HIV/AIDS and Asians & Pacific Islanders in San Francisco

Nationally HIV/AIDS continues to spread in communities of color including Asian and Pacific Islander (A&PI) communities. In the third decade of the epidemic, San Francisco remains one of the epicenters of the A&PI HIV/AIDS epidemic.

• 10% of A&PI men who have sex with men (MSM) tested positive for HIV by blood test in 2004, which was conducted as part of a behavioral surveillance survey of San Francisco MSM (Raymond 2005). When asked for their HIV status, only 6.1% of the A&PI MSM knew and/or reported that they were HIV positive.
  
  
• From 2000 to 2004 the HIV infection prevalence rate rose from 2.6% to 3.8% among A&PIs 18-29 years old in San Francisco, according to preliminary analysis (Raymond 2005).
  
  
• San Francisco’s A&PI AIDS incidence rate is the nation’s highest at more than six times the national A&PI AIDS incidence, making San Francisco an epicenter of the HIV/AIDS epidemic for A&PIs (Wortley et al. 2000). Nationally, according to the Centers for Disease Control and Prevention, the number of AIDS diagnoses increased among A&PIs by 34% from 1999 to 2003.
  
  
• In a 2002 community study conducted by A&PI Wellness Center in collaboration with UCSF Center for AIDS Prevention Studies, alarming baseline findings for the A&PI MSM in the study showed that with their regular partner:
  • 70% engaged in unprotected insertive anal intercourse (UIAI)
  • 56% engaged in unprotected receptive anal intercourse (URAI)
  • 40% never/almost never discussed safe sex or condom use
    
    
• 30% of A&PI MSM reported having unprotected receptive anal intercourse (URAI) in the three months prior to a 2003 survey conducted in Boston, Chicago, Los Angeles, Honolulu, New York, and San Francisco (A&PI Wellness Center 2004).
  
  
• From 2000 to 2002 the URAI rate increased by 9.6% for A&PIs in California. Whites had the second highest increase, 6.3% (UARP 2004).

Download our HIV and Asians & Pacific Islanders: The Epidemic in San Francisco Fact Sheet

Asians & Pacific Islanders (A&PIs) represent 34% of San Francisco's population, yet the number of A&PIs who get tested for HIV is alarm­ingly low. Nationally, it is estimated that one-third of A&PIs currently living with HIV do not know their status (Campsmith, Rhodes & Hall, Poster Session, 2009 CROI Conference). Real and perceived stigma sur­rounding HIV/AIDS within A&PI communities can delay testing and undermine the effectiveness of prevention education. Sexual silence also contributes to lower HIV testing rates (Nemoto, Operario, et al., 2003).

Whites, who account for about 44% of San Francisco's population, re­ceived nearly half of all HIV tests given in San Francisco between 2002 and 2009. Hispanics test at a rate nearly 1.25 times their population and African Americans at a rate nearly double. Asians & Pacific Islanders, however, test at a much lower rate—while A&PIs account for a third of San Francisco's population, they only receive about 11% of all HIV tests administered. Nationwide, only 33% of Asians and 32% of Native Hawaiians and Other Pacific Islanders have been tested for HIV.

A lack of culturally and lin­guistically competent servic­es contributes to low A&PI testing rates, late stage di­agnosis and increases bar­riers to HIV treatment and care (Nemoto, Operario, et al., 2003). 60% of A&PI HIV infections are among foreign-born individuals (Zaidi, Crepaz, Song, et al., 2005). For A&PIs, the like­lihood of testing increases when testing sites offer a sense of safety and cultural familiarity (Do, Hudes, Proctor, et al., 2006). In­creasing the number of A&PIs testing for HIV and accessing treatment and care services requires both stigma reduction and avail­ability of culturally and lin­guistically competent testing sites.

From the start of the epidemic through the end of 2010, there have been 911 Asian & Pacific Islander AIDS cases reported by the San Francisco Department of Public Health. At the end of 2010, the proportion of A&PIs diagnosed with AIDS increased to 8.7% of all AIDS diagnoses, up from 4.5% in 2000, a 93.3% increase.

To get a clear picture of the impact of HIV in the A&PI community, A&PI AIDS data must be disaggregated by A&PI ethnicity. San Francis­co provides specific data for some A&PI ethnicities, and yet nearly 20% of cases are still of unknown ethnicity. Furthermore, it is impossible to understand the reach of the epidemic in communities that are listed un­der broad sub-categories, like Pacific Islanders or Southeast Asians (i.e., Native Hawaiians as compared to Samoans, or Vietnamese compared to Cambodians). The largest proportion of cumulative AIDS cases are among Filipinos and Chinese, 30.6% and 21.1% respectively. These and other groups are shown in Figure 4.

Figure 5 tracks year of diagnosis from 2003-2009 for A&PIs. For 2009, A&PIs accounted for 8% of all HIV diagnoses in San Francisco.

