1. High HIV Prevalence Among
Low-Income Heterosexuals in
Urban Areas of the U.S.
Paul Denning MD, Elizabeth DiNenno PhD,
and Ryan Wiegand MS
National HIV Prevention Conference
August 17, 2011
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention

2. National HIV Behavioral
Surveillance System (NHBS)
● Anonymous, cross-sectional survey
● Cities with high AIDS morbidity
● High-risk populations
– MSM
– IDUs
– Heterosexuals
● Anonymous HIV testing offered

3. NHBS-HET1
● September 2006 to October 2007
● 25 cities

4. NHBS-HET1 Recruitment
● High-risk areas (HRAs)
– Poverty
– HIV diagnoses
● Methods
– Respondent-driven sampling
– Venue-based sampling

5. NHBS-HET1 Recruitment
Respondent-Driven Sampling

6. NHBS-HET1 Recruitment
Venue-Based Sampling

7. NHBS-HET1 Eligibility
● 18 − 50 years old
● City resident
● Sex with an opposite-gender
partner in the past 12 months
● English- or Spanish-speaking

8. NHBS-HET1 Analysis Methods
● Univariable and multivariable
Poisson regression models
– Associations with HIV prevalence
– Prevalence ratios
● Data were combined and analyzed
as a single convenience sample

9. NHBS-HET1 Analysis Criteria
Inclusion:
● Eligible and completed survey
● Consented to HIV testing
● Negative or confirmed positive HIV
test result
Exclusion:
● Ever injected drugs
● Men who ever had sex with another
man

10. NHBS-HET1 Participants
22,169 Recruited
18,377 (83%) Interviewed
17,655 (96%) Tested
14,837 (84%) Heterosexuals

11. Participant Characteristics
NHBS-HET1 2006-2007
Gender
43% Women
57%
Men
N= 14,837

12. Participant Characteristics
NHBS-HET1 2006-2007
5% 4%
Race
African-
18% American
Latino
72%
White
Other
N= 14,837

13. Participant Characteristics
NHBS-HET1 2006-2007
Age
29%
18 - 29
48%
30 - 39
23% 40 - 50
N= 14,837

14. Participant Characteristics
NHBS-HET1 2006-2007
Socioeconomic Status:
73% Income ≤ poverty level
31% < High school education
36% Unemployed
19% Homeless

15. Participant Characteristics
NHBS-HET1 2006-2007
15
10
Percent
5
0
Crack Exchange STD
Use Sex Diagnosis

16. HIV Prevalence
NHBS-HET1 2006-2007
HIV Test Result N (%)
Negative 14,543 (98)
Positive 294 (2)
Total 14,837 (100)

17. HIV Prevalence
NHBS-HET1 2006-2007
HIV Test Result N (%)
Negative 14,543 (98)
Positive 294 (2)
Total 14,837 (100)
2% HIV prevalence is 10 to 20 times greater
than that among all heterosexuals in the U.S.

18. HIV Prevalence
and Poverty

19. HIV Prevalence, by Census Tract Poverty
NHBS-HET1 2006-2007
3
Percent HIV-positive
Chi-Square Trend, p< 0.0001
2
1
0
0 − 9% 10 − 19% 20 − 29% 30 − 39% ≥ 40%
Proportion of Census Tract Residents Living Below the Poverty Level

20. HIV Prevalence, by Income
NHBS-HET1 2006-2007
3
Percent HIV-positive
Chi-Square Trend, p< 0.0001
2
1
0
0 − 9,999 10 − 19,999 20 − 49,999 ≥ 50,000
Annual Household Income (in Dollars)

21. HIV Prevalence, by Income
NHBS-HET1 2006-2007
3
Percent HIV-positive
6X Greater
2
1
0
0 − 9,999 10 − 19,999 20 − 49,999 ≥ 50,000
Annual Household Income (in Dollars)

22. HIV Prevalence, Multivariable Model*
NHBS-HET1 2006-2007
Low socioeconomic status was
associated with higher HIV prevalence:
● Low income
● Limited education
● Unemployment
*Controlling for city, sex, race/ethnicity, age, education, employment,
income, homeless status, crack use, exchange sex, and STD diagnosis.

