Racial Disparities in Sexually Transmitted Diseases (STDs)Erika Samoff, PhD, MPHSusan Watson, MPHCA DHS STD Control Branch
For which STDs do you think there are racial disparities? Which racial/ethnic group(s)?
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
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
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
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
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
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
Contributing Factors • Individual Factors • Systemic Factors
Individual Factors • What are some of the individual behaviors that can lead to these STD disparities?
Individual Factors • Number of sex partners • Concurrency of sex partners • No/inconsistent condom use • Not getting tested/screened
Systemic Factors • What are some of the systemic factors (things outside of the individual’s control) that can contribute to these disparities?
Systemic Factors • Racism • Poverty • Policies and laws** • Educational opportunities • Access to quality health care • Differential treatment from health care providers** • Community prevalence of disease
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)
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
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
Published in 2002 by the Institute of Medicine • Compilation of research demonstrating substantial racial and ethnic variation in quality of health care
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.
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
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
Increasing Workforce Diversity Increasing Cultural and Linguistic Competence Reducing Health Disparities Improving Quality of Care
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
Different Levels of Disparities • Health status • Health care access • Quality of health care received • Healthcare outcomes
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?
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
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+
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)