The Issue:

Sexually transmitted diseases are reported at higher rates for minority groups than in whites. In turn, the reported negative consequences of STDs disproportionately affect minorities. For example:

• Minority populations have higher rates of reported gonorrhea and syphilis than whites. In 1993, compared with whites, African Americans, Native Americans, and Hispanics had gonorrhea rates that were 42, 5, and 4 times higher, respectively; African Americans, Hispanics, and Native Americans had syphilis rates that were 64, 13, and 5 times higher, respectively.¹
• The South has consistently had higher rates of both gonorrhea and syphilis compared with other regions throughout the 1980s and 1990s. Minority populations are disproportionately located in southern states.²
• African American men have gonorrhea rates that are 68 times greater than those in white men. For women, these rates are 28 times greater in African Americans than in whites.³
• African American adolescents and young adults have STD rates that are more than 20 times higher than those in white adolescents.⁴
• Comprehensive chlamydia screening programs for women thus far show higher rates for minority women than for white women.⁵
• Non-white women are nearly three times as likely as white women to be hospitalized with acute Pelvic Inflammatory Disease (PID) and more than two times as likely to be hospitalized with chronic PID.⁶
• African American women are nearly three times more likely to die of cervical cancer than white women, when data are adjusted for age.⁷

Opportunities:

1. Involving affected communities in prevention planning. HIV prevention community planning involves racial/ethnic minority communities in determining the HIV prevention needs of their communities. STD programs, though somewhat different from HIV programs, can learn from this HIV prevention experience to help them identify ways to involve affected communities in STD prevention efforts.
2. Syphilis concentrated in the South. Focusing research and program efforts on syphilis in the South will allow increased opportunity to better focus prevention efforts on minority populations, both in terms of preventing syphilis and congenital syphilis and in terms of indirectly reducing HIV transmission.
3. Growing understanding of need for population-tailored programs. There is a growing understanding of the importance of culturally competent and linguistically appropriate behavioral interventions for STD and HIV prevention in minority communities. The increasing involvement of community-based organizations and national minority organizations in STD and HIV prevention affords an opportunity to capitalize on that understanding.
4. Negative STD-related consequences concentrated among minorities. As minority women have higher rates of chlamydia, gonorrhea and their consequences, there is an opportunity to avoid less effective generic prevention efforts and rather, to tailor prevention efforts to these populations.

Challenges:

1. Co-existence of STDs with other social problems. STD morbidity is concentrated in the same racial/ethnic populations that face competing problems such as increasing poverty, high levels of unemployment, teenage pregnancy, drug use/distribution, violence, and prostitution. These problems frequently impede attempts to provide services and, in some communities, are often perceived as outweighing the importance of health issues.
2. Unclear relationship between STDs and race/ethnicity and socioeconomic status (SES). Determining the effects of race/ethnicity and socioeconomic status on STD morbidity is a major scientific challenge.
3. Legacy of Tuskegee. After penicillin was identified as an effective drug against syphilis, African Americans participating in a Public Health Service (PHS) funded study who were infected with syphilis were left untreated. In turn, they suffered the consequences of syphilis under the justification that researchers needed to complete the original study to observe the natural course of syphilis. The Tuskegee study has left PHS with a legacy that is both a burden and an opportunity. PHS must live and deal with the mistrust born of the mistakes of the past and ongoing issues of racism. Yet, as new programs evolve, there is heightened sensitivity to issues of diversity, equality, and fairness during the process of refining and developing prevention and research programs.
4. Reporting bias. Racial/ethnic minority populations are over-represented among persons of lower socioeconomic status in the United States, and therefore, they more frequently seek health care through public providers than white Americans. Reporting by public providers is more complete than reporting by private providers. Consequently, STD surveillance data probably overestimate morbidity among racial/ethnic minorities relative to morbidity among white Americans.
5. Sociocultural differentials and risk behaviors. Deep-seated sociocultural differences may underpin some of the racial/ethnic differentials in risk behaviors. For example, beliefs in the effectiveness of condoms as prophylaxis against infection is most widespread among whites and least widespread among Hispanics. In addition, a 1988 national survey indicated that two-thirds of African American women compared to only one-third of white women reported douching, a practice that increases the risk for PID, ectopic pregnancy, and cervical cancer.
6. Higher concentration of youth and women. The age composition and sex ratio of African American and Hispanic populations are more conducive to the spread of STDs than that of the white population. Hispanic and African Americans have younger populations than white Americans; African Americans, especially, have an excess of women over men in young, sexually active age groups.

Recommendations:

1. STD prevention efforts should involve affected racial/ethnic minority communities in planning, developing, implementing and evaluating programs to begin to overcome many of the challenges that currently hinder STD prevention.
2. STD prevention in minority communities should be integrated with other relevant programs through which the population has been successfully reached.
3. In surveillance of STDs, methods to overcome potential reporting bias should be identified. These efforts should include increased and better enforcement of mandatory reporting requirements by private providers to assist in alleviating reporting bias.
4. The problem of reporting bias for STDs should be communicated to the general public and minority communities.

¹Division of STD Prevention, Sexually Transmitted Disease Surveillance 1994, CDC, Atlanta, 1995.

²Ibid.

³Ibid.

⁴Ibid.

⁵Division of STD Prevention, Sexually Transmitted Disease Surveillance 1994, CDC, Atlanta, 1995.

⁶Rolfs RT, Galaid EI, Zaidi AA. Pelvic inflammatory disease: Trends in hospitalizations and office visits, 1979-1988. Am J Obstet Gynecol 192;166:983-90.

⁷American Cancer Society Department of Epidemiology and Surveillance, Atlanta, GA, October 1994, based on data from the Division of Vital Statistics, the National Center for Health Statistics, CDC.