Minnesota HIV/AIDS Epidemiologic Profile
DECEMBER 2015
Executive Summary
Abbreviations Used
AIDS – Acquired Immune Deficiency Syndrome
ADAP–AIDS Drugs Assistance Program
CCCHAP – Community Cooperative Council on HIV/AIDS Prevention
CD4–Cluster of Differentiation 4
CDC–Centers for Disease Control and Prevention
CTR–HIV Counseling, Testing and Referral
DIS – Disease Intervention Specialist
eHARS– Enhanced HIV and AIDS Reporting System
HBV–Hepatitis B Virus
HCV–Hepatitis C Virus
HIV – Human Immunodeficiency Virus
HRSA–Health Resources and Services Administration
IDU – Injection Drug Use(r)
MCHACP–Minnesota Council for HIV/AIDS Care and Prevention
MDH – Minnesota Department of Health
MSM – Men Who Have Sex with Men
PLWHA–People Living with HIV/AIDS
STD – Sexually Transmitted Disease
STI – Sexually Transmitted Infection
TB–Tuberculosis
TGA – Transitional Grant Area
VL–Viral Load
Purpose
The epidemiological (epi) profile presents data on the HIV epidemic in the state of Minnesota.
The profile is intended to give the Minnesota Council for HIV/AIDS Care and Prevention
(MCHACP) a thorough understanding of the epidemic in our state. By showing who is becoming
infected and who is living with the disease, the epi profile helps identify the people who are in
need of prevention and care services, both those who are infected and those at risk. The epi
profile serves as a starting point for MCHACP in their consideration of which prevention and care
services are needed.
Minnesota HIV/AIDS Epidemiologic Profile—Executive Summary
December 2015
The profile presents data for the state as a whole, the 7-county metropolitan area 1, and the
Minneapolis-St. Paul Transitional Grant Area 2 (TGA), consisting of eleven Minnesota counties and
two Wisconsin counties.
Prevention funds are prioritized and distributed based on the epidemiology in the state, whereas
funds for services are prioritized and distributed based both on the epidemiology in the TGA (Part
A) and in the State (Part B).
Data Limitations
MDH has collected AIDS data since 1982 and HIV data since 1985. Data for the epi profile are
mainly obtained through the HIV/AIDS surveillance system (eHARS) at MDH. These data are
mostly obtained through passive surveillance from providers and consist of reports of
confirmatory tests, viral loads and CD4 counts, in addition to case reports and interview data that
include information on risk factors and behavior. Data on risk factors and demographics rely
heavily on patient and provider reporting. The data in this report are from both interviewed and
non-interviewed cases. Cases living with HIV/AIDS include persons currently living in Minnesota
regardless of residence of diagnosis, and therefore includes persons diagnosed in Minnesota as
well as those diagnosed outside of Minnesota, but have since moved to the state. However, these
analyses do not include persons diagnosed in Minnesota but are known to no longer reside in the
state, or who known to have died. The analyses also do not include persons incarcerated at
federal correctional facilities in Minnesota.
Additional data on reportable bacterial STDs, viral hepatitis and TB were obtained from the MDH
STD Surveillance System, MDH Viral Hepatitis Surveillance System, and MDH TB Surveillance
System, respectively.
INTRODUCTION
More people than ever are living with HIV/AIDS in Minnesota due to both the introduction of
new therapies that have slowed the progression of disease for many and, unfortunately, a
sustained number of new infections diagnosed each year. In June of 2015, an estimate of the
number of HIV positive people who are unaware of their status by state was published by the
Centers for Disease Control and Prevention (CDC). This publication estimates that there are 1,200
people living with HIV in Minnesota that have yet to be tested and diagnosed with the infection 3.
Given the number of people who are living with undiagnosed HIV in Minnesota, it is likely that
the state will continue to see a stable if not increasing number of diagnoses each year if testing
is increased and these infections are diagnosed. Therefore, the number of new diagnoses alone
should not be the only measured used to assess the state of HIV in Minnesota. Rather, a more
The 7-county metropolitan area includes the following Minnesota counties: Anoka, Carver, Dakota, Hennepin, Ramsey, Scott and Washington.
The Minneapolis-St. Paul TGA includes the following counties: Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne,
Washington, and Wright in Minnesota and Pierce and St. Croix in Wisconsin.
3 Hall, An, Tang, et al., Prevalence of Diagnosed and Undiagnosed HIV Infection-United States, 2008-2012. MMWR Morb Mortal Wkly Rep
2015;64:657-662.
1
2
Minnesota HIV/AIDS Epidemiologic Profile—Executive Summary
December 2015
comprehensive approach to evaluating HIV prevention and care in Minnesota is to look at the
ratio of new diagnoses to the increase in the number of people who achieve viral suppression. If
there is a greater increase in the number of people achieving viral suppression than the number
of people diagnosed with HIV each year, then we can begin to turn the curve on the HIV epidemic
in Minnesota. As of 2014, this ratio was 1.05 (or slightly more people were diagnosed with HIV
than the increase in viral suppression). With an average of 300 new cases of HIV reported each
year in Minnesota, getting to a ratio of less than 1.0 would require more than 300 person, either
newly or previously diagnosed to start or resume treatment and achieve viral suppression.
SUMMARY OF DATA
The HIV epidemic in Minnesota is driven by sexual exposure. Among men, MSM represent the
primary mode of exposure. Among females, heterosexual contact accounts for the vast majority
of living and new cases.
The HIV epidemic in Minnesota affects racial and ethnic minorities disproportionately, especially
African Americans, who are over represented in every risk group. While the emerging epidemic
among African-born persons seems to be leveling off, Minnesota continues to see an increasing
number of living cases among foreign-born persons. These disparities have significant
implications for both prevention and care activities.
Adolescents and young adults (ages 13-24) represent a small percentage of living cases however
they have represented an increasing proportion of new cases in the past decade.
While HIV/AIDS continues to be geographically centered in the Twin Cities metropolitan area,
injection drug users and heterosexual people living with HIV/AIDS appear to be more likely than
other groups to live in Greater Minnesota than within the TGA.
Over the past decade the HIV epidemic in Minnesota has changed in several ways, both when
looking at new infections and persons living with HIV/AIDS. The population living with HIV has
become more racially, ethnically, culturally and linguistically diverse, which will pose additional
challenges to both prevention and service providers. The success of antiretroviral medications
has not only extended the life of those recently diagnosed, but also of those diagnosed long ago,
which is reflected in the “aging” of those living with HIV/AIDS.
Minnesota HIV/AIDS Epidemiologic Profile—Executive Summary
December 2015
Minnesota General Demographics
DESCRIPTION OF MINNESOTA1
GEOGRAPHY
Minnesota is a geographically diverse state. Its 84,363 square miles are comprised of farmlands,
river valleys, forests, and lakes. Minnesota has one large urban center made up of Minneapolis
and St. Paul (the Twin Cities) in Hennepin and Ramsey Counties, respectively. The Twin Cities are
located on opposite banks of the Mississippi River in the southeastern area of the state. The
majority (54%) of the state’s 5,303,925 residents live in the Twin Cities and the surrounding
seven-county metropolitan region. Duluth (northeast), St. Cloud (central), Rochester (southeast),
Mankato (south central), and Moorhead (northwest) are other moderately sized population
centers. The rest of Minnesota’s population resides in smaller towns, many of which have
populations of less than 2,000.
Three large interstate highways traverse the state, two of which pass through Minneapolis-St.
Paul. I-35 runs north-south and I-94 runs northwest-southeast. I-90 parallels the southern border
of Minnesota. A host of state and county roads connect the remaining regions of the state.
AGE
Minnesota’s population is growing and, like the rest of the nation, getting older. The median age
in Minnesota increased from 35.4 years in 2000 to 37.4 years in 2010 mainly due to the aging
“baby boomer” population. Despite the rising median age, population growth was most apparent
in younger age groups, particularly among 20 to 29 year olds whose number increased by 13%
between 2000 and 2010. According to the 2010 Census, 3.18 million persons (60%) living in
Minnesota were under the age of 45. There is little difference in the age distribution between
the state and the TGA.
1
All data presented in this section are from the U.S. Census Bureau, unless otherwise noted.
Minnesota HIV Epidemiological Profile – General Demographics
December 2015
Age Distribution in Minnesota and in TGA
Minnesota
Age
(n = 5,303,925)
< 13
17.3%
13 – 19
9.6%
20 – 24
6.7%
25 – 29
7.0%
30 – 34
6.5%
35 – 39
6.2%
40 – 44
6.7%
45 – 49
7.7%
50 – 54
7.6%
55 – 59
6.6%
60 +
18.2%
Minneapolis – St. Paul TGA
(n = 3,279,833)
18.1. %
9.6%
6.5%
7.6%
7.0%
6.7%
7.2%
7.9%
7.5%
6.3%
15.8%
RACE/ETHNICITY
While Minnesota is predominantly White (approximately 85%), there has been an increase in the
number of Black, Hispanic, and Asian/Pacific Islander persons living in Minnesota since 2000. At
that time, 89% of Minnesotans were White, 3.5 Black, 2.9% Hispanic, 1.1% Native American, and
2.9% Asian. However, excluding the 2.4% of the Minnesota population that indicated two or more
races, Black, Hispanic, and Asian/Pacific Islander populations increased by about 60%, 75%, and
50% respectively. As of 2010, there were approximately 274,000 Black, 250,000 Hispanic, and
216,000 Asian/Pacific Islander persons living in Minnesota. Additionally, data from the 2011 –
2013 American Community Survey (ACS) show that foreign-born individuals account for 7.4% and
9.7% of the state and TGA population, respectively, compared to 5% and 7% in 2000.
The table below shows the race/ethnicity distribution for Minnesota and the TGA. While the race
distribution does not differ greatly by gender, it does vary by geography. A significantly smaller
percent of both White males (78% vs. 83%) and females (79% vs. 83%) reside in the TGA
compared to the state as a whole. Additionally, census data show differences in age for Whites
versus other groups. Twenty-one percent of non-Hispanic Whites in Minnesota were under the
age of 18 compared to 35.2% for African Americans, 31.5% for Asians/Pacific Islanders, 40.5%
for Hispanics 32.9% American Indians, and 56.3% of those identifying as multi-racial (two or more
races).
Minnesota HIV Epidemiological Profile – General Demographics
December 2015
Race and Ethnicity Distribution by Gender in Minnesota and TGA
Minnesota
(n=2,632,132) (n=2,671,793)
Race / Gender
Male
Female
White (non-Hispanic)
82.7%
83.4%
Black / African American
5.3%
5.0%
American Indian
1.1%
1.1%
Asian / Pacific Islander
4.0%
4.2%
Other race
2.1%
1.8%
Two or more races
2.4%
2.4%
Hispanic / Latino*
5.0%
4.4%
*Includes all races
Minneapolis-St. Paul TGA
(n=1,618,907) (n=1,660,926)
Male
Female
78.3%
78.9%
7.5%
78.3%
0.7%
0.7%
5.6%
5.9%
2.5%
2.2%
2.8%
2.8%
5.7%
5.0%
Of note is the growing number of African immigrants in Minnesota. The Minnesota State
Demographer’s office estimates there are 72,930 2 African-born persons living in Minnesota in
2011. However, many believe this to be an underestimate of the true African population in
Minnesota, with some community members estimating that number at close to 100,000 3.
Somalia, Ethiopia, and Liberia are the most common countries of origin although nearly every
country in Africa is represented in Minnesota. Data from the MDH Refugee Health Program
indicate that the number of sub-Saharan African primary refugees arriving in Minnesota has
declined dramatically between 2006 and 2013 (from 4,764 cases in 2006 to 953 cases in 2013 –
a decrease of 80%).
Additionally, in 2000 Minnesota became one of six initial sites in the United States to receive HIVinfected refugees. Prior to November 2009, immigrants, including refugees, were not permitted
entry into the U.S. if they tested positive for HIV during their overseas physical exam unless they
obtained a waiver. Agencies with local offices in the Twin Cities coordinated the arrival and
resettled 200 HIV-infected refugees to Minnesota from August 2000 through December 2010, of
which the majority were from African countries. However, beginning in 2010, the Federal
Government reversed the statute barring entry for HIV positive immigrants. Consequently, HIV
infection is no longer a barrier for entering the United States. Therefore, Minnesota added
routine HIV screening to the refugee screening protocol in 2010.
2 Based on U.S. Census 2010 data, the Minnesota State Demographic Center estimates that there are 380,764 foreign-born persons, including
72,930 African-born persons are living in Minnesota out of a total population of 5,303,925.
3
The American Community Survey is conducted by the U.S. Census Bureau for the years in between the decennial census. Because there are
many reasons African-born persons may not be included in the census count (e.g. difficulties with verbal or written English), even 50,000 is
likely an underestimate of the actual size of the African-born population living in Minnesota. Anecdotal estimates from African community
members in Minnesota are as high as 100,000.
Minnesota HIV Epidemiological Profile – General Demographics
December 2015
SOCIOECONOMIC STATUS
Poverty and Income
Minnesota overall has fared somewhat better than the nation as a whole in regards to poverty
and income. According to the 2011-2013 ACS, an estimated 11.6% of Minnesotans were living
below the Federal Poverty Level compared to 15.9% nationally. Likewise, the per capita income
from 2011-2013 for the United States was $27,884 and $30,902 in Minnesota. While these
aggregate numbers are favorable, they misrepresent the disproportionate impact poverty has on
persons of color. The 2011-2013 ACS estimates that 12% of all Minnesotans were living at or
below the poverty level, however, this percent varied greatly by race, with 8% of Whites at or
below the poverty level compared to 36%, 35%, 17%, and 24% of Blacks, American Indians,
Asians/Pacific Islanders, and Hispanics, respectively.
Employment
According to Minnesota Department of Employment and Economic Development, Minnesota’s
unemployment rate decreased from 5.6% in 2012 to 4.1% in 2014. This is the lowest rate of
unemployment since 2006 and the 2014 unemployment rate in Minnesota is substantially lower
than the 2014 national unemployment rate average of 6.2%. However, the overall
unemployment rates disguise staggering racial disparities. The 2011-2013 ACS indicated an
unemployment rate of 17.3%, 10.1% and 18.3% for Blacks, Hispanics and American Indians,
respectively in Minnesota compared to 5.4% among white (non-Hispanics).
Education
Minnesota’s emphasis on education is reflected in the low statewide percentage (7.7%) of people
aged 25 years or older who have less than a high school education; the national average is 14.4%.
However, the percentage of persons with less than a high school education is greater for persons
of color in Minnesota. According to the 2011-2013 ACS, 17% of Black men and 22% of Black
women are estimated to have less than a high school education compared to 6% and 5% of White
men and women, respectively. High school graduation rates are even lower among
Hispanics/Latinos, with 38% and 33% of Hispanic males and females not having a high school
diploma, respectively.
