The burden of stomach cancer mortality by county, race, and ethnicity in the USA, 2000-2019: a systematic analysis of health disparities

Background

There are persistent disparities in stomach cancer mortality among racial-ethnic groups in the USA, but the extent to which these patterns vary geographically is not well understood. This analysis estimated age-standardised mortality for five racial-ethnic groups, in 3110 USA counties over 20 years, to describe spatial-temporal variations in stomach cancer mortality and disparities between racial-ethnic groups.

Methods

Redistribution methods for insufficient cause of death codes and validated small area estimation methods were applied to death registration data from the US National Vital Statistics System and population data from the US National Center for Health Statistics to estimate annual stomach cancer mortality rates. Estimates were stratified by county and racial-ethnic group (non-Latino and non-Hispanic [NL] American Indian or Alaska Native [AIAN], NL Asian or Pacific Islander [Asian], NL Black [Black], Latino or Hispanic [Latino], and NL White [White]) from 2000 to 2019. Estimates were corrected for misreporting of racial-ethnic group on death certificates using published misclassification ratios. We masked (ie, did not display) estimates for county and racial-ethnic group combinations with a mean annual population of less than 1000; thus, we report estimates for 3079 (of 3110) counties for the total population, and 474, 667, 1488, 1478, and 3051 counties for the AIAN, Asian, Black, Latino, and White populations, respectively.

Findings

Between 2000 and 2019, national age-standardised stomach cancer mortality was lowest among the White population in every year. Nationally, stomach cancer mortality declined for all racial-ethnic groups across this time period, with the most rapid declines occurring among the Asian (percent decline 48.3% [45.1-51.1]) and Black populations (42.6% [40.2-44.6]). Mortality among the other racial-ethnic groups declined more moderately, decreasing by 36.7% (35.3-38.1), 35.1% (32.2-37.7), and 31.6% (23.9-38.0) among the White, Latino, and AIAN populations, respectively. Similar patterns were observed at the county level, although with wide geographic variation. In 2019, a majority of counties had higher mortality rates among minoritised racial-ethnic populations compared to the White population: 81.1% (377 of 465 counties with unmasked estimates for both racial-ethnic groups) among the AIAN population, 88.2% (1295 of 1469) among the Latino population, 99.4% (663 of 667) among the Asian population, and 99.9% (1484 of 1486) among the Black population. However, the size of these disparities ranged widely across counties, with the largest range from 0.3 to 17.1 among the AIAN population.

Interpretation

Stomach cancer mortality has decreased substantially across populations and geographies in the USA. However, disparities in stomach cancer mortality among racial-ethnic groups are widespread and have persisted over the last two decades. Local-level data are crucial to understanding the scope of this unequal burden among minoritised groups in the USA.

Funding

National Institute on Minority Health and Health Disparities; National Heart, Lung, and Blood Institute; National Cancer Institute; National Institute on Aging; National Institute of Arthritis and Musculoskeletal and Skin Diseases; Office of Disease Prevention; and Office of Behavioral and Social Sciences Research, National Institutes of Health (contract #75N94019C00016).

The geographic reach of community-based organizations in addressing HIV-related stigma in the Deep South

Community-based organizations (CBOs) have been instrumental in addressing the needs of people living with HIV, however, little is known about their efforts to address HIV-related stigma through stigma reduction efforts. This study examined practices of CBOs related to mitigating HIV-related stigma in nine Deep South states. CBOs were surveyed as part of a larger study through the Gilead COMPASS Initiative. The CBO survey asked CBO leadership about stigma in their communities and services available to address this stigma. Survey respondents (n = 207) indicated that HIV-related stigma was perceived as a substantial barrier to both HIV care and CBO services. Although just over two-thirds of survey participants reported that there were group-level programs to address HIV-related stigma, 73% reported that there were not enough interventions to meet the need in their community. Further, 68% reported a lack of individual-level stigma reduction interventions. A majority reported a lack of public media campaigns to address stigma and a lack of training available to assist CBOs to address stigma. In addition, services to address stigma were reportedly less available in rural areas compared to their urban counterparts. Study findings indicate a need to identify, implement, and scale-up effective interventions to reduce HIV stigma in the US Deep South.

