Social Determinants of HIV/AIDS and Sexually Transmitted Diseases Among Black Women: Implications for Health Equity

CDC Prioritizes HIV Prevention and Treatment to Reduce HIV Disparities Among Cis-Gender Black Women

To succeed in ending the HIV epidemic in the United States, the Centers for Disease Control and Prevention (CDC) focuses on delivering combinations of scientifically proven, cost-effective, and scalable interventions to priority populations. Systemic factors continue to contribute to persistent health disparities and disproportionately higher rates of HIV diagnosis in some communities. The National HIV/AIDS Strategy has designated cis-gender Black women (CgBW) as a priority population to address the racial and ethnic inequities in HIV. This report presents the portfolio of projects, programs, and initiatives funded by the CDC's Division of HIV Prevention (DHP) to address disparities in HIV and improve health and QOL among CgBW. These funded activities include the development, planning, and implementation of HIV prevention programs, mass media campaigns, and behavioral interventions focused on CgBW. This report also summarizes DHP's community engagement, capacity building, and partnership efforts, and highlights research and surveillance activities focusing on CgBW. Finally, this report outlines future directions for CDC's efforts to improve access to HIV testing, treatment, and prevention for CgBW in the United States.

Program Director Reports of COVID-19 Lockdown-Driven Service Changes in Community-Based STI Clinics and Syringe Services Programs in the Southeastern U.S

The COVID-19 pandemic strained the U.S. health care system, posing logistical challenges for community-based programs. This study surveyed 11 program directors in sexually transmitted infection (STI) clinics and syringe services programs (SSPs) that served people who use substances and are at risk for HIV in five southeastern U.S. states. Brief survey questions asked about programs' use of in-person and telehealth services. Results indicated widespread reduction of in-person services and concomitant adoption of telehealth services. In STI clinics, telehealth replaced in-person visits for all but urgent treatment of active symptoms. In SSPs, in-person contact continued or increased from pre-pandemic volumes. In both programs, the most salient telehealth use barrier was limited device or internet access and limited technological ease. Services were sustained through innovative adaptations. This snapshot of response to the early COVID-19 lockdown phase offers actionable guidance about service preparedness for future public health catastrophes in community-based programs serving vulnerable populations.

Black women in HIV research: Intersectionality, positionality and our commitment to build a just research enterprise

Black women in the United States are disproportionately affected by human immunodeficiency virus (HIV) and are less likely to be represented among HIV clinical research participants relative to their cumulative HIV burden. Likewise, Black women are underrepresented in large federally funded HIV research portfolios. Extensive research has demonstrated that Black applicants and women applicants are less likely to receive R01 level funding from the National Institutes of Health, among all applicants. Support for a diverse biomedical research workforce, particularly researcher-participant concordance, has been widely accepted as a much-needed strategy to advance health outcomes among racial and ethnic and sex and gender minority communities. The benefits of employing a diverse research workforce include building trust among historically marginalized populations and support for diverse perspectives among investigative teams. In this paper, we explore intersectional challenges specific to Black women researchers in the development and implementation of HIV research, intervention, and programming efforts which include perceptions of Blackness, HIV research "turf," inequitable funding, institutional difficulties hiring Black women with lived experiences, and limitations in participant connectedness following study completion. We emphasize proposed solutions to support equitable, ethical, and culturally appropriate advancements in ending the HIV epidemic which are contextualized within Black women's unique intersectional identities and experiences.

Digital Health App to Address Disparate HIV Outcomes Among Black Women Living in Metro-Atlanta: Protocol for a Multiphase, Mixed Methods Pilot Feasibility Study

BACKGROUND

Cisgender Black women in the southern United States are at heightened risk for HIV and adverse sexual and reproductive health outcomes. Mobile health interventions that target HIV risk while being adapted to the needs and lived experiences of Black women are remarkably limited.

OBJECTIVE

The study aims to refine SavvyHER, a mobile app for HIV prevention, with Black women residing in high HIV incidence areas of Georgia and evaluate the feasibility, acceptability, and usability of SavvyHER. This paper describes the procedures implemented to conduct this research.

METHODS

Community-based participatory research tenets guide this multiphase study to finalize the development of what we hypothesize will be an effective, sustainable, and culturally relevant HIV prevention and optimal sexual health and reproductive wellness app for Black women. This multiphased, mixed methods study consists of 3 phases. The first phase entails focus groups with Black women to understand their preferences for the functionality and design of a beta prototype version of SavvyHER. In the second phase, an app usability pretest (N=10) will be used to refine and optimize the SavvyHER app. The final phase will entail a pilot randomized controlled trial (N=60) to evaluate the app's feasibility and usability in preparation for a larger trial.

RESULTS

Findings from preliminary focus groups revealed educational content, app aesthetics, privacy considerations, and marketing preferred by Black women, thus informing the first functional SavvyHER prototype. As we adapt and test the feasibility of SavvyHER, we hypothesize that the app will be an effective, sustainable, and culturally relevant HIV prevention, sexual health, and reproductive wellness tool for Black women.

CONCLUSIONS

The findings from this research substantiate the importance of developing health interventions curated for and by Black women to address critical HIV disparities. The knowledge gained from this research can reduce HIV disparities among Black women through a targeted intervention that centers on their health needs and priorities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42712.

Social Correlates of HIV-Risky Behaviours among African Canadian Adolescents Living in British Columbia, Canada: A Secondary Data Analysis

Studies have linked HIV-risky behaviours among young people to several socio-contextual factors. However, the social factors that might increase African Canadian adolescents' exposure to HIV-risky behaviours, including unprotected sex and forced or multiple-sexual partnerships, have received little or no attention in the literature. Using data from the British Columbia Adolescent Health Surveys (2003-2018) and guided by intersectionality and socio-ecological frameworks, we examined the social determinants of HIV-risky behaviours (HRB) among African Canadian adolescents in British Columbia. We observed a general decline in HRB from 2008 to 2018. However, more than half (54.5%) of the 1042 who were sexually experienced in 2018 reported having 2 or more sexual partners, and nearly half reported condom-less sex. Our results demonstrate an important need to evaluate the impacts of several social factors on health outcomes for a unique, marginalized population.

Using Network Analysis to Assess the Effects of Trauma, Psychosocial, and Socioeconomic Factors on Health Outcomes Among Black Women Living with HIV

Black women living with HIV (BWLWH) face intersectional adversities impacting their wellbeing. This study utilized network analysis to assess the associations among adversities linked to racism, sexism, HIV stigma, and socioeconomic status (income, housing, education) and determine which adversities predict mental health outcomes, HIV viral load, and medication adherence more consistently among BWLWH. 119 BWLWH aged 18 years or older completed self-report measures on sociodemographics, adversity factors, and mental health outcomes. Viral load count was obtained through blood draws, and medication adherence was measured via Wisepill adherence monitoring device. Multiple regression analysis was used to assess if the more central factors in the network also predicted health outcomes more consistently than the less central factors. The four most central factors in the network were income, housing, gendered racial microaggression (GRM) frequency, and GRM appraisal. Multiple regression analysis revealed that GRM frequency, GRM appraisal, and the number of traumas contributed uniquely and were positively associated with both depressive symptoms and posttraumatic stress disorder symptoms. HIV-related discrimination contributed uniquely and was positively associated with HIV viral load.

