HIV Infection and AIDS, 2001
Surveillance for AIDS has been conducted in Minnesota since 1982. In 1985, AIDS officially became a reportable disease for all state and territorial health departments in the U.S. Also in 1985, when the Food and Drug Administration approved the first diagnostic test for HIV, Minnesota became the first state to make HIV infection a reportable condition; 34 states now require confidential reporting of HIV infection.
Compared to other U.S. states, the incidence of HIV/AIDS in Minnesota is moderately low. In 2000, state-specific AIDS incidence rates per 100,000 population ranged from 0.5 in North Dakota to 32.7 in New York, with 3.8 AIDS cases per 100,000 population reported in Minnesota. Similar comparisons for HIV (non-AIDS) incidence rates are not possible, because not all states require reporting of HIV.
As of December 31, 2001, a cumulative total of 6,661 cases of HIV infection have been reported to MDH, including 3,854 AIDS cases and 2,807 HIV (non-AIDS) cases. Of these HIV/AIDS case-patients, 2,332 are deceased. The annual number of new AIDS cases increased steadily from the beginning of the epidemic, reaching a peak of 370 cases in 1992. Beginning in 1996, the annual number of new AIDS diagnoses and deaths among AIDS case-patients declined sharply, primarily due to new antiretroviral therapies, including protease inhibitors, which can delay the progression from HIV to AIDS and improve survival among AIDS patients. In 2001, 124 new AIDS cases and 51 deaths among AIDS patients were reported in Minnesota (Figure 2).
The annual number of newly diagnosed HIV (non-AIDS) cases reported in Minnesota has remained fairly constant since the mid-1990s, with 197 cases reported in 2001. This trend, coupled with the improved survival of HIV-infected individuals who receive antiretrovival therapy, has led to an increasing number of people living with HIV or AIDS (Figure 3). Approximately 4,331 known persons with HIV/AIDS were residing in Minnesota at the end of 2001.
Historically, approximately 90% of new HIV infections reported in Minnesota occur in the seven-county Twin Cities metropolitan area. Although HIV infection is more common in communities with higher population densities and greater poverty, HIV or AIDS cases have been diagnosed in over 80% of counties statewide.
Males account for a majority of new HIV infections. Trends in the annual number of new HIV infections diagnosed among males differ by race/ethnicity. New cases occurred primarily among white males in the 1980s and early 1990s. Although whites still comprise the largest proportion of new HIV infections among males, the number generally has been decreasing since 1991. A recent exception to this trend occurred from 2000 to 2001, when cases diagnosed among white males increased from 93 to 130. In contrast to the large decline in the annual number of cases among white males, the decline among African American males has been more gradual, peaking at 82 cases in 1992 and gradually decreasing to 34 cases in 2001. The annual numbers of HIV infections diagnosed among Hispanic and African-born males have increased moderately, with 16 and 19 cases, respectively, reported in 2001.
The percentage of cases among females has risen from 10% of new HIV infections in 1990 to 25% in 2001. The number of HIV infections diagnosed annually among females also differs by race/ethnicity. Early in the epidemic, white women accounted for the majority of newly diagnosed cases. Since 1991, the number of new infections among women of color has exceeded that among white women. The annual number of new infections diagnosed among African American females nearly doubled from 1990 to 2001. The number of new infections diagnosed among African-born females increased nine-fold during the past 5 years. Among females, the only increase in the annual number of HIV infections from 2000 to 2001 occurred among African-born women. The annual numbers of new infections diagnosed among Hispanic, American Indian, and Asian females continue to be small, with fewer than 10 cases annually for each group.
Despite relatively small absolute numbers of cases, persons of color are disproportionately affected by HIV/AIDS. In 2001, non-white men comprised approximately 12% of the male population in Minnesota and 37% of new HIV infections among men. Similarly, non-white women comprised approximately 11% of the female population and 79% of new HIV infections among women. Although race is not considered a primary biological cause of disparities in the occurrence of HIV, race may be a marker for other factors associated with risk for HIV exposure, including socioeconomic status, education, and drug use.
Since the beginning of the HIV epidemic, male-to-male sex has been the predominant mode of exposure to HIV reported in Minnesota, although the number and proportion of new HIV infections attributed to men who have sex with men (MSM) have declined since 1991. In 1991, 70% (323/460) of new HIV infections were attributed to MSM (or MSM who also inject drugs); by 2001, this percentage decreased to 50% (140/282).
However, current attitudes, beliefs, and unsafe sexual practices documented in surveys among MSM nationwide, as well as a recent outbreak of syphilis in Minnesota among MSM, warrant concern. Other cities in the U.S. and abroad have reported increased numbers of syphilis cases among MSM, followed by increases in HIV diagnoses in the same group. In Minnesota, an increase in HIV cases diagnosed among white men (predominantly MSM) in 2001 preceded an outbreak of syphilis among MSM (67% of whom are white) that was detected in early 2002. "Burn out" from adopting safer sexual practices and exaggerated confidence in the ability of HIV treatments to diminish viral transmission may be contributing to a resurgence in risky sexual behavior among MSM. Consistent with these findings, CDC recommends annual screening for sexually transmitted diseases (including HIV and syphilis) for sexually active MSM and more frequent screening for MSM who report sex with anonymous partners or sex in conjunction with drug use.
The number and percentage of HIV cases attributed to injecting drug use (IDU) have declined over the past decade for men and women, falling from 24% (80/340) of cases in 1991 to 5% (14/282 ) of new HIV infections diagnosed in 2001. Heterosexual contact with a partner who has or is at increased risk of HIV infection is the predominant mode of exposure to HIV for women. An estimated 83% of 71 new HIV diagnoses among women in 2001 were attributable to heterosexual exposure.
Historically, race/ethnicity data for HIV/AIDS in Minnesota have grouped African Americans and African-born persons together as "black." In 2001, MDH retrospectively analyzed these groups separately, which identified an important trend. The number of new HIV infections diagnosed among African-born persons in Minnesota increased from seven cases in 1990 to 46 cases in 2001. During this time, immigration of Africans to Minnesota also increased. While African-born persons comprise less than 1% of the state's population, they accounted for 16% of all HIV infections diagnosed in Minnesota in 2001.
Until recently, culturally specific HIV prevention messages have not been directed to African communities in Minnesota. Taboos and other cultural barriers make it challenging to deliver such messages and to connect HIV-infected individuals with services. Collaborations between MDH and community organizations are underway to address these complex issues.