Minnesota HIV/AIDS Epidemiologic Profile

Transcription

1 Minnesota HIV/AIDS Epidemiologic Profile DECEMBER 2015

2 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

3 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 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 1 The 7-county metropolitan area includes the following Minnesota counties: Anoka, Carver, Dakota, Hennepin, Ramsey, Scott and Washington. 2 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, MMWR Morb Mortal Wkly Rep 2015;64: Minnesota HIV/AIDS Epidemiologic Profile Executive Summary

4 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

5 Minnesota General Demographics DESCRIPTION OF MINNESOTA 1 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 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

6 Age Distribution in Minnesota and in TGA Age Minnesota (n = 5,303,925) Minneapolis St. Paul TGA (n = 3,279,833) < % % % 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 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 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 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

7 Race and Ethnicity Distribution by Gender in Minnesota and TGA Minnesota Minneapolis-St. Paul TGA (n=2,632,132) (n=2,671,793) (n=1,618,907) (n=1,660,926) Race / Gender Male Female Male Female White (non-hispanic) 82.7% 83.4% 78.3% 78.9% Black / African American 5.3% 5.0% 7.5% 78.3% American Indian 1.1% 1.1% 0.7% 0.7% Asian / Pacific Islander 4.0% 4.2% 5.6% 5.9% Other race 2.1% 1.8% 2.5% 2.2% Two or more races 2.4% 2.4% 2.8% 2.8% Hispanic / Latino* 5.0% 4.4% 5.7% 5.0% *Includes all races 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 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, 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 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, 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

8 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 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 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 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 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 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 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

9 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 and experienced uninsurance rates significantly above the statewide rate (13.6% and 17.1% for and 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, Kinsey AC, Pomeroy WB, Martin CE. Sexual Behavior in the Human Female. Philadelphia: WB Saunders, 1953 Minnesota HIV Epidemiological Profile General Demographics

10 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. 7 Seidman SN, Rieder RO. A review of sexual behavior in the United States. American Journal of Psychiatry, 151(3): , 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: , 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 Minnesota HIV Epidemiological Profile General Demographics

11 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 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 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. 10 Bockting WO, Robinson BE, Rosser BR. Transgender HIV prevention: a qualitative needs assessment. AIDS Care, 10(4): , 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): , Minnesota HIV Epidemiological Profile General Demographics

12 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, 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 (non- AIDS) 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

13 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% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 100% 88% 72% 11 County TGA* Greater MN PLWH Linkage to Care Retention in Care Viral Suppression n=6,532 n=1,068 *Includes Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington, Wright Counties 83% 74% 63% 63% 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 status 2. 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

14 Persons Living with HIV/AIDS by Race/Ethnicity and Region of Residence, Minnesota 2014* TGA Greater Minnesota Total Race/Ethnicity N (%) N (%) N (%) Hispanic 605 (85%) 109 (15%) 714 (9%) American Indian 93 (77%) 28 (23%) 121 (2%) Asian/Pacific Islander 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%) Unknown 10 (91%) 1 (9%) 11 (0.1%) Total 6,822 (86%) 1,127 (14%) 7,949 (100%) *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 MSM 51% n = 7,988 IDU 5% MSM/IDU 5% Other 2% Heterosex 22% 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

15 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 AIDS Diagnoses Starting in the mid 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. Number of New Diagnoses HIV and AIDS Diagnoses in Minnesota, 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. AIDS HIV Infection Minnesota HIV/AIDS Epidemiologic Profile Scope of HIV/AIDS in Minnesota

16 Age 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. 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. In Minnesota, there are 7,628 people over the age of 13 who were diagnosed with HIV through 2013 and were living in Minnesota at the end of Of the 7,628 people living with HIV at the end of 2014, 5,514 (72%) had at least one CD4 or VL test performed in 2014 (retention in care). Additionally, of the 7,628 people living with HIV/AIDS, 4,826 (63%) had a VL 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Number of New Infections HIV/AIDS at first diagnosis HIV Infections* by Age at Diagnosis and Year of Diagnosis Percentage of persons diagnosed with HIV engaged in selected stages of the continuum of care Minnesota 100% 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). Year 87% of diagnosed in % of PLWH 88% of retained 63% of PLWH n=7, /299 5,514/7,628 4,826/7,628 Persons living with diagnosed HIV (PLWH) Linkage to Care Retention in care Viral Suppression Minnesota HIV/AIDS Epidemiologic Profile Scope of HIV/AIDS in Minnesota

