Epidemiologic Profile of HIV in Connecticut

Transcription

1 Connecticut Department of Public Health TB, HIV, STD & Viral Hepatitis Section Epidemiologic Profile of HIV in Connecticut ,000 HIV continuum of care, Connecticut, 2011 (data reported through 2012) 12,000 11,985 18% unaware 10,148 Number 9,000 6,000 36% not in care (no report of VL or CD4) 6,528 75% 5,149 4,866 3,000 79% 0 HIV infected HIV diagnosed One visit Two visits Suppression In 12 months Three months apart 200 copies/ml

2 Abbreviations: AAMR AIDS CDC CI DPH EMA HCV HIV HRSA IDU MSM PLWH STD TGA Age adjusted mortality rate Acquired immunodeficiency syndrome Centers for Disease Control and Prevention Confidence interval Department of Public Health Eligible metropolitan area hepatitis C virus Human immunodeficiency virus Health Resources and Services Administration Injection drug user Men who have sex with men People living with HIV or AIDS Sexually transmitted disease Transitional grant area

3 Connecticut Department of Public Health Jewel Mullen, MD, MPH, MPA, Commissioner Infectious Disease Division Matthew L. Cartter, MD, MPH, State Epidemiologist TB, HIV, STD and Viral Hepatitis Section Christian D. Andresen, Section Chief Heidi Jenkins, Program Coordinator HIV Surveillance Program Rory Angulo, MD, MBA, Case/Molecular Surveillance Amor Gamarra-Gross, Office Administration and Data Entry Heather Linardos, MPH, Case and Incidence Surveillance Suzanne Speers, MPH, Data Manager Jennifer Vargas, MPH, Case Surveillance Melinda Vazquez-Yopp, Incidence Surveillance Acknowledgements: The HIV Surveillance Program acknowledges the contributions of Department of Public Health staff who provided information for this report: Mukhtar Mohamed (Sexually Transmitted Diseases); Diane Aye (Behavioral Risk Factor Survey); Lloyd Mueller and Jon Olson (Population estimates, Deaths and Hospitalizations); and Ramon Rodriguez-Santana (HIV Prevention). Contact information (this document can be found at the website below): HIV Surveillance Program Capitol Avenue MS #11-ASV Telephone: (860) P.O. Box FAX: (860) Hartford, CT Website:

4 Table of Contents Executive Summary HIV SURVEILLANCE ONE-PAGE FACTSHEET Introduction... 1 Sections 1. Connecticut s People HIV Surveillance HIV Cases Characterizing Recently Diagnosed HIV Cases HIV Incidence in Connecticut and the US Reason for Testing in Newly Diagnosed HIV Cases People Living with HIV HIV Deaths and Hospitalizations CDC Funded Counseling and Testing Sites Ryan White Grant Areas Behavioral Risk Sexually Transmitted Diseases Surveillance Gonorrhea Chlamydia Matching Chlamydia and Gonorrhea with the HIV registry Syphilis Partner Services Hepatitis C Acute Hepatitis C Chronic Hepatitis C Appendices 1. HIV Surveillance Methods Description of Data Sources Glossary... 77

5 Executive Summary Since 1981, over 20,000 HIV cases have been reported in Connecticut and of these almost half have died. The Department of Public Health (DPH) monitors HIV disease through a system of reporting by laboratories and physicians. Information gathered through this system is used to analyze trends to determine who is at risk for infection and where services need to be provided. Each year approximately, $52.5 million comes from state and federal sources to provide prevention services for infected people and others at high risk, HIV medications, housing support, syringe exchange, HIV testing, and other services. The HIV Epidemiological Profile provides information about the trends and distribution of HIV to planning groups, DPH staff whose mission is to allocate prevention and care funding and other interested parties. Additional information about HIV and annual updates to the data provided here can be found on the DPH website ( A quick look at HIV in Connecticut: As of December 2011, 10,585 people were living with HIV in Connecticut (296 per 100,000). HIV is found disproportionately in certain groups including blacks and Hispanics who, although they make up only 24% of Connecticut s population, comprise 65% of all HIV cases. During , 1,915 HIV cases were newly diagnosed and reported to DPH. Of these, 44% were men who have sex with men (MSM), 22% injection drug use (IDU), 32% heterosexual contact (risk percent adjusted for unknown risks). Of concern, 30-40% of newly diagnosed cases meet the criteria of AIDS, meaning they have likely been infected for many years. The ongoing late tester problem supports the need for more widespread HIV testing. Data from the HIV and STD surveillance systems continue to point to ongoing transmission of syphilis and HIV in MSM. During , 247 syphilis cases were in MSM, 82% of all cases reported. Importantly, 40% of these men were co-infected with HIV. Many of these cases stem from contacts made through the internet and anonymous sex, highlighting the need for creative new prevention techniques. The number of HIV cases with IDU as a risk factor has decreased in recent years, but data from the hepatitis C surveillance system suggests sharing of needles is still occurring. During , 177 acute hepatitis C infections were reported and 62% had IDU as a risk factor. None of these cases were previously reported with HIV and 41% were less than 30 years of age. Although HIV has affected most cities and towns in Connecticut, the highest numbers continue to occur in the largest cities. Of the 10,585 people living with HIV, 45% reside in Hartford, New Haven, or Bridgeport. In 2011, 67% of people living with HIV diagnosed through 2010, had at least one viral load test which can be used as an indicator of entry into care. In 2010, 93% of adolescents and adults diagnosed with HIV were linked to care within 12 months of their diagnosis. HIV is a chronic infection and the many advances in scientific research and medical treatment have meant longer life spans. Currently, 42% of people living with HIV are over the age of 50. The aging of this population will have growing implications for both care and prevention. In the United States there are 871,846 people living with HIV. Among all states, Connecticut ranks 7th in the rate of people living with AIDS. 1 1 Centers for Disease Control and Prevention. HIV Surveillance Report, 2010; vol Published March Accessed June 4, 2013.

