Overall, 5.2% [95% confidence interval (CI), 2.9–7.2%] of participants screened HIV positive. Women were more likely to screen positive than men [6.3% (95% CI, 3.3–9.7%) versus 3.9% (95% CI, 1.6–5.7%)]. Nearly half [47.4% (95% CI, 30.9–78.7%)] of those who screened HIV positive did not know their HIV status prior to study participation. Despite the fact that more than three-quarters had seen a healthcare provider in the past 12 months, only half were offered an HIV test.
Three-quarters reported having three or fewer sex partners in the past year, and most reported their last sex partner as being a main partner (‘someone you have sex with and who you feel committed to above anyone else’). Condom use was low, with 71.2% of the most recent vaginal sex acts unprotected. Reported concurrency (having sex with someone else during the time they were having sex with their last partner) and perceived partner concurrency were common, with half of participants reporting a concurrent sexual relationship during at least one of their sexual partnerships in the past year. Men were more likely to report concurrency than women (P < 0.05), and half of the participants believed their partner had concurrent sex outside the partnership. Use of alcohol and/or drugs with sex, older partners, having been arrested and incarcerated, and experiencing depressive symptoms and emotional and/or physical abuse were common.
Although women were more likely than men to screen HIV positive (P> 0.05), they were less likely than men to have sexual debut at less than 13 years of age, have more than one sex partner in the past 12 months, and have a casual partner (having sex with someone one does not feel committed to or does not know very well) or exchange partner (having sex with someone in exchange for money or drugs) as their last sex partner to report use of alcohol at last sex (P < 0.05); they also had fewer total sex partners in the last 12 months than men (P < 0.05).
Among women, past IDU, being incarcerated, having depressive symptoms, and using a condom at last sex were associated with screening HIV positive (Table 2). Emotional and/or physical abuse was collinear with depressive symptomatology, which functioned more stably in the models; thus abuse was excluded from the multivariable models. For men, increased age was associated with screening HIV positive.
This study offers the first estimate of HIV and risk behaviors among urban, low income, and African–Americans in the nation's capital, revealing an HIV prevalence of 5.2%, with 6.3% among women and 3.9% among men. These data corroborate those from the District of Columbia DOH surveillance system , with the prevalence among women approaching that of Tanzania (7.0%) and Uganda (7.1%) in this sample . HIV risk behaviors reported here are parallel to those found in studies of heterosexual epidemics elsewhere in the world [23,24,34] and the United States [5,8,26–34]. The lack of condom use, early sexual debut, substance abuse, depressive symptomatology, emotional and/or physical abuse, and concurrency estimates were similar to those found in other studies [25–31,35,36]. Other research suggests [3,5,25–31,35,36] that the density of sexual networks in tandem with high rates of concurrency and unprotected heterosexual sex may be causal factors in expanding the epidemic among heterosexuals in the District of Columbia. We did not find evidence of high numbers of heterosexual males engaging in MSM behavior, and women had fewer sexual risk factors than men; this lack of traditional individual-level risk factors has been reported previously [3,25–31,35,36].
As a cross-sectional study, temporality and causality cannot be inferred. Risk behaviors are based on self-report and must be interpreted cautiously. The primary outcome was oral HIV screening result. Recent evaluation of oral HIV screening in New York City found false positive rates somewhat higher than the range presented by OraSure Technologies Inc. . Applying the wider range of false positives from oral specimens found in New York City (0.11–1.11%), we estimate that no more than one additional false positive would be likely among those with unknown HIV status (possible false positive range: n = 0.02–0.17); however, these results cannot be interpreted to be the true population prevalence, but only an estimate.
All RDS assumptions were met, suggesting that this sample is generalizable to the underlying population of networks from which it was drawn [13–21,33,37,38]. Biases in the sample may have been introduced due to the exclusion of current IDU, incomplete data, or RDS itself . To the extent that RDS can, we believe the weighted estimates may be applied to the population of networks living in or connected to communities from which they were recruited. Despite its limitations, use of RDS not only provides generalizable estimates, but also allows access to hard-to-reach populations often omitted from convenience samples.
This study suggests that the emergence of an HIV epidemic among heterosexual African–American individuals in communities and networks at risk for HIV may be network-based rather than individually-based. The primary risk may simply be engaging in normative heterosexual sexual behavior within a network with a high prevalence of HIV. Risks are perpetuated through concomitant behaviors such as having unprotected sex, partner concurrency, substance use, and early sexual debut. Innovation, implementation, and evaluation of evidence-based sex-specific and race-specific prevention strategies are critical steps towards slowing the HIV epidemic in the District of Columbia.
This study was funded by District of Columbia, DOH/HIV-AIDS Administration (HAA), contract number #POHC-2006-C-0030, funded in part by grant number #PS000966-01, from the United States Department of Health and Human Services (DHHS)/CDC. All coauthors have reviewed and approved the final draft of the study, including those from the District of Columbia DOH/HAA. Under the partnership contract, the District of Columbia DOH/HAA had the right to review and approve the manuscript. The content of this publication does not necessarily reflect the views or policies of DHHS/CDC, and responsibility for the content rests solely with the authors.