Measuring Unmet Needs among Persons Living with HIV at Different Stages of the Care Continuum

Unmet needs can impede optimal care engagement, impacting the health and well-being of people living with HIV (PLWH); yet, whether unmet needs differ by care engagement status is not well understood. Using surveys and qualitative interviews, we examined and compared unmet needs for PLWH (n = 172) at different levels of care engagement. Unmet needs varied only slightly by care status. Survey findings revealed that provision of housing, emergency financial assistance, employment assistance, and food security were the greatest unmet need; for those in care, housing was the greatest unmet need, whereas for those sporadically in care or out of care, employment assistance was the greatest unmet needs. Qualitative interviews likewise illustrated that a lack of financial resources including insurance, housing, employment, and transportation presented barriers to care engagement across all care groups. Our findings indicate that unmet needs among PLWH are complex and multi-faceted across care engagement status.

Validation of the HIV Pre-exposure Prophylaxis Stigma Scale: Performance of Likert and Semantic Differential Scale Versions

Stigma regarding HIV pre-exposure prophylaxis (PrEP) is commonly implicated as a factor limiting the scale-up of this highly effective HIV prevention modality. To quantify and characterize PrEP stigma, we developed and validated a brief HIV PrEP Stigma Scale (HPSS) among a group of 279 men who have sex with men (MSM). Scale development was informed by a theoretical model to enhance content validity. We assessed two scale versions, Semantic Differential and Likert, randomizing the order in which scales were presented to participants. Both scales demonstrated high internal consistency. The Likert scale had substantially better construct validity and was selected as the preferred option. Scale scores demonstrated construct validity through association with constructs of interest: healthcare distrust, HIV knowledge, perceived proportion of friends/partners on PrEP, perceived community evaluation of PrEP, and perceived effectiveness of PrEP. The scale accounted for 25% of the total variance in reported willingness to be on PrEP, indicating the substantial role PrEP stigma may have on decisions to initiate PrEP. Given increased efforts to roll-out PrEP, having a valid tool to determine the level and types of PrEP stigma in individuals, groups, and communities can help direct implementation plans, identify goals for stigma reduction, and monitor progress over time.

Small-area spatial-temporal changes in pre-exposure prophylaxis (PrEP) use in the general population and among men who have sex with men in the United States between 2012 and 2018

PURPOSE

Oral emtricitabine/tenofovir disoproxil fumarate was approved for use as pre-exposure prophylaxis (PrEP) by the U.S. Food and Drug Administration in 2012. We used national pharmacy data to examine trends of PrEP use in U.S. counties from 2012 to 2018.

METHODS

Using multi-level small-area spatio-temporal modeling, we calculated the estimated annual percentage change (EAPC) in prevalence of PrEP use in the general population from 2012 to 2018. We also used a proxy measure for prevalence of PrEP use among men who have sex with men (MSM) to evaluate trends of use among MSM, the PrEP use-to-MSM ratio (PmR) or number of male PrEP users per 1000 MSM population.

RESULTS

The prevalence of PrEP use and PmR increased (EAPC range: (+26.9%, +71.0%) and (+28.4%, +158.7%), respectively) in all counties with varying magnitude of increase. Counties of the Midwest and the upper South and upper West had the slowest increase in prevalence of PrEP use (EAPC range: (+26.9%; +52.9%)). Counties of the northern part of the South had the lowest PmR (EAPC range: (+28.4%; +76.0%)). Counties of the most populous core-based statistical areas had a relatively faster increase in population prevalence of PrEP use but slower increase in PmR.

