National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention Alexandra M. Oster, MD, Kate Russell, MD, MPH, Ryan E. Wiegand, MS, Eduardo Valverde, MPH, David W. Forrest, PhD, Melissa Cribbin, MPH, Binh C. Le, MD, Gabriela Paz-Bailey, MD, PhD, MSc, for the NHBS Study Group Division of HIV/AIDS Prevention Centers for Disease Control and Prevention Atlanta, GA, United States AIDS 2012 Abstract MOAC0103 July 23, 2012 Foreign location of birth and time since immigration are associated with HIV status among Latino MSM in the United States The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Background: Latinos and HIV  In the United States, Latinos are disproportionately affected by HIV  Rate of new infections among Latino men is two and a half times that of white men  In 2009, Latino men who have sex with men (MSM) accounted for 81% of new infections among Latino men *Prejean PLoS ONE 2011

Background: Latino MSM  Location of birth: U.S. vs. foreign-born  Different levels of HIV knowledge, risk behavior, and use of prevention services  Foreign-born Latinos are a diverse group who have different cultures and levels of acculturation  Among foreign-born populations, health status varies by  Location of birth  Time since arrival

Objectives  Describe prevalence of HIV infection among Latino MSM in the United States  Assess associations of location of birth and time since arrival with prevalent HIV infection

U.S. National HIV Behavioral Surveillance System (NHBS)  Implemented in 2003  NHBS conducted in annual rotating cycles among:  Men who have sex with men (MSM)  Injection drug users  Heterosexuals at increased risk of HIV infection

NHBS-MSM, 2008: 21 metropolitan statistical areas (MSAs) Atlanta Miami San Juan New Orleans Dallas Houston San Diego Los Angeles Seattle Denver St. Louis Chicago Detroit Boston Nassau New York City Newark Philadelphia Baltimore Washington DC San Francisco

NHBS-MSM data collection  Venue-based, time-space sampling  Identification of venues  Random selection of venues  Recruitment of participants  Standardized in-person interview (anonymous)  HIV testing (anonymous)  All participants offered HIV test

Eligibility and analysis criteria  Eligibility criteria  ≥ 18 years of age  Resident of metropolitan statistical area (MSA)  Able to complete interview in English or Spanish  Male sex at birth and identifies as male  Inclusion criteria for this analysis  Male sex partner during the past 12 months  Reported being Hispanic or Latino  20 MSAs in continental United States (excluded San Juan, Puerto Rico)

Analytic methods  Described HIV prevalence of Latino MSM by  Sociodemographic characteristics (age, education, income, sexual identity)  Migration status U.S. -born Arrived ≥5y ago Arrived <5y ago  Region of birth United States (excluding Puerto Rico) Puerto Rico Mexico Caribbean Central America South America

Multivariable analysis  Outcome variable: prevalent HIV infection  Predictor variable:  Model 1: Migration status: U.S.-born, arrived ≥5y ago, arrived <5y ago  Model 2: Region of birth: United States, Puerto Rico, Mexico, Caribbean, South America, Central America  Both models adjusted for age, education, income, sexual identity  GEE-based Poisson model  Accounted for clustering at MSA level

Sample characteristics

Race/ethnicity, NHBS-MSM, 2008 (N=8,153)

Migration status, Latino MSM (N=1,734)

Region of birth, Latino MSM (N=1,734)

HIV prevalence among Latino MSM

HIV prevalence, Latino MSM (N=1,734)

HIV prevalence by age, Latino MSM (N=1,734) p<0.0001

HIV prevalence by education, Latino MSM (N=1,734) p=0.3

HIV prevalence by income (in USD), Latino MSM (N=1,734) p=0.006

HIV prevalence by sexual identity, Latino MSM (N=1,734) p=0.003

HIV prevalence by migration status, Latino MSM (N=1,734) p=0.0001

HIV prevalence by region of birth, Latino MSM (N=1,734) p=0.007

Multivariable analysis

Model 1: Associations with prevalent HIV infection among Latino MSM, NHBS-MSM, 2008 Adjusted Prevalence Ratio*95% CI Age (y)1.5/10y increase Income 0-19,999 USD ,000-39,999 USD ,000-74,999 USD ,000+ USDReferent Sexual Identity Gay or homosexual Bisexual Straight or heterosexual Referent Migration status U.S.-born Arrived ≥5y ago Arrived <5y agoReferent *Adjusted for all variables listed and education.

 In model including region of birth, region of birth was not significantly associated with prevalent HIV infection  Other associations were similar to those in Model 1 Model 2: Associations with prevalent HIV infection among Latino MSM, NHBS-MSM, 2008

Summary  Among Latino MSM, HIV infection was associated with  Age  Income  Sexual identity  Migration status

Analysis Limitations  Not representative of all Latino MSM  Data collected in cities with high AIDS prevalence  Most of the men were recruited from bars or dance clubs  Sampling methods may result in selection bias  Data are not weighted to account for bias  We did not have data on intent to remain in the United States

Discussion (1)  Foreign-born men who arrived ≥5y ago and U.S.-born Latino MSM had higher HIV prevalence  Suggests many foreign-born MSM acquire HIV after arrival  Indicates presence of critical window for HIV prevention  Many Latino MSM immigrate to U.S. to escape hostile social environments  Arrival leads to increased sexual freedom and disinhibition  Targeting recent arrivals may be particularly important

Discussion (2)  In descriptive analysis, HIV prevalence varied substantially by region of birth  Highest among MSM born in Puerto Rico, South America, and Caribbean  Differences did not persist in multivariable analysis  May be due to confounding by other characteristics, such as age  This information may be useful when designing prevention strategies in cities with large Latino populations

Discussion (3)  HIV infection also associated with low income  Our study does not explain link between low income and HIV infection  Public health officials should make special efforts to reach low-income Latino MSM with HIV prevention efforts  We should work to improve access of this population to testing and care

Acknowledgements NHBS Study Group: J Taussig, R Gern, T Hoyte, L Salazar; C Flynn, F Sifakis, D Isenberg, M Driscoll, E Hurwitz, N Prachand, N Benbow, S Melville, P Pannala, R Yeager, A Sayegh, J Dyer, A Novoa, M Thrun, A Al-Tayyib, R Wilmoth, E Higgins, V Griffin, E Mokotoff, M Wolverton, J Risser, H Rehman, T Bingham, E Sey, M LaLota, L Metsch, D Forrest, D Beck, G Cardenas, C Nemeth, C Watson, L Smith, W Robinson, D Gruber, C Murrill, A Neaigus, S Jenness, H Hagan, T Wendel, H Cross, B Bolden, S D’Errico, K Brady, A Kirkland, V Miguelino, A Velasco, H Raymond, M Courogen, H Thiede, R Burt; M Herbert, Y Friedberg, D Wrigley, J Fisher, P Cunningham, M Sansone, T West-Ojo, M Magnus, I Kuo Behavioral Surveillance Team, CDC NHBS Participants

Alexa Oster, MD Medical Epidemiologist Behavioral and Clinical Surveillance Branch Alexa Oster, MD Medical Epidemiologist Behavioral and Clinical Surveillance Branch National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention