h i v d i s e a s e s u r v e i l l a n c e —cme

CME Article
Hiv Disease Surveillance
Collaboration between Medicine and Public Health
Sindy M. Paul, md, mph; Helene Cross, phd; Linda Dimasi, mpa;
Abdel R. Ibrahim, phd; and Carmine J. Grasso, mph, msw

Public Health Surveillance is critical to the management of programs designed to control the epidemic of hiv–aids. Sur-
veillance defines changing trends, helps to formulate preventive initiatives and evaluate their effectiveness, and to allocate
resources. Collaboration between clinical medicine and public health is essential to achieve reliable surveillance.

Learning Objectives and access to the Aids Drug Distribution Program

formulary; planning and evaluation of prevention
i. To describe three changing trends in hiv dis-
services; evaluation of the implementation of the
ease in New Jersey.
U.S. Public Health Service (phs) for the preven-
ii. To recognize the need for collaboration be-
tion of perinatal hiv transmission and for the pre-
tween medicine and public health to better un-
vention of opportunistic infections; presence and
derstand and respond to the hiv epidemic in
transmission of variant strains of hiv and changing
New Jersey.
trends in the epidemic.
iii. To recognize the importance of hiv–aids sur-
Public health surveillance is an important tool
veillance.
that classifies data, interprets data, and, most im-
portantly, helps guide interventions in public
n the busy daily practice of medicine, submit- health problems. Surveillance also has a role in

I ting required disease reports to the health de-

partment is rarely given a high priority. These
reports constitute the basis of public health surveil-
evaluation during which new information is col-
lected and analyzed to quantify the success of the
intervention in the public health problem. Aids has
lance, which is important for many diseases, includ- been a reportable disease by regulation in New Jer-
ing hiv–aids. The hiv and aids cases reported to sey since 1986. New Jersey was the first high-preva-
the New Jersey Department of Health and Senior lence state to implement name-based hiv reporting
Services (njdhss) provide the foundation for deci- in October 1991. Through December 31, 2001, a
sions relating to resource allocation, including total of 43,009 aids cases were reported and 16,412
1
funding for counseling and testing, medical care, persons with hiv disease (not aids) were reported.
Sindy M. Paul, md, mph, is the medical director of the Division of Aids Prevention and Control; Helene Cross, phd, is the acting
director of Epidemiologic Services in the Division of Aids Prevention and Control; Linda Dimasi, mpa, is an analyst i, research and
evaluation, in the Division of Aids Prevention and Control; Abdel R. Ibrahim, phd, is a research scientist with Epidemiologic
Services in the Division of Aids Prevention and Control; and Carmine J. Grasso, mph, msw, is the director of Care and Treatment
at the Division of Aids Prevention and Control. All authors are with the New Jersey Department of Health and Senior Services.
disclosure statement: Sindy M. Paul, md, mph; Helene Cross, phd; Linda Dimasi, mpa; Abdel R. Ibrahim, phd; and Carmine J.
Grasso, mph, msw, have no relationships to disclose.

