinics in Contra Costa County . . . . . 14 Children and HIVIAIDS in Contra Costa County . . . . . . . . . . . . . . . . . . . IS HIVIAIDS in adolescents in Contra Costa County . . . . . . . . . . . . . . . . . . . . 16 HIV infection in Contra Costa applicants for military service, 1985-1991 . . . . . . 16 California counties with highest cumulative incidence of AIDS . . . . . . . . . . . . 17 Contra Costa cities with the highest cumulative incidence of AIDS . . . . . . . . . . 17 Surveillance of the response: Services provided and unmet needs . . . . . . . . . 18-19 Site of medical diagnosis/care for AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . 19 ' Reporting AIDS cases to the health department (AIDS surveillance) . . . . . . . . . 20 Reporting AIDS: Summary of legislation . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Contra Costa County HIV/AIDS Epidemiology Report I :..::. FEE E WITH AIDS IN CONTRA COSTA`COUNTY ..: . . ......... half of 1993; 1169 cases:of AIDS:;were"reported to the Health represents a cumulative incidence of 14 5 per 10,000 population .. . s"data.;:This estimate is as on y on.report cases. ; ; Acquired Immunodeficiency Syndrome (AIDS) Surveillance Report (Cumulative through 7/31/93) ALL CASES Adult and adolescent cases (n=1161) Mode of HIV infection. Males (%) Females (%) Total (%) Gay or bisexual men 737 (69.6%) 0 (0.0%) . 737 (63.5%) Heterosexual injection drug user 155 (14.6%) 59 (57.8%) 214 (18.4%) Gay/bisexual injection drug user 65 (6.1%) 0 (0.0%) 65 (5.6%) Hemophiliac 15 (1.4%) 0 (0.0%) 15 (1.3%) Heterosexual contact 6 (0.6%) 28 (27.5%) 34 (2.9%) Transfusion with blood/products 25 (2.4%) 10 (9.8%) 35 (3.0%) None of the above/other 56 (5.3%) 5 (4.9%) 61 (5.3%) Total 1E1059 (100%) 102 (100%) 1161 (100%) ... Pediatric cases (n=8) Mode of HIV infection Males (%) Females (%) Total (%) Hemophiliac 0 (0.0%) 0 (0.0%) 0 (0.0%) Parent at risk or has AIDS/HIV 1 (25.0%) 4 (100%) 5 (62.5%) Transfusion with blood/products 3 (75.0%) 0 (0.0%) 3 (37.5%) None of the above/other IL 0 (0.0%) o(0.0%) 0 (0.0%) Total 4 (100%) 4(100%) 8.:(1009b) 2 August 1993 ALL CASES Race and ethnicity distribution Race/Ethnicity Adult/adolescent Pediatric Total (%) Cases M Cases (%) White, not Hispanic 733 (63.1%) 2 (25.0%) 735 (62.9%) African American, not Hispanic 304 (26.2%) 2 (25.0%) 306 (26.2%) Hispanic 109 (9.4%) 4 (50.0%) 113 (9.7%) Asian/Pacific Islander 10 (0.9%) - 10 (0.9%) American Indian/Alaskan 3 (0.3%) - 3 (0.3%) Unknown 2 (0.2%) - IL 2 (0.2 Total IF 1161 (100%) 8 (100%)—T— (100%) 1169(100%)::;: :;:: Age at the time of AIDS diagnosis New AIDS diagnoses by year Age Groups Total (% Under 5 6 (0.5%) 300- 5-12 2 (0.2%) .............................. .... 233 .... 250 13-19 2 (0.2%) 20 20-29 147 (12.6%) zoo 175 145 30-39 498 (42.6%) 150 95 9e 40-49 340 (29.1%) 100 79 65 ......................15.. 41 over 49 174(14.9%) 60 .. . ............. . ....... 7 8 Total .1169 (100%) 0 1982 1983 1884 1985 1986 1987 1988 1989 1990 1991 1992 1993 Contra Costa County HIV/AIDS Epidemiology Report 3 ........: ........:::. ...:.:::::::.:... ;::.:. :::.:::.::.... AIDCAES. NDERHENEW ' EXPANDED CA „S E .... . I.n 1993; the expanded:AIDS surveillance case. definition for adolescents and:adults:.(1) was implemented ly the Centers for Disease Control and Prevention(CDC) As a result of the expanded criteria,during the first:half bf:4993;;;225 new cases of.AIDS::were reported. These.people.would not have:received an:AIDS .: diagnosis under the old definition criteria, at least:until presenting one of.the diseases in the old list. ....... .. . More:thari half 6f:these new:definition cases occurred in previous years and:only now became reportable: ... .............. ..... .. The characteristics of:the newdefinition cases encountered:to date are.listed.below.Approximately 500.total ......... .;...::;::.:: ed:b the end of 1993 ainon Contra Co ta'residents. new definition:cases`are:expected.to be;report Y. . ; g s . .::::.. :::::::::::. 1993 Revised Clossification:System for HIV 7i fection.and Expanda.