Minnesota Treatment Cascade for People
Living with HIV/AIDS
April 2015
STD/HIV/TB Section
Infectious Disease Prevention, Epidemiology and Control Division
P.O. Box 64975, St. Paul, MN 55164-0975
651-201-5414
www.health.state.mn.us
Introduction
As part of the National HIV/AIDS Strategy for the United States, the Minnesota
Department of Health (MDH) has calculated an HIV treatment cascade using HIV surveillance
data. These calculations help us better understand the HIV epidemic and the disparities that exist
in delivery of care among HIV positive people in Minnesota.
Data Source
In Minnesota, laboratory-confirmed infections of human immunodeficiency virus (HIV)
are monitored by MDH through an active and passive surveillance system. State rules
(Minnesota Rule 4605.7040) require both physicians and laboratories to report all cases of HIV
infection (HIV or AIDS) directly to the MDH. Additionally, regular contact is maintained with
several clinical sites to ensure completeness of reporting. In June 2011, an amendment to the
communicable disease reporting rule was passed, requiring the report of all CD4 and viral load
(VL) test results.
Data in this report include cases diagnosed with HIV infection 1 as of December 31, 2013
and alive at year-end 2014 and reported to the MDH as of April 8th, 2015.
Data Limitations
Laboratory data are used as a proxy for a care visit to calculate each segment of the
treatment cascade, which may underestimate the true value of engagement in care. The accuracy
of the cascade depends on complete reporting of laboratory results.
1
HIV (non-AIDS) or AIDS at first report.
MINNESOTA HIV/AIDS SURVEILLANCE SYSTEM
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Definitions of measures used in Minnesota’s Treatment Cascade
People Living with HIV/AIDS (Diagnosed Prevalence)
CDC estimates that between 18% and 20% of HIV infected individuals are not diagnosed
and includes this estimate in the national treatment cascade. 2 CDC recommends for local
adaptations of the treatment cascade to use the diagnosed prevalence as the estimate for people
living with HIV/AIDS within their jurisdiction. This does not include an estimate of the
proportion of people living with undiagnosed HIV infection. Therefore Minnesota’s treatment
cascade is not a direct comparison to other cascades that include an estimate of positive persons
with unknown status.
To calculate the diagnosed prevalence used in this cascade, surveillance data were used to
estimate the number of people over the age of 13 living in Minnesota at the end of 2014 who
were diagnosed with HIV infection (regardless of residence at diagnosis) by the year end of
2013. This estimate serves as the underlying population for retention in care and viral
suppression measures, hence is seen on the graph as 100% as people living with HIV/AIDS in
Minnesota.
Retention in care
Retention in care is defined in Minnesota as one laboratory test within the year 2014 for
patients alive and living in Minnesota at the end of 2014 who were diagnosed through year-end
2013. Because Minnesota’s definition of retention in care is different than the national and other
local cascades, use caution when comparing the retention in care measure to the national
estimate.
Viral Suppression
Viral suppression is defined as a VL test result of ≤200 copies/mL at the most recent test
during 2014 for patients alive and living in Minnesota at the end of 2014 who were diagnosed
through year-end 2013.
2
http://www.cdc.gov/hiv/pdf/research_mmp_stagesofcare.pdf
MINNESOTA HIV/AIDS SURVEILLANCE SYSTEM
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Linkage to Care
Linkage to care is calculated using a denominator that is different than the other measures
on the cascade. Linkage to care is defined as those who are diagnosed in Minnesota during the
year 2013 and had a CD4 or VL test performed within 90 days of initial diagnosis. Because the
passage of the revised communicable disease reporting rule to mandate the report of all CD4 and
VL tests for HIV positive patients only occurred in 2011, reports of laboratory tests performed
before that time are incomplete. Therefore, estimates for linkage to care are not useful for cases
diagnosed prior to 2011.
The continuum of HIV care in Minnesota (Overall)
In Minnesota, there are 7,628 people over the age of 13 who were diagnosed with HIV
through 2013 and were living in Minnesota at the end of 2014. Of the 7,628 people living with
HIV at the end of 2014, 5,514 (72%) had at least one CD4 or VL test performed in 2014
(retention in care). Additionally, of the 7,628 people living with HIV/AIDS, 4,826 (63%) had a
VL test of ≤200 copies/mL at their most recent test in 2014 (viral suppression) (Table 1). In
2013, there were 299 persons over the age of 13 who were diagnosed in Minnesota. Of these
299, 261 (87%) had a CD4 or VL test performed within 90 days of their initial diagnosis (linkage
to care) (Table 2).
