VIRUSMYTH HOMEPAGE


HIV INFECTION AS LEADING CAUSE OF DEATH IN YOUNG ADULTS?

By Robert Maver

Rethinking AIDS July 1993


A recent article in JAMA (Selik, et al., 1993; 269:2991-2994) received quite a bit of play in the national media last month. The article reported that in 1990 HIV infection was the leading cause of death among young men and women (ages 25-44) in many United States cities. In fact, HIV infection was reported as the second leading cause of death overall among males ages 25-44 in the population at large (sixth leading cause of death overall among females ages 25-44).

Coming on the heels of the International AIDS Conference in Berlin, which presented HIV infection as a global pandemic, it was only natural that American newspapers would seize upon the article to trumpet the notion that HIV/AIDS is similarly a threat to the U.S. population at large. Heretofore, American journalists were constrained to support what is not going on in the U.S. and other industrialized nations (AIDS not spreading outside identified risk groups) by citing worldwide figures and trends which are dominated by third world countries.

Unfortunately, the mortality data source employed in the JAMA article did not provide information on the mode of HIV transmission. As a result, the conclusions can easily be misleading to the casual reader, who may assume that HIV deaths are prevalent in the young adult population at large.

The CDC records on AIDS capture exactly the data needed to establish the mode of transmission for AIDS deaths in 1990. The CDC public information diskettes with information reported through June, 1992 reveal the following profile for the JAMA mortality data.

Deaths from AIDS in 1990 for ages 25-44
Males
18,797
Females
2,323
Total
21,120

The male deaths can be further broken down as follows:

Homosexual and/or Bisexual Males 13,594
Heterosexual Males 5,203
Total Males 18,797

The Heterosexual Males can be further broken down as follows:

Intravenous Drug Abusers 4,102
Hemophiliacs 119
Heterosexual 265
Pattern II country 109
Transfusion 110
Unkown 498*
Total Heterosexual Males 5,203

* Most (90%) of these cases are subsequently reclassified into known high risk groups.

Of the 265 heterosexual male deaths above, CDC records reveal that 164 of these were in the category of "sex with an IV drug abuser." Thus, for the vast majority of the male population, i.e., heterosexuals not involved with IV drug abuse, there were 101 deaths in 1990.

Similarly, female deaths can be further broken down as follows:

Intravenous Drug Abusers 1,308
Hemophiliacs 4
Heterosexual 737
Pattern II country 49
Transfusion 86
Unknown 139*
Total Heterosexual Females 2,323

*Most (90%) of these cases are subsequently reclassified into known high risk groups.

Of the 737 heterosexual female deaths above, CDC records reveal that 542 of these were in the category of "sex with an IV drug abuser." Thus, for the vast majority of the female population, i.e., heterosexuals not involved with IV drug abuse, there were 195 deaths in 1990.

The total U.S. male population ages 25-44 is approximately 40 million. The homosexual/bisexual segment of this population is in the 2 to 4 million range. (The latest studies suggest a homosexual/bisexual population of less than 5%. Older studies estimated 10%.) If we use an estimate of 800,000 for the IV drug population, then we are left with 35.2 to 37.2 million male non-IV drug abusing heterosexuals. The death rate for this group, which comprises the vast majority of the male population at these ages, is calculated as 101/36,200,000=.28 per 100,000, again, an extremely low value.

The total U.S. female population ages 25-44 is approximately 40 million. If we use an estimate of 200,000 for the IV drug population, then we are left with 39.8 million female non-IV drug abusing heterosexuals. The death rate for this group, which comprises the vast majority of the female population at these ages, is calculated at .49 per 100,000.

The JAMA article presented the 10 leading causes of death for ages 25-44 as follows:

males (n=101,519) females (n=42,134)
Rank Cause Death, % Cause Death, %
1 Unintentional injury 21.2 Cancer 28.0
2 HIV infection 16.5 Unintentional injury 14.6
3 Hearth disease 11.0 Hearth disease 11.0
4 Cancer 9.7 Suicide 5.9
5 Suicide 9.6 Homicide 5.8
6 Homicide 9.5 HIV infection 4.8
7 Liver disease 3.2 Stroke 3.9
8 Stroke 1.7 Liver disease 3.1
9 Pneumonia 1.4 Diabetes 2.1
10 Diabetes 1.3 Pneumonia 1.8
??? Heterosexual AIDS
(non-IV drugs)
0.1 Heterosexual AIDS
(non-IV drugs)
0.5

As the figures make clear, HIV/AIDS deaths in the heterosexual non-IV drug abusing segment of the population are nowhere near the top 10 causes. For males, the 10th leading cause-diabetes-yielded 13 times more deaths in 1990. Indeed, it is difficult to construe 101 male heterosexual AIDS deaths as an epidemic.

In an accompanying editorial to the JAMA article, the opportunity to correct the misperception that HIV deaths are significant in the population at large was unfortunately missed. In fact, the editorial suggested that AIDS was moving out of its original epicenters and claimed that "adolescent and young adult HIV transmission guarantees the continuation of the AIDS/HIV epidemic." This is a curious statement given the fact that AIDS cases in adolescents and young adults have decreased three years in a row according to the following CDC data.

#AIDS cases* (in adolescents 13-19 years old, and adults 20-24 years old)
1990
1,786
1991
1,633
1992
1,605
* The vast majority (90%) of these cases are in high risk groups.

Perhaps the most unfortunate aspect of the JAMA article and the attendant media coverage is that it remains true that AIDS is the leading cause of death among young adults in many major U.S. cities. These deaths, however, are largely related to drug abuse. The JAMA article should have focused our attention on the problem of drug abuse in our inner cities instead of serving as a decoy for perpetuating the myth that AIDS is spreading out of its original high risk groups.*

Robert Maver is consulting actuary and formerly served as an executive with Mutual of New York.


VIRUSMYTH HOMEPAGE