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 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 People who struggle financially are often experiencing life circumstances that potentially increase their risk for STDs.⁶

Those who cannot afford basic necessities may have trouble accessing and affording quality sexual health services.⁷ Despite a decline in the overall U.S. poverty rate in 2013, from 15.0 in 2012 to 14.5 in 2013, many Americans continue to face economic challenges. For example, the poverty rate for whites was 9.6%, for blacks it was 27.2%, and for Hispanics it was 23.5%.^3,8 Access to health insurance is often related to employment. People of Hispanic ethnicity may face additional barriers accessing care arising from immigration or undocumented status.⁹  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.¹⁰  Moreover, the quality of care may differ substantially for minority patients.¹¹These 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, 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 the inequity 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 Interpreting STD Surveillance Data in the Appendix). In many state and local health jurisdictions, reporting from public sources (e.g., STD clinics) is thought to be more complete than reporting from private sources. Because minority populations may use public clinics more than whites, differences in rates between minorities and whites may be increased by this reporting bias.¹² However, prevalence data from population-based surveys, such as NHANES and the National Longitudinal Study of Adolescent Health, confirm the existence of marked STD disparities in some minority populations.^13,14

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. Data on race and Hispanic ethnicity are displayed in this report in compliance with the 1997 Office of Management and Budget (OMB) standards.¹⁵ Forty-seven jurisdictions (46 states and the District of Columbia) collect and report data in formats compliant with these standards as of 2013. One additional jurisdiction reported cases of primary & secondary syphilis by the appropriate standard, but did not report chlamydia and gonorrhea cases by this standard. Many jurisdictions only recently adopted OMB standards and used previous categories to report their case data to CDC in past years. Historical trend and rate data by race and Hispanic ethnicity displayed in figures and interpreted in this report for 2009–2013 include only those jurisdictions (39 states plus the District of Columbia) reporting in the current standard consistently for years 2009 through 2013. Please refer to Interpreting STD Surveillance Data in the Appendix for a complete listing of these jurisdictions.

Completeness of Race/Ethnicity Data

Chlamydia—In 2013, 26.0% of chlamydia case reports were missing race or ethnicity data, ranging by state from 0.4% to 63.5% (Table A1).

Gonorrhea—In 2013, 19.4% of gonorrhea case reports were missing information on race or ethnicity, ranging by state from 0.0% to 46.2% (Table A1).

Syphilis—In 2013, 3.8% of P&S syphilis case reports were missing information on race or ethnicity, ranging from 0.0% to 20.1% among states with 10 or more cases of P&S syphilis (Table A1).

Observations

Chlamydia

Among the 40 jurisdictions (39 states and the District of Columbia) that submitted data on race and Hispanic ethnicity for each year during 2009–2013 according to the OMB standards, rates of reported cases of chlamydia increased during 2009–2013 among all racial and ethnic groups except among Blacks (Figure 6). During 2009–2013, chlamydia rates increased by 23.9% among American Indians/Alaska Natives, 6.4% among Hispanics, 6.6% among Asians, 39.8% among Native Hawaiians/Other Pacific Islanders, and 32.7% among whites. During 2009–2013, rates of reported cases of chlamydia decreased 5.2% among blacks.

In 2013, 47 jurisdictions (46 states and the District of Columbia) submitted data on race and Hispanic ethnicity in 2013 according to the OMB standards. The following data pertain to those jurisdictions:

Blacks—In 2013, the overall rate among blacks in the United States was 1,147.2 cases per 100,000 population (Table 11B). The rate of reported cases of chlamydia among black women was 5.8 times the rate among white women (1,491.7 and 258.5 per 100,000 females, respectively) (Table 11B and Figure N). The chlamydia rate among black men was almost eight times the rate among white men (771.1 and 99.4 cases per 100,000 males, respectively).

Rates of reported cases of chlamydia were highest for blacks aged 15–19 and 20–24 years in 2013 (Table 11B). The chlamydia rate among black females aged 15–19 years was 6,907.6 cases per 100,000 females, which was five times the rate among white females in the same age group (1,383.3 per 100,000 females). The rate among black women aged 20–24 years was 4.1 times the rate among white women in the same age group (Table 11B).

