Geographic Correlates of HIV Risk
Behaviors and Utilization of HIV Testing
1
SHANNON M. MONNAT, PHD
DEPARTMENT OF SOCIOLOGY
UNIVERSITY OF NEVADA, LAS VEGAS
Community Disruption and HIV Risk in the District of Columbia
September 13-14, 2012
American University
Social Determinants of Health
2
Physical
Environment
Social
Environment
HIV
Risk
Service
Environment
County-Level HIV Prevalence, 2008
3
County N=2,054
Correlates of County HIV Rate, 2008
4
Characteristics Positively
Associated with County HIV Rate
Characteristics Negatively or Not
Associated with County HIV Rate
% black
+
Nonmetropolitan county
-
Gini coefficient
+
% poverty
-
% illiterate
+
% owner occupied housing
-
Violent crime rate
+
% same county
-
% college graduates
+
% public assistance receipt
NS
Population density
+
% Hispanic
NS
Total population (log)
+
significant at p< .01 or lower
HIV rate (logged) regressed on county characteristics, adjusted model N = 2,054 counties
HIV rate data source: National Center for Hepatitis, HIV, STD and TB Prevention, 2008
Data and Methods
5
 Individual-Level: Behavioral Risk Factor Surveillance System, 2011
 County-Level: 2005-2009 ACS, 2008 Area Resource File
 Dependent Variables (adults, aged 18-64)
 HIV risk behavior in past year (N=222,460 in 2,241 counties)
 HIV testing in past year (N=6,136 in 1,328 counties)
 Independent Variables
 County-level contextual variables: economic, demographic, health
infrastructure
 Controls
 Race/ethnicity, sex, age, income, education, employment, marital status,
children, checkup in past year, personal doctor, cost barrier to med care,
and health insurance coverage
 Multilevel Modeling (individuals within counties)
 ICC for HIV risk behavior = .173
 ICC for HIV testing = .361
Social Determinants of Health
6
SOCIAL/ECONOMIC
PHYSICAL
Population density
Population size
Region
Percent black
Percent Hispanic
Gini coefficient
Percent poverty
Percent public asst.
Percent college grads
Percent illiterate
Violent crime rate
Percent OO housing
Percent same county
HIV rate
Enabling Environment
SERVICE
Physician supply
Community outpatient
clinics
Indigent care clinics
Percent who Engaged in HIV Risk Behaviors in Past Year,
by Race/Ethnicity
7
7.0
6.2
6.0
5.0
***
6.0
***
4.2
4.0
3.5
3.5
3.0
2.0
1.0
0.0
Full Sample
White
Black
Hispanic
Other Race
Note: Any of the situations apply in past year: used intravenous drugs; treated for STD or venereal
disease; given or received money or drugs in exchange for sex; had anal sex without a condom
***p<.001; significantly different from white; two-tailed test; weighted percentages
Percent who Engaged in HIV Risk Behaviors in Past Year,
by Educational Attainment
8
8.0
7.0
6.8
6.0
5.0
4.4
4.0
***
3.0
4.3
***
2.7
***
2.0
1.0
0.0
Less than High
School
High School
Graduate
Some College
College Graduate
Note: Any of the situations apply in past year: used intravenous drugs; treated for STD or venereal
disease; given or received money or drugs in exchange for sex; had anal sex without a condom
***p<.001; significantly different from ‘less than high school’ ; two-tailed test; weighted percentages
Percent who Engaged in HIV Risk Behaviors in Past Year,
by Income
9
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
8.4
6.1
*
*
*
6.6
5.6
*
*
*
5.1
*
3.8
*
*
*
2.9
*
*
*
2.6
*
*
Note: Any of the situations apply in past year: used intravenous drugs; treated for STD or venereal
disease; given or received money or drugs in exchange for sex; had anal sex without a condom
***p<.001, **p<.01; *p<.05; significantly different from preceding income category; two-tailed test;
weighted percentages
Rate of Risky Behavior by County
10
Source: Behavioral Risk Factor Surveillance System, 2011; Weighted Rates
County Correlates of Individual Risky Behavior
 Positively associated with
engaging in HIV risky
behaviors:















% low income
% public assistance
% poverty
Gini coefficient
% illiterate
% black
% Hispanic
% college graduates
Total population size
% living in same county prior year
Population density
Housing density
Violent crime rate
HIV rate
South and west regions
11
 Negatively associated with
engaging in HIV risky
behaviors:






% owner occupied housing
% high school graduates
% high income
Median household income
Nonmetropolitan county
Northeast and Midwest regions
Geographic Predictors of Engaging in
High HIV Risk Behaviors
12
Characteristics
Percent black
Percent Hispanic
Gini coefficient
Percent poverty
Percent public assistance
Percent college grads
Percent illiterate
Violent crime rate
Percent owner occupied housing
Percent same county last year
Population density
Total population (logged)
Northeast (vs. South)
Midwest (vs. South)
West (vs. South)
County Vars. Only
+ Ind. Controls
+
NS
NS
NS
NS
NS
NS
NS
NS
+
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
+
NS
NS
NS
Percent Receiving HIV Test in Past Year, by Race/Ethnicity
(among those who engaged in HIV risk behavior in past year)
13
60.0
54.4
50.0
40.0
38.0
33.8
*
*
*
34.7
White
Black
Hispanic
38.3
30.0
20.0
10.0
0.0
Full Sample
***p<.001; significantly different from white; two-tailed test; weighted percentages
Other Race
Percent Receiving HIV Test in Past Year, by Education
(among those who engaged in HIV risk behavior in past year)
14
45.0
40.0
41.3
36.3
35.9
Less than high
school
High school
graduate
35.0
*
36.7
30.0
25.0
20.0
15.0
10.0
5.0
0.0
Some college
College graduate
***p<.001; significantly different from ‘less than high school’ ; two-tailed test; weighted percentages
Percent Receiving HIV Test in Past Year, by Income
(among those who engaged in HIV risk behavior in past year)
15
50.0
45.0
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
47.4
43.3
36.1
*
*
*
*
41.0
38.2
35.0
30.7
33.4
***p<.001, *p<.05; significantly different from preceding income category; two-tailed test; weighted
percentages
Geographic Predictors of HIV Testing in Past Year among
Individuals who Engaged in Risky Behaviors
16
 Percent black significantly associated with higher
odds of testing (p<.05)
 Percent owner-occupied housing significantly
associated with lower odds of testing (p<.05)
Summary
17
 Substantial variation in individual risky behaviors an
HIV testing in past year at the county-level;
 These variables do not explain that variation;
 Possible untested sources of variation




Community intervention efforts
Social networks
Law enforcement presence
Health care services not included in Health Care Services
Administration data
Limitations
18
 County not ideal proxy for “residential context” or




neighborhood;
Limited ‘HIV risk behavior’ variable;
Unable to control for sexuality;
Causality issues (HIV risk behaviors  testing)
Several counties excluded
Contact
19
Shannon M. Monnat
Assistant Professor of Sociology
University of Nevada, Las Vegas
4505 S. Maryland Parkway, Box 455033
Las Vegas, NV 89154
Shannon.Monnat@unlv.edu