ACCESS TO HEALTH CARE
Health Insurance
Overall, Minnesota has one of the lowest rates of uninsured residents in the nation. According to
data released from the 2013 Minnesota Health Access Survey, 8.2% of Minnesotans were not
covered by health insurance at the time of the survey compared to 9.0% in 2011, 9.0% in 2009,
7.2 in 2007 and 7.7% in the 2004 survey. However, the findings in this study suggest that
significant differences continue to exist according to race/ethnicity, age, and country of birth.
Minnesota HIV Epidemiological Profile – General Demographics
December 2015
Notable differences continue to exist among the different race/ethnic groups. While only 6.0%
of Whites were uninsured in 2013, the percentages among Hispanics (34.8%), American Indians
(18.0%), Blacks (14.7%), and Asians (13.2%) were considerably higher.
In 2013, persons aged 18-24 and 25-34 experienced uninsurance rates significantly above the
statewide rate (13.6% and 17.1% for 18-24 and 25-34 year olds, respectively, compared to 8.2%
statewide). Persons aged 0-17 and over 65 had uninsurance rates significantly below the
statewide rate 6.2% and 0.4%, respectively).
Country of birth is a significant factor in uninsurance rates in Minnesota. In 2013, people born in
the United States had significantly lower uninsurance rate than the statewide rate of 6.6% while
those not born in the United States had a significantly higher uninsurance rate of 26.4%.
Prenatal Care
Minnesota is known for its caliber of health care. Unfortunately, when it comes to prenatal care,
women do not access health services equally. According to unpublished data from the Minnesota
Pregnancy Risk Assessment Monitoring System, 85.3% of Minnesota mothers giving birth in 2011
began prenatal care in the first trimester. However, while 90.3% of White women began prenatal
care in the first trimester, only 69.8% of Black, 66.0% of American Indian, and 68.1% of Hispanic
women did. Additionally, 87.5% of US-born mothers began prenatal care in the first trimester
compared to 72.9% of foreign-born mothers.
GAY, LESBIAN, BISEXUAL AND TRANSGENDER (GLBT) PERSONS IN MINNESOTA
Accurate estimates of the GLBT 4 population in Minnesota are unavailable. However, the 2010
Census provides some data related to GLBT persons in Minnesota. Although not a valid measure
of the extent of same sex relationships in Minnesota, unmarried partners of the same sex made
up an estimated 13,718 households in Minnesota in the year 2010, with approximately 70% of
those households located in the TGA.
There have been some national studies that have attempted to estimate the prevalence of same
sex behavior, which is different than estimating the number of GLBT persons since some people
may engage in same sex behavior but not identify as GLBT. In early work by Kinsey and colleagues
in the 1940s and 1950s, 8% of men 5 and 4% of women 6 reported exclusively same gender sex for
at least 3 years during adulthood. Generalizing these findings to the general population is very
questionable because these data were based on convenience samples.
4
The term “GLBT” (gay, lesbian, bisexual, or transgender) refers to sexual identity. “MSM” (men who have sex with men), another term used
throughout this document, refers only to sexual behavior and is not synonymous with sexual identity.
5 Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Male. Philadelphia: WB Saunders, 1948
6 Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Female. Philadelphia: WB Saunders, 1953
Minnesota HIV Epidemiological Profile – General Demographics
December 2015
Subsequent to this work, studies more representative of the general U.S. population have been
undertaken. Comparing national surveys from 1970 and 1991, Seidman and Rieder estimated
that from 1% to 6% of men had sex with another man in the preceding year 7. Another populationbased study estimated the incidence of same sex behavior in the preceding five years at 6% for
males and 4% for females 8. Estimates vary for a number of reasons, including varying definitions
of homosexuality and/or methods of data collection. Approximately 77,000 men and 50,000
women in Minnesota would be predicted to engage in same sex behavior using the methodology
from the Sell study. The accuracy of these numbers is difficult to gauge, at best.
More recently, the SHAPE 2010 study conducted in Hennepin County found that 9.2% of adult
males and 4.7% of adult females in Hennepin County identified as GLBT 9. Applying these
percentages to the entire state adult population, we would estimate that approximately 182,000
men and 96,000 women identify as GLBT.
Also relevant to the context of GLBT life in Minnesota is the fact that Minnesota and the Twin
Cities, in particular, attract individuals with a variety of sexual orientations. A strong gay
community exists in the Minneapolis-St. Paul area. Additionally, Minnesota is one of sixteen
states and the District of Columbia that has laws banning discrimination based on sexual
orientation and gender identity.
A nationally renowned center for individuals seeking transgender support and services is located
in Minneapolis. Although transgender people identify as heterosexual, bisexual, gay, and lesbian,
variances in gender identity complicate the categorization. Some male to female transgender
individuals identify as lesbian, some as heterosexual, and others as bisexual. Similarly, some
female to male individuals identify as gay, some are heterosexual, and others are bisexual.
Politically, and sometimes for access to services, many transgender individuals find alliances
within the gay and lesbian community.
All of these factors may contribute to a larger GLBT population in Minnesota than would be
predicted based upon national averages. Any estimates for the GLBT population must be used
with caution.
In 2012 MDH began estimating the population of MSM in Minnesota. This estimate generates a
denominator for the most commonly reported risk factor in Minnesota and allows for the
calculation of a rate of infection and rate of prevalence among those in the risk group. It should
be noted that this is an estimate of a risk behavior and not an estimate of GLBT identification.
Estimation is done each year using the most recently available census data for men over the age
of 13 and using the model by on Laumann et al where 9% of the urban population, 4% of the
suburban population and 1% of the rural population are estimated to be MSM. Using 2010 census
data, this methodology estimates that there are 92,788 MSM in Minnesota.
Seidman SN, Rieder RO. A review of sexual behavior in the United States. American Journal of Psychiatry, 151(3):330-341, 1994
Sell RL, Wells JA, Wypij D. The prevalence of homosexual behavior and attraction in the United States, the United Kingdom, and France: results
of national population-based samples. Archives of Sexual Behavior, 24:235-248, 1995
9 Hennepin County Human Services and Public Health Department. SHAPE 2010 Adult Data Book, Survey of the Health of All the Population and
the Environment, Minneapolis, Minnesota, March 2011
7
8
Minnesota HIV Epidemiological Profile – General Demographics
December 2015
TRANSGENDER PERSONS
Minnesota appears to attract a relatively large number of individuals who describe themselves
as transgender due to the available treatment programs and access to hormonal and surgical sex
reassignment.
Studies show that transgender individuals have elevated rates of HIV, particularly among
transgender sex workers. These studies focus primarily on male to female transgender
individuals. Possible reasons for the higher rates among transgender sex workers are more
frequent anal receptive sex, increased efficiency of HIV transmission by the neovagina, use of
injectable hormones and sharing of needles, and a higher level of stigmatization, hopelessness,
and social isolation.
Female to male transgender persons who identify as gay or bisexual may be having sexual
intercourse with biological men who are gay or bisexual. Because the prevalence of HIV is higher
among MSM, female to male transgender persons who identify as gay or bisexual are at greater
risk for HIV than those who identify as heterosexual.
Studies by the University of Minnesota’s Program in Human Sexuality identified specific risk
factors such as sexual identity conflict, shame and isolation, secrecy, search for affirmation,
compulsive sexual behavior, prostitution, and found that transgender identity complicates
talking about sex. 10 11
SENSORY DISABILITY
Written and/or verbal communication can be hindered for persons with a sensory disability(ies).
Depending on the medium, general HIV awareness and prevention messages cannot be assumed
to reach such populations. According to 2011 - 2013 ACS data, 3.6% of non-institutionalized
Minnesotans are estimated to be living with hearing difficulty and 3.9% of non-institutionalized
Minnesotans are estimated to be living with vision difficulty.
HOMELESSNESS
Homelessness is also seen as a social determinant of health. According to the 2012 Wilder
Homelessness Survey, an estimated 10,214 people were homeless in Minnesota.12 This number
has increased by 10% since 2009 with the largest reported increase among persons age 55 years
and older (48% increase). Despite this increase of homelessness among older people, persons
age 21 and under still account for the largest proportion of homelessness (46%). For persons who
are HIV positive, homelessness can mean reduced access to treatment and lower survival rates,
Also, persons who are homeless (particularly youth) may be at higher risk for having unprotected
sex and using injection drugs.
Bockting WO, Robinson BE, Rosser BR. Transgender HIV prevention: a qualitative needs assessment. AIDS Care, 10(4):505-525, 1998
Bockting WO, Robinson BE, Forberg J, Scheltema K. Evaluation of a sexual health approach to reducing HIV/STD risk in the transgender
community. AIDS Care, 17(3):289-303, 2005
12 http://www.wilder.org/Wilder-Research/Research-Areas/Homelessness/Pages/Statewide-Homeless-Study-Most-Recent-Results.aspx
10
11
Minnesota HIV Epidemiological Profile – General Demographics
December 2015
SCOPE OF HIV/AIDS IN MINNESOTA
National Perspective
Compared to the rest of the nation, Minnesota is considered to be a low- to-moderate HIV/AIDS
incidence state. In 2013 (the most recent year for which national data is available), state-specific
HIV infection rates ranged from 1.6 per 100,000 persons in Montana to 30.4 per 100,000 persons
in the Louisiana. Minnesota had the 16th lowest HIV infection rate (5.9 HIV cases reported per
100,000 persons) in the country (not including dependent areas). Compared to surrounding
states (IA, ND, SD, & WI), Minnesota’s HIV infection rate was the highest, followed by Wisconsin
at 4.0 per 100,000.
Cumulative Cases
As of December 31, 2014, a cumulative total of 10,718 1 cases of HIV infection have been reported
among Minnesota residents. This includes 6,497 AIDS cases and 4,221 HIV, non-AIDS cases. Of all
these HIV/AIDS cases, 3,638 are known to be deceased through correspondence with the
reporting source, other health departments, reviews of death certificates, active surveillance,
and matches with the National Death Index and Social Security Death Master File.
OVERVIEW OF PEOPLE LIVING WITH HIV/AIDS IN MINNESOTA
An estimated 7,988 persons with HIV/AIDS
are assumed to be living in Minnesota as of
December 31, 2014. This number includes
persons whose most recently reported state
of residence was Minnesota, regardless of
residence at time of diagnosis. Of the 7,988
persons living with HIV/AIDS in Minnesota
4,221 (53%) are living with HIV infection (nonAIDS) and 3,767 (47%) are living with AIDS.
The majority of people living with HIV/AIDS in
Minnesota are male (76%), white (50%), have
a mode of exposure of MSM or joint risk of
MSM/IDU (56%), over the age of 45 years
(58%), and reside in the eleven-county TGA of
the metropolitan area surrounding the Twin
Cities of Minneapolis and St. Paul (86%).
1
This number includes persons who reported Minnesota as their state of residence at the time of their HIV and/or AIDS diagnosis. It also
includes persons who may have been diagnosed in a state that does not have HIV reporting and who subsequently moved to Minnesota and
were reported here. HIV-infected persons currently residing in Minnesota, but who resided in another HIV-reporting state at the time of
diagnosis are excluded.
Minnesota HIV/AIDS Epidemiologic Profile—Scope of HIV/AIDS in Minnesota
December 2015
GEOGRAPHY
Historically, about 90% of new
HIV infections diagnosed in
Minnesota have occurred in the
Minneapolis-St.
Paul
TGA.
Although HIV infection is more
common in communities with
higher population densities and
greater poverty, there are people
living with HIV or AIDS in 97% of
counties in Minnesota.
There are slight differences in
outcomes along the HIV
treatment cascade by geography.
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.
Percentage of persons diagnosed with HIV engaged in
selected stages of the continuum of care, by geography
2014– Minnesota
100%
90%
100%
100%
88%
80%
83%
74%
72%
70%
63%
63%
60%
50%
40%
30%
20%
10%
0%
11 County TGA*
PLWH
Linkage to Care
Retention in Care
Greater MN
Viral Suppression
n=6,532
n=1,068
*Includes Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington, Wright Counties
Race/Ethnicity
Disparities in health are often measured using race as the distinguishing factor, and throughout
this document disparities in HIV and AIDS rates are presented by race/ethnicity. However, there
is no biological reason for these disparities and race/ethnicity is used instead of income or
education since those data are not available through the HIV Surveillance System.
Race is often used as a factor in reporting health disparities because it is believed that it can be a
representation of environmental variations, such as income, education, drug use and others that
can greatly influence one’s health status2. Please see the General Demographics section for more
information.
In Minnesota, as well as the TGA, the epidemic affects populations of color disproportionately.
According to the 2010 Census, white people make up about 85% of the state population, but only
account for 51% of persons living with HIV/AIDS, while populations of color make up 15% of the
population and 50% of persons living with HIV/AIDS in Minnesota. For more information on HIV in
particular racial/ethnic populations in Minnesota, see the corresponding sections in this document.
2
Kaufman JS, Cooper RS. Commentary: Considerations for Use of Racial/Ethnic Classification in Etiologic Research. American Journal of
Epidemiology, 154(4), 2001
Minnesota HIV/AIDS Epidemiologic Profile—Scope of HIV/AIDS in Minnesota
December 2015
Persons Living with HIV/AIDS by Race/Ethnicity and Region of Residence, Minnesota 2014*
TGA
Greater Minnesota
Total
N (%)
N (%)
N (%)
605 (85%)
109 (15%)
714 (9%)
93 (77%)
28 (23%)
121 (2%)
123 (81%)
29 (19%)
152 (2%)
African American
1,571 (92%)
141 (8%)
1,712 (22%)
White
3,300 (83%)
661 (17%)
3,961 (50%)
African-born
967 (88%)
131 (12%)
1,098 (14%)
Multiple Races
153 (85%)
27 (14%)
180 (2%)
10 (91%)
1 (9%)
11 (0.1%)
6,822 (86%)
1,127 (14%)
7,949 (100%)
Race/Ethnicity
Hispanic
American Indian
Asian/Pacific Islander
Unknown
Total
*Does not include 28 cases with missing residence and 11 cases with missing race
Mode of Exposure
The majority of people living
with HIV are among MSM (51%
or 4,046 cases). Heterosexually
and IDU (including MSM/IDU)
acquired infections account for
22% and 10% of living cases,
respectively. Among living
cases, 15% have an unspecified
mode of exposure.
