Populations at Risk

This chapter examines the prevalence rates of HIV infection—that is, the number of people who have the disease in a specified time period versus the total number of people in the population being examined. The prevalence rates are based on surveys of selected segments of the general population and the prevalence rates of people in high-risk groups. These are not absolute numbers. The actual number of cases of HIV infection is likely to be higher than those reported here, since reporting is not universal and, as of June 2005, only thirty-eight U.S. states and the U.S. territories of Guam and the Virgin Islands subscribe to confidential reporting practices. But information on prevalence rates serves as a road map revealing trends and geographical or societal areas of special concern.

INCREASE IN AIDS AMONG HETEROSEXUALS

The increase in the number and proportion of HIV/AIDS cases among heterosexuals signals a major shift in the patterns of the epidemic. In 1997 the Centers for Disease Control and Prevention (CDC) reported that people diagnosed with AIDS who acquired HIV through heterosexual transmission accounted for the largest proportional increase of all cases in the previous year. During 2003, 44,963 new cases of AIDS among adults and adolescents were reported to the CDC. Nineteen percent of these new cases (8,605) were people who reported that their only exposure was through heterosexual contact. (See Table 3.5 in Chapter 3.) In comparison, in 1985 less than 2% of all AIDS cases were attributable to heterosexual transmission.

Between 1997 and 2000 the number of new AIDS cases dropped significantly, and the proportions of those infected in each exposure category also changed. Cases attributed to male-to-male sexual contact (MTM) represented 35% of all cases in 1997 and 1998, dropping to 34% in 1999, 32% in 2000, and 31% in 2001. In 2003 the MTM rate was again 35%. In spite of the decline from the late 1990s, MTM continued to represent the largest proportion (46% in both 2000 and 2001, and 45% in 2003) of cumulative AIDS cases since 1981. Among women, intravenous drug use decreased from 32% of all exposures in 1997 to 25% in 2000 and 20% in both 2001 and 2003. The overall incidence of AIDS based on heterosexual exposure has steadily increased, from 13% in 1997 to 16% in both 2000 and 2001 and then up to 19% in 2003. The proportion of women who contracted AIDS through heterosexual contact remained relatively constant at 38% in 2002 and 37% in 2001. However, in 2003 the proportion increased to 45%.

Risks of Heterosexual Contact

Data reported in 2003 reveal that 15% of adult and adolescent AIDS cases attributed to heterosexual contact resulted from sexual contact with an HIV-infected partner of an unspecified risk category (6,836 out of 44,963). In 2001 the numbers were 5,181 out of 42,983 (12%) and in 2000 4,799 out of 41,960 (11%). The actual number of cases reported during 2003 represents an 8% increase from the number of cases reported during 2001, with the 2001 number representing a 7% increase from the number of cases reported during 2000. A smaller proportion of cases in 2003 (3%, representing 1,462 cases out of 44,963) was attributed to heterosexual contact with an intravenous drug user. The data from 2001 and 2000 were very similar (3.5%, representing 1,486 cases out of 42,983 in 2001, and 3.6%, representing 1,496 cases out of 41,960 in 2000).

During 2000 heterosexual transmission accounted for 2,448 new cases of HIV infection reported among women in the United States, most of whom were African-American (67% ). In 2001 the number of cases rose to 3,071, with African-American women accounting for 65% of cases. In 2003 the number of cases rose again, to 5,234, with African-American women accounting for 44%. (See Table 3.8 in Chapter 3.)

Among heterosexual men, 1,231 cases of HIV were reported in 2000, 1,466 in 2001, and 2,009 in 2003. In 2000, 73% of these men were African-American and 11% were Hispanic. In 2001 the number fell to 68% for African-Americans but rose to 16% for Hispanics. Finally, in 2003 the percentage of heterosexual transmission was 60% for African-Americans (1,212 cases out of 2,009) and 23% (466 cases out of 2,009) for Hispanics. (See Table 4.1.)

