Intersectional Identities and HIV: Race and Ethnicity Drive Patterns of Sexual Mixing

HIV prevalence and factors associated with HIV positivity among Black people in primary care in Porto Alegre, Brazil, 2020-2022: a cross-sectional study

OBJECTIVE

To examine HIV prevalence among primary care service users and to investigate factors associated with positive HIV test results among Black people.

METHODS

This was a cross-sectional study with data from rapid HIV testing performed in health centers in Porto Alegre-RS, Brazil. Sociodemographic differences according to race/skin color and HIV test result were analyzed using the Chi-square test and Poisson regression with robust variance.

RESULTS

Out of 92,345 people tested, 38% were Black, with 3.4% HIV prevalence. Among Black people the following were associated with higher HIV prevalence ratios (PR): being male (PR 1.62; 95% confidence interval [95%CI] 1.41; 1.85), having elementary education (PR 1.69; 95%CI 1.27; 2.24), having tuberculosis (PR 1.76; 95%CI 1.22; 2.54) and being a street dweller (PR 1.75; 95%CI 1.41; 2.18).

CONCLUSION

Black people, especially Black men with lower education levels, tuberculosis and street dwellers, have higher HIV prevalence, requiring greater attention from prevention strategies and testing for sexually transmitted infections.

Racial and Ethnic Disparities in HIV Diagnosis Rates by Social Determinants of Health at the Census Tract Level Among Adults in the United States and Puerto Rico, 2021

BACKGROUND

We compared racial and ethnic disparities in HIV diagnosis rates among adults in census tracts with the most disadvantaged vs. the most advantaged levels of social determinants of health.

METHODS

In this ecologic analysis, we used the National HIV Surveillance System data from 2021 and social determinants of health data from 2017-2021 American Community Survey. We measured racial and ethnic disparities stratified by sex in the most disadvantaged quartiles and advantaged quartiles for (1) poverty, (2) education level, (3) median household income, and (4) insurance coverage. We calculated 8 relative disparity measures [Black-to-White rate ratio, Hispanic/Latino-to-White rate ratio, index of disparity (ID), population-weighted ID, mean log deviation, Theil index, population attributable proportion, Gini coefficient] and 4 absolute disparity measures (Black-to-White rate difference, Hispanic/Latino-to-White rate difference, absolute ID, and population-weighted absolute ID).

RESULTS

Comparing the most disadvantaged quartiles with the most advantaged quartiles, all 4 absolute disparity measures decreased, but 7 of the 8 relative disparity measures increased: the median percentage decreases in the absolute measures for men and women, respectively, were 38.1% and 47.6% for poverty, 12.4% and 42.6% for education level, 43.6% and 44.0% for median household income, and 44.2% and 45.4% for insurance coverage. The median percentage increases in the relative measures for men and women, respectively, were 44.3% and 61.3% for poverty, 54.9% and 95.3% for education level, 19.6% and 90.0% for median household income, and 32.8% and 46.4% for insurance coverage.

CONCLUSIONS

Racial and ethnic disparities in the most disadvantaged and the most advantaged quartiles highlight the need for strategies addressing the root causes of disparities.

Racial and Ethnic Differences in Mobile App Use for Meeting Sexual Partners Among Young Men Who Have Sex With Men and Young Transgender Women: Cross-Sectional Study

Background

Young men who have sex with men and young transgender women (YMSM-YTW) use online spaces to meet sexual partners with increasing regularity, and research shows that experiences of racism online mimics the real world.

Objective

We analyzed differences by race and ethnicity in web-based and mobile apps used to meet sexual partners as reported by Chicago-based YMSM-YTW in 2016-2017.

Methods

A racially and ethnically diverse sample of 643 YMSM-YTW aged 16-29 years were asked to name websites or mobile apps used to seek a sexual partner in the prior 6 months, as well as provide information about sexual partnerships from the same period. We used logistic regression to assess the adjusted association of race and ethnicity with (1) use of any website or mobile apps to find a sexual partner, (2) use of a "social network" to find a sexual partner compared to websites or mobile apps predominantly used for dating or hookups, (3) use of specific websites or mobile apps, and (4) reporting successfully meeting a sexual partner online among website or mobile app users.

