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HIV Infection Among Heterosexuals at Increased Risk -- United States, 2010

March 15, 2013

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Editorial Note

The findings from this analysis indicate that HIV prevalence among a sample of low-SES heterosexuals residing in MSAs with high AIDS prevalence was 2.3% overall and 1.1% among those who did not report a previous positive HIV test result. The overall 2.3% HIV prevalence among survey participants is approximately five times the 0.45% estimated for all persons aged ≥13 years in the United States.1 HIV prevalence was high among participants reporting exchange sex and crack cocaine use, those with less than a high school education, and those unemployed or disabled. These findings suggest the need for both behavioral and structural5 HIV prevention interventions for these populations. Additional efforts should address reducing health inequities, particularly among African Americans and Hispanics or Latinos, two populations that comprised 91.7% of the NHBS participants.

Among the 1.1% who were infected with HIV but did not report a previous positive HIV test, 43.9% reported that they had never been tested for HIV infection until participating in NHBS. A key step to reducing the number of new HIV infections in the United States, as indicated in the National HIV/AIDS Strategy,6 is to increase the percentage of persons living with HIV who know their serostatus through HIV testing. Persons aware of their HIV infection often take steps to reduce their risk behaviors substantially and can be referred for treatment and care, which can reduce HIV transmission.7 Overall, among participants in this study, 25.8% had never been tested for HIV, underscoring the need for increased HIV testing and linkage to care for low-SES heterosexuals living in urban areas with a high prevalence of AIDS. CDC currently supports an expanded testing program to increase HIV testing among populations disproportionately affected by HIV in 30 health jurisdictions, including the 21 NHBS MSAs. In the first 3 years of this program, 2.8 million tests were conducted, and approximately 18,000 persons were newly diagnosed with HIV infection.8

The findings in this report are subject to at least three limitations. First, some participants might not have accurately reported their HIV risk behaviors or previous HIV test results to interviewers, and results might be affected by social desirability bias. Second, sampling was limited to men and women who live in urban areas with a high prevalence of AIDS, and analyses were limited to those with low SES; findings might not be generalizable to other heterosexual groups. Finally, because of high levels of HIV stigma, poverty, and homelessness in this population, standard sampling methods were not considered practical; the data were not weighted to account for the complexities or potential biases of network-based sampling, and statistical tests were not conducted. Therefore, differences between groups should be interpreted with caution.


CDC and its partners are pursuing a high-impact prevention approach§§ to advance the goals of the National HIV/AIDS Strategy and maximize the effectiveness of current HIV prevention methods. This approach focuses on implementing prevention strategies that have shown the greatest potential to reduce new infections on a scale large enough to yield the greatest impact in populations and geographic areas with the greatest burden of disease. The high level of HIV infection observed in NHBS among low-SES heterosexuals living in MSAs with high AIDS prevalence is a serious public health concern. Efforts to 1) reduce stigma and make HIV testing accessible, affordable, and culturally acceptable9; 2) improve linkage to HIV care and treatment; and 3) implement interventions that address behavioral and structural factors that place low-SES heterosexuals at higher risk for contracting HIV infection6,9 could lead to reductions in HIV incidence and health inequities to achieve the goals of the National HIV/AIDS Strategy.


National HIV Behavioral Surveillance System staff members Atlanta, Georgia: Jianglan White, Laura Salazar, Jeff Todd; Baltimore, Maryland: Colin Flynn, Danielle German; Boston, Massachusetts: Maura Miminos, Rose Doherty, Chris Wittke; Chicago, Illinois: Nikhil Prachand, Nanette Benbow; Dallas, Texas: Sharon Melville, Shane Sheu; Alicia Novoa; Denver, Colorado: Mark Thrun, Alia Al-Tayyib, Ralph Wilmoth; Detroit, Michigan: Vivian Griffin, Emily Higgins, Karen MacMaster; Houston, Texas: Jan Risser, Aaron Sayegh, Hafeez Rehman; Los Angeles, California: Trista Bingham, Ekow Kwa Sey; Miami, Florida: Marlene LaLota, Lisa Metsch, David Forrest; Nassau-Suffolk, New York: Bridget J. Anderson, Carol-Ann Watson, Lou Smith; New Orleans, Louisiana: DeAnn Gruber, William T. Robinson, Narquis Barak; New York City, New York: Alan Neaigus, Samuel Jenness, Holly Hagan; Newark, New Jersey: Barbara Bolden, Sally D'Errico, Henry Godette; Philadelphia, Pennsylvania: Kathleen A. Brady, Andrea Sifferman; San Diego, California: Vanessa Miguelino-Keasling, Al Velasco; San Francisco, California: H. Fisher Raymond; San Juan, Puerto Rico: Sandra Miranda De León, Yadira Rolón-Colón, Melissa Marzan; Seattle, Washington: Maria Courogen, Hanne Thiede, Richard Burt; St Louis, Missouri: Michael Herbert, Yelena Friedberg, Dale Wrigley, Jacob Fisher; Washington, District of Columbia: Manya Magnus, Irene Kuo, Tiffany West; CDC Behavioral Surveillance Team.


