VII. HIV Seroprevalence in Clients of Sentinel Family Planning Clinics
Introduction Family planning clinics serve predominantly young, sexually active clients, a substantial proportion of whom may be infected-or at risk of infection-with human immunodeficiency virus (HIV). The purposes ofthis study were to document the prevalence of HIV antibody in women attending sentinel family planning clinics and to monitor the trends in infection over time. In New York State, there are approximately 200 discrete family planning clinics, located in all counties except Putnam (where negotiations for a clinic are in progress). All but one of these clinics are publicly subsidized. Other groups and/or individuals provide family planning services but do not have a clinic dedicated solely for this purpose. Family planning clinics provide medically approved methods of contraception, medical evaluations, screening and treatment for vaginal infections and sexually transmitted diseases, level-I screening for infertility, and voluntary HIV counseling and testing services. Most clients in New York State are women. Approximately 75 percent are under age 25. Overall 21 percent are Black and 13 percent Hispanic. [In New York State approximately 14 percent of the population is Black and 12 percent of Hispanic origin (Current Population Survey: March 1988)]. One constraint on this study was that relatively few of the clinics routinely obtain blood specimens. Random sampling of clients and/or clinics was therefore not feasible. Instead the qualifying clinics were considered sentinels, and the results were adjusted for extrapolation to the total population of clients.
Methods The study was conducted over a period of 26 months, from February 1, 1988 through March 31, 1990.
The study sites were limited to publicly subsidized family planning clinics that routinely drew whole blood specimens for syphilis serology from clients during the initial medical evaluation. Clinics throughout the state were screened for this practice. In early 1988, 38 clinics met this criterion, and 37 agreed to participate. Of the participating facilities, 13 were located in New York City boroughs and the rest in other counties: Westchester, seven; Nassau, four; Onondaga, three; Monroe, five; Orleans, one; Genesee, one; and Erie, three. One clinic in Monroe County was closed shortly after the study was initiated. Five additional clinics (Rockland, two; Orange, two; Nassau, one) entered the study after changes in their routine blood-collection practices. Study subjects were limited to clients undergoing an initial medical evaluation for contraceptive services. Clients seen for annual or follow-up visits were excluded to avoid repeat testing of the same individuals over time. Individuals seen solely for pregnancy testing were also excluded, because blood specimens were not routinely obtained on this population. Clients seen only for HIV counseling and testing were excluded to minimize selfselection bias. If a client met these criteria, a seroprevalence study test requisition (SSTR) form was completed by the clinic staff and submitted along with the routine laboratory request form and blood specimen to a contract laboratory. The completed form contained the client's age, race or ethnicity, and county and zip code of residence, as well as the clinic site and the month and year of specimen collection. Identifying information (e.g., name, street address, or medical record number) was not collected; thus the information could not be traced back to the individual client. If serum was left over after all routine laboratory tests were performed, the
American Journal of Public Health 41
Stnico£ et al. contract laboratory would pipette at least 0.5 ml into a tube labeled with the blind seroprevalence number and send the serum with the SSTR form to the New York State Department of Health's Wadsworth Center for Laboratories and Research. No additional blood was drawn for this study. When the blood drawn was insufficient for blind HIV testing, the SSTR alone was sent to the Department of Health. These data were used to estimate any bias from the loss of specimens. The data were not used for any other analysis. The Wadsworth Center performed an ELISA (enzyme-linked immunosorbent assay) (DuPont) for HIV antlbody. ELISA reactives were confirmed with a Western blot (in-house assay until May 1988, then DuPont). All Western blots were interpreted by the latest Association of State and Territorial Public Health Laboratory Directors criterion' for reactive specimens, i.e. virus-specific bands in at least two of the following major band locations: gpl60/120, gp4l, or p24. Specimens with other major virus-specific bands were interpreted as equivocal. All other specimens were considered nonreactive. Seroprevalence rates were calculated as: (number of Western blot reactives)/ (total number of specimens minus equivocals). Because the specimens could not be traced to individual clients, we could not request second samples for reevaluation of equivocals. Age-specific seroprevalence rates were calculated in five-year intervals for ages 15 to 