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Chapter 5: Maine Epidemiological Profile
The following epidemiological profile describes HIV and AIDS prevalence and incidence, as well as discussing overall Maine demographic characteristics. In this way, it is hoped that readers may gain an understanding of the epidemic and how it affects Maine people in the unique context of our State. The information outlined in this profile is also provided to CPG members when they consider both populations at risk and interventions to serve those populations.
Unlike past years, this chapter does not include the descriptions of specific populations at risk. Instead, epidemiological characteristics are inserted within each one of the prioritized Population Descriptions, found in Chapter 7. This change was made in an attempt to more clearly link populations at risk with related epidemiological information.
5.1 Maine Demographic Characteristics
Maine, is a large, rural, and relatively poor state. Within Maine there are dramatic variations in population density, socioeconomic conditions, and community resources. A synopsis of selected state population characteristics, much of it abstracted from the 1990 Census, follows:
5.1.1 Rural vs. Urban Residence
Fifty-five percent of Maine's 1,227,000 residents live in rural communities, compared to 25% for the U.S. population as a whole. Approximately one-third of the population lives in one of the three metropolitan statistical areas (MSA's), in and surrounding Portland, Lewiston, and Bangor. The Portland MSA is the state's largest with 222,000 persons,.
The majority of Mainers, almost two-thirds of the population, live along the I-95 corridor and on the coast. But vast areas of western, northern and downeast Maine are thinly populated, and distances to Maine cities from some rural communities are considerable. With 37 persons per square mile, Maine is the least densely populated state east of the Mississippi. Access to medical care and social services from many areas can be difficult. Despite the large rural population of the state, just under 3% of the workforce is employed in agriculture, forestry and fishing.
5.1.2 Race, Ethnicity, Culture, and Language
The proportion of non-white and Hispanic residents is small, less than 2% in total. Of 1,227,928 residents counted in the 1990 Census, 5,138 (0.4%) were black, 5,998 (0.5%) were American Indian, Aleut, or Eskimo, and 6,683 (0.5%) were Asian or Pacific Islander. Hispanic residents, 6,829 persons, constituted 0.6% of the population.
While there is geographic variability in the proportion of non-white and Hispanic residents in cities and counties, there are few identifiable areas of high minority population concentration. Among American Indians in Maine, fewer than thirty percent live on the reservations of the state's five tribes.
A cultural issue of interest (though one that has not been well-defined in terms of its public health ramifications), is the relatively high proportion of Franco-Americans living in the state. Data from the 1990 Census indicates that French and French-Canadian ancestry represents 22% of all ancestries reported by Maine residents, compared to 4% for the nation as a whole, and 14% for all of New England. Some cities (Biddeford and Lewiston, among others) and areas of Northern Maine have significantly greater proportions of Franco-American residents. Considerations of culture, socioeconomic status, and religion among Franco-Americans may influence approaches to prevention.
The proportion of Mainers native to their state of residence (71%) is slightly higher than that seen nationally (67%). While a relatively small proportion of persons over age five (1.8% compared to 6.1% nationally) report "not speaking English very well," the absolute number (27,759) should be of some concern to prevention workers. In addition, over 7,000 residents are foreign-born persons who entered the U.S. after 1980; cultural and language issues must also be considered here.
5.1.3 Socioeconomic Characteristics
As of 1996, 11.2% of Maine residents were living below the poverty line (U.S.: 13.7%). At the same time, reported per capita income ($19,590) compares poorly to the U.S. reported per capital income ($22,713). The 1990 U.S. Census indicates that, among families with young children headed by women, poverty rates are significantly higher in Maine (63%) than for the U.S. (57%), and in some counties (Androscoggin: 73%) are higher still.
Educational attainment rates in Maine are similar to those for the U.S. as a whole (proportion of adults who are high school graduates: 79% for Maine, 75% U.S.) but vary widely inside the state (Cumberland County: 85%, Androscoggin County: 72%).
