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.^1,2 Race and ethnicity in the United States are population characteristics that are correlated with other fundamental determinants of health status such as high rates of poverty, income inequality, unemployment and low educational attainment.^3-5 People who struggle financially are often experiencing life circumstances that potentially increase their risk for STDs.⁶

Those who cannot afford basic necessities may have trouble accessing and affording quality sexual health services.⁷ The overall U.S. poverty rate in 2013 was 14.5 (or 46.7 million) and remained the same in 2014 (the most recent year for which poverty statistics are available). Although the poverty rate did not change, many Americans continue to face economic challenges. For example, the poverty rate for whites was 10.1% (19.7 million), for blacks it was 26.2% (or 10.8 million), and for Hispanics it was 23.6% (or 13.1 million).^3,8 Although the overall proportion of adults without health insurance decreased from 13.3% in 2013 to 10.4% (or 316 million) in 2014, many people in the U.S. may still not have access to health care.⁹ Among all races and ethnicities in the U.S., Hispanics had the lowest rate of health insurance coverage in 2014 at 80.1% (or 55.6 million).^9,10 Non-U.S. citizens (i.e., immigrants or undocumented persons) may face additional barriers in accessing care. In 2014, 31.2% (or 7 million) of persons not U.S. citizens did not have health insurance coverage. 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.¹¹ Moreover, the quality of care may differ substantially for minority patients.¹² These inequities in social and economic conditions are reflected in the profound disparities observed in the incidence of STDs among some racial and ethnic minorities.

In communities where STD prevalence is higher because of these inequalities, 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.² 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 Section A.1 in the Appendix). In many state and local health jurisdictions, electronic laboratory reporting is increasingly a primary source of initial case notifications. These reports are often missing race and ethnicity of the patient; ascertainment of information on race and Hispanic ethnicity is often 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 National Health and Nutrition Examination Survey (NHANES) and the National Longitudinal Study of Adolescent Health, confirm the existence of marked STD disparities in some minority populations.^{13, 14}

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/ethnicity data are presented in Office of Management and Budget (OMB) race and ethnic categories, according to the 1997 revised OMB standards. However, NCHS bridged-race categories are used where OMB categories are not available (congenital syphilis).¹⁵ Forty-eight states collect and report data in formats compliant with these standards as of 2014. One additional jurisdiction reported cases of primary & secondary (P&S) syphilis by the appropriate standard, but did not report chlamydia and gonorrhea cases by this standard. Historical trend and rate data by race and Hispanic ethnicity displayed in figures and interpreted in this report for 2010–2014 include only those jurisdictions (43 states for chlamydia/gonorrhea and 44 states for syphilis) reporting in the current standard consistently for years 2010 through 2014. Please refer to Section A1.5 of the Appendix for additional information on reporting data for race and Hispanic ethnicity.

Completeness of Race/Ethnicity Data

Chlamydia — In 2014, 27.1% of chlamydia case reports were missing race or ethnicity data, ranging by state from 0.5% to 65.9% (Table A1).

Gonorrhea — In 2014, 19.3% of gonorrhea case reports were missing information on race or ethnicity, ranging by state from 0.0% to 64.0% (Table A1).

Syphilis — In 2014, 4.5% of P&S syphilis case reports were missing information on race or ethnicity, ranging from 0.0% to 31.3% among states with 10 or more cases of P&S syphilis (Table A1).

Observations

Chlamydia

Among the 43 states that submitted data on race and Hispanic ethnicity for each year during 2010–2014 according to the OMB standards, rates of reported cases of chlamydia increased during 2010–2014 among all racial and ethnic groups except among blacks (Figure 6). During 2010–2014, chlamydia rates increased 12.6% among American Indians/Alaska Natives, 5.6% among Hispanics, 11.5% among Asians, 34.5% among Native Hawaiians/Other Pacific Islanders, and 26.9% among whites. During 2010–2014, rates of reported cases of chlamydia decreased 6.2% among blacks.

In 2014, 48 states submitted data on race and Hispanic ethnicity according to the OMB standards. The following data pertain to those jurisdictions:

Blacks — In 2014, the overall rate among blacks in the United States was 1,117.9 cases per 100,000 population (Table 11B). The rate of reported cases of chlamydia among black women was 5.7 times the rate among white women (1,432.6 and 253.3 per 100,000 females, respectively) (Table 11B and Figure N). The chlamydia rate among black men was 7.3 times the rate among white men (772.0 and 105.5 cases per 100,000 males, respectively).

Rates of reported cases of chlamydia were highest for blacks aged 15–19 and 20–24 years in 2014 (Table 11B). The chlamydia rate among black females aged 15–19 years was 6,371.5 cases per 100,000 females, which was 4.9 times the rate among white females in the same age group (1,291.6 per 100,000 females). The rate among black women aged 20–24 years was 4.1 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 nine times the rate among whites (Table 11B). The chlamydia rate among black men aged 20–24 years was 5.4 times the rate among white men of the same age group (3,241.2 and 603.5 cases per 100,000 males, respectively).

