Guidelines for National Human

Immunodeficiency Virus Case

Surveillance, Including Monitoring for
Human Immunodeficiency Virus
Infection and Acquired
Immunodeficiency Syndrome
The folloing C!C staff mem"ers #re#ared this re#ort$
Patricia L. Fleming, Ph.D., M.S.
John W. Ward, M.D.
Robert S. Janssen, M.D.
Kevin M. De Cock, M.D.
Division of HIV/AIDS Prevention-
Surveillance and Epidemiology
National Center for HIV S!D and !" Prevention
Ronald . !aldiserri, M.D., M.P.".
"elene D. #a$le, M.D., M.P.".
#ffice of t$e Director
National Center for HIV S!D and !" Prevention
in collaboration %ith
Je&&re$ L. Jones, M.D., M.P.".
J. Stan Lehman, M.P."
Mar$ Lo' Lindegren, M.D.
(ll$n K. )akashima, M.D.
Jose*h M. Posid, M.P.".
Patrick S. S'llivan, D.!.M., Ph.D.
Patricia (. S%eene$, M.P.".
Pascale M. Wortle$, M.D., M.P.".
Division of HIV/AIDS Prevention
National Center for HIV S!D and !" Prevention
+va M. Seiler, M.P.(
#ffice of t$e Director
National Center for HIV S!D and !" Prevention
"arold W. Ja&&e, M.D.
Division of AIDS S!D and !" %a&oratory 'esearc$
National Center for Infectious Diseases
Summary
CDC recommends t$at all states and territories conduct case surveillance for $uman
immunodeficiency virus (HIV) infection as an e*tension of current ac+uired
immunodeficiency syndrome (AIDS) surveillance activities, !$e e*pansion of national
surveillance to include &ot$ HIV infection and AIDS cases is a necessary response to t$e
impact of advances in antiretroviral t$erapy t$e implementation of ne- HIV treatment
guidelines and t$e increased need for epidemiologic data regarding persons at all stages
of HIV disease, E*panded surveillance -ill provide additional data a&out HIV-infected
populations to en$ance local state and federal efforts to prevent HIV transmission
improve allocation of resources for treatment services and assist in evaluating t$e
impact of pu&lic $ealt$ interventions, CDC -ill provide tec$nical assistance to all state
and territorial $ealt$ departments to continue or esta&lis$ HIV and AIDS case
surveillance systems and to evaluate t$e performance of t$eir surveillance programs,
!$is report includes a revised case definition for HIV infection in adults and c$ildren
recommended program practices and performance and security standards for
conducting HIV/AIDS surveillance &y local state and territorial $ealt$ departments,
!$e revised surveillance case definition and associated recommendations &ecome
effective .anuary / 0111,
INT%&!'CTI&N
(,DS s'rveillance has been the cornerstone o& national e&&orts to monitor the s*read o&
",! in&ection in the -nited States and to target ",!.*revention *rograms and health.care
services. (ltho'gh (,DS is the end.stage o& the nat'ral histor$ o& ",! in&ection, in the
*ast, monitoring (,DS.de&ining conditions *rovided *o*'lation.based data that re&lected
changes in the incidence o& ",! in&ection. "o%ever, recent advances in ",! treatment
have slo%ed the *rogression o& ",! disease &or in&ected *ersons on treatment and
contrib'ted to a decline in (,DS incidence. /hese advances in treatment have diminished
the abilit$ o& (,DS s'rveillance data to re*resent trends in the incidence o& ",! in&ection
or the im*act o& the e*idemic on the health.care s$stem. (s a conse0'ence, the ca*acit$
o& local, state, and &ederal *'blic health agencies to monitor the ",! e*idemic has been
com*romised 12.34.
,n res*onse to these changes and &ollo%ing cons'ltations %ith m'lti*le and diverse
constit'encies 1incl'ding re*resentatives o& *'blic health, government, and comm'nit$
organi5ations4, CDC and the Co'ncil o& State and /erritorial +*idemiologists 1CS/+4
have recommended that all states and territories incl'de s'rveillance &or ",! in&ection as
an e6tension o& their (,DS s'rveillance activities 12,74. ,n this manner, the ",!8(,DS
e*idemic can be tracked more acc'ratel$ and a**ro*riate in&ormation abo't ",!
in&ection and (,DS can be made available to *olic$makers. CDC contin'es to s'**ort a
diverse set o& e*idemiologic methods to characteri5e *ersons a&&ected b$ the e*idemic in
the -nited States 19.2:4. (ltho'gh ",!8(,DS case s'rveillance re*resents onl$ one
com*onent among m'lti*le necessar$ s'rveillance strategies, this re*ort &oc'ses
*rimaril$ on CDC;s recommendation to im*lement ",! case re*orting nation%ide.
/his re*ort *rovides a revised case de&inition &or ",! in&ection in ad'lts and children,
recommended *rogram *ractices, and *er&ormance and sec'rit$ standards &or cond'cting
",!8(,DS s'rveillance b$ local, state, and territorial health de*artments. /he case
de&inition &or ",! in&ection %as revised in cons'ltation %ith CS/+ and incl'des the
c'rrent (,DS s'rveillance criteria as a com*onent 1224. /he recommended *rogram
*ractices and *er&ormance and sec'rit$ standards are based on a4 the established *ractices
o& (,DS and other *'blic health s'rveillance s$stems< b4 revie%s o& state and local
s'rveillance *rograms, con&identialit$ stat'tes, and sec'rit$ *roced'res< c4 st'dies o& the
*er&ormance o& s'rveillance s$stems< d4 ongoing eval'ations o& determinants o& test.
seeking or test.avoidance in relation to state *olicies and *ractices on ",! testing and
re*orting< and e4 disc'ssions at a cons'ltation held b$ CDC and CS/+ in Ma$ 2==>. (
dra&t o& this re*ort %as made available &or *'blic comment &rom December 2:, 2==?, to
Jan'ar$ 22, 2===, thro'gh a notice *'blished in the 2ederal 'egister 12@4.
(AC)G%&'N!
History of AI!S and HIV Case Surveillance
Since the e*idemic %as &irst identi&ied in the -nited States in 2=?2, *o*'lation.based
(,DS s'rveillance 1i.e., re*orting o& (,DS cases and their characteristics to *'blic health
a'thorities &or e*idemiologic anal$sis4 has been 'sed to track the *rogression o& the ",!
e*idemic &rom the initial case re*orts o& o**ort'nistic illnesses ca'sed b$ a then
'nkno%n agent in a &e% large cities to the re*orting o& >22,377 (,DS cases nation%ide
thro'gh J'ne 3:, 2=== 19,23.294. /he (,DS re*orting criteria have been *eriodicall$
revised to incor*orate ne% 'nderstanding o& ",! disease and changes in medical *ractice
12A.2=4. ,n the absence o& e&&ective thera*$ &or ",! in&ection, (,DS s'rveillance data
have reliabl$ detected changing *atterns o& ",! transmission and re&lected the e&&ect o&
",!.*revention *rograms on the incidence o& ",! in&ection and related illnesses in
s*eci&ic *o*'lations 1@:.@94. Beca'se o& these attrib'tes, (,DS s'rveillance data have
been 'sed as a basis &or allocating man$ &ederal reso'rces &or ",! treatment and care
services and as the e*idemiologic basis &or *lanning local ",!.*revention services.
With the advent o& more e&&ective thera*$ that slo%s the *rogression o& ",! disease,
(,DS s'rveillance data no longer reliabl$ re&lect trends in ",! transmission and do not
acc'ratel$ re*resent the need &or *revention and care services 1@A,@>4. ,n 2==A, national
(,DS incidence and (,DS deaths declined &or the &irst time d'ring the ",! e*idemic
1Fig're 24. /hese declines have been *rimaril$ attrib'ted to the earl$ 'se o& combination
antiretroviral thera*$, %hich dela$s the *rogression to (,DS and death &or *ersons %ith
",! in&ection 12.3,=4. Revised ",! treatment g'idelines recommend antiretroviral
thera*$ &or man$ ",!.in&ected *ersons in %hom (,DS.de&ining conditions have not $et
develo*ed 1@?.3:4. ,n addition, antiretroviral treatment o& *regnant %omen and their
ne%borns has red'ced *erinatal ",! transmission and res'lted in dramatic declines in the
incidence o& *erinatall$ ac0'ired (,DS 132,3@4 1Fig're @4. ,n res*onse to these changes
in ",! treatment *ractices and the in&ormation needs o& *'blic health and other
*olic$makers, CDC and CS/+ have recommended that all states and territories e6tend
their (,DS case s'rveillance activities to incl'de ",! case s'rveillance and the re*orting
o& ",!.e6*osed in&ants 12,7,334.
Since 2=?9, man$ states have im*lemented ",! case re*orting as *art o& their
com*rehensive ",!8(,DS s'rveillance *rograms. (s o& )ovember 2, 2===, a total o& 37
states and the !irgin ,slands 1!,4 had im*lemented ",! case s'rveillance 'sing the same
con&idential s$stem &or name.based case re*orting &or both ",! in&ection and (,DS< t%o
o& these states cond'ct *ediatric s'rveillance onl$ 194 1Fig're 34. (reas that cond'ct
integrated ",!8(,DS s'rveillance &or ad'lts, adolescents, and children have re*orted
7@C o& c'm'lative -.S. (,DS cases. ,n addition, &o'r states 1,llinois, Maine, Mar$land,
and Massach'setts4 and P'erto Rico, re*resenting 22C o& c'm'lative (,DS cases, are
re*orting cases o& ",! in&ection 'sing a coded identi&ier rather than *atient name.
Washington has im*lemented ",! re*orting b$ *atient name to enable *'blic health
&ollo%.'*< a&ter services and re&errals are o&&ered, names are converted into codes. ,n
most other states, ",! case re*orting is 'nder consideration or la%s, r'les, or reg'lations
enabling ",! s'rveillance are e6*ected to be im*lemented d'ring @:::.
,n contrast to (,DS case s'rveillance, ",! case s'rveillance *rovides data to better
characteri5e *o*'lations in %hich ",! in&ection has been ne%l$ diagnosed, incl'ding
*ersons %ith evidence o& recent ",! in&ection s'ch as adolescents and $o'ng ad'lts 123.
@7.$ear.olds4 137,394. & the 9@,A=: ",! in&ections diagnosed &rom Jan'ar$ 2==7
thro'gh J'ne 2==> in @9 states that cond'cted name.based ",! s'rveillance thro'gho't
this *eriod, 27C o& cases occ'rred in *ersons aged 23.@7 $ears. ,n com*arison, o& the
@:,@29 *ersons in %hom (,DS %as diagnosed in these @9 states, onl$ 3C o& cases
occ'rred in *ersons aged 23.@7 $ears. /h's, (,DS case s'rveillance alone does not
acc'ratel$ re&lect the e6tent o& the ",! e*idemic among adolescents and $o'ng ad'lts.
Com*ared %ith *ersons re*orted %ith (,DS, those re*orted %ith ",! in&ection in these
@9 states %ere more likel$ to be %omen and &rom racial8ethnic minorities 13A4 1/able 24.
/hese *atterns re&lect the characteristics o& *o*'lations that %ere a&&ected b$ the
e*idemic more recentl$, b't the$ might also re&lect changes in testing *ractices or
behaviors 1A,3A,3>4. Com*ared %ith the diagnosis o& (,DS, %hich can be dela$ed among
",!.in&ected *ersons receiving antiretroviral thera*$, the &irst diagnosis o& ",! in&ection
is not dela$ed b$ treatment b't is a&&ected b$ testing behaviors and targeted testing
*rograms. ,n addition, in these @9 states as o& J'ne 3:, 2===, the total n'mber o& *ersons
129=,:?34 %ho %ere re*orted as living %ith either a diagnosis o& ",! in&ection 1=:,A==4
or (,DS 1A?,3?74 %as 233C greater than that re*resented b$ the n'mber living %ith
(,DS alone 194. /here&ore, these states have doc'mented that the combined *revalence o&
those living %ith a diagnosis o& ",! in&ection and those living %ith (,DS *rovides a
more realistic and 'se&'l estimate o& the reso'rces needed &or *atient care and services
than does (,DS *revalence alone.
States %ith con&idential name.based ",! case s'rveillance s$stems have 'sed data on all
*erinatall$ e6*osed children to doc'ment the shar* decline in *erinatall$ ac0'ired ",!
in&ection, the increase in the *ro*ortion o& in&ected *regnant %omen %ho have been
tested &or ",! in&ection be&ore deliver$, and the high *ro*ortion o& ",!.in&ected
*regnant %omen %ho acce*t 5idov'dine thera*$ 132,3?.774. /hese &indings contrib'te to
",!.*revention *olic$ develo*ment. CS/+ and the (merican (cadem$ o& Pediatrics
have recommended that all states and territories cond'ct *ediatric ",! s'rveillance that
incl'des all *erinatall$ e6*osed in&ants to &acilitate &ollo%.'* to assess in&ection stat's
and access to care 122,32,33,7:,794.
Persons can choose to be tested &or ",! in the &ollo%ing %a$sD a4 anon$mo'sl$ ..
%hereb$ identi&$ing in&ormation, incl'ding *atient name and other locating in&ormation,
are not linked to the ",! test res'lt 1e.g., at anon$mo's testing sites4 and b4
con&identiall$ .. %hereb$ the ",! test res'lt is linked to identi&$ing in&ormation s'ch as
*atient and *rovider names 1e.g., at medical clinics4. ,n states that re0'ire ",! case
re*orting, *roviders in con&idential medical or testing sites are re0'ired to re*ort ",!.
in&ected *ersons to *'blic health a'thorities. )ot all *ersons in&ected %ith ",! are tested,
and o& those %ho are, testing occ'rs at di&&erent stages o& their in&ection. /here&ore, ",!
s'rveillance data *rovide a minim'm estimate o& the n'mber o& in&ected *ersons and are
most re*resentative o& *ersons %ho have had ",! in&ection diagnosed in medical clinics
and other con&idential diagnostic settings. /he data re*resent the characteristics o&
*ersons %ho recogni5e their risk and seek con&idential testing, %ho are o&&ered ",!
testing 1e.g., *regnant %omen and clients at se6'all$ transmitted disease ES/DF clinics4,
%ho are re0'ired to be tested 1e.g., blood donors and militar$ recr'its4, and %ho are
tested beca'se the$ *resent %ith s$m*toms o& ",!.related illnesses. CDC estimated that,
in 2==A, a**ro6imatel$ t%o thirds o& all in&ected *ersons in the -nited States had ",!
in&ection diagnosed in s'ch settings 17A4. ",! s'rveillance data might not re*resent
'ntested *ersons or those %ho seek testing at anon$mo's test sites or %ith home
collection kits< s'ch *ersons are not re*orted to con&idential ",!8(,DS s'rveillance
s$stems. "o%ever, the availabilit$ o& anon$mo's testing is im*ortant in *romoting
kno%ledge o& ",! stat's among at.risk *o*'lations and *rovides an o**ort'nit$ &or
co'nseling to red'ce high.risk behaviors and vol'ntar$ re&errals to a**ro*riate medical
diagnosis and *revention services.
Des*ite their c'rrent limitations, ",! and (,DS case s'rveillance data together can
*rovide a clearer *ict're o& the ",! e*idemic than (,DS case s'rveillance data alone.
/here&ore, CDC and CS/+ contin'e to recommend that all areas im*lement ",! case
re*orting as *art o& a com*rehensive strateg$ to monitor ",! in&ection and ",! disease.
/he strateg$ sho'ld also incl'de s'rve$s o& the incidence and *revalence o& ",!
in&ection< (,DS case s'rveillance< monitoring ",!.related mortalit$< s'**lemental
research and eval'ation st'dies, incl'ding behavioral s'rveillance< and statistical
estimation o& the incidence and *revalence o& in&ection and disease.
Considerations in Im#lementing Nationide HIV Case Surveillance
/he nation%ide im*lementation o& the 2==3 e6*anded (,DS s'rveillance case de&inition
*rom*ted rene%ed disc'ssions o& the rationale and need &or data re*resenting ",!.
in&ected *ersons %ho did not meet the (,DS.de&ining criteria. Beca'se man$ states %ere
considering im*lementing ",! re*orting, CDC held a cons'ltation in 2==3 %ith *'blic
health and comm'nit$ re*resentatives to disc'ss relevant iss'es and concerns.
Comm'nit$ re*resentatives; main concerns %ere that the sec'rit$ and con&identialit$
standards o& s'rveillance *rograms might not be s'&&icient to *revent disclos'res o&
in&ormation and that man$ *ersons at risk &or ",! in&ection might there&ore dela$
seeking ",! co'nseling and testing beca'se o& these con&identialit$ concerns. /he
consens's o& the cons'ltants %as that &e% *'blished st'dies %ere o& s'&&icient scienti&ic
0'alit$ to assess these concerns. /here&ore, the cons'ltants identi&ied several areas that
re0'ired additional research and *olic$ develo*ment be&ore CDC and CS/+ sho'ld
consider recommending &'rther e6*ansion o& ",! s'rveillance e&&orts. /hese areas
incl'ded a4 the im*act o& re*orting *olicies on testing behaviors and *ractices, incl'ding
the decreased availabilit$ o& anon$mo's testing in some states< b4 the role o& s'rveillance
data in linking re*orted *ersons to *revention and care *rograms< c4 the develo*ment o&
recommended standards &or the sec'rit$ and con&identialit$ o& *'blicl$ held ",!8(,DS
s'rveillance data< and d4 determining %hether alternatives to re*orting o& *atient names
%o'ld red'ce con&identialit$ risks %hile meeting the needs &or high.0'alit$ s'rveillance
data.
,n res*onse to the cons'ltants; recommendations, CDC initiated several research *roGects
to a4 assess the e&&ect o& con&idential name.based ",! s'rveillance on *ersons;
%illingness to seek ",! testing and care< b4 revie% *rogram *ractices and legal
re0'irements &or the sec'rit$ and con&identialit$ o& state and local ",!8(,DS
s'rveillance data< and c4 eval'ate the *er&ormance o& coded.identi&ier.based s'rveillance
s$stems. Findings &rom these *roGects and e6*ert advice &rom *artici*ants at n'mero's
technical meetings and cons'ltations held d'ring the intervening *eriod have g'ided
&orm'lation o& the *olicies and *ractices recommended in this re*ort. /he &indings &rom
these *roGects are s'mmari5ed in the &ollo%ing three s'bsectionsD ",! s'rveillance and
testing behavior, ",! s'rveillance 'sing non.name.based 'ni0'e identi&iers, and
con&identialit$ o& ",! s'rveillance data.
HIV Surveillance and Testing Behavior
Fe% st'dies have characteri5ed test. or care.seeking behaviors in relation to state ",!
re*orting *olicies. ( 2=?? general *o*'lation st'd$ o& *revio's or *lanned 'se o& ",!
testing services did not identi&$ an association o& re*orting *olic$ %ith testing behavior
17>4. ,n contrast, intervie%s o& *ersons seeking anon$mo's testing in 2=?= doc'mented
that man$ %o'ld avoid testing i& a *ositive test res'lted in name re*orting or *artner
noti&ication 17?4. ( revie% o& the *'blished literat're on ",! testing behaviors
highlighted several limitations and biases in *revio's st'dies 17=4, incl'ding small
n'mbers, lack o& geogra*hic and risk.gro'* re*resentativeness, and anal$sis o& intent to
test rather than o& act'al testing behavior. (n additional limitation o& the available
literat're is that st'dies *'blished 9.2: $ears ago might not re&lect act'al testing
behaviors in the c'rrent treatment era. Literat're that highlights *otential mis'se o&
*'blic health s'rveillance data might have the 'nintended e&&ect o& increasing test
avoidance among some at.risk *ersons 19:4. +6amining kno%ledge o& and *erce*tions
abo't testing and re*orting, as %ell as act'al testing behavior, in the conte6t o& c'rrent
treatment advances and evolving ",! re*orting *olicies, can address some o& the
limitations o& *revio's research.
/o determine the e&&ect o& changes in re*orting *olicies on act'al testing behaviors
among *ersons seeking testing at *'blicl$ &'nded ",! co'nseling and testing sites, CDC
and si6 state health de*artments revie%ed data ro'tinel$ collected &rom these sites to
com*are ",! testing *atterns d'ring the 2@ months be&ore and the 2@ months a&ter
im*lementation o& ",! case s'rveillance 1924. ,n these areas, the n'mber o& ",! tests
increased in &o'r states and decreased in t%o states< the declines %ere not statisticall$
signi&icant. (ll the anal$sis *eriods 1@9.month *eriods d'ring 2==@.2==A4 antedated the
%ides*read bene&icial e&&ects o& highl$ active antiretroviral thera*$. Slight variabilit$ in
testing trends %as observed among racial8ethnic s'bgro'*s and ",!.risk e6*os're
categories< ho%ever, these data do not s'ggest that, in these states, the *olic$ o&
im*lementing ",! case re*orting adversel$ a&&ected test.seeking behaviors overall 19@4.
CDC also s'**orted st'dies b$ researchers at the -niversit$ o& Cali&ornia at San
Francisco and *artici*ating state health de*artments to identi&$ the most im*ortant
determinants o& test seeking or test avoidance among high.risk *o*'lations and to assess
the im*act o& changes in ",! testing and ",! re*orting *olicies. Data &rom these s'rve$s
o& high.risk *ersons in nine selected states abo't their *erce*tions and kno%ledge o& ",!
testing and ",! re*orting *ractices doc'mented that &e% res*ondents had kno%ledge o&
the ",! re*orting *olicies in their res*ective states 193,974. ,n s'rve$s cond'cted d'ring
2==9.2==A, res*ondents re*orted high levels o& testing, %ith a**ro6imatel$ three &o'rths
re*orting that the$ had had an ",! test. /he most commonl$ re*orted &actors 1b$ nearl$
hal& o& res*ondents4 that might have contrib'ted to dela$s in seeking testing or not getting
tested %ere &ear o& having ",! in&ection diagnosed or belie& that the$ %ere not likel$ to
be ",! in&ected. HRe*orting to the governmentH %as a concern that might have
contrib'ted to a dela$ in seeking ",! testing &or 22C o& heterose6'als, 2?C o& inGecting.
dr'g 'sers, and @@C o& men %ho have se6 %ith men< less than 2C, 3C, and @C o&
res*ondents in these risk gro'*s, res*ectivel$, indicated that this %as their main concern.
Concern abo't name.based re*orting o& ",! in&ections to the government %as a &actor
&or not testing &or ",! &or 23C o& heterose6'als, 2?C o& inGecting.dr'g 'sers, and @?C
o& men %ho have se6 %ith men. (s the main &actor &or not testing &or ",!, concern abo't
name.based re*orting to the government %as s'bstantiall$ lo%er in all risk gro'*s 12C o&
heterose6'als, 2C o& inGecting.dr'g 'sers, and 7C o& men %ho have se6 %ith men4 1994.
/hese &indings s'ggest that name.based re*orting *olicies might deter a small *ro*ortion
o& *ersons %ith high.risk se6 or dr'g.'sing behaviors &rom seeking testing and, there&ore,
s'**ort the need &or strict adherence to con&identialit$ sa&eg'ards o& *'blic health testing
and s'rveillance data. ,n addition, the s'rve$ doc'mented that the availabilit$ o& an
anon$mo's testing o*tion is consistentl$ associated %ith higher rates o& intention to test
in the &'t're. ,n this s'rve$, high levels o& testing, together %ith high levels o& test dela$
or avoidance associated %ith reasons other than concern abo't name re*orting, s'ggest
that addressing these other concerns ma$ have a greater e&&ect on testing behavior. For
e6am*le, 9=C o& men %ho have se6 %ith men re*orted being Ha&raid to &ind o'tH as a
&actor &or not testing, and @>C re*orted it as the main &actor &or not testing. ,n addition,
9@C o& men %ho have se6 %ith men re*orted H'nlikel$ to have been e6*osedH as a &actor
&or not testing, and 2>C re*orted it as the main &actor.
,n a com*anion s'rve$ o& *ersons re*orted %ith (,DS in eight o& these same states,
*artici*ants %ho had recogni5ed their ",! risk and so'ght testing at anon$mo's testing
sites re*orted entering care at an earlier stage o& ",! disease than *ersons %ho %ere &irst
tested in a con&idential testing setting 1e.g., S/D clinics, medical clinics, or hos*itals4,
%here *ersons are &re0'entl$ &irst tested %hen the$ become ill 19A4. /hese data s'ggest
that anon$mo's testing o*tions are im*ortant in *romoting timel$ kno%ledge o& ",!
stat's &or some at.risk *ersons.
HIV Surveillance Using Non-Name-Based Unique Identifiers
/o assess the &easibilit$ o& 'sing alternatives to con&idential name.based methods &or ",!
s'rveillance, several states im*lemented re*orting o& cases o& ",! in&ection or CD7 1a
marker o& imm'nos'**ression in ",!.in&ected *ersons4 laborator$ test res'lts 'sing
vario's n'meric or al*han'meric codes. ther states considered or tried to cond'ct case
s'rveillance %itho't name identi&iers b$ 'sing codes designed &or nons'rveillance
*'r*oses 1e.g., codes intended &or 'se in tracking *atients in case.management s$stems4
19>4. ,n Ma$ 2==9, CDC convened a meeting at %hich these states identi&ied o*erational,
technical, and scienti&ic challenges in cond'cting s'rveillance 'sing coded identi&iers
rather than *atient names. /he states recommended that CDC eval'ate additional coded
identi&iers and assist them in doc'menting and disseminating the res'lts o& their &indings.