In comparison with the rest of the U.S., Maine's population may be considered relatively rural, poor, and racially homogeneous. At the same time, there is tremendous variability in demographic characteristics among counties, regions, and towns. The large size of the state presents limited access to services for a rural population scattered in areas remote from the more urban central and southern metropolitan communities.
Maine's relatively small, scattered racial and ethnic minority populations present difficulties for focused minority outreach efforts. In addition, a small but significant population of recent immigrants and non-English speakers must be considered in prevention activities.
5.2 HIV/AIDS in Maine
Through the end of 1998, 840 Maine AIDS diagnoses had been reported to the Bureau of Health. An estimated 950-1,300 persons in the state are believed to be living with HIV infection. The following pages describe sources of information about HIV and AIDS, show recent AIDS and HIV incidence, and give summary information about populations most affected.
Detailed epidemiological information pertaining to each prioritized population is included within the Population Descriptions found in Chapter 7.
5.2.1 Sources of Information about HIV and AIDS in Maine
Data for assessing the HIV epidemic in Maine comes from a number of sources. These include the following:
physician AIDS case reports;
reports of HIV infection from physicians and Anonymous HIV Testing and Counseling sites;
blinded HIV seroprevalence surveys conducted in STD clinic patients;
hospital discharge data;
HIV screening of Maine military recruits and blood donors; and
laboratory reports to the Bureau of Health of positive HIV tests and CD4 counts.
Additional information important to assessing the state of the epidemic in Maine includes reports of other sexually transmitted infections and Hepatitis B infection. None of these data sources alone provide a comprehensive picture of the epidemic in Maine. Collectively, however, they can provide at least the outline of current conditions and a sense of the direction in which the epidemic is going.
5.2.2 AIDS Data
Communicable disease reporting rules for the state of Maine require health professionals to report all AIDS diagnoses to the Bureau of Health. The information reported is considered highly confidential and epidemiologic data is released to the public only after it is determined that it cannot be used to directly or indirectly identify any individual. AIDS case reports include information on age, sex, race, HIV risks, town of residence and place of diagnosis as well as clinical data including CD4 count (a marker of the strength of a person's immune system).
The principal advantages of AIDS case data involve reliability and consistency (most persons with AIDS seek medical care and physicians report most AIDS cases) as well as the level of detail that is provided. A concerted effort is made to collect accurate and complete information. But AIDS case report data also has several important limitations:
AIDS statistics include data only on those individuals whose clinical conditions meet the CDC AIDS Case Definition. Most cases are defined on the basis of a CD4 count of less than 200 in the setting of an HIV diagnosis. Therefore, AIDS case reports do not include persons with HIV infection who are asymptomatic.
Persons with AIDS who reside in Maine, but were diagnosed with AIDS while living in another state, are not included in these statistics. Therefore the report statistics underestimate the actual number of persons living in Maine with AIDS.
Because the incubation period for AIDS is fairly long--often 10 or more years from infection until the onset of AIDS-defining illness--it has a limited value in telling us about recent patterns of HIV transmission.
AIDS Case Reports
Through December 1998, 840 AIDS cases had been reported to the Bureau of Health, with 462 deaths. Thirty-three cases, including 26 men and 7 women, were reported from January to December, 1998. 1998 case demographics are described below:
Transmission Risk: Of the 840 cases of AIDS reported to the Bureau of Health through December 1998, risk for HIV transmission is as follows: Men Who Have Sex with Men: 555 cases (66% of total); Injecting Drug Users: 95 (11%); Men Who Have Sex with Men and Inject Drugs: 28 (3%); Hemophilia/Coagulation Disorder: 25 (3%); Heterosexual Cases: 65 (8%); Recipients of Transfusion / Blood Components: 9 (1%); Child of parent with HIV: 8 (1%); Risk Unknown: 55 (7%)
As in past years, the majority of new AIDS diagnoses were among men who have sex with men (MSM), who comprise 18 of 33 cases reported in 1998. Other transmission categories include: heterosexual transmission (6 cases), injecting drug use (3 cases), and one case attributed to treatment for hemophilia
Race: For the 840 cumulative AIDS cases reported in Maine, 94% are White. Other races represented include Black (3%), Hispanic (2%), American Indians (1%) and Asians (<1%).
