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