Combined HIV prevention programs may not eliminate racial disparities

RESEARCH ARTICLE
Will "Combined Prevention" Eliminate Racial/
Ethnic Disparities in HIV Infection among
Persons Who Inject Drugs in New York City?
Don Des Jarlais1*, Kamyar Arasteh1, Courtney McKnight1,
Jonathan Feelemyer1,
Holly Hagan2, Hannah Cooper3, Aimee Campbell4, Susan
Tross4, David Perlman1
1 The Baron Edmond de Rothschild Chemical Dependency
Institute, Mount Sinai Beth Israel, New York,
New York, United States of America, 2 College of Nursing,
New York University, New York, New York,
United States of America, 3 Rollins School of Public Health at
Emory University, Atlanta, Georgia, United
States of America, 4 Department of Psychiatry, Columbia
University, New York, New York, United States of
America
* [email protected]
Abstract
It has not been determined whether implementation of combined
prevention programming
for persons who inject drugs reduce racial/ethnic disparities in
HIV infection. We examine
racial/ethnic disparities in New York City among persons who
inject drugs after implementa-
tion of the New York City Condom Social Marketing Program

in 2007. Quantitative inter-
views and HIV testing were conducted among persons who
inject drugs entering Mount
Sinai Beth Israel drug treatment (2007–2014). 703 persons who
inject drugs who began in-
jecting after implementation of large-scale syringe exchange
were included in the analyses.
Factors independently associated with being HIV seropositive
were identified and a pub-
lished model was used to estimate HIV infections due to sexual
transmission. Overall HIV
prevalence was 4%; Whites 1%, African-Americans 17%, and
Hispanics 4%. Adjusted
odds ratios were 21.0 (95% CI 5.7, 77.5) for African-Americans
to Whites and 4.5 (95% CI
1.3, 16.3) for Hispanics to Whites. There was an overall
significant trend towards reduced
HIV prevalence over time (adjusted odd ratio = 0.7 per year,
95% confidence interval (0.6–
0.8). An estimated 75% or more of the HIV infections were due
to sexual transmission. Ra-
cial/ethnic disparities among persons who inject drugs were not
significantly different from
previous disparities. Reducing these persistent disparities may

require new interventions
(treatment as prevention, pre-exposure prophylaxis) for all
racial/ethnic groups.
Introduction
Significant racial/ethnic disparities in HIV infection among
persons who inject drugs (PWID)
have been observed in many countries, with ethnic minority
group members [1] and females
[2] typically having higher HIV prevalence. There are effective
interventions to reduce HIV
transmission among PWID, and the logic of “combined”
prevention programming is that
PLOS ONE | DOI:10.1371/journal.pone.0126180 May 12, 2015
1 / 11
OPEN ACCESS
Citation: Des Jarlais D, Arasteh K, McKnight C,
Feelemyer J, Hagan H, Cooper H, et al. (2015) Will
"Combined Prevention" Eliminate Racial/Ethnic
Disparities in HIV Infection among Persons Who
Inject Drugs in New York City? PLoS ONE 10(5):
e0126180. doi:10.1371/journal.pone.0126180
Academic Editor: Gurudutt Pendyala, University of
Nebraska Medical Center, UNITED STATES
Received: July 25, 2014
Accepted: March 30, 2015
Published: May 12, 2015

Copyright: © 2015 Des Jarlais et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information files.
Funding: This work was supported through Grant
5R01DA003574 from the National Institutes of Health.
The findings and conclusions in this report are those
of the authors and do not necessarily represent the
views of the organizations and/or agencies the
authors are affiliated with. The funder had no role in
study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
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0126180&domain=pdf
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providing multiple interventions on a large scale will lead to
greater reductions in HIV infec-
tion than can be obtained through providing any single
intervention [3]. Whether combined
prevention leads to reductions in racial/ethnic and sex
disparities in HIV infection remains an
open question. A meta-analysis of racial/ethnic disparities [1]
found statistically significant dis-
parities at all levels of HIV seroprevalence; significant
disparities may exist at low and high
HIV prevalence levels. Indeed, it is possible that
implementation of combined prevention pro-

gramming may actually increase relative disparities if the
interventions are less accessible to ra-
cial/ethnic minority PWID or are less effective for racial/ethnic
minority PWID.
New York City has experienced the world’s largest local HIV
epidemic among PWID, and
racial/ethnic disparities emerged at the start of the epidemic [4].
“Combined prevention” pro-
gramming for PWID in New York City began with large-scale
expansion of syringe exchange
programs in the mid-1990s, adding to existing methadone
maintenance programs. The num-
bers of syringes exchanged annually increased from
approximately 250,000 in 1990–1993 to
approximately 3 million in 2000–2002. This was temporally
associated with a reduction in HIV
incidence among PWID in the city from 4/100 person-years to
1/100 person-years [5]. Racial/
ethnic disparities in HIV infection persisted after the expansion
of the syringe exchange pro-
grams, however, with adjusted odds ratios of 4.02 for HIV
prevalence among African-Ameri-
cans compared to White PWID and 1.49 for HIV prevalence
among Hispanic PWID
compared to White PWID, in data collected between 1995 and
2008 [5].
Studies of HIV infection in PWID in Baltimore [6], San
Francisco [7] and New York City
[8] indicate that sexual transmission has become an increasingly
important factor in HIV in-
fection among PWID. In 2007, the New York City Department
of Health and Mental Hygiene
launched the “New York City Condom Social Marketing
Program” [9]. This program includes

a specially branded NYC Condom with distinctive packaging
and distributes over 30 million
free condoms per year [10]. The program reaches drug users
through the free condoms distrib-
uted at drug treatment and syringe exchange programs, and the
program has been generally
well-received by drug users in New York City [3, 10].
In this report, we assess whether the implementation of the
NYC Condom Social Marketing
program, as an additional component of “combined prevention”
for HIV, was associated with
any change in racial/ethnic disparities in HIV infection among
PWID in New York City and
the prospects for possible reductions in disparities in the future.
Methods
The data reported here are derived from ongoing analyses of
data collected from drug users en-
tering the Mount Sinai Beth Israel drug detoxification and
methadone maintenance programs
in New York City. The methods for this “Risk Factors” study
have been previously described in
detail [5, 11] so only a summary will be presented here. The
programs are both large (approxi-
mately 5000 admissions per year in the detoxification program
and approximately 6000 pa-
tients participating in methadone treatment at any point in time)
and serve New York City as a
whole. There were no changes in the requirements for entrance
into the program over the time
periods for the data presented here.
Both injecting and non-injecting drug users entering the
detoxification and methadone
maintenance programs are eligible to participate in the study.

