STDs in Racial and Ethnic Minorities

Public Health Impact

Surveillance data show higher rates of reported STDs among some racial or ethnic minority groups when compared with rates among whites. Race and ethnicity in the United States are population characteristics that correlate with other fundamental determinants of health status.^1,2

Social and economic conditions, such as high rates of poverty, income inequality, unemployment, and low educational attainment, can make it more difficult for individuals to protect their sexual health.³ People who struggle financially are often experiencing life circumstances that increase their risk for STDs.⁴ Those who cannot afford basic necessities may have trouble accessing and affording quality sexual health services.⁵ As an example, in 2010, the poverty rates, unemployment rates, and high school drop-out rates for blacks, American Indians/Alaska Natives, and Hispanics were considerably higher than for whites, differences commensurate with observed disparities in STD burden.^6–9 Recent data show that one-fifth of blacks (20.8%) do not have health insurance. Many people of Hispanic ethnicity face similar challenges; and for some, there are the additional barriers arising from immigration or undocumented citizenship status.^10,11 Even when health care is available, fear and distrust of health care institutions can negatively affect the health care-seeking experience for many racial/ethnic minorities when there is social discrimination, provider bias, or the perception that these may exist.¹²

In communities where STD prevalence is higher, individuals may have a more difficult time reducing their risk for infection. With each sexual encounter, they face a greater chance of encountering an infected partner than those in lower prevalence settings.¹³ Acknowledging the inequity in STD rates by race or ethnicity is one of the first steps in empowering affected communities to organize and focus on this problem.

STD Reporting Practices

Surveillance data are based on cases of STDs reported to state and local health departments (see Interpreting STD Surveillance Data in the Appendix). In many state and local health jurisdictions, reporting from public sources (e.g., STD clinics) is thought to be more complete than reporting from private sources. Because minority populations may use public clinics more than whites, differences in rates between minorities and whites may be increased by this reporting bias.¹⁴ However, prevalence data from population-based surveys, such as NHANES and the National Longitudinal Study of Adolescent Health, confirm the existence of marked STD disparities in some minority populations.^15,16

Completeness of Race/Ethnicity Data

Many cases are reported with race and/or ethnicity missing. Rate data presented in this report are not adjusted for missing race or ethnicity.

Chlamydia—In 2011, 26.1% of chlamydia case reports were missing race or ethnicity data, ranging by state from 0.2% to 55.5% (Table A1).

Gonorrhea—In 2011, 20.4% of gonorrhea case reports were missing information on race or ethnicity, ranging by state from 0.0% to 42.3% (Table A1).

Syphilis—In 2011, 2.9% of P&S syphilis case reports were missing information on race or ethnicity, ranging from 0.0% to 30.0% among states with 10 or more cases of P&S syphilis (Table A1).

Observations

Chlamydia

Chlamydia rates based on reported cases increased during 2011–2012 among all racial and ethnic groups (Figure 6). During 2007–2011, chlamydia rates increased by 17.6% among blacks, 23.6% among American Indians/Alaska Natives, 14.4% among Hispanics, 17.1% among Asians/Pacific Islanders, and 34.6% among whites.

Blacks—In 2011, the overall rate among blacks in the United States was 1,194.4 cases per 100,000, a 3.8% increase from the 2010 rate of 1,150.4 cases per 100,000. The rate of chlamydia among black women was over six times the rate among white women (1,563.0 and 232.7 per 100,000 women, respectively) (Figure O). The chlamydia rate among black men was over nine times the rate among white men (787.7 and 82.3 cases per 100,000 men, respectively).

Chlamydia rates were highest for blacks aged 15–19 and 20–24 years in 2011 (Table 11B). The chlamydia rate among black females aged 15–19 years was 7,507.1 cases per 100,000 women, which was almost six times the rate among white females in the same age group (1,301.5). The rate among black women aged 20–24 years was 4.8 times the rate among white women in the same age group (Table 11B).

