STDs in Racial and Ethnic Minorities

Background

Disparities continue to persist in rates of STDs among some racial minority or Hispanic groups when compared with rates among Whites.1,2 This is also true across a wide variety of other health status indicators, providing evidence that race and Hispanic ethnicity in the United States are population characteristics strongly correlated with other factors affecting overall health status, such as income, employment, insurance coverage, and educational attainment.3-5 In 2016, the most recent year for which national data on poverty and insurance status are available, the overall proportion of the United States population living in poverty was 12.7% (or 40.6 million), a slight decrease from 2015. Although the overall poverty rate has declined slightly over the last few years, many Americans continue to face challenges overcoming inequalities in economic opportunity; the poverty rate in 2016 for Whites was 8.8% (17.3 million), for Blacks it was 22.0% (or 9.2 million), and for Hispanics it was 19.4% (or 11.1 million). Significant differences by race and Hispanic ethnicity in the proportion of the population living in poverty persisted in 2016 and were even more acute for family households headed by women (28.8% versus 10.7% for all households), regardless of other factors3. Those who cannot afford basic necessities often have trouble accessing and affording quality health care, including sexual health services.6

Access to, and routine use of, quality health care including STD prevention and treatment is key to reducing STD disparities in the United States. Of the estimated 19 million new cases of sexually transmitted infections (STIs) that occur each year, approximately half of all cases occur among people aged 15–24 years.7 Although the overall proportion of adults without health insurance decreased from 13.3% in 2013 to 8.8% (or 28.2 million) in 2016, many people in the United States continue to struggle to afford full, routine access to health care.8 Among all races or ethnic groups in the United States, Hispanics had the lowest rate of health insurance coverage in 2016 at 84.0% (a slight increase from 83.8% in 2015).8

Even when health care is readily available to racial and ethnic minority populations, fear and distrust of health care institutions can negatively affect the health care-seeking experience. Social and cultural discrimination, language barriers, provider bias, or the perception that these may exist, likely discourage some people from seeking care.9,10 Moreover, the quality of care can differ substantially for minority patients.11 Broader inequities in social and economic conditions for minority communities are reflected in the profound disparities observed in the incidence of STDs by race and Hispanic ethnicity.

In communities where STD prevalence is higher because of these and other factors, people may experience difficulties reducing their risk for STIs. With each sexual encounter, they face a greater chance of encountering an infected partner than those in lower prevalence settings do, regardless of similar sexual behavior patterns.2 Acknowledging inequities in STD rates by race and Hispanic ethnicity is a critical first step toward empowering affected groups and the public health community to collaborate in addressing systemic inequities in the burden of disease – with the ultimate goal of minimizing the health impacts of STDs on individuals and populations.

STD Reporting Practices

Surveillance data are based on cases of STDs reported to state and local health departments (see Section A.1 in the Appendix). In many state and local health departments, electronic laboratory reporting is increasingly becoming the primary source of initial case notifications. Laboratory reports are often missing race and Hispanic ethnicity of the patient; ascertainment of information on race and Hispanic ethnicity is therefore a function of active follow-up or dependent on previous information available about the patient in existing health department surveillance databases. Prevalence data from population-based surveys, such as the National Health and Nutrition Examination Survey (NHANES) and the National Longitudinal Study of Adolescent Health, confirm the existence of marked disparities in some minority populations (see Other STDs below) for both reportable and non-nationally reportable STDs.12,13

Method of Classifying Race and Hispanic Ethnicity

Interpretation of racial and ethnic disparities among persons with STDs is influenced by data collection methods and by the categories by which these data are displayed. Race/Hispanic ethnicity data in this report are presented in Office of Management and Budget (OMB) race and Hispanic ethnicity categories according to the 1997 revised OMB standards.14 As of 2017, most reporting jurisdictions are locally compliant with OMB standards and report in the standard categories, including the ability to collect more than one race per person. However, a small number of jurisdictions reported race in pre-1997 categories; while other jurisdictions were unable to report more than one race per person in 2017. All race and Hispanic ethnicity data reported by jurisdictions are summarized in tables, charts and interpretative text in this report regardless of local compliance with the 1997 OMB standards. No redistribution of cases is done; cases missing race and/or Hispanic ethnicity are not included in the calculation of rates by race and Hispanic ethnicity. See Section A1.5 of the Appendix for additional information on reporting of race and Hispanic ethnicity.