6 Quick stats about HIV in Connecticut HIV Surveillance Program From , 20,091 cases of HIV have been reported to DPH. 9,506 (47%) have died and 10,585 are currently living with HIV. Among people living with HIV in Connecticut: HIV cases, by sex: % male 34% female HIV cases, by race: % 3% white 32% black 32% hispanic 0 Male Female 0 White Black Hispanic 1% < 20 6% % % % % >60 35% injection drug use 24% MSM 22% heterosexual 17% perinatal/other 2% MSM/IDU HIV cases, by age: < < % 6% 13% % HIV cases, by risk: MSM IDU MSM/IDU Hetero Perinatal/Other Perinat/Other 17% MSM 24% % % Hetero 22% MSM/IDU 2% IDU 35% 2/2013 HML CT DPH HIV Surveillance Program 410 Capitol Ave, Hartford, CT Please visit us on the web at:

7 Introduction What is an Epidemiologic Profile? o The Epidemiologic Profile is a document prepared by the Department of Public Health describing HIV in Connecticut. As provided in the Centers for Disease Control and Prevention (CDC) guidance, the goals of the Epidemiologic Profile are the following: Provide a thorough description of the HIV epidemic among the various populations (overall and subpopulations) in Connecticut; Describe the current status of HIV cases in Connecticut and provide some understanding of how the epidemic may look in the future; Identify characteristics of the general population and of populations who are living with, or at high risk for, HIV in defined geographical areas and who need primary and secondary prevention or care services; Provide information required to conduct needs assessments and gap analyses. Organization of the Epidemiologic Profile: o CDC Guidance: The CDC provides guidance for the production of Epidemiologic Profiles. In the most recent version of CDC guidance, it is recommended that state Epidemiologic Profiles provide information for both: Prevention: Community Planning Group; Care: Ryan White Statewide Planning Consortium; In Connecticut these planning groups are combined into an integrated planning body Connecticut HIV Planning Consortium (CHPC). o Population of Connecticut: Information is included to provide background about the makeup of Connecticut s population. Since the most recent census was conducted in 2010, data included in the 2013 Epi Profile is based on more recent estimates generated by the US Census and DPH. Additional information can be found at o HIV Surveillance: The majority of the material presented is from the HIV surveillance system. This material is organized into several sections that include information about cumulative HIV cases, trends in HIV cases, incidence, hospitalizations and deaths, people living with HIV, and HIV cases in Ryan White Service areas (New Haven Eligible Metropolitan Area (EMA) and Hartford Transitional Grant Area (TGA)). Data will also be shown primarily as HIV cases. The AIDS designation, while still important as a measure of disease progression, is not useful as an indication of trends in new diagnosis of infection. HIV cases are 1

8 counted in the year of the initial diagnosis with an HIV infection, regardless of whether the person met the criteria for AIDS or not. o Behavioral Risk Factor Survey: This survey is a random, weighted telephone survey conducted annually in Connecticut. Several questions about HIV are included in the survey and offer insight into HIV testing and risk behavior in the general population. Selected results from the 2011 survey are included in this report. o Sexually Transmitted Diseases Surveillance: This information is relevant to HIV prevention because STDs can be transmitted in the same manner as HIV and tend to get diagnosed and reported much sooner after infection than HIV. The high proportion of recent syphilis cases associated with MSM underscores this connection with HIV. o Hepatitis C Surveillance: This data is of interest to HIV prevention and care because in Connecticut, IDU is a major risk behavior for both hepatitis C and HIV. Reading the Epidemiologic Profile: o The contents are presented in six sections. o Each of the sections can be read as a stand-alone document. o Within each section, subsections are numbered, based on the number of the section in which they appear. For example, Section 2, about various HIV surveillance topics, has eight subsections, 2.1 to 2.8. o Tables and figures are numbered according to their section. For example, two tables in subsection 2.1 would be numbered and Figures and Tables are numbered in individual sequence. For example, there could be both a Table and a Figure Sources HIV surveillance information: o HIV Surveillance Program website ( The web page is updated every January. Many of the HIV tables included in the Epidemiological Profile can also be found on the HIV surveillance website. o 2013 HIV Epidemiologic Profile ( Many of the tables and figures in the 2013 Epi Profile are continuations or updates of tables and figures in the 2010 Epi Profile. Some material in the 2010 Epi Profile is not repeated in the 2013 Epi Profile. o HIV statistics for Connecticut and other states ( o AIDSVu an interactive mapping tool ( o School Health Survey is conducted in consenting schools with high school students, grades Questions are included about sexual and drug use activity. 2

