1. Wisconsin Department of Health Services HIV/AIDS Surveillance Annual Review New diagnoses, prevalent cases, and deaths through December 31, 2013 April 2014

2. Wisconsin Department of Health Services BACKGROUND AND OVERVIEW OF HIV CASES IN WISCONSIN

3. Wisconsin Department of Health Services Figure 1: Flow of cases of HIV infection in and out of Wisconsin, 2013 Cases ever reported in Wisconsin but currently residing in another state (n ≈ 1,300) Deaths through 2011 (n = 4,623; newly occurring or retrospectively identified) New diagnoses in Wisconsin (n=255) Out of state cases moving into Wisconsin (n=140) Prevalent cases reported, (n=6,758) Cases already living in Wisconsin Out of state cases New diagnoses

4. Wisconsin Department of Health Services DATA CONCEPTS

5. HIV prevalence or prevalent cases: The number of people living with HIV at a given time, usually the end of the year. New HIV diagnoses: HIV diagnosis refers to the time when a case is first detected and reported. HIV incidence: HIV incidence refers to when the infection is acquired. Wisconsin does not receive federal support to conduct incidence testing so data are not available to determine when an infection was acquired, only when it was diagnosed. Therefore the term HIV incidence is not used in this report. Wisconsin Department of Health Services DATA CONCEPTS HIV prevalence, new diagnoses, and incidence

6. Unknown risk exposure: Some cases of HIV are reported without a known risk exposure. Adjusted or imputed risk: Data are often adjusted to account for cases with unknown risk exposure. With imputation, the known risks of individuals with similar characteristics to those with unknown risk, including age, sex, and race/ethnicity, are applied to those with unknown risk. If 11 Black women, ages 45-64, were diagnosed with HIV with risk exposure as shown below, the one with unknown risk would be assigned 0.7 heterosexual and 0.3 IDU. Imputed risk exposures are estimates, not actual case counts. Wisconsin Department of Health Services DATA CONCEPTS Unknown and adjusted risk exposure Heterosexual IDU Unknown 0.7 Het 0.3 IDU

7. Rates are often used when comparing the impact of HIV across two or more groups. When the population sizes of the groups being compared are different, using a rate shows what the impact of HIV would be if the populations sizes were identical. In the figure, if the size of the Black and Hispanic populations were both 100,000 people, 67 Blacks would be impacted by HIV, compared to 26 Hispanics. Wisconsin Department of Health Services DATA CONCEPTS Rates per 100,000 population

8. Rate Ratios are another method for comparing the impact of HIV across populations. After rates have been calculated for each population, a reference group is selected, which may be the group with the lowest rate, the largest population, or other criteria. The rate for each population is then divided by the rate for the reference population, which gives the rate ratio. Wisconsin Department of Health Services DATA CONCEPTS Rate Ratios Using the example to the right, and Whites as a reference population, we would say that the HIV diagnosis rate in Black males is 12-fold higher than in White males (55.8/5.7). Similarly the HIV diagnosis rate in Hispanic males is 4-fold higher than in White males (25.7/5.7).

9. Percent change is used to describe a trend in data, or change over time. Percent change is calculated as follows: Time 2 – Time 1 * 100 = Percent Change Time 1 The example below shows the number of new HIV diagnoses among Hispanics from 2004 to 2013. To describe the trend over time, we can calculate the percent change in the number of diagnoses from 2004 to 2013: Wisconsin Department of Health Services DATA CONCEPTS Percent change Caution must be used when comparing data from two consecutive years in a time-trend graph. Doing so might suggest a trend that is not real or a difference that is not statistically significant (See discussion about statistical significance on the next slide). 7 – 15 *100 = 15 53% decline in new diagnoses among Hispanics between 2004 and 2013.

10. Statistical Significance: Statements about statistical significance are sometimes made when looking at a change over time or when comparing groups. Tests of statistical significance allow us to determine whether the observed change over time or difference between groups is most likely due to random fluctuation or whether it is likely to be a real difference. Wisconsin Department of Health Services In the figure, the apparent increase in rates in males from 2012 to 2013 is not statistically significant. Therefore this difference likely reflects normal fluctuations in HIV diagnoses that occur on a year-to-year basis, rather than a true increase. Population health and social science data typically use 95% confidence intervals to test statistical significance. DATA CONCEPTS Statistical significance

11. Wisconsin Department of Health Services NEW HIV DIAGNOSES These include cases of HIV diagnosed in Wisconsin in 2013

12. Wisconsin Department of Health Services UNITED STATES Figure 2. HIV diagnosis rate per 100,000 population by state, 2011 U.S. IL MI MN WI IA IN Rate per 100,000 population Source: CDC HIV Surveillance Report, V 23, Table 19 State