HIV testing during pregnancy among women with a recent live birth-Seven US States, 2016-2019

BACKGROUND

Although the United States has made progress in reducing the transmission of HIV from mother-to-child, it has not yet met the goal of reducing such transmissions to 70%. Self-reported HIV testing varied by state of residence. Approximately, two in three women reported that their health care provider asked them about HIV testing during prenatal care, and 82.3% of those asked reported receipt of a test.

OBJECTIVES

The aim of this study was (1) to examine the prevalence of receipt of an HIV test during pregnancy and (2) to examine differences in HIV testing during pregnancy by race/ethnicity, state of residence, and other sociodemographic characteristics.

DESIGN

Population-based surveillance of women with a recent live birth from seven US states. Individuals were sampled from birth certificate records 2-6 months postpartum and surveyed about their behaviors and experiences before, during, and shortly after pregnancy.

METHODS

Data from the Pregnancy Risk Assessment Monitoring System, a large, population-based survey, were used to estimate the prevalence of HIV testing during pregnancy during 2016-2019. Weighted prevalence estimates and 95% confidence intervals were calculated overall and by demographic and other selected characteristics.

RESULTS

Approximately two-thirds of women (66.1%) self-reported having a test for HIV during pregnancy. Prevalence varied by maternal characteristics and was highest among women who were non-Hispanic Black (80.7%) and among women who were aged ⩽ 24 years, had a high school education or less, were unmarried, or had Medicaid or no insurance for prenatal care (each > 70%). Self-reported HIV testing varied by state of residence. Approximately two in three women reported that their health care provider asked them about HIV testing during prenatal care, and 82.3% of those asked reported receipt of a test.

CONCLUSION

About one in three Pregnancy Risk Assessment Monitoring System respondents did not report an HIV test during pregnancy. Health care providers can help educate pregnant patients about the importance of HIV testing and ensure universal testing to help identify individuals needing treatment and reduce the rates of mother-to-child HIV transmission.

Community perspectives on addressing and responding to HIV-testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) among African, Caribbean and Black (ACB) people in Ontario, Canada

BACKGROUND

The African, Caribbean, and Black (ACB) population of Ontario, Canada is comprised of individuals with diverse ethnic, cultural and linguistic backgrounds and experiences; some of whom have resided in Canada for many generations, and others who have migrated in recent decades. Even though the ACB population represents less than 3.5% of the Canadian population, this group accounts for 21.7% of all new HIV infections. It is well-documented that ACB populations, compared to the general population, experience multi-level barriers to accessing appropriate and responsive HIV services. In this paper, we present qualitative findings on the ACB population's experiences with HIV-testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) and obtain their perspectives on how to improve access.

METHODS

We conducted twelve Focus Group Discussions (FGDs), within a two-day World Café event and used socio-ecological framework and community-based participatory research (CBPR) approaches to guide this work. We meaningfully engaged ACB community members in discussions to identify barriers and facilitators to HIV testing, PEP and PrEP and how these may be addressed. The FGDs were transcribed verbatim and thematic analysis guided data interpretation. Credibility of data was established through data validation strategies such as external audit and peer-debriefing.

RESULTS

Our analyses revealed multi-level barriers that explain why ACB community members do not access HIV testing, PEP and PrEP. Fear, health beliefs, stigma and lack of information, were among the most frequently cited individual- and community-level barriers to care. Health system barriers included lack of provider awareness, issues related to cultural sensitivity and confidentiality, cost, and racism in the health care system. Participants identified multi-level strategies to address the HIV needs including community-based educational, health system and innovative inter-sectoral strategies.

CONCLUSION

CBPR, co-led by community members, is an important strategy for identifying the multi-level individual, interpersonal, community, institutional and structural factors that increase HIV vulnerability in ACB communities, notably anti-Black systemic racism. Study findings suggest the need for targeted community-based strategies and strategies aimed at reducing health system barriers to testing and care.

A Qualitative Study on the Social Determinants of HIV Treatment Engagement Among Black Older Women Living With HIV in the Southeastern United States

ABSTRACT

Black older women living with HIV (BOWLH) in the United States are disproportionately affected by HIV infection and poor treatment engagement rates, often caused by multiple social determinants of health. In this descriptive qualitative study, we interviewed 17 BOWLH to investigate the facilitators and barriers to HIV treatment engagement. Data were analyzed using the socioecological framework. Findings demonstrate the positive influences of supportive social networks, perceived benefits, HIV-related knowledge, raising HIV awareness in communities, and impact of HIV state laws. The highlighted barriers were mainly low income, substance use, HIV-related stigma, influence of stereotypes and assumptions about older women living with HIV, and health insurance. Religion, managing comorbidities, attitude toward, HIV disclosure, and caregiving roles had both positive and negative influences on engagement. These findings illuminate factors of HIV treatment engagement that might be culturally founded; disseminating these factors to health care professionals is a critical intervention to support this population.

"PrEP's just to secure you like insurance": a qualitative study on HIV pre-exposure prophylaxis (PrEP) adherence and retention among black cisgender women in Mississippi

BACKGROUND

Pre-exposure prophylaxis (PrEP) has the potential to reduce transmission of HIV among Black cisgender women in the Southern United States (U.S.); however, national data suggests that PrEP initiation is lowest in the South and among Black women compared to other U.S. regions and white women. This study applied intersectionality and PrEP multilevel resilience frameworks to assess how socio-structural and clinical contexts shaped PrEP persistence among Black cisgender women in Mississippi.

METHODS

Semi-structured interviews were conducted with eight Black cisgender women in Jackson, Mississippi. This sample was purposively recruited to include PrEP-initiated Black cisgender women.

RESULTS

Six themes identified that shaped PrEP care among Black cisgender women: (1) internal assets, (2) sole responsibility to HIV prevention, (3) added protection in HIV serodifferent relationships, (4) financial issues, (5) trust and distrust in the medical system, and (6) side effects. Black cisgender women reported that PrEP persistence increased control over their sexual health, reduced anxiety about HIV, and promoted self-care. Black cisgender women also indicated that medication assistance programs increased PrEP affordability resulting in continued persistence.

CONCLUSIONS

In addition to preventing HIV, PrEP may yield secondary positive impacts on the health and relationships of Black cisgender women. However, very few Black cisgender women in the South are using PrEP given intersectional barriers and thus necessitates adaptive strategies to support PrEP initiation and persistence. Efforts aimed at increasing the coverage of PrEP among Black cisgender women should consider implementation strategies responsive to lived realities of Black women.

