HIV prevention & community planning epidemiologic profile for North Carolina

              Epidemiologic Profile
for
HIV/STD Prevention &
Care Planning
December 2011
Please direct any comments or questions to:
Communicable Disease Surveillance Unit
North Carolina Communicable Disease Branch
1902 Mail Service Center
Raleigh, North Carolina 27699-1902
919-733-7301
http://epi.publichealth.nc.gov/cd/stds/figures.html
Note: See the inside back cover for a map of North Carolina regional
and geographic designations.
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PART I: CORE EPIDEMIOLOGY
What are the sociodemographic characteristics of the general population of
North Carolina? (Chapter 1)
What is the scope of the HIV/AIDS epidemic in North Carolina? (Chapter 2)
HIV Testing and Prevention (Chapter 3)
Partner Counseling and Referral Services (Chapter 4)
Special Studies (Chapter 5)
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CHAPTER 1: SOCIODEMOGRAPHIC CHARACTERISTICS
OF THE GENERAL POPULATION IN
NORTH CAROLINA
HIGHLIGHTS
 In 2009, North Carolina was the 10th most populous state in the U.S., with an estimated
population of 9,535,483.
 North Carolina’s population increased 18.5 percent from 2000 to 2010.
 In 2009, North Carolina ranked 3rd in the nation for annual population increase.
 The N.C. foreign-born population increased 38 percent from 2002 to 2008.
 North Carolina has the 18th largest non-white population in the nation.
 North Carolina has the 8th highest percentage of black population in the nation.
 North Carolina has the 26th largest Hispanic/Latino population and the 10th highest birth rate
among Hispanics in the nation.
 The median age for the Hispanic population was 23.7 years, while the median age for all
North Carolinians was 38.3 years in 2008.
 In 2010, North Carolina was 37th in the nation with a per capita income of $35,638 or 87.8
percent of the national average of $40,584.
 From 2008 to 2009, 19.7 percent of North Carolinians were living at or below the federal
poverty level (FPL); 39.9 percent of the overall population is considered low income (living
at or below 199% FPL).
 From 2008 to 2009, 23 percent of the 19 to 64 year old population in North Carolina was
uninsured.
 About 19 percent of the N.C. population was eligible for Medicaid coverage at some point
during 2009.
 About 70 percent of the state’s population lived in urban areas in 2009.
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SOCIODEMOGRAPHIC CHARACTERISTICS OF NORTH CAROLINA
Knowledge of sociodemographic characteristics is paramount to fully understanding the health
of a population. Sociodemographics can be used to identify certain populations that may be at
greater risk for morbidity and mortality. This knowledge can also assist in identifying underlying
factors that may contribute to a health condition. This chapter will discuss the relevant health
indicators and sociodemographic characteristics of the population of North Carolina, including
age, race/ethnicity, gender, income, poverty, education, and geography.
Population
According to the 2010 federal census, North Carolina was one of the most rapidly expanding
states during the previous decade. From 2000 to 2010, North Carolina’s population grew by 18.5
percent, from 8,049,313 to 9,535,483. Only five other states (Arizona, Idaho, Nevada, Texas, and
Utah) grew faster during the last decade. From 2008 to 2009, North Carolina ranked 3rd for
single year population growth. According to the N.C. State Demographer, the 2010 North
Carolina State provisional population estimate was 9,572,454, with county populations ranging
from 4,403 (Tyrrell) to 923,944 (Mecklenburg). More than one-half of North Carolina’s
population lived in only 16 counties (Mecklenburg, Wake, Guilford, Forsyth, Cumberland,
Durham, Buncombe, Gaston, New Hanover, Union, Onslow, Cabarrus, Johnston, Davidson, Pitt,
and Iredell). From July 2008 to July 2009, there were 129,618 births and 79,441 deaths. The
average life expectancy for North Carolinians was 75.8 years.
The most updated gender and age-specific population information available is for the year 2009,
so we use the 2009 population as a substitute for 2010 in order to analyze the HIV disease rates
in this profile. In 2009, North Carolina was the 10th most populous state in the United States
with an estimated population of 9,380,884 (US Census 2009 population estimate), representing a
16.1 percent increase from that of year 2000. Map 1 displays the population distribution among
the counties in North Carolina for 2009 (Appendix A, pg. A-3).
Age and Gender
Age and gender play an important role in public health planning and in understanding the health
of a community. These characteristics are significant indicators of the prevalence of certain
diseases, especially for HIV disease and other STDs, as shown in previous Epidemiologic
Profiles. Substantial morbidity and social problems among youth are the result of unsafe sex
practices, which can result in unwanted pregnancies and STDs, including HIV infection. Nearly
one-half of all new sexually transmitted diseases in North Carolina occur in youth ages 15 to 24
years. Research shows that adolescents (ages 13–19 years) are at increased risk, both
behaviorally and biologically, for HIV infection. Of the adolescents infected with HIV, more
than half are estimated to be unaware of their status due to never having been tested (Rotheram-
Borus and Futterman 2000).
In 2009, the median age for people living in North Carolina was 36 years old, with 25.7 percent
18 years and younger, and 12.7 percent 65 years and older. Approximately 49 percent of the
population is male and 51 percent is female. Table 1.1 displays the North Carolina population in
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2009 by selected gender and age groups. The trend in North Carolina follows the typical age
trend of slightly more males under 12 years old and more females in the older age groups. North
Carolina has a younger population than other states, ranking 10th in the nation in 2009 with more
people under 18 years of age. North Carolina’s young population might have extensive health-related
needs, such as STDs and unwanted pregnancies.
Table 1.1. North Carolina bridged-race population estimates by age group, 2009
Male Female Total
Age Population Percent Population Percent Population Percent
0-12 years 852,562 9.1% 814,513 8.7% 1,667,075 17.8%
13-14 years 123,186 1.3% 116,919 1.2% 240,105 2.6%
15-19 years 331,810 3.5% 313,702 3.3% 645,512 6.9%
20-24 years 352,186 3.8% 315,417 3.4% 667,603 7.1%
25-29 years 318,747 3.4% 312,056 3.3% 630,803 6.7%
30-34 years 297,877 3.2% 306,767 3.3% 604,644 6.4%
35-39 years 329,377 3.5% 333,088 3.6% 662,465 7.1%
40-44 years 324,252 3.5% 331,509 3.5% 655,761 7.0%
45-49 years 336,379 3.6% 352,478 3.8% 688,857 7.3%
50-54 years 311,837 3.3% 333,787 3.6% 645,624 6.9%
55-59 years 274,939 2.9% 302,483 3.2% 577,422 6.2%
60-64 years 238,302 2.5% 264,686 2.8% 502,988 5.4%
65+ years 498,731 5.3% 693,294 7.4% 1,192,025 12.7%
Total 4,590,185 48.9% 4,790,699 51.1% 9,380,884 100.0%
National Center for Health Statistics (NCHS), Bridged-Race Population Estimates, January 2011
Gender differences also exist in terms of vulnerability to illness, access to preventive and
curative measures, burdens of diseases, and quality of care in North Carolina. Table 1.2 displays
the percentages of males and females for the major race/ethnicity categories by North Carolina
regions. Race/ethnicity also varies by region with a larger proportion of white non-Hispanics in
Western Region, American Indians in Eastern Region, and black non-Hispanics in Eastern
Region. A state map showing the N.C regions is displayed on the inside back cover.
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Race/Ethnicity and Gender
The racial and ethnic differences of a population play an important role in interpreting gaps in
access to health care among the different groups, and these differences are especially true in
terms of HIV disease surveillance and intervention. Previous HIV disease surveillance showed
that HIV disproportionately affected ethnic minorities in North Carolina. North Carolina has the
18th largest non-white population in the United States (3,058,647 in year 2009) and there are
noticeable variations in the demographic composition of North Carolina from region to region.
Usually non-white minorities have poorer health conditions and less access to health care. In
2009, 14 counties had populations consisting of more than 50 percent non-white residents
(Robeson: 71.0%; Hertford: 65.1%; Bertie: 64.9%; Edgecombe: 61.6%; Warren: 61.4%;
Northampton: 59.8%; Halifax: 59.4%; Vance: 56.9 %; Hoke: 55.8%; Washington: 55.0%;
Durham: 54.2%; Greene: 53.6%; Anson: 51.3% and Scotland: 50.7%). Maps 3-6 (Appendix A,
pp.A-5 to A-8) display the racial and ethnic make-up of North Carolina’s counties, as reported in
the 2009 bridged-race estimates (please see Appendix C, pg. C-5 for more information about
Census data and the bridged-race categories used to calculate rates). Table 1.3 displays the
populations for the major race/ethnicity categories in North Carolina according to the bridged-race
estimates for 2009.
Table 1.2. North Carolina race/ethnicity proportions by gender and geographic region, 2009
Western Piedmont Eastern N.C.
Race/Ethnicity Pct. Pct. Pct. Pct.
Male White* 42.7% 32.3% 30.1% 32.9%
Black* 2.4% 10.1% 13.4% 10.1%
AI/AN* 0.5% 0.2% 1.4% 0.6%
Asian/PI* 0.5% 1.5% 0.5% 1.1%
Hispanic 2.7% 4.9% 3.6% 4.2%
Total 48.8% 48.9% 49.0% 48.9%
Female White* 45.7% 33.9% 30.9% 34.5%
Black* 2.4% 11.6% 15.1% 11.5%
AI/AN* 0.5% 0.2% 1.5% 0.6%
Asian/PI* 0.5% 1.5% 0.6% 1.1%
Hispanic 2.1% 3.9% 2.9% 3.4%
Total 51.2% 51.1% 51.0% 51.1%
Total White* 88.3% 66.1% 61.0% 67.4%
Black* 4.8% 21.8% 28.5% 21.6%
AI/AN* 1.0% 0.4% 2.8% 1.2%
Asian/PI* 1.0% 2.9% 1.2% 2.2%
Hispanic 4.8% 8.8% 6.5% 7.7%
Total 100.0% 100.0% 100.0% 100.0%
* non-Hispanic; AI/AN=American Indian/Alaska Native, PI=Pacific Islander
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Blacks
In 2009, North Carolina ranked 8th highest in percentage of blacks nationwide. According to the
N.C. Health Profile 2009, compared to whites, blacks have higher death rates from heart disease,
cancer, HIV, diabetes, homicide, and stroke. North Carolina has seven counties with blacks
consisting of more than 50 percent of the total population (Bertie 62.9 %, Hertford 61.3%,
Northampton 57.9%, Edgecombe 56.4%, Halifax 53.8%, and Warren County 53.0%). Map 3
(Appendix A, pg. A-5) displays the proportion of black population in 2009 by county.
Hispanics
Over the years, the N.C. Hispanic population has steadily increased. From 2002 to 2009, the
estimated Hispanic/Latino population increased from 451,095 to 717,662, representing a 59.1
percent increase. Hispanics represented 7.7 percent of the population of the state and ranked 26th
nationally. North Carolina ranked 10th in Hispanic births in 2008. Compared to other ethnic
groups in North Carolina, Hispanics are a relatively young population. Although the median age
of the non-Hispanic population is 38.3 years, the median age of Hispanics is 23.7 years. Seventy
percent (70%) of Hispanics are under 35 years old, while only 46 percent of non-Hispanic
population is in the same age range. Map 5 (Appendix A, pg. A-7) displays the proportion of
the Hispanic population in 2009, by county. Within North Carolina, Duplin County had the
highest proportion of Hispanic residents (22.0%), followed by Sampson County (17.0%), Lee
County (17.0%), and Montgomery County (16.5%).
American Indians
American Indians represent 1.2 percent of the N.C. population and are one of the largest
American Indian populations in the U.S. About 45 percent of American Indians in North
Carolina live in Robeson County, followed by Cumberland, Hoke, Mecklenburg, Wake, Jackson,
and Scotland counties. Map 4 (Appendix A, pg. A-6) displays the proportion of the American
Indian population in 2009 by county. The 2009 N.C. Health Profile shows that American
Indians experience higher death rates due to heart disease, stroke, homicide, diabetes, kidney
disease, and unintentional motor vehicle injuries compared to the white population.
Foreign-born Population
According to the Center for Immigration Studies, North Carolina has experienced a dramatic
increase in its immigrant population. The immigrant population in North Carolina has increased
three and one-half times between 1995 and 2007 (Camarota, 2007). According to the US Census
Bureau’s Annual American Community Survey, North Carolina’s foreign-born population
increased by 38 percent from 2002 to 2008 (480,248 to 665,270). In 2006, North Carolina ranked
15th nationally for the admitted number of immigrants from other countries. In 2009, 30.6
percent of the foreign-born populations in North Carolina were naturalized citizens, while 69.4
percent were not citizens. The various regions of birth are displayed in Table 1.4. The majority
(57.3%) of the foreign-born population come from Latin America, with the other 22.2 percent
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from Asia, 11.7 percent from Europe, 5.7 percent from Africa, 2.7 percent from North America,
and 0.5 percent from Oceania.
The majority of the 2009 foreign-born population was male (52.8%) as opposed to female
(47.2%). A majority (50%) of the foreign-born population is between ages 25 to 44 years (Table
1.5). About 83 percent speak a language other than English at home and 50 percent do not speak
English “very well.”
Table 1.3. North Carolina bridged-race population estimates by race/ethnicity, 2009
Male Female Total
Race/Ethnicity Population Percent Population Percent Population Percent
White* 3,088,480 67.3% 3,233,757 67.5% 6,322,237 67.4%
Black* 950,549 20.7% 1,076,621 22.5% 2,027,170 21.6%
AI/AN* 53,326 1.2% 56,249 1.2% 109,575 1.2%
Asian/PI* 99,748 2.2% 104,492 2.2% 204,240 2.2%
Hispanic 398,082 8.7% 319,580 6.7% 717,662 7.7%
Total 4,590,185 100.0% 4,790,699 100.0% 9,380,884 100.0%
* non-Hispanic; AI/AN=American Indian/Alaska Native, PI=Pacific Islander
National Center for Health Statistics (NCHS), Bridged-Race Population Estimates, January 2011
Table 1.4. North Carolina foreign-born population by region of birth, 2008
Region 2008
Estimated number Percentage
Europe 77,661 11.7%
Asia 147,358 22.2%
Africa 37,723 5.7%
Oceania 3,138 0.5%
Latin America 381,445 57.3%
North America 17,945 2.7%
Total 665,270 100.0%
Source: US Census Bureau, 2009 American Community Survey
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Table 1.5. Gender and age distribution of foreign-born and total population in N.C., 2008
Demographics N.C. population Foreign-born
N=9,380,884 N=665,270
Gender Male 48.8% 52.8% Female 51.2% 47.2%
Under 5 years 7.0% 1.0%
5–17 years 17.3% 9.5%
18–24 years 10.2% 11.4%
25–44 years 27.2% 50.4%
45–54 years 14.1% 13.9%
55–64 years 11.5% 7.1%
65–74 years 7.0% 4.1%
Age
75 + years 5.7% 2.7%
Source: US Census Bureau, 2009 American Community Survey
Metropolitan and Micropolitan Statistical Areas
Metropolitan and Micropolitan Statistical Areas are population areas that represent the social and
economic linkages and commuting patterns between urban cores and outlying integrated areas.
