Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 2 

 

Suggested citation: Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral 

Hepatitis, STD, and TB Prevention. Epidemiologic Profile 2010: Asians and Native Hawaiians and Other 

Pacific Islanders. Atlanta, GA: Centers for Disease Control and Prevention. 2012: [inclusive pages]. 

Centers for Disease Control and Prevention 

Kevin Fenton, MD, PhD, FFPH 

Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 

Contributors 

Chapter 1: Division of HIV/AIDS Prevention, CDC, Laurie Kamimoto, MD, MPH 

Chapter 2: Division of Tuberculosis Elimination, CDC, Lori Armstrong, PhD 

Chapter 3: Division of Viral Hepatitis, CDC, Kathleen Ly, MPH 

Chapter 4: Division of Sexually Transmitted Disease Prevention, CDC, Eloisa Llata, MD, MPH 

Chapter 5: Division of HIV/AIDS Prevention, CDC, Ann Do, MD, MPH; Laurie Kamimoto, MD, MPH 

Editor 

R. Elliott Churchill, MS, MA 

Desktop Publishing Specialist 

Michael Friend 

ACKNOWLEDGMENTS 

We wish to thank each of the following individuals who provided valuable time and assistance to this 

report. Asians and Native Hawaiians and Other Pacific Islanders in the United States chapter: Nicholas A. 

Jones, U.S. Census Bureau, and Brian Judd; Tuberculosis chapter: Kristen Renneker and Jeffrey Cope; 

Viral Hepatitis chapter: Scott Holmberg, Eyasu Teshale, Philip Spradling, Jian Xing, Anne Moorman, 

Stuart Gordon, David Nerenz, Mei Lu, Lois Lamerato, Lora Rupp, Joseph Boscarino, Cynthia Nakasato, 

and Emily Henkle, CHeCS Investigators; Sexually Transmitted Diseases chapter: Hillard Weinstock, 

Robert Kirkcaldy, Sarah Kidd, Mark Stenger, John Su, and Lizzie Torrone; HIV and AIDS chapter: 

Nevin Krishna, Emma Frazier, and Stella Chuke. 

Note to the reader: Because this document is provided as Web-based material, the project staff have 

tried to make it as compact as possible to facilitate copying and redistribution. For this reason, many 

reference tables that are not necessary for the mainstream flow of information have been placed in an 

Appendix at the end of the document. This allows readers to choose to have access to all the available 

documents or just to the mainstream report, in order to meet their informational needs. 
3 

Epidemiologic Profile 2010: Asians and Native Hawaiians 

and Other Pacific Islanders 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 4 

GLOSSARY

ACIP—Advisory Committee on Immunization Practices. Selected by the Secretary of U.S. Health and 

Human Services, the 15-member ACIP provides advice and guidance to the public health and clinical 

practice communities about controlling vaccine-preventable diseases. 

ACS—The American Community Survey, the nation’s largest annual ongoing demographic survey 

administered by the U.S. Census Bureau, provides communities with the current information they need to 

plan investments and services, including data on educational attainment, income, health insurance, 

commuting, and housing characteristics. 

API—Asian/Native Hawaiian and Other Pacific Islander or Asian/NHPI. API represents the combined 

racial group of Asian or Native Hawaiian and Other Pacific Islander. 

ART—Antiretroviral treatment. The clinical use of antiretroviral agents in the treatment of adults and 

adolescents who are infected with the HIV. 

Asian—Racial group profiled in this report. This group is defined as “A person having origins in any of 

the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, 

Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and 

Vietnam.”

CHeCS—Chronic Hepatitis Cohort Study. A long-term cohort study that comprehensively examines the 

clinical characteristics, treatment rates, behavioral qualities, and outcomes of patients for chronic hepatitis 

B and C infections. 

Emerging Infections Program—A CDC-based network that involves state and local health departments 

and academic institutions in population-based surveillance for acute hepatitis A and acute and/or chronic 

hepatitis B and C in the United States

GISP—Gonococcal Isolate Surveillance Project. Established in 1986 to monitor trends in antimicrobial 

susceptibilities of strains of N. gonorrhoeae in the United States in order to establish a rational basis for 

the selection of gonococcal therapies. GISP is a collaborative project among selected STD clinics, five 

regional laboratories, and CDC.

HIV and AIDS—Human immunodeficiency virus (HIV) and acquired immune deficiency syndrome 

(AIDS). A person with HIV infection may be diagnosed with AIDS, which usually occurs late in the 

disease course of HIV infection. 

IPP—Infertility Prevention Project. Program that funds chlamydia and gonorrhea screening and treatment 

services for low-income, sexually active women attending family planning, STD, and other women’s 

healthcare clinics.

M.africanum—Mycobacterium africanum. 

M.bovis—Mycobacterium bovis. 
GLOSSARY 5 

M tb—Mycobacterium tuberculosis. A bacterium that causes tuberculosis.

MDR TB—Multidrug-resistant Tuberculosis. 

MSM—Men who have sex with men. A term used in CDC surveillance systems to indicate males who 

ever had sex with another male, without regard to the nature of the sexual contact (e.g., oral or anal) or to 

how an individual may self-identify in terms of their sexuality.

MIC—Minimal inhibitory concentration. The lowest antibiotic concentration that prevents bacterial 

growth.

MMP—Medical Monitoring Project. A CDC surveillance system of HIV-infected persons receiving 

medical care.

Multiple race—A person self-identifying with more than one race group. 

NETSS—National Electronic Telecommunications System for Surveillance. Computerized public health 

surveillance information system providing CDC with weekly data regarding cases of nationally notifiable 

diseases.

Native Hawaiian and Other Pacific Islander—Racial group profiled in this report. This group is defined as 

“A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific 

Islands.”

N. gonorrhoeae—Neisseria gonorrhoeae. A bacterium that causes gonorrhea. 

NHBS—National HIV Behavioral Surveillance System. A CDC surveillance system that collects 

information from groups at high risk for HIV infection. 

NHIS—National Health Interview Survey is a cross-sectional household interview survey administered 

by the CDC’s National Center for Health Statistics to monitor the health of the U.S. population 

NHPI—Native Hawaiian and Other Pacific Islander: racial group profiled in this report. 

NNDSS—National Notifiable Diseases Surveillance System. 

Non-Hispanic American Indian or Alaska Native (Non-Hispanic AIAN)—A person having origins in any 

of the original peoples of North America, and who maintains cultural identification through tribal 

affiliation or community recognition.

Non-Hispanic Asian—see Asian.

Non-Hispanic black—A person having origins in any of the black racial groups of Africa.

Non-Hispanic Native Hawaiian and Other Pacific Islander (Non-Hispanic NHPI)—see Native Hawaiian 

and Other Pacific Islander.

Non-Hispanic white—A person having origins in any of the original peoples of Europe, North Africa, or 

the Middle East.
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 6 

NTSS—National Tuberculosis Surveillance System. 

OMB—U.S. Office of Management and Budget. A component of the Executive Office of the President of 

the United States, OMB established standards for the collection of race and ethnicity information.

Primary and secondary (P&S) syphilis—Primary syphilis. A stage of infection with Treponema pallidum

characterized by one or more chancres (ulcers); chancres might differ considerably in clinical appearance.

Secondary syphilis: A stage of infection caused by T. pallidum and characterized by localized or diffuse 

mucocutaneous lesions, often with generalized lymphadenopathy. The primary chancre may still be 

present.

QRNG—Fluoroquinolone-resistant N. gonorrhoeae. Defined as N. gonorrhoeae resistant to ciprofloxacin 

(minimal inhibitory concentration [MIC] >1.0 μg/mL by agar dilution or disk diffusion zone size <27 

mm) or ofloxacin (MIC >2.0 μg/mL or disk diffusion zone size <24 mm) by the National Committee on 

Clinical Laboratory Standards.

STD—Sexually transmitted diseases are infections that are spread primarily through person-to-person 

sexual contact; some STDs, however, can be transmitted nonsexually, such as transmission from motherto-child during pregnancy and childbirth or through blood products.

SSuN—STD Surveillance Network. In 2005, CDC established SSuN as a dynamic STD surveillance 

network comprised of local enhanced STD surveillance systems that follow common protocols for the 

purpose of improving the capacity of national, state, and local STD programs to detect, monitor, and 

respond rapidly to trends in STDs through enhanced collection, reporting, analysis, visualization, and 

interpretation of disease information.

TB—Tuberculosis. 

Treponema pallidum—Bacterium that causes syphilis.

Unprotected insertive anal intercourse—Insertive anal intercourse without a condom or with condom

breakage.

USPSTF—U.S. Preventive Services Task Force. An independent panel of non-federal experts in 

prevention and evidence-based medicine. The USPSTF conducts scientific evidence reviews of a broad 

range of clinical preventive healthcare services (such as screening, counseling, and preventive 

medications) and develops recommendations for primary care clinicians and health systems.

Viral Hepatitis—A term used collectively to refer to a group of viruses that can cause inflammation of the 

liver. In the United States, hepatitis A, B, and C are most commonly reported.

XDR TB—Extensively Drug-resistant Tuberculosis. 
CONTENTS 7 

CONTENTS

ACKNOWLEDGMENTS ............................................................................................................................ 2

GLOSSARY ........................................................................................................................................... 4

CONTENTS ........................................................................................................................................... 7

BACKGROUND .......................................................................................................................................... 9

CHAPTER 1: ASIANS AND NATIVE HAWAIIANS AND OTHER PACIFIC ISLANDERS IN THE 

UNITED STATES .......................................................................................................... 11

INTRODUCTION...................................................................................................................................................11

POPULATION DATA SOURCES .........................................................................................................................11

POPULATION GROUPS IN THIS REPORT.........................................................................................................12

ASIANS ...............................................................................................................................................................12

NATIVE HAWAIIANS AND OTHER PACIFIC ISLANDERS .............................................................................14

DISCUSSION .........................................................................................................................................................17

REFERENCES........................................................................................................................................................18

CHAPTER 2: TUBERCULOSIS................................................................................................................ 19

OVERVIEW ...........................................................................................................................................................19

TUBERCULOSIS DATA SOURCES.....................................................................................................................19

SNAPSHOT............................................................................................................................................................20

DISCUSSION .........................................................................................................................................................21

REFERENCES........................................................................................................................................................25

CHAPTER 3: VIRAL HEPATITIS............................................................................................................ 26

INTRODUCTION...................................................................................................................................................26

VIRAL HEPATITIS DATA SOURCES .................................................................................................................26

NATIONAL SURVEILLANCE OF ACUTE VIRAL HEPATITIS.........................................................................26

STUDY OF TESTING PRACTICES AND INFECTION PREVALENCE WITHIN U.S. HEALTHCARE 

ORGANIZATIONS ..........................................................................................................................................26

ENHANCED VIRAL HEPATITIS SURVEILLANCE SITES ...............................................................................27

NATIONAL MORTALITY DATA ........................................................................................................................27

ESTIMATED BIRTHS TO HEPATITIS B VIRUS-INFECTED MOTHERS........................................................27

HEPATITIS A .........................................................................................................................................................27

ABOUT HEPATITIS A........................................................................................................................................27

SNAPSHOT.........................................................................................................................................................28

HEPATITIS B .........................................................................................................................................................28

ABOUT HEPATITIS B........................................................................................................................................28

SNAPSHOT.........................................................................................................................................................29

HEPATITIS C .........................................................................................................................................................30

ABOUT HEPATITIS C........................................................................................................................................30

SNAPSHOT.........................................................................................................................................................31

DISCUSSION .........................................................................................................................................................32

REFERENCES........................................................................................................................................................36
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 8 

CHAPTER 4: SEXUALLY TRANSMITTED DISEASES ....................................................................... 38

INTRODUCTION...................................................................................................................................................38

SEXUALLY TRANSMITTED DISEASE DATA SOURCES ...............................................................................38

NATIONAL SURVEILLANCE OF CHLAMYDIA, GONORRHEA, AND SYPHILIS..........................................38

STD SURVEILLANCE NETWORK (SSUN)........................................................................................................39

GONOCOCCAL ISOLATE SURVEILLANCE PROJECT (GISP)......................................................................39

INFERTILITY PREVENTION PROJECT (IPP)................................................................................................. 39

CHLAMYDIA ........................................................................................................................................................39

ABOUT CHLAMYDIA ........................................................................................................................................39

SNAPSHOT.........................................................................................................................................................40

GONORRHEA........................................................................................................................................................41

ABOUT GONORRHEA.......................................................................................................................................41

SNAPSHOT.........................................................................................................................................................41

SYPHILIS ...............................................................................................................................................................43

ABOUT SYPHILIS ..............................................................................................................................................43

SNAPSHOT.........................................................................................................................................................43

DISCUSSION .........................................................................................................................................................44

REFERENCES........................................................................................................................................................50

CHAPTER 5: HIV and AIDS ..................................................................................................................... 53

OVERVIEW ...........................................................................................................................................................53

HIV AND AIDS DATA SOURCES .........................................................................................................................53

BURDEN OF HIV DISEASE ..............................................................................................................................53

MMP: HIV-INFECTED PERSONS IN CARE ....................................................................................................54

NHBS: AT-RISK POPULATIONS ......................................................................................................................55

SNAPSHOT............................................................................................................................................................55

DISCUSSION .........................................................................................................................................................59

REFERENCES........................................................................................................................................................67

APPENDIX ......................................................................................................................................... 69
BACKGROUND 9 

BACKGROUND

This Epidemiologic Profile is the first 

compilation of infectious disease-specific data in 

a single report that focuses on two racial groups

in the United States: the Asian population and 

the Native Hawaiian and Other Pacific Islander

population. It has been produced by the National 

Center for HIV/AIDS, Viral Hepatitis, STD, and 

TB Prevention at the Centers for Disease 

Control and Prevention (CDC), and each 

Division represented in the National Center 

participated in the development of the report. 

The U.S. Census Bureau contributed to the 

chapter that describes Asian and Native 

Hawaiian and Other Pacific Islander populations 

who reside in the United States.

Human immunodeficiency virus (HIV), viral 

hepatitis, sexually transmitted diseases (STDs), 

and tuberculosis (TB) share common risk 

factors, intersect as co-infections, and interact to 

increase transmission and complicate treatment. 

Men who have sex with men are at high risk for 

acquiring STDs and HIV. Persons who inject 

drugs and share their syringes are at risk for 

acquiring HIV and viral hepatitis. And TB takes 

advantage of a person’s impaired ability to fight 

infection or of poor living conditions to spread 

from person to person. A person infected with 

one disease may increase their chance of 

becoming infected with another disease (i.e., coinfection). For example, STDs that cause skin 

ulceration or mucosal inflammation allow HIV 

infection to occur more easily. Longstanding, 

untreated HIV infection is associated with 

waning immunity and increased risk of TB 

infection. Additionally, co-infection may make 

treating the primary infection more difficult. 

Viral hepatitis complicates HIV co-infection as 

both diseases progress faster, and treatment may 

be more difficult as drug-drug interactions may 

occur or drug resistance may develop.

Although Asians and Native Hawaiians and 

Other Pacific Islanders currently comprise about 

5% of the U.S. population, the percentage of 

Asians and Native Hawaiians and Other Pacific 

Islanders among persons with these selected 

diseases varies dramatically. For example, for 

hepatitis B and tuberculosis, Asians make up a 

disproportionately large percentage of cases

(~25%), in excess of their representation in the 

U.S. population. For STDs and HIV, Asians and 

Native Hawaiians and Other Pacific Islanders 

comprise a small percentage of cases (<5%), less 

than their representation in the U.S. population. 

Among Asians and Native Hawaiians and Other 

Pacific Islanders, additional risk factors need to 

be considered. Persons born in a country outside 

the United States (foreign-borna

) with endemic 

diseases are more likely to be infected with these 

diseases even if they currently reside in the 

United States. For foreign-born persons, age at 

immigration and fluency of English may 

determine how challenging it will be to contact, 

educate, and treat these individuals and their

infection. Identifying and addressing stigmatized

risk behaviors for disease acquisition among 

Asians and Native Hawaiians and Other Pacific 

Islanders, however, may be particularly 

challenging because of social and cultural 

customs within each racial group that suppress 

acknowledgment of these risks and individual 

perception of risk. This unwillingness to 

acknowledge such problems is exacerbated by a 

societal stereotype of Asians and Native 

Hawaiians and Other Pacific Islanders that 

depicts them as being at low risk so that

healthcare providers do not conduct disease 

testing or ask important questions of patients

from these groups. 

In 1977, the Office of Management and Budget 

(OMB) set forth a Statistical Policy Directive 

that established standards for the collection of 

race and ethnicity that included: white, black, 

American Indian or Alaskan Native, Asian or 

Pacific Islander, and Hispanic origin.b In 1997, 

after a review of its directive, OMB announced a 

 

a

 The definition of “foreign-born” varies somewhat; 

each chapter that uses the term defines it. b

 http://www.whitehouse.gov/omb/fedreg_raceethnicity/. 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 10 

revision to its standard for collection of race and 

ethnicity.c A minimum of five race categories 

were included: American Indian or Alaska 

Native, Asian, black or African American, 

Native Hawaiian or Other Pacific Islander, and 

white. Two categories of ethnicity were also 

used: Hispanic or Latino and not Hispanic or 

Latino (non-Hispanic). Surveillance programs at 

CDC began implementing the new directive in 

partnership with local reporting jurisdictions. At 

the time of this report, most CDC diseasespecific surveillance programs include

categorization of the Asian population and the 

Native Hawaiian and Other Pacific Islander

population as separate racial groups. Some 

disease programs continue to report for a 

combined Asian/Native Hawaiian and Other 

Pacific Islander (API) racial group, however. 

When possible, chapter authors have reported 

Asians and Native Hawaiians and Other Pacific 

Islanders separately. In some instances, case 

numbers were too small to allow meaningful 

statistical analysis or data collection processes 

did not allow separation of Asians from Native 

Hawaiians and Other Pacific Islanders; in these 

instances, results are reported in the grouped 

category “API.” For trend analyses that span the 

timeframe in which the directive was 

implemented, Asians and Native Hawaiians and 

Other Pacific Islanders are combined as “API” 

to bridge to data collected under the 1977 OMB 

directive.

The most currently available national 

surveillance data have been used for this report. 

Interested parties should consult annual 

surveillance reports produced by each Division

and made available on CDC’s website.d When 

possible, 2010 data have been used, but 

depending on the data source and type of 

analysis, older data have been used to provide a 

 

more comprehensive picture of Asians and 

Native Hawaiians and Other Pacific Islanders 

affected by TB, viral hepatitis, STDs, and HIV. 

This report complements the annual surveillance 

reports produced by each disease-specific 

program by bringing selected information 

together in a single report that profiles nonHispanic, single race Asians and Native 

Hawaiians and Other Pacific Islanders. It also 

complements the 2007 Disease Profile,

e which 

suggested ways to integrate data and prevention 

resources. By focusing on Asians and Native 

Hawaiians and Other Pacific Islanders, this 2010 

Epidemiologic Profile provides information to 

maximize population-specific prevention and 

disease-specific control efforts.

 

c

 http://www.whitehouse.gov/omb/fedreg_

1997standards/. d

 TB: http://www.cdc.gov/tb/statistics/reports/2010/

default.htm; Hepatitis: http://www.cdc.gov/

hepatitis/Statistics/2009Surveillance/index.htm; 

STD: http://www.cdc.gov/std/stats10/default.htm; 

HIV/AIDS: http://www.cdc.gov/hiv/surveillance/

resources/reports/2010report/index.htm.

e

 http://www.cdc.gov/nchhstp/Publications/

NCHHSTP_Disease_Profile_2007.pdf.
CHAPTER 1: ASIANS AND NATIVE HAWAIIANS AND OTHER PACIFIC ISLANDERS IN THE UNITED STATES 11 

CHAPTER 1: ASIANS AND NATIVE HAWAIIANS AND OTHER PACIFIC 

ISLANDERS IN THE UNITED STATES

INTRODUCTION 

Data from the U.S. decennial census provide a 

rich description of Asians and Native Hawaiians 

and Other Pacific Islanders who reside in the 

United States. These data set a foundation upon 

which readers can compare subsequent diseasespecific prevalence estimates to evaluate 

whether Asians or Native Hawaiians and Other 

Pacific Islanders are overrepresented for a 

particular disease or if other demographic- or 

race-specific factors play a role in disease 

acquisition, disease control, or prevention 

efforts. 

Because Asians and Native Hawaiians and Other 

Pacific Islanders are a diverse, heterogeneous 

group, readers should be cautious about drawing 

inferences about specific subpopulations within 

these groups.

POPULATION DATA SOURCES

The U.S. Census Bureau’s annual surveys and 

decennial census provide data that are used to 

enumerate the number of people residing in the 

United States and to describe the demographic, 

social, economic, and housing characteristics of 

the U.S. population and its trends. The decennial 

census, in which each person residing in the 

United States is counted, occurs every 10 years, 

most recently in 2010. Basic demographic 

information, which includes sex, race, and 

ethnicity, is collected in the decennial census. 

Between decennial censuses, the U.S. Census 

releases intercensal estimates each year to 

provide U.S. population estimates by basic 

demographic factors. To provide a description of 

the mid-year 2010 U.S. population by state, age, 

sex, race, and ethnicity, 2009 Vintage Estimates 

have been used in this report.f

The Census’ American Community Survey 

(ACS) is an annual, nationwide survey that 

includes a sample of all U.S. residents. The ACS 

collects more detailed information such as 

nativity (country of birth), income, education, 

and language spoken at home. The most current 

ACS data at the onset of this research were from 

2009. To determine nativity for foreign-born 

Asians, three years of ACS data have been used, 

2007–2009.

