1. Poverty and HIV Infection: 2006-2007 NHBS National* and San Diego Findings Vanessa Miguelino-Keasling, MPH National HIV Behavioral Surveillance System (NHBS) HIV Surveillance, Research, and Evaluation Branch October 2010 * The national level analyses presented here were conceptualized and originally presented by P. Denning et al. at the XVIII International AIDS Conference (Vienna, 2010) (http://www.cdc.gov/hiv/topics/surveillance/resources/other/poverty.htm )http://www.cdc.gov/hiv/topics/surveillance/resources/other/poverty.htm

2. UNAIDS Definitions Generalized HIV Epidemic: HIV prevalence rate >1% in the general population. Concentrated HIV Epidemic: HIV prevalence rate 5% in at least one high-risk population, such as MSM, IDUs, commercial sex workers (CSWs), or the clients of CSWs.

3. Background- NHBS 2000 - National plan for HIV/AIDS prevention “HIV Prevention Strategic Plan Through 2005” Monitor HIV epidemic to better direct and evaluate prevention efforts. 2002 – National HIV Behavioral Surveillance (NHBS) System

4. Objectives- NHBS Estimate the prevalence of HIV-related sexual and drug-use behaviors Estimate demographic, social, and behavioral correlates of HIV risks Estimate the prevalence and trends of HIV testing behaviors, and exposure to and utilization of HIV/STD prevention services. Characterize prevention-service gaps and missed opportunities for prevention.

5. Methodology- NHBS Rotating yearly cycles – MSM, IDU, HET MSM – venue based time-space sampling (VBS) IDU, HET – respondent driven sampling (RDS) Standardized HIV behavioral risk question- naire administered from handheld device HIV testing and counseling Participation incentives

6. Atlanta Miami San Juan New Orleans Dallas Houston San Diego Los Angeles San Francisco Seattle Denver St. Louis Chicago Detroit Boston Nassau New York City Newark Philadelphia Baltimore NHBS HET 1 cycle – 25 cities Washington DC Fort Lauderdale New Haven Norfolk Las Vegas

7.  Men who have sex with men  Injection drug users  Commercial sex workers/clients Exclusion Criteria: Inclusion Criteria:  18 − 50 years old  Opposite-gender sex partner  Resident of poverty area NHBS-HET-1 Analysis Sample

8. Analysis Sample Lived in a poverty area (census tract where ≥ 20% of residents had household incomes below the U.S. poverty level. Consented to HIV testing (98%) and had a valid HIV test result (99%). Resided in one of 23 cities with complete NHBS-HET1 and census tract data. (Norfolk, Virginia and San Juan, Puerto Rico excluded.)

9. HIV Prevalence Rate U.S. Poverty Areas in NHBS, 2006-2007 U.S. Poverty Areas Percent HIV+ 9,078 Participants 188 HIV+

10. HIV Prevalence Rate U.S. Poverty Areas in NHBS, 2006-2007 U.S. Poverty Areas Percent HIV+ UNAIDS Definition of a Generalized HIV Epidemic

11. HIV Prevalence Rate U.S. Poverty Areas and all Heterosexuals, 2006-2007 U.S. Poverty Areas U.S. Hetero- sexuals Percent HIV+ 10 − 20X Greater

12. HIV Prevalence Rate HIV Prevalence Rate U.S. Poverty Area and Selected Countries, 2006-2007 U.S. Poverty Areas BurundiU.S. Hetero- sexuals Haiti Percent HIV+ Ethiopia

13. HIV Prevalence Rate by San Diego Poverty Area, 2006-2007 San Diego Poverty Area Percent HIV+ 541 Participants 14 HIV+

14. HIV Prevalence Rate: U.S. Poverty Areas (NHBS), all US Heterosexuals, and San Diego poverty area, 2006-2007 U.S. Poverty Areas (N=188) U.S. Hetero- sexuals Percent HIV+ San Diego Poverty Area (N=14)

15. HIV Prevalence Rate, by Income NHBS-HET-1 2006-2007 Percent HIV+ 10 − 19,99920 − 49,999≥ 50,000 Annual Household Income (in U.S. Dollars) 0 − 9,999

16. HIV Prevalence Rate, by Income NHBS-HET-1 2006-2007 Percent HIV+ 10 − 19,99920 − 49,999≥ 50,000 Annual Household Income (in U.S. Dollars) 0 − 9,999 7X Greater

17. HIV Prevalence Rate, by Income San Diego, 2006 - 2007 Percent HIV+ 10 − 19,99920 − 49,999≥ 50,000 Annual Household Income (in U.S. Dollars) 0 − 9,999

18. Percent HIV+ U.S. Poverty Areas BlackHispanicWhite HIV Prevalence Rate, by Race/Ethnicity NHBS-HET-1 2006-2007 or U.S. 2006

19. Percent HIV+ U.S. Overall U.S. Poverty Areas BlackHispanicWhite HIV Prevalence Rate, by Race/Ethnicity NHBS-HET-1 2006-2007 or U.S. 2006

20. Percent HIV+ U.S. Overall U.S. Poverty Areas BlackHispanicWhite

21. HIV Prevalence Rate, by Race/Ethnicity NHBS-HET-1 2006-’07 and San Diego 2006-’07 Percent HIV+ San Diego Poverty Area (N=14) U.S. Poverty Areas (N=188) BlackHispanicWhite

22. HIV Prevalence Rate, by Age NHBS-HET-1 2006-’07 and San Diego 2006-’07 Percent HIV+ San Diego Poverty Area (N=14) U.S. Poverty Areas (N=188) 18 - 2930 - 3940 - 50

23. HIV Prevalence Rate, by Education NHBS-HET-1 2006-’07 and San Diego 2006-’07 Percent HIV+ San Diego Poverty Area (N=14) U.S. Poverty Areas (N=188) < High School High School Graduate > High School

24. Limitations NHBS HET1 – convenience sample and not representative of all urban poverty residents in the U.S. Findings are not generalizable to non-urban poverty area residents. Targeted census tracts with high rates of poverty and HIV diagnosis (HRAs) may overestimate the HIV prevalence rate in urban poverty areas. Statistical comparisons of San Diego groups not completed due to small number of HIV positive participants.

25. Conclusions HIV prevalence rate among NHBS-HET1 participants living in urban poverty areas for all sites was very high (2.1%) and exceeded the 1% cut-off that defines a generalized HIV epidemic. HIV prevalence rates in urban poverty areas nationally were inversely related to socioeconomic status (SES) – the lower the SES, the greater the HIV prevalence rate. Unlike overall HIV prevalence rates in the U.S., HIV prevalence rates in urban poverty areas did not differ significantly by race or ethnicity. Although small sample sizes prevent statistical significance testing for San Diego poverty areas, HIV prevalence patterns are similar to those seen nationally.

26. Recommendations Expand HIV prevention efforts in urban poverty areas in the U.S. - Community-level interventions - Structural interventions to improve socioeconomic conditions to help reduce HIV infection rates Assess the impact of the HIV epidemic in non- urban poverty areas, especially areas where high levels of rural poverty exist.

27. Acknowledgments The Chicano Federation of San Diego County, Inc. Paul Denning, MD, MPH Division of HIV/AIDS Prevention Centers for Disease Control and Prevention

28. Questions