&rveillance:.Case Definition for;:AIDS Among Adolescents and Adults. CDC *MMWR December 18, 1992 Vol 41 /No RR I NEW DEFINITION CASES ONLY Total AIDS cases reported meeting the expanded definition criteria only, by mode of infection and gender Mode of HIV infection Males (%) Females (%) Total (%) Gay or bisexual men 103 (55.1%) 0 (0) 103 (45.8%) Heterosexual injection drug user 45 (24.1%) 25 (65.8%) 70 (31.1%) Gay/bisexual injection drug user 15 (8.0%) 0 (0) 15 (6.7%) Hemophiliac 3 (l.6%) 0 (0) 3 (1.3%) Heterosexual contact 3 (1.6%) 8 (21%) 11 (4.9%) Transfusion with blood/products 2 (1.1%) 3 (7.9%) 5 (2.2%) None of the above/other 16 (8.6%) 2 (5.3%) 18 (8.0%) Total77771 187 (100%) 38 (100%) 1 225:(1009b) AIDS cases meeting the expanded definition criteria only, by race/ethnicity Race/ethnicity Total (%) White, not Hispanic 114(50.7%) Black, not Hispanic 87 (38.7%) Hispanic 21 (9.3%) Asian/Pacific Islander 1 (0.4%) American Indian/Alaskan 2 (0.9%) Total ......... ';:::225.(100): ::: 4 August 1993 130 130 . . . .. . .. .... . ....................... ... . .. . . ' ° . 106 DEATHS AMONG PEOPLE . 100 . DIAGNOSED 80 .. ........... ......................s,.. 71 . 63.. WITH AIDS 60 51 ,. ......................39 . .. IN CONTRA COSTA 40. BY YEAR OF DEATH 20 ; 0 1982 83 84 85 86 87 88 89 90 91 92 1993 Contra Costa residents living with AIDS (As of July 31, 1993) Mode of HIV infection Males (%) Females (%) Total (%) Gay or bisexual men 242 (59.6%) OR 242 (52.2%) Heterosexual injection drug user 93 (22.9%) 39 (67.2%) 132 (28.5%) Gay/bisexual injection drug user 29 (7.1%) 0 (0) 29 (6.25%) Hemophiliac 5 (1.2%) 0 (0) 5 (1.1%) Heterosexual contact 5 (1.2%) 10 (17.2%) 15 (3.2%) Transfusion with blood/products 2 (0.5%) 6 (10.3%) 8 (1.7%) Parents at risk for HIV 1 (0.2%) 1 (1.7%) 2. (0.4%) None of the above/other 29 (7.1%) 2 (3.4%) 31 (6.7%) Total 406 (100%) 58 (100% 464:(100%) ..... Race/ethnicity distribution of people living with AIDS Race/ethnicity Adult/adolescent Pediatric Total (%) Cases (%) Cases (%) White, not Hispanic 249 (53.9%) - 249 (53.7%) Black, not Hispanic 159 (34.4%) 1 (50%) 160 (34.5%) Hispanic 48 (10.4%) 1 (50%) 49 (10.6%) Asian/Pacific Islander 2 (0.4%) - 2 (0.4%) American Indian/Alaskan 2 (0.4%) - 2 (0.4%) Unknown 2 (0.4%) 2 (0.4%) Total 462 (100%) .2 (100%) 464 (100'�b) ........: Contra Costa County HIV/AIDS Epidemiology Report 5 CITY DISTRIBUTION OF AIDS CASES IN CONTRA COSTA COUNTY, 1982-1993 Oakley -T� 9 Brentwood = 10 Bay Point 25 Antioch = 59 Pittsburg A ,02 -F- Alamo 8 Moraga =!j 10 Clayton =! 12 San Ramon _ 23 Lafayette = 24 Danville 26 Orinda 30 Pleasant Hill —�1 40 Martinez = 47 Walnut Creek 116 -r ll Concord - 1 175 Rodeo 7 Kensington 7 EI Sobrante =� ,6 Hercules =00' 18 North Richmond - 21 Pinole = 25 EI Cerrito 28 San Pablo 62 Richmond - . 266 0 50 100 150 200 250 300 The chart includes only cities where five or more residents have been reported. Seven additional Contra Costa cities reported fewer than five cases each. 6 August 1993 ..:.... ......... ....::::.:. ................. .;::... ..::.::.::.:::.....::.::........ .. B L.VIEW;`of the AID .:EPIDEMI . . . ... . . : . .. .. ...... . .. . .. . . Cases Baths Contra os (7/3I J • ... , . Area. .. 23 533 > 14 938; 6i3o Bay >:�. J . . . California:: 60 017 .........37 816 6r3o : . .. . .. . .... .. ......:.........:.:.:...:.:.;::.:... .....:..;... US: >>289 320 1 2 27 �i31 . .. . .. . .. ... . ;: ::;World: estimate . 2 5009000 .....:........ : ::> 500 OOO (7/31 ESTIMATE OF CONTRA COSTA COUNTY RESIDENTS INFECTED WITH HIV Based on back calculations a total of approximately 3,800 Contra Costa County residents are estimated to have been infected with HIV, the virus that causes AIDS. Of these, 1169 have already been reported to have AIDS. Some 500 more are expected to be diagnosed with AIDS and reported before the end of 1993. After 1993, the number of new AIDS diagnoses expected: 200-250 a year. Approximately 3,800 Contra Costa residents are estimated to have been infected with HIV 55% 2160 People with HIV & without AIDS in 19 250 Exp cted Old Def. Cases 7% 955 :' .. 