For the 33 cases in 1998, one Black, one Hispanic and one American Indian/Alaskan Native case were reported. Race was identified as White for the remaining 30 (91%) diagnoses in 1998.
AIDS Trends by Region and Metropolitan Residence: During the mid-1980's, the majority of persons diagnosed with AIDS in Maine lived in southern Maine. AIDS incidence has increased in all regions, but since 1990 half of all new cases were living outside of the southern part of the state at the time of their diagnosis. Similarly, more recently diagnosed individuals are much more likely to be living in a community outside of the state's three metropolitan areas.
Despite this trend, the cumulative AIDS incidence rate continues to highest in Cumberland county and for the city of Portland located therein. Portland has a rate almost five times that of the cumulative rate for Maine as a whole, and almost three times the rate for Lewiston, the city with the second highest cumulative incidence
For diagnoses reported during 1998, 12 cases (36%) were diagnosed among residents of southern Maine, nine cases (27%) in central Maine and 12 (36%) cases in northern Maine.
Pediatric HIV/AIDS: There is a relatively low incidence of pediatric (<13 years at diagnosis) AIDS in Maine, with a cumulative total of 10 reported cases since 1984 and 1996, and no cases reported after 1996. Most cases of pediatric AIDS in the United States are related to perinatal transmission (transmission from infected mother to child during pregnancy or delivery) in which the mother has an HIV risk related to injecting drug use or sexual contact with a male injecting drug user. The fact that there are relatively low levels of injecting drug use in Maine may explain why there are low pediatric AIDS incidence rates in Maine relative to southern New England and the Middle Atlantic states.
Decline in AIDS Morbidity and Mortality: Nationally, There has been a marked decrease in the number of new AIDS cases and deaths due to AIDS. During 1997, for example, more than 50% fewer AIDS deaths were reported than in 1995. This is due in large part to improvements and availability of medical treatments, which often allow for both dramatic recovery from, and prevention of, AIDS-related illness.
Maine mirrors this national trend. The following graph shows Maine AIDS cases and deaths reported from 1984 through 1998. Since 1995, both AIDS diagnoses and deaths have declined in this state: in 1995, 112 new cases were diagnosed; in 1997, the number of new cases had declined to only 36 cases. Likewise, deaths decreased from 70 in 1995 to 20 in 1997.
5.2.3 HIV Data
Maine physicians and laboratories are required to report new cases of HIV infection diagnosis to the Bureau of Health, currently without name or other patient identifiers. Demographic and risk data is collected for these cases, but little denominator information is available. Starting July 1, 1999, providers will be required to report positive HIV tests using either patient name or a patient identifier code. This new reporting method will make HIV data more useful, and prevent duplicate reporting.
While reviewing HIV testing data, it is important to understand that persons testing HIV positive are unlikely to be a representative sample of all persons with HIV infection, many of whom have not been tested. Accordingly, both the number of positive tests and the risk and demographic characteristics should be considered cautiously. For this reason, cumulative totals of HIV-positive tests are not discussed in this epidemiological profile; only HIV-positive tests reported during 1998 are highlighted below.
Transmission Risk: Thirty-two positive HIV antibody test results were reported to the Bureau of Health during 1998. Twenty-nine were male, 3 were female. The primary risk for transmission of those receiving positive results during 1998 is as follows: men who have sex with men (MSM): 14 (44%); heterosexual contact: 12 (38%); injecting drug users (IDU): 4 (13%); MSM and IDU combined risk: 1 (3%); transfusion recipient: 1 (3%).
Race/Ethnicity: Twenty-nine individuals testing positive (91%) in 1998 were white, 1 person was Black, 1 person was Hispanic and 1 person was American Indian/Alaskan Native.
