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High HIV Prevalence Among Low-Income Heterosexuals in Urban Areas of the U.S.

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  • 1. High HIV Prevalence AmongLow-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 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention
  • 2. National HIV BehavioralSurveillance System (NHBS)● Anonymous, cross-sectional survey● Cities with high AIDS morbidity● High-risk populations – MSM – IDUs – Heterosexuals● Anonymous HIV testing offered
  • 3. NHBS-HET1● September 2006 to October 2007● 25 cities
  • 4. NHBS-HET1 Recruitment● High-risk areas (HRAs) – Poverty – HIV diagnoses● Methods – Respondent-driven sampling – Venue-based sampling
  • 5. NHBS-HET1 RecruitmentRespondent-Driven Sampling
  • 6. NHBS-HET1 Recruitment Venue-Based Sampling
  • 7. NHBS-HET1 Eligibility● 18 − 50 years old● City resident● Sex with an opposite-gender partner in the past 12 months● English- or Spanish-speaking
  • 8. NHBS-HET1 Analysis Methods ● Univariable and multivariable Poisson regression models – Associations with HIV prevalence – Prevalence ratios ● Data were combined and analyzed as a single convenience sample
  • 9. NHBS-HET1 Analysis Criteria Inclusion: ● Eligible and completed survey ● Consented to HIV testing ● Negative or confirmed positive HIV test result Exclusion: ● Ever injected drugs ● Men who ever had sex with another man
  • 10. NHBS-HET1 Participants 22,169 Recruited 18,377 (83%) Interviewed 17,655 (96%) Tested14,837 (84%) Heterosexuals
  • 11. Participant Characteristics NHBS-HET1 2006-2007 Gender 43% Women 57% Men N= 14,837
  • 12. Participant Characteristics NHBS-HET1 2006-2007 5% 4% Race African- 18% American Latino 72% White Other N= 14,837
  • 13. Participant Characteristics NHBS-HET1 2006-2007 Age 29% 18 - 29 48% 30 - 39 23% 40 - 50 N= 14,837
  • 14. Participant Characteristics NHBS-HET1 2006-2007Socioeconomic Status: 73% Income ≤ poverty level 31% < High school education 36% Unemployed 19% Homeless
  • 15. Participant Characteristics NHBS-HET1 2006-2007 15 10Percent 5 0 Crack Exchange STD Use Sex Diagnosis
  • 16. HIV Prevalence NHBS-HET1 2006-2007HIV Test Result N (%)Negative 14,543 (98)Positive 294 (2)Total 14,837 (100)
  • 17. HIV Prevalence NHBS-HET1 2006-2007 HIV Test Result N (%) Negative 14,543 (98) Positive 294 (2) Total 14,837 (100)2% HIV prevalence is 10 to 20 times greaterthan that among all heterosexuals in the U.S.
  • 18. HIV Prevalence and Poverty
  • 19. HIV Prevalence, by Census Tract Poverty NHBS-HET1 2006-2007 3 Percent HIV-positive Chi-Square Trend, p< 0.0001 2 1 0 0 − 9% 10 − 19% 20 − 29% 30 − 39% ≥ 40% Proportion of Census Tract Residents Living Below the Poverty Level
  • 20. HIV Prevalence, by Income NHBS-HET1 2006-2007 3Percent HIV-positive Chi-Square Trend, p< 0.0001 2 1 0 0 − 9,999 10 − 19,999 20 − 49,999 ≥ 50,000 Annual Household Income (in Dollars)
  • 21. HIV Prevalence, by Income NHBS-HET1 2006-2007 3Percent HIV-positive 6X Greater 2 1 0 0 − 9,999 10 − 19,999 20 − 49,999 ≥ 50,000 Annual Household Income (in Dollars)
  • 22. HIV Prevalence, Multivariable Model* NHBS-HET1 2006-2007Low socioeconomic status wasassociated with higher HIV prevalence: ● Low income ● Limited education ● Unemployment*Controlling for city, sex, race/ethnicity, age, education, employment,income, homeless status, crack use, exchange sex, and STD diagnosis.
  • 23. HIV Prevalenceand Race/Ethnicity
  • 24. HIV Surveillance & Census Data 37 States with HIV Reporting 2007Heterosexuals Living with HIV Adult & Adolescent Population 125 125Persons (in thousands) 100 100 Persons (in millions) 75 75 50 50 25 25 0 0 African- Latino White African- Latino White American American
  • 25. Ratio of Heterosexuals Livingwith HIV to the Population–African-Americans: > 20 times greaterLatinos: 6 times greater
  • 26. HIV Prevalence, by Race/Ethnicity NHBS-HET1 2006-2007 All Census Tracts High Poverty Census Tracts 2.5 2.5 2.0 2.0Percent HIV-positive Percent HIV-positive p= 0.73 1.5 1.5 p= 0.14 1.0 1.0 0.5 0.5 0.0 African- Latino White 0.0 African- Latino White American American
  • 27. HIV Prevalenceand Risk Behavior
  • 28. HIV Prevalence, by Risk Behavior NHBS-HET1 2006-2007 Yes No 5Percent HIV-positive 4 3 p< 0.0001 p< 0.0001 p< 0.0001 2 1 0 Crack Exchange STD Use Sex Diagnosis
  • 29. HIV Prevalence, by Risk Behavior NHBS-HET1 2006-2007 Multivariable Model* Adjusted HIV 95% Confidence Prevalence Ratio IntervalCrack Use 1.1 (0.8 – 1.6)Exchange Sex 1.1 (0.6 – 1.8)STD Diagnosis 2.1 (1.7 – 2.8)*Controlling for city, sex, race/ethnicity, age, education, employment,income, homeless status, crack use, exchange sex, and STD diagnosis.
  • 30. HIV Prevalence, by Risk Behavior NHBS-HET1 2006-2007 Multivariable Model* Adjusted HIV 95% Confidence Prevalence Ratio IntervalCrack Use 1.1 (0.8 – 1.6)Exchange Sex 1.1 (0.6 – 1.8)STD Diagnosis 2.1 (1.7 – 2.8)*Controlling for city, sex, race/ethnicity, age, education, employment,income, homeless status, crack use, exchange sex, and STD diagnosis.
  • 31. HIV Prevalence, by Risk Behavior NHBS-HET1 2006-2007 Multivariable Model* Adjusted HIV 95% Confidence Prevalence Ratio IntervalCrack Use 1.1 (0.8 – 1.6)Exchange Sex 1.1 (0.6 – 1.8)STD Diagnosis 2.1 (1.7 – 2.8)*Controlling for city, sex, race/ethnicity, age, education, employment,income, homeless status, crack use, exchange sex, and STD diagnosis.
  • 32. 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.
  • 33. Summary● 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
  • 34. Recommendations● HIV prevention activities should be expanded and focus on low- income communities● Community-level interventions● Structural interventions
  • 35. Characteristics Associated with HIV Infection AmongHeterosexuals in Urban Areas with High AIDSPrevalence – 24 Cities, United States, 2006 - 2007.MMWR 2011;60(31):1045-1049.http://www.cdc.gov/mmwrFor 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: cdcinfo@cdc.gov Web: http://www.cdc.govThe findings and conclusions in this report are those of the authors and do not necessarilyrepresent the official position of the Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention

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