Abstract
Background
People of Asian ethnicity represent one of the fastest-growing populations in the United States and may experience unique social and cultural challenges to accessing sexual healthcare. This analysis explores disparities in annual sexually transmitted infection screening and diagnosis rates per person-year between Asian and non-Asian people with human immunodeficiency virus in Washington, District Columbia.
Methods
Using District Columbia Cohort data, a longitudinal study of people living with human immunodeficiency virus receiving care in Washington, District of Columbia, we analyzed people with human immunodeficiency virus aged 18 or older with at least one year of follow-up between 2018 and 2023. Logistic regression was used to examine differences in sexually transmitted infection screening and diagnoses between Asian and non-Asian participants, while linear trend analyses were used to assess changes in the number of screenings and diagnoses between Asian and non-Asian participants.
Results
Among 8,679 eligible participants, 0.88% (n=76) were Asian. No significant differences in total sexually transmitted infection screenings or diagnoses were observed. However, Asian participants had higher screening rates per person-year for pharyngeal and urogenital gonorrhea, pharyngeal chlamydia, and syphilis. Chlamydia incidence was higher among Asians compared to non-Asian participants. Over 30% of both groups met the annual screening recommendation during the study period.
Conclusions
Asians had comparable screening rates to non-Asians, but the small sample size limits the generalizability of our findings. Nonetheless, the present study helps address an existing gap in the literature on Asian sexual health. Larger studies with detailed ethnic and social data are needed to deepen our understanding of sexual health service use within Asian communities.
Keywords: Sexually Transmitted Infections, STI screening, Ethnic disparity, Healthcare access, Gonorrhea, Chlamydia, Syphilis, Asian people with HIV
Summary text
Asian populations are often underrepresented in sexual health research, and prior studies indicate lower participation in STI screening compared to other racial/ethnic counterparts. In this study, we examined STI testing patterns among Asian people with HIV in Washington, DC, and report differences between racial/ethnic groups. These results expand the limited research on STI testing in Asian populations with HIV and provide a foundation for future studies exploring more in-depth factors influencing testing patterns in Asian communities.
1. Introduction
Sexually transmitted infections (STIs), including gonorrhea, chlamydia, and syphilis, have risen markedly in the United States in recent years, posing a growing public health concern. People with HIV (PWH) are particularly vulnerable to these infections, as concurrent STIs can trigger mucosal inflammation, promote HIV viral shedding, and heighten the risk of transmission. (1–3) When left undiagnosed or untreated, STI co-infections can exacerbate morbidity, complicate HIV management, and increase healthcare burden. To mitigate these risks, the Centers for Disease Control and Prevention (CDC) recommends that all PWH receive comprehensive STI screening at least annually as part of routine HIV care. (4) As part of a broader national strategy, the U.S. Department of Health and Human Services launched the Ending the HIV Epidemic (EHE) initiative in 2019 with the goal of reducing new HIV infections by 90% by the year 2030. (5, 6)
Despite established recommendations for routine STI screening, few studies have examined screening patterns among Asian PWH. Historically, Asians have been markedly underrepresented in HIV and STI research, even though they represent one of the fastest-growing racial groups in the United States—rising from 22.5 million in 2019 to a projected 46 million by 2060 (1). For example, one study assessing adherence to guideline-recommended STI screening frequencies using electronic health record data of PWH residing in North California found no significant difference in the odds of receiving annual gonorrhea and chlamydia screenings between Asian and White PWH. (7) However, Asians accounted for only 7% of the total analytic sample, limiting the precision and generalizability of these findings. Although HIV and STI testing are often performed together as part of comprehensive entry-to-care evaluations, national data indicate that Asians consistently have the lowest HIV testing coverage among all racial and ethnic groups. (8) This under-testing may partly explain the lower reported STI incidence among Asians, as undiagnosed HIV infection and missed screenings likely contribute to under-ascertainment.