Social and Behavioral Determinants of Health in the Era of Artificial Intelligence with Electronic Health Records: A Scoping Review

Background. There is growing evidence that social and behavioral determinants of health (SBDH) play a substantial effect in a wide range of health outcomes. Electronic health records (EHRs) have been widely employed to conduct observational studies in the age of artificial intelligence (AI). However, there has been limited review into how to make the most of SBDH information from EHRs using AI approaches.Methods. A systematic search was conducted in six databases to find relevant peer-reviewed publications that had recently been published. Relevance was determined by screening and evaluating the articles. Based on selected relevant studies, a methodological analysis of AI algorithms leveraging SBDH information in EHR data was provided.Results. Our synthesis was driven by an analysis of SBDH categories, the relationship between SBDH and healthcare-related statuses, natural language processing (NLP) approaches for extracting SBDH from clinical notes, and predictive models using SBDH for health outcomes.Discussion. The associations between SBDH and health outcomes are complicated and diverse; several pathways may be involved. Using NLP technology to support the extraction of SBDH and other clinical ideas simplifies the identification and extraction of essential concepts from clinical data, efficiently unlocks unstructured data, and aids in the resolution of unstructured data-related issues.Conclusion. Despite known associations between SBDH and diseases, SBDH factors are rarely investigated as interventions to improve patient outcomes. Gaining knowledge about SBDH and how SBDH data can be collected from EHRs using NLP approaches and predictive models improves the chances of influencing health policy change for patient wellness, ultimately promoting health and health equity.

HIV Related Knowledge, HIV Testing Decision-Making, and Perceptions of Alcohol Use as a Risk Factor for HIV among Black and African American Women

The HIV/AIDS epidemic disproportionately affects Black and African American women in the United States. This study examined the extent of HIV related knowledge, HIV testing decision-making, and perceptions of alcohol use as a risk factor for HIV among Black and African American women in urban and suburban communities. Seven focus groups were conducted with 37 women aged 18 to 49 residing in the Commonwealth of Massachusetts. Women participating in focus groups had a wide breadth of HIV related knowledge. Findings suggest the influence of interpersonal relationships and provider-patient interactions on HIV testing, the need for building community capacity and leveraging community resources towards HIV prevention, and the influence of alcohol outlet density on HIV vulnerability and exposure in communities of color. Comprehensive multifaceted evidence informed interventions that are culturally relevant and gender responsive are needed to reduce HIV/AIDS disparities.

Feminine gender norms and syndemic harmful drinking, sexual violence, and sexually transmitted infections among Black women at risk for HIV

BACKGROUND

This study examined the associations between feminine gender ideologies (i.e., socially constructed attitudes and beliefs of women's appropriate behavior and roles) and the syndemic comorbidities of harmful alcohol use, sexual violence, and sexually transmitted infections (STI), which disproportionately affect Black women.

METHODS

Black women, aged 18-44 (n = 305) were recruited from STI clinics in Baltimore, MD into a retrospective cohort study. A survey assessed feminine gender ideologies using a measure of hyperfemininity and sexual hyperfemininity (subscale of sexual domains), harmful drinking (AUDIT), lifetime STI (Y/N and count), and syndemic burden (no burden [0-1 morbidity] and syndemic burden [2-3 comorbidities]). Multivariable regression models identified correlates of harmful drinking, STI, and syndemic burden. The analytic sample included (n = 231) women with complete data.

RESULTS

Nearly half of our sample reported high hyperfemininity and high sexual hyperfemininity, 23% reported harmful drinking, 39% experienced sexual violence as an adult, and 74% reported a lifetime STI. High sexual hyperfemininity (Adjusted Odds Ratio [AOR] = 1.94, 95% Confidence Interval [CI]: 1.00-3.76) and sexual violence (AOR = 2.82, 95%CI: 1.43-5.58) were associated with greater odds of harmful drinking. Experiencing sexual violence in adulthood was associated with an increased count of lifetime STIs (Adjusted Incidence Rate Ratio [AIRR] = 1.33, 95%CI: 1.06-1.68). Syndemic burden affected 41% of our sample. High sexual hyperfemininity was associated with experiencing syndemic burden in unadjusted models (OR = 1.98, 95%CI: 1.16-3.37), but was not significant after controlling for confounders.

CONCLUSIONS

Interventions to reduce harmful drinking and STIs among Black women in the U.S. should address sexual gender ideologies and sexual violence.

An Examination of Geographic Differences in Social Determinants of Health Among Women with Diagnosed HIV in the United States and Puerto Rico, 2017

Objective:

To examine differences, at the census tract level, in the distribution of human immunodeficiency virus (HIV) diagnoses and social determinants of health (SDH) among women with diagnosed HIV in 2017 in the United States and Puerto Rico.

Background:

In the United States, HIV continues to disproportionately affect women, especially minority women and women in the South.

Methods:

Data reported in the National HIV Surveillance System (NHSS) of the Centers for Disease Control and Prevention were used to determine census tract-level HIV diagnosis rates and percentages among adult women (aged ≥18 years) in 2017. Data from the American Community Survey were combined with NHSS data to examine regional differences in federal poverty status, education level, income level, employment status, and health insurance coverage among adult women with diagnosed HIV infection in the United States and Puerto Rico.

Results:

In the United States and Puerto Rico, among 6,054 women who received an HIV diagnosis in 2017, the highest rates of HIV diagnoses generally were among those who lived in census tracts where the median household income was less than $40,000; at least 19% lived below the federal poverty level, at least 18% had less than a high school diploma, and at least 16% were without health insurance.

Conclusion:

This study is the first of its kind and gives insight into how subpopulations of women are affected differently by the likelihood of an HIV diagnosis. The findings show that rates of HIV diagnosis were highest among women who lived in census tracts having the lowest income and least health coverage.

Opioid Use Disorders in People Living with HIV/AIDS: A Review of Implications for Patient Outcomes, Drug Interactions, and Neurocognitive Disorders

The opioid epidemic has had a significant, negative impact in the United States, and people living with HIV/AIDS (PLWHA) represent a vulnerable sub-population that is at risk for negative sequela from prolonged opioid use or opioid use disorder (OUD). PLWHA are known to suffer from HIV-related pain and are commonly treated with opioids, leading to subsequent addictive disorders. PLWHA and OUD are at an increased risk for attrition in the HIV care continuum, including suboptimal HIV laboratory testing, delayed entry into HIV care, and initiation or adherence to antiretroviral therapy. Barriers to OUD treatment, such as medication-assisted therapy, are also apparent for PLWHA with OUD, particularly those living in rural areas. Additionally, PLWHA and OUD are at a high risk for serious drug–drug interactions through antiretroviral-opioid metabolic pathway-related inhibition/induction, or via the human ether-a-go-go-related gene potassium ion channel pathways. HIV-associated neurocognitive disorders can also be potentiated by the off-target inflammatory effects of opioid use. PLWHA and OUD might require more intensive, individualized protocols to sustain treatment for the underlying opioid addiction, as well as to provide proactive social support to aid in improving patient outcomes. Advancements in the understanding and management of PLWHA and OUD are needed to improve patient care. This review describes the effects of prescription and non-prescription opioid use in PLWHA.

