AIDS PATIENT CARE and STDs Volume 30, Number 7, 2016 ª Mary Ann Liebert, Inc. DOI: 10.1089/apc.2016.0120
HIV Testing Among Black and Hispanic Immigrants in the United States Bisola O. Ojikutu, MD, MPH,1–3 Emanuele Mazzola, PhD,4 Andrew Fullem, MPH,2 Rodolfo Vega, PhD,2 Stewart Landers, JD, MCP,2 Rebecca S. Gelman, PhD,3,4 and Laura M. Bogart, PhD3,5,6
Abstract
Late presentation is common among black and Hispanic US immigrants living with HIV. Little is known about HIV testing in this population because data are aggregated into racial and ethnic categories without regard to nativity. This study was undertaken to determine HIV testing patterns in these populations. We used data from the National Health Interview Survey (2007–2010), a nationally representative source of HIV testing data disaggregated by nativity. The sample consisted of 10,397 immigrants (83.9% Hispanic white, 13.1% non-Hispanic black, and 3.0% Hispanic black). The majority of participants were from the Caribbean, Central America, and Mexico (81.5%). Hispanic white immigrants were least likely to have undergone testing compared with nonHispanic and Hispanic black immigrants (46.7% vs. 70.5% and 65.8%). Among immigrants with known risk factors or prior STDs, 59.2% and 74.8% reported previous HIV testing. Immigrants who had not recently talked to a healthcare provider were less likely to report testing: Hispanic white (AOR 0.65, 95% CI 0.58–0.72), nonHispanic black (AOR 0.64, 95% CI 0.48–0.85), and Hispanic black (AOR 0.26, 95% CI 0.14–0.48). Only 17.2% of all immigrants intended to undergo HIV testing in the 12 months following participation in the survey. Among all three racial and ethnic groups, immigrants who reported a history of prior STDs were more likely to intend to test for HIV in the future. Many black and Hispanic immigrants to the United States have not undergone HIV testing. Interventions to increase access to HIV testing and awareness of transmission risk should be developed. Introduction
O
f the 1.1 million individuals living with HIV in the United States, an estimated 15.8% remain undiagnosed.1 HIV diagnosis is the first entryway into vital treatment services. Early diagnosis leads to timely initiation of antiretroviral therapy and decreased risk of sexual transmission.2,3 Black/African American and Hispanic people living with HIV (PLWH) are more likely to be undiagnosed compared with white individuals.4 One of the foremost goals of the US National AIDS Strategy is to increase the percentage of PLWH who know their HIV status to at least 90% by 2020.5 Efforts targeting higher risk populations, particularly minorities, have been implemented. The percentage of black and Hispanic individuals who had ever been tested for HIV increased significantly within the last decade (to 64.5% and 46.4%, respectively, p < 0.0001).6 Among black and Hispanic individuals, immigrants are more likely to be undiagnosed and to present late for care.7,8
Although the number of racial and ethnic minority immigrants in the United States is growing, few efforts to increase HIV testing have specifically targeted these groups. According to the US Census Bureau, 84% of non-US-born black individuals emigrate from the Caribbean and sub-Saharan Africa, where HIV prevalence ranges from 1.1% to 26.1%.9,10 A small, but compelling, body of literature indicates that black immigrants are more likely to be uninsured than US-born black individuals and have challenges navigating the healthcare system.11–13 Discrimination based on race, ethnicity and/or accent, low English proficiency, stigma, and low knowledge may serve as barriers to testing.14–16 Among Hispanic individuals living in the United States, more than 37% (or 18 million) are immigrants who have emigrated from Mexico where the HIV prevalence is low (0.2%).17,18 A significant proportion also derive from Central America and the Caribbean where HIV prevalence ranges from 0.3% to 3% with higher rates in concentrated subpopulations (e.g., men who have sex with men, injection drug
1
Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts. John Snow Research and Training Institute, Boston, Massachusetts. 3 Harvard Medical School, Boston, Massachusetts. 4 Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts. 5 Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts. 6 RAND Corporation, Santa Monica, California. 2
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users, and sex workers).19 Immigrants from Mexico and Central America constitute the largest proportion of non-USborn individuals living with HIV in the United States.20 A robust literature has documented barriers to healthcare access among Hispanic immigrants, which have likely contributed to higher rates of late HIV testing in this population.21 For both black and Hispanic immigrants, acquisition of infection in the country of origin and delayed timing of immigration may also contribute to late diagnosis. The US immigration policy may have further complicated access to HIV testing. In 1987, according to section 212(a)(1) of the Immigration and Nationality Act, any ‘‘alien’’ who was determined to be HIV infected would be inadmissible to the United States.22 Under this Act, known as the ‘‘HIV travel ban,’’ many immigrants were subject to HIV testing as a component of the medical screening examination for entry into the United States and denied entry if positive. In 2010, the United States removed this federal rule.23 This policy change places the United States in concert with most countries who also permit unrestricted travel for PLWH. This study was undertaken to determine the rate and characteristics associated with prior HIV testing and intention to test in the next year among immigrants to the United States. We hypothesize that immigrants faced and continue to experience barriers to HIV testing. For this study, we used data from the National Health Interview Study (NHIS), which is one of the few large, nationally representative data sets that tracked HIV testing and provides publically available access to nativity data by region of origin. Methodology
