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Communities in Crisis: Is There a Generalized HIV Epidemic in Impoverished Urban Areas of the United States?



Results from National HIV Behavioral Surveillance among high risk heterosexuals in the United States, CDC.
Communities in Crisis: Is There a Generalized HIV Epidemic
in Impoverished Urban Areas of the United States?
Paul Denning, MD, MPH and Elizabeth DiNenno, PhD
According to UNAIDS, the United States (U.S.) has a concentrated
HIV epidemic, primarily among men who have sex with men (MSM)
and injection drug users (IDUs).1,2 While the HIV epidemic has not
had a broad impact on the general U.S. population, it has greatly
affected the economically disadvantaged in many urban areas. We
sought to characterize the HIV epidemic in impoverished urban
areas of the U.S. and determine whether the epidemic in these
areas meets the UNAIDS definition of a generalized epidemic.
UNAIDS Definitions
Concentrated HIV Epidemic: The HIV prevalence rate is <1% in the general
population, but >5% in at least one high-risk subpopulation, such as MSM, IDUs,
commercial sex workers (CSWs), or the clients of CSWs.
Generalized HIV Epidemic: The HIV prevalence rate is >1% in the general
National HIV Behavioral Surveillance System for
Heterosexuals ±Round 1 (NHBS-HET-1)
ƔAnonymous, cross-sectional interview of men and women 18 í50
years old who had an opposite-gender sex partner in the past year.
ƔConducted in 25 cities throughout the U.S. from September 2006
to October 2007.
ƔSurvey topics included demographic characteristics, sexual
behavior, drug and alcohol use, HIV testing, sexually transmitted
diseases, health conditions, and the use of prevention services.
ƔAnonymous HIV testing was offered to all participants.
ƔParticipants were recruited using two methodologies: respondent-
driven sampling (RDS) and venue-based sampling (VBS).
ƔRecruitment efforts targeted census tracts with high rates of
±For RDS, only HRA residents were allowed to recruit other
±For VBS, recruitment venues were located in HRAs.
Analysis Sample
had household incomes below the U.S. poverty level).
ƔConsented to HIV testing (98%) and had a valid HIV test result
ƔResided in one of 23 cities with complete NHBS-HET-1 and
census tract data.
±Northeastern Region: Boston, Nassau/Suffolk Counties, New
Haven, New York City, Newark, and Philadelphia.
±Southern Region: Atlanta, Baltimore, Dallas, Fort Lauderdale,
Houston, Miami, New Orleans, and Washington, DC.
±Midwestern Region: Chicago, Detroit, and St. Louis.
±Western Region: Denver, Las Vegas, Los Angeles, San Diego,
San Francisco, and Seattle.
Data available
Data not availabl e
ƔNot a member of a high-risk sub-population (MSM, IDUs, CSWs,
or CSW clients).
Statistical Analysis
ƔAssociations with HIV prevalence were examined using chi-
ƔBecause outcomes did not differ by recruitment method (RDS
or VBS), data were combined in this analysis.
PLEASE NOTE: The data presented in this poster have been updated from the data presented in the published abstract.
Of 18,430 NHBS-HET-1 participants, 9,078 (49%) met our analysis criteria
and lived in urban poverty areas; 188 (2.1%) of whom had a positive HIV
test result. This HIV prevalence rate is more than 20 times greater than
the rate among all heterosexuals in the U.S. (0.1%).2,3
HIV Prevalence,
by Demographic Characteristics
Demographic characteristics significantly associated with HIV prevalence
were age, education, annual household income, poverty level, employment,
homeless status, and region. Multivariate modeling identified the same
predictors of HIV prevalence (data not shown).
HIV Prevalence Rate, by Country
Burundi Haiti
Percent HIV-positive
Ethiopia AngolaU.S.
Data Sources: NHBS-HET-1 2006 í2007 and UNAIDS HIV Estimates 2007.1
The 2.1% HIV prevalence rate found in urban poverty areas in the U.S.
exceeded the 1% cut-off that defines a generalized HIV epidemic and is
similar to the rates found in several low-income countries that have
generalized HIV epidemics.1
HIV Prevalence Rate, by Income
10 í19,999 20 í49,999 50,000
Annual Household Income (in U.S. Dollars)
Percent HIV-positive
Data Source: NHBS-HET-1 2006 í2007.
HIV prevalence rates in urban poverty areas were inversely related to
annual household income-- the lower the income, the greater the HIV
prevalence rate.
This inverse relationship between HIV prevalence and socioeconomic
status (SES) was observed for all SES metrics examined (education,
annual household income, poverty level, employment, and homeless
HIV Prevalence Rate, by Race/Ethnicity
U.S. Overall
U.S. Poverty Areas
Black Hispanic White
Percent HIV-positive
HIV prevalence rates in urban poverty areas did not differ significantly by
race or ethnicity. This contrasts with the substantial racial and ethnic
differences found in rates for the overall U.S. population (which includes
high-risk sub-populations). For the overall U.S. population, the HIV
prevalence rate for blacks (1.7%) is more than 8 times the rate for whites
(0.2%), and the rate for Hispanics (0.6%) is 3 times the rate for whites.2
Poverty may account for some of the racial and ethnic disparities found in
HIV prevalence rates for the overall U.S. population-- 46% of blacks and
40% of Hispanics live in poverty areas compared to just 10% of whites.4
Data Sources: NHBS-HET-1 2006 í2007 and U.S. HIV Prevalence Estimates 2006.2
1UNAIDS. 2008 report on the global AIDS epidemic 2008.