,n addition, CDC s'**orted research to eval'ate the *er&ormance o& a coded 'ni0'e
identi&ier 1-,4 in t%o states that im*lemented a non.name.based ",! case.re*orting
s$stem %hile maintaining name.based s'rveillance methods &or (,DS 19?4. /he st'd$,
cond'cted b$ Mar$land and /e6as d'ring 2==7.2==A in collaboration %ith CDC,
doc'mented nearl$ 9:C incom*lete re*orting, in *art beca'se the social sec'rit$ n'mber
necessar$ to constr'ct the identi&ier code %as not 'ni&orml$ available in medical or
laborator$ records. ,n Mar$land, *rovider.maintained logs %ere needed to link the -, to
name.based medical records to obtain &ollo%.'* data 1e.g., on ",! risk8e6*os're4. (
more recent eval'ation cond'cted b$ the Mar$land De*artment o& "ealth and Mental
"$giene 1MD"M"4 re*orted data &rom a *'blicl$ &'nded co'nseling and testing site and
doc'mented a higher level o& com*leteness o& ",! re*orting 1??C4 than the 9:C
doc'mented in the *revio's st'd$ 19?,9=4. MD"M" re*orts that their code is 'ni0'e to a
given *erson and that assignment o& t%o di&&erent codes to the same *erson is 'nlikel$.
/hat is, the *robabilit$ that a given code can disting'ish one *erson &rom an$ other is
greater than ==C i& all the elements o& the code are com*lete and acc'rate. )o *'blished
eval'ations have assessed the *robabilit$ o& assigning the same code to di&&erent *ersons,
%hich co'ld occ'r i& elements o& the code %ere missing. ,n contrast to MD"M";s
&indings, analogo's eval'ations in /e6as, as %ell as st'dies that 'sed more diverse
methods in Los (ngeles and )e% Jerse$, &ailed to identi&$ a code that *er&orms as %ell as
name.based methods 19?,A:.A>4. n the basis o& *'blished eval'ations 19?4, /e6as
recentl$ s%itched to name.based ",! case s'rveillance.
,n addition to Mar$land, three other states 1,llinois, Maine, and Massach'setts4 and
P'erto Rico recentl$ im*lemented ",! re*orting 'sing &o'r di&&erent coded identi&iers.
CDC %ill assist these states in im*lementing their s$stems, establishing standardi5ed
criteria &or assessing the overall *er&ormance o& their s$stems, as %ell as assessing
%hether the re0'ired standards are achieved. (dditional eval'ations %ill be cond'cted b$
the res*ective state health de*artments, in collaboration %ith CDC, to determine a4 the
abilit$ o& coded identi&iers to acc'ratel$ track disease *rogression &rom ",! in&ection to
(,DS to death, b4 their 'tilit$ &or eval'ating *'blic health e&&orts to eliminate *erinatal
",! transmission, c4 their acce*tabilit$, and d4 their 'se&'lness in matching to other
databases 1e.g., t'berc'losis4.
Confidentiality of HIV Surveillance Data
( 2==7 revie% o& state con&identialit$ la%s that *rotect ",! s'rveillance data
doc'mented that all states and man$ localities have legal sa&eg'ards &or con&identialit$ o&
government.held health data 1A?4. /hese la%s *rovide greater *rotection than la%s
*rotecting the con&identialit$ o& in&ormation in health records held b$ *rivate health.care
*roviders. Most states have s*eci&ic stat'tor$ *rotections &or *'blic health data related to
",! in&ection and other S/Ds. "o%ever, state legal *rotections var$, and CDC s'**orts
additional e&&orts to strengthen *rivac$ *rotections &or *'blic health data. n the basis o&
in*'t &rom e6*ert legal and *'blic health cons'ltants, the 3odel State Pu&lic Healt$
Privacy Act 1A=4 %as develo*ed b$ an inde*endent contractor at the behest o& CS/+. ,&
enacted b$ states, the *rovisions o& the Model (ct %o'ld ens're the con&identialit$ o&
s'rveillance data, strengthen stat'tor$ *rotections against disclos're, and *recl'de the
intended or 'nintended 'se o& s'rveillance data &or non.*'blic health *'r*oses.
CDC has revie%ed state and local sec'rit$ *olicies and *roced'res &or ",!8(,DS
s'rveillance data. Since 2=?2, states have cond'cted (,DS s'rveillance, and &e% breaches
o& sec'rit$ have res'lted in the 'na'thori5ed release o& data 1>:,>24. Beca'se s'rvival has
im*roved &or ",!.in&ected *ersons, in&ormation abo't them might be maintained in
*'blic health s'rveillance databases &or longer *eriods. /his has res'lted in increased
concerns abo't con&identialit$ o& s'rveillance data among *'blic health and comm'nit$
gro'*s 1>@4. /here&ore, CDC has iss'ed technical g'idance &or sec'rit$ *roced'res that
incl'de enhanced con&identialit$ and sec'rit$ sa&eg'ards as eval'ation criteria &or &ederal
&'nding o& state ",!8(,DS s'rveillance activities 1>34. /he recei*t o& &ederal s'rveillance
&'nding de*ends on the reci*ient;s abilit$ to ens're the *h$sical sec'rit$ and
con&identialit$ o& case re*orts. (t the &ederal level, ",!8(,DS s'rveillance data are
*rotected b$ several &ederal stat'tes, %hich ens're that CDC %ill not release ",!8(,DS
s'rveillance data &or non.*'blic health *'r*oses 1e.g., &or 'se in criminal, civil, or
administrative *roceedings4. Privac$ is also ens'red b$ the removal o& names and the
encr$*tion o& data transmitted to CDC. n the basis o& the im*ortance o& maintaining the
con&identialit$ o& *ersons in %hom ",! in&ection has been diagnosed b$ *'blic or *rivate
health.care *roviders, CDC has recommended additional standards to enhance the
sec'rit$ and con&identialit$ o& ",! and (,DS s'rveillance data 1>7,>94.
G'I!*+IN*S ,&% S'%V*I++ANC* &, HIV IN,*CTI&N AN! AI!S
HIV Surveillance Case !efinition for Adults and Children
CDC, in collaboration %ith CS/+, has established a ne% case de&inition &or ",!
in&ection in ad'lts and children that incl'des revised s'rveillance criteria &or ",!
in&ection and incor*orates the s'rveillance criteria &or (,DS 12>.2=,>A4 1(**endi64. ",!
in&ection and (,DS case re*orts &or%arded to CDC sho'ld be based on this de&inition.
For ad'lts and children aged greater than or e0'al to 2? months, the ",! s'rveillance
case de&inition incl'des laborator$ and clinical evidence s*eci&icall$ indicative o& ",!
in&ection and severe ",! disease 1(,DS4. For children aged less than 2? months 1e6ce*t
&or those %ho ac0'ired ",! in&ection other than b$ *erinatal transmission4, the ",!
s'rveillance case de&inition '*dates the de&inition in the 2==7 revised classi&ication
s$stem. ,n addition, the ne% case de&inition is based on recent data regarding the
sensitivit$ and s*eci&icit$ o& ",! diagnostic tests in in&ants and clinical g'idelines &or
Pneumocystis carinii *ne'monia 1PCP4 *ro*h$la6is &or children 12=,>>.??4 and &or 'se o&
antiretroviral agents &or *ediatric ",! in&ection 13:4. /he revised s'rveillance case
de&initions &or ad'lts and children become e&&ective Jan'ar$ 2, @:::.
HIV-AI!S Case Surveillance .ractices and Standards
CDC and CS/+ recommend that all states re0'ire re*orting to *'blic health s'rveillance
o& all cases o& *erinatal ",! e6*os're in in&ants, the earliest diagnosis o& ",! in&ection
1e6cl'sive o& anon$mo's tests4 and the earliest diagnosis o& (,DS in *ersons o& all ages,
and deaths among these *ersons 17,334. S'ch re*orting sho'ld constit'te the core
minim'm *er&ormance standard &or ",!8(,DS s'rveillance in all states and territories.
CDC *rovides &ederal &'nds and technical assistance to states to establish and cond'ct
active ",!8(,DS s'rveillance *rograms. n the basis o& &easibilit$, needs, and reso'rces,
areas ma$ be &'nded to im*lement additional s'rveillance activities 1e.g., s'**lemental
research and eval'ation st'dies and serologic s'rve$s4, b't these a**roaches might not be
necessar$ in all areas. /he &ollo%ing recommended *ractices '*date and revise the CDC
4uidelines for HIV/AIDS Surveillance released in 2==A and '*dated in 2==? as a
technical g'ide &or state and local ",!8(,DS s'rveillance *rograms 137,>3.>94.
Recommended *ractices re*resent CDC;s g'idance &or best *'blic health *ractice based
on available scienti&ic data. Programmatic standards set minim'm re0'irements &or states
to receive s'**ort &rom CDC &or ",!8(,DS s'rveillance activities.
ecommended Surveillance !ractices
(ll state and local *rograms sho'ld collect a standard set o& s'rveillance data &or
all cases that meet the re*orting criteria &or ",! in&ection and (,DS. /he standard
data set incl'des the a4 *atient identi&ier, b4 earliest date o& diagnosis o& ",!
in&ection, c4 earliest date o& diagnosis o& an (,DS.de&ining condition, d4
demogra*hic in&ormation 1e.g., date o& birth, race8ethnicit$, and se64 and
residence 1i.e., cit$ and state4 at diagnosis o& ",! in&ection and o& (,DS, e4 ",!
risk e6*os're, &4 &acilit$ o& diagnosis, and g4 date o& death and state o& residence
at death. ,n addition to this in&ormation, the date o& ",! diagnostic testing, the
res'lts o& these tests, and e6*os're to antiretroviral treatment &or red'cing
*erinatal ",! transmission sho'ld be collected &or all in&ants %ith *erinatal
e6*os'res to ",!. S'rveillance in&ormation, %itho't *atient identi&iers, sho'ld be
encr$*ted and &or%arded to CDC thro'gh the ",!8(,DS Re*orting S$stem 1or
e0'ivalent4 in accordance %ith c'rrent *ractice. /o address s*eci&ic *'blic health
in&ormation needs, local s'rveillance *rograms can cross.match ",! and (,DS
s'rveillance data %ith other *'blic health data 1e.g., t'berc'losis data4 and collect
s'**lemental s'rveillance data on all or a re*resentative sam*le o& cases. CDC
%ill *rovide technical assistance and recommend standardi5ed s'rveillance
methods to assist in collecting s'**lemental s'rveillance in&ormation.
n the basis o& st'dies o& coded identi&ier s$stems cond'cted in at least eight
states, *'blished eval'ations o& name.based and code.based s'rveillance s$stems,
and CDC;s assessment o& the 0'alit$ and re*rod'cibilit$ o& the available data,
CDC has concl'ded that con&idential name.based ",!8(,DS s'rveillance s$stems
are most likel$ to meet the necessar$ *er&ormance standards 13A,9?,A:.A>,?=,=:4,
as %ell as to serve the *'blic health *'r*oses &or %hich s'rveillance data are
re0'ired. /here&ore, CDC advises that state and local s'rveillance *rograms 'se
the same con&idential name.based a**roach &or ",! s'rveillance as is c'rrentl$
'sed &or (,DS s'rveillance nation%ide. "o%ever, CDC recogni5es that some
states have ado*ted, and others ma$ elect to ado*t, coded case identi&iers &or
*'blic health re*orting o& ",! in&ection. CDC %ill *rovide technical assistance to
all state and local areas to contin'e or establish ",!8(,DS s'rveillance s$stems
and to eval'ate their s'rveillance *rograms 'sing standardi5ed methods and
criteria %hether the$ 'se name or coded identi&iers.
",! and (,DS s'rveillance sho'ld be 'sed to identi&$ rare or *revio'sl$
'nrecogni5ed modes o& ",! transmission, 'n's'al clinical or virologic
mani&estations, and other cases o& *'blic health im*ortance. Providers are the
most likel$ and timel$ so'rce o& identi&$ing 'n's'al laborator$ or clinical cases.
/he$ are enco'raged to *rom*tl$ re*ort at$*ical cases to local, state, or territorial
*'blic health o&&icials &or &ollo%.'*. CDC %ill *rovide technical assistance to
state and local health de*artments cond'cting s'ch investigations and %ill revise
*'blic health recommendations based on the &indings, as a**ro*riate.
",! and (,DS case s'rveillance e&&orts sho'ld res'lt in collection o& data &rom all
*rivate and *'blic so'rces o& ",!.related testing and care services. Laborator$.
initiated s'rveillance methods sho'ld identi&$ all cases that meet the laborator$
re*orting criteria &or ",! in&ection and8or (,DS. "o%ever, these methods %ill
re0'ire &ollo%.'* %ith the *rovider to veri&$ the in&ection stat's or clinical stage
and obtain com*lete demogra*hic and e6*os're risk data. ",!.in&ected *ersons
%ho are initiall$ tested anon$mo'sl$ are eligible to be re*orted to CDC;s
",!8(,DS s'rveillance database onl$ a&ter the$ have had ",! in&ection
diagnosed in a con&idential testing setting 1e.g., b$ a health.care *rovider4 and
have test res'lts or clinical conditions that meet the ",! and8or (,DS re*orting
criteria.
(ll state and local s'rveillance *rograms sho'ld reg'larl$ *'blish, in *rint or
electronicall$, aggregated ",!8(,DS s'rveillance data in a &ormat that &acilitates
'se o& these data b$ &ederal, state, and local *'blic health agencies, ",!.
*revention comm'nit$ *lanning gro'*s and care.*lanning co'ncils, academic
instit'tions, *roviders and instit'tions that have re*orted cases, comm'nit$.based
organi5ations, and the general *'blic. Presentation o& s'rveillance data sho'ld be
consistent %ith established *olicies &or data release that *recl'de the direct or
indirect identi&ication o& a *erson %ith ",! in&ection or (,DS. CDC %ill increase
its e&&orts to coordinate re0'ests &or ",!8(,DS s'rveillance data across &ederal
government agencies to 'se state8local s'rveillance reso'rces e&&icientl$. CDC
%ill also develo* s*eci&ic g'idelines &or anal$5ing and inter*reting ",!8(,DS
s'rveillance data.
(ll state and local s'rveillance *rograms sho'ld cond'ct reg'lar, ongoing
assessments o& the *er&ormance o& the s'rveillance s$stem and redirect e&&orts and
reso'rces to ens're timel$ re*orting o& com*lete, re*resentative, and acc'rate
data. CDC %ill *rovide technical assistance and recommend standardi5ed
eval'ation methods to assist states in achieving the highest *ossible level o&
*er&ormance and to *romote com*arabilit$ o& data thro'gho't the -nited States.
"inimum !erformance Standards
/o *rovide acc'rate and timel$ data &or monitoring ",!8(,DS trends and
ens'ring a reliable meas're o& the n'mber o& *ersons in need o& ",!.related
*revention and care services, state and local ",!8(,DS s'rveillance s$stems
sho'ld 'se re*orting methods that *rovide case re*orting that is com*lete 1greater
than or e0'al to ?9C4 and timel$ 1greater than or e0'al to AAC o& cases re*orted
%ithin A months o& diagnosis4. ,n addition, eval'ation st'dies sho'ld demonstrate
that the a**roach 'sed to cond'ct s'rveillance 1i.e., name or coded identi&ier4
m'st res'lt in acc'rate case co'nts 1less than or e0'al to 9C d'*licate case re*orts
and less than or e0'al to 9C incorrectl$ matched case re*orts4. Finall$, at least
?9C o& re*orted cases or a re*resentative sam*le sho'ld have in&ormation
regarding risk &or ",! in&ection a&ter e*idemiologic &ollo%.'* is com*leted. (ll
",!8(,DS s'rveillance s$stems sho'ld collect the recommended standard data in
a reliable and valid manner, allo% matching to other *'blic health databases 1e.g.,
death registries4 to bene&it s*eci&ic *'blic health goals, and allo% identi&ication
and &ollo%.'* o& individ'al cases o& *'blic health im*ortance.
/o assess the 0'alit$ o& ",! and (,DS case s'rveillance as s*eci&ied in the
*er&ormance standards, states and local s'rveillance *rograms m'st cond'ct
*eriodic eval'ation st'dies. CDC %ill recommend several eval'ation methods to
enable states to select methods best s'ited to their *rogram needs and reso'rces.
States sho'ld also eval'ate the re*resentativeness o& their ",! case re*orts b$
monitoring the *otential im*act o& ",! s'rveillance on test.seeking *atterns and
behaviors and revie% the e6tent to %hich s'rveillance data are being 'sed &or
*lanning, targeting, and eval'ating ",!.*revention *rograms and services. /he
goal o& these *er&ormance eval'ations is to enhance the 0'alit$ and 'se&'lness o&
s'rveillance data &or *'blic health action. D'ring the ne6t several $ears 1i.e.,
@:::.@::@4, CDC %ill assist states in transitioning to an integrated ",!8(,DS
s'rveillance s$stem b$ eval'ating c'rrent *er&ormance levels, instit'ting revised
*rogram o*erations and *olicies as necessar$, and then reassessing *er&ormance.
Follo%ing this transition *eriod, CDC %ill eval'ate and a%ard *ro*osals &or
&ederal &'nding o& state and local s'rveillance *rograms based on their ca*acit$ to
meet these *er&ormance standards. (t that time, CDC %ill re0'ire that reci*ients
o& &ederal &'nds &or ",!8(,DS case s'rveillance ado*t s'rveillance methods and
*ractices that %ill enable them to achieve the standards to ens're that &ederal
&'nds are a%arded res*onsibl$.
ecommended Security and Confidentiality !ractices
State and local *rograms sho'ld doc'ment their sec'rit$ *olicies and *roced'res
and ens're their availabilit$ &or *eriodic revie%.
State and local health de*artments sho'ld minimi5e storage and retention o&
'nnecessar$ or red'ndant *a*er or electronic re*orts and sho'ld revie% their data.
retention *olicies consistent %ith CDC technical g'idelines 1>3.>94. States sho'ld
consider and eval'ate removing names &rom s'rveillance records %hen the$ no
longer serve the *'blic health *'r*ose &or %hich the$ %ere collected. Policies
sho'ld *rovide the &le6ibilit$ to remove cases that %ere re*orted in error or that
are determined not to be in&ected %ith ",! on &ollo%.'*. CDC %ill develo*
g'idance &or con&irming ",!.in&ection stat's as testing and vaccine technologies
evolve.
State and local health de*artments sho'ld also revie% their con&identialit$
*ractices to determine %hether additional *rotections sho'ld be established 1e.g.,
be&ore im*lementation o& ",! case s'rveillance4. States that *lan to im*lement
",! case s'rveillance sho'ld revie% their c'rrent con&identialit$ stat'tes to
determine %hether the$ need to be strengthened. /he 3odel State Pu&lic Healt$
Privacy Act 1A=4 sho'ld be considered b$ states in develo*ing their stat'tor$
*rotections o& ",!8(,DS s'rveillance data. Con&identialit$ la%s sho'ld *rotect
s'rveillance data that are transmitted 1in a sec're and con&idential manner
consistent %ith CDC;s ",!8(,DS s'rveillance *rogram re0'irements4 to other
*'blic health *rograms as *art o& eval'ation st'dies or &or &ollo%.'* o& cases o&
s*ecial *'blic health im*ortance. /he *enalties &or violating *rivac$ and sec'rit$
sho'ld a**l$ to all reci*ients o& ",!8(,DS case s'rveillance in&ormation.
/o &'rther enhance sec'rit$ and con&identialit$ o& data, states are enco'raged to
im*lement 'se o& a do'ble.ke$ encr$*tion and decr$*tion s$stem, in %hich
identi&$ing in&ormation encr$*ted b$ states 'sing the &irst ke$ can onl$ be
decr$*ted &or access 'sing the second ke$. CDC %ill develo* this o*tion at the
re0'est o& states that %ish to reass're ",!.in&ected *ersons that ",! and (,DS
s'rveillance data %ill be held con&identiall$ and %ill be 'sed onl$ &or s*eci&ied
*'blic health *'r*oses. CDC %ill hold the second ke$ 'nder an (ss'rance o&
Con&identialit$ 'nder Section 3:?1d4 o& the P'blic "ealth Service (ct, %hich
governs ho% CDC 'ses or releases s'rveillance data vol'ntaril$ shared %ith CDC
b$ the states. -nder this ass'rance, CDC is *rohibited &rom *roviding that ke$ to
a state *lanning to 'se ",!8(,DS s'rveillance data &or non.*'blic health
*'r*oses.
"inimum Security and Confidentiality Standards
/he sec'rit$ and con&identialit$ *olicies and *roced'res o& state and local s'rveillance
*rograms sho'ld be consistent %ith CDC standards &or the sec'rit$ o& ",!8(,DS
s'rveillance data 1>3,>74. /he minim'm sec'rit$ criteria %ere established &ollo%ing
revie%s o& all state and n'mero's local health de*artment ",!8(,DS s'rveillance
*rograms. ,n general, the revie%s doc'mented that health de*artments have achieved a
high level o& sec'rit$ and that most state health de*artments meet or e6ceed the minim'm
standards. Beginning in @:::, CDC %ill re0'ire that reci*ients o& &ederal &'nds &or
",!8(,DS s'rveillance establish the minim'm sec'rit$ standards and incl'de their
sec'rit$ *olic$ in a**lications &or s'rveillance &'nds 1>3,>74. +6am*les o& these
standards incl'de the &ollo%ingD
+lectronic ",!8(,DS s'rveillance data sho'ld be *rotected b$ com*'ter
encr$*tion d'ring data trans&er. States sho'ld contin'e the established *ractice o&
not incl'ding *ersonal identi&$ing in&ormation in ",!8(,DS s'rveillance data
&or%arded to CDC.
",! and (,DS s'rveillance records sho'ld be located in a *h$sicall$ sec'red area
and sho'ld be *rotected b$ coded *ass%ords and com*'ter encr$*tion.
(ccess to the ",!8(,DS s'rveillance registr$ sho'ld be restricted to a minim'm
n'mber o& a'thori5ed s'rveillance sta&&, %ho are designated b$ a res*onsible
a'thori5ing o&&icial, have been trained in con&identialit$ *roced'res, and are
a%are o& *enalties &or 'na'thori5ed disclos're o& s'rveillance in&ormation.
P'blic health *rograms that receive ",!8(,DS in&ormation &rom matching o&
*'blic health databases sho'ld have sec'rit$ and con&identialit$ *rotections and
*enalties &or 'na'thori5ed disclos're e0'ivalent to those &or ",!8(,DS
s'rveillance data and *ersonnel.
-se o& ",!8(,DS s'rveillance data &or research *'r*oses sho'ld be a**roved b$
a**ro*riate instit'tional revie% boards, and *ersons cond'cting the research m'st
sign con&identialit$ statements.
",! and (,DS s'rveillance data made available &or e*idemiologic anal$ses m'st
not incl'de names or other identi&$ing in&ormation. State and local data release
*olicies sho'ld ens're that the release o& data &or statistical *'r*oses does not
res'lt in the direct or indirect identi&ication o& *ersons re*orted %ith ",!
in&ection and (,DS.
,n the rare instance o& a *ossible sec'rit$ breach o& ",!8(,DS s'rveillance data,
state and local health de*artments sho'ld *rom*tl$ investigate and re*ort
con&irmed breaches to CDC to enable CDC to *rovide technical assistance to state
and local health de*artments, develo* recommendations &or im*rovements in
sec'rit$ meas'res, and *rovide oversight in monitoring changes in *rogram
*ractices.
elation to HIV-!revention and HIV-Care !rograms# ecommended !ractices
(t the &ederal level, the *rimar$ &'nction o& ",!8(,DS s'rveillance is collecting acc'rate
and timel$ e*idemiologic data &or *'blic health *lanning and *olic$. Conse0'entl$, CDC
is a'thori5ed to *rovide &ederal &'nds to states thro'gh s'rveillance coo*erative
agreements, both to achieve the goals o& the national s'rveillance *rogram and to assist
states in develo*ing their s'rveillance *rograms in accordance %ith state and local la%s
and *ractices. Federal &'nds a'thori5ed &or ",!8(,DS s'rveillance are not *rovided to
states &or develo*ing or *roviding *revention or treatment case.management services<
&'nds &or s'ch services are *rovided b$ CDC and other &ederal agencies 'nder se*arate
a'thori5ations.
Whether and ho% states establish a link bet%een individ'al case.*atients re*orted to their
",!8(,DS s'rveillance *rograms and other health de*artment *rograms and services &or
",! *revention and treatment is %ithin the *'rvie% o& the states. "o%ever, in
considering or establishing s'ch linkages, CDC recommends the &ollo%ingD
/he im*lementation o& ",! case s'rveillance sho'ld not inter&ere %ith ",!.
*revention *rograms, incl'ding those that o&&er anon$mo's ",! co'nseling and
testing services. -nless *rohibited b$ state la% or reg'lation, as a condition o&
&ederal &'nding &or ",! *revention 'nder a se*arate a'thori5ation, CDC re0'ires
that states and local areas *rovide anon$mo's ",! co'nseling and testing
services. CDC strongl$ recommends that states %hich *rohibit anon$mo's ",!
testing change this *ractice, given the overriding *'blic health obGective o&
enco'raging *ersons to become a%are o& their ",! serologic stat's. CDC does
not vie% the availabilit$ o& *'blicl$ &'nded anon$mo's co'nseling and ",!
testing as incom*atible %ith the abilit$ to cond'ct ",! case s'rveillance in the
*o*'lation.