Completeness of Race and Hispanic Ethnicity Data in 2017

Chlamydia — 27.8% of chlamydia case reports were missing race or Hispanic ethnicity data, ranging by jurisdiction from 0.2% to 90.9% (Table A1).

Gonorrhea — 19.0% of gonorrhea case reports were missing information on race or Hispanic ethnicity, ranging by jurisdiction from 0.1% to 88.0% (Table A1).

Syphilis — 4.2% of all primary and secondary (P&S) syphilis case reports were missing information on race or Hispanic ethnicity, ranging by jurisdiction from no missing information to 30.3% (Table A1).

Chlamydia

During 2013–2017, rates of reported chlamydia cases increased among all racial and Hispanic ethnicity groups. Specifically, rates increased 3.7% among American Indians/Alaska Natives (AI/AN), 29.6% among Asians, 6.1% among Blacks, 19.4% among Native Hawaiians/Other Pacific Islanders (NHOPI), 20.2% among Whites, 59.9% among Multirace, and 10.5% among Hispanics (Figure 8).

Blacks — In 2017, the overall rate of reported chlamydia cases among Blacks in the United States was 1,175.8 cases per 100,000 population (Table 11B). The rate of reported chlamydia cases among Black women was 5.0 times the rate among White women (1,419.9 and 283.3 cases per 100,000 females, respectively) (Figure S and Table 11B). The rate of reported chlamydia cases among Black men was 6.6 times the rate among White men (907.3 and 137.1 cases per 100,000 males, respectively). Rates of reported cases of chlamydia were highest for Blacks aged 15–19 and 20–24 years in 2017 (Table 11B). The rate of reported chlamydia cases among Black women aged 15–19 years (6,771.6 cases per 100,000 females) was 4.5 times the rate among White women in the same age group (1,518.5 cases per 100,000 females). The rate of reported chlamydia cases among Black women aged 20–24 years was 3.6 times the rate among White women in the same age group (6,971.7 and 1,936.0 cases per 100,000 females, respectively) (Table 11B). Among females aged 15–24 years, the population targeted for screening, rates were highest among Blacks in all US regions (Figure T).

Similar racial disparities in reported chlamydia rates exist among men. Among men aged 15–19 years, the rate of reported chlamydia cases among Blacks was 8.9 times the rate among Whites (2,589.3 and 291.5 cases per 100,000 males, respectively) (Table 11B). The rate of reported chlamydia cases among Black men aged 20–24 years was 5.0 times the rate among White men of the same age group (3,627.4 and 726.8 cases per 100,000 males, respectively).

American Indians/Alaska Natives — In 2017, the rate of reported chlamydia cases among AI/AN was 781.2 cases per 100,000 population (Table 11B). Overall, the rate of reported chlamydia cases among AI/AN in the United States as 3.7 times the rate among Whites.

Native Hawaiians/Other Pacific Islanders — In 2017, the rate of reported chlamydia cases among NHOPI was 715.4 cases per 100,000 population (Table 11B). The overall rate of reported chlamydia cases among NHOPI was 3.4 times the rate among Whites and 5.5 times the rate among Asians.

Hispanics — In 2017, the rate of reported chlamydia cases among Hispanics was 404.1 cases per 100,000 population, which was 1.9 times the rate among Whites (Table 11B).

Asians — In 2017, the rate of reported chlamydia cases among Asians was 129.6 cases per 100,000 population (Table 11B). The overall rate of reported chlamydia cases among Whites was 1.6 times the rate among Asians.

Gonorrhea

During 2013–2017, rates of reported gonorrhea cases increased 176.6% among Multirace persons (27.8 to 76.9 cases per 100,000 population), 122.4% among Asians (15.6 to 34.7 cases per 100,000 population), 109.1% among NHOPI (89.8 to 187.8 cases per 100,000 population), 100.6% among Whites (33.1 to 66.4 cases per 100,00 population), 95.3% among AI/AN (154.6 to 301.9 cases per 100,000 population), 77.4% among Hispanics (64.1 to 113.7 cases per 100,000 population), and 36.2% among Blacks (402.3 to 548.1 cases per 100,000 population) (Figure 22).

Blacks — In 2017, the overall rate of reported gonorrhea cases among Blacks in the United States was 548.1 cases per 100,000 population (Table 22B). The rate of reported gonorrhea cases among Blacks in 2017 was 8.3 times the rate among Whites (66.4 cases per 100,000 population) (Table 22B). In 2017, this disparity was similar for Black men (8.9 times the rate among White men) and Black women (7.6 times the rate among White women) (Figure U, Table 22B). As in previous years, the disparity in gonorrhea rates for Blacks in 2017 was larger in the Midwest and Northeast than in the South and West (Figure V).