Hospital records and the ques-
tionnaire results are checked for consistency on route of drug
administration and subjects are
examined for physical evidence of injecting. The data presented
here are from subjects who re-
ported injecting illicit drugs in the 6 months prior to entry into
drug treatment and who re-
ported that their first drug injection was in 1995 or later (after
large-scale expansion of syringe
exchange in New York, “combined prevention”).
Combined HIV Prevention and Eliminating Racial/Ethnic
Disparities
2 / 11
Competing Interests: The authors have declared
that no competing interests exist.
In the detoxification program, research staff visited the general
admission wards of the pro-
gram in a preset order and examined all intake records of a
specific ward to construct lists of
patients admitted within the prior 3 days. All of the patients on
the list for the specific ward
were then asked to participate in the study. After all of the
patients admitted to a specific ward
in the 3 day period have been asked to participate and
interviews have been conducted among
those who agreed to participate, the interviewer moved to the
next ward in the preset order. As
there was no relationship between the assignment of patients to
wards and the order that the

staff rotated through the wards, these procedures should
produce an unbiased sample of per-
sons entering the detoxification program. In the methadone
program, newly admitted patients
were asked to participate in the research. In both programs,
willingness to participate has been
high, with approximately 95% of those asked agreeing to
participate.
Written informed consent was obtained and a trained
interviewer administered a structured
questionnaire covering demographics, drug use, sexual risk
behavior, and use of HIV preven-
tion services. Most drug use and HIV risk behavior questions
referred to the 6 months prior to
the interview.
After completing the interview, each participant was seen by a
counselor for HIV and hepa-
titis C virus (HCV) pretest counseling and serum collection.
Participants were tested for HIV
and HCV regardless of any previous testing. We did not want to
depend upon self-reports of
previous testing, and we stored sera for future possible testing.
(Storage of sera was included in
the informed consent.) HIV testing was conducted at the New
York City Department of Health
Laboratory using a commercial, enzyme-linked, immunosorbent
assays (EIA) test with West-
ern blot confirmation (BioRad Genetic Systems HIV-1-2+0 EIA
and HIV-1 Western Blot,
BioRad Laboratories, Hercules, CA). Testing for anti-HCV was
also conducted by the City De-
partment of Health Laboratory using the Vitros anti-HCV
enhanced chemiluminescence im-
munoassay (Ortho Diagnostics).

Subjects are permitted to participate multiple times in the study,
though only once in any
one year. We used data from subjects who participated in
different years in the analyses pre-
sented here, as those subjects were members of the population
of interest in the different years.
Only about 3% of the subjects in any year were repeat
participants, however, so that these sub-
jects do not have a large influence on the results.
HIV counseling and testing has been provided on a large scale
for drug users in New York
City since the early 1990s. We do not present relationships
between risk behaviors in the 6
months prior to the interview and HIV status, as almost all HIV
infections would have oc-
curred prior to the 6 month period for recent risk and our
preliminary analyses suggest reduc-
tion in risk behavior by HIV seropositive persons in order to
avoid transmitting HIV to others.
Reductions in transmission behavior after HIV testing have been
noted in a number of studies
[12, 13].
We used the model developed by Vickerman and colleagues [14]
to estimate sexual versus
injecting related acquisition of HIV among PWID.
We used chi squared tests for comparisons across racial/ethnic
groups, and bivariate and
multivariable logistic regression analyses to identify factors
associated with being HIV seropos-
itive. Stata 12 statistical software [15] was used for statistical
analyses. The study was approved
by the Mount Sinai Beth Israel Institutional Review Board.

Results
Table 1 presents demographic characteristics (race/ethnicity,
gender and age) and recent drug
use and sexual behavior (for the 6 months prior to the
interview), date of interview and HIV
serostatus by racial/ethnic groups for subjects who began
injecting in 1995 or later. There are a
Disparities
3 / 11
number of statistically significant differences by race/ethnicity
in the demographic characteris-
tics and recent behaviors. Whites were younger and African-
Americans were older; Latino/as
were more likely to be male and African-Americans were more
likely to be female. Whites were
more likely to report injecting cocaine by itself or in
combination with heroin (speedball), Afri-
can-Americans were least likely to report daily injection and
most likely to report sniffing hero-
in and smoking crack cocaine.
Almost all subjects reported injecting heroin and there were no
significant racial/ethnic dif-
ferences in either “receptive sharing” (injecting with needles
and syringes that had been used
by others) or “distributive sharing” (passing on needles and
syringes that one had used to
others).

There were very large differences in HIV serostatus, with 1% of
White, 17% of African-
American, and 4% of Hispanic subjects testing HIV
seropositive. The racial/ethnic group dif-
ferences in HIV prevalence cannot be explained in terms of
recent (past 6 months) injecting
risk behaviors, where Whites tended to have the highest rates
and African-Americans tended
to have the lowest rates of injecting risks. The lack of
significant differences in sexual risk be-
haviors also indicates that recent sexual risk behavior does not
explain the substantial differ-
ences in HIV prevalence.
We used univariate and multivariable logistic regression to
identify factors independently
associated with being HIV seropositive. We began with all
variables in the univariate analyses
Table 1. Demographic and drug use characteristics of people
with injecting drug use who started injecting in 1995 or later
New York City Mount
Sinai Beth Israel drug treatment programs.
Race/Ethnicity
White African-American Latino/a Overall
n (%) n (%) n (%) n (%)
Avg. age (SD)# 32 (0.5) 42 (0.9) 36 (0.4) 35 (0.3)
Total 297 (100) 82 (100) 324 (100) 703 (100)
Males 234 (79) 61 (74) 271 (84) 566 (81)

Injection drugs use
Speedball 121 (41) 22 (27) 129 (40) 272 (39)
Heroin 284 (96) 77 (94) 310 (96) 671 (95)
Cocaine* 142 (48) 26 (32) 127 (39) 295 (42)
Non-injection drugs use
Speedball (sniffed) 25 (8) 9 (11) 32 (10) 66 (9)
Speedball (smoked) 19 (6) 7 (9) 16 (5) 42 (6)
Heroin (sniffed)* 127 (43) 64 (78) 146 (45) 337 (48)
Heroin (smoked) 15 (5) 4 (5) 9 (3) 28 (4)
Cocaine (snorted) 73 (25) 20 (24) 74 (23) 167 (24)
Crack Cocaine (smoked)* 127 (43) 50 (61) 112 (35) 289 (41)
Daily injection* 227 (76) 44 (54) 253 (78) 709 (75)
Receptive sharing 70 (24) 16 (20) 72 (22) 158 (22)
Distributive sharing 63 (21) 13 (16) 54 (17) 130 (18)
Unsafe sex w/ primary partner 137 (46) 37 (45) 166 (51) 340
(48)
Unsafe sex w/ casual partner 53 (18) 18 (22) 60 (19) 131 (19)
HIV+* 3 (1) 14 (17) 14 (4) 31 (4)

