AIDS Education and Prevention, 26(5), 459–470, 2014 © 2014 The Guilford Press REDUCTIONS IN HIV PREVALENCE REBACK AND FLETCHER
REDUCTIONS IN HIV PREVALENCE RATES AMONG SUBSTANCE-USING MEN WHO HAVE SEX WITH MEN IN LOS ANGELES COUNTY, 2008–2011 Cathy J. Reback and Jesse B. Fletcher
An outreach program performed street encounters with 5,599 unique substance-using MSM from January 2008 through December 2011. HIV prevalence reduced from 20.2% in the first half of 2008 to 8.1% in the second half of 2011. Older, gay-identified, non-Hispanic/Latino participants were each more likely to report a HIV-positive serostatus. When controlling for these cofactors, robust log-Poisson analysis revealed that each additional day of methamphetamine (RRR = 1.03; 95% CI [1.02, 1.03]) and/ or marijuana (RRR = 1.01; 95% CI [1.01, 1.02]) use in the previous 30 days, injection drug use at any point in their lifetime (RRR = 2.01; 95% CI [1.70, 2.37]), and/or unprotected anal intercourse with another male in the previous 30 days (RRR = 1.48; 95% CI [1.29, 1.71]) were associated with HIV-positive status. When controlling for all these cofactors, the probability of reporting a HIV-positive status reduced an estimated 9% (95% CI [6%, 12%]) every six months throughout the reporting period. Self-reported HIV prevalence decreased among this sample of substance-using MSM in LAC from 2008 to 2011.
Although men who have sex with men (MSM) comprise only an estimated 2% of the total United States (U.S.) population (Purcell et al., 2012), they account for the majority all new HIV cases in the U.S. each year (Centers for Disease Control and Prevention [CDC], 2011, 2012a). Prevalence of HIV in the general U.S. population is estimated to be 0.38% (CDC, 2012b). The national rate of HIV infection among MSM has been estimated to be 59 to 75 times higher than among other men (Purcell Cathy J. Reback, PhD, and Jesse B. Fletcher, PhD, are affiliated with Friends Research Institute, Inc. Cathy J. Reback is also affiliated with UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles This study was supported by the Los Angeles County, Department of Public Health, Division of HIV and STD Programs (formerly Office of AIDS Programs and Policy) contracts #H700861, PH#001039, and the City of West Hollywood, Department of Human Services, Social Services Division. Dr. Reback acknowledges additional support from the National Institute of Mental Health (P30 MH58107). The authors would like to acknowledge the work of the outreach team and their dedication to serve their community. The authors also thank Trista Bingham, PhD, and Mike Janson, MPH, for their guidance in the preparation of this manuscript. Address correspondence to Cathy J. Reback, PhD, Friends Research Institute, 1419 N. La Brea Ave., Los Angeles, CA 90028. E-mail: [email protected]
459
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REBACK AND FLETCHER
et al., 2012). Even among MSM the burden of HIV-infection has not been shared equally, as HIV infection has been associated with numerous sociodemographic and behavioral cofactors.
COFACTORS ASSOCIATED WITH HIV-POSITIVE STATUS AMONG MSM SOCIODEMOGRAPHICS Nationally, rates of HIV infection are highest among minority, particularly African American/Black, MSM (Fisher et al., 2011; Koblin et al., 2006). HIV prevalence has been estimated at 16% among Caucasian/White MSM, at 19% among Hispanic/Latino MSM, and at 28% among African American/Black MSM (CDC, 2010). Age has also been associated with HIV incidence and prevalence rates among MSM. HIV incidence rates are higher among younger MSM (Ackers et al., 2012; Fisher et al., 2011; Koblin et al., 2006), while prevalence, which accrues over time, is higher among older MSM (Chen et al., 2013; German et al., 2011; Harawa et al., 2004; Osmond, Pollack, Paul, & Catania, 2007). Sexual identity also affects risk for HIV infection, as gay-identified MSM are reported to engage in riskier behaviors with greater frequency than nongay-identified MSM (Flores, Mansergh, Marks, Guzman, & Colfax, 2009). African American/ Black and Hispanic/Latino MSM have been less likely to identify as gay and less likely or to be embedded within a broader gay-identified community than Caucasian/White MSM (Flores et al., 2009; Harawa et al., 2008), revealing the intersecting cofactors of race and sexual identity on HIV risk.