17 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 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 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 Number of Cases HIV Infections* Among Adolescents and Young Adults by Gender and Year of Diagnosis, Males Females In 2014, the number of increased from 41 in Year to 49. Of these 49 *HIV or AIDS at first diagnosis Adolescents defined as year-olds; Young Adults defined as 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

18 young women, this accounts for a 20% decrease from the ten cases diagnosed in Females accounted for 14% (8/57) of new HIV infections diagnosed among adolescents and young adults in 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 Race/Ethnicity Similar to the overall HIV/AIDS epidemic, people of color account for a disproportionate number of new HIV infections among adolescents and young adults. Among young men, white men accounted for 39% of new HIV infections diagnosed between 2012 and 2014, African American men accounted for 39%, and Hispanic men 15%. American Indian, Africanborn, and Asian/Pacific Islander men made up 2%, 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 HIV Infections* Among Adolescents and Young Adults by Gender and Race/Ethnicity, Combined White 39% Asian/PI 1% Other 2% Afr born 2% Males (n = 143) Females (n = 22) Amer Ind 2% Hispanic 15% *HIV or AIDS at first diagnosis Adolescents defined as year-olds; Young Adults defined as year-olds. Afr Amer 39% 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%. White 32% Other 5% Afr Amer 27% Afr born 32% Hispanic 4% n = Number of persons Amer Ind = American Indian Afr Amer = African American (Black, not African-born persons) Afr born = African-born (Black, African-born persons) Other = Multi-racial persons or persons with unknown race Minnesota HIV Epidemiologic Profile Adolescents and Young Adults

19 HIV Infections* Among Adolescents and Young Adults by Gender and Estimated Exposure Group #, Males (n = 143) Females (n = 22) MSM 93% Heterosex 94% Other 1% Heterosex MSM/IDU 2% 4% 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 year-olds; Young Adults defined as year-olds * HIV or AIDS at first diagnosis IDU 6% Treatment Cascade among Adolescents and Young Adults Although the treatment cascade for young people includes people living with HIV/AIDS up to age 29, the general trend can be seen for adolescents and young adults. There were 666 HIV positive persons aged included in the treatment cascade analyses and 101 cases in this age group reported in 2013 that were included in the linkage to care calculation. Young Percentage of persons years old diagnosed with HIV engaged in selected stages of the continuum of care, 2014 Minnesota 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 100% 87% 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%). 72% 63% 82% 75% Overall Cascade year olds PLWH Linkage to Care Retention in Care Viral Suppression n=7,728 n=666 59% Minnesota HIV Epidemiologic Profile Adolescents and Young Adults

20 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 31 st, 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 This represents a 22% decrease among African American males from 2013 to 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 Mode of Exposure Of the 160 African American males diagnosed between 2012 and 2014, 87% of cases had an estimated mode of exposure of MSM, 10% heterosexual contact to someone with or at risk for HIV, 2% IDU, and 1% other mode of exposure that includes hemophilia, transplant, transfusion or MSM 87% HIV Infections* Among African Americans by Estimated Mode of Exposure African American Males (n = 160) mother with HIV or HIV risk. Minnesota HIV/AIDS Epidemiologic Profile African American Other 1% IDU 2% Heterosex 10% African American Females (n = 53) Other 4% n = Number of persons MSM = Men who have sex with men IDU 3% 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 Heterosex 93%

21 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 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% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 100% 87% 87% 72% 63% n=1,639 67% Overall Cascade African Americans PLWH Linkage to Care Retention in Care Viral Suppression n=7,728 55% 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

22 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, 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 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 American Community Survey 3-year estimates. Additional calculations by the State Demographic Center 2 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

23 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 African-born Males (n =49) Heterosex 84% MSM 10% Other 6% African-born Females (n = 87) 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 Other 2% Heterosex 98% 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 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

