HIV/STD Trends in Texas Sharon K. Melville, M.D., M.P.H. Texas Department of State Health Services Texas Public Health Association April 22, 2010 Good Afternoon. I am pleased to be able to present to ‘you some HIV/STD data trends for Texas.

Outline HIV Epidemiology STD Epidemiology National data Texas trends HIV testing/treatment STD Epidemiology Syphilis Chlamydia Gonorrhea Here is what I am going to discuss today.

USA: Reported AIDS and HIV Cases As of the end of 2007, 1,051,875 AIDS cases have been reported in the United States Of these cases 7% were reported in Texas As of the end of 2007, 328,103 HIV cases have been reported in the United States* Of these cases 8% were reported in Texas *Includes 47 states, District of Columbia and 5 U.S. .territories with name-based reporting as of December 2007 As of December 2007 the three jurisdictions without named reporting for HIV were Hawaii, Vermont and Maryland As of April 2008, all 50 states, the District of Columbia, and 5 dependent areas—American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands—use the same confidential name-based reporting system to collect HIV and AIDS data. Texas started named base reporting of HIV in 1999 and has had reporting on AIDS since 1983. Check reference year? Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2006. Vol. 18

Cumulative Reported AIDS Cases: Top 5 States, 2007 Texas has the 4th highest cumulative numbers of AIDS cases behind New York California and Florida at about 73,000. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2006. Vol. 18

Texas: The Big Picture Since 1980, >107,000 Texans have been diagnosed with HIV/AIDS >41,000 Texans with HIV/AIDS have died As of year end 2008, 62,772 Texans were living with HIV/AIDS ? Whe 62, 805 on dot map for end of 2007

New AIDS Cases, Deaths, and Persons Living with AIDS: Texas, 1980-2008 This graph shows only AIDS cases (not HIV) since it provides historical data back to the early 80s and as I mentioned previously we only started HIV reporting in 1999. The Red line shows Persons Living With HIV has been increasing steadily since 1984. Blue line shows NEW AIDS cases-there has been a steady increase in new AIDS cases until 1993 then a small decline to 1996 then a huge drop in the number of new cases in 1996 and 1997. Since 1998 then there has been a steady number of new cases hovering around 2700 to 2800 cases per year. The Green line shows deaths among AIDS cases which show steady increases until 1995, then steep declines in deaths in 1996 and 1997 and has been fairly stable since 1998 with 1000-1200 deaths among AIDS cases per year. Why do you think there was such a sharp decline in new cases and deaths around 1996 and 1997? 1995 the first protease inhibitors were introduced and in 1996 was when HAART or Highly Active Antiretroviral Therapy (triple drug therapy) was started. Hit Early Hit HARD. HAART significantly impacted the life span of people with AIDS and also postponed those person with HIV infection from progressing to AIDS. Deaths among AIDS Cases

Persons Living with HIV/AIDS: Texas, 1987 N=1,204 These dot maps are provided to show the geographic distribution of HIV/AIDS cases in Texas. Each dot represents one case of HIV or AIDS. N=1,204. In 1987 the AIDS cases were concentrated in the large metropolitan areas and each of I-35.

Persons Living with HIV/AIDS: Texas, 1997 N=16,184 In 1997 the numbers of persons living with AIDS has increased to 16,184 and has spread more into the rural areas and the valley.

Persons Living with HIV/AIDS: Texas, 2007 N=62,805 In 2007, There is no area of the state that does not have a large number of persons living with HIV/AIDS and as we said previous over 62,000 persons living with HIV in the State of Texas.

2008 HIV/AIDS In 2008… 4,293 Texans were newly-diagnosed with HIV 33% of Texans who first learned they had HIV in 2008 were diagnosed with AIDS within 1 year 2,758 Texans living with HIV progressed to AIDS 1,280 Texans with HIV/AIDS died If 33 % of Texas diagnosed with AIDS within 1 years of their HIV diagnosis, that means that people are not getting tested and identified early in the course of the disease-this is late diagnosis. Therefore don’t get benefit of treatment sooner. 4293 includes persons new diagnosed with HIV or AIDS. The 2, 758 is a subset of the 4,293, some may have had HIV in previously years and only progressed to AIDS in 2008.

Newly-diagnosed HIV Cases: Texas, 1999-2008 This chart shows number of new diagnoses of HIV in blue and new AIDS diagnoses in red from 1999-2008. New Diagnoses have been fairly steady since 2003 with about 3200 new HIV diagnoses and about 1000 new AIDS diagnoses per year. So about 1/3 of the new cases are AIDS cases. 2006 2007 2008 2984 3248 3256 HIV 1095 1052 1037 AIDS

Newly-diagnosed HIV Case Rates by Race: Texas, 1999-2008 This graph show newly diagnoses HIV cases rates by year of diagnosis and race/ethnicity The blue line is African Americans and show a decrease in case rates since 1999 with a leveling out in recent years. However, African Americans have the highest overall rates HIV case rates. The case rate for AAs was almost 5 times greater than the rate in Hispanics who have the next highest rates. Hispanics have the second highest rates which have been very steady in in last 7 years. Whites are the green line and have smaller case rates that have been very steady. The lowest cases rates are in the other group which includes Asians, and Native Americans

Race/Ethnicity of New HIV/AIDS Case: Texas, 2008 Texas Population n=24,383,647 HIV/AIDS Cases n=4,293 White 29% 48% 11% 36% 5% 43% African American This chart compares proportions of new HIV/AIDS cases by race/ethnicity to the proportion of that group in the population of Texas. African Americans have the biggest disparity with 43% of HIV/AIDS cases being AA while only 11% of the population of Texas is African American. Hispanics represent 36% of the population but 26% of HIV/AIDS cases Whites represent 48% of the population in Texas but only 29% of HIV/AIDS cases. Hispanic Other/Unknown 26% 2%

Newly-diagnosed HIV Case Rates by Sex: Texas, 1999-2008 Male rates 3x higher than female rates.

