Surveillance of HIV/AIDS
The Minnesota Department of Health (MDH) collects case reports of HIV infection and AIDS diagnoses through a passive and active HIV/AIDS surveillance system. Passive surveillance relies on physicians and laboratories to report new cases of HIV infection or AIDS directly to the MDH in compliance with state rules (1). In June 2011, an amendment to the communicable disease reporting rule was passed, requiring the report of all CD4 and Viral Load test results, improving the completeness of passive reporting in Minnesota, and better allowing for the monitoring of disease progression. Active surveillance conducted by MDH staff involves routine visits and correspondence with select HIV clinical facilities to ensure completeness of reporting and accuracy of the data.
Factors that impact the completeness and accuracy of HIV/AIDS surveillance data include: availability and targeting of HIV testing services, test-seeking behaviors of HIV-infected individuals, compliance with case reporting, and timeliness of case reporting. Certain events have also impacted trends in HIV/AIDS surveillance data. For example changes over time in the surveillance case definition (most notably the 1993 expansion of the case definition for adults and adolescents (2)) have resulted in artificial jumps in AIDS case counts at the time the new definition went into effect or in the preceding year because changes in case definition allowed for retrospective diagnoses.
Vital Status of HIV/AIDS Cases
Persons are assumed alive unless the MDH has knowledge of their death. Vital status information is updated by monthly visits to select reporting facilities, correspondence with other health departments, annual death certificate reviews, and periodic matches with the National Death Index. “AIDS deaths” refers to all deaths among AIDS cases regardless of the cause of death. “All deaths” refers to all death among HIV/AIDS cases regardless of the cause of death.
Place of Residence for HIV/AIDS Cases
Persons are assumed to be residing in Minnesota if their most recently reported state of residence was Minnesota and the MDH has not received notice of relocation outside of the state. Likewise, a person’s county or city of residence is assumed to be the most recently reported value unless the MDH is otherwise notified. Residence information is updated through standard case reporting, monthly visits to select reporting facilities and/or correspondence with other state health departments. Persons diagnosed with HIV infection while imprisoned in a state correctional facility are included in the data presented unless otherwise noted (federal and private prisoners are excluded). Residential relocation, including release from state prison, is difficult to track and therefore data presented by current residence must be interpreted in this light. Data on residence at time of diagnosis are considered more accurate, limited only by the accuracy of self-reported residence location.
Data Tabulation and Presentation
Unless otherwise noted, data analyses exclude persons diagnosed in federal or private correctional facilities (inmates generally are not Minnesota residents before incarceration and do not stay in Minnesota upon their release), infants with unknown or negative HIV status who were born to HIV positive mothers. Data include HIV-infected refugees who resettled in Minnesota as part of the HIV-Positive Refugee Resettlement Program, as well as, other refugees/immigrants that resettled to Minnesota but had an HIV diagnosis prior to arrival.
The HIV/AIDS surveillance system is a live database that is continuously updated to reflect the most current information available. Variables such as current state of residence are over-written when updates are made. Annual archive files were initiated in 2001. Thus, the numbers of HIV/AIDS cases residing in Minnesota in 2000 and 2001 were estimated using the current state of residence variable while the number in previous years (1990-1999) was estimated using state of residence at time of diagnosis, vital status, and date of death variables. The number of HIV/AIDS cases alive in a certain year was calculated by summing cases with an HIV/AIDS diagnosis in that year or prior whose vital status in 2001 was “alive” or whose date of death was either after the calendar year of interest or missing.
Mode of Exposure Hierarchy
All state and city HIV/AIDS surveillance systems funded by the Centers for Disease Control and Prevention use a standardized hierarchy of mode of exposure categories. HIV and AIDS cases with more than one reported mode of exposure to HIV are classified in the exposure category listed first in the hierarchy. In this way, each case is counted as having only one mode of exposure. The only exception to this rule is the joint risk of male-to-male sex (MSM) and intravenous drug use (IDU), which makes up a separate exposure category in the hierarchy. The following is a list of the hierarchy for adolescent/adult HIV/AIDS cases:
- Hemophilia patient
- Heterosexual contact
- Receipt of blood transfusion or tissue/organ transplant
- Other (e.g. needle stick in a health care setting)
- Risk not specified.
The following is the list of the hierarchy for pediatric HIV/AIDS cases:
- Hemophilia patient
- Mother with HIV or HIV risk
- Receipt of blood transfusion or tissue/organ transplant
- Risk not specified.
Heterosexual contact is only designated if a male or female can report specific heterosexual contact with a partner who has, or is at increased risk for, HIV infection (e.g. an intravenous drug user). For females this includes heterosexual contact with a bisexual male (mainly due to the elevated prevalence of HIV infection among men who have sex with men).