CONCLUSIONS

All counties in the U.S. have witnessed an increase in PrEP use with important geographic variabilities. Identifying areas with slow improvement in PrEP use, as well as "model counties" with the fastest pace of progress in PrEP coverage, is critical to inform local and state-level policies and program evaluation for PrEP scale up, particularly among MSM at higher risk for HIV.

Policy- and county-level associations with HIV pre-exposure prophylaxis use, the United States, 2018

PURPOSE

HIV pre-exposure prophylaxis (PrEP) is highly efficacious, and yet most individuals indicated for it are not currently using it. To provide guidance for health policymakers, researchers, and community advocates, we developed county-level PrEP use estimates and assessed locality and policy associations.

METHODS

Using data from a national aggregator, we applied a validated crosswalk procedure to generate county-level estimates of PrEP users in 2018. A multilevel Poisson regression explored associations between PrEP use and (1) state policy variables of Medicaid expansion and state Drug Assistance Programs (PrEP-DAPs) and (2) county-level characteristics from the U.S. Census Bureau. Outcomes were PrEP per population (prevalence) and PrEP-to-need ratio (PnR), defined as the ratio of PrEP users per new HIV diagnosis. Higher levels of PrEP prevalence or PnR indicate more PrEP users relative to the total population or estimated need, respectively.

RESULTS

Our 2018 county-level data set included a total of 188,546 PrEP users in the United States. Nationally, PrEP prevalence was 70.3/100,000 population and PnR was 4.9. In an adjusted model, counties with a 5% higher proportion of black residents had 5% lower PnR (rate ratio (RR): 0.95, 95% confidence interval (CI): 0.93, 0.96). Similarly, counties with higher concentration of residents uninsured or living in poverty had lower PnR. Relative to states without Medicaid expansion or PrEP-DAPs, states with only one of those programs had 25% higher PrEP prevalence (RR: 1.25, 95% CI: 1.09, 1.45), and states with both programs had 99% higher PrEP prevalence (RR: 1.99, 95% CI: 1.60, 2.48). There was a significant linear trend across the three policy groups, and similar findings for the relation between PnR and the policy groups.

CONCLUSIONS

In a data set comprising approximately 80% of PrEP users in the United States, we found that Medicaid expansion and PrEP-DAPs were associated with higher PrEP use in states that adopted those policies, after controlling for potential confounders. Future research should identify which components of PrEP support programs have the most success and how to best promote PrEP among groups most impacted by the epidemic. States should support the admirable health decisions of their residents to get on PrEP by implementing policies that facilitate access.

Methods for county-level estimation of pre-exposure prophylaxis coverage and application to the U.S. Ending the HIV Epidemic jurisdictions

PURPOSE

Pre-exposure prophylaxis (PrEP) is a pillar of the US Department of Health and Human Services "Ending the HIV Epidemic" (EHE) initiative in 50 EHE jurisdictions (48 U.S. counties and two U.S. cities) and seven U.S. states with high numbers of HIV diagnoses rates in rural areas. Current data systems do not provide data on PrEP uptake in counties or cities.

METHODS

We report on PrEP users at the county level. Data from a large, commercial pharmacy database were used; we applied the U.S. Census Bureau's method to allocate PrEP users within a ZIP3 into counties and validated the results. We report counts and rates of PrEP users in 2018 for all EHE jurisdictions. We used joinpoint regression to model the estimated annual percent change in PrEP use for each jurisdiction and state.

RESULTS

93,156 people in the 50 EHE jurisdictions used PrEP in 2018; 94% were men and 39% were aged 25-34 years. There was more than an 80-fold difference in the range of rates of PrEP use per 100,000 population among the EHE jurisdictions (range: 8-644 per 100,000 population; median 93 per 100,000 population). PrEP use increased from 2012 to 2018 in all EHE counties and states. At current rates of growth of PrEP use, 94% of EHE counties and jurisdictions will reach their National HIV/AIDS Strategy goals of a 500% increase in PrEP use in 2020. EHE states had less variation in rates of PrEP use (range: 29-51/100,000 population; median 32/100,000 population).