23. HIV Prevalence
and Race/Ethnicity

24. HIV Surveillance & Census Data
37 States with HIV Reporting 2007
Heterosexuals Living with HIV Adult & Adolescent Population
125 125
Persons (in thousands)
100 100
Persons (in millions)
75 75
50 50
25 25
0 0
African- Latino White African- Latino White
American American

25. Ratio of Heterosexuals Living
with HIV to the Population–
African-Americans:
> 20 times greater
Latinos:
6 times greater

26. HIV Prevalence, by Race/Ethnicity
NHBS-HET1 2006-2007
All Census Tracts High Poverty Census Tracts
2.5 2.5
2.0 2.0
Percent HIV-positive
Percent HIV-positive
p= 0.73
1.5 1.5
p= 0.14
1.0 1.0
0.5 0.5
0.0 African- Latino White
0.0 African- Latino White
American American

27. HIV Prevalence
and Risk Behavior

28. HIV Prevalence, by Risk Behavior
NHBS-HET1 2006-2007
Yes No
5
Percent HIV-positive
4
3
p< 0.0001 p< 0.0001 p< 0.0001
2
1
0
Crack Exchange STD
Use Sex Diagnosis

29. HIV Prevalence, by Risk Behavior
NHBS-HET1 2006-2007
Multivariable Model*
Adjusted HIV 95% Confidence
Prevalence Ratio Interval
Crack Use 1.1 (0.8 – 1.6)
Exchange Sex 1.1 (0.6 – 1.8)
STD Diagnosis 2.1 (1.7 – 2.8)
*Controlling for city, sex, race/ethnicity, age, education, employment,
income, homeless status, crack use, exchange sex, and STD diagnosis.

30. HIV Prevalence, by Risk Behavior
NHBS-HET1 2006-2007
Multivariable Model*
Adjusted HIV 95% Confidence
Prevalence Ratio Interval
Crack Use 1.1 (0.8 – 1.6)
Exchange Sex 1.1 (0.6 – 1.8)
STD Diagnosis 2.1 (1.7 – 2.8)
*Controlling for city, sex, race/ethnicity, age, education, employment,
income, homeless status, crack use, exchange sex, and STD diagnosis.

31. HIV Prevalence, by Risk Behavior
NHBS-HET1 2006-2007
Multivariable Model*
Adjusted HIV 95% Confidence
Prevalence Ratio Interval
Crack Use 1.1 (0.8 – 1.6)
Exchange Sex 1.1 (0.6 – 1.8)
STD Diagnosis 2.1 (1.7 – 2.8)
*Controlling for city, sex, race/ethnicity, age, education, employment,
income, homeless status, crack use, exchange sex, and STD diagnosis.

32. Limitations
● Because NHBS-HET1 is a convenience
sample recruited from large urban areas
with high AIDS morbidity, participants may
not be representative of all low-income
heterosexuals in the U.S.
● Since NHBS-HET1 recruitment targeted
residents of areas with high rates of HIV
diagnoses in addition to high rates of
poverty, HIV prevalence may be over-
estimated.

33. Summary
● HIV prevalence was very high
● Low socioeconomic status was
associated with higher HIV prevalence
● Racial and ethnic disparities in HIV
prevalence were substantially less than
those in the general population
● Crack use and exchange sex were not
associated with higher HIV prevalence

34. Recommendations
● HIV prevention activities should
be expanded and focus on low-
income communities
● Community-level interventions
● Structural interventions

35. Characteristics Associated with HIV Infection Among
Heterosexuals in Urban Areas with High AIDS
Prevalence – 24 Cities, United States, 2006 - 2007.
MMWR 2011;60(31):1045-1049.
http://www.cdc.gov/mmwr
For more information please contact Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily
represent the official position of the Centers for Disease Control and Prevention.
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention