Contextual factors and the black-white disparity in heterosexual HIV transmission

Stigma, sexual risks, and the war on drugs: Examining drug policy and HIV/AIDS inequities among African Americans using the Drug War HIV/AIDS Inequities Model

The relationship between drug policy and HIV vulnerability is well documented. However, little research examines the links between racial/ethnic HIV disparities via the Drug War, sexual risk, and stigma. The Drug War HIV/AIDS Inequities Model has been developed to address this dearth. This model contends that inequitable policing and sentencing promotes sexual risks, resource deprivation, and ultimately greater HIV risk for African-Americans. The Drug War also socially marginalizes African Americans and compounds stigma for incarcerated and formerly incarcerated persons living with HIV/AIDS. This marginalization has implications for sexual risk-taking, access to health-promoting resources, and continuum of care participation. The Drug War HIV/AIDS Inequities Model may help illuminate mechanisms that promote increased HIV vulnerability as well as inform structural intervention development and targeting to address racial/ethnic disparities.

The Global HIV/AIDS Epidemic and Related Mental Health Issues: The Crisis for Africans and Black Americans

HIV/AIDS is one of the most devastating diseases that humanity has ever faced. Since the first clinical evidence of HIV/AIDS was reported in 1981, more than 60 million people have been infected with the virus and more than 20 million have died of AIDS. This article provides an overview of the global HIV/AIDS epidemic with a focus on its impact on sub-Saharan Africa and people of African descent in the United States.

Uptake of HIV testing and counseling, risk perception and linkage to HIV care among Thai university students

Background

HIV testing and counseling (HTC) with linkage to care after known infection are key components for HIV transmission prevention. This study was conducted to assess HTC uptake, HIV risk perception and linkage to care among Thai university students.

Methods

An outreach HTC program was conducted in a large public university in Thailand from January 2013 to December 2014. The program consisted of brief HIV knowledge assessment, free HTC, HIV risk assessment and education provided by the healthcare personnel. Students were categorized into low, moderate and high-risk groups according to the pre-defined HIV risk characteristics.

Results

One-thousand-eight-hundred-one students participated in the program, 494 (27 %) underwent HTC. Independent characteristics associated with no HTC uptake included female sex (P < 0.001), lower HIV knowledge score (P < 0.001), younger age (P < 0.001) and students from non-health science faculties (P = 0.02). Among the 494 students undergoing HTC, 141 (29 %) were categorized into moderate or high-risk group, of whom 45/141 (32 %) had false perception of low HIV risk. Being heterosexual was independently associated with false perception of low HIV risk (P = 0.04). The rate of new HIV infection diagnosis was 4/494 (0.8 %). Of these 4 HIV-infected students, 3 (75 %) were men who have sex with men and only 2 of the 4 students (50 %) showed up for HIV continuity care.

Conclusions

An outreach HIV prevention program with HTC was feasible and beneficial in detecting HIV risk and infection among the university students. However, interventions to improve HTC uptake, HIV risk perception and linkage to care are needed.

Individual and Partner-Level Factors Associated with Condom Non-Use Among African American STI Clinic Attendees in the Deep South: An Event-Level Analysis

The US HIV/AIDS epidemic is concentrated in the Deep South, yet factors contributing to HIV transmission are not fully understood. We examined relationships between substance use, sexual partnership characteristics, and condom non-use in an African American sample of STI clinic attendees in Jackson, Mississippi. We assessed condom non-use at last intercourse with up to three recent sexual partners reported by participants between January and June 2011. Participant- and partner-level correlates of condom non-use were examined using generalized estimating equations. The 1295 participants reported 2880 intercourse events, of which 1490 (51.7 %) involved condom non-use. Older age, lower educational attainment, reporting financial or material dependence on a sex partner, sex with a primary partner, and higher frequency of sex were associated with increased odds of condomless sex. HIV prevention efforts in the South should address underlying socioeconomic disparities and structural determinants that result in partner dependency and sexual risk behavior.

Attitudes Towards Power in Relationships and Sexual Concurrency Within Heterosexual Youth Partnerships in Baltimore, MD

Sexual concurrency may increase risk for HIV/STIs among youth. Attitudes about gender roles, including power balances within sexual partnerships, could be a driver. We examined this association among Baltimore youth (N = 352), aged 15-24. Data were collected from February, 2011 to May, 2013. We examined whether index concurrency in male-reported partnerships (N = 221) and sex partner's concurrency in female-reported partnerships (N = 241) were associated with youth's attitudes towards relationship power. Males with more equitable beliefs about power were less likely to report index concurrency. Females with more equitable beliefs were more likely to report sex partner's concurrency. The relationship was significant in main and casual partnerships among females and main partnerships among males. The strongest associations were detected among middle-socioeconomic status (SES) males and low-SES and African American females. Implementing interventions that recognize the complex relationship between socioeconomic context, partner dynamics, gender, and sexual behavior is an important step towards reducing HIV/STI risk among youth.

Does marital status matter in an HIV hyperendemic country? Findings from the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey

South Africa has experienced declining marriage rates and the increasing practice of cohabitation without marriage. This study aims to improve the understanding of the relationship between marital status and HIV in South Africa, an HIV hyperendemic country, through an analysis of findings from the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey. The nationally representative population-based cross-sectional survey collected data on HIV and socio-demographic and behavioural determinants in South Africa. This analysis considered respondents aged 16 years and older who consented to participate in the survey and provided dried blood spot specimens for HIV testing (N = 17,356). After controlling for age, race, having multiple sexual partners, condom use at last sex, urban/rural dwelling and level of household income, those who were married living with their spouse had significantly reduced odds of being HIV-positive compared to all other marital spouses groups. HIV incidence was 0.27% among respondents who were married living with their spouses; the highest HIV incidence was found in the cohabiting group (2.91%). Later marriage (after age 24) was associated with increased odds of HIV prevalence. Our analysis suggests an association between marital status and HIV prevalence and incidence in contemporary South Africa, where odds of being HIV-positive were found to be lower among married individuals who lived with their spouses compared to all other marital status groups. HIV prevention messages therefore need to be targeted to unmarried populations, especially cohabitating populations. As low socio-economic status, low social cohesion and the resulting destabilization of sexual relationships may explain the increased risk of HIV among unmarried populations, it is necessary to address structural issues including poverty that create an environment unfavourable to stable sexual relationships.

Violence Against Women in Selected Areas of the United States

OBJECTIVES

We determined the prevalence of recent emotional, physical, and sexual violence against women and their associations with HIV-related risk factors in women living in the United States.

METHODS

We performed an assessment of women ages 18 to 44 years with a history of unprotected sex and 1 or more personal or partner HIV risk factors in the past 6 months from 2009 to 2010. We used multivariable logistic regression to examine the association of experiencing violence.

RESULTS

Among 2099 women, the prevalence of emotional abuse, physical violence, and sexual violence in the previous 6 months was 31%, 19%, and 7%, respectively. Nonmarried status, food insecurity, childhood abuse, depression symptomology, and posttraumatic stress disorder were significantly associated with multiple types of violence. All types of violence were associated with at least 3 different partner or personal HIV risk behaviors, including unprotected anal sex, previous sexually transmitted infection diagnosis, sex work, or partner substance abuse.