vol. 100, no. 9, september 2003 • supplement to new jersey medicine • 7

h i v d i s e a s e s u r v e i l l a n c e —cme

New Jersey has the fifth highest prevalence of aids be obtained from the njdhss by calling 609-984-
cases in the United States, ranks third in pediatric 6125 or on the njdhss web site at url:
aids cases, and has the highest proportion of www.state.nj.us/health.
women among the cumulative aids cases in the
2
country.
Evaluation
Surveillance data is used to determine federal
funding levels for cities and states under the Ryan Surveillance activities based on reported hiv–aids
White Comprehensive Aids Resources Emergency cases include evaluation of both the implementa-
(care) Act of 1990. The Health Resources and tion and effectiveness of phs recommendations.
Services Administration distributes Care Act dol- From the clinician’s perspective of treating indi-
lars to states and cities for the development of vidual patients as well as the population-based
comprehensive care systems for low-income indi- health perspective of the njdhss, it is important to
viduals and families lacking other sources of pay- verify the effectiveness of phs recommendations.
ment for these services. The formula portion of the New Jersey was one of the original venues in which
Care Act awards is based on a 10-year weighted a critically important set of recommendations of the
average of aids cases reported to the Centers for phs was validated: prevention of perinatal hiv trans-
Disease Control and Prevention (cdc), which mission. The Pediatric Aids Clinical Trials Group
serves as an estimate of the number of individuals Protocol 076 (pactg 076) proved that zidovudine
living with hiv and aids in each state and local ju- (azt, zdv) use during pregnancy, labor, and deliv-
risdiction. ery, and in the neonatal period can reduce perina-
During federal fiscal year 2002, approximately
3
tal hiv transmission from 25% to 8%. In August
$82 million from the Ryan White program was al- 1994, the phs published recommendations for the
located to New Jersey under different titles of the use of azt to prevent perinatal hiv transmission.
Care Act. Comprehensive surveillance activities For children born in New Jersey in 1993, 33 (9%)
play an important role in ensuring that New Jersey of the hiv-exposed children received perinatal azt.
residents receive their fair share of federal resources As a result of the phs guidelines, this proportion
to address this burgeoning epidemic. increased markedly to 199 (76%) in birth year 2000.
In addition to federal funding, hiv–aids surveil- During these years, perinatal hiv transmission de-
lance data is also used in the annual appropriations creased from 73 (21%) in 1993, to 12 (4%) in 2000.
process by the njdhss and the legislature. There- Although there is continued room for improve-
fore, reporting all cases of hiv and aids to njdhss is ment, statewide surveillance activities show that the
imperative for sufficient federal and state funding. phs recommendations have been widely imple-
Surveillance data are also used as part of the mented and are indeed preventing perinatal trans-
decision-making process for determining the num- mission. Similar surveillance activities are currently
ber and distribution of counseling and testing sites being conducted in New Jersey to evaluate the
that are needed. These counseling and testing sites implementation and effectiveness of phs recom-
provide free hiv counseling and assessment of mendations to prevent active tuberculosis in co-
serostatus and are also established, at least in part, infected persons and to prevent Mycobacterium
on the number of reported hiv and aids cases. Phy- avium complex in hiv-infected children.
sicians can refer patients to these sites; however, Hiv reporting allows the njdhss to detect
the results can only be sent to the physician with emerging trends in the epidemic a decade or more
written permission from the patient. As with all hiv- sooner than with aids-only surveillance. Recogni-
infected persons, confidentiality must be strictly tion of these changes is important for daily interac-
maintained according to njac 26:5c. Information tions with patients, prevention planning, and
on publicly funded counseling and testing sites can resource allocation. A recently emerging trend is

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 h i v d i s e a s e s u r v e i l l a n c e —cme

