- Email: [email protected]
Publicly funded HIV counseling and testing — United States, 1985–1989
71
ing prevention activities (including school programs emphasizing smoking prevention [5]); state cigarette excise tax rates [2]; and the intensity of tobacco advertising or promotional events sponsored by the tobacco industry [6].
References Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC: Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87. Public Health Rep 1988; 103: 366-75. CDC: Reducing the health consequences of smoking: 25 years of progress - a report of the Surgeon General, 1989. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (CDC)89-841 I. Pierce JP, Fiore MC, Novotny TE, Hatziandreu EJ, Davis RM: Trends in cigarette smoking in the United States: educational differences are increasing. JAMA 1989; 261: 56-60. Fuchs VR: Who Shall Live? Health, Economics, and Social Choice. New York: Basic Books, 1974. CDC: School policies and programs on smoking and
Recent smoking prevention strategies have been directed toward young persons through the school, home, workplace, and community [2]. Life-skills instruction on resisting smoking has been effective in reducing smoking initiation [7]. Data from the BRFSS and National Health Interview Surveys [3] show that educational attainment levels are becoming an increasingly important factor in determining whether young persons smoke; therefore, effective smoking prevention strategies need to be targeted toward children and adolescents in groups with generally low educational attainment.
Publicly
Funded HIV Counseling
*Source: 137-140.
Morbidity
and Mortality
Weekly
programs perHIV-antibody positive. This risk, and site from January
Report
Glynn TJ: Essential prevention programs.
and Testing -
CDC provides support to 63 human immunodeficiency virus (HIV) prevention programs through health departments in 50 states, four cities, seven territories, the District of Columbia, and Puerto Rico. Each calendar quarter, the 63 programs report to CDC aggregate data regarding the number of (1) pretest counseling sessions, HIV-antibody tests, positive tests, and post-test counseling sessions, by type of testing site; (2) HIV-antibody tests and positive tests, by risk exposure category; and (3) HIV-antibody tests and positive tests, by age group, sex, and race/ethnicity. From 1985 through 1989,** the formed approximately 2.5 million tests; 149,639 (6.0%) tests were report summarizes demographic, type data from the 63 programs 1988 through September 1989.
health - United States, 1988. MMWR 1989: 38: 202203. Davis RM: Current trends in cigarette advertising and marketing. N Engl J Med 1987; 316: 725-732.
1990; 39:
**Estimated 12-month total for 1989 based on adjustment data received for January through September.
of
elements of school-based smoking J Sch Health 1989; 59: 181-188.
United States, 1985-1989*
Number and type of testing sites
From January 1988 through September 1989, the number of counseling and testing sites in the 63 programs increased from 1577 to 5013. In 1989, these included 1297 (25.9%) freestanding HIV counseling and testing sites, 877 (17.5%) sexually transmitted diseases (STD) clinics, 633 (12.6%) family-planning clinics, 522 (10.4%) other health department sites, 504 (10.1 olo) prenatal/obstetric clinics, 443 (S.SCro)tuberculosis clinics, 183 (3.7%) private physicians’ offices and clinics, 173 (3.5%) drug-treatment centers, 162 (3.2%) other nonhealth department testing sites, 109 (2.2%) prisons, 29 (0.6%) colleges, and 81 (1.6%) unclassified facilities. Characteristics
of counseling
and testing sites
From January 1988 through September 1989, the 63 programs reported 1,403,240 HIV-antibody tests and 64,347 positive tests (Table I). Of these, freestanding HIV counseling and testing sites and STD clinics together accounted for 916,290
12
Table I. Number and percentage of HIV-positive tests and positive tests at publicly funded sites reported to CDC, by type of test site - United States, January 19?38-September 1989. Test site
No. tested
No. Freestanding site Sexually transmitted diseases clinic Private physician’s office/clinic Family-planning clinic Prison Prenatal/obstetric clinic Other public health department Drug-treatment center College Tuberculosis clinic Other nonhealth department sites Unclassified sites Total’
070
Total HIV positive (Yo) positive (Sro)
3.4
40.1 25.2
50.4 18.6
450 3538 382 3266 1004 610 458 4540 2747
3.5 0.7 6.3 0.8 9.0 5.4 4.1 4.2 4.2 6.3
6.0 4.7 4.0 3.4 2.6 1.3 1.1 0.8 7.7 3.1
4.6 0.7 5.5 0.6 5.1 1.6 1.0 0.7 7.1 4.3
64,347
4.6
100.0
100.0
562,647 353,643
32,440 11,985
84,152 65,838 55,853 41,834 36,198 18,632 14,738 10,974 108,340 43,791
2927
1403,240
Total tests (vo) tests (vo)
HIV positive
5.8
aTotals vary from those in Table II because of variance in reporting by both persons and test sites.