2CDC. HIV prevalence estimates±United States, 2006. MMWR
3U.S. Census Bureau. Annual estimates of the resident population
by sex and selected age groups for the United States: April 1, 2000
to July 1, 2008. NC-EST2008-02 2009.
4U.S. Census Bureau. Areas with concentrated poverty: 1999.
Census 2000 Special Reports 2005.
ƔSince NHBS-HET-1 is a convenience sample drawn from selected
cities, the urban poverty area residents who participated in the
survey may not be representative of all urban poverty area
residents in the U.S.
±Nevertheless, our analysis sample included demographically
diverse participants from a large number (23) of cities throughout
the U.S.
ƔOur findings are not generalizable to non-urban poverty area
ƔBecause NHBS-HET-1 targeted census tracts with high rates of
poverty and HIV diagnosis (HRAs), our results may overestimate
the HIV prevalence rate in urban poverty areas.
±However, despite this potential bias, we found that HIV preva-
lence rates did not differ significantly between participants who
were residents of HRAs (2.1%) and those who were not (2.0%).
ƔThe HIV prevalence rate among NHBS-HET-1 participants living
in urban poverty areas was very high (2.1%) and exceeded the
1% cut-off that defines a generalized HIV epidemic.
ƔHIV prevalence rates in urban poverty areas were inversely
related to socioeconomic status (SES)-- the lower the SES, the
greater the HIV prevalence rate.
ƔUnlike overall HIV prevalence rates in the U.S., HIV prevalence
rates in urban poverty areas did not differ significantly by race or
ƔHIV prevention efforts should be expanded in urban poverty
areas in the U.S.
±Community-level interventions, in particular, would be ideal for
these foci of high HIV prevalence.
±Structural interventions to improve socioeconomic conditions in
these areas may reduce HIV infection rates.
ƔSpatial analysis should be used to identify areas of low
socioeconomic status for targeting HIV prevention activities for
heterosexuals at increased risk of HIV infection.
ƔThe impact of the HIV epidemic in non-urban poverty areas
should be assessed, especially in the Southern Region of the
U.S. where there are high levels of rural poverty.
Contact Information
Address: 1600 Clifton Road, MS E-46
Atlanta, GA 30333, USA
The findings and conclusions in this poster are those of the authors
and do not necessarily represent the official position of the CDC.
... From a geographic perspective, the CDC identi es impoverished urban areas as settings of generalized epidemics. By de nition, a concentrated epidemic exists when the prevalence rate is <1% in the general population but >5% in at least one high-risk subpopulation, such as is seen with HIV among MSM, persons who inject drugs (PWID), and persons who exchange sex for money (sometimes referred to as commercial sex workers or CSWs) in these areas (Denning & DiNenno, 2019). ...
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... The intricate interplay of racism, classism, gender power dynamics, and community conditions significantly exacerbate the vulnerability of Black/African American women living in low-income communities that are more vulnerable to HIV exposure [4]. According to Denning and Dinenno, HIV among heterosexual women who did not inject drugs and lived in geographic zones associated with poverty did not vary substantially by race [5]. However, the fact that a higher proportion of Black/African American women live in poverty (46%) compared to White women (10%) makes poverty one of the most significant social determinants of health for Black/African American women [6,7]. ...
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... Briefly, a recent investigation indicated that elevated HIV prevalence in the TCDA was associated with minorities, gay and bisexual populations up to 29 years old, and the socioeconomically disadvantaged, such as those experiencing homelessness, poverty, and unemployment (170). It is worth noting that this trend is observed nationwide (183,184). Researchers have also found that TCDA had a TB incidence twice than that of Michigan, affected by both racial inequity and places of interaction (185). ...
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... Poverty is also a social factor linked to HIV vulnerability. For example, one study with 9,078 participants reported the prevalence of HIV among individuals living in poverty was nearly 20 times the national average in the U.S. (Denning & DiNenno, 2017). ...
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HIV prevalence estimates United States
  • Cdc
CDC. HIV prevalence estimates United States, 2006. MMWR 2008;57:1073-76.
Annual estimates of the resident population by sex and selected age groups for the United States
  • U S Bureau
U.S. Census Bureau. Annual estimates of the resident population by sex and selected age groups for the United States: April 1, 2000 to July 1, 2008. NC-EST2008-02 2009.
Areas with concentrated poverty: 1999. Census
  • U S Bureau
U.S. Census Bureau. Areas with concentrated poverty: 1999. Census 2000 Special Reports 2005.