# Significant difference (p<0.05) across race/ethnicity groups
by one-way analysis-of- variance.
* Significant difference (p<0.05) across race/ethnicity groups
by chi-square test.
doi:10.1371/journal.pone.0126180.t001
Disparities
4 / 11
and then used backwards elimination to identify factors making
independent contribution.
Note that all variables that were significant in the univariate
analyses remained significant in
the multivariable analysis with essentially no change from the
univariate to the multivariable
(adjusted) odds ratios. Results are presented in Table 2. (As
noted in Methods, we did not in-
clude recent drug use and recent sexual risk behaviors into these
models as our preliminary
analyses suggested that HIV positive persons had reduced their
risk behaviors.) Gender, race/
ethnicity and year of interview were all significantly associated
with being HIV seropositive in
both univariate analyses and multivariable analyses. The
racial/ethnic disparities were large
and highly significant, particularly the odds ratios for HIV
prevalence among African-Ameri-
can compared to White subjects. HIV prevalence declined over
time among these subjects,

with an adjusted odds ratio of 0.7 per year.
The persistence of the racial/ethnic disparities, particularly the
African-American/White
disparity, raises questions as to how and when HIV transmission
is occurring among these sub-
jects. We used the model developed by Vickerman and
colleagues [14] for estimating sexual
versus injecting related transmission of HIV among PWID. The
HCV/HIV co-infection preva-
lence among our subjects (prevalence of HCV among HIV
positives) was 0.6, and the ratio of
HIV prevalence (4%) to HCV prevalence (54%) was 0.074.
Applying these data to the model
indicates that 75% or more of the HIV infections among these
subjects were acquired through
sexual transmission.
We used linear regression to model HIV prevalence as a
function of years since first injec-
tion among our subjects (Fig 1). This gave:
Likelihood of HIV seropositive ¼ 0:04 � ð0:001Þ � ðyears of
injectingÞ
The intercept of 0.04 was highly significant (P<0.01), and the
slope for years injecting was
not significantly different from zero (P = 0.5). This linear
regression model suggests that a very
large percentage of the subjects were HIV seropositive when
they began injecting and that very
few of the subjects became infected with HIV after they began
injecting.
There is additional evidence in our data to support the
interpretation that a substantial per-

centage of the HIV infections occurred prior to first injection.
The average age of first drug use
(for drugs other than alcohol, nicotine or marijuana) among
these subjects was 19, and the av-
erage age at first injection was 28, so that the subjects would
have had an average of 9 years of
Table 2. Univairate and multivariate logistic models of HIV
infection among PWID who began injecting in 1995 or later,
and interviewed between
2007- and 2014, New York City Mount Sinai Beth Israel drug
treatment programs.
Univariate Multivariate
OR (95%CI) 95% Confidence Interval OR (95%CI) 95%
Confidence Interval
Race/Ethnicity
White (ref.) 1.0 1.0
African- American 20.0 5.6, 72.2 19.0 4.8, 75.8
Latino/a 4.4 1.3, 15.6 4.4 1.2, 15.8
Gender
Male (ref.) 1.0 1.0
Female 3.2 1.5, 6.7 3.2 1.4–7.1
Year of interview 0.7 0.6, 0.8 0.7 0.6–0.8
Age 1.1 1.0, 1.1

Total years since first injection 0.9 0.9, 1.0
Disparities
5 / 11
using drugs such as heroin, powder cocaine and crack cocaine
during which they could have
acquired HIV through sexual transmission. Additionally, among
the 5 subjects who reported
that they were HIV seropositive and had been injecting for 4
years or less at the time of inter-
view, 3 of them reported that they were receiving ART. At the
times of interview for these 5
subjects, the New York City guidelines [16] were to begin ART
when CD4 cell counts
were < 350/mm3. Thus, it would appear that these 3 subjects
were very likely to have been in-
fected prior to their first injection. (Overall, 35% of subjects
who tested HIV positive reported
that they were receiving ART at the time of the interview.)
Discussion
The primary objective of this report was to examine whether
“combined prevention” for
PWID, including the addition of the NYC Condom Social
Marketing program in 2007, was as-
sociated with any reductions in racial/ethnic disparities in HIV
infection among PWID in New
York City. Comparisons of the data reported here with

previously published data collected
from PWID participating in our research from 1995–2008,
however, do not show any reduc-
tion in relative disparities. Table 3 presents a comparison of the
adjusted odds ratios for racial/
Fig 1. HIV prevalence and years of injection.
doi:10.1371/journal.pone.0126180.g001
Table 3. Adjusted odds ratio (aOR) for racial/ethnic disparities
in previously published data collected from 1995–2008 among
PWID who began in-
jecting in 1995 or later and interviewed at New York City
Mount Sinai Beth Israel drug treatment programs.
1995–2008 2007–2014
aOR 95% Confidence Interval aOR 95% Confidence Interval
Race/Ethnicity
White (ref.) 1.0 1.0
African-American 4.02 1.67, 9.69 21.0 5.7, 77.5
Hispanic 1.49 1.02, 2.17 4.5 1.3, 16.3
Disparities
6 / 11

ethnic disparities in previously published data collected from
1995–2008 among PWID who
began injecting in 1995 or later and interviewed at our research
site) [5]. There were no signifi-
cant differences the 1995–2008 versus the 2007–2014 adjusted
odds ratios, note the overlaps in
the 95% confidence intervals. The directions of these non-
significant changes were towards
larger racial/ethnic odds ratio disparities.
The current data suggest that the great majority of HIV
infections among these subjects oc-
curred through sexual transmission, and that much of this sexual
transmission may be occur-
ring prior to first injection (while subjects were using heroin
and cocaine through non-
injecting routes of administration). Herpes simplex virus type II
(HSV-2) infection both facili-
tates acquisition and transmission of HIV and is strongly
associated with HIV infection and ra-
cial/ethnic disparities in HIV infection among non-injecting
drug users (NIDUs) in New York
City [17]. Reduction in racial/ethnic disparities in HIV among
PWID may thus require ad-
dressing HSV-2 related sexual transmission disparities in HIV
infection among NIDUs before
they transition to injecting.
Data collection for this report began at the time of
implementation of the NYC Condom So-
cial Marketing program. As noted above, this program has
generally been well received by in-
jecting and non-injecting drug users in the New York City, and
it is possible that the NYC

