Longitudinal Predictors of Human Papillomavirus Vaccination Among a National Sample of Adolescent Males

Objectives. We conducted a longitudinal study to examine human papillomavirus (HPV) vaccine uptake among male adolescents and to identify vaccination predictors.Methods. In fall 2010 and 2011, a national sample of parents with sons aged 11 to 17 years (n = 327) and their sons (n = 228) completed online surveys. We used logistic regression to identify predictors of HPV vaccination that occurred between baseline and follow-up.Results. Only 2% of sons had received any doses of HPV vaccine at baseline, with an increase to 8% by follow-up. About 55% of parents who had ever received a doctor’s recommendation to get their sons HPV vaccine did vaccinate between baseline and follow-up, compared with only 1% of parents without a recommendation. Fathers (odds ratio = 0.29; 95% confidence interval = 0.09, 0.80) and non-Hispanic White parents (odds ratio = 0.29; 95% confidence interval = 0.11, 0.76) were less likely to have vaccinated sons. Willingness to get sons HPV vaccine decreased from baseline to follow-up among parents (P < .001) and sons (P = .003).Conclusions. Vaccination against HPV remained low in our study and willingness to vaccinate may be decreasing. Physician recommendation and education about HPV vaccine for males may be key strategies for improving vaccination.Quadrivalent human papillomavirus (HPV) vaccine against types 6, 11, 16, and 18 is approved to protect against genital warts (caused mostly by HPV types 6 and 111) and anal cancer (caused mostly by HPV types 16 and 182) in males.3 About 4% of men in the United States report a previous diagnosis of genital warts,4 and about 2250 new cases of anal cancer occur annually among males in the United States.5 Given the high levels of HPV concordance among sexual partners,6 vaccinating males may also have indirect health benefits for their partners.7 United States guidelines began including HPV vaccine for males in October 2009.8 The Advisory Committee on Immunization Practices first provided a permissive recommendation, recommending the 3-dose quadrivalent vaccine series for males aged 9 to 26 years but not making it part of their routine vaccination schedule.8 In October 2011, the Advisory Committee on Immunization Practices updated its stance on HPV vaccine for males and recommended routine vaccination of boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.9 The updated recommendation continues to allow HPV vaccine to be given to males aged as young as 9 years and up to 26 years.9Although numerous studies have examined HPV vaccine uptake among females,10 data on HPV vaccine uptake among males are sparse. Despite mostly encouraging early levels of parental acceptability of the vaccine for males,11–13 initial estimates found that only about 2% of male adolescents in the United States had received any doses of HPV vaccine by the end of 2010.14,15 Recent data suggest that this increased to about 8% by the end of 2011.16 We are not aware of any studies that have examined predictors of vaccine uptake among males.Our study addresses several important gaps in the existing literature. We provide the first longitudinal examination of HPV vaccination among males and identify predictors of vaccine uptake. In doing so, we used data from both parents and their adolescent sons because many adolescents are involved in vaccination decisions.17 We also examined longitudinal changes in vaccine acceptability among parents and sons and parents’ reasons for not getting their sons HPV vaccine, because these data may provide valuable insight about future HPV vaccine uptake among males.     

Initiation of Human Papillomavirus Vaccination Among Predominantly Minority Female and Male Adolescents at Inner-City Community Health Centers

Objectives. We examined the prevalence and correlates of human papillomavirus (HPV) vaccine initiation among adolescents in low-income, urban areas.Methods. The study consisted of electronic health record data on HPV vaccination for 3180 adolescents (aged 10–20 years) at a multisite community health center in 2011.Results. Only 27% initiated the HPV vaccine. The adjusted odds ratio (AOR) of HPV vaccination was lower among older adolescents (AOR = 0.552; 95% confidence interval [CI] = 0.424, 0.718) and those seen by nonpediatric health care providers (HCPs; AOR = 0.311; 95% CI = 0.222, 0.435), and higher among non-English speakers (AOR = 1.409; 95% CI = 1.134, 1.751) and those seen at 2 site locations (AOR = 1.890; 95% CI = 1.547, 2.311). Insurance status was significant only among female and Hispanic adolescents. Language was not a predictor among Hispanic adolescents. Across all analyses, the interaction of age and HCP specialty was associated with HPV vaccination. Dramatically lower HPV vaccination rates were found among older adolescents seen by nonpediatric HCPs (3%–5%) than among other adolescents (23%–45%).Conclusions. Improving HPV vaccination initiation in low-income urban areas is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.Human papillomavirus (HPV) infection is a known risk factor for the development of several cancers. Between 2004 and 2008, there was a national average of 33 369 HPV-associated cancers annually, including cervical, vulvar, vaginal, penile, anal, and oropharyngeal cancers.1 The Centers for Disease Control and Prevention estimates 26 000 new HPV-associated cancers each year, 18 000 for women and 8000 for men,1 which could be prevented through the HPV vaccine.According to the US Cancer Statistics Working Group,2 there are pervasive disparities in national morbidity and mortality rates of HPV-related cancers for Black and Hispanic individuals. Cervical cancer is more common among Black and Hispanic women and results in disproportionately higher mortality for Black women. In 2009, the national age-adjusted cervical cancer incidence rates (per 100 000) for Hispanic and Black women (10.9 and 10.0, respectively) were higher than the rate for White women (7.6).2 The national age-adjusted cervical cancer mortality rate (per 100 000) for Black women (4.2) is considerably higher than the rates for White and Hispanic women (2.1 and 2.9, respectively).2 Also, Black women have higher morbidity and mortality rates of vaginal cancer. Morbidity and mortality rates of penile cancers are significantly higher among Black and Hispanic men. Black men have higher morbidity and mortality rates of anal cancer.2 In addition to race/ethnicity, incidence rates of penile, cervical, and vaginal cancers increase with higher poverty rates.3 Factors that contribute to cancer disparities among Black, Hispanic, and low-income populations include higher exposure to risk factors such as smoking, physical inactivity, and HPV infection as well as lack of access to early detection and treatment services.4New Jersey had the 10th highest morbidity rate for cervical cancer nationally for 2006 through 2010.5 According to the New Jersey State Cancer Registry, cervical cancer morbidity from 2005 to 2009 was significantly higher in the Greater Newark area (relative risk = 1.86; the study target area) than other areas in the state, as well as among women who are Black, Hispanic, foreign-born, non–English-speaking, uninsured, with lower income and education, unmarried, unemployed, and living in a rented residence.6 According to a community health needs assessment for the City of Newark in 2013,7 52.4% of the residents are Black, 33.8% are Hispanic, and 30% are foreign-born, compared with 13%, 18%, and 20%, respectively, in the state. Also, 28.4% of the residents are below the federal poverty level compared with 9.4% statewide, and 28% are uninsured compared with 8.4% statewide. A significant proportion of the residents has less than a high-school education (30%) and a low level of English proficiency (25%).7Transmission of HPV can be reduced through limiting the number of sexual partners, delaying the initiation of sexual activity, practicing safe sex, and getting vaccinated.8 Two vaccines have been approved by the Food and Drug Administration for protection against HPV: the quadrivalent vaccine (Gardasil, Merck, Kenilworth, NJ) for female and male individuals aged 9 to 26 years,9 and the bivalent vaccine (Cervarix, GlaxoSmithKline, Middlesex, England) for female individuals aged 10 to 25 years.10 The HPV vaccine requires a series of 3 injections within 6 months. Markowitz et al.11 examined the rates of HPV infection among female individuals before and after the vaccine was introduced in 2006, by using data from the National Health and Nutrition Examination Surveys for 2003 through 2010. They found that for female adolescents aged 14 to 19 years, there was a 55.7% reduction in vaccine-type HPV infection rate (HPV types 6, 11, 16, and 18) and a 50% reduction in high-risk vaccine-type HPV infection rate (HPV types 16 and 18). There was also an 88% decrease among the sexually active women in their rate of vaccine-type HPV infection when they compared those who were vaccinated to those who were not vaccinated.11 Niccolai et al.12 also found significant decline in the rates of high-grade cervical lesions from 2008 to 2011 among women aged 21 to 24 years in Connecticut. Unfortunately, this trend was attenuated in urban areas as well as areas with higher concentrations of Black, Hispanic, and low-income populations.12According to the National Immunization Survey—Teen (NIS-Teen),13 HPV vaccine initiation rates for female adolescents were 44.3% in 2009, 48.7% in 2010, 53.0% in 2011, and 53.8% in 2012. This reflects minimal improvement in 2011, no improvement in 2012, and reaching a plateau for female vaccination at a level dramatically lower than the goal of 80% completion rate for girls aged 13 to 15 years set by Healthy People 2020. In site-based studies, HPV vaccine initiation among female adolescents ranged between 9.4% and 62.9%.14–21 Also, initiation for female adolescents was lower for Spanish speakers,22 those who were uninsured,23–25 those with shorter duration of enrollment in health insurance,26 in nonpediatric settings,21,24 among those who have not had a preventive visit in the past 12 months,21,24,27–30 and with mothers’ lack of knowledge about HPV infection or vaccine.18,27,28,31,32 Some studies reported lower initiation among younger female adolescents,15,18,21,24,29,30 whereas others reported the opposite.21,26 Several studies have shown the importance of health care providers’ (HCPs’) recommendations for HPV vaccine initiation among female adolescents.16,28,30,31,33According to NIS-Teen,13 HPV vaccine initiation rates for male adolescents were 1.4% in 2010, 8.3% in 2011, and 20.8% in 2012. This reflects low but steady improvement in HPV vaccination rates among male adolescents. In site-based studies, HPV vaccine initiation among male adolescents ranged between 1.1% and 30%.14,34–37 Literature is lacking on factors associated with HPV vaccine initiation among male adolescents. One study reported lower levels of knowledge among Black and Hispanic parents about the use of HPV vaccine for male adolescents.35 A few studies indicated the importance of HCPs’ recommendation for HPV vaccine initiation among male adolescents.14,35,36,38Pervasive disparities exist in HPV vaccination among Black, Hispanic, and low-income groups, and more specifically in the study target area. Even though the NIS-Teen data for 2011 and 2012 show slightly higher HPV vaccination among Black and low-income groups,39,40 several studies have demonstrated a significant and continuing trend of lower HPV vaccination among Black and Hispanic adolescents,14,15,17,24,26,41,42 as well as in low-income and urban areas.22,33,41,43 Vaccination disparities in urban areas (compared with suburban or rural areas) may be attributed to residential segregation, differential distribution of health clinics and health professionals, and unequal access to a broad range of services.44–46 As urban areas, particularly the Greater Newark area, have high proportions of immigrants who may be hesitant to seek health care services because of cultural or language barriers or concerns about immigration status,7 a study of adolescents’ adherence to public health recommendations in underserved, inner-city areas is warranted and important.Literature is lacking information on correlates of HPV vaccination among Black and Hispanic adolescents in low-income urban areas, who represent populations with the greatest disparities in cervical cancer and other HPV-related cancers compared with White and higher-income groups. Therefore, the purpose of this study was to examine the correlates of HPV vaccine initiation in a sample of predominantly Black and Hispanic adolescents at inner-city community health centers. The study addresses gaps in knowledge about the correlates of HPV vaccination among both male and female adolescents as well as a low-income predominantly minority population with pervasive disparities in cervical cancer morbidity and mortality.1–3,5,6     

