Despite considerably higher prevalence and incidence of HIV infection among black and Hispanic MSM, our findings indicate that compared with young white MSM, young black and Hispanic MSM report (1) similar use of health care and HIV testing services; (2) greater perceived importance of receiving HIV prevention services from their health care or HIV test provider; (3) a greater frequency of receiving HIV prevention services from their HCP; and (4) greater satisfaction with services received from a health care provider (black MSM only). Most of our findings did not change when adjusting for important confounders and when analyses were restricted to young MSM who were unaware of their HIV infection. Moreover, black and Hispanic MSM were more likely to report reducing one or more risk behaviors as a consequence of their last HIV counseling and testing experience. Overall, our findings do not indicate that racial disparities in health care utilization patterns and experiences and attitudes towards receipt of HIV prevention services at a health care or HIV test provider explain the racial disparities in HIV incidence and prevalence among young MSM.
Clearly, many racial health disparities in the U.S. result from lack of access to care and preventive services,25,26,44,45
attributed in part to lower income and lack of health insurance.22,46
In our survey, we found that minority MSM were more likely to report an income under $15,000 and just as likely to have health insurance. However, we also found, as others, that black and Hispanic MSM were equally as likely to use a regular source of health care but were more likely to use a hospital and community clinic as their regular source of health care than white MSM.19
This finding suggests that lower income and lack of insurance is offset by using services provided by public providers.
Our data support other studies that found having a HCP is associated with receiving preventive services (e.g., blood pressure and cholesterol screening).23,28,45–48
Adjusting for provider type and other confounders, we found that black and Hispanic MSM compared with white MSM were more likely to report receiving one or more prevention services, including testing and counseling to reduce HIV risk behaviors. The higher delivery of prevention services to black and Hispanic MSM from their regular HCP might be attributed, in part, to the greater importance placed on receiving these services by black and Hispanic MSM or to greater provider awareness. Over the past decade, racial disparities in HIV infection have been well documented.2,4,8,10,13
Increased awareness and funding of programmatic initiatives have increased the number of providers that perform risk assessments and offer HIV testing to minority MSM.1,49
Given the public-health expenditure and focus on HIV prevention among MSM since the late 1980s and on reducing disparities through the MAI since 1998,49
we were not surprised to find that the uptake of HIV testing was at least similar between young black, Hispanic, and white MSM. Many studies since the late 1990s suggest that nearly all MSM have been tested for HIV, and most have tested repeatedly.2,13,17,19,40,50
Similarly, given the considerable national investment on policy development and dissemination, training, and prevention programs to ensure that counseling routinely accompanies HIV testing,51,52
we were not surprised to find similar provision of counseling services for black, Hispanic, and white MSM who had tested in the past year. Our finding that black and Hispanic MSM placed greater importance on receiving counseling services at the time of testing support those of Spielberg and colleagues’ (2001) suggesting that many white MSM do not want counseling or perceive that counseling is a barrier to HIV testing.53
It is likely that the MAI had not been enacted long enough to impact the rates of HIV infection among this sample of minority MSM. However, more recent reports indicate that HIV prevalence and incidence among minority MSM are still high,13
which may result from the general decline in CDC’s prevention budget as well as the MAI budget since 2002.54,55
In 1989, the U.S. Preventive Task Force recommended that health care providers take a complete sexual and drug-use history from all adolescents and adults as a means of identifying behaviors associated with HIV infection.56,57
Furthermore, new recommendations suggest routine testing for all adults in health care settings.51
However, several studies, including ours, have found that providers of health care and HIV testing services miss opportunities to provide services that might help MSM avoid infection.31,58–63
Of those who reported using a regular source of health care, depending on race/ethnicity, one third to one half of participants reported that no one at their source of care had ever discussed whether they should test for HIV. Of those who had tested HIV-negative in the past year, nearly half reported that they did not receive any counseling with their test, including half of those who subsequently acquired HIV and could have benefited from counseling.
Health care providers can motivate their patients to change behaviors.32,33,36
Most black and Hispanic MSM felt it important and were satisfied with the prevention services they received, and some reported reducing their risks as a result of their last HIV counseling and testing experience. Combined with our findings on missed opportunities, these findings indicate that health care providers should routinely recommend HIV testing for all patients in health care settings where clients are at increased risk for acquiring HIV and thus support new national guidelines for at least annual screening of MSM at risk for HIV infection.51
We remain concerned about the overall quality and effectiveness of HIV prevention services for MSM, especially minority MSM. While minority MSM were more likely than white MSM to report reducing their risk behaviors, many MSM reported no change in risk behaviors. Many MSM reported that they wanted their HCP and HTP to give more information about HIV/AIDS and to improve their prevention services by doing a better job of assessing risks and discussing risk reduction and the need for testing. Given the high incidence and prevalence of HIV infection among MSM and the high proportion who are unaware they are HIV-infected, particularly among black and Hispanic MSM, providers of health care and HIV testing services should consider developing prevention messages that underscore the importance of consistently using condoms with all partners who are not mutually monogamous and have not recently tested HIV-negative.13,15
Limitations and Potential Biases
Our findings are subject to several limitations and potential biases. First, our findings may not generalize to black, Hispanic, and white MSM who do not attend the sampled venues or who do not reside in the five cities we surveyed. Second, our findings may reflect considerable investments in community-based minority MSM prevention efforts as a result of CDC’s Healthy People 2010
and Minority AIDS Initiative which focus on eliminating racial disparities. Third, because prevention services were self-reported, they may not correspond with services that were actually received.28,64,65
Given our long recall periods, findings may be subject to reporting inaccuracies. To minimize inaccuracies, we restricted our measures to use of a health care provider since age 20 and a HIV test provider within the past year. Fourth, some studies have documented systematic differences in the way members of various racial/ethnic groups respond to a variety of scale types,66–68
which could account in part for the findings that blacks and Hispanics were more likely than whites to report that prevention services were important or being satisfied with those services. Since responses to these measures are subjective and the recall periods are long, we are unable to say conclusively whether our findings are subject to a response bias based on the systematic differences in the way various racial/ethnic group members respond to scale types. Fifth, our findings may be subject to nonparticipation bias because approximately 42% of eligible men declined to participate. We do not know whether the opinions of respondents differed from those of nonrespondents. However, since participation rates did not vary by race/ethnicity, we do not expect a nonresponse bias to impact the differences found by race/ethnicity. Finally, because YMS is a cross-sectional survey, the efficacy of measured prevention services on reducing HIV transmission cannot be evaluated. Similarly, the questions we used to measure the importance of and satisfaction with HIV prevention services were not based on a theoretical framework. Therefore, satisfaction with services is not necessarily related to the quality of services or behavior change. Although some MSM participants apparently acquired HIV after receiving prevention services, it may also be true that some may have avoided becoming infected as a result of these services.