SUBSTANCE USE AND HIV RISK Findings have demonstrated the use of certain drugs (e.g., methamphetamine, amyl nitrite) are more commonly used among MSM who identify as gay (CDC, 2011), leading to increased risk for HIV infection. Large sample studies in the US have demonstrated the frequency of noninjection recreational drug use (46–61%) and alcohol use (87%) among MSM (Ackers et al., 2012; CDC, 2011). Recent injection drug use is less commonly reported (2%; CDC, 2011), although still elevated above U.S. national prevalence rates (Armstrong, 2007). HIV incidence is increased among MSM who use moderate or heavy amounts of alcohol (Koblin et al., 2006), who use amphetamines, crack, and/or amyl nitrite (Ackers et al., 2012; Neaigus et al., 2012), or who inject drugs (Koblin et al., 2006). In the Western U.S., methamphetamine use has been associated with increased HIV infection and sexual risk-taking among MSM (Bowers, Branson, Fletcher, & Reback, 2012; Shoptaw & Reback, 2006). Methamphetamine use rates among MSM are significantly higher in Los Angeles County (LAC) than are reported in national surveys of MSM (CDC, 2011), or that are found among MSM in the eastern U.S. (Mutchler et al., 2011). Self-reported rates of methamphetamine use in the previous 30 days among substance-using MSM in LAC have reached levels as high as 53%, and have not fallen below 11% in the past decade (Reback, Fletcher, Shoptaw, & Grella, 2013; Reback, Shoptaw, & Grella, 2008), a nadir still nearly double the yearly national prevalence rate among MSM in the U.S. (CDC, 2011). Compared to non-users, MSM who report metham-
REDUCTIONS IN HIV PREVALENCE 461
phetamine use are more likely to report unprotected anal intercourse and/or substance use during sex (Forrest et al., 2010), both of which have been associated with increased HIV prevalence and/or transmission risk among MSM (Schwarcz, 2007). As a result, HIV prevalence is significantly higher among MSM who report methamphetamine use (Chen et al., 2013), and highest among those meeting the criteria for methamphetamine dependence (Shoptaw & Reback, 2006).
HIV/AIDS AMONG MSM IN LOS ANGELES COUNTY LAC is divided into eight Service Planning Areas (SPAs); the Metro SPA, which includes Hollywood, West Hollywood, and Downtown, has the highest rates of HIV/ AIDS diagnoses, accounting for 33% of all diagnoses in 2011, and for 39% of all diagnoses in LAC since 1982 (Division of HIV and STD Programs [DHSP], 2012a). In 2010, LAC accounted for 5.8% of all HIV cases in the U.S. and in the Metro SPA of LAC MSM accounted for 91% of all new HIV/AIDS diagnoses. Although HIV remains a serious health concern among MSM in LAC, recent evidence from county-monitored testing centers has revealed that HIV incidence among MSM, both in LAC and California, may have decreased in the periods from 2003 to 2009 (Scheer et al., 2013; Xia, Nonoyama, Molitor, Webb, & Osmond, 2011). Additionally, HIV/AIDS diagnoses evidenced sharp declines in the Metro SPA of LAC (DHSP, 2012a), the SPA most characterized by both its high concentration of HIV/AIDS diagnoses and MSM (Perez, 2011). These findings warrant close attention, as even modest decreases in overall HIV incidence among MSM in the most impacted areas of LAC can have meaningful effects on this high-risk population. Given the recent observed decreases in HIV incidence among MSM in LAC, this report estimated the prevalence of self-reported HIV infection among a particularly high-risk subset of the MSM population: substance-users recruited from the highrisk locations in the Metro SPA of LAC. In addition, multivariate statistical analyses estimated the associations between self-reported HIV-positive status and participant sociodemographics, substance use and/or sexual risk behaviors in the previous 30 days.
METHODS PARTICIPANTS Participants were MSM who reported any substance use in the previous 30 days. All participants were contacted via HIV prevention outreach encounters on the street or in high-risk venues (e.g., commercial sex venues, public sex environments) in the Metro SPA of LAC. The specific outreach area comprised a 7-mile region within the Metro SPA, characterized by a high density of MSM residents and the highest HIV prevalence rate in LAC (Perez, 2011).