CONCLUSIONS

Our data suggested that personal and partner HIV risk behaviors, mental illness, and specific forms of violence frequently co-occurred in the lives of impoverished women. We shed light on factors purported to contribute to a syndemic in this population. HIV prevention programs in similar populations should address these co-occurring issues in a comprehensive manner.

Evaluation of a socio-cultural intervention to reduce unprotected sex for HIV among African American/Black women

African American/Black (Black) women suffer disproportionately to other women from HIV. An HIV prevention intervention combining two previous evidenced-based intervention programs; "Coping with Work and Family Stress" and "Hip Hop 2 Prevent Substance Abuse and HIV", was evaluated in a diverse sample of Black women (n = 205). Study participants at ten recruitment sites were assigned non-randomly to either the intervention or comparison group and then surveyed at baseline, immediate posttest, and 6-month follow-up. General Estimating Equation modeling revealed that participants in the comparison group reported less unprotected sex at immediate post-test and the intervention group less unprotected sex at 6-month follow-up. Despite the initial drop in reported unprotected sex in the comparison group, this study suggests that an HIV risk reduction intervention tailored to address Black women's socio-cultural stress and enhance their coping may reduce their unprotected sex at 6-months.

Racial residential segregation and risky sexual behavior among non-Hispanic blacks, 2006-2010

Sexually transmitted infections (STIs) including human immunodeficiency virus (HIV) have disproportionately affected the non-Hispanic black population in the United States. A person's community can affect his or her STI risk by the community's underlying prevalence of STIs, sexual networks, and social influences on individual behaviors. Racial residential segregation-the separation of racial groups in a residential context across physical environments-is a community factor that has been associated with negative health outcomes. The objective of this study was to examine if non-Hispanic blacks living in highly segregated areas were more likely to have risky sexual behavior. Demographic and sexual risk behavior data from non-Hispanic blacks aged 15-44 years participating in the National Survey of Family Growth were linked to Core-Based Statistical Area segregation data from the U.S. Census Bureau. Five dimensions measured racial residential segregation, each covering a different concept of spatial variation. Multilevel logistic regressions were performed to test the effect of each dimension on sexual risk behavior controlling for demographics and community poverty. Of the 3643 participants, 588 (14.5%) reported risky sexual behavior as defined as two or more partners in the last 12 months and no consistent condom use. Multilevel analysis results show that racial residential segregation was associated with risky sexual behavior with the association being stronger for the centralization [aOR (95% CI)][2.07 (2.05-2.08)] and concentration [2.05 (2.03-2.07)] dimensions. This suggests risky sexual behavior is more strongly associated with neighborhoods with high concentrations of non-Hispanic blacks and an accumulation of non-Hispanic blacks in an urban core. Findings suggest racial residential segregation is associated with risky sexual behavior in non-Hispanic blacks 15-44 years of age with magnitudes varying by dimension. Incorporating additional contextual factors may lead to the development of interventions that promote healthier behaviors and lower rates of HIV and other STIs.

Collateral consequences: implications of male incarceration rates, imbalanced sex ratios and partner availability for heterosexual Black women

While studies have found correlations between rates of incarceration and sexually transmitted infections (STIs), few studies have explored the mechanisms linking these phenomena. This qualitative study examines how male incarceration rates and sex ratios influence perceived partner availability and sexual partnerships for heterosexual Black women. Semi-structured interviews were conducted with 33 Black women living in two US neighbourhoods, one with a high male incarceration rate and an imbalanced sex ratio (referred to as 'Allentown') and one with a low male incarceration rate and an equitable sex ratio (referred to as 'Blackrock'). Data were analysed using grounded theory. In Allentown, male incarceration reduced the number of available men, and participants largely viewed men available for partnerships as being of an undesirable quality. The number and desirability of men impacted on the nature of partnerships such that they were shorter, focused on sexual activity and may be with higher-risk sexual partners (e.g. transactional sex partners). In Blackrock, marriage rates contributed to the shortage of desirable male partners. By highlighting the role that the quantity and quality of male partners has on shaping sexual partnerships, this study advances current understandings of how incarceration and sex ratios shape HIV- and STI-related risk.

Changes in Exposure to Neighborhood Characteristics are Associated with Sexual Network Characteristics in a Cohort of Adults Relocating from Public Housing

Ecologic and cross-sectional multilevel analyses suggest that characteristics of the places where people live influence their vulnerability to HIV and other sexually-transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African-American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater post-relocation improvements in economic disadvantage, violent crime, and male:female sex ratios would experience greater reductions in perceived partner risk and in the odds of having a partner who had another partner (i.e., indirect concurrency). Baseline data were collected from 172 public housing residents before relocations occurred; three waves of post-relocation data were collected every 9 months. Participants who experienced greater improvements in community violence and in economic conditions experienced greater reductions in partner risk. Reduced community violence was associated with reduced indirect concurrency. Structural interventions that decrease exposure to violence and economic disadvantage may reduce vulnerability to HIV/STIs.

Partner Incarceration and African-American Women's Sexual Relationships and Risk: A Longitudinal Qualitative Study

Racialized mass incarceration is associated with racial/ethnic disparities in HIV and other sexually transmitted infections (STIs) in the US. The purpose of this longitudinal qualitative study was to learn about the processes through which partner incarceration affects African-American women's sexual risk. Four waves of in-depth qualitative interviews were conducted in 2010-2011 with 30 women in Atlanta, Georgia (US) who had recently incarcerated partners. Approximately half the sample misused substances at baseline. Transcripts were analyzed using grounded theory. For over half the sample (N = 19), partner incarceration resulted in destitution, and half of this group (N = 9) developed new partnerships to secure shelter or food; most misused substances. Other women (N = 9) initiated casual relationships to meet emotional or sexual needs. When considered with past research, these findings suggest that reducing incarceration rates among African-American men may reduce HIV/STIs among African-American women, particularly among substance-misusing women, as might rapidly linking women with recently incarcerated partners to housing and economic support and drug treatment.

Neighborhood Condition and Geographic Locale in Assessing HIV/STI Risk Among African American Adolescents

Although region and neighborhood condition's effect on HIV/sexually transmitted infection (STI) risk has been studied separately, there is little research examining their interplay. African American adolescents (n = 1,602) from four matched cities in the Northeastern and Southeastern US completed Audio Computer Assisted Self-Interviews and submitted biospecimen samples to detect Sexually Transmitted Infections (chlamydia, gonorrhea, and trichomonas). Logistic and negative binomial regressions determined HIV/STI risk differences by region, neighborhood stress, and stress-region dyads. Northeastern participants demonstrated lower HIV/STI risk while participants from higher stress neighborhoods exhibited greater risk. Relationships between neighborhood condition and ever having anal sex (p < 0.01), anal condom use (p < 0.05), and number of anal partners (p < 0.05) were significant in the Northeast only. Participants in unstressed Northeastern neighborhoods were less likely to have vaginal sex than those in comparable Southeastern neighborhoods (p < 0.05). Participants in unfavorable Northeastern neighborhoods had fewer anal partners than participants in comparable Southeastern neighborhoods (p < 0.01). In concert, neighborhood and region differentially affect HIV/STI risk.