",! testing services sho'ld be o&&ered &or *artici*ation on a vol'ntar$ basis and
*receded b$ in&ormed consent in accordance %ith local la%s 1=24.
Both *'blic and *rivate *roviders sho'ld re&er *ersons in %hom ",! in&ection has
been diagnosed to *rograms that *rovide ",! care, treatment, and com*rehensive
*revention case.management services.
Provider.based re&errals o& *atients to *revention and care services sho'ld enable
a timel$, e&&ective, and e&&icient means o& ens'ring that *ersons in %hom ",!
in&ection has been diagnosed receive needed services.
States sho'ld cons'lt %ith *roviders, *revention. and care.*lanning bodies, and
*'blic health *ro&essionals in develo*ing the *olicies and *ractices necessar$ to
e&&ect these linkages< sho'ld re0'ire that reci*ients o& ",!8(,DS s'rveillance
in&ormation be s'bGect to the same *enalties &or 'na'thori5ed disclos're as
",!8(,DS s'rveillance *ersonnel< and sho'ld eval'ate the e&&ectiveness o& this
*'blic health a**roach. S'ch an eval'ation sho'ld ens're that the *'blic health
obGectives o& s'ch linkages are achieved %itho't 'nnecessaril$ increasing sec'rit$
and con&identialit$ risks to s'rveillance data or decreasing the acce*tabilit$ o&
s'rveillance *rograms to health.care *roviders and a&&ected comm'nities.
Providers and a&&ected comm'nities, incl'ding ",!.*revention comm'nit$
*lanning gro'*s, sho'ld *artici*ate %ith health de*artments in *lanning and
im*lementing s'rveillance strategies, as %ell as *rograms and services.
C&MM*NTA%/
Surveillance Case !efinition for HIV Infection and AI!S
/he revised case de&inition &or ",! in&ection in ad'lts and children integrates re*orting
criteria &or ",! in&ection and (,DS in a single case de&inition and incor*orates ne%
laborator$ tests in the laborator$ criteria &or ",! case re*orting. /he @::: case de&inition
&or ",! in&ection incl'des ",! n'cleic acid 1D)( or R)(4 detection tests that %ere not
commerciall$ available %hen the (,DS case de&inition %as revised in 2==3. /he revised
case de&inition &or ",! in&ection also *ermits states to re*ort cases to CDC based on the
res'lt o& an$ test licensed &or diagnosing ",! in&ection in the -nited States. (ltho'gh the
re*orting criteria generall$ re&lect the recommendations &or diagnosing ",! in&ection, the
",! re*orting criteria are &or *'blic health s'rveillance and are not designed &or making
a diagnosis &or an individ'al *atient. /he laborator$ criteria incl'de the serologic ",!
tests described in the clinical standards &or diagnosing ",! in&ection 1=@.=94.
/he *ediatric ",! re*orting criteria incl'de criteria &or monitoring all children %ith
*erinatal e6*os'res to ",! and re&lect recent advances in diagnostic a**roaches that
*ermit the diagnosis o& ",! in&ection d'ring the &irst months o& li&e. With ",! n'cleic
acid detection tests, ",! in&ection can be detected in nearl$ all in&ants aged greater than
or e0'al to 2 month. /he timing o& the ",! serologic and ",! n'cleic acid detection tests
and the n'mber o& ",! n'cleic acid detection tests in the de&initive and *res'm*tive
criteria &or ",! in&ection are based on the recommended *ractices &or diagnosing
in&ection in children aged less than 2? months and on eval'ations o& the *er&ormance o&
these tests &or children in this age gro'* 13:,>>.??4.
/he clinical criteria in the case de&inition &or ",! in&ection are incl'ded to ens're the
com*lete re*orting o& cases %ith doc'mented evidence o& ",! in&ection or conditions
meeting the (,DS case de&inition. /he (,DS.de&ining conditions are incl'ded as *art o&
the single case de&inition &or ",! in&ection. ,n ad'lts and adolescents aged greater than or
e0'al to 23 $ears, criteria &or *res'm*tive and de&initive (,DS.de&ining conditions have
not been revised since 2==3 and contin'e to incl'de the laborator$ markers o& severe
",!.related imm'nos'**ression and the o**ort'nistic illnesses indicative o& severe ",!
disease, %hich greatl$ increase mortalit$ risks.
*ffect of National HIV Case Surveillance on %e#orting Trends
Changes in the ",! re*orting criteria %ill have little e&&ect on re*orting trends in states
alread$ cond'cting ",! case s'rveillance. "o%ever, the n'mber o& cases o& ",!
in&ection re*orted nationall$ %ill increase *rimaril$ beca'se o& im*lementation o& ",!
s'rveillance b$ the remaining states and local areas. Man$ o& the states that %ill
im*lement ",! case s'rveillance in the &'t're have high (,DS incidence rates. Similar to
the e&&ect on (,DS s'rveillance trends a&ter the im*lementation o& the revised re*orting
criteria in 2==3, the initiation o& ",! s'rveillance b$ additional states might res'lt in a
s'dden and large increase in ",! case re*orts 1=A4. n the basis o& CDC;s estimate that
a**ro6imatel$ @@:,::: ",!.in&ected *ersons %itho't (,DS.de&ining conditions had had
",! in&ection diagnosed in con&idential testing settings and resided in states that %ere not
cond'cting ",! case s'rveillance at the end o& 2==A 17A4, the *ossibilit$ e6ists that this
n'mber o& *ersons co'ld be re*orted %ith ",! in&ection &rom these states in @:::.
"o%ever, re*orting o& *revalent ",! in&ections is more likel$ to be s*read over several
$ears, and the ann'al increases %ill most likel$ be more modest. ,nitiall$, most case
re*orts %ill re*resent *ersons %hose ",! in&ection %as diagnosed be&ore the
im*lementation o& ",! s'rveillance. (s the re*orting o& *revalent cases o& ",! in&ection
reaches &'ll im*lementation nation%ide, the n'mber o& ",! case re*orts %ill decrease,
and case re*orts %ill increasingl$ re*resent *ersons %ith recent diagnoses o& ",!
in&ection.
/o &acilitate inter*retation o& ",! s'rveillance data and given that CDC strongl$
*romotes contin'ed availabilit$ o& anon$mo's testing o*tions, eval'ations o& ",!8(,DS
s'rveillance s$stems %ill incl'de assessments o& the re*resentativeness o& ",! case
s'rveillance data. /hese assessments %ill incl'de s*ecial s'rve$s to eval'ate the dela$s
bet%een ",! testing and entr$ to care. ,n addition, these eval'ations %ill be 'se&'l in
determining the e&&ectiveness o& *rogram e&&orts to re&er *ersons into care services a&ter
the diagnosis o& ",! in&ection in anon$mo's testing settings.
(,DS cases have declined nation%ide< ho%ever, beca'se (,DS s'rveillance trends are
a&&ected b$ the incidence o& ",! in&ection, as %ell as the e&&ect o& treatment on the
*rogression o& ",! disease, &'t're (,DS trends cannot be *redicted. (,DS s'rveillance
%ill contin'e to be im*ortant in eval'ating access to care &or di&&erent *o*'lations and in
identi&$ing changes in trends that might signal a decrease in the e&&ectiveness o&
treatment. /he long.term bene&its o& antiretroviral thera*$ and antimicrobial *ro*h$la6is
&or (,DS.related illnesses contin'e to be de&ined. ,n addition, vario's &actors 1e.g.,
access, adherence, treatment costs, and viral resistance4 %ill in&l'ence the 'se and
e&&ectiveness o& these thera*ies and their e&&ects on (,DS incidence and mortalit$ trends
1=>.==4.
Beca'se trends in ne% diagnoses o& ",! in&ection are a&&ected b$ %hen in the co'rse o&
disease a *erson seeks or is o&&ered ",! testing, s'ch trends do not re&lect the incidence
o& ",! in&ection in the *o*'lation. ,n addition, beca'se all ",!.in&ected *ersons in the
*o*'lation might not have had the in&ection diagnosed, these data do not re*resent total
",! *revalence in the *o*'lation. C'rrentl$, inter*retation o& these data is com*licated
b$ several &actors. First, *ersons might have ",! in&ection diagnosed and later d'ring the
same calendar $ear have (,DS diagnosed, %hich can com*licate *resentation o& the data.
Second, dela$s in re*orting cases o& ",! in&ection tend to be shorter than &or (,DS cases,
necessitating develo*ment o& stage.s*eci&ic statistical adG'stments. /hird, methods o&
im*'tation o& e6*os're risk data &or (,DS cases have been develo*ed based on historical
*atterns o& reclassi&ication a&ter investigation, b't com*arable methods &or cases o& ",!
in&ection are onl$ recentl$ available at the national level. Finall$, %hether a trend in the
n'mber o& ne% ",! diagnoses is stable, increasing, or decreasing might re&lect c'rrent or
historical ",! transmission *atterns, changes in testing behaviors, and8or stage o& the
e*idemic in the local geogra*hic area.
verall, in the -nited States, the incidence o& ",! in&ection *eaked a**ro6imatel$ 29
$ears ago, and the ann'al n'mber o& ",! in&ections has been stable at a**ro6imatel$
7:,::: since 2==@, %hen CDC estimated the *revalence o& ",! in&ection in the range o&
A9:,:::.=::,::: in&ected *ersons 12::,2:24. Based on ",! and (,DS case s'rveillance
data, CDC estimates that the *revalence o& ",! in&ection at the end o& 2==? %as in the
range o& ?::,:::.=::,::: in&ected *ersons. & these *ersons, a**ro6imatel$ A@9,:::
1rangeD 9>9,:::.A>9,:::4 had had ",! in&ection or (,DS diagnosed 1CDC, 'n*'blished
data, 2===4. Beca'se the ann'al n'mber o& ne% in&ections in recent $ears is relativel$
lo%er than d'ring the *eak incidence $ears, over time the remaining 'ntested or
anon$mo'sl$ tested in&ected *ersons %ill have ",! in&ection diagnosed thro'gh test.
seeking, targeted testing, entr$ to care, or *rogression o& disease to (,DS. -ltimatel$, the
n'mber o& ne% diagnoses o& ",! in&ection %ill decrease each $ear as the$ increasingl$
re*resent the smaller *ool o& more recentl$ in&ected *ersons. /h's, in states that have
been cond'cting ",! case re*orting &or several $ears, the n'mber o& ne% diagnoses o&
",! in&ection is e6*ected to decrease, then stabili5e at a lo%er rate i& the n'mber o& ne%
in&ections remains stable.
For states that ne%l$ im*lement ",! re*orting, a large bol's o& re*orted *revalent
in&ections is e6*ected to occ'r, &ollo%ed b$ a decline in the ann'al n'mber o& ne% cases
'ntil the n'mber stabili5es at a lo%er level. Recentl$, since the im*act o& highl$ active
antiretroviral thera*$ on s'rvival, the estimated n'mber o& ne% in&ections each $ear
*robabl$ e6ceeds the n'mber o& deaths, and the *revalence o& ",! in&ection might be
increasing b$ a small *ro*ortion o& total *revalence. /h's, d'ring the transition *eriod to
nation%ide ",!.in&ection re*orting, meas'res o& the combined *revalence o& ",!
in&ection diagnoses and (,DS diagnoses %ill be most 'se&'l in *roGecting the need &or
reso'rces &or care and *revention. /rends in the n'mbers o& ne% cases re*orted %ill not
*rovide immediate insights into the d$namics o& the e*idemic beca'se *revalent case
re*orts re*resent a mi6t're o& ne% and old ",! in&ections. Within the ne6t several $ears,
ho%ever, all states %ill be able to characteri5e ne% diagnoses o& ",! in&ection or a
re*resentative sam*le b$ demogra*hic and clinical characteristics that %ill *rovide
meaning&'l insights into act'al ",! transmission *atterns and %ill have %ell.
characteri5ed the health and service needs o& the *o*'lation o& *revalent ",!.in&ected
*ersons. CDC %ill develo* anal$sis *ro&iles, statistical adG'stments &or re*orting dela$s
and im*'tation o& risk data, and recommendations &or data *resentation to assist states in
anal$5ing and inter*reting their ",!8(,DS s'rveillance data d'ring this transition *eriod.
HIV-AI!S Surveillance .ractices
Laboratories %ill be an increasingl$ im*ortant so'rce o& in&ormation &rom %hich to
initiate re*orting. ",! in&ection is &re0'entl$ diagnosed in the o't*atient clinical setting,
and laborator$.initiated re*orting %ill be *artic'larl$ 'se&'l in identi&$ing o't*atient
so'rces o& ",! testing 1?=4 altho'gh contact %ith individ'al *roviders is necessar$ to
com*lete the re*orting *rocess. /he ro'tine collection o& ",! and CD7 test data &rom
laboratories and managed.care organi5ations *romotes com*leteness o& re*orting and
ma$ increase the sim*licit$ and e&&icienc$ o& initial case.&inding activities b$ local
s'rveillance *rograms. )onetheless, re*eated testing o& the same *ersons res'lts in
m'lti*le re*orts and necessitates labor.intensive &ollo%.'* to eliminate d'*licates. CDC
is increasing its e&&orts to *romote standards in laborator$ re*orting and to &acilitate the
trans&er o& data &rom *'blic health and commercial laboratories to health de*artments.
Per&ormance criteria &or ",! and (,DS s'rveillance are necessar$ to ens're that
s'rveillance data are o& s'&&icient 0'alit$ to target *revention and care reso'rces and to
detect emerging trends in the ",! e*idemic. +val'ations o& ",! and (,DS s'rveillance
*rograms have doc'mented that areas sho'ld be able to meet these *er&ormance criteria
19,3A,A2.A>,?=,=:4. (ccording to these eval'ations o& name.based s'rveillance s$stems,
the com*leteness o& ",! s'rveillance 1&rom >=C to a**ro6imatel$ =9C4 and (,DS
s'rveillance 1&rom ?9C to a**ro6imatel$ =9C4 is high, and re*orting is timel$ %ith
nearl$ one hal& o& (,DS cases and three 0'arters o& cases o& ",! in&ection re*orted to the
national ",!8(,DS re*orting s$stem %ithin 3 months o& diagnosis 194. CDC estimates
that the d'*lication rate o& cases o& ",! in&ection re*orted &rom di&&erent states to the
national s'rveillance database %as a**ro6imatel$ @C< &or (,DS cases, the rate %as
a**ro6imatel$ 3C 19,3A4. /he *er&ormance criteria also re&lect the need &or *'blic health
s'rveillance s$stems to identi&$ and &ollo%.'* on cases o& *'blic health im*ortance.
n the basis o& c'rrent eval'ation st'dies o& non.name.based case identi&iers and the
c'rrent in&rastr'ct're o& state and local health de*artments, name.based methods &or
collecting and re*orting *'blic health data *rovide the most &easible, sim*le, and reliable
means &or ens'ring timel$, acc'rate, and com*lete re*orting o& *ersons in %hom ",!
in&ection or (,DS has been diagnosed. Con&idential name.based re*orting also &acilitates
&ollo%.'* o& *erinatall$ e6*osed in&ants to determine their in&ection stat's and o& *ersons
re*orted %ith ",! in&ection to determine *rogression to (,DS and vital stat's 13A,7@4. (
name.based *atient identi&ier allo%s *roviders to re*ort cases directl$ &rom their name.
based medical records, &acilitates elimination o& d'*licate case re*orts, enables cross.
matching o& ",! and (,DS data %ith other name.based *'blic health data 1e.g.,
t'berc'losis s'rveillance4, *ermits &ollo%.'* %ith *roviders to collect in&ormation
regarding risk &or ",! in&ection and other data o& *'blic health im*ortance. /hro'gh
&ollo%.'* %ith *roviders, the ",!8(,DS s'rveillance s$stem has *rovided an e&&ective
means to identi&$ rare or 'n's'al modes o& ",! transmission and in&ection %ith rare
strains o& ",! and to im*rove *revention o& ",!.related o**ort'nistic illnesses 12:@.
2:A4. CDC %ill assist states in monitoring the im*act o& changing medical interventions,
e*idemiolog$, and ",! case s'rveillance *olicies on test. and care.seeking behaviors.
Security and Confidentiality of HIV and $IDS Surveillance
/he revision o& the case de&inition &or ",! in&ection *rovides an o**ort'nit$ to revie%
and strengthen state and local con&identialit$ la%s and reg'lations. (ltho'gh state
",!8(,DS s'rveillance con&identialit$ la%s and reg'lations ade0'atel$ *rotect *rivac$
com*ared %ith the stat'tor$ *rotections o& other health.care data, state stat'tes di&&er in
the degree o& *rivac$ *rotections a&&orded health in&ormation and the criteria &or
*ermissible disclos'res o& *ersonal in&ormation. Most state stat'tes describe some
*ermissible disclos'res o& *'blic health in&ormation. /o hel* ens're 'ni&orm
con&identialit$ *rotections, the #eorgeto%n -niversit$ La% Center develo*ed the 3odel
State Pu&lic Healt$ Privacy Act 1A=4. P'blic health, legislative, legal, and comm'nit$
advocac$ re*resentatives *rovided e6*ert cons'ltation. /he model legislative lang'age
*rotects con&idential, identi&iable in&ormation held b$ state and local *'blic health
de*artments against 'na'thori5ed and ina**ro*riate non.*'blic health 'ses b't still
allo%s *'blic health o&&icials to 'se s'rveillance in&ormation to accom*lish the *'blic
health obGectives de&ined b$ the la% 1A=4. CDC recommends that states *lanning to
im*lement ",! case s'rveillance sho'ld consider ado*ting the model legislation, i&
necessar$, to strengthen the c'rrent level o& *rotection o& *'blic health data.
(ltho'gh ",!8(,DS s'rveillance s$stems have e6em*lar$ records o& sec'rit$ and
con&identialit$, it is essential &or all *rograms to identi&$ %a$s to strengthen data
*rotection beca'se o& a *erceived greater sensitivit$ o& ",! case s'rveillance com*ared
%ith that o& (,DS case s'rveillance alone 1>24. Providing acc'rate *'blic ed'cation and
&act'al media messages to in&orm v'lnerable *o*'lations, as %ell as *romoting testing
*rograms that &acilitate re&errals into treatment and *revention services, %ill be im*ortant
to ens're that test seeking and acce*tance are not adversel$ a&&ected as additional states
im*lement ",! case re*orting. /he revised sec'rit$ standards 1>74 *romote
enhancements to &'rther red'ce an$ *otential &or disclos're o& sensitive s'rveillance data.
CDC contin'es to cond'ct eval'ations o& methods to &'rther enhance data sec'rit$,
incl'ding the 'se o& coding and encr$*tion o& data collected in the ",!8(,DS re*orting
s$stem.
HIV !revention and Care
CDC has *'blished g'idelines concerning the *rovision and targeting o& ",! co'nseling
and testing services 1@=,72,2:>.2224 and *rovides s'**ort &or most *'blic so'rces o& ",!
testing. /he availabilit$ o& anon$mo's ",! testing services might be *artic'larl$
im*ortant &or *ersons %ho dela$ seeking testing beca'se o& a concern that others might
learn o& their serologic stat's 1994. St'dies have doc'mented that the availabilit$ o&
anon$mo's ",! testing is associated %ith increased n'mbers o& *ersons seeking testing
services 122@.2294. (non$mo's ",! testing services are a re0'ired element o& &ederall$
s'**orted *revention *rograms 'nless *rohibited b$ state la% or reg'lation. C'rrentl$, 3=
states, P'erto Rico, and the District o& Col'mbia *rovide anon$mo's ",! testing
services.
CDC advises that the decision to re&er *ersons re*orted to the s'rveillance s$stem to
*revention and care services 1e.g., *artner co'nseling and re&erral services EPCRSF4 be
made at the local level. PCRS *rograms *rovide ",! co'nseling and testing to *ersons
%ho might be 'na%are o& ",! risk e6*os'res, and these services are a re0'ired
com*onent o& &ederall$ s*onsored ",!.*revention *rograms 122A,22>4. /he *rovision o&
s'ch services to *ersons in %hom ",! in&ection or (,DS has been diagnosed, es*eciall$
those %ho receive services in *'blicl$ &'nded testing and clinic settings, is cond'cted
s'ccess&'ll$ b$ states regardless o& %hether the$ have im*lemented ",! re*orting 122?4.
Re&errals &rom s'rveillance to other health de*artment services, %hen the$ occ'r, sho'ld
be established in a manner that ens'res both the 0'alit$ o& the s'rveillance data and the
sec'rit$ o& the s'rveillance s$stem, as %ell as the 0'alit$, con&identialit$, and vol'ntar$
nat're o& ",!.*revention services 122=4. (t the &ederal level, the *rimar$ &'nction o&
",!8(,DS s'rveillance remains the *rovision o& acc'rate e*idemiologic data &or *'blic
health in&ormation, *lanning, and eval'ation.
Persons in %hom ",! in&ection has been diagnosed at either con&idential or anon$mo's
test sites sho'ld be *rom*tl$ re&erred to &acilities that *rovide con&idential ",! care.
Recent st'dies have doc'mented dis*arities in ens'ring timel$ testing and access to care
b$ demogra*hic, socioeconomic, and other &actors 12@:,2@24. (ltho'gh not directl$
res*onsible &or the deliver$ o& medical care, CDC *rovides &ederal direction &or state and
local *rograms that &acilitate re&erral o& ",!.in&ected *ersons &rom co'nseling and testing
centers and health ed'cation8risk.red'ction *rograms to ",! care &acilities. CDC has
develo*ed g'idelines to strengthen the s$stem o& re&errals bet%een ",! testing sites and
care *rograms, in *art b$ increasing coordination %ith the "ealth Reso'rces and Services
(dministration and the R$an White C(R+ (ct grantees 12@@4. /o *rovide &'rther
g'idance, CDC has *artici*ated in develo*ing model contract lang'age &or Medicaid
*rograms that serve *ersons %ith ",! in&ection to ens're coo*eration %ith *'blic health
a'thorities in case re*orting and &ollo%.'*. ( %ell.develo*ed and %ell.im*lemented ",!
and (,DS case s'rveillance s$stem is integral to *'blic health e&&orts to identi&$
dis*arities, target *rograms and reso'rces to v'lnerable *o*'lations, and assess the
im*act o& these *rograms in red'cing in&ection, disease, and *remat're death.
CDC is 'ndertaking a national e&&ort to &'rther red'ce *erinatal ",! transmission in the
-nited States. /his e&&ort %ill incor*orate ",! co'nseling and vol'ntar$ testing,
treatment, and o'treach to *regnant %omen, es*eciall$ those %ho are racial8ethnic
minorities and s'bstance ab'sers, and %ill integrate *revention and treatment services &or
%omen and children. S'rveillance &or *erinatall$ ",!.e6*osed and ",!. in&ected
children %ill remain a critical meas're o& the e&&ectiveness o& this cam*aign
13@,7:,72,2@3,2@74.
C&NC+'SI&N
/he im*lementation o& a national s'rveillance net%ork to incl'de both ",! and (,DS
case re*orting is a necessar$ res*onse to e*idemiologic trends and ne% standards &or ",!
care 12@9.2@>4. ,ntegrated ",!8(,DS s'rveillance *rograms %ill *rovide data to
characteri5e *ersons in %hom ",! in&ection has been ne%l$ diagnosed, incl'ding those
%ith evidence o& recent in&ection, *ersons %ith severe ",! disease 1(,DS4, and those
d$ing o& ",! disease or (,DS. /he revised ",! s'rveillance case de&inition and the
establishment o& minim'm *er&ormance standards %ill *romote 'ni&orm case
ascertainment and %ill ens're that the s'rveillance data are o& s'&&icient 0'alit$ &or
e&&ective *lanning and allocation o& reso'rces &or *revention and care *rograms.
%eferences
2. CDC. -*dateD trends in (,DS incidence .. -nited States, 2==A. MMWR
2==><7A<?A2.>.
@. CDC. -*dateD trends in (,DS incidence, deaths, and *revalence .. -nited States,
2==A. MMWR 2==><7AD2A9.>3.
3. Fleming PL, Ward JW, Karon JM, "anson DL, De Cock KM. Declines in (,DS
incidence and deaths in the -S(D a signal change in the e*idemic. (,DS
2==?<2@1s'**l (4DS99.SA2.
7. Co'ncil o& State and /erritorial +*idemiologists. CS/+ *osition statement ,D.7D
national ",! s'rveillance .. addition to the national *'blic health s'rveillance
s$stem. (tlanta, #(D Co'ncil o& State and /erritorial +*idemiologists, 2==>.
9. CDC. ",!8(,DS s'rveillance re*ort, 2===<221)o. 24.
A. CDC. )ational ",! *revalence s'rve$, 2==> s'mmar$. (tlanta, #(D -S
De*artment o& "ealth and "'man Services, CDC<2==?D2.@9.
>. Janssen RS, Satten #(, Stramer SL, et al. )e% testing strateg$ to detect earl$
",!.2 in&ection &or 'se in incidence estimates and &or clinical and *revention
*'r*oses. J(M( 2==?<@?:D7@.?. +rrat'mD J(M( 2===<@?2D2?=3.
?. B'ehler JW, Dia5 /, "ersh BS, Ch' SI. /he s'**lement to ",!.(,DS
s'rveillance *roGectD an a**roach &or monitoring ",! risk behaviors. P'blic
"ealth Re* 2==A<2221S24D233.>.