275 22 8 /o E pected New Del. Cases 60 25% Old Definition Cases New Def. Cases Contra Costa County HIV/AIDS Epidemiology Report 7 The local epidemic among injection drug users Percent of heterosexual injection drug users among new Contra Costa AIDS cases, 1982-1993 (The actual number of cases is shown inside the histogram bar) Since the first years of the AIDS epidemic in Contra Costa County 30%-/ 25.8% increasing number of AIDS cases have been 25% IDUs. In addition to increasing numbers, z°% 14.1%. 14.4.% IDUs are becoming t5% larger proportions of the people diagnosed 10% 26; 4.. ; 139; with AIDS in Contra 2.4% 6% Costa. 0% 1982=88 1987-'88 1989-190 1991'93 HIV prevalence among injection drug users entering treatment in Contra Costa County tested blindly, by year and race/ethnicty * (xx/xxx= tested positive/total tested) (7/31/93) 1989 1990 1991 19921993 1989-93 White *11/179 17/629 15/468 20/573 2/122 65/1971 6.1% 2.7% 3.2% 3.5% 1.6% .3.3% . . . 26/70 . 8.3%2.67 81/21.7 66/222 19/74 > ; African .. 275/85. American 37.1%;; 31.1% 37.3% 29.7.% 25.7%..... 32.4% Hispanic 1134 5/82 6/80 7/96 0/18 2.9% 6.1% 7.5% 7.3% 0% 6.I%;;:::> : Other 014 2/42 2/40 2/56 1123 7/365 0% 4.8% 5% 3.6% 4.3% 19.% Missing 0/1 0/4 115 0/8 0/0IL 111V . .. >> . . ..... Total 38/288. ..107/1024 105/810 95/955 22/237 367/3314 .. ........ .;:.;:.;::;:.:::..:.. .:...... 13.2%. 10:4%; :;::..>:::>::13.0%;:;;:::::''::9.9.%; >: ..::9.3 0 .>:::: :::::>::11:1 IDUs tested at methadone treatment clinics. Clients readmitted during the same calendar year were excluded. g August 1993 HIV prevalence among injection drug users in Contra Costa County sampled with street surveys The University of California San Francisco Institute of Health Policy Studies, Urban .Health Study, has conducted street surveys among injection drug users of several San Francisco Bay Area communities, including Richmond. Surveys in the city of Richmond started in 1991. The following are the HIV prevalence rates found in these communities: 1991 (1) Site n tested HIV antibodies HIV prevalence positive rate San Francisco-West 255 31 12.2% San Francisco-Central 441 79 17.9% San Francisco-South 366 41 11.2% Oakland-Northeast 223 11 4.9% Oakland-West 240 43 17.9% . ; . ..... >;;;; :...::..:.: Richmond 222 43 >> > > 1 o. 1992 (2) Site n tested HIV antibodies HIV.prevalence positive rate Oakland-Northeast 327 23 7.0% Oakland-West 351 67 19.1% . >; : . .... : ......:.:::.: :Richmn : . . ..... ... .....:. o For more information see the references or contact Dr.John Watters, Urban Health Study, (415)476-3400. 1. Drug Itjectors and HIV-1 Infection in the San Francisco Bay Area. Watters, John K., Cheng,K T., Bluthenthal,R,at alt.International Conference on AIDS,Amsterdam, The Netherlands,July 19-24,1992. 2. HIV-1 Infection and Drug Injectors in OaklandlRichmond,California.Bluthenthal,Ricky;Estilo,Michelle and Watters, John. International Conference on AIDS, Berlin, Germany, June 7-11,.1993. Contra Costa County HIV/AIDS Epidemiology Report 9 .... NEW INFECTIONS AMONG;I CUON:DRUG USERS . ... . >I .:.:. .:..... .... The;ligh levels of HIV prevalence:in DUs;:in;;Contra Costa County, even after thea. implementation of preferential admission and recruitment to drug addiction treatment of ... infected IDUs and the::.deatli :of many.infected IDUs;; l) appears sustained by the occurrence of rieW lrifections: .. . .. . . .::.:::.: anh ies oma rou o :w o During 1991; 16 IDUs:tested positive; or g ; P .......................... .......... . 1 4; o Fif;;>> > f ;;. reported a prior negative;status;within 12 months (2.3%,95%CI . % 3.7%).: teen o . the newly infected;IDUs were African American. .. . . .... Data for the year 1992 show a similar picture. There were 2T IDUs..who:tested positive,:. out of 1,001; reporting a pnor negative status. This suggests new infections in 2.1% .. . (95%CI ,>1.4%=3.2%) . :the ;IDUs;;in.. methadone ..treatment. All 21;;apparently ;new infections presented in African American injection drug users ..... ...... .. .. . .. . .. . .. . . 