2013 North Carolina
HIV/STD Epidemiologic
Profile
HIV/STD Surveillance Unit
Please direct any comments or questions to:
HIV/STD 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
Suggested Citation:
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Profile. North Carolina Department of Health and Human Services, Raleigh, North Carolina.
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2013 North Carolina
HIV/STD Epidemiologic
Profile
March 2015
State of North Carolina • Pat McCrory, Governor
Department of Health and Human Services
Aldona Z. Wos, M.D., Secretary
Division of Public Health • Robin Cummings, M.D., Interim State Health Director
www.ncdhhs.gov • www.publichealth.nc.gov
North Carolina Department of Health and Human Services (North Carolina DHHS) is an equal opportunity employer and
provider (03/15).
North Carolina
Department of Health and Human Services
Division of Public Health
Epidemiology Section
Communicable Disease Branch
Evelyn Foust, CPM, MPH, Head
Jacquelyn Clymore, MS, State HIV/STD Director
Contributing Editors:
Nicole Dzialowy
Janet Alexander
John Barnhart
Nicole Beckwith
Christy Crowley
Jenna Donovan
Douglas Griffin
Anne Hakenwerth
Kitty Herrin
Kearston Ingraham
Mara Larson
Jason Maxwell
Vicki Mobley
Pete Moore
Rob Pace
Erika Samoff
Lynne Sampson
Jasmine Stringer
Heidi Swygard
Mark Turner
Holly Watkins
Jenni Wheeler
March 2015
Funding to print this document was provided by the Centers for Disease Control and Prevention Cooperative
Agreement #5U62PS003999. Its contents are solely the responsibility of the authors and do not necessarily
represent the views of the Centers for Disease Control and Prevention.
2013 North Carolina HIV/STD Epidemiologic Profile Table of Contents
TABLE OF CONTENTS
List of Abbrevations ................................................................................................................................... ix
Executive Summary .................................................................................................................................... xi
Key Points by Chapter ....................................................................................................................... xi-xvii
Introduction ................................................................................................................................................ xix
Part I: Core Epidemiology
Chapter 1: Sociodemographic Characteristics of North Carolina ................................................ 1
Population .................................................................................................................................................................... 1
Age and Gender ............................................................................................................................................................... 1
Race/Ethnicity Populations in North Carolina .................................................................................................. 2
Race/Ethnicity and Physiographic Region .......................................................................................................... 3
Foreign-born Population ............................................................................................................................................ 4
Metropolitan Statistical Areas ............................................................................................................................... 5
Health Indicators ....................................................................................................................................................... 6
Household Income ......................................................................................................................................................... 6
Health Insurance ............................................................................................................................................................ 7
Medicaid ............................................................................................................................................................................. 7
Education ........................................................................................................................................................................... 7
Chapter 2: Scope of HIV Infection Epidemic in North Carolina ..................................................... 9
Special Notes ............................................................................................................................................................... 9
Background on HIV Infection and Surveillance in North Carolina ...................................................... 10
HIV Surveillance Case Definition ....................................................................................................................... 10
Overall HIV Infection Trends in North Carolina .......................................................................................... 11
North Carolina and the United States .............................................................................................................. 12
HIV Infection Prevalence in North Carolina .................................................................................................. 13
Demographics of Persons Living with HIV Infection ..................................................................................... 14
Hierarchical Risk of Exposure for HIV Prevalent Cases ............................................................................... 15
HIV Incidence Estimates in North Carolina ................................................................................................... 16
Newly Diagnosed HIV Infection Cases in North Carolina ........................................................................ 18
Demographics of Adult/Adolescent Newly Diagnosed HIV Infection Cases ....................................... 18
Adolescent Newly Diagnosed HIV Infection Cases .......................................................................................... 27
Females of Child-Bearing Age and Perinatal HIV Infection ....................................................................... 28
Geographic Distribution of HIV Infection in North Carolina .................................................................. 29
HIV Prevalence Cases in Urban/Rural Areas .................................................................................................... 30
Prevalent and Newly Diagnosed HIV Infection Cases by Physiographic Regions ............................ 30
HIV Infection by Regional Network of Care and Prevention (RNCP), including Charlotte
Transitional Grant Area (TGA) ........................................................................................................................... 32
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Newly Diagnosed HIV Infection Cases Diagnosed Late in North Carolina ........................................ 32
AIDS (Stage 3) Prevalence in North Carolina ............................................................................................... 35
Survival and HIV-Related Deaths in North Carolina .................................................................................. 36
Medical Monitoring Project ................................................................................................................................ 38
Part II: Testing, Care, and Treatment of HIV Infection in North Carolina
Chapter 3: HIV Testing in North Carolina ........................................................................................... 43
Background ............................................................................................................................................................... 43
History of State-Sponsored HIV Testing in North Carolina ........................................................................ 43
HIV Testing Protocol at the North Carolina State Laboratory of Public Health Starting
in November 2013 .............................................................................................................................................. 45
HIV Testing Protocol Prior to October 2013 ................................................................................................ 45
HIV Testing at the North Carolina State Laboratory of Public Health Results from
1991 to 2013......................................................................................................................................................... 46
State-Supported HIV Testing Outcomes 2013 ............................................................................................. 47
Gender ............................................................................................................................................................................... 48
Test Setting ..................................................................................................................................................................... 48
Age ...................................................................................................................................................................................... 50
Race/Ethnicity ............................................................................................................................................................... 50
Hierarchical Risk for HIV Exposure ...................................................................................................................... 50
Additional HIV Testing Project ........................................................................................................................... 52
Screening and Tracing Active Transmission (STAT) Program................................................................. 52
Chapter 4: HIV Infection Care and Treatment in North Carolina ............................................... 55
Ryan White ................................................................................................................................................................ 55
Ryan White Part B Base Grant Program ............................................................................................................ 57
AIDS Drug Assistance Program (ADAP) ............................................................................................................. 63
North Carolina “Unmet Needs” Estimate, 2013 ........................................................................................... 65
Background .................................................................................................................................................................... 65
Data Sources and Methodology .............................................................................................................................. 66
Results ............................................................................................................................................................................... 66
Data To Care ............................................................................................................................................................. 68
HIV Continuum of Care .............................................................................................................................................. 68
Out of Care Investigations ........................................................................................................................................ 71
Federally Funded Projects to Enhance Linkage, Retention, and Re-engagement in Care in
North Carolina........................................................................................................................................................... 71
Housing Opportunities for Persons with AIDS (HOPWA) ....................................................................... 72
Conclusion ................................................................................................................................................................. 73
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Part III: Sexually Tranmitted Diseases and HIV Comorbidities
Chapter 5: Bacterial and Other Sexually Transmitted Diseases in North Carolina ............. 75
Special Notes ............................................................................................................................................................ 75
Reportable Sexually Transmitted Diseases in North Carolina .............................................................. 76
Chlamydia .................................................................................................................................................................. 78
Chlamydia Disease ....................................................................................................................................................... 78
Chlamydia Reporting.................................................................................................................................................. 78
Chlamydia Trend Analysis ........................................................................................................................................ 79
Chlamydia Prevalence Data .................................................................................................................................... 80
Gonorrhea .................................................................................................................................................................. 81
Gonorrhea Disease ....................................................................................................................................................... 81
Gonorrhea Reporting ................................................................................................................................................. 82
Gonorrhea Trend Analysis........................................................................................................................................ 82
Gonorrhea Prevalence Data .................................................................................................................................... 83
Gonococcal Isolate Surveillance Project ............................................................................................................. 84
Syphilis ........................................................................................................................................................................ 85
Syphilis Disease ............................................................................................................................................................. 85
Syphilis Reporting ........................................................................................................................................................ 85
Syphilis Trend Analysis .............................................................................................................................................. 86
Congenital Syphilis ...................................................................................................................................................... 90
Non-Reportable Sexually Transmitted Diseases in North Carolina .................................................... 91
Human Papillomavirus .............................................................................................................................................. 91
Genital Herpes ............................................................................................................................................................... 92
Trichomoniasis .............................................................................................................................................................. 92
Ophthalmia Neonatorum ......................................................................................................................................... 92
Chapter 6: HIV Comorbidities in North Carolina ............................................................................. 93
Syphilis and HIV ...................................................................................................................................................... 93
Background .................................................................................................................................................................... 93
Syphilis and HIV in North Carolina ....................................................................................................................... 94
Tuberculosis and HIV ............................................................................................................................................ 98
Background .................................................................................................................................................................... 98
Tuberculosis and HIV in North Carolina ............................................................................................................ 98
Latent Tuberculosis Infection and HIV ............................................................................................................. 101
Hepatitis B and HIV in North Carolina ......................................................................................................... 102
Hepatitis C and HIV in North Carolina ......................................................................................................... 103
Part IV: Integrated Programs and Prevention
Chapter 7: Integrated Program Activities ....................................................................................... 105
HIV/STD Prevention Programs in North Carolina .................................................................................. 105
The Get Real. Get Tested. Get Treatment. Campaign ................................................................................. 105
Evidence-Based Intervention Services ............................................................................................................. 105
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Minority AIDS Initiative/Men Who Have Sex with Men Task Force Teams ..................................... 107
Partner Notification, Counseling, and Referral Services ....................................................................... 108
Care and Prevention in the United States (CAPUS) ................................................................................ 109
Expanded Capacity to Test via North Carolina State Laboratory of Public Health ..................... 110
Routine HIV Testing Campaign........................................................................................................................... 110
Minority Patient Navigators ................................................................................................................................ 110
Provider Cultural Competency Trainings ........................................................................................................ 110
Tele-health Consultations ..................................................................................................................................... 110
Minority Men’s Clinic ............................................................................................................................................... 111
Safe Spaces ................................................................................................................................................................... 111
Special Populations Bridge Counselor .............................................................................................................. 111
Special Projects of National Significance (SPNS-LINK) ......................................................................... 111
Program Collaboration and Service Integration (PCSI) ........................................................................ 113
Pitt County Health Department ........................................................................................................................... 113
Buncombe County Health Department ............................................................................................................ 114
Mecklenburg County Health Department ....................................................................................................... 114
Wake County Human Services .............................................................................................................................. 114
Appendices
Appendix A: Maps .................................................................................................................................... A-1
Map 1: North Carolina Population Demographics, 2012 ....................................................................... A-2
Map 2: North Carolina Metropolitan Designations ................................................................................... A-3
Map 3: North Carolina Per Capita Income, 2012 ....................................................................................... A-4
Map 4: North Carolina Medicaid Eligibles, 2013 ....................................................................................... A-5
Map 5: North Carolina Newly Diagnosed HIV Infection Cases
by County of Residence, 2013 ....................................................................................................................... A-6
Map 6: North Carolina Newly Diagnosed HIV Infection Rates
by County of Residence, 2013 ....................................................................................................................... A-7
Map 7: North Carolina Newly Reported Chlamydia Cases by County of Residence, 2013 ....... A-8
Map 8: North Carolina Newly Reported Chlamydia Rates by County of Residence, 2013 ....... A-9
Map 9: North Carolina Newly Reported Gonorrhea Cases by County of Residence, 2013 ..... A-10
Map 10: North Carolina Newly Reported Gonorrhea Rates by County of Residence, 2013 . A-11
Map 11: North Carolina Newly Diagnosed Early Syphilis Cases (Primary, Secondary, Early
Latent) by County of Residence, 2013 .................................................................................................... A-12
Map 12: North Carolina Newly Diagnosed Early Syphilis Rates (Primary, Secondary, Early
Latent) by County of Residence, 2013 .................................................................................................... A-13
Appendix B: Data Sources ................................................................................................................... B-14
Sociodemographic Information ....................................................................................................................... B-2
National Center for Health Statistics: Bridged-Race Population Estimates .................................... B-2
United States Census Bureau: American Community Survey .................................................................. B-2
Kaiser Family Foundation and Urban Institute: State Health Facts .................................................... B-2
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Core HIV Infection Surveillance ....................................................................................................................... B-3
enhanced HIV/AIDS Reporting System (eHARS) .......................................................................................... B-3
National HIV/AIDS Surveillance Data (CDC) ................................................................................................. B-3
North Carolina State Center for Health Statistics: Leading Cause of Death Data ......................... B-3
Medical Monitoring Project: Interview and Medical Record Abstraction Datasets ...................... B-4
HIV Testing Data ................................................................................................................................................... B-5
State-Supported HIV Testing Data ...................................................................................................................... B-5
HIV Care and Treatment Data ........................................................................................................................... B-6
Ryan White Care Act and Part B Base Program Data ................................................................................ B-6
AIDS Drug Assitance Program (ADAP) ............................................................................................................. B-7
Housing Opportunities for Persons with AIDS (HOPWA) .......................................................................... B-7
Medicaid ......................................................................................................................................................................... B-8
Sexually Transmitted Diseases and Comorbidity Surveillance ........................................................... B-8
North Carolina Electronic Disease Surveillance System (NC EDSS) .................................................... B-8
Gonococcal Isoalte Surveillance Project ........................................................................................................ B-10
North Carolina Syphiis Elimination Effort .................................................................................................... B-10
Appendix C: Technical Notes ................................................................................................................. C-1
HIV Infection ........................................................................................................................................................... C-2
HIV Infection Surveillance Reporting Issues .............................................................................................. C-2
HIV Incidence Estimation .................................................................................................................................. C-3
Testing and Treatment History (TTH) Questionnaire ................................................................................ C-4
HIV Exposure Risk Categories and Distribution ....................................................................................... C-4
Rate Calculation and Denominator Determination.................................................................................. C-5
Appendix D: Tables .................................................................................................................. D-1 to D-55
Appendix E: References by Chapter ................................................................................................... E-1
Index .............................................................................................................................................................. I-1
List of Tables (In Text)
Table 1.1. North Carolina Bridged-Race Population Estimates by Age Group, 2012 .......................... 2
Table 1.2. North Carolina Race/Ethnicity Proportions by Gender and
Physiographic Region, 2012 .................................................................................................................................. 4
Table 1.3. North Carolina Foreign-Born Population by Region of Birth, 2013 ...................................... 4
Table 1.4. North Carolina Population by Race/Ethnicity for Urban and Rural Areas, 2012 ............ 5
Table 1.5. North Carolina and United States Individual Poverty Rate
by Age and Race/Ethnicity, 2013 ......................................................................................................................... 6
Table 2.1. Top 10 United States (including District of Columbia and Six Dependent Territories)
for Newly Diagnosed HIV Infections, 2012 ................................................................................................... 12
Table 2.2. All Persons Living with HIV Infection as of 12/31/2013 in North Carolina by Selected
Demographics .......................................................................................................................................................... 15
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Table 2.3. North Carolina HIV Incidence Estimates by Gender, Race/Ethnicity, Age, and
Hierarchical Risk of HIV Exposure, 2012 ....................................................................................................... 17
Table 2.4. North Carolina Newly Diagnosed Adult/Adolescent HIV Infection Cases
by Age Group and Gender, 2013 ........................................................................................................................ 20
Table 2.5. Adult/Adolescent Newly Diagnosed HIV Infection Cases by Hierarchical Risk of HIV
Exposure, 2013 ........................................................................................................................................................ 22
Table 2.6. Adult/Adolescent Newly Diagnosed HIV Infection Cases by Hierarchical Risk of HIV
Exposure (Unknown Risk Redistributed), 2013 ......................................................................................... 23
Table 2.7. Adult/Adolescent Newly Diagnosed HIV Infections During and After Child-Bearing
Age, 2009-2013 ....................................................................................................................................................... 28
Table 2.8. HIV Infection Prevalence as of 12/31/2013 by Rural/Urban Areas and
Race/Ethnicity ......................................................................................................................................................... 30
Table 2.9. HIV Infection Prevalence as of 12/31/2013 by Physiographic Areas and
Race/Ethnicity ......................................................................................................................................................... 31
Table 2.10. Newly Diagnosed Adult/Adolescent HIV Infection Cases by Physiographic Regions
and Race/Ethnicity, 2013 .................................................................................................................................... 32
Table 2.11. Proportion of Newly Diagnosed HIV Infections Classified as AIDS (Stage 3) within
Six Months (“Late Testers”), 2013 .................................................................................................................... 33
Table 2.12. Propotion of Newly Diagnosed HIV Infections and Concurrent AIDS (Stage 3),
2004-2013 ................................................................................................................................................................. 34
Table 2.13. Late HIV Diagnoses by Gender and Race/Ethnicity, 2004-2013 ...................................... 34
Table 2.14. North Carolina Persons Living with HIV Infection by HIV Infection Classification
as of 12/31/2013 ................................................................................................................................................... 36
Table 2.15. Survival for More than 12, 24, and 36 Months after Initial HIV Diagnosis,
2005-2009 ................................................................................................................................................................. 37
Table 2.16. North Carolina HIV-Related Deaths by Race/Ethnicity and Gender, 2013 .................. 38
Table 2.17. Propotion of All Persons Living with HIV Infection as of 12/31/2011 and Weighted
North Carolina Medical Monitoring Project data ........................................................................................ 40
Table 3.1. North Carolina HIV Testing Positivity Rates by Setting and Gender, 2013 ..................... 49
Table 3.2. North Carolina HIV Testing Positivity Rates by Gender, Age, Race/Ethnicity,
and Hierarchical Risk of HIV Exposure, 2013 ............................................................................................. 51
Table 4.1. Proportion of North Carolina Ryan White Part B Clients, AIDS Drug Assistance
Program (ADAP) Clients, and Persons Living with HIV Infection by Selected Demographics,
2013 ............................................................................................................................................................................. 57
Table 4.2. Services Provided to Ryan White Part B Program Clients, Ryan White
Year (RWY) 2013-2014 ........................................................................................................................................ 59
Table 4.3. Proportion of Persons Living with HIV Infection in North Carolina with
“Unmet Need” for HIV Care by Selected Demographics, 2013 .............................................................. 67
Table 4.4. Proportion of Persons Living with HIV Infection in North Carolina with
“Unmet Need” for HIV Care by Regional Networks of Care and Prevention, 2013 ....................... 68
Table 5.1. North Carolina Repotable Bacterial Sexually Transmitted Diseases, 2013 .................... 77
Table 6.1. North Carolina Tuberculosis Cases with HIV Infection by Age Group, 2009-2013 .. 100
Table 6.2. North Carolina Reported HIV Results for Tuberculosis Cases, 2009-2013 ................. 100
Table 6.3. Percent of North Carolina Latent Tuberculosis Infection Cases Tested for HIV,
2009-2013 .............................................................................................................................................................. 102
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Table 6.4. North Carolina Latent Tuberculosis and HIV-Positive Infection Cases Initiated on
Tuberculosis Treatment, 2009-2013 ............................................................................................................ 102
Table 6.5. North Carolina Hepatitis B Infections Reported, including HIV Comorbidity
Infections, 2013 .................................................................................................................................................... 103
List of Figures (In Text)
Figure 2.1. Overall HIV Infection Trends in North Carolina ....................................................................... 11
Figure 2.2. Persons Living with HIV Infection Classification in North Carolina, 2009-2013 ........ 13
Figure 2.3. North Carolina HIV Incidence Estimates among Adults/Adolescents, 2007-2012 .... 16
Figure 2.4. Newly Diagnosed Adult/Adolescent HIV Infection Rates by Gender and
Race/Ethnicity, 2009-2013 ................................................................................................................................ 19
Figure 2.5. Newly Diagnosed HIV Infection Cases by Age and Gender, 2013 ..................................... 21
Figure 2.6. Newly Diagnosed Adult/Adolescent HIV Infection Cases by Hierarchical Risk of HIV
Exposure (Unknown Risk Redistributed), 2009-2013 ............................................................................. 24
Figure 2.7. Adult/Adolescent Newly Diagnosed HIV Infections by Gender and Hierarchical Risk
of HIV Exposure (Unknown Risk Redistributed), 2013 ........................................................................... 25
Figure 2.8. Hierarchical Risk of HIV Exposure among Adult/Adolescent Male HIV Infection
Cases Diagnosed (Unknown Risk Redistributed), 2013 .......................................................................... 26
