Based on STI/HIV testing, nearly half of respondents were HSV-2 infected (48%), 10% were HIV infected, and 6% had chlamydial infection. Smaller percentages were positive for syphilis (3%) and gonorrhea (1%). Marked gender and racial differences characterized infection with HSV-2 (nonblack women: 56%, nonblack men: 31%, black women: 63%, black men: 67%; P < 0.001) and HIV (nonblack women: 5%, nonblack men: 10%, black women: 15%, black men: 24%; P = 0.016). No racial or gender differences in the prevalence of chlamydia were observed.
STI/HIV Discordance and Condom Use in Sexual Partnerships
Of the 343 individuals involved in at least 1 sexual partnership in the past 3 months, there were 296 sexual partnerships for whom we had interview data for both members of the partnership; these partnerships were included in the partnership-level analyses. Partnership discordance was greatest for HSV-2 (40%), followed by HIV (13%), and chlamydia (11%) (Table 2). Condoms were used consistently in approximately 37% of partnerships.
Correlates of Sexual Partnership Between STI/HIV-Infected and Uninfected Individuals
Correlates of Sex With an HIV-Infected Partner, Among Those Uninfected With HIV
Sexual partnership in the past 3 months with an HIV-infected individual was strongly associated with respondent older age (≥25 years) (gender-adjusted PR: 3.66, 95% CI: 1.57 to 8.52); incarceration history (gender-adjusted PR: 2.03, 95% CI: 1.06 to 3.92); ever having used noninjected heroin (gender-adjusted PR: 4.38, 95% CI: 2.03 to 9.45), cocaine (gender-adjusted PR: 3.14, 95% CI: 1.27 to 7.75), or crack (gender-adjusted PR: 2.43, 95% CI: 1.27 to 4.65); ever having used injection drugs (gender-adjusted PR: 2.69, 95% CI: 1.49 to 4.86); and history of same sex partnership among men (PR: 2.06, 95% CI: 0.96 to 4.42) (Table 3). In general, respondent sexual risk behaviors such as recent multiple partnerships, sex trade, and group sex event participation were not associated with recent sex with an HIV-positive partner.
Characteristics of HIV-negative respondents' recent sexual partners were strongly associated with respondents' recent sex with an HIV-positive individual. The strongest correlate was having at least 1 partner in the past 3 months who was at least 25 years old (gender and respondent age-adjusted PR: 9.89, 95% CI: 1.16 to 84.3); nearly every person with an HIV-positive partner in the past 3 months had a partner who was at least 25 years old, creating extreme imprecision in the estimate. Other moderate or strong correlates included having at least 1 partner in the past 3 months who was more than 5 years older (gender and respondent age-adjusted PR: 2.54, 95% CI: 1.42 to 4.55), had ever been incarcerated (gender-adjusted PR: 2.03, 95% CI: 1.00 to 4.12), had ever used noninjected crack, cocaine, or heroin (gender-adjusted PR: 4.83, 95% CI: 1.19 to 19.7), had ever used injection drugs (gender-adjusted PR: 6.63, 95% CI: 2.66 to 16.5), reported greater than the median number of lifetime sexual partners (gender-adjusted PR: 3.68, 95% CI: 1.48 to 9.12), was a man who ever had sex with a man (gender-adjusted PR: 5.64, 95% CI: 3.12 to 10.2), and was a woman who had ever had sex with a woman (gender-adjusted PR: 1.81, 95% CI: 1.00 to 3.29).
Correlates of Sex With an HSV-2-Infected Partner, Among Those Uninfected with HSV-2
Few sociodemographic characteristics of HSV-2-negative respondents were strong indicators of sex with an HSV-2-positive partner in the past 3 months (Table 4). Of these, the strongest indicator was history of incarceration among uninfected women (gender-adjusted PR: 2.57, 95% CI: 1.86 to 3.53). Incarceration was not a correlate among men.
Among HSV-2-uninfected respondents, recent sexual and drug use behaviors were associated with recent partnership with an HSV-2-infected individual, with stronger associations observed among women than men. For women, the strongest behavioral correlates of HSV-2 discordance were multiple sexual partnerships in the past 3 months (gender-adjusted PR: 2.09, 95% CI: 1.25 to 3.51) and history of same sex partnerships (gender-adjusted PR: 1.97, 95% CI: 1.15 to 3.38).