American Indians/Alaska Natives — In 2014, the chlamydia rate among American Indians/Alaska Natives was 668.8 cases per 100,000 population (Table 11B). Overall, the rate of chlamydia among American Indians/Alaska Natives in the United States was 3.7 times the rate among whites.

Native Hawaiians/Other Pacific Islanders — In 2014, the chlamydia rate among Native Hawaiians/Other Pacific Islanders was 625.1 cases per 100,000 population (Table 11B). The overall rate among Native Hawaiians/Other Pacific Islanders was 5.6 times the rate among whites and 3.5 times the rate among Asians.

Hispanics — In 2014, the chlamydia rate among Hispanics was 380.6 cases per 100,000 population (Table 11B) which is 2.1 times the rate among whites.

Asians — In 2014, the chlamydia rate among Asians was 112.0 cases per 100,000 population (Table 11B). The overall rate among whites is 1.6 times the rate among Asians.

Gonorrhea

During 2010–2014, among the 43 states that submitted data for each year according to the OMB standards, rates of reported gonorrhea cases increased 100.4% among American Indians/Alaska Natives (84.7 to 169.7 per 100,000 population), 59.8% among whites (25.1 to 40.1 per 100,000), 51.1% among Hispanics (49.1 to 74.2 per 100,000), 44.8% among Asians (14.3 to 20.7 per 100,000), and 44.1% among Native Hawaiians/Other Pacific Islanders (74.3 to 107.1 per 100,000) (Figure 20). The gonorrhea rate decreased 8.2% among blacks (466.4 to 428.1 per 100,000).

In 2014, 48 states submitted data in race and ethnicity categories according to the OMB standards. The following data pertain to those jurisdictions:

Blacks — In 2014, 55.4% 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) (Table 22A). The rate of gonorrhea among blacks in 2014 was 405.4 cases per 100,000 population, which was 10.6 times the rate among whites (38.3 per 100,000) (Table 22B). Although the calculated rate ratio for 2014 differs when considering the 43 jurisdictions that submitted data in race and ethnic categories according to the OMB standards for each year during 2010–2014, this disparity has decreased slightly in recent years (Figure O). In 2014, this disparity was similar for black men (10.6 times the rate among white men) and black women (10.7 times the rate among white women) (Figure P, Table 22B).

As in previous years, the disparity in gonorrhea rates for blacks in 2014 was larger in the Midwest and Northeast than in the West or the South (Figure Q).

Considering all racial/ethnic and age categories, gonorrhea rates were highest for blacks aged 20–24, 15–19, and 25–29 years in 2014 (Table 22B). Black women aged 20–24 had a gonorrhea rate of 1,799.9 cases per 100,000 women. This rate was 9.5 times the rate among white women in the same age group (188.7 per 100,000). Black women aged 15–19 years had a gonorrhea rate of 1,541.0 cases per 100,000 women, which was 12.7 times the rate among white women in the same age group (121.3 per 100,000).
Black men aged 20–24 years had a gonorrhea rate of 1,670.4 cases per 100,000 men, which was 10.7 times the rate among white men in the same age group (155.4 per 100,000). Black men aged 25–29 years had a gonorrhea rate of 1,291.6 cases per 100,000 men, which was 8.9 times the rate among white men in the same age group (145.5 per 100,000).

American Indians/Alaska Natives — In 2014, the gonorrhea rate among American Indians/Alaska Natives was 159.4 cases per 100,000 population, which was 4.2 times the rate among whites (Table 22B). The disparity between gonorrhea rates for American Indians/Alaska Natives and whites was larger for American Indian/Alaska Native women (5.6 times the rate among white women) than for American Indian/Alaska Native men (2.9 times the rate among white men) (Figure P, Table 22B). The disparity in gonorrhea rates for American Indians/Alaska Natives in 2014 was larger in the Midwest than in the West, Northeast, and South (Figure Q).

Native Hawaiians/Other Pacific Islanders — In 2014, the gonorrhea rate among Native Hawaiians/Other Pacific Islanders was 102.1 cases per 100,00 population, which was 2.7 times the rate among whites (Table 22B). The disparity between gonorrhea rates for Native Hawaiians/Other Pacific Islanders and whites was the similar for Native Hawaiian/Other Pacific Islander women (2.9 times the rate among white women) and Native Hawaiian/Other Pacific Islander men (2.4 times the rate among white men) (Figure P, Table 22B). The disparity in gonorrhea rates for Native Hawaiians/Other Pacific Islanders in 2014 was lower in the West than in the Midwest, Northeast, and South (Figure Q).