These areas are collectively referred to as Core Based Statistical Areas (CBSAs), with a metro
area containing a core urban area of 50,000 or more population, and a micro area containing an
urban core of at least 10,000 (but less than 50,000) population (U.S. Census Bureau, Population
Division). A complete listing of all micropolitan, metropolitan, and combined statistical areas
can be obtained at the following website:
http://www.census.gov/population/www/estimates/metrodef.html. In the HIV/AIDS Surveillance
Supplemental Report, Volume 13 Number 2, the Centers for Disease Control and Prevention
(CDC) divides metropolitan areas into large (population greater than or equal to 500,000) and
medium-sized metropolitan areas (population 50,000 to 499,999), which are all defined as urban
areas. Areas other than metropolitan areas (including micropolitan and non-metropolitan areas)
are defined as rural areas. Eleven North Carolina counties, including Anson, Cabarrus, Franklin,
Gaston, Guilford, Johnston, Mecklenburg, Randolph, Rockingham, Union and Wake County, are
classified as large metropolitan areas, while other metropolitan counties are classified as
medium-sized metropolitan areas. About 35 percent of the N.C. population resides in large
metropolitan areas, 35 percent in medium-sized metropolitan areas, 22 percent in micropolitan
areas, and 8 percent in non-metropolitan areas in 2009. Asian and Pacific Islanders have the
highest proportion (56.7%) living in the large metropolitan areas, followed by Hispanics
(42.9%). Similar proportions (around 34%) of all race/ethnic groups, except American Indians
(18.0%), live in medium-sized metropolitan areas.
Data from the U.S. Census showed that in 2006, 65 percent of the general population of the
United States was living in large metropolitan areas, 19 percent in medium-size metropolitan
areas, and 17 percent in areas other than metropolitan, i.e. rural areas. Compared to national
figures, North Carolina has less people in urban areas, substantially less in large metropolitan
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areas, and more people in rural areas. In North Carolina, a majority of Asians (88%) live in
urban areas, followed by Hispanics (76%) and blacks (72%). A majority of American Indians
(69%) live in rural areas (Tables 1.6 and 1.7). North Carolina’s metropolitan and non-metropolitan
counties are displayed in Map 2 (Appendix A, pg. A-4).
Table 1.6. North Carolina population by race/ethnicity for urban areas, 2009
Large Metropolitan areas Medium Metropolitan
Race/ areas Urban total
Ethnicity
Population Percent Population Percent Population Percent
White* 2,151,894 64.1% 2,249,079 68.8% 4,400,973 66.4%
Black* 769,348 22.9% 693,577 21.2% 1,462,925 22.1%
AI/AN* 14,229 0.4% 19,758 0.6% 33,987 0.5%
Asian, PI* 115,818 3.4% 64,936 2.0% 180,754 2.7%
Hispanic 307,824 9.2% 239,475 7.3% 547,299 8.3%
Total 3,359,113 35.8% 3,266,825 34.8% 6,625,938 70.6%
* non-Hispanic; AI/AN=American Indian/Alaska Native, PI=Pacific Islander
National Center for Health Statistics (NCHS), Bridged-Race Population Estimates, January 2011
Table 1.7. North Carolina population by race/ethnicity for rural areas, 2009
Race/ Micro Metropolitan areas Non-Metropolitan areas Rural total
Ethnicity Population Percent Population Percent Population Percent
White* 1,428,791 70.4% 492,473 67.8% 1,921,264 69.7%
Black* 399,374 19.7% 164,871 22.7% 564,245 20.5%
AI/AN* 61,029 3.0% 14,559 2.0% 75,588 2.7%
Asian, PI* 19,723 1.0% 3,763 0.5% 23,486 0.9%
Hispanic 119,803 5.9% 50,560 7.0% 170,363 6.2%
Total 2,028,720 21.6% 726,226 7.7% 2,754,946 29.4%
* non-Hispanic; AI/AN=American Indian/Alaska Native, PI=Pacific Islander
National Center for Health Statistics (NCHS), Bridged-Race Population Estimates, January 2011
In 2009, a majority of whites, blacks, Hispanics, and Asians lived in urban areas, while the
majority of American Indians lived in rural areas.
HEALTH INDICATORS
Poverty and Income
Contextual factors such as poverty, income, and education, as well as racial segregation,
discrimination, and incarceration rates influence sexual behavior and sexual networks. These
factors likely contribute substantially to the persistence of marked racial disparities in rates of
STDs (Adimora and Schoenbach 2005).
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According to the US Department of Commerce’s Bureau of Economic Analysis, the 2010 per
capita income for North Carolina is $35,638, or 87.8 percent of the national average of $40,584.
This figure represents a 2.5 percent decrease from 2009 and placed North Carolina 37th in the
nation for personal per capita income and 4th in the Southeast.
Economic recession has impacted North Carolina more than the national average. According to
the Bureau of Labor Statistics, the unemployment rate in North Carolina rose from 5.0 percent in
January 2008 to 8.5 percent in December 2008 to 11.3 percent in December 2009 but has gone
down slightly to 9.8 percent in December 2010. These rates are all higher than the national
unemployment rate (the national unemployment rate was 5.0 percent in January 2008 to 7.3
percent in December 2008 to 9.9 percent in December 2009 and to 9.4 percent in December
2010) (Bureau of Labor Statistics).
According to Income, Earnings, and Poverty Data from the 2009 American Community Survey,
16.3 percent of North Carolinians are living under the poverty line (while 14.3% nationally).
From 2008 to 2009, 19.7 percent of North Carolinians were below the federal poverty level
(FPL); with an overall total of 39.9 percent of the population considered low income (199% or
below FPL). The median household income in North Carolina was $43,674, a figure much lower
than the national median of $50,221. North Carolina ranked 14th in percentage of people in
poverty in 2009. Table 1.8 displays the individual poverty rate by age group for the state (2008–
2009) and the nation (2009). Table 1.9 displays the individual poverty rate by race/ethnicity for
North Carolina and the United States (2008–2009). Map 7 (Appendix A, pg. A-9) displays the
N.C. per capita income for 2009 by county.
Health Insurance
The percentage of the non-elderly without health insurance in North Carolina has been
increasing over the years. In North Carolina (2008–2009), 23 percent of persons ages 19 to 64
years were uninsured (statehealthfacts.org. Kaiser Family Foundation). The primary reason
people lack health insurance is financial. According to statehealthfacts.org, 39 percent of the
non-elderly (0–64 year olds) uninsured had incomes less than 100 percent of the Federal Poverty
Guidelines.
Table 1.8. North Carolina and U.S. poverty rates by age, 2008–2009
Age in Years N.C. U.S.
Children 0–18 27% 27%
Adults 19–64 18% 17%
Elderly 65+ 14% 14%
Source: Urban Institute and Kaiser Family Foundation
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†non-elderly *non-Hispanic *non-Hispanic
Among the non-elderly (0–64 years old), 47 percent of those without health insurance in North
Carolina were white, 24.7 percent were black, and 20.6 percent were Hispanic
(statehealthfacts.org. Kaiser Family Foundation). The racial distribution of non-elderly uninsured
people in North Carolina is displayed in Figure 1.1.
Figure 1.2 displays the uninsured rates by race/ethnicity for North Carolina as compared to the
United States. In 2008 to 2009, 47 percent of Latinos or Hispanics, 22 percent of blacks, 13
percent of whites, and 25 percent of other races were uninsured in North Carolina
(statehealthfacts.org. Kaiser Family Foundation). Rates of uninsured among all racial/ethnic
groups in North Carolina were higher than those in the nation. Although whites comprise the
greatest proportion of the uninsured population (Figure 1.1), minorities have the highest
uninsured rates (Figure 1.2). Hispanics in North Carolina are more likely to be uninsured because
they are often recent immigrants with low-wage jobs in industries that do not offer health
insurance.
Table 1.9. North Carolina and U.S. poverty rates by race/ethnicity, 2008–2009
Individual Poverty Rate
Race/Ethnicity (% of each group at or below the federal poverty level)
N.C. (Pct.) US (Pct.)
White* 13% 13%
Black* 33% 35%
Hispanic 40% 34%
Other* 25% 23%
* non-Hispanic Source: Urban Institute and Kaiser Family Foundation
Figure 1.1. Distribution of uninsured†
by race/ethnicity, 2008–2009
Other*
7.7%
Black*
24.7%
White*
47%
Hispanic
20.6%
Figure 1.2. Percent of uninsured
by race/ethnicity, 2008–2009
14
21 24
49
14
23
18
34
0
10
20
30
40
50
60
White* Black* Other* Hispanic
Percent
N.C. U.S.
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Figure 1.3. N.C. Medicaid recipients by race, 2008
Black*
38% White*
45%
Other
17%
*non-Hispanic
Education
According to the 2009 American Community Survey, 84.3 percent of North Carolinians who
were 25 years or older had a high school diploma or higher and 26.5 percent had a bachelor’s
degree or higher. Around five percent of high school students (grades 9–12) dropped out during
the 2008 to 2009 school year (N.C. Public Schools Statistical Profile, 2010).
Internet access
To some extent, health education depends on the facilities at home and in the communities. The
internet has become one of the most important venues in health education. In 2007, North
Carolina ranked 42nd for the percentage of households with computers (57.7%), and 40th for the
percentage of households with internet access (56.8%).
Public Aid
Total Medicaid and
Medicaid-related
expenditures in North
Carolina for State Fiscal Year
(SFY) 2008 were
approximately $9 billion for
approximately 1.7 million
Medicaid recipients (an
average $5,262 per recipient).
The number of Medicaid
recipients increased by 2.6
percent from 2007 to 2008.
A total of 1,726,412 North
Carolinians, or 18.7 percent
of the total N.C. population,
received at least one
Medicaid service during the
2008 fiscal year (N.C.
Medicaid Report 2008). Among them, 40 percent were male and 60 percent were female.
Elderly and Disabled recipients comprised about 13.1 and 15.5 percent of total Medicaid
recipients, respectively, and their expenditures amounted to $6.2 billion or 65 percent of the total
service expenditures. Families and Children comprised 70 percent of all recipients, accounting
for $3 billion or about 34 percent of total service expenditures. Aliens and Refugees represented
1.3 percent of all recipients and accounted for about $67.8 million, or about 0.8 percent of total
service expenditures. Of all Medicaid services provided, Nursing Facility, Inpatient Hospital,
Prescription Drug, and Non-Physician Practitioner services were the top four expensive services
and accounted for about $4 billion, or 45 percent of total expenditures. Figure 1.3 displays the
percentage of North Carolinians by race who received Medicaid in 2008. Map 8 (Appendix A,
pg. A-10) displays the percent of Medicaid eligibles by county for 2010. (For more information
see http://www.ncdhhs.gov/dma/2008report/2008tables.pdf ).
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2009 by selected gender and age groups. The trend in North Carolina follows the typical age
trend of slightly more males under 12 years old and more females in the older age groups. North
Carolina has a younger population than other states, ranking 10th in the nation in 2009 for people
under 18 years of age.
Table 1.1. North Carolina bridged-race population estimates by age group, 2009
Male Female Total
Age Population Percent Population Percent Population Percent
0-12 years 852,562 9.1% 814,513 8.7% 1,667,075 17.8%
13-14 years 123,186 1.3% 116,919 1.2% 240,105 2.6%
15-19 years 331,810 3.5% 313,702 3.3% 645,512 6.9%
20-24 years 352,186 3.8% 315,417 3.4% 667,603 7.1%
25-29 years 318,747 3.4% 312,056 3.3% 630,803 6.7%
30-34 years 297,877 3.2% 306,767 3.3% 604,644 6.4%
35-39 years 329,377 3.5% 333,088 3.6% 662,465 7.1%
40-44 years 324,252 3.5% 331,509 3.5% 655,761 7.0%
45-49 years 336,379 3.6% 352,478 3.8% 688,857 7.3%
50-54 years 311,837 3.3% 333,787 3.6% 645,624 6.9%
55-59 years 274,939 2.9% 302,483 3.2% 577,422 6.2%
60-64 years 238,302 2.5% 264,686 2.8% 502,988 5.4%
65+ years 498,731 5.3% 693,294 7.4% 1,192,025 12.7%
Total 4,590,185 48.9% 4,790,699 51.1% 9,380,884 100.0%
National Center for Health Statistics (NCHS), Bridged-Race Population Estimates, January 2011
Gender differences also exist in terms of vulnerability to illness, access to preventive and
curative measures, burdens of diseases, and quality of care in North Carolina. Table 1.2 displays
the percentages of males and females for the major race/ethnicity categories by North Carolina
regions. Race/ethnicity also varies by region with a larger proportion of white non-Hispanics in
Western Region, American Indians in Eastern Region, and black non-Hispanics in Eastern
Region. A state map showing the N.C regions is displayed on the inside back cover.
NC Epidemiologic Profile for HIV/STD Prevention and Care Planning (12/11) Chapter 1
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Race/Ethnicity and Gender
The racial and ethnic differences of a population play an important role in interpreting gaps in
access to health care among the different groups, and these differences are especially true in
terms of HIV disease surveillance and intervention. Previous HIV disease surveillance showed
that HIV disproportionately affected ethnic minorities in North Carolina. North Carolina has the
18th largest non-white population in the United States (3,058,647 in year 2009) and there are
noticeable variations in the demographic composition of North Carolina from region to region.
Usually, non-white minorities have poorer health conditions and less access to health care. In
2009, 14 counties had populations consisting of more than 50 percent non-white residents
(Robeson: 71.0%; Hertford: 65.1%; Bertie: 64.9%; Edgecombe: 61.6%; Warren: 61.4%;
Northampton: 59.8%; Halifax: 59.4%; Vance: 56.9 %; Hoke: 55.8%; Washington: 55.0%;
Durham: 54.2%; Greene: 53.6%; Anson: 51.3% and Scotland: 50.7%). Maps 3-6 (Appendix A,
pp.A-5 to A-8) display the racial and ethnic make-up of North Carolina’s counties, as reported in
the 2009 bridged-race estimates (please see Appendix C, pg. C-5 for more information about
Census data and the bridged-race categories used to calculate rates). Table 1.3 displays the
populations for the major race/ethnicity categories in North Carolina according to the bridged-race
estimates for 2009.
Table 1.2. North Carolina race/ethnicity proportions by gender and geographic region, 2009
Western Piedmont Eastern N.C.
Race/Ethnicity Pct. Pct. Pct. Pct.
Male White* 42.7% 32.3% 30.1% 32.9%
Black* 2.4% 10.1% 13.4% 10.1%
AI/AN* 0.5% 0.2% 1.4% 0.6%
Asian/PI* 0.5% 1.5% 0.5% 1.1%
Hispanic 2.7% 4.9% 3.6% 4.2%
Total 48.8% 48.9% 49.0% 48.9%
Female White* 45.7% 33.9% 30.9% 34.5%
Black* 2.4% 11.6% 15.1% 11.5%
AI/AN* 0.5% 0.2% 1.5% 0.6%
Asian/PI* 0.5% 1.5% 0.6% 1.1%
Hispanic 2.1% 3.9% 2.9% 3.4%
Total 51.2% 51.1% 51.0% 51.1%
Total White* 88.3% 66.1% 61.0% 67.4%
Black* 4.8% 21.8% 28.5% 21.6%
AI/AN* 1.0% 0.4% 2.8% 1.2%
Asian/PI* 1.0% 2.9% 1.2% 2.2%
Hispanic 4.8% 8.8% 6.5% 7.7%
Total 100.0% 100.0% 100.0% 100.0%
* non-Hispanic; AI/AN=American Indian/Alaska Native, PI=Pacific Islander
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Blacks
In 2009, North Carolina ranked 8th highest in percentage of blacks nationwide. According to the
N.C. Health Profile 2009, compared to whites, blacks have higher death rates from heart disease,
cancer, HIV, diabetes, homicide, and stroke. North Carolina has seven counties in which blacks
comprise more than 50 percent of the total population (Bertie 62.9 %, Hertford 61.3%,
Northampton 57.9%, Edgecombe 56.4%, Halifax 53.8%, and Warren County 53.0%). Map 3
(Appendix A, pg. A-5) displays the proportion of black population in 2009 by county.