24 Percentage of African-born persons diagnosed with HIV engaged in selected stages of the continuum of care, 2014 Minnesota 100% 90% 100% 100% 87% 95% 80% 70% 60% 72% 63% 68% 57% 50% 40% 30% 20% 10% 0% Overall Cascade African-born PLWH Linkage to Care Retention in Care Viral Suppression n=7,728 n=1,032 Minnesota HIV/AIDS Epidemiologic Profile African-born

25 American Indian HIV/AIDS Prevalence among American Indians As of December 31 st 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 In 2014, there were 5 HIV/AIDS diagnoses among American Indians, two male and three female. Gender and Mode of Exposure HIV Infections* Among American Indians by Estimated Mode of Exposure CAUTION: Small number of cases interpret carefully. 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% MSM 37% American Indian Males (n = 12) MSM/IDU 18% Heterosex 18% IDU 27% American Indian Females (n = 9) IDU 25% 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 Heterosex 75% 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., Public Health Reports, 122(3): , 2007 Minnesota HIV/AIDS Epidemiologic Profile American Indian

26 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. 100% Percentage of American Indians diagnosed with HIV engaged in selected stages of the continuum of care, 2014 Minnesota 100% 100% 100% 90% 80% 70% 60% 87% 72% 63% 80% 67% 50% 40% 30% 20% 10% 0% Overall Cascade American Indian PLWH Linkage to Care Retention in Care Viral Suppression n=7,728 n=116 Minnesota HIV/AIDS Epidemiologic Profile American Indian

27 Asian/Pacific Islander HIV/AIDS Prevalence among Asian/Pacific Islanders As of December 31 st 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 are insufficient to make further MSM/IDU MSM 91% HIV Infections* by Estimated Mode of Exposure Among Asian/Pacific Islanders CAUTION: Small number of cases interpret carefully. Asian Males (n = 16) Other 5% Minnesota HIV/AIDS Epidemiologic Profile Asian/Pacific Islander Asian Females (n = 1) 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 Heterosex 95%

28 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% 70% 60% 72% 63% 74% 67% 50% 40% 30% 20% 10% 0% Overall Cascade ^ ^ Asian/Pacific Islanders ^ Strata have a n<5 PLWH Linkage to Care Retention in Care Viral Suppression n=7,728 n=138 Minnesota HIV/AIDS Epidemiologic Profile Asian/Pacific Islander

29 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 ) 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 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

30 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

31 Greater Minnesota HIV/AIDS Prevalence in Greater MN As of December 31 st 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 Unspecified 20% Greater MN (n=128) Other 1% MSM 50% Unspecified 23% TGA (n=792) Other <1% MSM 51% Heterosex 21% Heterosex 21% MSM/IDU 3% IDU 5% MSM/IDU 3% n = Number of persons MSM = Men who have sex with men IDU 2% 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

32 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 Greater MN (n=128) TGA (n=787) Other 1% Black, Afr born 13% Hispanic/ Latino 11% Am Ind 5% Asian/PI 2% Afr Am 6% Other 2% Black, Afr born 15% Hispanic/ Latino 11% Am Ind 2% Asian/PI 2% Afr Am 25% White 61% White 43% *HIV or AIDS at first diagnosis Does not include 6 cases with missing race or residence at diagnosis data Age at Diagnosis Persons aged 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 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

33 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% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 100% 88% n=6,532 72% n=1,068 *Includes Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington, Wright Counties 83% 74% 63% 63% 11 County TGA* Greater MN PLWH Linkage to Care Retention in Care Viral Suppression Minnesota HIV/AIDS Epidemiologic Profile Greater Minnesota

34 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 31 st 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 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 , 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 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 , 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 , 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

35 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% 100% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 87% 86% 72% 73% 63% 61% 0% Overall Cascade Heterosexual Risk PLWH Linkage to Care Retention in Care Viral Suppression n=7,728 n=1,712 Heterosexual risk=heterosexual contact with HIV+, or with someone with HIV risk Minnesota HIV/AIDS Epidemiologic Profile Heterosexual Risk December, 2015