=. CDC. S'rveillance &or (,DS.de&ining o**ort'nistic illnesses, 2==@.2==>. ,nD
CDC s'rveillance s'mmaries, (*ril 2A, 2===. MMWR 2===<7?1)o. SS.@4.
2:. CDC. Mortalit$ *atterns .. -nited States, 2==>. MMWR 2===<7?DAA7.?.
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de&inition &or case s'rveillance o& ",! in&ection 1incl'ding (,DS4. (tlanta, #(D
Co'ncil o& State and /erritorial +*idemiologists, 2==?.
2@. CDC. Dra&t g'idelines &or ",! case s'rveillance, incl'ding monitoring ",!
in&ection and ac0'ired imm'node&icienc$ s$ndrome 1(,DS4. Federal Register
2==?<A3DA?@?=.
23. CDC. Pneumocystis *ne'monia .. Los (ngeles. MMWR 2=?2<3:D@9:.@.
27. CDC. Ka*osi;s sarcoma and Pne'moc$stis *ne'monia among homose6'al men ..
)e% Iork Cit$ and Cali&ornia. MMWR 2=?2<3:D3:9.?.
29. CDC. -*date on ac0'ired imm'ne de&icienc$ s$ndrome 1(,DS4 .. -nited States.
MMWR 2=?@<32D9:>.?,923.7.
2A. CDC. Revision o& the case de&inition o& ac0'ired imm'node&icienc$ s$ndrome &or
national re*orting .. -nited States. MMWR 2=?9<37D3>3.9.
2>. CDC. Revision o& the CDC s'rveillance case de&inition &or ac0'ired
imm'node&icienc$ s$ndrome. MMWR 2=?><3A1s'**l 24D2.29.
2?. CDC. 2==3 Revised classi&ication s$stem &or ",! in&ection and e6*anded
s'rveillance case de&inition &or (,DS among adolescents and ad'lts. MMWR
2==@<721)o. RR.2>4.
2=. CDC. 2==7 Revised classi&ication s$stem &or h'man imm'node&icienc$ vir's
in&ection in children less than 23 $ears o& age. MMWR 2==7<731)o. RR.2@4.
@:. CDC. -*dateD ac0'ired imm'node&icienc$ s$ndrome .. -nited States, 2=?=.
MMWR 2==:<3=D?2.A.
@2. CDC. -*dateD ac0'ired imm'node&icienc$ s$ndrome .. -nited States, 2==2.
MMWR 2==@<72D7A3.?.
@@. CDC. ProGections o& the n'mber o& *ersons diagnosed %ith (,DS and the n'mber
o& imm'nos'**ressed ",!.in&ected *ersons .. -nited States, 2==@.2==7. MMWR
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@3. CDC. "eterose6'all$ ac0'ired (,DS .. -nited States, 2==3. MMWR
2==7<73D299.A:.
@7. CDC. (,DS among racial8ethnic minorities .. -nited States, 2==3. MMWR
2==7<73DA77.>,A93.9.
@9. CDC. (,DS among children .. -nited States, 2==A. MMWR 2==A<79D2::9.2:.
@A. "ammer SM, Kat5enstein D(, "'ghes MD, et al. ( trial com*aring n'cleoside
monothera*$ %ith combination thera*$ in ",!.in&ected ad'lts %ith CD7 cell
co'nts &rom @:: to 9:: *er c'bic millimeter. ) +ngl J Med 2==A<339D2:?2.=:.
@>. Collier (C, Coombs RW, Schoen&eld D(, et al. /reatment o& h'man
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@?. Car*enter CC, Fischel M(, "ammer SM, et al. (ntiretroviral thera*$ &or ",!
in&ection in 2==?D '*dated recommendations o& the ,nternational (,DS Societ$ ..
-S( *anel. J(M( 2==?< @?:D>?.?A.
@=. CDC. Re*ort o& the )," Panel to de&ine *rinci*les o& thera*$ o& ",! in&ection
and g'idelines &or the 'se o& antiretroviral agents in ",!.in&ected ad'lts and
adolescents. MMWR 2==?<7>1)o. RR.94.
3:. CDC. #'idelines &or the 'se o& antiretroviral agents in *ediatric ",! in&ection.
MMWR 2==?< 7>1)o. RR.74.
32. CDC. -*dateD *erinatall$ ac0'ired ",!8(,DS .. -nited States, 2==>. MMWR
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3@. Lindegren ML, B$ers R", /homas P, et al. /rends in *erinatal transmission o&
",!8(,DS in the -nited States. J(M( 2===<@?@D932.?.
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*ediatric ",! in&ection .. addition to the )ational P'blic "ealth S'rveillance
S$stem 1)P"SS4. (tlanta, #(D Co'ncil o& State and /erritorial +*idemiologists,
2==9.
37. CDC. ",! in&ection re*orting .. -nited States. MMWR 2=?=<3?D7=A.=.
39. S%eene$ P, Fleming PL, Ward JW, et al. ",! testing circ'mstances and se6'al
behavior change among *ersons likel$ to be recentl$ in&ected E(bstract no.
7327AF. 2@th World (,DS Con&erence, #eneva, J'ne @?.J'l$ 3, 2==?.
3A. CDC. Diagnosis and re*orting o& ",! and (,DS in states %ith integrated ",! and
(,DS s'rveillance .. -nited States. MMWR 2==?<7>D3:=.27.
3>. CDC. -*dateD *'blic health s'rveillance &or ",! in&ection .. -nited States, 2=?=
and 2==:. MMWR 2==:<3=D?93,?9=.A2.
3?. Wortle$ PM, Fleming PL, Lindegren ML, et al. -sing ",!8(,DS s'rveillance to
monitor *'blic health e&&orts to red'ce *erinatal transmission o& ",! ELetterF. J
(c0'ir ,mm'ne De&ic S$ndr "'m Retrovirol 2==A<22D@:9.A.
3=. Lindegren ML, Fleming P, Steinberg S, et al. ,m*lementation o& -.S. P'blic
"ealth Service 1-SP"S4 recommendations to *revent *erinatal ",! transmissionD
*ediatric ",! case s'rveillance, -.S. E(bstract ,.22?F. ,nD Program and abstracts
o& the ,nterscience Con&erence on (ntimicrobial (gents and Chemothera*$.
/oronto, CanadaD (merican Societ$ &or Microbiolog$, Se*tember 2==>.
7:. CDC. Recommendations o& the P'blic "ealth Service /ask Force on 'se o&
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MMWR 2==7<731)o. RR.224.
72. CDC. -.S. P'blic "ealth Service recommendations &or h'man imm'node&icienc$
vir's co'nseling and vol'ntar$ testing &or *regnant %omen. MMWR 2==9<771)o.
RR.>4.
7@. CDC. S'ccess in im*lementing P'blic "ealth Service g'idelines to red'ce
*erinatal transmission o& ",! .. Lo'isiana, Michigan, )e% Jerse$, and So'th
Carolina, 2==3, 2==9, and 2==A. MMWR 2==?<7>DA??.=2. +rrata. MMWR
2==?<7>D>2?.
73. Lansk$ (, Jones JL, B'rkham S, et al. (de0'ac$ o& *renatal care and *rescri*tion
o& 5idov'dine to *revent *erinatal ",! transmission. J (c0'ir ,mm'ne De&ic
S$ndr "'m Retrovirol 2===<@2D@@3.>.
77. CDC. P"S task &orce recommendations &or the 'se o& antiretroviral dr'gs in
*regnant %omen in&ected %ith ",!.2 &or maternal health and &or red'cing
*erinatal ",!.2 transmission in the -nited States. MMWR 2==?<7>1)o. RR.@4.
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living ",! in&ected *ersons con&identialit$ tested in the -nited States E(bstract ,.
2AF. ,nD Program and abstracts o& the ,nterscience Con&erence on (ntimicrobial
(gents and Chemothera*$. /oronto, CanadaD (merican Societ$ &or Microbiolog$,
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=.
7?. Kegeles SM, Coates /J, Lo B, Catania J(. Mandator$ re*orting o& ",! testing
%o'ld deter men &rom being tested ELetterF. J(M( 2=?=<@A2D2@>9.A.
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risk o& ",! testing. (,DS P'blic Polic$ Jo'rnal 2==><2@DAA.>?.
9:. Forbes (. )aming names .. mandator$ name.based ",! re*ortingD im*act and
alternatives. (,DS Polic$ La% 2==A 1Ma$4D2.7.
92. )akashima (K, "orsle$ RM, Fre$ RL, S%eene$ P(, Weber J/, Fleming PL.
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co'nseling and testing sites. J(M( 2==?<@?:D27@2.A.
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kno%ledge o& those at risk E(bstractF. J #en ,ntern Med 2==><2@D1s'**l 24D2:?.
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s'rve$ 1",/S4 E(bstractF. ,nD (bstracts o& the (merican P'blic "ealth
(ssociation 2@9th (nn'al Meeting and +6*osition, ,ndiana*olis, ,ndiana,
)ovember =.23, 2==>.
99. CDC. ",! testing among *o*'lations at risk &or ",! in&ection .. nine states.
MMWR 2==?D 7>D2:?A.=2.
9A. Bindman (B, smond D, "echt FM, et al. ( m'lti.state eval'ation o& anon$mo's
",! testing and access to medical care. J(M( 2==?<@?:D272A.@:.
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9?. CDC. +val'ation o& ",! case s'rveillance thro'gh the 'se o& non.name 'ni0'e
identi&iers .. Mar$land and /e6as, 2==7.2==A. MMWR 2==?<7AD2@97.?,2@>2.
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name.coded identi&iers in Los (ngeles Co'nt$ and )e% Jerse$ E(bstract 79=F. ,nD
(bstracts o& the )ational ",! Prevention Con&erence, (tlanta, #eorgia, ('g'st
@=.Se*tember 2, 2===.
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A@. B'ehler JW, Devine J, Berkelman RL, Chevarle$ FM. ,m*act o& the h'man
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&or +*idemiologic Research, (lberta, Canada, J'ne 2@.27, 2==>.
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AA. CDC. (ssessment o& laborator$ re*orting to s'**lement active (,DS s'rveillance
.. Colorado. MMWR 2==3<7@D>7=.9@.
A>. Sch%arc5 SK, "s' LC, Parisi MK, Kat5 M". /he im*act o& the 2==3 (,DS case
de&inition on the com*leteness and timeliness o& (,DS s'rveillance. (,DS
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A?. #ostin L, La55arini K, )esl'nd !S, sterholm M./he *'blic health in&ormation
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>:. Landr$ S. (,DS list is o't. St. Petersb'rg /imes. Se*tember @:, 2==AD2,2:.
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>9. CDC. ,ntegrating ",! and (,DS s'rveillanceD a reso'rce man'al &or s'rveillance
coordinators. (tlanta, #(D -S De*artment o& "ealth and "'man Services, 2==?.
>A. CDC. Classi&ication s$stem &or h'man imm'node&icienc$ vir's 1",!4 in&ection in
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>>. )esheim S, Lee F, Kalish ML, et al. Diagnosis o& *erinatal ",! in&ection b$
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22.
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&or the diagnosis o& verticall$ transmitted ",! in&ection. J ,n&ect Dis
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?:. D'nn D/, Brandt CD, Krivine (, et al. /he sensitivit$ o& ",!.2 D)( *ol$merase
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?2. Bremer JW, Le% JF, Coo*er +, et al. Diagnosis o& in&ection %ith h'man
imm'node&icienc$ t$*e 2 b$ a D)( *ol$merase chain reaction assa$ among
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earl$ diagnosis o& verticall$ transmitted in&ection. (rch Pediatr (dolesc Med
2==A<29:D9=?.A:@.
?9. CDC. 2==9 Revised g'idelines &or *ro*h$la6is against Pne'moc$stis carinii
*ne'monia &or children in&ected %ith or *erinatall$ e6*osed to h'man
imm'node&icienc$ vir's. MMWR 2==9< 771)o. RR.74D2.22.
?A. Perelson (S, )e'mann (-, Marko%it5 M, Leonard JM, "o DD. ",!.2 d$namics
in vivoD virion clearance rate, in&ected cell li&e s*onsored viral generation time.
Science 2==A<@>2D29?@.A.
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??. Io'ng )L, Sha&&er ), Chao%anachan /, et al. +arl$ diagnosis and viral d$namics
in ",!.2 in&ected in&ants in /hailand 'sing R)( and D)( PCR assa$s sensitive
to non.b s'bt$*es E(bstract 2?2F. Ath Con&erence on retrovir'ses and
o**ort'nistic in&ections, Chicago, Febr'ar$ 2===.
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o& CD7L / l$m*hoc$tes on -.S. (,DS s'rveillance. J (c0'ir ,mm'ne De&ic
S$ndr "'m Retrovirol 2==><27D9A.A:.
=:. Klevens RM, Fleming PL, )eal JJ, et al. ,s there reall$ a heterose6'al (,DS
e*idemic in the -nited StatesJ Findings &rom a m'ltisite validation st'd$, 2==@.
2==9. (m J +*id 2===<27=D>9.?7.
=2. CDC. P'blic "ealth Service g'idelines &or co'nseling and antibod$ testing to
*revent ",! in&ection and (,DS. MMWR 2=?><3AD9:=.29.
=@. CDC. ,nter*retation and 'se o& the Western blot assa$ &or serodiagnosis o& h'man
imm'no.de&icienc$ vir's t$*e 2 in&ections. MMWR 2=?=<3?1)o. S.>4D?>.=9.
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",!.2 *lasma viral load testingD a case series. (nn ,ntern Med 2===<23:D3>.=.
=7. CDC. /esting &or antibodies to h'man imm'node&icienc$ vir's t$*e @ in the
-nited States. MMWR 2==@<721)o. RR.2@4D2.=.
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2==?<7>D@22.9.
=A. CDC. -*dateD trends in (,DS diagnosis and re*orting 'nder the e6*anded
s'rveillance de&inition &or adolescents and ad'lts .. -nited States, 2==3. MMWR
2==7<73D2A:.2,2A>.>:.
=>. /ebas P, Ro$al M, Fichtenba'm C, et al. Relationshi* bet%een adherence to
"((R/ and disease state E(bstract 27=F. ,nD Program and abstracts o& the 9th
Con&erence on Retrovir'ses and **ort'nistic ,n&ections, Chicago, ,L, Febr'ar$
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=?. Melnick D, #reiner D, Little P, Melnick K. ,m*act o& aggressive management o&
",! in&ection on clinical o'tcome and cost o& care %ithin a health maintenance
organi5ation E(bstract @:2F. ,nD Program and abstracts o& the 9th Con&erence on
Retrovir'ses and **ort'nistic ,n&ections, Chicago, ,L, Febr'ar$ 2.9, 2==?.
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antiretroviral thera*$. (,DS Clin Rev 2==9.=AD@>>.3:3.
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in the -nited States, 2=?7 to 2==@. J(M( 2==AD@>AD2@A.32.
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d'ring an invasive dental *roced're. MMWR 2==:<3=D7?=.=3.
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imm'node&icienc$ vir's 1",!4 b$ blood trans&'sions screened as negative &or
",! antibod$. ) +ngl J Med 2=??<32?D7>3.?.
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seroconversion in health.care %orkers a&ter *erc'taneo's e6*os're. ) +ngl J Med
2==><33>D27?9.=:.
2:9. CDC. ,denti&ication o& ",!.2 gro'* in&ection .. Los (ngeles Co'nt$,
Cali&ornia, 2==A. MMWR 2==A<79D9A2.9.
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Pneumocystis carinii *ne'monia among children %ith *erinatall$ ac0'ired h'man
imm'node&icienc$ vir's in&ection in the -nited States. Pneumocystis carinii
Pne'monia Pro*h$la6is +val'ation Working #ro'*. ) +ngl J Med 2==9<33@D>?A.
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2:>. CDC. Recommendations &or ",! testing services &or in*atients and
o't*atients in ac'te.care hos*ital settings. MMWR 2==3<7@1)o. RR.@4.
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in&ections in *ersons in&ected %ith h'man imm'node&icienc$ vir's. MMWR
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2:=. CDC. 2==? #'idelines &or treatment o& se6'all$ transmitted diseases.
MMWR 2==><7>1)o. RR.24D22.2A.
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(tlanta, #(D -S De*artment o& "ealth and "'man Services, CDC, Ma$ 2==7.
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#(D -S De*artment o& "ealth and "'man Services, CDC, 2==?.
22@. Me$er P(, Jones JL, #arrison CK, et al. Com*arison o& individ'als
receiving anon$mo's and con&idential testing &or ",!. So'th Med J 2==7<?>D377.
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223. Fehrs LJ, Fleming D, Foster LR, et al. /rial o& anon$mo's vers's
con&idential h'man imm'node&icienc$ vir's testing. Lancet 2=??<@D3>=.?@.
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im*act o& availabilit$ on demand in (ri5ona. (m J P'blic "ealth 2==7<?7D@::?.
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229. Kassler WJ, Meri%ether R(, Klimko /B, et al. +liminating access to
anon$mo's ",! antibod$ testing in )orth CarolinaD e&&ects on ",! testing and
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=.
22A. West #R, Stark K(. Partner noti&ication &or ",! *reventionD a critical
ree6amination. (,DS +d'c Prev 2==><=1s'**l B4DA?.>?.
22>. Francis DP, (nderson R+, #orman M+, et al. /argeting (,DS *revention
and treatment to%ard ",!.2.in&ected *ersonsD the conce*t o& earl$ intervention.
J(M( 2=?=<@A@D@9>@.A.
22?. /oome$ K, Cates W. Partner noti&ication &or the *revention o& ",!
in&ection. (,DS 2=?=<S9>.SA@.
22=. smond D", Bindman (B, !rani5an K, et al. )ame.based s'rveillance
and *'blic health interventions &or *ersons %ith ",! in&ection. (nn ,ntern Med
2===<232D>>9.=.
2@:. Bo55ette S(, Berr$ S", D'an ), et al. /he care o& ",!.in&ected ad'lts in
the -nited States. ) +ngl J Med 2===<33=D2?=>.2=:7.
2@2. )akashima (K, Jones JL, B'rgess D(, Ward JW. Predictors &or not
c'rrentl$ receiving *rotease inhibitor thera*$D res'lts &rom a m'ltisite intervie%
*roGect E(bstract 723N87@@?@F. 2@th World (,DS Con&erence, #eneva, J'ne @?.
J'l$ 3, 2==?.
2@@. CDC. ",! *revention case managementD g'idance. (tlanta, #(D -S
De*artment o& "ealth and "'man Services, CDC, Se*tember 2==>.
2@3. ,nstit'te o& Medicine, )ational Research Co'ncil. Red'cing the oddsD
*reventing *erinatal transmission o& ",! in the -nited States. Stoto M(,
McCormick MC, eds. Washington, DCD )ational (cadem$ Press, 2===.
2@7. Wade )(, Birkhead #S, Warren BL, et al. (bbreviated regimens o&
5idov'dine *ro*h$la6is and *erinatal transmission o& the h'man
imm'node&icienc$ vir's. ) +ngl J Med 2==?<33=D27:=.27.
2@9. Francis DP, Singleton J(. Re*orting o& ",!.2 in&ection thro'gh the
*rovision o& essential services. J (c0'ir ,mm'ne De&ic S$ndr 2==3<AD@?9.A.
2@A. #ostin L, Ward JW, Baker (C. )ational ",! case re*orting &or the
-nited StatesD a de&ining moment in the histor$ o& the e*idemic. ) +ngl J Med
2==><33>D22A@.>.
2@>. Steinbrook R. Battling ",! on man$ &ronts. ) +ngl J Med 2==><33>D>>=.
?2.
Ta"le 0
Note$ /o *rint large tables and gra*hs 'sers ma$ have to change their *rinter settings to landsca*e and
'se a small &ont si5e.
TA(+* 01 Characteristics of #ersons aged 2304 years ith HIV, "y disease status at
initial diagnosis5 66 78 states
9
, :anuary 0;;<6:une 0;;=

!isease status at initial HIV
diagnosis

HIV AI!S
Characteristic No1
>
?@
A
B No1
>
?@
A
B Total
SeC
Male 3>,==A 1>@4 2A,?AA 1?34 97,?A@
Female 27,A?= 1@?4 3,37? 12>4 2?,:3>
%ace-*thnicity55
White, non."is*anic 2>,=@= 1374 =,2>2 1794 @>,2::
Black, non."is*anic 3:,@@= 19>4 =,2@> 1794 3=,39A
"is*anic 3,9?2 1 >4 2,AA: 1 ?4 9,@72
(P,8)(8-nkno%n =7= 1 @4 @9A 1 24 2,@:9
%isD-*C#osure category
Men having se6 %ith men 2>,:=? 13@4 ?,?AA 1774 @9,=A7
,nGecting.dr'g 'ser =,A>2 12?4 3,=9= 1@:4 23,A3:
Men having se6 %ith men8,nGecting.dr'g 'ser @,:?? 1 74 ?73 1 74 @,=32
"eterose6'al contact =,@>= 12?4 @,7@? 12@4 22,>:>
ther8-nre*orted 27,99@ 1@?4 7,22A 1@:4 2?,AA?
Age grou# ?yrsB
23.@7 >,@:: 1274 A93 1 34 >,?93
@9.@= =,3?7 12?4 @,@3= 1224 22,A@3
3:.37 22,=2A 1@34 7,9:3 1@@4 2A,72=
39.3= 2:,:3: 12=4 7,A:? 1@34 27,A3?
OP7: 27,29= 1@>4 ?,@2: 1724 @@,3A=
Total
99
87,E;F 7F,708 =7,;F8
N For *ersons %ho had not had an ",! diagnosis be&ore being diagnosed %ith (,DS, their (,DS diagnosis date is considered their earliest ",!
diagnosis date< &or *ersons initiall$ re*orted %ith ",! %ho s'bse0'entl$ had (,DS diagnosed and re*orted, the$ are *resented b$ the earliest
diagnosis date, %hich is their ",! diagnosis.
Q (labama, (ri5ona, (rkansas, Colorado, ,daho, ,ndiana, Lo'isiana, Michigan, Minnesota, Mississi**i, Misso'ri, )evada, )e% Jerse$, )orth
Carolina, )orth Dakota, hio, klahoma, So'th Carolina, So'th Dakota, /ennessee, -tah, !irginia, West !irginia, Wisconsin, and W$oming.
R )'mbers are estimates a&ter adG'stments &or re*orting dela$s. Point estimates are *resented &or re*rod'cibilit$ o& the data.
S Percentages ma$ not total 2:: beca'se o& ro'nding.
NN Persons o& races other than black and %hite %ere categori5ed as (P, 1(sian8Paci&ic ,slander4, )( 1)ative (merican4, 'nkno%n, beca'se
estimates %ere too small &or se*arate anal$sis.
QQCol'mn totals incl'de missing8other &or some categories 1e.g., missing se64. Persons in&ected thro'gh recei*t o& blood or blood *rod'cts are
incl'ded 'nder other8'nre*orted risk.
Ret'rn to to*.
,igure 0
Ret'rn to to*.
,igure 7
Ret'rn to to*.
,igure 4
Ret'rn to to*.
!isclaimer (ll 335' "/ML versions o& articles are electronic conversions &rom (SC,, te6t into
"/ML. /his conversion ma$ have res'lted in character translation or &ormat errors in the "/ML version.
-sers sho'ld not rel$ on this "/ML doc'ment, b't are re&erred to the electronic PDF version and8or the
original 335' *a*er co*$ &or the o&&icial te6t, &ig'res, and tables. (n original *a*er co*$ o& this iss'e can
be obtained &rom the S'*erintendent o& Doc'ments, -.S. #overnment Printing &&ice 1#P4, Washington,
DC @:7:@.=3>2< tele*honeD 1@:@4 92@.2?::. Contact #P &or c'rrent *rices.
NNM'estions or messages regarding errors in &ormatting sho'ld be addressed to
mm%r0Tcdc.gov.
0;;4 %evised Classification System for
HIV Infection and *C#anded Surveillance
Case !efinition for AI!S Among
Adolescents and Adults
/he &ollo%ing CDC sta&& members *re*ared this re*ortD
)ational Center &or ,n&ectio's Diseases Division o& ",!8(,DS Kenneth #. Castro, M.D.
John W. Ward, M.D. La'rence Sl'tsker, M.D., M.P.". James W. B'ehler, M.D. "arold W.
Ja&&e, M.D. R'th L. Berkelman, M.D.
&&ice o& the Director (ssociate Director &or ",!8(,DS James W. C'rran, M.D., M.P.".
2==3 Revised Classi&ication S$stem &or ",! ,n&ection and +6*anded S'rveillance Case
De&inition &or (,DS (mong (dolescents and (d'lts
S'mmar$
CDC has revised the classi&ication s$stem &or ",! in&ection to em*hasi5e the clinical
im*ortance o& the CD7L /.l$m*hoc$te co'nt in the categori5ation o& ",!.related clinical
conditions. /his classi&ication s$stem re*laces the s$stem *'blished b$ CDC in 2=?A 124
and is *rimaril$ intended &or 'se in *'blic health *ractice. Consistent %ith the 2==3
revised classi&ication s$stem, CDC has also e6*anded the (,DS s'rveillance case
de&inition to incl'de all ",!.in&ected *ersons %ho have less than @:: CD7L /.
l$m*hoc$tes8'L, or a CD7L /.l$m*hoc$te *ercentage o& total l$m*hoc$tes o& less than
27. /his e6*ansion incl'des the addition o& three clinical conditions
*'lmonar$ t'berc'losis, rec'rrent *ne'monia, and invasive cervical cancer .. and
retains the @3 clinical conditions in the (,DS s'rveillance case de&inition
*'blished in 2=?> 1@4< it is to be 'sed b$ all states &or (,DS case re*orting
e&&ective Jan'ar$ 2, 2==3.