HSV-2-uninfected respondents were at least twice as likely to have had an HSV-2-positive partner in the past 3 months if 1 or more of their partners in the past 3 months was at least 25 years old (gender and respondent age-adjusted PR: 2.02, 95% CI: 1.34 to 3.05); was greater than 5 years old (among HSV-2-uninfected women only, gender and respondent age-adjusted PR: 2.22, 95% CI: 1.26 to 3.92); had ever used noninjection drugs (gender-adjusted PR: 2.47, 95% CI: 1.42 to 4.31); and had a “high” lifetime number of partners (among HSV-2-uninfected men only, gender-adjusted PR: 3.09, 95% CI: 1.68 to 5.69).
Correlates of Sex With a Chlamydia-Infected Partner, Among Those Uninfected With Chlamydia
Among chlamydia-uninfected respondents, sexual partnership in the past 3 months with at least 1 chlamydia-infected partner was associated with respondent black race (gender-adjusted PR: 2.05, 95% CI: 1.12 to 3.72) (Table 5). Other respondent sociodemographic factors and substance use variables did not seem to be associated with recent sex with a chlamydia-infected partner.
Among women uninfected with chlamydia, recent sex with a chlamydia-infected partner was strongly correlated with sexual behavior variables including same sex partnership history (PR: 6.50, 95% CI: 1.93 to 21.9), multiple partnerships in the past 3 months (gender-adjusted PR: 5.19, 95% CI: 1.54 to 17.5), and sex trade (gender-adjusted PR: 7.61, 95% CI: 2.60 to 22.3).
Among men and women, group sex event attendance was associated with twice the prevalence of recent sex with a partner infected with chlamydia (gender-adjusted PR: 2.03, 95% CI: 1.06 to 3.86).
Chlamydia-uninfected respondents were approximately twice as likely to have had sex in the past 3 months with a chlamydia-infected partner if they had at least 1 sexual partner in the past 3 months who resided outside Bushwick (gender-adjusted PR: 2.14, 95% CI: 1.19 to 3.86), had not graduated from high school (gender-adjusted PR: 2.23, 95% CI: 1.03 to 4.78), had ever been incarcerated (gender-adjusted PR: 2.01, 95% CI: 0.97 to 4.13), or had ever used injection drugs (gender-adjusted PR: 1.98, 95% CI: 1.03 to 3.78) or noninjection drugs (gender-adjusted PR: 2.76, 95% CI: 0.88 to 8.67).
Among those uninfected with chlamydia, sex with a chlamydia-infected partner in the past 3 months was associated with having a recent partner who was a man who had ever had sex with a man (gender-adjusted PR: 3.10, 95% CI: 1.72 to 5.59), was a woman who had ever had sex with a woman (gender-adjusted PR: 4.14, 95% CI: 2.06 to 8.32), had multiple partnerships in the past 3 months (gender-adjusted PR: 17.4, 95% CI: 2.42 to 126), or had a “high” lifetime number of partners (gender-adjusted PR: 6.53, 95% CI: 2.02 to 21.1).
Screening Tools That Include Additional Social and Behavioral Indicators Improve Detection of Priority Populations at Greatest Risk of HIV and/or HSV-2
Among the strongest indicators of HIV- and HSV-2-discordant partnerships were respondent age of 25 years or older, having a recent sex partner who was 25 years or older, respondent non-IDU, and respondent incarceration. We assessed whether addition of these indicators to a “CDC Screener” based on indicators of sex trade, multiple sex partnerships, and sex with an IDU would improve identification of priority non-MSM and non-IDU populations.
For identification of individuals who were HIV infected or who had sex in the past 3 months with an HIV-infected partner, the “CDC Screener” alone was 57% sensitive and 53% specific and would result in HIV testing in 48% of the population; the “CDC Screener” plus an indicator of respondent older age was 95% sensitive and 32% specific and would result in testing 71% of the population; and the “CDC Screener” plus indicators of respondent older age and sex partner's older age was 100% sensitive and 27% specific and would result in testing 75% of the population (Table 6).