PROCEDURE Data collection was conducted by a team of ethnically diverse, indigenous, and bilingual (English and Spanish) outreach workers who provided low-intensity health education/risk-reduction interventions. Using a unique identifier, outreach workers recorded participant responses on a brief instrument that assessed demographics (race/ethnicity, age, sexual identity), self-reported HIV status, alcohol and other
462
REBACK AND FLETCHER
drug use (previous 30 days), injection drug use (lifetime), and unprotected (insertive or receptive) anal intercourse with another male (previous 30 days). All staff members were trained on noninvasive outreach strategies and how to safely approach and maintain confidentiality while conducting an outreach encounter. Procedures and the intervention design remained steady throughout the reporting period and have been reported elsewhere (Reback et al., 2008). All data were self-reported. Participants were not compensated for their participation. All program materials were approved by the LAC Department of Public Health, Division of HIV and STD Programs.
STATISTICAL ANALYSIS Assessments were completed by hand and then scanned into an electronic database. Once electronic versions of the assessments were created, assessments were sorted by date, duplicate unique identifiers as well as those MSM who reported no alcohol or drug use were deleted, leaving only one unique identifier from each individual corresponding to the first time they were encountered; thus, the same individual should not occur in the analytical sample more than once. Additionally, to measure HIV prevalence rates among a high-risk sample of MSM, only substanceusing MSM recruited from streets (e.g., cruising boulevards, corners), commercial sex venues (e.g., bathhouses, sex clubs), and public sex environments (e.g., parks, public restrooms) were included in the analytical sample. Data were then aggregated into 6-month cohorts. Basic counts and their corresponding percentages are supplied for all nominal variables, while means and standard deviations are supplied for continuous variables. Statistical contrasts in Table 1 were carried out using Chi-square or Fisher Exact analyses for nominal outcomes, and student’s t-tests for continuous variables (Table 1). Robust log-Poisson regression analysis was used to provide adjusted HIV prevalence rates (Figure 1) and to estimate the effects of 6-month cohort, sociodemographics, substance use, and sexual risk behavior on the likelihood of a self-reported HIV-positive status while controlling for each participant’s site of recruitment (e.g., commercial sex venue, public sex environment, the streets; Table 2; Figure 1; Deddens & Petersen, 2008). Log-binomial models were explored first, but failed to converge (as is common; Wolkewitz, Bruckner, & Schumacher, 2007). Robust logPoisson models are an efficient substitute and provide adjusted prevalence rates that account for potentially confounding cofactors of HIV infection, and are preferable to logistic regression methods when prevalence rates approach 10–15% (Lindquist, 2013). Though use of such inferential models is often intended to imply causal influence from the independent (e.g., sociodemographics, recent substance use) to dependent (self-reported HIV status) variables, no such causal influence is implied here. Rather, participant HIV status is simultaneously regressed onto the sociodemographic, behavioral, and temporal cofactors to provide adjusted HIV prevalence estimates (Deddens & Petersen, 2008; Wolkewitz et al., 2007), and to robustly estimate the partial associations between HIV status and its various cofactors. Coefficient estimates in Table 2 were provided as relative risk ratios (RRR), which describe the factor change in the probability of an outcome (in this case, a reported HIV-positive status) for each unit increase in the predictor variable (after controlling for all covariates; Table 2). All analyses were conducted using Stata v13SE (Stata Corporation, College Station, Texas, USA).
REDUCTIONS IN HIV PREVALENCE 463 TABLE 1. Sociodemographic Characteristics, Substance Use, and Unprotected Anal Intercourse with Another Male by Self-Reported HIV Status, January 2008-December 2011 (N = 5,599). HIV-Negative/DK
HIV-Positive
Total
(n = 4,849)
(n = 750)
(N = 5,599)
N (%) or Mean (SD)
N (%) or Mean (SD)
N (%) or Mean (SD)
4,026 (83.0%)
678 (90.4%)
4,704 (84.0%)
816 (16.8%)
71 (9.5%)
887 (15.8%)
7 (0.1%)
1 (0.1%)
8 (0.1%)
2,194 (45.3%)
435 (58.0%)
2,629 (47.0%)
502 (10.4%)
82 (10.9%)
584 (10.4%)
Hispanic/Latino
1,600 (33.0%)