Why women engage in anal intercourse: results from a qualitative study

This study used qualitative methods to assess why women engage in heterosexual anal (receptive) intercourse (AI) with a male partner. Four focus groups which comprised women from diverse ethnicities were conducted. All groups were digitally recorded for transcription; transcripts were analyzed using the methods of grounded theory to determine themes. Women's reasons for engaging in anal intercourse with a male partner can be described in broad categories including that the women wanted to have anal intercourse, either because of their own desire, to please a male partner, or they were responding to a quid pro quo situation. The riskiness of AI was assessed within relationship contexts. Past experience with AI including emotional and physical reactions was identified. Among the negative physical experiences of AI were pain and disliking the sensation, and uncomfortable side effects, such as bleeding of the rectum. Negative emotional experiences of AI included feelings of shame, disgust, and being offended by something her male partner did, such as spitting on his penis for lubrication. Positive physical experiences included liking the sensation. Many of the women also endorsed positive emotional experiences of AI, including that it was more intimate than vaginal sex, and that it was something they reserved only for special partners. The majority of AI episodes were unplanned and not discussed prior to initiation. Pain during AI was mitigated by the use of lubricants or illicit drugs. Even those women who found pleasure in AI expressed a preference for vaginal intercourse.

Elevated sexual risk behaviors among postincarcerated young African American males in the South

The dramatic racial disparities in the rates of HIV/STIs(sexually transmitted infections) among African Americans make understanding broader structural factors that increase the risk for HIV/STIs crucial. The current study of young 564 African American men attending STI clinics investigated whether those who had ever been incarcerated reported recent sexual behaviors relatively more risky than their counterparts who had never been incarcerated. Participants were recruited from clinics treating STIs in three southern U.S. cities. Males 15 to 23 years of age who identified as Black/African American and reported recent (past 2 months) sexual activity were eligible. Linear mixed-effects models and generalized estimating equation models were used to assess associations between baseline incarceration history and sexual risk behavior over a 6-month follow-up period. Mean age was 19.6 years (SD = 1.87). At baseline, 240 (42.6%) men reported history of incarceration. Incarceration history predicted several risk behaviors over a 6-month follow-up period. Compared with those with no incarceration history, men previously incarcerated reported a desire to conceive a pregnancy (β = .40, p = .02), were less likely to have used a condom at last sex act (odds ratio = .91, p = .02) and were more likely to have used drugs and alcohol before sex in the past 2 months (β = .69, p < .001; β = .41, p < .001). A history of incarceration may influence the sexual risk behavior of young African American males. Prevention programs and interventions should intensify support for postincarceration African American males to help mitigate this behavior.

Race/ethnicity, sexual partnerships with men involved with drugs, and sexually transmitted infections among a sample of urban young adult women

In many urban neighbourhoods in the United States, drug markets borne from disadvantage have produced risk for sexually transmitted infections through altered sexual norms and partnerships. Presently, we examined the association of race, sexual partnerships with men involved with drugs, and self-reported sexually transmitted infections among 240 African American and white women aged 18-30 years. Thirty seven per cent reported ever having a sexually transmitted infection. Almost 30% of Whites reported sex with a drug user, compared to 5% of African Americans. Fifty eight per cent of African Americans compared to 31% of Whites reported sex with a drug dealer. On Step 1 of a sequential logistic regression model, race was associated with lifetime sexually transmitted infections (OR = 4.7, 95% CI = 2.61-8.34). Results from the full sequential logistic regression model indicated a significant, but smaller association of race and lifetime sexually transmitted infections (Adjusted OR = 3.5, 95% CI = 1.78-7.02) and an association of sex with a drug dealer and lifetime sexually transmitted infections (Adjusted OR = 2.9, 95% CI = 1.55-5.20). Forming sexual partnerships with drug dealers may place women at increased risk for sexually transmitted infections and explain racial disparities. More research focused on drug dealers as core transmitters is needed.

Prevalence and predictors of concurrent sexual partnerships in a predominantly African American population in Jackson, Mississippi

Concurrent sexual partnerships, or sexual partnerships that overlap in time, have been associated with HIV and sexually transmitted infections (STI). How best to measure concurrency and the personal characteristics and predictors of concurrency are not yet well understood. We compared two frequently used concurrency definitions, including a self-reported measure based on participant response regarding overlapping sex with partners, and the UNAIDS measure based on overlapping dates of last sex and intention to have sex again. We performed multivariable logistic regression analyses to identify socio-demographic, behavioral, and structural predictors of concurrency among 1,542 patients at an urban STI clinic in Jackson, Mississippi. Nearly half (44 %) reported concurrency based on self-reported sex with other partners, and 26 % reported concurrency according to the UNAIDS concurrency measure. Using the self-reported concurrency measure, the strongest predictors of concurrency were perceived partner concurrency, drug use at last sex, having more than 10 lifetime partners, and being recently incarcerated. Strongest predictors of concurrency using the UNAIDS measure were lifetime number of partners and perceived partner concurrency. Concurrency is highly prevalent in this population in the Deep South and social, structural and behavioral factors were important predictors of concurrency for both measures. Future research should use time anchored data collection methods and biomarkers to assess whether both definitions of concurrency are associated with HIV outcomes.

A census tract-level examination of social determinants of health among black/African American men with diagnosed HIV infection, 2005-2009--17 US areas

BACKGROUND

HIV disproportionately affects black men in the United States: most diagnoses are for black gay, bisexual, and other men who have sex with men (collectively referred to as MSM). A better understanding of the social conditions in which black men live and work may better explain why HIV incidence and diagnosis rates are higher than expected in this population.

METHODS

Using data from the National HIV Surveillance System and the US Census Bureau's American Community Survey, we examined the relationships of HIV diagnosis rates and 5 census tract-level social determinants of health variables for 21,948 black MSM and non-MSM aged ≥ 15 years residing in 17 areas in the United States. We examined federal poverty status, marital status, education level, employment status, and vacancy status and computed rate ratios (RRs) and prevalence odds ratios (PORs), using logistic regression with zero-inflated negative binomial modeling.

RESULTS

Among black MSM, HIV diagnosis rates decreased as poverty increased (RR: 0.54). At the time of HIV diagnosis, black MSM were less likely than black non-MSM to live in census tracts with a higher proportion below the poverty level (POR: 0.81) and with a higher proportion of vacant houses (POR: 0.86). In comparison, housing vacancy was positively associated with HIV diagnosis rates among black non-MSM (RR: 1.65). HIV diagnosis rates were higher for black MSM (RR: 2.75) and non-MSM (RR: 4.90) whose educational level was low. Rates were significantly lower for black MSM (RR: 0.06) and non-MSM (RR: 0.26) as the proportion unemployed and the proportion married increased.

CONCLUSIONS

This exploratory study found differences in the patterns of HIV diagnosis rates for black MSM and non-MSM and provides insight into the transmission of HIV infection in areas that reflect substantial disadvantage in education, housing, employment, and income.

