# Presentation: 692833

## SOCIAL FORCES AND RACIAL DISPARITY IN HIV RATES IN THE UNITED STATES

**ADAORA A. ADIMORA, MD, MPH**
- Associate Professor of Medicine
- University of North Carolina at Chapel Hill

**Notes:**
Rates of heterosexually  transmitted HIV and other STIs are higher among blacks than whites in the US.
Indiv level behavior results in HIV transmission.  But I hope to show that:
1) social forces - specifically the socioeconomic context - are at the heart of the racial disparity in HIV rates in the US.
2) Structural solutions that effectively address the socioeconomic context will be critical in eliminating these racial disparities in HIV. 

## Slide 2

**Notes:**
The South has the largest number of people living with AIDS of all regions in the US.

## Slide 3

**Notes:**
By 2002 heterosexual contact had become the 2nd most common means of HIV transmission in the US.
Throughout much of the United States, rates of heterosexually transmitted HIV are dramatically higher among African Americans than whites; 74% of new heterosexually transmitted HIV cases in 29 states from 1999 through 2002 occurred among non-Hispanic blacks, although African Americans account for approximately 12% of the population.

## WHAT ARE RISK FACTORS?

- Why are rates of heterosexually transmitted HIV so high among blacks in the South?
- Sexual network characteristics?

**Notes:**
We asked what factors contribute to the high rates of heterosexually transmitted HIV among blacks in the south.  We were especially interested in the role of sexual network characteristics.

## POPULATION-BASED CASE-CONTROL STUDY

- All subjects:  African Americans, aged 18-59, who denied  MSM and IDU
- CASES (N=206)
- Recently reported heterosexually transmitted HIV infection
- Agreed to release their names to study staff
- CONTROLS (N=226)
- Randomly selected from general population ( NC Driver’s License file)
- Standardized interview at home re: demographic data, sexual behaviors/partnerships, drug use
*Adimora AA, Schoenbach VJ, et al. Heterosexually transmitted HIVinfection among African Americans in North Carolina. JAIDS 2006;41:616*

**Notes:**
We did a case control study among black men and women, in NC who denied male same sex behavior and IDU.
Cases were people with recently reported heterosexually transmitted HIV.
Controls were people randomly selected from the state driver’s license file.
Respondents were interviewed concerning sexual behavior and partnerships, drug use, and other risk behaviors

## DEMOGRAPHIC FEATURES

|  | Cases (%) | Controls (%) | OR (adj gender) |
| --- | --- | --- | --- |
| Men | 78 | 78 | N/A |
| Women | 128 | 148 | NA |
| < High school education | 41 | 17 | 3.4 (2.2, 5.3) |
| Annual income < $16K | 67 | 30 | 4.8 (3.0, 7.7) |
| Homeless in past 10 yrs | 18 | 5 | 3.9 (1.9, 7.7) |
| Food insecurity | 26 | 14 | 2.2 (1.4, 3.6) |
| > 24h in jail or prison | 40 | 12 | 5.7 (3.3, 9.7) |

**Notes:**
Cases were more likely to have low education,be poor, report homelessness, express concern about having enough food for themselves and their family in the past month, and report incarceration.

## RISK BEHAVIORS

|  | Cases (%) | Controls (%) | OR (adj. gender) |
| --- | --- | --- | --- |
| Lifetime # partners | 11 | 6 | P< .0001 (Wilcoxon) |
| # Partners past year | 2 | 1 | P< .0001 (Wilcoxon) |
| Exchanged sex | 31 | 7 | 5.9 (3.3, 10.7) |
| STD dx ever | 60 | 31 | 3.2 (2.2, 4.8) |
| Respondent used crack | 31 | 5 | 8.6 (4.4, 16.9) |
| Partner IDU | 19 | 5 | 4.6 (2.2, 9.7) |
| Partner used crack | 48 | 15 | 5.4 (3.4, 8.5) |
| Concurrent partnerships past 5 yrs | 60 | 38 | 2.3 (1.6, 3.5) |

**Notes:**
They were much more likely than controls to report behavioral risk: increased numbers of partners, use of crack, a partner who used drugs.