Figure 2.9. Hierarchical Risk of HIV Exposure among Adult/Adolescent Female HIV Infection
Cases Diagnosed (Unknown Risk Redistributed), 2013 .......................................................................... 26
Figure 2.10. New HIV Diagnoses among Adolescent (13-24 years) by Gender and
Race/Ethnicity, 2013 ............................................................................................................................................ 27
Figure 2.11. Hierarchical Risk of HIV Exposure among Adolescent (13-24 years) HIV Infection
Cases Diagnosed (Unknown Risk Redistributed), 2013 .......................................................................... 28
Figure 2.12. Likely Perinatal HIV Infection Cases by Year of Birth, 2004-2013 ................................ 29
Figure 3.1. Conventional HIV Tests Performed and Overall HIV Positivity Rates, North Carolina
State Laboratory of Public Health ..................................................................................................................... 47
Figure 4.1. HIV Services Provision in North Carolina: 10 Regional Networks of Care and
Prevention (RNCP) and Charlotte Metropolitan Transitional Grant Area (TGA) .......................... 58
Figure 4.2. Distribution of HIV Risk Factors among North Carolina Ryan White Part B Clients
by Gender, Ryan White Year (RWY) 2013-2014 ......................................................................................... 60
Figure 4.3. Viral Load Suppression among North Carolina Ryan White B Clients Ages Two Years
and Older by Race/Ethnicity, Ryan White Year (RWY) 2013-2014 .................................................... 61
Figure 4.4. North Carolina Progress toward Meeting Statewide Goals for Nine Performance
Measures for Quality, Ryan White Year (RWY) 2013-2014 ................................................................... 63
Figure 4.5. Gross Family Income among North Carolina AIDS Drug Assistance Program (ADAP)
Clients by Program, Ryan White Year (RWY) 2013-2014 ....................................................................... 64
Figure 4.6. Viral Load Suppression among North Carolina AIDS Drug Assistance Program
(ADAP) Clients by Program, Ryan White Year (RWY) 2013-2014 ...................................................... 65
Figure 4.7. Continuum of HIV Care among People with Last Known Residence in North Carolina,
2009-2013 ................................................................................................................................................................. 70
Figure 5.1. Chlamydia and Gonorrhea Tests Performed at North Carolina Laboratory of Public
Health and New Cases Reported, 2000-2013 ............................................................................................... 80
Figure 5.2. Chlamydia Testing Positivity Rates among Females by Age and Clinic Type,
2009-2013 ................................................................................................................................................................. 81
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Figure 5.3. Gonorrhea Testing Positivity Rates among Females by Age and Clinic Type,
2009-2013 ................................................................................................................................................................. 84
Figure 5.4. North Carolina Early Syphilis (Primary, Secondary, and Early Latent Syphilis)
Infections by Gender, 2007-2013...................................................................................................................... 87
Figure 5.5. North Carolina Early Syphilis (Primary, Secondary, and Early Latent Syphilis)
Infections among Males by Age at Diagnosis (Year), 2007-2013 ......................................................... 88
Figure 5.6. North Carolina Early Syphilis (Primary, Secondary, and Early Latent Syphilis)
Infections among Males by Race/Ethnicity, 2007-2013 .......................................................................... 89
Figure 5.7 North Carolina Congenital Syphilis Infections by Year of Birth and Race/Ethnicity,
2004-2013 ................................................................................................................................................................. 90
Figure 6.1. North Carolina Early Syphilis (Primary, Secondary, and Early Latent Syphilis)
Infections by Gender, 1999-2013...................................................................................................................... 94
Figure 6.2. North Carolina Early Syphilis (Primary, Secondary, and Early Latent Syphilis)
Co-Infections with HIV, 1999-2013 .................................................................................................................. 95
Figure 6.3. North Carolina Early Syphilis (Primary, Secondary, and Early Latent Syphilis)
Co-Infections with HIV by Gender, 1999-2013............................................................................................ 96
Figure 6.4. North Carolina Early Syphilis (Primary, Secondary, and Early Latent Syphilis)
Co-Infected Syphilis and HIV Infections among Males by Race/Ethnicity, 2007-2013 .............. 97
Figure 6.5. North Carolina Tuberculosis Cases with HIV Infection, 2004-2013 ................................ 99
Figure 6.6. North Carolina Tuberculosis Cases with Unknown HIV Status at Time of
Tuberculosis Diagnosis, 2001-2013.............................................................................................................. 101
Figure 7.1. Field Services Role in Partner Notification, Counseling, and Referral Services ....... 108
Figure 7.2. Care and Prevention in the United States (CAPUS) Interventions in
North Carolina ...................................................................................................................................................... 109
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2013 North Carolina HIV/STD Epidemiologic Profile List of Abbreviations
LIST OF ABBREVIATIONS
ACIP Advisory Committee for Immunization Practices
ACP AIDS Care Program
ADAP AIDS Drug Assistance Program
AIDS Acquired Immunodeficiency Syndrome
AIN Anal Intraepithelial Neoplasia
APP ADAP Pharmacy Program
ART Antiretroviral Treatment
ARTAS Antiretroviral Treatment and Access to Services
ATEC AIDS Training and Education Center
BED BED HIV-1 Capture Enzyme Immunoassay
CAPUS Care and Prevention in the United States
CARE Comprehensive AIDS Resources Emergency
CBO Community-Based Organization
CD4 CD4+ T-lymphocyte cell
CDC Centers for Disease Control and Prevention
CLIA Clinical Laboratory Improvement Amendment
CTS Counseling and Testing Site
CY Calendar Year
DHHS Department of Health and Human Services
DNA Deoxyribonucleic Acid
DOC Department of Correction
EBIS Evidence-Based Intervention Services
eHARS enhanced HIV/AIDS Reporting System
EIA Enzyme Immunoassay
FDA Food and Drug Administration
FDT Field Delivery Therapy
FOY Focus on Youth
FPL Federal Poverty Level
FY Fiscal Year
GED General Education Development
GISP Gonococcal Isolate Surveillance Project
GYN Gynecology
HAB HIV/AIDS Bureau
HBV Hepatitis B
HCV Hepatitis C
HIV Human Immunodeficiency Virus
HOPWA Housing Opportunities for Persons with AIDS
HPV Human Papillomavirus
HRSA Health Resources and Services Administration
HSV-2 Genital Herpes Simplex Virus Type 2
HUD United States Department of Housing and Urban Development
IA Immunoassay
IDU Injection Drug Use
ITTS Integrated Targeted Testing Services
LGV Lymphogranuloma Venereum
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2013 North Carolina HIV/STD Epidemiologic Profile List of Abbreviations
LTBI Latent Tuberculosis Infection
MAI Minority AIDS Initiative
MSA Metropolitan Statistical Area
MSM Men Who Have Sex With Men
NAAT Nucleic Acid Amplification Test
NC EDSS North Carolina Electronic Disease Surveillance System
NGU Nongonococcal Urethritis
NHAS National HIV/AIDS Strategy
NIR/NRR No Identified Risk/No Risk Reported
OB Obstetrics
OMB Office of Management and Budget
PCP Pneumocystis pneumonia
PCR Polymerase Chain Reaction
PCSI Program Coordination and Service Integration
PID Pelvic Inflammatory Disease
PLWA People Living with AIDS
PLWH People Living with HIV (non-AIDS)
PLWHA People Living with HIV/AIDS
QM Quality Management
RBC Regional Bridge Counselor
RIDR Routine Interstate Duplicate Review
RNA Ribonucleic Acid
RNCP Regional Network of Care and Prevention
RWY Ryan White Year
SAMHSA Substance Abuse and Mental Health Services Administration
SBC State Bridge Counselor
SISTA Sisters Informing Sisters About Topics on AIDS
SLPH State Laboratory of Public Health
SPAP State Pharmaceutical Assistance Program
SPNS Special Projects of National Significance
STARHS Serologic Testing Algorithm for Recent HIV Seroconversion
STAT Screening and Tracing Active Transmission
STD Sexually Transmitted Diseases
STD*MIS Sexually Transmitted Diseases Management Information System
STRMU Short-Term Rent, Mortgage, and Utility Assistance
TB Tuberculosis
TBRA Tenant-Based Rental Assistance
TGA Transitional Grant Area
TTH Testing and Treatment History
US United States
UNC-Chapel Hill University of North Carolina at Chapel Hill
VOICES/VOCES Video Opportunities for Innovative Condom Education and Safer Sex
North Carolina DHHS x Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Executive Summary
EXECUTIVE SUMMARY
The 2013 North Carolina HIV/STD Epidemiologic Profile describes the epidemiology of sexually
transmitted diseases (STD), including human immunodeficiency virus (HIV), in North Carolina. As in
previous versions, the majority of data presented are drawn from surveillance systems maintained by
the North Carolina Department of Health and Human Services (North Carolina DHHS), Division of Public
Health, Communicable Disease Branch. Throughout the profile, the following questions are addressed.
1. What are the sociodemographic characteristics of the general population in North Carolina?
2. What is the scope of HIV burden in North Carolina?
3. What are the indicators of risk for HIV infection in the North Carolina population?
4. What is the impact of Ryan White HIV/AIDS Program care and treatment services on the health
of HIV infected persons in North Carolina?
5. What is the scope of disease of chlamydia, gonorrhea, syphilis, and other sexually transmitted
diseases in North Carolina?
The North Carolina HIV/STD Epidemiologic Profile also reflects a broad spectrum of information about
prevention and integrated service activities across the state. Public health activities at the state level
aimed at controlling HIV infection and STDs throughout North Carolina have long been integrated.
A summary of key points for each topic discussed in the Epidemiologic Profile are presented by chapter
below.
CHAPTER 1: SOCIODEMOGRAPHIC CHARACTERISTICS OF NORTH CAROLINA
• In 2013, North Carolina was the 10th most populous state in the nation, with an estimated
population of 9,861,952 (page 1).
o North Carolina’s population increased 18.5 percent from 2000 to 2010 (among the top
five states with fastest growing population growth rate) (page 1).
o The North Carolina foreign-born population increased 56 percent from 2002 to 2012
(page 4).
o North Carolina has the 7th largest non-White/Caucasian population in the nation
(page 3).
o North Carolina has the 8th highest percentage of Black/African American population in
the nation (page 2).
o From 2002 to 2012, the estimated Hispanic/Latino population in North Carolina
increased by 88.6 percent (page 3).
• In 2013, North Carolina’s per capita income of $38,683 was 38th in the nation or 86.4 percent of
the national average of $44,765 (page 6).
• In 2013, 19 percent of North Carolinians were living at or below the federal poverty level (FPL);
40 percent of the overall population is considered low income (living at or below 199% FPL)
(page 6).
North Carolina DHHS xi Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Executive Summary
• In 2013, 24 percent of adults aged 19 to 64 years were uninsured in North Carolina (page 7).
• In 2012, approximately 70.8 percent of the state’s population lived in urban areas (page 5).
CHAPTER 2: SCOPE OF HIV INFECTION EPIDEMIC IN NORTH CAROLINA
• The cumulative number of individuals first diagnosed with HIV infection in North Carolina, which
includes those diagnosed with AIDS, was 42,889, of whom 28,101 were living as of December
31, 2013 (page 13).
• An estimated 36,300 people were living with HIV infection in North Carolina (including 6,500
individuals who may not be aware of their HIV infection), as of December 31, 2013 (page 14).
• The total number of new HIV infections diagnosed in North Carolina in 2013 was 1,525 (15.6 per
100,000 population), while the number of new diagnoses among the adult/adolescent
population was 1,513 (18.7 per 100,000 adult/adolescent population) in North Carolina. Please
note that this number is likely to be artificially inflated due to incomplete interstate
deduplication for 2013 (page 18).
• Among the newly diagnosed adult/adolescent HIV infections, Black/African American (non-
Hispanic/Latino) males had the highest rate at 92.3 per 100,000 adult/adolescent population,
which is nearly nine times higher than that for White/Caucasians (non-Hispanic/Latino) (12.0 per
100,000 adult/adolescent population). For females, the highest rate by race/ethnicity was
among Black/African Americans (non-Hispanic/Latina) females (24.7 per 00,000
adult/adolescent population), followed by Hispanic/Latina females at 8.1 per 100,000
adult/adolescent population, and White/Caucasian females at 1.9 per 100,000 population
(page 18).
• The majority of newly diagnosed HIV infections occurred among the 20-29 year old age group
(N = 495, 32.5%). Roughly 20 percent of all newly diagnosed HIV infections in 2013 were among
adolescent (13-24 years of age) males (page 20).
• After redistributing the unknown hierarchical risk of HIV exposure category (includes persons
who report sex with an opposite sex partner and do not report injection drug use [IDU], men
who have sex with men [MSM], or any other potential high risk behaviors, no identified risk
[NIR] and no reported risk [NRR]), MSM accounted for 60.5 percent of newly diagnosed
adult/adolescent cases in 2013. Heterosexual exposure accounted for roughly 33 percent of
adult/adolescent cases in 2013, followed by IDU at 4 percent (page 22).
• In 2013, Mecklenburg (31.0 per 100,000 population), Edgecombe (31.0 per 100,000 population),
Cumberland (26.0 per 100,000 population), Durham (25.7 per 100,000 population), and
Guildford (23.5 per 100,000 population) counties had the highest rates of newly diagnosed HIV
infections among the 100 counties in North Carolina (page 30).
• In 2013, HIV and AIDS were diagnosed at the same visit (“late testers”) for 29 percent of newly
diagnosed HIV infections (page 33).
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2013 North Carolina HIV/STD Epidemiologic Profile Executive Summary
• Overall, HIV-related deaths ranked as the 23rd most common leading cause of death in North
Carolina in 2013 (page 38).
• The Medical Monitoring Project (MMP) provides additional information, such as health
insurance information, education, and housing status that standard surveillance data collection
does not capture. Of those living in North Carolina with an HIV infection in 2011, who were in
care and participated in interviews, the majority were male, identify as heterosexual, were
Black/African American, aged 45-54 years, had more than a high school diploma or general
education development (GED) credential, and had known their HIV status for more than 10
years (page 40).
CHAPTER 3: HIV TESTING IN NORTH CAROLINA
• Starting in November 2013, the North Carolina State Laboratory of Public Health (North Carolina
SLPH) adopted a new HIV testing algorithm that incorporates a 4th generation HIV test (page 45).
• In 2013, a total of 228,938 HIV tests were performed through state-sponsored programs in
North Carolina. Of these, 1,032 tests were confirmed positive (0.4%). These programs identified
431 newly identified HIV-positive individuals (out of the 1,032 confirmed positive tests), which is
28.3 percent of newly diagnosed HIV cases reported to surveillance in 2013 (page 47).
• In 2013, positivity rates were much higher among North Carolina males (1.0%) than females
(0.2%) (page 48).
• In 2013, 53.8 percent (N = 232) of all new HIV infections found through state-supported testing
programs were from sexually transmitted disease (STD) clinics (page 48).
• In 2013, the largest age group tested through North Carolina state-sponsored HIV testing
programs were those aged 20 to 29 years (N=106,698, 46.6%). The highest positivity rate was
seen among those aged 40 to 49 years (N= 23,222, 0.9%) (page 50).
• Regarding hierarchical risk of HIV exposure, the highest positivity rate for new HIV infections
were among MSM (5.1% positive) and MSM/IDU (2.8% positive) (page 50).
• HIV is most transmissible during acute infection. North Carolina attempts to identify acute cases
and link these cases to medical care as soon as possible.
o In 2013, 23 acute (or recent) infections were identified through the North Carolina
screening and tracing active transmission (STAT) program. Since 2003, 259 HIV-infected
individuals have been identified in the state through this program (page 52).
o Twenty-five acute or recent cases were identified in 2013 through follow-up and
additional information collected during field investigations conducted by North Carolina
disease intervention specialists (DIS) (page 53).
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2013 North Carolina HIV/STD Epidemiologic Profile Executive Summary
CHAPTER 4: HIV INFECTION CARE AND TREATMENT IN NORTH CAROLINA
• During the Ryan White Year (RWY) 2013-2014 (April 1, 2013 to March 31, 2014), the Ryan White
Part B program served a total of 7,972 clients living with HIV infection in North Carolina
(page 57).