Mediation by Peer Violence Victimization of Sexual Orientation Disparities in Cancer-Related Tobacco,Alcohol, and Sexual Risk Behaviors: Pooled Youth Risk Behavior Surveys

Objectives. We examined the role of adolescent peer violence victimization (PVV) in sexual orientation disparities in cancer-related tobacco, alcohol, and sexual risk behaviors.Methods. We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. We classified youths with any same-sex sexual attraction, partners, or identity as sexual minority and the remainder as heterosexual. We had 4 indicators of tobacco and alcohol use and 4 of sexual risk and 2 PVV factors: victimization at school and carrying weapons. We stratified associations by gender and race/ethnicity.Results. PVV was related to disparities in cancer-related risk behaviors of substance use and sexual risk, with odds ratios (ORs) of 1.3 (95% confidence interval [CI] = 1.03, 1.6) to 11.3 (95% CI = 6.2, 20.8), and to being a sexual minority, with ORs of 1.4 (95% CI = 1.1, 1.9) to 5.6 (95% CI = 3.5, 8.9). PVV mediated sexual orientation disparities in substance use and sexual risk behaviors. Findings were pronounced for adolescent girls and Asian/Pacific Islanders.Conclusions. Interventions are needed to reduce PVV in schools as a way to reduce sexual orientation disparities in cancer risk across the life span.The Institute of Medicine recently reviewed the research literature on health disparities between lesbian, gay, bisexual, and transgender individuals and heterosexuals across the life span.1 It identified the significant role of stigma in the health of lesbian, gay, bisexual, and transgender individuals and areas in need of research, including disparities in cancer between sexual minorities (lesbian, gay, and bisexual persons) and heterosexuals. Behaviors that increase cancer risk (e.g., tobacco and alcohol use, unprotected sexual intercourse) may be initiated during adolescence. For sexual minorities, peer violence victimization (PVV) may partly explain disparities in cancer-related risk behaviors because such disparities between sexual minorities and heterosexuals have been attributed to the differential burden of stigma experienced by sexual minorities.1Certain behaviors place one at risk for cancer, and sexual orientation disparities exist in those cancer-related risk behaviors. Tobacco and alcohol use are risk factors for various types of cancers, such as lung, esophageal, oropharyngeal, and colon.2–8 More sexual minority adults and youths than their heterosexual peers report tobacco and alcohol use.9–18Several sexual risk behaviors (number of partners, early age of first intercourse, concurrent sexual partners, lack of condom use, and substance use during intercourse) are known to increase vulnerability to infection with, for example, human papillomavirus (HPV)19–29 and hepatitis B.30,31 Women who have sex with women have elevated rates of such sexual risk behaviors relative to women who only have sex with men.32–34 Women who only have sex with women are less likely to be screened for sexually transmitted infections,33,35,36 despite the risk of HPV transmission during female-to-female sexual intercourse.37 HPV in men is important because it is linked to anal, oral, and penile cancers.24,38 The risk of cancer-related sexual behaviors may be elevated among sexual minority men, because of the links between anal intercourse, HPV, and anal cancer,39 especially among men who are HIV positive.40 Hepatitis B has been linked to liver cancer41 and increased risk of anal HPV among men.31     

Vaccination Interest and Trends in Human Papillomavirus Vaccine Uptake in Young Adult Women Aged 18 to 26 Years in the United States: An Analysis Using the 2008–2012 National Health Interview Survey

Objectives. Human papillomavirus (HPV) vaccines have been approved since 2006, yet vaccination rates remain low. We investigated HPV vaccination trends, interest, and reasons for nonvaccination in young adult women.Methods. We used data from the 2008–2012 National Health Interview Survey to analyze HPV vaccine uptake trends (≥ 1 dose) in women aged 18 to 26 years. We used data from the 2008 and 2010 National Health Interview Survey to examine HPV vaccination interest and reasons for nonvaccination among unvaccinated women.Results. We saw significant increases in HPV vaccination for all young women from 2008 to 2012 (11.6% to 34.1%); however, Hispanics and women with limited access to care continued to have lower vaccination rates. Logistic regression demonstrated lower vaccination interest among unvaccinated women in 2010 than 2008. Respondents in 2010 were significantly less likely to give lack of knowledge as a primary reason for nonvaccination.Conclusions. Uptake of HPV vaccine has increased from 2008 to 2012 in young women. Yet vaccination rates remain low, especially among women with limited access to care. However, unvaccinated women with limited health care access were more likely to be interested in receiving the vaccine.Human papillomavirus (HPV) is widespread among young females in the United States, with an estimated prevalence of 59.8% in women aged 20 to 24 years in 2007 to 2010.1 Persistent infection with high-risk strains of HPV has been linked to development of certain cancers, including cervical, oropharyngeal, and anal cancers, with an estimated 13.2 per 100 000 women diagnosed annually with HPV-associated cancers between 2004 and 2008.2 Since 2006, 2 HPV vaccines have been approved by the Food and Drug Administration that safely3 and effectively1 prevent infection with several high-risk HPV strains.2Since 2006, the Advisory Committee on Immunization Practices has recommended that 3 doses of the HPV vaccine be administered to young females aged 11 to 26 years, with a focus on early vaccination.4,5 Data for 18- to 26-year-old women from the adult version of the 2007 National Immunization Survey estimated that 10% of young women had initiated the HPV vaccination series.6 For the same year, vaccine initiation among California women aged 18 to 27 years was estimated to be 11.0%.7 In 2011, vaccination rates (≥ 1 dose) among young women aged 19 to 26 years had increased to 29.5%.8 Vaccination rates for adolescents were more favorable (53.8% for ≥ 1 dose, 33.4% for ≥ 3 doses for 13- to 17-year-old adolescents in 2012³), but are far from the national goal of 80% vaccination completion for 13- to 15-year-old adolescents by 2020.9Despite these low vaccine initiation and even lower completion rates, few studies have examined reasons for nonvaccination of young adult women, and no study has specifically studied how these reasons may have changed over time.6,10–13 A recent study focusing on parental attitudes showed an increase in parents not intending to vaccinate adolescent daughters and citing safety concerns as one of the main reasons for nonvaccination.14 Furthermore, previous studies of trends in HPV vaccination have focused primarily on adolescents.3,15,16 However, with high levels of nonvaccination continuing in 2011 for both the main target group and young adults, it is critical to understand trends in vaccination and risk factors for nonvaccination in this age group, as these young women can still benefit from receiving the HPV vaccine and promote greater herd immunity.Therefore, using nationally representative data from the National Health Interview Survey (NHIS) for young women, our aim was to (1) estimate trends in HPV vaccination uptake (≥ 1 dose) in women aged 18 to 26 years from 2008 to 2012, (2) examine HPV vaccination interest among young unvaccinated women in 2008 and 2010, and (3) investigate reasons for nonvaccination among women who were not interested in receiving the vaccine in 2008 and 2010. Both vaccination interest, defined as whether an unvaccinated woman was interested in receiving the HPV vaccine in the survey, and reasons for nonvaccination for unvaccinated women, who were not interested or undecided, were only assessed in the 2008 and 2010 NHIS.     