Race/Ethnicity of New HIV/AIDS Cases: Texas, 2008 Males n=3,314 Females n=979 Males 38% AA Females 59% African American

Newly-diagnosed HIV Case Rates by Age: Texas, 1999-2008 Highest rates in 25-44 year olds. Decline in 25-34 years olds and 35-44 year olds. Similar rates for these groups. Increase in 15-24 year old group since 2004.

Age of New HIV/AIDS Cases: Texas, 2008 Over 50% of cases between 25-44

HIV/AIDS Cases by Transmission Category: Texas, 2008 Females Males Over 2/3 of males cases MSM 82% of female cases Heterosexuals Men who have sex with Men (MSM) Heterosexual contact* Injection drug use (IDU) MSM & IDU * Heterosexual contact with person known to have or to be at high risk for HIV infection ** Cases with an unknown or other mode of transmission are not included

Perinatally Exposed and Infected Children: Texas, 1999-2008 Exposures-# of HIV positive women giving birth been steady since around 2000 at about 350 births among HIV positive women per year. There has been a huge drop in mother to child transmission from 1999 to 2005. This is one of the great public health success stories. Due to implementation of 076 trial which give antiretroviral treatment to mothers during the third trimester, at delivery and to the baby in the neonatal period. The numbers of perinatallly transmitted cases has increased sinc 2005 but these are such small numbers that it is difficult to determine if a significant increase. n=9 n=7

HIV Testing and Care An estimated 16,686 people are living with HIV in Texas and are unaware of their status (undiagnosed) Approximately one-third of persons living with HIV in 2007 had unmet need for care 33% of Texans who first learned they had HIV in 2008 were diagnosed with AIDS within 1 year Only 14% of Texans had an HIV test last year Recently (2006) CDC came out with recommendations that there should be routine screening for HIV for all sexually active adults aged 18-64.

Reportable STDs in Texas Syphilis Chlamydia Gonorrhea

Primary and Secondary Syphilis Cases: Texas, 1971-2009 Syphilis is cyclical. Look at Primary and secondary Syphilis because that is when most infectious. Increases in early 80/s and then again in early 90s. Reached lowest number of cases in 2000- year of the implementation of Syphilis Elimination. Steady increases since 2000.

P&S Syphilis Case Rates by Race/Ethnicity: Texas, 1995-2009 Increases in cases in AA in green since 2003. in 2009, almost 14 times higher than lowest rate which is in white. Hispanics have just slightly higher rates than whites.

P&S Syphilis Case Rates* by Year of Report and Sex: Texas, 1998-2009 Male Female Increases seen in both males and females since 2000. However, in 2009 males rate over 2 times higher than female rate. * Rate = Cases per 100,000 population.

P&S Syphilis Cases by Sex and MSM: Texas, 2003-2009 More detailed look at P&S in MSM, Males (non-MSM) and females. Incarese in all groups however from 2002-2004 the increase were largely in the MSM population but in more recent years the increase have been higher among heterosexuals.

P&S Syphilis Case Rates by County: Texas, 2009

Congenital Syphilis Cases: Texas, 1991-2009 124 cases in 2008 and 2009. In 2008 Texas ranked highest in the number of cases of congenital syphilis and had the second highest rates in the nation behind Louisiana.

Chlamydia Cases: Texas, 1988-2009 Increase in Chlamydia in recent years. Over 100,000 cases reported in 2009.

Chlamydia Cases by Year of Report: Texas, 2000-2009 About 60% of Chlamydia cases in females aged 15-24. Increases in recent years in all groups-males females and young females

Chlamydia Case Rates Among Women by Race/Ethnicity: Texas, 1991-2009 Af. American Hispanic AA rate 2 x hispanic rate and almost 6X White rate White

Chlamydia Case Rates by County: Texas, 2009

Gonorrhea Cases: Texas, 1971-2009

Gonorrhea Case Rates by Race/Ethnicity: Texas, 1991-2009

Gonorrhea Cases by Age Group and Race/Ethnicity: Texas, 2009 About ½ 53% of cases in the AA and about 62% between 15-24 age group. So gonorrhea is predominately young african americans.

Gonorrhea Case Rates by County: Texas, 2009

Acknowledgements HIV/STD surveillance staff at local and regional health departments across the state and at the central DSHS HIV/STD program who collected the data used in this presentation Ed Weckerly and Jennifer Chase of the DSHS TB/HIV/STD Epidemiology and Surveillance Branch who analyzed the data and prepared the slides

Questions? Contact Information: Sharon K. Melville, M.D., M.P.H. Texas Department of State Health Services Manager, TB/HIV/STD Epidemiology and Surveillance Branch Sharon.Melville@dshs.state.tx.us