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 2017, 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 12.3% (or 39.7 million), a decrease of 0.4 percent from 2016. Although the overall poverty rate declined over the last few years, many Americans continue to face systemic challenges to achieving their full economic potential; the poverty rate in 2017 for Whites was 8.7% (16.9 million), for Blacks it was 21.2% (8.9 million), and for Hispanics it was 18.3% (10.7 million). Significant differences by race/Hispanic ethnicity in the proportion of the population living in poverty persisted in 2017 and were even more acute for family households headed by women (25.7% versus 9.3% for all family households), regardless of other factors.3 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 STIs that occur each year, approximately half of all cases occur among people aged 15–24 years.7 However, the overall proportion of adults without health insurance decreased from 13.3% in 2013 to 8.8% (or 28.2 million) in 2016 and remains unchanged at 8.8% (28.5 million) in 2017. By age groupings, the highest proportion of the population lacking health insurance in 2017 were 19–25 and 26–34 year olds (14.0% and 15.6%, respectively), demonstrating that 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 2017 at 84.0% (unchanged from 2016).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/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/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 2018, 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 continued to be unable to report more than one race per person in 2018. All race/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/Hispanic ethnicity are not included in the calculation of rates by race/Hispanic ethnicity. Caution should be used in interpreting and comparing rates for individual race groups or by Hispanic ethnicity. Because missing cases are excluded, rates presented underestimate the likely actual rate of reported cases for specific groups. See Section A1.5 of the Appendix for additional information on reporting of race/Hispanic ethnicity.

Completeness of Race/Hispanic Ethnicity Data in 2018

Chlamydia — 28.5% of chlamydia case reports were missing race/Hispanic ethnicity data, ranging by jurisdiction from 0.1% to 94.4% (Table A1).

Gonorrhea — 19.6% of gonorrhea case reports were missing information on race/Hispanic ethnicity, ranging by jurisdiction from 0.0% to 92.0% (Table A1).

Syphilis — 4.5% of all primary and secondary (P&S) syphilis case reports were missing information on race/Hispanic ethnicity, ranging by jurisdiction from 0.0% to 46.7% missing (Table A1).

Chlamydia

During 2014–2018, rates of reported chlamydia cases increased among all racial and Hispanic ethnicity groups. Specifically, rates increased 7.0% among American Indians/Alaska Natives (AI/AN), 8.1% among Hispanics, 9.0% among Blacks, 17.6% among Whites, 20.1% among Native Hawaiians/Other Pacific Islanders (NHOPI), 29.3% among Asians, and 59.7% among Multirace (Figure 8).

Blacks — In 2018, the overall rate of reported chlamydia cases among Blacks in the United States was 1,192.5 cases per 100,000 population (Figure 8, Table 11B). The rate of reported chlamydia cases among Black females was five times the rate among White females (1,411.1 and 281.7 cases per 100,000 population, respectively; Figure S and Table 11B). The rate of reported chlamydia cases among Black males was 6.8 times the rate among White males (952.3 and 140.4 cases per 100,000 population, respectively). Rates of reported cases of chlamydia were highest for Blacks aged 15–19 and 20–24 years in 2018 (Table 11B). The rate of reported chlamydia cases among Black females aged 15–19 years (6,817.3 cases per 100,000 population) was 4.5 times the rate among White females in the same age group (1,520.1 cases per 100,000 population). The rate of reported chlamydia cases among Black females aged 20–24 years was 3.7 times the rate among White females in the same age group (7,087.7 and 1,935.8 cases per 100,000 population, respectively). 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 males. Among males aged 15–19 years, the rate of reported chlamydia cases among Blacks was 9.1 times the rate among Whites (2,668.6 and 293.0 cases per 100,000 population, respectively; Table 11B). The rate of reported chlamydia cases among Black males aged 20–24 years was 5.3 times the rate among White males of the same age group (3,867.1 and 732.6 cases per 100,000 population, respectively).

American Indians/Alaska Natives — In 2018, the rate of reported chlamydia cases among AI/AN was 784.8 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 2018, the rate of reported chlamydia cases among NHOPI was 700.8 cases per 100,000 population (Table 11B). The overall rate of reported chlamydia cases among NHOPI was 3.3 times the rate among Whites and 5.3 times the rate among Asians.

