Epidemiological Profile of HIV/AIDS in Minnesota
The Scope of HIV/AIDS in Minnesota
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Epidemiological Surveillance - Data Quality and Sources
HIV/AIDS Reporting System (eHARS)
The Minnesota Department of Health (MDH) collects confidential name-based case reports of HIV infection (since 1985) and AIDS diagnoses (since 1982) through a passive and active HIV/AIDS surveillance system. In Minnesota, laboratory-confirmed infections of human immunodeficiency virus (HIV) are monitored by MDH through this active and passive surveillance system. State law (Minnesota Rule 4605.7040) requires both physicians and laboratories to report all cases of HIV infection (HIV or AIDS) and all subsequent CD4 and viral load test results 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 HIV-infected individuals, and the availability and targeting of HIV testing services.
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 percent of HIV-infected individuals are unaware of their status. And for gay/bisexual men, evidence suggests this percentage is much higher (77 percent) (MacKellar et al., 2002). This is partly because early HIV infection does not produce severe nor distinct symptoms and so delays in 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.
(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.
Additional HIV/AIDS Surveillance Activities
HIV Drug Resistance and Subtyping Surveillance in Minnesota
Minnesota's disease reporting rules were revised in 2005 to require submission of clinical materials from newly diagnosed cases of HIV infection. HIV drug resistance testing and viral subtype determination are conducted on eligible specimens.
Divergent strains of HIV have implications for testing, clinical care, and vaccine research/ implementation. Systems to monitor the introduction and spread of non-B subtypes of HIV-1 and, to a lesser extent, HIV-2 in the U.S. will be critical for biotechnology to evolve effectively alongside a dynamic epidemic.
Behavioral Surveillance
MDH collects a small amount of behavioral data as it relates to HIV and AIDS surveillance information. For example, reports of HIV infection received by MDH include information on drug use and sexual behaviors. Additionally, from time to time MDH will undertake special projects with the intent of collecting behavioral data on specific populations. Examples of these are the 2001 Minnesota STD Prevalence Study (ages 12-24) and the 2004 and 2007 Twin Cities Men’s Health Surveys (Men having Sex with Men 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.
HIV/AIDS in Minnesota
Compared to the rest of the nation, Minnesota is considered to be a low to moderate HIV/AIDS incidence state. In 2010, state-specific AIDS rates ranged from 0.5 per 100,000 persons in Vermont to 112.5 per 100,000 persons in the District of Columbia. Minnesota had the 14th lowest AIDS rate (4.0 AIDS cases reported per 100,000 persons). Compared to surrounding states (IA, ND, SD, & WI), Minnesota’s AIDS rate was the highest, followed by Wisconsin at 3.1. State-specific HIV rates cannot be compared nationally because HIV case surveillance is at various stages of implementation among different states (Centers for Disease Control and Prevention, 2011).
Cumulative Cases
As of December 31, 2011, a cumulative total of 9,785 (3) cases of HIV infection have been reported among Minnesota residents. This includes 5,997 AIDS cases and 3,808 HIV, non-AIDS cases. Of all these HIV/AIDS cases, 3,347 are known to be deceased through correspondence with the reporting source, other health departments, reviews of death certificates and obituaries, active surveillance, and matches with the National Death Index and Social Security Death Master File.
(3) 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.
Overview of New HIV/AIDS Cases in Minnesota
As depicted in Figure 1, the annual number of new AIDS cases has fluctuated slightly between 2002 and 2011. Starting in the mid-1990’s, both the number of newly diagnosed AIDS cases and the number of deaths among AIDS cases declined sharply, primarily due to the success of new antiretroviral therapies including protease inhibitors. This decline has continued over the last ten years. These treatments do not cure, but can delay progression to AIDS among persons with HIV infection and improve survival among those with AIDS. Thus, between 2002 and 2011 a few peaks and valleys are observed in the number of new AIDS cases, with an increase between 2002 and 2004. A slight decrease was observed between 2005 and 2007, after which the number of cases remained somewhat stable. The number of people living with HIV/AIDS has continued to increase over time (Figure 2). An estimated 7,136 persons with HIV/AIDS are assumed to be living in Minnesota as of December 31, 2011. This number includes persons whose most recently reported state of residence was Minnesota, regardless of residence at time of diagnosis.