Relation of Childhood Sexual Abuse,Intimate Partner Violence,and Depression to Risk Factors for HIV Among Black Men Who Have Sex With Men in 6 US Cities

Objectives. We assessed the relation of childhood sexual abuse (CSA), intimate partner violence (IPV), and depression to HIV sexual risk behaviors among Black men who have sex with men (MSM).Methods. Participants were 1522 Black MSM recruited from 6 US cities between July 2009 and December 2011. Univariate and multivariable logistic regression models were used.Results. Participants reported sex before age 12 years with someone at least 5 years older (31.1%), unwanted sex when aged 12 to 16 years (30%), IPV (51.8%), and depression (43.8%). Experiencing CSA when aged 12 to 16 years was inversely associated with any receptive condomless anal sex with a male partner (adjusted odds ratio [AOR] = 0.50; 95% confidence interval [CI] = 0.29, 0.86). Pressured or forced sex was positively associated with any receptive anal sex (AOR = 2.24; 95% CI = 1.57, 3.20). Experiencing CSA when younger than 12 years, physical abuse, emotional abuse, having been stalked, and pressured or forced sex were positively associated with having more than 3 male partners in the past 6 months. Among HIV-positive MSM (n = 337), CSA between ages 12 and 16 years was positively associated with having more than 3 male partners in the past 6 months.Conclusions. Rates of CSA, IPV, and depression were high, but associations with HIV sexual risk outcomes were modest.Despite significant medical advances, the HIV epidemic remains a health crisis in Black communities. The Black population represents only 14% of the total US population but accounted for 44% of all new HIV infection (68.9 of 100 000) in 2010.1 Black men who have sex with men (MSM) are disproportionately impacted by HIV compared with other racial/ethnic groups of MSM.1,2 Male-to-male sexual contact accounted for 72% of new infections among all Black men.1 Young Black MSM (aged 13–24 years) have a greater number of new infections than any other age or racial group among MSM.1 Researchers have been challenged with developing HIV prevention strategies for Black MSM.3–7 Higher frequencies of sexual risk behaviors, substance use, and nondisclosure of sexual identities do not adequately explain this disparity.8,9 High rates of sexually transmitted infections (STIs), which facilitate HIV transmission, and undetected or late diagnosis of HIV infection only partially explain disproportionate HIV rates.8Researchers have begun to examine a constellation of health factors that may contribute to HIV among MSM. For example, syndemic theory or the interaction of epidemics synergistically, such as intimate partner violence (IPV) and depression, may help explain HIV-related sexual risk behaviors among Black MSM.9 Childhood sexual abuse (CSA), IPV, and mental health disorders including depression may comprise such a constellation and warrant further exploration.Experiences of CSA have been identified as being associated with negative sexual health outcomes, with MSM reporting higher CSA rates than the general male population.10–12 Men with CSA experiences are more likely than men without CSA experiences to engage in high-risk sexual behaviors,13–21 have more lifetime sexual partners,13–16 use condoms less frequently,13,14,16 and have higher rates of STIs,13,14,17 exchanging sex for drugs or money,13,14,17 HIV,13,14 alcohol and substance use,13–21 and depression.13–15,18,21 Such findings suggest that sexual risk reduction counseling may need to be tailored for MSM with CSA experiences.15Childhood sexual abuse histories have also been correlated with sexual revictimization, including IPV.22–24 One study with population-based estimates of CSA found that gay and bisexually identified men had higher odds of reporting CSA (9.5 and 12.8, respectively) compared with heterosexual men.25 For sexual minority men, CSA histories were associated with higher HIV and STI incidence.25 However, research examining CSA, revictimization, and sexual risk behaviors is lacking among Black MSM.In one existing study, Black and Latino MSM with CSA histories identified their trauma experiences as influencing their adult sexual decision-making.26 Among Black MSM in 2 additional studies, emotional distress and substance use were attributed to having CSA experiences (Leo Wilton, PhD, written communication, October 2, 2013).27 In an ethnically diverse sample of 456 HIV-positive MSM, CSA was associated with insertive and receptive condomless anal sex.19Similar to CSA, IPV has not been extensively examined among MSM or Black MSM,28 but may be associated with sexual risk behaviors. Intimate partner violence is defined as a pattern of controlling, abusive behavior within an intimate relationship that may include physical, psychological or emotional, verbal, or sexual abuse.29 Little research exists on IPV among same-sex couples despite incidence rates being comparable to or greater than that of heterosexual women.28,30–34 Important IPV information comes from the National Intimate Partner and Sexual Violence Survey, a nationally representative survey for experiences of sexual violence, stalking, and IPV among men and women in the United States.28 Among men who experienced rape, physical violence, or stalking by an intimate partner, perpetrator differences by gender were found among gay, bisexual, and heterosexual men; 78% of bisexual and 99.5% of heterosexual men reported having only female perpetrators, and 90.7% of gay men reported having only male perpetrators.28 Being slapped, pushed, or shoved by an intimate partner during their lifetime was reported by gay (24%), bisexual (27%), and heterosexual (26.3%) men.28Intimate partner violence has been linked to condomless anal sex, HIV infection, substance use, CSA, and depression.35–37 Being an HIV-positive MSM has been linked with becoming a victim of IPV.38,39 Welles et al. found that being an African American MSM who initially disclosed having male partners and early life sexual abuse experiences was associated with IPV victimization.39 Wilton found that a high percentage of Black MSM reported IPV histories: emotional abuse (48.3%), physical abuse (28.3%), sexual abuse (21.7%), and stalking abuse (29.2%; Leo Wilton, PhD, written communication, October 2, 2013). Such findings lend to the importance of exploring, both independently and together, the association of CSA and IPV with sexual risk behaviors.Some studies have reported the influence of mental health (e.g., depression) on sexual risk behaviors among MSM,9,40,41 whereas others have not corroborated such findings.42 Greater rates of depression among MSM than among non-MSM samples43–45 and elevated rates of depression and anxiety among Black MSM have been reported.46 The Urban Men’s Health Study, a cross-sectional sample of MSM in 4 US cities, did not find a significant relationship between high depressive symptoms and condomless anal sex.42 However, the EXPLORE study, a randomized behavioral intervention for MSM in 6 US cities, supported the association between moderate depressive symptoms and an increased risk for HIV infection.47 Moderate levels of depression and higher rates of sexual risk were also reported for HIV-infected MSM over time.48 Another study conducted with 197 Black MSM found that moderate depressive symptoms were associated with having condomless anal sex with a serodiscordant casual partner.49 These mixed findings support the need to better understand the relationship between the severity of depression (i.e., moderate vs severe) and HIV risk behaviors.The HIV Prevention Trials Network 061 study, also known as the BROTHERS (Broadening the Reach of Testing, Health Education, Resources, and Services) Project, was a multisite study to determine the feasibility and acceptability of a multicomponent intervention for Black MSM. The current analysis aims to assess the prevalence of CSA, IPV, and depressive symptomology, and examine the relationships between these factors and insertive and receptive condomless anal sex and number of sexual partners in a large cohort of Black MSM.     

Up in Smoke: Vanishing Evidence of Tobacco Disparities in the Institute of Medicine’s Report on Sexual and Gender Minority Health

The Institute of Medicine (IOM) released a groundbreaking report on lesbian, gay, bisexual, and transgender (LGBT) health in 2011, finding limited evidence of tobacco disparities. We examined IOM search terms and used 2 systematic reviews to identify 71 articles on LGBT tobacco use. The IOM omitted standard tobacco-related search terms. The report also omitted references to studies on LGBT tobacco use (n = 56), some with rigorous designs. The IOM report may underestimate LGBT tobacco use compared with general population use.Tobacco remains the leading cause of premature mortality in the United States1; however, burdens of the epidemic are not equally shared among groups with various sociodemographic characteristics.2–4 Over the past 20 years, evidence has accumulated that lesbian, gay, bisexual, and transgender (LGBT) individuals (i.e., sexual and gender minorities) are among the groups at higher risk for smoking.5Two separate systematic reviews about the prevalence5 and etiology6 of smoking among sexual minorities report on the results of 63 unduplicated studies. Combined, the results suggest “compelling evidence that an elevated prevalence of tobacco use among LGBT men and women exists” compared with heterosexual men and women,5^(p279) a sentiment echoed by both the American Lung Association7 and Healthy People 2020.8By contrast, in the groundbreaking report on LGBT health by the Institute of Medicine (IOM),9 which is used by federal agencies and funders to set public health policy and priorities, tobacco use is largely absent and the limited discussion is equivocal: smoking rates among youths “may be higher”9^(p4) and adults “may have higher rates.”9^(p5) Given the seeming disconnect between the tobacco literature and the findings of the IOM report, we sought to identify possible gaps in tobacco-related evidence in the IOM report.     

Sexual Orientation–Related Differences in Tobacco Use and Secondhand Smoke Exposure Among US Adults Aged 20 to 59 Years: 2003–2010 National Health and Nutrition Examination Surveys

Objectives. We investigated sexual orientation–related differences in tobacco use and secondhand smoke (SHS) exposure in a nationally representative sample of US adults.Methods. The 2003–2010 National Health and Nutrition Examination Surveys assessed 11 744 individuals aged 20 to 59 years for sexual orientation, tobacco use, and SHS exposure (cotinine levels ≥ 0.05 ng/mL in a nonsmoker). We used multivariate methods to compare tobacco use prevalence and SHS exposure among gay or lesbian (n = 180), bisexual (n = 273), homosexually experienced (n = 388), and exclusively heterosexual (n = 10 903) individuals, with adjustment for demographic confounding.Results. Lesbian and bisexual women evidenced higher rates of tobacco use than heterosexual women. Among nonsmokers, SHS exposure was more prevalent among lesbian and homosexually experienced women than among heterosexual women. Nonsmoking lesbians reported greater workplace exposure and bisexual women greater household exposure than heterosexual women did. Identical comparisons among men were not significant except for lower workplace exposure among nonsmoking gay men than among heterosexual men.Conclusions. Nonsmoking sexual-minority women are more likely to be exposed to SHS than nonsmoking heterosexual women. Public health efforts to reduce SHS exposure in this vulnerable population are needed.In 2006, the US Surgeon General1 concluded that secondhand smoke (SHS) exposure causes premature death and disease in nonsmoking persons2,3 and that there is no risk-free level of exposure.4 Although public health efforts to lower the rates of cigarette smoking have been generally successful over the years, cigarette smoking nevertheless remains one of the leading causes of death.5 Among nonsmokers, minority sexual orientation (i.e., lesbian, gay, bisexual, and homosexually experienced status) may be an unrecognized risk indicator for SHS exposure. Sexual minority individuals are more likely, as a group, to smoke tobacco than heterosexual men and women are.6–20 Indeed, estimates indicate that smoking rates may be twice as high among persons with a minority sexual orientation than among heterosexual individuals.21 Women with minority sexual orientation, in particular, consistently show elevation in risk compared with their same-gender heterosexual counterparts.10,13,22,23 Overall, this greater prevalence of tobacco use among friends and relationship partners of sexual minorities may inadvertently lead to higher levels of SHS exposure among nonsmoking sexual minorities.Although there is evidence that sexual minorities share similar levels of concern as heterosexuals do about the risk of SHS exposure,21 whether SHS exposure is nonetheless greater in this subpopulation is currently unknown, though there is reasoned suspicion that this might be so.24 We investigated possible sexual orientation–related differences in prevalence of primary tobacco use and SHS exposure by using information available from the 2003–2010 National Health and Nutrition Examination Surveys (NHANES). During these years, the NHANES assessed both respondents’ sexual orientation status and markers of tobacco use and SHS exposure. Consistent with previous studies, we hypothesized that individuals with minority sexual orientation, especially women, will show elevated tobacco use compared with their same-gender heterosexual counterparts. However, we also anticipated that, among nonsmokers, evidence of secondhand exposure to tobacco would be positively associated with minority sexual orientation.     

Health Disparities Among Lesbian,Gay, and Bisexual Older Adults: Results From a Population-Based Study

Objectives. We investigated health disparities among lesbian, gay, and bisexual (LGB) adults aged 50 years and older.Methods. We analyzed data from the 2003–2010 Washington State Behavioral Risk Factor Surveillance System (n = 96 992) on health outcomes, chronic conditions, access to care, behaviors, and screening by gender and sexual orientation with adjusted logistic regressions.Results. LGB older adults had higher risk of disability, poor mental health, smoking, and excessive drinking than did heterosexuals. Lesbians and bisexual women had higher risk of cardiovascular disease and obesity, and gay and bisexual men had higher risk of poor physical health and living alone than did heterosexuals. Lesbians reported a higher rate of excessive drinking than did bisexual women; bisexual men reported a higher rate of diabetes and a lower rate of being tested for HIV than did gay men.Conclusions. Tailored interventions are needed to address the health disparities and unique health needs of LGB older adults. Research across the life course is needed to better understand health disparities by sexual orientation and age, and to assess subgroup differences within these communities.Changing demographics will make population aging a defining feature of the 21st century. Not only is the population older, it is becoming increasingly diverse.1 Existing research illustrates that older adults from socially and economically disadvantaged populations are at high risk of poor health and premature death.2 A commitment of the National Institutes of Health is to reduce and eliminate health disparities,3 which have been defined as differences in health outcomes for communities that have encountered systematic obstacles to health as a result of social, economic, and environmental disadvantage.4Social determinants of health disparities among older adults include age, race/ethnicity, and socioeconomic status.5 Centers for Disease Control and Prevention (CDC) and Healthy People 2020 identify health disparities related to sexual orientation as one of the main gaps in current health research.6 The Institute of Medicine identifies lesbian, gay, and bisexual (LGB) older adults as a population whose health needs are understudied.7 The institute has called for population-based studies to better assess the impact of background characteristics such as age on health outcomes among LGB adults. A review of 25 years of literature on LGB aging found that health research is glaringly sparse for this population and that most aging-related studies have used small, non-population-based samples.8Several important studies have begun to document health disparities by sexual orientation in population-based data and have revealed important differences in health between LGB adults and their heterosexual counterparts, including higher risks of poor mental health, smoking, and limitations in activities.9,10 Studies have found higher rates of excessive drinking among lesbians and bisexual women9,10 and higher rates of obesity among lesbians10,11 than among heterosexual women; bisexual men and women are at higher risk of limited health care access than are heterosexuals. In addition, important subgroup differences in health are beginning to be documented among LGB adults. For example, bisexual women are at higher risk than lesbians for mental distress and poor general health.12 A primary limitation of most existing population-based research is a failure to identify the specific health needs of LGB older adults. Most studies to date address the health needs of LGB adults aged 18 years and older9 or those younger than 65 years.10 This lack of attention to older adult health leaves unclear whether disparities diminish or persist or even become more pronounced in later life.A few studies have begun to examine health disparities among LGB adults aged 50 years and older.13,14 Wallace et al. analyzed data from the California Health Interview Survey and found that LGB adults aged 50 to 70 years report higher rates of mental distress, physical limitations, and poor general health than do their heterosexual counterparts. The researchers also found that older gay and bisexual men report higher rates of hypertension and diabetes than do heterosexual men.14 To better address the needs of an increasingly diverse older adult population and to develop responsive interventions and public health policies, health disparities research is needed for this at-risk group.Examining to what extent sexual orientation is related to health disparities among LGB older adults is a first step toward developing a more comprehensive understanding of their health and aging needs. We analyzed population-based data from the Washington State Behavioral Risk Factor Surveillance System (WA-BRFSS) to compare lesbians and bisexual women and gay and bisexual men with their heterosexual counterparts aged 50 years and older on key health indicators: outcomes, chronic conditions, access to care, behaviors, and screening. We also compared subgroups to identify differences in health disparities by sexual orientation among LGB older adults.     

The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men: Results of a Community Survey in Northern San Diego County,California

Objectives. We examined the sexual behavior, sexual identities, and HIV risk factors of a community sample of Latino men to inform efforts to reduce Latinos'' HIV risk.Methods. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey.Results. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors.Conclusions. Latino men who have a heterosexual identity and bisexual practices are at greater risk of HIV infection, and efforts to reduce HIV risk among Latinos should target this group.Latinos and sexual minorities are disproportionately affected by HIV/AIDS. Latinos represented 14% of the US population in 2005,¹ but they accounted for 18% of HIV/AIDS cases diagnosed in 2006.² Although an estimated 6% to 9% of the US population has a lifetime history of homosexual sex,^3,4 men who have sex with men accounted for 49% of all HIV/AIDS cases diagnosed in the United States in 2006.² Sexual risk for HIV varies considerably by sexual orientation, with gay-identified and bisexually identified men generally at greater risk.^5,6 However, a person''s self-identified sexual orientation frequently does not correspond to his or her sexual behavior.^7–9Within Latino culture, it is possible for a man to have sex with men while maintaining a heterosexual identity and protecting his sense of masculinity.^10–13 For Latino men, sexual identity appears to be contingent upon certain behavioral and contextual factors, such as whether they have female sexual partners, are primarily attracted to women, adopt an insertive role in sexual practices, have sex with effeminate men, or have sex with men when under the influence of alcohol or drugs. Homophobia, social stigma attached to same-sex practices, and sexual conservatism are commonly found throughout Latino culture and may inhibit Latino men who have sex with men from self-identifying as gay or bisexual.^9,10,14–16 Research suggests that Latino men are more likely than are White men to engage in bisexual behavior (i.e., to have sex with both men and women)^8,17,18 but are less likely than are White men to disclose a nonheterosexual orientation.^16,19,20Among men, bisexual behavior appears to be more prevalent than bisexual identity. Although approximately 1% to 2% of the US male population identifies as bisexual,^3,4 rates of male bisexual behavior in national samples have ranged from 1% to 5%.^4,21,22 However, these estimates are questionable because of differences in sampling methods and varying definitions of bisexuality.²³ Recent research conducted in the United States suggests that men who have sex with men and women (MSMW) are at greater risk of HIV infection than men who have sex with men (MSM) exclusively and men who have sex with women (MSW) exclusively.^24–26 By contrast, investigators in Mexico have found that MSMW who self-identify as bisexual practice less risky sexual behaviors with their male partners than do exclusively gay men.⁶It has been difficult to quantify the population of heterosexually identified Latino MSMW because of the secretive nature of their sexual practices. In a homophobic cultural context, the fear of social rejection encourages people to hide their same-sex sexual behavior and lead a double life.¹⁰ A study involving a large population of HIV-positive MSM found that 15% of the Latino sample identified as heterosexual had a history of same-sex intercourse,²⁷ whereas a survey of 455 men recruited from gay-oriented publications and venues in 12 US cities found that 17% (n = 26) of Hispanic respondents (as per terminology used in the original survey) reported being “on the down low”.⁹ Although these results may not generalize to community-based US samples of Latino men, they suggest that a substantial proportion of heterosexually identified Latino men have a history of sex with men. Similarly, a household probability survey in Mexico City found that 73% of men with a lifetime history of bisexual practices identified as heterosexual, as did 29% of those with a lifetime history of having sex only with men.⁶Men''s nondisclosure of sexual practices with men has implications for the health of their female sexual partners.^8,17 In the United States in 2006, Latinas accounted for 23.7% of HIV infections among Hispanics; of these, an estimated 51.7% were infected through heterosexual contact.² Although most cases of heterosexual transmission to Latinas are related to sex with injection drug users,²⁸ women who have unprotected sex with heterosexually identified MSMW are also at risk and are likely a subset of this population.Although there is some evidence of greater HIV risk among MSMW than among MSM or MSW,^24–26 previous research has not examined the roles that both sexual behavior and sexual identity play in HIV risk among Latino men in particular. Sexual identity may influence HIV risk among Latino MSMW because a man who identifies as heterosexual may perceive that he is at lower risk of sexually transmitted infections (STIs) than are gay or bisexual men and may thus take fewer measures to protect himself or his partner. MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.²⁹Our goal was to learn more about the sexual practices of Latino men and to better understand the interactions among sexual behaviors and sexual identities in this population so as to inform efforts to reduce HIV risk among Latinos. Using survey data, we examined the sexual behavior of a community sample of Latino men; determined the proportions of MSM, MSW, and MSMW among them; elicited any discrepancies between their sexual behavior and their sexual identity; and searched for differences in HIV risk by sexual orientation.     