Special ambulatory gynecologic considerations in the era of coronavirus disease 2019 (COVID-19) and implications for future practice

The coronavirus disease 2019 pandemic has altered medical practice in unprecedented ways. Although much of the emphasis in obstetrics and gynecology to date has been on the as yet uncertain effects of coronavirus disease 2019 in pregnancy and on changes to surgical management, the pandemic has broad implications for ambulatory gynecologic care. In this article, we review important ambulatory gynecologic topics such as safety and mental health, reproductive life planning, sexually transmitted infections, and routine screening for breast and cervical cancer. For each topic, we review how care may be modified during the pandemic, provide recommendations when possible on how to ensure continued access to comprehensive healthcare at this time, and discuss ways that future practice may change. Social distancing requirements may place patients at higher risk for intimate partner violence and mental health concerns, threaten continued access to contraception and abortion services, affect prepregnancy planning, interrupt routine screening for breast and cervical cancer, increase risk of sexually transmitted infection acquisition and decrease access to treatment, and exacerbate already underlying racial and minority disparities in care and health outcomes. We advocate for increased use of telemedicine services with increased screening for intimate partner violence and depression using validated questionnaires. Appointments for long-acting contraceptive insertions can be prioritized. Easier access to patient-controlled injectable contraception and pharmacist-provided hormonal contraception can be facilitated. Reproductive healthcare access can be ensured through reducing needs for ultrasonography and laboratory testing for certain eligible patients desiring abortion and conducting phone follow-up for medication abortions. Priority for in-person appointments should be given to patients with sexually transmitted infection symptoms, particularly if at risk for complications, while also offering expedited partner therapy. Although routine mammography screening and cervical cancer screening may be safely delayed, we discuss society guideline recommendations for higher-risk populations. There may be an increasing role for patient-collected human papillomavirus self-samples using new cervical cancer screening guidelines that can be expanded considering the pandemic situation. Although the pandemic has strained our healthcare system, it also affords ambulatory clinicians with opportunities to expand care to vulnerable populations in ways that were previously underutilized to improve health equity.

Perceptions of African American Women and Health Care Professionals Related to Pre-Exposure Prophylaxis to Prevent HIV

OBJECTIVE

To describe the perceptions of African American women and health care professionals (HCPs) about factors that likely influence the use of pre-exposure prophylaxis (PrEP) to prevent HIV among African American women.

DESIGN

Prospective mixed methods.

SETTING

Chicago, IL.

PARTICIPANTS

Fifty-eight participants included HCPs (n = 10) and African American women (n = 48).

METHODS

Following the six steps of concept mapping, participants identified and rated factors they perceived to influence decisions to use PrEP among African American women.

RESULTS

African American women generated a list of statements, and we grouped the statements into eight clusters: access, financial, best benefits, protection, medication, setbacks, network, and fear. HCPs ranked having an HIV-positive partner as the most influential factor that affected African American women's decisions to use PrEP (network cluster). African American women ranked ability to prevent HIV when condom use cannot be negotiated as their top reason (best benefits cluster) for using PrEP.

CONCLUSION

African American women wanted to know how they could protect themselves and were open to using PrEP. For African American women considering the use of PrEP, the most influential factors were related to the benefits and accessibility of PrEP. HCPs should know that African American women are not afraid to discuss HIV risk and testing.

A Community-Engaged Approach to Creating a Mobile HIV Prevention App for Black Women: Focus Group Study to Determine Preferences via Prototype Demos

Background

Black women are an important but relatively overlooked at-risk group in HIV prevention efforts. Although there is an aggregate decline of HIV diagnoses among women in the United States, there are persistent disparate rates of new HIV infections among Black women compared to any other cisgender female subgroup. Strategies to end the HIV epidemic—as outlined in the Ending the HIV Epidemic initiative—for all communities must consider HIV prevention messaging and message delivery mediums that are created with community input. Although mobile health (mHealth) is a popular platform for delivering HIV interventions, there are currently no mobile apps that consider cisgender Black women with the goal of promoting a comprehensive women’s reproductive health and HIV prevention lifestyle. Previous research recommends inclusion of the target population from project inception and iteratively throughout development, to promote use of the intervention.

Objective

The purpose of this study is to understand cisgender Black women’s preferences for functionality, format, and design of a mobile HIV prevention app and to examine their willingness to use an app for HIV prevention.

Methods

We conducted a series of four focus groups with 23 Black cisgender women. Focus groups included discussion and demonstration elements to address cisgender women’s general preference for apps, HIV prevention content that would be useful in an app, and preferred app features that would promote use of an HIV-centric app. During focus group discussions, participants were shown narrated, custom wireframes of HIV prevention app prototypes to demonstrate potential app function.

Results

Findings indicated the presence of eight subthemes within the coding structure of three overall themes: (1) health content within the mobile app, (2) mobile app functionality, format, and design, and (3) other suggested features. Specifically, participants detailed preferred educational content, content distribution, app aesthetics, privacy considerations, and marketing of the app.

Conclusions

Findings suggest that Black cisgender women preferred an app that integrated HIV prevention and optimal sexual health promotion. Participants provided a range of preferences for content integration and facilitators of app engagement with an HIV prevention app. Preferences centered on gender and cultural congruency of information and content, evidenced by visuals, language, and resources. Black cisgender women are viable consumers for a mobile app–based HIV prevention intervention.

States with higher minimum wages have lower STI rates among women: Results of an ecological study of 66 US metropolitan areas, 2003-2015

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003-2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage.

Racial and Ethnic Differences in Viral Suppression Among HIV-Positive Women in Care

BACKGROUND

Women with HIV diagnoses are less likely to be virally suppressed than men. Women of different racial/ethnic groups may be differentially affected by sociodemographic factors. We examined differences in viral suppression among women by race/ethnicity and associated variables to inform prevention interventions.

METHODS

We used data from the 2010-2014 cycles of the Medical Monitoring Project, a cross-sectional survey of HIV-positive adults in care. We limited analyses to black, Hispanic, and white women. We calculated weighted prevalences of recent viral suppression (undetectable or <200 copies/mL) and sustained viral suppression (consistent viral suppression during the past 12 months) among women by race/ethnicity. We computed adjusted prevalence differences (aPDs) and 95% confidence intervals (CIs) for viral suppression by racial/ethnic group, controlling for selected variables, including available social determinants of health variables.

RESULTS

Among women, 62.9% were black, 19.8% Hispanic, and 17.3% white. Overall, 74.3% had recent viral suppression, and 62.3% had sustained viral suppression. Compared with white women (79.7%, CI: 77.2 to 82.2), black (72.5%, CI: 70.3 to 74.7; PD: 7.2) and Hispanic (75.4%, CI: 72.6 to 78.3; PD: 4.3) women were less likely to have recent viral suppression. In multivariable analyses, after adjusting for antiretroviral therapy adherence, HIV disease stage, age, homelessness, and education, black-white aPDs remained significant for recent (aPD: 4.8, CI: 1.6 to 8.1) and sustained (aPD: 5.0, CI: 1.1 to 9.0) viral suppression.

CONCLUSION

Viral suppression was suboptimal for all women, but more for black and Hispanic women. Differences between black, Hispanic, and white women may be partially due to antiretroviral therapy adherence, HIV disease stage, and social determinants of health factors.