A perfect storm: crack cocaine, HSV-2, and HIV among non-injecting drug users in New York City

Prevalence of human immunodeficiency virus (HIV) infection has reached 16% among non-injecting drug users (NIDU) in New York City, an unusually high prevalence for a predominantly heterosexual population that does not inject drugs. Using a long-term study (1983-2011, >7,000 subjects) among persons entering the Beth Israel drug-treatment programs in New York City, we identified factors that contributed to this high prevalence: a preexisting HIV epidemic among injectors, a crack cocaine epidemic, mixing between injectors and crack users, policy responses not centered on public health, and herpes-simplex virus 2 facilitating HIV transmission. Implications for avoiding high prevalence among NIDU in other areas are discussed.

Beyond race and place: distal sociological determinants of HIV disparities

Informed behavior change as an HIV prevention tool has yielded unequal successes across populations. Despite decades of HIV education, some individuals remain at high risk. The mainstream media often portrays these risk factors as products of race and national borders; however, a rich body of recent literature proposes a host of complex social factors that influence behavior, including, but not limited to: poverty, income inequality, stigmatizing social institutions and health care access. We examined the relationship between numerous social indicators and HIV incidence across eighty large U.S. cities in 1990 and 2000. During this time, major correlating factors included income inequality, poverty, educational attainment, residential segregation and marriage rates. However, these ecological factors were weighted differentially across risk groups (e.g. heterosexual, intravenous drug use, men who have sex with men (MSM)). Heterosexual risk rose significantly with poor economic indicators, while MSM risk depended more heavily on anti-homosexual stigma (as measured by same-sex marriage laws). HIV incidence among black individuals correlated significantly with numerous economic factors but also with segregation and imbalances in the male:female ratio (often an effect of mass incarceration). Our results support an overall model of HIV ecology where poverty, income inequality and social inequality (in the form of institutionalized racism and anti-homosexual stigma) have over time developed into synergistic drivers of disease transmission in the U.S., inhibiting information-based prevention efforts. The relative weights of these distal factors vary over time and by HIV risk group. Our testable model may be more generally applicable within the U.S. and beyond.

HIV among women in the District of Columbia: an evolving epidemic?

The epidemiology of HIV in urban centers of the United States such as the District of Columbia (DC) is dynamic with rates of new HIV and AIDS diagnoses as well as risk factors elevated. Correlates of HIV among heterosexual women extend beyond traditional, individual risk factors to structural factors. The purpose of this study was to compare proportions of HIV and correlates of HIV among women participating in National HIV behavioral surveillance (NHBS) system in 2006-7 (NHBS Cycle 1) and 2010 (NHBS Cycle 2). Analysis of 677 female participants at elevated risk for HIV revealed high prevalence of individual-level HIV-associated risk factors (e.g., sexual behavior) and socio-structural associated risk factors (e.g., homelessness, incarceration, lack of health insurance). While a greater proportion of women were HIV-infected in Cycle 2, after controlling for the distribution of demographic characteristics to adjust for a change in eligibility criteria, the pooled sample did not reveal a significantly increased proportion of HIV-infected women in Cycle 2. Homelessness and condom use were associated with greater relative odds of HIV after adjustment for confounders, and non-injection drug use was associated with reduced odds. Findings inform our understanding of the continuing HIV epidemic in DC and support development of effective interventions to slow the epidemic among women in DC and similar urban centers.

Do metropolitan HIV epidemic histories and programs for people who inject drugs and men who have sex with men predict AIDS incidence and mortality among heterosexuals?

PURPOSE

We focus on a little-researched issue-how human immunodeficiency virus (HIV) epidemics and programs in key populations in metropolitan areas affect epidemics in other key populations. We consider (1) How are earlier epidemics among people who inject drugs (PWID) and men who have sex with men (MSM) related to later AIDS incidence and mortality among heterosexuals?; (2) Were prevention programs targeting PWID or MSM associated with lower AIDS incidence and mortality among heterosexuals?; and (3) Was the size of the potential bridge population of noninjecting drug users (NIDUs) in a metropolitan area associated with later AIDS incidence and mortality among heterosexuals?

METHODS

Using data for 96 large U.S. metropolitan areas, Poisson regression assessed associations of population prevalences of HIV-infected PWID and MSM (1992); NIDU population prevalence (1992-1994); drug use treatment coverage for PWID (1993); HIV counseling and testing coverage for MSM and for PWID (1992); and syringe exchange presence (2000) with CDC data on AIDS incidence and mortality among heterosexuals in 2006-2008, with appropriate socioeconomic controls.

RESULTS

Population density of HIV+ PWID and of NIDUs were positively related, and prevention programs for PWID negatively related to later AIDS incidence among heterosexuals and later mortality among heterosexuals living with AIDS. HIV+ MSM population density and prevention programs for MSM were not associated with these outcomes.

CONCLUSIONS

Efforts to reduce HIV transmission among PWID and NIDUs may reduce AIDS and AIDS-related mortality among heterosexuals. More research is needed at metropolitan area, network, and individual levels into HIV bridging across key populations and how interventions in one key population affect HIV epidemics in other key populations.

Characteristics of multiple and concurrent partnerships among women at high risk for HIV infection

OBJECTIVES

We examined parameters of sexual partnerships, including respondents' participation in concurrency, belief that their partner had concurrent partnerships (partners' concurrency), and partnership intervals, among the 2099 women in HIV Prevention Trials Network 064, a study of women at high risk for HIV infection, in 10 U.S. communities.

METHODS

We analyzed baseline survey responses about partnership dates to determine prevalence of participants' and partners' concurrency, intervals between partnerships, knowledge of whether recent partners had undergone HIV testing, and intercourse frequency during the preceding 6 months.

RESULTS

Prevalence of participants' and partners' concurrency was 40% and 36%, respectively; 24% respondents had both concurrent partnerships and nonmonogamous partners. Among women with >1 partner and no concurrent partnerships themselves, the median gap between partners was 1 month. Multiple episodes of unprotected vaginal intercourse with ≥2 of their most recent partners was reported by 60% of women who had both concurrent partnerships and nonmonogamous partners, 50% with only concurrent partners and no partners' concurrency, and 33% with only partners' concurrency versus 14% of women with neither type of concurrency (P < 0.0001). Women who had any involvement with concurrency were also more likely than women with no concurrency involvement to report lack of awareness of whether recent partners had undergone HIV testing (participants' concurrency 41%, partners' concurrency 40%, both participants' and partners' concurrency 48%, neither 17%; P < 0.0001).

CONCLUSIONS

These network patterns and short gaps between partnerships may create substantial opportunities for HIV transmission in this sample of women at high risk for HIV infection.