Established in 1957, the NHIS is an annual, cross-sectional survey of adults and children living in households and noninstitutionalized group settings throughout the United States.24 The survey is administered to participants by means of a personal visit to their living quarters by an employee of the US Bureau of the Census. From 1997 through 2010, NHIS included questions related to HIV risk, testing history, and intention to test in the future for persons aged 18 and older. As of 2011, detailed questions regarding HIV were eliminated from future surveys. For this analysis, data were aggregated over 4 years (2007–2010). Outcomes
The two primary outcomes of this study are self-report of prior HIV testing and intention to test within 12 months following survey administration. For self-report of prior HIV testing, participants were asked ‘‘Except for tests you may have had as part of blood donations, have you ever been tested for HIV?’’ The response categories were ‘‘yes,’’ ‘‘no,’’ and ‘‘unknown.’’ For intention to test, those who previously tested were asked, ‘‘Do you expect to have another test for HIV in the next 12 months, not including blood donations?’’ Those who had no history of HIV testing were asked, ‘‘Do you expect to have a test for HIV in the next 12 months, not including blood donations?’’ Intention to test in the next 12 months was analyzed for all participants in this study, those with any known and no known risk factors and those with and without prior STDs.
OJIKUTU ET AL. Sociodemographic covariates
Available sociodemographic covariates included age, gender, region of origin, US citizenship, time in the United States, language (Spanish speaking if respondent indicated that they would prefer to be interviewed either in part or entirely in Spanish), marital status, education, income, health insurance status, and if the person saw a healthcare provider in the last year. NHIS aggregates country of origin into regions: (e.g., South America; Africa; and Caribbean, Mexico, and Central America grouped together and abbreviated as CMC). Participants were also asked to report their duration of residence in the United States. For income, 47% of responses were either missing or unknown. Missing income data were imputed using the procedures suggested by the National Center for Health Statistics.25 A new covariate (reported+ imputed income) was coded and reflects the following: reported income (if that was known), imputed income (if reported income was unknown), and ‘‘unknown’’ if both reported and imputed income were unknown. ‘‘Unknown’’ may contain some individuals who had no income. To determine healthcare access, respondents were asked, ‘‘Are you covered by any kind of health insurance or some other kind of health care plan?’’ Recent healthcare access was determined by asking, ‘‘During the past 12 months, have you seen or talked to any of the following healthcare providers (general doctor who treats a variety of illnesses, a doctor in general practice, family medicine, or internal medicine) about your own health?’’ Predictors of HIV risk
To assess HIV risk, respondents were asked to indicate if any of the following previous risk factors were true: (1) You have hemophilia and have received clotting factor concentrations; (2) You are a man who has had sex with other men, even just one time; (3) You have taken street drugs by needle, even just one time; (4) You have traded sex for money or drugs, even just one time; (5) You have tested positive for HIV (the virus that causes AIDS); and (6) You have had sex (even just one time) with someone who would answer ‘‘yes’’ to any of these statements. History of other STDs that contribute to HIV risk was assessed by asking, ‘‘in the past five years, have you had an STD other than HIV or AIDS?’’ Respondents were asked to include newly contracted STDs as well as recurrent flare-ups of previously contracted STDs. Reasons to test or not to test
To ascertain reasons for undergoing prior HIV testing, participants are read the following: ‘‘I am going to show you a list of reasons why some people have been tested for HIV. Not including your blood donations, which of these would you say was the main reason for your last HIV test?’’ Participants who had not undergone HIV testing were asked to select all applicable reasons for not testing (e.g., low risk, did not know where to obtain testing, did not want to think about HIV, as well as others). Data analysis
All analyses and estimates were conducted using the NHIS sampling weights. Tests of differences in the distributions of respondent characteristics and reasons for testing (or not testing) used the Rao–Scott weighted version of the chi-
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Table 1. Demographic Characteristics of Immigrant Participants (Weighted Percentages by Column) in the National Health Interview Survey (2007–2010) by Race and Ethnicity
Percent of total sample Sociodemographic factors (%) Age 18–24 25–44 45–64 Gender Male Region of origin (%) Mexico, Caribbean, Central America South America Africa Other Immigration statusa Not a US citizen Unknown Time in the United States