Results

While most YMSM-YTW (454/643, 70.6%) used websites or mobile apps to find sexual partners, we found that Black non-Hispanic YMSM-YTW were significantly less likely to report doing so (comparing White non-Hispanic to Black non-Hispanic: adjusted odds ratio [aOR] 1.74, 95% CI 1.10-2.76). Black non-Hispanic YMSM-YTW were more likely to have used a social network site to find a sexual partner (comparing White non-Hispanic to Black non-Hispanic: aOR 0.20, 95% CI 0.11-0.37), though this was only reported by one-third (149/454, 32.8%) of all app-using participants. Individual apps used varied by race and ethnicity, with Grindr, Tinder, and Scruff being more common among White non-Hispanic YMSM-YTW (93/123, 75.6%; 72/123, 58.5%; and 30/123, 24.4%, respectively) than among Black non-Hispanic YMSM-YTW (65/178, 36.5%; 25/178, 14%; and 4/178, 2.2%, respectively) and Jack'd and Facebook being more common among Black non-Hispanic YMSM-YTW (105/178, 59% and 64/178, 36%, respectively) than among White non-Hispanic YMSM-YTW (6/123, 4.9% and 8/123, 6.5%, respectively). Finally, we found that while half (230/454, 50.7%) of YMSM-YTW app users reported successfully meeting a new sexual partner on an app, Black non-Hispanic YMSM-YTW app users were less likely to have done so than White non-Hispanic app users (comparing White non-Hispanic to Black non-Hispanic: aOR 2.46, 95% CI 1.50-4.05).

Conclusions

We found that Black non-Hispanic YMSM-YTW engaged with websites or mobile apps and found sexual partners systematically differently than White non-Hispanic YMSM-YTW. Our findings give a deeper understanding of how racial and ethnic sexual mixing patterns arise and have implications for the spread of sexually transmitted infections among Chicago's YMSM-YTW.

Sexual Identity Development and Social Ecological Facilitators and Barriers of PrEP Uptake and Adherence Among Latinx Men Who Have Sex with Men

Latinx gay, bisexual, and other men who have sex with men (LMSM) report lower pre-exposure prophylaxis (PrEP) use than their white, non-Latinx counterparts. We hypothesize that this disparity is partially attributable to social ecological factors that can be addressed via prevention interventions. In this retrospective study, we first examined data from 253 LMSM to determine whether theorized associations existed between acquisition of a PrEP prescription (uptake) in relation to several social ecological factors based on a conceptual framework of determinants of access to and uptake of PrEP for LMSM. We also explored relations between frequency of PrEP use (adherence) and social ecological factors with a subsample of 33 LMSM who had initiated PrEP 12 months prior to assessment. In this study, individual-level factors from this framework included age and socioeconomic status. Perceived access to medical care represented both individual- and community-level determinants of PrEP uptake and adherence. Interpersonal-level factors were social support and relationship status. Structural/cultural-level factors were sexual identity development status, the masculinity norm of heterosexual self-presentation, traditional Latinx masculine gender role beliefs of machismo and caballerismo, racial identity, and immigration status. Results indicated that older men and those who endorsed the synthesis/integration status of sexual identity development were more likely to acquire a PrEP prescription during their lifetime in comparison to peers. PrEP adherence was linked with being older, reporting higher socioeconomic status, reporting more appraisal social support, self-identifying as white-Latinx, being U.S.-born, and endorsing less sexual identity uncertainty and more heterosexual self-presentation. Results specify modifiable factors that may inform tailored, community-based prevention efforts to increase PrEP use and decrease existing HIV/AIDS disparities among LMSM.

Racial Differences in Social Determinants of Health and Outcomes Among Hispanic/Latino Persons with HIV-United States, 2015-2020

BACKGROUND

Hispanic/Latino people with HIV (PWH) experience disparities in health outcomes compared with other racial and ethnic groups. Disaggregated data based on race for Hispanic/Latino PWH in the United States are rarely reported, potentially masking inequities.

METHODS

The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV. We used weighted interview and medical record data collected from June 2015-May 2021 to examine differences in social determinants of health (SDH) and health outcomes by self-reported race among Hispanic/Latino adults with diagnosed HIV.

RESULTS

Compared with White Hispanic/Latino PWH, Black Hispanic/Latino PWH were more likely to be unemployed (PR, 1.4; CI, 1.2-1.8), have a disability (PR, 1.3; CI, 1.2-1.5), have experienced homelessness (PR, 1.8; CI, 1.2-2.6), and have been incarcerated (PR, 2.6; CI, 1.5-4.5). American Indian/Alaska Native (AI/AN) (PR, 1.8; CI, 1.1-2.7) and multiracial (PR, 2.0; CI, 1.4-2.9) Hispanic/Latino PWH were more likely to have experienced homelessness than White Hispanic/Latino PWH. Black (PR, 1.3; CI, 1.2-1.5) and multiracial (PR, 1.2; CI, 1.1-1.5) Hispanic/Latino PWH were more likely to be virally unsuppressed than White Hispanic/Latino PWH.