INTRAVENOUS DRUG USERS

The National Academy of Sciences (NAS) concluded in a 1995 report to Congress that "the HIV epidemic in this country is now clearly driven by infections occurring in the population of drug users, their sexual partners, and their offspring." During the 1990s the proportions of both HIV infection and AIDS deaths attributable to intravenous drug use (IDU) among adults and adolescents increased. In 1999 IDU was the exposure category for 32% of male and 47% of female AIDS deaths. To offset the rise in IDU-associated HIV infection and AIDS, the NAS urged members of Congress to adequately fund needle exchange programs. Since 1999 the percentage of HIV/AIDS cases attributable to IDU has been steadily decreasing. Of the 22,835 men and 11,561 women reported as HIV-infected during 2003, 11% of men (2,551 cases) and 20% (2,262 cases) of women reported IDU as the sole exposure category. (See Table 3.8 in Chapter 3 and Table 4.1.)

How HIV Is Transmitted through Drug Use

HIV can be transmitted through IDU when the blood of an HIV-infected drug user is transferred to a drug user who is not yet infected with HIV. This transfer occurs almost exclusively through the sharing of injecting equipment, primarily needles and syringes.

Blood makes it into the needle and syringe in two ways. The first occurs when blood is drawn from the syringe to verify that the needle is inside a vein, prior to the injection of the drug. The second occurs following the injection, when the syringe is refilled several times with blood from the vein to "wash out" any heroin, cocaine, or other drug left in the syringe after the first injection. Even the smallest amount of HIV-infected blood left in the syringe can cause the virus to be transmitted to the next user of the contaminated syringe and needle.

Among IDUs the risk of HIV infection increases in proportion to the duration of intravenous drug use. Put another way, the longer the drug use, the greater the risk of infection. Diseases such as hepatitis show this same pattern. Risk also increases with the frequency of needle sharing and intravenous drug use in a geographic area, such as a large city, where there is a high prevalence of HIV infection.

General Trends

Table 3.5 in Chapter 3 shows that, of the cumulative AIDS cases among adults and adolescents reported from 1981 through December 2003 (902,223), 218,196 were attributable to intravenous drug use (24%). Cumulatively, slightly more than 6% (57,998 cases) was attributable to MTM contact in conjunction with intravenous drug use, and an additional 4% (35,078 cases) was the result of heterosexual contact with an IDU.

HIV is also spread among non-IDUs who trade sex for drugs, especially "crack" cocaine, as well as the partners of these users. Those who trade sex for drugs often engage in unprotected sex and have multiple sex partners. People who exchange sex for drugs and have a sexually transmitted disease (STD) that causes ulcers or sores on the genitals, such as syphilis or herpes simplex, are at a higher risk for HIV infection. Drug and/or alcohol users also may be at greater risk for infection because these substances often lessen inhibitions and reduce the reluctance to have unsafe, unprotected sex.

Gender and Racial/Ethnic Differences

Annual adult and adolescent rates for AIDS reported in 2003 were far higher for African-Americans (75.2 per one hundred thousand people) and Hispanics (26.8 per one hundred thousand) than for whites (7.2 per one hundred thousand) and Native Americans/Alaska Natives (10.4 per one hundred thousand). The lowest rates were for Asian-Americans and Pacific Islanders (4.8 per one hundred thousand). (See Table 3.10 in Chapter 3.)

More than 8,500 cases of AIDS reported in 2001 were transmitted by IDUs. In 2001 the number had dropped to slightly less than 7,500. By the end of 2003 this reported number had dropped to 7,128. The number of women acquiring AIDS through intravenous drug use in 2000 (2,609), 2001 (2,212), and 2003 (2,262) was less than the number of women who were infected through heterosexual contact (3,981 in 2000, 4,142 in 2001, and 5,234 in 2003). In 2000, 2001, and 2003 about 19, 16, and 15%, respectively, of AIDS cases reported in males was attributable to IDUs, and approximately another 5% (in 2000, 2001, and 2003) were MTM who also injected drugs. (See Table 3.5 in Chapter 3.)

Of the 855 women who became infected with HIV through intravenous drug use during 2000, 53% were African-American, 38% were white, and 7.5% were Hispanic. In 2001 the number of cases of HIV infection that was attributable to IDU had jumped to 1,097. African-Americans accounted for 52%, whites for 33%, and Hispanics for 14% of these cases. Asian-American/Pacific Islander and Native American/Alaska Native women were more likely to be infected through heterosexual contact. In 2003 the number of cases of HIV infection attributable to IDU had increased still more, to 2,262. African-Americans accounted for 17% (1,277), whites for 29% (557), and Hispanics for 18% (385) of cases. Asian-American/Pacific Islander and Hispanic women were more likely to be infected through heterosexual contact. (See Table 3.8 in Chapter 3.)

