Highlights from the MN HIV Surveillance Report 2013

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HIGHLIGHTS FROM THE MN HIV SURVEILLANCE REPORT 2013

Minnesota Department of Health HIV/AIDS Surveillance System

Estimated Number of PersonsLiving with HIV/AIDS in Minnesota

• As of December 31, 2013, 7,723* persons are assumed alive and living in Minnesota with HIV/AIDS

• 4,095 living with HIV infection (non-AIDS)• 3,628 living with AIDS

* This number includes persons who reported Minnesota as their current state of residence, regardless of residence at time of diagnosis. Includes state prisoners and refugees arriving through the HIV+ Refugee Resettlement Program, as well as HIV+ refugee/immigrants arriving through other programs.

Minnesota HIV Treatment Cascade

Percentage of persons diagnosed with HIV engaged in selected stages of the continuum of care – Minnesota

Conclusions• There were 301 new HIV diagnoses reported in Minnesota

in 2013, a decrease of 4% from 2012• Great disparities in HIV diagnoses persist among

populations of color and American Indians living in Minnesota

• Male-to-male sex remains the leading risk factor for acquiring HIV/AIDS in Minnesota

• New HIV diagnoses remain concentrated in the Twin Cities seven-county metro area (82% of new diagnoses in 2013)

• Foreign-born persons made up nearly 1 in 5 of new HIV diagnoses in 2013, and progress from HIV to AIDS more quickly than U.S. born persons living with HIV in Minnesota

Thank You!

For more information, please contact:

Jessica Brehmer, HIV/AIDS Epidemiologist

jessica.brehmer@state.mn.us

(651) 201-5624

“The place where two discriminations exist is a dangerous place to live.”

- Richard (Anguksuar) LaFortune

Using Public Health Programming to Mitigate Disease and Death from Opiate

Drug UseSarah Gordon, MPH, NREMT-B

The issue is not simple…. disease, heroin, death, stigma, addiction, war on drugs, healthcare access, harm reduction

Injection drug use is a well-known route of transmission of blood borne infections, particularly HIV and hepatitis B and C. Use of illicit drugs is associated with increased rates of TB and STDs.

Recommended approaches, immunizations and screening, can protect the health of a person who uses drugs through medical interventions, while evidence-based behavioral interventions help prevent sexual and injection transmission by addressing risky behaviors.

Increase in Opiate Use In Minnesota 2005 - 2011

TwinCities.com DATA 2014

Maps show grams per 10,000 people of prescriptions for painkiller opiates (such as oxycodone, hydrocodone, codeine, morphine) in each three-digit ZIP code area. Source: Drug Enforcement Administration.

Heroin Influx in Midwest

Courtesy Carol Falkowski Drug Abuse Trends June 2013, Drug Abuse Dialogues

Twin Cities has the cheapest and strongest heroin in the country, officials say

By Aaron Rupar Thu., Jun. 6 2013 at 1:04 PM

At the newser, a doctor said there were four heroin-related deaths reported in Hennepin County in 2008. Last year, that number shot up to 37, and Hennepin County Sheriff Rich Stanek said the county is on pace to set a new record this year.

Stanek also said the heroin he's seeing these days in Hennepin County is the cheapest and strongest in the country, a combination he characterized as particularly deadly.

His comments reiterated what law enforcement officials said at a similar news conference last year. Then, they referenced an analysis showing that some heroin found on Twin Cities' streets was up to 93 percent pure, whereas typical American street heroin has a purity of about 35 percent.

"A heroin user in the Twin Cities has a greater chance of accidental overdose because the purity of that heroin is so high," Stanek said during that news conference.

At today's newser, officials pointed out the role prescription drugs play as a gateway to heroin. According to the Star Tribune, data showed that heroin and prescription drug abuse in the Twin Cities reached an all-time high last year. The two accounted for 21 percent of all addiction treatments in the state, with only alcohol abuse accounting for a higher share.

