Wisconsin Department of Health Services Wisconsin HIV/AIDS Surveillance Annual Review Addendum: City of Milwaukee Slide Set City of Milwaukee: New diagnoses, prevalent cases, syphilis diagnoses, and HIV testing through December 31, 2014 April, 2015 P-00484A

These slides provide selected HIV surveillance data for the city of Milwaukee. Throughout the slides, “Milwaukee” refers to the city of Milwaukee, unless otherwise specified. For more information on the methods and definitions used in these slides, please see the Technical Notes of the Wisconsin HIV/AIDS Surveillance Annual Review at: https://www.dhs.wisconsin.gov/publications/p0/p00484.pdf. Wisconsin Department of Health Services

New Diagnoses Number and statewide proportion of new HIV diagnoses, city of Milwaukee, 2005-2014 There were 119 new HIV diagnoses among Milwaukee residents during 2014. Milwaukee is disproportionately affected by HIV, as it makes up just 10% of the state’s population yet has 53% of all statewide HIV diagnoses. The annual number of new HIV diagnoses has been stable over the last decade, ranging from a low of 101 in 2005 to a high of 135 in 2010, with an average of 116 new diagnoses per year. Centers for Disease Control and Prevention. HIV Surveillance Report, 2013; vol.25. http://www.cdc.gov/hiv/library/reports/surveillance/. Published February 2015. Accessed 3/20/2015. Wisconsin Department of Health Services

HIV diagnosis rates in Milwaukee compared to other geographical areas HIV diagnosis rate by Metropolitan Statistical Area, 2013 According to the Centers for Disease Control and Prevention, the most recently available estimate for the Milwaukee Metropolitan Statistical Area (MSA) (8.7/100,000), which includes the lower-incidence Waukesha and West Allis areas, is low compared to the average rate (18/100,000) for other large MSAs in the United States . Centers for Disease Control and Prevention. HIV Surveillance Report, 2013; vol.25. http://www.cdc.gov/hiv/library/reports/surveillance/. Published February 2015. Accessed 3/20/2015. Wisconsin Department of Health Services

HIV diagnosis rates in Milwaukee compared to county, state, and U.S. City of Milwaukee HIV rate compared to other Wisconsin geographies (2014), and the United States (2013) This slides compares the HIV diagnosis rate in the city of Milwaukee with other geographies. The HIV diagnosis rate within the city of Milwaukee was 19.9 per 100,000 population, compared with only 1.9/100,000 for the rest of Wisconsin. The city of Milwaukee diagnosis rate is on par with the rate from other large metropolitan areas (e.g. Chicago 19.8/100,000 and Detroit 12.7/100,000). Wisconsin Department of Health Services

Sex and Age Number of new HIV diagnoses by sex and age, city of Milwaukee, 2005-2014 For both males and females, the trend in the number of new diagnoses varies by age. The annual number of new diagnoses among males ages 13-29 has almost tripled over the last decade, from 22 new diagnoses during 2005 to 61 new diagnoses during 2014. Over the same time period, the annual number of new diagnoses has declined among males ages 30 and older and was stable among females of all ages. Wisconsin Department of Health Services

Transgender Identity 24 transgender individuals diagnosed in city of Milwaukee since beginning of epidemic Likely an underestimate due to limited historical data collection on self-reported gender identity All from a racial/ethnic minority group Most (n=19) under age 30 at time of diagnosis The term “transgender” refers to people whose gender identity does not conform to their sex assigned at birth. It includes people who self-identify as male-to-female or transgender women, female-to-male or transgender men, and many other gender nonconforming identities. A transgender person may have the anatomy of their sex at birth, the other sex, or a combination. Gender identity and sexual orientation are separate, distinct concepts, with gender identity referring to an individual’s sense of themselves and sexual orientation referring to an individual’s attractions and partnering.   A total of 24 known transgender individuals have been diagnosed with HIV in the city of Milwaukee since the beginning of the epidemic (mostly male-to-female). While the collection of data on self-reported gender identity has improved over time, this count likely underestimates the true number of transgender individuals diagnosed with HIV infection in the city. Of the 24 known transgender individuals diagnosed with HIV in Milwaukee, all were from a racial/ethnic minority group and most (n=19) were under age 30. Wisconsin Department of Health Services