R+!,S+D ",! CL(SS,F,C(/,) SIS/+M FR (DL+SC+)/S ()D (D-L/S
/he etiologic agent o& ac0'ired imm'node&icienc$ s$ndrome 1(,DS4 is a retrovir's
designated h'man imm'node&icienc$ vir's 1",!4. /he CD7L /.l$m*hoc$te is the
*rimar$ target &or ",! in&ection beca'se o& the a&&init$ o& the vir's &or the CD7 s'r&ace
marker 134. /he CD7L /.l$m*hoc$te coordinates a n'mber o& im*ortant imm'nologic
&'nctions, and a loss o& these &'nctions res'lts in *rogressive im*airment o& the imm'ne
res*onse. St'dies o& the nat'ral histor$ o& ",! in&ection have doc'mented a %ide
s*ectr'm o& disease mani&estations, ranging &rom as$m*tomatic in&ection to li&e.
threatening conditions characteri5ed b$ severe imm'node&icienc$, serio's o**ort'nistic
in&ections, and cancers 17.234. ther st'dies have sho%n a strong association bet%een the
develo*ment o& li&e.threatening o**ort'nistic illnesses and the absol'te n'mber 1*er
microliter o& blood4 or *ercentage o& CD7L /. l$m*hoc$tes 127.@24. (s the n'mber o&
CD7L /.l$m*hoc$tes decreases, the risk and severit$ o& o**ort'nistic illnesses increase.
Meas'res o& CD7L /.l$m*hoc$tes are 'sed to g'ide clinical and thera*e'tic management
o& ",!.in&ected *ersons 1@@4. (ntimicrobial *ro*h$la6is and antiretroviral thera*ies have
been sho%n to be most e&&ective %ithin certain levels o& imm'ne d$s&'nction 1@3.@?4. (s
a res'lt, antiretroviral thera*$ sho'ld be considered &or all *ersons %ith CD7L /.
l$m*hoc$te co'nts o& less than 9::8'L, and *ro*h$la6is against Pne'moc$stis carinii
*ne'monia 1PCP4, the most common serio's o**ort'nistic in&ection diagnosed in men
and %omen %ith (,DS, is recommended &or all *ersons %ith CD7L /.l$m*hoc$te co'nts
o& less than @::8'L and &or *ersons %ho have had *rior e*isodes o& PCP. Beca'se o& these
recommendations, CD7L /. l$m*hoc$te determinations are an integral *art o& medical
management o& ",!.in&ected *ersons in the -nited States.
/he classi&ication s$stem &or ",! in&ection among adolescents and ad'lts has been
revised to incl'de the CD7L /.l$m*hoc$te co'nt as a marker &or ",!.related
imm'nos'**ression. /his revision establishes m't'all$ e6cl'sive s'bgro'*s &or %hich
the s*ectr'm o& clinical conditions is integrated %ith the CD7L /.l$m*hoc$te co'nt. /he
obGectives o& these changes are to sim*li&$ the classi&ication o& ",! in&ection, to re&lect
c'rrent standards o& medical care &or ",!.in&ected *ersons, and to categori5e more
acc'ratel$ ",!.related morbidit$.
/he revised CDC classi&ication s$stem &or ",!.in&ected adolescents and ad'lts N
categori5es *ersons on the basis o& clinical conditions associated %ith ",! in&ection and
CD7L /. l$m*hoc$te co'nts. /he s$stem is based on three ranges o& CD7L /.
l$m*hoc$te co'nts and three clinical categories and is re*resented b$ a matri6 o& nine
m't'all$ e6cl'sive categories 1/able 24. /his s$stem re*laces the classi&ication s$stem
*'blished in 2=?A, %hich incl'ded onl$ clinical disease criteria and %hich %as develo*ed
be&ore the %ides*read 'se o& CD7L /.cell testing 124.
Criteria &or ",! in&ection &or *ersons ages greater than 23 $earsD
a. re*eatedl$ reactive screening tests &or ",! antibod$ 1e.g., en5$me imm'noassa$4
%ith s*eci&ic antibod$ identi&ied b$ the 'se o& s'**lemental tests 1e.g., Western
blot, imm'no&l'orescence assa$4<
b. direct identi&ication o& vir's in host tiss'es b$ vir's isolation< c4 ",! antigen
detection< or d4 a *ositive res'lt on an$ other highl$ s*eci&ic licensed test &or ",!.
CD7L /.L$m*hoc$te Categories
/he three CD7L /.l$m*hoc$te categories are de&ined as &ollo%sD
Categor$ 2D greater than or e0'al to 9:: cells8mL
Categor$ @D @::.7== cells8'L
Categor$ 3D less than @:: cells8'L
/hese categories corres*ond to CD7L /.l$m*hoc$te co'nts *er microliter o& blood and
g'ide clinical and thera*e'tic actions in the management o& ",!.in&ected adolescents and
ad'lts 1@@.@?4. /he revised ",! classi&ication s$stem also allo%s &or the 'se o& the
*ercentage o& CD7L /.cells 1(**endi6 (4.
",!.in&ected *ersons sho'ld be classi&ied based on e6isting g'idelines &or the medical
management o& ",!.in&ected *ersons 1@@4. /h's, the lo%est acc'rate, b't not necessaril$
the most recent, CD7L /.l$m*hoc$te co'nt sho'ld be 'sed &or classi&ication *'r*oses.
Clinical Categories
/he clinical categories o& ",! in&ection are de&ined as &ollo%sD Categor$ (
Categor$ ( consists o& one or more o& the conditions listed belo% in an adolescent or
ad'lt 1greater than or e0'al to 23 $ears4 %ith doc'mented ",! in&ection. Conditions
listed in Categories B and C m'st not have occ'rred.
(s$m*tomatic ",! in&ection
Persistent generali5ed l$m*hadeno*ath$
(c'te 1*rimar$4 ",! in&ection %ith accom*an$ing illness or histor$ o& ac'te ",!
in&ection 1@=,3:4 Categor$ B
Categor$ B consists o& s$m*tomatic conditions in an ",!.in&ected adolescent or ad'lt
that are not incl'ded among conditions listed in clinical Categor$ C and that meet at least
one o& the &ollo%ing criteriaD a4 the conditions are attrib'ted to ",! in&ection or are
indicative o& a de&ect in cell.mediated imm'nit$< or b4 the conditions are considered b$
*h$sicians to have a clinical co'rse or to re0'ire management that is com*licated b$ ",!
in&ection. +6am*les o& conditions in clinical Categor$ B incl'de, b't are not limited toD
Bacillar$ angiomatosis
Candidiasis, oro*har$ngeal 1thr'sh4
Candidiasis, v'lvovaginal< *ersistent, &re0'ent, or *oorl$ res*onsive to thera*$
Cervical d$s*lasia 1moderate or severe48cervical carcinoma in sit'
Constit'tional s$m*toms, s'ch as &ever 13?.9 C4 or diarrhea lasting greater than 2
month
"air$ le'ko*lakia, oral
"er*es 5oster 1shingles4, involving at least t%o distinct e*isodes or more than one
dermatome
,dio*athic thromboc$to*enic *'r*'ra
Listeriosis
Pelvic in&lammator$ disease, *artic'larl$ i& com*licated b$ t'bo.ovarian abscess
Peri*heral ne'ro*ath$
For classi&ication *'r*oses, Categor$ B conditions take *recedence over those in
Categor$ (. For e6am*le, someone *revio'sl$ treated &or oral or *ersistent vaginal
candidiasis 1and %ho has not develo*ed a Categor$ C disease4 b't %ho is no%
as$m*tomatic sho'ld be classi&ied in clinical Categor$ B.
Categor$ C
Categor$ C incl'des the clinical conditions listed in the (,DS s'rveillance case de&inition
1(**endi6 B4. For classi&ication *'r*oses, once a Categor$ C condition has occ'rred, the
*erson %ill remain in Categor$ C.
+UP()S,) F /"+ CDC S-R!+,LL()C+ C(S+ D+F,),/,) FR (,DS
,n 2==2, CDC, in collaboration %ith the Co'ncil o& State and /erritorial +*idemiologists
1CS/+4, *ro*osed an e6*ansion o& the (,DS s'rveillance case de&inition. /his *ro*osal
%as made available &or *'blic comment in )ovember 2==2 and %as disc'ssed at an o*en
meeting on Se*tember @, 2==@. Based on in&ormation *resented and revie%ed d'ring the
*'blic comment *eriod and at the o*en meeting, CDC, in collaboration %ith CS/+, has
e6*anded the (,DS s'rveillance case de&inition to incl'de all ",!.in&ected *ersons %ith
CD7L /. l$m*hoc$te co'nts o& less than @:: cells8'L or a CD7L *ercentage o& less than
27. ,n addition to retaining the @3 clinical conditions in the *revio's (,DS s'rveillance
de&inition, the e6*anded de&inition incl'des *'lmonar$ t'berc'losis 1/B4, rec'rrent
*ne'monia, and invasive cervical cancer. N /his e6*anded de&inition re0'ires laborator$
con&irmation o& ",! in&ection in *ersons %ith a CD7L /.l$m*hoc$te co'nt o& less than
@:: cells8'L or %ith one o& the added clinical conditions. /his e6*anded de&inition &or
re*orting cases to CDC becomes e&&ective Jan'ar$ 2, 2==3.
Diagnostic criteria &or (,DS.de&ining conditions incl'ded in the e6*anded
s'rveillance case de&inition are *resented in (**endi6 C and (**endi6 D.
,n the revised ",! classi&ication s$stem, *ersons in s'bcategories (3, B3, and C3 meet
the imm'nologic criteria o& the s'rveillance case de&inition, and those *ersons %ith
conditions in s'bcategories C2, C@, and C3 meet the clinical criteria &or s'rveillance
*'r*oses 1/able 24.
CMM+)/(RI Revised Classi&ication S$stem
/he revised classi&ication s$stem &or ",! in&ection is based on the recommended clinical
standard o& monitoring CD7L /. l$m*hoc$te co'nts, since this *arameter consistentl$
correlates %ith ",!.related imm'ne d$s&'nction and disease *rogression and *rovides
in&ormation needed to g'ide medical management o& *ersons in&ected %ith ",! 127.2?,
@@.@?4. /he classi&ication s$stem also allo%s &or 'se o& the *ercentage o& CD7L /.cells
instead o& absol'te CD7L /.l$m*hoc$te co'nts 1(**endi6 (4. ther markers o& imm'ne
stat's .. s'ch as ser'm neo*terin, beta.@ microglob'lin, ",! *@7 antigen, sol'ble
interle'kin.@ rece*tors, imm'noglob'lin (, and dela$ed.t$*e h$*ersensitivit$ 1D/"4
skin.test reactions .. ma$ be 'se&'l in the eval'ation o& individ'al *atients b't are not as
strongl$ *redictive o& disease *rogression or as s*eci&ic &or ",!.related
imm'nos'**ression as meas'res o& CD7L /.l$m*hoc$tes 127.@2, 324. D/" skin.test
reactions are o&ten 'sed in conG'nction %ith the Manto'6 t'berc'lin skin test to eval'ate
",!.in&ected *atients &or /B in&ection and anerg$ 132.334.
ther s$stems have been *ro*osed &or classi&ication and staging o& ",! in&ection 12, 32,
37.3=4. ,n 2==:, the World "ealth rgani5ation 1W"4 *'blished an interim *ro*osal &or
a staging s$stem &or ",! in&ection and diseases that %as based *rimaril$ on clinical
criteria and incl'ded the 'se o& CD7L /.l$m*hoc$te determinations 1374. /he W"
s$stem incor*orates a *er&ormance scale and total l$m*hoc$te co'nts to be 'sed in lie' o&
CD7L /.l$m*hoc$te determinations in co'ntries %here CD7L /.l$m*hoc$te testing is not
available.
/he acc'rac$ o& CD7L /.l$m*hoc$te co'nts is im*ortant &or medical care o& individ'al
*atients. /o ass're reliabilit$, laboratories cond'cting CD7L /.l$m*hoc$te meas'rements
sho'ld be e6*erienced %ith test *roced'res, have established 0'alit$ ass'rance methods,
and *artici*ate in *ro&icienc$ testing *rograms cond'cted b$ CDC or other organi5ations
1@@, 7:4. CDC has *'blished g'idelines &or the *er&ormance o& CD7L /.cell
determinations &or ",!.in&ected *ersons 1724. /o ass're that test res'lts are indicative o&
a *atient;s medical condition, the health.care *rovider sho'ld eval'ate the res'lts %ith
those o& earlier tests and %ith the *atient;s clinical condition. ,n clinical *ractice, re*eat
CD7L testing ma$ be G'dged necessar$ in g'iding thera. *e'tic decisions &or individ'al
*atients. For s'rveillance *'r*oses, ho%ever, a re0'irement &or re*eat CD7L
determinations is im*ractical &or *o*'lation.based monitoring.
/he revised classi&ication s$stem o& the clinical and imm'nologic mani&estations o& ",!
in&ection *rovides a &rame%ork &or categori5ing ",!.related morbidit$ and
imm'nos'**ression and %ill assist e&&orts to eval'ate the overall im*act o& the ",!
e*idemic. Kno%ledge o& the s*ectr'm o& clinical conditions and the e6tent o&
imm'nos'**ression that ma$ occ'r d'ring the co'rse o& ",! in&ection is im*ortant &or
*rom*t eval'ation and &or *rovision o& a**ro*riate health services. Clinicians sho'ld be
a%are o& the clinical conditions s'ggestive o& ",! in&ection and the need &or *ro*h$lactic
and thera*e'tic interventions.
/his revised ",! classi&ication s$stem sho'ld be 'sed b$ state and territorial health
de*artments that cond'ct ",! in&ection s'rveillance. Beca'se (,DS s'rveillance data
%ill contin'e to re*resent onl$ a *ortion o& the total morbidit$ ca'sed b$ ",!,
s'rveillance &or ",! in&ection ma$ be *artic'larl$ 'se&'l in de*icting the total im*act o&
",! on health.care and social services 17@4. More acc'rate re*orting and anal$sis o&
CD7L /.l$m*hoc$te co'nts, together %ith ",!.related clinical conditions, sho'ld
&acilitate e&&orts to eval'ate health.care and re&erral needs &or *ersons %ith ",! in&ection
and to *roGect &'t're needs &or these services.
+6*anded (,DS S'rveillance Case De&inition
/he *o*'lation o& ",!.in&ected *ersons %ith CD7L /.l$m*hoc$te co'nts o& less than
@::8'L is s'bstantiall$ larger than the *o*'lation o& *ersons %ith (,DS.de&ining clinical
conditions 1734. /he incl'sion in the (,DS s'rveillance de&inition o& *ersons %ith a
CD7L /.l$m*hoc$te co'nt o& less than @:: cells8'L or a CD7L *ercentage less than 27
%ill enable (,DS s'rveillance to re&lect more acc'ratel$ the n'mber o& *ersons %ith
severe ",!.related imm'nos'**ression and those at highest risk &or severe ",!.related
morbidit$. Since the (,DS s'rveillance case de&inition %as last revised in 2=?>, the
increasing 'se o& *ro*h$la6is against PCP and antiretroviral thera*$ &or *ersons in&ected
%ith ",! has slo%ed the rate at %hich ",!.in&ected *ersons develo* (,DS.de&ining
clinical conditions 1@,@@.@94. For e6am*le, among homose6'al8bise6'al men %ith (,DS
re*orted to CDC, the *ro*ortion %ith PCP decreased &rom A@C in 2=?? to 7AC in 2==:
1774. /his trend is e6*ected to contin'e.
/he abilit$ o& clinicians to re*ort ",!.in&ected *ersons on the basis o& CD7L /.
l$m*hoc$te co'nts ma$ also sim*li&$ the case.re*orting *rocess. ( sim*li&ied (,DS
s'rveillance case de&inition %ill be *artic'larl$ im*ortant &or o't*atient clinics in %hich
the availabilit$ o& sta&& to cond'ct s'rveillance is limited and &rom %hich an increasing
*ro*ortion o& (,DS cases are being re*orted. For e6am*le, &rom *re.2=?9 to 2=??, the
*ro*ortion o& (,DS cases re*orted &rom o't*atient sites in the state o& Washington
increased &rom AC 1=82994 to @9C 1998@2=4 1794. ( similar increase occ'rred in regon
1@9C V7782>2W be&ore 2=?> to 3?C V7:82:9W in the &irst hal& o& 2=?=4 17A4.
P'lmonar$ /'berc'losis
/hro'gho't the %orld, *'lmonar$ /B is the most common t$*e o& /B in *ersons %ith
",! in&ection 17>4. /he addition o& *'lmonar$ /B to the list o& (,DS.indicator diseases
is based on the strong e*idemiologic link bet%een ",! in&ection and the develo*ment o&
/B 17?.9:4. Persons co.in&ected %ith ",! and /B have a s'bstantiall$ increased risk o&
develo*ing active /B com*ared %ith *ersons %itho't ",! in&ection 17?, 7=4. ,n a
*ros*ective eval'ation o& inGecting.dr'g 'sers 1,D-s4 %ith *ositive t'berc'lin skin tests,
the estimated ann'al incidence o& active /B among 7= ",!.in&ected ,D-s %as >.=
cases82:: *erson.$ears< ho%ever, no cases o& active /B occ'rred among A@ t'berc'lin.
*ositive b't ",!.seronegative ,D-s &ollo%ed &or as long as 3: months 17?4.
/here is also a s'bstantial imm'nologic association bet%een ",!.in&ected *ersons and
*'lmonar$ /B %hen com*ared %ith ",!.in&ected *ersons %ith e6tra*'lmonar$ /B 1a
condition incl'ded in the 2=?> s'rveillance de&inition4. ,n a recent revie%, median CD7L
/.l$m*hoc$te co'nts in ",!.in&ected *atients %ith *'lmonar$ /B ranged &rom @9: to
9:: cells8'L 1924. ,n com*arison, the median CD7L l$m*hoc$te co'nt %as @7@ cells8'L
in one st'd$ o& *ersons %ith locali5ed e6tra*'lmonar$ /B and ranged &rom >: to >=
cells8'L in t%o st'dies o& *atients %ith disseminated or miliar$ /B 192.934. ,n CDC;s
(d'lt and (dolescent S*ectr'm o& ",! Disease 1(SD4 ProGect, A=C o& ",!.in&ected
*ersons %ith *'lmonar$ /B had CD7L /.l$m*hoc$te co'nts o& less than @::8'L,
com*ared %ith >>C o& *ersons %ith e6tra*'lmonar$ /B 1CDC, 'n*'blished
observations4.
/he addition o& *'lmonar$ /B to (,DS s'rveillance criteria %ill re0'ire contin'ed
collaboration bet%een state and local /B and ",!8(,DS *rograms. Kno%ledge o& a
*atient;s ",! stat's is im*ortant &or the *ro*er medical management o& /B beca'se
longer co'rses o& thera*$ and *ro*h$la6is are recommended &or ",!.in&ected *atients
%ith /B 1974. F'rthermore, ",!.in&ected /B *atients sho'ld be a *riorit$ &or
e*idemiologic investigation beca'se these *ersons are more likel$ to have ",!.in&ected
contacts than are seronegative /B *atients. /B contact &ollo%.'* among ",!.in&ected
*ersons %ill hel* to ens're deliver$ o& a &'ll co'rse o& *reventive thera*$ to these
contacts, %ho are at greatl$ increased risk o& develo*ing active /B themselves.
Rec'rrent Pne'monia
With the e6ce*tion o& conditions incl'ded in the 2=?> (,DS s'rveillance case de&inition,
*ne'monia, %ith or %itho't a bacteriologic diagnosis, is the leading ca'se o& ",!.related
morbidit$ and death 199, 9A4. ,n addition, several st'dies have sho%n that *ersons %ith
",!.related imm'nos'**ression are at an increased risk o& bacterial *ne'monia 19>.9=4.
For e6am*le, one st'd$ &o'nd that the $earl$ incidence rate o& bacterial *ne'monia
among ",!.in&ected ,D-s %itho't (,DS %as &ive times that &o'nd in non.",!.in&ected
,D-s 19?4. Rec'rrent e*isodes o& *ne'monia 1t%o or more e*isodes %ithin a 2.$ear
*eriod4 are re0'ired &or (,DS case re*orting beca'se *ne'monia is a relativel$ common
diagnosis and m'lti*le e*isodes o& *ne'monia are more strongl$ associated %ith
imm'nos'**ression than are single e*isodes. For e6am*le, data &rom the (SD ProGect
indicate that the risk o& an ",!.in&ected *erson having had one e*isode o& *ne'monia in a
2@.month *eriod is a**ro6imatel$ &ive times higher among in&ected *ersons %ith CD7L
/.l$m*hoc$te co'nts o& less than @::8'L 13@:8@,7224 than among those %ith higher
CD7L /.l$m*hoc$te co'nts 1=:8@,>=@4. ,n contrast, data &rom the same st'd$ indicate
that the risk &or m'lti*le e*isodes o& *ne'monia in a 2@.month *eriod is a**ro6imatel$
@: times higher among ",!.in&ected *ersons %ith CD7L /.l$m*hoc$te co'nts o& less
than @::8'L 1A>8@,7224 than among those %ith higher CD7L /.cell co'nts 178@,>=@4
1CDC, 'n*'blished observations4.
,nvasive Cervical Cancer
Several st'dies have &o'nd an increased *revalence o& cervical d$s*lasia, a *rec'rsor
lesion &or cervical cancer, among ",!.in&ected %omen 1A:, A24. ,n a st'd$ o& 32: ",!.
in&ected %omen attending methadone maintenance and se6'all$ transmitted disease
clinics in )e% Iork Cit$ and )e%ark, )e% Jerse$, cervical d$s*lasia %as con&irmed b$
bio*s$ and8or col*osco*$ in a**ro6imatel$ @@C, a *revalence rate 2: times greater than
that &o'nd among %omen attending &amil$ *lanning clinics in the -nited States 1Wright
/C, *ersonal comm'nication< A@4. Several st'dies have doc'mented that a higher
*revalence o& cervical d$s*lasia among ",!.in&ected %omen is associated %ith greater
imm'nos'**ression 1Wright /C, *ersonal comm'nication< A2,A34. ,n addition, ",!
in&ection ma$ adversel$ a&&ect the clinical co'rse and treatment o& cervical d$s*lasia and
cancer 1A7.A=4.
,nvasive cervical cancer is a more a**ro*riate (,DS.indicator disease than is either
cervical d$s*lasia or carcinoma in sit' beca'se these latter cervical lesions are common
and &re0'entl$ do not *rogress to invasive disease 1>:4. (lso, cervical d$s*lasia or
carcinoma in sit' among %omen %ith severe cervicovaginal in&ections, %hich are
common in ",!.in&ected %omen, can be di&&ic'lt to diagnose. ,n contrast, the diagnosis
o& invasive cervical cancer is generall$ 'ne0'ivocal.
,nvasive cervical cancer is *reventable b$ the *ro*er recognition and treatment o&
cervical d$s*lasia. /h's, the occ'rrence o& invasive cervical cancer among all %omen ..
incl'ding those %ho are ",!.in&ected .. re*resents missed o**ort'nities &or disease
*revention. /he addition o& invasive cervical cancer to the list o& (,DS.indicator diseases
em*hasi5es the im*ortance o& integrating g$necologic care into medical services &or ",!.
in&ected %omen.
,m*act on (,DS Case Re*orting
/he e6*anded (,DS s'rveillance case de&inition is e6*ected to have a s'bstantial im*act
on the n'mber o& re*orted cases. /he immediate increase in case re*orting %ill be largel$
attrib'table to the addition o& severe imm'nos'**ression to the de&inition< a smaller
im*act is e6*ected &rom the addition o& *'lmonar$ /B, rec'rrent *ne'monia, and
invasive cervical cancer, since man$ *ersons %ith these diseases %ill also have CD7L /.
l$m*hoc$te co'nts o& less than @:: cells8'L. ,& all o& the a**ro6imatel$ 2,:::,:::
*ersons in the -nited States %ith ",! in&ection %ere diagnosed and their imm'ne stat's
%ere kno%n, it is estimated that 2@:,:::. 2=:,::: *ersons %ho do not have (,DS.
indicator diseases %o'ld be &o'nd to have CD7L /.l$m*hoc$te co'nts o& less than @::
cells8'L 1>24. "o%ever, not all o& these *ersons are a%are o& their ",! in&ection and o&
those %ho kno% their ",! in&ection stat's, not all have had an imm'nologic eval'ation<
th's, the immediate im*act on the n'mber o& (,DS cases %ill be considerabl$ less than
2@:,:::. 2=:,:::. ,& (,DS s'rveillance criteria %ere 'nchanged, a**ro6imatel$ 9:,:::.
A:,::: re*orted (,DS cases %o'ld be e6*ected in 2==3. Based on c'rrent levels o& ",!
and CD7L testing, CDC estimates that the e6*anded de&inition co'ld increase cases
re*orted in 2==3 b$ a**ro6imatel$ >9C. +arl$ e&&ects o& e6*anded s'rveillance %ill be
greater than long.term e&&ects beca'se *revalent as %ell as incident cases o&
imm'nos'**ression %ill be re*orted &ollo%ing im*lementation o& the e6*anded
s'rveillance case de&inition. ,n s'bse0'ent $ears, the e&&ect on the n'mber o& re*orted
cases is e6*ected to be m'ch smaller.
