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

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

NHBS-HET1

● September 2006 to October 2007 ● 25 cities

NHBS-HET1 Recruitment

● High-risk areas (HRAs) – Poverty – HIV diagnoses

● Methods – Respondent-driven sampling – Venue-based sampling

NHBS-HET1 Recruitment

Respondent-Driven Sampling

NHBS-HET1 Recruitment

Venue-Based Sampling

NHBS-HET1 Eligibility

● 18 − 50 years old

● City resident

● Sex with an opposite-gender partner in the past 12 months

● English- or Spanish-speaking

● 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

● 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

22,169 Recruited

18,377 (83%) Interviewed

17,655 (96%) Tested

14,837 (84%) Heterosexuals

NHBS-HET1 Participants

Participant Characteristics NHBS-HET1 2006-2007

57%43% Women

Men

Gender

N= 14,837

Participant Characteristics NHBS-HET1 2006-2007

72%

18%African-AmericanLatino

Race

WhiteOther

5% 4%

N= 14,837

18 - 2930 - 39

Age

40 - 50

48%29%

23%

Participant Characteristics NHBS-HET1 2006-2007

N= 14,837

Socioeconomic Status:

73% Income ≤ poverty level

31% < High school education 36% Unemployed 19% Homeless

Participant Characteristics NHBS-HET1 2006-2007

0

5

10

15

Per

cent

Exchange Sex

STD Diagnosis

Crack Use

Participant Characteristics NHBS-HET1 2006-2007

HIV Prevalence NHBS-HET1 2006-2007

HIV Test Result

Negative Positive

Total

14,543 294

14,837

N

(98) (2)

(100)

(%)

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.

HIV Prevalence and Poverty

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

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

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

*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

HIV Prevalence and Race/Ethnicity

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

Ratio of Heterosexuals Living with HIV to the Population–

African-Americans: > 20 times greater

Latinos: 6 times greater

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

HIV Prevalence and Risk Behavior

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

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

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

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

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.

● 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

● HIV prevention activities should be expanded and focus on low- income communities

● Community-level interventions

● Structural interventions

Recommendations

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: cdcinfo@cdc.gov 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.