(65.3%) of all tests and 44,425 (69.0%) of all positive tests. Family planning and prenatal/obstetric clinics accounted for 8.1% of all reported tests and 1.3% of positive tests. In contrast, drugtreatment centers and prisons accounted for 5.3% of total tests and 7.1% of positive tests.
Risk category and demographic data Information on self-reported risk category was available for 1,040,392 reported tests (Table II). Of these, seropositivity rates were highest for homosexual/bisexual intravenous-drug users
Table II. Number and percentage of HIV-antibody tests and positive tests at publicly funded sites reported to CDC, by self-reported risk category - United States, January 1988-September 1989. Risk category
No. tested
HIV positive No.
Heterosexuals with reported risk Other heterosexuals, no reported risk Homosexual/bisexual males Heterosexual intravenous drug users (IVDUs) Blood recipients, 1978-1985 Homosexual/bisexual male IVDUs Persons with hemophilia Total, risk reported Total, no risk reported
456,188 302,005 145,745 92,676
Total’
070
Total known tests (%)
Total known HIV positive (070)
43.9 29.0
24,092 10,746
1.7 2.3 16.5 11.6
14.0 8.9
15.0 13.1 45.5 20.3
28,415 13,295 2,068 1,040,392 256,061
647 2274 290 52,956 8126
2.3 17.1 14.0 5.1 3.2
2.7 1.3 0.2 100.0
1.2 4.3 0.6 100.0
1,296,453
61,082
4.7
7953 6954
*Totals vary from those in Table I because of variance in reporting by both persons and test sites.
73
Table III. Number and percentage of HIV-antibody tests and positive tests at publicly funded sites reported to CDC, by race/ethnicity, in comparison with racial/ethnic distribution of U.S. population* United States, January 1988 - September 1989. Race/Ethnicity
No. tested
HIV positive No.
%
Total known tests (o/o)
Total known HIV positive (o/o)
Total U.S. population (%)
White Black Hispanic Asian/Pacific Islander American Indian/ Alaskan Native Total known Unknown
425,130 246,935 71,098 7178
16,587 12,993 6078 150
3.9 5.3 8.6 2.1
56.3 32.7 9.4 1.0
46.2 36.2 16.9 0.4
78.5
4559 754,900 73,947
122 35,930 2641
2.7 4.8 3.6
0.6 100.0
0.3 100.0
0.7 100.0
TotaP
828,847
38,571
4.7
11.4 7.8 1.7
p 1980 U.S. census projected to 1988. bNumber of tests for which some demographic information was given.