Geography
Historically, about 90 percent of new HIV infections diagnosed in Minnesota have occurred in the Minneapolis-St. Paul TGA.
As depicted in Figures 3 and 4, this trend continued in 2011 with 35 percent of new cases diagnosed among people living in Minneapolis, 15 percent in St. Paul, 39 percent in the surrounding suburbs, and 11 percent in Greater Minnesota (outside of the TGA). Over the past ten years, residents in the suburban TGA have accounted for an increasing percentage of new infections, from 35 percent in 2002 to 39 percent in 2011. Although HIV infection is more common in communities with higher population densities and greater poverty, there are people living with HIV or AIDS in 92 percent of counties in Minnesota, however, 87 percent of those infected live in the TGA.
While the concentration of new HIV/AIDS infections is in the TGA (89 percent), there are notable differences between Greater Minnesota and the TGA in the racial and risk category distribution of those infected.
While most the risk category distributions are similar for Greater MN and the TGA there are a few interesting differences. The proportion of new infections between 2009 and 2011 attributed to MSM/IDU and unspecified modes of exposure are similar in the TGA and Greater Minnesota. However, MSM account for a greater percentage of cases in the TGA (57 percent) than in Greater MN (39 percent). Additionally, the percentage of heterosexual cases is higher in Greater MN (25 percent) than in the TGA (10 percent) (Figure 5).
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 (Figure 6). The main differences occur in African American, African-born, and White communities. African Americans accounted for 10 percent of Greater Minnesota cases and 24 percent of TGA cases and African-born persons accounted for 8 percent of Greater Minnesota cases and 12 percent of TGA cases. In contrast White made up a slightly greater percentage of new infections in Greater Minnesota than the TGA (64 percent and 49 percent, respectively). The proportion of Hispanic cases was the same in both the TGA and Greater Minnesota (9 percent). Persons age 13-24 years made up 24 percent of the new cases in the TGA between 2009 and 2011, while accounting for 19 percent of the new cases in Greater Minnesota. Conversely, persons over 45 years of age accounted for 24 percent of both new TGA and Greater Minnesota cases. Otherwise, there are no significant differences in the distributions for gender and age (data not shown).
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 percent of all new cases reported, over the past 10 years the males have accounted for only 75 percent of cases (Figure 7). This remained true in 2011; 75 percent of new infections occurred among males and 25 percent occurred among females. Males currently account for 77 percent of those living with HIV/AIDS in Minnesota.
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 (Kaufman and Cooper, 2001). 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, Whites make up about 85 percent of the state population, but only accounted for 49 percent of all new HIV infections in 2011, while populations of color make up 15 percent of the population and 51 percent of new HIV infections.
Trends in the annual number of new HIV infections diagnosed among males differ by racial/ethnic group (Table 1, Figure 8). Cases among White men still account for the majority of cases among males, and new diagnoses in this group have remained stable since 2002 despite increases in 2008 and 2009.
The number of cases among African American males has fluctuated between 2002 and 2011 (Table 1). The number of new cases among African American males decreased since a peak of 64 cases in 2009 to 43 cases in 2011.
Cases among Hispanic males have remained fairly stable over time. In 2006 the number of cases among Hispanic males more than doubled from 2005, but by 2011 decreased 48 percent to 19 cases. Among African-born males there was a large increase in the early 1990’s, but from 2000 to 2007, the numbers stayed fairly stable at around 20 cases per year. This trend continued in 2011 with 17 cases.
| Table 1. Annual Number of New HIV Infections Among Males by Race/Ethnicity and Year of Diagnosis, Minnesota 2002 – 2011 |
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| Race/Ethnicity | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 |
| White | 123 | 116 | 131 | 138 | 128 | 132 | 152 | 172 | 142 | 129 |
| Black: | 64 | 60 | 59 | 58 | 53 | 73 | 52 | 83 | 71 | 60 |
| African Amer. | 38 | 33 | 37 | 39 | 35 | 50 | 40 | 64 | 58 | 43 |
| African-Born | 26 | 27 | 22 | 19 | 18 | 23 | 12 | 19 | 13 | 17 |
| Hispanic | 27 | 25 | 26 | 17 | 37 | 33 | 25 | 30 | 29 | 19 |
| Amer. Indian | 2 | 5 | 4 | 0 | 7 | 1 | 3 | 4 | 7 | 3 |
| Asian/PI | 7 | 5 | 0 | 3 | 3 | 5 | 6 | 7 | 5 | 5 |
| Other* | 1 | 4 | 1 | 3 | 3 | 4 | 6 | 3 | 9 | 2 |
| Total | 224 | 215 | 221 | 219 | 231 | 248 | 244 | 299 | 263 | 218 |
*Other includes those with unknown race.