Association Between Socioeconomic Position Discrimination and Psychological Distress: Findings From a Community-Based Sample of Gay and Bisexual Men in New York City

Objectives. We examined the association between discrimination and mental health distress, focusing specifically on the relative importance of discrimination because of particular demographic domains (i.e., race/ethnicity, socioeconomic position [SEP]).Methods. The research team surveyed a sample of gay and bisexual men (n = 294) at a community event in New York City. Participants completed a survey on demographics, discrimination experiences in the past 12 months, attributed domains of discrimination, and mental health distress.Results. In adjusted models, discrimination was associated with higher depressive (B = 0.31; P < .01) and anxious (B = 0.29; P < .01) symptoms. A statistically significant quadratic term (discrimination-squared; P < .01) fit both models, such that moderate levels of discrimination were most robustly associated with poorer mental health. Discrimination because of SEP was associated with higher discrimination scores and was predictive of higher depressive (B = 0.22; P < .01) and anxious (B = 0.50; P < .01) symptoms. No other statistically significant relationship was found between discrimination domains and distress.Conclusions. In this sample, SEP emerged as the most important domain of discrimination in its association with mental health distress. Future research should consider intersecting domains of discrimination to better understand social disparities in mental health.In the United States, discrimination has increasingly become an important focus of scholarly inquiry in understanding social determinants of health.1–5 A growing body of empirical evidence points to the negative health consequences of social stressors for gay and bisexual males, including gay-related discrimination and prejudice.2,6–9 Studies demonstrate that gay and bisexual men experience discrimination at both structural and institutional levels, including in housing, employment, access to medical care, and legal policies,6,10 as well as at the individual level, such as harassment and violence.11,12 Previous research has also demonstrated that these discriminatory experiences operate as objective and subjective stressors in the lives of gay and bisexual males, and are significantly associated with psychiatric disorders9,13 and psychological distress14,15 in this population.Theoretical frameworks, including the minority stress model9 and psychological mediation framework,16 have been used to explain the higher prevalence of mental health problems among sexual minority male populations as a function of both acute and chronic social stressors. In these frameworks, discrimination and stigma create stressful social environments for gay and bisexual men, contributing to elevated rates of presenting mental health problems. These theoretical frameworks for understanding mental health disparities among gay and bisexual men provide generative starting points for testable hypotheses concerning the relationship between discrimination and mental health16; however, few studies have examined the relationship between perceptions of discrimination on the basis of specific domains (such as income or socioeconomic position [SEP], race/ethnicity, HIV status, age, gender identity, sexual identity) and mental health outcomes.17 More nuanced research on the association between attributions of discrimination experiences to particular domains and mental health distress for gay and bisexual men is warranted.We used cross-sectional data from a survey conducted at gay and bisexual community events in New York City to examine the associations between domain-specific perceptions of discrimination and mental health distress. The overarching aims of this study were 2-fold. First, we sought to examine whether experiences of discrimination were positively associated with mental health distress (depression and anxious symptom scores) in this community sample of gay and bisexual men. Second, building on previous work documenting the impact of multiple stigmatized identities,18–20 we sought to examine whether specific domains of self-reported discrimination (i.e., income or SEP, race/ethnicity, HIV status, age, gender identity, sexual identity) were differentially associated with mental health symptoms.     

Disparities in Weight and Weight Behaviors by Sexual Orientation in College Students

Objectives. We assessed disparities in weight and weight-related behaviors among college students by sexual orientation and gender.Methods. We performed cross-sectional analyses of pooled annual data (2007–2011; n = 33 907) from students participating in a Minnesota state-based survey of 40 two- and four-year colleges and universities. Sexual orientation included heterosexual, gay or lesbian, bisexual, unsure, and discordant heterosexual (heterosexuals engaging in same-sex sexual experiences). Dependent variables included weight status (derived from self-reported weight and height), diet (fruits, vegetables, soda, fast food, restaurant meals, breakfast), physical activity, screen time, unhealthy weight control, and body satisfaction.Results. Bisexual and lesbian women were more likely to be obese than heterosexual and discordant heterosexual women. Bisexual women were at high risk for unhealthy weight, diet, physical activity, and weight control behaviors. Gay and bisexual men exhibited poor activity patterns, though gay men consumed significantly less regular soda (and significantly more diet soda) than heterosexual men.Conclusions. We observed disparities in weight-, diet-, and physical activity–related factors across sexual orientation among college youths. Additional research is needed to better understand these disparities and the most appropriate intervention strategies to address them.In 2011, the Institute of Medicine highlighted the significant lack of research on the health of lesbian, gay, and bisexual (LGB) groups.1 Research has indicated that LGB adults experience worse health outcomes than their heterosexual peers.2–11 These disparities may be attributable to an array of factors, including stigmatization, stress, and limited access to and use of health services.1,12,13 Specific areas of potential disparities among LGB groups lacking substantial research evidence include obesity, diet, physical activity patterns, unhealthy weight control behaviors, and body image. With two thirds of US adults now overweight or obese,14 obesity prevention is a national health priority. Findings from studies examining adult weight disparities by sexual orientation have consistently indicated that lesbian women are more likely to be overweight than heterosexual women.2,11,15–19 Several recent population-based studies have suggested that gay men may be less likely to be overweight than heterosexual men,2,18,20 and additional studies have highlighted concerns regarding body image and unhealthy weight control behaviors among gay men.21–24 Disparities in other behaviors, such as dietary intake and physical activity patterns, have not been studied extensively using population-based samples and, when studied, have yielded inconsistent findings.11,25,26Furthermore, much of the work in this area to date has not focused on the college years. Because nearly half of US high school graduates up to age 24 years are enrolled in postsecondary education,27 colleges and universities offer unique environments for addressing health disparities among young people, including those of LGB students. For many, the college years represent a time during which health disparities emerge28,29 and adverse changes occur in weight, dietary quality, physical activity, and other behaviors.30–38 For LGB people, this age is commonly when sexual identity is declared and assimilation into the LGB community occurs.39 Important postsecondary institutions that could act as platforms for intervention delivery include not only traditional 4-year universities but also 2-year community and technical colleges, which serve millions of students, particularly those from lower income and minority backgrounds.40,41The objective of this study was to characterize gender-specific weight-related disparities among college students by sexual orientation. We analyzed state survey data of nearly 34 000 students attending a wide array of 2- and 4-year colleges and universities in 2007 to 2011, including a subsample of more than 2000 LGB-identified and LGB-questioning participants. This research was intended to fill several gaps in the literature. For example, although a recent wave of studies11,19,22–25 were published after the release of the Institute of Medicine report,1 most of these studies used data from 1999 to 2007 and thus were not able to characterize disparities during the past 5 to 8 years (when important societal shifts in weight-related factors42,43 and social shifts regarding LGB issues occurred). Moreover, a majority of these studies focused not on the college years but rather on adulthood overall (e.g., 18–74 years) or on adolescence (e.g., 9th–12th grade). Finally, only a small number of studies have examined population-level LGB disparities in dietary intake or physical activity,11,20,25,26 which are critical factors to address in weight-related intervention strategies. Among the few population-based studies that have addressed diet and activity, unidimensional indicators have been used to assess fruit and vegetable consumption or moderate to vigorous intensity physical activity, but these studies have generally lacked characterization of other important dietary factors (e.g., frequency of soda, fast food, away-from-home eating, or breakfast consumption) or activities (e.g., strengthening activities, screen time).     