175 (23.3%)
1,775 (31.7%)
Multiracial/other
553 (11.4%)
58 (7.7%)
611 (10.9%)
≤ 29 years
2,086 (43.0%)
177 (23.6%)
2,263 (40.4%)
30–39 years
1,823 (37.6%)
300 (40.0%)
2,123 (37.9%)
40–49 years
813 (16.8%)
234 (31.2%)
1,047 (18.7%)
≥ 50 years
127 (2.6%)
39 (5.2%)
166 (3.0%)
Pa
Sexual identity Gay Bisexual Heterosexual
REDUCTIONS IN HIV PREVALENCE RATES AMONG SUBSTANCE-USING MEN WHO HAVE SEX WITH MEN IN LOS ANGELES COUNTY, 2008–2011 Cathy J. Reback and Jesse B. Fletcher
An outreach program performed street encounters with 5,599 unique substance-using MSM from January 2008 through December 2011. HIV prevalence reduced from 20.2% in the first half of 2008 to 8.1% in the second half of 2011. Older, gay-identified, non-Hispanic/Latino participants were each more likely to report a HIV-positive serostatus. When controlling for these cofactors, robust log-Poisson analysis revealed that each additional day of methamphetamine (RRR = 1.03; 95% CI [1.02, 1.03]) and/ or marijuana (RRR = 1.01; 95% CI [1.01, 1.02]) use in the previous 30 days, injection drug use at any point in their lifetime (RRR = 2.01; 95% CI [1.70, 2.37]), and/or unprotected anal intercourse with another male in the previous 30 days (RRR = 1.48; 95% CI [1.29, 1.71]) were associated with HIV-positive status. When controlling for all these cofactors, the probability of reporting a HIV-positive status reduced an estimated 9% (95% CI [6%, 12%]) every six months throughout the reporting period. Self-reported HIV prevalence decreased among this sample of substance-using MSM in LAC from 2008 to 2011.
Although men who have sex with men (MSM) comprise only an estimated 2% of the total United States (U.S.) population (Purcell et al., 2012), they account for the majority all new HIV cases in the U.S. each year (Centers for Disease Control and Prevention [CDC], 2011, 2012a). Prevalence of HIV in the general U.S. population is estimated to be 0.38% (CDC, 2012b). The national rate of HIV infection among MSM has been estimated to be 59 to 75 times higher than among other men (Purcell Cathy J. Reback, PhD, and Jesse B. Fletcher, PhD, are affiliated with Friends Research Institute, Inc. Cathy J. Reback is also affiliated with UCLA Integrated Substance Abuse Programs, Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles This study was supported by the Los Angeles County, Department of Public Health, Division of HIV and STD Programs (formerly Office of AIDS Programs and Policy) contracts #H700861, PH#001039, and the City of West Hollywood, Department of Human Services, Social Services Division. Dr. Reback acknowledges additional support from the National Institute of Mental Health (P30 MH58107). The authors would like to acknowledge the work of the outreach team and their dedication to serve their community. The authors also thank Trista Bingham, PhD, and Mike Janson, MPH, for their guidance in the preparation of this manuscript. Address correspondence to Cathy J. Reback, PhD, Friends Research Institute, 1419 N. La Brea Ave., Los Angeles, CA 90028. E-mail: [email protected]
459
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REBACK AND FLETCHER
et al., 2012). Even among MSM the burden of HIV-infection has not been shared equally, as HIV infection has been associated with numerous sociodemographic and behavioral cofactors.
COFACTORS ASSOCIATED WITH HIV-POSITIVE STATUS AMONG MSM SOCIODEMOGRAPHICS Nationally, rates of HIV infection are highest among minority, particularly African American/Black, MSM (Fisher et al., 2011; Koblin et al., 2006). HIV prevalence has been estimated at 16% among Caucasian/White MSM, at 19% among Hispanic/Latino MSM, and at 28% among African American/Black MSM (CDC, 2010). Age has also been associated with HIV incidence and prevalence rates among MSM. HIV incidence rates are higher among younger MSM (Ackers et al., 2012; Fisher et al., 2011; Koblin et al., 2006), while prevalence, which accrues over time, is higher among older MSM (Chen et al., 2013; German et al., 2011; Harawa et al., 2004; Osmond, Pollack, Paul, & Catania, 2007). Sexual identity also affects risk for HIV infection, as gay-identified MSM are reported to engage in riskier behaviors with greater frequency than nongay-identified MSM (Flores, Mansergh, Marks, Guzman, & Colfax, 2009). African American/ Black and Hispanic/Latino MSM have been less likely to identify as gay and less likely or to be embedded within a broader gay-identified community than Caucasian/White MSM (Flores et al., 2009; Harawa et al., 2008), revealing the intersecting cofactors of race and sexual identity on HIV risk.