Older African Americans and the HIV Care Continuum: A Systematic Review of the Literature, 2003-2018

Evidence suggests that racial disparities in the HIV care continuum persist in older age groups, particularly among African Americans. The objective of this systematic review was to identify factors that facilitate or hinder older African Americans' engagement in the HIV care continuum. For studies published between 2003 and 2018, we: (1) searched databases using keywords, (2) excluded non-peer-reviewed studies, (3) limited findings to older African Americans and the HIV care continuum, and (4) retrieved and summarized data focused on barriers and facilitators of the HIV care continuum. Among the 1023 studies extracted, 13 were included: diagnosis/testing (n = 1), engagement in care (n = 7), and antiretroviral adherence (n = 5). Barriers included lack of HIV risk awareness, routine testing, and healthcare access, stigma, and multimorbidities. Social support, health/medication literacy, and increased self-efficacy facilitated engagement. A targeted focus on older African Americans is needed to achieve national goals of improving HIV care and treatment outcomes.

Mental Representation of Self in Relationships Indirectly Affects Young Black Women's Engagement in Risky Sexual Behaviors Through Psychosocial HIV/STI Risk Factors

Black females are disproportionately affected by HIV/STIs, though individual-level sexual risk factors do not appear to explain racial/ethnic HIV incidence rate disparities. The current study examined the roles of attachment representations, working models of self and others, with psychosocial risk factors related to population-level sexual network features in association with risky sexual behaviors. A total of 560 Black emerging adult females (M age= 20.58, SD = 1.89) enrolling in a behavioral HIV prevention intervention trial completed the baseline assessment used in the current analyses. A series of multiple mediator models examined indirect effects of working models of self and others on sexual risk engagement through the following psychosocial HIV/STI risk factor: (a) partner communication self-efficacy, (b) fear of condom negotiation, (c) peer norms for risky sexual behavior, (d) partner trust, and (e) sex-related alcohol expectancies. Results indicated indirect effects of working model of self on: condom use with boyfriend/main partner through peer norms for risky sex (ab = .08 ,95% CI [.02, .17]); any alcohol use prior to sex through peer norms for risky sex (ab = -.06, 95% CI [-.12, -.02]); and alcohol use prior to sex through sex-related alcohol expectancies (ab = -.13, 95% CI [-.21, -.05]). Findings indicated direct associations between working model of self and all the psychosocial HIV/STI risk factors included in the mediation models. Working model of self may help identify Black females elevated risk for HIV/STI through these psychosocial risk factors.

A Longitudinal Analysis of the Substance Abuse, Violence, and HIV/AIDS (SAVA) Syndemic among Women in the Criminal Justice System

Using data from a randomized controlled trial of 319 women mainly recruited from a Municipal Drug Court System in St. Louis, MO, this study evaluates substance use, victimization, and HIV/AIDS risk behaviors over time. The results indicated that, for all participants, the likelihood of victimization, using drugs, and meeting the criteria for HIV/AIDS risk decreased by 46% by the eight-month follow-up; however, results did not differ significantly by intervention group. Women who were sexually abused as a child, had 4+ arrests, or believed they had sexual and drug-using behaviors that need changing at baseline were more likely to experience these issues over time.

Risky Sexual Behaviors, Substance Use, and Perceptions of Risky Behaviors Among Criminal Justice Involved Women Who Trade Sex

This study examined risky sexual behaviors, Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV)-defined alcohol and substance use disorders, and perceptions of risky behaviors among community released, justice-involved women, who are currently trading sex (CTS), formerly traded sex (FTS), or have never traded sex. Data were derived from 266 sexually active women recruited from a Municipal Drug Court System in St. Louis, Missouri. In an adjusted multinomial regression model, being dependent on alcohol and cocaine was the most robust correlate of sex-trading status (adjusted odds ratio [AOR]: CTS = 4.21, FTS = 4.66). Perceptions of sexual risk and HIV were significantly associated with CTS (AOR = 3.39), however, not FTS. Other significant correlates of sex trading status included age, lifetime injection drug use, lower education, child sexual abuse, and unstable housing. Gender-specific interventions tailored toward currently and formerly sex-trading women are needed.

Trends in Geographic Rates of HIV Diagnoses Among Black Females in the United States, 2010-2015

BACKGROUND

HIV diagnoses among females in the United States declined 22% from 2010 to 2015, including a 27% decline in diagnoses among black females. Despite this progress, disparities persist. Black females accounted for 60% of new HIV diagnoses among females in 2015. Geographic disparities also exist. This article describes geographic differences in HIV diagnoses among black females in the United States, from 2010 to 2015.

MATERIALS AND METHODS

We examined HIV surveillance data from 2010 to 2015 to determine in which geographic areas decreases or increases in HIV diagnoses occurred. We used data from the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's (NCHHSTP) AtlasPlus to calculate percent changes in HIV diagnosis rates by geographic region for black females ≥13 years of age.

RESULTS

The number of new HIV diagnoses declined 27% among black females from 2010 to 2015. The highest rates of HIV diagnosis per 100,000 population of black females, from 2010 to 2015, were in the Northeast and the South. In 2015, five of the eight states reporting the highest rates of HIV diagnosis (i.e., the highest quartile) were in the South.

CONCLUSIONS

HIV diagnosis rates decreased nationally among black females, but the decreases were not uniform within regions or across the United States. Some states experienced increases, and black females in the South and Northeast remain disproportionately affected. Additional research is needed to ascertain factors associated with the increases to continue progress toward reducing HIV-related disparities among females in the United States.

Prevalence, Comorbidity, and Correlates of Psychiatric and Substance Use Disorders and Associations with HIV Risk Behaviors in a Multisite Cohort of Women Living with HIV

We used the World Health Organization’s Composite International Diagnostic Interview to determine the prevalence, comorbidity, and correlates of lifetime and 12-month behavioral health disorders in a multisite cohort of 1027 women living with HIV in the United States. Most (82.6%) had one or more lifetime disorders including 34.2% with mood disorders, 61.6% with anxiety disorders, and 58.3% with substance use disorders. Over half (53.9%) had at least one 12-month disorder, including 22.1% with mood disorders, 45.4% with anxiety disorders, and 11.1% with substance use disorders. Behavioral health disorder onset preceded HIV diagnosis by an average of 19 years. In multivariable models, likelihood of disorders was associated with women’s race/ethnicity, employment status, and income. Women with 12-month behavioral health disorders were significantly more likely than their counterparts to engage in subsequent sexual and substance use HIV risk behaviors. We discuss the complex physical and behavioral health needs of women living with HIV.

Racial Disparities in Invasive Methicillin-resistant Staphylococcus aureus Infections, 2005-2014

Background

Despite substantial attention to the individual topics, little is known about the relationship between racial disparities and antimicrobial-resistant and/or healthcare-associated infection trends, such as for methicillin-resistant Staphylococcus aureus (MRSA).

Methods

We analyzed Emerging Infections Program 2005-2014 surveillance data (9 US states) to determine whether reductions in invasive MRSA incidence (isolated from normally sterile body sites) affected racial disparities in rates. Case classification included hospital-onset (HO, culture >3 days after admission), healthcare-associated community onset (HACO, culture ≤3 days after admission and dialysis, hospitalization, surgery, or long-term care residence within 1 year prior), or community-associated (CA, all others). Negative binomial regression models were used to evaluate the adjusted rate ratio (aRR) of MRSA in black patients (vs in white patients) controlling for age, sex, and temporal trends.

