County of Orange Health Care Agency, Public Health Services HIV/AIDS Surveillance and Monitoring Program

Transcription

1 HIV DISEASE SURVEILLANCE STATISTICS 2010 County of Orange Health Care Agency, Public Health Services

2 HIV DISEASE SURVEILLANCE STATISTICS, 2010 David L. Riley Director County of Orange, Health Care Agency, Public Health Services David M. Souleles, MPH Deputy Agency Director County of Orange, Public Health Services Eric G. Handler, MD, MPH, FAAP Health Officer County of Orange, Public Health Services P repared By: Rebecca Mares Senior Epidemiologist Jane Chai, MPH Program Supervisor II HIV Planning and Coordination Brandon Page Program Supervisor II Review ed By: Donna Fleming, DrPA, MSW Chief, Public Health Operations County of Orange, Public Health Services Lydia Mikhail, MBA Division Manager Disease Control and Epidemiology Tamarra Jones, DrPH, CHES Program Manager II HIV Planning and Coordination The Ryan White Quality Management Committee Acknow ledgem ents: Craig Aguilera, Senior Communicable Disease Investigator Gena Arzaga, MPH, Senior Communicable Disease Investigator Linda Booth, Senior Communicable Disease Investigator Yvonne Cervantes, Information Processing Technician Issued November 2011

3 TABLE OF CONTENTS Introduction. 1 Executive Summary.. 3 Chapter 1: HIV Disease in Orange County Overall HIV Disease Reporting... 1:1 Summary of HIV and AIDS Prevalence and Incidence.. 1:1 Overall HIV Disease Prevalence and Incidence.. 1:2 HIV Disease by Gender. 1:3 Prevalence by Gender.. 1:3 Incidence by Gender.... 1:5 Mortality by Gender... 1:5 HIV Disease by Race/Ethnicity.. 1:6 Prevalence by Race/Ethnicity... 1:6 Incidence by Race/Ethnicity.. 1:8 Mortality by Race/Ethnicity... 1:9 HIV Disease by Age. 1:10 Prevalence by Current Age :10 Incidence by Age at Diagnosis. 1:12 Mortality by Age at Diagnosis... 1:12 HIV Disease by Mode of Transmission.. 1:13 Prevalence by Mode of Transmission :13 Incidence by Mode of Transmission.. 1:14 Mortality by Mode of Transmission... 1:14 Progression from HIV to AIDS.. 1:15 HIV Disease Survival :16 HIV Disease Mortality.... 1:16 Deaths Due to HIV :17 Chapter 1 Tables.. 1:19 Chapter 2: Geography of HIV Disease in Orange County Overall Geography and Population in Orange County.. 2:1 Number of Persons Living with HIV Disease by City. 2:2 HIV Disease Rates by City 2:3 HIV Disease in Select Cities: Anaheim, Laguna Beach, and Santa Ana.. 2:4 Incidence in Select Cities. 2:4 Prevalence in Select Cities by Gender.. 2:5 Prevalence in Select Cities by Race/Ethnicity 2:6 Prevalence in Select Cities by Current Age 2:7 Prevalence in Select Cities by Mode of Transmission.. 2:8 Chapter 2 Tables.. 2:9 Chapter 3: Pediatric HIV Disease in Orange County Overall Pediatric Reporting.... 3:1 Pediatric HIV Incidence.... 3:1 Pediatric HIV Prevalence.. 3:2 Pediatric HIV Prevalence by Gender.... 3:2 Pediatric HIV Prevalence by Race/Ethnicity.. 3:2 Pediatric HIV Prevalence by Current Age.. 3:3 HIV Disease Survival.. 3:3 Chapter 3 Tables.. 3:5

4 Chapter 4: HIV Counseling and Testing Overall HIV Counseling and Testing.. 4:1 HIV Counseling and Testing by Gender... 4:2 HIV Counseling and Testing by Race/Ethnicity. 4:2 HIV Counseling and Testing by Age.. 4:3 HIV Counseling and Testing by Mode of Exposure. 4:4 HIV Counseling and Testing by Use of Selected Substances... 4:5 HIV Counseling and Testing by Selected Risk Factors. 4:6 Chapter 5: Ryan White Act and Orange County Overview of Ryan White Act 5:1 HIV Disease by Eligible Metropolitan Area (EMA) and Transitional Grant Area (TGA) 5:2 Appendix I: HIV (non-aids) and AIDS Diagnosis and Reporting Years.. A1:1 Appendix II: Glossary of Terms.. A2:1 Appendix III: Technical Notes.... A3:1 Appendix IV: AIDS Definitions.... A4: 1 Appendix V: Data Sources.. A5:1

5 INTRODUCTION This report provides a summary of HIV/AIDS cases reported in Orange County through December 31, It is our hope that in providing accurate and timely information, we can assist in reducing the spread and impact of HIV throughout Orange County. This report supplements the information given through the annual HIV/AIDS Fact Sheet, data requests, website reports and presentations, and oral presentations at public meetings. HIV/AIDS Surveillance Program Orange County s HIV/AIDS surveillance is conducted through active surveillance to identify and collect information on cases of HIV and AIDS diagnosed at hospitals, clinics, private physician offices, laboratories, and community-based organizations (CBOs). Mandated reporters, including laboratories and health care providers, submit reports of HIV cases to the. HIV/AIDS Surveillance Communicable Disease Investigators (CDIs) then contact and visit sites to facilitate the completion of HIV/AIDS case reports. Case reports are entered into the County s HIV/AIDS registry. Until May 2009, the HIV/AIDS Surveillance and Monitoring Program of the Orange County Health Care Agency maintained the Centers for Disease Control and Prevention s (CDC) HIV/AIDS Reporting System (HARS) registry. The HARS registry included all reported cases of HIV and AIDS who were residents of Orange County at the time of diagnosis. In June 2009, the California Office of AIDS (OA) transitioned to the electronic HIV/AIDS Reporting System (ehars) and began maintaining data for the local health jurisdictions (LHJs). Because of this change, the Orange County HIV/AIDS Surveillance and Monitoring Program began relying on the HIV Case Registry (Registry), a local database containing information on individuals receiving care in Orange County, including those who reside outside of the county. However, all cases described in this report are only of those individuals who resided in Orange County at the time of their initial HIV or AIDS report. The Registry database is dynamic due to the nature of HIV disease reporting, and data extracted from the Registry is considered provisional. The database is updated as duplications are resolved and additional information is added. Therefore, a snapshot of the database is extracted at the end of each calendar year and is used to present data up until that point in time. The most current extraction will be the most up-to-date number for previous years; and therefore data reported each year will be different from that reported previously. The data in this report was extracted on December 31, This will be indicated with the note Data as of December 31, It is also important to note that while the Registry includes a comprehensive record of individuals who have been diagnosed and reported by name with HIV/AIDS, the Registry does not include individuals who have not been diagnosed with HIV and/or reported by name but are living with the disease. The Centers for Disease Control and Prevention (CDC) estimates that 21% of all individuals living with HIV/AIDS are undiagnosed and do not know their status. 1 Using the CDC recommended Estimated Back Calculation Methodology 2, as of December 31, 2010 there were an estimated 1,752 undiagnosed persons living with HIV/AIDS in Orange County who are not represented in this report. Update on Name-Based HIV Case Reporting Orange County AIDS case surveillance is a core public health activity that began in Orange County in Non-AIDS HIV case surveillance, which mandates laboratory reporting of confirmatory HIV tests, began in California in July Between July 2002 and April 16, 2006, 2,155 cases of HIV were reported in Orange County using a non-named, coded case reporting system. Based on recommendations by the CDC, in April 2006, California law was revised to require the reporting of HIV cases by name rather than by non-named code. 1 ML Campsmith, P Rhodes, HI Hall, and others. HIV Prevalence Estimates -- United States, Morbidity and Mortality Weekly Report. 57(39): October 3, CDC s Estimated Back Calculation = 0.21/0.79 x 6,591 reported persons with HIV disease as of December 31,

6 As of December 31, 2010, a total of 3,099 named non-aids HIV cases have been reported; this includes 2,014 or 93.5% of Orange County cases initially reported by non-named code that have been converted to a named HIV/AIDS case. CDC considers an area s name-based reporting to be mature after four years of reporting to allow for stabilization of data collection and for adjustment of the data in order to monitor trends. 3 Therefore, Orange County considers its name-based HIV reporting system to be representative of reported cases in the county. HIV Disease In an effort to better track the progression of the HIV/AIDS epidemic and conform to new guidelines presented by the CDC, this report will focus on HIV disease. The term HIV disease is used to describe the entire HIV spectrum, from initial HIV infection to advanced HIV disease (also known as AIDS). An AIDS (Acquired Immune Deficiency Syndrome) diagnosis is given to an HIV-positive person who has a CD4 count of less than 200/mm 3 (or under 14%) or a history of an "AIDS-defining illness." The HIV disease data presented in this report combines all AIDS cases reported and all HIV cases reported by name since April 17, For comparison purposes and to more fully understand the HIV epidemic, Appendix I breaks down HIV disease by HIV (non- AIDS) and AIDS diagnoses, by year reported and diagnosed. 3 Centers for Disease Control and Prevention, Diagnoses of HIV infection and AIDS in the United States and Dependent Areas,

7 EXECUTIVE SUMMARY Since reporting began (1981 for AIDS cases and 2006 for HIV cases), Orange County has reported 10,846 HIV Disease cases to the Centers for Disease Control and Prevention (CDC) as of December 31, Of these, 7,747 have been diagnosed with AIDS and 4,255 have died. Orange County cases represented 5% of California AIDS cases and 7% of California HIV cases. Orange County ranks fifth highest among California s 58 counties in number of AIDS cases reported and fourth highest in the number of HIV cases reported. Chapter 1: HIV Disease in Orange County Of the 10,846 HIV Disease cases reported by Orange County between 1981 and 2010, a total of 6,591 (60.8%) were living as of December 31, This translates to a rate of persons living with HIV Disease (PLWHD) per 100,000 Orange County population. In 2010, there were 261 HIV Disease (185 HIV (non-aids) and 76 AIDS) cases 1 diagnosed in Orange County residents, for a rate of 8.2 cases per 100,000 Orange County population. This number is preliminary, as cases diagnosed in 2010 will continue to be reported in 2011 and beyond. By gender: o 5,742 PLWHD are male (87.1%), 815 female (12.4%), and 34 (0.5%) are transgender male to female. o Of cases diagnosed in 2010, 239 (91.6%) were male, 20 (7.7%) female, and fewer than five were transgender male to female. By race/ethnicity: o 3,302 PLWHD are White (50.1%), 2,630 are Hispanic (39.9%), 346 are Black (5.2%), and 280 (4.2%) are Asian/Pacific Islander (API). o In 2010, 125 (47.9%) of cases diagnosed were Hispanic, 94 (36.0%) were White, 29 (11.1%) were API, and 13 (5.0%) were Black. By age: o The majority of PLWHD is currently age 40 years and over (4,762 or 72.3%) and is overrepresented in comparison to Orange County s population (44.1%). Persons under the age of 20 years account for 43 (0.7%) of PLWHD, and persons age years account for 1,786 (27.1%) of PLWHD. o Of cases diagnosed in 2010, 165 (63.2%) were age years at diagnosis, 87 (33.3%) were age 40 years and over, and 9 (3.4%) were under age 20 years. By mode of transmission o The majority of PLWHD are men who have sex with men (MSM) (4,791 or 72.7%), followed by persons infected through heterosexual contact (669 or 10.2%), persons who injected drugs (IDU) (598 or 9.1%), and MSM/IDU (289 or 4.4%). o In 2010, 223 (85.4%) of cases diagnosed were MSM, followed by heterosexual contact (18 or 6.9%), and IDU and MSM/IDU equally (9 or 3.4% each). Progression to AIDS o 1,548 or 45.6% of persons diagnosed with AIDS after 1995 were concurrently diagnosed with HIV. o Persons with the highest percentage of concurrent diagnoses were: Males (1,357 or 45.9%) API (77 or 52.4%) MSM (1,090 or 46.0%) 1 By year of HIV diagnosis. There were an additional 47 AIDS cases diagnosed with AIDS during 2010 but with HIV prior to

8 o o 666 (19.6%) of persons diagnosed with AIDS after 1995 were diagnosed within one year of their HIV diagnosis. Persons with the highest percentage of transitioning to AIDS within one year of their HIV diagnosis were: Males (586 or 19.8%) API (35 or 23.8%) Persons infected through heterosexual contact (82 or 22.8%) HIV Disease Survival o 2,035 (81.7%) of persons diagnosed with AIDS between 1996 and 2005 were still alive within five years of their AIDS diagnosis. o Persons with the highest survival rates were: Females 264 (82.5%) Hispanics 929 (84.1%) Persons infected through heterosexual contact 238 (88.8%) HIV Disease Mortality o Deaths of persons diagnosed with HIV disease peaked in 1992 with 373 deaths, regardless of cause, occurring that year. o This coincides with the peak in deaths due to HIV/AIDS. In 1992 there were 301 HIV/AIDS deaths, for an age-adjusted death rate of 11.9 deaths per 100,000 Orange County population. Chapter 2: Geography of HIV Disease in Orange County The most populous cities in Orange County are Santa Ana and Anaheim, with over 300,000 residents. These cities both have the largest numbers (between 454 and 1,372) of PLWHD at time of diagnosis. By rate, Laguna Beach is the city most heavily impacted by HIV Disease in Orange County. There are 453 PLWHD in Laguna Beach, which translates to 18 PLWHD for every 1,000 residents. In comparison, there are four PLWHD for every 1,000 persons in Santa Ana and three per 1,000 in Anaheim. In 2010, there are 23.7 new diagnoses for every 100,000 persons living in Laguna Beach, followed by 18.7 per 100,000 in Santa Ana and 12.2 per 100,000 in Anaheim. By gender: o 445 (98.2%) of PLWHD in Laguna Beach are male. o 760 (83.6%) of PLWHD in Anaheim are male. o 1,135 (82.7%) of PLWHD in Santa Ana are male. By race/ethnicity: o 398 (87.9%) of PLWHD in Laguna Beach are White, 36 (7.9%) Hispanic, 11 (2.4%) Black, and 6 (1.3%) API. o 928 (67.6%) of PLWHD in Santa Ana are Hispanic, 324 (23.6%) are White, 78 (5.7%) Black, and 36 (2.6%) API. o 513 (56.4%) of PLWHD in Anaheim are Hispanic, 298 (32.8%) are White, 52 (5.7%) Black, and 40 (4.4%) API. By age: o 238 (52.5%) of PLWHD in Laguna Beach are age 50 years and over; 214 (47.2%) ages years. o 652 (71.7%) of PLWHD in Anaheim are ages years, 248 (27.3%) age 50 years and over, and 9 (1.0%) under age 20. o 936 (68.2%) of PLWHD in Santa Ana are ages 20-49, 427 (31.1%) are age 50 years and over, and 9 (0.7%) under age 20. 4