In men with HIV infection, intravenous drug use was second only to MTM as a risk factor in 2000, 2001, and 2003. Of IDU-exposed men in 2003, 11% were African-American, 19% were Hispanic, 9% were Native American/Alaska Native, 7% were white, and 5% were Asian-American/Pacific Islander. (See Table 4.1.)

WOMEN AND AIDS

According to the CDC, the proportion of women among AIDS sufferers has increased steadily, from a reported 7% in 1985 to 23% in June 1999. During 2000, 10,459 American women were diagnosed with AIDS. In 2001 and 2003 the number of cases had risen to 11,082 and 11,561, respectively (HIV/AIDS Surveillance Report: Cases of HIV Infection and AIDS in the United States, 2003, vol. 15, Centers for Disease Control and Prevention, 2004).

Fifty-two percent of the 163,396 cumulative 1981–2003 cases among females were associated either directly or indirectly with intravenous drug use. Of those 85,769 cases, 72% (61,621 cases) occurred among female IDUs, and another 28% (24,148 cases) were among women who reported sexual contact with male IDUs. (See Table 3.5 in Chapter 3.)

Racial/ethnic differences among HIV-infected women and their children are striking. Although African-American and Hispanic women comprise about one-quarter of all U.S. women, they account for 78% of all U.S. women diagnosed with AIDS since 1981 (127,915 cumulative cases of 163,396 reported through 2003). (See Table 3.8 in Chapter 3.)

Women can infect their unborn children with HIV in the course of pregnancy, during delivery, or by breastfeeding after birth. The 48% decrease in the number of women who gave birth to HIV-infected babies during the 1990s was largely attributable to the introduction of the antiretroviral drug zidovudine (ZDV; also known as azidothymidine, or AZT). Women of childbearing age can be tested for HIV perinatally (before and during pregnancy), and, if they are positive, have the option of receiving ZDV to prevent passage of the disease to their unborn children.

Along with antiretroviral therapy, which lowers the mother's viral load to undetectable levels, deliveries via elective cesarean section (C-section; the surgical delivery of a baby) rather than vaginal births may also help to reduce mother-to-child transmission. States with HIV case surveillance data are better able to direct resources—targeted public health education programs, health professionals, and prenatal care—aimed at eliminating prenatal (before birth) transmission of HIV.

HIV/AIDS in Women in Small Towns and Rural Areas

Most HIV/AIDS cases occur among women who live in large metropolitan areas with populations of greater than five hundred thousand. However, the number of HIV/AIDS cases is increasing in rural areas, especially through heterosexual transmission. A significant number of the more than eighty-one thousand adult and adolescent women living with AIDS at the end of 2003 live in southern states. Since a large number lived in states that do not have HIV surveillance, it is likely that there are women who have not been tested. As a result, the numbers of HIV-infected women may be an underestimate.

Sexually Transmitted Diseases

Prevention, identification, and prompt treatment of STDs are vitally important for the health of young women. Most HIV cases in young women are spread through heterosexual sex (70,200 of the 163,396 total cases in 2003, representing 43%; see Table 3.8 in Chapter 3), and the increase in STDs parallels that of HIV. For instance, the geographic areas with the highest numbers of cases of syphilis and gonorrhea have the highest incidence of cases of HIV among women of childbearing age.

Women with STDs are more likely to become infected with HIV because they have an increased number of HIV target cells (CD4+ T cells) present in their cervical secretions. These cells facilitate the entrance of HIV into the body. Furthermore, women with STDs are more likely to shed HIV in both ulcer-forming and inflammatory genital secretions. They are also more likely to shed HIV in greater amounts than people infected with HIV alone, which contributes to the spread of HIV. By treating an STD, the shedding of HIV on sexual contact is lessened, which in turn reduces the spread of HIV infection.

MALE TO MALE SEXUAL CONTACT

Referred to in the 2003 CDC survey as male to male sexual contact (MTM), this category was previously designated as men having sex with men (MSM). MTM is still the major risk category for HIV infection, although the increase in the number of cases has slowed steadily over the past few years. Epidemiologists (public health researchers who analyze the extent and types of illnesses in a population and the factors that influence their distribution) believe that HIV/AIDS among MTM may have peaked in 1992.

