Epidemiological Profile of HIV/AIDS in Minnesota
General Population Demographics
Description of Minnesota (1)
(1) All data presented in this section are from the U.S. Census Bureau, unless otherwise noted.
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 percent) 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.
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 percent between 2000 and 2010. According to the 2010 Census, 3.18 million persons (60%) living in Minnesota were under the age of 45. As seen in Table 1, there is little difference in the age distribution between the state and the TGA.
|Table 1. Age Distribution in Minnesota and in TGA|
(n = 5,303,925)
|Minneapolis – St. Paul TGA
(n = 3,279,833)
|13 – 19||9.6%||9.6%|
|20 – 24||6.7%||6.5%|
|25 – 29||7.0%||7.6%|
|30 – 34||6.5%||7.0%|
|35 – 39||6.2%||6.7%|
|40 – 44||6.7%||7.2%|
|45 – 49||7.7%||7.9%|
|50 – 54||7.6%||7.5%|
|55 – 59||6.6%||6.3%|
While Minnesota is predominantly White (approximately 85 percent), there has been an increase in the number of Black, Hispanic, and Asian/Pacific Islander persons living in Minnesota since 2000. At that time, 89 percent of Minnesotans were White, 3.5 Black, 2.9 percent Hispanic, 1.1 percent Native American, and 2.9 percent Asian. However, excluding the 2.4 percent of the Minnesota population that indicated two or more races, Black, Hispanic, and Asian/Pacific Islander populations increased by about 60 percent, 75 percent, and 50 percent 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 2010 –2012 American Community Survey (ACS) show that foreign-born individuals account for 7.3 percent and 9.6 percent of the state and TGA population, respectively, compared to 5 percent and 7 percent in 2000.
Table 2 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 percent vs. 83 percent) and females (79 percent vs. 83 percent) 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 percent for African Americans, 31.5 percent for Asians/Pacific Islanders, 40.5 percent for Hispanics 32.9 percent American Indians, and 56.3 percent of those identifying as multi-racial (two or more races).
|Table 2. Race and Ethnicity Distribution by Gender in Minnesota and TGA|
Minneapolis-St. Paul TGA
|Race / Gender||Male||Female||Male||Female|
|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 73,930 (2) African-born persons living in Minnesota in 2011. However, many believe this to be an underestimate of the true African population in Minnesota, with some community members estimating that number at close to 100,000 (3). Somalia, Ethiopia, and Liberia are the most common countries of origin although nearly every country in Africa is represented in Minnesota. Data from the MDH Refugee Health Program indicate that the number of sub-Saharan African primary refugees arriving in Minnesota has declined dramatically between 2006 and 2011 (from 4,764 cases in 2006 to 533 cases in 2011 – a decrease of 89 percent). However, the Refugee Health program at MDH expects to see more refugees from Africa in the future due to policy changes at the federal level such as the reinstatement of the family reunification program on October 15th, 2012.
Additionally, in 2000 Minnesota became one of six initial sites in the United States to receive HIV-infected refugees. Prior to November 2009, immigrants, including refugees, were not permitted entry into the U.S. if they tested positive for HIV during their overseas physical exam unless they obtained a waiver. Agencies with local offices in the Twin Cities coordinated the arrival and resettled 200 HIV-infected refugees to Minnesota from August 2000 through December 2010, of which the majority were from African countries. However, beginning in 2010, the Federal Government reversed the statute barring entry for HIV positive immigrants. Consequently, HIV infection is no longer a barrier for entering the United States. Therefore, Minnesota added routine HIV screening to the refugee screening protocol in 2010.
(3) The American Community Survey is conducted by the U.S. Census Bureau for the years in between the decennial census. Because there are many reasons African-born persons may not be included in the census count (e.g. difficulties with verbal or written English), even 50,000 is likely an underestimate of the actual size of the African-born population living in Minnesota. Anecdotal estimates from African community members in Minnesota are as high as 100,000.
Poverty and Income
Minnesota overall has fared somewhat better than the nation as a whole in regards to poverty and income. According to the 2010-2012 ACS, an estimated 12 percent of Minnesotans were living below the Federal Poverty Level compared to 15.7 percent nationally. Likewise, the per capita income from 2010 – 2012 for the United States was $27,385 and $30,237 in Minnesota. While these aggregate numbers are favorable, they misrepresent the disproportionate impact poverty has on persons of color. The 2010-2012 ACS estimates that 12 percent of all Minnesotans were living at or below the poverty level, however, this percent varied greatly by race, with 9.0 percent of Whites at or below the poverty level compared to 37 percent, 37 percent, 17 percent, and 25 percent of Blacks, American Indians, Asians/Pacific Islanders, and Hispanics, respectively.