Hispanics
From 2002 to 2009, the estimated Hispanic/Latino population in North Carolina increased by
59.1 percent, from 451,095 to 717,662. Hispanics represented 7.7 percent of the population of
the state and ranked 26th nationally. North Carolina ranked 10th in Hispanic births in 2008.
Compared to other ethnic groups in North Carolina, Hispanics are a relatively young population.
Although the median age of the non-Hispanic population is 38.3 years, the median age of
Hispanics is 23.7 years. Seventy percent (70%) of Hispanics are under 35 years old, while only
46 percent of the non-Hispanic population is under 35. Map 5 (Appendix A, pg. A-7) displays
the proportion of the Hispanic population in 2009 by county. In North Carolina, Duplin County
had the highest proportion of Hispanic residents (22.0%), followed by Sampson County (17.0%),
Lee County (17.0%), and Montgomery County (16.5%).
American Indians
American Indians represent 1.2 percent of the N.C. population and are one of the largest
American Indian populations in the United States. About 45 percent of American Indians in
North Carolina live in Robeson County, followed by Cumberland, Hoke, Mecklenburg, Wake,
Jackson, and Scotland counties. Map 4 (Appendix A, pg. A-6) displays the proportion of
Hispanic population in 2009 by county. The 2009 N.C. Health Profile shows that American
Indians experience higher death rates due to heart disease, stroke, homicide, diabetes, kidney
disease, and unintentional motor vehicle injuries compared to the white population.
Foreign-born Population
According to the Center for Immigration Studies, North Carolina has experienced a dramatic
increase in its immigrant population. The immigrant population in North Carolina has increased
three and one-half times between 1995 and 2007 (Camarota, 2007). According to the U.S.
Census Bureau’s Annual American Community Survey, North Carolina’s foreign-born
population increased by 38 percent from 2002 to 2008 (480,248 to 665,270). In 2006, North
Carolina ranked 15th nationally for the admitted number of immigrants from other countries. In
2009, 30.6 percent of the foreign-born populations in North Carolina were naturalized citizens,
while 69.4 percent were not citizens. The various regions of birth are displayed in Table 1.4.
The majority (57.3%) of the foreign-born population comes from Latin America, with the other
22.2 percent from Asia, 11.7 percent from Europe, 5.7 percent from Africa, 2.7 percent from
North America, and 0.5 percent from Oceania.
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The majority of the 2009 foreign-born population was male (52.8%) as opposed to female
(47.2%). A majority (50%) of the foreign-born population is between ages 25 to 44 years (Table
1.5). About 83 percent speak a language other than English at home and 50 percent do not speak
English “very well.”
Table 1.3. North Carolina bridged-race population estimates by race/ethnicity, 2009
Male Female Total
Race/Ethnicity Population Percent Population Percent Population Percent
White* 3,088,480 67.3% 3,233,757 67.5% 6,322,237 67.4%
Black* 950,549 20.7% 1,076,621 22.5% 2,027,170 21.6%
AI/AN* 53,326 1.2% 56,249 1.2% 109,575 1.2%
Asian/PI* 99,748 2.2% 104,492 2.2% 204,240 2.2%
Hispanic 398,082 8.7% 319,580 6.7% 717,662 7.7%
Total 4,590,185 100.0% 4,790,699 100.0% 9,380,884 100.0%
* non-Hispanic; AI/AN=American Indian/Alaska Native, PI=Pacific Islander
National Center for Health Statistics (NCHS), Bridged-Race Population Estimates, January 2011
Table 1.4. North Carolina foreign-born population by region of birth, 2008
Region 2008
Estimated number Percentage
Europe 77,661 11.7%
Asia 147,358 22.2%
Africa 37,723 5.7%
Oceania 3,138 0.5%
Latin America 381,445 57.3%
North America 17,945 2.7%
Total 665,270 100.0%
Source: U.S. Census Bureau, 2009 American Community Survey
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Table 1.5. Gender and age distribution of foreign-born and total population in N.C., 2008
Demographics N.C. population Foreign-born
N=9,380,884 N=665,270
Gender Male 48.8% 52.8% Female 51.2% 47.2%
Under 5 years 7.0% 1.0%
5–17 years 17.3% 9.5%
18–24 years 10.2% 11.4%
25–44 years 27.2% 50.4%
45–54 years 14.1% 13.9%
55–64 years 11.5% 7.1%
65–74 years 7.0% 4.1%
Age
75 + years 5.7% 2.7%
Source: U.S. Census Bureau, 2009 American Community Survey
Metropolitan and Micropolitan Statistical Areas
Metropolitan and Micropolitan Statistical Areas are population areas that represent the social and
economic linkages and commuting patterns between urban cores and outlying integrated areas.
These areas are collectively referred to as Core Based Statistical Areas (CBSAs), with a metro
area containing a core urban area of 50,000 or more population, and a micro area containing an
urban core of at least 10,000 (but less than 50,000) population (U.S. Census Bureau, Population
Division). A complete listing of all micropolitan, metropolitan, and combined statistical areas
can be obtained at the following website:
http://www.census.gov/population/metro/data/metrodef.html.
In the HIV/AIDS Surveillance Supplemental Report, Volume 13 Number 2, the Centers for
Disease Control and Prevention (CDC) divides metropolitan areas into large (population greater
than or equal to 500,000) and medium-sized metropolitan areas (population 50,000 to 499,999),
which are all defined as urban areas. Areas other than metropolitan areas (including micropolitan
and non-metropolitan areas) are defined as rural areas. Eleven North Carolina counties,
including Anson, Cabarrus, Franklin, Gaston, Guilford, Johnston, Mecklenburg, Randolph,
Rockingham, Union and Wake County, are classified as large metropolitan areas, while other
metropolitan counties are classified as medium-sized metropolitan areas. About 35 percent of the
N.C. population resides in large metropolitan areas, 35 percent in medium-sized metropolitan
areas, 22 percent in micropolitan areas, and 8 percent in non-metropolitan areas in 2009. Asian
and Pacific Islanders have the highest proportion (56.7%) living in the large metropolitan areas,
followed by Hispanics (42.9%). Similar proportions (around 34%) of all race/ethnic groups,
except American Indians (18.0%), live in medium-sized metropolitan areas.
Data from the U.S. Census showed that in 2006, 65 percent of the general population of the
United States was living in large metropolitan areas, 19 percent in medium-size metropolitan
areas, and 17 percent in areas other than metropolitan, i.e. rural areas. Compared to national
NC Epidemiologic Profile for HIV/STD Prevention and Care Planning (12/11) Chapter 1
NC DHHS 12 Communicable Disease
figures, North Carolina has less people in urban areas, substantially less in large metropolitan
areas, and more people in rural areas. In North Carolina, a majority of Asians (88%) live in
urban areas, followed by Hispanics (76%) and blacks (72%). A majority of American Indians
(69%) live in rural areas (Tables 1.6 and 1.7). North Carolina’s metropolitan and non-metropolitan
counties are displayed in Map 2 (Appendix A, pg. A-4).
Table 1.6. North Carolina population by race/ethnicity for urban areas, 2009
Large Metropolitan areas Medium Metropolitan
Race/ areas Urban total
Ethnicity
Population Percent Population Percent Population Percent
White* 2,151,894 64.1% 2,249,079 68.8% 4,400,973 66.4%
Black* 769,348 22.9% 693,577 21.2% 1,462,925 22.1%
AI/AN* 14,229 0.4% 19,758 0.6% 33,987 0.5%
Asian, PI* 115,818 3.4% 64,936 2.0% 180,754 2.7%
Hispanic 307,824 9.2% 239,475 7.3% 547,299 8.3%
Total 3,359,113 35.8% 3,266,825 34.8% 6,625,938 70.6%
* non-Hispanic; AI/AN=American Indian/Alaska Native, PI=Pacific Islander
National Center for Health Statistics (NCHS), Bridged-Race Population Estimates, January 2011
Table 1.7. North Carolina population by race/ethnicity for rural areas, 2009
Race/ Micro Metropolitan areas Non-Metropolitan areas Rural total
Ethnicity Population Percent Population Percent Population Percent
White* 1,428,791 70.4% 492,473 67.8% 1,921,264 69.7%
Black* 399,374 19.7% 164,871 22.7% 564,245 20.5%
AI/AN* 61,029 3.0% 14,559 2.0% 75,588 2.7%
Asian, PI* 19,723 1.0% 3,763 0.5% 23,486 0.9%
Hispanic 119,803 5.9% 50,560 7.0% 170,363 6.2%
Total 2,028,720 21.6% 726,226 7.7% 2,754,946 29.4%
* non-Hispanic; AI/AN=American Indian/Alaska Native, PI=Pacific Islander
National Center for Health Statistics (NCHS), Bridged-Race Population Estimates, January 2011
In 2009, a majority of whites, blacks, Hispanics, and Asians lived in urban areas, while the
majority of American Indians lived in rural areas.
HEALTH INDICATORS
Poverty and Income
Contextual factors such as poverty, income, and education, as well as racial segregation,
discrimination, and incarceration rates influence sexual behavior and sexual networks. These
NC Epidemiologic Profile for HIV/STD Prevention and Care Planning (12/11) Chapter 1
NC DHHS 13 Communicable Disease
factors likely contribute substantially to the persistence of marked racial disparities in rates of
STDs (Adimora and Schoenbach 2005).
According to the U.S. Department of Commerce’s Bureau of Economic Analysis, the 2010 per
capita income for North Carolina is $35,638, or 87.8 percent of the national average of $40,584.
This figure represents a 2.5 percent decrease from 2009 and placed North Carolina 37th in the
nation for personal per capita income and 4th in the Southeast.
The economic recession has impacted North Carolina more than the national average. According
to the Bureau of Labor Statistics, the unemployment rate in North Carolina rose from 5.0 percent
in January 2008 to 8.5 percent in December 2008 to 11.3 percent in December 2009, but went
down slightly to 9.8 percent in December 2010. These rates are all higher than the national
unemployment rate (the national unemployment rate was 5.0 percent in January 2008 to 7.3
percent in December 2008 to 9.9 percent in December 2009 and to 9.4 percent in December
2010) (Bureau of Labor Statistics).
According to Income, Earnings, and Poverty Data from the 2009 American Community Survey,
16.3 percent of North Carolinians were living under the poverty line (while 14.3% nationally).
From 2008 to 2009, 19.7 percent of North Carolinians were below the federal poverty level
(FPL); with an overall total of 39.9 percent of the population considered low income (199% or
below FPL). The median household income in North Carolina was $43,674, a figure much lower
than the national median of $50,221. North Carolina ranked 14th in percentage of people in
poverty in 2009. Table 1.8 displays the individual poverty rate by age group for the state (2008–
2009) and the nation (2009). Table 1.9 displays the individual poverty rate by race/ethnicity for
North Carolina and the United States (2008–2009). Map 7 (Appendix A, pg. A-9) displays the
N.C. per capita income for 2009 by county.
Health Insurance
The percentage of the non-elderly without health insurance in North Carolina has been
increasing over the years. In North Carolina (2008–2009), 23 percent of persons ages 19 to 64
years were uninsured (statehealthfacts.org. Kaiser Family Foundation). According to
statehealthfacts.org, 39 percent of the non-elderly (0–64 year olds) uninsured had incomes less
than 100 percent of the Federal Poverty Guidelines.
Table 1.8. North Carolina and U.S. poverty rates by age, 2008–2009
Age in Years N.C. U.S.
Children 0–18 27% 27%
Adults 19–64 18% 17%
Elderly 65+ 14% 14%
Source: Urban Institute and Kaiser Family Foundation
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†non-elderly *non-Hispanic *non-Hispanic
Among the non-elderly (0–64 years old), 47 percent of those without health insurance in North
Carolina were white, 24.7 percent were black, and 20.6 percent were Hispanic
(statehealthfacts.org, Kaiser Family Foundation). The racial distribution of non-elderly uninsured
people in North Carolina is displayed in Figure 1.1.
Figure 1.2 displays the uninsured rates by race/ethnicity for North Carolina as compared to the
United States. In 2008 to 2009, 47 percent of Latinos or Hispanics, 22 percent of blacks, 13
percent of whites, and 25 percent of other races were uninsured in North Carolina
(statehealthfacts.org. Kaiser Family Foundation). Rates of uninsured among all racial/ethnic
groups in North Carolina were higher than those in the nation. Although whites comprise the
greatest proportion of the uninsured population (Figure 1.1), minorities have the highest
uninsured rates (Figure 1.2). Hispanics in North Carolina are more likely to be uninsured because
they are often recent immigrants with low-wage jobs in industries that do not offer health
insurance.
Table 1.9. North Carolina and U.S. poverty rates by race/ethnicity, 2008–2009
Individual Poverty Rate
Race/Ethnicity (% of each group at or below the federal poverty level)
N.C. (Pct.) US (Pct.)
White* 13% 13%
Black* 33% 35%
Hispanic 40% 34%
Other* 25% 23%
* non-Hispanic Source: Urban Institute and Kaiser Family Foundation
Figure 1.1. Distribution of uninsured†
by race/ethnicity, 2008–2009
Other*
7.7%
Black*
24.7%
White*
47%
Hispanic
20.6%
Figure 1.2. Percent of uninsured
by race/ethnicity, 2008–2009
14
21 24
49
14
23
18
34
0
10
20
30
40
50
60
White* Black* Other* Hispanic
Percent
N.C. U.S.
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NC DHHS 15 Communicable Disease
Figure 1.3. N.C. Medicaid recipients by race, 2008
Black*
38% White*
45%
Other
17%
*non-Hispanic
Education
According to the 2009 American Community Survey, 84.3 percent of North Carolinians who
were 25 years or older had a high school diploma or higher and 26.5 percent had a bachelor’s
degree or higher. Around 5 percent of high school students (grades 9–12) dropped out during the
2008 to 2009 school year (N.C. Public Schools Statistical Profile, 2010).
Internet access
The internet has become one of the most important venues for health education. In 2007, North
Carolina ranked 42nd for the percentage of households with computers (57.7%), and 40th for the
percentage of households with internet access (56.8%).
Public Aid
Total Medicaid and
Medicaid-related
expenditures in North
Carolina for State Fiscal Year
(SFY) 2008 were
approximately $9 billion for
approximately 1.7 million
Medicaid recipients (an
average $5,262 per recipient).
The number of Medicaid
recipients increased by 2.6
percent from 2007 to 2008.
A total of 1,726,412 North
Carolinians, or 18.7 percent
of the total N.C. population,
received at least one
Medicaid service during the
2008 fiscal year (N.C.
Medicaid Report 2008). Among them, 40 percent were male and 60 percent were female.