Similar racial disparities in reported chlamydia rates exist among men. Among males aged 15–19 years, the rate among blacks was 11.1 times the rate among whites (Table 11B). The chlamydia rate among black men aged 20–24 years was seven times the rate among white men of the same age group (3,662.0 and 516.4 cases per 100,000 men, respectively).

American Indians/Alaska Natives—In 2011, the chlamydia rate among American Indians/Alaska Natives was 648.3 cases per 100,000 population, an increase of 7.7% from the 2010 rate of 602.0 cases per 100,000. Overall, the rate of chlamydia among American Indians/Alaska Natives in the United States was more than four times the rate among whites.

Asians/Pacific Islanders—In 2011, the chlamydia rate among Asians/Pacific Islanders was 115.3 cases per 100,000 population, an increase of 7.9% from the 2010 rate of 106.9 cases per 100,000. The overall rate among Asians/Pacific Islanders was lower than the rate among whites.

Hispanics—In 2011, the chlamydia rate among Hispanics was 383.6 cases per 100,000 population, which is a 8.2% increase from the 2010 rate of 354.6 cases per 100,000 and over two times the rate among whites.

Gonorrhea

During 2010–2011, gonorrhea rates increased 12.3% among Hispanics (47.9 to 53.8), 7.7% among American Indians/Alaska Natives (107.4 to 115.7), 7.7% among whites (23.4 to 25.2), 4.9% among Asians/Pacific Islanders (14.4 to 15.1), and 0.3% among blacks (426.2 to 427.3) (Figure 24).

Blacks—In 2011, 67% of reported gonorrhea cases with known race/ethnicity occurred among blacks (excluding cases with missing information on race or ethnicity, and cases whose reported race or ethnicity was other). The rate of gonorrhea among blacks in 2011 was 427.3 cases per 100,000 population (Figure 24), which was 17.0 times the rate among whites (25.2 per 100,000). This disparity has changed little in recent years (Figure P). This disparity was larger for black men (19.4 times) than for black women (15.2 times) (Figure Q).

As in previous years, the disparity in gonorrhea rates for blacks in 2011 was larger in the Midwest and Northeast than in the West or the South (Figure R).

Considering all racial/ethnic and age categories, gonorrhea rates were highest for blacks aged 15–19 and 20–24 years in 2011 (Table 22B). Black women aged 15–19 years had a gonorrhea rate of 1,929.6 cases per 100,000 women. This rate was 15.9 times the rate among white women in the same age group (121.2). Black women aged 20–24 had a gonorrhea rate of 2050.4 cases per 100,000 women, which was 12.1 times the rate among white women in the same age group (169.2 per 100,000) (Table 22B).

Black men aged 15–19 years had a gonorrhea rate of 959.9 cases per 100,000 men, which was 30.3 times the rate among white men in the same age group (31.7 per 100,000). Black men aged 20–24 years had a gonorrhea rate of 1875.1 cases per 100,000 men, which was 20.4 times the rate among white men in the same age group (91.8 per 100,000) (Table 22B).

American Indians/Alaska Natives—In 2011, the gonorrhea rate among American Indians/Alaska Natives was 115.7 cases per 100,000 population, which was 4.6 times the rate among whites (Figure 24, Figure P). The disparity between gonorrhea rates for American Indians/Alaska Natives and whites was larger for American Indian/Alaska Native women (5.2 times) than for American Indian/Alaska Native men (3.8 times) (Figure Q). As in previous years, the disparity in gonorrhea rates for American Indians/Alaska Natives in 2011 was larger in the West and Midwest than in the Northeast or South (Figure R).

Asians/Pacific Islanders—In 2011, the gonorrhea rate among Asians/Pacific Islanders was 15.1 cases per 100,000 population, which was lower than the rate among whites (Figure 24, Figure P). This difference is larger for Asian/Pacific Islander women than for Asian/Pacific Islander men (Figure Q). In 2011, rates among Asians/Pacific Islanders were again lower than rates among whites in all four regions of the United States (Figure R).

