Supplement to HIV and AIDS Surveillance (SHAS)

Introduction SHAS was a CDC-funded project designed to provide an in depth description of people diagnosed with HIV/AIDS in MN, including information about the care and treatment they were receiving. The purpose of this information was to provide planning groups, providers, and health agencies with data that could be used to develop strategies and interventions to prevent HIV infection and improve care. CDC provided a questionnaire for the project. See the “Minnesota Supplement to HIV Surveillance (SHAS) Project Summary” on the MDH website for further detail and information about the project.

The 11 Minnesota Counties in the Minneapolis-St. Paul EMA Anoka Carver Chisago Dakota Hennepin Isanti Ramsey Scott Sherburne Washington Wright EMA = Eligible Metropolitan Area

Minnesota SHAS Eligibility Criteria Resident of the EMA for > 1 year > 18 years of age Case of HIV infection or AIDS diagnosed at least 6 months ago, but not more than 3 years ago Agreed to SHAS participation after contact by a MDH Disease Investigator for routine disease intervention OR Volunteered for SHAS by calling the SHAS interviewer

SHAS Cases with HIV (non-AIDS) Interviewed Aug Dec 2003 Compared to HARS EMA HIV (non-AIDS) Cases Diagnosed

SHAS Cases with AIDS Interviewed Aug 2000-Dec 2003 Compared to HARS EMA AIDS Cases Diagnosed

Agencies/Groups Given Formal SHAS Promotional Presentations Minnesota AIDS Project (an AIDS organization) Clinic 42 (an AIDS Clinic) Hennepin County Infectious Disease Clinic ( main clinic in MN for HIV care) Note: Interviewer often promotes SHAS with individuals/groups/clinics and distributes/posts flyers describing SHAS

Agencies/Groups Presented SHAS Data Minnesota Department of Health STD and HIV Section (prevention/surveillance personnel) African American Health Care Worker Network Needs Assessment and Evaluation Committee of the Minnesota HIV Services Planning Council

SHAS Limitations Biased sample of HIV/AIDS cases SHAS cases may not be representative of entire EMA HIV/AIDS population Greater MN cases not included, so data may not be representative of that population Answers to questions are self-reported –Recall bias –Social Desirability Bias Limited sample size

Demographic Data

SHAS Participants: Gender GenderNo.% Male15170% Female6430% Total215100%

SHAS Participants: Race/Ethnicity Race/Ethnicity Males No. (%) Females No. (%) Total No. (%) White (non-Hispanic)73 (48)14 (22) 87 (40) Black, African-American 55 (36)36 (56) 91 (42) Black, African-Born 5 (3) 7 (11)12 (6) Hispanic12 (8)3 (5)15 (7) Asian 1 (<1)0 (0) 1 (<1) American Indian 5 (3)4 (6) 9 (4) Total151 (100)64 (100)215 (100)

SHAS Participants: Category of Exposure (HARS) Category of Exposure Males No. (%) Females No. (%) MSM100 (66)-- IDU14 (9)13 (20) MSM/IDU 9 (6)-- Heterosexual11 (7)35 (55) Other/Not reported 17 (11)16 (25) Total151 (100)64 (100)

Socioeconomic Data

51% Employed Median number of hours worked per week = 39.0 hours (Average = 33.1 hours) Job change since diagnosis: 100/215 (47%) Reasons Quit / laid-off due to AIDS 60/100 (60%) Decreased hours/ changed jobs or tasks due to HIV 19/100 (19%) Other reasons not HIV-related 21/100 (21%) 11% = Sole provider for children (<18 years old) 41% Ever in Jail/Detention/Prison (1 refusal) SHAS Participants: Socioeconomic Status (N=215)

SHAS Participants: Socioeconomic Status Salary 40% Social Security 32% Public Assistance 9% Spouse 8% Savings 2% Pension 1% Friends 1% Other 3% No Income 3% Source of Main Financial Support (N=215)

SHAS Participants: Socioeconomic Status < $10,000 41% $10-$19,999 23% $20-$29,999 8% $30-$39,999 10% $40-$49,999 7% $50, % Refused <1% Unknown 3% Household Income Before Taxes Received or applied for public assistance, welfare, social security: 138/215 (64%) (N=215)

Drug Use

Ever had alcohol = 99% Possible alcohol problem = 54% Non-IDU drug use ever = 62% Non-IDU Drug use in 12 months prior to interview = 27% Injected drugs ever = 18% Injected in 12 months prior to interview = 3% SHAS Participants: Drug Use (N=203) (Excludes African-Born) (excludes 35 cases that used only marijuana and 7 cases that used marijuana and nitrites) 83% used any illegal drug