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Characteristics
Table 1
Treatment Cascade
Number of persons
Number of persons
diagnosed with HIV
Infection through
who have >=1 lab
12/31/2013 and living in
tests between
Minnesota on
1/1/2014 through
12/31/2014 (Overall
12/31/2014
population)
Number of persons who had a
VL test result of≤200
copies/ml at their last test
result in the year 2014
Sex
Male
Female
5850
1778
4213
1301
3743
1083
Current Age
13-29
30-44
45-59
60+
666
2432
3601
924
500
1716
2611
687
392
1426
2356
652
Race/Ethnicity
Hispanic
White
African-American
African-born
American Indian
Asian/Pacific Islander
Multiple Races
677
3835
1639
1032
116
138
175
425
2937
1105
706
93
102
145
381
2667
898
589
78
92
120
Mode of Exposure
MSM
IDU
MSM/IDU
Hetero
Other†
Unspecified
3899
423
396
1712
101
1091
2882
278
299
1257
84
714
2612
230
255
1045
62
621
Geography (Current Residence)
11- county Metropolitan Area*†
Greater Minnesota
6532
1068
4712
790
4141
673
Disease Status
HIV (non-AIDS)
AIDS
3951
3677
2613
2901
2279
2547
Total
7628
5514
4826
†Hemophilia, transplant, transfusion, mother with HIV or HIV risk
*† Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington, Wright Counties
MINNESOTA HIV/AIDS SURVEILLANCE SYSTEM
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Table 2
Linkage to Care
Characteristics
Number of persons
Number of persons diagnosed
who had >=1 lab
with HIV Infection in 2013 in
tests within 90 days
Minnesota (Overall population)
of diagnosis
Sex
Male
Female
299
68
200
61
Age at diagnosis
13-29
30-44
45-59
60+
101
93
80
18
83
84
78
16
Race/Ethnicity
Hispanic
White
African-American
African-born
American Indian
Asian/Pacific Islander
Multiple Races
27
144
70
42
6
-7
23
123
61
40
6
-7
Mode of Exposure
MSM
IDU
MSM/IDU
Hetero
Other†
Unspecified
155
5
10
77
0
52
137
4
9
66
0
45
Geography (Residence at diagnosis)
11- county Metropolitan Area*
Greater Minnesota
240
58
212
48
Disease Status
HIV (non-AIDS)
AIDS
196
103
165
96
299
261
Total
†Hemophilia, transplant, transfusion, mother wit HIV or HIV risk
*† Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne,
Washington, Wright Counties
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Highlights of the continuum of HIV care among select populations
Sex at Birth
Substantial differences in the continuum of HIV care are not seen between males and
females. However women are linked to care at a slightly higher than rate than men (90% versus
87%), but men have a higher rate of viral suppression than women (64% versus 61%).
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Race/Ethnicity
Trends in the cascade of HIV care in Minnesota differ by racial/ethnic group. White
people have the highest rate of viral suppression (70%) while African-American, Hispanic and
African-born persons have lower rates at 55%, 56% and 57%, respectively. Linkage to care
cannot be displayed for all racial/ethnic groups because some groups had less than 5 persons in
2013.
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Risk Group
Differences in retention of care and viral suppression exist between risk groups. People
who inject drugs (IDU) have the lowest rate of viral suppression (54%) while men who have sex
with men (MSM) have the highest viral suppression rate (67%). Linkage to care cannot be
displayed for all risk groups because some groups had less than 5 persons with that risk in 2013.
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Current Age
Young people living with HIV/AIDS (aged 13-29) have lower rates of linkage to care and
retention in care compared to other age groups and they also have the lowest rate of viral
suppression (59%). The rate of viral suppression increases in each of the age groups with people
living with HIV/AIDS age 60 and older with highest rate of suppression at 71%.
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Geography
The HIV treatment cascade differs for people who live in the 11-county metropolitan area
compared to those who live in Greater Minnesota. While linkage to care is higher in the metro
area (88% versus 83% in the Greater Minnesota), there is no difference in viral suppression by
geography.
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HIV disease status
People who have had an AIDS diagnosis have higher rates of engagement in care at every
step of the treatment cascade than people living with HIV (non-AIDS). There could be several
explanations for this difference. One possible explanation for this is AIDS patients could be
more closely monitored by their physician. Another potential explanation is there could be
underreporting of laboratory results for patients without an AIDS diagnosis as this was how CD4
and VL tests were reported prior to the rule change in 2011.
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Loss to follow-up
An analysis of those who were not virally suppressed was conducted to determine if
people had simply not had a VL test done during 2014 or if the VL result was >200 copies/mL
(Table 3). Of the 2,802 people who were not virally suppressed, 566 (20%) had a VL of >200
copies/mL, while 2,236 (80%) had no VL test performed at all.
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Table 3
Not Virally Suppressed
High Viral Load vs. No Viral Load Reported
Characteristics
VL >200
No VL in 2014
Sex
Male
Female
374
192
1733
503
Current Age
13-29
30-44
45-59
60+
93
257
189
27
181
749
1056
245
Race/Ethnicity
Hispanic
White
African-American
African-born
American Indian
Asian/Pacific Islander
Multiple races
35
214
177
96
11
10
23
261
954
564
347
27
36
32
Mode of Exposure
MSM
IDU
MSM/IDU
Hetero
Other†
Unspecified
208
42
37
185
21
73
1079
152
104
482
18
401
Geography (Current Residence)
11- county Metropolitan Area*†
Greater Minnesota
469
97
1922
298
Disease Status
HIV (non-AIDS)
AIDS
260
306
1412
824
Total
566
2236
*Persons with multiple, and unknown races
†Hemophilia, transplant, transfusion, mother wit HIV or HIV risk
*† Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey,
Scott, Sherburne, Washington, Wright Counties
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Future Work
Because CD4 and VL reporting did not become mandatory until 2011, it is not currently
possible to calculate a treatment cascade among people with new diagnoses. In the future, as
more years of data are complete, MDH will calculate a cascade for new diagnoses. This will
allow for the comparison of the treatment cascade for those newly diagnosed to those who were
diagnosed in the past as well as monitor changes in the trends over time.
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