(IVDUs) (17.1 Yo), homosexual/bisexual males (16.5%), persons with hemophilia (14.0%), and heterosexual IVDUs (11.6%). These four categories accounted for 24.4% of tests from persons who reported their risk category and 70.6% of all positive tests from the same population. Two groups accounted from 72.9% of tests with a self-reported risk category: (1) 456,188 (43.9%) were from persons categorized as “heterosexuals with reported risk” (including heterosexuals whose sex partners are at risk for of infected with HIV, heterosexuals with multiple sex partners, and heterosexuals with any other factor considered by local health authorities to pose a risk for HIV infection); and (2) 302,005 (29.0%) were from persons classified as “other heterosexual” (primarily heterosexual persons who correctly or incorrectly reported no history of risk behavior or no partners at risk for or infected with HIV) (Table II). These two heterosexual groups had a combined seropositivity rate of 2.0%, yet accounted for 28.1% of reported positive tests for persons whose risk category was reported. For the “heterosexual with reported risk” category, seropositivity rates by reported partner characteristic were: partner infected with HIV, 11.7% (1455/ 12,440); partner with hemophilia, 5.1% (34/667);
IV-drug-using partner, 5.0% (1792136, 167); and bisexual partner, 4.1% (2312/56,830). Of 828,847 tests for which some demographic information was given, race/ethnicity was specified for 754,900 (91.1 Ore).Of tested persons with known raceiethnicity, seropositivity was highest in Hispanics (8.6%) (Table III). When compared to the overall U.S. population, both blacks and overrepresented Hispanics were substantially among HIV-antibody tests and positive tests. Males accounted for 459,046 (55.4%) of the 828,847 tests and 30,758 (79.7%) of all positive tests. Seropositivity in males and females was 6.7% and 2.1070, respectively. Of 735,584 persons for whom age was known, most (73.1 (r/o)tests and most (78.9%) positive tests were from persons aged 20-39 years. Seropositivity rates for persons aged 20-29 and 30-39 years were 3.6% and 6.0070,respectively. Editorial Note: Of all HIV prevention efforts, counseling and testing activities receive the highest level of resource support from CDC. The data reported here indicate a large and increasing demand for HIV counseling and testing in the United States; from January 1988 through Sep-
14
tember 1989, one in 22 persons seeking publicly funded HIV counseling and testing services were confirmed to be infected. Knowledge of HIVinfection status and appropriate counseling can assist persons in initiating changes in behavior that will reduce the risk of infecting others or of becoming infected [ 1,2]. Positive behavioral changes can also occur in the large number of persons who elect not to be tested but who receive risk-reduction counseling. In addition, early detection of HIV infection and referral [3] can lead to optimal medical management and partner notification. Because of duplicate testing, the total number of persons tested and found to be HIV-antibody positive in U.S. publicly funded settings is not known.* However, four publicly funded HIV prevention programs that have monitored repeat tests estimated that 12-30% (mean 23%) of HIVantibody tests and 3-18070 (mean 13%) of positive tests represented previously tested persons (CDC, unpublished data). When these rates are applied to the data reported here, an estimated 2 million persons have been tested since 1985 through publicly funded counseling and testing programs, and 123,000-145,000 persons have been found to be infected. Many of the estimated 1 million HIV-infected persons in the United States remain unaware of *In addition to the tests reported here, a large but unknown number of persons are tested for HIV antibody in hospitals, outpatient medical facilities, physicians’ offices, blood-donation centers, military facilities, and other settings.
their infection [4]. Of persons who are aware of their HIV infection, a substantial proportion had their infection identified in publicly funded counseling and testing programs. To ensure that persons with undetected HIV infection receive appropriate counseling and testing, priorities should include increasing the number of persons, especially those engaging in risk behaviors, who come to the test sites and the number of persons who receive the full range of counseling and testing, referral, and partner notification services. Programs should attempt to maximize the proportion of persons at risk who (1) are offered and receive preset counseling; (2) accept and receive HIV-antibody testing; (3) return for HIV-antibody rest results; (4) are offered and receive post-test counseling; (5) if infected, participate in partner notification; and (6) if infected, are referred for and receive further medical and prevention services. References Cates W Jr, Handsfield HH: HIV counseling and testing: does it work? Am J Public Health 1988; 78: 1533-1534. Stempel RR, Moss AR: A review of studies of behavioral response to HIV-antibody testing among gay men [Poster session]., V International Conference on AIDS. Montreal, June 4Tg, 1989, p. 730. Francis DP, Anderson RE, Gorman ME et al: Targeting AIDS prevention and treatment toward HIV-l infected persons. JAMA 1989; 262: 2572-2576. CDC: Estimates of HIV prevalence and projected AIDS cases: summary of a workshop, October 3 1-November 1, 1989. MMWR 1990,39: 110-112, 117-l 19.
Alcohol-Related Mortality and Years of Potential Life Lost - United States, 1987* Public health problems associated with alcohol use and misuse include mortality from injuries (an outcome of acute exposure to alcohol) and mortality from chronic diseases (an outcome of longterm misuse of alcohol). In 1985, alcohol-related *Source: Morbidity and Mortality Weekly Report 1990; 39: 173-178.
mortality (ARM) for the United States was estimated at 94,768 deaths (University of CaliforniaSan Francisco [UCSF], unpublished data), accounting for 4.5% of deaths from all causes. A study of ARM in 1980 estimated 69,180 such deaths in the United States for that year [l]; however, that estimate was computed using a smaller number of alcohol-related diagnoses. This report
ing prevention activities (including school programs emphasizing smoking prevention [5]); state cigarette excise tax rates [2]; and the intensity of tobacco advertising or promotional events sponsored by the tobacco industry [6].
References Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC: Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87. Public Health Rep 1988; 103: 366-75. CDC: Reducing the health consequences of smoking: 25 years of progress - a report of the Surgeon General, 1989. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (CDC)89-841 I. Pierce JP, Fiore MC, Novotny TE, Hatziandreu EJ, Davis RM: Trends in cigarette smoking in the United States: educational differences are increasing. JAMA 1989; 261: 56-60. Fuchs VR: Who Shall Live? Health, Economics, and Social Choice. New York: Basic Books, 1974. CDC: School policies and programs on smoking and
Recent smoking prevention strategies have been directed toward young persons through the school, home, workplace, and community [2]. Life-skills instruction on resisting smoking has been effective in reducing smoking initiation [7]. Data from the BRFSS and National Health Interview Surveys [3] show that educational attainment levels are becoming an increasingly important factor in determining whether young persons smoke; therefore, effective smoking prevention strategies need to be targeted toward children and adolescents in groups with generally low educational attainment.
Publicly
Funded HIV Counseling
*Source: 137-140.
Morbidity
and Mortality
Weekly
programs perHIV-antibody positive. This risk, and site from January
Report
Glynn TJ: Essential prevention programs.
and Testing -
CDC provides support to 63 human immunodeficiency virus (HIV) prevention programs through health departments in 50 states, four cities, seven territories, the District of Columbia, and Puerto Rico. Each calendar quarter, the 63 programs report to CDC aggregate data regarding the number of (1) pretest counseling sessions, HIV-antibody tests, positive tests, and post-test counseling sessions, by type of testing site; (2) HIV-antibody tests and positive tests, by risk exposure category; and (3) HIV-antibody tests and positive tests, by age group, sex, and race/ethnicity. From 1985 through 1989,** the formed approximately 2.5 million tests; 149,639 (6.0%) tests were report summarizes demographic, type data from the 63 programs 1988 through September 1989.
health - United States, 1988. MMWR 1989: 38: 202203. Davis RM: Current trends in cigarette advertising and marketing. N Engl J Med 1987; 316: 725-732.
1990; 39:
**Estimated 12-month total for 1989 based on adjustment data received for January through September.
of
elements of school-based smoking J Sch Health 1989; 59: 181-188.
United States, 1985-1989*
Number and type of testing sites
From January 1988 through September 1989, the number of counseling and testing sites in the 63 programs increased from 1577 to 5013. In 1989, these included 1297 (25.9%) freestanding HIV counseling and testing sites, 877 (17.5%) sexually transmitted diseases (STD) clinics, 633 (12.6%) family-planning clinics, 522 (10.4%) other health department sites, 504 (10.1 olo) prenatal/obstetric clinics, 443 (S.SCro)tuberculosis clinics, 183 (3.7%) private physicians’ offices and clinics, 173 (3.5%) drug-treatment centers, 162 (3.2%) other nonhealth department testing sites, 109 (2.2%) prisons, 29 (0.6%) colleges, and 81 (1.6%) unclassified facilities. Characteristics
of counseling
and testing sites
From January 1988 through September 1989, the 63 programs reported 1,403,240 HIV-antibody tests and 64,347 positive tests (Table I). Of these, freestanding HIV counseling and testing sites and STD clinics together accounted for 916,290
12
Table I. Number and percentage of HIV-positive tests and positive tests at publicly funded sites reported to CDC, by type of test site - United States, January 19?38-September 1989. Test site
No. tested
No. Freestanding site Sexually transmitted diseases clinic Private physician’s office/clinic Family-planning clinic Prison Prenatal/obstetric clinic Other public health department Drug-treatment center College Tuberculosis clinic Other nonhealth department sites Unclassified sites Total’
070
Total HIV positive (Yo) positive (Sro)
3.4
40.1 25.2
50.4 18.6
450 3538 382 3266 1004 610 458 4540 2747
3.5 0.7 6.3 0.8 9.0 5.4 4.1 4.2 4.2 6.3
6.0 4.7 4.0 3.4 2.6 1.3 1.1 0.8 7.7 3.1
4.6 0.7 5.5 0.6 5.1 1.6 1.0 0.7 7.1 4.3
64,347
4.6
100.0
100.0
562,647 353,643
32,440 11,985
84,152 65,838 55,853 41,834 36,198 18,632 14,738 10,974 108,340 43,791
2927
1403,240
Total tests (vo) tests (vo)
HIV positive
5.8
aTotals vary from those in Table II because of variance in reporting by both persons and test sites.
