HIV Infection and AIDS, 2002
AIDS is the advanced state of HIV infection. Surveillance for AIDS has been conducted in Minnesota since 1982. In 1985, AIDS became a reportable disease for all state and territorial health departments in the U.S. Also in 1985, when the U.S. 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 states nationwide, the incidence of HIV/AIDS in Minnesota is moderately low. In 2001, state-specific AIDS incidence rates per 100,000 population ranged from 0.5 in North Dakota to 39.3 in New York, with 3.2 cases per 100,000 population reported in Minnesota. Similar comparisons for HIV (non-AIDS) incidence rates are not possible, because some states require only reporting of AIDS cases.
As of December 31, 2002, a cumulative total of 7,073 cases of HIV infection have been reported to MDH, including 4,008 AIDS cases and 3,065 HIV (non-AIDS) cases. Of these HIV/ AIDS case-patients, 2,528 (36%) are known to have died.
The annual number of new AIDS cases reported in Minnesota increased steadily from the beginning of the epidemic through the early 1990s, 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 in Minnesota, primarily due to new anti-retroviral therapies such as protease inhibitors, which delay the progression from HIV infection to AIDS and improve survival among AIDS patients. In 2002, 151 new AIDS cases and 46 deaths among AIDS patients were reported in Minnesota (Figure 3).
The annual number of newly diagnosed HIV (non-AIDS) cases reported in Minnesota has remained fairly constant since the mid-1990s, with 211 reported in 2002. This trend, coupled with the improved survival of HIV-infected individuals who receive anti-retroviral therapy, has led to an increasing number of persons in Minnesota living with HIV or AIDS (Figure 4). Approximately 4,600 persons with HIV/AIDS were residing in Minnesota at the end of 2002.
Historically and in 2002 (271/305), approximately 90% of new HIV infections (both HIV [non-AIDS] and AIDS at first diagnosis) reported in Minnesota occur in the seven-county Twin Cities metropolitan area. However, HIV or AIDS cases have been diagnosed in residents of more than 80% of counties statewide. HIV infection is most common in areas with higher population densities and greater poverty.
The majority of new HIV infections in Minnesota occur among males. Trends in the annual number of new HIV infections diagnosed among males differ by race/ethnicity. New infections 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 of new infections in this population has decreased since 1991. In contrast to declining numbers of new HIV infections among white males, the decline among U.S.-born black males has been more gradual, falling from a peak of 81 new infections in 1992 to 37 new infections in 2002. The number of HIV infections diagnosed among Hispanic and African-born males has increased annually, with 25 and 29 new infections, respectively, diagnosed in 2002.
Females account for an increasing percentage of new HIV infections, from 10% of new infections in 1990 to 29% in 2002. Trends in HIV infections diagnosed annually among females also differ by race/ethnicity. Early in the epidemic, whites accounted for the majority of newly diagnosed infections in women. Since 1991, the number of new infections among women of color has exceeded that among white women. The annual number of new HIV infections diagnosed among U.S.- born black females doubled from 1990 (12 cases) to 2002 (25 cases), whereas the number of new infections among African-born females has increased three-fold in the past 6 years to 36 cases in 2002. The annual number of new infections diagnosed among Hispanic, American Indian, and Asian females is small, with fewer than 10 cases annually in each group.
Despite relatively small numbers of cases, persons of color are disproportionately affected by HIV/AIDS in Minnesota. In 2002, non-white men comprised approximately 12% of the male population in Minnesota and 45% of new HIV infections among men. Similarly, persons of color comprised approximately 11% of the female population and 84% 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 risk factors, including socioeconomic status and education.
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, 69% (324/470) of new HIV infections were attributed to MSM (or MSM who also inject drugs); by 2002, this percentage had decreased to 44% (135/305). Current attitudes, beliefs, and unsafe sexual practices documented in surveys among MSM nationwide and a recent outbreak of syphilis documented in Minnesota among MSM, however, warrant concern. Similar to increasing rates of syphilis among MSM in other U.S. cities and abroad, nearly 50% of the recent outbreak-associated syphilis cases in Minnesota were co-infected with HIV, some for many years. “Burn out” from adopting safer sexual practices and exaggerated confidence in the efficacy of HIV treatments may be contributing to a resurgence in risky sexual behavior among MSM. Consistent with these findings, the 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 in conjunction with drug use.
The number and percentage of HIV infections in Minnesota that are attributed to injection drug use have declined over the past decade for men and women, falling from 17% (80/470) of cases in 1991 to 5% (15/305) in 2002. 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. Eighty percent of 87 new HIV diagnoses among women in 2002 were attributable to heterosexual exposure.
Historically, race/ethnicity data for HIV/ AIDS in Minnesota have grouped U.S.- born blacks and African-born persons together as “black.” In 2001, MDH began analyzing these groups separately, and a marked trend of increasing numbers of new HIV infections among African-born persons was observed. In 2002, the number of new HIV infections reported among Africans increased 41% (65 cases) compared to 46 cases in 2001. While African born persons comprise less than 1% of the state’s population, they accounted for 21% of all HIV infections diagnosed in Minnesota in 2002. 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 prevention and treatment services. Collaborations between MDH, the Minnesota Department of Human Services, and community based organizations serving African-born persons in Minnesota are underway to address these complex issues.