Living HIV/AIDS Cases by Mode of Exposure
Minnesota, 2014
n = 7,988
IDU
5%
MSM/IDU
5%
Other
2%
Heterosex
22%
MSM
51%
Unspecified
15%
n = Number of persons MSM = Men who have sex with men
IDU = Injecting drug use
Heterosex = Heterosexual contact with someone with or at risk for HIV
Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk
Minnesota HIV/AIDS Epidemiologic Profile—Scope of HIV/AIDS in Minnesota
December 2015
OVERVIEW OF NEW HIV/AIDS CASES IN MINNESOTA
The annual number of new HIV infection diagnoses has remained relatively stable over the last
decade with an average number of 319 new HIV infection diagnoses each year. Between 2005
and 2014, 2011 had the fewest number of HIV infection diagnosis with 293 while 2009 saw the
most with 371 new HIV infection diagnoses. There were 307 new diagnoses in 2014.
AIDS Diagnoses
HIV and AIDS Diagnoses in Minnesota, 1990-2014
500
450
400
HIV Infection
350
300
250
AIDS
200
150
100
50
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Number of New Diagnoses
Starting in the mid1990’s, the number of
deaths among AIDS
cases declined sharply,
primarily due to the
success of new
antiretroviral the
therapies including
protease inhibitors.
After a sharp decrease
in the number of ADIS
Cases in from 2012 to
2013, the number of
AIDS cases has
remained stable in
2013 and 2014 with
160 AIDS cases
diagnosed in both
years.
Year of Diagnosis
GENDER
Since the beginning of the epidemic, males have accounted for a majority of new HIV infections
diagnosed per year. While in the early nineties males accounted for over 90% of all new cases
reported, over the past 10 years the males have accounted for closer to 75% of cases. This
distribution of cases by gender remained true in 2014; 76% of new infections occurred among
males and 24% occurred among females.
Minnesota HIV/AIDS Epidemiologic Profile—Scope of HIV/AIDS in Minnesota
December 2015
HIV Infections* by Age at Diagnosis and Year of
Diagnosis
2005-2014†
Age
Continuum of HIV Care
As part of the National HIV/AIDS
Strategy for the United States, the
Minnesota Department of Health
(MDH) has updated the
Minnesota HIV treatment cascade
using HIV surveillance data.
These calculations help us
better understand the HIV
epidemic and the disparities
that exist in the delivery of care
among HIV positive people in
Minnesota.
13-24
25-44
45+
250
Number of New Infections
The number of cases diagnosed
over the past ten years by age
group has not changed
significantly. The majority of cases
diagnosed are among people aged
25 to 44 years of age.
200
150
100
50
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
†HIV/AIDS
at first diagnosis
Percentage of persons diagnosed with HIV engaged in
selected stages of the continuum of care – Minnesota
100%
90%
80%
100%
87% of diagnosed in 2013
72% of PLWH
In Minnesota, there are 7,628
70%
63% of PLWH
people over the age of 13 who
60%
were diagnosed with HIV
50%
through 2013 and were living in
88% of
40%
retained†
Minnesota at the end of 2014.
30%
Of the 7,628 people living with
20%
HIV at the end of 2014, 5,514
10%
5,514/7,628
4,826/7,628
(72%) had at least one CD4 or
261/299
n=7,628
0%
VL test performed in 2014
Persons living with
Retention in care
Viral Suppression
Linkage to Care
diagnosed HIV (PLWH)
(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). 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).
Minnesota HIV/AIDS Epidemiologic Profile—Scope of HIV/AIDS in Minnesota
December 2015
Adolescents and Young Adults
HIV/AIDS Prevalence among Adolescents and Young Adults
Adolescents and young adults between the ages of 13 and 24 years accounted for 4% of people
living with HIV/AIDS in Minnesota in 2014. This percent has stayed stable over the past 5 years,
however youth and adolescents are accounting for an increasing percent of new HIV/AIDS
diagnoses in recent years.
Many people are infected with HIV for years before they actually seek testing and become
aware of their HIV status. This phenomenon especially affects the observed case counts for
younger age groups. And as a result, the reported number of HIV infections among youth (with
few or no reports of AIDS at first diagnosis) is more likely to underestimate the true number of
new infections occurring in this age group compared to older age groups.
HIV Diagnoses among Adolescents and Young Adults
In 1990, 10% of new HIV infections reported to MDH were among youth. In 2014 this
percentage was 19%.
Gender
HIV Infections* Among Adolescents and Young Adults†
by Gender and Year of Diagnosis, 2005 - 2014
80
Males
Females
70
60
Number of Cases
Since
2001,
the
number of new cases
among young males
has been increasing
steadily, a few cases
per year. However, in
2009 the number of
cases
increased
dramatically by 82%
compared to 2008, to
80 cases, the highest
seen since 1986.
50
40
30
20
10
0
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
In 2014, the number of
Year
increased from 41 in
*HIV or AIDS at first diagnosis
2013 to 49. Of these 49 †Adolescents defined as 13-19 year-olds; Young Adults defined as 20-24 year-olds.
new cases among
adolescent and young adult men, 21 (43%) were known MSM of color. Since 2005, the number
of cases among young males has increased by about 63%.
Unlike young men, the annual number of new HIV infections diagnosed among young women
has remained relatively consistent over time. In 2014 there were 8 cases diagnosed among
Minnesota HIV Epidemiologic Profile – Adolescents and Young Adults
December 2015
young women, this accounts for a 20% decrease from the ten cases diagnosed in 2013. Females
accounted for 14% (8/57) of new HIV infections diagnosed among adolescents and young adults
in 2014.
Overall, young women accounted for 11% (8/73) of new infections among females and young
males accounted for 21% (49/237) of new infections among males in 2014.
Race/Ethnicity
Similar to the overall
HIV Infections* Among Adolescents and Young Adults†
HIV/AIDS epidemic, people
by Gender and Race/Ethnicity, 2012 - 2014 Combined
of color account for a
Males (n = 143)
Females (n = 22)
disproportionate number
of new HIV infections
Afr Amer
27%
White
among adolescents and
39%
White
young adults. Among
32%
Hispanic
young men, white men
4%
accounted for 39% of new
Asian/PI
HIV infections diagnosed
Afr Amer
1%
39%
between 2012 and 2014,
Other
2%
African American men
Afr born
Afr born
Other
32%
Amer Ind
2%
5%
accounted for 39%, and
Hispanic
2%
15%
Hispanic men 15%.
n = Number of persons
Amer Ind = American Indian
American Indian, African*HIV or AIDS at first diagnosis
Afr
Amer
=
African
American
(Black, not African-born persons)
born, and Asian/Pacific
†Adolescents defined as 13-19 year-olds;
Afr born = African-born (Black, African-born persons)
Young Adults defined as 20-24 year-olds.
Islander men made up 2%,
Other = Multi-racial persons or persons with unknown race
2%, and 1% of the
remaining cases, respectively. Among young women, white women accounted for 32%, African
American women 27%, African-born women 32%, Hispanic women 4%, and women with
multiple or unknown race accounted 5% of the new infections diagnosed during the same time
period.
Mode of Exposure
Men having sex with men (MSM) was the predominant mode of HIV exposure among
adolescent and young adult males, accounting for an estimated 93% of the new HIV infections
diagnosed between 2012 and 2014, while the joint risk of MSM and injecting drug use (IDU)
accounted for an estimated 4% of the cases in the same time period. Heterosexual sex
accounted for an estimated 2% of cases. Heterosexual contact accounted for an estimated 94%
of new HIV infections diagnosed among adolescent and young adult females between 2012 and
2014 while IDU accounted for an estimated 6%.
Minnesota HIV Epidemiologic Profile – Adolescents and Young Adults
December 2015
HIV Infections* Among Adolescents and
Young Adults† by Gender and Estimated Exposure Group#,
2012- 2014
Males (n = 143)
Females (n = 22)
Heterosex
94%
MSM
93%
Other
1%
Heterosex
MSM/IDU 2%
4%
IDU
6%
n = Number of persons MSM = Men who have sex with men
IDU = Injecting drug use
Heterosex = Heterosexual contact with someone with or at risk for HIV
Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk
†Adolescents defined as 13-19 year-olds; Young Adults defined as 20-24 year-olds
* HIV or AIDS at first diagnosis
Treatment Cascade among Adolescents and Young Adults
Although the treatment
Percentage of persons 13-29 years old diagnosed with HIV
cascade for young people
engaged in selected stages of the continuum of care,
includes people living
2014– Minnesota
100%
100%
with HIV/AIDS up to age
100%
29, the general trend can
87%
90%
82%
be seen for adolescents
80%
75%
72%
and young adults. There
70%
63%
59%
were 666 HIV positive
60%
persons aged 13-29
50%
40%
included in the treatment
30%
cascade analyses and 101
20%
cases in this age group
10%
reported in 2013 that
0%
were included in the
Overall Cascade
13-29 year olds
linkage
to
care
Linkage to Care
PLWH
Retention in Care
Viral Suppression
calculation.
Young
n=7,728
n=666
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%).
Minnesota HIV Epidemiologic Profile – Adolescents and Young Adults
December 2015
African American
HIV/AIDS Prevalence among African Americans
While African Americans account for 4% of the total population in Minnesota, they make up
22% of the number of people living with HIV/AIDS in Minnesota. As of December 31st, 2014
there were 1,719 African Americans living with HIV/AIDS in Minnesota.
HIV Diagnoses among African Americans
In 2014, there were 61 HIV diagnoses among African Americans in Minnesota accounting for
20% of all HIV infection diagnoses.
Gender
Of the 61 HIV diagnoses among African Americans in Minnesota in 2014, 45 (74%) were males
while 16 (26%) were females. During the past decade, the number of cases among African
American males has fluctuated from year to year, with 45 new HIV diagnoses in 2014. This
represents a 22% decrease among African American males from 2013 to 2014. Since 2005, the
annual number of new infections diagnosed among African American females has decreased
overall. However, in 2014 there was a slight increase to 16 cases diagnosed among African
American women, compared to 13 in 2013.
Mode of Exposure
HIV Infections* Among African Americans
Of the 160 African
by Estimated Mode of Exposure
American
males
2012 - 2014
diagnosed between
African American Males
African American Females
2012 and 2014, 87%
(n = 160)
(n = 53)
of cases had an
estimated mode of
Heterosex
MSM
93%
87%
exposure of MSM,
10%
heterosexual
contact to someone
IDU
2%
with or at risk for
Heterosex
HIV, 2% IDU, and 1%
10%
other
mode
of
Other
Other
1%
IDU
exposure
that
4%
3%
n
=
Number
of
persons
MSM
=
Men
who
have
sex
with
men
IDU
=
Injecting
drug
use
includes hemophilia,
Heterosex = Heterosexual contact with someone with or at risk for HIV
transplant,
Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk
transfusion
or * HIV or AIDS at first diagnosis
mother with HIV or HIV risk.
Minnesota HIV/AIDS Epidemiologic Profile—African American
December 2015
Of the 45 African American females diagnosed between 2012 and 2014, 93% of cases had an
estimated mode of exposure of heterosexual contact to someone with or at risk for HIV, 3%
had a risk of IDU, and 4% other mode of exposure that includes hemophilia, transplant,
transfusion or mother with HIV or HIV risk.
Age at Diagnosis
African American men and women are diagnosed at a younger age compared to other
race/ethnicities. The average age at diagnosis for African American men diagnosed between
2012 and 2014 was 31 years old compared to 39 years old among African-born and white men.
The average age at diagnosis for African American women diagnosed between 2012 and 2014
was 35 years old compared to 39 years old among white women and 37 years old among
Hispanic and American Indian women. African American women are diagnosed at a slightly
younger age than African-born women, who are diagnosed at an average age of 36 between
2012 and 2014.
HIV Treatment Cascade among African Americans
There were 1,639 HIV
positive African Americans
included in the treatment
cascade analyses. African
Americans living with HIV
in Minnesota have lower
percentages
of
engagement of care at
every step of the HIV
treatment cascade when
compared to the overall
cascade in Minnesota.
African Americans have the
lowest rate of viral
suppression of all the
racial/ethnic groups with
55% of PLWHA virally
suppressed.
Percentage of African Americans diagnosed with HIV engaged
in selected stages of the continuum of care, 2014– Minnesota
100%
90%
100%
100%
87%
80%
87%
72%
70%
67%
63%
60%
55%
50%
40%
30%
20%
10%
0%
Overall Cascade
PLWH
Linkage to Care
Retention in Care
African Americans
Viral Suppression
n=7,728
n=1,639
There were 70 cases among African Americans reported in 2013 that were included in the
linkage to care calculation. African Americans have the third lowest linkage to care rate
compared to other racial/ethnic groups with 87% linked to care.
Minnesota HIV/AIDS Epidemiologic Profile—African American
December 2015
African-born
African-born Persons in Minnesota
African immigration to Minnesota increased markedly during the
mid-1990s; there are an estimated 77,557 1 African-born persons
living in Minnesota. However, many believe this to be an
underestimate of the true African population in Minnesota, with
some community members estimating that number at close to
100,000 2.
The sheer diversity of cultures (34 different African countries are
represented among those living with HIV/AIDS in Minnesota; many
nations are home to tens of cultures within their borders) as well as
language and cultural barriers all pose significant challenges for HIV
prevention and care efforts.
HIV/AIDS Prevalence among African-born Persons
Countries of Origin of
HIV+ African-born
Persons in Minnesota
Country Number HIV+
Ethiopia
241
Liberia
169
Kenya
155
Somalia
111
Cameroon
84
Sudan
66
Nigeria
46
Uganda
32
Zambia
23
(25 additional Countries)
At the end of 2014, there were 1,109 African-born persons living with
HIV in Minnesota. Three countries (Ethiopia, Liberia, and Kenya) account for a majority (51%) of
African-born cases living in Minnesota. However, there are 31 additional countries represented
among African-born persons living with HIV in Minnesota. The characteristics of African-born
persons living with HIV/AIDS in Minnesota differ from U.S.-born, especially in gender. While
females account for 17% of cases among U.S.-born persons, they account for 57% of Africanborn cases.
New HIV Diagnoses among African born-persons
The number of new HIV infections diagnosed among African-born persons in Minnesota
increased steadily from 8 cases in 1990 to 65 cases in 2002 (data not shown). However, since
2002 those numbers have decreased with 52 cases diagnosed in 2014. Still, African-born
persons accounted for 17% of new HIV infections diagnosed in 2014, but account for an
estimated 1% of the statewide population. African-born persons have the highest rate of
infection of any of the other racial groups with 67.0 cases per 100,000 population compared to
an overall rate of 5.8 per 100,000 for the state of Minnesota.