Similarly, trends in the annual number of HIV infections diagnosed among females differ by racial/ethnic group (Table 2, Figure 9). 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 whites since 1991.
| Table 2. Annual Number of New HIV Infections Among Females by Race/Ethnicity and Year of Diagnosis, Minnesota 2000 – 2011 |
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| Race/Ethnicity | 2002 | 2003 | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 | 2011 |
| White | 13 | 7 | 23 | 18 | 30 | 19 | 22 | 19 | 22 | 14 |
| Black: | 60 | 47 | 49 | 54 | 45 | 43 | 46 | 40 | 36 | 48 |
| African Amer. | 21 | 18 | 18 | 28 | 28 | 17 | 23 | 19 | 16 | 21 |
| African-Born | 39 | 29 | 31 | 26 | 17 | 26 | 23 | 21 | 20 | 27 |
| Hispanic | 6 | 4 | 9 | 6 | 6 | 7 | 4 | 5 | 2 | 5 |
| Amer. Indian | 5 | 4 | 3 | 4 | 2 | 5 | 3 | 4 | 5 | 1 |
| Asian/PI | 1 | 2 | 2 | 0 | 2 | 1 | 1 | 0 | 1 | 3 |
| Other* | 0 | 1 | 0 | 1 | 4 | 3 | 3 | 3 | 2 | 3 |
| Total | 85 | 65 | 86 | 83 | 89 | 78 | 79 | 71 | 68 | 74 |
*Other includes those with unknown race.
In 2011, women of color accounted for 81 percent of new infections among females, with African American and African-born women accounting for 65 percent of infections among women.
The number of new infections among White women had decreased to a low of 7 in 2003. The number of cases was 14 in 2011, this is down from 22 cases in 2010 (36 percent). Since 2000, the annual number of new infections diagnosed among African American females had been stable at around 20 cases, with peaks of 28 new cases in 2005 and 2006. In 2011 there were 21 cases among African American females, an increase of 31 percent from the number of cases in 2010. Cases among African-born females had risen sharply from 17 cases in 2000 to a high of 39 cases in 2002. However since 2002, the number of new HIV infections has decreased, with 27 cases reported in 2011. Among women, African-born women continue to have the highest number of new infections annually. The annual number of new infections diagnosed among Hispanic, American Indian, and Asian females continues to be quite small.
While men and women of color overall are disproportionately affected by HIV/AIDS, in Minnesota this disparity is most evident among women. As previously mentioned, women of color accounted for 81 percent of new infections among women in 2011 (Figure 10) however, women of color account for approximately 13 percent of the female population.
African-born Persons
African immigration to Minnesota increased markedly during the mid-1990s; the Minnesota State Demographer’s office estimates there are 73,930 (4) 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 (5). 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 44 cases diagnosed in 2011. Still, African-born persons accounted for 15 percent of new HIV infections diagnosed in 2011, but account for an estimated 1 percent of the statewide population. African-born persons have the highest rate of infection of any of the other racial groups with 60.3 cases per 100,000 population. This is nearly twice the rate of the next highest racial group, African-Americans at 32.6 per 100,000 population.
A notable difference in the local epidemic among African-born persons is the distribution of cases between males and females. In 2011, 61 percent of the new infections diagnosed among African-born persons were females compared to 16 percent among the remaining infections of other races/ethnicities (data not shown).
The sheer diversity of cultures (32 different African countries are represented among those living with HIV/AIDS in Minnesota; many nations are home to tens of cultures within their borders), and lack of education about HIV, and language and cultural barriers all pose significant challenges for HIV prevention and care efforts.
(4) Based on U.S. Census 2010 data, the Minnesota State Demographic Center estimates that there are 380,764 foreign-born persons, including 72,930 African-born persons are living in Minnesota out of a total population of 5,303,925.