36 Hispanic HIV/AIDS Prevalence among Hispanic persons As of December 31 st 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 The annual number of new infections diagnosed among Hispanic females continues to be quite small with six diagnoses in 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 MSM 92% HIV Infections* Among Hispanic Persons by Estimated Mode of Exposure Hispanic Males (n =87) MSM/IDU 3% Heterosex 3% Other 2% Minnesota HIV/AIDS Epidemiologic Profile Hispanic Hispanic Females (n = 16) CAUTION: Small number of cases interpret carefully. 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 IDU 8% Heterosex 92%

37 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 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% 85% 80% 70% 60% 72% 63% 63% 56% 50% 40% 30% 20% 10% 0% Overall Cascade Hispanic PLWH Linkage to Care Retention in Care Viral Suppression n=7,728 n=677 Minnesota HIV/AIDS Epidemiologic Profile Hispanic

38 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 The positivity rate (percent of positive tests among all tests performed) has ranged from 1.0% in 2010 to 1.5% in 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

39 CTR System Tests by Gender, Race, Age, and Risk 2014 Client Characteristics* Number of Tests (percent) Positivity Rate Gender Male 9,286 (70) 1.0 Female 3,779(29) 0.4 Transgender 83(0.6) 1.2 Unknown 89 (0.6) 0.0 Race/Ethnicity White 6,461 (49) 0.7 African American/Black 4,126 (31) 1.1 Asian/Pacific Islander 497 (4) 0.2 American Indian 692 (5) 0.6 Multiple Races 405 (3) 1.0 Unknown 1,056 (8) 0.9 Hispanic 1,378 (10) 1.0 Age 19 and under 629 (5) ,889 (67) ,297 (25) and older 392 (3) 1.3 Unknown 30 (0.2) 0.0 Risk Category MSM 4,143 (31) 1.6 IDU 616 (5) 0.5 MSM/IDU 195 (1) 3.6 High-risk heterosexual 3,787 (29) contact 0.4 Low-risk heterosexual 3,507 (27) contact 0.3 Other # 144 (0.4) 0.0 Unknown Risk 845 (6) 0.8 Total 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

40 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 31 st 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 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 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 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

41 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. 100% 90% 80% 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% 80% 90% 76% 70% 60% 50% 40% 30% 20% 10% 66% 54% 64% 0% IDU MSM/IDU PLWH Linkage to Care Retention in Care Viral Suppression n=423 n=396 MSM=Men who have sex with men IDU=Injection drug use Minnesota HIV/AIDS Epidemiologic Profile Injection Drug Use

42 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 One of the success stories in the history of HIV infection is the use of medication to successfully reduce 80 perinatal 70 Births HIV Infections transmission of the virus. Without treatment, the risk of HIV transmission 40 from a pregnant 30 woman to her child before or during birth 20 is approximately 10 25% 1. Preventive 0 antiretroviral treatment can reduce Year this percentage to 1 2% 2. If breastfeeding is avoided, nearly all children born to HIV-infected mothers can be spared infection. Births to HIV-Infected Women and Number of Perinatally Acquired HIV Infections* by Year of Birth, Number of Cases Rate of Perinatal Transmission for years = 1.1% * HIV or AIDS at first diagnosis for a child exposed to HIV during mother s pregnancy, at birth, and/or during breastfeeding. 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): , 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, Epidemiologic Profile Infants and Children

43 testing for pregnant women. With the widespread adoption of these guidelines, perinatal HIV transmission in the United States decreased by 81% between 1995 and For the past decade the number of births to HIV-infected women increased steadily from 41 in 2005 to 65 births in 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 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, Epidemiologic Profile Infants and Children

44 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. 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. Number of Cases Time of Progression to AIDS for HIV Infections Diagnosed in Minnesota*, %^ No AIDS DX AIDS DX > 1yr AIDS DX <= 1yr 29.9%^ 31.6%^ 33.1%^ 29.4%^ 31.1%^ 31.4%^ 29.6%^ 34.0%^ 27.4%^ Year *Numbers include AIDS at 1 st 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, Minnesota HIV/AIDS Epidemiologic Profile Late Testers

