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The importance of population denominators for high-impact public health for marginalized populations
Purcell DW , Hall HI , Bernstein KL , Gift TL , McCray E , Mermin J . JMIR Public Health Surveill 2016 2 (1) e26 The lack of consistent methods to enumerate population-level denominators for hidden populations has made it difficult for public health to articulate some of the most pressing disparities in America. For example, since the first cases of AIDS in the United States struck gay and bisexual men, injection drug users, and transgender persons, calculating rates of disease to compare impact across populations and geographic areas to highlight disparities and target resources has been challenging. While routine census data have allowed the Centers for Disease Control and Prevention (CDC) to calculate disease rates by sex, age, race/ethnicity, and geographic area [1], the census does not collect information on sexual orientation or same-sex sexual behavior, persons who inject drugs or injection behaviors, heterosexuals who are at higher risk of HIV infection, or transgender persons. This lack of information is nowhere more evident than among gay, bisexual, and other men who have sex with men (MSM), who comprise 67% of estimated number of persons with HIV diagnosed in 2014 (70% when MSM who also inject drugs are included) [1]. Among youth ages 13 to 24, 80% of diagnoses in 2014 were among MSM or MSM who also inject drugs [1]. The impact of HIV on MSM has made them a key focus of the National HIV/AIDS Strategy (NHAS) [2,3]; yet, proportions alone cannot accurately describe disparities, because the size of population denominators vary. | Over the past 5 years, CDC has tried to fill the gap in national, population-wide denominators by using various analytic techniques to estimate the US population size of MSM [4], persons who inject drugs [5], and high-risk heterosexuals [6], and to estimate the population size of MSM and persons who inject drugs by urbanicity and region [7]. Other groups have tried to estimate the size of the population of transgender adults [8] and youth [9]. These national estimates have allowed for the calculation of disease rates for these populations for HIV and other sexually transmitted diseases, which in turn has allowed for national disparities to be highlighted and for federal resources to be better targeted to maximize health impact and increase equity. MSM, who constitute 4% of men in the United States [4], have HIV prevalence and diagnosis rates at least 40 times as great, and syphilis rates at least 60 times as great as for women and other men [4]. However, national estimates may not be applicable to state or local areas because the proportion of the population that is MSM may differ greatly between and within states. Therefore, more refined information is necessary for accurate local information to help plan local programs and allocate resources. |
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