Elderly and Disabled recipients comprised about 13.1 and 15.5 percent of total Medicaid
recipients, respectively, and their expenditures amounted to $6.2 billion or 65 percent of the total
service expenditures. Families and Children comprised 70 percent of all recipients, accounting
for $3 billion or about 34 percent of total service expenditures. Aliens and Refugees represented
1.3 percent of all recipients and accounted for about $67.8 million, or about 0.8 percent of total
service expenditures. Of all Medicaid services provided, Nursing Facility, Inpatient Hospital,
Prescription Drug, and Non-Physician Practitioner services were the top four expensive services
and accounted for about $4 billion, or 45 percent of total expenditures. Figure 1.3 displays the
percentage of North Carolinians by race who received Medicaid in 2008. Map 8 (Appendix A,
pg. A-10) displays the percent of Medicaid eligibles by county for 2010. (For more information
see http://www.ncdhhs.gov/dma/2008report/2008tables.pdf ).
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CHAPTER 2: SCOPE OF THE HIV DISEASE EPIDEMIC IN
NORTH CAROLINA
HIGHLIGHTS
 As of December 31, 2010, the cumulative number of individuals in North Carolina diagnosed
with HIV infection was 38,397 people.
 An estimated 35,000 people were living with HIV/AIDS in North Carolina (including 7,000
individuals who may have been unaware of their infections) as of December 31, 2010.
 The total number of new HIV diagnoses in 2010 was 1,487 (15.9 per 100,000 population)
and the number of new diagnoses of HIV infection among adults/adolescents was 1,482
(19.2 per 100,000 adult/adolescent population).
 In 2010, the rate of new HIV diagnoses for adult/adolescent blacks (59.7 per 100,000) was
more than 10 times greater than that for adult/adolescent whites (5.6 per 100,000). The rate
of new HIV diagnosis for adult/adolescent Hispanics (24.7 per 100,000) was more than four
times greater than for whites.
 The highest rate of new HIV diagnoses in 2010 was among adult/adolescent, black males
(94.0 per 100,000). This rate was eight times greater than the rate for adult/adolescent white
males (11.6 per 100,000). The rate of new HIV diagnoses for adult/adolescent Hispanic
males (35.5 per 100,000) was three times the rate among white males.
 The largest disparity in 2010 was for adult/adolescent black females; with a rate of new HIV
diagnoses (30.5 per 100,000) that was nearly 17 times higher than that of white females (1.8
per 100,000). The rate among Hispanic adult/adolescent females (10.0 per 100,000) was
more than five times the rate among white females.
 For 2010 adult/adolescent HIV disease cases, men who have sex with men (MSM) was the
risk category in an estimated 57 percent of total cases, heterosexual transmission risk was
estimated in 39 percent, and IDU was estimated in 4 percent of total cases (including 1
percent among MSM who also indicated injection drug use).
 In 2010, MSM (including MSM/IDU) accounted for 76 percent of new HIV disease cases
among adult/adolescent males.
 In 2010, heterosexual contact accounted for about 95 percent and injecting drug use
accounted for 5 percent of HIV disease cases for adult/adolescent females.
 Twenty percent (20%) of newly diagnosed HIV disease cases in 2010 were among
adolescent males ages 13 to 24 years old.
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 In 2010, 26.0 percent of newly diagnosed HIV disease cases also represented new AIDS
cases (i.e., HIV and AIDS diagnosed at the same time or within six months).
 Mecklenburg County had the most HIV cases diagnosed in 2010 (n=312), followed by Wake
County (n=172) and Guilford County (n=118).
 In 2010, Edgecombe County had the highest three-year average HIV disease rate (41.0 per
100,000), followed by Mecklenburg County (38.1 per 100,000), Durham County (33.7 per
100,000), Northampton County (31.2 per 100,000), Wilson County (29.0 per 100,000), and
Guilford County (27.5 per 100,000).
 In 2010, HIV/AIDS was listed as the 7th leading cause of death for N.C. adults from 25 to 44
years old. The crude HIV disease death rate for blacks is more than 13 times higher than for
whites (12.1 vs. 0.9 per 100,000).
 From the beginning of the epidemic through December 2010 (1983–2010), 19,761 AIDS
cases have been reported in North Carolina
 North Carolina ranked 11th among the 50 states in AIDS cases diagnosed in 2009 (the most
recent year available for national comparisons) and 13th in the nation in 2008 for estimated
persons living with AIDS.
 Seven hundred ninety-six AIDS cases were diagnosed in North Carolina in 2010 (8.5 per
100,000 population).
Special notes:
 HIV disease includes all initial diagnoses of HIV as well as those diagnosed with AIDS as
their initial diagnosis. More information about this designation of HIV disease can be found
in Appendix C (pg. C-3).
 The HIV disease and AIDS case totals and rates presented in the demographic tables (See
Appendix D: Tables A–H, O–P) and discussed in this document are restricted to
adults/adolescents only for comparability across states and with national data reported by
the Centers for Disease Control and Prevention (CDC). All county totals and references to
cumulative cases and persons living with HIV/AIDS do include the 0 to 12 age group.
 Unless otherwise noted, year refers to year of diagnosis, not year of report, as in previous
publications.
 Unless otherwise noted, references to all racial groups in surveillance data are presented in
a race/ethnic designation. Hispanics are considered a separate racial/ethnic group. Thus,
“white” refers to white non-Hispanics; “black” refers to black non-Hispanics, etc.
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NC DHHS 19 Communicable Disease
OVERALL HIV DISEASE TRENDS
Figure 2.1 displays the number of HIV disease cases diagnosed from 1992 to 2010 by the year of
HIV diagnosis for the individual. New diagnoses for 2010 reflect a continuation of the decline
seen in 2009 and the lowest number of new cases diagnosed since the year 2000. The highest
point in the HIV epidemic occurred in 1992 in North Carolina with 2,202 cases diagnosed and
then moderated from 1995 to 2010 with an average of 1,600 cases (range: 1,400–1,800) each
year. The number of HIV disease cases diagnosed in 1992 represented a time when HIV
incidence was likely at its peak. From 1995 to 2010, the epidemic was relatively stable;
however, changes in reporting practices contributed to the fluctuations during this period,
especially for 2002. The increase in cases in 2007 and 2008 was at least partially a result of
Communicable Disease Branch efforts to increase HIV testing, including the Get Real. Get
Tested campaign, and might not necessarily represent increased incidence. The fact that a
decrease was seen in 2009 and further in 2010 might be evidence of a true decline in incidence;
however, only additional years of data will determine whether this is actually the case.
Figure 2.1. HIV disease cases diagnosed in North Carolina, 1992–2010
1,487
1,628
1,798 1,812
1,642
1,435
2,202
0
500
1,000
1,500
2,000
2,500
1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
Year of Diagnosis
Number of Diagnoses
Please note the numbers in Figure 2.1 (above) are periodically updated due to completion of
information and deletion of interstate duplications. Readers are encouraged to use the numbers
in the latest report.
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NC DHHS 20 Communicable Disease
Figure 2.2. Persons (reported) living with HIV disease in N.C., 2006–2010*
7,035 7,744 8,559 9,440 10,221
11,616 12,559
13,427 14,116
14,833
0
4,000
8,000
12,000
16,000
20,000
24,000
28,000
2006 2007 2008 2009 2010 Number of cases
AIDS HIV(non AIDS)
*represents December 31 of each year
HIV DISEASE PREVALENCE
Prevalent cases represent all individuals living with HIV disease in North Carolina communities.
Information about persons living with HIV disease is very critical for case follow-up, AIDS care
provision, and strategic intervention and testing activities. From the first HIV disease case
diagnosed and reported to the Division of Public Health in 1983, through December 31, 2010,
the cumulative number of HIV disease cases diagnosed in North Carolina is 38,397, of whom
25,074 are living and 13,323 have died. This number includes some HIV-positive individuals
that died of non AIDS-related causes (see pg. 49 for HIV disease related deaths). Figure 2.2
displays the numbers of people living with HIV disease, which represent prevalent cases at the
end of each year from 2006 to 2010. The number of people living with HIV disease has been
increasing every year, indicating that the number of newly diagnosed HIV disease cases exceeds
the number of people who died. Due to the advancement of highly effective anti-retroviral
treatment and opportunistic infection control, people with HIV disease may live longer and
healthier lives.
Persons living with HIV represent individuals that have been diagnosed and subsequently
reported to the North Carolina public health surveillance system. Case counts are affected by
some amount of under-reporting by clinicians as well as people who are infected with HIV but
have not been tested and reported. Efforts to identify the unaware positive population will
increase new diagnoses in the future. However, the current number of total living cases in Figure
2.2 under-represents true HIV prevalence and must be adjusted to account for those who have
been diagnosed but not reported and those who are unaware of their status. One method for
estimating people who are unaware they are HIV positive is based on the CDC estimate that 80
percent of people living with HIV have been tested and know their status. Studies indicate that
the N.C. HIV surveillance system currently captures 85 to 95 percent of HIV diagnoses
(Appendix B, pg. B-3). Applying these two statistics to our current surveillance total of 25,074
people living in North Carolina with HIV/AIDS increases the estimated HIV disease prevalence
in the state to approximately 35,000 people.
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NC DHHS 21 Communicable Disease
Please note HIV disease reports are periodically updated with vital status data available from the
State Center for Health Statistics, thus “living totals” for earlier years, especially for the last two
years, have been revised.
Demographics of Persons Living with HIV Disease
Gender, race/ethnicity, and age distribution
Table 2.1 and Table J (Appendix D, pg. D-13) display the demographics of people living with
HIV disease as of December 31, 2010. Male prevalent cases were 70 percent of the total and
more than double the female prevalence. Blacks comprised the majority (66%) of cases,
followed by whites (26%) and Hispanics (6%). Older individuals represented a larger percentage
of people living with HIV, as people can live for many years on HAART (Highly Active
AntiRetroviral Treatment) with an HIV diagnosis. The greater percentages of males (70%) and
blacks (66%) living with HIV disease indicates that these groups are most affected by the HIV
epidemic in North Carolina.
Table 2.1. North Carolina HIV cases living as of 12/31/2010 by selected demographics
Males Females Total
No. Pct. Rate** No. Pct. Rate** No. Pct. Rate**
17,544 70.0% 382.2 7,530 30.0% 157.2 25,074 100.0% 267.3
Race/Ethnicity
White* 5,216 20.8% 168.9 1,220 4.9% 37.7 6,436 25.7% 101.8
Black* 10,822 43.2% 1138.5 5,828 23.2% 541.3 16,650 66.4% 821.3
AI/AN* 139 0.6% 260.7 63 0.3% 112.0 202 0.8% 184.3
Asian/PI* 85 0.3% 85.2 35 0.1% 33.5 120 0.5% 58.8
Hispanic 1,129 4.5% 283.6 309 1.2% 96.7 1,438 5.7% 200.4
Current Age
0-12 33 0.1% 3.9 24 0.1% 2.9 57 0.2% 3.4
13-14 10 0.0% 8.1 15 0.1% 12.8 25 0.1% 10.4
15-19 100 0.4% 30.1 72 0.3% 23.0 172 0.7% 26.6
20-24 741 3.0% 210.4 215 0.9% 68.2 956 3.8% 143.2
25-29 1,201 4.8% 376.8 407 1.6% 130.4 1,608 6.4% 254.9
30-34 1,518 6.1% 509.6 673 2.7% 219.4 2,191 8.7% 362.4
35-39 1,695 6.8% 514.6 1,054 4.2% 316.4 2,749 11.0% 415.0
40-44 2,670 10.6% 823.4 1,256 5.0% 378.9 3,926 15.7% 598.7
45-49 3,352 13.4% 996.5 1,387 5.5% 393.5 4,739 18.9% 688.0
50-54 2,769 11.0% 888.0 1,067 4.3% 319.7 3,836 15.3% 594.2
55-59 1,713 6.8% 623.0 670 2.7% 221.5 2,383 9.5% 412.7
60-64 877 3.5% 368.0 372 1.5% 140.5 1,249 5.0% 248.3
65+ 623 2.5% 124.9 239 1.0% 34.5 862 3.4% 72.3
*non-Hispanic; AI/AN=American Indian/Alaska Native; PI=Pacific Islander **per 100,000 population
NC Epidemiologic Profile for HIV/STD Prevention and Care Planning (12/11) Chapter 2
NC DHHS 22 Communicable Disease
Mode of Transmission for HIV Prevalent Cases
Information about modes of transmission of HIV is very useful for disease prevention; without
effective behavioral interventions for people living with HIV disease, they may continue to
transmit HIV to others. Table I (Appendix D, pg. D-12) shows that 46 percent of living cases
were likely infected through MSM activities, 38 percent through heterosexual transmission, 11
percent through injection drug use practices (IDU), and 3 percent through MSM/IDU activities.
NEWLY DIAGNOSED HIV DISEASE CASES IN 2010
In 2010, 1,487 (15.9 per 100,000) individuals were newly diagnosed with HIV infection in North
Carolina. Of the newly diagnosed persons, 1,482 of them were over 13 years old, which makes
the rate of HIV infection among adults/adolescents 19.2 per 100,000 (Table 2.2.).
Gender and race/ethnicity
Among individuals diagnosed with HIV disease in 2010, about three times as many were male
compared to female. Table 2.2 displays the gender and race/ethnicity distribution of newly
diagnosed HIV disease among adults/adolescents for 2010.
Among the adult/adolescent population newly diagnosed with HIV disease in 2010, blacks made
up the majority of cases (65.7%), followed by whites (23.9%), and Hispanics (7.8%). Over the
previous five years (2006–2010), blacks have consisted of about 65 percent, whites 26 percent,
and Hispanics around 8 percent of total cases, as shown in Figure 2.3 and Table B (Appendix D,
pg. D-5). HIV disease rates are different from the proportion of HIV cases because rates take
into account the race/ethnicity of the state’s population. The highest rate of newly diagnosed
HIV disease was among black males (94.0 per 100,000 adult/adolescent population), which was
eight times that for white males (11.6 per 100,000 adult/adolescent population). The HIV
disease rate among adult/adolescent black females (30.5 per 100,000 adult/adolescent
population) was nearly 17 times higher than the rate for adult/adolescent white females (1.8 per
100,000), which represented the largest disparity noted within gender and race/ethnicity
categories.
Table 2.2. N.C. adult/adolescent HIV disease cases by gender and race/ethnicity, 2010
Race/ Males Females Total
Ethnicity No. Pct. Rate** No. Pct. Rate** No. Pct. Rate**
White* 300 20% 11.6 50 3% 1.8 350 24% 6.5
Black* 706 48% 94.0 269 18% 30.5 975 66% 59.7
AI/AN* 3 0% 7.1 1 0% 2.2 4 0% 4.5
Asian/PI* 7 0% 9.0 2 0% 2.4 9 1% 5.6
Hispanic 97 7% 35.5 20 1% 10.0 117 8% 24.7
Multiple* 15 1% --- 12 1% --- 27 2% ---
Total 1,128 76% 30.2 354 24% 8.9 1,482 100% 19.2
*non-Hispanic; AI/AN=American Indian/Alaska Native; PI=Pacific Islander **per 100,000 adult/adolescent population
NC Epidemiologic Profile for HIV/STD Prevention and Care Planning (12/11) Chapter 2
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Figure 2.4. Adult/adolescent HIV disease rates by race/ethnicity and gender, 2006–2010
Disparities also existed for Hispanics as compared to whites. The rate for adult/adolescent
Hispanic men (35.5 per 100,000) was more than three times the rate for white men, and Hispanic
males ranked second highest among the gender and race/ethnicity rates. The rate for
adult/adolescent Hispanic women (10.0 per 100,000) was more than five times that for white
women. Rates for other racial/ethnic groups are based on numbers too small for meaningful
comparisons but are displayed in Table 2.2. Figure 2.3 shows that the proportions of racial
composition of HIV disease cases remained stable over the last five years, and blacks have
consistently represented over 60 percent of HIV disease cases. Figure 2.4 shows the gender and
race/ethnicity (for whites, blacks, and Hispanics) specific HIV disease rates. From 2006 to 2010,
HIV disease rates for black males have increased slightly while the rates for black females,
Hispanic females, and white men have decreased slightly.