SUBSTANCE USE AND HIV RISK Findings have demonstrated the use of certain drugs (e.g., methamphetamine, amyl nitrite) are more commonly used among MSM who identify as gay (CDC, 2011), leading to increased risk for HIV infection. Large sample studies in the US have demonstrated the frequency of noninjection recreational drug use (46–61%) and alcohol use (87%) among MSM (Ackers et al., 2012; CDC, 2011). Recent injection drug use is less commonly reported (2%; CDC, 2011), although still elevated above U.S. national prevalence rates (Armstrong, 2007). HIV incidence is increased among MSM who use moderate or heavy amounts of alcohol (Koblin et al., 2006), who use amphetamines, crack, and/or amyl nitrite (Ackers et al., 2012; Neaigus et al., 2012), or who inject drugs (Koblin et al., 2006). In the Western U.S., methamphetamine use has been associated with increased HIV infection and sexual risk-taking among MSM (Bowers, Branson, Fletcher, & Reback, 2012; Shoptaw & Reback, 2006). Methamphetamine use rates among MSM are significantly higher in Los Angeles County (LAC) than are reported in national surveys of MSM (CDC, 2011), or that are found among MSM in the eastern U.S. (Mutchler et al., 2011). Self-reported rates of methamphetamine use in the previous 30 days among substance-using MSM in LAC have reached levels as high as 53%, and have not fallen below 11% in the past decade (Reback, Fletcher, Shoptaw, & Grella, 2013; Reback, Shoptaw, & Grella, 2008), a nadir still nearly double the yearly national prevalence rate among MSM in the U.S. (CDC, 2011). Compared to non-users, MSM who report metham-
REDUCTIONS IN HIV PREVALENCE 461
phetamine use are more likely to report unprotected anal intercourse and/or substance use during sex (Forrest et al., 2010), both of which have been associated with increased HIV prevalence and/or transmission risk among MSM (Schwarcz, 2007). As a result, HIV prevalence is significantly higher among MSM who report methamphetamine use (Chen et al., 2013), and highest among those meeting the criteria for methamphetamine dependence (Shoptaw & Reback, 2006).
HIV/AIDS AMONG MSM IN LOS ANGELES COUNTY LAC is divided into eight Service Planning Areas (SPAs); the Metro SPA, which includes Hollywood, West Hollywood, and Downtown, has the highest rates of HIV/ AIDS diagnoses, accounting for 33% of all diagnoses in 2011, and for 39% of all diagnoses in LAC since 1982 (Division of HIV and STD Programs [DHSP], 2012a). In 2010, LAC accounted for 5.8% of all HIV cases in the U.S. and in the Metro SPA of LAC MSM accounted for 91% of all new HIV/AIDS diagnoses. Although HIV remains a serious health concern among MSM in LAC, recent evidence from county-monitored testing centers has revealed that HIV incidence among MSM, both in LAC and California, may have decreased in the periods from 2003 to 2009 (Scheer et al., 2013; Xia, Nonoyama, Molitor, Webb, & Osmond, 2011). Additionally, HIV/AIDS diagnoses evidenced sharp declines in the Metro SPA of LAC (DHSP, 2012a), the SPA most characterized by both its high concentration of HIV/AIDS diagnoses and MSM (Perez, 2011). These findings warrant close attention, as even modest decreases in overall HIV incidence among MSM in the most impacted areas of LAC can have meaningful effects on this high-risk population. Given the recent observed decreases in HIV incidence among MSM in LAC, this report estimated the prevalence of self-reported HIV infection among a particularly high-risk subset of the MSM population: substance-users recruited from the highrisk locations in the Metro SPA of LAC. In addition, multivariate statistical analyses estimated the associations between self-reported HIV-positive status and participant sociodemographics, substance use and/or sexual risk behaviors in the previous 30 days.
METHODS PARTICIPANTS Participants were MSM who reported any substance use in the previous 30 days. All participants were contacted via HIV prevention outreach encounters on the street or in high-risk venues (e.g., commercial sex venues, public sex environments) in the Metro SPA of LAC. The specific outreach area comprised a 7-mile region within the Metro SPA, characterized by a high density of MSM residents and the highest HIV prevalence rate in LAC (Perez, 2011).
