Edtorian
The Surveillance Definition for AIDS Throughout the acquired immunodeficiency syndrome (AIDS) epidemic, the Centers for Disease Control, in partnership with state and tenitorial health departments, has made several modifications to the criteria used to conduct AIDS surveillance in the United States. These revisions, the most recent ofwhich was in 1987,1 have reflected advances in the understanding and care of disease caused by human iunodeficiency virus (HIV) infection. In 1991, the Centers for Disease Control issued a proposal to expand the AIDS surveillance definition to include all HIV-infected individuals with severe immunosuppression, as determined by a CD4+ T-lymphocyte count of fewer than 200 cells per microliter (or a CD4+ percentage below 14).2 In this issue of the Journal, Des Jarlais et al. document that this proposal could lead to a substantial increase in the number of H1V-infected drug injectors who meet AIDS surveillance criteria.3 This is an important observation given the controversy that has surrounded the proposed surveillance definition.4 All states and US territories require physicians and other health care providers to report AIDS cases to local or state health departments. In addition, 24 states require reporting of HIV infection at all stages of the infection. Preliminary data from 19 of these states indicate that HIVinfected persons who have not yet developed AIDS-indicator diseases are more likely to be women or Black than are persons reported through AIDS surveillance.5 While this finding could reflect patterns of HIV testing, it may also reflect differences in the evolution of the HIV epidemic among demographic groups. This suggests that revising the AIDS surveillance definition to add earlier stages or more manifestations of HIV infection would affect case reporting among different groups in various ways. Such an outcome was observed when the expansion of AIDS surveillance criteria in 1987 led to increases in the proportion of AIDS reports among women, Blacks, Hispanics, and drug injectors.6 Although reported AIDS cases are not increasing as rapidly as they did during earlier years, AIDS surveillance is demonstrating that cases are increasing more rapidly among Blacks and Hispanics compared with Whites, among women compared with men, among persons infected with HIV through drug injection or het1462 American Journal of Public Health
erosexual contact compared with men infected through homosexual contact, and among residents of the South compared with those of other regions.7 If AIDS surveillance is successftlly describing the course of the epidemic, why revise the surveillance definition? The answer is that advances in the understanding and care of HIV disease have created a need for further revision. Monitoring of CD4+ T-lymphocyte counts has become standard in HV care, enabling physicians to measure directly the immunosuppressive effect of HIV infection. CD4 counts provide the basis for therapies that delay the appearance of AIDS-indicator diseases, and therapies have contributed to the slowed growth in reported AIDS cases.8 In addition, there has been increasing recognition of the wide spectrum of diseases that can occur in association with HIV infection, including infections linked with drug injection and gynecologic conditions.9'10 As a result, current AIDS surveillance is not meeting public health needs to descnrbe the number and characteristics of HIV-infected persons who are severely immunosuppressed, who require close medical follow-up, who are incurring substantial health care costs,11 and who are at high risk for AIDS-indicator and other severe diseases.9 For example, while there are approximately 90 000 persons living with AIDS in the United States, there are an additional 115 000 to 170 000 with severe immunosuppression (CD4 count below 200 cells per microliter) who have not developed AIDS-indicator conditions (John Karon, PhD, Centers for Disease Control, personal communication). Concomitant with a need to expand AIDS surveillance is a need to simplify the surveillance definition to streamline reporting procedures. With more than 47 000 AIDS cases reported in the past 12 months, many health departments are struggling to keep abreast of the demands of maintaining AIDS surveillance. What, then, is the optimal approach to expanding andyet simplifying the AIDS surveillance definition? The approach of adding immunosuppression as an AIDS surveillance criterion has been recommended by the Centers for Disease Control and strongly endorsed by the Association of State and Territorial Health Officers, the Council of State and Territorial Epidemiologists, and the National Alliance of State and Territorial AIDS Di-
rectors for several reasons. Most notably, this expansion would improve the usefulness ofAIDS surveillance in assessing the extent of severe HlV-related immunosuppression and morbidity. The inclusion of a single, direct, and widely used measure of immunosuppressionwould sixmplify AIDS reporting procedures while comprising all diseases in HIV-infected persons with severe immunosuppression. The potential impact of expanded surveillance criteria on AIDS reporting can be measured in HIV-infected populations by exaning the ratio of the number of immunosuppressed individuals who have not developed AIDS-indicator conditions to the number with these conditions. Using this approach, Des Jarlais et al. conclude that the proposed expansion could lead to a three- to fourfold increase in AIDS reports among drug injectors. However, such estimates are highly sensitive to study methods. For example, they will be higher if they are based on an estimate of the total number of immunosuppressed individuals and lower if based on the numberwhose CD4 count has been measured and documented as part of routine HIV care. The former approximates the maximum possible effect of the proposed expansion, while the latter reflects the likely effect given current levels of care access and use. In identifying HIV-infected drug injectors who were actively recruited from drug treatment and outreach programs, Des Jarlais et al.'s approach represents an attempt to identify all immunosuppressed individuals among a group at high risk for HlV infection. In addition, in their count of the number with AIDS-indicator conditions, Des Jarlais et al. excluded those with CD4 counts above 200. As a result, their approach was likely to yield a maximum estimate of the potential impact of the proposed expansion. Similarly, Sheppard et al. noted that the proposed expansion could lead to a threefold increase in prevalent AIDS cases among a careftllly studied group of homosexual and bisexual men in San Francisco.12 In contrast, estimates based on populations already under care for HIV infection are likely to include a greater proportion of persons who have developed AIDS-indicator diseases, yielding lower estimates. For example, based on a review of records from HIV care sites in Editores Note. See related article by Des Jarlais et al. (p 1531) in this issue.