In the absence of extensive data on Asian PWH, population-level studies offer indirect insight into potential screening gaps in this group. Beste et al (2022) performed a retrospective study of chlamydia, gonorrhea, syphilis, and human immunodeficiency virus (HIV) testing rates among the patients in the national Veterans Health Administration (VHA) system during 2019–2021 to look at the impact of pandemic-related care disruption. The authors reported a 27% decline in chlamydia and gonorrhea testing rates per 100,000 among Asian patients, the second largest decline behind the 28% decrease observed among Hawaiian and Pacific Islanders. By 2021, while the majority of population groups remained below the pre-pandemic testing levels, testing among Asians was the slowest to recover, with 14% below the baseline. (9) In Sharma et al (2023), 115 U.S. South Asian gay, bisexual, and other men who have sex with men were surveyed about their HIV and STI testing patterns from April to July 2022. In their study, authors reported approximately 28% had not been tested for HIV, and over 40% had not been tested for STIs in the past year. (10) These findings are concerning as sexually experienced Asians are equally or more likely than their White counterparts to have multiple sex partners and engage in sexual activity. (11–13)
The reasons for these disparities are multifactorial, often involving sociocultural stigmas that cause people to refuse testing and delay treatment. One example is the significant stigma attached to sexual education in many Asian communities. The high social value placed on preserving women’s virginity before marriage can prevent women from seeking necessary sexual health services, as being seen at sexual health clinics can jeopardize their standing in the community. (14, 15) Emphasis on modesty and shyness also pose barriers to accessing these services. (16–18) Language barriers further contribute to testing disparities by impacting access to healthcare and understanding of healthcare services. Immigrants with limited English proficiency (LEP) experience communication barriers that affect trust in patient-provider relationships but also their health outcomes and quality of medical visits. (19, 20) A study by Chen et al (2023) involving qualitative interviews and quantitative surveys with 69 Asian Americans living with HIV (AALWH) in New York, San Francisco, and Los Angeles highlighted the impact of language barriers on HIV care. The study found that language facilitators, such as family members, friends, case managers, or interpreters, who could communicate with healthcare providers in the AALWH’s native language, had a positive impact. The authors concluded that language barriers negatively impact access to HIV-related services, resulting in decreased adherence to antiretroviral therapy, increased unmet healthcare needs, and heightened HIV-related stigma. (21)
Unfortunately, Asian Americans, Native Hawaiians, and Pacific Islanders (AANPH) also remain a widely understudied group, with NIH research funding for AANPI comprising only 0.17% of the total budget. (22) In large data collection surveys such as the National Health and Nutrition Examination Survey, non-Hispanic Asians were not included as a separate racial category until 2011- they were previously categorized as “Other”. (23) There is a significant lack of studies conducted in the US that quantify the degree of sexual health services in this specific population, particularly without being categorized as the “Non-Hispanic Other” ethnic group. There is a significant gap in research that adequately looks at the factors associated with HIV/STI screenings and prevention among Asians in the US. In particular, it is unclear whether the historically low screening rates observed in the broader Asian population extend to PWH within this group. Such paucity in literature, therefore, calls for additional studies on this domain. To fill these gaps, we aimed to assess the differences in STI screening and incidence between Asian and Non-Asian PWH in Washington, District of Columbia (DC), using the DC Cohort study.
2. Materials and Methods
2.1. Participants
The DC Cohort is a longitudinal prospective study of PWH who receive HIV-related care in Washington, DC. Enrollment in the cohort began in 2011 and is ongoing. The DC Cohort has Institutional Review Board (IRB) approval from the George Washington University IRB as well as site specific IRBs as required. As of January 1, 2024, there were over 12,000 participants enrolled in the Cohort across 14 sites in Washington, DC. The follow-up period for this analysis began on either January 1st, 2018, or the date of consent and ended on January 1st, 2024, or on the date a participant became inactive in the cohort. Participants were considered inactive if they went one calendar year without any HIV labs or HIV-care encounters, withdrew from the study, transferred to another care site, or died prior to January 1, 2024. We evaluated DC Cohort participants who enrolled at age 18 or older with at least one year of follow-up during the follow-up period.