9 By mode of transmission o 412 (90.9%) of PLWHD in Laguna Beach were infected through MSM, 22 (4.9%) MSM/IDU, and 8 (1.8%) IDU or were infected through heterosexual contact. o 866 (63.1%) of PLWHD in Santa Ana were infected through MSM, 207 (15.1%) IDU, 171 (12.5%) were infected through heterosexual contact, and 70 (5.1%) MSM/IDU. o 627 (69.0%) of PLWHD in Anaheim were infected through MSM, 117 (12.9%) were infected through heterosexual contact, 91 (10.0%) IDU, and 34 (3.7%) MSM/IDU. Chapter 3: Pediatric HIV Disease in Orange County Between 1991 and 1995, there were 17 pediatric HIV Disease cases diagnosed in Orange County, the peak five-year time period since the first pediatric case was diagnosed in This number had decreased to five by Overall, 60 pediatric cases have been diagnosed. As of December 31, 2010, 42 of the 60 children diagnosed before the age of 13 were living (70.0%) By gender: o Females account for 23 (54.8%) of PLWHD who were diagnosed as a child; males 19 (45.2%). By race/ethnicity: o 24 (57.1%) of pediatric PLWHD are Hispanic, 9 (21.4%) are White, 6 (14.3%) are Black, and less than five persons are API. By age: o 12 (28.6%) of persons diagnosed as a child are currently still under the age of (40.5%) are currently age years, and 13 (30.9%) are age 20 years and over. By mode of transmission o 39 (92.9%) of perinatal PLWHD were infected perinatally. Chapter 4: HIV Counseling and Testing The Orange County Health Care Agency provides support for HIV counseling and testing services in Orange County through the provision of HIV rapid test kits funded by the California Department of Public Health, Office of AIDS. Counseling and Testing (C&T) sites receiving kits include: 17 th Street Testing and Treatment, AIDS Services Foundation (ASF), the Health Care Agency Risk Reduction, Education, and Community Health (REACH) Program, and The Center Orange County. In 2010, 9,003 persons were tested at Orange County Counseling and Testing sites. Of these, 88 (1.0%) tested positive for HIV. By gender: o 80 (1.2%) of males tested positive, while only 6 (0.3%) of females tested positive. By race/ethnicity: o 51 (1.2%) of Hispanics, 23 (0.8%) of Whites, and 8 (0.8%) of APIs tested positive. There were fewer than five positive tests among Blacks. By age: o 38 persons age years and 23 persons age years had positivity rates of 1.0%, while persons age years had a positivity rate of 1.2% (17 positive tests). 5

10 By mode of transmission: o 68 (2.7%) of persons who indicated that they were MSMs tested positive, while only 8 (0.2%) of persons with heterosexual contact tested positive. By substance use in the past two years: o 30 (1.9%) of persons who reported the use of alcohol, 9 (1.8%) of persons who used marijuana, 15 (1.3%) of persons who used amphetamines, and 5 (1.1%) of persons who used cocaine tested positive. Chapter 5: Ryan White Act and Orange County The Ryan White Act was first authorized in 1990 and is the largest piece of federal legislation that offers funding for the care and treatment of PLWHD who have no other source for care. Three main goals of the Ryan White Act are: o To lessen the burden of treatment and care in areas most affected by HIV. o To foster a coordinated approach to core treatment and support of HIV services. o To build a community-based, strategic response to HIV from local organizations and advocates, as well as local public entities. There are three Eligible Metropolitan Areas (EMAs) and six Transitional Grant Areas (TGAs) in California. o An EMA is an area that has reported at least 2,000 AIDS cases in the most recent five years and has a population of at least 50,000 persons. o A TGA is an area that has 1,000 to 1,999 new AIDS cases in the most recent five years and has a population of at least 50,000 persons. Orange County is a TGA. Los Angeles, San Francisco, and San Diego (EMAs) have 40,669, 17,325, and 11,636 PLWHD, respectively. Orange County ranks third among the TGAs, with 6,591 PLWHD. Other TGAs include: o Inland Empire (8,399 PLWHD) o Oakland (7,105 PLWHD) o Sacramento (3,397 PLWHD) o Santa Clara (3,068 PLWHD) o Santa Rosa (1,252 PLWHD) 6

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12 CHAPTER 1: HIV DISEASE IN ORANGE COUNTY Overall HIV Disease Case Reporting: Since reporting began (1981 for AIDS cases and 2006 for HIV cases), Orange County has reported 10,846 HIV disease cases to the Centers for Disease Control and Prevention (CDC) as of December 31, Of these, 7,747 have been diagnosed with AIDS and 4,255 have died. The overall case rate of HIV disease in Orange County is 8.2 per 100,000 residents. Orange County cases represented 5% of California AIDS cases and 7% of California HIV cases. Orange County ranks fifth highest among California s 58 counties in number of AIDS cases reported and fourth highest in the number of HIV cases reported. Summary of HIV and AIDS Prevalence and Incidence: The following section provides an overview of: HIV Incidence: Individuals with a current diagnosis of HIV (non-aids) who resided in Orange County at time of diagnosis. This does not include persons now diagnosed with AIDS. AIDS Incidence: Individuals with a current diagnosis of AIDS and resided in Orange County at time of diagnosis. Figure 1.1 (below) shows the number of PLWHD as of December 31 of each year between 2001 and As of December 31, 2010, there were an estimated 6,591 persons living with HIV disease (PLWHD) in the county. Of these: 3,716 were diagnosed with AIDS 2,875 were diagnosed with HIV (non-aids) 4,228 4,497 4,757 5,038 5,294 5,539 5,843 6,119 6,365 6,591 1:1

13 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Figure 1.2 (below) shows the number of HIV (non-aids) and AIDS cases reported in Orange County by year of diagnosis. In 2010, there were 308 persons newly diagnosed with HIV (non-aids) or AIDS. Of these: 123 were diagnosed with AIDS 185 were diagnosed with HIV (non-aids) Figure 1.2. Number of HIV (non-aids) and AIDS Cases by Year of Diagnosis, Number HIV (non-aids) AIDS Overall HIV Disease Prevalence and Incidence: In an effort to better track the progression of the HIV/AIDS epidemic and conform to new guidelines presented by the CDC, the remainder of this report will focus on HIV disease. The term HIV disease is used to describe the entire HIV spectrum, from initial HIV infection to advanced HIV disease (also known as AIDS). Acquired immune deficiency syndrome (AIDS) first became reportable in 1981; an AIDS diagnosis is given to an HIVpositive person who has a CD4 count of less than 200/mm 3 (or under 14%) or a history of an "AIDS-defining illness." HIV infection, by name, without an AIDS diagnosis, first became reportable in California in The HIV disease data presented in this report combines all AIDS cases reported and all HIV cases reported by name since April 17, Figure 1.3 (next page) shows the number of HIV disease cases diagnosed by the earliest reported HIV diagnosis year 1 and the number of persons living with HIV disease (PLWHD) each year. 2 Table 1.1 at the end of this chapter corresponds to Figure 1.3 shown below. As shown: Trends in Incidence: The number of new cases peaked in the late 1980s and are currently approximately 325 to 375 cases each year. With 261 new cases diagnosed in 2010, the incidence rate of HIV disease in 2010 was 8.2 per 100,000 population. However, as 2010 diagnosed cases are considered provisional due to normal reporting delays, throughout this document, incidence for the past two years ( ) are used when looking at disease trends in Orange County. Trends in Prevalence: The number of PLWHD has increased by about four to five percent each year. In 1995, highly active antiretroviral therapy (HAART) was introduced. Since then, the number of PLWHD increased 115% from 3,060 persons to 6,591, while the number of new cases decreased by about 33%. 1 HIV disease cases by year are by the year of their HIV diagnosis, regardless of what year their AIDS diagnosis was for cases diagnosed with AIDS. 2 The earliest diagnosis year shown is typically the year the person was diagnosed with HIV; in cases where the HIV date is missing or the HIV test was performed sometime after the AIDS diagnosis, the year of AIDS diagnosis is shown. 1:2

14 HIV Disease Surveillance Statistics, * * * *Fewer than five cases/plwhd diagnosed cases are considered provisional due to reporting delays. HIV Disease by Gender Persons diagnosed with HIV disease may self-report their gender in four different categories: (1) male; (2) female; (3) transgender male to female; or (4) transgender female to male. Due to the small number of transgender PLWHD, unless indicated, 3 transgender HIV disease cases are not included in the male or female category of figures in this section. Tables 1.2a-1.4 at the end of this chapter correspond to figures in this section. P revalence by Gender: Of the 6,591 PLWHD diagnosed in Orange County as of December 31, 2010, 5,742 male, 815 female, and 34 were transgender male to female. Figure 1.4 (right) shows the number of PLWHD as of December 31, 2010 compared to Orange County s 2010 population by gender. There were 5,742 male PLWHD and 815 female PLWHD. As shown: Males accounted for 87.1% of PLWHD compared to 49.6% of the population. Females are under-represented with 12.4% of PLWHD and 50.4% of the population. Transgender male to female 4 information is available for PLWHD. However, Orange County population for transgender persons is not available. Percent 100% 80% 60% 40% 20% Figure 1.4. PLWHD by Gender and 2010 Population, Orange County 0% 87.1% 49.6% 12.4% 50.4% 0.5% Ma le Female Tra nsgender (M-F) Gender PLWHD 2010 Population 3 Information is only shown where there are five or more cases in each subgroup. 4 As of December 31, 2010, there have been no reported HIV disease cases among transgender female to male in Orange County. 1:3

15 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Rate per 100,000 population Figure 1.5. Rate per 100,000 Population of PLWHD by Gender and Race/Ethnicity, Orange County ,061.8 Male Fe male White Black Hispanic API Total Race/Ethnicity Figure 1.5 (left) shows the number of PLWHD cases per 100,000 Orange County residents by gender and self-reported race/ethnicity 5. As shown: Black males and females have the highest rate of HIV disease. The black male rate is nearly three times that of all males. The black female rate is nine times that of all females. White males have the next highest rate at per 100,000. Hispanic females have the second highest rate amongst females at 65.7 per 100,000. APIs have lowest rate among males and females. Figure 1.6 (right) shows the number of PLWHD cases per 100,000 Orange County residents by gender and current age. As shown: Among males and females, the highest rate of HIV disease is among persons age years for both genders. There is a higher rate of PLWHD in the and age groups compared to total PLWHD in each gender, regardless of current age. Rate per 100,000 population 1, Figure 1.6. Rate per 100,000 Population of PLWHD by Gender and Current Age, Orange County Total Male * Female Figure 1.7 (below) shows the distribution of PLWHD by mode of transmission 6 among males and females. Mode of Transmission among Males: The vast majority (83.0%) of males living with HIV disease reported being exposed through men who have sex with men (MSM), followed by injection drug use (IDU), men who have sex with men who use injection drugs (MSM/IDU), and heterosexual contact. Mode of Transmission among Females: The majority (68.3%) of females living with HIV disease reported being exposed through heterosexual contact, followed by IDU (23.2%). Females were also more likely to be reported as having been exposed through other or unknown means, which includes blood transfusions. Figure 1.7: Percent of PLWHD by Gender and Mode of Transmission, Orange County Males (N=5,742) Females (N=815) Heterosexual 68.3% MSM 83.0% IDU 7.1% MSM/IDU 4.9% Heterosexual 2.0% IDU 23.2% Other/ Unknown 3.0% Other/ Unknown 8.5% 5 See the HIV disease by Race/Ethnicity section on page 1:6 for description on race/ethnicity reporting. 6 See the HIV disease by Mode of Transmission section on page 1:12 for description of mode of transmission reporting. 1:4

16 HIV Disease Surveillance Statistics, 2010 Incidence by Gender: Figure 1.8 (below) displays the rate of HIV disease cases per 100,000 population by gender diagnosed each year between 1984 (the first year a female was diagnosed) and As shown, case rates of HIV disease among males have been much higher than among females. The highest rate of HIV disease diagnosis occurred in 1988 for both males (59.7 per 100,000) and females (5.7 per 100,000) and have since declined. In 2010, there were 239 new cases of HIV disease diagnosed among males and 20 new cases among females. Rate per 100,000 population Figure 1.8. Rate per 100,000 Population of HIV Disease Cases by Year of Diagnosis and Gender, Orange County, '84 '85 '86 '8 7 '88 '89 '90 '91 '9 2 '9 3 '94 '95 '96 '97 '9 8 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Male Female Figure 1.8 begins in 1984, the first year a female was diagnosed with HIV disease. Rates for 2010 are provisional due to reporting delays. Transgender cases are excluded from Figure 1.8 because they have fewer than five cases diagnosed in any given year. Mortality by Gender: Figure 1.9 (below) shows the death rate (due to any cause) per 100,000 population by gender per year in persons reported with HIV disease between 1987 (the first year with a female death) and Table 1.4 at the end of this chapter shows the number of deaths in each year for each gender. Since the beginning of the epidemic in 1980, 3,914 males and 338 females diagnosed with HIV disease have died. Death Rates among Males: The highest death rate among males was in 1992, with 28.0 deaths per 100,000 males in Orange County. Since the introduction of Highly Active Antiretroviral Therapy (HAART) in 1995, the death rate of PLWHD has decreased significantly. Death Rates among Females: The highest death rate among females was in 1994, with 2.0 deaths per 100,000 females in Orange County. Rate per 100,000 population Figure 1.9. Death Rate per 100,000 Population Among Persons Diagnosed with HIV Disease by Year of Death and Gender, Orange County, '8 7 '88 '89 '90 '91 '92 '93 '94 '95 '9 6 '97 '98 '99 '0 0 '01 '02 '03 '04 '05 '06 '07 '08 '09 '1 0 Male Female * Figure 1.9 begins in 1987 because there were fewer than five female deaths in each year between 1981 and *Fewer than five deaths Transgender cases are excluded from Figure 1.7 because they have fewer than five deaths in any given year. Deaths in 2010 are provisional due to reporting delays. 1:5