Routine HIV screening in North Carolina in the era of the Affordable Care Act: update on laws, reimbursement, and tests

Eighteen percent of the 1.2 million human immunodeficiency virus (HIV)-infected individuals in the United States are undiagnosed, with North Carolina accounting for the eighth largest number of new HIV diagnoses in 2011. In an effort to identify more HIV-infected individuals by reducing physician barriers to HIV testing, the Centers for Disease Control and Prevention have expanded their HIV screening recommendations to adolescents and adults without HIV risk factors or behaviors, eliminated federal requirements for pretest counseling, and modified the informed consent process. In 2010, the Office of National AIDS (acquired immunodeficiency syndrome) Policy released the first-ever national HIV/AIDS strategy, with the goal of reducing new infections, increasing access to care, improving HIV outcomes, and reducing HIV racial/ethnic disparities. In 2013, the US Preventive Services Task Force released A-level recommendations recommending nonrisk-based HIV screening for adults and adolescents that are consistent with the recommendations of the Centers for Disease Control and Prevention. In concert with these federal recommendations, the majority of states have modified their consent and counseling requirements. The implementation of the Patient Protection and Affordable Care Act will add requirements and incentives for federal (Medicare), state (Medicaid), and private (insurance) payers to reimburse physicians and patients for nonrisk-based HIV screening.

Income inequality and sexually transmitted in the United States: who bears the burden?

Three causal processes have been proposed to explain associations between group income inequality and individual health outcomes, each of which implies health effects for different segments of the population. We present a novel conceptual and analytic framework for the quantitative evaluation of these pathways, assessing the contribution of: (i) absolute deprivation - affecting the poor in all settings - using family income; (ii) structural inequality - affecting all those in unequal settings - using the Gini coefficient; and (iii) relative deprivation - affecting only the poor in unequal settings - using the Yitzhaki index. We conceptualize relative deprivation as the interaction of absolute deprivation and structural inequality. We test our approach using hierarchical models of 11,183 individuals in the National Longitudinal Study of Adolescent Health (Add Health). We examine the relationship between school-level inequality and sexually transmitted infections (STI) - self-reported or laboratory-confirmed Chlamydia, Gonorrhoea or Trichomoniasis. Results suggest that increased poverty and inequality were both independently associated with STI diagnosis, and that being poor in an unequal community imposed an additional risk. However, the effects of inequality and relative deprivation were confounded by individuals' race/ethnicity.

Sex ratio, poverty, and concurrent partnerships among men and women in the United States: a multilevel analysis

PURPOSE

Social and economic contextual factors may promote concurrent sexual partnerships, which can accelerate population HIV transmission and are more common among African Americans than U.S. Whites. We investigated the relationship between contextual factors and concurrency.

METHODS

We analyzed past 12-month concurrency prevalence in the 2002 National Survey of Family Growth and its contextual database in relation to county sex ratio (among respondent's racial and ethnic group), percentage in poverty (among respondent's racial and ethnic group), and violent crime rate. Analyses examined counties with balanced (0.95-1.05 males/female) or low (<0.9) sex ratios.

RESULTS

Concurrency prevalence was greater (odds ratio [OR]; 95% confidence interval [CI]) in counties with low sex ratios (OR, 1.67; 95% CI, 1.17-2.39), more poverty (OR, 1.18; 95% CI, 0.98-1.42 per 10 percentage-point increase), and higher crime rates (OR, 1.04; 95% CI, 1.00-1.09 per 1000 population/year). Notably, 99.5% of Whites and 93.7% of Hispanics, but only 7.85% of Blacks, lived in balanced sex ratio counties; about 5% of Whites, half of Hispanics, and three-fourths of Blacks resided in counties with >20% same-race poverty.

CONCLUSIONS

The dramatic Black-White differences in contextual factors in the United States and their association with sexual concurrency could contribute to the nation's profound racial disparities in HIV infection.

HSV-2 Infection as a Cause of Female/Male and Racial/Ethnic Disparities in HIV Infection

OBJECTIVES

To examine the potential contribution of herpes simplex virus 2 (HSV-2) infection to female/male and racial/ethnic disparities in HIV among non-injecting heroin and cocaine drug users. HSV-2 infection increases susceptibility to HIV infection by a factor of two to three.

METHODS

Subjects were recruited from entrants to the Beth Israel drug detoxification program in New York City 2005-11. All subjects reported current use of heroin and/or cocaine and no lifetime injection drug use. A structured questionnaire was administered and serum samples collected for HIV and HSV-2 testing. Population-attributable risk percentages (PAR%s) were calculated for associations between HSV-2 infection and increased susceptibility to HIV.

RESULTS

1745 subjects were recruited from 2005-11. Overall HIV prevalence was 14%. Females had higher prevalence than males (22% vs. 12%) (p<0.001), African-Americans had the highest prevalence (15%), Hispanics an intermediate prevalence (12%), and Whites the lowest prevalence (3%) (p<.001). There were parallel variations in HSV-2 prevalence (females 86%, males 51%, African-Americans 66%, Hispanics 47%, Whites 36%), HSV-2 prevalence was strongly associated with HIV prevalence (OR  =  3.12 95% CI 2.24 to 4.32). PAR%s for HSV-2 as a cause of HIV ranged from 21% for Whites to 50% for females. Adjusting for the effect of increased susceptibility to HIV due to HSV-2 infection greatly reduced all disparities (adjusted prevalence  =  males 8%, females 11%; Whites 3%, African-Americans 10%, Hispanics 9%).

CONCLUSIONS

Female/male and racial/ethnic variations in HSV-2 infection provide a biological mechanism that may generate female/male and racial/ethnic disparities in HIV infection among non-injecting heroin and cocaine users in New York City. HSV-2 infection should be assessed as a potential contributing factor to disparities in sexually transmitted HIV throughout the US.

Macro-level approaches to HIV prevention among ethnic minority youth: state of the science, opportunities, and challenges

The HIV epidemic continues to disproportionately affect ethnic minority youth. These disconcerting health disparities indicate that although existing HIV preventive strategies for ethnic minority youth have been efficacious, they have not significantly reduced the impact of the epidemic in this population. Macro-level interventions, such as structural or policy interventions, have the potential to impact the HIV epidemic at a population level, and thus reduce the HIV health disparities that exist among ethnic minority youth and other segments of the U.S. population. This article calls for a paradigm shift to develop, evaluate, and disseminate interventions that target upstream/macro-level factors or that, at a minimum, integrate both a macro and individual level perspective. The article also discusses the challenges in developing and evaluating such interventions. Psychologists and other behavioral scientists can play a critical role in reducing the impact of HIV on ethnic minority youth by integrating macro-level approaches to future HIV prevention strategies.

Experiences of racial discrimination and relation to sexual risk for HIV among a sample of urban black and African American men

This study aimed to examine racial discrimination and relation to sexual risk for HIV among a sample of urban black and African American men. Participants of this cross-sectional study were black and African American men (N = 703) between the ages of 18 and 65 years, recruited from four urban clinical sites in the northeast. Multivariate logistic regression models were used to analyze the relation of reported racial discrimination to the following: (1) sex trade involvement, (2) recent unprotected sex, and (3) reporting a number of sex partners in the past 12 months greater than the sample average. The majority of the sample (96%) reported racial discrimination. In adjusted analyses, men reporting high levels of discrimination were significantly more likely to report recent sex trade involvement (buying and/or selling) (adjusted odds ratio (AOR) range = 1.7-2.3), having recent unprotected vaginal sex with a female partner (AOR = 1.4, 95% confidence interval (CI), 1.1-2.0), and reporting more than four sex partners in the past year (AOR = 1.4, 95% CI, 1.1-1.9). Findings highlight the link between experiences of racial discrimination and men's sexual risk for HIV.