CONCLUSIONS

At the outset of a major U.S. government program to reduce HIV infections, rates of PrEP use are highly variable among the 50 EHE jurisdictions. Data from commercial prescription databases will be a useful public resource to understand progress in promoting use of PrEP as part of the EHE initiative and evaluating progress in PrEP use across health jurisdictions.

High-Sensitive Troponin T, Natriuretic Peptide, and Cognitive Change

OBJECTIVES

Cardiac troponin T, measured using a high-sensitive assay (hs-cTnT), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are associated with increased stroke risk and perhaps with cognitive decline. However, few well-designed prospective studies with extended follow-up have been conducted. We aimed to estimate the association of hs-cTnT and NT-proBNP with 15-year cognitive change in the Atherosclerosis Risk in Communities (ARIC) study.

DESIGN

Prospective cohort study.

SETTING

Four US communities.

PARTICIPANTS

A total of 9114 and 9108 participants from the Atherosclerosis Risk in Communities study for analyses of hs-cTnT and NT-proBNP, respectively.

MEASUREMENTS

We examined association of hs-cTnT and NT-proBNP with 15-year change (1996-1998 to 2011-2013) in three cognitive tests of executive function (Digit Symbol Substitution Test), verbal learning memory (Delayed Word Recall Test), and semantic fluency (Word Fluency Test), and an overall score combining the three tests using multivariable linear mixed effect models. We conducted several sensitivity analyses including multiple imputations to address bias due to missing data and attrition, and we compared associations within groups combining hs-cTnT and NT-proBNP into a three-level categorical variable.

RESULTS

At baseline (1996-1998), mean age was 63.4 (standard deviation [SD] = 5.7) years; 56.4% were women, and 17.5% were black. The hs-cTnT at baseline was not associated with cognitive change in any measure. Some evidence indicated accelerated decline in verbal learning and memory when comparing those in the highest with the lowest NT-proBNP quintiles; however, this association was not replicated when considering clinically relevant cutoffs or deciles of exposure in survivors. Sensitivity analyses were consistent with our primary analyses. There was little evidence to support effect modification by any considered factors. People with highest levels of both biomarkers had excessive decline in global z scores vs people with lowest levels (-.34; 95% confidence interval = -.63 to -.04).

CONCLUSION

Markers of myocardial injury and stretch were not associated with cognitive decline following 15 years among survivors, but when combined together they were suggestive in post hoc analysis. Whether this represents targets of intervention should be examined in the future. J Am Geriatr Soc 67:2353-2361, 2019.

ApoB, small-dense LDL-C, Lp(a), LpPLA2 activity, and cognitive change

OBJECTIVE

To examine the association of specific lipoproteins/inflammatory enzyme with cognitive change.

METHODS

We examined the association of apolipoprotein B (ApoB), small-dense low-density lipoprotein cholesterol (sdLDL-C), lipoprotein (a) (Lp[a]), and lipoprotein-associated phospholipase A2 (LpPLA2) activity with 15-year change in Delayed Word Recall Test, Digit Symbol Substitution Test (DSST), Word Fluency Test (WFT), and overall summary score in 9,350 participants in the Atherosclerosis Risk in Communities study. We assessed interaction by race, sex, education, APOE ε4 status, and statin use. We also addressed questions of informative missingness, the role of stroke, and the influence of fasting status.