-ses o& the ",! Classi&ication S$stem or (,DS S'rveillance Case De&inition
/he revised ",! classi&ication s$stem and the (,DS s'rveillance case de&inition are
intended &or 'se in cond'cting *'blic health s'rveillance. /he CDC;s (,DS s'rveillance
case de&inition %as not develo*ed to determine %hether stat'tor$ or other legal
re0'irements &or entitlement to Federal disabilit$ or other bene&its are met. Conse0'entl$,
this revised s'rveillance case de&inition does not alter the criteria 'sed b$ the Social
Sec'rit$ (dministration in eval'ating claims based on ",! in&ection 'nder the Social
Sec'rit$ disabilit$ ins'rance and S'**lemental Sec'rit$ ,ncome *rograms. ther
organi5ations and agencies *roviding medical and social services sho'ld develo*
eligibilit$ criteria a**ro*riate to the services *rovided and local needs.
Con&identialit$
/he con&identialit$ o& (,DS case re*orts .. incl'ding laborator$ re*orts o& ",! test
res'lts, CD7L /.l$m*hoc$te test res'lts, and medical records 'nder revie% b$ health
de*artment sta&& .. is o& critical im*ortance to maintaining e&&ective ",!8(,DS
s'rveillance. CDC and state health de*artments have im*lemented *roced'res and
*olicies to maintain con&identialit$ and sec'rit$ o& ",!8(,DS s'rveillance data 1>@4.
CDC;s e&&orts incl'de a &ederal ass'rance o& con&identialit$, the removal o& names be&ore
encr$*ted records are transmitted to CDC, strict g'idelines &or the release o& aggregate
data, and the incl'sion o& con&identialit$ and sec'rit$ sa&eg'ards as eval'ation criteria &or
&ederal &'nding o& state ",!8(,DS s'rveillance activities 1>34. /hese strict criteria %ill
contin'e to a**l$ to cases re*orted 'nder the e6*anded de&inition. CDC &'nding o&
s'rveillance coo*erative agreements is de*endent on the reci*ient;s abilit$ to ens're the
*h$sical sec'rit$ o& case re*orts and on state *olicies or la%s to *rotect the con&identialit$
o& *ersons re*orted %ith (,DS. Fail're to ens're the sec'rit$ and con&identialit$ o&
*ersonal identi&$ing in&ormation collected as *art o& (,DS or ",! s'rveillance activities
%ill Geo*ardi5e &ederal s'rveillance &'nding.
CD7L /.l$m*hoc$te test res'lts re*orted b$ laboratories %ill be an im*ortant adG'nct to
medical record revie% and *rovider.initiated re*orting in order to increase com*leteness,
timeliness, and e&&icienc$ o& (,DS s'rveillance. ,n&ormation &rom a laborator$.initiated
re*ort o& a CD7L /.l$m*hoc$te co'nt is ins'&&icient &or re*orting a case o& (,DS.
Con&irmation o& ",! in&ection stat's and recei*t o& other s'rveillance in&ormation &rom
the health.care *rovider or &rom medical or *'blic health records %ill remain necessar$.
+ver$ e&&ort sho'ld be made b$ health.care *roviders, laboratories, and *'blic health
agencies to *rotect the con&identialit$ o& CD7L /.l$m*hoc$te test res'lts, incl'ding the
revie% o& record.kee*ing *ractices in laboratories and health.care settings. Some states
have considered additional means to ass're the con&identialit$ o& CD7L /.l$m*hoc$te
test res'lts. For e6am*le, a *ro*osal in regon %o'ld allo% health.care *roviders to send
s*ecimens to laboratories &or CD7L /.l$m*hoc$te testing %ith a 'ni0'e code &or each
*erson being tested. ,& the test res'lt indicates a CD7L /.l$m*hoc$te co'nt o& less than
@:: cells8'L, the health de*artment %o'ld noti&$ the health.care *rovider that an (,DS
case re*ort is re0'ired i& the *erson is ",! in&ected, the CD7L /.l$m*hoc$te co'nt is
valid, and the case has not been *revio'sl$ re*orted. ,n&ormed consent &or CD7L /.
l$m*hoc$te testing sho'ld be obtained in accordance %ith local la%s or reg'lations.
CD7L /.l$m*hoc$te test res'lts alone sho'ld not be 'sed as a s'rrogate marker &or ",!
or (,DS. ( lo% CD7L /.l$m*hoc$te co'nt %itho't a *ositive ",! test res'lt %ill not be
re*ortable since other conditions ma$ res'lt in a lo% CD7L /.l$m*hoc$te co'nt. "ealth.
care *roviders m'st ens're that *ersons %ho have a CD7L /.l$m*hoc$te co'nt o& less
than @::8'L are ",! in&ected be&ore initiating treatment &or ",! disease or re*orting
those *ersons as cases o& (,DS.
C)CL-S,)
/he revised ",! classi&ication s$stem *rovides 'ni&orm and sim*le criteria &or
categori5ing conditions among adolescents and ad'lts %ith ",! in&ection and sho'ld
&acilitate e&&orts to eval'ate c'rrent and &'t're health.care and re&erral needs &or *ersons
%ith ",! in&ection. /he addition o& a meas're o& severe imm'nos'**ression, as de&ined
b$ a CD7L /.l$m*hoc$te co'nt o& less than @:: cells8'L or a CD7L *ercentage o& less
than 27, re&lects the standard o& imm'nologic monitoring &or ",!.in&ected *ersons and
%ill enable (,DS s'rveillance data to more acc'ratel$ re*resent those %ho are recogni5ed
as being imm'nos'**ressed, %ho are in greatest need o& close medical &ollo%.'*, and
%ho are at greatest risk &or the &'ll s*ectr'm o& severe ",!.related morbidit$. /he
addition o& three clinical conditions .. *'lmonar$ /B, rec'rrent *ne'monia, and invasive
cervical cancer .. to (,DS s'rveillance criteria re&lects the doc'mented or *otential
im*ortance o& these diseases in the ",! e*idemic. /%o o& these conditions 1*'lmonar$
/B and cervical cancer4 are *reventable i& a**ro*riate screening tests are linked %ith
*ro*er &ollo%.'*. /he third, rec'rrent *ne'monia, re&lects the im*ortance o& *'lmonar$
in&ections not incl'ded in the 2=?> de&inition as leading ca'ses o& ",!.related morbidit$
and mortalit$. S'ccess&'l im*lementation o& e6*anded s'rveillance criteria %ill re0'ire
the e6tension o& e6isting sa&eg'ards to *rotect the sec'rit$ and con&identialit$ o& (,DS
s'rveillance in&ormation.
(PP+)D,U (. +0'ivalences &or CD7L /.l$m*hoc$te co'nt and *ercentage o& total
l$m*hoc$tes
Com*ared %ith the absol'te CD7L /.l$m*hoc$te co'nt, the *ercentage o& CD7L /.cells
o& total l$m*hoc$tes 1or CD7L *ercentage4 is less s'bGect to variation on re*eated
meas'rements 12?,>74. "o%ever, data correlating nat'ral histor$ o& ",! in&ection %ith
the CD7L *ercentage have not been as consistentl$ available as data on absol'te CD7L /.
l$m*hoc$te co'nts 127.2A,2?,2=,@2,324. /here&ore, the revised classi&ication s$stem
em*hasi5es the 'se o& CD7L /.l$m*hoc$te co'nts b't allo%s &or the 'se o& CD7L
*ercentages.
+0'ivalences 1/able (24 %ere derived &rom anal$ses o& more than 29,9:: l$m*hoc$te
s'bset determinations &rom seven di&&erent so'rcesD one m'ltistate st'd$ o& diseases in
",!.in&ected adolescents and ad'lts 19=4 and si6 laboratories 1t%o commercial, one
research, and three 'niversit$.based4. /he si6 laboratories are involved in *ro&icienc$
testing *rograms &or l$m*hoc$te s'bset determinations. ,n the anal$ses, concordance %as
de&ined as the *ro*ortion o& *atients classi&ied as having CD7L /.l$m*hoc$te co'nts in a
*artic'lar range among *atients %ith a given CD7L *ercentage. ( threshold val'e o& the
CD7L *ercentage %as calc'lated to obtain o*timal concordance %ith each strati&$ing
val'e o& the CD7L /.l$m*hoc$te co'nts 1i.e., less than @::8'L and greater than or e0'al
to 9::8'L4. /he thresholds &or the CD7L *ercentages that best correlated %ith a CD7L /.
l$m*hoc$te co'nt o& less than @::8'L varied minimall$ among the seven data so'rces
1range, 23C.27C< median, 23C< mean, 23.7C4. /he average concordance &or a CD7L
*ercentage o& less than 27 and a CD7L /.l$m*hoc$te co'nt o& less than @::8'L %as
=:.@C. /he threshold &or the CD7L *ercentages most concordant %ith CD7L /.
l$m*hoc$te co'nts o& greater than or e0'al to 9::8'L varied more %idel$ among the
seven data so'rces 1range, @@.9C.39C< median, @=C< mean, @=.2C4. /his %ide range o&
*ercentages o*timall$ concordant %ith greater than or e0'al to 9::8'L CD7L /.
l$m*hoc$tes makes the concordance at this strati&$ing val'e less certain. /he average
concordance &or a CD7L *ercentage o& greater than or e0'al to @= and a CD7L /.
l$m*hoc$te co'nt o& greater than or e0'al to 9::8'L %as ?9C 1CDC, 'n*'blished data4.
Clinicians and other *ractitioners m'st recogni5e that these s'ggested e0'ivalences ma$
not al%a$s corres*ond %ith val'es observed in individ'al *atients.
(PP+)D,U B. Conditions incl'ded in the 2==3 (,DS s'rveillance case de&inition
Candidiasis o& bronchi, trachea, or l'ngs
Candidiasis, eso*hageal
Cervical cancer, invasive N
Coccidioidom$cosis, disseminated or e6tra*'lmonar$
Cr$*tococcosis, e6tra*'lmonar$
Cr$*tos*oridiosis, chronic intestinal 1greater than 2 month;s d'ration4
C$tomegalovir's disease 1other than liver, s*leen, or nodes4
C$tomegalovir's retinitis 1%ith loss o& vision4
+nce*halo*ath$, ",!.related
"er*es sim*le6D chronic 'lcer1s4 1greater than 2 month;s d'ration4< or bronchitis,
*ne'monitis, or eso*hagitis
"isto*lasmosis, disseminated or e6tra*'lmonar$
,sos*oriasis, chronic intestinal 1greater than 2 month;s d'ration4
Ka*osi;s sarcoma
L$m*homa, B'rkitt;s 1or e0'ivalent term4
L$m*homa, imm'noblastic 1or e0'ivalent term4
L$m*homa, *rimar$, o& brain
M$cobacteri'm avi'm com*le6 or M. kansasii, disseminated or e6tra*'lmonar$
M$cobacteri'm t'berc'losis, an$ site 1*'lmonar$ N or e6tra*'lmonar$4
M$cobacteri'm, other s*ecies or 'nidenti&ied s*ecies, disseminated or
e6tra*'lmonar$
Pne'moc$stis carinii *ne'monia
Pne'monia, rec'rrent N
Progressive m'lti&ocal le'koence*halo*ath$
Salmonella se*ticemia, rec'rrent
/o6o*lasmosis o& brain
Wasting s$ndrome d'e to ",!
(dded in the 2==3 e6*ansion o& the (,DS s'rveillance case de&inition.
(PP+)D,U C. De&initive diagnostic methods &or diseases indicative o& (,DS
Cr$*tos*oridiosis, ,sos*oriasis, Ka*osi;s sarcoma, L$m*homa, Pne'moc$stis carinii
*ne'monia, Progressive m'lti&ocal le'koence*halo*ath$, /o6o*lasmosis, Cervical cancer
Microsco*$ 1histolog$ or c$tolog$4
Candidiasis #ross ins*ection b$ endosco*$ or a'to*s$ or b$ microsco*$ 1histolog$ or
c$tolog$4 on a s*ecimen obtained directl$ &rom the tiss'es a&&ected 1incl'ding scra*ings
&rom the m'cosal s'r&ace4, not &rom a c'lt're
Coccidioidom$cosis, Cr$*tococcosis, C$tomegalovir's, "er*es sim*le6 vir's,
"isto*lasmosis Microsco*$ 1histolog$ or c$tolog$4, c'lt're, or detection o& antigen in a
s*ecimen obtained directl$ &rom the tiss'es a&&ected or a &l'id &rom those tiss'es
/'berc'losis, ther m$cobacteriosis, Salmonellosis C'lt're
",! ence*halo*ath$ 1dementia4 Clinical &indings o& disabling cognitive or motor
d$s&'nction inter&ering %ith occ'*ation or activities o& dail$ living, *rogressing over
%eeks to months, in the absence o& a conc'rrent illness or condition other than ",!
in&ection that co'ld e6*lain the &indings. Methods to r'le o't s'ch conc'rrent illness and
conditions m'st incl'de cerebros*inal &l'id e6amination and either brain imaging
1com*'ted tomogra*h$ or magnetic resonance4 or a'to*s$.
",! %asting s$ndrome Findings o& *ro&o'nd invol'ntar$ %eight loss o& greater than 2:C
o& baseline bod$ %eight *l's either chronic diarrhea 1at least t%o loose stools *er da$ &or
greater than or e0'al to 3: da$s4, or chronic %eakness and doc'mented &ever 1&or greater
than or e0'al to 3: da$s, intermittent or constant4 in the absence o& a conc'rrent illness or
condition other than ",! in&ection that co'ld e6*lain the &indings 1e.g., cancer,
t'berc'losis, cr$*tos*oridiosis, or other s*eci&ic enteritis4.
Pne'monia, rec'rrent Rec'rrent 1more than one e*isode in a 2.$ear *eriod4, ac'te 1ne%
6.ra$ evidence not *resent earlier4 *ne'monia diagnosed b$ bothD a4 c'lt're 1or other
organism.s*eci&ic diagnostic method4 obtained &rom a clinicall$ reliable s*ecimen o& a
*athogen that t$*icall$ ca'ses *ne'monia 1other than Pne'moc$stis carinii or
M$cobacteri'm t'berc'losis4, and b4 radiologic evidence o& *ne'monia< cases that do not
have laborator$ con&irmation o& a ca'sative organism &or one o& the e*isodes o&
*ne'monia %ill be considered to be *res'm*tivel$ diagnosed.
(PP+)D,U D. S'ggested g'idelines &or *res'm*tive diagnosis o& diseases indicative o&
(,DS
Candidiasis o& eso*hag's
a. Recent onset o& retrosternal *ain on s%allo%ing< ()D
b. ral candidiasis diagnosed b$ the gross a**earance o& %hite *atches or *la0'es
on an er$themato's base or b$ the microsco*ic a**earance o& &'ngal m$celial
&ilaments &rom a nonc'lt'red s*ecimen scra*ed &rom the oral m'cosa.
C$tomegalovir's retinitis ( characteristic a**earance on serial o*hthalmo.sco*ic
e6aminations 1e.g., discrete *atches o& retinal %hitening %ith distinct borders, s*reading
in a centri&'gal manner along the *aths o& blood vessels, *rogressing over several
months, and &re0'entl$ associated %ith retinal vasc'litis, hemorrhage, and necrosis4.
Resol'tion o& active disease leaves retinal scarring and atro*h$ %ith retinal *igment
e*ithelial mottling.
M$cobacteriosis Microsco*$ o& a s*ecimen &rom stool or normall$ sterile bod$ &l'ids or
tiss'e &rom a site other than l'ngs, skin, or cervical or hilar l$m*h nodes that sho%s acid.
&ast bacilli o& a s*ecies not identi&ied b$ c'lt're.
Ka*osi;s sarcoma ( characteristic gross a**earance o& an er$themato's or violaceo's
*la0'e.like lesion on skin or m'co's membrane. 1)oteD Pres'm*tive diagnosis o&
Ka*osi;s sarcoma sho'ld not be made b$ clinicians %ho have seen &e% cases o& it.4
Pne'moc$stis carinii *ne'monia
a. ( histor$ o& d$s*nea on e6ertion or non*rod'ctive co'gh o& recent onset 1%ithin
the *ast 3 months4< ()D
b. Chest 6.ra$ evidence o& di&&'se bilateral interstitial in&iltrates or evidence b$
galli'm scan o& di&&'se bilateral *'lmonar$ disease< ()D
c. (rterial blood gas anal$sis sho%ing an arterial *11@44 o& less than >: mm "g or
a lo% res*irator$ di&&'sing ca*acit$ 1less than ?:C o& *redicted val'es4 or an
increase in the alveolar.arterial o6$gen tension gradient< ()D
d. )o evidence o& a bacterial *ne'monia.
Pne'monia, rec'rrent Rec'rrent 1more than one e*isode in a 2.$ear *eriod4, ac'te 1ne%
s$m*toms, signs, or 6.ra$ evidence not *resent earlier4 *ne'monia diagnosed on clinical
or radiologic gro'nds b$ the *atient;s *h$sician.
/o6o*lasmosis o& brain
a. Recent onset o& a &ocal ne'rologic abnormalit$ consistent %ith intracranial disease
or a red'ced level o& conscio'sness< ()D
b. +vidence b$ brain imaging 1com*'ted tomogra*h$ or n'clear magnetic
resonance4 o& a lesion having a mass e&&ect or the radiogra*hic a**earance o&
%hich is enhanced b$ inGection o& contrast medi'm< ()D
c. Ser'm antibod$ to to6o*lasmosis or s'ccess&'l res*onse to thera*$ &or
to6o*lasmosis.
/'berc'losis, *'lmonar$ When bacteriologic con&irmation is not available, other re*orts
ma$ be considered to be veri&ied cases o& *'lmonar$ t'berc'losis i& the criteria o& the
Division o& /'berc'losis +limination, )ational Center &or Prevention Services, CDC, are
'sed. /he criteria in 'se as o& Jan'ar$ 2, 2==3, are available in MMWR 2==:<3=1)o. RR.
234D3=. 7:.
%eferences
2. CDC. Classi&ication s$stem &or h'man /.l$m*hotro*ic vir's t$*e
,,,8l$m*hadeno*ath$.associated vir's in&ections. MMWR 2=?A<39D337.
@.
3. CDC. Revision o& the CDC s'rveillance case de&inition &or ac0'ired
imm'node&icienc$ s$ndrome. MMWR 2=?><3AD2.29S.
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>. M'Xo5 (, Wang MC, Bass S, et al. (c0'ired imm'node&icienc$ s$ndrome
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?. Re55a #, La55arin (, (ngarano #, et al. /he nat'ral histor$ o& ",! in&ection in
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1(K/4 in the treatment o& s'bGects %ith mildl$ s$m*tomatic h'man
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h'man imm'node&icienc$ vir's in&ectionD a controlled trial in *ersons %ith &e%er
than 9:: CD7.*ositive cells *er c'bic millimeter. ) +ngl J Med 2==:<3@@D=72.
@>. Lagakos S, Fischl M(, Stein DS, Lim L, !olberding P(. +&&ects o& 5idov'dine
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@=. "amilton JD, "artigan PM, Simberko&& MS, et al. ( controlled trial o& earl$
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vir's in&ection. ) +ngl J Med 2==@<3@AD73>.
3:.
32. "o DD, Sarngadharan M#, Resnick L, et al. Primar$ h'man /.l$m*hotro*ic vir's
t$*e ,,, in&ection. (nn ,ntern Med 2=?9<2:3D??:.3.
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strategies. (,DS 2==2<9D2.27.
33. Red&ield RR, Wright DC, /ramont +C. /he Walter Reed Staging Classi&ication
&or "/L!.,,,8L(! in&ection. ) +ngl J Med 2=?A<327D232.@.
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settings, %ith s*ecial &oc's on ",!.related iss'es. MMWR 2==:<3=1)o. RR.
2>4D2.@=.
39. CDC. P'ri&ied *rotein derivative 1PPD4.t'berc'lin anerg$ and ",! in&ection.
MMWR 2==2<7:1)o. RR.294D3>.73.
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diseases. Weekl$ +*idemiol Record 2==:<A9D@@2.7.
3>. Chaisson R+, !olberding P(. Clinical mani&estations o& ",! in&ection. ,nD
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diseases. )e% Iork, )ID Ch'rchill Livingstone, 2==:D2:A2.
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,,,8L(!.related diseases. J ,n&ect Dis 2=?9<29@D2=:9.
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imm'nologic abnormalities a&ter in&ection %ith h'man imm'node&icienc$ vir'sD
im*lications &or imm'nologic classi&ication o& the disease. Proc )atl (cad Sci
-S( 2=?><?7D97:7.?.
7:. Ro$ce R(, L'ckmann RS, F'saro R+, Winkelstein W Jr. /he nat'ral histor$ o&
",!.2 in&ectionD staging classi&ications o& disease. (,DS 2==2<9D399.A7.
72. J'stice (C, Feinstein (R, Wells CK. ( ne% *rognostic staging s$stem &or the
ac0'ired imm'node&icienc$ s$ndrome. ) +ngl J Med 2=?=<3@:D23??.=3.
7@. !aldiserri R, Cross #D, #erber (R, Sch%art5 R+, "earn /L. Ca*acit$ o& -S
labs to *rovide /L, in s'**ort o& earl$ ",!.2 intervention. (m J P'blic "ealth
2==2<?2D7=2.7.
73. CDC. #'idelines &or the *er&ormance o& CD7L /.cell determinations in *ersons
%ith h'man imm'node&icienc$ vir's in&ections. MMWR 2==@<721)o. RR.?4D2.
2@.
77. CDC. S'rveillance &or ",! in&ection .. -nited States. MMWR 2==:<3=D?93,?9=.
A2.
79. Brookme$er R. Reconstr'ction and &'t're trends o& the (,DS e*idemic in the
-nited States. Science 2==2<@93D3>.7@.
7A. Ciesielski C(, Fleming PL, Berkelman RL. Changing trends in (,DS.indicator
diseases in the -.S. .. role o& thera*$ and *ro*h$la6isJ 1abstract @974. 32st
,nterscience Con&erence on (ntimicrobial (gents and Chemothera*$, Chicago,
,L, 2==2D272.
7>. "o*kins S, La&&ert$ W, "one$ J, "'rlich M. /rends in the o't*atient diagnosis o&
(,DSD im*lications &or e*idemiologic anal$sis and s'rveillance 1abstract
/.(.P.>@4. ! ,nternational Con&erence on (,DS, Montreal, Canada, 2=?=D222.
7?. Modesitt S, +s*enla'b C, Klockner R, Fleming D. (,DS cases diagnosed as
o't*atients 1abstract /h.C.>3A4. !, ,nternational Con&erence on (,DS, San
Francisco, C(, 2==:<2D3:=.
7=. Raviglione MC, )arain JP, Kochi (. ",!.associated t'berc'losis in develo*ing
co'ntriesD clinical &eat'res, diagnosis, and treatment. B'll W" 2==@<>:D929.@A.
9:. Sel%$n P(, "artel D, Le%is !(, et al. ( *ros*ective st'd$ o& the risk o&
t'berc'losis among intraveno's dr'g 'sers %ith h'man imm'node&icienc$ vir's
in&ection. ) +ngl J Med 2=?=<3@:D979.9:.
92. Sel%$n P(, Sckell BM, (lcabes P, Friedland #", Klein RS, Schoenba'm ++.
"igh risk o& active t'berc'losis in ",! in&ected dr'g 'sers %ith c'taneo's anerg$.
J(M( 2==@<@A?D9:7.=.
9@. Bra'n MM, Badi ), R$der R, et al. ( retros*ective cohort st'd$ o& the risk o&
t'berc'losis among %omen o& childbearing age %ith ",!.in&ection in Kaire. (m
Rev Res* Dis 2==2< 273D9:2.7.
93. De Cock KM, Soro B, Co'libal$ ,M, L'cas SB. /'berc'losis and ",! in&ection
in s'b.Saharan (&rica. J(M( 2==@<@A?D29?2.>.
97. Sha&er RW, Chirg%in KD, #latt (+, Dahdo'h M(, Landesman S", S'ster B.
",! *revalence, imm'nos'**ression, and dr'g resistance in *atients %ith
t'berc'losis in an area endemic &or (,DS. (,DS 2==2<9D3==.7:9.
99. Barber /W, Craven D+, McCabe WR. Bacteremia d'e to M$cobacteri'm
t'berc'losis in *atients %ith h'man imm'node&icienc$ vir's in&ectionD a re*ort o&
= cases and revie% o& the literat're. Medicine 2==:<A=D3>9.?3.
9A. CDC. /'berc'losis and h'man imm'node&icienc$ vir's in&ectionD
recommendations o& the (dvisor$ Committee &or the +limination o& /'berc'losis
1(C+/4. MMWR 2=?=< 3?D@3A.?,@73.9:.
9>. B'ehler JW, Devine J, Berkelman RL, Chevarle$ FM. ,m*act o& the h'man
imm'node&icienc$ vir's e*idemic on mortalit$ trends in $o'ng men, -nited
States. (m J P'blic "ealth 2==:<?:D2:?:.A.
9?. Ch' SI, B'ehler JW, Berkelman RL. ,m*act o& the h'man imm'node&icienc$
vir's e*idemic on mortalit$ in %omen o& re*rod'ctive age, -nited States. J(M(
2==:<@A7D@@9.=.