45 Race/Ethnicity The most significant differences occur by race/ethnicity, with the proportion of late testers in 2014 among African-born (40%) and whites (29%) being higher than that among Hispanic (15%) and No AIDS DX AIDS DX > 1yr AIDS DX <= 1yr African Americans (16%). 100 Similar data for American 41.4%^ 35.4%^ Indians and Asian/Pacific 46.7%^ 41.9%^ %^ 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. 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 The combined percentage of late testers from is 36% in Greater Minnesota compared to 30% in the TGA. Percent of Cases Time of Progression to AIDS for HIV Infections* Diagnosed Among Foreign-Born Persons, Minnesota %^ Year Numbers include AIDS at 1 st 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, Minnesota HIV/AIDS Epidemiologic Profile Late Testers

46 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 31 st, 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 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 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, White 64% African-born 1% *HIV or AIDS at first diagnosis Excludes 1 case with missing race. MSM/IDU By Race, (n = 496) Asian American Indian 2% 1% Hispanic 13% Minnesota HIV/AIDS Epidemiologic Profile Men Who Have Sex With Men African American 19%

47 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 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 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 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

48 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% 88% 90% 80% 70% 74% 67% 76% 64% 60% 50% 40% 30% 20% 10% 0% MSM MSM/IDU MSM=Men who have sex with men IDU=Injection drug use PLWH Linkage to Care Retention in Care Viral Suppression n=3,899 n=396 Minnesota HIV/AIDS Epidemiologic Profile Men Who Have Sex With Men

49 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 31 st 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 color account for a disproportionate number of transgender people living with HIV in Minnesota. White people account for just 27% of transgender people living with HIV, while people of color account for 73% of transgender people living with HIV whereas only 17% of the general population in Minnesota are people of color. Additionally, transgender people Transgender persons living with HIV by Race, Minnesota, 2014 White 27% Multiple 2% African-born 10% n=41 Hispanic 20% African American 34% American Indian 2% Asian/PI 5% 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

50 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 Sexual Transmission/IDU 10% n=41 Unspecified 2% n = Number of persons IDU = Injecting drug use 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

51 White (non-hispanic) HIV/AIDS Prevalence among White (non-hispanic) persons As of December 31 st 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 In 2014 white women made up 19% of the new infections among women in Minnesota, with 14 new diagnoses. 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 IDU 2% MSM/IDU 7% Heterosex 2% MSM 89% HIV Infections* Among White (non-hispanic) by Estimated Mode of Exposure White Males (n = 376) Minnesota HIV/AIDS Epidemiologic Profile White (non-hispanic) White Females (n = 39) 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 IDU 14% Heterosex 86%

52 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 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% 100% 100% 90% 87% 85% 80% 70% 60% 72% 63% 77% 70% 50% 40% 30% 20% 10% 0% Overall Cascade White non-hispanic PLWH Linkage to Care Retention in Care Viral Suppression n=7,728 n=3,835 Minnesota HIV/AIDS Epidemiologic Profile White (non-hispanic)

53 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 31 st 2014, there were 1,880 women living with HIV in Minnesota. Race/Ethnicity Women of color account for a disproportionate number of women living with HIV in Minnesota. White women account for just 24% of women living with HIV, while women of color account for 73% of prevalent female HIV/AIDS cases whereas only 17% of the general female population in Minnesota are women of color. The largest number of women living with HIV/AIDS is among African-born women (672 persons) Women Living with HIV/AIDS in Minnesota by Race/Ethnicity, 2014 Other 3% followed by African-American and white women (515 and 459 women, respectively). White 25% Asian 2% Amer Ind 3% Hispanic 7% (n = 1,880) Afr born 33% Afr Amer 27% 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

54 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 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 White Asian African American American Indian Hispanic African-born * HIV or AIDS at first diagnosis Year 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. Number of Cases HIV Infections* Among Females by Race/Ethnicity and Year of Diagnosis, Minnesota HIV/AIDS Epidemiologic Profile Women

