Disparities in sexually transmitted disease rates across the "eight Americas"

Census Tract-Level Social Vulnerability and Gonorrhea Rates in Central Ohio: Results From the STD Surveillance Network, 2020-2021

BACKGROUND

Gonorrhea remains a significant burden in central Ohio, particularly in socially disadvantaged communities. This study evaluates gonorrhea case rates and changes from 2020 to 2021, focusing on geographic patterns associated with social vulnerability.

METHODS

We analyzed gonorrhea case data from the Columbus STD Surveillance Network for 2020 and 2021. Cases were linked to census tracts and categorized into low (0-0.66) or high (0.67-1.0) vulnerability groups based on the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry Social Vulnerability Index (SVI). We mapped gonorrhea case rates per 100,000 population, stratified by SVI group, and compared changes using Jenks natural breaks to determine cutpoints. High case rates were defined as ≥605 (2020) and ≥532 (2021). A change in case rates was defined as <154 (decrease/no change) or ≥154 (increase). Demographic factors were summarized for both years.

RESULTS

In 2020 and 2021, nearly half of high-SVI tracts had high gonorrhea rates, compared with about 4% to 7% of low-SVI tracts. Median rates in high-SVI tracts were approximately 5 times higher than in low-SVI tracts, with rates of 546 and 598 per 100,000 in 2020 and 2021, compared with 98 and 104 per 100,000, respectively. Gonorrhea rates increased in 23 (9%) of low-SVI tracts and 37 (25%) of high-SVI tracts. Demographic characteristics remained consistent between the 2 years.

CONCLUSIONS

Gonorrhea rates increased in central Ohio between 2020 and 2021, with higher burdens in high-SVI census tracts. Understanding the dynamics of social vulnerability at the community level is crucial for targeting limited STD resources effectively.

Behaviors associated with HIV transmission risk among rural sexual and gender minority and majority residents

Multiple rural states and communities experience elevated rates of human immunodeficiency virus (HIV), often associated with diminished healthcare access and increased drug use. Though a substantial proportion of rural populations are sexual and gender minorities (SGM), little is known of this group regarding substance use, healthcare utilization, and HIV transmission behaviors. During May-July 2021, we surveyed 398 individuals across 22 rural Illinois counties. Participants included cisgender heterosexual males (CHm) and females (CHf) (n = 110); cisgender non-heterosexual males and females (C-MSM and C-WSW; n = 264); and transgender individuals (TG; n = 24). C-MSM participants were more likely to report daily-to-weekly alcohol and illicit drug use prescription medication misuse (versus CHf; aOR = 5.64 [2.37-13.41], 4.42 [1.56-12.53], and 29.13 [3.80-223.20], respectively), and C-MSM participants more frequently reported traveling to meet with romantic/sex partners. Further, more C-MSM and TG than C-WSW reported healthcare avoidance and denial due to their orientation/identity (p < 0.001 and p = 0.011, respectively); 47.6% of C-MSM and 58.3% of TG had not informed their provider about their orientation/identity; and only 8.6% of C-MSM reported ever receiving a pre-exposure prophylaxis (PrEP) recommendation. More work is needed to explore the substance use and sexual behaviors of rural SGM, as well as their healthcare interactions, to better target health and PrEP engagement campaigns.

It Is Not Just the Southeast-Geographically Pervasive Racial Disparities in Neisseria gonorrhoeae Between Non-Hispanic Black and White US Women

Background:

Spatial analyses of gonorrhea morbidity among females often highlight the southeastern US but may not provide information on geographic variation in the magnitude of racial disparities; such maps also focus on geographic space, obscuring underlying population characteristics. We created a series of visualizations depicting both county-level racial disparities in female gonorrhea diagnoses and variations in population size.

Methods:

We calculated county- and region-level race-specific relative rates (RelR) and between-race rate differences (RD) and rate ratios (RR) comparing gonorrhea case rates in non-Hispanic Black (NHB) vs non-Hispanic White (NHW) females. We then created proportional symbol maps with color representing counties’ RelR/RD/RR category and symbol size representing counties’ female population.

Results:

Gonorrhea rates among NHB females were highest in the Midwest (718.7/100,000) and West (504.8), rates among NHW females were highest in the West (74.1) and Southeast (72.1). RDs were highest in the Midwest (654.6 excess cases/100,000) and West (430.7), while RRs were highest in the Northeast (12.4) and Midwest (11.2). Nearly all US counties had NHB female rates ≥3x those in NHW females, with NHB females in most highly populated counties experiencing ≥9-fold difference in gonorrhea rates.

Conclusions:

Racial disparities in gonorrhea were not confined to the Southeast; both relative and absolute disparities were equivalent or larger in magnitude in areas of the Northeast, Midwest, and West. Our findings help counter damaging regional stereotypes, provide evidence to refocus prevention efforts to areas of highest disparities, and suggest a useful template for monitoring racial disparities as an actionable public health metric.

Racial disparities in female gonorrhea rates are not confined to the Southeast; both relative and absolute disparities are equivalent or larger in areas of the Northeast, Midwest, and West.

County-Level Chlamydia and Gonorrhea Rates by Social Vulnerability, United States, 2014-2018

ABSTRACT

We examined mean chlamydia and gonorrhea case rates from 2014 to 2018 by categorizing US counties by social vulnerability. Overall, these rates were approximately 1.0 to 2.4 times higher in high vulnerability counties than low vulnerability counties. Percentage change in case rates from low to high social vulnerability counties varied by sex, geographic region, and urbanicity.