CONCLUSION

Black, multiracial, and AI/AN Hispanic/Latino PWH experience disparities in SDH and HIV outcomes. Lumping Hispanic/Latino people into one racial and ethnic category obscures health disparities, which might limit our progress towards reaching national HIV goals. Future studies should consider disaggregating by other factors such as Hispanic origin, place of birth, immigration status, and primary language. Doing so recognizes the diversity of the Hispanic/Latino population.

Mpox: Clinical Outcomes and Impact of Vaccination in People with and without HIV: A Population-Wide Study

We investigated differences in mpox clinical outcomes in people with HIV (PWH) and without HIV (PWoH) and the impact of vaccination in Catalonia, Spain. We used surveillance data and the PISCIS HIV cohort. We included all confirmed mpox cases (May-December 2022). Of 2122 mpox cases, the majority had mild disease, 56% were Spanish, and 24% were from Latin America. A total of 40% were PWH, with a median CD4+T-cell of 715 cells/μL; 83% had HIV-RNA < 50 copies/mL; and 1.8% CD4+T-cell < 200 cells/μL. PWH had no increased risk for complications, except those with CD4+T-cell < 200 cells/μL. PWH with CD4+T-cell < 200 cells/μL were more likely to be from Latin America, had more generalized exanthema, and required hospitalization more frequently (p = 0.001). Diagnosis of other sexually transmitted infections (STIs) was common, both at mpox diagnosis (17%) and two years before (43%). Dose-sparing smallpox intradermal vaccination was accompanied by a sharp decrease in mpox incidence in both populations (p < 0.0001). In conclusion, unless immunosuppressed, PWH were not at increased risk of severe disease or hospitalization. Mpox is a marker of high-risk sexual behavior and was associated with high HIV and STI rates, supporting the need for screening in all mpox cases. Ethnicity disparities demonstrate the need for interventions to ensure equitable healthcare access. Dose-sparing smallpox vaccination retained effectiveness.

Racial and Ethnic Disparities in Mpox Cases and Vaccination Among Adult Males - United States, May-December 2022

As of December 31, 2022, a total of 29,939 monkeypox (mpox) cases* had been reported in the United States, 93.3% of which occurred in adult males. During May 10-December 31, 2022, 723,112 persons in the United States received the first dose in a 2-dose mpox (JYNNEOS)^† vaccination series; 89.7% of these doses were administered to males (1). The current mpox outbreak has disproportionately affected gay, bisexual, and other men who have sex with men (MSM) and racial and ethnic minority groups (1,2). To examine racial and ethnic disparities in mpox incidence and vaccination rates, rate ratios (RRs) for incidence and vaccination rates and vaccination-to-case ratios were calculated, and trends in these measures were assessed among males aged ≥18 years (males) (3). Incidence in males in all racial and ethnic minority groups except non-Hispanic Asian (Asian) males was higher than that among non-Hispanic White (White) males. At the peak of the outbreak in August 2022, incidences among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) males were higher than incidence among White males (RR = 6.9 and 4.1, respectively). Overall, vaccination rates were higher among males in racial and ethnic minority groups than among White males. However, the vaccination-to-case ratio was lower among Black (8.8) and Hispanic (16.2) males than among White males (42.5) during the full analytic period, indicating that vaccination rates among Black and Hispanic males were not proportionate to the elevated incidence rates (i.e., these groups had a higher unmet vaccination need). Efforts to increase vaccination among Black and Hispanic males might have resulted in the observed relative increased rates of vaccination; however, these increases were only partially successful in reducing overall incidence disparities. Continued implementation of equity-based vaccination strategies is needed to further increase vaccination rates and reduce the incidence of mpox among all racial and ethnic groups. Recent modeling data (4) showing that, based on current vaccination coverage levels, many U.S. jurisdictions are vulnerable to resurgent mpox outbreaks, underscore the need for continued vaccination efforts, particularly among racial and ethnic minority groups.

Race and Sexual Identity Differences in PrEP Continuum Outcomes Among Latino Men in a Large Chicago Area Healthcare Network

U.S. HIV incidence is threefold higher among Latino individuals than non-Latino Whites. Pre-exposure prophylaxis (PrEP) uptake remains low among Latino men. Most HIV studies view Latino communities as a monolithic group, ignoring racial and sexual diversity. This analysis examines PrEP-related outcomes including eligibility, first prescription, and second prescription across race and sexual identity in a sample of Latino cisgender men (n = 8271) who sought services from a healthcare network in Chicago in 2012-2019. Logistic regression was used to calculate adjusted odds ratios. Latino-only participants had lower odds of PrEP eligibility and first prescription compared to White-Latino participants. No other significant differences by race were detected. While bisexual participants had equivalent odds of PrEP eligibility, they had lower odds of first PrEP prescription compared to gay participants. Heterosexual participants also had lower odds of PrEP eligibility and initiation. Future research should address unique factors shaping PrEP-related outcomes among diverse Latino populations.