PROCEDURE Data collection was conducted by a team of ethnically diverse, indigenous, and bilingual (English and Spanish) outreach workers who provided low-intensity health education/risk-reduction interventions. Using a unique identifier, outreach workers recorded participant responses on a brief instrument that assessed demographics (race/ethnicity, age, sexual identity), self-reported HIV status, alcohol and other
462
REBACK AND FLETCHER
drug use (previous 30 days), injection drug use (lifetime), and unprotected (insertive or receptive) anal intercourse with another male (previous 30 days). All staff members were trained on noninvasive outreach strategies and how to safely approach and maintain confidentiality while conducting an outreach encounter. Procedures and the intervention design remained steady throughout the reporting period and have been reported elsewhere (Reback et al., 2008). All data were self-reported. Participants were not compensated for their participation. All program materials were approved by the LAC Department of Public Health, Division of HIV and STD Programs.
STATISTICAL ANALYSIS Assessments were completed by hand and then scanned into an electronic database. Once electronic versions of the assessments were created, assessments were sorted by date, duplicate unique identifiers as well as those MSM who reported no alcohol or drug use were deleted, leaving only one unique identifier from each individual corresponding to the first time they were encountered; thus, the same individual should not occur in the analytical sample more than once. Additionally, to measure HIV prevalence rates among a high-risk sample of MSM, only substanceusing MSM recruited from streets (e.g., cruising boulevards, corners), commercial sex venues (e.g., bathhouses, sex clubs), and public sex environments (e.g., parks, public restrooms) were included in the analytical sample. Data were then aggregated into 6-month cohorts. Basic counts and their corresponding percentages are supplied for all nominal variables, while means and standard deviations are supplied for continuous variables. Statistical contrasts in Table 1 were carried out using Chi-square or Fisher Exact analyses for nominal outcomes, and student’s t-tests for continuous variables (Table 1). Robust log-Poisson regression analysis was used to provide adjusted HIV prevalence rates (Figure 1) and to estimate the effects of 6-month cohort, sociodemographics, substance use, and sexual risk behavior on the likelihood of a self-reported HIV-positive status while controlling for each participant’s site of recruitment (e.g., commercial sex venue, public sex environment, the streets; Table 2; Figure 1; Deddens & Petersen, 2008). Log-binomial models were explored first, but failed to converge (as is common; Wolkewitz, Bruckner, & Schumacher, 2007). Robust logPoisson models are an efficient substitute and provide adjusted prevalence rates that account for potentially confounding cofactors of HIV infection, and are preferable to logistic regression methods when prevalence rates approach 10–15% (Lindquist, 2013). Though use of such inferential models is often intended to imply causal influence from the independent (e.g., sociodemographics, recent substance use) to dependent (self-reported HIV status) variables, no such causal influence is implied here. Rather, participant HIV status is simultaneously regressed onto the sociodemographic, behavioral, and temporal cofactors to provide adjusted HIV prevalence estimates (Deddens & Petersen, 2008; Wolkewitz et al., 2007), and to robustly estimate the partial associations between HIV status and its various cofactors. Coefficient estimates in Table 2 were provided as relative risk ratios (RRR), which describe the factor change in the probability of an outcome (in this case, a reported HIV-positive status) for each unit increase in the predictor variable (after controlling for all covariates; Table 2). All analyses were conducted using Stata v13SE (Stata Corporation, College Station, Texas, USA).
REDUCTIONS IN HIV PREVALENCE 463 TABLE 1. Sociodemographic Characteristics, Substance Use, and Unprotected Anal Intercourse with Another Male by Self-Reported HIV Status, January 2008-December 2011 (N = 5,599). HIV-Negative/DK
HIV-Positive
Total
(n = 4,849)
(n = 750)
(N = 5,599)
N (%) or Mean (SD)
N (%) or Mean (SD)
N (%) or Mean (SD)
4,026 (83.0%)
678 (90.4%)
4,704 (84.0%)
816 (16.8%)
71 (9.5%)
887 (15.8%)
7 (0.1%)
1 (0.1%)
8 (0.1%)
2,194 (45.3%)
435 (58.0%)
2,629 (47.0%)
502 (10.4%)
82 (10.9%)
584 (10.4%)
Hispanic/Latino
1,600 (33.0%)
175 (23.3%)
1,775 (31.7%)
Multiracial/other
553 (11.4%)
58 (7.7%)
611 (10.9%)
≤ 29 years
2,086 (43.0%)
177 (23.6%)
2,263 (40.4%)
30–39 years
1,823 (37.6%)
300 (40.0%)
2,123 (37.9%)
40–49 years
813 (16.8%)
234 (31.2%)
1,047 (18.7%)
≥ 50 years
127 (2.6%)
39 (5.2%)
166 (3.0%)
Pa
Sexual identity Gay Bisexual Heterosexual