17 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency HIV Disease by Race/Ethnicity: This section describes trends in HIV disease by race/ethnicity. HIV reporting complies with guidelines provided by the Federal Office of Management and Budget. 7 Persons diagnosed with HIV or AIDS are asked to report their race and ethnicity. To determine ethnicity, persons are asked whether they identify as Hispanic. Individuals are then asked to choose one or more of the following race categories: (1) American Indian or Alaskan Native (AI/AN); (2) Asian; (3) Black or African-American; (4) Native Hawaiian or Other Pacific Islander (NHOPI); and (5) White. For the purposes of this report, persons who indicate that they are Hispanic are shown as Hispanic regardless of race chosen. The remaining racial categories capture the race of persons who indicate that they are not Hispanic. Individuals who are Black or African-American are referred to as Black throughout this report. Due to the small numbers of NHOPIs, this category has been combined with Asians and both groups are included in the Asian/Pacific Islander (API) category. Due to their small numbers, individuals identifying as AI/AN are included in the Other/Unknown category along with non-hispanic individuals who identified with more than one racial category. Tables 1.2a, 1.2b, 1.5, 1.6, and 1.7 at the end of this chapter correspond to Figures 1.10 to 1.14 in this section. Prevalence by Race/Ethnicity: Of the 6,591 PLWHD in the county as of December 31, 2010, 3,302 were White, 346 were Black, 2,630 were Hispanic, and 280 were API. The remaining 33 were either American Indian/Alaskan Native (AIAN), more than one race, or were of unknown race. Figure 1.10 (below) compares PLWHD by race/ethnicity to the 2010 Orange County population. As shown: Whites are over-represented with 50.1% PLWHD versus comprising 44.0% of the population. Blacks are over-represented with 5.2% PLWHD versus comprising 1.4% of the population. Hispanics are over-represented with 39.9%, PLWHD versus comprising 35.9% of the population. APIs are under-represented at 4.2% PLWHD as compared to their representation in the population (16.4%). 100% 80% Figure PLWHD by Race/Ethnicity and 2010 Population, Orange County PLWHD 2010 Population Percent 60% 40% 50.1% 44.0% 39.9% 35.9% 20% 0% 16.4% 5.2% 1.4% 4.2% 0.5% 2.3% White Black Hispanic API Other/Unk Race/Ethnicity 7 Office of Management and Budget, Washington, D.C. Provisional Guidance on the Implementation on the 1997 Standards for Federal Data on Race and Ethnicity, December 15, :6

18 HIV Disease Surveillance Statistics, 2010 Figure 1.11 (below) shows the rate of PLWHD per 100,000 Orange County residents by race/ethnicity and current age. As shown: Blacks in all age groups have the highest rate of PLWHD. Hispanics have the second highest rate per 100,000 population in all age groups of PLWHD. Whites, Hispanics, and APIs have higher rates of PLWHD in the age groups years, years, and years than persons of all ages. For Blacks, their rates are higher in the years and years categories. Rate per 100,000 population 2,000 1,500 1, Figure Rate per 100,000 Population of PLWHD by Race/Ethnicity and Current Age, Orange County Total White Black * , , Hispanic API * *Fewer than five cases See Figure 1.5 on page 1:3 for case rates of PLWHD by race/ethnicity and gender. Figure 1.12 (next page) shows the distribution of PLWHD by mode of transmission 8 among each race/ethnicity. Mode of Transmission among Whites: A large majority (77.4%) of Whites reported being exposed through MSM followed by IDU, heterosexual contact, and MSM/IDU. Mode of Transmission among Blacks: Black PLWHD are the only racial/ethnic group that did not have a single exposure category reported as the major mode of transmission. Almost half (45.7%) of Black PLWHD reported being exposed through MSM. Compared to other groups, a larger proportion of Black PLWHD reported heterosexual contact (24.6%) and IDU (19.7%) as their mode of transmission. Mode of Transmission among Hispanics: 69.1% of Hispanic PLWHD reported being exposed through MSM, followed by heterosexual contact (13.3%), IDU (9.6%), and MSM/IDU (3.1%). Mode of Transmission among APIs: A large majority (71.7%) of API PLWHD reported being exposed through MSM, followed by heterosexual contact (13.1%). Compared to other racial/ethnic groups, a large proportion (8.4%) of API reported other/unknown as their mode of transmission. 8 See the HIV disease by Mode of Transmission section on page 1:12 for description of mode of transmission reporting. 1:7

19 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Figure Percent of PLWHD by Race/Ethnicity and Mode of Transmission, Orange County MSM 77.4% Whites (N=3,302) IDU 8.7% MSM/IDU 5.3% Heterosexual 6.0% MSM 45.7% Blacks (N=346) IDU 19.7% MSM/IDU 3.2% Hispanics (N=2,630) IDU 9.6% Other/ Unknown 2.6% MSM/IDU 3.1% Other/ Unknown 6.9% APIs (N=280) Heterosexual 24.6% IDU 3.6% MSM/IDU 3.2% MSM 69.1% Heterosexual 13.3% Heterosexual 13.1% MSM 71.7% Other/ Unknown 4.9% Other/ Unknown 8.4% Incidence by Race/Ethnicity: Of the 590 new HIV disease cases diagnosed in Orange County , 239 were White, 33 were Black, 269 Hispanic, and 48 were API. Figure 1.13 (next page) shows the number of newly diagnosed HIV disease cases per 100,000 Orange County population by race/ethnicity and year of diagnosis. Due to the low number of cases diagnosed in most race/ethnicities between 1980 and 1984, this figure begins in Case rates peaked in 1988 for Whites, 1989 for Hispanics, and 1991 for Blacks, and have since continued to decline. In 2010, Blacks had the highest case rate (29.0), followed by Hispanics (10.8), Whites (6.6), and APIs (5.5). Since the beginning of the epidemic in Orange County, Blacks have been the most highly impacted by HIV disease with case rates ranging from 76.5 per 100,000 in 1991 to 24.1 per 100,000 in In 1992, Hispanics became the racial/ethnic group with the second highest case rate and have remained so since. Prior to 1992, Whites had the second highest HIV disease case rates in the county. Case rates among APIs have been the lowest among all racial/ethnic groups and have remained relatively constant since the beginning of the epidemic. 9 Due to the small number of Black cases diagnosed each year, case rates in this community can appear to shift significantly from year to year. 1:8

20 HIV Disease Surveillance Statistics, 2010 Rate per 100,000 population *Fewer than five cases Rates for 2010 are provisional due to reporting delays. Mortality by Race/Ethnicity: Figure Rate per 100,000 Population of HIV Disease Cases by Year of Diagnosis and Race/Ethnicity, Orange County, '85 '8 6 '87 '8 8 '89 '90 '91 '92 '93 '94 '95 '96 '9 7 '98 '9 9 '00 '01 '02 '03 '04 '05 '06 '07 '0 8 '09 '1 0 White Black Hispanic API 3.3 * Figure 1.14 (below) shows the death rate (due to any cause) per 100,000 population by race/ethnicity for each year in persons reported with HIV disease. Since the beginning of the epidemic, 3,029 Whites, 209 Blacks, 930 Hispanics, and 72 API diagnosed with HIV disease have died. Table 1.7 at the end of this chapter shows the number of deaths in each year for each race/ethnicity. Death rates among all racial/ethnic groups shown have declined since their peak in the early 1990s. Black PLWHD have consistently had the highest death rates among all race/ethnicities in Orange County. 8 Prior to 1995, Whites had the second highest death among all race/ethnicities. Since 1996 death rates among White and Hispanics began to look increasingly similar. The number of API deaths is not displayed due to the low number of deaths (fewer than five) in most years. The cumulative number of API deaths reported was 72, which represented 20% of the 352 APIs diagnosed and reported with HIV disease during the same time period. Rate per 100,000 population Figure Death Rate per 100,000 Population Among Persons Diagnosed with HIV Disease by Year of Death and Race/Ethnicity, Orange County, '87 '88 '89 '90 '91 '9 2 '93 '94 '95 '96 '97 '98 '99 '0 0 '0 1 '02 '03 '04 '05 '06 '07 '08 '0 9 '1 0 White Black * * 11.2 * Hispanic *Fewer than five deaths Figure 1.14 begins in 1987 because there were fewer than five deaths in Blacks and Hispanics between 1981 and Deaths in 2010 are provisional due to reporting delays. 1:9

21 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency HIV Disease by Age: This section describes trends in HIV disease by age groups. When describing individuals currently living with HIV disease (prevalence), the current age of the individual is used. When describing trends in the number of new cases (incidence), the age of diagnosis is used. Age groups for which there are fewer than five cases in each subgroup are not shown. Tables 1.2a, 1.2b, 1.8, 1.9, and 1.10 at the end of this chapter correspond to Figures 1.15 to 1.18 in this section. See Chapter 3 for a more detailed description of pediatric HIV/AIDS (HIV disease among children under age 13 at time of diagnosis) in Orange County. Prevalence by Current Age: Of the 6,591 PLWHD in the county as of December 31, 2010, 12 were under 12 years of age, 31 were between ages 13-19, 500 were between ages 20-29, 1,286 were between ages 20-29, 2,464 were between ages 40-49, 1,688 were between ages 50-59, and 610 were age 60 or over. Figure 1.15 (below) compares the current age of PLWHD to the 2010 Orange County population. As shown, the vast majority (82.5%) of PLWHD are between the ages of 30 and 59 compared to Orange County s population (42.2%). 100% 80% Figure PLWHD by Current Age and 2010 Population, Orange County PLWHD 2010 Population Percent 60% 40% 20% 0% 37.4% 25.6% 17.7% 19.5% 15.3% 16.0% 10.1% 14.0% 14.1% 12.8% 9.3% 0.2 % 7.6% 0.5% 0-12 years years years years years years 60+ years Age See Figure 1.6 on page 1:3 to see the rate per 100,000 of PLWHD by gender and current age. See Figure 1.11 on page 1:6 to see the rate per 100,000 of PLWHD by race/ethnicity and current age. Figure 1.16 (next page) shows the distribution of PLWHD by mode of transmission 10 for five different age groups (by current age). Those currently under the age of 13 are discussed in Chapter 3. Mode of Transmission among year-olds: 41.9% of persons currently age have MSM as a mode of transmission, while 54.8% have a pediatric mode of transmission. Mode of Transmission among year-olds: The vast majority (78.5%) of year-old PLWHD reported being exposed through MSM, followed by heterosexual contact (8.8%). This is the age group with the highest proportion of PLWHD who reported exposure through MSM and the lowest proportion of PLWHD who reported being exposed through IDU. Mode of Transmission among year-olds: The majority (72.0%) of PLWHD ages reported being exposed through MSM, followed by heterosexual contact (13.3%). This age group had the largest percentage of individuals who reported heterosexual contact as a mode of transmission and the lowest percentage who reported other/unknown as a mode of transmission. 10 See the HIV disease by Mode of Transmission section on page 1:12 for description of mode of transmission reporting. 1:10

22 HIV Disease Surveillance Statistics, 2010 Mode of Transmission among year-olds: For persons currently ages of 40-49, 72.6% reported being exposed through MSM, followed by heterosexual contact (10.3%), and IDU (9.1%). Mode of Transmission among year-olds: Though the largest proportion of year-old PLWHD reported being exposed through MSM, this was the smallest percentage of all age groups to report MSM as a mode of transmission. This age group also had the highest proportion who reported IDU as a mode of transmission (14.5%) compared to all other age groups. Mode of Transmission among Individuals Over 60 Years: For PLWHD currently ages 60 or older, 74.4% reported being exposed through MSM, followed by heterosexual contact (10.7%), and IDU (6.6%). This age group had the largest percentage of individuals who reported other/unknown as a mode of transmission and the lowest percentage who reported MSM/IDU as a mode of transmission. MSM/IDU 0.0% IDU 0.0% Figure Percent of PLWHD by Current Age and Mode of Transmission, Orange County Age (N=31) Pedia tric 54.8% MSM 78.6% Age (N=500) IDU 2.8% MSM/IDU 4.6 % Heterosexual 8.8% MSM 41.9% Age (N=1,286) Other/ Unknown * Age (N=2,464) Other/ Unknow n 5.2% MSM 72.0% IDU 5.8% MSM/IDU 4.6% MSM 72.6% IDU 9.1 % MS M/IDU 5.0% Heterosexual 13.3% Heterosexual 10.3% Age (N=1,688) Other/ Unknow n 2.3% Age 60+ (N=610) Other/ Unknow n 3.0% IDU 14.5% IDU 6.6% MSM/IDU 2.6% MSM 70.6% MSM/IDU 4.0 % Heterosexual 8.1% MSM 74.4% Other/ Unknow n 2.8% Those who are currently 0-12 years have a pediatric mode of transmission discussed in Chapter 3. Heterosexual 10.7% Other/ Unknown 5.7% 1:11