Courtesy Carol Falkowski, Drug Abuse Trends June 2012, Drug Abuse Dialogues

Heroin vs. other opiate treatment admission 1998-2013

Source: DAANES, PMQI, MN DHS 2014Slide courtesy Rick Moldenhauer, DHS

CDC Declares an Epidemic• In 2010, overdose death become the leading

cause of injury death in the US

Local Impact – Hennepin/Ramsey County Drug Deaths

2006 2007 2008 2009 2010 2011 20120

OpiatesCocaineMethamphetamineD

Hennepin County Medical Examiner and Ramsey County Medical Examiner, 2013

What makes opioid users at particular risk of overdose fatality?

• Among patients receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of opioid overdose death.

• Bohnert, et al. 2011

• Poly-drug use • Bohnert, et al. 2011

• Substance use disorders and co-occuring mental health disorders

• Hall, et. al., 2008

• Purity! Mexican heroin purity in Minneapolis highest in country and sold at lowest cost

• DEA Domestic Monitoring Program 2009

• Fear of police response was the most commonly cited reason for not calling or delaying before calling for help

• Efforts to equip drug users to manage overdoses effectively, including training in first aid and the provision of naloxone, and the reduction of police involvement at overdose events may have a substantial impact on overdose-related morbidity and mortality.– Tracy, et al. Drug and Alcohol Dependence. 09/2005

What makes opioid users at particular risk of overdose fatality?

(continued)

Reality of drug use…. • Non-fatal overdose in

injection drug users– Lifetime prevalence ~ 40%– Of these ~ 70% reversed by

naloxone– Lifetime witnesses ~ 90%

• Fatal– 1-3 hour window for medical

intervention• Sackoff et al. Ann Int Med,

2006; Ermak et al. 2009

The other reality of drug use….

Public Health Programming to Prevent Disease

Role of Needle Exchange in HIV and Hepatitis C Prevention Efforts

• The public health approach to disease prevention is to reduce risk of infection whether individual stops the risk behavior or not, which thereby protects the health of the community

Syringe Exchange is low-threshold entry point for drug users into prevention

services and treatment• Exchange participants 5x more

likely to enter drug treatment than nonparticipants

• 67% of all exchange programs offer HCV testing and 87% offer HIV testing and linkage to care

• Since implementation of exchange programs in the late ’80s, HIV rates in injection drug users decreased overall by 80 %

Syringe Exchange Promotes Public Safety

• Post implementation of syringe exchange programs reduce number of syringes found in public areas….– 50% drop in Baltimore– 2/3 reduction in Portland,

• Implementation of syringe exchange programs reduces needle-stick injuries to police….– 2/3 injury reduction for

Connecticut law enforcement

– 66% reduction for Macon County, NC law enforcement

Testing is Prevention!

• 2 good reasons to get tested for HIV and HCV – If you have HIV and/or HCV, you can get treatment and

healthy lifestyle education that may help you live a longer, healthier life.

– If you do not have HIV or HCV, you can learn how to stay that way.

• Studies show persons who are aware of their status decrease behaviors that help transmit infection

911 Good Samaritan Laws• Purpose: increase overdose survival rates by encouraging

overdose witnesses to seek medical help through limited immunity from arrest and prosecution for minor drug and alcohol violation

• Good Sam laws do not protect from arrest for other offenses, such as selling or trafficking, or driving while drugged

• 15 states and District of Columbia have Good Sam policies – New Mexico, California, Colorado, New Jersey, New York, Rhode

Island, Illinois, Florida, Massachusetts, Connecticut, North Carolina, Vermont, Delaware, Georgia, and Washington

Broadening Naloxone Access• Broader naloxone access policies puts overdose

antidote in the hands of witnesses, first responders, community prevention programs– High affinity opioid receptor antagonist– Rapidly absorbed via IV, IM, SC, IN routes– Half-life ~ 40 minutes– Non-abusable– Adverse effect – withdrawal– Shelf-life – 3 years

What is the Overdose Antidote?