(65.3%) of all tests and 44,425 (69.0%) of all positive tests. Family planning and prenatal/obstetric clinics accounted for 8.1% of all reported tests and 1.3% of positive tests. In contrast, drugtreatment centers and prisons accounted for 5.3% of total tests and 7.1% of positive tests.
Risk category and demographic data Information on self-reported risk category was available for 1,040,392 reported tests (Table II). Of these, seropositivity rates were highest for homosexual/bisexual intravenous-drug users
Table II. Number and percentage of HIV-antibody tests and positive tests at publicly funded sites reported to CDC, by self-reported risk category - United States, January 1988-September 1989. Risk category
No. tested
HIV positive No.
Heterosexuals with reported risk Other heterosexuals, no reported risk Homosexual/bisexual males Heterosexual intravenous drug users (IVDUs) Blood recipients, 1978-1985 Homosexual/bisexual male IVDUs Persons with hemophilia Total, risk reported Total, no risk reported
456,188 302,005 145,745 92,676
Total’
070
Total known tests (%)
Total known HIV positive (070)
43.9 29.0
24,092 10,746
1.7 2.3 16.5 11.6
14.0 8.9
15.0 13.1 45.5 20.3
28,415 13,295 2,068 1,040,392 256,061
647 2274 290 52,956 8126
2.3 17.1 14.0 5.1 3.2
2.7 1.3 0.2 100.0
1.2 4.3 0.6 100.0
1,296,453
61,082
4.7
7953 6954
*Totals vary from those in Table I because of variance in reporting by both persons and test sites.
73
Table III. Number and percentage of HIV-antibody tests and positive tests at publicly funded sites reported to CDC, by race/ethnicity, in comparison with racial/ethnic distribution of U.S. population* United States, January 1988 - September 1989. Race/Ethnicity
No. tested
HIV positive No.
%
Total known tests (o/o)
Total known HIV positive (o/o)
Total U.S. population (%)
White Black Hispanic Asian/Pacific Islander American Indian/ Alaskan Native Total known Unknown
425,130 246,935 71,098 7178
16,587 12,993 6078 150
3.9 5.3 8.6 2.1
56.3 32.7 9.4 1.0
46.2 36.2 16.9 0.4
78.5
4559 754,900 73,947
122 35,930 2641
2.7 4.8 3.6
0.6 100.0
0.3 100.0
0.7 100.0
TotaP
828,847
38,571
4.7
11.4 7.8 1.7
p 1980 U.S. census projected to 1988. bNumber of tests for which some demographic information was given.