November 1992, Vol. 82, No. 11
Editrias
nine cities,9 the proposed expansion could increase AIDS counts by 50 to 75% in its frst year of implementation, depending on whether prevalent or incident AIDS cases were considered in the denominator ofthe above ratio.13 The finding by Des Jarlais et al. that the proposed expansion could lead to marked increases in AIDS counts among drug injectors is supported by others. In a study of H1V-infected persons receiving care in Baltimore, Stanton et al. observed that persons meeting the expanded surveillance criteria were more likely to be drug injectors and female compared with persons meeting the 1987 surveillance definition.14 (In both cases, odds ratios exceeded 2.0.) In the above project from nine cities, proportionate increases in potential case reports were comparable among drug injectors and homosexual/ bisexual men.13 Short-term effects of a new surveillance definition would be greater than long-term effects. Upon implementation, persons meeting expanded surveillance criteria would include those with prevalent and incident immunosuppression. Ultimately, however, trends would stabilize, and case counts would increase by approximately 5%, reflecting the extent to which HIV-infected persons are diagnosed as being immunosuppressed but die before developing AIDS-indicator diseases.13 In the long term, the main effect of expanded surveillance criteria would be the inclusion of many individuals earlier in the course of HIV infection. An alternative approach to expanding the AIDS surveillance definition would be to add more diseases. A number of potentially severe conditions are relatively common among populations at risk for FHV infection, particularly those populations who are disadvantaged. These conditions include pulmonary tuberculosis (extrapuhmonaiy tuberculosis is a current AIDS-indicator condition) and bacterial infections, which are associated with drug injection, and cervical dysplasia, which is associated with human papillomavirus infection and various markers of sexual activity and which may progress to invasive cancer. These and other diseases may be more frequent or severe when combined with HV-induced immunosuppression and with limited or delayed access to medical care. Clearly, conditions of public health importance that may occur in tandemwith H1V infection need to be effectively monitored. There are various approaches to achieving this objective. For example, the November 1992, Vol. 82, No. 11
interaction between HIV and Mycobacteriwn tuberclasis could be monitored by making coinfections reportable, a step that has been taken in Connecticut (James Hadler, MD, MPH, personal communication). Alternatively, HIV infection or AIDS surveillance procedures could be modified to allow for coreporting of pulmonary tuberculosis, or pulmonary tuberculosis could be included as an AIDSindicator disease. The usefulness of this information would depend on the completeness of follow-up efforts to document the occurrence of tuberculosis during the course of HIV infection. There are two other considerations in regard to adding more diseases to the AIDS surveillance definition. First, compared with the current AIDS-indicator conditions, some of the diseases that have been suggested for inclusion often occur in the absence of HIV infection and are much less specific markers for late-stage HIV disease. Second, the list of severe conditions that may occur in association with HIV infection is lengthy. Adding a long list ofdiseases to the surveillance definition would render that definition unmanageable for its intended purpose; adding just a few diseases, however, would make it necessaxy to articulate why others were being excluded. These and other issues were recently discussed at a public meeting convened by the Centers for Disease Control to consider recommendations to add pulmonary tuberculosis, recurrent bacterial infections, and cervical cancer to the list of AIDS-indicator conditions. AIDS surveillance has been a powerful tool for documenting the impact of the HIV epidemic. In addition, the AIDS surveillance definition has become a focal point for discussion of a broad range of important public health concerns, including the need for physician education regarding the early signs of HIV infection in women, the use of appropriate screening and diagnostic tests during the course of HIV infection, improved access to HIV care services, and additional research on the manifestations of HIV infection in different groups. Rather than depending on surveillance criteria, organizations that provide services to HIV-infected persons should develop eligibility criteria that fit their programs. These concerns relate to the needs of people with all stages of HIV infection, not just those with late-stage disease, regardless of how AIDS is defined. There is also a need to measure the full impact of H1V infection on morbidity and mortality. No surveillance definition