Hombres Sanos: evaluation of a social marketing campaign for heterosexually identified Latino men who have sex with men and women

Objectives. We evaluated the effectiveness of Hombres Sanos [Healthy Men] a social marketing campaign to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino men who have sex with men and women (MSMW).Methods. Hombres Sanos was implemented in northern San Diego County, California, from June 2006 through December 2006. Every other month we conducted cross-sectional surveys with independent samples of heterosexually identified Latino men before (n = 626), during (n = 752), and after (n = 385) the campaign. Respondents were randomly selected from 12 targeted community venues to complete an anonymous, self-administered survey on sexual practices and testing for HIV and other sexually transmitted infections. About 5.6% of respondents (n = 98) were heterosexually identified Latino MSMW.Results. The intervention was associated with reduced rates of recent unprotected sex with both females and males among heterosexually identified Latino MSMW. The campaign was also associated with increases in perception of HIV risk, knowledge of testing locations, and condom carrying among heterosexual Latinos.Conclusions. Social marketing represents a promising approach for abating HIV transmission among heterosexually identified Latinos, particularly for heterosexually identified Latino MSMW. Given the scarcity of evidence-based HIV prevention interventions for these populations, this prevention strategy warrants further investigation.In the United States, adult and adolescent Latino males represent 5.6% of the total population¹ but 18.7% of HIV/AIDS cases.² Low rates of condom use^3–5 and limited HIV testing^5–7 likely contribute to the risk for infection and transmission among Latinos.Sex between men continues to account for the majority of new HIV infections in the United States.² HIV prevention efforts have traditionally targeted gay and bisexual men. However, individuals’ self-identified sexual orientation frequently does not correspond to their sexual behavior,^8–12 and recent research has been focused on men who self-identify as heterosexual but have sex with men. The results of studies on men who have sex with both men and women (MSMW) suggest that, regardless of sexual identity, this population is at greater risk for HIV than are men who exclusively have sex with men; likewise, MSMW are at greater risk than are men who exclusively have sex with women (MSW).^11,13–16 Reasons for greater risk among MSMW may include lower rates of condom use^11,16 and having sexual partners who engage in high-risk sexual practices.¹¹Previous studies have suggested that Latino men are more likely than are White men to engage in bisexual sexual behavior^9,11,17,18 but less likely than are White men to self-identify as gay or bisexual or to disclose their sexual orientation.^19–23 Cultural factors such as homophobia, social stigma related to same-sex practices, and sexual conservatism may inhibit Latino men from self-identifying as homosexual or bisexual.^{10,13,23–26} The degree to which Latinos integrate same-sex sexual practices into their sexual identities may influence their risk for HIV infection.²⁷ Latino MSMW who identify as heterosexual may perceive that they are at lower risk for sexually transmitted infections (STIs) than are gay or bisexual men, and Latino MSMW may thus be less likely to use condoms to protect themselves or their partners. Latino MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.^19,27Nondisclosure of same-sex sexual practices among MSMW also has significant implications for the health of their female sexual partners.^9,17 More than 70% of Latinas living with HIV/AIDS in the United States were infected via heterosexual contact.² Most cases of heterosexual transmission to Latinas are related to sex with partners who use injection drugs,²⁸ but unprotected sex with men who have multiple partners, including MSMW, has likely contributed to a subset of HIV cases among Latina women.^2,29Social marketing involves applying the principles and techniques of commercial marketing to the promotion of behavioral change for the good of a target audience.^30,31 Social marketing has been successfully used for HIV prevention with gay and bisexual males,^32,33 racial and ethnic minorities,³⁴ and youths.^35–38 Interventions using social marketing have been associated with improvements in HIV/STI testing^32,34 and condom use.^36,37,39,40 To our knowledge, no social marketing campaigns have been designed to reduce HIV risk among heterosexually identified Latino MSMW. Because of the secrecy of their sexual practices and the perceived association of HIV infection with homosexuality,^24,41,42 heterosexually identified Latino MSMW are difficult to reach with HIV prevention efforts. This population is not likely to be exposed to prevention messages or programs targeted to the gay and bisexual communities.¹⁸ Moreover, interventions requiring active recruitment of heterosexually identified MSMW may fail to reach sufficient numbers or may not reach those who are most secretive about their same-sex sexual practices.⁴¹ We sought to evaluate the effectiveness of a social marketing campaign to increase condom use and HIV testing among heterosexual Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW.     

Protective Factors in the Lives of Bisexual Adolescents in North America

Objectives. We compared protective factors among bisexual adolescents with those of heterosexual, mostly heterosexual, and gay or lesbian adolescents.Methods. We analyzed 6 school-based surveys in Minnesota and British Columbia. Sexual orientation was measured by gender of sexual partners, attraction, or self-labeling. Protective factors included family connectedness, school connectedness, and religious involvement. General linear models, conducted separately by gender and adjusted for age, tested differences between orientation groups.Results. Bisexual adolescents reported significantly less family and school connectedness than did heterosexual and mostly heterosexual adolescents and higher or similar levels of religious involvement. In surveys that measured orientation by self-labeling or attraction, levels of protective factors were generally higher among bisexual than among gay and lesbian respondents. Adolescents with sexual partners of both genders reported levels of protective factors lower than or similar to those of adolescents with same-gender partners.Conclusions. Bisexual adolescents had lower levels of most protective factors than did heterosexual adolescents, which may help explain their higher prevalence of risky behavior. Social connectedness should be monitored by including questions about protective factors in youth health surveys.Adolescence is a key developmental period with long-term effects on physical and psychological health, and adolescents negotiate a variety of environmental challenges during these years. Although public health practice often focuses on preventing or decreasing health risks, in the past decade increasing attention has been paid to identifying protective factors that can foster healthy development. Protective factors are events, circumstances, and life experiences that promote confidence and competence among adolescents and help to protect them from negative developmental risks and health outcomes.^1,2 Such protective resources enhance resilience among adolescents who face adversities,³ and they arise from individual characteristics and social environments such as families, schools, and communities.⁴Several individual assets and external resources have been identified as protective factors that reduce the likelihood of risky behaviors such as suicidality, substance use, unprotected sexual behavior, and disordered eating. Individual-level protective factors include higher levels of self-esteem, psychological well-being, and religiosity.^5–8 Relational factors such as strong connectedness to family^5,7–13 and school^{5,7,9,10,12,13} also reduce the likelihood of engaging in behaviors that compromise health. Some community-level factors also appear to be protective against risk taking among adolescents; these include the presence of a caring adult role model outside the family^8,13 and community involvement, including volunteering.⁸Most studies focus on adolescents in general, but some populations, such as lesbian, gay, and bisexual adolescents, face greater environmental challenges in negotiating adolescence and navigating developmental tasks. LGB adolescents are disproportionately subjected to violence and harassment at school^14–16 and to physical and sexual abuse.^17,18 In addition, LGB adolescents are more likely than their heterosexual peers to be involved in health-compromising behaviors, including substance use,^14–17 risky sexual behaviors and injection drug use,^14,19,20 and suicide attempts.^{10,14,15,17,21–24}Researchers have recently started illuminating relationships between lower levels of protective factors and negative health outcomes among LGB adolescents. In an analysis of the 2004 Minnesota Student Survey, Eisenberg and Resnick found that LGB students were less likely than were other students to report high levels of family connectedness, teacher caring, other adult caring, and perceived safety at school.²⁵ However, these protective factors, when present, decreased the likelihood of suicidal ideation and attempts, and protective factors accounted for more of the variation in suicide behaviors than did sexual orientation. Similarly, in his analysis of the National Longitudinal Study of Adolescent Health, Ueno found that less-positive relationships with parents, school, and friends explained higher levels of psychological distress among sexual-minority students than among heterosexual students.²⁶ Homma and Saewyc found that higher levels of perceived family caring and more-positive perceptions of school climate were linked to lower levels of emotional distress among Asian American LGB high school students in Minnesota.²⁷These studies provide some evidence that protective factors may work in similar ways for LGB adolescents as for other adolescents, but not consistently; for example, high levels of religious involvement in a faith with negative attitudes about nonheterosexual orientations might actually be more harmful than protective. Further, if LGB adolescents as a group experience lower levels of these assets, this might help explain their higher risks. Only a handful of population-based studies have focused on sexual-minority adolescents and protective factors, and they provide limited information about protective factors among bisexual adolescents separately from gay or lesbian adolescents; most research combines these groups because of small samples. Measuring sexual orientation during adolescence can be difficult; sexual identity development is a task of adolescence, and many youths engage in exploration of romantic attraction, sexual behavior, or identity labels during the adolescent years. Behavior and self-labeling may be discordant at various times, and there is evidence that some adolescents’ perception of their orientation and labels will shift during adolescence and young adulthood.In the few studies that have disaggregated the groups, bisexual adolescents were more likely than were heterosexual peers to report risky sexual behaviors,^19,20 suicide attempts,¹⁶ victimization,¹⁶ delinquency,²⁸ and substance use^16,28; in some cases gay and lesbian adolescents did not significantly differ from their heterosexual peers in these risks.^16,19,28 Some studies used romantic attraction as a measure of orientation,^23,24,26 some used self-labels,^18,22 and some used gender of sexual partners.^{16,20,25,27,28} Few studies offer the opportunity to incorporate correlates for orientation measured in different ways in the same data set.No matter how it is measured, it is important to examine levels of protective factors among bisexual adolescents separately, given the greater likelihood of risk-taking behavior and negative experiences at school among bisexual students. Drawing on data from different waves of the National Longitudinal Study of Adolescent Health, 2 studies have found lower levels of connectedness to family and school and lower perceived caring by other adults among bisexual than among heterosexual adolescents.^29,30 Bisexual and gay or lesbian adolescents generally did not differ in their levels of protective factors, but this may have been partly attributable to relatively small samples of LGB adolescents in the longitudinal study cohort, which limits statistical power for comparisons between the 2 groups. Furthermore, the study is nationally representative of US adolescents in general but may not reflect the full ethnic diversity of LGB populations across the United States or Canada. Studies analyzing larger regional population-based surveys offer opportunities to confirm those findings for specific regions.Identifying whether protective factors work similarly for bisexual adolescents and their peers is useful, but it is equally important to monitor whether bisexual adolescents have the same levels of those protective factors in their lives. We therefore explored levels of protective factors among bisexual adolescents compared with heterosexual, mostly heterosexual, and gay or lesbian peers in 6 school-based surveys in the midwestern United States and western Canada. We posed 3 questions: (1) Are levels of protective factors different between bisexual adolescents and heterosexual adolescents? (2) Are levels of protective factors different between bisexual adolescents and gay or lesbian adolescents? (3) Are these patterns consistent across varying measures of sexual orientation?     