Sexual Role Identity and Anal Sex Positioning among Brazilian, Colombian, and Dominican Immigrant Sexual Minority Men

Sexual role identities for anal sex and anal sex positionings are often conflated in research. This study aimed to identify profiles of sexual minority men based on sexual role identity and anal sex positioning and determine correlates of these profiles, including individual (i.e., HIV-status identity, condom use, partner type, sexual orientation) and cultural (i.e., same-race partnering, country of birth, acculturation) factors. A sample of Brazilian, Colombian, and Dominican immigrant sexual minority men (n = 480) living in New York City were surveyed about identity and positioning at the two most recent encounters. Individual and cultural factors were examined as correlates of profiles identified through latent class analysis. Four latent classes were identified: No Labels (12%), Receptive Bottoms (16%), Insertive Tops (23%), Insertive and Receptive Versatiles (49%). We found a concordance rate of ~70% between identity and behavior. A proportion (12%) of behaviorally versatile men chose not to use sexual role labels. Living with HIV was associated with receptive and versatile classes, sex with main partners was associated with versatility, and sexual orientation differed across classes. Identity and behavior should not be used interchangeably in research or applied domains, particularly given the complexities of versatility and men who prefer to not use labels.

Predicting Emergence of Primary and Secondary Syphilis Among Women of Reproductive Age in US Counties

BACKGROUND

Syphilis, a sexually transmitted infection that can cause severe congenital disease when not treated during pregnancy, is on the rise in the United States. Our objective was to identify US counties with elevated risk for emergence of primary and secondary (P&S) syphilis among women of reproductive age.

METHODS

Using syphilis case reports, we identified counties with no cases of P&S syphilis among women of reproductive age in 2017 and 1 case or more in 2018. Using county-level syphilis and sociodemographic data, we developed a model to predict counties with emergence of P&S syphilis among women and a risk score to identify counties at elevated risk.

RESULTS

Of 2451 counties with no cases of P&S syphilis among women of reproductive age in 2017, 345 counties (14.1%) had documented emergence of syphilis in 2018. Emergence was predicted by the county's P&S syphilis rate among men; violent crime rate; proportions of Black, White, Asian, and Hawaiian/Pacific Islander persons; urbanicity; presence of a metropolitan area; population size; and having a neighboring county with P&S syphilis among women. A risk score of 20 or more identified 75% of counties with emergence.

CONCLUSIONS

Jurisdictions can identify counties at elevated risk for emergence of syphilis in women and tailor prevention efforts. Prevention of syphilis requires multidisciplinary collaboration to address underlying social factors.

A call for epidemic modeling to examine historical and structural drivers of racial disparities in infectious disease

Since this is a commentary, there is no abstract.

PrEP4Love: The Role of Messaging and Prevention Advocacy in PrEP Attitudes, Perceptions, and Uptake Among YMSM and Transgender Women

BACKGROUND

Despite high efficacy, use of pre-exposure prophylaxis (PrEP) remains low among young men who have sex with men (MSM) and transgender women (TW), primarily because of barriers such as stigma and resource awareness. We evaluated a social marketing campaign known as PrEP4Love that works to eliminate PrEP stigma; and awareness gaps through targeted advertising.

SETTING

Chicago, Illinois.

METHODS

Participants were enrolled within a cohort study of young MSM and TW (RADAR). Data were collected between June 2017 and April 2018 from HIV-negative individuals attending a follow-up visit. Surveys assessed demographics, PrEP attitudes and perceptions, and PrEP4Love campaign awareness. Associations between PrEP4Love awareness and PrEP perceptions, uptake, and behaviors were assessed using multiple logistic regression controlling for age, race/ethnicity, gender, sexual identity, and ever having used PrEP.

RESULTS

Of 700 participants, the majority (75.9%) indicated seeing PrEP4Love ads in Chicago. Those who had seen ads were more likely to be out to their providers (odds ratio = 1.95; 95% confidence interval: 1.17 to 3.23) than those who had not, and those who had conversations were significantly more likely to have initiated the conversation themselves. Individuals who had seen ads were more likely to have taken PrEP in the last 6 months (odds ratio = 1.87; 95% confidence interval: 1.15 to 3.16) and more likely to believe their friends and the general public approved of and used PrEP.

CONCLUSION

Social marketing campaigns are promising interventions that have the potential to alleviate barriers to HIV prevention, particularly among MSM and TW. Future research should evaluate the impact of these initiatives at multiple time points.