an increasing number of persons living with hiv– New Jersey has increased from 22,391 on Decem-
aids, especially adolescents and women. ber 31, 1995, to 30,535 on December 31, 2001. This
The number of adolescents living with hiv–aids increased prevalence of hiv–aids in the era of com-
increased over 50% from 146 in 1995, to 226 in 2001. bination therapy may be due, in part, to a decrease
This increase may be related to improved pediat- in opportunistic infection–related mortality and/or
ric antiretroviral therapy and fewer opportunistic an increasing incidence of hiv disease.
infections. The increasing number of adolescents
with hiv disease has implications for prevention.
New Initiatives
First, vertical hiv transmission may occur from
these adolescents to their children. Second, a larger Patients on combination therapy who live longer
prevalence of hiv-infected adolescents who may with hiv disease will need medical care for such
engage in high-risk behavior with other adolescents complications as hyperglycemia and diabetes mel-
may result in a higher incidence of hiv among ado- litus, lipid abnormalities, fat redistribution, and
lescents. Njdhss is collaborating with the cdc on a lactic acidosis with hepatomegaly and hepatic ste-
study to describe, for the first time, the medical and
5,6
atosis. The emerging history of hiv-infected per-
social histories and pregnancy outcomes of a group sons on combination therapy has yet to be fully
of perinatally hiv-infected adolescent girls who described. A new surveillance effort entitled “Sur-
were recently pregnant, and to assess, through a vey of Hiv Disease and Care (shdc)” is being de-
case-control study, the risk factors associated with veloped in collaboration with the cdc to determine
pregnancy among these perinatally hiv-infected access to and utilization of care, to better describe
adolescents. The study is also designed to deter- the clinical course of hiv-infected persons on com-
mine the prevalence of pregnancy among bination therapy, to determine the occurrence of
perinatally hiv-infected adolescents and to describe opportunistic infections, and to evaluate the imple-
the viral characteristics of hiv subspecies transmit- mentation of phs recommendations.
ted across three generations. The increasing number of persons living with
An increase has been detected among women hiv–aids may lead to changing trends in new in-
(those aged 12 and over) living with hiv–aids. The fections. Incident cases of hiv can be identified by
number of women living with hiv–aids increased collaboration between medicine and public health.
by 37% from 7,534 in 1995, to 10,316 in 2001. New Njdhss is starting a new cdc-funded project.
Jersey had the highest estimated proportion of This project depends on prompt notification (re-
women living with aids by the end of 1999. Women porting) of patients newly diagnosed with hiv dis-
currently account for 28% of aids diagnoses; 38% ease. The goal is to determine population-based
of hiv diagnoses, and 36% of persons living with hiv incidence through a new laboratory assay. In-
hiv–aids. This changing trend emphasizes the need cidence data is particularly important for planning,
for physicians to discuss hiv disease with women, targeting, and evaluating prevention interventions;
perform a complete sexual and drug-use history, planning and resource allocation for direct patient
and offer (or provide a referral for) counseling and care; location and staffing of counseling and test-
testing. Since the majority of the women are of re- ing sites; and determining changing trends in the
productive age, it also emphasizes the need to com- epidemic.
ply with njac 8:61-3.1, which requires providers
to give hiv counseling and offer hiv testing to preg-
Special Studies
nant patients. Recommendations for the preven-
tion of perinatal hiv transmission should be Special epidemiologic studies are conducted by the
followed for hiv-infected pregnant women. njdhss. Investigations of unusual cases are con-
The number of persons living with hiv–aids in ducted, for example, in situations in which there is