39. Individuals under age 15 were grouped, as were those over age 39. Racial/ethnic-specific seroprevalence rates were calculated for non-Hispanic Whites, non-Hispanic Blacks, Hispanics, Others, and Unknowns. Others and Unknowns had to be combined due to small cell sizes for some combinations of age and race/ethnicity groups. HIV seroprevalence rates by quarter-year of clinic visit were calculated to describe changes in seroprevalence over time. For this analysis three of the 37 initial clinics were eliminated: one that closed early in the study and two that closed later. Trends were calculated only for the 34 clinics that participated throughout the entire study period. To estimate the completeness of the data set, we used the number of initial medical examinations in 1988 reported by each participating clinic to the New York State Department of Health's Bureau of Reproductive Health. This number was 42 American Journal of Public Health
compared to the number of specimens submitted during the first year ofthe study (February 1988-January 1989). Clinic records were available from all but one site in upstate New York. Bureau of Reproductive Health statistics were also used to adjust for differences between the sentinel clinic clients and the overall family planning clinic population. The age, raciaVethnic, and residence distributions of the two groupswere compared and the HIV seroprevalence rates were adjusted directly for differences, using the overall population as the standard. The results ofthe sentinel clinic study were compared to the results of the Newborn HIV Seroprevalence Study. Sentinel clinic rates were adjusted for the differences in age, racial/ethnic, and residence distributions. The adjusted rates were calculated for New York City, New York State exclusive of New York City, and statewide, using the distribution of childbearing women as the standard population. Between February and July 1988 a separate, unlinked HIV risk assessment questionnaire was administered to clients of 30 family planning clinics by clinic staff. Participation in the risk study was voluntary and not limited to the subset of women seen for an initial medical evaluation. The results were submitted to the New York State Department of Health without patient identifiers. Participation was voluntary on the part of the facility and the clients. The questionnaire included items on the client's age; race/ethnicity; county of residence; history of intravenous drug use; history of living in a high-risk country (as defined by the Centers for Disease Control); history of being a sex partner of a bisexual male, drug user, hemophiliac, or person with AIDS or HIV infection; and maximum number of sex partners in any six-month period since 1978 (0,1, 2,3, or 4+).
Results Sentinel Clnic Results Between February 1, 1988 and March 31, 1990, a total of 28,745 specimens were obtained from women having initial medical examinations in the sentinel family planning clinics. Of these specimens, 896 (3 percent) had an insufficient quantity of serum left over for analysis. An additional 1 percent were not tested due to improper shipping, leakage of
tubes, or blank forms or because the specimen was obtained from a male client. Twelve (0.04 percent) had equivocal HIV test results and were eliminated from the analysis. Of the 27,549 remaining specimens 144 (0.52 percent) were HIV antibody-positive. Fourteen of the 41 clinic sites (one in New York City, 13 in New York State exclusive of New York City), which contributed 11.8 percent of the study population, had no seropositives identified during the study period. Eight clinics (two in New York City) had rates of seropositivity between 0.01 and 0.50 percent; 11 clinics (six in New York City) had rates between 0.51 and 1.00 percent; and eight clinics (four in New York City) had rates in excess of 1 percent. The highest seroprevalence rate was 3.91 percent, detected in a mobile clinic in New York City. The highest seroprevalence rate by residence of the client was detected among residents of New York City, with 0.82 percent identified as positive. The rates by boroughs (and the numbers tested/received) were: Manhattan, 0.73 percent (15/2,050); Bronx, 0.98 percent (20/2,031); Kings, 0.81 percent (50/6,187); Queens, 0.84 percent (20/2,387); and Staten Island, 0.67 percent (6/891). Residents living elsewhere in the state had a 0.24 percent rate of seropositivity. Clients from counties nearest New York City (Westchester, Nassau, and Rockland) had five times the seroprevalence of residents from other counties (Eric, Monroe, Orleans, Genesee, Onondaga, and Orange): 0.54 versus 0.11 percent, respectively. No seropositives were detected among the 805 individuals tested under the age of 15, and three seropositives (0.42 percent) were detected among the 722 individuals age 40 or more (Table VII-1). Between these groups HIV seroprevalence increased with age. Women 35-39 years old had approximately nine times the HIV seroprevalence rate of 15-19 year olds (1.56 versus 0.18 percent). The trend of increasing HIV seroprevalence with age was seen for all racial/ethnic groups.