Hispanics — In 2018, the rate of reported chlamydia cases among Hispanics was 392.6 cases per 100,000 population, which was 1.9 times the rate among Whites (Table 11B).

Asians — In 2018, the rate of reported chlamydia cases among Asians was 132.1 cases per 100,000 population (Table 11B). The overall rate of reported chlamydia cases among Whites was 1.6 times the rate among Asians.

Figure S - The rate of reported chlamydia cases among Black females was five times the rate among White females (1,411.1 and 281.7 cases per 100,000 population, respectively). The rate of reported chlamydia cases among Black males was 6.8 times the rate among White males (952.3 and 140.4 cases per 100,000 population, respectively).

Figure T - Among females aged 15–24 years, the population targeted for screening, rates were highest among Blacks in all US regions.

Gonorrhea

During 2014–2018, rates of reported gonorrhea cases increased 119.5% among Multirace persons (43.0 to 94.4 cases per 100,000 population), 99.4% among Asians (17.6 to 35.1 cases per 100,000 population), 90.3% among NHOPI (95.3 to 181.4 cases per 100,000 population), 89.1% among Whites (37.6 to 71.1 cases per 100,000 population), 84.2% among AI/AN (178.9 to 329.5 cases per 100,000 population), 66.0% among Hispanics (69.8 to 115.9 cases per 100,000 population), and 38.8% among Blacks (395.4 to 548.9 cases per 100,000 population) (Figure 22).

Blacks — In 2018, the overall rate of reported gonorrhea cases among Blacks in the United States was 7.7 times the rate among Whites (Table 22B). This disparity was similar for Black males (8.5 times the rate among White males) and Black females (6.9 times the rate among White females) (Figure U, Table 22B). As in previous years, the disparity in gonorrhea rates for Blacks in 2018 was larger in the Midwest and Northeast than in the South and West (Figure V).

Considering Hispanic ethnicity and all race and age categories, rates of reported gonorrhea cases were highest for Blacks aged 20–24, 15–19, and 25–29 years in 2018 (Table 22B). The rate of reported gonorrhea cases among Black females aged 20–24 years (2,040.3 cases per 100,000 population) was 6.9 times the rate among White females in the same age group (297.5 cases per 100,000 population). The rate of reported gonorrhea cases among Black females aged 15–19 years (1,756.4 cases per 100,000 population) was 8.8 times the rate among White females in the same age group (200.1 cases per 100,000 population). Among Black males aged 20–24 years, the rate of reported gonorrhea cases (2,212.1 cases per 100,000 population) was 9.4 times the rate among White males in the same age group (236.3 cases per 100,000 population). The rate of reported gonorrhea cases among Black males aged 25–29 years (1,860.7 cases per 100,000 population) was 7.0 times the rate among White males in the same age group (265.5 cases per 100,000 population).

American Indians/Alaska Natives — In 2018, the rate of reported gonorrhea cases among AI/AN (329.5 cases per 100,000 population) was 4.6 times the rate among Whites (Table 22B). The disparity between gonorrhea rates for AI/AN and Whites was larger for AI/AN females (6.3 times the rate among White females) than for AI/AN males (3.3 times the rate among White males) (Figure U, Table 22B). The disparity in gonorrhea rates for AI/AN in 2018 was larger in the Midwest than in the West, Northeast, and South (Figure V).

Native Hawaiians/Other Pacific Islanders — In 2018, the rate of reported gonorrhea cases among NHOPI (181.4 cases per 100,000 population) was 2.6 times the rate among Whites (Table 22B). This disparity was similar for NHOPI females (2.6 times the rate among White females) and NHOPI males (2.5 times the rate among White males) (Figure U, Table 22B). The disparity in gonorrhea rates for NHOPI in 2018 was higher in the Midwest than in the West, Northeast, and South (Figure V).

Hispanics — In 2018, the rate of reported gonorrhea cases among Hispanics was 115.9 cases per 100,000 population, which was 1.6 times the rate among Whites (Table 22B). This disparity was similar for Hispanic females (1.4 times the rate among White females) and Hispanic males (1.8 times the rate among White males) (Figure U, Table 22B). The disparity in gonorrhea rates for Hispanics in 2018 was higher in the Northeast than in the Midwest, South, and West (Figure V).