Factors Associated with Syphilis Transmission and Acquisition Among Men Who Have Sex with Men (MSM): Protocol for a Multi-Site Egocentric Network Study (Preprint)

BACKGROUND

In the United States, the rates of primary and secondary syphilis have increased more rapidly among men who have sex with men (MSM) than among any other subpopulation. Rising syphilis rates among MSM reflect changes in both individual behaviors and the role of sexual networks (eg, persons linked directly or indirectly by sexual contact) in the spread of the infection. Decades of research examined how sexual networks influence sexually transmitted infections (STIs) among MSM; however, few longitudinal data sources focusing on syphilis have collected network characteristics. The Centers for Disease Control and Prevention, in collaboration with 3 sites, enrolled a prospective cohort of MSM in 3 US cities to longitudinally study sexual behaviors and STIs, including HIV, for up to 24 months.

OBJECTIVE

The Network Epidemiology of Syphilis Transmission (NEST) study aimed to collect data on the factors related to syphilis transmission and acquisition among MSM.

METHODS

The NEST study was a prospective cohort study that enrolled 748 MSM in Baltimore, Maryland; Chicago, Illinois; and Columbus, Ohio. NEST recruitment used a combination of convenience sampling, venue-based recruitment, and respondent-driven sampling approaches. At quarterly visits, participants completed a behavioral questionnaire and were tested for syphilis, HIV, gonorrhea, and chlamydia. The participants also provided a list of their sexual partners and described their 3 most recent partners in greater detail.

RESULTS

The NEST participants were enrolled in the study from July 2018 to December 2021. At baseline, the mean age of the participants was 31.5 (SD 9.1) years. More than half (396/727. 54.5%) of the participants were non-Hispanic Black, 29.8% (217/727) were non-Hispanic White, and 8.8% (64/727) were Hispanic or Latino. Multiple recruitment strategies across the 3 study locations, including respondent-driven sampling, clinic referrals, flyers, and social media advertisements, strengthened NEST participation. Upon the completion of follow-up visits in March 2022, the mean number of visits per participant was 5.1 (SD 3.2; range 1-9) in Baltimore, 2.2 (SD 1.6; range 1-8) in Chicago, and 7.2 (SD 2.9; range 1-9) in Columbus. Using a community-based participatory research approach, site-specific staff were able to draw upon collaborations with local communities to address stigma concerning STIs, particularly syphilis, among potential NEST participants. Community-led efforts also provided a forum for staff to describe the NEST study objectives and plans for research dissemination to the target audience. Strategies to bolster data collection during the COVID-19 pandemic included telehealth visits (all sites) and adaptation to self-collection of STI specimens (Baltimore only).

CONCLUSIONS

Data from NEST will be used to address important questions regarding individual and partnership-based sexual risk behaviors among MSM, with the goal of informing interventions to prevent syphilis in high-burden areas.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/40095.

Variation in Patterns of Racial and Ethnic Disparities in Primary and Secondary Syphilis Diagnosis Rates Among Heterosexually Active Women by Region and Age Group in the United States

BACKGROUND

Syphilis rates have increased substantially over the past decade. Women are an important population because of negative sequalae and adverse maternal outcomes including congenital syphilis. We assessed whether racial and ethnic disparities in primary and secondary (P&S) syphilis among heterosexually active women differ by region and age group.

METHODS

We synthesized 4 national surveys to estimate numbers of heterosexually active women in the United States from 2014 to 2018 by region, race and ethnicity, and age group (18-24, 25-29, 30-44, and ≥45 years). We calculated annual P&S syphilis diagnosis rates, assessing disparities with rate differences and rate ratios comparing White, Hispanic, and Black heterosexually active women.

RESULTS

Nationally, annual rates were 6.42 and 2.20 times as high among Black and Hispanic than among White heterosexually active women (10.99, 3.77, and 1.71 per 100,000, respectively). Younger women experienced a disproportionate burden of P&S syphilis and the highest disparities. Regionally, the Northeast had the highest Black-White and Hispanic-White disparities using a relative disparity measure (relative rate), and the West had the highest disparities using an absolute disparity measure (rate difference).

CONCLUSIONS

To meet the racial and ethnic disparity goals of the Sexually Transmitted Infections National Strategic Plan, tailored local interventions that address the social and structural factors associated with disparities are needed for different age groups.

Access to Contraceptives in School-Based Health Centers: Progress and Opportunities

INTRODUCTION

The U.S. has a higher adolescent pregnancy rate than other industrialized countries. School-based health centers can improve access to contraceptives among youth, which can prevent unplanned pregnancies. This cross-sectional study examines the characteristics and predictors of contraceptive provision at school-based health centers in 2016-2017 and changes in and barriers to provision between 2001 and 2017.

METHODS

In 2020-2021, the authors conducted analyses of the National School-Based Health Care Census data collected from 2001 to 2017. The primary outcome of interest was whether adolescent-serving school-based health centers dispense contraceptives, and a secondary outcome of interest was the policies that prohibit school-based health centers from dispensing contraceptives. A multivariate regression analysis examined the associations between contraceptive provision and various covariates, including geographic region, years of operation, and provider team composition.

RESULTS

Less than half of adolescent-serving school-based health centers reported providing contraceptives on site. Those that provided contraceptives were more likely located in the Western and Northeastern regions of the U.S., older in terms of years of operation, and staffed by a wide variety of health provider types. Among school-based health centers that experienced policy barriers to providing access to contraceptive methods, most attributed the source to the school or school district where the school-based health center was located.

CONCLUSIONS

School-based health centers are an evidence-based model for providing contraceptives to adolescents but not enough are providing direct access. Understanding the predictors, characteristics, and barriers influencing the provision of contraceptives at school-based health centers may help to expand the number doing so.