0%
10%
20%
30%
40%
50%
60%
70%
2006 2007 2008 2009 2010
Proportion
White*
Black*
Hispanic
0
20
40
60
80
100
120
2005 2006 2007 2008 2009
Rate per 100,000
White* male
White* female
Black* male
Black* female
Hispanic male
Hispanic female
Figure 2.3. Adult/adolescent HIV disease proportions by race/ethnicity, 2006–2010
*non-Hispanic
*non-Hispanic
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Age distribution
Most HIV disease diagnoses in 2010 were for adults and adolescents, with less than 1 percent
(n=5) of newly diagnosed cases representing infants or children younger than 13 years. Overall,
adults ages 20 to 29 years and 40 to 49 years accounted for the greatest proportion (about 54%
together) of individuals diagnosed in 2010 (Table 2.3).
Figure 2.5 displays the difference of ages between males and females diagnosed with HIV
disease in 2010. More males between ages 20 to 29 years (20%) were diagnosed, while
proportionately more females between ages 35 to 39 years (16%) and 45 to 49 years (16%) were
diagnosed. The difference of ages at diagnosis reflects the difference in risk for male and
females. In recent years, HIV disease has been increasing among young black men in North
Carolina, unlike previous years, when the HIV epidemic was increasing primarily among an
older population.
Table 2.3. North Carolina HIV disease cases by age group and gender, 2010
Males Females Total
Age
No. Pct. Rate* No. Pct. Rate* No. Pct. Rate*
0-12 3 0% 0.4 2 0% 0.2 5 0% 0.3
13-14 1 0% 0.8 1 0% 0.9 2 0% 0.8
15-19 65 4% 19.6 15 1% 4.8 80 5% 12.4
20-24 229 15% 65.0 29 2% 9.2 258 17% 38.6
25-29 166 11% 52.1 38 3% 12.2 204 14% 32.3
30-34 113 8% 37.9 40 3% 13.0 153 10% 25.3
35-39 100 7% 30.4 56 4% 16.8 156 10% 23.5
40-44 130 9% 40.1 33 2% 10.0 163 11% 24.9
45-49 126 8% 37.5 55 4% 15.6 181 12% 26.3
50-54 90 6% 28.9 32 2% 9.6 122 8% 18.9
55-59 60 4% 21.8 28 2% 9.3 88 6% 15.2
60-64 23 2% 9.7 19 1% 7.2 42 3% 8.4
65+ 24 2% 4.8 8 1% 1.2 32 2% 2.7
Total 1,131 76% 24.6 356 24% 7.4 1,487 100% 15.9
* per 100,000 population
NC Epidemiologic Profile for HIV/STD Prevention and Care Planning (12/11) Chapter 2
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Mode of HIV Disease Transmission for Adults/Adolescents
As part of HIV surveillance activities, a great deal of importance is placed on determining the
key HIV risk factors associated with each case. Interviewing the patient, the sex and/or drug-using
partners, and the treating physician are all methods used to determine risk factors.
Ultimately, each case is assigned to one primary risk category based on a hierarchy of disease
transmission developed by the CDC and others.
Table 2.4 displays the mode of transmission for adult/adolescent HIV disease cases diagnosed in
2010. The principal risk categories were: men who have sex with men (MSM), injection drug
use (IDU), and heterosexual sex. The proportion of cases for which there was no identified risk
(NIR) reported was substantial (38%). A portion of these NIR cases were classified as NIR not
due to missing or incomplete information, but rather because the reported risk(s) did not meet
one of the CDC-defined risk classifications; this was especially common for the heterosexual
risk category. Meeting the CDC-defined risk of heterosexual transmission includes the
requirement of knowing a partner’s risk (sex with known MSM or IDU, or sex with known HIV-positive
person). Consequently, some NIR cases have been reevaluated and reassigned to a
“presumed heterosexual” risk category based on additional information gathered from follow-up
interviews with newly diagnosed individuals (such as the exchange of sex for drugs or money,
previous diagnoses with other STDs, or multiple sexual partners). Even with the reassignment of
presumed heterosexual risk for some NIR cases, a substantial proportion (24%) of cases
remained assigned as no identified risk.
0%
5%
10%
15%
20%
13-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
Male
0%
5%
10%
15%
20%
13-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65+
Female
Figure 2.5. Percentage of adult/adolescent HIV disease cases by age and gender,
2010
NC Epidemiologic Profile for HIV/STD Prevention and Care Planning (12/11) Chapter 2
NC DHHS 26 Communicable Disease
Figure 2.6 shows more than 90 percent of the HIV disease cases were likely transmitted via sex,
either homosexual or heterosexual. Over the period of 2006 to 2010, MSM have been the
leading mode of transmission, increasing from 50 percent in 2006 to 57 percent in 2010 (14%
increase). During the same time period, IDU (including MSM/IDU) transmission decreased 43
percent and heterosexual transmission decreased 9 percent.
Table 2.5. Adult/adolescent HIV disease cases by transmission category, NIR*
redistributed, 2010
Table 2.4. Adult/adolescent HIV disease cases by transmission category, NIR*
included, 2010
Exposure Males Females Total
category No. Pct. No. Pct. No. Pct.
MSM 681 60% --- --- 681 46%
IDU 24 2% 10 3% 34 2%
MSM/IDU 10 1% --- --- 10 1%
Heterosexual 72 6% 115 32% 187 13%
Presumed
heterosexual 121 11% 90 25% 211 14%
NIR* 219 19% 139 39% 358 24%
Total 1,128 100% 354 100% 1,482 100%
*no identified risk
To better describe the overall changes, the remaining NIR cases have been assigned a risk
based on the proportionate representation of the various risk groups within the surveillance
data (Table 2.5). Table 2.5 shows that in 2010, MSM were estimated to represent about 57
percent of all HIV disease cases. Heterosexual transmission risk represented about 39 percent
of all HIV disease cases and IDU and MSM/IDU (men who have sex with men and inject
drugs) represented about 4 percent (including MSM/IDU). More explanation of this general
risk reassignment of NIR cases can be found in Appendix C (pg. C-4). In addition, the
redistributed risk assignment of NIR cases for all living cases can found in Table I (Appendix
D, pg. D-12). Please note all further discussions of risk or transmission categories in this
profile will be based on the fully redistributed risk of all HIV disease cases.
Exposure Males Females Total
Category No. Pct. No. Pct. No. Pct.
MSM 845 75% --- --- 354 57%
IDU 30 3% 16 5% 46 3%
MSM/IDU 12 1% --- --- 12 1%
Heterosexual 239 21% 338 95% 577 39%
Total 1,128 100% 354 100% 1,482 100%
*no identified risk
NC Epidemiologic Profile for HIV/STD Prevention and Care Planning (12/11) Chapter 2
NC DHHS 27 Communicable Disease
* Adult/adolescent
0
10
20
30
40
50
60
2006 2007 2008 2009 2010
Proportion
MSM IDU & MSM/IDU Heterosexual
Figure 2.6. Proportion of HIV disease* cases by mode of transmission,
2006–2010 (NIRs redistributed)
Figure 2.7. Adult/adolescent females Figure 2.8. Adult/adolescent males
HIV disease cases, 2010 HIV disease cases, 2010
N=354 N=1,128
Gender and mode of transmission
HIV risk is very different for males and females; therefore, risk is discussed separately for each
gender (Figures 2.7 and 2.8 display adult/adolescent risk categories for each gender). For males,
MSM accounted for about 75 percent of HIV disease cases diagnosed in 2010; heterosexual
contact cases accounted for about 21 percent of cases; and IDU cases (including MSM/IDU)
accounted for about 4 percent. For females, heterosexual contact accounted for about 95 percent
of cases and IDU about 5 percent.
IDU
5%
Hetero-sexual
95%
IDU
3% Hetero-sexual
21%
MSM/
IDU
1%
MSM
75%
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Tables D and E (Appendix D, pg. D-7 to D-8) display the risk categories by gender for HIV
disease cases from 2006 to 2010. For males, the proportion of MSM cases has risen in recent
years, from 70 percent in 2006 to 75 percent in 2010. The proportion of IDU cases (including
MSM/IDU) for males has declined from 6 percent to 4 percent from 2006 through 2010. For
females, the proportion of heterosexual contact reports has increased from 91 to 95 percent and
proportion of IDU transmission decreased from 9 to 4 percent from 2006 through 2010.
Gender, race/ethnicity, and mode of transmission
Among white males, MSM represented 87 percent of cases, heterosexual risk represented 8
percent of cases, and IDU risk represented 2 percent of cases. For black males, MSM
represented about 72 percent of HIV cases, heterosexual risk represented about 25 percent of
cases, and IDU risk (including MSM/IDU) about 4 percent of cases. The risk breakdown for
other races/ethnicities (Hispanics, American Indians, and Asian/Pacific Islanders) are grouped
together as “All other” because of low case numbers. Within this aggregated group, MSM risk
represented 76 percent of male cases, heterosexual risk 34 percent of cases, and IDU risk
(including MSM/IDU) 4 percent of cases. The proportions of HIV cases attributed to
heterosexual risk among black males (25%) and other races (34%) are higher than the proportion
among white males (8%). Although some of this observed difference may be due to
underreporting of MSM activity among minority males, some is attributed to the difference in
disease prevalence for each racial/ethnic group and the subsequent affect on risk.
Unlike the differences in risk observed for males among the racial/ethnic groups, the majority of
all HIV cases among females, regardless of race/ethnicity, are attributed to heterosexual sex.
IDU is attributed to a greater proportion of white female cases (17%) than to minority females
(2–5%; Figures 2.9 and 2.10).
Hetero-sexual
MSM
MSM/IDU
IDU
MSM
IDU
MSM/
IDU
Hetero-sexual
Hetero-sexual
MSM/
IDU
IDU
MSM
White* n=300 Black* n=706 All other n=122
Figure 2.9. Adult/Adolescent male HIV disease cases, 2010
*non Hispanic
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ADOLESCENT ACQUIRED HIV/AIDS
Figures 2.11 through 2.14 display the percentage of newly diagnosed HIV disease cases by risk
and demographic categories for each gender for individuals ages 13 to 24 years when diagnosed
with HIV. Because there can be significant delay between infection and subsequent testing and
reporting, the age group 13 to 24 years better describes infections that likely occurred during
adolescence. In 2010, while just 5.5 percent of total cases diagnosed were found among
teenagers from 13 to 19 years, the percentage increased to 22.9 percent when 20 to 24 year olds
were included. From 2006 to 2010, the proportion of adolescents among HIV disease cases has
increased from 15.9 percent to 22.9 percent of all reports. The proportion of cases among each
racial group for adolescents is similar to that of HIV cases overall: minorities are
disproportionally affected. Examining the race of new adolescent HIV cases 2010 shows that
infections were concentrated among blacks for both men (81%) and women (85%; Figures 2.11
and 2.12). Although adolescent cases do not represent the majority of HIV cases diagnosed in
each year, adolescence is the critical age for health education and HIV prevention.
Hetero-sexual
IDU
Hetero-sexual
IDU
Hetero-sexual
IDU
Figure 2.10. Adult/adolescent female HIV disease cases, 2010
White* n=50 Black* n=262 All other* n=35
*non Hispanic
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*non Hispanic
The exposure or risk categories for male and female adolescents are very different (Figures 2.13
and 2.14). In 2010, all new HIV disease cases among adolescent females were attributed to
heterosexual contact. For adolescent males, the proportion of HIV disease cases attributed to
heterosexual contact was only 6 percent and the proportion attributed to MSM risk accounted for
92 percent, up from the 88 percent of the diagnosed in 2006. As compared to cases for older
persons, adolescent cases are more likely to be associated with sexual activity (99% vs. 96%)
and not injection drug use practices. Table C (Appendix D, pg. D-6) shows the detailed statistics
about the percentage by gender over the past five years (2006-2010).
MSM/
IDU
<1%
Hetero-sexual
6%
IDU
<1%
MSM
93%
Hetero-sexual
100%
n = 295
81%
10%
9%
Black*
White*
Other
n = 45
85%
4%
11%
Black*
White*
Other*
Figure 2.13. Adolescent (13-24 years)
male HIV cases, 2010
Figure 2.14. Adolescent (13-24 years)
female HIV cases, 2010
n = 295
n = 45
Figure 2.12. New HIV diagnoses among
adolescent (13-24) females,
by race, 2010
Figure 2.11. New HIV diagnoses among
adolescent (13-24) males,
by race, 2010
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FEMALES OF CHILD-BEARING AGE AND PERINATAL HIV/AIDS
Perinatal transmission of HIV is generally preventable if appropriate drugs are administered to
mothers during pregnancy and delivery. For this reason, special emphasis is placed on follow-up
for known HIV-infected mothers in North Carolina. Table 2.6 displays the proportion of HIV-infected
women who were of child-bearing age (15–44 years old). Approximately 300 women
of child-bearing age are diagnosed with HIV each year in North Carolina (65% of total female
HIV cases). Note that the number and proportion of HIV diagnoses among N.C. females has
decreased in recent years. Readers should keep in mind that the delays in testing and diagnosis
can significantly affect the assessment of the actual number of females in this category.
Table 2.7 displays the numbers of likely perinatal HIV transmissions that have occurred from
2001 to 2010 by year of birth. These numbers represent pediatric reports that indicate likely
perinatal transmission based on exposure categories in HIV surveillance data. Since 2007, there
have been decreases noted in the number of HIV-positive babies born in North Carolina.
Confirming HIV in perinatal cases takes time, so case totals for recent years should be
considered preliminary. In November 2007, North Carolina implemented new HIV testing
statues that require every pregnant woman be offered HIV testing by her attending physician at
her first prenatal visit and in the third trimester. If there is no HIV result test on record during
the current pregnancy, the pregnant woman will be tested at labor and delivery and/or the infant
will be tested for HIV.
HIV DISEASE AMONG FOREIGN-BORN RESIDENTS
Information about foreign-born HIV cases is important for planning outreach and prevention
initiatives because messages and information must be tailored or designed for the appropriate
culture and language. Information on the foreign-born population in North Carolina is presented
Table 2.6. Female HIV disease cases by special age groups, 2006–2010
2006 2007 2008 2009 2010
Age
No. Pct. No. Pct. No. Pct. No. Pct. No. Pct.