9 A complete report of findings is available on the DPH website ( o Connecticut Epidemiologist: The Connecticut Epidemiologist is an electronic newsletter produced by the Infectious Disease Section at DPH for medical providers, local health staff, infection control practitioners and others. Several articles about HIV have been published in recent years. HIV sex partner notification services available, electronic matching of the HIV/AIDS and hepatitis C surveillance registries Estimating HIV incidence in CT, HIV viral load reporting update HIV genotype testing a survey of infectious disease specialists, routine HIV testing recommended in healthcare settings, evaluating HIV/AIDS reporting HIV in Connecticut - 30 Years Later o CDC website ( National HIV/AIDS statistics HIV/AIDS Surveillance: Questions and Answers HIPAA Privacy Rule and Public Health CDC HIV/AIDS surveillance slide sets Estimating the national population size of men who have sex with men Diagnoses of HIV infection in the United States and Dependent Areas, NCHHSTP Atlas an interactive mapping and data tool for accessing data collected by CDC s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Estimating HIV Incidence in the United States, Selected MMWR articles ( ) o Twenty-Five Years of HIV/AIDS--United States,

10 o o Human Immunodeficiency Virus (HIV) Risk, Prevention, and Testing Behaviors--United States, National HIV Behavioral Surveillance System: Men Who Have Sex with Men, November 2003-April Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. o HIV Prevalence Estimates--United States, o Estimation of HIV incidence in the United States. JAMA. 2008; 300:520 o Subpopulation Estimates from the HIV Incidence Surveillance System-- United States, o Late HIV Testing--34 States, o o Revised Surveillance Case Definitions for HIV Infection Among Adults, Adolescents, and Children Aged <18 Months and for HIV Infection and AIDS Among Children Aged 18 Months to <13 Years--United States, Monitoring selected national HIV prevention and care objective by using HIV surveillance data- United States and 6 US dependent areas

11 Section 1: Connecticut s People Information in this section comes primarily from the 2010 census. During 2000 to 2010 it is estimated that the population of Connecticut increased by 168,532 (5%) to 3,574,097 (Table 1.1). Selected trends in population included the following: o Hispanics increased by 158,764 (50%). o Blacks increased by 39,548 (13%). o Asians increased by 52,527 (64%). o Whites decreased by 92,583 (-4%). Due to the relatively large change in Hispanic numbers and the significant impact of HIV in that population, Table 1.2 is included to provide information on the Hispanic population and establish that ethnic populations are not homogenous and are subject to change which can impact HIV prevention and care. Table 1.3 shows the estimate of town populations for the 169 communities for which the HIV surveillance system collects information. These data can be used for town-specific rates using prevalence or single year reporting data shown elsewhere in the profile or on the web. Table 1.1: Connecticut population from the 2000 and 2010 Census, Connecticut. Race and Hispanic ethnicity 2000 census 2010 census Percent Percent Percent Race/ethnicity category Number of total Number of total Change difference Total 3,405, % 3,574, % 168, % White non-hispanic 1 2,638, % 2,546, % -92, % Hispanic/Latino 2 320, % 479, % 158, % Black/African American non-hispanic 3 295, % 335, % 39, % Asian 4 81, % 134, % 52, % Two or more races 4 52, % 59, % 6, % Some other race 4 8, % 12, % 4, % American Indian/Alaska Native 4 7, % 6, % % Native Hawaiian/Other Pacific Islander % % 0 0.0% 1 Abbreviated to white; 2 Hispanic; 3 black; 4 typically combined as Other in this document 5

12 Table 1.2: Connecticut population of Hispanic origin from the 2000 and 2010 Census, Connecticut 2000 census 2010 census Hispanic origin Number Percent of Hispanics Number Percent of Hispanics Change Percent difference Hispanic or Latino Total 320, % 479, % 158, % Puerto Rican 194, % 252, % 58, % Mexican 23, % 50, % 27, % Dominican Republic 9, % 26, % 16, % Cuban 7, % 9, % 2, % Central American: 12, % 35, % 22, % Guatemalan 5, % 16, % 11, % Honduran 1, % 6, % 4, % Salvadoran 1, % 6, % 5, % Costa Rican 1, % 2, % 1, % Nicaraguan % 1, % % Panamanian % 1, % % Other % % % South American: 31, % 71, % 40, % Ecuadorian 7, % 23, % 15, % Colombian 10, % 20, % 9, % Peruvian 6, % 16, % 9, % Argentinean 1, % 3, % 2, % Chilean 1, % 2, % 1, % Venezuelan 1, % 2, % 1, % Bolivian % % % Other 1, % % % Paraguayan % % % Other Hispanic/Latino: 41, % 33, % -7, % All other 33, % 24, % -9, % Spaniard 1, % 5, % 4, % Spanish 5, % 3, % -1, % Spanish American % % % 6