Improving Sexual Health in U.S. Rural Communities: Reducing the Impact of Stigma

Sexually transmitted infections (STI), including HIV, are among the most reported diseases in the U.S. and represent some of America's most significant health disparities. The growing scarcity of health care services in rural settings limits STI prevention and treatment for rural Americans. Local health departments are the primary source for STI care in rural communities; however, these providers experience two main challenges, also known as a double disparity: (1) inadequate capacity and (2) poor health in rural populations. Moreover, in rural communities the interaction of rural status and key determinants of health increase STI disparities. These key determinants can include structural, behavioral, and interpersonal factors, one of which is stigma. Engaging the expertise and involvement of affected community members in decisions regarding the needs, barriers, and opportunities for better sexual health is an asset and offers a gateway to sustainable, successful, and non-stigmatizing STI prevention programs.

Sexually Transmitted Infection Epidemiology and Care in Rural Areas: A Narrative Review

BACKGROUND

Although rural areas contain approximately 19% of the US population, little research has explored sexually transmitted infection (STI) risk and how urban-developed interventions may be suitable in more population-thin areas. Although STI rates vary across rural areas, these areas share diminishing access to screening and limited rural-specific testing of STI interventions.

METHODS

This narrative review uses a political ecology model of health and explores 4 domains influencing STI risk and screening: epidemiology, health services, political and economic, and social. Articles describing aspects of rural STI epidemiology, screening access and use, and intervention utility within these domains were found by a search of PubMed.

RESULTS

Epidemiology contributes to risk via multiple means, such as the presence of increased-risk populations and the at-times disproportionate impact of the opioid/drug use epidemic. Rural health services are diminishing in quantity, often have lesser accessibility, and may be stigmatizing to those needing services. Local political and economic influences include funding decisions, variable enforcement of laws/statutes, and systemic prevention of harm reduction services. Social norms such as stigma and discrimination can prevent individuals from seeking appropriate care, and also lessen individual self-efficacy to reduce personal risk.

CONCLUSIONS

Sexually transmitted infection in rural areas is significant in scope and facing diminished prevention opportunities and resources. Although many STI interventions have been developed and piloted, few have been tested to scale or operationalized in rural areas. By considering rural STI risk reduction within a holistic model, purposeful exploration of interventions tailored to rural environments may be explored.

Collateral Damage: A Narrative Review on Epidemics of Substance Use Disorders and Their Relationships to Sexually Transmitted Infections in the United States

ABSTRACT

Associations between substance use disorders and outbreaks of HIV and acute viral hepatitis have received considerable attention, but less research has focused on links between substance use disorders and sexually transmitted infections, apart from alcohol misuse. This narrative review describes the history of this public health crisis in the United States and direct and indirect effects opioids and specific stimulants have on high-risk sexual behaviors. We also review the epidemiology of sexually transmitted infections associated with opioids and stimulants in the United States and discuss opportunities for integrated interventions.

Investigating the Impact of Using an Alternate Classification Method for Race and Hispanic Ethnicity on Rates of Reported Gonorrhea

BACKGROUND

We aimed to examine how the classification of gonorrhea cases by race and Hispanic ethnicity (HE) affects the measurement of racial/HE disparities in the rates of reported gonorrhea.

METHODS

We examined gonorrhea cases reported through the National Notifiable Diseases Surveillance System from January 1, 2010, to December 31, 2017, and assigned race and HE using (1) "current classification," where cases with HE are classified as Hispanic regardless of race (e.g., Hispanic, non-Hispanic White, and non-Hispanic Black), and 2) "alternate classification," which separates each race category by HE (e.g., Hispanic White and non-Hispanic White). We estimated annual gonorrhea rates during 2010 to 2017 by race/HE category and calculated disparity measures (index of disparity, population-attributable proportion, and Gini coefficient) for gonorrhea rates under each classification strategy.

RESULTS

All disparity measures revealed decreases in racial/HE disparities in the rates of reported gonorrhea during 2010 to 2017, regardless of classification strategy; however, the magnitude of the disparity and the percent change in the disparity over time varied across disparity measures.

CONCLUSIONS

Understanding how classification of race/HE affects observed disparities is critical when monitoring interventions to reduce disparities and improve health equity.

Sexually transmitted disease clinics in the United States: Understanding the needs of patients and the capabilities of providers

Reports of bacterial sexually transmitted infections are at the highest levels ever reported in the United States, and state and local budgetary issues are placing specialized sexually transmitted disease (STD) care at risk. This study collected information from 4138 patients seeking care at 26 STD clinics in large metropolitan areas across the United States with high levels of reported STDs to determine patient needs and clinic capabilities. Surveys were provided to patients attending these STD clinics to assess their demographic information as well as reasons for coming to the clinic and surveys were also provided to clinic administrators to determine their operational capacities and services provided by the clinic. For this initial study, we conducted univariate analyses to report all data collected from these surveys. Patients attending STD clinics across the country indicated that they do so because of the relative ease of getting an appointment; including walk-in and same-day appointments as well as the welcoming environment and expertise of the staff at the clinic. Additionally, STD clinics provide specialized care to patients; including HIV testing and counseling as well as on-site, injectable medications for the treatment of gonorrhea and syphilis in an environment that helps to reduce the role of stigma in seeking this kind of care. Sexually transmitted disease clinics continue to play an important role in helping to curb the rising epidemic of sexually transmitted infections.

Mapping Geographical Patterns and High Rate Areas for Sexually Transmitted Infections in Portugal: A Retrospective Study Based on the National Epidemiological Surveillance System

OBJECTIVE

Monitoring disease variation using finer scales to identify high-rate communities is a critical aspect for precision public health and for efficient resource allocation. This study aimed to map the spatial patterns of chlamydia, gonorrhea, and syphilis; identify high-rate areas across Portuguese municipalities; and determine the association of these sexually transmitted infections (STIs) with socioeconomic deprivation, urbanicity level, and population density.