An Opiate Antagonist

What’s coming in MN? Steve's Law (HF2307 / SF1900)

https://www.facebook.com/#!/911GoodSamaritanNaloxoneCampaign

Thank you!!

For more information, please contact:

Sarah Gordon, MPHCoordinator, HIV Testing and Syringe Services ProgramsMinnesota Department of Health651-201-4011sarah.gordon@state.mn.us

Hepatitis A, B & C in Minnesota, 2013

Minnesota Department of HealthHepatitis Surveillance SystemMinnesota Department of HealthHepatitis Surveillance System

Minnesota Hepatitis Surveillance System Minnesota Hepatitis Surveillance System

Hepatitis B reportable since 1987

Hepatitis C reportable since 1998

Passive data collection

Viral Hepatitis Overview Viral Hepatitis Overview

Data Source: Minnesota Viral Hepatitis Surveillance System

IntroductionIntroduction

Data in this presentation are current through 2013 Definitions:

Acute case: Infected within the last six months Symptomatic OR negative test in six months before diagnosis

Chronic case: Infected for over six months Asymptomatic or symptomatic

Resolved cases: No evidence of current infection Evidence of past infection

Data limitationsData limitations The slides rely on data from HCV and HBV cases diagnosed through 2013

and reported to the Minnesota Department of Health (MDH) Hepatitis Surveillance System.

Some limitations of surveillance data: Data do not include hepatitis-infected persons who have not been tested Data do not include persons whose positive test results have not been

reported to the MDH

Persons are assumed to be alive unless the MDH has knowledge of their death.

Persons whose most recently reported state of residence was Minnesota are assumed to be currently residing in Minnesota unless the MDH has knowledge of their relocation.

Acute Viral HepatitisAcute Viral Hepatitis

Acute case: Infected within the last six months Symptomatic OR negative test within 6

months before diagnosis

Reported rate per 100,000 population of acute viral hepatitis

United States, 1998-2011

Reported rate per 100,000 population of acute viral hepatitis

United States, 1998-2011

Data Source: Viral Hepatitis Statistics & Surveillance at www.cdc.gov/hepatitis/Statistics/2011Surveillance/index.htm

Number of Acute* Cases per year Minnesota,1998-2013

Data Source: MN Viral Hepatitis Surveillance System *Acute cases include seroconverters for all years for HBV and HCV

Chronic Viral HepatitisChronic Viral Hepatitis

Overview of Chronic HBV in MNOverview of Chronic HBV in MN

Chronic case: Infected for over six months

Includes cases with no evidence of recent infection

Asymptomatic or symptomatic

Reported Number of Personswith Chronic HBV in MN

As of December 31, 2013, 21,585* persons are assumed alive and living in MN with chronic HBV

*Includes persons with unknown city of residence

Note: Includes all chronic, and probable chronic cases.

Data Source: MN Viral Hepatitis Surveillance System

Persons Living with HBV in MN by Current Residence, 2013

Metro = Seven-county metro area including Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and Washington counties. Greater MN = All other Minnesota counties, outside the seven-county metro area.

Total number with residence information = 21,242

(343 missing residence information)

Persons with Chronic HBV in MN by Age, 2013Persons with Chronic HBV in MN by Age, 2013

Median Age: 43

Chronic HBV in MN by Gender, 2013Chronic HBV in MN by Gender, 2013

Persons Living with Chronic HBV in Minnesota by Race,2013

Persons with unknown race=3,365

Afr Amer = African American /Black Asian=Asian or Pacific IslanderAmer Ind = American IndianOther = Multi-racial persons or persons with other race

Unknown16%

White11%

Amer Ind0%

Hispanic1%

Other1%

Afr Amer27%

Asian44%

Persons Living with Chronic HBV in Minnesota by Racerates (per 100,000 persons*), 2013

*Rates calculated using 2010 U.S. Census data

Excludes 3,396 cases with multiple races and unknown raceData Source: MN Viral Hepatitis Surveillance System

Overview of HCV in MinnesotaOverview of HCV in Minnesota

A hepatitis C case is defined as current or past infection with hepatitis C and includes:

Acute cases: Infected within the last six months Symptomatic

Chronic cases: Infected for over six months

Resolved cases: No evidence of current infection Evidence of past infection

Reported Number of PersonsLiving with HCV in MN

As of December 31, 2013, 40,943* persons are assumed alive and living in MN with HCV

Note: Includes all acute, chronic, probable chronic, and resolved cases.