1
2
2010-2012 American Community Survey 3-year estimates. Additional calculations by the State Demographic Center
The American Community Survey is conducted by the U.S. Census Bureau for the years in between the decennial census. Because there are
many reasons African-born persons may not be included in the census count (e.g. difficulties with verbal or written English), even 50,000 is
likely an underestimate of the actual size of the African-born population living in Minnesota. Anecdotal estimates from African community
members in Minnesota are as high as 100,000.
Minnesota HIV/AIDS Epidemiologic Profile—African-born
December 2015
Gender and Mode of Exposure
African-born persons have a
higher proportion of HIV
infections acquired through
heterosexual contact than
other racial/ethnic groups. It
is estimated that 84% of new
HIV
infections
among
African-born
males
diagnosed between 2012
and 2014 were attributable
to
heterosexual
sex.
However heterosexual sex
was not the only mode of
exposure for African-born
males; MSM accounted for
10% of new HIV infections
among African-born males
during this time period.
HIV Infections* Among African-born persons by Estimated
Mode of Exposure
2012 - 2014
African-born Females (n = 87)
African-born Males (n =49)
MSM
10%
Other
2%
Other
6%
Heterosex
84%
Heterosex
98%
n = Number of persons MSM = Men who have sex with men
IDU = Injecting drug use
Heterosex = Heterosexual contact with someone with or at risk for HIV
Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk
*HIV or AIDS at first diagnosis
Heterosexual contact with a partner who has or is at increased risk for HIV infection is
estimated to account for 98% of cases among African-born females during 2012-2014. Africanborn women accounted for the largest number of new infections among women during this
time period.
HIV Treatment Cascade among African-born persons
There were 1,032 HIV positive African-born persons included in the treatment cascade
analyses. African-born persons living with HIV in Minnesota have lower percentages of
retention in care and viral suppression when compared to the overall cascade in Minnesota.
Viral suppression among African-born persons is 57% compared to 63% overall in Minnesota.
Compared to other racial/ethnic groups, African-born persons have similar outcomes as other
persons of color, but lower engagement in care than white non-Hispanic persons.
There were 42 cases among African-born persons reported in 2013 that were included in the
linkage to care calculation. African-born persons have a similar percentage of linkage to care
than the overall cascade at 87%.
Minnesota HIV/AIDS Epidemiologic Profile—African-born
December 2015
Percentage of African-born persons diagnosed with HIV
engaged in selected stages of the continuum of care, 2014–
Minnesota
100%
90%
100%
100%
95%
87%
80%
72%
70%
68%
63%
57%
60%
50%
40%
30%
20%
10%
0%
Overall Cascade
PLWH
Linkage to Care
n=7,728
Retention in Care
African-born
Viral Suppression
n=1,032
Minnesota HIV/AIDS Epidemiologic Profile—African-born
December 2015
American Indian
HIV/AIDS Prevalence among American Indians
As of December 31st 2014, there were 121 American Indians living with HIV/AIDS in Minnesota.
Although this only accounts for 2 percent of persons living with HIV/AIDS in Minnesota, American
Indian persons have more than twice the rate of people living with HIV than white, non-Hispanic
persons (198.6 per 100,000 persons and 90.3 per 100,000 persons respectively).
While the number of cases among American Indians in Minnesota has been relatively stable and
low it is important to note this group has been found to have their race misclassified often by
providers. A study by the Centers for Disease Control and Prevention (CDC) of the HIV/AIDS
Surveillance data for five states found that thirty percent of American Indian cases were
misclassified, mostly as white 1. It is possible that similar misclassification occurs in the Minnesota
data and impacts the reported number of cases for American Indians in the state.
HIV Diagnoses among American Indians
Over the past ten years, new infections among American Indians has remained relatively low with
an average of 6 new diagnoses a year with low of 3 diagnoses in 2005 and a high of 11 diagnoses
in 2010. In 2014, there were 5 HIV/AIDS diagnoses among American Indians, two male and three
female.
HIV Infections* Among American Indians
by Estimated Mode of Exposure
2012 - 2014
Gender and Mode of
Exposure
Of the 12 American Indian males
diagnosed between 2012 and
2014, 37% had an estimated
mode of exposure of MSM, 27%
IDU, 18% MSM/IDU, and
18%heterosexual contact with
someone with or at risk for HIV
infection. Of the 9 American
Indian
females
diagnosed
between 2012 and 2014, 75%
CAUTION: Small number of cases – interpret carefully.
American Indian Males (n = 12)
American Indian Females (n = 9)
MSM/IDU
18%
IDU
25%
IDU
27%
MSM
37%
Heterosex
18%
n = Number of persons MSM = Men who have sex with men
IDU = Injecting drug use
Heterosex = Heterosexual contact with someone with or at risk for HIV
Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk
* HIV or AIDS at first diagnosis
1
Bertolli J, Lee LM, Sullivan PS, AI/AN Race Ethnicity Validation Workgroup. Racial Misclassification of American Indians/Alaska Natives in
the HIV/AIDS Reporting Systems of Five States and One Urban Health Jurisdiction, U.S., 1984-2002. Public Health Reports, 122(3):382392, 2007
Minnesota HIV/AIDS Epidemiologic Profile—American Indian
December 2015
Heterosex
75%
had an estimated mode of exposure of heterosexual contact with someone with or at risk for HIV
infection and 25% IDU.
Geography
Compared to other race/ethnicities, HIV positive American Indians have a higher percentage of
people living in Greater Minnesota (outside the 11-county metro area) at 23%. This is not
surprising since there are several Indian reservations in Greater Minnesota.
HIV Treatment Cascade among American Indians
There were 116 HIV positive American Indians included in the treatment cascade analyses.
Compared to the overall treatment cascade in Minnesota, American Indians have a higher
percentage in retention in care, and viral suppression.
There were six diagnoses among American Indians in 2013 that were included in the linkage to
care calculation. All six diagnoses linked to medical care within 90 days of their diagnosis. It is
important to note the numbers of HIV cases in this community are quite small, particularly for
linkage to care measure and should be interpreted carefully.
Percentage of American Indians diagnosed with HIV
engaged in selected stages of the continuum of care,
2014– Minnesota
100%
100%
100%
100%
87%
90%
80%
80%
72%
70%
67%
63%
60%
50%
40%
30%
20%
10%
0%
Overall Cascade
PLWH
Linkage to Care
n=7,728
American Indian
Retention in Care
Viral Suppression
n=116
Minnesota HIV/AIDS Epidemiologic Profile—American Indian
December 2015
Asian/Pacific Islander
HIV/AIDS Prevalence among Asian/Pacific Islanders
As of December 31st 2014, there were 153 Asian/Pacific Islanders living with HIV/AIDS in
Minnesota, accounting for 2% of people living with HIV in Minnesota. Of the 153 Asian/Pacific
Islanders living with HIV in Minnesota, 108 were male and 45 were female. Of the 108 male API
cases, 83% had a risk of men who have sex with men (MSM), 8% heterosexual contact with
someone with or at risk for HIV, 3% injection drug use (IDU), 3% MSM/IDU and 3% other risk
(hemophilia, transplant, transfusion or mother with HIV or HIV risk). Of the 42 female API cases,
83% had a risk of heterosexual contact with someone with or at risk for HIV, 2% IDU, and 15%
other mode of exposure.
HIV Diagnoses among Asian/Pacific Islanders
Nationally, through 2010, according to the Centers for Disease Control and Prevention (CDC),
Asian and Pacific Islanders are one of the fastest-growing ethnic/racial populations in the U.S.
According to the CDC, the number of APIs living with AIDS has climbed by about 10% in each of
the last 5 years.
In Minnesota, however, the number of new HIV/AIDS diagnoses has remained low over the past
decade at less than 10 new cases a year. In 2014 there were 10 HIV diagnosis among
Asian/Pacific Islanders accounting for 3% of all HIV infection diagnoses.
Mode of Exposure
Of the 16 Asian males
diagnosed between 2012 and
2014, 91% of cases had an
estimated mode of exposure
of MSM and 9% had an
estimated risk of MSM/IDU.
The one Asian female
diagnosed between 2012 and
2014, did not have a specified
risk. The number of cases
among Asian/Pacific Islander
men and women during the
years
2012-2014
are
insufficient to make further
HIV Infections* by Estimated Mode of Exposure
Among Asian/Pacific Islanders
2012 - 2014
CAUTION: Small number of cases – interpret carefully.
Asian Males (n = 16)
Asian Females (n = 1)
Heterosex
95%
MSM/IDU
MSM
91%
Other
5%
n = Number of persons MSM = Men who have sex with men
IDU = Injecting drug use
Heterosex = Heterosexual contact with someone with or at risk for HIV
Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk
* HIV or AIDS at first diagnosis
Minnesota HIV/AIDS Epidemiologic Profile—Asian/Pacific Islander
December 2015
generalizations regarding risk.
HIV Treatment Cascade among Asian/Pacific Islanders
There were 138 HIV positive Asian/Pacific Islanders included in the treatment cascade analyses.
Compared to the overall treatment cascade in Minnesota, Asian/Pacific Islanders have slightly
lower retention in care and viral suppression rates. It is important to note the numbers of HIV
cases in this community are quite small.
There were too few cases among Asian/Pacific Islanders diagnosed in 2013 to calculate the
linkage to care measure.
Percentage of Asian/Pacific Islanders diagnosed with HIV
engaged in selected stages of the continuum of care,
2014– Minnesota
100%
100%
100%
90%
87%
80%
74%
72%
70%
67%
63%
60%
50%
40%
30%
20%
10%
^
0%
^
Overall Cascade
PLWH
^ Strata have a n<5
Linkage to Care
n=7,728
Asian/Pacific Islanders
Retention in Care
Viral Suppression
n=138
Minnesota HIV/AIDS Epidemiologic Profile—Asian/Pacific Islander
December 2015
Co-infections
HIV and other infectious disease co-infections
Risk factors for HIV infection are common to other diseases, namely other STDs (such as
chlamydia, gonorrhea and syphilis), hepatitis B and hepatitis C. Also, having an STD may make
an individual more susceptible to HIV infection and vice versa. Although Minnesota is
considered a low to medium incidence state for chlamydia, gonorrhea and syphilis, many
people infected with these STDs are also at risk for acquiring HIV.
HIV and STD co-infection
In the state of Minnesota, laboratory-confirmed infections of chlamydia, gonorrhea, syphilis,
and chancroid are monitored by MDH through a passive, combined physician and laboratorybased surveillance system. State law (Minnesota Rule 4605.7040) requires both physicians and
laboratories to report all cases of these four bacterial STDs directly to MDH. In 2002, MDH
added an active component to the surveillance system for chlamydia and gonorrhea infections,
and in 2008 changed the case report form to include gender of sexual partners and country of
origin to better describe STDs in Minnesota. In addition to the regular surveillance, additional
behavioral information is collected on syphilis and gonorrhea cases. Other common sexually
transmitted conditions caused by viral pathogens, such as herpes simplex virus (HSV) and
human papillomavirus (HPV) are not reported to MDH. Factors that impact the completeness
and accuracy of the available data on STDs include: level of screening, accuracy of diagnostic
tests, and compliance with case reporting. Thus, any changes in STD rates may be due to one of
these factors, or due to actual changes in STD occurrence.
In 2014, 19,897 chlamydia cases and 4,073 gonorrhea cases were reported to MDH. 64% of
combined chlamydia and gonorrhea cases reported to the MDH were among females and 64%
were among persons aged 15-24. Minnesota has also seen resurgence in syphilis cases reported
to the MDH. In 2014, the number of early syphilis cases (that is, primary, secondary, and early
latent stages) increased by 25% (from 332 cases in 2013 to 416 cases in 2014). Of the 416 cases,
34% reported being co-infected with HIV. Most of these cases had been diagnosed with HIV
before being diagnosed with syphilis.
HIV and viral hepatitis co-infection
People with viral hepatitis also share risk factors for HIV including sexual transmission (in the
case of hepatitis B) and sharing needles (in the case of hepatitis C). In 2014, there were an
estimated 22,967 people living in Minnesota with hepatitis B, and 43,543 living with past or
present hepatitis C. Surveillance data from 2014 indicate that around 11% of people living with
HIV/AIDS are also living with hepatitis B or hepatitis C (4% with hepatitis B and 7% with
hepatitis C). Nationally, it is estimated that one quarter of people living with HIV are also
infected with hepatitis C. Hepatitis B or C co-infection may lead to treatment complications
with HIV/AIDS and vice versa.
Minnesota HIV/AIDS Epidemiologic Profile—Co-Infections
December 2015
HIV and TB co-infection
Tuberculosis (TB) co-infection may also be a problem among persons with HIV/AIDS. TB
infection after HIV diagnosis is considered to be an AIDS-defining condition. In 2014, 147 new
cases of TB were reported in Minnesota, and there were 250 documented cases of people living
with TB or receiving treatment for TB. At least 153 (2%) of persons living with HIV/AIDS in
Minnesota indicated TB co-infection at some point (44% with disseminated TB and 56% with
pulmonary TB).
Minnesota HIV/AIDS Epidemiologic Profile—Co-Infections
December 2015
Greater Minnesota
HIV/AIDS Prevalence in Greater MN
As of December 31st 2014, there were 1,128 persons living with HIV/AIDS in Greater Minnesota
(defined as living in counties outside of the 11-county metropolitan area of Minneapolis and St.
Paul). This accounts for 14% of all persons living with HIV/AIDS in Minnesota.
The gender distribution varies slightly by geography. Males make up a smaller proportion of
cases in Greater Minnesota at 73% when compared to the TGA at 77%.
HIV Diagnoses in Greater Minnesota
In 2014, there were 36 cases of HIV diagnosed in greater Minnesota. While new HIV/AIDS
diagnoses in 2014 were concentrated in the TGA (88%), there are notable differences between
Greater Minnesota and the TGA in the racial and risk category distribution of those infected.
Mode of Exposure
While most the risk category distributions are similar for Greater MN and the TGA there are a
few interesting differences. The proportion of new diagnoses between 2012 and 2014
attributed to MSM, MSM/IDU and heterosexual contact with some with or at risk for HIV are
similar in the TGA and Greater Minnesota. However, IDU account for a slightly greater
percentage of cases in Greater Minnesota (5.5%) than in the TGA (1.9%). Additionally, the
percentage of cases with an unspecified risk is slightly lower in Greater MN (20%) than in the
TGA (23%).
