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 Hispanic 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 Those who cannot afford basic necessities may have trouble accessing and affording quality sexual health services.⁶ The overall proportion of the U.S. population living in poverty in 2014, the most recent year for which poverty statistics are available, was 14.8% (or 46.7 million) and remained statistically unchanged from the previous year. Although the overall poverty rate is currently stable, many Americans continue to face challenges overcoming inequalities in economic opportunity. 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 People who struggle financially are often experiencing life circumstances that potentially increase their risk for STDs.⁶

Access to quality STD prevention and treatment services is key to reducing STD disparities in the United States. In March 2010 the Patient Protection and Affordable Care Act (ACA) was signed into law significantly increasing the availability of insurance coverage for all Americans, particularly for young adults aged 19–26 years – an important demographic for STD prevention.⁷ Of the estimated 19 million new cases of sexually transmitted infections that occur each year, approximately half of the cases occur among people aged 15–24 years.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 For example many of the states with the highest burden of STDs and disparities in STD incidence did not expand Medicaid coverage as the ACA allowed.¹⁰ Among all races and ethnicities in the U.S., Hispanics had the lowest rate of health insurance coverage in 2014 at 80.1%.^9,12,14

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 non-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.¹⁴ Moreover, the quality of care may differ substantially for minority patients.¹⁵ 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 inequities 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 Appendix A). In many state and local health departments, electronic laboratory reporting is increasingly a primary source of initial case notification. The reports are often missing race and ethnicity of the patient; ascertainment of information on race and Hispanic ethnicity is therefore 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 the 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.^{16, 17}

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, the National Center for Health Statistics (NCHS) bridged-race categories are used where OMB categories are not available (i.e., congenital syphilis).¹⁸ As of 2015, fifty states and/or reporting jurisdictions now collect and report data in OMB-compliant formats for chlamydia and gonorrhea and 49 states and/or reporting jurisdictions report syphilis cases in OMB-compliant formats. Historical trend and rate data by race and Hispanic ethnicity displayed in figures and interpreted in this report for 2011–2015 include only those states and/or reporting jurisdictions (45 jurisdictions for chlamydia, gonorrhea and syphilis) reporting in the current standard consistently for all years from 2011 through 2015 (See Section A1.5 of Appendix A) for additional information on reporting of race and Hispanic ethnicity).

Completeness of Race/Ethnicity Data in 2015

Chlamydia — 29.3% of chlamydia case reports were missing race or ethnicity data, ranging by jurisdiction from 0.9% to 100% (Table A1).

Gonorrhea — 19.8% of gonorrhea case reports were missing information on race or ethnicity, ranging by jurisdiction from 0.0% to 100% (Table A1).

Syphilis — 4.4% of P&S syphilis case reports were missing information on race or ethnicity, ranging from 0.0% to 100% among jurisdiction with 10 or more cases of P&S syphilis (Table A1).

Observations

Chlamydia

Among the 45 states that submitted data on race and ethnicity for each year during 2011–2015 according to the OMB standards, rates of reported chlamydia cases increased during that time frame among Asians (7.8%), Native Hawaiians/Other Pacific Islanders (8.9%), Whites (14.6%), and Multirace persons (43.1%), and decreased among Blacks (11.2%) (Figure 6). Rates were stable among American Indians/Alaska Natives and Hispanics during 2011–2015.

In 2015, 50 states submitted data on race and ethnicity according to the OMB standards. The following data pertain to those states:

Blacks — In 2015, the overall rate of reported chlamydia cases among Blacks in the United States was 1,097.6 cases per 100,000 population (Table 11B). The rate among Black women was 5.4 times the rate among White women (1,384.8 and 256.7 cases per 100,000 females, respectively) (Figure P and Table 11B). The rate among Black men was 6.8 times the rate among White men (782.0 and 115.4 cases per 100,000 males, respectively). Rates of reported cases of chlamydia were highest for Blacks aged 15–19 and 20–24 years in 2015 (Table 11B). The rate of reported chlamydia cases among Black women aged 15–19 years was 6,340.3 cases per 100,000 females, which was 4.7 times the rate among White women in the same age group (1,339.1 cases per 100,000 females). The rate among Black women aged 20–24 years was 3.9 times the rate among White women in the same age group (6,782.5 and 1,737.8 cases per 100,000 females, respectively) (Table 11B).

Similar racial disparities in reported chlamydia rates exist among men. Among males aged 15–19 years, the rate of reported chlamydia cases among Blacks was 8.8 times the rate among Whites (2,119.6 and 240.3 cases per 100,000 males, respectively) (Table 11B). The rate among Black men aged 20–24 years was 4.9 times the rate among White men of the same age group (3128.8 and 637.2 cases per 100,000 males, respectively).