Race/ethnicity and sex HIV diagnosis rate by sex and race/ethnicity, city of Milwaukee, 2010-2014 For all racial/ethnic groups, the HIV diagnosis rate is higher in Milwaukee than in the state excluding Milwaukee . Due to Milwaukee’s higher HIV diagnosis rate for Whites (used as the reference group), rate ratios are much lower in Milwaukee compared to the rest of the state, meaning the disparities between racial/ethnic groups aren’t as large as those observed statewide. Racial disparities are not due to innate biologic factors—one’s race alone does not make one more or less susceptible to HIV infection. Rather, other determinants of health, such as poverty, access to education and healthcare, stigma, and racism that can disproportionately affect people of color, can put individuals at greater risk for HIV exposure.   The table below shows the rate and rate ratios by sex and racial/ethnic group for the city of Milwaukee compared to the rest of Wisconsin, 2010-2014. Wisconsin Department of Health Services Rate per 100,000 Population Rate Ratio City of Milwaukee Wisconsin (excluding city of Milwaukee) Male   Black 57.0 29.0 3.7 10.4 Hispanic 26.3 12.5 1.7 4.5 White 15.6 2.8 Reference group Female 11.0 13.3 4.8 39.3 6.4 1.9 5.7 2.3 0.3

Risk exposure HIV diagnoses by estimated risk exposure group*, city of Milwaukee, 2005-2014 From 2005 to 2014, the estimated annual number of new HIV diagnoses increased among MSM (from about 48 to 94 cases), and was stable among those with high-risk heterosexual contact and those with a history of injection drug use (PWID). Wisconsin Department of Health Services

Risk exposure and sex Proportion of HIV diagnoses by sex and estimated risk exposure group*, city of Milwaukee, 2014 After adjusting to account for those with unknown risk, 90% of 2014 Milwaukee diagnoses were among MSM, including 2% who also injected drugs (PWID). Among males, injection drug use alone (non-MSM/PWID) accounted for 4% of diagnoses and high-risk heterosexual exposure for 5%. Among females, 69% of diagnoses were attributable to high-risk heterosexual contact and 31% were due to injection drug use. Wisconsin Department of Health Services

Risk exposure and age Median age at HIV diagnosis by reported risk exposure, and among MSM by race/ethnicity, city of Milwaukee, 2014 The median age at diagnosis in Milwaukee during 2014 was 28 years, with variation by risk exposure group. The median age at diagnosis was older among those with high-risk heterosexual and PWID exposure, at 48.5 and 52 years, respectively. The median age at diagnosis among all MSM was 26 years, but was lower among Black MSM (23.5 years) and Hispanic MSM (26 years). Wisconsin Department of Health Services

Risk exposure, sex, race/ethnicity, age Number of HIV diagnoses by selected sex, race/ethnicity, age and risk group*, City of Milwaukee, 2012-2014 After adjusting to account for those with unknown risk, new HIV diagnoses among young (ages 13-29 years) Black MSM accounted for one-third of all new diagnoses in Milwaukee during 2012-2014 . Older (ages 30 and older) Black MSM had the second highest number of new diagnoses, accounting for 12% of all diagnoses during this three-year period. In total, the demographic groups shown in the figure account for almost 80% of all new HIV infections in Milwaukee during 2012-2014. Another way of presenting the same message is the picture to the right. Wisconsin Department of Health Services

New diagnoses: zip codes HIV diagnoses by zip code of residence*, city of Milwaukee, 2012-2014 1 dot = 1 HIV diagnosis This map shows the zip code of residence for people newly diagnosed during 2012-2014. Dots are randomly distributed within a zip code and do not represent actual addresses. The top 6 zip codes (53206, 53208, 53215, 53204, 53212, and 53209) all had 20 or more new cases over the past three years and account for 50% of all new HIV diagnoses among Milwaukee residents during 2012-2014. * Dots are placed randomly within zip codes and do not reflect the actual case residence. Wisconsin Department of Health Services

New diagnoses among young Black MSM: zip codes Relative number of new HIV diagnoses among young (ages 13-29) Black MSM by zip code of residence, city of Milwaukee, 2012-2014 This “word cloud” shows zip codes of residence for young Black MSM diagnosed during 2012-2014. The size of the text corresponds to the relative number of new cases. 52308 in the center had the largest number of cases within this demographic group. The zip codes at diagnosis are concentrated; just four zip codes (53208, 53209, 53206 and 53210) account for half of new HIV diagnoses among young Black MSM in Milwaukee. Wisconsin Department of Health Services