13 Table 1.3: Town 1 populations (n=169), Connecticut, US Census, 2010 Town Pop Town Pop Town Pop Bridgeport 144,229 Montville 19,571 Old Lyme 7,603 New Haven 129,779 Waterford 19,517 Middlebury 7,575 Hartford 124,775 Monroe 19,479 Easton 7,490 Stamford 122,643 Ansonia 19,249 Durham 7,388 Waterbury 110,366 East Lyme 19,159 Lebanon 7,308 Norwalk 85,603 Bethel 18,584 New Hartford 6,970 Danbury 80,893 Stonington 18,545 Westbrook 6,938 New Britain 73,206 Madison 18,269 Essex 6,683 West Hartford 63,268 Avon 18,098 Killingworth 6,525 Greenwich 61,171 Wilton 18,062 Marlborough 6,404 Hamden 60,960 Plainville 17,716 Beacon Falls 6,049 Meriden 60,868 Killingly 17,370 Willington 6,041 Bristol 60,477 Wolcott 16,680 Harwinton 5,642 Fairfield 59,404 Seymour 16,540 Bethany 5,563 Manchester 58,241 Brookfield 16,452 Columbia 5,485 West Haven 55,564 Colchester 16,068 North Stonington 5,297 Milford 52,759 Suffield 15,735 East Granby 5,148 Stratford 51,384 Ellington 15,602 Canterbury 5,132 East Hartford 51,252 Plainfield 15,405 Bolton 4,980 Middletown 47,648 Tolland 15,052 Preston 4,726 Wallingford 45,135 Ledyard 15,051 Deep River 4,629 Enfield 44,654 North Branford 14,407 Middlefield 4,425 Southington 43,069 Cromwell 14,005 Lisbon 4,338 Norwich 40,493 Orange 13,956 Ashford 4,317 Groton 40,115 New Fairfield 13,881 Pomfret 4,247 Shelton 39,559 Clinton 13,260 Salem 4,151 Torrington 36,383 East Hampton 12,959 Chester 3,994 Trumbull 36,018 Derby 12,902 Sterling 3,830 Glastonbury 34,427 Oxford 12,683 Barkhamsted 3,799 Naugatuck 31,862 Windsor Locks 12,498 Salisbury 3,741 Newington 30,562 Coventry 12,435 Bethlehem 3,607 Cheshire 29,261 Plymouth 12,243 Sherman 3,581 East Haven 29,257 Stafford 12,087 Washington 3,578 Vernon 29,179 Griswold 11,951 North Canaan 3,315 Windsor 29,044 Somers 11,444 Andover 3,303 New Milford 28,142 Granby 11,282 Sprague 2,984 Branford 28,026 Winchester 11,242 Kent 2,979 New London 27,620 East Windsor 11,162 Goshen 2,976 Newtown 27,560 Canton 10,292 Sharon 2,782 Wethersfield 26,668 Old Saybrook 10,242 Bozrah 2,627 Mansfield 26,543 Weston 10,179 Voluntown 2,603 Westport 26,391 Woodbury 9,975 Lyme 2,406 South Windsor 25,709 Hebron 9,686 Morris 2,388 Farmington 25,340 Putnam 9,584 Chaplin 2,305 Windham 25,268 Portland 9,508 Roxbury 2,262 Ridgefield 24,638 Thompson 9,458 Hartland 2,114 North Haven 24,093 Prospect 9,405 Franklin 1,922 Simsbury 23,511 Burlington 9,301 Hampton 1,863 Watertown 22,514 Redding 9,158 Eastford 1,749 Guilford 22,375 East Haddam 9,126 Bridgewater 1,727 Darien 20,732 Woodbridge 8,990 Scotland 1,726 Bloomfield 20,486 Litchfield 8,466 Norfolk 1,709 Southbury 19,904 Haddam 8,346 Colebrook 1,485 Berlin 19,866 Brooklyn 8,210 Warren 1,461 New Canaan 19,738 Woodstock 7,964 Cornwall 1,420 Rocky Hill 19,709 Thomaston 7,887 Canaan 1,234 Union These are the towns of residence for which HIV data are collected. 7