American Indians/Alaska Natives — In 2015, the rate of reported chlamydia cases among American Indians/Alaska Natives was 709.1 cases per 100,000 population (Table 11B). Overall, the rate of chlamydia among American Indians/Alaska Natives in the United States was 3.8 times the rate among Whites.

Native Hawaiians/Other Pacific Islanders — In 2015, the rate of reported chlamydia cases among Native Hawaiians/Other Pacific Islanders was 622.1 cases per 100,000 population (Table 11B). The overall rate among Native Hawaiians/Other Pacific Islanders was 3.3 times the rate among Whites and 5.5 times the rate among Asians.

Hispanics — In 2015, the rate of reported chlamydia cases among Hispanics was 372.7 cases per 100,000 population, which is 2.0 times the rate among Whites (Table 11B).

Asians — In 2015, the rate of reported chlamydia cases among Asians was 114.1 cases per 100,000 population (Table 11B). The overall rate among Whites is 1.6 times the rate among Asians.

Gonorrhea

Among 45 states submitting race and ethnicity data consistently according to OMB standards for all years from 2011–2015, rates of reported gonorrhea cases increased 75.1% among Whites (26.1 to 45.7 cases per 100,00 population), 71.3% among American Indians/Alaska Natives (104.5 to 179.0 cases per 100,000 population), 70.0% among Asians (14.0 to 23.8 cases per 100,000 population), 61.0% among Native Hawaiians/Other Pacific Islanders (72.6 to 116.9 cases per 100,000 population), and 53.8% among Hispanics (52.4 to 80.6 cases per 100,000 population) (Figure 20). The gonorrhea rate decreased 4.0% among Blacks (451.3 to 433.3 cases per 100,000 population).

In 2015, 50 states submitted data on race and ethnicity according to the OMB standards. The following data pertain to those states:

Blacks — In 2015, 42.2% of reported gonorrhea cases with known race and 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 2015 was 424.9 cases per 100,000 population, which was 9.6 times the rate among Whites (44.2 cases per 100,000 population) (Table 22B). Although the calculated rate ratio for 2015 differs when considering only the 45 jurisdictions that submitted data in race and ethnic categories according to the OMB standards for each year during 2011–2015, this disparity has decreased slightly in recent years (Figure Q). In 2015, this disparity was similar for Black men (9.6 times the rate among White men) and Black women (9.7 times the rate among White women) (Figure R, Table 22B). As in previous years, the disparity in gonorrhea rates for Blacks in 2015 was larger in the Midwest and Northeast than in the West or the South (Figure S).

Considering all racial/ethnic and age categories, rates of gonorrhea were highest for Blacks aged 20–24, 15–19, and 25–29 years in 2015 (Table 22B). Black women aged 20–24 years had a gonorrhea rate of 1,760.5 cases per 100,000 females, which was 9.0 times the rate among White women in the same age group (195.8 cases per 100,000 females). Black women aged 15–19 years had a gonorrhea rate of 1,547.3 cases per 100,000 females, which was 11.3 times the rate among White women in the same age group (136.4 cases per 100,000 females). Black men aged 20–24 years had a gonorrhea rate of 1,681.5 cases per 100,000 males, which was 9.5 times the rate among White men in the same age group (176.1 cases per 100,000 males). Black men aged 25–29 years had a gonorrhea rate of 1,415.0 cases per 100,000 males, which was 8.2 times the rate among White men in the same age group (173.6 cases per 100,000 males).

American Indians/Alaska Natives — In 2015, the gonorrhea rate among American Indians/Alaska Natives was 192.8 cases per 100,000 population, which was 4.4 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 (6.1 times the rate among White women) than for American Indian/Alaska Native men (3.0 times the rate among White men) (Figure R, Table 22B). The disparity in gonorrhea rates for American Indians/Alaska Natives in 2015 was larger in the Midwest than in the West, Northeast, and South (Figure S).

Native Hawaiians/Other Pacific Islanders — In 2015, the gonorrhea rate among Native Hawaiians/Other Pacific Islanders was 123.0 cases per 100,000 population, which was 2.8 times the rate among Whites (Table 22B). The disparity between gonorrhea rates for Native Hawaiians/Other Pacific Islanders and Whites was the same for Native Hawaiian/Other Pacific Islander women (2.8 times the rate among White women) and Native Hawaiian/Other Pacific Islander men (2.8 times the rate among White men) (Figure R, Table 22B). The disparity in gonorrhea rates for Native Hawaiians/Other Pacific Islanders in 2015 was lower in the West than in the Midwest, Northeast, and South (Figure S).

