Neighborhood Health Care Access and Sexually Transmitted Infections Among Women in the Southern United States: A Cross-Sectional Multilevel Analysis

Sex Transm Dis. 2018 Jan;45(1):19-24. doi: 10.1097/OLQ.0000000000000685.


Introduction: The United States has experienced an increase in reportable sexually transmitted infections (STIs) while simultaneously experiencing a decline in safety net services for STI testing and treatment. This multilevel study assessed relationships between neighborhood-level access to health care and STIs among a predominantly Human Immunodeficiency Virus (HIV)-seropositive cohort of women living in the south.

Methods: This cross-sectional multilevel analysis included baseline data from HIV-seropositive and HIV-seronegative women enrolled in the Women's Interagency HIV Study sites in Alabama, Florida, Georgia, Mississippi, and North Carolina between 2013 and 2015 (N = 666). Administrative data (eg, United States Census) described health care access (eg, percentage of residents with a primary care provider, percentage of residents with health insurance) in the census tracts where women lived. Sexually transmitted infections (chlamydia, gonorrhea, trichomoniasis, or early syphilis) were diagnosed using laboratory testing. Generalized estimating equations were used to determine relationships between tract-level characteristics and STIs. Analyses were conducted using SAS 9.4.

Results: Seventy percent of participants were HIV-seropositive. Eleven percent of participants had an STI. A 4-unit increase in the percentage of residents with a primary care provider was associated with 39% lower STI risk (risk ratio, 0.61, 95% confidence interval, 0.38-0.99). The percentage of tract residents with health insurance was not associated with STIs (risk ratio, 0.98, 95% confidence interval, 0.91-1.05). Relationships did not vary by HIV status.

Conclusions: Greater neighborhood health care access was associated with fewer STIs. Research should establish the causality of this relationship and pathways through which neighborhood health care access influences STIs. Structural interventions and programs increasing linkage to care may reduce STIs.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Cross-Sectional Studies
  • Educational Status
  • Ethnicity
  • Female
  • Health Knowledge, Attitudes, Practice
  • Health Services Accessibility / statistics & numerical data*
  • Humans
  • Middle Aged
  • Multilevel Analysis
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Residence Characteristics
  • Sexual Behavior
  • Sexually Transmitted Diseases / epidemiology*
  • Southwestern United States / epidemiology
  • Women's Health*
  • Young Adult