Condom program is contributing to the decline in HIV
prevalence that we observed. However,
the relative disparities, particularly among African-Americans
compared to Whites, have clear-
ly continued. Additional interventions are needed to address
these disparities.
The City Department of Health and Mental Hygiene has
developed a policy of offering ART
to all HIV seropositives in New York City, with a goal of
having 80% or more of HIV seroposi-
tives at viral suppression, [18] where they would not be capable
of transmitting HIV. This
treatment as prevention (TasP) protocol has the potential to
successfully address racial/ethnic
disparities in HIV among PWID and NIDUs. Fig 2 presents a
state transition diagram for tran-
sitions from HIV seronegative to HIV seropositive status, from
non-injecting to injecting drug
use and from HIV seropositive viremic to HIV seropositive viral
suppressed status. The num-
bers of lines for W (White), H (Hispanic) and B (Black)
represent the relative proportions of
HIV positive drug users among different racial/ethnic groups
making the transitions, and thus
generating the disparities. For TasP to be effective in
eliminating racial/ethnic disparities, it will
be necessary to achieve much higher coverage of TasP (dashed
lines) among Hispanics and
particularly among African-American drug users in New York
City. From Table 1, 1% of
White PWID are HIV seropositive, and 17% of African-
American PWID are HIV seropositive.
It would thus require that 16/17 (94%) of HIV seropositive
African-American PWID would
need to achieve viral suppression just to reach the HIV

prevalence among White PWID with
1% of the population is HIV positive.
The CDC has recently recommended large-scale implementation
of pre-exposure prophy-
laxis (PrEP) as another method for reducing HIV transmission
in the United States [19]. If
PrEP were successfully provided to HSV-2 positive/HIV
negative NIDUs and PWID in New
York City, it would very likely reduce the existing racial/ethnic
disparities. Meaningful reduc-
tion in the existing racial/ethnic disparities would, however,
require implementing PrEP on a
large scale.
In this long-running study, HIV infection among White PWID
has almost been eliminated—
prevalence among the White PWID in this sample was only 1%.
Thus, eliminating the disparities
will probably require virtual elimination of new HIV infections
among African American and
Latino/a drug users. TasP and PrEP have the potential for
almost eliminating HIV infection
among African American and Latino/a drug users, but will need
to be implemented on a large
scale to accomplish this.
Disparities
7 / 11
Limitations

There are several limitations of this study that should be noted.
First, the study design is serial
cross sectional surveys, rather than a cohort design. Thus, we do
not have data on when HIV
seronegative individuals became infected with HIV, and when
HIV seropositives might have
left the active injecting population due to either cessation of
injecting or to disability or death.
We also do not have behavior data on HIV seronegatives and
HIV seropositives and risk net-
work factors at the actual times of HIV transmission. Thus we
cannot directly compare acquisi-
tion and transmission risk behaviors and risk network factors
among the groups.
An ethically conducted cohort study, however, would have had
other important limitations.
The repeated contact between research staff and cohort
participants would provide many op-
portunities for positive relationships to develop between staff
and participants. These positive
relationships should then enhance the effectiveness of the risk
reduction counseling that would
be provided in an ethically conducted cohort study. The positive
relationships with research
staff and the repeated risk reduction counseling, along with
differential drop out from the co-
hort, would make the remaining participants less and less
representative of the local PWID
population.
Also with respect to the date of HIV infections, our data
collection period for this report
began with the year the Condom Social Marketing program was
introduced and then covered
the eight years following the introduction. It is possible that

there simply were not enough new
Fig 2. HIV Transmission and Transitions to Injecting Drug Use.
doi:10.1371/journal.pone.0126180.g002
Disparities
8 / 11
HIV infections during this time period to create any change in
the racial/ethnic disparities that
existed prior to the introduction of the Condom Social
Marketing program.
Second, even though our comparisons reached conventional
levels of statistical significance,
we had only modest numbers of HIV seropositive subjects.
Larger numbers of HIV seroposi-
tive subjects will be needed for analyses of receiving ART over
time and of possible racial/eth-
nic differences in receiving ART.
Third, PWID who enter drug treatment programs may not be
representative of all PWID at
risk for HIV infection. It is likely that the levels of drug use
that would lead to entering drug
treatment are associated with higher risk for acquiring HIV
infection.
Finally, there was an overlap of two years in the comparison
between the new data presented

in this report and the previously published data. This is only a
modest overlap and would not
be expected to obscure any reduction in the racial/ethnic
disparities had such a reduction
been occurring.
The limitations of the present study are important, but it is
difficult to imagine that they
would have created the patterns of persistent racial/ethnic
disparities. Rather, it would appear
that these patterns were observed despite any limitations of the
study.
Conclusions
Racial/ethnic disparities in HIV infection among PWID in New
York City have persisted for
the last two decades despite successive implementation of
additional components of “combined
prevention.” It may be helpful to reframe the disparities
question to a question of achieving an
“AIDS free generation,” [20] in which there are “very few” new
HIV infections among adults.
The most optimistic findings in our 2007–2014 data are the flat
slope of HIV prevalence by
years injecting, suggesting very few new HIV infections after
beginning to inject, and the reduc-
tion in HIV prevalence over the time period (aOR = 0.7/year,
95% CI 0.6–0.8, from Table 2),
which does suggest that an “AIDS free” generation may be
possible for PWID in New York
City. With a current HIV seroprevalence of 1% among White
PWID who began injecting in
1995 or later, we may be very close to achieving an AIDS free
generation among White PWID
in New York City.

Achieving an AIDS free generation for African-American and
Hispanic PWID would seem
to require considerable additional efforts to reduce sexual
transmission among ethnic minority
drug users. Treatment as prevention (TasP) and Pre-Exposure
Prophylaxis (PrEP) may be im-
portant methods for further reducing HIV transmission among
PWID and NIDUs. Both TasP
and PrEP appear to be very effective in the presence of HSV-2
infection. HIV seropositive drug
users who are also HSV-2 seropositive could be given high
priority for TasP, and HSV-2 sero-
positive/HIV seronegative drug users could be given high
priority for PrEP. The NYC Condom
Social Marketing program should also be continued.
Disparities in HIV infection have persisted since the beginning
of the HIV epidemic among
PWID in New York City, and now would be the time to increase
efforts to finally eliminate
these disparities through addressing both injecting and sexual
transmission and achieving an
AIDS free generation for all groups of injecting and non-
injecting drug users in New York
City.
Acknowledgments
The authors express their gratitude to the clinicians at Mount
Sinai Beth Israel staff and to all
participants of the study. The findings and conclusions in this
report are those of the authors
and do not necessarily represent the views of the organizations
and/or agencies the authors are
affiliated with.