of AIDS will feasibly encompass the full spectrum of HIV-related morbidity, short of defining AIDS as HIV infection itself, and multiple surveillance techniques are needed.15 To be effective, the surveillance definition for AIDS must reflect current knowledge of HIV disease and focus on public health information needs and goals. El James W. Buehkei, AD James W. Buehler is with the National Center for Infectious Disases, Centers for Disease Control, Atlanta, Ga. Requests for reprints should be sent to James W. Buehler, MD, Division of HIV/ AIDS, National Center for Infectious Diseases, Centers for Disease Control, Atlanta, GA 30333.
Acknowledgents The author thanks Drs. Ruth Berkelman, James Curran, and John Ward of the Centers for Disease Control for their thoughtful critique of this editorial.
References 1. Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MAWR 1987;36(suppl 1S):3S-15S. 2. Centers for Disease Control. 1992 revised classification system for HIV infection and expanded AIDS surveillance case definition for adolescents and adults. Draft, issued November 15, 1991. 3. Des Jarlais DC, Wenston J, Friedman SR, et al. Implications of the revised surveillance definition: AIDS among New York City drug users. Am JPublic Health 1992;
82:1531-1533. 4. The CDC's case definition of AIDS: implications of the proposed revisions. Report from a workshop held October 22, 1991; Washington, DC: US Congress, Office of Technology Assessment. 5. Flemming PL, Ward JW, Morgan MW, Hanson IC, Buehler JW, Berkelman RL.
HIV surveillance: implementing reporting of HIV infection in the United States. HIV reports from selected states, through 1991. In: Poster Abstracts, Eighth International Conference on AIDS/Third STD World Congress; July 19-24, 1992; Amsterdam, The Netherlands. Vol 2, abstract PoC4454. 6. Selik RM, Buehler JW, Karon JM, Chamberdand ME, Berkelman RL. Impact of the 1987 revision of the case definition of acquired immune deficiency syndrome in the United States. JAIDS. 1990;3:73-82. 7. Centers for Disase Control. Update: acquired immunodeficiency syndromeUnited States, 1991.MMWR 1992;41:463468. 8. Rosenberg PS, Gail MH, Schrager LK, et al. National AIDS incidence trends and the extent of zidovudine therapy in selected demographic groups. JAIDS. 1991;4:392401. 9. Farizo, KM. Buehler JW, Chamberland ME, et al. Spectrum of disease in persons
American Journal of Public Health 1463
Ed1d.k.
with human immunodeficiencyvirus infection in the United States.JAMA 1992;267: 1798-1805. 10. MinkoffHL, DeHovitzJA. Care of women infectedwith the human immunodeficiency virus. JAMA 1991;266:2253-2258. 11. Hellinger FJ. Assessing the health care costs of the HV epidemic in the United States: 1992-1995. In: Final Program and Oral Abstracts, Eighth Intenational Conference on AIDSfThird STD World Congress; July 19-24, 1992; Amsterdam, The Netherlands. Vol 1, abstract WeC 1033.
12. Sheppard HW, Winkelstein W, Osmond D. Effect of new AIDS case definition among homosexual and biexual men in San Francisco.JAMA. 1991;266:2221. Letter. 13. Buehler J, Farizo K, Berkelman R, et al. Potential impact of new surveillance criteria on AIDS reporting, United States. In: Poster Abstracts, Eighth International Conference on AIDS/Third STD World Congress; July 19-24, 1992; Amsterdam, The Netherlands. Vol 2, abstract PoC4457. 14. Stanton D, Chaisson RE, RuckerS, McAv-
inue S, Moore R, Bardett J. Impact of the 1992 AIDS case definition on the prevalence of AIDS in a clinical setting. In: Poster Abstracts, Eighth International Conference on AIDS/Third STD World Congress; July 19-24, 1992; Amsterdam, The Netherlands. Vol 2, abstract PoC4460. 15. Berkelman RL, Buehler JW, Dondero TJ. Surveillance of acquired immunodeficiency syndrome (AIDS). In: Halperin W, Baker EL, eds. Public Health Swuveillance. NewYork, NY: Van Nostrand Reinhold; 1992:108-120.