1.Preferential:Admission of HIV:1Infected.;Ityection Drug;Users (ID:.W:10 Methdd6ne.Maintenance Treahnent .Policy Success:and E�{j`ect►veness: Reardon, Juan, Velten, E,Brunner,W„ Deutschman, C. ...... .... :::: &Ruiz,J Mh ti ternaiional.Cot fere►rce.on AIDS;Berliii;:Germany;June 6-11; I .93,Abs:#P.0=D183935 i; Most common diseases reported in people with AIDS in Contra Costa The available data largely represents the distribution of diseases present among PWA at the time of their first AIDS diagnosis, because diseases ocurring in people with AIDS after the initial AIDS diagnosis are usually not reported. The diseases listed are only the most commonly reported(07/93) Disease In injection drug users :.:.JJn all people..... with AIDS with`E1IDS Pneumocystis carinii pneumonia 28.5% 38:7;%... Kaposi's sarcoma 1.9% 13:8%. Wasting syndrome 14.0% 1.1.;:5..%:::: :::::::: Mycobacterium. avium 12.1% 91 Candidiasis, esophageal 9.8% 8.:9,°l0;:;:;::::::;. HIV encephalopathy 4.7% Cytomegalovirus disease, retinitis 0.9% 5.5.%..: Cryptococcosis 2.8% ..3.4,%.: : ;: Pulmonary TB, Other TB 8.4% 24 ; ::: .;...::. Toxoplasmosis of the brain 0.9% 23%::;:;;:;:::: io THE HIV / AIDS EPIDEMIC What is the problem? • AIDS stands for Acquired Immune Deficiency Syndrome, a condition that destroys the body's defenses against certain infections and cancers. AIDS is a fatal disease. • AIDS results from infection with the Human Immunodeficiency Virus (HIV). HIV is passed from one person to another through blood or sexual contact. HIV infection can result from one sexual encounter or from sharing a needle to inject drugs. • Many people with HIV infection appear healthy and do not know they are infected. HIV infection can be detected through an HIV antibody test, but many people most at risk for HIV infection have not yet taken a test. • Although medications can slow the deterioration of the immune system, there is no cure. • AIDS can be avoided, but risky behaviors are difficult to change even knowing the facts. Who is being affected by HIV/AIDS? • Since 1982, 1169 cases of AIDS have been reported in Contra Costa County. At least 701 persons have died. Currently an estimated 3,800 Contra Costans are infected with HIV. An additional 500 AIDS cases are projected by the end of 1993. To date 1059 men, 102 women, and 8 children have been diagnosed with AIDS. • The majority of people with AIDS are gay and bisexual men (63%) or gaylbisexual.men who injected drugs (6%), although increasing proportions of the people with AIDS are heterosexual injection drug users, women, African Americans and Latinos. The numbers of such cases are disproportionate to the population size. • Heterosexual injection drug users account for 18% of the cases. If the spread of HIV among injection drug users is not dramatically curtailed, this population soon could reach the levels of infection found in areas of the East Coast of the United States (60-70%). Currently the rate of infection among African American injection drug users in Contra Costa is 30%. • At least .5% of the general population, 10%-13% of all drug injectors, 12%-20% of gay and bisexual men, and 1 per thousand women delivering babies in Contra Costa are estimated to be HIV infected. • Increasingly, AIDS is occurring in West County and East County. Of people now living with AIDS, 40% now live in Central County, 40% in West County and 20% in East County. • AIDS in poor communities puts an increasing burden on the public health care system. IN CONTRA COSTA COUNTY 11 What are the social and economic costs of HIV/AIDS? • AIDS is largely a disease of the young. Already, early deaths of Contra Costa County residents from AIDS represents a loss of 19,000 potential years of life. If all HIV-infected Contra Costa residents develop AIDS, our communities could lose 130,000 potential years of life. • The estimated potential earnings lost by Contra Costa residents who have died from AIDS totals $388 million. Using the same rates for all persons estimated to be HIV-infected, the potential lost earnings could amount to more than $2.5 billion. • The annual cost of medical care for each person with AIDS