• Overall, 69.3 percent of Ryan White Part B clients were virally suppressed, 16.7 percent were
not suppressed, and 14.1 percent of clients did not have any viral load tests recorded in
CAREWare during RWY 2013-2014 (page 60).
• The AIDS Drug Assistance Program (ADAP) had 7,470 HIV clients enrolled during the RWY 2013-
2014 (page 63).
• Overall, 74.4 percent of ADAP enrollees were virally suppressed (page 64).
• In total, 73.9 percent of persons living in North Carolina with HIV infection were estimated to
have “met need” during calendar year 2013. The remaining 26.1 percent were estimated to
represent those with “unmet need” (page 66).
• North Carolina is designing its own strategy to follow-up with people who are potentially out of
care, based in part upon the Center for Disease Control and Prevention’s (CDC) toolkit, which
will initially be implemented in fall 2014/winter 2015. State bridge counselors (SBC) will follow-up
and attempt to re-engage these persons in care (page 71).
• Surveillance and care data are routinely assessed to describe the proportion of HIV-infected
residents who are receiving medical care and who have very low to undetectable viral loads
(virally suppressed).
o Please note that data for this assessment are incomplete.
o Among cases diagnosed and reported through December 31, 2012 and evaluated during
2013, an estimated 36.4 percent of the total cases were virally suppressed, compared to
25.3 percent nationally in 2009 (the most recent data available). However, current viral
load data are not available from many care settings. This may be an underestimate of
the proportion of patients virally suppressed (page 70).
o Approximately two-thirds of the people receiving at least one care visit during a given
evaluation year also had a second care visit three or more months apart during the
same evaluation year (page 70).
o Roughly half the people who have been diagnosed and reported with HIV infection
whose last known address was in North Carolina did not have documentation in
surveillance data showing that they received care during the evaluation year. However,
data are not provided by all care settings. This may be an underestimate of the
proportion of patients in care (page 70).
• North Carolina is part of a Special Project of National Significance (SPNS-LINK) and Care and
Prevention in the United States (CAPUS) initiative, two federally funded, time-limited, multi-site
projects designed to enhance linkage, retention, and re-engagement in HIV care (pages 72 and
112 for SPNS-LINK; pages 72 and 109 for CAPUS).
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2013 North Carolina HIV/STD Epidemiologic Profile Executive Summary
• In 2013, approximately 1,654 clients received services from the state-run housing opportunities
for persons with AIDS (HOPWA) program (page 73).
CHAPTER 5: BACTERIAL AND OTHER SEXUALLY TRANSMITTED DISEASES IN NORTH CAROLINA
• STDs are more frequently reported among Black/African American (non-Hispanic/Latino) males
and females in North Carolina (pages 79, 83, and 88).
• Per 2012 and 2013 screening data, the number of chlamydia and gonorrhea screening tests
submitted for testing by publicly-funded clinics is declining (page 80).
• The highest chlamydia rates in 2013 were among 20 to 24 year olds for females, which can be
attributed to the screening programs targeted at women under 25 years of age (page 79).
• Six hundred seventy-seven (677) cases of early syphilis were diagnosed and reported in 2013,
compared to 598 cases in 2012. Please note that a significant syphilis outbreak occurred in
North Carolina in 2009 with 873 cases reported that year (page 86).
• The overall early syphilis rate in 2013 was 6.9 cases per 100,000 population. Males represented
approximately 86 percent of all reported early syphilis cases (page 86).
• The six most populous counties (Mecklenburg, Guilford, Wake, Forsyth, Cumberland, and
Durham) accounted for 65.8 percent (13.2 per 100,000 population) of 2013 early syphilis reports
in North Carolina (page 89).
• In 2013, Black/African American (non-Hispanic/Latino) males represented 56 percent of all early
syphilis cases, with a rate of 37.7 per 100,000. The syphilis rate among Black/African American
(non-Hispanic/Latino) males was more than 7 times the rate for White/Caucasian (non-
Hispanic/Latino) males (4.9 per 100,000), and the rate of syphilis among Hispanic/Latino males
(5.5 per 100,000) was 1.1 times the rate for White/Caucasian (non-Hispanic/Latino) males
(page 88).
• Congenital syphilis cases in North Carolina remain unacceptably high. Early and complete
prenatal care for the pregnant woman is the best tool for prevention. Birthing hospitals act as a
safety net to ensure that pregnant women who are positive for syphilis and their newborns
receive the appropriate post-delivery prophylaxis (page 90).
CHAPTER 6: HIV COMORBIDITIES IN NORTH CAROLINA
• In 1999, the proportion of individuals with an early syphilis diagnosis who also had an HIV
diagnosis (either prior to or within six months of syphilis diagnosis) was 5.1 percent (N=1,207).
In 2013, this proportion increased to 40.3 percent (N=677) (page 95).
• Among males infected with syphilis, 46.3 percent (N=585) were also diagnosed with HIV in 2013.
The female proportion of comorbid infections was 2.2 percent (N=92) (page 95).
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2013 North Carolina HIV/STD Epidemiologic Profile Executive Summary
• Since 2003, the race/ethnicity proportions of comorbid male infections have fluctuated between
67.2 and 77.1 for Black/African American males and between 14.7 and 27.1 for White/Caucasian
males (page 97).
• Tuberculosis (TB) incidence in North Carolina decreased 35.5 percent between 2008 and 2013,
down from 335 cases to 216 cases. While fewer cases of TB are reported in the United States
(US) than ever before, TB rates have decreased much faster in North Carolina than in the nation
as a whole (page 98).
• In 2013, every acute TB cases who were alive at diagnosis were tested for HIV (page 100).
• Of 216 known acute TB cases in North Carolina in 2013, 13 (6.0%) cases also tested positive for
HIV (page 100).
• Between 2009 and 2013, the percent of persons tested for latent TB infection (LTBI) who also
tested positive for HIV and who were started on treatment increased from 16.0 percent to 60.9
percent (page 102).
• Eighty-four acute hepatitis B (HBV) and 1,029 chronic HBV cases were reported in North Carolina
in 2013. While acute HBV infection is more likely to result from sexual transmission, chronic HBV
cases in North Carolina represent a mix of perinatal and sexual transmission. The majority of
infections due to perinatal transmission diagnosed in North Carolina are found in persons born
in other countries, primarily Asian and African countries, who are now North Carolina residents
(page 103).
• In 2013, three acute HBV cases (3.6%) had a previous diagnosis of HIV, while 102 cases (9.9%)
diagnosed with chronic HBV had a previous HIV diagnosis (page 103).
• Due to the narrow case definition for acute hepatitis C (HCV) infection, North Carolina
surveillance data do not provide a representative picture of acute or chronic HCV comorbidity
and possible sexual transmission. This will not change until chronic HCV becomes reportable.
Therefore, the number of HCV cases that have also been diagnosed with HIV is unknown at this
time (page 103).
CHAPTER 7: INTEGRATED PROGRAM ACTIVITIES IN NORTH CAROLINA
• North Carolina has a fully integrated HIV and STD program, with collaboration on prevention,
surveillance, and education strategies for both HIV and STD cases (page 105).
• The Get Real. Get Tested. Get Treatment. campaign, started in 2006, aims to test for and
educate people about HIV and STDs, identify persons living with HIV/AIDS (PLWHA) who need
care, and link HIV-positive patients to care. Each commercial has targeted a different group of
people and encourages them to get tested for HIV and other STDs. The Get Real. Get Tested. Get
Treatment. commercials have been nominated for three Emmy awards (page 105).
North Carolina DHHS xvi Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Executive Summary
• Evidence-based intervention services (EBIS) had approximately 1,300 participants at the end of
2013. The primary mission of EBIS is to target persons at increased risk of becoming infected
with HIV in order to reduce their risk or, if already infected, prevent the transmission of the virus
to others. There were eight specific interventions utilized by 11 different agencies in North
Carolina in 2013 (page 105).
• Regional Minority AIDS Initiative (MAI)/MSM Task Force teams work throughout the state to
improve the health outcomes of HIV-positive individuals and minority MSM in an atmosphere
free from stigma and discrimination. The Regional MAI/MSM Task Force teams are extremely
important to the success of the state’s prevention strategy (page 107).
• In North Carolina, partner notification, counseling, and referral services for HIV and syphilis are
performed by a specialized group within the North Carolina DHHS, known as the Field Services
Unit. Disease intervention specialists (DIS) are the backbone of the Field Services Unit. The DIS
are highly skilled in contact tracing and other activities aimed at interrupting disease
transmission networks (page 108).
• North Carolina was one of only eight states to be awarded with Care and Prevention in the
United States (CAPUS) funding. The project started in North Carolina in September 2012. The
primary goals of the project are to increase the proportion of racial and ethnic minorities who
have HIV infection who are linked to and retained or re-engaged in care. Eight CAPUS-specific
interventions were selected for the three-year project in North Carolina (page 109).
• Special Projects of National Significance (SPNS-LINK) and the North Carolina DHHS have
implemented NC-LINK: Systems Linkage and Access to HIV Care in North Carolina. This program
is in collaboration with Duke University and the University of North Carolina-Chapel Hill (UNC-Chapel
Hill). The goal of NC-LINK is to increase the number of people living with HIV infection
who are engaged in consistent care by creating a system to link out-of-care persons to providers
(page 112).
• North Carolina was one of six health departments in the US awarded funds from the CDC for the
Program Coordination and Services Integration (PCSI) project in September 2010. The goal of
PCSI is to provide prevention services that are holistic, evidence-based, comprehensive, and
high quality to appropriate populations at every interaction with the health care system (page
113).
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North Carolina DHHS xviii Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Introduction
INTRODUCTION
The North Carolina Epidemiologic Profile is divided into four sections. Part I describes the general
population demographics and social characteristics of our state, the human immunodeficiency virus
(HIV) infection epidemic, and indicators of HIV exposure or risk in North Carolina. Part II describes HIV
testing and HIV care and treatment, while part III describes other sexually transmitted diseases (STD)
and HIV comorbidities in the state. Part IV describes North Carolina’s integrated program activities,
including special projects the state is conducting to reduce the number of HIV infections in
North Carolina.
Several appendices are included with this document: Appendix A: Maps, Appendix B: Data Sources,
Appendix C: Technical Notes, Appendix D: Tables, and Appendix E: References (starting on page A-1).
Readers may find it beneficial to review the information in the appendices first, especially Appendix B:
Data Sources, which contains information about the data sources used in creating this report (page B-1)
and Appendix C: Technical Notes, which has information on the definitions used, HIV infection
surveillance reporting issues, HIV exposure categories, and rate calculations (page C-1).
Readers should note the following:
• HIV infection is defined as a diagnosis of HIV infection, regardless of the stage of infection (1, 2,
3, or unknown). In this document, use of the term acquired immunodeficiency syndrome (AIDS)
refers to HIV infection Stage 3. AIDS is classified based on either CD4+ T-lymphocyte (CD4) cell
count results (CD4 cell count of less than 200 or a T-lymphocyte percentage of total lymphocytes
of less than 14) or documentation of an AIDS-defining condition.
• AIDS (Stage 3) classification is based on lab test or opportunistic infection and can be at the
same time as HIV or later, but once a person is classified as AIDS (Stage 3) (for surveillance
purposes) they are always AIDS (Stage 3).
• HIV infection and syphilis data are summarized by date of diagnosis. Chlamydia, gonorrhea,
tuberculosis (TB), hepatitis B (HBV), and hepatitis C (HCV) data are presented by date of report.
This categorization represents a change in data presentation from previous publications.
• References to race/ethnicity in this document may be different from those found in documents
from other agencies. Unless otherwise noted, Hispanics/Latinos are considered a separate
racial/ethnic group. Thus, White/Caucasian refers to White/Caucasian non-Hispanic/Latinos;
Black/African American refers to Black/African American non-Hispanics/Latinos, etc.
• The HIV infection case totals and rates 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 infection do include those younger than 13 years.
• All calculated rates in this document are based on the United States (US) Census Bureau
bridged-race population estimates. All rates are presented as per 100,000 population.