14 Section 2: HIV Surveillance In this section, Connecticut HIV surveillance data are provided in seven subsections: 2.1 HIV cases; 2.2 Characterizing recently diagnosed HIV cases; 2.3 HIV incidence in Connecticut and US; 2.4 Reason for testing in newly diagnosed HIV cases; 2.5 People living with HIV; 2.6 HIV deaths and hospitalizations; 2.7 CDC funded counseling and testing sites. AIDS was made reportable in In 2002, HIV in adults was made reportable. In 2006, laboratory results for HIV viral load tests were made reportable. In 2009, HIV genotype results were made reportable. 2.1 HIV infection cases 20,091 HIV cases have been reported (through December 2011) (Table 2.1.1). Among all HIV cases reported in Connecticut, 70% were male, 30% female; 36% white, 35% black, and 28% Hispanic; 2% less than 20 years of age at diagnosis, 15% were years of age, 69% years, 11% were 50-59, and 3% were 60 or more years of age at diagnosis; 43% had IDU as a probable source of infection, 23% MSM, 19% had heterosexual risk, and 2% were infected by transmission at birth. 9,506 (47%) have died and 10,585 are living with HIV (prevalent cases) (Figure 2.1.1). Table 2.1.1: Total HIV infection cases by sex, race, and risk/mode of transmission, Connecticut, Risk IDU MSM MSM/IDU Hetero Pedi Oth/unk Total % of row % of row % of row % of row % of row % of row % of N total N total N total N total N total N total N total Total 8, , , , , Sex Male 6, , , , , Female 2, , , Race White 2, , , Black 3, , , Hispanic 2, , , Other Diagnosis age , , , , , , , , , ,

15 Figure 2.1.1: Cases of HIV disease: diagnosed, deaths, and prevalent cases, Connecticut, ,000 12, ,082 9,419 9,600 9,806 9,991 10,103 10,205 10,401 10,585 10,000 8, ,000 Number of cases ,000 4, , Year 0 Deaths* Diagnosed Prevalent *Deaths in the most recent year are preliminary Notes: The number of deaths slowly declined during the 2000 s even as the number of prevalent cases (PLWH) increased steadily. In 2002, 322 deaths were reported (4% of PLWH). In 2011, 164 deaths were reported (2% of PLWH). Historically, deaths have been reported by DPH Vital Records. However, beginning in 2008, additional deaths have been detected through use of national death registries that include deaths in cases that moved out-of-state. Furthermore, CDC has increased the frequency with which states de-duplicate cases that may be reported in more than one state. These new surveillance activities have increased the accuracy of the PLWH number. Over the past five years the number of PLWH has increased by 594 (6%). 9

16 2.2 Characterizing recently diagnosed HIV cases HIV cases diagnosed in 2011 As of December 31, 2012, 348 HIV cases were diagnosed in % were white (4.0 per 100,000), 38.8% black (37.4 per 100,000), 29% Hispanic (20.4 per 100,000), and 3% were other races. 74% were male (14.7 per 100,000) and 26% were female (5.0 per 100,000). As shown in Table 2.2.1, using a multiple imputation statistical method to allocate cases with missing risk into existing categories, 53% were MSM, 32% heterosexual and 14% were IDU. This statistical method uses SAS programs provided by the CDC which can be applied to statewide data only. Although they may eventually be able to be used on smaller geographic areas (cities, Ryan White Care areas) and population subsets, currently they can only be used on statewide data. PLWH data are also adjusted using this method in a subsequent section. Based on this adjusted risk assessment, since 2007, IDU as a mode of transmission has decreased 70% while MSM has continued to increase with a 16% percent change. Table 2.2.1: HIV cases diagnosed in 2011 by risk and race, Connecticut, 2011 White Black Hispanic Asian Hawaiian/ Pacific Islander Multiple race Risk 1 N % N % N % N % N % N % N % MSM IDU MSM/IDU Heterosexual Perinatal Other/unknown Total Risk adjusted for cases with missing risk using multiple imputation. Numbers in columns don t always add to totals due to weighted methods. Total HIV cases diagnosed during ,915 HIV cases were diagnosed during (Table 2.2.2). o 31% white, 38% black, 29% Hispanic, and 3% other races. o 72% male, 28% female. o 3% less than 20 years of age, 23% 20-29, 53% 30-49, 20% 50+. o 35% MSM, 13% IDU, 1% MSM/IDU, 19% heterosexual, 0.3% perinatal, 32% other/unknown. 10

17 The geographic distribution of cases diagnosed during in selected cities is shown in Figure and Table o Over one-third of all cases (36%) were from the three largest cities, Hartford, Bridgeport, and New Haven. Of the cases residing in these cities, blacks continue to have the highest diagnosis rate ranging from 42% in Hartford to 59% in New Haven. o Over the five-year period, approximately, 86% of cases reside in the cities listed in Table and 265 (14%) cases were from medium to small cities with fewer than 10 cases per city. o HIV cases have been reported in almost all Connecticut towns but most cases and the highest rates are in the urban centers. The number of cases diagnosed in by town ranges from o In Figure 2.2.1, the towns shown in cream had no diagnosed cases during that were reported by the end of o Waterbury, New Haven, Bridgeport and Hartford all had more than 100 cases diagnosed and reported during (43% of all cases diagnosed in the time period) Figure 2.2.1: HIV cases diagnosed, Connecticut, Number of HIV cases >100 State of Connecticut Department of Public Health HIV Surveillance Miles Total reported HIV/AIDS cases diagnosed, : 1,915 Range of HIV cases per town: Town of residence based on first report of HIV Data supplied by HIV Surveillance Program 11

18 12 Table 2.2.2: HIV cases diagnosed during by city of residence, sex, race/ethnicity, and risk, Connecticut, 2011 Sex Race/ethnicity Risk group Residence at Total Male Female White Black Hisp Other IDU MSM M/I Het Pedi O/u diagnosis N % % % % % % % % % % % % % Total 1, Hartford Bridgeport New Haven Waterbury Stamford New Britain Hamden Norwalk Danbury Meriden East Hartford West Haven Manchester New London Norwich Middletown Stratford Bristol East Haven Milford Greenwich Windsor Bloomfield Ansonia Groton Wallingford West Hartford Windham Fairfield Torrington Enfield Shelton other towns Risk groups: IDU - injection drug use; MSM - men who have sex with men; M/I - MSM and IDU; Het - heterosexual contact; Pedi - perinatal transmission from mother at birth; O/u - other and unknown.

