Georgia HIV Behavioral Surveillance (GHBS) : 2010 and 2013 survey of metro Atlanta heterosexuals at increased risk for HIV

The Georgia Department of Public Health

GEORGIA HIV BEHAVIORAL SURVEILLANCE (GHBS)
2010 and 2013 Survey of Metro Atlanta Heterosexuals at increased risk for HIV

What is GHBS? Each year throughout the United States, 20 health departments serving the cities with the highest HIV prevalence collaborate with the Centers for Disease Control and Prevention (CDC) to implement the National HIV Behavioral Surveillance System (NHBS). NHBS assesses and monitors HIV-related risk behavior, testing behavior and use of prevention programs among three populations at heightened risk for HIV infection: men who have sex with men (MSM), persons who use injection drugs (IDU), and heterosexual men and women at increased risk of HIV infection (HET). In 2010 (HET2) and 2013 (HET3), the Georgia Department of Public Health implemented the survey with a focus on heterosexuals at increased risk of HIV infection in the Atlanta area.
Background: HIV among HET According to the most recently-available CDC Surveillance Report, Georgia ranked 5th in the nation for new HIV diagnoses among adults and adolescents in 2013. Georgia also ranked 5th for the total number of adults and adolescents living with HIV and an AIDS diagnosis. Similarly, the Atlanta MSA ranked 5th in the nation for new HIV diagnoses and 7th in the nation for new AIDS diagnoses in 2013 (CDC, Today's HIV/AIDS Epidemic, 2015).
In 2013, the rate of all new HIV diagnoses was highest in the South (20.5 per 100,000 people) (CDC, Today's HIV/AIDS Epidemic, 2015).In Georgia, heterosexual contact accounted for 7% of all new HIV diagnoses and 7% of all new AIDS diagnoses among males in 2013. Among females, transmission by heterosexual contact accounted for 81% of new HIV diagnoses and 84% of new AIDS diagnoses in 2012 (Georgia Department of Public Health, 2015).

Counties in the Atlanta Metropolitan Statistical Area
Survey Methods Data collection took place between November and December of 2010 and September and December of 2013. During this time participants were recruited into the study using respondent-driven sampling (RDS), a type of peer-driven chain-referral sampling. Men and women were recruited by social contacts in neighborhoods of high poverty and HIV prevalence in the Atlanta MSA and were screened for eligibility after providing voluntary consent. Surveys were conducted by trained interviewers using hand-held touch-screen computers. If consent was obtained, participants were asked core survey questions followed by a set of local questions of interest to Atlanta-based researchers. HIV testing and counseling were offered to every participant. During HET2, HIV testing was conducted using the OraSure HIV-1 Oral Specimen Collection Device. During HET3, rapid HIV testing was conducted using the Clearview COMPLETE HIV 1/2 device.

Research assistants demonstrate use of a hand-held device

2 Peachtree Street, Atlanta, Ga 30303 | www.dph.georgia.gov

Mar 2015

RESULTS
A total of 279 heterosexual men and women at increased risk for HIV from the HET2 cycle and 561 from the HET3 cycle met the eligibility criteria and consented to completing the survey. Data are presented for both cycles combined (n=840) because results varied little. Meaningful differences between cycles are described in the text.
DEMOGRAPHICS (Table 1)
Gender and Age Among the eligible HETs, 54% were male and 46% were female. Among HET2s 52% were age 18-29 years old, 16% age 30-39, 18% age 40-49, and 14% age 50 and older. Among HET3s, 24% were age 1829 years old, 21% age 30-39, 27% age 40-49, and 28% age 50 and older.
Education Highest educational attainment was diverse among participants. Less than 2% completed a Bachelor's degree or higher degree, 18% completed a 2-year degree or some college, 45% completed a High School Diploma or a General Equivalency Degree (GED), and 35% did not have a High School Diploma or equivalent.
Income and unemployment The great majority (84%) reported earning an income of $0-$19,999 annually followed by 13% earning $20,000 to $49,999, 2% earning $50,000-$74,000, and 1% earning $75,000 or more. Fifty-one percent reported being unemployed (data not shown).
Homelessness Twenty-nine percent of HET2s said they had been homeless in the past 12 months and of these, 54% were currently homeless. Forty-nine percent of HET3s said they had been homeless in the past 12 months and 64% of these were currently homeless (data not shown).
County of residence The majority of HETs (93%) surveyed said they lived in Fulton County, followed by Dekalb County (4%), and other MSA counties (3%).
Health Insurance and Healthcare Most HETs (67%) said they had no health insurance coverage at the present time. Of those who had insurance, 68% said that their health care expenses were paid for by Medicaid, 17% Medicare, 7% private health insurance or HMO, and 3% Veterans Administration coverage.