New HIV/AIDS Infections* By Mode of Exposure
Greater Minnesota & TGA 2012-2014
TGA (n=792)
Greater MN (n=128)
Unspecified
20%
Other
1%
MSM
50%
Unspecified
23%
Other
<1%
MSM
51%
Heterosex
21%
Heterosex
21%
MSM/IDU
IDU
3%
5%
MSM/IDU
IDU
3%
2%
n = Number of persons MSM = Men who have sex with men
IDU = Injecting drug use
Heterosex = Heterosexual contact with someone with or at risk for HIV
Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk
* HIV or AIDS at first diagnosis
Minnesota HIV/AIDS Epidemiologic Profile—Greater Minnesota
December 2015
RACIAL/ETHNIC GROUP
Similarly, looking at the racial/ethnic distribution of the new infections over the past three
years, there are differences between Greater Minnesota and the TGA. The main differences
occur in African American, and White communities. African Americans accounted for 6% of
Greater Minnesota cases and 25% of TGA cases and African-born persons accounted for 13% of
Greater Minnesota cases and 15% of TGA cases. In contrast white persons made up a greater
percentage of new infections in Greater Minnesota than the TGA (61% and 43%, respectively).
The proportion of Hispanic, American Indian and Asian cases was the very similar in both the
TGA and Greater Minnesota.
New HIV/AIDS Infections* By Race/Ethnicity
Greater Minnesota & TGA 2012-2014
Greater MN (n=128)
Black, Afr
born
13%
Hispanic/
Latino
11%
TGA (n=787)
Black, Afr
born
15%
Am Ind
5%
Other
2%
Asian/PI
2%
Afr Am
6%
Other
1%
Hispanic/
Latino
11%
Am Ind
2%
Asian/PI
2%
Afr Am
25%
White
43%
White
61%
*HIV or AIDS at first diagnosis
Does not include 6 cases with missing race or residence at diagnosis data
Age at Diagnosis
Persons aged 13-24 years made up 14% of the new cases in Greater Minnesota while they
accounted for 19% of the new cases in the TGA between 2012 and 2014. There is also a slight
difference in persons diagnosed over the age of 45 in Greater Minnesota compared to the TGA,
as they accounted for 30% of new diagnoses in Greater Minnesota between 2012 and 2014
compared to 27% of the cases in the TGA during this time period.
Minnesota HIV/AIDS Epidemiologic Profile—Greater Minnesota
December 2015
HIV Treatment Cascade among people living in Greater Minnesota
There were 1,068 HIV positive people living in Greater Minnesota included in the treatment
cascade analyses. Compared to the treatment cascade for the TGA, Greater Minnesota has a
lower percentages of linkage to care. However, there is little difference in retention in care and
viral suppression in Greater Minnesota compared to the TGA cascade.
Percentage of persons diagnosed with HIV engaged in
selected stages of the continuum of care, by geography
2014– Minnesota
100%
90%
100%
100%
88%
80%
83%
74%
72%
70%
63%
63%
60%
50%
40%
30%
20%
10%
0%
11 County TGA*
PLWH
Linkage to Care
n=6,532
Retention in Care
Greater MN
Viral Suppression
n=1,068
*Includes Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington, Wright Counties
Minnesota HIV/AIDS Epidemiologic Profile—Greater Minnesota
December 2015
Heterosexual Risk
HIV/AIDS Prevalence among heterosexuals
Throughout the epidemic, heterosexual contact has been the predominate mode of HIV
exposure reported among females in Minnesota. As of December 31st 2014, heterosexually
acquired HIV infections accounted for 1,775 (22%) of living cases. Of the 1,775 heterosexual
cases, 1,531 (86%) were among women and the remaining 244 (14%) were among men.
HIV Diagnoses among heterosexuals
Gender and Race/Ethnicity
The numbers of male cases attributed heterosexual contact have remained somewhat stable
over the past decade. However, the trend varies by racial/ethnic group. The number of male
newly diagnosed cases attributed to heterosexual contact was 6 in 2014. Heterosexual contact
with a partner who has or is at increased risk for HIV infection was estimated to account for 2%
of cases among white males diagnosed between 2012-2014, 10% of cases among African
American males, 84% African-born males and 3% of Hispanic males. Heterosexual contact
among American Indian and Asian men accounted for and estimated 18% and 0% of new
infections from 2012-2014 respectively, but should be interpreted with caution as each of the
groups had a small number of new diagnoses during the time period.
Heterosexual contact with a partner who has or is at increased risk for HIV infection is
estimated to account for 86% of cases among white females diagnosed between 2012-2014,
93% of cases among African American females, 98% of African-born females, and 92% of
Hispanic females. Heterosexual contact among American Indian women accounted for 75%, of
new infections from 2012-2014, but should be interpreted with caution as this group had less
than 12 new diagnoses during the time period. There was only one Asian female diagnosed
with HIV during the time period and did not have a specified risk.
Minnesota HIV/AIDS Epidemiologic Profile—Heterosexual Risk
December, 2015
Treatment Cascade among heterosexuals
There were 1,712 HIV positive persons with heterosexual contact as their identified risk
included in the treatment cascade analyses. Compared to the overall HIV treatment cascade in
Minnesota, people with an identified HIV risk of heterosexual contact have similar percentages
of retention in care, but slightly lower percentage of viral suppression. There were 77 cases
among heterosexuals reported in 2013 that were included in the linkage to care calculation.
Heterosexuals have a similar percentage of linkage to care than the overall cascade for
Minnesota.
Percentage of persons with heterosexual mode of exposure
diagnosed with HIV engaged in selected stages of the
continuum of care, 2014– Minnesota
100%
90%
80%
70%
100%
100%
87%
86%
73%
72%
63%
61%
60%
50%
40%
30%
20%
10%
0%
Overall Cascade
PLWH
Linkage to Care
n=7,728
Retention in Care
Heterosexual risk=Heterosexual contact with HIV+, or with someone with HIV risk
Heterosexual Risk
Viral Suppression
n=1,712
Minnesota HIV/AIDS Epidemiologic Profile—Heterosexual Risk
December, 2015
Hispanic
HIV/AIDS Prevalence among Hispanic persons
As of December 31st 2014, there were 716 Hispanic persons living with HIV/AIDS in Minnesota.
While this accounts for 9% of persons living with HIV/AIDS in Minnesota, Hispanic persons have
more than three times the rate of people living with HIV than white, non-Hispanic persons
(286.1 per 100,000 persons and 90.3 per 100,000 persons respectively).
HIV Diagnoses among Hispanic persons
Over the past ten years new infections among Hispanic persons in Minnesota has remained
relatively stable from year to year. In 2014, there were 34 HIV diagnoses among Hispanics in
Minnesota accounting for 11% of all HIV diagnoses that year.
Gender
In 2014, there were 28 new HIV diagnoses among Hispanic males. This is up from 23 diagnoses
in 2013. The annual number of new infections diagnosed among Hispanic females continues to
be quite small with six diagnoses in 2014.
Mode of Exposure
Of the 87 new HIV
infections diagnosed
among
Hispanic
males between 2012
and 2014, MSM and
MSM/IDU accounted
for an estimated
95% of diagnoses,
while
3%
were
estimated to have
heterosexual contact
with someone with
or at risk for HIV
infection as their
mode of exposure.
The remaining 2%
had and other mode
HIV Infections* Among Hispanic Persons
by Estimated Mode of Exposure
2012 - 2014
Hispanic Males (n =87)
Hispanic Females (n = 16)
CAUTION: Small number of cases – interpret
carefully.
IDU
8%
MSM
92%
MSM/IDU
3%
Heterosex
3%
Other
2%
n = Number of persons MSM = Men who have sex with men
IDU = Injecting drug use
Heterosex = Heterosexual contact with someone with or at risk for HIV
Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk
* HIV or AIDS at first diagnosis
Minnesota HIV/AIDS Epidemiologic Profile—Hispanic
December 2015
Heterosex
92%
of exposure which includes hemophilia, transplant, transfusion or mother with HIV or HIV risk.
Of the 16 Hispanic females diagnosed between 2012 and 2014, 92% had an estimated mode of
exposure of heterosexual contact with someone with or at risk for HIV infection. The remaining
8% had a risk of injection drug use. However, the number of cases among Hispanic women
during the years 2012-2014 is insufficient to make further generalizations regarding risk.
HIV Treatment Cascade among Hispanic people
There were 677 HIV positive Hispanics included in the treatment cascade analyses. Compared
to the overall treatment cascade in Minnesota, Hispanics have a lower percentage of retention
in care and viral suppression. Hispanics have the second lowest percent of viral suppression
compared to other racial/ethnic groups at 56%.
There were 27 cases among Hispanics reported in 2013 that were included in the linkage to
care calculation. Hispanics had a slightly lower percentage of linkage to care than the overall
cascade at 85%.
Percentage of Hispanics diagnosed with HIV engaged in
selected stages of the continuum of care, 2014– Minnesota
100%
90%
100%
100%
87%
80%
85%
72%
70%
63%
63%
60%
56%
50%
40%
30%
20%
10%
0%
Overall Cascade
PLWH
Linkage to Care
n=7,728
Hispanic
Retention in Care
Viral Suppression
n=677
Minnesota HIV/AIDS Epidemiologic Profile—Hispanic
December 2015
HIV Testing
COUNSELING, TESTING AND REFERRAL SYSTEM
The Counseling, Testing and Referral (CTR) System consists of MDH-funded agencies that provide
free or low-cost HIV testing to Minnesota residents. The system offers anonymous and
confidential testing in clinical and office settings or during outreach, and most of these sites have
moved to offering rapid HIV testing instead of the more traditional blood draw. Confidential tests
are name-based and can therefore be reported to MDH and added to the yearly surveillance
statistics. Anonymous tests are code-based and are not included in yearly surveillance, although
positive anonymous results are reported to MDH. Occasionally, an anonymous test will be linked
to a surveillance case if the individual mentions having received a previous positive diagnosis and
recalls the date and site of that test, as well as the code given to him/her.
The number of tests conducted by the CTR agencies has grown from 10,597 in 2005 to 13,237 in
2014. The positivity rate (percent of positive tests among all tests performed) has ranged from
1.0% in 2010 to 1.5% in 2007. However in 2014, the positivity rate dropped to 0.8%
The majority of those tested in 2014 were males (70%), between the ages of 20 and 39 (67%),
and people of color (52%). Of the 13,237 tests conducted, 33% indicated male-to-male sex, and
6% indicated injection drug use in the past 12 months. The table below shows the number of
tests by client characteristics along with positivity rate. Fifteen percent of those tested had
never had a previous test. Of those with a previous test, 99% reported a negative result for
their most recent HIV test.
In 2014, 4% of those tested chose an anonymous test, and 28% of the tests were done outside of
a health care setting
Minnesota HIV/AIDS Epidemiologic Profile—HIV Testing
December 2015
CTR System Tests by Gender, Race, Age, and Risk 2014
Client Characteristics*
Number of Tests (percent)
Gender
Male
9,286 (70)
Female
3,779(29)
Transgender
83(0.6)
Unknown
89 (0.6)
Race/Ethnicity
White
African American/Black
Asian/Pacific Islander
American Indian
Multiple Races
Unknown
Hispanic†
Age
19 and under
20 - 39
40 - 59
60 and older
Unknown
Risk Category
MSM
IDU
MSM/IDU
High-risk heterosexual
contact
Low-risk heterosexual
contact
Other#
Unknown Risk
Total
Positivity Rate
1.0
0.4
1.2
0.0
6,461 (49)
4,126 (31)
497 (4)
692 (5)
405 (3)
1,056 (8)
1,378 (10)
0.7
1.1
0.2
0.6
1.0
0.9
1.0
629 (5)
8,889 (67)
3,297 (25)
392 (3)
30 (0.2)
0.2
0.8
0.9
1.3
0.0
4,143 (31)
616 (5)
195 (1)
1.6
0.5
3.6
3,787 (29)
3,507 (27)
0.4
144 (0.4)
845 (6)
0.3
0.0
0.8
13,237 (100)
0.8
* Numbers will not add to total
Includes all races
#Includes low and high risk sex with transgender person and female to female contact
†
Minnesota HIV/AIDS Epidemiologic Profile—HIV Testing
December 2015
Injection Drug Use
HIV/AIDS Prevalence among People Who Inject Drugs
Minnesota has a relatively low rate of infection among people who inject drugs (IDU). However,
it is important to note that injection drug use may be under reported due to social stigma.
People who inject drugs (including people with a joint risk of MSM and IDU) account for
approximately 10% of all living HIV cases in Minnesota. As of December 31st 2014, there were
429 people who inject drugs and 405 men who have sex with men and inject drugs (MSM/IDU)
living with HIV/AIDS in Minnesota.
HIV Diagnoses among IDU
The number of new diagnoses attributable to injection drug use has remained low from year to
year over the past decade. However there are differences by racial/ethnic group as well as by
gender.
Gender and Race/Ethnicity
IDU is the second most common known mode of transmission among women after
heterosexual contact with someone with or at risk for HIV, and accounted for 3% of cases
among women in 2014. IDU was estimated as a risk for 14% of cases among white women, 25%
among American Indian women, 8% among Hispanic women, and 3% among African American
women during 2012-2014. No cases were attributed to IDU among African-born or Asian
women during this same time period. It is important to note the number of American Indian
females diagnosed during this time period was small and is difficult to make generalizations
about risk.
Among men, IDU and MSM/IDU accounted for 6% of new cases in 2014, however percentages
varied by racial/ethnic group. IDU and MSM/IDU was estimated as a risk for 9% of cases among
white men, 2% among African American men, 3% among Hispanic men, 9% among Asian men,
and 45% among American Indian men during 2012-2014. It is important to note the number of
American Indian and Asian males diagnosed during this time period was small and is difficult to
make generalizations about risk. No cases were attributed to IDU or MSM/IDU among Africanborn males during this same time period.
Minnesota HIV/AIDS Epidemiologic Profile—Injection Drug Use
December 2015
Treatment Cascade for IDU and MSM/IDU in Minnesota
There were 423 HIV positive persons with IDU as their identified risk and 396 with MSM/IDU as
their risk included in the treatment cascade analyses. Compared to the overall HIV treatment
cascade in Minnesota, people who have an identified HIV risk of IDU have lower percentages of
retention in care as well as viral suppression. Persons with a HIV risk of MSM/IDU have higher
percentages of retention in care and viral suppression compared to the overall cascade for the
state. The MSM/IDU risk group had high levels of linkage to HIV care within three months of
HIV diagnosis, while IDU had low percentage of linkage to HIV care but the number of cases in
2013 among IDU and MSM IDU were small and should be interpreted with caution.