Asians — In 2018, the rate of reported gonorrhea cases among Asians (35.1 cases per 100,000 population) was 0.5 times the rate among Whites (Table 22B). This difference was larger for Asian females (0.3 times the rate among White females) than for Asian males (0.7 times the rate among White males) (Figure U, Table 22B). In 2018, gonorrhea rates among Asians were lower than rates among Whites in all four regions of the United States (Figure V).

Figure U - In 2018, the disparity between gonorrhea rates Blacks and Whites was larger for Black males (8.5 times the rate among White males) than Black females (6.9 times the rate among White females). The disparity between gonorrhea rates for AI/AN and Whites was larger for AI/AN females (6.3 times the rate among White females) than for AI/AN males (3.3 times the rate among White males). The disparity between gonorrhea rates for NHOPI and Whites was larger for NHOPI females (2.6 times the rate among White females) and NHOPI males (2.5 times the rate among White males). The disparity between gonorrhea rates for Hispanics and Whites was larger for Hispanic females (1.4 times the rate among White females) and Hispanic males (1.8 times the rate among White males). The disparity between gonorrhea rates for Asians and Whites was larger for Asian females (0.3 times the rate among White females) than for Asian males (0.7 times the rate among White males).

Figure V - As in previous years, the disparity in gonorrhea rates for Blacks in 2018 was larger in the Midwest and Northeast than in the South and West. The disparity in gonorrhea rates for AI/AN and HNOPI, each, was larger in the Midwest than in the West, Northeast, and South. The disparity in gonorrhea rates for Hispanics was higher in the Northeast than in the Midwest, South, and West. In 2018, gonorrhea rates among Asians were lower than rates among Whites in all four regions of the United States.

Primary and Secondary Syphilis

During 2014–2018, rates of reported P&S syphilis cases increased for all race/Hispanic ethnicity groups, more than doubling for some groups (Figure 45). The rate of reported P&S syphilis cases increased 171.7% among NHOPI (6.0 to 16.3 cases per 100,000 population), 115.3% among AI/AN (7.2 to 15.5 cases per 100,000 population), 104.3% among those who identified as Multirace (4.6 to 9.4 cases per 100,000 population), 78.1% among Hispanics (7.3 to 13.0 cases per 100,000 population), 76.9% among Asians (2.6 to 4.6 cases per 100,000 population), 71.4% among Whites (3.5 to 6.0 cases per 100,000 population), and 51.9% among Blacks (18.5 to 28.1 cases per 100,000 population). Across all race/Hispanic ethnicity groups, MSM accounted for the highest proportion of P&S syphilis cases (Figure Z).

Blacks — In 2018, 34.7% of reported P&S syphilis cases with known race/Hispanic ethnicity information occurred among Blacks (Table 35A). The rate of reported P&S syphilis cases among Blacks was 4.7 times the rate among Whites (28.1 versus 6.0 cases per 100,000 population, respectively) (Table 35B). This disparity was similar for Black females and males (Figure W). Similar disparities were seen in all regions of the United States (Figure X).

Hispanics — In 2018, 23.3% of reported P&S syphilis cases with known race/Hispanic ethnicity information occurred among Hispanics (Table 35A). The rate of reported P&S syphilis cases among Hispanics was 2.2 times the rate among Whites (13.0 versus 6.0 cases per 100,000 population, respectively) (Table 35B). This disparity was greater for Hispanic males (2.2 times the rate among White males) than Hispanic females (1.7 times the rate among White females) (Figure W).

Native Hawaiians/Other Pacific Islanders — In 2018, the rate of reported P&S syphilis cases among NHOPI was 2.7 times the rate among Whites (16.3 versus 6.0 cases per 100,000 population, respectively) (Table 35B). This disparity was greater for NHOPI males (2.8 times the rate among White males) than  NHOPI females (1.9 times the rate among White females) (Figure W).

Native Hawaiians/Other Pacific Islanders — In 2018, the rate of reported P&S syphilis cases among NHOPI was 2.7 times the rate among Whites (16.3 versus 6.0 cases per 100,000 population, respectively) (Table 35B). This disparity was greater for NHOPI males (2.8 times the rate among White males) than NHOPI females (1.9 times the rate among White females) (Figure W).