vol. 100, no. 9, september 2003 • supplement to new jersey medicine • 9

h i v d i s e a s e s u r v e i l l a n c e —cme

discordance between clinical presentation and seling and testing services with which they can
laboratory findings. Recent special epidemiolgic maximize the number of persons who know their
studies have identified the presence of variant serostatus, in addition to providing information on
strains of hiv in New Jersey and a case of hiv-1 prevention and medical management for those who
group m subtype b (the most common strain of hiv are infected. Case reports for hiv and aids allow
in New Jersey and in the United States) that was public health personnel to optimize resource allo-
not detectable using currently fda-approved hiv cation, detect emerging trends, provide prevention
7
diagnostic tests. Identification of variant strains of services, and evaluate the effectiveness of phs rec-
hiv can provide the foundation for further epide- ommendations. The critical importance of federal
miologic studies describing the predilection for and state funding commensurate with the size of
transmission, immunologic response, and treat- New Jersey’s hiv–aids population is an additional
ment response for these emerging pathogens within reason that surveillance must be conscientiously
the hiv epidemic. These special studies can pro- addressed by all members of the health care com-
vide information, and possibly laboratory speci- munity. Providers and laboratories are required
mens, for the development of diagnostic tests and (njac 8:57-2.1-2.7) to report all cases of hiv, aids,
viral load monitoring tests that consistently and cd4 counts of less than 200 or 14%, and viral load
reliably detect these strains. Detecting and moni- results to the njdhss. Information on reporting re-
toring these strains are crucial for diagnosis, medi- quirements and report forms can be obtained by
cal management, and protection of the blood calling 609-984-5940 or 973-648-7500. Surveil-
supply. lance data is available on the department’s web site
at url: www.state.nj.us/health. NJM
Collaboration
References
In addition to hiv disease surveillance, the njdhss
1. New Jersey Department of Health and Senior Services.
can collaborate with physicians to follow-up on hiv- New Jersey Hiv–Aids cases reported as of December 31, 2001.
infected persons. The Notification Assistance Pro- 2. Centers for Disease Control and Prevention. Hiv–Aids
gram (nap) is a statewide service of the njdhss Surveillance Report 10, no. 1 (1998).
designed to provide follow-up services to health 3. E. M. Connor et al. “Reduction of Maternal–Infant
Transmission of Human Immunodeficiency Virus Type 1 with
care providers for hiv-positive patients who do not Zidovudine Treatment,” N Engl J Med 331 (1994): 1173–1180.
return for test results, counseling, and medical re- 4. Centers for Disease Control and Prevention. “Recom-
ferrals. Nap can also contact the sexual or needle- mendations of the US Public Health Service Task Force on
the Use of Zidovudine to Reduce Perinatal Transmission of
sharing partners of patients to provide confidential
Human Immunodeficiency Virus,” MMWR 43, rr-11 (1994).
counseling and testing. Nap is a voluntary, 5. Panel on Clinician Practices for Treatment of Hiv In-
confidential service through which no partners will fection, convened by the Department of Health and Human
become aware of the source of the referral or the Services and the Henry J. Kaiser Foundation. “2002 Guide-
lines for the Use of Antiretroviral Agents in Hiv-Infected
identity of the hiv-positive individual naming them. Adults and Adolescents.”
Health care providers interested in using nap ser- 6. Food and Drug Administration. “Public Health Advi-
vices for locating contacts or providing follow-up sory: Reports of Diabetes and Hyperglycemia in Patients Re-
for their hiv-positive patients can call nap at 877- ceiving Protease Inhibitors for the Treatment of Human
Immunodeficiency Virus (hiv),” JAMA 278 (1997): 379.
356-8312. 7. R. S. Janssen et al. “New Testing Strategy to Detect
Collaboration between medicine and public Early Hiv-1 Infection for Use in Incidence Estimates and for
health is essential to control any major health prob- Clinical and Prevention Purposes,” JAMA 280 (1998): 42–48.
8. P. S. Sullivan et al. “Persistently Negative Hiv-1 Anti-
lem in our community, and this cooperation has
body Enzyme Immunoassay Screening Results for Patients
never been so important as in managing the aids with Hiv-1 Infection and Aids: Serologic, Clinical, and Viro-
epidemic. Clinicians provide a vital link to coun- logic Results,” AIDS 13 (1999): 89–96.

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vol. 100, no. 9, september 2003 • supplement to new jersey medicine • 11

h i v d i s e a s e s u r v e i l l a n c e —cme

cme examination: deadline september 30, 2004

“Hiv Disease Surveillance”

1. Which of the following is not described in the article as a changing trend in hiv–aids in New Jersey?
a. Increasing number of adolescents living with hiv–aids
b. Increasing number of children born infected with hiv–aids
c. Increasing number of persons living with hiv–aids
d. Increasing proportion of women reported with hiv–aids
2. Hiv–aids surveillance data is used in New Jersey to:
a. Detect changing epidemiologic trends
b. Determine federal and state funding levels
c. Evaluate the implementation and effectiveness of phs recommendations
d. All of the above
3. The Notification Assistance Program (nap) is designed to:
a. Conduct special epidemiologic studies related to hiv–aids
b. Contact sexual or needle sharing partners of hiv positive patients
c. Notify the Centers for Disease Control and Prevention of unusual hiv–aids cases
d. Report hiv–aids case to the New Jersey Department of Health and Senior Services
4. Which of the following is reportable to the New Jersey Department of Health and Senior Services?
a. Cases of hiv or aids
b. cd4 counts less than 200 or 14%
c. Viral load results
d. All of the above
5. Which of the following best describes the prevalence of aids in New Jersey?
a. Highest overall prevalence in the United States
b. Highest prevalence of pediatric cases in the United States
c. Highest proportion of adolescents in the United States
d. Highest proportion of women in the United States

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 h i v d i s e a s e s u r v e i l l a n c e —cme

Answer Sheet
“Hiv Disease Surveillance”
Darken the correct answers
. a b c d . a b c d . a b c d
. a b c d . a b c d
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“Hiv Disease Surveillance”

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vol. 100, no. 9, september 2003 • supplement to new jersey medicine • 13