Percentage of IDU and MSM/IDU diagnosed with HIV
engaged in selected stages of the continuum of care, by
mode of exposure, 2014– Minnesota
100%
100%
100%
90%
90%
80%
80%
76%
66%
70%
60%
64%
54%
50%
40%
30%
20%
10%
0%
IDU
PLWH
Linkage to Care
n=423
MSM/IDU
Retention in Care
Viral Suppression
n=396
MSM=Men who have sex with men IDU=Injection drug use
Minnesota HIV/AIDS Epidemiologic Profile—Injection Drug Use
December 2015
Infants and Children
Pediatric cases of HIV/AIDS in Minnesota
Pediatric cases are defined in accordance with the CDC criteria as those cases of HIV or AIDS
who were less than 13 years of age at the time of test or diagnosis. In Minnesota, 77 cases of
pediatric HIV infection have been diagnosed in Minnesota to date, 56 (73%) of whom are still
assumed to be alive. Fifty-six (72%) of the 77 cases resulted from perinatal exposure, 9% were
associated with hemophilia or other coagulation disorder, 5% associated with blood transfusion
or transplant, and 13% had an undetermined exposure. These data reflect cases that were
diagnosed with HIV in Minnesota and does not include cases that were diagnosed elsewhere
and are now living in Minnesota.
As of December 31, 2014 there were 49 people under the age of 13 living with HIV/AIDS in
Minnesota.
Perinatal Transmission
Number of Cases
One of the success
Births to HIV-Infected Women and Number of Perinatally
stories in the history
Acquired HIV Infections* by Year of Birth, 2005 - 2014
of HIV infection is the
use of medication to
80
successfully reduce
HIV Infections
Births
70
perinatal
transmission of the
60
virus.
Without
50
treatment, the risk of
40
HIV
transmission
Rate of Perinatal Transmission
from a pregnant
30
for years 2012-2014 = 1.1%
woman to her child
20
before or during birth
10
is
approximately
0
25% 1.
Preventive
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
antiretroviral
Year
treatment can reduce
HIV or AIDS at first diagnosis for a child exposed to HIV during mother’s pregnancy, at birth, and/or
this percentage to 1– *during
breastfeeding.
2
2% . If breastfeeding
is avoided, nearly all children born to HIV-infected mothers can be spared infection.
The U.S. Public Health Service released guidelines in 1994 for the use of zidovudine to prevent
perinatal transmission of HIV and in 1995 recommended universal counseling and voluntary HIV
1
Conner EM, Sperling RS, Gelber R. et al. Reduction of Maternal-Infant Transmission of Human Immunodeficiency Virus Type 1 with
Zidovudine Treatment. New England Journal of Medicine, 331(28): 1173-80, 1994.
2
Cooper ER, Charurat M, Mofenson L, et al. Combination antiretroviral strategies for the treatment of pregnant HIV-1 infected women and
prevention of perinatal HIV-1 transmission. Journal of Acquired Immune Deficiency Syndrome, 29:484-94, 2002.
Epidemiologic Profile – Infants and Children
December 2015
testing for pregnant women. With the widespread adoption of these guidelines, perinatal HIV
transmission in the United States decreased by 81% between 1995 and 1999 3.
For the past decade the number of births to HIV-infected women increased steadily from 41 in
2005 to 65 births in 2014. The rate of transmission has decreased from 15% between 1994 and
1996 to 1.1% over the past three years, with one HIV+ baby born to an HIV+ mother in
Minnesota in 2014.
Reporting of births to HIV positive women is known to be incomplete. As a result of a project
conducted in 2001, MDH has both implemented an active component for perinatal surveillance
in collaboration with pediatric HIV clinicians in the Twin Cities to increase reporting of births to
HIV-infected mothers, and in 2005 changed reporting rules to explicitly state that a pregnancy
in an HIV-positive woman is a reportable condition. In addition, surveillance staff matches
surveillance records with vital statistics records on a yearly basis to identify births to HIV
positive women. Despite these efforts, reporting of pregnancy among women living with
HIV/AIDS continues to be incomplete.
3
Bulterys M, Nolan ML, Jamieson DJ, Dominguez K, Fowler MG. Advances in the prevention of mother-to-child HIV-1 transmission: current
issues, future challenges. AIDScience, 2(4):1-18, 2002.
Epidemiologic Profile – Infants and Children
December 2015
Late Testers
Late Testers in Minnesota
A characteristic of the HIV epidemic that impacts both prevention and care services is the
percentage of cases that are considered late testers. Late testers are defined as cases who had
their first positive HIV test within one year of receiving an AIDS diagnosis. An AIDS diagnosis so
close to initial diagnosis with HIV infection represents missed opportunities for both prevention
and medical care. The percentage of late testers in Minnesota is computed using data from the
HIV/AIDS Surveillance System (eHARS) on date of initial diagnosis and date of AIDS diagnosis.
Time of Progression to AIDS for HIV Infections Diagnosed
in Minnesota*, 2005 - 2014†
No AIDS DX
400
350
300
Number of Cases
Since
2000,
approximately
one
third of all new HIV
cases diagnosed in
Minnesota have either
been AIDS at first
diagnosis, or have
progressed to an AIDS
diagnosis within one
year of initial diagnosis
with HIV (non-AIDS)
infection.
However,
this overall stability
masks
important
differences
by
demographic
characteristics.
30.2%^
29.9%^
31.6%^
AIDS DX > 1yr
29.4%^
33.1%^
AIDS DX <= 1yr
31.1%^
31.4%^
29.6%^
34.0%^
27.4%^
250
200
150
100
50
0
2005
2006
2007
2008
2009 2010
Year
2011
2012
2013
2014
*Numbers include AIDS at 1st report but exclude persons arriving to Minnesota through the HIV+ Refugee Resettlement
Program, as well as other refugee/immigrants with an HIV diagnosis prior to arrival in Minnesota.
^ Percent of cases progressing to AIDS within one year of initial diagnosis with HIV Infection.
† Numbers/Percent
for cases diagnosed in 2014 only represents cases progressing to AIDS through April 1, 2015.
Minnesota HIV/AIDS Epidemiologic Profile—Late Testers
December 2015
Race/Ethnicity
Percent of Cases
The most significant differences occur by race/ethnicity, with the proportion of late testers in
2014 among African-born
Time of Progression to AIDS for HIV Infections*
(40%) and whites (29%)
Diagnosed
Among Foreign-Born Persons, Minnesota
being higher than that
2005 - 2014†
among Hispanic (15%) and
No AIDS DX
AIDS DX > 1yr
AIDS DX <= 1yr
African Americans (16%).
100
41.4%^
Similar data for American
35.4%^
Indians and Asian/Pacific
46.7%^
41.9%^
41.1%^
75
43.3%^
40.6%^
Islanders in a single year
42.9%^
48.3%^
48.3%^
had fewer than 10 cases
50
and are considered not
stable.
The percentage of late
testers is also higher among
foreign-born cases
compared to other cases. In
2014, 41% of foreign-born
cases were late testers
compared to 30% of USborn cases.
25
0
2005
2006
2007
2008
2009
2010
Year
2011
2012
2013
2014
Numbers include AIDS at 1st report but exclude persons arriving to Minnesota through the HIV+ Refugee Resettlement
Program, as well as other refugee/immigrants with an HIV diagnosis prior to arrival in Minnesota.
^ Percent of cases progressing to AIDS within one year of initial diagnosis with HIV Infection.
† Numbers/Percent
for cases diagnosed in 2014 only represents cases progressing to AIDS through April 2, 2015.
Age
Differences by age are as expected with the percentage of late testers increasing with age at
time of diagnosis. In 2014, 7% of those diagnosed between the ages of 13 and 24 were late
testers compared to 43% of those 45 years and older.
Geography
Over the past ten years, the percentage of late testers by geography has varied greatly from
46% in greater Minnesota compared to 29% in the TGA in 2010 to 23% in greater Minnesota
compared to 33% in the TGA in 2007. The combined percentage of late testers from 2004-2015
is 36% in Greater Minnesota compared to 30% in the TGA.
Minnesota HIV/AIDS Epidemiologic Profile—Late Testers
December 2015
Men Who Have Sex With Men (MSM)
HIV/AIDS Prevalence among MSM and MSM/IDU
Since the beginning of the HIV epidemic, the majority of HIV/AIDS cases in Minnesota have
been among MSM. As of December 31st, 2014, MSM and those with the joint risk of MSM and
IDU accounted for over half (56%) of the 7, 988 people living with HIV/AIDS in Minnesota.
Rate of HIV among MSM and MSM/IDU
Men who have sex with men have the highest rate of persons living with and new diagnoses of
HIV/AIDS than any other population. In 2014, the estimated rate of people living with HIV/AIDS
among MSM was 4,797 per 100,000 population. This is more than 60 times higher than the rate
among non-MSM men (77.1 per 100,000 population). The estimated rate of new diagnoses
among MSM in 2014 was 167.0 per 100,000 population. This is more than 40 times higher than
the rate of diagnoses among non-MSM men (3.8 per 100,000 population). It’s important to
note that MSM contains cases from all racial/ethnic categories and therefore cannot be directly
compared to the rates by race/ethnicity.
HIV Diagnoses among MSM
In 2014, MSM accounted for 47% of all new diagnosis (62% among males) with 144 cases
diagnosed. This is the fewest number of cases among MSM over the past decade and a 7%
decrease from 2013. In 2014, the majority (54%) of MSM diagnosed with HIV/AIDS resided in
Hennepin County, followed by 16% in Ramsey County. MSM/IDU accounted for 4% of the cases
diagnosed in 2014 at 11
New HIV/AIDS Infections* Among MSM and
cases.
Race/Ethnicity
While the majority (63%) of
new
HIV
infections
diagnosed among MSM
and MSM/IDU between
2012 and 2014 were white,
the proportion of new
diagnoses among men
differs by race/ethnicity. Of
the new HIV infections
diagnosed among males
between 2012 and 2014,
MSM/IDU By Race, 2012-2014
(n = 496)
African-born
1%
Asian American Indian
1%
2%
Hispanic
13%
African American
19%
White
64%
*HIV or AIDS at first diagnosis
Excludes 1 case with missing race.
Minnesota HIV/AIDS Epidemiologic Profile—Men Who Have Sex With Men
December 2015
MSM or MSM/IDU were estimated to account for 95% of cases among Hispanic males, 96% of
cases among White males, 87% of cases among African American males, and 10% of cases
among African-born males. During the same time period, 100% of all Asian males had MSM as
their mode of exposure and 55% among American Indian males; however the number of new
diagnoses during this time is too small to make further generalizations about risk.
Age at Diagnosis
While the majority of MSM and MSM/IDU living with HIV in 2014 were over the age of 45
(61%), young MSM (between the ages of 13 and 24) account for a growing percentage of the
new diagnoses among MSM and MSM/IDU. the number of new infections among this group
more than quadrupled from 15 in 2001 to 74 in 2009. In 2014, there were 37 cases of young
MSM and MSM/IDU diagnosed with HIV/AIDS which accounted for 24% of all diagnoses among
this population. For more information about HIV infection in youth, please see the Adolescent
and Young Adult section of this document.
The reason behind the increase in HIV infections among young MSM in Minnesota is somewhat
unclear. However, 61% of young male cases were interviewed in 2009, and behaviors most
commonly reported included anonymous sex, using technology (e.g., chat rooms), having
multiple partners, and using condoms infrequently.
MSM/IDU
MSM/IDU represent a smaller number of cases, accounting for 5% of people living with
HIV/AIDS in Minnesota and 4% of newly reported HIV infections in 2014. For more information
about the demographics of MSM/IDU risk group please see the Injection Drug Use section of
this document.
HIV Treatment Cascade among MSM and MDM/IDU
There were 3,899 HIV positive persons with MSM as their identified risk and 396 with MSM/IDU
as their risk included in the treatment cascade analyses. Compared to the overall HIV treatment
cascade in Minnesota, people who have an identified HIV risk of MSM have higher percentages
of viral suppression. MSM have the highest percentage of viral suppression than any other risk
group at 67%. MSM/IDU also have higher percentages of retention in care as well as viral
suppression as compared to the overall cascade for Minnesota.
There were 155 cases among MSM reported in 2013 that were included to calculate linkage to
care. Ninety-three percent of MSM linked to care within three months of their initial HIV
diagnosis in 2013. This is six percentage points higher than the overall cascade. There were 10
cases among MSM/IDU reported in 2013 included in the linkage to care calculation. Linkage to
care among MSM/IDU was 90%, or three percentage points higher than the overall treatment
Minnesota HIV/AIDS Epidemiologic Profile—Men Who Have Sex With Men
December 2015
cascade. However, the number of cases among MSM/IDU included in the linkage to care
calculation is small and should therefore be interpreted with caution.
Percentage of IDU and MSM/IDU diagnosed with HIV
engaged in selected stages of the continuum of care, by
mode of exposure, 2014– Minnesota
100%
90%
100%
100%
90%
88%
80%
76%
74%
67%
70%
64%
60%
50%
40%
30%
20%
10%
0%
MSM
PLWH
Linkage to Care
n=3,899
MSM/IDU
Retention in Care
Viral Suppression
n=396
MSM=Men who have sex with men IDU=Injection drug use
Minnesota HIV/AIDS Epidemiologic Profile—Men Who Have Sex With Men
December 2015
Transgender
HIV/AIDS Prevalence among transgender persons
Historically, current gender identity was not regularly collected as part of HIV Surveillance. In
2014, current gender identity was added to the HIV case report form, which is how data on cases
are reported to MDH. However, it is known that gender identity is not routinely collected in all
health care settings and is likely under reported to the Minnesota Department of Health. In 2014,
there were 60 transgender clients receiving Ryan White services. This is more than the number
of transgender individuals that are in the MDH HIV surveillance system, eHARS. Therefore, the
data reported here can be considered an underestimation and serve as a minimum estimate for
HIV among transgender people in Minnesota. As of December 31st 2014, there were 41
transgender persons living with HIV in Minnesota according to eHARS. The data presented here
reflect data from HIV surveillance which is also reported to CDC.
Race/Ethnicity
Transgender people of
Transgender persons living with HIV by Race,
color account for a
Minnesota, 2014
disproportionate
n=41
number of transgender
African-born
10%
Hispanic
people living with HIV in
Multiple
20%
2%
Minnesota.
White
people account for just
27% of transgender
American Indian
2%
people living with HIV,
while people of color
Asian/PI
5%
White
account for 73% of
27%
transgender
people
living with HIV whereas
only 17% of the general
population in Minnesota
African American
34%
are people of color.
Additionally,
transgender
people
living with HIV are more racially diverse than the population living with HIV in Minnesota as a
whole as 56% of all people living with HIV in Minnesota are people of color.
Minnesota HIV/AIDS Epidemiologic Profile—Transgender
December 2015
Mode of Exposure
The majority (88%) of
transgender people living
with HIV in Minnesota have
an estimated mode of
exposure of sexual contact.
The joint risk of sexual
transmission
and
IDU
accounts for 10% of the
cases.