19 Table 2.2.3: HIV diagnosis among adult and adolescent Hispanics, by risk and place of birth, Connecticut, Central America 1 Dominican Republic Mexico Puerto Rico South America United States Total Risk N % N % N % N % N % N % N 2 % MSM IDU MSM/IDU Heterosexual Other/Unknown Total Includes Central American countries and the Caribbean Islands excluding Cuba and Dominican Republic 2 Cases include persons whose place of birth is not among those listed and persons whose place of birth is unknown (n=189). 3 Includes hemophilia, blood transfusion, perinatal exposure, and risk factor not reported or not identified. 13

20 HIV and AIDS status of recently diagnosed cases A significant percentage of cases continue to have AIDS at their initial diagnosis with HIV infection. These cases are referred to as late testers. As shown in Table 2.2.4, in % of cases had AIDS at their initial diagnosis. Approximately 43% of cases transitioned to AIDS since their 2011 diagnosis. Typically, transition to AIDS is detected by reporting of low CD4 laboratory test results (<200 or <14% CD4+ cells per microliter). Table 2.2.4: 2011 HIV cases meeting the AIDS case definition during 12 months after initial diagnosis with HIV infection. Diagnosed with HIV in 2011 AIDS at 0-30 days % AIDS at 1-12 months % Total AIDS by 12 months % HIV (not AIDS) at 12 months % Total Sex Male Female Race White Black Hispanic Other Age < Risk MSM IDU-Males IDU-Females MSM and IDU Hetero 1 - Males Hetero 1 - Females O/u 2 - Males O/u 2 - Females heterosexual contact 2 other and unknown 14

21 Figure 2.2.2: HIV cases by percentage that were AIDS at diagnosis, transitioned to AIDS, or continue to be HIV, Connecticut, % 90% 80% 70% 60% 50% 40% 30% 20% 10% HIV at diagnosis and continue to be HIV HIV at diagnosis but transitioned to AIDS AIDS at diagnosis (late testers) 0% Figure 2.2.3: Late testing for HIV: HIV cases diagnosed in 2011 meeting criteria for AIDS by 12 months after initial diagnosis with HIV infection, Connecticut, 2011 Number of diagnosed HIV cases by town Region* Hartford TGA New Haven EMA Number of late testers by grant area *Ryan White Funding Regions Hartford Transiontal Grant Area New Haven Eligible Metropolitan Area Total HIV cases diagnosed in 2011 = 348 Range of late testers per town = Number of HIV cases meeting AIDS criteria by 12 months of initial HIV diagnosis no HIV cases reported <5 10+ State of Connecticut Department of Public Health HIV Surveillance Miles no AIDS cases reported 5-9 Region* 15

22 Trends in HIV cases by SEX Males continue to constitute the majority of HIV cases diagnosed in Connecticut with 74% of cases in Figure 2.2.3: Rate per 100,000 of HIV by sex and year of diagnosis, Connecticut, Rate Female Male Year Diagnosed Figure 2.2.4: Rate per 100,000 person years of HIV cases by sex, Connecticut, Rate Female Sex Male 16

23 Trends in HIV cases by RACE/ETHNICITY Blacks are disproportionately diagnosed with HIV at a rate 9 times whites and Hispanics at a rate 5 times whites (Figure 2.2.7). Overall, the number of cases has decreased over the time period shown but the lowest decrease is seen in black cases, with only a 5% decrease from 2007 to Other race includes cases categorized with more multiple races as well as Asians and other races with very small numbers. Figure 2.2.6: Rate per 100,000 of diagnosed HIV by race/ethnicity, Connecticut, Rate Year Diagnosed Black Hispanic White other Figure 2.2.7: HIV Diagnosis per 100,000 person years by race ethnicity, Connecticut, Rate per 100,000 person years Black Hispanic White Other Race/Ethnicity 17

24 Trends in HIV cases by AGE GROUP Over the past five years, the number of cases diagnosed in has seen a 31% increase while all other age group have seen a decrease in numbers from 2007 to 2011 (range of decrease amongst age groups: 14% - 33%). Figure 2.2.8: Number of cases diagnosed with HIV by age group, Connecticut, Number < Year Diagnosed Figure 2.2.9: Rate per 100,000 of cases diagnosed with HIV by age group, Connecticut, Rate < Year Diagnosed 18