Considering all race, Hispanic ethnicity, and age categories, rates of reported gonorrhea cases were highest for Blacks aged 20–24, 15–19, and 25–29 years in 2017 (Table 22B). The rate of reported gonorrhea cases among Black women aged 20–24 years (2,066.8 cases per 100,000 females) was 7.4 times the rate among White women in the same age group (280.0 cases per 100,000 females). The rate of reported gonorrhea cases among Black women aged 15–19 years (1,843.8 cases per 100,000 females) was 9.3 times the rate among White women in the same age group (197.5 cases per 100,000 females). Among Black men aged 20–24 years, the rate of reported gonorrhea cases (2,154.8 cases per 100,000 males) was 9.3 times the rate among White men in the same age group (231.3 cases per 100,000 males). The rate of reported gonorrhea cases among Black men aged 25–29 years (1,863.1 cases per 100,000 males) was 7.3 times the rate among White men in the same age group (253.5 cases per 100,000 males).

American Indians/Alaska Natives — In 2017, the rate of reported gonorrhea cases among AI/AN (301.9 cases per 100,000 population) was 4.5 times the rate among Whites (Table 22B). The disparity between gonorrhea rates for AI/AN and Whites was larger for AI/AN women (6.2 times the rate among White women) than for AI/AN men (3.2 times the rate among White men) (Figure U, Table 22B). The disparity in gonorrhea rates for AI/AN in 2017 was larger in the Midwest than in the West, Northeast, and South (Figure V).

Native Hawaiians/Other Pacific Islanders — In 2017, the rate of reported gonorrhea cases among NHOPI (187.8 cases per 100,000 population) was 2.8 times the rate among Whites (Table 22B). This disparity was similar for NHOPI women (3.0 times the rate among White women) and NHOPI men (2.7 times the rate among White men) (Figure U, Table 22B). The disparity in gonorrhea rates for NHOPI in 2017 was lower in the West than in the Midwest, Northeast, or South (Figure V).

Hispanics — In 2017, the rate of reported gonorrhea cases among Hispanics was 113.7 cases per 100,000 population, which was 1.7 times the rate among Whites (Table 22B). This disparity was similar for Hispanic women (1.5 times the rate among White women) and Hispanic men (1.9 times the rate among White men) (Figure U, Table 22B). The disparity in gonorrhea rates for Hispanics in 2017 was higher in the Northeast than in the Midwest, South, or West (Figure V).

Asians — In 2017, the rate of reported gonorrhea cases among Asians (34.7 cases per 100,000 population) was 0.5 times the rate among Whites (Table 22B). This difference was larger for Asian women than for Asian men (Figure U, Table 22B). In 2017, gonorrhea rates among Asians were lower than rates among Whites in all four regions of the United States (Figure V).

Primary and Secondary Syphilis

During 2013–2017, rates of reported P&S syphilis cases increased 192.6% among those who identified as Multirace (2.7 to 7.9 cases per 100,000 population), 141.3% among AI/AN (4.6 to 11.1 cases per 100,000 population), 91.3% among Asians (2.3 to 4.4 cases per 100,000 population), 84.4% among Hispanics (6.4 to 11.8 cases per 100,000 population), 80.0% among Whites (3.0 to 5.4 cases per 100,000 population), 58.0% among NHOPI (8.8 to 13.9 cases per 100,000 population), and 44.0% among Blacks (16.8 to 24.2 cases per 100,000 population) (Figure 45). Across race and Hispanic ethnicity groups, MSM accounted for the highest proportion of P&S syphilis cases (Figure W).

Blacks — In 2017, 33.7% of reported P&S syphilis cases with known race and Hispanic ethnicity (excluding cases with missing information on race and Hispanic ethnicity, and cases whose reported race was ‘Other’ and Hispanic ethnicity was ‘No’ or ‘Unknown’) occurred among Blacks (Table 35A). The rate of reported P&S syphilis cases among Blacks in 2017 (24.2 cases per 100,000 population) was 4.5 times the rate among Whites (5.4 cases per 100,000 population) (Table 35B). The disparity was greater for Black women (5.2 times the rate among White women) than for Black men (4.5 times the rate among White men) (Figure X, Table 35B). Similar disparities were seen in all regions of the United States (Figure Y).