METHODS

The STI notifications at municipality level for the period 2015 to 2017 were obtained from Portugal's Epidemiologic Surveillance System (Sistema Nacional de Vigilância Epidemiológica). Spatial Bayesian models were used to calculate smoothed standardized notification rates, identify high- and low-rate areas and estimate associations (relative risk [RR], 95% credible intervals [95%CrI]).

RESULTS

There were 4819 cases of chlamydia, gonorrhea, and syphilis reported, accounting for 15.3%, 33.2%, and 51.5% of the notifications, respectively. The STI notification rates were substantially higher in Porto and Lisbon Metropolitan Areas and concentrically disperse around those. Notification rates of the 3 STIs were strongly correlated (r > 0.8). Rates of gonorrhea (Q1-lowest density vs. Q5-highest RR, 2.10; 95% CrI, 1.08-4.25) and syphilis (RR, 3.16; 95% CrI, 2.00-5.13) were associated with population density. Notifications of chlamydia (Q1-least urban vs. Q5-most RR, 9.64; 95% CrI, 1.73-93.59) and syphilis (RR, 1.92; 95% CrI, 1.30-2.88) increased with urbanicity level. We also found that notification rates of gonorrhea were associated with socioeconomic deprivation (Q1-least vs. Q5-most deprived RR, 1.75; 95% CrI, 1.07-2.88).

CONCLUSIONS

Wide spatial inequalities in STI notification rates were observed, which were predominantly concentrated in the 2 metropolitan areas of the country. Our findings can help guide more targeted interventions to reduce STIs incidence.

The Potential Population-Level Impact of Different Gonorrhea Screening Strategies in Baltimore and San Francisco: An Exploratory Mathematical Modeling Analysis

BACKGROUND

Baltimore and San Francisco represent high burden areas for gonorrhea in the United States. We explored different gonorrhea screening strategies and their comparative impact in the 2 cities.

METHODS

We used a compartmental transmission model of gonorrhea stratified by sex, sexual orientation, age, and race/ethnicity, calibrated to city-level surveillance data for 2010 to 2017. We analyzed the benefits of 5-year interventions which improved retention in care cascade or increased screening from current levels. We also examined a 1-year outreach screening intervention of high-activity populations.

RESULTS

In Baltimore, annual screening of population aged 15 to 24 years was the most efficient of the 5-year interventions with 17.9 additional screening tests (95% credible interval [CrI], 11.8-31.4) needed per infection averted while twice annual screening of the same population averted the most infections (5.4%; 95% CrI, 3.1-8.2%) overall with 25.3 (95% CrI, 19.4-33.4) tests per infection averted. In San Francisco, quarter-annual screening of all men who have sex with men was the most efficient with 16.2 additional (95% CrI, 12.5-44.5) tests needed per infection averted, and it also averted the most infections (10.8%; 95% CrI, 1.2-17.8%). Interventions that reduce loss to follow-up after diagnosis improved outcomes. Depending on the ability of a short-term outreach screening to screen populations at higher acquisition risk, such interventions can offer efficient ways to expand screening coverage.

CONCLUSIONS

Data on gonorrhea prevalence distribution and time trends locally would improve the analyses. More focused intervention strategies could increase the impact and efficiency of screening interventions.

Adolescent Chlamydia Rates by Region, Race, and Sex: Trends From 2013 to 2017

INTRODUCTION

Chlamydia is the most common bacterial sexually transmitted infection in the United States. Adolescents (ages 15-19 years) have the highest infection rate, second only to young adults (ages 20-24 years). The purpose of this secondary data analysis is to examine trends from 2013 to 2017 in adolescent chlamydia rates by region, race, and sex.

METHOD

Adolescent chlamydia rate data were obtained from the Center for Disease Control's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention database. Descriptive statistics were used to analyze the trends.

RESULTS

The overall trend in male and female adolescent chlamydia rates increased from 2013 to 2017. Specifically, the trend increased faster in males, White adolescents, and those in the Northeast and Midwest regions of the country.

DISCUSSION

Health care providers are uniquely positioned to positively affect adolescent chlamydia rates through targeted sexual health discussions and increased screening for sexually transmitted infections.

Racial and Ethnic Disparities in Reproductive Health Services and Outcomes, 2020

Racial and ethnic disparities in women's health have existed for decades, despite efforts to strengthen women's reproductive health access and utilization. Recent guidance by the American College of Obstetricians and Gynecologists (ACOG) underscores the often unacknowledged and unmeasured role of racial bias and systemic racial injustice in reproductive health disparities and highlights a renewed commitment to eliminating them. Reaching health equity requires an understanding of current racial-ethnic gaps in reproductive health and a concerted effort to develop and implement strategies to close gaps. We summarized national data for several reproductive health measures, such as contraceptive use, Pap tests, mammograms, maternal mortality, and unintended pregnancies, by race-ethnicity to inform health-equity strategies. Studies were retrieved by systematically searching the PubMed (2010-2020) electronic database to identify most recently published national estimates by race-ethnicity (non-Hispanic Black or African American, Hispanic or Latinx, and non-Hispanic White women). Disparities were found in each reproductive health category. We describe relevant components of the Affordable Care Act (ACA) and the Preventing Maternal Deaths Act, which can help to further strengthen reproductive health care, close gaps in services and outcomes, and decrease racial-ethnic reproductive health disparities. Owing to continued diminishment of certain components of the ACA, to optimally reach reproductive health equity, comprehensive health insurance coverage is vital. Strengthening policy-level strategies, along with ACOG's heightened commitment to eliminating racial disparities in women's health by confronting bias and racism, can strengthen actions toward reproductive health equity.

