Social Environmental Factors and Their Effects on Risky Sexual Behavior: A Multilevel Approach.

HIV continues to disproportionately plague select communities across the United States. Individual sexual behavior serves as a dominant explanation for differences in HIV infection. In public health, little attention has been placed on community context and features of the community environment as important predictors of sexual health. The community environment and resources or lack of resources may influence sexual behavior. This may contribute to disparate rates of HIV transmission. I examine how socioenvironmental factors and sex ratios influence sexual behavior and HIV rates, and contribute to race/ethnic differences in risky sexual behavior. I used multilevel models and data from the Behavioral Risks Factor Surveillance System (BRFSS) to determine the cross-sectional association across 15 states between county-level factors and risky sexual behavior for different racial/ethnic groups. The measure of sexual behavior examined was the number of sexual partners. The county level factors examined included imbalanced sex ratio, residential segregation, and the percent of residents below poverty. Results: Increased residential segregation was associated with higher odds of risky sexual behavior in all groups although a clear dose response trend was only observed in Whites. The association between sexual behavior and county sex ratios partly followed the pattern predicted by the Alternative Sex Ratio Mate Preference Shifts Hypothesis. Racial/ethnic differences in risky sexual behavior were reduced after adjustment for marital status and age. I did not find a substantial effect of adjustment for racial residential segregation, percent below poverty, or the sex ratio at the county level. Conclusion This is one of the first studies to examine the hierarchical association of county-level variables with risky sexual behavior. Future multilevel work with different measures of sexual behavior and alternative contextual measures is needed to better understand the social processes affecting HIV risk and the factors contributing to persistent race/ethnic differences.Ph.D.Epidemiological ScienceUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/63624/1/zgant_1.pd

A census tract-level examination of social determinants of health among black/African American men with diagnosed HIV infection, 2005-2009--17 US areas.

HIV disproportionately affects black men in the United States: most diagnoses are for black gay, bisexual, and other men who have sex with men (collectively referred to as MSM). A better understanding of the social conditions in which black men live and work may better explain why HIV incidence and diagnosis rates are higher than expected in this population.Using data from the National HIV Surveillance System and the US Census Bureau's American Community Survey, we examined the relationships of HIV diagnosis rates and 5 census tract-level social determinants of health variables for 21,948 black MSM and non-MSM aged ≥ 15 years residing in 17 areas in the United States. We examined federal poverty status, marital status, education level, employment status, and vacancy status and computed rate ratios (RRs) and prevalence odds ratios (PORs), using logistic regression with zero-inflated negative binomial modeling.Among black MSM, HIV diagnosis rates decreased as poverty increased (RR: 0.54). At the time of HIV diagnosis, black MSM were less likely than black non-MSM to live in census tracts with a higher proportion below the poverty level (POR: 0.81) and with a higher proportion of vacant houses (POR: 0.86). In comparison, housing vacancy was positively associated with HIV diagnosis rates among black non-MSM (RR: 1.65). HIV diagnosis rates were higher for black MSM (RR: 2.75) and non-MSM (RR: 4.90) whose educational level was low. Rates were significantly lower for black MSM (RR: 0.06) and non-MSM (RR: 0.26) as the proportion unemployed and the proportion married increased.This exploratory study found differences in the patterns of HIV diagnosis rates for black MSM and non-MSM and provides insight into the transmission of HIV infection in areas that reflect substantial disadvantage in education, housing, employment, and income

Prevalence odds ratios^a of HIV infection diagnosis for black/African American MSM vs. non-MSM, by selected census tract-level social determinants of health (SDH), 2005–2009—17 areas.

<p>Note. Data include persons with diagnosed HIV infection regardless of stage of disease at diagnosis. HIV diagnosis data were statistically adjusted for missing transmission category, but not for reporting delays or incomplete reporting. All results for each outcome of interest in the models are based on controlling for all other variables.</p><p>MSM, men who reported ever having had sexual contact with other men.</p><p>CI, confidence interval.</p>a<p>Black non-MSM is the reference group.</p>b<p>The prevalence odds is defined as (#MSM+1)/(#non-MSM+1), where adding 1 to both the numerator and the denominator avoids the prevalence odds undefined when there are no diagnosed HIV infections among black non-MSM. PORs>1 indicates that among black males, as the proportion of a SDH variable of interest increases, the probability of black MSM diagnosed with HIV is higher compared to black non-MSM.</p><p>Prevalence odds ratios^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0107701#nt110" target="_blank">a</a>} of HIV infection diagnosis for black/African American MSM vs. non-MSM, by selected census tract-level social determinants of health (SDH), 2005–2009—17 areas.</p

HIV diagnosis rate ratios among black/African American MSM and non-MSM, by selected census tract–level social determinants of health, 2005–2009—17 areas.