0-14 yrs 5 1% 5 1% 5 1% 3 1% 3 1%
15-44 yrs 296 64% 353 68% 312 67% 257 62% 211 59%
45+ yrs 163 35% 159 31% 147 32% 154 37% 142 40%
Total 464 100% 517 100% 464 100% 414 100% 356 100%
Table 2.7. Likely perinatal HIV disease cases by year of birth, 2001–2010
Year of birth 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Number of Cases 7 3 5 4 1 6 6 3 2 0
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in Chapter 1. The number of HIV disease cases identified among foreign-born people in North
Carolina (Figure 2.15) has increased in the last eight years. These increases reflect the greater
pattern of migration to the state and may indicate better data collection of country of origin in
surveillance data. The number of foreign-born HIV disease cases in 2010 (n=93) represented
approximately 9 percent of all foreign-born HIV cases (987) for the last 10 years (2001–2010).
Table 2.8 shows the race/ethnicity of the foreign-born HIV cases. Hispanics comprised the
highest proportion (61.2%). Non-Hispanic blacks comprised 27.5 percent of cases; whites and
Asian/PI made up 5.4 and 4.5 percent respectively.
Table 2.8. Race/Ethnicity of foreign-born HIV disease cases diagnosed, 2001–2010
Race/ethnicity No. Pct
White* 53 5.4%
Black* 271 27.5%
Asian/Pacific Islander* 44 4.5%
Hispanic 616 62.4%
Others* 3 0.3 %
Total 987 100.0%
* non-Hispanic
For the previous 10 years, Mexico was the origin country with the highest number (Figure 2.16)
of foreign-born HIV cases (n=436), followed by Honduras, South Africa, Guatemala, El
Salvador, Kenya, Puerto Rico, Zambia, Jamaica, and Zimbabwe. The majority (63%) of foreign-born
HIV disease cases were diagnosed in urban counties including Wake (20%), Mecklenburg
(20%), Durham (9%), Guilford (9%), and Forsyth (5%). About 7 percent of foreign-born cases
were diagnosed in rural counties, including Duplin, Davidson, Rowan, Hertford, Craven,
Robeson, Sampson, and Lee counties.
Figure 2.15. Foreign-born HIV disease cases diagnosed, 2001–2010
32
89 88
78
111
117
132 129
118
93
0
20
40
60
80
100
120
140
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year of Diagnosis
Number of Diagnosis
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GEOGRAPHIC DISTRIBUTION OF HIV/AIDS
Urban/Rural and Metropolitan areas
Based on criteria from the Office of Management and Budget (OMB) and the Centers for
Disease Control and Prevention (CDC), North Carolina can be categorized into large
metropolitan (metropolitan area with 500,000 population or more), medium-sized metropolitan
(metropolitan area with population between 50,000 to 499,999), micropolitan and non-metropolitan
areas. Large and medium-sized metropolitan areas are usually referred to as urban
areas, and micropolitan and non-metropolitan areas as rural areas. According to CDC, 79
percent of national AIDS reports are from large metropolitan areas and 13 percent are from
medium-sized metropolitan areas, resulting in 92 percent of reports from urban areas and 8
percent from rural areas in 2009.
New HIV Diagnoses in Urban/Rural and Metropolitan Areas
While 77 percent of new diagnosis in 2010 were from urban areas, (See Table 2.9, Map 9,
Appendix A, pg. A-11), some of the highest HIV disease rates (per 100,000 population) are
found in rural areas, especially among blacks and Hispanics (See Table 2.13, Map 10, pg. A-12).
The HIV disease rate in medium metropolitan areas in 2010 was slightly higher than the rates in
micropolitan and non-metropolitan areas (Table 2.10).
Figure 2.16. Country of birth for foreign-born HIV disease cases, 2001–2010
35 29 25 18 17 15 55 41 38
436
0
50
100
150
200
250
300
350
400
450
500
Mexico
Ho nduras
South Africa
Guatemala
El Salvador
Kenya
Puerto Ric o
Zambia
Jamaica
Zimbabwe
Number of Diagnoses
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NC DHHS 34 Communicable Disease
Table 2.9. Newly diagnosed HIV disease cases by metropolitan areas, 2010
Rural Urban N.C. Total***
Race/Ethnicity
Cases Pct Rate* Cases Pct Rate* Cases Pct Rate*
White** 70 4.7% 3.6 270 18.2% 6.1 352 23.7% 5.6
Black** 177 11.9% 31.4 757 50.9% 51.7 977 65.7% 48.2
AI/AN** 2 0.1% 2.6 2 0.1% 5.9 4 0.3% 3.7
Asian/PI** 1 0.1% 4.3 8 0.5% 4.4 9 0.6% 4.4
Hispanic 25 1.7% 14.7 86 5.8% 15.7 118 7.9% 16.4
Multiple** 8 0.5% --- 17 1.1% --- 27 1.8% ---
Total 283 19.0% 10.3 1,140 76.7% 17.2 1,487 100.0% 15.9
* Rate per 100,000 population ** non-Hispanic; AI/AN=American Indian/Alaska Native; PI=Pacific Islander
***N.C. Total includes cases unassigned to areas.
Tables K–L (Appendix D, pg. D- 14–17) give county totals of HIV disease and AIDS cases
reported, cases living at the end of 2010, and a ranking of case rates (per 100,000 population)
based on a three-year average (2008–2010). Edgecombe County ranked highest with an HIV
disease three-year average rate of 41.0 per 100,000 population in 2010, followed by
Mecklenburg County (38.1), Durham County (33.7), Northampton County (31.2), Wilson
County (29.0), and Guilford County (27.5). Readers are cautioned to view rates carefully, as
rates based on small numbers (generally less than 20) are considered unreliable. Persons
diagnosed in long-term institutions, such as prisons, are removed from county totals for a better
comparison of HIV impact among communities.
Table 2.10. Newly diagnosed HIV disease cases by metropolitan areas, 2010
Rural Areas Urban Areas
Mirco
metropolitan
Non-metropolitan
Large
metropolitan
Medium
metropolitan
Race/Ethnicity
Cases Rate* Cases Rate* Cases Rate* Cases Rate*
White** 49 3.4 21 4.3 155 7.2 115 5.1
Black** 111 27.8 66 40.0 469 61.0 288 41.5
AI/AN** 2 3.3 0 0.0 0 0.0 2 10.1
Asian/PI** 1 5.1 0 0.0 5 4.3 3 4.6
Hispanic 19 15.9 6 11.9 46 14.9 40 16.7
Multiple** 5 --- 3 --- 10 --- 7 ---
Total 187 9.2 96 13.2 685 20.4 455 13.9
* Rate per 100,000 population ** non-Hispanic; AI/AN=American Indian/Alaska Native; PI=Pacific Islander
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HIV Prevalence Cases in Urban/Rural and Metropolitan Areas
Among the HIV disease cases living through the end of 2010, about 20 percent were diagnosed
and reported from rural areas (Table 2.14). More than 50 percent of living cases diagnosed in
North Carolina were from seven counties, which included Mecklenburg (17.6%), Wake (10.4%),
Guilford (7.4%), Durham (5.8%), Forsyth (4.9%), Cumberland (4.7%), and New Hanover (2.4%)
counties. About 75 percent of living HIV cases were in urban areas and 20 percent in rural areas.
Roughly, the prevalence rates for blacks and whites were higher in urban than in rural areas
(Table 2.11).
County of residence is based on where an individual was living when diagnosed with HIV
disease. People may move to other areas in the years after diagnosis. Assuming no significant
difference between the numbers of HIV disease cases moving in and out of the original residence
county, the statistics still indicate roughly the number and rate of living HIV disease cases in the
corresponding counties.
Although the highest prevalence rates for whites and blacks were in urban (large and medium-sized
metropolitan areas), the highest rate for Hispanics was in non-metropolitan areas (Table
2.12). As with new HIV diagnoses in 2010, more American Indian prevalent cases were
diagnosed and reported in micropolitan areas, making the rate in that area much higher than the
rate in other areas (Table 2.12). The number of prevalent cases for Asian/Pacific Islanders and
American Indians/Alaska Natives were still too small to make comparisons, especially in non-metropolitan
areas.
Table 2.11. HIV Disease prevalence as of 12/31/2010 by rural/urban areas, 2010
Rural Urban N.C. Total***
Race/Ethnicity
Cases Pct Rate* Cases Pct Rate* Cases Pct Rate*
White** 1,190 4.7% 61.9 5,041 20.1% 114.5 6,436 25.7% 101.8
Black** 3,367 13.4% 596.7 12,238 48.8% 836.5 16,650 66.4% 821.3
AI/AN** 116 0.5% 153.5 70 0.3% 206.0 202 0.8% 184.3
Asian/PI** 24 0.1% 102.2 93 0.4% 51.5 120 0.5% 58.8
Hispanic 288 1.1% 169.1 1,098 4.4% 200.6 1,438 5.7% 200.4
Multiple** 56 0.2% 159 0.6% 228 0.9%
Total 5,041 20.1% 183.0 18,699 74.6% 282.2 25,074 100.0% 267.3
* Rate per 100,000 population ** non-Hispanic; AI/AN=American Indian/Alaska Native; PI=Pacific Islander
***N.C. Total includes cases unassigned to areas.
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Physiographic Regions
Geographic areas can be defined in many ways. In this HIV/STD Epidemiologic Profile, data are
presented in three categories of geographic areas for the convenience of readers: metropolitan
areas, rural/urban areas, and physiographic regions. The distribution of HIV disease is uneven
across North Carolina, as can be seen in Maps 9 and 10 (Appendix A, pg. A-11 to A-12). Cases
are assigned to the county of residence at first diagnosis. This distribution can be partly
explained by the population distribution in Map 1 (Appendix A, pg. A-3), as the epidemic tends
to be concentrated in urban areas.
The North Carolina state demographer and the GIS lab at the State Center for Health Statistics
have produced a Geographic Regional Classification scheme based on "physiographic" qualities.
According to this scheme, North Carolina has three regions, West Region, Piedmont Region, and
East Region (Table 2.16). Western Region includes counties west of (and including) Surry,
Wilkes, Caldwell, Burke, and Rutherford; Eastern Region includes everything east of (and
including) Northampton, Halifax, Nash, Johnston, Cumberland, Hoke, Harnett, and Scotland.
Piedmont Region includes the counties in between the Western Region and the Eastern Region.
Table 2.12. HIV Disease prevalence as of 12/31/2010 by metropolitan areas, 2010
Rural Areas Urban Areas
Micro
metropolitan
Non-metropolitan
Large
metropolitan
Medium
Race/Ethnicity metropolitan
Cases Rate* Cases Rate* Cases Rate* Cases Rate*
White** 2,695 127.2 2,187 98.7 863 60.7 278 56.2
Black** 6,756 903.6 5,090 748.8 2,435 612.2 846 511.9
AI/AN** 34 248.1 36 188.6 102 167.1 16 110.8
Asian/PI** 51 48.0 34 55.8 18 101.6 5 144.7
Hispanic 553 189.0 461 199.8 159 139.6 110 231.4
Multiple** 73 --- 66 --- 39 --- 10 ---
Total 10,162 309.9 7,874 245.5 3,616 179.8 1,265 174.5
* Rate per 100,000 population ** non-Hispanic; AI/AN=American Indian/Alaska Native; PI=Pacific Islander
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Table 2.13. Newly diagnosed HIV disease cases by physiographic regions, 2010
Eastern Piedmont Western N.C. Total***
Race/Ethnicity
Cases Rate* Cases Rate* Cases Rate* Cases Rate*
White** 61 3.8 243 6.6 36 3.6 352 5.6
Black** 282 37.2 641 52.8 11 20.0 977 48.2
AI/AN** 4 5.3 0 0.0 0 0.0 4 3.7
Asian/PI** 2 6.5 7 4.3 0 0.0 9 4.4
Hispanic 28 16.2 81 16.5 2 3.6 118 16.4
Multiple** 7 --- 17 --- 1 --- 27 ---
Total 384 14.4 989 17.7 50 4.4 1,487 15.9
* Rate per 100,000 population ** non-Hispanic; AI/AN=American Indian/Alaska Native; PI=Pacific
Islander ***N.C. Total includes cases unassigned to areas.
For whites, blacks, and Hispanics, the majority of HIV disease cases (67%) were diagnosed in
the Piedmont Region in 2010, followed by the Eastern Region. For American Indian/Alaska
Natives, most HIV disease cases were diagnosed in the Eastern Region. For Asian/Pacific
Islanders, HIV cases were most prominent in the Piedmont Region, while the rate in the Eastern
Region is higher than the Piedmont Region because of a smaller Asian/PI population in Eastern
Region (Table 2.13).
Among the HIV disease cases living through the end of 2010, a majority of whites, blacks, and
Hispanics were diagnosed and reported from Piedmont Region (66%), followed by the Eastern
Region. Because the American Indian population in the Piedmont Region is smaller than in the
Eastern Region, the prevalence rate in the Piedmont Region is higher than the rate in the Eastern
Region (Table 2.14). The Western Region had fewer HIV cases and rates for both new
diagnoses and prevalent cases in 2010.
Table 2.14. HIV Disease prevalence as of 12/31/2010 by physiographic regions, 2010
Race/Ethnicity Eastern Piedmont Western N.C. Total***
Cases Rate* Cases Rate* Cases Rate* Cases Rate*
White** 1,379 84.9 4,122 111.7 730 72.4 6,231 98.6
Black** 5,003 659.7 10,337 851.6 265 482.2 15,605 769.8
AI/AN** 134 178.2 41 179.3 11 95.4 186 169.7
Asian PI** 37 120.9 74 45.5 6 53.7 117 57.3
Hispanic 359 208.0 967 197.4 60 108.6 1,386 193.1
Multiple** 63 --- 139 --- 13 --- 215 ---
Total 6975 262.2 15680 281.0 1085 95.1 23,740 253.1
* Rate per 100,000 population **non-Hispanic ***N.C. Total includes cases unassigned to areas.
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HIV DISEASE CASES DIAGNOSED LATE
Late testers represent a significant proportion of new HIV diagnoses in North Carolina,
indicating the need for increased HIV testing and linkage to medical care. People who test late in
the course of HIV infection may already have serious HIV-associated complications and are not
able to benefit fully from antiretroviral therapy and prophylaxis to prevent opportunistic
infections. Late testing also results in missed opportunities for preventing new HIV infections,
as knowledge of positive HIV status promotes adoption of safer sex practices (CDC, 2000). The
estimated 20 percent of people in the United States who have HIV and do not know it are
estimated to account for 54 percent of new transmissions (Marks, 2006).
Table 2.15 shows the proportion of individuals diagnosed as AIDS when they were first
diagnosed as HIV infected (late HIV diagnosis or concurrent AIDS cases) in 2010. These
persons with concurrent diagnosis are generally referred to as “late testers” and include any
person who receives an AIDS diagnosis within six months of the initial HIV positive screening.
Hispanic males had the highest proportion (43.9%) of late testers, reflecting possible cultural and
language barriers to testing and access to care.
Overall, 26.0 percent of newly diagnosed individuals had a concurrent AIDS or late HIV
diagnosis in 2010, indicating that they probably had HIV for at least five to seven years (CDC,
2006). Hispanic men experienced a much higher proportion of late testers than other racial/ethnic
groups, with nearly 44 percent of new infections diagnosed late. This figure represents an
increase from the proportion of late testers among Hispanic men in 2009 (36.5%).
As shown in Table 2.16, roughly 25 to 30 percent of individuals newly diagnosed with HIV
disease each year also represent AIDS cases (i.e. late testers) during the 2006–2010 period.
