Epidemiological Profile of HIV/AIDS in Minnesota
Ryan White Care Act Services: Unmet Need
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Ryan White CARE Act Services in Minnesota
This section of the profile provides a description of people who use the Ryan White HIV/AIDS Program services in Minnesota, both within the TGA (Part A and Part B) and Greater Minnesota (Part B), and quantifies the unmet need for primary medical care.
Data Sources
The data presented in this section comes primarily from two sources, the enhanced HIV/AIDS Reporting System (eHARS) and the Minnesota CAREWare system used by all agencies providing Part A, Part B, ADAP and state-funded HIV services.
Since almost all Ryan White services are dependent on financial eligibility, it should not be expected that everyone living with HIV/AIDS in Minnesota would be eligible and/or receiving Ryan White services. Therefore, surveillance data should not be used as the standard by which services are measured, but as an additional piece of the puzzle in describing HIV/AIDS care in Minnesota.
Overview of Ryan White in Minnesota
The number of clients utilizing Ryan White services has steadily grown from 1,771 in 1996 to 4,143 in 2011. Additionally, over the past three years, several of the funded services have seen increases in the number of people being served. Figures 1 and 2 show the increase in some of the essential care and essential access services. Essential care services are those services considered necessary to address care needs, and essential access are services that help people gain access to HIV care and support services.
Comparison of Epi and Utilization Data
While the center of the epidemic in Minnesota is the Minneapolis-St. Paul TGA, there are people living with HIV/AIDS in 92 percent of Minnesota counties. There are people receiving Ryan White services in over 80 percent of Minnesota counties. In 2011, 4,143 people utilized Ryan White Services in Minnesota, compared to 7,136 people living with HIV/AIDS in Minnesota.
Gender
Males comprise the majority of those living with HIV/AIDS in Minnesota, accounting for 77 percent of all cases. A similar distribution is seen among those receiving services, with males accounting for 72 percent of clients and females accounting for 28 percent. Transgender persons make up less than 1 percent of those receiving services (data not shown).
Age
Persons over the age of 44 account for the most (49 percent) of those receiving services. Adolescents and young adults (ages 13–24) account for 5 percent of those receiving services. The age distribution of those receiving services is similar to those living with HIV/AIDS. People over the age of 44 account for 53 percent of those living with HIV/AIDS and adolescents and young adults account for 4 percent (data not shown).
Mode of Exposure
There are also significant differences in the mode of exposure distribution of those living with HIV/AIDS in the TGA and greater Minnesota. Figure 3 shows that while MSM account for 53 percent of those living with HIV/AIDS in the TGA, they only account for 39 percent in Greater Minnesota. Additionally, while IDU-associated (IDU, MSM/IDU) and heterosexual contact account for 16 and 20 percent of living cases in Greater Minnesota, respectively, they each account for 10 and 11 percent respectively of people living with HIV/AIDS in the TGA.
Mode of exposure for those receiving Ryan White services also differs for people residing in the TGA and those residing in Greater Minnesota. MSM account for 46 percent of those receiving services in the TGA compared to 31 percent in Greater Minnesota. Injection drug use accounts for 5 percent of cases in the TGA compared to 8 percent in Greater Minnesota (Figure 4).
Race/Ethnicity
There are significant differences in the racial/ethnic distribution between those living with HIV/AIDS in the TGA and Greater Minnesota. Figure 5 shows the racial breakdown for people living with HIV/AIDS in the TGA and Greater Minnesota. While Whites account for the majority of cases in both areas, people of color make up 48 percent of cases in the TGA compared to 37 percent in Greater Minnesota.
As with surveillance data, there are racial/ethnic differences between those receiving services in the TGA and Greater Minnesota. While Whites account for 43 percent of those receiving services in Minnesota, they account for 38 percent in the TGA compared to 53 percent in Greater Minnesota. Additionally, Blacks (includes African-born) account for 38 percent of those receiving services in the TGA compared to 20 percent in Greater Minnesota (Figure 6).
Geography
Table 1 shows that the proportion of people receiving services in Greater Minnesota is larger than those receiving services in the TGA. However, based on the numbers of people served, the majority of people accessing Ryan White services live in the TGA (85 percent) compared to 15 percent in Greater Minnesota. In addition, less than 1 percent of people receiving services have unknown counties of residence, and less than 1 percent reside in other states. Figure 7 shows the distribution of those receiving services by county.
| Table 1. Number of People Receiving Ryan White CARE Act Services and Living Cases of HIV/AIDS, Minnesota 2010 | |||
| Number Receiving Services* | Number in SurveillanceŦ | Percentage Receiving Services | |
Greater MN |
624 |
917 |
68% |
13-County TGA |
3,519 |
6,149 |
57% |
| * Includes 8 cases from Pierce and St. Croix counties. Ŧ Does not include 70 cases with unknown residence. |
|||
Services Received in 2011
In 2011, the service category of Medical Case Management was the most utilized, with 2,876 clients (69 percent of total clients) accessing case management services. Medical Transportation Services was the next most utilized service with 1,421 clients (34 percent of total clients), followed by the AIDS Pharmaceutical Assistance Program (ADAP) with 1,398 clients (34 percent of total clients), and Meals Service with 1,348 clients (33 percent of total clients). The next most used services were Outpatient/Ambulatory Care, Emergency Financial Assistance, and Oral Health Care, with 1134, 1081 and 611 clients, respectively.