Minority women (non-Hispanic Black or Hispanic) had an H{IV seroprevalence of 0.76 percent (Table VII-1). This was about six times the rate detected among non-Hispanic Whites (0.13 per-
cent). HIV seroprevalence rates by quarter-year of clinic visit are shown in Table VII-2. The highest rates (0.63 and 0.71
May 1991, Vol. 81, Supplement
HIV Seroprevalence in Family Planning Clinics
percent) occurred in the second quarter of 1988 and first quarter of 1990. The lowest rate (0.34 percent) was detected in the incomplete first quarter of 1988. No trend over time is evident.
Extrapolation to All Family Planning Clinics According to Bureau of Reproductive Health statistics, a statewide total of 68,644 initial medical examinations at family planning clinics were done in 1988. Of these examinations, 15,112 (22 percent) involved clients at the sentinel clinics. During the first year of the study (beginning in February 1988) 12,575 client specimens were included in the analysis. This is an estimated sampling rate of 83 percent in the sentinel clinics for 1988: 86 percent in New York City, 80 percent in New York State exclusive of New York City. Sentinel clinic clients were more likely to be non-Hispanic Black (36.5 percent) or Hispanic (25.3 percent) than were clients in general (21.2 percent and 13.5 percent, respectively). The age distributions were similar: women under age 25 were 72.3 percent of clients at sentinel clinics and 73.4 percent at all clinics statewide. After adjustments for differences in the racial/ethnic and residence distributions, the extrapolated HIV seroprevalence rates for all family planning clinic clients were: New York City, 0.82 percent; New York State exclusive of New York City, 0.15 percent; and statewide, 0.31 percent.
May 1991, Vol. 81, Supplement
American Journal of Public Health 43
Stiicof, et al. The women who volunteered for this study were not limited to those in the seroprevalence study. Not all sentinel clinics participated, and the extent of participation varied considerably among the participating clinics. For these reasons the results should be considered background information and not interpreted to explain seroprevalence results obtained for the full study population.
Biscussion
Comparison to Newbom Seroprevalence Data Because there were substantial differences between the demographic profiles of family planning clinic clients and those of childbearing women, adjusted seroprevalence rates were calculated using the age, racial/ethnic, and residence distributions of childbearing women as the standard. The adjusted seroprevalence rates were: New York City, 1.53 percent; New York State exclusive of New York City, 0.25 percent; and statewide, 0.92 percent. These figures were 24 to 47 percent higher than the rates for childbearing women in the Newborn HIV Seroprevalence Study: New York City, 1.24 percent; New York State exclusive of New York City, 0.17 percent; and statewide, 0.66 percent.2
Risk Factors Thirty sentinel clinics participated in the voluntary risk assessment study. Risk assessment forms were completed on 44 American Journal of Public Health
6,892 clients, who were generally of the same age (71 percent under age 25) as the whole study population. The risk-assessment group was more likely to reside in New York City and to be non-Hispanic Black (50 percent) or Hispanic (27 percent) than the overall sentinel population. (Of the risk-assessment group 21 percent were non-Hispanic White, and 3 percent were of Other or Unknown race/ ethnicity.) The number and percent of clients in the sentinel clinics admitting to the selected risk factors for HIV infection are presented in Table VII-3. The most frequently reported risk factors were having sex with four or more sex partners in a six-month period, having lived in a highrisk country, having had sex with an intravenous drug user, and having had sex with a bisexual male. Of all the participating clients, 583 (8.46 percent) admitted to at least one of the risk factors. Fifty-nine (11.64 percent) of the pregnant women admitted to at least one risk factor.
Family planning clinics serve predominantlyyoung, sexually active clients. In this study of 41 sentinel clinics, approximately one in 200 clients was infected with HIV. The clinics in this study were not representative of all of the approximately 200 clinics in the state. Sentinel clinics were limited to those that routinely drew blood for syphilis serology on all initial clients. These clinics tended to be in areas with higher syphilis incidence rates and thus potentially higher HIV infection rates. The crude and adjusted HIV seroprevalence rates obtained in this study may overestimate the actual rate for the total family planning clinic population. The true rates are likely to be closer to those found in the Newborn HIV Seroprevalence Study. A slightly low bias in statewide rates may have been introduced by the 896 specimens that were insufficient for testing. These specimens represented clients who resided primarily in New York City (79.7 percent). The 896 clients resembled the entire study group in their age distribution (71.5 percent under age 25) and resembled other New York City clients in their racial/ethnic distribution (non-Hispanic White, 21.0 percent; non-Hispanic Black, 42.5 percent; Hispanic, 34.4 percent; Other, 2.1 percent). After reviewing the results of this and other seroprevalence studies involving New York State residents, the New York State Department of Health required HIV education, counseling, and testing programs as a condition of funding in all publicly subsidized clinics for family planning and prenatal care. Since virtually all women seen in these clinics are sexually active, they are potentially at risk for HIV infection. Knowledge of an individual's HIV infection status is important to prevent transmission, particularly vertical transmission from mother to infant, and to prevent or defer certain complications of HIV infection with early therapeutic intervention.