They also had a much higher likelihood of having had an STD dx.

## RISK FACTORS FOR HETEROSEXUALLY TRANSMITTED HIV: MULTIVARIABLE ANALYSIS

| Variable | Odds Ratio |
| --- | --- |
| Less than HS education | 3.0 (1.8, 5.2) |
| Number of partners during lifetime (log) | 1.5 (1.1, 1.9) |
| Respondent smoked crack | 3.7 (1.7, 8.1) |
| Partner(s) injected drugs | 3.0 (1.2, 7.7) |
| Partner smoked crack | 2.1 (1.2, 3.8) |

**Notes:**
Independent risk factors for HIV infection were less than HS education, increased partner number, crack use, having a partner who injected drugs, and having a partner who smoked crack.

## RISK FACTORS FOR HETEROSEXUALLY TRANSMITTED HIV: AFRICAN AMERICANS IN NORTH CAROLINA

- African Americans with heterosexually acquired HIV infection:
- Most reported high-risk behavior and/or high-risk partners
- BUT
- 27% of cases (and 69% of controls) denied high-risk sexual partners or behaviors
*Adimora AA, Schoenbach VJ, et al. Heterosexually transmitted HIV infection among African Americans in North Carolina. JAIDS 2006;41:616*

**Notes:**
So most people had high -risk behaviors and/or high-risk partners, 
BUT 27% of cases (and 69% of controls) denied high-risk sexual partners or behaviors.

## LOWER RISK RESPONDENTS

- STD dx past year
- Crack use
- Binge alcohol
- IDU partner

- Trading sex
- Partner who smoked crack
- MSM partner

- Lower Risk Respondents *DENIED**:*

**Notes:**
These people, whom we called lower risk partners denied
STD dx past year
Crack use	
Binge alcohol
IDU partner	
Trading sex
Partner who smoked crack
MSM partner	

## LOWER RISK RESPONDENTS: HIV RISK

|  | CASES (%) | CONTROLS (%) | OR (adj gender) |
| --- | --- | --- | --- |
| < High school | 36 | 13 | 3.7 (1.8, 7.5) |
| Annual income < $16K | 56 | 22 | 4.1 (1.8, 9.0) |
| Food insecurity | 24 | 10 | 2.8 (1.3, 6.2) |
| Incarcerated > 24 hrs | 14 | 3 | 7.7 (2.0, 28.8) |
| Lifetime # partners | 8 | 5 | p=.02,  (Wilcoxon) |
| STD ever | 48 | 24 | 2.1 (1.1, 4.0) |
| Partner not monogamous | 78 | 53 | 3.3 (1.6, 6.7) |

**Notes:**
Lower risk cases were more likely to have had more partners (though not many), an STD, had a partner who was not monogamous, - and have indicators of low SES - been incarcerated, have low education, low income, and report food insecurity.

## LOWER RISK RESPONDENTS: MULTIVARIABLE ANALYSIS

- Risk factors among lower risk cases:
- Less than HS education (OR 5.2; 2.2, 11.1)
- Food insecurity (OR 3.7; 1.5, 8.9)
- Non-monogamous sex partner (OR 2.9; 1.3, 6.4)
*Adimora AA, Schoenbach VJ, et al. Heterosexually transmitted HIV infection among African Americans in North Carolina. JAIDS 2006;41:616*

**Notes:**
Independent risk factors for HIV infection in this lower risk group were less than HS education, food insecurity, and a non-monogamous partner