For their assistance and expertise throughout the study, the authors acknowledge Dr Amanda Castel, Dr Dante Verme, Ms Michelle Folkers, Ms Dodi Hathazi, Ms Sarah Jackson, Ms Katrina Jones, Ms Mackenzie Nowell, and Ms Manuela Sifuentes of GWU School of Public Health and Health Services (SPHHS); Dr Amy Lansky, Dr Elizabeth DiNenno, Ms Amy Drake, and Ms Tricia Martin of CDC; the Washington Outreach Research Drive to Understand Prevention (WORD UP) Community Advisory Board Members; and Dr Marsha Martin, Mr Paul Cunningham, Ms Marie Sansone, and Mr Leo Rennie formerly of the District of Columbia DOH/HAA. This study could not have been conducted without the enormous support of Ms Angela Wood, Mr Ricardo Branic, and the Family and Medical Counseling Service Inc. (FMCS) management and staff. For their participation in and support of NHBS, the study team would like to acknowledge the participants of the study and the citizens of Washington, District of Columbia, without whom this study would not have been possible.
Manya Magnus, PhD, MPH – principal investigator and primary responsibility for study; conducted all analyses for manuscript, and holds the primary writing responsibility of manuscript.
Irene Kuo, PhD, MPH – Project Director/Coinvestigator; directed all day-to-day functions of study, integral to analyses and writing of manuscript.
Katharine Shelley, MPH – Data Manager; responsible for all data cleaning, uploading, and management, data analysis, and participated materially in writing and review of manuscript.
Anthony Rawls – Field Supervisor; directed all day-to-day functions of study in the field and participated materially in writing and review of manuscript.
James Peterson, EdD, MHS – conducted all formative and qualitative data collection and analysis and participated in writing and review of manuscript.
Luz Montanez – Field Interviewer; actively involved in all day-to-day interview functions of study and also reviewed the manuscript.
Tiffany West-Ojo, MSPH, MPH – Surveillance Division Bureau Chief, DC DOH co-PI and integral to oversight of study; reviewed the manuscript.
Shannon Hader, MD, MPH – Director of DOH/HAA; participated materially in writing and review of the manuscript.
Flora Hamilton, DSW – Executive Director of FMCS; participated in overseeing collaboration at FMCS and reviewed the manuscript.
Alan E. Greenberg, MD, MPH – Principal Investigator of Public Health-Academic Partnership between GWU and the District of Columbia DOH/HAA, primary overall oversight for NHBS within the Partnership; guidance for faculty and staff; participated materially in writing and review of the manuscript.
1. District of Columbia Department of Health, HIV/AIDS Administration. District of Columbia HIV/AIDS Epidemiology Annual Report 2007; 2007.
2. Levine S. Study calls HIV in D.C. a ‘Modern Epidemic’
. The Washington Post 2007; 2007.
3. Wilson DHD. ‘Know your epidemic, know your response’: a useful approach, if we get it right. Lancet 2008; 372:423–426.
4. Hall H, Song R, Rhodes P, Prejean J, An Q, Lee LM, et al
. Estimation of HIV incidence in the United States. JAMA 2008; 300:520–529.
5. Osborn J. The past present, and future of AIDS. JAMA 2008; 300:581–583.
6. Wilson P, Wright K, Isbell MT. Left behind: Black America: a neglected priority in the Global AIDS Epidemic
. A report of the Black AIDS Institute 2008; 2008.
7. Lansky A, Drake A, DiNenno E, Lee CW. HIV behavioral surveillance among the U.S. general population. Public Health Rep 2007; 122(Suppl 1):24–31.
8. Lansky A, MacKellar D, Gallagher KM, Lin LS, Sullivan PS, Onorato IM. Evaluation of the new National HIV Behavioral Surveillance System (NHBS) is imperative. Sex Transm Dis 2006; 33:272–273, author reply 4–5.
9. Lansky A, Sullivan PS, Gallagher KM, Fleming PL. HIV behavioral surveillance in the U.S.: a conceptual framework. Public Health Rep 2007; 122(Suppl 1):16–23.
10. MacKellar DA, Gallagher KM, Finlayson T, Sanchez T, Lansky A, Sullivan PS. Surveillance of HIV risk and prevention behaviors of men who have sex with men: a national application of venue-based, time-space sampling. Public Health Rep 2007; 122(Suppl 1):39–47.
11. Allen DRFT, Abdul-Quader A, Lansky A. The role of formative research in the National HIV Behavioral Surveillance System. Public Health Rep 2009; 124:26–33.
13. Abdul-Quader AS, Heckathorn DD, McKnight C, Bramson H, Nemeth C, Sabin K, et al
. Effectiveness of respondent-driven sampling for recruiting drug users in New York City: findings from a pilot study. J Urban Health 2006; 83:459–476.