The U.S. Census collects race and Hispanic 

origin information following the guidance of the 

U.S. Office of Management and Budget’s 

(OMB) 1997 Revisions to the Standards for the 

Classification of Federal Data on Race and 

Ethnicity (1). Starting in 1997, OMB required 

federal agencies to use a minimum of five race 

categories: American Indian or Alaska Native, 

Asian, black or African American, Native 

Hawaiian or Other Pacific Islander, and white. 

Respondents are instructed to select from as 

many of those designations as they feel apply to 

them, but if they are unable to identify with any 

of these five race categories, OMB has approved 

the U.S. Census Bureau’s inclusion of a sixth 

category—Some Other Race—on the Census 

2000 and 2010 Census questionnaires (2). 

In addition to race, ethnicity (i.e., 

Hispanic/Latino origin) is also collected. 

Persons of Hispanic ethnicity may be of any 

single race or combination of races. For the 

Census Bureau’s surveys, identification of race 

and ethnicity is by self-report. 

 

f

 Vintage population estimates are produced each 

year by the U.S. Census Bureau on the basis of the 

most recent decennial census. Vintage 2009 

estimates were created in 2009 on the basis of the 

2000 decennial census. At the time this report was 

being prepared, some demographic characteristics 

from the 2010 Census were not available. 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 12 

POPULATION GROUPS IN THIS 

REPORT

According to the 2010 Census, 308.7 million 

people reside in the United States, reflecting a 

9.7% increase from Census 2000. People who 

listed Asian as their only race and were not of 

Hispanic origin made up 4.7% (14,465,124) of 

the U.S. population. Between 2000 and 2010, 

numbers of non-Hispanic Asians increased

42.9% (2). People who listed Native Hawaiian 

or Other Pacific Islander as their only race and 

were not of Hispanic origin made up 0.2% 

(481,576) of the U.S. population. From 2000 to

2010, numbers of non-Hispanic Native 

Hawaiians and Other Pacific Islanders increased 

by 36.2% (2). See Appendix for Table A1. 

For the remainder of this chapter, non-Hispanic 

single race Asians or Native Hawaiians and 

Other Pacific Islanders residing in the United 

States will be profiled.

Asians

The term “Asian” is defined by OMB as 

designating people with origins from the Far 

East, Southeast Asia, or the Indian subcontinent, 

including countries such as Cambodia, China, 

India, Japan, Korea, Malaysia, Pakistan, 

Philippines, Thailand, Vietnam, or other Asian 

countries (2). The age distribution of Asians 

who reside in the United States in 2010 is shown 

in Figure 1. Among the almost 15 million nonHispanic Asians who resided in the United 

States in 2010, 48% were male. The median age 

for males was 30–34 years, compared with 35–

39 years for females. 

Figure 1. Age distribution of Asians in the United States, 2010* 

* Based on intercensal estimates. Population in thousands
CHAPTER 1: ASIANS AND NATIVE HAWAIIANS AND OTHER PACIFIC ISLANDERS IN THE UNITED STATES 13 

Table 1. Percentage distribution of Asians, by sex and age group, 2010*

Male Female

Age group, years % % 

<5 6.5 5.7

5–9 6.6 6.0

10–14 6.4 5.7

15–19 7.0 6.0

20–24 8.0 7.1

25–29 8.4 8.4

30–34 8.3 8.6

35–39 8.7 8.9

40–44 7.8 8.0

45–49 7.3 7.4

50–54 6.5 6.9

55–59 5.5 6.1

60–64 4.5 5.0

65–69 3.1 3.4

70–74 2.3 2.5

75–79 1.5 1.9

≥80 1.7 2.5

* Based on intercensal estimates. 

Figure 2. Distribution of Asians, top 10 states, 2010
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 14 

GEOGRAPHIC DISTRIBUTION OF ASIANS

According to the 2010 Census, the top ten states 

with the largest populations of Asians are

California, New York, Texas, New Jersey, 

Illinois, Hawaii, Washington, Florida, Virginia, 

and Massachusetts (see Figure 2). 

The 2010 Census showed that the five 

metropolitan or micropolitan statistical areasg

with the largest Asian population were the New 

York-Northern New Jersey-Long Island, New 

York-New Jersey-Pennsylvania Metro Area 

(1,860,840); the Los Angeles-Long Beach-Santa 

Ana, California Metro Area (1,858,148); the San 

Francisco-Oakland-Fremont, California Metro 

Area (994,616); the San Jose-Sunnyvale-Santa 

Clara, California Metro Area (566,764); and the 

Chicago-Joliet-Naperville, Illinois-IndianaWisconsin Metro Area (526,857). See the 

Appendix for Table A2, which shows the 20 

metro/micro areas with the largest Asian 

populations in the United States.

OTHER CHARACTERISTICS OF ASIANS

According to the 2009 ACS, 9 million or 63% 

(9,152,456/14,465,124) of Asians were foreignborn,h and accounted for 24% of all foreign-born 

individuals in the United States. Of foreign-born 

Asians, approximately 4.2 million (46%) were 

male and 4.9 million (54%) were female. Using 

2007–2009 ACS data, the top countries of birth 

for foreign-born Asians in the United States

were, in descending order, China (including 

Hong Kong, Macau, Paracel Islands, and 

Taiwan), Philippines, India, Vietnam, and 

Korea. 

Of 12.7 million Asians ≥5 years of age, 77% 

spoke a language other than English at home, 

and of these, over one-third reported that they 

spoke English “not very well.”

 

Using 2009 inflation-adjusted dollars, median 

household income was $68,900, and per capita 

income was $30,000 for Asians. Among Asian 

families, 9% had incomes below the poverty 

threshold.

i

In 2009, 17.2% of Asians did not 

have health insurance (3). Seven percent of 

Asians lived in overcrowded conditions,

j

compared with 3% for the U.S. population. 

Additionally, 89% of Asians had one or more 

vehicles available at their home which was

comparable to 91% of the U.S. population. 

Educational attainment among Asians is shifted 

toward advanced degrees in comparison with the 

overall U.S. population, with 50% of Asians 

≥25 years of age having at least a bachelor’s 

degree, as do 28% of the general U.S. 

population. More specifically, 30% of the U.S. 

resident Asians had a bachelor’s degree, and 

20% had a graduate or professional degree, 

compared with 18% and 10%, respectively, for 

the general U.S. population.

Native Hawaiians and Other Pacific 

Islanders 

The OMB definition of “Native Hawaiian or 

Other Pacific Islander” refers to people from 

Guam, Hawaii, Samoa, or Other Pacific Islands

(2). The age distribution of Native Hawaiians 

and Other Pacific Islanders who resided in the 

United States in 2010 is shown in Figure 3. 

Among the almost 500,000 Native Hawaiians 

and Other Pacific Islanders residing in the 

United States in 2010, 50% were male. The 

median age for males and females was 30–34 

years (see Figure 3 and Table 2). 

 

g

 A metropolitan statistical area (Metro Area) 

contains a core urban area of 50,000 or more

population, and a micropolitan statistical area 

(Micro Area) contains an urban core of at least 

10,000 (but less than 50,000) population 

(http://www.census.gov/population/metro/). h

 Not a U.S. citizen at birth.

i

 Each year the Office of Management and Budget 

establishes the poverty threshold for the nation. It 

is based on the Consumer Price Index and takes 

into consideration family size and the number of 

children. The 2009 poverty threshold is based on 

family size, the number of children, and whether 

the head of household for 1- or 2-member 

households is elderly. For more information, see 

http://www.census.gov/hhes/www/poverty/data/

threshld/thresh09.html. j

 On the basis of the number of household members 

divided by the number of rooms in the home, >1.0 

persons/room is considered overcrowding.
CHAPTER 1: ASIANS AND NATIVE HAWAIIANS AND OTHER PACIFIC ISLANDERS IN THE UNITED STATES 15 

Figure 3. Age distribution of Native Hawaiians and Other Pacific Islanders in the United 

States, 2010*

* Based on intercensal estimates. Population in thousands

Table 2. Distribution of Native Hawaiians and Other Pacific Islanders by sex and age group, 2010*

Male Female

Age group, years % % 

<5 7.9 7.8

5–9 7.9 7.6

10–14 7.9 7.5

15–19 8.6 8.4

20–24 9.8 9.3

25–29 9.2 8.9

30–34 8.2 8.0

35–39 7.3 7.2

40–44 6.8 6.9

45–49 6.7 6.9

50–54 6.0 6.1

55–59 4.5 4.9

60–64 3.6 3.8

65–69 2.3 2.5

70–74 1.5 1.7

75–79 0.9 1.2

≥80 0.8 1.4

* Based on intercensal estimates. 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 16 

Figure 4. Distribution of Native Hawaiians and Other Pacific Islanders, top 10 states, 2010

GEOGRAPHIC DISTRIBUTION OF NATIVE 

HAWAIIANS AND OTHER PACIFIC 

ISLANDERS

The top ten states with the largest population of 

Native Hawaiians and Other Pacific Islanders 

were California, Hawaii, Washington, Texas, 

Utah, Nevada, Oregon, Arizona, Florida, and 

New York (see Figure 4). 

The 2010 Census showed that the five 

metropolitan or micropolitan statistical areas

with the largest Native Hawaiian and Other 

Pacific Islander population were the Honolulu, 

Hawaii Metro Area (86,235); the Los AngelesLong Beach-Santa Ana, California Metro 

Area (30,821); the San Francisco-OaklandFremont, California Metro Area (29,761); the 

Seattle-Tacoma-Bellevue, Washington Metro 

Area (27,275); and the Hilo, Hawaii Micro Area 

(20,970). The 20 metro/micro areas with the 

largest Native Hawaiian and Other Pacific 

Islander populations are shown in the Appendix 

in Table A3. 

OTHER CHARACTERISTICS OF NATIVE 

HAWAIIANS AND OTHER PACIFIC 

ISLANDERS

Over 90,000k or 0.2% of all foreignbornh persons in the United States were Native

Hawaiians and Other Pacific Islanders, 

according to the 2009 ACS. Of this total, males 

slightly outnumbered females, comprising 52% 

(47,600) of the Native Hawaiian and Other 

Pacific Islander population in the United States. 

Of almost 400,000 Native Hawaiians and Other 

Pacific Islanders ≥5 years of age, 43% spoke a 

language other than English at home and of 

these, just over one-tenth reported they spoke 

English “not very well.”

Using 2009 inflation-adjusted dollars, median 

household income was approximately $53,500, 

and per capita income was $20,000 for Native 

Hawaiians and Other Pacific Islanders, 

compared with $50,000 and $26,000, 

 

k

 19% (91,545/481,576) of Native Hawaiians and 

Other Pacific Islanders were foreign-born.
CHAPTER 1: ASIANS AND NATIVE HAWAIIANS AND OTHER PACIFIC ISLANDERS IN THE UNITED STATES 17 

respectively, for the general U.S. population. 

Among Native Hawaiian and Other Pacific 

Islander families, 12% had incomes below the 

poverty threshold. In 2009, 17.3% of Native 

Hawaiians and Other Pacific Islanders did not 

have health insurance (3). 

Sixteen percent of Native Hawaiians and Other 

Pacific Islanders lived in overcrowded 

conditions, compared with 3% for the overall

U.S. population. Additionally, 91% of Native 

Hawaiians and Other Pacific Islanders had one 

or more vehicles available at their home, which 

was comparable with the percentage for the 

overall U.S. population. 

Educational attainment among Native Hawaiians 

and Other Pacific Islanders differed from that for 

the overall U.S. population. Among Native 

Hawaiians and Other Pacific Islanders ≥25 years

of age, 51% had a high school education or less, 

and 14% had a bachelor’s degree or higher, 

compared with 43% and 28%, respectively, for 

the overall U.S. population. More specifically, 

14% of Native Hawaiians and Other Pacific 

Islanders had not completed high school

(compared with 15% of the overall U.S. 

population), 37% (compared with 29% of the 

overall U.S. population) had a high school 

diploma or equivalent, 35% (29% U.S.) had 

some college or an associate’s degree, 10% 

(18% U.S.) had a bachelor’s degree, and 4% 

(10% U.S.) had a graduate or professional

degree. 

DISCUSSION 

The reader should consider several important 

issues that impact the interpretation or 

integration of census versus surveillance data. 

U.S. Census data, notably those for race, are 

generally collected by self-report, whereas 

disease surveillance data are frequently collected 

from secondary data sources such as medical 

records. As such, surveillance data may reflect a 

healthcare provider’s interpretation of a patient’s 

race and ethnicity, which may be different from 

the way in which the patient would self-identify. 

The infectious diseases reported in the

Epidemiologic Profile 2010 are usually based on 

case data defined by a combination of 

race/ethnicity concepts. For example, the 

surveillance data reflect Asians and Native 

Hawaiians and Other Pacific Islanders who are 

single race and not of Hispanic origin. U.S. 

Census data provide information about Asians 

and Native Hawaiians and Other Pacific 

Islanders who are not of Hispanic origin, as well 

as for those who are of Hispanic origin. 

Currently for Asians who reside in the United 

States, exclusion of those who are of Hispanic 

origin is a reasonable analytic decision, since 

only approximately 1% of Asians are of 

Hispanic origin, but for Native Hawaiians and 

Other Pacific Islanders approximately 11% are 

of Hispanic origin (2). Additionally, the use of 

single-race data for Asians and especially for 

Native Hawaiians and Other Pacific Islanders, 

which are often used by surveillance for disease 

reporting, may be an oversimplification of the 

racial composition of these populations. Among 

non-Hispanic Asians who reside in the United 

States, if Asian in combination with any other 

racial group were included, the population 

would increase by 14%. And the group 

designated as Native Hawaiians and Other 

Pacific Islanders would increase by 53%. For 

consistency, U.S. Census data reported in this 

chapter were restricted to those of a single race 

and of non-Hispanic origin.

Excluding about one-half of Native Hawaiians 

and Other Pacific Islanders from the description 

of members of those groups who reside in the 

United States may negatively alter the reference 

population the reader is using as a base of 

comparison. Furthermore, this comparison is 

exacerbated by the fact that Census data used for 

Native Hawaiians and Other Pacific Islanders 

originated from those people who reside in the 

United States—not in U.S. territories or other 

dependent areas, many of which are in the 

Pacific Region. 

Asians and Native Hawaiians and Other Pacific 

Islanders are diverse, heterogeneous groups, and 

therefore readers should be cautious when 

drawing inferences about racial subpopulations.

New data standards recently adopted by the U.S. 

Department of Health and Human Services will 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 18 

help provide more granular information on race 

in the future, but the stability and reliability of 

ever-smaller estimates may overcome the 

intended benefit (4). Additionally, the motivated 

reader could explore racial subgroups by

selecting subgroups of interest and using data 

from the U.S. Census Bureau’s American 

Community Survey, Asian Population: 2010 

Brief, and Native Hawaiian and Other Pacific 

Islander: 2010 Brief (5,6). 

REFERENCES

1. U.S. Office of Management and Budget. Revision 

to the standards for the classification of federal data 

on race and ethnicity, Federal Register Notice, 

October 30, 1997. http://www.whitehouse.gov/

omb/fedreg_1997standards/. Accessed August 1, 

2011.

2. Humes KR, Jones NA, Ramirez RR. Overview of 

race and Hispanic origin: 2010. Issued March 

2011. U.S. Census Bureau: 2010 Census Brief. 

http://www.census.gov/prod/cen2010/briefs/

c2010br-02.pdf. Accessed May 24, 2011.

3. U.S. Census Bureau. Asian/Pacific Islander 

American Heritage Month: May 

2011. http://www.census.gov/newsroom/releases/

pdf/cb11ff-06_asian.pdf. Accessed February 8, 

2012.

4. Dorsey R and Graham G. New HHS standards for 

race, ethnicity, sex, primary language, and 

disability status. JAMA 2011;306(21):2378–2379.

5. Hoeffel E, Rastogi S, Kim MO, Shahid H. The

Asian Population: 2010. Issued March 2012. U.S. 

Census Bureau: 2010 Census 

Brief. http://www.census.gov/prod/cen2010/

briefs/c2010br-11.pdf. Accessed March 21, 2012. 

6. Hixson L, Hepler B, Kim MO. The Native

Hawaiian and Other Pacific Islander Population: 

2010. Issued May 2012. U.S. Census Bureau: 

2010 Census Brief. http://www.gov/prod/

cen2010/briefs/c2010br-12.pdf. Accessed May 

16, 2012.
CHAPTER 2: TUBERCULOSIS 19 

CHAPTER 2: TUBERCULOSIS

OVERVIEW

Tuberculosis (TB) is an infectious disease 

caused by Mycobacterium tuberculosis, although 

other mycobacteria species (e.g., M. bovis and 

M. africanum) also can cause disease. Most 

commonly, TB is spread when the germs of 

persons with infectious TB disease are released 

into the air (e.g., through coughing, sneezing, 

and talking) and are inhaled by another person. 

The symptoms of TB disease include lethargy, 

weight loss, fever, and night sweats. 

TB disease can occur anywhere in the body; 

however, most disease occurs in the lungs. If the 

disease affects the lungs, other symptoms can 

include coughing, chest pain, and coughing up 

blood. Latent TB infection must be distinguished 

from active TB disease. The term latent TB 

infection is used to describe infection with 

inactive TB germs. Persons that have latent TB 

infection have been exposed to the disease and 

have been infected but have no symptoms. 

These persons are not infectious, although they 

are at risk of the eventual development of active 

disease. In general, persons with active TB (or 

TB disease) are symptomatic and can transmit 

the infection to others.

According to the 1999–2000 National Health 

and Nutrition Examination Survey, a group of 

health surveys conducted each year among U.S. 

populations, more than 11 million persons have 

latent TB infection (1). An estimated 5%–10% 

of persons with latent infection will eventually 

develop active TB disease. In addition, persons 

infected with human immunodeficiency virus 

(HIV), who also have TB disease, are more 

likely to die without treatment (2). In 2009, 547 

persons died of TB disease, representing a rate 

of 0.2 deaths per 100,000 population (3). 

Most persons with TB disease can be treated 

with a 6- to 12-month course of multidrug 

therapy; however, some cases are caused by 

organisms that are resistant to these medications. 

Multidrug-resistant TB (MDR TB), as defined 

by the World Health Organization, is TB that is 

resistant to at least two of the first-line drugs 

used to treat the disease (i.e., isoniazid and 

rifampin) (4). MDR TB complicates public 

health efforts to control disease. Other cases of 

MDR TB are caused by organisms that are 

resistant not only to first-line antibiotics, but 

also to the best second-line drugs—

fluoroquinolones and at least one of three 

injectable drugs. This subtype of MDR TB, 

known as extensively drug-resistant (XDR) TB, 

occurs very rarely in the United States (5). Less 

than 6 cases of XDR TB have been reported 

annually for the years 2003–2009, whereas 

approximately 100–130 cases of MDR TB were 

reported each year during the same period (3). 

TUBERCULOSIS DATA SOURCES

The Division of TB Elimination at CDC 

conducts TB surveillance which provides 

national, state, and local level data that helps to

inform prevention and control efforts. Each year, 

as part of the National Tuberculosis Surveillance 

System (NTSS), all 50 U.S. states and several 

other reporting areas (i.e., the District of 

Columbia, New York City, Puerto Rico, and 

other U.S.-affiliated areas in the Pacific and 

Caribbean) routinely report new cases of TB 

disease to CDC. TB data are then examined by 

race/ethnicity, age, and sex to determine how 

various populations are affected by this disease. 

Data are also examined for other risk factors 

known to be associated with TB (e.g., birth in a 

country with high rates of TB or HIV infection, 

residence in correctional and long-term care 

facilities, homelessness, and drug and alcohol 

abuse). In an effort to more effectively monitor 

TB caused by drug-resistant strains, CDC also 

gathers information regarding drug susceptibility 

testing for culture-confirmed cases. 

Race/ethnicity is a risk factor for TB disease, 

and reporting of race/ethnicity has changed since 

1953 when standardized TB reporting first 

began. In 1985, the NTSS first reported national 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 20 

counts and rates for Asians and Pacific Islanders 

as a combined racial group. In 2003, all federal 

agencies, under the direction of the U.S. Census 

Bureau, began reporting separate population 

estimates for persons of Asian descent and for 

persons of Native Hawaiian and Other Pacific 

Islander descent (NHPI) (6). That year, the 

Division of TB Elimination began reporting 

cases by separate non-Hispanic Asian or nonHispanic NHPI race/ethnicity. 

SNAPSHOT 

Population Trends in Race/Ethnicity 

The rate of tuberculosis (new cases per 100,000 

population) among Asians or Native Hawaiians 

and Other Pacific Islanders (API) has always 

been higher than the rate for whites or that 

reported for all TB cases. The total number of 

TB cases reported in the United States in 2000 

was 16,309, a rate of 5.8 new cases for every 

100,000 population (5.8/100,000) (3). In the 

same year, persons of non-Hispanic API race 

had a rate of 31.3 per 100,000 population, more 

than 6 times the overall TB rate and more than 

16 times that reported in non-Hispanic whites 

(1.9/100,000). In the decade since, the case rate 

for TB in the United States has fallen to 3.6 per 

100,000 population, and to 0.9 per 100,000 

members of the non-Hispanic white population 

in 2010. 

