In this study, we found that despite similar overall prevalence of infection, Latino patients reported fewer behavioral risk factors associated with STD/HIV than non-Latino patients. We found differences in the prevalence of specific infections, with Latinos having a higher prevalence of syphilis among Latinos and lower prevalence of gonorrhea than non-Latino patients. We also found associations among Latinas between sexual risk behaviors, sexually transmitted infections, and marginal associations with level of acculturation, as measured by self-reported language proficiency.
Based on the prevalence of sexual risk factors among Latino patients, we would have expected to see lower prevalence of all sexually transmitted infections for both males and females. The discrepancy that we observed between reported behavioral risk factors and infection prevalence among Latino patients compared to non-Latino patients has several possible explanations, including reporting bias, differences in natural history of infection, and differences in sexual networks.
One concern is that Latino patients under-reported behavioral risk factors. Cultural factors can impact disclosure of risk behavior, and fear of deportation could be an obstacle to full disclosure of illicit activities such as injection drug use or relations with commercial sex workers, especially among undocumented immigrants. Communication barriers can complicate the assessment of risk behavior, even when conducted by an experienced STD clinician fluent in Spanish. We found that English-proficient Latina patients were more likely to report some risk behaviors than Spanish-speaking Latinas. However, the English speakers also had a higher prevalence of STDs than Spanish speakers, suggesting that at least some of the reported differences in risk behavior are accurate.
Although most sexual risk behaviors and gonorrhea infection were less prevalent in Latinos than in non-Latinos, Latino patients were more likely to have a syphilis diagnosis than non-Latino patients. The natural history of the infections may provide some explanation; gonorrhea has a short (2–100 day) infectious period which reflects recent high-risk behavior [27
], while syphilis is a chronic infection which may go undetected for years [28
]. However, with no observable difference in the proportion of syphilis cases that were early syphilis (primary or secondary) between Latinos compared to non-Latinos (15% vs. 19%, p = 0.45), our results suggest that the higher risk of syphilis among Latino patients was related to current risk behavior.
These findings might also be consistent with a sexual networks approach; syphilis may be more common than gonorrhea in the sexual networks of Latino patients presenting to the STD clinic. The disparity in infection prevalence by racial and ethnic group is also consistent with our earlier hypothesis that partner selection patterns are influenced by ethnicity, contributing to an increased risk of syphilis among Latinos choosing Latino partners. While data on the race/ethnicity of partner are needed to further supporting this hypothesis, these data are not currently collected as part of the clinical record.
Unexpectedly, we found that patients who reported a contact to STD were actually less likely to have an STD. Contact to STD was elicited as part of a “reason for visit” variable, and may have been more frequently recorded when patients did not report symptoms or high-risk behaviors. We found that patients who did not report risk behaviors (e.g. non-condom use, sex for drugs or money) were significantly more likely to indicate an STD contact.
In addition to measuring disparities in infection and behavior prevalence, this study also adds to the growing body of literature on the impact of acculturation on sexual behavioral and sexually transmitted infection risk among Latinos. We found that Spanish-speaking Latinas were marginally less likely to be diagnosed with STD/HIV than English-proficient Latinas, even after accounting for behavioral and demographic risk factors. These results are consistent with other studies showing that acculturation (as measured by language proficiency) is associated with increases in reported sexual risk behaviors and sexually transmitted infections among Latinos [13
]. Interestingly, English language proficiency was significantly associated in multivariate models with sexual risk behaviors and infection among female but not male Latino patients, suggesting that acculturation has differential impact on these outcomes by gender. Other studies have found that gender may modify the association between acculturation and risk behavior. [31
] Some studies have specifically found that acculturation effects are significant for women but not for men. [33
] Changing traditional gender roles perpetuated by machismo
, or “male pride,” during the acculturation process possibly has a different influence on female than male decision-making power and STD risk behavior. [36
This study has several limitations. Our study sample was drawn from public STD clinics, so our findings are not representative of the general U.S. population. National surveillance consistently finds racial disparities in STD/HIV prevalence that were not evident in the BCHD STD clinic patient population. STD clinic patients are not a representative sample of the general population, tending to be poor, uninsured, and people of color. [37
] Measurement of risk factors is likely to be incomplete in this study, especially since the data used were collected for the purpose of routine care delivery. Residual confounding by unmeasured factors may contribute to the continued association of race/ethnicity and language with disease outcomes.
Heterogeneity within the Latino population by immigrant status and culture may make classification of patients as a single “Latino” group difficult, and may introduce noise into the estimates of risk factor and infection prevalence. The impact of acculturation may be meaningful only for foreign-born Latino populations, and immigrant status was not assessed as part of the clinical record. Finally, while many public health studies use language proficiency to measure acculturation, theory-based, multidimensional acculturation scales may have measured acculturation more accurately.
In conclusion, this study showed that despite lower reported risk behavior, Latino patients had a higher prevalence of syphilis than non-Latino patients. English-speaking Latinas had the highest risk of syphilis compared to non-Latina and Spanish-speaking Latinas, suggesting that acculturation plays an important role in the risk of syphilis, at least among females in this population. In contrast, prevalence of gonorrhea was lowest in Latinos compared to African-Americans and whites. Future studies on partnership selection among specific Latino populations characterized by country of origin, level of acculturation, and years in the U.S. may further elucidate additional risk factors and help guide interventions to address disparities in STD/HIV among Latinos.