While Ryan White funds in many states are primarily used to pay for primary medical care for people living with HIV/AIDS, Minnesota has historically been fortunate enough to provide extensive access to health insurance through public programs. Additionally, several clinics and hospitals throughout Minnesota have had a tradition of providing extensive charitable care for HIV/AIDS. This has reduced the need to use Ryan White Part A and B funds to support primary medical care, and allowed the dollars to be used to create a comprehensive system of support services. However, due to the rise in health care costs, hospitals and clinics are cutting back on the amount of charitable care provided, which may signal a change in the way in which Part A and B funds will be spent in Minnesota in the future.
Characterizing Unmet Need for Primary Care Among HIV Positive People
The definition of unmet need for primary medical care is: “An individual with HIV or AIDS is considered to have an unmet need for care (or to be out of care) when there is no evidence that s/he has received any of the following three components of HIV primary medical care during a defined 12-month time frame: (1) viral load testing, (2) CD4 count, or (3) provision of anti-retroviral therapy (ART).” (1)
(1) HRSA/HAB definition of unmet need
MDH calculated an estimate of unmet need using data in eHARS to determine the number of people living with HIV/AIDS as of December 31, 2011 and how many of those individuals had received a CD4 or viral load test in 2011. In addition, two large providers of HIV clinical services reported new HIV and new AIDS cases, but did not routinely report all CD4 counts and viral loads. Cases in eHARS that listed either of these providers as their current clinic in 2011 were considered to be in care. MDH was able to gather additional data from conducting reviews of patient records at HCMC.
By December 31, 2011 there were 7,136 persons living with HIV/AIDS in Minnesota. Using the methodology described above, we are able to estimate that of those, the number not receiving primary medical care for their HIV is 1,599 or 22 percent of people living with HIV/AIDS in Minnesota. Table 2 on the following page shows the number of people living with HIV/AIDS who are in and out of care by race, gender and mode of exposure.
The Minnesota communicable disease reporting rule was amended in June 2011 to require the reporting of all CD4 and viral load results. This will greatly improve the completeness of data contained within eHARS and will allow MDH to provide more accurate estimates of the number of people who are in care in the future.
| Table 2: Demographic Characteristics of Out of Care PLWHA in Minnesota, 2011 | ||||
| Number In Surveillance |
Number In Care |
Number Out of Care |
Percent Out of Care |
|
Race* |
|
|
|
|
White, not Hispanic |
3,715 |
2,901 |
814 |
22% |
Black, not Hispanic |
2,480 |
1,933 |
547 |
22% |
African American |
1,539 |
1,216 |
323 |
21% |
African-born |
941 |
717 |
224 |
24% |
Hispanic |
595 |
434 |
161 |
27% |
American Indian |
121 |
99 |
22 |
18% |
Asian/Pacific Islander |
129 |
96 |
33 |
26% |
Gender** |
|
|
|
|
Male |
5,474 |
4,236 |
1,238 |
23% |
Female |
1,662 |
1,301 |
361 |
22% |
Mode of Exposure |
|
|
|
|
MSM |
3,648 |
2,855 |
793 |
22% |
IDU |
415 |
312 |
103 |
25% |
MSM/IDU |
362 |
291 |
71 |
20% |
Heterosexual contact^ |
861 |
693 |
168 |
20% |
Mother with HIV |
80 |
71 |
9 |
11% |
Other/hemophilia/blood transfusion |
40 |
31 |
9 |
23% |
Unspecified risk |
1,730 |
1,284 |
446 |
26% |
Total |
7,136 |
5,537 |
1,599 |
22% |
| *Excludes individuals of multiple races and individuals of unknown race ** Does not include transgender individuals ^HCMC patient records may identify heterosexual contact but mode of exposure was not reported to MDH. These cases are captured under Unspecified risk in surveillance. |
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Summary of Ryan White CARE Act Services in Minnesota
More people than ever are living with HIV/AIDS and utilizing Ryan White services in Minnesota. The number of people utilizing services has steadily grown from 1,771 clients in 1996 to 4,143 in 2011 — a 134 percent increase.
As with the epidemic, in 2011, men accounted for the majority of those served (72 percent), Whites accounted for 43 percent of all served, and the majority (85 percent) lived in the TGA.
There are racial/ethnic and mode of exposure differences among those being served in the TGA and in Greater Minnesota. While Whites account for 53 percent of those being served in Greater Minnesota, they account for 38 percent in the TGA. Similarly, while MSM account for 46 percent of those being served in the TGA, they account for 31 percent in Greater Minnesota.
While the epidemic continues to be geographically centered in the TGA, there are people living with HIV/AIDS and utilizing Ryan White CARE Act services in over 80 percent of Minnesota counties.