• Please note that all references are separated out by chapter.
Note: The portable document format or PDF version of this document contains hyperlinks to related
topics in other sections of the document. To navigate to the related topic, click the hyperlink.
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North Carolina DHHS xx Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 1
CHAPTER 1: 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, gender,
race/ethnicity, geography, income, poverty, health insurance, Medicaid, and education.
POPULATION
According to the 2010 United States (US) Census, North Carolina was the 10th most populous state and
one of the most rapidly expanding states during the previous decade.1 From 2000 to 2010, North
Carolina’s population grew by 18.5 percent, from 8,049,313 to 9,535,483 residents. Only four other
states (Texas, California, Florida, and Georgia) had a faster population growth rate.2
The 2013 North Carolina provisional population estimate was 9,861,952, with county populations
ranging from 4,142 (Tyrrell County) to 991,970 (Mecklenburg County).1 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, Pitt, Davidson and
Iredell).1 In 2013, there were 118,983 births and 83,317 deaths in the state, and the average life
expectancy for North Carolinians was 78.1 years.3
Age and Gender
The most updated gender- and age-specific population estimates available at time of analysis were for
the year 2012, so the 2012 population is used as a substitute for 2013 to analyze the HIV infection
rates in this profile.4
Age and gender play an important role in public health planning and in understanding the health of a
community. These characteristics are significant indicators in the prevalence of certain diseases,
especially human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs), as
shown in previous North Carolina HIV/STD Epidemiologic Profiles.
In 2012, the median age for people living in North Carolina was 38 years old, with 33.4 percent 18 years
and younger, and 13.8 percent 65 years and older. Approximately 48.7 percent of the population was
male and 51.3 percent was female (Table 1.1).
North Carolina DHHS 1 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 1
Table 1.1. North Carolina Bridged-Race Population Estimates by Age Group, 2012
Race/Ethnicity Populations in North Carolina
American Indian/Alaska Natives
American Indian/Alaska Natives represent 1.2 percent of the state population and are one of the largest
American Indian/Alaska Native populations in the US. About 44.0 percent of American Indian/Alaska
Natives in North Carolina live in Robeson, Cumberland, Hoke, Scotland, Swain, Mecklenburg, and
Jackson counties.4 In Appendix A: Maps, Map 1 displays the proportion of American Indian/Alaska Native
population in North Carolina by county for 2012 (page A-2 ).
Asian/Pacific Islander
Asian/Pacific Islanders represent 2.6 percent of the state population. Over half (57.1 percent) of
Asian/Pacific Islanders in North Carolina live in Wake, Mecklenburg, Guilford, and Durham counties.4 In
Appendix A: Maps, Map 1 displays the proportion of Asian/Pacific Islander population in North Carolina
by county for 2012 (page A-2).
Black/African Americans
In 2012, North Carolina ranked 8th highest in percentage of Black/African Americans nationwide. North
Carolina has eight counties in which Black/African American comprise more than half of the total
population (Bertie: 62.2%; Hertford: 60.6%; Northampton: 58.4%; Edgecombe: 57.7%; Halifax: 53.3%;
Warren: 52.2%; and Vance: 50.3%).4 In Appendix A: Maps, Map 1 displays the proportion of
Black/African American population in North Carolina by county for 2012 (page A-2).
North Carolina DHHS 2 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 1
Hispanic/Latinos
From 2002 to 2012, the estimated Hispanic/Latino population in North Carolina increased by 88.6
percent, from 451,095 to 850,853 residents. Hispanic/Latinos represented 8.7 percent of the population
of the state. Among North Carolina counties, Duplin County had the highest proportion of
Hispanic/Latino residents (21.2%), followed by Lee County (19.4%), Sampson County (17.5%), and
Montgomery County (14.6%).4 In Appendix A: Maps, Map 1 displays the proportion of Hispanic/Latino
population in North Carolina by county for 2012 (page A-2).
White/Caucasian
White/Caucasian individuals represent 65.2 percent of the state population. Almost one-third (30.3
percent) of White/Caucasians in North Carolina live in Wake, Mecklenburg, Guilford, Forsyth,
Buncombe, and New Hanover counties.4 In Appendix A: Maps, Map 1 displays the proportion of
White/Caucasian population in North Carolina by county for 2012 (page A-2).
Race/Ethnicity and Physiographic Region
North Carolina has the nation’s 7th largest non-White/Caucasian population (2,934,632 people in 2012),
with noticeable variations in the demographic composition from region to region. The racial and ethnic
differences within the state’s population play an important role in interpreting gaps in access to health
care among groups. These health and health care differences are documented using public health
surveillance and are shown to be especially large in terms of HIV infection morbidity and intervention.
Previous HIV infection surveillance has shown that HIV disproportionately affects ethnic minorities in
North Carolina.
Race/ethnicity also varies by physiographic region with a larger proportion of White/Caucasian in the
Western region, American Indian/Alaska Natives in the Eastern region, and Black/African American non-
Hispanics in the Eastern region (Table 1.2). A state map showing the physiographic regions is displayed
on the last page.
North Carolina DHHS 3 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 1
Table 1.2. North Carolina Race/Ethnicity Proportions by Gender and Physiographic Regionᵃ, 2012
Foreign-born Population
According to the US Census Bureau’s Annual American Community Survey, North Carolina’s foreign-born
population increased by 56.0 percent from 2002 to 2013 (480,248 to 749,426).5 In 2013, naturalized
citizens represented 31.9 percent of the foreign-born populations in North Carolina, while 68.1 percent
were non-citizens. The various regions of birth are displayed in Table 1.3.
Table 1.3. North Carolina Foreign-Born Population by Region of Birth, 2013
North Carolina DHHS 4 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 1
METROPOLITAN STATISTICAL AREAS
Metropolitan statistical areas (MSAs) are population areas that represent the social and economic
linkages and commuting patterns between urban cores and outlying integrated areas. These geographic
designations are managed by the Office of Management and Budget (OMB) in order to have nationally
consistent areas for developing federal statistics. These areas are collectively referred to as core based
statistical areas with a metropolitan area containing a core urban area population of 50,000 or more.6 In
the HIV/AIDS Surveillance Supplemental Report, Volume 13 Number 2, the Centers for Disease Control
and Prevention (CDC) divides urban/metropolitan areas into large- (population greater than or equal to
500,000) and medium-sized urban/metropolitan areas (population 50,000 to 499,999), which are all
defined as urban areas. Areas other than metropolitan areas are defined as rural areas.7 Eleven North
Carolina counties (Anson, Cabarrus, Franklin, Gaston, Guilford, Johnston, Mecklenburg, Randolph,
Rockingham, Union and Wake) are classified as large urban/metropolitan areas. Twenty-nine North
Carolina counties (Alamance, Alexander, Brunswick, Buncombe, Burke, Caldwell, Catawba, Chatham,
Cumberland, Currituck, Davie, Durham, Edgecombe, Forsyth, Greene, Haywood, Henderson, Hoke,
Madison, Nash, New Hanover, Onslow, Orange, Pender, Person, Pitt, Stokes, Wayne, and Yadkin) are
classified as medium urban/metropolitan areas. The remaining 60 counties are classified as rural. More
information on the urban and rural counties in North Carolina can be found in Appendix A: Maps, Map 2
(page A-3).
Data from the US Census showed that in 2010, 80.7 percent of the general population of the US was
living in urban areas and 19.3 percent in rural areas.8 For North Carolina in 2010, 66.1 percent of North
Carolinians lived in urban areas, while 33.9 percent lived in rural areas.8 Using the most current estimate
for 2012, North Carolina remains more rural than the US as a whole, with 70.8 percent living in urban
areas, and 29.2 percent in rural areas (Table 1.4).
In North Carolina, a majority of Asian/Pacific Islanders (57.9%) live in large metropolitan areas, followed
by Hispanic/Latinos (41.8%) and Black/African Americans (39.3%). A majority of American Indian/Alaska
Natives (70.2%) live in rural areas (Tables 1.4).
Table 1.4. North Carolina Population by Race/Ethnicity for Urban and Rural Areas, 2012
North Carolina DHHS 5 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 1
HEALTH INDICATORS
Household 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 contribute
substantially to the persistence of marked racial disparities in STD rates.9
According to the US Department of Commerce’s Bureau of Economic Analysis, the 2013 per capita
income for North Carolina was $38,683 or 86.4 percent of the national average ($44,765). This figure
represents a 6.9 percent increase from 2011, placed North Carolina 38th in the nation for personal per
capita income and 4th in the Southeast region (includes Alabama, Florida, Georgia, Kentucky, Mississippi,
North Carolina, South Carolina, Tennessee, Virginia, and West Virginia).10 The 2013 annual
unemployment rate in North Carolina was 8.0, down from a rate of 9.2 in 2012.11,12 In 2013, the median
household income in North Carolina was $45,906, lower than the national median of $52,250.13
In 2013, 19.0 percent of North Carolinians were below the federal poverty level (FPL), which is slightly
higher than the national percent below the FPL.14 Children (less than 18 years of age) and the elderly
had higher percentages below the FPL than the US. Approximately 43.0 percent of the Hispanic/Latino
population in the state were living below the FPL through 2013, which is higher than the national
proportion (Table 1.5).15 North Carolina also has an overall total of 40.0 percent of the population
considered low income (199% FPL or below).16
Table 1.5. North Carolina and United States Individual Poverty Rate
by Age and Race/Ethnicity, 2013
North Carolina DHHS 6 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 1
Health Insurance
The percentage of the non-elderly without health insurance in North Carolina has been increasing over
the years. In 2013, 24.0 percent of adults (aged 19 to 64 years) in North Carolina were uninsured.17 Of
that 24.0 percent, roughly 45.0 percent were White/Caucasian, 20.0 percent Black/African American,
24.0 percent were Hispanic/Latino, and 11.0 percent were other (including American Indian/Alaska
Natives, Asian/Pacific Islanders, and persons of two or more races).18 Rates of uninsured among all
racial/ethnic groups in North Carolina were higher than those in the nation. Although White/Caucasians
comprise the greatest proportion of the uninsured population, minorities have the highest uninsured
rates. Among adults uninsured with health insurance in North Carolina in 2013, around 44.0 percent had
a low income 199% FPL or below.19
Medicaid
Medicaid serves low-income parents, children, seniors, and people with disabilities in North
Carolina. For the North Carolina State Fiscal Year (FY) 2013, Medicaid served 1.7 million low-income
families and persons with disabilities, which is an estimated 17.2 percent of the overall state
population.1,20 The majority of people living with HIV infection in North Carolina do not fall into these
categories; they are generally older and male, while the newly diagnosed HIV infections are among
younger men; many are not currently supporting children (Chapter 2: Scope of HIV Infection Epidemic,
pages 13 and 17 through 20). Medicaid, as expanded by the federal government, does cover these
populations in some states. In North Carolina, these populations are not covered by Medicaid and must
obtain medical care by other means or go without care.
For more information on Medicaid and its services, contact the Division of Medical Assistance
(http://www.ncdhhs.gov/dma/medicaid/ and http://www.ncdhhs.gov/dma/sectioncontacts.htm).
Education
For those North Carolinians aged 25 years or older, 85.7 percent had a high school diploma or higher,
and 28.4 percent had a bachelor’s degree or higher.21 In the most current North Carolina Public Schools
Statistical Profile, 2.5 percent of high school students in North Carolina (grades 9–13) dropped out
during the 2012-2013 school year, down from 4.9 percent in the 2003-2004 school year.22
North Carolina DHHS 7 Communicable Disease
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North Carolina DHHS 8 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
CHAPTER 2: SCOPE OF THE HIV INFECTION EPIDEMIC IN
NORTH CAROLINA
SPECIAL NOTES
• Human immunodeficiency virus (HIV) infection includes all initial diagnoses of HIV as well as
those diagnosed and classified as acquired immunodeficiency syndrome (AIDS) as their initial
diagnosis. More information about the designation of HIV infection can be found on page 10 and
in Appendix C (page C-2).
• The HIV infection case totals and rates 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 infection do include the 0 to 12 age group.
