AFRICAN AMERICAN COMMUNITIES continue to have higher rates of gonorrhea, chlamydia, and syphilis than any other population group in the United States. A review of racial/ethnic disparities in health outcomes measured by the Healthy People 2010 objectives found that sexually transmitted diseases (STD) and HIV accounted for the five greatest disparities for the African American population in 2003.1 National STD surveillance data in 2006 indicated that the African American:white rate ratio was 18:1 for gonorrhea, 8:1 for chlamydia, and 6:1 for primary and secondary syphilis, and that African Americans accounted for 69%, 47%, and 43% of all reported cases of these infections, respectively.2 Studies have shown that unlike whites, African Americans need not engage in high-risk behavior to be at high risk of contracting an STD owing to factors other than individual risk behaviors which seem to contribute to racial STD disparities.3 Therefore, it is critical to examine the social determinants that may affect the prevalence of STDs in African American communities to effectively reduce STDs in these communities.
STD prevention and control strategies are used to reduce the transmission of STDs nationwide. These strategies traditionally include surveillance, screening and treatment, behavioral interventions, and partner management. They are implemented in a variety of settings at the federal, state, and local levels. However, given the persistence of marked disparities in STD rates for African American communities, it is clear that these strategies as currently applied are not adequate for all populations.
The Division of STD Prevention, Centers for Disease Control and Prevention (CDC), recognized that the current disparities, especially in African American communities, were unacceptable and wanted to develop an approach that would provide CDC the opportunity to work with external partners to address STD disparities in the United States. To explore possibilities for enhancing prevention and control strategies that were likely to be acceptable and effective, the Division of STD Prevention sought guidance from community leaders and representatives, and other partners serving African American communities.
A Consultation to Address STD Disparities in African American Communities, held on June 5 to 6, 2007, brought together community leaders and representatives, and other partners serving African American communities to discuss the following issues:
1. The context of bacterial STDs (with a focus on gonorrhea) in African American communities, including the epidemiology, determinants that contribute to STD disparities among African Americans (e.g. stigma, access to care), and the individual, social, and health impact of these disparities in African American communities.
2. Effective and acceptable prevention and control strategies for addressing bacterial STDs in affected African American communities.
3. Specific strategies to be communicated and framed for different African American communities.
4. How to develop an action plan for CDC and key community stakeholders to address STD disparities among African Americans, including opportunities for collaboration with other sexual health issues for which there are important disparities such as infection with HIV, herpes simplex virus type 2, and hepatitis B virus.
A copy of the meeting report is available at: www.cdc.gov/std.
A monograph containing seven background papers was provided to participants in advance of the consultation meeting. The monograph was designed to review and summarize pertinent background information related to STD disparities for African American communities and included the following topics: epidemiology, social determinants, attitudes regarding sexual behavior, access to care, prevention and control strategies, measurement of disparities, and health communication. In addition to reviewing existing literature, each paper addressed how the information could inform STD prevention and control efforts. At the consultation, participants encouraged CDC to share these background papers with a broader audience. This special issue includes many of the background papers, which highlight relevant issues related to STD disparities in African American communities. It is hoped that by sharing these background papers, the authors can raise awareness of STD disparities, and assist and encourage others to address them.
Awareness and understanding of the epidemiology of disparities in STD for African American communities is the first step to addressing them. Blacks are not a monolithic community, so a detailed understanding of who is affected is critical for appropriate framing and communicating. For example, Newman and Berman show that gonorrhea rates among African Americans are highest for adolescents and young adults, and disparities are greatest for adolescent men.4 Although disparities among men who have sex with men (MSM) are not as great as for heterosexual populations, STD rates for both white and African American MSM populations are high, so efforts to address disparities must also include African American MSM.
Individual risk behavior and sociodemographic characteristics of African Americans do not seem to account fully for increased STD rates for African Americans. Hogben and Leichliter explain how social determinants of health seem to be critical factors in the persistence of STD disparities for African American communities.5 Population-level determinants such as sexual networks, core geographic areas, segregation, health care provision, socioeconomics, and correctional experiences are interrelated and seem to play an important role in STD disparities.
Reduced access to care is a function of both individual and population level factors and is a key contributor to health disparities in African American communities. As described by Parrish and Kent, structural factors such as poverty, lack of insurance, and lack of a regular source of care are known to decrease healthcare service utilization and have been identified as barriers to STD care.6
Other individual level factors that influence access to care, particularly for STDs, include concerns about confidentiality and privacy, perceptions of discrimination and perceptions of risk. Valentine summarizes the unintended consequences of the impact of attitudes and beliefs regarding African American sexual behavior on STD prevention and control.7 For example, legacies of slavery, racism, and economic or class discrimination leave many African Americans suspicious of interventions aimed at improving their health. At the population level, availability of services, organizational inefficiencies, and staff perceptions affect access. Provider bias, prejudice, and stereotyping contribute to negative experiences for many African Americans across health care settings and may hinder access to care.