## WHAT ABOUT SEXUAL NETWORK PATTERNS?

**Notes:**
SEXUAL NETWORK PATTERNS (WHO HAS SEX W/ WHOM) ARE MAJOR DETERMINANTS OF POPULATION HIV/STD SPREAD.

## CONCURRENT SEXUAL PARTNERSHIPS

- Sexual partnerships that overlap in time
- Permit more rapid spread of an STI throughout a population than same number of sequentially monogamous partnerships
- Individual infected by 1 partner already has others to infect
- Earlier partners are put at risk by individual’s subsequent partners

**Notes:**
NOW WHAT ABOUT SEXUAL NETWORK PATTERNS?

Concurrent partnerships are relationships that overlap in time.
They can spread an STI throughout a population much more rapidly than the same number of relationships held sequentially.
Compared to sequential monogamy, concurrent relationships permit more rapid spread of an STI through a population, because an individual becoming infected by one partner already has other partners to infect.  In addition, in contrast to serial monogamy, concurrent partnerships put  an individual’s earlier partners at risk for infections from his or her subsequent partners.  

## PARTNERSHIP SEQUENCES

|  |  | MONTH |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| Person | Relation | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| A | Monogamy |  | E | E |  | E |  | E | F | F | F |
| B | Concurrency |  | G | G | H | G | H | G | H | H |  |
| C | Monogamy |  |  |  | I |  | I |  | I | I | I |
| D | Concurrency |  | J | J | J | K | J | J | J | J | J |

**Notes:**
This is what they look like (B and D above)

## CONCURRENCY PREVALENCE WOMEN,  U.S. (1995, NSFG)

-  *Adimora  AA, Schoenbach VJ, Bonas DM, et al. Concurrent Partnerships among*
*   **Women in the US.  *Epidemiology* 2002; 13;320-327*

**Notes:**

In separate studies of a national database (National Survey of Family Growth) we saw that the 5-year prevalence of concurrency among black women in the US (21%) was considerably higher than among the general US female population but...

## MARITAL STATUS BY ETHNICITY (1995, NSFG)

**Notes:**
There were major ethnic differences in marital status. Black women were half as likely to be married as other ethnic groups.
And
Black women were only slightly more likely than white women to have had more than five partners during their lifetime (32% vs 30%).  

## NSFG:CONCURRENCY ODDS RATIOS

**Notes:**
When we used multivariable analysis to control for marital status, age at sexual debut, and age at interview- the  black -white concurrency differences markedly decreased as you can see from the fall in the OR to ~1.3.

## CONCURRENCY PREVALENCE (%)

*Adimora AA, Schoenbach VJ, et al. Concurrent partnerships among African Americans in the rural South. Annals of Epidemiology 2004;14:155*

**Notes:**
Returning to the South now in our NC study:  we found that 5 yr concurrency prevalence among women in the rural south was much higher (31%) than US women in the NSFG, and was even higher (53%) among men. 
1-yr concurrency prevalence also high...

## CONCURRENCY ODDS(BLACK GENERAL POPULATION)

|  | Males | Females |
| --- | --- | --- |
| Marital status | 4.2 (1.6, 11.0)* | 1.9 (0.9, 4.1) |
| Income < $16K | 2.6 (0.8, 8.6) | 1.8 (0.8, 4.2) |
| Respondent incarceration | 5.3 (1.6, 17.8)* | 1.7 (0.4, 7.9) |
| Partner incarceration | 2.7 (0.7, 11.3) | 3.0 (1.4, 6.4)* |
| Partner had other partners | 4.5 (1.7, 11.9)* | 11.3 (3.3, 38.7)* |

*Adimora AA, Schoenbach VJ, et al. Concurrent partnerships among African Americans in the rural South. Annals of Epidemiology 2004;14:155*

**Notes:**
Concurrency in the general population was associated with single marital status, incarceration of the respondent or a partner, and belief that the partner had other partners.