Following the implementation of the new 

race/ethnicity reporting standards in 2003, the 

TB case rate for non-Hispanic Asians was 29.9 

per 100,000 population. In 2010, the rate had 

declined 25% to 22.4 per 100,000 population 

(see Figure 5). For non-Hispanic NHPI, the 2003 

TB case rate was 16.2 per 100,000 population, 

but had risen 28% to 20.8 per 100,000 

population in 2010. This represents a higher rate 

than that for all other races combined 

(2.7/100,000) and for non-Hispanic whites 

(0.9/100,000) in 2010 (see Figure 5). In 2010, 

Asians represented 28% of all reported TB cases 

(n=3,143), behind Hispanics (29%, n=3,236), 

and NHPI represented 1% of all reported TB 

cases (n=95). 

Some reporting areas report more TB cases 

among persons of Asian or NHPI descent than 

others. The areas reporting the most TB cases 

among Asians from 2006 to 2010 are California 

(n=5,779, 45% of total cases), New York City 

(n=1,435, 34% of total cases), Texas (n=1,035, 

14% of total cases), and New Jersey (n=777, 

35% of total cases). States with the highest 

percentage of Asians among all their TB cases 

are Hawaii (n=441, 75%), followed by 

California, New Hampshire (n=29, 39%), and 

Virginia (n=531, 36%). States reporting the most 

TB cases among NHPI from 2006 to 2010 are 

Hawaii (n=105, 18% of total cases), California 

(n=67, 0.5% of total cases), and Washington 

(n=55, 4% of total cases). 

U.S. or Foreign Birth 

The Centers for Disease Control first collected 

information on origin of birth (nativity) among 

persons with TB in 1993, and those born outside 

the United States have outnumbered U.S.-born 

persons with TB since 2001. In 1993, 29% of all 

TB cases affected the foreign-born; in 2010, 

60% of all cases were among foreign-born. 

Among Asians (n=26,493) with reported TB 

from 2003 to 2010, 95% were foreign-born. 

Foreign-born, non-Hispanic Asians represent the 

group with the highest proportion of TB cases 

among members of all racial/ethnic groups 

reported in the United States. This proportion 

remained steady throughout the years, with 94% 

of all Asian cases affecting foreign-born persons 

in 2003, and 92% in 2010 (see Figure 6). The 

top four countries of origin among foreign-born 

Asians with TB were the Philippines (26%), 

Vietnam (19%), India (17%), and China (12%). 

Contrasted with Asians, the proportion of TB 

cases among foreign-born NHPI (total cases = 

568) from 2003 to 2010 has been much lower, 

19%. Most NHPI with TB are U.S.-born (80% 

are U.S.-born; country of birth is unknown for 

1%). The NTSS collects incident TB cases from 

the U.S.-affiliated Pacific Islands of Guam, 

Palau, Northern Mariana Islands, American 

Samoa, Marshall Islands, and the Federated 

States of Micronesia. The foreign-born cases 

listed here are reported from the 50 states and 
CHAPTER 2: TUBERCULOSIS 21 

the District of Columbia. The proportion of 

foreign-born among NHPI ranged from 9% in 

2009 to 27% in 2006 (see Figure 7). Among all 

reported NHPI TB cases, 60% (n=338) were 

reported as U.S.-born and were from one of the 

six U.S.-affiliated Pacific Islands. The foreignborn NHPI (n=109) were reported most often 

from Fiji (n=33, 30%), Tonga (n=20, 19%), and 

the Philippines (n=14, 13%). 

Sex and Age 

Overall, there were consistently more males 

reported with TB than females for most 

racial/ethnic groups. From 2003 to 2010, males 

comprised 55% of all Asians and 50% of all 

NHPI reported to have TB. The rate among 

Asian males in 2010 was 26 per 100,000 

population (n=1,786), and 19 per 100,000 

population (n=1,344) for females. Tuberculosis 

rates for males under age 15 were lower than 

those for older Asians (3.8/100,000 for under age 

5, 2.9/100,000 for 5–14 years of age), but the rate 

increased to a high of 76 per 100,000 population 

among males ≥65 years of age (see Figure 8). 

Rates were slightly higher for females than for 

males in the younger age groups (4.2/100,000 for 

ages 5 and under, 3.8/100,000 for 5–14 years of 

age) and rose to a high of 34 per 100,000 

population for Asian females ≥65 years of age. 

From 2003 to 2010, 50% of all NHPI reported to 

have TB were male. In 2010, the highest rate 

among NHPI males occurred in the 15–24-year 

age group (38/100,000), and the next highest 

rate occurred among children <5 years 

(21/100,000) (see Figure 9). Among females, 

similar patterns were seen, with the highest rates 

among children <5 years of age (44/100,000) 

and those 15–24 years of age (37/100,000). 

Other Considerations 

Beyond race/ethnicity, sex, age, and origin of 

birth, other factors can disproportionately affect 

persons with TB. For example, TB occurs more 

often in persons infected with HIV because HIV 

weakens the immune system, greatly increasing 

the likelihood of progression from latent to 

active TB disease. Other risk factors such as 

homelessness, living in a long-term care facility 

or corrections facility, alcoholism and drug 

abuse can increase someone’s likelihood of 

developing active TB disease. Asians and NHPI 

with TB typically have lower rates of infection 

than the national average for persons in all these 

risk categories. One exception to this is MDR 

TB. From 2003 to 2010, Asians with TB had 

nearly twice (1.6%) the percentage of MDR TB 

as all cases of TB (0.9%) and nearly three times 

the rates for non-Hispanic whites (0.6%). The 

rate of MDR TB among NHPI (0.5%) is lower 

than the national percentage. About 6% of 

Asians with TB, the vast majority being foreignborn, were reported to have a history of TB 

disease, as did <5% of all persons reported to 

have TB disease. In the United States in 2010, 

among persons with no history of TB disease, 

1.2% were diagnosed with MDR TB, whereas 

4.9% of persons with a history of TB disease 

were reported to have MDR TB. This pattern is 

similar among Asians, in that 7% of persons 

with a history of TB were reported with current 

cases of MDR TB (a rate four times higher than 

that for persons with no history of TB). 

DISCUSSION 

The number of tuberculosis cases diagnosed 

among Asians is declining in the United States. 

This may be due to the decline in recent years of 

TB cases among foreign-born persons, 

particularly since 2008 when the number of 

cases among the foreign-born began to decline 

in the United States, along with the overall rate 

of TB cases per 100,000 in the general 

population that had been declining for many 

years. The reasons for this change in trend may 

reflect better overseas pre-immigration 

screening procedures for persons relocating to 

the United States or the fact that fewer foreignborn persons are relocating to the United States 

in a time of economic recession (7,8). Because 

U.S.-resident Asians with TB are predominately 

foreign-born, this seems a likely explanation for 

their reduction in rate and numbers in the United 

States. However, in 2010, Asians still have the 

second highest rate of TB among all 

racial/ethnic groups, second only to Hispanics. 

Certain minority populations continue to be 

disproportionately affected by TB. Asians are 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 22 

also more likely to have MDR TB than members 

of other racial/ethnic groups. Certain factors are 

associated with this pattern, such as having had 

previous treatment with anti-TB medications and 

being foreign-born. Persons who have been 

treated in the past for TB are more likely to 

develop MDR TB. According to the World 

Health Organization, 15% of previously treated 

patients have MDR TB, which is five times 

higher than the global average of 3% in new 

patients diagnosed with TB (9). Asians with TB 

emigrate from areas of the world where TB is 

prevalent and, therefore, are more likely to have 

a history of TB treatment.

Recent trends in TB rates among NHPI are 

difficult to assess. Persons of NHPI descent with 

TB are small in number compared with members 

of all other racial/ethnic groups. Fewer than 100 

cases are diagnosed in the United States every 

year. For example, in 2010, 95 cases of TB were 

diagnosed in the United States. 

Tuberculosis incidence is disproportionately 

higher in minority racial/ethnic groups in the 

United States. Ongoing surveillance and 

improved TB control and prevention activities, 

especially among disproportionately affected 

populations, are needed to eliminate TB in the 

United States.

Note: In all the figures that accompany this 

chapter, all races are non-Hispanic. Starting in 

2003, persons reported race as Asian only or 

Native Hawaiian and Other Pacific Islander 

only. Prior to 2003, these persons were reported 

as one category as a combined Asian or Native 

Hawaiian and Other Pacific Islander, API. 

Figure 5. Tuberculosis incidence by race/ethnicity, United States, 2003–2010

0

5

10

15

20

25

30

35

2003 2004 2005 2006 2007 2008 2009 2010

Incidence rate per 100,000 population

Year of reporting

Asian Native Hawaiian or Other Pacific Islander White
CHAPTER 2: TUBERCULOSIS 23 

Figure 6. Tuberculosis cases among Asians by nativity, United States, 2003–2010

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005 2006 2007 2008 2009 2010

Percent 

Year of reporting

Foreign-Born Cases US-Born Cases

Figure 7. Tuberculosis cases among Native Hawaiians and Other Pacific Islanders, by nativity, 

United States, 2003–2010

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005 2006 2007 2008 2009 2010

Percent 

Year of reporting 

Foreign-Born Cases US-Born Cases
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 24 

Figure 8. Tuberculosis case rates and counts, by age group and sex, Asians, 2010

0

10

20

30

40

50

60

70

80

0

100

200

300

400

500

600

< 5 5–14 15–24 25–44 45–64 ≥65

Incidence rate per 100,000 population

No. of TB Cases

Age Group (years)

Asian Males No. Cases

Asian Females No. Cases

Asian Males Rate

Asian Females Rate

Figure 9. Tuberculosis case rates and counts, by age group and sex, Native Hawaiians and Other 

Pacific Islanders, 2010

0

5

10

15

20

25

30

35

40

45

50

0

2

4

6

8

10

12

14

16

18

< 5 5–14 15–24 25–44 45–64 ≥65

Incidence Rate per 100,000 population

No. of TB Cases

Age Group (years)

NHPI Males No. Cases

NHPI Females No. Cases

NHPI Males Rate

NHPI Females Rate
CHAPTER 2: TUBERCULOSIS 25 

REFERENCES

1. Bennett DE, Courval JM, Onorato I, et al. 

Prevalence of tuberculosis infection in the United 

States population: The national health and 

nutrition examination survey, 1999–2000. Am J 

Respir Crit Care Med 2008;177(3):348–355.

2. World Health Organization. Frequently asked 

questions about TB and HIV. http://www.who.int/

tb/challenges/hiv/faq/en/#. Accessed April 5, 

2012.

3. Centers for Disease Control and Prevention. 

Reported Tuberculosis in the United States, 2010. 

Atlanta, GA: U.S. Department of Health and 

Human Services, CDC, October 2011.

http://www.cdc.gov/tb/statistics/reports/2010/pdf/

report2010.pdf. Accessed July 19, 2012.

4. World Health Organization. Multidrug and 

extensively drug-resistant TB (M/XDR-TB): 2010 

global report on surveillance and response. 

http://whqlibdoc.who.int/publications/2010/

9789241599191_eng.pdf. Accessed July 19, 2012. 

5. Centers for Disease Control and Prevention. 

Notice to readers: Revised definition of 

extensively drug-resistant tuberculosis. MMWR

2006;55(43):1176. http://www.cdc.gov/mmwr/

preview/mmwrhtml/mm5543a4.htm. Accessed 

July 19, 2012.

6. U.S. Census. http://www.census.gov/population/

www/socdemo/race/racefactcb.html. Accessed 

November 7, 2011.

7. Centers for Disease Control and Prevention. CDC 

immigration requirements: Technical instructions 

for tuberculosis screening and treatment. Using 

cultures and directly observed therapy. U.S. 

Department of Health and Human Services, CDC; 

2009. http://www.cdc.gov/

immigrantrefugeehealth/pdf/tuberculosis-ti2009.pdf. Accessed April 5, 2012.

8. Winston CA, Navin TR, Becerra JE, et al. 

Unexpected decline in tuberculosis cases 

coincident with economic recession―United 

States, 2009. BMC Public Health 2011;11:846.

9. World Health Organization. Treatment of 

Tuberculosis: Guidelines. 4th ed. Geneva, 

Switzerland: WHO, 2009. 

http://whqlibdoc.who.int/publications/2010/

9789241547833_eng.pdf. Accessed April 5, 2012.
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 26 

CHAPTER 3: VIRAL HEPATITIS

INTRODUCTION

Viral hepatitis is a term used collectively to refer 

to a group of viruses that can cause 

inflammation of the liver. Although a number of 

hepatitis viruses have been discovered, the most 

common types, which are also currently under 

surveillance in the United States, are hepatitis A, 

B, and C. Infection with any of these viruses can 

result in an acute infection that can cause shortterm illness. However, infection with the 

hepatitis B and C viruses can develop into 

chronic infection that is associated with an 

increased risk of developing cirrhosis or liver 

cancer (1). While the risk of progressing to 

chronic hepatitis B virus infection is inversely 

related to the age at the time of initial infection 

and is diagnosed among about 10% of the adult 

U.S. population (2), 80% of adults who become 

infected with the hepatitis C virus will develop 

chronic infection (3). 

Rates of new infection with acute hepatitis A, B, 

or C virus are at an all-time low primarily as a 

result of successful and effective prevention 

strategies (1). Historically, however, Asians or

Native Hawaiians and Pacific Islanders (APIs) 

have been disproportionately affected by 

hepatitis B. These populations carry the highest 

burden of chronic infection. The morbidity and 

mortality burden associated with chronic 

hepatitis B and C continues to represent a 

substantial public health problem in the United 

States. During 2001–2006, the incidence of 

hepatocellular carcinoma, a type of liver cancer 

resulting from years of infection with viral 

hepatitis, was highest among APIs when 

compared with blacks, American Indians and 

Alaska Natives, and whites (4). A Markov 

simulation model predicted direct medical costs 

from 2010 to 2019 of about $10.7 billion from 

hepatitis C alone (5). 

Chronic hepatitis B and C infections affect 

millions of Americans. However, due to the 

asymptomatic nature of the disease, many 

people do not realize they are infected until they 

develop liver-related complications many years 

after becoming infected (6). In 2010, the 

Assistant Secretary for Health for the U.S. 

Department of Health and Human Services, Dr. 

Howard Koh, dubbed the number of growing 

cases of chronic hepatitis B and C virus 

infections “the silent epidemic” because of the 

lack of awareness among the general public, atrisk populations, policymakers, and healthcare 

providers (7). 

VIRAL HEPATITIS DATA SOURCES

National Surveillance of Acute Viral 

Hepatitis 

The Division of Viral Hepatitis at CDC receives 

reports weekly of cases of acute and chronic 

viral hepatitis from the 50 state health 

departments and the District of Columbia health 

department—and occasionally from the 

territorial health departments—through the 

National Notifiable Diseases Surveillance 

System (NNDSS). The case reports include 

basic information, such as age, race/ethnicity, 

sex, date of onset, date of report, and county of 

residence. Patients of API descent are reported 

under one combined race category. Case reports 

include clinical data, laboratory results, and 

exposure history as optional extended data 

elements. Rates of acute, symptomatic viral 

hepatitis reported through this system are 

included in this report (see Figure 10 and Table 

3) and are calculated using the U.S. Census 

Bureau population estimates.

Study of Testing Practices and 

Infection Prevalence within U.S. 

Healthcare Organizations 

Investigators from the Chronic Hepatitis Cohort 

Study (CHeCS) collected clinical and 

demographic information from medical and 

billing records of over 1.2 million persons 

enrolled at four integrated healthcare networks 

in the United States (Honolulu, Hawaii; 

Portland, Oregon; Detroit, Michigan; Danville, 
CHAPTER 3: VIRAL HEPATITIS 27 

Pennsylvania). Adults with one or more visits 

during 2006–2008 and 12 months or more of 

continuous follow-up during any period of 

enrollment before 2009 were included in the 

study. A total of 867,589 persons were included 

in the analysis. Of these, 7% (60,255) were 

Asian and 3% (28,531) were Native Hawaiian 

and Other Pacific Islander (NHPI). The 

categories of ever being tested for infection with 

the hepatitis B and C viruses and ever testing 

positive for these viruses were ascertained (8). 

Enhanced Viral Hepatitis Surveillance 

Sites

CDC currently funds ten sites for viral hepatitis 

surveillance through the Emerging Infections 

Program, a network involving CDC, state and 

local health departments, and academic 

institutions. The ten sites are funded to conduct 

enhanced population-based surveillance for 

acute hepatitis A and acute and/or chronic 

hepatitis B and C in the United States (9). 

During 2005–2007, the Emerging Infections 

Program included six sites that conducted 

surveillance and follow-up of acute hepatitis A, 

B, and C in a population of 29.8 million persons. 

The results from the study describing the 

number and rate of acute, symptomatic hepatitis 

among APIs during 2005–2007 (10) are 

included in this report (see Table 4). 

National Mortality Data

Death certificates from each state and the 

District of Columbia are compiled by CDC’s 

National Center for Health Statistics to produce 

annual, national mortality data. Demographic 

information—such as age at death, 

race/ethnicity, and sex—and cause of death 

information, including viral hepatitis, are 

included in mortality data (11). The results from 

death certificate studies characterizing place of 

birth among hepatitis B decedents during 2000–

2004 (12) and trends in hepatitis C mortality 

rates during 1995–2004 (13) are included in this 

report. Decedents born outside of the 50 states 

and the District of Columbia were considered 

foreign-born.

Estimated Births to Hepatitis B VirusInfected Mothers

Birth certificate data from 22 states in 2006 and 

hepatitis B virus infection prevalence estimates 

were used to estimate the number of births to 

women infected with the hepatitis B virus (14). 

U.S.- and Canadian-born women were 

categorized as non-foreign born. Women who 

were born elsewhere were considered foreignborn and were divided into global regions based 

on country of birth. The medical literature was 

consulted to obtain U.S.-derived prevalence 

estimates of hepatitis B virus infection for nonforeign-born mothers while regional 

seroprevalence estimates were obtained for 

foreign-born mothers (15–17). These prevalence 

estimates were used to calculate the number of 

estimated births to non-foreign-born and 

foreign-born hepatitis B virus-infected mothers. 

In this chapter, cases of acute viral hepatitis 

among Asians and Native Hawaiians and Other 

Pacific Islanders reported through national 

surveillance are combined under a single race 

category, Asians or Native Hawaiians and Other 

Pacific Islanders (API), and Hispanic ethnicity is 

not examined separately from API race. For the 

CHeCS study, Hispanic ethnicity of Asians and 

Native Hawaiians and Other Pacific Islanders is 

not examined separately from race. All other 

special studies from which data are cited use 

mutually exclusive race/ethnicity categorization 

profiling non-Hispanic, Asians and Native 

Hawaiians and Other Pacific Islanders.

HEPATITIS A

About Hepatitis A

The hepatitis A virus is transmitted from direct 

contact with the stool or blood of an infected 

person or consumption of food or water that has 

been contaminated with fecal matter of an 

infected person. Symptoms such as jaundice, 

dark urine, and nausea are common (10,18). For 

U.S. residents, international travel to a hepatitis 

A-endemic country, household contact with a 

person with hepatitis A, injection drug use, 

being a man who has sex with other men, and 

international adoption of a child infected with 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 28 

hepatitis A are all commonly reported risks 

factors for contracting the virus (18). Because 

hepatitis A only exists in an acute form, serious 

complications, such as death from infection, are 

rare. However, certain populations, such as the 

elderly and persons with chronic liver disease, 

are more likely to die if infected (19,20). 

Since 1995, safe and effective vaccines have 

been licensed in the United States to prevent 

hepatitis A. The Advisory Committee on 

Immunization Practices recommends that 

children 12–23 months of age, persons traveling 

to countries where hepatitis A is endemic, men 

who have sex with men, illicit drug users, 

persons with chronic liver disease, and persons 

with occupational risks for infection receive 

hepatitis A vaccination (19). Additionally, postexposure prophylaxis, with immunoglobulin, is 

available for persons who were recently exposed 

to hepatitis A and is over 85% effective in 

preventing infection if given within two weeks 

of exposure (21). 

Snapshot

During 2000–2009, the incidence of acute, 

symptomatic hepatitis A among APIs in the 

United States decreased from 2.1 cases per 

100,000 population in 2000 to 1.0 cases 

per 100,000 population in 2009 (absolute rate 

change, 1.1 cases/100,000), although a slight 

increase was observed from 2007 to 2008

(see Figure 10). In 2009, acute, symptomatic 

hepatitis A among APIs identified by CDC’s 

National Notifiable Diseases Surveillance 

System accounted for a total of 150 (7.5%) cases

(see Table 3) (1). 

Of the 1,156 cases of acute, symptomatic 

hepatitis A reported by six U.S. sites conducting 

enhanced hepatitis surveillance from 2005 to 

2007, 79 were among APIs (see Table 4). The 

total incidence rate among APIs was 1.7 cases 

per 100,000 population, almost three times 

higher than blacks and two times higher than 

whites. In New York City, all of the 56 cases of 

hepatitis A occurred among Asians and yielded 

an incidence rate of 2.0 cases per 100,000 

population. 

Sex and Age

In 2009, males made up 55% of acute, 

symptomatic hepatitis A infections occurring 

among APIs in the United States (see Table 3). 

The incidence rate per 100,000 population was 

highest among males when compared with 

females and among the younger age groups 

when compared with the older age groups. 

Persons 20–29 years of age had the highest 

incidence rate of 2.0 cases per 100,000 

population.

HEPATITIS B 

About Hepatitis B

The hepatitis B virus is transmitted through 

exposure of mucous membranes to blood or 

body fluids containing the virus. Modes of 

transmission include sexual contact and sharing 

needles or personal hygiene items such as 

toothbrushes or razors with a person infected 

with the hepatitis B virus (22). Perinatal 

transmission, which plays a critical role in 

sustaining a high prevalence of disease, occurs 

when an infected mother passes on the virus to 

her infant during the birthing process. Chronic 

infection develops for up to 90% of persons 

infected as infants compared with 25%–30% of 

persons who acquire their infection between 1–5 

years of age and about 10% of persons infected 

at >5 years of age (2,23). In many developing 

regions of the world such as Southeast Asia, 

infection acquired in infancy or early childhood 

contributes greatly to the overall burden of 

chronic hepatitis B virus infection in those 

regions. 

