AB 1 & 2

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, 1Ji Hyun Lee, MD, MPH, 1Caroline Kuo, DPhil, MPhil, 2,3 and Nickolas Zaller, PhD 4 To the Editor, United States national dataindicate an estimated 110 million prevalent sexually transmitted infections (STIs) and nearly 20 million new infections annually. 1Among these incident STIs, of particular concern are the approximately 50,000 new HIV infections annually. 2Racial 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. 4Data 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 nal analytic sample ofn=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 whitesserved as the reference group for all regressions. Analyses were conducted using the STATA version 13.0. All analyses were executed using thesvypre x command to incorporate the NHANES sampling weights and account for the complex sampling design, including oversampling, survey nonre- sponse, and post-strati cation.

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). 1School of Public Health, and 2Department of Behavioral and Social Sciences and Center for Alcohol and Addiction Sturides, Brown University, Providence, Rhode Island. 3Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.4Fay W. Boozman College of Public Health, University of Arkansas, Little Rock, Arkansas. AIDS PATIENT CARE and STDs Volume 29, Number 12, 2015 ªMary Ann Liebert, Inc.

DOI: 10.1089/apc.2015.0169 635 Table1.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 antibody0.02 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 antibody0.16 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) aSelf-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 con dence 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 con dence 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. 5Increased efforts to reduce undiagnosed HIV infection are also warranted. 6In 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; 9social factors such as racial and ethnic discrimination; 10 and neighborhood disad- vantage. 11The 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. Table2.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.

aSelf-reported; b, omitted. LETTER TO THE EDITOR637 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 con icting nancial interests exist.

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Dr. Don Operario School of Public Health Brown University 121 South Main Street Providence RI 02906 E-mail:[email protected] 638OPERARIO ET AL. Copyright ofAIDS Patient Care&STDs isthe property ofMary AnnLiebert, Inc.andits content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.