Traditionally, public health efforts to prevent and control bacterial STDs have focused on the individual, through clinical services, surveillance, partner management, and behavioral intervention strategies. However, the persistence of disparities in STDs among African Americans indicates that these strategies have had insufficient impact. Barrow et al. review these strategies and highlight the importance of considering population and community characteristics to more effectively tailor the strategies to the community context.8
Finally, in addition to taking into account the epidemiology of what communities are affected, what social determinants are at play, and, how strategies are implemented, the methodology for the actual measurement of health disparities is critical for understanding them and their response to public health efforts. The impact of measurement technique selection on STD incidence is reviewed by Hoover et al.9 Different measurement strategies may result in different conclusions about the size of health disparities and how these disparities change over time.
Implications for Prevention and Control
The authors of these papers identified many ways in which this knowledge could be used to reduce disparities as well as improve the prevention and control of STDs. Several major themes emerged.
Know Your Affected Communities.
It is important to have surveillance systems in place that can track not only basic demographics, but also more complex data such as clinical, behavioral, and socioeconomic information on individual patients and their communities that allow better understanding of the multifaceted dynamics of STD transmission and the diversity of African American communities. Measuring, evaluating, and monitoring the impact of prevention and control activities is critical for ensuring that limited resources are used as effectively and efficiently as possible, and are reaching the intended audience. When racial and ethnic disparities are measured, it is important to select methods carefully so that the information obtained is consistent and appropriate for the intended use.
Improve Access and Quality of STD Services.
Given the diversity of African American communities, improved STD services in the public sector, the private sector, and in alternative settings are all important. Though public STD clinics are seeing a smaller proportion of the STD burden each year, they are still important sources of STD care for large numbers of African Americans, especially young men, who often have no other readily available sources of care. There are many ways to improve the quality of care in public STD clinics through interventions such as reducing waiting times, expanding clinic hours for patients who work, facilitating the screening of individuals without symptoms through express visits, improving confidentiality in the collection of personal information, and improving cultural competence of clinic staff to improve trust between staff and patients.
Ensuring availability of quality STD services also involves expanding partnerships between public and private agencies and organizations in the community. Healthcare systems and providers should focus on reducing the number of missed opportunities to provide comprehensive STD care services such as STD screening, partner services, and STD risk assessment, through interactions with patients that are culturally sensitive. Although working with the private sector and public STD clinics is likely to improve care for African Americans who can and do access the healthcare system, additional interventions are needed to reach those who currently lie outside the system. Expanded STD services in nontraditional venues such as school-based clinics, HIV care facilities, emergency departments, mobile vans, and correctional facilities will be important to improving quality and access to STD care and prevention services for the broader community of African Americans.
Work at Multiple Levels of Intervention.
Collaboration with other health promotion and control programs whose outcomes are also affected by population level determinants of health should be a priority as a means to provide needed services most efficiently for maximum health impact. In addition to the traditional individually focused STD prevention strategies of clinical services, partner services, and behavioral interventions, public health leadership should also encourage policymakers and the community to address the social, cultural, systems-level, and political factors that promote the spread of STDs and catalyze efforts to respond to them. These efforts can help shift the dialogue away from a predominant focus on individual risk behavior toward a more balanced view that considers underlying social disparities as well, thus mobilizing entire communities to advocate for broader social and public policy changes.
Engage Individuals and Communities.
STD prevention programs at various levels should engage communities with ongoing, genuine, and mutual advice and feedback to better understand the stressors and strengths of their community to ensure that the program's content and strategies are relevant to that context. In this way prevention information can be made meaningful, relevant, and responsive to the context of community realities and priorities. Without community involvement, well-intended STD prevention strategies may be perceived negatively or perpetuate negative historical images in African American communities, consequently reducing their benefit. Therefore it is important for African American communities to share leadership roles in addressing STD disparities, as they are increasingly doing in response to other problems such as for the National Heightened Response to HIV/AIDS crisis in African American communities, which is focused on disparities in HIV/AIDS infection.10
Each of the above themes will be important in effectively addressing STD disparities in African American communities. However, these strategies can only be implemented if a public health system has sufficient resources, both human capacity and program funding, for these functions, and strengthening such capacity at the state and local level is an important step in addressing STD disparities. In addition to capacity, it is critical to focus and frame public health activities such that they strengthen and empower African American communities, and involve both individuals and communities in a shared responsibility to reduce racial disparities and improve sexual health community-wide. We hope that the compilation of perspectives on STD disparities in African American populations included in this issue will help catalyze innovative and effective partnerships between prevention programs and communities in addressing this major public health issue.