23 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Incidence by Age at Diagnosis: Of the 590 new cases of HIV disease diagnosed in , 194 were between ages 20-29, 157 were between ages 30-39, 142 were between ages 40-49, and 79 were age 50 or over at time of diagnosis. Figure 1.17 (below) shows the rate per 100,000 population by age at diagnosis of cases diagnosed each year within each age group. In general, case rates have declined since their peak in 1988 for all age groups. Until 2006, persons aged consistently had the highest case rates. Until 1998, persons aged had the second highest case rates. Persons 50 years or older have consistently had the lowest case rates among age groups shown. Rate per 100,000 population Figure Rate per 100,000 Population of HIV Disease Cases by Year of Diagnosed and Age at Diagnosis, Orange County, '83 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '0 4 '05 '06 '07 '08 '09 ' years years years years Figure 1.15 begins in 1983, due to the low number of cases diagnosed in most age groups in Rates for 2010 are provisional due to reporting delays. Mortality by Age at Diagnosis: Figure 1.18 (below) shows the death rate (due to any cause) per 100,000 population by age groups (by age at diagnosis) per year in persons reported with HIV disease. Since the beginning of the epidemic, 784 of those diagnosed between the ages of 20-29, 1,799 of those diagnosed between the ages of 30-39, 1,013 of those diagnosed between the ages of 40-49, and 630 of those diagnosed between at age 50 or over have died. Table 1.10 at the end of this chapter shows the number of deaths in each year for each age group. Death rates among all age groups were highest in the early 1990s and have since continued to decline. In general, death rates have been highest among year-olds, followed by year-olds, yearolds, and lowest among those over 50 years of age. Around 1998, death rates among all age groups have become increasingly similar. Rate per 100,000 population Figure Death Rates Among Persons Diagnosed with HIV Disease by Year of Death and Age at HIV Diagnosis, Orange County, '8 4 '85 '86 '8 7' '88 '89 '90 '91 '9 2 '93 '94 '95 '96 '97 '98 '99 '0 0 '01 '02 '03 '04 '05 '06 '07 '08 '09 ' * *Fewer than five deaths Deaths in 2010 are provisional due to reporting delays. Figure 1.18 begins in 1984 because there were fewer than five deaths in most age groups between 1981 and :12

24 HIV Disease Surveillance Statistics, 2010 HIV Disease by Mode of Transmission: This section describes trends in HIV disease by mode of transmission. The term mode of transmission is used to summarize a person s possible HIV risk factors. Individuals diagnosed with HIV or AIDS are asked to report potential modes of transmission. The Orange County HIV/AIDS reporting system uses a hierarchy established by the Centers for Disease Control and Prevention (CDC), in determining the primary mode of transmission for each HIV disease case. Persons with more than one reported risk factor for HIV infection are classified in the transmission category listed first in the hierarchy. The following are modes of transmission listed in hierarchical order for adults: (1) men who have sex with men (MSM); (2) injection drug use (IDU); (3) men who have sex with men who use injection drugs (MSM/IDU) (4) treatment for hemophilia (5) heterosexual contact (with person known to have or at high-risk for HIV); (6) received transfusion of blood or blood components/transplant; (8) adult, confirmed other risk; (9) cannot be classified in above categories. Modes of transmission for pediatric cases (children under age 13 at time of diagnosis), listed in hierarchical order, include: (1) treatment for hemophilia; (2) mother has HIV/AIDS or has had sex with someone with or at-risk for HIV; (3) received transfusion of blood or blood components/transplant; (4) pediatric other risk; (5) pediatric, confirmed other risk; and (6) cannot be classified in above categories. For the purposes of this report, persons whose mode of transmission could not be classified in any of the transmission categories will be shown as Unknown. Due to their small numbers (fewer than five cases), many of the mode of transmission categories are not shown in this report or are shown as Other. See Chapter 3 for more detailed description of pediatric HIV/AIDS in Orange County. Tables 1.2a, 1.2b, 1.11, and 1.12 at the end of this chapter correspond to Figures 1.19 to 1.21 in this section. Prevalence by Mode of Transmission: Of the 6,591 PLWHD in the county as of December 31, 2010, 4,791 were MSM, 669 were reported to be infected through heterosexual contact, 598 were IDU, 289 were MSM/IDU, and 244 were infected through other or unknown means. Figure 1.19 (below) displays the proportion of PLWHD by reported mode of transmission. As shown, MSM accounted for the largest proportion of prevalent cases (72.7%), followed by persons infected through heterosexual contact (10.1%) and IDU (9.1%). MSM/IDU accounted for 4.4% of prevalent cases, and the remaining 0.8% of cases were attributed to transfusion or hemophiliac (T/H), unknown adult risk category, and pediatric cases. Figure PLWHD by Reported Mode of Transmission, Orange County T/H, 0.8% Heterosexual, 10.2% Unknown, 2.2% Pediatric, 0.7% MSM/IDU, 4.4% IDU, 9.1% MSM, 72.7% See Figure 1.7 on page 1:4 to see PLWHD by gender and mode of transmission. See Figure 1.12 on page 1:7 to see PLWHD by race/ethnicity and mode of transmission. See Figure 1.16 on page 1:10 to see PLWHD by current age and mode of transmission. 1:13

25 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Incidence by Mode of Transmission: Figure 1.20 (below) presents cases diagnosed by mode of transmission by year of diagnosis. 11 Exposure through MSM has consistently been reported as the highest mode of transmission. Since 1996, the second highest reported mode of transmission has been heterosexual contact; prior to that, IDU was the second highest mode of transmission in Orange County. Cases reported as acquired through a transfusion, transplant, or by a hemophiliac have declined since the beginning of the epidemic, as have cases in pediatric cases (persons infected under the age of 13) Figure Number of HIV Disease Cases by Year of Diagnosis and Mode of Transmission, Orange County, Number '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '9 6 '97 '98 '99 '00 '0 1 '02 '03' '0 4 '05 '06 '07 '08 '0 9 '10 MSM IDU MSM/IDU Heterosexual Figure 1.20 begins in 1986, due to the low number of cases diagnosed in most modes of transmission in Rates for 2010 are provisional due to reporting delays. Mortality by Mode of Transmission: Figure 1.21 (below) shows the number of deaths per year in persons reported with HIV disease between 1987 and 2010 by age at diagnosis. 10 Those reported as exposed through MSM have consistently had the highest number of deaths among individuals diagnosed with HIV disease; the number of deaths peaked in 1992 for this group. IDU has generally been the exposure group with the second highest number of deaths. Deaths among those exposed through MSM/IDU had been the mode of transmission group with the third highest number of deaths until 1997 when the number of deaths became increasingly similar to those found among those reported to be exposed through heterosexual contact. 300 Figure Deaths Among Persons Diagnosed with HIV Disease by Year of Death and Mode of Transmission, Orange County, Number '87 '88 '89 '90 '91 '92 '9 3 '94 '9 5 '9 6 '9 7 '9 8 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 MSM IDU * 5 MSM/IDU * * * * * Heterosexual * * * 12 * * *Fewer than five deaths Figure 1.21 begins in 1987 because there were fewer than five deaths in most modes of transmission between 1981 and Deaths in 2010 are provisional due to reporting delays. 11 Rates for transmission categories are not provided because of the absence of denominator data (i.e., the denominator data used in this report come from the U.S. Census Bureau, but the U.S. Census Bureau does not collect data on transmission categories). 1:14

26 HIV Disease Surveillance Statistics, 2010 Progression from HIV to AIDS The introduction of HAART in 1996 has substantially prolonged the interval between the diagnosis of HIV infection and the development of AIDS. 12 Since 1996, Orange County has reported 3,405 AIDS cases. HIV infection, by name, without an AIDS diagnosis, first became reportable in California in Due to the relative newness of HIV (non-aids) reporting compared to AIDS reporting, the dates of HIV (non-aids) diagnosis are sometimes unknown or incomplete, especially for individuals diagnosed well before There are 10 individuals diagnosed with AIDS after 1995 for which an HIV diagnosis date is unknown. This section describes the time between diagnosis of HIV infection and AIDS diagnosis for these 3,395 persons for which an HIV and AIDS diagnosis date is known. Transgender male to female are included in the female percentage in Figures 1.22 through 1.24 due to the small number of cases. Table 1.13a at the end of this chapter correspond to Figures 1.22 and 1.23 in this section. Figure 1.22 (below) shows the proportion of individuals who were diagnosed with HIV at the same time (concurrently) as AIDS for persons who received their diagnoses after 1995 (since the introduction of HAART). The proportion of all individuals who were concurrently diagnosed with HIV and AIDS 45.6%. The proportion of males, Hispanics, API, and those who reported transmission through heterosexual contact received concurrent HIV and AIDS diagnoses compared to the overall proportion. 100% Figure Proportion of Individuals Progressing to AIDS Concurrently of HIV Diagnosis by Gender, Race/Ethnicity, and Mode of Transmission, Persons Diagnosed after 1995, Orange County 80% Percent 60% 40% 45.9% 43.5% 40.7% 43.7% 50.0% 52.4% 46.0% 39.1% 43.2% 37.8% 45.6% 20% 0% Male Female W hite Black Hispanic API MSM IDU MSM/IDU Heterose xual Gender Race/Ethnicity Mode of Transmission Overall Figure 1.23 (below) shows the proportion of individuals progressing to AIDS within one year (not concurrently) of HIV diagnosis for persons diagnosed with AIDS after The proportion of all individuals who progressed to AIDS within one year of their HIV diagnosis was 19.6%. The proportion of males, Blacks, Hispanics, API, and those who reported transmission through heterosexual contact progressed to AIDS within one year of HIV diagnosis compared to the overall proportion. 19.6% Gender Race/Ethnicity Mode of Transmission Overall 12 Karon JM, Fleming PL, Steketee RW, De Cock KM. HIV in the United States at the turn of the century: an epidemic in transition. Am J Public Health 2001;91: :15

27 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency HIV Disease Survival The widespread use of HAART beginning in 1996 in the United States has resulted in a large reduction in mortality rates among HIV infected persons. HIV/AIDS is now conceptualized as a chronic illness, to be managed in similar ways to diseases like diabetes, where a major goal of therapy is to prevent later complications and ensure quality of life. This section describes the characteristics of the 2,492 individuals who were diagnosed with AIDS between 1996 and Table 1.13b at the end of this chapter correspond to Figure 1.24 in this section. Figure 1.24 (below) shows the proportion of individuals surviving five or more years after receiving an AIDS diagnosis for persons diagnosed with AIDS between 1996 (since the introduction of HAART) and The overall five-year survival after AIDS for persons diagnosed with AIDS between 1996 and 2005 is 81.7%. Differences in survival occurred across gender, race/ethnicity, and mode of transmission categories. By Gender: The proportion of males surviving five or more years after an AIDS diagnosis is almost the same as the overall proportion, while the proportion of females and transgender male to female with fiveyear survival exceeded the overall proportion. By Race/Ethnicity: The proportion of Whites, Blacks, and API who have survived five or more years since receiving their AIDS diagnosis is lower than the overall proportion. By Mode of Transmission: The proportion of IDU who have survived five or more years since receiving their AIDS diagnosis is lower than the overall proportion. Figure Proportion Surviving Five Years After AIDS Diagnosis by Gender, Race/Ethnicity, and Mode of Transmission, Persons Diagnosed with AIDS , Orange County 100% 80% 81.5% 82.5% 80.0% 77.0% 84.1% 80.7% 82.9% 71.4 % 83.5% 88.8% 81.7% Percent 60% 40% 20% 0% Male Female White Black Hispanic API MS M IDU MSM/IDU Heterosexual Gender Race/Ethnicity Mode of Transmission Overall HIV Disease Mortality Individuals reported with HIV disease are presumed living until a death report is received. A date of death may be reported through the following sources: (1) a death notice from an Orange County HIV service provider; (2) a death certificate provided by County of Orange Vital Records; (3) an update from the State Office of AIDS; or (4) through matching living cases with the annual file of death certificates certified by Orange County Vital Records. Persons diagnosed with HIV disease may die of any cause, although the majority of deaths are due to HIV disease. When a death notification is received, the date of the person s death is added to the HIV Case Registry and their vital status is changed to deceased. Though these modes are meant to capture all instances in which a person may be deceased, there are instances when death notifications do not occur (e.g. if the person moves out of the country and no death records exist in the United States). Therefore, it is possible that some of the persons counted as living with HIV disease may actually be deceased. Table 1.4 at the end of this chapter corresponds to Figure 1.25 in this section. 1:16

28 HIV Disease Surveillance Statistics, 2010 Figure 1.25 (below) shows the number of deaths of persons reported with HIV disease as residents of Orange County between 1981 and 2010, regardless of cause of death. As shown, there was a dramatic decrease in deaths after the introduction of HAART in As of December 31, 2010, the cumulative number of deaths reported was 4,255, which represented 39% of the 10,846 cases reported with HIV disease during the same time period. Number Figure Deaths Among Persons Diagnosed with HIV Disease by Year of Death, Orange County, Fewer than five deaths occurred in 1981, 1982, and Deaths in 2010 are provisional due to reporting delays See Figure 1.9 on page 1:5 for death rates by gender ( ). See Figure 1.14 on page 1:8 for death rates by race/ethnicity ( ). See Figure 1.18 on page 1:11 for death rates by age at diagnosis ( ). See Figure 1.21 on page 1:13 for number of deaths by mode of transmission ( ) Death Year Deaths Due to HIV 13 : Figure 1.26 (below) shows age-adjusted rate of death 14 due to HIV disease per 100,000 Orange County population between 1987 and These HIV related deaths of Orange County residents do not include persons diagnosed with HIV disease in Orange County if they did not live in Orange County at the time of death. Death rates due to HIV disease peaked in 1992 and have since declined. Since 2001, there have been between 40 and 60 deaths each year due to HIV disease. Age adjusted rate per 100,000 population Figure Number of Deaths Due to HIV Disease and Death Rates per 100,000 Population, Orange County Residents, '87 '8 8 '89 '90 '9 1 '92 '93 '94 '95 '9 6 '97 '98 '9 9 '00 '01 '0 2 '03 '04 '05 '06 '0 7 '08 '09 Numbe r Death Rate Due to reporting delays for death statistics, data is only available through The International Classification of Diseases (ICD) is used to facilitate the collection, processing, classification, and presentation of mortality statistics. The 9 th Revision of this code (ICD-9) applied to deaths that occurred from 1979 until 1998; the 10 th Revision (ICD-10) applied to deaths since The figure includes deaths due to HIV disease in Orange County as indicated by the ICD-9 between 1987 (the first year HIV disease deaths were reported) and 1998 and deaths due to HIV disease as coded by the ICD-10 since 1999.The ICD-10 included 1.1 times as many deaths coded as due to HIV disease as ICD The age-adjusted death rate considers the number of deaths occurring in a specified age group divided by the midyear population of the age group. Age-adjusted death rates allow comparison of mortality risk among groups or over time within a particular age group. 1:17