Disparities
9 / 11
Author Contributions
Conceived and designed the experiments: DDJ HH HC.
Performed the experiments: CM KA
DDJ. Analyzed the data: KA DDJ. Contributed
reagents/materials/analysis tools: KA CM DDJ
AC ST JF HH. Wrote the paper: DDJ KA CM JF HH HC AC ST
DP. Revised the final manu-
script: DDJ KA CM JF HH HC AC ST DP.
References
1. Des Jarlais DC, Bramson HA, Wong C, Gostnell K, Cepeda J,
Arasteh K, et al. (2012) Racial/Ethnic
Disparities in HIV infection among people who inject drugs: An
international systematic review and
meta-analysis. Addiction.2012.
2. Des Jarlais DC, Feelemyer JP, Modi SN, Arasteh A, Hagan H
(2012) Are females who inject drugs at
higher risk for HIV infection than males who inject drugs: An
international systematic review of high se-
roprevalence areas. Drug Alcohol Depend 124: 95–107. doi:
10.1016/j.drugalcdep.2011.12.020 PMID:
22257753
3. Des Jarlais DC, Arasteh K, McKnight C, Feelemyer J, Hagan
H, Cooper HLF, et al. (2014) Combined
HIV prevention, the New York City condom distribution
program, and the evolution of safer sex behavior

among persons who inject drugs in New York City. AIDS Behav
18: 443–451. doi: 10.1007/s10461-
013-0664-0 PMID: 24271348
4. Friedman SR, Chapman TF, Perlis TE, Rockwell R, Paone D,
Southeran JL, et al. (1999) Similarities
and differences by race/ethnicity in changes of HIV
seroprevalence and related behaviors among drug
injectors in New York City, 1991–1996. J Acquir Immune Defic
Syndr 22: 83–91. PMID: 10534151
5. Des Jarlais D, Arasteh A, Hagan H, McKnight C, Perlman D,
Friedman SR (2009) Persistence and
change in disparities in HIV infection among injecting drug
users in New York City after large-scale sy-
ringe exchange. Am J Public Health 99: S445–S451. doi:
10.2105/AJPH.2008.159327 PMID:
19797757
6. Strathdee SA, Sherman SG (2003) The role of sexual
transmission of HIV infection among injection
and non-injection drug users. J Urban Health 80: iii7–iii14.
PMID: 14713667
7. Kral AH, Bluthenthal RN, Lorvick J, Gee L, Bacchetti P,
Edlin BR (2001) Sexual transmission of HIV-1
among injection drug users in San Francisco, USA: Risk-factor
analysis. Lancet 357: 1397–1401.
PMID: 11356437
8. Des Jarlais DC, Arasteh K, McKnight C, Hagan H, Perlman
D, Friedman SR (2009) Using hepatitis C
virus and herpes simplex virus-2 to track HIV among injecting
drug users in New York City. Drug Alco-
hol Depend 101: 88–91. doi: 10.1016/j.drugalcdep.2008.11.007
PMID: 19108958

9. New York City Department of Health and Mental Hygiene
(2007) Health Department Launches the
Nation's First Official City Condom. In: NYCDOHMH, editor
editors. New York: New York City Depart-
ment of Health and Mental Hygeine.
10. Des Jarlais DC, McKnight C, Arasteh K, Feelemyer J,
Perlman D, Hagan H, et al. (2013) Use of the
“NYC Condom” among people who use drugs. Journal of Urban
Health: 1–8.
11. Des Jarlais DC, Friedman SR, Novick DM, Sotheran JL,
Thomas P, Yankovitz SR, et al. (1989) HIV-1
infection among intravenous drug users in Manhattan, New
York City, from 1977 through 1987. JAMA
261: 1008–1012. PMID: 2915408
12. Crepaz N, Lyles C, Wolitski R, Passin W, Rama S, Herbst
JH, et al. (2006) Do prevention interventions
reduce HIV risk behaviours among people living with HIV? A
meta-analytic review of controlled trials.
AIDS 20: 143–157. PMID: 16511407
13. Marks G, Crepaz N, Janssen RS (2006) Estimating sexual
transmission of HIV from persons aware
and unaware that they are infected with the virus in the USA.
AIDS 20: 1447–1450. PMID: 16791020
14. Vickerman P, Martin NK, Roy A, Beattie T, Des Jarlais D,
Strathdee S, et al. (2013) Is the HCV–HIV co-
infection prevalence amongst injecting drug users a marker for
the level of sexual and injection related
HIV transmission? Drug Alcohol Depend 132: 172–181. doi:
10.1016/j.drugalcdep.2013.01.020 PMID:
23453261

15. STATA Corp (2012) Stata 12. College Station, Texas.
16. New York City State Department of Health (2014) New
York State Summary Statement on Pre-Expo-
sure Prophylaxis to Prevent HIV Infection. In: NYSDOH, editor
editors.
17. Guidance for the Use of Pre-Exposure Prophylaxis (PrEP) to
Prevent HIV Transmission. Albany: New
York City State Department of Health.
18. Des Jarlais DC, Arasteh K, McKnight C, Perlman DC,
Cooper HL, Hagan H (2013) HSV-2 Infection as
a Cause of Female/Male and Racial/Ethnic Disparities in HIV
Infection. PLoS ONE 18;(8) 6: e66874.
Disparities
10 / 11
http://dx.doi.org/10.1016/j.drugalcdep.2011.12.020
http://www.ncbi.nlm.nih.gov/pubmed/22257753
http://dx.doi.org/10.1007/s10461-013-0664-0
http://dx.doi.org/10.1007/s10461-013-0664-0
http://dx.doi.org/10.2105/AJPH.2008.159327

19. Farley T (2011) 2011 Advisory #27: Health Department
Releases New HIV Treatment Recommenda-
tions. In: Department of Health and Mental Hygiene, Queens:
NYC Health.
20. Clinton H (2011) Creating an AIDS-free generation.
Washington (DC): Department of State; 2011 Nov
8 (cited 2012 Jun 5).
Disparities
11 / 11
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LETTERS TO THE EDITOR

Racial and Ethnic Disparities in HIV and STIs
in the United States—National Health and Nutrition
Examination Survey 1999–2012
Don Operario, PhD,
1
Ji Hyun Lee, MD, MPH,
1
Caroline Kuo, DPhil, MPhil,
2,3
and Nickolas Zaller, PhD
4
To the Editor,
United States national data indicate an estimated 110
million prevalent sexually transmitted infections (STIs) and
nearly 20 million new infections annually.
1
Among these
incident STIs, of particular concern are the approximately
50,000 new HIV infections annually.
2
Racial and ethnic
disparities in HIV and STIs are national priorities. National
representative data are critical to examine health disparities at
the population level.