(5) 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.
American Indians
While the number of cases among American Indian males and females 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 recent 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 (Bertolli et al., 2007). It is possible that similar misclassification occurs in the Minnesota data and impacts the reported number of cases for American Indians in the state.
Late Testing
A characteristic of the HIV epidemic that impacts both prevention and care services is the percent of persons that are considered late testers. Late testers are defined as persons who had their first positive HIV test within one year of receiving an AIDS diagnosis (6) (CDC, 2003). 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, the percentage of newly diagnosed persons progressing to AIDS within one year of initial diagnosis with HIV infection has remained relatively stable around 30 percent (Figure 11). However, this overall stability masks important differences by race and ethnicity. While the percentage of newly diagnosed cases progressing to AIDS within one year among Whites and African Americans in 2011 is around 25 percent, this percentage is significantly higher among Hispanics (44 percent) and African-born (36 percent) (data not shown). Numbers for American Indians and Asian/Pacific Islanders are too small to draw any conclusions. Most of the late-tester cases among Hispanics were among foreign-born individuals in 2011. This has significant implications for prevention and care.
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. However, the number of cases diagnosed among those 13 to 24 years of age has increased substantially over the past ten years. The number of new cases in that age group increased by 67 percent from 33 in 2002 to 55 in 2011; 2009 and 2010 saw record numbers in this age group with 95 and 78 cases, respectively. The number of new infections among those aged 45 and older has also substantially grown, with a 15 percent increase from 60 cases in 2002 to 69 in 2011 (Figure 12).
While trends in new infections have not changed significantly overall, trends by age and gender show some differences. Since 2002, cases among young males (age 13 – 24) have nearly doubled (with a peak in 2009 of nearly a four-fold increase from the number of 2002 cases) while cases among females in the same age group have decreased by nearly 50 percent between 2002 (15 cases) and 2011 (8 cases). Cases among females aged 45 and older increased by 57 percent from 14 cases in 2001 to 22 cases in 2011, while cases among males in this age group has remained the same since 2001 (data not shown). Figure 13 shows the distribution by age and gender for cases diagnosed between 2009 and 2011.
Similarly, there are differences by age and race/ethnicity. Between 2009 and 2011, 35 percent of the cases among African Americans were among those aged 13 to 24 years of age, compared to 20 percent among Whites, 7 percent among African-born, and 26 percent among Hispanics. 70 percent of cases among African-born cases were among those aged 25 to 44 years of age, compared to 61 percent for Hispanics, 42 percent for African Americans and 51 percent for Whites. Among Whites, 29 percent of those diagnosed are 45 and older compared to 22 percent for African Americans, 22 percent for African-born and 13 percent for Hispanics (data not shown). Numbers for American Indians and Asian/Pacific Islanders are too small to draw any conclusions.
Adolescents and Young Adults (7)
(7) In this report, adolescents are defined as 13-19 year-olds and young adults as 20-24 year-olds; these two groups are jointly referred to as “youth.” Analyses are performed for adolescents and young adults combined because case numbers are too small to present meaningful data separately for each.
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.
In 1990, 10 percent of new HIV infections reported to MDH were among youth. In 2011 this percentage was 19 percent. Among young men, the number of new HIV diagnoses has been steadily increasing since 2001. In 2001 there were 18 new cases reported among young men and that number increased by more than four-fold in 2009 with 78 new cases reported (Figure 14). The number of new cases among male youth decreased to 67 in 2010 and 47 in 2011 –but remained above the 2008 number of 44. The increase of new diagnoses among young males is a worrisome trend that needs to be addressed by prevention and care.
Unlike young men, the annual number of new HIV infections diagnosed among young women has remained relatively consistent over time (Figure 14). However, in 2004 the number of new infections among young women increased to 21, the highest ever recorded among young women. In 2011 there were 8 new HIV cases among young women, accounting for 15 percent of new infections diagnosed among adolescents and young adults.
Similar to the adult HIV/AIDS epidemic, persons of color account for a disproportionate number of new HIV infections among adolescents and young adults, especially among young women. Among young men, Whites accounted for 44 percent of new HIV infections diagnosed between 2009 and 2011, African Americans accounted for 36 percent, and Hispanics for 11 percent of the cases. Among young women, African Americans accounted for 20 percent, African-born for 20 percent, Whites for 36 percent, and Hispanics and American Indians for 6 percent and 9 percent of the new infections diagnosed during the same time period, respectively (data not shown).