SHAS Participants: Non-Injecting Drug Use (Excludes African-Born) * In the 12 months prior to interview. ** Only non-AIDS cases diagnosed (as in HARS) (85 cases)

SHAS Participants: Crack Use (Excludes African-Born)

Injected drugs ever = 37/203 (18%) 51% in a shooting gallery (n=19) Of the 37 IDU’S: 54% shared needles (n=20) Most often shared with: Friends 60% Strangers 25% Lovers 10% MSM 5% 2 cases may have shared needles/equipment. 2 cases who did not share needles shared equipment SHAS Participants: Injecting Drug Use (Excludes African-Born)

Heroin or other opiates 10% Cocaine 12% Heroin & Cocaine (“Speedball”) 8% PCP, Hallucinogens <1% Barbiturates <1% Stimulants/Amphetamines/Meth 4% Steroids/Testosterone <1% Other 2% Unknown 2% (N=203) Ever Use Note: Only 6 cases injected in the 12 months prior to the interview.

Sexual Behavior

Number of Sexual Partners in Lifetime by Declared Sexual Orientation* 1 – Females Heterosexual 1 – 2, Heterosexual 1 – 3,000 Males Homosexual/Gay Range Median # of Partners # of Cases *Excludes persons with a prostitution history Bisexual 13 Male 6 Female

Ever had STD = 66% (133/203) Last received treatment at: Private MD/Community/Public Clinic 35% (47/133) STD Clinic 37% (49/133) Emergency Room 14% (18/133) Other 14% (19/133/) STD after HIV diagnosis: 25 cases were treated for an STD > 6 months after learning of their HIV diagnosis. However, we do not always know the specific STD for which they were treated (list includes HSV, HPV, and syphilis that could be recurrent or old infections recently treated). We do know 8 cases had either gonorrhea, trichomonas, or chlamydia infections after HIV diagnosis. SHAS Participants: Sexually Transmitted Diseases (Excludes African-Born)

EverLast 12 Months* Male 45/146 (31%) 13/146 (9%) Female 18/57 (32%) 6/57 (11%) * Note: Prostitution may have stopped after diagnosis if HIV diagnosis < 12 months ago. SHAS Participants: Prostitution (Excludes African-Born)

Had at least 1 new partner = 66% (55/83) The following questions were asked about the last time sex with steady and non-steady partners. Risky* insertive anal sex by case with steady or non-steady partner = 5% (4/83) Risky receptive anal sex by case = 11% (9/83) (excludes 4 cases with risky insertive anal sex) Risky insertive oral sex by case = 20% (17/83) (excludes cases with anal insertive sex) *Risky sex means no condom used or unsure and partner’s HIV status was negative or unknown per case. SHAS Participants: Men Who Had Sex With Men in the 12 Months Prior to the Interview (N=83)

Of the 13 cases with risky anal sex:* 3 were drunk and on drugs 1 was drunk 2 were on drugs 6 of 13 impaired by alcohol/drugs (46%) Of the 17 cases with only risky oral sex: 1 was drunk and on drugs 2 were drunk 1 was on drugs 4 of 17 impaired by alcohol/drugs (24%) * With steady or non-steady partner SHAS Participants: Risky Sex and Alcohol/Drug Usage Last Time Sex With Steady or Non-Steady Partner – Men with Men

SHAS Participants: Men Who Had Sex With Men in the 12 Months Prior to the Interview 23/83 (28%) only had oral sex during their most recent sexual encounters with steady and non-steady partners (no anal sex)

Had at least one new partner = 40% (20/50) Risky vaginal sex 24% (12/50) Alcohol or drug involvement = 42% (5/12) SHAS Participants: Men Who Had Sex With Women in the 12 Months Prior to Interview (N=50) Note: 7/50 had sex with men and women during this time

Had at least one new partner = 32% (16/50) Risky vaginal sex = 16% (8/50) Alcohol or drug involvement = 38% (3/8) SHAS Participants: Women Who Had Sex With Men in the 12 Months Prior to Interview (N=50)

SHAS PARTICIPANTS: CASES WITH RISKY SEX IN THE 12 MONTHS PRIOR TO THE INTERVIEW 3/4 of the men “who had sex with men” with risky insertive anal sex did so after diagnosis of HIV infection 7/9 of the men “who had sex with men” with risky receptive anal sex in the absence of insertive did so after diagnosis 11/17 of the “men who had sex with men” with risky insertive oral sex without any insertive anal sex did so after diagnosis 8/12 of the “men who had sex with women” with risky vaginal sex did so after diagnosis 6/8 of the “women who had sex with men” with risky vaginal sex did so after diagnosis