is now estimated to be$38,000. The lifetime cost of caring for all Contra Costa residents estimated to be HIV-infected could require an additional $300 million. The amount of suffering by these persons and their families is immeasurable. What needs to be done? • Learn all you can about HIV and AIDS. Inform your families and friends and influence them to adopt healthy behaviors. • Increase AIDS awareness so that Contra Costa residents understand the disease. Understanding helps to eliminate unnecessary fears and prejudices and encourages a compassionate and supportive response to those who are suffering. • Protect people living with HIV infection from discrimination. • Provide testing, counseling, medical care and support for all people infected with HIV. • Increase HIV/AIDS prevention efforts by county, city and community agencies. • Reach the populations most at risk with concentrated prevention messages and innovative programs. • Expand efforts to involve city, community and church leaders in delivering AIDS prevention messages in the most affected areas of the county. 12 August 1993 The local MWAIDS epidemic among gay and bisexual men Percent of gay/bisexual men among new AIDS cases, 1982-1993 (The actual number of cases is shown inside the histogram bars) Gay/bisexual men =_----- --"-_-- constitute the group from which over 60% of all cases have been 100% reported in Contra 75.9% II Costa and the largest70% 89% i; eo% 64.8% group from which new 80% s2.a% cases are emerging. A so% a5.a% Nevertheless, a ii . . 40% declining trend is . observed in the i proportion of AIDS 20% 132 67 101 120 122 116 37 cases from this group. 0%- 1982-87 % 1982-87 1988 1989 1990 1991 1992 1993 HIV prevalence among non-IDU gay/bisexual men tested voluntarily in Contra Costa County publicly funded clinics, 1985-1993 * (xx/xxx= tested positive/total tested) 1985-87 1988 1989 1990 1991 1 1992 1993 1985-93 [*14'/7081 84/490 56/443 51/469 45/570 31/643 19/2828.8 17.1% 12.6% 10.9% 7.9% 4.8% 6.70/c Data includes only clients without a prior positive test. The tests may be of clients who repeated testing. 18.8% .. 20% 1 //-7 17.1% 15% 12.6% 10.4% 7.9% 10% - 6.7% 4.8% 5% 48 84 56 51 5 3`1 19 0%i° 1985-87 1988 1989 1990 1991 1992 1993 Contra Costa County HIV/AIDS Epidemiology Report 13 The local HIV/AIDS epidemic in women Annual HIV prevalence among childbearing women in Contra Costa County and California per 10,000 births . .................... .Contra Costa .. California 30 25 20 - 27.7: 027 7 12 15 10 5 7.6 6.4 7 8 V; - 1988 1989 1990 1991 Women of reproductive age with AIDS in Contra Costa County, by age group (n=91) 40 - 35 - ............ 0 35 Women constitute approximately 9% 30 of adult AIDS cases. 20 Assuming they may 25 also represent 9% of 20 1s all HIV infections, some 300 Contra 15 . ... . ............9.......... Costa women of 10 - reproductive oreproductive age may 2 be infected with HIV. 5 0 • At least 43 babies / have already been 0 born to these women. 13-19 20-24 25-29 30-34 35-39 40-44 AGE GROUP Data collected through July 31,1993 14 August 1993 HIV seroprevalence in female prostitutes and female injection drug users (IDUs): Between September 1989 and February 1992, 77 different female prostitutes were tested for HIV antibodies after a conviction in a local municipal court (Pittsburg, California). During the same period of time 244 female injection drug users residing in the same area (Pittsburg/Antioch) were blindly tested for HIV upon admission to methadone treatment. Results: Ten of the 77 female prostitutes (13%, 95% CI 7.2%-22.3%) 26 of the 244 female IDUs (10.7%, 95% CI 7.4%-15.2%) HIV infection among women attending pre-natal care clinics in Contra Costa County, 1989-1992. * (xx/xxx= tested positive/total tested) **HIV infected per 1000 pregnant women 1989 1990 1991 1992 1989-1992 White * 0/479 1/810 2/642 0/577 .::: ...3/2508 .. ....... ...... ** 1.23 3.1 1:2 . African 4/258 2/305 0/284 4/288 101135; American 15.5 6.6 13.9 . 88 Hispanic 0/378 0/620 0/781 0/85502634 Other 0/60 1/88 0/94 0/121 1/366 11.4 2.7 Missing 2/52 1/51 0/42 0/72J ::.