Planning 7hemes in the Journal: A Cafffor Papers This annotation introduces a small experiment, an innovation for the Journal. For a number of the issues in each volume, our intention is to plan and announce ahead their themes (the featured topic of each issue). For this purpose, we invite potential authors among our readership to submit papers relevant to the chosen topic by a date far enough ahead to permit review and preparation (see below for topics and dates; for guidelines and submission address, see "WhatAlPHAuthors Should Know" in each issue). In recent volumes, Journal editors have managed with growing frequency to assemble themes out of the material on hand. Readers' response has been positive. Theme issues that have been announced in advance will certainly be more coherent if they attract the number of authors we hope for. They will also enable us to indicate the Journal's interest in neglected areas that authors may not see as high on our agenda. (In general, we suspect that authors tend to submit topics that they recognize are already the domain of a journal. The result is a self-perpetuating cycle difficult to break.) We begin the trial by announcing three themes. The first two deadlines will have a 4-month interval. The third deadline is still to be decided. Until we get a sense of the flow of manuscripts and of the review process entailed, we shall not attempt to set exact publication dates for the theme issues, but we do expect them to be expedited to some degree. With too exiguous a flow, the featured theme may not be realizable. With too full a flow, some papers submitted and publishable may not fit into the single issue and may be deferred. The first three themes and the deadlines for submission are as follows: Children: Societal and Individual Violence, Injury, and Abuse Submirssions due April 1, 1993 Age and Aging: Epidemiology, Health Care, and General Public Health Submissions due August 1, 1993 Primary Care and Public Health Submission date to be announced
1464 American Journal of Public Health
November 1992, Vol. 82, No. 11
The Surveillance Definition for AIDS Throughout the acquired immunodeficiency syndrome (AIDS) epidemic, the Centers for Disease Control, in partnership with state and tenitorial health departments, has made several modifications to the criteria used to conduct AIDS surveillance in the United States. These revisions, the most recent ofwhich was in 1987,1 have reflected advances in the understanding and care of disease caused by human iunodeficiency virus (HIV) infection. In 1991, the Centers for Disease Control issued a proposal to expand the AIDS surveillance definition to include all HIV-infected individuals with severe immunosuppression, as determined by a CD4+ T-lymphocyte count of fewer than 200 cells per microliter (or a CD4+ percentage below 14).2 In this issue of the Journal, Des Jarlais et al. document that this proposal could lead to a substantial increase in the number of H1V-infected drug injectors who meet AIDS surveillance criteria.3 This is an important observation given the controversy that has surrounded the proposed surveillance definition.4 All states and US territories require physicians and other health care providers to report AIDS cases to local or state health departments. In addition, 24 states require reporting of HIV infection at all stages of the infection. Preliminary data from 19 of these states indicate that HIVinfected persons who have not yet developed AIDS-indicator diseases are more likely to be women or Black than are persons reported through AIDS surveillance.5 While this finding could reflect patterns of HIV testing, it may also reflect differences in the evolution of the HIV epidemic among demographic groups. This suggests that revising the AIDS surveillance definition to add earlier stages or more manifestations of HIV infection would affect case reporting among different groups in various ways. Such an outcome was observed when the expansion of AIDS surveillance criteria in 1987 led to increases in the proportion of AIDS reports among women, Blacks, Hispanics, and drug injectors.6 Although reported AIDS cases are not increasing as rapidly as they did during earlier years, AIDS surveillance is demonstrating that cases are increasing more rapidly among Blacks and Hispanics compared with Whites, among women compared with men, among persons infected with HIV through drug injection or het1462 American Journal of Public Health