For identification of individuals who were infected with HSV-2 or who had sex in the past 3 months with a partner who was infected with HSV-2, the “CDC Screener” alone was 53% sensitive and 66% specific and would result in HSV-2 testing in 47% of the population; the “CDC Screener” plus an indicator of respondent older age was 81% sensitive and 50% specific and would result in testing 71% of the population; and the “CDC Screener” plus indicators of respondent older age and sex partner's older age was 85% sensitive and 45% specific and would result in testing 76% of the population. With the addition of respondent non-IDU and incarceration, the screener for HSV-2 priority populations was 90% sensitive and 30% specific and would result in testing 84% of the population (Table 6).
The high levels of HSV-2, HIV, and chlamydia discordance measured in this Bushwick population reflected the high prevalence of these infections in the sample, which far exceeded national prevalence levels.17-19 Condoms were used in a minority of partnerships. Continued high levels of STI/HIV-discordant sexual partnerships, without improvements in condom use and STI treatment, may lead to further STI/HIV transmission. Improved identification of high-risk populations may prevent growth of the STI/HIV epidemics within this network and expansion into lower risk Bushwick populations and neighboring communities.
To obtain data needed to target STI/HIV interventions, we identified respondent and partner characteristics most strongly associated with HSV-2, HIV, and chlamydia partnership discordance. In this population, the CDC-recommended indicators of sexually transmitted HIV infection risk that were strongly associated with HIV-discordant sexual partnerships included respondent and sexual partner's IDU. Surprisingly, many of the CDC sexual behavioral indicators were not good markers of potential sexual exposure to HIV, including respondent recent history of multiple sexual partnerships, sex work, or recent sexual partnership with someone who had recently had multiple partners. The weak associations between these sexual behavior indicators and partnership with an HIV-infected sexual partner resulted from high levels of sexual behaviors in the study population as a whole; these sexual risk behaviors were common among those with and without HIV-positive partners.
Our analyses suggested that some variables not recommended by the CDC as priority indicators of sexually transmitted HIV infection risk were strongly associated with HIV partnership discordance. The strongest correlate of HIV discordance was partner's older age; nearly all HIV-uninfected respondents with a recent HIV-positive partner reported sex with someone who was 25 years or older. Likewise, respondent older age and having a partner who was at least 5 years old was associated with HIV partnership discordance. Age mixing is an established risk factor of STI/HIV.7,20-27 Subsequent analyses of NNAHRAY indicated that age mixing was common, suggesting its potential importance for STI/HIV transmission through the network. Just over half (64%) of partnerships in which partners differed in age were male-female partnerships between older men and younger women. The findings imply gender-specific messages emphasizing that the risk of sex with older partners should reach both men and women in this population. Numerous prior studies have documented women's lack of autonomy in sexual relationships and resulting difficulties in negotiating for protected sex;28-33 having an older male sex partner may exacerbate this power dynamic. Hence, interventions also should address the particular vulnerability of young women, such as by providing them with negotiating tools in relationships and by addressing sociostructural norms that may create the gender power imbalances.
Non-IDU among respondents and/or their recent sexual partners also was a strong and consistent indicator of HIV-discordant partnerships, a result supporting prior evidence that non-IDU is a strong correlate of HIV infection.6,34 Health facilities should systematically provide HIV prevention education and testing to non-IDUs and IDUs. In addition, drug treatment centers are preexisting infrastructures that may allow public health workers to reach populations vulnerable to infection that may otherwise be difficult to reach.
Finally, incarceration history of respondents or their sexual partners was associated with HIV partnership discordance. This finding supports prior evidence of an association between incarceration and HIV35-37 and points to the need for STI/HIV prevention efforts among former prisoners and their partners. Prison-based and jail-based STI/HIV interventions should be strengthened and community-based efforts should be designed for partners of those who are currently incarcerated and for newly released prisoners being reintegrated into their communities and social networks.
We also investigated indicators of HSV-2-discordant and chlamydia-discordant partnerships and found that partnership discordance for these infections, as expected, was associated with respondent or partner sexual risk behaviors, including multiple partnerships, sex trade, and involvement in group sex. Additional social and behavioral correlates of discordant partnerships included older partner age, use of noninjection drugs by respondents or their partners, and incarceration history. The findings suggest that assessment of key social and behavioral indicators in addition to traditional markers of sexual risk taking may improve STI case-finding effectiveness.