�:.�:: .;:3/690 A7/7549_:::: . Total 1731 5/1922;;>;; 2/1936. . .411960 6l . ... .. . ... ..... . . . 34 2.6;;;> 1. 0 2.0 Contra Costa County HIV/AIDS Epidemiology Report IS > ;: ..:.. ::.;::::. >... ...;.. n HIV/AID . Children a d . . . . >.. . . ... . . . Eight Contra Costa children (1-12 years have been,reporte wit ...:.:::::. .. . : .. ..:.......... . :. ;> .....:... .......::.::.: . At least;43r Contra Costa children.mere born to HIV infected::women..' " ....... . . .; ; . . . .. : :::: .. .; . . . .. >;.. . ..... .. .:;:. Children's Hospital Oakland Pediaf I AIDS/HIV...... m has evaluated;cared for and monitored:43 children with residence in Contra Costa who at some time presented with :>>; . .. ::antibodies against the HIV v rus. Of these; a third:is`estimated.to:be infected:' .. .... . .. . The maternal antibodies'presentrin;the of ers wi isappear y t e sewn year: .:.;;.:: . . ............. . ...... .. . ..... .... ..;...;.; .;. .. .... ............... Demographic characteristics;of,rthe above 43;c ildren ....... .. . .... .. . . . . ti • . .. . . Gender;;;> Race/et mcit . . . . ..:.:.:::.::.::::::. . . . Male= 22 51.2% White= 9 20,9% ( ) — Female= 21 48.8% :::::;::>::; :African American= 27 62.8% . ... ) .. . ( ) .. ..... . . ... . H . . ;. ... _ ispariic 7 (1 , .. ... rm .eabove .wweo, proheet .. . ......... . ... . .. . :: =9 . 912; 186198childrenf: . .. r.. d .::.. . . . ... ... . e .. . . ; . .. . ....... .. 09 =1referred;9clnd .. . . . . . . . . ... . ; Risk:factorrfor HIV Uthe mothers of the above children . . . ... . ..... .. ..... .... . .. . .... . . .. . .. De 2.. InJection :. . . ... . :. ...... . ..... .U ..... ..... ;: :... ....... 8 (1 ) : C86l aa ...xr .n ..Unknown= :. .. : 3" 7" %. : 16 August 1993 . ........................ . in teenagers �n Contra Costa. . ..... . , Only two of the 1169 Contra Costa AIDS cases`re rt. since the be innin o.. Y ............. . .... .P°; .. . , .... ......:.:::::.. ... r h ti: 'o t eir is n si . the epi emit were'teenage s at>t; e t ° :s; . .. ............ . . . ....... ....... ............ >> .. .. r m>Contra osta County:are ein car for and . A total of ii ung adults o Y g . followed-u at :Oakland. Children's Hospital;,;Five ; of; these ;six cases ,are m hiliac. he o . ... . .:.......:.......:.:::::::::::::::.:.::::::::::.. .. . ..... .... .. . . . . .; .. . . Dunn 1992 a ;;total of 951 teenagers;:;;:; resented ::voluntarily ffor testing:at. g P ublicl funded saes in Contra osta ounty: o m ections were o. ..u. h d p l 1 .....:::...... . n r re "rted t at un 989 0 000 Kaiser Northern California;Ce to s . . Po g members includingapproximatelY 200 teenagers (15=19) were:blindly tested for HIV. No HIV infections were found;in Kaiser members aged 15,=19. .. . Young gay.and bisexual:men,(17-19 years.old) :in:the<San Francisco Bay Area often continue to have unprotected sex (35.2%) and presented, with a 4 1% HIV infection rate.(2) . . . . Contra Costa Teenagers represented 26%:;of the 560:cases of penicillin resistant,;;;; P gonorr ,ea: an o o e; ;; cases .o s i is re or in; on ra . .. ... Y Costa'Count between 19.88.an .::..::.:::: . . ....... , ........... .. . :..:....... . ::.;. ..... : .. .. fl)Seroprevalence of HIV::Ty.pe 1 to:a Northern Ca i omit Hent an opu tition.. n. i in Survey: Hiatt RA, Capell FJ, Ascher MS. Americaii Journal of Public Health, vol. 82, 4 April ..: 55: 1 , p96 ..:::::::::::.. .. . .. .............. ... ... ....... .......:......:.. ..... .. ... ... (2)HIV-1: valence.and Risk Behaviors Among:Young Men:who:;Have.Sex.w.ith Min.Lem .:. . ......... .... . . P . GF,Hirozawa A; Givertz D. et.al.;San Francisco Dept.o Pu is:Hea.i. Salt.Franciseoi.Ca.;1993;: HIV prevalence for civilian applicants for military ser:betvveen from Contra Costa County, by year * (xx/xxx= tested positive/total tested) F[j/ 1986 1987 1988 1989 1990 195-91 7 5/1417 3/1358 4/1245 1/1248 0/978 0/ 7488'0.35% 0.22% 0.32% 0.08% 0.0% 0. 