Racial Disparities in Sexually Transmitted Diseases (STDs) Erika Samoff, PhD, MPH Susan Watson, MPH CA DHS STD Control

1. Racial Disparities in Sexually Transmitted Diseases (STDs)Erika Samoff, PhD, MPHSusan Watson, MPHCA DHS STD Control Branch

2. For which STDs do you think there are racial disparities? Which racial/ethnic group(s)?

3. Rates of Chlamydia, Gonorrhea, P&S Syphilis, and AIDS byRace/Ethnicity and Gender — California, 2005 Rate per 100,000 population Race/Ethnicity Note: NA/AN = Native American/Alaskan Native; A/PI = Asian/Pacific Islander Source: California Department of Health Services, STD Control Branch and Office of AIDS

4. National HSV-2 Data Percentages by Race/Ethnicity NHANES

5. Gonorrhea Rates, Females, by Race/Ethnicity and Age GroupCalifornia, 2005 13 times white rate Note: Native American/Alaskan Native and Asian/Pacific Islander rates were excluded due to small case counts. Source: California Department of Health Services, STD Control Branch

6. Gonorrhea Rates by Health Jurisdiction & Race/EthnicityCalifornia, 2005 AFRICAN AMERICAN ASIAN/PI LATINO WHITE Note: Cases with unspecified race have been redistributed based on the ratio of individual races to total known races. Cases with missing gender have been excluded from the gender-specific redistribution analysis. Source: California Department of Health Services, STD Control Branch

7. Gonorrhea, Rates by Race/Ethnicity California, 1990–2005 Low Point Note: Race/ethnicity “Not Specified” ranged from 24.7% to 39.4% of cases for males in any given year. Source: California Department of Health Services, STD Control Branch

8. Sexually Transmitted Disease and HIV • Genital ulcer disease (syphilis, HSV) is associated with increased risk of HIV seroconversion • Treatment of STDs decreases HIV concentration in genital fluids • One community trial showed decreases in HIV acquisition following improvements in STD care

9. Highlights of HIV Surveillance, 2000-2003 • Although blacks constituted 13% of the population, they accounted for 51% of the HIV/AIDS diagnoses • Rates of HIV/AIDS among African American females were 19 times higher than rates among non-Hispanic white females • Overall, 28% of cases were female; 69% of African American cases were female • In 2004, 73% of infants perinatally infected with HIV were African American Wald and Link (2002) estimate that 35% of HIV infection among African Americans can be attributed to herpes infection MMWR Dec 3, 2004: 53 (47): 1106-1110 CDC HIV/AIDS Fact Sheet “HIV/AIDS among African Americans February 2006 Wald A and K Link. J. Inf. Dis. 185:45-52. 2002

10. Contributing Factors • Individual Factors • Systemic Factors

11. Individual Factors • What are some of the individual behaviors that can lead to these STD disparities?

12. Individual Factors • Number of sex partners • Concurrency of sex partners • No/inconsistent condom use • Not getting tested/screened

13. Systemic Factors • What are some of the systemic factors (things outside of the individual’s control) that can contribute to these disparities?

14. Systemic Factors • Racism • Poverty • Policies and laws** • Educational opportunities • Access to quality health care • Differential treatment from health care providers** • Community prevalence of disease

15. Historical Laws & Policies • 1930’s to present: • Neighborhood covenants • Discrimination for housing loans • 1940’s to 1960’s: • Subsidized housing creating “the projects” • Urban renewal highway projects • Collapse of urban industries • The war on drugs (1980’s-present)

16. Prophylactic Measures Many Can’t Buy Condoms Now Before Paging a Store Clerk to Unlock Them By Suz Redfearn Special to The Washington PostTuesday, April 11, 2006 … An informal survey found that almost half -- 22 of 50 -- of the District's CVS pharmacies lock up their condoms -- this in a city where one in 20 residents is HIV-positive. Most of those stores are in less affluent areas where the incidence of HIV/AIDS, other sexually transmitted diseases and unwanted pregnancy -- all preventable with condoms -- are highest. http://www.washingtonpost.com/wp-dyn/content/article/2006/04/10/AR2006041001312.html

17. It’s Illegal, but Mortgage Firms Aren’t Colorblind… Kenneth Harney Sunday, June 18, 2006 …Do mortgage brokers offer the same deals to African American and Latino applicants with identical -- or superior -- incomes, credit scores and employment histories compared with white applicants? … …The complaint alleges that Allied brokers are "quoting different interest rates and fees on the basis of race" and steering African American borrowers to higher-cost subprime mortgages even when they are fully qualified for lower-cost, prime-rate products. … URL: http://sfgate.com/cgi-bin/article.cgi?file=/c/a/2006/06/18/REGONJF4I51.DTL

18. Published in 2002 by the Institute of Medicine • Compilation of research demonstrating substantial racial and ethnic variation in quality of health care

19. Summary of IOM Findings • Disparities occur in the context of broader historic and contemporary social and economic inequality, and evidence of persistent racial and ethnic discrimination in many sectors of American life. • Many sources – including health systems, health care providers, patients, and utilization managers – contribute to racial and ethnic disparities in health care. • Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare.

20. What does culture have to do with it?

21. The Need for Cultural Competence in Health Care • The perception of illness and disease and their causes varies by culture • Diverse belief systems exist related to health, healing, and wellness • Culture influences help-seeking behaviors and attitudes toward health care providers

22. The Need for Cultural Competence in Health Care (con’t) • Individual preferences affect traditional and non-traditional approaches to health care • Patients must overcome personal experiences of biases within health care systems • Health care providers from culturally and linguistically diverse groups are under-represented in the current service delivery system Source: Cohen & Goode, National Center for Cultural Competence, 1999

23. Increasing Workforce Diversity Increasing Cultural and Linguistic Competence Reducing Health Disparities Improving Quality of Care

24. Connecting the Dots • Poor access to careincreased duration of infection, increased risk for HIV transmission • Poor access to preventionno/inconsistent condom use • Poor educational systemslack of knowledge about prevention, symptoms, available resources • Incarcerationavailable partners & concurrency, gender ratio imbalances • Historical laws/policiesgeographic isolation, mistrust

25. Different Levels of Disparities • Health status • Health care access • Quality of health care received • Healthcare outcomes

26. Discussion Questions • What is being done about these disparities? • What can we learn from successful health disparity efforts? • What else should be done? • How do we avoid stigmatizing racial/ethnic groups while trying to reduce the disparities?

27. Advisory Groups/Initiatives • CDC: African American Working Group & Minority AIDS Initiative • CA DHS Office of AIDS: Statewide African American Initiative • CA DHS Office of Multicultural Health: Cultural Competency training curriculum • Tavis Smiley’s Covenant with Black America

28. Potential Interventions to Impact Disparities • Education: development/implementation of comprehensive school sexual health curriculum • Screening: increased screening in high-yield settings (e.g., juvenile halls) • Surveillance: provision of timely, community-specific epidemiologic data to allow targeted screening • Treatment: recommendation for suppressive herpes treatment for HSV-2+/HIV+

29. Culturally Appropriate Behavioral Interventions • Popular Opinion Leader (adapted for African American MSM) • Sisters Informing Sisters About Topics on AIDS (SISTA) • Many Men, Many Voices • VOICES/VOCES • Be Proud! Be Responsible! (Jemmott & Jemmott)