29 CHAPTER 1 TABLES-HIV DISEASE IN ORANGE COUNTY Table 1.1 (Figure 1.3): HIV Disease Cases by Year of Diagnosis and Persons Living with HIV Disease (PLWHD), Orange County, Diagnosed PLWHD Year Rate per 100,000 Rate per 100,000 Number Number Population Population , , , , , , , , , , , , , , , , , , , , , , , , Total 10, , DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, California County Population Estimates and Components of Change, July 1, Sacramento, California. State of California, Department of Finance, Revised County Population Estimates and Components of Change by County, July 1, Sacramento, California, February State of California, Department of Finance, California County Population Estimates and Components of Change by Year, July 1, Sacramento, California, December Total rate is per 100, population. Table 1.1 begins in 1982 because that was the first year of diagnosis for which 5 or more persons were diagnosed. 1:19

30 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Table 1.2a (Figures , 1.10, 1.15, and 1.19): Persons Living with HIV Disease (PLWHD) by Gender and Race/Ethnicity, Current Age, and Mode of Transmission, Orange County Race/Ethnicity, Current Age, and Mode of Males Females Total PLWHD (Includes Transgender male to female) Transmission Number Percent Rate Number Percent Rate Number Percent Rate Race/Ethnicity White 3, % % , % Black % 1, % % Hispanic 2, % % , % API % % % 52.9 Other/Unknown % NC * * NC % NC Total 5, % % , % Current Age 0-12 * * * 9 1.1% % * * * 8 1.0% % % % % , % % , % , % % , % , % % , % % % % Total 5, % % , % Mode of Transmission MSM 4, % NC , % NC IDU % NC % NC % NC MSM/IDU % NC % NC Heterosexual % NC % NC % NC Other/Unknown % NC % NC % NC Total 5, % NC % NC 6, % NC DATA SOURCES: HIV Case Registry, data as of December 31, Other race includes American Indian/Alaskan Native and persons of more than one race. Other mode includes transfusion, hemophilia, and all Pediatric modes of transmission. Transgender persons are included in the Total column but are not shown above due to their small number. --Mode does not apply to females. NC: Rate not calculated due to lack of population estimates. Rate is per 100, population. * The number is suppressed due categories having fewer than five PLWHD. Table 1.2b (Figures 1.4, 1.10, and 1.15): Population by Gender and Race/Ethnicity and Age, Orange County, 2010 Race/Ethnicity and Age Males Females Total Race/Ethnicity White 697, ,244 1,419,887 Black 23,263 21,610 44,873 Hispanic 587, ,065 1,158,270 API 256, , ,670 Total 1,601,876 1,625,960 3,227,836 Age ,601,876 1,625,960 3,227, , , , , , , , , , , , , , , , , , ,006 Total 1,601,876 1,625,960 3,227,836 DATA SOURCES: State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, July :20

31 HIV Disease Surveillance Statistics, 2010 Table 1.3 (Figure 1.8): HIV Disease Cases by Year of Diagnosis and Gender, Orange County, Males Females Year Number Percent Rate Number Percent Rate 1980 * * * 0 0.0% * * * 0 0.0% % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % 1.2 Total 9, % , % 70.9 DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, December State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, CA, Revised May State of California, Department of Finance, E-3 Race / Ethnic Population Estimates with Age and Sex Detail, Sacramento, CA, June State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, July State of California, Department of Finance, California County Population Estimates and Components of Change by Year, July 1, Sacramento, California, December *Fewer than 5 cases. 1:21

32 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Table 1.4 (Figures 1.9 and 1.25): Deaths (regardless of cause) Among Persons Diagnosed with HIV Disease by Year of Death and Gender, Total Deaths (Includes Transgender Males Females male to female) Year Number Percent Rate Number Percent Rate Number Rate 1981 * * * * * * * * 1982 * * * * * * * * 1983 * * * * * * * * % 2.8 * * * % 4.7 * * * % 8.3 * * * % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % 2.0 * * * * 1.1 Total 3, % % , DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, December State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, CA, Revised May State of California, Department of Finance, E-3 Race / Ethnic Population Estimates with Age and Sex Detail, Sacramento, CA, June State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, July State of California, Department of Finance, California County Population Estimates and Components of Change by Year, July 1, Sacramento, California, December Transgender persons are included in the Total column but are not shown above due to their small number. Rate is per 100,000. Total rate is per 100, population. *Fewer than 5 cases. 1:22

33 HIV Disease Surveillance Statistics, 2010 Table 1.5 (Figures ): Persons Living with HIV Disease (PLWHD) by Race/Ethnicity and Current Age and Mode of Transmission, Orange County Current Age and White Black Hispanic API Mode of Transmission Number Percent Rate Number Percent Rate Number Percent Rate Number Percent Rate Current Age 0-12 * * * * * * 8 0.3% 2.8 * * * * * * * * * % 13.0 * * * % % % % % % % % , % % 1, % % , % % 1, % % % % % % 29.5 Total 3, % % , % % 52.9 Mode of Transmission MSM 2, % NC % NC 1, % NC % NC IDU % NC % NC % NC % NC MSM/IDU % NC % NC % NC 8 2.9% NC Heterosexual % NC % NC % NC % NC Other/Unknown % NC % NC % NC % NC Total 3, % NC % NC 2, % NC % NC DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, July Other includes transfusion, hemophilia, and all Pediatric modes of transmission. NC: Rate not calculated due to lack of population estimates. Rate is per 100, population. * The number is suppressed due categories having fewer than five PLWHD. 1:23

34 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Table 1.6 (Figure 1.13): HIV Disease Cases by Year of Diagnosis and Race/Ethnicity, Orange County, White Black Hispanic API Year Number Percent Rate Number Percent Rate Number Percent Rate Number Percent Rate 1980 * * * * * * * * * * * * 1981 * * * * * * * * * * * * % 0.8 * * * % 1.4 * * * % 2.7 * * * % 1.6 * * * % 6.4 * * * 9 8.0% 2.2 * * * % % % % % % % 8.3 * * * % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % 5.5 Total 6, % % 1, , % % 66.5 DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, December State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, CA, Revised May State of California, Department of Finance, E-3 Race / Ethnic Population Estimates with Age and Sex Detail, Sacramento, CA, June State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, July Rate is per 100,000. Total rate is per 100, population. AIAN are not shown due to the small number of cases diagnosed each year. *Fewer than 5 cases. 1:24

35 HIV Disease Surveillance Statistics, 2010 Table 1.7 (Figure 1.14): Deaths (regardless of cause) Among Persons Diagnosed with HIV Disease by Year of Death and Race/Ethnicity, Orange County, White Black Hispanic Year Number Percent Rate Number Percent Rate Number Percent Rate 1981 * * * * * * * * * 1982 * * * * * * * * * 1983 * * * * * * * * * % 1.8 * * * * * * % 3.2 * * * * * * % 5.1 * * * % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % 3.2 * * * % % % % % % % % % % % 2.9 * * * % % % % % 1.5 * * * % 0.8 Total 3, % % % 80.3 DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, December State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, CA, Revised May State of California, Department of Finance, E-3 Race / Ethnic Population Estimates with Age and Sex Detail, Sacramento, CA, June State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, July Rate is per 100,000. Total rate is per 100, population. *Fewer than 5 cases. Disease Control & Epidemiology Division 1:25 HIV/AIDS Surveillance & Monitoring Program

36 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Table 1.8 (Figure 1.16): Persons Living with HIV Disease (PLWHD) by Current Age and Mode of Transmission, Orange County Mode of Transmission Number Percent Number Percent Number Percent MSM % % 1, % IDU % % % MSM/IDU % % % Heterosexual % % % Other/Unknown % % % Total % 1, % 2, % Mode of Transmission Number Percent Number Percent MSM 1, % % IDU % % MSM/IDU % % Heterosexual % % Other/Unknown % % Total 1, % % Mode of Transmission Number Percent Number Percent MSM * * % Perinatal % % Other Pediatric/Unknown * * * * Total % % DATA HIV Case Registry, data as of December 31, State of California, Department of Finance, Race/Ethnic Population with SOURCES: Age and Sex Detail, Sacramento, California, July Rate is per 100,000. Other includes transfusion, hemophilia, and all Pediatric modes of transmission. Age at AIDS diagnosis is used if HIV diagnosis age is unknown. Persons age 0-12 are not shown due to the small number of cases and that all cases have a pediatric mode of transmission, the majority, 93%, are due to perinatal transmission. Disease Control & Epidemiology Division 1:26 HIV/AIDS Surveillance & Monitoring Program

37 HIV Disease Surveillance Statistics, 2010 Table 1.9 (Figure 1.17): HIV Disease Cases by Year of Diagnosis and Age at Diagnosis, Orange County, Year Number Percent Rate Number Percent Rate Number Percent Rate Number Percent Rate 1980 * * * * * * * * * * * * 1981 * * * * * * * * * * * * 1982 * * * % 3.0 * * * * * * % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % 3.2 Total 2, % , % , % , % DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, December State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, CA, Revised May State of California, Department of Finance, E-3 Race / Ethnic Population Estimates with Age and Sex Detail, Sacramento, CA, June State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, July Age at AIDS diagnosis is used if HIV diagnosis age is unknown. Rate is per 100,000. Total rate is per 100, population. *Fewer than 5 cases. 1:27

38 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Table 1.10 (Figure 1.18): Deaths among Persons Diagnosed with HIV Disease by Year of Death and Age at HIV Diagnosis, Orange County, Year Number Percent Rate Number Percent Rate Number Percent Rate Number Percent Rate 1981 * * * * * * * * * * * * 1982 * * * * * * * * * * * * 1983 * * * * * * * * * * * * % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % * * * % % % 1.3 Total % , % , % % 67.8 DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, December State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, CA, Revised May State of California, Department of Finance, E-3 Race / Ethnic Population Estimates with Age and Sex Detail, Sacramento, CA, June State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, July Age at AIDS diagnosis is used if HIV diagnosis age is unknown. Rate is per 100,000. Total rate is per 100, population. *Fewer than 5 cases. 1:28

39 HIV Disease Surveillance Statistics, 2010 Table 1.11 (Figure 1.20): HIV Disease Cases by Year of Diagnosis and Mode of Transmission, Orange County, MSM IDU MSM/IDU Heterosexual Year Number Percent Number Percent Number Percent Number Percent 1980 * * * * * * * * 1981 * * * * * * * * % * * * * * * % * * % * * % * * % * * % % % * * % % % 7 1.9% % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % 9 3.4% 9 3.4% % Total 7, % 1, % % % DATA SOURCE: HIV Case Registry, data as of December 31, *Fewer than 5 cases. Disease Control & Epidemiology Division 1:29 HIV/AIDS Surveillance & Monitoring Program

40 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Table 1.12 (Figure 1.21): Deaths among Persons Diagnosed with HIV Disease by Year of Death and Mode of Transmission, Orange County, MSM IDU MSM/IDU Heterosexual Year Number Percent Number Percent Number Percent Number Percent 1981 * * * * * * * * 1982 * * * * * * * * 1983 * * * * * * * * % * * % * * % * * % * * % 5 5.4% * * * * % 9 6.2% % * * % % % 5 2.8% % % % 7 2.6% % % % 6 2.1% % % % * * % % % 6 1.6% % % % % % % % % % % % % % % % % % % % 7 4.7% % % 6 5.4% 5 4.5% % % 7 6.9% 7 6.9% % % * * 5 6.7% % % * * % % % 9 9.5% 6 6.3% % % 6 5.9% 9 8.8% % % 6 8.1% * * % % 8 7.5% % % % 7 7.6% * * % % 5 6.4% 6 7.7% % % * * % % * * * * 8 9.6% % % * * * * Total 3, % % % % DATA SOURCE: HIV Case Registry, data as of December 31, Other includes transfusion, hemophilia, and all Pediatric modes of transmission. *Fewer than 5 cases. Disease Control & Epidemiology Division 1:30 HIV/AIDS Surveillance & Monitoring Program

41 HIV Disease Surveillance Statistics, 2010 Table 1.13a (Figures ): Length of Time Between HIV and AIDS Diagnosis, Persons Diagnosed with AIDS After 1995 by Gender, Race/Ethnicity, and Mode of Transmission, Orange County Gender, Number Percent Race/Ethnicity, Diagnosed Diagnosed Total Diagnosed Diagnosed Diag-nosed and Mode of Concurrently Within One Year After 1995 Concurrently Within One Year Transmission Gender Male 1, , % 19.8% Female % 18.2% Total 1, , % 19.6% Race/Ethnicity White , % 15.4% Black % 20.0% Hispanic , % 23.2% API % 23.8% Other/Unknown % 22.7% Total 1, , % 19.6% Mode of Transmission MSM 1, , % 19.7% IDU % 17.2% MSM/IDU % 20.3% Heterosexual % 22.8% Other/Unknown % 16.3% Total 1, , % 19.6% Table 1.13b (Figures 1.24): Persons Diagnosed with AIDS Surviving Five or More Years by Gender, Race/Ethnicity, and Mode of Transmission, Orange County Gender, Race/Ethnicity, and Mode of Transmission Number Surviving Five or More Years Total Diagnosed Percent Gender Male 1,771 2, % Female % Total 2,035 2, % Race/Ethnicity White 913 1, % Black % Hispanic 929 1, % API % Other/Unknown % Total 2,035 2, % Mode of Transmission MSM 1,391 1, % IDU % MSM/IDU % Heterosexual % Other/Unknown % Total 2,035 2, % DATA SOURCES: HIV Case Registry, data as of December 31, Other race includes American Indian/Alaskan Native and persons of more than one race. Other mode includes transfusion, hemophilia, and all Pediatric modes of transmission. Transgender (all male to female) persons are included in the female row due to their small number. Disease Control & Epidemiology Division 1:31 HIV/AIDS Surveillance & Monitoring Program

42

43 CHAPTER 2: GEOGRAPHY OF HIV DISEASE IN ORANGE COUNTY Overall Geography and Population in Orange County Orange County is a large suburban county located between Los Angeles and San Diego Counties in Southern California. The county is comprised of 34 cities and covers approximately 798 square miles. With almost 3.2 million residents, Orange County has a population larger than 21 U.S. states and is the fifth largest county in the United States, exceeded in population only by Los Angeles County, California; Cook County, Illinois; Harris County, Texas; and Maricopa County, Arizona. 1 Between and Orange County s total population increased by 63.6% from 1.9 to 3.2 million. As of July 1, 2010, Orange County s population density stood at 3,988 persons per square mile. The density of cities within Orange County vary from a low of 421 persons per square mile in unincorporated areas to highs of 13,266 in Stanton, 13,250 in Santa Ana, and 9,757 in Garden Grove. 4 Figure 2.1 (below) shows a map of the population in Orange County by city in As shown: The most populous cities are Santa Ana and Anaheim, with over 300,000 residents. Cities with between 100,000 and 299,999 include Costa Mesa, Fullerton, Garden Grove, Huntington Beach, Irvine, the City of Orange, and Mission Viejo. Figure Orange County Population by City La Habra Brea 2010 Population in Incorporated Orange County Cities Rossmoor Los Alamitos La Palma Seal Beach Buena Park Cypress Stanton Huntington Beach Fullerton Anaheim Garden Grove Westminster Fountain Valley Costa Mesa Santa Ana Newport Beach Placentia Orange Newport Coast Tustin Irvine Laguna Beach Yorba Linda Villa Park Tustin Foothills Lake Forest Mission Laguna Viejo Woods Laguna Aliso Hills Viejo Las Flores Laguna Niguel Dana Point Foothill Ranch San Juan Capistrano Portola Hills San Clemente Rancho Santa Margarita Coto de Caza Population not estimated <10,000 10,000-99, , , , U.S. Census Bureau, American Community Survey, State of California, Department of Finance, E-6 County Population Estimates and Components of Change July 1, , Sacramento, California. 3 State of California, Department of Finance, California County Population Estimates and Components of Change by Year, July 1, Sacramento, California, December U.S. Census Bureau, 2000; State of California, Department of Finance, E-4 Population Estimates for Cities, Counties and the State, , with 2000 Benchmark. Sacramento, California, May :1

44 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Number of Persons Living with HIV Disease by City As of December 31, 2010, there were 6,591 persons living with HIV disease (PLWHD) in Orange County. Figure 2.2 (below) shows a map of the number of PLWHD by city of residence at time of diagnosis. 5 Figure 2.3 (below) shows the 10 cities with the highest number of PLWHD at time of diagnosis. As shown: Anaheim and Santa Ana have the largest numbers (909 and 1,373, respectively) of PLWHD at time of diagnosis. Cities with the second highest level of PLWHD at time of diagnosis include Laguna Beach (the third highest city with 453 PLWHD), Costa Mesa, Garden Grove, Huntington Beach, Fullerton, and the City of Orange. The number of PLWHD in each city can be found in Table 2.1 at the end of this chapter. Figure 2.2. Map of Number PLWHD by City of Residence at Time of Diagnosis, Orange County La Habra Brea Yorba Linda Number of PLWHD Fewer than 5 PLWHD Los Alamitos La Palma Buena Park Fullerton Placentia Rossmoor Cypress Stanton Anaheim Orange Villa Park Seal Beach Garden Grove Westminster Fountain Valley Huntington Beach Costa Mesa Santa Ana Tustin Irvine Tustin Foothills Laguna Woods Lake Forest Foothill Ranch Portola Hills Rancho Santa Margarita 909-1,373 Newport Beach Mission Viejo Newport Coast Laguna Beach Laguna Aliso Hills Viejo Laguna Niguel Dana Point Las Flores San Juan Capistrano San Clemente Coto de Caza Figure 2.3. Number of PLWHD by City of Residence at Time of Diagnosis, Top 10 Cities, Orange County Santa Ana 1,372 Anaheim 909 City Laguna Beach Garden Grove Costa Mesa Huntington Beach Orange 289 Fullerton 251 Irvine 221 Laguna Niguel Number of Person Living with HIV Disease 5 City of residence is indicated based on the city of residence during the last diagnosis date. PLWHD who received an AIDS diagnosis at a later date than an HIV diagnosis are shown by the city of residence at the time of the AIDS diagnosis date. 2:2

45 HIV Disease Surveillance Statistics, 2010 HIV Disease Rates by City The overall HIV disease rate in Orange County in 2010 was 8.2 per 100,000. This rate is based on the number of new cases per 100,000 population. Because it considers the population of an area, disease rates may provide a better depiction of the impact of a disease on the population. Figure 2.4 (below) shows a map of the PLWHD per 100,000 population based on city of residence at time of diagnosis. Figure 2.5 (below) shows the 10 cities with the highest HIV Disease rate. As shown: Laguna Beach is the city most heavily impacted by HIV Disease in Orange County. There are 453 PLWHD in Laguna Beach (as shown in Figure 3), which translates to nearly 1,800 PLWHD for every 100,000 residents. Aliso Viejo, Anaheim, Costa Mesa, Dana Point, Laguna Niguel, Santa Ana, and Tustin are the next most heavily impacted areas with between to PLWHD per 100,000 residents. Figure 2.4. Rate per 100,000 Population of PLWHD by City of Residence at Time of Diagnosis, Orange County Rossmoor Los Alamitos La Palma Seal Beach Buena Park Cypress Stanton La Habra Fullerton Anaheim Garden Grove Westminster Fountain Valley Huntington Beach Brea Costa Mesa Santa Ana Newport Beach Placentia Orange Newport Coast Tustin Irvine Laguna Beach Yorba Linda Villa Park Tustin Foothills Lake Forest Mission Laguna Viejo Woods Laguna Aliso Hills Viejo Las Flores Laguna Niguel Dana Point Foothill Ranch San Juan Capistrano Portola Hills San Clemente Rancho Santa Margarita Coto de Caza Rate per 100,000 Population of PLWHD Fewer than 5 PLWHD ,786.7 Laguna Beach Santa Ana Laguna Niguel Costa Mesa Figure 2.5. Rate per 100,000 Population of PLWHD by City of Residence at Time of Diagnosis, Top 10 Cities, Orange County ,786.7 City Anaheim Aliso Viejo Dana Point Tustin Stanton Orange ,000 1,200 1,400 1,600 1,800 2,000 Rate per 100,000 population in :3

46 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency HIV Disease in Select Cities: Anaheim, Laguna Beach, and Santa Ana This section provides the demographics of persons who live in the three cities in Orange County with the highest number of PLWHD at time of diagnosis: Anaheim, Laguna Beach, and Santa Ana. Anaheim The city of Anaheim is located in the northern region of Orange County. Home to 353,643 residents 6, Anaheim is the second most populous city in Orange County. Anaheim is also home to the second highest number of PLWHD at time of diagnosis (909 PLWHD) and has the fifth highest rate of PLWHD (257.0 per 100,000). Laguna Beach Laguna Beach is a coastal city located in the south west region of the county and is home to 25,354 residents 6. Since the beginning of the epidemic, Laguna Beach has been the city most heavily impacted by HIV Disease in the county when looking at the number of cases for the size of the population. Laguna Beach is home to the third highest largest number of PLWHD at time of diagnosis (453 PLWHD). Due to the small number of residents in Laguna Beach, the city has, by far, the highest rate of PLWHD per 100,000 (1,786.7 per 100,000 population). Santa Ana Located in central Orange County, Santa Ana is the most populous city in the county with 357,754 6 residents. Santa Ana is challenged by some of the highest hardship indicators in the county; almost one in five (19.8%) residents in the city live below 100% of the federal poverty level compared to almost one in 10 (9.9%) 7 in Orange County. Santa Ana is home to the largest numbers of PLWHD at time of diagnosis (1,373 PLWHD) and has the second highest rate of PLWHD (383.8 per 100,000 population). Incidence in Select Cities: Figure 2.6 (below) shows the number of newly diagnosed HIV Disease cases per 100,000 population in Anaheim, Laguna Beach, Santa Ana, and Orange County by year of diagnosis. Anaheim: HIV Disease case rates peaked in 1988 (38.5 cases per 100,000) and have since declined to an average of 15 cases per 100,000 for the past five years, which has been slightly higher than rates in the county. Laguna Beach: Since the beginning of the epidemic in Orange County, Laguna Beach has been the most most highly impacted city by HIV Disease with case rates over 350 per 100,000 population between 1987 and 1989, dropping to an average of 38 cases per 100,000 in the past five years. Santa Ana: Since 1987 HIV Disease case rates in Santa Ana have consistently been higher than the Orange County average. Rates peaked in 1988 and have since dropped to an average of 21 cases per 100,000 (five year average). Rate per 100,000 population Figure 2.6. Rate per 100,000 Population of HIV Disease Cases by Year of Diagnosis, Anaheim, Laguna Beach, Santa Ana, and Orange County 0 '84 '85 '86 '87 '88 '89 '90 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Laguna Beach Santa Ana Anaheim Orange County Rates for 2010 are provisional due to reporting delays. 6 State of California, Department of Finance, E-4 Population Estimates for Cities, Counties and the State, , with 2000 Benchmark. Sacramento, California, May U.S. Census Bureau. 2:4

47 HIV Disease Surveillance Statistics, 2010 Prevalence in Select Cities by Gender 8 : Figures 2.7.a-2.7.d (below) show the distribution of PLWHD by gender in Orange County (Figure 2.7.a), and the cities of Anaheim (Figure 2.7.b), Laguna Beach (Figure 2.7.c), and Santa Ana (Figure 2.7.d). As shown, Anaheim and Santa Ana have slightly higher proportions of female PLWHD compared to Orange County while Laguna Beach has a much higher proportion of male PLWHD. Anaheim (Figure 2.7.b): The majority (83.6%) of PLWHD diagnosed while residents of Anaheim are male. However, compared to Orange County, there is a slightly higher proportion of female PLWHD (15.6% in Anaheim vs. 12.4% in Orange County) and transgender male to female PLWHD (0.8% in Anaheim vs. 0.5% in Orange County) who were diagnosed while residents of Anaheim. Laguna Beach (Figure 2.7.c): The vast majority (98.2%) of PLWHD who were diagnosed while residents of Laguna Beach are male. This is much higher than the county-wide proportion of male PLWHD. Santa Ana (Figure 2.7.d): The majority (82.7%) of PLWHD diagnosed while residents of Santa Ana are male. However, compared to the county overall, there is a higher proportion of female PLWHD (16.3% in Santa Ana vs. 12.4% in Orange County) and transgender male to female PLWHD (0.9% in Santa Ana vs. 0.5% in Orange County) who were diagnosed while residents of Santa Ana. Figure 2.7.a. PLWHD by Gender, Orange County (N=6,591) Figure 2.7.b. PLWHD by Gender, Anaheim (N=909) Male 87.1% Male 83.6% Female 15.6 % Female 12.4 % Transgender 0.5% Transgender, 0.8% Figure 2.7.c. PLWHD by Gender, Laguna Beach (N=453) Figure 2.7.d. PLWHD by Gender, Santa Ana (N=1.373) Male 98.2% Male 82.7% Female 1.8 % Female % Transgender, 0.0% Transgender 0.9% 8 See Chapter 1, HIV Disease by Gender section on page 1:2 for description of reporting of gender for persons diagnosed with HIV Disease. 2:5

48 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Prevalence in Select Cities by Race/Ethnicity 9 : Figures 2.8.a-2.8.d (below) show the distribution of PLWHD by race/ethnicity in Orange County (Figure 2.8.a), and the cities of Anaheim (Figure 2.8.b), Laguna Beach (Figure 2.8.c), and Santa Ana (Figure 2.8.d). As shown, the racial/ethnic makeup of the epidemic varies greatly from city to city. Anaheim (Figure 2.8.b): The majority (56.4%) of PLWHD diagnosed while residents of Anaheim are Hispanic, while 32.8% are White. There is a greater proportion of Hispanic PLWHD and a smaller proportion of White PLWHD as compared to Orange County as a whole. The proportion of Black, API, and Other/Unknown PLWHD is also slightly higher than that in Orange County. Laguna Beach (Figure 2.8.c): The vast majority (87.9%) of PLWHD who were diagnosed while residents of Laguna Beach are White. This greatly contrasts with Orange County where only half of PLWHD are White. Santa Ana (Figure 2.8.d): A large majority (67.6%) of PLWHD diagnosed while residents of Santa Ana are Hispanic, while almost one in four (23.6%) are White. PLWHD diagnosed while residents of Santa Ana are much more likely to be Hispanic (67.6% compared to 39.9% of Orange County) and much less likely to be White (23.6% compared to 50.1%). PLWHD diagnosed while residents of Santa Ana are also slightly more likely to be Black (5.7% compared to 5.2% in the county). White 50.1% Figure 2.8.a. PLWHD by Race/Ethnicity, Orange County (N=6,591) Black 5.2% Figure 2.8.b. PLWHD by Race/Ethnicity, Anaheim (N=909) White 32.8% Black 5.7% Hispanic 39.9% Other/ Unknown, 0.7% API 4.4% Other/ Unknown 0.5% API 4.2% Hispanic 56.4% Figure 2.8.c. PLWHD by Race/Ethnicity, Laguna Beach (N=453) Figure 2.8.d. PLWHD by Race/Ethnicity, Santa Ana (N=1,373) White, 87.9% Black 2.4% Black 5.7% Hispanic 67.7% Hispanic 7.9% API 1. 3 % White 23.6% Other/ Unknown, * Other/ Unknown 0.4% API 2.6% 9 See Chapter 1, HIV Disease by Race/Ethnicity section on page 1:5 for description on race/ethnicity reporting. 2:6