25 Trends in HIV cases by RISK GROUP During the most significant change has been the decrease in the number of cases with IDU risk and the continued increase in MSM. The decrease in IDU numbers has meant that the other risk categories have become more prominent. The current profile of HIV in Connecticut is showing increased numbers in MSM transmission than in previous years with regard to newly diagnosed cases. Rate of HIV in MSM: To calculate a rate, the number of cases (numerator) and the size of the population (denominator) must be known. For some groups, such as MSM and IDU, the size of the population has not been known and therefore rates have not been provided. However, CDC has recently released an estimate that 4% of men 13+ years of age are MSM. Using this percentage with Connecticut population estimates suggests that 58,000 men are MSM. With 186 MSM infections in 2011, there was a rate of 321 HIV infections per 100,000 MSM in Connecticut: (186/57,000) x 100,000. This could also be expressed as 3 per 1,000 MSM. Figure : HIV cases by adjusted risk group and year of diagnosis, Connecticut, Number Year Diagnosed Note: Risk groups adjusted for cases reported with unknown risk using multiple imputation MSM IDU MSM/IDU Hetero Perinatal 19

26 The trend in the recently diagnosed youth has demonstrated a continuous rise in MSM being diagnosed with HIV while IDU risk has remained relatively low and flat. Although the total number of cases in youth is small, MSM has become a prominent mode of transmission. Of the 278 youth diagnosed with HIV between 2007 and 2011, 61% of year olds had a risk factor of MSM. Of the MSM youth diagnosed with HIV, 44% were black, 29% were white and 25% were Hispanic. Figure : HIV cases in youth, years of age, by risk and year of diagnosis, Connecticut, Number MSM IDU MSM/IDU Hetero Pedi Oth/Unk Year Diagnosed 2.3 HIV incidence in the US and Connecticut HIV incidence surveillance was implemented in the US and Connecticut in HIV incidence reflects the leading edge of HIV transmission, infection trends, and the impact of prevention efforts. An HIV Surveillance Report released by the CDC in 2012 included national trend data ( ) that showed the estimated number of new infections in the United States to be stable at 47,500 per year. National Incidence Data, 2008 to 2010: o The estimated number of new HIV infections remained stable across all age groups and was highest among individuals aged o Blacks continue to be disproportionately affected by HIV infection accounting for 44% of new infections. o The estimated number of new HIV infections decreased 21% among females from 12,000 in 2008 to 9,500 in o The estimated number of new HIV infections among MSM increased 12% from 26,700 in 2008 to 29,800 in 2010 with a 22% increase among MSM aged

27 years. HIV infections among females with infection attributed to heterosexual contact decreased. o Notably, the estimated number of new HIV infections was greatest among young black MSM in the youngest age group (13 24 years). Young black MSM accounted for 55% of new HIV infections among young MSM overall. o Comparing incidence estimates for 2008 and 2010, the number of new HIV infections among young MSM increased significantly overall. The Connecticut estimate indicated that 496 people were newly infected with HIV in 2010, but with a wide confidence interval due to small numbers (Figures 2.3). As with the US estimate, there were specific groups at higher risk for HIV infection. Men had twice the risk of women and the risk for blacks was six times higher than in whites. References to articles about the national and Connecticut incidence estimate are found in the introduction. Figure 2.3: HIV incidence estimates, United States and Connecticut, United States 80 Connecticut Rate per 100,000* Total Male Female White Black Hispanic *Rates per 100,000 in persons 13 years of age 21

28 Table 2.3: Estimate of HIV incidence by sex, race/ethnicity, age and risk, Connecticut, 2010 Incidence estimate Rate 95% C.I. (Lower) 95% C.I. (Upper) Total Sex Male Female Race/ethnicity White Black Hispanic/Other Age at Infection Risk group MSM HET/IDU/OTH Heterosexual contact/idu/other 2.4 Reason for testing in newly diagnosed HIV cases As part of the HIV incidence surveillance system described in the previous section, the confidential case report form used to collect information about new HIV cases was modified in order to add questions about HIV testing history. Included was a question about the reason(s) for testing. Information about test history has been collected for 1,352 (93%) of the 1,460 newly diagnosed HIV cases that were eligible to be enrolled in the HIV incidence system between 2008 through Table shows the reasons HIV-positive patients were tested. Patients could report more than one reason for testing. During , 368 (27%) cases were tested because they had symptoms that prompted their provider to order HIV testing. In addition, 258 (19%) were tested because they were just checking and 232 (17%) were tested as a result of exposure ( worried that in the past 6 months they might have been exposed to HIV ). There were also many and varied reasons for testing that were mentioned on less than 10% of responses including 4% who were tested at an STD clinic or currently had an STD, TB, or viral hepatitis, 3% as part of prenatal care and various required testing settings (entry into military, etc). 22