## CONCURRENCY ODDS  MULTIVARIABLE ANALYSIS, MEN & WOMEN, NC

*Adimora AA, Schoenbach VJ, et al. Concurrent partnerships among African Americans in the rural South. Annals of Epidemiology 2004;14:155*

**Notes:**

Concurrency was independently associated with male gender (3.7), young age of debut (1.2 per year of decrease in age of first intercourse; 1.1, 1.4), being unmarried (2.4), and  incarceration of any of respondent’s last 3 partners (2.3).
Cases:
Male gender, 
youth, 
crack cocaine, 
incarceration of a sex partner

## SOCIAL CONTEXT/SEXUAL NETWORKS

- How does the social and economic environment contribute to sexual network patterns that promote population spread of HIV?

**Notes:**
What’s the reason for the concurrency in this population?  HIV is a behaviorally acquired infection, but is there something about the socio-economic environment that increases likelihood of engaging in high-risk behaviors and that increases risk of getting infection once the individual participates in these behaviors? 
We did focus groups among 93 black men and women, aged 18-59 from rural North Carolina’s general population to address this question

## FOCUS GROUPS

- Employment and economic opportunities
*“**There are no jobs for anybody coming right out of high school...”*
*“**You can have all the schooling in the world, but if you’re black you can’t get a good job.”*
*“**Most of the temporary agencies ...like to send the blacks to jobs in factories...”*
*“**Every job here is dead end with terrible pay.”*
*Adimora AA, Schoenbach VJ. Social context of sexual relationships among rural African Americans. Sexually Transm Dis 2001;28:69*

**Notes:**

Respondents reported extensive economic oppression and racial discrimination that restricted educational and employment opportunities, and other aspects of their lives.  
While some felt lack of a college education was a major hindrance in their employment search, others believed racial discrimination was so overwhelming that no amount of education would give blacks an opportunity for good employment in their community. 
Here are some examples of their comments.

## FOCUS GROUPS

- Racism/Race relations
*“**A lot of things are divided racially... you have a white side of town, and the black side...doesn’t usually mix.  It’s sort of covert.  You don’t have white folks walking around in robes or anything, but in the schools and things you can see it.”*
*“**It’s hard to get a loan to get a house.  Banks don’t just give black people loans.  You got to know somebody.”*

**Notes:**
Most said community race relations were poor and described residential segregation, but focused their concerns on institutional racism, such as preferential hiring and job advancement of whites, blacks’ inability to get mortgages, and academic tracking of black youth in schools.

## FOCUS GROUPS

- Racism/Race relations (cont)
- “I would say it was greatly polarized.  When I was going to school here in the high school, the type of classes you could get into, like the college prep courses, had a lot to do with what type of family you came from, your race,...”

## FOCUS GROUPS

- Relationships between men and women
*“**To get to the next semi-urban city, if you don’t have a job, or a good education, you’ve got to depend on somebody to get you there.  For young black women, it’s not a good position to be in without a good job or a good education.”*
*“**The choices in men are very limited around here.  I guess the women put up with the men they have because there aren’t that many.”*

**Notes:**
Some women noted gender inequality and women’s perception (especially those who are poor or had low educational attainment) that they are dependent on men.

## FOCUS GROUPS

- Relationships between men and women
*“**There’s so many black men in prison, strung out on drugs, or dead, that if a decent black lady finds a decent black man, she’s going to do whatever it takes to get him.”*
*“**It’s not that many good men worth anything in this area.”*
*“**The ratio of women to men is very high.”*

**Notes:**
As you can see, they perceived a huge disparity in the ratio of available black men to women b/o male attrition due to incarceration, drug addiction, or death.

## FOCUS GROUPS

- Concurrent partnerships
*“**Most [unmarried] couples aren’t going to be true to each other.”*
*“**If they aren’t planning on getting married, they’re probably going to have relationships on the side.”*
*“**I say it’s quite common for people to be involved in relationships with more than one person at a time.”*

**Notes:**
They described concurrency as widespread among unmarried men and indicated that the male shortage and the bad socioeconomic plight of both black women and men profoundly affect 
partner selection and the types of male behavior women tolerate.