Dual-Method Contraception Use Among Young Women Pre- and Post-ACA Implementation

The 2012 implementation of the Patient Protection and Affordable Care Act (ACA) contraceptive coverage mandate removed financial barriers to contraception access for many insured women. Since that time, increases in sexually transmitted disease (STD) rates have been noted, particularly among Black adolescent and young adult women aged 15 to 24 years. It is unclear whether changes in dual-method contraception use (simultaneous use of nonbarrier contraceptive methods and condoms) are associated with the increase in STD rates. A repeated cross-sectional analysis was conducted among adolescent and young adult women to compare pre-ACA data from the 2006-2010 cohort and post-ACA data from the 2013-2015 cohort of the National Survey for Family Growth. A significant decrease in short-acting reversible contraception use (SARC; 78.2% vs. 67.5%; p < .01) and a significant increase in long-acting reversible contraception use (LARC; 8.9% vs. 21.8%; p < .01) were found, but no significant change in dual-method contraception use was found among pre- versus post-ACA SARC users and SARC nonusers (odds ratio [OR]: 1.88, 95% confidence interval [CI]: 0.64-5.46, p = .25), LARC users and LARC nonusers (adjusted odds ratio [AOR]: 1.62, 95% CI: 0.42-6.18, p = .48), or White and Black women (AOR: 1.45, 95% CI: 0.66-3.18, p = .35). There was no direct association between changes in contraception use and decreased condom use and therefore no indirect association between changes in contraception use and increased STD rates. Health care providers should continue promoting consistent condom use. Additional research is needed to understand recent increases in STD rates among Black women in the post-ACA era.

Stability of the vaginal, oral, and gut microbiota across pregnancy among African American women: the effect of socioeconomic status and antibiotic exposure

OBJECTIVE

A growing body of research has investigated the human microbiota and pregnancy outcomes, especially preterm birth. Most studies of the prenatal microbiota have focused on the vagina, with fewer investigating other body sites during pregnancy. Although pregnancy involves profound hormonal, immunological and metabolic changes, few studies have investigated either shifts in microbiota composition across pregnancy at different body sites or variation in composition at any site that may be explained by maternal characteristics. The purpose of this study was to investigate: (1) the stability of the vaginal, oral, and gut microbiota from early (8-14 weeks) through later (24-30 weeks) pregnancy among African American women according to measures of socioeconomic status, accounting for prenatal antibiotic use; (2) whether measures of socioeconomic status are associated with changes in microbiota composition over pregnancy; and (3) whether exposure to prenatal antibiotics mediate any observed associations between measures of socioeconomic status and stability of the vaginal, oral, and gut microbiota across pregnancy.

METHODS

We used paired vaginal, oral, or gut samples available for 16S rRNA gene sequencing from two time points in pregnancy (8-14 and 24-30 weeks) to compare within-woman changes in measures of alpha diversity (Shannon and Chao1) and beta-diversity (Bray-Curtis dissimilarity) among pregnant African American women (n = 110). Multivariable linear regression was used to examine the effect of level of education and prenatal health insurance as explanatory variables for changes in diversity, considering antibiotic exposure as a mediator, adjusting for age, obstetrical history, and weeks between sampling.

RESULTS

For the oral and gut microbiota, there were no significant associations between measures of socioeconomic status or prenatal antibiotic use and change in Shannon or Chao1 diversity. For the vaginal microbiota, low level of education (high school or less) was associated with an increase in Shannon and Chao1 diversity over pregnancy, with minimal attenuation when controlling for prenatal antibiotic use. Conversely, for within-woman Bray-Curtis dissimilarity for early compared to later pregnancy, low level of education and prenatal antibiotics were associated with greater dissimilarity for the oral and gut sites, with minimal attenuation when controlling for prenatal antibiotics, and no difference in dissimilarity for the vaginal site.

CONCLUSIONS

Measures of maternal socioeconomic status are variably associated with changes in diversity across pregnancy for the vaginal, oral, and gut microbiota, with minimal attenuation by prenatal antibiotic exposure. Studies that evaluate stability of the microbiota across pregnancy in association with health outcomes themselves associated with socioeconomic status (such as preterm birth) should incorporate measures of socioeconomic status to avoid finding spurious relationships.

Recent Changes in Prevention Funding to Areas With High Racial and Ethnic Disparities in Sexually Transmitted Disease Rates

We examined changes in federal sexually transmitted disease funding allocations to areas with high racial/ethnic disparities in sexually transmitted diseases after the implementation of a funding formula in 2014. The funding formula increased prevention funding allocations to areas with high relative racial/ethnic disparities. Results were mixed for areas with high absolute disparities.

Unraveling Race, Socioeconomic Factors, and Geographical Context in the Heterogeneity of Lupus Mortality in the United States

Objective

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease disproportionately affecting women and racial/ethnic minorities. We examined SLE-related mortality over time to assess whether the impact of race is attenuated when social economic status (SES) and geographic context are also considered.

Methods

This study examined whether social environment attenuates racial disparities in SLE-related mortality using race-geographical combinations of the US population known as the "Eight Americas." This framework jointly characterizes race, SES, and geographical location in relation to health disparities in the United States. Using National Vital Statistics and US Census data, we estimated mortality parameters for each of the Eight Americas.

Results

We identified 24 773 SLE deaths (2003-2014). Average annual mortality rates were highest among blacks in three race-geographical contexts: average-income blacks, southern low-income blacks, and high-risk urban blacks (14 to 15 deaths per million population) and lowest among nonblacks living in average-income settings (3 to 4 deaths per million population). Age at death was lowest (~47.5 years) for blacks and Asians and highest among low-income rural whites (~64.8 years).