55 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 IDU is the second most common known mode of transmission, and accounted for 3% of cases among women in An unspecified risk has been designated for a growing percentage of cases for the past several years and represented 24% of female cases in 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% 87% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 72% 73% 63% Overall Cascade for Minnesota Females PLWH Linkage to Care Retention in Care Viral Suppression n=7,728 n=1,778 61% Minnesota HIV/AIDS Epidemiologic Profile Women

56 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 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

57 AGE Persons ages account for the most (47%) of the people receiving Ryan White services in 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 account for 50% of those living with HIV/AIDS and adolescents and young adults account for 4% (data not shown). MODE OF EXPOSURE There are substantial differences in the mode of exposure distribution between people receiving Ryan White Services and the mode of exposure distribution of everyone living with HIV in Minnesota who are in surveillance. While MSM account for 51% of those living with HIV/AIDS in surveillance, they only account for 44% in Ryan White clients. People with a 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 People Living with HIV/AIDS By Mode of Exposure in Minnesota, Ryan White Clients and Surveillance, 2014 Hetero 38% Ryan White Clients n=4,117 Unspecified Other 7% 3% 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. MSM 44% Hetero 22% Unspecified 15% Other 2% Surveillance n=7,988 MSM/IDU IDU MSM/IDU IDU 3% 5% 5% 5% 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 Other = Hemophilia, transplant, transfusion, mother w/ HIV or HIV risk MSM 51% Minnesota HIV/AIDS Epidemiologic Profile Ryan White Services and Unmet Need

58 People Living with HIV/AIDS By Race/Ethnicity in Minnesota, Ryan White Clients and Surveillance, 2014 Other 4% Asian/Pacific Islander 2% Black** 41% Ryan White Clients (n=4,117) Hispanic 11% *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 Native American 2% White 40% Surveillance (n=7,988) Black** 35% White 50% Other 3% Hispanic 9% Native American 1% Asian/PI 2% 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 Number Receiving Services* Number in Surveillance Ŧ Percentage Receiving Services Greater MN 541 1,128 48% 13-County TGA 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

59 SERVICES RECEIVED IN 2014 In 2014, Medical Case Management was the most utilized service, with 2,960 clients (72% of clients) accessing case management services. Medical Transportation Services was the next most utilized service with 1,517 clients (37% of clients), followed by the Meal Services with 1,442 clients served (35% of clients), AIDS Pharmaceutical Assistance Program (ADAP) with 1,311 clients (32% of clients), and emergency financial Number of Clients Served Most Utilized Ryan White Care Services, Minnesota 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 MCM ADAP Outpt./Amb. Med. Care Emergency Financial Assistance Transportation Meal Services 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 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

60 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 In Surveillance In Care Number Out of Care Percent Out of Care Race* White, not Hispanic 3,977 3, % Black, not Hispanic 2,819 1, % African American 1,719 1, % African-born 1, % Hispanic % American Indian % Asian/Pacific Islander % Multiple Races % Sex at Birth Male 6,108 4,443 1,665 27% Female 1,880 1, % Mode of Exposure MSM 4,046 3,012 1,034 26% IDU % MSM/IDU % Heterosexual contact 1,775 1, % Mother with HIV % Other/hemophilia/blood transfusion % Unspecified risk 1, % Total 7,988 5,839 2,149 27% *Excludes individuals of unknown race Minnesota HIV/AIDS Epidemiologic Profile Ryan White Services and Unmet Need

61 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 ) 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 1 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 Minnesota HIV/AIDS Epidemiologic Profile Technical Notes

62 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 most likely detect the case. Thus, although HIV case reporting is our best estimate of new HIV infections, the system does not capture all new cases and there are varying amounts of delay between infection, 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 Annual HIV/AIDS Surveillance Summaries Annual HIV/AIDS surveillance summaries for Minnesota are available on the MDH website: diseases/hiv/hivsurvrpts.html 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

63 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. 4 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, See annual reports at 6 Detailed methodology available in the HIV Surveillance Technical Notes at Minnesota HIV/AIDS Epidemiologic Profile Technical Notes

64 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 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

65 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 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 Minnesota HIV/AIDS Epidemiologic Profile Technical Notes