Journal of Acquired Immune Deficiency Syndromes (08.01.01) Vol
Surveillance of AIDS is necessary to monitor trends in the
epidemic, follow changes in the characteristics of persons
most severely affected by HIV infection, focus prevention
efforts, and plan medical, social services and community
programs. It is imperative that surveillance is accurate,
complete, and representative of all populations affected. One
way to evaluate the AIDS reporting system is to count cases of
HIV-infected persons dying with undiagnosed AIDS, or cases
that go unreported. Use of medical examiner reports offer data
on both undiagnosed cases and unreported cases.
The investigators, members of the San Francisco Department of
Public Health (SFDPH), the National Center for HIV, STD and TB
Prevention (NCHSTP/CDC) and the San Francisco Medical
Examiner's Office, performed HIV antibody testing on all San
Francisco medical examiner cases in which toxicology testing
had been done from March 1995 through May 1997. Autopsy,
external examination, and medical record review determined
AIDS diagnoses. Record reviews also allowed the authors to
determine the completeness of AIDS reporting by identifying
previously diagnosed but unreported cases. Medical examiner
cases were chosen because they are more likely than the
general population of HIV-infected persons to include
substance users, persons of color, and the homeless. These
disadvantaged populations are more likely to have difficulty
receiving health care services and are thus more likely to be
missed by the AIDS reporting system.
AIDS cases diagnosed in the City and County of San Francisco
must be reported to the San Francisco Department of Public
Health. AIDS surveillance data are routinely collected through
both active and passive activities. During the study period
active surveillance included data collected at 10 of 11 acute
care hospitals, four of the nine health department clinics,
and 10 private physicians' offices in which a large number of
persons with AIDS received care. With persons who met the AIDS
case definition, additional information was abstracted from
the medical record. Death certificates were reviewed weekly to
identify persons who died with AIDS. The medical records of
men ages 25 to 60 whose death certificates did not list a
specific cause of death were also reviewed to identify
previously unreported persons with AIDS.
Passive surveillance by the San Francisco Department of Public
Health is accomplished by having physicians and infection
control practitioners notify the health department of patients
diagnosed with AIDS. During the period of this investigation,
85 percent of AIDS cases were reported through active
surveillance. Fifteen percent were reported through passive
surveillance, death certificate review and through data from
other health departments.
The results were cross-referenced with the San Francisco AIDS
registry to identify previously reported AIDS cases, as well
as with national AIDS registries. The medical records of
unreported cases were procured and analyzed to determine
whether AIDS had been diagnosed prior to death.
According to the authors, "Of 1959 decedents tested, 176 (9%)
were HIV positive; 105 (60%) were identified as having AIDS by
the Medical Examiner. Of the 105 AIDS cases, 101 (96%) had
been previously diagnosed; 98 (97%) had been previously
reported. Overall, diagnosis and reporting were 93% complete.
HIV-infected decedents were more likely than those uninfected
to be men and <45 years old, and less likely to be
Asian/Pacific Islander or Native American (p <.001). They were
more likely to have died of suicide (p <.05) or drug
abuse/overdose (p <.001)."
The authors found only 4 persons with AIDS in a 27-month
period who had died without an AIDS diagnosis prior to death.
The results of this study indicate that in San Francisco, AIDS
case reporting is highly complete. According to the
investigators, the study "provides strong evidence that
persons with AIDS in San Francisco are likely to be diagnosed
with AIDS at a medical facility prior to death and refutes
concerns that the current surveillance system has missed a
substantial proportion of patients by relying on health care
settings to identify persons with AIDS."
Free health care services are available to everyone in San
Francisco, including those without health insurance and
undocumented immigrants. Cities with lower access to health
services might identify a higher proportion of previously
undiagnosed or unreported persons.
Programmatically, according to the authors, the results of the
study call for more programs in suicide prevention and
substance abuse treatment in order to decrease deaths among