7:%;«:;ata provided by the U.S.Department of Defense,and CDC.Data collection -12/91. Contra Costa County HIV/AIDS Epidemiology Report 17 California counties with the highest cumulative incidence of AIDS cases per 100,000 population San Francisco - 1894.17 Marin -N�w 313.35 Los Angeles - 225.53 Alameda - 216.31 Sonoma 205.0.4 San Diego T1.46.7 169.97: San Mateo Contra Costa 126.78 Solano - � 116.62 Sacramento - 112.46 F7--- 0 7 --0 500 1000 1500 2000 2500 Contra Costa County cities with the highest cumulative incidence of AIDS (Population based incidence per 1,000 residents reported for cities with >50 cases) Richmond - 2.7 San Pablo 2.4 Pittsburg 2.1 Walnut Creek - � 1.9 Concord - 1.5 Antioch - 0.96 0 0.5 1 1.5 2 2.5 3 3.5 Residents of unincorporated areas (i.e. Bay Point, North Richmond) have not been included in this analysis. 18 August 1993 . Surveillance of the response to needs emerging from the AIDS epidemic in Contra Costa County In the last 12 months, 918 unduplicated individuals were provided services by eight agencies receiving funds from the federal government under the Ryan White CARE Act and Housing Opportunities for People with AIDS (HOPWA). The funds received totaled $1.1 millon. There were a total of 14,561 client contacts, which represents an average of 1,200 contacts per month, 40 contacts per day. For 403 (44%) of these clients the following income information is available: Iri m n c e .. . ..::...... .:.:::::.:. . ..... ..::.:.:... ...::.:::::.... .....0......:. o ..::::.:::.:::::......: ..;:. ... .. . .....:.:.:::.::..... . .:::.. . . Less.than er rn t 3859. . Between 601 and.:. 900 per month 106; .. 26:3%. Between $901:and $1 200 er:month 34 8 4%:::.:.. . ; P Over $1 20Q per.:month 25 > > 62% . . . .. .. . .. The HIV/AIDS status of 538 (58.6%) of these clients is known, as follows: . . .......... ...... . .; ...::..:.... tatus n; . . ..::::::::.::. ..::::::::::.:. AID 2 4 .. ... ... . ;.. ; ;; 38...:::::.>:: 4.2% .. S . . . . ... .::.::.::.;.::. AR Di blin HIV 10 1 > ; . . .. . .. . ........... . . . ..... HIV Infected 1 4>< 2 . ... ....:::::.....:::.;:.;:.;:.;:.;:.;.... o of 1Family..!members PeoPle wi HIV 1,400 vouchers were issued to people with HIV for.items such as food, transportation to and from medical appointments, emergency housing/utility payments to allow to maintain secure housing. 3,696 bags of groceries were delivered.to 175 clients. 80 West County residents took advantage of the drop in center at Tranquilium. 55 clients received housing advocacy services to maintain or acquire affordable housing. 82 clients became eligible for AIDS Drug Assistance Program(State4unded-program to subsidize medically prescribed therapies). (7he above list of services provided is only a partial one. Data is not available frotn several local organizations and tnany individuals assisting those affected by the epidemic are not funded by the CARE Act or HOPWA). Contra Costa County HIVtA1DS Epidemiology Report 19 ury i 1 n S e ace of unmet:needs r e following unmeet n s have been reported'by co nmum, y;based organizations as not :available for the HIWAIDS clients theyserve or;in need of expansion c ease_case:management services - especially in<Gentral County,:: l Y h' * Increase services of all lands in Spanish and other languages * .. <; ousiri arta y cu az in st u f g .. o my or HIV/AIDS'unemployed'people Da dr Y op, n.center n;East Dunt 1 *:Increase ser . es all kinds) in North Richmond<;; »; Den care Resid ental;has ice in each re ion of;the I? g ; County. * Increase direct"Financial assistance for food and transportation: * Mental health services 'Increase services in he ails Increase test in services; o rsons:at increased risk. . g: 1� . Contra Costa County AIDS diagnoses by diagnosing medical care facility type (7he distribution of medical facilities where AIDS cases were diagnosed is likely to mimic the distribution of medical facilities providing health care for HIV infected Contra Costans) Medical Facility AIDS Diagnoses % Contra Costa County hospital and clinics: 386 33.0% Kaiser Permanente Facilities in Contra Costa and the Bay Area: 273 23.4% Private Facilities in other counties: 130 11.1% Public Facilities in other counties: 109 9.3% Other Private Hospitals in Central Contra Costa County: 95 8.1% Other Private Hospitals in West Contra Costa County: 54 4.6% Other Private Hospitals in.East Contra Costa County: 14 1.2% Private Medical Doctors: 60 5.1% VA/Naval Hospitals: 46 3.9% Diagnoses at medical facilities in other counties largely reflect diagnoses which occurred at the beginning of the AIDS epidemic when diagnosis and treatment was available only in a few sites of the region. 