HIV Testing Among Black and Hispanic Immigrants in the United States Bisola O. Ojikutu, MD, MPH,1–3 Emanuele Mazzola, PhD,4 Andrew Fullem, MPH,2 Rodolfo Vega, PhD,2 Stewart Landers, JD, MCP,2 Rebecca S. Gelman, PhD,3,4 and Laura M. Bogart, PhD3,5,6
Abstract
Late presentation is common among black and Hispanic US immigrants living with HIV. Little is known about HIV testing in this population because data are aggregated into racial and ethnic categories without regard to nativity. This study was undertaken to determine HIV testing patterns in these populations. We used data from the National Health Interview Survey (2007–2010), a nationally representative source of HIV testing data disaggregated by nativity. The sample consisted of 10,397 immigrants (83.9% Hispanic white, 13.1% non-Hispanic black, and 3.0% Hispanic black). The majority of participants were from the Caribbean, Central America, and Mexico (81.5%). Hispanic white immigrants were least likely to have undergone testing compared with nonHispanic and Hispanic black immigrants (46.7% vs. 70.5% and 65.8%). Among immigrants with known risk factors or prior STDs, 59.2% and 74.8% reported previous HIV testing. Immigrants who had not recently talked to a healthcare provider were less likely to report testing: Hispanic white (AOR 0.65, 95% CI 0.58–0.72), nonHispanic black (AOR 0.64, 95% CI 0.48–0.85), and Hispanic black (AOR 0.26, 95% CI 0.14–0.48). Only 17.2% of all immigrants intended to undergo HIV testing in the 12 months following participation in the survey. Among all three racial and ethnic groups, immigrants who reported a history of prior STDs were more likely to intend to test for HIV in the future. Many black and Hispanic immigrants to the United States have not undergone HIV testing. Interventions to increase access to HIV testing and awareness of transmission risk should be developed. Introduction
O
f the 1.1 million individuals living with HIV in the United States, an estimated 15.8% remain undiagnosed.1 HIV diagnosis is the first entryway into vital treatment services. Early diagnosis leads to timely initiation of antiretroviral therapy and decreased risk of sexual transmission.2,3 Black/African American and Hispanic people living with HIV (PLWH) are more likely to be undiagnosed compared with white individuals.4 One of the foremost goals of the US National AIDS Strategy is to increase the percentage of PLWH who know their HIV status to at least 90% by 2020.5 Efforts targeting higher risk populations, particularly minorities, have been implemented. The percentage of black and Hispanic individuals who had ever been tested for HIV increased significantly within the last decade (to 64.5% and 46.4%, respectively, p < 0.0001).6 Among black and Hispanic individuals, immigrants are more likely to be undiagnosed and to present late for care.7,8
Although the number of racial and ethnic minority immigrants in the United States is growing, few efforts to increase HIV testing have specifically targeted these groups. According to the US Census Bureau, 84% of non-US-born black individuals emigrate from the Caribbean and sub-Saharan Africa, where HIV prevalence ranges from 1.1% to 26.1%.9,10 A small, but compelling, body of literature indicates that black immigrants are more likely to be uninsured than US-born black individuals and have challenges navigating the healthcare system.11–13 Discrimination based on race, ethnicity and/or accent, low English proficiency, stigma, and low knowledge may serve as barriers to testing.14–16 Among Hispanic individuals living in the United States, more than 37% (or 18 million) are immigrants who have emigrated from Mexico where the HIV prevalence is low (0.2%).17,18 A significant proportion also derive from Central America and the Caribbean where HIV prevalence ranges from 0.3% to 3% with higher rates in concentrated subpopulations (e.g., men who have sex with men, injection drug
1
Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts. John Snow Research and Training Institute, Boston, Massachusetts. 3 Harvard Medical School, Boston, Massachusetts. 4 Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts. 5 Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts. 6 RAND Corporation, Santa Monica, California. 2
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users, and sex workers).19 Immigrants from Mexico and Central America constitute the largest proportion of non-USborn individuals living with HIV in the United States.20 A robust literature has documented barriers to healthcare access among Hispanic immigrants, which have likely contributed to higher rates of late HIV testing in this population.21 For both black and Hispanic immigrants, acquisition of infection in the country of origin and delayed timing of immigration may also contribute to late diagnosis. The US immigration policy may have further complicated access to HIV testing. In 1987, according to section 212(a)(1) of the Immigration and Nationality Act, any ‘‘alien’’ who was determined to be HIV infected would be inadmissible to the United States.22 Under this Act, known as the ‘‘HIV travel ban,’’ many immigrants were subject to HIV testing as a component of the medical screening examination for entry into the United States and denied entry if positive. In 2010, the United States removed this federal rule.23 This policy change places the United States in concert with most countries who also permit unrestricted travel for PLWH. This study was undertaken to determine the rate and characteristics associated with prior HIV testing and intention to test in the next year among immigrants to the United States. We hypothesize that immigrants faced and continue to experience barriers to HIV testing. For this study, we used data from the National Health Interview Study (NHIS), which is one of the few large, nationally representative data sets that tracked HIV testing and provides publically available access to nativity data by region of origin. Methodology