As of December 2000, 44,467 adult and adolescent males whose only stated mode of exposure to HIV was through MTM contact made up 46% of the 97,712 cumulative male adult and adolescent HIV infection cases. In 2001 the percentage had fallen slightly, to forty-three. But the actual number of cases attributable to MTM had risen to 52,139 out of a total of 120,868. In 2003, 72,745 reported cases of HIV infection were attributable to MTM, representing 48% of the total of 152,739 cases. (See Table 4.1.)

As in previous years, in 2003 MTM contact is the overwhelming mode of exposure and transmission for non-Hispanic white males with or without intravenous drug use (41,048 cumulative cases, representing 65% of the cumulative total). In 2003 approximately 32% of MTM are comprised of African-American, non-Hispanic males, and 37% are comprised of Hispanic males. Homosexual sex is also the leading mode of HIV exposure for these latter groups. Cumulatively through 2003, 46% of all HIV-infected Hispanic males and 38% of all HIV-infected African-American males had MTM contact, with or without intravenous drug use. (See Table 4.1.)

PRISONERS AND AIDS

According to the Bureau of Justice Statistics' HIV in Prisons and Jails, 2002 (Laura M. Maruschak, December 2004), the number of HIV-positive prisoners in federal and state prisons grew at about the same rate from 1991 to 1995 as the overall prison population. Between 1995 and 1999 the number of HIV-positive prisoners grew at a slower rate (6%) than the overall prison population (19%). In 1995, however, the rate of HIV/AIDS cases reported among the U.S. prison population (0.51%) was more than six times the rate of the general U.S. public (0.08%). Though this rate of difference has slowly decreased, by 2002 it was still four times the rate of that for the general public (0.14% for the general U.S. population versus 0.48% for state and federal prisoners). (See Table 4.2.) At the end of 2002 the estimated number of confirmed AIDS cases in U.S. prisons stood at 5,643.

Every year since statistics have been gathered, AIDS-related conditions have been the second-leading cause of death for state prison inmates, behind "illness/natural causes." But the proportion of deaths attributable to AIDS has declined markedly since 1995. That year, out of the total number of inmate deaths in state prisons (3,133), 1,569 (50%) were from natural causes other than AIDS and 1,010 (32% of the total) were from AIDS. But by 2002, of the total number of deaths (3,105), 2,405 (77%) were from natural causes other than AIDS while only 215 (7%) were from AIDS. This remarkable decline in AIDS-related deaths is also reflected by the statistics in the rate of deaths per one hundred thousand inmates. In 1995 the death rate in state prisons due to AIDS was one hundred per one hundred thousand inmates; in 2000 the rate had decreased to seventeen per one hundred thousand. (See Table 4.3.) The sharp drop may be the result of effective treatment with protease inhibitors and combination antiretroviral therapies.

A similar trend is also apparent when the inmate death figures from federal prisons in 2001 and 2002 are examined. Of the total number of inmate deaths in federal prisons in 2001 (303), 247 (82%) were from natural causes other than AIDS, and twenty-two (7%) were from AIDS. By the following year, 289 out of a total of 335

deaths (86%) were from natural causes other than AIDS, while seventeen (5%) were from AIDS. (See Table 4.4.) The decline is more modest than the data for state prisons because the data for federal prisons was compiled over two years instead of seven.

Geographic Differences

At the conclusion of 2002, 23,864 U.S. inmates were confirmed as being infected with HIV, according to the Bureau of Justice Statistics (BJS). This represents 1.9% of the custody population at that time—a decrease from the 2.2% of inmates known to be HIV-infected in 1998. This modest decrease has not been geographically uniform, however. At year end 2002, New York State held a fifth of all inmates (5,000, or 21%) known to be

HIV-positive. In contrast, California held 5% (1,181) of all HIV-positive inmates. (See Table 4.5.)

Gender, Racial, and Age Differences

At the end of 2002 an estimated 5,643 U.S. inmates had confirmed cases of AIDS, according to the BJS. This was a decrease from the estimated 6,809 cases confirmed in 1999.