49 HIV Disease Surveillance Statistics, 2010 Prevalence in Select Cities by Current Age 10 : Figures 2.9.a-2.9.d (below) show the distribution of PLWHD by current age in Orange County (Figure 2.9.a), and the cities of Anaheim (Figure 2.9.b), Laguna Beach (Figure 2.9.c), and Santa Ana (Figure 2.9.d). Anaheim (Figure 2.9.b): The largest percent of PLWHD diagnosed while residents of Anaheim are between the ages of 40 and 49. The proportion of PLWHD under age 39 diagnosed while residents of Anaheim is higher compared to Orange County as a whole, while the proportion who are age 50 years or over is lower. Laguna Beach (Figure 2.9.c): The two largest age groups of PLWHD diagnosed while residents of Laguna Beach are year-olds (36.6%) and year-olds (36.2%), while those age 60 years and over make up 16.3% of PLWHD. PLWHD diagnosed while residents of Laguna Beach are older compared to those in diagnosed in Orange County; over half (52.5%) of PLWHD diagnosed while residents of Laguna Beach are age 50 years or over, compared to just over one-third of Orange County PLWHD. Santa Ana (Figure 2.9.d): Those in the age group make up the largest proportion (37.0%) of PLWHD diagnosed while residents of Santa Ana. PLWHD diagnosed while living in Santa Ana are much more likely to be in the age group compared to PLWHD diagnosed in Orange County (23.7% compared to 19.5%) and less likely to be 50 years of age or older. Figure 2.9.a. PLWHD by Current Age, Orange County (N=6,591) 40-49, 37.4% Figure 2.9.b PLWHD by Current Age, Anaheim (N=909) 30-39, 24.0% 40-49, 37.3% 30-39, 19.5 % 20-29, 7.6% 0-19, 0.7% 60+, 9.3% 50-59, 25.6% 20-29, 10.5 % 0-19, 1.0 % 60+, 5.8% 50-59, 21.5% Figure 2.9.c PLWHD by Current Age, Laguna Beach (N=453) Figure 2.9.d PLWHD by Current Age, Santa Ana (N=1,373) 40-49, 36.6% 40-49, 37.0% 50-59, 36.2% 30-39, 23.7% 30-39, 9.1% 20-29, 1.5% 0-19, * 60+, 16.3% 20-29, 7.5% 50-59, 23.8% 0-19, 0.7% 60+, 7.3% 10 See Chapter 1, HIV Disease by Age section on page 1:9 for description on age reporting. 2:7

50 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Prevalence in Select Cities by Mode of Transmission 11 : Figures 2.10.a-2.10.d (below) show the distribution of PLWHD by mode of transmission in Orange County (Figure 2.10.a), and the cities of Anaheim (Figure 2.10.b), Laguna Beach (Figure 2.10.c), and Santa Ana (Figure 2.10.d). Anaheim (Figure 2.10.b): A large majority (69.0%) of PLWHD diagnosed while residents of Anaheim reported being exposed through men who have sex with men (MSM) followed by heterosexual contact, injection drug use (IDU), and MSM/IDU. These proportions generally reflect those of Orange County as a whole. Laguna Beach (Figure 2.10.c): The vast majority (90.9%) of PLWHD diagnosed while residents of Laguna Beach reported exposure through MSM. This is much higher than the proportion of PLWHD who reported exposure through MSM diagnosed in Orange County. Santa Ana (Figure 2.10.d): For PLWHD diagnosed while residents of Santa Ana, 63.1% reported being exposed through MSM, followed by IDU (15.1%), and heterosexual contact (12.5%). Compared to Orange County as a whole, PLWHD diagnosed in Santa Ana are less likely to report MSM as a mode of transmission and much more likely to report heterosexual contact and IDU as a mode of transmission. Figure 2.10.a. PLWHD by Mode of Transmission, Orange County (N=6,591) MSM, 72.7% MSM, 69.0% Figure 2.10.b. PLWHD by Mode of Transmission, Anaheim (N=909) IDU, 10.0% IDU, 9.1% Other/ Unknown, 3.7% Heterosexual, 10.2 % MSM/IDU, 4.4% Other/ Unknown, 4.4% Heterosexual, 12.9 % MSM/IDU, 3.7% Figure 2.10.c. PLWHD by Mode of Transmission, Laguna Beach (N=453) Figure 2.10.d. PLWHD by Mode of Transmission, Santa Ana (N=1,373) IDU, 1.8% MSM, 63.1% MSM, 90.9% MSM/IDU, 4.9% Heterosexual, 1.8 % IDU, 15.1% Other/ Unknown, * MSM/IDU, 5.1% Other/ Unknown, 4.2% Heterosexual, % 11 See Chapter 1, HIV Disease by Mode of Transmission section on page 1:12 for description of mode of transmission reporting. 2:8

51 CHAPTER 2 TABLES-GEOGRAPHY Table 2.1 (Figures ): Persons Living with HIV Disease (PLWHD), Annual Population, and Case Rates per 100,000 Population, Orange County Rate per 100,000 PLWHD Population City Population Aliso Viejo , Anaheim , Brea 36 40, Buena Park , Costa Mesa , Cypress 50 49, Dana Point 92 37, Fountain Valley 90 58, Fullerton , Garden Grove , Huntington Beach , Irvine , La Habra 81 63, La Palma 7 16, Laguna Beach , Laguna Hills 67 33, Laguna Niguel , Laguna Woods 9 18, Lake Forest 93 78, Los Alamitos 18 12, Mission Viejo , Newport Beach , Orange , Placentia 72 52, Rancho Santa Margarita 36 49, San Clemente , San Juan Capistrano 43 37, Santa Ana 1, , Seal Beach 22 26, Stanton 86 39, Tustin , Villa Park * 6,307 * Westminster , Yorba Linda 37 69, TOTAL 6,591 3,166, DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, E-1 Population Estimates for Cities, Counties and the State with Annual Percent Change January 1, 2009 and Sacramento, California, May *The number is suppressed due to cities with fewer than five PLWHD. Disease Control & Epidemiology Division 2:9 HIV/AIDS Surveillance & Monitoring Program

52 HIV Disease Surveillance Statistics, 2010 Table 2.2 (Figure 2.6): Number and Rate per 100,000 Population of HIV Disease Cases by Year of Diagnosis, Laguna Beach, Santa Ana, Anaheim, and Orange County, Laguna Beach Santa Ana Anaheim All PLWHD Year Number Rate Number Rate Number Rate Number Rate Total 888 3, , , , DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, Population Estimates for California Cities and Counties, January 1, 1981 to January 1, State of California, Department of Finance, E-4 Historical Population Estimates for City, County and the State, , with 1990 and 2000 Census Counts. State of California, Department of Finance, E-4 Population Estimates for Cities, Counties and the State, , with 2000 Benchmark. Sacramento, California, May Disease Control & Epidemiology Division 2:10 HIV/AIDS Surveillance & Monitoring Program

53 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Table 2.3 (Figures ): Persons Living with HIV Disease (PLWHD) by Gender, Race/Ethnicity, Current Age, and Mode of Transmission, Laguna Beach, Santa Ana, Anaheim, and Orange County Gender, Laguna Beach Santa Ana Anaheim All PLWHD Race/Ethnicity, and Current Age Number Percent Number Percent Number Percent Number Percent Gender Male % 1, % % 5, % Female 8 1.8% % % % Transgender Male to Female 0 0.0% % 7 0.8% % Total % 1, % % 6, % Race/Ethnicity White % % % 3, % Black % % % % Hispanic % % % 2, % API 6 1.3% % % % Other/Unknown * * 6 0.4% 6 0.7% % Total % 1, % % 6, % Current Age 0-19 * * 9 0.7% 9 1.0% % % % % % % % % 1, % % % % 2, % % % % 1, % % % % % Total % 1, % % 6, % Mode of Transmission MSM % % % 4, % IDU 8 1.8% % % % MSM/IDU % % % % Heterosexual 8 1.8% % % % Other/Unknown * * % % % Total % 1, % % 6, % DATA SOURCES: HIV Case Registry, data as of December 31, Other race includes American Indian/Alaskan Native and persons of more than one race. Other mode includes transfusion, hemophilia, and all Pediatric modes of transmission. *The number is suppressed due to categories with fewer than five PLWHD. Disease Control & Epidemiology Division 2:11 HIV/AIDS Surveillance & Monitoring Program

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55 CHAPTER 3: PEDIATRIC HIV DISEASE IN ORANGE COUNTY Overview of Pediatric HIV Reporting This section describes trends in HIV Disease for pediatric cases (children under the age of 13 at time of diagnosis). As of December 31, 2010, there have been a total of 60 pediatric cases (children under the age of 13) reported in Orange County. This represents less than 1% of total HIV Disease cases reported in the county. Most (82%) of these pediatric cases are attributed to perinatal transmission, or transmission from mother to child during pregnancy, labor, or delivery. Due to the small numbers of pediatric cases, reported each year 1 data is presented in five or ten year periods. In this report, when describing individuals currently living with HIV Disease (prevalence), the current age of the individual is shown. When describing trends in the number of new cases (incidence), the age of diagnosis is used. Age groups for which there are fewer than five cases in each subgroup will not be shown in this section. Incidence Figure 3.1 (below) displays the number of pediatric cases diagnosed (by age at diagnosis) since 1986 in fiveyear periods by the earliest date of diagnosis. As shown, between and , there was a significant decrease in the number of pediatric cases. This is likely due to decreases that began in 1994 after research showed that zidovudine (ZDV) given to pregnant women infected with HIV and their newborns reduced the risk for this type of HIV transmission. Since then, the testing of pregnant women and treatment for those who are infected have resulted in a dramatic decline in the number of children perinatally infected with HIV nationally. Cases diagnosed in were due to perinatal transmission, a child receiving treatment for hemophilia, and children who were infected due to a blood transfusion. By 1996 until 2010, all the pediatric cases diagnosed have been due to perinatal transmission. By , 40.0% of the cases were in children born in the United States and not those infected because they were born in an endemic country. Figure 3.1. Pediatric Cases by Age of Diagnosis, Orange County < Number Fewer than five cases for most years. 3:1

56 HIV Disease Surveillance Statistics, 2010 Prevalence This section provides information on the 42 children living with HIV Disease (PLWHD) who were under age 13 at time of diagnosis. Comparisons are made to All PLWHD or the 6,591 PLWHD as of December 31, 2010 regardless of age at diagnosis and Orange County s total 2010 population. Prevalence by Gender Figure 3.2 (below) shows the proportion of pediatric PLWHD compared to Orange County s 2010 population by gender. As shown, the distribution of pediatric PLWHD is generally reflective of Orange County s population and does not reflect the disproportionate impact among males seen in PLWHD overall. Figure 3.2. Pediatric PLWHD, All PLWHD, and Orange County Population by Gender, Orange County 100% Percent 80% 60% 40% 45.2% 49.6% 54.8% 50.4% 20% 0% Male Female Gender Pediatric PLWHD 2010 Population Prevalence by Race/Ethnicity Figure 3.3 (below) shows the proportion of pediatric PLWHD compared to all PLWHD and Orange County s 2010 population by race/ethnicity. As shown, the pediatric PLWHD are more likely to be Hispanic and Black, and less likely to be White than all PLWHD and the overall population. 100% Figure 3.3. Pedatric PLWHD, All PLWHD, and Orange County Population by Race/Ethnicity, Orange County 80% Percent 60% 40% 20% 0% 50.1% 57.1% 44.0% 39.9% 35. 9% 21.4% 14.3% 16.4% 5.2% 4.2% 1.4% 0.5% 2.3% * 0. 0% White Blac k Hispanic API Othe r/unk Rac e/e thnic ity Pediatric PLWHD All PLWHD 2010 Population *Fewer than 5 cases. 3:2

57 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Prevalence by Current Age Figure 3.4 (below) shows the distribution of pediatric PLWHD by current age. As shown, the largest group of pediatric PLWHD are between the ages of 13 and 19. Those 0-12 and years of age make up about the same proportion of pediatric PLWHD. Figure 3.4. Current Age of PLWHD Diagnosed as a Child % % * % *Fewer than 5 cases. Survival Figure 3.5 (below) shows the percent of pediatric cases and all reported cases of HIV Disease in Orange County who are still living. As shown, 70.0% (42 of 60) of all reported pediatric cases are still living and 60.8% (6,591 of 10,846) of all reported HIV Disease Cases in Orange County are living as of December 31, Figure 3.5. Percent of Pediatric Cases Compared to All HIV Cases Living as of December 31, 2010, Orange County 100% Percent 80% 60% 40% Pediatric Cases, 70.0% All Cases, 60.8% 20% 0% Survival 3:3