From 2007 to 2008, CDC estimated that there 

were approximately 25,000 births each year to 

women in the United States who were 

chronically infected with the hepatitis B virus. 

Of these, an estimated three-fourths were among 

women of API descent (24). However, infection 

at birth often can be prevented if the infant 

receives appropriate post-exposure prophylaxes, 

which are the hepatitis B immune globulin and 

the first dose of the hepatitis B vaccine, 

administered within 12 hours after birth (22). 
CHAPTER 3: VIRAL HEPATITIS 29 

In the United States, trends in the rate of acute 

hepatitis B have declined over time, largely in 

part due to recommendations of the Advisory 

Committee on Immunization Practices

implemented in 1991 for a comprehensive 

national strategy to prevent the spread of 

hepatitis B virus infection (25,26). The strategy 

recommends routine testing of all pregnant 

women for hepatitis B virus infection, universal 

hepatitis B vaccination of infants beginning at 

birth, catch-up vaccination of previously 

unvaccinated children and adolescents, and 

vaccination and testing of adults who are at an 

increased risk for contracting hepatitis B virus

infection. Adult populations at risk for acquiring 

hepatitis B include injection drug users, men 

who have sex with other men, healthcare 

workers, dialysis patients, household and sexual 

contacts of persons with hepatitis B, recipients 

of certain blood products, and persons with 

recent multiple sex partners (26). Despite public 

health efforts, hepatitis B vaccination coverage 

is low among U.S. adults who are at risk for 

acquiring infection. Results from the 2009 

National Health Interview Survey indicated that 

only 51% of high-risk adults 18–49 years of age

had received more than one dose of the hepatitis 

B vaccine. These data also showed that the age 

group 18–20 years had the highest vaccination 

coverage, and that coverage declined with 

increasing age among both high-risk and lowrisk adults (27). 

Snapshot

During 2000–2009, the incidence of acute, 

symptomatic hepatitis B among APIs in the 

United States fell dramatically from 3.7 

cases/100,000 population in 2000 to 0.7 

cases/100,000 population in 2009 (absolute rate 

change, 3.1 cases/100,000) (see Figure 10). In 

2009, the total number of reported cases among 

APIs identified by CDC’s National Notifiable 

Diseases Surveillance System reached an alltime low of 98 (2.9%) cases (see Table 3) (1). 

In the CHeCS study from 2006 to 2008, 

approximately 27% of Asians and 26% of 

NHPIs who had no prior documented infection 

with hepatitis B virus when they entered a health 

plan were later tested for infection (see 

Appendix for Tables A4 and A5). Since persons 

included in this study were limited to adults and 

most hepatitis B virus infections among APIs 

occur during birth or early childhood, the vast 

majority of APIs who tested positive for the 

hepatitis B virus were chronically infected. The 

proportion of healthcare-plan members who

tested positive for hepatitis B virus infection 

ranged from 0.6% among whites to 4.2% among 

Asians (8). Infection prevalence was highest 

among the following groups: Asians (4.2%), 

NHPIs (2.5%), age group 50–59 years (1.9%), 

age group 40–49 years (1.7%), and blacks 

(1.2%). Investigators calculated the expected 

number of hepatitis B virus infections among 

health-plan members who participated in the 

study on the basis of race-adjusted national 

estimates of the prevalence of chronic hepatitis 

B virus infections for 1999–2006 (28). The 

number of hepatitis B virus infections that had 

been diagnosed among health-plan members was 

more than 25% lower than expected, suggesting 

that over a quarter of infected persons might not 

have been identified in the calculations, 

including APIs. 

Sex

In 2009, males made up 60% of acute, 

symptomatic hepatitis B infections occurring 

among APIs in the United States (see Table 3). 

The incidence per 100,000 population was 1.6 

times higher for males than for females (0.8 vs. 

0.5). 

During 2006–2008, Asians in the CHeCS study 

were comprised of more females than males 

(59% vs. 41%) (see Appendix for Table A4). Of 

the Asian females who had been tested for the 

hepatitis B virus, 4.0% had at least one positive 

test. Of the Asian males who had been tested, 

4.6% had at least one positive test. 

Among NHPIs in the CHeCS study, there were 

more females than males (55% vs. 45%). Of the 

NHPI females who had been tested for the 

hepatitis B virus, 2.2% had at least one positive 

test. Of the NHPI males who had been tested, 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 30 

3.0% had at least one positive test (see Appendix 

for Table A5). 

Age

In 2009, the incidence rate of acute, 

symptomatic hepatitis B among APIs was lowest 

among persons in the youngest age group, 0–19 

years of age, an age group that is recommended 

for vaccination at birth or during early childhood 

(rate, 0.2 cases/100,000) (see Table 3). The 

highest incidence occurred among young adults 

and persons ≥80 years of age with rates of about 

1 case per 100,000 population.

During 2006–2008, age groups among Asians in 

the CHeCS study <70 years of age were fairly 

evenly distributed (14.0%–18.8%) (see 

Appendix for Table A4). Asians 40–49 years of 

age and 50–59 years of age who had been tested 

for the hepatitis B virus tested positive for

infection most frequently (5.0% and 5.8%, 

respectively) compared to other age groups; 

Asians ≥80 years of age tested positive less 

often than any other age group (2.2%).

The proportion of NHPIs <30 years of age in the 

CHeCS study was 26%, which was greater than 

any other age group (see Appendix for Table 

A5). NHPIs 40–49 years of age and ≥80 years of 

age most often had at least one positive test 

(3.5% and 3.4%, respectively), while NHPIs 70–

79 years of age had the lowest proportion of 

positive tests (0.6%).

Median Household Income

Nearly 80% of Asian patients in the CHeCS 

study had a median household income between 

$30,000 and $74,999, according to census tract 

geocode data (see Appendix for Table A4). 

Overall, testing did not vary substantially by 

income bracket. Approximately 3.8%–4.5% of 

Asians in each income bracket who were tested 

for hepatitis B virus infection tested positive. 

Similarly, about 82% of NHPIs in the CHeCS 

study had a median household income between 

$30,000 and $74,999 (see Appendix for Table 

A5). Approximately 1.2%–2.8% of NHPIs in 

each income bracket who had tested for hepatitis 

B virus infection tested positive.

Mortality

From 2000 to 2004, the hepatitis B-related 

mortality rate per 100,000 population was about 

three times higher among foreign-born persons 

than among U.S.-born persons (1.0 vs. 0.3 per 

100,000 population, respectively) (see Figure 

11a). In APIs alone, average mortality rates were 

almost four times higher in APIs not born in the 

Unites States than APIs born in the United 

States (2.9 vs. 0.8 per 100,000 population, 

respectively) (see Figure 11b). During 1990–

2004, average hepatitis B-related mortality rates 

per 100,000 population were highest among 

APIs compared to other racial/ethnic groups 

(12). In 2004, rates per 100,000 population were 

8.5 times higher among APIs than among whites 

(2.0 vs. 0.2 per 100,000 population, 

respectively). 

Estimated Births to Infected Mothers 

Foreign-born mothers represented about onequarter of all registered births in 22 states in 

2006 (14). Of the foreign-born mothers, 80.6% 

were infected with hepatitis B. Women born in 

regions highly endemic with hepatitis B 

accounted for 69.3% of all estimated hepatitis B 

virus-infected mothers. When stratified by 

region of birth, the highest proportion of 

foreign-born mothers with infection was from 

Southeast Asia (31.2%). Women born in the 

Pacific Islands accounted for 1% of foreign-born 

mothers with infection. Of the mothers born in 

the United States and Canada, regardless of 

hepatitis B virus infection status, API mothers 

accounted for 1.5%. However, of the U.S.- and 

Canadian-born mothers who were infected with 

hepatitis B, APIs accounted for 11.6% (14). 

HEPATITIS C

About Hepatitis C

Hepatitis C virus infection, previously identified 

as non-A non-B viral hepatitis until 1995, is the 

most common infection spread through 

contaminated blood in the United States. An 
CHAPTER 3: VIRAL HEPATITIS 31 

estimated 3.2 million persons, representing 1.3% 

of the U.S. population, are chronically infected

with the hepatitis C virus (29). Chronic hepatitis 

C virus infection is a major cause of liver 

disease (18). In addition, long-term infection 

with the virus is the main factor leading to liver 

transplantation. The major mode of transmission 

in the United States is injection drug use. 

Although there is no vaccine available for 

protection against the virus, the 1998 national 

recommendations for the prevention and control 

of hepatitis C provide guidelines for 

a) preventing transmission; b) identifying, 

counseling, and screening persons at risk; and 

c) providing proper medical evaluation and 

management of infected persons (30). About 

20% of persons who become infected with the 

hepatitis C virus will spontaneously clear the 

virus (3). 

Snapshot

The incidence of acute, symptomatic hepatitis C 

among APIs in the United States from 2000 to 

2009 is lower than the rates of acute, 

symptomatic hepatitis A and B among APIs for 

the same period. During 2000–2009, APIspecific rates have varied and ranged from a 

high of 0.1 cases per 100,000 population in 2000 

to less than 0.1 cases per 100,000 population in 

2005 and 2007 (see Figure 10). In 2009, there 

were only 5 (0.6%) cases of acute, symptomatic 

hepatitis C among APIs identified by CDC’s 

National Notifiable Diseases Surveillance 

System (see Table 3) (1). 

In the CHeCS testing study during 2006–2008, 

approximately 15% of Asians and 14% of 

NHPIs did not have prior documented infection 

with hepatitis C virus at health plan entry and 

were later tested for infection (see Appendix 

for Tables A6 and A7). Asians were less likely 

than other racial/ethnic groups to test positive 

for hepatitis C virus infection (8). 

Due to the small number of total API cases 

reported to the National Notifiable Diseases 

Surveillance System, API-specific rates for 

acute, symptomatic hepatitis C stratified by sex 

and age group could not be reported. 

Sex

During 2006–2008, 4.0% of Asian females in 

the CHeCS study who had been tested for 

hepatitis C had at least one positive test (see 

Appendix for Table A6). Asian males tested 

positive as frequently (4.8%) as their female 

counterparts. 

Of the NHPI females who had been tested for 

the hepatitis C virus, 3.5% had at least one 

positive test. Of the NHPI males who had been 

tested, 5.4% had at least one positive test (see 

Appendix for Table A7). 

Age

During 2006–2008, Asians in the CHeCS study

50–59 years of age who were tested for hepatitis 

C virus infection tested positive most frequently 

(7.2%) compared to other age groups; Asians 

30–39 years of age tested positive less often than 

any other age group (2.3%) (see Appendix 

for Table A6). 

In the CHeCS study, NHPIs 40–49, 50–59, and 

60–69 years of age tested positive most often 

(5.1%, 7.0%, and 6.5%, respectively) than other 

age groups (see Appendix for Table A7). 

Median Household Income 

Like most participants in the CHeCS study, 

about 78% of Asians had a median household 

income (by census tract data) between $30,000 

and $74,999 (see Appendix for Table A6). The 

proportion testing positive within each income 

bracket was highest among those with a median 

household income of > $30,000, ranging from 

4.7% among those earning $30,000–$49,999 to 

4.0% among those earning > $75,000 annually. 

Approximately 82% of NHPIs in the CHeCS 

study had a median household income between 

$30,000 and $74,999 (see Appendix for Table 

A7). Of about 14%–15% of NHPIs belonging to 

each income bracket who were tested for 

hepatitis C virus infection, approximately 3.7%–

5.7% tested positive. 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 32 

Mortality

In 2004, APIs had the lowest age-adjusted 

hepatitis C-related mortality rate per 100,000 

population (rate, 1.9; 95% CI, 1.6–2.1) when 

compared with rates for other race/ethnic groups

(13). From 1995 to 2004, there was a 24.9% 

total percent increase in the age-adjusted 

mortality rate among APIs and an average 

annual rate change of 0.05 deaths per 100,000 

population per year (13). 

DISCUSSION

APIs residing in the United States are not 

disproportionately affected by acute hepatitis A, 

B, and C or chronic hepatitis C. Based on data 

from the National Notifiable Diseases 

Surveillance System, the 2000–2009 incidence 

rates of acute, symptomatic hepatitis A, B, and C 

among APIs have been on a downward trend. In 

2009, APIs represented 7.5%, 2.9%, and 0.6% of 

acute, symptomatic hepatitis A, B, and C cases, 

respectively. In the CHeCS study, Asian healthplan members were less likely than other 

race/ethnic groups to have ever been infected 

with the hepatitis C virus. 

Despite low and declining incidence rates, the 

data presented here highlight the substantial 

burden of disease and mortality attributable to 

chronic hepatitis B virus infection among APIs 

in the United States. Asians in the CHeCS study 

had the highest infection prevalence when 

compared with other race/ethnic groups in the 

health plans. Results from population-based 

surveys indicated that there were about 730,000 

adults living with chronic hepatitis B from 1999

to 2006 in the United States, of whom 43% were 

foreign-born (31). Regions of the world, such as 

Southeast Asia, are considered highly endemic 

for hepatitis B. Infant and early childhood 

infections play a crucial role in sustaining a high 

prevalence in the region (22). Immigration from 

hepatitis B-endemic areas into the United States 

contributes to the growing U.S. burden of 

chronic hepatitis B. Hepatitis B-associated 

mortality is highest among APIs and the foreignborn.

Surveillance data from the National Notifiable 

Diseases Surveillance System are subject to 

limitations. First, because APIs are combined 

under a single race category on the case report 

form, assessment of disease occurrence within 

each race group is not possible. Second, only 

data on acute cases are validated and published. 

However, supplementing these data with other 

sources, such as the Emerging Infections 

Program, CHeCS, and the National Vital 

Statistics System, provides valuable information 

regarding the burden of viral hepatitis morbidity 

and mortality among APIs.

This report highlights the substantial burden of 

chronic hepatitis B virus infection among APIs, 

many of whom are unaware of their infection 

status. Given the data presented here, improved 

viral hepatitis surveillance, culturally 

appropriate public health campaigns, increased 

and wider testing and vaccination of persons at 

high risk, and linkage of infected persons to 

good quality care and treatment are needed in 

order to see measurable declines during this 

epidemic (32). 
CHAPTER 3: VIRAL HEPATITIS 33 

Figure 10. Incidence of acute, symptomatic hepatitis A, B, and C among Asians or Native 

Hawaiians and Other Pacific Islanders (APIs), United States, 2000–2009

Source: National Notifiable Diseases Surveillance System. 

Figures 11a and 11b. Average age-adjusted hepatitis B mortality rates by place of birth, United 

States, 2000–2004

Foreign-born U.S.-born Foreign-born U.S.-born

* Asians or Native Hawaiians and Other Pacific Islanders. 

Source: Vogt TM, Wise ME, Shih H, Williams IT. Hepatitis B mortality in the United States, 1990–2004 [Abstract].

In: Final Program and Abstracts of the 45th Annual Meeting of the Infectious Diseases Society of America; San 

Diego, CA. October 4–7, 2007; Arlington, VA: Infectious Diseases Society of America; 2007. Abstract 731. 

https://idsa.confex.com/idsa/2007/webprogram/Paper23644.html. Accessed July 19, 2012.
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 34 

Table 3. Number of cases and incidence of acute, symptomatic hepatitis A, B, and C, by sex and age 

group among Asians or Native Hawaiians and Other Pacific Islanders, United States, 2009

Hepatitis A Hepatitis B Hepatitis C*

Demographic characteristics Number Rate† Number Rate† Number Rate†

Overall 150 1.0 98 0.7 5 <0.1

Sex§

 Male 82 1.2 59 0.8 — —

 Female 67 0.9 38 0.5 — —

Age group (years)¶

 0–19 34 0.9 8 0.2 — —

 20–29 42 2.0 19 0.9 — —

 30–39 45 1.7 25 1.0 — —

 40–49 11 0.5 24 1.1 — —

 50–59 10 0.6 9 0.5 — —

 60–69 3 0.3 6 0.6 — —

 70–79 3 0.5 2 0.3 — —

 80+ 1 0.3 4 1.2 — —

* Data could not be produced due to the small number of cases.

† Rates are per 100,000 population. 

§ One case of hepatitis A and one case of hepatitis B are not represented in sex category due to missing data.

¶ One case of hepatitis A and one case of hepatitis B are not represented in age group category due to missing data.

Source: National Notifiable Diseases Surveillance System
CHAPTER 3: VIRAL HEPATITIS 35 

Table 4. Number of cases and incidence of acute, symptomatic cases of hepatitis A, by race/ethnicity and reporting site,

* United States, 

2005–2007

Colorado Connecticut Minnesota New York State New York City Oregon Row Total

Variable No. Rate† No. Rate† No. Rate† No. Rate† No. Rate† No. Rate† No. Rate†

Cases reported 120 0.8 121 1.2 155 1.0 86 0.7 566 2.3 108 1.0 1,156 1.3

Race/ethnicity 

 American Indian/Alaska Native 0 0.0 2 8.2 4 2.4 0 0.0 0 0.0 1 0.8 7 1.3

 Asian/NHPI§ 5 1.4 7 2.0 3 0.6 7 3.2 56 2.0 1 0.2 79 1.7

 Black 1 0.2 4 0.4 7 1.1 4 0.4 40 0.7 0 0.0 56 0.6

 White 76 0.7 62 0.8 91 0.7 66 0.6 114 1.3 79 0.9 488 0.8

 Hispanic 31 1.1 39 3.3 28 4.7 8 1.8 219 3.2 20 1.8 345 2.7

 Multiple/other 0 0.0 1 0.8 0 0.0 1 0.7 66 22.6 0 0.0 68 5.6

 Missing 7 — 6 — 22 — 0 — 71 — 7 — 113 —

* Emerging Infections Program Hepatitis Surveillance Sites, 2005–2007.

† Rates are per 100,000 population. 

§ Native Hawaiian and Other Pacific Islander. 

Source: Klevens RM, Miller JT, Iqbal K, et al. The evolving epidemiology of hepatitis A in the United States. Arch Intern Med 2010;170(20):1811–1818.

http://archinte.jamanetwork.com/article.aspx?articleid=226193. Accessed July 19, 2012.
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 36 

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Wang S. Estimating the number of births to 

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Accessed July 19, 2012.
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 38 

CHAPTER 4: SEXUALLY TRANSMITTED DISEASES

INTRODUCTION

Sexually transmitted diseases (STDs) are among 

the most common infectious diseases in the 

United States and are important causes of 

disease burden. Sexually transmitted diseases 

present enormous health and economic 

consequences. The Centers for Disease Control 

and Prevention (CDC) estimate that 19 million 

new cases of sexually transmitted infections

occur annually in the United States, with nearly 

half occurring in persons 15–24 years of age (1). 

Direct medical costs associated with STDs in the 

United States are estimated at $15 billion 

annually (2). It is estimated that reported cases 

of STDs represent a fraction of the STD 

infections in the United States, likely reflecting 

limited screening and low disease reporting.

Many sexually transmitted infections can be 

asymptomatic, causing no recognizable 

symptoms and hence go undiagnosed. 

The spectrum of health consequences from 

STDs ranges from mild acute illness to serious 

long-term complications. Women and infants 

bear a disproportionate burden of STDassociated complications. Women are less likely 

to have noticeable symptoms and are likely to 

experience long-term consequences—such as 

tubal factor infertility, ectopic pregnancy, and 

chronic pelvic pain—if their STDs are not 

diagnosed and treated. STDs can also result in 

adverse outcomes in pregnancy, including 

spontaneous abortion, still birth, premature birth, 

and congenital infection. Sexually transmitted 

infections enhance the sexual transmission and 

acquisition of HIV infection (3). Improvement in 

the diagnosis, treatment, and management of 

STDs helps prevent disease sequelae and is an

important component in a comprehensive HIV 

prevention strategy. This chapter will focus on

three of the most commonly reported STDs: 

chlamydia, gonorrhea and primary and 

secondary (P&S) syphilis. 

SEXUALLY TRANSMITTED DISEASE 

DATA SOURCES

National Surveillance of Chlamydia, 

Gonorrhea, and Syphilis 

The Division of Sexually Transmitted Disease 

Prevention at CDC has been monitoring the 

prevalence of gonorrhea and syphilis since the 

early 1940s and began monitoring chlamydia in 

the mid-1980s. Currently, chlamydia, gonorrhea, 

and syphilis infections are reported from all 50 

states, the District of Columbia, and U.S. 

dependent areas, including Guam, Puerto Rico, 

and the U.S. Virgin Islands. Nationally 

notifiable STD surveillance data are reported to 

CDC through the National Electronic 

Telecommunications System for Surveillance 

(NETSS). Most of the STD-related morbidity 

data are reported electronically, but a few 

areas—such as Guam and Puerto Rico—

continue to report STD data through summary 

hard-copy forms. Reported cases of STD 

infections reflect the number of infections and 

not the number of people with STDs, since one 

person may account for more than one infection 

during a given reporting period.

In 2007 the Office of Management and Budget 

(OMB) released final guidance for the collection 

of data on race and ethnicity that allowed for 

a) individuals to self-identify their ethnicity, 

b) individuals to select one or more racial or 

ethnic categories and c) the expansion of 

reporting options to seven categories (American 

Indian or Alaska Native, Asian, black or African 

American, Hispanic, Native Hawaiian or Other 

Pacific Islander, white, and multi-race). 

