Study Reveals High HIV Infection Rates Linked to Poverty More Than Race
Local HIV/AIDS epidemics in some large U.S. cities have reached
the status of "generalized epidemic," meaning there
is significant HIV transmission outside defined risk groups
such as gay/bisexual men and injection drug users, researchers
from the Centers for Disease Control and Prevention (CDC)
reported at the XVIII International AIDS Epidemic this week
in Vienna. They also found that poverty, rather than race/ethnicity
per se, is the major demographic factor influencing HIV prevalence
among heterosexuals in economically disadvantaged urban areas.
findings come from interviews with more than 9000 individuals living
in "poverty areas" (census tracts where > 20% of
residents had household income below the U.S. poverty level, or about
$10,000) in 23 cities who took part in the U.S. National HIV Behavioral
Surveillance system during 2006-2007. Men who have sex with men, injection
drug users, and sex workers were excluded. Overall, about 2% were found
to be HIV positive.
is a press release from the CDC describing the study and its findings.
Analysis Reveals Strong Link Between Poverty and HIV Infection
Study in Low-Income Heterosexuals in America's Inner Cities Reveals
High HIV Rates
Austria -- July 19, 2010 -- The Centers for Disease Control and Prevention
today released a first-of-its-kind analysis showing that 2.1 percent
of heterosexuals living in high-poverty urban areas in the United States
are infected with HIV. This analysis suggests that many low-income cities
across the United States now have generalized HIV epidemics as defined
by the United Nations Joint Program on HIV/AIDS (UNAIDS).
UNAIDS defines a generalized epidemic as one that is firmly established
in the general population, with an overall HIV prevalence in the general
population of more than 1 percent. While subpopulations with higher
risk (such as men who have sex with men and injection drug users) may
still contribute disproportionately to the spread of HIV in these areas,
heterosexual transmission is also sufficient to sustain an epidemic
independent of those groups.
The analysis also shows that poverty is the single most important demographic
factor associated with HIV infection among inner-city heterosexuals.
Contrary to severe racial disparities that characterize the overall
U.S. epidemic, researchers found no differences in HIV prevalence by
race/ethnicity in this population. The analysis will be presented at
the XVIII International AIDS Conference in Vienna, Austria.
"This study reveals a powerful link between poverty and HIV risk,
and a widespread HIV epidemic in America's inner cities," said
Kevin Fenton, MD, PhD, director of CDC's National Center for HIV/AIDS,
Viral Hepatitis, STD, and TB Prevention. "In this country, HIV
clearly strikes the economically disadvantaged in a devastating way."
The analysis, led by Paul Denning, MD, a medical epidemiologist in CDC's
Division of HIV/AIDS Prevention, included more than 9,000 heterosexual
adults (aged 18-50) in high-poverty areas of 23 cities who participated
in the 2006-2007 heterosexual cycle of the CDC's National HIV Behavioral
Surveillance System. This system monitors HIV risk behaviors, HIV testing
patterns, and use of HIV prevention services among U.S. populations
High-poverty areas were defined according to the U.S. Census Bureau,
and included areas in which at least 20 percent of residents have household
incomes below the poverty line.
Nationally, the United States is considered to have a concentrated HIV
epidemic, meaning that it is confined mainly to individuals who engage
in high-risk behaviors, which in the United States are primarily gay
and bisexual men and injection drug users.
For this analysis, researchers followed UNAIDS criteria for determining
a generalized epidemic, and excluded groups at highest risk for becoming
HIV infected. Those groups not included in this analysis were gay and
bisexual men -- who continue to represent the majority of new HIV infections
in the United States -- injection drug users, and sex workers and their
"These findings have significant implications for how we think
about HIV prevention. We can't look at HIV in isolation from the environment
in which people live," said Jonathan Mermin, MD, director of CDC's
Division of HIV/AIDS Prevention. "This analysis points to an urgent
need to prioritize HIV prevention efforts in disadvantaged communities.
We are pleased that President Obama's new National HIV/AIDS Strategy
reflects this type of approach, in terms of targeting HIV prevention
resources to those in greatest need."
Prevalence was especially high in those with the lowest socioeconomic
status. Within the low income urban areas included in the study, individuals
living below the poverty line were at greater risk for HIV than those
living above it (2.4 percent prevalence vs. 1.2 percent), though prevalence
for both groups was far higher than the national average (0.45 percent).
There were no significant differences in HIV prevalence by race or ethnicity
in these low income urban areas: prevalence was 2.1 percent among blacks,
2.1 percent among Hispanics, and 1.7 percent among whites. By contrast,
the U.S. epidemic overall is characterized by severe racial/ethnic disparities:
the HIV prevalence rate for blacks is almost 8 times that of whites,
and the HIV prevalence rate among Hispanics is nearly 3 times that of
The absence of race-based differences in this analysis is likely due
to existing high prevalence of HIV in poor urban areas, which -- regardless
of race or ethnicity -- places individuals living in these areas at
greater risk for exposure to HIV with each sexual encounter.
Authors note that other factors associated with poverty also likely
contribute to high HIV prevalence in these settings. Some of these factors
include limited health care access, which can reduce utilization of
HIV testing and prevention services; substance abuse, which can increase
sexual risk behavior; and high rates of incarceration, which can disrupt
the stability of relationships.
This analysis provides greater insight into factors that may be driving
heterosexual HIV transmission in the United States, which accounts for
31 percent of new infections each year. This study did not examine HIV
prevalence among groups at higher risk for HIV in these areas, including
MSM and IDU. Nationally, MSM account for 53 percent of new infections,
IDU account for 12 percent, and those exposed through both MSM and IDU
account for 4 percent.
Investigator affiliations: U.S. Centers for Disease Control and Prevention,
Division of HIV/AIDS Prevention, Atlanta, GA.
Denning and E DiNenno. Communities in crisis: is there a generalized
HIV epidemic in impoverished urban areas of the United States. XVIII
International AIDS Conference. Vienna, July 18-23, 2010. Abstract WEPDD101.
for Disease Control and Prevention. New CDC Analysis Reveals Strong
Link Between Poverty and HIV Infection. Press release. July 19, 2010.