2.2. Human Subjects Research
The DC Cohort has Institutional Review Board (IRB) approval from the George Washington University IRB (IRB #: 071029), as well as site specific IRBs as required. Participants undergo informed consent with clinic staff at the local site where they receive their HIV-related clinical care. In the informed consent process, participants are informed of the study’s objectives, procedures, risks, and benefits of participating. Participants at Kaiser Permanente are automatically enrolled if they have previously provided informed consent for de-identified data to be used. This is outlined in their Annual Explanation of Benefits. Participants can withdraw from the cohort at any time.
2.3. STI Screening & Diagnosis Outcomes
We evaluated whether participants received at least one screening for gonorrhea, chlamydia, or syphilis, in each year from 2018 to the end of 2023, using lab data from the DC Cohort database. Rapid tests were not included for any of the screenings described in this analysis. We selected this period to capture a contemporary sample, as data from the most recent years best reflect current patterns of STI transmission in the context of Undetectable = Untransmissible (U=U) and the introduction of doxycycline post-exposure prophylaxis (doxy-PEP). If a participant had a screening for an STI in a given year, we evaluated whether they had a diagnosis for that STI in the same year. If a participant received a screening for all three STIs in one year (gonorrhea, chlamydia, and syphilis), they were considered to have met the recommended CDC annual STI screening guidance. (4) Among those who met the recommended STI screening guidance in a given year, we evaluated whether participants had at least one STI diagnosis in that year. Specifically, gonorrhea and chlamydia were defined as a positive nucleic acid amplification test or a positive culture test. For syphilis, we used a combination of titers, treponemal, and nontreponemal tests to classify cases of syphilis. In our study, a new case of syphilis was defined by meeting one of the following criteria: a) Having a titer of 4 or more after a previous titer of 0; b) Having a current titer greater than or equal to 4 times the previous titer; c) Having a current titer of 8 and a positive treponemal or nontreponemal test after a previous negative treponemal and nontreponemal test; d) Having a current titer of 32 or more. Finally, we evaluated the anatomical site for each screening and calculated the screening rates per person-year at each anatomical site in our study sample. Anatomical sites for gonorrhea and chlamydia screening included the cervix, urethra, rectum, throat, urine, and vagina. Syphilis screening was typically performed using blood samples.
2.4. Covariates
The primary independent variable was race/ethnicity. Participants were considered Asian if Asian race was listed anywhere in their provider reported Electronic Health Record (EHR) demographics and all others were considered non-Asian. Multiracial Asian participants were considered to be Asian for the purposes of this analysis. Non-Asian participants included the non-Hispanic Black, non-Hispanic White, Hispanic, American Indian or Alaskan Native, Native Hawaiian or Pacific Islander, and anyone categorized as mixed race without specific mention of being Multiracial Asian. Other demographic data, including age, gender, HIV transmission factor, insurance, employment, and housing status were extracted from the EHR data stored in the DC Cohort database. Viral suppression was defined as < 200 copies/mL and was measured as of the most recent viral load lab recorded prior to the participant’s end of follow-up.
2.5. Statistical analysis
We used descriptive statistics to describe the distribution of participant characteristics, number of participants who met the annual STI screening recommendation, and anatomical site of STI screening, stratified by Asian and Non-Asian participants. Chi-squared tests, Fisher’s Exact tests, and Wilcoxon rank-sum tests were used to evaluate differences across groups. Multivariable logistic regression accounting for repeated observations across each year with an independent correlation structure was used to evaluate the association between race/ethnicity and each of the STI screening and diagnosis outcomes using unadjusted and adjusted odds ratio with their 95% confidence intervals (CI). Adjusted models included age, gender, HIV transmission risk factor, insurance status, and whether the participant had a history of the respective STI. Given the small sample size of Asian participants (N=76) compared to Non-Asian participants (N=8,364), we conducted a power calculation using OpenEpi (24) to estimate the power to detect differences at a significant level of 0.05, based on STI screening percentages reported in the literature. (7, 9, 25–27) The results demonstrate consistently high-power values, ranging from 0.89 to 1.00, when fewer Asian participants undergo STI screenings (4% to 10%) compared to their non-Asian counterparts (26% to 93%). However, the power begins to decline as the proportions of participants undergoing STI screenings in the two groups become more similar, with power values ranging from 0.12 to 0.75 in these scenarios (Supplementary Table 1). Finally, we used linear trend analysis to evaluate whether rates of STI screening and diagnoses changed significantly from 2018 to 2023 among all our participants, as well as stratified by Asian and Non-Asian participants.