The concrete jungle: city stress and substance abuse among young adult African American men

Substance use is prevalent among African American men living in urban communities. The impact of substance use on the social, psychological, and physical health of African American men has important public health implications for families, communities, and society. Given the adverse consequences of alcohol and drug abuse within communities of color, this study evaluated the relationship between city stress, alcohol consumption, and drug use among African American men. Eighty heterosexual, African American men, 18 to 29 years old, completed psychosocial risk assessments that assessed substance use and city stress. Multiple logistic regression analyses, controlling for age, indicated that participants reporting high levels of urban stress, relative to low levels of urban stress, were more likely to report a history of marijuana use (AOR = 5.19, p = .05), history of ecstasy and/or GHB use (AOR = 3.34, p = .04), having family/friends expressing strong concerns about their illicit drug use (AOR = 4.06, p = .02), and being unable to remember what happened the night before due to drinking (AOR = 4.98, p = .01). African American men living within the confines of a stressful urban environment are at increased risk for exposure to and utilization of illicit substances. Culturally competent public health interventions for substance use/abuse should address psychological factors, such as stress and neighborhood violence.

Racial discrimination, social support, and sexual HIV risk among Black heterosexual men

Numerous studies document the adverse impact of racial discrimination on African Americans' health outcomes, but few have focused on HIV risk. We examined the relationship between racial discrimination and sexual risk in a sample of 526 Black heterosexual men and tested the hypothesis that social support would moderate this relationship. Participants in the predominantly low-income urban sample ranged in age from 18 to 45. High social support had a buffering impact on the relationship between racial discrimination and sexual risk. Among men reporting high racial discrimination, those with more social support reported less sexual risk than men with low social support. Men who reported high racial discrimination and low social support reported more sexual risk than men in any of the other groups. The study highlights social support as an important but understudied protective factor that may reduce sexual risk for Black heterosexual men who report high levels of racial discrimination.

Attitudes Toward and Sexual Partnerships With Drug Dealers Among Young Adult African American Females in Socially Disorganized Communities

Drug markets in disadvantaged African American neighborhoods have altered social and sexual norms as well as sexual networks, which impact an individual's risk of contracting a sexually transmitted infection. Presently, we describe the prevalence of sexual partnerships with males involved with illegal drugs among a sample of non-drug-dependent females. In 2010, 120 Black females aged 18 to 30 years completed a semistructured HIV-risk interview. Descriptive statistics revealed approximately 80% of females perceived neighborhood drug activity as a major problem, 58% had sex with a male drug dealer, 48% reported sex with a male incarcerated for selling drugs, and 56% believed drug dealers have the most sexual partners. Our results suggest sexual partnerships with males involved in the distribution of drugs are prevalent. These partnerships may play a substantial role in the spread of sexually transmitted infections among low-risk females, as drug dealers likely serve as a bridge between higher HIV-risk drug and prison populations and lower HIV-risk females. However, the significance of partnerships with males involved in drug dealing has received little attention in HIV and drug abuse literature. Presently, there is a need for more research focused on understanding the extent to which the drug epidemic affects the HIV risk of non-drug-dependent Black female residents of neighborhoods inundated with drugs. Special consideration should be given to the role of the neighborhood drug dealer in the spread of sexually transmitted infections.

College graduation reduces vulnerability to STIs/HIV among African-American young adult women

African-American women are disproportionately affected by sexually transmitted infections (STIs), including HIV. The Theory of Gender and Power (TGP) posits that socioeconomic exposures, including educational attainment, place women at increased risk for STIs/HIV. This study examined the association between educational attainment and vulnerability to STIs/HIV, as well as potential TGP-driven mediators of this association, among African-American women. Baseline data were assessed from an STI/HIV prevention intervention for African-American women (n = 848) aged 18 to 29 recruited from three Kaiser Permanente Centers in Atlanta, Georgia. Data collection included a survey of demographic, psychosocial, and behavioral measures and self-collected, laboratory-confirmed vaginal swabs for STIs (trichomoniasis, chlamydia, gonorrhea, and human papillomavirus). Multiple regression analyses and multivariate mediation analyses were used to examine the association between educational attainment with a laboratory-confirmed STI and potential TGP mediators. Controlling for age and receipt of public assistance, the odds of an STI diagnosis were 73% lower among participants with a college degree or greater compared with participants who had not completed high school. There were also significant associations between educational attainment and multiple TGP mediators from the sexual division of power and the structure of cathexis. TGP constructs did not mediate the association between educational attainment and laboratory-confirmed STI. The current study suggests that graduating from college may lead to a beneficial reduction in vulnerability to STIs/HIV among African-American women. Findings from this study support expanding structural-level interventions, emphasizing both high school and college graduation, as a means of reducing vulnerability to STIs/HIV among African-American women.

Parents, peers and pornography: the influence of formative sexual scripts on adult HIV sexual risk behaviour among Black men in the USA

Black men in the USA experience disproportionately high rates of HIV infection, particularly in the Southeastern part of the country. We conducted 90 qualitative in-depth interviews with Black men living in the state of Georgia and analysed the transcripts using Sexual Script Theory to: (1) characterise the sources and content of sexual scripts that Black men were exposed to during their childhood and adolescence and (2) describe the potential influence of formative scripts on adult HIV sexual risk behaviour. Our analyses highlighted salient sources of cultural scenarios (parents, peers, pornography, sexual education and television), interpersonal scripts (early sex- play, older female partners, experiences of child abuse) and intrapsychic scripts that participants described. Stratification of participant responses based on sexual-risk behaviour revealed that lower- and higher-risk men described exposure to similar scripts during their formative years; however, lower-risk men reported an ability to cognitively process and challenge the validity of risk-promoting scripts that they encountered. Implications for future research are discussed.

Efficacy of HIV/STI behavioral interventions for heterosexual African American men in the United States: a meta-analysis

This meta-analysis estimates the overall efficacy of HIV prevention interventions to reduce HIV sexual risk behaviors and sexually transmitted infections (STIs) among heterosexual African American men. A comprehensive search of the literature published during 1988-2008 yielded 44 relevant studies. Interventions significantly reduced HIV sexual risk behaviors and STIs. The stratified analysis for HIV sexual risk behaviors indicated that interventions were efficacious for studies specifically targeting African American men and men with incarceration history. In addition, interventions that had provision/referral of medical services, male facilitators, shorter follow-up periods, or emphasized the importance of protecting family and significant others were associated with reductions in HIV sexual risk behaviors. Meta-regression analyses indicated that the most robust intervention component is the provision/referral of medical services. Findings indicate that HIV interventions for heterosexual African American men might be more efficacious if they incorporated a range of health care services rather than HIV/STI-related services alone.