Results

During 2005-2014, invasive HO and HACO (but not CA) MRSA rates decreased. Despite this, blacks had higher rates for HO (aRR, 3.20; 95% confidence interval [CI], 2.35-4.35), HACO (aRR, 3.84; 95% CI, 2.94-5.01), and CA (aRR, 2.78; 95% CI, 2.30-3.37) MRSA. Limiting the analysis to chronic dialysis patients reduced, but did not eliminate, the higher HACO MRSA rates among blacks (aRR, 1.83; 95% CI, 1.72-1.96), even though invasive MRSA rates among dialysis patients decreased during 2005-2014. These racial differences did not change over time.

Conclusions

Previous reductions in healthcare-associated MRSA infections have not affected racial disparities in MRSA rates. Improved understanding of the underlying causes of these differences is needed to develop effective prevention interventions that reduce racial disparities in MRSA infections.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Intersectional stigma among midlife and older Black women living with HIV

HIV-related stigma is a barrier to the prevention and treatment of HIV. For midlife and older Black women, the nature and intensity of HIV-related stigma may be compounded by their multiple marginalised social status based on gender, race, and age. We examined the perceptions and experiences of HIV-related stigma among midlife and older Black women living in Prince George's County, Maryland, USA. Between 2014 and 2015, we conducted semi-structured interviews with a sample of 35 midlife and older Black women living with HIV. Using a modified grounded theory approach, we explored emergent themes related to the manifestation and experience of intersectional stigma and changes in stigma experience over time. Our findings suggest that intersectional stigma is a central feature in midlife and older Black women's lives, with women reporting experiences of intersectional stigma at the interpersonal/familial, community, and institutional/structural levels. Although women acknowledged gradual acceptance of their HIV-positive status over time, they continued to experience negative responses related to gender, race, age, and disease. Our findings indicate that a more robust understanding of the impact of HIV-related stigma requires work to consider the complex manifestations of intersectional stigma among an increasingly aging population of Black women in the USA.

Evaluation of the Southern Harm Reduction Coalition for HIV Prevention: Advocacy Accomplishments

BACKGROUND

HIV/AIDS rates are higher in the Southern United States compared to other regions of the country. Reasons for disparities include poverty, health care access, and racism. People who inject drugs (PWID) account for 8% of HIV/AIDS incidence rates. Harm reduction can connect PWID to needed resources. AIDS United Southern REACH grantees developed the Southern Harm Reduction Coalition (SHRC) as a means to decrease HIV/AIDS and viral hepatitis rates, criminalization of drug users and sex workers, and drug overdose.

METHOD

Investigators used an intrinsic case study design to examine the context of harm reduction in the Southern United States, successful strategies, and outcomes. Data collection included key informant interviews and coalition documents. The community coalition action theory was used to examine the data.

RESULTS

The SHRC initiated regional conferences and customized trainings. Strengths-based language and utilization of diverse strengths among coalition members were used to effect change. Coalition outcomes included syringe decriminalization legislation, syringe exchange, naloxone access, naloxone funding legislation, and 911 Good Samaritan laws, along with expanded support for PWID.

CONCLUSIONS

Advocacy successes can be applied to similar organizations in the Southern United States to promote harm reduction and potentially decrease HIV/AIDS burden, viral hepatitis, criminalization, and overdose.

Reductions in HIV Diagnoses Among African American Women: A Search for Explanations

BACKGROUND

African American women experienced a 46% reduction in the rate of HIV diagnoses from 56.0 in 2008, to 30.0 in 2014 (per 100,000). The reasons for this decrease are unknown; however, we hypothesize that improvements in socioeconomic status, health care access, and risk behaviors may have contributed to this reduction.

METHODS

We analyzed data from 2006, 2010, and 2013 of the National HIV Behavioral Surveillance system. African American women living at or below poverty were surveyed from 19 United States cities using respondent-driven and venue-based sampling, and tested for HIV infection. We used generalized estimating equations to determine differences for selected outcomes regarding health care and risk behaviors over time.

RESULTS

Among 11,065 women, we found increases in the percentage of women who reported having a recent HIV test (P value = 0.0002); having health insurance (P < 0.0001); and recently visiting a health care provider (P < 0.0001). Being unemployed declined significantly (P = 0.0057), as did reporting recent injection drug use (P < 0.0001). Crack use declined among women aged 25-44 years (P < 0.0001). However, reporting condomless vaginal sex at last sex (P = 0.0268), condomless anal sex at last sex (P = 0.6462), or 3 or more sex partners in the past 12 months (P = 0.5449) remained stable.

DISCUSSION

Enhanced health care access and socioeconomic status and reductions in drug use may have contributed to the declines in HIV diagnoses among African American women in the United States.

Educated and At-Risk: How the Shortage of Available Partners Influences HIV Risk for College-Educated African-American Women

BACKGROUND

African-Americans have the greatest gender-ratio imbalance compared to other racial groups in the United States. This has been associated with higher rates of concurrent sexual partnerships, increasing risk of HIV infection. College-educated African-American women are of particular interest as they are not often represented in studies on HIV prevention, while their dating and sexual negotiation patterns may differ from those of their lower-educated and lower-income counterparts more often the subject of study in HIV research among African-Americans.

METHOD

In this qualitative study, we investigate: a) how the gender-ratio imbalance is perceived by college-educated African-American women, b) how they feel limited partner availability impacts heterosexual relationships in the African-American community, and c) the influence this has on their sexual decision making and HIV protective behaviors.

RESULTS

Four major themes emerged- Limited pool of available male partners, Pressure to get married, Feelings of competition among women for male partners, and Men's negotiating power in relationships.

CONCLUSIONS

Using the PEN-3 Cultural Model, we discuss how this information may be used to develop interventions for this group of women designed to address their more specific barriers to HIV risk reduction.

Advice for prevention from HIV-positive African-American women: 'My story is not just a story'

Large disparities in HIV incidence, prevalence and mortality exist for African-American women, especially in the southern region of the USA. Based on the culture-centric health promotion model, HIV-positive African American women can use their stories to support primary prevention. The purpose of this study was to document advice from HIV-positive African-American women (n = 25) to young African-American women, as described in their own cultural narratives collected through qualitative interviews. Content analysis of women's advice identified five common themes revolving broadly around: (1) advice for prevention, (2) support systems for prevention, (3) education, (4) empowerment/self-care and (5) potential barriers to prevention. Advice reflected recommendations based on personal experience and highlighted social determinants linked to HIV, such as stigma, access to education and healthcare, social support, and gender and power dynamics. Women also offered advice for coping with an HIV-positive diagnosis. Communication with parents, family and friends regarding education and social support emerged as an important interpersonal factor for participants, as were interactions with sexual/romantic partners. Stigma, at the community level, was consistently discussed as a hindrance to prevention. Narratives of HIV-positive women as community health agents of change can enhance the effectiveness of HIV prevention interventions for young US African-American women.

Lessons Learned From the Field-Testing of Healthy Love: An HIV Prevention Intervention for Black Women

BACKGROUND

Healthy Love is a brief, highly interactive, single-session, group-level HIV prevention intervention designed for African American women that is effective at reducing sex risk behaviors and increasing condom use and HIV testing among participants. The Centers for Disease Control and Prevention, through a contract, developed a user-friendly intervention package that would allow organizations to adopt and implement Healthy Love with fidelity.