9=. Polsk$ B, #old JW, Whimbe$ +, et al. Bacterial *ne'monia in *atients %ith the
ac0'ired imm'node&icienc$ s$ndrome. (nn ,ntern Med 2=?A<2:7D3?.72.
A:. Sel%$n P(, Feingold (R, "artel D, et al. ,ncreased risk o& bacterial *ne'monia in
",!.in&ected intraveno's dr'g 'sers %itho't (,DS. (,DS 2=??<@D@A>.>@.
A2. Fari5o KM, B'ehler JW, Chamberland M+, et al. S*ectr'm o& disease in *ersons
%ith h'man imm'node&icienc$ vir's in&ection in the -nited States. J(M(
2==@<@A>D2>=?.2?:9.
A@. Laga M, ,cenogle JP, Marsella R, et al. #enital *a*illomavir's in&ection and
cervical d$s*lasia .. o**ort'nistic com*lications o& ",! in&ection. ,nt J Cancer
2==@<9:D79.?.
A3. Scha&er (, Friedmann W, Mielke M, Sch%artlander B, Koch M(. /he increased
&re0'enc$ o& cervical d$s*lasia.neo*lasia in %omen in&ected %ith the h'man
imm'node&icienc$ vir's is related to the degree o& imm'nos'**ression. (m J
bstet #$necol 2==2<2A7D9=3.=.
A7. Sadeghi SB, Sadeghi (, Robbo$ SJ. Prevalence o& d$s*lasia and cancer o& the
cervi6 in a nation%ide Planned Parenthood *o*'lation. Cancer 2=??<A2D@39=.A2.
A9. Feingold (R, !erm'nd S", B'rk RD, et al. Cervical c$tologic abnormalities and
*a*illomavir's in %omen in&ected %ith h'man imm'node&icienc$ vir's. J (c0'ir
,mm'ne De&ic S$ndr 2==:<3D?=A.=:3.
AA. Maiman M, Fr'chter R#, Ser'r +, Rem$ JC, Fe'er #, Bo$ce J. "'man
imm'node&icienc$ vir's in&ection and cervical neo*lasia. #$necol ncol
2==:<3?D3>>.?@.
A>. Klein RS, (dachi (, Fleming ,, "o #IF, B'rk R. ( *ros*ective st'd$ o& genital
neo*lasia and h'man *a*illomavir's 1"P!4 in ",!.in&ected %omen 1abstract4.
!ol.2. Presented at the !,,, ,nternational Con&erence on (,DS8,,, S/D World
Congress, (msterdam, /he )etherlands, J'l$ 2=.@7, 2==@.
A?. Fr'chter R, Maiman M, Ser'r +, C'thill S. Cervical intrae*ithelial neo*lasia in
",! in&ected %omen 1abstract4. !ol.2. Presented at the !,,, ,nternational
Con&erence on (,DS8,,, S/D World Congress, (msterdam, /he )etherlands, J'l$
2=.@7, 2==@.
A=. Richart RM, Wright /C. Controversies and the management o& lo%.grade cervical
intrae*ithelial neo*lasia. Cancer 1in *ress4.
>:. Rellihan M(, Doole$ DP, B'rke /W, Berkland M+, Long&ield R). Ra*idl$
*rogressing cervical cancer in a *atient %ith h'man imm'node&icienc$ vir's
in&ection. #$necol ncol 2==:< 3AD739.?.
>2. Sch%art5 LB, Carcangi' ML, Bradham L, Sch%art5 P+. Ra*idl$ *rogressive
s0'amo's carcinoma o& the cervi6 coe6isting %ith h'man imm'node&icienc$
vir's in&ectionD clinical o*inion. #$necol ncol 2==2<72D@99.?.
>@. Richart RM. Cervical intrae*ithelial neo*lasiaD a revie%. ,nD Sommers SC, ed.
Patholog$ ann'al, 2=>3. )e% IorkD (**leton.Cent'r$.Cro&ts, 2=>3D3:2.@?.
C!C1 .roGections of the num"er of
#ersons diagnosed ith AI!S and the
num"er of immunosu##ressed HIV6
infected #ersons 66 'nited States, 0;;76
0;;<1 MMH% 0;;7I<0?No1 %%60JB ?in
#ressB1 0;;4 %evised Classification
System for HIV Infection and
*C#anded Surveillance Case !efinition
for AI!S Among Adolescents and
Adults
/he &ollo%ing CDC sta&& members *re*ared this re*ortD
)ational Center &or ,n&ectio's Diseases Division o& ",!8(,DS Kenneth #. Castro, M.D.
John W. Ward, M.D. La'rence Sl'tsker, M.D., M.P.". James W. B'ehler, M.D. "arold W.
Ja&&e, M.D. R'th L. Berkelman, M.D.
&&ice o& the Director (ssociate Director &or ",!8(,DS James W. C'rran, M.D., M.P.".
2==3 Revised Classi&ication S$stem &or ",! ,n&ection and +6*anded S'rveillance Case
De&inition &or (,DS (mong (dolescents and (d'lts
S'mmar$
CDC has revised the classi&ication s$stem &or ",! in&ection to em*hasi5e the clinical
im*ortance o& the CD7L /.l$m*hoc$te co'nt in the categori5ation o& ",!.related clinical
conditions. /his classi&ication s$stem re*laces the s$stem *'blished b$ CDC in 2=?A 124
and is *rimaril$ intended &or 'se in *'blic health *ractice. Consistent %ith the 2==3
revised classi&ication s$stem, CDC has also e6*anded the (,DS s'rveillance case
de&inition to incl'de all ",!.in&ected *ersons %ho have less than @:: CD7L /.
l$m*hoc$tes8'L, or a CD7L /.l$m*hoc$te *ercentage o& total l$m*hoc$tes o& less than
27. /his e6*ansion incl'des the addition o& three clinical conditions
*'lmonar$ t'berc'losis, rec'rrent *ne'monia, and invasive cervical cancer .. and
retains the @3 clinical conditions in the (,DS s'rveillance case de&inition
*'blished in 2=?> 1@4< it is to be 'sed b$ all states &or (,DS case re*orting
e&&ective Jan'ar$ 2, 2==3.
R+!,S+D ",! CL(SS,F,C(/,) SIS/+M FR (DL+SC+)/S ()D (D-L/S
/he etiologic agent o& ac0'ired imm'node&icienc$ s$ndrome 1(,DS4 is a retrovir's
designated h'man imm'node&icienc$ vir's 1",!4. /he CD7L /.l$m*hoc$te is the
*rimar$ target &or ",! in&ection beca'se o& the a&&init$ o& the vir's &or the CD7 s'r&ace
marker 134. /he CD7L /.l$m*hoc$te coordinates a n'mber o& im*ortant imm'nologic
&'nctions, and a loss o& these &'nctions res'lts in *rogressive im*airment o& the imm'ne
res*onse. St'dies o& the nat'ral histor$ o& ",! in&ection have doc'mented a %ide
s*ectr'm o& disease mani&estations, ranging &rom as$m*tomatic in&ection to li&e.
threatening conditions characteri5ed b$ severe imm'node&icienc$, serio's o**ort'nistic
in&ections, and cancers 17.234. ther st'dies have sho%n a strong association bet%een the
develo*ment o& li&e.threatening o**ort'nistic illnesses and the absol'te n'mber 1*er
microliter o& blood4 or *ercentage o& CD7L /. l$m*hoc$tes 127.@24. (s the n'mber o&
CD7L /.l$m*hoc$tes decreases, the risk and severit$ o& o**ort'nistic illnesses increase.
Meas'res o& CD7L /.l$m*hoc$tes are 'sed to g'ide clinical and thera*e'tic management
o& ",!.in&ected *ersons 1@@4. (ntimicrobial *ro*h$la6is and antiretroviral thera*ies have
been sho%n to be most e&&ective %ithin certain levels o& imm'ne d$s&'nction 1@3.@?4. (s
a res'lt, antiretroviral thera*$ sho'ld be considered &or all *ersons %ith CD7L /.
l$m*hoc$te co'nts o& less than 9::8'L, and *ro*h$la6is against Pne'moc$stis carinii
*ne'monia 1PCP4, the most common serio's o**ort'nistic in&ection diagnosed in men
and %omen %ith (,DS, is recommended &or all *ersons %ith CD7L /.l$m*hoc$te co'nts
o& less than @::8'L and &or *ersons %ho have had *rior e*isodes o& PCP. Beca'se o& these
recommendations, CD7L /. l$m*hoc$te determinations are an integral *art o& medical
management o& ",!.in&ected *ersons in the -nited States.
/he classi&ication s$stem &or ",! in&ection among adolescents and ad'lts has been
revised to incl'de the CD7L /.l$m*hoc$te co'nt as a marker &or ",!.related
imm'nos'**ression. /his revision establishes m't'all$ e6cl'sive s'bgro'*s &or %hich
the s*ectr'm o& clinical conditions is integrated %ith the CD7L /.l$m*hoc$te co'nt. /he
obGectives o& these changes are to sim*li&$ the classi&ication o& ",! in&ection, to re&lect
c'rrent standards o& medical care &or ",!.in&ected *ersons, and to categori5e more
acc'ratel$ ",!.related morbidit$.
/he revised CDC classi&ication s$stem &or ",!.in&ected adolescents and ad'lts N
categori5es *ersons on the basis o& clinical conditions associated %ith ",! in&ection and
CD7L /. l$m*hoc$te co'nts. /he s$stem is based on three ranges o& CD7L /.
l$m*hoc$te co'nts and three clinical categories and is re*resented b$ a matri6 o& nine
m't'all$ e6cl'sive categories 1/able 24. /his s$stem re*laces the classi&ication s$stem
*'blished in 2=?A, %hich incl'ded onl$ clinical disease criteria and %hich %as develo*ed
be&ore the %ides*read 'se o& CD7L /.cell testing 124.
Criteria &or ",! in&ection &or *ersons ages greater than 23 $earsD
a. re*eatedl$ reactive screening tests &or ",! antibod$ 1e.g., en5$me imm'noassa$4
%ith s*eci&ic antibod$ identi&ied b$ the 'se o& s'**lemental tests 1e.g., Western
blot, imm'no&l'orescence assa$4<
b. direct identi&ication o& vir's in host tiss'es b$ vir's isolation< c4 ",! antigen
detection< or d4 a *ositive res'lt on an$ other highl$ s*eci&ic licensed test &or ",!.
CD7L /.L$m*hoc$te Categories
/he three CD7L /.l$m*hoc$te categories are de&ined as &ollo%sD
Categor$ 2D greater than or e0'al to 9:: cells8mL
Categor$ @D @::.7== cells8'L
Categor$ 3D less than @:: cells8'L
/hese categories corres*ond to CD7L /.l$m*hoc$te co'nts *er microliter o& blood and
g'ide clinical and thera*e'tic actions in the management o& ",!.in&ected adolescents and
ad'lts 1@@.@?4. /he revised ",! classi&ication s$stem also allo%s &or the 'se o& the
*ercentage o& CD7L /.cells 1(**endi6 (4.
",!.in&ected *ersons sho'ld be classi&ied based on e6isting g'idelines &or the medical
management o& ",!.in&ected *ersons 1@@4. /h's, the lo%est acc'rate, b't not necessaril$
the most recent, CD7L /.l$m*hoc$te co'nt sho'ld be 'sed &or classi&ication *'r*oses.
Clinical Categories
/he clinical categories o& ",! in&ection are de&ined as &ollo%sD Categor$ (
Categor$ ( consists o& one or more o& the conditions listed belo% in an adolescent or
ad'lt 1greater than or e0'al to 23 $ears4 %ith doc'mented ",! in&ection. Conditions
listed in Categories B and C m'st not have occ'rred.
(s$m*tomatic ",! in&ection
Persistent generali5ed l$m*hadeno*ath$
(c'te 1*rimar$4 ",! in&ection %ith accom*an$ing illness or histor$ o& ac'te ",!
in&ection 1@=,3:4 Categor$ B
Categor$ B consists o& s$m*tomatic conditions in an ",!.in&ected adolescent or ad'lt
that are not incl'ded among conditions listed in clinical Categor$ C and that meet at least
one o& the &ollo%ing criteriaD a4 the conditions are attrib'ted to ",! in&ection or are
indicative o& a de&ect in cell.mediated imm'nit$< or b4 the conditions are considered b$
*h$sicians to have a clinical co'rse or to re0'ire management that is com*licated b$ ",!
in&ection. +6am*les o& conditions in clinical Categor$ B incl'de, b't are not limited toD
Bacillar$ angiomatosis
Candidiasis, oro*har$ngeal 1thr'sh4
Candidiasis, v'lvovaginal< *ersistent, &re0'ent, or *oorl$ res*onsive to thera*$
Cervical d$s*lasia 1moderate or severe48cervical carcinoma in sit'
Constit'tional s$m*toms, s'ch as &ever 13?.9 C4 or diarrhea lasting greater than 2
month
"air$ le'ko*lakia, oral
"er*es 5oster 1shingles4, involving at least t%o distinct e*isodes or more than one
dermatome
,dio*athic thromboc$to*enic *'r*'ra
Listeriosis
Pelvic in&lammator$ disease, *artic'larl$ i& com*licated b$ t'bo.ovarian abscess
Peri*heral ne'ro*ath$
For classi&ication *'r*oses, Categor$ B conditions take *recedence over those in
Categor$ (. For e6am*le, someone *revio'sl$ treated &or oral or *ersistent vaginal
candidiasis 1and %ho has not develo*ed a Categor$ C disease4 b't %ho is no%
as$m*tomatic sho'ld be classi&ied in clinical Categor$ B.
Categor$ C
Categor$ C incl'des the clinical conditions listed in the (,DS s'rveillance case de&inition
1(**endi6 B4. For classi&ication *'r*oses, once a Categor$ C condition has occ'rred, the
*erson %ill remain in Categor$ C.
+UP()S,) F /"+ CDC S-R!+,LL()C+ C(S+ D+F,),/,) FR (,DS
,n 2==2, CDC, in collaboration %ith the Co'ncil o& State and /erritorial +*idemiologists
1CS/+4, *ro*osed an e6*ansion o& the (,DS s'rveillance case de&inition. /his *ro*osal
%as made available &or *'blic comment in )ovember 2==2 and %as disc'ssed at an o*en
meeting on Se*tember @, 2==@. Based on in&ormation *resented and revie%ed d'ring the
*'blic comment *eriod and at the o*en meeting, CDC, in collaboration %ith CS/+, has
e6*anded the (,DS s'rveillance case de&inition to incl'de all ",!.in&ected *ersons %ith
CD7L /. l$m*hoc$te co'nts o& less than @:: cells8'L or a CD7L *ercentage o& less than
27. ,n addition to retaining the @3 clinical conditions in the *revio's (,DS s'rveillance
de&inition, the e6*anded de&inition incl'des *'lmonar$ t'berc'losis 1/B4, rec'rrent
*ne'monia, and invasive cervical cancer. N /his e6*anded de&inition re0'ires laborator$
con&irmation o& ",! in&ection in *ersons %ith a CD7L /.l$m*hoc$te co'nt o& less than
@:: cells8'L or %ith one o& the added clinical conditions. /his e6*anded de&inition &or
re*orting cases to CDC becomes e&&ective Jan'ar$ 2, 2==3.
Diagnostic criteria &or (,DS.de&ining conditions incl'ded in the e6*anded
s'rveillance case de&inition are *resented in (**endi6 C and (**endi6 D.
,n the revised ",! classi&ication s$stem, *ersons in s'bcategories (3, B3, and C3 meet
the imm'nologic criteria o& the s'rveillance case de&inition, and those *ersons %ith
conditions in s'bcategories C2, C@, and C3 meet the clinical criteria &or s'rveillance
*'r*oses 1/able 24.
CMM+)/(RI Revised Classi&ication S$stem
/he revised classi&ication s$stem &or ",! in&ection is based on the recommended clinical
standard o& monitoring CD7L /. l$m*hoc$te co'nts, since this *arameter consistentl$
correlates %ith ",!.related imm'ne d$s&'nction and disease *rogression and *rovides
in&ormation needed to g'ide medical management o& *ersons in&ected %ith ",! 127.2?,
@@.@?4. /he classi&ication s$stem also allo%s &or 'se o& the *ercentage o& CD7L /.cells
instead o& absol'te CD7L /.l$m*hoc$te co'nts 1(**endi6 (4. ther markers o& imm'ne
stat's .. s'ch as ser'm neo*terin, beta.@ microglob'lin, ",! *@7 antigen, sol'ble
interle'kin.@ rece*tors, imm'noglob'lin (, and dela$ed.t$*e h$*ersensitivit$ 1D/"4
skin.test reactions .. ma$ be 'se&'l in the eval'ation o& individ'al *atients b't are not as
strongl$ *redictive o& disease *rogression or as s*eci&ic &or ",!.related
imm'nos'**ression as meas'res o& CD7L /.l$m*hoc$tes 127.@2, 324. D/" skin.test
reactions are o&ten 'sed in conG'nction %ith the Manto'6 t'berc'lin skin test to eval'ate
",!.in&ected *atients &or /B in&ection and anerg$ 132.334.
ther s$stems have been *ro*osed &or classi&ication and staging o& ",! in&ection 12, 32,
37.3=4. ,n 2==:, the World "ealth rgani5ation 1W"4 *'blished an interim *ro*osal &or
a staging s$stem &or ",! in&ection and diseases that %as based *rimaril$ on clinical
criteria and incl'ded the 'se o& CD7L /.l$m*hoc$te determinations 1374. /he W"
s$stem incor*orates a *er&ormance scale and total l$m*hoc$te co'nts to be 'sed in lie' o&
CD7L /.l$m*hoc$te determinations in co'ntries %here CD7L /.l$m*hoc$te testing is not
available.
/he acc'rac$ o& CD7L /.l$m*hoc$te co'nts is im*ortant &or medical care o& individ'al
*atients. /o ass're reliabilit$, laboratories cond'cting CD7L /.l$m*hoc$te meas'rements
sho'ld be e6*erienced %ith test *roced'res, have established 0'alit$ ass'rance methods,
and *artici*ate in *ro&icienc$ testing *rograms cond'cted b$ CDC or other organi5ations
1@@, 7:4. CDC has *'blished g'idelines &or the *er&ormance o& CD7L /.cell
determinations &or ",!.in&ected *ersons 1724. /o ass're that test res'lts are indicative o&
a *atient;s medical condition, the health.care *rovider sho'ld eval'ate the res'lts %ith
those o& earlier tests and %ith the *atient;s clinical condition. ,n clinical *ractice, re*eat
CD7L testing ma$ be G'dged necessar$ in g'iding thera. *e'tic decisions &or individ'al
*atients. For s'rveillance *'r*oses, ho%ever, a re0'irement &or re*eat CD7L
determinations is im*ractical &or *o*'lation.based monitoring.
/he revised classi&ication s$stem o& the clinical and imm'nologic mani&estations o& ",!
in&ection *rovides a &rame%ork &or categori5ing ",!.related morbidit$ and
imm'nos'**ression and %ill assist e&&orts to eval'ate the overall im*act o& the ",!
e*idemic. Kno%ledge o& the s*ectr'm o& clinical conditions and the e6tent o&
imm'nos'**ression that ma$ occ'r d'ring the co'rse o& ",! in&ection is im*ortant &or
*rom*t eval'ation and &or *rovision o& a**ro*riate health services. Clinicians sho'ld be
a%are o& the clinical conditions s'ggestive o& ",! in&ection and the need &or *ro*h$lactic
and thera*e'tic interventions.
/his revised ",! classi&ication s$stem sho'ld be 'sed b$ state and territorial health
de*artments that cond'ct ",! in&ection s'rveillance. Beca'se (,DS s'rveillance data
%ill contin'e to re*resent onl$ a *ortion o& the total morbidit$ ca'sed b$ ",!,
s'rveillance &or ",! in&ection ma$ be *artic'larl$ 'se&'l in de*icting the total im*act o&
",! on health.care and social services 17@4. More acc'rate re*orting and anal$sis o&
CD7L /.l$m*hoc$te co'nts, together %ith ",!.related clinical conditions, sho'ld
&acilitate e&&orts to eval'ate health.care and re&erral needs &or *ersons %ith ",! in&ection
and to *roGect &'t're needs &or these services.
+6*anded (,DS S'rveillance Case De&inition
/he *o*'lation o& ",!.in&ected *ersons %ith CD7L /.l$m*hoc$te co'nts o& less than
@::8'L is s'bstantiall$ larger than the *o*'lation o& *ersons %ith (,DS.de&ining clinical
conditions 1734. /he incl'sion in the (,DS s'rveillance de&inition o& *ersons %ith a
CD7L /.l$m*hoc$te co'nt o& less than @:: cells8'L or a CD7L *ercentage less than 27
%ill enable (,DS s'rveillance to re&lect more acc'ratel$ the n'mber o& *ersons %ith
severe ",!.related imm'nos'**ression and those at highest risk &or severe ",!.related
morbidit$. Since the (,DS s'rveillance case de&inition %as last revised in 2=?>, the
increasing 'se o& *ro*h$la6is against PCP and antiretroviral thera*$ &or *ersons in&ected
%ith ",! has slo%ed the rate at %hich ",!.in&ected *ersons develo* (,DS.de&ining
clinical conditions 1@,@@.@94. For e6am*le, among homose6'al8bise6'al men %ith (,DS
re*orted to CDC, the *ro*ortion %ith PCP decreased &rom A@C in 2=?? to 7AC in 2==:
1774. /his trend is e6*ected to contin'e.
/he abilit$ o& clinicians to re*ort ",!.in&ected *ersons on the basis o& CD7L /.
l$m*hoc$te co'nts ma$ also sim*li&$ the case.re*orting *rocess. ( sim*li&ied (,DS
s'rveillance case de&inition %ill be *artic'larl$ im*ortant &or o't*atient clinics in %hich
the availabilit$ o& sta&& to cond'ct s'rveillance is limited and &rom %hich an increasing
*ro*ortion o& (,DS cases are being re*orted. For e6am*le, &rom *re.2=?9 to 2=??, the
*ro*ortion o& (,DS cases re*orted &rom o't*atient sites in the state o& Washington
increased &rom AC 1=82994 to @9C 1998@2=4 1794. ( similar increase occ'rred in regon
1@9C V7782>2W be&ore 2=?> to 3?C V7:82:9W in the &irst hal& o& 2=?=4 17A4.
P'lmonar$ /'berc'losis
/hro'gho't the %orld, *'lmonar$ /B is the most common t$*e o& /B in *ersons %ith
",! in&ection 17>4. /he addition o& *'lmonar$ /B to the list o& (,DS.indicator diseases
is based on the strong e*idemiologic link bet%een ",! in&ection and the develo*ment o&
/B 17?.9:4. Persons co.in&ected %ith ",! and /B have a s'bstantiall$ increased risk o&
develo*ing active /B com*ared %ith *ersons %itho't ",! in&ection 17?, 7=4. ,n a
*ros*ective eval'ation o& inGecting.dr'g 'sers 1,D-s4 %ith *ositive t'berc'lin skin tests,
the estimated ann'al incidence o& active /B among 7= ",!.in&ected ,D-s %as >.=
cases82:: *erson.$ears< ho%ever, no cases o& active /B occ'rred among A@ t'berc'lin.
*ositive b't ",!.seronegative ,D-s &ollo%ed &or as long as 3: months 17?4.
/here is also a s'bstantial imm'nologic association bet%een ",!.in&ected *ersons and
*'lmonar$ /B %hen com*ared %ith ",!.in&ected *ersons %ith e6tra*'lmonar$ /B 1a
condition incl'ded in the 2=?> s'rveillance de&inition4. ,n a recent revie%, median CD7L
/.l$m*hoc$te co'nts in ",!.in&ected *atients %ith *'lmonar$ /B ranged &rom @9: to
9:: cells8'L 1924. ,n com*arison, the median CD7L l$m*hoc$te co'nt %as @7@ cells8'L
in one st'd$ o& *ersons %ith locali5ed e6tra*'lmonar$ /B and ranged &rom >: to >=
cells8'L in t%o st'dies o& *atients %ith disseminated or miliar$ /B 192.934. ,n CDC;s
(d'lt and (dolescent S*ectr'm o& ",! Disease 1(SD4 ProGect, A=C o& ",!.in&ected
*ersons %ith *'lmonar$ /B had CD7L /.l$m*hoc$te co'nts o& less than @::8'L,
com*ared %ith >>C o& *ersons %ith e6tra*'lmonar$ /B 1CDC, 'n*'blished
observations4.
/he addition o& *'lmonar$ /B to (,DS s'rveillance criteria %ill re0'ire contin'ed
collaboration bet%een state and local /B and ",!8(,DS *rograms. Kno%ledge o& a
*atient;s ",! stat's is im*ortant &or the *ro*er medical management o& /B beca'se
longer co'rses o& thera*$ and *ro*h$la6is are recommended &or ",!.in&ected *atients
%ith /B 1974. F'rthermore, ",!.in&ected /B *atients sho'ld be a *riorit$ &or
e*idemiologic investigation beca'se these *ersons are more likel$ to have ",!.in&ected
contacts than are seronegative /B *atients. /B contact &ollo%.'* among ",!.in&ected
*ersons %ill hel* to ens're deliver$ o& a &'ll co'rse o& *reventive thera*$ to these
contacts, %ho are at greatl$ increased risk o& develo*ing active /B themselves.