Table 1: Demographics Gender Male Female Race/Ethnicity White, non-Hispanic Black, non-Hispanic Hispanic/Latino Other Age group (years) 18-29 30-39 40-49 50 and older Education < High school
High school diploma or equivalent
Some college or technical degree
College degree or post graduate education

(n=840)
54% 46%
<1% 97%
2% <1%
33% 19% 24% 23%
35%
45%
18%
2%

Annual household income $0-$19,999 $20,000-$49,999 $50,000-$74,999 $75,000 County of residence Dekalb Fulton Other Health insurance No health insurance Type of health insurance Medicaid Medicare Private or HMO Veterans Administration

84% 13%
2% 1%
4% 93%
3%
67% (n=277)
68% 17%
7% 3%

SEXUAL BEHAVIORS (Table 2) Results are presented for men and women separately; for men, results are presented for men overall (454), and for the subset of men who reported sex with men and with women (44).

Sexual debut and number of partners The average sexual debut age was 15 years for males, 15 years for bisexual males, and 16 years for females.

Male participants reported an average of 8 partners over the past 12 months, bisexual men reported an average of 9 female partners, and female participants reported an average of 5 partners.

Condom use Seventy-one percent of men reported not using a condom the last time they had vaginal sex with a women. Of 41 bisexual men reporting vaginal sex with women, 90% reported not using a condom. Of 74 men reporting anal sex with a woman, 90% of men reported not using a condom, and of the 23 bisexual men reporting anal sex with a woman, 96% reported not using a condom. Eighty-one percent of women did not use a condom the last time they had vaginal sex. Of 42 women reporting anal sex, 79% did not use a condom.

Knowledge of partner HIV status Fifty-seven percent of men did not know their last partner's HIV status, and for the subset of bisexual men, 70% did not know their last partner's HIV status. Overall, 53% or women did not know the HIV status of their last sex partner.

Table 2: Sexual risk behaviors

Sexual debut (average age)

Men (n=453)

15

Bisexual men (n=44)

15

Women (n=387)

16

Number of sex partners

(average)

Men (n=453)

8

Bisexual men (n=44)

9

Women (n=387)

5

No condom at last vaginal sex

Men (n=436)

71%

Bisexual men (n=41)

90%

Women (n=380)

81%

No condom at last anal sex

Men (n=74)

90%

Bisexual men (n=23)

96%

Women (n=42)

79%

Did not know last sex partner's HIV status

Men (n=453)

55%

Bisexual men (n=44)

70%

Women (n=386)

53%

ALCOHOL AND DRUGS (Table 3)
Alcohol and drugs during sex Among men, 25% said they used only alcohol, 9% said they used only drugs, and 28% said they used both alcohol and drugs during their most recent sex.
Among women, 20% said they used only alcohol, 7% said they used only drugs, and 15% said they used both alcohol and drugs during their most recent sex.
Injection Drugs Eight percent of men and 5% of women indicated they had ever injected drugs. Two percent of men and 1% of women reported injection in the last 12 months.

Non-Injection Drugs Seventy two percent of men and 52% of women indicated they had used non-injection drugs other than those prescribed to them in the last 12 months.

Table 3: Alcohol and drugs

Alcohol and/or drugs during

last sex

Men

Only alcohol

25%

Only drugs

9%

Both alcohol and drugs

28%

Women

Only alcohol

20%

Only drugs

7%

Both alcohol and drugs

15%

Injection drug use

Men

Ever in their lifetime

8%

In the past 12 months

2%

Women

Ever in their lifetime

4%

In the past 12 months

1%

Non-injection drug use

Men

In the past 12 months

72%

Women

In the past 12 months

52%

HIV TESTING AND PREVENTION (Table 4)

HIV testing behaviors Overall 85% reported ever having a HIV test, and 40% were tested in the last 12 months. The proportion reporting testing in the last 12 months increased from 33% for HET2s to 43% for HET3s.

Participants reported being tested an average of 2 times in the past 2 years.

Reasons for not having a recent HIV test Among HET3 participants who said they were not tested for HIV during the past 12 months, the most common reason was "no particular reason" (51%), followed by "afraid of finding out they had HIV" (16%), "thought to be at low risk for HIV infection" (14%) and "didn't have time" (13%). Among HET2s, the most important reasons reported for not being tested were "didn't have the money or insurance to pay for the test" (23%), followed by "afraid of finding out they had HIV" (21%), "thought to be at low risk for HIV infection" (19%), "didn't like needles" (14%), and "didn't have time" (13%). In contrast to HET3, HET2 participants were not given an option to select "no particular reason".