Conclusion

Blacks sharing the same social and geographical contexts as whites were disproportionately more likely to die young. Although blacks inhabited three vastly different contexts, SLE-related mortality parameters did not vary among socially advantaged and disadvantaged blacks. These findings suggest that race may transcend SES and geographical parameters as a key determinant of SLE-related mortality.

The Impact of Screening and Partner Notification on Chlamydia Prevalence and Numbers of Infections Averted in the United States, 2000-2015: Evaluation of Epidemiologic Trends Using a Pair-Formation Transmission Model

Population-level effects of control strategies on the dynamics of Chlamydia trachomatis transmission are difficult to quantify. In this study, we calibrated a novel sex- and age-stratified pair-formation transmission model of chlamydial infection to epidemiologic data in the United States for 2000–2015. We used sex- and age-specific prevalence estimates from the National Health and Nutrition Examination Surveys, case report data from national chlamydia surveillance, and survey data from the Youth Risk Behavior Survey on the proportion of the sexually active population aged 15–18 years. We were able to reconcile national prevalence estimates and case report data by allowing for changes over time in screening coverage and reporting completeness. In retrospective analysis, chlamydia prevalence was estimated to be almost twice the current levels in the absence of screening and partner notification. Although chlamydia screening and partner notification were both found to reduce chlamydia burden, the relative magnitude of their estimated impacts varied in our sensitivity analyses. The variation in the model predictions highlights the need for further data collection and research to improve our understanding of the natural history of chlamydia and the pathways through which prevention strategies affect transmission dynamics.

Resilience attenuates the association between neurocognitive functioning and everyday functioning in individuals aging with HIV in the Deep South

OBJECTIVES

Adults aging with HIV are at risk for poorer neurocognitive and daily functioning. Identifying factors to protect such outcomes is a significant research priority. The aim of this study was to explore the role of resilience in cognitive and everyday functioning in a largely African American and low socioeconomic status sample of adults and older adults with HIV in the Deep South.

METHODS/DESIGN

In this cross-sectional study 100 HIV+ middle-aged and older adults (range 40-73; 61% aged 50+) completed a comprehensive neurocognitive battery along with self-reported measures of resilience and everyday functioning.

RESULTS

Higher resilience was associated with better global neurocognitive functioning (rho = 0.31, P < 0.01), as well as better functioning in all domains (verbal fluency, executive functioning, speed of information processing, learning, working memory) except recall and motor skills. Resilience was also significantly associated with instrumental activities of daily living (IADL) dependence, with lower resilience observed in those with IADL dependence compared with those who were IADL independent (P < 0.01). In a multiple regression adjusting for data-driven covariates (verbal IQ, income, depression), and global neurocognitive impairment, resilience was the only significant (P = 0.02) correlate of IADL dependence. A follow-up mediation showed that the direct relationship between neurocognitive functioning and IADL declines was fully attenuated after accounting for shared variance with resilience.

CONCLUSIONS

Resilience is associated with better cognitive and functional outcomes in people aging with HIV. While further work is needed to understand these associations over time, results suggest interventions to build resilience may promote successful aging in this vulnerable population.

Sexually transmitted infections in the Delta Regional Authority: significant disparities in the 252 counties of the eight-state Delta Region Authority

OBJECTIVE

Chlamydia, gonorrhoea and syphilis (primary and secondary) are at high levels in the USA. Disparities by race, gender and sexual orientation have been characterised, but while there are indications that rural poor populations may also be at distinct risk this has been subjected to little study by comparison. The federally designated Delta Regional Authority, similar in structure to the Appalachian Regional Commission, oversees 252 counties within eight Mississippi Delta states experiencing chronic economic and health disparities. Our objective was to identify differences in infection risk between Delta Region (DR)/non-DR counties and examine how they might vary by rurality, population density, primary care access and education attainment.

METHODS

Reported chlamydia/gonorrhoea/syphilis data were obtained from the Centers for Disease Control and Prevention AtlasPlus, county demographic data from the Area Health Resource File and rurality classifications from the Department of Agriculture. Data were subjected to analysis by t-test, χ² and linear regression to assess geographical disparities in incidence and their association with measures of rurality, population and primary care density, and education.

RESULTS

Overall rates for each infection were significantly higher in DR versus non-DR counties (577.8 vs 330.1/100 000 for chlamydia; 142.8 vs 61.8 for gonorrhoea; 3.6 vs 1.7 for syphilis; all P<0.001) and for nearly every infection for every individual state. DR rates for each infection were near-universally significantly increased for every level of rurality (nine levels) and population density (quintiles). Regression found that primary care and population density and HS graduation rates were significantly associated with each, though model predictive abilities were poor.

CONCLUSIONS

The nearly 10 million people living in the DR face significant disparities in the incidence of chlamydia, gonorrhoea and syphilis-in many instances a near-doubling of risk. Our findings suggest that resource-constrained areas, as measured by rurality, should be considered a priority for future intervention efforts.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Using Reported Rates of Sexually Transmitted Diseases to Illustrate Potential Methodological Issues in the Measurement of Racial and Ethnic Disparities

BACKGROUND

Racial disparities in the burden of sexually transmitted diseases (STDs) have been documented and described for decades. Similarly, methodological issues and limitations in the use of disparity measures to quantify disparities in health have also been well documented. The purpose of this study was to use historic STD surveillance data to illustrate four of the most well-known methodological issues associated with the use of disparity measures.

METHODS

We manually searched STD surveillance reports to find examples of racial/ethnic distributions of reported STDs that illustrate key methodological issues in the use of disparity measures. The disparity measures we calculated included the black-white rate ratio, the Index of Disparity (weighted and unweighted by subgroup population), and the Gini coefficient.