METHOD

Training and implementation materials were developed to support original research protocols, and piloted and revised to conduct field-testing with case study agencies (CSAs). Three CSAs were selected to deliver the intervention over a 3-month period to test the utility of intervention materials and feasibility of implementation.

RESULTS

All CSAs were able to successfully deliver 10 sessions with a total of 185 women ranging from 18 to 59 years of age. Successes and challenges encountered in training, preimplementation activities, and intervention delivery are described.

DISCUSSION

Lessons learned from training, technical assistance, and process monitoring and evaluation informed final package revisions. Research to practice recommendations are shared as is guidance for future implementations of Healthy Love. The research to practice process used is a model approach for developing a comprehensive intervention package and will support the adoption of Healthy Love by other organizations.

Partnership-Level Analysis of African American Women's Risky Sexual Behavior in Main and Non-Main Partnerships

The majority of research on risky sexual behavior in African American women has examined global associations between individual-level predictors and behavior. However, this method obscures the potentially significant impact of the specific relationship or relationship partner on risky sexual behavior. To address this gap, we conducted partnership-level analysis of risky sexual behavior among 718 African American women recruited from HIV counseling, testing, and referral sites in four states. Using mixed model regressions, we tested relationships between condomless vaginal intercourse with men and variables drawn from the Theory of Planned Behavior, Theory of Gender and Power, and previous research specifically on sexual risks among African American women. Significant associations with risky sexual behavior indicate the need for continued emphasis on condom attitudes, condom negotiation behaviors, and overcoming partner resistance to condoms within both main and non-main partnerships when implementing interventions designed to address HIV and sexually transmitted infection risks among African American women.

Racial and Ethnic Differences in Substance Use Diagnoses, Comorbid Psychiatric Disorders, and Treatment Initiation among HIV-Positive and HIV-Negative Women in an Integrated Health Plan

Access to substance use disorder (SUD) treatment is a critical issue for women with HIV. This study examined differences in SUD diagnoses, comorbid psychiatric diagnoses, and predictors of SUD treatment initiation among a diverse sample of HIV-positive women (n = 228) and a demographically similar cohort of HIV-negative women (n = 693). Diagnoses and service utilization data were obtained from electronic health records of members of a large integrated healthcare system in Northern California. HIV-positive women were less likely to initiate SUD treatment. Significant racial/ethnic differences were found among both HIV-positive and HIV-negative women with respect to SUD diagnosis type and diagnosis of comorbid psychiatric disorders. Among the HIV-negative women, rates of SUD treatment initiation were lower for black women than for white or Latina women. Multivariable logistic regression models showed that alcohol, cannabis, and opiate diagnoses were predictive of SUD treatment initiation for both cohorts, while amphetamine diagnoses, comorbid depressive disorder, and being white or Latina were predictive of SUD treatment initiation for HIV-negative, but not HIV-positive, women. Findings suggest that clinicians need to be aware of differences in substances of abuse, comorbid psychiatric disorders, and to consider the demographic and social factors that may contribute to differences in SUD treatment initiation among HIV-positive and HIV-negative women.

Congenital syphilis: trends in mortality and morbidity in the United States, 1999 through 2013

BACKGROUND

Congenital syphilis (CS) results when an infected pregnant mother transmits syphilis to her unborn child prior to or at delivery. The severity of infection can range from a delivery at term without signs of infection to stillbirth or death after delivery.

OBJECTIVE

We sought to describe CS morbidity and mortality during 1999 through 2013.

STUDY DESIGN

National CS case data reported to Centers for Disease Control and Prevention during 1999 through 2013 were analyzed. Cases were classified as dead (stillbirths and deaths up to 12 months after delivery), morbid (cases with strong [physical, radiographic, and/or nonserologic laboratory] evidence of CS), and nonmorbid (cases with a normal physical examination reported, without strong evidence of infection). Annual rates of these cases were calculated. Cases were compared using selected maternal and infant criteria.

RESULTS

During 1999 through 2013, 6383 cases of CS were reported: 6.5% dead, 33.6% morbid, 53.9% nonmorbid, and 5.9% unknown morbidity; 81.8% of dead cases were stillbirths. Rates of dead, morbid, and nonmorbid cases all decreased over this time period, but the overall proportions that were dead or morbid cases did not significantly change. The overall case fatality ratio during 1999 through 2013 was 6.5%. Among cases of CS, maternal race/ethnicity was not associated with increased morbidity or death, although most cases (83%) occurred among black or Hispanic mothers. No or inadequate treatment for maternal syphilis, <10 prenatal visits, and maternal nontreponemal titer ≥1:8 increased the likelihood of a dead case; risk of a dead case increased with maternal nontreponemal titer (χ(2) for trend P < .001). Infants with CS born alive at <28 weeks' gestation (relative risk, 107.4; P < .001) or born weighing <1500 g (relative risk, 43.9; P < .001) were at greatly increased risk of death.

CONCLUSION

CS remains an important preventable cause of perinatal morbidity and mortality, with comparable case fatality ratios during 1999 through 2013 (6.5%) and 1992 through 1998 (6.4%). Detection and treatment of syphilis early during pregnancy remain crucial to reducing CS morbidity and mortality.

Structural community factors and sub-optimal engagement in HIV care among low-income women in the Deep South of the USA

This study describes the ways in which poverty and other structural factors create a risk environment for sub-optimal engagement in HIV care among low-income women living with HIV in the Southern USA, contributing to existing health disparities. We conducted a qualitative study in 2012, involving in-depth interviews with 14 stakeholders (service providers and representatives of community-based organisations) and 7 focus-group discussions with 46 women living with HIV (89% African American). A thematic approach in the context of the social ecological model guided data analysis. Data were coded and analysed using NVivo qualitative software. The findings suggested that structural community factors, such as poverty, poor employment opportunities, limited access to healthcare resources, stigma, transportation challenges and access to illicit substances, may work independently and in synergy to impact women's health seeking behaviour and decision-making, thereby influencing their ability to engage in HIV care. Interventions designed to improve engagement in HIV care should address structural factors to bolster low-income women's ability to engage in care.

Violence Against Women in Selected Areas of the United States

OBJECTIVES

We determined the prevalence of recent emotional, physical, and sexual violence against women and their associations with HIV-related risk factors in women living in the United States.

METHODS

We performed an assessment of women ages 18 to 44 years with a history of unprotected sex and 1 or more personal or partner HIV risk factors in the past 6 months from 2009 to 2010. We used multivariable logistic regression to examine the association of experiencing violence.

RESULTS

Among 2099 women, the prevalence of emotional abuse, physical violence, and sexual violence in the previous 6 months was 31%, 19%, and 7%, respectively. Nonmarried status, food insecurity, childhood abuse, depression symptomology, and posttraumatic stress disorder were significantly associated with multiple types of violence. All types of violence were associated with at least 3 different partner or personal HIV risk behaviors, including unprotected anal sex, previous sexually transmitted infection diagnosis, sex work, or partner substance abuse.