## FOCUS GROUPS

- Respondents described:
- Pervasive economic and racial oppression
- Lack of community recreation, boredom, resultant substance abuse
- Shortage of black men (higher mortality and incarceration rates)
- Widespread concurrency among unmarried people
- Conclusion:
- Contextual features may promote sexual patterns that transmit STIs
*Adimora, Schoenbach, et al. Sexually Transm Dis 2001;28:69-76*

**Notes:**

We concluded that contextual features including racism, discrimination, limited employment opportunity, and resultant economic and social inequity may promote sexual patterns that transmit HIV. 

## SEX RATIO AMONG SELECTED ETHNIC GROUPS, US, 2000	

- Source: US Bureau of the Census. Census 2000 Summary File 1. Vol 2003, 2000.

**Notes:**
I’ll look now at contextual features and sexual networks from the perspective of social scientists.
FG respondents were correct.  Sex ratio (men:women) is notoriously low among blacks in the US b/o increased black male mortality due to violence and disease and is further lowered by the disproportionate incarceration of black men.

## CONTEXT-NETWORK PATHWAYS

**CONTEXT-NETWORK PATHWAYS**

**P  O  V  E  R  T  Y**

**pool of**

**marriageable men**

**marital**

**instability**

**CONCURRENCY**

**SEX RATIO**

*Adimora VJ, Schoenbach VJ. Social context, sexual networks, and*
*racial disparities in rates of sexually transmitted infections. JID 2005:191:S115*

**Notes:**
There are pathways between contextual forces, such as poverty, incarceration, and segregation - and some network patterns.
Here are some possible effects of the sex ratio and poverty
The low sex ratio is one of sociologists’ main explanations for decreased marriage rates among blacks, which we saw is an important factor in concurrency; it may also increase bridging between low-risk women and men from high-risk subpopulations. 
The other major reason for blacks’ low marriage rates is poverty, which further decreases the pool of economically viable men and destabilizes marriages. 

## Slide 32

**Notes:**
Incarceration is also a major contextual factor.  Young B men are 10 times as likely to be incarcerated as white men, and incarceration directly affects sexual networks.

## CONTEXT-NETWORK RELATIONSHIPS

**INCARCERATION**

**disrupts ****partnerships**

**employment prospects**

**pool of men****in community**

**new long term links****with antisocial****networks**

**inmates: sex in****pool with high****HIV prevalence**

**SEXUAL NETWORKS**

*Adimora VJ, Schoenbach VJ. Social context, sexual networks, and*
*racial disparities in rates of sexually transmitted infections. JID 2005:191:S115*

**Notes:**
Incarceration physically removes people from partnerships.  
	The partner entering prison may have sex while there with people whose likelihood of HIV/STI is high.  
	The partner left behind loses the social and other supports of the incarcerated partner and may seek other partners. (We saw that women whose partner had been incarcerated were more likely to have concurrent partnerships.) 
	As inmates return to the community they may resume old partnerships and/or start new ones, increasing likelihood of concurrency. While in prison, inmates may join gangs and forge new long-term links with antisocial networks that can affect sexual networks by connecting previously lower risk people with new high-risk subgroups. Incarceration reduces employment prospects, which increases poverty risk and destabilizes long-term partnerships.

High incarceration rates also affect the community, causing high unemployment rates, and shrink not only the absolute number of men, but also the proportion of financially viable men.  

## CONTEXT-NETWORK RELATIONSHIPS

**residential segregation by race**

**concentration of adverse ****social and economic influences**
**(poverty, drugs, violence)**

**selection of partners ****from neighborhood**

*Adimora VJ, Schoenbach VJ. Social context, sexual networks, and*
*racial disparities in rates of sexually transmitted infections. JID 2005:191:S115*

**Notes:**
Residential segregation by race, a prominent feature of racial discrimination in the US, concentrates poverty and other negative influences within the segregated group.  
For ex, youth in these neighborhoods are more likely to be exposed to drugs and therefore use them.  
Many people choose sex partners from their neighborhoods, so even if they don’t use drugs themselves, they are much more likely to encounter a high-risk partner than they would be in the absence of segregation.