Following a revision in the NETSS 

implementation guide in April 2008, 

jurisdictions reporting STD data were to collect 

race using these newly expanded racial/ethnic 

groups that included Asian and Native Hawaiian 

and Other Pacific Islander (NHPI). For purposes 

of data reporting, a combined race/ethnicity 

categorization has been used by STD 
CHAPTER 4: SEXUALLY TRANSMITTED DISEASES 39 

surveillance in which Hispanic/Latino may 

describe any racial group, and each of the five 

standard racial groups can include persons who 

are reported as being of a single race. Although 

many jurisdictions report STD data using this 

format, some jurisdictions have not had the 

capacity to adopt these new standards. Hence, 

for uniformity, race categories for the STD 

morbidity data and the 2000 U.S. Census Bureau 

data are bridged to the five race/ethnicity groups 

specified in the 1977 OMB standards, with 

Asian and NHPI reported as a single combined 

race group of Asian or NHPI (API). The counts 

presented in this report are summations of all 

valid data reported in reporting years 2000–

2010, and hence reflect rates based on reported 

data only.

STD Surveillance Network (SSuN)

In 2005, CDC established the STD Surveillance 

Network (SSuN) to improve the capacity of 

national, state, and local STD programs to 

detect, monitor, and respond rapidly to trends in 

STDs through enhanced collection, reporting, 

analysis, visualization, and interpretation of 

disease information. Currently, SSuN is 

composed of 12 collaborating sites in 11 states, 

which together encompass 115 counties and 42 

STD clinics. There are two main activities 

within SSuN, a population-based component and 

a clinic-based component. The population-based 

surveillance activity includes extensive data 

collection on demographics, risk and sexual 

behaviors, and treatment on a random sample of 

patients with reported gonorrhea within the 

site’s jurisdiction. The second activity involves 

the collection of demographic, behavioral, 

clinical, and laboratory information from all 

patients attending 42 STD clinics within the 12 

jurisdictions.

Gonococcal Isolate Surveillance 

Project (GISP)

GISP is a CDC-sponsored, sentinel surveillance 

system that monitors antimicrobial 

susceptibilities in Neisseria gonorrhoeae

through ongoing testing of male urethral 

gonococcal isolates from a systematic sample of 

men at 25–30 STD clinics in the United States. 

The gonococcal isolates are tested against a 

range of antimicrobials to determine 

susceptibility to therapeutically important 

antimicrobial agents, and the results are linked 

to patients’ epidemiologic data. 

Infertility Prevention Project (IPP) 

IPP is a national program funded by CDC in 

collaboration with the Office of Population 

Affairs to prevent chlamydia infections and 

associated reproductive complications in 

women, as well as to monitor test positivity in 

participating clinics. IPP participating sites are 

located across the United States and include 

family planning clinics, STD clinics, community 

health centers, adolescent teen clinics, outreach 

settings, and youth detention facilities. 

Screening criteria and practices vary by clinic, 

but the majority of sites screen all females under 

26 years of age and females ≥26 years of age

with defined risk factors. 

CHLAMYDIA

About Chlamydia

Chlamydia trachomatis infection is the most 

commonly reported condition in the United 

States, with more than 1.3 million infections 

reported in 2010 (4). Age is the strongest 

predictor of infection, with adolescent girls and 

young adult men recording the highest rates. 

Based on estimates from national surveys 

conducted during 1999–2008, chlamydia 

prevalence is 6.8% among sexually active 

females 14–19 years of age (5). Due to the high 

burden of disease and the lack of symptoms in 

most infected persons, CDC recommends annual 

chlamydia screening for all sexually active 

women 25 years of age or younger, and for 

women older than 25 years of age with specific 

risk factors such as a new sex partner or multiple 

sex partners (6). Chlamydia screening is one of 

the most cost-effective yet underused prevention 

services available (7). Although no formal 

national recommendations exist for screening 

young men for chlamydia, their roles in 

transmitting initial and recurrent infections to 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 40 

women are important; a 2006 CDC consultation 

emphasized the importance of screening men in 

certain venues, such as STD clinics and 

corrections facilities (8). 

C. trachomatis causes important diseases in 

men, women, and infants. The primary anatomic 

sites of infection in women are the uterine cervix 

and urethra and for men it is the urethra. Rectal 

infections, acquired through receptive anal 

intercourse, are also common, particularly 

among men who have sex with men (MSM). 

Chlamydia presents the greatest health threat in 

women, primarily through infection that ascends 

from the cervix to involve the uterus and 

fallopian tubes, resulting in pelvic inflammatory 

disease (PID) (9). Both clinically diagnosed 

PID and subclinical upper genital tract 

infection can result in tubal scarring, which 

increases the risk for infertility, ectopic 

pregnancy, and chronic pelvic pain. Chlamydial 

infection can lead to adverse health 

consequences for infants born to infected 

mothers, including conjunctivitis and 

pneumonia. Exposed infants can also develop 

symptomatic infections of the oropharynx, 

genital tract, and rectum. The occurrence of 

neonatal chlamydia represents a failure of 

prevention, since all pregnant women prior to 

delivery should be tested and treated if infected. 

Chlamydia, like other STDs, may increase risk 

for HIV acquisition and transmission (10). 

Snapshot 

Chlamydia case rates among APIs have 

traditionally been lower than the rates for 

members of other race/ethnic groups. In 2010, 

the total number of reported chlamydia cases 

among APIs was 17,188, which accounted for 

approximately 2% of all reported chlamydia 

cases. During 2000–2010, chlamydia case rates 

among APIs increased from 99.5 cases per 

100,000 population to 134.1 cases per 100,000

(see Figure 12). Although national chlamydia 

case report data suggests a continued increase in

case reports in APIs and in all other race/ethnic 

groups, it is likely due to improvements in 

reporting, expanded use of increasingly sensitive 

test technology, and better screening of young, 

sexually active women ≤25 years of age. 

SEX AND AGE

Since 2000, chlamydia case rates among API 

females and males have been gradually 

increasing. Comparing chlamydia rates in 2010 

to 2000, female morbidity has increased 26.3% 

and male morbidity increased 68.5%. Similar to 

other race/ethnicities, API females continue to 

have approximately three times the rate of 

infection of that for API males. Reported 

chlamydia rates for women greatly exceed those 

for men largely because screening programs 

have been primarily directed at women. In 2010, 

the highest rates of chlamydia among APIs are 

among females 15–19 years of age (661.3 per 

100,000) and 20–24 years of age (994.6 per 

100,000), and for males 20–24 years of age

(275.0 per 100,000) and 25–29 years of age

(170.6 per 100,000) (see Figure 13). 

TRENDS AMONG WOMEN 15–24 YEARS OF 

AGE WHO ATTEND IPP CLINICS

Data from prevalence monitoring activities 

indicates modest increases in chlamydia test 

positivity across all race/ethnic groups over the 

past ten years (see Figure 14). Non-Hispanic 

black females have consistently had the highest 

test positivity across all race/ethnic groups. 

Among API women, the median positivity is 

6.5% (range: 6.0–7.9%), higher than among 

white women (median positivity of 4.8%, range: 

3.6–5.5%) and Hispanic women (median 

positivity is 6.1%, range: 5.6–7.5%). Beginning 

in 2007, the majority of IPP sites were collecting 

information consistent with the revisions to the 

OMB directive for the collection of race and 

ethnicity. Examining IPP data from 2007

through 2010 reveals consistently higher 

chlamydia positivity rates among NHPI women 

than among Asian women. This highlights the 

importance of exploring potential differences in 

risk factors that might explain these differences 

in rates. Approximately 17% of tests per year in 

IPP have missing race/ethnicity so interpretation 

of the data may be difficult. Additionally, trends 

may be influenced by changes in diagnostic test 
CHAPTER 4: SEXUALLY TRANSMITTED DISEASES 41 

technology (e.g., expanded use of more sensitive 

laboratory tests) and screening coverage. 

GONORRHEA

About Gonorrhea

N. gonorrhoeae infection is the second most 

commonly reported condition in the United 

States behind chlamydia. In 2010, there were 

309,341 reports of gonorrhea cases, for an 

incidence of 100.8 per 100,000 population (4). 

From the mid-1970s to the mid-1990s, the rate 

of reported gonorrhea cases in the United States 

declined 74% following implementation of a 

national gonorrhea control program. Between 

1996 and 2006, rates stabilized and between 

2006 and 2010, gonorrhea rates decreased by 

15.8%. Despite these apparent decreases, rates 

of infection remain high among certain 

subgroups, including adolescents, young adults, 

African American men and women, and gay and 

bisexual men. It is important to keep in mind 

that changes in screening practices, reporting 

practices, and use of diagnostic tests with 

different levels of sensitivity and specificity may 

influence the number of case reports of 

infection. 

Men with N. gonorrhoeae infection often 

experience symptoms. Urethritis is the most 

common genitourinary manifestation in men and 

occasionally can be complicated by

epididymitis. For women, gonococcal infections 

can cause cervicitis and/or urethritis, which may 

or may not be accompanied by clinical signs and 

symptoms. Gonorrhea remains a major cause of 

pelvic inflammatory disease and subsequent 

tubal-factor infertility and ectopic pregnancy 

among women (9,11). Because gonococcal 

infections among women are frequently 

asymptomatic, the U.S. Preventive Services 

Task Force recommends that clinicians screen 

all sexually active women, including those who 

are pregnant, for gonorrhea if they are at an 

increased risk. In addition, for both men and 

women exposed orally or anally, gonococcal 

infection can cause pharyngitis or proctitis, 

which is often asymptomatic. Especially among 

gay men and other MSM, these extragenital sites 

can be a reservoir for transmitting infection. 

Additionally, studies have suggested that 

gonorrhea can facilitate HIV acquisition and 

transmission (3,12). 

Effective treatment of gonorrhea has been 

complicated by the ability of N. gonorrhoeae to 

develop resistance to antimicrobial agents. 

Emergence of gonococcal resistance to penicillin 

and tetracycline occurred during the 1970s and 

became widespread during the early 1980s. In 

the mid to late 1990s, resistance to 

fluoroquinolones was documented first in Asia, 

then emerged in the United States in Hawaii 

followed by other western states. CDC now

recommends dual therapy for gonorrhea with a 

cephalosporin plus azithromycin or doxycycline.

Recent increases in minimal inhibitory 

concentrations (MICs) to oral cephalosporins 

have been observed in the United States and are 

concerning as the emergence of resistance to

cephalosporins would substantially limit 

treatment options for gonorrhea. 

Snapshot

In 2010, there were 2,314 reported cases of 

gonorrhea among APIs in the United States, 

resulting in a case rate of 18.1 per 100,000 

population (see Figure 15). Comparing the 

single-year rates, gonorrhea case rates among 

APIs in 2010 have decreased by 23.9% since 

2000 (23.8% versus 18.1%). Similar to 

chlamydia case rates, gonorrhea case rates 

among APIs have consistently been lower than 

all other race/ethnic groups. In 2010, the total 

number of reported gonorrhea cases among APIs 

accounted for approximately 1% of all reported 

gonorrhea cases. For comparative purposes, the 

rate for the black population in 2010 (512.2 per 

100,000) was 28 times the rate for the API 

population.

SEX AND AGE

Unlike the gender distribution of reported 

chlamydia cases, gonorrhea is more evenly 

distributed among API males and females. For 

2010, the rate for males was 20.1 cases per 

100,000, whereas that for females was 16.1 

cases per 100,000. However, when stratified by 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 42 

age group, API females exceeded males, with 

infection rates for API females 5.5 times higher 

than those for males in the 10–14-year age 

group, and 2.3 times than those for males in the 

20–24-year age group. Similar female to male 

ratios in these age groups are also seen among 

all race/ethnic groups. During 2000–2010, 

gonorrhea case rates decreased by approximately 

25% among API males and females. A 

comparison of age groups indicates that the case 

rate of gonorrhea in 2010 is highest for the 20–

24-year age group, followed by the rate for the 

15–19-year age group. Differences by age 

groups are similar for both males and females. 

GONORRHEA AMONG API MSM IN STD

SURVEILLANCE NETWORK (SSUN)

With the exception of reported syphilis cases, 

most nationally notifiable STD surveillance data 

do not include information on sexual behavior. 

However, using SSuN’s population component, 

we are able to access more complete information 

on sex of sex partners (complete for 92% of 

male GC patients interviewed in SSuN, 

compared with 6% of male GC patients reported 

through NETSS in 2010). In weighted analysis 

from the GC patients interviewed, we were able 

to develop national estimates for 2010 that

indicate that Asians represent 1% of all GC 

cases in SSuN jurisdictions. However, MSM 

account for nearly 70% of the gonorrhea cases 

among API males, suggesting that MSM are at 

the highest risk for gonorrhea in this population. 

Enhanced surveillance collected in STD clinic 

patients in whom sexual orientation data are 

more complete can also be used to supplement 

case report data. Figure 16 presents gonorrhea 

positivity by sex and sex of partner among API 

patients attending SSuN STD clinics in 2010. 

Only those SSuN sites that had >5 API MSM 

attending STD clinics were included. The 

median site-specific gonorrhea prevalence was 

11.7% (range by SSuN site: 7.5%–20.0%) 

among API MSM compared to 2.3% (range: 0–

2.9%) among API men who have sex with 

women only (MSW) and 1.1% (range: 0–2.9%) 

for API women. 

GONORRHEA RESISTANCE IN GONOCOCCAL 

ISOLATE SURVEILLANCE PROJECT (GISP)

Approximately 64,000 isolates were tested 

during 2000–2010.The percentage of gonorrhea 

isolates with fluoroquinolone-resistant 

N. gonorrhoeae (QRNG) by race/ethnic group in 

the United States during 2000–2010 is shown 

in Figure 17. Shortly after the emergence of 

QRNG in the United States, the prevalence of 

QRNG increased rapidly among gonococcal 

isolates in API and whites as compared to 

blacks. In 2000, 15.7 percent of isolates among 

API were QRNG compared to 0.6% in whites 

and 0.1% in blacks. Although the proportion of 

QRNG among API decreased in 2002 to 4.4%, 

the proportion of QRNG gonococcal isolates 

among API increased to 25.7% in 2010, 

demonstrating a nearly 6-fold increase. Among 

whites, the percentage of isolates with QRNG 

increased steadily to 26.5% in 2010. A similar, 

although less dramatic, increase was seen among 

blacks from 2000 to 2010 (0.1% to 7.4%).

The increase in QRNG led CDC, in 2007, to 

discontinue recommending any fluoroquinolone

regimens for the treatment of gonorrhea. Thirdgeneration cephalosporins are now considered 

one of the classes of antibiotics that are wellstudied and effective against N. gonorrhoeae

infections in the United States (19). Dual 

therapy with a cephalosporin (ceftriaxone is 

preferred) and either azithromycin or 

doxycycline is recommended by CDC for 

treatment of gonorrhea in adults (20). Recent 

GISP data has documented an increasing trend 

of gonococcal isolates in the United States with 

elevated cefixime MICs (≥0.25 μg/mL) from 

0.2% in 2000 to 1.4% in 2010 and the 

percentage of isolates with elevated ceftriaxone 

MICs (≥0.125 μg/mL) has increased from 0.1% 

to 0.3% during 2000–2010. Although 

proportionally few isolates have exhibited 

elevated MICs for these antimicrobials, 

interesting observations are noted when 

stratified by race/ethnicity (see Figure 18). For 

example, the prevalence of isolates exhibiting 

decreased susceptibility to ceftriaxone (MIC 

≥0.125 μg /mL) is considerably higher among 

API, 1.1% compared to 0.6% of whites and 
CHAPTER 4: SEXUALLY TRANSMITTED DISEASES 43 

0.2% blacks. Prevalence of isolates with 

elevated cefixime MICs (≥0.25 μg/mL) and 

azithromycin MICs (≥2.0 μg/mL) are higher 

among whites (4.2% and 1.5%) and APIs (3.2% 

and 1.1%, respectively) as compared to blacks 

(0.4% and 0.1%). This epidemiologic pattern of

increasing percentages of GC isolates with 

elevated cephalosporin and azithromycin MICs 

is particularly concerning since it is similar to 

the pattern seen with GC and fluoroquinolone 

susceptibility shortly before fluoroquinoloneresistant GC strains emerged over a decade ago.

SYPHILIS

About Syphilis

Syphilis is a sexually transmitted disease caused 

by Treponema pallidum that, if untreated, has a

long and complicated clinical course. Syphilis 

progresses through defined stages and can last 

for decades but is treatable with penicillin. 

Patients with the earliest symptomatic stages of 

syphilis (primary and secondary, or P&S, 

syphilis) are most likely to present for 

examination and subsequent treatment, with 

symptoms that include genital ulcers or a rash.

Patients with P&S syphilis can transmit the 

disease sexually. P&S syphilis is followed by a 

long asymptomatic latent stage, followed by a 

late stage that may include serious complications 

such as cardiac or neurological manifestations. 

Latent syphilis cases are generally found 

through screening or partner notification, since 

the patient does not have any symptoms. 

Pregnant women with syphilis can transmit the 

infection to their child, which can cause 

miscarriage, stillbirth, and other serious 

consequences such as deafness, blindness, 

mental retardation, and neonatal death. In 

addition to the significant sequelae of syphilis 

infection, syphilis has been estimated to increase 

HIV transmission 2–9-fold and HIV acquisition 

2–4-fold (13,14). 

Snapshot

In 2010, the total number of reported P&S 

syphilis cases (201) among APIs accounted for 

less than 2% of all reported P&S syphilis cases.

Although the total number of P&S syphilis cases 

for APIs was relatively low (compared to other 

races or ethnicities), case rates increased steadily 

during 2000–2009 (0.3/100,000 population to 

1.7/100,000) before decreasing slightly in 2010 

(1.6/100,000). The largest increase in case rates, 

75%, was seen from 2001 to 2002 (0.4/100,000 

compared with 0.7/100,000). Despite these 

apparent increases, the overall rate among APIs 

was the lowest among all races/ethnicities. 

SEX AND AGE

Surveillance data reveal that the overall increase 

in P&S syphilis rates among API from 2000 to

2010 largely reflects an increase in rates 

reported among males (see Figure 19). The P&S 

syphilis rates among API males steadily 

increased from a low of 0.6 per 100,000 

population in 2000 to 3.1 per 1000,000 in 2010. 

The P&S syphilis rates among females have 

remained relatively stable since 2000. In 2000, 

the P&S syphilis rate in men was 3.6 times the 

rate in women; by 2010, the P&S syphilis rate in 

men increased to 15 times the rate in women. 

P&S infections are disproportionately found in 

males among other race/ethnic groups as well, 

an indication that syphilis transmission among 

MSM is a factor. 

Unlike chlamydia and gonorrhea, syphilis is not 

predominant in a particular age group. In 2010, 

the P&S syphilis rates among API peaked in the 

20–24-year-old age group for both genders 

(see Figure 20). After the peak, the P&S syphilis

rates among females continue to decline with 

age, while among males rates peak for a second 

time in the 30–34-year-old age group. The 

higher rates among 20–24-year-old males is a 

trend that first became apparent in 2007. 

SEX AND SEX OF PARTNERS 

Beginning in the early 2000s, increasing cases of 

P&S syphilis were noted primarily among 

MSM. This increase represented a shift from the 

previous epidemiology of P&S syphilis during 

the 1990s, when syphilis primarily occurred 

among heterosexual men and women. In part 

because of this shift, CDC began collecting data 

on the sex of sex partners of reported P&S 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 44 

syphilis cases in 2005. The percentage of cases 

of P&S syphilis among API during 2007–2010 

by sex and sex of sex partner is shown in Figure 

21. These data come from 31 states that reported 

sex of sex partner data for 70% or more of male 

cases of P&S syphilis for each of the years, 

accounting for 89% of male P&S syphilis in the 

United States in 2010. The percentage of cases 

was highest among API MSM, with percentages 

6–7 times higher than among MSW and 12–19 

times higher than among women, depending 

upon year. 

DISCUSSION

Americans of every age and every geographical, 

racial, cultural, and socioeconomic background 

are affected by STDs. Although each STD has a 

different magnitude of impact on various 

population groups, STD rates among 

Asians/Native Hawaiians and Other Pacific 

Islanders are often among the lowest for each of 

the notifiable STDs. However, the failure to 

recognize the diversity across API ethnic groups 

can contribute to perceptions of a ‘model 

minority’ whose successful acculturation into 

American society implies lack of need for sexual 

health services. APIs are a diverse group and 

classifying them within one race group lessens 

the importance of socioeconomic, cultural, and 

lifestyle variables in explaining variations 

among them. There are limited references to 

national STD data that separate Asians from 

Native Hawaiians and Other Pacific Islanders, 

but when these data are available, differences in 

rates have been noted. For example, IPP data 

demonstrated differences in chlamydia positivity 

rates among Asian women compared to NHPI 

women, which suggests additional studies are 

needed to assess individual and community-level 

risk factors that might help to explain some of 

these differences. 

In addition to recognizing the diversity within 

the API community, it is also important to note 

that certain subpopulations within the API 

community, such as MSM and youth, are 

particularly affected by STDs. Based on case 

report and enhanced surveillance data, API 

MSM are disproportionately affected by 

gonorrhea and syphilis infections when 

compared with API MSW and women. 

Investigations of STDs and HIV among API 

MSM have found that they are more likely to 

engage in unprotected sex when they have not 

been in the United States for very long or do not 

identify as being gay/homosexual (15,16). 