Established in 1957, the NHIS is an annual, cross-sectional survey of adults and children living in households and noninstitutionalized group settings throughout the United States.24 The survey is administered to participants by means of a personal visit to their living quarters by an employee of the US Bureau of the Census. From 1997 through 2010, NHIS included questions related to HIV risk, testing history, and intention to test in the future for persons aged 18 and older. As of 2011, detailed questions regarding HIV were eliminated from future surveys. For this analysis, data were aggregated over 4 years (2007–2010). Outcomes
The two primary outcomes of this study are self-report of prior HIV testing and intention to test within 12 months following survey administration. For self-report of prior HIV testing, participants were asked ‘‘Except for tests you may have had as part of blood donations, have you ever been tested for HIV?’’ The response categories were ‘‘yes,’’ ‘‘no,’’ and ‘‘unknown.’’ For intention to test, those who previously tested were asked, ‘‘Do you expect to have another test for HIV in the next 12 months, not including blood donations?’’ Those who had no history of HIV testing were asked, ‘‘Do you expect to have a test for HIV in the next 12 months, not including blood donations?’’ Intention to test in the next 12 months was analyzed for all participants in this study, those with any known and no known risk factors and those with and without prior STDs.
OJIKUTU ET AL. Sociodemographic covariates
Available sociodemographic covariates included age, gender, region of origin, US citizenship, time in the United States, language (Spanish speaking if respondent indicated that they would prefer to be interviewed either in part or entirely in Spanish), marital status, education, income, health insurance status, and if the person saw a healthcare provider in the last year. NHIS aggregates country of origin into regions: (e.g., South America; Africa; and Caribbean, Mexico, and Central America grouped together and abbreviated as CMC). Participants were also asked to report their duration of residence in the United States. For income, 47% of responses were either missing or unknown. Missing income data were imputed using the procedures suggested by the National Center for Health Statistics.25 A new covariate (reported+ imputed income) was coded and reflects the following: reported income (if that was known), imputed income (if reported income was unknown), and ‘‘unknown’’ if both reported and imputed income were unknown. ‘‘Unknown’’ may contain some individuals who had no income. To determine healthcare access, respondents were asked, ‘‘Are you covered by any kind of health insurance or some other kind of health care plan?’’ Recent healthcare access was determined by asking, ‘‘During the past 12 months, have you seen or talked to any of the following healthcare providers (general doctor who treats a variety of illnesses, a doctor in general practice, family medicine, or internal medicine) about your own health?’’ Predictors of HIV risk
To assess HIV risk, respondents were asked to indicate if any of the following previous risk factors were true: (1) You have hemophilia and have received clotting factor concentrations; (2) You are a man who has had sex with other men, even just one time; (3) You have taken street drugs by needle, even just one time; (4) You have traded sex for money or drugs, even just one time; (5) You have tested positive for HIV (the virus that causes AIDS); and (6) You have had sex (even just one time) with someone who would answer ‘‘yes’’ to any of these statements. History of other STDs that contribute to HIV risk was assessed by asking, ‘‘in the past five years, have you had an STD other than HIV or AIDS?’’ Respondents were asked to include newly contracted STDs as well as recurrent flare-ups of previously contracted STDs. Reasons to test or not to test
To ascertain reasons for undergoing prior HIV testing, participants are read the following: ‘‘I am going to show you a list of reasons why some people have been tested for HIV. Not including your blood donations, which of these would you say was the main reason for your last HIV test?’’ Participants who had not undergone HIV testing were asked to select all applicable reasons for not testing (e.g., low risk, did not know where to obtain testing, did not want to think about HIV, as well as others). Data analysis
All analyses and estimates were conducted using the NHIS sampling weights. Tests of differences in the distributions of respondent characteristics and reasons for testing (or not testing) used the Rao–Scott weighted version of the chi-
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Table 1. Demographic Characteristics of Immigrant Participants (Weighted Percentages by Column) in the National Health Interview Survey (2007–2010) by Race and Ethnicity
Percent of total sample Sociodemographic factors (%) Age 18–24 25–44 45–64 Gender Male Region of origin (%) Mexico, Caribbean, Central America South America Africa Other Immigration statusa Not a US citizen Unknown Time in the United States
