HIV Infection and AIDS, 2008

Surveillance for AIDS has been conducted in Minnesota since 1982. In 1985, Minnesota became the first state to make HIV infection a name-based reportable condition; all states now require name-based HIV infection reporting.

The incidence of HIV/AIDS in Minnesota is moderately low. In 2006, state-specific AIDS rates ranged from 0.7 per 100,000 population in Montana to 29 per 100,000 in Maryland. Minnesota had the 11th lowest AIDS rate (4.1 cases per 100,000). Similar comparisons for HIV (non-AIDS) incidence rates are not possible because some states only began HIV (non-AIDS) reporting recently.

As of December 31, 2008, a cumulative total of 8,819 cases of HIV infection, 5,348 AIDS cases and 3,471 HIV (non-AIDS) cases had been reported among Minnesota residents. Of the HIV/AIDS case-patients, 2,976 (34%) are known to have died.

The annual number of 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, primarily due to new antiretroviral therapies, which delay the progression from HIV infection to AIDS and improve survival. In 2008, 175 new AIDS cases (Figure 3) and 54 deaths among AIDS patients were reported.

The annual number of newly diagnosed HIV (non-AIDS) cases reported in Minnesota has increased from 198 in 2004 to 244 in 2008 (a 23% increase). This trend, coupled with improved survival, has led to an increasing number of persons in Minnesota living with HIV or AIDS. Approximately 6,200 persons with HIV/AIDS were residing in Minnesota at the end of 2008.

Historically, and in 2008, nearly 90% (287/326) of new HIV infections (both HIV [non-AIDS] and AIDS at first diagnosis) reported in Minnesota occurred in the metropolitan area. However, HIV or AIDS cases have been diagnosed in residents of more than 90% 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 79 new infections in 1992 to 41 new infections in 2008. The number of HIV infections diagnosed among Hispanic males decreased slightly in 2007 from the previous year (32 versus 38) and that trend continued in 2008, with 25 new infections reported among Hispanic males. The number of new infections among African-born males decreased in 2008 to 13 from 23 in 2007.

Females account for an increasing percentage of new HIV infections, from 11% of new infections in 1990 to 27% in 2008. 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 of white women. The annual number of new HIV infections diagnosed among U.S.-born black females had remained stable at 22 or fewer cases during 2001 to 2004, but increased to 28 new cases in both 2005 and 2006. In 2008 the number increased again, with 27 infections reported compared to 17 in 2007. In contrast, the number of new infections among African-born females increased greatly from 4 cases in 1996 to 41 in 2002. However, since 2002 the number of new HIV infections in African-born females has decreased steadily, with 18 new cases diagnosed in 2006. In 2007, the number of new cases among African-born females increased again to 26 and decreased slightly in 2008 to 24. The annual number of new infections diagnosed among Hispanic, American Indian, and Asian females is small, with 10 or fewer cases annually in each group.

Despite relatively small numbers of cases, persons of color are disproportionately affected by HIV/AIDS in Minnesota. In 2008, non-white men comprised approximately 12% of the male population in Minnesota and 37% of new HIV infections among men. Similarly, persons of color comprised approximately 11% of the female population and 69% of new HIV infections among women. It bears noting that race is not considered a biological cause of disparities in the occurrence of HIV, but instead race can be used as a proxy for other risk factors, including lower 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) has declined since 1991. In 1991, 70% (318/455) of new HIV infections were attributed to MSM (or MSM who also inject drugs); in 2008, this group accounted for 52% of new infections (171/326). However, current attitudes, beliefs, and unsafe sexual practices documented in surveys among MSM nationwide, and a current epidemic of syphilis among MSM documented in Minnesota and elsewhere, warrant concern. Similar to syphilis increases in other U.S. cities and abroad, 40% of the recent syphilis cases in Minnesota among MSM 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 contributors to resurging risky sexual behavior among MSM. 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 has declined over the past decade for men and women, falling from 12% (54/455) of cases in 1991 to 4% (13/326) in 2008. 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-nine percent of 179 new HIV diagnoses among women between 2006 and 2008 can be attributed to heterosexual exposure after re-distributing those with unspecified risk.

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 2008, there were 37 new HIV infections reported among Africans. While African-born persons comprise less than 1% of the state’s population, they accounted for 11% of all HIV infections diagnosed in Minnesota in 2008. 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. However, in 2005, several African agencies were awarded HIV prevention funds to initiate and in some cases continue prevention programs in these communities. Additionally, collaborations between MDH, the Minnesota Department of Human Services, and community-based organizations serving African-born persons in Minnesota are continuing to address these complex issues.

One of the few success stories in the history of HIV infection is the use of medication to successfully reduce HIV perinatal transmission. Since the release of the U.S. Public Health Service guidelines in 1994, HIV perinatal transmission in the United States decreased 81% between 1995 and 1999. The trend in Minnesota has been similar but on a much smaller scale. While the number of births to HIV-infected women increased seven-fold between 1990 and 2008, the rate of perinatal transmission decreased six-fold, from 18% in 1990 to 1995 to 3% in 1996–2006. The overall rate of transmission for 2006 to 2008 was 1.2%; however, it was twice that among foreign-born mothers indicating the need for additional education and prevention.

Another population of concern for HIV infection is adolescents and young adults (15 to 24 years of age). The number of new HIV infections among males in this age group has remained higher than new infections among females since 1999. In 2001, the number of HIV infections among young males decreased to 18 cases from 31 cases in 2000. However, there has been a steady increase in new cases among males in this age group since 2001, with 42 cases reported in 2008. The number of new HIV infections among females decreased to 13 cases in 2007 from 21 cases in 2006. However, the number of cases among female young adults and adolescents increased again in 2008 to 17 cases. From 2006 to 2008, the majority (49%) of new infections among male adolescents and young adults were white (57/117), while among females, the majority (41%) of new cases was among African Americans (21/51). In the same time period, 91% (107/117) of new cases among males were attributed to male-to-male sex. Among females, 94% (48/51) of new cases were attributed to heterosexual sex.

• For up to date information see>> HIV (HIV/AIDS)
  
• Full issue>> Annual Summary of Communicable Diseases Reported to the Minnesota Department of Health, 2008