Social and sexual network characteristics and concurrent sexual partnerships among urban African American high-risk women with main sex partners

Social networks, including sexual networks, have increasingly been considered in research addressing HIV disparities in the United States. The goal of this study is to examine correlates of concurrent involvement in multiple sexual partnerships with social (i.e., non-sexual) and sexual network characteristics among a sample of 337 low-income urban African American women reporting main sexual partnerships longer than 6 months in duration. In the multivariate analyses, women who had larger non-sexual social networks, more family members in that network, and reported high levels of trust in their partner(s) were less likely to be in concurrent partnerships. Women who had one or more sexual partner who used drugs in the past 6 months were more likely to be in concurrent partnerships. Our results provide further evidence of the important association of drug use and concurrent sexual partnerships, but suggest that family members, immediate and extended, may be an important area of focus in addition to structural interventions that address the root causes of poverty and drug abuse.

HIV risk perception and preexposure prophylaxis interest among a heterosexual population visiting a sexually transmitted infection clinic

Low perception of HIV risk despite behaviors associated with increased risk is thought to be a contributing factor for a higher prevalence of HIV in blacks than other groups in the United States. We sought to determine HIV risk perception and its impact on safer sex practices and interest in preexposure prophylaxis (PrEP). From August 1 to October 31, 2010, an anonymous survey was conducted at a sexually transmitted infection clinic asking questions about demographics, risk behaviors, and PrEP interest. Participants were categorized into high-risk, moderate-risk, and low-risk groups according to predefined HIV risk characteristics. Only heterosexual high-risk participants were further assessed for their risk perception, condom use and PrEP interest. There were 494 participants; 63% male, 70% blacks, 88% heterosexual; 83% were categorized into the high-risk group. Of the 359 heterosexual high-risk participants, 301 (84%) perceived themselves at no or low-risk. Rates of consistent condom use with vaginal, oral, and anal sex were low (<20%) in this group despite high levels of knowledge about HIV transmission risks. Rates of condom use were not affected by risk perception. No interest in PrEP was associated with low education level (adjusted odds ratio 4.97; p=0.02) and low risk perception. These findings suggest that despite having knowledge about HIV transmission risks, the majority of high-risk participants did not recognize their risks and used condoms with low frequency. Low risk perception and low education level may impact PrEP interest. Enhanced interventions are needed to improve HIV risk perception, safer sex practices, and knowledge about PrEP.

A County-Level Examination of the Relationship Between HIV and Social Determinants of Health: 40 States, 2006-2008

BACKGROUND

Social determinants of health (SDH) are the social and physical factors that can influence unhealthy or risky behavior. Social determinants of health can affect the chances of acquiring an infectious disease - such as HIV - through behavioral influences and limited preventative and healthcare access. We analyzed the relationship between social determinants of health and HIV diagnosis rates to better understand the disparity in rates between different populations in the United States.

METHODS

Using National HIV Surveillance data and American Community Survey data at the county level, we examined the relationships between social determinants of health variables (e.g., proportion of whites, income inequality) and HIV diagnosis rates (averaged for 2006-2008) among adults and adolescents from 40 states with mature name-based HIV surveillance.

RESULTS

Analysis of data from 1,560 counties showed a significant, positive correlation between HIV diagnosis rates and income inequality (Pearson correlation coefficient ρ = 0.40) and proportion unmarried - ages >15 (ρ = 0.52). There was a significant, negative correlation between proportion of whites and rates (ρ = -0.67). Correlations were low between racespecific social determinants of health indicators and rates.

CONCLUSIONS/IMPLICATIONS

Overall, HIV diagnosis rates increased as income inequality and the proportion unmarried increased, and rates decreased as proportion of whites increased. The data reflect the higher HIV prevalence among non-whites. Although statistical correlations were moderate, identifying and understanding these social determinants of health variables can help target prevention efforts to aid in reducing HIV diagnosis rates. Future analyses need to determine whether the higher proportion of singles reflects higher populations of gay and bisexual men.

Racial/ethnic and gender differences among older adults in nonmonogamous partnerships, time spent single, and human immunodeficiency virus testing

BACKGROUND

A higher frequency of nonmonogamy, due in part to lower marriage prevalence, may contribute to elevated human immunodeficiency virus (HIV)/sexually transmitted disease rates among older blacks.

METHODS

To examine race and gender differences in nonmonogamy, time spent single (i.e., not married or cohabiting), and HIV testing in older adults, we analyzed US population-based data from the 2005-2006 National Social Life, Health, and Aging Project for 2825 heterosexual participants ages 57 to 85 years.

RESULTS

Blacks spent greater portions of their adult lives single than did Hispanics or whites and were far more likely to report recent nonmonogamous partnerships (23.4% vs. 10.0% and 8.2%). Among individuals reporting sex in the prior 5 years, nonmonogamous partnerships were strongly associated with time spent single during the period. Control for time spent single and other covariates reduced the association of black race with nonmonogamous partnerships for men, but increased it for women. Less than 20% reported ever testing for HIV; less than 6% had been recommended testing by a provider. Testing rates, highest in black men and white women, differed little by history of nonmonogamous partnerships within gender strata.

CONCLUSIONS

Singlehood helps to explain higher nonmonogamous partnership rates in older black men but not in older black women. Older adults rarely receive or are recommended HIV testing, a key strategy for reducing heterosexual HIV transmission.

Collection of social determinant of health measures in U.S. national surveillance systems for HIV, viral hepatitis, STDs, and TB

Challenges exist in the study of social determinants of health (SDH) because of limited comparability of population-based U.S. data on SDH. This limitation is due to differences in disparity or equity measurements, as well as general data quality and availability. We reviewed the current SDH variables collected for HIV, viral hepatitis, sexually transmitted diseases, and tuberculosis at the Centers for Disease Control and Prevention through its population-based surveillance systems and assessed specific system attributes. Results were used to provide recommendations for a core set of SDH variables to collect that are both feasible and useful. We also conducted an environmental literature scan to determine the status of knowledge of SDH as underlying causes of disease and to inform the recommended core set of SDH variables.

HIV/AIDS knowledge scores and perceptions of risk among African American students attending historically black colleges and universities

OBJECTIVE

African American young adults are disproportionately affected by the HIV/AIDS epidemic and often unaware of their personal risk for HIV. Historically black colleges and universities (HBCUs) enroll 25% of college-educated African American young adults and can play an important role in HIV prevention. We examined HIV/AIDS knowledge of students at HBCUs to inform and strengthen our HIV prevention efforts at HBCUs.

METHODS

African American undergraduate HBCU students completed online surveys assessing HIV/AIDS knowledge and behaviors, and we analyzed data to assess their knowledge and behaviors.

RESULTS

A total of 1,051 of 1,230 surveys completed (85.4%) were analyzable. Eighty-two percent of students had average/high HIV knowledge scores. Seventy-nine percent of students surveyed perceived themselves to be at low risk for HIV infection; 64% of those who had at least two or more sex partners had not used a condom at last sex encounter. In the final model, significant independent effects were identified for average/high knowledge of HIV risk, including agreeing with assessing a potential partner's HIV risk by all of the five actions listed (adjusted odds ratio [AOR] = 2.7, 95% confidence interval [CI] 1.7, 4.3) and never using a needle to inject drugs (AOR=5.6, 95% CI 3.2, 9.7).

CONCLUSIONS

Educating students about effectively assessing sex partner risk will improve HIV knowledge and prevention efforts at HBCUs.