• Unless otherwise noted, “year” refers to year of diagnosis for HIV cases, not year of report that
was used in previous publications.
• State public health staff determine whether potentially duplicative pairs of HIV infection
represent one person and, if so, that person's residence at the time of diagnosis. This is done
through a process called routine interstate duplicate review (RIDR), which is coordinated by the
CDC (see Appendix C: Technical Notes for further information, page C-2).1 RIDR is usually
processed by the time data is closed for the calendar year, however there was a delay in 2013,
and this process was not completed by the time the 2013 data was closed on July 1, 2014. This,
in turn, could potentially artificially inflate the HIV infection numbers for 2013. North Carolina
typically determines that 150 to 200 duplicate HIV infection cases per year were previously
diagnosed in other states to this process. Once the duplicates are removed, the newly diagnosed
HIV infection case counts for 2013 should be in line with the overall decreasing trend seen since
2008.
North Carolina DHHS 9 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
BACKGROUND ON HIV INFECTION AND SURVEILLANCE IN NORTH CAROLINA
The first acquired immunodeficiency syndrome (AIDS) case reported in North Carolina was in 1982.2 In
North Carolina, AIDS became a reportable disease in 1984, and a diagnosis of human immunodeficiency
virus (HIV) infection was made reportable in the state in 1990.2 State law requires reporting of HIV
infection as well as associated laboratory tests. Starting July 1, 2013, all viral load and CD4+ T-lymphocyte
(CD4) cell counts became reportable to the state. While the proportion of tests that are
reported is increasing, reporting of these tests is still incomplete. Data regarding morbidity reports of
HIV and AIDS from health providers are collected by health department staff on confidential case report
forms. These case reports include demographic and clinical information for the patient, as well as
questions regarding mode of exposure.
Prior to 2012, HIV infection surveillance data were managed directly in the enhanced HIV/AIDS reporting
system (eHARS), while the field investigation information, such as interviews and contact information,
were managed through the Sexually Transmitted Disease Management Information System (STD*MIS).
Since 2012, HIV case report data (surveillance) and field investigations have been entered into the North
Carolina Electronic Disease Surveillance System (NC EDSS), the statewide disease reporting system, and
then exported for reporting to the Centers for Disease Control and Prevention (CDC) into eHARS. Data
used in this chapter were obtained from eHARS on July 1, 2014. National data used in this chapter were
compiled by the CDC and represent de-identified HIV infection case report information from each of the
50 states, the District of Columbia, and six United States (US) territories. More information about the
data sources used in this chapter can be found in Appendix B: Data Sources (page B-4). Rates were
calculated using bridged-race population estimates for 2012 as the denominator, as the 2013 estimates
were not available at time of data analysis. More information concerning denominator or rate
calculation information can be found in Appendix B: Data Sources (page B-2) and Appendix C: Technical
Notes (page C-5).
HIV SURVEILLANCE CASE DEFINITION
In 2008, the CDC revised the existing surveillance case definitions for HIV/AIDS and combined them into
a single case definition using a staging system in order to monitor the epidemic. This staging system is
based on CD4 cell counts or percentages and includes four different stages of HIV infection (stages 1, 2,
3, and unknown).3 HIV infection is categorized based on the person’s age: adults and adolescents
greater than 13 years of age, children at least 18 months but under 13 years of age, and children under
18 months of age. In this chapter, HIV infection is defined as a diagnosis of HIV infection, regardless of
the stage, for persons diagnosed in 2013 and earlier. HIV infection Stage 3 represents the traditional
definition of AIDS based on having a CD4 cell count of less than 200, a T-lymphocyte percentage of total
lymphocytes of less than 14, or documentation of an AIDS-defining condition.3 In this document, use of
the term AIDS refers to HIV infection Stage 3. AIDS (Stage 3) is defined as persons who were diagnosed
with HIV infection and classified as Stage 3 in 2013 or earlier (used for prevalence and number of
deaths).
North Carolina DHHS 10 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
OVERALL HIV INFECTION TRENDS IN NORTH CAROLINA
Figure 2.1 displays the rates of people living with HIV infection and the rates of newly diagnosed HIV
infection from 2000 to 2013 in North Carolina, by the year of HIV diagnosis for the individual. While the
rate of people living with HIV infection has steadily increased as new diagnoses continue and people
survive longer, the rate of newly diagnosed HIV infections has been decreasing since 2008. Newly
diagnosed HIV infection peaks occurring in 2007 and 2008 may be attributed to the Communicable
Disease Branch’s effort to increase HIV testing, including the Get Real. Get Tested. Get Treatment.
campaign and may not necessarily represent an increase in cases. In 2013, the rate for new diagnoses of
HIV infection did increase from 2012. This rate is likely to be inflated, as interstate deduplication review
was not conducted before the data was closed (see “Special Notes” and Appendix C: Technical Notes for
more information, pages 9 and C-2 respectively).
Figure 2.1. HIV Infectionᵃ Rates Diagnosed in North Carolina, 2000–2013ᵇ
Please note the numbers in Figure 2.1 (above) are periodically updated as additional information is
received. Readers are encouraged to use the numbers for previous years that appear in this profile, as
opposed to prior publications.
126.9 139.4 153.0 165.9 178.5 191.3 203.1 216.6
233.7 246.9 257.2 270.9 280.3 285.3
17.9
19.6 20.2
19.4
18.2 18.5 18.6
20.1 19.6
17.5
15.3 15.4
13.8
15.0
0
5
10
15
20
25
0
50
100
150
200
250
300
Newly Diagnosed Rate per 100,000
Prevalence Rate per 100,000
Year
Prevalence Newly Diagnosed
ᵃHIV infection includes all newly reported HIV infected individuals by the year of first diagnosis, regardless of the stage of infection
(HIV or AIDS).
ᵇ2013 values are likely to be artificially inflated due to incomplete interstate deduplication (see "Special Notes" for more information,
page 9).
Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of July 1, 2014).
North Carolina DHHS 11 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
HIV INFECTION TRENDS IN NORTH CAROLINA AND THE REST OF THE UNITED
STATES
All states require name-based HIV infection case reporting by law in order to provide data that are
useable for state-to-state and state-to-national comparisons. Comparing North Carolina data to national
data is limited to earlier years because national surveillance data are released later than state data
(usually about a two-year delay). Comparisons made between other states, North Carolina, and the US
are based on counts and rates calculated by the CDC and have been statistically adjusted for delays in
reporting; these numbers slightly differ from North Carolina’s unadjusted case counts and rates
published in 2013. According to the CDC, the national newly diagnosed HIV infection rate in 2012 was
15.4 per 100,000 population. During the same time period, North Carolina’s newly diagnosed HIV
infection rate was 15.1 per 100,000 population.4 North Carolina ranked 8th overall among all states,
District of Columbia, and US dependent territories in the number of newly diagnosed HIV infections in
2012 (Table 2.1). Similarly in 2012, North Carolina ranked for overall population (10th in country).5
Table 2.1 Top 10 United States (including District of Columbia and Six Dependent Territories)
for Newly Diagnosed HIV Infections, 2012
The rate of HIV infection in the South continues to be a concern. In 2012, the South (Alabama, Arkansas,
Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North
Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia) had 48.8 percent of
all new HIV diagnoses in the US (including District of Columbia and US dependent territories), including
five states in the top ten areas of residence reporting the highest number of new HIV diagnoses in 2012
(Table 2.1). Eight of the top ten US areas (including District of Columbia and US dependent territories) by
newly diagnosed HIV infection rates were also in the South (Top 10 were District of Columbia, Georgia,
Maryland, Louisiana, Florida, Puerto Rico, US Virgin Islands, New York, New Mexico, Texas, and Illinois).
North Carolina had the 17th highest rate overall.4
North Carolina DHHS 12 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
HIV INFECTION PREVALENCE IN NORTH CAROLINA
Individuals living with HIV infection in North Carolina communities are referred to as prevalent cases.
Information about persons living with HIV infection is critical for case follow-up, AIDS care provision, and
strategic intervention and testing activities. While reporting to the North Carolina Division of Public
Health started in 1982, we report HIV data starting in 1983, as it is the first complete year for HIV
infection reporting to the state. From January 1, 1983 through December 31, 2013, the cumulative
number of HIV infection cases diagnosed in North Carolina is 42,889, of whom 28,101 are currently living
in North Carolina and 14,788 have moved out of the state or have died. This number includes some HIV-positive
individuals who died of non HIV-related causes (see page 35 for HIV-related deaths). Figure 2.2
displays the numbers of people living with HIV infection, which represent prevalent cases at the end of
each year from 2007 to 2013. The number of people living with HIV infection in North Carolina has been
increasing every year, indicating that the number of newly diagnosed HIV infection cases exceeds the
number of people who died (Figure 2.2). Due to the advancement of antiretroviral treatment (ART) and
opportunistic infection control, people with HIV infections can and are living longer and healthier lives.
Figure 2.2. Persons Living with HIV Infection Classificationᵃ in North Carolina, 2009-2013ᵇ
Note: Represents data through December 31 of each year.
ᵃHIV (non-AIDS) includes those living in North Carolina and have never been diagnosed with AIDS (HIV infection Stage 3). An individual is
classified as having AIDS (Stage 3) if they were diagnosed with HIV infection during the year of diagnosis and were classified as AIDS (Stage 3)
within a year or who have ever been diagnosed with ever having a CD4+ T-lymphocyte count of less than 200 or a CD4+ T-lymphocyte
percentage of total lymphocytes of less than 14, while living in North Carolina.
ᵇ2013 values are likely to be artificially inflated due to incomplete interstate deduplication (see "Special Notes" for more information, page 9).
Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of July 1, 2014).
12,092 12,935 13,644 14,334 15,019 15,602 16,272
7,216
7,979
8,791
9,488
10,221 10,950
11,829
0
5,000
10,000
15,000
20,000
25,000
30,000
2007 2008 2009 2010 2011 2012 2013ᵇ
Number of People
Year
HIV (non-AIDS) AIDS (Stage 3)
North Carolina DHHS 13 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Please note HIV infection 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 since the previous report.
Persons living with HIV are individuals who have been diagnosed and subsequently reported to the
North Carolina public health surveillance system. Case counts are affected by some amount of
underreporting by clinicians as well as the lack of information on people who are infected with HIV but
have not been tested and reported. Efforts to identify the unaware positive population will increase the
number of new diagnoses in the future. The current number of total living cases in Figure 2.2
underrepresents 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 positive status. One method for
estimating the number of people who are unaware they are HIV positive is based on the CDC estimate
that 81.9 percent of people living with HIV have been tested and know their status.6 Evaluation of the
completeness of the 2013 HIV infection reporting in North Carolina suggested that North Carolina
surveillance captures 90 to 95 percent of HIV diagnoses (Appendix B: Data Sources, page B-4). If we
apply these two proportions (81.9% awareness of status and the 90-95% completeness) to the number
of persons living with HIV in North Carolina from our current surveillance data, we can estimate the total
number of individuals who are infected with HIV, including those that are unaware of their HIV status, as
approximately 36,300 people.
Demographics of Persons Living with HIV Infection
Gender, race/ethnicity, and age distribution
Table 2.1 displays the demographics of people living with HIV infection in North Carolina as of December
31, 2013. Males living with HIV infection were the majority of the total (71.0%) and more than double
the female prevalence (29.0%). Black/African Americans comprised the majority (65.4%) of cases,
followed by White/Caucasians (25.2%) and Hispanic/Latinos (6.2%). Older individuals represented a
larger percentage of people living with HIV, as people can live for many years on ART after an HIV
diagnosis. The large percentages of males and Black/African Americans living with HIV infection indicates
that these groups are most affected by the HIV epidemic in North Carolina (Table 2.2).
North Carolina DHHS 14 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Table 2.2. All Persons Living with HIV Infectionᵃ as of 12/31/2013 in North Carolina
by Selected Demographics
Hierarchical Risk of Exposure for HIV Prevalent Cases
Information about risk or exposure categories of HIV is very useful for disease prevention efforts
focusing on behavior change. Successful behavior change reduces HIV transmission. Without effective
behavioral interventions for people living with HIV infection, they may continue to transmit HIV to
others. Exposure categories (referred to by the CDC as modes of transmission) are determined using a
presumed hierarchical order of probability of potential risk factors as defined by the CDC.5 If a person’s
exposure category was unknown (not identified or reported), we used a percent redistribution method
to estimate exposure category and reclassify these cases. Reassigning these cases to an exposure
category allows for a more complete picture of trends over time. More information on this methodology
can be found in Appendix C: Technical Notes (page C-4 through C-6).
After reassigning the unknown risk of exposure group among persons living with HIV infection in North
Carolina as of 12/31/2013, 43.8 percent were likely infected through men who have sex with men
(MSM) activities, 38.6 percent through heterosexual contact, 10.0 percent through injection drug use
practices (IDU), and 2.8 percent reported both MSM and IDU; these risks are considered to be equal and
this category is referred to as MSM/IDU (Appendix D: Table B, page D-4).
North Carolina DHHS 15 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
HIV INCIDENCE ESTIMATES IN NORTH CAROLINA
North Carolina is one of 25 jurisdictions funded by the CDC as part of a cooperative agreement to
participate in the HIV incidence or serologic testing algorithm for recent HIV seroconversion (STARHS)
program. Data obtained from the STARHS project generate timely and relevant estimates of the annual
number of new HIV infections and help to focus prevention efforts and evaluate progress toward
reducing the spread of HIV.7 New infections are slightly different than new diagnoses. New infection
estimates are recent infections, among people who know and who do not know their HIV status. New
diagnoses reflect only recent tests, not the actual date of infection, which could be many years prior to
the diagnosis. Persons could have been infected years before being diagnosed.8 The HIV incidence
program builds upon the existing HIV infection case reporting system by combining additional data
collected about HIV testing history with supplemental laboratory testing on remnant diagnostic
specimens to identify specimens from people recently infected with HIV. The estimate only looks at the
adolescent and adult population (those over the age of 13).9 For more information on the methodology
behind the HIV incidence estimate calculation, refer to Appendix C: Technical Notes (page C-4).
Multiple elements are needed to calculate the HIV incidence for any given year, including a testing and
treatment history (TTH) questionnaire and laboratory test results; therefore, a slight delay occurs in
getting current data. Due to this delay, HIV incidence estimates were calculated for the adult and
adolescent population through 2012 for this profile. North Carolina has revised the incidence estimate
for 2007 through 2012 utilizing the revised methodology and additional data. The estimate released in
2014 indicates that the estimated HIV incidence has declined since 2007 (Figure 2.3).
Figure 2.3. North Carolina HIV Incidence Estimatesᵃ among Adults/Adolescents, 2007-2012
0
500
1,000
1,500
2,000
2,500
3,000
3,500
2007 2008 2009 2010 2011 2012
Estimated Number of New HIV Infections
Year
Estimate Lower 95%CI Upper 95% CI
ᵃIncidence estimates account for all newly infected individuals ,both those who are aware and are not aware of their HIV-positive status.
Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of July 1, 2014).
North Carolina DHHS 16 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
The HIV incidence estimate for North Carolina is limited to stratification by gender, race/ethnicity, age
groups, and categories of hierarchical risk of exposure. The state-specific estimate is limited to this level
of stratification due to the large amount of data required for presenting additional stratifications.
In 2012, the estimated number of new HIV infections per 100,000 population (incidence rate) was 1,740
(95% confidence intervals: 1,348-2,131). This estimate includes infections that have not been reported
to North Carolina surveillance and is higher than the number of newly diagnosed and reported HIV
infections in North Carolina for 2012 (N=1,347). The national HIV incidence rate is estimated at 21.5 per
100,000 population (95% confidence intervals: 16.6-26.3 per 100,000 population), which is slightly
higher than the most current CDC estimate of 18.8 per 100,000 population (95% confidence intervals:
16.6-20.9 per 100,000) from 2010.10
The highest estimated HIV incidence rates are among males at 35.1 per 100,000 population (95%
confidence intervals: 26.4 - 43.9 per 100,000), Black/African Americans at 60.8 per 100,000 population
(95% confidence intervals: 44.1 - 77.4 per 100,000), and the 13 to 24 and 25 to 34 age groups at 34.2 per
100,000 population (95% confidence intervals: 22.2 - 46.3 per 100,000) and 36.7 per 100,000 population
(95% confidence intervals: 23.6 - 49.9 per 100,000), respectively (Table 2.3).
Table 2.3. North Carolina HIV Incidence Estimatesᵃ by Gender, Race/Ethnicity, Age, and Hierarchical
Risk of HIV Exposure, 2012
Accurately measuring HIV incidence will help us better understand how HIV is spreading, where to more
effectively focus prevention efforts, and evaluate our progress in reducing the spread of HIV in North
North Carolina DHHS 17 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Carolina. The new HIV incidence estimates illustrate the critical need for adequate funding of HIV
prevention efforts in North Carolina. Additionally, these findings confirm the need to provide focused
HIV prevention efforts tailored for youth, MSM, and minority populations (including Black/African
Americans and Hispanic/Latinos) that are disproportionally impacted by HIV.
NEWLY DIAGNOSED HIV INFECTION CASES IN NORTH CAROLINA
Newly diagnosed HIV infections include all HIV cases diagnosed and reported to North Carolina in 2013.
In 2013, 1,525 (15.6 per 100,000 population) individuals were newly diagnosed with HIV infection in
North Carolina (Appendix D: Table D, page D-10). Of the newly diagnosed persons, 1,513 of them were
over 13 years old, which makes the rate of newly diagnosed HIV infection among adults/adolescents
18.7 per 100,000 adult/adolescent population (Appendix D: Table F, page D-14).
Demographics of Adult/Adolescent Newly Diagnosed HIV Infection Cases
Gender and Race/Ethnicity
Among individuals newly diagnosed with HIV infection in 2013, the majority of cases were reported
among males, specifically Black/African American males. Among the adult/adolescent newly diagnosed
population in 2013, Black/African Americans made up the majority of cases (64.0%), followed by
White/Caucasians (24.5%), Hispanic/Latinos (8.3%), Asian/Pacific Islanders (1.1%), and American
Indian/Alaska Natives (0.7%) (Appendix D: Table G, page D-16).
The highest rate of newly diagnosed HIV cases was among Black/African American males (92.3 per
100,000 adult/adolescent population), which was nearly 8 times that for White/Caucasian males (12.0
per 100,000 adult/adolescent population; see Figure 2.4 and Appendix D: Table G, page D-16). The
newly diagnosed HIV infection rate among adult/adolescent Black/African American females (24.7 per
100,000 adult/adolescent population) was 13 times the rate for adult/adolescent White/Caucasian
females (1.9 per 100,000), which represented the largest disparity noted between gender and
race/ethnicity categories (Figure 2.4 and Appendix D: Table G, page D-16).
Disparities also existed for Hispanic/Latinos as compared to White/Caucasians. The rate for
adult/adolescent Hispanic/Latino males (32.5 per 100,000 adult/adolescent population) was almost 3
times that for White/Caucasian males, and Hispanic/Latino males ranked third highest among the
gender and race/ethnicity rates. The rate for adult/adolescent Hispanic/Latina females (8.1 per 100,000
adult/adolescent population) was more than 3 times that for White/Caucasian females. The newly
diagnosed HIV infection rate for American Indian/Alaska Native males (15.4 per 100,000
adult/adolescent population) was higher than that for White/Caucasian males, while the rate among
Asian/Pacific Islander males (10.5 per 100,000 adult/adolescent population) was slightly lower than that
for White/Caucasians (Figure 2.4 and Appendix D: Table G, page D-16).
Figure 2.4 shows newly diagnosed HIV infection rates for 2009-2013 by gender and race/ethnicity. In
2013, newly diagnosed HIV infection rates appear higher for all groups. This increase is likely due to
incomplete deduplication analysis for 2013 (“Special Notes” and Appendix C: Technical Notes pages 9
and C-2, respectively). We are still in the process of evaluating all 2013 HIV reports for potential
North Carolina DHHS 18 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
interstate duplicate resolution. Once this analysis is complete, we will have a better understanding of
the epidemic in 2013.
Figure 2.4. Newly Diagnosed Adult/Adolescent HIV Infectionᵃ Rates by Gender and
Race/Ethnicity, 2009-2013ᵇ
Age distribution
Diagnoses in adults and adolescents represent most HIV diagnoses in 2013, with less than one percent
(N=12) of newly diagnosed case patients younger than 13 years of age (not in Table 2.4). Overall, adults
ages 20 to 49 years accounted for the greatest proportion (56.4%) of individuals diagnosed in 2013
(Table 2.4).
0
10
20
30
40
50
60
70
80
90
100
110
2009 2010 2011 2012 2013ᵇ
Rate per 100,000 Adolescent/Adult Population
Year
American Indian/Alaska Native Malesᶜ American Indian/Alaska Native Femalesᶜ
Asian/Pacific Islander Malesᶜ Asian/Pacific Islander Femalesᶜ
Black/African American Malesᶜ Black/African American Femalesᶜ
Hispanic/Latino Males Hispanic/Latina Females
White/Caucasian Malesᶜ White/Caucasian Femalesᶜ
Note: Rates for unknown and other race/ethnicity categories are not calculated due to lack of population data.
ᵃHIV infection includes all newly reported HIV infected individuals by the year of first diagnosis, regardless of the stage of infection
(HIV or AIDS).
ᵇ2013 values are likely artificially inflated due to incomplete interstate deduplication (see "Special Notes" for more information, page 9).
ᶜNon-Hispanic/Latino.
Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of July 1, 2014).
North Carolina DHHS 19 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Table 2.4. North Carolina Newly Diagnosed Adult/Adolescent HIV Infectionᵃ Cases by Age Group and
Gender, 2013
Figure 2.5 displays the age differences between males and females newly diagnosed with HIV infection
in 2013. Diagnoses in males were highest between ages 20 through 29 years (36.6% total), while the
proportion of female diagnoses was highest for ages 40 through 49 (29.9% total). The difference in age
at diagnosis reflects the difference in exposure risk for male and females. In recent years, new HIV
infection cases have been increasing among younger males in North Carolina, unlike previous years
when the HIV epidemic was primarily increasing among an older population. Young Black/African
American males (ages 13-24 years) represented 16.3% of new cases in 2013 compared to 8.0% in 2004
and 13.0% in 2009 (Appendix D: Table H, page D-17). The relatively higher proportion of diagnoses
among older females compared to males may represent existing infections that have gone undiagnosed
for longer periods of time (Figure 2.5).
North Carolina DHHS 20 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Figure 2.5. Newly Diagnosed HIV Infectionᵃ Cases by Age and Gender, 2013
Hierarchical Risk of Exposure for HIV Infection in 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, their partners, and the treating physician are
all methods used to determine risk/exposure factors. Ultimately, each case is assigned to one primary
risk category based on a hierarchy of disease exposure developed by the CDC and others. More
information on this methodology can be found in Appendix C: Technical Notes (pages C-4 through C-6).
Table 2.5 displays the most likely modes of exposure (as defined by the CDC) of 2013 newly diagnosed
adult/adolescent HIV infections. The principal categories are: MSM, IDU, and heterosexual-high risk sex
with a high-risk partner (MSM, IDU, or HIV-infected partner). The proportion of cases for which the risk
is unknown was substantial (45.1%). A portion of these unknown risk cases were classified as unknown
because the reported risk(s) did not meet one of the CDC-defined risk classifications. In particular,
persons reporting heterosexual partners who are not aware of their partners’ risk may be classified as
having an unknown exposure.
In the following tables, a broader grouping is used: MSM, IDU, heterosexual. Rather than being limited
to high-risk heterosexual encounters, the heterosexual-other category includes all women reporting sex
0%
5%
10%
15%
20%
25%
<13 13-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+
Percent of cases
Age at Diagnosis (Year)
Male Females
ᵃHIV infection includes all newly reported HIV infected individuals diagnosed in 2013, regardless of stage of infection (HIV or AIDS).
Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of July 1, 2014).
North Carolina DHHS 21 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
with men only and all men reporting sex with women only. Even with these categories, the likely route
of exposure to HIV remains unknown for a substantial proportion (33.8%) of cases (Table 2.5).
Table 2.5. Adult/Adolescent Newly Diagnosed HIV Infectionᵃ Cases by Hierarchical Risk of
HIV Exposure, 2013
To better describe the overall changes, the remaining unknown risk cases have been assigned a risk
based on the proportionate representation of the various risk groups within the surveillance data. More
explanation of this general risk reassignment of unknown risk cases can be found Appendix C: Technical
Notes (pages C-4 through C-6). Table 2.6 displays the redistributed hierarchical risk of newly diagnosed
HIV infections in North Carolina for 2013. MSM were estimated to represent about 60.5 percent of all
newly diagnosed HIV infection cases. Heterosexual risk of exposure represented about 33.0 percent of
all HIV infection cases, IDU about 4.0 percent and MSM/IDU at 2.5 percent.
Please note all further discussions of risk or exposure categories in this document will be
based on the fully redistributed risk of all cases as described above.
North Carolina DHHS 22 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Table 2.6. Adult/Adolescent Newly Diagnosed HIV Infectionᵃ Cases by Hierarchical Risk of
HIV Exposure (Unknown Riskᵇ Redistributed), 2013
The majority of newly diagnosed HIV infections among adults and adolescents were likely exposed to
HIV via sex, either homosexual or heterosexual. Over the period from 2009 to 2013, persons who
identified as MSM and MSM/IDU exposures made up the largest proportion of newly diagnosed North
Carolina HIV infections, increasing from 52.6 percent in 2009 to 63.0 percent in 2013. During this same
time period, the proportion of people reporting heterosexual exposure declined around 9.1 percent. IDU
exposure was reported by the smallest group (4.0% in 2013) and has not fluctuated drastically in the
past five years. However, IDU remains an important mode of exposure for new HIV infection cases
(Figure 2.6).
North Carolina DHHS 23 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Figure 2.6. Newly Diagnosed Adult/Adolescent HIV Infectionᵃ Cases by Hierarchical Risk of
HIV Exposure (Unknown Riskᵇ Redistributed), 2009-2013ᶜ
Gender and Hierarchical Risk of Exposure
Differences exist in the reported exposures for males and females. For males, sex with men (MSM) was
reported by for 77.0 percent of people diagnosed with HIV in 2013; sex with women only was reported
by 17.2 percent of the newly diagnosed; and IDU was reported by 2.6 percent (Figure 2.7). The
proportion of diagnoses among men reporting sex with men has risen in recent years, from 73.1 percent
in 2009 to 80.1 percent in 2013. The proportion of men reporting IDU has remained the same (around
3.0%) over the five-year time period.
Heterosexual contact was reported for 90.7 percent of newly diagnosed HIV women, while IDU was
reported for 9.3 percent of women in North Carolina for 2013 (Figure 2.7). For women, the proportion
of heterosexual contact reports has fluctuated between 89.9 and 95.2 percent, and proportion of IDU
exposure varied between 4.9 and 9.3 percent during the last five years (Figure 2.7).
0%
10%
20%
30%
40%
50%
60%
70%
2009 2010 2011 2012 2013ᵇ
Percent of newly diagnosed HIV infection
Year
Heterosexual-Allᵈ IDUᵉ MSM and MSM/IDUᵉ
ᵃHIV infection includes all newly reported HIV infected individuals diagnosed in 2013, regardless of stage of infection (HIV or AIDS).
ᵇUnknown risk includes individuals classified as no identified risk (NIR) and no reported risk (NRR). For distribution calculations,
see Appendix C: Technical Notes for more information (page C-5).
ᶜ2013 values are likely artificially inflated due to incomplete interstate deduplication (see "Special Notes" for more information, page 9).
ᵈHeterosexual-All includes cases those individuals reporting heterosexual contact with a known HIV-positive or high risk
individual and cases redistributed into the heterosexual classification from the unknown group .
ᵉIDU= injection drug use; MSM=men who have sex with men.
Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of July 1, 2014).
North Carolina DHHS 24 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Figure 2.7. Adult/Adolescent Newly Diagnosed HIV Infectionsᵃ by Gender and Hierarchical Risk of
HIV Exposure (Unknown Riskᵇ Redistributed), 2013
Gender, Race/Ethnicity, and Hierarchical Risk of Exposure
For Black/African American males diagnosed with HIV, MSM represented about 79.8 percent of cases,
heterosexual exposure represented about 18.1 percent of cases, and IDU exposure about 2.2 percent of
cases. The modes of exposure for minority races/ethnicities (American Indian/Alaska Natives,
Asian/Pacific Islanders, and Hispanic/Latinos) were grouped together because of low case numbers.
Within this aggregated group, MSM exposure represented 68.9 percent of male cases, heterosexual
exposure 27.4 percent of cases, and IDU exposure 3.7 percent of cases. Among White/Caucasian males,
MSM (including MSM/IDU) represented 85.5 percent of cases, heterosexual exposure represented 11.0
percent of cases, and IDU exposure represented 3.1 percent of cases (Figure 2.8).
The proportion of HIV cases attributed to heterosexual exposure among males, who are Black/African
Americans and of other minority race/ethnic groups, is higher than the proportion among
White/Caucasian males. Although some portion of this observed difference may be due to
underreporting of MSM activity among minority males, some can be attributed to the difference in
disease prevalence for each racial/ethnic group and the subsequent effect on HIV exposure (Figure 2.8).
North Carolina DHHS 25 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Figure 2.8. Hierarchical Risk of HIV Exposure among Adult/Adolescent Male HIV Infectionᵃ Cases
Diagnosed (Unknown Riskᵇ Redistributed), 2013
As with males, the majority of all newly diagnosed HIV infections among females, regardless of
race/ethnicity, are attributed to sex with men. Heterosexual sex is the primary mode of exposure to HIV
infection for women of all race/ethnicity groups. A greater proportion of White/Caucasian females
report injecting drug use (26.4%) than Black/African American females (5.6%) (Figure 2.9).
Figure 2.9. Hierarchical Risk of HIV Exposure among Adult/Adolescent Female HIV Infectionᵃ Cases
Diagnosed (Unknown Riskᵇ Redistributed), 2013
North Carolina DHHS 26 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Adolescent Newly Diagnosed HIV Infection Cases
Figures 2.10 and 2.11 display the percentage of newly diagnosed HIV infection cases by race/ethnicity
and hierarchical risk of exposure categories for each gender for individuals ages 13 to 24 years
diagnosed with HIV in 2013. Significant delays may occur between infection and subsequent testing and
reporting; therefore, the age group of 13 to 24 years describes infections that likely occurred during
adolescence. In 2013, just 3.9 percent of total cases diagnosed were found among teenagers from 13 to
19 years. This percentage increased to 17.9 percent when 20 to 24 year olds were included. From 2012
to 2013, the rate of newly diagnosed cases of HIV infections among adolescents (13 to 24 years old) has
increased from 19.8 percent to 20.8 percent of all reports (Appendix D: Table H, page D-17). The
proportion of cases among each racial group in adolescents is similar to that of HIV cases overall, with
minorities disproportionally affected. Black/African Americans represented the majority of newly
diagnosed HIV infection diagnoses for both men and women among 13 to 24 year olds at 84.2 percent
and 68.8 percent, respectively (Figure 2.10). 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.
Figure 2.10. New HIV Diagnosesᵃ among Adolescent (13-24 years) by Gender and Race/Ethnicity, 2013
The hierarchical HIV exposure categories for male and female adolescents are very different (Figure
2.11). For adolescent males in 2013, 93.7 percent of new HIV infection cases were classified as MSM
exposure (including MSM/IDU), an increase from 90.3 percent reported in 2009 (Appendix D: Table N,
page D-23). In 2013, 96.9 percent of new HIV infection cases among adolescent females were exposed
to HIV through heterosexual contact. Compared to newly diagnosed adult HIV infections for 2013, newly
diagnosed adolescents are slightly less likely to report IDU, at 3.1 percent (4.0% for adults) (Figure 2.11).
North Carolina DHHS 27 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
Figure 2.11. Hierarchical Risk of HIV Exposure among Adolescent (13-24 years) HIV Infectionᵃ Cases
Diagnosed (Unknown Riskᵇ Redistributed), 2013
Females of Child-Bearing Age and Perinatal HIV Infection
Perinatal transmission of HIV is generally preventable if mothers receive appropriate drugs during
pregnancy and delivery. For this reason, special emphasis is placed on follow-up with HIV-infected
pregnant women in North Carolina. Table 2.7 displays the proportion of newly diagnosed women who
are of child-bearing age (15-44) and older. In the last five years, an average of 348 women of child-bearing
age were diagnosed with HIV each year in North Carolina (approximately 60% of total female
HIV cases). Note that the number and proportion of HIV diagnoses among North Carolina females has
decreased in recent years. For females under 15 years of age (not included in Table 2.7), the total
number of annual cases of perinatal HIV infection from 2009 to 2013 was fewer than five each year.
Readers should keep in mind that delays in testing and diagnosis can significantly affect the assessment
of the actual number of very young women with HIV.
Table 2.7. Adult/Adolescent Female Newly Diagnosed HIV Infectionsᵃ During and After
Child-Bearing Age, 2009-2013
North Carolina DHHS 28 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
In November 2007, North Carolina implemented new HIV testing statutes that require every pregnant
woman be offered HIV testing by her attending physician both at her first prenatal visit and in the third
trimester. If there is no HIV result test on record for the current pregnancy, the pregnant woman will be
tested at labor and delivery and the infant will be tested as well.
Figure 2.12 displays the numbers of likely perinatal HIV transmissions that have occurred from 2004 to
2013 by year of birth. These numbers represent pediatric reports that indicate likely perinatal
transmission based on exposure categories in HIV surveillance data. Confirming HIV in perinatal cases
takes time, so case totals for recent years should be considered preliminary. Before the new testing
statutes in 2007, the average annual number of perinatal cases was five (95% confidence interval: 4.3-
5.7 births). After the implementation of the law, the average annual number of perinatal cases dropped
to 1.6 (95% confidence interval: 0.8-2.4).
Figure 2.12. Likely Perinatal HIV Infectionᵃ Cases by Year of Birth, 2004-2013
GEOGRAPHIC DISTRIBUTION OF HIV INFECTION IN NORTH CAROLINA
Geographic areas can be defined in many ways. In this profile, data are presented in three geographic
categories for the convenience of readers: rural/urban areas, physiographic regions, and regional
networks of care and prevention (RNCP). Cases are assigned to the county of residence at first diagnosis.
People may move to other areas in the years after diagnosis. Assuming no significant difference
between the numbers of HIV infection cases moving in and out of the original residence county, the
statistics still indicate roughly the number and rate of living HIV infection cases in the corresponding
counties. The distribution of HIV infection is uneven across North Carolina. This uneven distribution can
4
5
7
9
5
3
0
2 2
1
0
1
2
3
4
5
6
7
8
9
10
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
NUmber of Cases
Year
ᵃHIV infection includes all newly reported HIV infections by year of first diagnosis.
Data Source: enhanced HIV/AIDS Reporting System (eHARS) (data as of July 1, 2014).
November 2007:
New HIV testing
statutes
implemented
North Carolina DHHS 29 Communicable Disease
2013 North Carolina HIV/STD Epidemiologic Profile Part I: Chapter 2
be partly explained by the population distribution, as the epidemic tends to be concentrated in
urban areas.
Tables 1 through 6 of the North Carolina 2013 HIV/STD Surveillance Report give county totals of HIV
infection, including AIDS diagnoses, cases living at the end of 2013, and a ranking of case rates (per
100,000 population) based on a three-year average.11 Both Mecklenburg and Edgecombe Counties
ranked highest with a newly diagnosed HIV infection three-year average rate of 31.0 per 100,000
population in 2013. They were followed by Cumberland County (26.0 per 100,000), Durham County
(25.7 per 100,000), and Guilford County (23.5 per 100,000).11 Readers are cautioned to view rates
carefully, as rates based on small numbers (generally less than 20 cases) 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.
HIV Prevalence Cases in Urban/Rural Areas
More than half of the HIV-infected persons diagnosed in North C