CONCLUSIONS

Our data suggested that personal and partner HIV risk behaviors, mental illness, and specific forms of violence frequently co-occurred in the lives of impoverished women. We shed light on factors purported to contribute to a syndemic in this population. HIV prevention programs in similar populations should address these co-occurring issues in a comprehensive manner.

The Epidemiology of Human Immunodeficiency Virus Infection and Care among Adult and Adolescent Females in the United States, 2008-2012

OBJECTIVE

We sought to determine epidemiological patterns in diagnoses of human immunodeficiency virus (HIV) infection and prevalence among females by age, race/ethnicity and transmission category, and essential steps in the continuum of HIV care.

METHODS

Using data from the National HIV Surveillance System, we estimated the number of females aged 13 years or older diagnosed with HIV infection in 2008 through 2012 and living with HIV at the end of 2011 in the United States. We determined percentages of females linked to care, retained in care, and virally suppressed in 18 jurisdictions with complete reporting of CD4 and viral load test results.

RESULTS

From 2008 to 2012, the estimated rate of HIV diagnoses among females decreased from 9.3 to 6.9 per 100,000 (-7.1% per year; 95% confidence interval [CI], -7.9, -6.3). In 2012, the diagnosis rate was highest among Blacks/African Americans (35.7), followed by Hispanics or Latinos (6.4), and Native Hawaiian Other Pacific Islander (5.1), and lowest among Whites (1.8). Most females diagnosed in 2012 were linked to care within 3 months of diagnosis (82.5%). About one-half (52.4%) of females living with HIV in 2011 received ongoing care in 2011 and 44.3% had a suppressed viral load. Viral suppression was lower among American Indian/Alaska Native (29.7%) and Black/African American (41.6%) compared with White females (46.5%). The percentage in care and with viral suppression was lower among younger compared with older females.

CONCLUSION

HIV diagnoses continue to decrease among females; however, disparities exist in HIV burden and viral suppression. Improvements in care and treatment outcomes are needed for all women with particular emphasis on younger women.

Context of risk for HIV and sexually transmitted infections among incarcerated women in the south: individual, interpersonal, and societal factors

Incarcerated women are disproportionately affected by HIV and sexually transmitted infections (STIs) due to risk factors before, during, and after imprisonment. This study assessed the behavioral, social, and contextual conditions that contribute to continuing sexual risk behaviors among incarcerated women to inform the adaptation of an evidenced-based behavioral intervention for this population. Individual, in-depth interviews were conducted with 25 current and 28 former women prisoners to assess HIV/STI knowledge, perceptions of risk, intimate relationships, and life circumstances. Interviews were independently coded using an iterative process and analyzed using established qualitative analytic methods. Major themes identified in the interviews involved three focal points: individual risk (substance abuse, emotional need, self-worth, perceptions of risk, and safer sex practices); interpersonal risk (partner pressure, betrayal, and violence); and risk environment (economic self-sufficiency and preparation for reentry). These findings highlight the critical components of HIV/STI prevention interventions for incarcerated women.

Race/ethnicity, sexual partnerships with men involved with drugs, and sexually transmitted infections among a sample of urban young adult women

In many urban neighbourhoods in the United States, drug markets borne from disadvantage have produced risk for sexually transmitted infections through altered sexual norms and partnerships. Presently, we examined the association of race, sexual partnerships with men involved with drugs, and self-reported sexually transmitted infections among 240 African American and white women aged 18-30 years. Thirty seven per cent reported ever having a sexually transmitted infection. Almost 30% of Whites reported sex with a drug user, compared to 5% of African Americans. Fifty eight per cent of African Americans compared to 31% of Whites reported sex with a drug dealer. On Step 1 of a sequential logistic regression model, race was associated with lifetime sexually transmitted infections (OR = 4.7, 95% CI = 2.61-8.34). Results from the full sequential logistic regression model indicated a significant, but smaller association of race and lifetime sexually transmitted infections (Adjusted OR = 3.5, 95% CI = 1.78-7.02) and an association of sex with a drug dealer and lifetime sexually transmitted infections (Adjusted OR = 2.9, 95% CI = 1.55-5.20). Forming sexual partnerships with drug dealers may place women at increased risk for sexually transmitted infections and explain racial disparities. More research focused on drug dealers as core transmitters is needed.

Race and health profiles in the United States: an examination of the social gradient through the 2009 CHIS adult survey

OBJECTIVE

To examine the role of the social gradient on multiple health outcomes and behaviors. It was predicted that higher levels of SES, measured by educational attainment and family income, would be associated with positive health behaviors (i.e., smoking, drinking, physical activity, and diet) and health status (i.e., limited physical activity due to chronic condition, blood pressure, obesity, diabetes, BMI, and perceived health condition). The study also examined the differential effects of the social gradient in health among different racial/ethnic groups (i.e., non-Hispanic Whites, Blacks, Asian, Hispanics, and American Indians).

STUDY DESIGN

Cross-sectional study.

METHODS

The data were from the adult 2009 California Health Interview Survey (CHIS). Weighted multivariable linear and logistic regression models were conducted to examine trends found between SES and health conditions and health behaviors. Polynomial trends were examined for all linear and logistic models to test for the possible effects (linear, quadratic, and cubic) of the social gradient on health behaviors and outcomes stratified by race/ethnicity.

RESULTS

Findings indicated that, in general, Whites had more favorable health profiles in comparison to other racial/ethnic groups with the exception of Asians who were likely to be as healthy as or healthier than Whites. Predicted marginals indicated that Asians in the upper two strata of social class display the healthiest outcomes of health status among all other racial/ethnic groups. Also, the social gradient was differentially associated with health outcomes across race/ethnicity groups. While the social gradient was most consistently observed for Whites, education did not have the same protective effect on health among Blacks and American Indians. Also, compared to other minority groups, Hispanics and Asians were more likely to display curvilinear trends of the social gradient: an initial increase from low SES to mid-level SES was associated with worse health outcomes and behaviors; however, continued increase from mid-SES to high SES saw returns to healthy outcomes and behaviors.

CONCLUSION

The study contributes to the literature by illustrating unique patterns and trends of the social gradient across various racial/ethnic populations in a nationally representative sample. Future studies should further explore temporal trends to track the impact of the social gradient for different racial and ethnic populations in tandem with indices of national income inequalities.

Population-based study of food insecurity and HIV transmission risk behaviors and symptoms of sexually transmitted infections among linked couples in Nepal

Food insecurity has recently emerged as an important risk factor for HIV acquisition among women worldwide. No previous studies have used linked data that would permit investigation of the extent to which food insecurity may have differential associations with HIV transmission risk behaviors or symptoms of sexually transmitted infections (STIs) among men and women in the same households. We used nationally representative data on linked couples from the Nepal 2011 Demographic and Health Survey. The primary explanatory variable of interest was food insecurity, measured with a modified version of the Household Food Insecurity Access Scale. In multivariable logistic regression models, women in food insecure households were less likely to report recent condom use and more likely to report symptoms consistent with STIs. These patterns were absent among men. Interventions targeting food insecurity may have beneficial implications for both HIV prevention and gender equity in Nepal.