Prevalence of HIV infection Among those who consented to HIV testing as part of the survey (n=839), 3% (26) had an HIV-positive test. Of these, 31% indicated they were not aware of their HIV-positive status before taking the survey.

Availability/Use of Free Condoms Overall 39% indicated they had received free condoms not counting those given to them by a friend, relative or sex partner. This varied by cycle, with 27% of HET2s and 45% of HET3s reporting receipt of free condoms. Seventy-one percent of those who received free condoms indicated using them.

HIV Prevention Resources Only 10% of said they had a one-on-one conversation with an outreach worker, counselor, or prevention program worker about ways to prevent HIV in the past 12 months. Six percent of reported being a participant in an organized session(s) involving a small group of people to discuss ways to prevent HIV in the past 12 months.

Table 4: HIV testing and prevention
HIV Testing

Ever tested

85%

Tested in past 12 months

39%

Number of times tested in the

past 2 years (average)

2

HIV Prevalence (n=839)

Positive

3%

If HIV Positive (n=26)

Unaware of HIV positive status

31%

HIV Prevention

Received free condoms in past 12

months

39%

Used free condoms received in

past 12 months

71%

Had a one-on-one conversation

about ways to prevent HIV in the

past 12 months

10%

Participated in an organized

session to discuss ways to

prevent HIV in the past 12

months

6%

RECOMMENDATIONS
There is a need to promote access to health care among HETs. Over two-thirds did not have health insurance and almost a third had not seen a health care provider in the past 12 months.
Thirty one percent were not aware of their positive HIV status. Programs for HIV testing, prevention and treatment should include components to promote regular testing to increase awareness of HIV status among men and women.
Because of the association between alcohol, drugs and HIV-related risk behavior, programs for HIV prevention and treatment in metro Atlanta should factor into consideration the prevalence of drug use and heavy alcohol consumption among HETs.
There was a substantial increase in receipt of free condoms between 2010 and 2013, suggesting increased programmatic efforts. Nonetheless, less than half of HET3s and about a third of HET2s said they had received free condoms in the community (not including those obtained from friends, family or sex partners). Of those participants who received free condoms, almost three quarters reported using them. With the majority of people who receive free condoms reporting using them, opportunities should be explored for strengthening and expanding the existing network of condom distribution programs in metro Atlanta.
In comparison to straight identified males and females from the HET3 cycle, bisexual men reported a higher average number of sex partners and much lower condoms use at last sex. HIV testing programs should target this high risk subgroup with prevention messages designed specifically with them in mind.

Limitations
Findings are not representative of all HETs in metro Atlanta because participants were recruited into the study using response-driven sampling (RDS), a type of peer-driven chain-referral sampling. Basic demographic differences in age and race between HET2 and HET3 could have an influence on the findings. Also, only sexually-active HETs were included in this analysis. Findings might not be generalizable to other cities. The number of men and women unaware of their HIV-positive status might be inflated because some men who knew their positive status may have described themselves as HIVnegative to the interviewer because of HIV-related stigma.
Acknowledgments
Special thanks to our storefront locations that made their venues accessible to NHBS surveyors for the 2010 and 2013 survey: Berean Seventh-Day Adventist Church, Zion Grove Baptist Church, and Central Presbyterian Church. Grateful recognition is also given to the NHBS Atlanta 2010 and 2013 team of research assistants.
Brenda Fitzgerald, MD, Commissioner J. Patrick O'Neal, MD, Director of Health Protection Cherie L. Drenzek, DVM, MS, State Epidemiologist Pascale Wortley, MD, HIV Epidemiology Section Director
Jeffery D. Todd, MA, GHBS Team Lead, Kimi Sato, MPH, GHBS Project Coordinator Sandi Brown, MPH, GHBS Program Consultant Genetha Mustaafaa, MFT, GHBS Program Consultant
Suggested Citation: Georgia Department of Public Health. (2015). HIV Behavioral Surveillance Fact Sheet: 2010 and 2013 Survey of Heterosexual Men and Women at Increased Risk for HIV who Reside in Metropolitan Atlanta. Reported by: Jeff Todd, MA; Kimi Sato, MPH; Sandi Brown, MPH; Genetha Mustaafaa, MFT. For more information please contact: Jeff Todd, GHBS Team Lead, Georgia Department of Public Health, 2 Peachtree ST NW, Suite 14-464, Atlanta, GA 30303.
http://dph.georgia.gov
For resources related to HIV, syphilis and other infections including screening, treatment and supportive services please call the Georgia AIDS/STD InfoLine at 1-800-551-2728.