Download our HIV and Asians & Pacific Islanders: National Epidemic Fact Sheet

Recent analysis of data from the Centers for Disease Control and Prevention reveals that A&PIs have the highest rate of increase in new HIV infections in the nation, the only statis­tically significant growth among any racial or ethnic group (4.4%) During the same time period, the rate of HIV infection declined for all other racial and ethnic groups.1

Two-thirds of Asians, Native Hawaiians and Other Pacific Is­landers have never been tested for HIV. In fact, A&PIs have the lowest HIV testing rates of all races and ethnicities: 37.9% of Whites, 57.8% of Blacks or African Americans, 42.7% of American Indian or Alaska Natives, and 42.4% of Hispanic/Latinos report having been tested for HIV.2

Low testing rates and annual increases in HIV infections mean that more A&PIs are getting HIV. It is estimated that 1 in 3 A&PIs living with HIV don't even know it.3 A lack of HIV testing in A&PI communities may mask HIV/AIDS infection rates among A&PIs at the national level. CDC estimates that 470 Asians and 34 Native Hawaiians and other Pacific Island­ers were diagnosed with HIV infection in the 40 states with confidential name-based HIV infection reporting in 2008. This data exclude California, Hawaii, Oregon, and Washington—states with large populations of A&PIs. This means major segments of the A&PI population are not represetned in the national picture. When A&PIs do test, it is usually at a late stage in the disease's progression. At the end of 2008, 36% of Asians diagnosed with HIV developed AIDS, second behind Hispanics and Latinos. CDC also estimates that through the end of 2008, there are 4,861 Asians and 441 Native Hawai­ians and other Pacific Islanders living with HIV.4

Another analysis of the estimated number of A&PIs living with HIV at the end of 2007 was 3483, but this was in only 33 States and 4 US Dependent areas. Again, this data does not include high A&PI population states.5 Without true, compre­hensive national data, it's difficult to fully understand the full impact of HIV in the A&PI community.

A&PI women are often ignored when it comes to HIV preven­tion messaging and services, but they're still at risk for HIV. In fact, young A&PI women are the least likely of all races and ethnicities to get tested for HIV. An overwhelming majority of A&PI women living with HIV got it through heterosexual sex (86%).6 In OB/GYN settings, A&PI women are less likely to be offered an HIV test than women of other ethnicities.7

CDC classifies trans women as "men who have sex with men," or "MSM," making it very difficult to determine the extent of HIV infection among the trans community. It is unclear how data is collected for trans men. Very little data exists on A&PI trans women and men; most studies are on male-to-female trans women and in the Bay Area. A literature analysis from 2008 estimated that as many as 27% of male-to-female trans women nationwide may be HIV-positive. Prevalence rates were low for female-to-male trans men.8 One San Francisco-based study of A&PI trans women estimated that up to 27% may be HIV-positive.9

The number of HIV diagnoses among young A&PI gay men more than doubled in recent years. Between 2001-2006, new HIV diagnoses jumped by 255.6%, an estimated annual in­crease of 30.8%, the highest of all races and ethnicity.10

Men who have sex with men are by far the largest at-risk group among A&PI men. 77% of HIV cases among A&PI men through the end of 2007 were from male-to-male sexual contact. 12% contracted HIV through heterosexual contact, 6% contracted through injection drug use, and 3% from a combination of male-to-male sexual contact and injection drug use. From 2001-2008, A&PI men had the highest rate of HIV diagnoses, increasing 5.1% each year. This was the high­est rate for all races/ethnicities; in fact, the rate for every other racial/ethnic group (except American Indian/Alaska Natives) declined.

References available in fact sheet.

The cumulative number of A&PI AIDS cases in San Francisco is 785 as of Mar. 31, 2005:
By gender: Male (89%), female (7%), and transgender (4%)

By transmission: Gay/bisexual men (77.8%), gay/bisexual/IDU (7.3%), lesbian/bisexual intravenous drug user (IDU) (0.3%), IDU not gay/bi men (5.0%), hemophiliac transfusion recipient (2.9%), heterosexual (3.4%)

By age: 14.5% are 13-29 years old, 44.3% are 30-39 years old

By A&PI ethnicity: Filipinos (33%), Chinese (23%), Japanese (12%), Pacific Islander (8%), Southeast Asian (9%), Korean (2%), and “other” (13%)

REFERENCES
Asian & Pacific Islander Wellness Center in collaboration with five other A&PI AIDS service organizations. 2004. “National A&PI MSM Knowledge, Attitudes, Beliefs, and Behaviors, 2003.”

Osmond, D.H., Page, K., Wiley, J., Garrett. K., Sheppard, H.W., Moss, A.R., Schrager, L., and Winkelstein, W. 1994. ”HIV infection in homosexual and bisexual men 18 to 29 years of age: the San Francisco Young Men's Health Study.” American Journal of Public Health 84: 1993-1997.

Raymond, H. 2005. Telephone communication.

San Francisco Department of Public Health. 2005. “Quarterly AIDS Surveillance Report AIDS Cases Reported through March 2005.”

University-wide AIDS Research Program and the HIV Prevention Research and Evaluation Section (2004) “Report on race/ethnicity: California HIV prevention indicators.”

Wortley, P.M., Metler, R.P., Hu, D.J., and Fleming, P.L. 2000. “AIDS among Asian and Pacific Islanders in the United States.” American Journal of Preventive Medicine 18(3): 208-214.

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