According to Minnesota Department of Employment and Economic Development, Minnesota’s unemployment rate decreased from 6.5 percent in 2011 to 5.6 percent in 2012. While these rates are higher than years prior to 2008, they are substantially lower than the 2012 national average of 8.1 percent. However, the overall unemployment rates disguise staggering racial disparities. The 2010-2012 ACS indicated an unemployment rate of 18.7 percent, 11.0 percent and 18.3 percent for Blacks, Hispanics and American Indians, respectively in Minnesota compared to 6.4 percent among white (non-Hispanics).
Minnesota’s emphasis on education is reflected in the low statewide percentage (8.0 percent) of people aged 25 years or older who have less than a high school education; the national average is 14.1 percent. However, the percentage of persons with less than a high school education is greater for persons of color in Minnesota. According to the 2011 ACS, 17 percent of Black men and 25 percent of Black women are estimated to have less than a high school education compared to 6 percent and 5 percent of White men and women, respectively. High school graduation rates are even lower among Hispanics/Latinos, with 37 percent and 36 percent of Hispanic males and females not having a high school diploma, respectively.
Access to Health Care
Overall, Minnesota has one of the lowest rates of uninsured residents in the nation. According to data released from the 2011 Minnesota Health Access Survey, 9.1 percent of Minnesotans were not covered by health insurance at the time of the survey compared to 9.0 percent in 2009, 7.2 percent in 2007 and 7.7 percent 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.
Notable differences continue to exist among the different race/ethnic groups. While only 7.6 percent of Whites were uninsured in 2011, the percentages among Hispanics (26.0 percent), American Indians (14.3%), and Blacks (17.9%) were considerably higher. The percentage among Asians/Pacific Islanders (11.8%) was similar to that of the statewide rate.
In 2011, persons aged 18-24 and 25-34 experienced uninsurance rates significantly above the statewide rate (16.9 percent and 18.3 percent for 18-24 and 25-34 year olds, respectively, compared to 9.1 percent statewide). Persons aged 0-5, 6-17 and over 65 had uninsurance rates significantly below the statewide rate (5.1 percent, 5.5 percent and 0.7 percent, respectively). Between 2009 and 2011, uninsurance rates decreased in most of the age groups but increased among 25-34, 35-54 and 55-64 year olds.
Country of birth is a significant factor in unisurance rates in Minnesota. In 2011, people born in the United States had significantly lower unisurance rate than the statewide rate of 7.7 percent while those not born in the United States had a significantly higher uninsurance rate of 28.1 percent. The unisurance rate of 28.1 percent among non-US born persons increased significantly from the 2009 rate of 17.9 percent.
Minnesota is known for its caliber of health care. Unfortunately, when it comes to prenatal care, women do not access health services equally. Overall, 87.9 percent of Minnesota mothers giving birth in 2010 began prenatal care in the first trimester. However, while 90.5 percent of White women began prenatal care in the first trimester, only 78.1 percent of Black, 79.0 percent of American Indian, and 82.5 percent of Hispanic women did (Minnesota Pregnancy Risk Assessment Monitoring System, 2012). Additionally, 89.2 percent of US-born mothers began prenatal care in the first trimester compared to 81.6 percent 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 percent 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 percent of men and 4 percent of women reported exclusively same gender sex for at least 3 years during adulthood (Kinsey et al., 1948; Kinsey et al., 1953). Generalizing these findings to the general population is very questionable because these data were based on convenience samples.
Subsequent to this work, studies more representative of the general U.S. population have been undertaken. Comparing national surveys from 1970 and 1991, Siedman and Rieder (1994) estimated that from 1 percent to 6 percent of men had sex with another man in the preceding year. In another population-based study, Sell et al. (1995) estimated the incidence of same sex behavior in the preceding five years at 6 percent for males and 4 percent for females. 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 percent of adult males and 4.7 percent of adult females in Hennepin County identified as GLBT (Hennepin County Community Health Department, 2011). 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.
(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.
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. While the transgender population considers itself to be at elevated risk for transmission due to circumstances described in the needs assessment section of this plan, we lack comprehensive epidemiological data on this population.
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 (Bockting et al., 1998; Bockting et al., 2005).
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 2010 - 2012 ACS data, 2.6 percent of non-institutionalized Minnesotans are estimated to be living with hearing difficulty and 2.9 percent of non-institutionalized Minnesotans are estimated to be living with vision difficulty.
Homelessness is also seen as a social determinant of health. In 2012, an estimated 10,214 people were homeless in Minnesota. According to the 2012 Wilder Homelessness Survey, this number has increased by 10 percent 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.