MSM is the predominant estimated (8) mode of HIV exposure among adolescent and young adult males, accounting for 96 percent of the new HIV infections diagnosed between 2009 and 2011 (Figure 15). The joint risk of MSM and injecting drug use (MSM/IDU) was estimated to account for 3 percent of the cases.
(8) Starting in 2004, the MDH estimated mode of exposure for both new and living cases of HIV/AIDS. For details on the process see the HIV Surveillance Technical notes report on our website or contact 651-201-5414 for a copy.
Among females, heterosexual contact is estimated to account for 100 percent of new HIV infections diagnosed between 2009 and 2011 (Figure 15). Adolescents and young adults accounted for 4 percent of those living with HIV/AIDS in Minnesota in 2011. This percent has stayed constant over the past 5 years.
Pediatric Cases of HIV/AIDS
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, 73 cases of pediatric HIV infection have been diagnosed to date, 55 (75 percent) of whom are still assumed to be alive. Fifty-four (74 percent) of the 73 cases resulted from perinatal exposure, 10 percent were associated with hemophilia or other coagulation disorder, 6 percent associated with blood transfusion, and 11 percent were undetermined.
One of the few success stories in the history of HIV infection is the use of medication to successfully reduce perinatal transmission of the virus. Without treatment, the risk of HIV transmission from a pregnant woman to her child before or during birth is approximately 25 percent (Conner et al., 1994). Preventive antiretroviral treatment can reduce this percentage to 1–2 percent (Cooper et al., 2002). If breastfeeding is avoided, nearly all children born to HIV-infected mothers can be spared infection.
The U.S. Public Health Service released guidelines in 1994 for the use of zidovudine to prevent perinatal transmission of HIV and in 1995 recommended universal counseling and voluntary HIV testing for pregnant women. With the widespread adoption of these guidelines, perinatal HIV transmission in the United States decreased by 81 percent between 1995 and 1999 (Bulterys et al., 2002).
The trend in Minnesota has been similar but on a much smaller scale. Between 1990 and 1995, 16 cases of perinatally acquired HIV infection were diagnosed among children born in Minnesota compared to 15 cases between 1996 and 2011. While there is no difference in the number of cases, the difference in the rate of transmission is nine-fold, from 18 percent in 1990–1995 to 2 percent in 1996–2011.
The overall rate of transmission for 2009–2011 was 1 percent (2 cases out of 186 births). Figure 16 shows the trend lines for both births among HIV-infected women and the number of perinatally acquired infections, by year of birth. 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.
People Living with HIV/AIDS in Minnesota
As of December 31, 2011 it was estimated that 7,136 persons with HIV/AIDS were living in Minnesota. Of these, most are White males (46 percent or 3,283 cases), followed by African American males (15 percent or 1,062 cases). For women, the largest number of living cases is among African-born women (523 cases) followed by African-American and White women (477 and 432 cases, respectively) (data not shown).
Mode of Exposure among HIV Positive Persons
The majority of living cases are among MSM (51 percent or 3,648 cases). Heterosexually and IDU (including MSM/IDU) acquired infections each account for 20 percent and 11 percent of living cases, respectively. Among living cases, 17 percent have an unspecified mode of exposure. Mode of exposure by gender is shown in Figure 17.
Geography among HIV Positive Persons
Whites account for 52 percent of those living with HIV/AIDS in Minnesota, compared to 22 percent for African Americans, 13 percent for African-born and 8 percent for Hispanics. American Indians and Asians each account for 2 percent people living with HIV/AIDS. However, the distribution by race varies across gender with White males accounting for 60 percent of males living with HIV/AIDS, compared to 26 percent for White females.
As previously stated, 11 percent of new infections occurred in Greater Minnesota in 2011 and, similarly, 13 percent of those living with HIV/AIDS live in Greater Minnesota (Figure 18). The gender distribution by geography is similar with males representing 77 percent of those living with HIV/AIDS residing in the TGA, compared to 73 percent in Greater Minnesota (data not shown).