Youth, particularly women, also suffer 

disproportionately from STDs regardless of 

race/ethnicity. Existing literature may provide 

some insight into the behavioral and contextual 

factors that may influence API adolescents and 

young adults’ STD risk. Several researchers 

have concluded that API share certain cultural 

characteristics—such as sexual activity only 

within the context of marriage, the importance 

of family with an emphasis on propriety and 

social codes, and an absence of open discussions 

of sexuality—that may have significant impact 

on sexual health of APIs, particularly among 

youth (17–21). API youth appear to have a 

somewhat lower risk of STD acquisition than do 

other racial groups because a lower proportion 

engage in sexual activity (22,23). However, 

APIs who are sexually experienced do not differ 

in age at sexual debut or lifetime sexual partners 

as compared to white adolescents. Additionally, 

sexually experienced APIs are more likely than 

their white counterparts to have had multiple sex 

partners in the recent past (24). Data from the 

National Longitudinal Study of Adolescent 

Health found an overall 9% prevalence of any 

STD among API study participants, with a 

higher occurrence of STDs among young 

women compared with young men (13% vs. 4%)

(25). And while national chlamydia and 

gonorrhea rates are higher in young women than 

young men among all racial/ethnic groups, API 

women may have broader and more racially 

diverse sexual networks than men, exposing 

them to more STDs (19). 

The presence of antibiotic-resistant Neisseria 

gonorrhoeae is a public health concern in the 

management of the infection. Over the years,

this organism has acquired resistance to a 

number of antibiotics, including penicillin and 

fluoroquinolones, and historically much of this 

resistance has first appeared in the Western 

Pacific and Southeast Asia regions. During the 
CHAPTER 4: SEXUALLY TRANSMITTED DISEASES 45 

1970s and 1980s, the emergence and widespread 

dissemination of strains of N. gonorrhoeae 

resistant to penicillin necessitated abandoning 

these antimicrobials as treatment for gonorrhea 

in the United States. In the mid-1990s, QRNG 

was first documented in Hawaii, likely due to 

importation from tourists and immigrants from 

the Western Pacific and Southeast Asia (26,27). 

Since 2001, several reports of possible 

cephalosporin treatment failures have been 

identified in Japan (28–30). Additionally, trends 

in decreasing gonococcal susceptibility to 

cephalosporins over time have also been 

described, primarily in Asia (31–33). Given the 

historical experience with N. gonorrhoeae, it is 

likely that resistance to cephalosporins will 

eventually develop first among Asians and 

Asian Americans. The ability to monitor 

emerging strains of antibiotic-resistant 

N. gonorrhoeae arising from Asia and Pacific 

regions may provide early warning signs for the 

continental United States. 

Although APIs as a group appear to be at less 

sexual risk, substantial numbers of APIs engage 

in sexual activities that place them at risk for 

acquisition and transmission of STDs. 

Additionally, the possibility that APIs may 

develop risk profiles comparable to other groups 

once they initiate sexual activity reinforces the 

importance of providing them with the culturally 

sensitive information and skills they need to 

make informed decisions. Education, prevention, 

and treatment of STDs are important for the API 

population not only to prevent sequelae from 

STD infection, but also because of the 

relationship of STDs with HIV infection and 

transmission. 

Figure 12. Chlamydia case rates and counts among Asians or Native Hawaiians and Other Pacific 

Islanders (APIs), United States, 2000–2010

0

5000

10000

15000

20000

25000

0

20

40

60

80

100

120

140

160

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

No. of Cases

Rate per 100,000 population

Total No. of Cases Case Rate
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 46 

Figure 13. Chlamydia case rates among Asians or Native Hawaiians and Other Pacific Islanders 

(APIs), by sex and age groups, United States, 2010

0

200

400

600

800

1000

1200

10-12 15-19 20-24 25-29 30-34 35-39 40-44 45-54 55-64 65+

Rate per 100,000 population

Males Females

Figure 14. Chlamydia positivity among 15–24-year-old women in Infertility Prevention Project

clinics, by race, 2000–2010

* API=Asian/Native Hawaiian and Other Pacific Islander; positivity rates for APIs are available from 2000 to 2006.

† AIAN=American Indian/Alaska Native. 

§ UNK=Unknown race. 

¶ NHPI=Native Hawaiian/Other Pacific Islander; positivity rates for NHPIs and Asians are available from 2007 to 

2010. 
CHAPTER 4: SEXUALLY TRANSMITTED DISEASES 47 

Figure 15. Gonorrhea case rates and counts among Asians or Native Hawaiians and Other Pacific 

Islanders (APIs), United States, 2000–2010

0

500

1000

1500

2000

2500

3000

3500

0

5

10

15

20

25

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

No. of Cases

Rate per 100,000 population

Total No. of Cases Case Rate

Figure 16. Gonorrhea test positivity among Asian or Native Hawaiian and Other Pacific Islander 

(API) STD clinic attendees in STD Surveillance Network, by sex and sex of partners, 

2010

12.7

7.5

13.2

20

10.7 10.6

1.1 0 

1.9 2.7 2.9 3.4

0 0 1.2

2.9

0.9

2.3

0

5

10

15

20

25

CA/LA Chic NYC Phil SF WA

Positivity (%)

SSuN site

MSM MSW Women

Note: Only sites with >5 MSM were included. 

MSM=men who have sex with men; MSW=men who have sex with women only. 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 48 

Figure 17. Prevalence of QRNG among Neisseria gonorrhoeae isolates by year and race, GISP, 

2000–2010

* Native Hawaiian and Other Pacific Islander. 

QRNG=Fluoroquinolone-resistant Neisseria gonorrhoeae; GISP=Gonococcal Isolate Surveillance Project. 

Figure 18. Percentage of gonorrhea isolates with cefixime MICs ≥0.25 μg/mL, ceftriaxone 

MICs ≥0.125 μg/mL, and azithromycin MICs ≥2 μg/mL by race/ethnicity—Gonococcal 

Isolate Surveillance Project, United States, 2010

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Ceftriaxone Cefixime Azithromycin

% of isoaltes

API Black White

MIC=Minimal inhibitory concentration.
CHAPTER 4: SEXUALLY TRANSMITTED DISEASES 49 

Figure 19. Primary and secondary syphilis case rates by sex, Asians or Native Hawaiians and 

Other Pacific Islanders (APIs), United States, 2000–2010

0

1

2

3

4

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Rate per 100,000 population

Male Female

Figure 20. Primary and secondary syphilis case rates by sex and age group, Asians or Native 

Hawaiians and Other Pacific Islanders (APIs), United States, 2010

0

1

2

3

4

5

6

7

10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-54 55-64 65+

Rate per 100,000 population

Males Females
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 50 

Figure 21. Percentage of primary and secondary syphilis cases among Asian or Native Hawaiian 

and Other Pacific Islander (API) MSM, MSW, and women in 31 states*

, 2007–2010

0

10

20

30

40

50

60

70

80

2007 2008 2009 2010

Percentage of cases

MSM

MSW

Women

* States reporting sex of sex partner for 70% or more of reported P&S syphilis cases among API males. 

MSM=men who have sex with men; MSW=men who have sex with women only. 

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CHAPTER 5: HIV and AIDS 53 

CHAPTER 5: HIV and AIDS

OVERVIEW

Human immunodeficiency virus (HIV) can

infect persons of any age and race. The virus is 

most commonly transmitted through sex with an 

infected partner; injection drugs using a 

contaminated syringe; perinatal exposure from

an HIV-infected mother to child at birth or 

through breast feeding; or transfusion or 

organ/tissue transplantation from an infected 

donor. Initially, acute HIV infection may present 

as an influenza-like illness or other viral illness 

with a range of symptoms that usually last for a 

few days to several weeks and then resolve. 

Over time, however, there is progressive 

destruction of the immune system—specifically, 

CD4+ T-lymphocytes, a type of white blood cell

that fights infection, are destroyed. When the 

number of CD4+ T-lymphocytes declines to 

very low levels, certain opportunistic infections, 

cancers, or other conditions that are associated 

with acquired immunodeficiency syndrome 

(AIDS) may develop. The spectrum of HIV 

infection—from acute infection to death, with or 

without the development of AIDS—is called 

HIV disease.

In the absence of a cure, efforts to prevent 

primary infection remain critical in controlling 

the HIV epidemic. Prevention measures are 

developed for specific at-risk populations, with 

the basic strategies of identifying HIV infection 

soon after infection, linking infected persons to 

care early during the course of infection and 

retaining them in care, and providing prevention 

services for both HIV-infected and HIVuninfected persons. Because HIV infection is 

predominantly transmitted through sexual 

intercourse or injection drug use, a great deal of 

effort is focused on reducing these modes of 

HIV transmission with behavioral 

interventions (1). Recently, there also has been 

an increasing recognition of the role 

of antiretroviral treatment (ART) in HIV 

prevention; in addition to improving or 

maintaining the clinical status of and the quality 

of life for HIV-infected persons, ART can 

suppress HIV viral loads to levels that are 

associated with a substantial decreased risk for 

HIV transmission (2–4). 

As prevention interventions are implemented or 

modified for maximal impact, it is important to 

monitor their effectiveness in terms of the trend 

in HIV infection rates, prevalence of HIV risk 

behaviors or health-seeking behaviors, and the 

clinical status of and quality of care received by 

HIV-infected persons. At the Centers for 

Disease Control and Prevention (CDC), 

surveillance systems that are central to 

monitoring key aspects of the continually 

evolving HIV epidemic include the National 

HIV Surveillance System, the Medical 

Monitoring Project (MMP), and the National 

HIV Behavioral Surveillance System (NHBS). 

HIV and AIDS DATA SOURCES

Burden of HIV Disease

The Division of HIV/AIDS Prevention at CDC 

is responsible for monitoring the U.S. epidemic. 

AIDS diagnoses and deaths among persons with 

AIDS have been reported to CDC by all 50 

states, the District of Columbia, and U.S. 

dependent areas since the 1980s. HIV reporting 

includes the diagnosis of HIV infection, 

irrespective of the stage of HIV disease. 

Confidential, name-based HIV reporting began 

in a limited number of states in the mid-1980s 

and has been implemented by the remaining 

reporting jurisdictions over time. By April 2008, 

all states, the District of Columbia, and six 

dependent areas had implemented such 

reporting. At the time of this report, 46 states 

and 5 dependent areas had mature (i.e., 

confidential, name-based reporting in place for 

at least 4 years) and stable HIV data through 

2010 that could be used for the present

analysis (5). These areas include: Alabama, 

Alaska, Arizona, Arkansas, California, 

Colorado, Connecticut, Delaware, Florida, 

Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, 

Kentucky, Louisiana, Maine, Michigan, 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 54 

Minnesota, Mississippi, Missouri, Montana, 

Nebraska, New Hampshire, New Jersey, New 

Mexico, New York, Nevada, North Carolina, 

North Dakota, Ohio, Oklahoma, Oregon, 

Pennsylvania, Rhode Island, South Carolina, 

South Dakota, Tennessee, Texas, Utah, Virginia, 

Washington, West Virginia, Wisconsin, and 

Wyoming and 5 U.S. dependent areas 

(American Samoa, Guam, the Northern Mariana 

Islands, Puerto Rico, and the U.S. Virgin 

Islandsl

). 

Beginning in January 2003, following the Office 

of Management and Budget (OMB) directive, 

the collection of data on race uses at least five 

racial groups, which include Asian and Native 

Hawaiian or Other Pacific Islander (NHPI). Two 

categories of ethnicity, Hispanic or nonHispanic, are also used. For purposes of data 

reporting, a combined race/ethnicity 

categorization has been used by HIV 

surveillance in which Hispanics/Latinos may be 

of any racial group and each of the five standard 

OMB racial groups includes non-Hispanic 

persons who were reported with a single race. 

When Asians and NHPIs cannot be reported 

separately, a combined Asian/Native Hawaiian 

and Other Pacific Islander (API) group is used. 

Surveillance data may not be complete—risk 

exposures for transmission categories may be 

missing or unknown (i.e., no risk factor reported 

or identified). In such cases, multiple imputation 

is used to assign risk exposure information to 

persons with HIV disease who are reported 

without this information (5). 

The time from initial diagnosis of HIV until the 

case is reported to CDC is the reporting lag time 

and may be as long as 2 to 3 years (5). Statistical 

adjustments are made to the case counts to 

account for this delay and are reported as 

estimated numbers. Because of the delay for 

death ascertainment, an 18-month lag time is 

allowed so deaths described in this analysis are 

accounted for through June 2009. Thus, 

 

estimates for persons living with HIV or AIDS 

that used 2010 data are limited to the period 

ending December 31, 2009. Estimates based on 

data other than 2010 data are referenced.

Although adjustments are made to surveillance 

data for incomplete risk information and for 

delayed reporting, as noted above, the data do 

not include an adjustment to account for persons 

who are HIV infected and not reported, either 

because they are undiagnosed or tested 

anonymously.

Rates have been calculated using U.S. Census 

Bureau population estimates.

MMP: HIV-Infected Persons in Care 

MMP is a multi-site supplemental surveillance 

project developed to provide nationally and 

locally representative estimates of behaviors, 

clinical characteristics, and quality of care of 

HIV-infected persons who are receiving care. 

The project began with a pilot phase in 2005 and 

was fully implemented in 2007 (6,7). 

MMP data are collected through interviews and 

medical record abstractions on an annual 

probability sample of persons in care for HIV 

infection in the United States. Details on the 

design and methods of MMP have been 

previously reported (7,8). Briefly, eligible 

persons are HIV-infected individuals ≥18 years 

of age who receive outpatient care at an HIV 

care facility from January through April during 

the year of an MMP cycle. Data collected 

through interviews focus on behavioral issues, 

including behaviors that may facilitate HIV 

transmission; health seeking behaviors; 

utilization of HIV-related medical and 

prevention services; and adherence to 

medication regimens. Data collected through

medical record abstractions focus on clinical 

conditions that result from a person’s HIV 

infection or medications taken, laboratory tests 

performed and their results, and the type and 

quality of HIV care and support services these 

individuals receive. 

The MMP data presented in this report are from 

interviews conducted during the 2007 and 2008 

l

 When AIDS cases were reported and data were 

available, data from the Republic of Palau have 

been included for a total of 6 U.S. dependent areas.
CHAPTER 5: HIV and AIDS 55

MMP cycles (data collected from June 2007 to 

April 2009) in 26 project areas: California; 

Chicago, Illinois; Delaware; Florida; Georgia; 

Houston, Texas; Illinois; Indiana, Los Angeles 

County, California; Maryland; Massachusetts; 

Michigan; Mississippi; New Jersey; New York; 

New York City, New York; North Carolina; 

Oregon; Pennsylvania; Philadelphia, 

Pennsylvania; Puerto Rico; San Francisco, 

California; South Carolina; Texas; Virginia; and 

Washington. 

MMP collects information on race/ethnicity in 

accordance with the 2003 OMB directive. MMP 

also reports data on race/ethnicity using a 

combined categorization similar to that 

described above for the National HIV 

Surveillance System. For the MMP data in this 

report, however, the Asian and NHPI categories 

are combined because of the small number of 

MMP participants in each of these categories. In 

addition, several participants who reported being 

both Asian and NHPI are included in the 

descriptive analysis of API persons in care for 

HIV infection.

NHBS: At-Risk Populations

NHBS is a behavioral surveillance system 

developed in recognition of the need for 

information on populations at high risk for 

acquiring HIV infection. The data presented in 

this report were collected in the 2008 NHBS 

cycle, which focused on men who have sex with 

men (MSM).

In 2008, NHBS project activities were 

conducted in 21 urban areas. These areas were 

selected based on high burden of AIDS and 

included approximately 60% of all prevalent 

urban U.S. AIDS cases in 2008 (9). Men were 

sampled using venue-based (e.g., bars, clubs, 

organizations, and street locations), time-space 

sampling methods (10). Those eligible for 

participation were ≥18 years of age, residents of 

the selected geographic area, and able to 

complete an in-person interview in English or 

Spanish. For this report, analyses were limited to 

men who reported having sex with another man 

in the 12 months preceding the interview. The 

interview consisted of questions about sex, drug 

use, HIV testing behaviors, and use of HIV 

prevention services. Respondents, regardless of 

self-reported HIV infection status, were also 

offered anonymous HIV testing, given the 

opportunity to receive their test results, and 

anonymously referred to care when appropriate. 

Like MMP, NHBS collects information on 

race/ethnicity in accordance with the 2003 OMB 

directive. In addition, specific information on 

the ancestry of Hispanic participants is collected. 

For the NHBS data in this report, the Asian and 

NHPI categories were combined due to the small 

number of NHPI participants, which limits the 

ability to further categorize this group by 

different characteristics in a descriptive analysis.

SNAPSHOT

Persons with HIV Disease

In 2010, 818 (1.7%m) Asians and 67 (0.1%) 

NHPIs were diagnosed with HIV infection in 46

states and 5 dependent areas. The rate of HIV 

diagnoses for Asians has remained stable over 

time from 6.5 per 100,000 population in 2007 to 

6.5 per 100,000 population in 2010 (see Figure 

22). Among NHPIs, the rate of HIV diagnoses 

changed little from 21.3 per 1000,000 

population in 2007 to 19.3 per 100,000 

population in 2010 (see Figure 23). The 

estimated number of AIDS diagnoses in the 

United States, the District of Columbia, and 

6 dependent areas for Asians and NHPIs in 2010 

were 480 and 45, respectively, and contributed 

to an estimated cumulative total of 8,795 and 

889, respectively, diagnosed with AIDS from 

the start of the epidemic.

At the end of 2009, there were 8,422 Asians and 

620 NHPIs estimated to be living with HIV

disease in the United States and 5 dependent 

areas. An estimated 5,112 Asians and 481

NHPIs were living with AIDS in the United 

States and 6 dependent areas at the end of 2009.

The geographic distribution of persons ≥13 

years of age who were living with AIDS at the 

 m Of all HIV diagnoses in 2010.
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 56

end of 2009 varied by race. Among Asians, the 

top 10 states with the greatest number of persons 

living with AIDS were (in decreasing order)

California, New York, Texas, Hawaii, Illinois, 

Washington, Massachusetts, Virginia, Florida, 

and New Jersey. Among NHPIs living with 

AIDS, states (in decreasing order) were

California, Hawaii, Washington, Texas, Florida, 

then equally Nevada and Maryland, followed by 

equal numbers in New York and Pennsylvania.

SEX AND AGE

The percentage of men and women ≥13 years of 

age living with HIV disease at the end of 2009

was similar for Asians and NHPIs:

approximately 80% were men and 20% were 

women. Over 60% of HIV-infected Asians and 

NHPIs were 30–49 years of age. One percent or 

less of Asians and NHPIs living with HIV

were <20 years of age at the end of 2009

(see Table 5).

Previously published data that examined the 

estimated annual percentage change for HIV 

diagnoses from 2001 to 2008 reported a 

significant average annual increase of 5.1% for 

API men (11). Among API women, there was no 

substantial change in the rate of HIV diagnoses 

during this period.

FOREIGN-BORN

Foreign-born status is based on country of birth 

and is defined as any birth that occurs outside 

the United States and its territories. A recent 

analysis of National HIV Surveillance System

data from 46 states and 5 territories in which 

country of birth information was available 

estimated that 1,987 (64%) Asians who were 

diagnosed with HIV infection and reported to 

CDC from 2007 to 2010 were foreign-born (12). 

In contrast, 89 (32%) NHPIs diagnosed with 

HIV infection during the same period were 

reported as foreign-born (12).

Among APIs diagnosed with AIDS from 1999

to 2002, the most common countries of birth 

outside the United States were India, Vietnam,

the Philippines, Thailand, and Cambodia (13).

TRANSMISSION CATEGORY

Transmission categories are routes of HIV 

transmission that are believed to have led to HIV 

infection. Individuals may have more than one 

risk factor for HIV infection, but—for 

surveillance purposes—risks are categorized in a 

hierarchy so that each individual is classified 

into a single transmission category. The most 

commonly reported categories of HIV 

transmission in 2010 for Asians and NHPIs vary

by age and gender. Among Asian men ≥13 years

of age, sex with another man accounted for 

approximately 80% of cases and heterosexual 

contact for about 9%. Among NHPI men, sex

with another man accounted for almost 85% of 

cases and heterosexual contact for

approximately 6% of cases. For Asian and NHPI

women, heterosexual contact was the most 

prevalent risk factor. Among Asian women, 

heterosexual contact accounted for over 85% 

and injection drug use for about 9% of cases.

Among NHPI women, injection drug use 

accounted for over 15% and heterosexual

contact approximately 80% of cases (see Table 

6). Among Asian and NHPI children, <13 years

of age, perinatal exposure was the most 

prevalent risk exposure.

STAGE AT TIME OF HIV DIAGNOSIS

Immune function, as assessed by CD4+ Tlymphocyte count at the time of HIV diagnosis,

may be used to stage HIV infection and make 

general inferences of the length of time since 

HIV acquisition. Beyond the period of acute 

HIV infection, normal or nearly normal CD4+

T-lymphocyte counts in ART-naïve persons

suggests the diagnosis of HIV infection was 

made early in the course of HIV disease; a low 

CD4+ T-lymphocyte count that meets the 

serological criteria for AIDS (<200 cells/μL) 

suggests longstanding HIV infection. CD4+ Tlymphocyte counts of persons diagnosed 

with HIV infection in 2007 and subsequently 

assessed for immune function within 12 months 

of diagnosis varied by race/ethnicity. The 

median CD4+ T-lymphocyte count for Asians 

was 182 cells/μL (interquartile range [IQR]: 67–

358 cells/μL) and for NHPIs was 268 cells/μL 
CHAPTER 5: HIV and AIDS 57

(IQR: 114–396), in contrast to 248 cells/μL 

(IQR: 99–434) for whites (14).