13. Wisconsin Department of Health Services TOTAL CASES Figure 3. Cases of HIV diagnosed in Wisconsin, 1983-2013 * * Cases are shown using 3-year rolling averages Number of HIV diagnoses Year of diagnosis

14. Wisconsin Department of Health Services CASES BY SEX Figure 4. HIV diagnosis rate per 100,000 population by sex, Wisconsin, 2004-2013 Male Female Rate per 100,000 population Year of diagnosis

15. Wisconsin Department of Health Services SEX AND AGE Figure 5. HIV diagnosis rates per 100,000 population by sex and age group, Wisconsin, 2004-2013 Males 15-29 Males 30-59 Females 15-29 Females 30-59 Rate per 100,000 population Year of diagnosis

16. Wisconsin Department of Health Services TRANSGENDER INDIVIDUALS Figure 6. HIV diagnoses among transgender individuals by race/ethnicity and age group, Wisconsin, 2004-2013 Number of HIV diagnoses

17. Wisconsin Department of Health Services Racial/ethnic minority RACE/ETHNICITY Figure 7. Percent of HIV diagnoses in Whites and racial/ethnic minorities, Wisconsin, 1983-2013 2013 diagnoses (n=255) Percent of HIV diagnoses Multi-racial Asian American Indian Hispanic Black White Year of diagnosis

18. Wisconsin Department of Health Services SEX AND RACE/ETHNICITY: RATES Figure 8. HIV diagnosis rate per 100,000 population by sex and race/ethnicity, Wisconsin, 2009-2013 Rate per 100,000 population

19. Wisconsin Department of Health Services AGE BY SEX Figure 9. HIV diagnosis rate per 100,000 population by sex and age group, Wisconsin, 2013 (n=255) Rate per 100,000 population 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+ Males Females

20. RISK EXPOSURE Figure 10. HIV diagnoses by sex and estimated risk exposure group*, Wisconsin, 2013 * Data have been statistically adjusted to account for unknown risk. See technical notes. Wisconsin Department of Health Services Males (n= 217) Females (n=39)

21. Wisconsin Department of Health Services RISK EXPOSURE Figure 11. HIV diagnoses by estimated risk exposure group*, Wisconsin, 2004-2013 MSM** Heterosexual IDU * Data have been statistically adjusted to account for unknown risk. See technical notes. ** Includes MSM who also inject drugs. Number of HIV diagnoses Year of diagnosis

22. Wisconsin Department of Health Services YOUNG MSM: RACE/ETHNICITY Figure 12. HIV diagnoses in MSM* ages 15-29, by race/ethnicity, Wisconsin, 2004-2013 Black White Hispanic Year of diagnosis * Data have been statistically adjusted to account for unknown risk. See technical notes. MSM Includes those who also inject drugs. Number of HIV diagnoses

23. Wisconsin Department of Health Services * Excludes cases with unknown risk exposure. ** Includes MSM who also inject drugs. AGE AT DIAGNOSIS BY RISK Figure 13: Median age at HIV diagnosis by risk exposure*, and among MSM by race/ethnicity, Wisconsin, 2013 Median age at HIV diagnosis MSM**

24. Wisconsin Department of Health Services Figure 14. HIV diagnoses by county, Wisconsin, 2013 DIAGNOSES BY COUNTY

25. Wisconsin Department of Health Services MILWAUKEE DISPARITY Figure 15. City of Milwaukee’s share of Wisconsin’s HIV diagnoses and population by demographic characteristic, 2013 Source: American Community Survey 5 year (2008-2012) population estimates

26. Wisconsin Department of Health Services LATE TESTERS Figure 16. Percent of HIV diagnoses with concurrent AIDS diagnosis or progressing to AIDS within one year, Wisconsin, 2011-2013 * Those diagnosed with HIV infection during 2013 have not had one full year to evaluate progression to AIDS and therefore this category is excluded. Unknown

27. Wisconsin Department of Health Services Summary of HIV diagnoses in Wisconsin, 2013 Total −255 diagnoses in Wisconsin in 2013 Sex and gender –Males, 85% of 2013 diagnoses –Males and females, stable rates, 2004-2013 –Transgender individuals, 22 diagnoses, 2004-2013 Race/Ethnicity: –Males: Rates in Blacks 10 times and Hispanics 5 times higher than in Whites –Females: Rates in Blacks 25 times and Hispanics 5 times higher than in Whites Geography –Diagnosis rate in Milwaukee County 5 times higher than in Wisconsin excluding Milwaukee County Late testers –About 37% of individuals first diagnosed with HIV in the Wisconsin during 2012 progressed to AIDS within one year of HIV diagnoses