May 1991, Vol. 81, Supplement
HIV Seroprvalence in Family Pbnning Clinics
In addition to providing HIV counseling and testing, family planning and prenatal care clinics must be prepared to provide or offer referral for care for their HIV-positive clients.
Sumwy In February 1988 the New York State Department of Health initiated a study to determine the prevalence ofHIV antibody in women attending selected, publicly subsidized family planning clinics. During a 26-month study period, 27,549
May 1991, Vol. 81, Supplement
blood specimens were obtained from women having an initial medical exaniination in 41 clinic sites throughout the state. Of these clients 144 (0.52 percent) were seropositive. The HIV seroprevalence rate increasedwith age to a high of 1.56 percent for 831 women ages 35 to 39. The seroprevalence rate for non-Hispanic Black or Hispanic clients (0.76 percent) was about six times the rate fornon-Hispanic Whites (0.13 percent). No overall increasing or decreasingtrend in prevalence ofHIVinfection was detected during the study period. E]
Acknowledgments The authors gratefilly acknowledge the contribution of the clinical and laboratory staff of the participating clinics and laboratories.
References 1. Centers for Disease Control: Interpretation and use of the Western blot assay for serodiagnosis of Human Immunodeficiency Virus type 1 infections. MMWR 1989; 38(suppl S-7):1-7. 2. Novick LF, Glebatis DM, Stricof RL, MacCubbin PA, LessnerL, Berns DS: Newborn seroprevalence study: Methods and results. Am J Public Health 1991; 81(suppl):15-21, Ch II.
American Journal of Public Health 45
Introduction Family planning clinics serve predominantly young, sexually active clients, a substantial proportion of whom may be infected-or at risk of infection-with human immunodeficiency virus (HIV). The purposes ofthis study were to document the prevalence of HIV antibody in women attending sentinel family planning clinics and to monitor the trends in infection over time. In New York State, there are approximately 200 discrete family planning clinics, located in all counties except Putnam (where negotiations for a clinic are in progress). All but one of these clinics are publicly subsidized. Other groups and/or individuals provide family planning services but do not have a clinic dedicated solely for this purpose. Family planning clinics provide medically approved methods of contraception, medical evaluations, screening and treatment for vaginal infections and sexually transmitted diseases, level-I screening for infertility, and voluntary HIV counseling and testing services. Most clients in New York State are women. Approximately 75 percent are under age 25. Overall 21 percent are Black and 13 percent Hispanic. [In New York State approximately 14 percent of the population is Black and 12 percent of Hispanic origin (Current Population Survey: March 1988)]. One constraint on this study was that relatively few of the clinics routinely obtain blood specimens. Random sampling of clients and/or clinics was therefore not feasible. Instead the qualifying clinics were considered sentinels, and the results were adjusted for extrapolation to the total population of clients.
Methods The study was conducted over a period of 26 months, from February 1, 1988 through March 31, 1990.