Region: Forty-eight percent of those testing positive during 1998 lived in southern Maine. Another 29% lived in central Maine and 23% were from the northern part of the state.
Decline in Number of Positive Tests: Overall, the number of people testing positive in 1998 represents a decline in comparison with recent years; for example, 89 people tested positive in 1996, 68 in 1995, and 70 people during 1994. Maine has seen a steady decline in the number of people testing positive since the late 1980s. During 1997, 48 positive HIV antibody tests were reported to the Bureau of Health. The number of specimens tested has remained largely constant and the reason for this trend is unclear, although it may be due to the fact that fewer at-risk people are currently seeking testing.
Estimates of the Number of Persons with HIV Living in Maine
A recent analysis of state and national surveillance data suggests that there are approximately 950-1,300 persons living with HIV in Maine. The data available is not sufficient to arrive at a meaningful estimate of the distribution of those numbers in specific areas or populations within Maine.
5.2.4 Other Sources of HIV/AIDS Data
Military Recruit Data
Since screening was initiated in 1985, only one of 30,000 (<0.01%) Maine resident recruits has tested HIV+. The national average has been .09%. Military recruits are less likely than other adolescents and young adults to have high risks for HIV.
HIV Seroprevalence among STD Clinic Patients
Since 1990, blinded HIV seroprevalence surveys (conducted among patients treated for non-HIV related STD's at three municipal clinics) have shown an overall mean seropositivity of 0.4% (range by year: 0%-0.8%) in a predominantly urban, male clinic population. The rates have been highest among self-identified gay and bisexual men, and in patients over age 30. There has been no significant trend in seropositivity from 1990 - 1998.
The population surveyed under-represents women and may also under represent gay men. At the same time, this population may be at an increased HIV risk because of the fact that they are being treated or evaluated for another sexually transmitted disease.
While the surveys do not have the statistical power to detect subtle changes and provide a very limited view of the populations at high HIV risk, they may provide a reasonable sentinel for large increases in HIV prevalence among sexually active urban poor and working class heterosexuals.
5.3 Sexually Transmitted Diseases Other Than HIV
In 1998, there were 1,073 cases of chlamydia, 67 cases of gonorrhea and one (1) case of secondary syphilis. Maine has one of the lowest rates for gonorrhea and syphilis incidence in the United States. Likewise, there has been a more than 60% decrease in all three diseases between 1990 and 1998.
As the above figures show, infection with Chlamydia is the most commonly reported sexually transmitted disease in Maine. High Chlamydia rates among Maine teenage girls are of particular concern. Forty-five percent of female chlamydia infections were reported among females between 15 and 19 years old.
Recent scientific evidence shows a strong link between infection with a sexually transmitted disease and HIV transmission. STD infection leads to both increased susceptibility for acquiring HIV and increased infectiousness as well, meaning that it is more likely both to infect someone else or become infected with HIV if one is already infected with another STD. Some reports show that STD's increase the risk of HIV transmission by two- to four-fold.
Through a variety of data sources, a general picture emerges of the shape and direction of the HIV epidemic in Maine. Though AIDS cases and deaths and HIV-positive tests reports continue to decline in the state, several key populations continue to be disproportionately affected. These include males who have sex with males, injection drug users, women, people of color and youth. Epidemiological information about these specific groups is shared later in the document, in Chapter 7. Information about the CPG priority population “Other At-Risk Populations with Special Needs” is also presented, although there is a paucity of data about this group.
In addition, recent cases of AIDS and HIV infection are well-diffused throughout the state, and have occurred in both urban and rural areas.
It is important to remember that the HIV epidemic is complex and dynamic and that there are limitations to the data; our inability to adequately characterize “special need” populations is one such limitation.Persons working for HIV prevention and planning in Maine should review and discuss the available epidemiological information and seek consultation with the HIV/AIDS Surveillance Office as the need arises. A focused prevention approach, such as the one advocated by the Maine CPG, should improve our ability to intervene effectively.
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