(IVDUs) (17.1 Yo), homosexual/bisexual males (16.5%), persons with hemophilia (14.0%), and heterosexual IVDUs (11.6%). These four categories accounted for 24.4% of tests from persons who reported their risk category and 70.6% of all positive tests from the same population. Two groups accounted from 72.9% of tests with a self-reported risk category: (1) 456,188 (43.9%) were from persons categorized as “heterosexuals with reported risk” (including heterosexuals whose sex partners are at risk for of infected with HIV, heterosexuals with multiple sex partners, and heterosexuals with any other factor considered by local health authorities to pose a risk for HIV infection); and (2) 302,005 (29.0%) were from persons classified as “other heterosexual” (primarily heterosexual persons who correctly or incorrectly reported no history of risk behavior or no partners at risk for or infected with HIV) (Table II). These two heterosexual groups had a combined seropositivity rate of 2.0%, yet accounted for 28.1% of reported positive tests for persons whose risk category was reported. For the “heterosexual with reported risk” category, seropositivity rates by reported partner characteristic were: partner infected with HIV, 11.7% (1455/ 12,440); partner with hemophilia, 5.1% (34/667);
IV-drug-using partner, 5.0% (1792136, 167); and bisexual partner, 4.1% (2312/56,830). Of 828,847 tests for which some demographic information was given, race/ethnicity was specified for 754,900 (91.1 Ore).Of tested persons with known raceiethnicity, seropositivity was highest in Hispanics (8.6%) (Table III). When compared to the overall U.S. population, both blacks and overrepresented Hispanics were substantially among HIV-antibody tests and positive tests. Males accounted for 459,046 (55.4%) of the 828,847 tests and 30,758 (79.7%) of all positive tests. Seropositivity in males and females was 6.7% and 2.1070, respectively. Of 735,584 persons for whom age was known, most (73.1 (r/o)tests and most (78.9%) positive tests were from persons aged 20-39 years. Seropositivity rates for persons aged 20-29 and 30-39 years were 3.6% and 6.0070,respectively. Editorial Note: Of all HIV prevention efforts, counseling and testing activities receive the highest level of resource support from CDC. The data reported here indicate a large and increasing demand for HIV counseling and testing in the United States; from January 1988 through Sep-
14
tember 1989, one in 22 persons seeking publicly funded HIV counseling and testing services were confirmed to be infected. Knowledge of HIVinfection status and appropriate counseling can assist persons in initiating changes in behavior that will reduce the risk of infecting others or of becoming infected [ 1,2]. Positive behavioral changes can also occur in the large number of persons who elect not to be tested but who receive risk-reduction counseling. In addition, early detection of HIV infection and referral [3] can lead to optimal medical management and partner notification. Because of duplicate testing, the total number of persons tested and found to be HIV-antibody positive in U.S. publicly funded settings is not known.* However, four publicly funded HIV prevention programs that have monitored repeat tests estimated that 12-30% (mean 23%) of HIVantibody tests and 3-18070 (mean 13%) of positive tests represented previously tested persons (CDC, unpublished data). When these rates are applied to the data reported here, an estimated 2 million persons have been tested since 1985 through publicly funded counseling and testing programs, and 123,000-145,000 persons have been found to be infected. Many of the estimated 1 million HIV-infected persons in the United States remain unaware of *In addition to the tests reported here, a large but unknown number of persons are tested for HIV antibody in hospitals, outpatient medical facilities, physicians’ offices, blood-donation centers, military facilities, and other settings.
their infection [4]. Of persons who are aware of their HIV infection, a substantial proportion had their infection identified in publicly funded counseling and testing programs. To ensure that persons with undetected HIV infection receive appropriate counseling and testing, priorities should include increasing the number of persons, especially those engaging in risk behaviors, who come to the test sites and the number of persons who receive the full range of counseling and testing, referral, and partner notification services. Programs should attempt to maximize the proportion of persons at risk who (1) are offered and receive preset counseling; (2) accept and receive HIV-antibody testing; (3) return for HIV-antibody rest results; (4) are offered and receive post-test counseling; (5) if infected, participate in partner notification; and (6) if infected, are referred for and receive further medical and prevention services. References Cates W Jr, Handsfield HH: HIV counseling and testing: does it work? Am J Public Health 1988; 78: 1533-1534. Stempel RR, Moss AR: A review of studies of behavioral response to HIV-antibody testing among gay men [Poster session]., V International Conference on AIDS. Montreal, June 4Tg, 1989, p. 730. Francis DP, Anderson RE, Gorman ME et al: Targeting AIDS prevention and treatment toward HIV-l infected persons. JAMA 1989; 262: 2572-2576. CDC: Estimates of HIV prevalence and projected AIDS cases: summary of a workshop, October 3 1-November 1, 1989. MMWR 1990,39: 110-112, 117-l 19.
Alcohol-Related Mortality and Years of Potential Life Lost - United States, 1987* Public health problems associated with alcohol use and misuse include mortality from injuries (an outcome of acute exposure to alcohol) and mortality from chronic diseases (an outcome of longterm misuse of alcohol). In 1985, alcohol-related *Source: Morbidity and Mortality Weekly Report 1990; 39: 173-178.
mortality (ARM) for the United States was estimated at 94,768 deaths (University of CaliforniaSan Francisco [UCSF], unpublished data), accounting for 4.5% of deaths from all causes. A study of ARM in 1980 estimated 69,180 such deaths in the United States for that year [l]; however, that estimate was computed using a smaller number of alcohol-related diagnoses. This report