The significant proportions of late diagnoses indicate the need for increased HIV testing within
North Carolina. These figures support the recommendation to include voluntary HIV testing as
part of routine medical examinations for all U.S. residents ages 13 to 64 years (CDC, 2006).
Table 2.17 displays the gender and race specific proportions of all late testers (concurrent AIDS
cases) diagnosed from 2006 to 2010. Blacks comprise 57 to 61 percent of total late testers,
whites comprise 23 to 27 percent, and Hispanics comprise 10 to 15 percent in the past five years.
Table 2.15. Proportion of late testers by race/ethnicity among HIV disease cases, 2010
Race/ ethnicity Males Females Total
White* 29.9% 19.6% 28.4%
Black* 23.3% 24.4% 23.6%
Hispanic 43.9% 20.0% 39.8%
Other* 24.0% 20.0% 22.5%
Total 26.9% 23.3% 26.0%
*non-Hispanic
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In general, significant proportions of late HIV diagnoses indicate a need for increased HIV
testing in North Carolina. The N.C. Division of Public Health is actively pursuing new policies
and guidelines aimed at making HIV testing part of routine medical care settings and continues
to work with HIV-infected persons and their partners to reduce transmission. Rapid HIV tests
have also created new opportunities to expand HIV testing into nontraditional and high
prevalence settings (e.g. emergency rooms, correctional facilities, community settings and
mobile testing sites). In addition, specific initiatives such as the statewide Get Real. Get Tested.
Campaign have been designed to encourage North Carolinians to get educated about and tested
for HIV. As a result of the implementation of the CDC HIV testing recommendations, statewide
Table 2.16. Proportion of HIV and concurrent* AIDS at diagnosis, 2006–2010
Status at Diagnosis
Year of Diagnosis HIV (non-AIDS) AIDS
2006 71.4% 28.6%
2007 75.5% 24.5%
2008 73.6% 26.4%
2009 72.1% 27.9%
2010 74.0% 26.0%
*HIV and AIDS diagnosed within six months of testing ; also referenced as “late testers”
Table 2.17. Late HIV diagnoses by sex and race/ethnicity, 2006–2010
Year of Diagnosis
Sex Race/Ethnicity 2006 2007 2008 2009 2010
Male White* 21.7% 21.8% 23.8% 20.0% 23.3%
Black* 41.3% 41.6% 39.3% 47.5% 42.6%
Hispanic 1.9% 0.5% 1.3% 2.2% 1.6%
Other/Unknown 12.1% 10.2% 11.5% 9.0% 11.1%
Total 77.0% 74.1% 75.9% 78.7% 78.6%
Female White* 3.0% 5.0% 3.1% 3.3% 2.6%
Black* 16.6% 19.1% 19.5% 16.5% 17.1%
Hispanic 0.4% 0.2% 0.4% 0.7% 0.8%
Other/Unknown 3.0% 1.6% 1.0% 0.9% 1.0%
Total 23.0% 25.9% 24.1% 21.3% 21.4%
Total White* 24.7% 26.8% 27.0% 23.3% 25.8%
Black* 57.9% 60.7% 58.8% 64.0% 59.7%
Hispanic 2.3% 0.7% 1.7% 2.9% 2.3%
Other/Unknown 15.1% 11.8% 12.6% 9.9% 12.1%
Total 100.0% 100.0% 100.0% 100.0% 100.0%
*non-Hispanic
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testing initiatives like the Get Real. Get Tested campaign and expanded HIV testing in
nontraditional settings, HIV testing has increased substantially. In 2010, the State Laboratory of
Public Health performed about 227,038 HIV tests, which represents a 55 percent increase in
testing since 2006 when about 146,548 tests were performed (See Chapter 3 for more
information about HIV testing in North Carolina).
HIV DISEASE STAGING
The Centers for Disease Control and Prevention (CDC) uses a new staging system for HIV
disease to monitor the epidemic. This staging system is based on CD4+ cell counts as well as the
existence of certain HIV-related clinical conditions at the time of diagnosis and is meant to
assess the severity of HIV disease. Table 2.18 below shows the current staging definitions used
by the CDC. The nine mutually exclusive categories allow clinicians and epidemiologists to view
HIV disease on a spectrum, ranging from acute HIV infection (A1) to advanced AIDS (C3). In
order to properly stage HIV infection using these new categories, it will be important to increase
CD-4 reporting in North Carolina.
Table 2.18. CDC classification system for HIV infection
Clinical categories
A B C
CD4+ cell count
(CD4%)
Asymptomatic, acute
(primary) HIV or
PGL*
Symptomatic, not A
or C conditions†
AIDS-indicator
conditions‡
> 500 (28%) A1 B1 C1
200–499 (15–28%) A2 B2 C2
< 200 (14%) A3 B3 C3
*Category A: asymptomatic HIV infection, persistent generalized lymphadenopathy (PGL).
†Category B: oropharyngeal and vulvovaginal candidiasis, constitutional symptoms such as fever (38·5°C) or
diarrhea lasting >1 month, herpes zoster (shingles).
‡Category C: Mycobacterium tuberculosis (pulmonary and disseminated), Pneumocystis carinii pneumonia,
candidiasis of bronchi; trachea or lungs, extrapulmonary cryptococcosis, CMV, HIV-related encephalopathy,
Kaposi's sarcoma, wasting syndrome due to HIV.
THE IMPACT OF AIDS IN NORTH CAROLINA
All 50 states, the District of Columbia, and the U.S. dependent areas report AIDS cases to the
Centers for Disease Control and Prevention (CDC) by using a uniform surveillance case
definition and a case report form. For persons with laboratory-confirmed HIV infection, AIDS
cases represent individuals with CD4+ T-lymphocyte percentages of less than 14 or CD4+ T-lymphocyte
counts of fewer than 200 cells/μL or the presence of one of 23 clinical conditions
indicating an impaired immune system. The date of AIDS diagnosis represents the date that an
individual is diagnosed with AIDS based on the above case definition. Ideally, individuals are
diagnosed with HIV infection long before they are diagnosed with AIDS. In North Carolina,
however, 49 percent of 2010 AIDS diagnoses were made at the same time or within six months
of HIV diagnoses.
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Monitoring cases that transition from HIV to AIDS in North Carolina provides both a valuable
measure of the continuing efficacy of treatment and also indicates which patients may not have
access to care. Increases in AIDS diagnoses have several implications. First, these increases may
indicate that more HIV-infected individuals are being tested and reported in North Carolina.
Another possible implication is that HIV-infected (status aware) individuals are not receiving
proper medical care. Finally, increases in AIDS diagnoses may suggest that current treatments
are no longer as effective or patients are not adherent to their HIV drug regimes. Because
changes in AIDS cases and rates may indicate changes in the anticipated care needs, agencies
that provide medical care and support services to persons living with HIV/AIDS should closely
monitor cases.
NORTH CAROLINA AND THE U.S.
All states have name-based AIDS case reporting by law and provide data that are acceptable for
state–to–state and state–to–U.S. comparisons. Comparing North Carolina to the nation is limited
to earlier years because national surveillance data is released later than state data. According to
the Centers for Disease Control and Prevention (CDC), the national AIDS case rate in 2009 was
11.2 per 100,000 population (CDC, HIV/AIDS Surveillance Report, 2009). During the same
time period, North Carolina’s AIDS case rate was 11.6 per 100,000 population. North Carolina
ranked 9th among all states and the District of Columbia in the number of new AIDS cases
reported (Table 2.19). Please note that comparisons made between other states, North Carolina,
and the U.S. are based on counts and rates calculated by the CDC and have been statistically
adjusted for delays in reporting; these numbers may differ slightly from North Carolina’s
unadjusted case counts and rates.
The impact of HIV/AIDS in the South is a growing concern. In 2009, the South had 49 percent
of new AIDS cases overall, including five of the top 10 states reporting the most AIDS cases
(Table 2.19). The South also had the highest regional rate in 2009 (13.9 per 100,000). In 2009,
seven of the top 10 states by AIDS case rate were in the South (Top 10: DC, NY, FL, MD, LA,
Puerto Rico, DE, NJ, SC, and GA); Mississippi (11th) and North Carolina (12th) followed.
Table 2.19. Top 10 States for AIDS diagnoses
State AIDS Cases Diagnosed in 2009
1. New York 4,799
2. Florida 4,392
3. California 3,760
4. Texas 2,652
5. New Jersey 1,475
6. Georgia 1,391
7. Illinois 1,202
8. Maryland 1,134
9. North Carolina 1,088
10. Pennsylvania 917
Source:CDC HIV/AIDS Surveillance Report, 2009. Vol.21
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AIDS PREVALENCE IN NORTH CAROLINA
North Carolina is ranked 13th in the nation for estimated number of persons living with an AIDS
diagnosis (CDC, HIV/AIDS Surveillance Report, 2009). Table 2.20 displays HIV disease
prevalence in North Carolina by HIV disease stage (HIV/AIDS), demographic characteristics,
and transmission categories. AIDS cases were notably higher (proportionately) than HIV (non
AIDS) cases for males, Hispanics, injection drug users (IDU), heterosexuals (CDC defined), and
persons ages 45 years and older. Sixty seven percent (67%) of both AIDS and HIV (non AIDS)
cases were among blacks in North Carolina. North Carolina ranked 7th in the nation and D.C.
for the percentage of all AIDS cases among blacks in 2007 (CDC special request, 2/2010).
Table 2.20. North Carolina living† HIV/AIDS cases
Disease Status
HIV non AIDS AIDS
TOTAL
Demographics
Cases Pct Cases Pct Cases Pct
Gender
Male 10,052 67.8 7,492 73.2 17,544 70.0
Female 4,781 32.2 2,749 26.8 7,530 30.0
Current Age
Unknown 18 0.1 3 0 21 0.1
<2 1 0 0 0 0 0.0
2-12 48 0.3 5 0 53 0.2
13-24 840 5.7 152 1.5 992 4.0
25-44 6,327 42.7 3,431 33.5 9,758 38.9
45-64 6,978 47 6,106 59.6 13,084 52.2
65+ 621 4.2 543 5.3 1,164 4.6
Race/ethnicity
White* 3,855 26 2,581 25.2 6,436 25.7
Black* 9,831 66.3 6,819 66.6 16,650 66.4
American Indian/AN* 112 0.8 90 0.9 202 0.8
Asian/PI* 84 0.6 36 0.4 120 0.5
Hispanic 789 5.3 649 6.3 1,438 5.7
Multiple races 162 1.1 66 0.6 228 0.9
Mode of Transmission
MSM 5,215 35.2 3,316 32.4 8,531 34.0
IDU 1,022 6.9 1,055 10.3 2,077 8.3
MSM/IDU 310 2.1 285 2.8 595 2.4
Blood Products 35 0.2 51 0.5 86 0.3
Heterosexual-all 3,644 24.6 2,609 25.5 6,253 24.9
Pediatric 168 1.1 63 0.6 231 0.9
NIR/NRR 4,439 29.9 2,862 27.9 7,301 29.1
Total 14,833 100 10,241 100 25,074 100.0
† Living as of 12/31/10 * non-Hispanic
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AIDS TRENDS IN NORTH CAROLINA
A total of 19,761 AIDS cases have been diagnosed and reported among North Carolina residents
since the beginning of the epidemic in 1983. In 2010, 796 new AIDS cases were diagnosed in
North Carolina with a rate of 8.5 per 100,000 population (10.3 per 100,000 adult/adolescent
population). Most subpopulations in North Carolina have experienced stable or decreasing rates
of AIDS. Particularly large decreases were seen among black males ages 35-39 (63% decrease;
from 68 cases in 2006 to 25 cases in 2010), black males ages 40 to 44 (45% decrease; from 74
cases in 2006 to 41 cases in 2010) and Hispanic males ages 25 to 29 (67% decrease; from 15 in
2006 to 5 in 2010). However, over the past five years, AIDS cases have increased 60 percent
among white males ages 45 to 49 (from 28 cases in 2006 to 45 cases in 2010) and 50 percent
among white males ages 50 to 54 (from 16 cases in 2006 to 24 cases in 2010). Although AIDS
cases among females have generally decreased over the past five years, increases were observed
among younger black females ages 20 to 24 (67% increase; from 6 cases in 2006 to 10 cases in
2010) as well as older black females ages 60 to 64 (200% increase; from 5 cases in 2006 to 15
cases in 2010) and black females age 65 years and older (300% increase; from 2 cases in 2006 to
8 cases in 2010). The number of AIDS cases among American Indians has decreased over the
past five years to a minimum of three cases in 2010. Asians experienced a return to pre-2009
levels with three AIDS cases in 2010.
AIDS IMPACT ON RACIAL AND ETHNIC MINORITIES
As observed for HIV disease, racial and ethnic minorities continue to be disproportionately
affected by the AIDS epidemic in North Carolina (Figure 2.17). Blacks account for a
disproportionate share of AIDS cases, relative to their size in the population of North Carolina.
Figure 2.17. AIDS cases by race/ethnicity, 2006–2010
406
377
407
447
343
39 44 33 37 24
185 199
227
202 193
151
159
160
175
147
70 56 64
51
65
0
50
100
150
200
250
300
350
400
450
500
2006 2007 2008 2009 2010
AIDS cases
White* male Black* male Hispanic male
White* female Black* female Hispanic female
*non-Hispanic
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According to the National Center for Health Statistics 2009 bridged race estimates, blacks
comprise 22 percent of the total population of North Carolina, yet they represent 68 percent of
North Carolinians living with AIDS. The disparity between blacks and whites is slightly greater
for AIDS than for HIV disease in North Carolina. The AIDS rate among blacks is nearly 10
times higher than for whites while the rate for HIV disease is nine times higher among blacks
than whites. In 2010, black males represented 60 percent of all adult/adolescent male AIDS
cases and the AIDS rate among adult/adolescent black men (45.7 per 100,000) was 7.5 times the
rate for white men in 2010 (6.1 per 100,000). Hispanics represented six percent of all 2010 AIDS
cases and the AIDS rate among Hispanic males (18.7 per 100,000 adult/adolescent population)
was 3.1 times higher than for whites (Figure 2.18).
Figure 2.19. Relative AIDS rates for females in N.C. by race/ethnicity, 2006–2010
*Referent group=White, non-Hispanic females **non-Hispanic
Figure 2.18. Relative AIDS rates for males in N.C. by race/ethnicity, 2006–2010
0
5
10
15
20
25
30
2006 2007 2008 2009 2010
Year of AIDS Diagnosis
Relative Rate*
Black**
Hispanic
White**
0
2
4
6
8
10
12
2006 2007 2008 2009 2010
Year of AIDS Diagnosis
Relative Rate*
Black**
Hispanic
White**
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In North Carolina, black females represented 85 percent of 2010 AIDS cases diagnosed among
women and the 2010 rate of AIDS diagnosed in adult/adolescent black women (21.9 per
100,000) was 24 times the rate for white women in 2010 (0.9 per 100,000). Latinas represented
three percent of female AIDS cases in 2010 and the AIDS rate among Latinas (3.0 per 100,000)
was almost more than three times the rate among white women (Figure 2.19).
TREATMENT
The lifetime cost of treating HIV disease is approximately $367,000 (CDC, 2010). Identifying
HIV infected individuals early in the course of disease and linking those individuals to medical
care extends life expectancy, reduces medical costs, and reduces the spread of HIV to others.