Hispanics — In 2015, the gonorrhea rate among Hispanics was 80.5 cases per 100,000 population, which was 1.8 times the rate among Whites (Table 22B). This disparity was similar for Hispanic women (1.7 times the rate among White women) and Hispanic men (1.9 times the rate among White men) (Figure R, Table 22B). The disparity in gonorrhea rates for Hispanics in 2015 was higher in the Northeast than in the Midwest, South, and West (Figure S).

Asians — In 2015, the gonorrhea rate among Asians was 22.9 cases per 100,000 population, which was 0.5 times the rate among Whites (Table 22B). This difference is larger for Asian women than for Asian men (Figure R, Table 22B). In 2015, rates among Asians were lower than rates among Whites in all four regions of the United States (Figure S).

Primary and Secondary Syphilis

During 2011–2015, 45 states submitted race and Hispanic ethnicity data for syphilis for each year according to the OMB standards. In these states, rates of reported primary and secondary (P&S) syphilis cases increased 130.8% among Asians (1.3 to 3.0 cases per 100,000 population), 102.3% among Hispanics (4.4 to 8.9 cases per 100,000 population), 90.3% among American Indians/Alaska Natives (3.1 to 5.9 cases per 100,000 population), 66.7% among Whites (2.4 to 4.0 cases per 100,000 population), 51.4% among Native Hawaiians/Other Pacific Islanders (7.0 to 10.6 cases per 100,000 population), and 31.8% among Blacks (15.7 to 20.7 cases per 100,000 population) (Figure 39).

In 2015, 49 states submitted syphilis data by race and ethnicity according to the OMB standards. The following data pertain to those states:

Blacks — In 2015, 37.6% 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 35A). The P&S syphilis rate among Blacks in 2015 was 21.4 cases per 100,000 population, which was 5.2 times the rate among Whites (4.1 cases per 100,000 population) (Table 35B). The disparity was higher for Black women (8.8 times the rate among White women) than for Black men (5.1 times the rate among White men) (Figure T, Table 35B).

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 2015 (Table 35B). Black men aged 20–24 years had a P&S syphilis rate of 110.1 cases per 100,000 males. This rate was 7.6 times the rate among White men in the same age group (14.5 cases per 100,000 males). Black men aged 25–29 years had a P&S syphilis rate of 133.2 cases per 100,000 males, which was 6.9 times the rate among White men in the same age group (19.4 cases per 100,000 males).

Native Hawaiians/Other Pacific Islanders — In 2015, the P&S syphilis rate among Native Hawaiians/Other Pacific Islanders was 10.4 cases per 100,000 population, which was 2.5 times the rate among Whites (Table 35B). This disparity was similar for Native Hawaiian/Other Pacific Islander women (2.7 times the rate among White women) and Native Hawaiian/Other Pacific Islander men (2.5 times the rate among White men).

Hispanics — In 2015, the P&S syphilis rate among Hispanics was 9.1 cases per 100,000 population, which was 2.2 times the rate among Whites (Table 35B). This disparity was similar for Hispanic women (2.3 times the rate among White women) and Hispanic men (2.2 times the rate among White men).

American Indians/Alaska Natives — In 2015, the P&S syphilis rate among American Indians/Alaska Natives was 5.6 cases per 100,000 population, 1.4 times the rate among Whites (Table 35B). This disparity was larger for American Indian/Alaska Native women (3.5 times the rate among White women) than for American Indian/Alaska Native men (1.2 times the rate among White men).

Asians — In 2015, the P&S syphilis rate among Asians was 3.0 cases per 100,000 population, which was 0.7 times the rate among Whites (Table 35B). This difference was larger for Asian women (0.5 times the rate among White women) than for Asian men (0.8 times the rate among White men).

Congenital Syphilis

Race/ethnicity for cases of congenital syphilis is based on the mother’s race/ethnicity. During 2014–2015, rates of reported congenital syphilis cases increased 25.0% among Hispanics and 18.9% among Whites (Figure U, Table 42). However, rates decreased 19.5% among American Indians/Alaska Natives, 15.7% among Asians/Pacific Islanders, and 8.8% among Blacks.

In 2015, 44.9% 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 42). The rate of congenital syphilis among Blacks in 2015 was 35.2 cases per 100,000 live births, which was 8.0 times the rate among Whites (4.4 cases per 100,000 live births). The rate of congenital syphilis was 15.5 cases per 100,000 live births among Hispanics (3.5 times the rate among Whites), 10.3 cases per 100,000 live births among American Indians/Alaska Natives (2.3 times the rate among Whites), and 5.9 cases per 100,000 live births among Asians/Pacific Islanders (1.3 times the rate among Whites).

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