The relative role of perceived partner risks in promoting condom use in a three-city sample of high-risk, low-income women

We examined the effect of women’s perceptions of sexual partner risks on condom use. Women from three US cities (n = 1,967) were recruited to provide data on HIV risks. In univariate models, increased odds of condom use were associated with perceiving that partners had concurrent partners and being unaware of partners': (a) HIV status, (b) bisexuality, (c) concurrency; and/or (d) injection drug use. In multivariate models, neither being unaware of the four partner risk factors nor perceiving a partner as being high risk was associated with condom use. Contextual factors associated with decreased odds of condom use were having sex with a main partner, homelessness in the past year, alcohol use during sex, and crack use in the past 30 days. Awareness of a partner’s risks may not be sufficient for increasing condom use. Contextual factors, sex with a main partner in particular, decrease condom use despite awareness of partner risk factors.

Examining racial/ethnic disparities in sexually transmitted diseases among recent heroin-using and cocaine-using women

BACKGROUND

This study examined racial differences in the prevalence of sexual risk behaviors and their associations with sexually transmitted diseases (STDs) among recent heroin-using and cocaine-using women.

METHODS

Participants were 214 women (59% black, 41% white) who were recruited during 2002-2010 using targeted sampling to participate in a study in Baltimore, Maryland, and reported using heroin, cocaine, or crack during the previous 6 months. Participants completed self-report questionnaires about their drug use, sexual risk behaviors, and lifetime history of one of six STDs, including gonorrhea, syphilis, chlamydia, genital herpes, genital warts, or trichomoniasis.

RESULTS

More black women (50%) than white women (28%) reported a lifetime STD. Although there were no racial differences in the lifetime prevalence of sexual risk behaviors assessed, there were racial differences in the sexual behaviors associated with ever having a lifetime STD. Simple logistic regressions revealed that ever having a casual sex partner or anal sex were correlates of having a lifetime STD among black women but not among white women. Multiple logistic regression analyses revealed that ever having a casual sex partner was significantly associated with having a lifetime STD among black women, and ever trading sex for money was significantly associated with having a lifetime STD among white women.

CONCLUSIONS

Findings are consistent with national studies and elucidate racial disparities in STDs and associated sexual behaviors among recent heroin-using and cocaine-using women. Findings underscore the need to tailor STD prevention interventions differently for black and white recent heroin-using and cocaine-using women.

Structural interventions for HIV prevention in the United States

BACKGROUND

Structural interventions change the environment in which people act to influence their health behaviors. Most structural interventions research for HIV infection has focused on developing countries, with the United States receiving substantially less attention. This article identifies some social determinants of HIV vulnerability in the United States and structural interventions to address them.

METHODS

Review of the medical, public health, and social science literature.

RESULTS

Evidence supports widespread implementation of a number of structural interventions in the United States clearly proximate to HIV, including comprehensive sex education, universal condom availability, expanded syringe access for drug users, health care coverage, and stable housing. Sociological plausibility supports evaluation and implementation of other interventions that target social determinants more distal but of relevance to HIV, such as initiatives to eliminate racial and ethnic disparities in criminal sentencing, to promote early childhood education and to decrease poverty.

CONCLUSIONS

Structural interventions that address social determinants of HIV infection may be among the most cost effective methods of preventing HIV infection in the United States over the long term.

High HIV prevalence and diagnosis rates in New York City black men

We sought to identify population and subpopulation disparities in rates of HIV diagnosis and prevalence among black males 13 years and older in New York City. We used population-based data from the New York City HIV/AIDS surveillance registry and US Census 2000 to calculate HIV prevalence in 2006 and HIV diagnosis rates in 2007. Black males were the largest demographic group of new HIV diagnoses (n = 1,161, 33%) and persons living with HIV/AIDS in New York City (n = 24,294, 29%) and had the highest diagnosis rates (1.7 per 1,000 population) and prevalence (3.7%). Prevalence and diagnosis rates among black males were higher in higher-poverty neighborhoods than in lower-poverty neighborhoods (p < 0.01). However, very high prevalence (19.3%) was found among black males in three adjacent Manhattan neighborhoods with relatively low poverty rates, and where overall diagnosis rates among black males (7.4 per 1,000) and proportions attributable to men who have sex with men (60.0%) were high. HIV-related disparities exist not only between black males and other groups but also within black males. Success addressing the citywide HIV epidemic will be linked to success in the various portions of this highly affected, heterogeneous population.

Racial and ethnic disparities in sexual risk behaviors and STDs during young men's transition to adulthood

CONTEXT

Racial and ethnic health disparities are an important issue in the United States. The extent to which racial and ethnic differences in STDs among youth are related to differences in socioeconomic characteristics and risky sexual behaviors requires investigation.

METHODS

Data from three waves of the National Survey of Adolescent Males (1988, 1990-1991 and 1995) were used to examine 1,880 young men's history of STDs and their patterns and trajectories of sexual risk behavior during adolescence and early adulthood. Multinomial and logistic regression analyses were conducted to test whether racial and ethnic differences in STDs are due to the lower socioeconomic status and higher levels of risky sexual behavior among minority groups.

RESULTS

Young black men reported the highest rates of sexual risk and STDs at each wave and across waves. Compared with white men, black and Latino men had higher odds of maintaining high sexual risk and increasing sexual risk over time (odds ratios, 1.7-1.9). In multivariate analyses controlling for socioeconomic characteristics, black men were more likely than white men to have a history of STDs (3.2-5.0); disparities persisted in analyses controlling for level of risky sexual behavior.

CONCLUSIONS

Race and ethnicity continue to differentiate young black and Latino men from their white peers in terms of STDs. Prevention programs that target different racial and ethnic subgroups of adolescent men and address both individual- and contextual-level factors are needed to curb STD incidence.

It's not just who you are but where you live: an exploration of community influences on individual HIV status in rural Malawi

Approximately 1 million people are infected with Human Immunodeficiency Virus (HIV) in Malawi. Despite efforts aimed at changing individual risk behaviors, HIV prevalence continues to rise among rural populations. Both previous research and the Political Economy of Health framework suggest that community-based socio-economic factors and accessibility may influence HIV transmission; however, these community factors have received little empirical investigation. To fill this gap, this research uses data from a nationally representative probability sample of rural Malawians combined with small area estimates of community socio-economic and accessibility data in logistic regression models to: 1) reveal relationships between community factors and individual HIV status; 2) determine whether these relationships operate through individual HIV risk behaviors; and 3) explore whether these associations vary by gender. Community socio-economic factors include relative and absolute poverty; community accessibility factors include distance to roads, cities, and public health facilities. Individual HIV risk behaviors include reported condom use, sexually transmitted infections, multiple partnerships, and paid sex. Results show that higher community income inequality, community proximity to a major road, and community proximity to a public health clinic are associated with increased odds of HIV for women. For men, community proximity to a major road and community proximity to a public health clinic are associated with increased odds of HIV infection. These direct relationships between community factors and individual HIV status are not mediated by individual HIV risk behaviors. The Political Economy of Health frames the discussion. This study provides evidence for expanding HIV prevention efforts beyond individual risk behaviors to consideration of community factors that may drive the HIV epidemic in rural Malawi.