3. Results
We evaluated 8,679 eligible DC Cohort participants who had at least one year of follow-up from 2018 to 2023. Among the eligible participants, 0.88% were Asian (N=76), 71.24% were male, 42.37% were men who have sex with men (MSM), and the median age was 56 [IQR: 45, 64] years. Asian and Non-Asian participants had similar median length of follow-up time (5.5 years [IQR: 3,6] vs. 6 years [IQR: 3, 6], p = 0.838). Asian participants had a lower median age (52 years vs. 56 years, p= 0.006) and were more likely to have private insurance (60.53% vs. 34.51%, p < 0.001). (Table 1). No other significant differences between Asian and Non-Asian participants were found.
Table 1.
Distribution of covariates between Asian and non-Asian participants in the DC Cohort from 2018–2023
| Participant Characteristicsa | Total Participants N (%) (N = 8679) |
Asian Participants N (%) (N = 76) |
Non-Asian Participants N (%) (N = 8603) |
p-valueb |
|---|---|---|---|---|
| Race/Ethnicity | < 0.001 | |||
| Asian | 76 (0.88) | 76 (100.0) | 0 (0.00) | |
| Non-Hispanic Black | 6872 (79.18) | 0 (0.00) | 6872 (79.88) | |
| Non-Hispanic White | 1100 (12.67) | 0 (0.00) | 1100 (12.79) | |
| Hispanic | 385 (4.44) | 0 (0.00) | 385 (4.48) | |
| Mixed Race | 216 (2.49) | 0 (0.00) | 216 (2.51) | |
| American Indian or Alaskan Native | 18 (0.21) | 0 (0.00) | 18 (0.21) | |
| Native Hawaiian or Pacific Islander | 12 (0.14) | 0 (0.00) | 12 (0.14) | |
| Age [years](Median [IQR]) | 56 (45, 64) | 52 (39.5, 60.5) | 56 (45, 64) | 0.006c |
| Gender | 0.366 | |||
| Male | 6183(71.24) | 60(78.95) | 6123(71.17) | |
| Female | 2310(26.62) | 16(21.05) | 2294(26.67) | |
| Transgender: male-to-female | 168(1.94) | 0 (0.00) | 168(1.95) | |
| Transgender: female-to-male | 18(0.21) | 0 (0.00) | 18(0.21) | |
| HIV Transmission Factor | 0.245 | |||
| Men who have sex with Men | 3677(42.37) | 42(55.26) | 3635(42.25) | |
| Intravenous Drug Use (IDU) | 476(5.48) | 3(3.95) | 473(5.5) | |
| MSM and IDU | 108(1.24) | 2(2.63) | 106(1.23) | |
| Heterosexual (HRH) | 2833(32.64) | 21(27.63) | 2812(32.69) | |
| Perinatal | 61(0.7) | 0 (0.00) | 61(0.71) | |
| Other | 1495(17.23) | 8(10.53) | 1487(17.28) | |
| Unknown | 29(0.33) | 0 (0.00) | 29(0.34) | |
| Insurance | < 0.001 | |||
| Private | 3015(34.74) | 46(60.53) | 2969(34.51) | |
| Public c | 5053(58.22) | 26(34.21) | 5027(58.43) | |
| Other d | 166(1.91) | 1(1.32) | 165(1.92) | |
| Unknown | 445(5.13) | 3(3.95) | 442(5.14) | |
| Employment | 0.08 | |||
| Working Full-Time | 2420(27.88) | 29(38.16) | 2391(27.79) | |
| Working Part-Time | 258(2.97) | 2(2.63) | 256(2.98) | |
| Unemployed | 1832(21.11) | 7(9.21) | 1825(21.21) | |
| Other | 658(7.58) | 7(9.21) | 651(7.57) | |
| Unknown | 3511(40.45) | 31(40.79) | 3480(40.45) | |
| Housing | 0.546 | |||
