high hiv prevalence among low-income heterosexuals in urban areas of the u.s
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National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention
High HIV Prevalence Among Low-Income Heterosexuals in
Urban Areas of the U.S.
Paul Denning MD, Elizabeth DiNenno PhD, and Ryan Wiegand MS
National HIV Prevention Conference August 17, 2011
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National HIV Behavioral Surveillance System (NHBS)
● Anonymous, cross-sectional survey
● Cities with high AIDS morbidity
● High-risk populations – MSM – IDUs – Heterosexuals
● Anonymous HIV testing offered
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NHBS-HET1
● September 2006 to October 2007 ● 25 cities
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NHBS-HET1 Recruitment
● High-risk areas (HRAs) – Poverty – HIV diagnoses
● Methods – Respondent-driven sampling – Venue-based sampling
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NHBS-HET1 Recruitment
Respondent-Driven Sampling
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NHBS-HET1 Recruitment
Venue-Based Sampling
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NHBS-HET1 Eligibility
● 18 − 50 years old
● City resident
● Sex with an opposite-gender partner in the past 12 months
● English- or Spanish-speaking
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● Univariable and multivariable Poisson regression models
– Associations with HIV prevalence – Prevalence ratios
● Data were combined and analyzed as a single convenience sample
NHBS-HET1 Analysis Methods
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● Ever injected drugs ● Men who ever had sex with another man
Exclusion:
NHBS-HET1 Analysis Criteria
Inclusion: ● Eligible and completed survey ● Consented to HIV testing ● Negative or confirmed positive HIV test result
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22,169 Recruited
18,377 (83%) Interviewed
17,655 (96%) Tested
14,837 (84%) Heterosexuals
NHBS-HET1 Participants
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Participant Characteristics NHBS-HET1 2006-2007
57%43% Women
Men
Gender
N= 14,837
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Participant Characteristics NHBS-HET1 2006-2007
72%
18%African-AmericanLatino
Race
WhiteOther
5% 4%
N= 14,837
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18 - 2930 - 39
Age
40 - 50
48%29%
23%
Participant Characteristics NHBS-HET1 2006-2007
N= 14,837
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Socioeconomic Status:
73% Income ≤ poverty level
31% < High school education 36% Unemployed 19% Homeless
Participant Characteristics NHBS-HET1 2006-2007
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0
5
10
15
Per
cent
Exchange Sex
STD Diagnosis
Crack Use
Participant Characteristics NHBS-HET1 2006-2007
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HIV Prevalence NHBS-HET1 2006-2007
HIV Test Result
Negative Positive
Total
14,543 294
14,837
N
(98) (2)
(100)
(%)
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HIV Prevalence NHBS-HET1 2006-2007
HIV Test Result
Negative Positive
Total
14,543 294
14,837
N
(98) (2)
(100)
(%)
2% HIV prevalence is 10 to 20 times greater than that among all heterosexuals in the U.S.
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HIV Prevalence and Poverty
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0
1
2
3
10 − 19% 20 − 29% ≥ 40% Proportion of Census Tract Residents Living Below the Poverty Level
0 − 9%
Per
cent
HIV
-pos
itive
30 − 39%
HIV Prevalence, by Census Tract Poverty NHBS-HET1 2006-2007
Chi-Square Trend, p< 0.0001
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0
1
2
3
10 − 19,999 20 − 49,999 ≥ 50,000 Annual Household Income (in Dollars)
0 − 9,999
Per
cent
HIV
-pos
itive
HIV Prevalence, by Income
NHBS-HET1 2006-2007
Chi-Square Trend, p< 0.0001
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0
1
2
3
10 − 19,999 20 − 49,999 ≥ 50,000 Annual Household Income (in Dollars)
0 − 9,999
Per
cent
HIV
-pos
itive
HIV Prevalence, by Income
NHBS-HET1 2006-2007
6X Greater
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*Controlling for city, sex, race/ethnicity, age, education, employment, income, homeless status, crack use, exchange sex, and STD diagnosis.