RESULTS

The 4 examples we developed included illustrations of potential differences in relative and absolute disparity measures, potential differences in weighted and nonweighted disparity measures, the importance of the reference point when calculating disparities, and differences in disparity measures in the assessment of trends in disparities over time. For example, the gonorrhea rate increased for all minority groups (relative to whites) from 1992 to 1993, yet the Index of Disparity suggested that racial/ethnic disparities had decreased.

CONCLUSIONS

Although imperfect, disparity measures can be useful to quantify racial/ethnic disparities in STDs, to assess trends in these disparities, and to inform interventions to reduce these disparities. Our study uses reported STD rates to illustrate potential methodological issues with these disparity measures and highlights key considerations when selecting disparity measures for quantifying disparities in STDs.

The Influence of Childhood Adversity on Rural Black Men's Sexual Risk Behavior

BACKGROUND

Young Black men living in resource-poor rural environments are disproportionately affected by both adverse childhood experiences and HIV/STIs. The influence of childhood adversity on sexual risk behavior remains to be examined among this vulnerable population.

PURPOSE

In this study, we investigated the influence of overall adversity as well as three subcomponents, abusive parenting, parental neglect, and witnessing family violence, on men's engagement in sexual risk behavior. We hypothesized that adverse experiences would predict engagement in sexual risk behaviors including multiple sexual partnerships, inconsistent condom use, frequent sexual activity, and concurrent substance abuse and sexual activity. We tested formally the extent to which defensive relational schemas mediated these associations.

METHODS

Hypotheses were tested with data from 505 rural Black men (M age = 20.29, SD = 1.10) participating in the African American Men's Health Project. Participants were recruited using respondent-driven sampling. Self-report data were gathered from participants via audio computer-assisted self-interviews.

RESULTS

Bi-factor analyses revealed that, in addition to a common adversity factor, neglect independently predicted sexual risk behavior. Men's defensive relational schemas partially mediated the influence of the common adversity factor as well as the neglect subcomponent on sexual risk behavior.

CONCLUSIONS

The present research identified a potential risk factor for sexual risk behavior in an understudied and vulnerable population. Adverse childhood experiences in general, and neglect in particular, may place many young Black men at risk for engaging in sexual risk behavior due in part to the influence of these experiences on men's development of relational schemas characterized by defensiveness and mistrust.

Testing a Computerized Cognitive Training Protocol in Adults Aging With HIV-Associated Neurocognitive Disorders: Randomized Controlled Trial Rationale and Protocol

Background

HIV-associated neurocognitive disorders occur in nearly 50% of adults with HIV. Such disorders can interfere with everyday functioning such as driving and medication adherence. Therefore, cognitive interventions are needed to address such neurocognitive disorders as well as improve everyday functioning, especially as people age with HIV.

Objective

This article reports and discusses the overall rationale and development of speed of processing training, a computerized Internet cognitive training program, to improve this specific neurocognitive ability as well as everyday functioning and quality of life in adults aging with HIV. Although this protocol has been shown to improve speed of processing, everyday functioning, and quality of life in healthy, community-dwelling older adults in the advanced cognitive training in vital elderly (ACTIVE) study, its efficacy in adults aging with HIV has not been established. Nevertheless, such a cognitive intervention is particularly germane as 52%-59% of adults with HIV experience HIV-associated neurocognitive disorders (HAND), and both the frequency and severity of such disorders may increase with advancing age.

Methods

The description of this longitudinal randomized controlled trial covers the following: (1) rationale for speed of processing training in this clinical population, (2) overview of overall study design, (3) eligibility criteria and HAND, (4) intervention dosage, (5) assessment battery, and (6) examination of biomarkers.

Results

The project was funded in April 2016 and enrolment is on-going. The first results are expected to be submitted for publication in 2020.

Conclusions

Similar novel cognitive intervention approaches are suggested as they may be of value to those with HAND and may utilize similar features of this current randomized controlled trial (RCT) protocol to examine their therapeutic efficacy.

Trial Registration

ClinicalTrials.gov NCT02758093; https://clinicaltrials.gov/ct2/show/NCT02758093 (Archived by Webcite at http://www.webcitation.org/6p8C5fBCX)

Correlates of county-level nonviral sexually transmitted infection hot spots in the US: application of hot spot analysis and spatial logistic regression

PURPOSE

We used a combination of hot spot analysis (HSA) and spatial regression to examine county-level hot spot correlates for the most commonly reported nonviral sexually transmitted infections (STIs) in the 48 contiguous states in the United States (US).

METHODS

We obtained reported county-level total case rates of chlamydia, gonorrhea, and primary and secondary (P&S) syphilis in all counties in the 48 contiguous states from national surveillance data and computed temporally smoothed rates using 2008-2012 data. Covariates were obtained from county-level multiyear (2008-2012) American Community Surveys from the US census. We conducted HSA to identify hot spot counties for all three STIs. We then applied spatial logistic regression with the spatial error model to determine the association between the identified hot spots and the covariates.

RESULTS

HSA indicated that ≥84% of hot spots for each STI were in the South. Spatial regression results indicated that, a 10-unit increase in the percentage of Black non-Hispanics was associated with ≈42% (P < 0.01) [≈22% (P < 0.01), for Hispanics] increase in the odds of being a hot spot county for chlamydia and gonorrhea, and ≈27% (P < 0.01) [≈11% (P < 0.01) for Hispanics] for P&S syphilis. Compared with the other regions (West, Midwest, and Northeast), counties in the South were 6.5 (P < 0.01; chlamydia), 9.6 (P < 0.01; gonorrhea), and 4.7 (P < 0.01; P&S syphilis) times more likely to be hot spots.

CONCLUSION

Our study provides important information on hot spot clusters of nonviral STIs in the entire United States, including associations between hot spot counties and sociodemographic factors.