| Permanent | 7581(87.35) | 71(93.42) | 7510(87.3) | |
| Temporary/Unstable | 457(5.27) | 3(3.95) | 454(5.28) | |
| Homeless | 97(1.12) | 0 (0.00) | 97(1.13) | |
| Other | 14(0.16) | 0 (0.00) | 14(0.16) | |
| Unknown | 530(6.11) | 2(2.63) | 528(6.14) | |
|
Viral Suppression
e
(< 200 copies/ml) |
0.687 | |||
| Virally Suppressed | 7327(84.42) | 64(84.21) | 7263(84.42) | |
| Not Virally Suppressed | 942(10.85) | 7(9.21) | 935(10.87) | |
| Unknown | 410(4.72) | 5(6.58) | 405(4.71) | |
| CD4 [cells/μL] (Mean [SD]) f | 675.85(348.28) | 620.11(273.03) | 676.35(348.85) | 0.216 |
Measured at the end of follow-up;
Chi-square tests and Wilcoxon rank-sum tests used to calculate differences in categorical and continuous variables, respectively;
Calculated by a Kruskal-Wallis test;
DC Alliance, Medicaid, Medicare, Ryan White/ADAP, Other Public Funding;
Clinical study, insurance terminated, self pay/fee for service, other;
Most recent lab measure taken prior to the end of follow-up for each participant
Over 30% of all participants met the recommended annual STI screening between 2018 and 2023 (32.98–52.63%) and there were no significant differences in the proportion of participants meeting the annual screening recommendation, between Asian and non-Asian participants (Table 2). Additionally, on average, all participants had more than one STI screening during the study period (Asian: 6.63 screenings per person-year, non-Asian: 5.35 screenings per person-year, p=0.121) (Table 3). We did not observe any significant difference between Asian and Non-Asians across the overall individual STI screenings. When stratified by anatomical site for STI testing, Asian participants had higher annual screening rates for pharyngeal gonorrhea (Asian: 0.16 screenings per person-year, Non-Asian: 0.12 screenings per person-year, p = 0.033), urogenital gonorrhea (Asian: 0.31 screenings per person-year, Non-Asian: 0.19 screenings per person-year, p = 0.002), and syphilis (Asian: 0.52 screenings per person-year, Non-Asian: 0.33 screenings per person-year, p = 0.007). Annual chlamydia diagnosis was also higher among Asians (Asian: 0.1, Non-Asian: 0.004, p-value < 0.001). (Table 3). Notably, annual STI screening and incidence rates significantly changed over time among Non-Asian participants, but this change was not significant among Asian participants (Table S2).
Table 2.
Number of Asian and Non-Asian PWH meeting the annual STI screening recommendation, DC Cohort, 2018–2023
| Asian participants N (%) (N = 76) |
Non-Asian participants N (%) (N = 8,364) |
p-value | |
|---|---|---|---|
| No | 45 (59.21%) | 5039 (58.57%) | |
| No | 36 (47.37%) | 4939 (57.40%) | |
| No | 47 (61.84%) | 5752 (66.87%) | |
| No | 49 (64.47%) | 5550 (64.50%) | |
| No | 44 (57.89%) | 5517 (64.13%) | |
| No | 49. (64.47%) | 5766 (67.02%) |
Table 3.