Late testers Percentage of new HIV diagnoses with concurrent AIDS diagnosis or progressing to AIDS within one year, city of Milwaukee, 2011-2014 According to the CDC, late testers are individuals who progress to AIDS within one year of receiving their initial HIV diagnosis, including those who receive an HIV and AIDS diagnosis at the same time. Early diagnosis is important for optimal health outcomes for the infected individual and for reducing the risk of further disease transmission.   The total proportion of people diagnosed with HIV infection in Milwaukee who progressed to AIDS within one year of HIV diagnosis, including concurrent diagnoses, remained stable from 2011 to 2013 (30-31%). The number concurrently diagnosed with HIV and AIDS fluctuated during 2011-2014 (19-21%). Wisconsin Department of Health Services

Prevalent cases: zip codes Prevalent cases of HIV infection by last known zip code of residence, city of Milwaukee, as of December 31, 2014 As of December 31, 2014, an estimated 3,359 people were living with HIV in Milwaukee County, most of whom (n=3,163) were living in the city of Milwaukee. CDC estimates that 14% of people living with HIV nationwide are unaware of their HIV infection; therefore, actual HIV prevalence in the city of Milwaukee may be closer to 3,680.   HIV prevalence by last known zip code of residence is shown in the figure. Zip codes with the highest HIV prevalence were 53204, 53208, 53212, 53215, 53209 and 53206, all of which have 200 or more HIV cases each. The remaining zip codes have fewer than 165 cases each. Prevalent Cases 1 - 47 48 - 105 106 - 164 >165 Wisconsin Department of Health Services

HIV testing New positivity rate at publically-funded counseling and testing sites in the city of Milwaukee for various populations, 2009-2014 The high positivity rate of HIV tests among MSM in the city of Milwaukee is an indication of success in publically-funded programs’ aim to reach high-risk populations for HIV testing. The overall new positivity rate for all tests conducted by publically-funded sites in Milwaukee between 2009 and 2014 was 0.7%. However, the new positivity rate was higher among MSM, especially Black MSM (3.2%). Wisconsin Department of Health Services

Syphilis and HIV diagnoses Syphilis diagnoses in Milwaukee County from 2004-2013, and syphilis or syphilis-HIV diagnoses in Milwaukee County among males ages 13-29 from 2012-2014 Tracking syphilis diagnoses can be an indicator of high-risk activity within the MSM community. Genital sores associated with syphilis infection can make it easier to transmit and acquire HIV. This graph looks at syphilis and syphilis/HIV co-infection among males ages 13-29 in Milwaukee County, and total syphilis diagnosis in Milwaukee County.   The bars on the right show that total syphilis and syphilis-HIV co-infections among males ages 13-29 have trended downward between 2012-2014. However, the proportion of all syphilis diagnoses in this population where HIV is present remains high (33-42%). In addition, total syphilis infections in Milwaukee County have increased from 2005 to 2013. Centers for Disease Control and Prevention. Syphilis & MSM (Men Who Have Sex With Men) – CDC Fact Sheet. http://www.cdc.gov/std/syphilis/stdfact-msm-syphilis.htm. Accessed 4/9/2015. Wisconsin Department of Health Services. Sexually Transmitted Disease in Wisconsin 2013: Milwaukee County. https://www.dhs.wisconsin.gov/publications/p0/p00415-2013-milwaukee.pdf. Accessed 4/9/2015. Wisconsin Department of Health Services

Full reports For additional information and methodology, visit our website: https://www.dhs.wisconsin.gov/aids-hiv/data.htm Statewide report: https://www.dhs.wisconsin.gov/publications/p0/p00484.pdf City of Milwaukee report: https://www.dhs.wisconsin.gov/publications/p0/p00484a.pdf The full Milwaukee report is available here: https://www.dhs.wisconsin.gov/publications/p0/p00484a.pdf The full statewide report is available at: https://www.dhs.wisconsin.gov/publications/p0/p00484.pdf The full statewide report also contains technical notes that explain the methodology used in the report.