HIV transmission category among Transgender
persons living with HIV, Minnesota, 2014
n=41
Sexual
Transmission/IDU
10%
n = Number of persons
IDU = Injecting drug use
Unspecified
2%
Sexual
Transmission
88%
HIV Diagnoses among transgender persons
Between 2010 and 2014, there have been two transgender persons diagnosed with HIV each
year, for a total of 10 diagnoses during this five-year time period. During this time, the racial
distribution of diagnoses among transgender persons was 30% Hispanic, 30% African American,
30% White and 10% African-born. Over the past five years, half of the HIV cases diagnosed
among transgender persons were over the age of 35. The remaining 50% were between the
ages of 20 and 34 years old.
Minnesota HIV/AIDS Epidemiologic Profile—Transgender
December 2015
White (non-Hispanic)
HIV/AIDS Prevalence among White (non-Hispanic) persons
As of December 31st 2014, there were 3,977 white (non-Hispanic) persons living with HIV/AIDS
in Minnesota, representing half (50%) of people living with HIV/AIDS in Minnesota. Of the 3,977
white persons living with HIV in Minnesota, 3,518 (88%) are male and 459 (12%) are female.
Of the 3,518 white male cases, 86% were estimated to have a risk of men who have sex with
men (MSM), 9% MSM/IDU, 2% IDU and 2% heterosexual contact with someone with or at risk
for HIV infection and 1% other risk (hemophilia, transplant, transfusion or mother with HIV or
HIV risk). Of the 459 white females living with HIV in Minnesota, 81% have a risk of
heterosexual contact with someone with or at risk for HIV infection, 16% IDU, and 3% other
(hemophilia, transplant, transfusion or mother with HIV or HIV risk).
HIV Diagnoses among White (non-Hispanic) persons
White males drove the epidemic in the 1980s and early 1990s, and today white males still
account for the largest number of new infections, but the proportion of cases that white males
account for is decreasing. In 2014, white males accounted for 40% of all of the new HIV
diagnoses, with 122 diagnoses.
In the beginning of the epidemic, white women accounted for a majority of newly diagnosed
cases among females. However, the number of new infections among women of color has
exceeded the number among white women since 1991. In 2014 white women made up 19% of
the new infections among women in Minnesota, with 14 new diagnoses.
HIV Infections* Among White (non-Hispanic)
by Estimated Mode of Exposure
2012 – 2014
Mode of Exposure
Of the 376 white males
diagnosed between 2012
and 2014, 89% of cases had
an estimated mode of
exposure of MSM, 7%
MSM/IDU, 2% heterosexual
contact with someone with
or at risk for HIV infection
and 2% IDU. Of the 39 white
females diagnosed between
2012 and 2014, 86% had an
estimated mode of exposure
of heterosexual contact with
White Males (n = 376)
White Females (n = 39)
Heterosex
2%
IDU
14%
IDU
2%
MSM/IDU
7%
MSM
89%
n = Number of persons MSM = Men who have sex with men
IDU = Injecting drug use
Heterosex = Heterosexual contact with someone with or at risk for HIV
Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk
* HIV or AIDS at first diagnosis
Minnesota HIV/AIDS Epidemiologic Profile—White (non-Hispanic)
December 2015
Heterosex
86%
someone with or at risk for HIV and 14% IDU.
Geography
A greater proportion of white persons diagnosed with HIV live in Greater Minnesota than
persons of color. Twenty-six percent of white women diagnosed with HIV from 2012-2014 lived
in greater Minnesota, compared to 10% of women of color. Eighteen percent of white men
diagnosed during the same time period lived in greater Minnesota compared to 10% of men of
color.
HIV Treatment Cascade among White (non-Hispanic) persons
There were 3,835 HIV positive white persons included in the treatment cascade analyses.
Compared to the overall HIV treatment cascade in Minnesota, white persons have higher
percentages of retention in care as well as viral suppression. White people have the highest
percentage of people who achieved viral suppression at 70%
There were 144 cases among white persons reported in 2013 that were included in the linkage
to care calculation. Whites have a slightly lower percentage of linkage to care than the overall
cascade for Minnesota.
Percentage of White (non-Hispanic) persons diagnosed with HIV engaged
in selected stages of the continuum of care, 2014 – Minnesota
100%
90%
100%
100%
87%
80%
85%
77%
72%
70%
70%
63%
60%
50%
40%
30%
20%
10%
0%
Overall Cascade
PLWH
n=7,728
Linkage to Care
White non-Hispanic
Retention in Care
Viral Suppression
n=3,835
Minnesota HIV/AIDS Epidemiologic Profile—White (non-Hispanic)
December 2015
Women
HIV/AIDS Prevalence among Women
Since the beginning of the epidemic, women have accounted for approximately 25% of persons
living with HIV in Minnesota as well as new HIV diagnoses. As of December 31st 2014, there
were 1,880 women living with HIV in Minnesota.
Race/Ethnicity
Women of color account
for a disproportionate
Women Living with HIV/AIDS in Minnesota
by Race/Ethnicity, 2014
number of women living
with HIV in Minnesota.
(n = 1,880)
White women account for
Afr Amer
27%
just 24% of women living
White
with HIV, while women of
25%
color account for 73% of
prevalent female HIV/AIDS
cases whereas only 17% of
Other
3%
the
general
female
population in Minnesota
Asian
2%
are women of color. The
Amer Ind
largest number of women
Afr born
3%
33%
living with HIV/AIDS is
Hispanic
7%
among
African-born
women (672 persons)
followed by African-American and white women (515 and 459 women, respectively).
Mode of Exposure
The majority (81%) of women living with HIV in Minnesota have an estimated mode of
exposure of heterosexual contact. Injection drug use accounts for 9% of prevalent HIV
infections in Minnesota among women.
Across all race/ethnicity groups, females most frequently report heterosexual contact with
someone with or at risk for HIV infection as their mode of HIV exposure. However, IDU also
accounts for the next largest percentage of female cases among most race/ethnicity
groups. The largest estimated percentage of IDU cases are among American Indian women
(20%), followed by white women with 16%, African Americans with 14% and Hispanics with
Minnesota HIV/AIDS Epidemiologic Profile—Women
December 2015
9%. Among Asian and Pacific Islander females, heterosexual contact accounted for an
estimated 81% of cases, and IDU for an estimated 2%. However, the number of prevalent cases
among Asian/Pacific Islander and American Indian females is quite small, so the results need to
be interpreted carefully. Finally, while African-born women make up the largest proportion
(33%) of females living with HIV in Minnesota, they account for less than one percent of the IDU
cases among HIV positive women.
HIV Diagnoses among Women
In 2014 the number of newly diagnosed HIV positive women increased by 7%, from 68 cases in
2013 to 73 cases.
Race/Ethnicity
In 2014, women of color accounted for 13% of the female population in Minnesota but made
up 79% of new infections among females, with African American and African-born women
accounting for 66% of infections among women. White, non-Hispanics make up approximately
83% of the female population but only 23% of new infections among women in 2014. Africanborn women continue to have the highest number of new infections among women annually.
The annual number of new infections diagnosed among Hispanic, American Indian, and Asian
females continues to be quite small.
HIV Infections* Among Females
by Race/Ethnicity† and Year of Diagnosis, 2005 – 2014
50
White
Asian
45
African American
American Indian
Hispanic
African-born
2009 2010
Year
2012
40
Number of Cases
35
30
25
20
15
10
5
0
2005
2006
2007
2008
2011
2013
2014
* HIV or AIDS at first diagnosis
† “African-born” refers to Blacks who reported an African country of birth; “African
American” refers to all other Blacks. Cases with unknown race are excluded.
Minnesota HIV/AIDS Epidemiologic Profile—Women
December 2015
Mode of Exposure
Throughout the epidemic, heterosexual contact has been the predominant mode of HIV
exposure reported among females accounting for 73% of female cases in 2014. IDU is the
second most common known mode of transmission, and accounted for 3% of cases among
women in 2014. An unspecified risk has been designated for a growing percentage of cases for
the past several years and represented 24% of female cases in 2014.
HIV Treatment Cascade among Women
There were 1,778 HIV positive women included in the treatment cascade analyses. Compared
to the overall cascade, women are retained in care at a slightly higher rate (73% versus 72%).
Women achieve viral suppression at a slightly lower rate than the overall cascade (61% versus
63%).
There were 68 cases among women reported in 2013 that were included in the linkage to care
calculation. Women were linked to care at a slightly higher rate than the overall cascade in
2013 (80% versus 87%).
Percentage of females diagnosed with HIV engaged in
selected stages of the continuum of care, 2014– Minnesota
100%
90%
100%
100%
90%
87%
80%
73%
72%
70%
63%
61%
60%
50%
40%
30%
20%
10%
0%
Overall Cascade for Minnesota
PLWH
Linkage to Care
n=7,728
Retention in Care
Females
Viral Suppression
n=1,778
Minnesota HIV/AIDS Epidemiologic Profile—Women
December 2015
Ryan White Services and Unmet Need
Ryan White Services in Minnesota
This section of the profile provides a description of people who use the Ryan White HIV/AIDS
Program services in Minnesota, both within the TGA (Part A and Part B) and Greater Minnesota
(Part B), and quantifies the unmet need for primary medical care.
DATA SOURCES
The data presented in this section comes primarily from two sources, the enhanced HIV/AIDS
Reporting System (eHARS) and the Minnesota CAREWare system used by all agencies providing
Part A, Part B, ADAP and state-funded HIV services.
Since almost all Ryan White services are dependent on financial eligibility, it should not be
expected that everyone living with HIV/AIDS in Minnesota would be eligible and/or receiving
Ryan White services. Therefore, surveillance data should not be used as the standard by which
services are measured, but as an additional piece of the puzzle in describing HIV/AIDS care in
Minnesota.
OVERVIEW OF RYAN WHITE IN MINNESOTA
COMPARISON OF EPI AND UTILIZATION DATA
The number of clients utilizing Ryan White services has steadily grown from 1,771 in 1996 to
4,117 in 2014. This is compared to 7,988 people assumed to be living with HIV in Minnesota that
are in surveillance. Over the past three years, several of the funded services have seen increases
in the number of people being served.
GENDER
Males comprise the majority of those living with HIV/AIDS in Minnesota, accounting for 76% of
all cases. A similar distribution is seen among those receiving services, with males accounting for
70% of clients and females accounting for 29%. Transgender persons make up about 1% of those
receiving services and 0.5% of all cases in surveillance.
Minnesota HIV/AIDS Epidemiologic Profile—Ryan White Services and Unmet Need
December 2015
AGE
Persons ages 40-55 account for the most (47%) of the people receiving Ryan White services in
2014. Adolescents and young adults (ages 13–24) account for 5% of those receiving services. The
age distribution of those receiving services is similar to those living with HIV/AIDS according to
surveillance. People ages 40-55 account for 50% of those living with HIV/AIDS and adolescents
and young adults account for 4% (data not shown).
MODE OF EXPOSURE
People Living with HIV/AIDS By Mode of Exposure in
Minnesota, Ryan White Clients and Surveillance, 2014
There are substantial
Surveillance
differences in the mode of
Ryan White Clients
n=7,988
n=4,117
exposure distribution
Unspecified
Unspecified
between people receiving
15%
Other 7%
Other
3%
Ryan White Services and the
MSM
2%
44%
mode of exposure
distribution of everyone living
with HIV in Minnesota who
Hetero
are in surveillance. While
38%
Hetero
MSM account for 51% of
22%
those living with HIV/AIDS in
IDU
MSM/IDU
MSM/IDU
surveillance, they only
IDU
5%
5%
3%
5%
account for 44% in Ryan
n = Number of persons MSM = Men who have sex with men
IDU = Injecting drug use
Heterosexual contact with someone with or at risk for HIV
White clients. People with a
Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk
risk of heterosexual contact
make up a greater proportion of Ryan White clients than in surveillance, accounting for 38% of
Ryan White clients and 22% of people in surveillance.
RACE/ETHNICITY
There are differences in the racial/ethnic distribution between people receiving Ryan White
Services and everyone living with HIV in Minnesota who is in surveillance. While white people
account for half of the people living with HIV/AIDS in Minnesota, they account for 40% of the
people receiving Ryan White services. People of color account for the other half of the people
living with HIV/AIDS in Minnesota, and 60% of those receiving Ryan White Services.
Minnesota HIV/AIDS Epidemiologic Profile—Ryan White Services and Unmet Need
December 2015
MSM
51%
People Living with HIV/AIDS By Race/Ethnicity in Minnesota,
Ryan White Clients and Surveillance, 2014
Ryan White Clients
(n=4,117) Native
Other
4%
Asian/Pacific
Islander
2%
Hispanic
11%
Surveillance
(n=7,988)
American
2%
White
50%
White
40%
Other
3%
Black**
41%
Black**
35%
Hispanic
9%
Native
American
1%
Asian/PI
2%
*Includes 2 cases from Pierce and St. Croix Counties in WI.
**Black – includes both African Americans and Black, African-born persons.
***Other – Multi-racial persons or persons with unknown race
GEOGRAPHY
The table below shows that the proportion of HIV positive people receiving services is greater
the TGA than in Greater Minnesota. Additionally, based on the number of people served by Ryan
White, the majority of people accessing Ryan White services live in the TGA (86%) compared to
13% in Greater Minnesota. In addition, 1% of people receiving services have unknown counties
of residence, and less than 1% reside in other states.
Number of People Receiving Ryan White Services and Living Cases of HIV/AIDS, Minnesota 2014
Greater MN
13-County TGA
Number Receiving
Services*
Number in Surveillance Ŧ
Percentage Receiving
Services
541
1,128
48%
3,529
6,832
52%
* Includes 10 cases from Pierce and St. Croix counties, does not include 43 cases with unknown residence.
Ŧ
Does not include 38 cases with unknown residence.
Minnesota HIV/AIDS Epidemiologic Profile—Ryan White Services and Unmet Need
December 2015
SERVICES RECEIVED IN 2014
Number of Clients Served
In 2014, Medical Case
Most Utilized Ryan White Care Services, Minnesota
Management was the
2012-2014
most utilized service,
with 2,960 clients (72%
2012
2013
2014
of clients) accessing
3500
case
management
3067
2968 2960
3000
services.
Medical
Transportation Services
2500
was the next most
utilized service with
2000
1,517 clients (37% of
1610 1584 1571
1479 1510
1460
1444 1429 1442
1500
clients), followed by the
1311
1091
1086 1132 1044
Meal Services with
1000
773
1,442 clients served
(35% of clients), AIDS
500
Pharmaceutical
0
Assistance
Program
MCM
ADAP
Outpt./Amb. Med.