29 Also shown is a trend in the number of cases that may have been tested as a part of routine or regular testing. This data is combined from the MD recommended, regular tester, routine testing, just checking, and screening options on the form. In 2011, 51% of cases enrolled were tested because of one of these reasons. However, being tested due to symptoms was the reason most often selected in all four years with no evident trend. Table 2.4.1: Reason for testing in HIV cases eligible for inclusion in the HIV incidence surveillance system, Connecticut, Total N % N % N % N % N % Incidence eligible cases 1, Cases with Test History (TH) 1, Reasons for HIV testing Symptom Just checking Exposed MD recommend Routine testing Regular Tester STD or viral hepatitis Screening Prenatal screening Other reason Total reasons given 1, No reason given for testing Routine testing: (MD recommended, regular tester, routine testing, just checking, screening) 23

30 2.5 People living with HIV (PLWH) (Prevalence) As of December 2011, there were 10,585 PLWH in Connecticut (Table 2.5.1). CDC estimates that, nationally, in addition to PLWH that are aware of their status, there are an additional 18.1% of PLWH who are not aware of their HIV-positive status. In Connecticut, this unaware population is estimated to be 2,339 people giving a total of 12,924 PLWH in Connecticut (Table 2.5.2). Of 10,585 reported PLWH, 66% are male and 34% are female (Table 2.5.1). Approximately one-third are white (33%), black (32%) and Hispanic (32%). The risk associated with HIV infection is known in 85% of cases. When cases with unknown risk are statistically adjusted into known categories, 40% are associated with IDU risk, 28% with MSM and 27% with heterosexual risk. Table shows the cross-tabulation of unadjusted risk with demographic characteristics. Only 7% of PLWH are currently less than 30 years of age and 13% are The majority of cases are (33%) and (34%) years of age (Table 2.5.1). Reflecting the aging of the PLWH population, 13% (n = 1,412) of cases are 60 or more years of age. Table shows 28 cities with 50 or more cases of PLWH. Seventeen cities have over 100 cases each and account for 79% of all PLWH. Three cities, Hartford, New Haven, and Bridgeport, have over 1,000 cases each and account for 45% of all PLWH. In Windham, over 50% of PLWH are IDU. Notably, MSM is highest in several smaller cities: Wallingford (48%), Milford (48%), West Hartford (48%), and Greenwich (46%). Importantly, 1,438 or 14.0% of all PLWH live in smaller cities with fewer than 50 cases. The statewide distribution of HIV is also shown using maps. Figure shows the distribution by number and rates of cases in each city. Cities with rates over 300 per 100,000: Hartford, New Haven, Bridgeport, New London, Waterbury, New Britain, Windham, Stamford, East Hartford, Norwalk, Meriden, Middletown, and East Haven. Figure shows a comparison of the prevalence in race/ethnicity-sex groups by age group per 100,000 population. The highest prevalence is in black (4,059 per 100,000) and Hispanic (3,444/100,000) males in the age group. The highest white male prevalence is in the and age groups at approximately 430/100,000. White female prevalence is low in all age groups but highest in the age group (162/100,000). Using these prevalence rates risk can be compared between groups. For example there is a 9-fold higher risk of HIV infection in black males in the age group compared to white males (4,059/453=9). The error bars indicate the 95% confidence intervals. Additional PLWH tables specific for male, female, black, Hispanic, white, MSM, IDU, heterosexual, age groups, cities and counties can be found on the HIV/AIDS surveillance webpage ( 24

31 Table 2.5.1: PLWH by risk group, sex, race/ethnicity and current age, Connecticut, Risk 25 N IDU MSM MSM/IDU Hetero Pedi Oth/unk % of row total N % of row total N % of row total Total 3, , , , , Sex Male 2, , , Female 1, , , Race White , , Black 1, , Hispanic 1, , Other Current age < , , , , , , , N % of row total N % of row total N % of row total N Total % of total

32 Table 2.5.2: Statewide estimate 1 of the population unaware of their HIV infection and demographic distribution, Connecticut, 2011 Diagnosed PLWH PLWH plus unaware 3 Distribution of unaware 4 Total 1, % 10,585 12,924 2, % Male 1, % 1, % Female % % White % % Black % % Hispanic % % Multi-race % % Asian % % IDU % % MSM % % MSM/IDU % % Hetero % % Pedi 6 0.3% 7 0.3% Unknown % % % 6 0.3% % % % % % % % % % % 1 This estimate is based on the CDC estimate of the percentage of persons with HIV infection unaware of their HIV positive status (HIV Surveillance Supplemental Report 2012; 17(No.3, part A). The limitations of this approach include: a) the national estimate may not be applicable to local jurisdictions; b) not all cases diagnosed in have been reported as of December 31, 2012; c) among recently diagnosed cases the number reported without a presumed source of infection is higher than cases diagnosed several years ago due to the lag in reporting of this information; and, the PLW number includes some cases who have died but for whom the death has not been reported and cases that were previously diagnosed in other states but have not yet been de-duplicated. 2 Connecticut HIV/AIDS Surveillance Program data as of December 31, % of people infected with HIV are unaware of their status. 4 The demographic and behavioral risk distributions are based on the distribution of recently diagnosed cases ( ). Erratum: 1/8/2014- table updated due to incorrect number of cases diagnosed for