This decrease was not uniform for males and females. Of the total U.S. prison population in 2002, 3% of female inmates were known to be HIV-positive, in contrast to 1.9% of male inmates. The increased infection rate for females was not mirrored in the number of AIDS-related deaths, however. In state prisons in both 2001 and 2002, the number of male deaths (256 and 236, respectively) was far greater than the number of female AIDS-related deaths (fourteen and nine, respectively). (See Table 4.6.)

BJS statistics from state prisons also reveal age and racial differences. The number of deaths in state prisons in 2001 and 2002 was greatest for thirty-five to forty-four-year-olds (130 and 119, respectively), followed by the forty-five and older age group (ninety-one and ninety-eight, respectively). Fewer deaths were evident in the twenty-five to thirty-four age category (forty-five and twenty-eight, respectively). (See Table 4.6.)

Statistics obtained from local jails reveal similar trends. In 2000, 2001, and 2002 male deaths (fifty-three, fifty-one, and thirty-eight, respectively) greatly exceeded the number of female deaths in the same years (five, four, and four, respectively). The thirty-five to forty-four age group experienced more deaths than the other age groups, and the number of deaths of African-Americans was four to eight times more than that of whites and Hispanics. (See Table 4.7.)

Statistics from 2002 indicate that the current reason for incarceration is not associated with a prisoner's HIV-positive status. But a history of prior drug use is associated with whether or not a prisoner is HIV-positive. Only 0.4% of the 51,248 prisoners who were drug-free were HIV-positive, in contrast to 3.2% of the 66,606 prisoners who had used a needle to inject drugs and 7.5% of prisoners who shared a needle in drug injection. (See Table 4.8.)

Testing Policies in U.S. Prisons

Guidelines for the testing of inmates for HIV exist in all fifty states, the District of Columbia, and the regulations of the Federal Bureau of Prisons. But the timing of

testing varies. As of 2003 nineteen of the fifty-two jurisdictions tested prisoners entering the prison system, and three states plus federal prisons tested prisoners on their release. Forty-five jurisdictions and federal prisons tested prisoners if inmates request a test; forty-five jurisdictions plus federal prisons tested inmates if they display HIV-related symptoms. Forty states and all federal facilities tested prisoners after they have been involved in incidents such as fights, and fifteen states tested inmates who have been classified as "high risk."

The testing guidelines adhere to the policy on management of infectious diseases that is detailed in a 2005 Program Statement (Number P6190.03) of the Department of Justice's Federal Bureau of Prisons. Testing can be performed on a voluntary basis, when requested by an inmate. But if there is concern over the possibility of infection or exposure to HIV, testing is mandatory, and can override inmate objections. All inmates who are tested receive pre- and post-test counseling, even if they test negative. This helps to increase awareness of HIV and AIDS and deter the spread of the infection through inmate populations.

HIV testing of prisoners is controversial in many states because of patient confidentiality laws that require medical test results to be kept secret. In Washington State, concern for prison guards' health prompted the passage of legislation almost a decade ago that allows corrections workers who have been exposed to a prisoner's bodily fluids to find out if that prisoner tested positive for STDs, including HIV.

Drug and Needle Use among Prisoners

Public education campaigns about the "safer" use of drugs and syringes appear to be reducing HIV infection in the general public. In contrast, these measures seem to be having no effect in prisons. Many incarcerated IDUs continue to inject while in prison, often sharing needles because injection equipment is in short supply. Indeed, more than 70% of incarcerated IDUs reported borrowing syringes while in prison. The consequences of this behavior are evident in the high rate of HIV infection among prisoners who shared a needle for drug injection prior to incarceration (7.5%, representing 1,672 of 22,288 HIV-positive inmates, according to BJS statistics from 2002). (See Table 4.8.)

This is a dilemma for prisons, where syringes and needles are prohibited, as are illegal drugs, and chemicals for disinfecting the illicit needles are not readily available to prisoners. While state and federal prison officials in the United States want to stop the spread of HIV among inmates, most cannot keep pace with or stem the flow of illegal drugs into prisons. To minimize the spread of HIV in prisons, countries such as Switzerland and the United Kingdom provide prisoners with disinfectant or clean needles. U.S. officials believe that these actions endorse illegal drug use. Instead, they focus on providing treatment and rehabilitation programs for drug-addicted prisoners.