Hispanics — In 2014, the gonorrhea rate among Hispanics was 73.3 cases per 100,000 population, which was 1.9 times the rate among whites (Table 22B). This disparity was similar for Hispanic women (1.8 times the rate among white women) and Hispanic men (2.0 times the rate among white men) (Figure P, Table 22B). The disparity in gonorrhea rates for Hispanics was highest in the Northeast and lowest in the West and Midwest (Figure Q).

Asians — In 2014, the gonorrhea rate among Asians was 19.3 cases per 100,000 population, which was lower than (0.5 times) the rate among whites (Table 22B). This difference is larger for Asian women than for Asian men (Figure P, Table 22B). In 2014, rates among Asians were lower than rates among whites in all four regions of the United States (Figure Q).

Primary and Secondary (P&S) Syphilis

During 2010–2014, 44 states submitted syphilis data for each year according to the OMB standards. Among these states during 2010–2014, rates of reported P&S syphilis cases increased 152.6% among American Indians/Alaska Natives (3.1 to 7.9 per 100,000 population), 135.2% among Asians (1.2 to 2.9 per 100,000), 80.2% among Hispanics (4.2 to 7.5 per 100,000 population), 56.7% among whites (2.2 to 3.5 per 100,000), 38.2% among Native Hawaiians/Other Pacific Islanders (5.1 to 7.1 per 100,000), and 7.8% among blacks (17.8 to 19.2 per 100,000) (Figure 40).

In 2014, 49 states submitted syphilis data by race and ethnicity according to the OMB standards. The following data pertain to those jurisdictions:

Blacks — In 2014, 38.1% of reported P&S syphilis 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) (Table 36A). The P&S syphilis rate among blacks in 2014 was 18.9 cases per 100,000 population, which was 5.4 times the rate among whites (3.5 per 100,000) (Table 36B). This disparity was higher for black women (9.2 times the rate among white women) than for black men (5.3 times the rate among white men) (Figure R, Table 36B).

Considering all race/ethnicity, sex, and age categories, P&S syphilis rates were highest among black men aged 20–24 years and 25–29 years in 2014 (Table 36B). Black men aged 20–24 years had a P&S syphilis rate of 106.3 cases per 100,000 men. This rate was 8.5 times the rate among white men in the same age group (12.5 per 100,000). Black men aged 25–29 years had a P&S syphilis rate of 121.3 cases per 100,000 men, which was 7.9 times the rate among white men in the same age group (15.4 per 100,000).

American Indians/Alaska Natives — In 2014, the P&S syphilis rate among American Indians/Alaska Natives was 7.6 cases per 100,000 population, 2.2 times the rate among whites (Table 36B). This disparity was larger for American Indian/Alaska Native women (9.6 times the rate among white women) than for American Indian/Alaska Native men (1.6 times the rate among white men).

Native Hawaiians/Other Pacific Islanders — In 2014, the P&S syphilis rate among Native Hawaiians/Other Pacific Islanders was 6.5 cases per 100,000 population, which was 1.9 times the rate among whites (Table 36B). This disparity was similar for Native Hawaiian/Other Pacific Islander women (1.6 times the rate among white women) and Native Hawaiian/Other Pacific Islander men (1.8 times the rate among white men).

Hispanics — In 2014, the P&S syphilis rate among Hispanics was 7.6 cases per 100,000 population, which was 2.2 times the rate among whites (Table 36B). This disparity was similar for Hispanic women (2.2 times the rate among white women) and Hispanic men (2.1 times the rate among white men).

Asians — In 2014, the P&S syphilis rate among Asians was 2.8 cases per 100,000 population, which was 0.8 times the rate among whites (Table 36B). This difference is larger for Asian women (0.4 times the rate among white women) than for Asian men (0.9 times the rate among white men).

Congenital Syphilis

Race/ethnicity for cases of congenital syphilis is based on the mother’s race/ethnicity. During 2013–2014, rates of reported congenital syphilis cases increased 102.9% among Asians/Pacific Islanders, 32.1% among whites, 21.7% among blacks, and 19.8% among Hispanics (Table 43, Figure U). The congenital syphilis rate did not change among American Indians/Alaska Natives.

In 2014, 50.6% of congenital syphilis 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) (Table 43). The rate of congenital syphilis among blacks in 2014 was 38.2 cases per 100,000 live births, which was 10.3 times the rate among whites (3.7 per 100,000 live births). The rate of congenital syphilis was 12.7 cases per 100,000 live births among American Indians/Alaska Natives (3.4 times the rate among whites), 12.1 cases per 100,000 live births among Hispanics (3.3 times the rate among whites), and 6.9 cases per 100,000 births among Asians/Pacific Islanders (1.9 times the rate among whites).

     

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