Trends in Selected Measures of Racial and Ethnic Disparities in Gonorrhea and Syphilis in the United States, 1981-2013

BACKGROUND

The purpose of this study was to examine selected measures of racial and ethnic disparities in the reported incidence of syphilis and gonorrhea from 1981 to 2013 in the United States.

METHODS

For each year, from 1981 to 2013, we calculated values for 5 disparity measures (Gini coefficient, 2 versions of the index of disparity, population attributable proportion, and the black-to-white rate ratio) for 5 racial/ethnic categories (non-Hispanic white, non-Hispanic black, Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander). We also examined annual and 5-year changes to see if the disparity measures agreed on the direction of change in disparity.

RESULTS

With a few exceptions, the disparity measures increased from 1981 to 1993 and decreased from 1993 to 2013, whereas syphilis and gonorrhea rates decreased for most groups from 1981 to 1993 and increased from 1993 to 2013. Overall, the disparity measures we examined were highly correlated with one another, particularly when examining 5-year changes rather than annual changes in disparity. For example, all 5 measures agreed on the direction of change in the disparity of syphilis in 56% of the annual comparisons and in 82% of the 5-year comparisons.

CONCLUSIONS

Although the disparity measures we examined were generally consistent with one another, these measures can sometimes yield divergent assessments of whether racial/ethnic disparities are increasing or decreasing for a given sexually transmitted disease from one point in time to another, as well as divergent assessments of the relative magnitude of the change.

Community-Based Assessment to Inform a Chlamydia Screening Program for Women in a Rural American Indian Community

BACKGROUND

Rates of chlamydial infection in American Indian/Alaska Native women in the United States are approximately 4-fold those in non-Hispanic white women. We conducted a community-based survey of self-identified American Indian/Alaska Native women 14 to 25 years of age on a reservation in the Northwestern United States to inform a chlamydia screening strategy.

METHODS

The anonymous survey assessed respondents' knowledge, perceptions, and preferences related to chlamydia screening, results receipt, and partner notification. We recruited women using respondent-driven sampling, school-based sampling, and direct recruitment through social media and fliers. Participants in schools completed the survey as a paper-based, self-administered survey. Other participants could complete the survey in person, by phone as an interviewer-administered survey, or online.

RESULTS

We recruited 162 participants, most in schools (n = 83; 51%) or by peer referral (n = 55; 34%). Only 1 woman completed the survey online. Thirty-one respondents (19%) reported a history of an unplanned first pregnancy, and 19 (12%) reported a history of a diagnosed sexually transmitted disease. Most women (n = 98; 63%) recognized the potential impact of Chlamydia trachomatis on fertility. The preferred site for chlamydia screening was the Indian Health Service Clinic (n = 114; 70%), but 79 women (41%) would accept a C. trachomatis test at a nonclinical testing site. Of the 56 women (35%) who would accept home testing, most preferred to get the test kit from a clinic.

CONCLUSIONS

Our results suggest that Indian Health Service efforts to increase chlamydia screening in the clinic and through outreach may be more successful than promotion of home testing in this population.

HIV Infection Among People Who Inject Drugs in the United States: Geographically Explained Variance Across Racial and Ethnic Groups

OBJECTIVES

We explored how variance in HIV infection is distributed across multiple geographical scales among people who inject drugs (PWID) in the United States, overall and within racial/ethnic groups.

METHODS

People who inject drugs (n = 9077) were recruited via respondent-driven sampling from 19 metropolitan statistical areas (MSAs) for the Centers for Disease Control and Prevention's 2009 National HIV Behavioral Surveillance system. We used multilevel modeling to determine the percentage of variance in HIV infection explained by zip codes, counties, and MSAs where PWID lived, overall and for specific racial/ethnic groups.

RESULTS

Collectively, zip codes, counties, and MSAs explained 29% of variance in HIV infection. Within specific racial/ethnic groups, all 3 scales explained variance in HIV infection among non-Hispanic/Latino White PWID (4.3%, 0.2%, and 7.5%, respectively), MSAs explained variance among Hispanic/Latino PWID (10.1%), and counties explained variance among non-Hispanic/Latino Black PWID (6.9%).

CONCLUSIONS

Exposure to potential determinants of HIV infection at zip codes, counties, and MSAs may vary for different racial/ethnic groups of PWID, and may reveal opportunities to identify and ameliorate intraracial inequities in exposure to determinants of HIV infection at these geographical scales.

Neighborhoods at risk: estimating risk of higher Neisseria gonorrhoeae incidence among women at the census tract level

BACKGROUND

The association between area-based social factors and sexually transmitted diseases has been demonstrated in numerous studies. Such associations have not previously been explored for their potential to quantify likelihood of higher transmission of gonorrhea in small geographic areas.

METHODS

Aggregate census tract-level sociodemographic factors in 4 domains (demographics, educational attainment, household income, and housing characteristics) were merged with female gonorrhea incidence data from 113 counties in 10 US states. Multivariate models were constructed, and a tract-level composite gonorrhea risk index was calculated. This composite risk index was validated against gonorrhea incidence among women from 2 independent states.

RESULTS

Seven tract-level factors were found to be most strongly correlated with female gonorrhea incidence: educational attainment, proportion of female headed households, annual household income below US $20,000, proportion of population non-Hispanic black, proportion of housing units currently vacant, proportion of population reporting moving in last year, and proportion of households that are nonfamily units. Composite index was highly correlated with female gonorrhea in the study area and validated with independent data.

CONCLUSIONS

Social factors predict gonorrhea incidence at the census tract level and identify small areas at risk for higher morbidity. These data may be used by health departments and health care practices to develop geographically based disease prevention and control efforts. This is especially useful because gonorrhea incidence data are not routinely available below the county level in many states.