RESULTS

The mean (SD) age was 63.4 (5.7) years; 56.4% were women and 17.4% were black. We observed faster cognitive decline on DSST and global z scores with every 10-mg/dL higher sdLDL-C level (Δ DSST z score, -0.010; 95% confidence interval [CI] -0.017, -0.002 and Δ global z score, -0.011; -0.021, -0.001) and the highest vs the lowest ApoB quintiles (Δ DSST z score, -0.092; -0.0164, -0.019 and Δ global z score, -0.101; -0.200, -0.002). Association for the ApoB quintiles with Δ global z score (-0.10) was comparable with that of having 1 APOE ε4 allele (-0.11). Higher Lp(a) was associated with slower decline in DSST, WFT, and global z scores. LpPLA2 activity was not associated with cognitive change. Results were similar in sensitivity analyses. The associations of sdLDL-C or Lp(a) on cognitive change were more pronounced in statin users.

CONCLUSIONS

Optimal control of atherogenic lipoproteins such as ApoB and sdLDL-C in midlife for cardiovascular health may also benefit late-life cognitive health.

Location location location: an exploration of disparities in access to publicly listed pre-exposure prophylaxis clinics in the United States

PURPOSE

HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission. Finding a PrEP provider, however, can be a barrier to accessing care. This study explores the distribution of publicly listed PrEP-providing clinics in the United States.

METHODS

Data regarding 2094 PrEP-providing clinics come from PrEP Locator, a national database of PrEP-providing clinics. We compared the distribution of these PrEP clinics to the distribution of new HIV diagnoses within various geographical areas and by key populations.

RESULTS

Most (43/50) states had less than one PrEP-providing clinic per 100,000 population. Among states, the median was two clinics per 1000 PrEP-eligible men who have sex with men. Differences between disease burden and service provision were seen for counties with higher proportions of their residents living in poverty, lacking health insurance, identifying as African American, or identifying as Hispanic/Latino. The Southern region accounted for over half of all new HIV diagnoses but only one-quarter of PrEP-providing clinics.

CONCLUSIONS

The current number of PrEP-providing clinics is not sufficient to meet needs. In addition, PrEP-providing clinics are unevenly distributed compared to disease burden, with poor coverage in the Southern divisions and areas with higher poverty, uninsured, and larger minority populations. PrEP services should be expanded and targeted to address disparities.

Trends in the use of oral emtricitabine/tenofovir disoproxil fumarate for pre-exposure prophylaxis against HIV infection, United States, 2012-2017

PURPOSE

Pre-exposure prophylaxis (PrEP) with oral emtricitibine/tenofovir disoproxil fumarate (TDF/FTC) reduces the risk of HIV infection by >90% when taken as prescribed. Trends in prevalence of PrEP use, which account for persons who have stopped PrEP, increased through 2016, but have not been described since.

METHODS

Annual prevalence estimates of unique, TDF/FTC PrEP users (individuals with ≥1 day of a filled PrEP prescription in a given year) in the United States (US) were generated for 2012-2017 from a national prescription database. A validated algorithm was used to distinguish users of TDF/FTC for HIV or chronic Hepatitis B treatment or postexposure prophylaxis from PrEP users. We calculated annual prevalence of PrEP use overall and by age, sex, and region. We used log-transformation to calculate estimated annual percent change (EAPC) in the prevalence of PrEP use.

RESULTS

Annual prevalence of PrEP use increased from 3.3/100,000 population in 2012 to 36.7 in 2017 -a 56% annual increase from 2012 to 2017 (EAPC: +56%). Annual prevalence of PrEP use increased faster among men than among women (EAPC: +68% and +5%, respectively). By age group, annual prevalence of PrEP use increased fastest among 25- to 34-year olds (EAPC: +61%) and slowest among ≥55-year olds (EAPC: +52%) and ≤24-year olds (EAPC: +51%). In 2017, PrEP use was lowest in the South (29.8/100,000) and highest in the Northeast (62.3/100,000).

CONCLUSIONS

Despite overall increases in the annual number of TDF/FTC PrEP users in the US from 2012 to 2017, the growth of PrEP coverage is inconsistent across groups. Efforts to optimize PrEP access are especially needed for women and for those living in the South.