  1. CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data -- United States and 6 U.S. dependent areas -- 2010. HIV surveillance supplemental report, Vol. 17, no. 3, part A. Atlanta, GA: US Department of Health and Human Services, CDC; 2012.
  2. CDC. Characteristics associated with HIV infection among heterosexuals in urban areas with high AIDS prevalence -- 24 cities, United States, 2006-2007. MMWR 2011;60:1045-9.
  3. DiNenno EA, Oster AM, Sionean C, Denning P, Lansky A. Piloting a system for behavioral surveillance among heterosexuals at increased risk of HIV in the United States. Open AIDS J 2012;6:169-76.
  4. Salganik MJ, Heckathorn DD. Sampling and estimation in hidden populations using respondent-driven sampling. Sociol Methodol 2004;34:193-240.
  5. Adimora AA, Auerbach JD. Structural interventions for HIV prevention in the United States. J Acquir Immune Defic Syndr 2010;55(Suppl 2):S132-5.
  6. Office of National AIDS Policy. National HIV/AIDS strategy for the United States. Washington, DC: Office of National AIDS Policy; 2010.
  7. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr 2005;39:446-53.
  8. CDC. Results of the expanded HIV testing initiative -- 25 jurisdictions, United States, 2007-2010. MMWR 2011;60:805-10.
  9. Wallace SA, McLellan-Lemal E, Harris MJ, Townsend TG, Miller KS. Why take an HIV test? Concerns, benefits, and strategies to promote HIV testing among low-income heterosexual African American young adults. Health Educ Behav 2011;38:462-70.

* Low SES was defined as having a household income (adjusted for household size) at or below the poverty level guidelines or no more than a high school education. Additional information available at

† Poverty areas are defined by the U.S. Census Bureau as census tracts in which 20% or more of the residents live below the poverty threshold. Additional information available at

§ Persons not reporting a previous positive HIV test result included those who reported that their most recent HIV test result was negative, indeterminate, or unknown, or that they had never been tested.

¶ Persons were excluded from the analysis for the following reasons (categories are not mutually exclusive): 715 did not report a low SES, 1,339 reported IDU in the past 12 months, 753 men reported male-male sex, and 262 persons had no record of consent for the NHBS HIV testing, indeterminate or discordant NHBS HIV test results (i.e., they reported being HIV-positive but had a negative or indeterminate test result), or invalid NHBS HIV test results.

** An exchange sex partner was defined as someone the participant gave things such as money or drugs to in exchange for sex or someone who gave the participant things such as money or drugs in exchange for sex.

†† Excludes seven participants who reported that their most recent HIV test was >12 months before the interview but did not report the year of that test.

§§ Additional information available at

What is already known on this topic?

An estimated 27% of prevalent human immunodeficiency virus (HIV) infections in the United States are attributed to heterosexual contact. Heterosexuals with a low socioeconomic status (SES) are disproportionately more likely to be infected with HIV.

What is added by this report?

Low-SES heterosexuals in metropolitan statistical areas (MSAs) with a high acquired immunodeficiency syndrome (AIDS) prevalence were recruited by the National HIV Behavioral Surveillance System (NHBS) for interviews and HIV testing. Of 8,473 persons tested, 197 (2.3%) were infected with HIV, with the highest prevalence of infection occurring among blacks, persons reporting crack cocaine use or exchange sex, those with low levels of education or income, and persons living in participating MSAs in the Northeast or South. Overall, 25.8% of participants had never been tested previously for HIV. Among participants who tested positive during the survey but did not report a previous positive HIV test, 36 (43.9%) said they had never had an HIV test before NHBS.

What are the implications for public health practice?

Efforts to prevent HIV among heterosexuals that include encouraging HIV testing among persons living in low SES communities in urban areas with high prevalence of AIDS are likely to have the greatest potential impact. It is particularly important to increase HIV testing and linkage to care among the heterosexual populations with the highest prevalence of HIV: blacks, persons who use crack cocaine or engage in exchange sex, and persons with low levels of income and education. Participating MSAs, particularly in the Northeast and South, are most likely to benefit from focused interventions among low-SES heterosexuals.

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This article was provided by U.S. Centers for Disease Control and Prevention. It is a part of the publication Morbidity and Mortality Weekly Report. Visit the CDC's website to find out more about their activities, publications and services.
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