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Neighborhood Health Care Access and Sexually Transmitted Infections Among Women in the Southern United States: A Cross-Sectional Multilevel Analysis

Haley, Danielle, F., PhD*; Edmonds, Andrew, PhD; Belenky, Nadya, PhD; Hickson, DeMarc, A., PhD§; Ramirez, Catalina, MPH, MPA; Wingood, Gina, M., ScD; Bolivar, Hector, MD; Golub, Elizabeth, PhD∥**; Adimora, Adaora, A., MD†‡††

Sexually Transmitted Diseases: January 2018 - Volume 45 - Issue 1 - p 19–24
doi: 10.1097/OLQ.0000000000000685
Original Studies

Introduction The United States has experienced an increase in reportable sexually transmitted infections (STIs) while simultaneously experiencing a decline in safety net services for STI testing and treatment. This multilevel study assessed relationships between neighborhood-level access to health care and STIs among a predominantly Human Immunodeficiency Virus (HIV)-seropositive cohort of women living in the south.

Methods This cross-sectional multilevel analysis included baseline data from HIV-seropositive and HIV-seronegative women enrolled in the Women’s Interagency HIV Study sites in Alabama, Florida, Georgia, Mississippi, and North Carolina between 2013 and 2015 (N = 666). Administrative data (eg, United States Census) described health care access (eg, percentage of residents with a primary care provider, percentage of residents with health insurance) in the census tracts where women lived. Sexually transmitted infections (chlamydia, gonorrhea, trichomoniasis, or early syphilis) were diagnosed using laboratory testing. Generalized estimating equations were used to determine relationships between tract-level characteristics and STIs. Analyses were conducted using SAS 9.4.

Results Seventy percent of participants were HIV-seropositive. Eleven percent of participants had an STI. A 4-unit increase in the percentage of residents with a primary care provider was associated with 39% lower STI risk (risk ratio, 0.61, 95% confidence interval, 0.38–0.99). The percentage of tract residents with health insurance was not associated with STIs (risk ratio, 0.98, 95% confidence interval, 0.91–1.05). Relationships did not vary by HIV status.

Conclusions Greater neighborhood health care access was associated with fewer STIs. Research should establish the causality of this relationship and pathways through which neighborhood health care access influences STIs. Structural interventions and programs increasing linkage to care may reduce STIs.

In a predominantly human immunodeficiency virus–seropositive cohort of women living in the southern United States, women living in neighborhoods with better health care access were less likely to have sexually transmitted infections.

From the *Institute for Global Health and Infectious Diseases, School of Medicine, †Department of Epidemiology, Gillings School of Global Public Health, ‡Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; §Department of Epidemiology and Biostatistics, Jackson State University School of Public Health, Jackson, MS; ¶Department of Sociomedical Sciences, Lerner Center for Public Health Promotion, Mailman School of Public Health at Columbia University, New York, NY; ∥Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL; **Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and ††Department of Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC

Acknowledgements: The authors thank the Women’s Interagency HIV Study participants for sharing their time and experiences. The authors also acknowledge the efforts and dedication of WIHS study staff, with special thanks to Ighovwerha Ofotokun, Sarah Sanford, Deja Er, Rachael Farah-Abraham, Carrigan Parrish, Zenoria Causey, Venetra McKinney, Lisa Rohn, Jess Donohue, and Christine Alden.

Conflict of interest: None declared.

The Women’s Interagency HIV Study (WIHS) is funded primarily by the National Institute of Allergy and Infectious Diseases, with additional co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Cancer Institute, the National Institute on Drug Abuse, and the National Institute on Mental Health. Participant data in this manuscript were collected by the UAB-MS WIHS (PIs: Michael Saag, Mirjam-Colette Kempf, and Deborah Konkle-Parker), U01-AI-103401; Atlanta WIHS (PIs: Ighovwerha Ofotokun and Gina Wingood), U01-AI-103408; Miami WIHS (PIs: Margaret Fischl and Lisa Metsch), U01-AI-103397; UNC WIHS (PI: Adaora Adimora) U01-AI-103390; WIHS Data Management and Analysis Center (PIs: Stephen Gange and Elizabeth Golub) U01-AI-042590. Targeted supplemental funding for specific projects is also provided by the National Institute of Dental and Craniofacial Research, the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Deafness and other Communication Disorders, and the NIH Office of Research on Women’s Health. WIHS data collection is also supported by UL1-TR000454 (Atlanta CTSA). DAH’s time was supported by the Centers for Disease Control and Prevention under Cooperative Agreement U01PS003315 as part of the Minority HIV/AIDS Research Initiative. The contents of this publication are solely the responsibility of the authors and do not represent the official views of the National Institutes of Health.

Author Contributions: D.F.H. conceptualized the study, analyzed and interpreted data, and led article development. A.E., N.B., D.A.H., C.R., G.M.W., H.B., E.G., and A.A.A. contributed meaningfully to the interpretation of data and revision of the article. All authors approved the final version.

Correspondence: Danielle F. Haley, PhD, University of North Carolina at Chapel Hill School of Medicine, Institute for Global Health and Infectious Diseases, 130 Mason Farm Road, Chapel Hill, NC, 27599. E-mail:

Received for publication April 17, 2017, and accepted June 20, 2017.

© Copyright 2018 American Sexually Transmitted Diseases Association