erosexual contact compared with men infected through homosexual contact, and among residents of the South compared with those of other regions.7 If AIDS surveillance is successftlly describing the course of the epidemic, why revise the surveillance definition? The answer is that advances in the understanding and care of HIV disease have created a need for further revision. Monitoring of CD4+ T-lymphocyte counts has become standard in HV care, enabling physicians to measure directly the immunosuppressive effect of HIV infection. CD4 counts provide the basis for therapies that delay the appearance of AIDS-indicator diseases, and therapies have contributed to the slowed growth in reported AIDS cases.8 In addition, there has been increasing recognition of the wide spectrum of diseases that can occur in association with HIV infection, including infections linked with drug injection and gynecologic conditions.9'10 As a result, current AIDS surveillance is not meeting public health needs to descnrbe the number and characteristics of HIV-infected persons who are severely immunosuppressed, who require close medical follow-up, who are incurring substantial health care costs,11 and who are at high risk for AIDS-indicator and other severe diseases.9 For example, while there are approximately 90 000 persons living with AIDS in the United States, there are an additional 115 000 to 170 000 with severe immunosuppression (CD4 count below 200 cells per microliter) who have not developed AIDS-indicator conditions (John Karon, PhD, Centers for Disease Control, personal communication). Concomitant with a need to expand AIDS surveillance is a need to simplify the surveillance definition to streamline reporting procedures. With more than 47 000 AIDS cases reported in the past 12 months, many health departments are struggling to keep abreast of the demands of maintaining AIDS surveillance. What, then, is the optimal approach to expanding andyet simplifying the AIDS surveillance definition? The approach of adding immunosuppression as an AIDS surveillance criterion has been recommended by the Centers for Disease Control and strongly endorsed by the Association of State and Territorial Health Officers, the Council of State and Territorial Epidemiologists, and the National Alliance of State and Territorial AIDS Di-
rectors for several reasons. Most notably, this expansion would improve the usefulness ofAIDS surveillance in assessing the extent of severe HlV-related immunosuppression and morbidity. The inclusion of a single, direct, and widely used measure of immunosuppressionwould sixmplify AIDS reporting procedures while comprising all diseases in HIV-infected persons with severe immunosuppression. The potential impact of expanded surveillance criteria on AIDS reporting can be measured in HIV-infected populations by exaning the ratio of the number of immunosuppressed individuals who have not developed AIDS-indicator conditions to the number with these conditions. Using this approach, Des Jarlais et al. conclude that the proposed expansion could lead to a three- to fourfold increase in AIDS reports among drug injectors. However, such estimates are highly sensitive to study methods. For example, they will be higher if they are based on an estimate of the total number of immunosuppressed individuals and lower if based on the numberwhose CD4 count has been measured and documented as part of routine HIV care. The former approximates the maximum possible effect of the proposed expansion, while the latter reflects the likely effect given current levels of care access and use. In identifying HIV-infected drug injectors who were actively recruited from drug treatment and outreach programs, Des Jarlais et al.'s approach represents an attempt to identify all immunosuppressed individuals among a group at high risk for HlV infection. In addition, in their count of the number with AIDS-indicator conditions, Des Jarlais et al. excluded those with CD4 counts above 200. As a result, their approach was likely to yield a maximum estimate of the potential impact of the proposed expansion. Similarly, Sheppard et al. noted that the proposed expansion could lead to a threefold increase in prevalent AIDS cases among a careftllly studied group of homosexual and bisexual men in San Francisco.12 In contrast, estimates based on populations already under care for HIV infection are likely to include a greater proportion of persons who have developed AIDS-indicator diseases, yielding lower estimates. For example, based on a review of records from HIV care sites in Editores Note. See related article by Des Jarlais et al. (p 1531) in this issue.