MORTALITY 

Cumulative deaths among Asians and NHPIs 

diagnosed and reported as having AIDS, from 

the start of the epidemic through 2009, have 

been estimated to be 3,203 and 363, 

respectively.

PERSONS IN CARE FOR HIV DISEASE

Among 6,916 participants in the 2007 and 2008 

MMP cycles, 94 (1%) were APIs. Of these, 55

(58.5%) were Asian, 77 (81.9%) were male, 65 

(69.1%) were 35–54 years of age, 66 (70.2%) 

had completed some education beyond high 

school, and 48 (51.1%) had been diagnosed with 

HIV infection for ≥10 years (see Appendix 

for Table A8). A total of 38 (40.4%) participants 

were born outside of the United States; the 

country of birth varied greatly, with the most

common being the Philippines (n=10) and 

Vietnam (n=5). In the 12 months prior to 

participating in MMP, nearly half (47.9%) of 

API participants reported receiving public 

assistance despite the fact that 85.1% of all API 

participants reported having health insurance or 

coverage. 

Sixty-seven percent of API participants reported 

having their first visit for HIV medical care 

within 3 months following diagnosis. Among 

API participants, 87.2% reported being on ART 

during the 12 months before interview, 40.4% 

reported that their most recent CD4+ Tlymphocyte count was ≥500 cells/μL; 75.5% 

reported that their lowest CD4+ T-lymphocyte 

count was <500 cells/μL (see Figure 24); and 

63.8% reported that their most recent HIV viral 

load was undetectable.

The ancillary services needs most commonly 

reported among API participants in the 

preceding 12 months were HIV case 

management services (40.4%), mental health 

counseling (30.9%), dental care (27.7%), social 

services (26.6%), and transportation assistance 

(26.6%). Among API participants who reported 

needs for the aforementioned ancillary services, 

<15% of those who needed HIV case 

management, 28.0% of those who needed 

mental health counseling, 24.1% of those who 

needed social services, 34.6% of those who 

needed dental care, and 20.0% who needed 

transportation assistance reported that they had 

not received these services at the time of the 

MMP interview.

In order to specifically assess risky behaviors 

and receipt of prevention services after HIV 

infection, the analysis below was restricted to 

participants whose diagnosis of HIV had 

occurred at least 12 months earlier. Among the 

90 API participants diagnosed with HIV at least 

12 months prior to interview, 60 (66.7%) 

reported being sexually active in the preceding

12 months. Among 50 participants who reported 

vaginal or anal intercourse in the past 12 

months, 27 (54.0%) reported having had 

unprotected intercourse. Non-injection drug use 

in the previous 12 months was reported by 

34 (37.8%) of API participants; of these, the 

most common drugs reported were marijuana 

(70.6%), amyl nitrate or “poppers” (20.6%), 

and crystal methamphetamine (14.7%). 

Although injection drug use at any time in the 

past was reported by 16 (17.8%) participants, 

<5% reported injection drug use in the preceding 

12 months. Alcohol use was more common, 

with 57 (63.3%) API participants reporting any 

alcohol use in the previous 12 months and 

11 (12.2%) reporting excessive alcohol use (≥5 

drinks for men and ≥4 drinks for women in one 

day) in the preceding 30 days. Regarding 

prevention services, 45 (50.0%) API participants 

reported receiving free condoms, 22 (24.4%) 

reported participating in an individual-level 

intervention, and 6 (6.7%) reported participating 

in a group-level intervention in the past 12 

months.

Persons at Risk for HIV—MSM 

Participants of NHBS

For this report, we summarize the results from 

two descriptive analyses of 2008 NHBS data. 

The first characterizes API MSM who

participated in NHBS and did not report a 

previous positive test result or diagnosis (i.e., 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 58 

those considered to be at risk for HIV infection) 

and the second describes the prevalence of HIV 

infection among API MSM who completed 

NHBS HIV testing and had a negative or 

confirmed positive test result.

CHARACTERISTICS OF AT-RISK API MSM

Of 8,175 men participating in NHBS who 

reported having sex with another man in the 12 

months preceding the NHBS interview, 

completed the interview, and did not report a 

previous HIV-positive test result or diagnosis

(15), 258 (3.2%) were API. Among these, most 

were 25–39 years of age (65.8%), were born 

outside of the United States (57.0%), and had 

some education beyond high school (88.8%)

(see Appendix for Table A9). Among those who 

were foreign-born, the most commonly reported 

country of birth was the Philippines (36.1%). 

While 90.7% of API MSM reported being gay, 

8.5% self-identified as bisexual. Most (70.9%)

reported having private health insurance, but a 

substantial percentage (23.6%) had no health 

insurance. 

In the 12 months preceding the NHBS interview, 

140 (54.3%) of API MSM participants reported 

having had unprotected anal or vaginal sex. Of 

the 134 MSM who reported having had 

unprotected anal sex with a male partner, 98 

(73.1%) reported unprotected anal sex with a 

main male partner,n and 55 (41.0%) reported 

unprotected anal sex with a casual male partner.o

Of the 18 API MSM who reported sex with both 

male and female partners, <30% reported 

unprotected anal sex with their male partners, 

and 44.4% reported unprotected vaginal or anal 

sex with their female partners. 

When questioned about behaviors during their

most recent sexual encounter with a male 

partner, 118 men reported sex with a main 

 

partner, and 140 men reported sex with a casual 

partner. Unprotected anal intercourse was 

reported by 37.3% of those who had insertive 

anal intercourse with a main partner and by

28.0% of those who had insertive anal 

intercourse with a casual partner. Unprotected 

receptive anal intercourse was reported by

44.0% of those who had receptive anal 

intercourse with a main partner and by 35.4% of 

those who had receptive anal intercourse with a

casual partner (see Appendix for Table A10). 

Alcohol use was prevalent, with 220 (85.3%) 

API MSM reporting current use, 25 (9.7%) 

reporting heavy use (consuming >2 alcoholic 

beverages per day on average during the 30 days 

before the interview), and 102 (39.5%) reporting 

excessive or “binge” drinking (i.e., consuming

more than 5 alcoholic beverages at one sitting 

during the 30 days preceding the interview) (15). 

A total of 114 (44.2%) reported using noninjection drugs in the past 12 months, and 85 

(32.9%) reported using alcohol or drugs during 

their most recent sexual encounter with a male 

partner (see Appendix for Table A10). 

Among 235 participants who reported ever

having been tested for HIV, 76 (32.3%) had not 

been tested during the past 12 months. Of the 

158 participants who tested within the past 12 

months, the most common testing venues were a 

private physician’s office (28.5%), an HIV 

counseling and testing site (24.7%), and a public 

health clinic or community health center 

(19.0%). Among 99 API MSM participants who 

had not been tested for HIV in the preceding 12 

months, the most common reported reasons for 

not getting tested were the belief that they were 

at low risk for HIV (74.7%), fear of finding out 

that they were infected (32.3%), concern that 

someone would find out the test results (24.2%), 

and not having the time to get tested (18.2%).

A total of 44 (17.1%) API MSM reported 

participating in any HIV prevention service or 

program in the preceding 12 months. By type of 

service or program, 32 (12.4%) participated in 

an individual-level intervention, and 16 (6.2%) 

participated in a group-level intervention.

n

 A main partner is defined as a sex partner with 

whom the participant feels committed to above 

anyone else (e.g., boyfriend, spouse, significant 

other, or life partner). o

 A casual partner is defined as a sex partner with 

whom the participant does not feel committed to or 

does not know very well. 
CHAPTER 5: HIV and AIDS 59

PREVALENCE OF HIV INFECTION

This analysis examined data on men

participating in NHBS who reported having sex 

with another man in the 12 months preceding the 

NHBS interview, completed both the interview 

and HIV testing for NHBS, and either had a 

negative or confirmed positive HIV test result

(16). Data on participants who had indeterminate 

test results or who reported being HIV-positive 

but who had negative NHBS HIV test results

were excluded to avoid the potential for 

misclassification of HIV infection status. 

Among the 8,153 MSM included in the analysis

(16), 247 (3.0%) were API. Of the 247 API

MSM, 25 (10.1%) had positive HIV test results. 

The HIV prevalence was highest among persons 

30–39 years of age (18.4%) compared to those 

18–24 (0%), 25–29 (6.7%), or ≥40 (<15%) years 

of age. The HIV prevalence was 11.3% among 

foreign-born and 8.6% among those born in the 

United States; 20.0% among those with high 

school education or less compared to 8.8% 

among those with more than high school 

education; 20.8% among those with an annual 

household income <$20,000 compared to 9.1% 

among those with income of $20,000–$39,999 

and 7.0% among those with income of $40,000 

or more; 15.0% among those with no insurance 

compared to 8.6% among those with private or 

public health insurance; and 17.5% among those 

who had never been tested for HIV or had not 

been tested in the past 12 months compared to 

4.9% among those who had been tested in the 

past 12 months (see Appendix for Table A11). 

Among those testing positive for HIV, 11 

(44.0%) did not report being HIV infected 

during the interview; of these, most (63.6%) had 

reported having never been tested previously or 

having been tested more than 12 months before 

the interview.

DISCUSSION

Persons with HIV Disease

The percentage of Asians and NHPIs who were 

diagnosed with HIV were lower than the

percentages for members of other racial and 

ethnic groups in the United States during 2010.

Asians comprised 4.7% of the U.S. population in 

2010 and 1.7% of HIV diagnoses in 46 states 

and 5 U.S. dependent areas and NHPIs made up

0.2% of the U.S. populationp and 0.1% of HIV 

diagnoses in 2010.

Although the relative number of Asian and 

NHPIs infected with HIV may be small in the 

United States, Asians, in particular, represent a 

heterogeneous group. The racial group of 

“Asian” includes a number of different ethnic 

populations from different parts of the world, 

with different languages and social norms. In 

addition, the majority of HIV-infected Asians in 

the United States are foreign-born and thus 

factors such as acculturation, language, and 

socioeconomic status may further compound the 

challenge to find and deliver the appropriate 

prevention messages to individuals in this

heterogeneous group.

The median CD4+ T-lymphocyte count at the 

time of HIV diagnosis (182 cells/μL) for Asians 

suggests that most Asians were diagnosed late in 

the course of their infection and that there may 

have been missed opportunities to reduce HIV 

morbidity, mortality, and forward transmission. 

In addition, a telephone survey conducted 

among persons ≥18 years of age in the United 

States and 3 territories found that Asians, despite 

having similar HIV risks, were less likely to 

report having ever been tested for HIV when 

compared to all other races/ethnicity 

combined (13). Multiple cultural and social 

factors, including a lack of perceived individual 

risk, may contribute to the lower rate of HIV 

testing and to late HIV diagnoses among

Asians (13,17).

Little published information is available about 

NHPIs and HIV. Because of the methods 

adopted for surveillance in terms of 

race/ethnicity categorization, the actual number 

of NHPIs who are HIV-infected is higher than 

what has been estimated. Prior to 2003, a 

combined category of Asian and Native 

Hawaiian or Other Pacific Islander was used to 

report race. Current cumulative case counts for 

 p U.S. dependent areas’ population not included.
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 60

Asians also include counts of NHPIs that cannot 

be separated from Asians prior to 2003. As a 

result, current cumulative estimates for NHPI 

are underestimates. Additionally, the majority of 

NHPIs self-identify as multiracial, as reported 

from U.S. Census Bureau data (see Chapter 1,

page 17). Surveillance data, however, are most 

commonly derived from medical encounter 

information, which may include a subjective 

interpretation of race by healthcare providers 

and others.

HIV data do not represent all U.S. reporting 

jurisdictions. Not until 2013 will all local and 

state health department HIV cases be aggregated

and summarized into national data. Until then, 

Hawaii, a state with large Asian and NHPI

populations, is not included in HIV estimates. In 

the analysis that examined geographic 

distribution of Asians and NHPIs affected by 

HIV, the list of the top 10 states with the largest 

number of Asians and NHPIs was based on data 

for persons living with AIDS. Examination of 

the relative distribution of demographic and risk 

characteristics for persons diagnosed with AIDS 

from all reporting jurisdictions and the subset 

diagnosed with HIV infection from name-based 

reporting jurisdictions are similar (see Table 5), 

however. Our analysis provides interim 

information until 2013 when all reporting 

jurisdictions’ data for HIV disease can be 

analyzed together.

National HIV Surveillance System data are 

limited to what data are collected and reported.

Because of the need to create a standardized data 

collection form that all local and state health 

departments will use, important information for 

a risk group may not be collected. For example, 

racial ethnicities (e.g., Thai, Chinese, Korean, 

etc.) are not routinely collected. Although 

information about country of birth is collected, it 

is not known when HIV infection occurred (i.e., 

in the United States or the country of birth). The 

degree of acculturation as assessed by year of 

immigration to the United States and whether 

English is spoken at home—information that 

may help better target education and prevention 

efforts—is not routinely collected. Some studies 

have undertaken collection of such information 

but they are often limited to a region or state and

cannot provide a national snapshot.

Persons in Care for HIV Disease

API comprise a small percentage of HIVinfected persons in care in MMP, and this 

percentage is similar to the percentage reported 

among all persons diagnosed with HIV in 2007 

or 2008 (5). However, we found 40.4% of the 

API population in MMP to be foreign-born, in 

contrast to over two-thirds of APIs diagnosed 

with HIV disease and reported from case

surveillance. It is unclear whether this underrepresentation of foreign-born among API who 

are in care reflects a difference in engagement in 

care between foreign-born versus U.S.-born API 

rather than a difference in MMP participation. 

Nevertheless, language and cultural barriers to 

obtaining medical care among foreign-born API 

should be considered when designing

interventions to link HIV-infected persons to 

care. 

Over two-thirds of HIV-infected APIs who are 

in care entered medical care within 3 months of 

their HIV diagnosis. However, the degree of 

retention in care over time is unknown. More 

than half of these individuals had an HIV 

diagnosis for 10 or more years; many had 

advanced HIV disease (42.6% reporting their 

lowest CD4 count as <200 cells/μL) (see Figure 

24). Nevertheless, among these APIs who were 

in care, a high percentage reported receiving 

ART and having an undetectable HIV viral load, 

indicators of successful engagement in HIV 

care. 

Previous studies have shown that the prevalence 

of risky sexual behaviors decrease after 

individuals become aware that they are HIVinfected (18). Although the prevalence of 

unprotected vaginal or anal intercourse was high 

among the API MMP participants in this report, 

further investigation is needed to better 

understand these behaviors and the associated 

transmission risk. Nevertheless, given the 

importance of maintaining behaviors associated 

with low risk for HIV transmission over time, 

the reported participation in individual- or 
CHAPTER 5: HIV and AIDS 61

group-level interventions appears low among the 

API MMP participants and suggests that greater 

efforts are needed to improve the availability 

and acceptability of these prevention services for 

these HIV-infected APIs. 

Alcohol and drug treatment interventions have 

been used to enhance HIV prevention activities 

because alcohol and drug use are associated with 

engagement in risky sexual behaviors. Among 

the API participants of MMP, the prevalence of 

noninjection drug use in the preceding 12 

months (37.8%) and excessive alcohol use in the 

preceding month (12.2%) were substantial. HIV 

care providers can play an important role in HIV 

prevention as well as in improving treatment 

adherence in their patients by screening for 

substance use problems, delivering prevention 

messages, and providing referrals for substance 

abuse treatment when appropriate. 

The MMP findings are subject to several 

limitations. First, although MMP was designed 

to produce nationally representative data on all 

HIV-infected persons in care, it was not 

specifically designed to produce representative 

data for HIV-infected APIs. Thus, our reported

results may not be generalizable to all HIVinfected APIs in care in the United States. 

Second, because the survey was conducted as an 

in-person interview, responses to some questions 

(e.g., drug use, sexual behaviors) are subject to 

social desirability bias. Finally, self-reported 

information, in general, and on CD4+ Tlymphocyte counts and HIV viral load results, 

specifically, are subject to the participant’s 

ability to recall the clinical information. 

Persons at Risk for HIV: MSM 

Participants of NHBS

In the United States., MSM continue to bear the 

largest burden of HIV infection, and among 

APIs, this is also true (5,13). Therefore, efforts 

to reduce the risk for HIV infection among 

MSM remain a critical part of HIV prevention. 

Based on the NHBS data in this report, efforts to 

reduce HIV risk among API MSM should

consider cultural and language issues facing API 

men, particularly because a large percentage of 

this population is foreign-born. In addition, 

prevention efforts may need to focus on API 

MSM with low socioeconomic status, as HIV 

prevalence is higher among API MSM of lower

socioeconomic status. 

As was observed with MSM of other 

race/ethnicity in NHBS (15), risky sexual 

practices and noninjection drug use were also 

commonly seen among API MSM. However, 

some of the highest risk behaviors, such as 

unprotected receptive anal intercourse with a 

casual partner or with a partner whose HIV 

status is positive or unknown, were less 

frequently reported among API participants than 

among all NHBS participants as a whole (15). 

The reason for this is not clear, but cultural and 

socioeconomic factors may explain some of 

these differences, particularly given the higher 

levels of education, household income, and 

insurance coverage seen among API 

participants, relative to NHBS participants in 

general (13). Higher educational attainment, 

higher income, and having health insurance 

indicate greater access to health resources, 

which may affect knowledge and behaviors. 

Because of the high risk for HIV infection 

among MSM, CDC currently recommends that 

sexually active MSM get tested for HIV at least 

once per year (19). Although many API MSM in 

NHBS reported having been tested for HIV in 

the preceding 12 months, over one-third never 

tested or were tested more than 12 months

before the interview. One of the most common 

reasons API MSM gave for not getting tested 

was a belief that they were at low risk for HIV 

infection, indicating the need for HIV education 

in this population. In addition, participation in 

individual- or group-level behavioral 

interventions, which have demonstrated 

effectiveness for reducing HIV risk behaviors, is 

reported by a small percentage of API MSM in 

NHBS. Because low participation rates have 

also been observed among MSM of other racial 

and ethnic groups (13), renewed effort to 

improve participation in these programs is 

needed. 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 62

The NHBS results should be interpreted with 

caution, given a number of limitations. Although 

NHBS includes a large number of MSM 

participants, the participants were sampled and 

recruited at selected venues, and would, 

therefore, not include MSM who do not attend 

such venues. As a result, the NHBS data may 

not be representative of MSM in the 

participating urban areas or those in states or 

cities outside of these areas. Similarly, the 

NHBS data on API MSM may not be 

representative of API MSM at the local or 

national level. In addition, because of the 

relatively small number of API MSM, the results 

within categories or subgroups should be 

interpreted with caution. Lastly, no statistical 

test was done to assess differences between 

groups, but our descriptive analyses provide 

some baseline information that can be refined 

and added to over time.
CHAPTER 5: HIV and AIDS 63 

Figure 22. Estimated rate* of HIV diagnoses among Asians, 2007–2010

* Per 100,000 population; Centers for Disease Control and Prevention. HIV Surveillance Report 2010, vol. 22. Page 

17, Table 1A (46 states) data used. http://www.cdc.gov/hiv/topics/surveillance/resources/reports/. Published 

March 2012. Accessed April 6, 2012.

Figure 23. Estimated rate* of HIV diagnoses among Native Hawaiians and Other Pacific Islanders, 

2007–2010

* Per 100,000 population; Centers for Disease Control and Prevention. HIV Surveillance Report 2010, vol. 22. Page 

17, Table 1A (46 states) data used. http://www.cdc.gov/hiv/topics/surveillance/resources/reports/. Published 

March 2012. Accessed April 6, 2012.
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 64 

Figure 24. Self-reported lowest and most recent CD4+ T-lymphocyte counts among Asian and

Native Hawaiian and Other Pacific Islander participants during the 12 months before 

interview—Medical Monitoring Project, United States, June 2007–April 2009 

0

5

10

15

20

25

30

35

40

45

<200 200-349 350-499 >=500 Missing/Unknown

Percentage

CD4 Count (cells/mm3)

Lowest Most Recent
CHAPTER 5: HIV and AIDS 65 

Table 5. Age distribution of Asians and Native Hawaiians and Other Pacific Islanders living with 

HIV disease through December 31, 2009 

Asians Native Hawaiians and Other Pacific Islanders

HIV* AIDS† HIV* AIDS†

Age group, years

Estimated 

number %

Estimated 

number %

Estimated 

number %

Estimated 

number %

<15 53 0.6 7 0.1 1 0.2 3 0.6

15–19 36 0.4 11 0.2 1 0.2 2 0.4

20–24 241 2.9 51 1.0 29 4.7 4 0.8

25–29 581 6.9 192 3.8 67 10.8 32 6.7

30–34 1,024 12.2 435 8.5 87 14.0 41 8.5

35–39 1,566 18.6 850 16.6 105 16.9 60 12.5

40–44 1,605 19.1 1,008 19.7 103 16.6 97 20.2

45–49 1,274 15.1 912 17.8 98 15.8 101 21.0

50–54 919 10.9 683 13.4 66 10.6 70 14.6

55–59 557 6.6 478 9.4 32 5.2 35 7.3

60–64 330 3.9 284 5.6 17 2.7 19 4.0

65+ 237 2.8 200 3.9 14 2.3 17 3.5

Total 8,422 5,112 620 481

Modified from Tables 17b and 18b, Centers for Disease Control and Prevention. HIV Surveillance Report 2010, vol. 22. Pages 

59, 62, 63. http://www.cdc.gov/hiv/topics/surveillance/resources/reports/. Published March 2012. Accessed April 6, 2012.

Column totals may differ from sum of estimated age groups counts because of rounding.

* Data from 46 states and 5 U.S. dependent areas were used for these estimates. 