Considering all race, Hispanic ethnicity, sex, and age categories, rates of reported P&S syphilis cases were highest among Black men aged 25–29 years in 2017 (Table 35B). The rate of reported P&S syphilis cases among Black men aged 25–29 years (142.4 cases per 100,000 males) was 5.8 times the rate among White men in the same age group (24.7 cases per 100,000 males).

Native Hawaiians/Other Pacific Islanders — In 2017, the rate of reported P&S syphilis cases among NHOPI was 13.9 cases per 100,000 population, which was 2.6 times the rate among Whites (Table 35B). This disparity was similar for NHOPI women (2.5 times the rate among White women) and NHOPI men (2.6 times the rate among White men).

Hispanics — In 2017, the rate of reported P&S syphilis cases among Hispanics (11.8 cases per 100,000 population) was 2.2 times the rate among Whites (Table 35B). This disparity was similar for Hispanic men (2.2 times the rate  among White men) and Hispanic women (1.8 times the rate among White women).

American Indians/Alaska Natives — In 2017, the rate of reported P&S syphilis cases among AI/AN (11.1 cases per 100,000 population) was 2.1 times the rate among Whites (Table 35B). This disparity was greater for AI/AN women (4.6 times the rate among White women) than for AI/AN men (1.7 times the rate among White men).

Asians — In 2017, the rate of reported P&S syphilis cases among Asians was 4.4 cases per 100,000 population, which was 0.8 times the rate among Whites (Table 35B). This difference was larger for Asian women (0.3 times the rate among White women) than for Asian men (0.9 times the rate among White men).

Congenital Syphilis

Race and Hispanic ethnicity for cases of congenital syphilis are based on the mother’s information. During 2013–2017, rates of reported congenital syphilis cases increased in all population groups. Rates increased 234.5% among Whites, 225.2% among Hispanics, 177.3% among AI/AN, 87.6% among Blacks, and 22.9% among Asians/Pacific Islanders (Figure Z, Table 42).

In 2017, 39.1% of congenital syphilis cases with known race and Hispanic ethnicity (excluding cases with missing information on race and Hispanic ethnicity, and cases whose reported race was ‘Other’ and Hispanic ethnicity was ‘No’ or ‘Unknown’) occurred among Blacks (Table 42). The rate of reported cases of congenital syphilis among Blacks in 2017 (58.9 cases per 100,000 live births) was 6.1 times the rate among Whites (9.7 cases per 100,000 live births). The rate of reported cases of congenital syphilis was 35.5 cases per 100,000 live births among AI/AN (3.7 times the rate among Whites), 33.5 cases per 100,000 live births among Hispanics (3.5 times the rate among Whites), and 4.3 cases per 100,000 live births among Asians/Pacific Islanders (0.4 times the rate among Whites).

Other STDs

Data from the National Health and Nutrition Examination Survey (NHANES; see Section A2.4 in the Appendix) indicate the seroprevalence of herpes simplex virus type 2 (HSV-2) in the United States has decreased from 1999–2000 to 2015–2016 for all race and Hispanic ethnicity groups (Figure 53);15 however, HSV-2 seroprevalence was highest among non-Hispanic Blacks throughout the entire time period. See Other STDs for more information on HSV infections.

Trichomonas vaginalis prevalence in urine specimens obtained from adult NHANES participants aged 18–59 years during 2013–2014 indicated a prevalence of 0.5% among males and 1.8% among females; highest rates were observed among non-Hispanic Black males (4.2%) and females (8.9%).16 A separate analysis of NHANES data during 2013–2016 among men aged 18–59 years also found higher prevalence among non-Hispanic Blacks.17 An analysis of NHANES data from 2001–2004 from cervicovaginal swab specimens also found higher T. vaginalis prevalence among non-Hispanic Black females.18 See Other STDs for more information on T. vaginalis infections.

Summary

Inequities in the burden of disease for chlamydia, gonorrhea, syphilis and other STDs by race and Hispanic ethnicity continue to persist at unacceptable levels in the United States. These disparities are not explained by individual or population-level behavioral differences; rather they result in large measure from stubbornly entrenched systemic, societal, and cultural barriers to STD diagnoses, treatment and preventive services accessible on a routine basis. Some progress has been achieved in recent years in reducing the magnitude of disparities in some STDs, especially for Blacks, but much more needs to be done to address these issues through individual, group, and structural-level health care interventions. Continued monitoring of differences across groups in reported case incidence is also critical to the success of these efforts, including a sharpened focus on ascertainment of race and Hispanic ethnicity for persons diagnosed and reported with STDs.

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