Hispanics—In 2011, the gonorrhea rate among Hispanics was 53.8 cases per 100,000 population, which was 2.1 times the rate among whites (Figures 24 and P). This disparity between Hispanics and whites was similar to that in recent years and was larger for Hispanic men than for Hispanic women (Figure Q). As In previous years, the disparity in gonorrhea rates for Hispanics was highest in the Northeast and lowest in the West (Figure R).

Primary and Secondary Syphilis

The syphilis epidemic in the late 1980s occurred primarily among men who have sex with women only (MSW), women, and minority populations.^17,18 During the 1990s, the rate of P&S syphilis declined among all racial and ethnic groups. During 2007–2011, the rate increased among all racial and ethnic groups except American Indians/Alaska Natives (Figure 45).

Blacks—During 2010–2011, the rate of P&S syphilis among blacks decreased 6.6% (from 16.6 to 15.5 cases per 100,000 population). In 2011, 43.8% of all cases reported to CDC were among blacks and 32.8% of all cases were among whites.

The overall 2011 rate for blacks was 7.0 times the rate for whites, while the 2010 rate was 7.9 times the rate for whites (Figure 45). In 2011, the rate of P&S syphilis among black men was 6.1 times the rate among white men; the rate among black women was 17 times the rate among white women (Figure S).

In some age groups, particularly black men (including men who have sex with men) aged 20–24 years and 25–29 years, disparities have increased markedly in recent years as rates of disease have increased (Table 35B). ¹⁹ During 2007–2011, rates among black men aged 20–24 years increased from 54.9 to 96.2 cases per 100,000 population (75%); the magnitude of this increase (41.3 cases per 100,000 population) was the greatest reported regardless of age, sex, or race/ethnicity. Among men and women aged 15–19 years, disparities between blacks and other races/ethnicities have decreased since 2009 (Figures T and U). Nonetheless, large disparities remain; the 2011 rate among black men aged 15–19 years was 16 times the rate for whites and 5 times the rate for Hispanics (Table 35B).

The largest rate increases among black women during 2007–2011 occurred among women aged 20–24 years (from 15.7 to 18.9 cases per 100,000 population). In 2011, rates for black women aged 15–19 years were 30 times and 24 times the rate for white and Hispanic women of the same ages, respectively.

Recent trends in syphilis rates in young black men are of particular concern given data indicating high HIV incidence in this population.^20,21

American Indians/Alaska Natives—During 2010–2011, the rate of P&S syphilis among American Indians/Alaska Natives increased 8.0% (from 2.5 to 2.7 cases per 100,000 population). In 2011, 0.5% of all cases reported to CDC were among American Indians/Alaska Natives. The 2011 rate of P&S syphilis for American Indians/Alaska Natives was 1.2 times the rate for whites (Figure 45).

Asians/Pacific Islanders—During 2010–2011, the rate of P&S syphilis among Asians/Pacific Islanders increased 33.3% (from 1.2 to 1.6 cases per 100,000 population). In 2011, 1.8% of all cases reported to CDC were among Asians/Pacific Islanders. The 2011 rate of P&S syphilis for Asians/Pacific Islanders was less than the rate for whites (Figure 45).

Hispanics—During 2010–2011, the rate of P&S syphilis among Hispanics increased 4.5% (from 4.4 to 4.6 cases per 100,000 population). In 2011, 16.7% of all cases reported to CDC were among Hispanics. The 2011 rate of P&S syphilis for Hispanics was 2.0 times the rate for whites (Figure 45).

Congenital Syphilis

In 2011, the rate of congenital syphilis was 33.0 cases per 100,000 live births among blacks and 7.6 cases per 100,000 live births among Hispanics. Race/ethnicity for cases of congenital syphilis is based on the mother’s race/ethnicity. These rates were 15.0 and 3.5 times, respectively, the rate among whites (2.2 cases per 100,000 live births) (Table 42, Figure V).