A very strong correlate of chlamydia partnership discordance-also associated with HSV-2 and HIV partnership discordance-was women's same sex partnership history. This finding supports extant evidence of increased STI/HIV risk among women who have a history of sex with a woman.38-41 Transmission of STIs including HIV within female-female partnerships has been documented.42 However, most women experienced STI/HIV risk resulting from sex with men; further analysis of the NNAHRAY data indicated that, of the partnerships in which 1 partner was a woman who reported a history of same-sex partnerships (n = 122 partnerships), nearly 90% were male to female partnerships. Women in this study reporting a same sex partnership history may be disproportionately likely to have had an STI/HIV-infected partner as a result of involvement in high-risk sexual behaviors, such as involvement in sex trade, or because they have a sexual network of male and female partners who are more likely to be HIV infected. Community STI/HIV prevention efforts must make special efforts to reach this vulnerable population with information about transmission risks and the need for, and community availability of, STI and drug use screening and treatment. This is particularly important because the potential marginalization of this group may inhibit heath seeking behaviors and uptake of prevention messages.41
We assessed whether the addition of indicators of older age (defined in this population as 25 years or older), non-IDU history, and incarceration history would improve identification of priority populations who should be tested for HIV and HSV-2. We excluded participants who reported a history of IDU or MSM because these populations already are identified in routine practice as high-risk populations for STI/HIV screening. Our findings suggested that inclusion of these additional indicators could markedly improve the identification of priority populations. For example, if we used a “CDC screener” composed of IDU and sexual risk indicators only, we would have identified just over half of those in need of HIV testing, including those who either were HIV infected or who recently had sex with an HIV-infected individual. If we used a “CDC screener” plus 2 additional indicators-respondent age of 25 years or older or respondent recent sex with a partner who was older-we would have tested 100% of this priority population. The implication is that addition of sociodemographic and other behavioral indicators should be considered when designing tools to identify priority populations to test for infection. By expanding the definition of “high risk,” the specificity of the screening tool will decrease and the number of uninfected individuals who receive testing will increase. However, recent analyses suggest that routine HIV testing for all adults is cost effective except in settings where there is evidence that the prevalence of undiagnosed HIV infection is below 0.02%.43 If the screening tools available to health providers identified a broader range of priority populations-such as by including social and behavioral indicators associated with HIV infection or partnership with an HIV-infected individual-HIV case-finding likely would improve.
Likewise, given the high prevalence of HSV-2,44 the dramatic racial disparity in infection,44 the importance of HSV-2 as a cofactor of HIV transmission,2 and the high proportion of asymptomatic infection,45 screening for HSV-2 should be more aggressive. The addition of social and behavioral indicators to HSV-2 screening tools should be considered, and future studies should be conducted to evaluate these tools for case finding and cost effectiveness.2
The results from this study should be interpreted in the context of NNAHRAY study design limitations. First, analysis of these data cannot yield a screening tool that can be used universally, in all US populations, for identification of priority populations for STI/HIV testing. Even though we cannot assume that the specific social and behavioral indicators that were strongly correlated with STI/HIV discordance in Bushwick also will be key indicators in other populations, the implications of this study's findings are relevant to STI/HIV screening everywhere: addition of only a few additional social and behavioral indicators may greatly improve identification of populations in need of testing. To most effectively identify priority populations in a specific geographic area, screening tools should be adapted based on analyses of transmission dynamics in that specific area.
A second limitation of these data is that months may have elapsed between when the first and second partner were interviewed, hence the behaviors and infection status of each partner measured during data collection may not have represented behavior and infection status at the time when the partnership actually occurred.
Our findings suggested that current indicators typically used to identify those at greatest risk of infection may be inadequate. The analysis indicates that in Bushwick, providers should offer repeat STI/HIV testing to those reporting older partners, personal or partners' non-IDU, and personal or partners' incarceration, in addition to those reporting sexual and IDU behaviors. Other large scale and nationally based studies of STI/HIV risk, including CDC's National HIV Behavioral Surveillance System study on risk factors of heterosexually transmitted HIV, should investigate whether inclusion of additional behavioral and social indicators would enhance screening tools used to identify high-risk populations in need of repeat STI/HIV testing. Doing so may reduce the numbers of STI/HIV-infected individuals who come into contact with the health care system but who fail to be screened, diagnosed, treated, and educated about transmission risks.
The authors would like to acknowledge the assistance of the participants in this study.
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Keywords:© 2009 Lippincott Williams & Wilkins, Inc.
Bushwick; discordant partnerships; HIV; sexual behavior; sexually transmitted infections; social factors; substance use