American Indians/Alaska Natives — In 2018, the rate of reported P&S syphilis cases among AI/AN was 2.6 times the rate among Whites (15.5 versus 6.0 cases per 100,000 population, respectively) (Table 35B). This disparity was greater for AI/AN females (5.4 times the rate among White females) than for AI/AN males (2.1 times the rate among White males) (Figure W).

Asians — In 2018, the rate of reported P&S syphilis cases among Asians was 0.8 times the rate among Whites (4.6 versus 6.0 cases per 100,000 population, respectively) (Table 35B). This disparity was greater for Asian females (0.3 times the rate among White females) than for Asian males (0.9 times the rate among White males) (Figure W). Similar disparities were seen in all regions of the United States (Figure X).

See text for description.

See text for description.

Congenital Syphilis

Race/Hispanic ethnicity for cases of congenital syphilis are assigned according to the mother’s race/Hispanic ethnicity information. During 2014–2018, rates of reported congenital syphilis cases increased for all race/Hispanic ethnicity groups (Figure Y). The rate of reported congenital syphilis increased 500.0% among AI/AN (13.2 to 79.2 cases per 100,000 live births), 275.0% among Whites (3.6 to 13.5 cases per 100,000 live births), 263.4% among Hispanics (12.3 to 44.7 cases per 100,000 live births), 126.7% among Blacks (38.2 to 86.6 cases per 100,000 live births), and 31.4% among Asian/Pacific Islanders (7.0 to 9.2 cases per 100,000 live births).

In 2018, 40.4% of reported congenital syphilis cases with known race/Hispanic ethnicity information occurred among Blacks, 32.6% occurred among Hispanics, and 22.7% occurred among Whites (Table 42). Disparities persist across race/ Hispanic ethnicity groups. The rate of reported cases of congenital syphilis among Blacks was 6.4 times the rate among Whites (86.6 versus 13.5 cases per 100,000 live births, respectively). The rate of reported cases of congenital syphilis among AI/AN (79.2 cases per 100,000 live births) was 5.9 times the rate among Whites, the rate among Hispanics (44.7 cases per 100,000 live births) was 3.3 times the rate among Whites, and the rate among Asians/Pacific Islanders (9.2 cases per 100,000 live births) was 0.7 times the rate among Whites.

Figure Y - During 2014–2018, rates of reported congenital syphilis cases increased for all race/Hispanic ethnicity groups. The rate of reported congenital syphilis increased 500.0% among AI/AN (13.2 to 79.2 cases per 100,000 live births), 275.0% among Whites (3.6 to 13.5 cases per 100,000 live births), 263.4% among Hispanics (12.3 to 44.7 cases per 100,000 live births), 126.7% among Blacks (38.2 to 86.6 cases per 100,000 live births), and 31.4% among Asian/Pacific Islanders (7.0 to 9.2 cases per 100,000 live births).

Figure Z - Across race and Hispanic ethnicity groups, MSM accounted for the highest proportion of P&S syphilis cases. Of MSM P&S syphilis cases, 36.0% were White, 29.0% were Black, and 24.0% were Hispanic.

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) among the civilian, non-institutionalized population in the United States has decreased from 1999–2000 to 2015–2016 for all race/Hispanic ethnicity groups (Figure 53);15 however, HSV-2 seroprevalence was highest among non-Hispanic Blacks throughout the entire time period. For more information on HSV infections, see Other STDs.

Trichomonas vaginalis prevalence in urine specimens obtained from NHANES participants aged 14–59 years during 2013–2016 indicated a prevalence of 0.5% among males and 2.1% among females; highest rates were observed among non-Hispanic Black males (3.4%) and females (9.6%).16 An analysis of NHANES data from 2001–2004 from cervicovaginal swab specimens also found higher T. vaginalis prevalence among non-Hispanic Black females.17 For more information on T. vaginalis infections, see Other STDs.

Summary

Inequities in the burden of disease for chlamydia, gonorrhea, syphilis and other STDs by race/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 to some groups on a routine basis. While incremental progress has been achieved in recent years in reducing the magnitude of disparities in some STDs, especially for Blacks, 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/Hispanic ethnicity in categories congruent with the 1997 OMB guidance for persons diagnosed and reported with STDs.14

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