† Data from 50 states, the District of Columbia, and 6 U.S. dependent areas were used for these estimates. 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 66 

Table 6. Transmission category among Asians and Native Hawaiians and Other Pacific Islanders

living with HIV disease through December 31, 2009 

Asians

Native Hawaiians and

Other Pacific Islanders

HIV* AIDS† HIV* AIDS†

Category

Estimated 

number %

Estimated 

number %

Estimated 

number %

Estimated 

number %

Males

Men who have sex 

with men (MSM)

5,609 81.8 3,283 77.7 425 84.0 317 80.7

Injection drug use 

(IDU)

286 4.2 228 5.4 18 3.6 21 5.3

MSM & IDU 290 4.2 211 5.0 33 6.5 27 6.9

Heterosexual contact 618 9.0 446 10.6 28 5.5 26 6.6

Other 51 0.7 59 1.4 1 0.2 3 0.8

Subtotal 6,854 4,226 506 393

Females

IDU 127 8.6 90 10.4 17 15.2 14 16.9

Heterosexual contact 1,287 87.4 711 82.0 92 82.1 66 79.5

Other 60 4.1 65 7.5 2 1.8 3 3.6

Subtotal 1,473 867 112 83

Children (<13 years)

Perinatal 63 67.0 14 77.8 2 100.0 5 100.0

Other 31 33.0 4 22.2 0 0.0 0 0.0

Subtotal 94 18 2

Modified from Tables 17b and 18b, Centers for Disease Control and Prevention. HIV Surveillance Report 2010, vol. 22. Pages 

59, 62, 63. http://www.cdc.gov/hiv/topics/surveillance/resources/reports/. Published March 2012. Accessed April 6, 2012.

Column subtotals may differ from sum of sex- and risk exposure-specific estimated counts due to rounding.

* Data from 46 states and 5 U.S. dependent areas were used for these estimates. 

† Data from 50 states, the District of Columbia, and 6 U.S. dependent areas were used for these estimates. 
CHAPTER 5: HIV and AIDS 67 

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12. Prosser AT, Tang T, Hall I. HIV in persons born 

outside the United States, 2007–2010. JAMA

2012. doi: 10.1001/jama.2012.9046. Accessed 

July 24, 2012.

13. Zaidi IF, Crepaz N, Song R, et al. Epidemiology 

of HIV/AIDS among Asians and Pacific 

Islanders in the United States. AIDS Educ Prev

2005;17(5):405–417.

14. Centers for Disease Control and Prevention. 

Reported CD4+ T-lymphocyte and viral load 

results for adults and adolescents with HIV 

infection—37 states, 2005–2007. HIV Surveillance 

Supplemental Report 2010;16(1). Table 2b. 

http://www.cdc.gov/hiv/topics/surveillance/

resources/reports/index.htm#supplemental. 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 68 

Published March 2011. Accessed September 1, 

2011.

15. Centers for Disease Control and Prevention. HIV 

risk, prevention, and testing behaviors among 

men who have sex with men—National HIV 

Behavioral Surveillance System, 21 U.S. Cities, 

United States, 2008. MMWR 2011;60(SS-14):1–

34.

16. Centers for Disease Control and Prevention. 

Prevalence and awareness of HIV infection 

among men who have sex with men—21 cities, 

United States, 2008. MMWR 2010;59:1201–

1207.

17. Wortley PM, Metler RP, Hu DJ, Fleming PL. 

AIDS among Asians and Pacific Islanders in the 

United States. Am J Prev Med 2000;18(3):208–

214.

18. Marks G, Crepaz N, Janssen RS. Estimating 

sexual transmission of HIV from persons aware 

and unaware that they are infected with the virus 

in the USA. AIDS 2006;20(10):1447–1450.

19. Centers for Disease Control and Prevention.

Revised recommendations for HIV testing of 

adults, adolescents, and pregnant women in 

health-care settings. MMWR 2006;55(RR-14):1–

17. 
APPENDIX 69 

APPENDIX
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 70 

Table A1. Distribution of population groups in the overall U.S. population, 2010

Population Group Number Percent

Hispanic 50,477,594 16.3

Non-Hispanic

 American Indian and Alaska Native 2,247,098 0.7

 Asian 14,465,124 4.7

 Black or African American 37,685,848 12.2

 Native Hawaiian and Other Pacific Islander 481,576 0.2

 White 196,817,552 63.7

 Other race 604,265 0.2

 Two or more races 5,966,481 1.9

Total 308,745,538 100.0
APPENDIX 71 

Table A2. Top 20 U.S. metropolitan or micropolitan statistical areas with the largest Asian

populations, 2010

Rank Metropolitan or micropolitan statistical area

Total 

population

Non-Hispanic

Asian

population

1 New York-Northern New Jersey-Long Island, NY-NJ-PA 18,897,109 1,860,840

2 Los Angeles-Long Beach-Santa Ana, CA 12,828,837 1,858,148

3 San Francisco-Oakland-Fremont, CA 4,335,391 994,616

4 San Jose-Sunnyvale-Santa Clara, CA 1,836,911 566,764

5 Chicago-Joliet-Naperville, IL-IN-WI 9,461,105 526,857

6 Washington-Arlington-Alexandria, DC-VA-MD-WV 5,582,170 513,919

7 Honolulu, HI 953,207 410,019

8 Seattle-Tacoma-Bellevue, WA 3,439,809 389,309

9 Houston-Sugar Land-Baytown, TX 5,946,800 384,596

10 Dallas-Fort Worth-Arlington, TX 6,371,773 337,815

11 San Diego-Carlsbad-San Marcos, CA 3,095,313 328,058

12 Philadelphia-Camden-Wilmington, PA-NJ-DE-MD 5,965,343 293,656

13 Boston-Cambridge-Quincy, MA-NH 4,552,402 292,786

14 Atlanta-Sandy Springs-Marietta, GA 5,268,860 252,510

15 Sacramento--Arden-Arcade--Roseville, CA 2,149,127 250,690

16 Riverside-San Bernardino-Ontario, CA 4,224,851 249,899

17 Minneapolis-St. Paul-Bloomington, MN-WI 3,279,833 187,047

18 Las Vegas-Paradise, NV 1,951,269 165,121

19 Detroit-Warren-Livonia, MI 4,296,250 140,558

20 Phoenix-Mesa-Glendale, AZ 4,192,887 134,415

Source: 2010 Census National Summary File of Redistricting Data (Table P2, Race and Hispanic Origin).

For an explanation of metropolitan and micropolitan statistical areas, see http://www.census.gov/population/metro/. 
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 72

Table A3. Top 20 U.S. metropolitan or micropolitan statistical areas with the largest Native 

Hawaiian and Other Pacific Islander populations, 2010

Rank Metropolitan or micropolitan statistical area

Total 

population

Non-Hispanic Native 

Hawaiian and Other 

Pacific Islander

population

1 Honolulu, HI Metro Area 953,207 86,235

2 Los Angeles-Long Beach-Santa Ana, CA Metro Area 12,828,837 30,821

3 San Francisco-Oakland-Fremont, CA Metro Area 4,335,391 29,761

4 Seattle-Tacoma-Bellevue, WA Metro Area 3,439,809 27,275

5 Hilo, HI Micro Area 185,079 20,970

6 Salt Lake City, UT Metro Area 1,124,197 15,686

7 Kahului-Wailuku, HI Micro Area 154,834 15,257

8 Sacramento–Arden-Arcade–Roseville, CA Metro Area 2,149,127 14,874

9 San Diego-Carlsbad-San Marcos, CA Metro Area 3,095,313 13,504

10 Las Vegas-Paradise, NV Metro Area 1,951,269 12,474

11 Riverside-San Bernardino-Ontario, CA Metro Area 4,224,851 11,694

12 Portland-Vancouver-Hillsboro, OR-WA Metro Area 2,226,009 9,812

13 Phoenix-Mesa-Glendale, AZ Metro Area 4,192,887 8,212

14 San Jose-Sunnyvale-Santa Clara, CA Metro Area 1,836,911 6,317

15 Anchorage, AK Metro Area 380,821 5,990

16 Kapaa, HI Micro Area 67,091 5,716

17 Dallas-Fort Worth-Arlington, TX Metro Area 6,371,773 5,431

18 Fayetteville-Springdale-Rogers, AR-MO Metro Area 463,204 5,000

19 New York-Northern New Jersey-Long Island, NY-NJPA Metro Area

18,897,109 4,859

20 Provo-Orem, UT Metro Area 526,810 3,832

Source: 2010 Census National Summary File of Redistricting Data (Table P2, Race and Hispanic Origin).

For an explanation of metropolitan and micropolitan statistical areas, see http://www.census.gov/population/metro/.
APPENDIX 73

Table A4. Selected characteristics for hepatitis B testing and testing positive among Asians in 4 

health plans*

Asian members in 

4 health plans†

Had at least one positive test (surface 

antigen or DNA§

) among those tested¶

% Total N % Row (n/N)

Overall 100.0% 60,097 4.2% (671/16,044)

Sex

 Female 59.1% 35,517 4.0% (429/10,721)

 Male 40.9% 24,580 4.6% (242/5,323)

Age group, years

 <30 15.5% 9,282 3.3% (84/2,548)

 30–39 17.2% 10,316 3.8% (152/4,022)

 40–49 17.9% 10,764 5.0% (151/3,024)

 50–59 18.8% 11,299 5.8% (153/2,661)

 60–69 14.0% 8,438 4.1% (78/1,902)

 70–79 9.1% 5,442 3.2% (36/1,110)

 ≥80 7.6% 4,556 2.2% (17/777)

Median household income**

 <$30K 6.1% 3,647 3.8% (35/931)

 $30–49K 34.4% 20,641 4.5% (254/5,669)

 $50–74K 43.7% 26,279 3.9% (270/6,855)

 ≥$75K 13.0% 7,834 4.5% (103/2,272)

 Not reported 2.8% 1,696 2.8% (9/317)

* The four health plans are Geisinger Health System, Danville, PA; Henry Ford Health System, Detroit MI; Kaiser 

Permanente-Northwest, Portland, OR; and Kaiser Permanente-Hawaii.

† Excluded in study if had a prior documented infection with hepatitis B at health plan entry.

§ Laboratory markers indicating the presence of circulating hepatitis B virus.

¶ The denominator used to derive the percent of prevalent positives was the number of Asian patients who were 

ever tested for hepatitis B.

** Census tract geocoding, defined as matching patient address information to census tract data, was used to obtain 

median household income information.

Source: Spradling PR, Rupp L, Moorman AC, et al. Hepatitis B and C virus infection among 1.2 million persons 

with access to care: Factors associated with testing and infection prevalence. Clin Infect Dis [in press].
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 74

Table A5. Selected characteristics for hepatitis B testing and testing positive among Native 

Hawaiians and Other Pacific Islanders in 4 health plans*

NHPI† members in 

4 health plans§

Had at least one positive test (surface 

antigen or DNA¶) among those tested**

% Total N % Row (n/N)

Overall 100.0% 28,492 2.5% (180/7,294)

Sex

 Female 55.0% 15,667 2.2% (99/4,596)

 Male 45.0% 12,825 3.0% (81/2,698)

Age group, years

 <30 25.9% 7,390 2.3% (47/2,027)

 30–39 19.8% 5,641 1.9% (34/1,812)

 40–49 18.4% 5,232 3.5% (45/1,288)

 50–59 15.9% 4,527 2.6% (26/992)

 60–69 11.1% 3,173 3.1% (21/682)

 70–79 5.9% 1,675 0.6% (2/346)

 >80 3.0% 854 3.4% (5/147)

Median household income††

 <$30K 5.3% 1,514 1.2% (5/411)

 $30–49K 34.9% 9,942 2.2% (55/2,509)

 $50–74K 47.4% 13,516 2.8% (97/3,488)

 >$75K 11.0% 3,122 2.7% (22/816)

 Not reported 1.4% 398 1.4% (1/70)

* The four health plans are Geisinger Health System, Danville, PA; Henry Ford Health System, Detroit MI; Kaiser 

Permanente-Northwest, Portland, OR; and Kaiser Permanente-Hawaii.

† Native Hawaiian and Other Pacific Islander.

§ Excluded in study if had a prior documented infection with hepatitis B at health plan entry.

¶ Laboratory markers indicating the presence of circulating hepatitis B virus.

** The denominator used to derive the percent of prevalent positives was the number of Native Hawaiians and 

Other Pacific Islanders patients who were ever tested for hepatitis B.

†† Census tract geocoding, defined as matching patient address information to census tract data, was used to obtain 

median household income information.

Source: Spradling PR, Rupp L, Moorman AC, et al. Hepatitis B and C virus infection among 1.2 million persons 

with access to care: Factors associated with testing and infection prevalence. Clin Infect Dis [in press].
APPENDIX 75

Table A6. Selected characteristics for hepatitis C testing and testing positive among Asians in 4 

health plans*

Asian members in 

4 health plans†

Ever tested positive (antibody§

) among 

those tested¶

% Total N % Row (n/N)

Overall 100.0% 60,177 4.3% (391/9,025)

Sex

 Female 59.1% 35,559 4.0% (213/5,289)

 Male 40.9% 24,618 4.8% (178/3,736)

Age group, years

 <30 15.5% 9,302 3.9% (42/1,067)

 30–39 17.2% 10,342 2.3% (35/1,535)

 40–49 17.9% 10,783 3.3% (57/1,723)

 50–59 18.8% 11,311 7.2% (136/1,888)

 60–69 14.0% 8,443 4.9% (68/1,390)

 70–79 9.0% 5,437 4.1% (34/834)

 ≥80 7.6% 4,559 3.2% (19/588)

Median household income**

 <$30K 6.1% 3,649 2.8% (15/545)

 $30–49K 34.3% 20,666 4.7% (144/3,048)

 $50–74K 43.7% 26,312 4.5% (176/3,891)

 ≥$75K 13.1% 7,854 4.0% (54/1,348)

 Not reported 2.8% 1,696 1.0% (2/193)

* The four health plans are Geisinger Health System, Danville, PA; Henry Ford Health System, Detroit MI; Kaiser 

Permanente-Northwest, Portland, OR; and Kaiser Permanente-Hawaii.

† Excluded in study if had a prior documented infection with hepatitis C at health plan entry.

§ Laboratory marker indicating past or present infection with hepatitis C.

¶ The denominator used to derive the percent of prevalent positives was the number of Asian patients who were 

ever tested for hepatitis C.

** Census tract geocoding, defined as matching patient address information to census tract data, was used to obtain 

median household income information.

Source: Spradling PR, Rupp L, Moorman AC, et al. Hepatitis B and C virus infection among 1.2 million persons 

with access to care: Factors associated with testing and infection prevalence. Clin Infect Dis [in press].
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 76

Table A7. Selected characteristics for hepatitis C testing and testing positive among Native 

Hawaiians and Other Pacific Islanders (NHPI) in 4 health plans*

NHPI members in 4 health plans†

Ever tested positive (antibody§

) 

among those tested¶

% Total N % Row (n/N)

Overall 100.0% 28,494 4.4% (175/3,999)

Sex

 Female 55.0% 15,667 3.5% (78/2,211)

 Male 45.0% 12,827 5.4% (97/1,788)

Age group, years

 <30 25.9% 7,391 3.0% (26/869)

 30–39 19.8% 5,641 2.3% (19/824)

 40–49 18.3% 5,227 5.1% (37/730)

 50–59 15.9% 4,529 7.0% (48/682)

 60–69 11.1% 3,176 6.5% (33/509)

 70–79 5.9% 1,676 3.7% (10/269)

 ≥80 3.0% 854 1.7% (2/116)

Median household 

income**

 <$30K 5.3% 1,514 5.7% (13/230)

 $30–49K 34.9% 9,950 3.7% (50/1,361)

 $50–74K 47.4% 13,516 4.4% (86/1,940)

 ≥$75K 10.9% 3,117 5.7% (25/438)

 Not reported 1.4% 397 3.3% (1/30)

* The four health plans are Geisinger Health System, Danville, PA; Henry Ford Health System, Detroit MI; Kaiser 

Permanente-Northwest, Portland, OR; and Kaiser Permanente-Hawaii.

† Excluded in study if had a prior documented infection with hepatitis C at health plan entry.

§ Laboratory marker indicating past or present infection with hepatitis C.

¶ The denominator used to derive the percent of prevalent positives was the number of Native Hawaiians and 

Other Pacific Islanders patients who were ever tested for hepatitis C.

** Census tract geocoding, defined as matching patient address information to census tract data, was used to obtain 

median household income information.

Source: Spradling PR, Rupp L, Moorman AC, et al. Hepatitis B and C virus infection among 1.2 million persons 

with access to care: Factors associated with testing and infection prevalence. Clin Infect Dis [in press].
APPENDIX 77

Table A8. Characteristics of Asian or Native Hawaiian and Other Pacific Islander (API) 

Participants of the Medical Monitoring Project, 2007–2009

Characteristics N* (%)

Age group, years

18–34 19 (20.2)

35–44 29 (30.9)

45–54 36 (38.3)

≥55 10 (10.6)

Gender 

Male 77 (81.9)

Female 14 (14.9)

Country of birth

United States 56 (59.6)

Outside United States 38 (40.4)

Education

<High school 13 (13.8)

High school diploma or GED credential 15 (16.0)

>High school 66 (70.2)

Health insurance or coverage, past 12 months 

Yes 80 (85.1)

No 14 (14.9)

Received public assistance, past 12 months 

Yes 45 (47.9)

No 49 (52.1)

Year(s) since HIV diagnosis 

<5 20 (21.3)

5–9 22 (23.4)

≥10 years 48 (51.1)

Total 94 (100)

* Numbers might not add to total because of missing or unknown data.
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 78

Table A9. Characteristics of Asian or Native Hawaiian and Other Pacific Islander (API) men who 

have sex with men participants* of the National HIV Behavioral Surveillance System

(NHBS), 2008

Characteristics N† (%)

Age group (interview data), years

18–24 46 (17.8)

25–29 77 (29.8)

30–39 93 (36.0)

≥40 42 (16.3)

Sexual identity

Gay 234 (90.7)

Bisexual 22 (8.5)

Race

Asian 199 (77.1)

Native Hawaiian and Other Pacific Islander 59 (22.9)

Country of birth 

United States 111 (43.0)

Outside United States 147 (57.0)

Education

Not more than high school diploma or equivalent 29 (11.2)

More than high school 229 (88.8)

Annual household income

<$20,000 47 (18.2)

$20,000–$39,999 55 (21.3)

$40,000–$74,999 79 (30.6)

≥$75,000 76 (29.5)

Health insurance or coverage, past 12 months 

None 61 (23.6)

Private only 183 (70.9)

Public only 13 (5.0)

Total 258 (100)

* This analysis included API men who reported having sex with another man in the 12 months preceding the 

NHBS interview, completed the interview, and did not report being HIV positive. 

† Numbers might not add to total because of missing or unknown data.
APPENDIX 79

Table A10. Among Asian or Native Hawaiian and Other Pacific Islander (API) men who have sex 

with men*

, number† and percentage reporting anal sex during their most recent sexual 

encounter with a male partner, by type and HIV status of partner and substance use 

during encounter, National HIV Behavioral Surveillance System (NHBS), 2008

Characteristic

Insertive anal sex Receptive anal sex

Total

Total

N (%)

Unprotected

n (%)

Total

N (%)

Unprotected

n (%)

Partner type

Main 83 (70.3) 31 (37.3) 84 (71.2) 37 (44.0) 118

Casual 82 (58.6) 23 (28.0) 79 (56.4) 28 (35.4) 140

Partner’s HIV status

Not infected 93 (50.5) 29 (31.2) 89 (48.4) 33 (37.1) 184

Infected or unknown 31 (41.9) 9 (29.0) 26 (35.1) 9 (34.6) 74

Alcohol or drug use 

during most recent 

sexual encounter

Yes 43 (50.6) 14 (32.6) 43 (50.6) 13 (30.2) 85

No 81 (46.8) 24 (29.6) 72 (41.6) 29 (40.3) 173

Total 124 (48.1) 38 (30.6) 115 (44.6) 42 (36.5) 258

* This analysis included API men who reported having sex with another man in the 12 months preceding the 

NHBS interview, completed the interview, and did not report being HIV positive.

† Numbers might not add to total because of missing or unknown data.
Epidemiologic Profile 2010: Asians and Native Hawaiians and Other Pacific Islanders 80

Table A11. Prevalence of HIV infection, by selected characteristics of Asian or Native Hawaiian 

and Other Pacific Islander (API) men who have sex with men who were tested for 

HIV* as part of the National HIV Behavioral Surveillance System (NHBS), 2008

Number tested for HIV†

Tested positive for HIV

n (%)

Age group, years

18–24 45 0 (0.0)

25–29 75 5 (6.7)

30–39 87 16 (18.4)

40+ 40 <5 (<15)

Country of birth

United States 105 9 (8.6)

Outside United States 142 16 (11.3)

Education

Not more than high school 

diploma or equivalent

30 6 (20.0)

More than high school 217 19 (8.8)

Annual household income

0 to $19,999 48 10 (20.8)

$20,000 to $39,999 55 5 (9.1)

$40,000 or more 143 10 (7.0)

Health insurance

Private only 170 12 (7.1)

None or public only 76 13 (17.1)

Previous HIV test

Past 12 months 143 7 (4.9)

Never tested or tested more 

than 1 year ago

103 18 (17.5)

Total 247 25 (10.1)

* This analysis included API men who reported having sex with another man in the 12 months preceding the 

NHBS interview, completed both the interview and HIV testing for NHBS, and either had a negative or 

confirmed positive HIV test result.

† Numbers might not add to total because of missing or unknown data.