“Risk not specified” refers to cases with no reported history of exposure to HIV through any of the routes listed in the hierarchy of exposure categories. These cases include persons who have not yet been interviewed by MDH staff; persons whose exposure history is incomplete because they died, declined to be interviewed, or were lost to follow-up; and persons who were interviewed or for whom follow-up information was available but no exposure was identified/acknowledged.
The growing number of cases with unspecified risk in recent years is, in part, artificial and due to interviews that have not yet been completed. In time, a number of these will be assigned a mode of exposure category. However, part of the observed increase is real. As stated above, a person must have intimate knowledge about his/her partner to meet the criteria for heterosexual mode of exposure. Often cases will not be certain about their partners’ HIV status or risk. Additionally, the perception of social stigma presumably decreases the likelihood that a person will acknowledge certain risk behaviors, particularly male-to-male sex or injecting drug use. Thus, if the true numbers of cases due to heterosexual contact, MSM, and/or IDU increase, a larger number of cases without a specified risk would be expected.
A recent study by the Centers for Disease Control and Prevention used statistical methods to redistribute risk among female HIV/AIDS cases with unspecified risk (3). The results are helpful but are based on national data that are not necessarily applicable to the state or local level. Speculation regarding the distribution of risk behaviors among those with unspecified risk is difficult, especially in men, for whom even a national study is not available.
Re-distribution of Mode of Exposure
In 2004 the Minnesota Department of Health began estimating mode of exposure for cases with unspecified risk in its annual summary slides. Estimation was done by using the risk distribution for living cases with known risk by race and gender and applying it to those with unspecified risk of the same race and gender. For females an additional step was added to the process. If females were interviewed by a Disease Intervention Specialist and injecting drug use and receipt of blood products were eliminated as possible causes of transmission and the female reported sex with males, then she was placed in a new category named “Heterosexual – with unknown risk”. The same was not done for males given the high level of stigma associated with male-to-male sex in certain communities.
When applying the proportions from those with known risk to those with unspecified risk there were two exceptions to the method, African-born cases and Asian/Pacific Islander women. For both African-born and Asian/Pacific Islander women a breakdown of 95% heterosexual risk and 5% other risk was used. For African-born males a breakdown of 5% male-to-male sex, 90% heterosexual risk, and 5% other risk was used. These percentages are based on epidemiological literature and/or community experience.
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. 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 (4) where 9% of the urban population, 4% of the suburban population and 1% of the rural population are estimated to be MSM.
After consulting with stakeholders, it was agreed that it was appropriate to assign urban/suburban/rural designation based on the unique geography of Minnesota. The counties of Hennepin and Ramsey are assigned as urban, the counties of Anoka, Carver, Dakota, Scott and Washington along with the cities of Rochester, St. Cloud and Duluth are assigned as suburban, and the remaining areas were are assigned as rural. In 2015, this method utilized 2010 census data and produced an estimate of the MSM population in Minnesota to be 92,788. Overall, this represents 4.3% of the adolescent and adult male population in Minnesota.
Definitions Related to Race/Ethnicity
When data are stratified by race, Black race is broken down into African-born and African American (not African-born) based on reported country of birth.
The terms “persons of color” and “non-Whites” refer to all race/ethnicity categories other than White (Black, Hispanic, American Indian, and Asian/Pacific Islander).
Routine Interstate Duplicate Review (RIDR)
The Minnesota Department of Health (MDH) continues to participate in RIDR. RIDR is a CDC project aimed at eliminating duplicate reports of HIV and AIDS cases among states. Each case of HIV and AIDS is assigned to the state (or states when the diagnosis of HIV and AIDS occurs in two different states) where a person was first diagnosed. RIDR was the second such de-duplication initiative by CDC. The first initiative, IDEP, looked at cases reported through December 31, 2001. RIDR is now an ongoing activity that all states are expected to undertake. CDC will release a RIDR report every 6 months which will affect the ownership of Minnesota cases. While the Surveillance staff will always inquire about previous diagnosis and will check with CDC to determine if the case has been previously reported, it is possible that cases we believe to have been initially diagnosed in Minnesota were in fact diagnosed in another state. Ongoing participation in this initiative will allow for proper attribution of incident and prevalent cases in Minnesota.
(1) Minnesota Rule 4605.7040 (return to text)
(2) MMWR 1992;41[no.RR-17]:1-19 (return to text)
(3) MMWR 2001; 50(RR-6):31-40 (return to text)
(4) Laumann EO, Gagnon JH, Michael RT, et al. The social organization of sexuality: sexual practices in the United States, chapter 8. Chicago: University of Chicago Press; 1994 (return to text)