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North America
In the USA and Canada there were an estimated 980,000 people living with HIV at the end of 2002. The availability of antiretroviral treatment has brought a decline in death rates, while there is continuing transmission of HIV, increasingly concentrated among ethnic minority populations in the USA. African-Americans, for example, are 12% of the population of the USA but constituted 47% of reported AIDS cases in 2000. Forty five thousand people were newly infected during 2002 and 15,000 deaths occurred due to AIDS.
It is important to note that for AIDS surveillance purposes the USA now uses a different definition of AIDS from the one employed in Europe. Since 1993 anyone with a CD4 count below 200 is considered to have AIDS. In Europe a diagnosis of AIDS can only occur after the diagnosis of specified opportunistic infections (see the HIV & AIDS Treatments Directory for more information on this subject).
HIV reporting in the United States is not universal; 23 states have anonymised testing systems which prevent reporting, including New York, California and Florida, and in none of these states does HIV reporting extend back as far as 1985. Data on HIV infection are thus highly incomplete.
1996 was the first year that in which the US reported a fall in the incidence of AIDS since the epidemic first appeared. The fall is attributed to improvements in treatment. The number of deaths declined 12% from 24,900 in the first six months of 1995 to 22,000 in the first half of 1996. During the first half of 1997 AIDS diagnoses fell by a further 15% compared with the first half of 1996.
40,000 Americans died of AIDS in 1993, the highest number in any year of the epidemic. However, there are significant variations between racial groups and between genders. Whilst deaths declined by 21% amongst whites in 1996, they declined only 2% amongst African/ Americans, and deaths have increased by 3% amongst women. In part these variations can be explained by the differing rates at which HIV spread amongst these population groups during the 1980s, but they are also a reflection of access to, and uptake of, treatment.
Death rates in the major cities declined further than the national average. New York, San Francisco, Los Angeles, and Miami all reported a decline of 20% in the death rate in the first half of 1996 compared to 1995.
In the 34 areas of the United States with confidential HIV reporting, the bulk of HIV infections among 13–19-year-olds reported in July 2000–June 2001 were among females (56%), a disproportionate percentage of them African-American. Most young women had acquired the virus through heterosexual intercourse.
According to a 2002 CDC report, AIDS-related illnesses remained the leading cause of death for African-American men aged 25–44 and the third-leading cause of death for Hispanic men in the same age group.
In Canada, meanwhile, aboriginal persons accounted for 9% of new HIV infections in 1999, although they constituted less than 3% of the general population.
HIV prevalence levels are exceptionally high among African-American men who have sex with men in the USA—up to 30% among 23–29-year-olds, according to one six-city survey. About 64% of the women diagnosed with HIV in 2001 in the United States were African-American. A significant number of these women acquired the virus from men who also have sex with men.
Surveys, regularly conducted among several thousand gay men in San Francisco, have identified a continuing increase in the proportion of men who are reporting multiple partners and unprotected sex over the past six months. Rectal gonorrhea among gay men had been declining until 1993, but since that time has been steadily increasing, in line with the reported increase in unprotected anal sex.
Surveillance systems show that the rate of new HIV infections among men in San Francisco with rectal gonhorrhea almost doubled between 1996 and 1998. During 1999 the prevalence of HIV among men presenting for voluntary counselling and testing almost tripled from 1.3% in 1997 to 3.7% in 1999.
The San Francisco survey reveals that risk behaviour has increased most rapidly among men under 25. The survey identified an increase in the percentage of men reporting unprotected sex and multiple partners from 22% in 1994 to 32% in 1997.
In New York, it is estimated that 9 out of 10 cases of HIV acquired through sex between men and women are related to sex with a drug user.
In Canada there are an estimated 49,000 people living with HIV/AIDS, or 0.30% of the adult population.