HCV Infected Persons Identified through Passive Surveillance in MN through 2013

**http://www.cdc.gov/ncidod/diseases/hepatitis/c/fact.htm

*Includes all acute, chronic, probable chronic, and resolved cases.

HCV infected persons* identified through passive surveillance

Estimated unidentified HCV infected persons

40,943

43,920

N=84,863**

Persons Living with HCV in MN by Current Residence, 2013

Suburban = Seven-county metro area including Anoka, Carver, Dakota, Hennepin (except Minneapolis), Ramsey (except St. Paul), Scott, and Washington counties including those in Hennepin County or Ramsey County with unknown city. Greater MN = All other Minnesota counties, outside the seven-county metro area.

Total number with residence information= 40,033

(1,271 missing residence information)

Persons Living with HCV in MN by Age, 2013Persons Living with HCV in MN by Age, 2013

Median Age: 56

*Includes anonymous methadone patients

Persons Living with HCV in MN by Gender*, 2013

Persons Living with Chronic HCV in Minnesota by Race, 2013

Afr Amer = African American /Black Asian=Asian or Pacific IslanderAmer Ind = American IndianOther = Multi-racial persons or persons with other race

Persons Living with HCV in Minnesotarates (per 100,000 persons*), 2013

*Rates calculated using 2010 U.S. Census data

Excludes persons with multiple races or unknown race

Hepatitis C in Populations of InterestHepatitis C in Populations of Interest

Hepatitis C in young adultsunder age 30

Reported Number of Persons <30Living with HCV in MN

As of December 31, 2013, 1,764* persons under the age of 30 are assumed alive and living in MN with HCV

Persons <30 Living with HCV in MN by Current Residence, 2013

MN Overall MN Age Under 30 years

Persons <30 Living with HCV in MN by Gender*, 2013Persons <30 Living with HCV in MN by Gender*, 2013

Persons <30 Living with HCV in MN by Race, 2013

Hepatitis C in American IndiansHepatitis C in American Indians

Reported Number of American Indian PersonsLiving with HCV in MN

As of December 31, 2013, 2,073* persons who identify as American Indian are assumed alive and living in MN with HCV

American Indian Persons Living with HCV in MN by Current Residence, 2013

MN Overall MN American Indian

American Indian Persons Living with HCV in MN by Age, 2013American Indian Persons Living with HCV in MN by Age, 2013

Median Age: 51

Persons Living HCV in MN by Gender*, 2013Persons Living HCV in MN by Gender*, 2013

MN Overall MN American Indian

Hepatitis C TreatmentHepatitis C Treatment

Hepatitis C Treatment ChangesHepatitis C Treatment Changes

Direct acting antiviral agents approved in the U.S.

Improved rates of sustained virologic response

Rapidly changing recommendations

hcvguidelines.org

Thank you!Thank you!

For more information please contact:

Kristin Sweet651.201.4888

kristin.sweet@state.mn.us

QUESTIONS?

Jessica Brehmer, MPH, HIV Epidemiologist, MDH 651-201-5624, jessica.brehmer@state.mn.us

Sarah Gordon, MPH, Coordinator, HIV Testing and Syringe Services Programs, MDH651-201-4011, sarah.gordon@state.mn.us

Kristin Sweet, MPH, Hepatitis Epidemiologist, MDH651-201-4888, kristin.sweet@state.mn.us

Highlights from the MN HIV Surveillance Report 2013

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