November 1992, Vol. 82, No. 11
Editrias
nine cities,9 the proposed expansion could increase AIDS counts by 50 to 75% in its frst year of implementation, depending on whether prevalent or incident AIDS cases were considered in the denominator ofthe above ratio.13 The finding by Des Jarlais et al. that the proposed expansion could lead to marked increases in AIDS counts among drug injectors is supported by others. In a study of H1V-infected persons receiving care in Baltimore, Stanton et al. observed that persons meeting the expanded surveillance criteria were more likely to be drug injectors and female compared with persons meeting the 1987 surveillance definition.14 (In both cases, odds ratios exceeded 2.0.) In the above project from nine cities, proportionate increases in potential case reports were comparable among drug injectors and homosexual/ bisexual men.13 Short-term effects of a new surveillance definition would be greater than long-term effects. Upon implementation, persons meeting expanded surveillance criteria would include those with prevalent and incident immunosuppression. Ultimately, however, trends would stabilize, and case counts would increase by approximately 5%, reflecting the extent to which HIV-infected persons are diagnosed as being immunosuppressed but die before developing AIDS-indicator diseases.13 In the long term, the main effect of expanded surveillance criteria would be the inclusion of many individuals earlier in the course of HIV infection. An alternative approach to expanding the AIDS surveillance definition would be to add more diseases. A number of potentially severe conditions are relatively common among populations at risk for FHV infection, particularly those populations who are disadvantaged. These conditions include pulmonary tuberculosis (extrapuhmonaiy tuberculosis is a current AIDS-indicator condition) and bacterial infections, which are associated with drug injection, and cervical dysplasia, which is associated with human papillomavirus infection and various markers of sexual activity and which may progress to invasive cancer. These and other diseases may be more frequent or severe when combined with HV-induced immunosuppression and with limited or delayed access to medical care. Clearly, conditions of public health importance that may occur in tandemwith H1V infection need to be effectively monitored. There are various approaches to achieving this objective. For example, the November 1992, Vol. 82, No. 11
interaction between HIV and Mycobacteriwn tuberclasis could be monitored by making coinfections reportable, a step that has been taken in Connecticut (James Hadler, MD, MPH, personal communication). Alternatively, HIV infection or AIDS surveillance procedures could be modified to allow for coreporting of pulmonary tuberculosis, or pulmonary tuberculosis could be included as an AIDSindicator disease. The usefulness of this information would depend on the completeness of follow-up efforts to document the occurrence of tuberculosis during the course of HIV infection. There are two other considerations in regard to adding more diseases to the AIDS surveillance definition. First, compared with the current AIDS-indicator conditions, some of the diseases that have been suggested for inclusion often occur in the absence of HIV infection and are much less specific markers for late-stage HIV disease. Second, the list of severe conditions that may occur in association with HIV infection is lengthy. Adding a long list ofdiseases to the surveillance definition would render that definition unmanageable for its intended purpose; adding just a few diseases, however, would make it necessaxy to articulate why others were being excluded. These and other issues were recently discussed at a public meeting convened by the Centers for Disease Control to consider recommendations to add pulmonary tuberculosis, recurrent bacterial infections, and cervical cancer to the list of AIDS-indicator conditions. AIDS surveillance has been a powerful tool for documenting the impact of the HIV epidemic. In addition, the AIDS surveillance definition has become a focal point for discussion of a broad range of important public health concerns, including the need for physician education regarding the early signs of HIV infection in women, the use of appropriate screening and diagnostic tests during the course of HIV infection, improved access to HIV care services, and additional research on the manifestations of HIV infection in different groups. Rather than depending on surveillance criteria, organizations that provide services to HIV-infected persons should develop eligibility criteria that fit their programs. These concerns relate to the needs of people with all stages of HIV infection, not just those with late-stage disease, regardless of how AIDS is defined. There is also a need to measure the full impact of H1V infection on morbidity and mortality. No surveillance definition
of AIDS will feasibly encompass the full spectrum of HIV-related morbidity, short of defining AIDS as HIV infection itself, and multiple surveillance techniques are needed.15 To be effective, the surveillance definition for AIDS must reflect current knowledge of HIV disease and focus on public health information needs and goals. El James W. Buehkei, AD James W. Buehler is with the National Center for Infectious Disases, Centers for Disease Control, Atlanta, Ga. Requests for reprints should be sent to James W. Buehler, MD, Division of HIV/ AIDS, National Center for Infectious Diseases, Centers for Disease Control, Atlanta, GA 30333.
Acknowledgents The author thanks Drs. Ruth Berkelman, James Curran, and John Ward of the Centers for Disease Control for their thoughtful critique of this editorial.
References 1. Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MAWR 1987;36(suppl 1S):3S-15S. 2. Centers for Disease Control. 1992 revised classification system for HIV infection and expanded AIDS surveillance case definition for adolescents and adults. Draft, issued November 15, 1991. 3. Des Jarlais DC, Wenston J, Friedman SR, et al. Implications of the revised surveillance definition: AIDS among New York City drug users. Am JPublic Health 1992;
82:1531-1533. 4. The CDC's case definition of AIDS: implications of the proposed revisions. Report from a workshop held October 22, 1991; Washington, DC: US Congress, Office of Technology Assessment. 5. Flemming PL, Ward JW, Morgan MW, Hanson IC, Buehler JW, Berkelman RL.