The prevalence of pre-exposure prophylaxis use and the pre-exposure prophylaxis-to-need ratio in the fourth quarter of 2017, United States

PURPOSE

The number of individuals who have started a regimen for HIV pre-exposure prophylaxis (PrEP) in the United States is not well characterized but has been on the rise since 2012. This analysis assesses the distribution of PrEP use nationally and among subgroups.

METHODS

A validated algorithm quantifying tenofovir disoproxil fumarate/emtricitabine for PrEP in the United States was applied to a national prescription database to determine the quarterly prevalence of PrEP use. HIV diagnoses from 2016 were used as an epidemiological proxy for PrEP need. The PrEP-to-need ratio (PnR) was defined as the number of PrEP users divided by new HIV diagnoses.

RESULTS

A total of 70,395 individuals used PrEP in the fourth quarter of 2017: 67,166 males and 3229 females. Nationally, prevalence of PrEP use was 26/100,000 (range across states per 100,000 [RAS/100k]: 4-73) and the PnR was 1.8 (RAS: 0.5-6.6). Prevalence of PrEP use among males and females, respectively, was 50/100,000 and 2/100,000 (RAS/100k: 7-143 and 0.3-7) and PnR was 2.1 and 0.4 (RAS: 0.6-7.1 and 0.1-4.0). Prevalence of PrEP use was lowest among individuals aged less than or equal to 24 and more than or equal to 55 years (15/100,000 and 6/100,000, RAS/100k: 1-45 and 0.4-14), with PnR 0.9 and 1.5 (RAS: 0.2-5.6 and 0.3-7.0). The Northeast had the highest PnR (3.3); the South had the lowest (1.0). States with Medicaid expansion had more than double the PnR than states without expansion.

CONCLUSIONS

Available data suggest that females, individuals aged less than or equal to 24 years and residents of the South had lower levels of PrEP use relative to epidemic need. These results are ecological, and misclassification may attenuate results. PnR is useful for future assessments of HIV prevention strategy uptake.

Factors associated with alcohol and/or drug use at sexual debut among sexually active university students: cross-sectional findings from Lebanon

Background

Sexual activity accompanied by substance use can impair youth decision-making and enhance risk-taking behaviors. Less is known, however, about the sexual values, perceptions and subsequent sexual practices of youth whose sexual debut occurs while using alcohol/drugs.

Methods

A cross-sectional anonymous online survey was conducted in April-August 2012 among undergraduate and graduate university students (aged 18 to 30) attending the 4th largest private university in Beirut. Pearson’s Chi-square and regression models were run using Stata/IC 10.0.

Results

940 university students had engaged in oral, anal and/or vaginal sex, of whom 10% admitted to having had consumed alcohol or taken drugs at sexual debut, a behavior that was more common in the males, less religious, non-Arabs, students living alone or who had lived abroad. Students who used alcohol/drugs at sexual debut were twice as likely to have: their first oral and vaginal sex with an unfamiliar partner [odds ratio (OR) = 2.6, 95% confidence interval (CI): (1.6, 4.2) and OR = 2.1 (1.2, 3.5), respectively], controlling for sex, nationality, current relationship status, living abroad after the age of 12, and spirituality. Students who had sex the first time while using alcohol/drugs were three times as likely to report having had 11 or more subsequent sexual partners versus one or two [OR = 3.0 (1.5-6.0)]; and almost twice as likely to ever engage in something sexual they did not want to do [OR = 1.7 (1.1, 2.8)]. Perceived peer pressure to have sex by a certain age [OR = 1.8 (1.1, 2.9)], and perceived peer norms to consume alcohol/drugs before sex [OR = 4.8 (2.3, 9.9)] were also strong correlates of having sex for the first time while using alcohol and/or drugs.

Conclusions

Findings stress the importance of sexuality education for youth, and the need to begin understanding the true interplay – beyond association - between youth sexual practices and substance use behaviors from a broader public health perspective.