VIRUSMYTH HOMEPAGE
HIV INFECTION AS LEADING CAUSE OF DEATH IN YOUNG ADULTS?
By Robert Maver
Rethinking AIDS July 1993
A recent article in JAMA (Selik, et al., 1993; 269:2991-2994) received
quite a bit of play in the national media last month. The article reported
that in 1990 HIV infection was the leading cause of death among young men
and women (ages 25-44) in many United States cities. In fact, HIV infection
was reported as the second leading cause of death overall among males ages
25-44 in the population at large (sixth leading cause of death overall
among females ages 25-44).
Coming on the heels of the International AIDS Conference in Berlin,
which presented HIV infection as a global pandemic, it was only natural
that American newspapers would seize upon the article to trumpet the notion
that HIV/AIDS is similarly a threat to the U.S. population at large. Heretofore,
American journalists were constrained to support what is not going on in
the U.S. and other industrialized nations (AIDS not spreading outside identified
risk groups) by citing worldwide figures and trends which are dominated
by third world countries.
Unfortunately, the mortality data source employed in the JAMA article
did not provide information on the mode of HIV transmission. As a result,
the conclusions can easily be misleading to the casual reader, who may
assume that HIV deaths are prevalent in the young adult population at large.
The CDC records on AIDS capture exactly the data needed to establish
the mode of transmission for AIDS deaths in 1990. The CDC public information
diskettes with information reported through June, 1992 reveal the following
profile for the JAMA mortality data.
|
Deaths from AIDS in 1990 for ages 25-44
|
|
Males
|
18,797
|
|
Females
|
2,323
|
|
Total
|
21,120
|
The male deaths can be further broken down as follows:
| Homosexual and/or Bisexual Males |
13,594 |
| Heterosexual Males |
5,203 |
| Total Males |
18,797 |
The Heterosexual Males can be further broken down as follows:
| Intravenous Drug Abusers |
4,102 |
| Hemophiliacs |
119 |
| Heterosexual |
265 |
| Pattern II country |
109 |
| Transfusion |
110 |
| Unkown |
498* |
| Total Heterosexual Males |
5,203 |
* Most (90%) of these cases are subsequently reclassified into known
high risk groups.
Of the 265 heterosexual male deaths above, CDC records reveal that 164
of these were in the category of "sex with an IV drug abuser."
Thus, for the vast majority of the male population, i.e., heterosexuals
not involved with IV drug abuse, there were 101 deaths in 1990.
Similarly, female deaths can be further broken down as follows:
| Intravenous Drug Abusers |
1,308 |
| Hemophiliacs |
4 |
| Heterosexual |
737 |
| Pattern II country |
49 |
| Transfusion |
86 |
| Unknown |
139* |
| Total Heterosexual Females |
2,323 |
*Most (90%) of these cases are subsequently reclassified into known
high risk groups.
Of the 737 heterosexual female deaths above, CDC records reveal that
542 of these were in the category of "sex with an IV drug abuser."
Thus, for the vast majority of the female population, i.e., heterosexuals
not involved with IV drug abuse, there were 195 deaths in 1990.
The total U.S. male population ages 25-44 is approximately 40 million.
The homosexual/bisexual segment of this population is in the 2 to 4 million
range. (The latest studies suggest a homosexual/bisexual population of
less than 5%. Older studies estimated 10%.) If we use an estimate of 800,000
for the IV drug population, then we are left with 35.2 to 37.2 million
male non-IV drug abusing heterosexuals. The death rate for this group,
which comprises the vast majority of the male population at these ages,
is calculated as 101/36,200,000=.28 per 100,000, again, an extremely low
value.
The total U.S. female population ages 25-44 is approximately 40 million.
If we use an estimate of 200,000 for the IV drug population, then we are
left with 39.8 million female non-IV drug abusing heterosexuals. The death
rate for this group, which comprises the vast majority of the female population
at these ages, is calculated at .49 per 100,000.
The JAMA article presented the 10 leading causes of death for ages 25-44
as follows:
|
males (n=101,519) |
females (n=42,134) |
| Rank |
Cause |
Death, % |
Cause |
Death, % |
| 1 |
Unintentional injury |
21.2 |
Cancer |
28.0 |
| 2 |
HIV infection |
16.5 |
Unintentional injury |
14.6 |
| 3 |
Hearth disease |
11.0 |
Hearth disease |
11.0 |
| 4 |
Cancer |
9.7 |
Suicide |
5.9 |
| 5 |
Suicide |
9.6 |
Homicide |
5.8 |
| 6 |
Homicide |
9.5 |
HIV infection |
4.8 |
| 7 |
Liver disease |
3.2 |
Stroke |
3.9 |
| 8 |
Stroke |
1.7 |
Liver disease |
3.1 |
| 9 |
Pneumonia |
1.4 |
Diabetes |
2.1 |
| 10 |
Diabetes |
1.3 |
Pneumonia |
1.8 |
| ??? |
Heterosexual AIDS
(non-IV drugs) |
0.1 |
Heterosexual AIDS
(non-IV drugs) |
0.5 |
As the figures make clear, HIV/AIDS deaths in the heterosexual non-IV
drug abusing segment of the population are nowhere near the top 10 causes.
For males, the 10th leading cause-diabetes-yielded 13 times more deaths
in 1990. Indeed, it is difficult to construe 101 male heterosexual AIDS
deaths as an epidemic.
In an accompanying editorial to the JAMA article, the opportunity to
correct the misperception that HIV deaths are significant in the population
at large was unfortunately missed. In fact, the editorial suggested that
AIDS was moving out of its original epicenters and claimed that "adolescent
and young adult HIV transmission guarantees the continuation of the AIDS/HIV
epidemic." This is a curious statement given the fact that AIDS cases
in adolescents and young adults have decreased three years in a row according
to the following CDC data.
|
#AIDS cases* (in adolescents 13-19 years old, and adults
20-24 years old)
|
|
1990
|
1,786
|
|
1991
|
1,633
|
|
1992
|
1,605
|
|
* The vast majority (90%) of these cases are in high risk groups.
|
Perhaps the most unfortunate aspect of the JAMA article and the attendant
media coverage is that it remains true that AIDS is the leading cause of
death among young adults in many major U.S. cities. These deaths, however,
are largely related to drug abuse. The JAMA article should have focused
our attention on the problem of drug abuse in our inner cities instead
of serving as a decoy for perpetuating the myth that AIDS is spreading
out of its original high risk groups.*
Robert Maver is consulting actuary and formerly served as
an executive with Mutual of New York.
VIRUSMYTH HOMEPAGE