There are some differences in race by region of residence. While 16 percent of White living cases live in Greater Minnesota, this percentage is considerably smaller among African Americans (7 percent) and African-born (10 percent) cases. However, among HIV positive American Indian, Hispanic and Asian/Pacific Islander persons living with HIV/AIDS, 19 percent, 15 percent, and 19 percent reside in Greater Minnesota, respectively (Table 3). This is not surprising since there are several Indian reservations in Greater Minnesota, in addition to large Hispanic communities.
Table 3. Persons Living with HIV/AIDS by Race/Ethnicity and Region of Residence, Minnesota 2011* |
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Race/Ethnicity |
EMA |
Greater Minnesota |
Total |
Hispanic |
502 (85%) |
86 (15%) |
588 |
American Indian |
96 (81%) |
23 (19%) |
119 |
Asian/Pacific Islander |
103 (81%) |
24 (19%) |
127 |
African American |
1,414 (93%) |
107 (7%) |
1,521 |
White |
3,110 (84%) |
571 (16%) |
3,681 |
African-born |
841 (90%) |
94 (10%) |
935 |
Other |
83 (87%) |
12 (13%) |
95 |
*Does not include 70 cases with missing residence.
Age Distribution of HIV Positive Persons
Two-thirds of those living with HIV or AIDS in Minnesota are forty years of age or older. However, the age distribution varies both by race and gender. Adolescents and young adults account for 4 percent of those living with HIV/AIDS and the distribution is similar among males and females (4 percent and 5 percent respectively). Additionally, while 57 percent of living cases among men are 45 and older, this age group accounts for only 40 percent of living cases among women (Table 4). While 12 percent of those living with HIV/AIDS in Minnesota were 50 years and older in 2000, this percentage grew to 33 percent in 2011, a secondary effect of the success of antiretroviral medications.
| Table 4. Age Distribution for Persons Living with HIV/AIDS by Gender, Minnesota 2011 | ||||
| Males | Females | |||
| Age* | # | % | # | % |
12 and under |
20 |
0.4% |
19 |
1.2% |
13 – 19 |
30 |
0.6% |
30 |
1.8% |
20 – 24 |
166 |
3.0% |
53 |
3.2% |
25 – 29 |
338 |
6.2% |
163 |
9.8% |
30 – 34 |
442 |
8.1% |
221 |
13.3% |
35 – 39 |
536 |
9.8% |
243 |
14.7% |
40 – 44 |
812 |
14.9% |
270 |
16.3% |
45+ |
3,111 |
57.0% |
660 |
39.8% |
Total |
5,455 |
100.0% |
1,659 |
100.0% |
*Age missing for 22 people.
Age differences are also present by race/ethnicity. African American males have a higher percentage of living cases between 13–29 years of age than African-born, White and Hispanic males; 16 percent compared to 10 percent, 7 percent and 11 percent, respectively. The pattern is different among women, where females between 13–29 years of age account for 16 percent of cases among African-born females compared to 14 percent, 14 percent and 13 percent for African American, Hispanic and White females, respectively (data not shown).
HIV (non-AIDS) and AIDS Distribution
Of the 7,136 people living with HIV/AIDS in Minnesota, 47 percent are living with AIDS and the remainder with HIV (non-AIDS). While there are no significant differences in the distribution of HIV (non-AIDS) and AIDS cases by geography and gender, there are some differences by age and race/ethnicity within gender. Sixty-two percent of those living with AIDS are 45 and older compared to 45 percent of those living with HIV (non-AIDS). Additionally, Hispanic males have a higher percentage of cases living with AIDS (58 percent) than White, African American and African-born males with 45 percent, 50 percent and 53 percent, respectively. No differences exist for females by race/ethnicity (data not shown).
For more information on People Living with HIV/AIDS, please see the 2011 HIV/AIDS Prevalence Surveillance Reports.
HIV/AIDS in Other Populations
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. 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).
Co-Infection with Other Diseases Reportable to MDH
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.