Current treatment for HIV infection consists of highly active antiretroviral therapy (HAART).
Without treatment, progression from HIV infection to AIDS has been observed to occur at a
median of between nine to ten years with the median survival time after developing AIDS only
9.2 months (Morgan, 2002). Since the mid 1990s and the introduction of antiretroviral drugs to
combat the progression of HIV disease, increases in the length of time between HIV and AIDS
diagnosis have been observed in North Carolina surveillance data, generally indicating an
improvement in health status and access to care for many HIV infected persons (Figure 2.20).
*Average excludes late testers or persons with an AIDS diagnosis within six months of their initial HIV
diagnoses
Figure 2.20. Average* years between HIV & AIDS diagnoses, 1994–2010
2.8
3.4 3.4
4.4
5.1 5.3
5.6
6.1 6.2 6.4
6.7
7.2
7.5 7.6
4.0
7.0
8.2
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year of AIDS diagnosis
Average years
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NC DHHS 46 Communicable Disease
Continued access to effective drug treatments and medical case management that includes
adherence counseling and education should further improve health status for infected persons
and continue this trend.
HAART does not cure the patient of HIV, nor does it remove all symptoms. If treatment is
stopped, high levels of HIV-1 virus return, and may be anti-retroviral drug resistant (Dybul,
2002). Non-adherence to antiretroviral therapy is the major reason individuals fail to benefit
from HAART (Becker, 2002). The reasons for non-adherence with HAART are varied and
include: poor access to medical care, inadequate social supports, psychiatric disease, and drug
abuse (Nieuwkerk, 2001). The complexity of HAART regimens, whether due to pill number,
dosing frequency, meal restrictions or side effects of the medication, contribute to the problem of
intentional non-adherence (Heath, 2002). Although antiretroviral therapy frequently improves
quality of life among symptomatic patients, antiretrovirals may also be associated with reduced
quality of life in asymptomatic patients. Adverse effects, including nausea, vomiting, diarrhea,
and abdominal pain, as well as the inconvenience of taking medication every day, may outweigh
the overall benefit in some patients. As a result, the patient may decide to delay therapy
whenever possible. Known complications related to cumulative use of antiretroviral drugs
include increased incidence of cardiovascular disease, loss of bone density, loss of subcutaneous
fat, the accumulation of fat in some parts of the body, and insulin resistance (DHHS, 2009;
Montessori, 2004).
SURVIVAL
In North Carolina, survival (the estimated proportion of persons surviving a given length of time
after diagnosis) increased with the year of diagnosis for HIV diagnoses made during 2001 to
2005, although year-to-year differences were small. Survival decreased as age increased,
particularly among the 65+ age group. Survival was greatest for persons ages under 13 and ages
13 to 24 and lowest among the ages 65+ group. Survival was greater among Asians and
Hispanics than among blacks, American Indians, and whites (Table 2.21). Survival was greater
among MSM and lowest among females who were injecting drug users (IDU). Vital status may
not be determined or reported for all cases, however, the reporting of deaths for persons reported
as having AIDS is estimated to be more than 90 percent complete.
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Table 2.21. Survival for more than 12, 24, and 36 months after initial HIV diagnosis,
2002–2006
No. of Proportion Survived (in months)
Persons <=12 >12 >24 >36
Age at Diagnosis (yr)
<13 36 0.94 0.94 0.94 0.94
13-24 1,175 0.99 0.99 0.98 0.98
25-44 4,676 0.96 0.94 0.93 0.93
45-64 2,067 0.89 0.85 0.82 0.82
65+ 128 0.70 0.65 0.60 0.60
Race/ethnicity
White* 2,000 0.94 0.93 0.91 0.91
Black* 5,356 0.94 0.91 0.90 0.90
Am. Indian/AN* 78 0.90 0.90 0.90 0.90
Asian, PI* 45 0.96 0.96 0.93 0.93
Hispanic 565 0.96 0.95 0.94 0.94
Unknown 38 0.95 0.84 0.82 0.82
Male Mode of Transmission
MSM 2,771 0.97 0.96 0.95 0.95
IDU 299 0.92 0.89 0.86 0.86
MSM/IDU 101 0.96 0.95 0.91 0.91
Blood Products 11 0.64 0.55 0.55 0.55
Heterosexual-CDC 504 0.93 0.90 0.88 0.88
Pediatric 19 1.00 1.00 1.00 1.00
NIR/NRR 1,995 0.89 0.87 0.85 0.85
Female Mode of Transmission
IDU 138 0.95 0.91 0.87 0.87
Blood Products 7 1.00 1.00 1.00 1.00
Heterosexual-CDC 742 0.96 0.93 0.91 0.91
Pediatric 14 1.00 1.00 1.00 1.00
NIR/NRR 1,480 0.95 0.92 0.90 0.90
Year of HIV Diagnosis
2002 1,672 0.94 0.92 0.89 0.89
2003 1,626 0.93 0.91 0.89 0.89
2004 1,553 0.95 0.92 0.91 0.91
2005 1,589 0.94 0.92 0.90 0.90
2006 1,642 0.95 0.93 0.92 0.92
Total 8,082 0.94 0.92 0.90 0.90
*non-Hispanic
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HIV/AIDS RELATED DEATH
According to the National Center for Health Statistics, the cumulative number of people with
HIV disease as cause of death through 2006 in North Carolina is 10,421. The North Carolina
State Center for Health Statistics reported 321 HIV/AIDS deaths in 2010 (3.4 per 100,000)
(Table 2.22). Together with 1,095 deaths occurring from 2007-2009, the total number of deaths
caused by HIV disease in North Carolina through 2010 is 11,837 (different from the total number
of deaths for persons infected with HIV/AIDS mentioned in pg. 20). Unlike chronic diseases
with high death rates among older populations (such as cancer or cardiovascular diseases),
HIV/AIDS death rates are concentrated among young and middle-aged people. According to the
State Center for Health Statistics, the crude death rate is about 13 times higher for blacks (12.1
per 100,000) than for whites (0.9 per 100,000).
Advances in treatment of HIV with antiretrovirals (ARVs) have been reflected with a major
increase in life expectancy for people diagnosed with HIV infection. Between 1996 and 2005,
average life expectancy after HIV diagnosis increased from 10.5 to 22.5 years (Harrison, 2010).
Despite advances in combating HIV, eventually most HIV-infected individuals develop AIDS.
However, individuals diagnosed with AIDS have also seen increases in life expectancy: among
individuals diagnosed with HIV having an initial CD4 count of <200 or a CD4 count of <200
within 6 months of their initial diagnosis, the average survival time had nearly quadrupled from
1996 to 2005 (5.5 years in 1996 to 19.4 years in 2005; Harrison, 2010). Patients with AIDS
mostly die from opportunistic infections or malignancies associated with the progressive failure
of the immune system.
The age adjusted death rate for HIV disease in North Carolina for 2008 (the last year of data for
national comparisons) was 4.2 per 100,000 (the U.S. death rate was 5.3 per 100,000) (CDC,
2011). HIV Disease is a leading cause of death among younger individuals ages 25 to 64 and
varies by race/ethnicity in North Carolina (Table 2.23). According to North Carolina’s State
Center for Health Statistics (SCHS, 2011), in 2009, HIV disease was the 3rd leading cause of
death among black females ages 25 to 44 (n=46 deaths) and the 5th leading cause of death among
black males of the same age (n=53 deaths). HIV disease was the 7th leading cause of death
among Hispanic males ages 25 to 44 in 2009 (n=10 deaths) and HIV was not listed in the top 10
leading cause of death among Hispanic females of the same age. HIV disease was not listed
among the top 10 causes of death among white males or females ages 25 to 44 in 2009. HIV
disease was the 8th leading cause of death among American Indian males ages 25 to 44 in 2009
(n=1) and was not a leading cause of death among American Indian females of the same age.
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Table 2.23. HIV Disease as the leading cause of death among N.C. residents, 2009
Age Group Race/Ethnicity Number of Deaths Rank as the leading
cause of death
American Indian* 1 9th
Black* 99 4th
Hispanic 10 7th
25–44 years
All Races 134 7th
45–64 years Black* 146 5th
*non-Hispanic Source: N.C. State Center for Health Statistics
Table 2.22. N.C. HIV/AIDS-related deaths by race/ethnicity and gender, 2010
Males Females Total
Race/ ethnicity No. Pct. Rate* No. Pct. Rate* No. Pct. Rate*
White** 48 23.6% 1.6 12 10.2% 0.4 60 18.7% 0.9
Black** 144 70.9% 15.1 102 86.4% 9.5 246 76.6% 12.1
Hispanic 9 4.4% 2.3 3 2.5% 0.9 12 3.7% 1.7
Other 2 1.0% 1.3 1 0.8% 0.6 3 0.9% 1.0
Total 203 100.0% 4.4 118 100.0% 2.5 321 100.0% 3.4
**non-Hispanic * per 100,000 population Source: N.C. State Center for Health Statistics
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CHAPTER 3: HIV TESTING AND PREVENTION
INNORTH CAROLINA
HIGHLIGHTS
 Since November 2002, 176 people have been identified with acute HIV infection by the N.C.
State Lab of Public Health (N.C. SLPH). Acute HIV infection refers to the very early,
particularly infectious stages of HIV infection. The diagnosis of acute HIV provides an
opportunity for early linkage to HIV care and helps reduce potential HIV transmission by
newly infected patients.
 In 2010, 24 acute infections were detected by N.C. SLPH.
 In 2010, a total of 246,458 persons were tested through state-sponsored HIV testing
programs. Of those tested, 1,103 were positive (501 new cases, 546 previous positives, and
56 unknown).
 In 2010, 49 percent (n=244) of all new HIV cases were found through testing done at STD
clinics, where a majority of the testing takes place.
 New case positivity rates were highest for testing done through partner counseling and
referral services (5.7%). HIV positivity rates were also elevated for those tested in HIV test
sites (usually nontraditional testing sites, 0.9% positivity), and community health sites
(0.5%).
 In 2010, 69 percent of those tested were female and 30.7 percent were male. Positivity rates
were higher for males (0.55%) compared to females (0.06%).
 Overall, 44 percent of those tested for HIV in 2010 were black non-Hispanic, 27.5 percent
were white non-Hispanic, 18.1 percent Hispanic, 1 percent American Indian, 1.1 percent
Asian/Pacific Islanders, and 0.1 percent other race/ mixed race .
 HIV positivity rates were highest for males in the other/mixed race group (1.25%) followed
by black non-Hispanic males (0.67%). The disparity was greatest among women. In 2010,
the HIV positivity rate for black non-Hispanic women (0.31%) was 2.6 times the rate for
white women (0.12%).
 In 2010, the largest number of new HIV cases was found in the group with the most tests
(age 20-29 years, n=250 cases). Overall the highest positivity rates were seen among those 40
years and older (0.29%).
 The highest new positivity rates in 2010 were among those in the MSM (3.7%) and
MSM/IDU (1.0%). The highest new HIV positivity for women was among those with
heterosexual high risk (0.13%).
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 During 2010, 20,741 people were tested through the N.C. Rapid HIV Testing Program (40
new cases, 0.2% positivity); 22,171 people were tested through the nontraditional testing site
program (68 new cases, 0.3% positivity); 45,861 people were tested through the expanded
testing program (96 new cases, 0.3% positive) and 2,230 people were tested through the
substance abuse testing program (7 new cases, 0. 3% positive).
 During 2010, 2,617 people participated in health education and risk reduction programs that
were supported by the Communicable Disease Control Branch of the N.C. Division of Public
Health.
BACKGROUND
The information in this chapter will focus on state-supported HIV testing programs and on
prevention activities that encourage testing for HIV. In North Carolina, HIV testing is offered at
no charge to clients in all local health departments and a number of community-based
organizations (CBOs). In addition, the Communicable Disease Branch provides resources and
technical support to community health centers, emergency departments, health departments, and
state prisons to expand HIV testing in clinical and jail settings. HIV Prevention activities include
health education and risk reduction projects conducted by local health departments and CBOs
and the Get Real. Get Tested. campaign.
History of State-Sponsored HIV Testing in North Carolina
The North Carolina State Laboratory of Public Health (SLPH) has been processing blood
samples for HIV testing since about 1987. When the state-sponsored program began, testing was
available anonymously at 100 local health departments. In September 1991, North Carolina
began to evaluate the use of confidential (client’s name obtained), rather than anonymous HIV
testing. All 100 sites offered confidential tests, and 18 of these sites continued to offer
anonymous testing as an option. Effective in May 1997, anonymous testing in North Carolina
was eliminated through a ruling made by the North Carolina Commission of Health Services.
The North Carolina Commission for Health Services’ ruling raised some concern that by
removing the anonymous test option, testing among people with high risk for HIV infection
would be reduced. Prior to implementation of the ruling, the Communicable Disease Branch
implemented procedures to increase access to HIV testing by making testing available in
nontraditional settings. Some nontraditional test sites are operated by CBOs or local health
departments and offer HIV testing in venues outside of traditional health department testing sites.
Others are physically located in a local health department but operate outside the normal working
hours.
Changes in policy, HIV testing technology and funding have enabled the Branch to expand the
numbers of people tested for HIV each year. In 2006, the Centers for Disease Control and
Prevention (CDC) published revised HIV testing guidelines that encouraged HIV testing for
adults as part of their routine healthcare (CDC 2006). Screening for HIV infection should be
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performed routinely for all patients ages 13 to 64 years, and should be included in the routine
panel of prenatal screening tests for all pregnant women. The CDC further recommended that
separate written consent for HIV testing should not be required (general consent for medical care
should be considered sufficient to encompass consent for HIV testing) and that prevention
counseling should not be required with HIV diagnostic testing or as part of screening programs
in clinical settings. In response to these new guidelines, North Carolina passed a rule change to
the administrative code on November 1, 2007. For tests done in clinical settings, a written HIV
consent form and pre-test counseling were no longer required, thereby removing some of the
barriers to routine HIV testing (10A N.C.AC 41A.0202(10); 10A N.C.AC 41A.0202(16)
). Additional rule changes require that pregnant women shall be offered HIV tests at the first
prenatal visit and in the third trimester (10A N.C.AC 41A.0202(14)). In total, these policy
changes have resulted in increased testing in prenatal/obstetric clinics, STD clinics, jails, and
prisons in N.C. and greatly facilitated the establishment of new testing programs in emergency
departments and community health centers.
The N.C. Communicable Disease Branch initiated a rapid testing program in 2004 that has
provided new opportunities for improving access to testing in both clinical and outreach settings.
Rapid HIV testing technology was first approved by the Food and Drug Administration in 2002.
Currently there are 6 FDA approved rapid tests, four of which have Clinical Laboratory
Improvement Amendment (CLIA) waivers (Oraquick Advance Rapid HIV1/2 antibody test,
Unigold recombigen HIV, Clearview HIV 1/2 Stat Pak, Clearview Complete HIV1/2). Rapid
tests with a CLIA waiver can be processed outside of a clinical setting, which allows HIV testing
to be done more easily in outreach settings. Rapid HIV tests can be performed using oral fluid,
finger stick blood, serum, plasma, or whole blood collected by venipuncture. Preliminary rapid
test results can be obtained in 10 to 20 minutes (all preliminary rapid tests should then be
followed by a confirmatory conventional HIV test). Because clients undergoing rapid HIV
testin