STI screening and incidence rates per person-year among DC Cohort Asian and Non-Asian PWH from 2018–2023
| Asian Participants (N = 76) |
Non-Asian Participants (N = 8,364) |
p-value | |
|---|---|---|---|
| Any STI Screening | 6.63 | 5.35 | 0.121 |
| Gonorrhea Screening | 2.1 | 1.64 | 0.059 |
| Body Site | |||
| Cervical | 0.01 | 0.01 | 0.686 |
| Nasal | 0.00 | 0.00 | 0.925 |
| Rectal | 0.11 | 0.09 | 0.466 |
| Throat | 0.16 | 0.12 | 0.033 |
| Urethra | 0.01 | 0.00 | 0.38 |
| Urine | 0.31 | 0.19 | 0.002 |
| Vaginal | 0.00 | 0.00 | 0.703 |
| Unknown Body Site | 1.48 | 1.2 | 0.792 |
| Chlamydia Screening | 2.77 | 1.98 | 0.019 |
| Body Site | |||
| Blood | 0.00 | 0.00 | 0.925 |
| Cervical | 0.01 | 0.01 | 0.686 |
| Rectal | 0.15 | 0.13 | 0.164 |
| Throat | 0.16 | 0.12 | 0.033 |
| Urethra | 0.00 | 0.01 | 0.857 |
| Urine | 0.31 | 0.19 | 0.002 |
| Vaginal | 0.00 | 0.00 | 0.703 |
| Unknown Body Site | 1.62 | 1.19 | 0.549 |
| Syphilis Screening | 2.29 | 2.08 | 0.685 |
| Body Site | |||
| Blood | 0.52 | 0.33 | 0.007 |
| Unknown Body Site | 1.77 | 1.74 | 0.354 |
| Any STI Diagnosis | 7.16 | 5.7 | 0.096 |
| Gonorrhea Diagnosis | 0.05 | 0.05 | 0.167 |
| Chlamydia Diagnosis | 0.1 | 0.04 | <0.001 |
| Syphilis Diagnosis | 0.06 | 0.04 | 0.169 |
| Number of diagnoses per screen | |||
| Any STI | 1.08 | 1.07 | 0.118 |
| Gonorrhea | 0.01 | 0.01 | 0.2 |
| Chlamydia | 0.01 | 0.01 | <0.001 |
| Syphilis | 0.01 | 0.01 | 0.21 |
There were no significant differences in the odds of annual STI screenings for gonorrhea (OR: 1.14 [95% CI: 0.8, 1.61], p-value = 0.474), chlamydia (OR: 1.19 [95% CI: 0.84, 1.7], p-value = 0.323), and syphilis (OR: 0.87 [95% CI: 0.63, 1.21], p-value = 0.413), nor were there any significant differences in meeting the annual STI screening criteria between Asian and Non-Asian participants criteria (OR: 1.15 [95% CI: 0.81, 1.65], p-value = 0.434) (Table 4). Furthermore, there were no significant differences in diagnoses regardless of anatomical site for gonorrhea (OR: 1.33 [95% CI: 0.66, 2.7], p-value = 0.422) and syphilis (OR: 1.71 [95% CI: 0.86, 3.42], p-value = 0.127) between Asian and Non-Asian participants, except for chlamydia (OR: 1.94 [95% CI: 1.04, 3.63], p-value = 0.037). None of these associations were significant after adjusting for age, gender, HIV transmission factor, insurance status, and history of the respective STI (Table 4).
Table 4.
Associations between race/ethnicity and receiving annual STI screenings and STI diagnosis among DC Cohort Asian and Non-Asian PWH from 2018–2023
| Race | OR (95% CI) | p-value | aORa (95% CI) | p-value | |
|---|---|---|---|---|---|
| Annual STI screening recommendation | Non-Asian | REF | 0.434 | REF | 0.893 |
| Asian | 1.15 (0.81, 1.65) | 0.98 (0.39, 0.34) | |||
| Annual Gonorrhea screening | Non-Asian | REF | 0.474 | REF | 0.932 |
| Asian | 1.14 (0.8, 1.61) | 1.02(0.71, 1.45) | |||
| Annual Chlamydia screening | Non-Asian | REF | 0.323 | REF | 0.766 |
| Asian | 1.19 (0.84, 1.70) | 1.06 (0.74, 1.51) | |||
| Annual Syphilis screening | Non-Asian | REF | 0.413 | REF | 0.766 |
| Asian | 0.87 (0.63, 1.21) | 1.06 (0.74, 1.51) | |||
| Any STI diagnosis | Non-Asian | REF | 0.48 | REF | 0.963 |
| Asian | 1.22 (0.70, 2.15) | 0.99 (0.52, 1.86) | |||
| Gonorrhea diagnosis | Non-Asian | REF | 0.422 | REF | 0.733 |
| Asian | 1.33 (0.66, 2.70) | 1.13 (0.55, 2.34) | |||
| Chlamydia diagnosis | Non-Asian | REF | 0.037 | REF | 0.102 |
| Asian | 1.94 (1.04, 3.63) | 1.67 (0.90, 3.08) | |||
| Syphilis diagnosis | Non-Asian | REF | 0.127 | REF | 0.366 |
| Asian | 1.71 (0.86, 3.42) | 1.40 (0.68, 2.87) |
OR = Odds Ratio; aOR = Adjusted Odds Ratio; CI = Confidence Interval;
Adjusted for age, gender, HIV transmission factor, insurance status, and history of the respective STI
4. Discussion