The study sites were limited to publicly subsidized family planning clinics that routinely drew whole blood specimens for syphilis serology from clients during the initial medical evaluation. Clinics throughout the state were screened for this practice. In early 1988, 38 clinics met this criterion, and 37 agreed to participate. Of the participating facilities, 13 were located in New York City boroughs and the rest in other counties: Westchester, seven; Nassau, four; Onondaga, three; Monroe, five; Orleans, one; Genesee, one; and Erie, three. One clinic in Monroe County was closed shortly after the study was initiated. Five additional clinics (Rockland, two; Orange, two; Nassau, one) entered the study after changes in their routine blood-collection practices. Study subjects were limited to clients undergoing an initial medical evaluation for contraceptive services. Clients seen for annual or follow-up visits were excluded to avoid repeat testing of the same individuals over time. Individuals seen solely for pregnancy testing were also excluded, because blood specimens were not routinely obtained on this population. Clients seen only for HIV counseling and testing were excluded to minimize selfselection bias. If a client met these criteria, a seroprevalence study test requisition (SSTR) form was completed by the clinic staff and submitted along with the routine laboratory request form and blood specimen to a contract laboratory. The completed form contained the client's age, race or ethnicity, and county and zip code of residence, as well as the clinic site and the month and year of specimen collection. Identifying information (e.g., name, street address, or medical record number) was not collected; thus the information could not be traced back to the individual client. If serum was left over after all routine laboratory tests were performed, the
American Journal of Public Health 41
Stnico£ et al. contract laboratory would pipette at least 0.5 ml into a tube labeled with the blind seroprevalence number and send the serum with the SSTR form to the New York State Department of Health's Wadsworth Center for Laboratories and Research. No additional blood was drawn for this study. When the blood drawn was insufficient for blind HIV testing, the SSTR alone was sent to the Department of Health. These data were used to estimate any bias from the loss of specimens. The data were not used for any other analysis. The Wadsworth Center performed an ELISA (enzyme-linked immunosorbent assay) (DuPont) for HIV antlbody. ELISA reactives were confirmed with a Western blot (in-house assay until May 1988, then DuPont). All Western blots were interpreted by the latest Association of State and Territorial Public Health Laboratory Directors criterion' for reactive specimens, i.e. virus-specific bands in at least two of the following major band locations: gpl60/120, gp4l, or p24. Specimens with other major virus-specific bands were interpreted as equivocal. All other specimens were considered nonreactive. Seroprevalence rates were calculated as: (number of Western blot reactives)/ (total number of specimens minus equivocals). Because the specimens could not be traced to individual clients, we could not request second samples for reevaluation of equivocals. Age-specific seroprevalence rates were calculated in five-year intervals for ages 15 to 39. Individuals under age 15 were grouped, as were those over age 39. Racial/ethnic-specific seroprevalence rates were calculated for non-Hispanic Whites, non-Hispanic Blacks, Hispanics, Others, and Unknowns. Others and Unknowns had to be combined due to small cell sizes for some combinations of age and race/ethnicity groups. HIV seroprevalence rates by quarter-year of clinic visit were calculated to describe changes in seroprevalence over time. For this analysis three of the 37 initial clinics were eliminated: one that closed early in the study and two that closed later. Trends were calculated only for the 34 clinics that participated throughout the entire study period. To estimate the completeness of the data set, we used the number of initial medical examinations in 1988 reported by each participating clinic to the New York State Department of Health's Bureau of Reproductive Health. This number was 42 American Journal of Public Health
compared to the number of specimens submitted during the first year ofthe study (February 1988-January 1989). Clinic records were available from all but one site in upstate New York. Bureau of Reproductive Health statistics were also used to adjust for differences between the sentinel clinic clients and the overall family planning clinic population. The age, raciaVethnic, and residence distributions of the two groupswere compared and the HIV seroprevalence rates were adjusted directly for differences, using the overall population as the standard. The results ofthe sentinel clinic study were compared to the results of the Newborn HIV Seroprevalence Study. Sentinel clinic rates were adjusted for the differences in age, racial/ethnic, and residence distributions. The adjusted rates were calculated for New York City, New York State exclusive of New York City, and statewide, using the distribution of childbearing women as the standard population. Between February and July 1988 a separate, unlinked HIV risk assessment questionnaire was administered to clients of 30 family planning clinics by clinic staff. Participation in the risk study was voluntary and not limited to the subset of women seen for an initial medical evaluation. The results were submitted to the New York State Department of Health without patient identifiers. Participation was voluntary on the part of the facility and the clients. The questionnaire included items on the client's age; race/ethnicity; county of residence; history of intravenous drug use; history of living in a high-risk country (as defined by the Centers for Disease Control); history of being a sex partner of a bisexual male, drug user, hemophiliac, or person with AIDS or HIV infection; and maximum number of sex partners in any six-month period since 1978 (0,1, 2,3, or 4+).