Rec'rrent Pne'monia
With the e6ce*tion o& conditions incl'ded in the 2=?> (,DS s'rveillance case de&inition,
*ne'monia, %ith or %itho't a bacteriologic diagnosis, is the leading ca'se o& ",!.related
morbidit$ and death 199, 9A4. ,n addition, several st'dies have sho%n that *ersons %ith
",!.related imm'nos'**ression are at an increased risk o& bacterial *ne'monia 19>.9=4.
For e6am*le, one st'd$ &o'nd that the $earl$ incidence rate o& bacterial *ne'monia
among ",!.in&ected ,D-s %itho't (,DS %as &ive times that &o'nd in non.",!.in&ected
,D-s 19?4. Rec'rrent e*isodes o& *ne'monia 1t%o or more e*isodes %ithin a 2.$ear
*eriod4 are re0'ired &or (,DS case re*orting beca'se *ne'monia is a relativel$ common
diagnosis and m'lti*le e*isodes o& *ne'monia are more strongl$ associated %ith
imm'nos'**ression than are single e*isodes. For e6am*le, data &rom the (SD ProGect
indicate that the risk o& an ",!.in&ected *erson having had one e*isode o& *ne'monia in a
2@.month *eriod is a**ro6imatel$ &ive times higher among in&ected *ersons %ith CD7L
/.l$m*hoc$te co'nts o& less than @::8'L 13@:8@,7224 than among those %ith higher
CD7L /.l$m*hoc$te co'nts 1=:8@,>=@4. ,n contrast, data &rom the same st'd$ indicate
that the risk &or m'lti*le e*isodes o& *ne'monia in a 2@.month *eriod is a**ro6imatel$
@: times higher among ",!.in&ected *ersons %ith CD7L /.l$m*hoc$te co'nts o& less
than @::8'L 1A>8@,7224 than among those %ith higher CD7L /.cell co'nts 178@,>=@4
1CDC, 'n*'blished observations4.
,nvasive Cervical Cancer
Several st'dies have &o'nd an increased *revalence o& cervical d$s*lasia, a *rec'rsor
lesion &or cervical cancer, among ",!.in&ected %omen 1A:, A24. ,n a st'd$ o& 32: ",!.
in&ected %omen attending methadone maintenance and se6'all$ transmitted disease
clinics in )e% Iork Cit$ and )e%ark, )e% Jerse$, cervical d$s*lasia %as con&irmed b$
bio*s$ and8or col*osco*$ in a**ro6imatel$ @@C, a *revalence rate 2: times greater than
that &o'nd among %omen attending &amil$ *lanning clinics in the -nited States 1Wright
/C, *ersonal comm'nication< A@4. Several st'dies have doc'mented that a higher
*revalence o& cervical d$s*lasia among ",!.in&ected %omen is associated %ith greater
imm'nos'**ression 1Wright /C, *ersonal comm'nication< A2,A34. ,n addition, ",!
in&ection ma$ adversel$ a&&ect the clinical co'rse and treatment o& cervical d$s*lasia and
cancer 1A7.A=4.
,nvasive cervical cancer is a more a**ro*riate (,DS.indicator disease than is either
cervical d$s*lasia or carcinoma in sit' beca'se these latter cervical lesions are common
and &re0'entl$ do not *rogress to invasive disease 1>:4. (lso, cervical d$s*lasia or
carcinoma in sit' among %omen %ith severe cervicovaginal in&ections, %hich are
common in ",!.in&ected %omen, can be di&&ic'lt to diagnose. ,n contrast, the diagnosis
o& invasive cervical cancer is generall$ 'ne0'ivocal.
,nvasive cervical cancer is *reventable b$ the *ro*er recognition and treatment o&
cervical d$s*lasia. /h's, the occ'rrence o& invasive cervical cancer among all %omen ..
incl'ding those %ho are ",!.in&ected .. re*resents missed o**ort'nities &or disease
*revention. /he addition o& invasive cervical cancer to the list o& (,DS.indicator diseases
em*hasi5es the im*ortance o& integrating g$necologic care into medical services &or ",!.
in&ected %omen.
,m*act on (,DS Case Re*orting
/he e6*anded (,DS s'rveillance case de&inition is e6*ected to have a s'bstantial im*act
on the n'mber o& re*orted cases. /he immediate increase in case re*orting %ill be largel$
attrib'table to the addition o& severe imm'nos'**ression to the de&inition< a smaller
im*act is e6*ected &rom the addition o& *'lmonar$ /B, rec'rrent *ne'monia, and
invasive cervical cancer, since man$ *ersons %ith these diseases %ill also have CD7L /.
l$m*hoc$te co'nts o& less than @:: cells8'L. ,& all o& the a**ro6imatel$ 2,:::,:::
*ersons in the -nited States %ith ",! in&ection %ere diagnosed and their imm'ne stat's
%ere kno%n, it is estimated that 2@:,:::. 2=:,::: *ersons %ho do not have (,DS.
indicator diseases %o'ld be &o'nd to have CD7L /.l$m*hoc$te co'nts o& less than @::
cells8'L 1>24. "o%ever, not all o& these *ersons are a%are o& their ",! in&ection and o&
those %ho kno% their ",! in&ection stat's, not all have had an imm'nologic eval'ation<
th's, the immediate im*act on the n'mber o& (,DS cases %ill be considerabl$ less than
2@:,:::. 2=:,:::. ,& (,DS s'rveillance criteria %ere 'nchanged, a**ro6imatel$ 9:,:::.
A:,::: re*orted (,DS cases %o'ld be e6*ected in 2==3. Based on c'rrent levels o& ",!
and CD7L testing, CDC estimates that the e6*anded de&inition co'ld increase cases
re*orted in 2==3 b$ a**ro6imatel$ >9C. +arl$ e&&ects o& e6*anded s'rveillance %ill be
greater than long.term e&&ects beca'se *revalent as %ell as incident cases o&
imm'nos'**ression %ill be re*orted &ollo%ing im*lementation o& the e6*anded
s'rveillance case de&inition. ,n s'bse0'ent $ears, the e&&ect on the n'mber o& re*orted
cases is e6*ected to be m'ch smaller.
-ses o& the ",! Classi&ication S$stem or (,DS S'rveillance Case De&inition
/he revised ",! classi&ication s$stem and the (,DS s'rveillance case de&inition are
intended &or 'se in cond'cting *'blic health s'rveillance. /he CDC;s (,DS s'rveillance
case de&inition %as not develo*ed to determine %hether stat'tor$ or other legal
re0'irements &or entitlement to Federal disabilit$ or other bene&its are met. Conse0'entl$,
this revised s'rveillance case de&inition does not alter the criteria 'sed b$ the Social
Sec'rit$ (dministration in eval'ating claims based on ",! in&ection 'nder the Social
Sec'rit$ disabilit$ ins'rance and S'**lemental Sec'rit$ ,ncome *rograms. ther
organi5ations and agencies *roviding medical and social services sho'ld develo*
eligibilit$ criteria a**ro*riate to the services *rovided and local needs.
Con&identialit$
/he con&identialit$ o& (,DS case re*orts .. incl'ding laborator$ re*orts o& ",! test
res'lts, CD7L /.l$m*hoc$te test res'lts, and medical records 'nder revie% b$ health
de*artment sta&& .. is o& critical im*ortance to maintaining e&&ective ",!8(,DS
s'rveillance. CDC and state health de*artments have im*lemented *roced'res and
*olicies to maintain con&identialit$ and sec'rit$ o& ",!8(,DS s'rveillance data 1>@4.
CDC;s e&&orts incl'de a &ederal ass'rance o& con&identialit$, the removal o& names be&ore
encr$*ted records are transmitted to CDC, strict g'idelines &or the release o& aggregate
data, and the incl'sion o& con&identialit$ and sec'rit$ sa&eg'ards as eval'ation criteria &or
&ederal &'nding o& state ",!8(,DS s'rveillance activities 1>34. /hese strict criteria %ill
contin'e to a**l$ to cases re*orted 'nder the e6*anded de&inition. CDC &'nding o&
s'rveillance coo*erative agreements is de*endent on the reci*ient;s abilit$ to ens're the
*h$sical sec'rit$ o& case re*orts and on state *olicies or la%s to *rotect the con&identialit$
o& *ersons re*orted %ith (,DS. Fail're to ens're the sec'rit$ and con&identialit$ o&
*ersonal identi&$ing in&ormation collected as *art o& (,DS or ",! s'rveillance activities
%ill Geo*ardi5e &ederal s'rveillance &'nding.
CD7L /.l$m*hoc$te test res'lts re*orted b$ laboratories %ill be an im*ortant adG'nct to
medical record revie% and *rovider.initiated re*orting in order to increase com*leteness,
timeliness, and e&&icienc$ o& (,DS s'rveillance. ,n&ormation &rom a laborator$.initiated
re*ort o& a CD7L /.l$m*hoc$te co'nt is ins'&&icient &or re*orting a case o& (,DS.
Con&irmation o& ",! in&ection stat's and recei*t o& other s'rveillance in&ormation &rom
the health.care *rovider or &rom medical or *'blic health records %ill remain necessar$.
+ver$ e&&ort sho'ld be made b$ health.care *roviders, laboratories, and *'blic health
agencies to *rotect the con&identialit$ o& CD7L /.l$m*hoc$te test res'lts, incl'ding the
revie% o& record.kee*ing *ractices in laboratories and health.care settings. Some states
have considered additional means to ass're the con&identialit$ o& CD7L /.l$m*hoc$te
test res'lts. For e6am*le, a *ro*osal in regon %o'ld allo% health.care *roviders to send
s*ecimens to laboratories &or CD7L /.l$m*hoc$te testing %ith a 'ni0'e code &or each
*erson being tested. ,& the test res'lt indicates a CD7L /.l$m*hoc$te co'nt o& less than
@:: cells8'L, the health de*artment %o'ld noti&$ the health.care *rovider that an (,DS
case re*ort is re0'ired i& the *erson is ",! in&ected, the CD7L /.l$m*hoc$te co'nt is
valid, and the case has not been *revio'sl$ re*orted. ,n&ormed consent &or CD7L /.
l$m*hoc$te testing sho'ld be obtained in accordance %ith local la%s or reg'lations.
CD7L /.l$m*hoc$te test res'lts alone sho'ld not be 'sed as a s'rrogate marker &or ",!
or (,DS. ( lo% CD7L /.l$m*hoc$te co'nt %itho't a *ositive ",! test res'lt %ill not be
re*ortable since other conditions ma$ res'lt in a lo% CD7L /.l$m*hoc$te co'nt. "ealth.
care *roviders m'st ens're that *ersons %ho have a CD7L /.l$m*hoc$te co'nt o& less
than @::8'L are ",! in&ected be&ore initiating treatment &or ",! disease or re*orting
those *ersons as cases o& (,DS.
C)CL-S,)
/he revised ",! classi&ication s$stem *rovides 'ni&orm and sim*le criteria &or
categori5ing conditions among adolescents and ad'lts %ith ",! in&ection and sho'ld
&acilitate e&&orts to eval'ate c'rrent and &'t're health.care and re&erral needs &or *ersons
%ith ",! in&ection. /he addition o& a meas're o& severe imm'nos'**ression, as de&ined
b$ a CD7L /.l$m*hoc$te co'nt o& less than @:: cells8'L or a CD7L *ercentage o& less
than 27, re&lects the standard o& imm'nologic monitoring &or ",!.in&ected *ersons and
%ill enable (,DS s'rveillance data to more acc'ratel$ re*resent those %ho are recogni5ed
as being imm'nos'**ressed, %ho are in greatest need o& close medical &ollo%.'*, and
%ho are at greatest risk &or the &'ll s*ectr'm o& severe ",!.related morbidit$. /he
addition o& three clinical conditions .. *'lmonar$ /B, rec'rrent *ne'monia, and invasive
cervical cancer .. to (,DS s'rveillance criteria re&lects the doc'mented or *otential
im*ortance o& these diseases in the ",! e*idemic. /%o o& these conditions 1*'lmonar$
/B and cervical cancer4 are *reventable i& a**ro*riate screening tests are linked %ith
*ro*er &ollo%.'*. /he third, rec'rrent *ne'monia, re&lects the im*ortance o& *'lmonar$
in&ections not incl'ded in the 2=?> de&inition as leading ca'ses o& ",!.related morbidit$
and mortalit$. S'ccess&'l im*lementation o& e6*anded s'rveillance criteria %ill re0'ire
the e6tension o& e6isting sa&eg'ards to *rotect the sec'rit$ and con&identialit$ o& (,DS
s'rveillance in&ormation.
(PP+)D,U (. +0'ivalences &or CD7L /.l$m*hoc$te co'nt and *ercentage o& total
l$m*hoc$tes
Com*ared %ith the absol'te CD7L /.l$m*hoc$te co'nt, the *ercentage o& CD7L /.cells
o& total l$m*hoc$tes 1or CD7L *ercentage4 is less s'bGect to variation on re*eated
meas'rements 12?,>74. "o%ever, data correlating nat'ral histor$ o& ",! in&ection %ith
the CD7L *ercentage have not been as consistentl$ available as data on absol'te CD7L /.
l$m*hoc$te co'nts 127.2A,2?,2=,@2,324. /here&ore, the revised classi&ication s$stem
em*hasi5es the 'se o& CD7L /.l$m*hoc$te co'nts b't allo%s &or the 'se o& CD7L
*ercentages.
+0'ivalences 1/able (24 %ere derived &rom anal$ses o& more than 29,9:: l$m*hoc$te
s'bset determinations &rom seven di&&erent so'rcesD one m'ltistate st'd$ o& diseases in
",!.in&ected adolescents and ad'lts 19=4 and si6 laboratories 1t%o commercial, one
research, and three 'niversit$.based4. /he si6 laboratories are involved in *ro&icienc$
testing *rograms &or l$m*hoc$te s'bset determinations. ,n the anal$ses, concordance %as
de&ined as the *ro*ortion o& *atients classi&ied as having CD7L /.l$m*hoc$te co'nts in a
*artic'lar range among *atients %ith a given CD7L *ercentage. ( threshold val'e o& the
CD7L *ercentage %as calc'lated to obtain o*timal concordance %ith each strati&$ing
val'e o& the CD7L /.l$m*hoc$te co'nts 1i.e., less than @::8'L and greater than or e0'al
to 9::8'L4. /he thresholds &or the CD7L *ercentages that best correlated %ith a CD7L /.
l$m*hoc$te co'nt o& less than @::8'L varied minimall$ among the seven data so'rces
1range, 23C.27C< median, 23C< mean, 23.7C4. /he average concordance &or a CD7L
*ercentage o& less than 27 and a CD7L /.l$m*hoc$te co'nt o& less than @::8'L %as
=:.@C. /he threshold &or the CD7L *ercentages most concordant %ith CD7L /.
l$m*hoc$te co'nts o& greater than or e0'al to 9::8'L varied more %idel$ among the
seven data so'rces 1range, @@.9C.39C< median, @=C< mean, @=.2C4. /his %ide range o&
*ercentages o*timall$ concordant %ith greater than or e0'al to 9::8'L CD7L /.
l$m*hoc$tes makes the concordance at this strati&$ing val'e less certain. /he average
concordance &or a CD7L *ercentage o& greater than or e0'al to @= and a CD7L /.
l$m*hoc$te co'nt o& greater than or e0'al to 9::8'L %as ?9C 1CDC, 'n*'blished data4.
Clinicians and other *ractitioners m'st recogni5e that these s'ggested e0'ivalences ma$
not al%a$s corres*ond %ith val'es observed in individ'al *atients.
(PP+)D,U B. Conditions incl'ded in the 2==3 (,DS s'rveillance case de&inition
Candidiasis o& bronchi, trachea, or l'ngs
Candidiasis, eso*hageal
Cervical cancer, invasive N
Coccidioidom$cosis, disseminated or e6tra*'lmonar$
Cr$*tococcosis, e6tra*'lmonar$
Cr$*tos*oridiosis, chronic intestinal 1greater than 2 month;s d'ration4
C$tomegalovir's disease 1other than liver, s*leen, or nodes4
C$tomegalovir's retinitis 1%ith loss o& vision4
+nce*halo*ath$, ",!.related
"er*es sim*le6D chronic 'lcer1s4 1greater than 2 month;s d'ration4< or bronchitis,
*ne'monitis, or eso*hagitis
"isto*lasmosis, disseminated or e6tra*'lmonar$
,sos*oriasis, chronic intestinal 1greater than 2 month;s d'ration4
Ka*osi;s sarcoma
L$m*homa, B'rkitt;s 1or e0'ivalent term4
L$m*homa, imm'noblastic 1or e0'ivalent term4
L$m*homa, *rimar$, o& brain
M$cobacteri'm avi'm com*le6 or M. kansasii, disseminated or e6tra*'lmonar$
M$cobacteri'm t'berc'losis, an$ site 1*'lmonar$ N or e6tra*'lmonar$4
M$cobacteri'm, other s*ecies or 'nidenti&ied s*ecies, disseminated or
e6tra*'lmonar$
Pne'moc$stis carinii *ne'monia
Pne'monia, rec'rrent N
Progressive m'lti&ocal le'koence*halo*ath$
Salmonella se*ticemia, rec'rrent
/o6o*lasmosis o& brain
Wasting s$ndrome d'e to ",!
(dded in the 2==3 e6*ansion o& the (,DS s'rveillance case de&inition.
(PP+)D,U C. De&initive diagnostic methods &or diseases indicative o& (,DS
Cr$*tos*oridiosis, ,sos*oriasis, Ka*osi;s sarcoma, L$m*homa, Pne'moc$stis carinii
*ne'monia, Progressive m'lti&ocal le'koence*halo*ath$, /o6o*lasmosis, Cervical cancer
Microsco*$ 1histolog$ or c$tolog$4
Candidiasis #ross ins*ection b$ endosco*$ or a'to*s$ or b$ microsco*$ 1histolog$ or
c$tolog$4 on a s*ecimen obtained directl$ &rom the tiss'es a&&ected 1incl'ding scra*ings
&rom the m'cosal s'r&ace4, not &rom a c'lt're
Coccidioidom$cosis, Cr$*tococcosis, C$tomegalovir's, "er*es sim*le6 vir's,
"isto*lasmosis Microsco*$ 1histolog$ or c$tolog$4, c'lt're, or detection o& antigen in a
s*ecimen obtained directl$ &rom the tiss'es a&&ected or a &l'id &rom those tiss'es
/'berc'losis, ther m$cobacteriosis, Salmonellosis C'lt're
",! ence*halo*ath$ 1dementia4 Clinical &indings o& disabling cognitive or motor
d$s&'nction inter&ering %ith occ'*ation or activities o& dail$ living, *rogressing over
%eeks to months, in the absence o& a conc'rrent illness or condition other than ",!
in&ection that co'ld e6*lain the &indings. Methods to r'le o't s'ch conc'rrent illness and
conditions m'st incl'de cerebros*inal &l'id e6amination and either brain imaging
1com*'ted tomogra*h$ or magnetic resonance4 or a'to*s$.
",! %asting s$ndrome Findings o& *ro&o'nd invol'ntar$ %eight loss o& greater than 2:C
o& baseline bod$ %eight *l's either chronic diarrhea 1at least t%o loose stools *er da$ &or
greater than or e0'al to 3: da$s4, or chronic %eakness and doc'mented &ever 1&or greater
than or e0'al to 3: da$s, intermittent or constant4 in the absence o& a conc'rrent illness or
condition other than ",! in&ection that co'ld e6*lain the &indings 1e.g., cancer,
t'berc'losis, cr$*tos*oridiosis, or other s*eci&ic enteritis4.
Pne'monia, rec'rrent Rec'rrent 1more than one e*isode in a 2.$ear *eriod4, ac'te 1ne%
6.ra$ evidence not *resent earlier4 *ne'monia diagnosed b$ bothD a4 c'lt're 1or other
organism.s*eci&ic diagnostic method4 obtained &rom a clinicall$ reliable s*ecimen o& a
*athogen that t$*icall$ ca'ses *ne'monia 1other than Pne'moc$stis carinii or
M$cobacteri'm t'berc'losis4, and b4 radiologic evidence o& *ne'monia< cases that do not
have laborator$ con&irmation o& a ca'sative organism &or one o& the e*isodes o&
*ne'monia %ill be considered to be *res'm*tivel$ diagnosed.
(PP+)D,U D. S'ggested g'idelines &or *res'm*tive diagnosis o& diseases indicative o&
(,DS
Candidiasis o& eso*hag's
a. Recent onset o& retrosternal *ain on s%allo%ing< ()D
b. ral candidiasis diagnosed b$ the gross a**earance o& %hite *atches or *la0'es
on an er$themato's base or b$ the microsco*ic a**earance o& &'ngal m$celial
&ilaments &rom a nonc'lt'red s*ecimen scra*ed &rom the oral m'cosa.
C$tomegalovir's retinitis ( characteristic a**earance on serial o*hthalmo.sco*ic
e6aminations 1e.g., discrete *atches o& retinal %hitening %ith distinct borders, s*reading
in a centri&'gal manner along the *aths o& blood vessels, *rogressing over several
months, and &re0'entl$ associated %ith retinal vasc'litis, hemorrhage, and necrosis4.
Resol'tion o& active disease leaves retinal scarring and atro*h$ %ith retinal *igment
e*ithelial mottling.
M$cobacteriosis Microsco*$ o& a s*ecimen &rom stool or normall$ sterile bod$ &l'ids or
tiss'e &rom a site other than l'ngs, skin, or cervical or hilar l$m*h nodes that sho%s acid.
&ast bacilli o& a s*ecies not identi&ied b$ c'lt're.
Ka*osi;s sarcoma ( characteristic gross a**earance o& an er$themato's or violaceo's
*la0'e.like lesion on skin or m'co's membrane. 1)oteD Pres'm*tive diagnosis o&
Ka*osi;s sarcoma sho'ld not be made b$ clinicians %ho have seen &e% cases o& it.4
Pne'moc$stis carinii *ne'monia
a. ( histor$ o& d$s*nea on e6ertion or non*rod'ctive co'gh o& recent onset 1%ithin
the *ast 3 months4< ()D
b. Chest 6.ra$ evidence o& di&&'se bilateral interstitial in&iltrates or evidence b$
galli'm scan o& di&&'se bilateral *'lmonar$ disease< ()D
c. (rterial blood gas anal$sis sho%ing an arterial *11@44 o& less than >: mm "g or
a lo% res*irator$ di&&'sing ca*acit$ 1less than ?:C o& *redicted val'es4 or an
increase in the alveolar.arterial o6$gen tension gradient< ()D
d. )o evidence o& a bacterial *ne'monia.
Pne'monia, rec'rrent Rec'rrent 1more than one e*isode in a 2.$ear *eriod4, ac'te 1ne%
s$m*toms, signs, or 6.ra$ evidence not *resent earlier4 *ne'monia diagnosed on clinical
or radiologic gro'nds b$ the *atient;s *h$sician.
/o6o*lasmosis o& brain
a. Recent onset o& a &ocal ne'rologic abnormalit$ consistent %ith intracranial disease
or a red'ced level o& conscio'sness< ()D
b. +vidence b$ brain imaging 1com*'ted tomogra*h$ or n'clear magnetic
resonance4 o& a lesion having a mass e&&ect or the radiogra*hic a**earance o&
%hich is enhanced b$ inGection o& contrast medi'm< ()D
c. Ser'm antibod$ to to6o*lasmosis or s'ccess&'l res*onse to thera*$ &or
to6o*lasmosis.
/'berc'losis, *'lmonar$ When bacteriologic con&irmation is not available, other re*orts
ma$ be considered to be veri&ied cases o& *'lmonar$ t'berc'losis i& the criteria o& the
Division o& /'berc'losis +limination, )ational Center &or Prevention Services, CDC, are
'sed. /he criteria in 'se as o& Jan'ar$ 2, 2==3, are available in MMWR 2==:<3=1)o. RR.
234D3=. 7:.
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(,DSD im*lications o& the *ro*osed revisions. Backgro'nd Pa*er, /(.BP.".?=.
Washington, DCD -S #overnment Printing &&ice, ('g'st 2==@.
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!isclaimer (ll 335' "/ML doc'ments *'blished be&ore Jan'ar$ 2==3 electronic conversions
&rom (SC,, te6t into "/ML. /his conversion ma$ have res'lted in character translation or &ormat errors in
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*a*er co*$ &or the o&&icial te6t, &ig'res, and tables. (n original *a*er co*$ o& this iss'e can be obtained
&rom the S'*erintendent o& Doc'ments, -.S. #overnment Printing &&ice 1#P4, Washington, DC @:7:@.
=3>2< tele*honeD 1@:@4 92@.2?::. Contact #P &or c'rrent *rices.
>3.
>7. -S Congress, &&ice o& /echnolog$ (ssessment. /he CDC;s case de&inition o&
(,DSD im*lications o& the *ro*osed revisions. Backgro'nd Pa*er, /(.BP.".?=.
Washington, DCD -S #overnment Printing &&ice, ('g'st 2==@.
>9. /orres C#, /'rner M+, "arkess JR, ,stre #R. Sec'rit$ meas'res &or (,DS and
",!. (m J P'blic "ealth 2==2<?2D@:?.=.
>A. Kessler "(, Landa$ (, Pottage JC, Benson C(. (bsol'te n'mber vers's
*ercentage o& /.hel*er l$m*hoc$tes in h'man imm'node&icienc$ vir's in&ection.
J ,n&ect Dis 2==:<2A2D39A.>.