Emergency
Transportation
Meal Services
(ADAP) with 1,311
Care
Financial
Assistance
clients (32% of clients),
and emergency financial
assistance with 1,044 clients (25% of clients). The next most used services were Case
Management (non-medical), Outpatient/Ambulatory Care, and Oral Health Care with 871, 773,
and 622 clients, respectively.
Characterizing Unmet Need for Primary Care among HIV Positive People
The definition of unmet need for primary medical care is: “An individual with HIV or AIDS is
considered to have an unmet need for care (or to be out of care) when there is no evidence that
s/he has received any of the following three components of HIV primary medical care during a
defined 12-month time frame: (1) viral load testing, (2) CD4 count, or (3) provision of antiretroviral therapy (ART).” 1
MDH calculated an estimate of unmet need using data in eHARS to determine the number of
people living with HIV/AIDS as of December 31, 2014 and how many of those individuals had
received a CD4 or viral load test in 2014.
As of December 31, 2014 there were 7,988 persons living with HIV/AIDS in Minnesota. Using the
methodology described above, we are able to estimate that of those, the number not receiving
primary medical care for their HIV is 2,149 or 27% of people living with HIV/AIDS in Minnesota.
1
HRSA/HAB definition of unmet need
Minnesota HIV/AIDS Epidemiologic Profile—Ryan White Services and Unmet Need
December 2015
The table below shows the number of people living with HIV/AIDS who are in and out of care by
race, gender and mode of exposure.
Demographic Characteristics of Out of Care PLWHA in Minnesota, 2014
Number
Number
Number
In Surveillance
In Care
Out of Care
Race*
White, not Hispanic
3,977
3,065
912
Black, not Hispanic
2,819
1,948
871
African American
1,719
1,177
542
African-born
1,100
771
329
Hispanic
716
459
257
American Indian
121
96
25
Asian/Pacific Islander
153
117
36
Multiple Races
180
147
33
Sex at Birth
Male
6,108
4,443
1,665
Female
1,880
1,396
484
Mode of Exposure
MSM
4,046
3,012
1,034
IDU
429
283
146
MSM/IDU
405
307
98
Heterosexual contact
1,775
1,316
459
Mother with HIV
103
90
13
Other/hemophilia/blood transfusion
34
27
7
Unspecified risk
1,196
804
392
Total
7,988
5,839
2,149
Percent
Out of Care
23%
31%
32%
30%
36%
21%
24%
18%
27%
26%
26%
34%
24%
26%
13%
21%
33%
27%
*Excludes individuals of unknown race
Minnesota HIV/AIDS Epidemiologic Profile—Ryan White Services and Unmet Need
December 2015
Technical Notes
EPIDEMIOLOGICAL SURVEILLANCE – DATA QUALITY AND SOURCES
HIV/AIDS REPORTING SYSTEM (eHARS)
The Minnesota Department of Health (MDH) collects confidential name-based case reports of
HIV infection (since 1985) and AIDS diagnoses (since 1982) through a passive and active HIV/AIDS
surveillance system. In Minnesota, laboratory-confirmed infections of human immunodeficiency
virus (HIV) are monitored by MDH through this active and passive surveillance system. State law
(Minnesota Rule 4605.7040) requires both physicians and laboratories to report all cases of HIV
infection (HIV or AIDS) directly to MDH (passive surveillance). 1 Additionally, regular contact is
maintained with the following clinical sites to help ensure completeness of reporting (active
surveillance): Hennepin County Medical Center and Veterans Administration. Demographic,
exposure, and clinical data are collected on each case 2 and entered into Minnesota’s HIV/AIDS
Reporting System (eHARS) database developed by the U.S. Centers for Disease Control and
Prevention (CDC).
Factors that impact the completeness and accuracy of HIV/AIDS surveillance data include:
compliance with case reporting, timeliness of case reporting, test-seeking behaviors of HIVinfected individuals, the availability and targeting of HIV testing services, and the willingness of
persons recently diagnosed with HIV to be interviewed by DIS.
Given the long period of time between infection with HIV and the clinical manifestation of AIDS,
patterns of new HIV case reports are believed to describe the current epidemic more accurately
than AIDS case reports. The introduction of highly active antiretroviral therapies in the mid-1990s
further delayed the onset of AIDS for many patients and makes AIDS case reporting a weak tool
for describing the present epidemic. Including AIDS case reports is useful for looking at the whole
epidemic or trends over time.
While HIV case reports do represent persons more recently infected than AIDS case reports, there
are still several limitations that affect the completeness and timeliness of the data. There are
multiple ways for a case to be undetected by the state surveillance system promptly after
seroconversion.
First, CDC estimates that about 20% of HIV-infected individuals are unaware of their status. And
for gay/bisexual men, evidence suggests this percentage is much higher (77%) 3. This is partly
because early HIV infection does not produce severe nor distinct symptoms and so delays in
Tribal health centers are exempt from this reporting requirement. However, a recent survey of tribal health directors found that most of these
facilities report new HIV cases on a regular basis (data not published) (MDH, 2005).
2 CDC has refined the case definition for AIDS over the years. The most recent change to the case definition occurred in 1993 when (in
conjunction with confirmed HIV infection) tuberculosis, recurring pneumonia, invasive cervical cancer, or a CD4 count of less than 200 (or
below 14% of lymphocytes) joined 23 other AIDS-defining infections/conditions.
3
MacKellar DA, Valleroy LA, Secura GM, Bartholow BN, McFarland W, Shehan D, Ford W, LaLota M, Celentano DD, Koblin BA, Torian LV, Thomas
E, Janssen RS, Young Men’s Survey Group. Repeat HIV testing, risk behaviors, and HIV seroconversion among young men who have sex with
men: a call to monitor and improve the practice of prevention. Journal of Acquired Immune Deficiency Syndromes, 29(1):76-85, 2002
1
Minnesota HIV/AIDS Epidemiologic Profile – Technical Notes
December 2015
testing are common. Additionally, many people acknowledge avoiding testing for fear of a
positive test result or because they believe that they are not at risk.
Second, cases of new HIV infection can also go undetected by disease surveillance due to the
availability of anonymous testing. Once a person begins care, however, other HIV/AIDS
surveillance reporting mechanisms would Annual HIV/AIDS Surveillance Summaries
most likely detect the case. Thus, although Annual HIV/AIDS surveillance summaries for
HIV case reporting is our best estimate of Minnesota are available on the MDH
new HIV infections, the system does not website:
capture all new cases and there are varying http://www.health.state.mn.us/divs/idepc/
amounts of delay between infection, diseases/hiv/hivsurvrpts.html
testing, and reporting.
New testing methodologies are becoming more widely available and will enable more timely
descriptions of the epidemic as it continues to unfold. In addition, continued efforts to encourage
testing and counseling help limit the amount of undiagnosed HIV infection.
BEHAVIORAL SURVEILLANCE
MDH collects a small amount of behavioral data as it relates to HIV and AIDS surveillance
information. For example, reports of HIV infection received by MDH include information on drug
use and sexual behaviors. Additionally, from time to time MDH will undertake special projects
with the intent of collecting behavioral data on specific populations. Examples of these are the
2001 Minnesota STD Prevalence Study (ages 12-24) and the 2004 and 2007 Twin Cities Men’s
Health Surveys (MSM 18 and older) and the 2011 Minnesota Men’s Health Study (MSM 18 and
older).
OTHER DATA SOURCES
Data regarding risk factors for acquiring HIV that are presented in this report include sexually
transmitted disease rates (Epidemiology and Surveillance Unit, STD and HIV Section, MDH), teen
pregnancy rates (Minnesota Center for Health Statistics), chemical health indicators (Minnesota
Behavioral Risk Factor Surveillance System), behavioral survey data (Minnesota Student Survey
and Minnesota Behavioral Risk Factor Surveillance System), a variety of social and economic data
from the 2010 Census (U.S. Census Bureau), and results from specific scientific studies. These
data serve to characterize the population at risk for acquiring or transmitting HIV.
MODE OF EXPOSURE
Cases can have unspecified risk for two reasons. The first is that the person has not yet been
interviewed or has refused an interview by a Disease Intervention Specialist (DIS) from MDH, and
therefore we have little information on their risk category. Disease Intervention Specialists have
reported difficulty interviewing recent cases due to language and cultural barriers, as well as
difficulty locating the individuals. Second, the person may have no obvious risk. However,
heterosexual contact as a mode of HIV transmission is only assigned when the person knows that
their partner was HIV-infected or at increased risk for HIV. Often this level of knowledge about
sexual partners (anonymous, casual, or exclusive) may be unknown. According to a study
Minnesota HIV/AIDS Epidemiologic Profile – Technical Notes
December 2015
conducted by the CDC, it is likely that at least 80% of women with unspecified risk acquired HIV
through heterosexual contact 4.
In 2004, MDH began estimating mode of exposure for cases with unspecified risk in its annual
PowerPoint summary slides 5. In 2014, estimation was done by using the risk distribution for
cases reported between 2012 and 2014 with known risk by race and gender and applying the
distribution to those with unspecified risk of the same race and gender. For females a step was
added in 2007, whereby females that were interviewed by a DIS and determined not to have
any risk other than heterosexual exposure were designated as having heterosexual mode of
transmission. There are two exceptions to this method, African-born cases and Asian/Pacific
Islander women. For both African-born and Asian/Pacific Islander women, a breakdown of 95%
heterosexual risk and 5% other risk was used. For African-born males, a breakdown of 5% maleto-male sex, 90% heterosexual risk, and 5% other risk was used. These percentages are based
on epidemiological literature and/or community experience 6.
TREATMENT CASCADE
As part of the National HIV/AIDS Strategy for the United States, MDH began calculating an HIV
treatment cascade in 2013 using HIV surveillance data. These calculation help us better
understand the HIV epidemic and the disparities that exist in the delivery of care among HIV
positive people in Minnesota.
Limitations
Laboratory data are used as a proxy for a care visit to calculate each segment of the treatment
cascade. The accuracy of the cascade depends on complete reporting of laboratory results. The
transition from voluntary reporting of CD4 and VL results to mandated reporting in 2011 has
occurred at different rates among the various reporting laboratory facilities. We have been
made aware of at least one lab in the state that has had difficulty consistently reporting all CD4
and VL results which could potentially bias the results. We also know that patients who have
laboratories drawn as part of research studies are not reported to MDH. One clinic estimates
that approximately 90 of their patients are participating in a research study.
Linkage to Care
Linkage to care is defined as those who were diagnosed in Minnesota during the year 2013 and
had a CD4 or VL test performed within 90 days of initial diagnosis. Calculation of the linkage to
care measure use a denominator that is different due to guidance from CDC that instructs local
jurisdictions to make this calculation based on one year of diagnoses. Therefore results for this
measure are displayed in a different color in the graphics.
Lansky A, Fleming PL, Buyers RH, Karon JM, Wortley PM. A method for classification of HIV exposure category for women with HIV risk
information. Monthly Morbidity and Mortality Report, 50(RR-6):29-40, 2001
5 See annual reports at http://www.health.state.mn.us/divs/idepc/diseases/hiv/stats/hivsurvrpts2012.html
6 Detailed methodology available in the HIV Surveillance Technical Notes at
http://www.health.state.mn.us/divs/idepc/diseases/hiv/stats/pmtech2010.html
4
Minnesota HIV/AIDS Epidemiologic Profile – Technical Notes
December 2015
GLOSSARY OF TERMS
Greater Minnesota: All counties outside of Transitional Grant Area. The counties include:
Aitkin, Becker, Beltrami, Benton, Big Stone, Blue Earth, Brown, Carlton, Cass, Chippewa, Clay,
Clearwater, Cook, Cottonwood, Crow Wing, Dodge, Douglas, Faribault, Fillmore, Freeborn,
Goodhue, Grant, Houston, Hubbard, Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Koochiching,
Lac qui Parle, Lake, Lake of the Woods, Le Sueur, Lincoln, Lyon, McLeod, Mahnomen, Marshall,
Martin, Meeker, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter
Tail, Pennington, Pine, Pipestone, Polk, Pope, Red Lake, Redwood, Renville, Rice, Rock, Roseau,
Saint Louis, Sibley, Stearns, Steele, Stevens, Swift, Todd, Traverse, Wabasha, Wadena, Waseca,
Watonwan, Wilkin, Winona, and Yellow Medicine counties.
HIV Infection: Includes all new cases of HIV infection, both HIV (non-AIDS) and AIDS at first
diagnosis, diagnosed within a given calendar year.
Incidence: The number of new cases of a disease that occur in a population during a certain
time period, usually a year.
Late Tester: Persons with an AIDS diagnosis within one year of initial HIV infection diagnosis
Linkage to Care: Linkage to care is defined as those who were diagnosed in Minnesota during
the year 2012 and had a CD4 or VL test performed within 90 days of initial diagnosis.
Pediatric case: Children less than 13 years of age at time of diagnosis.
People Living with HIV/AIDS (Diagnosed Prevalence): CDC estimates that between 18 and 20
percent of HIV infected individuals are not diagnosed and includes this estimate of unaware
individuals in the national treatment cascade. For local adaptations of the treatment cascade,
CDC recommends 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.
Prevalence: The total number of persons living with a specific disease or condition at a given
time.
Minnesota HIV/AIDS Epidemiologic Profile – Technical Notes
December 2015
Retention in care: The CDC defines retention in care for local adaptations of the treatment
cascade for jurisdictions without medical monitoring funding as two laboratory results at least
three months apart. This is not displayed on Minnesota’s treatment cascade because initial
analyses showed that 30% of people who were virally suppressed at the end of 2012, did not
meet this definition of retention in care. After discussing with our prevention and care partners,
it was noted that patients who are doing well on treatment may have only one laboratory
ordered each year to monitor progression of disease. Therefore, on Minnesota’s treatment
cascade, retention in care is defined 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 of Minnesota’s adaptation of retention in care, use caution when comparing the
retention in care measure to the national estimate.
Transitional Grant Area: A geographical area highly impacted by HIV/AIDS that are eligible to
receive Ryan White HIV/AIDS Program Part A funds. To be an eligible TGA and area must have
reported at least 1,000 but fewer than 2,000 new AIDS cases in the most recent five years. In
Minnesota the TGA comprises the 13 counties in the Minneapolis-St. Paul-Bloomington
metropolitan statistical. This includes 11 counties in Minnesota as well as two counties in
Wisconsin. The Minnesota Counties include: Anoka, Dakota, Carver, Chisago, Hennepin, Isanti,
Ramsey, Scott, Sherburne, Washington, and Wright counties. The Wisconsin counties include
Pierce and St. Croix counties.
Viral suppression: Viral suppression is defined as a viral load test result of ≤200 copies/mL at
the most recent test during 2014.
Minnesota HIV/AIDS Epidemiologic Profile – Technical Notes
December 2015