28. Wisconsin Department of Health Services Summary of HIV diagnoses by risk exposure in Wisconsin, 2013 Risk: Males –MSM (including MSM/IDU), 90% –Injection drug users, 5% –High-risk heterosexual, 4% Risk: Females –High-risk heterosexual, 79% –Injection drug users, 21% MSM –Median age of diagnosis: Black: 24; Hispanic MSM: 33; White MSM:38 –Young MSM ages 15-29: Blacks accounted for 63% –Black MSM ages 15-29: diagnoses nearly tripled 2004-2013

29. Wisconsin Department of Health Services PREVALENT CASES Prevalence is the number of people living with HIV infection at a given point in time

30. Wisconsin Department of Health Services UNAWARE OF HIV INFECTION: UNITED STATES Figure 17. Estimated percent unaware of their HIV infection, by demographic group, United States, 2011 Source: HIV Surveillance Supplemental Report, Vol. 18, No. 5, p 10, http://www.cdc.gov/hiv/pdf/2011_Monitoring_HIV_Indicators_HSSR_FINAL.pdf

31. Wisconsin Department of Health Services NUMBER UNAWARE OF HIV INFECTION Figure 18. Estimated number unaware of their HIV infection, by demographic group, Wisconsin, 2013 *MSM includes MSM & IDU Source: HIV Surveillance Supplemental Report, Vol. 18, No. 5, p 10, http://www.cdc.gov/hiv/pdf/2011_Monitoring_HIV_Indicators_HSSR_FINAL.pdf

32. Wisconsin Department of Health Services PREVALENCE: STATE OF DIAGNOSIS Figure 19. Prevalent cases of HIV infection in Wisconsin, as of December 31, 2013, by state of initial HIV diagnosis n = 6,756* *2 individuals with missing state of HIV diagnosis are excluded from the graph

33. Wisconsin Department of Health Services PREVALENCE: AGE Figure 20. Prevalent cases of HIV infection by current age as of December 31, 2013 and cases reported during 2013 by age at diagnosis, Wisconsin

34. Wisconsin Department of Health Services ESTIMATED PREVALENCE* BY DEMOGRAPHIC GROUP Figure 21. Impact of HIV on selected demographic groups, ages 15-59 years, Wisconsin, as of December 31, 2013 * The estimated prevalence is adjusted to account for the CDC’s estimate that 15.8% of HIV-infected persons are unaware of their infection and therefore not reported. The percent of males that are MSM was calculated using published estimates (Lieb, 2011). Less than 0.5%

35. Wisconsin Department of Health Services PREVALENCE: GEOGRAPHY Figure 22. Reported cases of HIV infection presumed to be alive by county, Wisconsin, as of December 31, 2013 *Excludes 168 cases with the Wisconsin Department of Corrections as the last known address.

36. Wisconsin Department of Health Services DEATHS Deaths are the number of people with HIV infection who died in a given year, irrespective of cause of death

37. Wisconsin Department of Health Services DEATHS Figure 23. Deaths due to any cause among persons reported with HIV infection by year of death, Wisconsin, 1990-2011

38. Wisconsin Department of Health Services DEATHS: AGE Figure 24. Deaths due to any cause among persons reported with HIV infection, by median age at death, Wisconsin, 2002-2011 n =1,290

39. Wisconsin Department of Health Services HIV CARE CONTINUUM Deaths are the number of people with HIV infection who died in a given year, irrespective of cause of death

40. CONTINUUM OF CARE Figure 25. Wisconsin HIV Continuum of Care, 2011 New Diagnoses and Prevalent Cases Unaware of their infection Wisconsin Department of Health Services

41. Summary of HIV Prevalence, Deaths, and HIV Care as of December 31, 2013 Prevalent Cases –Wisconsin’s HIV prevalence rate is one-third of the national rate –6,758 reported + 1,270 estimated unaware of HIV infection ≈ 8,030 Age –50% are age 45 or older Estimated HIV positive by risk and race –General population: 2 in 1,000 –Blacks: Non-MSM males, 0.4%; females, 0.6% –MSM: Black, 32%; Hispanic, 8%; White, 3% Geography –Milwaukee County: 49%; Dane County, 12%; all other, 4% or fewer Deaths –130 deaths in HIV-infected individuals in 2011 Continuum of HIV Care –In 2012, 47% of people diagnosed and living with HIV had suppressed viral load