14. Heckathorn D. Respondent-driven sampling: a new approach to the study of hidden populations. Soc Probl 1997; 44:174–199.
15. Heckathorn D. Respondent-driven sampling II: deriving valid population estimates from chain-referral samples of hidden populations. Soc Probl 2002; 49:11–34.
16. Heckathorn D. Extensions of respondent-driven sampling: analyzing continuous variables and controlling for differential recruitment. Sociological Methodol 2007; 37:151–207.
17. Lansky A, Mastro TD. Using respondent-driven sampling for behavioural surveillance: response to Scott. Int J Drug Policy 2008; 19:241–243.
18. McKnight C, Des Jarlais D, Bramson H, Tower L, Abdul-Quader AS, Nemeth C, Heckathorn D. Respondent-driven sampling in a study of drug users in New York City: notes from the field. J Urban Health 2006; 83(6 Suppl):i54–i59.
19. Ramirez-Valles J, Heckathorn DD, Vazquez R, Diaz RM, Campbell RT. From networks to populations: the development and application of respondent-driven sampling among IDUs and Latino gay men. AIDS Behav 2005; 9:387–402.
20. Stormer A, Tun W, Guli L, Harxhi A, Bodanovskaia Z, Yakovleva A, et al
. An analysis of respondent driven sampling with injection drug users (IDU) in Albania and the Russian Federation. J Urban Health 2006; 83(6 Suppl):i73–i82.
21. Deiss RG, Brouwer KC, Loza O, Lozada RM, Ramos R, Cruz MA, et al
. High-risk sexual and drug using behaviors among male injection drug users who have sex with men in 2 Mexico-US border cities. Sex Transm Dis 2008; 35:243–249.
23. Pisani E, Lazzari S, Walker N, Schwartlander B. HIV surveillance: a global perspective. J Acquir Immune Defic Syndr 2003; 32:S3–S11.
24. Joint United Nations Programme on HIV/AIDS (UNAIDS)/World Health Organization (WHO), Guidelines for second generation HIV surveillance; 2000.
25. Adimora AA, Schoenbach VJ. Contextual factors and the black-white disparity in heterosexual HIV transmission. Epidemiology 2002; 13:707–712.
26. Adimora AA, Schoenbach VJ, Bonas DM, Martinson FE, Donaldson KH, Stancil TR. Concurrent sexual partnerships among women in the United States. Epidemiology 2002; 13:320–327.
27. Adimora AA, Schoenbach VJ, Martinson F, Donaldson KH, Stancil TR, Fullilove RE. Concurrent sexual partnerships among African Americans in the rural south. Ann Epidemiol 2004; 14:155–160.
28. Adimora AA, Schoenbach VJ, Martinson FE, Donaldson KH, Stancil TR, Fullilove RE. Concurrent partnerships among rural African Americans with recently reported heterosexually transmitted HIV infection. J Acquir Immune Defic Syndr 2003; 34:423–429.
29. Forna FM, Fitzpatrick L, Adimora AA, McLellan-Lemal E, Leone P, Brooks JT, et al
. A case-control study of factors associated with HIV infection among black women. J Natl Med Assoc 2006; 98:1798–1804.
30. Adimora AA. Public health and the AIDS epidemic in North Carolina. N C Med J 1990; 51:571–572.
31. Adimora AA, Schoenbach VJ, Martinson FE, Donaldson KH, Fullilove RE, Aral SO. Social context of sexual relationships among rural African Americans. Sex Transm Dis 2001; 28:69–76.
32. Centers for Disease Control and Prevention (CDC). False-positive oral fluid rapid HIV tests: New York City, 2005–2008.MMWR Morb Mortal Wkly Rep
33. Abdul-Quader AS, Heckathorn DD, Sabin K, Saidel T. Implementation and analysis of respondent driven sampling: lessons learned from the field. J Urban Health 2006; 83(6 Suppl):i1–i5.
34. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO). AIDS Epidemic Update 2007; 2007.
35. Adimora AA, Schoenbach VJ, Doherty IA. Concurrent sexual partnerships among men in the United States. Am J Public Health 2007; 97:2230–2237.
36. Adimora AA, Schoenbach VJ, Martinson FE, Coyne-Beasley T, Doherty I, Stancil TR, Fullilove RE. Heterosexually transmitted HIV infection among African Americans in North Carolina. J Acquir Immune Defic Syndr 2006; 41:616–623.
37. Magnani R, Sabin K, Saidel T, Heckathorn D. Review of sampling hard-to-reach and hidden populations for HIV surveillance. AIDS 2005; 19(Suppl 2):S67–S72.
38. Scott G. ‘They got their program, and I got mine’: a cautionary tale concerning the ethical implications of using respondent-driven sampling to study injection drug users. Int J Drug Policy 2008; 19:42–51.
Keywords:© 2009 Lippincott Williams & Wilkins, Inc.
behavioral surveillance; HIV/AIDS; HIV/AIDS prevention