HIV Testing

MN Diagnosed SHAS Participants By Test Site (N=188) STD Clinic Physician/HMO Hospital Outpatient/AIDS Clinic/ER Hospital Inpatient Community Center Blood Bank/Plasma Center Prenatal/OB Clinic Correctional Other Note: 44% tested at an active surveillance site 21% 15% 14% 11% 9% 4% 1% 4%

SHAS Participants: Reason for Testing (N=215) Illness 40% Risk (m/m; IDU; partner: IDU, Bi-sexual, or HIV+) 19% Routine checkup or curious 19% Blood donor 9% Pregnancy 4% Pre-op physical <1% Test required Other 3% 6%

Test type when 1 st tested Anonymous 8% Confidential 90% Unsure 2% Partner notification offered by MDH/MD/other Yes 76% No20% Unsure 4% Of those offered partner notification (n=142) MDH/MD notification 45% Case notification 35% Both 10% Other (partner known+ or aware, etc) 10% SHAS Participants: Minnesota Diagnosed Cases (N=188)

Preventive Therapy

SHAS Participants: Laboratory Tests (N=215) YesNoUnsure CD4 Count Ever 98% (210/215) <1% (2/215) 1% (3/215) Viral Load Ever 93% (199/215) 2% (4/215) 6% (12/215)

SHAS Participants: Hepatitis History (N=215) Number Percentage Hepatitis A 8 4 Hepatitis B 18 8 Hepatitis C 25 15/25 IDU HX 12 Other (2)/Unknown (3) 5 2 Note: IDU ever is 2 times higher among SHAS cases compared to all cases. Of those that never had Hepatitis B Received hepatitis B vaccine = 75% (138/184) Note: 13 cases unsure if vaccinated excluded from data

SHAS Participants: Antiretroviral Therapy Main reason for no therapy MD recommended waiting 75% Don’t need/feel good 12% CD4 count high 3% Concerned about side effects 1% Not in care 1% Psychological problems No money Other 1% 4% Ever received therapy = 69% (148/215) Of those never on therapy (n=67):

SHAS Participants: Receiving Antiretroviral (ART) Therapy Past 30 days exact ART adherence Rarely 3% Sometimes 6% Usually34% Always58% 42% (53cases) didn’t always take ART exactly (continued next slide) 125 cases on ART at time of interview

SHAS Participants: Receiving Antiretroviral (ART) Therapy But With Incomplete Adherence (N=53) Reason for ART not taken exactly: Forgot 36% Side effects 15% Fell asleep 9% Alcohol/drug use 9% Can’t fit into schedule 9% Sick of pills 6% Other* 15% *Other reasons, 1 each: Methadone interference, hard to swallow, social situations, vacation-refrigeration problem, ran out, can’t afford, anger, record snafu

SHAS Participants: Source of Advice on Taking Antiretrovirals 41 % (61/148) sought advice Most useful source of advice: Physician48% Nurse 13% Pharmacist 11% AIDS organization10% Case manager 8% Friends 5% Other 5%

SHAS Participants: Skin Testing for Tuberculosis Ever had a skin test for TB Yes = 94% (203/215) No = 3%(9/215) Unknown = 1% (3/215) Skin test in year prior to or since HIV diagnosis 79% (152/193) ( excludes 22 cases with no recent test but with previous + skin test) Note: 18 cases had unknown skin test dates. It is assumed these occurred more than a year ago.

Health Care

SHAS Participants: Source of HIV Care Source of HIV Care (N=214) Private MD/HMO/HIV Clinic 53% Public Clinic (includes HCMC) 43% VA Center (VAMC, Mpls.) State Prison System AIDS Clinical Trials 2%<1% Received HIV care in last year = 99.5% (214/215)

SHAS Participants: Source of Health Insurance (N=215) Medicaid 59% Medicare 8% Private 33% VA 2% None 8% Note: Percentages total >100 percent since some persons have multiple Insurance coverage

Since HIV+ diagnosis: Lost health insurance >30 in a row 9% Kept insurance87% Never had insurance 4% Last 12 months ever denied health care because couldn’t pay for it: Yes 3% No97% Delayed care in the last 12 months Yes 7% No 93% SHAS Participants: Insurance Coverage (N=215)

Yes = 29% No = 71% SHAS Participants: HIV Induced Health Problem or Impairment (N=215)

Conclusions Alcohol and drugs (non-IDU and IDU) appear to have a major role in acquiring HIV infections High lifetime number of sexual partners among HIV infected Risky sexual practices among some HIV + persons is responsible for them becoming infected and transmitting the disease to others

Conclusions cont. Level of health care for HIV-infected persons may be higher than expected, particularly for the non-transient White and Black (American born) populations (not enough data on Asian, American Indian and Hispanic populations ) Public assistance for HIV care and survival is needed