58 CHAPTER 3 TABLES-PEDIATRIC HIV DISEASE Table 3.1 (Figures ): Persons Living with HIV Disease (PLWHD) Diagnosed Prior to Age 13 (Pediatric), All PLWHD, and 2010 Population by Gender, Race/Ethnicity, and Current Age, Orange County Gender, Pediatric PLWHD All PLWHD Population Race/Ethnicity, and Current Age Number Percent Rate Number Percent Rate Number Percent Gender Male % 1.2 5, % ,601, % Female % % ,625, % Transgender 0 0.0% NC % NC NA NA Total % 1.3 6, % ,227, % Race/Ethnicity White % 0.6 3, % ,419, % Black % % , % Hispanic % 2.1 2, % ,158, % API * * * % , % Other/Unknown * * * % NC 75, % Total % 1.3 6, % ,227, % Current Age % % , % % % , % % % , % * * * 1, % , % * * * 2, % , % * * * 1, % , % 60+ * * * % , % Total % 1.3 6, % ,227, % DATA SOURCES: HIV Case Registry, data as of December 31, State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, Sacramento, California, July Other race includes American Indian/Alaskan Native and persons of more than one race. Other mode includes transfusion, hemophilia, and all Pediatric modes of transmission. NC: Rate not calculated due to lack of population estimates. NA: Number is not available. *The number is suppressed due to categories with fewer than five PLWHD. Rate is per 100, population. Disease Control & Epidemiology Division 3:5 HIV/AIDS Surveillance & Monitoring Program

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60 CHAPTER 4: HIV COUNSELING AND TESTING Overall HIV Counseling and Testing: The Orange County Health Care Agency provides support for HIV counseling and testing services in Orange County through the provision of HIV rapid test kits funded by the HIV Prevention Services Branch of the California Department of Public Health, Office of AIDS. Counseling and Testing (C&T) sites receiving kits include: 17 th Street Testing and Treatment, AIDS Services Foundation (ASF), the Health Care Agency Risk Reduction, Education, and Community Health (REACH) Program, and The Center Orange County. Tests conducted at private provider offices and other sites not listed here are not included in this chapter. This chapter describes the trends and demographics of those who received tests and those who tested positive for HIV at C&T sites between 2006 and C&T sites provide counseling and testing services at no cost to individuals. An individual may take more than one test in a single year or over multiple years. Therefore, the numbers in this chapter should not be considered an unduplicated count of individuals. Though no one is refused testing at these sites, it is important to note that the C&T sites target outreach to high-risk populations such as men who have sex with men, substance users, and partners of infected individuals. Therefore, positivity rates shown here are likely higher than those expected in the general population. Figure 4.1 (below), displays the number of tests provided each year at all of the C&T sites between 2006 and As shown, during this time, a total of 43,357 tests were conducted, with an average of 8,671 tests conducted each year. Number Tested 10,000 9,0 00 8,0 00 7,0 00 6,0 00 5,0 00 4,0 00 3,0 00 2,0 00 1, Figure 4.1. Numberof Tests at Orange County C&T Sites, 9, ,205 9,003 8,383 7, Figure 4.2 (below), displays the positivity rate (number of positive tests divided by number of persons tested) and number of individuals (indicated with n ) who tested positive for HIV in each year. As shown, an average of 1.1% of tests were positive in the last five years. Figure 4.2. Positivity Rate at Orange County C&T Sites, % Percent Positive 4% 3% 2% 1% 1.3 % (n=118) 1.4% (n=114) 1.0% (n=75) 1.0% (n=89) 1.0% (n=88) 0% :1

61 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency HIV Counseling and Testing by Gender Table 4.1 (below) displays the number of tests and the number of positive results each year at C&T sites between 2006 and 2010 by gender. As shown, there were more tests conducted for males than females each year. Though tests were provided to transgender individuals, the number of positive tests each year for this population was too low (fewer than five) to show. Table 4.1. Number of Tests Provided and Positive Results at Orange County C&T Sites by Gender, Gender Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Male 6, , , , , Female 2, , , , ,281 6 Transgender 84 * 83 * 88 * 105 * 125 * *Fewer than five positive tests. Transgender includes both male to female and female to male transgender individuals. Figure 4.3 (below) displays the percent of individuals who tested positive for HIV by gender and overall between 2006 and As shown, males tend to have higher positivity rates, while females had lower positivity rates than total tests. Information for transgender individuals is not shown as the number of positive tests each year for this population was too low (fewer than five) to show. 5.0% Figure 4.3. Percent Positivity at Orange County C&T Sites by Gender, Percent Positive 4.0% 3.0% 2.0% 1.0% 0.0% Male 1.6 % 1.7% 1.3 % 1.2% 1.2% Female 0.4 % 0.5% 0.4 % 0.2% 0.3% Total 1.3 % 1.4% 1.0 % 1.0% 1.0% HIV Counseling and Testing by Race/Ethnicity Table 4.2 (below), displays the number of tests and the number of positive results each year at C&T sites between 2006 and 2010 by race/ethnicity. As shown, Hispanics received the most tests and had the highest number of positive test results, followed by Whites, APIs, and Blacks. However, it is important to note, as shown in Figure 4.4, Blacks have consistently had the highest positivity rates. Table 4.2. Number of Tests Provided and Positive Results at Orange County C&T Sites by Race/Ethnicity, Race/Ethnicity Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive White 3, , , , , Black * Hispanic 4, , , , , API * ,002 8 *Fewer than five positive tests. 4:2

62 HIV Disease Surveillance Statistics, 2010 Figure 4.4 (below) displays the percent of positive tests within each race/ethnicity by year. As shown, in general, Blacks have had the highest percent positivity, followed by Hispanics; Whites and API have had similar percent positivity. 5.0% Figure 4.4. Percent Positivity at Orange County C&T Sites by Race/Ethnicity, Percent Positive 4.0% 3.0% 2.0% 1.0% 0.0% White 1.0% 1.3% 0.7% 0.8% 0.8% Black 1.8% 2.8% 1.5% 1.5% * Hispanic 1.4% 1.3% 1.2% 1.1% 1.2% API 1.1% * 1.1% 0.9% 0.8% *Fewer than five positive tests. HIV Counseling and Testing by Age Table 4.3 (below) displays the number of tests and the number of positive results each year at C&T sites between 2006 and 2010 by age group. As shown, 20 to 29 years olds received the most tests, followed by 30 to 39 years olds, and 40 to 49 year olds. Table 4.3. Number of Tests Provided and Positive Results at Orange County C&T Sites by Race/Ethnicity, Age Group Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive * , , , , , , , , , , , , , , , * *Fewer than five positive tests. (Continued on next page) 4:3

63 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Figure 4.5 (below), displays the percent of positive tests by age group between 2006 and No single age group has had the highest positivity rate over this period of time. 5.0% Figure 4.5. Percent Positivity at Orange County C&T Sites by Age Group, Percent Positive 4.0% 3.0% 2.0% 1.0% 0.0% % 0.7% * 0.9% 0.7% % 1.2% 1.0% 0.9% 1.0% % 1.7% 1.2% 1.2% 1.0% % 1.5% 1.2% 0.7% 1.2% 50 and over 0.7% 1.4% 0.8% 0.9% * *Fewer than five positive tests. HIV Counseling and Testing by Mode of Exposure Table 4.4 (below) displays the number of tests and the number of positive results each year at C&T sites between 2006 and 2010 by mode of exposure. As shown, those exposed through heterosexual contact received the highest number of tests each year, followed by men who have sex with men (MSM), and injection drug users (IDU). Table 4.4. Number of Tests Provided and Positive Results at Orange County C&T Sites by Mode of Exposure, Mode of Exposure Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive MSM 1, , , , , IDU 732 * 618 * 353 * 506 * 513 * MSM/IDU 51 * 37 * 692 * * Heterosexual Contact 5, , , , ,152 8 Sex Worker * 134 * 120 * 99 * Infected Partner * 136 * Transgender 84 * 83 * 105 * 105 * 125 * Unknown * 390 * 390 * 391 * *Fewer than five positive tests. Transgender includes both male to female and female to male transgender individuals. 4:4

64 HIV Disease Surveillance Statistics, 2010 Figure 4.6 (below), displays the percent of positive tests by mode of exposure for MSM and those who reported exposure through heterosexual contact. Other exposure groups are not shown as there were too few cases to show trends for the indicated years. As shown, MSM have had higher positivity rates compared to those exposed through heterosexual contact. 5.0% Figure 4.6. Percent Positivity of Persons Tested at Orange County C&T Sites by Selected Mode of Exposure and Year of Test, Percent Positive 4.0% 3.0% 2.0% 1.0% 0.0% MSM 4.2% 4.2% 2.9 % 2.4% 2.7% Heterosexual Contact 0.3% 0.4% 0.2 % 0.2% 0.2% HIV Counseling and Testing by Use of Selected Substances Table 4.5 (below) displays the number of tests and the number of positive results each year at C&T sites between 2006 and 2010 by use of selected substances within the past two years. Starting July 2010, information on alcohol use and marijuana use is no longer captured; therefore, the information provided for those categories in 2010 is only through June 30, Table 4.5. Number of Tests Provided and Positive Results at Orange County C&T Sites by Use of Selected Substances, Substance Use Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Total Tests Number Positive Alcohol Use 5, , , , , Amphetamine Use 2 1, , , , Cocaine Use * 552 * Marijuana Use 1, , , Any Substance Use 3 6, , , , , *Fewer than five positive tests. 1 Starting July 2010, information on alcohol use and marijuana use is no longer captured; therefore, the information provided for those categories in 2010 is only through June 30, Questions about amphetamine use in 2004 through were about amphetamines (e.g. crank, crystal, Tina), while questions about amphetamine use in 2008 through 2010 asked about methamphetamine (e.g. crystal, meth, speed, crank, Tina). 3 Any substance in included Alcohol, Amphetamines, Barbiturates, Cocaine, Crack, Ecstasy, GHB, Hallucinogens, Heroin, Ketamine, Marijuana, Nitrates, Viagra, and other drugs not specified. In it only includes Alcohol, Amphetamines, Cocaine, Crack, Heroin (injected only), Marijuana, Nitrates, and other drugs not specified. 4:5

65 HIV Disease Surveillance Statistics, 2010, County of Orange, Health Care Agency Figure 4.7 (below) displays the number of HIV-positive results per year at each of the C&T sites between 2006 and 2010 by selected substance use in the past two years. No single group has had the highest positivity rate over this period of time. 5.0% Figure 4.7. Percent Positivity at Orange County C&T Sites by Use of Selected Substances within Past Two Years, Percent Positive 4.0% 3.0% 2.0% 1.0% 0.0% Alcohol Use 1.3 % 1.4 % 1.7 % 1.7% 1.9% Amphetamine Use 0.9 % 1.6 % 1.7 % 1.7% 1.3% Cocaine Use 0.7 % 0.9 % * * 1.1% Marijuana Use 0.9 % 1.2 % 1.3 % 0.8% 1.8% Any Substance 1.2 % 1.4 % 1.7 % 1.4% 1.5% *Fewer than five positive tests. HIV Counseling and Testing by Additional Factors Table 4.6 (below) displays the number of tests and the number of positive results each year at C&T sites between 2006 and 2010 by additional factors including homelessness, lack of health insurance, and incarceration. Information regarding health insurance and incarceration was not collected prior to Table 4.6. Number of Tests Provided and Positive Results at Orange County C&T Sites by Additional Factors, Number Number Number Number (%) (%) (%) (%) Number (%) Positive Total Total Total Total Total Additional Tests Tests Tests Tests Tests Factors Positive Positive Positive Positive Homeless 1,157 9 (0.8%) 1,164 9 (0.8%) 573 * 845 * 773 * No Health Insurance NC NC NC NC NC NC 2, , Incarcerated NC NC NC NC NC NC (0.7%) (1.3%) *Fewer than five positive tests. NC indicates information was not collected. 4:6

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67 CHAPTER 5: RYAN WHITE ACT AND ORANGE COUNTY Overview of Ryan White Act First authorized in 1990, the Ryan White Act is the largest piece of federal legislation that offers funding for the care and treatment of persons living with HIV disease (PLWHD) who have no other source for care. Three main goals of the Ryan White Act are: To lessen the burden of treatment and care in areas most affected by HIV. To foster a coordinated approach to core treatment and support of HIV services. To build a community-based, strategic response to HIV by local organizations and advocates, as well as local public entities. The Ryan White Act is administered by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), HIV/AIDS Bureau (HAB). Federal funds are awarded to agencies located around the country, which in turn deliver care to eligible individuals under funding categories called Parts, as outlined below. The Ryan White legislation created a number of programs, called Parts, to meet the needs for different communities and populations affected by HIV/AIDS. Each is described below. Orange County receives funding from Ryan White Parts A, B, and C, as well as MAI to provide primary medical care and support services to HIVpositive individuals. Part A provides emergency assistance to Eligible Metropolitan Areas (EMAs) and Transitional Grant Areas (TGAs) that are most severely affected by the HIV/AIDS epidemic. A map of the EMAs and TGAs in California is shown on the next page. Orange County receives Ryan White Part A funds directly through the federal government as a TGA. The Orange County Health Care Agency (HCA) HIV Planning and Coordination Unit acts as Orange County s grantee for these funds. The Orange County HIV Planning Council acts as the planning body for Ryan White Part A funding. Part B provides grants to all 50 States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, and 5 U.S. Pacific Territories or Associated Jurisdictions. Orange County receives Ryan White Part B funds through the California Office of AIDS. Part C provides comprehensive primary health care in an outpatient setting for people living with HIV disease. The HCA s HIV Ambulatory Care Clinic (known as 17 th Street Care) receives Part C funds directly from the federal government to provide outpatient ambulatory medical care. Part D provides family-centered care involving outpatient or ambulatory care for women, infants, children, and youth with HIV/AIDS. Part F provides funds for a variety of programs: The Special Projects of National Significance Program grants fund innovative models of care and supports the development of effective delivery systems for HIV care. The AIDS Education and Training Centers Program supports a network of 11 regional centers and several National centers that conduct targeted, multidisciplinary education and training programs for health care providers treating people living with HIV/AIDS. The Dental Programs provide additional funding for oral health care for people with HIV. The Minority AIDS Initiative (MAI) provides funding to evaluate and address the disproportionate impact of HIV/AIDS on African Americans and other minorities. Orange County receives MAI funds directly through the federal government. 5:1