Results Sentinel Clnic Results Between February 1, 1988 and March 31, 1990, a total of 28,745 specimens were obtained from women having initial medical examinations in the sentinel family planning clinics. Of these specimens, 896 (3 percent) had an insufficient quantity of serum left over for analysis. An additional 1 percent were not tested due to improper shipping, leakage of
tubes, or blank forms or because the specimen was obtained from a male client. Twelve (0.04 percent) had equivocal HIV test results and were eliminated from the analysis. Of the 27,549 remaining specimens 144 (0.52 percent) were HIV antibody-positive. Fourteen of the 41 clinic sites (one in New York City, 13 in New York State exclusive of New York City), which contributed 11.8 percent of the study population, had no seropositives identified during the study period. Eight clinics (two in New York City) had rates of seropositivity between 0.01 and 0.50 percent; 11 clinics (six in New York City) had rates between 0.51 and 1.00 percent; and eight clinics (four in New York City) had rates in excess of 1 percent. The highest seroprevalence rate was 3.91 percent, detected in a mobile clinic in New York City. The highest seroprevalence rate by residence of the client was detected among residents of New York City, with 0.82 percent identified as positive. The rates by boroughs (and the numbers tested/received) were: Manhattan, 0.73 percent (15/2,050); Bronx, 0.98 percent (20/2,031); Kings, 0.81 percent (50/6,187); Queens, 0.84 percent (20/2,387); and Staten Island, 0.67 percent (6/891). Residents living elsewhere in the state had a 0.24 percent rate of seropositivity. Clients from counties nearest New York City (Westchester, Nassau, and Rockland) had five times the seroprevalence of residents from other counties (Eric, Monroe, Orleans, Genesee, Onondaga, and Orange): 0.54 versus 0.11 percent, respectively. No seropositives were detected among the 805 individuals tested under the age of 15, and three seropositives (0.42 percent) were detected among the 722 individuals age 40 or more (Table VII-1). Between these groups HIV seroprevalence increased with age. Women 35-39 years old had approximately nine times the HIV seroprevalence rate of 15-19 year olds (1.56 versus 0.18 percent). The trend of increasing HIV seroprevalence with age was seen for all racial/ethnic groups.
Minority women (non-Hispanic Black or Hispanic) had an H{IV seroprevalence of 0.76 percent (Table VII-1). This was about six times the rate detected among non-Hispanic Whites (0.13 per-
cent). HIV seroprevalence rates by quarter-year of clinic visit are shown in Table VII-2. The highest rates (0.63 and 0.71
May 1991, Vol. 81, Supplement
HIV Seroprevalence in Family Planning Clinics
percent) occurred in the second quarter of 1988 and first quarter of 1990. The lowest rate (0.34 percent) was detected in the incomplete first quarter of 1988. No trend over time is evident.
Extrapolation to All Family Planning Clinics According to Bureau of Reproductive Health statistics, a statewide total of 68,644 initial medical examinations at family planning clinics were done in 1988. Of these examinations, 15,112 (22 percent) involved clients at the sentinel clinics. During the first year of the study (beginning in February 1988) 12,575 client specimens were included in the analysis. This is an estimated sampling rate of 83 percent in the sentinel clinics for 1988: 86 percent in New York City, 80 percent in New York State exclusive of New York City. Sentinel clinic clients were more likely to be non-Hispanic Black (36.5 percent) or Hispanic (25.3 percent) than were clients in general (21.2 percent and 13.5 percent, respectively). The age distributions were similar: women under age 25 were 72.3 percent of clients at sentinel clinics and 73.4 percent at all clinics statewide. After adjustments for differences in the racial/ethnic and residence distributions, the extrapolated HIV seroprevalence rates for all family planning clinic clients were: New York City, 0.82 percent; New York State exclusive of New York City, 0.15 percent; and statewide, 0.31 percent.
May 1991, Vol. 81, Supplement
American Journal of Public Health 43
Stiicof, et al. The women who volunteered for this study were not limited to those in the seroprevalence study. Not all sentinel clinics participated, and the extent of participation varied considerably among the participating clinics. For these reasons the results should be considered background information and not interpreted to explain seroprevalence results obtained for the full study population.