Similar racial disparities in reported chlamydia rates exist among men. Among males aged 15–19 years, the rate among blacks was 9.5 times the rate among whites (Table 11B). The chlamydia rate among black men aged 20–24 years was 5.5 times the rate among white men of the same age group (3,282.5 and 594.0 cases per 100,000 males, respectively).

American Indians/Alaska Natives— In 2013, the chlamydia rate among American Indians/Alaska Natives was 697.9 cases per 100,000 population (Table 11B). Overall, the rate of chlamydia among American Indians/Alaska Natives in the United States was 3.9 times the rate among whites.

Native Hawaiians/Other Pacific Islanders— In 2013, the chlamydia rate among Native Hawaiians/Other Pacific Islanders was 633.3 cases per 100,000 population (Table 11B). The overall rate among Native Hawaiians/Other Pacific Islanders was 3.5 times the rate among whites and 5.7 times the rate among Asians.

Hispanics— In 2013, the chlamydia rate among Hispanics was 377.0 cases per 100,000 population (Table 11B) which is 2.1 times the rate among whites.

Asians— In 2013, the chlamydia rate among Asians was 111.5 cases per 100,000 population (Table 11B). The overall rate among whites is 1.6 times the rate among Asians.

Gonorrhea

During 2009–2013, among the 40 jurisdictions (39 states and the District of Columbia) that submitted data for each year according to the OMB standards, rates of reported gonorrhea cases increased 87.5% among American Indians/Alaska Natives (76.6 to 143.6), 79.3% among Native Hawaiians/Other Pacific Islanders (56.4 to 101.1), 54.8% among whites (23.0 to 35.6), 50.1% among Hispanics (45.5 to 68.3), and 29.4% among Asians (13.6 to 17.6) (Figure 19). The gonorrhea rate decreased 9.1% among blacks (471.6 to 428.5).

In 2013, 47 jurisdictions (46 states and the District of Columbia) submitted data in race and ethnic categories according to the OMB standards. The following data pertain to those jurisdictions:

Blacks—In 2013, 58.4% of reported gonorrhea 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 22A). The rate of gonorrhea among blacks in 2013 was 426.6 cases per 100,000 population, which was 12.4 times the rate among whites (34.5 per 100,000) (Table 22B). This disparity has decreased slightly in recent years (Figure O). This disparity was similar for black men (12.7 times the rate among white men) and black women (12.0 times the rate among white women) (Figure P, Table 22B).

As in previous years, the disparity in gonorrhea rates for blacks in 2013 was larger in the Midwest and Northeast than in the West or the South (Figure Q).

Considering all racial/ethnic and age categories, gonorrhea rates were highest for blacks aged 20–24 and 15–19 years in 2013 (Table 22B). Black women aged 20–24 had a gonorrhea rate of 1,949.1 cases per 100,000 women. This rate was 10.2 times the rate among white women in the same age group (190.3 per 100,000). Black women aged 15–19 years had a gonorrhea rate of 1,768.5 cases per 100,000 women, which was 13.6 times the rate among white women in the same age group (130.1 per 100,000).

Black men aged 20–24 years had a gonorrhea rate of 1,734.5 cases per 100,000 men, which was 13.0 times the rate among white men in the same age group (133.7 per 100,000). Black men aged 25–29 years had a gonorrhea rate of 1,207.2 cases per 100,000 men, which was 10.4 times the rate among white men in the same age group (116.5 per 100,000).

American Indians/Alaska Natives—In 2013, the gonorrhea rate among American Indians/Alaska Natives was 137.4 cases per 100,000 population, which was 4.0 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 (5.2 times the rate among white women) than for American Indian/Alaska Native men (2.7 times the rate among white men) (Figure P, Table 22 B). The disparity in gonorrhea rates for American Indians/Alaska Natives in 2013 was larger in the Midwest than in the West, Northeast, and South (Figure Q).

Native Hawaiians/Other Pacific Islanders—In 2013, the gonorrhea rate among Native Hawaiians/Other Pacific Islanders was 94.0 cases per 100,00 population, which was 2.7 times the rate among whites (Table 22B). The disparity between gonorrhea rates for Native Hawaiians/Other Pacific Islanders and whites was the similar for Native Hawaiian/Other Pacific Islander women (2.7 times the rate among white women) and Native Hawaiian/Other Pacific Islander men (2.8 times the rate among white men) (Figure P, Table 22B). The disparity in gonorrhea rates for Native Hawaiians/Other Pacific Islanders in 2013 was lower in the West than in the Midwest, Northeast, and South (Figure Q).

