Supplement to HIV and AIDS Surveillance

(SHAS)

IntroductionSHAS 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 2000- Dec 2003 Compared to HARS EMA HIV (non-AIDS) Cases Diagnosed 1999-2003

SHAS (N=112) HARS (N=799)Gender % %Male 70 73Female 30 27

SHAS (N=78) HARS (N=584) SHAS (N=34) HARS (N=215)Race/Ethnicity % % % %White (not Hispanic) 49 57 26 23Black (not Hisp, not Af born 33 21 56 35Black (African Born) 5 9 9 30Hispanic 10 9 6 6Asian 1 2 0 2American Indian 1 1 3 4Unknown 0 <1 0 <1

SHAS (N=78) HARS (N=584) SHAS (N=34) HARS (N=215)Mode of Exposure % % %MSM 68 67 -- --

IDU 8 3 15 5

MSM/IDU 5 4 -- --Heterosexual 8 4 62 42

Other/Not Reported 12 23 24 53

Males

Males Females

Females

SHAS Cases with AIDS Interviewed Aug 2000-Dec 2003 Compared to HARS EMA AIDS Cases Diagnosed 1999-2003

SHAS (N=103) HARS (N=694)Gender % %Male 71 76Female 29 24

SHAS (N=73) HARS (N=527) SHAS (N=30) HARS (N=167)Race/Ethnicity % % % %White (not Hispanic) 48 51 17 19Black (not Hisp, not Af Born) 40 21 57 35Black (African Born) 1 10 13 35Hispanic 5 13 3 3Asian 0 2 0 2American Indian 5 4 10 6Unknown 0 0 0 0

SHAS (N=73) HARS (N=600) SHAS (N=30) HARS (N=164)Mode of Exposure % % % %MSM 64 57 -- --

IDU 11 6 27 12

MSM/IDU 7 5 -- --Heterosexual 7 5 47 34

Other/Not Reported 11 27 27 54

Females

Males Females

Males

Agencies/Groups Given Formal SHASPromotional 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

Gender No. %

Male 151 70%

Female 64 30%

Total 215 100%

SHAS Participants: Race/Ethnicity

Race/EthnicityMalesNo. (%)

FemalesNo. (%)

TotalNo. (%)

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)

Hispanic 12 (8) 3 (5) 15 (7)

Asian 1 (<1) 0 (0) 1 (<1)

American Indian 5 (3) 4 (6) 9 (4)

Total 151 (100) 64 (100) 215 (100)

SHAS Participants: Category of Exposure (HARS)

Category of ExposureMalesNo. (%)

Females No. (%)

MSM 100 (66) --

IDU 14 (9) 13 (20)

MSM/IDU 9 (6) --

Heterosexual 11 (7) 35 (55)

Other/Not reported 17 (11) 16 (25)

Total 151 (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%

$50,000 + 7%

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 1999-2003 (as in HARS) (85 cases)

Non-AIDS** Non-AIDSTotal (% of 85) Total (% of 85)

Crack 43 32 18 15Cocaine 43 36 11 11Heroin or other opiates 16 14 4 2Methamphetamine 15 16 4 7Valium or related drugs 14 11 3 4

PCP, LSD, hallucinogens 19 16 1 1Barbituates, downers 9 7 1 0Amphetamine/Speed 22 21 <1 1Party Drugs (Ecstasy, GHB, etc.)

12 13 3 5

Other 4 7 <1 2Unknown 2 5 0 0

Ever Use Use in the last 12 months*

Total (% of 203) Total (% of 203)

SHAS Participants: Crack Use (Excludes African-Born)

White (non-Hispanic) 22 (25) 7 (19)

Black (non-Hispanic) 57 (65) 25 (68)

Hispanic 4 (5) 3 (8)

Asian 0 () 0 ()

American Indian 5 (6) 2 (5)

Total 88 (100) 37 (100)

Ever Use Use in the Past 12 Months

No.Race/Ethnicity No.(%) (%)

• 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)

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 – 99 9

44Females

Heterosexual

1 – 2,000

40

20Heterosexual

1 – 3,000Males

Homosexual/Gay

RangeMedian # of

Partners# of

Cases

56

37

*Excludes persons with a prostitution history

Bisexual 13 Male 6

Female 5

1-33 1-100

• 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)

Ever Last 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 ParticipantsBy 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%

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 1st tested• Anonymous 8%• Confidential 90%• Unsure 2%

• Partner notification offered by MDH/MD/other• Yes 76%• No 20%• 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)

Yes No Unsure

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%

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%

Usually 34%

Always 58%

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:

Physician 48%

Nurse 13%

Pharmacist 11%

AIDS organization 10%

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% <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 insurance 87%• Never had insurance 4%

• Last 12 months ever denied health care because couldn’t pay for it:

• Yes 3%• No 97%

• 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