We envision a Hennepin County where: All people living with HIV/AIDS have healthy, vibrant lives There are NO new HIV infections All people have equitable access to HIV prevention and health care services INTRO/BACKGROUND Halting the spread of HIV, long an elusive goal, is now achievable, thanks to emerging advances in treatment and prevention. Much has changed in our approach to the epidemic in recent years: The White House issued the first National HIV/AIDS Strategy in 2010 to guide the nation’s approach to the epidemic by achieving 4 goals: Reduce new HIV infections Increase access to care and improve health outcomes Reduce HIV related disparities Undertake a more coordinated national response to the epidemic The Affordable Care Act is increasing access to health care. Research clearly demonstrates that effective HIV treatment prevents transmission of the virus Biomedical prevention interventions, such as PrEP and PEP are highly effective in preventing acquisition of the virus among those who might be exposed through sexual contact or needle sharing Add vision statement to this slide, (can remove Public Health Department) Add slide with NHAS goals

National HIV/AIDS Strategy Goals Reduce new infections Increase access to care and improve health outcomes to people living with HIV Reduce HIV-related health disparities Undertake a more coordinated national response to the epidemic

HIV/AIDS in Hennepin County: Number of New Cases, Prevalent Cases, and Deaths by Year, 1990-2014 4,349 157 PROBLEM (CONTEXT) The blue line shows new HIV (non-AIDS) diagnoses and pink line shows new AIDS diagnoses The orange line shows the number of AIDS deaths which dramatically dropped beginning in 1996 when highly active antiretroviral treatment became available The dotted line shows the number of living HIV cases More than half of all Minnesotans living with HIV reside in Hennepin County. As of December 31, 2014 there were 4,349 diagnosed people living with HIV in the County. HIV prevalence continues to increase by 3-5% annually due to a steady number of new infections and fewer AIDS deaths. The number of new infections is not declining. There were 157 new infections in 2014 and the number of annual new infections in Hennepin County has remained relatively stable for the past 15 years. By the end of 2014 there were 4,349 PLWH in the County There were 29 AIDS deaths in 2014 Animate to drop-in prevalence line Explain antiretrovirals Sprinkle in narrative about where we’ve been successful 29

Hennepin Population v. HIV Prevalence by Race/Ethnicity (2014) BACKGROUND/PROBLEM HIV disproportionately impacts people of color The graph on the right shows known living cases of HIV in the County as of 12/31/2014. 50% of PLWH in Hennepin are people of color, primarily African American, African-born and Latinos. whereas 57% of new infections in the County in 2014 were among people of color. The graph on the left shows the County’s population by race/ethnicity. While only 13% of County residents are African American or Blacks born in Africa, 36% of people living with HIV in the County are African American or African born If the demographic trend in new infections continues, the disproportional impact on communities of color will only increase. HIV Prevalence Hennepin Population

Number of Cases and Rates (per 100,000) of Persons Living with HIV/AIDS by Race/Ethnicity Hennepin, 2014 Race/Ethnicity Cases % Rate White, non-Hispanic 2,160 50% 249 Black, African American 1,044 25% 986 Black, African-born 538 12% Hispanic 351 8% 415 American Indian 73 2% 668 Asian/PI 61 1% 67 Other/Unknown 113 3% x TOTAL 4,256 100% 355 Blacks are living with HIV at 4X the rate of whites BACKGROUND/PROBLEM This table shows HIV prevalence rates by race and ethnicity. The prevalence rate is expressed as the number of living diagnosed HIV cases per 100,000 population. Blacks, both African American and African-born, Latinos and American Indians have much higher prevalence rates than Whites, further illuminating the significantly disproportionate impact on these communities. Blacks have a prevalence rate 4xs higher than Whites. State prevalence rates are the highest among the African-born (1,418). Use colors to emphasize specific lines of interest. Perhaps red border around 986. Add and animate pop up numbers on rate differences (e.g. Blacks have x4 the rate of whites)

Number of Cases and Rates (per 100,000) of Adults and Adolescents Living with HIV/AIDS by Gender/Risk Hennepin 2014 Gender/Risk Cases % Rate Men (Total) 3,480 80% 720 MSM & MSM/IDU 2,741 79% 7,999 Non-MSM 739 21% 153 Women 869 20% 174 Total 4,349 100% 443 BACKGROUND/PROBLEM This table reports number of living diagnosed cases and HIV prevalence rates by gender and risk for men. Prevalence rates are expressed as the number of living HIV per 100,000 population. Men who have sex with men including those that identify as gay or bisexual and those that do not, are the most disproportionately impacted population. 80% of people living with HIV in the County are male. Of these men, 79% are men who have sex with men. We estimate that 8% of gay/bi/MSM in Hennepin are living with HIV. We estimate that 9% of the male population in Minneapolis are MSM and 4% of the male population in the surrounding suburbs are MSM. Gay/bi/MSM are 52 times more likely to acquire HIV than non-MSM. In Minnesota as a whole, African American gay/bi/MSM are 63 times more likely to acquire HIV than African American males who do not have sex with men. The Centers for Disease Control recently estimated that 1 in 2 African American gay and bisexual men will acquire HIV in their lifetime unless we can change the dynamic of the epidemic. Explain that IDUs are not as big a concern because we’ve been successful in prevention

Hennepin HIV Care Continuum (2014) 708 undiagnosed 4,349 1,218 out of care THE PROBLEM This graph presents how we now look at the population of people living with HIV in a jurisdiction. This is what we call the HIV Care Continuum (aka HIV Treatment Cascade) for Hennepin County based on 2013 and 2014 HIV surveillance data. It’s an assessment of how well our population is moving along the HIV Care Continuum to achieve the ultimate goal of viral suppression. The first bar represents PLWH who are known to have an HIV diagnosis in the County. It does not include those who are unaware of their HIV infection or remain undiagnosed. The CDC estimates that 14% of Minnesota’s population of PLWH are unaware of their HIV infection. In 2014 we estimate that there were 708 people living with HIV in the County who were undiagnosed. The second bar represents the number of newly diagnosed cases that were linked to HIV medical care within 90 days of their diagnosis. 90% of those diagnosed in 2013 were linked to care. We’re doing a pretty good job of initially linking people to care. The largest drop happens between linkage and retention in care. 28% of those who know their status are not retained in care. 1,218 people in Hennepin County who know their status are not retained in care. The last bar shows the proportion of people diagnosed with HIV that have suppressed virus because they are in care and are on antiretroviral treatment. 36% of those who are aware of their HIV status are not virally suppressed. If we include an estimated 14% (est. of U.S. from CDC) of the PLWH who are undiagnosed and add it to the proportion of people who are not retained in care, 36% of the population of PLWH in Hennepin are out of care and 45% do not have suppressed virus. There are two reasons why it’s so important for people living with HIV to move across the care continuum from infection to viral suppression as quickly as possible First, the earlier someone is on effective antiretroviral therapy and achieves viral suppression, the less the risk of HIV adversely affecting their health. Recent pilot studies on cost effectiveness of early linkage to care suggest that people who are linked to care early have a life expectancy gain of 5 years compared to those who are linked to care late. It also appears that linking two people with HIV infection to care early prevents one new infection compared to every two people who are linked to care late. 2) Treatment that leads to viral suppression is 96% effective in preventing HIV transmission. Treatment is our most powerful prevention tool. The CDC estimates that about 30% of new infections are acquired from those who are unaware of their HIV infection (haven’t received a diagnosis) and 61% originate from those who know that they have HIV infection and are not in care. Less than 10% of new infections are acquired from those in care. So, helping people access care is key to changing the dynamic of the epidemic and reducing the rate of infection. Those receiving care are likely to receive treatments that effectively reduces their viral load, have access to supportive services such as case management, mental health and chemical dependency treatment, housing and transportation that support retention in care. Being in care, they are also are more likely to receive prevention interventions that reduce transmission risk. Pop in # of people in each of the categories Add the undiagnosed on top of the diagnosed Urban might be able to help with animations