## HETEROSEXUAL HIV AND AFRICAN AMERICANS

- MAJOR PROXIMAL CAUSES:
- High prevalence of STDs
- Sexual network patterns:  concurrency and mixing among different subpopulations
- DISTAL DETERMINANTS help shape behavior and risk associated with behavior
- Poverty, inequality, discrimination

**Notes:**

Major proximal causes of heterosexual HIV among African Americans are
High prevalence of STDs
Sexual network patterns, such as concurrency and mixing among different subpopulations.
Distal determinants help shape behavior and risk associated with behavior.
Foremost among these distal determinants are:
	poverty
	inequality
	and discrimination

## WHAT TO DO?

## STRUCTURAL INTERVENTIONS

- Contextual feature and structural inequities that support them are important in promoting risk behaviors
- Develop structural interventions - programs, laws, policies -
- that alter the context of life to improve health behaviors and health outcomes
*Blankenship KM, et al. AIDS 2001;14:S11-S21*

**Notes:**

Contextual features and structural inequities that support them are important in promoting risk behaviors- and for increasing risk of infection - even among people who don’t have high risk behavior.
To effectively fight HIV in the US - esp among minority populations - it will be critical to develop structural interventions - programs, laws, policies -
that alter the context of life to improve health behaviors and health outcomes

## STRUCTURAL INTERVENTIONS: PROGRAMS, POLICIES, LAWS

- Examples
- Increase economic opportunities
- Individual development accounts to increase savings
- Tax incentives for employers to hire employees who live in poor areas
- Decrease incarceration and its adverse impact
- Evaluate and reform sentencing inequity
- Alternatives to incarceration for non-violent crime

**Notes:**
Fundamental question is what are effective and feasible ways of addressing structural inequities to decrease rates of HIV (and other diseases) in minority populations? Who should come to the table to develop interventions? Because so much of the problem is economic and policy driven, perhaps economists, sociologists, criminal justice experts, politicians - in addition to the public health experts and clinicians.   Some possible examples: READ SLIDE

## HIV: A UNITED STATES HUMAN RIGHTS ISSUE

- Feasible and effective ways to address structural inequities that underpin racial disparity in HIV rates

**Notes:**
Because structural inequalities underlie the problem, a successful US prevention campaign will also require structural changes and a broadening of the public health paradigm beyond its usual individual-level behavioral approach to one that recognizes the influence of social context on disease in different populations.  
Usual response to this suggestion is to shrug and say “We can’t change poverty and racism.”  As long as we accept the status quo we should acknowledge that we’re accepting racial disparities in disease rates.  
The racial disparity in HIV rates in the US is a major human rights issue. 

## ACKNOWLEDGMENTS

**ACKNOWLEDGMENTS**

- Victor J. Schoenbach, PhD
- Francis Martinson, MD, PhD
- Dana Bonas, MPH
- Sevgi Aral, PhD
- Ward Cates, MD, MPH
- JoAnne Earp, PhD
- Robert Fullilove, EdD
- Amy Lansky, PhD
- Greg Samsa, PhD
- Stephanie Betran, RN
- Kathryn Donaldson, MPH
- Tonya Stancil, MPH
- Merritha Williams, RN
- Evelyn Foust, MPH
- Judy Owen-O’Dowd
- NC HIV/STD Control Section and DIS
- Respondents

**Notes:**

I thank all the people who contributed to this presentation - including everyone listed on the slide.
I’d like to particularly acknowledge Vic Shoenbach, Sevgi Aral, Amy Lansky (QQ design), the contribution of the NC HIV/STD Control Section - especially the DIS and the respondents themselves - without whom much of these data would not have been collected.