HEMOPHILIACS

Hemophilia is a group of genetic disorders in which defects in a number of genes located on the X chromosome disrupt the proper clotting of blood. The most common type of hemophilia—hemophilia A—is a deficiency of a clotting substance designated Factor VIII. Varying severities of hemophilia can occur, depending on the level of Factor VIII present in the patient's plasma. Treatment of hemophilia involves close attention to injury prevention and periodic intravenous administration of Factor VIII concentrates, commonly known as clotting factors.

Because screening for HIV antibodies was not available until 1985, many hemophiliacs were exposed to HIV-contaminated blood and clotting factors prior to widespread use of screening procedures. National distribution of clotting factor concentrates prior to 1985 led to a high prevalence of HIV infections among hemophiliacs. The prevalence of HIV infection differs by the type and severity of the coagulation (clotting) disorder.

According to the CDC, as of December 2003, 5,448 adult, adolescent, and pediatric hemophiliacs had been diagnosed with AIDS in the United States, representing 1% of the total AIDS population. While statistics are unavailable, many health officials believe that 70 to 90% of the approximately seventeen thousand Americans with hemophilia A are HIV-positive. The eight thousand or so Americans with the less clinically severe hemophilia B most likely have a lower prevalence rate because they required fewer treatments with the clotting factor and, therefore, were less exposed to HIV-contaminated products. Hemophilia A rates may be overrepresented, according to the CDC, since the studies were performed at hemophilia treatment centers where the more severe hemophilia A cases are likely to be found.

Prior to the 1980s, most hemophiliacs died from intracranial hemorrhage (bleeding within the brain). But by 1995 one-third of all deaths were related to HIV infection while one-fourth were related to hemorrhage. Hemophiliacs often report that virtually all their fellow hemophiliacs are infected with the virus. Many sexual partners of hemophiliacs have also contracted the virus from sexual intercourse. In the case of females, the virus can subsequently be passed to their offspring.

A Slow Reaction

Concentrated clotting factor, which is derived from human blood obtained from as many as two thousand donors, became available in the mid-1970s. Its success at stopping bleeding was so dramatic that hemophilia changed from a disease that produced intense pain, disability, and the possibility of premature death to one that allowed sufferers to lead nearly normal lives. Hemophiliacs could infuse clotting factors into their own veins if they felt bleeding was about to start. Patients were advised by their physicians to "infuse early and often."

Disastrously, during the late 1970s and early 1980s some clotting factor concentrates were infected with HIV. Even after the first cases of HIV/AIDS appeared in people with hemophilia and the CDC, along with the Hemophiliac Foundation, identified this new disease as being blood-borne, physicians did not advise their patients to alter their clotting factor treatments. Hemophiliacs were encouraged to continue using their clotting factor because Hemophilia Foundation officials were not sure there would be a major epidemic.

Anecdotal comments from hemophiliacs indicate that when many of them became infected, primary care doctors were slow to respond and supplied very little information. There was no warning to practice "safe sex" to prevent the spread of HIV. Some hemophiliacs reported receiving more information from gay men's organizations than from their own hematologists (physicians who specialize in diseases and disorders of the blood).

ANGER AND COMPENSATION

Many hemophiliacs feel they are entitled to compensation or, at the very least, assistance in paying their overwhelming medical expenses. They maintain that the companies that produced the clotting factors were slow to warn the public about HIV and slow to use heat treatment to eliminate the live virus from the clotting factors (although this procedure has not gained widespread acceptance among scientists as an adequate method to inactivate HIV).

Hemophilia foundations in some countries have convinced governments or insurance companies to compensate HIV-infected hemophiliacs. Japan agreed to pay $1,500 a month to affected patients; Canada offered each patient a lump sum of $120,000 (although legal arguments have delayed this compensation); Denmark will pay $42,500; and Britain $30,000 a person. France dispenses funds from its $5.5 billion pool to hemophiliacs who were infected with HIV/AIDS because of tainted blood products.

The U.S. government has no plans to compensate people with HIV/AIDS and hemophilia, and in 1995 the U.S. Supreme Court refused to hear a class action suit brought by hemophiliacs against a pharmaceutical company and other blood product manufacturers (Barton v. American Red Cross, 826 F. Supp. 412 and 826 F. Supp. 407. Append 43 F. 3rd 678. Certiori denied 116 S. Ct. 84). Nonetheless, some companies have reached out-of-court settlements with affected people. In May 1996 four manufacturers of blood clotting products offered $640 million to an estimated six thousand people.