We envision a Hennepin County where: All people living with HIV/AIDS have healthy, vibrant lives There are NO new HIV infections All people have equitable access to HIV prevention and health care services SOLUTION The Hennepin HIV Strategy we’ve developed lays out a solid framework for the County to move towards ending the epidemic. Development of the strategy was steered by a core group of key Hennepin County Public Health and Human Services staff, fifty strategists representing HIV service providers, health care and social service providers and people living with HIV. The strategy was also informed by over 80 people living with HIV from disproportionately impacted communities who participated in listening sessions. The strategy would align Hennepin County’s efforts with the National HIV/AIDS Strategy. The strategy envisions a County where: Use as first slide

HIV Strategy Goals Goal A: Decrease New HIV Infections Testing, PrEP/PEP Goal B: Ensure Access to and Retention in Care Open door, barrier-free access Goal C: Engage and Facilitate the Empowerment of Communities Disproportionately Affected by HIV to stop new infections and eliminate disparities Partnerships, education, marketing, mobilizing SOLUTION The Strategy has three goals. Each goal has three actions to be taken in the first two years to move towards achieving the goals. The strategy also lays out tactics which inform how the actions will be taken. The first goal is to decrease new HIV infections. The first actions we will take to achieve this goal are: Increase opportunities for routine HIV testing Expand access to PrEP and PEP Resolve barriers to testing especially for people at high risk of HIV infection In fact, as a result of our first strategists meeting, HCMC has already taken action towards achieving the first goal by implementing routine HIV testing through the health maintenance function in EPIC, their electronic health record system. Now, for anyone that has not had an HIV according to the CDC’s recommendations for routine testing of all adults, the clinician is alerted that an HIV test should be added to routine screening for health conditions. The second goal is to ensure access to and retention in HIV medical care. The first actions we will take to achieve this goal are: Ensure ‘All Doors Open’ – No matter where people who test positive for HIV access services or community resources they are connected to health care and supportive services, so that more people living with HIV are efficiently and effectively connected to care or re-engaged in care Eliminate barriers to care – Improve access to services that meet basic needs for people living with HIV, so that any barriers to adhering to their HIV medical care plan are eliminated Engage and retain in care – Engage those people living with HIV who left care or were never connected to care, so that they are retained in care and achieve viral suppression The third goal is to engage and facilitate the empowerment of communities disproportionately affected by HIV to stop new infections and eliminate disparities. The first actions to achieve this goal include: Partnering with communities – To understand stigma and why some communities are disproportionately affected by HIV, so that effective strategies can be identified and supported to achieve increased awareness of HIV status and the importance of retention in care, and achieving viral suppression for those living with HIV Develop education and marketing campaigns to reduce HIV related stigma in disproportionately affected communities Provide community access by increase testing services and access to care in community settings, so more isolated, marginalized people in communities are tested and stay in care

Implementing the Strategy Hennepin County Board Endorsement Strategy implementation manager and community organizer SOLUTION Here’s what we think is needed to fully implement the strategy. Formal Board endorsement will communicate to the community and stakeholders that ending the epidemic is a Public Health priority for Hennepin It provides the imprimatur or legitimacy needed for strong community partnerships Strategy implementation staff will ensure that the goal actions are taken using the tactics identified by the strategists and will facilitate mobilization of communities most disproportionately increase citizen engagement in prevention and care to eliminate gaps in the HIV Care Continuum Business case – why this is important, cost savings etc. Say that we’re pursuing resources.

HIV Transmission Potential                                    OPTIONAL SLIDE ILLUSTRATES PROBLEM AND INDICATES SOLUTION This graphic illustrates HIV transmission potential depending on care status. As a greater proportion of people living with HIV become aware of their status and receive care, transmission potential will decline. There were an estimated 693 people living with HIV in the County who were unaware of their infection. It’s estimated that this population would be the source of 30% of future HIV transmissions. Because a larger number of people living with HIV are aware of their status are not retained in care, they are not virally suppressed Those receiving care are likely to receive treatments that effectively reduces their viral load, have access to supportive services such as case management, mental health and chemical dependency treatment and are more likely to receive prevention interventions that reduce transmission risk. Unaware of Infection No Care (708) Aware of Infection In Care (3,131) Aware of Infection No Care (1,218)