Sexual Minority Women and Depressive Symptoms Throughout Adulthood

Objectives. We examined the associations between depressive symptoms and sexual identity and behavior among women with or at risk for HIV.Methods. We analyzed longitudinal data from 1811 participants in the Women’s Interagency HIV Study (WIHS) from 1994 to 2013 in Brooklyn and the Bronx, New York; Chicago, Illinois; Washington, DC; and Los Angeles and San Francisco, California, by comparing depressive symptoms by baseline sexual identity and ongoing sexual behavior. We controlled for age, socioeconomic status, violence history, and substance use.Results. In separate analyses, bisexual women and women who reported having sex with both men and women during follow-up had higher unadjusted odds of depressive symptoms compared with heterosexuals and women who reported only having male sexual partners (adjusted odd ratio [AOR] = 1.36; 95% confidence interval [CI]  = 1.10, 1.69 and AOR = 1.21; 95% CI = 1.06, 1.37, respectively). Age was a significant effect modifier in multivariable analysis; sexual minority women had increased odds of depressive symptoms in early adulthood, but they did not have these odds at midlife. Odds of depressive symptoms were lower among some sexual minority women at older ages.Conclusions. Patterns of depressive symptoms over the life course of sexual minority women with or at risk for HIV might differ from heterosexual women and from patterns observed in the general aging population.Depression is a major health concern for women. According to the Centers for Disease Control and Prevention (CDC), 10% of US women reported any depression and 5% reported major depression in the previous 2 weeks.1 Depression has been reported in 19% to 62%2–4 of HIV-infected women and is associated with reduced cognitive function,5 decreased adherence to highly active antiretroviral therapy (HAART),6 higher rates of unprotected sex among substance users,7 and increased mortality.2,6Women with or at risk for HIV are often exposed to factors such as poverty,8 substance use, and violence,9–11 which can independently and jointly contribute to depression. A recent study found that any combination of intimate partner violence (IPV), substance use, and HIV infection increased the odds of depression.12 Lower socioeconomic status (SES) in women12 and HIV infection4,5 were also independently associated with depression. However, studies showed no association among HIV stage, HAART use,4,8 CD4 count,8,13 or viral load and depression.4,8,13There is a strong association between sexual minority status (i.e., women who identify as lesbian or bisexual or have female sex partners) and poor mental health. In a US survey, lifetime major depression was reported by 42% of lesbians, 52% of bisexuals, and 27% of heterosexual women (P < .01); in the same study, major depression was reported by 15% of women who have sex with women (WSW), 51% of women who have sex with men and women (WSMW), and 27% of women who have sex with men (WSM; P < .01).14 In this study, we examined 2 aspects of sexual orientation15–17: sexual identity and sexual behavior. Although sexual attraction is also considered part of an individual’s sexual orientation, data on attraction was not collected in the original study.Despite the strong association between sexual minority status and depression, it is unknown whether sexual minority status acts as an independent predictor or effect modifier of depressive symptoms among women affected by HIV, substance use, and violence. Our original hypothesis was that lesbian, bisexual, and WSMW (but not WSW) would have higher odds of depression, with race/ethnicity acting as a potential effect modifier.     

Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

Quadrivalent Human Papillomavirus Vaccine Uptake in Adolescent Boys and Maternal Utilization of Preventive Care and History of Sexually Transmitted Infections

Objectives. We examined whether maternal utilization of preventive care and history of sexually transmitted infections (STIs) predicted quadrivalent human papillomavirus vaccine (HPV4) uptake among adolescent boys 1 year following the recommendation for permissive use of HPV4 for males.Methods. We linked maternal information with electronic health records of 254 489 boys aged 9 to 17 years who enrolled in Kaiser Permanente Southern California health plan from October 21, 2009, through December 21, 2010. We used multivariable Poisson regression with robust error variance to examine whether HPV4 initiation was associated with maternal uptake of influenza vaccine, Papanicolaou (Pap) screening, and history of STIs.Results. We identified a modest but statistically significant association between initiation of HPV4 series and maternal receipt of influenza vaccine (rate ratio [RR] = 1.16; 95% confidence interval [CI] = 1.07, 1.26) and Pap screening (RR = 1.13; 95% CI = 1.01, 1.26). Boys whose mothers had a history of genital warts were more likely to initiate HPV4 (RR = 1.47; 95% CI = 0.93, 2.34), although the association did not reach statistical significance (P = .1).Conclusions. Maternal utilization of preventive care and history of genital warts may influence HPV4 uptake among adolescent boys. The important role of maternal health characteristics and health behaviors needs be considered in intervention efforts to increase vaccine uptake among boys.In October 2009, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommended that quadrivalent human papillomavirus vaccine (HPV4) may be given to males aged 9 to 26 years at the discretion of the patient’s health care provider (permissive use) to reduce the likelihood of acquiring genital warts (condyloma acuminata).1 However, uptake among eligible males was low following this recommendation for permissive use, with only an estimated 2% of male adolescents initiating the vaccine.2 As the national data indicated that uptake among females remained suboptimal for a few years following the recommendation for routine vaccination in females,3 human papillomavirus (HPV) vaccination of males offers an opportunity to achieve herd immunity in the whole population. On the basis of these considerations and the clinical trial data indicating HPV4’s high efficacy for prevention of genital warts and grade 2 or 3 anal intraepithelial neoplasia (AIN2/3, a precursor of anal cancer) in males, in October 2011, the ACIP recommended routine use of HPV4 in boys aged 11 or 12 years. The ACIP also recommended vaccination with HPV4 for males aged 13 through 21 years who have not been vaccinated previously or who have not completed the 3-dose series; men aged 22 through 26 years may be vaccinated.4Parents are involved in deciding whether their adolescent children get vaccinated regardless of whether the vaccine is recommended for routine use, because parental consent is typically required for adolescent HPV vaccination.5,6 Previous experience with HPV vaccination in female adolescents suggests that the decision to vaccinate their children with HPV vaccines is often affected by parents’ knowledge about HPV infection, attitudes toward the vaccine, and parental history of sexually transmitted infections (STIs) or HPV-related disease.7,8 In a previous study, we found that mothers’ Papanicolaou (Pap) screening behavior was associated with their daughters’ uptake of HPV4 in an insured population.9 Therefore, we hypothesized that previous maternal utilization of Pap screening might reflect a positive attitude toward prevention of HPV infection. In addition, mothers with a history of STIs, especially genital warts, might be familiar with preventive measures for HPV infection, which might influence their decision to vaccinate their children with HPV4 vaccine. We hypothesized that this influence might be even more important for HPV4 uptake among adolescent boys when the vaccine was initially recommended for permissive use among males in the United States.In this study, we sought to determine whether initiation of HPV4 in a large cohort of insured boys aged 9 to 17 years was associated with maternal utilization of preventive care and history of STIs during the time period when the vaccine was indicated for permissive use in males.     