3
We analyzed the National Health and Nutrition Ex-
amination Survey (NHANES) conducted from 1999 to 2012.
NHANES is a nationally representative sample of civilian, non-
institutionalized populations in the United States. Full descrip-
tion of the NHANES plan and operations is provided else-
where.
4
Data for this study came from the 1999–2012 cycles of
NHANES. We restricted analyses to adults ages 20–49. Adults
under the age of 20 and over the age of 49 were excluded
because NHANES did not systematically collect data on key
variables for those age ranges. The analytic sample included
only those participants who provided data on all covariates and
who participated in the clinical examination phase of the
NHANES protocol, during which biospecimen data were col-
lected. This yielded a final analytic sample of n = 19,510 adults.
Participants self-reported sociodemographics including
race/ethnicity, age, education, family income, marital status,
place of birth, and possession of health insurance and a reg-
ular health provider. Participants provided biological speci-
mens, including blood draw and urine, which allowed for
detection of the HIV antibody, chlamydia, HSV-2, and the
hepatitis C antibody. Participants self-reported on any life-
time gonorrhea, chlamydia, herpes, genital warts, and life-
time HIV testing. Participants who self-reported on any of
four STIs were grouped as ‘ever had STI’.
Analyses were conducted separately for males and fe-
males. Multivariable logistic regression analyses were com-
pared with prevalence of biologically assessed HIV and STIs
and self-reported STIs according to racial/ethnic group. Re-

gression analyses adjusted for all sociodemographic charac-
teristics mentioned previously, and non-Hispanic whites
served as the reference group for all regressions. Analyses
were conducted using the STATA version 13.0. All analyses
were executed using the svy prefix command to incorporate
the NHANES sampling weights and account for the complex
sampling design, including oversampling, survey nonre-
sponse, and post-stratification.
Weighted prevalence estimates and racial/ethnic group
comparisons for HIV and STIs are presented in Table 1.
Among males, both white and black males had the highest
prevalence of any self-reported lifetime STIs; black males
also had the highest prevalence of HIV antibody, urine
chlamydia, HSV-2, hepatitis C antibody, and self-reported
lifetime gonorrhea and chlamydia. Lifetime prevalence of
HIV testing was highest among black males. Hispanic males
had elevated prevalence of urine chlamydia and HSV-2
compared with whites. Self-reported lifetime prevalence of
genital warts was highest among white males.
Among females, black females had the highest prevalence
of HIV antibodies, urine chlamydia, HSV-2, and any self-
reported lifetime STI including lifetime gonorrhea, chla-
mydia, and herpes. Lifetime prevalence of HIV testing was
highest among black females. Self-reported lifetime preva-
lence of genital warts was highest among white females.
In adjusted multivariable analyses comparing males by ra-
cial/ethnic group (Table 2), black males were more likely than
white males to test positive for HIV antibody (OR = 5.20, 95%
CI 2.19, 12.35), urine chlamydia (OR = 5.04, 95% CI 2.97,
8.56), and HSV-2 (OR 4.75, 95% CI = 3.87, 5.83). Black males
were also more likely than white males to report lifetime
gonorrhea (OR = 7.84, 95% CI 2.41, 25.50), lifetime chla-

mydia (OR = 2.67, 95% CI 1.27, 5.62), and lifetime HIV
testing (OR = 2.16, 95% CI 1.88, 2.49).
Black males were less likely than white males to report
lifetime genital warts (OR = 0.48, 95% CI 0.31, 0.73). His-
panic males were more likely than white males to test posi-
tive for HIV antibody (OR = 3.78, 95% CI 1.62, 8.82), urine
chlamydia (OR = 2.52, 95% CI 1.24, 5.10), and HSV-2
(OR = 1.54, 95% CI 1.15, 2.07). Mixed/other males were
less likely than white males to report lifetime HIV testing
(OR = 0.70, 95% CI 0.54, 0.91).
1
School of Public Health, and
2
Department of Behavioral and Social Sciences and Center for
Alcohol and Addiction Sturides, Brown
University, Providence, Rhode Island.
3
Department of Psychiatry and Mental Health, University of
Cape Town, Cape Town, South Africa.
4
Fay W. Boozman College of Public Health, University of
Arkansas, Little Rock, Arkansas.
AIDS PATIENT CARE and STDs
Volume 29, Number 12, 2015
ª Mary Ann Liebert, Inc.
DOI: 10.1089/apc.2015.0169
635

Table 1. Weighted Prevalence of HIV and STIs Among US
Adult Males
and Females (n = 19,510) by Race/Ethnicity: NHANES, 1999–
2012
African American Hispanic White Mixed, other
% (95 CI) % (95 CI) % (95 CI) % (95 CI) p
Males
HIV antibody <0.001
Yes 2.6 (2.0, 3.6) 0.9 (0.5, 1.4) 0.3 (0.2, 0.7) 0.0
No 99.7 (99.4, 99.8) 99.2 (98.6, 99.5) 99.7 (99.4, 99.8) 100.0
Urine chlamydia (ages 20–39 only) <0.0001
Yes 4.6 (3.4, 6.1) 1.9 (1.3, 2.7) 1.0 (0.7, 1.4) 0.4 (0.1, 1.0)
No 95.4 (93.9, 96.6) 98.1 (97.3, 98.7) 99.0 (98.6, 99.3) 99.7
(99.0, 99.9)
HSV-2 <0.0001
Yes 34.2 (31.6, 36.9) 12.8 (11.1, 14.7) 10.1 (9.0, 11.3) 10.1
(6.9, 14.5)
No 65.8 (63.2, 68.4) 87.3 (85.3, 89.0) 89.9 (88.7, 91.0) 89.9
(85.5, 93.1)
Hep C antibody 0.02
Yes 3.0 (2.3, 4.1) 1.7 (1.2, 2.3) 2.4 (1.9, 3.0) 0.9 (0.3, 2.5)
No 97.0 (95.9, 97.8) 98.4 (97.7, 98.8) 97.6 (97.0, 98.1) 99.1
(97.5, 99.7)
Ever had STI
a <0.001
Yes 7.3 (6.1, 8.7) 4.1 (3.2, 5.3) 7.3 (6.2, 8.5) 4.5 (2.7, 7.4)

No 92.7 (91.3, 93.9) 95.9 (94.7, 96.8) 92.7 (91.5, 93.8) 95.5
(92.7, 97.3)
Ever had gonorrhea
a <0.0001
Yes 1.4 (1.0, 2.0) 0.4 (0.2, 0.8) 0.2 (<0.01, 0.4) 0.2 (<0.01, 0.8)
No 98.6 (98.0, 99.0) 99.6 (99.2, 99.8) 99.9 (99.6, 99.9) 99.8
(98.6, 100.0)
Ever had chlamydia
a <0.01
Yes 1.9 (1.3, 2.7) 0.4 (0.2, 0.8) 0.5 (0.3, 0.8) 0.7 (<0.01, 4.5)
No 98.1 (97.3, 98.7) 99.6 (98.2, 99.8) 99.5 (99.2, 99.7) 99.4
(95.5, 99.9)
Ever had herpes
a
0.38
Yes 2.8 (2.2, 3.7) 1.8 (1.2, 2.8) 2.4 (1.9, 3.1) 1.7 (0.8, 3.7)
No 97.2 (96.3, 97.8) 98.2 (97.5, 98.7) 97.6 (96.9, 98.2) 98.3
(96.4, 99.2)
Ever had warts
a <0.0001
Yes 2.3 (1.7, 3.2) 1.8 (1.3, 2.5) 5.0 (4.1, 6.2) 2.5 (1.2, 5.0)
No 97.7 (96.8, 98.3) 98.2 (97.5, 98.7) 95.0 (93.9, 95.9) 97.5
(95.0, 98.8)
Ever tested for HIV
a <0.0001
Yes 58.6 (56.0, 61.2) 32.9 (30.4, 35.5) 42.2 (40.4, 44.1) 33.0