HIV Prevalence, Multivariable Model* NHBS-HET1 2006-2007
Low socioeconomic status was associated with higher HIV prevalence:
● Low income
● Limited education
● Unemployment
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HIV Prevalence and Race/Ethnicity
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HIV Surveillance & Census Data 37 States with HIV Reporting 2007
0
25
50
75
100
125
Per
sons
(in
thou
sand
s)
Heterosexuals Living with HIV
African- American
Latino White 0
25
50
75
100
125
Per
sons
(in
mill
ions
)
Adult & Adolescent Population
African- American
Latino White
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Ratio of Heterosexuals Living with HIV to the Population–
African-Americans: > 20 times greater
Latinos: 6 times greater
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HIV Prevalence, by Race/Ethnicity NHBS-HET1 2006-2007
0.0
0.5
1.0
1.5
2.0
2.5
All Census Tracts
African- American
Latino White
Perc
ent H
IV-p
ositi
ve
0.0
0.5
1.0
1.5
2.0
2.5
African- American
Latino White
High Poverty Census Tracts
Perc
ent H
IV-p
ositi
ve
p= 0.14
p= 0.73
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HIV Prevalence and Risk Behavior
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0
1
2
3
4
5
Exchange Sex
STD Diagnosis
Crack Use
Per
cent
HIV
-pos
itive
Yes No
HIV Prevalence, by Risk Behavior NHBS-HET1 2006-2007
p< 0.0001 p< 0.0001 p< 0.0001
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Exchange Sex
STD Diagnosis
Crack Use
Multivariable Model*
*Controlling for city, sex, race/ethnicity, age, education, employment, income, homeless status, crack use, exchange sex, and STD diagnosis.
1.1
1.1
2.1
Adjusted HIV Prevalence Ratio
(0.8 – 1.6)
(0.6 – 1.8)
(1.7 – 2.8)
95% Confidence Interval
HIV Prevalence, by Risk Behavior NHBS-HET1 2006-2007
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Exchange Sex
STD Diagnosis
Crack Use
Multivariable Model*
*Controlling for city, sex, race/ethnicity, age, education, employment, income, homeless status, crack use, exchange sex, and STD diagnosis.
1.1
1.1
2.1
Adjusted HIV Prevalence Ratio
(0.8 – 1.6)
(0.6 – 1.8)
(1.7 – 2.8)
95% Confidence Interval
HIV Prevalence, by Risk Behavior NHBS-HET1 2006-2007
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Exchange Sex
STD Diagnosis
Crack Use
Multivariable Model*
*Controlling for city, sex, race/ethnicity, age, education, employment, income, homeless status, crack use, exchange sex, and STD diagnosis.
1.1
1.1
2.1
Adjusted HIV Prevalence Ratio
(0.8 – 1.6)
(0.6 – 1.8)
(1.7 – 2.8)
95% Confidence Interval
HIV Prevalence, by Risk Behavior NHBS-HET1 2006-2007
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Limitations ● Because NHBS-HET1 is a convenience
sample recruited from large urban areas with high AIDS morbidity, participants may not be representative of all low-income heterosexuals in the U.S.
● Since NHBS-HET1 recruitment targeted residents of areas with high rates of HIV diagnoses in addition to high rates of poverty, HIV prevalence may be over-estimated.
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● HIV prevalence was very high
● Low socioeconomic status was associated with higher HIV prevalence
● Racial and ethnic disparities in HIV prevalence were substantially less than those in the general population
● Crack use and exchange sex were not associated with higher HIV prevalence
Summary
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● HIV prevention activities should be expanded and focus on low- income communities
● Community-level interventions
● Structural interventions
Recommendations
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For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone: 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348E-mail: [email protected] Web: http://www.cdc.gov
Characteristics Associated with HIV Infection Among Heterosexuals in Urban Areas with High AIDS Prevalence – 24 Cities, United States, 2006 - 2007. MMWR 2011;60(31):1045-1049. http://www.cdc.gov/mmwr
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.