Lesbian,Gay, Bisexual,and Transgender Hate Crimes and Suicidality Among a Population-Based Sample of Sexual-Minority Adolescents in Boston

Objectives. We examined whether past-year suicidality among sexual-minority adolescents was more common in neighborhoods with a higher prevalence of hate crimes targeting lesbian, gay, bisexual, and transgender (LGBT) individuals.Methods. Participants’ data came from a racially/ethnically diverse population-based sample of 9th- through 12th-grade public school students in Boston, Massachusetts (n = 1292). Of these, 108 (8.36%) reported a minority sexual orientation. We obtained data on LGBT hate crimes involving assaults or assaults with battery between 2005 and 2008 from the Boston Police Department and linked the data to the adolescent’s residential address.Results. Sexual-minority youths residing in neighborhoods with higher rates of LGBT assault hate crimes were significantly more likely to report suicidal ideation (P = .013) and suicide attempts (P = .006), than were those residing in neighborhoods with lower LGBT assault hate crime rates. We observed no relationships between overall neighborhood-level violent and property crimes and suicidality among sexual-minority adolescents (P > .05), providing evidence for specificity of the results to LGBT assault hate crimes.Conclusions. Neighborhood context (i.e., LGBT hate crimes) may contribute to sexual-orientation disparities in adolescent suicidality, highlighting potential targets for community-level suicide-prevention programs.Suicide is the second-leading cause of death among all youths worldwide and is the third-leading cause of death among all youths in the United States,1 making the topic of adolescent suicidality a global public health and medical priority.2 One of the most consistent findings in psychiatric epidemiology is the existence of marked sexual orientation disparities in adolescent suicidality (e.g., suicidal ideation and suicide attempts).3 Lesbian, gay, bisexual, and transgender (LGBT, or sexual minority) adolescents are more likely to contemplate,4–6 plan,7 and attempt4,5,8 suicide than their heterosexual peers, and these disparities have been documented across multiple countries.4,5,8Despite the increased attention devoted to eliminating sexual orientation disparities in adolescent suicide, a 2011 report from the Institute of Medicine on LGBT health disparities noted the dearth of research into determinants of adverse health outcomes, including suicidality, within this population.9 To date, research has focused predominantly on individual (e.g., hopelessness, depressed mood),5,8,10–13 peer (e.g., recent suicide attempts by a peer, peer victimization),5,8,14,15 family (e.g., family rejection, family abuse),5,8,13,16–18 and school (e.g., presence of gay–straight alliances in schools, school safety)14,18,19 factors that are associated with suicidality among sexual-minority adolescents, which mirrors research on adolescent suicidality more broadly.20 This research has offered key insights into determinants of suicide risk, but sexual orientation–related disparities in suicidality remain after control for these established risk factors.4,5,8 The persistence of these disparities indicates the importance of considering additional risk factors, including at the social-ecological level, which we define as influences that occur above individuals, peers, families, and schools, including neighborhoods as well as institutional practices and policies (e.g., state policies that ban same-sex marriage).21,22Decades of research in medical sociology and social epidemiology have provided substantial evidence for the role that broad social-ecological factors play in shaping population health,23,24 and Healthy People 2020 recognizes that such factors may be implicated in LGBT health.25 Yet there is a paucity of research into the social-ecological risk factors for suicide among sexual-minority adolescents. In one of the few studies to address this topic, Hatzenbuehler26 created an ecological measure of the social environment surrounding lesbian, gay, and bisexual youths living in counties across the state of Oregon. Compared with lesbian, gay, and bisexual youths living in counties with supportive environments, the risk of attempting suicide was 20% higher among sexual-minority youths in less-supportive environments,26 suggesting that ecological measures can reveal previously unrecognized social determinants of suicide risk among sexual-minority adolescents. However, additional research on other social-ecological factors that may influence suicide risk within this population is warranted.Therefore, in the current study, we used a novel measure of the social environment: neighborhood-level hate crimes targeting LGBT persons. Hate crimes refer to “unlawful, violent, destructive or threatening conduct in which the perpetrator is motivated by prejudice toward the victim’s putative social group.”27^(p480) Evidence demonstrates that many sexual minorities experience hate crimes28; data from the Federal Bureau of Investigation demonstrated that 17.4% of the 88 463 hate crimes between the years of 1995 and 2008 targeted sexual minorities,29 a rate that was more than 8 times what would be expected when one considers the relatively low percentage of sexual minorities in the general population.30The objective of the present study was to examine whether suicidal ideation and suicide attempts among sexual-minority adolescents are more common in neighborhoods with a higher prevalence of hate crimes targeting LGBT individuals. Although there is limited research on the relationship between neighborhood-level LGBT hate crimes and suicidality among sexual-minority populations, existing research suggests strong associations between neighborhood-level exposure to violence and suicide in general (i.e., non-LGBT) populations.31,32 On the basis of this literature, we hypothesized higher rates of suicidal ideation and attempts among sexual minority adolescents residing in neighborhoods with more LGBT hate crimes. To test this hypothesis, we obtained LGBT hate crimes data from the Boston Police Department Community Disorders Unit and linked this information to individual-level data on suicidality (i.e., ideation and attempts) and sexual orientation from a population-based sample of Boston, Massachusetts, adolescents. This study therefore capitalizes on a rare opportunity to examine a potentially salient social-ecological risk factor for suicidality among sexual-minority adolescents.     

Insurance Continuity and Human Papillomavirus Vaccine Uptake in Oregon and California Federally Qualified Health Centers

Objectives. We examined the association between insurance continuity and human papillomavirus (HPV) vaccine uptake in a network of federally qualified health clinics (FQHCs).Methods. We analyzed retrospective electronic health record data for females, aged 9–26 years in 2008 through 2010. Based on electronic health record insurance coverage information, patients were categorized by percent of time insured during the study period (0%, 1%–32%, 33%–65%, 66%–99%, or 100%). We used bilevel multivariable Poisson regression to compare vaccine-initiation prevalence between insurance groups, stratified by race/ethnicity and age. We also examined vaccine series completion among initiators who had at least 12 months to complete all 3 doses.Results. Significant interactions were observed between insurance category, age, and race/ethnicity. Juxtaposed with their continuously insured peers, patients were less likely to initiate the HPV vaccine if they were insured for less than 66% of the study period, aged 13 years or older, and identified as a racial/ethnic minority. Insurance coverage was not associated with vaccine series completion.Conclusions. Disparities in vaccine uptake by insurance status were present in the FQHCs studied here, despite the fact that HPV vaccines are available to many patients regardless of ability to pay.Cervical cancer is a significant public health challenge in the United States. Approximately 12 300 women were expected to be diagnosed with cervical cancer in 2013, and 4030 were expected to die from the disease.1 The burden of cervical cancer disproportionately affects minority, low-income, and uninsured populations.2–4 The primary risk factor for virtually all cervical cancer is infection with certain types of human papillomavirus (HPV). Effective vaccines have been developed against HPV-16 and HPV-18, which alone are responsible for approximately 70% of cervical cancer cases.5–7 These vaccines hold great potential for reducing disparities in cervical cancer morbidity and mortality, if utilization can be encouraged in populations most at risk for cervical cancer.Federally Qualified Health Centers (FQHCs) serve the primary health care needs of more than 20 million patients in the United States, many of whom are low income, minorities or uninsured,8 and are thus an ideal setting in which to study the utilization of HPV vaccination among populations at highest risk for cervical cancer.9 However, few investigators have directly examined HPV vaccination rates in such settings,9–11 in part because of a lack of readily available data. Consequently, factors affecting HPV vaccine uptake in FQHCs are not well understood. In particular, the role of insurance coverage remains unclear.To date, studies of HPV vaccination rates in FQHCs have modeled insurance as a static variable, determined at a single visit or at the time services were rendered.9–11 This approach might be unsuitable when considering the association between insurance and HPV vaccine series completion, which requires multiple visits over several months,12 and may not accurately reflect the experience of FQHC patients whose coverage can change frequently affecting health care utilization.13–16 Furthermore, defining insurance status from a single visit prevents consideration of insurance duration or coverage continuity as potential factors influencing vaccine uptake. Among Medicaid enrolled patients, who constitute almost 40% of FQHC patients nationally,8 duration of insurance enrollment has been associated with HPV vaccine initiation, with longer enrollment being a predictor for initiating the vaccine series.17,18 Other researchers have demonstrated that, compared with being uninsured or sporadically insured, having continuous insurance coverage is positively associated with the receipt of preventive services in FQHCs, despite the fact that patients can receive care regardless of insurance coverage in these settings.16,19,20Existing studies of HPV vaccination in FQHCs have also been limited to patients younger than 19 years,9–11 precluding examination of insurance effects across the full age range for which the vaccine is recommended (9–26 years).12 In FQHC settings, the role insurance plays in vaccine uptake likely differs with age, as HPV vaccine is free for eligible children and adolescents younger than 19 years through the federal Vaccine for Children (VFC) program,21 but no similar program exists for patients aged 19 to 26 years. A better understanding of how insurance coverage and other factors affect uptake among female FQHC patients aged 19 to 26 years is needed to allow design of future interventions to reduce cervical cancer disparities in underserved populations.We leveraged electronic health record (EHR) data from a network of FQHCs to examine the association between insurance continuity and HPV vaccination in a large cohort of female patients (9–26 years of age) who accessed care between 2008 and 2010. We hypothesized that HPV vaccine uptake in our study population would be affected by insurance continuity, with lower rates of vaccine series initiation and completion among uninsured and discontinuously insured patients, compared with the continuously insured. We also hypothesized that insurance-related disparities would be most pronounced among women older than 18 years, who are ineligible for VFC. Our study helps fill a gap in published research by assessing the uptake of HPV vaccine in FQHC patients, including those older than 18 years, and applying EHRs to gather objective longitudinal data on insurance coverage and HPV vaccination rates in this population.