HIV surveillance: implementing reporting of HIV infection in the United States. HIV reports from selected states, through 1991. In: Poster Abstracts, Eighth International Conference on AIDS/Third STD World Congress; July 19-24, 1992; Amsterdam, The Netherlands. Vol 2, abstract PoC4454. 6. Selik RM, Buehler JW, Karon JM, Chamberdand ME, Berkelman RL. Impact of the 1987 revision of the case definition of acquired immune deficiency syndrome in the United States. JAIDS. 1990;3:73-82. 7. Centers for Disase Control. Update: acquired immunodeficiency syndromeUnited States, 1991.MMWR 1992;41:463468. 8. Rosenberg PS, Gail MH, Schrager LK, et al. National AIDS incidence trends and the extent of zidovudine therapy in selected demographic groups. JAIDS. 1991;4:392401. 9. Farizo, KM. Buehler JW, Chamberland ME, et al. Spectrum of disease in persons
American Journal of Public Health 1463
Ed1d.k.
with human immunodeficiencyvirus infection in the United States.JAMA 1992;267: 1798-1805. 10. MinkoffHL, DeHovitzJA. Care of women infectedwith the human immunodeficiency virus. JAMA 1991;266:2253-2258. 11. Hellinger FJ. Assessing the health care costs of the HV epidemic in the United States: 1992-1995. In: Final Program and Oral Abstracts, Eighth Intenational Conference on AIDSfThird STD World Congress; July 19-24, 1992; Amsterdam, The Netherlands. Vol 1, abstract WeC 1033.
12. Sheppard HW, Winkelstein W, Osmond D. Effect of new AIDS case definition among homosexual and biexual men in San Francisco.JAMA. 1991;266:2221. Letter. 13. Buehler J, Farizo K, Berkelman R, et al. Potential impact of new surveillance criteria on AIDS reporting, United States. In: Poster Abstracts, Eighth International Conference on AIDS/Third STD World Congress; July 19-24, 1992; Amsterdam, The Netherlands. Vol 2, abstract PoC4457. 14. Stanton D, Chaisson RE, RuckerS, McAv-
inue S, Moore R, Bardett J. Impact of the 1992 AIDS case definition on the prevalence of AIDS in a clinical setting. In: Poster Abstracts, Eighth International Conference on AIDS/Third STD World Congress; July 19-24, 1992; Amsterdam, The Netherlands. Vol 2, abstract PoC4460. 15. Berkelman RL, Buehler JW, Dondero TJ. Surveillance of acquired immunodeficiency syndrome (AIDS). In: Halperin W, Baker EL, eds. Public Health Swuveillance. NewYork, NY: Van Nostrand Reinhold; 1992:108-120.
Planning 7hemes in the Journal: A Cafffor Papers This annotation introduces a small experiment, an innovation for the Journal. For a number of the issues in each volume, our intention is to plan and announce ahead their themes (the featured topic of each issue). For this purpose, we invite potential authors among our readership to submit papers relevant to the chosen topic by a date far enough ahead to permit review and preparation (see below for topics and dates; for guidelines and submission address, see "WhatAlPHAuthors Should Know" in each issue). In recent volumes, Journal editors have managed with growing frequency to assemble themes out of the material on hand. Readers' response has been positive. Theme issues that have been announced in advance will certainly be more coherent if they attract the number of authors we hope for. They will also enable us to indicate the Journal's interest in neglected areas that authors may not see as high on our agenda. (In general, we suspect that authors tend to submit topics that they recognize are already the domain of a journal. The result is a self-perpetuating cycle difficult to break.) We begin the trial by announcing three themes. The first two deadlines will have a 4-month interval. The third deadline is still to be decided. Until we get a sense of the flow of manuscripts and of the review process entailed, we shall not attempt to set exact publication dates for the theme issues, but we do expect them to be expedited to some degree. With too exiguous a flow, the featured theme may not be realizable. With too full a flow, some papers submitted and publishable may not fit into the single issue and may be deferred. The first three themes and the deadlines for submission are as follows: Children: Societal and Individual Violence, Injury, and Abuse Submirssions due April 1, 1993 Age and Aging: Epidemiology, Health Care, and General Public Health Submissions due August 1, 1993 Primary Care and Public Health Submission date to be announced
1464 American Journal of Public Health
November 1992, Vol. 82, No. 11