This analysis evaluated racial/ethnic disparities in STI screening between Asian and Non-Asian participants, addressing a historical gap in STI research focusing on the Asian population living with HIV. We did not observe any significant differences in overall STI screening and incidence rates between Asian and non-Asian participants from 2018 to 2023. However, Asian participants exhibited higher screening rates for pharyngeal gonorrhea and chlamydia, and syphilis compared to Non-Asian participants. Pharyngeal infections are frequently asymptomatic and often undiagnosed in the absence of targeted testing, making differential screening practices particularly relevant for interpreting population-level disparities. The higher frequency of pharyngeal screening among Asian participants may reflect variation in sexual behaviors, including a greater prevalence of oral sexual exposure or more accurate reporting of such behaviors during clinical encounters. Prior population-based studies have documented an increasing prevalence of oral sex across diverse populations, particularly among younger adults, which may partly explain the observed testing pattern. (28–30) This finding highlights the importance of integrating detailed behavioral data and site-specific testing information into surveillance analyses to better distinguish differences driven by behavioral risk from those arising due to variations in screening intensity. Furthermore, we found that, except in 2019, less than half of participants received annual screening for all STIs. Screening rates declined notably after 2019, likely reflecting the pandemic’s impact on access to healthcare services. In the United States, all components of HIV care were disrupted, with multiple studies documenting not only reduced testing but also fewer HIV care encounters. (31–33) These observations underscore the need for continued research to better understand the long-term effects of disruptions on HIV and STI care.
Interestingly, we observed a higher annual incidence of chlamydia among Asian participants, which contrasts with recent CDC reports showing the lowest reported STI rates in this group. There are two possible explanations for this discrepancy. First, DC Cohort participants have previously been found to be more engaged in care than the general population of PWH living in DC. (34) These population characteristics may be indicative of a population with high access to care, resulting in the low disparities in STI screening and diagnoses found here. (34) Second, Asian PWH may be more likely to present later to care. Prior studies have reported delayed HIV diagnosis among individuals in Asia, with stigma, discrimination, limited knowledge, and structural barriers contributing to lower rates of testing and treatment uptake. (35–37) Late HIV presenters in these settings have also been shown to experience a higher burden of concurrent infections and more advanced disease stages. (35, 37) Similar factors may have influenced care engagement among Asian participants in this study, emphasizing the importance of examining these patterns in greater depth.
This analysis has several strengths. First, this analysis is one of the few studies focusing on the sexual health of Asians residing in Washington, DC. According to the US Census 2020, there are 33,545 Asian Americans in Washington, DC, constituting approximately 5% of the total population. (38) Despite their demographic presence, our systematic literature search revealed a lack of epidemiological studies reporting trends in the use of STI services among Asians at a local level. Second, our study provides screening rates stratified by body sites to detect any further differences between our groups instead of reporting aggregate rates only. This detailed approach allowed for a more comprehensive understanding of the sexual health status among Asian participants, producing site-specific prevalence that may be obscured in aggregate data. By doing so, we were able to observe the absence of disparities in STI rates both overall and at specific body sites. Finally, the longitudinal nature of the DC Cohort allowed us to evaluate STI screenings and diagnoses over multiple years, rather at one point in time. This is especially important in recent years during which the COVID-19 may have disrupted care for some patients.