(28.3, 38.1)
No 41.4 (38.8, 44.0) 67.1 (64.5, 69.6) 57.8 (55.5, 59.7) 67.0
(61.9, 71.7)
Females
HIV antibody <0.0001
Yes 1.3 (0.9, 2.0) <0.01 (<0.01, 0.1) <0.01 (<0.01, 0.1) 0.3
(<0.01, 1.9)
No 98.7 (98.0, 99.1) 100.0 (99.9, 100.0) 100.0 (99.9, 100.0)
99.7 (98.1, 100.0)
Urine chlamydia (ages 20–39) <0.0001
Yes 4.4 (3.4, 5.7) 2.0 (1.3, 2.9) 0.9 (0.6, 1.4) 3.0 (1.4, 6.2)
No 95.6 (94.3, 96.6) 98.0 (97.1, 98.7) 99.1 (98.6, 99.4) 97.0
(93.8, 98.6)
HSV-2 <0.0001
Yes 58.3 (55.9, 60.6) 23.7 (21.4, 26.3) 19.8 (18.4, 21.2) 18.3
(14.6, 22.6)
No 41.7 (39.4, 44.1) 76.3 (73.7, 78.7) 80.2 (78.8, 81.6) 81.7
(77.4, 85.4)
Hep C antibody 0.16
Yes 2.0 (1.4, 2.7) 0.9 (0.5, 1.7) 1.5 (1.2, 2.0) 0.9 (0.3, 2.4)
No 98.1 (97.3, 98.6) 99.1 (98.3, 99.5) 98.5 (98.0, 98.9) 99.1
(97.6, 99.7)
Ever had STI
a <0.0001
Yes 16.7 (14.8, 18.7) 8.6 (7.0, 10.4) 13.5 (12.2, 14.8) 10.9 (7.7,
15.4)
No 83.3 (81.3, 85.2) 91.4 (89.6, 93.0) 86.5 (85.2, 87.8) 89.1
(84.7, 92.3)

Ever had gonorrhea
a <0.0001
Yes 1.3 (0.9, 2.0) 0.2 (<0.01, 0.7) 0.2 (<0.01, 0.4) 1.1 (0.3, 3.7)
No 98.7 (98.0, 99.1) 99.8 (99.3, 99.9) 99.8 (99.6, 99.9) 99.0
(96.3, 99.7)
Ever had chlamydia
a <0.0001
Yes 2.9 (2.2, 4.0) 1.5 (0.9, 2.3) 0.5 (0.3, 0.9) 1.5 (0.7, 3.0)
No 97.1 (96.0, 97.9) 98.5 (97.7, 99.1) 99.5 (99.2, 99.7) 98.6
(97.0, 99.3)
Ever had herpes
a <0.0001
Yes 8.6 (7.2, 10.2) 4.0 (2.9, 5.5) 6.1 (5.3, 7.1) 4.7 (2.8, 7.7)
No 91.4 (89.8, 92.8) 96.0 (94.5, 97.1) 93.9 (92.9, 94.7) 95.3
(92.3, 97.2)
Ever had warts
a <0.0001
Yes 6.2 (5.2, 7.4) 3.6 (2.8, 4.8) 8.4 (7.5,9.5) 5.3 (2.9, 9.4)
No 93.8 (92.6, 94.8) 96.4 (95.3, 97.2) 91.6 (90.5, 92.5) 94.7
(90.6, 97.1)
Ever tested for HIV
a <0.0001
Yes 67.9 (64.9, 70.8) 48.5 (45.7, 51.4) 51.3 (49.3, 53.3) 40.2
(34.8, 45.8)
No 32.1 (29.2, 35.1) 51.5 (48.6, 54.3) 48.7 (46.7, 50.7) 59.8
(54.2, 65.3)

a
Self-reported.
636
In adjusted multivariable analyses comparing females by
racial/ethnic group (Table 2), Black females were more likely
than white females to test positive for urine chlamydia
(OR = 4.83, 95% CI 2.41, 9.67), and HSV-2 (OR = 5.83, 95%
CI 4.91, 6.92). Black females were also more likely than
white females to report any lifetime STI (OR = 1.35, 95% CI
1.10, 1.66), lifetime gonorrhea (OR = 5.23, 95% CI 1.45,
18.86), lifetime chlamydia (OR = 3.36, 95% CI 1.89, 5.96),
lifetime herpes (OR = 1.52, 95% CI 1.15, 2.01), and lifetime
HIV testing (OR = 2.49, 95% CI 2.10, 2.96).
Although black females were more likely than white fe-
males to test positive for HIV antibody (OR = 46.27, 95%
CI 5.06, 423.36), it is important to note the wide-range
confidence interval. Hispanic females were more likely than
white females to test positive for HSV-2 (OR = 1.34, 95% CI
1.08, 1.66) and less likely to report lifetime genital warts
(OR = 0.55, 95% CI 0.35, 0.85). Mixed/other females were
more likely than white females to test positive for urine
chlamydia (OR = 3.47, 95% CI 1.50, 8.02).
To our knowledge, this is among the most robust reports of
national representative data on racial and ethnic disparities in
HIV and STIs by including population data spanning 14 years
of recruitment. Adjusting for sociodemographic characteris-
tics, black males had nearly 5 times greater odds than white
males to test positive for HIV, and black females had nearly
46 times greater odds than white females to test positive for
HIV antibodies, though the latter is marked by wide range

confidence intervals. Other STIs were more prevalent in
black and Hispanic males and females compared with their
white counterparts.
Findings highlight the continued need to address dis-
parities in HIV and STIs among black and Hispanic adults in
the United States.
5
Increased efforts to reduce undiagnosed
HIV infection are also warranted.
6
In light of national policy-
level changes associated with the Affordable Care Act
(ACA), access to primary care in racial/ethnic minority
populations may increase. The ACA offers a compelling
opportunity for enacting new strategies to address the heavy
burden of HIV and STIs in black and Hispanic Americans.
7
Integrating HIV and STI testing and STI treatment into
primary care is one such strategy. Efforts to coordinate health
services and increase linkage to HIV care for black and
Hispanics who test HIV positive are critical to improving
individual health outcomes and lowering transmission rates.
Targeting services in geographic locations with dense con-
centrations of African Americans and Hispanics might fa-
cilitate service uptake and retention. Culturally competent
care is also needed to improve trust, uptake, and engagement
with members of these populations.
8