Biscussion
Comparison to Newbom Seroprevalence Data Because there were substantial differences between the demographic profiles of family planning clinic clients and those of childbearing women, adjusted seroprevalence rates were calculated using the age, racial/ethnic, and residence distributions of childbearing women as the standard. The adjusted seroprevalence rates were: New York City, 1.53 percent; New York State exclusive of New York City, 0.25 percent; and statewide, 0.92 percent. These figures were 24 to 47 percent higher than the rates for childbearing women in the Newborn HIV Seroprevalence Study: New York City, 1.24 percent; New York State exclusive of New York City, 0.17 percent; and statewide, 0.66 percent.2
Risk Factors Thirty sentinel clinics participated in the voluntary risk assessment study. Risk assessment forms were completed on 44 American Journal of Public Health
6,892 clients, who were generally of the same age (71 percent under age 25) as the whole study population. The risk-assessment group was more likely to reside in New York City and to be non-Hispanic Black (50 percent) or Hispanic (27 percent) than the overall sentinel population. (Of the risk-assessment group 21 percent were non-Hispanic White, and 3 percent were of Other or Unknown race/ ethnicity.) The number and percent of clients in the sentinel clinics admitting to the selected risk factors for HIV infection are presented in Table VII-3. The most frequently reported risk factors were having sex with four or more sex partners in a six-month period, having lived in a highrisk country, having had sex with an intravenous drug user, and having had sex with a bisexual male. Of all the participating clients, 583 (8.46 percent) admitted to at least one of the risk factors. Fifty-nine (11.64 percent) of the pregnant women admitted to at least one risk factor.
Family planning clinics serve predominantlyyoung, sexually active clients. In this study of 41 sentinel clinics, approximately one in 200 clients was infected with HIV. The clinics in this study were not representative of all of the approximately 200 clinics in the state. Sentinel clinics were limited to those that routinely drew blood for syphilis serology on all initial clients. These clinics tended to be in areas with higher syphilis incidence rates and thus potentially higher HIV infection rates. The crude and adjusted HIV seroprevalence rates obtained in this study may overestimate the actual rate for the total family planning clinic population. The true rates are likely to be closer to those found in the Newborn HIV Seroprevalence Study. A slightly low bias in statewide rates may have been introduced by the 896 specimens that were insufficient for testing. These specimens represented clients who resided primarily in New York City (79.7 percent). The 896 clients resembled the entire study group in their age distribution (71.5 percent under age 25) and resembled other New York City clients in their racial/ethnic distribution (non-Hispanic White, 21.0 percent; non-Hispanic Black, 42.5 percent; Hispanic, 34.4 percent; Other, 2.1 percent). After reviewing the results of this and other seroprevalence studies involving New York State residents, the New York State Department of Health required HIV education, counseling, and testing programs as a condition of funding in all publicly subsidized clinics for family planning and prenatal care. Since virtually all women seen in these clinics are sexually active, they are potentially at risk for HIV infection. Knowledge of an individual's HIV infection status is important to prevent transmission, particularly vertical transmission from mother to infant, and to prevent or defer certain complications of HIV infection with early therapeutic intervention.
May 1991, Vol. 81, Supplement
HIV Seroprvalence in Family Pbnning Clinics
In addition to providing HIV counseling and testing, family planning and prenatal care clinics must be prepared to provide or offer referral for care for their HIV-positive clients.
Sumwy In February 1988 the New York State Department of Health initiated a study to determine the prevalence ofHIV antibody in women attending selected, publicly subsidized family planning clinics. During a 26-month study period, 27,549
May 1991, Vol. 81, Supplement
blood specimens were obtained from women having an initial medical exaniination in 41 clinic sites throughout the state. Of these clients 144 (0.52 percent) were seropositive. The HIV seroprevalence rate increasedwith age to a high of 1.56 percent for 831 women ages 35 to 39. The seroprevalence rate for non-Hispanic Black or Hispanic clients (0.76 percent) was about six times the rate fornon-Hispanic Whites (0.13 percent). No overall increasing or decreasingtrend in prevalence ofHIVinfection was detected during the study period. E]
Acknowledgments The authors gratefilly acknowledge the contribution of the clinical and laboratory staff of the participating clinics and laboratories.
References 1. Centers for Disease Control: Interpretation and use of the Western blot assay for serodiagnosis of Human Immunodeficiency Virus type 1 infections. MMWR 1989; 38(suppl S-7):1-7. 2. Novick LF, Glebatis DM, Stricof RL, MacCubbin PA, LessnerL, Berns DS: Newborn seroprevalence study: Methods and results. Am J Public Health 1991; 81(suppl):15-21, Ch II.
American Journal of Public Health 45