In the state of Minnesota, laboratory-confirmed infections of chlamydia, gonorrhea, syphilis, and chancroid are monitored by MDH through a passive, combined physician and laboratory-based surveillance system. State law (Minnesota Rule 4605.7040) requires both physicians and laboratories to report all cases of these four bacterial STDs directly to MDH. In 2002, MDH added an active component to the surveillance system for chlamydia and gonorrhea infections, and in 2008 changed the case report form to include gender of sexual partners and country of origin to better describe STDs in Minnesota. In addition to the regular surveillance, additional behavioral information is collected on syphilis and gonorrhea cases. Other common sexually transmitted conditions caused by viral pathogens, such as herpes simplex virus (HSV) and human papillomavirus (HPV) are not reported to MDH. Factors that impact the completeness and accuracy of the available data on STDs include: level of screening, accuracy of diagnostic tests, and compliance with case reporting. Thus, any changes in STD rates may be due to one of these factors, or due to actual changes in STD occurrence.
While the actual number of chlamydia and gonorrhea cases that are co-infected with HIV is unknown, 16,898 chlamydia cases and 2,283 gonorrhea cases were reported to the MDH in 2011. Over 70 percent of chlamydia and gonorrhea cases reported to the MDH were among females and 69 percent were among persons aged 15-24. Minnesota has also seen resurgence in syphilis cases reported to the MDH. In 2011, the number of early syphilis cases (that is, primary, secondary, and early latent stages) increased by 18 percent (from 221 cases in 2010 to 260 cases in 2010). Of the 260 cases, 49 percent reported being co-infected with HIV. Most of these cases had been diagnosed with HIV before being diagnosed with syphilis. The HIV/syphilis co-infection percentage is up from 38 percent reported in 2006.
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 2011, there were an estimated 20,216 people living in Minnesota with hepatitis B, and 37,303 living with past or present hepatitis C. Although the actual number of people in Minnesota currently co-infected with hepatitis B/C is unknown, surveillance data from 2008 indicates that around 12 percent of people living with HIV/AIDS are also living with hepatitis B or hepatitis C (4 percent with hepatitis B and 8 percent 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.
Tuberculosis (TB) co-infection may also be a problem in among persons with HIV/AIDS. TB infection after HIV diagnosis is considered to be an AIDS-defining condition. In 2011, 137 new cases of TB were reported in Minnesota, and there were 234 documented cases of people living with TB or receiving treatment for TB. At least 124 persons living with HIV/AIDS in Minnesota indicated TB co-infection at some point (53 percent with disseminated TB and 65 percent with pulmonary TB). Nationally, 6 percent of TB-cases diagnosed in 2011 who received an HIV test were also positive for HIV.
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 13,822 in 2011. During those years, the positivity rate (percent of positive tests among all tests performed) ranged from 1.5 percent in 2007 to 1.0 percent in 2010. Over the past three years the number of tests conducted has remained fairly stable. However, the positivity rate decreased from 1.3 percent in 2009 to 1.1 percent in 2011.
In 2011, 6 percent of those tested chose an anonymous test, 32 percent of the tests were done during outreach, and the percent of anonymous tests during outreach was higher than the overall percentage (32 percent vs. 8 percent). Twenty-seven percent of those tested had never had a previous test. Of those with a previous test, 97 percent reported a negative result for their most recent HIV test.
The majority of those tested were males (68 percent), between the ages of 20 and 49 (82 percent), and White (40 percent). Of the 13,822 tests conducted, 53 percent indicated male-to-male sex, and 1 percent indicated injection drug use in the past 12 months. Table 3 shows the number of tests by client characteristics along with positivity rate.
| Table 3. CTR System Tests by Gender, Race, and Age, 2011 | ||
| Client Characteristics* | Number of Tests (percent) | Positivity Rate |
| Gender | ||
Male |
9,385 (68) |
1.4 |
Female |
4,401 (32) |
0.4 |
Transgender |
36(0.2) |
2.8 |
Race/Ethnicity |
|
|
White |
5,586 (40) |
1.4 |
African American/Black |
4,378(32) |
1.1 |
Asian/Pacific Islander |
420 (3) |
0.5 |
American Indian |
1,476(11) |
0.3 |
Other# |
2,047 (15) |
1.0 |
Hispanic† |
1,186 (9) |
1.2 |
Age |
|
|
19 and under |
694 (5) |
0.4 |
20 – 49 |
11,341 (82) |
1.1 |
50 and older |
1,787 (13) |
1.3 |
Total |
13,822 (100) |
1.1 |
* Numbers will not add to total
# Includes multiracial persons and those who refused to answer or were not asked their race.
† Includes all races