Hispanics—In 2013, the gonorrhea rate among Hispanics was 65.8 cases per 100,000 population, which was 1.9 times the rate among whites (Table 22B). This disparity was similar for Hispanic women (1.8 times the rate among white women) and Hispanic men (2.0 times) (Figure P, Table 22B). The disparity in gonorrhea rates for Hispanics was highest in the Northeast and lowest in the West and Midwest (Figure Q).

Asians—In 2013, the gonorrhea rate among Asians was 17.1 cases per 100,000 population, which was lower than (0.5 times) the rate among whites (Table 22B). This difference is larger for Asian women than for Asian men (Figure P, Table 22B). In 2013, rates among Asians were lower than rates among whites in all four regions of the United States (Figure Q).

Primary and Secondary Syphilis

The syphilis epidemic in the late 1980s occurred primarily among men who have sex with women only (MSW), women, and minority populations.^16,17 While the rate of primary and secondary (P&S) syphilis declined among all racial and ethnic groups during the 1990s, rates again began increasing in the early 2000s among gay, bisexual and other men who have sex with men (MSM) in their 30s and 40s of varied racial and ethnic groups.¹⁷ During 2009–2013, 40 jurisdictions (39 states and the District of Columbia) submitted data on race and Hispanic ethnicity for each year according to the OMB standards. Among these areas, rates of reported cases increased among non-Hispanic whites, non-Hispanic blacks, Hispanics, Asians, American Indians/Alaska Natives, and Native Hawaiians/Other Pacific Islanders, and decreased slightly among multirace individuals, during 2013 (Figure 39).

In 2013, 48 jurisdictions (47 states and the District of Columbia) submitted syphilis data by race and Hispanic ethnicity according to the OMB standards. The following data pertain to those jurisdictions:

Blacks — In 2013, 37.3% of all cases reported to CDC were among blacks. The overall 2013 rate for blacks was 5.6 times the rate for whites. In 2013, the rate of P&S syphilis among black men was 5.3 times the rate among white men; the rate among black women was 15 times the rate among white women (Table 36B).

In 2013, rates among both men and women aged 25–29 years remained highest among blacks (97.2 cases and 12.9 cases per 100,000 population, respectively).  Rates among both men and women aged 20–24 years remained highest among blacks (96.4 cases and 17.0 cases per 100,000 population, respectively).

American Indians/Alaska Natives — In 2013, 0.6% of all cases reported to CDC were among American Indians/Alaska Natives. The 2013 rate of P&S syphilis for American Indians/Alaska Natives was 4.6 cases per 100,000 population, 1.5 times the rate for whites (Table 36B).

Native Hawaiians/Other Pacific Islanders — In 2013, 0.3% of all cases reported to CDC were among Native Hawaiians/Other Pacific Islanders. The 2013 rate of P&S syphilis for Native Hawaiians/Other Pacific Islanders  was 8.6 cases per 100,000 population, which was 2.9 times the rate for whites (Table 36B).

Hispanics — In 2013, 19.9% of all cases reported to CDC were among Hispanics. The 2013 rate of P&S syphilis for Hispanics was 6.3 cases per 100,000 population, which was 2.1 times the rate for whites (Table 36B).

Asians — In 2013, 2.2% of all cases reported to CDC were among Asians. The 2013 rate of P&S syphilis for Asians was 2.5 cases per 100,000 population, which was 0.8 times the rate for whites (Table 36B).

Congenital Syphilis

Race/ethnicity for cases of congenital syphilis is based on the mother’s race/ethnicity. In 2013, the rate of congenital syphilis was 29.0 cases per 100,000 live births among blacks and 9.7 cases per 100,000 live births among Hispanics. These rates were 10.4 and 3.5 times, respectively, the rate among whites (2.8 cases per 100,000 live births) (Table 43, Figure U).

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8 Bureau of Labor Statistics Report, August 2014
http://www.bls.gov.

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15 Office of Management and Budget. Provisional guidance on the implementation of the 1997 standards for federal data on race and ethnicity. 1999. [Accessed July 29, 2013]. Available at: https://obamawhitehouse.archives.gov/omb/fedreg_1997standards

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