20 August 1993 REPORTING AIDS CASES All health care providers are required to report AIDS cases to their local health department. AIDS is reportable under the California Code of Regulations, Title 17, Health, Section 2500. HOW TO REPORT: By telephone. By completing a Confidential Morbidity Report (CMR) card. By completing an Acquired Immunodeficiency Syndrome Pediatric or Adult Confidential Case Report Form. WHERE TO REPORT: Contra Costa Department of Health Service AIDS Program 597 Center Street, Suite 200 Martinez, CA 94553 Denise Johnson (510) 313-67.93 or Derrick A. Green (510) 313-6792 WHY REPORTING IS NECESSARY: * It is the law. * To monitor trends in HIV-related disease. * To monitor trends in HIV-infection. * To project future numbers of AIDS cases. * To plan for future health care needs and services. * To provide information on the natural history of HIV infection. * To plan prevention and educational activities. * To identify persons in need of specific services from State and local health departments, (i.e. voluntary partner notification, counseling, and treatment). * To develop funding formulas and eligibility criteria for distributing AIDS resources from agencies such as the Health Resources Administration (HRSA), the National Institute on Drug Abuse (NIDA), the Centers for Disease Control and Prevention (CDC) and the million of dollars to State and local health departments for programs such as AIDS drug distribution, hospice care, outreach programs,prevention programs, coordination of patient services, pediatric AIDS health care and out-of-hospital care programs. Contra Costa County HIV/AIDS Epidemiology Report 21 .....:. .::::. ....... Re ortin AIDS: Summar of Le illation .... p > ;$> . . ... . . ::.::.....::: calif tnia.Adminmrative Code, Title 17'(Section 1603.1), ,;::a hospttal all 'report; the name, date of birth, address, social security number; name of hospital; the date of, , . hospital and any other information required on all contrmed cases gf A1DS fo;the;;;;; P State De artment o Health and the coun heals o cer ' P .: f . ... ty. : ria. 4 2 O5 a 25 250 5 .. . i 2 ,00 03 CaLfornia Administrative ;Code, Title 17 : ect on ...... .., , ... . .::....:. .:::.. 1508).7&e erson must report'tothe;Healtli 0f�`acer any;diagnosed;or suspecte case. . . of any of the following diseases or condtttons:Acquired Immunodef ciency Syndrome " ... .. . . . . ..:....: :.... .. . ........ ... :: California Administrative.Code, Title 17;;(Sedion 2512)-.Allows the;local:health officer to investi ate communicable diseases. . ....:.. ...:::: X. g . . . .. .... California Health and.:...S..afetk;:Code,; (Section :199...21:.[i]) HIV;: test results may be ` reported to local health authorities as part of AIDS diagnosis. .. 2 California Health and:Safety. ;Code; (Section 199 21:199. and 1603.3). ' owl ; disclosure to public health'authorities of result of HIV test.performed on cadavers Allows . ... for.HIV. test.t be.performed on cadavers without written consent:.as part of an autopsy'. ; or m;conjunction with anatomical gifts. California Health and>Safety Code, ;(Section'199:2 n Allows. for volunta .contact..:.:.... . . D'.. acingwith the;written consent,of the HIV;sero osit ye;individual:;;..; . RAL R S EFER . :::;For:information::on services available for:people with HIV/AIDS;;:::: in Contra Costa County call the,HIWAIDS:program . . . 313-6770 .... ... . ... ........ . .. . ,, . . ::..Copies'of this;report or madditional a idemioI ic. information; ; P P g . can be obtained b callin . . Y . . . . . .;. . . . . : . : 313 6791 :;, � n ton « o n may ® k ƒ