The limitations of our analyses are also noteworthy. First, the small sample size of the Asian population in our study restricts the generalizability of our findings to Asian communities residing in DC and other geographic regions. This constraint highlights the necessity for research in larger cohorts to better capture the heterogeneity within Asian populations. Secondly, our database captured limited data on ethnicity, preventing us from disaggregating the Asian population for analyses within specific subgroups of Asian ethnicities. This limitation underscores the importance of including detailed ethnic data in health research to identify and address disparities more effectively. Third, our race/ethnicity variable was extracted from EHR submitted by a physician, making it a potentially imperfect variable to represent the actual demographic characteristics of patients. Thus, the use of EHR may inherently limit the assessment of the true impact of race/ethnicity on screening disparities. Lastly the study’s scope is limited by the absence of additional contextual information about participants, such as their sociocultural and economic barriers to STI care. Understanding these barriers is crucial for designing interventions that are culturally and economically tailored to the needs of diverse communities.
This study calls attention to the imperative need for further research that surveys the perceptions and health behaviors of Asian populations concerning STI care. Such research should aim to assess the level of STI awareness, the cultural relevance of current services, and the accessibility of these services. By doing so, we can enhance the engagement of Asian populations in STI care, ultimately improving health outcomes and reducing disparities in STI rates. While our small sample size limits the generalizability of findings, it also highlights the critical underrepresentation of Asian PWH in sexual health research. The scarcity of such data makes this study a valuable contribution toward filling an important gap in the current literature. More inclusive and larger-scale studies are essential for capturing the diversity within Asian communities, particularly when it comes to variations in STI risk and screening behaviors across different ethnic subgroups. Thus, prioritizing inclusivity and representation of diverse racial groups in future studies will be key to developing interventions that are more culturally sensitive and help close the existing gaps in Asian sexual health among PWH.
Supplementary Material
Acknowledgements
Data in this manuscript were collected by the DC Cohort Study Group with investigators and research staff located at: Children’s National Hospital Pediatric clinic (Natella Rakhmanina); the Senior Deputy Director of the DC Department of Health HAHSTA (Clover Barnes); Family and Medical Counseling Service (Rita Aidoo); Georgetown University (Princy Kumar); The George Washington University Biostatistics Center (Tsedenia Bezabeh, Vinay Bhandaru, Asare Buahin, Nisha Grover, Lisa Mele, Susan Reamer, Alla Sapozhnikova, Greg Strylewicz, and Marinella Temprosa); The George Washington University Department of Epidemiology (Elisabeth Andersen, Shannon Barth, Morgan Byrne, Amanda Castel, Alan Greenberg, Shannon Hammerlund, Olivia Kirby, Paige Kulie, Anne Monroe, Lauren O’Connor, James Peterson, Bianca Stewart, and Mark Storey) and Department of Biostatistics and Bioinformatics; The George Washington University Medical Faculty Associates (Jose Lucar); Howard University Adult Infectious Disease Clinic (Jhansi L. Gajjala) and Pediatric Clinic (Sohail Rana); Kaiser Permanente Mid-Atlantic States (Michael Horberg); La Clínica Del Pueblo (Ricardo Fernandez); MetroHealth (Duane Taylor); Washington Health Institute, formerly Providence Hospital (Jose Bordon); Unity Health Care (Gebeyehu Teferi); Veterans Affairs Medical Center (Debra Benator and Rachel Denyer); Washington Hospital Center (Adam Klein); and Whitman-Walker Institute (Stephen Abbott).
Declaration of Funding
The DC Cohort is funded by the National Institute Of Allergy And Infectious Diseases of the National Institutes of Health under Award Number R24AI152598. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. All work for this manuscript was completed prior to 20 January 2025.
Footnotes
Informed Consent
Informed consent was obtained from all participants involved in the study.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability
Per DC Cohort protocols, data are available upon request and approval of the DC Cohort Executive Committee. Interested parties should email the Principal Investigator at acastel@gwu.edu.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Per DC Cohort protocols, data are available upon request and approval of the DC Cohort Executive Committee. Interested parties should email the Principal Investigator at acastel@gwu.edu.