Notably, disparities in HIV and STIs persisted after ad-
justing for individual-level sociodemographics variables. This
suggests that health determinants operating outside of these
socioeconomic variables contribute to the health disparities
faced by racial/ethnic minorities, and may include access to
diagnosis, prevention, and treatment;
9
social factors such as
racial and ethnic discrimination;
10
and neighborhood disad-
vantage.
11
The roles of racial/ethnic discrimination, access to
services, and social and environmental factors should be ex-
plored further in order to develop appropriate interventions to
reduce HIV and STIs among blacks and Hispanics.
Table 2. Adjusted Multivariate Regressions to Examine
Racial/Ethnic Disparities on HIV, STIs, Alcohol,
and Illicit Drug Use Among US Adult Males and Females (n =
19,510): NHANES, 1999–2012
African American Hispanic Mixed, other
White
OR (95% CI) p OR (95% CI) p OR (95% CI) p (ref.)
Males
HIV antibody 5.20 (2.19, 12.35) <0.001 3.78 (1.62, 8.82) <0.01
b 1.00

Urine chlamydia (ages 20–39) 5.04 (2.97, 8.56) <0.001 2.52
(1.24, 5.10) 0.01 0.38 (0.10, 1.50) 0.16 1.00
HSV-2 4.75 (3.87, 5.83) <0.001 1.54 (1.15, 2.07) <0.01 1.42
(0.85, 2.37) 0.18 1.00
Hep C antibody 0.64 (0.39, 1.06) 0.08 1.29 (0.77, 2.16) 0.34
0.56 (0.15, 2.10) 0.38 1.00
Ever had STI
a
1.15 (0.85, 1.54) 0.36 0.91 (0.60, 1.36) 0.64 0.71 (0.36, 1.38)
0.31 1.00
Ever had gonorrhea
a
7.84 (2.41, 25.50) <0.01 2.76 (0.70, 10.96) 0.15 1.88 (0.32,
11.14) 0.48 1.00
Ever had chlamydia
a
2.67 (1.27, 5.62) 0.01 0.84 (0.31, 2.28) 0.74 1.37 (0.19, 9.63)
0.75 1.00
Ever had herpes
a
1.40 (0.92, 2.11) 0.11 1.53 (0.83, 2.82) 0.18 1.02 (0.39, 2.62)
0.97 1.00
Ever had warts
a
0.48 (0.31, 0.73) <0.01 0.58 (0.33, 1.02) 0.06 0.50 (0.19, 1.29)
0.15 1.00
Ever tested for HIV
a

2.16 (1.88, 2.49) <0.001 0.94 (0.78, 1.12) 0.47 0.70 (0.54, 0.91)
<0.01 1.00
Females
HIV antibody 46.27 (5.06, 423.36) <0.01 0.49 (0.04, 6.50) 0.58
9.18 (0.68, 123.04) 0.09 1.00
Urine chlamydia (ages 20–39) 4.83 (2.41, 9.67) <0.001 2.25
(0.86, 5.89) 0.10 3.47 (1.50, 8.02) <0.01 1.00
HSV-2 5.83 (4.91, 6.92) <0.001 1.34 (1.08, 1.66) <0.01 1.28
(0.92, 1.78) 0.14 1.00
Hep C antibody 0.70 (0.42, 1.16) 0.16 0.73 (0.35, 1.54) 0.41
1.19 (0.37, 3.86) 0.77 1.00
Ever had STI
a
1.35 (1.10, 1.66) <0.01 0.80 (0.60, 1.07) 0.12 1.04 (0.66, 1.63)
0.86 1.00
Ever had gonorrhea
a
5.23 (1.45, 18.86) 0.01 0.65 (0.15, 2.72) 0.55 7.39 (0.87, 62.91)
0.07 1.00
Ever had chlamydia
a
3.36 (1.89, 5.96) <0.001 1.56 (0.67, 3.68) 0.30 2.69 (1.00, 7.19)
0.05 1.00
Ever had herpes
a
1.52 (1.15, 2.01) <0.01 0.89 (0.59, 1.34) 0.58 0.88 (0.46, 1.67)
0.69 1.00
Ever had warts

a
0.25 (0.65, 1.12) 025 0.55 (0.35, 0.85) <0.01 0.80 (0.38, 1.69)
0.55 1.00
Ever tested for HIV
a
2.49 (2.10, 2.96) <0.001 1.02 (0.85, 1.22) 0.84 0.80 (0.61, 1.03)
0.09 1.00
Adjusted for age, education, employment, marital status, born in
US, health care access, family income, health insurance and
regular
provider.
a
Self-reported;
b
, omitted.
LETTER TO THE EDITOR 637
Acknowledgments
Funding was provided by the National Institute of Alcohol
Abuse and Alcoholism (Grants U24 AA022000 and P01
AA019072) and by the National Institute for Mental Health
(Grants K01 MH096646 and L30 MH098313).
Author Disclosure Statement
No conflicting financial interests exist.

References
1. Satterwhite CL, Torrone E, Meites E, et al. Sexually
transmitted infections among US women and men: Pre-
valence and incidence estimates, 2008. Sex Trans Dis
2013;40:187–193.
2. Prejean J, Song R, Hernandez A, et al. Estimated HIV in-
cidence in the United States, 2006–2009. PLoS ONE
2011;6:e17502.
3. The White House Office of National AIDS Policy. National
HIV/AIDS Strategy for the United States. Washington, DC:
White House, July 13, 2010.
4. National Health and Nutrition Examination Survey Data.
In: Prevention CDC, editor. Hyattsville: US Department of
Health and Human Services, 2014.
5. Hemmige V, McFadden R, Cook S, et al. HIV prevention
interventions to reduce racial disparities in the United States:
A systematic review. J Gen Intern Med 2012;27:1047–1067.
6. Hall HI, An Q, Tang T, Song R, Chen M, Green T, Kang J.
Prevalence of diagnosed and undiagnosed HIV infection–
United States, 2008–2012. MMWR Morb Mortal Wkly Rep
2015;64:657–662.
7. Lanier Y, Sutton MY. Reframing the context of preventive
health care services and prevention of HIV and other sex-
ually transmitted infections for young men: New opportu-
nities to reduce racial/ethnic sexual health disparities. Am J
Public Health 2012;103:262–269.
8. Wyatt GE, Williams JK, Gupta A, Malebranche D. Are

cultural values and beliefs included in US based HIV in-
terventions? Prev Med 2012;55:362–370.
9. Harling G, Subramanian S, Bärnighausen T, et al. Socio-
economic disparities in sexually transmitted infections
among young adults in the United States: Examining the
interaction between income and race/ethnicity. Sex Transm
Dis 2013;40:575–581.
10. Earnshaw VA, Bogart LM, Dovidio JF, Williams DR.
Stigma and racial/ethnic HIV disparities: Moving toward
resilience. Am Psychol 2013;68:225–236.
11. Carlson D, McNulty T, Bellair P, Watts S. Neighborhoods
and racial/ethnic disparities in adolescent sexual risk be-
havior. J Youth Adolesc 2014;43:1536–1549.
Address correspondence to:
Dr. Don Operario
School of Public Health
Brown University
121 South Main Street
Providence RI 02906
E-mail: [email protected]
638 OPERARIO ET AL.
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