<p>Note. Data include persons with diagnosed HIV infection regardless of stage of disease at diagnosis. HIV diagnosis data were statistically adjusted for missing transmission category, but not for reporting delays or incomplete reporting. All results for each outcome of interest in the models are based on controlling for all other variables.</p><p>MSM, men who reported ever having had sexual contact with other men.</p><p>CI, confidence interval.</p><p>HIV diagnosis rate ratios among black/African American MSM and non-MSM, by selected census tract–level social determinants of health, 2005–2009—17 areas.</p

Diagnoses of HIV infection among black/African American MSM and non-MSM, by age at diagnosis, 2005–2009—17 areas.

<p>Note. Data include persons with diagnosed HIV infection regardless of stage of disease at diagnosis. HIV diagnosis data were statistically adjusted for missing transmission category, but not for reporting delays or incomplete reporting.</p><p>MSM, men who reported ever having had sexual contact with other men.</p>a<p>Rates are per 100,000 population.</p><p>Diagnoses of HIV infection among black/African American MSM and non-MSM, by age at diagnosis, 2005–2009—17 areas.</p

HIV Infection-Related Care Outcomes among U.S.-Born and Non-U.S.-Born Blacks with Diagnosed HIV in 40 U.S. Areas: The National HIV Surveillance System, 2016

HIV care outcomes must be improved to reduce new human immunodeficiency virus (HIV) infections and health disparities. HIV infection-related care outcome measures were examined for U.S.-born and non-U.S.-born black persons aged &#8805;13 years by using National HIV Surveillance System data from 40 U.S. areas. These measures include late-stage HIV diagnosis, timing of linkage to medical care after HIV diagnosis, retention in care, and viral suppression. Ninety-five percent of non-U.S.-born blacks had been born in Africa or the Caribbean. Compared with U.S.-born blacks, higher percentages of non-U.S.-born blacks with HIV infection diagnosed during 2016 received a late-stage diagnoses (28.3% versus 19.1%) and were linked to care in &#8804;1 month after HIV infection diagnosis (76.8% versus 71.3%). Among persons with HIV diagnosed in 2014 and who were alive at year-end 2015, a higher percentage of non-U.S.-born blacks were retained in care (67.8% versus 61.1%) and achieved viral suppression (68.7% versus 57.8%). Care outcomes varied between African- and Caribbean-born blacks. Non-U.S.-born blacks achieved higher care outcomes than U.S.-born blacks, despite delayed entry to care. Possible explanations include a late-stage presentation that requires immediate linkage and optimal treatment and care provided through government-funded programs

A Two-Gender Human Papillomavirus Model with an Investigation of the Effects of Male Screening

27 pages, 1 article*A Two-Gender Human Papillomavirus Model with an Investigation of the Effects of Male Screening* (Froelich, Jennifer; Gant, Zanetta; Majumdar, Aveek; Ortiz-Albino, Reyes M.; Lanham, Michael) 27 page

The associations of income and Black-White racial segregation with HIV outcomes among adults aged ≥18 years-United States and Puerto Rico, 2019.

Objective(s)To examine associations between Index of Concentration at the Extremes (ICE) measures for economic and racial segregation and HIV outcomes in the United States (U.S.) and Puerto Rico.MethodsCounty-level HIV testing data from CDC's National HIV Prevention Program Monitoring and Evaluation and census tract-level HIV diagnoses, linkage to HIV medical care, and viral suppression data from the National HIV Surveillance System were used. Three ICE measures of spatial polarization were obtained from the U.S. Census Bureau's American Community Survey: ICEincome (income segregation), ICErace (Black-White racial segregation), and ICEincome+race (Black-White racialized economic segregation). Rate ratios (RRs) for HIV diagnoses and prevalence ratios (PRs) for HIV testing, linkage to care within 1 month of diagnosis, and viral suppression within 6 months of diagnosis were estimated with 95% confidence intervals (CIs) to examine changes across ICE quintiles using the most privileged communities (Quintile 5, Q5) as the reference group.ResultsPRs and RRs showed a higher likelihood of testing and adverse HIV outcomes among persons residing in Q1 (least privileged) communities compared with Q5 (most privileged) across ICE measures. For HIV testing percentages and diagnosis rates, across quintiles, PRs and RRs were consistently greatest for ICErace. For linkage to care and viral suppression, PRs were consistently lower for ICEincome+race.ConclusionsWe found that poor HIV outcomes and disparities were associated with income, racial, and economic segregation as measured by ICE. These ICE measures contribute to poor HIV outcomes and disparities by unfairly concentrating certain groups (i.e., Black persons) in highly segregated and deprived communities that experience a lack of access to quality, affordable health care. Expanded efforts are needed to address the social/economic barriers that impede access to HIV care among Black persons. Increased partnerships between government agencies and the private sector are needed to change policies that promote and sustain racial and income segregation