1 Hogben M, Leichliter JS. Social determinants and sexually transmitted disease disparities. Sex Transm Dis. 2008;35(12 Suppl):S13-8.

2 Cunningham PJ, Cornelius LJ. Access to ambulatory care for American Indians and Alaska Natives; the relative importance of personal and community resources. Soc Sci Med. 1995:40(3): 393-407.

3 Gonzalez JS, Hendriksen ES, Collins EM, Duran RE, Safren SA. Latinos and HIV/AIDS: examining factors related to disparity and identifying opportunities for psychosocial intervention research. AIDS Behav. 2009:13:582-602.

4 Laumann EO, Youm Y. Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sex Transm Dis. 1999;26(5):250-61.

5 Institute of Medicine. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1997.

6 DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith, U.S. Census Bureau, Current Population Reports, P60-238, Income, Poverty, and Health Insurance Coverage in the United States: 2010, U.S. Government Printing Office, Washington, DC, 2011.

7 U.S. Department of Labor U.S. Bureau of Labor Statistics. Labor Force Characteristics by Race and Ethnicity, 2010. August 2011.Report 1032.

8 U.S. Department of Commerce, Census Bureau. Current Population Survey (CPS), October 1967-October 2010.

9 Austin, Algernon. Different Race, Different Recession: American Indian Unemployment in 2010. www.epi.org/publication/ib289.

10 Pérez-Escamilla R. Health care access among latinos: implications for social and health care reform. J Hispanic High Educ. 2010:9(1):43-60.

11 Berk ML, Schur CL. The effect of fear on access to care among undocumented latino immigrants. J Immigr Health. 2001;3(3):151-156.

12 Wiehe SE, Rosenman MB, Wang J, Katz BP, Fortenberry D. Chlamydia screening among young women: individual- and provider-level differences in testing. Pediatrics. 2011;127(2): e336-44.

13 Hogben M, Leichliter JS. Social determinants and sexually transmitted disease disparities. Sex Transm Dis. 2008;35(12 Suppl):S13-8.

14 Miller WC. Epidemiology of chlamydial infection: are we losing ground? Sex Transm Infect. 2008;84:82-6.

15 Datta SD, Sternberg M, Johnson RE, Berman S, Papp JR, McQuillan G, et al. Gonorrhea and chlamydia in the United States among persons 14 to 39 years of age, 1999 to 2002. Ann Intern Med. 2007;147(2):89-96.

16 Miller WC, Ford CA, Morris M, Handcock MS, Schmitz JL, Hobbs MM, et al. Prevalence of chlamydial and gonococcal infections among young adults in the United States. JAMA. 2004;291(18):2229-36.

17 Nakashima AK, Rolfs RT, Flock ML, Kilmarx P, Greenspan JR. Epidemiology of syphilis in the United States, 1941 through 1993. Sex Transm Dis. 1996;23:16-23.

18 Peterman TA, Heffelfinger JD, Swint EB, Groseclose SL. The changing epidemiology of syphilis. Sex Transm Dis. 2005;32(Suppl 10):S4-10.

19 Su JR, Beltrami JF, Zaidi AA, Weinstock HS. Primary and secondary syphilis among black and Hispanic men who have sex with men: case report data from 27 States. Ann Intern Med. 2011;155(3):145-51.

20 Centers for Disease Control and Prevention. Increase in newly diagnosed HIV infections among young black men who have sex with men--Milwaukee County, Wisconsin, 1999-2008.MMWR Morb Mortal Wkly Rep. 2011;60(4):99-102.

21 Brewer TH, Schillinger J, Lewis FM, Blank S, Pathela P, Jordahl L, et al. Infectious syphilis among adolescent and young adult men: implications for human immunodeficiency virus transmission and public health interventions. Sex Transm Dis. 2011 May;38(5):367-71.